MEDICAL PARASITOLOGY

APHASMIDS
DR. ROXAS
OLFU • FUMC ½ COLLEGE OF MEDICINE
Ref: Medical Parasitology in the Philippines by: Belizario

§ With esophagus and “stichosome”- nervous organ of

APHASMIDS: the worm
• Trichinella spiralis § With single testis and ovary
• Trichuris trichura § With stichocyte ® nerve cells that
• Capillaria philippinensis compose the organ
• Adult male:
INTRODUCTION § Size: 1.2mm long and 60um wide
• Subclass – ADENOPHOREA § Cylindrical body with
• 3 main characteristics: slightly curved posterior
§ Reduced or absent caudal papilla – “chemoreceptor end, provided with a pair of
organs” (nervous tissue) acts when a parasite puts in conspicuous conical
any chemical solution as manifested by moving of tail papillae (diagnostic)
or body § Single testis located at
§ Excretory system are without lateral canals posterior end and extends
§ Absent caudal chemoreceptor organs (phasmids) – this forward to about midway of
determine if the parasite is aphasmids or phasmids the body (genital tube)
§ The esophagus is lined with
TRICHINELLA SPIRALIS “stichosome”
• “Trichina worm” • Adult female:
• Trichinosis, trichiniasis § 2.3mm long (2x longer and 1 ½ times broader than
• Discovered at autopsy in London in human cadavers males)
• Parasite of Carnivorous / Omnivorous animal (cats, dogs, hogs, § Single ovary situated at the extreme posterior portion
of the body
rats, etc.)
§ Oviduct, seminal receptacle, uterus and vagina form an
• (Self-Limiting Disease but can become debilitating if brain damage
almost straight canal toward the vulva
is affected or heart is severely affected)
§ The uterus filled is located at the about ¼ from anterior
• Co-Morbid Conditions may pause threats to patients (HIV, DM,
end
HPN)
§ The esophagus is lined with stichosome (individual cell
called stichocyte)
• Larvae – encysted (diagnostic stage)
Nurse Cell
§ Always in spiral form, and lodge in various parts of the
body
§ 1,300 microns
§ Maybe lodged in various foci (brain, heart, body
cavities)
Stichosome of § Encyst – developed only in skeletal muscle
larval worm
§ Has spear-like, burrowing anterior tip
§ The larva are tightly coiled in between muscle fibers
Infective Stage Encysted larva § Surrounded by a thick capsule, which is ellipsoidal in
Diagnostic Stage Encysted larva shape
Habitat Muscle fibers (skeletal, smooth , cardiac) § Surrounded by large, round eosinophilic cells
Encystation: muscle (larva) § Adjacent muscle fiber may show hypertrophy and
Excystation: duodenum (adult) hyperplasia and/or trichinella spiralis fragmentation
MOT Ingestion of infected muscle with encysted larva
Host Carnivore/Omnivore (main host)
Human (accidental host)
Disease Trichinosis, Trichiniasis, Trichinellosis
Diagnostic Muscle biopsy, Serology (ELISA, Bachmann
Intradermal test), Fecalysis
Treatment Mebendazole (2 weeks) ® kill larva
Thiabendazole ® expels adult worm
Prevention Cook meet at minimum of 77c
Storage food at 15c for 20days or 30c for 6 days
Smoking, salting, drying is not effective Note: T. spiralis
• Habitat – muscle fibers (skeletal, smooth, cardiac)
Parasitic Biology • Host – Carnivore/Omnivore (main host) and Human (accidental
• Morphology of Adult worm host)
§ “Thread-like” appearance • MOT: ingestion of undercooked meat with larva
§ Female is longer than males • Infective stage – encysted larva and ingestion of undercook
§ Anterior half of the body is thin and pointed, will meat with larva
adapted for burrowing (protusible stylet) into the
• Diagnostic stage – Encysted larva in the striated muscle
mucosal epithelium
§ The posterior end of the male has pair of pear-shaped
clasping papillae “claspers”® hold female during
mating

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 MEDICAL PARASITOLOGY
APHASMIDS
• Life cycle:
§ 5 larva/gram of the body – death
§ Every infected animal by this parasite can become as:
o Definitive Host ® May end it here “dead
end alley”
o Potential Intermediate Host - If eaten
uncooked/wild consumption with (encysted
larva)
o Second host is needed in order perpetuate
this parasite
§ 2 Cycles: CDC
o Domestic Cycle ® Pigs, Horses and Rodents
o Sylvatic Cycle ® Bear, Moose, And Wild
Boar
§ When Ingested: CDC
o Exposure to Gastric Acid and Pepsin ® Can
cause the release of the larva from
encystment and affects the small bowel and
eventually travels to organs with muscle
tissue

• Portal of Entry: Oral

Ingesting a Raw Food/Uncooked Meat (Pork)

with Positive with Trichinella Infective Larva
¯
The larva excysts in Stomach or in the Intestine upon digestion
¯
Adult worms burrowing of the subepithelium
of villi where they mature
¯
Adult worms with Male and Female mate and fertilization occurs.
¯
The female adult worm lays its egg in the its uterus and deposits its larva in
the mucosa.
¯
Flow within the lymphatic system into the circulation and
targets the Striated Muscles Pathogenesis and Clinical Presentation
¯ • Pathology
3-weeks they start to coil into individual cysts. § Depend on: ® 5 larva/gram of the body – death
¯ o Number of worms
After a month/ to 5 weeks encapsulation occurs and can o Size and age of patients
become visible for many years (5-10 years) that may lead to o Tissues invaded
calcification 6-months to 1 year o General resistance of patient

• Transmitted: Only if the infected striated muscle is consumed by

the other potential hosts.

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 MEDICAL PARASITOLOGY
APHASMIDS
-
Fever, weakness, pain, facial
edema
Encysted larva enters the o Encystment and encapsulated
stomach - Disappearance of symptoms
(but resist by gastric juices)
¯ Note: T. spiralis
Enters down to the Small • Good prognosis – mild infection
Intestine • Poor prognosis – low grade or absent of peripheral blood
(duodenum) eosinophilia
the duodenal juice that • A negative biopsy doesn’t rule out trichinosis!
contains the bile will now
enrapture the cyst
¯ Diagnosis
The larvae inside the cyst will • Muscle biopsy – most definitive
now come out at the level of § 0.2 to 0.5g of muscle tissue
duodenum o Diaphragm
¯ o Pectoral muscle
This may now carry throughout o Biceps muscle
the blood stream o Gastrocnemius muscle
¯ o Gluteus muscle
Until finds the skeletal muscle § Pepsin and Hcl acid (gastric juices) – determine the
number or larvae/gram of muscle
• Clinical manifestation § Positive larva within the skeletal muscle tissue (usually
§ 3 cardinal signs: occurs 1 week after infection/if the 2nd phase is
o severe myalgia achieved) Chapter 3: nematode Infections
o periorbital edema • Serologic test: – risk for false negative and false positive
o eosinophilia § ELIZA
myokinase), and total IgE in serum may be children 2 years and older, albend
Bachman
§ useful intradermal
in diagnosis. test for the
An algorithm be given at 10 mg/kg body weight
Bantomite
§ diagnosis Flocculation test (BFT)
of individual cases is shown in Table cycle may be repeated five days af
§ [Link]’s Xenodiagnoses cycle in case of severe infection. T
§ Latex agglutination test is no longer used due to its assoc
Table 3.4. Algorithm for the diagnosis of the drug reactions.
probability of acute trichinellosis in humans Supportive treatment throu
and antipyretics is commonly us
Group Symptom symptoms. Corticosteroids may b
A Fever, eyelid and/or facial edema, myalgia anthelminthics to control hyp
B Diarrhea, neurological signs, cardiac signs, reactions to the larvae, and may
§ 3 Phases: cutaneous rash to treat acute vasculitis and myos
o 1. Enteric phase ® (intestinal invasion) C
or increased total IgE levels, increased
Epidemiology
- Diarrhea and constipation levels of muscular enzymes
Trichinella infections in h
D Positive serology (with a highly specific test),
- Abdominal cramps, malaise, already been documented in 5
seroconversion, positive muscular biopsy
nausea and vomiting worldwide. There are about 1
• Other Diagnostic Investigations using Biochemicalreported Tests: each year, 0.2% resulting
- Attack of food poisoning
§ Muscle Damage
The diagnosis of Indicators:
trichinellosis is very Human trichinellosis occurs wh
o 2. Invasion phase ® (migration of larva) unlikely inothe occurrence
Creatinine of only one symptom
Phosphokinase is a part of the diet. Outbreak
- Metabolic reactions from group A, B or C. Trichinellosis may be
o Lactate Dehydrogenase reported in Argentina, Bosnia-H
- Inflammatory reactions suspected in the presence of one symptom China, France, Laos, Romania, Sp
from group o A orMyokinase
two from group B, and one Thailand, Turkey, Ukraine, Uzb
- Pericardial pain, tachycardia ECG § fromWBC Differential:
group ® Eosinophilia
C, while a diagnosis is probable Vietnam. Trichinella infection ha
abnormalities § whenSerologic
there areTests:
three group A and one group documented in a small numb
- Neurological complication C symptoms.o Diagnosis
Bentonite is highly probable in
Flocculation Tests countries, including the Philippin
- Ocular disturbances the presence of three group A and two group
o Latex Flocculation Tests
Trichinellosis is primarily
C symptoms. A diagnosis is confirmed in case Humans get infected after inge
- Periorbital Edema o ELISA for Trichinosis
of three group A, two group C, and one group or insufficiently cooked meat fr
- Eosinophilia on Differential WBC § D Beck’s
symptoms; Xenodiagnosis
or any of symptom ® using experimental
from group [Link]
The infection is usually m
(if Low grade or Absent ® POOR A or B, and one from group C and one from a pig-to-pig or pig-to-rat-to-pig c
OUTCOME) group D. Treatment Prevention and Control
Currently, enzyme-linked immunosorbent
- Paralysis of the Extremities • Thiabendazole ® 25mg/kg/body ® 1st phase Health education is an
assay (ELISA) is recommended weight
for the diagnosis
- Splenomegaly § of Expels the adult
trichinellosis. worm
Confirmation of ELISA- component of prevention a
- Hemorrhages of the Gastric and No effects
§ positive sampleson maylarva
be done through Western measures against this parasitic
Intestinal Mucosa • blot technique.
Mebendazole Latex agglutination
® 20mg/kg/body weighttechnique
® 2nd and 3isrdrecommended
phase that meat be
- Heart with Pericardial Effusion may be utilized for rapid (<1 hour) confirmation minimum of 77°C (170°F). Freez
§ Kills the larva
of trichinellosis. way to kill larvae. Storage at –15°
and Neurological Complications § Used for 2 weeks or –30°C for six days is suggeste
(Meningitis) may occur (Severe) Treatment
• Prednisone ® anti-inflammatory salting, or drying meat is not eff
o 3. Convalescent phase ® S/Sx start to abate The treatment of choice for trichinellosis control measures include reg
- Fever, weakness, pain, is mebendazole 5 mg/kg body weight daily, or monitoring (meat inspection or
albendazole 15 mg/kg body weight per day circulating antibodies), keeping p
§ 3 stages: Prevention and Control
in two divided doses, for 10 to 15 days. For pens, and proper disposal of suspec
o Incubation and intestinal invasion ® after • Health education
eating while the larva is in the duodenum • Cook meat properly (170-1770F)
- Diarrhea and constipation • Freezing ®15c for 20 days or 30c for 6 days
- Nausea and vomiting
- Abdominal cramps
o Larval migration and muscle invasion ® last
for 2 to 3 days

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 MEDICAL PARASITOLOGY
APHASMIDS
CAPILLARIA PHILIPPINENSIS • Female adult worm:
• Common name: “Pudoc worm” – “hair-like” worm § The esophagus, located at the anterior half of the body,
• Disease: Intestinal capillariasis – zoonotic disease characterized by is lined with glandular cells (stichoscytes)
abdominal pain, resulting in chronic diarrhea and gurgling § The posterior half of the body contains the intestinal
stomach “borborygmi” and reproductive organs
• Discovered in Northern Luzon (Ilocos, Norte) § Oftentimes, the uterus is filled-up with eggs (diagnostic)
• This may associate with protein-losing enteropathy, electrolyte § 2.3 mm to 5.3 mm
imbalance and intestinal malabsorption § ANUS ® subterminal
• Usual Signs: Abdominal pains, Chronic Diarrhea, and Gurgling § VULVA ® Junction of the anterior and middle third
Stomach (200,000 worms in 1L of Bowel Fluid) § ESOPHAGUS ® Stichosome
• Found/Habitat: SMALL INTESTINES (Jejunum) • Life cycle:
• Common Name: PUDOC WORM § Definitive host: Birds (fish eating birds)
• Disease: INTESTINAL CAPILLARIASIS § Intermediate host: Fish which harboring the infective
larvae
§ Autoinfection ® degree of infection in human

Infective Stage 3rd stage larva (in human)

typical and atypical capillaria egg (in fish)
Diagnostic Stage Unembryonated egg
Habitat Mucosa of Small Intestine (jejunum)
Host Fish-eating birds (natural host)
Human (accidental)
Disease Capillariasis
Diagnosis Direct Fecal Smear ® wet mount
Treatment Electrolyte replacement
Mebendazole
Prevention Improve sanitation and health education program
to prevent indiscriminate disposal of human waste
Avoid eating raw fish

Parasitic Biology
• Superfamily of Trichinelloidea belongs to trichuris and trichinella
• Adult:
§ Characterized by thin filamentous anterior end and
slightly thicker and shorter posterior end
§ Lives in jejunum – adult worm
§ Tiny worm
• Eggs – this passed in the feces
o Male – 2.3 to 3.2 mm
§ 26 to 45 x 21um, peanut-shaped with striated shells and
o Female – 2.5 to 4.3 mm
flattened bipolar plugs
§ Elongated oval and almost straight on the sides, with
the both poles having flat mucus plugs
§ Unembryonated eggs, the egg shell is thin and coarsely
pitted – diagnostic stage
§ Yolk cells may be disorganized or organized thus laid in
the unsegmented stage
§ Embryonate in 10 to 14 days – pass from soil or water
ingested by small species of freshwater or brackish
water fish
§ Developed into infective stage in fish and hatch in the
• Male adult worm:
intestine
§ With ventro-lateral expansion at the caudal end and
§ Brackish water fish ® becomes infective larva
very long, smooth specular sheath (overhanging sheath
in diagnostic) § Larva ® causes autoinfection
§ Long chitinous copulatory spicule originates internally § Typical – mainly the egg
at about the posterior ¼ and extends beyond the caudal o Yellow, “peanut shape”
end (diagnostic) o Thick shelled with striations
o With flattened bipolar plug
§ 1.3 mm to 3.9 mm ® long, smooth unspined specular
§ Atypical – matured egg
sheath
o Thin shell
§ It has a SPICULE (230 um to 300um)
o No bipolar pugs
§ Thin filamentous ® (ANTERIOR)
o With segmentation
§ Thicker but shorter ®(POSTERIOR END)
o Embryonated form
§ Esophagus ® Stichosome

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 MEDICAL PARASITOLOGY
APHASMIDS
C. philippinensis T. trichiura ova Typical Capillaria ova Atypical Capillaria Ova

Egg shell • Host

§ Fish-easting birds
• Accidental host
FLAT
mucus plug § Man
Embryonic
• MOT
shell § Ingestion of fish with infective stage of larva, the larvae
escape from the fish intestine and develop into adult
worms in human intestines

Pathogenic and Clinical Manifestation

• Pathology:
The parasite does not invade intestinal tissue but responsible for
micro-ulcers in the epithelium
¯
Resulting to compressive degeneration and mechanical
compression of cells
¯
Ulcerative and degenerative lesion on the intestinal mucosa
¯
Malabsorption of fluid, protein and electrolytes

• Endoscopic finding:
§ Non-specific segmental erythematous inflammation in
the small bowel with superficial erosion with exudate

• Histology findings:
§ Flattened and denuded villi
§ Dilated mucosal glands
§ The lamina propria is infiltrated with plasma cells,
lymphocytes, macrophages and neutrophils

• Sympathology:
§ Intestinal malabsorption of fluid and electrolyte losses
• Larva o Malabsorption of fats and sugars
§ Infective stage to the fresh water o Low in potassium, calcium and sodium
§ The first generation of female worms produces larvae or § Free passage of plasma protein
eggs only to build up population o Severe protein-losing enteropathy and
§ These larvae retained in the gut of the lumen and hypoalbuminemia
developed into adults ® lead to hyperinfection and o High level of IgE
autoinfection due to large number of worms § Cachexia and emancipation
o Weight loos, malaise, anorexia, edema and
vomiting
§ Intermitted diarrhea ® 8 to 10 voluminous stools/day

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 MEDICAL PARASITOLOGY
APHASMIDS
Parasitic Biology
Note: Clinical Findings: • Adult worms
• Abdominal Pains § Flesh colored
• Borborygmus / Gurgling Stomach § Fleshy posterior end
• Chronic Diarrhea (For Several Weeks) § With ventral bacillary band
• Weight Loss § Male > female – the male is bigger than female
• Edema (Due to Severe Protein Losing Enteropathy) § The worms have an attenuated anterior 3/5 traversed
• Electrolyte absorption for Potassium (affected) by a narrow esophagus resembling a “string of beads”
• Increase in IgE with diminished levels of IgA, IgM, and IgG

Diagnosis
• Direct fecal smear or wet mount – eggs in the feces
• Duodenal aspiration ® done to recover parasites in the small
intestines
• ELISA – detection of coproantigen from stool samples
• Acid ether concentration technique
• Other rest are supportive like Albumin and Serum Electrolyte

Treatment
• Mebendazole – 200mg BID for 20 days ® DOC (CDC)
• Albendazole
• Electrolyte replacement and high protein diet

Note:
• Correction of the Electrolyte Imbalances by replacement of
losses
• Provision of High Protein Diet
• Antidiarrheal and Anthelmintic Agents
§ Mebendazole 200 mg BID for 20 days
§ Albendazole 400mg OD for 10 days ® Drug of
Choice (Doc Roxas***)
• Male worm
§ Slightly shorter than Helminths wh
solution
Prevention and Control female Enterobius verm

• Improve sanitation and health education § Coiled posterior in Ancylostoma du

Necator america

• Proper disposal of human waste 360 degrees with a Ascaris lumbrico

Trichuris trichiu

• Discourage eating raw fish single spicule and Helminths whos

retractile sheath solution
Eggs of Taenia
§ 30 to 45mm Eggs of all intes
Fig. 16.1: Adult Trichuris trichiura worms (male and female)

TRICHURIS TRICHURA • Female worm Unfertilized eg

• “whip worm” – secrete pore-forming protein “TT47” that allows § Blunt posterior end (Female)posterior part contains the intestines and reproductive
organs. Life Cycle
them to imbed their entire whip-like protein in the intestinal wall § Coiled posterior (male) The posterior end of the male is coiled ventrally, while
the hind end of the female is straight, blunt, and
Natural host: Man
Infective form: Em
• Classified as Holomyarian ® based on the arrangement of § 3,000 to 10,000 eggs/dayrounded (Fig. 16.1).
The worm has a lifespan of 5–10 years.
larva.
Adult female w
somatic muscles in cross-section where the cells are small, • Egg Egg
eggs which are
The egg underg
numerous and closely packed in the narrow zone § “lemon” “barrel” The“football”
egg has a characteristic appearance. warm, moist,
It is brown in color being bile-stained. rhabditiform
• One of the Top 3 Soil-Transmitted Round worms “Japanese lantern” in shapedIt has a triple shell, the outermost layer of which is weeks. At lowe
stained brown. 3 months or m
§ Prominent bipolar mucusItplugs on and about 50 µm long and 25 µm are infective to
is barrel-shaped
wide in the middle, with a projecting mucus plug at Mode of Tran
both ends “plug-like translucent polar prominences”
each pole containing an unsegmented ovum (Fig. 16.2). when the mat
The plugs are colorless.
§ Triple sheathed – yellowish The outer
egg floats in and
saturated transparent
salt solution. inner infective or water.
larvae

When freshly passed, the egg contains an unsegmented

shell ovum. At this stage, it is not infective for humans.
The eggs hatch
which emerges
§ Passed in the feces in fertilized unsegmented stage - down into the c
The fertilized female lays about 5,000 eggs per day.

fertilization take place inside the human body

§ 12 weeks – if swallowed, the infective embryonated
eggs go to the small intestine and undergo 4 larval
stages to become adult worm
§ 60 million eggs/2 years
§ Loves warms, humid climate
§ Deposited in the soil from the human A
feces B

14-21 days before this egg becomes mature (infective

Fig. 16.2: Egg of Trichuris trichiura. A. As seen under microscope; B. S

Infective stage Fully embryonated egg §

Diagnostic stage Unembryonated egg stage)
Habitat Colon § Until this mature egg is ingested
MOT Ingestion of infected muscle with encysted
larva/fecal-oral route
Hosts Human (definitive host)
Disease Trichuriasis
Diagnosis Kato-katz thick smear, DFS
Treatment Mebendazole (100mg BID for 3 days)
Albendazole
Pyrantel pamoate

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 MEDICAL PARASITOLOGY
APHASMIDS

Passed out infected stool (Unembryonated

eggs) within the soil
¯
2-Cell Stages (Soil) as it matures
15-30 days ® CDC: before it becomes mature
¯
Ingestion of Embryonated Egg
¯
Hatches in Small Intestine releases the larva
¯
Become Adult in the COLON (Cecum and Ascending Colon)
• Larva ¯
§ Developed after ingestion of eggs and hatches in the Females starts lay eggs 70 days after
small intestine – the larvae escape and penetrate infection with lifespan 1 year
intestinal villi where they remain for 3 to 10 days
§ Enters the crypts of the colon (habitat) Pathogenic and Clinical Manifestations
§ Grows with an adult worm in 3 months • Pathology: ® NO heart-lung migration
§ Obstruction – balls of worm
§ Trauma – surrounding the affected tissue
• Sympathology: – >5,000 ingested eggs/gram
Note: T. trichura § Abdominal cramps and pain
• Infective stage – embryonated eggs § Blood-streaked stool
• Diagnostic stage – unembryonated eggs § Anemia – loss 0.8 to 8.6ml/day
• Habitat – cecum and colon § Diarrhea
• Definitive host – Man § Weight loss
• Petechial hemorrhage – due to anterior portions of the worms
which are embedded in the mucosa
• Life cycle:
§ Predisposed to amebic dysentery due to site tissue
§ 3,000 to 10,000 eggs/day
invasion of E. histolytica
§ Lifespan – 4 to 6 years
• Appendicitis
Eggs in soil – fertilized § Filled with worms as manifested by inflammation
(embryonate in 2 to 3 weeks) leading to granuloma formation
¯ • Rectal prolapse
Ingestion of embryonated egg § Results in Trichuris dysentery by chronic dysentery
(infective stage) § Heavy intensity infection as results throughout the
¯ colon and rectum
Stays in the small intestine for • Growth Retardation ® Children due to Malnutrition
3 to 10 days • Light Infections ® Usually Asymptomatic
¯ • Heavy Infection ® >300 worms (Diarrhea or Dysentery may
Goes down to the colon occur)
(habitat) § Affects more Children (Circa - >800 worms)
¯ § This can be associated with Dehydration or Anemia -
Maturation to adult Strickland 2000
¯ § High Parasitic Burden will involve the distal parts of the
Eggs in the feces large intestine

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 MEDICAL PARASITOLOGY
APHASMIDS

• Other:
§ Poor appetite
§ Wasting and Stunting
§ Reduced intellectual and cognitive in children

Diagnosis
• Direct Fecal Smear (DFS) ® commonly used
§ < 10 eggs/smear – light infection
§ > 50 eggs/smear – heavy infection
§ 11 to 49 eggs/smear – moderate
• Proctoscopy of rectal mucosa
• Kato thick smear – alternative diagnostic technique 20-60g of
stool sample
• Kato-Katz Technique ® Quantitative Method for Egg Counting to
determine the Cure Rate (CR), and Egg Reduction Rate (ERR) plus
intensity of Infection.

Treatment
• Mebendazole – 100mg BID for 3 days
• Pyrantel Pamoate
• Albendazole - alternative

Prevention and Control

• Similar to Ascariasis
• Provision of safe water
• Environmental sanitation
• Hygiene and education

End

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