Nematodes (Roundworm): Intestinal
Overview
intestinal-- Strongyloides larva systemic-- microfilaria (Wuchereria)
Transmission and Clinical Complications
Large Intestine transmission complications
Trichuris (whipworm) oral hemorrhagic colitis
Enterobius (pinworm) oral perianal itch
Small intestine
Ascaris (round worm) oral small intestine obstruction
percutaneous and duodenitis, cutaneous larva currens,
Strongyloides (thread worm)
autoinfection hyperinfection in immunocompromised
Ancylostoma & Necator
percutaneous iron deficiency anemia
(hookworms)
Diagnosis: stool examination for larvae (strongyloides) or eggs (the rest)
Treatment: albendizole or ivermectin (strongyloides) or mebendazole (the rest)
Systemic
Worm transmission clinical picture &
myositis, diarrhea
Trichinella spiralis or nativa raw pork, bear, walrus
Dx. eosinophilia, rais
Toxocara canis eosinophilia, hepatom
oral
(visceral larva migrans) Dx: serology
Wuchereria bancrofti or Brugia malayi elephantiasis, chyluri
mosquito vector
(lymphatic filariasis) Dx: microfilaria in bl
Onchocera volvulus itchiness, persistant sk
black fly vector
(river blindness) Dx: adults in skin nod
Calabar swellings (3-
Loa loa (eye worm) horse fly vector
Dx: microfilaria in bl
Diagnosis: blood or tissue examination for microfilaria; serology for
Trichinella and Toxocara
Treatment: Wuchereria, Onchocerca, Loa- ivermectin,
diethylcarbamazine, albendizole
Trichinosis, Toxocara- albendizole
Introduction
The helminths (from the Greek meaning worm) are higher, multicellular forms
of parasite with specialized organs. There are two basic groups:
Nematodes - roundworms
Platyhelminths - flatworms - cestodes (tapeworm)
- trematodes (fluke)
Nematodes
Characteristics
- round in cross section
- bilaterally symmetrical
- variable size - 1 mm to 1 meter
- organs - digestive, nervous, excretory, cuticle, muscle, sexual
- develops by molting (shedding cuticle
- separate sexes
- reproduction and development: egg
egg fertilization
embryo in egg
larva
4 molts
adult
Categories
Bowel nematodes - with adults in bowel
Trichuris trichiura
Ancylostoma duodenale and Necator americanus
Enterobius vermicularis
Strongyloides stercoralis
Enterobius vermicularis
Tissue nematodes - adults or larval stage in tissue
Trichinella spiralis, native etc
Toxocara canis (visceral larva migrans)
Filaria - Wuchereria bancrofti
Brugia malayi
Onchocerca volvulus
Loa loa
etc.
Trichuris trichiura (Whipworm)
Epidemiology
- about 350 million infected, in some areas 90-100% of population
- restricted to warm climate by necessity for egg to embryonate on moist warm
soil for10-14 days before becoming infective
- spread: fecal - oral (esp. via foods and hands)
Biology
- life cycle: people infected by swallowing embryonated egg egg hatches in
small intestine attaches to colonic epithelium and matures to egg laying in 3
months.
adult female, approx. 45 mm eggs approx. 52 mu long
Clinical
- clinical: 99% assymptomatic
- heavy load gives diarrhea, dysentery, anemia, rectal prolapse
Diagnosis
- examine stool (standard techniques) - pathognomonic egg
Treatment
- mebendizole, albendizole
Problems
- lack of cost effective control methods in LDC (least developed countries)
Enterobius vermicularis (Pinworm)
Epidemiology
-very common in all geographic areas - 20%+ in Toronto's children
- spread: fecal - oral; eggs can survive days to weeks in environment
Biology
- infected by swallowing egg which hatches after contact with stomach acid and
matures to adult which then resides in lumen of caecum (from egg to adult
maturation in 15-43 days) . Female migrates onto perianal skin to lay eggs at
night.
- organism: adult female approx. 10 mm long; egg approx. 55 µm long
pinworm egg 50-60 µm
pinworm adult 8-13 mm
Clinical
- most asymptomatic
<10% anal pruritus; rarely vaginitis
Diagnosis
-less then 10% found in stools, i.e. not a useful examination;
-best is pinworm swab - cellophane tape swab, or sticky paddle
Treatment
- mebendizole, albendazole, pyrantel pamoate
Problems
- insensitivity of pinworm swabs (intermittent deposition of eggs) : eradication
of infection from rest of family.
Ascaris lumbricoides (Roundworm)
Epidemiology
-About 650 million infected worldwide mainly tropics. Transmission is faecal-
oral; egg very resistant, can survive years
Biology
-egg ingested, hatches in duodenum; larvae penetrate intestine wall, enter blood
vessels and embolize through liver to lungs. They then migrate into airspaces,
up trachea and are swallowed, taking up permanent adult residence in the small
intestine; ~ 2 months from egg to mature adult
eggs ~68 mµ long
adult female 20-35 cm long
adults fro
Adult worms1 live in the lumen of the small intestine. A female may produce up to
240,000 eggs
per day, which are passed with the feces 2. Fertile eggs embryonate and become infective
after
18 days to several weeks 3, depending on the environmental conditions (optimum: moist,
warm,
shaded soil). After infective eggs are swallowed 4, the larvae hatch 5, invade the
intestinal
mucosa, and are carried via the portal, then systemic circulation to the lungs 6 . The
larvae
mature further in the lungs (10 to 14 days), penetrate the alveolar walls, ascend the
bronchial tree
to the throat, and are swallowed 7. Upon reaching the small intestine, they develop into
adult
worms 1. Between 2 and 3 months are required from ingestion of the infective eggs to
oviposition
by the adult female. Adult worms can live 1 to 2 years. (CDC 1999)
Clinical
- related to number of worms; small numbers asymptomatic
- large numbers of adults in intestine -- obstruction, pains
- at times adults migrate into bile duct, up esophagus or through surgical
anastomoses of intestine
- cause malnutrition if in large numbers
Diagnosis: stool examination for eggs
Treatment: mebendizole, albendazole
Strongyloides stercoralis (Threadworm)
Epidemiology
The only important helminth that can complete its life cycle in the human host
and hence increase its numbers. Special problem in immunocompromized
because of this. Mainly a tropical parasite because requires warm moist soil for
transmission.
Transmission: skin contact with invasive larvae in soil.
Biology
Larvae passed into soil in human feces where mature in several days to skin
invasive (filariform) larvae. Can exist for months in soil "free living" by
completing life cycle without contact with human host man. Larvae penetrate
skin, move via blood vessels to lung, invade airspace, move up bronchi, are
swallowed, and then penetrate small intestinal mucosa where they mature to
adults in submucosa. They deposit eggs in submucosa and these hatch and
migrate into intestinal lumen. Small numbers of larvae get into blood vessels
and circulate again to produce more adults (internal autoinfective cycle) or
invade perianal skin and enter blood vessels to eventually produce new adults
(external autoinfective cycle).
Organism: female adult - 2.7 mm long, rhabditiform larvae approx. 0.38 mm,
filariform larvae approx. 0.6 mm long
adult filariform (invasive) larva
Clinical
most asymptomatic
GI - peptic ulcer like symptoms, diarrhea rarely, cutaneous larvae currens
(trunkal itchy dermatitis)
hyperinfection (disseminated strongyloides) in immunocompromised;
spread of larvae to peritoneum, lung, CNS with contamination of those organs
with gram negative bacteria; transmural small intestine spread of larvae and
bacteria with necrosis of intestine
Diagnosis
stool examination . NB: difficult to find strongyloides
duodenal aspirate or Enterotest duodenal string test
serology (the most sensitive)
culture of stool (Harada-Mori or Baerman) allows "free living" strongyloides
to multiply
agar plate tracking
Treatment: albendazole, ivermectin
Problems: diagnostic techniques not sensitive
untreated it persists for life
Ancylostoma duodenale and Necator americanus
(Hookworm)
Epidemiology: transmission by contact of skin with soil contaminated with
larvae.
Biology: eggs in feces hatch and mature as larvae in warm moist soil; develops
into to infective (filariform) larvae in 7 days. Filariform larvae penetrate skin of
host (e.g. bare feet), circulate to lungs where they penetrate alveoli, move up
bronchi and are swallowed. Then, as adults, they attach by mouth to small
intestinal mucosa and suck blood. (Necator 0.03 ml/day, Ancylostoma 0.15
ml/day). Prepatent period (time from skin penetration to egg production) is 4-5
weeks. Adults can live 5-15 years.
Organism
Adult female 12 mm long (A.d); ova approx. 60 mu long
Adult female 10 mm long (N.a); ova approx. 65 mu long
filariform larva
h
mouth of Ancylostoma duodenale
egg 60 x 40 mµ
Clinical
usually assymptomatic 90%
heavy infections (20 - 100 worms)
iron deficiency anemia
malnutrition from protein loss
rarely itch at skin entry site
Diagnosis: Stool examination for ova
Treatment: mebendizole, albendazole
Problems: Lack of cost effective LDC (least developed country) control
Cutaneous Larva Migrans
Ancylostoma caninum, Ancylostoma braziliensis etc.
Non-human (dog, cat etc) hookworms that penetrate human skin (as does
human hookworm) but cannot go further. Migrate and produce serpiginous
itchy traits in subcutaneous tissue.
Treatment albendizole, ivermectin.
Laboratory procedures for diagnosing intestinal helminths
Stool ova and parasite (O & P) examination
1. Direct microscopic (without a concentration technique) examination: not very
sensitive
2. Kato technique: uses glycerin mixed with stool which "clears" (makes
transparent) fecal debris making eggs visable. Can be used for counting
eggs/gram feces.
3. Concentration techniques:
i. zinc sulfate solution flotation - eggs float to top of solution
ii. formal ethyl acetate sedimentation
4. Culture: Harada Mori or Baerman culture or charcoal culture - only
Strongyloides will multiply in an incubated stool specimen - increases numbers
of larvae and sensitivity of microscopy.
Eosinophilia
Increased blood eosinophil counts are normal host response to helminth
infection; not seen in protozoan infections
very high (30-80% of moderate (10-30% of low or absent (0-10% of
WBC) WBC) WBC)
Trichinella hookworm Enterobius
Toxocara Strongyloides Ascaris
Fasciola Trichuris
Trichinella spiralis, nativa (Trichinosis, Trichinellosis)
Epidemiology
Common in geographic areas where undercooked pork is eaten, in the Arctic
where raw walrus is eaten and among bear hunters in North America; 5-15% of
North American population infected at some time.This is a zoonosis infecting
most carnivorous mammals; especially pigs, bear, walrus, and rats. Man
infected by eating Trichinella infected uncooked meat.
Biology
Encysted larvae in meat, when eaten, excyst (hatch) and penetrate into small
intestine submucosa where they mature to adults in 1-2 weeks producing larvae
which penetrate blood vessels and diseminate to all muscles. There, they cause
inflammation and encyst in muscle cells (not cardiac), remaining viable and
quiet for many years. Adult female is 5 mm.long
larva extracted from muscle adult from intestine wall
Clinical
Early (1-2 weeks) - abdominal pain, diarrhea
Midterm (2-6 weeks) - myalgia, muscle weakness, facial and periferal
edema, rash; sometimes encephalitis and myocarditis
Long term (months) - usually assymptomatic despite presence of trichinella
"cysts"
Diagnosis
clinical picture with laboratory support (eosinophilia and raised creatine
phosphokinase (CK)
microscopic examination of muscle biopsy
serology
larva in muscle cell at biopsy
Treatment: steroids and mebendizole or albendazole
Problems: education of meat consumer
lack of good drugs
Toxocara Canis (Visceral Larva Migrans)
Epidemiology: This is a zoonotic roundworm with the dog as reservoir.
Uncommon human infection but consequences serious. Transmission is dog
fecal (dog)-oral (human) .
Dog feces especially in sandboxes and parks where children play. Eggs in soil
viable and infective for several months.
Biology: Adult has cycle in dog the same as Ascaris in man. Man an accidental
"dead end" host. Eggs ingested by man/child, hatch after stomach passage and
larvae migrate through small intestinal wall into vasculature and then to liver
and lungs and beyond. Do not mature to adults but cause local inflammation
especially in liver.
Organism: In man larvae are 0. 5 mm long; egg in dog feces, looks like a
round Ascaris egg.
Toxocara eggs
Clinical
Hepatomegaly, pneumonitis, encephalitis, fever and eosinophilia in heavy
infections
Retinal lesion (similar to retinoblastoma) or focal retinitis when single larva
reaches retina.
Diagnosis
Clinical syndrome with very high eosinophilia
Serology
Nothing in stools
Treatment: Steroids and albendizole
Problems: - Control of dog and cat feces in parks and sandboxes
- Diagnosis difficult because of nonspecificity of symptoms
Other Nematodes
1. Anisakis sp: Salt water fish (cod, herring etc) roundworm that when ingested
produces a nematode inflammatory mass in stomach of raw fish consumer or
eosinophilic gastritis (mainly Japan, Holland).
2. Angiostrongylus cantonensis: nematode of amphibians producing
eosinophilic meningitis (mainly SE Asia).
3. Gnathostoma spinigerum: nematode of cat producing migratory local
subcutaneous swelling, and at times encephalomyelitis (mainly SE Asia).
4. Capillaria philippinensis: small intestine nematode producing diarrhea and
malabsorption (Philippines).
5. Bayliascaris procyonis: Raccoon nematode in North America producing a
visceral larva migrans like Toxocaris (above) but with severe encephalitis
