Helminth Tropical
Infections
Infection vs. disease
• successful parasites live in, but do not
kill their hosts
• protozoa multiply within hosts
expression of disease depends on host
factors
• helminths do not multiply within hosts
severity of disease depends on parasite
burden and immunologic response to
parasites
3
Helminth forms
Larva
Egg
Cyst
Adults
4
C. Engleberg/V. Carruthers
Helminth modes of entry
• Ingestion (eggs or cysts)
• Arthropod bites (larvae)
• Penetration of intact skin or
mucous membranes (larvae)
5
Spread and tropisms
• Some parasites must migrate to
certain locations within the host
in order to complete their life
cycle
• Non-human parasites, in humans,
often fail to migrate properly and
become “dead-end infections”
6
Cary Engleberg
7
Mechanisms for evading the host response
• antigenic variation - trypanosomes, malaria,
giardia
• intracellular infection - malaria, toxoplasma
• encystation* - Toxoplasma, cestodes
• camouflage - schistosomes
• cleavage of ABs or C’ components - amoebae,
leishmania
• suppression/redirection of the cellular immune
response - malaria, leishmania, schistosomes
* “cyst” has multiple meanings 8
Tissue damage and host
response
• direct destruction of tissue
• hypersensitivity reactions
• eosinophila
–occurs with helminths, not protozoa
–results from tissue migration
9
Classification of helminths
Nematodes (roundworms)
Platyhelminthes (flatworms)
Trematodes (“flukes”)
Cestodes (“tapeworms”)
C. Engleberg/V. Carruthers
10
Helmintic diseases
• Intestinal
–Others
–Strongyloides (autoinfection cycle)
roundworms • Invasive
–Trichinosis (muscle pain, uncooked carnivores)
–Filaria (worms in lymphatics or under skin)
flukes –Schistosomiasis (liver or urinary tract
granulomas and fibrosis)
–Cysticercosis (cysts in brain, seizures)
–Echinococcus (massive cysts in liver or lung)
tapeworms
11
Intestinal nematodes
Adult worms in the
the intestine
Larvae pass
through lungs
Trichiuris (whipworm)
Enterobius (pinworm)
Larvae enter Eggs
bloodstream Eggs ingested
ascaris
strongyloides
hookworm Larvae hatch
Larvae penetrate
from eggs
through intact skin
C. Engleberg/V. Carruthers
12
Strongyloides life cycle
Adult worms in the
the intestine
Larvae pass
through lungs
Larvae enter Eggs
bloodstream Autoinfection
1st stage
Larvae penetrate larvae hatch
through intact skin Larvae molt from eggs
twice to form
filariform larvae 13
C. Engleberg/V. Carruthers (infectious)
Source Undetermined
14
Strongyloides - clinical features
• uncomplicated
–GI upset
• autoinfection
• hyperinfection
–rash
–bronchspasm, chest X-ray infiltrates
–diarrhea
–profound eosinophilia
–recurrent Gram-negative bacteremia 15
Trichinosis
16
Trichinella spiralis - life cycle
• “cycle of carnivorism” among hogs and rats
• humans ingest encysted larvae in infected,
undercooked pork
• larvae exist in stomach and burrow into small
intestinal mucosa
• adult males and female reemerge and produce
larvae which penetrate intestine and circulate in
bloodstream
• larvae enter skeletal muscle cells and encyst
17
Source Undetermined Source Undetermined
18
Trichinosis cases, by source of
infection, U.S.,1981
Pork products
sausage 93
other 44
unspecified 9
Non-pork products
hamburger 18
bear 10
other wild animals 7
Unknown 7
188 19
Clinical features of trichinosis
• Most common sxs:
–muscle pain and tenderness
–fever +/- chills
–edema (often periorbital)
• >10% eosinophilia (often ~50%)
• elevated creatine phosphokinase (CPK)
• +/- chronic neurologic/myocardial sxs
• self-limited (2% mortality)
20
Treatment of trichinosis
• antihelmintic (albendazole) to kill
any intestinal adults
• steroids to relieve inflammatory
reactions
• antipyretics
21
Filaria
22
Life cycles of two types of
filaria
Arthropod Adult Larvae
vector worm pairs (microfilariae)
Lymph- mosquitoes peripheral circulate
dwelling lymphatics in bloodstream
(e.g, Wuchereria
bancroftii )
Skin- biting flies skin nodules migrate through
dwelling or migratory dermis
23
Microfiliaria found in the blood of
lymph dwelling species
Armed Forces Institute of Pathology
24
Long-term
consequences of
persistent lymph-
dwelling filarial
infection:
Blockage of lymph
drainage with
chronic lymphedema
(elephantiasis)
Source Undetermined
25
Source Undetermined
26
Life cycles of two types of
filaria
Arthropod Adult Larvae
vector worm pairs (microfilariae)
Lymph- mosquitoes peripheral circulate
dwelling lymphatics in bloodstream
(e.g, Wuchereria
bancroftii )
Skin- biting flies skin nodules migrate through
dwelling or migratory dermis
(e.g., Onchocerca
volvulus &
Loa loa )
27
Source Undetermined
Black fly: vector of Onchocerciasis
28
O. volvulus microfilaria (a skin-
dwelling species) in skin snip
Snip site
Source Undetermined
Depigmentation due to chronic
microfilarial production, degradation,
and allergic host responses in the skin
Cary Engleberg
29
Cary Engleberg
30
Source Undetermined
O. volvulus skin nodule removed and sectioned,
showing cross-sections of male and female
adult worms (source of microfiliariae)
31
Source Undetermined
Onchocerciasis (”River blindness”) 32
Schistosomiasis
34
Geographic distribution of
schistosomiasis
S. mansoni
S. hematobium
S. japonicum
35
Cary Engleberg
Schistosomiasis - life cycle
Eggs
Cercaria
S.m. S.h. S.j.
(snail) Pearson Scott Foresman, wikimedia commons
36
Cary Engleberg (All other images)
Source Undetermined
Source Undetermined Source Undetermined
S. mansoni S. haematobium S. japonicum
37
Source Undetermined
38
Events following cercarial penetration
1. Larva migrate to lungs and develop as
“schistosomulae” (this may trigger a self-
limited febrile illness).
2. Male and female schistomulae migrate to the
abdominal venules:
I. Superior mesenteric (S. japonicum)
II. Inferior mesenteric (S. mansoni)
III. Bladder plexus (S. hematobium)
3. Males and females pair off and egg production
begins
4. Eggs migrate out of the body through visceral
organs or become trapped and die in tissues.
39
Immune response to
schistosoma infection
Source Undetermined
40
Source Undetermined
41
Source Undetermined
42
Source Undetermined
43
Source Undetermined
44
Source Undetermined
45
Source Undetermined
“pipestem” fibrosis
46
Source Undetermined
47
Schistosomiasis - pathogenesis
• egg granuloma (type IV reaction)--> fibrosis
• morbidity ~ worm (egg) burden
• concomitant immunity to schistosomula
• adult worms: invisible to the immune
system (survive for years)
48
Schistosomiasis- clinical features
• Cercarial dermatitis
• Intestinal schistosomiasis (granulomas -->
polyps, protein loss, malabsorption, strictures)
• Hepatosplenic schistosomiasis (portal
hypertension --> ascites, varices, splenomegaly,
normal hepatic function)
• Urinary schistosomiasis (hematuria, chronic
infection, obstruction)
• Other (cardiopulmonary, CNS, etc.)
49
Drug treatment of
schistosomiasis
• Praziquantel increases permeability
of adult parasite to Ca++.
• Tetanospasm --> death
50
Cestode infections
51
Tapeworms
• Definitive hosts: harbor adult worms
• Intermediate hosts: harbor tissue cysts
(containing worm heads)
• Humans acquire infection two ways:
–ingestion of eggs from feces (to acquire
tissue cysts) = Intermediate host
–ingestion of tissue cysts in undercooked
meat (to acquire a tapeworm) = Definitive host
52
Taeniasis poor
sanitation
ingestion of
undercooked pork
poor
hygiene
Tapeworm Cysticercosis
(pig) Martin von Nathusius, wikimedia commons
53
Cary Engleberg (All other images)
Source Undetermined
54
Source Undetermined
55
Source Undetermined
56
Source Undetermined
57
Cysticerci Hydatid Cyst
C. Engleberg/V. Carruthers
58
Isolated cysticerci Hydatid cyst
Source Undetermined
Source Undetermined
59
Source Undetermined
Duane Newton 60
Echinococcosis ingestion of
eggs in
pastures
ingestion of
entrails
contact
with
dogs
(dog) Abujoy, wikimedia commons Cystic Hydatid Disease
(sheep) wikimedia commons 61
Cary Engleberg (All other images)
Cary Engleberg
62
Treatment of cysticercosis and
echinococcosis
• Antihelminthic therapy (e.g.,
albendazole, praziquantel)
• (Echinococcus only)
–Surgical removal
–Irrigation-evacuation of cysts
63
Comparison of pork tapeworm
and Echinococcus life cycles
Definitive
hosts
Dog Dead-end
(adult Human hosts
tapeworms)
Human
Human
Intermediate
hosts Sheep
(tissue cysts) Pig
C. Engleberg/V. Carruthers
64
