INTESTINAL
NEMATODES
Phylum Nematoda
unsegmented, elongated and
cylindrical
sexes are separate ; females
larger than males
posterior end of male usually
curved
Life cycles:
include 1) the egg stage
2) 4 larval stages
3) adult stage
Adult female may be:
A. Oviparous – eggs are oviposited and
embryo develops outside the
maternal body
(A. lumbridoides)
B.Viviparous – female gives birth to larvae (C.
Philippinensis)
C.Parthenogenetic – can produce viable eggs
without being fertlized by the
male worms (S.
stercoralis)
CLASSIFICATION
Phylum Nematoda
Class Aphasmidia (lacking
phasmids or caudal receptors)
Class Phasmidia ( with phasmids
or caudal
papillae)
Class Phasmidia ( with
phasmids)
Species which parasitize the small intestines
1. Ascaris lumbricoides
2. Necator americanus
3. Ancylostoma duodenale
4. Strongyloides stercoralis
5. Capillaria philippinensis
Species which parasitizes the large intestines
1. Enterobius vermicularis
2. Trichuris trichiura
Ascaris Lumbricoides
The most common intestinal
roundworm of man
Occurs most frequently in tropical
and subtropical regions of Asia,
Central and South America and
Africa
Estimated to infect 1.2 billion
individuals (1/5 of the world’s
population)
Ascaris lumbricoides
Thrives in areas with lack of
sanitation and poverty and
ignorance
Most common source of infection –
soil contaminated foods esp. in raw
vegetables
2 separate populations and
reservations
1. adult Ascaris – parasitizing man
2. Ascaris eggs - environment
Ascaris lumbricoides
(Morphology)
Adult – creamy white or
pinkish yellow
A. Female
– tapered at both
ends; large;
- measures 20 t0 35
cm by 5 mm ; may
grow up to 45 cm
long
- reproductive
potential : 240,000
eggs/day
B. Male – curved posteriorly
- measures 15 to 25
cm by 3
mm
Ascaris lumbricoides
(Morphology)
Fertilized eggs: mostly oval or
spherical, golden brown
: capable of further
development in soil
from single cell to
embryonated eggs
Shell contains:
1. inner non-permeable
lipoidal
vitelline
membrane
2. thick transparent
middle layer or glycogen
layer
3. outermost coarsely
mammilated albuminoid
layer
Absent mamillated layer
decorticated
Ascaris lumbricoides
(Morphology)
Unfertilized eggs
- 1st two layers
absent; shell is
thinner
- generally larger,
narrower, more
elongate
- inside are highly
refractile granules
of varying sizes
- can never undergo
development in
soil
Ascaris lumbricoides
(Life cycle)
Ascaris lumbricoides
(Pathology & Clinical
Manifestations)
Migratory larvae
hemorrhages and
destruction of the lung
parenchyma as the larvae
breaks break through the
capillaries
- asthmatic type of
respiration
- cough with rales and chest
pain
- Ascaris pneumonitis
- Loeffler’s syndrome
( allergic eosinophilic
infiltration of
the lungs)
Larva bloodstream
lodge in brain, spinal cord,
the eyeball, kidneys
Ascaris lumbricoides
(Pathology & Clinical
Manifestations
Adult worms in small intestines:
- Decreased fat and nitrogen absorption
- Lactose intolerance
- Decreased growth rates in children
- Diarrhea, vague abdominal pain, loss of
appetite
Vomited Ascaris pass larynx
suffocation
May enter Eustachian tube otitis
media
Ascaris lumbricoides
(Pathology & Clinical
Manifestations)
Due to erratic behavior
May become
entangled
intestinal obstruction
Appendix acute
appendicitis
Bile duct biliary
ascariasis
Liver multiple
abscesses
Perforate the bowel
peritonitis
Gallstones (Ascaris
eggs)
Ascaris lumbricoides
(Diagnosis)
1. Direct Fecal Smear (DFS) – 2 mg of stool used
2. Kato-Katz technique – 40-60mg of stool
ADVANTAGES:
a)quantitative: can count the number of eggs
found in a measured
stool sample
b) can determine egg reduction rate after
treatment
c)determine intensity of infection
Negative stool exam:
i. When patients are actually free from infection
j. During early larval migration via blood stream
k. When worms are still sexually immature
l. When only male worms are found in intestines
Ascaris lumbricoides
(Treatment)
Broad Spectrum antihelminthics -
neuromuscular blocking effect on
parasites → paralysis of worms
1. albendazole- 400 mg single dose
2. mebendazole – 500 mg single dose
3. pyrantel pamoate – 10 mg/kg single
dose
Community based chemotherapy –
interval of 4 months or 3 times a year for
3 years
Among schoolchildren – treatment at
least twice a year at an interval of 4-6
Ascaris lumbricoides
(Control)
Mass treatment
Selective treatment – treating
only those found positive for
eggs on stool
* Targeted group – treating
children alone
Ascaris lumbricoides
(Prevention)
Sanitary disposal of human
excreta
Personal hygiene
Avoiding use of human feces
for fertilizer
Thorough cooking of food
The Hookworms
1. Necator americanus*
2. Ancylostoma duodenale*
3. Ancylostoma braziliense
4. Ancylostoma caninum
* soil-helminths that infect man
HOOKWORMS
(Morphology)
Necator americanus Ancylostoma duodenale
Adult Small,cylindrical,fusiform, gray- -Larger
white - single-paired male & female
-females>males reproductive organs
- Posterior end of the male has -head continues in the same
broad,membranous caudal bursa
with rib-like rays direction as the curvature of the
-Ventral pair of semilunar cutting
body
plates - 2 pairs of curved ventral teeth
Rhabditi- Resemble those of
- hook-like head - Same -
Strongyloides; somewhat
form
larger, more attenuated
larva posteriorly, and have a longer
( 1st buccal cavity;
stage)
Filariform Conspicuous and parallel Inconscpicuous buccal spears and
throughout their lengths; transverse striations on the sheath in
larva
conspicuous transverse striations the tail region
(3rd present on the sheath in the tail
Ancylostoma duodenale
Copulatory bursa
Necator americanus
COPULATORY
BURSA
Hookworm rhabditiform
larva
Hookworm filariform
larva
Hookworm egg
Eggs:
ovoidal, thin-shelled,
colorless
4-8 cell stage
in constipated stool –
embryo may develop
inside shell
• Differentiation of Necator
and Ancylostoma – difficult
and impractical
Hookworms: Life Cycle
The Hookworms : Pathology
and Clinical Manifestations
I. CAUSED BY LARVAL STAGE
1. Ground Itch / Coolie Itch
- Intense localized itching,
edema, erythema and
papulovesicular
eruption
- Lasts up to 2 weeks
- Site of entrance of filariform
larvae dermatitis
The Hookworms : Pathology
and Clinical Manifestations
2. Creeping eruption or Cutaneous
Larva Migrans
- Due to exposure of the skin to
filariform larvae of A.
braziliense/caninum;
- occasional – N. americanus and
A.
duodenale
- Serpiginous tunnel in stratum
germinativum of skin
- Larvae move at a rate of several mm
to few cm per day
- Pruritus pyogenic infection
The Hookworms : Pathology
and Clinical Manifestations
3. Pulmonary lesions
- Petecchial hemorrhages
- Eosinophilic and leucocytic
infiltration
The Hookworms : Pathology
and Clinical Manifestations
II. CAUSED BY ADULT WORM
Hookworm anemia
Due to continuous mechanical suction
of blood from intestinal mucosa
Microcytic, hypochromic anemia
Loss of RBC in gut
0.03-0.05 ml blood/ day (N. americanus)
0.16-0.34 ml blood/day (A. duodenale)
The Hookworms : Pathology
and Clinical Manifestations
Hypoalbuminemia
Combined loss of blood and
lymph
HOOKWORMS
(Diagnosis)
Ground itch and creeping
eruption
- character of lesion
- history of contact with soil
recovery of eggs on stool
( DFS, Kato, Formalin Ether
concentration)
HOOKWORMS
(Epidemiology)
Hookworm infections:
96% - N. americanus
2% - Ancyclostoma
2% - mixed
Sandy loam type of soil with plenty of
rain favorable for infection
Chief sources of infection:
Unsanitary disposal of feces
Use of human feces as fertilizer
HOOKWORMS
(Treatment)
Treat all infections
Severe anemia – increase Hgb to 7-8 g/dL before
dealing with worm infection
Severe hypoalbuminemia – deworm quickly
Broad spectrum anti-helmintics:
1. albendazole
2. mebendazole
3. pyrantel
4. oxantel/pyrantel
Ferrous sulfate – 200 mg TID p.o for 3 months
HOOKWORMS
(Control Measures)
Proper disposal of feces
Proper treatment of human
excreta used as fertilizer
Personal hygiene – use of
shoes/slipper
Avoiding ingestion of raw
vegetables not washed
properly
Strongyloides
stercoralis
Disease : Strongyloides,
Cochin-China diarrhea,
Threaworm
Epidemiology : infections runs
parallel with hookworm
infection
Infective stage – filariform
larvae – skin penetration
Life Cycle of
Strongyloides
Adult parasite, Eggs
Rhabditiform
Female, in small → in → larva
hatches
Intestine of man mucosa from egg
↑
Esophagus 1. Autoinfection 2.Direct Cycle 3.Indirect
↑ in intestine (like hookworm)
Swallowed
↑ Passed in feces into
soil
Pharynx Becomes
↑ filariform larva Free living adult
(M & F)
Trachea Penetrates intestinal
↑ mucosa Eggs
Breaks out
Into alveoli Larva in colon Rhabditiform
larva
↑
Lungs Filariform larva on
Strongyloides
(Rhabditiform larva)
- free-living
- Smaller than the
filariform larva
- Female: muscular double-
bulbed esophagus and the
intestine is a straight
cylindrical tube
- Male: smaller than
female; ventraly curved
tail, 2 copulatory spicules,
gubernaculum with no
caudal alae
Strongyloides
(Filariform larva)
- parasitic; semi-
transparent, with fine
striated cuticle
- Slender tapering
anterior end and short
conical pointed tail
- Buccal cavity has 4
distinct lips
- Uteri contain a single
file of 8-12 thin-
shelled transparent,
segmented ova
Strongyloides stercoralis
(Pathology &
Manifestations)
Filariform larva – entry skin penetration
“petechial hemorrhage, congestion & edema,
pruritus
- lungs >>>pneumonitis (cough),
pleural effusion
Filariform & Adult – intestines >>>GIT
disturbances
Stool – water mucous diarrhea
depends on
A. Intessity of infection
B. Duration
C. Host-tissue rxn = encapsulated the worms
Blood picture – leukocytosis (WBC 25,000)
Eosinophilia ( 40%)
Strongyloides
stercoralis
(Diagnosis)
Finding the rhabditiform larvae
– feces or duodenal aspirate
direct or concentration
methods
Eggs can only be obtained by
drastic purge /NGT duodenal
aspirates
Strongyloides
stercoralis
(Treatment)
1. Albendazole– drug of
choice
- 400 mg x 3 days
- eradicates 80% of infections
2. Thiabendazole
- 50mg/kg into 2 divided
doses daily X 2 days after
meals
Strongyloides
stercoralis
(epidemiology)
- Found throughout the world
- More of a fecally-transmitted worm
that a soil-tansmitted helminth
because it is infective shortly after
passage with the feces
- Low local prevalence
- More frequently found among male
children 7-14 years old than among
females and adults
Strongyloides
stercoralis
(Prevention)
Proper waste disposal
Protection of the skin from
contact with contaminated soil
Early detection & Treatment of
cases
Capillaria philippinensis
(Epidemiology)
Capillariasis first recorded in Northern Luzon
Also reported in Thailand, Iran, Japan, Egypt,
Korea, Taiwan and India
Migratory fish-eating birds are considered
natural hosts
In the Philippines, this has been documented
in the Northern Luzon provinces,Zambales,
Southern Leyte, Compostela Valley and
Zamboanga del Norte
Mode of transmission: eating uncooked small
freshwater/brackish water fish; Northern
people like to eat “bagsit” and other fish found
in lagoons
Capillaria philippinensis
(Parasite Biology)
MALE FEMALE
- 1.5-3.9mm - 2.3-5.3mm
- spicule 230-300um long - thin filamentous anterior
and has unspined sheath end and a slightly thicker
- thin filamentous anterior and shorter posterior end
end and a slightly thicker - esophagus has rows of
and shorter posterior end secretory cells
- esophagus has rows of - anus is subterminal
secretory cells - vulva seen at the junction
- anus is subterminal of anterior and middle
thirds
Capillaria philippinensis
(Parasite Biology)
EGG
- peanut-shaped with striated shells and
flattened bipolar plugs
- 36-45um by 20um
- embryonate in the soil or water
Capillaria philippinensis
(Life Cycle)
Capillaria philippinensis
(Clinical
Manifestations)
Symptoms: abdominal pains, gurgling stomach
(borborygmus), and diarrhea; weight loss,
malaise, anorexia, vomiting, and edema
Laboratory findings: severe protein-losing
enteropathy, malabsorption of fats and sugars,
decreased excretion of xylose, low electrolyte
levels (esp. potassium), and high levels of
immunoglobulin E
Capillaria philippinensis
(Diagnosis)
Direct fecal smear – finding the
egg
Stool concentration method
Duodenal aspiration
Capillaria philippinensis
(Treatment)
Electrolyte replacement and high
protein diet – in severe cases
Antidiarrheal agents
Antihelminthics
- albendazole 400 mg once daily x 10
days
- mebendazole 200mg twice daily x 20
days
* Albendazole preferred as it destroys
larvae more readily than mebendazole
Enterobius vermicularis
Enterobiasis – human pinworm
- characterized by
perianal
itching
Enterobius vermicularis
(Morphology)
MALE
Adults:
small, whitish or brownish in
color
anterior end – pair of lateral
cuticular
expansion (LATERAL WINGS
or
CEPHALIC ALAE)
posterior esophageal bulb
male - 2-5 mm ; tail
curves ventrad;
single copulatory
spicule
female – 8-13 mm ; long
pointed tail
FEMALE
Eggs:
measure 50-60 um by
20- 30 um
elongated, ovoid,
flattened on the ventral
side
similar to letter “D”
egg shell – two layers
(outer thick hyaline
albuminous shell
and Inner embryonic
lipoidal membrane)
larva – folded once
within the shell
(creating a line
visible along the
egg’s long axis)
Enterobius vermicularis Life
Cycle
Life Cycle:
eggs deposited by a single female vary from
4,672 to
16,888 (mean 11,105/day)
female usually dies after oviposition
male dies after copluation
eggs become fully mature/embryonate within 6
hours
eggs are resistant to putrefaction and
disinfectants
succumb to dehydration in dry air within a day
may remain viable up to several days under cool
and moist conditions
Enterobius vermicularis
(Pathology and Manifestations)
1/3 asymptomatic
3 forms:
I. Pathology at the site of attachment of the worm
Minute ulcerations or abscesses in cecal
mucosa
II. Pathology due to egg deposition in the perineal
area
- intense itching or pruritus in the perianal
region
- scratching scarified
- pruritus ani hemorrhage, eczema,
bacterial infection of the anal and
perianal regions and perineum
III.Pathology caused by migrating adults
- migrating worms lay eggs in genital organs
vulvovaginitis
- worms enter fallopian tube salpingitis
Enterobius vermicularis
(Diagnosis)
History and physical exam
Perianal cellulose tape swab
– D shaped ova
- best time is soon after patient
awaken and before bathing
5% only are demonstrable in feces
worms may be seen migrating out of the
child’s anus at night
Enterobius vermicularis
(Epidemiology)
1. Infection may occur through:
a.Hand to mouth transmission – most
common transmission
b. Inhalation of airborne eggs in dust
c.Retroinfection through the anus
- eggs hatch in the perianal region
and larvae migrate back into large
intestine
2. Only nematode that cannot be controlled
through sanitary disposal of human
feces because eggs are deposited in the
perianal region.
Enterobius vermicularis
(Epidemiology)
1. Local prevalence
- 29% among schoolchildren from
exlcusive private schools
- 56% among those from public schools
4. Local prevalence higher in females
compared to males
5. Have been collected from fingertips and
fingernails of schoolchildren
6. Adult female worms migrate to the
perianal area even during daytime but
more migration occurs at night time.
Enterobius vermicularis
(Treatment)
1. Pyrantel pamoate – drug of
choice
- 10 mg/kg with a second dose
2-4 weeks later
2. Albendazole – 400 mg as single
dose
3. Mebendazole – 500 mg tab as
single dose
Enterobius vermicularis
(Prevention & Control)
all members of household who are
positive
should be treated
at least 7 consecutive post-treatment
perianal smears using scotch-tape swab
method shld be negative - declare
negative
infection
personal hygiene
cut fingernails short
bed linens and clothing of infected
persons – sterilized by boiling
Trichuris trichiura
Whipworm
Soil-transmitted
Frequently occurs together with
Ascaris
Children from 5 – 15 years old are
more frequently infected
In the Philippines, prevalence is
from 80-84%
Trichuris trichiura
Factors affecting transmission:
a. Indiscriminate defecation of
children around yards
b. Poor health education
c. Poor personal, family and
community hygiene.
Trichuris trichiura
(Parasite Biology)
Male worm Female worm
- 30 – 45mm - 35-50 mm
- shorter than female - bluntly rounded
posterior
- coiled posterior end with
a single spicule and - attenuated anterior 3/5
retractile sheath traversed by a narrow
esophagus; posterior 2/5
- attenuated anterior 3/5 contains the intestine
traversed by a narrow and a single set of
esophagus; posterior 2/5 reproductive organs
contains the intestine
and a single set of - lays 3,000-10,000
reproductive organs eggs/day
Trichuris trichiura
(Parasite Biology)
EGG
- 50-54um by 23 um
- lemon shaped with pluglike translucent
polar prominences
- yellowish outer and a transparent inner shell
- embryonic development takes place in the
environment when eggs are deposited in
clayish soil
Trichuris trichiura
(Parasite Biology)
Inhabit the large intestine
Entire whip-like portion embedded
into the intestinal wall of the
cecum
Eggs become embryonated within
2-3 weeks
No heart-lung migration
Trichuris trichiura
(Life Cycle)
Trichuris trichiura
(Clinical
Manifestations)
Worms embedded in the
mucosa can cause petechial
hemorrhages
Rectal prolapse
Appendicitis
>20,000 eggs/gm of feces:
severe diarrhea or
dysenteric syndrome
Light infections:
asymptomatic
In heavy parasitism: blood-
streaked stools, abdominal
pain, anemia, weight loss
Trichuris trichiura
(Laboratory Diagnosis)
In heavy infections, clinical
symptoms may be relied upon to
make a diagnosis
In light infections:
1. direct fecal smear
2. Kato thick smear method
Trichuris trichiura
(Treatment)
Mebendazole 500 mg single dose
in light infections; 2-3 days therapy
in moderate and heavy infections –
drug of choice
Albendazole 400 mg single dose –
alternative drug
Trichuris trichiura
(Prevention and
Control)
Mass treatment if infection rate is >
50%
Preventive measures
a. Treatment of infected individuals
b. Sanitary disposal of human feces by constructing toilets
c. Washing of hands with soap and water before and after
meals
d. Health education on sanitation and personal hygiene
e. Thorough washing and scalding of uncooked vegetables
especially in those areas where night soil is used as fertilizer
