NEMATODES:

APHASMIDS
DR. HALIDE ABELLA-TANGARORANG
TRICHURIS
TRICHIURA
HABITAT: LARGE INTESTINE
INTRODUCTION

•  Another name: Whipworm

•  Disease: Trichuriasis
•  Soil transmitted
•  Frequently observed occurring together with Ascaris
•  Similar distribution
•  Similar mode of transmission
•  3rd most common roundworm infection
•  1st: ascariasis
•  2nd: hookworm infection
PARASITE BIOLOGY

•  Male
• 30-35mm
• Shorter than the female
• Coiled posterior end
• A single spicule and
retractile sheath
•  Female
•  35-50mm
•  Bluntly rounded posterior
end
PARASITE BIOLOGY

•  Anterior three-fifths of the body

•  Attenuated
•  Traversed by a narrow
esophagus
•  2/3 of the body length
•  Thin-walled tubed
surrounded by
stichocytes
•  The whole structure is
called stichosome
•  Resembles a string of
beads
PARASITE BIOLOGY

•  Posterior two-fifths of the body

•  Robust or fleshy
•  Contains the intestine
•  A single set of reproductive
organs
•  Male
•  Single spicule
surrounded by a spiny
spicule sheath
•  Female
•  Lays approximately
3,000-10,000 eggs/day
PARASITE BIOLOGY

•  Larvae
•  Released soon after the ingestion of
the embryonated eggs
•  Penetrate the intestinal villi
•  Remain for 3-10 days
PARASITE BIOLOGY

•  Egg
•  50-54 um x 23 um
•  Lemon-shaped with plug-like
translucent polar prominences
•  Yellowish outer shell
•  Transparent inner shell
•  Unsegmented when laid
•  Embryonic development occurs in
the environment
•  Clayish soil
•  More susceptible to dessication
compared to Ascaris eggs
PARASITE BIOLOGY

•  Habitat
•  Large intestine: most common-cecum
•  2nd most common site: ascending
colon
•  Attenuated anterior end
•  Whiplike portion
•  Deeply embedded into the intestinal
wall
•  Fleshy posterior end
•  Protrudes into the intestinal lumen
PARASITE BIOLOGY
•  After copulation, female lays egg
•  Passed out with the feces and deposited in the soil
•  Under favorable condition
•  Egg develops and becomes embryonated within 2-3
weeks
•  Once swallowed
•  Infective eggs go to the small intestine
•  Undergo 4 larval stages
•  Become adult worms
•  No heart-lung migration
•  Lifespan
•  Average for females
•  2 years
•  Can produce a total of over 60 million eggs over its
lifespan
LIFE CYCLE
PATHOGENESIS AND CLINICAL
MANIFESTATIONS

•  The anterior portion of the worm

•  Embedded in the mucosa
•  Cause petechial hemorrhages – lead to anemia
•  May predispose to amoebic dysentery
•  The ulcers provide a suitable site for E. histolytica
invasion.
•  Manifestations
•  Mucosal appearance
•  Hyperemic and edematous
•  Enterorrhagia is common
PATHOGENESIS AND CLINICAL
MANIFESTATIONS
•  Rectal prolapse may occur: in heavy
infection
•  A hallmark of whipworm
infection
•  Rare
•  Rectum loses internal support
•  Worms bury their thin heads
into the intestinal lining
•  Loosening of the elastic
epithelium
•  Weakening of the
surrounding muscles
•  Appendicitis may occur
•  Lumen may be filled with worms
•  Irritation and inflammation
PATHOGENESIS AND CLINICAL
MANIFESTATIONS
•  Symptomatic infection
•  5,000 eggs/gram of feces
•  Dysenteric syndrome
•  20,000 eggs/gram of feces
•  Severe diarrhea
•  Light infections
•  No clinical manifestations
•  Parasite is discovered only in routine S/E
•  Heavy infections
•  Worms found throughout the colon and rectum
•  Marked by frequent blood-streaked diarrheal stool,
abdominal pain and tenderness, nausea and vomiting,
anemia and weight loss.
PATHOGENESIS AND CLINICAL
MANIFESTATIONS

•  Prognosis
•  Very good
•  No lung pathology occurs
•  No larval migration through the lungs as in Ascaris
and hookworms
DIAGNOSIS
•  Clinical diagnosis
•  Possible only in very heavy chronic infection
•  Frequent blood-streaked diarrhea, abdominal pain
and tenderness
•  Rectal prolapse
•  Adult worms attach to the rectal mucosa
•  Laboratory diagnosis
•  Essential in light infections where symptoms are absent
•  Direct Fecal Smears
•  Kato Katz Technique
•  Quantitative method
•  Used for egg counting
•  Determine cure rate, egg reduction rate and
the intensity of the infection
TREATMENT

•  Mebendazole: treatment of choice

•  500mg single dose
•  Contraindications: hypersensitivity and early pregnancy
•  Albendazole: alternative
•  500mg single dose
•  Contraindication: pregnancy
•  In moderate and heavy infection
•  Needs 2-3 days of consecutive treatment
•  Adverse effects of both drugs
•  Transient gastrointestinal discomfort
•  headache
EPIDEMIOLOGY

•  Trichuriasis
•  Occurs both in temperate and tropical countries
•  More widely distributed in the tropics
•  Prevalence
•  Temperate countries: 20-30%
•  Tropical countries: 60-85%
•  Philippines: 80-84%
•  Age more frequently infected: 5 to 15 years old
•  Distribution and prevalence of trichuriasis is co-extensive
with that of A. lumbricoides.
EPIDEMIOLOGY

•  Factors affecting transmission of trichuriasis

•  Same as that with A. lumbricoides
•  Indiscriminate defecation of children around yards
•  Frequent contact between fingers and soil among
children at play
•  Poor health education
•  Poor personal, family and community hygiene
•  Unhygienic behavior and eating habits should be
corrected
PREVENTION AND CONTROL

•  Mass treatment
•  Indicated if infection rates are greater than 50%
•  Prevention of infection in highly endemic areas
•  Treatment of infected individuals
•  Sanitary disposal of human feces by construction of
toilets and their proper use.
•  Washing of hands with soap and water before and after
meals
•  Health education on sanitation and personal hygiene
•  Thorough washing and scalding of uncooked vegetables
especially in areas where night soil is used as fertilizer.
CAPILLARIA
PHILIPPINENSIS
HABITAT: SMALL INTESTINE
INTRODUCTION

•  Disease: intestinal capillariasis

•  Abdominal discomfort
•  Chronic diarrhea
•  Gurgling stomach
•  1963
•  Described first in the Philippines
•  1967-1968
•  An epidemic occurred
•  More than 1,000 cases
•  Almost 100 individuals died
PARASITE BIOLOGY
•  A tiny nematode that resides in
the small intestine of humans.
•  Male
•  1.5 to 3.9mm in length
•  Spicule is 230-300um long
•  Unspined sheath
•  Female
•  2.3 to 5.3mm in length
•  Body is divided into 2 almost
equal parts
•  Anterior: esophagus
•  Posterior: intestine and
reproductive system
•  Prominent vulva
PARASITE BIOLOGY

•  Eggs
•  Peanut-shaped with striated
shells and flattened bipolar
plugs
•  36-45um x 20um
•  Passed in the feces
•  Unembryonated when passed
out
•  Embryonates in the soil or
water
PARASITE BIOLOGY
•  In the water
•  Ingested by small species
of freshwater or brackish
water fish
•  In the intestine of the small
fish
•  Eggs hatch
•  Grows into infective larvae
•  When the small fish is
eaten uncooked
•  The larvae escape from the
fish intestine
•  Develops into adult worms
in human intestine
PARASITE BIOLOGY
•  In the human intestine
•  1st generation female
worms
•  Produce larvae to
build up the
population
•  Subsequent generations
•  Predominantly
produce eggs
•  A few produce both
larvae and eggs or
larvae only
•  Some of the larvae are
retained in the gut lumen
and develop into adults
PARASITE BIOLOGY

•  Leads to hyperinfection
and autoinfection
•  Produce very large number
of worms
•  An autopsy was done
on one expired patient
•  200,000 worms in 1
liter of bowel fluid
PATHOGENESIS AND MANIFESTATIONS
•  Initial clinical manifestations
•  Abdominal pain
•  Borborygmus: most constant feature
•  Diarrhea
•  After a few weeks
•  Weigh loss, malaise, anorexia, vomiting and edema
•  Laboratory findings
•  Severe protein-losing enteropathy
•  Malabsorption of fats and sugars
•  Decreased excretion of xylose
•  Low electrolyte levels (potassium)
•  High levels of IgE
•  If not treated, it leads to death.
PATHOGENESIS AND MANIFESTATIONS

•  Large number of worms that develop in humans

•  Responsible for the pathology
•  Do not invade intestinal tissues
•  Cause micro-ulcers in the epithelium
•  Cause compressive degeneration and mechanical
compression of cells
•  Ulcerative and degenerative lesions in the intestinal
mucosa
•  Responsible for the malabsorption of fluids and
electrolytes
DIAGNOSIS

•  Based on finding the characteristic eggs in the feces.

•  Direct Smear or Wet Mount
•  Stool Exam with concentration method
•  With these 2 tests various larval stages and adult
worms may be seen
•  The uterus of the adult female may contain eggs and
sometimes larvae.
•  Recovery of the parasite from the small intestine by
duodenal aspiration
TREATMENT

•  Electrolyte replacement and high protein diet

•  In severe cases of electrolyte and protein loss
•  Antidiarrheals
•  Antihelminthics
•  Albendazole
•  400mg OD x 10D
•  Drug of choice
•  Destroys larval stages more readily
•  Mebendazole
•  200mg BID x 20D
•  Relapse may occur if the regimen is not followed.
EPIDEMIOLOGY

•  First recorded capillariasis

•  Northern Luzon, Philippines
•  Countries where it was later reported
•  Thailand, Iran, Japan, Egypt, Korea, Taiwan and India
•  In these countries, small fishes have been implicated
•  Natural hosts
•  Fish-eating birds
•  Mode of Infection
•  Eating uncooked small freshwater/brackish water fish
•  Endemic areas in the Philippines
•  Zambales, Southern Leyte, Ilocos, Compostela Valley and
Zamboanga del Norte
EPIDEMIOLOGY

•  1998
•  Outbreak in Monkayo, Compostela Valley
•  Called a “mystery disease”
•  Resulted in death of villagers due to misdiagnosis
PREVENTION AND CONTROL

•  Discourage people in endemic areas from eating raw fish

•  Good sanitary practice should be followed
•  1967-1968
•  Epidemic in the Philippines
•  Washing of fecally contaminated bedsheets in
lagoons in the Tagudin area of Ilocos Sur
•  All infected persons should be treated quickly
•  Their feces disposed of in a sanitary manner
•  Health education
•  Inform populations at risk about the hazards of eating
uncooked fish
TRICHINELLA
SPIRALIS
HABITAT: SMALL INTESTINE
INTRODUCTION
•  1828 in London
•  First found in the muscles of patients that were autopsied
•  1835
•  Richard Owen
•  The first investigator to describe and name the encysted
larvae
•  Before the turn of the century
•  German investigators were able to prove that raw or
insufficiently cooked meat (pork) was responsible for
trichinosis in humans
•  3 subspecies that can infect humans
•  T. spiralis spiralis -temperate regions
•  T. spiralis nativa -arctic regions
•  T. spiralis nelsoni -Africa
PARASITE BIOLOGY
•  Adult worm
•  Whitish in color
•  Male
•  1.5mm x 0.04mm
•  Single testis located near the
posterior end of the body
•  Joined in the midbody by the
genital tube
•  Extends back to the cloaca
•  Cloaca
•  A pair of caudal appendage
•  Copulatory pseudobursa
•  Two pairs of papillae
•  No copulatory spicule
PARASITE BIOLOGY

•  Females
•  3.5mm x 0.06mm
•  Single ovary
•  Posterior part of the body
•  Oviduct, a seminal receptacle, coiled
uterus, vagina and a vulva
•  Vulva is found on the anterior
fifth on the ventral side of the
body
•  Viviparous female
•  Lives for 30 days
•  Capable of producing 1,500 larvae or
more in her lifetime
PARASITE BIOLOGY
•  Larva
•  Measures 80-120um x 5.6um at
birth
•  Max: 900-1,300um by 35-40um
after it enters a muscle fiber
•  Has a spear-like burrowing
anterior tip
•  Encysted larvae
•  The digestive tract resembles
that of the adult worm
•  The reproductive organs are not
yet fully developed
•  It is possible to identify the sex
of the parasite
PARASITE BIOLOGY

•  Trichinella infection
•  The host serves as both the final
and intermediate host
•  Humans, rats, dogs, cats, pigs,
bears, and foxes
•  The host harbors both the adult
and the larval stages
•  Infective stage
•  Encysted larvae
•  Seen in the muscle fiber of the
host
PARASITE BIOLOGY

•  Mode of transmission
•  Ingestion of the encysted larvae through raw
or insufficiently cooked meat (usually pork).
•  Once ingested
•  The cysts are digested in the stomach
•  The larvae excyst either in the stomach or in
the small intestine
PARASITE BIOLOGY
•  Larvae
•  Burrows into the subepithelium of the villi where they
mature
•  Adult worms
•  Mate
•  After fertilization
•  Female begins to produce eggs that grow into larvae
in the uterus
•  Female worms deposit larvae in the mucosa after a
few days
•  Larvae
•  Penetrates the mucosa
•  Pass through the lymphatic system into the circulation
•  Finally ending in the striated muscles
PARASITE BIOLOGY

•  In the muscles
•  Larvae grow and develop
•  After about 3 weeks, they start to coil into individual
cysts
PARASITE BIOLOGY

•  Encapsulation
•  Is consummated 4-5 weeks after infection
•  The larva in the cyst remains viable for many years
•  Calcification
•  May occur in humans
•  May take place 6-12 months after infection
•  May lead to the destruction or death of the larva
•  Average lifespan is 5-10 years
PARASITE BIOLOGY

•  When a carnivore or
omnivore consumes
meat containing infective
larvae
•  The larvae break out
through gastric
digestion of the cysts
•  The cycle continues
PATHOGENESIS AND MANIFESTATIONS

•  The severity of symptoms

•  Depends on the intensity of infection
•  Light infection
•  Patients harboring up to 10 larvae
•  Asymptomatic
•  Moderate infection
•  50-500 larvae
•  Symptomatic
•  Severe infection
•  More than 1,000 larvae
•  Potentially fatal
PATHOGENESIS AND MANIFESTATIONS

•  Clinical manifestations
•  Vary depending on the stage of the parasite
•  3 phases: corresponds to the stage of the parasite
•  Enteric phase: incubation and intestinal invasion
•  Invasion phase: larval migration and muscle invasion
•  Convalescent phase: encystment and encapsulation
•  Enteric phase
•  May resemble an attack of food poisoning
•  Diarrhea or constipation
•  Vomiting and abdominal cramps
•  Malaise and nausea
•  Red blotches on the skin
PATHOGENESIS AND MANIFESTATIONS

•  Invasion phase
•  Cardinal signs and symptoms
•  Severe myalgia
•  Periorbital edema
•  Eosinophilia
•  Other typical signs and symptoms
•  High remittent fever
•  Dyspnea and dysphagia
•  Difficulty in chewing
•  Sometimes some paralysis of the extremities
•  Occasional signs and symptoms
•  Splenomegaly
PATHOGENESIS AND MANIFESTATIONS
•  In severe cases
•  Gastric and intestinal hemorrhages
•  Myocardial complications
•  Myocarditis: most common grave manifestation
•  Pericardial effusion
•  Congestive heart failure
•  Neurological complications
•  Meningitis, meningoencephalitis
•  Cerebral lesions may develop
•  In heavy infection
•  Ocular disturbances
•  Diplegia, deafness, epileptic attacks
•  Coma
PATHOGENESIS AND MANIFESTATIONS

•  Convalescent phase
•  The following will start to abate:
•  Fever, weakness, pain and other symptoms
•  Full recovery is expected.
•  Trichinosis is a self-limiting disease.
•  Prognosis
•  Good in mild infection
•  Death is uncommon except in cases of heart failure,
encephalitis and other complications such as pneumonia
and septicemia
•  Indicative ofe poor prognosis
•  Low grade or absent peripheral blood eosinophilia
DIAGNOSIS

•  Diagnosis is usually based on

•  History of exposure
•  Physical examination
•  Laboratory exams
1.  Demonstration of larva in muscle biopsy
•  Most definitive diagnostic exam
•  Done only when encystment has started
•  Usually 7 days after infection and onwards
•  Most parasitized muscles
•  Diaphragm, pectorals, gluteus, deltoid, biceps and
gastrocnemius
DIAGNOSIS

•  The likelihood of demonstrating the parasite larva

depends on
•  Mainly the intensity of the infection
•  Partly on chance
•  A negative biopsy does not necessarily mean that the
patient is negative for trichinosis.
2.  Biochemical tests -will strengthen the diagnosis
•  Elevated creatine phosphokinase, lactate
dehydrogenase and myokinase levels
•  Chemical evidence of muscle damage
DIAGNOSIS
3.  Serology: provide confirmatory diagnosis
•  Look for a rise in antibody titer
•  Starts 3-4 weeks after a light infections
•  Starts to rise as early as 2 weeks in heavy infection
•  Bentonite Flocculation Test (BFT)
•  Latex Flocculation Test (LFT)
•  IFAT
•  ELISA
4. Beck’s Xenodiagnosis
•  Done on meat suspected of harboring the encysted larva of
Trichinella
•  Involves feeding the meat to albino rats
•  Observe for 14 days
•  Look for the presence of the female worm in the duodenum
and larvae in the muscles of the experimental animal.
TREATMENT

•  Usually managed through bed rest and supportive

treatment
•  Drugs used
•  Analgesics and antipyretics to control symptoms
•  Adenocorticosteroids
•  Prednisone 20mg TID tapered over a period of 2-3
weeks
•  Inhibits the severity of the disease
•  For the allergic reaction to the death of the parasite
TREATMENT

•  Thiabendazole
•  25mg/kg body weight BID x 7D
•  If done during the 1st week of infection
•  Expel the adult worm from the GIT
•  No effect on the migrating larvae
•  Useless for infections detected 2 weeks after
exposure
•  Mebendazole: larvicidal
•  20mg/kg body weight q6H for 10-14D
EPIDEMIOLOGY

•  Trichinosis occurs whenever meat is part of the diet

•  Countries where infection is reported
•  Canada, Mexico, Holland, Ukraine, Lithuania, Yugoslavia,
Spain, Egypt, Lebanon, Syria, Brazil, Uruguay, Chile,
Ecuador, Vietnam, Malaysia and Thailand.
•  Countries where infection is absent or rare
•  India, Australia, New Zealand, New Guinea and some
islands in the Pacific.
•  It’s possible to acquire the disease anywhere in the world.
•  More than a hundred species of carnivores and
omnivores harbor the parasite.
EPIDEMIOLOGY

•  Trichinosis
•  Primarily a zoonotic disease
•  Mode of infection
•  Ingestion of raw or insufficiently cooked meat of infected
animals
•  Human infection
•  A dead-end infection for the parasite.
•  The infection is maintained in pig-pig or pig-rat-pig cycle
EPIDEMIOLOGY
•  2 distinct types of the life cycle
•  Domestic life cycle
•  Involves pigs, rats
around human habitation
•  More important to
humans
•  Infected pork is the most
common source of
infection
•  Important to cook pork
thoroughly before being
eaten
•  Meat is considered safe
when all traces of pink
have disappeared
•  Rat to tat infection
occurs by cannibalism
EPIDEMIOLOGY

•  2 distinct types of the life cycle

•  Sylvatic life cycle
•  Involves wild animals
•  Humans may possibly be infected
•  When domestic animals have been fed with
infected wild game
•  When humans rely on wild games for food
PREVENTION AND CONTROL

•  Health education
•  Recommendations
•  Cook meat at 77C (177F)
•  Freezing can kill the larvae
•  15C for 20 days
•  30C for 6 days
•  Smoking, salting, and drying meat is not effective
•  Other control measures
•  Meat inspection
•  Keeping pigs in rat-free farm.