Dr.

Kyaw Min
Assoc. Prof. Clinical Tropical Medicine & Public Health
HOD ComMed
MBBS, DTM&H, MCTM, MPH, PhD. PH
FACTM, FRSTM&H

Intestinal helminths
List intestinal helminths.
Describe life cycle, clinical manifestation
and management (Inv+Tt+prevention) of
each intestinal helminthiasis.

Filariasis
1. Mention the prevalence of filariasis in
Malaysia and globally.
2. Discuss epidemiology of filariasis
according to chain of transmission.
3. Discuss prevention and control of filariasis

Nematodes (Roundworms)
Tissue Nematode Infections

Intestinal Nematode Infections

Trichinella.spiralis &
others
Toxocara. Canis
Ancylostoma braziliense

Ascariasis
Hookworm (A.d & N.a)
Strongyloidiasis
Enterobiasis
Filariasis
Onchocerciasis

Large/I
Trichuris (whipworm), oral, hemorrhagic colitis
Enterobius (pinworm), oral, perianal itch
Small/I
Ascaris (round worm), oral, small intestine obstruction
Strongyloides, (thread worm), percutaneous and
autoinfection duodenitis, cutaneous larva currens,
hyperinfection in immunocompromised
Ancylostoma & Necator (hookworms) ,percutaneous,
iron deficiency anemia

Trematodes (Flatworms)
Blood Fluke (Schistosomiasis) Liver fluke
Intestinal
1.S. mansoni
2.S. japonicum
3.S. mekongi
4.S. intercalatum
Urinary
1. S. haematobium

1. Opisthochiasis
2. Clonorchiasis
3. Fascioliasis
Lung Flukes
1. Paragonimus

Cestodes (Tapeworms)
Tinea. Solium &
Cysticercosi
T. Saginata

Echinococcosis
Diphylobothriasis

Intestinal nematodes
Adult worms in the
the intestine
Larvae pass
through lungs
trichiuris
enterobius

Larvae enter
bloodstream

Eggs
ascaris

Eggs ingested

Larvae penetrate
through intact skin

strongyloides
hookworm

Larvae hatch
from eggs

Intestinal Nematode
Ascariasis
Ascaris. lumbricoides

The largest intestinal nematodes

Fecally contaminated soil

Swallowed eggs hatch in intestine to lungs break into alveoli
ascending bronchial tree swallow SI mature Produce up to
240,000 eggs/d
CF: asymptomatic
Tx:
Lungs: cough, substernal discomfort, A single dose of
dyspnoea, bld-tinged sputum,
Albendazole 400 mg
Eosinophilia
Mebendazole 500 mg
Eosinophilic pneumonitis (Lfflers Ivermectin 150-200 g/kg
Syn)
Pyrantel pamoate 11mg/kg up to 1
Heavy infections: pain, small bowel gm
obst, perforation, volvulus, biliary
obstruction, colic, and pancreatitis.

A pair of female and male worms of A. lumbricoides.

Notice the vulvar waist(arrow)of the female worm and the
coiled end of the male worm.

Life cycle
Adult worms (intestine)
Throat, swallow,
small intestine

Unembryonated
eggs (stool)

Right heart, lung,

respiratory
passage,

Embryonated eggs
in 2-3 weeks in soil
(infective form)

Penetrate
intestine, reach
liver

Rhabditiform
larva hatches

Ingestion of
eggs

Ancylostoma duodenale

Egg

Rhabditiform
larva

Adult
parasite lab
by l.wafa menawi

2. Eggs: 6040 m in size, oval in

shape, shell is thin and colorless.
Content is 2-8cells.

parasite lab
by l.wafa menawi

Ancylostoma duodenale & Necator

americanus -- human hookworms
Small nematodes (1-1.5
cm)
Head is slightly bend
(hook) and the mouth
carries characteristic teeth
(Ancylostoma) or plates
(Necator, note that these
are not real teeth but
cuticular formations of the
buccal capsule)
The posterior end of the
male worm is elaborated
into a copulatory bursa
parasite lab
by l.wafa menawi

 Scanning electron micrograph of the mouth capsule of

Ancylostoma duodenale, note the presence of four "teeth," two
on each side.
parasite lab
by l.wafa menawi

 Scanning electron micrograph of the mouth capsule of Necator

americanus, another species of human hookworm. Note the
presence of two cutting "teeth.

parasite lab
by l.wafa menawi

Life cycle of hookworm

parasite lab
by l.wafa menawi

parasite lab
by l.wafa menawi

Pathogenesis and Clinical

Manifestations

1. Larval migration
(1) Dermatitis, known as "ground
itch" or "stool poison".The larvae
penetrating the skin cause allergic
reaction, petechiae 0r papule with
itching and burning sensation.
Scratching leads to secondary infection.

(2) pneumonitis (allergic reaction),

Loeffier's syndrome: cough,
asthma, low fever, blood-tinged
sputum or hemoptysis, chest-pain,
inflammation shadows in lungs
under X-ray. These manifestations
go on about 2 weeks.

Hookworm
Ancylostoma duodenale
Necator americanus

Infectious larvae penetrate the skin

Lungs via the blood stream invade alveoli swallow SI mature into
adult attach to the mucosa, suck blood and intestinal fluid
CF: most asymptomatic
Chronic: Iron defi A+ ,
hypoproteinemia, weakness, shortness
of breath,
Dx: stool examination

Tx:
Albedazole 400mg once
Mebendazole 500mg once
Pyrantel pamoate 11mg/kg od for 3 d
Nutritional support
Iron replacement

 Then, as adults, they attach by mouth to

small intestinal mucosa and suck blood.
(Necator 0.03 ml/day, Ancylostoma 0.15
ml/day).

Strongyloidiasis
Strongyloides stercoralis

Unlike others , can replicate in the

human host

Autoinfection most common among

immunocompromised hosts

Life cycle

CF: mild cutaneous and/or abd

manifestation such as urticaria, pruritus,
erythematous eruption along the course
of larva migration, abd pain, nausea, D+,
wt loss, colitis, enteritis, malabsorption.

Disseminated disease:
*CNS, peritoneum, liver, kidney.
*Bacteremia can develop when enteric
flora enter the bldstream. G-ve sepsis,
*pneumonia, or meningitis can
complicate the disease.

Dx: Eosiniphilia, rhabditiform larvae in

stool
ELISA

Tx:
Ivermectin (200g/kg daily for 2 D) is
more effective than
Albendazole (400 mg daily for 3 D)
Disseminated case: Ivermectin 5-7 D

Enterobiasis
Enterobius vermicularis (pinworm)
Adult worms migrate nocturnally out
Autoinfection results from perianal
into the perianal region releasing
scratching mouth.
immature eggs infective within hours. Person to person spread occurs.
CF: pruritus ani
Tx:
One dose of
Mebendazole 100 mg or
Albendazole 400 mg or,
Pyrantel pamoate 11mg/kg, max 1 gm
* Same Tx repeated after 2 wks.
Household members should also be
treated.

Dx: cellulose acetate tape

Eggs are flattened on one side.

Key to the diagnosis of Intestinal

Nematodes
Intestinal
Intestinal
Nematodes
Nematodes

Larvae in
in Stool
Stool
Larvae
S. stercoralis
stercoralis
S.

Eggs in
in stool
stool
Eggs

Colored
Colored
(BileStained)
Stained)
(Bile
A.lumbricoides
lumbricoides
A.
T.trichiura
trichiura
T.

Colorless
Colorless
(NonBile
Bile Stained)
Stained)
(Non
A. duodenale
duodenale
A.
N.americanus
americanus
N.
E.vermicularis
vermicularis
E.

Eggs on
on
Eggs
Perianal Skin
Skin
Perianal

Colorless
Colorless
(NonBile
BileStained)
Stained)
(Non
E.vermicularis
vermicularis
E.

Trichenellosis
Trichenella. spiralis & 7 other

Ingest meat (usly. pork)

contains cysts with T.
larvae.

During 1st wk larvae

invade small bowel
mucosa 2nd & 3rd wks
mature into adults
which release new larva
migrate to striated
muscle via circulation
and encyst.

Trichenellosis
Week 1

Diarrhea, abd pain, constipation, N+, V+

Week 2

H/S reaction with fever, hypereosinophilia, periorbital and

facial edema, Hge in conjunctiva, retina, and nail beds,
mp rashes, headache, cough, dyspnea, dysphagia.
Death are usly due to myocarditis with arrhythmais or
CCF

Week 2-3 Myositis, myalgias, muscle edema, weakness(esply:

extraocular muscle biceps, diaphragm). Symptoms peak at
3 weeks.

splinter hemorrhage

Eosinophilia in > 90%

Drugs are ineffective against

muscle larvae

Ig E and muscle enzymes level

Mebendazole
200-400 mg tid 3 days, then
400 mg tid 8-14 days, then
Albendazole
400 mg bid 8-14 days
May be active against enteric
parasites.

specific Ab titres by 3 weeks

Definite Dx is by detection of larva

ob biopsy
Highest at near insertions of tendon

Glucocorticoids (1mg/kg daily for 5

days) may reduce severe myositis
and myocarditis.

Prevention: cooking pork until it is no longer pink or freezing it at 15 C for

3 weeks kills larvae and prevents infection.

Filarial infections
Nematodes
Dwell in SC tissue and lymphatics

> 170 million people are infected

Disease tends to be more intense and

acute in newly exposed persons than in
natives of endemic areas.

Adult worm live for years

Microfilariae live for 3-36 months

Wuchereria bancrofti (nocturnally

periodic)
Brugia malayi
B. Timori

Adult worms cause inflammatory

damage to the lymphatics

Agent Factors

S.no

1.
2.
3.

Parasite
W.bancrofti
B.malayi
B.timori

Mosquito

Disease

Culex

LF

Mansonia

LF

Anopheles/
Mansonia

LF

Host Factors
Man Natural Host
Age All age (6 months) Max: 20-30 years
Sex Higher in men
Migration leading to extension of
infection to non-endemic areas
Immunity may develop after long year of
exposure

Social & Environmental Factors

Associated with Urbanization, Poverty,
Industrialization, Illiteracy and Poor
sanitation.
Climate: is an important factor which
influences:
1. The breeding of mosquito
2. Longevity (Optimum temperature 20-300C
& Humidity 70%)
3. The development of parasite in the vector
4. Sanitation, Town planning, Sewage &
Drainage.

Filarial and related infections

Nematodes
CF:
Asymptomatic microfilaremia
Hydrocele
ADL acute adenolymphangitis (fever,
lymphatic inflammation, transient
local edema).

Dx: Microfilariae can be found in

blood, hydrocele fluid,

W. B particularly affects genital

lymphatics.

Tx:
DEC diethycarbamazine 6mg/kg daily
for 12 D

ADL may progress to lymphatic

obstruction and elephantiasis with
brawny edema.

PCR (w.B and B.m)

Eosinophilia and Ig E

Albendazole 400 mg bid for 21 D (less

effective)

http://www.ncbi.nlm.nih.gov/pubmed/7973937

Vector Control
Vector control involves anti larval measures, anti
adult
measures, personal prophylaxis. An
integrated method using all the vector control
measures alone will bring about sustained vector
control.
I. Anti larval measures:
1. Chemical control
a. Mosquito larvicidal oil
b. Pyrosene oil
c. Organo phosphorous compounds such as
Temephos, Fenthion,
2. Removal of pistia plants
3. Minor environmental measures

Vector Control
II. Anti adult measures:
Anti adult measures as indoor residual spay
using DDT, HCH and Dieldrin. Pyrethrum as
a space spray is also followed.
III. Personal Prophylaxis:
Reduction of man mosquito contact by using
mosquito nets, screening of houses, etc.

 brugian filariasis vectors, mainly Mansonia

bonneae and Mansonia dives
pirimiphos-methyl residual spraying
Mansonia species breed in swampy areas,
water hyacinth

 mass drug administration (MDA)

usually bite indoors at night and rest on walls
while they digest host-blood and develop
their eggs.
impact on night-biting and indoor resting
populations of C. quninquefasciatus, Aedes
and Mansonia mosquitoes.

 expanded polystyrene beads into septic tanks and

pit latrines can produce a drastic reduction in
Culex mosquito populations.
This mechanically prevents gravid mosquitoes
from laying eggs, or larvae and pupae from
breathing.
Long lasting insecticide impregnated nets
(LLINs):

 Environmental sanitation involving cleaning up of

drains
Larval control using bio- larvicides such as Bacillus
sphaericus can effectively be used to significantly
reduce populations of C. quinquefasciatus in urban
and peri-urban areas.
Removal of certain aquatic vegetation from
potential breeding sites of Mansonia species is also
a feasible option of reducing the vector in clearly
defined settings.

Pistia plants

Cestodes Tapeworms
Taenia saginata
Humans are definitive
Dx:
host
Stool examination (eggs,
proglottids)
Eosinophilia, Ig E
Inhabits Upper jejunum
Perianal discomfort, mild
abd pain, change in
appetite, weakness, wt
loss

Tx:
Praziquantel a single dose
of 10mg/kg

T. solium and cysticercosis

pork tapeworm
Humans are definitive
host
Intestinal: epigastric
discomfort, nausea, sensation
of hunger, wt loss, diarrhea or
asymptomatic

Cysticercosis:
Cysticerci can be found
anywhere in the body, most
often in brain, sketal muscle,
SC tissue or eye.
Seizures due to
inflammation surrounding
cysticerci in brain,
hydrcephalus, headache, N+,
V+, dizziness, ataxia,
confusion

 Two different forms in humans:

- Human taeniases
- Human cysticercosis

Human infection - taeniasis

The scolex attaches to the mucosa and begins
forming segments (proglotids)
After two months of infection, gravid proglotids
begin to detach from the distal end - excreted in the
feces
Each segment contains 60,000 eggs
Worm causes only minor inflammation to the
intestine (mild symptoms - abdominal pain,
distension, diarrhea and nausea - or none at all)

Human infection - cysticercosis

Faecal-oral contamination with T. solium eggs from
tapeworm carriers
The invasive oncosphere (embryos) in the eggs are
liberated by the action of gastric acid and cross the
bowel wall
They establish at small terminal vessels (muscles,
brain, eye) where they grow to about the size of 1
cm in 2-3 months

Human cysticercosis
Muscle - small, palpable, movable nodules - chests
and arms - mild or no symptoms
Ophthalmic cysticercosis - intraocular cysts floating
freely in the vitreous humor - decreased visual
acuity
Neurocysticercosis - most symptoms are because of
the inflammatory reaction associated with cyst
degeneration (that may take years to happen) epilepsy, hydrocephalus, encephalitis, meningitis

Diagnosis - taeniasis
Visualization of Taenia eggs are the only
diagnosis until recently - has poor sensitivity
and difficult to differentiate from taenia
saginata.
Best diagnosis - coproantigen detection ELISA
(detect taenia specific molecules in the feces 95% sensitivity and 99% specificity)

Diagnosis - cysticercosis
Depends on the targeted organ:
CNS - CSF immunology, neuroimaging (the
scolex can be seen)
Muscle - imaging, bx
Eye - imaging (ultrasound)
(serological exam - ELISA)

Treatment - taeniasis
Taeniasis - relatively easy for intestinal
disease - PO drugs - niclosamide and
praziquantel.
niclosamide is the choice as it is not
absorbed; however, it is an expensive drug

Treatment - cysticercosis
Neurocysticercosis is the main problem
The problem of the cyst is the inflammatory
reaction
Use of parasiticide (praziquantel or albendazole) debatable - aim is to reduce inflammation and scar
tissue
palliative treatment to control inflammation corticosteroids, antihistamines

Diagnostic Criteria for Human

Cysticercosis
1. Absolute criteria
a.
b.
c.

Demonstration of cysticerci by histologic or microscopic

examination of biopsy material
Visualization of parasite in the eye by fundoscopy
Neuroradiologic demonstration of cystic lesions containing
a characteristic scolex

2. Major criteria
a.
b.
c.

Neuroradiologic lesions suggestive of neurocysticercosis

Demonstration of Ab to cysticerci by ELISA
Resolution of IC cystic lesions spontaneously or after Tx
with albendazole or praziquantel

Diagnostic Criteria (Cont.)

3. Minor criteria
a.
b.
c.
d.

Lesions compatible with neurocysticercosis detected by

neuroimaging studies
Clinical manifestation suggestive of neurocysticercosis
Demonstration of Ab to cysticerci or Ag in CSF by ELISA
Evidence of cysticercosis outside the CNS (eg. Cigarshaped soft tissue calcification)

4. Epidemiologic criteria
a.
b.
c.

Residence in endemic area

Frequent travel to a endemic area
Household contact with an individual infected with T.
solium

Dx is comfirmed by
One absolute criteria or
2 major + 1 minor + 1 Epi
A probable Dx
1 major + 2 minor
1 major + 1 minor + 1 Epi
3 minor + 1 Epi