Human intestinal worms.

By Okot Joseph
 Nematodes:
 Also sometimes referred to as soil-transmitted helminths, or
geohelminths live in the human gut.
 There are two main types of life cycle, both including a soil-
based stage.
 In some cases, infection is spread by ingestion of eggs (which
often require a period of maturation in the environment),
while in others, the eggs hatch in the soil and larvae penetrate
directly through the skin of a new host.
 Commonn nematodes includes:
1. Ascaris lumbricoides
2. Strongyloides
3. Threadworm (Enterobius vermicularis
4. Whipworm (Trichuris trichiura)
5. Hookworm infection
 Ascariasis (roundworm infection)
• Ascaris lumbricoides is a pale yellow worm, 20–35 cm
in length (Fig. 4.35).
• It is found worldwide but is particularly common in
poor rural communities, where there is heavy faecal
contamination of the immediate environment.
• Larvae migrate through the tissues to the lungs before
being expectorated and swallowed.
• Adult worms are found in the small intestine.
• Ova are deposited in faeces and require a 2–4- month
maturation in the soil before they are infective.
Ascarias worm.
 Life cycle of [Link]
1. Adult males and females live in ileum.
2. Female releases 200,000 eggs/day which are
passed in the feces.
3. Eggs embryonate in warm, moist shady soil &
rhabditiform larve stages are passed within the
egg.
[Link] egg is the infective stage & is
ingested by a human.
5. L2 hatches from egg in the duodenum,
penetrates the duodenum, enters the circulation,
travels through the heart, and reaches the lungs via
the pulmonary circulation.
6. In the lungs, the L2 molts twice to the L4 stage.
7. L4 break into the alveoli, move up the
respiratory tree to the pharynx, & swallowed.
8. L4 move into the ileum where they molt to the
adult stage. Become mature in 2 mo.
. Migratory phase (time from ingestion of the L2 in
egg until L4 reach ileum) is about 25d
 Pathology
Migration stage
-hemorrgage & pneumonitis

-allergy (asthma+oedema)
-Eosionophilia,clinical
manifestation is called Loeffler’s
syndrome.
-Fever,cough,if goes to heart-
emboli
Intestinal stage
-Obstruction
-Peritonitis after perforation
-Occlude bile duct/pancreatic duct
-Vomited or cough thru
nose,mouth
-toxemia from Ascaris waste
products
 Clinical features:
• Infection is usually asymptomatic, although heavy infections are
associated with nausea, vomiting, abdominal discomfort and
anorexia.
• Worms can sometimes obstruct the small intestine, the most
common site being at the ileocaecal valve.
• They may also occasionally invade the appendix, causing acute
appendicitis,
• Or they may invade the bile duct, resulting in biliary obstruction
and suppurative cholangitis.
• Larvae in the lung may produce pulmonary eosinophilia.
• Heavy infection in children, especially those who are already
malnourished, may have significant effects on nutrition and
development.
 Diagnosis
• ID eggs in [Link] have thick, rough outer shell
• Larvae may also be found in sputum esp. Heart-lung
migration.
• They may also be seen on barium enema studies.
 Treatment:
• Very rarely, surgical or endoscopic intervention
may be required for intestinal or biliary
obstruction.
• Common drugs used include:
Mebendazole 500mg, Albendazole 400mg,
Piperazine 75mg/kg.
• Sanitary disposal of feces.
• Hygienic habits such as cleaning of hands before
meals.
• Health education.
Threadworm (Enterobius
vermicularis)
 Introduction
• Enterobius vermicularis or pin worm as it is commonly referred to
lives in the large intestines (caecum, appendix and colon) of man.
• The word vermicularis means “small worm” becoz of it’s diminutive
size.
• Males die off after mating.
• The gravid female moves down the colon to rectum out through the
anus esp. at night when person is asleep to lay its sticky
embryonated
• Eggs are laid (OVOVIPAROUS) on the perineum & peri-anal areas
causing intense perianal pruritis esp. in children.
• Worm re-enters the anus or wanders about into vulva, vagina,& even
uterus & fallopian tubes.
• A single worm can lay up to 17,000 eggs,infective larvae form in 6h
after eggs are deposited on the anal skin & remain viable for 2wk.
Pinworm usually infects a gp of people or whole family, esp.
children
 Life cycle of [Link]

1. Adults copulate in the human

digestive tract. Male dies after
copulation.
2. Female migrates at night to the
perianal folds of the anus &
deposits egg in the skin of the
perianal area. Female dies after all
eggs have been laid.
[Link] contain L1 larvae when laid,
but within 6 hours larvae molt
twice in the egg to infective stage.
4. Eggs are infective & when
ingested by a human, the L3 hatch
in the small intestine.
5. L3 molt twice to the adult stage
as the worms move into ileum &
large intestine.
 Methods of infection

•Auto infection( hand to mouth)

•Handling contaminated clothing
or beddings
•Inhalation of airborne eggs in dust
( viable & infective 2-3 wks in dust)
•Retroinfection;eggs hatch in
perianal area & larvae migrate
back thru anus.
 Clinical features.
• Pruritus ani if severe causes fatigue &
insomnia.
• Migration to vagina,uterus,tubes & urinary
bladder may cause irritation & inflammation.
 Diagnosis
1. Direct microscopy to
demonstrate eggs in
faeces.
A count of <10 is mild
infection; >50 is heavy.
Double-stick tape is used on a
tongue depresser. This is
pressed against the perianal
folds where eggs will stick to
the tape.
Tape is then stuck onto a
microscope slide and
examined for eggs.
2. Proctoscopy.
 Prevention
Treatment • Good personal hygiene
i. Mebendazole • proper disposal of stool
500mg, • drinking boiled water
ii. Albendazole • washing fruits & vegetables
400mg, thoroughly before eating.
Pyrantel
• Public health education of
iii. pamoete
community to create
(combatrin),
awareness.
iv. pyrvinium, &
• Treatment of infected
v. Piperazine
citrate . persons.
 Whipworm (Trichuris trichiura)
• Infections with whipworm are common worldwide, especially in
poor communities with inadequate sanitation.
• Adult worms, which are 3–5 cm long, inhabit the terminal ileum and
caecum, although in heavy infection they are found throughout the
large bowel.
• The head of the worm is embedded in the intestinal mucosa.
• Ova are deposited in the faeces and require a maturation period of
3–4 weeks in the soil before becoming infective.
• Infection is usually asymptomatic, but mucosal damage can
occasionally be so severe that there is colonic ulceration, dysentery
or rectal prolapse.
• Diagnosis is made by finding ova on stool microscopy, or
occasionally by seeing adult worms on sigmoidoscopy.
 Trichuris trichuria
• Trichuris means (Greek trichos – hair; oura – tail).
• The worm looks like a whip – its anterior end, long
& thin & posterior end is short & thick.
• The worm is whitish.
• Females (40 – 50mm long)
• Males(30mm x 45mm long).
• Eggs (80µm x 40µm) & are unsegmented & have
mucoid plug.
Morphology of [Link]
 Life cycle of [Link]

1. Adults live in the human

colon(caecun)
2. Female releases 1000 to
7000 unembryonated double-
plugged eggs each day.
3. Eggs are deposited onto
warm, moist shady soil where
they embryonate to the L1
stage.
4. Embryonated egg is the
infective stage & is ingested.
5. L1 hatch from the egg in the
small intestine & burrow into
the mucosa.
6. Adults migrate to the
ileocecal & colon regions.
 Pathology
1. Stichosome is inserted into the
wall of the intestine
penetrating through the
mucosa & into the submucosa
where blood is ingested.
2. Fewer than 100 worms cause
pathology associated with no
symptom to minor intestinal
pain.
3. Heavy infections cause serious
problems like hemorrhage as
worms penetrate into the
submucosal region & feed on
blood.
4. Worms cause loss of muscle
tone in wall of rectum & it
everts out the anus;
whipworms are often seen
attached to the rectal tissue.
Fatalities common in children
Diagnsosis, Treatment & Prevention.
• Direct microscopy- demonstrate eggs in faeces. Count<10 -mild
infection; >50heavy.
• Proctoscopy.

Treatment – mebendazole, albendazole.

Prevention
i. Good personal hygiene,
ii. proper disposal of stool,
iii. drinking boiled water,
iv. washing fruits & vegetables thoroughly before eating.
v. Public health education of community to create awareness.
vi. Treatment of infected persons.
 Hook worms
 Hookworms are blood sucking nematodes.
 Two important types,
1. Ancylostoma duodenale &
2. Necator americanus;
 “ankylos” is Greek word for hooked; “stoma” = mouth,
“necator” = murderer.
 Ancylostoma duodenale affects a large ppln about 90% of
the ppln in tropics are affected.
 Hookworms are worldwide distribution but mostly in the
tropics & subtropical regions.
 Found in temperate zones, esp. in summer.
 Live in the ileum of man & animals, esp. the jejunum.
Hookworm Distribution
 General Morphology
Females:
9-13 mm long with egg-
filled uterus

Male hookworms:
7-11 mm long
Posterior end forms a
bursa
 Pathogenesis
• Adult worms (which are about 1 cm long) live in the
duodenum and upper jejunum, where they are often found in
large numbers.
• They attach firmly to the mucosa using the buccal plate,
feeding on blood.
• Eggs passed in the faeces develop in warm moist soil,
producing infective filariform larvae.
• These penetrate directly through the skin of a new host and
are carried in the bloodstream to the lungs.
• Having crossed into the alveoli, the parasites are
expectorated and then swallowed, thus arriving at their
definitive home.
Life cycle of 2 Hookworms is similar
Adults occur in the human ileum
1. Male & female are commonly
found in copula. Both are well
attached to the intestinal
mucosa with the buccal
capsule.
2. Female releases eggs which are
passed in the feces.
Both species show high fecundity:
A. duodenale produces 25,000 to
30,000 eggs/day. N. americanus
produces 9,000 eggs/day.
[Link] embryonate in warm,
moist shady soil.
4. In 1-2 days, the L1 (rhabditiform
larva) hatches & feeds on bacteria
& debris in the faeces & soil.
 Life cycle of Hookworm
cont.
5. L1 molts twice to the L3stage
( filariform larva) in a week.
6. L3 are infective migrates to the
surface of the soil & upon
contact with human skin will
penetrate
7. After penetrating the skin, the
L3 enter the circulation, are
carried to the heart, & follow
the pulmonary circulation to
the lungs. Here, they break out
of the lung capillaries, enter
the alveoli, migrate up the
respiratory tree, & are
swallowed.
8. Arriving in ileum,L3 molts
twice to the adult stage. Takes
5 wks from the time of skin
penetration until the adults are
mature.
 Clinical features
 Local irritation as the larvae penetrate the skin (‘ground itch’).
 may be followed by transient pulmonary signs and symptoms.
 often accompanied by eosinophilia.
 Light infections, especially in a well-nourished person, are
often asymptomatic.
 Heavier worm loads may be associated with epigastric pain
and nausea, resembling peptic ulcer disease.
 Chronic heavy infection, particularly on a background of
malnourishment, may cause iron deficiency anaemia and
hypoproteinaemia.
 Heavy infection in children is associated with delays in
physical and mental development.
 Diagnosis and treatment
• The diagnosis is made by finding eggs on faecal
microscopy.
• In infections heavy enough to cause anaemia these
will be present in large numbers.
• The aim of treatment in endemic areas is reduction
of worm burden rather than complete eradication:
albendazole given as a single dose is the best drug.
NB: The WHO is promoting mass treatment
programmes for school-children in many parts of the
world, together with treatment for schistosomiasis
where appropriate.
Strongyloidiasis
 Introduction.
• Strongylus – round
• Stercoralis – faecal
• Strongyloides inhabits the upper small intestine of
man.
• Only female worms are parasitic, males are never.
• The most important species is Strongyloides stercoralis.
• Strongyloides is found in warm tropical countries.
• Adult worm 2.5mm long.
• It lives in intestines as well as freely in soil.
• Infection in man is by skin penetration.
 Pathogenesis:
• Eggs hatch in the bowel and larvae are found in the
stool.
• Usually these are non-infective rhabditiform larvae,
which require a further period of maturation in the
soil to filariform larvae (L3) before they can infect a
new host.
• Sometimes this maturation can occur in the large
bowel into filariform (L3).
• Infective filariform larvae (L3) can therefore
penetrate directly through the perianal skin,
reinfecting the host.
 Pathogenesis ctn.
• In this way, autoinfection may continue for
years or even decades. (i.e Some war veterans
who were imprisoned in the Far East during
the Second World War have been found to
have active strongyloidiasis over 50 years
later).
• After skin penetration the life cycle is similar
to that of the hookworm, except that the
adult worms may burrow into the intestinal
mucosa, causing a local inflammatory
response.
 Life cycle of S. stercoralis
• This worm has four development cycles;
-indirect life cycle,
- direct life cycle,
- auto infection
• - internal re-infection [Link] ISS pt.(larvae
mature in gut mucosa, penetrate deep tissues,
mesenteric venules, into the vena cava, lungs
coughed up into the pharynx, then swallowed. In the
duodenum & jejunum more adult worms form
leading to extensive infections).
Life cycle of S. stercoralis
 Clinical features:
• S. stercoralis, following skin penetration, causes a
similar local dermatitis to hookworm.
• In autoinfection this manifests as a migratory
linear weal around the buttocks and lower
abdomen (cutaneous larva currens).
• In heavy infections damage to the small
intestinal mucosa can cause malabsorption,
diarrhoea and even perforation.
• There is usually a persistent eosinophilia.
 c. features.
• In patients who are immunosuppressed (e.g. by
corticosteroid therapy or intercurrent illness)
filariform larvae may penetrate directly through
the bowel wall in huge numbers, causing an
overwhelming and usually fatal generalized
infection (the strongyloidiasis hyperinfestation
syndrome).
• This condition is often complicated by a Gram-
negative septicaemiadue to bowel organisms.
 Diagnosis
 Motile larvae may be seen on stool microscopy, especially after a
period of incubation.
 Serological tests are also useful eg. ELISA.

 Strongyloides larvae may be present in the stool in very small

numbers & culture methods may be needed to encourage the
rhabditiform larvae to develop into filariform larvae & migrate from
the sample.

.
 Treatment + Prevention
• Thiabedazole
• Mebendazole
• Ivermectin

• Avoid contaminating soil with infected feces.

• Use toilets or latrines.
• Wear protective shoes or hand gloves in case of
field workers so as not to get in contact with soil.
• Public awareness.
 Drugs used for treating human intestinal nematodes
(single dose unless otherwise stated)
Ascaris Hookworm Enterobius Trichuris Strongyloid
es

Piperazine 75 mg/kg ++ + ++ _ _
Pyrantel pamoate 10 ++ + ++ _ _
mg/kg
Oxantel pamoate 10 ++ + n/a ++ _
mg/kg
Albendazole 400 mg ++ ++ ++ + +
Mebendazole 500 mg ++ ++ ++ + +
Tiabendazole 25 mg/kg n/a n/a n/a n/a ++

Ivermectin 200 μg/kg ++ n/a n/a n/a ++

++, Highly effective; +, moderately effective; −, ineffective; n/a, drug not used for this
indication/no data available.
 Cestodes:
• Cestodes (tapeworms) are ribbon-shaped worms,
which vary from a few millimetres to several
metres in length.
• Adult worms live in the human intestine, where
they attach to the epithelium using suckers on the
anterior portion (scolex).
• From the scolex arises a series of progressively
developing segments, called proglottids.
• The mature distal segments contain eggs, which
may either be released directly into the faeces, or
are carried out with an intact detached proglottid.
 Cestodes
• The eggs are consumed by intermediate hosts, after
which they hatch into larvae (oncospheres).
• These penetrate the intestinal wall of the host (pig or
cattle) and encyst in the tissues.
• Man ingests the cysts in undercooked meat and the
cycle is completed when the parasites excyst in the
stomach and develop into adult worms in the small
intestine.
• Infections are usually solitary, but several adult
tapeworms may co-exist.
 Taenia saginata
• T. saginata, the beef tapeworm, may reach a length of several
metres.
• It is common in all countries where undercooked beef is
eaten.
• The adult worm causes few if any symptoms.
• Infection is usually discovered when proglottids are found in
faeces or on underclothing, often causing considerable
anxiety.
• Ova may also be seen on stool microscopy. Infection can be
cleared with a single dose of praziquantel (10 mg/kg).
• It can be prevented by careful meat inspection, or by
thorough cooking of beef.
 Taenia solium and cysticercosis
• T. solium, the pork tapeworm, is generally smaller
than T. saginata, although it can still reach 6
metres in length.
• It is particularly common in South America, South
Africa, China and parts of South-east Asia.
• As with T. saginata, infection is usually
asymptomatic.
• Pork tapeworm infection is acquired by eating
uncooked pork.
 Treatment
• Treatment is with praziquantel or niclosamide

NB: The ova of the two species are identical, but

the proglottids can be distinguished on
inspection.
• Cysticercosis is caused by ingestion of cysts rather than
• the adult worm and follows the ingestion of eggs from
contaminated food and water.
• Faeco-oral autoinfection can occur but is rare.
• Patients with tapeworms do not usually develop
cysticercosis and patients with cysticercosis do not
usually harbour tapeworms.
• Following the ingestion of eggs, the larvae are
liberated, penetrate the intestinal wall and are carried
to various parts of the body where they develop into
cysticerci.
 Treatment and prevention.
• These are cysts, 0.5–1 cm in diameter, containing the scolex of
a new adult worm.
• Common sites for cysticerci include subcutaneous tissue,
skeletal muscle and brain.
Treatment :
 Albendazole 15 mg/kg daily for 8–20 days is the drug of
choice;
 The alternative is praziquantel 50 mg/kg daily (in divided
doses) for 15 days.
 Successful treatment is accompanied by increased local
inflammation and corticosteroids should be given during and
after the course of anthelminthic.
 Prevention of cysticercosis depends on good hygiene, as well
as on the eradication of human T. solium infection
 Drancuculus Medinensis
• Causative agent of dracunculiasis.
• DISTRIBUTION - it is estimated that some 10 million people are
infected.
• Draco” is Greek for dragon or serpent, thus fiery serpent.
• Occurs in tropical Africa, Asia & Middle East.
 Morphology

• Adults occur in
subcutaneous
connective tissues of
man who is a final
host.
•Adult females are
largest nematodes of
humans – 4 feet long.
• Male is smaller-4cm.
• HOSTS - humans &
many other mammals
(dogs, cats, cattle,
horses, monkeys)
 Life cycle of D. Medinensis
1. Female migrates to surface of
the skin & produces a blister thru
which the ant. of worm
protrudes.
2. Uterus of female worm
ruptures when worm is
immersed in water. Thousands of
larvae (eggs hatch inside female).
3. L1 must be ingested by cyclops-
intermediate host. Larvae molt
to infective L3 stage within
coyclops.
4. Humans (& other mammals)
become infected by ingestion of
infected cyclops.
5. L3 penetrate ileum & migrate to
subcutaneous tissues ,molt twice
to become adults; female
matures in a yr.
 Pathology

Symptoms of dracunculiasis occur as worms migrate under the skin. The

affected parts are legs, shoulders, arms, breasts, buttocks, & genitalia
1. Female releases metabolic wastes that cause toxemia that causes
rash, nausea, diarrhea, & dizziness.
2. Blister formation results in a large inflamed sore which ruptures
when comes into contact with water. Secondary bacterial infections
can occur thru ruptured blister (Tetanus, cellulitis...)
3. Some worms may migrate into deeper tissues such as the joints
(causing arthritis )where they calcify.
 Diagnosis,Treatment & Prevention
• Appearance of red blister followed by emergence of the
female worm.
• Metronidazole, thiabendazole, & niridazole coupled with
steroids & antihistamines can be used.
• Manual worm removal (but the worm should not break)
• Today, surgery is commonly used.
• Control- Filter & boil drinking water.
-Treat water sources with chemicals to kill the
copepod cyclops. i.e. improved water supply.
- Infected persons should not bathe or swim in
drinking water sources as this attracts the female worm to
the surface to lay her eggs.