Nematode

Introduction to
Medical Helminthology
Medical helminthology : the study of parasitic worms
(helminthes) affecting man, which :
⚫ Spend part or the entire life cycle in a
human host
⚫ Animal parasite causing disease in human
Introduction
general characteristic
⚫ Among the commonest of all parasites and
responsible for diseases of major importance in
humans
⚫ Non-segmented roundworms belonging to the
Phylum Nemathelminthes, Class Nematoda
⚫ The sexes are usually separate (Dioecious), the
male which is smaller than the female commonly
has a curved posterior end
⚫ Cylindrical and slender
⚫ Bilaterally symmetrical
⚫ Sex-differentiated
⚫ Celomic cavity: protocoele
⚫ The supporting body wall consists of cuticle layer,
syncytial layer (subcutical layer) and longitudinal
muscular layer
⚫ The alimentary tract is a simple tube extending from
the mouth to the anus
Common medical nematodes species

⚫ Intestinal lumen residing nematodes:

⚫ Ascaris, Hookworm, Whip worm, Pinworm----the adult
parasite inhabit in human intestinal tract
⚫ Blood and tissue residing nematodes:
⚫ Filaria, Thichinella----the location of the adult parasite
is blood or tissue
 Nematodes Life cycle
❑ Transmission to a new host :
✔ Ingestion the mature infectious egg or larva
✔ Penetration of the skin or mucous membranes by the
larva
❑ Some species have an intermediate host – usually an
arthropod
❑ The same animal both the definitive and intermediate
host of Trichinella spiralis
❑ Nematodes, do not multiply in man
 Nematodes Pathogenicity
❑ The effect of parasitic nematodes upon the host depends
upon : species, the intensity of the infection and the
location of the parasite
❑ Simultaneous infection with several species of intestinal
nematodes is common in tropical and subtropical countries
❑ Injury may be produced by adult and larval parasites
❑ Intestinal parasites produce less local and systemic effect
than tissue parasites
 Nematodes Pathogenicity
❑ The local reaction from intestinal parasites result from
irritation, invasion of the intestinal wall and occasionally
penertation to extraneous site
❑ The local reaction in the liver, lungs (and other) – may destroy
or encapsulate the larvae
❑ The degree of local reaction – depend upon the sensitivity of the
host to the protein product of the parasite
❑ Intestinal mucosa is damaged by biting and bloodsucking, by
lytic ferment secreted by the parasite and by mechanical
irritation
 Pathogenicity
❑ The general reaction are produced by loss of blood,
absorption of toxin, nervous reflexes and proteic
sensitization
❑ The larvae of certain species, produce local and general
reaction
❑ In unatural host the larvae may be pass through their
invasive stages, never become established as adult
parasite – paratenic host
❑ Immunity is acquired through the invasion of the tissues
by the parasite and its larvae or through the absorption of
its products
❑ Immunity is both humoral and cellular
 NEMATODES
❑ Soil Transmitted Helminthes
✔ Ascaris lumbricoides
✔ Trichuris trichiura
✔ Hookworm (Necator americanus,
Ancylostoma duodenale) Important
✔ Strongyloides stercoralis

❑ Non-Soil Transmitted Helminthes

✔ Enterobius vermicularis
✔ Trichinella spiralis

❑ Filaria and Dracunculus

✔ Wuchereria bancrofti Important
✔ Brugia malayi
✔ Brugia timori
Disease caused by Soil transmitted helminthes
: DEFINITION Soil transmittedhelminth

NEMATODE WORMS WHICH REQUIRE

PERIOD OF DEVELOPMENT AND
MATURATION DURING ITS LIFE
CYCLE ON SOIL

IMMATURE INTO
INFECTIVE
Life Cycle
.Adults inhabit in the cecum .1
Female lay eggs in the perianal
.region of the host
No intermediate host, the egg .2
takes around 6 hours to be
matured and becomes the
.infective stage
Mode of infection may be .3
auto-infection or
.cross-infection
 Pathogenesis
The migratory phase of the pinworm is restricted to the gastrointestinal.1
.tract and thus the host does not experience any systemic reactions
Perianal itching may be complicated. Heavy infections in children may .2
also produce such symptoms as sleeplessness, weight loss,
.hyperactivity, grinding of teeth, abdominal pain, and vomiting
Ectopic parasitism may happen, which can cause uro-genital .3
inflammations or even the pelvic cavity
.be involved occasionally
Laboratory Diagnosis

:Anal swab method

Cotton swab
Cellophane tape
Epidemiology

Endemic in children concentrated units. There is no

differences on the basis of sex, race, or socio-economic
.class
:Infection rate
;urban > rural
children > adults
Principles of Control

Chemotherapy .1
Personal Sanitation .2
Ascaris lumbricoides
DISTRIBUTION
● Cosmopolitan
● Prevalence 70-90 %
● Primarily affects under fives
and school children

HABITAT
● Lumen of the intestine :
Jejunum
Media ileum
Source : Dept. of Parasitologi FKUP, 1999

Adult worms expelled after

deworming

Source : Color Atlas of Medicine and Parasitology. 1977

.Peters W. & Gillers H.M
The lips of A. lumbricoides

The three lips are

seen at the anterior
end. The margin of
each lip is lined with
minute teeth which are
not visible at this
magnification
 Ascaris lumbricoides and Ascaris suum
(intestinal roundworms of humans and pigs)

:Introduction
Ascaris lumbricoides is one of the largest and most common
parasites found in humans. The adult females of this species can
measure up 25 cm long (males are generally shorter), and it is
estimated that 25% of the world's population is infected with
this nematode.
Life Cycle
⚫ Site of inhabitation: small intestine
⚫ Infective stage: embryonated eggs
⚫ Route of infection: by mouth
⚫ Blood-lung migration: intestine--- blood stream --- right
side of the heart --- lung --- respiratory tree --- coughed
up and swallowed --- small intestine
Life Cycle
⚫ No intermediate and reservoir hosts
⚫ The time from the ingestion of embryonated eggs to
oviposition by the females is about 60-75 days
⚫ Life span of the adult: about 1 year
⚫ Female may produce approximately 240,000 eggs per
day, which are passed in feces
⚫ Life cycle:
⚫ - The adult worms live in the small intestine and eggs are passed in the feces. A single
female can produce up to 200,000 eggs each day
⚫ - About two weeks after passage in the feces the eggs contain an infective larval or
juvenile stage, and humans are infected when they ingest such infective eggs.
⚫ - The eggs hatch in the small intestine, the juvenile penetrates the small intestine and
enters the circulatory system, and eventually the juvenile worm enters the lungs.
⚫ - In the lungs the juvenile worm leaves the circulatory system and enters the air
passages of the lungs.
⚫ - The juvenile worm then migrates up the air passages into the pharynx where it is
swallowed, and once in the small intestine the juvenile grows into an adult worm. Why
Ascaris undergoes such a migration through the body to only end up where it
started is unknown. Such a migration is not unique to Ascaris, as its close relatives
undergo a similar migration in the bodies of their hosts
 Morphology
Egg
⚫ There are three kinds of the eggs
⚫ fertilized eggs
⚫ unfertilized eggs
⚫ decorticated eggs
⚫ We usually describe an egg in 5 aspects
⚫ size, color, shape, shell and content
 Morphology
⚫ Fertilized egg:
⚫ an average size 60×45µm
⚫ broad oval in shape
⚫ brown in color
⚫ The shell is thick
⚫ Albuminous coat is thick and stained brown by bile
⚫ The content is a fertilized ovum
⚫ There is a new-moon(crescent) shaped clear space at each
end inside the shell
 Morphology
⚫ Unfertilized egg
⚫ Longer and slender than fertilized egg
⚫ The shell and albuminous coat are thinner
than those of the fertilized egg
⚫ The content is made of many refractable
granules various in size
⚫ Decorticated egg:
⚫ Both fertilized and unfertilized eggs sometimes
may lack their outer albuminous coats and are
colorless
 Ascaris lumbricoides
PATHOGENESIS AND CLINICAL SYMPTOMS
Disease ; Ascariasis
Complaints due to direct effect
Larvaby
.(1)
● Allergic manifestation : urticaria,
swollen lips, asthma attack
● Loffler Syndromes :
Ascaris pneumonia (coughing)
Hyper-eosinophilia
Thorax X-ray : temporary white spots
● Larva migration
Pathogenesis
1. The blood-lung migration phase of the larvae: During
the migration through the lungs, the larvae may cause a
pneumonia (temporary).
⚫ The symptoms of the pneumonia are low fever, cough,
blood-tinged sputum, asthma
⚫ The clinical manifestation is also called Loeffler’s
syndrome
Pathogenesis
2. The intestinal phase of the adults
• No symptoms to vague abdominal pains or intermittent
colic, especially in children
• A heavy worm burden can result in malnutrition
• Wandering adults may block the appendical lumen or the
common bile duct and even perforate the intestinal wall
which cause complications of ascariasis:
• intestinal obstruction
• Appendicitis
• biliary ascariasis (the most common one)
• perforation of the intestine
• cholecystitis, pancreatitis and peritonitis
 Ascaris lumbricoides
PATHOGENESIS AND CLINICAL SYMPTOMS
Complaints due to direct effect
by
Adult worm .(2)

● Irritations of the mucosal folds

● Blocking of the intestine - ileus
● Erratic migration
● Competes in the absorption of food
and vitamins
● Release of toxic metabolic products
⚫ . extraintestainal ascariasis
⚫ Ascaris is infamous for its character to migrate within the small
intestine, and when a large worm begins to migrate there is not much
that can stop it. Cases have been reported in which Ascaris have
migrated into and blocked the bile or pancreatic duct or in which the
worms have penetrated the small intestine resulting in acute (and
fatal) peritonitis. Ascaris seems to be especially sensitive to
anesthetics, and numerous cases have been documented where
patients in surgical recovery rooms have had worms migrate from the
small intestine, through the stomach, and out the patient's nose or
mouth.
Ascaris lumbricoides
Diagnosis

Laboratory diagnosis
● Identify the eggs found in feces using
following methods :
✔ Direct smear method
✔ Concentration method
● Identify larva found in sputum
● Identify adult worm found expelled
from anus, mouth, nostril
● Do quantitative lab method to measure
level of infection
● Additional : chest X-ray
⚫ Treatment
⚫ Treatment includes medications that paralyze or kill
intestinal parasitic worms, such as albendazole or
mebendazole. These drugs should not be used for pregnant
patients.
⚫ Pyrantel pamoate is the preferred medication for pregnant
patients.
⚫ If there is a blockage of the intestine caused by a large
number of worms, endoscopy to remove the worms or,
rarely, surgery may be needed.
Ascaris lumbricoides
PREVENTION
● treatment of individual case
● Provision of sanitary public bath,
wash and toilet facilities
● Media information and health
education
● Routine health check up of children
⚫ Factors favoring the spread of the transmission:
⚫ Simple life cycle
⚫ Enormous egg production ( 240,000 eggs/ day/ female )
⚫ Eggs are highly resistant to ordinary disinfectants ( due to the
ascroside) which may remain viable for several years
⚫ Social customs and living habits.
⚫ Disposal of feces is unsuitable
⚫ Ascaris suum
⚫ Ascaris suum is found in pigs. Its life cycle is identical
to that of A. lumbricoides. If a human ingests eggs of A.
suum the larvae will migrate to the lungs and die. This can
cause a particularly serious form of "ascaris pneumonia."
Adult worms of this species do not develop in the human's
intestine.
⚫ Diagnosis
⚫ Infections of Ascaris are diagnosed by finding
characteristic eggs in the feces of the infected host.
Toxocara canis
(intestinal roundworm of dogs)
The life cycle of Toxocara canis, a common
roundworm of dogs, is similar to that of Ascaris
lumbricoides, but with a few additional
accompaniments. Assuming a dog has never been
infected with Toxocara, the first time it is infected
the worms develop as described for Ascaris.
 If a dog has been infected previously and
ingests infective eggs, most of the larvae that
hatch from the eggs do NOT develop into
adults. Rather, they remain in the dog's tissues
as "second stage somatic larvae."
If these second stage somatic larvae are in a female and ⚫
she gets pregnant, transplacental infection of the fetus will
occur. This explains why, in some areas, up to 95% of
.puppies are born with infections of Toxocara canis
If another animal, such as a rodent, eats infective eggs of ⚫
Toxocara, second stage somatic larvae will develop in this
animal. If a dog then eats this animal, the dog gets
.infected
Humans can also be infected with second stage somatic ⚫
larvae of Toxocara canis, as well as the larvae of other
species of nematodes, resulting in a condition known as
visceral larval migrans or VLM
⚫ The eggs of Toxocara are extremely resistant to
adverse environmental conditions, and, once an area is
contaminated with eggs (such as a playground, park,
or your yard), it's very difficult to sanitize the area.
Thus, it's very important that dogs be checked for
this parasite on a regular basis, and that dog's not
be allowed to defecate indiscriminately.
⚫ Diagnosis:
⚫ Toxocara canis in dogs are diagnosed by finding
characteristic eggs in the feces of the infected host.
Infections of hosts with second stage somatic larvae of
this parasite are more difficult to detect, and many
probably go undiagnosed.
Trichuris trichiura
(whipworm)
 Infection by
Trichuris trichiura
Distribution
Trichuriasis - cosmopolitan
Primarily in hot and humid areas
prevalence 80-90 %, especially among underfives
and school children

Habitat
Caecum, appendix, colon (proximal end)
Mode of infection oral
Infective eggs embedded under fingernail
(hand to mouth infection)
Ingested with contaminated food/drinks
(carried by insect vector: cockroach, flies)
General Introductions
⚫ A common nematode residing in human colon
⚫ Worldwide distributed in the same areas
where the Ascaris are found
⚫ Trichuriasis are usually not serious clinically,
but overwhelming infections leading to death
have been reported in children
Morphology: adults
The adult female
measures about 35-50
mm in length, and the
male about 30-45 mm
Morphology: eggs
☆ barrel-shaped or fusiform with
bipolar prominences (plugs)
☆ measures 50-55 by 22-24 µm
☆ brown, smooth shell
☆ contains a single-cell ovum
 Life cycle
⚫ No intermediate host
⚫ Infected through
fecal-oral route by the
embryonated egg
⚫ Ileocecal portion is the
most favorite site of
residing
Pathogenesis

⚫ Symptoms are determined largely by the worm

burden: less than 10 worms are asymptomatic
⚫ Only heavily infected patients develop clinical
disease:
⚫ Chronic diarrhea, characterized by mucous stools,
and associated with tenesmus
⚫ If the diarrhea is protracted, the patient may develop
rectal prolapse, more likely to occur in small children
⚫ Many individuals infected with whipworm tend to be
malnourished and anemic
Pathogenesis

prolapsed rectum
whipworms are often seen
attached to the rectal tissue
 Trichuris trichiura
PATHOLOGY AND CLINICAL SYMPTOMS

Chronic and heavy infection

● Heavy anemia (Hb = 3 gr%) (1
Mixed infection may
worm absorb 0,005 cc blood/day) occur with Ascaris
● Abdominal pain, nausea, weight lumbricoides,
loss, vomiting
● Prolapsus recti
hookworm and
● Headache, fever Entamoeba histolytica
Trichuris trichiura
Diagnosis
Identify egg worm found in fecal
sample
Identify adult worm from prolapsed
anus and rectum (by proctoscopy)
Measure level of infection by counting
:
✴ Number of eggs per gram feces
✴ Number of female worm expelled through
deworming
Trichuris trichiura
PREVENTION
Treatment

Elimination of source of available

:Drugs infection
Improved personal hygiene
Oxantel (hand
pamoate
Mebendazol
washing, (drug of choice)
toilet training)
Through washing of sold
vegetables
Health education
Provision of sanitary public toilet
HOOK WORMS
There are two species of hookworm:
1. Ancylostoma duodenale
2. Necator americanus
The adults are found in the small intestines of
man.
Ancylostoma duodenale:
Habitat The adult worms live in
the small intestines of infected
persons, mostly in the jejunum,
less often in the duodenum, and
infrequently in the ileum.
Life Cycle:
Life cycle of Ancylostoma is completed in a single host
Definitive host: Humans are the only natural host.
No intermediate host is required like other helminths.
Infective form: Third stage filariform larva.
Adult worm inhabiting the small intestine of man attach
themselves to the mucous membrane by means of their
mouth parts.
The female worm lays eggs.
The eggs containing segmented ova with 4 blastomeres, are
passed out in the feces of infected person .
Eggs freshly passed in feces are not infective for humans.
When deposited in the soil, the embryo develops inside the eggs.
Its development takes place optimally in sandy loamy soil with decaying
vegetation under a moist, warm, shady environment.
In about 2 days, a rhabditiform larva, measuring 250 µm in length, hatches
out of the egg. It feeds on bacteria and other organic matter in the soil and
grows in size It moults twice, on the 3rd and 5th days after hatching to
become the third-stage infective filariform larva .
Filariform larva is about 500–600 µm long, with a sharp pointed tail.
The filariform larva are non-feeding. They can live in the soil for 5–6 weeks,
with their heads waving in the air, waiting for their hosts.
They can also ascend on blades of grass or other vegetation, being carried in
capillary water films on their surface.
Direct sunlight, drying, or salt water can kill the larva.
Mode of Infection: When a person walks barefooted on soil containing the filariform
larva, they penetrate the skin and enter the subcutaneous tissue. The common sites of
entry are the skin between the toes, the dorsum of the foot, and the medial aspect of
the sole.
In farm workers and miners, the larvae may penetrate the skin of the hands. Rarely,
infection may take place by the oral route, the filariform larva being carried on
contaminated vegetables or fruits.
The larvae may penetrate the buccal mucosa to reach the venous circulation and
complete their migration via the lungs.
Transmammary and transplacental transmission has been also reported for
Ancylostoma, but not for Necator.
⚫ Inside the human body, the larvae are carried along the venous circulation to the
right side of the heart and to the lungs.
⚫ Here, they escape from the pulmonary capillaries into the alveoli, migrate up the
respiratory tract to the pharynx, and are swallowed, reaching their final destination
small intestine.
⚫ During migration or on reaching the esophagus, they undergo third moulting.
⚫ They feed, grow in size, and undergo a fourth and final moulting in the small
intestine and develop the buccal capsule, by which they attach themselves to the
small intestine and grow into adults.
⚫ There is no multiplication in the host and a single infective larva develops into a
single adult, male or female.
⚫ It takes usually about 6 weeks from the time of infection for the adult worms to
become sexually mature and start laying eggs. But sometimes, there may be an arrest
in development and the process may take much longer, 6 months or more.
⚫ Alternatively, the larvae may be swallowed and may develop directly into adults in
the small intestine without a tissue phase
Pathogenicity and Clinical Features
Causes of anemia in Hookworm infection:
⚫ Blood sucking by the parasite for their food
⚫ Chronic hemorrhages from the punctured sites from jejunal mucosa
⚫ Deficient absorption of vit B12 and folic acid
⚫ Depression of hemopoitic system by deficient intake of proteins
⚫ Average blood loss by the host per worm per day is 0.03 mL with N.
americans and 0.2 mL with A. duodenale
⚫ With iron deficiency, hypochromic microcytic anemia is caused and with
deficiency of both iron and vit B12 or folic acid, dimorphic anemia is
caused.
HOOKWORM
PATHOLOGY CAUSED BY ADULT WORM
(Anemia by hookworm)

Patient
Glositis atrofik pada with atrophic glossitis
anemi hipokrom
also show fingernail
mikrositer yang
deformity (koilonichia)
disebabkan infection
Fingernail becomes thin and
berat HOOKWORM
Tampak lidah concave
halus with elevated ridge
dan kurang papila

.source : Atlas Parasitologi Kedokteran, Zaman P. Alih Bahasa : Anwar C.; Mursal Y
 HOOKWORM
PATHOLOGY AND CLINICAL SYMPTOMS

Disease: Ancylostomiasis
Synonym: Uncinariasis, necatoriasis
infection by A. duodenale are more
serious than N. americanus
Chronic infection rarely produce acute
manifestation
Tissue damage and symptoms are caused
by :
⚫ Larva stage
⚫ Adult worm
HOOKWORM
PATHOLOGY CAUSED BY LARVA STAGE

Larva penetrates the skin -

maculopapules - erythema - heavy
itching : ground itch/dew itch
In sensitive patient, larva carried in the
circulation, may cause:
⚫ Bronchitis / Pneumonitis
HOOKWORM
PATHOLOGY CAUSED BY ADULT WORM

Hooked to the intestinal mucosal wall :

abdominal pain, nausea, diarrhea
Absorbing 0,2-0,3 ml of blood/day/worm :
progressive anemia, hypo chrome, microcytic
type of Fe deficiency anemia
Heavy anemia (Hb may reach 2 gr %) :
⚫ Dyspnea, physical weakness, headache
⚫ Rapid pulse beat, cardiac weakness
⚫ Children : physical growth retardation, mental
 HOOKWORM
PATHOLOGY CAUSED BY ADULT WORM
(Anemia by HOOKWORM)

Blood smear of patient with heavy infection caused by hookworm

indicating Fe deficiency anemia with low MCHC and low serum Fe
concentration
.Source : Color Atlas of Medicine and Parasitology. 1977 Peters W. & Gillers H.M
HOOKWORM

Diagnosis
Identify eggs from feces sample
Identify larva from :
⚫ Fecal culture
⚫ Old feces sample
ANTIHELMINTHICS
HOOKWORM
Tetrachlorethylen
Mebendazole
Albendazole
Pyrantel pamoate
Bitoskanate
Bephenium hidroxynaphtoate

PREVENTION
Same as with Ascariasis but with the addition of :
wearing shoes during work in plantation or mine
area
LARVA MIGRANS
⚫ There are three types of larva migrans:
⚫ a. Cutaneous larva migrans (Creeping eruption)
⚫ Various animals harbor hookworms. Two species of dogs and
cats are important.
⚫ 1. Ancylostoma braziliens: infects both dogs and cats.
⚫ 2. Ancylostoma caninum: infects only dogs.
⚫ Both of these are common in the tropics and subtropical
regions where human hookworms can best complete their life
cycles.
⚫ If man comes in contact with infective larvae, penetration of
the skin may take place; but the larvae are then unable to
complete their migratory cycle. Trapped larvae may survive for
weeks or even months, migrating through the subcutaneous
tissues. They may evoke a fairly severe reaction - purities and
dermatitis.
⚫ The dermatitis leads to scratching and then bacterial
superinfection.
⚫ Treatment
⚫ Thiabendazole: Applied topically.
⚫ b. Visceral larva migrans
⚫ A syndrome caused by the migration of parasitic
larvae in the viscera of a host for months or years. It
may be caused by transient larval migration in the life
cycles of several parasites such as hookworm, Ascaris
lumbricoides, T. spiralis, S. strecoralis, other filarial
worms and Toxocara canis (Dog ascarid) and
Toxocara catis (Cat ascarid).
C. Intestinal larva migrans ⚫
.This is an extremely rare kind of larva migrans ⚫
An interior view of Ascaris. Note the presence of three large lips, a characteristic of
.all ascarids
Ascaris lumbricoides, fertilized egg. Note that the egg is covered with a thick shell that
appears lumpy (bumpy) or mammillated; approximate size = 65 μm in length
Eggs of Ascaris suum. A. suum is a common parasite of pigs.
The eggs are virtually indistinguishable from those of
[Link].
The lips of A. lumbricoides

The three lips are

seen at the anterior
end. The margin of
each lip is lined with
minute teeth which are
not visible at this
magnification
An egg of Toxocara canis. Ingestion of these eggs by a human can
result in visceral larval migrans