PARASITIC HELMINTHS

Three classes SOURCES OF EXPOSURE TO INFECTION

• Trematodes (flukes) A. STH GROUP (Soil-Transmitted Helminths)
• Venous system: Schistosoma - Soil are ideal conditions for thriving: MOIST, WARM,
• Biliary tract: Clonorchis, Fasciola SHADY
• Lung: Paragonimus  Ascaris lumbricoides
 Strongylodes stercoralis
• Cestodes (tapeworms)  Necator americanus
• Taenia saginata, Taenia solium, H. nana  Ancylostoma duodenale
• segmented  Trichuris trichiura

• Nematodes (roundworm) B. VECTOR TRANSMITTED GROUP (Biological or

• Intestinal Mechanical vector)
• Tropical countries - Mosquito are the vectors but different specie
• Blood, lymphatic, subcutaneous  Wuchereria bancrofti
• called roundworm because their outer surface is  Brugia malayi
smooth and rounded, even larvae
• common names are given by their gross morphology C. CONTACT TRANSMITTED
- Direct contact with infected individual or direct contact
NEMATODES with worm itself
 Nematodes or true roundworms  Enterobius vermicularis
 Unsegmented, elongated and cylindrical in shape
(covered with thick, flexible multi-layered collagenous D. FOOD BORNE
cuticle) - Ingestion of raw intermediate host or
 Outer layer: cuticle  Trichinella spiralis
 Sexes are separate and the females are larger than  Capillaria philippinensis
males (dioecious)  Angiostrongylus cantonensis
o Males’ tip are coiled
 Life cycle includes: INFECTIVE STAGES
1) the egg stage which will be embryonated A. EMBRYONATED EGGS
2) larval stage (rhabditiform and filariform) o A. lumbricoides
3) the adult stage o T. trichiura
o vermicularis
Class aphasmidia (no caudal adhesive glands
and epidermal glands) B. FILARIFORM LARVA/FILIFORM (L3) Hookworms
- Glands that are needed to adhere to the mucosa o Threadworm
A. Species which parasitize the small intestines o Filarial worm
1. Trichinella spiralis o Capillarial worm
2. Capillaria philippinensis ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1. Ascaris lumbricoides
B. Species which parasitize the large intestines Common name Giant intestinal roundworm
1. Trichuris trichiura Final host Man
Habitat Small intestine (JEJUNUM)
Class phasmidia (with caudal adhesive glands Diagnostic Ova (unfertilized or fertilized)
and epidermal glands) Stage
- They readily adhere to mucosa Infective Stage Embyronated ova
A. Species which parasitize the small intestines Source of STH
1. Ascaris lumbricoides Infection
2. Necator americanus Mode of Ingestion
3. Ancylostoma duodenale Transmission
4. Ancylostoma caylanicum Portal of Entry Mouth (oral-fecal route)
5. Strongyloides stercoralis Life span 1-2 years
Ascaris suum – ascariasis of swine Morphology - Creamy-white to pinkish
yellow when freshly expelled
B. Species which parasitize the large intestines - Head is provided with 3 lips
1. Enterobius vermicularis and a small triangular buccal
o Near the rectum/perianal area cavity
 1/8th the world’s population infected (in the equatorial
C. Species which parasitize the tissues (blood and belt)
lymphatics)  Largest intestinal nematodes infecting humans
1. Wuchereria bancrofti  Obligatory extra-intestinal migration (eosinophilia)
2. Brugia malayi
 Intensity of infection greatest in children, ages 5 – 10
years
D. Species which cause cutaneous larva migrans in man
 Ingestion of ova > GIT > hatches > larvae pierces
(creeps underneath the skin)
intestines > gains entry to lymphatics > finds its way
1. Ancylostoma braziliense
to lungs (pneumonia characterized by eosinophilia) >
2. Ancylostoma caninum
3. Angiostrongylus cantonensis
 creeps up to trachea and swallow > grow back to GIT The chitinous layer and
and live their life in the small intestine albuminous coat are thinner than
 LOFFLER’S syndrome: atypical pneumonitis, those of the fertilized eggs and
eosinophilia, typical pneumonia appearance on chest lacks fertilizing membrane. The
x-ray content is made of many coarse
refractile granules various in size.
FEMALE MALE No vitelline layer. It is very
-female worm is - smaller and unorganized.
tapered at both slender, curve
ends and large (20 posteriorly and ***- unfertilized egg (all females or males are still immature)
to 35 cm long, up to equipped with
45cm) copulatory spicule
Ascaris lumbricoides – Ascaris lumbricoides – Geographic prevalence: highest in warm, wet climates
female (cross section) male (cross section) 1 adult female = 200,000 eggs/day
1. Cuticle and 1. Cuticle and
hypodermis hypodermis
2. Longitudinal muscle 2. Longitudinal
layer muscle layer
3. Ovary 3. Testis
4. Oviduct 4. Vas deferens
5. Uterus 5. Lateral line with
6. Intestine excretory canal
6. Intestine
7. Pseudocoelom

Prepatency: 2 months
Pneumonitis: 4 – 16 days after infection, short duration (~3
 Note 3 and 4 were corrected by Dr. Yolo, initially weeks)
#3 was the VD and #4 was the testis

Ascaris lumbricoides – lips (triradial lips)

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 – egg
A fertilized corticated (which means it
has an outer mammillary coat made of
albumin) Ascaris egg, still at the
unicellular stage, as they are passed in
stool. All membranes are present. The
outer mamillary coat, the middle
glycogen layer and the innermost
lipoidal vitelline layer. The middle
golden staining portion is the glycogen
and the inner is the embryo which is
the vitelline layer. It is finely granular
and organized.
*Lacking in decorticated ova.
LIFE CYCLE
1.Adult worms live in the lumen of the small intestine.
2. A female may produce up to 240,000 eggs per day, which
are passed with the feces
3. Fertile eggs embryonate and become infective after 18
days to several weeks, depending on the environmental
conditions (optimum: moist, warm, shaded soil).
4. infective eggs are swallowed
5. the larvae hatch
6. invade the intestinal mucosa, and are carried via the portal,
then systemic circulation to the lungs.
7. The larvae mature further in the lungs (10-14 days), Source of STH
Infection
penetrate the alveolar walls, ascend the bronchial tree to Mode of Ingestion
the throat, and are swallowed Transmission
8. Upon reaching the small intestine, they develop into adult Portal of Entry Mouth (oral-fecal route)
Life span 1-3 years
worms. Between 2 and 3 months are required from
Morphology - Flesh colored or pinkish slender
ingestion of the infective eggs to oviposition by the adult worm
female. Adult worms can live 1 to 2 years - Anterior 2/3 of the worm is
attenuated and thin in contrast
DIAGNOSIS: to the remaining posterior 1/3
1. Direct Fecal Exam which is fleshy and robust
2. Kato (qualitative) and Kato-katz technique - “Whip like appearance”
 Is a close relative of A. lumbricoides, since they often
(quantitative)
co-infect
3. Zinc Sulfate Conc. technique  No extra-intestinal phase
4. Brine floatation  90% infections are asymptomatic
5. FECT  Symptoms with heavy infections
o Intensity of infection peaks by age 10
CLINICAL
- Larval phase: eosinophilia, pneumonitis (Loeffler’s) MORPHOLOGY
LEFT: FEMALE (posterior is straight)
- Adult phase:
RIGHT: MALE (posterior is curved)
 Malnutrition, Impaired Physical Growth So that during copulation, male can carry female because
 Mild abdominal discomfort → → Small bowel female is on top. The curved part of the male is where the
copulatory spicule is so it can penetrate.
obstruction (in children, few as 60 worms)
 Wandering ascaris: biliary tract obstruction,
cholangitis, pancreatitis, liver abscess
 Treatment Approach: Selective and or Mass
Treatment
Drug of choice: Albendazole x 1 dose

Löeffler Syndrome Transverse sections of

Ascaris larvae in pulmonary The attenuated is the anterior segment (the mouthpiece). It is
(Pneumonitis) alveoli what pierces the mucosa.

Trichuris trichiura – ova

 With mucoid, bipolar plug

 Foot ball shaped
 Lemon-shaped
 Barrel-shaped
 Common name “Japanese-lantern
Adult Ascaris worms Acute G.I. Obstruction from ova”
migrating in liver Ascaris containing a BOLUS  Polar ends are curved
of Ascaris  Outer is yellowish, inner is
transparent
 Diagnostic stage
Pre-patency: 2 months before adulthood

LIFE CYCLE
1. The unembryonated eggs are passed with the stool.
2. In the soil, the eggs develop into a 2-cell stage, an
advanced cleavage stage,
3. and then they embryonate; eggs become infective
2. Trichuris trichiura in 15 to 30 days.
Common name Whipworm (cause anterior 2/3 is 4. After ingestion (soil-contaminated hands or food), the
whiplike) eggs hatch in the small intestine, and release larvae
5. that mature and establish themselves as adults in the
Final host Man
colon
Habitat Large intestine (CECUM)
6. The adult worms (approximately 4 cm in length) live in
Diagnostic Ova
the cecum and ascending colon. The adult worms are
Stage fixed in that location, with the anterior portions
Infective Stage Embyronated ova threaded into the mucosa. The females begin to
oviposit 60 to 70 days after infection. Female worms in
 the cecum shed between 3,000 and 20,000 eggs per
day. The life span of the adults is about 1 -3 years.
Clinical Features:
o Asymptomatic
o Physical Weakness, Anemia (prevents iron
absorption)
o Stunted Growth, Cognitive Deficits
o Stool frequency (12+/day), nocturnal urgency
to defecate
o Trichuris dysentery syndrome
o Trichuris colitis (inflammation of colon)
o Rectal prolapse
whipworms Rectal Prolapse from
Trichuris trichiura
DIAGNOSIS: same with Ascaris lumbricoides
To declare free from A. lumbricoides and T. trichiura
- three specimens are negative
Caution!
If stool is negative for egg…
- could be male parasites only
- female worms are still immature (migration stage)
Drug of choice: Mebendazole, Albendazole X 3 days
3. The Hookworms
- called hookworm because their teeth are like hooks
1. Necator americanus (human)
2. Ancylostoma ceylanicum (zoonotic)
3. Ancylostoma duodenale (human hookworms)
4. Ancylostoma braziliense (zoonotic)
5. Ancylostoma caninum (zoonotic)
HEAD:
- Consider the # of teeth
Necator americanus – bungi
Ancylostoma duodenale – 2 pairs
Ancylostoma braziliense – 1 pair
Ancylostoma caninum – 3 pairs
COPULATORY BURSA:
1. Spicule
2. Dorsal Ray
3. Cleft
Necator americanus
 spicule is fused and barbed
 dorsal ray is bidigitate or bifid
 cleft: deep
Ancylostoma duodenale
 spicule is not fused and not barbed
 dorsal ray is tridigitate or tripartite
 cleft: very shallow
MODE OF TRANSMISSION: contact with infected soil
LIFE CYCLE
1. Eggs are passed in the stool and under favorable
conditions (moisture, warmth, shade), larvae hatch in 1
to 2 days.
2. The released rhabditiform larvae (feeding and
young stage) grow in the feces and/or the soil ,
3. and after 5 to 10 days (and two molts) they become
filariform (third-stage) larvae that are infective
4. These infective larvae can survive 3 to 4 weeks in
favorable environmental conditions. On contact with
the human host, the larvae penetrate the skin and are
carried through the veins to the heart and then to the
lungs. They penetrate into the pulmonary alveoli,
ascend the bronchial tree to the pharynx, and are
swallowed .
5. The larvae reach the small intestine, where they reside
and mature into adults. Adult worms live in the lumen
 of the small intestine, where they attach to the intestinal 4. Strongyloides stercoralis
wall with resultant blood loss by the host Common name Threadworm
Final host Man
Habitat Small intestine
Diagnostic Rhabditiform Larva
Stage
Infective Stage Filariform Larva

COMPARATIVE STUDY ON HOOKWORM AND

STRONGYLOIDES STERCORALIS LARVA

Ova: Thin-shelled 2-8 cell stages (blastomeres)

*No species identification
- Often mistaken as decorticated
Ascaris egg
- inside are 2-8 germ cells
- clean and transparent cytoplasm
- thin shells
Diagnostic test: Stool Exam and Harada Mori Technique
Rx of choice: Albendazole, Mebendazole
PATHOLOGY:
 Clinical Features:
o DUE TO LARVA
 Ground-itch (upon skin penetration)
–> Dry cough, wheezing (1-2 weeks
later) in primary infection
 Creeping eruption – cutaneous
larva migrans (CML)
 Pneumonitis (Wakana Disease)

o DUE TO ADULT
 Abdominal discomfort
 Progressive iron-deficiency anemia
(40 – 160 worms associated with
Hb < 11 g/dl)
 Extreme fatigue, IQ loss
Treatment: Albendazole x 1 dose

HOOKWORM-BLOOD LOSS
Adult worms injure their host by causing intestinal blood loss: PATHOLOGY:
 Anticoagulants, Hemolysins, and Hemoglobinases  Diarrhea - causative agent of Cochin China (in Malaysia,
 30 to 200 μL blood per day per hookworm a place with a lot of migrant Chinese) Diarrhea
 Intestinal bloodloss and Iron Deficiency Anemia  Honey Comb Ulcer
 Hyper-Infection:
o Intestinal perforation hemorrhagic pneumonia,
shock, sepsis, eosinophilia may be limited
 Larva currens

Pruritic Larva Currens from

Strongyloides
Adult size: 0.5 ─ 1 cm - Larva currens = autoinfection
Daily eggs per worm: 5 ─ 20,000 with Strongyloides filariform
larvae
- Moves rapidly (2 ─ 10 cm/hr), lasts shorter than
cutaneous larva migrans
Lab Test:
 Stool Exam
 Duodenal Aspirate
 Entero Test
 Harada Mori
5. Enterobius verminularis
Common name Pinworm, seatworm, society worm Adult Male:
Final host Man This image shows a closeup of the
Habitat Large intestine male. Note the esophageal bulb,
Diagnostic Ova characteristic of the species, in the
Stage anterior end (black arrow) and the
Infective Stage Embryonated ova curled posterior tail with a spicule,
Source of Close contact (contact-borne) characteristic of the male (red
Infection arrow).
MOT Ingestion, inhalation of eggs
Life span Around 2 months Egg
The egg of E. vermicularis is approximately 25 x 60 um in
 Creeps out on the anal area and lays eggs
size. It has a thin shell and one of the sides
 Severe itching in the anus – pruritus anus
is flattened. Eggs are collected by swabbing
 Retroinfection is possible the perianal area during the early morning
 D-SHAPED EGG with an adhesive tape and then examining
the tape with a microscope.
PATHOLOGY:
 Itchiness
 Secondary bacterial infection
 Nocturnal pruritus ani
Lab diagnosis:
 Cellulose tape swab (Scotch tape swab)
 Swellengrebel
 Petrolatum Coated Swab
Rx of choice: Mebendazole

LIFE CYCLE:
1. Eggs are deposited at night by the gravid females.
2. Eggs are ingested via person-to-person transmission
through the handling of contaminated surfaces (such as
clothing, linen, curtains, and carpeting), or airbourne eggs
may be inhaled and swallowed. Self-infection may also
occur if eggs are transferred from to the mouth by fingers
that have scratched the perianal area.
3. After ingestion, larvae hatch from the eggs in the small
intestine. The adults then migrate to the colon. The life
span of the adults is about two months. Adults mate in the
colon, and the males die after mating.
4. Gravid females migrate nocturnally to the anus and
ovideposit eggs in the perianal area. The females die after
laying their eggs. The time period from ingestion of
infective eggs to the ovideposition of eggs by females is
approximately one month.
5. The larvae develop and the eggs become infection within
4-6 hours. Newly hatched larvae may also migrate back
into the anus, and this is known as retroinfection.
MORPHOLOGY:

Adult Female: E. vermicularis have a long,

pointed tail (arrow) leading to the common
name of pinworm. They are about 8-13 mm
in length

Adult Male:
The adult male is about 2-5 mm in
length and has a curved, relatively
blunt posterior end (arrow).