INTESTINAL

NEMATODES
Phylum Nematoda
 unsegmented, elongated and
cylindrical

 sexes are separate ; females

larger than males

 posterior end of male usually

curved
Life cycles:

 include 1) the egg stage

2) 4 larval stages
3) adult stage
 Adult female may be:
A. Oviparous – eggs are oviposited and
embryo develops outside the
maternal body
(A. lumbridoides)
B.Viviparous – female gives birth to larvae (C.
Philippinensis)
C.Parthenogenetic – can produce viable eggs
without being fertlized by the
male worms (S.
stercoralis)
CLASSIFICATION

Phylum Nematoda
 Class Aphasmidia (lacking
phasmids or caudal receptors)

 Class Phasmidia ( with phasmids

or caudal
papillae)
Class Phasmidia ( with
phasmids)
Species which parasitize the small intestines

 1. Ascaris lumbricoides
 2. Necator americanus
 3. Ancylostoma duodenale
 4. Strongyloides stercoralis
 5. Capillaria philippinensis

Species which parasitizes the large intestines

 1. Enterobius vermicularis
 2. Trichuris trichiura
Ascaris Lumbricoides
 The most common intestinal
roundworm of man

 Occurs most frequently in tropical

and subtropical regions of Asia,
Central and South America and
Africa

 Estimated to infect 1.2 billion

individuals (1/5 of the world’s
population)
Ascaris lumbricoides
 Thrives in areas with lack of
sanitation and poverty and
ignorance

 Most common source of infection –

soil contaminated foods esp. in raw
vegetables

 2 separate populations and

reservations
1. adult Ascaris – parasitizing man
2. Ascaris eggs - environment
 Ascaris lumbricoides
(Morphology)
 Adult – creamy white or
pinkish yellow
A. Female
– tapered at both
ends; large;
- measures 20 t0 35
cm by 5 mm ; may
grow up to 45 cm
long
- reproductive
potential : 240,000
eggs/day

B. Male – curved posteriorly

- measures 15 to 25
cm by 3
mm
 Ascaris lumbricoides
(Morphology)
 Fertilized eggs: mostly oval or
spherical, golden brown
: capable of further
development in soil
from single cell to
embryonated eggs
 Shell contains:
1. inner non-permeable
lipoidal
vitelline
membrane
2. thick transparent
middle layer or glycogen
layer
3. outermost coarsely
mammilated albuminoid
layer
 Absent mamillated layer 
decorticated
 Ascaris lumbricoides
(Morphology)
 Unfertilized eggs
- 1st two layers
absent; shell is
thinner
- generally larger,
narrower, more
elongate
- inside are highly
refractile granules
of varying sizes
- can never undergo
development in
soil
Ascaris lumbricoides
(Life cycle)
 Ascaris lumbricoides
(Pathology & Clinical
Manifestations)
 Migratory larvae 
hemorrhages and
destruction of the lung
parenchyma as the larvae
breaks break through the
capillaries
- asthmatic type of
respiration
- cough with rales and chest
pain
- Ascaris pneumonitis
- Loeffler’s syndrome
( allergic eosinophilic
infiltration of
the lungs)

 Larva  bloodstream 
lodge in brain, spinal cord,
the eyeball, kidneys 
 Ascaris lumbricoides
(Pathology & Clinical
Manifestations
 Adult worms in small intestines:
- Decreased fat and nitrogen absorption
- Lactose intolerance
- Decreased growth rates in children
- Diarrhea, vague abdominal pain, loss of
appetite

 Vomited Ascaris  pass larynx 

suffocation

 May enter Eustachian tube  otitis

media
 Ascaris lumbricoides
(Pathology & Clinical
Manifestations)
 Due to erratic behavior
 May become

entangled 
intestinal obstruction
 Appendix  acute

appendicitis
 Bile duct  biliary

ascariasis
 Liver  multiple

abscesses
 Perforate the bowel

 peritonitis
 Gallstones (Ascaris
eggs)
 Ascaris lumbricoides
(Diagnosis)
1. Direct Fecal Smear (DFS) – 2 mg of stool used
2. Kato-Katz technique – 40-60mg of stool
ADVANTAGES:
a)quantitative: can count the number of eggs
found in a measured
stool sample
b) can determine egg reduction rate after
treatment
c)determine intensity of infection

Negative stool exam:

i. When patients are actually free from infection
j. During early larval migration via blood stream
k. When worms are still sexually immature
l. When only male worms are found in intestines
Ascaris lumbricoides
(Treatment)
 Broad Spectrum antihelminthics -
neuromuscular blocking effect on
parasites → paralysis of worms
1. albendazole- 400 mg single dose
2. mebendazole – 500 mg single dose
3. pyrantel pamoate – 10 mg/kg single
dose

 Community based chemotherapy –

interval of 4 months or 3 times a year for
3 years

 Among schoolchildren – treatment at

least twice a year at an interval of 4-6
Ascaris lumbricoides
(Control)
 Mass treatment
 Selective treatment – treating
only those found positive for
eggs on stool
 * Targeted group – treating
children alone
Ascaris lumbricoides
(Prevention)
 Sanitary disposal of human
excreta
 Personal hygiene
 Avoiding use of human feces
for fertilizer
 Thorough cooking of food
The Hookworms
1. Necator americanus*
2. Ancylostoma duodenale*
3. Ancylostoma braziliense
4. Ancylostoma caninum

* soil-helminths that infect man

 HOOKWORMS
(Morphology)
Necator americanus Ancylostoma duodenale

Adult Small,cylindrical,fusiform, gray- -Larger

white - single-paired male & female
-females>males reproductive organs
- Posterior end of the male has -head continues in the same
broad,membranous caudal bursa
with rib-like rays direction as the curvature of the
-Ventral pair of semilunar cutting
body
plates - 2 pairs of curved ventral teeth

Rhabditi- Resemble those of

- hook-like head - Same -
Strongyloides; somewhat
form
larger, more attenuated
larva posteriorly, and have a longer
( 1st buccal cavity;
stage)
Filariform Conspicuous and parallel Inconscpicuous buccal spears and
throughout their lengths; transverse striations on the sheath in
larva
conspicuous transverse striations the tail region
(3rd present on the sheath in the tail
Ancylostoma duodenale

Copulatory bursa
Necator americanus

COPULATORY
BURSA
Hookworm rhabditiform
larva
Hookworm filariform
larva
 Hookworm egg
 Eggs:

ovoidal, thin-shelled,
colorless

4-8 cell stage

in constipated stool –
embryo may develop
inside shell

• Differentiation of Necator
and Ancylostoma – difficult
and impractical
Hookworms: Life Cycle
The Hookworms : Pathology
and Clinical Manifestations
I. CAUSED BY LARVAL STAGE

1. Ground Itch / Coolie Itch

- Intense localized itching,
edema, erythema and
papulovesicular
eruption
- Lasts up to 2 weeks
- Site of entrance of filariform
larvae  dermatitis
The Hookworms : Pathology
and Clinical Manifestations
2. Creeping eruption or Cutaneous
Larva Migrans
- Due to exposure of the skin to
filariform larvae of A.
braziliense/caninum;
- occasional – N. americanus and
A.
duodenale
- Serpiginous tunnel in stratum
germinativum of skin
- Larvae move at a rate of several mm
to few cm per day
- Pruritus  pyogenic infection
The Hookworms : Pathology
and Clinical Manifestations

3. Pulmonary lesions
- Petecchial hemorrhages
- Eosinophilic and leucocytic
infiltration
The Hookworms : Pathology
and Clinical Manifestations

II. CAUSED BY ADULT WORM

 Hookworm anemia

 Due to continuous mechanical suction

of blood from intestinal mucosa
 Microcytic, hypochromic anemia
 Loss of RBC in gut
 0.03-0.05 ml blood/ day (N. americanus)
 0.16-0.34 ml blood/day (A. duodenale)
The Hookworms : Pathology
and Clinical Manifestations
 Hypoalbuminemia
 Combined loss of blood and
lymph
HOOKWORMS
(Diagnosis)
 Ground itch and creeping
eruption
- character of lesion
- history of contact with soil

 recovery of eggs on stool

( DFS, Kato, Formalin Ether
concentration)
HOOKWORMS
(Epidemiology)
 Hookworm infections:
 96% - N. americanus
 2% - Ancyclostoma
 2% - mixed

 Sandy loam type of soil with plenty of

rain  favorable for infection

 Chief sources of infection:

 Unsanitary disposal of feces
 Use of human feces as fertilizer
HOOKWORMS
(Treatment)
 Treat all infections
 Severe anemia – increase Hgb to 7-8 g/dL before
dealing with worm infection
 Severe hypoalbuminemia – deworm quickly

 Broad spectrum anti-helmintics:

1. albendazole
2. mebendazole
3. pyrantel
4. oxantel/pyrantel

 Ferrous sulfate – 200 mg TID p.o for 3 months

HOOKWORMS
(Control Measures)
 Proper disposal of feces
 Proper treatment of human
excreta used as fertilizer
 Personal hygiene – use of
shoes/slipper
 Avoiding ingestion of raw
vegetables not washed
properly
Strongyloides
stercoralis
 Disease : Strongyloides,
Cochin-China diarrhea,
Threaworm

 Epidemiology : infections runs

parallel with hookworm
infection

 Infective stage – filariform

larvae – skin penetration
 Life Cycle of
Strongyloides
Adult parasite, Eggs
Rhabditiform
Female, in small → in → larva
hatches
Intestine of man mucosa from egg
↑
Esophagus 1. Autoinfection 2.Direct Cycle 3.Indirect
↑ in intestine (like hookworm)
Swallowed
↑ Passed in feces into
soil
Pharynx Becomes
↑ filariform larva Free living adult
(M & F)
Trachea Penetrates intestinal
↑ mucosa Eggs
Breaks out
Into alveoli Larva in colon Rhabditiform
larva
↑
Lungs Filariform larva on
 Strongyloides
(Rhabditiform larva)
- free-living
- Smaller than the
filariform larva
- Female: muscular double-
bulbed esophagus and the
intestine is a straight
cylindrical tube
- Male: smaller than
female; ventraly curved
tail, 2 copulatory spicules,
gubernaculum with no
caudal alae
Strongyloides
(Filariform larva)
- parasitic; semi-
transparent, with fine
striated cuticle
- Slender tapering
anterior end and short
conical pointed tail
- Buccal cavity has 4
distinct lips
- Uteri contain a single
file of 8-12 thin-
shelled transparent,
segmented ova
Strongyloides stercoralis
(Pathology &
Manifestations)
 Filariform larva – entry skin penetration
“petechial hemorrhage, congestion & edema,
pruritus
- lungs >>>pneumonitis (cough),
pleural effusion
 Filariform & Adult – intestines >>>GIT
disturbances
Stool – water mucous diarrhea
depends on
 A. Intessity of infection
 B. Duration
 C. Host-tissue rxn = encapsulated the worms
 Blood picture – leukocytosis (WBC 25,000)
Eosinophilia ( 40%)
Strongyloides
stercoralis
(Diagnosis)
 Finding the rhabditiform larvae
– feces or duodenal aspirate
direct or concentration
methods

 Eggs can only be obtained by

drastic purge /NGT duodenal
aspirates
Strongyloides
stercoralis
(Treatment)
 1. Albendazole– drug of
choice
- 400 mg x 3 days
- eradicates 80% of infections

 2. Thiabendazole
- 50mg/kg into 2 divided
doses daily X 2 days after
meals
Strongyloides
stercoralis
(epidemiology)
- Found throughout the world
- More of a fecally-transmitted worm
that a soil-tansmitted helminth
because it is infective shortly after
passage with the feces
- Low local prevalence
- More frequently found among male
children 7-14 years old than among
females and adults
Strongyloides
stercoralis
(Prevention)
 Proper waste disposal

 Protection of the skin from

contact with contaminated soil

 Early detection & Treatment of

cases
Capillaria philippinensis
(Epidemiology)
 Capillariasis first recorded in Northern Luzon
 Also reported in Thailand, Iran, Japan, Egypt,
Korea, Taiwan and India
 Migratory fish-eating birds are considered
natural hosts
 In the Philippines, this has been documented
in the Northern Luzon provinces,Zambales,
Southern Leyte, Compostela Valley and
Zamboanga del Norte
 Mode of transmission: eating uncooked small
freshwater/brackish water fish; Northern
people like to eat “bagsit” and other fish found
in lagoons
Capillaria philippinensis
(Parasite Biology)
 MALE
- 1.5-3.9mm
- spicule 230-300um long
and has unspined sheath
- thin filamentous anterior
end and a slightly thicker
and shorter posterior end
- esophagus has rows of
secretory cells
- anus is subterminal
 FEMALE
- 2.3-5.3mm
- thin filamentous anterior
end and a slightly thicker
and shorter posterior end
- esophagus has rows of
secretory cells
- anus is subterminal
- vulva seen at the junction
of anterior and middle
thirds
Capillaria philippinensis
(Parasite Biology)
 EGG
- peanut-shaped with striated shells and
flattened bipolar plugs
- 36-45um by 20um
- embryonate in the soil or water
Capillaria philippinensis
(Life Cycle)
Capillaria philippinensis
(Clinical
Manifestations)
 Symptoms: abdominal pains, gurgling stomach
(borborygmus), and diarrhea; weight loss,
malaise, anorexia, vomiting, and edema

 Laboratory findings: severe protein-losing

enteropathy, malabsorption of fats and sugars,
decreased excretion of xylose, low electrolyte
levels (esp. potassium), and high levels of
immunoglobulin E
Capillaria philippinensis
(Diagnosis)
 Direct fecal smear – finding the
egg
 Stool concentration method
 Duodenal aspiration
Capillaria philippinensis
(Treatment)
 Electrolyte replacement and high
protein diet – in severe cases
 Antidiarrheal agents
 Antihelminthics
- albendazole 400 mg once daily x 10
days
- mebendazole 200mg twice daily x 20
days
* Albendazole preferred as it destroys
larvae more readily than mebendazole
Enterobius vermicularis
 Enterobiasis – human pinworm
- characterized by
perianal
itching
 Enterobius vermicularis
(Morphology)
MALE
 Adults:
small, whitish or brownish in
color
anterior end – pair of lateral
cuticular
expansion (LATERAL WINGS
or
CEPHALIC ALAE)

posterior esophageal bulb

male - 2-5 mm ; tail
curves ventrad;
single copulatory
spicule
female – 8-13 mm ; long
pointed tail
FEMALE
 Eggs:
 measure 50-60 um by
20- 30 um
 elongated, ovoid,
flattened on the ventral
side
 similar to letter “D”
 egg shell – two layers
(outer thick hyaline
 albuminous shell
and Inner embryonic
lipoidal membrane)

 larva – folded once

within the shell
(creating a line
visible along the
egg’s long axis)
Enterobius vermicularis Life
Cycle
Life Cycle:

 eggs deposited by a single female vary from

4,672 to
16,888 (mean 11,105/day)
 female usually dies after oviposition
 male dies after copluation

 eggs become fully mature/embryonate within 6

hours
 eggs are resistant to putrefaction and
disinfectants
 succumb to dehydration in dry air within a day
 may remain viable up to several days under cool
and moist conditions
Enterobius vermicularis
(Pathology and Manifestations)
 1/3 asymptomatic
 3 forms:
I. Pathology at the site of attachment of the worm
 Minute ulcerations or abscesses in cecal
mucosa
II. Pathology due to egg deposition in the perineal
area
- intense itching or pruritus in the perianal
region
- scratching  scarified
- pruritus ani  hemorrhage, eczema,
bacterial infection of the anal and
perianal regions and perineum
III.Pathology caused by migrating adults
- migrating worms lay eggs in genital organs
 vulvovaginitis
- worms enter fallopian tube  salpingitis
Enterobius vermicularis
(Diagnosis)

 History and physical exam

 Perianal cellulose tape swab
 – D shaped ova
 - best time is soon after patient
awaken and before bathing
 5% only are demonstrable in feces
 worms may be seen migrating out of the
child’s anus at night
Enterobius vermicularis
(Epidemiology)
1. Infection may occur through:
a.Hand to mouth transmission – most
common transmission
b. Inhalation of airborne eggs in dust
c.Retroinfection through the anus
- eggs hatch in the perianal region
and larvae migrate back into large
intestine
2. Only nematode that cannot be controlled
through sanitary disposal of human
feces because eggs are deposited in the
perianal region.
Enterobius vermicularis
(Epidemiology)
1. Local prevalence
- 29% among schoolchildren from
exlcusive private schools
- 56% among those from public schools
4. Local prevalence higher in females
compared to males
5. Have been collected from fingertips and
fingernails of schoolchildren
6. Adult female worms migrate to the
perianal area even during daytime but
more migration occurs at night time.
Enterobius vermicularis
(Treatment)
1. Pyrantel pamoate – drug of
choice
- 10 mg/kg with a second dose
2-4 weeks later
2. Albendazole – 400 mg as single
dose

3. Mebendazole – 500 mg tab as

single dose
Enterobius vermicularis
(Prevention & Control)
 all members of household who are
positive
should be treated
 at least 7 consecutive post-treatment

perianal smears using scotch-tape swab

method shld be negative - declare
negative
infection
 personal hygiene
 cut fingernails short
 bed linens and clothing of infected
persons – sterilized by boiling
Trichuris trichiura
 Whipworm
 Soil-transmitted
 Frequently occurs together with
Ascaris
 Children from 5 – 15 years old are
more frequently infected
 In the Philippines, prevalence is
from 80-84%
Trichuris trichiura
 Factors affecting transmission:
a. Indiscriminate defecation of
children around yards
b. Poor health education
c. Poor personal, family and
community hygiene.
Trichuris trichiura
(Parasite Biology)
 Male worm  Female worm
- 30 – 45mm
- shorter than female
- coiled posterior end with
a single spicule and
retractile sheath
- attenuated anterior 3/5
traversed by a narrow
esophagus; posterior 2/5
contains the intestine
and a single set of
reproductive organs
- 35-50 mm
- bluntly rounded
posterior
- attenuated anterior 3/5
traversed by a narrow
esophagus; posterior 2/5
contains the intestine
and a single set of
reproductive organs
- lays 3,000-10,000
eggs/day
Trichuris trichiura
(Parasite Biology)
 EGG
- 50-54um by 23 um
- lemon shaped with pluglike translucent
polar prominences
- yellowish outer and a transparent inner shell
- embryonic development takes place in the
environment when eggs are deposited in
clayish soil
Trichuris trichiura
(Parasite Biology)
 Inhabit the large intestine
 Entire whip-like portion embedded
into the intestinal wall of the
cecum
 Eggs become embryonated within
2-3 weeks
 No heart-lung migration
Trichuris trichiura
(Life Cycle)
Trichuris trichiura
(Clinical
Manifestations)
 Worms embedded in the
mucosa can cause petechial
hemorrhages
 Rectal prolapse
 Appendicitis
 >20,000 eggs/gm of feces:
severe diarrhea or
dysenteric syndrome
 Light infections:
asymptomatic
 In heavy parasitism: blood-
streaked stools, abdominal
pain, anemia, weight loss
Trichuris trichiura
(Laboratory Diagnosis)
 In heavy infections, clinical
symptoms may be relied upon to
make a diagnosis

 In light infections:
1. direct fecal smear
2. Kato thick smear method
Trichuris trichiura
(Treatment)
 Mebendazole 500 mg single dose
in light infections; 2-3 days therapy
in moderate and heavy infections –
drug of choice

 Albendazole 400 mg single dose –

alternative drug
Trichuris trichiura
(Prevention and
Control)
 Mass treatment if infection rate is >
50%
 Preventive measures
a. Treatment of infected individuals
b. Sanitary disposal of human feces by constructing toilets
c. Washing of hands with soap and water before and after
meals
d. Health education on sanitation and personal hygiene
e. Thorough washing and scalding of uncooked vegetables
especially in those areas where night soil is used as fertilizer