Dr. Maramion Intestinal_nematodes 2

7/21/2019 Dr. Maramion Intestinal_nematodes 2

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INTESTINAL NEMATODES



ASCARIS LUMBRICOIDES

• Giant intestinal round worm• Ascariasis – intestinal• Loefer’s syndrome – pulmonary

• osmopolitan! endemic in t"e tropicsand su#tropics

• $%&' in(ected! )&* in Asia e+posed• ,re-alent. / – 0 yrs old m1( • Areas o( poor sanitation! crowded! (eces

used as (ertili2er



A. lumbricoides

• Adult.

– Male $34&$cm! (emale 554&/cm

– Smoot" 6nely striated cuticle

– onical anterior7posterior e+tremeties

– 8entrally cur-ed posterior end o( malewit" 5 spicules

– ,aired reproducti-e or9ans in (emale!sin9le in male



A. lumbricoides

• E99.

a% :ertile e99s. ;/4)3um + &/4/3um

–

Outer coarsely mammilated al#uminousco-erin9

– T"ic< transparent "yaline s"eat"7s"ell wit"t"ic< outer layer

–

Delicate -itelline lipoidal inner mem#erane=impermea#le>

'% In(ertile e99s. ??40;um + &04;;um! wit"re(ractile 9ranules



Morphology

ylindrical wit" tapered ends

@"itis" strea<B



$/4&3 cm

534;3 cm

:emale

Male

:

M



:ertili2ed E99

)/ Ccm

'roadly o-oidal wit" t"ic< s"ell

Al#uminous coat

8itelline mem#rane



n(ertili2ed e99 wit" no outer mamillated layer =decortic



Unfertilized egg.Prominent mamillationsof outer layer.

Fertilized egg.

The embryo can be distinguisheinside the egg



E99 containin9 a lar-a w"ic" will #e in(ecti-e i( in9est



• A (emale may li-e in t"e intestine (or $5 to

$? mont"s and "as a capacity o( producin95/ million e99s at an a-era9e daily outputo( 533333%

• E99s are resistant to c"emical disin(ectantand sur-i-e (or mont"s in sewa9e #ut are<illed #y "eat =;3F (or $/ "ours>%

• omplete de-elopment o( lar-a reuires $?days





• ,at"olo9y.• Immune reaction o( "ost

• Mec"anical eHects o( adult worms• EHects o( adult worms on t"e "ost

nutrition



• linical presentation.• $% mi9ratin9 lar-ae. lun9s. Loefer’s pneumonitis!

Loefer’s syndrome – transient pulmonary

symptoms accompanied #y eosinop"ilia• 5% adult worm in t"e small intestine – Mild – Intermittent GI pro#lems

– "ronic in(ection. -illi atrop"y! elon9ation o(crypts! round cell in6ltrates in t"e lamina propria

• Nutritional impairment• Growt" impairment

•

&% aller9ic response• ;% complications. O#struction• Intussusceptions• Ectopic mi9ration





•

La#oratory Dia9nosis.• Stool e+amination

– Direct (ecal smear

–

ato tec"niue 7 cellop"ane t"ic< met"od – ato at2 tec"niue or Modi6ed ato

tec"niue

•

Ancillary met"ods – '

– "est J4ray



Treatment.• Supporti-e

•

Speci6c – Al#enda2ole. ;33m9 sin9le dose

– Me#enda2ole. /33m9 sin9le dose

– ,yrantel palmoate. $3m97<9 =ma+% $9m

4 ,ipera2ine citrate. $/3m97<9 initially(ollowed #y K/m97<9 at $5"rsinter-als (or erratic worm mi9ration



Enterobius vermicularis

• A%<%a pinworm seatworm or societyworm

• osmopolitan distri#ution

• An ur#an disease o( c"ildren in

crowded en-ironment%

• Adults may 9et it (rom t"eir c"ildren%



MO,OLOG

2-5 mm8-! mm

"ur#ed posterior en

"ephalic alae

Pointed posterior end



$op-sided% Plano-con#e&%'-shaped

"olorless shell

5(-)( *m



$+F, ""$,

,mbryonated are ingeste

atched in the duodenu

Matures in the ileum

/dults reach cecum and co

0ra#id female migrateto the perianal region

to deposit eggs



• Em#ryonated e99s 4 in(ecti-e sta9e

• A 9ra-id (emales contains more t"an $3333e99s

•

E99s mature in an o+y9enated moisten-ironment and are in(ectious & to ; "ourslater%

• Man4to4man and auto in(ection are common%

• Man is t"e only "ost%



Entero#ius -ermicularis adults in section o( appendi+



1ymptoms•

Entero#iasis is relati-ely innocuous andrarely produces serious lesions%

• T"e most common symptom is perianal

perineal and -a9inal irritation caused #y t"e(emale mi9ration%

• T"e itc"in9 results in insomnia and

restlessness%

• In some cases 9astrointestinal symptoms=pain nausea -omitin9 etc%> may de-elop%



'iagnosis

• Dia9nosis is made #y 6ndin9 t"eadult worm or e99s in t"e perianalarea particularly at ni9"t%

• Scotc" tape or a pinworm paddle isused to o#tain e99s%



Treatment and "ontrol

• Two doses =$3 m97<9! ma+imum o( $9 eac"> o( ,yrantel,amoate two wee<s apart 9i-es a -ery "i9" cure rate%

• Me#enda2ole is an alternati-e%

• T"e w"ole (amily s"ould #e treated to a-oidrein(ection%

• 'eddin9 and underclot"in9 must #e saniti2ed #etweent"e two treatment doses%

• ,ersonal cleanliness pro-ides t"e most eHecti-e inpre-ention%



TRICHURIS TRICHIURA

+P34M

,pidemiology

•

A tropical disease o( c"ildren =/ to $/yrs> in rural Asia =K/* o( t"e /334)33million cases>%



Morphology

• T"e (emale or9anism is /3 mm lon9 wit" aslender anterior =$33 micrometer diameter>and a t"ic<er =/33 micrometers diameter>posterior end%

• T"e male is smaller and "as a coiledposterior end%

• T"e Tric"uris e99s are lemon or (oot#alls"aped and "a-e terminal plu9s at #ot"ends%



Tric"uris tric"iura adult male and (emale

@"ip4li<eB



'arrel s"aped Two polar plu9s ellow #rown e+ternal layer



• Met"od o( transmission. in9estion o( in(ecti-e e99 wit" L$•

Li(e cycle. a-era9e o( &333 – 53333 e99s7day• Li(e span. $ year



linical ,resentation

• Asymptomatic• lassical tric"uriasis wit" dysentery

syndrome• "ronic tric"uriasis = P$ year>• Growt" stuntin9! malnutrition• ectal prolapse• Tenesmus• Geop"a9ia• :in9er clu##in9 =anemia! su#stance

secreted #y parasite>• "ronic #loody mucoid stools•

A#dominal pain



,at"olo9y.• Anterior portions o( t"e worms

em#edded in t"e mucosa• esem#les ulcerati-e colitis

• Aller9y



La#oratory Dia9nosis.• Stool e+amination.

• Direct (ecal smear

•

ato cellop"ane t"ic< smear• ato4<at2 tec"niue. e99

countin9 to determine cure rate

e99 reduction rate and intensityo( in(ection

• Stool concentration = acid et"er!

(ormalin et"er>



Treatment.

• Al#enda2ole. ;33 m9 sin9le dose

•

Me#enda2ole. /33 m9 sin9le doseQ $33 m9 #id (or & days

• ,yrantel palmoate



OOOMS•

Ancylostoma duodenale OLD world• !ecator americanus NE world

• A. duodenale: Europe! Sout"western Asia

• N. americanus: A(rica America

• oo<worm in(ection7 disease

• osmopolitan tropical and su#tropicalareas

• 033 million in(ected

•

/3333 deat"s annually due to anemia



:actors aHectin9 pre-alence.• ontinuous presence o( in(ection

• De(ecation "a#its

• Appropriate en-ironmental conditions• 4 temperature! rain(all! s"aded!

sandy soil

• Opportunity (or in(ecti-e sta9e tocome in contact wit" t"e s<in o( man



Morp"olo9y.Adult.

• N. americanus . 04$$mm + 3%&/mm

. small cylindrical (usi(orm 9rayis"

. #uccal capsule "as a -entral pair o(

uttin9 plate

• A.duodenale

. #uccal capsule "as two pairs o(

cur-ed -entral teet". #i99er t"an N. americanus



Ancylostoma duodenale adult

Males are 9enerally smallit" a dilated posterior p – @#ursa copulatri+B

:emale Male



Necator americanus adult (emale anterior end

Semilunar cuttin9 plates



Scannin9 electron micro9rap" o( t"e oral openin9 o( Ancylostomaduodenale anot"er species o( "uman "oo<worm% Note t"e presence o(

(our cuttin9 Rteet"R two on eac" side%



Necator americanus adult male posterior end

'ursa is wide and lon9

,air o( "air li<e copulatory spicules@'ar#ed tipB'ipartite dorsal rays



• Lar-a. resem#les lar-a o( S% stecoralis

4usually lar9er wit" attenuate posteriorend

4r"a#diti(orm – L$

4r"a#diti(orm – L5

46lari(orm – L& -ia#le (or 5 wee<s

• E99s. #luntly rounded e99s and sin9le t"in

transparent "yaline s"ell• 4e+creted in t"e (eces in early clea-a9e

sta9e "atc" in $45 days



oo<worm 6lari(orm lar-ae=In(ecti-e sta9e>

losed mout":ili(orm esop"a9us

@s"eat"edB,ointed ends



O-al or ellipsoidal s"ape T"in transparent s"ellontains an em#ryo

Li(e ycle



Li(e ycle



linical ,resentation.

•

utaneous. @9round itc"B @dew itc"B –reepin9 eruption =LM>

–S<in entry o( 6lari(orm lar-ae

• ,ulmonary. Loefer’s syndrome

–Lar-al lun9 in(ection

• Intestinal in(ection.

–Acute "ea-y

–"ronic "oo<worm



oo<worm Disease• Microcytic "ypoc"romic anemia (rom

"oo<worm in(ection =>stoole+amination – A% duodenale. 3%5ml #lood7worm7day

– N%americanus. 3%3& ml7#lood7worm7day

• ,ro9ressi-e secondary microcytic"yoc"romic anemia o( iron4de6ciency

type due to continous #lood loss• ypoal#uminemia due to loss o(

#lood lymp" and protein



La#oratory Dia9nosis.

A% Stool e+amination• Direct (ecal smear. low yield

• oncentration tec"niue!

–

inc Sul(ate entri(u9al :loatation – :ormalin4Et"er Met"od

'% Stool ulture.

•

arada Mori. culture met"od allowin9"atc"in9 o( lar-a (rom e99s on stripso( 6lter paper wit" one end immersedin water



Treatment.• Me#enda2le. $33m9 #id + &days or

/334K33m9 sin9le dose• Al#enda2ole. ;33 m9 sin9le dose

• ,yrantel palmoate

• T"ia#enda2ole

STRO!"#LOIDES



STRO!"#LOIDESSTERCORALIS

• A%<%a @T"readwormB

•

@oc"in4"ina diarr"eaB

• ,re-alent in tropical and su#tropical

areas wit" poor sanitation%



Morphology

• as a (ree4li-in9 =r"a#diti(orm> andparasitic =6lari(orm> (orm%

• T"e r"a#diti(orm is t"e (eedin9 lar-alsta9e

• T"e 6lari(orm lar-a is t"e non (eedin9and in(ecti-e sta9e



"a#diti(orm lar-a

U'roadly (usi(ormU,ointed and cur-ed tail wit" 5 spicules



UDelicate loo<in9 V slender

ULon9 and capillary esop"a9usUlosed mout"UNotc" or #i6d tail

$if l



$ife cycle

•

"aracteri2ed #y t"ree =&> diHerentp"ases o( de-elopment$% Direct de-elopment cycle

5% Indirect de-elopment cycle

&% Auto in(ection cycle cycle

a% E+ternal#% Internal

i l l



Direct De-elopment ycle WAdults worm =upper small intestines>

lay partially em#ryonated e99s

"a#diti(orm lar-ae are e+creted in t"e (eces

:ilari(orm lar-a =soil>

,enetrates "ost’s s<in

eac" capillaries – "eart – lun9sMi9rate in epi9lottis – swallowed

UMatures in t"e small intestines

di l l



Indirect De-elopment cycleW E+creted "a#diti(orm lar-a

mature in soil

:ree4li-in9 adults copulates

and lays e99s

:ree4li-in9 r"a#diti(orm lar-a

Matures into adults :ilari(orm lar-a

A i ( i l



Autoin(ection cycle W

"a#diti(orm lar-ain t"e small intestine

:ilari(orm lar-a

,enetrates s<inin perianal area

=E+ternal>

,enetrates t"esmall intestine

=Internal>

apillaries 444 eart 4444Lun9s

Matures in t"e small intestine





,at"olo9y

A% utaneous sta9e.• Eryt"ematous serpin9inous pruritic

s<in =creepin9 eruptions>

•@Lar-a currensB – i( multiple

'% Lar-al (orm

• ,neumonitis



% Adult.

• @oney4com#B lesions o( t"eintestine

• Diarr"ea and a#dominal pain

La#oratory Dia9nosis



La#oratory Dia9nosis

• Stool e+amination –

D:S "as low yield =/3 e99s7day> – ulture. sand7c"arcoal tec"niue!

'aerman’s tec"niue! arada4Mori culture

• 'ody Xuids

– Duodenal aspirate. Enterotest – Sputum! urine! ascitic Xuid! S:

• Small #owel #iopsy

•

Serolo9y – I:A -s% =(> lar-a =?/403*>

– ELISA

• '. "ypereosinop"ilia



Treatment.• A#enda2ole. as dru9 o( c"oice ;33m9

(or & days• T"ia#enda2ole. 5/ m97<9 in & di-ided

doses daily (or & days



apillaria p"ilippinensis

Distri#ution. ,"ilippines V T"ailand

ost. Marine mammals4 de6niti-e "ost

6s". in9est e99s P

in(ecti-e lar-a in muscles =in &4; w<s>

Transmission. In9estion o( raw orundercoo<ed 6s"











,at"o9enesis V linical Diease

4 adult. #urrow in t"e YeYunum wall

4 inXammation V -illi atrop"y

P pain diarr"ea mala#sorption




• Dia9nosis

4 e99s in (eces

• Traetment

4 Me#enda2ole. dru9 o( c"oice



T/67 3U

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Dr. Maramion Intestinal_nematodes 2