cmo 33-mid

7/25/2019 cmo 33-mid

1/150

NEMATODES

1

MARK M. CALBAN, MD, MPM

CSU

Colle e of Medicine & Sur er

7/25/2019 cmo 33-mid

2/150

7/25/2019 cmo 33-mid

3/150

3

7/25/2019 cmo 33-mid

4/150

4

7/25/2019 cmo 33-mid

5/150

5

7/25/2019 cmo 33-mid

6/150

6

7/25/2019 cmo 33-mid

7/150

7

7/25/2019 cmo 33-mid

8/150

7/25/2019 cmo 33-mid

9/150

9

7/25/2019 cmo 33-mid

10/150

7/25/2019 cmo 33-mid

11/150

11

7/25/2019 cmo 33-mid

12/150

12

7/25/2019 cmo 33-mid

13/150

13

7/25/2019 cmo 33-mid

14/150

14

7/25/2019 cmo 33-mid

15/150

15

7/25/2019 cmo 33-mid

16/150

16

7/25/2019 cmo 33-mid

17/150

ASCARIS LUMBRICOIDES Male

Cross Section

1. Cuticle and Hypodermis

2. Longitudinal MuscleLayer

3. Vas Deferens

4. Testis

5. Lateral Line w/

Excretory Canal6. Intestine

7. Pseudocoelom

7/25/2019 cmo 33-mid

18/150

ASCARIS LUMBRICOIDES Female

Cross Section

1. Cuticle and

Hypodermis

2. LongitudinalMuscle Layer

3. Ovary

4. Oviduct

5. Uterus

6. Intestine

7/25/2019 cmo 33-mid

19/150

ASCARIS LUMBRICOIDES Lips

The THREE (3)lips & sensory

papillae are seen at

the anterior end.The margin of each

lip is lined withminute teeth whichare NOT visible atthis magnification.

7/25/2019 cmo 33-mid

20/150

20

7/25/2019 cmo 33-mid

21/150

What is the lifespan of the adult

ascaris worm?

A. 1 year

B. 2 years

C. 5 yearsD. 10 years

E. NONE OF THE ABOVE

7/25/2019 cmo 33-mid

22/150

The female ascaris worms lays approx

how many eggs/day?

A. 100,000

B. 200, 000

C. 300,000D. 400,000

E. NONE OF THE ABOVE

7/25/2019 cmo 33-mid

23/150

23

7/25/2019 cmo 33-mid

24/150

24

7/25/2019 cmo 33-mid

25/150

25

7/25/2019 cmo 33-mid

26/150

26

7/25/2019 cmo 33-mid

27/150

27

7/25/2019 cmo 33-mid

28/150

28

7/25/2019 cmo 33-mid

29/150

29

7/25/2019 cmo 33-mid

30/150

7/25/2019 cmo 33-mid

31/150

31

7/25/2019 cmo 33-mid

32/150

32

7/25/2019 cmo 33-mid

33/150

33

7/25/2019 cmo 33-mid

34/150

PATHOLOGY

Reactions of tissues to invading larvae.

Irritation of the intestine by the mechanical and toxic actionof the adult.

Complications arising from the parasites extra intestinalmigration.

7/25/2019 cmo 33-mid

35/150

PATHOLOGY

Tissue phase: With heavy or repeated

infection, pneumonia,

cough, low-grade fever,

30% to 50% eosinophilia

(Lfflers syndrome) resultfrom migration of larvae

through the lungs (1 to 2

weeks after ingestion of

eggs).

Allergic asthmatic reactionmay occur with reinfection.

Intestinal phase: Intestinal or appendixobstruction results frommigrating adults in heavyinfections.

a. Vomiting and abdominal pain resultfrom adult migration.

b. Protein malnutrition can occur inchildren with heavy infections and poordiets.

c. Some patients are asymptomatic.

7/25/2019 cmo 33-mid

36/150

7/25/2019 cmo 33-mid

37/150

PATHOLOGY LARVA:

Ascaris Pneumonitis/Loefflers Syndrome

Difficulty of breathing,cough, fever, lunginfiltration.

May become ERRATIC

ADULT: Diarrhea

Malnutrition

Villous AtrophyWorm bolus/obstruction

7/25/2019 cmo 33-mid

38/150

Pathogenesis & Clinical Findings

The major damageoccurs during larval migrationrather

than from the presence of the adult worm in the intestine.

The principal site of tissue reaction are the lungs, where

inflammation with an eosinophilic exudate occurs inresponse to larval antigens (Loefflers Syndrome)

Because the adults derive their nourishment from ingested

food, a heavy worm burdenmay contribute to

malnutrition, especially in children in developingcountries.

7/25/2019 cmo 33-mid

39/150

PATHOLOGY

Complications fromintestinal obstructionarecaused by tangling of thelarge worms or migrationof adults to other sites, such

as the appendix, bile duct,or liver(detectable byradiograph).

7/25/2019 cmo 33-mid

40/150

7/25/2019 cmo 33-mid

41/150

Intestinal Ascariasis

Protruberant Abdomen

Intermittent Colicky

Cramps

Loss of Appetite

Jejunal Mucosa broadening and

shortening of villi,

elongation of crypts,

decrease in villus crypts

ratio, round cellinfiltration of lamina

propria

7/25/2019 cmo 33-mid

42/150

7/25/2019 cmo 33-mid

43/150

43

7/25/2019 cmo 33-mid

44/150

Laboratory Diagnosis

DIRECT FECAL SMEAR

2mg of Feces + 1 gtt NSSLPO/MPO KATO TECHNIQUES

20-60mg feces

qualitative tech, MASSexamination KATO KATZ TECHNIQUE

QuantitativeEgg counts/gram fecesdetermine egg reduction aftertreatmentDetermine intensity of ascarisinfection.

7/25/2019 cmo 33-mid

45/150

TREATMENT

Albendazole- Drug of Choice; 400mg SD

Mebendazole - 500mg SD

Pyrantel Pamoate - 10mg/kg

Ivermectin - 200ug/kg SD

7/25/2019 cmo 33-mid

46/150

PREVENTION

HANDWASHINGProper disposal of human wastes

Health Education

Mass Chemotherapy done periodically

7/25/2019 cmo 33-mid

47/150

Trichuris trichiura

(Whipworm/)

Disease Caused: Trichiuriasis

Cousin of Ascaris

Trichocephalus trichiura

47

7/25/2019 cmo 33-mid

48/150

Trichiuris trichiura

Common Name: Whipworm

Holomyarian Type of Somatic Muscle Arrangement.

Final Host: Man

Habitat: Large Intestine

Diagnostic Stage: Ova

Infective Stage: Embryonated Ova; MOT: Ingestion

Portal of Entry: Mouth

7/25/2019 cmo 33-mid

49/150

49Anterior 2/3 attenuated & Thin

Posterior 1/3 fleshy & robust

7/25/2019 cmo 33-mid

50/150

50

7/25/2019 cmo 33-mid

51/150

51

Bipolar Plug

Foot Ball Shape

Lemon-Shaped

Barrel-Shaped

7/25/2019 cmo 33-mid

52/150

52

7/25/2019 cmo 33-mid

53/150

7/25/2019 cmo 33-mid

54/150

7/25/2019 cmo 33-mid

55/150

MAJOR PATHOLOGY AND SYMPTOMS

The surface of the colon may be matted

with worms. Patients will have:

a. Bloody or mucoid diarrhea

b. Weight loss and weaknessc. Abdominal pain and tenderness(colitis may be seriously debilitating)d. Increased peristalsis and rectal

prolapse, especially in children

Chronic infections in children

Growth stuntingStool is loose with mucus (and obviousblood) in heavy infection.

7/25/2019 cmo 33-mid

56/150

56

Enterrorhagia,RECTALPROLAPSE

(increased

peristalsis that

occurs in an effort

to expel the

worms.,

Appendicitis

NOT cause significantanemia, unlike the

hookworms. !

Diff fr Ascaris: Noheart & Lung

migration

7/25/2019 cmo 33-mid

57/150

Notes:

Adult worms

live in the cecum and ascending colon.

Anterior portion is threaded into the mucosa.

Female worms shed between 3,000 20,000 eggs/day

Lifespan is 1 year

7/25/2019 cmo 33-mid

58/150


Needed to confirm yoursuspicion based on History& PE.

1. Direct Fecal Exam

2. Kato Technique(qualitative) & Kato-KatzTechnique (quantitative)

3. Concentration Techniques(Sedimentation/FlotationMx)

7/25/2019 cmo 33-mid

59/150

59

7/25/2019 cmo 33-mid

60/150

60

7/25/2019 cmo 33-mid

61/150


DIRECT FECAL SMEAR

2mg of Feces + 1 gtt NSSLPO/MPO

KATO TECHNIQUES

20-60mg feces

qualitative tech, MASSexamination

KATO KATZ TECHNIQUE

QuantitativeEgg counts/gram feces

determine egg reduction aftertreatment

Determine intensity of ascarisinfection.

7/25/2019 cmo 33-mid

62/150

TREATMENT

DOC: MEBENDAZOLE

500mg SD - light infxns500 mg x 3 doses - heavy infxns

7/25/2019 cmo 33-mid

63/150

PREVENTION

Treatment of infected individualsSanitary disposal of human wastes by construction of toilets

and their proper useFrequent handwashingHealth EducationThorough scalding and washing of uncooked vegetables

7/25/2019 cmo 33-mid

64/150

Enterobius vermicularis

(pinworm/seatworm)

Oxyuris vermicularis

7/25/2019 cmo 33-mid

65/150

MORPHOLOGY ADULT WORM

7/25/2019 cmo 33-mid

66/150

MORPHOLOGY EGGS

7/25/2019 cmo 33-mid

67/150

LIFE CYCLE

7/25/2019 cmo 33-mid

68/150

68

7/25/2019 cmo 33-mid

69/150

The eggs are distributed in the environment. Infection can be acquired by ingestion/inhalation of eggs.

The adult worm invades the colon.

At around 12mn-4am, the gravid female migrates to the

perianal area. Here, the female worm ruptures to release

eggs causing pruritis (thats why affected individuals

scratch their perianal area at night.

Fully gravid female migrates down the colon and anus

7/25/2019 cmo 33-mid

70/150

Fully gravid female migrates down the colon and anus

(crawls on perianal and perineal skin)15-43 days after

ingestion of infective stage ova. (rupture of eggs caused

pruritus)

Eggs found in the environment

Transmission: anus to mouth by finger contamination

(by scratching; contamination by carriers on soiled bed

linen; airborne eggs; retrofection(female worm after

laying eggs will crawl back making it difficult to cure)

7/25/2019 cmo 33-mid

71/150

PATHOLOGY

7/25/2019 cmo 33-mid

72/150

CELLOPHANE/SCOTCH TAPE

7/25/2019 cmo 33-mid

73/150


SWAB


7/25/2019 cmo 33-mid

74/150


SWAB

7/25/2019 cmo 33-mid

75/150

TREATMENT

7/25/2019 cmo 33-mid

76/150

7/25/2019 cmo 33-mid

77/150

7/25/2019 cmo 33-mid

78/150

STRONGYLOIDES STERCORALIS

Common Name:THREADWORM;

Smallest Nematode of

Man

Habitat: Small Intestine

Cochin China

Diarrhea

7/25/2019 cmo 33-mid

79/150

7/25/2019 cmo 33-mid

80/150

EPIDEMIOLOGY

Tropics, especially in Southeast Asia.

Its geographic pattern is similar to that of hookworm becausethe same type of soil is required.

More of a focally transmitted worm than a soil transmittedhelminth because it is infective shortly after passage w/ thefeces

7/25/2019 cmo 33-mid

81/150

81

7/25/2019 cmo 33-mid

82/150

82

7/25/2019 cmo 33-mid

83/150

83

7/25/2019 cmo 33-mid

84/150

84

7/25/2019 cmo 33-mid

85/150

85

7/25/2019 cmo 33-mid

86/150

86

7/25/2019 cmo 33-mid

87/150

87

7/25/2019 cmo 33-mid

88/150

LIFE CYCLE

7/25/2019 cmo 33-mid

89/150

89

7/25/2019 cmo 33-mid

90/150

90

7/25/2019 cmo 33-mid

91/150

91

7/25/2019 cmo 33-mid

92/150

92

7/25/2019 cmo 33-mid

93/150

93

7/25/2019 cmo 33-mid

94/150


1. Major clinical features areabdominal pain, diarrhea, andurticaria, with eosinophilia.

2. Skin shows recurringallergic, raised, itchy, redwheals from larval penetration.

3. Migration of larvae:

Primary symptoms are in thelungs; bronchial verminous(from worms) pneumonia.

7/25/2019 cmo 33-mid

95/150


4. Intestinal symptoms include abdominal pain, diarrhea,constipation, vomiting, weight loss, variable anemia,eosinophilia, and protein-losing enteropathy.Light infections are often asymptomatic; gross lesions are

usually absent.The bowel is edematous and congested with heavy infection.

5. S. stercoralis has caused sudden deterioration and death inimmunocompromised persons because of heavy

autoinfection and larval migration throughout body(hyperinfection), with bacterial infection secondary to larvalspread and intestinal leakage.

7/25/2019 cmo 33-mid

96/150

96

BAERMANN TECHNIQUE

7/25/2019 cmo 33-mid

97/150

BAERMANN TECHNIQUE

LAB DIAGNOSIS

7/25/2019 cmo 33-mid

98/150

LAB DIAGNOSIS

1. Recovery of the rhabditiform (noninfective) larvae is

normally from the stool concentrate. Caution: Filariform

(infective) larvae can also be recovered in the stool.

A minimum of four (4) stools are recommended beforeindicating that the patient is not infected (routine formalin,

ethyl acetate sedimentation concentration);

2. If the stool specimens are negative, examination of duodenal

contents is recommended (duodenal aspirates, Entero-Testcapsule); however, the overalL sensitivity of the method varies.

LAB DIAGNOSIS

7/25/2019 cmo 33-mid

99/150

LAB DIAGNOSIS

7/25/2019 cmo 33-mid

100/150

7/25/2019 cmo 33-mid

101/150

7/25/2019 cmo 33-mid

102/150

7/25/2019 cmo 33-mid

103/150

7/25/2019 cmo 33-mid

104/150

7/25/2019 cmo 33-mid

105/150

105

7/25/2019 cmo 33-mid

106/150

106

7/25/2019 cmo 33-mid

107/150

107

7/25/2019 cmo 33-mid

108/150

108

7/25/2019 cmo 33-mid

109/150

109

7/25/2019 cmo 33-mid

110/150

7/25/2019 cmo 33-mid

111/150

111

7/25/2019 cmo 33-mid

112/150

7/25/2019 cmo 33-mid

113/150

7/25/2019 cmo 33-mid

114/150

114

7/25/2019 cmo 33-mid

115/150

115

7/25/2019 cmo 33-mid

116/150

7/25/2019 cmo 33-mid

117/150

7/25/2019 cmo 33-mid

118/150

118

7/25/2019 cmo 33-mid

119/150

119

7/25/2019 cmo 33-mid

120/150

120

7/25/2019 cmo 33-mid

121/150

121

7/25/2019 cmo 33-mid

122/150

122

7/25/2019 cmo 33-mid

123/150

123

7/25/2019 cmo 33-mid

124/150

METHOD OF DIAGNOSIS

7/25/2019 cmo 33-mid

125/150

METHOD OF DIAGNOSIS

DIAGNOSTIC CRITERIA

Identification of encysted larvae in biopsied muscle;

Serologic testing (ELISA) 3 to 4 weeks after infection.

A history of eating undercooked pork or bear

Fever, muscle pain, bilateral periorbital edema, and rising

eosinophilia

DIAGNOSTICS

7/25/2019 cmo 33-mid

126/150

DIAGNOSTICS

7/25/2019 cmo 33-mid

127/150

7/25/2019 cmo 33-mid

128/150

128

7/25/2019 cmo 33-mid

129/150

Capillaria philippinensis

( d WORM)

7/25/2019 cmo 33-mid

130/150

(pudoc WORM)

7/25/2019 cmo 33-mid

131/150

Capillaria philippinensis

(Pudoc Worm)

131

7/25/2019 cmo 33-mid

132/150

132

7/25/2019 cmo 33-mid

133/150

7/25/2019 cmo 33-mid

134/150

134

7/25/2019 cmo 33-mid

135/150

135

7/25/2019 cmo 33-mid

136/150

136

7/25/2019 cmo 33-mid

137/150

137

7/25/2019 cmo 33-mid

138/150

138

7/25/2019 cmo 33-mid

139/150

139

PATHOLOGY

7/25/2019 cmo 33-mid

140/150

The first proven caseof human infection with Capillariaphilippinensis occurred in 1963in a patient from thePhilippines who died 3 days after admission to thehospital with a diagnosis of malabsorption syndrome.

Although the significance was not recognized until 4 yearslater, C. philippinensis eggs were found in the stools andautopsy showed parasitism of the large and smallintestines.

7/25/2019 cmo 33-mid

141/150

141

7/25/2019 cmo 33-mid

142/150

LIFE CYCLE

7/25/2019 cmo 33-mid

143/150

Although the exact mode of transmission is unknown,experimental infection is transmitted through small fish that serve

as the intermediate host; often, whole, small fish may be ingested.

Development to the infective stage in the fish takes at least 3

weeks.

In areas of the Philippines where this infection occurs, people alsoeat raw shrimp, crabs, and snails.

They also tend to defecate in the fields or water where the fish,

shrimp, crabs, and snails are obtained, thus completing the life

cycle.

The worms live burrowed into the mucosa of the small bowel,mainly the jejunum.

7/25/2019 cmo 33-mid

144/150

7/25/2019 cmo 33-mid

145/150

145

7/25/2019 cmo 33-mid

146/150

7/25/2019 cmo 33-mid

147/150

147

7/25/2019 cmo 33-mid

148/150

148

7/25/2019 cmo 33-mid

149/150

149

7/25/2019 cmo 33-mid

150/150

THANK YOU!

The harder thestruggle, the

greater the glory.

Documents

cmo 33-mid