28/02/2019

HOOKWORMS
AND
FILARIAL WORMS

Kingdom: Animalia
Phylum: Nematoda
Class: Secernentea
Order: Strongylida
Family: Ancylostomatidae
Genus: Ancylostoma
Necator
Species: duodenale
https://phylumdigestivesystem.weebly.com/hookworm.html
caninum
tubaeforme
braziliense
americanus
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Hookworm disease
• May lead to
an iron deficiency
anemia (as
hookworms suck
blood from the
host's intestinal
walls) –can be
severe enough to
cause fatigue and
occasionally,
heart failure
• People can
become infected
when walking
barefoot because
hookworm larvae
live in the soil and
can penetrate the
skin.
https://www.verywellhealth.com/hookworm-overview-4176230

Hookworm disease
("Uncinariasis" or "Ground itch")

• is a cutaneous (skin) condition

characterized by skin lesions that
are erythematous
macules and
papules.

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• Human = Ancylostoma duodenale,

Necator americanus
• Hookworms parasitize more than 900 M
people worldwide and cause daily blood
loss of 7 M liters.

• Dog/ cat = A.caninum, A. braziliense

Urcinaria stenocephala
• Ancylostomiasis is the most prevalent
hookworm infection and is 2nd only to
ascariasis in infections by parasitic worms.

Hookworm eggs on
wet mount
(Ancylostoma duodenale
and Necator americanus
cannot be distinguished
A morphologically).
Necator egg esembles those of A.duodenale but
somewhat longer and narrower.
Vitelline
membrane

B. The embryo has begun

cellular division and is at
an early (gastrula)
developmental stage.
thin hyaline shell B
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By the time they are discharged in the

normal stool, they are in the 2-8 cell stage of
segmentation.

In constipated stool, development continues

so that the egg may contain motile 1st stage larva.

Ancylostoma eggs (left), L1 larvae (middle),

diagram of L1 larvae (right).

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Rhabditiform larva

Filariform larva
Elongated esophagus

Filariform larva of Necator

americanus.
• longer than the
rhabditiform.
• esophageal
bulb extends to about 1/3
the body length
• posterior end is more
acutely tapered than in
the rhabditiform.

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ADULTS
FEMALE

MALE

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Ancylostoma duodenale

• grayish white or pinkish with the head

slightly bent in relation to the rest of the
body.

• This bend forms a definitive hook shape at the anterior

end for which hookworms are named.

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BUCCAL CAPSULE

The oral opening contains one large (and one smaller)

cutting "tooth" one each side.
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• a leading cause of maternal and child

morbidity in the developing countries of the
tropics and subtropics.

• susceptible children hookworms cause:

➢ intellectual, cognitive and growth

retardation

➢ intrauterine growth retardation,

prematurity, and low birth weight
among newborns born to infected
mothers.
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• infection is rarely fatal, but anemia can be

significant in the heavily infected
individual.

• hookworm larvae on penetrating humans

may produce a creeping eruption
called cutaneous larva migrans.

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• larvae migrate in tortuous tunnels in between stratum

germinativum and stratum corneum of the skin, causing
serpigenous vesicular lesions.
• With advancing movement of the larvae, the rear
portions of the lesions become dry and crusty. The lesions
are typically intensely pruritic.

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Clinical features of hookworm disease

Site Symptoms Pathogenesis
Cutaneous invasion and
Local erythema, macules,
Dermal subcutaneous migration
papules (ground itch)
of larva

Bronchitis, pneumonitis Migration of larvae

Pulmo-
and, sometimes, through lung, bronchi,
nary
eosinophilia and trachea

Anorexia, epigastric pain Attachment of adult

Gastro-
and gastro-intestinal worms and injury to
intestinal
hemorrhage upper intestinal mucosa

Iron deficiency, anemia,

Hemato-
hypoproteinemia, edema, Intestinal blood loss
logic
cardiac failure
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Genus and Species Necator americanus

Common Name New world hookworm
Etiologic Agent of: Necatoriasis, Uncinariasis
Infective stage Filariform larva
Definitive Host Human
Portal of Entry Usually via skin penetration rather than ingestion
Mode of Transmission Skin > Mouth
Habitat Small Intestine (jejunum, ileum)
Pathogenic Stage L3 Larva

Maturation time in host (days) 49-56

Mode of Attachment Oral attachment to mucosa by sucking

Mode of Nutrition Sucking and Ingesting of blood

Pathogenesis Larva – ground / dew itch, creeping eruptionAdult – IDA Microcytic, Hypochromic Anemia

Laboratory diagnosis Concentration methods and Direct Fecal Smear

Treatment Albendazole, Mebendazole, or Pyrantel Pamoate
Length of adult hookworm
5-9 for males; 9-11 for females
(mm)

Shape Head curved opposite to curvature of body, giving a hooked appearance to anterior end

Egg output per female worm

5,000-10,000
per day
Blood loss per worm per day
0.03
(ml)
Temperature at which 90% of
20-35
eggs hatch (C)[55]

Diagnostic Feature - Adult Semi-lunar cutting plate; Bipartite dorsal ray

Diagnostic Feature - Egg In Morula
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Genus and Species Necator americanus Ancylostoma duodenale

Common Name New world hookworm Old world hookworm
Etiologic Agent of: Necatoriasis, Uncinariasis Ancylostomiasis,Wakana disease[54]
Infective stage Filariform larva Filariform larva
Definitive Host Human Human
Portal of Entry Usually via skin penetration rather than ingestion Usually via ingestion rather than skin penetration

Mode of Transmission Skin > Mouth Mouth > Skin

Habitat[55] Small Intestine (jejunum, ileum) Small Intestine (duodenum, jejunum)
Pathogenic Stage L3 Larva L3 Larva
Maturation time in host
49-56 53
(days)[55]
Mode of Attachment Oral attachment to mucosa by sucking Same
Mode of Nutrition Sucking and Ingesting of blood Same
Larva – ground / dew itch, creeping eruptionAdult – IDA
Pathogenesis Same
Microcytic, Hypochromic Anemia
Laboratory diagnosis Concentration methods and Direct Fecal Smear Same

Treatment Albendazole, Mebendazole, or Pyrantel Pamoate Same

Length of adult hookworm
5-9 for males; 9-11 for females 8-11 for males; 10-13 for females
(mm)[56]
Head curved opposite to curvature of body, giving a hooked
Shape[56] Head continuous in same direction as the body
appearance to anterior end
Egg output per female worm
5,000-10,000 10,000-25,000
per day[55]
Blood loss per worm per day
0.03 0.15-0.23
(ml)[55]
Temperature at which 90% of
20-35 15-35
eggs hatch (C)[55]

Diagnostic Feature - Adult Semi-lunar cutting plate; Bipartite dorsal ray Male – Tripartite dorsal ray

Diagnostic Feature - Egg In Morula Same

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Wuchereria bancrofti
Kingdom: Animalia
Phylum: Nematoda
Class: Secernentea
Order: Spirurida
Suborder: Spirurina
Family: Onchocercidae
Genus: Wuchereria

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• common name = Bancroft’s filaria

• it affects over 120 million people,
primarily in Africa, South America, and
other tropical and sub-tropical
countries.

• found throughout the tropics as in the

Figi Islands, Samoa, China, Japan, Korea,
Thailand, Malaysia, Philippines & others.
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• with hyaline sheath

best seen where it
projects slightly
beyond the anterior
& posterior ends of
the embryo.
• single stylet is seen
at the anterior end.

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The microfilariae can be found

free in the fluid within the
nodules and in the dermal
layers of the skin spreading
centrifugally from the area
where an adult lies.

Microfilariae also can be found

in the blood and eye during
heavy infections.

first stage larvae are known as MICROFILARIAE. The

microfilaria are present in the circulation. The microfilaria
migrate between the deep and the peripheral circulation.
During the day they are present in the deep veins and during
the night the migrate to the peripheral circulation

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Different species of mosquitoes are vectors of W. bancrofti filariasis

depending on geographical distribution.
•Culex (C. annulirostris, C. bitaeniorhynchus, C. quinquefasciatus
and C. pipiens);
•Anopheles (A. arabinensis, A. bancroftii, A. farauti, A. funestus, A.
gambiae, A. koliensis, A. melas, A. merus, A. punctulatus and
A. wellcomei);
•Aedes (A. aegypti, A. aquasalis, A. bellator, A. cooki, A. darlingi, A.
kochi, A. polynesiensis, A. pseudoscutellaris, A. rotumae, A.
scapularis, and A. vigilax);
•Mansonia (M. pseudotitillans, M. uniformis);
•Coquillettidia (C. juxtamansonia).

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They infect their fly vectors while the flies are feeding on
the human host and mature into stage three infective
larvae in the flight muscles of the fly (in about 10 days).
A mosquito is the intermediate host and
carrier. The most common vectors/carriers
are:
in Africa: Anopheles species
in the Americas: Culex quinquefasciatus
in the Pacific and in
Asia: Mansonia and Aedes species.

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The larvae moves to the

lymph nodes, an adult female can
predominantly in the produce microfilariae
legs and genital area, herself.
and develops into adult
worm over the course
of a year.

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The pathogenesis of W. bancrofti infection is

dependent on the host's immune system
and inflammatory responses.

1. Asymptomatic Phase - Usually consists

of high microfilaremia infection and
individuals show no symptoms of being
infected. This can occur for years until the
inflammatory reaction rise again.

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2. Inflammatory (Acute) Phase

antigens from the female adult worms elicit
inflammatory responses.

- The worms in the lymph channels disrupt the

flow of the lymph causing lymphedema.

- The individual will exhibit fever, chills, skin

infections, painful lymph nodes, and tender
skin of the lymphedematous extremity.
-

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These symptoms often lessen after 5-7 days.

Other symptoms that may occur include:

Orchitis -inflammation of the testes, which

is accompanied by painful
immediate enlargement

Epididymitis - which is the inflammation of

the spermatic cord.

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3. Obstructive (Chronic) Phase

- marked by lymph varices, lymph

scrotum, hydrocele, chyluria (lymph in
urine), and elephantiasis.

- Microfilariae are not normally present in this

phase.

- A key feature of this phase is scar formation

from affected tissue areas.

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Other features include thickening of the skin and

elephantiasis which develops gradually with the
attack of the lymphatic system.

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In women,
Elephantiasis
the legs and
affect men mainly arms are
on the legs, arms, affected.
and scrotum.

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Podoconiosis - a non-infectious geochemical

elephantiasis caused by exposure of bare feet
to irritant alkalic clay soils.

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PATHOLOGY
Sequence of events:
1. biological incubation period lasts 1 year
or more.

2. Latent (evident, obvious) symptomless

period.

3. Acute stage with lymphangitis,

lymphadenitis, “filarial fever” as the
conspicuous symptoms.
4. Chronic stage develops w/ the
enlargement of the involved organ.

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Prognosis in the absence of elephantiasis is good.

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Treatment

The severe symptoms caused by the parasite can be avoided

by cleansing the skin, surgery, or the use of therapeutic
drugs, such as Diethylcarbamazine (DEC), ivermectin, or
albendazole.

The drug of choice however, is DEC, which can eliminate the

microfilariae from the blood and also kill the adult worms with
a dosage of 6 mg/kg semiannually or annually.

A polytherapy treatment that includes ivermectin with DEC or

albendazole is more effective than each drug alone.

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Prevention and control:

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Brugia
Kingdom: Animalia
Phylum: Nematoda
Class: Secernentea
Order: Spirurida
Family: Onchocercidae
Genus: Brugia
Species: B. malayi
(Brug 1927)

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Common Name :
Malayan filarial worm

causing Malayan filariasis

• Identified by Lichtenstein
• formerly known asFilaria malayi

B. malayi infects 13 million people in south and southeast

Asia and is responsible for nearly 10% of the world’s total
cases of lymphatic filariasis. B. malayi infection is
endemic or potentially endemic in 16 countries, where it is
most common in southern China and India, but also
occurs in Indonesia, Thailand, Vietnam, Malaysia, the
Philippines, and South Korea. The distribution of B.
malayi overlaps with W. bancrofti in these regions.
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Detail from the microfilaria of Brugia malayi

showing the tapered tail, with a subterminal
and a terminal nuclei (seen as swellings),
separated by a gap without nuclei.

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They migrate
to the lymphatics,
where they
develop into
adults, a slow
process that
can require
up to 18 months.

Inside the mosquito,

the microfilariae develop in 1
to 2 weeks into infective
filariform (third-stage) larvae.

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Pathology (similar to W. bancrofti)

Observed symptoms - similar to

allergic reactions such as :
• adenopathy
• asthmatic attacks
• eosinophilia
• severe dermatitis (complication)
• elephantiasis of the
groin and upper extremities
(instead of the lower as observed
HYDROCOELE
in W.bancrofti) – in advanced cases

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Treatment:
➢ same as for bancroftian filariasis.
Diethylcarbamazine (DEC) has been used in mass
treatment programs in the form of DEC-medicated salt, as
an effective microfilaricidal drug in several locations,
including India.

➢ While DEC tends to cause adverse reactions like

immediate fever and weakness, it is not known to cause
any long-term adverse drug effects.

➢ DEC has been shown to kill both adult worms and

microfilariae. Microfilariae numbers slowly return many
months after treatment, thus requiring multiple drug doses
over time in order to achieve long-term control of DEC
resistance.

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Onchocerca
Kingdom: Animalia
Phylum: Nematoda
Class: Secernentea
http://www.microbe.tv/twip/24-onchocerca-volvulus-a-vector-
Order: Spirurida borne-filarial-nematode/

Family: Onchocercidae
Genus: Onchocerca
Species: O.volvulus
(Bickel 1982)

is the world's second leading infectious cause of blindness.

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➢ Human onchocerciasis is found in both the Old

and New World but about 96% of all cases are
in Africa and mostly in Western Africa.

➢ Of the 36 countries where the disease is

endemic, 30 are in sub-Sahara Africa (plus
Yemen) and six are in the Americas.

➢ Important foci exist also in Mexico, Guatemala,

Venezuela and Ecuador.

➢ A total of 18 million people are infected with

the disease and have dermal microfilariae, of
whom 99% are in Africa.

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• disease is confined to neighborhoods of

low elevation with rapidly flowing small
streams where black flies breed.

• Blinding filariasis; river blindness;

Onchocerciasis
• prevalent throughout eastern,
central & western Africa, where it is
the major cause of blindness. In
the Americas, it is found in
Guatemala, Mexico, Colombia
& Venezuela.

• Man is the only host.

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• filiform and blunt at both ends.

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After mating the female sheds microfilariae 300

mm in length and 0.8 mm in diameter. The
microfilariae are sheathless with sharply
pointed, curved tails.

The microfilariae can be found free in the fluid

within the nodules and in the dermal layers of
the skin spreading away from the nodules
containing the adults.

Microfilariae also can be found in the blood and

eye during heavy infections.

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Onchocerca volvulus, posterior end

Vector : Simulium (Blackfly)

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microfilariae lifespan is 1–2 years.

they mature over the course of

one to three weeks to stage
three larvae. produce between 1,000
and 3,000 microfilariae per day.

The normal adult worm lifespan is up to fifteen

years. The eggs mature internally to form stage one
microfilariae, which are released from the female's
body one at a time and remain in the subcutaneous
tissue.
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SYMPTOMS
• fibrous nodules (onchocercomas)
develop around the adult worms in the
skin & subcutaneous tissues.
• elephantiasis sometimes result (adults
obstructing lymph flow) = hanging
groins.
• presence of microfilariae in the skin
cause svere dermatitis (itchiness),
thickening, discoloration & cracking of
skin.

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The burden of onchocerciasis: children leading blind adults in Africa.

Ocular complications may occur from

infection of the scalp near the eye orbit
where the microfilariae migrate and
invade the cornea causing inflammation
of sclera leading to BLINDNESS.
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• Diagnosis is based on symptoms, history of

exposure to black flies and presence of
microfilaria in nodules.

• Treatment and control

Diethylcarbamazine is effective in killing
the worm. Destruction of microfilaria
produces extreme allergic reaction which
can be controlled with corticosteroids.
Prevention measures include vector
control, treatment of infected individuals and
avoidance of black fly.

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Loa loa
Kingdom: Animalia
Phylum: Nematoda
Class: Secernentea
Order: Spirurida
Family: Onchocercidae
Genus: Loa
Species: L.loa
Loiasis is endemic to 11 countries and 12 million Africans are infected
mostly in Cameroon, Equatorial Guinea, Gabon, Nigeria, the Central
African Republic, the Democratic Republic of Congo and the Republic of
the Congo.

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• African Eye worm,

producing African Loiasis
or Calabar swellings
Lives under the skin in the subcutaneous fat causing
loiasis. Because it is often spotted migrating in the eye, it
is known as the eye worm.
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Loa loa adults live up to

17 years.

Loa loa, posterior end.

female worms measure 40 to 70 mm in length and 0.5
mm in diameter, while the males measure 30 to 34
mm in length and 0.35 to 0.43 mm in diameter.

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nuclei extending to the tip of the tail.

Chrysops (deer fly)

vector of human
Loiasis.

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Filariasis such as loiasis most often consists of

asymptomatic microfilaremia.

Some patients develop lymphatic dysfunction

causing lymphedema.

Episodic angioedema (Calabar swellings) in the

arms and legs, caused by immune reactions are
common.
When chronic, they can form cyst-like enlargements of the
connective tissue around the sheaths of muscle tendons,
becoming very painful when moved.

The swellings may last for 1-3 days, may be accompanied

by localized urticaria (skin eruptions) and pruritus (itching).

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Treatment involves chemotherapy or, in some

cases, surgical removal of adult worms followed by
systemic treatment. The current drug of choice for
therapy is diethylcarbamazine (DEC), though
ivermectin use is not unwarranted. The
recommend dosage of DEC is 6 mg/kg/d taken
three times daily for 12 days.

DEC can cause encephalopathy (brain disease) and

death in people who are infected with Loa loa.

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