ASCARIS LUMBRICOIDES

 a common cream colored roundworm that is parasitic in

the intestines of humans
* Most common nematodes among human
* Found/resides in the small intestine
 Most common helminthic human infection
*Considered as an erratic parasite
 Largest nematode to infect the human intestine
 The adult parasites live in the duodenum and proximal
 An estimated 1 billion people are infected (1 out of 4
jejunum but not attach in the mucosa.
people in the world)
 Larva morphology is similar to the adult.
 Ascaris is a soil-transmitted helminth (STH), along with
 Produce pepsin inhibitor 3 (PI-3) that protects worms from
hookworms and Trichuris.
digestion, and phosphorylcholine that suppresses
- The soil plays a major role in the development and
lymphocyte proliferation.
transmission of the parasite.
 Each female lays approximately 200,000 non-
*they survive better on clay soil
embryonated eggs per day.
 STH infections are diseases of poverty, and contribute to
 When the eggs are deposited in a satisfactory
malnutrition and impairment of cognitive performances;
environment, they become infective in four to six weeks.
also reduce work capacity and productivity of adults.
ii. Fertile egg
 It causes a varying degree of pathology:
 mammillated
- Tissue reaction to the invading larvae
 thick external layer
- Intestinal irritation to the adult, and
 Delicate vitelline, lipoidal, inner membrane, which is highly
- Other complications due to heavy infection and
impermeable
extraintestinal migration.
 unembryonated
 measures 55-75 mm by 35-50 mm
Geography:
 When oviposited, it will develop into larvae in about
 Worldwide
14days.
 High prevalence in underdeveloped countries that have
iii. Infertile egg
poor sanitation (parts of Asia, South America and Africa)
 elongated and larger than fertile egg
 Occurs during rainy months, tropical and subtropical
 thin shelled
countries
 shell ranges from irregular mammillations to a relatively
 Even occurs in rural areas in the United States
smooth layer completely lacking mammillations
 Like Trichuris, it is especially common in children, who are
 measures between 85-95 mm by 43-47 mm
also more likely to have heavy infections.

Host: Fertile: Infertile:

 Definitive host : Humans or pigs
 Intermediate Host : -none-

Modes of transmission:
 Occurs mainly via ingestion of water or food (raw
vegetables or fruit in particular) contaminated with A.
lumbricoides eggs.
 Occasionally inhalation of contaminated dust Eggs:
 Children playing in contaminated soil may acquire the
 Can survive for prolonged periods as long as warm, shade,
parasite from their hands
moist conditions are available and can live up to 10 years
 Enhanced by the fact that individuals can be
 Eggs are resistant to unusual methods of chemical water
asymptomatically infected and continues to shed eggs for
purification
years
 Eggs are removed by filtration and killed by boiling.
 Prior infection does not confer protective immunity
Developing larvae are destroyed by sunlight and
desiccation
Morphology:
i. Adult worm: Life Cycle:
 tapered ends; length 15 to 35 cm 1. Females lay eggs in small intestine and eggs are passed out
 Female are larger in size and have a genital girdle through feces.
 Male are smaller and has the posterior end curved 2. After 14 days, L1 larvae develops in eggs
ventrally 3. L2 larvae develops after one week
 4. Ingestion of raw foods, fruits or vege contaminated with
eggs will cause infection
5. Eggs hatch in small intestine, releases L2 rhabditiform
larvae
6. L2 penetrate intestinal wall, enter portal blood stream,
migrate to liver, heart and lungs in 1-7 days
7. Moults twice to become L4 larvae
8. Borrow out of blood vessels and enter bronchioles
9. Migrate through the lungs into the trachea
10. Enter throat and swallowed to end up in the small
intestine
11. Mature and mate, where they complete their life cycle
12. The entire development from embryonated egg to adult
takes approximately two months.
*Sometimes they lodge into the eyeball, kidney, brain, spinal chord
*initiate granulomatous reaction
Food Habits :
 Feeds on semi-digested contents in the gut
 Evidence show that they can bite the intestinal mucus
membrane and feed on blood and tissue fluids
Symptoms:
Symptoms associated with larvae migration
 Migration of larvae in lungs may cause hemorrhagic/
eosinophilic pneumonia, cough (Loeffler's
Syndrome)characterized by diffuse mottled infiltrates of
both lungs in radiographs.
 The syndrome occurs in persons who have been previously
sensitized to Ascaris antigens.
 Breathing difficulties and fever
 Complications caused by parasite proteins that are highly
allergenic - asthmatic attacks, pulmonary infiltration and
urticaria (hives)
Symptoms associated with adult parasite in the intestine
 Ascariasis varies from asymptomatic infection to severe
disease.
 Abdominal discomfort, nausea in mild cases
 Malnutrition in host especially children in severe cases
 Sometimes fatality may occur when mass of worm blocks
the intestine, especially in young children, and migration
to the common bile duct may cause biliary colic and
obstruction, leading to cholangitis and intrahepatic
abscess.
 Migration to the appendix may cause appendicitis and to
the stomach, emesis.
 Fever or drug therapy (esp. anesthetics)may stimulate
migration.
* In the intestine a few worms will not usually cause noticeable
symptoms, but heavy infection may produce pain, abdominal
discomfort, and diarrhea.
Host immune response:
Innate Immune Response
 Macrophage, neutrophils and most importantly
eosinophils
 The worms would be coated with IgG or IgE which would
increase the release of eosinophil granules on the worm’s
surface
Adaptive Immune Response
 General consensus is a Th2 (T-Helper 2) immune response
with high IL-4 (Inter Leukin 4) production, high levels of
IgE, eosinophilia and mastocytosis
 Stool microscopy :eggs may be seen on direct examination
of feces.
 Eosinophilia: eosinophilia can be found, particularly
during larval migration through the lungs
 Imaging: In heavily infested individuals, particularly
children, large collections of worms may be detectable on
plain film of the abdomen.
 Ultrasound: ultrasound exams can help to diagnose
hepatobiliary or pancreatic ascariasis. Single worms,
bundles of worms, or pseudotumor-like appearance,
individual body segments of worms may be seen.
 Endoscopic Retrograde Cholangiopancreatography
(ERCP) : A duodenoscope with a snare to extract the worm
out of the patient
* The 200,000 eggs that one female produces every 24 hours will
give at least 5 eggs per slide of 2 mg of feces. Counts of less than 20
eggs per slide indicate light infections and over 100, heavy
infections.
*Possible reasons why test results negative:
- The parasite residing is all male
- The infection is too early for detection
In this case, the test should be repeated after 1 month
Treatment: safe treatment of foodstuffs
 Mebendazole Latrine use
 Albendazole Use of footwear
 Pyrantel pamoate Deworming:
 Ivermectin Regular mass and drug administration (twice a year for
 Piperazine citrate school-age children).
 Levamisole
*these drugs has a neuromascular blocking effect, paralyzing
the parasite TRICHURIS TRICHIURA
Whip worm
Factors that affect the level of transmission to humans:
1. High Density of human population  Common name: whip worm
2. Involvement of agriculture  Disease: trichuriasis, whip worm infection
3. Illiteracy  Final host: human, dogs, pig, monkey
4. Poor sanitation  Habitat: large intestine(cecum, appendix, rectum)
5. Poor health education on personal family and community  Geographical distribution: Cosmopolitan with poor
hygiene sanitation.
 Children are more likely to be infected than adults
Prevention: because they are more likely to have close physical
 Prevention of reinfection poses a substantial problem contact with contaminated soil
since this parasite is abundant in soil – therefore good  Infective stage: infective larva in egg
sanitation is needed to prevent fecal contamination of soil  Transmission occurs through ingestion of eggs, usually on
 Limit using human feces as fertilizer contaminated vegetables or soil.
 Treatment can be done on contaminated soil although it is  Diagnostic stage: Egg barrel shape with polar plugs
not highly advised *Trichuris trichiura and Enterobius vermicularis are the
 Mass treatments of children with single doses of only parasites that can be found in the large intestine
mebendazole or albendazole – helps reduce transmission Morphology:
in community but can cause reinfection Adult female worm:
 WHO recommends parasitologic monitoring among school  The anterior two-thirds of the body being very thin
children.  (looks like a whip) and the remaining posterior end is thick
 Stool samples are collected for examination using kato- and linear.
katz methods.  Size: 3.5-5cm in length
*Direct Fecal Smear is less sensitive than the kato-katz and  Lays approx. 3,000 t0 10,000 eggs/day
kato-thick method  Longer than the male.
 Monitoring is recommended every 2 years.  Posterior end is thick and linear.
 Reinfection is usually observed four months
posttreatment and full reinfection appears 6 to 7 months Adult Male worm:
after treatment.  smaller than the female, 3.0-3.5cm.
 Nutritional status and school performance may also be  The posterior end is coiled or curved and has a single
monitored. spicule
 WASHED (water, sanitation, hygiene, education,  enveloped with sheath
deworming)  Shorter than the female.
 Water:  posterior end curved and
- Access to potable water  has a single spicule
- Drainage and disposal/reuse/recycling of household  enveloped with sheath.
wastewater (also referred to as grey water)
 Sanitation: *Adult worm penetrates into and
- Access to safe and clean sanitation facilities embed its whip-like anterior portion in the intestinal mucosa, By
- Safe collection, storage, treatment, and disposal (feces small spear.
and urine) * posterior end curved and has a single
- Management/reuse, recycling of solid waste spicule enveloped with sheath
 Hygiene Education:
- Appropriate info regarding prevention and treatment of
STH infections.
- Dissemination of key messages to promote the following
practices:
safe water storage
safe handwashing and bathing practices
Eggs:
 Shape: barrel–shaped Pathology:
 Size: 50-55 x 25-30μm  Light infection with

 Shell: thick egg shell with 2 polar plugs (yellowish outer Trichiuris are
and transparent inner shell) asymptomatic
 Color: Yellow-brown  Heavier infections are

 Content: immature egg cells characterized by

 3000-10000 eggs daily output  diarrhea,
*conditioned in clay soil – warm, shaded, moist, or clay soil ; less  anorexia,
resistant to adverse conditions than the ascaris eggs  nausea
 abdominal pain
 mucosal -- anemia may be the result of hemorrhaging
when the worms penetrate the intestinal wall (damage)
 Rectal prolapse.
Children’s infection can cause rectal prolapse, The reason is the
cecum is damaged by the worm, the cecum can be pushed out from
the anus.

Laboratory diagnosis:
 Eggs or worm in feces. Eggs are oval, barrel shaped,
 Eosinophilia may occur.
 In heavy infection proctoscopy or sigmoidoscopy, can show
the worms attached to the mucosa.
 Visual detection of adult worms on prolapsed rectum.
Techniques:
 DFS
Life cycle:
 Kato Thick Smear
 Eggs pass out immature
 Kato-Katz Technique to assess the efficacy of
 Embryo develops inside the egg (that takes about 3weeks at
antihelminthic drugs in terms of cure rate (CR) and Egg
25C)
Reduction Rate (ERR)
 Mature eggs swallowed  1st stage larvae hatch in small  Concentration Techniques (AECT and FECT)
intestine and penetrate villi  FLOTAC technique – more sensitive than Kato-Katz and
 Then migrate to large intestine and attach to mucosa with the concentration techniques
thin anterior end
 After 2-4 month females mature and lay eggs.

Treatment:
 Mebendazole
 Albendazole
Epidemiology:
 Its distribution is similar to Ascariasis
 Prevalence of coinfection with Ascaris is 19.1%
Prevention and Control
 Similar to Ascaris infections
  WHO recommends biannual mass drug administration
with mebendazole or albendazole
 Once a year treatment is recommended in communities
with STH prevalence <50%
 Provision of safe water, environmental sanitation, and
hygiene education are important in STH control.
II. Necator Americanus

HOOKWORMS

 are soil-transmitted helminths.

 are blood-sucking nematodes that attach to the mucosa of
the small intestines.
 all hookworms have the meromyarian type of somatic
muscle w/ two to five cells arranged per dorsal or ventral
half.
 Eggs are conditioned in a sandy, loam soil with rainfall

History and distribution:

 Ancient times – ebers papyrus
 Tropics and subtropicss
 Ancylostoma duodenale and Necator americanus are
human parasites.
 Ancylostoma braziliense, Ancylostoma ceylanicum, and
Ancylostoma caninum are animal parasites – cause larva
migrans in humans.
 A. duodenale described by Dubini in 1843 in Italy. Life
cycle was described by Looss 1898 in Egypt.
 N. americanus identified by Stiles 1902 in USA
 A. duodenale was distributed to north and N. americanus
to the south in endemic zones.
 A. duodenale – Old World hookworm
 N. americanus – New World hookworm
 The hookworms cause hookworm disease.  Morphologically it is not possible to differentiate between A.
 Lives in small intestine. duodenale and N. americanus. Interference contrast. ×400.
Enlarged by 5.4.
I. Ancylostoma duodenale
Morphology: The Morphological Differences between Two species of
 Stout, cylindroidal, pale Hookworms:
pink or greyish white but _____________________________________________________
appear reddish brown due A. duodenale N. americanus
to ingested blood ______________________________________________________
 Body is curved, dorsal
Size larger smaller
concave, ventral convex, ______________________________________________________
anterior end is constricted Shape single curve, looks like C double curves, looks like S
and bent dorsally, and ______________________________________________________
mouth is directed dorsally. Mouth 2 pairs of ventral teeth 1pair of ventral cutting plates
 The adult is slightly larger than N. americanus, and each adult ______________________________________________________
has single-paired male or female reproductive organs. Copulatory circle in shape oval in shape
Bursa (a top view) (a top view)
______________________________________________________
Copulatory 1pair with separate 1pair of which unite to form
spicule endings a terminal hooklet
______________________________________________________
caudal spine present none
______________________________________________________
vulva position post-equatorial pre-equatorial
_______________________________________________________
Rhabditiform characteristics: Necator Americanus:
 Rhabditiform larvae of N. americanus and A. duodenale are
indistinguishable.
 They resemble those of S. stercoralis, but are somewhat
larger, more attenuated posteriorly, and have a longer buccal
cavity.
 The genital primordium is smaller in hookworms compared
with S. stercoralis.

Filariform characteristics
 The buccal spears of the N. americanus are conspicuous and
parallel throughout their lengths; and there are conspicuous
transverse striations present on the sheath in the tail region. Pathogenesis
 The buccal spears of the A. duodenale are inconspicuous; also Involves:
the transverse striations on the sheath of the tail region is 1. The skin at the site of entry of the filariform larvae
inconspicuous. 2. The lung during larval migration
3. The small intestine, the habitat of the adult worms
Life Cycle:

 Final host: man

 Inf. Stage: Larva 3 or filariform larva
 Inf. Route: by skin
 Food: blood and tissue fluid
 Site of inhabitation: small intestine
 Life span: Ad 2-7years, Na 4-20years
 Blood-lung migration:
skin, cavum, right heart, lungs
 Techniques:
III. Pathogenesis and Clinical Manifestations
1. Larval migration
(1) Dermatitis, known as "ground itch" or "stool poison".The
larvae penetrating the skin cause allergic reaction, petechiae or
papule with itching and burning sensation. Scratching leads to
secondary infection.
(2) pneumonitis (allergic reaction), Loeffier's syndrome: cough,
asthma, low fever, biood-tinged sputum or hemoptysis, chest-pain,
inflammation shadows in lungs under X-ray. These manifestations
go on about 2 weeks.
2. Adults in small intestine
(1) Epigastric pain as that of a duodenal ulcer.
(2) A large worm burden results in microcytic hypochromic
anemia (character manifestation). The symptoms are lassitude,
edema, palpitation of the heart. In severe case, death may result
from cardiac failure or physical exhaustion.
(3) Allotriophagy (orpica) is due to the lack of trace element iron .
(4) Amenorrhea, sterility, abortion may take place in women.
(5) Gastrointestinal bleeding
(6) Infantile hookworm disease
 Hypoalbuminemia is another manifestation of hookworm
infection.
 There is low level of albumin due to combined loss of blood,
lymph, and protein.
 Unlike in ascariasis, the complications in hookworm infection are
quite mild, and remedial measures are readily applied.
 In general, the prognosis of hookworm infection is good.
 During the migration of the larva in th ehuman body, the
parasite continuously presents diverse immunogenic challenges
to the host.
 Extensive humoral responses are produced against the larva and
the adult hookworm, which share many antigens.
 Cellular immune response is primarily mediated by eosinophils,
mast cells, and Th2 cells.
 Despite all of these, there has been no clear evidence that the
host develops perpetual immunity against hookworm infection;
however, polyvalent IgE antibodies have been suggested to
provide some protective roles.
Diagnosis:
 The clinical picture, though characteristic, is not pathognomonic
to permit differentiation from other helminth infections.
 Final diagnosis depends on the identification of parasite ova in
the feces.
Criterion:
1. hemoglobin is lower than 120g/L in man, 110g/L in
woman.
2. find hookworm egg
1. Direct fecal smear
2. Kato thick or Kato-Katz Method
3. Concentration methods like saturated brine flotation
technique and FECT
4. culture of larvae like Harada-Mori method
5. Molecular approaches, which include PCR-based detection
of hookworm DNA in feces and ELISA for the detection of
secretory/excretory coproantigens.
 DFS is of value only when the infection is quite heavy but
not in light infections.
 The Kato-Katz provide quantitative diagnosis by
determining the intensity of infection in terms of number
of helminth eggs per gram of feces; however, the
disadvantage is the rapid clearance of hookworm eggs
after 30 to 60 minutes with the use of glycerine as clearing
agent.
 In concentration methods, may contribute to the increase
in sensitivity.
 In culture methods, this allow hatching of larvae from eggs
on strips of filter paper with one immersed in water; This
is recommended for species identification.
Treatment:
 WHO recommends mass drug administration among
school-age children at least once a year for communities
with cumulative STH prevalence greater than or equal to
20%.
1. Albendazole – drug of choice (larvicidal and ovicidal) – 400
mg single dose both adults and children over 2y/o
2. Mebendazole – 500 mg single dose both adults and
children over 2y/o.
 These drugs block the uptake of glucose by most intestinal
and tissue nematodes.
 Anemia and hypoproteinemia should also be addressed by
giving iron supplementation and adequate diet.
 In recent years, tolerance and resistance of human
hookworms to these drugs had been reported in countries
where regular deworming is the main control strategy.
 Studies had shown that the use of the recommended
single dose of the drugs led to low cure rate.
 So, baseline data are necessary for the evaluation and
adjustment of the treatment regimen.
 Cure rates, egg reduction rates, and reinfection rates are
important parameters in drug monitoring.
Epidemiology
 worldwide distribution.
 22-26℃ is the optimal temperature for A. duodenale
development; A. duodenale mainly prevalent in north of
China.
 31-35℃ is suitable for N. americanus, it is mainly
prevalent in south of China.
 In the Phil., local studies on speciation of human
hookworms revealed that out of 1,958 samples positive
for hookworm in cultures, 97% were identified as N.
americanus, 1% as A. duodenale, and 2% were mixed
infections.
Factors that contribute to the distribution and transmission of  Both Necator americanus and Ancylostoma doudenale are
hookworms: transmitted through precutaneous and oral transmission.
 Suitability of the environment for eggs or larvae: damp, sandy,
or friable soil with decaying vegetation, and temperature of 24 Difference between S. stercoralis and hookworm rabditiform:
to 32oC. Hookworm S. stercoralis
 Mode and extent of fecal pollution of the soil (Through open Rabditiform Short and stout, Muscular,
defecation or the use of night soil as fertilizer). Characteristics flask shape, elongated
 Mode and extent of contact between infected soil and skin or muscular bulbous esophagus with a
esophagus pyriform
mouth.
posterior bulb
Morphology More attenuated Less attenuated
Method of human infection:
posteriorly posteriorly
 Necatoriasis – pure percutaneous Buccal Cavity longer Shorter
 Ancylostomiasis – both percutaneous and through the oral Genital Smaller larger
route. primordium
 Oral route occurs through eating raw vegetables contaminated Filariform Slender and long
with infective larvae and probably also through ingestion of Chracteristics
raw or insufficiently cooked infected meat, although it is not
clear whether infection through eating raw meat occurs in
humans.
 A. duodenale may remain dormant in the intestines or in the
muscles, resulting in a prolonged incubation period and
creating problems in treatment.
 Transmammary transmission has also been reported.

Prevention:
 Unified measures:
 sanitary disposal of night soil
 individual protection
 health education
 cultivate hygienic habits
 treat the patients and carriers
 In the Phil, the WASHED approach is being advocated for a
more comprehensive control of STH infections.
 This approach refers to improvement in access to clean water
and sanitation, promotion of hygiene education, and regular
deworming.
 Open defecation should be discouraged and sanitary disposal
of human feces as well as wearing of shoes, slippers, and boots
should be advised.

**
1. Necator americanus – American hookworm
 American Murderer
 New world hookworm
 from North and South
America
2. Ancylostoma duodenale – Old hookworm; from Africa, India,
China, Japan and Southern Europe
3. Ancylostoma braziliense – Cat hookworm
4. Ancylostoma caninum – Dog hookworm
5. Ancylostoma ceylanicum – no common name, but is
known to cause cutaneous larva
migrans or creeping eruption
 Human hookworms: Necator americanus and Ancylostoma
duodenale
 Can cause cutaneous larva migrans: Ancylostoma braziliense,
Caninum and ceylanicum