Module 2: Phylum Platyhelminthes Slide

No.
2.1 CESTODES (TAPEWORMS)
2.1.1 INTESTINAL CESTODES
2.1.1.1 Taenia saginata 8

2.1.1.2 Taenia solium 19

2.1.1.3 42
Hymenolepis diminuta
2.1.14 52
Hymenolepis nana
2.1.1.5 64
Dipylidium caninum
2.1.1.6 73
Raillietina garrisoni
2.1.1.7 83
Diphyllobothrium latum
2.1.2 EXTRAINTESTINAL CESTODES
2.1.2.1 95
Echinococcus granulosus
2.2 TREMATODES (FLUKES)
General Characteristics of Cestodes --
▪ Cestodes are segmented, with ribbon-like appearance; do not have a digestive tract &
circulatory system.
▪ Adult tapeworms are hermaphroditic.
▪ Found in the intestines of definitive host, and the larval stage is encysted in the tissues of
the intermediate host.
▪ Have an anterior structure called the scolex, the main organ of attachment to the definitive
host. (Slide #s 3/4)
▪ After the scolex is the neck, followed by the strobila. The neck is considered the region of
growth, because segmentation or strobilization originates from it. (Slide # 4)
▪ Segments or proglottids that are nearest to the neck are the most immature, followed by
increasingly mature segments, and the most distal are gravid segments. (Slide # 4)
▪ The cestodes are grouped together into different orders, just like the nematodes. However,
there are only two orders of tapeworms with medical and public health significance, namely,
Order Pseudophyllidea and Order Cyclophyllidea.
▪ These two orders differ in terms of the morphology of the scolex, segments, and eggs, as
well as in the number of intermediate hosts and the type of encysted larvae that develop in
the intermediate hosts.
Pseudophyllidean Scolex Cyclophyllidean Scolex
Features of tapeworm morphology-overview --
 General Characteristics of Cestodes – (Cont’d.)
▪ Pseudophyllidean tapeworms have a spatulate scolex with sucking grooves, called bothria,
while the Cyclophyllidean scolex is globular with four cup-like, muscular suckers.
▪ Segments of both orders have genital pores but Pseudophyllidean segments, in addition,
have a uterine pore which allows release of eggs from the gravid uterus.
▪ Since Cyclophyllidean segments do not have the uterine pore, they undergo the process of
apolysis whereby gravid segments are detached from the main body of the worm and eggs
are eventually released.
▪ For diagnostic purposes, in Cyclophyllidean infections, both eggs and segments are
recovered from the patients, while in Pseudophyllidean infections, segments may not be
found.
▪ Non-operculated Cyclophyllidean eggs are passed out readily, containing the hexacanth
embryo.
▪ Pseudophyllidean eggs, which are operculated and immature, require aquatic development
of the embryo, called the coracidium.
▪ Pseudophyllidean worms generally require two intermediate hosts in their life cycle:
a) first intermediate host - eggs encyst as procercoid larvae
b) second intermediate host - plerocercoid larvae
 General Characteristics of Cestodes – (Cont’d.)
▪ Two members of medical importance:
a) Diphyllobothrium, which utilizes humans as definitive hosts
b) Spirometra, which employs humans as an intermediate host.
▪ Cyclophyllidean worms require only one intermediate host. Different species of
Cyclophyllideans produce different types of encysted larvae in their intermediate hosts.
▪ Pseudophyllideans have 2 intermediate host (1ST/2nd); Cyclops and Diaptomus as first
intermediate hosts and the fish as second intermediate host containing the Plerocercoid
larva or Sparganum which is infective for man.
▪ Among Cyclophylideans, there is only one intermediate host. Each species of
Cyclophyllidean has its own intermediate host which harbors the infective stage for man.
▪ Taenia produce cysticercus larvae; Hymenolepis, Dypilidium & Raillietina produce
cysticercoid larvae; Echinococcus produce hydatid cyst - all infective to the final host which
is man or other forms of animals or arthropod.
▪ Infection with adult tapeworms is generally acquired through the consumption of infected
intermediate hosts. There are cases, however, where humans are infected with the larval
stage of Taenia solium, a condition known as cysticercosis, and of Echinococcus spp. hydatid
cyst, called Echinococcosis.
2.1.1.1 Taenia saginata -

Intestinal Cestodes - Taenia saginata -

▪ Taenia saginata is known as the beef tapeworm of humans.
▪ Humans serve only as definitive host and never as intermediates host. Therefore, human
cysticercosis due to this species does not occur.
▪ The epidemiology, prevention, and control of T. saginata will be considered jointly under the
section on T. solium.
Parasite Biology (Taenia saginata) -- (Slides # 10, 12)
▪ The adult worm inhabits the upper jejunum and can live for up to 25 years. It derives
nourishment from intestinal contents.
▪ Adults measure 4 to 10 m in length and may have 1,000 to 4,000 proglottids. There have
been reports of worms reaching 25 m in length.
▪ The cuboidal scolex measures 1–2 mm in diameter and has four prominent suckers.
▪ Some tapeworms are devoid of hooks or a rostellum while other species have. Attached to
the scolex is a short neck from which a chain of immature, mature, and gravid proglottids
develop
▪ Mature proglottids are approximately square in shape, and they contain mature male and
female reproductive organs.
• There are two large lobes of ovaries
• Follicular testes numbering 300 to 400 are scattered throughout the proglottid.
• The vagina of T. saginata has a sphincter. Gravid proglottids are longer than they are
wide (16- 20 mm by 5-7 mm) and are most distal from the neck.
• The uterus is distended with ova and has 15 to 20 lateral branches.
Morphology --
 Cestodes, Parasite Biology (Taenia saginata) -- (Cont’d.)
▪ Taenia spp. ova are spherical or subspherical in shape, measuring 30 to 45 µm in diameter.
The original thin outer membrane surrounding the egg is rarely retained after pits. Inside the
eggshell is the oncosphere or embryo provided with three pairs of hooklets.
▪ The gravid proglottid contains 97,000 to 124,000 ova. Annually, a worm may pass out
594,000,000 ova.
▪ Gravid proglottids undergo apolysis and are either passed out with the feces or actively
crawl out of the bowel to the external environment. With apolysis of gravid segments, eggs
are released and they remain viable in the soil for weeks.
▪ Usually, only one adult tapeworm is present in T. saginata infections.
▪ The adult seems to be irritated by alcohol, and passage of proglottids sometimes results
after a drinking bout.
▪ While humans are suitable intermediate hosts for T. solium, they are not for T. saginata.
▪ Life Cycle (slide # 13)
Life Cycle (Taenia saginata)
▪ Eggs or gravid proglottids pass out in
feces and into the environment.
▪ Embryonated eggs and/or gravid
proglottids ingested by cattle.
▪ Oncosphere hatc, penetrate intestinal
wall and circulate to musculature.
▪ Oncosphere develop into cysticerci in
pig muscle.
▪ Humans infected by ingesting raw or
undercooked meat.
▪ Scolex attaches to intestines and
develops into adult (Taeniasis).
Pathogenesis and Clinical Manifestations -- Cestodes, (Taenia saginata) -- (Cont’d.)

▪ The most common chief complaint of persons infected is the passage of proglottids or
segments in the stool.
▪ T. saginata causes mild irritation at the site of attachment. Patients with taeniasis may
experience non-specific symptoms, such as epigastric pain, vague discomfort, hunger pangs,
weakness, weight loss, loss of appetite, and pruritus ani (perianal itching).
▪ Rarely, entangled proglottids may result in intestinal obstruction. (Slide # 15) Individual T.
saginata proglottids are actively motile and they have been documented to cause
obstruction in the bile and pancreatic ducts, as well as the appendix.
▪ The sight of actively motile proglottids in the perianal area and in the undergarments may
result in anxiety and distress.
Whole worm may be entangled and cause obstruction in the intestines, bile and
pancreatic ducts and appendix.
Diagnosis Cestodes, (Taenia saginata) -- (Cont’d.)

▪ Specific diagnosis rests on identifying the characteristic proglottids, eggs or scolex.

▪ The first specimen usually brought in by patients are the gravid proglottids, either single or
in chains. They are passed out with the feces or may be recovered in the patient’s
undergarments.
▪ Gravid proglottids are pressed or flattened in between two glass slides and are examined
against the light. This will allow one to have a rough count of the lateral branches from the
main uterus. . (Slide # 17)
▪ Injection of India ink through the genital pore will help one make an accurate count of the
lateral branches of the uterus (15-20 for T. saginata and 7-13 for T. solium).
▪ Mature segments can be stained to demonstrate the vaginal sphincter for T. saginata and
the accessory ovarian lobe for T. solium.
▪ Examination of the stool can be done for the presence of eggs, but eggs are irregularly
passed out with the stools. Concentration techniques like the formalin-ether/ethyl acetate
concentration technique will be useful in increasing the chance of demonstrating the eggs.
(The eggs are however, indistinguishable from that of the Taenia solium.)
▪ Perianal swabs may also be useful because eggs are left in the perianal skin as the gravid
segments squeeze out of the anal opening.
Gravid proglottid pressed between two
slides and read against the light or focused
under the microscope. The number of
lateral uterine branches are counted: 15 or
more is suggestive of Taenia saginata.
Treatment -- Cestodes, (Taenia saginata) -- (Cont’d.)

▪ The drug of choice is praziquantel. Praziquantel is given at a dose of 5 to 10 mg/ kg as a

single dose for both adults and children.
▪ It is not necessary to recover the scolex unless species-specific diagnosis is needed.
▪ Criteria for the cure include the following:
a) recovery of the scolex, or
b) a negative stool examination 3 months after treatment.
2.1.1.2 Taenia solium
▪ Taenia solium is known as the pork tapeworm of man.
▪ Man may serve as both a definitive host and an intermediate host. Therefore, both intestinal
and tissue infections occur in man. (This does not happen in T. saginata infection)
Parasite Biology -- Cestodes, (T. solium) -- (Cont’d.)

▪ The adult worm inhabits the upper small intestines. Like other intestinal cestodes, it derives
nourishment from intestinal contents of the host.
▪ It is shorter than T. saginata and has less number of proglottids. The adults measure 2 to 4 m
in length and may have 8,000 to 10,000 proglottids.
▪ The scolex of T. solium has four acetabula, but it is smaller (1 mm) and more spherical than
that of the beef tapeworm. (For morphological differences, Slide #22)
▪ The scolex carries a cushion-like rostellum with a double crown of 25 to 30 large and small
hooks, which are absent in T. saginata.
▪ After the scolex, comes the neck from which the proglottids develop.
▪ The general morphology of the proglottids resembles that of Taenia saginata. The following
are the differences of the proglottid of Taenia solium from that of Taenia saginata:
1) The presence of an accessory ovarian lobe
2) Absence of vaginal sphincter, and
3) The smaller number of follicular testes (100-200 in the mature proglottid)
▪ The gravid proglottid characteristically contains 7 to 13 lateral branches as opposed to 15 to
20 branches of T. saginata (Slide # 22)
 Morphological Differences between Taenia
saginata & taenia solium scolex & gravid
proglottid --

Ova
 Cestodes, Parasite Biology (T. solium) -- (Cont’d.)
▪ T. solium proglottids are relatively less active than the proglottids of T. saginata. They have
not been observed to actively crawl about.
▪ The gravid proglottid contains approximately 30,000 to 50,000 ova. The gravid proglottids
also undergo apolysis to eventually release eggs, which remain viable for weeks.
▪ The eggs of T. solium are indistinguishable from that of T. saginata. They measure 30 to 45
µm and have a thick brown striated embryophore surrounding a hexacanth embryo.
▪ The eggs are ingested by hogs and the oncospheres are released in the intestines
▪ The oncosphere penetrates the intestinal mucosa to typically encyst in muscles as cysticercus
cellulosae (Slide # 21)
▪ The cysticercus may be found in all tissues. Commonly, infected are the muscles, tongue,
heart, diaphragm, liver, spleen, and mesentery.
▪ Upon ingestion of improperly cooked infected meat (known as “measly pork”), the larva is
liberated and the scolex attaches to the intestinal mucosa. (Slide # 25)
 Cestodes, Parasite Biology (T. solium) -- (Cont’d.)
▪ Maturity is attained in approximately 12 weeks from the time of ingestion of the cysticercus.
▪ Man may also be an intermediate host of T. solium. Taenia eggs are very resistant and when
the eggs are ingested, development to cysticerci in man ensues as it does in pigs.
▪ The oncosphere hatches in the duodenum, and spreads to different organs through the
bloodstream. This results in human cysticercosis.
▪ The mature cysticercus is oval, translucent, and has an opaque invaginated scolex with four
suckers and a circlet of hooks. It is usually encapsulated with adventitious host tissue.
However, in the vitreous humor and in the brain, it may be unencapsulated. A full size of 5
mm may be attained in 10 weeks. (Slide # 25)
▪ Individuals harboring the adult Taenia solium can infect themselves (autoinfection) due to
poor hygienic practice. (scratching the anus, eggs may be picked up by the host, ingest them, and so, just like in
pigs, man then suffers from cysticercosis.)

Life Cycle of Taenia Solium: (Slide # 28)

Evagination with Taenia solium from cysticercus cellulosae
 Morphology of the different parts of Taenia solium

Mature proglottid

Rostellum
Pathogenesis and Clinical Manifestations Cestodes, (T. solium) -- (Cont’d.)

A. Intestinal infection
- T. solium intestinal infection results in mild non-specific abdominal complaints.
- Unlike in T. saginata infections, proglottids are not as active and, therefore, obstruction of the
bile duct, pancreatic duct, or the appendix is unlikely. But the whole adult worm may cause
intestinal obstruction as they become entangled. (Slide # 29)
B. Cysticercosis
- The cysticerci are often multiple and can develop in any organ or tissue. Most commonly, they
are located in striated muscle and in the brain, but the subcutaneous tissues, eye, heart,
lung, and peritoneum may be involved. The living cyst may produce inflammation.
- Cysts may survive up to 5 years. Upon death, cystic fluid increases and there is a pronounced
tissue response to the parasite. The parasite is eventually calcified.
Symptomatology:
- Symptomatology is dependent on the number, size, and location of the lesion.
- Neurocysticercosis (NCC), which is considered as one of the most serious zoonotic diseases
worldwide is one of the most serious manifestations.
Life cycle of Taenia solium cysticercosis
1 Cysticercosis is an infection of both humans and pigs with
the larval stages of the parasitic cestode, Taenia solium .
This infection is caused by ingestion of eggs shed in the
feces of a human tapeworm carrier
2/7 Pigs and humans become infected by ingesting eggs or
gravid proglottids
3/8 Humans are infected either by ingestion of food
contaminated with feces, or by autoinfection. In the latter
case, a human infected with adult T. solium can ingest eggs
produced by that tapeworm, either through fecal
contamination or, possibly, from proglottids carried into the
stomach by reverse peristalsis. Once eggs are ingested,
oncospheres hatch in the intestine
4 In humans, cysts can cause serious sequellae if they
localize in the brain, resulting in neurocysticercosis. The
parasite life cycle is completed, resulting in human
tapeworm infection, when humans ingest under- cooked
pork containing cysticerci
5 Cysts evaginate and attach to the small intestine by their
scolex
6 Adult tapeworms develop, (up to 2 to 7 m in length and
produce less than 1000 proglottids, each with approximately
50,000 eggs) and reside in the small intestine for years
9 invade the intestinal wall, and migrate to striated muscles,
as well as the brain, liver, and other tissues, where they
develop into cysticerci
Whole worm may be entangled and cause obstruction in the intestines, bile and
pancreatic ducts and appendix.

Taenia solium, live, whole worm

 Pathogenesis and Clinical Manifestations, T. solium (Cont’d.) -
▪ Cysticerci containing a scolex may be found in the brain parenchyma or floating freely in the
ventricles. Cysticerci may also appear as large vesicular structures devoid of a scolex and are
usually located in the basal cisternal spaces.
▪ Neurocysticercosis (NCC) is divided into two general forms, parenchymal and
extraparenchymal, which, in turn, is further divided into subarachnoid or meningitic,
intraventricular, and spinal.
▪ Clinical manifestations and corresponding management depend on the form of NCC present
in the patient.
- Focal or generalized seizures are observed when cysts are located in the cortex.
- The subarachnoid form may lead to an aggressive form of NCC called racemous
cysticercosis. In this form, there is a proliferation of cysts in the base of the brain. This
form has a poor prognosis.
- In the intraventricular form, cysts are usually present in the third or fourth ventricle and
often lead to obstructive hydrocephalus.
- The spinal form is rare.
 Pathogenesis and Clinical Manifestations, T. solium (Cont’d.) -
▪ The death of the larva leads to inflammation of the affected region.
▪ Calcification is the end-result of the cellular reaction. Convulsions are the most common
manifestations of cerebral cysticercosis. Visual and motor deficits, headache, and vomiting
may occur.
▪ Cerebrospinal fluid (CSF) tap results may show an increased opening pressure, elevated
protein, decreased glucose, and increased mononuclear cells.
▪ Half of the cases may present with CSF eosinophilia without peripheral blood eosinophil.
▪ In the eyes, cysticerci are often retinal or subretinal in location. They may float freely in the
vitreous or aqueous humors.
▪ Vision is usually affected due to chorioretinitis and vasculitis. Detachment of the retina has
also been reported.
▪ The patient may complain of intraorbital pain, photopsia, and blurring or loss of vision.
(Photopsia. A term meaning light flashes or the sensation of flickering of lights. It is a visual phenomena that is usually
benign, but could be an early indication of a retinal tear or detachment. It is caused by shrinkage that occurs with the
vitreous gel in the back of the eye.)
Diagnosis -- Cestodes, (T. solium) -- (Cont’d.)

A. Taeniasis
- Specific diagnosis of taeniasis rests on identifying the characteristic proglottids (with 3
lobes of ovaries in the mature proglottid), eggs, or scolex. (Slide # 33 for scolex identification
which is the easiest & practical, in the event of expulsion after treatment)
- Stool examination; Perianal Scotch Tape Swab Technique (Characteristic eggs of Taenia slolium &
saginata _ Slide # 34; Other comparative differences in Slide # 35)

B. Cysticercosis
- Neurocysticercosis may be suspected in a patient coming from an endemic area with
epileptic seizures without associated systemic symptoms.
- Concomitant infection with T. solium adult occurs only in 25% of cases. If a patient has
subcutaneous cysticerci concomitant with neurologic symptoms, this provides
presumptive evidence for neurocysticercosis.
- CSF abnormalities such as an elevated protein, reduced glucose, and increased
mononuclear cells may be seen.
- Computed axial tomography (CAT) scans and nuclear magnetic resonance imaging (MRI)
are useful for localizing cysticerci and evaluating the pathology before and after
treatment.
- Ophthalmic cysticercosis can be diagnosed through the visualization of the cysticerci using
ophthalmoscopy but the procedure may induce movement and/or evagination of the
scolex.
Comparing Taenia eggs from Trichuris and Ascaris ova.

Taenia ova. (Taenia saginata and Taenia solium ova

are indistinguishable)
The difference between Taenia solium & Taenia saginata
 Diagnosis - Cestodes, (T. solium) -- (Cont’d.)
▪ Muscular and subcutaneous cysticerci are usually palpable and can be recovered through
tissue biopsy for histopathologic processing
▪ Serologic tests include
a) Enzyme-linked immunosorbent assay (ELISA) - using serum and CSF
b) Electro-immuno transfer blot (EITB) or Western blot - for specific IgG and IgM
anticysticercal antibodies.
- These tests have a sensitivity of 75 to 100% using a partially purified glycoprotein
antigen to detect antibodies
c) Dot-ELISA test is a very good screening test for cysticercosis. It uses crude antigen from
the cysticerci obtained from pigs.
▪ Recent studies are looking into the use of antigen B of cysticercus cellulosae as a useful
adjunct in diagnosis.
Treatment -- Cestodes, (T. solium) -- (Cont’d.)

A. Taeniasis
▪ The drugs of choice are praziquantel and niclosamide. Praziquantel is given as 5 to 10 mg/kg,
single dose for both adults and children. Niclosamide is not available locally.
▪ Because of the theoretical possibility of autoinfection and subsequent cysticercosis, treatment
should not be delayed.
▪ Criteria for cure include the following:
a recovery of the scolex
b a negative stool examination 3 months after treatment
B. Cysticercosis Cestodes, (T. solium) -- (Cont’d.)
▪ Management of NCC depends on the form present in the patient.
▪ Multiple parenchymal cystic lesions - praziquantel at a dose of 50 to 75 mg/kg divided into
three doses for 30 days or albendazole at a dose of 400 mg twice daily for 8 to 30 days.
Corticosteroids are then given (either 80 mg of prednisone or 10 mg of IM dexamethasone) 4
hours after the last dose.
▪ For the subarachnoid form, some experts recommend surgical removal of the lesions, while
others recommend albendazole therapy in which albendazole is given at a dose of 10 to 15
mg/kg/day for 8 days
▪ Ventricular forms are best treated with surgical removal of the cyst.
▪ Ocular cysticercosis should be treated surgically before praziquantel or albendazole is given
because ocular inflammation cannot be controlled with steroids.
▪ Symptomatic cysts outside the CNS may be surgically removed.
Epidemiology -- Cestodes, (T. solium) -- (Cont’d.)

▪ The distribution of T. solium and T. saginata infections is highly related to the habit of eating
raw or improperly cooked meat.
▪ Abstinence from beef as part of the religious beliefs among the Hindus prevent T. saginata
infections; while among the Moslems, prevention of T. solium infections happens because of
abstinence from pork.
▪ T. solium is especially common in Slavic countries, Latin America, Southeast Asia, China, and
India; T. saginata has high endemicity in Ethiopia and East Africa. It has also been reported in
Japan, Europe, Australia, Canada, and the United States of America
▪ Maintenance of the life cycle in nature is dependent on the level of environmental sanitation
practiced in the area.
▪ Animal intermediate hosts, especially pigs should be kept in pens to avoid access to human
feces.
▪ Contamination of the grazing fields with human feces favors infection of the intermediate hosts
in T. saginata infection.
Prevention -- Cestodes, (T. solium) -- (Cont’d.)

1. The most effective way to prevent taeniasis is to cook food thoroughly. This means cooking
meat to a temperature above 140°F (60°F) for five minutes or more.
2. Sanitation – proper waste disposal
3. Inspection of meat (pork or beef)
4. Prompt treatment of infected persons
5. Health education
Note: Cysticerci survive temperature below – 2OC for nearly 2 months and at room
temperature for 26 days. Freezing at -10oC for 4 days or more is an effective means of
killing the larva. Pickling in brine is not always successful.