PARASITOLOGY

Topic: Phasmids 4
References: Old Trans + Belizario

INTRODUCTION
 Angiostrongylus cantonensis
 Gnathostoma spinigerum
 Dracunculus medinensis
Angiostrongylus cantonensis
 Previously classified under the genus Angiostrongylus,
Parastrongylus cantonensis, or the rat lungworm
 The nematode, which normally lives in rat lungs, has been known to
cause eosinophilic meningoencephalitis in man
Found in the pulmonary arteriole of brown & black rat
 Outbreaks have been documented in Southeast Asia and Pacific
Island
Parasite Biology
Morphology:
 The morphologic features of the worm may be observed through its
transparent cuticle
 The adult worm, which is pale and filiform, has a length of 17 to 25
mm
 Male worms
o Measure 16 to 22 mm in length and 0.25 to 0.35 mm in
diameter
o They have a well-developed caudal bursa, which is kidney-
shaped and single-lobed
 Female worms
o Measure 19 to 33 mm in length and 0.28 to 0.50 mm in
diameter
o The female worms have uterine tubules that are wound
spirally around the intestine
This arrangement is usually described as the “barber’s
pole” pattern
o The posterior end of the female worm is blunt shaped
o A single female worm can lay up to 15,000 eggs daily
 The elongated ovoidal eggs have delicate hyaline shells
o They measure 46 to 48 µm by 68 to 74 µm and are
unembryonated when oviposited
o The 1st stage larva, found in the lungs of the rodent host,
has a distinct small knob near the tip of the tail
o 2 well-developed chitinous rods below its buccal cavity
identify the 3rd stage larva
These rods have expanded knob-like tips
 After 6 days, eggs hatch and release the first stage larvae that
penetrate into the respiratory tract
 The larvae then migrate up to the trachea and reach the oropharynx
where they are then swallowed and eventually expelled in the feces
 It takes about 6 to 8 weeks from infection before the rat excretes 1st
stage larvae
 The first stage larva is the infective stage for the molluscan
intermediate host
 In the Philippines, the known intermediate hosts include the
following slugs and snails:
o Achatina fulica or giant African snail
o Hemiplecta sagittifera
o Helicostyla macrostoma
o Vaginilus plebeius
o Veronicella altae
 Its mode of infection is by ingestion or active penetration
 In the mollusk, larva eventually develops into the 3rd larval stage in
about 12 days
Transmission:
 Although the mechanism by which humans get infected is not yet
entirely clear, transmission is usually attributed to:
o Ingestion of the raw mollusk intermediate host infected
with the third stage larvae
o Ingestion of leafy vegetables contaminated with mucus
secretions of the mollusk carrying the infective stage (3rd
larval stage) of the parasite
o Ingestion of a paratenic host, such as freshwater prawn or
crab harboring the infective stage of the parasite
o Drinking of contaminated water
 When humans get infected, the larvae pass through the stomach into
the intestine, enter the circulatory system and migrate to the brain
or spinal cord, or occasionally migrate into the eye chamber
In humans, however, the larvae probably remain in the brain for
a longer period of time and do not develop to the adult stage
NOTES:
 Incidental host: Humans
 Definitive host: Rats
 Intermediate host: Snails & Slugs
 Infective stage: L3 larva

Life Cycle
 Rats are the definitive hosts of P. cantonensis
Rats are infected through ingestion of the third stage larvae

 The larvae penetrate the stomach wall and travel in the bloodstream
until they reach the CNS
 They undergo two molts, which take about 2 weeks, before they
reach maturity
 Early development occurs in the brain
 After the final molt in rats, the young adults migrate to the
pulmonary arteries to complete their development
 After 2 weeks, the adult females start laying eggs
 Adult worms live in the two main branches of the pulmonary arteries
of the rat
 In the bloodstream, gravid females lay eggs, which are transported
into the smaller vessels of the lungs

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 PARASITOLOGY
Topic: Phasmids 4
References: Old Trans + Belizario
Life Cycle (CDC) continued…..
Adult worms of A. cantonensis live in the pulmonary arteries and right ventricle of the
normal definitive host (1) . The females lay eggs that hatch in the terminal branches of the
pulmonary arteries, yielding first-stage larvae. The first-stage larvae migrate to the pharynx,
are swallowed, and passed in the feces. They penetrate or are ingested by a gastropod
intermediate host (2) . After two molts, third-stage larvae are produced (3) which are
infective to mammalian hosts. When the infected gastropod is ingested by the definitive
host, the third-stage larvae migrate to the brain where they develop into young adults (4) .
The young adults return to the venous system and then the pulmonary arteries where they
become sexually mature. Of note, various animals act as paratenic (transport) hosts: after
ingesting the infected snails, they carry the third-stage larvae which can resume their
development when the paratenic host is ingested by a definitive host. Humans can acquire
the infection by eating raw or undercooked snails or slugs infected with the parasite; they
may also acquire the infection by eating raw produce that contains a small snail or slug, or
part of one (5) . There is some question whether or not larvae can exit the infected
gastropods in slime (which may be infective to humans if ingested, for example, on
produce). Infection may also be acquired by ingestion of invertebrate paratenic hosts
containing L3 larvae (e.g. crabs, freshwater shrimp). In humans, larvae migrate to the brain,
or rarely to the lungs, where the worms ultimately die (6) . Larvae may develop to fourth or
fifth stage in the human host, but seem to be incapable of maturing fully.
Pathogenesis & Clinical Manifestations
 In most cases, the incubation period is around 6 to 15 days, but may
vary from 12 to 47 days
 The chief complaint in many cases is acute, severe, intermittent
occipital or bitemporal headache
 Other common symptoms include:
o Stiffness of the neck
o Paresthesia
o Vomiting
o Fever
o Nausea
o Blurred vision or diplopia
o Body or muscle pain
o Fatigue
 Confusion, incoherence, disorientation, memory lapses, or coma
have also been observed during illness
 Intraocular hemorrhage and retinal detachment as associated
complications have also been reported
 Postmortem examination may show:
o Leptomeningitis
o Encephalomalacia
o Moderate ventricular dilation
 Immature worms may also be seen in the cerebrum and cerebellum
 Eosinophils, monocytes, and foreign body giant cells in the spinal
cord or in the cerebrospinal fluid (CSF) are usually associated with the
infection
The CSF usually contains 100 to 1,000 leukocytes per μL
 Adult worms have also been recovered from the eyes and pulmonary
arteries of patients
 Large numbers of Charcot-Leyden crystals have also been
demonstrated in the meninges
 Dead worms can also result in inflammatory reaction and local tissue
necrosis
Prognosis:
 Prognosis is usually good
 In most cases, the disease is mild and no hospitalization is necessary
 The infection is self-limited and symptoms gradually disappear with
recovery
 Meningeal symptoms are often the FIRST to subside, followed by
improvements in vision, and relief from paresthesia
 Cranial nerve involvement is the LAST to recover
 Permanent neurologic deficits have been documented, and in rare
cases, the disease may result in death
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Diagnosis
 Diagnosis of parastrongyliasis in humans is relatively difficult, since
the primary site of infection is the brain
 Presumptive diagnosis may be made based on travel and exposure
history, correlated with clinical symptoms, medical history,
laboratory findings, brain imaging results, and serological tests
 Examination of blood may reveal a high proportion of eosinophils,
comprising 7 to 36% of the white blood cell (WBC) count
 Examination of CSF may contribute to increased sensitivity in the
diagnosis of parastrongyliasis
CSF eosinophilia of >10% in proportion to WBC will EXCLUDE
other common causes of meningitis
 The CSF protein level in most patients is mildly elevated, while the
CSF glucose is normal
 Meningeal lesions may be appreciated with the use of CT scan
CT scans may also reveal non-specific cerebral edema and
ventricular dilatation
 MRI may show lesions with hyperintense T2 signal
 Although ELISA for the diagnosis of parastrongyliasis is still not
commercially available, a dot-blot ELISA that tests blood has been
demonstrated to be 100% sensitive and specific for use in
epidemiological surveys
 In addition, serum antigens from P. cantonensis can also be detected
by immunopolymerase chain reaction (PCR)
Treatment
 No anthelminthic treatment is recommended at present, although
mebendazole and albendazole have been demonstrated to
effectively treat parastrongyliasis in China, Taiwan, and Thailand
Anthelminthic therapy has been shown to relieve symptoms and
reduce the duration of the disease
 Ocular parastrongyliasis may require surgical removal of worms from
the eyes
 Symptomatic treatment with the use of analgesics and lumbar
puncture can relieve the headaches experienced by the patient with
eosinophilic meningitis
 Prednisone 30 mg daily  recommended, particularly in severe cases
with cranial nerve involvement
 The anti-inflammatory and immunosuppressive effects of steroids
are helpful in mitigating the disease process
Prevention & Control
 Awareness and education on proper eating habits and safe food
preparation
 The public should be discouraged from eating raw or poorly cooked
mollusks or unwashed vegetables
 Hand washing after gardening should also be advised
 Farmers occasionally use molluscicides, such as metaldehyde or iron
phosphate food bait pellets to control intermediate hosts
 Copper barriers against snails and slugs are also utilized by farmers
to prevent contamination of vegetable and fruit crops
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 PARASITOLOGY
Topic: Phasmids 4
References: Old Trans + Belizario

Gnathostoma spinigerum In definitive hosts, adult worms of most Gnathostoma spp reside in a tumor-like mass in the
gastric wall; adult worms of some species are found in the esophagus or kidney. Adults mate
 “Creeping worm”
and produce unembryonated eggs, which pass through a small opening in the tumor-like
mass and ultimately into the feces (1) . Eggs become embryonated in water, and eggs
Parasite Biology release sheathed first-stage larvae (L1) (2) . Freshwater copepods, which serve as first
Morphology: intermediate hosts, ingest the free-swimming L1, and the larvae molt twice to become early
 Followed by a bare portion third-stage larvae (EL3) (3) . Following ingestion of the copepod by a suitable second
 Posterior tip has numerous, tiny, cuticular spines intermediate host, the EL3 migrate into the tissues of the host and develop further into
advanced L3 larvae (AL3) (4) . When the second intermediate host is ingested by a definitive
 Eggs are unembryonated when laid
host, the AL3 develop into adult parasites in the gastric wall (5) . Alternatively, the second
 Outer shell is pitted intermediate host may be ingested by a paratenic host, in which the AL3 do not develop
 Adult form: further but remain infective (6) . Humans become infected by eating raw or undercooked
o Size is about 1-3 cm, stout and pink meat of second intermediate or paratenic hosts containing AL3. In the human host, AL3
o Distinct head bulb covered by leaf spines which are migrate in various tissues and may develop into immature adults but never achieve
tridented reproductive maturity; they may range in size from 2 mm to about 2 cm depending on the
species and the extent of development (7) . Whether humans can become infected by
o Anterior half  covered by rows of flat, toothed spines
drinking water that contains infected copepods is not clear
(tridented, leaf-like spines)
 Eggs: NOTES:
o Ovoid in shape  Incidental host: Human
o Single polar thickening or a mucus plug  1st Intermediate host: Crustacean (Cyclops)
 2nd Intermediate Host: Fish, Frogs
Old Trans Info:  Paratenic Host: Birds, Snakes
 Definitive Host: Pigs, Cats, Dogs, Wild Animals
Adult: worm’s body is covered with cuticle armed with spines
 Infective stage to cates or dogs: L2 larva
along the body  Infective stage to humans: L2 or L3 larva
o Head bulb covered with hooks  unique characteristic  Diagnostic stage:L3 larva
of Gnathostoma
Eggs: single celled, unembryonated when shed, ovoid and has one Mode of Transmission:
polar cap  Ingestion of inadequately cooked fish

Life Cycle Clinical Manifestations

 Due to L3 larva migration
 Cutaneous Larva Migrans
o Also in hookworm
o Intermittent, migratory, painful pruritic swellings in the
subcutaneous tissue  migrating edema
Old Trans Info:
Skin and soft tissue involved with tenderness or swelling;
creeping eruptions; pain, pruritus, and erythema; nodules
and boils

 May become dominant in the abscessed pockets

 Visceral Larva Migrans
o Also in Toxocara
o Cough, chest pain, dyspnea, and/or hemoptysis
o Myeloencephalitis
o Eosinophilic meningitis

 Decreased visual acuity, blindness and/or photophobia due to larval

migration along optic nerve

Diagnosis
 Leukocytosis with high eosinophilia
 Removal of ID worm is both diagnostic and therapeutic
 Intradermal test in endemic areas
 Excision biopsy  if larva is accessible for surgery

Treatment
 Mostly supportive and symptomatic
 Surgical removal of worm if possible
 Albendazole or Ivermectin
 No DOC
 Prevention is best

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 PARASITOLOGY
Topic: Phasmids 4
References: Old Trans + Belizario

Dracunculus medinensis Humans become infected by drinking unfiltered water containing copepods (small
crustaceans) which are infected with larvae of D. medinensis (1). Following ingestion, the
 “Guinea worm”
copepods die and release the larvae, which penetrate the host stomach and intestinal wall
and enter the abdominal cavity and retroperitoneal space (2). After maturation into adults
Parasite Biology and copulation, the male worms die and the females (length: 70 to 120 cm) migrate in the
Morphology: subcutaneous tissues towards the skin surface (3). Approximately one year after infection,
 Larvae: the female worm induces a blister on the skin, generally on the distal lower extremity, which
o Rhabditiform larvae (L2)  The tails is 1/3 of the body ruptures. When this lesion comes into contact with water, a contact that the patient seeks
to relieve the local discomfort, the female worm emerges and releases larvae (4). The larvae
length and culminates in a point
are ingested by a copepod (5) and after two weeks (and two molts) have developed into
o L3  Reside in intermediate host; not well described infective larvae (6). Ingestion of the copepods closes the cycle (1)
 Adult:
o One of the largest nematodes Mode of Transmission:
o Female: possess a prominent blunt, rounded anterior end  Drinking unfiltered water containing copepods
o Male: smaller
Clinical Manifestations
Old Trans Info:
 Localized but incapacitating
 Usually in 3rd world countries
 Worms emerges 1-3 weeks after larvae in the center of a painful
 Freshwater lakes and rivers
ulcer, with inflammation, secondary to bacterial infection
 Definitive host: Human, Wolves, Horses, Cows, Leopards, Monkey
 Often in exposed parts of body (legs, scrotum)
and Baboons
 Sterile abscess
 Intermediate Host: Cyclops, Copepods
 Joint pains, arthritis
 Infective stage to human: L3  released in the intestine  mature
 After rupture of blister, worm emerges as a whitish filament
 male and female  male dies  female moves to skin
 Emergent worms
Diagnosis
o Severe pain
 Diagnosis may be difficult before worn emerges
o Allergic reaction
 Calcified dead worms may be visible on x-rays
o Blisters
 Exam by fluid discharge by worms may show rhabditiform larvae
 Non-emergent worms
o Arthritis  No serologic test available
o Cellulitis  May be different before worm emerges
o Necrosis
o Calcification of worm Treatment
 Signs & Symptoms  Thiabendazole or Metronidazole with variable results
o Slight fever  Winding worms on a stick gradually extract worms over 3-4 weeks
o Itchy rash  Local cleaning
o Vomiting and diarrhea  Immerse foot
 Complications  Extract worm
o Cellulitis  Bandage
o Boils  Drugs: none
o Lockjaw
o Infection (Sepsis) Epidemiology
o Joint infection  Mainly in Africa, Middle East, Iran, Pakistan, India
 Incidence has markedly reduced
Life Cycle
Prevention
 Use of properly treated water for consumption
 Boiling of water suspected of contamination

A. cantonensis
CSF analysis
o High eosinophil count,
low sugar, high protein,
positive larva in the CSF
CT Scan of the brain
Summary Tables:
C. spinigerum D. medinensis
Excision biopsy  if (+) worm from skin lesion
larva is accessible for X-ray may become (+) due
surgery to calcified deadworm
Serological Test
High Eosinophilia

References:
 Medical Parasitology in the Philippines by
Belizario & de Leon (3rd Ed.)
 Lecture Notes

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