The Nematodes

What are NEMATODES?

• Helminths (multicellular and contain internal organ systems)
⁃ Intestinal round worms
⁃ Class Nematoda
⁃ multicellular parasites that appear round in cross section
⁃ Most are free-living

Soil-transmitted Helminths (HAT) (unholy three)

⁃ Ascaris lumbrecoides
⁃ Hookworms
⁃ Trichuris trichiura

Heart-lung migration
⁃ Ascaris
⁃ Strongyloides stercoralis
⁃ Hookworms

3 BASIC MORPHOLOGICAL FORMS

EGGS
⁃ female sex cells after fertilization

LABORATORY DIAGNOSIS
⁃ recovery of eggs, larvae, and occasional adult worms
⁃ specimens of choice vary by species and include:
⁃ cellophane tape preparations (anal opening)
⁃ stool samples o tissue biopsies
⁃ infected skin ulcers
⁃ serologic test methods

Three possible factors may contribute to the ultimate severity of a nematode

infection:
• the number of worms present
• the length of time the infection persists
• the overall health of the host

⁃ WORM BURDEN

PATHOGENESIS & CLINICAL SYMPTOMS

• Infections have been known to last for up to 12 months or longer (some infections
may last 10 to 15 years or more)
• occurrence of reinfections and/or autoinfection may increase the infection time
up to several years and beyond, (some infections persist indefinitely)
• Heavy worm burden are probably associated with severe symptoms and/or
complications.

• Life cycle involves the intestinal tract

• All the nematodes may cause intestinal infection symptoms:
• abdominal pain
• or diarrhea or nausea
• vomiting o fever
• eosinophilia

MAY ALSO BE PRESENT:

• Skin irritation or skin blisters
• muscle involvement

1 EOSINOPHILS → parastic infection

 Allergic reaction
0-6%

NEMATODE CLASSIFICATION

Intestinal Species
Enterobius vermicularis
Trichuris trichiura
Ascaris lumbricoldes
Necator americanus
Ancylostoma duodenale
Strongloides stercoralis

Intestinal-Tissue Species
Trichinella spiralis
Dracunculus medinensis

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ENTEROBIUS VERMICULARIS

(Pin worm)


Enterobius gregorii - EU, AFRICA, ASIA (immature form of E. vermicularis)

LIFE CYCLE
HUMANS (ONLY KNOWN HOST)
• DS: EGGS
• IS: EMBRYONATED EGGS
• hatch and release young larvae: Small intestine
• Habitat of adult worms : Colon (Cecum)
• After copulation, the gravid worms migrates to the perineal region (15,000 eggs
deposited)
• Can be dislodged through intense scratching of the anal area
• Infective eggs may survive for a few days up to several weeks under suitable
environmental
conditions.

Pruritus Ani - Pera-anal itching

EPIDEMIOLOGY
• worldwide (temperate areas)
• White children appear to be at the greatest risk.
• It is a common helminth known to cause infection in the United States.

MOT
• hand-to-mouth contamination
• D. fragilis trophozoites may actually take up residence inside the pinworm egg
for transmission.

EAT (frequency of infection worldwide)

1. Enterobius
2. Ascaris
3. Trichuris
LABORATORY DIAGNOSIS
• Specimen of choice: cellophane tape preparation (perianal region)
• EGGS (primary morphologic form seen)
• Adult females (laying eggs)
• multiple samples - confirm light infection or determine if patient is free of
infection
• stool samples: eggs and/or adult females may be overed (rarely)

CLINICAL SYMPTOMS

• ASYMPTOMATIC
• Enterobiasis: Pinworm Infection (self-limiting)
o intense itching and inflammation of the anal and/or
vaginal areas
• intestinal irritation, mild nausea or vomiting, irritability, and difficulty
sleeping
• minute ulcers, mild intestinal inflammation and abdominal pain (less frequent)
• Autoreinfection: Infected individuals may reinfect themselves (hand-to-mouth
contamination)

TREATMENT
TREATMENT OF CHOICE:
o albendazole o mebendazole
• pyrantel pamoate
• Treatment is suggested for the family members of an infected individual.

CONTROL AND PREVENTION

• Practicing proper personal hygiene (hand washing)

• Applying an ointment to an infected perianal area
• Avoid scratching the infected area.
• Thorough cleaning of all potentially infected environmental surfaces, including
linens
• Providing treatment to all household members are important steps to help prevent
future infections.

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Trichuris trichiura (Whipworm)



LIFE CYCLE
DS: Unembryonated eggs
IS: EMBRYONATED EGGS
• Eggs →> larvae: Small intestine
• Growth & development of Larvae :
Intestinal villi
• Larvae—>adults: Cecum
• Residence: Colon (mucosa)
• Life span of adult: 4-8yrs. (Untreated)
• copulation → underdeveloped eggs passed into the outside environment via the
feces
1 month outside the human body (soil),

EPIDEMIOLOGY
• third most common helminth
• Warm climates
• Where poor sanitation practices are common
• Children & Individuals in psychiatric facilities

MOT
• fecal-oral transmission

LAB DX:
SPECIMEN OF CHOICE: STOOL
• zinc sulfate flotation method (eggs)
• macroscopic examination of the intestinal mucosa (adult worms)
• Adults may also be seen from intestinal tract down to and including the rectum in
heavy infections.

NOTE: It is important to be aware that samples examined from patients treated for
whipworm infection may reveal distorted eggs, showing a variety of unusual shapes.

Rectal Prolapse


CLINICAL SYMPTOMS
• Asymptomatic
• Trichuriasis: Whipworm
Infection
• Heavy infections (500 to 5000 worms) produce a wide variety of symptoms which may
vary with the age of the host.

CHILDREN
• resemble ulcerative colitis
• infection of as few as 200 worms:
• chronic dysentery, severe anemia, and possibly growth retardation
• catch-up growth usually occurs
• increased rectal prolapse and peristalsis are common

ADULTS
• mimic those of inflammatory bowel disease.
• abdominal tenderness/pain, weight loss, weakness, and mucoid or bloody diarrhea

TREATMENT
Treatment of choice:
• Mebendazole
• Albendazole

PREVENTION AND CONTROL

• Proper sanitation practices
• Educating children
• Aiding institutionalized mentally handicapped persons in their personal hygiene
and sanitation practices

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Ascaris lumbricoides
Large intestinal roundworm | roundworm of man





Life cycle
• Infected Eggs -> Viable larvae: Small intestine
• Larvae-›liver-lung migration->blood:
Intestinal wall
• First stop: Liver
• Second stop: Lung
• Lung—>capillaries—>alveoli→>bronchioles
-Larvae—>pharynx
• Adult: undeveloped eggs (up to 250,000/ day) are passed in the feces.
• Infected eggs may remain viable in soil, fecal matter, sewage or water.
• Stool processing: Eggs survive in 10% formalin fixative.

EPIDEMIOLOGY
• The most common intestinal helminth infection.
• It ranks second in frequency in the United States.
• The frequency in the United States is highest in the Appalachian Mountains and in
the surrounding areas

MOT:
• Contaminated hands put into their mouth
• Vegetables are grown using contaminated human feces as fertilizer
• Contaminated food or water

LABORATORY DIAGNOSIS
SPECIMEN OF CHOICE: STOOL
• Adult worms may be recovered in several specimen types, depending on the severity
of infection.
• May include small intestine, gallbladder, liver and appendix
• Adult worms may be present in the stool, vomited up, or removed from the external
nares.
• Immunosorbent assay (ELISA)

CLINICAL SYMPTOMS
• Asymptomatic
• Ascariasis: Roundworm Infection
• Patient infected with many worms may exhibit:
• vague abdominal pain o vomiting o fever
• abdominal distention

Pulmonary symptoms
• low-grade fever
• cough
• eosinophilia
• pneumonia
• Asthmatic reaction

Treatment
• Albendazole
• Thiabendazole

Prevention & Control

• Avoid using human feces as fertilizer
• Exercise proper sanitation and practice personal hygiene

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Necator americanus - New World Hookworms

Ancylostoma duodenale - Old world hookworms





LIFE CYCLE
• Humans come into contact with hookworm (third-stage), through the skin
(unprotected feet)
• Maturation of the larvae into adult hookworms occurs in the intestine and the
resulting adult live and multiply in the small intestine.
• Adult females lay 10,000 to 20,000 eggs/day.

EPIDEMIOLOGY
• Estimated almost 25% of the world's population is infected with hookworm
• Prefers high warm areas
• N. americans is primarily found in North and South America and also in China,
India, and Africa
• A. duodenale may be found in Europe, China, Africa, South America and the
Caribbean islands.

LAB DX:
SPECIMEN OF CHOICE: STOOL
• Larvae mature and hatch from the eggs in stool that has been allowed to sit at
room temperature, without fixative added.
• Recovery and examination of the buccal capsule to determine the specific hookworm
organism

CLINICAL SYMPTOMS
• Asymptomatic Hookworm
Infection
• Hookworm Disease:
Ancylostomiasis,
Necatoriasis
o allergic itching also known
as ground itch
• sore throat
• bloody sputum o wheezing
• headache
• mild pneumonia with cough

Chronic infections
(<500eggs/g of feces)
o vague mild gastrointestinal
symptoms
o slight anemia
o weight loss or weakness

Acute infections
(>500eggs/g of feces)
• diarrhea
• anorexia
• edema o pain
o enteritis
o epigastric discomfort
Infected Patients
• microcytic, hypochromic iron deficiency
- weakness
• hypoproteinemia

Treatment
• Mebendazole
• Pyrantel pamoate
• Person with asymptomatic hookworm infection - only iron replacement or other
dietary therapy (protein, iron, other vitamins)

Prevention & Control

• Proper sanitation practices
• Appropriate fecal disposal
• Personal protection

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Strongyloides stercoralis (Threadworm)


LIFE CYCLE
- Primary morphologic form: Eggs (feces)
- Rhabditiform Larvae—> Filariform Larvae (third-stage/warm, moist soil)

EPIDEMIOLOGY
Found:
Tropical and subtropical regions of the world
Immigrants to the US from known endemic areas
At risk;
• Areas with poor sanitation (psychiatric facilities)
• Person who come into skin contact with contaminated soil.

LABORATORY DIAGNOSIS
• Baermann funnel gauze method
• Harada-Mori culture (most successful methods)
• nutrient agar plates
Other methods: Beale's string test, duodenal aspiration, and small bowel biopsy
Specimen: sputum or urine
• Serology may not be useful.

CLINICAL SYMPTOMS
Light Infection: Asymptomatic
Strongyloidiasis: Threadworm infection

• Urticaria accompanied by eosinophilia

• Intestinal symptoms:
-vomiting
-constipation
-weight loss
-variable anemia
• Heavy infection: malabsorption syndrome
• Site of larvae penetration: itchy & red (allergic reaction
• Pulmonary symptoms (larvae migrate to the lungs)

• Immunocompromised persons
- severe autoinfection
-increased secondary bacterial infections
-death

TREATMENT
• Albendazole
• Thiabendazole
• Ivermectin ( provides the best results in chronic uncomplicated strongyloidiasis)

PREVENTION AND CONTROL

• Proper handling and disposal of fecal material
• Adequate protection of the skin from contaminated soil
• Prompt & thorough treatment of the infected person is essential.

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TRICHINELLA SPIRALIS (Trichina worm)


Life cycle

Trichinellosis is caused by the ingestion of undercooked meat containing encysted
larvae (except for T. pseudospiralis and T. papuae, which do not encyst) of
Trichinella species.

After exposure to gastric acid and pepsin, the larvae are released from the cysts
and invade the small bowel mucosa where they develop into adult worms.

Females are 2.2 mm in length; males 1.2 mm.

The life span in the small bowel is about four weeks. After 1 week, the females
release larvae that migrate to striated muscles where they encyst.

EPIDEMIOLOGY
• Found worldwide (meat-eating population)
• Organism may be found in a number of different animals. (e.g. pig, deer, bear,
walrus, rat)
• Resistant to colder regions

МОТ:
Consumption of contaminated meat

LAB DX:
-Examination of the affected skeletal muscle (muscle biopsy)
• Digestion of muscle samples with pepsin and hydrochloric acid
• Non-specific laboratory tests to detect eosinophilia, muscle enzymes (creatine
phosphokinase, lactate dehydrogenase, and myokinase), and total IgE in serum
• Serologic methods are also available.
• No known test is completely 100% accurate.

O CLINICAL SYMPTOMS
• Light Infection: harboring up to 10
asymptomatic
• Moderate Infection: 50-500 larvae show symptoms
Light Infection:
-diarrhea
-slight fever (flu)
TREATMENT
• No medications (non-life-threatening strain)
• Plenty of rest, supplemented with adequate fluid intake, fever reducers, and pain
relievers
• Prednisone (life-threatening)
• Thiabendazole
Steroids

P AND C
• Thorough cooking of meats
• Proper storage (i.e, -15 degree C- 20days/-30 degree C-6days)
• Avoidance of feeding pork scraps to hogs

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• Dracunculosis
• Dracunculiasis
• Guinea worm infection



Epidemiology
• Found in parts of Africa, India, Asia, Pakistan, and the Middle East.
• Copepods, resides in fresh water
• Ponds, man-made water holes, and standing water may also serve as sources of
infection.
• Estimates of the number of people infected with Dracunculus medinensis in Africa,
the Middle East, India, and other tropical areas range from 50-150 million.

Reservoir Hosts:
• Dogs

МОТ:
Ingestion of drinking water contaminated with infected copepods.

Diagnosis
• Adult D. medinensis worms may be recovered by observing infected ulcers for the
emergence of the worms.
• Induced rupture of the infected ulcers by immersing in cool water reveals the
first-stage larvae.

PREVENTION AND CONTROL

• Use of properly treated water for consumption
• Boiling of water suspected of contamination
• Prohibiting the practice of drinking and bathing in the same water
• Ceasing the practice of allowing standing water to be ingested
• Educate the entire population in endemic areas, the religious practices of some
people in these areas lead to water contamination