Cestode parasites

Medical Parasitology, 2009

University of Palangkaraya

Agus Haryono
 Cestodes
Include all tapeworms.
They have suckers and teeth that grasp the host.
Behind a short neck are repeated parts of the worm, each containing reproductive
structures with eggs and sperm, which can be released with the host's feces.
The pieces give the worm a ribbon-like structure, beneficial for absorbing nutrients
from the intestine.

http://www.ndpteachers.org/p
erit/biology_image_gallery1.h
tm
 CESTODES
Order pseudophyllidea: have scolex with bothria; the sperm whale
tapeworm, H. physesteris, can be > 30 m long; the genital pore and uterine pore are
located on the mid-ventral surface, and the ovary is bilobed ("dumbbell-shaped"); each
segment has 4-14 complete sets of genitalia, can be up to 45,000 segments in a worm
Diphyllobothrium sp.

Diphyllobotrium latum

Order cyclophyllidea: most important group of tapeworms of

humans and domestic animals, multiple proglottid, scolex ("head") with four
suckers. Proglottids have genital openings on one side (except the family
Dilepididae, which has them on both sides), and a compact yolk gland or
vitellarium posterior to the ovary; can be small (a few mm's) or large (up to
10 m); mammals serve as intermediate hosts
Family Taeniidae:Taenia saginata, Taenia solium, taenia
multiceps; Echinococcus granulosus, E. multilocularis
Family Hymenolepididae: Hymenolepis diminuta,
Hymenolepis nana,
 HOSTS

INTERMEDIATE: harbors the

immature forms of the parasite.
Insect of herbivorous vertebrate
that ingest parasite eggs

DEFINITIVE: Harbors the

mature forms of the parasite.
Carnivorous or omnivorous
mammal that acquires infection
by consuming larval cysts in the
uncooked tissues of an IH
 Tapeworms
The body plan of adult
scolex cestodes includes a
scolex (looks like the
neck head), a neck and
strobila that can extend
for only a few proglottids
or thousands
The strobila is not truly
strobila metameric though as
several organs like the
excretory system extend
through the entire worm
Proglottid: each individual
segment
Most worms are very
long: occupying the entire
length of small intestine
 Morphology of tapeworms:
The scolex
The scolex is the part of the worm that anchors it to the intestinal
epithelium and prevents that the worm is passed with the digested
food
Different types of scoleces
Some cestodes carry a
protrusible rostellum which is
armed with hooks
Muscular holdfast organs Scolex of Diphyllobothrium latum.

include suckers or acetabula

(usually 4 per scolex), weakly
muscled grooves (bothria, 2
per scoles), and more
muscular bothridia (4 per
scolex).

Scolex of Taenia Saginata

Scolex of Taenia Solium
 Tapeworms morphology: the proglottid

Proglottids are budded off from the

head and neck region.
Proglottids are hermaphroditic, egg-
producing units
In cross-sections the tapeworm body
is seen to be filled with parenchyma.
Muscle layers separate the body into
an outer cortex and an inner medulla.
The reproductive organs are usually in
the medulla.
Strobila

In most cestodes the scolex

is tiny when compared to the
strobila which makes up
most of the actual worm
The strobila consists of a
linear series of proglottids
Tape worms are
hermaphrodites and each
proglottid carries a set of
female and male
reproductive organs
Strobila

Strobilation: asexual process of

forming segments
New proglottids are continuously
formed in the neck just below the
scolex (A)
Along the length of the worm the
proglottids increase in size and
maturity, developing from
premature (B) to mature (C,
carrying fully functional and active
sexual organs), to the gravid
stage (D) in which essentially the
entire proglottid is filled with the
uterus and eggs
 The reproductive system
The male system
consists of numerous
testes, vasa efferentia
from each testis to the
sperm duct. The cirrus
is surrounded by the
cirrus pouch. Most
often the cirrus pouch
and female vagina enter
a common chamber, the
genital atrium, and
The female includes a vagina from the genital pore
share a common
to a seminal receptacle; an ovary; a single oviduct,
the ootype, the duct from the seminal receptacle. opening, the genital
The uterus leads from the ootype and may have pore.
either an opening or uteropore or end blindly.
Proglottids without uteropores detach when gravid.
The egg is formed in the ootype with the
contributions from the ovary and the vitellaria (or the
vitelline gland in some cestodes)
 http://www.perso
Excretion and nal.psu.edu/user
s/t/r/trp2/proglotti

osmoregulation
d.jpeg

Pair of dorsal and ventral

excretory or osmoregulatory
canals traverse the entire strobila
from scolex to the last proglottid.
The dorsal one is often smaller
than the ventral. Transverse
canals can be seen.
The dorsal and ventral canals
unite in the scolex
Posteriorly, the two pair of canals
merge into an excretory bladder
with a single pore to the outside.
When the terminal proglottid
detaches, the canals empty
independently at the end of the
strobila.
The tegument
Cestodes do not have a
mouth or any form of
intestine
The entire uptake of
nutrients occurs through
the tegument
In reflection of this
important role in uptake
the absortive surface is
highly enlarged by small
microvilli or microtriches
Microfilaments (actin
polymers are the
molecular backbone of
microtriches)
 Developmental stages
With very few exceptions vertebrates are
the final host harboring the adult tape
worms
Many invertebrates and vertebrates are
parasitized as intermediate hosts
The embryonate egg contains the
oncosphere a larva that will penetrate the
intestinal wall after eggs are swallowed by
intermediate host
The oncospheres of eucestoda have three
pairs of hooks which makes it easy to
identify them
Taeniid eggs. The eggs
of Taenia saginata and
T. solium are
indistinguishable
morphologically. The
Diagram of oncosphere of Hymenolepis diminuta, dorsal view eggs are rounded, 31
to 43 m, with a thick
radially striated brown
shell. Inside each shell
is an embryonated
oncosphere with 6
hooks. CDC
Developmental
stages
The zygote develops into
an oncosphere
In some species with
aquatic hosts the inner
envelope develops into a
ciliated epithelium.
These motile coracidia
have to be taken up by an
intermediate host within a
short time
Once inside the gut of the
host the oncosphere
sheds the ciliated layer
and invades and
differentiates into a
procercoid
 Developmental stages
(metacestodes)
In pseudophyllidean
cestodes the larvae look
fairly similar to the adult
(the first host is infected
by a procercoid which
still carries the larval
hooks
In the second host a
(D. latum) (D. latum) plerocercoid forms (there
is no asexual
amplification)
The cyclophyllidean
larvae are more complex
and come in a quite a
variety
The medically important
(T. solium) larvae are cysticercoid,
cysticercus and hydatid
(some of these larvae
(Hymenolepis sp.) (E. granulosus) provided amplification)
Cestode Metabolism
Cestodes are
facultative
anaerobes and take
up glucose as main
source of energy
Glucose is taken
down to pyruvate
and PEP through
glycolysis (NAD is
recycled by
reduction of
pyruvate to lactate,
succinate and
acetate)
The adult cestode
stores large
amounts of
glycogen to provide
energy between
host meals
 Diphyllobotrium latum - the fish tape
worm
Common in fish
eating carnivores
with little host
specificity. Salmon,
trout, perch, white
fish, eel, pike, etc.
Adults get quite long
(10 m) and shed up
to a million eggs per
day
Eggs must reach
water for
embryonation
After several days a
coracidium hatches
through the
operculum and is
eaten by a copepod

http://www.dpd.cdc.gov/DPDx/HTML/Diphyllobothriasis.htm
 Diphyllobotrium
latum - the fish tape
worm
The coracidium is eaten by the
copepod (First Intermediate Host)
It looses its ciliated coat and once
through the intestine and into the
hemocoel, it develops into the
procercoid in 3 weeks ( 500 m)
with a cercomer at the posterior
end
The copepod is weakened by the
parasite and less motile
The procercoid can not develop
any further until is eaten by a fish.
The larvae penetrate the small
fish gut (Second Intermediate
Host) and migrates in the muscle
Here it grows and matures into
the plerocercoid
Diphyllobotrium latum - the fish tape
worm
Mature plerocercoids can be easily
seen as white masses in uncooked
fish
If host fish is eaten by other fish
plerocercoids will migrate into muscle
of new fish host (paratenic host)

About 9 million people infected (was

wide spread in northern Europe and
Japan, more cases in the US due to
sushi, sashimi and ceviche)
Infection occurs through raw fish
dishes or handling (tasting) of fish
dishes before cooking
Infection rate can be locally quite high,
especially when untreated sewer is led
into lakes (there are also reservoirs in
many carnivores)
 Diphyllobotrium latum -
the fish tape worm

Definitive host:fish-eating
carnivores:dogs,bears, humans, etc.
Infection of humans cause no or little
symptoms (abdominal discomfort, nausea
diarrhea are rare)
The parasite takes up large amounts of
Vitamin B12
In patients with genetic deficiencies in Vit B12
uptake the parasite competes effectively for the
entire vitamin leading to severe pernicious
anemia
Geographic distribution: Northern Europe,
Chile, Japan, Korea North America

Diphyllobothrium latum (broad fish

tapeworm)
http://animaldiversity.ummz.umich.edu/site/reso
urces/Grzimek_inverts/Cestoda/Diphyllobothriu
m_latum.jpg/view. html
Diphyllobotrium latum - the fish tape
worm
Diagnosis through detection of
characteristic eggs in feces
These eggs are oval or
ellipsoidal an operculum
(arrows) at one end that can be
inconspicuous. At the opposite
end there is a small knob that
can be barely discernible
The eggs are passed in the
stool unembryonated. Size
range: 58 to 76 m by 40 to 51
m.
Treatment with praziquantel

Proglottids of
Diphyllobothrium latum.
These proglottids tend to
be passed in strands of
variable length in the
stool. The proglottids tend
to be broader than long.
Image contributed by
Georgia Division of Public
Health.
Taenia life cycle
Humans are the only
DHs
The eggs can survive
for days to months in
the environment
The adult worm
attaches by their
scolex to the human
small intestine.
The adults produce
proglottids passed
with stool
The eggs are released
after the proglottids
are passed with the
feces
 TAENIA SAGINATA

Beef tapeworm Taenia

Ranges in length from 6-30 ft saginata
adult
Geographic distribution: cosmopolitan. worm.

Most common where poor sanitation

and no inspection of meat combine
Africa and South America
Transmission: Ingestion of larval form
in undercooked beef
In N. America 1 in 100 is infected. In
third-world nations could be up to 10%
No symptoms or some abdominal
discomfort
Diagnosis: finding eggs or proglottids
in feces
Taenia saginata,
Scolex
(Mit freundlicher
Genehmigung
Roche AG)
 TAENIA
SOLIUM
The armed
scolex of T.
solium (note
hooks on top
of scolex).
CDC

T. solium has a scolex (A) with four suckers and a double

crown of hooks, a narrow neck, and a large strobila (2-4 m) (B)
consisting of several hundred proglottids.
About 2 months after ingestion, proglottids begin to detach from
the distal end and are excreted in the feces.
Each segment contains 50-60,000 fertile eggs.

The Lancet (2003) 361: 547

 TAENIA SOLIUM
Endemic in less developed countries
where pigs are raised as food source. Latin
America, most of Asia, sub-saharan Africa,
and parts of Oceania.
Infection with the adult forms of the
parasite produces similar symptoms to
infection with T. saginata.

Cysticerci: (A) as seen in infected

pork; (B) excised into a Petri dish.
The white dot in each cyst
The Lancet (2003) 361: 547 corresponds to the scolex. The
Lancet (2003) 361: 547.
Taxonomic classification of helminths
Sub Phylum
kingdom
Metazoa Nematodes
Round worms; appear round
in cross section, they have
body cavities, a straight
alimentary canal and an
anus
Platyhelminthes
Flat worms; dorsoventrally
flattened, no body cavity
and, if present, the
alimentary canal is blind
ending
Class Genus
examples
Ascaris (roundworm)
Trichuris (whipworm)
Ancylostoma (hookworm)
Necator (hookworm)
Enterobius (pinworm or
threadworm)
Strongyloides
Cestodes Taenia (tapeworm)
Adult tapeworms are found in
the intestine of their host
They have a head (scolex) with
sucking organs, a segmented
body but no alimentary canal
Each body segment is
hermaphrodite
Trematodes Fasciolopsis (liver fluke)
Non-segmented, usually leaf- Schistosoma (not leaf
shaped, with two suckers but shaped!)
no distinct head
They have an alimentary canal
and are usually hermaphrodite
and leaf shaped
Schistosomes are the
exception. They are thread-
 Human cysticercosis
When humans plays the role of the
Intermediate Host
Larval stages develop in the human host
Humans acquire cysticercosis through faecal-oral contamination with T. solium
eggs
The oncosphere in the eggs is released by the action of gastric acid and
intestinal fluids
Cross the gut wall and enter the bloodstream
They are carried to the muscles and other tissues
They encyst as cysticerci at small terminal vessels (1 cm) (A) and (B)
Neurocysticercosis and ophtalmic cysticercosis serious

MRI of multiple
cysts. Image
courtesy of the
Centers for Disease
Control and
Prevention.
Racemose Cysticercosis-MRI
 Neurocysticercosis

Neuroimaging: MRI of viable (A) and degenerating (B) cysts and CT of

calcified cysticerci. The Lancet (2003) 361: 547

The parasite infects the CNS

Epileptic seizures (58-80% when parenchymal
brain cysts).
Intracranial hypertension, hydrocephalus, or
both. This syndrome is related to the location of From: NEJM (2001) 345:879
parasites in the cerebral ventricles or vasal
cisterns.
Occasionally a cyst may grow larger (giant cyst)
Geographical variation in clinical manifestations
 Cysticercosis pathology
Cysts are rounded or oval vesicles from a few mm to 1-2 cm
Most common location is in the cerebral hemispheres, mainly at the junction of
grey and white matter.
Cysts can be found in the cerebellum, ventricles, brainstem, basal cisterns, and
spine.
Viable cysts have a translucent membrane through which the scolex is visible.
Cysts degenerate: the fluid becomes opaque and dense and edges irregular and
shrink.
Calcification starts in the cephalic portion and leaves a whitish calcified nodule
Racemose form: high mortality. Large translucent vesicle lobulated without
scolex which develops in the basis of the brain or in the ventricles. Sometimes
several small vesicles surround a pedicle like a bunch of grapes.
 Cysticercosis diagnosis

Serologic diagnosis:
Antibody assays for cysticercosis: 8
kDa antigens, GP50, FAST-ELISA
with the 8 kDA antigen
Antigen-detection assays: circulating
antigens means live parasites.
Ongoing viable infection. Monoclonal MRI showing parenchymal (A) and
antibodies seem to detect AGs in extraparenchymal (basal ccs) (B) viable NCC.
CSF.
Antibody assays for taeniasis: MRI showing
calcified cyst with
TSE33 and TSE38 were recognized surrounding
by a panel of taeniasis but not edema
cysticercocis, patient serum samples.
Neuroimaging diagnosis: CT and
MRI provide objective evidence on
number and location of cysticerci. Also
their viability and the severity of the host
inflammatory reaction.
 Cysticercosis treatment
Treatment should be individualized based on
cyst location, level of inflammation and clinical
presentation
Therapy should include analgesics, antiepileptic
drugs, cysticidal drugs, surgical resection of
lesions and placement of ventricular shunts
Parenchymal cysticercosis with viable cysts:
Albendazole 15 (mg/kg/day) with
dexamethasone (0.1 mg/kg/day). Praziquantel.
Subarachnoid ccs: antiparasitic therapy
No reason to use antiparasitic drugs to treat
dead calcified cysts. Symptomatic therapy.
Surgical therapy: ventricular shunting to resolve
hydrocephalus. Also excision of giant cysts or
intraventricular cysts

Albendazole
 Transmission
You do not get NCC by eating pork
Ingestion of infected pork only causes adult
tapeworm infestation: taeniasis.
Infected pork contains only the larval cysts that
develop into adult worms in the human intestine
What is that transmits CCS?
The eggs
Most common source of infective eggs?
A symptom-free tapeworm carrier in the household
 Echinococcosis

Echinococcus multilocularis:
alveolar echinococcosis. Invasive solid
lesions of firm consistency, full of connective
tissue and a jelly-like material.

Echinococcus granulosus: cystic

echinococcosis. Produces cystic lesions
 Echinococcus granulosus -
the dog tape worm

Adult E. granulosus adult worms live in the intestine of dogs

They produce eggs which are shed with the feces
Eggs are infective to herbivores (and humans)
Echinococcus granulosus

The oncosphere
penetrate intestine
of intermediate host
and develops into a
hydatid
Hydatides are
spherical fluid-filled
cysts surrounded by
a granuloma formed
by the host
The Hydatid Cyst
The cyst is lined by a multilayer parasite tissue
with the innermost layer being the germinal layer
This layer is a undifferentiated stem cell layer
that can spawn the formation of brood capsules
which are themselves lined by GL
The daughter cysts (the encircled body) "bud"
into the center of the fluid-filled cyst.
This is a very small portion of the cyst which may
become quite large.
Each of the smaller bodies will develop into
diminutive tapeworms should this be eaten by a
definitive or final host such as a canine.
The Hydatid Cyst
Thousands of
protoscolices can fill the
hydatid (hydatide sand)
Protoscolices are the
infective stage for dogs
Hydatides usually grow
slowly but steadily (1-5
cm per year)
They are usually well
tolerated until their size
becomes a problem or
they rupture
Cyst rupture or leakage
can result in allergic
reactions and metastasis
 Echinococcosis:
Cystic hydatid disease

Hydatides can be
found in several
organs but are most
frequent in the liver
 Echinococcosis:
Cystic hydatid disease
Liver cysts cause liver
swelling, right epigastric
pain, nausea, vomiting
Obstruction of bile ducts and
blood vessels can cause
cholangitis, jaundice,
cirrhosis and portal
hypertension

This upper abdominal CT scan shows multiple cysts in the liver, caused
by echinococcus. Note the large circular cyst (seen on the left side of
the screen) and multiple smaller cysts throughout the liver.
http://www.drkoop.com/ency/93/ImagePages/1177.html
 Echinococcosis:
Cystic hydatid disease
Lung cyst are often well tolerated but
obstruction and or rupture can cause
chestpain, cough and dyspnea
The first symptoms of brain cyst is often
focal epilepsy
Diagnosis is by serology, radiology, CT
scans and sonograms.
Treatment is surgical. Prognosis
depends on size and location of
hydatide (mortality is around 5-10%)
Hydatide is often injected with sterilizing
fluids to avoid metastases
Benefit of chemotherapy is inconsistent
 Echinococcosis:
Cystic hydatid disease
Sylvatic and domestic strains.
Strains adapted to dogs &
sheep are more aggressive
upon human infection
Ecchinococcosis can be
locally quite important
Control of feral dogs, limit
access of dogs to sheep offal,
treat pet dogs regularly
Effective control programs in
many countries including
New Zealand, Tasmania,
Cyprus and Iceland
Echinococcus multilocularis - the
fox tape worm
Sylvatic zoonosis in Europe
and northern America
Humans get infected by
eating contaminated berries
and mushrooms collected in
forests populated by foxes
Life Cycle: (A) Adult parasite.
(B) Foxes (left, red fox; right,
Arctic fox) as principal
definitive hosts; dogs, other
canids, and cats can be
involved in the cycle. (C)
Proglottid with eggs. (D) Egg
with oncosphere. (E) Infection
of humans. (F) Rodent
infected with metacestodes.
(G) Rodent liver with
metacestodes. (H) single
metacestode cyst with
protoscoleces.
Echinococcus multilocularis

Alveolar or multilocular
hydatide
Hydatide grows like a
sponge through entire liver
Symptoms closely mimic
cirrhosis or hepatocarcinoma
Metastases can form in lung
or brain
Prognosis is poor and
depends on extend of organ
involvement
 Hymenolepis nana -
the dwarf tape worm
Hymenolepis nana
occurs relatively
frequently world
wide and is usually
an infection of
children
An intermediate
host is not required
and autoinfections
occur frequently
Cysicercoids
develop in the
lymphatics of villi
Alternatively
infection through
cysticercoids in
insects that
contaminate grains
or cereal
 Hymenolepis nana -
the dwarf tape worm

Usually asymptomatic (very

high burden can lead to
unspecific gastrointestinal
symptoms
Infections are cleared with
adolescence
Diagnosis by demonstration
of characteristic eggs
(accidental infections with H.
diminuta the rat tape worm)