Nematodes I

Helminthes
Nematodes I
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Dr. Koshila Ranasinghe

BSc. Sp. (Hons), PhD
Helminthes
• Heliminthic parasites are multicellular, bilaterally
symmetrical
• Helminths of importance to human beings are divided into
three main groups
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• Medical helminthology is concerned with the study of
helminths or parasitic worms
Medical parasitology
• Helminths are among the common parasitic causes of
human suffering
• They are the cause of high morbidity and mortality of
people worldwide
• They cause different diseases in humans, but few
helminthic infections cause life- threatening diseases
• They cause anaemia and malnutrition. In children they 2
cause a reduction in academic performance.
Helminthes cont.
• Sources of helminthic parasites are different
• Exposure of humans to helminths may occur in one of the
following ways:
1. Contaminated soil (Geo-helminths), water (cercariae of
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blood flukes) and food (Taenia in raw meat)
2. Blood sucking insects or arthropods (as in filarial worms)
3. Domestic or wild animals harbouring the parasite (as in
Echinococcus in dogs).
4. Person to person (as in Enterobius vermicularis,
Hymenolepis nana)
5. Oneself (auto-infection) as in Enterobius vermicularis
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Helminthes cont.
• They enter the body through different routes including:
mouth, skin and the respiratory tract by means of
inhalation of airborne eggs
• Helminths are classified into three major groups
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1. Nematodes (Round worms)
2. Trematodes (Flukes)
3. Cestodes (Tape worms)
• The Trematodes and Cestodes are groups of flat worms
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Nematodes (Round Worms)
General Characteristics of parasitic
Nematodes
• Are un-segmented, elongated and
cylindrical
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• Have separate sexes with separate
appearances
• Have a tough protective covering or
cuticle
• They have a complete digestive tract
with both oral and anal openings
• Generally light cream-white coloured
• Life cycle includes: egg, larvae and adult
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Parasitic nematodes are divided
• Intestinal nematodes
• Intestinal nematodes with tissue stage
• Ascaris lumbricoides
• Necator americanus
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• Roundworms
• Strongyloides stercoralis
• Intestinal nematodes without tissue stage
• Enterobius vermicularis
• Trichuris trichuira
• Tissue and blood dwelling nematodes
• Filarial worms
• Dracunculus medinensis
• Trichinella 6
• Larva migrans
Intestinal Nematodes with a Tissue
stage
• Round worms - Ascaris lumbricoides, Toxocara canis
• Hookworms - Ancylostoma duodenale, Necator
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americanus
• Strongyloides stercoralis
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1) Ascaris lumbricoides
Common roundworms infecting more than 700 million
people worldwide
History and Distribution
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Largest nematode parasite in the human intestine
Most commonest human helminth and
• A billion people are estimated to be infected
• Individual worm burden could be very high, even up to
over a thousand
• An editorial in the Lancet in 1989 observed that if all the
roundworms in all the people worldwide were placed end-
to-end they would encircle the world 50 times.
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Geographic distribution
• Worldwide in areas with warm, moist climates and are
widely overlapping
• Infection occurs worldwide and is most common in tropical
and subtropical areas where sanitation and hygiene are
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poor
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Morphology and Life Cycle
• Adult worms live in the small intestines of infected
individuals
• Large cylindrical worms, with tapering ends, the anterior
end being more pointed than the posterior
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• Pale pink or flesh coloured when freshly passed in stools,
but become white outside the body
• The male measures 15
to 30 cm in length and
2 to 4 mm in thickness
• Its posterior end is
curved ventrally to
form a hook and carries
two copulatory spicules 10
Morphology and Life Cycle cont.
Copulatory spicules
• Needle-like mating structures found only in males
• Males may have one or two spicules, which serve to open
the vulva of females, and facilitate the transmission of
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sperm, although sperm is not transferred directly by or
through the spicules
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• Female is larger, 20 to 40 cm long and 3 to 6 mm thick
• Its posterior extremity is straight and conical
• Vulva is situated mid-ventrally, near the junction of the
anterior and middle thirds of the body
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• A single worm lays up to 200,000 eggs per day

• Eggs are passed in to the exterior via faeces
• Two types of eggs are passed
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• Fertilised eggs - laid by females inseminated by mating
with a male, are embryonated and develop into the
infective eggs
• Unfertilised eggs - uninseminated female also lays
eggs, but these are non-embryonated and cannot
become infective
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• Fertilised ascarid egg is spherical or

ovoid, bile stained to a golden brown
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colour and measures 60 to 75 μm in
length and 40 to 50 μm in breadth
• Enclosed in a stout translucent shell
consisting of three layers
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• Unfertilized egg is relatively heavy and does not float in
saturated salt solution used for concentration by salt
floatation while the fertilised eggs float
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• Stool samples may show both fertilized and unfertilized
eggs, or either one type
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• The fertilised egg passed in faeces, is not immediately
infective
• It has to undergo a period of incubation in soil before
acquiring infectivity
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• Eggs are resistant to adverse conditions and can survive for
several years
• Development of the egg in soil depends on the nature of
the soil and various environmental factors
• A heavy clayey soil and moist shady location, with
temperature between 20° and 30°C are optimal for rapid
development of the embryo
• The development usually takes from 10 to 40 days, during
which time the embryo moults twice and becomes
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infective rhabditiform larva, coiled up within the egg
• Infection occurs when the egg containing
the infective rhabditiform larva is
swallowed
• A frequent mode of transmission is
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through fresh vegetables grown in fields
manured with human faeces
• Infection may be transmitted through
contaminated drinking water
• Children playing about in mud can
transmit eggs to their mouth through
dirty fingers
• Where soil contamination is heavy due to
indiscriminate defecation, the eggs
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sometimes get airborne along with
windswept dust and inhaled
Life cycle of A. lumbricoides
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• Inhaled eggs get swallowed
• When the swallowed eggs reach the duodenum, the larvae
hatch out
• Rhabditiform larvae, about 250 μm in length and 14 μm in
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diameter, are actively motile
• They penetrate the intestinal mucosa, enter the portal
vessels and are carried to the liver
• Then pass via the hepatic vein, inferior vena cava and the
right compartments of heart, and in about four days reach
the lungs, where they grow and moult twice
• After development in the lungs, in about 10 to 15 days, the
larvae pierce the lung capillaries and reach the alveoli
• Then they crawl up or are carried up the respiratory 19
passage to the throat and are swallowed
• Larvae moult and develop into adults in the upper part of
the small intestine
• They become sexually mature in about 6 to 12 weeks and
the gravid females start laying eggs to repeat the cycle
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• Adult worm has a lifespan of 12 to 20 months
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Pathogenesis and Clinical Features
• Clinical manifestations in ascariasis can be caused by either
the migrating larvae or the adult worms
• Pathogenic effects of larval migration are due to allergic
reaction and not the presence of larvae as such
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• Therefore, the initial exposure to larvae is usually
asymptomatic, except when the larval load is very heavy
• Ascaris pneumonia is characterised by low grade fever, dry
cough, asthmatic wheezing, urticaria and eosinophilia
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• Presence of Charcot-Leyden crystals in sputum
• Larvae may occasionally be found in the sputum, but are
seen more often in gastric washings - Loeffler’s syndrome
• Clinical features generally clear in one or two weeks,
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though it may sometimes be severe and rarely even fatal
Loeffler’s syndrome can also be caused by hypersensitivity
to other agents, both living and non-living
• Allergic inflammatory reaction to
migrating larvae may involve other
organs such as the kidney or liver
• Clinical manifestations due to adult

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worm vary from asymptomatic
infection to severe and even fatal
consequences
• The pathological effects, when present, are caused by
• Spoliative action
• Toxic action
• Mechanical effects
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i) Spoliative or nutritional effects
• Are usually seen when the worm burden is heavy
• Worms may be present in enormous numbers, sometimes
exceeding 500, in small children, occupying a large part of the
intestinal tract
• This interferes with proper digestion and absorption of food
• May contribute to protein-energy malnutrition and vitamin A
deficiency 23
• Patients have loss of appetite
ii)Toxic action
• Due to hypersensitivity to the worm antigens and may be
manifested as fever, urticaria, wheezing, conjunctivitis and
Angioneurotic oedema
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• These are more often seen in inviduals who come into contact
with the worm occupationally, as in laboratory technicians
and abattoir workers, than in children having intestinal
infestation
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iii) Mechanical effects
• Most important manifestations of ascariasis
• Mechanical effects can be due to masses of worms causing
luminal occlusion or even a single worm infiltrating into a vital
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area
Worms may be clumped together into a mass, filling the lumen,
leading to intestinal obstruction
25
• Male worm is more responsive to illness of the host, than
the female
• Worm may wander up or down along the gut
• Going up, it may enter the opening of the biliary or
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pancreatic duct causing acute biliary obstruction or
pancreatitis
• It may enter the liver parenchyma, where it may lead to
abscesses
• Worm may go up the oesophagus and come out through
the mouth or nose
• May crawl into the trachea and the lung causing
respiratory obstruction or lung abscesses
26
• Migrating downwards, the worm may cause obstructive
appendicitis
• It may lead to peritonitis when it perforates the intestine,
generally at weak spots.
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• Wandering worm may reach the kidneys, lungs or other
organs and cause ectopic lesions
27
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Diagnosis
• In the early stages of infection, when migrating larvae
cause Loeffler’s syndrome, the diagnosis may be made by
demonstrating the larvae in sputum, or more often in
gastric washings
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• Presence of Charcot-Leyden crystals in sputum and an
attendant eosinophilia support the diagnosis
• At this stage no eggs are seen in faeces
29
Diagnosis cont.
• Most important method for the diagnosis of ascariasis is
the demonstration of eggs in faeces
• A single female may account for about 3 eggs per mg of
faeces
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• At this concentration, the eggs can be readily seen by
microscopic examination of a saline emulsion of faeces
• Both fertilized and unfertilized eggs are usually present.
And occasionally only one type is seen
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Diagnosis cont.
• Sometimes the diagnosis becomes evident when the
worm is passed either through the anus, or through the
mouth or nose
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• A skin test with ascaris antigen gives a positive result,
but is unreliable and not used for diagnosis
• Serological tests are not useful in diagnosis
• Diagnosis may often be made by barium contrast

radiography of the abdomen
31
Diagnosis cont.
• Low radioactive barium is
swallowed as contrast
medium for the X-ray film
• It shows the duodenum,
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the first portion of the
bowel after the stomach,
packed with worms
• The worms are the black
areas showing up as a
tangled mass within the
white of the contrast
medium
32
Treatment
• Several safe and effective drugs are now available
• Pyrantel pamoate, albendazole, mebendazole and
piperazine citrate
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33
Prevention
• Ascariasis can be eliminated only if faecal contamination of
soil can be prevented
• Ascaris egg is highly resistant. Therefore the use of night
soil as manure will lead to spread of the infection unless
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destruction of the eggs is ensured by proper composting.
• Treatment of vegetables and other garden crops with
water containing iodine 200 ppm for 15 minutes kills the
eggs and larvae of Ascaris and other helminths
• Transmission of infection to others can be prevented by
• Not defecating outdoors
• Effective sewage disposal systems
• Awareness of hygiene to prevent infection
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Ascariasis in Sri Lanka
• Many prevalence surveys have performed
• 50% - workers in a tea plantation (2000)
• 77% children and 69% women in a plantation (1996)
• 0.27% school children in Gampaha district (2010)
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• 24.5% school children in plantation sector (2012)
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2) Toxocara canis
• Toxocariasis is the parasitic disease caused by the larvae of
two species of Toxocara roundworms: Toxocara canis from
dogs and, less commonly, Toxocara cati from cats
• Toxocariasis is considered one of the Neglected Parasitic
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Infections, a group of five parasitic diseases that have been
targeted for public health action
• A natural parasite of dogs and cats respectively can cause
aberrant infection in humans leading to visceral larva
migrans (VLM)
36
Toxocara canis life cycle
• Infection is acquired in pups by transmission of larvae
transplacentally or lactogenically, but in kittens, only
lactogenic transmission is recorded
• Older animals are infected by ingestion of mature eggs in
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soil or of larva by eating infected rodents, birds or other
paratenic hosts
• Eggs are shed in faeces and become infective in 2-3 weeks
• Human infection is by ingestion of eggs
• Larvae hatch out in the small intestine, penetrate the
mucosa and reach the liver, lungs or other viscera
• They do not develop any further – dead end life cycle
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Toxocara canis life cycle
Medical parasitology 17/01/2017

38
Toxocara canis life cycle cont.
• Infected dogs and cats shed Toxocara eggs in their faeces
into the environment
• Once in the environment, it takes 2 to 4 weeks for
Toxocara larvae to develop and for the eggs to become
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infectious
• Humans or other animals can be infected by accidentally
ingesting Toxocara eggs
• Although rarely, people can be infected by eating
undercooked or raw meat from an infected animal such as
a lamb or rabbit
• Because dogs and cats are frequently found where people
live, there may be large numbers of infected eggs in the
environment
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Toxocara canis life cycle cont.
• Once in the body, eggs hatch and roundworm larvae can
travel in the bloodstream to different parts of the body,
including the liver, heart, lungs, brain, muscles, or eyes
• Most infected people do not have any symptoms
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• However, in some people, the Toxocara larvae can cause
damage to these tissues and organs
• Symptoms of toxocariasis, the disease caused by these
migrating larvae, include fever, coughing, inflammation of
the liver, or eye problems
40
risk factors
• Studies have shown that almost all puppies are born
already infected with Toxocara canis
• Infection rates are higher for dogs and cats that are left
outside for more time and allowed to eat other animals
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• Several factors associated with higher rates of infection
• Dog owners
• Children and adolescents under the age of 20
• People living in poverty
• Geographic location plays a role as well, because Toxocara

is more prevalent in hot, humid regions where eggs are
kept viable in the soil
41
Disease
• Most people do not have any symptoms
• Two major forms of toxocariasis
• Visceral toxocariasis (VT)/visceral larva migrans (VLM)
• Ocular toxocariasis (OT)/ocular larva migrans (OLM)
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• In a few people who are infected with high numbers of
Toxocara larvae or have repeated infections, the larvae can
travel through parts of the body such as the liver, lungs, or
CNS and cause symptoms such as fever, coughing, enlarged
liver or pneumonia - VT
• Larvae can also travel to the eye and cause ocular
toxocariasis (OT)
• OT occurs when a microscopic Toxocara larva enters the
eye and causes inflammation and scarring on the retina,
typically in one eye and can cause irreversible vision loss 42
Disease

43
Diagnosis
• Difficult to diagnose because the symptoms of toxocariasis
are similar to the symptoms of other infections
• Blood test is available that looks for evidence of infection
with Toxocara larvae
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• Identifying the presence of typical clinical signs of VT or OT
and a history of exposure to cats and dogs
• In human since there is no adult worm no eggs will be seen
passed out with faeces. ?
44
Treatment
• Visceral toxocariasis can be treated with antiparasitic drugs
such as albendazole or mebendazole
• Treatment of ocular toxocariasis is more difficult and
usually consists of measures to prevent progressive
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damage to the eye – surgical removal of worm
45
Prevention and control
• Controlling Toxocara infection in dogs and cats
• Have your veterinarian treat your dogs and cats, especially
young animals, regularly for worms
• Clean your pet’s living area at least once a week. Faeces
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should be either buried or bagged and disposed of in the
trash. Wash your hands after handling pet waste.
• Minimize handling suspected soil contaminated with
faeces
• Good hygienic habits
• Toxocara eggs can survive in the environment for months
or even years under the right conditions
• Many common disinfectants are not therefore effective
against eggs but extreme heat will kill the eggs 46
47

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Nematodes I

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Helminthes

Click to add text

Dr. Koshila Ranasinghe

History and Distribution

• A single worm lays up to 200,000 eggs per day

• Fertilised ascarid egg is spherical or

• Clinical manifestations due to adult

• Diagnosis may often be made by barium contrast

Medical parasitology 17/01/2017

• Geographic location plays a role as well, because Toxocara

Medical parasitology 17/01/2017

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