NEMATODES

Learning Outcomes

1. Be able to describe intestinal manifestations of Helminths;

2. Be able to classify helminths into nematodes, trematodes and flukes

3. Show knowledge of classification of nematode and species with the group;

4. Be able to identify and describe pictures of the soil-transmitted helminths - hookworm;

5. List the names of anti-helminthic drugs and those contra-indicated during pregnancies;

6. Describe life cycle helminths and subsequent symptoms during larvae migration; identify symptoms due to adult worms, complication and prophylactic and
treatment;

7. Understand the role of suboptimal sanitation vis-a vis of increased prevalence of ascariasis
HELMINTHS
 Helminths
Nematodes
Trematodes
(round worms)
(flukes)

Cestodes (tape worms)

• Intestinal Worms
• Cysticercosis
• Hydatid Disease
NEMATODES
 SOIL TRANSMITTED HELMINTHS

Nematodes
• Ascaris
• Trichuris
• Strongyloides
• Hookworms
 Ascaris lumbricoides
•Eggs in faeces – non-infectious
•Develop in soil → infectious agents
•Transmitted to mouth (unwashed produce)
Ascaris –
life cycle
 Symptoms due to adult worms
• None
• Horror!
• Heavy infection – malnutrition
• Usually don’t damage/invade mucosa
• Obstructive symptoms - vomiting
• RARE - intestinal obstruction,
• - volvulus, perforation, peritonitis
• Often unnoticed
 Possible complications
 Granulomatous reaction to stray eggs

 Ductal blockage by adult worms

Biliary colic / cholangitis
In Phillipines 20% biliary surgery shows live / dead
Ascaris in the biliary tree
Appendicitis, pancreatitis

 Wandering worms – NG tubes!, sinuses!

 Diagnosis
Faecal examination:
Eggs in stool
Adult worms in stool [less common]

Wandering worms – mouth, nose

Radiology - Barium meal

Serology not helpful
Treatment – avoid in 1st trimester of pregnancy
Single dose:
 Albendazole - 2-5 yrs old – 200 mg
- >5yrs – 400 mg
 Mebendazole - 500 mg (not absorbed – effective only on worms in gut)
 Levamisole - 2.5 mg/kg
 Pyrantel pamoate - 10 mg/kg

Treatment of complications:
Not Mebendazole (because not absorbed)
Inflammatory reactions can be managed with steroids
Trichuris trichiura
• About 900 million people – usually age 5 – 15

• Global distribution – esp. warm, moist climates

• Eggs ingested - infective eggs go from anus to mouth

- no development in soil

• Larvae (whip shaped) liberated in caecum, then migrate in mucosa

• Handle of the whip is anterior; buried in caecum, colon, or rectum

• Feed on tissue fluid juices

Trichuris life cycle:
incubation period 60
days
• Diagnosis
• Eggs in stool
• Rectal prolapse in young
• Eosinophilia
• Adult worms up to 4cm long

• Treatment
• Albendazole 400 mg once
• Mebendazole 500 mg once
 Strongyloides stercoralis
• Tropics and subtropics

• SE Asia, S.S. Africa, Latin America, Caribbean

• Rarely temperate

• 30 – 100 million worldwide

• Common in institutions
 Strongyloides stercoralis
Mature in small intestine, penetrate intestinal mucosa
Rhabdatidiform larvae - passed in stool – usually non-infectious
- independent life cycle in soil
May → auto-infective cycle - larvae in stool become infective
Infection persists for decades
May → larva currens
• Serpiginous wheal with surrounding flare
• Comes and goes in a few hours
• Itchy
 Strongyloides stercoralis

• Very small worm – female adults 2 mm

• Lives in small intestine
• Infective filariform larvae penetrate intact skin
• Travel in blood → lungs → alveoli - lung maturation phase
• Move up trachea and are swallowed
 Strongyloides stercoralis:
incubation period 1 month
 Clinically
• Small bowel pathogen

• Often asymptomatic

• Primary infection
• rash x 3 weeks
• respiratory symptoms during larval migration
• abdominal discomfort and diarrhoea

• Chronic Strongyliodiasis
• may persist for decades
• classic symptoms - Mild non-specific GI upset
- Abdo pain – epigastric and RUQ
- Wt loss

• Complicated infection
 Complicated Strongyloidiasis
• Usually in debilitated patients
• Sprue-like syndrome
• Steatorrhoea
• Protein losing enteropathy
• Low albumin, oedema

• Abdo pain, vomiting, diarrhoea

• Sepsis-like picture
• Obstruction or ileus
.
• Pulmonary
• Pulmonary syndrome of SOB, cough, wheeze
• Pneumonitis
• Pulmonary abscess
• Neurological
 Diagnosis of strongyloidiasis
• Clinical
• Diarrhoea
• Abdo pain
• Urticaria
• Larva currens – pathognomonic

• Lab
• Eosinophilia (rare in hyperinfection)
• Serum IgE raised
• Culture – charcoal medium

• Serology – ELISA
 Treatment
• Ivermectin
• 200 mcg/kg/d x 3 days
• [once off may also work]

• Albendazole
• 400 mg/d or 400 mg/BD x 3 days (7 days if chronic)

• Thiabendazole
• 25 mg/kg BD x 3 days
 Hookworm
• Ancylostoma duodenale
• Necator americanus

• Non-infectious eggs passed in stool

• Hatch in warm, damp soil (24 - 32 Co)

→ larvae
Larva migrans of hookworm
• Larvae penetrate human skin on contact

• Hookworms
• LUNG STAGE following piercing of skin by
filariform larvae

• Have mouth, teeth/cutting plates,

pharynx, oesophagus, anus

• Suction – attach to mucosa of small intestine

Hookworms – life cycle
 Primary infection
• Ground itch at site of entry
– often ex-pats

• At 1-2 weeks – lung stage

• Dry cough, wheeze
• Fever, eosinophilia

• Self limiting – 2-3 months

• May be followed by abdominal pain

similar to DU
 Adult worms:
• Bloodsuckers!

• Anc. duodenale eats 0.15 - 0.26 ml blood / day

• N. americanus eats 0.03 ml blood / day

40 N americanus = 1.2 ml of blood = 0.6mg Fe daily

• Adult worms live 1 to 9 years

• 9,000 – 30,000 eggs / day / adult female

• <25 worms is insignificant

500 – 1000 worms will give disease
 Hookworm
• Eosinophilia

• Fe deficiency anaemia

• Eggs in stool on microscopy

Concentration methods may be needed

Be careful – rhabditiform larvae may

have hatched and make you consider
strongyloides
Hookworm - treatment

o Albendazole - single dose - 400 mg

o Mebendazole 100 mg bd x 3 days

o Pyrantel pamoate 11 mg/kg (max 1g) x 3 days

o Treat for iron deficiency anaemia

 Soil transmitted Helminths - prevention
 Anthelmintic drugs* – treatment, prophylactic
 Sanitation – disposal of faeces, pit latrines
 Personal hygiene
 Shoes

Conclusions: - Neglected diseases

- Huge infection rate
- Effective drugs
- Public health programs – difficult to run
*Very cheap! A tablet of albendazole costs 0.02 USD (10 USD for 500 children)
A tablet of praziquantel costs 0.07 USD (10 USD for 50 children
TREMATODES
 Trematodes (flukes)
Life cycle of all involves freshwater snails as intermediate, amplifying host

Species Host Transmitted via Geographical

distribution
Liver Fasciola hepatica Sheep Raw water plants Widespread
& F.gigantica Cattle S American
Andes

Oriental
liver
– s Opisthorcis
sinensis &
Dogs
Cats
Raw/undercooked
fish
China, S E
Asia, Europe,
O.felinius Russia
• Loa loa
Intestinal Fasciolopsis buski Raw water plants S E Asia, India
– eyeworm
Lung Paragonimus Carnivores Raw/undercooked Asia
fish, crabs, crayfish
 Diagnosis – laboratory investigations
Stool / urine examination for eggs

Sediment / centrifuge of urine

Concentration techniques for stoo l

S. haematobium S. mansoni S japonicum

FBC: eosinophilia (>80% of patients with acute infections)

Serology:
May be diagnostic in patients if no eggs are present
eg. those with Katayama syndrome

But - expensive
- non quantitative. Not species specific
- 3 months before tests become positive
 Treatment

Praziquantel – an isoquinolone
 Drug of choice – only against mature worms
therefore

 Delay treatment for 3 months after exposure in travellers

CESTODES
 Cestode Primary Host Intermediate Host

T solium Humans Pigs, humans, dogs, cats, sheep

T. saginata Humans Cattle

Diphyllobothrium Humans Fish

Hymenolepis Humans None

H. nana
H. diminuta Rodents

Echinococcus sp. Dogs Sheep, cattle, goats

Humans
(Hydatid disease)