Clinical Parasitology: Intestinal

Nematodes
SOMATIC
Intestinal Nematodes
(Roundworms) Lymphatic system

1. Ascaris lumbricoides Wuchereria bancrofti

2. Enterobius vermicularis Brugia malayi

3. Ancylostoma duodenale

4. Necator americanus Small intestine

5. Strongyloides trichiura Ascaris lumbricoides

6. Capillaria philippinensis Ancylostoma duodenale

Necator americanus

TISSUE ROUNDWORMS Strongyloides stercoralis

Trichinella spiralis Trichinella spiralis

Dracunculus medinensis Capillaris philippinensis

Subcutaneous tissues

GENERAL CHARACTERISTICS Loa loa

elongated and cylindrical in shape, with O. volvulus

bilateral symmetry
D. medinensis
complete digestive tract (mouth to
Body cavity
anus)
Mansonella perstans
most nematodes are found in small and
large intestines Mansonella ozzardi

they have separate sexes although some Conjunctiva

may be pathogenetic (asexual Loa loa
reproduction)

there are sensory organs in the anterior Ascaris lumbricoides

and posterior ends of the worm called the most common intestinal nematodes
amphids & phasmids

Clinical Parasitology: Intestinal Nematodes 1

 PHASMIDS giant roundworm

useful in the grouping of (STH) soil transmitted helminth, soil

nematodes plays a major role in the development
and transmission of the parasite
phasmid nematodes, roundworms
with phasmids has a so called polymarian type of
somatic muscle arrangement
AMPHIDS
worldwide distribution, prevalent in the
worms without phasmids are
tropics
aphasmid worms
adult worm resides in the small
Trichuris, Trichinella, Capillaris
intestine

has shown to produce pepsin inhibitor

FEMALE NEMATODES 3(PI-3)
Oviparous - lay eggs only when an infective or embryonated
Ascaris lumbricoides egg is swallowed can humans become
infected with Ascaris
Trichuris trichiura

Ancylostoma duodenale
PEPSIN INHIBITOR
Necator americanus
pepsin inhibitor 3(PI-3) protects the
Lay eggs containing larvae
worm from digestion
Enterobius vermicularis
and produce phosphorylcholine that
Viviparous - give birth to larvae suppresses lymphocyte proliferation
(immune response)
D. medinensis

W. bancrofti
MORPHOLOGY
B. malayi
larval morphology is similar to the
T. spiralis
adult
Ovo- viviparous - lay eggs
whitish, pinkish, large
containing larvae which are
immediately hatched out has terminal mouth with three lips &
sensory papillae
S. stercoralis

MALE A. lumbricoides
INTESTINAL

Clinical Parasitology: Intestinal Nematodes 2

 Large intestine measures 10-31 cm in length

Enterobius vermicularis have a ventrally curved posterior end

with two spicules, forming a hook
Trichuris trichiura
copulatory spicules are of equal size

FEMALE A. lumbricoides
Trichuris trichiura
measures 22-35 cm in length
human whipworm
longer & stouter than males
a soil transmitted helminth
smooth striated muscles
habitat - large intestine
mature females lay eggs about 200,000
adult form - whip shaped, anterior three
eggs per day
fifth is very thin and hair like

and the posterior two fifth is thick and

TYPES OF OVA stout resembling the handle of the whip
fertilized egg MALE
broadly oval, golden brown (bile slightly shorter than the females
stained
has a coiled posterior with a single
single cell when passed out with spicule & retractile sheath
feces
FEMALE
has 3 layer of egg shell:
has a posterior end
lipoidal vitteline inner membrane
lays approximately 3,000 to 10,000
which is none permeable
eggs per day
thick transparent middle layer or
TRICHURIS EGG
glycogen membrane
lemon or football shaped with plug like
outermost coarsely mammilated
translucent prominences (barrel,
albuminoid layer
japanese lantern shape)
floats in saturated solution of salt
yellowish outer and a transparent inner
unfertilized egg shell (bile stained)

Clinical Parasitology: Intestinal Nematodes 3

 never undergoes further ovum/fertilized eggs are unsegmented
development at oviposition and embryonic

longer and narrower than fertile floats in saturated solution of salt

eggs
worm secretes a pore forming protein,
thin shell & irregular mammilated called the TT47 that allows them to
coating filled with refractile imbed their entire whip like portion
granules into the intestinal wall

bile stained, brown in color if swallowed, the infective

embryonated egg go to the small
heaviest of all the eggs thus they
intestine and undergo 4 larval stages to
do not float in a saturated solution
become adult worms (12 weeks)
of common salt
each female worm can produce about
innermost lipoidal vitteline
60 million eggs over 2 years
membrane of the shell is absent

PATHOGENECITY
PATHOGENECITY
anterior portions of the worms may
the infection can lead to tissue reactions
cause petechial hemorrhages, which
to invading larvae
may predispose to amebic dysentery
irritation of the intestine by adult
may result in Trichuris dysentery
worms
syndrome manifested by chronic
complications from the worms moving dysentery & rectal prolapse
outside the intestine
such cases of heavy chronic trichuriasis
affect the nutritional status of the host are often marked by blood streaked
leading to malnutrition (retardation of diarrhea, abdmonial cramps, nausea,
growth) & night blindness (vit A vomiting, anemia, & weight loss
deficiency)
poor appetite, wasting, stunting,
leads to loss of appetite & obstruction reduced intellectual & cognitive
of the intestinal tract development in children
release toxic body fluid (ascarion) no larval migration through the lungs
leading to various allergic so no lung pathology occurs
manifestations

LABORATORY Dx
LABORATORY Dx

Clinical Parasitology: Intestinal Nematodes 4

 demonstration of adult worms clinical diagnosis - very heavy trichuris
infection
demonstration of larvae: detected in the
sputum during the stage of migration laboratory diagnosis - light infections

demonstration of both fertilized & lab diagnosis may be done by

unfertilized eggs
direct fecal smear with a drop of
the clinical diagnosis of ascariasis saline
should be confirmed or established by
kato katz
microscopic examination of a stool
sample FECT

TREATMENT

TREATMENT mebendazole oral administration

individual infections are cured by a albendazole may be used as an

single dose of any of the broad spectrum alternative drug
anthelminthics
Hookworms
albendazole
hookworms that infect humans:
mebendazole
necator americanus
pyrantel pamoate
ancylostoma duodenale
PROPHYLAXIS
STH, blood sucking nematodes that
preventive measures taken to avoid or attach to mucosa of small intestines
reduce the risk of disease
most commonly found in tropical &
proper disposal of human feces sub tropical countries where they occur
avoidance of eating raw vegetable as single or mixed infections
& salads

periodic treatment with an

effective anti-helminthic

WASHED (water, sanitation,

hygiene, education, deworming)

all hookworms have the meromyarian type penetrate the skin and enter venules
of somatic muscle

Clinical Parasitology: Intestinal Nematodes 5

 with two to five cells arranged per dorsal they migrate to the heart and lungs,
or ventral half then into the alveoli. The larvae then
ascend to the trachea and are finally
N. AMERICANUS
swallowed.
“new world hookworm”
and then it is passed down to the
small, cylindrical, fusiform, grayish-white small intestine where the worms
nematodes become sexually mature and the
no teeth, semi-lunar cutting plate female will start laying eggs

adult worms are slightly smaller and

thinner than A. duodenale HOOKWORM EGGS
females (9-11 mm by 0.35 mm) are larger
than males

males (5-9 mm by 0.30 mm) the posterior

end has a broad, membranous caudal
burse with rib-like rays which are used for
copulation

the head is curved opposite to the

curvature of the body, which is like a hood
at the anterior end hookworm eggs

buccal spears of the N. americanus

filariform larva are conspicuous and oval or elliptical
parallel throughout their lengths colorless (not bile stained) &
there are conspicuous transverse striations surrounded by a thin transparent
present on the sheath in the tail region hyaline shell

possess segmented ovum with 4

blastomeres; a clean space between
A.DUODENALE
the segmented ovum & the egg shell
slightly larger than N. americanus
4-8 cell stage in feces
adult has a single-paired male or female
in delayed transit time, embryo may
reproductive organs
develop inside the shell
its head continues in the same direction as
egg floats in saturated salt solution
the curvature of the body
differentiation of necator egg from
buccal capsule has two pairs of curved
ancylostoma egg is difficult
ventral teeth

Clinical Parasitology: Intestinal Nematodes 6

 has inconspicuous buccal spears and
traverse striations on the sheath in the tail HOOKWORM LIFE CYCLE
region

hookworm life cycle is direct

COPULATORY BURSA
man is the only host; no
present in the male worm for attachment intermediate host is required
with the female during copulation
begins with the adult worms
consists of 3 lobes: 1 dorsal & 2 lateral copulating while attached to the
mucosa of the small intestines

RHABDITIFORM LARVAE female worms oviposit into the

intestinal lumen and the eggs are
rhabditiform larvae of N. americanus and
passed out with human feces
A. duodenale are indistinguishable
in the soil, the embryo within the
they resemble those of Strongyloides
egg develops and hatches after 1-2
stercoralis, but are somewhat larger, more
days into the rhabditiform larva
attenuated posteriorly, and have a longer
buccal cavity after 7-10 days, larva undergoes two
stages of molting
the genital primordium is smaller in
hookworms compared with S. stercoralis then transforms into the non-feeding
filariform larva, the infective stage
of the parasite
FILARIFORM LARVAE

Clinical Parasitology: Intestinal Nematodes 7

 hookworm filariform larvae

PATHOGENICITY FREE LIVING FEMALE

the pathology of hookworm infection has a muscular double-bulbed

involves esophagus

the skin at the site of entry of the the intestine is a straight cylindrical
filariform larvae tube

the lung during larval migration

small intestine, the habitat or the FREE LIVING MALE

adult worms is smaller than the female
causes 3 types of lesions: has a ventrally curved tail, two
1. Ancylostoma dermatitis (ground copulatory spicules
itch;) - when filariform larvae a gubernaculum but no caudal alae
enter the skin may lead to
dermatitis parasitic males have not been reliably
identified
2. Creeping eruption (cutaneous
larva migrans) - is a parasitic skin
infection caused by hookworm RHABDITIFORM LARVAE
larvae
has an elongated esophagus with a
3. Pulmonary lesions - occurs when pyriform posterior bulb
the filariform larvae break through
differs from the hookworm in being
the pulmonary capillaries & enter
slightly smaller and less attenuated
the alveoli, they may lead to
posteriorly
bronchitis & bronchopneumonia

Clinical Parasitology: Intestinal Nematodes 8

 Hypoalbuminemia, low level of has a shorter buccal capsule and large
albumin due to loss of blood, lymph genital primordium
and CHON.

INFECTIVE FILARIFORM LARVAE

non feeding, slender

is similar to the hookworm filariform

larva but is usually smaller with a
distinct cleft at the tip of the tail

LABORATORY Dx

direct methods: demonstration of eggs

& adult wors in feces & aspiration of
duodenal contents THREADWORM EGGS
DFS ( direct fecal smear)

Kato thick or Kato-Katz method

zinc sulfate centrifugal flotation

formalin-ether/ethyl acetate
concentration method

indirect methods : through blood

examination (anemia & eosinophilia)
and stool exam showing (+) occult
blood & charcot-leyden crystals have a clear thin shell and are similar to
TREATMENT those of hookworm

mebendazole

Phrophylaxis LIFE CYCLE

improved living conditions & filariform larvae infect humans through

sanitation skin

sanitary disposal of human feces pass

Clinical Parasitology: Intestinal Nematodes 9

 wearing of shoes and gloves for female worms lays embryonated eggs,
personal protection which develop into rhabditiform after a
few hours
Strongyloides stercoralis
transform into free living adults
threadworm
when conditions in the soil become
characterized by free-living unfavorable, rhabditiform develop into
rhabditiform and parasitic filariform filariform larvae, which are infective to
stages humans
only species of this genus which is
naturally pathogenic to humans

opportunistic pathogen in
immunocompromised host

habitat: mucosa of the small intestine

especially in the duodenum & jejenum

some species have been reported in

mammals & in birds

PARASITIC/FILARIFORM FEMALE

colorless, semi-transparent with a finely

striated cutitcle

has slender tapering anterior end and

short conical pointed tail

free living female is smaller than the

parasitic female

PATHOGENICITY TREATMENT:

three phases of acute infection in ivermectin; according to recent studies

strongyloidiasis provides best results in strongyloidiasis

a. invasion of skin by filariform albdendazole, thiabendazole, and

larvae ivermectin have been used to treat

Clinical Parasitology: Intestinal Nematodes 10

 b. migration of larvae through the hyperinfection or disseminated disease
body singly or in combination

c. penetration of the intestinal

mucosa by adult female worms

first phase: larval invasion of the skin

produces erythema, and pruritic

elevated hemorrhagic papules

larval migration phase

lungs are destroyed causing lobar

pneumonia with hemorrhage

cough and tracheal irritation may

also occur, mimicking bronchitis

third phase

adult female worms may be found

in the intestinal mucosa from the
pylorus to the rectum

the greatest numbers are found in

the duodenal and upper jejunal
regions

migration of larvae & penetration of

intestinal mucosa may occur
simultaneously in hyperinfection

light infection does not cause intestinal

symptoms

moderate infections causes diarrhea

alternating with constipation

heavy infections produces intractable,

painless, intermittent diarrhea

hyperinfection - exacerbation of
gastrointestinal and pulmonary
symptoms, increased number of larvae
in the stool and/or sputum

Clinical Parasitology: Intestinal Nematodes 11

 chronic strongyloidiasis

LABORATORY Dx

basic techniques

stool exam (microscopic exam for

rhabditiform larvae)

direct fecal smear (saline or

preserved stool)

concentration technique (kato-

katz/thick technique, FECT)

other specialized techniques

stool culture (Harada-Mori) to

demonstrate rhabditiform larvae.
Harada Mori culture should be
examined after 5 days for
Strongyloides and after 10 days for
hookworm

direct examination of sputum

serology

HARADA-MORI CULTURE

is considered one of the most

successful methods in parasite
identification

allows the hatching of larvae from eggs

on strips of filter paper with 1 end
immersed in water

recommended for specie I.D

modified Harada-Mori makes us of

polyethylene plastic bags or tubes
instead of glass tubes

Clinical Parasitology: Intestinal Nematodes 12