WEEK 13: THE CESTODES

Class Cestoda: multicellular worms with flat or ribbon-like appearance

Common names: flatworms or tapeworms

2 Morphologic Forms:

Egg
● Consists of hexacanth embryo a.k.a oncosphere defined as the motile, first larval stage characterized by
presence of six small hooks called hooklets, arranged in pairs believed to pierce intestinal wall of infected host
Morphology and LIfe Cycle Notes

Larval Stages

Adult Worm
● Adult tapeworm
○ Ribbon appearance; 15 - 20 m
○ Absorb nutrients and secrete waste products through outer surface called tegument
○ Lack mouth, digestive tract, internal means of excretion
○ Distinct features:
■ Scolex - defined anterior end; contains 4 cup-shaped structures (suckers) that provide worm with
the ability to attach to intestinal mucosa of infected host
● Rostellum - fleshy extension of scolex which one or two rows of hooks might be present
■ Neck region
■ Proglottids - series of individual segments equipped with both male and female reproductive
organs, referred to as strobila
○ Self-fertilizing (hermaphroditic)
● Autoreinfection: Hymenolepis nana

Laboratory Diagnosis ● Specimen of choice: Stool

○ Presence of eggs, gravid proglottids
○ Tissue Biopsy
○ Serologic Tests

Pathogenesis and Clinical Asymptomatic

 Symptoms Symptoms:
● Nondescript gastrointestinal discomfort, diarrhea, abdominal pain
● Nausea, dizziness, headache, weight loss
● Diphyllobothrium latum: intestinal obstruction and Vitamin B12-induced macrocytic anemia
● Echinococcus granulosus: liver and lung involvement; persistent cough, localized pain, eosinophilia
● Serious allergic reactions (anaphylactic shock)

THE CESTODES

Phylum Class Intestinal Species

Platyhelminthes Cestoda Taenia saginata
Taenia solium
Hymenolepis diminuta
Hymenolepis nana
Dipylidium caninum
Diphyllobothrium latum
Intestinal-Extraintestinal Species
Echinococcus granulosus

Taenia Species
Taenia saginata

Common name Beef tapeworm

Associated Diseases Taeniasis, beef tapeworm infection
Intermediate host cow / cattle
Infective stage Cysticercus larva / boris

Taenia solium

Common name Pork tapeworm

Associated Diseases Taeniasis, pork tapeworm infection
Intermediate host cow / cattle
Infective stage cysticercus cellulosae
Final host human
 Size range Hooklets Other Features

Eggs 28 - 40 microns by 18 - 3 pairs; hexacanth embryo Radial striations on yellow-brown embryophore

30 microns;
- radially-striated outer
shell average: 33 - 23
microns

Characteristics T. saginata T. solium

Scolex:

No. of suckers 4 4

Rostellum Absent / Unarmed Present / Armed

Hooks Absent Present / double-crown of hooks

Gravid Proglottid:

Appearance, shape Longer than wide; average, 17.5 by 5.5 microns Somewhat square

Number of lateral branches on each side of 15 - 30 7 - 15

uterus

Laboratory Diagnosis ● Specimen of choice: Stool

● High recovery rate of Taenia eggs: samples collected around perianal area using cellophane tape
prep procedure
● Eggs are identical
● Infection of larva to the meat → cysticercosis in pork meat: measly pork = having measles, spotted
● T. saginata: 15 - 39 gravid proglottids
● T. solium: 5 -18 gravid proglottids
Life Cycle Notes ● Ingestion of raw / undercooked meat contaminated with cysticercus larva (larva with scolex
surrounded by bladder-like, fluid-filled, thin-walled cyst)
 Epidemiology ● Areas that do not practice sanitation and beef/pork is eaten routinely
● T. saginata: cosmopolitan areas
● T. solium: worldwide
● Intermediate host: cow or pig
Clinical Symptoms Asymptomatic

Taeniasis: Beef or Pork Tapeworm Infection

● Diarrhea, abdominal pain, change in appetite, slight weight loss,
● Dizziness, nausea, vomiting
● Moderate eosinophilia
Treatment ● Most important: total eradication of scolex
● Praziquantel: effective against adult worm; not used when there is ocular or central nervous system
(CNS) involvement (neurocysticercosis)
● Paromomycin and quinacrine hydrochloride (Atabrine) - alternative
Prevention and Control ● Proper sanitation practices
● Thorough cooking of meat prior to consumption
● Promptly treating infected persons
Notes of Interest and New Trends Cysticercosis: human tissue infection associated with Taenia solium
● Ingestion of T. solium eggs
○ Transmission: food, water, soil contamination
○ Brain infection (neurocysticercosis) - common
■ Headache, seizures, confusion, ataxia, death
○ Treatment:
■ surgical removal and medication
■ Immunologic test - diagnosis
● Indirect hemagglutination
● ELISA

Taenia saginata asiatica (Asian Taenia) or Taenia asiatica

● Acquired by eating raw pig liver, consumption of cattle and goat
● Contains sunken rostellum and two rows of hooklets
● Multiple adults may be present in infection unlike T. saginata or T. solium
● May be asymptomatic or experience nausea, abdominal pain, weakness, weight loss, and headaches
● Treatment of choice: Praziquantel
 Figure A: Scolex of T. solium. Note the four large suckers and rostellum containing
two rows of hooks.

Figure E: Unstained Taenia sp. egg, teased from a proglottid of an adult. Four
hooks can easily be seen in this image.
Figure A: Mature proglottid of T. saginata, stained with carmine. Note the number of
primary uterine branches (>12).

Hymenolepis diminuta

Common name Rat tapeworm

Associated Diseases Hymenolepiasis, rat tapeworm disease

Size range Hooklets Polar thickenings Polar filaments Embryophore

Eggs 55 by 85 microns 3 pairs; hexacanth embryo Present Absent Present; colorless

Parameters

Adult

Scolex:

No. of suckers 4
 Rostellum Present

Hooks Absent

Gravid Proglottid:

Size Twice as wide as long

Appearance Saclike uterus filled with eggs

Laboratory Diagnosis ● Recovery of characteristic eggs in stool

● Proglottids are not found in stool as they disintegrate in the gut
● Scolex is rarely seen
Life Cycle Notes ● H. diminuta: parasite of rats
● Source of Transmission: contaminated droppings of rats into intermediate hosts
● Intermediate hosts: grain beetle or flea (cysticercoid larva occurs)
● Development adult worm due to consumption by a rat of infected insects residing in grains or cereal
● Accidental Parasitic Disease: Zoonotic occurrence or Zoonosis: human takes place of rat in
parasite life cycle

Epidemiology ● Worldwide
● Areas in which foodstuffs such as grain or cereal are not protected from rats and insects
Clinical Symptoms Asymptomatic

Hymenolepis: Rat Tapeworm Disease

● Diarrhea, nausea, abdominal pain, anorexia
Treatment ● Praziquantel
● Niclosamide - alternative
Prevention and Control ● Administering effective rodent control measures
● Protection of food from rat droppings and intermediate host insects
● Thorough inspection of contaminated foodstuffs
 Figure A: Egg of H. diminuta in a wet mount stained with iodine. Four of the
hooks are visible at this level of focus. Figure D: Proglottids of H. diminuta stained with carmine

Hymenolepis nana

Common name Dwarf tapeworm

Associated Diseases Hymenolepiasis, Dwarf tapeworm disease

Size range Hooklets Polar thickenings Polar filaments Embryophore

Eggs 45 by 38 microns 3 pairs; hexacanth embryo Present Present Present; colorless

Parameters

Adult

Scolex:

No. of suckers 4

Rostellum Present / Armed with hooks; short

 Hooks Present; one row; 20 - 30 Y-shaped hooks

Gravid Proglottid:

Size Twice as wide as long

Appearance Saclike uterus filled with eggs

Laboratory Diagnosis ● Examining stool samples for characteristics eggs

Life Cycle Notes ● Human infection: consumption of infective egg
● Cysticercoid larva: development occurs in the intestine
● Transport host: fleas, beetles, rats, house mice
Epidemiology ● H. nana - most common tapeworm recovered in southeastern U.S.
● Tropical and subtropical climates
● High risk: Close quarters, institutional settings; children attending preschool and day care centers
● Source of infection: infective eggs generated by contaminated human feces and stool from
contaminated rodents
Clinical Symptoms Asymptomatic
● Light infections

Hymenolepiasis: Dwarf Tapeworm Disease

● Gastrointestinal symptoms such as abdominal pain, anorexia, diarrhea, dizziness, and headache
Treatment ● Treatment of choice: Praziquantel
● Alternative: Niclosamide
Prevention and Control ● Proper personal hygiene and sanitation practices
● Controlling transport host population and avoidance of contact with potentially infected rodent feces
 Figure A: Egg of H. nana in an unstained wet mount. Figure A: Cross-sections of mature proglottids of H. nana stained with
hematoxylin and eosin (H&E), taken at 100x.

Dipylidium caninum

Common name Dog or cat tapeworm, pumpkin seed tapeworm

Associated Diseases Dipylidiasis, dog or cat tapeworm disease

Intermediate hosts -Ctenocephalides canis: dog flea

- Ctenocephalides felis: cat flea
- Trichodectes canis: dog louse
- Pulex irritans: human flea

Number of eggs in Diameter range per egg Individual egg features

enclosed packet
Eggs 5 - 30 30 - 60 microns Six-hooked oncosphere

Parameters
Scolex:

No. of suckers 4

Rostellum Present; club shaped, with 1-7 circlets of spines

Hooks Absent

Gravid Proglottid:

Shape Pumpkin seed

Appearance Full of eggs in enclosed embryonic membrane

Laboratory Diagnosis ● Examining stool samples for characteristics eggs packets or gravid proglottids
● Presence of a single egg in stool sample may occur, but is extremely rare
Life Cycle Notes ● Host : dogs and cats
● Accidental Host : Humans ( through ingestion of fleas )
● Infective Stage : Ingestion of the larval stage / Ingestion of contaminated food

● Egg packets and gravid proglottids may be subsequently passed in the stool
● Swallowing an infected flea initiates a new cycle

Important note : Humans take the place of the dog or cat in the life cycle when they become infected.
Epidemiology ● Incidence of the infection is worldwide
● Children - most at risk for infection transmission
Clinical Symptoms Asymptomatic
● Light infections

Dipylidiasis: Dog or Cat Tapeworm Disease

● Appetite loss, diarrhea, abdominal discomfort, and indigestion
● Anal pruritus caused by gravid proglottids migrating out of the anus
Treatment ● Treatment of choice: Praziquantel
● Alternative: Niclosamide and Paromomycin
 Prevention and Control ● Dogs and cats should be examined by a veterinarian on a regular basis.
○ Routine procedures should include deworming infected animals and periodic
administration of prophylactic anti-helminth medications
● Dogs and cats should be treated and protected against flea infestation regularly
● Children should be taught not to let dogs and cats lick them in or near their mouth.

Figure D: D. caninum proglottid. The genital pores are clearly visible in the
carmine-stained proglottid.
Figure A: D. caninum egg packet, containing 8 visible eggs, in a wet mount.

Diphyllobothrium latum

Common name Broad fish tapeworm

Associated Diseases Diphyllobothriasis, fish tapeworm infection, broad fish tapeworm infection
● Only cestode with operculum

Length Width Shape Embryo Shell Other

Features
Eggs 55 - 75 microns 40 - 55 microns Somewhat oblong Undeveloped, Smooth; yellow brown in color Operculum on one end;
termed terminal knob on
coracidium opposite end
 Parameters

Adult

Scolex:

No. of sucking grooves 2 long sucking grooves (bothria)

Shape of sucking groove Almond

Gravid Proglottid:

Shape Wider than long

Location and appearance of uterine structure Central; rosette

Laboratory Diagnosis ● Examining stool samples for characteristics eggs packets and/or proglottids
● Presence of a single egg in stool sample may occur, but is extremely rare
Life Cycle Notes ● Relatively complex that it requires two intermediate hosts : Cyclops species copepods
and freshwater fish

Humans
● Infective Stage : Ingestion of pleurocercoid when consuming raw/undercooked
contaminated freshwater fish
○ Pleurocercoid - precursor larval stage
● The undeveloped eggs are passed to the outside world via stool.
● If the eggs come in contact with fresh water, coracidium would hatch.
● Larva is ingested by the first intermediate host, Cyclops species copepods

● Procercoid - next larval stage that occurs in the copepod

○ Ingested by second intermediate host, a freshwater fish
○ Once inside the fish, procercoid develops into pleurocercoid larva in the muscle
tissue
○ Human ingestion of contaminated fish initiates a new cycle
 ● Larger fishes harbor the parasite and serve as a transport host once they eat a
contaminated freshwater fish.
● Human consumption of larger fishes will result in the release of pleurocercoid larva, which
will develop and continue the life cycle.

Epidemiology ● Found in a variety of temperate regions worldwide

● United States, Alaska, and the Great Lakes region are known to harbor the parasite
● Other noted endemic areas : parts of South America and Asia, Central Africa, Baltic region,
and Finland
○ Areas where raw and/or freshwater fishes are routinely consumed
● Number of fish-eating animals may also become infected and serve as definitive hosts.

Clinical Symptoms Asymptomatic

● Most infected with adult worms exhibit no clinical symptoms

Diphyllobothriasis : Fish Tapeworm Infection, Broad Fish Tapeworm Infection

● Overall weakness, weight loss, abdominal pain

Adult worm attaches itself to the proximal part of jejunum

● At risk for developing vitamin B12 deficiency
● Mimics pernicious anemia

● Finland : appear to be at higher risk for contracting this parasite-induced condition

- Some also appear to be inherently predisposed to contracting pernicious
anemia.
Treatment ● Treatment of choice: Praziquantel and Niclosamide
Prevention and Control ● Proper human fecal disposal
● Avoidance of eating raw or undercooked fish
● Thorough cooking of all fish before consumption
Notes of Interests and New Trends ● Sparganosis - condition results from ingesting the procercoid larvae of D. latum and
Diphyllobothrium species
○ Routes: water contaminated with infected copepods and medicines contaminated
with infected animal by-products
○ Formation of sparganum (infected subcutaneous tissue often described as white,
 wrinkled, and ribbon-shaped) typically results.
○ Treatment of choice: surgical removal of sparganum, praziquantel

Figure B: Note the knob at the abopercular end. Image courtesy of the Oregon Figure B: Close-up of a few of the proglottids
State Public Health Laboratory.

Echinococcus granulosus

Common name Dog tapeworm, hydatid tapeworm

Associated Diseases Echinococcosis, hyatid disease, hyatidosis

● Emerging, re-emerging zoonotic disease

● Extraintestinal cestode
● Smallest tapeworm with only 3 proglottids

Parameters Description

Hydatid Cyst (canine species intermediate host)

 Protective coverings Cyst wall; multiple laminated germinal tissue layers

Basic cyst makeup Fluid-filled bladder

Structures that arise Daughter cysts

From inner germinal layer Brood capsules

(lack protective cell wall)

Other possible structures present Hydatid sand

(components found in the fluid of older E.granulosus cysts that typically include daughter cysts,
free scolices, hooklets, and miscellaneous nondescript material)

Adults (not typically seen in humans but is commonly found in canines, which serve as definitive hosts)

Size 4.5 mm in length

Worm Consists of scolex, small neck, 3 proglottids; one at each developmental stage–
immature, mature, and gravid

Scolex 4 suckers with 36 hooks

Laboratory Diagnosis ● Hydatid cyst - examined on biopsy samples for presence of scolices, daughter cysts, brood capsules,
or hydatid sand
● Serologic tests - ELISA
● Indirect hemagglutination
● Western Blot
● Detection of hydatid cyst may be accomplished though radiography, computed tomography (CT), or
ultrasound scan techniques
Life Cycle Notes ● Accidental Intermediate Host : Humans
● Typical Intermediate Host : Sheep / other herbivores
● Definitive Host : Dog or Wild Canine (contracts parasite by consuming infected sheep viscera)

● Infective stage for humans : Ingestion of Echinococcus eggs obtained by contact with contaminated
dog feces
● Larvae from the eggs penetrate from intestine → lung and liver via bloodstream
 ● Humans are considered as dead-end hosts because the parasite’s life cycle ceases in human tissue.
● Hydatid cyst forms in the viscera (soft parts and internal organs of major cavities in the body) of the
sheep.
Epidemiology ● Great Britain, South America, Australia, Africa, Asia, China, West and Southwest Alaska, and Middle
East
Clinical Symptoms Echinococcosis: Hydatid Cyst, Hydatid Disease, Hydatidosis
● Necrosis of infected tissues, buildup of pressure on these tissues
● Death, rupture of cyst, anaphylactic shock, eosinophilia, allergic reactions
● E. granulosus Lung Infection
○ Chest pain, coughing,and shortness of breath
○ Liver involvement may result to obstructive jaundice
Treatment ● Treatment of choice: Surgical removal of hydatid cyst
● Alternative: antiparasitic medications
● Mebendazole, albendazole, and praziquantel
Prevention and Control ● Proper personal hygiene
● Discontinuing the practice of feeding canines potentially contaminated viscera
● Treating infected canines and humans
● Education program for those in high-risk areas
Notes of Interest and New Trends ● Echinococcus multilocularis
○ accidental cause of hydatid disease in humans living in Subarctic, central Europe, and India.
○ Primary Definitive Host : Foxes
○ Usual Intermediate Hosts : Rodents such as mice and voles
○ Disease manifestation in humans is similar to E. granulosus
 Figure A: Echinococcus granulosus adult, stained with carmine. This specimen
has four segments (1: scolex; 2: immature proglottid; 3: mature proglottid; 4:
gravid proglottid). Features highlighted are the armed rostellum (R) and suckers
(S) of the scolex, and reproductive structures including the testes (TE), cirrus
sac (CS), ovaries (OV), branched uterus containing eggs (UT), and genital
pores on the mature and gravid proglottids (GP).

Figure B: Close-up of the scolex of E. granulosus. In this focal plane, one of the
suckers is clearly visible, as is the ring of rostellar hooks.

Other sources used:

● Belizario, Vincent Jr. Medical Parasitology in the Philippines. University of the Philippines Press 2013.
● Images from Center for Disease Control and Prevention(CDC) - DPDx
● PowerPoint Presentation from the course lecturer/s and Mrs. Leah Clemente-Co
● Zeibig, Elizabeth A. Clinical Parasitology: A Practical Approach. 2nd Edition. MOSBY