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PARASITOLOGY - CHAPTER FIVE
CESTODES (TAPE WORMS)
Jeffrey Nelson, Rush University,
nois and The MicrobeLibrary
Dr Abdul Ghaffar and Dr Mohamed

Murray et al. (6th

, pp 881-891
Clinically important cestodes pathogenic to man are Tenia solium (pork tapeworm), T. saginata (beef tapeworm),
Diphyllobothrium lattum (fish or broad tapeworm), Hymenolepis nana (dwarf tapeworm) and Echinococcus granulosus a
multilocularis (hydatid).

NG OBJECTIVES
ology, morbidity and
mortality TENIA SOLIUM T. SAGINATA (TENIASIS)
ogy of the organism
e, hosts and vectors Epidemiology
ase, symptoms, These cestodes have a worldwide distribution but incidence is higher in developing countries. Infection rate is as low as
genesis and site 1000 in most of North America and as high as 10% in the third world. Pork tapeworm shows a higher incidence but this
Diagnosis dependent on dietary habits.
ntion and control
Morphology
T. saginata can be up to 4 to 6 meters long and 12 mm broad; it has a pear-shaped head (scolex) with four suckers bu
or neck. It has a long flat body with several hundred segments (proglottids). Each segment is about 18 x 6 mm with a br
uterus (15-30 branches). The egg is 35 x 45 micrometers, roundish and yellow-brown. It has peripheral radial striations
contains an embryo with 3 hooklets (figure 2).

T. solium is slightly smaller than T. saginata. It has a globular scolex with four suckers and a circular row of hooks (rost
that gives it a solar appearance. There is a neck and it has a long flat body (0.1 meter in length). The proglottids are 5 x
with a 7-12 branch uterus. The eggs of T. solium and T. saginata are indistinguishable (figure 2).

Life cycle
A tapeworm larval cyst (cysticercus) is ingested with poorly cooked infected meat; the larva escapes the cyst and passe
small intestine where it attaches to the mucosa by the scolex suckers. The proglottids develop as the worm matures in 3
months. The adult may live in the small intestine as long as 25 years and pass gravid proglottids with the feces. Eggs e
from the proglottid contaminate and persist on vegetation for several days and are consumed by cattle or pigs in which
and form cysticerci (Figure 1).

Symptoms
Light infections remain asymptomatic, but heavier infections may produce abdominal discomfort, epigastric pain, vomitin
diarrhea.

Cysticercosis
T. solium eggs can also infect humans and cause cysticercosis (larval cysts in lung, liver, eye and brain) resulting in blin
and neurological disorders. The incidence of cerebral cysticercosis can be as high 1 per 1000 population and may acco
to 20% of neurological case in some countries (e.g., Mexico); cysticercosis ocular involvement occurs in about 2.5% of
and muscular involvement is as high as 10% (India).

Pathology and Immunology

Gastrointestinal symptoms are due to the presence of the tape worm. Cysticercosis symptoms are a result of
inflammatory/immune responses. Antibodies are produced in cysticercosis and are useful epidemiological tools.

Diagnosis
Diagnosis is based on the recovery of eggs or proglottids in stool or from the perianal area. Cysticercosis is confirmed b
presence of antibodies.

Treatment and control

Praziquantel is the drug of choice. Expulsion of scolex must be assured to assume a satisfactory treatment. A thorough
inspection of beef and pork, adequate cooking or freezing of meat are effective precautions, since cysticerci do not surv
temperatures below -10o C and above 50o C.
Figure 1

Figure 1
Life cycle of Taenia saginata and Taenia solium
Humans are the only definitive hosts for Taenia saginata and Taenia solium. Eggs or gravid proglottids are passed with feces ; the eggs can
days to months in the environment. Cattle (T. saginata) and pigs (T. solium) become infected by ingesting vegetation contaminated with eggs o
proglottids . In the animal's intestine, the oncospheres hatch , invade the intestinal wall, and migrate to the striated muscles, where they d
cysticerci. A cysticercus can survive for several years in the animal. Humans become infected by ingesting raw or undercooked infected meat
human intestine, the cysticercus develops over 2 months into an adult tapeworm, which can survive for years. The adult tapeworms attach to th
intestine by their scolex and reside in the small intestine . Length of adult worms is usually 5 m or less for T. saginata (however it may rea
m) and 2 to 7 m for T. solium. The adults produce proglottids which mature, become gravid, detach from the tapeworm, and migrate to the anu
passed in the stool (approximately 6 per day). T. saginata adults usually have 1,000 to 2,000 proglottids, while T. solium adults have an averag
proglottids. The eggs contained in the gravid proglottids are released after the proglottids are passed with the feces. T. saginata may produce
100,000 and T. solium may produce 50,000 eggs per proglottid respectively. CDC DPDx Parasite Image Library

Figure 2A
Taeniid eggs. The eggs of Taenia saginata and T. solium are undistinguishable morphologically (morphologic species identification will have to
proglottids or scolices). The eggs are rounded or subspherical, diameter 31 - 43 µm, with a thick radially striated brown shell. Inside each shell
embryonated oncosphere with 6 hooks. The egg in B still has the primary membrane that surrounds eggs in the proglottids. CDC

Figure 2B
Gravid proglottids of (left) Taenia saginata and (right) T. solium. Injection of India ink in the uterus allows visualization of the primary lateral bran
number allows differentiation between the two species: T. saginata has 15 - 20 branches on each side, while T. solium has 7 - 13. Note the gen
mid-lateral position. CDC

Figure 2C
Taenia saginata gravid proglottid © Dr Peter Darben, Queensland University of Technology clinical parasitology collection. Used with permission

Figure 2D
 Taenia solium cysticercus, whole and in section of muscle (H&E) © Dr Peter Darben, Queensland University of Technology clinical parasitology collection. Used with pe

Figure 2E
Taenia sp. egg © Dr Peter Darben, Queensland University of Technology clinical parasitology collection. Used with permission

Figure 2F

B RESOURCES DIPHYLLOBOTHRIUM LATUM (FISH OR BROAD TAPEWORM)

hyllobothriasis - CDC

Epidemiology
Fish tapeworm infection is distributed worldwide, in the subarctic and temperate regions; it is associated with eating of r
improperly cooked fresh water fish.

Morphology
This is the longest tapeworm found in man, ranging from 3-10 meters with more than 3000 proglottids. The scolex resem
almond-shaped leaves and the proglottids are broader than they are long, a morphology reflected in the organism's nam
are 30 x 50 micrometers in size and contain an embryo with 3 pairs of hooklets (figure 4).

Life cycle
Man and other animals are infected by eating uncooked fish that contains plerocercoid larvae (15 x 2 mm) which attach
small intestinal wall and mature into adult worms in 3 to 5 weeks. Eggs discharged from gravid proglottids in the small in
are passed in the feces. The egg hatches in fresh water to produce a ciliated coracidium which needs to be ingested by
flea (Cyclops) where it develops into a procercoid larva. When infected Cyclops are ingested by the freshwater fish, the
procercoid larva penetrates the intestinal wall and develops into a plerocercoid larva, infectious to man (figure 3).
 Symptoms
Clinical symptoms may be mild, depending on the number of worms. They include abdominal discomfort, loss of weight
appetite and some malnutrition. Anemia and neurological problems associated with vitamin B12 deficiency are seen in h
infected individuals.

Diagnosis
Diagnosis is based on finding many typical eggs and empty proglottids in feces (Figure 3). A history of raw fish consum
residence in an endemic locality is helpful.

Treatment and control

Praziquantel is the drug of choice. Freezing for 24 hours, thorough cooking or pickling of fish kills the larvae. Fish reserv
should be kept free of raw sewage.

Figure 4
Figure 3
Immature eggs are passed in feces . Under appropriate conditions, the eggs mature (approximately 18 to 20 days) and yield oncosphere
develop into a coracidia . After ingestion by a suitable freshwater crustacean (the copepod first intermediate host) the coracidia develop into
larvae . Following ingestion of the copepod by a suitable second intermediate host, typically minnows and other small freshwater fish, the pr
larvae are released from the crustacean and migrate into the fish flesh where they develop into a plerocercoid larvae (sparganum) . The ple
larvae are the infective stage for humans. Because humans do not generally eat undercooked minnows and similar small freshwater fish, these
represent an important source of infection. Nevertheless, these small second intermediate hosts can be eaten by larger predator species, e.g.,
walleyed pike . In this case, the sparganum can migrate to the musculature of the larger predator fish and humans can acquire the disease
these later intermediate infected host fish raw or undercooked . After ingestion of the infected fish, the plerocercoid develop into immature a
then into mature adult tapeworms which will reside in the small intestine. The adults of D. latum attach to the intestinal mucosa by means of the
bilateral groves (bothria) of their scolex . The adults can reach more than 10 m in length, with more than 3,000 proglottids. Immature eggs a
discharged from the proglottids (up to 1,000,000 eggs per day per worm) and are passed in the feces . Eggs appear in the feces 5 to 6 w
infection. In addition to humans, many other mammals can also serve as definitive hosts for D. latum. CDC DPDx Parasite Image Library

Figure 4A
Eggs of Diphyllobothrium latum. These eggs are oval or ellipsoidal, with at one end an operculum (arrows) that can be inconspicuous (right). At
opposite (abopercular) end is a small knob that can be barely discernible (left). The eggs are passed in the stool unembryonated. Size range: 5
by 40 to 51 µm. CDC. Image A contributed by Georgia Division of Public Health

Figure 4B
Gravid proglottids of Diphyllobothrium latum. CDC/Dr. Mae Melvin
 Figure 4C
Proglottids of Diphyllobothrium latum. The species characteristics are: the proglottid is broader than it is long; size 2 to 4 mm long by 10 to 12 m
uterus coiled in rosette appearance; genital pore at the center of the proglottid. CDC

Figure 4E
Diphyllobothrium latum scolex and gravid proglottids © Dr Peter Darben, Queensland University of Technology clinical parasitology collection. Used with permission

HYMENOLEPIS NANA (DWARF TAPEWORM)

This is a small tapeworm (20 x 0.7 mm) which infects children. Rodents are the reservoir. Infection is by the oro-fecal m
hence, cross infection and auto infection by eggs in feces in normal (figure 6). The worm develops from ingested eggs i
B RESOURCES adult in the small intestine and resides there for several weeks (figure 5). Light infections produce vague abdominal dis
menolepiasis - CDC
but heavier infections may cause enteritis. Diagnosis is based on finding eggs in the feces. Praziquantel is the drug of c
Hygiene is the best control.

Figure 5
Eggs of Hymenolepis nana are immediately infective when passed with the stool and cannot survive more than 10 days in the external environm
When eggs are ingested by an arthropod intermediate host (various species of beetles and fleas may serve as intermediate hosts), they dev
cysticercoids, which can infect humans or rodents upon ingestion and develop into adults in the small intestine. A morphologically identical v
nana var. fraterna, infects rodents and uses arthropods as intermediate hosts. When eggs are ingested (in contaminated food or water or fro
contaminated with feces), the oncospheres contained in the eggs are released. The oncospheres (hexacanth larvae) penetrate the intestinal vi
develop into cysticercoid larvae . Upon rupture of the villus, the cysticercoids return to the intestinal lumen, evaginate their scoleces , atta
intestinal mucosa and develop into adults that reside in the ileal portion of the small intestine producing gravid proglottids . Eggs are passed
when released from proglottids through its genital atrium or when proglottids disintegrate in the small intestine . An alternate mode of infectio
of internal autoinfection, where the eggs release their hexacanth embryo, which penetrates the villus continuing the infective cycle without pass
the external environment . The life span of adult worms is 4 to 6 weeks, but internal autoinfection allows the infection to persist for years. CD
Parasite Image Library

Figure 6A
Three adult Hymenolepis nana tapeworms. Each tapeworm (length: 15-40 mm) has a small, rounded scolex at the anterior end, and proglottids
distinguished at the posterior, wider end. CDC. Image contributed by the Georgia Division of Public Health.

Figure 6B
Egg of Hymenolepis diminuta. These eggs are round or slightly oval, size 70 - 86 µm X 60 - 80 µm, with a striated outer membrane and a thin in
membrane. The space between the membranes is smooth or faintly granular. The oncosphere has six hooks (of which at least four are visible a
of focus). CDC. Image contributed by Georgia Department of Public Health.

Figure 6C
Egg of Hymenolepis nana. These eggs are oval or subspherical and smaller than those of H. diminuta, their size being 40 - 60 µm X 30 - 50 µm
inner membrane are two poles, from which 4-8 polar filaments spread out between the two membranes. The oncosphere has six hooks (seen a
at 8 o'clock). CDC. Image contributed by Georgia Department of Public Health.

Figure 6D
Hymenolepis nana egg © Dr Peter Darben, Queensland University of Technology clinical parasitology collection. Used with permission

Figure 6E
Hymenolepis nana cysticercoid © Dr Peter Darben, Queensland University of Technology clinical parasitology collection. Used with permission

Figure 6F
Hymenolepis nana adult © Dr Peter Darben, Queensland University of Technology clinical parasitology collection. Used with permission
 ECHINOCOCCOSIS (HYDATID)
B RESOURCES Echinococcus granulosus and E. multilocularis are causative agents of hydatid cysts.
hinococcosis - CDC

ECHINOCOCCUS GRANULOSUS

Epidemiology
The organism is common in Asia, Australia, Eastern Africa, southern Spain, southern parts of South America and northe
of North America. The incidence of human infection about 1 to 2 per 1000 population and may be higher in rural areas o
regions.

Morphology
This is the smallest of all tapeworms (3 to 9 mm long) with only 3 proglottids.

Life cycle
The adult worm lives in domestic and wild carnivorous animals. Eggs, passed by infected animals, are ingested by the g
farm animals or man, localize in different organs and develop into hydatid cysts containing many larvae (proto-scolices
sand) (Figure 8). When other animals consume infected organs of these animals, proto-scolices escape the cyst, enter
intestine and develop into adult worms (Figure 7). Echinococcus eggs, when swallowed by man, produce embryos that
the small intestine, enter the circulation and form cysts in liver, lung, bones, and sometimes, brain. The cyst is round an
measures 1 to 7 cm in diameter, although it may grow to be 30 cm. The cyst consists of an outer anuclear hyaline cuticu
inner nucleated germinal layer containing clear yellow fluid. Daughter cysts attach to the germinal layer, although some
known as brood cysts, may have only larvae (hydatid sand). Man is a dead end host.

Symptoms
The symptoms, comparable to those of a slowly growing tumor, depend upon the location of the cyst. Large abdominal
produce increasing discomfort. Liver cysts cause obstructive jaundice. Peribronchial cysts may produce pulmonary abs
Brain cysts produce intracranial pressure and Jacksonian epilepsy. Kidney cysts cause renal dysfunction. The contents
may produce anaphylactic responses.

Diagnosis
Clinical symptoms of a slow-growing tumor accompanied by eosinophilia are suggestive. Intradermal (Casoni) test with
fluid is useful. Pulmonary cysts and calcified cysts can be visualized using x-rays. Antibodies against hydatid fluid antige
been detected in a sizable population of infected individuals by ELISA or indirect hemagglutination test.

Treatment and control

Treatment involves surgical removal of cyst or inactivation of hydatid sand by injecting the cyst with 10% formalin and it
within few (4-5) minutes. Prazequantel has been shown to be effective in many cases. Albendazole, in high doses, is an
alternative. Preventive measures involve avoiding contact with infected dogs and cats and elimination of their infection.
Figure 8
Figure 7
The adult Echinococcus granulosus (3 to 6 mm long) (1) resides in the small bowel of the definitive hosts, dogs or other canids. Gravid proglotti
eggs (2) that are passed in the feces. After ingestion by a suitable intermediate host (under natural conditions: sheep, goat, swine, cattle, horse
the egg hatches in the small bowel and releases an oncosphere (3) that penetrates the intestinal wall and migrates through the circulatory syste
various organs, especially the liver and lungs. Inthese organs, the oncosphere develops into a cyst (4) that enlarges gradually, producing protos
daughter cysts that fill the cyst interior. The definitive host becomes infected by ingesting the cyst-containing organs of the infected intermediate
ingestion, the protoscolices (5) evaginate, attach to the intestinal mucosa (6), and develop into adult stages (1) in 32 to 80 days. The same life c
with E. multilocularis (1.2 to 3.7 mm), with the following differences: the definitive hosts are foxes, and to a lesser extent dogs, cats, coyotes an
the intermediate host are small rodents; and larval growth (in the liver) remains indefinitely in the proliferative stage, resulting in invasion of the
tissues. With E. vogeli (up to 5.6 mm long), the definitive hosts are bush dogs and dogs; the intermediate hosts are rodents; and the larval stag
liver, lungs and other organs) develops both externally and internally, resulting in multiple vesicles. E. oligarthrus (up to 2.9 mm long) has a life
involves wild felids as definitive hosts and rodents as intermediate hosts. Humans become infected by ingesting eggs (2), with resulting release
oncospheres (3) in the intestine and the development of cysts (4) in various organs CDC DPDx Parasite Image Library

Figure 8A
"Hydatid sand". Fluid aspirated from a hydatid cyst will shows multiple protoscolices (size approximately 100 µm), each of which has typical hoo
protoscolices are normally invaginated (left), and evaginate (middle, then right) when put in saline. CDC Image contributed by Georgia Division of Public Heal

Figure 8B
Echinococcus granulosus egg © Dr Peter Darben, Queensland University of Technology clinical parasitology collection. Used with permission

Figure 8C
Echinococcus granulosus adult © Dr Peter Darben, Queensland University of Technology clinical parasitology collection. Used with permission

Figure 8D
Echinococcus granulosus hydatid cysts in section of lung (H&E) © Dr Peter Darben, Queensland University of Technology clinical parasitology collection. Used with perm

Figure 8E
Echinococcus granulosus hydatid sand © Dr Peter Darben, Queensland University of Technology clinical parasitology collection. Used with permission
 Figure 8F
Histopathology of hydatid cyst. Echinococcus, echinococcosis, CDC/Dr. Mae Melvin

Figure 8G
Hydatid cysts

Figure 8F
Gross pathology of cotton rat infected with Echinococcus multilocularis. First E. locularis isolated in the United States proper. CDC/Dr. I. Kagan

E. MULTILOCULARIS
Figure 8G
This is a tapeworm, similar to E. granulosus, that also causes hydatid in northern parts of Asia and North America. It ha
similar morphology and life cycle except that rodents are its intermediate host. Humans, when infected with this worm, a
develop hydatid cysts which produce symptoms similar to those caused by E. granulosus. However, the cysts are multil
(many chambers). The organism is resistant to praziquantel; high doses of Albendazole has some anti-parasitic effect. S
the means of removing the cyst. Rodent control is the means of prevention.
 Summary

Organism Transmission Symptoms Diagnosis Treatment

Tenia saginata Cyst in beef Epigastric pain, vomiting, Praziquantel

diarrhea Proglottids or eggs in
stool or perianal area

Tenia solium Cyst in pork Epigastric pain, vomiting, Praziquantel

diarrhea Proglottids or eggs in
stool or perianal area

T. solium Oro-fecal Muscle pain and Praziquantel

Cysticercosis weakness, ocular and Roentgenography, anti-
neurologic problems cysticercal antibody (EIA)

D. latum Cyst in fish Abdominal pain, loss of Proglottids or eggs in Praziquantel

weight, anorexia, stool or perianal area
malnutrition and B12
deficiency problems

E. granulosus Oro-fecal Large cysts produce Roentgenography, anti- Surgery, formalin injection
various symptoms hydatid fluid antibody and drainage,
depending on the (EIA), Casoni skin test Praziquantel
location of the organism.

E. multiloculoris Oro-fecal As above As above Surgery, Albendazole

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