LEC.7 Helminthes (Cestodes) Dr. Maysoon A.

Merdaw

Worms of humans, belong to two phyla: Nemathelminthes (roundworms) and

Platyhelminthes (flatworms).

Platyhelminthes are flatworms that are dorsoventrally flattened in cross section

and are hermaphroditic, with a few exceptions. All medically important species
belong to two classes: Trematoda (flukes) and Cestoda (tapeworms).

Cestodes, or tapeworms, are flat and have a ribbon-like chain of segments

(proglottids) containing male and female reproductive structures. Adult
tapeworms can reach lengths of 10m and have hundreds of segments, with each
segment releasing thousands of eggs. At the anterior end of an adult tapeworm
is the scolex, which is often elaborated with muscular suckers, hooks, or
structures that aid in its ability to attach to the intestinal wall. Behind the scolex
there is a neck from which proglottids of the body are generated. Three types of
proglottids are recognized; immature, mature and gravid. Adult tapeworms have
no mouth or gut and absorb their nutrients directly from their host through their
integument.

Taenia saginata & T. solium

Life cycle

Humans are the only definitive hosts who harbours the adult worm for Taenia
saginata (beef tapeworm) and Taenia solium (pork tapeworm). Natural habitat
is the small intestine (upper jejunum) of man (definitive host). Eggs or gravid
proglottids are passed with feces; the eggs can survive for days to months in the
environment. The intermediate host is cattle (T. saginata) and pigs (T. solium),
they become infected by ingesting vegetation contaminated with eggs or gravid
proglottids.

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In the animal's intestine, the oncospheres hatch, invade the intestinal wall, and
migrate to the striated muscles, where they develop into cysticerci (cysticercus
bovis in case of T. saginata and cysticercus cellulosae in case of T. solium). A
cysticercus can survive for months in the animal. Humans become infected by
ingesting raw or undercooked infected meat. In the human intestine, the
cysticercus develops over 2 months into an adult tapeworm, which can survive
for years. The adult tapeworms attach to the small 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 reach up to 25 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 anus or are 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 average of 1,000 proglottids. The eggs contained in the
gravid proglottids are released after the proglottids are passed with the feces.

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Pathology & Pathogenesis

One medically significant difference between T saginata and T solium is that

humans can be the intermediate host for T solium, similar to pigs. Thus, if
humans ingest T solium eggs, the cysticerci encyst in various human tissues,
including skin, muscle, kidney, heart, liver, and brain. This condition in humans
is known as cysticercosis, and symptoms are associated with the involved
tissues (eg, diminution of visual acuity with ophthalmocysticercosis; in
neurocysticercosis, symptoms include headache, nausea, vomiting, mental
disturbances, and seizures caused by encysted cysticerci in the brain). With the
beef tapeworm T saginata, adult worms develop only in humans, and cysticerci
of T saginata do not develop in humans (only in cattle or other herbivores).

Diagnosis

The diagnosis of both tapeworms disease is made by finding eggs or proglottids

in the stool. The adhesive cellophane tape technique described for pinworm can
be used to recover the worms from this area. Because the eggs of T solium and
T saginata are morphologically identical, it is necessary to examine a proglottid
to identify the species.

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 Life cycle T. solium

Treatment and Prevention

Praziquantel is the drug of choice for treatment of infection by T. saginata,

although niclosamide can also be used. Niclosamide is preferred for treatment
of intestinal infections with T. solium. Albendazole is the drug of choice for
treating cysticercosis.

Ultimately, control is best effected through the sanitary disposal of human

feces. Meat inspection is helpful; the cysticerci are readily visible. In areas
where the infection is common, thorough cooking is the most practical method
of control. Internal temperatures of 56°C or more for 5 minutes or longer
destroy the cysticerci. Salting or freezing for 1 week at –15°C or less is also
effective.

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Hymenolepis nana (Dwarf Tapeworm—Intestinal Cestode)

Hymenolepis nana, the dwarf tapeworm of humans (and rodents), reaching only
4–5 cm in length and 1 mm in diameter. The incidence is higher in children. It is
found worldwide and is one of the most common tapeworm infections in
humans.

Life cycle

H. nana is the only cestode which is capable of completing its life cycle in a
single host. In humans the adult tapeworms are found in the small intestine (
distal portion of ileum) of man and rodents.

-Direct cycle: the eggs are passed in the faeces of infected man or rodent. Man
acquire infection by ingestion of contaminated food or water. In the intestine a
free oncosphere is liberated from the egg. It penetrates into a villus and
develops into cysticercoid larva. Later, it attaches to the intestine wall and
develop to adult. In heavy infections the eggs may hatch in the intestine before
passing out in faeces, resulting in autoinfection.

-Indirect cycle: in presence of insects (include beetles) as the intermediate host.

These insects eat eggs of H. nana. In the body cavity of insect, the oncosphere
transform into cysticercoid, which is infective to final host. Man is infected by
accidentally ingestion of these insects. In the intestine the cysticercoid larva
develop into adult worm.

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 Life cycle of Hymenolepis nana

Pathogenesis

The mechanism by which symptoms are produced is an allergic reaction. Patient

develops headache, anorexia, abdominal pain, diarrhea and eosinophilia.

Diagnosis

The diagnosis is made by finding eggs in the stool by direct microscopy.

Treatment

Praziquantel is effective against H. nana infections, but higher doses than used
for other tapeworm infections usually are required.

Prevention and treatment

Preventing fecal contamination of food and water in institutions and crowded

areas is of primary importance. Rodent and insect control (especially control of

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fleas and grain insects) are also essential for prevention. The drug of choice is
praziquantel and the second choice is niclosamide.

Echinococcus granulosus (Hydatid Cyst)

Echinococcus granulosus is a dog tapeworm found only in the small intestine of

dogs and other canids. The adult tapeworm ranges in length from 3 mm to 6 mm
and has three proglottids ("segments"); an immature proglottid, mature
proglottid and a gravid proglottid. E. granulosus has four suckers on its scolex
("head"), and also has a rostellum with hooks.

Life Cycle

Adult worm resides in the small intestine of dog and other canine animals.
Larval form is seen in the intermediate hosts (sheep, goat, cattle, pig and
horse).The eggs leave the final hosts and infect grazing animals. Similar to the
beef and pork tapeworms, a larva hatches from the egg in an intermediate hosts,
penetrates the gut, and migrates to various tissues, especially liver, spleen,
muscle, and brain. Instead of a cysticercus developing, as in the case of the beef
and pork tapeworms, the larva of Echinococcus develops into a fluid-filled cyst
called a hydatid cyst. The cyst contains germinal epithelium in which thousands
of future larvae (called protoscolices) develop. Inside the hydatid cyst, the
protoscolices are contained within brood capsules. If the hydatid cyst ruptures,
the brood capsules can spill out of the cyst, metastasize to other sites, and
develop into a hydatid cyst. Thus, ingestion of a single egg can give rise to
several hydatid cysts, each containing several brood capsules.

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Humans can also be an intermediate host for E. granulosus, however this is
uncommon and therefore humans are considered an aberrant intermediate host
(by ingesting Echinococcus eggs from dog feces). Hydatid cysts which
developed in viscera of man, comes to dead end.

The dog, in turn, can acquire the infection only when consuming offal
containing E. granulosus from an infected herbivore.

Pathology & Pathogenesis

Hydatid cysts can grow about 1–7 cm per year, and the symptoms depend on
the location of the cysts in the body. The liver is the most common site, where
compression, atrophy, portal hypertension from mechanical obstruction, and
cirrhosis can occur. Extreme care must be taken when removing the cyst. If the
cyst ruptures, the highly immunogenic hydatid fluid can lead to anaphylactic
shock and brood capsules can metastasize to form additional hydatid cysts.
When the embryo break free from the membrane and float in the fluid within
the cyst, they are known as hydatid sand.

Diagnosis

-Casoni test: an immediate hypersensitivity skin test. Antigen here is sterile,

filtered hydatid fluid injected intradermal. Positive case develops a large wheal
(5 cm. or more) within 30 minutes.

- X-ray, ultrasound and CT scan are also helpful in the diagnosis.

-Serologic testing.

-Differential leucocyte count may reveal eosinophilia (20–25%).

-Histological examination.

-Polymerase chain reaction assay has been shown capable of detecting very
small quantities of Echinococcus genomic DNA in fine-needle biopsy material
from patients with suspected echinococcosis.
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Treatment and Prevention

For years, the only definitive therapy available was surgical extirpation.
Presently, it is recommended that high-dose albendazole be administered before
and for several weeks after surgery and/or aspiration. Infected dogs should be
wormed, and infected carcasses and offal burned or buried. Hands should be
carefully washed after contact with potentially infected dogs.

Life cycle of Echinococcus granulosus

Echinococcus Multilocularis

E. multilocularis is found primarily in subarctic and arctic regions in North

America, Europe, and Asia.
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Life Cycle

The adult worms are found in the gut of foxes and wolves. Their larval forms
find in the tissues of field mice and squirrels as an intermediate hosts. Domestic
dogs may acquire adult tapeworms by killing and ingesting these larval-infected
rodents. Humans are accidental intermediate host, infected with larval forms
through the ingestion of eggs passed in the feces of their domestic dogs or
ingestion of egg-contaminated vegetation.

Pathogenicity

Unlike the larval forms of E. granulosis, those of E. multilocularis bud

externally, producing proliferative, multilocular cysts called alveolar
echinococcosis that slowly but progressively invade and destroy the affected
organs and adjacent tissues (may be mistaken for a malignant tumer). The organ
most commonly involved is the liver.

Diagnosis

- Biopsy of affected organs.

- CT scan and ultrasound.
- Serologic testing.

Treatment

Similar to that for E. granulosis.

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