CLINICAL PARASITOLOGY

LECTURE / LESSON 4

CESTODA
Cestodes  All adult tapeworms are self-fertilizing (hermaphroditic),
 Commonly known as the “flatworms” or “tapeworms” both male and female reproductive organs are present in
 Cestodes are under platyhelminthes or flatworms the mature proglottid.
 Class of multicellular worms noted for their segmented  Following self-fertilization, the resulting pregnant (gravid)
and flat or ribbon-like appearance proglottids each consist of a uterus filled with eggs.
Characteristics  The gravid proglottids rupture when these eggs are

1. Adult tapeworms resemble a ribbon in appearance and released into the intestine. The resulting eggs are usually
range in length from several millimeters up to an impressive passed into the outside environment via the stool.
15 to 20 m. Contamination can come from the feces of cows, pigs, fish,
2. These worms are very primitive in that they absorb and humans.
nutrients and excrete waste products through their outer Laboratory Diagnosis
surface, called a tegument.  The primary specimen necessary to recover and identify
3. Although this group of adult parasites possess a intestinal tapeworms is stool. Microscopically examined
reproductive system, they lack sophisticated body parts for the presence of eggs and, occasionally, gravid
and systems, such as a mouth, digestive tract, and internal proglottids
means of excretion.  Rarely, a scolex may be recovered, particularly following
4. Three distinct features common to all adult tapeworms are: treatment
(1) Scolex anterior portion of the body containing  A biopsy of tissue presumed to be infected with the atrial
suckers and sometimes hooklets responsible for cestode E. granulosus may be examined for the presence
attachment to the host. The “crown” of the scolex is of organisms
called rostellum, from which one or two rows of hooks  Serologic tests are available for select organisms
might be present. Pathogenesis and Clinical Symptoms
(2) Proglottids (Strobila) chain of segments that in  Many patients infected with intestinal cestodes remain
their mature form are equipped with both male and asymptomatic
female reproductive organs. Series of reproductive  Symptoms
organs in various stages of development (Immature → - Vague, nondescript gastrointestinal discomfort
Mature → Gravid (filled with eggs). Strobila is the - Diarrhea and abdominal pain
entire length of the tapeworm except for the scolex and - Nausea, dizziness, headache, weight loss
neck.  Intestinal obstruction and vitamin B12–induced
(3) Neck located directly behind the scolex and is the macrocytic anemia (Diphyllobothrium latum)
site of new proglottid production (chain of growth)  Liver and lung involvement (E. granulosus)
5. The typical scolex contains four cup-shaped structures, - Persistent cough
known as suckers, that provide the worm with the ability to - Localized pain
attach to the intestinal mucosa of the infected host. - Eosinophilia
- A serious allergic response may develop, known as
anaphylactic shock, which produces large amounts of
histamine and other chemical mediators and may be fatal
Cestode Classification

Life Cycle
Egg → Larval stage(s) → Adult worm
 The egg consists of a hexacanth embryo (also known as
Taenia Saginata
an oncosphere) defined as the motile, first larval stage (tee’nee-uh/sadj-i-nay’tuh)
characterized by the presence of six small hooks (called Common name: Beef tapeworm
hooklets), arranged in pairs, that are believed to pierce the Common associated disease and condition names:
intestinal wall of the infected host. Taeniasis, Beef tapeworm infection
 In the intestinal tapeworm life cycle, human ingestion of
an egg or larval stage results in an adult worm eventually Taenia Solium
emerging in the intestine. Transmission of infective eggs (tee’nee-uh/so-lee’um)
occurs with contaminated food and water. Common name: Pork tapeworm
 An intermediate host is required for the development of
Common associated disease and condition names:
the larval form in certain life cycles. Cestodes have Taeniasis, Pork tapeworm infection
several intermediate hosts.
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LECTURE / LESSON 4
Epidemiology side of uterus
 Distribution of T. saginata and T. solium directly
correlates with areas of the world in which the inhabitants
do not practice sanitary conditions and beef or pork is
eaten on a routine basis
 T. saginata is found primarily in these types of
cosmopolitan areas, whereas T. solium is found worldwide
 As noted, both organisms require an intermediate host, a
cattle or pig, depending on the species
 Taenia saginata is known as the longest tapeworm

Morphology
Taenia Species
Egg: Typical Characteristics at a Glance
Parameter Description
Size range 28-40 μm by 18-30 μm
Hooklets Three pairs; hexacanth embryo
Other features Radial striations on yellow-brown
embryophore
 The average, somewhat roundish Taenia spp. egg
measures 33 by 23 µm
 Egg consists of a hexacanth embryo, including the
standard three pairs of hooklets
 Embryo is surrounded by a yellow-brown shell present on
select tapeworm eggs known as an embryophore on
which distinct radial striations reside. These eggs may be
non-embryonated or embryonated

Life Cycle
Infection with Taenia spp. occurs following the ingestion of
raw or undercooked beef (T. saginata) or pork (T. solium)
contaminated with a cysticercus larva, a type of larva that
consists of a scolex surrounded by a bladder-like, thin-walled
cyst that is filled with fluid.
 Definitive Host: Humans
 Intermediate Host: Pig or cow/cattle

Taenia Species
Adult: Typical Characteristics at a Glance
Characteristics T. Saginata T. Solium
Scolex
Number of suckers Four Four
Rostellum Absent Present
Hooks Absent Present; double
crown
Gravid Proglottid
Appearance, shape Longer than Somewhat
wide; average, square Diagnostic Stage: Eggs or Gravid proglottids
17.5 by 5.5 μm Infective Stage: Cysticercus larva
Number of lateral 15-30 7-15
branches on each

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Mode of Transmission: Ingestion of raw or undercooked hemagglutination and the enzyme-linked immunosorbent
meat infected with cysticercus larva assay (ELISA).
(1) Eggs or gravid proglottids in feces and passed into Hymenolepis Diminuta
environment (high”men-ol’e-pis/dim-in-oo’tuh)
(2) Cattle (T. saginata) and pigs (T. solium) become infected Common name: Rat tapeworm
by ingesting vegetation contaminated by eggs or gravid Common associated disease and condition names:
proglottids Hymenolepiasis, Rat tapeworm disease
(3) Oncospheres hatch, penetrate intestinal wall, and circulate Epidemiology
to musculature. Oncospheres develop into cysticerci in muscle  The distribution of H. diminuta is worldwide
(4) Humans infected by ingesting raw or undercooked  Areas in which foodstuffs such as grain or cereal are not
infected meat protected from rats and insects are at risk of transmitting
(5) Scolex attaches to intestine the parasite
(6) Adults in small intestine
Morphology
Laboratory Diagnosis
Hymenolepis Diminuta
 Taenia eggs and gravid proglottids - stool (specimen
Egg: Typical Characteristics at a Glance
choice for recovery)
Parameter Description
 The scolex may be seen only after the patient has been
Size range 55 by 85 μm
treated with antiparasitic medication
 Cellophane tape prep procedure - specimens collected
Hooklets Three pairs; hexacanth embryo
around the perianal area have a very high recovery rate of Polar thickenings Present
Taenia eggs Polar filaments Absent
 It is important to note that the eggs of Taenia are identical. Embryophore Present; colorless
To speciate in the laboratory, a gravid proglottid or scolex * Sunny side egg
must be recovered and examined
Signs and Symptoms
1. Asymptomatic: Most people who become infected with
Taenia spp. typically remain asymptomatic
2. Nondescript symptoms:
- Diarrhea
- Abdominal pain
- Change in appetite, slight weight loss
- Dizziness, vomiting, nausea
3. Laboratory tests often reveal the presence of a moderate
eosinophilia Hymenolepis Diminuta
Prevention and Control Adult: Typical Characteristics at a Glance
 Exercising proper sanitation practices Parameter Description
 Thorough cooking of beef and pork prior to consumption Scolex
 Promptly treating infected persons Number of suckers Four
Treatment: Praziquantel (however, it is not used when there Rostellum Present
is ocular or central nervous system (CNS) involvement) Hooks Absent
 Paramomycin and quinacrine hydrochloride (Atabrine) Gravid Proglottid
may also be used as alternative treatments Size Twice as wide as long
Notes of Interest and New Trends Appearance Sac-like uterus filled with eggs
 Humans have been known to contract a human tissue
infection associated with T. solium known as cysticercosis.
This occurs when a human accidentally ingests the T.
solium eggs that are passed in human feces.
 Food, water, and soil contamination are likely methods of
transmitting the eggs from person to person. Once inside
the body, the eggs lose their outer covering, allowing the
developing oncosphere to invade the bloodstream and
tissues, primarily the voluntary muscles.
 Although some patients remain asymptomatic, symptoms
may vary by location of the infection. Manifestations of
brain infections (neurocysticercosis) are common and
may include headache, seizures, confusion, ataxia, and Life Cycle
even death.  Definitive Host: Rat, Humans
 Treatment is available, including surgical removal and  Intermediate Host: Insects
medication. Immunologic tests are available for the (1) Eggs passed in feces
diagnosis of cysticercosis, including indirect (2) Ingested by an arthropod intermediate host
(3) Oncospheres hatch and penetrate the intestinal wall

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(4) Cysticerci in body cavity of insect ingested by rodent or  Persons residing in close quarters, such as in institutional
human settings, as well as children attending preschool or at day
(5) Scolex care centers, are at a particularly high risk of contracting H.
(6) Adults in small intestine nana
(7) Gravid proglottids  Stool from contaminated rodents may also serve as a
source of infection
 Smallest tapeworm

Morphology
Hymenolepis Nana
Egg: Typical Characteristics at a Glance
Parameter Description
Size range 45 by 38 μm
Hooklets Three pairs; hexacanth embryo
Polar thickenings Present
Polar filaments Present
Embryophore Present; colorless

Diagnostic Stage: Eggs

Infective Stage: Cysticercoid larva
Mode of Transmission: Ingestion of insect infected with
cysticercoid larva
Laboratory Diagnosis Hymenolepis Nana
 Hymenolepis Diminuta eggs - stool (specimen choice for Adult: Typical Characteristics at a Glance
recovery) Parameter Description
 Proglottids are typically not found in stool because they Scolex
usually disintegrate in the human gut Number of suckers Four
 Scolex is rarely seen in these samples Rostellum Present; short
Signs and Symptoms Hooks Present; one row
1. Asymptomatic: Many patients infected with H. diminuta Gravid Proglottid
remain asymptomatic Size Twice as wide as long
2. Mild symptoms: Appearance Sac-like uterus filled with eggs
- Diarrhea
- Nausea
- Abdominal pain
- Anorexia
Prevention and Control
 Administering effective rodent control, preventing rats
from contaminating foodstuffs such as grains and cereals
 Protection of these foods from both rat droppings and from
intermediate host insects
 Thorough inspection of all potentially contaminated
foodstuffs prior to human consumption
Treatment: Praziquantel, Niclosamide (not yet readily
available in the US) Life Cycle
Hymenolepis Nana  Definitive Host: Humans

(high”men-ol’e-pis/nay’nuh)  Intermediate Host: None

Common name: Dwarf tapeworm (1) Embryonated egg in feces

Common associated disease and condition names: (2) Egg ingested by insect. Cysticercoid develops in insect
Hymenolepiasis, Dwarf tapeworm disease (3) Humans and rodents are infected when they ingest
Epidemiology cysticercoid-infected arthropods
 Considered to be the most common tapeworm recovered
(4) Embryonated egg ingested by humans from contaminated
in the United States, particularly in the southeastern part of food, water, or hands
the country (5) Oncosphere hatches. Cysticercoid develops in intestinal
 Tropical and subtropical climates worldwide are known to
villus
harbor this parasite (6) Scolex

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(7) Adult in ileal portion of small intestine Morphology
(8) Eggs can be released through the genital atrium of the Dipylidium Caninum
gravid proglottids. Gravid proglottids can also disintegrate Egg Packet: Typical Characteristics at a Glance
releasing eggs that are passed in stools Parameter Description
(9) Autoinfection can occur if eggs remain in the intestine. Number of eggs in 5-30
The eggs then release the hexacanth embryo, which penetrates enclosed packet
the intestinal villus continuing the cycle Diameter range per egg 30-60 μm
Individual egg Six-hooked oncosphere

Dipylidium Caninum
Adult: Typical Characteristics at a Glance
Parameter Description
Scolex
Number of suckers Four
Diagnostic Stage: Embryonated eggs Rostellum Present; club-shaped, with one to
Infective Stage: Direct: Embryonated eggs ; Indirect: seven circlets of spines
Cysticercoid larva Hooks Absent
Mode of Transmission: Ingestion of embryonated Gravid Proglottid
eggs/cysticercoid-infected arthropods (Autoinfection can Shape Pumpkin seed
occur) Appearance Full of eggs enclosed in embryonic
Laboratory Diagnosis membrane
 Hymenolepis Nana eggs - stool (specimen choice for
recovery)
Signs and Symptoms
1. Asymptomatic: Light infections with H. nana typically
remain asymptomatic
2. Gastrointestinal symptoms:
- Abdominal pain
- Anorexia
- Diarrhea
- Dizziness
- Headache
Prevention and Control Life Cycle
 Proper personal hygiene and sanitation practices  Definitive Host: Dog or Cat
 Controlling transport host populations  Intermediate Host: Fleas (Ctenocephalides canis -
 Avoidance of contact with potentially infected rodent Dog flea ; Ctenocephalides felis - Cat flea ; Pulex
feces irritans - Human flea)
Treatment: Praziquantel, Niclosamide (not yet readily  Accidental Host: Humans (Ingestion of fleas
available in the US) containing cysticercoid larva)
Dipylidium Caninum Diagnostic Stage: Gravid proglottids
(dip” i-lid’e-um/kain-i’num ˇ ) Infective Stage: Cysticercoid larva
Common name: Dog or cat tapeworm, Pumpkin seed Mode of Transmission: Ingestion of fleas containing
tapeworm cysticercoid larva
Common associated disease and condition names: (1) Gravid proglottids are passed intact in the feces or emerge
Dipylidiasis, Dog or cat tapeworm disease from perianal region of either animal or human hosts
Epidemiology (2) The proglottids disintegrate and release the egg packets
 The incidence of D. caninum infection is worldwide
(3) Larvae of the typical flea intermediate host ingests egg
 Children appear to be the most at risk for infection
packets. Oncospheres hatch and develop into cysticercoids
transmission (4) Flea larvae mature into adult fleas, which continue to
harbor infective cysticercoids

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(5) Definitive host is infected by ingesting fleas containing  Other noted endemic areas include parts of South America
cysticercoids. Incidental human transmission via ingestion of and Asia, Central Africa, the Baltic region, and Finland. It
infected fleas is in these areas that raw and/or freshwater fish are
(6) Scolex. Adult in small intestine routinely consumed
(7) Cats and dogs can harbor fleas infectious to humans  In addition to humans, a number of fish-eating animals
may also become infected with D. latum and serve as
definitive hosts
 Largest tapeworm to man

Morphology
Diphyllobothrium Latum
Egg: Typical Characteristics at a Glance
Parameter Description
Size range 55-75 μm long, 40-55 μm wide
Shape Somewhat oblong
Embryo Undeveloped, termed coracidium
Shell Smooth; yellow-brown in color
Other features Operculum on one end; terminal knob
on opposite end

Laboratory Diagnosis
 Dipylidium Caninum egg packets or gravid proglottids -
stool (specimen choice for recovery)
 The presence of a single egg in a stool sample may occur,
but is extremely rare
Signs and Symptoms
1. Asymptomatic: Most infected persons experience no Diphyllobothrium Latum
symptoms because of a light worm burden (infection) Adult: Typical Characteristics at a Glance
2. Heavy worm burden:
Parameter Description
- Appetite loss
Scolex
- Diarrhea
Number of sucking grooves Two
- Abdominal discomfort, indigestion
- Anal pruritus (caused by gravid proglottids migrating Shape of sucking groove Almond
out of the anus) Gravid Proglottid
Shape Wider than long
Prevention and Control
Location and appearance Central; rosette
 Dogs and cats should be examined by a veterinarian on a
of uterine structure
regular basis. Routine procedures should include
deworming infected animals (the process of worm removal
via medication) and periodic administration of
prophylactic antihelminth medications
 Dogs and cats should be treated and protected against flea
infestation regularly
 Children should be taught not to let dogs or cats lick them
in or near their mouths
Treatment: Praziquantel, Niclosamide (if available),
Paromomycin Life Cycle
Diphyllobothrium Latum  Definitive Host: Humans

(dye-fil”o-both-ree-um/lay’tum)  Intermediate Host: Copepods → Freshwater fish

Common name: Broad fish tapeworm, Broad or Fish Diagnostic Stage: Unembryonated eggs
Common associated disease and condition names: Infective Stage: Plerocercoid larva
Diphyllobothriasis, Fish tapeworm infection, Broad fish Mode of Transmission: Ingestion of raw or undercooked
tapeworm infection infected fish
Epidemiology (1) Unembryonated eggs passed in feces
 D. latum may be found in a variety of temperate regions
(2) Eggs embryonate in water
worldwide (3) Coracidia hatch from eggs and are ingested by
 In the United States, Alaska and the Great Lakes region
crustaceans
are known to harbor the parasite (4) Procercoid larvae in body cavity of crustaceans

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(5) Infected crustacean ingested by small freshwater fish. (infected subcutaneous tissue often described as white,
Procercoid larva released from crustacean, develops into wrinkled, and ribbon-shaped) typically results
plerocercoid larva  In the life cycle of certain species, humans serve as the
(6) Predator fish eats infected small fish intermediate host for the parasite. In that of other species,
(7) Human ingests raw or undercooked, infected fish the life cycle ceases once it is consumed by a human
(8) Scolex. Adults in small intestine  Surgical removal of the sparganum is the treatment of
(9) Proglottids release immature eggs choice. Praziquantel has also proven effective against the
sparganum
Echinococcus Granulosus
(eh-kigh”no-kock’us/gran-yoo-lo’sus)
Common name: Hydatid tapeworm, Dog tapeworm
Common associated disease and condition names:
Echinococcosis, Hydatid cyst, Hydatid disease, Hydatidosis
Epidemiology
 Primarily found in areas in which sheep or other
herbivores are raised and are in close contact with dogs or
wild canines
 Other criteria for areas at risk include those in which close
contact between canines and humans occurs
 These areas include Great Britain, parts of South America,
Australia, parts of Africa, Asia, and China, and select
portions of the Middle East
 There have been several cases reported in the United
States, particularly in Alaska, as well as in the West and
Southwest
 Former name: Taenia Granulosus
Laboratory Diagnosis  Known as the shortest tapeworm
 Diphyllobothrium Latum eggs and/or less frequently,
proglottids - stool (specimen choice for recovery) Morphology
 On occasion, a scolex may also be seen
Echinococcus Granulosus
 Recovery of intact D. latum proglottids and scolices from
Hydatid Cyst: Typical Characteristics at a Glance
untreated patients is rare Parameter Description
 Stool samples from infected patients who have had drug Protective coverings Cyst wall; multiple laminated
treatment should be examined germinal tissue layers
 To ensure that the treatment was successful, the expected Basic cyst makeup Fluid-filled bladder
findings consist of the passage of the scolex and absence Structures that arise Daughter cysts
of (new) proglottids from inner germinal
Signs and Symptoms layer
1. Asymptomatic: Most infected persons with adult D. latum Other possible Hydatid sand
worms exhibit no clinical symptoms structure present
2. Symptoms:
- Digestive discomfort
- Overall weakness, weight loss
- Abdominal pain
- Vitamin B12 deficiency (when the adult worm attaches
itself to the proximal part of the jejunum)
- Pernicious anemia
Prevention and Control
 Proper human fecal disposal
 Avoidance of eating raw or undercooked fish
 Thorough cooking of all fish before consumption
Treatment: Praziquantel, Niclosamide (if available)
Notes of Interest and New Trends
 Humans have been known to suffer from sparganosis.
Life Cycle
 Definitive Host: Dog, Humans
This condition results from ingesting the procercoid
 Intermediate Host: Ruminants (Cattle, Sheep, Goat)
larvae of D. latum as well as that of other related species
 Accidental and Dead end Host: Humans
 Two primary routes whereby humans can contract this
form of the parasite: water contaminated with infected Diagnostic Stage: Hydatid cyst
copepods and medicines contaminated with infected Infective Stage: Embryonated egg
animal by-products. The formation of a sparganum Mode of Transmission: Ingestion of embryonated egg
(1) Adult in small intestine

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(2) Embryonated egg in feces Treatment: Surgical removal of the hydatid cyst (when
(3) Oncosphere hatches; penetrate intestinal wall located in a suitable area for surgery)
(4) Hydatid cyst in liver, lungs, etc. Medications: Mebendazole, Albendazole, Praziquantel (if
(5) Protoscolex from cyst hydatid cyst in inoperable)
(6) Scolex attaches to intestine Notes of Interest and New Trends
 Echinococcus multilocularis is an accidental cause of
hydatid disease in humans living in the Subarctic, as well
as central Europe and India
 Foxes are the primary definitive hosts; rodents, such as
mice and voles, are the usual intermediate hosts
 Disease manifestion in humans is similar to that of E.
granulosus

Laboratory Diagnosis
 Hydatid cyst fluid may be examined on biopsy samples for
the presence of scolices, daughter cysts, brood capsules,
or hydatid sand
 Care must be used when choosing this method of
diagnosis because infected patients may suffer from
anaphylaxis if fluid escapes from the hydatid cyst during
specimen collection
 Serologic tests such as ELISA, indirect hemagglutination,
and the Western blot test are available
 Detection of the hydatid cyst may be accomplished using
radiography, computed tomography (CT), or ultrasound
scan techniques
Signs and Symptoms
The extent to which infected patients may experience
discomfort varies, depending on the size and location of the
hydatid cyst
1. In general, patients experience little if any symptoms for
approximately one year or more following ingestion of the
Echinococcus eggs
2. As the cyst continues to enlarge, necrosis of the infected
tissues, accompanied by a buildup of pressure on these tissues,
usually results
- Anaphylactic shock
- Eosinophilia
- Allergic reactions
- Death
- Lung infection
- Chest pain, coughing, and shortness of breath
- Liver involvement: Obstructive jaundice
3. The cyst fluid that emerges from the rupturing cyst, under
the right conditions, can spread to other sites and form new
cysts
Prevention and Control
 Personal hygiene practices
 Discontinuing the practice of feeding canines potentially
contaminated viscera
 Promptly treating canines and humans
 Instituting a thorough education program

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