Lesson 2

NEMATODES – PART 1

Intended Learning Outcomes

At the end of this unit, the learners will be able to:
1. describe the general characteristics and morphology of each Nematode;
2. explain the life cycle of each Nematode;
3. select the specimen of choice, collection and processing protocol, and laboratory
diagnostic technique for the recovery of each of the Nematodes;
4. state and identify the geographic distribution of the Nematodes and the populations
prone to contracting symptoms and clinically significant disease processes associated
with each Nematode; and
5. identify and describe the disease or conditions, prognosis, treatment options, prevention
and control measures, as related to the Nematodes.

Introduction
Nematodes are also known as roundworms. It belongs to the Phylum Nemathelminthes,
Class Nematoda. These parasites are usually grouped according to the presence or absence of
phasmids. Among the nematodes of medical and public health importance, only three are
aphasmid worms (Class Adenophorea). These are Trichuris, Trichinella, and Capillaria. The rest
of the nematodes are, therefore, phasmid nematodes (Class Secernentia).

In this lesson we will cover Class Adenophorea and other nematodes belonging to Class
Secernentia, namely:Ascaris lumbricoides, Enterobius vermicularis, Strongyloides stercolaris and
Dracunculus medinensis..

Pre-Discussion Assessment
Instructions: Write TRUE if the statement is correct and FALSE if it is incorrect
____ 1.
False The rhabditiform larvae of the guinea worm is also known as its L3 larvae.
____
True 2. Albendazole is used to treat helminths infection.
____ 3.
False Trichinella spiralis is also known as threadworm.
____ 4. Direct fecal smear measures the intensity of helminth infection in eggs per gram
False
(epg) of stool.
____
True 5. Scotch tape method is the common test done to detect pinworm infection.
Notes:
Lecture Notes 1. Rhabditiform - L1 larvae; Filariform - L3 larvae
3. Trichinella spiralis - a.k.a Trichina worm; Strongyloides stercolaris - a.k.a Threadworm
I. NEMATODES 4. Kato-Katz smear

 roundworms
also known as __________________________
 belongs to Phylum Nemathelminthes, Class Nematoda
 are nonsegmented, elongated and cylindrical in shape, with bilateral symmetry, tapered at
both ends, and covered by a tough protective covering (__________________________)
cuticle

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)

 generally, have a complete digestive tract and a muscular pharynx that is characteristically
triradiate
 parthenogenetic
generally, with separate sexes, although some may be __________________________
(development of a female gamete without fertilization)

 Reproductive organs are tubular and lie coiled in the body cavity
o Male - there is a single tubule, which at its smaller end consists of testicular cells; it
extends into a vas deferens and seminal vesicle and terminates in an ejaculatory duct
opening into the cloaca
o Female - has two cylindrical ovaries, which expand into uteri which may open to the
exterior through a single vulva, or there may be a common vagina between the vulva
and uteri

 adult female worms are usually larger than the adult males
 musculature (muscle cell arrangement) varies:
polymyarian
o __________________________- an arrangement of multiple, longitudinal rows of
muscle cells in each quadrant
o __________________________
holomyarian - one with no more than two rows of cells
o __________________________
meromyarian - one with two to five rows

 have sensory organs in the anterior (amphids) and posterior ends of the worm (phasmids)

 life cycles of nematodes are similar but organism-specific, stages in the life cycle include:
o egg
o larvae (undergo several molts)
o adult
 exact means whereby each organism enters the host and migrates into the intestinal tract
varies by species
 most nematodes have the ability to exist independent of a host (free-living)

 severity of a nematode infection can be attributed to the following factors:

o the number of worms present;
o the length of time the infection persists
o the overall health of the host

 grouped according to phasmids: presence (phasmid nematodes or

Class Secernentia
__________________________) or absence (aphasmid nematodes or
__________________________)
Class Adenophorea

Aphasmid (Class Phasmid (Class Secernentia)

Adenophorea, Order
Trichocephalida) Order Nematode

Trichuris trichiura Ascaridida Ascaris lumbricoides

Trichinella spiralis
Capillaria philippinensis Strongylida Parastrongylus /
Angiostrongylus
cantonensis and
hookworms

Oxyurida Enterobius vermicularis

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 Spirurida Filarial worms

Camallanida Dracunculus medinensis

 grouped according to habitat:

o intestinal nematodes
small intestines
 __________________________- Ascaris, hookworms,
Strongyloides, and Capillaria
 __________________________-
colon / large intestine Trichuris and Enterobius
o extraintestinal nematodes
lymph nodes and lymph vessels Wuchereria and Brugia
__________________________-
 __________________________–
eyes and meninges Parastrongylus/Angiostrongylus
 __________________________–
muscles encysted larvae of Trichinella

 Mode of Infection / Transmission

o ingestion of embryonated eggs Ascaris, Trichuris, and Enterobius
__________________________-
oskin penetration by filariform larvae hookworms and Strongyloides
__________________________-
o __________________________-
bite of mosquito vectors Wuchereria and Brugia
o __________________________larvae
ingestion of infective - Capillaria (fish), Trichinella (pork),
Parastrongylus (snails), Dracunculus (contaminated water with copepods
containing larvae)
inhalation of embryonated eggs Enterobius and Ascaris
o __________________________-

II. APHASMIDS

Trichuris trichiura
 also known as whipworm, one of the soil-transmitted helminth causing trichuriasis

General Characteristics
 with __________________________
holomyarian type of muscle arrangement
 Female worm lays approximately 3000 to 10000 eggs per day

Geographic Distribution
 3rd most common round worm of humans
 About 800 million people are infected
 infections are more frequent in areas with tropical weather and poor sanitation practices,
and among children

Morphology
a. Adult worm
 Attenuated anterior three-fifths traversed by a narrow esophagus resembling a string
of beads
 robust posterior two-fifths contain the intestine and a single set of reproductive organs

i. Male – measures 30 to 45 mm, slightly shorter than the female; has a coiled
posterior with a single spicule and retractile sheath
ii. Female - 35 to 50 mm long; has a blunt posterior end

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)

 b. Larvae – not usually described probably because soon after the embryonated eggs are
ingested, the larvae escape and penetrate intestinal villi where they remain for 3 to 10 days
c. Eggs
 50 to 54 μm by 23 μm
 lemon or football-shaped with plug-like translucent polar prominence
 has a yellowish outer and a transparent inner shell

Life Cycle
 The unembryonated eggs are passed with the stool.
 In the soil, the eggs develop into a 2-cell stage, an advanced cleavage stage, and then they
embryonate; eggs become infective in 15 to 30 days.
 After ingestion (soil-contaminated hands or food), the eggs hatch in the small intestine, and
release larvae that mature and establish themselves as adults in the colon.
 The adult worms (approximately 4 cm in length) live in the cecum and ascending colon. The
adult worms are fixed in that location, with the anterior portions threaded into the mucosa.
 The females begin to oviposit 60 to 70 days after infection. Note: Female worms in the
cecum shed between 3,000 and 20,000 eggs per day. The life span of the adults is about 1
year.

Clinical Manifestations
 The anterior portions of the worms, which are embedded in the mucosa, cause petechial
hemorrhages, which may predispose to amebic dysentery.
 Lumen of appendix filled with worms may lead to appendicitis or granuloma formation
 Infections with more than 5000 eggs per gram of feces are usually symptomatic.
 Heavy intensity infections may lead to Trichuris dysentery syndrome manifested by chronic
dysentery and rectal prolapsed with symptoms such as frequent blood-streaked diarrheal
stools, abdominal pain and tenderness, nausea and vomiting, and weight loss
 Anemia is correlated to intensity of Trichuris infections.
 No larval migration through the lungs.

Laboratory Diagnosis
 direct fecal smear (DFS)
 Kato thick smear - about 20 to 60 mg stool sample
 Kato-Katz smear – quantitative method for counting eggs; can be used to assess the
efficacy of anthelminthic drugs in terms of cure rate (CR) and egg reduction rate (ERR);
used for epidemiological surveys
 acid-ether and the formalin-ether/ethyl acetate concentration techniques
 FLOTAC/mini-FLOTAC

Epidemiology
 It occurs in both temperate and tropical countries but is more widely distributed in warm,
moist areas of the world
 Approximately 604 to 795 million are infected globally.
 In the Philippines, the prevalence of Trichuris ranged from 4.5 to 55.1% in preschool
children, and from 8.1 to 57.9% in school-age children.
 Prevalence of co-infections with Ascaris is 19.1% in a recent sentinel survey.

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Prevention and Control
 Similar strategies with Ascaris
 The WHO recommends biannual mass drug administration with mebendazole 500 mg or
albendazole 400 mg among school-age children in communities where the prevalence of
STH infections is ≥50%.
 Once a year treatment is recommended in communities with STH prevalence <50%.
 Treatment of other high-risk groups such as preschool children, women of childbearing age,
including pregnant women in the 2nd and 3rd trimesters as well as lactating women, adults
in certain high-risk occupations are also considered.

 WASHED framework is used to control STH infections.

Water
o __________________________
 Access to potable water
 Drainage and disposal/re-use/recycling of household wastewater (gray water)
Sanitation
o __________________________Access to safe and sanitary sanitation facilities
 Safe collection, storage, treatment, and disposal (feces and urine)
 Management/re-use/recycling of solid waste
Hygiene education
o __________________________
 Appropriate information regarding prevention and treatment of STH infections
 Dissemination of key messages to promote the following practices
 Safe water storage
 Safe handwashing and bathing practices
 Safe treatment of foodstuffs
 Latrine use
 Use of footwear
Deworming
o __________________________
 Regular mass drug administration (twice a year for school-age children)

Treatment
 ______________________(drug
Mebendazole of choice) - 100 mg twice a day for 3 days
 Albendazole (alternative)

Trichinella spiralis
 Also known as the ______________________________
trichina worm causing trichinosis or
trichinellosis

General Characteristics
o The viviparous female lives for 30 days and is capable of producing more than 1,500 larvae
in its lifetime.
o The host (ex: humans, rats, dogs, cats, pigs, bears, foxes, walruses, or any other carnivore
or omnivore) serves as both the final and intermediate host by harboring both the adult and
the larval stages

Geographic Distribution
 worldwide

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Morphology
 Larvae
o 5.6 μm at birth, but reaches the size of 0.65 to 1.45 mm in length and 0.026 to 0.040 mm
in width after it enters a muscle fiber
o has a spear-like, burrowing anterior tip
o Infective larvae are usually encysted in the muscle fibers of the host
 Adults
i. Male
o measures 0.62 to 1.58 mm by 0.025 to 0.033 mm
o has a single testis located near the posterior end of the body, and is joined in the
mid-body by the genital tube which, in turn, extends back to the cloaca
o cloaca has a pair of caudal appendages and two pairs of papillae
i. Female
o measures about 1.26 to 3.35 mm by 0.029 to 0.038 mm, and has a single ovary
which is situated in the posterior part of the body
o has an oviduct, a seminal receptacle, a coiled uterus, a vagina, and a vulva

Life Cycle
o Trichinellosis is caused by the ingestion of undercooked meat containing encysted larvae.
(Sylvatic Cycle / Domestic Cycle)
o After exposure to gastric acid and pepsin in the stomach, the larvae are released from the
cysts and invade the stomach or the small intestine where they develop into adult worms.
o The larvae then burrow into the subepithelium of the villi where they undergo four molts.
o Maturation takes about 2 days, and adult worms begin to mate 5 to 7 days post infection.
The female produces eggs that grow into larvae in its uterus.
o After a few days, the female worm deposits larvae in the mucosa.
o The larvae penetrate the mucosa, pass through the lymphatic system into the circulation,
and finally into striated muscles
o In the muscles, the larvae grow and develop. After about 3 weeks, they start to coil into
individual cysts. Encapsulation is completed 4 to 5 weeks after infection.

Note: The larva in the cyst remains viable for many years. The average lifespan of the
encysted larva is about 5 to 10 years, and can survive for up to 40 years in humans. In
humans, calcification of the collagen capsule in the infected muscle cell and the larva may
occur which may lead to the destruction or death of the larva.

Clinical Manifestations
 The severity of symptoms depends on the intensity of infection.
i. Light infections ( 10 larvae) – asymptomatic
ii. Moderate infection (50 – 500 larvae) – symptomatic
iii. Heavy infection (1000 – 3000 larvae) – severe disease
 result in gastroenteritis, diarrhea, and abdominal pain approximately two days, post
infection
 three phases:
i. enteric phase
o incubation and intestinal invasion
o symptoms resemble those of an attack of acute food poisoning, including diarrhea
or constipation, vomiting, abdominal cramps, malaise, and nausea

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)

 ii. invasion phase
o larval migration and muscle invasion
o results to immunological, pathological, and metabolic reactions
o Severe myalgia, periorbital edema, eosinophilia, high remittent fever, chills,
headache, dyspnea, dysphagia, and difficulty in chewing are observed.
o Occasionally, there is paralysis of the extremities and splenomegaly.
o In severe cases, there may be gastric and intestinal hemorrhages.
o Larval migration in the heart may result in pericardial pain, tachycardia,
electrocardiogram abnormalities, pericardial effusion, congestive heart failure, and
other chronic heart abnormalities may be observed.
o Neurological complications may occur in chronic infections. Meningitis and
meningoencephalitis may also develop.
o In heavy infections, ocular disturbances diplegia, deafness, epileptiform attacks,
and coma may occur.

iii. convalescent phase

o encystment and encapsulation
o fever, weakness, pain, and other symptoms start to abate
o full recovery is expected (self-limiting)

Laboratory Diagnosis
 histological examination - demonstration of the larva through muscle biopsy
 nonspecific laboratory tests – detect eosinophilia, muscle enzymes (creatine
phosphokinase, lactate dehydrogenase, and myokinase), and total IgE in serum
 Latex agglutination
 enzyme-linked immunosorbent assay (ELISA) – recommended
 Western blot – confirm ELISA-positive samples

Epidemiology
 Trichinosis have been documented in 55 countries worldwide.
 There are about 10,000 cases reported each year, 0.2% resulting in mortality.
 It has never been documented in a small number of island countries, including the
Philippines.
 It is primarily a zoonosis.

Prevention and Control

 Health education
o meat be cooked at a minimum of 77°C (170°F) or freeze to kill larvae
o regular animal monitoring
o keeping pigs in rat-free pens
o proper disposal of suspected carcasses

Treatment
 Mebendazole or Albendazole
 Analgesics and antipyretics – as supportive treatment to control symptoms

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)

  Corticosteroids - may be given with anthelminthics to control hypersensitivity reactions to
the larvae, and may also be given to treat acute vasculitis and myositis

Capillaria philippinensis / Paracapillaria philipinensis

 Also known as pudoc worm causing intestinal capillariasis

Geographic Distribution
 endemic in the Philippines and epidemics have occurred in the Northern Luzon region
 endemic also in Thailand, and sporadic cases have been reported from other East and
Southeast Asian countries
 a number of cases have been identified in northern Egypt

Morphology
i. Egg
o measure 36 to 45 μm by 20μm
o peanut-shaped with striated shells and flattened bipolar plugs
ii. Larvae
iii. Adult
o Male
 1.5 to 3.9 mm in length
 spicule is 230 to 300 μm long and has an unspined sheath
 esophagus has rows of secretory cells called stichocytes, and the entire
esophageal structure is called a stichosome
 anus is subterminal
o Female
 2.3 to 5.3 mm in length
 first generation of female worms produces larvae to build up the population
 subsequent generations predominantly produce eggs, although there are always
a few female worms that produce both larvae and eggs, or larvae only
 vulva in females is located at the junction of anterior and middle thirds

Life Cycle
o Unembryonated, thick-shelled eggs are passed in the human stool and become
embryonated in the external environment in 5—10 days.
o After ingestion by freshwater fish, larvae hatch, penetrate the intestine, and migrate to the
tissues. Ingestion of raw or undercooked fish results in infection of the human host.
o The adults of Capillaria philippinensis reside in the human small intestine, where they
burrow in the mucosa .
o In addition to the unembryonated, shelled eggs which pass into the environment, the
females can also produce eggs lacking shells (possessing only a vitelline membrane),
which become embryonated within the female’s uterus or in the intestine.
o The released larvae can re-invade the intestinal mucosa and cause internal autoinfection.
This process may lead to hyperinfection (a massive number of adult worms).

Note: Fish-eating birds are believed to be the natural hosts of C. philippinensis, and
humans are considered incidental hosts.

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)

Clinical Manifestations
 characterized by abdominal pain, chronic diarrhea, and gurgling stomach, protein-losing
enteropathy, electrolyte imbalance, and intestinal malabsorption, and may lead to death
(severe cases)

Laboratory Diagnosis
 Direct fecal smear
 Concentration techniques
 sandwich enzyme-linked immunosorbent assay (ELISA)

Epidemiology
 Intestinal capillariasis was first recorded in Northern Luzon in the Philippines. In 1966, an
Pudoc West, Tagudin, Ilocos Sur
epidemic in _______________________________________________was reported, that
spread to neighboring towns and resulted in more than 1,000 cases and 77 deaths.
 Ilocano people enjoy eating bagsit and other fishes found in the lagoons.
 In Monkayo, Compostela Valley Province, an outbreak described as a “mystery disease” in
1998 resulted in the death of villagers due to misdiagnosis.
 A few cases have also been confirmed in Zamboanga del Sur, Agusan del Sur, and Misamis
Occidental.

Prevention and Control

 Sanitation and health educational programs to prevent indiscriminate disposal of human
waste and to discourage eating raw fish are important in controlling the spread of infection.
 Capacity building for health personnel in the field, including laboratory staff, for early and
accurate diagnosis and treatment is important in preventing mortality.
Treatment
 __________________________
Mebendazole – drug of choice
 __________________________
Albendazole - alternative
 Electrolyte replacement and high protein diet – for severe cases with electrolyte and
protein loss

III. Phasmids

Ascaris lumbricoides
 Also known as __________________________
giant intestinal roundworm / giant roundworm
 a soil-transmitted helminth (STH), together with Trichuris trichiura and hookworms

General Characteristics
 Adults reside in but do not attach to the mucosa of the small intestines.
 It produces pepsin inhibitor 3 (PI-3) that protects them from digestion and
phosphorylcholine that suppresses lymphocyte proliferation.

Geographic Distribution
 most common human helminthic infection globally
 highest in tropical and subtropical regions, especially in areas with inadequate sanitation
 generally rare to absent in developed countries, but sporadic cases may occur in rural,
impoverished regions of those countries

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)

Morphology
 Adult worms
o large with whitish or pinkish appearance with smooth and striated cuticles, measuring
about:
 male - 10 to 31 cm
 female - 22 to 35 cm
o have __________________________of
polymyarian type somatic muscle arrangement
o have a terminal mouth with three lips and sensory papillae
o Males have a ventrally curved posterior end with two spicules.
o Females can be as thick as a pencil.
o Females have paired reproductive organs in the posterior two-thirds, while males have
a single, long, tortuous, tubule.

 Larva - similar to adult

 Eggs
i. Infertile (unfertilized)
o Measure about 88 to 94 μm by 39 to 44 μm, longer and narrower than fertile
eggs, with a thin shell and irregular mammilated coating filled with refractile
granules
o may be difficult to identify and are found not only in the absence of males

Fertile (fertilized)
ii. _____________________________
o measure 45 to 70 μm by 35 to 50 μm
o an outer, coarsely mammilated albuminous covering which may be absent or
lost in “decorticated” egg
o has a thick, transparent, hyaline shell with a thick outer layer as a supporting
structure and a delicate vitelline, lipoidal, inner membrane, which is highly
impermeable
o At oviposition, the fertile eggs have an ovoid mass of protoplasm, which will
develop into larvae in about 14 days

iii. Embryonated eggs

o Fully embryonated egg is the infective stage

Life Cycle
 Adult worms live in the lumen of the small intestine.
 A female worm may produce approximately 200,000 eggs per day, which are passed with
the feces.
 Unfertilized eggs may be ingested but are not infective. Larvae develop to infectivity within
fertile eggs after 18 days to several weeks, depending on the environmental conditions
(optimum: moist, warm, shaded soil).
 After infective eggs are swallowed, the larvae hatch, invade the intestinal mucosa, and are
carried via the portal, then systemic circulation to the lungs.
 The larvae mature further in the lungs (10 to 14 days), penetrate the alveolar walls, ascend
the bronchial tree to the throat, and are swallowed.
 Upon reaching the small intestine, they develop into adult worms. Between 2 and 3 months
are required from ingestion of the infective eggs to oviposition by the adult female.
 Adult worms can live 1 to 2 years.

Clinical Manifestations
 majority of Ascaris infections are asymptomatic

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)

  usual infection of 10 to 20 worms may not show symptoms
 During lung migration, the larvae may cause host sensitization resulting in allergic
manifestations such as lung infiltration, asthmatic attacks, and edema of the lips.
 difficulty of breathing and fever similar to pneumonia may occur as a result of penetration
by several larvae through the lung capillaries as they enter the air sacs
 vague abdominal pain is the most frequent complaint of patients
 eosinophilia is present during larval migration
 moderate infections may cause lactose intolerance and vitamin A malabsorption
 Heavy infections are may cause bowel obstruction, intussusception, or volvulus that may
result in bowel infarction and intestinal perforation.
 Patients with biliary ascariasis experience severe colicky abdominal pain, which is brought
about by the movement of the worms inside the biliary tract.
 Worms may also lodge in the appendix or occlude the pancreatic duct and cause acute
appendicitis or pancreatitis, respectively.
 Penetration of the worms through the intestinal wall into the peritoneal cavity may occur
and result in either acute peritonitis or chronic granulomatous peritonitis.

Laboratory Diagnosis
 direct fecal smear (DFS) – less sensitive
 ____________________________
Kato thick Smear
 Kato-Katz techniques - provides quantitative diagnosis in terms of the intensity of
helminth infection in eggs per gram (epg) of stool that is useful in monitoring the efficacy
of treatment
 Formalin ether/ ethyl acetate concentration technique

Epidemiology
 Has a cosmopolitan distribution
 About 1.2 billion people globally are estimated to have ascariasis, and about 2,000 die
annually.
 The disease remains endemic in many countries of Southeast Asia, Africa, and Central
and South America.
 Children ages 5 to 15 years have the highest intensities of infection with Ascaris.
 In many low and middle income countries like the Philippines, the prevalence may reach
80 to 90% in certain high risk groups like public elementary school children.
 Surveys showed an overall prevalence of 27.7% among school-age children and 30.9%
among preschool children.
 Its transmission depends on socio-economic factors more than on physical factors such
as high density of human population, involvement in agriculture (including use of night-soil
as fertilizer), illiteracy, poor sanitation, and health education.

Prevention and Control

 Surveillance and monitoring are essential in the STH Control Program.
 Baseline cumulative prevalence and prevalence of heavy intensity infections should be
compared with follow-up data.
 WHO recommends parasitologic monitoring, every 2 years, involving the selection of 5 to
10 schools to represent a district or municipality.
 WASHED framework

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)

  World Health Assembly (in 2001), recommended preventive chemotherapy among high
risk groups (preschool- and school-age children) for morbidity control in communities
where the cumulative prevalence of STH infections is greater than 20%. Preventive
chemotherapy is done through mass drug administration (MDA) with anthelminthics, either
alone or in combination, among target populations, even without the benefit of stool
examination. Pregnant women in their 2nd or 3rd trimester, as well as lactating women
may receive albendazole or mebendazole.
 Integrated Helminth Control Program (IHCP) of the Department of Health (DOH), is being
conducted in elementary schools every January and July for school-age children through
the Department of Education (DepEd).

Treatment
 Single dose of broad-spectrum antheminthics
o Albendazole
o Mebendazole
o Pyrantel pamoate

Enterobius vermicularis
 Also known as pinworm or seat worm causing enterobiasis or oxyuriasis

Geographic Distribution
 worldwide, with infections occurring most frequently in school- or preschool-children and
in crowded conditions

Morphology
a. Egg
o are asymmetrical, with one side flattened (D-shaped) and the other side convex, and
range from 50 to 60 μm by 20 to 30 μm in size averaging 55 by 36 μm
o translucent shell consists of an outer triple albuminous covering for mechanical
protection and an innerembryonic lipoidal membrane for chemical protection
o has a tadpole like embryo that becomes fully mature outside the host within 4 to 6
hours
b. Larvae
c. Adult
meromyarian
o Classified as ___________________
o Has cuticular alar expansions at the anterior end and a prominent posterior
esophageal bulb
o Male – measuring 2 to 5 mm by 0.1 to 0.2 mm has a curved tail and a single spicule;
rarely seen as it ususally dies after copulation
o Female - measures 8 to 13 mm by 0.4 mm and has a long pointed tail; uteri of gravid
females are distended with eggs

Life Cycle
 Gravid adult female Enterobius vermicularis deposit eggs on perianal folds.
 Infection occurs via self-inoculation (transferring eggs to the mouth with hands that have
scratched the perianal area) or through exposure to eggs in the environment (contaminated
surfaces, clothes, bed linens.).

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)

 Following ingestion of infective eggs, the larvae hatch in the small intestine and the adults
establish themselves in the colon, usually in the cecum. The time interval from ingestion of
infective eggs to oviposition by the adult females is about one month. The adult life span is
about two months.
 Gravid females migrate nocturnally outside the anus and oviposit while crawling on the skin
of the perianal area.
 The larvae contained inside the eggs develop (the eggs become infective) in 4 to 6 hours
under optimal conditions. Note: Rarely, eggs may become airborne and be inhaled and
swallowed. Eggs are resistant to disinfectants but succumb to dehydration in dry air within a
day, however, in moist conditions high humidity and moderate temperature, these eggs
remain viable for up to 13 days. Retroinfection, or the migration of newly hatched larvae from
the anal skin back into the rectum, may occur but the frequency with which this happens is
unknown.

Clinical Manifestations
 Mild catarrhal inflammation of the intestinal mucosa may result from the attachment of
the worms.
 Mechanical irritation and secondary bacterial invasion may lead to inflammation of the
deeper layers of the intestines.
 Migration of egg-laying females to the anus causes irritation of the perineal region.
 Intense itching leads to scratching and insomnia in children, and may give rise to
secondary bacterial infection.
 It may also cause poor appetite, weight loss, irritability, grinding of teeth, and
abdominal pain.
 Complications such as appendicitis, vaginitis, endometritis, salpingitis, and peritonitis
are all due to adult worm migration.
 Entry into the peritoneal cavity via the female reproductive system may result in the
formation of granuloma around eggs or worms.
 This can also be recovered from other ectopic sites such as the liver and lung.
 It is considered a group or familial disease due to being extremely contagious.

Laboratory Diagnosis
 Graham’s scotch adhesive tape swab (perianal cellulose tape swab)

Epidemiology
 There are around 208.8 million infected persons in the world
 In the Philippines, prevalence levels have been found to be 29% among
schoolchildren from exclusive private schools, and 56% among those from public
schools. Locally, prevalence is consistently higher in females (16%) compared to
males (9%). Eggs were found in nail clippings of school children.
 Enterobiasis occurs in both temperate and tropical regions of the world, and has a
high prevalence in both developed and developing countries.
 It is the only nematode infection that cannot be controlled by sanitary disposal of
human feces due to eggs deposition at the perianal region.
 Eggs usually contaminate underwear and beddings.

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)

  The route of infection is through the mouth, the respiratory system (by inhalation of
dust containing Enterobius eggs), and through the anus (wherein the hatched larvae
enter the anus and cause retroinfection when they go back into the large intestine).
 Risk factors for infection include overcrowding, thumb-sucking, nailbiting, and lack of
parental knowledge on pinworms.

Prevention and Control

a. Health education and Personal hygiene
i. fingernails should be cut short and handwashing after using the toilet
ii. use of showers rather than bathtubs is suggested
iii. infected persons should sleep alone until adequately treated
iv. underwear, night clothes, blankets, and bed sheets should be handled with
care and washed in hot soapy water
b. chemotherapy of the entire family is recommended

Treatment
a. Mebendazole and Albendazole – drug of choice
b. Pyrantel pamoate – second drug of choice

Strongyloides stercoralis
 Also known as threadworm causing strongyloidisasis
 only specie of this genus which is naturally pathogenic to humans
 characterized by free-living rhabditiform and parasitic filariform stages

Geographic Distribution
 globally distributed in tropical and subtropical areas
 most common in areas with poor sanitation, rural and remote communities, institutional
settings, and among socially marginalized groups

Morphology
a. Egg
 Has a clear thin shell and are similar to those of hookworms except that they
measure only about 50 to 58 μm by 30 to 34 μm
 Rarely seen

b. Larvae
 Rhabditiform
 measures 225 μm by 16 μm
 has an elongated esophagus with a pyriform posterior bulb
 differs from the hookworm in being slightly smaller and less attenuated
posteriorly
 has a shorter buccal capsule and a larger genital primordium

 Filariform
 nonfeeding, slender, and about 550 μm in length similar to the
hookworm filariform larva but is usually smaller, with a distinct cleft at
the tip of the tail or notched tail

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)

 c. Adult
 parasitic female is 2.2 mm by 0.04 mm, colorless, semi-transparent, with a
finely striated cuticle
o has a slender tapering anterior end and a short conical
pointed tail
o short buccal cavity has four indistinct lips
o esophagus extends to the anterior fourth of the body,
o intestine is continuous to the subterminal anus
o vulva is located one-third the length of the body from the
posterior end
o uteri contain a single file of 8 to 12 thin-shelled, transparent,
segmented ova, 50 to 58 μm by 30 to 34 μm
 Free-living adult worms mate and females produce fertilized,
embryonated eggs.
o Rhabditiform larvae hatch from these eggs, and either
develop into filariform larvae or into another generation
of free-living adults.
o The free-living female measures 1 mm by 0.06 mm and is
smaller than the parasitic female and it has a muscular
double-bulbed esophagus, and the intestine is a straight
cylindrical tube.
o The free-living male, measuring 0.7 mm by 0.04 mm, is
smaller than the fem le, and has a ventrally curved tail, two
copulatory spicules, a gubernaculum, but no caudal alae.
o Parasitic males have not been reliably identified.

Life Cycle
 Its cycle is alternating between free-living and parasitic cycles and involving autoinfection.
 In the free-living cycle: Rhabditiform larvae are passed in the stool of an infected definitive
host, develop into either infective filariform larvae (direct development) or free-living adult
males and females that mate and produce eggs, from which rhabditiform larvae hatch and
eventually become infective filariform (L3) larvae.
 The filariform larvae penetrate the human host skin to initiate the parasitic cycle . This
second generation of filariform larvae cannot mature into free-living adults and must find a
new host to continue the life cycle.
 Parasitic cycle: Filariform larvae in contaminated soil penetrate human skin when skin
contacts soil, and migrate to the small intestine.
 L3 larvae can migrate via the bloodstream and lymphatics to the lungs, where they are
eventually coughed up and swallowed. The same larvae are also capable of migrating to
the intestine via alternate routes (through abdominal viscera or connective tissue).
 In the small intestine, the larvae molt twice and become adult female worms.
 The females live embedded in the submucosa of the small intestine and produce eggs via
parthenogenesis (parasitic males do not exist) , which yield rhabditiform larvae.
 The rhabditiform larvae can either be passed in the stool (Free-living cycle), or can cause
autoinfection.

Clinical Manifestations
 Three phases of acute infection:
o invasion of the skin by filariform larvae

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)

  larval invasion of the skin produces erythema, and pruritic elevated
hemorrhagic
o migration of larvae through the body
 the lungs are destroyed causing lobar pneumonia with hemorrhage, cough
and tracheal irritation
o penetration of the intestinal mucosa by adult female worms
 adult female worms may be found in the intestinal mucosa from the pylorus
to the rectum, but the greatest numbers are found in the duodenal and
upper jejunal regions
 Light infection does not cause intestinal symptoms.
 Moderate infection causes diarrhea alternating with constipation.
 Heavy infections cause Cochin China diarrhea.
 Hyperinfection occurs in immunocompromised individuals.
 In chronic infections, if not asymptomatic, the patient may experience intermittent
vomiting, diarrhea, constipation, borborygmi, pruritus an, urticaria, larva currens rashes,
recurrent asthma and nephritic syndrome.
 Complications include edema, emaciation, loss of appetite, anemia, lobar pneumonia,
ileus, intestinal obstruction, gastrointestinal bleeding, and malabsorption leading to
cachexia.
 Prognosis is good in light infections only.
 Disseminated infection occurs among patients with cancer, malnutrition, HIV/AIDS, HTLV-
1, or those using immunosuppressive drugs after organ transplantation.

Laboratory Diagnosis
 Unexplained eosinophilia as clue
 Baermann funnel gauze method
 Harada-Mori culture – recommended in field use
 Nutrient agar plates
 Beale’s string test
 Duodenal aspiration
 Small bowel biopsy
 Serological tests – rapid result but not recommended in filariasis endemic areas due to
cross-reactions

Epidemiology
 Strongyloides stercoralis is distributed worldwide and follows a distribution pattern similar
to hookworm in the tropics and subtropics.
 In the Philippines, strongyloidiasis is relatively rare. Local data on the prevalence of
Strongyloides stercoralis reveal 0 to 2.3% only.
 Transmission is affected by poor sanitation and indiscriminate disposal of human feces
that may contain Strongyloides larvae.
 Autoinfection occurs in some individuals who leave the endemic areas.

Prevention and Control

 Health education on personal, family and community hygiene to change behavior and
practices is needed.
 Infected individuals should be treated in order to prevent morbidity and mortality.

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)

  People with cancer, debilitating diseases like pulmonary tuberculosis, and malnutrition,
and those about to undergo organ transplantation should be cleared of Strongyloides
infection.

Treatment
 Albendazole & ________________________
Thiabendazole – contraindicated in pregnant women and
those with hypersensitivity to the drug
 Ivermectin – chronic uncomplicated strongyloidiasis

Dracunculus medinensis
 Also known as guinea worm or __________________________
Medina worm causing dracunculosis,
dracunculiasis or guinea worm infection
 It is thought that the “fiery serpents” that plagued the Israelites by the Red Sea were
Dracunculus.

Geographic Distribution
 restricted to rural, isolated areas in a narrow belt of African countries

Morphology

a. Larvae
i. Rhabditiform larvae – L1 larvae, relatively small, measuring an average size
of 620 by 15 μm
Infective larvae
ii. _______________________ – sheathed L3 larvae
a. Adults
i. Considered as one of the largest adult nematodes, the average elongated
female Dracunculus medinensis measures approximately 840 mm long by 1.5
mm wide, and possesses a prominent blunt, rounded anterior end
ii. The rarely seen adult male is smaller than the female, measuring only 21 by
0.4 mm. The anterior end of the male characteristically coils on itself a
minimum of one time.
Life Cycle
 Humans become infected by drinking unfiltered water containing copepods (small
crustaceans or freshwater fleas) which are infected with larvae of D. medinensis.
 Following ingestion, the copepods die and release the larvae, which penetrate the host
stomach and intestinal wall and enter the abdominal cavity and retroperitoneal space.
 After maturation into adults and copulation, the male worms die and the females (length: 70
to 120 cm) migrate in the subcutaneous tissues towards the skin surface.
 Approximately one year after infection, the female worm induces a blister on the skin,
generally on the distal lower extremity, which ruptures.
 When this lesion comes into contact with water, a contact that the patient seeks to relieve
the local discomfort, the female worm emerges and releases larvae.
 The larvae are ingested by a copepod and after two weeks (and two molts) have developed
into infective larvae.
 Ingestion of the copepods will continue the cycle.

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)

Clinical Manifestations
 Symptoms experienced by patients are associated with allergic reactions and nodule
formation.
 Secondary bacterial infections may also develop.
 The worm emerges as a whitish filament (duration of emergence: 1 to 3 weeks) in the center
of a painful ulcer, accompanied by inflammation and frequently by secondary bacterial
infection.

Laboratory Diagnosis
 recovered by observing infected ulcers for the emergence of the worms
 No serologic test is available.

Epidemiology
 Guinea worm is found in parts of Africa, India, Asia, Pakistan, and the Middle East.
 Copepods reside in fresh water, located particularly in areas called step wells, from which
people obtain drinking water and bathe.
 Other sources of infection include ponds, human-made water holes and standing water.
 Reservoir hosts, like dogs, are infected by drinking contaminated water.

Prevention and Control

 Use of properly treated water for consumption
 boiling water suspected of contamination
 prohibiting the practice of drinking and bathing in the same water
 ceasing the practice of allowing standing water to be ingested
 filtering, using a finely meshed filter, the suspected water are all logical guinea worm
prevention

Treatment
Total worm removal
 ______________________

Supplemental Readings
 For further understanding of the nematodes covered:
o download and use some google play store apps to aid you in your studies:
 Pocket Parasitology Free
 Parasitology Image Atlas
 Atlas of Tropical Medicine and Parasitology
o check the WHO Bench AIDS for the Diagnosis of Intestinal Parasites
(https://apps.who.int/iris/bitstream/handle/10665/37323/9789241544764_eng.pdf
?sequence=1)

References

Belizario, V.Y. & De Leon, W.U. (2015). Medical Parasitology in the Philippines. 3rd ed. Manila,
Philippines : University of the Philippines Press

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)

Bogitsh, B.J., Carter, C.E., & Oeltmann, T.N. (2012). Human Parasitology. 4th ed. Amsterdam ;
Boston : Academic Press
Indiana Pathology Images. (2016). Parasitology Image Atlas. [Mobile App]. Google Play Store.
https://play.google.com/store/apps/details?id=com.IPImages.Parasitology
JACOAPPS. (2020). Atlas of Tropical Medicine and Parasitology (5.1.8) [Mobile App]. Google
Play Store.
https://play.google.com/store/apps/details?id=com.andromo.dev677517.app688987
John, David T. & Petri, William A. Jr. (2010). Markell and Voge’s Medical Parasitology. 9th ed.
Singapore: Elsevier
Paniker, C.K.J. & Ghosh, S. (2018). Paniker’s Textbook of Medical Parasitology. 8th ed.
Shorakhute, Kathmandu, Nepal : Jaypee Brothers Medical Publishers (P) Ltd
World Health Organization. (2012). Bench Aids for the Diagnosis of Intestinal Parasites. Retrieved
from
https://apps.who.int/iris/bitstream/handle/10665/37323/9789241544764_eng.pdf?sequence=
1
Zeibig, E. A. (2013). Clinical Parasitology A Practical Approach. 2nd ed. St. Louis, Missouri :
Elsevier Saunders

https://www.cdc.gov/dpdx/

MEDT09 – CLINICAL PARASITOLOGY LECTURE (KKEC & JJBD, 2022)