PARASITOLOGY

Topic: Aphasmids
References: Old Trans + Belizario

INTRODUCTION  Adult Female

o Measures about 1.26 to 3.35 mm by 0.029 to 0.038 mm
Helminth
o Has a single ovary which is situated in the posterior part
of the body
o It has an oviduct, a seminal receptacle, a coiled uterus,
Roundworm Flatworm
a vagina, and a vulva
o The vulva is situated in the anterior 5th on the ventral side
of the body
Aphasmids
o The viviparous female lives for 30 days and is capable of
producing more than 1,500 larvae in its lifetime

Phasmids

Aphasmids
 Roundworms
 Characteristics:
1. Reduced/absent caudal papilla
2. Excretory system are without lateral canals
3. Most important characteristic  No caudal
chemoreceptors
Even with the prior 2 properties but with the 3rd, it
would still be considered an aphasmid

 Under subclass Adenophorea/Asphasmidia

 Dioecious
 Female is larger than Male
 Anterior portion is slightly widened and posterior portion is slightly  Larva
pointed o Measures 80 to 120 μm by 5.6 µm at birth, BUT reaches
 Species with medical importance: the size of 0.65 to 1.45 mm in length and 0.026 to 0.040
o Trichinella spiralis mm in width after it enters a muscle fiber
o Trichuris trichiura o It has a spear-like, burrowing anterior tip
o Capillaria philippinensis o The digestive tract of a mature larva encysted in a muscle
fiber resembles that of the adult worm
Trichinella spiralis o The reproductive organs, at this stage, are not yet fully
 Common name: Trichina worm developed but even then, it is already possible to identify
 “Dead end alley”  infection cannot be transmitted from human to the sex of the parasite
human
 Pathology: Trichinosis, Trichiniasis, Trichinellosis
 Discovered at autopsy in London
 Parasite is carnivorous/omnivorous animals (cats, dogs, hogs, rats)
 Not actually a parasite to humans
 Accidental host: Human

Based on Belizario:
 First described in 1822 in Germany
 It causes Trichinellosis
 German investigators were able to prove that raw or insufficiently
cooked meat was responsible for trichinellosis in humans Old Trans Info:
 Adult Form:
Parasite Biology o Male measures 1.6 x 0.04 mm
Morphology o Female measures 3.5 x 0.6 mm (Bigger)
 Adult Male o With STICHOSOME (Stichocytes)  sensory organ; nerve
o Measures 0.62 to 1.58 mm by cell  only in T. spiralis
0.025 to 0.033 mm o With esophagus
o With a single testis located near o Mouth bears protrusible stylet (only protrudes when
the posterior end of the body, eating)
and is joined in the mid-body by o With single testis and ovary
the genital tube which, in turn, o May be mistaken for Strongyloides due to its thread-like
extends back to the cloaca structure
o The posteriorly-located cloaca o Presence of stichosome is the differentiating
has a pair of caudal appendages characteristic
and two pairs of papillae o Stichosome – cell, a substitute receptor organ due to
their lack of a phasmid
o Stichocytes – group of cells/stichosomes

Page 1 of 6
 PARASITOLOGY
Topic: Aphasmids
References: Old Trans + Belizario

Old Trans Info continued….. NOTES:

 Larva:  Infective stage: Encysted larva
o At birth 120 x 5.6 microns  Habitat: Skeletal Muscle
o In the muscles: 1300 x 40 microns  Encystation: Muscle
o May be lodged in various foci (brain, heart, body cavities)  Excystation: Duodenum
o Encyst/develop only in striated muscle  diaphragm,  MOT: Ingestion of infected muscle with encysted larva
laryngeal, abdominal, psoas, pectoral, deltoid, gluteus,  Accidental host: Human
biceps
o Liberated from female worm after 4-16 weeks Based on Belizario:
o No egg stage, born larva  In Trichinella infection, the host (i.e., humans, rats, dogs, cats, pigs,
o Migrates until it finds its permanent habitat: Skeletal bears, foxes, walruses, or any other carnivore or omnivore) serves
Muscle as both the final and intermediate host by harboring both the adult
o When it migrates, it can be trapped to other parts of the and the larval stages
body, where they eventually die  Infective larvae are usually encysted in the muscle fibers of the host
The infective encysted larvae enter the host through ingestion of
Reproduction: raw or insufficiently cooked meat
 After mating, MALES are dislodged from the mucosa, and die
afterwards ( males mate only ONCE)  The cysts are digested in the stomach, and the larvae EXCYST either
 Female burrows deeply in the mucosa (duodenum to cecum) in the stomach or in the small intestine
 Female dies after passing the larva  The larvae then burrow into the subepithelium of the villi where they
 Affects small to upper part of large intestine undergo 4 molts
Maturation takes about 2 days, and adult worms begin to mate
Life Cycle 5 to 7 days post infection

 The female produces eggs that grow into larvae in its uterus
 The larvae penetrate the mucosa, pass through the lymphatic system
into the circulation, and finally into striated muscles
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

 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
This process may be observed 6 to 12 months after infection and
may lead to the destruction or death of the larva

Pathogenesis & Clinical Manifestations

 Light infection - harboring up to 10 larvae, are usually asymptomatic
 Moderate infection (50-500 larvae) show symptoms
o Infection with a few hundred larvae can result in
gastroenteritis, diarrhea, & abdominal pain
approximately two days post infection
o Infection with 100 to 300 larvae may lead to symptomatic
Trichinellosis is acquired by ingesting meat containing cysts (encysted
trichinellosis
larvae) (1) of Trichinella. After exposure to gastric acid and pepsin, the larvae are
released (2) from the cysts and invade the small bowel mucosa where they develop into  >1,000 to 3,000 larvae can result in severe disease
adult worms (3) (female 2.2 mm in length, males 1.2 mm; life span in the small bowel: 4  Clinical phases and condition:
weeks). After 1 week, the females release larvae (4) that migrate to the striated muscles o Enteric phase – incubation and intestinal invasion
where they encyst (5). Trichinella pseudospiralis, however, does not encyst. Encystment is  Acute food poisoning
completed in 4 to 5 weeks and the encysted larvae may remain viable for several years.  Diarrhea
Ingestion of the encysted larvae perpetuates the cycle. Rats and rodents are primarily
 Vomiting
responsible for maintaining the endemicity of this infection. Carnivorous/omnivorous
animals, such as pigs or bears, feed on infected rodents or meat from other animals.
 Abdominal cramps
Different animal hosts are implicated in the life cycle of the different species of Trichinella.  Malaise
Humans are accidentally infected when eating improperly processed meat of these  Nausea
carnivorous animals (or eating food contaminated with such meat). o Invasion phase – larval migration and muscle invasion
 It results to immunological, pathological and
metabolic reactions
 Inflammatory reaction to the infection results
in eosinophilia, which results in the release of
histamines

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 PARASITOLOGY
Topic: Aphasmids
References: Old Trans + Belizario

Invasion phase continued….. Treatment

 Histamines, serotonins, bradykinins, and  Mebendazole (DOC)
prostaglandins contribute to an ↑ in vascular o Dose: 5 mg/kg body weight daily
permeability, resulting in tissue edema  Albendazole
 The cardinal signs and symptoms of o Adult dose: 1 mg/kg per day in two divided doses for 10-
trichinellosis include: 15 days
 Severe myalgia o Pedia dose: 10 mg/kg
 Periorbital edema
 Eosinophilia Thiabendazole is NO LONGER USED due to its associated adverse
 Other typical signs and symptoms include: drug reactions
 High remittent fever and chills
 Headache Epidemiology
 Dyspnea
 Trichinella infection has never been documented in a small number
 Dysphagia
of island countries, including the Philippines
 Difficulty in chewing
 Trichinellosis is primarily a zoonosis
 Occasionally, there is paralysis of the
 Humans get infected after ingestion of raw or insufficiently cooked
extremities and splenomegaly
meat from infected animals
 In severe cases, there may be gastric and
 The infection is usually maintained in a pig-to-pig or pig-to-rat-to-pig
intestinal hemorrhages
cycle
 Larval migration into the heart muscle can
result in:
Prevention & Control
 Pericardial pain
 Tachycardia  Health education
 ECG abnormalities  Regular animal monitoring
Pericardial effusion, congestive heart  Disposal of carcasses
failure, and other chronic heart  Cooked and store the meats properly
abnormalities have also been observed
Trichuris trichiura
 Neurological complications, which are  Common name: Whipworm
caused by small subacute cortical infarcts,  Soil-transmitted helminth, and is classified as holomyarian
may occur in chronic infections
 Meningitis and meningoencephalitis may Parasite Biology
also develop Morphology:
 In heavy infections:  The worms have an attenuated anterior three-fifths traversed by a
 Ocular disturbances narrow esophagus resembling a string of beads. The robust posterior
 Diplegia two-fifths contain the intestine and a single set of reproductive
 Deafness organs
 Epileptiform attacks  Adult Male:
 Coma o 30 to 45 mm
o Convalescent phase – encystment and encapsulation o Shorter than the female
 Fever, weakness, pain, and other symptoms o Has a coiled posterior with a single spicule and retractile
start to abate sheath
 Full recovery is expected since trichinellosis is
a self-limiting disease  Adult Female:
However, protean neurologic signs arising o 15 to 50 mm
from brain damage may persist o Has a blunt posterior end
o A female lays approximately 3,000 to 10,000 eggs per day
 Prognosis is good, especially in mild infections
 Death is uncommon except in cases of heart failure, encephalitis, or  Egg:
other complications such as pneumonia or septicemia o 50 to 54 µm by 23 µm
 Low-grade or absent peripheral blood eosinophilia is indicative of o It is lemon or football-shaped with plug-like translucent
poor prognosis polar prominences
o It has a yellowish outer and a transparent inner shell
Diagnosis o Fertilized eggs are unsegmented at oviposition and
 Muscle Biopsy – the most definitive diagnostic examination embryonic development takes place outside the host
Muscle biopsy is done through histological examination of 0.2 to when eggs are deposited in clayish soil
0.5 g of muscle tissue o Trichuris eggs in soil are more susceptible to desiccation

 Non-specific laboratory tests to detect eosinophilia, muscle  Larvae are not usually described probably because soon after the
enzymes (creatine phosphokinase, lactate dehydrogenase, and embryonated eggs are ingested, the larvae escape and penetrate
myokinase), and total IgE in serum may be useful in diagnosis intestinal villi where they remain for 3 to 10 days
 ELISA is recommended for the diagnosis of Trichinellosis

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 PARASITOLOGY
Topic: Aphasmids
References: Old Trans + Belizario

Life Cycle  In patients with heavy intensity infection, the worms may be found
throughout the colon and rectum, and may result in Trichuris
dysentery syndrome manifested by chronic dysentery & rectal
prolapse
Such cases of heavy chronic trichuriasis are often marked by
frequent bloodstreaked diarrheal stools, abdominal pain and
tenderness, nausea and vomiting, and weight loss

 Anemia is strongly correlated to heavy intensity trichuriasis, and

blood loss from such infections can range from 0.8 to 8.6 ml per day
Infection with over 800 worms can result in anemia in children
Light infections are moderately associated with anemia, although
these infections are usually asymptomatic and the presence of
the parasite may be discovered only in routine stool examinations

 Trichuriasis has also been shown to result in poor appetite, wasting,

stunting, as well as reduced intellectual and cognitive development
in children
 The prognosis of trichuriasis is very good
Because there is no larval migration through the lungs as in
Ascaris and hookworm infections, no lung pathology occurs

Diagnosis
 Direct Fecal Smear (DFS)
The unembryonated eggs are passed with the stool (1). In the soil, the eggs develop into a
2-cell stage (2), an advanced cleavage stage (3), and then they embryonate (4); eggs  Kato thick smear  this method is highly recommended in the
become infective in 15 to 30 days. After ingestion (soil-contaminated hands or food), the diagnosis of trichuriasis
eggs hatch in the small intestine, and release larvae (5) that mature and establish  Kato-Katz technique  a quantitative method that employs egg
themselves as adults in the colon (6). The adult worms (approximately 4 cm in length) live counting to determine the intensity of helminth infection
in the cecum and ascending colon. The adult worms are fixed in that location, with the This technique can be used to assess the efficacy of anthelminthic
anterior portions threaded into the mucosa. The females begin to oviposit 60 to 70 days
drugs in terms of cure rate (CR) and egg reduction rate (ERR)
after infection. 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 This technique can also be used for epidemiological surveys for
the monitoring of a helminth control program
Based on Belizario:
 Trichuris worms inhabit the cecum and the colon  Kato-Katz technique – 91% sensitivity and 94% specificity
 The worms secrete a pore-forming protein, called the TT47 that
allows them to imbed their entire whip-like portion into the intestinal Other diagnostic techniques:
wall  Acid-ether & Formalin-ether/Ethyl acetate concentration
 After copulation, the female worm lays eggs, which are passed out techniques
with the feces and deposited in the soil  FLOTAC technique  shown to be more sensitive in the diagnosis
 Under favorable conditions, the eggs develop and become of trichuriasis compared with Kato-Katz and ether/ethyl acetate
embryonated within 2 to 3 weeks concentration techniques
 If swallowed, the infective embryonated eggs go to the small
intestine and undergo 4 larval stages to become adult worms Treatment
This process takes about 12 weeks  Mebendazole (DOC)
o Dose: 100 mg twice a day for 3 days
 Unlike Ascaris, there is NO heart-lung migration o Has a higher cure rate than albendazole
 Each female worm can produce about 60 million eggs over an average  Albendazole
lifespan of 2 years o Alternative drug

Pathogenesis & Clinical Manifestations Epidemiology

 The anterior portions of the worms, which are embedded in the  Occurs in both temperate and tropical countries
mucosa, cause petechial hemorrhages, which may predispose to  More widely distributed in warm, moist areas of the world
amebic dysentery, presumably because the ulcers provide a suitable  Approximately 604 to 795 million are infected globally
site for tissue invasion by E. histolytica  Prevalent in East Asia and Pacific Island regions
 The mucosa is hyperemic and edematous; enterorrhagia or intestinal  Least prevalent in the Middle East and North African regions
bleeding is common
 The lumen of the appendix may be filled with worms, and consequent Prevention & Control
irritation and inflammation may lead to appendicitis or granuloma  Biannual mass drug administration with mebendazole 500 mg or
formation albendazole 400 mg among school-age children in communities
 Infections with over 5,000 T. trichiura eggs per gram of feces are  Provision of safe water, environmental sanitation, and hygiene
usually symptomatic education

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 PARASITOLOGY
Topic: Aphasmids
References: Old Trans + Belizario

Capillaria philippinensis Typically, unembryonated, thick-shelled eggs are passed in the human stool (1) and become
embryonated in the external environment in 5—10 days (2) ; after ingestion by freshwater
 Common name: Pudoc worm
fish, larvae hatch, penetrate the intestine, and migrate to the tissues (3) . Ingestion of raw
 Disease: Intestinal capillariasis or undercooked fish results in infection of the human host. (4) The adults of Capillaria
 Discovered in Ilocos Norte, Philippines philippinensis are very small (males: 2.3 to 3.2mm; females: 2.5 to 4.3 mm) and reside in the
 Native in the Philippines human small intestine, where they burrow in the mucosa (5) . In addition to the
 Thinnest aphasmid unembryonated, shelled eggs which pass into the environment, the females can also
produce eggs lacking shells (possessing only a vitelline membrane) (6) , which become
embryonated within the female’s uterus or in the intestine. The released larvae can re-
Based on Belizario:
invade the intestinal mucosa and cause internal autoinfection (7) . This process may lead to
 Was first reported by Chitwood et al. in 1963 in a 29 year old male hyperinfection (a massive number of adult worms).
from Northern Luzon
 Intestinal capillariasis, a zoonotic disease, is characterized by Based on Belizario:
abdominal pain, chronic diarrhea, & gurgling stomach  The eggs hatch in the intestines of the fish and grow into the infective
The disease may also be associated with protein losing larvae
enteropathy, electrolyte imbalance, & intestinal malabsorption  When the fish is eaten uncooked, the larvae escape from the fish
intestines and develop into adult worms in human intestines
 Fish-eating birds are the natural hosts of the nematode  The first generation of female worms produces larvae to build up the
population
Parasite Biology  Subsequent generations predominantly produce eggs, although
 Have a thin filamentous anterior end and a slightly thicker and there are always a few female worms that produce both larvae and
shorter posterior end eggs, or larvae only
 The esophagus has rows of secretory cells called stichocytes, and the  Some of these larvae are retained in the gut lumen and develop into
entire esophageal structure is called a stichosome adults
 The anus is subterminal, and the vulva in females is located at the This leads to hyperinfection and autoinfection, which result in
junction of anterior and middle thirds the production of very large numbers of worms
 Adult Male:
o 1.5 to 3.9 mm in length  Fish-eating birds are believed to be the natural hosts
o Male spicule is 230 to 300 µm long and has an unspined  Humans are considered incidental hosts
sheath
 Adult Female: NOTES:
o 2.3 to 5.3 mm in length  Intermediate host: Freshwater fish (If man defecates in the river
o Produce characteristic eggs or infected soil gets into the river)
 Eggs:  Infective stage: Larva
o Peanut-shaped with striated shells and flattened bipolar  MOT: Eating of infected fish with larva stage
plugs  Diagnostic stage: Eggs in the feces (infective stage in fish)
o 36 to 45 µm by 20 µm
o Passed in the feces and embryonate in the soil or water Pathogenesis & Clinical Manifestations
They must reach the water in order to be ingested by  Abdominal pain and Borborygmi
small species of freshwater or brackish water fish  Patients initially experience intermittent diarrhea, which progresses
to passing out 8 to 10 voluminous stools per day
Life Cycle  After a few weeks, there is:
o Noticeable weight loss
o Malaise
o Anorexia
o Vomiting
o Edema
 Laboratory findings show:
o Severe protein-losing enteropathy
o Hypoalbuminemia
o Malabsorption of fats and sugars
o Decreased excretion of xylose
o Low serum potassium, sodium and calcium
o High levels of IgE
 The large number of worms that develop in humans is responsible
for the severe pathology
 The parasites do not invade intestinal tissue, but they are responsible
for:
o Micro-ulcers in the epithelium
o Compressive degeneration of cells
o Mechanical compression of cells

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 PARASITOLOGY
Topic: Aphasmids
References: Old Trans + Belizario

Clinical manifestations continued….. Summary Table:

 Homogeneous material is seen at the anterior end of the worm by Trichuriasis Capillariasis Trichinosis
electron microscopy Stool examination – Stool examination – Biopsy of infected muscle
identification of ova identification of ova, Double slide compression
 Endoscopic finding may reveal non-specific segmental erythematous
Kato-Katz technique larva, and adult forms technique
inflammation in the small bowel with superficial erosions with
Acid ether concentration Serologic tests
exudation technique o Latex agglutination
 Histologically, the intestines also show flattened and denuded villi, Serological Test – ELISA test
and dilated mucosal glands. The lamina propria is infiltrated with o Bentonite flocculation
plasma cells, lymphocytes, macrophages, and neutrophils test
o Xenodiagnosis
Clinical Manifestations based on Old Trans:
 Intestinal malabsorption (Outstanding sign)
 Severe fat malabsorption (very fatty stool) References:
 Medical Parasitology in the Philippines by
 Fluid and electrolyte losses
Belizario & de Leon (3rd Ed.)
 Free passage of plasma protein
 Lecture Notes
 Abdominal pain and distention
 Cachexia and amancipation

Of all Aphasmids, Capillaria has the WORST symptoms

Diagnosis
 Direct Fecal Smear (DFS) – for identification of eggs in the feces
 Wet mounts
 Stool concentration methods
 Duodenal aspiration – parasites can be also recovered from the small
intestine
 ELISA – detection of coproantigen prepared from stool samples of
patients with capillariasis
ELISA using T. spiralis antigen has been tested and shown to have
a sensitivity of 100% in the diagnosis of capillariasis (43 positive
cases) and a specificity of 100% (57 negative cases)

Treatment
 Electrolyte replacement and high protein diet
 Mebendazole
o Dose: 200 mg 2x a day for 20 days
 Albendazole
o Dose: 400 mg once daily for 10 days

Epidemiology
 Intestinal capillariasis was first recorded in Northern Luzon in the
Philippines
 In 1966, an epidemic in Pudoc West, Tagudin, Ilocos Sur was
reported, that spread to neighboring towns and resulted in more
than 1,000 cases and 77 deaths
 In the Philippines, nearly 2,000 cases have been documented from
the Northern Luzon provinces from 1967 to 1990
 Infections are acquired by eating uncooked small freshwater/
brackish water fish. Ilocano people enjoy eating bagsit and other
fishes found in the lagoons

Prevention & Control

 Improve sanitation and health educational programs to prevent
indiscriminate disposal of human waste
 Discourage eating raw fish are important in controlling the spread of
infection
 Accurate diagnosis and treatment is important in preventing
mortality
 Health education can also help improve patient health-seeking
behaviors

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