blok 4 - infectious agents parasitology i - helminths

Muthia CenderadewiBagian Parasitologi FK UNRAM

INFECTIOUS AGENTS – HELMINTHS

Penyakit/Ketrampilan Level KompetensiDaftar penyakit :Ascariasis 4A Penyakit cacing tambang 4A Strongyloidiasis 4ATaeniasis 4A Schistosomiasis 4A (akan dimasukkan di blok 6)Daftar skills pemeriksaan diagnostik :Identifikasi parasit 4A Pemeriksaan feses ( cacing) 4AAnal swab 4A

SKDI : Sistem Gastrointestinal, Hepatobilier, dan Pankreas

• Memahami dasar-dasar Nematoda,Trematoda, dan Cestoda• Memahami epidemiologi, morfologi, siklus hidup, manifestasi klinis,

serta prinsip pemeriksaan parasitologi pada beberapa nematoda intestinal yang penting :• Ascaris lumbricoides• Ancylostoma duodenale, Necator americanus• Strongyloides stercoralis• Enterobius vermicularis• Trichuris trichiura

• Memahami epidemiologi, morfologi, siklus hidup, manifestasi klinis, serta prinsip pemeriksaan parasitologi pada Trematoda yang penting• Fasciola hepatica

• Memahami epidemiologi, morfologi, siklus hidup, manifestasi klinis, serta prinsip pemeriksaan parasitologi pada Cestoda yang penting • Taenia saginata, Taenia solium)

Learning outcomes :

• Medical Protozoology• Medical Helminthology• Medical Entomology• Medical Mycology

MEDICAL PARASITOLOGY

Helminth

Platyhelminthes

Cestoda

Trematoda

Nemathelminthes

Nematoda

Helminthology

Nemathelminthes Platyhelminthes

Class Nematoda Class Cestoda dan Class Trematoda

Silindris, panjang Pipih seperti pita atau daun

Tidak bersegmen Umumnya bersegmen

Sex terpisah antara jantan dan betina Pada umumnya hermaphrodyte

Saluran pencernaan lengkap Saluran pencernaan tidak lengkap

Mempunyai rongga tubuh Tidak memiliki rongga tubuh

Medical helminthology

The Nematodes

Morphologic features :- Nonsegmented- Generally cylindrical, mostly tapered at both ends- Covered by cuticle- Generally a light cream-white colour- Well formed digestive tracts, with anal and oral openings- Separated sexes (in which the males are generally

smaller than the females)- Certain modifications of apparatus in the oral opening

and esophagus are important in the identification of the species

The Nematodes (roundworms)

NematodesIntestinal nematodes

Ascaris lumbricoides, Enterobius vermicularis, Ancylostoma duodenale, Necator americanus, Strongyloides stercoralis, Trichuris trichiura, etc

Blood & tissue-dwelling nematodesWuchereria bancrofti,

Brugia malayi, Brugia timori, Mansonella ozzardi, Mansonella streptocerca, Onchocerca volvulus, Trichinella spiralis, Toxocara canis, etc

The Nematodes

Epidemiology :- Affects more than other parasitic diseases- More prevalent in areas with poor sanitation,

areas where human feces are used as fertilizer

Morphologic features of adult worms :- Cylindrical, resembles earth worm but

unsegmented- Length : females 20-35 cm, males seldom excedeed 30 cm long- Creamy white in colour

Ascaris lumbricoides

Telur infektif tertelan

Larva menetas di sal.cerna, penetrasi ke mukosa

intestinal

Terbawa aliran darah portal, terbawa aliran darah

sistemik ke paru

Larva matur di paru (10-14 hari), menembus alveolus

naik ke bronchial tree, tertelan kembali ke

sal.cerna

Larva menjadi cacing dewasa di usus halus deposisi 200.000

telur per hari

Telur keluar bersama

tinja

Telur fertil menjadi infektif setelah 18 hari sampai

beberapa minggu

Clinical manifestations :- Asymptomatic in mild infection- Fever, cough, pneumonia during larval migration through

the lungs- Moderate infection can produce symptomatic

maldigestion- Heavy infection can cause bowel obstruction (ileus)

fever, malaise, abdominal distention, abdominal pain, vomitting


• Diagnosis :- Examination of the stool fertile or infertile eggs


Ascaris lumbricoides eggs in fresh stool examination

Fertile

Corticated

Decorticated

Infertile

Fertile corticated eggs :- Broadly oval- 45-75 µm X 35-50 µm- Consists of 3 layers :

- Outer covering (albuminoid coat), stained golden brown by the bile- Glycogen- Lipid

- coarse surface (mamillated)


Fertile corticated eggs of Ascaris lumbricoides

Fertile corticated eggs of Ascaris lumbricoides

Fertile decorticated eggs :- Broadly oval- 45-75 µm X 35-50 µm- Consists of 2 layers (already lost its outer

covering/albuminoid coat) thick yellowish inner shell is obvious

- Glycogen- Lipid

- Smooth surface


Fertile decorticated eggs of Ascaris lumbricoides

Fertile decorticated eggs of Ascaris lumbricoides

Infertile eggs :- Longer and narrower than the fertile eggs- ±90 µm X 40 µm- The wall might consists of 2 thin layers

- Albuminoid coat- Glycogen

- Coarse surface (mamillated)- Contains rough granule-like materials


Infertile eggs of Ascaris lumbricoides Infertile eggs of Ascaris lumbricoides

Treatment of infections :• Albendazole single dose 400 mg• Mebendazole 2x100 mg selama 3 hari• Pyrantel pamoate single dose 10-11 mg/KgBB


• N. americanus adult worms similar to Ancylostoma duodenale but slighly smaller clinically it is considered unimportant to differ these two• Difference : the buccal capsule of N. americanus armed

with a pair of cutting plates, while the buccal capsule of Ancylostoma duodenale had 2 pair of teeth• Grayish white or pinkish• Male 1 x 0.5 cm, female somewhat larger

Hookworm (Ancylostoma duodenale and Necator americanus)

Ancylostoma duodenale Necator americanus

the infective larvae penetrate the skin

carried through the blood vessels to the heart and

then to the lungs

penetrate into the pulmonary alveoli, ascend the bronchial tree to the

pharynx, and are swallowed

larvae reach the small intestine, where they reside

and mature into adultsAdult worms attach to the

intestinal wall with resultant blood loss

Eggs are passed in the stool

under favorable conditions (moisture, warmth, shade)

larvae hatch in 1 to 2 days rhabditiform larvae

after 5 to 10 days rhabditiform become filariform (third-stage)

larvae that are infective

Epidemiology :- High prevalence in population which defecate directly onto the soil and

do not costumarily wear shoes- Climate : sufficient rainfall, sandy loam soil

Clinical manifestations :- In penetrating the skin may cause ground itch (less common with

Ancylostoma than with N. americanus)- Pneumonia less severe than in Ascariasis- Heavy infection : gastrointestinal discomfort, diarrhea- Acute intestinal hemorrhage is rare- Chronic infection : iron deficiency anemia


Diagnosis : - eggs in fresh stool examination- larvae might be seen in the eggs of hours long specimens

- Hatched larvae in the stools must be differentiated from larvae of Strongyloides stercoralis

- rhabditiform larvae of hookworms have a long & narrow buccal capsule (between oral opening and esophagus)

- Rhabditiform larvae of Strongyloides has a very short and somewhat stout buccal capsule


Hookworm’s Rhabditiform Larvae Strongyloides stercoralis’s Rhabditiform Larvae

Differentiating the larvae

Eggs in stool examination :- Oval- 56-60 µm X 36-40 µm- Thin and colourless shell- Smooth surface- Contains of 4-8 morula

Treatment :• Albendazole single dose 400mg• Mebendazole 2x100mg selama 3 hari• Pyrantel pamoate single dose 11 mg/KgBB• Additional treatment : Fe supplementation


• Morphologic features :- Very small- adult male : 0.7 - 1 x 0.04 mm , adult female : 2.2 x

0.04 mm- Grayish white or pinkish

Strongyloides stercoralis

life cycle of Strongyloides stercoralis

Free living cycle

Parasitic cycle


Epidemiology : - similar as hookworm

Clinical manifestations :- Ground itch similar to hookworms infection- Pneumonia less severe than in Ascariasis- Heavy infection : gastrointestinal discomfort, duodenal ulcer,

melena, diarrhea

Diagnosis :- Larvae in the stools- In a case with severe diarrhea, embryonated eggs may be present

in stool


• Larvae in stool examination : similar to hookworms larvae with a very short and stout buccal cavity.• Eggs in stool examination : similar to hookworms eggs,

but always contained well-developed larvae


Hookworm’s eggs Egg of Strongyloides stercoralis

Differentiating the eggs

Treatment :• albendazole 400 mg/hari selama 3 hari• Ivermectin 200 µg/KgBB per hari selama 2 hari


• Morphologic features of adult worms :- Length : female 8-13 mm long & 0.5 mm wide, - male 2-5 mm long & < 0.2 mm wide- Yellowish white- Female distiguished from the male by the thin and sharply pointed tail

Enterobius vermicularis (pinworms)

Enterobius vermicularis

Transmision by swallowing th eggs (from bed linens, contaminated clothes, or

hand to mouth)

Larvae hatch in small intestine

Adult worms established in colon

Gravid females migrate nocturnally outside the anus and oviposit in the

perianal area

the eggs become infective in 4 to 6 hours under optimal conditions

Retroinfection by migration of newly hatched larvae

from the anal skin back into the rectum

Epidemiology :- Spread of infection is facilitated by crowded indoor living, along with poor sanitation

Clinical manifestations :- Pruritus ani, local irritation in perianal- Sleep disturbance as the worms migrated to anus at night

Diagnosis :- Swab of perianal region using cellophane tape eggs- Rarely, eggs may be found in stool examination- Adult worms crawling in perianal region


Eggs in stool examination :• Broadly oval, asymmetrical• 50-60 µm X 10-32 µm• Smooth surface• Distinguished morphologic features of the eggs :

flattened on one side


Treatments : • Albendazole single dose 400 mg, repeated in 2 weeks• Water enema to help eliminate the symptoms, if

necessary


• Morphologic features :- The adult worms : 2-5 cm long, male slightly smaller than female- Whip-like tail

Trichuris trichiura (whipworm)

Trichuris trichiura

ingestion of infective eggs

Larvae hatch in the small intestine

Larvae matured and established themselves as adults in the colon

The adult worms are fixed in caecum and

ascending colon, with the anterior portions threaded into the

mucosaFemale worms in the cecum shed between 3,000 and

20,000 eggs per day

unembryonated eggs are passed with the stool

the eggs develop into a 2-cell stage in the soil

2-cell stage eggs embryonate and become infective in 15 to 30 days

Epidemiology :- High prevalence in population which defecate directly onto the

soil and where human feces are used for fertilizer

Clinical manifestations :- Mild infection : asymptomatic- Heavy infection : abdominal pain, abdominal distention, bloody

or mucoid diarrhea, tenesmus, prolapse of the rectum, weakness- Chronic infection : anemia

Diagnosis : eggs in stool examination

Trichuris trichiura

Eggs in stool examination :- barrel-shaped/football-shaped- 50-54 x 22 µm- polar plugs in either ends- Thick dark brown shells, smooth surface

Trichuris trichiura

Treatment :- Albendazole single dose 400 mg

Trichuris trichiura

The Trematodes

• Also called “flukes”, mostly leaf shaped• The largest is Fasciolopsis buski (reaching the size of 75

x 20 mm), the smallest is Heterophyes heterophyes (< 2 x 0.5 mm)• Most are hermaphoditic• All have complex life cycles, requiring 1 or more

intermediate hosts• Two suckers or attachment organs : an anterior sucker

(oral sucker) and acetabulum (ventral sucker)

The Trematodes

Trematodes

Intestinal flukesFasciolopsis buski, Echinostoma ilocanum, Heterophyes

heterophyes, Gastrodiscoides hominis, etc

Blood flukesSchistosoma mansoni, Schistosoma japonicum, Schistosoma

haematobium, etc

Liver flukesClonorchis sinensis, Fasciola hepatica, Fasciola gigantica,

Opisthorchis viverrini, etc

Lung flukes

Paragonimus spp (Paragonimus westermani etc)

The Trematodes

• Epidemiology :- Cosmopolitan in distribution

• Morphologic features :- leaf-shaped- nearly 3 x 1.5 cm- Characteristic : cephalic cone in the anterior end

Fasciola hepatica

Fasciola hepatica

Clinical manifestations :- Signs and symptoms of biliary obstruction and

cholangitis : fever, chills, pain in the right upper quadrant of abdomen with radiation to scapula, jaundice, enlarged tender liver

Diagnosis : Eggs in stool examination

Fasciola hepatica

Eggs in stool examination :- Oval- 130-150 x 63-90

µm- yellow-brown in colour- smooth surface- a small operculum at the more pointed end

The Cestodes

• Also called tapeworms• Adult tapeworms found in human all have a flat, ribbon-like body,

white or yellowish in colour• The cestode body consists of an attachment organ named scolex,

followed by a chain of segments (proglottids) named strobila• Strobila growth throughout the life of tapeworms by continous

proliferation of new proglottids in the region immediately posterior to the scolex• The terminal portion of strobila contains gravid segments• In some cestodes, these terminal proglottids may become

detached in the intestine and pass out with stool

The Cestodes

The cestodesDiphyllobothrium latum, Taenia saginata, Taenia solium,

Echinococcus granulosus, Dipylidium caninum, etc

Epidemiology : worldwide distribution

Morphologic features :- flat, ribbon-like body

may reach several meters- Yellowish white in colour- T. saginata : scolex bears 4 muscular suckers and a small

rostellum without hooks- T. solium : scolex bears 4 muscular suckers and a double

crown with hooks

Taenia saginata (beef tapeworm) & Taenia solium (pork tapeworm)

T. saginata’s scolex T. solium’s scolex

Differentiating the scolex

Clinical manifestations :• Mostly asymptomatic• Seldomly with mild abdominal discomfort, diarrhea, constipation

Diagnosis : • Eggs and or gravid proglottids in stool examination

Eggs (undifferentiated between the T. saginata or T. solium) :- Round shaped- ±35 x 30 µm- Dark brown in color- Contains hexacanth embryo- Distinguished characteristic : a thick, radially striated covering, called the

embryophore

- Mature segments : width > length

- Gravid segments : length > width- ±18 x 6 mm- Gravid segments contain a

branched uterus filled with eggs : - T. solium : 7-13 branches on

each side- T. saginata : 15-30 branches on

each side

Differentiating the gravid proglottids

Treatment :- Praziquantel single dose 10 mg/KgBB

Taenia saginata (beef tapeworm) & Taenia solium (pork tapeworm)

• A condition where humans ingested T. solium eggs oncosphere hatch in small intestine invade intestinal wall enter systemic circulation lodge in any tissues (most commonly in voluntary muscles) cysts

• Treatment : - surgical removal- albendazole 15 mg/KgBB per hari selama 8 hari

Cysticercosis

1. a. Sebutkan spesies yang memiliki telur cacing pada gambar di atas!b. Sebutkan 3 ciri-ciri morfologi telur cacing pada pemeriksaan mikroskopik!



Pre-Test Praktikum

blok 4 - infectious agents parasitology i - helminths

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