helminthic infections. infection vs. disease successful parasites live in, but do not kill their...
TRANSCRIPT
Helminthic infectionsHelminthic infectionsHelminthic infectionsHelminthic infections
Infection vs. diseaseInfection vs. diseaseInfection vs. diseaseInfection vs. disease
• successful parasites live in, but do not successful parasites live in, but do not kill their hostskill their hosts
• protozoa multiply within hostsprotozoa multiply within hostsexpression of disease depends on host expression of disease depends on host
factorsfactors
• helminths do not multiply within hostshelminths do not multiply within hostsseverity of disease depends on parasite severity of disease depends on parasite
burden and immunologic response to burden and immunologic response to parasitesparasites
Parasite modes of entryParasite modes of entryParasite modes of entryParasite modes of entry
•IngestionIngestion
•Arthropod bitesArthropod bites
•Penetration of intact skin Penetration of intact skin or mucous membranesor mucous membranes
Spread and tropismsSpread and tropismsSpread and tropismsSpread and tropisms
•Some parasites must migrate to Some parasites must migrate to certain locations within the host certain locations within the host in order to complete their life in order to complete their life cyclecycle
•Non-human parasites, in Non-human parasites, in humans, often fail to migrate humans, often fail to migrate properly and properly and becomebecome “dead-end “dead-end infections”infections”
Mechanisms for evading the host response
Mechanisms for evading the host response
•antigenic variation - trypanosomes
• intracellular infection - plasmodia
•encystation* - amoebae, cestodes
•camouflage - schistosomes
* “cyst” has multiple meanings
Tissue damage and host Tissue damage and host responseresponse
Tissue damage and host Tissue damage and host responseresponse
•direct destruction of tissuedirect destruction of tissue
•hypersensitivity reactionshypersensitivity reactions
• eosinophiliaeosinophilia
–occurs with helminths, not protozoaoccurs with helminths, not protozoa
–results from tissue migrationresults from tissue migration
Classification of helminthsClassification of helminthsClassification of helminthsClassification of helminths
Nematodes (roundworms)Nematodes (roundworms)
Platyhelminthes (flatworms)Platyhelminthes (flatworms)
Trematodes (“flukes”)Trematodes (“flukes”)
Cestodes (“tapeworms”)Cestodes (“tapeworms”)
Helminthic diseasesHelminthic diseases
• Intestinal
–Others
–Strongyloides
• Invasive
–Trichinosis
–Filaria
–Schistosomiasis
–Cysticercosis
–Echinococcus
(autoinfection cycle)
(muscle pain, uncooked carnivores)
(worms in lymphatics or under skin)
(liver or urinary tract granulomas and fibrosis)
(cysts in brain, seizures)
(massive cysts in liver or lung)
roundworms
flukes
tapeworms
Intestinal nematodesIntestinal nematodesIntestinal nematodesIntestinal nematodes
Larvae passthrough lungs
Larvae penetratethrough intact skin
strongyloides hookworm
Eggs ingested
trichiurisenterobius
Larvae enterbloodstream
ascaris
Adult worms in the the intestine
Eggs
Larvae hatch from eggs
Strongyloides life cycleStrongyloides life cycle
Adult worms in the the intestine
Eggs
1st stage larvae hatch from eggs
Larvae penetratethrough intact skin
Larvae enterbloodstream
Larvae passthrough lungs
Larvae molt twice to formfilariform larvae (infectious)
Autoinfection
Strongyloides - clinical featuresStrongyloides - clinical features
• uncomplicated
–GI upset
• autoinfection
• hyperinfection
–rash
–bronchspasm, CXR infiltrates
–diarrhea
–profound eosinophilia
–recurrent Gram-negative bacteremia
Trichinella spiralisTrichinella spiralis - life cycle - life cycleTrichinella spiralisTrichinella spiralis - life cycle - life cycle
• ““cycle of carnivorism” among hogs and ratscycle of carnivorism” among hogs and rats
• humans ingest encysted larvae in infected, humans ingest encysted larvae in infected, undercooked porkundercooked pork
• larvae exist in stomach and burrow into small larvae exist in stomach and burrow into small intestinal mucosaintestinal mucosa
• adult males and female reemerge and produce adult males and female reemerge and produce larvae which penetrate intestine and circulate larvae which penetrate intestine and circulate in bloodstreamin bloodstream
• larvae enter skeletal muscle cells and encystlarvae enter skeletal muscle cells and encyst
Clinical features of trichinosisClinical features of trichinosisClinical features of trichinosisClinical features of trichinosis
•Most common sxs: Most common sxs:
–muscle pain and tenderness muscle pain and tenderness
–fever +/- chillsfever +/- chills
–edema (often periorbital)edema (often periorbital)
• >10% eosinophilia (often ~50%)>10% eosinophilia (often ~50%)
• elevated CPKelevated CPK
• +/- chronic neurologic/myocardial sxs+/- chronic neurologic/myocardial sxs
• self-limited (2% mortality)self-limited (2% mortality)
Treatment of trichinosisTreatment of trichinosisTreatment of trichinosisTreatment of trichinosis
• antihelminthic (albendazole) to antihelminthic (albendazole) to kill any intestinal adultskill any intestinal adults
• steroids to relieve inflammatory steroids to relieve inflammatory reactionsreactions
• antipyreticsantipyretics
Life cycles of two types of filariaLife cycles of two types of filariaLife cycles of two types of filariaLife cycles of two types of filaria
Arthropod vector
Adultworm pairs
Larvae(microfilariae)
Lymph- mosquitoes peripheral circulate dwelling lymphatics in bloodstream(e.g, Wuchereria bancroftii )
Skin- biting flies skin nodules migrate through dwelling or migratory dermis
O. volvulus microfilaria in skin snip
O. volvulus nodule
DirofilariaDirofilaria in a human lung in a human lung
Role of endosymbiont Role of endosymbiont WohlbachiaWohlbachia sp. in filiaria infectionsp. in filiaria infection
Role of endosymbiont Role of endosymbiont WohlbachiaWohlbachia sp. in filiaria infectionsp. in filiaria infection
• Rickettsia-like organisms required Rickettsia-like organisms required for fecundity and viability of filariafor fecundity and viability of filaria
•Wohlbachia-free worms produce Wohlbachia-free worms produce less inflammation in tissue (? LPS)less inflammation in tissue (? LPS)
• Implications for rx:Implications for rx:
–ivermectin kills microfilaria onlyivermectin kills microfilaria only
–tetracycline may destroy adult wormstetracycline may destroy adult worms
Geographic distribution of Geographic distribution of schistosomiasisschistosomiasis
Geographic distribution of Geographic distribution of schistosomiasisschistosomiasis
S. mansoniS. mansoni
S. hematobiumS. hematobium
S. japonicumS. japonicum
Schistosomiasis - life cycleSchistosomiasis - life cycleSchistosomiasis - life cycleSchistosomiasis - life cycle
S.m. S.h. S.j.
“pipestem” fibrosis
Schistosomiasis - pathogenesisSchistosomiasis - pathogenesisSchistosomiasis - pathogenesisSchistosomiasis - pathogenesis
• egg granuloma (type IV reaction)--> egg granuloma (type IV reaction)--> fibrosisfibrosis
•morbidity ~ worm (egg) burdenmorbidity ~ worm (egg) burden
• concomitant immunity to schistosomulaconcomitant immunity to schistosomula
• adult worms: invisible to the immune adult worms: invisible to the immune system (survive for years)system (survive for years)
Schistosomiasis- clinical featuresSchistosomiasis- clinical featuresSchistosomiasis- clinical featuresSchistosomiasis- clinical features
• Cercarial dermatitisCercarial dermatitis
• Intestinal schistosomiasis Intestinal schistosomiasis (granulomas --> (granulomas --> polyps, protein loss, malabsorption, strictures)polyps, protein loss, malabsorption, strictures)
•Hepatosplenic schistosomiasis Hepatosplenic schistosomiasis (portal (portal hypertension --> ascites, varices, splenomegaly, hypertension --> ascites, varices, splenomegaly, normal hepatic function)normal hepatic function)
• Urinary schistosomiasis Urinary schistosomiasis (hematuria, chronic (hematuria, chronic infection, obstruction)infection, obstruction)
• Other (cardiopulmonary, CNS, etc.)Other (cardiopulmonary, CNS, etc.)
Drug treatment of Drug treatment of schistosomiasisschistosomiasis
Drug treatment of Drug treatment of schistosomiasisschistosomiasis
• Praziquantel increases permeability Praziquantel increases permeability of adult parasite to Caof adult parasite to Ca++++..
• Tetanospasm --> deathTetanospasm --> death
Control of SchistosomiasisControl of Schistosomiasis
REDUCE CARRIERS mass rx program
ELIMINATE SNAILS molluscicides
destroy snail habitats
snail-eating fish
PREVENT WATER
CONTAMINATION latrines, toilets
public health education
PREVENT HUMAN
EXPOSURE water systems
TapewormsTapeworms
•Definitive hosts: harbor adult worms
• Intermediate hosts: harbor tissue cysts (containing worm heads)
•Humans acquire infection two ways:
–ingestion of eggs from feces (to acquire tissue cysts)
–ingestion of tissue cysts in undercooked meat (to acquire a tapeworm)
= Intermediate host
= Definitive host
TaeniasisTaeniasis
Tapeworm Cysticercosis
poorhygiene
poorsanitation
ingestion ofundercooked pork
CysticerciCysticerci Hydatid CystHydatid Cyst
Isolated cysticerci Hydatid cyst
EchinococcosisEchinococcosis
Cystic Hydatid Disease
contact with dogs
ingestion of entrails
ingestion ofeggs inpastures
Treatment of cysticercosis and Treatment of cysticercosis and echinococcosisechinococcosis
Treatment of cysticercosis and Treatment of cysticercosis and echinococcosisechinococcosis
• Antihelminthic therapy (e.g., Antihelminthic therapy (e.g., albendazole, praziquantel)albendazole, praziquantel)
• (Echinococcus only)(Echinococcus only)
–Surgical removalSurgical removal
–Irrigation-evacuation of cystsIrrigation-evacuation of cysts
Comparison of pork tapeworm and Echinococcus life cycles
Comparison of pork tapeworm and Echinococcus life cycles
Definitive hosts (adult tapeworms)
Intermediate hosts(tissue cysts)
Dead-end hosts
Dog
Sheep
Human
Pig
Human
Human