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Nematodes

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BLOOD AND TISSUE NEMATODES
LYMPHATIC FILARIA PARASITES - Wuchereria bancrofti - Brugia malayi

* One of the most debilitating diseases today * 120 million worldwide are affected
> 25million men suffer from genital disease
>15million suffer from lymphedema or elephantiasis * Disease of poverty * Adult – frequently infected * Habitat: Banana trees and Abaca plantation * Bicol region: hydroceles are more frequent * Mosquito-borne causative agents:
- Wuchereria bancrofti or Bancroft’s filarial worm
- Brugia malayi or the Malayan filarial worm

* WUCHERERIA BANCROFTI * more widespread * adult worms: creamy, white, long, and filiform in shape * male worm: 2-4 cm.; female worm: 8-10 cm. * Disease: Bancroftian filariasis * causes chronic disfiguring disease which may present as lymphedema, elephantiasis, or hydrocele * microfilaria in fresh specimens appear as snake-like organisms moving among the RBC * when stained, central axis shows dark staining nuclei (serve as an important identifying feature) * column of nuclei is arranged in 2 or 3 rows * tapered tail but no tail nuclei * adult male and female are found tightly coiled in nodular dilatations in lymph vessels and sinuses of lymph glands * Biologic vectors: Aedes, Culex, Anopheles * Microfilaria ingested by the mosquito migrate to its muscles & develop into 3 larva stages: * First (L1) * Second (L2) * Third (L3)- after 6-20 days, force their way out of the muscles and migrate towards the mosquito’s head and proboscis * Causes brochial-asthmatic condition known as “ tropical pulmonary eosinophilia”

* BRUGIA MALAYI * More tightly coiled * Nuclear column is more tightly packed * Tapered tail with a subterminal or terminal nuclei * Distinguishable characteristic: presence of the nuclei in the terminal end * Disease: Malayan Filariasis * Male worm: 13-23mm.; female: 43-55mm. * Adult females of B. malayi and W. bancrofti are indistinguishable. * Mosquito vector: belongs to genus Mansonia * Development of the microfilaria to the infective stage in the mosquito takes about 2 weeks * 3-9 months – maturation time for the third stage larva to become adults * Hydrocele and chyluria are rare

Pathogenesis and Clinical manifestations * Incubation period: 3 – 12 months without symptoms * Infection usually acquired in childhood * Signs and symptoms different from one another * 3 stages: * Asymptomatic stage * Presence of thousands to millions of microfilaria in the peripheral blood * Adult worms in the lymphatic system no clinical manifestations of filariasis * Usually seen in immunosuppressed individuals * Individuals who appear healthy may have hidden lymphatic pathology & kidney damage * “endemic normals” – those who harbor in their blood the parasite antigen instead of the microfilaria * Acute Syptomatic Stage * Early manifestations:
- lymphadenitis (particularly male genital organs, arms, legs) * Reccurent attacks:
- funiculitis
- swelling, & redness of the arms & legs * Affected area – tender * Adenolymphngitis (ADL) – collective term for the immunologic phenomenon caused by the sensitization to the products of living or dead worms * Dermatolymphangioadenitis – signs ang symptoms start eripherally and drain towards the lymph nodes * “Expatriate syndrome” – characterized by clinical and immunologic hyperresponsiveness to the mature or maturing worms

* Chronic stage * Cellular reaction and edema are replaced by fibrous hyperplasia * Continual reinfection, the cycle repeats * Progression in the pathology of elephantiasis is greatly due to bacterial or fungal superinfection in the affected area

* Hydrocele or chylocoele – results in the obstruction of the lymphatics of the tunica vaginalis * Usually clear or straw-colored hydrocele fluid * Chylocoele – rare; fluid has a milky appearance caused by the presence of lymph * Common chronic disease of bancroftian filariasis * Defromities resulting from Malayan filariasis are not as severe as in Bancroftian filariasis * Tropical pulmonary eosinophilia (TPE) – classic example of occult filariasis * Elephantiasis – last consequence of the swelling of limbs and scrotum

Diagnosis * Microscopic finding * Wet smears or thick blood smears taken between 8pm and 4am * Best time to collect is at night * Not demonstrable in peripheral blood smear in chronic infections brought about by the ff factors: a. Low intensity of infection b. Dead worms c. Obstructed lymphatics * Knott’s method for concentration may be used * Diethylcarbamazine provocative test – stimulates microfilaria to come out to the peripheral circulation allowing blood smear collection even during daytime * Antigen detection techniques – alternative to night-time blood sampling
Collection time: W. Bancrofti – 12 mn ; nocturnal B. malayi – 12 mn ; nocturnal Loa Loa – 1 pm ; diurnal Mansonella Persians – anytime ; nonperiodic

4 characteristics used in diagnosing microfilaria: 1. Presence or absence of a sheath 2. Presence or absence of nuclei in the tip of the tail 3. Inner body – can or cannot be demonstrated 4. Size of the microfilaria

Treatment * Diethylcarbamazine citrate (DEC) – drug of choice for bancroftian filariasis
- causes a rapid disappearance of the microfilariae in the circulation * For acute attacks, initial step is to relieve the pain (cooling the affected area, rest & elevate the leg, analgesics) * Psychological counseling – essential to support those patients affected

Comparison of W. bancrofti & B. malayi

| W. bancrofti | B. malayi | Mean length(um) | 290 | 222 | Cephalic space: breadth | 1:1 | 2:1 | Shieth in Giemsa | unstained | Pink | Nuclei | Regularly spaced, separately situated | Irregularly spaced & overlapping | Tail | Single row of nuclei that does not reach the tail’s end | Single row of nuclei that reaches the tail’s end | Terminal nuclei | none | 2 nuclei, which bulge the cuticle, conspicuously placed | Appearance in blood film | Smoothly curved | kinky |

* ANGIOSTRONGYLUS CANTONENSIS * Also called the rat lung worm * Normally lives in the lungs of rats, can cause eosinophilic meningoencephalitis in man * Disease: angiostrongylosis or angiostrongyliasis * Adult worm: pale and filiform * Male worms
- 16-19mm
- have a well-developed caudal bursa, which is kidney0shaped and single-lobed * Female worms
- 21-25mm
- has uterine tubules which are wound spirally around the intestine (“barber’s pole” pattern) * Elongated ovoidal eggs have delicate hyaline shells, unembryonated when oviposited * First stage larva – found in the lungs of the rodent host
- has a distinct small knob near the tip of the tail * Infective third stage of larva – has two well-developed chitinous rods below its buccal cavity found in mollusks.
- these rods have expanded knob-like tips
- remains viable for a long time * Intermediate hosts in the Philippines
> slugs and snails: * Achatina fulica or Giant African snail * Hemiplecta sagittifera * Helicostyla macrostoma * Vaginilus plebeius * Veronicella altae * mode of infection: ingestion or active penetration * Early development occurs in the brain * After the final molts in the rats, young adults migrate to the pulmonary arteries to complete their development * In humans, larva probably remains in the brain for a longer period of time & does not develop to the adult stage * Also migrate to the eye

Pathogenesis and manifestations * Incubation period : 6-15 days (may vary 12-47 days) * Chief complaint: acute severe intermittent occipital or bitemporal headache * Other symptoms:
> stiff neck
> abdominal pain
> paresthesia
> peripheral eosinophilia
> weakness of hands or legs
> facial paralysis
> ocular involvement * Postmortem examination show:
> leptomeningitis
> encephalomalacia
> moderate ventricular dilation * Prognosis is usually good * Infection is self-limiting * Cranial nerve involvement is last to recover * Symptoms gradually disappear with recovery

Diagnosis * Presumptive diagnosis is made by travel and exposure history * CT scans

Treatment * No antihelminthic treatment at present * Mebendazole, thiabendazole, albendazole found to be successful * Prednisone – in severe cases with cranial nerve involvement

Epidemiology * Transmission attributed by: a. Ingestion of the raw mollusk intermediate host infected with the third stage larva b. Ingestion of leafy vegetables contaminated with mucus secretion of the mollusk carrying the infective stage of the parasite (third larval stage) c. Ingestion of a paratenic host (eg. freshwater prawn, crab) harboring the infective stage of the parasite d. Drinking contaminated water

Prevention and control * Proper eating habits * Safe food preparation * Elimination of the intermediate hosts * Eradication of the rodent hosts

* TRICHINELLA SPIRALIS * First found in the muscles of the autopsied peacock * Raw or insufficiently cooked meat (i.e pork) was responsible for trichinosis in humans * 3 subspecies which can infect humans:
> Trichinella spiralis spiralis – found in temperate regions
> Trichinella spiralis native – found in arctic regions
> Trichinella spiralis nelson – found in Africa * Adult worm:
> whitish in color
>1.5-3.5 mm * Male:
> has a single testis located near the posterior end of the body * Female:
> has a single ovary, situated in the posterior part of the body * Hosts: humans, rats, dogs, cats, pigs, bears, foxes, walruses, any other carnivore or omnivore
- both the final and intermediate host by harboring the adult and the larval stages * Infective larvae – encysted in the muscle fibers of the host * Encapsulation is consummated 4 – 5 weeks after infection

Pathogenesis and manifestations * Severity of symptoms depends on the intensity of infection * Patients harboring up to 10 larvae are usually asymptomatic (light infection)
> 50 – 500 worms shows symptoms (moderate infection)
> more than 1000 severe & potentially fatal * 3 phases of clinical conditions: a. Enteric phase (incubation & intestinal invasion) – resemble those of an attack of acute food poisoning, diarrhea or constipation, vomiting, abdominal cramps, malaise & nausea b. Invasion phase (larval migration & muscle invasion) – cardinal s/sx are sever myalgia, periorbital edema & eosinophilia c. Convalescent phase (encystment & encapsulation) – fever, weakness, pain, and other symptoms start to abate * Full recovery is expected since trichinosis is self-limiting * Prognosis is good especially in mild infections

Diagnosis * Based on history of exposure & physical examination * Demonstration of the larva using muscle biopsy – most definitive diagnostic exam

Treatment * Managed through bed rest & supportive treatment * Analgesics and antipyretics used to control symptoms

Epidemiology * Occurs wherever meat is a part of the diet * Trichinosis is primarily a zoonosis * Human infection - said to be a dead end infection for the parasite * Infection is usually maintained in a pig-to-pig or pig-to-rat-to-pig cycle.

Prevention and control * Health education – important component of prevention & control measures

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