CHAPTER 15: NEMATODES

Also called roundworms are unsegmented, bilaterally symmetrical worms

with elongated, cylindrical body.

Stages of life cycle:

EMBRYONATED EGG OR OVA

LARVA

ADULT WORMS
Body covering of Nematodes are called “cuticle.”
Long muscles underneath the layer of the cells allow the worms to move its
body from side to side.
Nematodes have separate sexes which are the female worm (larger) and the
male worm.
ADULT WORMS
Complete digestive system
- Stomodeum (mouth, esophagus, buccal cavity)
- Intestines
- Anus (called proctodeum)
Simple nervous system
Excretory system
Reproductive system
Nematodes have a sensory organ called “amphid.”
- Usually found in the anterior end of the head region of the worms.
- In aphasmids Trichuris and Trichinella, it is found in the posterior head
region.

Some nematodes like Ascaris, Necator, and the filarial worm Wuchereria are
equipped with a pair of caudal chemoreceptors called “phasmids.”

Unlike primitive worms, nematodes have excretory canals along each side of
the body for the elimination of waste materials.

Patients with nematode infection are asymptomatic and the severity of the
disease depends on the worm burden and the host’s immunity.
Important Intestinal Nematodes include Enterobius, Ascaris, Trichuris, Necator,
Ancylostoma, Strongyloides, and Capillaria.

Most prevalent in the Philippines: Ascaris, Trichuris, and Necator

The major source of infection for the intestinal nematodes except of Capillaria is
soil contaminated with human feces.

Ascaris, Enterobius, and Trichuris are transmitted by ingestion of undercooked or

raw infected fish, is endemic in certain areas in the Philippines, particularly in
Northern Luzon.
Medically important Blood-tissue Nematodes in the Philippines are the filarial
worms Wuchereria and Brugia.

Filarial worms found in specific locales in the Philippines are transmitted by the
bite from arthropod vectors (usually mosquitoes).

The muscle worm, Trichinella is an intestinal-tissue nematode acquired by

ingesting improperly cooked or raw pork meat containing the worm’s encysted
larva.
 INTESTINAL NEMATODES

INTESTINAL-TISSUE NEMATODES

BLOOD-TISSUE NEMATODES
 INTESTINAL NEMATODES
Ascaris lumbricoides (Large Intestinal Roundworm)
Properties
Largest intestinal roundworm infecting humans

Adult worm is creamy white in color and covered with cuticle

Humans acquire infection through ingestion of food or water contaminated
with human feces containing the infective embryonated ova.
 INTESTINAL NEMATODES
Ascaris lumbricoides (Large Intestinal Roundworm)
Life Cycle
Upon entry into the small intestines, larvae are released from the eggs, penetrate the
intestinal wall, enter the blood to go initially to the liver, and finally localizes to the lung.

In the lungs, the larvae gain entrance into the air sacs and migrate into the bronchioles.

The larvae are then coughed up with the sputum which is swallowed thereby returning
the worm to the intestines.

The larvae mature into adult worms in the small intestines, where they lay their eggs
that are eliminated with the feces.

The eggs are capable of surviving in soil, sewage, or water for several years.
 INTESTINAL NEMATODES
Ascaris lumbricoides (Large Intestinal Roundworm)
Life Cycle
 INTESTINAL NEMATODES
Ascaris lumbricoides (Large Intestinal Roundworm)
Epidemiology & Pathogenesis
Ascaris infection is considered as the most common helminth infection worldwide.
Parasites are common in areas with warm climates and poor sanitation.
Areas that use human feces as fertilizers or where children defecate directly on the
ground are highly susceptible to infection.
Young children are the most affected when they play in soil contaminated with human
feces.

Adult worms produce little damage in the intestines, contribute to the development of
malnutrition, and cause lung inflammation during their larval migration.
 INTESTINAL NEMATODES
Ascaris lumbricoides (Large Intestinal Roundworm)
Disease: Ascariasis
Asymptomatic infection is usually seen with low worm burden.
Symptomatic infection occurs due to migration of the parasite through the host.
During larval migration, larvae may induce allergic reactions manifesting as asthmatic
attacks accompanied by eosinophilia (called Loeffler’s syndrome).
Penetration of the lung capillaries by the larvae as they enter the air sacs can lead to
pneumonia.
Presence of multiple adult worms in the intestine can lead to abdominal pain, vomiting,
fever, and abdominal distention.
Mature worms entangled with each other form a mass that can cause intestinal
obstruction.
 INTESTINAL NEMATODES
Ascaris lumbricoides (Large Intestinal Roundworm)
Disease: Ascariasis
Adult worms can obstruct the appendix leading to appendicitis.

Liver and bile ducts can also be obstructed due to the capability of the mature worms to
travel in the different organs of the body because of its erratic nature.

The toughness and flexibility of the worm may cause perforation of the intestines that
leads to peritonitis which can be fatal.

Secondary bacterial infections may also occur in the damaged tissues.

 INTESTINAL NEMATODES
Ascaris lumbricoides (Large Intestinal Roundworm)
Disease: Ascariasis

Comparison of male and female ascaris adult worms

 INTESTINAL NEMATODES
Ascaris lumbricoides (Large Intestinal Roundworm)
Disease: Ascariasis
Children with massive ascariasis with worms coming out of the mouth and nose of
the child and out of the anus.
 INTESTINAL NEMATODES
Ascaris lumbricoides (Large Intestinal Roundworm)
Laboratory Diagnosis
Established by finding of the eggs in a stool specimen.

In cases of heavy worm burden, the adult worm may be present in the stool or be
regurgitated.

Larvae may be recovered from the sputum during pulmonary phase of the disease.

Treatment
Drugs that have been proven effective are mebendazole, albendazole, and pyrantel
pamoate.
 INTESTINAL NEMATODES
Ascaris lumbricoides (Large Intestinal Roundworm)
Prevention and Control
Proper disposal of human feces
Health education of the population
Improve personal hygiene
Avoid using human feces as fertilizer
Conduct a program of mass chemotherapy especially for children and in areas with high
incidence of parasitism
 INTESTINAL NEMATODES
Enterobius vermicularis (Pinworm, Seatworm)
Properties
Egg of E. vernmicularis is typically oval and flat on one side.
Adult worms are small and yellowish-white in color.
Common name pinworm is based on the appearance of clear, pointed tail of the adult
female that resembles a pinhead.
Humans acquire the infection through ingestion of the eggs of the worm.
 INTESTINAL NEMATODES
Enterobius vermicularis (Pinworm, Seatworm)
Life cycle
As the eggs of the worm reach the small intestines, larvae will emerge and mature into
adult worms in the large intestines.

Once the female becomes impregnated, it migrates to the perianal region where egg
laying occurs, usually at night.

The infective eggs may dislodge from the body due in part to intense scratching of the
anal area, and deposit in dust, soil, linens, and clothing.

Some infective pinworm eggs may migrate back into the host body rather than be
dislodged leading to a retroinfection.

Autoinfection occurs as a result of hand-to-mouth transmission. It is possible to ingest

the eggs through breathing them in, as the eggs are so small.
 INTESTINAL NEMATODES
Enterobius vermicularis (Pinworm, Seatworm)
Life cycle
 INTESTINAL NEMATODES
Enterobius vermicularis (Pinworm, Seatworm)
Disease: Enterobiasis
Most cases of enterobiasis are asymptomatic.
Most common manifestation is intense itching with inflammation in the anal area or
vaginal area which occurs most frequently at night.
Other symptoms: intestinal irritation, mild nausea.
Since the itchiness occurs at night, infected persons may be deprived of sleep and
become irritable.
 INTESTINAL NEMATODES
Enterobius vermicularis (Pinworm, Seatworm)
Disease: Enterobiasis
Most cases of enterobiasis are asymptomatic.
Most common manifestation is intense itching with inflammation in the anal area or
vaginal area which occurs most frequently at night.
Other symptoms: intestinal irritation, mild nausea.
Since the itchiness occurs at night, infected persons may be deprived of sleep and
become irritable.
 INTESTINAL NEMATODES
Enterobius vermicularis (Pinworm, Seatworm)
Laboratory Diagnosis
Established by demonstration of the eggs or adult females using the Scotch Tape
method or cellophane tape method.

The small size of the eggs may make recovery from stool difficult. Several samples may
be necessary to confirm the diagnosis.

Treatment
Drugs of choice for treatment are albendazole, mebendazole, or pyrantel pamoate.

It is recommended that household members also undergo treatment as pinworm

infection is considered a group infection.
 INTESTINAL NEMATODES
Enterobius vermicularis (Pinworm, Seatworm)
Prevention & Control
Good personal hygiene
Clipping of fingernails
Thorough washing of beddings
Prompt treatment of infected persons to control and prevent the spread of parasites to
other individuals
Thoroughly clean the house using a damp mop in areas including the floor under the
beds, the windowsills, and overdoors to avoid ingestion or inhalation of the eggs.
 INTESTINAL NEMATODES
Trichuris trichiura (Whipworm)
Properties
Eggs of human whipworm have barrel or football shape with a prominent hyaline plug at
each end of the egg.

Anterior end of the adult worm appears colorless while posterior end is pinkish in color.

The male worm has a recognizable curled tail. The posterior end is larger and resembles
the handle of a whip while the anterior end resembles the whip itself.

Humans acquire the infection through ingestion of food or water contaminated by

human feces containing the infective eggs.
 INTESTINAL NEMATODES
Trichuris trichiura (Whipworm)
Life cycle
Larvae emerge from the eggs in the small
intestines, become immature adults, and
migrate to the colon where complete
maturation and mating occurs.

Thousands of eggs are produced each day,

which are then passed into feces.
 INTESTINAL NEMATODES
Trichuris trichiura (Whipworm)
Epidemiology & Pathogenesis
The whipworm is the third most common roundworm affecting humans.
Infection is seen worldwide, especially in tropical countries and areas with poor
sanitation practices.
Infection is acquired primarily by ingesting foods or water contaminated by human feces
containing infective eggs.
Adult worms burrow their hair-like anterior ends into the intestinal mucosa but do not
cause significant anemia.
 INTESTINAL NEMATODES
Trichuris trichiura (Whipworm)
Disease: Trichuriasis
Severity and occurrence of manifestation of trichuriasis are related to the intensity of the
worm burden.
Heavy infection in children resemble manifestations of ulcerative colitis, a chronic
inflammatory condition of the colon that has autoimmune etiology.
Manifestations may include chronic dysentery (bloody, mucoid diarrhea), severe anemia,
or growth retardation.
Rectal prolapse and hyperperistalsis are also seen in infected children.
Rectal prolapse occurs due to irritation and straining during defecation. Manifestations in
adults resemble those of inflammatory bowel disease and include abdominal pain and
tenderness, weakness, and dysentery.
 INTESTINAL NEMATODES
Trichuris trichiura (Whipworm)
Laboratory Diagnosis
Diagnosis is confirmed by demonstrating the presence of characteristic eggs in stool
specimens.
Treatment
Drug of choice for treatment are mebendazole or albendazole.

Prevention and Control

Effective prevention and control measures include health education, proper sanitation,
good personal hygiene, and avoidance of use of human feces as fertilizer.
 INTESTINAL NEMATODES
Ancylostoma duodenale (Old World Hookworm)
Necator americanus (New World Hookworm)
Properties and Life Cycle
Two common species of hookworms: Ancylostoma duodenale and the Necator
americanus
Stages of life cycle: Egg Rhabditiform larvae Filariform larvae Adults
Eggs of two hookworms vary only in size.
Rhabditiform larva is immature, newly hatched larva. It is an actively feeding from that consists of a long
oral cavity called buccal cavity or buccal capsule, and a small genital primordium.
Filariform larva is the non-feeding, infective larva that has a distinct pointed tail.
Adult worms of two hookworms are differentiated by the appearance of their buccal capsule. N.
americanus buccal capsule is equipped with a pair of cutting plates while that of A. duodenale consists of
teeth.
 INTESTINAL NEMATODES
Ancylostoma duodenale (Old World Hookworm)
Necator americanus (New World Hookworm)
Properties and Life Cycle
Infective stage for hookworms is the larva and transmission through skin penetration by
the filariform larva. Feet and legs are the usual sites of penetration.
After penetration, the larvae are carried by the blood to the lungs, migrate to the air
sacs, pass up to the bronchi and trachea, are coughed up and then swallowed with
sputum, similar to the larval migration phase of Ascaris lumbricoides.
Once in the small intestines, the larvae mature into adult worms and attach themselves
to the intestinal wall using their cutting plates or teeth.
The adult worms feed on blood from the capillaries of the intestinal villi. Mating occurs
in the small intestines, where thousands of eggs are laid each day. The eggs are then
passed out with the feces.
 INTESTINAL NEMATODES
Ancylostoma duodenale (Old World Hookworm)
Necator americanus (New World Hookworm)
Life Cycle
 INTESTINAL NEMATODES
Ancylostoma duodenale (Old World Hookworm)
Necator americanus (New World Hookworm)
Epidemiology & Pathogenesis
Hookworms are found worldwide, especially in tropical countries.
Walking barefoot on soil puts one at risk of acquiring the infection.
Irritation of the skin at the site of penetration may be seen, as well as inflammatory
reactions in the lungs during the larval phase.
The major damage to the host is due to the chronic blood loss at the site of attachment
in the small intestines.
 INTESTINAL NEMATODES
Ancylostoma duodenale (Old World Hookworm)
Necator americanus (New World Hookworm)
Disease: Hookworm Infection
Penetration of the skin by the filiform larvae produces a pruritic papule or vesicle called
“ground itch.”
Pneumonia with eosinophilia may occur during the lung phase.
Presence of adult worms in the intestines can manifest nausea, vomiting, and diarrhea.
As the worms feed on blood, a microcytic, hypochromic anemia skin to iron-deficiency
anemia may occur. Intestinal sites may be secondarily infected by bacteria.
 INTESTINAL NEMATODES
Ancylostoma duodenale (Old World Hookworm)
Necator americanus (New World Hookworm)
Laboratory Diagnosis
Stool examination will show the characteristic thin-shelled eggs.
Occult blood in the stool and blood eosinophilia are frequent findings.
Peripheral blood smear will show microcytic, hypochromic anemia.

Larvae may be recovered from sputum.

 INTESTINAL NEMATODES
Ancylostoma duodenale (Old World Hookworm)
Necator americanus (New World Hookworm)
Treatment
Recommended drugs are mebendazole and pyrantel pamoate.
Iron replacement therapy is recommended for anemia. In severe cases, blood
transfusion may be necessary.

Prevention and Control

The preventive measures are similar to those of Ascaris lumbricoides and the other
intestinal roundworms.

Wearing shoes or any protective footwear is also important, especially in the endemic
areas.
 INTESTINAL NEMATODES
Strongyloides stercoralis (Threadworm)
Properties and Life Cycle
Eggs of Strongyloides stercoralis are similar to those of hookworms except for two
features – Strongyloides ova are smaller and contains well-developed larvae.

The rhabditiform larva of Strongyloides differ from that of hookworms in having a longer
buccal cavity and smaller genital primordium.

Like hookworms, the infective stage is the filariform larva.

Filariform larva of S. Stercoralis has longer esophagus and a notched tail.

S. Stercoralis is unique among the intestinal roundworms for having two distinct life
cycles – one within the host and a free-living cycle in soil.
 INTESTINAL NEMATODES
Strongyloides stercoralis (Threadworm)
Properties and Life Cycle
Humans acquire the infection through three possible means:
First, through direct skin penetration by the infective filariform larva. This direct mode of
transmission marks the beginning of the human cycle.
The direct or human cycle resembles that of the hookworm life cycle where a lung
phase also occurs. It differs from the hookworm cycle in that it is usually the
rhabditiform larvae that are passed out with the feces instead of the eggs.
The rhabditiform larvae transform directly to the infective filariform larvae in warm,
moist soil.
 INTESTINAL NEMATODES
Strongyloides stercoralis (Threadworm)
Properties and Life Cycle
Humans acquire the infection through three possible means:
Second, the indirect mode, rhabditiform larvae are passed out in the feces which
transform into filariform larvae in the soil. These mature into adult, free-living, non-
parasitic adult worms.

This is the free-living cycle which occurs in the soil. The adult female worm lays eggs that
develop into rhabditiform larvae, which transforms into the infective filariform larvae
that can enter a host to start a direct life cycle.
 INTESTINAL NEMATODES
Strongyloides stercoralis (Threadworm)
Properties and Life Cycle
Humans acquire the infection through three possible means:
Third, infection occurs through autoinfection. This occurs when the rhabditiform larvae
develop into filariform larvae in the intestines of the infected person. These then enter
the lymphatic system or the bloodstream of the infected host, thus starting a new cycle.
 INTESTINAL NEMATODES
Strongyloides stercoralis (Threadworm)
Properties and Life Cycle
 INTESTINAL NEMATODES
Strongyloides stercoralis (Threadworm)
Properties and Life Cycle
Comparison of rhabditiform larvae and hookworm Comparison of filariform larvae and hookworm
 INTESTINAL NEMATODES
Strongyloides stercoralis (Threadworm)
Epidemiology and Pathogenesis
Threadworm infection occurs worldwide but is more common in tropical, sub-tropical,
and warm temperate areas.
The parasite is frequently seen in agricultural areas where there is constant contact with
soil.
Irritation at the site of skin penetration also occurs (ground itch) similar to hookworm
infection.
The larvae in the lungs can produce an inflammatory reaction similar to Ascaris.
Adult worms in the small intestines can initiate an inflammatory reaction on the
intestinal wall, resulting in diarrhea. This is especially seen in autoinfection, where
significant damage can occur in the intestinal mucosa which may lead to secondary
bacterial infection and sepsis.
 INTESTINAL NEMATODES
Strongyloides stercoralis (Threadworm)
Disease: Strongyloidiasis (Cochin China Diarrhea)
Patients with light infection are usually asymptomatic. Like hookworm infection, skin
irritation at the site of entry is seen.
Migration of the larvae into the lungs lead to pneumonitis while the presence of
numerous adult worms in the intestines will lead to diarrhea and abdominal pain.
In some patients, the parasite can stimulate recurrent allergic reactions resulting to
urticaria and eosinophilia.
In patients with very high worm burden, which is seen in autoinfection, malabsorption
syndrome may occur due to involvement of the biliary ducts, pancreas, small intestines,
and colon. This can lead to steatorrhea (fat in the stool) and resulting nutrient
deficiencies, epigastric pain and tenderness, and increasing diarrhea. These symptoms
constitute a hyper-infection syndrome where in some instances, disease presentation is
mistaken for peptic ulcer disease.
 INTESTINAL NEMATODES
Strongyloides stercoralis (Threadworm)
Disease: Strongyloidiasis (Cochin China Diarrhea)
Autoinfection can also lead to development of chronic infection, increasing the risk
developing hyper-infection syndrome, which can prove fatal in patients who are
immunocompromised.

Aside from potentially fatal electrolyte abnormalities, fatal complications of the hyper-
infection syndrome include bacterial sepsis, peritonitis, and endocarditis.
 INTESTINAL NEMATODES
Strongyloides stercoralis (Threadworm)
Laboratory Diagnosis
Eggs, although not commonly present, may be recovered from stool of patients with
heavy worm burden who have severe diarrhea.

Usual diagnostic method is through the recovery of the rhabditiform larva in fresh stool
samples.

Examination of duodenal aspirates may also yield the larvae. It may also be recovered
from sputum during the lung phase of the parasite’s life cycle.

Striking eosinophilia may occur in a massive infection. Serologic test such as ELISA have
already been developed.
 INTESTINAL NEMATODES
Strongyloides stercoralis (Threadworm)
Treatment
Drug for treatment is ivermectin with mebendazole and thiabendazole as alternative
drugs.

Prevention and Control

Thorough health education of the population at risk, proper sanitation and sewage
disposal, wearing of protective footwear, and prompt treatment of infected individuals.
 INTESTINAL NEMATODES
Capillaria philippinensis (Pudoc worm)
Properties and Life Cycle
This parasite was first described in the Philippines in 1963 after the first human case
died from infection.

Unlike other intestinal roundworms, migratory fish-eating birds are the natural hosts.

Typically, the unembryonated eggs are passed out to the external environment with the
feces of the birds or infected humans, usually in fresh water.

The eggs become embryonated and are ingested by freshwater fish (usually bagsit in
the Ilocos region). The larvae encyst in the tissues of the fish.

Humans acquire the infection by eating improperly cooked or raw freshwater fish.
 INTESTINAL NEMATODES
Capillaria philippinensis (Pudoc worm)
Properties and Life Cycle
Once in the small intestines, the larvae mature into adult worms that burrow into the
wall of the intestines, where the worms lay eggs.

Some of the eggs may become embryonated in the intestines which leads to
development of autoinfection.
 INTESTINAL NEMATODES
Capillaria philippinensis (Pudoc worm)
Life Cycle
 INTESTINAL NEMATODES
Capillaria philippinensis (Pudoc worm)
Epidemiology and Pathogenesis
Endemic in the Philippines particularly in the Ilocos region but there are also cases seen
in Thailand. It can also be found in Zambales and Southern Leyte.

The large number of worms that develop within the infected host is responsible for the
pathology seen.

Adult worms can cause micro-ulcers in the intestinal mucosa that if severe, can lead to
malabsorption syndrome.
 INTESTINAL NEMATODES
Capillaria philippinensis (Pudoc worm)
Disease: Intestinal Capillariasis
Characterized by abdominal pain with a gurgling stomach (borborygmus) and chronic
diarrhea.
The chronic diarrhea leads to weight loss which is aggravated by the accompanying loss
of appetite (anorexia), nausea, and vomiting.
Malabsorption of fat, carbohydrates, and proteins as wells as electrolyte abnormalities
can be fatal.

Laboratory Diagnosis
Diagnosis is confirmed by demonstration of the characteristic eggs in stool specimens. In
high worm burden, larvae as well as adult worms may also be demonstrated in stool.
 INTESTINAL NEMATODES
Capillaria philippinensis (Pudoc worm)
Treatment
Drugs for treatment are albendazole, with mebendazole as alternative especially for
adult patients.
Chemotherapy is given for at least 20 days in order to totally eradicate the parasite.
Relapses may occur if the treatment regimen is not followed.

Patients with severe infection with electrolyte loss and malabsorption must be managed
with electrolyte replacement and a high-protein diet.
Prevention and Control
Adequate and thorough cooking of seafood before consumption, especially in endemic
areas. Other measures include proper human waste disposal, health education, and
prompt treatment of infected persons.
 BLOOD AND TISSUE NEMATODES
Wuchereria bancrofti (Bancroft’s Filarial Worm)
Brugia malayi (Malayan Filarial Worm)
Properties and Life Cycle
These are both mosquito-borne parasites and both have two important morphologic
forms – the adult worm and the larvae called microfilariae.
The adult male is usually the size of the female worm. Both are threadlike in appearance
with creamy white color.

The microfilariae have a delicate transparent covering called a sheath.

Humans acquire the infection through the bite of mosquito vector.

The infective larvae migrate to the tissues, mature, and localize in the lymphatics,
subcutaneous tissues, or internal body cavities.
 BLOOD AND TISSUE NEMATODES
Wuchereria bancrofti (Bancroft’s Filarial Worm)
Brugia malayi (Malayan Filarial Worm)
Properties and Life Cycle
Migration of the parasites exhibit periodicity, where the parasites are present in the
bloodstream during specific times of the day, which corresponds to the feeding schedule
of the mosquito vector.
Migration may occur at night (nocturnal), during the day (diurnal), or with no clear-cut
timing (sub-periodic).
 BLOOD AND TISSUE NEMATODES
Wuchereria bancrofti (Bancroft’s Filarial Worm)
Brugia malayi (Malayan Filarial Worm)
Properties and Life Cycle
 BLOOD AND TISSUE NEMATODES
Wuchereria bancrofti (Bancroft’s Filarial Worm)
Brugia malayi (Malayan Filarial Worm)
Epidemiology & Pathogenesis
Majority of filarial worm infections worldwide are caused by Wuchereria bancrofti.
Infections in Asia are frequently due to Brugia malayi.
In the Philippines, bancroftian filariasis is more common.

Mosquito vectors for W. bancrofti include Culex spp., Anopheles spp., Aedes spp., and
Mansonia spp.

The typical vectors for B. malayi are Mansonia and Aedes mosquitoes.

In rural areas, the major vector is Anopheles minimus falvirostris. In urban areas, the
parasite is transmitted chiefly by Cules spp., which can breed in latrines, sewage,
ditches.
 BLOOD AND TISSUE NEMATODES
Wuchereria bancrofti (Bancroft’s Filarial Worm)
Brugia malayi (Malayan Filarial Worm)
Epidemiology & Pathogenesis
Fourty-four (44) provinces in the Philippines have been identified by DOH as endemic
and those are mainly in the Southern portion.

Filaria-free provinces are: Southern Leyte, Sorsogon, Biliran, Bukidnon, Romblon,

Agusan del Sur, and Dinagat Islands.

The manifestations of filariasis are due to the obstruction of the lymphatic vessels by
the adult worms causing edema of the limbs. The adult worms cause inflammatory and
fibrotic reactions. Microfilariae cause less severe pathology.
 BLOOD AND TISSUE NEMATODES
Wuchereria bancrofti (Bancroft’s Filarial Worm)
Brugia malayi (Malayan Filarial Worm)
Disease: Filariasis
Symptoms may vary depending on the species.
Three stages of clinical courses:
1. Asymptomatic stage – characterized by the presence of thousands of microfilariae in
the peripheral blood. Adult worms may be found in the
lymphatic system without clinical manifestations of filariasis.
2. Acute stage of infection – is marked by fever with inflammation of the lymph nodes
(lymphadenitis), particularly those of the male genitalia (in
Bancroft’s filariasis) and of the extremities (due to Brugia).
In females, involvement of the lymphatics of the breast
may be seen.
 BLOOD AND TISSUE NEMATODES
Wuchereria bancrofti (Bancroft’s Filarial Worm)
Brugia malayi (Malayan Filarial Worm)
Disease: Filariasis
Recurrent attacks in the acute stage are characterized by epididymitis (inflammation of
the epididymis), orchitis (inflammation of the testes), retrograde lymphangitis, and
localized inflammation of the arms and legs.
The acute stage is also called adenolymphangitis. Transient swellings of subcutaneous
tissues may also occur called Calabar swellings.
 BLOOD AND TISSUE NEMATODES
Wuchereria bancrofti (Bancroft’s Filarial Worm)
Brugia malayi (Malayan Filarial Worm)
Disease: Filariasis
3. Chronic filariasis – it develops slowly after several years of infection. Manifestations
include chronic edema and repeated acute inflammatory episodes. The edema and
fibrosis gradually lead to lymphatic obstruction of the legs and genitalia (especially the
scrotum). The enlarged extremity hardens with loss of skin elasticity producing
elephantiasis. Obstruction of the lymphatics of the tunica vaginalis of the testes lead to
accumulation of edema fluid in the scrotum (called hydrocele).
Hydrocele, chronic epididymitis, and lymphedematous thickening of the scrotal skin are
commonly seen in Bancroft’s filariasis.

Deformities resulting from Malayan filariasis are not as severe and include enlargement
of the epitrochear, inguinal, and axillary lymph nodes.
 BLOOD AND TISSUE NEMATODES
Wuchereria bancrofti (Bancroft’s Filarial Worm)
Brugia malayi (Malayan Filarial Worm)
Disease: Filariasis
In more advanced cases of Malayan filariasis, elephantiasis of one or more limbs, usually
involving the area below the knee may occur however the scrotum is rarely involved.
 BLOOD AND TISSUE NEMATODES
Wuchereria bancrofti (Bancroft’s Filarial Worm)
Brugia malayi (Malayan Filarial Worm)
Laboratory Diagnosis
Examination of Giemsa-stained peripheral blood smear is the diagnostic method of
choice demonstrating the microfilariae.
In light infections, the blood specimen (approx. 1 mL) may be immersed in 10 mL of a 2%
formalin solution to lyse the red blood cells. Optimal sampling collection is at night,
especially for species that demonstrates nocturnal periodicity (usually Wuchereria).

The ideal time for specimen collection is between 9:00 pm – 4:00 am, the peak periods
for the appearance of mosquito vectors.

Antigen detection methods and serologic tests have been developed as alternative
diagnostic methods.
 BLOOD AND TISSUE NEMATODES
Wuchereria bancrofti (Bancroft’s Filarial Worm)
Brugia malayi (Malayan Filarial Worm)
Treatment
Recommended drugs for treatment are diethylcarbamazine (DEC) and invermectin in
combination with albendazole. Both DEC and invermectin are effective in killing the
microfilariae, however, higher doses are necessary to kill the adult worms.

Microsurgery may be necessary to remove the obstructing parasite from the lymphatics.

Other supportive measures include anti-inflammatory drugs to reduce the

inflammation.

The use of elastic bandages or elevation of the involved limbs may help reduce the size
of the involved limb.
 BLOOD AND TISSUE NEMATODES
Wuchereria bancrofti (Bancroft’s Filarial Worm)
Brugia malayi (Malayan Filarial Worm)
Prevention and Control
WHO Division of Control of Tropical Diseases recommend mass treatment in endemic
areas. In the Philippines, Filariasis Control Program was implemented in 2001 which
entailed mass treatment in endemic areas using a combination of DEC and albendazole
which resulted in the elimination of infection in some endemic areas.

Other measures include the use of mosquito nets and repellents, the use of insecticides
to control the mosquito vectors, wearing of protective clothing, and thorough health
education of the population.
 INTESTINAL-TISSUE NEMATODE
Trichinella spiralis (Muscle Worm, Trichina Worm)
Properties and Life Cycle
Two important morphologic forms of the parasite – larva and adult worm.
Larvae have a coiled appearance and encysts in muscle tissues surrounded by striated
muscle cells called nurse cells.
The adult worms are small and rarely recovered.
The usual and natural host is the pig but any mammal can be infected. Humans are
accidental hosts and acquire the infection by ingesting raw or improperly cooked pork
meat containing encysted larva.
Larvae are released from the cysts with exposure to gastric acid and pepsin, after which
they invade the mucosa of the small intestines where they mature into adult worms.
 INTESTINAL-TISSUE NEMATODE
Trichinella spiralis (Muscle Worm, Trichina Worm)
Properties and Life Cycle
After mating, the gravid female “gives birth” to the larvae in the intestinal submucosa.

Among the nematodes, the life cycle of the muscle worm has no egg stage. The larvae
then migrate through the bloodstream and localize to striated muscles where they
undergo encystation.
 INTESTINAL-TISSUE NEMATODE
Trichinella spiralis (Muscle Worm, Trichina Worm)
Properties and Life Cycle
 INTESTINAL-TISSUE NEMATODE
Trichinella spiralis (Muscle Worm, Trichina Worm)
Epidemiology and Pathogenesis
Infection with T. spiralis is seen worldwide especially in parts of Europe and United
States where meat can be eaten raw.
Aside from pigs, other animals that may be infected include deer, bear, walrus, and
rodents (rats).

The severity of symptoms depends on the intensity of the infection. Patients harboring
a hundred or more worms are usually symptomatic.

Encystation of the larvae may lead to inflammation, then granuloma formation which
can later become calcified.
 INTESTINAL-TISSUE NEMATODE
Trichinella spiralis (Muscle Worm, Trichina Worm)
Disease: Trichinosis, Trichinellosis
Trichinosis may be divided into three phases – enteric phase, invasion phase, and
convalescent phase.
Enteric phase – incubation and intestinal invasion stage
Invasion phase – larval migration and muscle invasion stage
Convalescent phase – encystation and encapsulation stage of the larva
Enteric or intestinal phase may manifest with diarrhea, abdominal pain, and vomiting.
Invasion phase, potentially any organ with striated muscles may be the target of the
parasite.
Symptoms may include periorbital and facial edema, conjunctivitis, fever, muscle pain
(myalgia), splinter hemorrhages, rashes, and peripheral eosinophilia.
 INTESTINAL-TISSUE NEMATODE
Trichinella spiralis (Muscle Worm, Trichina Worm)
Disease: Trichinosis, Trichinellosis
Involvement of the heart can lead to life-threatening myocarditis.

During the convalescent phase, the manifestations start to decline. The disease is self-
limiting, hence full recovery is expected. Rare cause of death are congestive heart
failure and respiratory paralysis.
Laboratory Diagnosis
Definitive diagnosis is done by demonstrating the encysted larvae in muscle biopsy
specimen. Blood examination results include eosinophilia, leukocytosis, and elevated
serum muscle enzyme levels (lactate dehydrogenase, aldolase, creatine
phosphokinase). Serologic tests are available. False negative results may be seen during
early infection, hence it is often necessary to perform multiple test.
 INTESTINAL-TISSUE NEMATODE
Trichinella spiralis (Muscle Worm, Trichina Worm)
Treatment
The disease is self-limiting therefore, it does not require any medication. Supportive
measures include bed rest as well as the giving of analgesics and anti-pyretics to relieve
muscle pain and fever. Corticosteroids may be given for severe infections.
Thiabendazole may be given during the early stages of the disease, especially during
the first week, to kill the adult worms. The drug has no effect on the migrating larvae.
Prevention and Control
Health education is important in preventing infection. Thoroughly and adequately cook
meat before consumption. Freezing meat may also kill the encysted larvae. Avoidance
of feeding pork scraps to hogs may help break the life cycle of the parasite. Other
measures include strict meat inspection and keeping pigs and other farm animals in rat-
free pens.
 Summary of Intestinal Nematodes
Parasite/Disease Site of Infection Mode of Diagnosis Treatment
Transmission
Enterobius Lumen of cecum, Ingestion of eggs; Scotch tape test; Pyrantel pamoate,
Vermicularis colon self-contamination or microscopy for eggs mebendazole
(Pinworm) autoinfection
Trichuris trichiura Cecum, colon Ingestion of eggs Stool exam for eggs Mebendazole,
(Whipworm) from fecally- albendazole
contaminated soil or
food
Ascaris lumbricoides Small intestines; Ingestion of eggs Stool exam for eggs; Albendazole,
(Common larvae through lungs from fecally sputum exam for mebendazole
roundworm) contaminated soil or larvae
food
Ancylostoma Small intestines; Larvae in soil Stool exam for eggs; Albendazole,
duodenale, Necator larvae through skin, penetrate skin sputum exam for mebendazole
americanus (Human lungs larvae
hookworms)
Strongyloides Small intestines; Larvae in soil Stool exam, sputum Ivermectin,
stercoralis larvae through skin, penetrate skin; exam or bronchial albendazole
(Threadworm) lungs autoinfection (rare) lavage for larvae
 Summary of Blood and Tissue Nematodes
Parasite/Disease Site of Infection Mode of Diagnosis Treatment
Transmission
Trichinella spiralis Adults in small Eating undercooked, Serology and muscle Albendazole +
(Muscle worm) intestines for 1-4 infected pork or other biopsy (larvae) steroids (for severe
months; larvae animal symptoms)
encysted in muscle
tissue
Wuchereria bancrofti, Adult worms in lymph Bite of mosquitoes Blood smear for Diethylcarbamazine
Brugia malayi (Filarial nodes, lymphatic transmit larvae microfilariae
worms) ducts