1

Helminths
- Helminths include flukes, tapeworms, and roundworms.
- Humans infected by directly ingesting eggs (ova), by
ingesting larvae in an intermediate host, or through direct
larval penetration of the skin.
- Adult forms do not multiply in the human body; therefore,
the number of adult worms present is related to the number
of eggs or larvae ingested.
- The pathologic consequences and severity of infection are
related to the number of adults present (worm burden).
Patients with only a few adult worms are usually
asymptomatic, whereas a patient with a large number of
adults shows clinical symptoms.
- Most of the parasites inhabit the intestinal tract, but
species also infect the liver, lungs, lymphatics, and blood
vessels.
Flukes
- Flukes (trematodes) are members of the phylum
Platyhelminthes (flatworms).
- Most infections are seen in people from East Asia, Africa,
South America, and some areas of the Caribbean.
- Adults can range in size from several millimeters to almost 8
cm.
- With the exception of the blood flukes, adult flukes are
dorsoventrally flattened and have an oral sucker at the
anterior end and a ventral sucker located midline, posterior
to the anterior sucker.
- Also, except for the blood flukes, flukes are
hermaphroditic, possessing male and female reproductive
organs.
- Figure 28-41 shows a generalized life cycle of the liver, lung,
and intestinal flukes.
- In all species, eggs must reach water to mature, and all have
a snail species as the first intermediate host.
 2

- The miracidium (first-stage larva) is ingested by a snail

while within the egg or is released from eggs and penetrates
the snail.
- Within the snail, a complex development of germinal tissue
occurs, resulting first in sporocysts, which contain
undifferentiated germinal structures, and then in rediae,
which contain partially differentiated germinal material.
- The cercaria (second-stage larva) develops within the redia
and is released into the water.
- The cercaria then attaches to aquatic vegetation or invades
the flesh of aquatic organisms. At this stage, the organism
is referred to as a metacercaria and is infective for
humans. With the exception of the schistosomes, which
infect humans by direct cercarial penetration, infection
occurs when an individual ingests the metacercaria in raw or
undercooked aquatic animals or on water vegetation.
- Prevention includes adequate cooking of water vegetation,
fish, and crustaceans. In the case of the blood flukes,
individuals should wear clothing and shoes to prevent
cercarial penetration.
- The egg is the primary diagnostic stage. It is best detected
on a wet mount of a concentrated specimen. Routine
concentration procedures for feces, such as FES, may be
used. The zinc sulfate method is not satisfactory, however,
because all eggs except those of schistosomes are
operculated. With the zinc sulfate method, the operculum
might open and release the contents or cause the egg to
sink.
- Table 28-7 compares the characteristics of the fluke eggs.
………………………………………………………………………………………….
Intestinal Flukes.
Fasciolopsis buski,
- known as the giant intestinal fluke, is found in the Far East,
including China, Vietnam, and India.
 3

- Dogs and pigs serve as reservoir hosts. Humans acquire the

infection by ingesting metacercaria on freshwater
vegetation such as bamboo shoots and water chestnuts.
- Adults of F. buski live in the duodenum, where they cause
mechanical and toxic damage. Inflammation and ulceration of
the mucosa may be present. Heavy infections result in
persistent diarrhea, anorexia, edema, ascites, nausea and
vomiting, and/or intestinal obstruction.
- Finding the adult or egg is diagnostic, although the egg is
more commonly seen. The adult is flattened, is 2 to 7 cm
long, and lacks the cephalic cone seen in Fasciola hepatica.
- Adults are usually not seen in a stool sample unless it is a
purged specimen.
- Eggs are yellow-brown, average 130 to 140 μm by 80 to 85
μm, and have a small, relatively inconspicuous operculum.
They are unembryonated when passed (Figure 28-42). Are
identical to those of F. hepatica and, when seen, should be
reported as Fasciolopsis buski–Fasciola hepatica eggs.
Metagonimus yokogawai and Heterophyes heterophyes
- Are two small flukes found in the Far East and Middle East.
- Humans acquire infection with these organisms by ingesting
the metacercaria in undercooked or raw fish.
- Adults live in the small intestine and produce few symptoms.
A patient with a heavy worm burden may have diarrhea,
colic, and loose stools, with a large amount of mucus.
- Adults of both species are small (1 to 2 mm) and delicate.
- Eggs serve as the primary diagnostic stage. They are 28 to
30 μm long and have a vase or flask shape. They are
embryonated and operculated, with inconspicuous ‫غير واضح‬
shoulders at the operculum.
- Eggs of these species resemble each other and those of
Clonorchis sinensis.
Liver Flukes.
Fasciola hepatica,
 4

- The sheep liver fluke, is seen in the major sheep-raising

areas of the world. In addition, the organism is found in
some cattle-raising areas.
- In sheep, the organism causes a disease known as liver rot
‫تعفن‬, which is characterized by liver destruction.
- Humans acquire the infection by ingesting metacercaria on
raw water vegetation, especially watercress.
- The larvae reach the liver by migrating through the
intestinal wall and peritoneal cavity.
- Adults live in the biliary passages and gallbladder and rarely
cause overt symptoms because infections are light.
- Tissue damage during migration through the liver can result
in eosinophilia, an inflammatory reaction, secondary
bacterial infection, and fibrosis in the biliary ducts.
- Heavy infections induce diarrhea, upper right quadrant
abdominal pain, hepatomegaly, cirrhosis, and liver
obstruction, with resulting jaundice.
- Chronic infections are usually asymptomatic. Adults are
approximately 3 cm long and have a prominent cephalic cone.
- The unembryonated, operculated eggs are carried in the bile
to the intestinal tract and are passed in the feces. The size
range is 130 to 150 μm × 60 to 90 μm. They are almost
indistinguishable from eggs of F. buski (see Figure 28-42).
The Chinese liver fluke, Clonorchis (Opisthorchis)
sinensis,
- Is limited to the Far East, where dogs and cats serve as
reservoir hosts.
- The adults live in the distal bile ducts. As with F. hepatica,
light infections produce few or no symptoms.
- Repeated or heavy infections cause inflammation because of
mechanical irritation, fever, diarrhea, pain, fibrotic changes,
or obstruction of the bile duct.
- Humans acquire the infection by ingesting the metacercaria
in raw, undercooked, or pickled ‫ المخلل‬fish.
 5

- The diagnosis is made by finding the egg in feces or,

occasionally, in duodenal aspirates.
- Adults are thin, tapered at both ends, and 1 to 2.5 cm long.
- The egg is 29 to 35 μm long, embryonated when passed,
flask-shaped, and operculated, with prominent shoulders at
the operculum and a knob at the opposite end (Figure 28-
43).
- Lung Flukes.
- Organisms of the genus Paragonimus usually infect tigers,
leopards, dogs, and foxes. Paragonimus westermani, the lung
fluke, is found primarily in Southeast Asia and in focal areas
of Latin America and Africa.
- Humans acquire the infection by ingesting metacercariae in
raw, pickled, wine soaked, or undercooked freshwater crabs
‫ سلطعون‬or crayfish.
- The metacercaria excysts in the small intestine and burrows
through the duodenal wall into the peritoneal cavity. It
eventually‫ في أخر األمر‬penetrates the diaphragm and enters
the lung.
- The host shows few symptoms during migration but may
exhibit intermittent coughing and chest pain. The parasite
induces an inflammatory response in the lung characterized
by the presence of neutrophils and eosinophils.
- Major‫ معظم‬symptoms associated with lung habitation are
nonspecific and often include persistent cough, chest pain,
and hemoptysis.
- Adults, which are reddish brown and approximately 1 cm
long, live within capsules in the bronchioles.
- Sputum is the primary diagnostic specimen.
- Eggs are expelled‫ تقذف‬from the capsule into the bronchioles
and carried upward in the sputum. Eggs may be found in the
feces if they have been coughed up and subsequently
swallowed. Eggs are oval, 80 to 115 μm × 48 to 60 μm, with a
flattened operculum and slight‫ نحيل‬shoulders. They are
 6

unembryonated when passed. The shell thickens at the end

opposite the operculum (Figure 28-44).
- These eggs similar to those of Diphyllobothrium latum and
must be carefully examined when seen in the feces.
- A wet mount of sputum demonstrates the egg in some
patients.
Blood Flukes.
- The blood flukes, Schistosoma spp., differ
from other flukes in the following manner:
• There is both a male and female form; the female lives in an
involuted chamber, the gynecophoral canal, which extends the
length of the male.
• The eggs are unoperculated.
• Humans are infected by direct cercarial penetration of the
skin.
• They have a cylindric shape rather than being dorsoventrally
flattened.
- The three primary pathogenic species to humans are
Schistosoma mansoni, Schistosoma haematobium, and
Schistosoma japonicum.
- Adults measure 7 to 20 mm for males and 7 to 26 mm for
females.
- S. mansoni, which is most commonly found in Africa, parts of
South America, and West Indies, lives in venules of the
mesentery and large intestines????.
- S. japonicum, which is commonly found in the Far East,
including Japan, China, and the Philippines, lives in venules of
the small intestine. This species, unlike the other two, has
many mammalian reservoir hosts.
- S. haematobium, which is primarily found in the Nile Valley
‫ وادى‬, the Middle East, and East Africa, lives in the veins
surrounding the bladder.
- Two additional species pathogenic for humans are S.
intercalatum and S. mekongi.
Clinical Infections.
 7

- Schistosomiasis (bilharziasis) affects approximately 200

million people worldwide.
- The term schistosomiasis is used to describe conditions
caused by any of the schistosomes.
- Symptoms are related to the phases of the fluke’s life
cycle.
- Cercarial penetration may cause a self-limiting local
dermatitis, including irritation, redness, and rash, that
persists for approximately 3 days.
- Larval migration through the body causes generalized
symptoms such as urticaria, fever, and malaise, which can
last up to 4 weeks.
- The presence of the migrating larvae and adults causes little
inflammatory damage because they acquire host human
leukocyte antigens and ABO blood group antigens on their
surface that diminish‫ يقلل‬the host’s immune response.
- Egg production and egg migration through the tissues are
responsible for most of the acute damage because the eggs
are highly immunogenic. After release by the adult female,
the eggs secrete enzymes and begin to penetrate vessel
walls and tissue. Eggs subsequently pass into the lumen of
the intestines or bladder. The egg spines cause trauma to
the tissues and walls of the vessels during the early stage
of acute infections and can result in hematuria (S.
haematobium) or diarrhea (S. mansoni and S. japonicum).
- In some individuals, especially those heavily infected with S.
japonicum, an acute serum sickness–like illness (Katayama
fever) occurs during the initial egg laying period. This is
induced by antigenic response to the egg and is
characterized by increased circulating immune complexes
and eosinophils.
- In chronic infections, the eggs remaining in the tissue
induce an immune response, resulting in granuloma
formation, which leads to thickening and fibrotic changes.
 8

Scarring of the veins, development of ascites, pain, anemia,

hypertension, hepatomegaly, and splenomegaly are also seen.
- In urinary schistosomiasis, microscopic bleeding into the
urine is present during the acute phase. In chronic stages,
dysuria, urine retention, and urinary tract infections occur.
- Penetration of humans by cercariae of the flukes of birds
and other mammals cause schistosomal dermatitis, commonly
referred to as swimmer’s itch. Foreign proteins from these
cercariae elicit a tissue reaction characterized by small
papules 3 to 5 mm in diameter, edema, erythema, and
intense itching. Symptoms last about 1 week and disappear
as cercariae die and degenerate.
Life Cycle.
- The life cycles of all three schistosomes are identical
(Figure 28-45). The eggs are embryonated when passed, and
the miracidium is released when the egg reaches water.
- After the miracidium penetrates a snail (the first
intermediate host), sporocysts and then cercariae are
produced during a 6-week period.
- Cercariae migrate from the snail into water. Cercariae
attach by oral and ventral suckers and, with the help of
enzymes, penetrate intact human skin.
- Inter the venous, and shed their forked tails and are
referred to as schistosomula. They circulate until they
reach the lungs or enter the liver, where they mature into
adult female and male. Then they use the portal system to
reach veins of the intestine or bladder.
- Adults lining in the veins can be killed with praziquantel but
the drug does not affect the eggs in the tissue.
Laboratory Diagnosis.
- Diagnosis is made by finding embryonated eggs in the feces
(S. mansoni and S. japonicum) or in the urine (S.
haematobium).
 9

- The egg of S. mansoni (Figure 28-46, A) is yellowish,

elongated, and 115 to 175 μm × 45 to 75 μm and has a
prominent lateral spine.
- S. haematobium eggs (see Figure 28-46, B) are elongated
and 110 to 170 μm × 40 to 70 μm and have a terminal spine.
- S. japonicum eggs (see Figure 28-46, C), which resemble S.
mekongi eggs, are round, 60 to 95 μm × × 40 to 60 μm, and
have a small, curved, rudimentary spine that might be
obscured‫يخفي‬.
- The best time to collect eggs in urinary schistosomiasis is
during peak excretion time in the early afternoon (noon to 2
PM).
- Biopsies may also be used in the diagnosis of
schistosomiasis.
- Serodiagnosis can be useful to diagnose infection in patients
from nonendemic countries who develop symptoms after
visiting endemic areas.
………………………………………………Cestodes……………………………..
Tapeworms
 Tapeworms (cestodes). phylum Platyhelminthes.
 They show extensive size variation, from 3 mm to 10 m.
 Generally require intermediate hosts in their life cycle, and
are hermaphroditic.
 They are ribbon %‫شريط‬-like organisms whose method of growth
involves the addition of segments, termed proglottids. Each
proglottid, when mature, produces eggs infective for the
intermediate host.
 Figure 28-47 shows a general diagram of the tapeworm.
 The anterior head like segment of a tapeworm, or scolex,
has suckers and, in some species, hooklets as a means of
attachment to the intestinal mucosa.
 The neck is directly behind the scolex.
 Treatment is targeted at detaching the scolex from the
mucosa, because the neck area is where proglottid
production occurs.
 10

 Gravid proglottids at the distal end of the organism

discharge eggs into the feces.
 Eggs of most of the tapeworms contain a hexacanth embryo
or oncosphere (tapeworm embryo with three pairs of hooks
that is infective for the intermediate host).
 Transmission to humans involves ingestion of a larval stage,
called the cysticercus (larva consisting of a fluid-filled sac
containing an invaginated scolex), cysticercoid, or
plerocercoid larva (depending on the genus) in raw or
undercooked meat or fish or of insects harboring the larval
stage. This larval stage contains an invaginated scolex of
the tapeworm inside a protective membrane.
 The diagnosis of tapeworm infection is usually made by
finding the eggs in feces, although proglottids can be used
if passed intact.
 Table 28-8 compares the characteristics of tapeworm eggs.
Diphyllobothrium latum.
 Diphyllobothrium latum, the fish tapeworm, is found
worldwide in areas in which the population eats pickled‫المخلل‬
or raw freshwater fish. Fish-eating mammals in endemic
areas may also be infected.
 Humans usually harbor only a single worm, which attaches in
the jejunum and can reach a length of up to 10 m.
 Most infected individuals demonstrate no clinical symptoms;
others have vague ‫ غير واضح‬GI symptoms, including nausea
and vomiting and intestinal irritation. The organism may
cause a vitamin B12 deficiency, especially in persons of
northern European descent, and long-term infection may
lead to a megaloblastic anemia.
 The life cycle of D. latum is somewhat of a hybrid between
that of the flukes and that of the tapeworms (Figure 28-
48).
 The operculated, unembryonated egg, passed in human
feces, must reach water to mature.
 11

 The first larval stage (coracidium) is ingested by a copepod

and develops into a procercoid larva within the copepod.
‫ األرجل‬%‫المجذافي‬
 When the infected copepod is ingested by a fish, the larva
leaves the fish’s intestine and invades the flesh, where it
develops into a plerocercoid larva, which consists of a scolex
with a thin, ribbon-like portion of tissue.
 Humans ingest the plerocercoid larvae by eating raw or
undercooked fish. The scolex is released in the intestine,
where it develops into an adult worm.
 The scolex, proglottid, and egg are diagnostic structures
that can be found in a fecal specimen.
 The scolex, which is 2 to 3 mm long, is elongated and has
two sucking grooves, one located on the dorsal surface and
the other on the ventral surface.
 The proglottid is wider than it is long, with a characteristic
rosette-shaped or coiled ‫ ملفوف‬uterus.
 The egg - usually detected. Are unembryonated when
passed, operculated, and yellow-brown. It is about 58 to 76
μm × 40 to 50 μm and has a small, knoblike bulge at the end
opposite the operculum. The knob may not be seen on all
eggs, so size and lack of shoulders must be used to
distinguish the egg from that of Paragonimus westermani.
Taenia. Two Taenia spp. infect humans—
 Taenia saginata - The beef tapeworm, which is found
primarily in beef-eating countries of the world, and Taenia
solium, the pork tapeworm, which is found in areas of the
world with a high consumption of pork, such as Latin
America.
 Both organisms attach to the intestinal mucosa of the small
intestine.
 Adults of T. saginata can reach a length of 10 m, whereas
those of T. solium may reach only 7 m.
 Infection with the adult tapeworm of either species usually
causes few clinical symptoms, although vague ‫غير واضح‬
 12

abdominal pain, indigestion, and loss of appetite may be

present.
 The major complication of infection with T. solium is
cysticercosis, in which the infected individual becomes the
intermediate host and harbors the larvae in tissues.
 The life cycles of the two Taenia spp. are identical except
for the fact that humans may also serve as intermediate
hosts for T. solium.
 Embryonated eggs are passed in human feces and ingested
by the intermediate host. Then, the oncosphere is freed in
the intestinal tract, migrates through the intestinal wall,
and gains access via the circulatory system to the muscles
of the host, where it transforms into a cysticercus.
 When humans ingest raw or undercooked meat, the scolex in
the cysticercus is freed, attaches in the human small
intestine, and matures into the adult tapeworm within 10
weeks.
 The proglottids are motile and, if broken off in the
intestinal tract, may actively migrate out the anus.
 Laboratory diagnosis of Taenia infection can be made by
finding the egg, scolex, or proglottid in the feces.
 The egg, is the most common stage found, is yellow-brown,
round, and surrounded by a thick wall with radial striations;
it measures 30 to 43 μm in diameter. The egg is
embryonated, with a six-hooked oncosphere when passed in
the feces. Eggs of these species are indistinguishable and
must be reported as “Taenia sp. eggs.”
 Gravid proglottids may be seen in the stool specimen and can
be used to differentiate the two species. Proglottids of T.
solium have 7 to 13 primary uterine branches on each side of
the uterine, whereas proglottids of T. saginata show 15 to
20 per side.
 The scolex, if found, can also be used to distinguish the
organisms. The scolex of T. saginata is less than 5 mm long
and has four suckers, whereas that of T. solium has a
 13

rostellum, with a double row of 25 to 30 hooklets in addition

to the four suckers.
Hymenolepis nana and Hymenolepis diminuta.
 The dwarf tapeworm, Hymenolepis nana, is found worldwide
and is a common tapeworm in children, whereas Hymenolepis
diminuta, the rat tapeworm, is seen less frequently.
 Light infections are usually asymptomatic; large numbers of
worms may cause abdominal pain and diarrhea.
 Infections with H. nana are easily transmitted among
children, because an intermediate host is not required.
 Direct fecal-oral transmission of the egg, development of
the cysticercoid in the intestinal tissue of the host, and
reentry into the lumen for development into an adult
characterize the life cycle (Figure 52). This autoinfective
life cycle is most common, although an insect vector may
serve as intermediate host in an alternate form of the life
cycle.
 The adult H. nana is approximately 40 mm long and has a
small scolex, with four suckers and a rostellum with spines.
 The primary method of diagnosis is finding the egg in a stool
specimen. The egg is spherical to oval, measures 30 to 47
μm, and has a grayish color. The hexacanth embryo is
contained within an inner membrane, and the area between
the inner membrane and egg wall contains two polar
thickenings from which four to eight polar filaments extend
(Figure 28-53).
 Infection with H. diminuta is acquired by ingesting fleas
that contain the infective cysticercoid.
 The adult tapeworm is 20 to 60 cm long.
 The egg, which must be distinguished from that of H. nana,
is 50 to 75 μm, gray or straw ‫أصفر‬-colored, and oval. An inner
membrane with inconspicuous polar thickenings but no polar
filaments surrounds the oncosphere (Figure 28-54).
 14

Dipylidium caninum.
 Humans serve as accidental hosts for Dipylidium caninum,
the dog tapeworm. Children are usually infected by ingesting
fleas ‫برغوث‬containing the larval stage.
 Infection is generally asymptomatic.
 The proglottid may be seen in human feces and is
characterized by its pumpkin‫ " اليقطين "نبات‬seed ‫ بذرة‬shape, twin
‫ توأمى‬genitalia, and the presence of two genital pores, one on
each side of the proglottid.
 The eggs are characteristically seen in packets of 15 to 25
eggs. Individual eggs are 20 to 40 μm and resemble those of
Taenia spp. (Figure 28-55).
Tissue Infections with Cestodes
 Cysticercosis, sparganosis, and hydatid cyst disease are the
major ‫ أهم‬diseases caused by the tissue stage of tapeworms.
 They originate when a human accidentally becomes the
intermediate host for the parasite.
Cysticercosis.
 Cysticercosis results when a human ingests the infective
eggs of T. solium, thus becoming an intermediate host.
 The disease is endemic in areas of rural Latin America, Asia,
and Africa and is reemerging as a zoonosis in the United
States as a result of immigration from endemic areas.
 Contributing factors for infection include poor hygiene and
sanitary habits that result in ingestion of food containing an
infective egg.
 Once the egg is ingested, the hexacanth embryo is released
into the intestines, penetrates the intestinal wall, and
enters the circulation to develop as a cysticercus in any
tissue or organ. The larva can live up to 7 years and elicits a
host tissue reaction, resulting in production of a fibrous
capsule. Once the organism dies and releases larval antigens,
there is an intense host inflammatory reaction that leads to
tissue damage in the area. Calcification of the cysticercus
occur.
 15

 The most commonly infected sites are striated muscle, the

eye, and the brain.
 Light infections usually cause no clinical symptoms.
 Symptoms depend on the organ affected and size and
number of cysticerci.
 Muscular pain characterize infections of the striated
muscle.
 A cysticercus can form in the vitreous or subretinal space
of the eye. Retinal detachment, intraorbital pain, flashes of
light, and blurred ‫ ضبابية‬vision may occur.
 Neurocysticercosis, is the most serious, and is the cause of
10% of neurologic problems in developing countries. In the
United States, the condition is often seen in Hispanic
immigrants from endemic areas. Infection may be
manifested by headaches, symptoms resembling those seen
with meningitis or a brain tumor, convulsions, or motor and
sensory problems.
 The cysticercus is oval, translucent ‫شفانى وهو نصف شفاف‬, and
about 5 to 18 mm in size. It contains an invaginated scolex
containing four suckers and a circle of hooklets on the
rostellum.
 The infection may be diagnosed by various methods,
including radiography to detect calcified cysts,
ophthalmoscopic examination of the eye to detect
cysticerci, imaging techniques (CT and MRI) to locate larvae
in the brain, and biopsy and histologic staining of tissue.
 Serologic tests, including immunoblot techniques, have been
developed to detect antibodies against specific cysticercal
antigens.
Sparganosis
 Human infection with the plerocercoid larva (sparganum) of
a dog or cat tapeworm can result in sparganosis.
 Humans acquire the infection by ingesting a copepod
containing the procercoid larva, by ingesting reptiles‫الزواحف‬,
amphibians‫برمائي‬, or other animals containing the
 16

plerocercoid larva, or through invasion by the plerocercoid

larva. The disease is most common in Southeast Asia. An
infection is often seen in the eye after a poultice has been
applied to relieve an infection. The organism may also cause
migratory subcutaneous nodules, itching, and pain.
 The diagnosis of sparganosis is made by finding a small,
white, ribbon-like organism with a rudimentary scolex.
 Size varies from a few millimeters to 40 cm. The organism
may be removed surgically.
Echinococcosis.
 Echinococcosis (hydatid cyst disease) is an infection by
Echinococcus granulosus that normally involves the dog or
other member of the family Canidae as the definitive host.
 Sheep ‫ نعجة‬and other herbivores are the usual host of the
larval stage (hydatid cyst).
 The disease is primarily seen in sheep-raising areas of the
world, including Australia, and southern South America.
 The adult worm is approximately 5 mm long and contains only
three proglottids.
 The eggs are found in the feces of dogs or other definitive
hosts and resemble those of Taenia spp.
 A human becomes an intermediate host by accidentally
ingesting the eggs of E. granulosus containing the hexacanth
embryo.
 The oncosphere is liberated in the intestine, penetrates the
mucosa, enters the circulation, and usually lodges in the
liver. The embryo develops a central cavity–like structure
lined with a germinal membrane, from which brood capsules
and protoscolices (hydatid sand) develop.
 The hydatid cyst’s size is limited by the organ in which it
develops. In bone, a limiting membrane never develops, so
the cyst fills the marrow and eventually erodes the bone.
Symptoms vary according to the organ infected.
 Pressure from the increasing size of a cyst may cause
necrosis of surrounding tissue.
 17

 Rupture of the cyst liberates large amounts of foreign

protein (allergin) that may elicit an anaphylactic response.
 In addition, freed germinal epithelium may serve as a source
of new infection.
 The diagnosis can be made by radiologic examination,
ultrasound, or other imaging techniques.
 Aspiration of the cyst contents usually reveals the presence
of protoscolices.
………………………………………………………………………………………………
Roundworms (Nematodes)
 Human roundworms infect the intestinal tract and blood and
tissue.
 They found worldwide and transmitted by the ingestion of
the embryonated egg or by direct penetration of the skin by
larvae in the soil, or they may require an insect vector.
 The highest number of infected individuals fond in warm,
moist areas and in areas with poor sanitation.
 Roundworms are characterized by the presence of two
sexes and their life cycle involve larval migration throughout
the body.
 The adults obtain nourishment by absorbing nutrients from
partly digested intestinal contents or by sucking blood.
 Patients may be asymptomatic or symptomatic; the severity
of the symptoms is related to the worm burden, host’s
nutritional status and age, and duration of infection.
 Most roundworm infections can be treated with oral
albendazole or mebendazole.
 Table 28-9 compares the diagnostic characteristics of the
eggs and larvae of intestinal roundworms.
Enterobius vermicularis.
 Enterobius vermicularis, often called the pinworm, is a
worldwide parasite commonly detected in children, especially
those 5 to 10 years old.
 It is estimated that 20 to 40 million individuals are infected
in the United States alone.
 18

 Risk factors for this infection are inadequate personal

and/or community hygiene.
 Enterobiasis is frequently found in families, kindergartens
‫ روضة أطفال‬, daycare centers ‫(الحضانة‬nursery), or crowded
conditions in which the eggs can be easily transmitted.
 The eggs are resistant to drying and are easily spread in the
environment.
 Adult worms live in the large intestine (cecum), although
they have occasionally been found in the appendix or vagina.
Ectopic infections have also caused endometritis, urethritis,
and salpingitis. There is evidence that the organism may also
be associated with urinary tract infections in young girls.
 Although infection with E. vermicularis is often
asymptomatic, the patient may experience loss of appetite,
abdominal pain, loss of sleep, and nausea and vomiting.
 Anal pruritus is caused by migration of the female worm to
the perianal area.
 Treatment with mebendazole may need to be repeated in
several weeks to eliminate organisms that have matured as a
result of ingestion of eggs remaining in the environment.
 The life cycle of this organism (Figure 28-56) is
characterized by migration of the female out the anus at
night to lay eggs in the perianal area.
 The eggs are infective with a third-stage larva within
several hours of being laid.
 Typically, transmission involves inhalation or ingestion of the
infective eggs. Direct anal-oral transmission caused by poor
hand washing or fingernail biting occurs in children.
 Autoinfection, in which the hatched larvae reenter the
intestine to mature into an adult, may also occur.
 Because eggs are laid outside the body in the perianal area
and are rarely present in the stool, a fecal specimen is
unsatisfactory for diagnosis. The cellophane tape
preparation or commercially available sticky paddle is
considered the diagnostic method of choice.
 19

 The procedure must be done as soon as the child arises in

the morning. The perianal area is touched with the sticky
side of the tape or paddle. The adult female can occasionally
be seen in this preparation.
 Because the gravid female can migrate into the vagina, eggs
can also be seen in vaginal specimens.
 The adult female measures 8 to 13 mm long and has a long
pointed tail and three cuticle lips, with alae‫ اجنحة‬at the
anterior end.
 The less commonly seen male is 2 to 5 mm long, with a
curved posterior.
 The egg is oval, colorless, and slightly flattened on one side.
It measures approximately 50 to 60 μm × 20 to 30 μm. The
egg is usually seen embryonated, with a C-shaped larva
(Figure 28-57).
Trichuris trichiura.
 Ascaris lumbricoides, Trichuris trichiura, and two genera of
hookworms, Ancylostoma and Necator, are the most common
soil-transmitted helminths.
 These organisms have a worldwide distribution and are
major‫ رئيسى‬causes of morbidity, rather than mortality, in
developing areas of the world. Estimates indicate that 25%
of the world’s population is infected with one or more of
these organisms.
 Chronic infection caused by these helminths, especially
hookworm, can adversely affect physical and mental
development in children.
 A heavy worm burden is more likely to result in
complications.
 Some of the risk factors for infection include poor
sanitation (personal and community), poverty, occupation,
and climate (necessary for maturation and survival of the
eggs in the soil).
 20

 Strongyloides stercoralis is also a soil-transmitted helminth

but does not have the broad geographic distribution of the
other organisms.
T. trichiura,
 referred to as the “whipworm,” is found worldwide,
especially in areas with a moist, warm climate. It is found in
the southeastern United States, often as a co-infection
with A. lumbricoides.
 Light infections with T. trichiura rarely cause symptoms;
heavy infections result in intestinal bleeding, weight loss,
abdominal pain, nausea and vomiting, and chronic diarrhea.
As the adults thread themselves through the intestinal
mucosa, inflammation develops. Prolonged heavy infection
can result in colitis or diarrhea with blood-tinged stools.
Rectal prolapse can be seen as the result of repeated heavy
infections in undernourished children. Hypochromic anemia
may occur in children with inadequate iron and protein intake
in the presence of constant, low-level bleeding with chronic
infection. Although treatment is not always necessary,
albendazole has been reported to be effective, especially in
undernourished children. Eggs are passed in the feces and
require at least 14 days in warm, moist soil for embryonation
to occur. Humans acquire infection by ingesting the infective
egg. The larva is released in the small intestine and
undergoes several molts before maturing into an adult worm
in the cecum ‫األعور‬. The egg and occasionally the adult of T.
trichiura may be seen in fecal specimens. The adult male
measures 30 to 45 mm and has a thin anterior and a thick,
coiled posterior. The female is 30 to 50 mm long, with a thin
anterior and thick, straight posterior. The brown, barrel
shaped egg is unembryonated when passed, 50 to 55 μm × 22
to 23 μm, with a thick wall and hyaline polar plugs at each
end (Figure 28-58).
Ascaris lumbricoides.
 21

 More than 1 billion people worldwide are infected with A.

lumbricoides. The organism can be found in tropical and
temperate areas, and children are most commonly infected.
In the United States, the organism is most frequently seen
in rural parts of the Southeast. Transmission is primarily
fecal-oral, and clinical symptoms may be related to the
different phases of the life cycle. The organism is often
found concurrently with whipworm. Abdominal discomfort,
loss of appetite, and colicky pains are caused by the
presence of adults in the intestine. There is evidence that
heavy infections may contribute to lactose intolerance and
malabsorption of some vitamins, including vitamin A. In
children, large numbers of adult worms can cause intestinal
obstruction. Because the worms feed on liquid intestinal
contents, chronic infection with A. lumbricoides in children
may hamper growth and development. Larvae migrating
through the lungs can cause an immune response in the host
characterized by asthma, edema, pneumonitis, and
eosinophilic infiltration. Rarely, larvae are seen in the
sputum in heavy infections. Occasionally, fever or other
disease conditions cause the adults to migrate from the
intestine and invade other organs, resulting in peritonitis,
liver abscess, or secondary infection in the lungs. Adults
may also exit through the mouth, tear duct, or nose and
have been reported to enter and block catheters.
Eosinophilia may be present. Eggs that are deposited in
warm, moist soil become infective within about 2 weeks.
After the egg is ingested, larvae hatch in the duodenum,
penetrate the intestinal wall, and gain access to the hepatic
portal circulation. They break out from capillaries into the
lungs, travel up the bronchial tree and trachea and over the
epiglottis, and are swallowed. Maturation is completed in the
intestine. The life cycle (Figure 28-59) takes about 50 days
after infection until adults are mature. The usual diagnostic
stage is the egg. Fertile Ascaris eggs are oval, measure 45
 22

to 75 μm × 35 to 50 μm, and have a thick hyaline wall

surrounding a one-cell stage embryo. Most eggs have a
brown, bile-stained, mammillated outer layer (Figure 28-60).
Some eggs, termed decorticated, lack the mammillated
outer coat. Infertile eggs, whose size can range up to 90 μm,
are often elongated and contain a mass of highly refractile
granules. Adults, measuring 15 to 35 cm long and about the
diameter of a lead pencil, may be seen in stool samples. The
female has a straight posterior, and the male has a curved
posterior. Both have three anterior lips with small, toothlike
projections.
Hookworms
 Hookworm is one of the most common human parasites.
Infection worldwide is estimated at close to 1 billion, and in
the United States, hookworm is the second most commonly
reported helminth infection. Unlike other helminths, in
which infection peaks in childhood and adolescence,
hookworm burden often increases with age. Two species of
hookworm, Necator americanus (New World) and
Ancylostoma duodenale (Old World), infect humans. A.
duodenale is seen in southern Europe and northern Africa
along the Mediterranean, as well as in parts of Southeast
Asia and South America. N. americanus has a geographic
distribution in Africa, Southeast Asia, and South and
Central America and is endemic in rural areas of the
southeastern United States. In the United States, there is
a racial distribution, with infections more prevalent in
whites than in African Americans. Adults of the two species
can be differentiated by the morphology of the buccal
capsule or, in the male, the copulatory bursa. The eggs,
however, are identical. These worms live in the small
intestine and attach to the mucosa by means of teeth (A.
duodenale) or cutting plates (N. americanus). They digest
the tissue plug and pierce capillaries. Once attached, they
continue to ingest blood as a source of nourishment by
 23

secreting anticoagulants, platelet inhibitors, and substances

that interfere with the factor VIIa tissue factor complex.
The organisms also secrete substances that interfere with
the action of digestive enzymes and inhibit host absorption
of nutrients. Clinical symptoms vary according to the phase
of the life cycle and worm burden. A small, red, itchy papule,
referred to as ground itch, develops at the site of larval
penetration. If large numbers of larvae are present during
the lung phase of migration, the patient may have bronchitis,
but unlike with Ascaris larvae, no host sensitization occurs.
The most severe symptoms are associated with the adult,
including nonspecific symptoms such as diarrhea, fever, and
nausea and vomiting. Eosinophilia is often present. A few
patients may experience pica and then ingest dirt
(geophagia). Blood loss, ranging from 0.03 to 0.2
mL/worm/day, is primarily the result of the ingestion of
blood by the adult worm. Hemorrhages at the site of
attachment, however, also contribute to total blood loss.
Chronic heavy infection with hookworm can lead to
microcytic hypochromic anemia, especially in children whose
diet is inadequate in iron and protein. The mental and
physical development of a child may be affected by chronic
heavy infections because of the complications of anemia and
malnutrition. Infection is usually treated with albendazole or
mebendazole. Supportive therapy, including iron and protein
supplements, may be needed in severe cases, especially if
the child shows evidence of anemia or if the infection is in a
pregnant woman. Vaccine development using hookworm
antigens is being targeted as a way to help control
infections. Once the eggs have been deposited in warm,
moist soil, the noninfective, feeding, first-stage
rhabditiform larva develops within 1 to 2 days and feeds on
bacteria in the soil. A nonfeeding, infective, filariform larva
develops within 1 week. Humans are infected when the
filariform larvae penetrate their skin. The organisms enter
 24

the circulation and break out of the capillaries into the lung
and then migrate up the bronchial tree, over the epiglottis,
and into the digestive tract. After additional larval molts,
the worms attach to the mucosa in the small intestine. Eggs
are produced within 6 to 8 weeks after skin penetration by
the filariform larva. Figure 28-61 shows the life cycle of the
hookworm. Adult hookworms are rarely seen in stool
specimens; the egg and rhabditiform larva are the usual
diagnostic stages. The eggs and rhabditiform larvae of the
two species are indistinguishable; therefore, the laboratory
can report only “hookworm” when a characteristic egg or
larva is found in a stool specimen. The egg is oval, colorless,
thin-shelled, 50 to 60 μm long, and usually contains an
embryo in the four- to eight-cell stage of cleavage (Figure
28-62). The rhabditiform larva must be differentiated from
that of S. stercoralis because treatment is different. The
hookworm rhabditiform larva is 250 to 300 μm long and has
a small, inconspicuous, genital primordium (Figure 28-63, A)
and a long buccal capsule (see Figure 28-63, B). The
filariform larva also must be distinguished from that of S.
stercoralis. Hookworm filariform larvae are about 500 μm
long, with a pointed tail and an esophageal-intestinal ratio of
1 : 4.
Strongyloides stercoralis
 S. stercoralis, known as the threadworm, inhabits the small
intestine but is also capable of existing as a free-living
worm. It is endemic in the tropics and subtropics, including
Southeast Asia, Latin American, and sub-Saharan Africa. It
is estimated that 100 to 200 million people are infected
worldwide. S. stercoralis can persist in the host for decades
after initial infection and may progress to hyperinfection if
the host becomes immunocompromised. In the United
States, the prevalence rate ranges from 0.4% to 4%, with
most cases found in people living in Appalachia, in rural areas
of the Southeast, or in immigrants from endemic areas.
 25

Although many people with S. stercoralis infection are

asymptomatic, patients may exhibit fever, nausea and
vomiting, and sharp, stabbing pains that resemble those of
an ulcer. Chronic mild diarrhea may be present. The
eosinophil count is often elevated. Unlike hookworms, S.
stercoralis larval penetration of the skin does not cause a
prominent papule, and migration through the lungs rarely
elicits pneumonitis, but the patient may have wheezing and a
mild cough. In contrast to the mild symptoms in an
immunocompetent host, patients with a drug-induced
immunocompromised state (corticosteroids), lymphoma,
malignancy, or other condition that causes T-cell depletion
can develop severe infections, referred to as disseminated
strongyloidiasis or hyperinfection. In this population, large
numbers of the filariform larvae develop in the intestine in
an autoinfective cycle and migrate from the intestine into
the lungs and other organs, such as the liver, heart, and
CNS, causing a fulminating, often fatal infection. Most cases
in organ transplant patients are caused by reactivation of
latent or chronic infection, although some cases may result
from primary infection. Individuals undergoing
transplantation who have a history of travel to or residence
in endemic areas may need to be screened for S. stercoralis.
Secondary bacterial infections, which occur as a result of
massive larval migration, may be seen in up to 40% of
patients with disseminated strongyloidiasis and can delay
diagnosis of the underlying infection. The mortality rate in
immunocompromised patients is over 80%; the usual causes
of death are complications resulting in respiratory failure.
Disseminated strongyloidiasis, however, is not common in
patients with advanced AIDS, despite their
immunocompromised status. Research into this seeming
contradiction has shown that individuals with severe
immunosuppression may harbor larval stages that are more
likely to develop into free-living females or males rather
 26

than into filariform larvae. The life cycle of S. stercoralis

can take one of three phases— direct, which is similar to
that of hookworm; indirect, which involves a free-living
phase; or autoinfection (Figure 28-64). In the direct life
cycle, the fertile egg hatches in the intestine and develops
into the rhabditiform larva (noninfective form), which is
passed in the stool. In the soil, the rhabditiform larvae
develop into filariform larvae, which are infective for
humans by direct penetration. Once the larva has
penetrated the skin, it enters the circulation, breaks out
from capillaries in the lung, migrates up the bronchial tree
and over the epiglottis, and enters the digestive tract,
where it matures into the adult worm. In the indirect life
cycle, the rhabditiform larvae in the soil develop into free-
living males and females that produce eggs. At any point, the
free-living cycle may revert and result in the production of
infective filariform larvae. In most individuals, the
autoinfective life cycle allows the initial infection to persist
at low levels for years and is the underlying cause for
hyperinfection. In this cycle the rhabditiform larvae, rather
than being passed in the stool, develop into the filariform
larvae in the intestine. These filariform larvae then
penetrate the mucosa, enter the circulation, and return to
the intestine to develop into adults. The parasitic female
threadworm is small (2.5 mm) and rarely seen in a stool
specimen. No male has been identified in intestinal
infections. The primary diagnostic stage in humans is the
rhabditiform larva. It is 200 to 250 μm long, with a short
buccal capsule (Figure 28-65, A), large bulb in the
esophagus, and prominent genital primordium located in its
posterior half to posterior third (see Figure 28-65, B). The
egg, which is rarely seen except in cases of severe diarrhea,
resembles that of a hookworm. It is thin-shelled, measures
54 by 32 μm, and often is segmented. The filariform larva
has a notched tail, is 500 μm long, and has an esophageal-to-
 27

intestinal ratio of 1 : 1. Filariform larvae may be identified

in the sputum of patients with hyperinfection. If clinical
symptoms suggest Strongyloides infection but multiple stool
specimens test negative for the larvae, a duodenal aspirate
or biopsy may be used for diagnosis because the organism
lives in the upper small intestine. Albendazole or ivermectin
can be used to treat intestinal and disseminated
Strongyloides infection.
✓ Case Check 28-2
 The patient in the Case in Point shows several
characteristics associated with hookworm infection. The
vesicular lesions on the foot (ground itch) represent sites at
which filariform larvae have penetrated the skin and
entered circulation. With other roundworms, the egg would
be ingested; with tapeworms, there could possibly be a
history of eating raw or undercooked meat. The presence of
a low hemoglobin level and microcytic hypochromic anemia is
common in severe or long-term hookworm infection because
the organism attaches to the intestinal mucosa and uses
blood as a source of nourishment. The long-term, low-level
blood loss will cause this type of anemia, characteristic of
iron deficiency anemia, in individuals who are malnourished
or lack adequate dietary iron. Pica, although not common,
may be seen.
Blood and Tissue Roundworm Infections
 Trichinella spiralis. Trichinosis is the infection of muscle
tissue with the larval form of T. spiralis, a helminth whose
adult stages live in the human intestine. Humans acquire the
infection by eating undercooked meat, particularly pork that
contains the larval forms. In recent years, ingestion of wild
game has led to infection by other species of Trichinella.
The larvae are released from the tissue capsule in the
intestine and mature into adults. The female produces
liveborn larvae that penetrate the intestinal wall, enter
circulation, and are carried throughout the body. Once the
 28

larvae enter the striated muscle, they begin a maturation

cycle that is completed in about 1 month. The larvae coil and
become encapsulated. Although larvae remain viable for
many years, eventually the capsules calcify and the larvae
die. During the intestinal phase, infected individuals have
few symptoms, although diarrhea and abdominal discomfort
may be present. Most symptoms occur during the migration
and encapsulation periods; the severity of symptoms
depends on the number of parasites, tissues invaded, and
person’s general health. Symptoms that occur during the
larval phase are the result of an intense inflammatory
response by the host. Common symptoms include periorbital
edema, fever, muscular pain or tenderness, headache, and
general weakness. Muscle enzyme levels may be elevated.
Splinter hemorrhages beneath the nails can be seen in many
patients. Eosinophilia of 40% to 80% is common. Patients
with symptoms should be treated with analgesics and
general supportive measures. Steroids are given only in rare
cases. Because it is difficult to recover adults or larvae in a
stool specimen, the diagnosis is often based on clinical
symptoms and the patient’s history. Biopsy of muscle tissue
and identification of the encapsulated, coiled larva is the
definitive diagnostic method. Figure 28-66 shows a biopsy
specimen of a muscle containing a larva of T. spiralis.
Specimens from large muscles, such as the deltoid and
gastrocnemius, should be stained for histologic examination.
The presence of calcified larvae on a radiographic film
indicates infection. Serologic tests are available.
Larva Migrans.
 Two forms of larva migrans exist in humans: cutaneous
(creeping eruption) and visceral. In both cases, humans are
the accidental host for nonhuman nematode larvae that are
unable to complete their life cycle in humans. In the United
States, cutaneous larva migrans occurs primarily in the
Southwest, Mid-Atlantic, and Gulf Coast areas and is most
 29

commonly caused by the filariform larva of the dog or cat

hookworm (Ancylostoma braziliense). The larva penetrates
the human skin through a hair follicle or break in the skin or
through unbroken skin. Once inside the body, it does not
enter circulation but wanders through the subcutaneous
tissue, creating long, winding tunnels. Secretions from the
larva create a severe allergic reaction, with intensely itchy
skin lesions that are vesicular and erythematous. Secondary
bacterial infections can result from scratching. The
infection resolves within several weeks when the larva dies.
The diagnosis is based primarily on history and clinical
symptoms. In visceral larva migrans, a human accidentally
ingests the eggs of the dog roundworm (Toxocara canis) or
cat roundworm (Toxocara cati). The larvae hatch in the
intestine, penetrate the intestinal mucosa, and wander
through the abdominal cavity and can enter the lungs, eye,
liver, or brain. The infection is seen primarily in children 1 to
4 years old. Clinical symptoms include malaise, fever,
pneumonitis, and hepatomegaly. Eosinophilia ranging from
30% to 50%, and as high as 85%, has been reported. CNS
complications may develop. Eye invasion is referred to as
ocular larva migrans and in these cases, eosinophilia is
usually absent. The diagnosis is made on the basis of clinical
findings and results of serologic tests using Toxocara-
specific antigens.
Filarial Worms.
 Filarial worms are roundworms of blood and tissue found
primarily in tropical areas of the world. A number of species
infect humans. Those considered most pathogenic are Brugia
malayi, Wuchereria bancrofti, Onchocerca volvulus, and Loa
loa. Lymphatic filariasis (caused by W. bancrofti and B.
malayi) is the second most common mosquito-borne disease
after malaria. In addition, the nonpathogens Mansonella
ozzardi, Mansonella (Dipetalonema) perstans, and Mansonella
(Dipetalonema) streptocerca may be seen in clinical
 30

specimens. These adult roundworms give birth to liveborn

larvae referred to as microfilariae. Identification of the
various species depends on the morphology of the
microfilaria, periodicity (microfilaria migration), and location
of the worms in the host. Important microfilaria
morphologic characteristics include the presence or absence
of a sheath (the remnant of the egg from which the larva
hatched) and presence and arrangement of nuclei in the tail.
Table 28-10 compares the species of microfilariae commonly
found in humans. Adults, which may range in size from 2 to
50 cm, live in human lymphatics, muscles, or connective
tissues. Mature females produce microfilariae that are the
infective stage for the insect during the insect’s blood meal.
Once ingested, microfilariae penetrate the insect’s gut wall
and develop into infective thirdstage (filariform) larvae.
These larvae enter the insect proboscis and are introduced
into human circulation when the insect feeds. Figure 28-67
illustrates a generalized life cycle for microfilariae.
Wuchereria bancrofti.
 The causative agent of Bancroftian filariasis and
elephantiasis, W. bancrofti is primarily limited to tropical
and subtropical regions. The insect vector is a mosquito,
Culex or Aedes. The adult filarial worm lives in the
lymphatics and lymph nodes, especially those in the lower
extremities. Presence of the adults initiates an immunologic
response consisting of cellular reactions, edema, and
hyperplasia. A strong granulomatous reaction with
production of fibrous tissue around dead worms ensues. The
resulting reaction causes the small lymphatics to become
narrowed or closed, causing increased hydrostatic pressure,
with subsequent leakage of fluid into the surrounding tissue.
During this period, the patient may experience generalized
symptoms such as fever, headache, and chills as well as
localized swelling, redness, and lymphangitis, primarily at
sites in the male and female genitalia and extremities.
 31

Elephantiasis, a debilitating and deforming complication,

occurs in less than 10% of infections, usually after many
years of continual filarial infection. Chronic obstruction to
the lymphatic flow results in lymphatic varices, fibrosis, and
proliferation of dermal and connective tissue. The enlarged
areas eventually develop a hard, leathery appearance.
Diagnosis of W. bancrofti should include the examination of
a blood specimen obtained at night (10 PM to 2 AM) for the
presence of microfilariae. The blood may be examined
immediately for live microfilariae or may be pooled on a slide
and stained. Filtration of up to 5 mL of blood through a 5-μm
Nuclepore filter (Nuclepore, Pleasanton, CA) can detect
light infections. The microfilariae of W. bancrofti are
sheathed, and the nuclei do not extend to the tip of the tail
(Figure 28-68). Immunochromatographic tests have limited
applications for identification of W. bancrofti antigens in
blood.
Brugia malayi.
 B. malayi, another nocturnal microfilarial species, is limited
to the Far East, including Korea, China, and the Philippines.
Mosquitoes of the genera Mansonia, Anopheles, and Aedes
have been shown to transmit the organism. The pathology of
the disease and clinical symptoms are the same as those
seen with W. bancrofti infections. The distinguishing
characteristics of the microfilariae are the presence of a
sheath and the arrangement of tail nuclei—the nuclei extend
to the tip, but a space separates the two terminal nuclei.
Loa loa.
 Infection with L. loa, the eye worm, is limited to the African
equatorial rain forest, where the fly vector (Chrysops)
breeds. Adults, which may live as long as 15 years in humans,
migrate through the subcutaneous tissue, causing temporary
inflammatory reactions, called Calabar swellings. These
characteristic swellings can cause pain and pruritus that last
about 1 week before disappearing, only to reappear in
 32

another part of the body. The adult worm can often be seen
as it migrates across the surface of the eye. Diagnosis can
be based on the presence of Calabar swellings or of the
adult worm in the conjunctiva of the eye. Microfilariae may
be seen in a blood specimen if it is taken during the day,
especially around noon, when migration peaks. The
microfilaria is sheathed, and nuclei extend to the tip of the
tail.
Onchocerca volvulus.
 Infection with O. volvulus is referred to as onchocercosis,
or river blindness. The organism can be found in Africa and
South and Central America; transmission occurs by the bite
of the black fly (Simulium). Adult worms are encapsulated in
fibrous tumors in human subcutaneous tissues. Microfilariae
can be isolated from the subcutaneous tissue, skin, and the
nodule itself, but are rarely found in blood or lymphatic
fluid. The nodules in which adults live may measure up to 25
mm and can be found on most parts of the body. They are
the result of an inflammatory and granulomatous reaction
around the adult worms. Figure 28-69 depicts a cross
section of tissue containing these organisms. Blindness, the
most serious complication, results when microfilariae collect
in the cornea and iris, causing hemorrhages, keratitis, and
atrophy of the iris. The presence of endosymbiotic bacteria
of the genus Wolbachia have been linked to stimulation of
the host immune response and may contribute to the
inflammatory tissue reaction. Diagnosis involves clinical
symptoms, such as the presence of nodules, and microscopic
identification of microfilariae. The diagnostic method used
is the skin snip, in which a small slice of skin is obtained and
placed on a saline mount. Microfilariae with no sheath and
with nuclei that do not extend into the tip of the tail are
characteristic of this organism. Because the skin snip is
painful and poses a risk of infection, researchers are trying
to develop immunochromatographic tests for parasite-
 33

specific antigens in body fluids such as urine and tears.

Mansonella spp. M. ozzardi, M. streptocerca, and M.
perstans are filarial worms not usually associated with
serious infections. They are transmitted by midges
belonging to the genus Culicoides. The microfilariae of M.
streptocerca are found in the skin. They are unsheathed and
have nuclei that extend to the end of the so-called
shepherd’s crook tail. Microfilariae of M. ozzardi and M.
perstans are found in the blood as unsheathed organisms. M.
ozzardi microfilariae have tails with nuclei that do not
extend to the tips, whereas the nuclei in the tail of an M.
perstans microfilaria extend to the tip.
Dracunculus medinensis.
 Dracunculus medinensis (guinea worm, fiery serpent of the
Israelites) causes serious infections in the Middle East,
parts of Africa, and India. It is often found in areas where
step-down wells are used. In the 1990s, several health
agencies, including the WHO and United Nations Children’s
Fund, launched an eradication program. In 1986, an
estimated 3.5 million people were infected annually; in 2008,
only about 4600 cases were reported. In 2012, only 542
cases were reported, and dracunculiasis was limited to four
African countries. Adult worms mature in the deep
connective tissue, and the gravid females migrate to the
subcutaneous tissue. Initially, a painful, blister-like,
inflammatory papule appears on the leg in the area of the
gravid female. The papule ulcerates and when the person’s
body comes in contact with water, the female worm exposes
her uterus through the ulceration and releases larvae into
the water. Patients may have nausea and vomiting, urticaria,
and dyspnea before the rupture of the worm’s uterus. If the
worm is broken during an attempt to remove it, the patient
may experience a severe inflammatory reaction and
secondary bacterial infection. Humans acquire the infection
by ingesting a copepod (Cyclops) that contains an infective
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larva. The larva is released in the intestine, penetrates the

intestinal wall, and migrates to the body cavity, in which
males and females mature. When mature and gravid, the
female migrates through the subcutaneous tissues to the
arm or leg to release liveborn larvae into the water. The
rhabditiform larvae are then ingested by the copepod. The
diagnosis is made from the typical appearance of the lesion.
Although organism-specific antibodies develop with
infection, immunity does not develop and an individual can be
infected multiple times. Metronidazole is given to treat the
infection. The ancient method of removal by rolling the
worm a few inches at a time onto a stick is still practiced in
some areas of the world.
………………………………………………………………………………………………………………..
Points to Remember
■ Protozoan cysts, helminth eggs, and helminth larvae can be
identified on a wet mount preparation of a fecal concentrate.
The identification of protozoan trophozoites and cysts is
confirmed on a permanently stained smear.
■ Fecal-oral transmission is the route of infection for enteric
protozoa. The cyst is the infective stage, and the trophozoite
is the stage that causes tissue damage.
■ The major intestinal protozoan pathogens include E.
histolytica and G. lamblia. D. fragilis and B. hominis cause
symptomatic infections in some patients.
■ E. histolytica, E. dispar, and E. moshkovkii are morphologically
identical, and specific immunoassay techniques must be
performed to differentiate the pathogenic E. histolytica from
the nonpathogenic E. dispar and E. moshkovkii. If ingested
RBCs are present in the trophozoite, the organism can be
reported as E. histolytica. N. fowleri, Acanthamoeba spp., and
Balamuthia mandrillaris are free-living amebae that can infect
humans. N. fowleri causes an acute condition called primary
amebic meningoencephalitis, which is rapidly fatal.
Acanthamoeba spp. cause keratitis, skin infections, or
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granulomatous amebic encephalitis, whereas Balamuthia is

associated with GAE and skin infections.
■ The genera Leishmania and Trypanosoma are blood
flagellates of humans transmitted by insects.
■ Human malaria can be caused by four different Plasmodium
spp.— P. vivax, P. ovale, P. malariae, and P. falciparum.
■ The life cycle of malaria is complex, with asexual
reproduction taking place in human RBCs and sexual
reproduction in the gut of the mosquito.
■ Identification of Plasmodium spp. is made by observing
characteristics of the infected RBCs and the malarial organism
on a Wright or Giemsa-stained peripheral blood smear.
■ B. microti, an intraerythrocytic parasite, morphologically
resembles P. falciparum on blood smears.
■ The intestinal Apicomplexa include C. parvum, C. belli, and C.
cayetanensis; the infective stage for humans is the acid-fast–
positive oocyst.
■ T. gondii causes a tissue infection that is usually
asymptomatic in immunocompetent hosts. In patients with
AIDS, a latent infection can reactivate and cause encephalitis
or pneumonia. Congenital transmission can result in serious
complications.
………………………………………………………………………………………………
■ For most flukes, diagnosis is made by finding the egg in a
fecal specimen. For the lung fluke (P. westermani), the egg may
be found in sputum; for S. haematobium, the egg is found in
urine.
■ Humans are the definitive host and animals or insects serve
as the intermediate host for most tapeworms infecting
humans.
■ Eggs of the beef tapeworm, T. saginata, and eggs of the
pork
tapeworm, T. solium, are identical and must be reported as
Taenia sp.
 36

■ The diagnostic stage for a roundworm may be an egg or a

larval form, depending on the species.
■ Pinworm, E. vermicularis, infection is common in children and
is diagnosed by finding eggs on a cellophane tape preparation.
Eggs are laid on the perianal area when the female migrates
out the anus at night.
■ Human hookworm infection may be caused by N. americanus
and A. duodenale. The eggs are identical and are reported as
“hookworm eggs.”
■ Eggs of S. stercoralis are not usually present in the stool;
the typical diagnostic stage is the rhabditiform larva.
■ T. spiralis is acquired when humans ingest raw or
undercooked pork containing the larval form.
■ Diagnosis of trichinosis is made through biopsy of tissue to
identify the coiled larval stage.
■ Diagnosis of filarial worm infection is made by observing the
microfilariae in blood or tissue specimens. Larval
characteristics include the presence or absence of a sheath
and the location and arrangement of nuclei in the tail of the
microfilariae.
Learning Assessment Questions
1. A trichrome-stained smear of a patient’s fecal specimen
shows the presence of cysts that are oval, approximately 11 μm
in size and have four nuclei containing large karyosomes with no
peripheral chromatin and a cluttered appearance in the
cytoplasm.
What is the most likely identification of the organism? Is
the organism considered a pathogen?
2. A patient with a history of travel to Africa has fever and
chills. The physician suspects malaria and orders a blood smear
for examination.
Why should you do both a thin film and thick film? Why
would final species identification be made from the thin
smear?
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3. Give the major characteristics (including size) that you

would use to identify eggs of the following organisms: Taenia
spp., Ascaris lumbricoides, Trichuris trichiura, and hookworm.
4. Describe the diagnostic method you would use to detect
Enterobius vermicularis eggs that would not be used with the
other types of eggs of intestinal helminths. Explain why.
5. Describe the microscopic characteristics you would use to
differentiate the oocysts of Cyclospora cayetanensis and
Cryptosporidium parvum. Include size, appearance on routine
wet mount or trichrome, and appearance with special stains.
6. You identify a trophozoite on a trichrome-stained smear of
a stool sample that is approximately 22 μm in diameter. There
is a single nucleus that shows even peripheral chromatin and a
small central karyosome. The cytoplasm is relatively clean but
ingested red blood cells are seen. What is the most likely
identification of the organism? Is the organism considered a
pathogen?
If yes, describe the typical patient symptoms and possible
complications.
7. For both Cryptosporidium parvum and Strongyloides
stercoralis, explain the mechanism of autoinfection in the life
cycle and why this phase contributes to increased severity of
infection.
8. You are examining a blood smear and find an extracellular
structure that is approximately 18 μm long. It is tapered at
both ends and has an anterior flagellum. An undulating
membrane extends the length of the body. What is the genus
of this organism? What is the morphologic stage of this
organism? With what two diseases do you see this stage in the
blood?
9. Compare primary amebic meningoencephalitis and
granulomatous amebic encephalitis. Include the following in
your discussion: causative organism, population usually infected,
route of infection, clinical symptoms, and method of diagnosis.
 38

10. For the following three organisms, Toxoplasma gondii, C.

parvum, and S. stercoralis, compare the clinical presentation in
the immunocompetent host and in the immunocompromised
host.
BIBLIOGRAPHY