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Module
8

Module
8
MTPC 124
CLINICAL
PARASITOLOGY
EFREN II C. DEOCADES, RMT

JMJ Marists Brothers

Notre Dame of Marbel University

NOTRE DAME OF MARBEL UNIVERSITY
College of Arts and Sciences Medical Technology Department
MEDICAL TECHNOLOGY DEPARTMENT
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MODULE VIII:

The nematodes
`

Learning Outcomes

At the end of the session, the students must be able to:

1. thoroughly explain the pathogenesis, epidemiology, prevention and control, treatment,

and diagnosis of clinically-relevant nematodes.
2. exemplify mastery of the concept through passing the online assessment.

Introduction

In this module, we will discuss the first group of multicellular parasites—the Nematodes.
There are more than 60 species of nematodes that are known to infect humans and they are
classified as intestinal or extraintestinal nematodes. They are non-segmented, elongated,
cylindrical worms with a well-developed digestive tract and reproductive system. These group of
parasites are very important causes of parasitic infections affecting more than 1 billion people in
the entire world.

Activity/ Application

The students will be tasked to watch documentaries regarding Nematode cases.

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The Nematodes GENERAL CHARACTERISTICS:

− Adult: elongated, cylindrical worm (usually
bilaterally symetrical)
NEMATODE CLASSIFICATION
− Anterior End: may be equipped with hooks,
A. Intestinal Species
teeth, plates and papillae
1. Enterobius vermicularis – Pinworm
2. Trichuris trichiura – Whipworm − No circulatory system
3. Ascaris lumbricoides – Large Intestinal Round − Dioecious (except S. stercoralis-
worm/ Giant Round Worm parthenogenetic)
4. Necator americanus – New World Hookworm
5. Ancylostoma duodenale – Old World Hookworm Female: larger, pointed posterior, no spicule
6. Strongyloides stercoralis – Threadworm found
7. Capillaria philippinensis- Pudoc Worm Male: small, curved posterior, with spicule

B. Intestinal-Tissue Species Oviparous

1. Trichinella spiralis – Trichina worm − lay immature/ unembryonated/ unsegmented
2. Dracunculus medinensis – Guinea Worm eggs (e.g. Ascaris)
Oviviparous/ Ovoviviparous
Specific Locations: − lay embryonated/ mature eggs; lay eggs in
segmented stage (e.g., E. vermicularis)
Small Intestine Viviparous/Larviparous
Large Intestine
(Duodenum, Jejunum,
Colon − lay larva, not eggs (e.g, T.spiralis, D.
Ileum)
medinensis)
1. Capillaria 1. Enterobius
philippinensis vermicularis Amphids (cephalic chemoreceptors):
2. Ascaris 2. Trichuris trichiura − sensory organs/chemoreceptors found in the
lumbricoides anterior end of the worm
3. Strongyloides Phasmids (caudal chemoreceptors):
stercoralis − sensory organs/chemoreceptors found in the
4. Hookworms posterior end of the worm
5. Trichinella spiralis − Aphasmids: Trichuris, Trichinella, and
adult Capillaria
− Without caudal chemoreceptors
− Phasmids: the rest of the nematodes
Extraintestinal Nematodes
KEY DEFINITIONS
Lymph Node and Lymph Eyes and Meninges: Nematode
Vessel: 1. Angiostrongylus − Multicellular parasites that appear round in cross
1. Wuchereria Cantonensis/ section
bancrofti Parastrongylus
2. Brugia malayi Autoreinfection
Encysted in the host − Reinfecting oneself
muscle:
1. T. spiralis larva Retroinfection
− Infective pinworm eggs that migrate back into the
host body, develop, and reproduce rather than
becoming dislodged

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Buccal capsule 1. Ascaris lumbricoides

− Long oral cavity; also known as a buccal cavity
− Common Name: Giant Intestinal Round Worm
− the most common intestinal nematode of man
Chitin
− a soil-transmitted helminth (STH)
− Shell made up of a thick nitrogen-containing
polysaccharide coating

Cuticle
− Surface covering present on adult nematodes

Copulation
− Mating of select worms

Egg
− Female sex cells after fertilization

Embryonated
− Fertilized egg

Unembryonated
− Unfertilized egg

Corticated Life Cycle Notes

− Eggs containing a mammillated albuminous Diagnostic Stage: Egg in stool
material Infective Stage: Embryonated Egg
MOT: Ingestion of Embryonated Egg
Decorticated Vectors: Flies and Cockroaches
− Eggs lacking an outer mammillated albuminous
coating Egg Adult Worm

Larva
− Juvenile worms

Filariform larva
− Infective, nonfeeding stage that occurs after the
rhabditiform larvae completes their second molt

Rhabditiform larva
− Average immature newly hatched hookworm
characterized by the presence of a buccal
cavity/capsule and a small genital primordium − Infection begins following ingestion of infective
eggs that contain viable larvae.
Gravid − Larvae emerge from eggs once inside small
− Pregnant intestine.
− Larvae complete a liver-lung migration via
bloodstream.
− Once inside lung, larvae burrow inside alveoli,
then migration to bronchioles follows.
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− the larvae may cause host sensitization resulting hepatobiliary, or pancreatic ducts and cause an
in allergic manifestations such as lung infiltration, obstruction
asthmatic attacks, and edema of the lips. − Patients with pulmonary symptoms have cough,
− Larvae are then transferred through coughing into eosinophilia, and/or pneumonia.
the pharynx, where they are swallowed and return − Löffler syndrome: eosinophils accumulation in
to the intestine. the lung as a response to a parasitic infection;
− Maturation of larvae occurs, resulting in adult immune-mediated, peripheral eosinophilia
worms that take up residence in small intestine. − Moderate infections: lactose intolerance and
− Adults (whitish or pinkish worms with terminal vitamin A malabsorption.
mouth with three lips and sensory papillae, do not
attach to the mucosa of the small intestines) Laboratory Diagnosis
multiply and resulting undeveloped eggs (as many − Specimen of choice is stool (DFS, Kato-Katz,
as 250,000/day) are passed in stool—this number Kato thick, FECT)
decreases with increasing worm load. − If negative:
− The soil contains the necessary environment for 1. No infection
eggs to embryonate (2-3 weeks/2-6 weeks). 2. Early infection (no eggs laid yet)
− Infective eggs may remain in outside environment 3. All male worm infection
for years (months to 2 years) and can even survive − Adult worms may be recovered in several
10% formalin fixative. specimen types depending on the severity of
− Eggs that are in infective stage are consumed by infection:
host, and new cycle is initiated. 1. Small intestine
2. Gallbladder
Epidemiology 3. Liver
− Most common intestinal helminth infection in the 4. Appendix
world (affects 1 billion people worldwide, 70% from 5. Gastric Aspirates
Asia). − ELISA test is available.
− Warm climates and areas of poor sanitation are
most effected. Treatment
− Children are particularly vulnerable − Albendazole (alternative: Ivermectin)
− It is suspected that A. lumbricoides may be − Mebendazole
responsible for transmission of D. fragilis. − Pyrantel Pamoate

Clinical Symptoms Prevention and Control

− Asymptomatic − WASHED: water, sanitation, hygiene, education,
− Infected with 5-10 worms; not noticeable usually deworming
− Ascariasis: roundworm infection − WOW: War on Worms
− Produce pepsin inhibitor 3 (PI-3) that protects
worms from digestion and phosphorylcholine
that suppresses lymphocyte proliferation.
− Some may be only infected with a single worm,
which perforates out of the intestine causing
secondary bacterial infection.
− Patients with many worms may exhibit vague
abdominal pain, vomiting, fever, and distention
caused by a mass of worms entangled together to
cause obstruction in intestines.
− Ectopic ascariasis: worms escaping the
gastrointestinal tract and enter the appendix,
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− Following copulation, adult female lays her eggs

2. Trichuris trichiura approximately 3,000 to 10,000 eggs per day,
which pass through stool.
− Common Name: Whipworm
− Eggs embryonate, usually in the clayish soil,
− A soil-transmitted helminth (STH)
become infective, and another life cycle is
initiated.
− Trichuris eggs in soil are more susceptible to
desiccation than Ascaris eggs.

Epidemiology
− Considered third most common helminth
− Found primarily in warm climates where poor
sanitation practices are common
− Children and those in psychiatric hospitals known
to be at risk for contracting T. trichiura

Clinical Symptoms
− Asymptomatic
− Trichuriasis: whipworm infection
− pathogenesis and severity of the disease are
closely related to the worm burden
− secrete a pore-forming protein, called the TT47
that allows them to imbed their entire whip-like
portion into the intestinal wall.
Life Cycle Notes − Heavy infections (500-5,000 worms) have various
Diagnostic Stage: Embryonated Egg symptoms:
Infective Stage: Egg in stool  Abdominal tenderness and pain, weight loss,
MOT: Ingestion weakness, mucoid or bloody diarrhea
− Children who are infected present with symptoms
Egg Adult Worm like ulcerative colitis:
 As few as 200 worms can cause chronic
dysentery, severe hypochromic anemia,
and possible growth retardation.
 In treated children, catch-up growth is noted.
 Increased rectal prolapse (heavy
infection) and peristalsis are common.

− Ingestion of infective eggs initiates human

infection.
− Larvae emerge from eggs in small intestine.
− Larvae return to the intestinal lumen and proceed
to the cecum where maturation is complete.
− Adults take up residence in colon where they can
live 4-8 years if untreated. Rectal prolapse caused by T. trichiura
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Laboratory Diagnosis
− Specimen of choice is stool (DFS/ Kato-thick/
Kato-Katz- for identifying the Cure Rate/ Egg
Reduction Rate)
− Eggs are prominent in infected samples
processed using zinc-sulfate flotation
method/FECT.
− Adult worms may be visible on macroscopic exam.

Treatment
− Mebendazole or albendazole (alternative)

Prevention and Control

− Exercising proper sanitation practices
− Educating children and assisting mentally
handicapped
− Prompt treatment of infected persons
− Avoidance of: Life Cycle Notes
− Defecating directly into the soil Diagnostic Stage: Egg/ Larvae
− Using feces as a fertilizer Infective Stage: L3/ Non-feeding Filariform Larva
(Sheathed)
3. Hookworms MOT: Skin Penetration (main)
− are soil-transmitted helminths − Necatoriasis: purely percutaneous
− blood-sucking nematodes − Ancylostomiasis: both
− Consist of two species infecting man: percutaneous and oral route.
1. Necator americanus
− Common names: New World Egg Adult Worm
Hookworm, American Hookworm,
American murderer
− Semilunar cutting plates
2. Ancylostoma duodenale
− Common name: Old World Hookworm
− Slightly larger than N. americanus
− 2 pairs of Teeth
− These two parasites are covered as a unit called
“hookworms” because of several similarities
including the fact that their eggs are
indistinguishable.
− Other Species: causative agents of “creeping − Mode of transmission: Penetration of filariform
eruption,” also known as cutaneous larva larvae into skin, typically a bare foot (Dew/
migrans (CLM) Ground Itch)
1. Ancylostoma braziliense − Larvae migrate via the bloodstream and
− Cat Hookworm lymphatics to the lungs, where they enter the
− 2 pairs of teeth alveoli, and then the bronchioles, where they are
2. Ancylostoma caninum coughed up and swallowed back into the intestine
− Dog Hookworm (maturation occurs).
− 3 pairs of teeth − Adult females lay 10,000 to 20,000 eggs/day.
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− Eggs are shed in stool, and soil is where the 3. Concentration methods: increase in
rhabditiform larvae emerge. sensitivity
− After two moltings, the third-stage infective 4. Molecular (PCR-based)
filariform larvae can begin a new cycle. 5. ELISA
6. Culture methods (Harada-Mori):
Epidemiology − hatching of larvae from eggs on strips
− 25% of the world’s population is infected with of filter paper with one end immersed
hookworm. in water
− Philippines: 97%-N. americanus, 1%- A. − recommended for species
duodenale, 2%-mixed infections identification
− Local distribution of human hookworm infection is − Recovery and examination of buccal cavity are
greater in agricultural areas. necessary to determine specific hookworm
organism.
Clinical Symptoms Treatment
− Asymptomatic − Albendazole- drug of choice
− Hookworm disease: anclyostomiasis, − Mebendazole and pyrantel pamoate
necatoriasis − MOA: block the uptake of glucose by most
− Intense allergic itching at penetration site (ground intestinal and tissue nematode
itch) − Iron supplementation
− Sore throat
− Bloody sputum Prevention and Control
− Wheezing − Like those of A. lumbricoides
− Headache 1. WASHED
− Mild pneumonia with cough 2. Vaccine development due to drug resistance
− Pneumonitis: decreased sensitization compared
with A. lumbricoides and S. stercoralis. 4. Strongyloides stercoralis
− Mild infection (<500 eggs/g of feces) − Common Name: Thread worm
 Mild gastrointestinal symptoms, slight − Smallest nematode infecting man
anemia, weight loss, weakness − Facultative nematode
− Acute infection (>5,000 eggs/g of feces) − Characterized by free-living rhabditiform and
 Diarrhea, anorexia, edema, pain, enteritis, parasitic filariform stages
epigastric discomfort − only species of this genus which is naturally
 Due to worms competing with body for pathogenic to humans
nutrients, patients may experience
microcytic hypochromic anemia, iron
deficiency, weakness, hypoproteinemia
(hypoalbuminemia), possible mortality from
loss of blood
 greater blood loss per worm per day in A.
duodenale infection compared with N.
americanus infection

Laboratory Diagnosis
− Recovery of eggs in stool sample.
1. DFS: is of value only when the infection is
quite heavy
2. Kato thick or Kato-Katz method: increase
detection rates
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Life Cycle Notes Clinical Symptoms

Diagnostic Stage: Egg (heavy infections)/ Larva − Asymptomatic (chronic)
Infective Stage: L3/ Filariform Larva − Strongyloidiasis: threadworm infection
(Unsheathed) − Diarrhea (Cochin China diarrhea):
MOT: Skin Penetration (Swamp Itch) characterized by numerous episodes of watery
and bloody stools
Egg Adult Worm − Abdominal pain
− Urticaria with eosinophilia
− Vomiting
− Constipation
− Weight loss
− Variable anemia
− Death
− Pulmonary symptoms possible during parasite
migration (Löffler syndrome)
− Hyperinfection is possible

Laboratory Diagnosis
− Diagnostic eggs (indistinguishable from
hookworm eggs) may be present in diarrhea.
− Baermann Funnel Technique
− Harada-Mori Culture Method-most successful
− Zinc sulfate concentration = good egg recovery
− Diagnostic rhabditiform larvae recovered in fresh
− Three ways: stool samples and duodenal aspirates.
− Direct − Beale’s string test, duodenal aspiration, and small
 Mimics hookworm life cycle except bowel biopsy
rhabditiform larvae are usually passed in the − Serologic tests, including ELISA tests available
stool; eggs are only occasionally found in
such samples. Treatment
− Indirect − Ivermectin
 Rhabditiform larvae are passed in outside − Albendazole/ Thiabendazole (contraindicated to
environment and mature into free living pregnant women)
adults that are non-parasitic; may initiate
new indirect cycle. Prevention and Control
− Autoinfection (Internal) − Exercising proper sanitation and personal
 Rhabditiform larvae develop inside human hygiene practices
intestines, enter lymphatics or bloodstream, − Avoidance of:
and initiate new cycle. − Defecating directly into the soil
− Using feces as a fertilizer
Epidemiology
− Covering of bare feet and skin from contaminated
− Found predominately in tropical and subtropical
soil
regions of the world and areas of poor sanitation
− In U.S, areas of the South and Appalachian
Mountain region affected

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5. Enterobius vermicularis − Humans are only known host.

− Also known as Oxyuris vermicularis − Initiated following ingestion of infected eggs.
− Common Names: Pinworm, Social Worm, − Eggs migrate through digestive tract, hatch,
Society Worm release larvae, and mature, growing into adult
worms.
− Familial or group infection tendency
− Following mating of select worms, the pregnant
− most common helminth parasite identified in
female worm migrates outside the body and
temperate regions
deposits up to 15,000 eggs (4,672 to 16,888 eggs
− the only intestinal nematode infection that cannot
per day with an average of 11,105 eggs); after 4-
be controlled through sanitary disposal of human
6 hours these eggs will have reached infectious
feces
status.
− Infective eggs can survive days to weeks outside
host (13 days)
− Eggs are resistant to disinfectants.
− Prone to dehydration in dry air within 1 day.
− Retroinfection and autoreinfection can occur.

Epidemiology
− Found worldwide, particularly in temperate areas
− Most common helminth known to cause infection
in United States
− May be responsible for the transmission of
Dientamoeba fragilis

Clinical symptoms
− Asymptomatic
− Enterobiasis: pinworm infection
− Intense itching
− Inflammation of anal or vaginal areas
− Intestinal irritation
− Nausea
Life cycle notes − Vomiting
Diagnostic Stage: Embryonated Egg and Adult − Difficulty sleeping
Worm − Can be found in the Lungs and Liver
Infective Stage: Embryonated Egg
MOT: Ingestion, Inhalation, External Autoinfection Laboratory diagnosis
− Specimen of choice is cellophane tape prep
Egg Adult Worm collected from perianal region (Graham’s scotch
adhesive tape swab/ perianal cellulose tape
swab)
− Eggs are found in the feces in only about 5% of
infected persons
− Multiple samples may be required to:
• Confirm the presence of a light infection
• Confirm patient is free from infection

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Treatment Life Cycle Notes

− Albendazole Diagnostic Stage: Egg / Larva
− Mebendazole Infective Stage: Larval Stages found in Fish
− Pyrantel pamoate MOT: Ingestion of raw/ undercooked fish bearing
− Treat family members in addition to infected the infective larva
person Natural Host: Migratory Birds (Final Host in the
− Cure can only be considered after seven environment)
perianal smears, on consecutive days using Incidental Host: Man
scotch-tape swab method, are all found to be Intermediate Host: Freshwater/ Brackish Water
negative. Fishes (Ipon- Hypselotris bipartita, Birot, Bagsang,
Bagtu )
Prevention and Control
− Practicing proper personal hygiene (hand Egg Adult Worm
washing)
− Applying ointment to infected perianal area to
prevent dispersal of eggs into environment
− Avoid scratching the infected area
− Thorough cleaning of all potentially infected
surfaces (such as linens)
− Total eradication of pinworm highly unlikely

6. Capillaria philippinensis
− Common names: Pudoc Worm, Pudoc Disease/
Mystery Disease (Compostella valley)
− first recorded in a case in Pudoc West, Tagudin,
Ilocos Sur
− close relative of Trichuris trichiura
− one of four Capillaria species that are known to − Female worms produce characteristic eggs, which
infect humans are peanut-shaped with striated shells and
flattened bipolar plugs
− These eggs are passed in the feces and
embryonate in the soil or water.
− They must reach the water in order to be ingested
by small species of freshwater or brackish water
fish
− The eggs hatch in the intestines of the fish and
grow into the infective larvae
− The first generation of female worms produces
larvae to build up the population.
− Some of these larvae are retained in the gut lumen
and develop into adults

Epidemiology
− was first recorded in Northern Luzon in the
Philippines in 1966
− Cases have also been documented in Zambales
and Southern Leyte
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− Monkayo, Compostela Valley Province, an

outbreak described as a “mystery disease” in 1998 7. Trichinella spiralis
resulted in the death of villagers due to
− Common names: Muscle Worm, Trichina Worm
misdiagnosis
− Records the highest Eosinophil count among
other parasitic infections
Clinical Symptoms
− abdominal pain and borborygmi
− intermittent diarrhea/ 8-10 voluminous stool per
day
− weight loss, malaise, anorexia, vomiting, and
edema

31-year-old female with intestinal capillariasis before

treatment (left) and 1 year after treatment (right)

− severe protein-losing enteropathy and Life Cycle Notes

hypoalbuminemia. Diagnostic Stage: Encysted Larva (muscle
− malabsorption of fats and sugars → Steatorrhea; biopsy)
decreased excretion of xylose; Infective Stage: Encysted Larva
− low serum potassium, sodium and calcium; and MOT: Ingestion of raw/ undercooked meat with
high levels of immunoglobulin E encysted larva
− large number of worms that develop in humans is Adult: Small Intestine
responsible for the severe pathology. Larva: Muscles
− responsible for micro-ulcers in the epithelium
Larvae Adult Worm
Laboratory Diagnosis
− Stool Examination

Treatment
1. Mebendazole
2. Albendazole

Prevention and Control

− Improve sanitation and health educational
programs
− prevent indiscriminate disposal of human waste
− discourage eating raw fish
− Capacity building for health personnel
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− Human infection is result of accidental human − No known test is 100% accurate for diagnosis.
infection with a parasite whose normal host is an − Test can lead to false negative results if done too
animal. early.
− Initiated upon consumption of undercooked meat
(striated muscle) that is contaminated. Treatment
− No egg stage in this life cycle; live larvae enter − No medications indicated if person infected has
bloodstream and travel to muscle, where they non-life-threatening strain of disease
encyst nurse cells and over time a granuloma − Prednisone for those with severe infection
form. − Removal of muscle with encysted larvae
− Since humans are not traditional hosts, completion − Thiabendazole
of life cycle does not occur, and cycle ceases.
Prevention and Control
Epidemiology − Thorough cooking of meats
− Found worldwide with the exception of the tropics, − Proper storage of meats at below zero
where it is rarely reported; resistant to colder temperatures
regions − Avoidance of feeding pork scraps to hogs
− Found in pig, deer, bear, walrus, and rat
− In developed areas a major source is
contaminated pork
8. Dracunculus medinensis
− Common Name: Guinea Worm, Fiery Serpent of
Clinical Symptoms the Israelites, Medina Worm, Dragon Worm,
− Asymptomatic Serpent Worm
− Trichinosis/trichinellosis − Longest nematode of man (1 meter)
1. Few hundred larvae:
− can result in gastroenteritis, diarrhea, and
abdominal pain approximately two days post
infection.
2. Infection with 100 to 300 larvae
− may lead to symptomatic trichinellosis, while
3. more than 1,000 to 3,000 larvae
− can result in severe disease.

Laboratory Diagnosis
− Clinical symptoms and patient history are
necessary.
− Examination of affected skeletal muscle is
method of choice for recovery of encysted larvae
(muscle biopsy).
− Immuno tests: Life Cycle Notes
1. Bentonite Flocculation Test (EG/TS) Diagnostic Stage: Removal of adult worm
2. Bachmann Intradermal Test Infective Stage: Larva
3. Beck’s Xenodiagnosis- test animals: Albino MOT: Ingestion of crustacean with larva
mice/rats (TC/TS) Adult: Subcutaneous tissue

− Elevated serum muscle enzymes: − Ingestion of water contaminated with infected

− LDH copepods (third-stage larvae) initiates infection.
− Aldolase − Larvae mature into adult worms in intestine and
− Creatinine phosphokinase (CPK) proceed to connective tissues or body cavities.
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− Following mating, the gravid worms migrate into • Step 5: Apply topical antibiotics to ensure
subcutaneous tissue where they lay first-stage no bacterial infection
larvae.
− Fate of adult males is unknown.
− An infected ulcer results at the spot the larvae
deposit.
− Cool water will rupture ulcers and release larvae.
− Copepods living in the water consume them, and
maturation into the third-stage infective form
occurs.
− Ingestion of infected copepod begins cycle again.

Epidemiology
− Guinea worm is found in parts of Africa, India,
Asia, Pakistan, and the Middle East. Prevention and Control
− Ponds, human-made water holes, and standing − Properly treat water before consumption
water serve as sources of infection. − Prohibit practices of drinking and bathing in same
− Numerous reservoir hosts are known water
− Cease the practice of allowing standing water to
Clinical Symptoms be ingested
− Guinea worm infection: dracunculosis, − Educate the entire population in endemic areas
drancunculiasis − Highly unlikely total eradication of guinea worm
• Allergic reaction as migration of organism will ever occur
occurs and a secondary bacterial infection
may occur
• Painful ulcers develop and nodule formation
can occur on the death and calcification of
adult worm

Laboratory Diagnosis
− Recovered by observing infected ulcers for the
emergence of worms
− Induced rupture of infected ulcers under cool
water reveals first-stage larvae

Treatment
− No specific dracunculiasis medicines available
− Successful treatment means total worm removal
• Step 1: Place affected body part in cool
water
• Step 2: Adult worm breaks through blister;
explores water
• Step 3: Clean resulting wound thoroughly
• Step 4: Wind worm around stick to manually
extract

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References
Belizario Jr., V. Y., & de Leon, W. U. (Eds.). (2015). Medical Parasitology in the
Philippines (3rd ed.). University of the Philippines Press.

Tille, P. M. (2017). Bailey and Scott’s diagnostic microbiology (14th ed.). Elsevier Inc.

Zeibig, E. A. (2013). Clinical Parasitology: A Practical Approach (2nd ed.). Saunders Elsevier.

Assessment
An online, 50-item quiz will be given and will be accessed using the Learning
Management System.

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