Blood and Tissue nematodes

Outline
– General features
– Classification
– Geographical distribution Morphology, differential characteristics, life
Cycles, Laboratory diagnosis, prevention and control of:
• Wuchereria bancrofti
• Brugia malayi/timori
• Loa loa

• Onchocerca volvulus
• Trichinella spiralis
• Dracunculus medinensis
 Blood and tissue nematodes
General features:
• Their adult lives in the tissues of human
(lymphatic system, subcutaneous tissues or
muscle)
• Long thread - like worms
• Requires two host to complete their life cycle.
• Females are viviparous, larvae hatch in
the uterus

• The female produce first stage larvae (L1)

The immature L1 stage larva is called

Microfilariae
Small , slender, motile forms

L1 require blood sucking insects (IH) to develop

to infective form (L3)

No reproduction in the vector, rather

development(Cyclodevelopmental)
 Classification:

• Tissue nematodes can be classified

based on:

– Habitat in the body

– Clinical manifestation

– Morphology
 Three families/ groups
1. FAMILY FILARIDAE( Filarial worm)
- Common/pathogenic filaria
• Wuchereria bancrofti
• Brugia malayi
• Brugia timori
• Loa loa
• Onchocerca ovolvulus
– Less/non-pathogenic Filaria
• Mansonella perstance
• Mansonella streptocerca
• Mansonella ozardi
2. FAMILY TRICHINELOIDAE

• Trichinella sps

3. FAMILY DRACUNCULIDAE( guinea worm)

• Dracunculus medinensis

Animal tissue nematode rarely infect human

• Dirofilaria sps
• Angiostrongylus cantonensis
• Gnathostoma spinigerem
 FAMILY FILARIDAE ( Filarial worm)

General features:
 Filariae live as adults in various human tissues

Agents of LF reside in lymphatic vessels and lymph nodes

O. Volvulus, Loa loa, M. Ozzardi and M. Streptocerca in

subcuraneous tissues

M. Streptocerca besides reside in the dermis

M. Perstans resides in body cavities and surrounding

tissues 7
 Cont ….

 Three of these are responsible for most of the morbidity:

W. bancrofti and B. malayi cause lymphatic filariasis, and

O. volvulus causes onchocerciasis (river blindness).

Animal reservoirs play no role of significance in

most places, except in sub-periodic B. malayi.

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 FAMILY FILARIDAE( Filarial worm)
Morphology
• Adult
– The adults are long thread like
worms.
– Live in body cavities, lymphatic,
and subcutaneous tissues
– Release embryos (microfilaria)
which live in blood or dermis (skin)
– all require an insect or crustaean
vector as intermediate host
• Microfilaria
– The immature first stage larva of filarial worms
– Are motile and live in blood or dermis
– Measure, 150-350 µ long
– Transparent and colorless with rounded or pointed
tail in unstained smear
– Internal structure can be visualized by the use of
fixed stained preparation
– Can be sheathed or unsheathed
Periodicity:-
• Microfilaria of pathogenic filarial
worms that found in the blood (m.f of
filarial worms that causes lymphatic
filariasis and Loasis) show periodicity
Periodicity:-
– Mf are found in the blood in greater number in a
certain hours of a day or a night
– Corresponds to peak biting times of their insect
vector
• Nocturnal periodicity -mf is high in blood during night
hrs
• Diurnal periodicity-mf is high in blood during day hrs
• Nocturnal or diurnal subperiodicity;- mf can found in
blood 24 hrs with slight increase in number during day
or night hrs
Filarial worms Periodicity Main Vector Reservoir
(Synonym) (IH)
O. volvulus Non Black fly (Simulium) Human
(River blindness) Periodic
W. ancrofti (LF) Periodic (N) Culex, Human
22 – 04hr Anopheles
(24hr)
Sub Periodic Aedes Human
20 – 22
(21hr)
14 – 18
(16hr)
B. Malayi (LF) Periodic (N) Anopheles Human
22 – 04hr
(24hr)
Sub Periodic Mansonia Human, Monkey, Cat
20 – 22 – Zoonotic
(21hr)
B. Timori (LF) Periodic (N) Anopheles Human
L. Loa (Eye worm) Periodic (D) Deer fly Man, Monkeys
M. streptocerca Non Midge (Culicoides)
Periodic
M. perstans Sub Midge13(Culicoides)
• Flarial worm causes 3 main diseases
– lymphatic filariasis (Elephantiasis)
– Loasis
– Onchocerciasis (river blindness)
 Lymphatic Filariasis
• Disease caused by filarial worms living in the human
lymphatic system
• Causative agents
• Wuchereria bancrofti
• Brugia malayi
• Burigia timori
• These worms lodge in the lymphatic system
• They live for four to six years, producing millions
of minute larvae that circulate in the blood”
 Lymphatic Filariasis
• Large numbers are present in the lymphatics
of the:
Lower extremities (inguinal and obturator groups),

Upper extremities (axillary lymph nodes), and,

Male genitalia (epididymis, spermatic cord, testicle) -

particular for W. bancrofti
 Social consequences
It is one of the most debilitating and disfiguring
diseases of the world
1. Disfigurement of the limbs and genitals leads
to:
– Stigma
– Anxiety
– Ostracization
– Psychological trauma
– Sexual disability
 Social consequences…..
2. The disease impeds
– Mobility
– Travel
– Educational opportiity
– Employment opportunity
– Marriage prospect
Distribution
 Distributin
• Wuchereria bancrofti
• affects an estimated 119 million individuals and
disfigures 40 million.
• Wide distribution (Africa, SE Asia, Indonesia, South
Pacific Islands)

• Brugia malayi
• Limited distribution (China, India, SE Asia, Indonesia,
Philippines)

• Brugia timori
• Leser sunda, island of Indonesia
 Wuchereria bancrofti
Disease: Bancroftian filariasis, Wuchereriasis, elephantiasis
Distribution: tropical and subtropical countries
Morphology:
 Adult female is viviparous(produce microfilaria(L1))
 Diagnostic stage is L1 larva
 Infective stage is L3 larva

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Transmission and life
cycle
 Cont ....
• Requires two host
• Human-DH
• Mosquitoes-IH

• Transmission
• Bite female mosquitoes (Genera Culex, Aedes,
Anopheles, Mansonia)
• Infective larvae deposited onto human
skin during the mosquito's blood meal

• Enter through the mosquito bite

puncture wound or local abrasions.

• In humans:
– Parasites passes to the lymphatic
system
– Undergo further molts
– Become adult male and female worms
• Adult female worms produce thousands of
sheathed microfilariae per day
• Mf can be found in blood 9 months after infection
(W.bancrofti) and 3 months (Burigia species)
• Normally found in peripheral circulation in evening.
• Microfilariae ingested during blood meal from
infected person
• Penetrate the mosquito stomach wall

• Enter the body cavity (hemocoel)

• Migrate to the insect's flight muscles for growth.

• After 2 molts, the L3 migrate through the head,

• Reach the proboscis of the mosquito.

 Clinical manifestation.
• Depends on:
– Site occupied by adult
– Number of worms,
– Length of infection and
– Immune response of the host
 Clinical manifestation.
1. Many infections are asymptomatic

2. Circulating Mf probably do not cause pathology

3. The main pathological lesions are:

a) Inflammatory manifestations – due to toxic products of living or

dead adult worms
– There may be:
• Recurrent attacks of lymphangitis
– Funiculits, Epididymitis, Orchitis, etc...
• Lymphadenitis, Swelling and redness of affected parts
• Fever, chills, headache, vomiting and malais
b) Obstructive manifestations –
• Fibrosis following the inflammatory process
• Coiled worms inside lymphatics.
• This may result in:
 Dilatation
 Rupture of distended lymphatics
 In the urinary passage – chyluria
 In the pleura – chylothorax
 In the peritoneal cavity – chylous ascitis
 In the testis – chylocoele
C) Elephantiasis:
 Hard and thick, rough and fissured skin
 Frequently legs & genitalia (scrotum, penis
and vulva)
 Less often arms and breasts.
 Clinical ......
4. Tropical pulmonary eosinophilia
• Pulmonary symptoms: cough, dyspnoea, "asthmatic syndrome".
• Chest X-rays: patchy infiltrates
• Splenomegaly
• High ESR & marked eosinophilia
• No microfilariae in the peripheral blood.
• Serological tests strongly positive
• Responds very well to therapy with DEC

32
 Diagnosis of W. bancrofti
1. BF (taken at night)

 Thin and thick smears

 Concentration methods

• Lyzed capillary blood technique

• Tube centrifugation lyzed blood technique

• Microhematocrite tube technique

• Membrane filtration technique

• Counting chamber technique

 DEC provocation test
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 Diagnosis of W. bancrofti
 Mf in:
 Aspirates of hydrocele
 Lymph gland fluid
 Chylous urine
2. Intradermal test (antigen from Dirofilaria immitis)

3. Serological tests as IHA, IFA

4. Antigen detection: ICT filariasis test

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 Differential diagnosis
• Podoconiosis (syn. lymphatic siderosilicosis or
lymphoconiosis): caused by long-term exposure of bare
feet to irritant soils(red clay soil).
– Very slow onset of oedema

– Lymphoedema

– Elephantiasis (mostly limited to below the knee)

• Caused by immune response to certain minerals.

• No hydrocoele, eosinophilia, nocturnal microfilaraemia
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 Treatment of W. bancrofti
 Diethyl carbamazine (DEC)
 General measures:
 Rest, antibiotics, antihistamines, and bandaging

 Surgical measures for elephantiasis

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 Prevention and control of W. bancrofti
 Control of mosquitoes
 Avoid mosquito bite
 Treat patients
 Health education
 Global LF elimination program strategy:
 Mass drug administration
 Care for chronic cases

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Loiasis
 Loiasis
• Caused by filarial worms living in subcutaneous tissue

• Causative agents
• Loa loa (Eye worm)
• Distributed in Rain Forest areas of West Africa
and equatorial Sudan.
 Loa loa (Eye worm)
 Habitat:
 Adults live in:
 Connective tissues under the skin
 Mesentry
 Parietal peritoneum
 Subconjunctival tissue of the eye or thin skinned areas

 Microfilaria in peripheral blood of man during day time

 Infective larvae in the gut, mouth parts and muscles of

chrysops

41
 Transmission
• Horse flies (Tabanidae) in genus Chrysops

• Day-feeding & forest-dwelling

• Also called the “deer fly” or mango fly.

Life cycle
 Life Cycle
• Adult worms continuously migrate through tissue at
a rate of about 1 cm per minute.

• Found in back, chest, axilla, groin, penis, scalp and

eyes.
 Clinical manifastation
• Loiasis is often asymptomatic.

• Calabar swellings (episodic angioedema)

– Itchy, red, and nonpitting swollen areas in the skin

– 2-10 cm in diameter, Often painful/may be painless

– In any portion of the skin/wrists & ankles most frequent

 Clinical manifastation
• Adult worms also migrate in sub-conjunctival
tissues.
• They can cause inflammation and irritation but
not blindness
 Laboratory diagnosis
• Mf in stained BF taken during the daytime
• Occasionally the Mf can be found in joint fluid
• Differentiation from mansonella required
(hematoxylin staining)

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 ONCHOCERCIASIS
• Commonly known as river blindness
• The world’s second leading infectious cause of blindness
• WHO estimates the global prevalence is 17.7 million, of whom about
270,000 are blind
 DISTRUBUTION MAP

Foci are present in

Southern Arabia, Tropical Africa
Yemen and in S. & C. between the 15°
America north and the 13°
south
• Occurs most widely along the
courses of fast running rivers in the
forests and Savannah areas of
west and central Africa

• Also occurs in the Yemen, Arab

Republic, Central and South America
 Onchocerca volvulus
• Habitat:

– Adult:

• Subcutaneous nodules and in the skin

• Adults can live ~ 8 – 10 years in nodules

– Microfilariae:

• Skin, eye and other organs of the body

– Infective larvae in:

• Gut, mouth parts and51muscles of black fly

 Onchocerca volvulus
Transmission:
• By the bite of infected blak fly (simulium species)

52
 Life cycle
• During a blood meal, infected blackfly introduces L3 (infective
stage) larvae onto the skin of the human

• L3 penetrate into the bite wound

• In subcutaneous tissues the larvae develop into adult filariae

• Adult commonly reside in nodules in subcutaneous

connective tissues
• Mosquito takes L1 during blood meal and it develop to L3,
She deposits L3 During another blood meal.
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Life cycle of Onchocerca volvulus

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 Clinical feature
Onchocerciasis
• Acute onchocerciasis:
– Itchy (pruritic)
– Erythematous
– Papular rash with thickening of the skin

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 Clinical feature
• Chronic onchocerciasis:
– Elephant or lizard skin: skin atrophy Hanging groin

– Leopard skin: depigmentation River blindness

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 Clinical feature
• Onchocercomata:
– Upper part of the body
(American onchocerchiasis)
– Pelvic region (African form)

• Nodules surrounded by
concentric bands of fibrous
tissue

57
 Laboratory diagnosis
• Mf in skin snips

Skin biopsy Skin

fragment
• Mf in urine, blood & most body fluids (in heavy
infection)
– Wet mount preparation Staining

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 Prevention and control
• Destruction of Simulium

• Avoiding Simulium bites

• Treatment of communities (~APOC)

59
 Treatment
• Ivermectin:
– Paralysis of worms

– Reduces the microfilarial load

• Surgical Care:
– Nodulectomy

– Removes adult worms

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Trichinellosis
 Trichinella spiralis
 A tissue nematode caused by Trichinella spiralis
 Zoonotic disease
 Disease in humans: Trichinosis, Trichiniasis,
Trichinelliasis, Trichinellosis
 Distribution: Temperate regions where pork is
eaten
1. T. Spiralis spiralis – found in temperate regions
2. T. Spiralis nativa – found in the Arctic
3. T. Spiralis nelsoni – found in Africa and S. Europe

62
 Trichinella spiralis
 Habitat:
 Adults in the small intestine of man and animals
specially pigs and rats (reservoir hosts)
 Larvae : encysted in muscles

63
 Morphology
Encycted larva: in cyst wall formed by tissue reaction
 Larva (1mm) coiled inside the cyst (0.5 x 0.2 mm)
 Larva grows from 0.1 to 1mm (~ 2 weeks to become
infective)
 Lies along the longitudinal axis of muscle fibres
 Cyst usually become calcified

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 Transmission
• Eating flesh of infected pork (raw/undercooked)

65
Life cycle

66
 Life cycle
 The same host (animal/man) act as DH & IH
 After fertilization, males die and are expelled.
 Females penetrate deeply in the mucosa and lay
 Female lays ~ 1500 larvae in its life span (~ 2 months)

67
• Larvae to the circulation
• Passes through pulmonary filter
• Distributed all over the body (esp. diaphragm, tongue, eye, deltoid,
pectoralis, intercostals, etc)
 Larvae coil and encyst in the long axis of muscles

 Pigs become infected by eating infected flesh from other pigs or ingestion
of infected dead pigs and rats
 Rats are infected by eating flesh of dead pigs or rats and by canibalism

68
 Life cycle
 Larvae liberated from the cysts in small intestine
and mature to adults
 Larvae start to be deposited by the female

69
 Pathogenicity
 Intestinal invasion by adult worms
 Abdominal pain, nausea, vomiting, diarrhoea and
colic.

70
 Migration of larvae

71
 Encystment of larvae
 Manifestations depend
up on organs affected.
 > 50 – 100 larvae/gm of
muscle are symptomatic
 < 10 larvae are often
asymptomatic

72
 Clinical signs & syptoms
 The main findings are:

o Oedema chiefly orbital

o Muscle pain and tenderness

o Headache, fever, rash, dyspnoea, general weakness

o Death occurs in severe cases from exhaustion,

heart failure (myocarditis), pneumonia, etc.

73
 Laboratory diagnosis
1. Immunodiagnosis:
a) Intradermal test (Bachman test)
b) Serological tests:
• Bentonite flocculation (BF)
• Latex agglutination (LA)
• Counter – current electrophoresis (CEP)
• Complement fixation test (CFT)
• IFA and IHA

74
 Diagnosis .....
2. Muscle biopsy:
• Direct examination
• After digestion in a pepsin hydrochloric acid medium

3. Eosinophilic leucocytosis in the acute stage

75
 Prevention & control
 Thorough cooking of pork
 770c or freezing at – 150c for 20 days
 – 180c for 24 hours
 Proper breeding of pigs
 Sterilizing garbage
 Antirat campaign
 Inspection of pork in slaughter houses
 Trichinoscope.

76
 Treatment
 Non specific symptomatic treatment:
 Sedatives
 Cortisone and ACTH
 Supportive treatment:
 Rest, fluids, smooth diet and vitamins
 Thiabendazole
 Mebendazole

77
Dracontiasis
Dracunculus medinenis
“Guinea worm, ”
 Dracunculosis
 Synonyms: Dracontiasis, Dracunculosis, Dracunculiasis

 Causative agent
 Scientific name: Dracunculus medinensis
 Common name: Medina worm or Guinea worm

80
 Epidemiology

• Most common in areas of limited water

supply where individuals acquire water
by physically entering water sources.
– “Walk-in well”
– Water holes in parts of Africa
 Distribution of
Dracunculus medinensis
Global: Nile
valley, India
and areas
where wells
are used for
water supply
Ethiopia:
around
 Dracunculosis
 Habitat:

 Adults in subcutaneous tissues of man/reservoir

animals

83
Life Cycle of Dracunculus medinensis

Infective larvae
In water, larvae Must be eaten by Copepod
(Crustacean), the IH,
 Life cycle of D. medinensis
 3rd stage larva get consumed when humans drink water with infected
copepods.
 In the small intestine, the cyclops is digested , larvae liberated and
penetrate through the duodenal wall and migrate to the subcutaneous
tissues probably via lymphatics.
• At this point the females are fertilized by the males, and the males die.
The females then migrate to the skin, reach sexual maturity, and produce
juveniles.
 They tend to go to parts most likely to come in contact with water as the
lower extremities (positive hygrotropism and geotropism to produce larva)
 Several months (9 or more) elapse between infection and appearance of
the gravid female at the skin surface

85
 Life cycle of D. medinensis
 Male dies after copulation
 The cephalic end of the fertilized female pressing on the
skin, produces a papule that becomes a blister and then
ruptures forming an ulcer
 When the ulcer contacts water, a loop of the uterus
prolapses through a rupture in the anterior end of the
worm and larvae are discharged.
 . They penetrate its intestine and settle in the body cavity
to become infective in about 3 weeks

86
Copepod

87
Life Cycle of D. medinensis

88
 Pathogencity of D. medinensis
 Early manifestatiosn are produced when the female worm approaches
the skin. It liberates a toxic substance that results in local erythema,
tenderness and pain.

 This is followed by formation of a blister that turns into a cesicle and

ultimately ulcerates

 There may be local or systemic symptoms as urticaria, pruritus, pain,

dyspnoea, nausea and vomiting, which subside with rupture of the
blister

 The ulcer may be secondarily infected producing cellulitis and induration

 Eosinophilia

89
Before  The cephalic end
of the fertilized
female pressing
on the skin,
produces a papule
that becomes a
blister and then
After ruptures forming
an ulcer
Adult worm of D. medinensis

91
Adult worm of D. medinensis

92
 D. medinensis

Blister containing the worm Ruptured blister with filamentous worm

A B
93
D. medinensis

94
 D. medinensis

Adult Dracunculus in foot

95
B
 Diagnosis of D. medinensis
 Laboratory tests to investigate dracunculiasis are limited
because the larvae are normally washed into water

 A diagnosis is usually made when the blister has ruptured

and the anterior end of the female worm can be seen

96
 Diagnosis of D. medinensis
 If required, laboratory confirmation of the diagnosis can
be made as follows:
1. Place a few drops of water on the ulcer to encourage discharge
of the larvae

1. After a few minutes collect the water in a plastic bulb pipette

or pasteur pipette

3. Transfer the water to a slide and examine microscopically using

10x objective – motile larvae will be observed

97
Adult D. medinensis

98
 Prevention & Treatment
• People with an open Guinea worm wound should not enter ponds or
wells used for drinking water.

• Water can be boiled, filtered through tightly woven nylon cloth, or

treated with a larvae-killing chemical.

• No medication is available to end or prevent infection.

– The only treatment is to remove the worm over many weeks by winding
it around a small stick and pulling it out a tiny bit at a time.

– Sometimes the worm can be pulled out completely within a few days, but
the process usually takes weeks or months.

– The worm can be surgically removed before the wound begins to swell.

– Antihistamines and antibiotics can reduce swelling and ease removal of

the worm.
 The Arthropod Vectors of
Infectious Disease
• Arthropods – exoskeleton and jointed legs;
includes arachnids and crustaceans; many must
feed on blood and tissue fluid of host during
life cycle; ectoparasites
• Those of medical importance transmit
infectious microbes in the process of feeding –
biological vectors

100
Insects
•Mosquitoes – require an aquatic habitat; females take
blood meal transmitting disease: malaria, filariasis,
zoonoses
•Fleas – highly motile, flattened bodies; feed on warm-
blooded animals; carry zoonotic diseases: plague,
murine typhus
•Lice – small, soft; attach to head and body hair feeding
inconspicuously on blood and tissue fluid; release feces
that contaminate wound; epidemic typhus, relapsing
fever
•Flies – tsetse fly, sand fly, black fly

101
 Arachnis
• Ticks – cling on vegetation and attach to host
on contact; larvae, nymph and adults get
blood meal by piercing skin of host
– hard ticks – Dermacentor, Ixodes – small compact,
rigid bodies; transmit rickettsial, borrelial, and viral
diseases
– soft or argasid ticks – Ornithodoros- flexible outer
bodies; transmit relapsing fever

102
 Reading assignment
• Hydatidosis
• Fascioliasis