UNIT-TWO

HELMINTHS

18/02/2023

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 Objectives
At the end of this session, students will be able to:
Define helminthes

Describe the general features of helminthes

Discuss the characteristics of each nematode

Explain the life cycle of each nematode

Apply the necessary laboratory procedures for the

detection and identification of nematodes

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 Introduction to Helminths
 Medical Helminthology:
 Study of the parasitic worms and their
medical consequence
Helminths derived from the Greek word
“helminthose” meaning worm.
 Belong to two major groups of animals
i) The round worms (Nematodes)
ii) The flat worms or Platyhelminthes
- Cestodes and
- Trematodes
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 Classification

HELMINTHES

NEMATHELMINT PLATYHELMINTHES
HES
(Flatworms)
(Round worms)

TREMATODES CESTODES

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 General features of Nemathelminths

• Round in cross-section
• Unsegmented
• Digestive system complete
 Possess mouth, oesophagus and anus
• Have separate sexes
• Can be oviparous/ovoviviporous/viviparous
• Egg (ova) -Larva(L1-L4)-Adult

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 Classification of Nemathelminths
A. Intestine nematodes B. Blood & tissue
• Adults or larval stage in nematodes
the intestine • Adults or larval stage
in tissue
Small intestine
• Filaria
• Ascaris lumbricoides • Wuchereria
• Hook worm bancrofti
• Strongyloides • Brugia malayi
stercoralis • Burgia timori
Large intestine • Onchocerca volvulus
• Trichuris trichuria • Loa loa
• Enterobius vermicularis • Trichinella spiralis,
• Draconculus medinensis
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 INTESTINAL NEMATODES
General features
• Humans are the only or major host of intestinal
nematodes

• Live in gastro-intestinal tract

• Often spread by poor hygiene related to feces

• Most species are geo-helminths (soil transmitted)

• Female worms are oviparous

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 Transmission
Usually only two sites of entry for intestinal nematodes
infecting humans:
Ingestion of infective egg
Larva penetrating skin
Laboratory diagnosis:
 Eggs ( most often) and Larvae in faeces
 Recovering egg in the skin around the anus (perianal
area)
• Occasional adult worms: A. lumricoudes, E. vermicularies

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 Intestinal nematodes infecting humans includes
• Ascaris lumbricoides
• Trichuris trichiura
• Enterobius vermicularis
• Strongyloides stercoralis
• Ancylostoma duodenale
• Nectator amircanus

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 1. Ascaris lumbricoides
 Also known as largest intestinal round worm
 Are pathogenic in their adult stage
Epidemiology
 world wide,
1.45 billion people infected annually
 High prevalent area with poor sanitati
School children are most affected
High in moist tropical countries
In Ethiopia
the commonest nematode parasite of man
The prevalence ranges from 17% to 77.7%
Distribution is affected by altitude and climate
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 A. lumbricoides…
Habitat
Adult: In the small intestine
Reservoir: human
Egg: In the faeces
 extremely resistant to adverse
environmental condition and chemicals
 Remains viable in soil and dust for up to
10 and above years
Incubation petiod (IP): 4-8 weeks
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 Transmission and Life Cycle
• Transmission
• A. lumbricoides is spread by faecal pollution of soil
• Infective stage: embryonated egg (egg containing 2nd
stage larva)
A person acquires infection by
1- Ingestion of food or water contaminated with
embryonated eggs
2- eating soil(geophge) frequently seen in children
3-putting contaminated finger or toys with infective egg in
to mouth
4- rarely by inhalation of eggs carried in air
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 Life cycle and transmission
• Transmission Environment
6.egg became infective
1.Infective eggs ingested in (embryonated in soil in 30-40
foods, or from hands days)
Contaminated with faeces 7. Infective eggs contaminate
the environment

• Human host

2.larvae hatch migrate through Liver and

lungs
3. Pass up trachea and swallowed
4. became mature worms in small intestine
5. Eggs produced & passed through faeces
 Pathogenesis
1. “Verminous” pneumonia, lung tissue damage
due to migratory larvae.
2. Bowel obstruction - too many adult worms.

3. Parasite secretes trypsin inhibitor, prevents

host from digesting proteins.

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 Clinical features
• Most infection are asymptomatic
• Abdominal pain and discomfort
• Malabsorption of nutrients
• Stunted growth, cognitive impairment
• Intestinal obstruction by high worm numbers
• Wandering worms: causing pathogenesis
• Intestinal perforation: peritonitis
• Blockage of bile ducts
• Obstruction of respiratory tract
• Liver abscess
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 Laboratory Diagnosis
A. Finding and identification of eggs in the stool.

B. Adult worms occasionally passed in the stool or

through the mouth or nose
C. Larvae can be identified in sputum or gastric aspirate
during the pulmonary migration phase
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Treatment
• Mebendazole, 200 mg, for adults and
• 100 mg for children, for 3 days is effective
• Albendazole
Prevention and Control
1.Prevention of infection by
 washing hands before eating & trimming finger nails
 Avoid eating uncooked foods such as vegetables
2. Preventing soil become fecally polluted by
• sanitary disposal of faeces in latrines
3.Treatment and health education
• Mass de-worming programmes repeated at 3-6 month
intervals, have been advocated in areas of high prevalence
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 2. Trichuris trichiura
• Common name : whipworm, due to the whip-like form of the
body.
Habitat
 Adult: large intestine
• Reservoir-human
 Eggs: In the faeces, not infective when passed
• IP: indefinite
Distribution: world-wide, common in warm areas
- 1.5 billion people infected annually
• children are more affected (3-11 yrs old)
In Ethiopia: One national survey showed 36.1%

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 Transmission and life Cycle
 Transmission
 Ingestion of embryonated egg in contaminated
food, water, or from contaminated hand

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Clinical Features and pathology
Are largely determined by the worm burden:
 < 10 worms are asymptomatic (99% asymptomatic)
 Heavy worm burden mechanical damage to the
intestinal mucosa
 Chronic profuse mucoid & bloody diarrhea,
abdominal cramps and severe rectal tenesmus
Edematous prolapsed rectum ( in serious infection)
especially in children
 Laboratory diagnosis
1. Finding of characteristic eggs in faeces
2. Sigmoidoscopy may enable visualisation of worms
 Treatment
Mebendazole, 200 mg for adults & 100 mg for
children, for 3 days is effective.
Albendazole: Alternative
Prevention and control
• Sanitary disposal of faeces in latrine
• Avoidance of the use of night soil as a fertilizer
• Treatment of infected individuals and health
education
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 3. Enetrobius vermicularis “Pin Worm”
 Geographical distribution
• Cosmopolitan, highly prevalent in areas of poor sanitary
condition , children are more commonly infected
In Ethiopia
Prevalence rate up to 1% were reported in routine stool
examination methods
Habitat
Adult: small intestine Caecum, appendix and adjacent portion
of the ascending colon
Gravid female: Caecum and rectum
Eggs: deposited on perianal skin and occasionally in faeces

IP: 2-6 weeks

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 Transmission and life cycle
Transmission:
Person - to- person transmission (ingestion of eggs)
Exposure to viable eggs in the soil (Ingestion)
Eggs remains viable for several weeks

Autoinfection: occurs by transferring infective eggs to the mouth with

hands that have scratched the perianal area
Children who suck their fingers are more likely to be infected
• Air borne: Some small number of eggs can also be inhaled and ingested

• Retro infection : the migration of newly hatched larvae from the anal
skin back into the rectum

• Ingestion of embryonated eggs, usually carried on fingernails, clothing,

bedding or house-dust.

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Life cycle of E.vermicularis

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 Pathogenesis and Clinical features
• Mild perianal itching
 Irritability, disturbed sleep because of the irritation
• Vulvovaginitis, & even urethritis may occur in girls
• Pneumonia during heavy larva migration
• Abdominal pain or appendicitis resulting

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Laboratory Diagnosis
1.Finding eggs from perianal skin using adhesive tape or
swab method tape ("Scotch test", cellulose-tape)
2. Finding eggs in the faeces
3. Finding of female worms from perianal skin or faece
Treatment
Mebendazole (100 mg once) is an alternative
 Albendazole 400 mg once
*The whole family should be treated, to avoid reinfection
Prevention and control
• Proper disposal of human excreta
• washing hands after using toilet and before eating
• Treating all members of a family in which infection has
occurred
• avoidance of putting fingers in the mouth & trimming finger
4. Strongyloides stercoralis “Dwarf thread worm’’
Geographical distribution
- world wide
• An estimated 50 to 100 million cases
In Ethiopia:
• Not highly prevalent in most areas and is found in the
same geographical areas with hookworm

 Reservoir: human

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 Habitat
• Has both free living and parasitic generations
• Parasitic males are absent
• Parasitic adult females : reside in the mocusal
epithelium of the small intestine of human which
produce eggs parthenogenically (parthenogenesis)
• Free living male and female: in the external
environment
• Rhabditiform larvae ( diagnostic stage ) : Passed in the
faeces & external environments
• Filariform larvae ( infective stage ) : in the soil & water
• Egg : laid in the sub mucosa of small intestine
 Transmission and life cycle
Transmission:
Commonly - penetration of the skin by the
filariform larvae from the soil

Ingestion of food or drinks contaminated with

filariform larva

Internal or external autoinfection with rhabditi

form larva

Rarely: transmammary

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 Life cycle
• Strongyloides life cycle is more complex than
that of most nematodes with its alternation
between:
• free-living and
• parasitic cycles, and
• its potential for autoinfection and
multiplication within the host.
• Two types of cycles exist:
• 1.Free-living (indirect) cycle
• 2. Parasitic (direct) cycle
Life cycle of S.stercoralis

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 Clinical features and pathology
• People with weaker immune systems such as elderly
people & children are more susceptible.
Cutaneous phase: itching & erythema at the site entry
Pulmonary phase: Pneumonia during heavy larva
migration
Intestinal phase : Invasion by adult worms may produce
abdominal pain, mucoid diarrhea , nausea, vomiting,
anemia
Hyperinfection syndrome
 characterized by massive larval invasion of the lung or
any other organ including CNS, which is fatal
 occurs when the immune status of the host suppressed
by either drugs, malnutrition or the concurrent
diseases
 Laboratory diagnosis
1. Finding the larvae in faeces or duodenal aspirates using
microscopy
In hyper-infection syndrome the larva may be found in
sputum, urine and other specimens
2. Serological tests
Treatment
 Ivermectin or thiabendozole
Prevention and control
1. Sanitary disposal of faeces in latrine
2. Avoidance of use of night soil as a fertilizer
3. Wearing protective footwear
4. Treatment of infected individuals and Health education
Are hematophagous nematodes
Two major species
Ancylostoma duodenale/old world H.worm
Necator americanus/New world H.kworm
Less important : A. ceylanicum, A. braziliense, A. caninum , A.
tubaeforme, A. buckleyi
Geographical distribution
Found in all tropical and sub tropical countries
 N. americanus is the most widespread hookworm globally.
• Although most of those affected are asymptomatic,
approximately 10% experience anemia.
In Ethiopia
• Necator americanus is more common than Ancylostoma duodenale
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 Cont…
Habitat
• Adult: Jejunum & less often in the duodenum of man
( female lay 10,000-30,000 eggs/day)
• Eggs: In the faeces; not infective to man

• Rhabditiform & filariform larvae: free in the soil & water

• filariform larvae are the infective stage

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 Transmission and life cycle
• Penetration of the skin by filariform larvae from the soil
• Ingestion of the filariform larvae present in the soil
• Transmammary and transplacental-- rare
 Clinical features and pathology
1. Dermal (Cutaneous) ground itch : Local erythema
2. Pulmonary Migration of larvae , Bronchitis, pneumonia
and eosinophilia
3. Intestinal
• Attachment of adult worms and injury to upper intestinal
mucosa, feed on blood
Blood loss up to 200 ml per day in heavy infections
 chronic infection the main symptoms are:
- Iron deficiency anemia (microcytic, hypochromic) with pallor,
- Edema of the face and feet
- Hemoglobin level 5 gm/dl or less
• Malnutrition, stunt growth & poor mental development in
children
Laboratory diagnosis
Finding eggs in faeces
• Microscopic identification of eggs in the stool is the most
common method
Treatment
• Mebendazole or albendazole
• If anemic : high protein diet supplemented with
ferrous sulphate, folic acid and vitamin B12
Prevention and control
Similar to Strongyloides stercoralis
Blood and Tissue Nematodes

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 Three families/ groups
1. Family Filaridae (Filarial 2. Family Trichineloidae
worm)
 Trichinella species
Common/pathogenic filaria
• Wuchereria bancrofti
• Brugia malayi 3. Family Dracunculidae(
• Brugia timori guinea worm)
• Loa loa • Dracunculus medinensis
• Onchocerca volvulus
• Less/non-pathogenic Filaria
• Mansonella perstance
• Mansonella streptocerca
• Mansonella ozardi

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 Filarial nematodes (Family filaridae)

Filarial worms are widely distributed in nature. live as

adults in various human tissues
Arthropod-borne worms that reside in
Subcutaneous tissues
Deep connective tissues
Lymphatic system or
Body cavities of human (depending on the type
species)
Females produce large number of microfilaria
(viviparous) which may be sheathed or
unsheathed
Filarial...
It includes 8 species where humans are definitive
hosts
 Wuchereria bancrofti, Brugia malayi and Brugia
timori = cause lymphatic filariasis
 Loa loa= calabar swelling and allergic
manifestations
 Onchocerca volvulus= dermatitis and eye lesions,
causes river blindness
 Mansonella streptocerca= skin disease
 Mansonella ozzardi and Mansonella Perstans are
thought to be non pathogenic.
 Filarial…

Morphology
Adult
 The adults are long
thread like worms.
(long and slender)
 Measure 2 cm – 120
cm
 Release microfilaria
which live in blood or
dermis (skin)
Filarial…
Microfilaria
• The immature first stage larva of filarial worms
• Are motile and live in blood or dermis
• Rounded or pointed tail
• Can be sheathed or unsheathed
 Filarial…
Periodicity
• Microfilariae (mf) of pathogenic filarial worms that
found in the blood which causes lymphatic filariasis
and Loiasis show periodicity
• Mf are found in the blood in greater number in a
certain hours of a day or night
• Corresponds to peak biting times of their insect
vector
 Filarial…
• Nocturnal periodicity: microfilariae are present in
greatest numbers in the peripheral blood during night
hours, e.g. periodic W. bancrofti, B.malayi and
B.timori

• Diurnal periodicity: microfilariae are present in

greatest numbers in the peripheral blood during day
hours, e.g. Loa loa

• Nocturnal sub-periodicity or diurnal sub-periodicity:

mf can found in blood 24 hrs with only slight increase
in number during night or day hrs.
Filarial…

Filarial worms cause 3 main diseases

1. lymphatic filariasis (Elephantiasis)
2. Loiasis
3. Onchocerciasis (river blindness)
 Lymphatic Filariasis

• Disease caused by filarial worms living in the human

lymphatic system
• Causative agents
• Wuchereria bancrofti
• Brugia malayi and 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”
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 Lymphatic…
• Large numbers are present in the lymphatics
of the:
 Lower extremities (inguinal & obturator
groups),
 Upper extremities (axillary lymph nodes), &
 Male genitalia (epididymis, spermatic cord,
testicle) - particular for W. bancrofti

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 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
• Psychological trauma
• Sexual disability
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Social consequences…..

2. The disease impedes

• Mobility
• Travel
• Educational
opportunity
• Employment
opportunity
• Marriage
prospect
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Wuchereria bancrofti

Disease: Bancroftian filariasis, Wuchereriasis,

elephantiasis
• Requires two host
• Human-DH, Mosquitoes-IH

• Transmission
• Bite of female mosquitoes (Genera Culex,
Aedes, Anopheles)
Transmission and life cycle
Clinical manifestation
1. Many infections are asymptomatic
2. Circulating Mf probably do not cause
pathology

The main pathological lesions are:

a) Inflammatory manifestations: due to toxic
products of living or dead adult worms
 Clinical manifest…

b) Obstructive manifestations
Fibrosis following the inflammatory process
Coiled worms inside lymphatics
This may result in:
Dilatation/enlrgment
Rupture of distended lymphatics in the
. urinary passage – chyluria
. peritoneal cavity – chylous ascites
. In the testis – chylocoele
 Differential diagnosis
• Podoconosis (syn. lymphatic siderosilicosis or
lymphoconosis):
• crystalline blockage of the limb
• Very slow onset of edema
• 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
Prevention and control
• Avoid mosquito bite
• Control of mosquitoes
• Treat patients
• Health education

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Loa loa (Eye worm) Loiasis
Caused by filarial worms living in subcutaneous tissue
Causative agent:
Loa loa (Eye worm), African Eye worm
‘Eye worm’ because adult worm sometimes migrate
across the conjunctiva or eyelid
Distributed in Rain Forest areas of West and central Africa &
equatorial Sudan.
 Loa… Habitat

Adults live in:

 Subcutaneous and deep connective tissues
 Subconjunctival tissue of the eye or thin skinned areas
Microfilariae
 Found in peripheral blood of man
 Diurnal periodicity – peak hours about midday
Infective larvae : in the gut, mouth parts and muscles of chrysops /
Horse flies

Adult Loa loa in the process of surgical removal after its subconjunctival migration.
 Transmission

• Horse flies (Tabanidae) in genus

Chrysops

• Day-feeding & forest-dwelling

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

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 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.

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Clinical manifestation
Loiasis is often asymptomatic.
Calabar swellings (episodic angioedema)- the most
common pathologic sequelae associated with L. loa.
Itchy, red, and non pitting swollen areas in the skin
In any portion of the skin/wrists & ankles most
frequent
Laboratory diagnosis
• Finding the characteristic microfilariae in stained blood films
taken during the day time
Treatment
• Diethyl carbamazine (DEC) is effective against both adults
and microfilaria
• Albendazole
• Ivermectin
• Anti-inflammatory drugs
Prevention and Control
• Avoid deer fly (chrysops) bite E.g. wearing protective
clothing
• Destruction of chrysop E.g. - Using insecticides
• Treatment of infected individuals
• Health education
Onchocerca volvulus
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
 Oncho…
Occurs most widely along
the courses of fast running
rivers in the forests &
Savannah areas of west and
central Africa
Relevance to Ethiopia:
Endemic in a large fertile
western, southern and
north western part of Ethiopia
• 27.8% settlers and
38.6% indigenous were
found infected in pawe
western Ethiopia
 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 and muscles of black fly
Transmission:
• By the bite of infected vector (simulium species), black fly

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Clinical feature
Onchocercomas: These subcutaneous nodules, which can be
palpable and/or visible, contain the adult worm

Hanging groin
 Clinical..
Skin diseases
Chronic :the skin loses its elasticity & becomes
wrinkled: elephant skin
-also lose pigment :leopard skin

Elephant or lizard skin Leopard skin

Clinical..
Ocular manifestation
When microfilariae in the skin of face migrate in to the
eye
 consists of trapping of microfilaria in the cornea, iris &
anterior chambers, leading to photophobia, lacrimation
& blindness
 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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 Treatment
• Ivermectin:
• Paralysis of worms
• Reduces the microfilarial load
• Surgical Care:
• Nodulectomy
• Removes adult worms
Prevention and control
• Destruction of vector (Simulium)
• Avoiding Simulium bites
• Treatment of communities
• Vaccination is on trail
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Dracunculus medinenis(Guinea worm)
• Dracunculosis
Guinea worm disease, considered a Neglected Tropical
Disease, affects poor communities in remote parts of
Africa that do not have safe water to drink.
• Causative agent
Scientific name: Dracunculus medinensis
Common name: Medina worm or Guinea worm
• Habitat: Adults/femal/ in subcutaneous tissues of man:lower
extrimites; especially around the ankle.

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Life Cycle

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

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Adult worm of D. medinensis

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Laboratory Diagnosis
 A diagnosis is usually made when the blister has
ruptured and the anterior end of the female worm
can be seen
 examine microscopically using 10x objective – motile
larvae from water
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.
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 TREMATODES(flukes)

unsegmented leaf-shaped worms 82

 Trematodes (Flukes)
Introduction to Trematodes/Flukes
Basic characteristics:
• Leaf like, leaf shaped (except schistosomes i.e. cylindrical)
• Unsegmented
• Hermaphrodite ( except Schistosoma species)
• Digestive tract present, but no anus
• Attach to their host by means of suckers(holes)
=trematoda = "body with holes."
Oral sucker – at anterior end surrounding the mouth ,
no hooks.
Ventral sucker (acetabulum)– posterior to the oral
sucker

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 General characterstics
 Are
generally flat, unsegmented, leaf shaped
worms (exception, schistosomes- cylindrical)

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 Classification Based on their habitat

• Liver fluke. • Intestinal fluke

 F buski
F. hepatica
 H. hetrophyes
F. gigantica reside in liver  M. yokogawi

O. vivereni • Blood fluke

C. sinensis reside in bile duct  S. mansoni
 S. hematobium
• Lung fluke  S. japonicum

P. westermani  S. intrecalatum

 S. mekongi
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 Life cycle
• The life cycle is passed in two hosts

• involving one or more intermediate hosts

1. Definitive host: harbour the sexual(adult) stage of

the parasite
• Man (DH)
• Other animals (RH)

2. Intermediate host: harbour the asexual stages of the

parasite, Snail (molluscan host)
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Blood Flukes
General Characteristics
The adults flukes depending on species live in the veins that
drains the intestine or urinary bladder

Adults are Cylindrical shaped

Sexes are separate (dioecious)

Cercaria is the infective stage to humans

Second to malaria among parasitic diseases regarding public

health importance

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 Cont…
There are five medically important species:

1. Schistosoma mansoni

2. Schistosoma haematobium

3. Schistosoma japonicum

4. Schistosoma mekongi

5. Schistosoma intercalatum
Causes the disease Schistosomiasis or Bilharziasis or snail fever

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 Geographical Distribution
• Wide spread species
• Schistosoma mansoni
• Common name: Manson’s blood fluke
- causes intestinal schistosomiasis
- Endemic in 52 countries
- It is wide spread in many African countries,
Madagascar, part of the Middle East, South
America, and Caribbean
 Water development project for water conservation,
irrigation, and hydroelectric power have contributed
to the spread of S. mansoni and changes in its
distribution.

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Schistosoma haematobium
• Common name: Vesical blood fluke
• Causes urinary schistosomiasis
• Endemic in 54 countries, mainly in Africa and Middle East.
• It is also found in India and several Indian Ocean Islands

Ova of Schistosoma
haematobium

cercaria

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Schistosoma japonicum
• Common name: Oriental blood fluke

• cause intestinal schistosomiasis

• Common in parts of Japan, China, Taiwan,
Philippines, Thailand, and other parts of
Southeast Asia

91
 Cont…
• Less wide spread species
• Schistosoma mekongi
- Occur in the Mekong River basin in Thailand, Cambodia, and
Laos
- cause intestinal schistosomiasis
- Looks very much like S. japonicum egg
(very small hook-like spine, may be difficult to see)

- Schistosoma intercalatum
- found in Central and Western Africa
- cause intestinal schistosomiasis
- Egg resembles S. haematobium egg
. Terminal spine
92
 Cont….
Habitat:
 Adults (male and female )
• S. mansoni –In the mesenteric venous(veins of Large
Intestine)
• S. haematobium – veins of bladder, prostate, seminal
vesicle
• S. japonicum – veins of small intestine
Egg:
 In the faeces ,rarely in urine (intestinal schistosomiasis )
 In the urine ,rarely in faeces(urinary schistosomiasis )
Cercariae:- In fresh water, infective to man

93
 Schistosomiasis in Ethiopia
 In Ethiopia
Intestinal schistosomiasis
 Schistosoma mansoni with infection rates of 30%
to 70% were reported among children in different
parts of the country.
 Reported from all administrative regions
Urinary schistosomiasis
Schistosoma haematobium were reported in
Awash, Wabeshebelle & Assosa
• Both S. mansoni and S. haematobium are endemic in
Ethiopia
• Small streams and irrigation canals are most important
transmission sites

94
Transmission
Water-body contamination with human excreta containing
schistosomal eggs is the key to continued transmission

Typical transmission site (Worke river, Kemisse)

• Transmission: infection
through skin of larvae from
snail hosts.

• Infective stage: cercariae.

• Intermediate host: snail.

• Definitive host: man.

• Mode of transmission:
penetration of skin by cercarie.
Life cycle of Schistosoma species 97
 Immunopathology
• Host immune response against adult worm is minimal

• Eggs induce intense inflammatory reaction ,leading to

granuloma formation
• Granuloma consists of egg at center surrounded
by eosinophils, macrophages and lymphocytes

• Larvae inside the egg produce enzymes (histolytic

enzymes) that aid in tissue destruction and allow the
eggs to pass through the mucosa and in to lumen of
bowel and bladder.
98
Chronic…

• In less than 10% of

cases, granulomas can
cause blockage of
blood flow in liver
causing enlargement
of the spleen and fluid
retention in abdomen.

99
 Laboratory diagnosis
• Microscopic identification of eggs in stool or urine is the
most practical method for diagnosis.
• Stool examination should be performed when
infection with S. mansoni or S. japonicum is suspected,
and
• urine examination should be performed if S.
haematobium is suspected.
• Immunodiagnosis

100
2/17/2023
Treatment
Praziquantel, most effective and most
readily available agent
Prevention and Control
1. Avoid contact with water known to contain cercariae
2. Providing safe recreational bathing & swimming sites
5. Latrine construction and sanitary disposal of faeces & urine
6. Sitting settlements away from irrigation canals,
drains & dams
7. Destroying snail hosts & their breeding sites
 Use of Endod by local production and application
8. Treatment of infected individuals
101
Liver, lung, and Intestinal Flukes
• The trematodes that infect liver, lung, and intestine are all
food-borne.

• Freshwater fish, crustaceans (crabs), and aquatic vegetation

are the sources of human infection.

Developmental stages :

102
2. Liver Flukes
General Features
Adults are large and live in the liver or biliary duct

 They are hermaphrodite

Include
Fasciola hepatica
Fasciola gigantica
Clonorchis sinensis
Opisthorchis viverrini
Opisthorchis felineus
103
 Fasciola hepatica
Common name: sheep liver fluke or liver fluke
Geographical Distribution
Cosmopolitan; prevalent in most sheep and cattle raising
countries
Fascioliasis is primarily a zoonotic disease that causes liver
infections with adult flukes
F. hepatica was the first trematodes to be described
 it is an important parasite of sheep and cattle
In Ethiopia
does not play an important role in human health
Causes serious economic loss throughout the highlands
by infecting cattle and sheep
- The disease is known as liver rot
104
 Habitat and morphology
• Adult: In the bile duct of sheep, goat ,
cattle, horse, camel & man

• Egg: In faeces, oval with rounded poles Fasciola hepatica adult stage
& marked operculum at one pole

• larva stages: Fresh water snails

• Galba truncatula

• Metacercaria: on water vegetations

105
Life cycle of F.hepatica and F.gigantica 106
Clinical…

Once the worms have established themselves

in the bile ducts and matured, they cause
considerable damage from mechanical irritation
and metabolic biproducts as well as obstruction

In chronic infection:
 obstructive jaundice
 Hepatomegaly
 Persistent diarrhea, anemia

107
Fasciola hepatica in the bile duct

108
 Laboratory Diagnosis
1. Finding Eggs in the faces
 Multiple stool specimens may be required to find the eggs. In light
infection eggs may not be recovered
 Concentration method should be used
 Eggs can also be found in duodenal aspirates &
in bile
2.Testing serum for antibodies: early stages of infection
Treatment
 Triclabendazole
 is 1st line treatment
Biothionol

109
 Prevention and Control
both vector control and parasite control
1. Avoid eating uncooked water plants
2. Treating infected animals & fencing grazing land
known to be infected with metacercariae
3. Identifying & destroying snail hosts & snail
habitat. Using molluscicides / snail killer
4.Sanitary disposal of faeces
5.Treating infected individuals & giving health
education

110
 Fasciola gigantica

Common name: Large or Giant liver fluke

• Closely related to F. hepatica
Geographical Distribution
Widely distributed in tropical Africa including
Ethiopia
Far East, south and south East Asia
Southern Europe

111
 cont…
Habitat
Adult: In the bile duct of sheep, goat , cattle
camel & man
Egg: In faeces, unembryonated
Eggs of Fasciola gigantica can resemble the eggs of
F. hepatica; however, they are somewhat larger

larva stages: Fresh water snail

Metacercaria: on water vegetations

112
113
 cont.
Life cycle
 similar to the life cycle of F.hepatica except the
species of snail hosts infected by F.gigantica are
aquatic( life in wate) not amphibious( adapted to live
in both environments)
e.g. of the genus Lymnaea, Physopis, Radix
Clinical feature and Pathology
 Similar to F.hepatica but less adapted to humans

114
cont...
Laboratory Diagnosis
Finding of Eggs in the faeces
Finding of Eggs in aspirates of the duodenal fluid

Treatment ,
 Similar to F.hepatica
(Biothionol or Triclabendazole )
Prevention and Control
 Similar to F.hepatica

115
3.Intestinal Flukes
General Characteristics
Adults live in the intestine

They are hermaphrodite

Include
Fasciolopsis buski
Heterophyes heterophyes
Metagonimus yokogawai

116
Fasciolopsis buski
Common name: Giant intestinal fluke
First noted by Busk in 1843- found adult
Geographical Distribution :China, Taiwan, Thailand,
Vietnam, Indonesia

Habitat
• Adults: small intestine of man, pig, dog
• Eggs: In the faeces of man, Pig, dog
• Larval forms: Fresh water snails
• Metacercariae: encysted on certain aquatic
vegetation
• Human become infected by ingesting the raw or under-
cooked plants containing the matacercaria
117
Life cycle of Fasciolopsis buski 118
Clinical feature and Pathology
Diarrhae,
Ulceration and inflammation of the
intestine,
malabsorption, eosinophilia
Laboratory Diagnosis
Finding eggs in the faeces
Occasionally adult worm may also be passed in
faeces
Treatment
Praziquantel
Prevention and Control
same as Fasciola hepatica
119
4. Lung Fluke
Paragonimus westermani

Common name: Oriental lung fluke

Geographical Distribution
Found in the Far East & African countries : Zaire,
Nigeria, Cameroon & South America
Habitat:
• Adults: In the lung of man
• Eggs: In the sputum of man
• Metacercariae: Fresh water crabs and crayfish

120
Life cycle of P.westermani 121
 Clinical feature and pathology
Causes paragonimiasis
Light to moderate infection are asymptomatic
Symptoms sever pulmonary paragonimiasis: chest
pain , cough, night sweets, pleural effusion, &
coughing up blood
Worms may migrate to the brain where they lay eggs
and cause a granulomatous abscess resulting in
symptoms similar to epilepsy

Paragonimus in lung 122

 Cestodes
(Tape Worms)

123
 General characteristics

• Segmented long tape-like worms

• Vary from few mm to several meters
• Flattened dorsoventrally
• Has no body cavity/alimentary canal, circulatory
system & respiratory system
• Obtains its nutrient by absorption through body
surface.

2/17/2023 124
Morphology
The body is divided in to three main body regions:
Head (scolex) – attachment region
Neck – growth region
Strobila

Scolex (head)

Neck

Strobila made up of
2/17/2023 proglottids 125
Life cycle
• Complete in two host (exception H.nana)

• Habitat: Adult live in small intestine

Human:
• The only or main definitive host for T. Saginata, T.
solium, H. nana and D. latum
• Intermediate host for E. granulosus & E.
multilocularis
• Both as definitive & intermediate host for H. nana
& T. solium 126
 Cont…
Most common cestodes of medically important
include:
o Taenia saginata (Beef tapeworm)
o Taenia solium (Pork tapeworm)
o Hymenolepis nana (Dwarf tapeworm)
o Hymenolepis diminuta
o Diphyllobothrium latum (Broad fish tapeworm)
o Dipylidium caninum (Dog tapeworm)

127
 Taenia species
Habitat
• Adult : in the small intesine of man
• Larvae: in muscular tissues of cattle, pigs
• Eggs: in faeces of man or in gravid segments
• Geographical Distribution:-
• T. saginata
• World wide distribution where cattle are raised &
beef is eaten raw or under cooked.
• Very common in Ethiopia
• studies showed prevalence vary widely, from 2%
to over 70%
2/17/2023 128
 Geographic…
• T. solium
• Not widely distributed as T saginata.
• Common in all areas where raw or partially
cooked pork is eaten.
• Common throughout Mexico, South America
and southern Africa & southern Europe.
• Not reported from Ethiopia

2/17/2023 129
 Transmission and lifecycle
• Transmission
• Humans become infected by ingesting raw or
undercooked meat infected with infective cysticercus
larvae:
• Beef- T. saginata*
• pork meat –T. solium
• T. solium can also be transmitted by :
• Ingesting ova in food or water
• Internal autoinfection
2/17/2023 130
Life cycle of Taenia saginata and Taenia solium 131
 Clinical manifestation
• T saginata
• Taeniasis.
• Usually asymptomatic but may cause dizziness,
abdominal pain, diarrhea, headache and nausea.
• Proglottids obvious in feces.

• Proglottides of T.saginata have a strong tendency to

crawl from the anus during the day when its host is
active unlike Entrobius vermicularis.

2/17/2023 132
 Clinical….
• Taenia solium taeniasis
• Major symptoms are as a result of the adult worm
and its location.
• include abdominal pain, loss of appetite, weight loss,
Unger pains
• Cysticercosis
• when infected by eggs
• larval cysts in lung, liver, eye and brain resulting in
blindness and neurological disorders.

2/17/2023 133
 Laboratory diagnosis
• Detecting eggs in faeces.
• Macroscopic Identification of gravid segments/proglotids in faeces
Treatment
• Praziquqntel in adults 2.5-10mg/kg given in a single dose
• Albendazole: adults 6.6mg/kg or two doses each of
200mg/day on 3consecutive days.
• this drug should not be used in children <2years old or
during pregnancy.

Ethiopians traditional plant medicines: Kosso (Hagenia

abyssinica), Enkoko (Embelia schimperi), and Metere (Glinus
lotoides)

2/17/2023 134
 Prevention and Control
1.Avoid eating raw or insufficiently cooked meat which
may contain infective larvae
The cysticerci can be heat killed at 56oc or by deep
freezing meat for a minimum of three weeks
2. Inspecting meat and condemning any found to
contain larvae
3. Provide latrine for the proper waste disposal
4. Not using untreated human faeces as fertilizer for
pasture land (grazing land)
5. Protection of cattle from grazing on faeces or
sewage polluted grass
6. Treating infected person & providing health
information dissemination
135
 H.nana(Dwarf Tape worm)
• Disease: Hymenolepiasis nana
• Distribution: cosmopolitan (more common in
children)
Geographical Distribution
• H. nana is widely distributed in countries with warm
climates than in cold climates and fairly common in
Ethiopia.
• Prevalent in school children in tropical and
subtropical climates
2/17/2023 136136
 Transmission and life cycle
• Mode of Transmisssion: -
• Ingestion of egg with contaminated food, drink or
finger.
• Autoinfection.

• Life Cycle:

• Has a direct life cycle with a human host serving as

both definitive and intermediate host.
2/17/2023 137
 Clinical manifestations
• Majority of infections are asymptomatic and are
probably associated with low no. of parasites.
• Symptoms are vague abdominal discomfort,
nausea, vomiting, weight loss, diarrhea &
irritability in light infections.
• In heavy infections, ulcerations of the mucosa lead
to enteritis

2/17/2023 138
Diagnosis
• Finding eggs in the feces
Treatment
• Niclosamide (Yomesan): dose of 2g daily for 5consequetive
days
• Praziquantel at a dose of 25mg/kg

Prevention and control

• Personal cleanliness (to avoid autoinfection)
Wash hands before eating & after defecation
• Sanitary disposal of feces in to latrines
• Avoiding eating uncooked food
2/17/2023 139
 Echinococcus granulosus
Common name: Hydatid worm
or minute tape worm of dog.
Geographical Distribution
worldwide, and more frequently in
rural, grazing areas where dogs
ingest organs from infected
animals, sheep for example

In Ethiopia
 pastoral people in the South
and South-East of Ethiopia

140
 Morphology:
• Smallest of all tapeworms
• Scolex, neck, 3 segments
• Largest larval stage of all tapeworms (Hydatid cyst)
Adult: 3 – 6mm
• Scolex with 4 suckers, rostellum with two rows of hooklets
• Strobila: 3 proglottids (1 immature, 1 mature,
1 gravid)
Egg: morphologically indistinguishable from
eggs of Taenia spp.
Habitat
Adult: small intestine of carnivores such as
dog, fox
141
Life cycle of E.granulosus 142
Clinical features and Pathology
The symptoms depend upon the location and size of the
hydatid cyst.
• Causes obstruction and pressure on vital organs
• The majority of hydatid cyst occur in the liver
• Liver cysts cause obstructive jaundice
• Cysts in the lungs may produce cough, dyspnea and chest pain.
Cyst rupture can lead to pulmonary abscesses.
• Large abdominal cysts produce increasing discomfort
• Kidney cysts cause renal dysfunction.
• Brain cysts produce intracranial pressure and epilepsy.
• In bones, the growing hydatid cyst leads to bone erosion and
pathological fractures
143
 Laboratory diagnosis
• Serological diagnosis – ELISA for Antibody detection
• Examination of cystic fluid (for brood capsules and
protoscolices) following surgical removal of a cyst or fine
needle aspiration
• In symptomatic hydatid cyst: X-ray, CT scan, ultrasound
studies are useful
Treatment
• Surgery is the main line of treatment in hydatid cyst disease
• Albendazole
Prevention and Control
• Proper personal hygiene
• Thorough washing of hands after handling dogs
• Periodic deworming of pet dogs is useful
• Preventing dogs access to butchering site or offals of infected
animals is useful in controlling E. granulosus

144
 Diphyllobothrium latum

Common name: Fish tapeworm

Geographical Distribution
Widely distributed in the lake areas of Europe, Asia, Far
East, North America, South America and Central Africa

In Ethiopia: Not reported

145