Class Nematoda - The Roundworms

1. Class Nematoda -The Roundworms Introduction: Nematodes comprise the group of organisms containing the largest number of helminth parasites of humans. They are unsegmented, bilaterally symmetrical, and exhibit great variation in their life cycles. Generally, they are long-lived (1-30+ years). • Both free-living and parasitic forms - some can have both free-living and parasitic stages in their life cycle. • Vary greatly in size - from a few millimeters to over a meter. • Male worms - frequently have a curved or coiled posterior end with copulatory spicules; Some species exhibit a copulatory bursa.

2. Class Nematoda -The Roundworms The adult anterior - may have hooks, teeth, or cutting plates in the buccal cavity. These are used for attachment. • Body is complex - the outer body surface is a cuticle, there are muscle layers underneath. • Internal organs - include a complex nerve cord, a well-developed digestive system and complete reproductive organs. Males have testes, vas deferens, seminal vesicle and an ejaculatory duct. Females have ovaries, oviduct, seminal receptacle, uterus and vagina. • Reproductive capacity - proportional to complexity of life cycle.

3. Class Nematoda -The Roundworms • Humans are definitive hosts. • Arthropods may serve as intermediate hosts and/or vectors. Many nematodes require no intermediate host. • The adult female produces fertilized eggs, or larvae which may be infective to new host. • Eggs may be immediately infective after ingestion by humans.

4. Class Nematoda -The Roundworms • Eggs or larvae require a period of development in the environment to become infective. • Eggs or larvae are transmitted to a new host by an insect. • Developing larvae go through a series of 4 molts with the third stage, the filariform larva, most often being the infective stage.

5. Class Nematoda -The Roundworms • Infection with roundworms can be by ingestion of infective eggs or larvae, by larval penetration of skin, or by transmission of larvae through insect bite. • About one-half of the nematodes parasitic for man are intestinal, the others are found in various tissues. • Pathogenicity of intestinal nematodes may be due to larval migration through tissue, piercing of intestinal wall, blood loss, or allergic reactions to secretions of adults or larvae.

6. Class Nematoda -The Roundworms Terminology: • Filariform larvae - the 3rd or infective stage; Long, thread-like; Designed for penetration. • Rhabditiform larvae - characterized by the presence of a muscular esophagus and bulbular pharynx. The worms leaving the egg are termed “rhabditiform” larvae.

7. Class Nematoda -The Roundworms • Egg - characteristic of the genus. Size & shape are relatively consistent. • Larvae - undergo several molts (third stage usually the infective stage). • Adult -varies in size from genus to genus; Range from less than 1 mm to over one meter.

8. Class Nematoda -The Roundworms General life cycle of intestinal nematodes: • Humans ingest infective eggs. Hookworm and Strongyloides stercoralis are exceptions. In these, filariform larvae penetrate the skin to gain entry. • Larvae hatch in intestine. • Male and female adults develop in the intestine. With Ascaris lumbricoides, hookworms, and Strongyloides stercoralis larvae penetrate the intestinal mucosa and initiate a heart - lung cycle enroute to the intestinal tract to mature to adults.

9. Class Nematoda - The Roundworms • Fertilized eggs are produced. • Diagnostic stages, eggs or larvae, exit the host in its feces. • Larvae develop within the egg in warm, moist soil (except for Strongyloides stercoralis, whose eggs hatch in the intestine, with larvae passing in the feces).

10. Class Nematoda -The Roundworms Enterobius vermicularis - the pinworm. • Most common helminth infection in the U.S.A. • Transmission is direct, person-to-person. • Egg is infective immediately or within hours of being shed by the female. • Common worldwide but more prevalent in temperate climates. • Higher prevalence in Caucasians than in Negroes. • It is a group infection especially common among children. Very often associated with low sanitation and hygiene. • Humans are the only known host. Dogs and cats are not infected.

11. Class Nematoda -The Roundworms Life cycle: • Eggs are ingested, hatch in intestine, larvae mature to adults. • Gravid females migrate to the perianal area at night to lay eggs. • Eggs develop to infective stage within 4-6 hours. Eggs can survive for extended periods in cool, moist environment. • Eggs are found rarely in fecal samples; Release is most often external to the intestines. Dying worms may release eggs in the bowel.

12. Class Nematoda - The Roundworms • Adults -female: creamy white, ~ 8-13 mm long, with sharply pointed tails; Wing-like flaps (cervical alae) at head end; Male: small (2-5 mm) with strongly curved posterior. • Eggs -50 to 60 x 20 to 32 microns, broadly oval, and flattened on one side. Compressed laterally; Normally are embryonated (contain a larva).

13. Class Nematoda - The Roundworms Diagnosis: • Recovery and identification of eggs or adults from the perianal region utilizing the cellophane tape preparation. • Specimens must be collected the first thing in the morning upon waking, especially before bathing or bowel movements. • Eggs are rarely found in fecal samples because release is usually external to the intestines.

14. Class Nematoda -The Roundworms Major pathology and symptoms: • One third of all cases are asymptomatic. • Infections rarely cause serious lesions. • Symptoms associated with the migration of the female out of the anus to lay her eggs include: perianal itching, nausea or vomiting, loss of sleep, irritability, irritation of the intestinal mucosa, and vulval irritation in females due to migrating worms entering the vagina instead of the re-entering anus.

15. Class Nematoda -The Roundworms Trichuris trichiura - the whipworm. Life cycle: • Infective, fully embryonated eggs are ingested, larvae hatch in small intestine, penetrate and develop in the intestinal villi, return to lumen and migrate to the area of the cecum. • Larvae mature and live in the colon. Worms embed their anterior portion (as much as two-thirds of the worm) into the mucosa.

16. Class Nematoda -The Roundworms Life Cycle: (continued) • Barrel-shaped eggs are released into the stool. • Eggs must undergo development in the soil for approximately 10 days to 3 weeks before they become infective. • The worm’s life span is estimated to be 4 - 8 years.

17. Class Nematoda -The Roundworms Morphology: • Adults - females: 35 to 50 mm long, anterior two-thirds is long and threadlike, expanding into a broader posterior; males: 30 to 45 mm long, similar to female but exhibiting a strong curvature of tail. • Eggs - 50 to 55 x 22 to 25 microns, barrel-shaped, with clear polar plug at each end.

18. Class Nematoda -The Roundworms • Diagnosis - recovery and identification of eggs in the feces. Major pathology and symptoms: • Slight infections - usually asymptomatic. • Heavy infections - surface of colon is matted with worms which causesbloody or mucous diarrhea. • weight loss and weakness - infections with 200 or more worms in children may cause a chronic dysentery, profound anemia and growth retardation.

19. Class Nematoda -The Roundworms Major pathology and symptoms: (continued) • Abdominal pain and tenderness. • increased peristalsis and rectal prolapse, especially in children.

20. Class Nematoda -The Roundworms Distribution: • In the U.S.A., prevalent in the warm, humid climate of the southeastern states. Commonly found in refugees from tropical areas. • The third most common intestinal helminth infection. • Higher prevalence in warm countries and areas of poor sanitation, especially in countries which utilize "night soil" for fertilizer. • Common among children and in the institutionalized mentally retarded. • Commonly seen along with Ascaris lumbricoides because of the similar mode of infection.

21. Class Nematoda -The Roundworms Ascaris lumbricoides - Large Intestinal Roundworm Life cycle: (complex, involves a heart-lung cycle) • Humans ingest embryonated eggs containing infective larvae. • Larvae hatch from the eggs in the small intestine, penetrate the intestine wall, enter the bloodstream, migrate to the liver, travel to the lung via the blood stream. • Larvae break out of lung capillaries into alveoli, travel to the bronchioles, and are coughed up to the pharynx. They are swallowed and return to the intestine. Two molts to 4th stage larvae take place in alveoli.

22. Class Nematoda -The Roundworms Life cycle: (continued) • Larvae mature to adults in the small intestine. • Worms do not attach to the intestinal wall, but maintain their position by constant movement. Worms have a life span of approximately 1 year. • Undeveloped eggs are passed in the feces. These eggs develop in soil and are infective after two weeks to one month. The egg shell is very thick and resistant to environmental changes. • Eggs can remain infective for up to 5 years if protected from direct sunlight and desiccation.

23. Class Nematoda -The Roundworms Morphology: • Adults -males are 15 to 30 cm long, with strongly curved tails; females are 20 to 35 cm long, with straight tails. • Eggs - one female produces 200,000 per day. The egg has an outer shell membrane which is heavily mamillated. This layer is sometimes rubbed off in passage down the fecal stream. Infertile eggs often appear longer, and thinner shelled.

24. Class Nematoda -The Roundworms Diagnosis - Identification of eggs and/or adults in fecal samples. Major pathology and symptoms: • Pneumonia associated with migration of larvae in the lungs. • Obstruction of the intestines, appendix, or common bile duct. • Vomiting and abdominal pain. • May cause malnutrition in children with heavy infections or poor diet. • Some infections are asymptomatic.

25. Class Nematoda -The Roundworms Distribution - Worldwide, similar to T. trichiura; Eggs thrive best in soil with dense shade, heavy rain and warm climate. General Information: • Ascaris is the largest intestinal nematode. • The second most common helminth infection in the U.S.

26. Class Nematoda -The Roundworms • Mixed infections with T. trichiura are common. If both are present, treat the Ascaris infection first, since it is the more likely of the two to migrate. • Non-specific treatment or administration of anesthesia can cause worms to migrate, including penetrating the intestinal wall; forcing through the pyloric and cardiac valves of the stomach, thus entering the esophagus; or crawling into the common bile duct. • Adult worms may rarely be recovered from the anus, mouth, throat or nose.

27. Class Nematoda -The Roundworms Necator americanus - The New World hookworm Ancylostoma duodenale - The Old World hookworm Life cycle: • Eggs shed in soil hatch within 48 hours, becoming rhabditiform larvae (1st & 2nd stages). • After ~ 7 days, worms stop feeding and molt, transforming from the rhabditiform larvae to infective filariform larvae. • Infections are acquired when the filariform larvae penetrates the skin of a human. Female Male Hookworm egg

28. Class Nematoda -The Roundworms Life cycle: (continued) • Larvae enter the lymphatic system or bloodstream, and travel to the lungs. After maturating in the lungs, they migrate up the trachea to be swallowed and reach the small intestine, where they mature to adults. • Immature adults attach to the intestinal mucosa by means of their stout mouth parts and suck blood and tissue juices of the host. • About five weeks after infection, the worms have undergone a final molt to become sexually mature adults. Fertilization occurs, and the females begin to release eggs. Worm life span is about 1 year. Hookworm rhabditiform larva Hookworm filariform larva

29. Class Nematoda -The Roundworms Morphology: • Rhabditiform larvae - long buccal cavity, indistinct genital primordium. Filariform larvae lose oral structures & have sharp pointed tails. • Adults - males: 7 to 11 mm long with a copulatory bursa; females: 8 to 15 mm long. • Eggs -55 to 70 x 35 to 40 microns; very thin shell; usually seen in the 8 - 32 stage of cleavage. Hookworm rhabditiform larva Hookworm filariform larva Hookworm egg

30. Class Nematoda -The Roundworms Diagnosis: • Recovery and identification of eggs (rarely larvae) in the feces. • Cannot differentiate Hookworm species by egg appearance. • To determine if a significant infection is present, count the number of eggs on a direct smear of the unconcentrated specimen. Five eggs per smear indicates a light infection; 20 or more eggs is clinically significant; 100 or more is indicative of a very heavy infection.

31. Class Nematoda -The Roundworms Major pathology and symptoms: • Serpent-like tunneling at site of penetration may occur (cutaneous larva migrans). • During migration through the lungs, patients may experience a sore throat and / or bloody sputum. • Heavy intestinal infections may result in enteritis, anemia, weakness, and loss of strength due to the anemia. • Chronic infections may experience anemia, weakness, weight loss and gastro-intestinal symptoms. • Nutritional and disease factors are commonly seen in endemic areas. Children may exhibit stunted growth and intellectual development. • Blood loss can be up to 100 milliliters/day.

32. Class Nematoda -The Roundworms Distribution: • A. duodenale - Europe and south America • N. americanus - North America and Africa • Moist, warm regions of the world where the skin frequently contacts the soil is optimal for infection, especially in areas of poor sanitation. Ancylostoma duodenale adults Necator americanus adults

33. Class Nematoda -The Roundworms Strongyloides stercoralis - The Threadworm Life cycle: (very complex) • Infective third stage filariform larvae penetrate skin, enter the lymphatics or bloodstream. • Larvae migrate to the lungs, break out of lung capillaries into alveoli. • After maturation, larvae travel to the pharynx, are swallowed, and return to the intestine. • Larvae mature to adults and attach to the mucosa of the small intestine. Strongyloides stercoralis rhabditiform larva Strongyloides stercoralis filariform larva

34. Class Nematoda -The Roundworms Life cycle: (Continued) • Parthogenetic Females only - no parasitic males. Females are capable of unisexual reproduction, no fertilization required. Produce viable eggs. • Eggs hatch in mucosa. • Larvae: Are passed in feces, live in the soil, mature into a free-living adult males and females, which produce eggs; Rhabditiform larvae feed in soil and develop into infective stage larvae which penetrate the skin; First stage larvae develop into infective stage larvae in the intestine (autoinfection). Strongyloides stercoralis rhabditiform larva Strongyloides stercoralis filariform larva

35. Class Nematoda -The Roundworms Morphology: • Rhabditiform larvae - short buccal cavity; large, prominent genital primordium. • Filariform larvae - tail has a notch in it, in contrast with the filariform larva of hookworms. • Must be able to differentiate these from hookworm larvae. • Eggs hatch in the intestine (not usually passed in stool specimens). Eggs resemble hookworm eggs, but are embryonated. Buccal cavity of rhabditiform larva Notch in tail of filariform larva

36. Class Nematoda -The Roundworms Diagnosis: • Recovery and identification of larvae in the feces. • Recovery and identification of eggs in duodenal drainage.

37. Class Nematoda -The Roundworms Major pathology and symptoms: • Skin – allergic reactions; raised, itchy, red blotches at the site of larval penetration. • Lungs – pneumonia. • Intestinal - abdominal pain, diarrhea, vomiting, weight loss, anemia, eosinophilia. Light infections usually asymptomatic; Heavy infection - bowel becomes edematous and congested. • Death occurs in immunosuppressed patients due to heavy autoinfection.

38. Class Nematoda -The Roundworms Strongyloides stercoralis - The Threadworm (Continued) • Distribution - worldwide, similar to hookworm. • While hookworm infection dies out over a period of years after the patient has moved from an endemic area, strongyloidiasis may persist for years, due to autoinfection (internal infection). • In cases with severe diarrhea, Strongyloides eggs may be present in stool specimens. These must be differentiated from hookworm eggs. Strongyloides eggs contain well-developed larvae. Hookworm eggs do not have well developed larvae until passed from the body and mature for one to two weeks in the soil.

39. Class Nematoda -The Roundworms Blood and Tissue-Dwelling Nematodes Trichinella spiralis – trichinosis • Due to meat inspection programs, not very prevalent in U.S.A. When seen, it is usually due to home butchering and meat preparation. Outbreaks most commonly associated with pork. • Trichinella spiralis is a parasite of carnivorous mammals. It is common in rats and in swine fed uncooked garbage and slaughterhouse scraps. • Human infections occur most often as a result of consumption of raw or undercooked pork.

40. Class Nematoda -The Roundworms Trichinella spiralis – trichinosis Life cycle: • Infective stage larvae are ingested in meat products. • Tissue is digested, larvae are freed in the intestine. They mature into adult males and females. • Female in mucosa releases larvae. These disseminate throughout the body via the bloodstream. • Larvae encyst in striated muscle.

41. Class Nematoda -The Roundworms Trichinella spiralis - trichinosis Morphology - females are 3.5 mm long; males measure 1.5 mm long; larvae measure 100 microns long. Diagnosis - Identification of encysted larvae in muscle biopsy. Serology becomes positive 3 to 4 weeks after infection. A history of eating undercooked pork, deer, walrus or bear is indicative whenever appropriate symptoms appear.

42. Class Nematoda -The Roundworms Trichinella spiralis – trichinosis Major pathology and symptoms: • Fever, muscle pain, bilateral periorbital edema, and increased eosinophil count • Intestinal phase – small intestine edema and inflammation, nausea, vomiting, abdominal pain, diarrhea, headache, and fever. • Migrational phase - high fever (104 degrees), blurred vision, edema, cough and pleural pains. • Muscle phase – acute, local inflammation with edema and pain.

43. Class Nematoda -The Roundworms Trichinella spiralis – trichinosis Distribution: • Cosmopolitan among meat-eating populations, highest incidence is reported from China, common in Spain, France, Italy, and Yugoslavia. • Prevalence in U.S.A. is about 4% based on autopsy studies. • Only about 100 cases are recognized and reported per year in the U.S.A.

44. Class Nematoda -The Roundworms Dracunculus medinensis – The Guinea Worm Overview: • An important parasite in the Middle East, central India and Pakistan. Also found in Africa in the Sudan and scattered through central equatorial regions, and on its west coast. • It is believed to no longer occur in the Western Hemisphere. • Sometimes classified with the filarial worms, but Dracunculus is not a true filaria. Blister containing Dracunculus medinensis Adult Dracunculus emerging from broken blister

45. Class Nematoda -The Roundworms Dracunculus medinensis – The Guinea Worm Life cycle: • Infective stage exists in a water flea (copepod – the intermediate host). • Humans become infected by drinking water containing the infected copepod. • Larvae penetrate the digestive tract to enter the deep connective tissues where they mature in about 1 year. • Females migrate to the subcutaneous tissue (usually the skin of the extremities). • Females release larvae which leave the human through ruptured blisters on the skin. • The larvae enter the water and are ingested by copepods.

46. Class Nematoda -The Roundworms Dracunculus medinensis – The Guinea Worm Morphology – • Males measure 40mm in length. • Females measure 800mm in length. Diagnosis - • Visual observation of skin blister. The worm’s serpentine presence beneath skin can be seen. • Induce release of larvae from the skin ulcer by applying cold water.

47. Class Nematoda -The Roundworms Dracunculus medinensis – The Guinea Worm Major pathology and symptoms – • Mild allergic symptoms such as urticaria during the migration phase. • A papule develops into a blister with localized erythrema and tenderness. • Generalized symptoms include nausea, vomiting, diarrhea, and possibly asthma attacks. • Additional complications include secondary bacterial infections, permanent damage to joints. Distribution - Middle East and Africa.

48. Class Nematoda -The Roundworms The Filarial Worms • The Filariae are long thread-like nematodes. Eight species inhabit portions of the human subcutaneous tissues and lymphatic system. • Adults of all species are parasites of vertebrate hosts. • Female worms produce eggs. The eggs modify, becoming elongated and worm-like in appearance and adapting to life within the vascular system. • Modified eggs, referred to as microfilariae, are capable of living a long time in the vertebrate host, but cannot develop further until ingested by an intermediate host and vector, an insect. • Microfilariae transform into infective larvae in the insect and are deposited in the next host when the insect takes a blood meal.

49. Class Nematoda -The Roundworms The Filarial Worms General life cycle: • Human infection is acquired when infective larvae enter the skin at the arthropod’s feeding site. • Larval migration and development takes place in tissue. • Adults are in various tissues (according to species). They mature and produce microfilariae.

50. Class Nematoda -The Roundworms The Filarial Worms Wuchereria bancrofti: “Bancroft's Filariasis.”A blood & lymphatic dweller. The infection often results in elephantiasis. • Vectors -Culex, Aedes, & Anopheles mosquitoes. • Diagnosis - Detection and identification of microfilaria in stained blood smears. Exhibits a marked circadian migration, best seen at night after 10 P.M. • Morphology - Microfilariae are sheathed, and the nuclear column does not extend to tip of tail. Wuchereria bancrofti microfilaria in blood smear