TISSUE

HELMINTHS

DR. KRESNAWATI WAHYU SETIONO, MCTM

DEPT. KEDOKTERAN TROPIS
FK UNDANA
 HELMINTHS
• Nematode
• Trichinella spiralis
• Toxocara canis (VLM)
• Wucheria bancrofti, b.malayi, b.timori (filariasis)
• Gnathostoma spinigerum
• Anisakis

• Cestode
• Taenia solium – cytisercosis
• Echinococcus granulosus, E. multilocularisis
• Spirometra erinaceieuropaei, Diphyllobothrium mansonoides

• Trematodes
• Liver flukes
• Lung flukes
TRICHINELLOSIS
EPIDEMIOLOGY
Bruno Gottsein, et al. Microbiology Reviews (2009) 127-145
EAST NUSA TENGGARA
ANATOMY
q The male measures about 1.2 mm in
length by 60 µm in diameter. Trichinella    spiralis    female
q The posterior end bears a pair of
conical papillae or copulatory bursa
Male

q The female is about 2.2 mm in length

Female with a vulva opening located on the
anterior one forth of body

q The females produce eggs that

develop into larvae in the uterus
 TRICHINELLA SPECIES :2 CLADES

• ENCAPSULATED • NONENCAPSULATED
ëT.SPIRALIS Ø T.PSEUDOSPIRALIS
ëT.NATIVA Ø T. PAPUAE
ëT.BRITOVI Ø T.ZIMBABWENSIS
ëT.MURRELLI
ëT.NELSONI
LIFE CYCLE
 PATHOLOGY

• INTESTINE : DAMAGE AT BRUSH BORDER, LAMINA

PROPRIA, VILLI AND SMOOTH MUSCLE OF SMALL
INTESTINE( JEJUNUM)

• STRIATED MUSCLE : NURSE CELL LARVA

COMPLEX
• BASOPHILIC TRANSFORMATION
• ENCAPSULATION OF THE LARVAE : 18-20 DAYS AFTER
INFECTION OR DAY 4 AFTER INVADE TO SKELETAL
MUSCLE.
• DEVELOPMENT OF CAPILLARY NETWORK
 PATHOLOGY (CONT)

• HEART: EOSINOPHILIC MYOCARDITIS AND GRANULOMATOUS FORMATION ---

INTERSTITIAL MYOCARDITIS
• EYE: INFLAMMATION , ANGIOMYOSITIS
• RESPIRATORY SYSTEM: INFLAMMATION--- LOFFLER’S PNEUMONITIS,
OBSTRUCTIVE BRONCHITIS
• CNS: VASCULITIS OR PERIVASCULITIS
• RENAL: MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS
 CLINICAL MANIFESTATION
• INCUBATION PERIOD : 7-30 DAYS

• ENTERIC PHASE OR INTESTINAL PHASE :

IRRITATION AND INFLAMMATION OF DUODENUM AND
JEJUNUM WHERE THE LARVAE PENETRATE CAUSE
NAUSEA, VOMITING, COLIC PAIN AND DIARRHEA

• MIGRATORY( INVASION) PHASE: 2ND WEEKS :

REMITTENT FEVER, SEVERE MYALGIA WITH
PSEUDOHYPERTROPHY OF MUSCLE AND
PSEUDOPARALYSIS, PERIORBIAL OEDEMA AND
EOSINOPHILIA

• ENCYSTMENT PHASE: 2 MONTHS AFTER INFECTION :

CACHEXIA, OEDEMA AND EXTREME DEHYDRATION
Symptoms Incidence

Fever 30-90%
Diffuse myalgia 30-100%
Paralysis like state 10-35%
Periorbital and/or facial edema 15-90%
Skin rash, maculopapular examthema and 15-65% Periorbital edema
subungual bleeding

Difficulties in swallowing 35%

Diarrhea 23%
Abdominal pain , nausea , vomiting 28-40%

SEVERE FORMS (5-10%) Splinter hemorrhage

• MYOCARDITIS 20%
• ENCEPHALITIS/MENINGOENCEPHALITIS 10-20%
• PNEUMONIA 6%

Turk M , et al., 2006, Wanda Kociecka,et al.,2000, Virginia Capo, et al., 1996)
 DIAGNOSIS

• PATIENT’S HISTORY
• SYMPTOMS
• INVESTIGATOR : MUSCLE BIOPSY, SEROLOGICAL TEST
 Management of Trichinellosis
In asymptomatic cases
1. only anthelmintics should
be administered
2. leukocyte and eosinophil
counts should be monitored
in the peripheral blood.
Treatment of pregnant
women
1. the patient should be
admitted to a hospital
independent of the clinical
course she manifests,
2. anthelmintics not
absorbable from the
intestinal lumen should be
used exclusively, i.e.
Pyrantel at 10 mg/kg BW
for 1–3 days
In benign or abortive In severe and
disease moderately severe
disease
1. administration of 1.Hospitalization
anthelmintics
2.administration of
2. Administration of anthelmintics
nonsteroidal anti-
inflammatory drugs if 3. application of
necessary glycocorticosteroids
(prednisolone)
4. compensation of water
and electrolyte deficits
5. administration of
analgesic drugs
(Bruno Gottstein, et al.,2009)
 ANTHELMINTIC DRUGS
ADULT AND CHILDREN AGE > 2YRS

• ALBENDAZOLE 10-15 MG/KG/DAY FOR 10 TO 15DAYS

• MEBENDAZOLE 5 MG/KG/ DAY FOR 10 TO 15 DAYS

• THIABENDAZOLE 50 MG/KG IN DIVIDED DOSE FOR 5 DAYS

PREGNANT WOMEN AND CHILDREN < 2YRS

• PYRANTEL PAMOAT 10MG/KG BW SINGLE DOSE, REPEATED FOR 2 TO 3 DAYS

( ACTIVE ONLY AGAINST WORMS IN THE GUT AND IT HAS NO EFFECT AGAINST NEWBORN AND MUSCLE LARVAE)

( Virginia Capo, et al., 2000,Bruno Gottstein, et al.,2009)

 PREVENTION
1. EDUCATION OF THE CONSUMER

2. FARMING OF PIGS IN MODERN, INDUSTRIALIZED,

INDOOR PIGSTIES UNDER STRICT VETERINARY CONTROL
AND USE OF CERTIFIED FEEDSTUFF

3. CONTROL OF ALL SUSCEPTIBLE ANIMAL (BOTH

DOMESTIC AND SYLVATIC) BY A STANDARDIZED
ARTIFICIAL DIGESTION METHOD AT SLAUGHTERING OR
AFTER HUNTING
TOXOCARIASIS
TOXOCARIASIS
LIFE CYCLE
 CLINICAL MANIFESTATION

• FEBRILE, COUGH, ABDOMINAL PAIN, HEADACHE

• LARVA MIGRANS
• VISCERAL LARVA MIGRANS
• OCULAR TOXOCARIASIS
 OCULAR TOXOCARIASIS

• OCULAR TOXOCARIASIS OCCURS WHEN TOXOCARA LARVAE

MIGRATE TO THE EYE
• SYMPTOMS AND SIGNS: VISION LOSS, EYE INFLAMMATION OR
DAMAGE TO THE RETINA
• UNILATERAL
 DIAGNOSIS

• LAB
• ELISA, IMMUNOBLOT
 TREATMENT

• ALBENDAZOLE 400MG AND MEBENDAZOLE 500MG GIVEN

TWICE DAILY FOR 5 DAYS
• IN SEVERE OCULAR TOXOCARIASIS, CORTICOSTEROIDS
MAY BE NEEDED IN ADDITION.
• OCULAR GRANULOMAS : LASER PHOTOCOAGULATION,
CRYORETINOPEXY.
FILARIASIS
FILARIASIS
LIFE CYCLE
PERIODICITY
 CLINICAL MANIFESTATION
• ASYMPTOMATIC >>
• ACUTE FILARIASIS
- ACUTE FILARIAL LYMPHANGITIS
- ACUTE DERMATOLYMPHANGITIS

• CHRONIC CONDITION: LYMPHEDEMA, CHYURIA, HYDROCELE,

ELEPHANTIASIS
• TROPICAL PULMONARY EOSINOPHILIA
 DIAGNOSIS

• PATIENT’S HISTORY
• LABORATORY
• PCR
• ELISA
• USG
 MANAGEMENT

• MEDICATION
• SUPPORTIVE CARE
• PATIENT EDUCATION AND COUNSELLING
• PREVENTION
• CONTROL
 MEDICATION

• RECOMMEND INDIVIDUAL TREATMENT

• DEC 6MG/KG.DAY FOR 1 OR 12 DAYS (CDC)

• MDA
• ALBENDAZOLE 400MG AND DEC 6MG/KG
• ALBENDAZOLE 400MG AND IVERMECTIN 150-200MCG/KG
 SUPPORTIVE CARE

• TO IMPROVE FUNCTION, REDUCE SUFFERING, AND PREVENT

INFECTION
• FOOT-CARE PROGRAM
• HYDROCELE: SURGERY
TISSUE HELMINTHS (2)
DR. KRESNAWATI W. SETIONO, DTM&H, MCTM
LECT. DEPT. TROPICAL MEDICINE
NUSA CENDANA UNIVERSITY
CYSTISERCOSIS
CLINICAL MANIFESTATION
• ABDOMINAL PAIN
• DISTENSION
• DIARRHEA
• NAUSEA
• ANEMIA
 DIAGNOSIS
• STOOL MICROSCOPY
• ELISA
• DIVERSE DNA-BASED ASSAY
 TREATMENT
• NICLOSAMIDE : 2 G ORALLY IN SINGLE DOSE
• PRAZIQUANTEL 10-20 MG/KG ORALLY IN A SINGLE DOSE
• MEBENDAZOLE OR ALBENDAZOLE 300-400MG/DAY FOR 3-4DAYS

* NEED TO FOLLOW UP EVERY 6 MOS

 CLINICAL PRESENTATION
• NEUROCYSTICERCOSIS
• OPTHALMIC CYSTICERCOSIS
• EXTRANEURAL CYSTICERCOSIS
 TREATMENTS
• ALBENDAZOLE : 400MG PO BID FOR 30 DAYS
• PRAZIQUANTEL 50MG/KG/D PO DIVIDED Q6-8H FOR 15 DAYS
• CORTICOSTEROIDS
• ANTICONVULSANT
• SURGERY
ECHINOCOCCUS
ECHINOCOCCUS SP
 LOCALISATION CYSTIC
ECHINOCOCCOSIS
• LIVER 62%
• LUNGS 20%
• SPLEEN 6%
• BONES/ MUSCLES 4%
• KIDNEY 2%
• HEART/ THORAX 2%
• BRAIN >1%
• OTHERS 2%

• MULTIPLE ORGAN INVOLVEMENT IN 10-15%

OF CASES
 Larval forms (=metacestodes ) with protoscolices
Daughter vesicle (also called daughter cysts) attached to parent-cyst wall
 CLINICAL FEATURES
- DEPENDS SITE OF THE CYST
- LUNG
- LIVER
- HEART
- BRAIN
- SPINE
Cysts can be huge…. (>15 cm)
DIAGNOSIS CE
• IMAGING:
• ULTRASOUND!
• CT
• MRI

• SEROLOGY
• CYTOLOGY
 TREATMENT
• SURGERY WITH CONCOMITANT CHEMOTHERAPY.
• AD SURGERY:
• RADICAL SURGERY ONLY POSSIBLE IN 15-58%
• EVEN THEN FREQUENT RECURRENT DISEASE (10-20%)

• AD CHEMOTHERAPY:
• ALBENDAZOL=MEBENDAZOL; PRAZIQUANTEL?
• LONG COURSE: >2 YEARS
LUNG FLUKES
 DIAGNOSIS
• CBC: LEUCOCYTOSIS WITH EOSINOPHILIA
• EGGS IN SPUTUM, STOOL, PLEURAL FLUID
• EGG DETECTION RATE IN RECENT STUDIES: 28-38%
• EXPECTORATION OF INTACT FLUKE: RARE
• SERODIAGNOSIS: ELISA OR IMMUNOBLOT – HIGHLY SENSITIVE (90-
100%) & SPECIFIC (>90%)
 TREATMENT
• PRAZIQUANTEL – DRUG OF CHOICE
DOSE: 25 MG/KG BODY WT. * 3 TIMES/DAY FOR 2 OR 3 DAY
• PLEURAL EFFUSION: DRUG + REPEATED THORACENTESIS
• OTHER DRUGS:
• TRICLABENDAZOLE: BETTER TOLERATED
• BITHIONOL, NICLOFALAN: NOT AVAILABLE
LIVER FLUKES
 DIAGNOSIS
• STOOL EXAM : EGG
• SEROLOGICAL TEST: ELISA
 TREATMENT
• PRAZIQUANTEL 25MG/KG TID : 1-2 DAYS
• TRICLABENDAZOLE 10MG/KG OD/BID X 1 DAY
THANK YOU