Enterobius

vermicularis
 4.4.3. Enterobius vermicularis
. Common name: “Pin Worm” or “threadworm”
or “ seat worm”

Epidimology
occurs world-wide

Children (5-14 years ) are more commonly

infected than adults

Occur in group living together

• Pinworm eggs can be
spread throughout a
house and difficult to
eliminate.
• Small children are most
apt/active to pick up
them during the
“teething stage.”
 Geographical distribution

• It has cosmopolitan distribution

• More common in temperate & cold climate
than warm climate because of less frequent
bathing & infrequent changing of
underclothing.
• Humans are considered to be the only host of
E.vermicularis.
 In Ethiopia : 5 % school children in rural
communities in Gonder region had
E. Vermicularis eggs under their finger nails
and that only 0.5% of them were found to
shed eggs in the stool

Recent studies done using routine stool examination

method, a prevalence rate up to 1% were reported
Habitat
Adult: Caecum & appendix
Gravid female: Caecum & rectum
Eggs: deposited on perianal skin & occasionally in
faeces

Morphology
Adults: Color: yellow white
Male: Size 2-5mm Coiled tailed
Female: 8-13mm, thin pointed tail
Morphology of Enterobius vermicularis adult
female

They are small white worms with pointed tail

swollen cuticle at anterior end prominent
esophageal end bulb
Egg
Size: 50-60m
Shape: oval but flattened
on one side (planoconvex),
rounded on the other side
Shell : Smooth and thin
but with double shell
Content: either a small
granular mass or a
small curved up larvae
 Life cycle
• Ingestion embryonated eggs, usually carried on
fingernails, clothing, bedding or house-dust.

• Eggs hatch in stomach/small intestine, larvae

migrate to caecum & appendix where they
mature into adults

• Copulation takes place in the caecum, after

copulation male die & excreted in faeces
• Gravid females migrate nocturnally outside the
anus and oviposit on the perianal area
• 1 pin worm lay over 10,000 -15,000 eggs/day
• With in 4-6 hours being laid the egg contain
infective larvae

• Perianal itching from the eggs Induces scratching,

and hence the eggs are transmitted to the mouth
on the fingers

• Retroinfection, or the migration of newly hatched

larvae from the anal skin back into the rectum

• interval from ingestion of infective eggs to

oviposition by the adult females is about one month

• The life span of the adults is about two months

 Transmission of E. vermicularis
Transmission
 Person –to- person transmission: occur through
handling & sharing of contaminated clothes or
bed linens
 Self (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
13
 Transmission …
 Exposure to viable eggs on soil (Ingestion)
 Air born: Some small number of eggs may
become airborne and inhaled
Eggs remain viable 20 days
 Retro infection may occur after hatching larva on
the anal mucosa

14
• Retroinfection :- when eggs are laid on the anus larvae hatch
on the anus return to the GIT of the original host leading to
very high parasitic load & ensuring continued infestation.

• Autoinfection:- infection occurs via ingestion of infectious

eggs by direct anus to mouth transfer by fingers.

– This is facilitated by perianal itch, & also occur by

touching contaminated surface such as clothing,
bed linen, & bathroom fixtures followed by
ingestion.
 Clinical features
Nocturnal anal pruritis.
• The cause of this is unknown, but may be related to the
intensity of the infestation, and/or an allergic reaction to
parasite
 Sleeplessness, because of the irritation

Vulvovaginitis, and even urethritis may occur

in girls when migrating worms lay their eggs
in these sites
 Abdominal pain or appendicitis resulting from
the worms are considered to be very rare
Adult Pinworms on the perianal skin
 Laboratory Diagnosis
1.Finding eggs from perianal skin using adhesive
tape or swab method
– Done by pressing transparent adhesive tape
("Scotch test", cellulose-tape slide test) on the
perianal skin and then examining the tape placed
on a slide.
– Alternatively, anal swabs or "Swube tubes" (a
paddle coated with adhesive material/ NIH swab
can also be used.
– Collect sample in the morning, before defecation
and washing,
• The “Scotch Tape
Test”
– place a piece of
Scotch Tape on the
anal area.
– The tape is placed on
a slide and examined
under a microscope
for the flat sided eggs.
Egg of E. vermicularis and scotch tape preparation
 NIH/ National institute of health swab
• NIH swab consist of glass rod at
one end of which a piece of
transparent cellophane is warped
& held in place with rubber band
– Other end of glass rod is fixed in a
rubber stopper & kept in the test
tube
– The cellophane used for swabbing by
rolling over perianal area
– Then detached, spread over glass
slide & examine microscopically.
2. Finding eggs in the faeces
– Eggs can also be found stool, but less frequently

– Less then 10% found in stools, i.e. not a useful

examination;

– occasionally eggs can be found in the urine or

vaginal smears
3. Finding of female worms from perianal skin or
faeces
Adult worms are also diagnostic, when found in
the perianal area, or during vaginal examinations
Adult also detected in the appendix during
appendicectomy.
 Treatment
Two doses (10 mg/kg; maximum of 1g) each of
Pyrental Pamoate two weeks apart give a very
high cure rate.
 Mebendazole is an alternative.

*The whole family should be treated, to avoid

reinfection
 Prevention and Control
1.Treating all members of a family in which infection has
occurred
2. Wearing tight-fitting cotton pants to infected children
3. Washing of the anal skin each morning
4. Washing of clothing worn at night
5. Washing hands after using toilet and before eating
6. Avoidance of putting fingers in the mouth &
trimming finger
4.2.4.Strongyloides stercoralis
• Common name: Dwarf thread worm

Epidemiology
 Found worldwide

– An estimated 80 to 100 million cases

– Favors warmer tropical and subtropical climate
– Important opportunistic pathogen on immuno-
compromised host
 Strong. Ster. Cont.
In Ethiopia
 Not highly prevalent in most areas and found in
the same geographical areas with hookworm
 The infection is rare or absent in many arid
lowland areas, including the Ogaden and
pastoral areas in the Awash Valley
– Worms can be free-living in
the soil or live in a host.
– The definitive host is
humans, but may also affect
other primates and dogs
• S. stercoralis show the following
characteristics
1. Parasitic males are absent
2. Parasitic females are present in the
submucosa of small intestine which produce
egg parthenogenically
3. Can develop in to free living generation in
the soil out side the human host
4. Has internal autoinfection
Habitat
 Has both free living and parasitic generations
 Parasitic Adult females: buried in the mucosal
epithelium of the small intestine of man

 Rhabditiform larvae: Passed in the faeces and

external environments

 Filariform larvae: soil and water the infective

stage
 Free living male and female : on external
environment

 Egg : laid in the sub mucosa of small intestine

 Morphology
The size and shape of the worm are dependent
on whether it’s parasitic or free-living.

• Free-living females – 1 mm by 60 µm
• Parasitic females – 2.2 mm by 45 µm
• Eggs – 55 µm by 30 µm:as soon as they are laid in
sub mucosa, the rhabditiform larvae ready to hatch
 Eggs
Size: 50-58 m
Shape: oval
Shell : thin and transparent
Content: contain larvae ready to
hatch,
As soon as the eggs are laid,
rhabditiform larvae start
hatching.
 Morphology-Larva
• Rhabditiform Larvae • Filariforml Larave
– Size: 200-300m long ; – About 600-700m
15m thick – Cylinderical
– Motility: very actively esophagus
motile in the stool – Bifid tail end
– Tail: Moderately
tapered
– Short buccal cavity and
rhabiditiform
esophagus
 Larvae
Rhabditiform larvae Filariform larvae
(non-infective form) (pathogenic form)
 Transmission and Life cycle
• Transmission
1. Commonly by penetration of skin by filariform larva

2. Ingestion of food or water contaminated with

filariform larva( oral rout)

3. Rarely: Transmamary & Organ transplantation

4. Autoinfection with rhabiditiform larva

Life Cycle
 Complex , Two types of cycles exist:
1.Free-living (indirect) cycle
Rhabditiform larvae(stool) molt 4x free-
living adult males and females produce eggs
rhabditiform larvae develop to free living
molt 2x adult males or females
Filariform larvae(this initiate parasitic life
cycle)
2.Parasitic (direct) cycle
Rhabditiform larvae(stool) molt 2x develop
to filarifrom penetrate skin lung Alveolar
space bronchial tree pharynx
swallowed &develop to adult female in small
intestine(molt 2x) produce egg by
parthenogenesis which yield rhabditiform larvae
Autoinfection, the rhabditiform larvae
become infective filariform larvae in the host
tissue ,penetrate
 intestinal mucosa (internal autoinfection)
or perianal area (external autoinfection)
Life cycle

Parasitic life cycle

Free-living cycle
Clinical feature
• It is usually asymptomatic, in symptomatic cases
• People with weaker immune systems
such as elder people and children
are more susceptible
1.Cutaneous phase
 large number of larva produce itching and
erythema at the site of infection within 24 hours of
invasion

2.Pulmonary phase: The migratory larva in the lung

producing bronchopneumonia and full blown
pneumonitis
3. Intestinal phase : Invasion by adult worms may
produce abdominal pain and mucus diarrhea ,
nausea, vomiting and anemia

Auto- and hyper-infection syndromes

 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 in duodenal
aspirates using direct or concentration
method by microscopy
 In hyper-infection syndrome the larva may be
found in sputum, urine and in other
specimens
– Examination of serial samples may be
necessary because direct stool examination is
relatively insensitive
• The stool can be examined in wet mounts:
– Directly
– After concentration (formalin-ethyl acetate)

– After culture by the harada-mori filter paper

technique

– After culture in agar plates

2. Serological tests
• Antibody Detection
• Indicated when the infection is suspected and the
organism cannot be demonstrated by:
• duodenal aspiration by string tests, or
• by repeated examinations of stool
• Use antigens derived from filariform larvae for the highest
sensitivity and specificity
• EIAs currently recommended because of its greater
sensitivity (90%).
• IFA and IHA tests can be used
 Duodenal aspiration by string tests
• Enterotest /string tests
• A gelatin capsule attached to a long string.
• The end of the string remains outside the
mouth and is taped to your cheek.
• The gelatin capsule is then swallowed
• The capsule dissolves in the stomach and
the string passes into the upper part of the
small intestine (duodenum).
• The string is left in place for 4 to 6 hours or
overnight. Then it is withdrawn and the
end is examined under the microscope for
parasites that have become attached.
Treatment
Ivermectin or thiabendozole

Prevention and Control

1. Sanitary disposal of faeces in latrine
2. Avoid use of night soil as a fertilizer

3. Wearing protective footwear

4.Treatment of infected individuals and Health

education
 Properly dispose of
human wastes.

Wear Shoes.

…Don’t eat dirt.

 Strongyloides fuelleborni

Geographical Distribution

Widely distributed in Zimbabwe, Zambia, New

Guinea, co-exists with S.stercoralis in Ethiopia

 It is a common parasite of old world monkeys ,

apes &dog
Transmission and life cycle

Transmission
 Skin penetration by filariform larvae
 Transmammary

Habitat:-Has both free living and parasitic life

Life cycle
 similar to S.stercoralis except it shed eggs in the
feaces
Pathology and treatment: similar to S.stercoralis

Laboratory diagnosis
Finding eggs in fresh stool specimens
Egg:-Resembles eggs of hookworms but are
shorter and smaller
-Colorless, Oval and 50 by 35μm in size
-Contain partially developed larvae
– N.B. If there is a delay in examining the feaces , the
larva will hatch
Prevention and Control
 The same as described for S. stercoralis