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Parasitic GI infections- Keller

How do we know its a parasite?
CHRONIC diarrhea- lasts wks - mos, look at poop, immune status- more common in IC patients, eosinophilia with helminthes/worms!, negative
for pathogens in stool
Organism
Characteristics
Path/ epidemiology
Clinical manifestations
Tx and prevention
Protozoa
- small single cell organisms; life fxns occur in a single cell; simple nutritional requirements
- cyst form: infectious form, allows for survival in harsh conditions, but isnt as metabolically active (protozoa w/o cysts have direct
transmission via arthropod vector)
- evade immune system via SA variation, cyst form is excreted from host (diagnostic)
- trophozoite is the vegetative form
Entamoeba
Psuedopod- forming
2nd to malaria for protozoan death Carrier states exist
Paromycin DOC for
histolitica**
protozoan
In US assoc. w/ camping & hiking
Amebic dysentary
Non-invasive (no
-lytic effect on cells
Other at risk: immigrants,
Amebic colitis
liver)
(enduces apoptosis)
homosexual men/anal sex, IC pts,
Ab pain, cramps, colitis, Bloody
institutionalized
diarrhea(d/t invasion apoptosis)
Metronidozole DOC
Microscopy of stool:
- weight loss and anorexia
for symptomatic,
wet mount (for things
Tr: fecal- oral, passed in stool
-can progress to dysentery
invasive dz
that move)
(cyst & trophozoites)
Amebic liver abscess
insensitive, PMNs may Only cyst form is infectious
most commom manifestation flask
Note that parasites
be present
Food contaminated from workers
shaped ulcers
may persist, so follow
or food grown in contaminated
fever, RUQ pain >10 days duration
metronidazole tx w/
Stool ELISA or PCR
soil
paromycin to cure
(more specific)
luminal infection
Path: gastric acidexcystation
cytotoxin stimulates local
necrosis in large
intestinedestruction of epithelial
cells (invasion!) allowing
penetration and spread to other
tissues
Balantidium
Large
At risk: US in psych hospitals,
Most infections are asymptomatic
Tetracycline is DOC
coli
handling pigs (farmers/butchers)
(carriers)
Cilia aid in motility
Ciliate is the only spp that infects
Watery diarrhea w/ blood and pus
Metro and
humans
Ab pain
iodoquionol are
Microscopy of stool
Nausea
alternative
Tr: fecal oral ingestion of cyst
Anorexia
Resovoir = pigs
Secondary bacterial infections of GI

Giardia
lamblia/intest
inalis

Microscopy of stool
Resistant to
chloronation
Falling leaf motility

Found in streams, lakes

Reservoir= beavers (beaver
fever), muskrat
At risk: travelers, hikers, campers,
children in day care,
institutionalized, homosexuals

mucosa
Asymptomatic carriers
Diarrhea
Foul smelling, explosive watery diarrhea
w/ cramps, vomiting, fever, malaise,
weight loss

Bi-lobed nucleus

**

Cryptosporidi
um**
-C. parvum
-c. hominis

Isospora belli
Only pick if
you see acid
fast oocysts
AND
malabsorption
in AIDS pt.

Resistant to
chloronation
Microscopy: acid fast
+ Visualize round
oocyst form

Micro of iodine stained

stool- oocyst found in
feces
Elliptical Acid fast +
oocytes

Cyclospora
cayetanensis

Micro for oocyst, acid

fast +
Fluoresces blue under
UV

Microsporidia

Obligate intracellular

Tr: fecal-oral, drinking

contaminated well water, eating
contaminated food, direct person
to person
Path: cyst stage is infective, only
low dose needed
In stable envtoocyst =
infectious form
Tr: contaminated water supply
Mostly affects kids <5 yo
Adults: animal handlers,
homosexuals
Path: infects intestinal epithelial
cells (brush border)- oocyst is
infectious
More prevalent in AIDS pts (AIDS
defining illness), daycare centers
& mental institutions,
contaminated food or water
Tr: fecal oral, oral-anal sexual
contact
Path: mature oocysts ingested,
replicates inside the
epitheliumtissue damage
Tropics
Tr: fecal contaminated water or
food
-Raspberries from Guatemala
-Basil from Mexico
Zoonosis, possibly water born

Malabsorption syndrome
Stools: malodorous, mushy/greasysteatorrhea

Asymptomatic in some, severe in IC pts.

Enterocolitis
Watery diarrhea, dehydration, weight
loss, ab pain, fever, N/V
**#1 cause of AIDS assoc.
diarrhea**
AIDS >50 stools/day, can last mos-yrs

Most recover
spontaneously
Metronidazole,
Tinidiazole
Prevention: cysts can
survive in chlorinated
water- tx water
appropriately

Replace

fluids/electrolytes
Often self limited
Nitazoxanide for IC
pts, in AIDS pts
retroviral therapy
reduces oocyst
excretion

TMP-SMX is DOC
Mimics giardiasis w/ Malabsorption
Syndromesteatorrhea

Pyrimethamine w/
folinic acid

Resembles crypto- Explosive watery

diarrhea
Fever, fatigue, anorexia, ab pain, N/V
Lasts 10-12 wks & may relapse

TMP-SMX is DOC

IC pts: chronic watery diarrhea, weight

Oral fumagillin for

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encephalitoxoo
n intestinalis
enterocytozoon
bieneusi

Spore forming

Assoc. w/ immunosuppression:
AIDs pt. and organ transplants

loss, ab pain, N/V

Dx: TEM* gold

standard, IFA, PCR

bieneusi
Albendazole for
intestinalis

Metazoa- Helminthes/Worms
Nematodes (roundworms), Trematodes (flukes), Cestodes
-Ingest host tissue and/or fluid, reproduce & lay eggs in GI tract, look for eggs in
samples
-Sexual reproduction
-Protective measures: tough external capsule, immune evasion w/ antigenic variation and enzymes that destroy host cells
Nematodes (roundworms)
-Most common worms in US, commonly assoc. w/ poor sanitation, SW US (dt warmer climate)
-kids can have poly-parasitic infectionsgrowth and mental retardation
Enterobius
Dx:
Most common worm in the US,
Usually asymptomatic
Pyrantel pamoate
vermicularis
Cellophane tape
more in kids
Intense NOCTURNAL perianal itching,
is DOC [Used for
Pinworm
method [Early
Assoc. w/ crowded unsanitary
prickling pain
prophylactic tx of
morning before
conditions
Diarrhea during acute infection (d/t
those in contact]
defecation]
inflamm.)
Tr:
Ab pain rarely- no assoc. w/ appendicitis Mebedazole
Repeat exam in 3
Ingestion of pinworm *STICKY*
Need script for this
days
eggs
Ectopic infection: rare, eggs mgrate to
CI in pregnancy
FOMITES
extracolonic sites vaginal itching,
Sex
granulomas in females
Path: auto-infection occurs

Ascaris
lumbricoides
Roundworm

Largest nematode
Dx:
Knobby coated
Oval shaped
Bile stained eggs
Early/ larval
migration:
Eosinophilia on CBC.
Larvae in sputum

Tr: fecal oral, contaminated food

or water, eggs can survive for
mos
Assoc. w/ poor sanitation
At risk: Travelers, immigrants,
rural SE US
Path: in GI tractportal v. liver
heart & lungs, pt. will cough it
up & swallow it at night and at

Disease dependent on number of eggs

Few asymptomatic
Early phase (4-16 days):
larvae migrate thru lungsfever, nonproductive cough, dyspnea, wheezing
Late phase(6-8wks):
diffuse or epigastric ab pain, n/v.
Bolus can obstruct, perforate bowel
Migration of worm to liver cirrhosis or
portal HTN- dangerous

-azoles are CI in
pregnancy
Albendazole is DOC
Pyrantel pamoate in
preggers

Toxocariasis
-toxocara
canis
-toxocara cati
Dog & cat
roundworms
Trichuris
trichicuria
Whipworm

anal.
Established/ adult
phase: Eggs in stool
Dx:
Eosinophilia, eggs in
pet feces NOT found
in human feces

this point it is an adult

adult worm 3-5cm in

length, life span of 1-3
yrs

Light infection (<100): lower ab

Tr: fecal-oral
discomfort, flatulence, diarrhea,
At risk southern Appalachian
constipation
range & gulf
Heavy infections (100-1000s): ab
pain, vomiting, anorexia, weight loss,
diarrhea (can be bloody), tenesmus
Rectal prolapse
Anemia (~5L of blood loss/day/worm)
Tricurus dysentery syndrome:
bloody mucoid diarrhea, small frequent
stools, anemia, growth mental
retardation in kids
Tr and path: beaches- body contact
Mostly asymptomatic
w/ sand & it directly penetrates the
Early symptoms/ larval
skin, travels to lung, cough it up then migration: itching localized
swallow it, shed in the stool
maculopapular eruption, low grade
fever, cough and wheezing (if in
lungs)
Late symptoms (20-100 worms):
N/V/D, microcytic hypochromic
anemiafatigue/ dyspnea
Chronic dz: emaciation,
physical/mental retardation
Larvae penetrate host skin and
Cutaneous larval migrans:
wander for weeks- mo. (similar to
Aka ground itch, creeping eruption
ascaris worms)- only causes local
Severe: 2 bacterial infections from
infection of skin
scratching
Loeffler syndrome: pulmonary
At risk: children (sandboxes,
infiltrates with peripheral eosoinophilia
beaches)
Eggs hatch
Pneumonitis (similar to hookworm)

dx: hx of travel,
barrel/football shaped
eggs w/ plugged ends
RBCs & WBCs present
Eosinophilia is
UNcommon
Hookworm
Ancylostoma
duodenale- old
world (japan)
Necator
americanusnew world (US)

Early infection:
eosinophilia, normal
stool, patchy infiltrate
on xray (migrating
larvae)
Gi infection: non-bile
stained, segmented
eggs in stool. Fe def
anemia

Ancylostoma
braziliense
Dog and cat
hookworm

Strongyloides

Similar to hookworm

At risk: exposure to dogs, cats

Bleeding
Eosinophilia

Albendazole

Path: eggs ingested, larvae hatch

and get lost, and worms migrate
through tissues (can penetrate
any tissue) disease
Mebendazole

Albendazole
Mebendazole
Thiabendazole for
migrating larvae
Fe therapy for
anemia, transfuse if
severe

Thiabendazole

Ivermectin is DOC

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stercoralis
threadworm

Trichinosis
Tricheenella
spiralis

Dx: microscopy of
larval worms in stooleggs not seen
Baerman funnel gauze
method- concentrates
larvae from fecal
samples or dueodenal
aspirates

Eyncysted larvae in
meat or muscle biopsy
Marked eosinophilia
differentiate from
mono- mono will have
downy cells
Serologic
conformation

Anisakiasis
simplex
Roundworm of
marine fish

Dx: microscopy or
gastroscopy

inintestineautoinfection
Free-living stage outside host
Endemic in US

Larvae ingested in undercooked

meat
*#1Pork- world-wide
Wild game in US (*BEAR*, fox,
walrus)
Path: mate and bar offspring
which are expelled in stooltravel
to muscle via blood (larval form
found in striated muscle) and
encyst (viable for years): we eat
the encysted organism from mm.
tissue
High incidence in Japan, S.
America and Netherlands where
raw fish are eaten
SUSHI worm

Heavy burden: vomiting,diarrhea (may

be bloody), malabsorption
Peptic ulcer, peripheral eosinophilia
Chronic infection: hyperinfection
syndrome
Seen in IC pts, pts on corticosteroids or
transplants
Dessiminated strongyloides:
larvae spread through bodyprofound
diarrhea, malabsorption, electrolyte
imbalance, meningitis, secondary
bacteremia.
Mostly asymptomatic- severity depends
on location/ number of worms
Early stage (1st week): mild diarrhea,
ab discomfort
Acute stage (10-14days, last 2 mo):
larvae invade tissue; fever, myalgias,
eosinophilia, periorbial edema
Late stage (5-7 wks): most initial
symptoms disappear; myalgia, fatigue
Lethal when heart, brain and lungs
infected (4-6wks)

Onset hrs after ingestion of raw fish,

causes hypersensitivity rxn in the gut:
violent ab pain, N/V within hrs
Severe eosinophilic granulomatous
response if larvae pass into bowelmimics Crohns Dz

Bedrest antipyretics,
analgesics
Albendazole for adult
worms

If needed- surgery to
remove larvae

Trematode
-Flukes- flat leaf shaped worms, larger than nematodes
-Most hermaphroditic exept schistosomes
-Have clam or snail intermediate host (which is infected by free swimming cercaria)
-Humans ingest metacercariae (fecal oral transmission, except for schistosomes- CERCARIAE directly infect humans)
-Have OPERCULATED eggs

Giant
intestinal
fluke
Fasciolopsis
buski

Micro exam of eggs in

stool
-large, bile stained

Liver flukes

Fasciola hepaticaSheep liver fluke

Examine bile for eggs
(identical to f. buski)

Clonorchis sinensisChinese liver fluke

Eggs in stool

Paragonimus
westermani
Lung fluke
Schistosomes

Dx: eggs in sputum or

FECES
Male and female
worms
Eggs do not have
operculum
Labs: leukocytosis,
eosinophilia,
polyclonal

China, Vietnam, Thailand, india,

Malaysia
At risk: immigrants, travelers
Tr: ingestion of contaminated
water chestnuts- not the ones
found in cans
Life cycle similar
Former soviet
to fasciolopsis
union, japan,
buski, snail
egypt, central
intermediate
am.
host, adult worm
Tr:
found in bile duct contaminated
water plants
(water cress)
China, japan,
korea,
Vietnam
Tr:
consumption
of
undercooked/r
aw fish
Asia, Africa, India, Latin America
Tr: undercooked/raw crab or
crayfish
Mansoni: Africa, S. America
Tr:
Contact w/ fresh water snailsstanding in water, parasite will
directly penetrate skin and travel
to various organs

Mostly asymptomatic
Severe infections: diarrhea alternating
with constipation, anorexia, n/v
Malabsorption syndrome with
malodorous, greasy stools

Praziquantel

Upper right quandrant pain, fever, chills,

eosinphilia
-hepatitis, biliry obstruction

Bithionol

Less severe than hepatica

If sever: fever, diarrhea, epigastric pain,
hepatomegaly, anorexia, jaundice

Praziquantel

Pulmonary: cough, bloody (rust

colored) sputum

Praziquantel

Haematobium (bladder)- hematuria

bladder cancer
Japonicum (bowel)- occasional bloody
diarrhea
Mansoni (bowel): bloody diarrhea
Acute Dz: Katayama syndromeinflammatory rxn to skin penetration,

Praziquantel

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gammopathy

swimmers itch- body itches everywhere

Wks-mos after initial infection
Fever, chills, cough, uticaria, abdominal
pair, diarrhea, eosinophilia (d/t release
of parasite antigens and immune
complex formation)
Chronic infectiongranulomatous
rxns & fibrosis in affected organs
bloody diarrhea w/ mansoni
Assoc. w/ clay pipestem fibrosis
(fibrous tissue surrounds portal v. in
liver, usually fatal)

Microscopic ID of eggs
-Japonicum- no spine,
found in urine
-Mansoni- lateral spine
S for side, s for
mansoni
-Haematobium- term
spine
T for terminal t for
tobium

Cestode
Tapeworms: flat and ribbon-like, head (SCOLEX) has cup shaped suckers and hooks,
(proglottids)
-Hermaphroditic w/ complex life cycles
-Eggs in feces are diagnostic- cannot differentiate btwn species, all are OPERCULATED

Taenia solium
Pork tapeworm

Proglottids and eggs

in feces
Dx: imaging for
calcified cysterci (CT,
MRI)
Serologic tests

Taenia
saginata
Beef tapeworm
Diphyllobothr
ium latum
Fish tapeworm

One of longest
tapeworms (20-30ft)
Larval worm- scolex
lance shaped
Dx: eggs in stool

Africa, SE Asia, India, Mexico,

Latin Am., China, Slavic countries
Tr: ingesting undercooked PORK
Cysticercosis: calcification of
tissues
Path: ingestion of eggs (may lead
to autoinfection)larvae
disseminate and calcify in tissues
Tr: ingestion of undercooked beef
Similar lifecycle and dz as T.
solium
Tr: ingestion of undercooked
freshwater fish
Raw, picked fish Jewish
grandmothers- gefilte fish
Wild animal reservoir: bears,
minks, walruses, canine, feline

&segmented bodies

If larvae ingested in meat: mostly

asymptomatic or GI symptoms (ab
discomfort, diarrhea, indigestion)
Nuerocystercercosis: calcify in the
brain hydroencephalitis, menigits, nerve
damage, seizures/ epilepsy, visual
defects
Muscle Connective Tissue: usually
asymptomatic, larval death stimulates
immune response
Similar to above but no cysticercosis
**Do NOT pick this answer**

Praziquantel,
albendazole

Most asymptomatic
Epigastric pain, abdominal cramps,
nausea, vomiting, weight loss
Assoc. w/ depeleted serum vit B12
~40% of pts megaloblastic anemia,
nuero manifestations (tingling,
numbness, etc.)

Niclosamide
Praziquantel
Vit B12 supplements

Steroids, surgery

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Echinococcus
ssp
Echinococcus
granulosus,
Echinococcus
multilocularis

Eosinophilia
ELISA
Imaging- Xrays for
cysts in lungs, bone,
muscle
Ultrasound for
asymptomatic dz

Tapeworm of dogs, foxes in sheep

raising areas
Most frequent in westerns statesCali, Arizona, New Mexico and
Utah

Hyatid cyst Dz
Cysts develop in LIVER & LUNGS
Abdominal pain, hepatic mass, bile duct
obstruction
Chest pain , cough, hemoptysis

Multilocularis more severe, more likely

to affect lungs, alveolar hyatid
diseasedeath from anaphylactic shock
after rupture (be careful w/ surgical
removal)
Severity depends on location and size of
cysts
Metronidazole- DOC for anaerobic infections and most protozoa and enteric trichimonas
Multilocularis- cats and rats
Humans are intermediate host

Surgery- 1st choice

Albendazole and
mebendazole