Beruflich Dokumente
Kultur Dokumente
nematode Infections
Intestinal Nematodes
Vicente Y. Belizario, Jr., Francis Isidore G. Totañes
129
130 MedICal parasItology In the phIlIppInes
Plate 3.1. Ascaris unfertilized egg (a), fertilized egg (b), and embryonated egg (c)
(Courtesy of the Department of Parasitology, UP-CPH)
to the cecum or proximal colon where of the infection. Ascariasis was estimated to
they penetrate the intestinal wall. These have contributed to a total of 1.85 million
larvae enter the venules to go to the liver disability- adjusted life years (DALYs) in
through the portal vein, on to the heart and 2004.
pulmonary vessels where they break out of The varied pathology of ascariasis
capillaries to enter the air sacs. In the includes the reaction of tissues to invading
lungs, larvae undergo molting before larvae, irritation of the intestine by the
migrating to the larynx and oropharynx to mechanical and toxic action of the adult, and
be swallowed into the digestive tract. This complications arising from the parasite’s
hepato-tracheal migration phase takes extraintestinal migration (Plates 3.2–3.4).
about 14 days, while the development of The usual infection of 10 to 20 worms may
egg-laying adult worms takes about 9 to not show symptoms, hence, may go
11 weeks after egg ingestion. The life span unnoticed by the host unless it is
of an adult worm is about 1 year. discovered by stool examination or the
A female Ascaris produces about spontaneous passing of worms in the stool.
200,000 eggs per day, but this number During lung migration, the larvae
decreases with increasing worm load. The may cause host sensitization resulting in
eggs are deposited in the soil when a person allergic manifestations such as lung
with Ascaris infection defecates infiltration, asthmatic attacks, and
indiscriminately. In the soil, it takes about 2 edema of the lips. Symptoms of difficulty
to 3 weeks for eggs to develop into the of breathing and fever similar to
infective stage (embryonation) under pneumonia may occur as a result of
favorable conditions with suitable penetration by several larvae through the
temperature, moisture, and humidity. The lung capillaries as they enter the air
larvae undergo two molts to reach their 3rd sacs. The most frequent complaint of
stage within the egg and become patients is vague abdominal pain.
embryonated. Only when this infective egg Eosinophilia is present during larval
is swallowed can humans become infected migration. Moderate infections may
with Ascaris (Figure 3.1). The embryonated produce lactose intolerance and vitamin A
eggs can survive in moist shaded soil for a malabsorption. Heavy infections are likely
few months to about two years in tropical to cause bowel obstruction (due to
and sub-tropical areas, but for much longer bolus formation), intussusception, or
in temperate regions. volvulus that may result in bowel
infarction and intestinal perforation.
Pathogenesis and Clinical Manifestations Serious, and at times, fatal effects of
ascariasis are due to erratic migration of
A majority of Ascaris infections are adult worms. They may be regurgitated and
asymptomatic, although an estimated 120 to vomited, may escape through the nostrils or
220 million cases exhibit morbidity as a rarely, inhaled
result
Chapter 3: nematode Infections 131
into the trachea. The worms may invade bile abscesses. Penetration of the worms
ducts through the ampulla of Vater and enter through the intestinal wall into the
the gallbladder or liver. Patients with biliary peritoneal cavity may occur and result in
ascariasis experience severe colicky either acute peritonitis or chronic
abdominal pain, which is brought about by granulomatous peritonitis.
the movement of the worms inside the Complications brought about by the
biliary tract. Worms may also lodge in the larvae and adult worms are a cause for
appendix or occlude the pancreatic duct and concern. The continuous biting or pricking
cause acute appendicitis or pancreatitis, of the intestinal mucosa for food by a few
respectively. Intestinal bacteria may be Ascaris adults may irritate nerve endings
carried to these migration sites producing in the mucosa and result in intestinal
spasm leading to intestinal
132 MedICal parasItology In the phIlIppInes
Plate 3.2. Ascaris in the liver Plate 3.3. Intestinal obstruction with Ascaris
(Courtesy of Dr. Benjamin Cabrera) (Courtesy of Dr. Benjamin Cabrera)
Figure 3.2. Global distribution of soil-transmitted helminth (STH) infections and proportion of children
requiring preventive chemotherapy for STH infections in each country
(From World Health Organization. Helminth control in school-age children: a guide for managers of
control programmes. 2nd ed. Geneva: World Health Organization; 2011.)
are estimated to have ascariasis, and about reported an overall prevalence of 27.7%
2,000 die annually. The disease remains among school-age children and 30.9%
endemic in many countries of Southeast among preschool children. Prevalence rates
Asia, Africa, and Central and South are parallel with those of trichuriasis due to
America. Children ages 5 to 15 years have similar modes of infection and risk factors.
the highest intensities of infection with The level of transmission of Ascaris
Ascaris compared with the other age groups. and other STH from soil to humans depends
Children are particularly vulnerable since on socio-economic factors more than on
they are at risk of ingesting embryonated physical factors. The main factors appear to
Ascaris eggs while playing in soil be a high density of human population,
contaminated with human feces. involvement in agriculture (including use of
Worldwide estimates reveal that the night-soil as fertilizer), illiteracy, and poor
highest number of cases of ascariasis is sanitation. Poor health education on
found in East Asia and the Pacific Islands, personal, family, and community hygiene
although are also important factors contributing to the
A. lumbricoides is also known to be able transmission of Ascaris.
to survive colder temperatures compared
with Trichuris and hookworm. In many Prevention and Control
low and middle income countries like the Surveillance and monitoring are
Philippines, the prevalence may reach 80 important components of an STH
to 90% in certain high risk groups like Control Program. Baseline cumulative
public elementary school children. Recent prevalence and prevalence
local sentinel surveys have
Chapter 3: nematode Infections 135
Table 3.1. Core indicators of mass drug administration for soil-transmitted helminth infections
deworming. Nutritional status and school framework (Table 3.2) for the control of
performance may also be monitored STH infections. When mass treatment is
alongside parasitologic parameters. being undertaken, submission to the said
Prevention and control measures for intervention should be a goal of health
Ascaris and other STH infections involve education.
provision of safe water, environmental War on Worms (WOW) approach in
sanitation, hygiene education, and Biñan, Laguna is a school-based, school
regular deworming, which are the teacher- assisted mass drug administration
components of the WASHED (water, led by the Local Government Unit (LGU)
sanitation, hygiene, education, which started in 1999. The approach was
deworming) initially supported by
Table 3.2. The WASHED framework for a comprehensive control of soil-transmitted helminth infections
Johnson & Johnson, Inc. (J&J) and do not reach the point of eradication due
eventually taken over by LGU and the to implementation challenges and the
Department of Education (DepEd) limited practice of the WASHED
District of Biñan. Part of the WOW strategies in the communities (Figure 3.4).
experience was that STH infections
Figure 3.4. Comparison of cumulative prevalence in San Vicente Elementary School (SVES) and sentinel
schools in Biñan, Laguna from 1999 to 2010 (Courtesy of Dr. Vicente Belizario, Jr.)
Trichuris trichiura
Vicente Y. Belizario, Jr., Francis Isidore G. Totañes
T
richuris trichiura or the whipworm is a
soil-transmitted helminth, and is
classified
as holomyarian, based on the arrangement
of somatic muscles in cross-section where the
cells are small, numerous, and closely
packed in a narrow zone.
Parasite Biology
The male worm (Plate 3.5a) measures
30 to 45 mm, slightly shorter than the
female,
which is 35 to 50 mm long. The female
(Plate 3.5b) has a blunt posterior end, while Plate 3.6. Trichuris egg
the male has a coiled posterior with a single (Courtesy of the Department of Parasitology,
spicule and retractile sheath. The worms UP-CPH)
have an attenuated anterior three-fifths
traversed by a narrow esophagus yellowish outer and a transparent inner
resembling a string of beads. The robust shell. Fertilized eggs are unsegmented at
posterior two-fifths contain the intestine and oviposition and embryonic development
a single set of reproductive organs. A female takes place outside the host when eggs are
lays approximately 3,000 to 10,000 eggs per deposited in clayish soil. Compared with
day. Ascaris eggs, Trichuris eggs in soil are more
susceptible to desiccation.
Larvae are not usually described
probably because soon after the
embryonated eggs are ingested, the
larvae escape and penetrate intestinal villi
where they remain for 3 to 10 days.
Trichuris worms inhabit the cecum and the
colon. The worms secrete a pore-forming
protein, called the TT47 that allows them
to imbed their entire whip-like portion
into the intestinal wall. After copulation,
the female worm lays eggs, which are
passed out with the feces and deposited in
the soil. Under favorable conditions, the
eggs develop and become embryonated
within 2 to 3 weeks. If swallowed, the
Plate 3.5. Trichuris male (a) and female (b) infective embryonated eggs go to the small
(Courtesy of the Department of Parasitology, intestine and undergo four larval stages
UP-CPH) to become adult worms. This process takes
about 12 weeks (Figure 3.5). Unlike
The approximate measurements of the Ascaris, there is no heart-lung migration.
egg are 50 to 54 μm by 23 μm. It is lemon- Each female worm can produce about 60
or football-shaped with plug-like translucent million eggs over an average lifespan of 2
polar prominences (Plate 3.6). The egg has years.
a
Chapter 3: nematode Infections 141
Pathogenesis and Clinical Manifestations is common. The lumen of the appendix may
be filled with worms, and consequent
The anterior portions of the worms, irritation and inflammation may lead to
which are embedded in the mucosa, cause appendicitis or granuloma formation.
petechial hemorrhages, which may The intensity of infection is important
predispose to amebic dysentery, presumably in understanding the clinical picture.
because the ulcers provide a suitable site for Infections with over 5,000 T. trichiura
tissue invasion by E. histolytica. The mucosa eggs per gram of feces are usually
is hyperemic and edematous; enterorrhagia symptomatic. In patients with heavy
or intestinal bleeding intensity infection, the worms may be
142 MedICal parasItology In the phIlIppInes
found throughout the colon and rectum, and patient suffers from frequent blood-streaked
may result in Trichuris dysentery diarrhea, abdominal pain and tenderness,
syndrome manifested by chronic dysentery and rectal prolapse where adult worms
and rectal prolapse (Plate 3.7). Such cases of attached to the rectal mucosa can be seen. In
heavy chronic trichuriasis are often marked light infections where symptoms are absent,
by frequent blood- streaked diarrheal stools, laboratory diagnosis is essential.
abdominal pain and tenderness, nausea and Laboratory diagnosis may be done by
vomiting, and weight loss. Anemia is direct fecal smear (DFS) with a drop of
strongly correlated to heavy intensity saline. An alternative diagnostic technique
trichuriasis, and blood loss from such is the Kato thick smear method that uses
infections can range from 0.8 to 8.6 ml per about 20 to 60 mg of stool sample. This
day. Furthermore, infection with over 800 method is highly recommended in the
worms can result in anemia in children. On diagnosis of trichuriasis. The Kato-Katz
the other hand, light infections are technique is a quantitative method that
moderately associated with anemia, employs egg counting to determine the
although these infections are usually intensity of helminth infection. This
asymptomatic and the presence of the technique can be used to assess the efficacy
parasite may be discovered only in routine of anthelminthic drugs in terms of cure rate
stool examinations. Trichuriasis has also (CR) and egg reduction rate (ERR). This
been shown to result in poor appetite, technique can also be used for
wasting, stunting, as well as reduced epidemiological surveys for the monitoring
intellectual and cognitive development in of a helminth control program. Both Kato
children. thick and Kato-Katz techniques are simple
and low-cost methods that have high
sensitivity and specificity for the detection
of Trichuris eggs, as well as eggs of other
soil- transmitted helminths. A single Kato-
Katz examination has a sensitivity and
specificity for the detection of Trichuris of
91.4% and 94.4%, respectively.
The acid-ether and the formalin-
ether/ ethyl acetate concentration
techniques can also be used for the
diagnosis of trichuriasis. The FLOTAC
technique has also been shown to be more
sensitive in the diagnosis of trichuriasis
compared with Kato-Katz and
ether/ethyl acetate concentration
Plate 3.7. Rectal prolapse in a 9-year old female techniques.
seen at the Philippine General Hospital with Treatment
heavy Trichuris infection
(Courtesy of Dr. Benjamin Cabrera) The drug of choice in the treatment of
trichuriasis is mebendazole given 100 mg
The prognosis of trichuriasis is very twice a day for 3 days. Albendazole may be
good. Because there is no larval migration used as an alternative drug. Both are
through the lungs as in Ascaris and benzimidazole derivatives and are available
hookworm infections, no lung pathology as chewable tablets. Administration of
occurs. mebendazole 500 mg once a day for 3 days
has been shown to have the highest cure rate
Diagnosis (71%) compared with albendazole 400
Clinical diagnosis is possible only in
very heavy chronic Trichuris infection
where the
Chapter 3: nematode Infections 143
mg given once a day for 3 days (56%). For Prevention and Control
the purposes of preventive chemotherapy
through mass drug administration, Strategies for the prevention and
mebendazole is given as a 500 mg single control of Trichuris infection are similar
dose, while albendazole is given as a 400 to those for Ascaris infections. The WHO
mg single dose. In recent local studies, it recommends biannual mass drug
has been shown that albendazole in administration with mebendazole 500
combination with ivermectin, a drug that mg or albendazole 400 mg among school-
is also used to treat filariasis, exhibited better age children in communities where the
cure and egg reduction rates than albendazole prevalence of STH infections is
alone. A contraindication for 50%. Treatment of other high-risk groups
mebendazole and albendazole is such as preschool children, women of
hypersensitivity and early pregnancy childbearing age, including pregnant
(within the 1st trimester). Adverse effects of women in the 2nd and 3rd trimesters as
these two drugs are usually mild and well as lactating women, adults in certain
transient and may present as headache, high-risk occupations should also be
nausea, vomiting, gastrointestinal considered. On the other hand, once a year
discomfort, and treatment is recommended in communities
itchiness. with STH prevalence <50%. Other
Deworming of children has been strategies such as provision of safe water,
shown to contribute to improved motor environmental sanitation, and hygiene
and language development, as well as to education are also important in STH
reduced malnutrition. Nutritional status and control.
intellectual development have also been References
shown to improve after deworming.
Epidemiology Bates I, McKew S, Sarkinfada F.
Anaemia: a useful indicator of
Trichuriasis occurs in both temperate neglected disease burden and control.
and tropical countries but is more widely PLoS Med. 2007;4(8):e231.
distributed in warm, moist areas of the Belizario VY, Amarillo ML, de Leon WU,
world. Approximately 604 to 795 million de los Reyes AE, Bugayong MG,
are infected globally. In tropical and Macatangay BJ. A comparison of the
subtropical regions, Trichuris is most efficacy of single doses of
prevalent in East Asia and Pacific Island albendazole, ivermectin, and
regions, and least prevalent in the Middle diethylcarbamazine alone or in
East and North African regions. Among the combinations against Ascaris and
different age groups, children 5 to 15 years Trichuris spp. Bull World Health Organ.
of age are most frequently infected, and 2003;81:35–42.
have the highest intensities of infection. In a Bethony J, Brooker S, Albonico M, Geiger
recent sentinel survey in the Philippines, the SM, Loukas A, Diemert D, et al. Soil-
prevalence of Trichuris ranged from 4.5 to transmitted helminth infections:
55.1% in preschool children, and from 8.1 ascariasis, trichuriasis, and hookworm.
to 57.9% in school-age children. Lancet. 2006;367:1521–32.
Distribution of trichuriasis is similar to that of Cabrera BD, Cruz AC. A comparative
A. lumbricoides. Prevalence of co-infections study on the effect of mass treatment
with the two helminths is 19.1% in a recent of the entire community and selective
sentinel survey. treatment of children alone in the total
prevalence of soil-transmitted
helminthiases in two
144 MedICal parasItology In the phIlIppInes
Hookworms
Vicente Y. Belizario, Jr., Francis Isidore G. Totañes, John Robert C. Medina
Plate 3.8. Buccal capsules of hookworms: N. americanus (a) and A. duodenale (b)
(Courtesy of Dr. Benjamin Cabrera)
146 MedICal parasItology In the phIlIppInes
these manifestations seem to be rare in the lymph, and protein. Other symptoms are
tropics. In the stage of maturation of the exertional dyspnea, weakness, dizziness,
worm in the intestine, there is abdominal and lassitude, while signs include rapid
pain, steatorrhea, or sometimes diarrhea pulse, edema, and albuminuria. Unlike in
with blood and mucus, as well as ascariasis, the complications in hookworm
eosinophilia. infection are quite mild, and remedial
Hookworm infection is usually chronic, measures are readily applied. In general, the
hence patients often show no acute prognosis of hookworm infection is good.
symptoms. Studies have shown greater blood During the migration of the larva in
loss per worm per day in A. duodenale the human body, the parasite continuously
infection compared with presents diverse immunogenic challenges
N. americanus infection. Chronic moderate to the host. Extensive humoral responses
or heavy hookworm infection results in a are produced against the larva and the
progressive, secondary, microcytic, adult hookworm, which share many
hypochromic anemia of the iron-deficient antigens. Cellular immune response is
type, due primarily to continuous loss of primarily mediated by eosinophils, mast
blood. cells, and Th2 cells. Despite all of these,
Hypoalbuminemia is another there has been no clear evidence that
manifestation of hookworm infection. the
There is low level of albumin due to
combined loss of blood,
148 MedICal parasItology In the phIlIppInes
of the drugs led to low cure rate. Monitoring high. Among pregnant women and
the efficacy of and drug resistance to these adolescent females, the prevalence rates
benzimidazole derivatives has not yet been are 5.5% and 2.8%, respectively. A study
done in the local setting. Baseline data are among military and para-military
necessary for the evaluation and personnel showed that 46.9% had the
adjustment of the treatment regimen. Cure infection. In indigenous people
rates, egg reduction rates, and reinfection communities in Davao del Norte, 13.6% of
rates are important parameters in drug the school children were found to be
monitoring. infected. Among food handlers, 22.7% in
Metro Manila and 14.8% in Cebu had
Epidemiology hookworm infection.
About 576 to 740 million people in Factors that contribute to the
tropical and subtropical countries are distribution and transmission of
estimated to be infected with either A. hookworms are: (a) suitability of the
environment for eggs or larvae: damp,
duodenale or N. americanus. Associated sandy or friable soil with decaying
anemia causes at least 50,000 deaths vegetation, and temperature of 24 to 32°C,
annually. (b) mode and extent of fecal pollution of the
Geographical distribution of the two soil (through open defecation or the use of
human hookworms used to be relatively night soil as fertilizer), and (c) mode and
distinct. A. duodenale was prevalent in extent of contact between infected soil and
Europe and Southwestern Asia, while N. skin or mouth.
americanus was prevalent in tropical Whereas the method of human infection
Africa and the Americas. But now, both in necatoriasis is purely percutaneous, in
species have become widely distributed ancylostomiasis, it is both percutaneous and
throughout the tropics and subtropics, and through the oral route. The latter occurs
rigid demarcations are no longer present. upon eating raw vegetables contaminated
In the Philippines, local studies on with infective larvae and probably also
speciation of human hookworms revealed through ingestion of raw or insufficiently
that out of 1,958 samples positive for cooked infected meat, although it is not clear
hookworm in cultures, 97% were identified whether infection through eating raw meat
as N. americanus, 1% as A. duodenale, and occurs in humans. A. duodenale may remain
2% were mixed infections. dormant in the intestines or in the muscles,
The local distribution of human resulting in a prolonged incubation period
hookworm infection is greater in agricultural and creating problems in treatment.
areas. Farmers are prone to the infection Transmammary transmission has also been
because they work in rice fields and reported.
vegetable gardens, and they are not In the Philippines, the first human case
properly protected from contact with of Ancylostoma ceylanicum was reported in
infective soil. In agricultural areas of 1968 from a 53-year old woman from Ilocos
Compostela Valley province, infection rates Norte where 23 adult worms were collected.
have been shown to be more than 50% in There are also animal hookworms like
the late 1990s. Recent surveillance in Ancylostoma braziliense (cat hookworm)
sentinel sites in the Philippines revealed an and Ancylostoma caninum (dog
overall prevalence of hookworm infection hookworm) that can infect humans
at 1.1% and 1.9% for preschool children causing “creeping eruption,” also known
and school children, respectively. as cutaneous larva migrans (CLM) (Plate
In other high-risk groups, the 3.11).
prevalence of hookworm infection Much of the necessary information
remains relatively about hookworm infection and the
disease, i.e, morbidity and mortality
rates, are still lacking
150 MedICal parasItology In the phIlIppInes
Strongyloides stercoralis
Vicente Y. Belizario, Jr., Percy G. Balderia
hatch into rhabditiform larvae, migrate into intestinal mucosa by adult females may
the lumen, and pass out in the feces. occur simultaneously, particularly in
Autoinfection occurs when hyperinfection. In the first phase of acute
rhabditiform larvae pass down the large infection, larval invasion of the skin
intestine and develop into filariform larvae. produces erythema, and pruritic elevated
Being the infective stage, these filariform hemorrhagic papules. During the larval
larvae may invade the mucosa and enter migration phase, the lungs are destroyed
the circulation to start another parasitic causing lobar pneumonia with
cycle without leaving the body of the host hemorrhage. Cough and tracheal irritation
(Figure 3.7). may also occur, mimicking bronchitis. In
the third phase, adult female worms may
Pathogenesis and Clinical Manifestations be found in the intestinal mucosa from the
There are three phases of acute pylorus to the rectum, but the greatest
infection in strongyloidiasis: (a) invasion of numbers are found in
the skin by filariform larvae, (b) migration of the duodenal and upper jejunal regions.
larvae through the body, and (c) penetration Light infection does not cause
of the intestinal mucosa by adult female intestinal symptoms. Moderate infection
worms. The migration of larvae through the causes diarrhea alternating with
body and penetration of constipation. Heavy infection produces
intractable, painless, intermittent
154 MedICal parasItology In the phIlIppInes
Enterobius vermicularis
Vicente Y. Belizario, Jr., Percy G. Balderia
E
nterobius vermicularis or human posterior esophageal bulb. The small adult
pinworm causes enterobiasis or female worm measures 8 to 13 mm by 0.4
oxyuriasis. The infection is typically mm and has a long pointed tail. The uteri of
characterized by perianal itching or gravid females are distended with eggs.
pruritus ani. Although not a usual cause The male, measuring 2 to 5 mm by 0.1 to
of significant morbidity or mortality, 0.2 mm has a curved tail and a single spicule.
migrating worms may go beyond the Males are rarely seen because they usually die
perianal region and can occasionally cause after copulation.
complications The rhabditiform larva, measuring 140
in ectopic areas. to 150 μm by 10 μm, has the characteristic
This intestinal nematode is classified as esophageal bulb, but has no cuticular
meromyarian, based on the arrangement of expansion on the anterior end.
the somatic muscles where there are two to Eggs (Plate 3.14) are asymmetrical,
five cells per dorsal or ventral half. with one side flattened and the other side
The human pinworm is the most convex, and range from 50 to 60 μm by 20
common helminth parasite identified in to 30 μm in size averaging 55 by 36 μm. The
temperate regions, where environmental translucent shell consists of an outer triple
sanitation is in place. Less attention is albuminous covering for mechanical
given to pinworm infection in tropical protection and an inner embryonic lipoidal
areas, likely due to the presence of other, membrane for chemical protection. Inside
more clinically significant parasites. the egg is a tadpole like embryo that
becomes fully mature outside the host
Parasite Biology within 4 to 6 hours.
Adult worms are found in the cecum
Adult worms have cuticular alar and adjacent portions of the small and
expansions (Plate 3.13) at the anterior end large
and a prominent
intestines. Gravid female worms migrate usually dies. Eggs on the perianal region
down the intestinal tract and exit through the become fully embryonated within 6
anus to deposit eggs on the perianal skin. hours. When ingested, eggs containing
Adult female worms migrate to the perianal the 3rd stage larvae hatch in the
area, usually in the evening hours. A single duodenum, pass down the small intestines
female lays from 4,672 to 16,888 eggs per to the cecum, and develop into adults
day with an average of 11,105 eggs. After (Figure 3.8). Eggs are resistant to
egg deposition, the female disinfectants but succumb to dehydration
in dry air within
Capillaria philippinensis
Vicente Y. Belizario, Jr., Francis Isidore G. Totañes
the soil or water. They must reach the water The eggs hatch in the intestines of the fish
in order to be ingested by small species of and grow into the infective larvae. When the
freshwater or brackish water fish (Figure fish is eaten uncooked, the larvae escape
3.9). from the
fish intestines and develop into adult Endoscopic finding may reveal non-
worms in human intestines. specific segmental erythematous
The first generation of female inflammation in the small bowel with
worms produces larvae to build up the superficial erosions with exudation.
population. Subsequent generations Histologically, the intestines also show
predominantly produce eggs, although flattened and denuded villi, and dilated
there are always a few female worms that mucosal glands. The lamina propria is
produce both larvae and eggs, or larvae infiltrated with plasma cells, lymphocytes,
only. Some of these larvae are retained in macrophages, and neutrophils.
the gut lumen and develop into adults. This
leads to hyperinfection and Diagnosis
autoinfection, which result in the Diagnosis is based on finding
production of very large numbers of characteristic eggs in the feces by direct
worms. In one autopsy, as many as 200,000 smear or wet mount, as well as by stool
worms were recovered from one liter of concentration methods. There may also be
bowel fluid. various larval stages of the parasites, as well
Fish-eating birds are believed to be the as adult worms in the feces. The uterus of
natural hosts of C. philippinensis, and the female worms may contain developing
humans are considered incidental hosts. eggs and sometimes larvae (Plate 3.18). The
Pathogenesis and Clinical Manifestations parasites can also be recovered from the
small intestines by duodenal aspiration.
Persons with C. philippinensis usually
have abdominal pain and borborygmi.
Patients initially experience intermittent
diarrhea, which progresses to passing out 8
to 10 voluminous stools per day. After a
few weeks, there is noticeable weight
loss, malaise, anorexia, vomiting, and
edema. Laboratory findings show severe
protein-losing enteropathy and
hypoalbuminemia; malabsorption of fats
and sugars; decreased excretion of xylose;
low serum potassium, sodium and calcium;
and high levels of immunoglobulin E. If
the disease is not treated soon after the Plate 3.18. Capillaria philippinensis second stage
symptoms occur, severe manifestations of larva from the feces of a person with intestinal
the disease develop with a potentially capillariasis (Courtesy of Dr. John Cross)
fatal outcome.
The large number of worms that A study done in Egypt demonstrated
develop in humans is responsible for high specificity of sandwich enzyme-
the severe pathology. The parasites do not linked immunosorbent assay (ELISA) in the
invade intestinal tissue, but they are detection of coproantigen prepared from
responsible for micro-ulcers in the stool samples of patients with capillariasis.
epithelium, and the compressive This technique did not show cross-reaction
degeneration and mechanical with coproantigen from patients with Fasciola
compression of cells. Homogeneous gigantica and Schistosoma mansoni. Another
material is seen at the anterior end of the study demonstrated cross- reaction of
worm by electron microscopy. The capillariasis patient antibodies with
ulcerative and degenerative lesions in the Trichinella spiralis antigen in immunoblot
intestinal mucosa may account for assay, suggesting the prospective use of
malabsorption of fluid, protein, and T.
electrolytes.
164 MedICal parasItology In the phIlIppInes
spiralis antigen for the immunodiagnosis of towns and resulted in more than 1,000 cases
capillariasis. ELISA using T. spiralis antigen and 77 deaths. Cases of human capillariasis
has been tested and shown to have a have been subsequently reported in
sensitivity of 100% in the diagnosis of Thailand, Iran, Japan, Indonesia, United
capillariasis (43 positive cases) and a Arab Emirates, South Korea, India, Taiwan,
specificity of 100% (57 negative cases). Egypt, and Lao People’s Democratic
Republic. A review of data from local
Treatment hospitals throughout Taiwan from 1983 to
2003 revealed a total of 30 capillariasis cases,
In severe cases with electrolyte and 21 of whom were from two major
protein loss, patients should be given Taiwanese aboriginal tribes.
electrolyte replacement and a high protein In the Philippines, nearly 2,000 cases
diet (Plate 3.19). Anthelminthic drugs have been documented from the Northern
should also be given. The drug of choice Luzon provinces from 1967 to 1990. Cases
for the treatment of intestinal capillariasis have also been documented in Zambales and
is mebendazole, 200 mg twice a day for 20 Southern Leyte. Infections are acquired
days. Alternatively, albendazole 400 mg by eating uncooked small
may be given once daily for 10 days. freshwater/brackish water fish. Ilocano
Relapses may occur if the treatment regimen people enjoy eating bagsit and other fishes
is not followed and completed. found in the lagoons. In Monkayo,
Compostela Valley Province, an outbreak
described as a “mystery disease” in 1998
resulted in the death of villagers due to
misdiagnosis. Intestinal capillariasis was
diagnosed in 17% of the cases presenting
with chronic diarrhea. A more recently
described endemic area in the Philippines
involved Zamboanga del Norte, where more
than 70 deaths were recorded and 4.9% of
those examined in a parasitologic survey were
confirmed to have capillariasis. A few cases
have also been confirmed in Zamboanga del
Sur, Agusan del Sur, and Misamis
Occidental.
Prevention and Control
It is believed that the 1967 to 1968
Philippine epidemic was due to washing
of fecally contaminated bed sheets in lagoons
in the Tagudin area of Ilocos Sur. Efforts to
Plate 3.19. 31-year old female with intestinal improve sanitation and health educational
capillariasis before treatment (left) programs to prevent indiscriminate disposal
and 1 year after treatment (right) of human waste and to discourage eating
(Courtesy of Dr. Vicente Belizario, Jr.) raw fish are important in controlling the
spread of infection (Plate 3.20). Capacity
Epidemiology building for health personnel in the field,
including laboratory staff, for early and
Intestinal capillariasis was first accurate diagnosis and treatment is important
recorded in Northern Luzon in the in preventing mortality. Health education
Philippines. In 1966, an epidemic in can also help improve patient health-
Pudoc West, Tagudin, Ilocos Sur was seeking behaviors.
reported, that spread to neighboring
Chapter 3: nematode Infections 165
Tissue Nematodes
Vicente Y. Belizario, Jr., Timothy M. Ting
be seen enclosed in a sheath, and having damage, and migrate towards the
angular curvatures with secondary kinks, and mosquito’s head and proboscis. During a
two nuclei at the tip of the tail. The column blood meal, larvae emerge from the
of indistinct and confluent nuclei is proboscis onto the skin of the susceptible
composed of two rows. host and actively penetrate the skin through
Adult male and female W. bancrofti the bite wound to reach the lymphatic
worms are found tightly coiled in nodular vessels and nodes where they develop into
dilated nests (lymphangiectasia) in lymph adult worms. They are usually localized in
vessels and in sinuses of lymph glands. the lymph vessels of the lower extremities,
Adult females produce microfilariae, which inguinal lymph nodes, epididymis of males,
gain entrance to the peripheral blood and labia of females. Microfilariae migrate
circulation where they are picked up by the from the parent worm, through the walls of
appropriate mosquito vector during a blood the lymphatics, and into the neighboring
meal (Plate 3.22). Mosquitoes belonging to blood vessels.
the genera Aedes, Culex, and Anopheles The life cycle of B. malayi generally
have been shown to be biologic vectors of follows the same pattern as that of W.
Wuchereria. Microfilariae ingested by the bancrofti with a few exceptions (Figure
mosquito migrate to its muscles where they 3.10). Mosquito vectors of B. malayi belong
develop into first (L1), second (L2), and to the genus Mansonia. Development of
third (L3) stage larvae. After 6 to 20 days the microfilariae to the infective stage in
of development, 3rd stage larvae force their the mosquito takes about 2 weeks.
way out of the muscles, causing Maturation time for the 3rd stage larvae to
considerable become adults takes about 3 to 9 months.
Thereafter, microfilariae are produced and
may be seen in the circulation.
Pathogenesis and Clinical Manifestations
LF is characterized by a wide
spectrum of clinical manifestations, with
signs and symptoms different from one
host to another. The infection is usually
acquired in childhood but may take years to
manifest itself. The clinical course may be
divided into asymptomatic, acute, and
chronic stages, generally progressing in that
order. In an endemic community, the
different stages of the disease frequently
overlap, and in certain groups of people
from non- endemic areas, the disease may be
characterized by an initial acute stage
followed directly by a chronic stage in a
relatively short period of time. Individuals
who grew up outside regions endemic for
these filarial parasites and who get infected
by them after migration to the endemic
regions may clinically present with
“Expatriate Syndrome.” The syndrome is
characterized by clinical and immunologic
hyper-responsiveness to the mature or
Plate 3.22. Wuchereria bancrofti microfilaria maturing worms. Together with the usual
(Courtesy of the Department of Parasitology, acute manifestations of lymphadenitis
UP-CPH)
168 MedICal parasItology In the phIlIppInes
and lymphangitis, individuals with this lymphatic endothelial cell proliferation and
syndrome also present with allergic differentiation leading to
reactions such as hives, rashes, and blood collateralization. These lymphatic
eosinophilia. dysfunctions have been shown to predispose
Lymphatic localization is infected individuals to secondary bacterial
important in parasite survival because infections and trigger inflammatory
lymph is a less aggressive medium than reactions in the skin and subcutaneous
blood: no platelets, no complement system, tissue, leading to lymphedema and
incomplete coagulation system, and no elephantiasis.
granulocytes; in addition, its flow is much A characteristic feature of chronic LF
less violent. Filarial adult worms cause infection is fibrosis and cellular hyperplasia
parasite-induced lymphatic dilatation in and around the lymphatic walls; these
(lymphangiectasia); this is a common changes are postulated to render lymphatic
feature of patent infection, though clinically endothelial cells less effective at
apparent lymphedema is rarely seen. transporting interstitial fluid, thereby
Another cardinal feature of LF is contributing to the edema and collagen
lymphangiogenesis, where live filarial accumulation. Dead and decalcifying adult
parasites or filarial antigens induce worms elicit immune
Chapter 3: nematode Infections 169
use of properly fitting footwear; and (e) effects, and have not been adequately
raising the affected limb at night to reduce evaluated in filariasis-endemic areas.
the swelling. In the setting of severe Current WHO guidelines call for the
lymphedema and elephantiasis, the hygiene complete surgical removal of the tunica
education program stated above may be vaginalis to minimize or prevent recurrence.
supplemented with the use of compressive
bandages, stockings, manual lymphatic Epidemiology
drainage (massage), heat therapy, About 120 million people worldwide
and, in refractory cases, surgical procedures. are affected by the disease, and more than
An estimated 27 million males suffer 1 billion people are at risk (one-fifth of the
from hydroceles, and the prevalence is world’s population), mostly in the
strongly associated with the intensity of poorest areas. Bancroftian filariasis
parasite transmission (microfilaremia accounts for 90% of cases in 83 endemic
prevalence). Recent observations from countries while the Malayan filarial worm
Brazil, Egypt, and Haiti indicate that many (and B. timori) causes the remainder. W.
acute hydroceles resolve spontaneously, and bancrofti affects more than l00 million
about 24% persist to become chronic. people in the tropical areas of India,
Surgery is the recommended treatment for Southeast Asia, the Pacific Islands, Africa,
hydrocele, and if done properly, is deemed and South and Central America. India has the
curative. Other methods such as aspiration largest number of cases. B. malayi and B.
of fluid and injection of sclerosing timori affect
substances are less effective, are associated 12.5 million people in Southeast Asia
with hydrocele recurrence, have (Figure 3.11). The prevalence of infection
unacceptable side
continues to
Figure 3.11. Distribution and status of preventive chemotherapy for lymphatic filariasis, worldwide, 2010
(Accessed from gamapserver.who.int)
Chapter 3: nematode Infections 175
Parastrongylus cantonensis
Vicente Y. Belizario, Jr., Francis Isidore G. Totañes
include the following slugs and snails: Although the mechanism by which
Achatina fulica (Plate 3.30) or giant humans get infected is not yet entirely clear,
African snail, Hemiplecta sagittifera, transmission is usually attributed to: (a)
Helicostyla macrostoma, Vaginilus plebeius, and ingestion of the raw mollusk intermediate
Veronicella altae. Its mode of infection is by host infected with the third stage larva; (b)
ingestion or active penetration. In the ingestion of leafy vegetables contaminated
mollusk, larva eventually develops into the with mucus secretions of the mollusk
3rd larval stage in about 12 days. carrying the infective stage (3rd larval
Chapter 3: nematode Infections 181
Meningeal lesions may be appreciated Further studies showed that its prevalence
with the use of computed tomography (CT) in rats is less than 7%. The presence of P.
scan. CT scans may also reveal non-specific cantonensis as a parasite of rats and/or
cerebral edema and ventricular dilatation. snails has been reported in the following
Magnetic resonance imaging (MRI) may provinces of Luzon: Batangas, Bulacan,
show lesions with hyperintense T2 signal. Cavite, Ilocos Norte, Laguna, Mountain
Although enzyme-linked immunosorbent Province, Nueva Ecija, Pampanga,
assay (ELISA) for the diagnosis of Pangasinan, Quezon, Rizal, Sorsogon,
parastrongyliasis is still not commercially Tarlac, and Metro Manila. Two cases of
available, a dot-blot ELISA that tests blood ocular parastrongyliasis have been reported
has been demonstrated to be 100% sensitive from the East Avenue Medical Center. The
and specific for use in epidemiological patients were blood relatives coming from
surveys. In addition, serum antigens from P. Isabela who have eating history of
cantonensis can also be detected by improperly cooked snails. The worms were
immuno- polymerase chain reaction (PCR). identified at the College of Public Health,
University of the Philippines Manila.
Treatment
Prevention and Control
No a n t h e l mi n t h i c tre a t me n t is
recommended at present, although The main preventive strategy against
mebendazole and albendazole have been parastrongyliasis is through awareness and
demonstrated to effectively treat education on proper eating habits and safe
parastrongyliasis in China, Taiwan, and food preparation. The public should be
Thailand. Anthelminthic therapy has been discouraged from eating raw or poorly
shown to relieve symptoms and reduce the cooked mollusks or unwashed
duration of the disease. Ocular vegetables. Hand washing after gardening
parastrongyliasis may require surgical should also be advised. Farmers occasionally
removal of worms from the eyes. use molluscicides, such as metaldehyde or
Symptomatic treatment with the use of iron phosphate food bait pellets to control
analgesics and lumbar puncture can relieve intermediate hosts. Copper barriers against
the headaches experienced by the patient snails and slugs are also utilized by
with eosinophilic meningitis. Prednisone 30 farmers to prevent contamination of
mg daily is recommended, particularly in vegetable and fruit crops. Health workers in
severe cases with cranial nerve involvement. endemic areas should also be educated on
The anti-inflammatory and the diagnosis, treatment, control, and
immunosuppressive effects of steroids are prevention of parastrongyliasis.
helpful in mitigating the disease process.
References
Epidemiology
Chen ER. Angiostrongyliasis and
Human infection with P. cantonensis eosinophilic meningitis in Taiwan: a
was first reported in 1945 by Nomura and review.. In: Cross JH, editor. Studies on
Lin in Taiwan. As a human parasite, P. angiostrongyliasis in East Asia and
cantonensis has also been documented in Australia. Taipei, Taiwan:
approximately 30 countries including U.S. Naval Medical Research Unit No.
Thailand, China, Tahiti, French Polynesia, 2,; 1979. p. 57–73.
USA, Cuba, New Caledonia, Japan, Cross JH. Public health importance of
Australia, Vanuatu, India, and the Angiostrongylus cantonensis and its
Philippines. relations. Parasitol Today. 1987;367–9.
In the Philippines, Nishimura and
Yogore reported the presence of
Parastrongylus in rats.
Chapter 3: nematode Infections 183
Trichinella spiralis
Vicente Y. Belizario, Jr., Francis Isidore G. Totañes
T richinella was first described by the body. In addition, the female worm has
Tiedemann in 1822. In 1835, James an oviduct, a seminal receptacle, a coiled
Paget and Richard uterus, a vagina, and a vulva. The vulva is
Owen demonstrated Trichinella in situated in the anterior 5th on the ventral
human cadavers in London. Before the side of the body. The viviparous female
turn of the century, German investigators lives for 30 days and is capable of producing
were able to prove that raw or more than 1,500 larvae in its lifetime.
insufficiently cooked meat (i.e., pork) was The larva measures 80 to 120 μm by
responsible for trichinellosis in humans. 5.6 μm at birth, but reaches the size of
Trichinellosis was initially attributed to a 0.65 to 1.45 mm in length and 0.026 to
single species, T. spiralis, but the discovery 0.040 mm in width after it enters a muscle
of marked strain differences in Trichinella fiber. It has a spear-like, burrowing
isolates have led to the identification of anterior tip. The digestive tract of a
new species. mature larva encysted in a muscle fiber
There are eight recognized species and resembles that of the adult worm. The
three genotypes under the genus Trichinella. reproductive organs, at this stage, are not
Trichinella spiralis is the most important yet fully developed but even then, it is
cause of trichinellosis in humans, and is the already possible to identify the sex of the
species that is most adapted to domestic parasite.
and wild pigs. Trichinella britovi, on the In Trichinella infection, the host
other hand, is the most widely distributed (i.e., humans, rats, dogs, cats, pigs,
species among wild animals in Asia, bears, foxes, walruses, or any other
Europe, Northern Africa, and Western carnivore or omnivore) serves as both the
Africa, although it can also infect domestic final and intermediate host by harboring
pigs. T. britovi is the 2nd most common both the adult and the larval stages.
Trichinella species affecting humans. Infective larvae are usually encysted in
Trichinella nativa infects primarily wild the muscle fibers of the host (Plate 3.31).
carnivores in the frigid zones of Asia, North
America, and North Eastern Europe. Other
species that have been known to cause
human trichinellosis include T. murrelli, T.
nelsoni, T.papuae, and T. pseudospiralis.
Parasite Biology
The infective encysted larvae enter After a few days, the female worm
the host through ingestion of raw or deposits larvae in the mucosa. The larvae
insufficiently cooked meat. The cysts are penetrate the mucosa, pass through the
digested in the stomach, and the larvae lymphatic system into the circulation, and
excyst either in the stomach or in the finally into striated muscles (Figure 3.14).
small intestine. The larvae then burrow In the muscles, the larvae grow and
into the subepithelium of the villi where develop. After about 3 weeks, they start to
they undergo four molts. Maturation takes coil into individual cysts. Encapsulation is
about 2 days, and adult worms begin to completed 4 to 5 weeks after infection. The
mate 5 to 7 days post infection. The larva in the cyst remains viable for many
female produces eggs that grow into larvae years. The average lifespan of the encysted
in its uterus. larva is about 5
to 10 years, and can survive for up to 40 years dyspnea, dysphagia, and difficulty in
in humans. In humans, calcification of the chewing. Occasionally, there is paralysis of
collagen capsule in the infected muscle cell the extremities and splenomegaly. In severe
and the larva may occur. This process may cases, there may be gastric and intestinal
be observed 6 to 12 months after infection hemorrhages.
and may lead to the destruction or death of Larval migration into the heart muscle
the larva. can result in pericardial pain, tachycardia,
and electrocardiogram abnormalities.
Pathogenesis and Clinical Manifestations Pericardial effusion, congestive heart
The severity of symptoms depends on failure, and other chronic heart
the intensity of infection. Patients with light abnormalities have also been observed.
infection, i.e., harboring up to 10 larvae, are Neurological complications, which are
usually asymptomatic, while patients with caused by small subacute cortical infarcts,
moderate infection (50-500 larvae) show may occur in chronic infections. Meningitis
symptoms. Infection with a few hundred and meningoencephalitis may also develop.
larvae can result in gastroenteritis, diarrhea, In heavy infections, ocular disturbances,
and abdominal pain approximately two days diplegia, deafness, epileptiform attacks, and
post infection. Infection with 100 to 300 coma may occur. In the convalescent phase,
larvae may lead to symptomatic fever, weakness, pain, and other symptoms
trichinellosis, while more than 1,000 to start to abate. Full recovery is expected
3,000 larvae can result in severe disease. since trichinellosis is a self-limiting disease.
Clinical manifestations vary depending However, protean neurologic signs arising
on the stage of the parasite. The clinical from brain damage may persist.
conditions are divided into three phases, Prognosis is good, especially in mild
namely: enteric phase, invasion phase, and infections. Death is uncommon except in
convalescent phase. These correspond to the cases of heart failure, encephalitis, or other
stages of: (a) incubation and intestinal complications such as pneumonia or
invasion, (b) larval migration and muscle septicemia. Low-grade or absent
invasion, and (c) encystment and peripheral blood eosinophilia is
encapsulation. indicative of poor prognosis.
Symptoms in the enteric phase Diagnosis
may resemble those of an attack of
acute food poisoning, including diarrhea The most definitive diagnostic
or constipation, vomiting, abdominal examination is the demonstration of the
cramps, malaise, and nausea. During larva through muscle biopsy. Muscle
the invasion phase, the migrating larvae biopsy is done through histological
and resulting metabolites lead to examination of 0.2 to 0.5 g of muscle tissue.
immunological, pathological, and Digestion of muscle samples with pepsin and
metabolic reactions. Inflammatory reaction hydrochloric acid can also be done to
to the infection results in eosinophilia, determine the number of larvae per gram
which results in the release of histamines. of muscle, or to isolate larvae for molecular
Histamines, serotonins, bradykinins, and characterization. The digestion technique,
prostaglandins contribute to an increase in however, is limited to muscle larvae that are
vascular permeability, resulting in tissue about 10 to 12 days old (about 2-3 weeks
edema. The cardinal signs and post infection) since younger larvae may be
symptoms of trichinellosis include destroyed by the digestion fluid.
severe myalgia, periorbital edema, and Non-specific laboratory tests to detect
eosinophilia. Other typical signs and eosinophilia, muscle enzymes (creatine
symptoms include high remittent fever phosphokinase, lactate dehydrogenase,
and chills, headache, and
Chapter 3: nematode Infections 187
myokinase), and total IgE in serum may be children 2 years and older, albendazole
useful in diagnosis. An algorithm for the should be given at 10 mg/kg body weight. A
diagnosis of individual cases is shown in treatment cycle may be repeated five days
Table 3.4. after the initial cycle in case of severe
infection. Thiabendazole is no longer used
Table 3.4. Algorithm for the diagnosis of the due to its associated adverse drug reactions.
probability of acute trichinellosis in humans Supportive treatment through
analgesics and antipyretics is commonly
Group Symptom used to control symptoms. Corticosteroids
A Fever, eyelid and/or facial edema, myalgia
may be given with anthelminthics to
control hypersensitivity reactions to the
B Diarrhea, neurological signs, cardiac signs, larvae, and may also be given to treat acute
conjunctivitis, subungual hemorrhages,
cutaneous rash
vasculitis and myositis.
C Eosinophilia (>1,000 eosinophils/ml) and/ Epidemiology
or increased total IgE levels, increased
levels of muscular enzymes Trichinella infections in humans have
D Positive serology (with a highly specific test), already been documented in 55 countries
seroconversion, positive muscular biopsy worldwide. There are about 10,000 cases
reported each year, 0.2% resulting in
mortality. Human trichinellosis occurs
The diagnosis of trichinellosis is very wherever meat is a part of the diet.
unlikely in the occurrence of only one Outbreaks have been reported in
symptom from group A, B or C. Argentina, Bosnia-Herzegovina, China,
Trichinellosis may be suspected in the France, Laos, Romania, Spain, Sweden,
presence of one symptom from group A or Thailand, Turkey, Ukraine, Uzbekistan, and
two from group B, and one from group C, Vietnam. Trichinella infection has never
while a diagnosis is probable when there are been documented in a small number of
three group A and one group C symptoms. island countries, including the Philippines.
Diagnosis is highly probable in the presence Trichinellosis is primarily a
of three group A and two group C zoonosis. Humans get infected after
symptoms. A diagnosis is confirmed in case ingestion of raw or insufficiently cooked
of three group A, two group C, and one meat from infected animals. The infection
group D symptoms; or any of symptom from is usually maintained in a pig-to-pig or pig-
group A or B, and one from group C and to-rat-to-pig cycle.
one from group D.
Currently, enzyme-linked Prevention and Control
immunosorbent assay (ELISA) is Health education is an important
recommended for the diagnosis of component of prevention and control
trichinellosis. Confirmation of ELISA- measures against this parasitic infection.
positive samples may be done through It is recommended that meat be cooked
Western blot technique. Latex agglutination at a minimum of 77°C (170°F). Freezing is
technique may be utilized for rapid (<1 hour) another way to kill larvae. Storage at –15°C
confirmation of trichinellosis. for 20 days or –30°C for six days is
Treatment suggested. Smoking, salting, or drying
meat is not effective. Other control
The treatment of choice for measures include regular animal
trichinellosis is mebendazole 5 mg/kg body monitoring (meat inspection or detection
weight daily, or albendazole 15 mg/kg body of circulating antibodies), keeping pigs in
weight per day in two divided doses, for rat-free pens, and proper disposal of
10 to 15 days. For suspected carcasses.
188 MedICal parasItology In the phIlIppInes
Anisakis spp.
Winifreda U. de Leon
Acute allergic reactions have been There have been reported cases from Egypt
reported in anisakidosis, when biochemical as well. The condition is more common in
substances are released by the parasites into the coastal population of these countries due
the flesh of the host fish. Urticaria, asthma, to the consumption of raw and inadequately
conjunctivitis, and contact dermatitis have cooked fish. In the Philippines, anisakidosis
been observed among workers in fish and has not yet been documented.
marine products processing factories and Considered to be high risk for
are forms of occupational anisakidosis are fish dishes such as
hypersensitivity. Japanese sushi and sashimi, pickled
anchovies, gravlax, salted and smoked
Diagnosis herring, and possibly fish bagoong as well
Anisakidosis should be highly as fish kinilaw in the Philippines. Salting,
suspected if there is a recent history of marinating, pickling, smoking, and other
eating raw or improperly cooked fish or curing techniques are effective against some
squid prior to the acute onset of foodborne pathogens, but not for anisakid
symptoms. Through larvae.
gastroscopic/endoscopic examination, the Several species of marine fish and
larvae can be visualized and removed for cephalophods (squid) have been found to be
identification. Intestinal anisakidosis is infected with anisakid larvae. Mostly
more difficult to establish, and may be involved are the Pacific/Atlantic cod, Pacific
diagnosed only after surgery. Serological halibut, red snapper, mackerel, eels, salmon,
procedures to detect specific antibodies have and anchovies. In the Philippines, anisakid
been employed with good results, such as larvae have been found in blue mackerel
enzyme-linked immunosorbent assay scad (galunggong), but the prevalence and
(ELISA), and radioallergosorbent test density of the larvae seems to be seasonal.
(RAST). Infected eels (palos) have been found in
Cebu, Mactan, and Leyte.
Treatment The increasing number of cases is
believed to be due to multi-factorial
The main approach is to mechanically causes. Deep sea marine mammals are
remove the larva using endoscopic currently being protected. Therefore,
forceps. It is strongly recommended that there has been an increase in the
endoscopic removal be done early to avoid population of the definitive hosts. The
invasion of the gastric submucosa. worldwide distribution of the anisakid
Corticosteroids have been used in cases of nematodes may result in widespread
allergic anisakidosis but clinical trials have contamination of marine fish and squid. The
not been performed. A possible therapeutic increasing popularity of the consumption of
benefit from albendazole for intestinal sushi and sashimi globally may also
anisakidosis has been reported in Spain. contribute to the increase in cases.
Epidemiology Control and Prevention
Human anisakidosis is not a very In order to best control and prevent
common infection, but it has been anisakidosis, marine fish, squid,
reported from all over the world. In Asia, and shellfish must be thoroughly
the majority of reports have come from cooked prior to consumption. For raw or
Japan and Korea, while in Europe, human undercooked preparations, fish and
cases have been identified in the shellfish must undergo blast freezing at –
Netherlands, France, Germany, Italy, 35°C for at least 15 hours. Freezing at –
Spain, and the United Kingdom. It has 20°C for 7 days has also been found to be
also been reported in North and South effective. Furthermore, raising the
America.
192 MedICal parasItology In the phIlIppInes
Toxocara canis
Toxocara cati
Ernesto C. Balolong, Jr., Winifreda U. de Leon