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InfeksiCacing

Parasitologi Klinik
Buku Ajar Ilmu Penyakit Dalam
Harrisons Internal Medicine

CASE

A 4-year-old male child was admitted to

the emergency department with


abdominal pain and biliary vomiting for
three days.
Physical examination revealed
abdomen tenderness and rigidity. X-ray
showed air-fluid levels indicative of
intestinal obstruction.
USG demonstrated masses in the
intestinal lumen.

IM AG IN G

ASCARIASIS AN D FRIEN D S

Donnie Lumban Gaol


Internal Medicine

BACKG RO U N D
Ascariasis is the most common

helminthic infection, with an estimated


worldwide prevalence of 25% (0.8-1.22
billion people).

BACKG RO U N D
Ascaris lumbricoidesis the largest of

the commonnematodes
(roundworms) that infect humans.
AdultA lumbricoidesare white or
yellow and 15-35 cm long (see first
image below). They live 10-24
months in the jejunum and middle
ileum of the intestine.

femaleA lumbricoidesproduce

240,000 eggs

Pathophysiology

Fertilized eggs released into

favorable soil may become infectious


within 5-10 days.
Eggs may remain viable in soil for up
to 17 months.
Infection occurs through soil
contamination of hands or food,
ingestion, and the subsequent
hatching of eggs in the small
intestine

There are tw o phase in


ascariasis
The blood-lung migration phase of

the larvae
The symptoms of the pneumonia are low

fever, cough, blood-tinged sputum,


asthma.
Large numbers of worms may give rise
to allergic symptoms.
Eosionophilia is generally present. These
clinical manifestation is also called
Loefflers syndrome

There are tw o phase in


ascariasis
The intestinal phase of the adults.
vague abdominal pains or intermittent colic,

especially in children.
Wandering adults may block the appendical lumen
or the common bile duct and even perforate the
intestinal wall.
Thus complications of ascariasis, such as intestinal
obstruction, appendicitis, biliary ascariasis,
perforation of the intestine, cholecystitis,
pancreatitis and peritonitis, etc., may occur, in
which
biliary ascariasis is the most common
complication.

Epidem iology

The prevalence of ascariasis is

highest in children aged 2-10 years,


with the highest intensity of infection
occurring in children aged 5-15 years
who have simultaneous infections
with other helminths such as
Trichuris trichiuraandhookworm.

Epidem iology

Because the lifespan of adult worms

in the intestine is only one year,


persistent infection requires frequent
re-exposure and reinfection.

In children, intestinal obstruction

caused by heavy worm burden (60)


is the most common manifestation of
disease.
Adults with ascariasis are more likely
to develop biliary complications due
to migration of adult worms

ClinicalPresentation
Early symptoms of ascariasis, during

the initial lung migration, include


cough, dyspnea, wheezing, and
chest pain.
Abdominal pain, distension, colic,
nausea, anorexia, and intermittent
diarrhea may be manifestations of
partial or complete intestinal
obstruction by adult worms

ClinicalPresentation
Jaundice, nausea, vomiting, fever,

and severe or radiating abdominal


pain may suggest cholangitis,
pancreatitis, orappendicitis.

PhysicalExam

Rales, wheezes, and tachypnea may

develop during pulmonary migration,


particularly in persons with a high
worm burden.
Urticaria and fever may also develop
late in the migratory phase.

Laboratory Studies

Stool examination for ova and

parasites almost always discloses


large, brown 60 m X 50 m
trilayered eggs in persons with
ascariasis.
stool examination may be negative
for ova for up to 40 days after
infection because of the time needed
for migration and maturation of the
worm.

CBC counts show eosinophilia during

the tissue migration phase of the


infection.
Serological tests are not clinically
useful for ascariasis.

Im aging Studies

Chest radiographs may show fleeting

opacities during pulmonary


migration.
Worms have been increasingly
identified in the biliary duct or
gallbladder with ultrasonography and
CT scanning.
Endoscopic retrograde
cholangiopancreatography (ERCP)

M edicalCare

Albendazole 400 mg one dose orally

is the drug of choice.


Alternative therapy is mebendazole
(100 mg bid for 3 d or 500 mg as a
single dose).
Paralyzing vermifuges (eg, pyrantel
pamoate, piperazine, ivermectin)
should be avoided in patients with
complete or partial intestinal
obstruction

Prevention and Treatment


1.Treatment

to

ascariasis:Mebendazole,
Albendazole and Levamizole are
effective.
2.Sanitary disposal of feces.
3.Hygienic habits such as cleaning
of hands before meals.
4.Health education.

H ookw orm
Hookworms represent a widespread

and clinically important human


nematode infection.
they causeanemiain approximately
10%

H ookw orm
Ancylostoma duodenale
andNecator americanus

ClinicalPresentations
Asymptomatic until worms have already

started multiplying
Symptoms include:

Irritation of skin at site of penetration


Iron-deficiency anemia
Abdominal pain
Diarrhea
Loss of appetite
Weight loss
Tiredness
Difficulty breathing
Cardiomegaly
Irregular heartbeat
Extreme cases include stunted growth and
mental retardation

Necatorproduces a local irritation,

termed ground itch, at the site of


skin invasion. An intensely pruritic,
erythematous, or vesicular rash
usually appears on the feet or hands.

Signs of iron deficiency anemia are

often insensitive.
In severe cases, patients may exhibit

pallor, spooning nails, tachycardia, and


peripheral edema. Poor skin texture,
edema, and susceptibility to cutaneous
infection suggest possible malnutrition.

Spooning nails

H ookw orm Infection

Laboratory Studies
Direct microscopic stool examination

for ova and parasites


Anemia is confirmed by CBC count
and peripheral blood smear results
that demonstrate signs typical of iron
deficiency anemia.
Eosinophilia is surprisingly persistent
and may be due to attachment of the
adult worms to the intestinal mucosa

Im aging
Chest radiography may show diffuse

alveolar infiltrates during the


migration of the worms through the
lung in severe infection

Treatm ent
Albendazole or mebendazole is the drug of

choice for hookworm infection. These drugs


provide a short-term cure in 90-95% of
children, with up to a 99% reduction in egg
counts.
Imidazoles are the most convenient and
effective drugs to treat hookworm. Other
older agents are also effective but may have
lower clearance rates.
Pyrantel pamoate has been effectively used
in hookworm infections.

Treatm ent
Iron replacement and nutritional

supplementation (protein and


vitamins) should be part of the
management strategy

Filarialw orm s
Filarial worms are thread-like nematodes of
which there are at least 8 species for which
humans, especially in tropical regions, are
the definitive host.
Approximately 250 million people
worldwide are infected with these worms
which are spread by mosquitoes.
Different species inhabit different locations
in the body. Some live in the lymphatic
system, others subcutaneously and others
in the abdominal cavity.

http://en.wikipedia.org/wiki/File:Filariasis_01.png

Filarialw orm s
Females can be 10cm long and they
release live young microfilariae into
the blood and lymphatic system.
The microfilariae are picked up by
mosquitoes where they develop,
become infective and can infect
another person.

Filarialw orm s
In some people exposed to persistent
infections with filarial parasites that live
in the lymphatic system,
elephantiasis may develop.
This is caused by blockage of lymphatic
ducts and inflammation. There may be
excessive growth of connective tissue
and enormous swelling of infected parts
including legs, arms and scrotum.

Signs and sym ptom s


Lymphatic filariasis
Fever
Inguinal or axillary lymphadenopathy
Testicular and/or inguinal pain
Skin exfoliation
Limb or genital swelling - Repeated

episodes of inflammation and


lymphedema lead to lymphatic damage,
chronic swelling, and elephantiasis of the
legs, arms, scrotum, vulva, and breasts.

O nchocerciasis
The clinical triad of infection in onchocerciasis is as

follows:
Dermatitis
Skin lesions include edema, pruritus, erythema, papules,

scablike eruptions, altered pigmentation, and


lichenification

Skin nodules (ie, onchocercomas)


Skin nodules tend to be common over bony prominences

Ocular lesions
Eye lesions are usually related to the duration and

severity of infection and are caused by an abnormal host


immune response to microfilariae; loss of visual acuity
may occur

O nchocerciasis

Loiasis
Clinical Findings
Recurring skin lesions at different

body sites with pruritus and urticaria


followed by oedema (calabar swelling)
are transient (for 23 days)
Migration of the adult worm across the
conjunctiva may result in irritation,
pain and congestion of the conjunctiva
but is also often without symptoms

Loiasis

Loiasis

Figure 15.11

Elephantiasis of leg
caused by filarial worms

9.12

Filarialw orm s
The most common filarial worm in the
U.S. Dirofilaria immitis is the cause of
heartworm in dogs.
Adult worms may be as long as 40cm
and they live in the dog's heart and
lungs.
Because they damage the heart,
infection is often fatal, and killing adult
worms is difficult and dangerous to the
dog.
Prevention of infection by regular
dosing of a dog with drugs that kill
circulating larvae is a better strategy.

D iagnosis
Microfilariae can be detected through

examination of the following:


Blood
Urine
Skin : Onchocerca volvulusandM

streptocercainfections
Eye - Microfilariae ofO volvulusmay be
detected in the cornea or anterior chamber
of the eye using slit-lamp examination

im aging studies
Chest radiography - Diffuse

pulmonary infiltrates are visible in


patients with TPE
Ultrasonography - Can be used to
demonstrate and monitor lymphatic
obstruction of the inguinal and
scrotal lymphatics; has also been
used to demonstrate the presence of
viable worms
Lymphoscintigraphy[

M anagem ent
Anthelmintics used in the treatment of

filariasis include the following:


Diethylcarbamazine (DEC)
Ivermectin - Drug of choice forWuchereria
bancrofti
Suramin - Only drug in clinical use for
onchocerciasis that is effective against adult
worms
Mebendazole
Flubendazole
Albendazole

Surgery
In lymphatic filariasis, large

hydroceles and scrotal elephantiasis


can be managed with surgical
excision.

Next Worm..

Diagnostic Quiz :
A 43-year-old immunocompetent female
was admitted to the hospital in a confused,
lethargic state. An adequate history was
not possible; however, the patient had
seen her physician about 10 days before
complaining of headache, weakness,
malaise and fever. She was treated for
sinusitis, however, she failed to improve on
this therapy. Her temperature continued to
be elevated about 4-5 degrees. She
became semi-stuporous and was
hospitalized.

On examination, she was a well-developed,

acutely ill female who was confused. The


heart was normal, but the lungs exhibited
rales at both bases. There was a wrist drop
on the left and weakness of the flexor
muscles of both arms and left leg. The
patient had numerous splinter hemorrhages
under the fingernails and periorbital
edema.

Laboratory findings included a very

high peripheral eosinophilia of 50%.


Brain scan was normal
CSF examination revealed normal
pressure, clear fluid, and no cells or
bacteria. Based on this information, a
parasitic disease was suspected.
Please comment on the possible

diagnosis related to the history , the


patient's clinical symptoms and the
laboratory test results to date.
Examination of the patient revealed the

TR IC H IN ELLO S IS

CausalAgents:
T. spiralis (found worldwide in many

carnivorous and omnivorous animals)


T. pseudospiralis (mammals and birds
worldwide)
T. nativa (Arctic bears)
T. nelsoni (African predators and
scavengers)
T. britovi (carnivores of Europe and
western Asia).

T. spiralis is the primary cause associated with

domesticated animals.
T. britovi is seen frequently in wild boar,
horses, and free-ranging swine.
T. nelsoni is seen in various large carnivores.
T. nativa has been documented in cougar,
walrus, whale, and bear flesh.
T. pseudospiralis has been documented in
birds and does not form a capsule in the
muscle.
T. papuae in wild pigs has been identified in
Papua-New Guinea as a source of infection
among forest-dwelling hunters.

M orphology

Life Cycle:
Ingestion of meat containing
(encysted larvae)

the larvae are


released from the
cysts and invade the
small bowel mucosa
where they develop
into adult worms

Rats and rodents are primarily


responsible for maintaining the
endemicity of this infection.
Carnivorous/omnivorous animals,

females release
larvae that migrate
to the striated
muscles where they
encyst

G eographic D istribution:
Worldwide. Most common in parts of

Europe and the United States.


Average of 12 cases per year were
reported in 1997-2000
China Serologic population surveys
have revealed prevalence rates of
between 0.66-12%. (Takahashi, 2000), (Liu,
2002)

M ortality/M orbidity:
Death is rare without development of

neurologic and cardiac involvement.


The primary morbidity is persistent
myalgia and fatigue in cases that do not
develop neurocardiac involvement.
Persistent variable dysfunction of either
system may develop, depending upon the
distribution of lesions.

H istory:
Myalgia (75%) - Most commonly occurs in masseter,

diaphragm, and intercostal muscles; may be severe to


point of inability to ambulate or perform simple upper
extremity or truncal tasks like feeding or sitting upright
Fever (60-75%) - 38.5-40.5C
Weakness (75%)
Diarrhea (40-60%) - Usually only in the acute intestinal
proliferative and penetration phases of helminth
infestation
Facial edema (40-50%) - Usually considered one of the
hallmark features, particularly when localized to the
eyelids
Headache (50-60%)
Fatigue
Arthralgia

Cardioneurologic syndrom e
Onset of these symptoms occurs in the

first few days following general


symptoms and prior to muscle invasion.
The syndrome includes varying
combinations of the following:
Diffuse encephalopathy
Focal neurological deficits
Acute myocardial injury (eg,
myocarditis, sinus and atrial nodal
dysfunction, congestive heart failure,
infarction); also late myocarditis as
isolated sequela possible
Hypereosinophilia (>4000

Rash - This may occur in several

forms.
Urticaria (most common)
Petechiae
Splinter hemorrhages
Palmar rash - Peripheral palmar and
volar digital edema and erythema;
desquamation occurs (10% in one
study [Walsh, 2001])

ClinicalFeatures:
Light infections may be asymptomatic.
Intestinal invasion can be accompanied by

gastrointestinal symptoms (diarrhea,


abdominal pain, vomiting).
Larval migration into muscle tissues (one
week after infection) can cause periorbital
and facial edema, conjunctivitis, fever,
myalgias, splinter hemorrhages, rashes,
and blood eosinophilia.

ClinicalFeatures:
Occasional life-threatening

manifestations includes
myocarditis, central nervous system

involvement, and pneumonitis.

Larval encystment in the muscles

causes myalgia and weakness,


followed by subsidence of symptoms.

Com plications:

Arrhythmias from heart

inflammation (myocarditis)
Heart failure
Encephalitis
Pneumonia

Laboratory D iagnosis:
clinical symptoms
Eosinophilia
antibody detection
muscle biopsy
microscopy

Lab Studies:

CBC reveals eosinophilia in virtually all patients.


UA may reveal myoglobinuria.
Creatine kinase is elevated in 90% of patients.
Parasite-specific indirect immunoglobulin G (IgG)
enzyme-linked immunosorbent assay (ELISA) titers
(100%) and antinewborn larvae antibodies (30%)
are recommended. These may not be positive
initially, and they also are subject to some crossreactivity with other parasitic disorders making their
specificity less when weakly positive (Yera, 2003).
Western-blot analysis is used as a confirmatory
evaluation (Robert, 1996).

Im aging Studies:
Plain radiographs of the extremities
Calcified densities in the muscles,

indicating an old trichinization, may


be the only positive radiographic
findings.
Radiographs do not help evaluate
acute infestation.

CT scanning ofthe brain


CT scan reveals focal deficits with

small hypodensities in the cortex and


white matter.
CT scan may be helpful in patients
demonstrating neurologic symptoms.
Abnormal findings are unlikely in
patients without neurologic
symptoms.
CT scanning of the orbits is
warranted in patients with chemosis
to rule out other causes of proptosis.

O ther Tests:
ECG may show signs of ischemia or

pericarditis with nonspecific STsegment changes. An ECG also may


reveal a pericardial effusion.

Procedures:
A muscle biopsy is the definitive

diagnostic test
Larvae are found free or
encapsulated, depending upon the
species of Trichinella causing the
infection.
At the time of biopsy, initial
preparation may be made by
crushing a portion of muscle tissue
between 2 slides and viewing

Encysted larvae ofTrichinella in pressed m uscle tissue sam ple

Larvae ofTrichinella,freed from their cysts,typically coiled

Trichinella spiralis
M uscle Biopsy

intense inflammation that circumscribes the cyst


wall (arrows)

Em ergency D epartm ent Care:


Patients with mild cases require no special

care.
Patients with more severe cases of muscle
involvement may need basic supportive
therapy (eg, oxygen, IV fluids).
Cardiac monitoring is suggested for patients
who present early.
Cardiac findings are unlikely to develop late
in the course (ie, after peripheral muscle
invasion has started).

Consultations:
Infectious disease specialists
Surgeons (for muscle biopsy)
Cardiologists

Treatm ent:
Prehospital Care: Institute

appropriate supportive therapy for


patients presenting with symptoms
of neurocardiac involvement.

Treatm ent:
Steroids are used for infections with

severe symptoms
mebendazole
albendazole

H ow can Iprevent
trichinellosis?
Cook meat products until the juices run clear or to an

internal temperature of 170 o F.


Freeze pork less than 6 inches thick for 20 days at 5
o F to kill any worms.
Cook wild game meat thoroughly. Freezing wild game
meats, unlike freezing pork products, even for long
periods of time, may not effectively kill all worms.
Cook all meat fed to pigs or other wild animals.
Do not allow hogs to eat uncooked carcasses of other
animals, including rats, which may be infected with
trichinellosis.
Clean meat grinders thoroughly if you prepare your
own ground meats.
Curing (salting), drying, smoking, or microwaving
meat does not consistently kill infective worms.

Sleepy?