AMYA

POLYTECHNIC COLLEGE MEDICAL LABORATORY

Bonum Est Sui Diffusivum SCIENCE PROGRAM

COURSE MODULE
Clinical Parasitology
Course No.: MT 206
Course Title: Clinical Parasitology
Unit: 3 Units (2 Units Lec, 1 Unit Lab)
Pre-/Co-Requisite: BIO 101
Year Level: 2nd Year, 2nd Semester

Course Description:
The course deals with the study of parasites and its life cycle, hosts, and the relationship between them. It
also covers the characteristics and habits of parasitic animals. Includes investigation of undiagnosed human illness,
and possible parasitic invasion related to the illness
with emphasis on laboratory methodology and clinical application.

Course Objectives:
At the end of the course, the learners are expected to:

COGNITIVE
1. Identify fundamental understanding of science and competence in parasitological methods.
2. Explain the principles and mechanism involved in the pathogenesis of the parasites
and its associated clinical manifestation.

AFFECTIVE
1. Demonstrate awareness to public health concerns in the aspect of parasitism
2. Exemplify competence in the conduct of parasitological methods and techniques.

PSYCHOMOTOR
1. Adapt advanced knowledge, understanding, and critical judgment appropriate for
professional employment in Parasitology or a related discipline.
2. Demonstrate Integrity Honesty, Critical Thinking, Empathy and Value for Life.
3. Execute routine and special laboratory methods employed in the proper handling,
examination and disposal of different body fluids and secretions.

Learning Module No. 1

Topic: Introduction to Medical Parasitology
Materials: Laptop and Internet Connection
Assessment: MCQ Post-Test via Infinit

Learning Outcomes:
At the end of the session, the students should be able to:
1. Define and understand the scope of Parasitology.
2. Explain the concept of parasitism.
3. Explain the nature of host-parasite relationship.
4. Explain epidemiology, pathogenesis, transmission, control and treatment of various
human parasites.

Introduction
This lecture is intended to highlight the major groups of parasitic organisms as well as
the strategies used by all parasites to survive in the host and techniques used by parasites to
move between hosts.

Relationships between Host and Parasite

Symbiosis – Levels of interdependency between species
1. Phoresis (traveling together – no physiological dependence)
2. Mutualism (benefit to both organisms)
3. Commensalism – ecto and endo (host not harmed – other species gains)
4. Parasitism (parasite lives at the expense of its host)

Life Cycle Survival Strategies

1. Types of Infection
Cyclo-developmental - a single parasite develops from a single infective
organism by maturation, e.g. ascarid nematodes, many cestodes
Cyclo-propagative - a number, generally a large number, of progeny are produced from
a single infective organism, e.g. malarial parasites, trematodes

2. Duration of Infections
Acute or self-limiting - these infections are similar in many ways to bacterial or
viral infections. Infections are acquired and are rapidly resolved in most cases, generally
with a species or strain-specific immunity developed that protects against subsequent
infections with the same parasite. Examples include coccidia and cryptosporidia.
Prolonged or chronic – these infections are more typical of parasitic infections.
Many helminths and some tissue cyst-forming protists are known to cause prolonged
infections (i.e. tens of years or 'for life'). Encysted or arrested stages of a number of
parasitic protists can remain in hosts for many years. The ability to form a long-lasting
resting phase is especially common in intermediate hosts that will be eaten by the final
or definitive host.
3. Fecundity
Most parasites are prodigious egg or cyst producers as an adaptation to the
relatively low chance of survival for their progeny. As an example, a single ascarid worm
may produce 20,000 or more eggs per day and may live for many years.

4. Over-dispersion in the Host Population

 A distribution of parasites amongst hosts is said to be overdispersed, or
aggregated, if parasites are found to co-occur in particular hosts more often than if the
parasites were distributed at random amongst all hosts. Macroparasites (large parasites
such as worms as opposed to microparasites such as protists) are typically
overdispersed in their host populations, so that the majority of hosts harbour few or no
parasites while a few hosts harbour large parasite burdens. This distribution serves to
limit negative effects of carrying parasites to a small number of hosts. The health of the
population (although not the heavily infected individuals) is generally not affected by the
infections being carried.

Modifications to Host Behavior to Promote Transmission

A number of parasites will modify the behaviour of their hosts to enhance their
survival and/or chance of transmission to the next host. This is particularly evident in
intermediate hosts (both invertebrate and vertebrate) that are eaten by a definitive host
of the parasite. Some examples of this include coccidia (some Sarcocystis spp. that
reduce the speed and efficiency with which their rodent intermediate hosts move away
from the centre of an open area and hide along walls or in crevices) and
acanthocephalan worms (intermediate stages of a one species changes the colour of its
Daphnia sp. intermediate host and reverses its negative phototaxis -- these changes
greatly enhance the chances that the intermediate host will be ingested by the definitive
host, a duck.

Major Groups of Parasites

Starting from smallest to largest, the major groups of parasites that are frequently
encountered are grouped into 5 major groups. These are:
• Protists (=Protozoa)
- amoebae, microsporidia, myxozoa, flagellates, apicomplexan protists
• Trematodes
- monogenetic and digenetic flukes
• Cestodes
- tapeworms of various forms
• Nematodes
- roundworms of various types
• Arthropods
- ticks and mites, insects, crustaceans, pentastomes (tongueworms)

Host Spectrum
A parasite may be capable of developing completely in only one type of host, e.g., dogs,
and is considered highly host-specific. Other parasites may develop in any one of a number of
species of hosts e.g., cattle, sheep, horses, and thus have a broad host spectrum.
A parasite may have a single host (monoxenous) or require more than one host for
complete development (heteroxenous). These hosts are identified as a definitive (final) host or
an intermediate host. A parasite may enter or be on other hosts in which there is no
development and such hosts are either a paratenic or mechanical host.
1. Definitive or Final Host (DH) - the host(s) in which sexual reproduction occurs
Intermediate
2. Host (IH) - the host(s) in which the immature stages or asexual replication occurs
3. Paratenic Host (PH) - a host in which the parasite does not develop but which can serve
in the dissemination or transport of the parasite. Such hosts are usually part of the food
chain of other PHs, IHs or DHs
 Some parasites use arthropodan hosts as Vectors. A Vector is an invertebrate
such as a flea, non-biting fly, mosquito, etc, that transmits (vectors) a parasite from one
host to the next. There are two types of vectors that are differentiated based on their
relationship with the parasite.

4. Biological Vector – these are invertebrates that form an essential role in the life cycle of
the parasite and in which the parasite grows or develops by invasion of the vectors’
body. The parasite is biologically dependent on the invertebrate vector for nourishment
and survival. Widely known examples include mosquitoes transmitting malaria or tsetse
flies transmitting African sleeping sickness (trypanosomiasis).

5. Mechanical Vector - a host, usually an arthropod, that transmits, usually externally on its
mouth parts, the parasite from one host to another and in which there is no growth or
development.

GENERAL CONSIDERATIONS:

Parasitology - area of biology concerned with phenomenon of

dependence of one living organism on another
Medical Parasitology - concerned primarily with the animal parasites of humans,
their medical significance as well as their importance in
human communities.

TROPICAL MEDICINE
Tropical disease: an illness indigenous to or endemic in a tropical area.
- sporadic ) in non – tropical - epidemic )

A. BIOLOGICAL RELATIONSHIP

Symbiosis: living together of unlike organisms

a. Commensalism E. coli in intestinal lumen

b. Mutualism termites and flagellates in their digestive system
c. Parasitism Entamoeba histolytica in intestinal lumen

B. PARASITE
1. Relationship as to location or habitat
- endoparasite - infection
- ectoparasite - infestation erratic
- obligate parasites - need a host to develop and propagate their species (tapeworms)
- facultative parasite - may exist in a free living stage or may become parasitic when
the need arises

2. Host specificity
a. incidental parasite - establishes itself in a host where it does not ordinarily live
b. permanent parasite - remains on or in the host for its entire life

c. temporary - lives on the host for a short period of time

d. spurious - a free living organism that passes through the digestive
tract without infecting the host
C. HOST
1. Definitive (final host) - one in which parasite attains sexual maturity in man
2. Intermediate host - harbors the asexual or larval stage of the parasite (pigs
and cattle and taenia)
3. Paratenic host - the parasite does not develop but remains alive and able
to infect another susceptible host. (Paragonimus
westermani metacercaria in raw wild boar meat)

* they widen the parasite distribution and bridge the

ecological gap between the definitive and intermediate
host.
4. Reservoir hosts - they allow the parasites life cycle to continue and become
an additional source of human infection (pigs and
Balantidium coli)

D. Vectors
- biologic - essential to life cycle (where infective stage develops)
- mechanical or phoretic - only transports

E. Exposure and Infection

- pathogens - autoinfection
- carrier - hyperinfection or super infection

F. Incubation period - period between infection and evidence of symptoms

a. clinical incubation period

b. biologic incubation period - or prepatent period ; period between infection or
acquisition of the parasite and evidence or demonstration of infection

G. Sources of Infection
- soil - water - food - raw meat, snails, crabs
- vectors - anthropods
- mosquitos
- bugs, flies
- other animals
- humans
- clothing
- self

H. Modes of transmission (Portal of entry)

1. Mouth - most common
2. Skin penetration - Hookworms, Strongyloids, Schistosome
3. Arthropod bites - malaria, filaria, leishmania
4. Congenital transmission - Placental - toxoplasma gondii
* transmammary - Ancylostoma and
5. Inhalation of airborne eggs - Enterobius
6. Sexual intercourse - Trichomonas

LIFE CYCLE
1. Simple: ova - larva - adult
 Figure 1. Basic Life Cycle

2. Complicated
- several hosts - intermediate hosts
- developmental stages in environment or other hosts
- as the life cycle becomes more complicated the lesser the chances are, for the
individual parasite to survive.

Figure 2. Complicated Life Cycle

Perpetuation of species depends on

ability to ensure transmission thru:
a. adaptation to protect itself from host defenses and environment
b. overcoming attrition in the species, by producing numerous progeny
 - infective stage -
embryonated ova

Figure 3. Ascaris Egg

I. Host - Parasite Relationship

Adaptation - led to changes in molecular biology, biochemistry, immunology and
structure of the parasite essential to survival

A. Locomotory and digestive organs

B. Reproductive systems
- highly and elaborate - tapeworms
- hermophroditic - flukes and tapeworms
- asexual reproduction in flukes

C. stream lining - biochemical adaptation - parasite can no longer

synthesize certain cellular components
D. Specialized mechanisms for entry
- enzymes
- penetration glands
- hooklets

A. Effects of Parasite on the host

1. Interference with vital proceses of host through enzyme systems

2. Invasion and destruction of host tissues cutting plates of Hookworms, deposition of
schistosome eggs in the liver
3. Deprivation of essential substances to the host
4. Stimulation of host tissue reaction
5. Toxic and allergic phenomenon

B. Effects of the Host on the Parasite

1. Genetic make-up maybe favorable or not to the parasites (sickle cell tract and
falciparum malaria)
2. Nutritional states - carbohydrate vs. Protein rich diet
3. Immune processes may modify severity of disease in endemic area

J. Immunology of Parasitic Infections

1. Immune response a. humoral b. cell mediated

2. Acquired resistance Adaptive mechanisms of parasites to
 evade host immune response:
a. being intracellular in macrophages
(Leishmania and Toxoplasma)
b. production of variable surface
glycoproteins (VSG) – trypanosomes
c. alternating populations of parasites –
malaria
d. acquisition of host antigens –
Schistosomes
e. Production of proteases

3. Immune dependence of drug action

The immune response is crucial to the successful treatment of some parasitic
infections. * Praziquantel
- diagnostic stage -
fertilized ova 4. Immunopathology
Hypersensitive immune responses a parasite can sometimes cause more harm
than the parasite itself

5. Vaccines
available against Ancylostoma caninum for dogs Babesia for cattle Leishmania
major for humans

Use of Vaccine

1. Prophylactic - anti-infection
2. Transmission blocking - targets development
3. Anti-pathology -down regulates immunopathology

K. Parasite Diagnostic Procedures

1. Fecal examination

a. Specimen collection and handling

a.1 wide mouth container
a.2 uncontaminated
a.3 use of laxatives
a.4 liquid specimen - must be examined within 30 mins. or put in preservatives
a.5 formed specimen - several hours/same day
a.6 multiple collections for several days to optimize diagnosis

b. Specimen Processing
b.1 wet mount
b.2 concentration procedures
- ZnSO4 flotation
- formalin-ether sedimentation

c. Permanent stains
Dx of intestinal protozoan infections
fixatives- Schaudinn’s
- PVA
 [figure4]

trichrome

[figure5]

hematoxylin

d. Preservation of feces
- PVA
- 5-10% formalin
- formal-saline

e. Special procedures
1. Culture media - some protozoan
2. Larval hatching - helminths
3. Kato thick smear - examination of large amount of feces

2. Blood examination
A. Thick smear
B. Thin smear
C. Blood concentration procedures
1. Knott’s technique - microfilariae
1 ml. Blood in 10 ml of 2% formalin when centrifuged, RBC are lyzed and only
WBC and microfilariae remains maybe allowed to dry on slides and stained with
hematoxylin or giemsa

[figure6]
Learning Module No. 2

Topic: Protozoan Infection

Materials: Laptop and Internet Connection
Assessment: MCQ Post-Test via Infinit

Learning Outcomes:
At the end of the session, the students should be able to:
1. Describe different criteria concerning each parasite
2. Explain of the morphology of the parasite in-order to identify the parasite under the
microscope in the laboratory.
3. Describe the habitat or the site of the parasite
4. Explain Infective stage and mode of transmission.
5. Familiarize the Definitive host, intermediate host and reservoir host of any parasite.
6. Describe Signs and symptoms of any parasitic infection.
7. Enumerate Laboratory diagnosis and treatment for the

INTESTINAL AMEBAE

ENTAMOEBA HISTOLYTICA

 Classification
o subphylum Sarcodina
o superclass Rhizopoda
o class Lobosea
o order Amoebida
o family Entamoebidae
o genus Entamoeba

DISEASE
 cause invasive intestinal and extraintestinal disease

MORPHOLOGY
 a pseudopod-forming nonflagellated protozoan parasite
 the most invasive in the Entamoeba family (which includes E. dispar, E. hartmanni,
E.polecki, E. coli and E. gingivalis)
 only member of the family to cause colitis and liver abscess
 a eukaryotic organism
 cellular features
o lack organelles that resemble mitochondria
o no ER
o no Golgi apparatus
o cell surface and secreted proteins contain signal sequences
o Ribosomes form aggregated crystalline arrays in the cytoplasm in trophozoite
 biochemical characteristics
o lack glutathione metabolism
o uses pyrophosphate instead of ATP at several steps in glycolysis
o inability to synthesize purine nucleotides de novo
 o glucose is actively transported into cytoplasm
o end products of metab are EtOH and CO2 (acetate in aerobic conditions)

LIFE CYCLE

 2 stages
1. Infective cyst
2. invasive trophozoite form
 humans are the only known hosts
 life cycle is simple and no intermediate hosts involved
 extracellularly located and do not undergo antigenic variation
 Cyst
o Quadrinucleate
o Resistant to gastic acidity and dessication
o Can survive in a moist environment for several weeks
o Infection occurs when cysts are ingested from fecally-contaminated material
o Modes of transmission
 Fecal-oral route
 Direct colonic inoculation through contaminated enema equipment
o Excystation occurs in the small or large bowel
a. nuclear fission
b. cytoplasmic division (forms 8 trophozoites)

immature cysts
mature cysts

 Trophozoites
o Highly motile
o Possess pseudopodia
o Have the ability to colonize and/or invade the large bowel (cysts are never found
w/in invaded tissues)
o Multiply by binary fission
o Encyst
a. produces uninucleate cysts
b. undergo 2 successive nuclear divisions (forms quadrinucleate cysts)

PATHOGENESIS AND CLINICAL MANIESTATION

 most cases present as asymptomatic infections with cysts being passed out in the stools
(cyst carrier state)
 the non-pathogenic E. dispar has a higher prevalence than E. histolytica
 most E. histolytica infections are asymptomatic in endemic communities
 Amebic colitis
o Gradual onset of abdominal pain and diarrhea w/ or w/o blood and mucus in
stools
o Fever occurs only in 1/3 of patients
o Intermittent diarrhea alternating with constipation
o Children may develop fulminant colitis
 Severe bloody diarrhea
 Fever
 Abdominal pain
 colitis
 Ameboma
o Occurs in less than 1% of intestinal infections
o Mass-like lesion with abdominal pain and history of dysentery
o Can be mistaken for carcinoma

 Amebic liver abscess (ALA)

o Most common extra-intestinal form of amebiasis
o Cardinal manifestations (most frequent complaints in acute cases {<2 weeks
duration})
 Fever
 Right Upper Quadrant pain (RUQ) – local or referred to the right shoulder
shoulder
o Liver is tender
o Hepatomegaly is present in 50% of cases
o Chronic disease (>2 weeks duration)
 found in older patients
 Wasting disease
 Weight loss rather than fever
o 72% of daily stool cultures harbored trophozoites even in asymptomatic
infections
o mortality uncomplicated <1%

PATHOLOGY

 E. histolytica named because of its ability to lyse human tissues

 Invasive process initiated when trophozoite stage is able to penetrate mucus layer
covering the colonic epithelium
 Invasion facilitated by expression of virulence factors
1. Gal/Gal NAc lectin – mediates adherence to host cells
2. Amebapores – form pores in host cell membranes
3. cystein proteinases – cytopathic for host tissues
 In amebic invasion, Trophozoites…
o Cause thinning of mucin layer action of
 o Shortening of villi cystein
o Breakdown of extracellular matrix proteases
o Attach to mucosal cells  facilitated by lectin
o Lyse cells  amebapores
o Stimulate release of IL8 which attracts and activates neutrophils
o Trophozoites erode the lamina propria and extend laterally producing
characteristic flask-shaped ulcer

 Flask-shape ulcer = small defect in the mucosa and larger area of necrosis in the
submucosa and muscularis layers surrounded by normal epithelium
 Most common sites of amebic ulcer are cecum, ascending colon and sigmoid

o From the primary site in the colon, trophozoites reach liver through portal vein
o Causes periportal inflammation
 Amebic hepatitis – postulated for this initial condition
o Liver involvement occur through direct extension from the intestinal ulcer
o In the liver, trophozoites lyse both inflammatory and liver cells
o Abscess becomes filled with necrotic proteinaceious debris (anchovy sauce-like
aspirate)
o Trophozoites are found at the edge of the abscess

 Aspirate = odorless and bacteriologically sterile (secondary bacterial invasion may

occur)

 Complications
o Amebic Colitis:
 Perforation and Secondary Bacterial peritonitis – most serious
complication
o ALA
 Rupture into the pericardium, rupture into the pleura and super infection –
most serious
 Intraperitoneal rupture – second most common complication (not as
serious because ALA is sterile)
o Secondary amebic meningoencephalitis – considered in cases with abnormal
mental status
o Renal involvement caused by extension of ALA ore retroperitoneal colonic
perforation (rare)
o Genital involvement – caused by fistulae from ALA and colitis or infection by
sexual transmission

 Immunity

o Natural or innate immunity

 In the intestines – involves mucin inhibition of amebic attachment to
underlysing mucosal cells
 Systemic circulation – mechanism is of complement-mediated killing of
trophozoites

o Acquired immunity
  Involves cell-mediated responses and humoral responses
 Activated T-cells kills E. histolytica
i. by lysing trophozoites (by contact)
ii. producing cytokines w/c activate macrophages and effector cells
iii. providing helper effect for Bcell Ab production

o Amebic modulation of host immune responses

 Infected subjects have been shown to be in a state of immunosuppresion
during the acute stage
i. T cell hyporesponsiveness
ii. Depressed DTH
iii. Macrophage suppression

DIFFERENTIAL DIAGNOSIS
 acute amebic colitis should be differentiated from bacillary dysentery of the ff. etiology:
Shigella, Salmonella, Campylobacter, Yersinia, Entero-invasive E. coli)
o Fever and significantly elevated leukocyte count are less common in amebic
colitis

Comparison of bacillary and Amebic dysentery

BACILIARY DYSENTERY AMEBIC DYSENTERY
Maybe epidemic Seldom epidemic
Acute onset Gradual onset
Prodromal fever and malaise common No prodromal features
Vomiting common No vomiting
Patient prostrate Patient usually ambulant
Watery, bloody diarrhea Bloody diarrhea
Odorless stool Fishy odor stool
Stool microscopy: numerous bacilli, pus cells, Stool microscopy: few bacilli, red cells,
macrophages, red cells, no Charcot-Leyden trophozoites with ingested RBCs, Charcot-
crystals Leyden crystals
Abdominal cramps common and severe Mild abdominal cramps
Tenesmus common Tenesmus uncommon
Natural history: spontaneous recovery in a Natural history; lasts for weeks; dysentery
few days, weeks or more; no relapse returns after remission; infection persists for
years

 Differentiate amebic colitis from inflammatory bowel disease

o Amebic colitis should be ruled out before steroid therapy is started because of
risk of developing toxic megacolon
 ALA vs. pyogenic liver abscess, TB of the liver and hepatic carcinoma
 Genital amebiasis vs. carcinoma, TB, chancroid and lymphogranuloma venereum

DIAGNOSIS
1. Microscopy
 standard method of diagnosis of trophozoites and cysts in stool specimens
 for detection of trophozoites
o fresh stool sample examined w/in 30 minutes from defecation
 use DFS with saline solution  able to observe trophozoite motility
 o unidirectional movement is characteristic
 use saline and methyline blue
o Entamoeba species will stain blue (differentiate from WBCs)
 Use saline and iodine
o Nucleus and karyosome can be observed (differentiate E. histolytica from non-
pathogenic E. hartmanni, E. coli, Endolimax nana)
 Detection of E. histolytica trophozoite w/ ingested RBCs is diagnostic of amebiasis.
Charcot-Leyden crystals can also be seen in stool
 concentration methods such as Formalin Ether Conc Test (FECT) and Merthiolate Iodine
Formalin Conc. Test (MIFC) are more sensitive than DFS for detection of cysts
 morphologic structures observed:
1. size of cyst
2. number of nuclei
3. location and appearance of karyosome
4. appearance of chromatoid bodies
5. presence of cytolasmic structures such as glycogen vacuole
 Species Identification of E. histolytica and E. dispar is not possible for microscopy
o Done by PCR, ELISA and isoenzyme analysis

2. Serology
 Detection of antibodies in the serum is still the key diagnosis of ALA
 In ALA, microscopic detection cannot be done because aspiration is an invasive
procedure and trophozoites are missed because they are found at the periphery of the
abscess
 Serological tests: Indirect hemagglutination (IHAT), counter immunoelectrophoresis
(CIE), agar gel diffusion (AGD), indirect fluorescent antibody test (IFAT) and ELISA
o IHAT can detect antibodies of past infection, even as long as 10 years
 Abs demonstrated in asymptomatic infections so serology can be used to monitor cyst
carriers

3. Radiographic
 Ultrasound, CT scan and MRI – non-invasive and sensitive methods in early detection of
ALA

TREATMENT AND PROGNOSIS

 Treatment has 2 objections
1. cure invasive disease at both intestinal and extra-intestinal sites
2. eliminate the passage of cysts from intestinal lumen
 Metronidazole is drug of choice
o Tinidazole and Secnidazole are also effective
 o Diloxanide furoate drug of choice for asymptomatic cyst passers.
 Percutaneous drainage of live abscess
o For patients who do not respond to metronidazole
o For prompt symptomatic relief of severe pain
o For those with left lobe abscess that may rupture into the pericardium (and large
and multiple abscess with danger of rupture)

EPIDEMIOLOGY

 infections occur worldwide but more prevalent in tropics

 worldwide cases 50 million, 100,000 of which end fatally
 second to malaria in terms of mortality caused by protozoan parasites
 humans are major reservoirs of infection
 Mexico, Indonesia, Africa, Central and South America, Philippines
 Risk factors: treatment with corticosteroids, malignancy and malnutrition

PREVENTION AND CONTROL

 improve environmental sanitation and sanitary disposal of human feces, safe drinking
water, safe food
 proper use of latrines and proper hygiene such as washing hands
 Vaccines are cost-effective and a potent strategy for amebiasis prevention

COMMENSAL AMEBAE

 the presence of commensal amebae in stool is significant because:

1. may be mistaken for E. histolytica
2. indication of fecal contamination of food or water

MORPHOLOGY
 differentiated from pathogenic E. histolytica
 the three genera of intestinal amebae can be differentiated through morphological
features of their nuclei
1. Entamoeba –
o spherical nucleus
o distinct nuclear membrane lined w/ chromatin granules
o small karyosome near the center of the nucleus
 o trophozoites – usually only have one nucleus
2. Endolimax –
o vesicular nucleus
o large, irregularly-shaped karyosome anchored to nucleus by achromatic fibrils

3. Iodamoeba –
o large chromatin-rich karyosome surrounded by a lyer of achromatic globules
anchored to nuclear membrane by achromatic fibrils

LIFE CYCLE
 all species have the following stages
1. Trophozoite
2. Precyst
3. Cyst
4. Metacystic trophozoite
o exception of E. gingivalis w/c has no cyst stage and does not inhabit the
intestines
 cysts pass through the acidic stomach unscathed, protected by cyst walls
 excystion occurs in the alkaline environment of lower small intestines
 Metacystic trophozoites colonize large intestines and live on mucus coat covering
intestinal mucosa
 Amebae are non-invasive and do not cause disease
 Reproduction by binary fission of trophozoites
 Encystion occurs as amebae pass through lower colon

ENTAMOEBA HARTMANNI

 similar to E. histolytica except that it is much smaller and does not ingest RBCs
 more sluggish movement
 mature cyst are quadrinucleated and have a coarse cytoplasm
 immature cysts have chromatoidal bars (short with tapered ends, or thin and bar-like)

cyst trophozoite

ENTAMOEBA COLI

 cosmopolitan distribution
 harmless inhabitant of colon
 typical Entamoeba nucleus
 Trophozoite can be diff. from E. histolytica by features:
o More vacuolated or granular ER w/ bacteria and debris but no RBCs
o Narrower, less differentiated ectoplasm
 o Broader, blunter pseudopodia
o More sluggish undirected movements
o Thicker, irregular peripheral chromatin w/ large eccentric karyosomes in the
nucleus
 Cysts of E. coli vs. E. histolytica
o Larger size
o Greater number of nuclei (8 vs 4 in E. histolytica)
o More granular cytoplasm
o Splinter-like chromatoidal bodies

Cyst trophozoites

ENDOLIMAX NANA

 small size of 6 to 15 um
 sluggish movement
 characteristic Endolimax nucleus (w/ large irregular karyosome)
 cysts are quadrinucleate when mature

cyst

trophozoite

IODAMOEBA BüTSCHLII

 trophozoite is usually 9-14 um long

 characteristic large vesicular nucleus w/ large endosome surrounded by achromatic
granules
 no peripheral chromatin granules on nuclear membrane
 cysts is uninucleated w/ large glycogen body w/c stains deeply w/ iodine

cyst
trophozoite

DIAGNOSIS

 stool examination
 liquid stools will show trophozoites
 formed stools will show cysts
 DFS to demonstrate trophozoites
 Formalin-ether concentration technique to differentiate species

TREATMENT

 not necessary because does not cause disease

EPIDEMIOLOGY

 human infection by ingestion of viable cysts in food or water

 21% of Filipinos infected with E.coli, 9% - Endolimax nana, 1% Iodamoeba butschlii

PREVENTION AND CONTROL

 The usual…

FREE-LIVING PATHOGENIC AMEBAE

LIFE CYCLE
ACANTHAMOEBA

 route of invasion and penetration into the CNS via the circulatory system
 primary sites of infection are skin or lungs

DISEASE

 causes granulomatous amebic encephalitis (GAE)

MORPHOLOGY

 Trophozoites
o trophozoites exhibit a single and large nucleus with a
centrally-located, densely staining nucleolus, a large
endosome, finely granulated cytoplasm and a large
contractile vacuole
o exhibit small, spiny filaments for locomotion known as
acanthapodia
o sluggish movement w/ polydirectional movement
 Cysts
o Double-walled w/ outer wrinkeled wall and an inner polygonally-shaped wall
o Pores or ostioles are seen at the point of contact bet the two walls
 Presence of naturally-occuring bacterial endosymbionts in Acanthamoeaba sp.

LIFE CYCLE

 a small free-living ameba characterized by an active trophozoite stage and a dormant

cyst stage.
 Sluggishly motile trophozoites
 Feed on gram negative bacteria, blue-green algae, or yeasts
 Reproduce by binary fission
 Encysts if the environment is not favorable
 A ubiquitous organism

PATHOGENESIS AND CLINICAL MANIFESTATION

 causes GAE
 o occur in chronically ill and debilitated individuals
o with impaired immune defense mechanisms
o under immunosuppressive therapy
 Signs and symptoms of GAE are related to destructive encephalopathy and associated
w/ meningeal irritation
o Non-specific constitutional manifestations
 Fever
 Chills
 Fatigue
 Weight losss
o Common
 Headache
 Confusion
 Somnolence
 Coma
 Hallucinations
 Seizures
o Neurologic symptoms
 Focal hemiparesis
 Cranial nerve palsies
 Visual disturbances
 Ataxia
o Increased intracranial pressure can cause papilledema
o Skin lesions are an important diagnostic feature of the infection
 Incubation period is about 10 days
o w/ subacute and chronic clinical course of infection that lasts for several weeks
o clinical manifestations
 mental abnormalities
 meningism
 localized neurological signs
 coma
 cerebral hemispheres
o edematous
o soft with hemorrhages and abscesses
o most affected areas are posterior fossa, diencephalons, thalamus and brainstem
o leptomeninges are opaque w/ purulent exudates
 also an ocular surface pathogen that causes amebic keratitis
o associated with the use of soft contact lenses
o viable trophozoites can adhere to lenses if not properly cleaned and disinfected
o signs and symptoms
 corneal ulceration
 progressive corneal infiltration and clouding
 iritis
 scleritis
 severe pain
 hypopyon
 loss of vision
o often confused w/ fungal or herpetic keratitis
Amebic keratitis
DIAGNOSIS

 GAE (A. encephalitis)

o Made only after death in majority of cases
o Failure to diagnose is the result of a variety of factors
 Lack of initial suspicion
 Inaccurate early clinical diagnosis
 Rapid progression of illness
o Has high incidence in AIDS patients w/ low CD4+ T-lymphocytes counts,
especially if associated w/ skin lesions and/or sinusitis

o specific diagnosis
 demonstration of trophozoites or cysts in tissues by microscopy
 can be isolated from CSF and cultured
 A. keratitis
o Epithelial biopsy for histologic analysis
o Isolation of organisms from lens of contact lens weares
o Etiologic agents:
 A. castellani
 A. culbertsoni
 A. hutchetti
 A. polyphaga
 A. rhysoides

TREATMENT AND MANAGEMENT

 w/ appearance of cerebral manifestation, A. encephalitis has a fatal outcome in 3-40

days
o some patients respond to treatment with:
 5-fluorocytosine
 ketoconazole
 itraconazole
 pentamidine
 amphotericin B
 A. keratitis treatment achieved w/ multidrug treatment if started early
o Clotrimazole +
o Pentamidine,
o Isethionate,
o Neosporin
o – avoidance of corticosteroids
o surgery for A. keratitis

EPIDEMIOLOGY

 Acanthamoeba species have been isolated from all kinds of water (sea, fresh,
mineral,etc), air, sewage, soil, compost, vegetables, mushrooms, fish, reptiles, birds,
mammals
 in humans, isolated in nasal cavity, throat and intestines as well as cerebral tissue, lung
 tissue, skin wounds and cornea
 encephalitis in US
 Keratitis in Japan, Korea, South America, Germany

PREVENTION AND CONTROL

 boiling water is the best possible way of killing trophozoites and cysts
 regular disinfection of contact lenses
NAEGLERIA

 free-living amebo-flagellate
 can exists as an ameba (trophozoite form) and as a flagellate (swimming form)
 Naegleria gruberi most commonly studied non-pathogenic species
 Pathogenic species, N. fowleri, causes fatal meningoencephalitis in humans and
laboratory animals such as mice
o Causes degenerative or cytopathic effects in cell cultures
 Non-pathogenic can be distinguished from pathogenic by a combinations of cell
morphology, culture medium preference, temperature tolerance, lectin sensitivity,
isozyme pattern, DNA restriction patterns, mouse pathogenicity and serology
 Locally occurring species named N. philippinensis
 Mode of transmission – oral or intranasal routes while swimming in contaminated pools,
lakes and rivers

MORPHOLOGY

 Trophozoite easily recognizable under phase contrast microscope

o Characteristic lobose monopseudopodium
o Very prominent nucleus w/ centrally-located nucleolus
o Forms a pair of flagella originating from the tip of a pear-shaped cell body
o Transforms into a biflagellated organism
 Flagellated organism
o Allows it to move towards a food souce more rapidly

Trophozoite in spinal fluid Trophozoite in CSF

LIFE CYCLE
 trophozoite stage that can transform reversibly into non-reproductive flagellate or a
resistant cyst
 transformation can take place w/in a period of 2-3 hours or up to 3-4 days

PATHOGENESIS AND CLINICAL MANIFESTATION

 causes gastritis and diarrhea
  causes primary amebic meningoencephalitis (PAM) – rare disease that leads to
inflammation of the brain and destruction of brain tissue
 N. fowleri able to survie in elevated temperatures (46oC) and 0.5 ug/ml of
hyperchlorinated water
 PAM is characterized by fever, headache, vomiting, signs of meningeal irritation and
encephalitis with rapid progression to coma and death
o CSF findings of pleocytosis
o High percentage of polymorphonuclear cells
o Hypoglycorrhachia
o Eleveated protein leves

DIAGNOSIS
 diagnosis of PAM – based on presence of trophozoites in brain and CSF
 Naegleria trophozoites can be identified by presence of blunt, lobose pseudopodia and
directional motility

TREATMENT
 Amphotericin B – drug of choice for treating PAM
o Induces changes in nucleus and mitochondria
o Increases proliferation of both rough and smooth ER
o Decreases number of food vacuoles
o Increases formation of autophagic vacuoles
o Inhibiting pseudopod formation
o Induces blebbing of the ameba plasma membrane
 N. fowleri
o tolerant between 65o - 100o C
o inhibted by 0.2 NaCl and KCl
o CaCl2 stimulates encystment
o Drying is lethal to trophozoites
o Cysts remain viable if rehydrated w/in 23 months
o Cysts are non viable if lyophilized

EPIDEMIOLOGY
 all types of water
 soil is preferred habitat

PREVENTION AND CONTROL

 avoid diving into and swimming gin warm and stagnant freshwater pools, discharge
pools, unchlorinated poorly maintained poos or mud-lined lakes and ponds
Learning Module No. 3

Topic: Nematode Infection

Materials: Laptop and Internet Connection
Assessment: MCQ Post-Test via Infinit

Learning Outcomes:
At the end of the session, the students should be able to:
1. Recognize the morphology of the worms
2. Familiarize their life cycle and pathogenesis.
3. Explain diagnosis &amp; treatment of parasitic infections.
4. Identify all details about Ascaris.
5. Recognize the morphology of Trichuris, how man gets the infection, life cycle, clinical
manifestations and management.
6. Identify different types of anemia caused by hookworms and how to treat it.
7. Recognize all about the morphology and distribution of filarial worms.

TRICHURIS TRICHIURIA

 also called as whipworm

 incidence of occurrence, same as Ascaris
  2nd common intestinal worm aside from Ascaris
 usually occur in moist, warm, tropical region of Asia, Central and South America, Africa and the Caribbean Islands

MORPHOLOGY:

 ADULT WORM
o Color: Flesh or pinkish colored slender worms
o Size:
1. Female – 3.5 to 5.5 cm
2. Male = 3.0 to 3.5 cm
Male is smaller than female
3. Anterior 3/5 o f the worm – fine hair-like structure which forms the esophagus
Esophagus – is characteristically embedded in glandular cells called stichocytes
4. Posterior 2/5 of the worm contain the intestine and reproductive organs
Tail end:
Female – straight and blunt
Male – usually curved at 360o
 EGG
o Shape
- Barrel-shaped egg
- thick, smooth brown egg shell and 2 transparent plugs protruding from
both poles
o Size – measures 50 to 54 microns by 22 to 23 microns
1. Fertilized egg

2. Embryonated egg

LIFE CYCLE OF TRICHURIS TRICHIURIA

 After copulation in the cecum

Female worms start to lay eggs w/c are passed out with
feces and deposited in the stool in unsegmented form

With favorable environmental condition, in 2-3 weeks they

develop into their infective stage with larval stage w/in the
egg (embryonation).

Note:
Whipworms inhabit the large intestine where the entire
whiplike portion is deeply inserted into the wall of large
intestine. Because of this mode of attachment, it is much
harder to expel whipworm than ascaris by anti helmintics

Once the infective embryonated egg is swallowed by the

host, they hatch in the intestine to release the larva and
this larva undergoes 4 larval stages to become adult worm.

 There is no migration phase in the lungs, heart or liver

 It require about 2-3 months from the time the eggs are swallowed until they are seen in the stool of infected person
 Each female whipworm can produce 7,000 to 10,000 eggs per day or a total of over 60 million eggs by single whipworm
over an average life span of 2 years

PATHOLOGY AND CLINICAL MANIFESTATION

A. Light infection with trichiuris are asymptomatic and without clinical significance
B. Symptoms produced by trichiuris are due to worms unique mode of attachment on the wall of the large intestine where
it got its nutrition
- therefore, the degree of clinical symptoms is related to the intensity of the infection.

 CLINICAL MANIFESTATION
1. Diarrhea due to chronic
Hypoalbuminemia impairment of host’s
Iron Deficiency Anemia nutritional status

2. Anemia
- due to ulceration of the intestine resulting from heavy worm burden
- Anemia is less frequent than hookworm]

3. Prolapse of the anus and the rectum

- due to frequent loose bowel movement resulting to the loss of muscle tone of the anal sphincter
- could also resort to bleeding thus aggravates the anemia

4. Appendicitis
- due to invasion of trichiuris
DIAGNOSIS:

1. Direct Fecal Smear (DFS)

2. Cellophane thick smear method or the Kato thick smear
EPIDEMIOLOGY

In the Philippines
- prevalence of trichiuris is 80-90% almost parallel with Ascaris
- Most infections are light to moderate and seldom produce clinical symptoms
- Trichiuris eggs are less resistant to adverse reaction than Ascaris eggs

TREATMENT

A. Albendazole
- Dose – 400 mgs single dose
B. Mebendazole
- Dose – 500 mgs single dose or 100 mgs twice a day for 3 days
C. Oxantel-Pyrantel
- Dose – 10-20 mgs per kg/body weight single dose

CAPILLARIA PHILIPPINENSIS

 intestinal capillariasis is a disease characterized by:

1. intestinal malabsortion
2. chronic diarrhea
3. Borborygmi
 first recognized in the Philippines in 1963 where the first human case died in PGH
 Origin: Bacarra Ilocos Norte
 Order Trichurida
 Prevalence
1. Philippines
- Ilocos Norte
- Ilocos Sur
- Cagayan
- La Union
- Pangasinan
- Zambales
- Agusan del Norte
- Leyte
2. Thailand
3. Japan
4. Iran
5. Egypt
6. Taiwan

MORPHOLOGY:

 ADULT WORM
o Small worm
1. Female worm
 size: 2.3 to 5.3 mm by length
 larger than male
2. Male worm
 size: 1.5 to 3.9 mm by length
 smaller than female
 characterized by the presence of a chitinized spicule and a long spicule sheath extending
beyond the length of worm

2 Types of Female worms

a. Typical female – which has 8-10 eggs in utero arranged in a single row
b. Atypical female – which has 40-45 eggs in utero arranged in 2 to 3 rows

 CAPILLARIA EGGS
o Color : pale yellow in color with a moderately thick, striated shell with flattened bipolar plugs
o Shape: Peanut-shaped
o Size:: Measures 42 by 20 um
 o Development stage – single or 2 segmented stage development

LIFE CYCLE OF CAPILLARIA PHILIPPINENSIS

Adult worms inhabit primarily in the jejunum and are

threaded into the mucosa (Larvae and eggs are produced
by typical and atypical female worms)

Eggs passed out in the feces embryonate in the fresh

water in 3 to 5 days

Upon ingestion by fresh water fish, hatch in the intestine

of fish. Larvae are found mostly in the gastric mucosa
and Intestines

When infected fish is ingested the worm’s mature in the

host’s small intestine

In 2 weeks, atypical females start producing larvae then

grow into mature adult worms

PATHOLOGY AND CLNICAL MANIFESTATIONS

A. Disease is characterized by:

1. Borborygmi or gurgling stomach
2. Abdominal pain
3. Diarrhea

B. Without Treatment the patient may experience

1. Weight loss
2. Dehydration
3. Malaise
4. Anorexia
5. Vomiting
 6. Anasarca
7. Muscle wasting
8. Cachexia

C. Other Manifestations
1. Malabsorption of fats and sugar
2. Protein-losing enteropathy
3. Low level of K, Ca++, Carotene
4. Low plasma level of total protein

D. Death is attributed to massive parasitic infection resulting to:

1. Electrolyte loss
2. Heart failure
3. Septicemia secondary to bacterial infection

 PATHOLOGIC CHANGES
a. Atrophy of the crypts of Liberkuhn
b. Flattened villi with lamina propia infiltrated by plasma cells, lymphocytes and macrophages

DIAGNOSIS:
 by finding characteristic
o eggs
o larvae
o adult worms in stool
 eggs can readily be seen in a simple fecal smear
o concentration technique acid ether or formalin ether method

EPIDEMIOLOGY:

- first recognized in 1963

- 1,800 confirmed cases w/ 108 deaths
- male is affected twice than females
- Peak age: 20-49 years old

TREATMENT:

A. Mebendazole
- Dose: 200 mgs twice daily for 20 days
B. Albendazole
- Dose: 400 mgs daily for 60 days

PREVENTION AND CONTROL:

 changing the eating habits from raw uncooked fresh water fish9 to cooked fish

TRICHINELLA SPIRALIS

 diseases:
a. Trichinosis
b. Trichiniasis
c. Trichinelliasis

MORPHOLOGY

 ADULT WORM
o Small worm
o Size
1. Male – 1.50 mm by 0.04 mm
2. Female – 3.50 mm by 0.50 by 0.06 mm
o Shape
- thread-like appearance
o characteristics
1. Anterior end
o provided w/ a small orbicular, non-papillated mouth
o in female, Anterior fifth is provided w/ a single ovary with vulva and a long narrow digestive
 system
2. Posterior end
o Female: bluntly rounded
o Male: ventrally curved with 2 lobular appendages
 LARVAE
o Has a spear-like burrowing tip at its tapering anterior end
o Measures 80-120 h by 5.6 u at birth
o Matured encysted larvae have digestive tracts although the reproductive are not fully developed.

DIAGNOSIS

 Clinical Diagnosis
o History of eating raw or inadequetly cooked or improperly processed meat usually pork
o History of intestinal flu or rheumatic pain
o Marked eosinophilia in blood
o Swollen eyelids or severe conjunctivitis
 Specific Diagnosis
o Biopsy - free larvae or encapsulated larvae in skeletal muscle
o Xenodiagnosis
o Bachman Intradermal test

TREATMENT

 No established specific treatment

A. Thiabendazole
- Dose: 50 mg/kg/body weight
- Effect:
- may prevent the appearance of symptoms if given from the second day after ingestion of infected meat
- greatly mitigate the illness if drug is given between the fifth and ninth day after ingestion
B. ACTH or corticosteroid
- treatment of allergic reaction
C. Mebendazole
- lethal effect
LIFE CYCLE OF TRICHINELLA SPIRALIS
PATHOGENESIS

 Pathologic changes and the symptomatology are divided into 3 stages:

1. incubation or intestinal phase
2. acute or larval invasion
3. chronic or encapsulated

1. Intestinal Phase
- Inflammation of duodenal and jejunal mucosa:
a. Malaise
b. Nausea
c. Diarrhea
d. Abdominal cramps

2. Stage of Muscle Invasion

a. Fever
b. Facial edema
c. Muscle pain, swelling and weakness
d. Peripheral eosinophilia

 Less common symptoms:

a. headache
b. Flushing of face
c. Conjunctivitis
d. Pruritus
e. Diaphoresis
f. Anorexia
g. Thirst

 Damage of muscle may cause difficulty in:

a. Eye movement
b. Breathing
c. Chewing
d. Swallowing
e. Speech
f. Movement of extremities

 Myocarditis – appear as early as the second week but more ofteh after the third week.

- Death from myocarditis usually occurs between the fourth and eight weeks of infection.
- Encephalitis and meningitis may also occur at this stage

3. Stages of Convalescence
- end of the 3rd week of infection where encapsulation start to be seen

SYMPTOMS
1. Fever subsided
2. Muscular symptoms begin to decline
3. If there is marked edemaàdiuresis may occur
4. Appetite return to normal
5. Malaise subsided
- myocarditis may still be present at this stage and physical exertion may precipitate congestive heart
failure
- venous thrombosis and encephalitis
- eventually- when all symptoms subsided, the cyst wall and larva itself calcify

Biological Stage Beginning/Onset Clinical Conditions

Ingested larvae exist in epithelium 2-4 hrs GI symptoms
24
Worms become mature and mate 30
Females deposit larvae, which invade skeletal 6 days
muscles
7 Edema of face and fever
Maximum invasion of muscle fibers 10 Fever at max (40-41oC)
11 Myositis and “rheumatic” pains
Decrease in larviposting 14 Eosinophilia and circulating antibody
Larvae in muscles fully differentiated 17
20 Eosinophilia reaches maximum
Early encapsulation 21 Myocarditis or encephalitis appear
Intestine practically free of adults 23
26 Respiratory symptoms
Encapsulation practically complete 1 Month
2 Fever subsides
Maximum life of worms in intestine 3 Death from myocarditis or encephalitis most
likely
Cyst calcification may begin 6 Slow convalescence
8 Neurological symptoms and myocarditis subside
Cyst calcification may be complete 1 year
Larvae possibly still viable w/in calcified capsules 6

PREVENTION

 smoking, drying and slating of meat are not effective measures

A. Refrigeration at 5°F (-15°C) for not less than 20 days

- at –10°F (for 10 days)
- at -20°F for 6 days
- Deep freezing

B. Avoid feeding raw garbage to hogs

C. Extermination of rats around the farms
D. Thorough cooking or deep freezing of all pork

ENTEROBIUS VERMICUALRIS

 Seatworm or pinworm
 affecting 208 million population
 Habitat
o Cecum
o Appendix
o adjacent portion of ascending colon
o ileum

MORPHOLOGY

 ADULT WORMS
o Color: whitish or brownish
o Shape: spindle-shaped
o Size: very small
1. Female: measures 8-13 mm by 0.3 to 0.5 mm
2. Male: 2 to 5 mm by 0.1 to 0.2 mm
 o Posterior end
1. Female: long sharp pointed end
2. Male: ventrally curved; has a single conspicuous copulatory spicule but lack gubernaculums

o Anterior End
- is a pair of lateral cuticular expansions known as “lateral wings or cephalic alae”
- Another feature of pinworm adult is the presence of posterior esophageal bulb

 EGGS
o Size: 50-60 um by 20 to 30 um
o Shape: elongated, ovoid flattened on ventral side giving a letter D appearance
o Egg shell composed of 2 layers
1. An outer thick hyaline albuminous shell
2. Inner embryonic lipoidal membrane

LIFE CYCLE OF ENTEROBIUS VERMICULARIS

Adult worms inhabit the cecum where the head attached to

the intestinal wall

In gravid female, the uteri packed with eggs and the body
becomes distended which makes the female releases its hold
on the Intestinal wall and migrate down the colon and
out the anus to lay eggs on the perianal and perineal region

Eggs laid on the perianal region become fully matured or

embryonated within 6 hours

When ingested, eggs containing the third stage juvenile

larva hatch in the duodenum, pass down the small intestines
to the cecum and develop into egg laying worm
PATHOGENESIS AND CLINICAL MANIFESTIONS

 Pathogenesis in enterobiasis take 3 forms

1. Pathology at the site of attachment of the worm
2. Pathology due to egg deposition in perianal region
 3. Pathology caused by migrating worms

A. At the site of attachment

- minute ulceration and abscesses develop in cecal mucosa
B. Egg Laying
- intense itching or pruritus in the perianal region resulting to scratching the area until it is scarified
- can also result to hemorrhages, eczema and bacterial infection
C. Migrating worm may go beyond the perianal region and may cause
1. Vulvovaginitis
2. Salphingitis

DIAGNOSIS

 Pinworm infection may be suspected in patient exhibiting manifestation like pruritus of the perianal area, restlessness
 Use of Perianal cellulose tape swab or Scotch tape swab
o recovery of D shaped embryonated egg
 Since oviposition take place at night the best time to take the swab right after the patient awakens or before taking a
bath.

EPIDEMIOLOGY

 Prevalence among regions varies from 10% in rural area to 75% in crowded urban area
 women are infected more than men
 children are infected more than adult
 infection may occur thru
1. Hand to mouth transmission from scratching the perianal region or from handling contaminated
objects
2. Inhalation of airborne egg in dust
3. Reinfection through the anus
 The most common mode of transmission hand to mouth transmission
 Retroinfection, the eggs hatch in the perianal region and the larvae migrate back into intestines

TREATMENT

A. Mebendazole
- single dose of 100 mg tab for everyone above 2 years of age -à this is repeated after 2 weeks
B. Pyrantel pamoate
- Dose:
o 11 mg/kg orally (maximum of 1 g) as a single dose
o a second dose should be given after 2 weeks

PREVENTION

1. Personal hygiene
2. Finger nail should be cut short.
3. Handwashing after using the toilet or before meal.
4. Bed linens and clothing of infected person should be sterilized by boiling.
Learning Module No. 4

Topic: Cestode Infection

Materials: Laptop and Internet Connection
Assessment: MCQ Post-Test via Infinit

Learning Outcomes:
At the end of the session, the students should be able to:
1. Recognize the pathology of both urinary and intestinal bilharziasis that causes severe
pathology and complications.
2. Recognize the three common cestoda worms with the differences in morphology, life
history, and pathogenesis, clinical presentation of the disease, its diagnosis &amp;
treatment.
3. Appraise all the points of the structure of the parasite, life cycle clinical picture,
pathogenesis as well as the treatment measures that may extend to surgical
interference.

HYMENOLEPIS NANA (dwarf tapeworm)

  smallest tapeworm infecting man
 only human tapeworm which can complete its entire life cycle in a single host
 does not require an obligatory intermediate host
 man can harbor both adult and larval stages of parasite

DISTRIBUTION

 worldwide among children

DISEASES

 hymenolepiasis

MORPHOLOGY

1. Adult Worm
- found in the ileum
- delicate strobila that measures 25 to 45 mm x 1 mm (lw)
- Scolex
o Subglobular
o 4 cup-shaped suckers
o retractable rostellum with a single row of 20 to 30 y-shaped hooklets
- Neck
o long and slender
- Proglottids
o Anterior = short
o Posterior = broader
o Measures 0.15 to 0.3 mm x 0.8 to 1.0 mm (lw)
o Mature proglottids : contain 3 ovoid testes and one ovary
o Gravid proglottids :
 testes and ovary disappear
 uterus hollows out and becomes filled with eggs
 segments are separated from the strobila and disintegrate as they pass
out of the intestines, releasing eggs in stool
- Segments
o 175 to 220 segments
o genital pores found along the side of segments

2. Eggs

- Shape : spherical or subspherical

- Measures 30 to 47 um in diameter
- Oncosphere
o thin outer membrane
o thick inner membrane with conspicuous bipolar thickenings
 4 to 8 hair-like polar filaments arise
 filaments are embedded in the inner membrane

H. nana cysticercoid

LIFE CYCLE

- Dual pathway

1. Direct
 host ingests eggs which hatch in the duodenum
 liberated embryos penetrate mucosal villi
 develop into infective cysticercoid larvae
 larvae break out of villi and attaches to intestinal mucosa 4 to 5 days later
  develop into adults

2. Indirect
 infection is usually via accidental ingestion of infected arthropod intermediate hosts like rice and flour beetles
(Tenebrio sp.)
 cysticercoid larvae are released and will eventually develop into adult tapeworms in the intestines of the host
- takes 20 to 30 days from time of ingestion for eggs to appear in the feces
- eggs are viable immediately after discharge from bowel
- autoinfection can occur through the fecal-oral route or w/in the small bowel
- oncospheres from eggs are released and they invade the host villi to start new generation

PATHOGENESIS AND CLINICAL MANIFESTATION

 symptoms are produced because of patient’s immunological response to the presence of the parasite
 asymptomatic – light worm burden
 clinical manifestations:
o headache
o dizziness
o anorexia
o pruritus of nose and anus
o diarrhea
o abdominal pain
o pallor
 infected children
o restless
o irritable
o exhibit sleep disturbances
o convulsions (rare)
 Heavy infections
o Enteritis due to necrosis and desquamation of the intestinal epithelial cells
 Regulatory immunity
o (time) clears H. nana spontaneously.

DIAGNOSIS

 specific diagnosis = demonstration of characteristic eggs in stool

 light infections = need to concentrate stool specimens
 proglottids are not recovered because they undergo degeneration prior to passage with stools

TREATMENT

 *Praziquantel = 25mg/kg single dose

o causes vacuolization and disruption of tegument in the neck region
o dosage for hymenolepiasis is higher than for taeniasis because of relative resistant cysticercoids in the
intestinal tissue
  examine stool after 2 weeks
o repeat treatment to cover for the worms emerging from remaining viable cysticercoids

EPIDEMIOLOGY

 found in warm countries

o Southern USA
o Latin America
o Mediterranean
o East Asia
o Philippines
 Transmission : poor sanitation, overcrowding, poor personal hygiene
 Direct contact plays an important role because eggs cannot survive long outside host
 Familial and institutional infection
 Found in mice and rats

PREVENTION AND CONTROL

 involves a single host and transmission is direct

 personal hygiene and environmental sanitation
 rodent control
 prevent food from infections by grain beetles

HYMENOLEPIS DIMINUTA (rat tapeworm)

 cosmopolitan parasite primarily of rats

 differs from H. nana in that it requires an intermediate host

DISEASE

 Hymenolepiasis – due to accidental human infections

MORPHOLOGY

1. Adult
- larger than H. nana
- Measures : 60 cm in length
- Scolex :
o Has a rudimentary unarmed rostellum
- Proglottids :
o Broader than long
o Arrangement of sexual organs is similar to H.nana
o Larger than H. nana may reach 7.5mm x 3.5 mm (lw)
o Unilateral genital pores
o Gravid proglottids:
 @ contains a sac-like uterus filled with eggs.

2. Eggs
- Shape : circular
- Measures 60 to 80 um
- Bile-stained
- Oncosphere
o Enclosed in an inner membrane
o Has bipolar thickenings
 o Lacks bipolar filaments
- Hooklets have a fan-like arrangements

LIFE CYCLE

 Gravid proglottids separate from the main body of worm  disintegrates  release
eggs in feces
 Eggs are ingested by a wide range of adult and larval insects
o Fleas, beetles, cockroaches, mealworms and earwigs
 Once ingested, they develop into cysticercoid larvae
 When infected insects are ingested by rats or man, larva is released
 Develops into adult worm in ~ 3 weeks

PATHOGENESIS AND CLINICAL MANIFESTATIONS

 worm burden in rodents is relatively low

 in man, the highest number recorded is 19 worms
 manifestations are minimal and non-specific

DIAGNOSIS

 based on identification of eggs from stool

 H. diminuta eggs are more circular, larger and lack bipolar filaments
 At times the whole worm is expelled and the scolex may be used in diagnosis

TREATMENT

 similar to H. nana = Praziquantel 25mg/kg single dose

EPIDEMIOLOGY

 human infections occur worldwide but more common among children

 in poor countries with rat infestations
 occurs by accidental ingestion of grain beetles infesting dried grains, dried fruits, flour and cereals
 prevalence in Phil in rats is 8%

PREVENTION AND CONTROL

 rodent control
 elimination of insect intermediate hosts
 protection of food
 sanitary disposal of waste

DIPYLIDIUM CANINUM (double pored tapeworm)

  very common intestinal parasite of dogs and cats

DISEASE

 Dipylidiasis in humans is accidental

MORPHOLOGY

1. Adult worm
- Color : pale reddish
- Measures 10 to 70 cm in length

- Scolex :
o Small
o Globular
o 4 deeply cupped suckers
o protrusible rostellum
o 1-7 rows of rosethorn-shaped hooklets

- Proglottids:
o Narrow
o 2 sets of male and female reproductive organs
o bilateral genital pores (hence double pored tapeworm)
o Gravid proglottids
 Shape : pumpkin seed
 Filled with capsules or packets of 8 to 15 eggs enclosed in an
embryonic membrane

2. Eggs
- Shape : spherical
- Thin-shelled
- Hexacanth embryo

LIFE CYCLE

 when gravid segments are detached, they either:

o migrate out of the anus
o passed out with feces
 ova are released by:
o contraction of the proglottid or
o disintegration outside the host
 egg capsules may remain in the fur of the host
o larval fleas feed on epidermal debris

 Intermediate hosts
o Ctenocephalides canis (dog flea)
o Ctenocephalides felis (cat flea)
o Pulex irritans (human flea)
o Trichodectes canis (dog louse)
 In the arthropod host, the hexacanth embryo develops into cysticercoid larvae
 o Able to survive flea’s development
o When ingested, the cysticercoid is liberated and becomes an adult in 3 to 4 weeks

PATHOGENESIS AND CLINICAL MANIFESTATIONS

 infection rarely multiple

 symptoms are minimal
o slight intestinal discomfort
o epigastric pain
o diarrhea
o anal pruritus
o allergic reactions
 some are asymptomatic

DIAGNOSIS

 recovery of gravid proglottids passed out single or in chains

 proglottids may crawl out of anus or passed out involuntarily
 proglottids should be pressed or flatted between 2 glass slides for examination
 Stool examination is not recommended since gravid proglottids do not disintegrate in intestines but in the environment
 Egg capsules are rarely recovered

TREATMENT

 Praziquantel = 5 to 10 mg/kg single dose

EPIDEMIOLOGY

 human infections rare but reported in:

o Europe
o USA
o Argentina
o Rhodesia
o China
o Philippines
 Infants and young children usually infected
 Observe actively motile proglottids in feces or underwear
 Adults are not commonly infected because of age tolerance against the parasite

PREVENTION AND CONTROL

 periodic deworming of pet cats and dogs

 insecticide dusting of dogs and cats against fleas

DIPHYLLOBOTHRIUM LATUM (fish tapeworm or broad tapeworm)

 belongs to order Pseudophyllidea

  one of 13 species that infects humans

DISEASE

 Diphyllobothriasis – intestinal infection with the adult worm

MORPHOLOGY

1. Adult
- Measures 3 to 10 m length
- Up to 4000 proglottids

- Scolex :
o Shape: spatulate
o Measures 2 to 3 mm x 1 mm (ld)
o Has 2 bothria or sucking grooves located dorsally and ventrally

- Neck :
o Long and attenuated

- Proglottids:
o Immature
o Mature
 Longer width than length
 Measures 2 to 4 mm x 10 to 12 mm (lw)
 Contains one set of reproductive organs
 Testes
 Located at dorsolateral part of proglottid
 Vas efferens converge to form a vas deferens  enlarge into seminal vesicle  terminates
in muscular cirrus (at midventral genital pore)
 Ovary
 Symmetrical
 Bilobed
 Present at posterior third immediately above Mehlis’ gland
o Gravid
 Uterus
 Dark
 Rosette-like
 Coiled
 Located at middle
 Extends from ootyle and opens through uterine pore behind common genital pore
 Proglottids disintegrate only when the segment has completed its reproductive function

2. Eggs
- Color: yellowish brown
- Moderately thick shell
- Inconspicuous operculum
- Opposite operculum is a knob-like thickening
- Measures 66 x 44 um
LIFE CYCLE

 with disintegration of uterus, the uterine pore is relaxed and unembryonated ova are discharged
 approx. 1,000,000 may be released daily
 ova complete development in water
 release free-swimming coracidium (a ciliated embryo)
 ingested by copepods of genera Cyclops and Diaptomus
 a procercoid larva develops in copepods
o still retains 3 hooklets in the cercomer (a caudal attachment organ)
 copepod ingested by fish
 procercoid larva migrates to tissues and develops into plerocercoid larva in muscles and viscera
 plerocercoid larva appears glistening, opaque, white and unsegmented
 fish is ingested raw by definitive host :man, dog, cat, other mammals
 Paratenic hosts : carnivorous fish
 2nd Intermediate hosts (fish)=perch, trout, salmon & pike
 The plerocercoid attaches to the intestinal wall and reaches maturity in 3 weeks within the
definitive host

PATHOGENESIS AND CLINICAL MANIFESTATIONS

 usually limited to one worm

 infected individuals may be asymptomatic
 symptoms
o nervous disturbances
o digestive disorders
o abdominal discomfort
o weight loss
o weakness
o anemia

 symptoms may be due to absorbed toxins or byproducts of degenerating proglottids or

due to mucosal irritation
 infection results in
o hyperchromic, megaloblastic anemia with thrombocytopenia and leucopenia
o anemia seen is typically similar to that seen in Vit B12 deficiency

 worms in jejunum compete effectively with the host for Vit B 12

  if worms are pushed down the intestines with treatment, anemia is relieved
 Vit B12 content of D. latum is 50 x of T. saginata

DIAGNOSIS

- suggestive:
 residence or travel to endemic area
 raw fish diet
 pernicious type of anemia

- definite diagnosis:
o finding characteristic operculated eggs
o or proglottids in stools
o sometimes proglottids may be vomited
o direct fecal smear
o Kato technique to demonstrate eggs

- differential diagnosis (anemia due to diphyllobothriasis from pernicious anemia)

o examination of gastric juice for presence of free hydrocholoric acid
o pernicious anemia is associated with achlorhydria

TREATMENT

 Praziquantel – 5 to 10 mg/kg single dose

 Criterior : recovery of scolex in feces after treatment
 If scolex is not recovered, repeat stool examination after 3 months to be certain that
patient is no longer infected

EPIDEMIOLOGY

 human infection is dependent on:

1. presence of human or animal definitive hosts
2. presence of suitable intermediate hosts
3. dietary habits
4. amount of pollution of fresh waters
5. preference for eating raw fish
6. lack of sanitary toilet facilities

 Reservoir hosts
o Dogs
o Cats
o Bears

 prevalent in temperate zones

 Baltic countries: Switzerland, Romania, Danube basin
 Asia : Russia, Turkistan, Israel, Manchuria, Japan
 Americas: Chile, Argentina, N. American states, Canada
 Philippines – 7 cases

SPARGANOSIS

 larval infection with plerocercoid larvae (aka spargana of pseudophyllidean tapeworms

under Genus Spirometra)
 involved in human sparganosis
o Spirometra mansoni
o Spirometra erinacei
o Spirometra ranarum

MORHOPHOLOGY

 Adults are intestinal parasites of cats, dogs, and other carnivores

 Adults are usually mistaken for D. latum
 Spargana showed typical solid body with worm-like appearance
 Pseudosegmentation with a slit-like invagination at the head end
 Larvae
o Opaque, glistening, white
 o Found in any part of the body
o Most commonly found in the eye, subcutaneous tissue, muscular tissues of thorax, abdomen, thighs, inguinal
region and in viscera

proglottid scolex

S. mansoni eggs

LIFE CYCLE

 Human infected through

1. drinking water containing Cyclops or copepods infected with procercoid larvae
2. eating infected 2nd intermediate hosts like frogs, toads or snakes containing plerocercoird larvae
3. applying plerocercoid infected flesh of frogs and snakes as poultices in sores in the eye, vagina, and skin 
penetration into cutaneous tissues
4. consumption of infected flesh of pratenic hosts (wild pigs)

PATHOGENESIS AND CLINICAL MANIFESTATION

- Symptoms
o Complain of painful edema due to migrating larvae
o Local indurations
o Periodic giant urticaria
o Edema
o Erythema with chills, fever
o High eosinophilia
DIAGNOSIS

 Finding white larvae in the lesion

 Species identification done by experimental infection of animals

TREATMENT

- Surgical removal of plerocercoid

- In cases reported, spargana were motile upon excision of the mass

PREVENTION AND CONTROL

- Drinking boiled or filtered water

- Proper cooking
- Avoid applying flesh of frogs to inflamed areas

Learning Module No. 5

Topic: Trematodes Infection

Materials: Laptop and Internet Connection
Assessment: MCQ Post-Test via Infinit

Learning Outcomes:
At the end of the session, the students should be able to:
1. Enumerate blood flukes (Schistosomes) that inhabit the venous plexuses draining
the urinary bladder, large intestine &amp; small intestine.
2. Differentiate morphological features, clinical picture, diagnosis, treatment, and ways
of the prevention and control.
3. Identify different snails and their pathogenicity with regards to the medical
importance.

PARASITOLOGY LECTURE 5 – Trematodes (Flukes) by Dr. E.H Carandang

Notes from Lecture
USTMED ’07 Sec C – AsM

TREMATODES OR FLUKES

- class under Platyhelminthes (flat worms) along with class Cestoidea

- the trematodes (sp. The digenetic flukes) have complicated life cycles involving alternation of generations of hosts.
- The usual primary hosts are terrestrial and aquatic mollusks
- The human trematodes affect various areas of the body
o Circulatory system (blood flukes)
o Intestines (Echinostoma ilocanium)
 o Liver (Fasciola hepatica)
o Lungs (Paragoniums westermani)
- vary in size
- organs of attachment are found around the mouth and ventral region of the body (oral and ventral suckers)
- most are hermaphroditic; Schistosomes, however, are sexually dimorphic
- the alimentary canal is incomplete with a mouth leading to a short pharynx and an esophagus that bifurcates into a
pair of blind intestinal ceca which may be simple or branched or which may reunite to form a single cecum.
- The reproductive system is highly developed w/ both male and female organs found in a single worm
- Are oviparous; eggs are operculated except for the schistosomes; can only develop in water
- Life cycle includes:
1) egg stage
2) larval stages (miracidium, sporocyst, redia, cercaria, metacercaria)
3) adult stage
- definitive host = man; harbors the adult worm
- intermdediate host = freshwater mollusk; provides shelter to the larval stages
- second intermediate host = fish, crustacean, snail or plant; required by the parasite for encystment.

PHYLUM
- Platyhelminthes

CLASS
- Trematoda

NOTES
- Species parasitic in humans belong to the Digenea, in which sexual reproduction in adult is followed by asexual
multiplication in the larval stages in snails.

MORPHOLOGY
- Adult digenetic trematodes are usually flat, elongated, leaf-shaped worm but they may be ovoid, conical or cylindrical
- Vary in size from less than 1 mm to several centimeters
- Worm is enveloped by a noncellular integument which may be partially or completely covered with spines, tubercles or
ridges

INTEGUMENT
- plays an important role in the absorption of carbohydrates
- serve for secretion of excess metabolites and mucus
- by electron microscopic studies, it is syncitial without nuclei, contain many vacuoles and mitochrondria, and connected
by protoplasmic tubes with an inner layer of cells.
- no microtrichia or pore canals are found in the integument of cestodes.

SCHEMATIC REPRESENTATION OF MORPHOLOGY OF A TYPICAL TREMATODE

LIFE CYCLE
- definitive host (usually a vertebrate, multiplication takes place sexually with the production of eggs)
- primary or first intermediate host (usually a snail producing asexual generations)
- secondary or 2nd intermediate host (fish, crustacean, snails or aquatic plants)

HUMAN BLOOD FLUKES

(SCHISTOSOMIASIS/BILHARZIASIS)

HUMAN BLOOD FLUKES:

- Three major species:
1) Schistosoma haematobium
2) Schistosoma mansoni
3) Schistosoma japonicum
- Minor species:
1) Mekongi
2) Malayensis
3) Intercalatum

FEATURES OF HUMAN SCHISTOSOMES

- they develop in the portal venous system and adult flukes (depending on species) live in the vein of the intestine or
bladder
- Sexes are separate
- Unlike most trematodes, they are not flattened and leaflike. They are long and worm-like
- Humans are the only definitive host
- Transmission is by contact with water containing the infective form of parasite (cercariae)
SCHISTOSOMA HAEMATOBIUM

- causes urinary schistosomiasis, schistosomal hematuria, vesical schistosomiasis, or urinary bilharziasis

male female

LIFE CYCLE

GEOGRAPHICAL DISTRIBUTION
- Tropical and subtropical. Africa, Iran, Iraq, Saudi Arabia, Yemen, Syria, India, Mauritus, Malagasy Republic, Zanzibar
 Shell of a Bulinus snail
Other genera:
Physopsis
Biophalaria

PATHOGENESIS
- skin rash at site of cercarial penetration (swimmer’s itch)
- within a few days after penetration, the young flukes become coated with host red cell antigens and histocompatibility
antigens, so they are not recognized as foreign and live free from host attack to develop and produce eggs for long
periods
- it is the eggs not the adult flukes which are responsible for the clinical features and damage to the bladder or ureters
- Eggs trapped in the bladder wall and surrounding tissues cause inflammatory reactions with the formation of
granulomata (contains egg, toxic products, eosinophils, epitheloid cells, and lymphocytes).
- Many of the eggs die and become calcified producing what are known as “sandy patches” in the bladder.
- In heavy infection, eggs can be carried to other parts of the body

SYMPTOMATOLOGY
- in light infections, symptoms may not develop for years
- in heavy infections, symptoms may be just noticed as early as 1 month after infection
- following prolonged untreated infection and marked cellular response, the ureters may become obstructed and the
bladder wall thickened, leading to abnormal bladder function with painful and frequent urination, urinary infection,
and eventually kidney damage.
- terminal hematuria is the most characteristic symptom.
- in some areas, S. haematobium infection has been linked to an increase in Salmonella typhi and S. paratyphi carriers
following acute infection
- patients are more likely to become urinary rather than fecal carriers
- patients may also exhibit a syndrome of chronic, intermittent, enteric bacteremia that clinically resembles Kala-azar
- Both of these chronic bacterial infections have been attributed to a mechanism of adhesion of the bacteria to the
integument of the intravascular schistosomes.

LABORATORY DIAGNOSIS:
- Specific
o Finding the eggs or occasionally the hatched miracidia in the urine
o occasionally, eggs can be found in faeces
o detecting eggs in rectal biopsy or bladder mucosal biopsy

Eggs of S. haematobium. White Ciliated, and rapidly motile

arrows show the position of the miracidium hatched from an
flame cells S. haematobium egg in urine that has
been left to stand.

NON-SPECIFIC FINDINGS
- hematuria
- proteinuria
- cells, especially eosinophils can often be found in the urine
- bacteriuria may accompany urinary schistosomiasis
SCHISTOSOMA MANSONI
male female

LIFE CYCLE

GEOGRAPHICAL DISTRIBUTION
- Parts of Africa, Middle East, South America (Brazil), West India

Shell of a Biomphalaria snail

PATHOGENESIS/SYMPTOMATOLOGY
- skin rash after cercarial penetration
- flukes acquire host antigen protecting them from host immune response
- eggs penetrate through the intestinal wall and are excreted in the faeces often with blood and mucus
 - host reaction to eggs leads to the formation of granulomata, ulceration, and thickening of the bowel wall
- a proportion of the eggs reach the liver through the portal vein
- reaction to the eggs causes thickening of the portal vessels known as claypipe-stem fibrosis
- hepatomegaly with fibrosis
- splenomegaly
- portal hypertension
- ascites
- ova can be deposited in the spinal cord, lungs, and other organs of the body
- Salmonella infections can become chronic and prolonged

LABORATORY DIAGNOSIS
- finding S. mansoni ova in faeces
- occasionally may also be found in the urine following fecal contamination

- Rectal biopsy especially after a patient has been partially treated

OTHER FINDINGS
- mucus and blood are often present in fecal specimens
- blood eosinophilia
- for patients with hepatic involvement, increased liver enzymes, low serum albumin, increased serum protein due to
increased globulin
SCHISTOSOMA JAPONICUM

male female
GEOGRAPHICAL DISTRIBUTION
- China, Philippines, Western Indonesia
- Eastern Visayas and Mindanao

Shell of an Oncomelania snail Oncomelania quadrasi

(intermediate host of
S. japonicum) as compared to
the size of a 1 peso coin

PATHOGENESIS/SYMPTOMATOLOGY
- skin rash at the site of cercarial penetration
- 20-60 days after infection, patient develop fever, muscular and abdominal pain, spleen enlargement, urticaria, and
eosinophilia (Katayama reaction or Katayama fever)
- Reactions to eggs in the tissue can cause intestinal or hepatosplenic disease with dysentery, liver fibrosis, marked
hepatosplenomegaly egg deposition in the lungs, CNS, and other parts of the body

Portal hypertension with prominent ascites

LABORATORY DIAGNOSIS
- Finding of the ova in faeces
- Typical ova on rectal biopsy
- Serologic tests
1) Circumoval Precipitin Test (COPT)
2) ELISA

OTHER FINDINGS
- Mucus and blood in fecal specimen
- blood eosinophilia
- in patients with hepatic involvement raised hepatic enzymes, low serum albumin, increased total protein due to
increased globulin
OTHER SCHISTOSOMA

SCHISTOSOMA INTERCALATUM

- similar to Schistosoma mansoni In terms of life cycle, pathology and clinical feature
- intermediate host is the Bulinus snail

SCHISTOSOMA MEKONGI

- similar to Schistosoma japonicum in terms of life cycle, pathology, and clinical features
- intermediate host is the snail Lithoglyphopsis aperta

TREATMENT

- Praziquantrel

40-50 Single dose

mg/kg
25 mg/kg Two doses
20 mg/kg Three doses

PREVENTION AND CONTROL

- Health Education
- Control snail vector
 Environmental method
o Removing the environmental requirement of the snails
o drainage of breeding sites and proper management of irrigation system
 o removal of shade or shelter from the sun by clearing vegetation armed bodies of water
o prevention of breeding on the banks of streams or irrigation canals by living these concretes or making
these more perpendicular
o acceleration of flow of water by proper grading and clearing of the stream bed and removal of debris
o construction of ponds if the area cannot be drained
o covering snail habitats with land fills
 Chemical method
 Environmental sanitation