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  1. 1. Nematodes By Dr. Osman Bukhari
  2. 2. <ul><li>Nematodes : 1- Human Intestinal nematodes 2-Tissue dewelling nematodes 3- Animal nematodes </li></ul>
  3. 3. <ul><li>1- Human Intestinal nematodes - T. trichuria - E. vermicularis - A. lumbricoides - Hook worms - S. stercolaris, - C. phillipinensis . </li></ul><ul><li>2-Tissue dewelling nematodes - Filarial - D. medinensis </li></ul><ul><li>3- Animal nematodes - T. canis - A. braziliensis - T. spiralis </li></ul>
  4. 4. <ul><li>Human Intestinal nematodes </li></ul><ul><li>- Largest group of human helmithic infection . </li></ul><ul><li>- Infection indicative of za level of hygiene and sanitation in z community. Soil pollution by human faeces is a major factor in transmission . (SOIL transmitted worms.) </li></ul><ul><li>- Multiple infection can occur. </li></ul><ul><li>- Clinical manifestations depend on worm load . </li></ul><ul><li>-Transmission is either: 1- direct fecal-oral 2- modified fecal-oral 3 - through skin penetration. </li></ul>
  5. 5. <ul><li>Direct faecal oral : ( E. vermicularis & T. trichuria) </li></ul><ul><li>Infective eggs Adult in the bowel </li></ul><ul><li>Modified direct faecal oral : ( A. lumbricoides) </li></ul><ul><li>Infective eggs small bowel & larvae penetrate </li></ul><ul><li>venules lungs small bowel adult </li></ul><ul><li>Percutaneous or skin penetration : ( Hook worms) </li></ul><ul><li>Eggs Rabditiform larvae Flariform larvae </li></ul><ul><li>Skin Lungs Small bowel Adult </li></ul><ul><li>( Strongyloides) </li></ul><ul><li>Rabditiform larvae Flariform larvae Skin </li></ul><ul><li>Lungs Small bowel Adult </li></ul>
  6. 6. <ul><li>Trichuriasis </li></ul><ul><li>- Infection is world wide occurring under unhygienic conditions. </li></ul><ul><li>- Adult lives in za caecum & adjacent bowel . In </li></ul><ul><li>heavy infection in the whole colon </li></ul><ul><li>- Human is za principle host , specially children.. </li></ul><ul><li>- Infective stage is za eggs & transmission is direct fecal- oral. </li></ul><ul><li>- Asymptomatic infection is common . </li></ul><ul><li>- Heavy infections: Bloody diarrhea (colitis) </li></ul><ul><li>associated wz abd pain, tenesmus, anorexia </li></ul><ul><li>and Wt loss. </li></ul>
  7. 7. <ul><li>- Rectal prolapse - growth retardation in children. Associated malnutrition & other parasitic infections play a role.. </li></ul><ul><li>- May cause appendicitis </li></ul><ul><li>- No signif. eosinophilia . </li></ul><ul><li>- Diag. : characteristic egg in za stools . </li></ul><ul><li>- Management: Mebendazole 100mg x2x3 days, Pyrentel pamoate 10 mg/kg 3 tabs of 250 mg for adults., Levamesol 3 tabs of 40mg for adults. </li></ul>
  8. 8. <ul><li>Entrobiasis </li></ul><ul><li>- Institutional & familial disease specially in children . </li></ul><ul><li>- Associated with poor hygiene . </li></ul><ul><li>- Eggs are za infective stage - transmission is direct fecal oral . </li></ul><ul><li>- Adult lives in za caecum & adjacent bowel and have short life span and infection is maintained by autoinfection . </li></ul>
  9. 9. <ul><li>- Most infections are asymptomatic . </li></ul><ul><li>- Peri anal pruritus & abnormal behavior - Pruritus vulvae in females. </li></ul><ul><li>- Mild GIT symptoms . </li></ul><ul><li>- Migrating worms cause ectopic disease e.g. appendicitis, salpingitis. </li></ul><ul><li>- No significant eosinophilia . </li></ul><ul><li>- Diagnosis is by naked appearance of za adult and definitely by finding eggs with adhesive cellophane tape </li></ul><ul><li>- Diagnosis in a member necessitates ex of others.. </li></ul>
  10. 10. <ul><li>- All family members with symptoms should be treated. </li></ul><ul><li>- Mebendazole 100 mg , Pyrentel pamoate 3 tabs, Levamesol 3 tabs, Piperazine 4g ; All single dose & repeated after 2 weeks. </li></ul>
  11. 11. <ul><li>Ascariasis </li></ul><ul><li>- Most common human helmnithic infectn </li></ul><ul><li>- Infection is common in all age groups, </li></ul><ul><li>specially children . </li></ul><ul><li>- Eggs are za infective stage. - Transmission is modified direct & is enhanced by high egg output. </li></ul><ul><li>- Part of life cycle in za lungs. </li></ul><ul><li>- Most infections are asymptomatic and manifestatios depend on za intensity of infestation. </li></ul>
  12. 12. <ul><li>Clinical features : </li></ul><ul><li>- asymptomatic . </li></ul><ul><li>- Lofflers ( respiratory symptoms) </li></ul><ul><li>- Dyspepsia , abdominal pain and patient may vomit za worm or pass it in z stool. </li></ul><ul><li>- Obstructive manifestations : small intestine, biliary and pancreatic duct obstruction. Suppurative cholangitis and appendicitis. </li></ul>
  13. 13. <ul><li>- In malnourished children heavy infection have significant effects on nutrition and development - Serious morbidity & mortality is rare - Diagnosis by finding characteristic eggs in the stools. </li></ul><ul><li>- Mebendazole 100 mg x2x3 , Pyrentel pamoate 10 mg /kg 3tab, Levamizol 3 tab. Piperazine 4 g ( 75 mg / kg) specially in obstructive disease. </li></ul><ul><li>- Surgery in obstruction if no resopnse to conservative management. </li></ul>
  14. 14. <ul><li>Anklystomiasis </li></ul><ul><li>- Caused by A. duodenale & N. americanus . </li></ul><ul><li>- Adults live in upper small bowel attached to za mucosa by buccal capsules leading to blood loss . </li></ul><ul><li>- Flariform larvae are za infective stage and transmission is through za skin . </li></ul><ul><li>- Superficial position of za larvae in z soil , lack of safety disposal of human excreta and the habbit of walking bare feet facilitate transmission & prevalence. </li></ul>
  15. 15. <ul><li>Clinical features : - Ground itch. </li></ul><ul><li>- Lofflers syndrome. </li></ul><ul><li>- Epigastric pain, dyspepsia & weight loss.. </li></ul><ul><li>- Iron deficiency & hypoprotienaemia. </li></ul><ul><li>- Physical and mental retardation. </li></ul><ul><li>- Positive occult blood in the stools. </li></ul><ul><li>Diagnosis: by finding eggs in za stools. </li></ul>
  16. 16. <ul><li>- Treatment : </li></ul><ul><li>- Mebendazole 100 mg X2X3 (95% cure rate) </li></ul><ul><li>and 99% reduction in egg load. </li></ul><ul><li>- Pyrental pamoate 10 mg/kg (max 1gm) </li></ul><ul><li>- Levamizole 3 tabs </li></ul><ul><li>- Piperazine 75 mg/kg (4 gm) </li></ul><ul><li>- Iron therapy for anaemia </li></ul><ul><li>- High protein diet </li></ul>
  17. 17. <ul><li>Srongyloidosis </li></ul><ul><li>- High prevalence in za tropics. </li></ul><ul><li>- Adult lives in the small bowel - Free living forms occur in za soil. </li></ul><ul><li>- Potentially lethal in za immunosupressed because of overwhelming hyper infection </li></ul><ul><li>- Larvae passed in z stools , become infective in the soil & penetrate za skin . </li></ul><ul><li>- Autoinfection can occur through lower GIT and peri anal region. </li></ul>
  18. 18. <ul><li>- Clinical features include skin itching, Lofflers, abdominal pain, diarrhea , malabsorption & protein losing enteropathy. Rarely perforation. </li></ul><ul><li>- Eosinophilia ++++. </li></ul><ul><li>- Larva currens . </li></ul><ul><li>- 1/3 are asymptomatic . </li></ul><ul><li>- Massive larval invasion of z lungs, brain, liver, heart & kidneys occur in autoinfection in z immunosupressed (Hyper infection) and may be fatal. </li></ul>
  19. 19. <ul><li>- Hyper infection causes severe abd pain, diarrhea, ileus, pneumonia with pulmonary infiltrations, meningoencephalitis, sepsis and shock from gram negative septicemia leading to death if not diagnosed & treated early. </li></ul><ul><li>Diagnosis by demonstration of larvae in za stools or jejunal aspirate or by serology. </li></ul><ul><li>Treatment : Aim of management is to eradicate the infection. </li></ul>
  20. 20. <ul><li>- Thiabendazole 25 mg x2x3 - Albendazole 15 mg x2x3=may need 2 nd course. - Ivermectin 200 microg. Single dose or 2 daily doses. </li></ul><ul><li>- Hyper infection needs prolonged course and mortality is high. </li></ul><ul><li>- In endemic areas exclude the infection before immunosuppression . </li></ul>
  21. 21. <ul><li>Prevention of Nematodes </li></ul><ul><li>- Improvement in hygiene </li></ul><ul><li>- improvement in sanitation </li></ul><ul><li>- health education </li></ul>
  22. 22. <ul><li>Lofflers </li></ul><ul><li>Dyspepsia - Under nutrition </li></ul><ul><li>Obstructive syndr </li></ul>Small bowel Mature eggs Modified Direct F/oral A. lumbricoi Ascariasis <ul><li>Pruritus ani </li></ul><ul><li>pruritus vulvae </li></ul><ul><li>Ectopic dis </li></ul>Caecum & Adjacent Bowel Eggs Direct F/oral E. vermicul Entrobiasis <ul><li>- Colitis </li></ul><ul><li>Rectal prolapse </li></ul><ul><li>Ectopic disease </li></ul><ul><li>growth retardation </li></ul>Caecum & Adjacent Bowel Eggs Direct F F/oral T. trichuria Tricuriasis Clinical features Final habitat Infective stage Mode of transmissi Sp. Infecting human infection
  23. 23. - Malabsorption Small bowel larvae Ingestion Of fish Cap phillpinensis capillariasis <ul><li>Lofflers </li></ul><ul><li>Dyspepsia, diarrh - Malabsorption </li></ul><ul><li>Hyper infection </li></ul>Small bowel Flariform larvae Skin penetratio Str. sterclaris Strongloido <ul><li>Ground itch - Iron deficiency </li></ul><ul><li>anaemia </li></ul><ul><li>Dyspepsia </li></ul><ul><li>-Hypoalbuminaemia </li></ul>Small bowel Flariform larvae Skin penetratio A. Duode N. ameri Hook worms Clinical features Final habitat Infective stage Mode of transmiss Sp. Infecting human infection
  24. 24. <ul><li>Drug therapy in nematodes </li></ul><ul><li>- Mebendazole 100 mg </li></ul><ul><li>- Albendazole 400 mg </li></ul><ul><li>- Pyrental pamoate 100 mg/ kg ( 3 tabs) </li></ul><ul><li>- Oxantel 100 mg/kg </li></ul><ul><li>- Levamizole 3 tabs </li></ul><ul><li>- Thiabendazole 25 mg/kg </li></ul><ul><li>- Piperazine 100 mg/kg. 4 gm single dose </li></ul><ul><li>- Ivermectin for strongloidosis </li></ul><ul><li>** Single doses of pyrental, oxantel or </li></ul><ul><li>albendazole is used for multiple infestation . </li></ul>