Abdominal parasitic infection: Difference between revisions

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===== '''Infection intensity''' =====
===== '''Infection intensity''' =====
* The intensity of intestinal schistosomiasis is classified as:  
* The intensity of [[intestinal schistosomiasis]] is classified as:  
* Light: up to 100 eggs per gram  
{| class="wikitable"
* Moderate: 100 to 400 eggs per gram  
!Infection Intensity
* Severe: >400 eggs per gram  
!Egss per gram
* The intensity of urinary schistosomiasis is classified as:
|-
* Light to moderate: up to 50 eggs/10 mL
|Light
* Severe: >50 eggs/10 mL
|100 eggs per gram
|-
|Moderate
|100 to 400 eggs per gram
|-
|Severe
|>400 eggs per gram
|}
* The intensity of [[urinary schistosomiasis]] is classified as:
** Light to moderate: up to 50 eggs/10 mL
** Severe: >50 eggs/10 mL


===== '''Serology''' =====
===== '''Serology''' =====
* Schistosome antigens including extracts of adult worms, cercarial antigens can develop antibodies that may be used in serology test.<ref name="pmid1802520">{{cite journal| author=Tsang VC, Wilkins PP| title=Immunodiagnosis of schistosomiasis. Screen with FAST-ELISA and confirm with immunoblot. | journal=Clin Lab Med | year= 1991 | volume= 11 | issue= 4 | pages= 1029-39 | pmid=1802520 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1802520  }}</ref>
* Schistosome antigens including extracts of adult worms, cercarial antigens can develop antibodies that may be used in serology test.<ref name="pmid1802520">{{cite journal| author=Tsang VC, Wilkins PP| title=Immunodiagnosis of schistosomiasis. Screen with FAST-ELISA and confirm with immunoblot. | journal=Clin Lab Med | year= 1991 | volume= 11 | issue= 4 | pages= 1029-39 | pmid=1802520 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1802520  }}</ref>
* Serology is used as screening mainly because of low sensitivity.  
* Serology is used as screening mainly because of low sensitivity.  
* Serologic tests include:  
* Serologic tests include:
* Indirect hemagglutination
** [[Hemagglutination|Indirect hemagglutination]]
* Complement fixation
** [[Complement fixation]]
* Enzyme-linked immunosorbent assay
** [[Enzyme-linked immunosorbent assay]]


===== '''Molecular tests''' =====
===== '''Molecular tests''' =====
* PCR on urine samples noted sensitivity and specificity of 94 and 100 percent, respectively.
* [[PCR]] on urine samples noted sensitivity and specificity of 94 and 100 percent, respectively.
* ''S. mansoni'' PCR sensitivity is 100 percent and specificity is 90 percent.<ref name="pmid19646307">{{cite journal| author=Webster BL, Rollinson D, Stothard JR, Huyse T| title=Rapid diagnostic multiplex PCR (RD-PCR) to discriminate Schistosoma haematobium and S. bovis. | journal=J Helminthol | year= 2010 | volume= 84 | issue= 1 | pages= 107-14 | pmid=19646307 | doi=10.1017/S0022149X09990447 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19646307  }}</ref>
* ''[[Schistosoma mansoni|S. mansoni]]'' [[PCR]] sensitivity is 100 percent and specificity is 90 percent.<ref name="pmid19646307">{{cite journal| author=Webster BL, Rollinson D, Stothard JR, Huyse T| title=Rapid diagnostic multiplex PCR (RD-PCR) to discriminate Schistosoma haematobium and S. bovis. | journal=J Helminthol | year= 2010 | volume= 84 | issue= 1 | pages= 107-14 | pmid=19646307 | doi=10.1017/S0022149X09990447 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19646307  }}</ref>


===== '''Biopsy''' =====
===== '''Biopsy''' =====
* Histopathology of superficial rectal biopsies is more sensitive than stool microscopy and may demonstrate eggs even when multiple stool specimens are negative.<ref name="pmid2867326">{{cite journal| author=Harries AD, Fryatt R, Walker J, Chiodini PL, Bryceson AD| title=Schistosomiasis in expatriates returning to Britain from the tropics: a controlled study. | journal=Lancet | year= 1986 | volume= 1 | issue= 8472 | pages= 86-8 | pmid=2867326 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2867326  }}</ref>
* Histopathology of superficial rectal [[biopsies]] is more sensitive than stool microscopy and may demonstrate eggs even when multiple stool specimens are negative.<ref name="pmid2867326">{{cite journal| author=Harries AD, Fryatt R, Walker J, Chiodini PL, Bryceson AD| title=Schistosomiasis in expatriates returning to Britain from the tropics: a controlled study. | journal=Lancet | year= 1986 | volume= 1 | issue= 8472 | pages= 86-8 | pmid=2867326 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2867326  }}</ref>


=== '''Treatment''' ===
=== '''Treatment''' ===
* Praziquantel is the drug of choice for schistosomiasis. It increases calcium ion permeability. Calcium ions accumulate in the cytosol, leading to muscular contractions and subsequent paralysis.<ref name="pmid24955523">{{cite journal| author=Cioli D, Pica-Mattoccia L, Basso A, Guidi A| title=Schistosomiasis control: praziquantel forever? | journal=Mol Biochem Parasitol | year= 2014 | volume= 195 | issue= 1 | pages= 23-9 | pmid=24955523 | doi=10.1016/j.molbiopara.2014.06.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24955523  }}</ref>
* [[Praziquantel]] is the drug of choice for [[schistosomiasis]]. It increases calcium ion permeability. [[Calcium]] ions accumulate in the [[cytosol]], leading to muscular contractions and subsequent [[paralysis]].<ref name="pmid24955523">{{cite journal| author=Cioli D, Pica-Mattoccia L, Basso A, Guidi A| title=Schistosomiasis control: praziquantel forever? | journal=Mol Biochem Parasitol | year= 2014 | volume= 195 | issue= 1 | pages= 23-9 | pmid=24955523 | doi=10.1016/j.molbiopara.2014.06.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24955523  }}</ref>
* Praziquantel side effects include dizziness, headache, vomiting, abdominal pain, diarrhea, and pruritus.<ref name="pmid1841998">{{cite journal| author=Araújo N, Kohn A, Katz N| title=Activity of the artemether in experimental schistosomiasis mansoni. | journal=Mem Inst Oswaldo Cruz | year= 1991 | volume= 86 Suppl 2 | issue=  | pages= 185-8 | pmid=1841998 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1841998  }}</ref>
* [[Praziquantel]] side effects include [[dizziness]], [[headache]], [[vomiting]], [[abdominal pain]], [[diarrhea]], and [[pruritus]].<ref name="pmid1841998">{{cite journal| author=Araújo N, Kohn A, Katz N| title=Activity of the artemether in experimental schistosomiasis mansoni. | journal=Mem Inst Oswaldo Cruz | year= 1991 | volume= 86 Suppl 2 | issue=  | pages= 185-8 | pmid=1841998 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1841998  }}</ref>


* Oxamniquine can be used for refractory schistosomiasis infection and may be as effective as praziquantel.  
* [[Oxamniquine]] can be used for refractory [[schistosomiasis]] infection and may be as effective as [[praziquantel]].  
[[File:Schistosoma mansoni.jpg|300px|center|thumb|Schistosoma mansoni egg, source: By US federal government - Work of US federal government, Public Domain, https://commons.wikimedia.org/w/index.php?curid=218201]]
[[File:Schistosoma mansoni.jpg|300px|center|thumb|Schistosoma mansoni egg, source: By US federal government - Work of US federal government, Public Domain, https://commons.wikimedia.org/w/index.php?curid=218201]]
[[File:Couple of Schistosoma mansoni.jpg|center|300px|thumb|Couple of Schistosoma mansoni, source: CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=55038168]]
[[File:Couple of Schistosoma mansoni.jpg|center|300px|thumb|Couple of Schistosoma mansoni, source: CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=55038168]]
Line 367: Line 377:


== Hymenolepis Nana ==
== Hymenolepis Nana ==
* [[Hymenolepis infection|Hymenolepis Nana]] is a species though most common in temperate zones, and is one of the most common [[cestodes]] infecting humans, especially children.
* [[Hymenolepis infection|Hymenolepis Nana]] is a species most commonly in temperate zones, and is one of the most common [[cestodes]] infecting humans, especially children.
* The [[prevalence]] of Hymenolepis Nana is higher in warm parts of South Europe, Russia, India, US and Latin America.<ref name="pmid19456836">{{cite journal| author=Utzinger J, Botero-Kleiven S, Castelli F, Chiodini PL, Edwards H, Köhler N et al.| title=Microscopic diagnosis of sodium acetate-acetic acid-formalin-fixed stool samples for helminths and intestinal protozoa: a comparison among European reference laboratories. | journal=Clin Microbiol Infect | year= 2010 | volume= 16 | issue= 3 | pages= 267-73 | pmid=19456836 | doi=10.1111/j.1469-0691.2009.02782.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19456836  }}</ref>
* The [[prevalence]] of Hymenolepis Nana is higher in warm parts of South Europe, Russia, India, US and Latin America.<ref name="pmid19456836">{{cite journal| author=Utzinger J, Botero-Kleiven S, Castelli F, Chiodini PL, Edwards H, Köhler N et al.| title=Microscopic diagnosis of sodium acetate-acetic acid-formalin-fixed stool samples for helminths and intestinal protozoa: a comparison among European reference laboratories. | journal=Clin Microbiol Infect | year= 2010 | volume= 16 | issue= 3 | pages= 267-73 | pmid=19456836 | doi=10.1111/j.1469-0691.2009.02782.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19456836  }}</ref>
* Prevalence is 97% in Moscow children and 34% in Argentina children. It has been reported to affect 4 percent of schoolchildren in rural southeastern United States.
* Prevalence is 97% in Moscow children and 34% in Argentina children. It has been reported to affect 4 percent of schoolchildren in rural southeastern United States.
'''Clinical manifestations'''
'''Clinical manifestations'''
* Most infections are asymptomatic.<ref name="pmid26535513">{{cite journal| author=Muehlenbachs A, Bhatnagar J, Agudelo CA, Hidron A, Eberhard ML, Mathison BA et al.| title=Malignant Transformation of Hymenolepis nana in a Human Host. | journal=N Engl J Med | year= 2015 | volume= 373 | issue= 19 | pages= 1845-52 | pmid=26535513 | doi=10.1056/NEJMoa1505892 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26535513  }}</ref>
* Most infections are asymptomatic.<ref name="pmid26535513">{{cite journal| author=Muehlenbachs A, Bhatnagar J, Agudelo CA, Hidron A, Eberhard ML, Mathison BA et al.| title=Malignant Transformation of Hymenolepis nana in a Human Host. | journal=N Engl J Med | year= 2015 | volume= 373 | issue= 19 | pages= 1845-52 | pmid=26535513 | doi=10.1056/NEJMoa1505892 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26535513  }}</ref>

Revision as of 19:30, 28 February 2018


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]

Abdominal parasitic infection Main page

Overview

Causes

Ascaris lumbricoides

Necator americanus

Giardia lamblia

Fasciola Hepaticum

Schistosoma

Strongyloidis Stercoralis

E. Histolytica (Amebiasis)

Taeniasis

Trichuris trichiura

Hymenolepis Nana

Overview

An intestinal parasite infection is a condition in which a parasite infects the gastro-intestinal tract of humans and other animals. Mode of transmission of infection can be due to ingestion of undercooked meat, drinking infected water, fecal-oral transmission and skin absorption. There are many types of parasites that can cause abdomial infections but the most common types are caused by Ascaris lumbricoides, Necator americanus, Fasciola, Schistosoma, Trichuris trichiura, Strongyloides stercoralis, Taenia, Hymenolepis nana, and Entamoeba histolytica. Ascaris lumbricoides is a common in Asia and during six to eight weeks after egg ingestion, symptoms of ascariasis are abdominal discomfort, anorexia, nausea, vomiting, and diarrhea. Stool microscopy is the most common diagnostic tool for evaluation of Ascaris ova and albendazole is the drug of choice for treatment. Necator americanus is common in rural areas of the US and presents with nausea, diarrhea, vomiting, and epigastric pain. Giardiasis is common in children and mountains hikers who drink water that has not been boiled. Most of the cases are asymptomatic but acute giardiasis symptoms include diarrhea, malaise, steatorrhea, abdominal cramps, bloating, nausea, and weight loss. ELISA is sensitive for detection of giardiasis and stool examination is specific. Tinidazole and nitazoxanide are the preferred drug for Giardiasis. Fasciola appears with fever, anorexia, nausea, vomiting, myalgia, cough, right upper quadrant pain, hematomas of the liver, jaundice, and hepatomegaly. Complications include focal neurologic changes, pericarditis, arrhythmia, and right-sided pleural effusion. Computed tomography and magnetic resonance imaging radiographic findings in fascioliasis are vmultiple small nodules, thickening of the liver capsule, subcapsular hematoma, or parenchymal calcifications or tortuous tracks due to migration of the parasite through the liver. The treatment of choice is triclabendazole. Dosing consists of 10 mg/kg orally for one or two days. Bithionol and nitazoxanide are alternative choices. Intestinal schistosomiasis is caused by infection due to S. mansoni, S. japonicum, and S. haematobium. The most common symptoms include chronic or intermittent abdominal pain, poor appetite, bleeding from colonic ulcers that may cause anemia if heavily infested. The left lobe of liver is enlarged with splenomegaly that may extend below the umbilicus. Increased portal hypertension is due to high resistance in the hepatic circulation. The predominant pathological process consists of collagen deposition in the periportal spaces causing periportal fibrosis. Identification of schistosome eggs is the gold standard for the diagnosis of schistosomiasis with low sensitivity and high specificity. Serology is used as screening mainly because of low sensitivity. Praziquantel is the drug of choice for schistosomiasis. It increases calcium ion permeability. Calcium accumulate in the cytosol leading to muscular contractions and subsequent paralysis. Hymenolepis Nana is most common in temperate zones, and is one of the most common cestodes infecting humans, especially children. Most infections are asymptomatic. The diagnosis is generally established by identifying eggs in the stool. Praziquantel is the treatment of choice for hymenolepiasis. Most infections with T. trichiura are asymptomatic. Main symptoms are loose stool which may contain mucus and blood. The diagnosis of trichuriasis is made by stool examination for eggs. Mebendazole is the drug of choice for trichuriasis.

Causes

Ascaris lumbricoides

Mode of infection

  • Ingestion of Ascaris eggs secreted in the feces of humans or pigs.
  • Ingesting uncooked pig or chicken liver with the larvae.[1]

Epidemiology and demographics

  • Approximately 800 million people are infected.[2]
  • Majority of individuals infected with ascariasis are in Asia (73 percent), Africa (12 percent), and South America (8 percent).[3]

Clinical manifestations

Complications

Laboratory findings

  • Stool microscopy is the most common diagnostic tool for evaluation of Ascaris ova.
  • Characteristic eggs may be seen on direct examination of stool.

Imaging findings

Treatment

Drug Dosage
Albendazole 400 mg orally once
Mebendazole 100 mg orally twice daily for 3 days or 500 mg orally once
Ivermectin 150-200 mcg/kg orally once
Ascaris lumbricoides adult worms, source: By SuSanA Secretariat - https://www.flickr.com/photos/gtzecosan/15701719491/in/set-72157648708895830, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=37077525
+/−, Public Domain, https://commons.wikimedia.org/w/index.php?curid=781546

Necator americanus

  • Approximetly 800 million people are infected with hookworms worldwide.[8]
  • The prevalence of hookworm infection in rural areas of United States in the early 20th century was high.

Acute gastrointestinal symptoms

  • Nausea, diarrhea, vomiting, epigastric pain, and increased flatulence may be observed.[9]
  • In patients with recurrent infections, gastrointestinal symptoms become less in the proceeding attacks, mild after the second, and absent after the third and fourth infection.

Chronic nutritional impairment

  • Hookworms cause blood loss during attachment to the intestinal mucosa by lacerating capillaries and ingesting extravasated blood.[10]
  • The daily losses of blood, iron, and albumin can lead to anemia and contribute to impaired nutrition, especially in patients with heavy infection.
  • Pregnant females with hookworm infection are associated with low birth weight.

Stool examination

Treatment

  • Albendazole is the first line of treatment for hookworms.[12]
  • Mebendazole is an alternative therapy; 100 mg twice daily for three days.
  • Another alternative therapy is pyrantel pamoate (11 mg/kg per day for three days, not to exceed 1 g/day).[13]
Necator Americanus, source: By Jasper Lawrence - I took the photograph using a Nikon E200 Trinocular microscope, an M99 microscope adaptor from the Martin Microscope Company (S/N3734), a D10NLC C-Mount manufactured by Diagnostic Instruments and a Sony HDV-A1U HD digital video camera., GFDL, https://commons.wikimedia.org/w/index.php?curid=4335265
Hookworm life cycle , source: By The original uploader was Sonett72 at English Wikipedia - CDC - Department of Parasitic Diseaseshttp://www.dpd.cdc.gov/dpdx/HTML/ImageLibrary/Hookworm_il.htmhttp://www.dpd.cdc.gov/dpdx/images/ParasiteImages/G-L/Hookworm/Hookworm_LifeCycle.gifOriginally from en.wikipedia; description page is/was here., Public Domain, https://commons.wikimedia.org/w/index.php?curid=1860052


Giardia lamblia

  • The prevalence of giardiasis is 20 to 40 percent in endemic areas.
  • The highest risk group for infection are children <5 years.[14]
  • Approximately, 15,223 cases were reported in the United States in 2012.[15]
  • Giardiasis is a major cause of diarrhea among mountains hikers who drink water that has not been boiled.[16]
  • Transmission of giardiasis can occur via ingestion of raw or undercooked food contaminated with cysts.[17]
  • Giardiasis can be transmitted via anal-oral sexual contact.[18]

Clinical presentation

Asymptomatic infection 

  • Most of the cases are asymptomatic.[19]

Acute giardiasis

Chronic giardiasis

Complications

Laboratory diagnosis

Antigen detection assays 

Nucleic acid amplification assays

  • Nucleic acid amplification assays (NAAT) detect Giardia in stool samples.[22]

Stool microscopy

  • Stool microscopy to detect Giardia can be specific but needs expert to examine the stool and needs intermittent excretion of Giardia cysts.

Treatment

Preferred agents
  • Tinidazole and nitazoxanide are the preferred drug for Giardiasis.[23]
  • Tinidazole has a longer half-life than nitazoxanide and may be administered as a single dose with high efficacy (>90 percent).
Drug Dose
Adults Children
Tinidazole 2 g orally, single dose Age ≥3 years: 50 mg/kg orally, single dose (maximum dose 2 g)
Nitazoxanide 500 mg orally two times per day for three days Age 1 to 3 years: 100 mg orally two times per day for 3 days

Age 4 to 11 years: 200 mg orally two times per day for 3 days Age ≥12 years: Same as adult dose

Giardia lamblia cytology, source: By Jerad M Gardner, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=15125058
, source: By CDC/Alexander J. da Silva, PhD/Melanie Moser - NIH, or CDC, or CDC PHIL #3394., Public Domain, https://commons.wikimedia.org/w/index.php?curid=3195726

Fasciola Hepaticum

  • Fasciola infection is endemic in Central and South America, Asia (China, Vietnam, Taiwan, Korea, and Thailand), Europe (Portugal, France, Spain, and Turkey), Africa, and the Middle East.
  • Children and women are the highest risk groups. It is highly infectious and in some endemic areas to the extent of infecting 100% of the individuals.

Clinical manifestations

  • Many infections are mild. Forms of infection include two phases; the acute liver phase and chronic biliary phase.[24]

Acute phase

Chronic phase

Complications

Diagnosis

  • Diagnosis of fascioliasis should be associated with evaluation of family members.[30]

Microscopy

  • The diagnosis can be established by identifying eggs in stool, duodenal aspirates, or bile specimens.[31]
  • Eggs are not detectable in stool during the acute phase of infection.
  • Examination of multiple specimens may be needed or concentration of specimens to facilitate egg identification.[32]

Serology

Imaging

Treatment

  • The treatment of choice is triclabendazole. Dosing consists of 10 mg/kg orally for one or two days. Bithionol and nitazoxanide are alternative choices.[35]

Schistosoma

  • The prevalence of schistosomiasis is highest in sub-Saharan Africa.[36]
  • Approximately 200 million people are infected annually with 200,000 deaths per year.

Clinical presentation

Acute schistosomiasis syndrome
Chronic infection
  • Chronic infection related to schistosomiasis is most common among individuals in endemic areas.[39]

Intestinal schistosomiasis

Hepatosplenic schistosomiasis

  • The left lobe of liver is enlarged with splenomegy that may extend below the umbilicus. Increased portal hypertension is due to high resistance in the hepatic circulation.[43]
  • The predominant pathological process consists of collagen deposition in the periportal spaces causing periportal fibrosis.[44]
  • This leads to occlusion of the portal veins, portal hypertension with splenomegaly, portocaval shunting, and gastrointestinal varices.

Pulmonary complications

  • Pulmonary manifestations of schistosomiasis occur most frequently among patients with hepatosplenic disease due to chronic infection with S. mansoni, S. japonicum, or S. haematobium.
  • Dyspnea is the primary clinical manifestation.[45]
  • Chest radiography demonstrates fine miliary nodules.[46]
Genitourinary schistosomiasis
  • In early infection, eggs are excreted in the urine and patients present with microscopic or macroscopic hematuria and/or pyuria.[47]
  • Blood is usually seen at the end of voiding terminal hematuria, although in severe cases hematuria may be observed for the entire duration of voiding.
  • In early chronic infection, the eggs provoke granulomatous inflammation, ulcerations, and development of pseudopolyps in the vesical and ureteral walls, which may be observed on cystoscopy and mimic malignancy.[48]

Laboratory findings

  • Eosinophilia is observed in 30 to 60 percent of patients. Eosinophilia is very common among patients with acute schistosomiasis infection.[49]
  • Anemia and thrombocytopenia may be observed secondary to splenic sequestration in an enlarged spleen.
  • Liver enzymes are near normal even if hepatic fibrosis occurred in most cases.
  • Hematuria may occur with S. haematobium infection due to deposition of eggs in the urinary bladder wall.
Microscopy
  • Identification of schistosome eggs in a stool or urine sample via microscopy is the gold standard for the diagnosis of schistosomiasis with low sensitivity and high specificity.
Infection intensity
Infection Intensity Egss per gram
Light 100 eggs per gram
Moderate 100 to 400 eggs per gram
Severe >400 eggs per gram
  • The intensity of urinary schistosomiasis is classified as:
    • Light to moderate: up to 50 eggs/10 mL
    • Severe: >50 eggs/10 mL
Serology
Molecular tests
  • PCR on urine samples noted sensitivity and specificity of 94 and 100 percent, respectively.
  • S. mansoni PCR sensitivity is 100 percent and specificity is 90 percent.[51]
Biopsy
  • Histopathology of superficial rectal biopsies is more sensitive than stool microscopy and may demonstrate eggs even when multiple stool specimens are negative.[52]

Treatment

Schistosoma mansoni egg, source: By US federal government - Work of US federal government, Public Domain, https://commons.wikimedia.org/w/index.php?curid=218201
Couple of Schistosoma mansoni, source: CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=55038168

Strongyloidis Stercoralis

  • In tropical and subtropical regions, the prevalence of Strongyloidis Stercoralis infection may exceed 25 percent.[55]
  • The highest rates of infection in the United States are among residents of the southeastern states and among individuals who have been in endemic areas.

Gastrointestinal symptoms

The most common manifestations of the hyperinfection syndrome include:[56]

Diagnosis

  • Aspiration of duodenojejunal fluid is sometimes used to detect Strongyloides larvae in patients with negative stool samples.[57]
  • Polymerase chain reaction tests have also been developed for detection of Strongyloides in stool samples and have been found to be more sensitive and more reliable in detection of S. stercoralis.

Serology

Endoscopy

  • Upper endoscopy is not usual diagnostic test. Strongyloidiasis has a broad range of endoscopic features:[59]
  • In the duodenum, the findings included edema, brown discoloration of the mucosa, erythematous spots, subepithelial hemorrhages, and megaduodenum.
  • In the colon, the findings include loss of vascular pattern, edema, aphthous ulcers, erosions, serpiginous ulcerations, and xanthoma-like lesions.
  • In the stomach, thickened folds and mucosal erosions are seen.[60]

Treatment

  • Ivermectin is the preferred drug for treatment. Administered as two single 200 mcg/kg doses of ivermectin administered on two consecutive days.[61]

Albendazole

  • Albendazole (400 mg by mouth on empty stomach twice daily for three to seven days) also has activity against Strongyloides.[62]
Strongyloides Stercoralis, source: Public Domain, https://commons.wikimedia.org/w/index.php?curid=219824

E. Histolytica (Amebiasis)

  • Areas with high rates of amebic infection include India, Africa, Mexico, and parts of Central and South America. The overall prevalence of amebic infection may be as high as 50 percent in some areas.[63]

Clinical presentation

  • The majority of entamoeba infections are asymptomatic; this includes 90 percent of E. histolytica infections.[64]
  • Clinical amebiasis generally has a subacute onset, usually over one to three weeks. Symptoms range from mild diarrhea to severe dysentery, producing abdominal pain (12 to 80 percent), diarrhea (94 to 100 percent), and bloody stools (94 to 100 percent), to fulminant amebic colitis.
  • Weight loss occurs in about half of patients, and fever occurs in up to 38 percent.[65]
  • Amebic dysentery is diarrhea with visible blood and mucus in stools and the presence of hematophagous trophozoites (trophozoites with ingested red blood cells) in stools or tissues.
  • Fulminant colitis with bowel necrosis leading to perforation, and peritonitis has been observed in approximately 0.5 percent of cases; associated mortality rate is more than 40 percent. Toxic megacolon can also develop.
  • Amebic colitis has been recognized in asymptomatic patients.[66]

Diagnosis

Stool microscopy

  • The demonstration of cysts or trophozoites in the stool suggests intestinal amebiasis, but microscopy cannot differentiate between E. histolytica and E. dispar or E. moshkovskii strains. In addition, microscopy requires specialized expertise and is subject to operator error.[67]

Antigen testing

  • Stool and serum antigen detection assays that use monoclonal antibodies to bind to epitopes present on pathogenic E. histolytica strains (but not on nonpathogenic E. dispar strains) are commercially available for diagnosis of E. histolytica infection.[68]
  • Antigen detection kits using enzyme-linked immunosorbent assay (ELISA), radioimmunoassay, or immunofluorescence have been developed.
  • Antigen detection has many advantages, including ease and rapidity of the tests, capacity to differentiate between strains, greater sensitivity than microscopy, and potential for diagnosis in early infection and in endemic areas.

Serology

  • Antibodies are detectable within five to seven days of acute infection and may persist for years.
  • Approximately 10 to 35 percent of uninfected individuals in endemic areas have antiamebic antibodies due to previous infection with E. histolytica.
  • Negative serology is helpful for exclusion of disease, but positive serology cannot distinguish between acute and previous infection.

Molecular methods

  • Techniques can detect E. histolytica in stool specimens.
  • Studies have shown that PCR is significantly more sensitive than microscopy and that it was 100 percent specific for E. histolytica.[69]
  • PCR is about 100 times more sensitive than fecal antigen tests.

Treatment

  • All E. histolytica infections should be treated, even in the absence of symptoms, given the potential risk of developing invasive disease and the risk of spread to family members.[70]
  • The goals of antibiotic therapy of intestinal amebiasis are to eliminate the invading trophozoites and to eradicate intestinal carriage of the organism.
Amebiasis life cycle , source: By CDC - https://www.cdc.gov/dpdx/amebiasis/index.html, Public Domain, https://commons.wikimedia.org/w/index.php?curid=41751982
Amoebic cyst, source: By CDC’s Division of Parasitic Diseases - http://dpd.cdc.gov/DPDx/HTML/ImageLibrary/Amebiasis_il.htm, Public Domain, https://commons.wikimedia.org/w/index.php?curid=5030067

Taeniasis

Taeniasis

  • There are two main species of human Taenia; Taenia saginata, the beef tapeworm, and Taenia solium, the pork tapeworm.[71]
  • T. saginata occurs worldwide but is most common in areas where consumption of undercooked beef is customary, such as Europe and parts of Asia.

Clinical presentation

Diagnosis

Treatment

  • Praziquantel is the treatment of choice for taeniasis.[72]
  • Dosing for taeniasis is 5 to 10 mg/kg orally (single dose), although excellent efficacy against T. saginata infections has been reported at doses as low as 2.5 mg/kg.[73]
  • Niclosamide is an acceptable alternative treatment for tapeworms if praziquantel is not available.
Taenia Saginata life cycle , source: By Centers for Disease Control & Prevention, National Center for Infectious Diseases, Division of Parasitic Diseases - Centers for Disease Control & Prevention, National Center for Infectious Diseases, Division of Parasitic DiseasesThe work compiled from original Life cycle of Taenia spp. - http://www.dpd.cdc.gov/dpdx/html/Taeniasis.htm, Public Domain, https://commons.wikimedia.org/w/index.php?curid=26668532

Trichuris trichiura

  • Trichuris trichiura is a round worm that causes trichuriasis when it infects a human large intestine.
  • It is commonly known as the whipworm due to the shape of the worm.

 Clinical manifestations

  • Most infections with T. trichiura are asymptomatic.[74]
  • Main symptoms are loose stool which may contain mucus and blood.
  • Nocturnal stooling is common. Colitis and dysentery occur most frequently among individuals with >200 worms, and secondary anemia with pica may occur.
  • Rectal prolapse can occur in heavily infested patients.
  • Children who are heavily infected may have impaired growth and cognition.

Diagnosis

Treatment

  • Mebendazole is the drug of choice for trichuriasis: 500 mg once daily for three days or 100 mg orally twice daily for three days.[77]
  • Albendazole is second-line treatment: 400 mg orally on empty stomach once daily.[78]
Trichuris Trichiura, source: By Delorieux for Johann Gottfried Bremser - XIX tabulae : Anatomiam entozoorum illustrantes, congestae, nec non explicatione praeditae, Public Domain, https://commons.wikimedia.org/w/index.php?curid=11412733

Hymenolepis Nana

  • Hymenolepis Nana is a species most commonly in temperate zones, and is one of the most common cestodes infecting humans, especially children.
  • The prevalence of Hymenolepis Nana is higher in warm parts of South Europe, Russia, India, US and Latin America.[79]
  • Prevalence is 97% in Moscow children and 34% in Argentina children. It has been reported to affect 4 percent of schoolchildren in rural southeastern United States.

Clinical manifestations

Diagnosis

  • The diagnosis is generally established by identifying eggs in the stool.
  • The sensitivity of stool microscopy can be increased by using concentration techniques such as the FLOTAC method.[81]
  • Diagnosis of hymenolepiasis should prompt family screening or empiric treatment, given the potential for person-to-person spread.

Treatment

  • Praziquantel is the treatment of choice for hymenolepiasis.[72]
  • Dosing for hymenolepiasis is 25 mg/kg orally (single dose), followed by repeat dose 10 days later.[73]
Hymenolepis Nana life cycle , source: Public Domain, https://commons.wikimedia.org/w/index.php?curid=2936828

References

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  73. ↑ 73.0 73.1 Pawłowski ZS (1990). "Efficacy of low doses of praziquantel in taeniasis". Acta Trop. 48 (2): 83–8. PMID 1980572.
  74. ↑ Forrester JE, Bailar JC, Esrey SA, José MV, Castillejos BT, Ocampo G (1998). "Randomised trial of albendazole and pyrantel in symptomless trichuriasis in children". Lancet. 352 (9134): 1103–8. PMID 9798586.
  75. ↑ Forrester JE, Bailar JC, Esrey SA, José MV, Castillejos BT, Ocampo G (1998). "Randomised trial of albendazole and pyrantel in symptomless trichuriasis in children". Lancet. 352 (9134): 1103–8. PMID 9798586.
  76. ↑ Phuphisut O, Yoonuan T, Sanguankiat S, Chaisiri K, Maipanich W, Pubampen S; et al. (2014). "Triplex polymerase chain reaction assay for detection of major soil-transmitted helminths, Ascaris lumbricoides, Trichuris trichiura, Necator americanus, in fecal samples". Southeast Asian J Trop Med Public Health. 45 (2): 267–75. PMID 24968666.
  77. ↑ Rossignol JF, Maisonneuve H (1984). "Benzimidazoles in the treatment of trichuriasis: a review". Ann Trop Med Parasitol. 78 (2): 135–44. PMID 6378109.
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  79. ↑ Utzinger J, Botero-Kleiven S, Castelli F, Chiodini PL, Edwards H, Köhler N; et al. (2010). "Microscopic diagnosis of sodium acetate-acetic acid-formalin-fixed stool samples for helminths and intestinal protozoa: a comparison among European reference laboratories". Clin Microbiol Infect. 16 (3): 267–73. doi:10.1111/j.1469-0691.2009.02782.x. PMID 19456836.
  80. ↑ Muehlenbachs A, Bhatnagar J, Agudelo CA, Hidron A, Eberhard ML, Mathison BA; et al. (2015). "Malignant Transformation of Hymenolepis nana in a Human Host". N Engl J Med. 373 (19): 1845–52. doi:10.1056/NEJMoa1505892. PMID 26535513.
  81. ↑ Steinmann P, Cringoli G, Bruschi F, Matthys B, Lohourignon LK, Castagna B; et al. (2012). "FLOTAC for the diagnosis of Hymenolepis spp. infection: proof-of-concept and comparing diagnostic accuracy with other methods". Parasitol Res. 111 (2): 749–54. doi:10.1007/s00436-012-2895-9. PMID 22461006.
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