N.I. Pirogov Vinnitsya National Medical University

Ministry of Healthcare of Ukraine

N.I. Pirogov Vinnitsya National Medical University

Department of Infectious Diseases

Approved

at the methodical meeting

«__» ______20__

Head of the Department, prof. Moroz L.V.

WORKBOOK

for practical training on infectious diseases for 5-year students of medical departments ( the topic of which is included in the plan of classroom training).

Topic 4.2:

CESTODIASISTREMATODIASIS.

Prepaired by: assistantMedvedevaL.S.

2009

1. Relevance of the topic:

Cestodiasis - invasions caused by representatives of tapeworms — cestodes: diphyllobothriasis, teniarinhoze, taeniasis, hymenolepiasis, echinococcosis, alveococcosis and others.

Diphyllobothriasis is spread around the globe, mainly in the areas with a moderate climate. In Russia, difilobotriasis is an endemic pathology for pools of northern and Siberian rivers, the Volga region, the Kola Peninsula, Sakhalin, Far East. In Ukraine, diphyllobothriasis is present in the Danube Delta and the basin of the Dnieper (Dnieper reservoirs).

Teniarinhoze can be found on all continents of the globe. Areas of high endemicity are the regions with livestock development. Teniarinhoza cases are recorded to be present in the Caucasus, Central Asia, Kazakhstan, Yakutia. In Ukraine, there are isolated cases of infestation.

Taeniasis and cysticercosis are registered in the areas of pig breeding development. In Ukraine, isolated cases of infestation are reported.

Hymenolepiasis is spread all around the globe.

Echinococcosis can be found everywhere, especially in the regions with livestock development. In Ukraine, echinococcosis is regularly registered in Odessa, Mykolayiv, Donetsk, Kherson, Zaporozhye and other areas of the Autonomous Republic of Crimea.

Trematodiasis - invasions caused by representatives of flukes - trematodes: opisthorchiasis, fascioliasis, etc.

Opisthorchiasis - one of the most common human helminthiasis. In Ukraine, a fairly significant focuses of opisthorchiasis are found in the basins of the Dnieper, Desna, Southern Bug, Seversky Donets. There are recorded cases of opisthorchiasis infection in 20 regions of Ukraine.

Fascioliasis is usually registered in humans in the form of sporadic cases, however, in tropical climate zones the number of infected people can reach high level.

2. The aim of the course (with an indicating level of adoption of the program):

2.1.A student must understand (learn): a-1

• have a general understanding of the place of cestodiasis and opisthorchiasis in the structure of infectious diseases, prevalence in different regions of Ukraine and the world, learn the statistical data on the sickness rate, lethality, complication rates.
• learn the history of the scientific study of cestodiasis and opisthorchiasis, have an understanding of the scientific contribution of Ukranian scientists in the history of scientific research in this field.

2.2. A student must know: а-2

–rules for hospitalizing patients with cestodiasis and trematodiasis;

–etiology of cestodiasis and trematodiasis, pathogen virulence;

–epidemiology of cestodiasis and trematodiasis;

–life cycle of cestodes and trematodes;

–basic processes of pathogenesis of cestodiasis and trematodiasis;

–clinical manifestations of the different phases of cestodiasis and trematodiasis;

–specific and non-specific laboratory diagnosis of cestodiasis and trematodiasis;

–principles of treatment and prevention;

–therapeutic approach for helping a patient in the events of emergency conditions;

–convalescent discharge process rules and prophylactic medical examination.

2.3. A student must know how to: а-3

–collect medical history with the assessment of epidemiological data;

–examine the patient and identify the main symptoms and syndromes of cestodiasis and trematodiasis;

–make a differential diagnosis of cestodiasis and trematodiasis;

–make a plan of laboratory and additional inspection of the patient;

–interpret the results of the laboratory tests;

–analyze the results of specific diagnostic methods;

–make an individual treatment plan considering the epidemiological data, stage of disease, complications, condition severity, allergic history, concomitant pathology;

–make a plan of antiepidemic and preventive measures in the nidus of infection;

–give an advise on the treatment, diet, medical examination and the observation in recovery period.

2.4. Creative level (for most capable and trained students): а-4

Develop creative abilities of students in the process of conducting clinical researches and during analysis of scientific sources: get involved in a scientific study group of the faculty; suggest topics for essays about the most pressing issues, for example: “Perspectives for the study of helminthiasis as etiological factors of oncological diseases”, etc.

1. Educational aims (personality development):

• Develop a deontological view. Know and be able to follow the principles of medical deontology. Master the ability to establish psychological contact with the patient and his family.
• Develop an understanding of the impact of social hygiene factors on the prevalence of cestodes.
• Develop a sense of responsibility for the timeliness and accuracy of professional activities.

4. Intersubject integration.

Discipline / Know / Know how to
Foregoing disciplines
Biology / The morphology of cestodes and trematodes, their form, means of life, biological life cycle / Identify helminths by the shape, assess the means of invasion
Physiology / The characteristics of physiological norms of human organs and systems; norms of the laboratory examination (CBC, urine, biochemistry of blood, etc.) / Evaluate the results of the laboratory examination
Pathophysiology / The mechanism of organ and system malfunction in pathological conditions of various origins / Interpret pathological changes based on the results of laboratory examination
Epidemiology / An epidemic process (source, infecting mechanism,way of transmission) of cestodiasis and trematodiasis; prevalence of the disease in Ukraine and in the world. / Collect an epidemiologic evidence, conduct an antiepidemic and preventive measures in the nidus of infection, fill in an emergency report to SES and epidemiological survey map.
Immunology and allergology / The basic concepts of the subject, role of the immune system in the infectious process, an effect on the period of eliminating the helminth from the human body. Immunological aspects of the disease course / Evaluate the results of the immunological research
Surgery / Clinical and laboratory signs of rupture of cysts, appendicitis, peritonitis, liver cancer, intestinal obstruction, first aid tactics / Diagnose these complications, assign an appropriate examination, provide emergency care
Neurology / Pathogenesis, clinical characteristics of toxic encephalopathy, meningism, eclampsia / Carry out the clinical examination of the patient with affection of CNS
Ophthalmology / Clinical and laboratory characteristics of eye-lesion, first aid tactics / Diagnose these complications, assign an appropriate examination, provide emergency care
Internal diseases propedeutics / Methods and rules for conducting the clinical examination of the patient for the detection of cestodes and trematodes / Obtain the medical history, conduct the clinical examination, determine the presence of pathological symptoms, evaluate the data of the clinical examination
Pharmacology / Pharmacokinetics and pharmacodynamics of drugs used in the treatment of cestodiasis and trematodiasis, possible side effects. / Choose an effective drug, prescribe an adequate dose and taking frequency
Therapeutics / The main clinical symptoms of diseases that occur with lesions of the gastrointestinal tract, respiratory tract, anemia, etc / Evaluate the data of the clinical examination of the patient, diagnose the patient, assign a laboratory examination, make a differential diagnosis.
Consecutive subjects
Family medicine / Epidemiology, pathogenesis, clinical course of cestodiasis and trematodiasis, possible complications, principles of treatment and prevention / Make a differential diagnosis of cestodiasis and trematodiasis with other nosologies.Idetify cestodiasis and trematodiasis, complications, interpret the results of laboratory tests (blood count, methods of specific diagnostics); provide emergency care
Interdisciplinary integration
Infectious diseases. / Characteristics of infectious diseases. Principles of diagnosis, treatment and prevention of infectious diseases. Epidemiology pathogenesis, clinical symptoms of various phases of cestodiasis and trematodiasis pathogenesis, possible complications. Criteria for the diagnosis, treatment principles (etiotropic, pathogenetic and symptomatic therapy), preventionism. / Carry out a differential diagnosis of cestodiasis and trematodiasis with other infectious and non-infectious diseases, identify cestodiasis and trematodiasis, complication, interpret the results of laboratory tests (clinical and specific diagnosis). Prescribe the treatment. Provide emergency care in the prehospital phase.

5. The content of the course.

1. Cestodiasis and trematodiasis etiology. Structural features of the worm. Pathogenicity factors.
2. Trematodiasis epidemiology at the present stage.
3. Pathogenesis.
4. Clinical characteristics, features of modern treatment of cestodiasis and trematodiasis Pathogenesis and complications.
5. Laboratory diagnosis. The possibility of early diagnosis. Regulatory documents of MOH of Ukraine regarding analysis of stool for the presence of helminth eggs. Emphasize the importance of modern highly sensitive and specific immunological diagnostic methods.
6. The problem of chronic carriers of the pathogen.
7. Treatment of patients. Emergency care in case of complications.
8. Convalescent discharge process rules and prophylactic medical examination.
9. Principles of prevention.
10. At the end of the course sort out a number of unsolved problems, their interdisciplinary significance, emphasize the importance of extracurricular training of students, the use of independent information search for answers on questions that arose during the practice session.

5.1. The content of the topic

DIPHYLLOBOTHRIASIS

Etiology / Broad tapeworm (Diphylobotrium latum)
Epidemiology / Zoonosis. Oral biogelmintoz
The source of infection and the final host– a human, a dogand other
First intermediate host – freshwater crustaceans
Second intermediate host – freshwater fish (pike, perch, trout)
Infection of humans - not properly heated fish and spawn
Pathogenesis / Mechanical effect
Attachment to the wall of the small intestine → mucous membrane bothria suction → atrophy and necrosis of the mucous membrane / Toxicoallergic effect
Metabolic products sensitization of helminth → self-sensitization → endogenous hypo- and avitaminosis В12 and folic acid →
 / 
Clinical picture
Complications / asthenia, dizziness
signs of gastrointestinal tract affection
discomfort during meals
 dynamic or obturation intestinal obstruction
megaloblastic anemia
В12 and folate anemia / Chronic low-gradefever, stoxicosis symptoms, allergic skin eruption;
Tachycardia , hypotension, dilatation of the heart, systolic murmur
Diagnostics / hyperchromic anemia
hypo- or gastric achylia
bilirubinemia (indirect), hypoproteinemia,
microscopy of faeces: finding eggs or fragments of strobila
Treatment
Causal treatment / Pathogenetic therapy
praziquantel
albendazole,
phenasalum / treatment of anemia
Prevention
protection of the environment from faecal contamination
preventing the fire formation on hydraulic work construction site
thermal treatment of fish and spawn before food consumption

TENIARINHOZE

Etiology / Beef tapeworm (Taenairhynchus saginatus)
Epidemiology / Anthroponosis. Oral helminthiasis
The source of infection and the final host– a human.
Intermediate host – cattle
Transfer factor – not properly heated meat
Pathogenesis / small intestine: Finn is released and attached to the mucous membrane, after 2 months becomes mature, produces segments with eggs
-
Clinical picture / right iliac fossa pain – proglottids pass through Ileocecal valve
nausea, impaired appetite (anorexia replaces bulimia ), weight loss
flatulence, loose stools
epigastric pain
active passing of proglottids, more often at night tim / general signs of toxicity
asthenia
undue fatigability
sleep disturbance
irritability
headache
dizziness
Complications / acute appendicitis, pancreatitis, cholecystitis
intestinal obstruction and ileus
hypo-, anacidic gastritis
obstructive jaundice
anaemia
Diagnostics / Clinical methods
-eosinophilia, hyperchromic anemia
contrast x-rays of the digestive tract / Specific methods
microscopy of eggs and segments of the helminth in the feces
Treatment
praziquantel
albendazole,
phenasаlum
Prevention
preventing the pollution of pastures and water with human feces
veterinary and sanitary control
proper thermal processing of beef

TAENIASIS AND CYSTICERCOSIS

Etiology / Pork tapeworm (Taenia solium)
Epidemiology / Anthroponosis.
Oral biogelmintoz
The source of infection and the final host– a human.
Intermediate host – pigs, cats, dogs, human
Transfer factors - raw or half-baked pig meat with Finns
Pathogenesis / Taeniasis
pork tapeworm Finns in 2-3 months → mature helminth
↓ / Сysticercosis
Ingestion of eggs →larvae emerge in the stomach→penetration of the capillaries→ enters the brain, myocardium, skeletal muscle, subcutaneous tissue, →encapsulation→infiltration, vasculitis
↓
mechanical effect
mucous membrane damage in the fixing place of parasite
irritation of interoceptors
violation of the absorption process
intoxication
sensibilization / -mechanical effect on tissue
allergic reactions
increased signs of toxicity
↓ / ↓
Clinical picture / moderate dyspepsia symptoms and toxic syndrome / Clinical manifestations depend on the location (brain, eyes, skin, subcutaneous tissue, muscles)
Clinical methods
cysticercosis / hemogram: mild eosinophilia
ophthalmoscopy
tissue radiography, CT
surface biopsy
Taeniasis / finding segments in the feces
faecal analysis of helminth
Complications
taeniasis / praziquantel, albendazole
cysticercosis / praziquantel, albendazole, surgical
Prevention
sanitary measures
pig keeping hygienic requirements
veterinary control of pork

HYMENOLEPIASIS

Etiology / Dwarf tapeworm (Hymenolepis nana)
Epidemiology / Oral contagious helminthiasis.
The source of infection – a human
Intermediate host – rodents (rats)
Transfer mechanism - fecal-oral
Transfer factors - vegetables, fruits, household things, cockroaches, flies
Pathogenesis / Larvae leaves the egg → penetrates the small intestine villus → cysticercoids maturation , falls into the intestinal lumen, hooks to the mucous membrane → produces eggs in the environment or repeats the same cycle in the intestine (autoinvasion)
Mechanical effect
edema, intestinal hyperaemia
dystrophy, necrosis of epithelium, ulceration
enzymatic systems affection, violation of digestion
-disbacteriosis / worm metabolites cause intoxication and sensitization
violation of liver antitoxic funtion and protein synthesis
gastric acid secretion
↓ / ↓
Clinical picture / gastrointestinal lesions
nausea, vomiting
salivation
abdominal pain
unstable stool
mild hepatomegaly / affection of central nervous system
asthenia, fatigability
headache, irritability
dizziness
epileptiform attacks
sensitization
pruritus, urticaria
vasomotor rhinitis, angioedema
asthmatic bronchitis
Complications / disbacteriosis
Diagnostics / hemogram: mild eosinophilia
faecal analysis on helminth
Treatment / praziquantel,
albendazole
phenasаlum
Prevention / sanitary-educational work
personal hygiene

ECHINOCOCCOSIS

Etiology / Pathogen - larvae Echinococus granulosus
Epidemiology / Zoonosis. Oral biogelmintoz.
2 types of nidus:
1. natural (wild herbivores - deer, roe deer and wild predators - wolves, foxes)
2. synanthropic - farm animals (sheep and goats) and dogs (final host)
Pathogenesis / Eggs in food → larvae is released and attached to the mucous membrane of the duodenum → passes through the wall of blood vessels, enters the liver, lungs, etc. → cyst formation, local inflammatory response
↓ / ↓
Toxicoallergic effect
-echinococcus metabolites effect,
-host proteins absorption, development of mimicry,
-immunosuppression / Local tissue damage
compression of the surrounding tissue, trophic disorder
necrosis, granulation
connective tissue replacement of dead cells
Clinical picture / asthenia, fatigability
headache
rise of temperature
dyspeptic symptoms
skin eruption, pruritus
Latency phase from several months to decades
Liver (localization)
сaudate lobe of liver → / jaundice (bile duct compression)
diaphragmatic surface of liver → / pain on the right side of the chest, shortness of breath
closer to the Glisson capsule → / right upper quadrant pain
on the anterior surface of the liver → / during palpation - fixed, dense, tumor formation
lungs→ / dyspnea
chest pain
cough
brain → / signs of brain tumor development
Complications / Rupture of hydatid cysts → anaphylactic shock
↓
dissemination of scolices
acute inflammatory reaction (peritonitis, meningitis, pleurisy)
cyst suppurating → abscess
during prolonged invasion → amyloidosis in parenchymal organs
hydatid disease (50%) – 3 stages: jaundice, cirrhosis, portal hypertension
liver – massive bleeding
brain – epileptiform seizures, blindness, paralysis and paresis
ovaries – fallopian tubes rupture, bleeding
Diagnostics / hemogram: leukocytosis, anemia, eosinophilia, ESR acceleration
X-ray, CT, MRI
DS
angiography, bronchography, cholecystography
serological tests (CFT, IHA, immunoelectrophoresis)
Treatment / basic method - surgery
albendazole
Prevention / personal hygiene
helminthological study and dehelmintization of dogs

OPISTHORCHIASIS

Etiology / cat liver fluke
Opisthorchis felineus
Epidemiology / Naturofocal zoonosis. biogelmintoz
Final host – a human and animals
(cats, dogs, pigs)
Intermediate host – freshwater mollusc Bithynia; cyprinidae
Transfer factor - the fish (raw or salted), which contains live larvae (metacercariae)
Pathogenesis / Metacercariae → biliary duct → gallbladder → intrahepatic bile ducts and pancreatic ducts
↓ / ↓
Early acute phase
The toxic effect of the larvae decay products → toxicoallergic reactions (increased vascular permeability, perivascular edema, impaired trophic tissue) → damage of biliary and pancreatic ducts (local inflammation, impaired outflow of bile and pancreatic enzymes) / Late chronic phase
allergic effect of helminths (Allergic hepatitis with cholestasis → telangiectasia, chronic hepatitis → cirrhosis,
 cholangitis cholangiocarcinoma pancreatitis → canaliculitis, fibrosis)
toxic effect
mechanical effect (violation of the secrets outflow caused by mucus, helminth)
Clinical picture / ↓ / ↓
diarrhea, allergic rash, liver pain
asymptomatic disease course / pain in liver and gall bladder
dyspeptic symptoms
hepatomegaly
yellow sclera
Complications / liver abscesses, cellulitis and gallbladder, biliary peritonitis, primary liver cancer
chronic cholangitis, cholecystitis, hepatitis
rupture of the parasitic cyst
stomach and duodenal ulcers
sclerosis of the biliary, major duodenal papilla, jaundice
Diagnostics / hemogram: leukocytosis, eosinophilia
biochemical methods: increased bilirubin, ALT, AST, LF, amylase, lipase, trypsin, dysproteinemia, hyperglycemia
increased amylase in urine
hypo- or gastric achylia желудочного сока
bile ovoscope
serological tests (Chronicle opisthorchiasis): IHA, ELISA, etc.
Treatment / chloxylum
praziquantel
pathogenetic therapy
Prevention
environmental protection (water reservoirs)
extermination of mollusks
sanitary control over the manufacture of fish products

Fascioliasis

Etiology / Common liver fluke (Fasciola hepatica)
Epidemiology / Naturofocal zoonosis.
Oral biogelmintoz.
The source of infection and the final host– a human, large and small cattle, rodents
Intermediate host – freshwater mollusc
Transfer factors - water plants, garden vegetables
Pathogenesis / Fasciola larvae penetrates mucous membrane of the small intestine → liver and bile ducts, pancreas, brain, eyes and other.
↓ / ↓
Acute migratory phase
toxicoallergic effect of helminth metabolic products
→ liver - eosinophilic infiltration, necrosis of hepatocytes / Chronic phase
toxicoallergic effect of helminth metabolic products
→ mechanical effect
↓
biliary dyskinesia, congestion, bile duct obstruction, hemorrhage, necrosis → secondary microflora, inflammation
cholecystitis, cholangitis
pancreatitis
gastrointestinal tract disorders (digestion, absorption) → increased peristalsis → malabsorption syndromes
Clinical picture
Acute phase / Subacute phase
(after several weeks) / Chronic phase
General toxic and allergic symptoms
rise of temperature
skin eruption
arthralgia
hepatomegaly, jaundice / paroxysmal abdominal pain in the liver, gallbladder, pancreas
large liver mass, jaundice
diarrhea, weight loss, anemia диарея
боли в области печени и желчного пузыря
secondary microflora
↓ / ↓
Complications / anemia
cachexia / suppurative cholangitis, cholecystitis, gallbladder phlegmon
liver abscess , jaundice, liver fibrosis
acute pancreatitis
myocarditis
Diagnostics / hemogram: leukocytosis, anemia, eosinophilia
biochemical methods
increased ALT, AST, bilirubin, dysproteinemia
specific diagnosis
serological methods (ELISA, TPHA)
faecal analysis of helminth
Treatment / chloxylum
praziquantel
Prevention
avoid eating aquatic plants
boil water
protection of water sources from faecal contamination
sanitization of infected animals

6. Organizational structure and planning of the course.