Dracunculus medinensis

Dr. Subhash Chandra Parija

MD , PhD, DSc, FRCPath
Dean (Research) , JIPMER

Taxonomy
Phylum Nematoda
Class Secernentea
Order Spirurida
Family Dracunculidae
Dracunculus medinensis
Dracunculus medinensis
Guinea worm, medina worm, or serpent worm
The traditional symbol for a doctor is the serpent
wound round a stick.
This has always been supposed to be a snake but a
more serious suggestion is that the creature is the
guinea worm and the sign of a healer is a man who
can get rid of the worm.

Morphology
Adult worms
Female
One of the largest nematodes known
Milky white, slender worm
Measure 50-120 cm x 07-1.7 mm
In anterior end, a minute triangular mouth is
present
They are viviparous
Uterus is filled with thousands of eggs, embryos
and first stage larvae


Morphology
Male
Measures 15-40 mm x 0.4 mm
Die immediately after fertilizing the females

First-stage larva
Unsheathed and coiled with round
anterior end and long slender
filariform tail

Larva
Hosts
Definitive Host: Humans
Intermediate Host: Cyclops (Mesocyclops
leuckarti, M. hyalinus)
Life cycle
Life Cycle
Source: Water containing infected cyclops
3
rd
Stage larva released in stomach and then reaches
small intestine
After fertilisation the female migrates into tissues
On contact with water the female releases large
number of first stage rhabditiform larvae
The larvae are ingested by cyclops
In the cyclops it undergoes 2 moults to develop into
third stage larvae
Cyclops harbouring the third stage larvae infects the
human host and the cycle continues



3 Mandatory Conditions
Skin of infected persons must come into
contact with water
Water must have cyclopoid crustacean
Water must be used for drinking
Pathology and Clinical Signs
Three major disease conditions can
occur from Dracunculus infection:
1. Emergent adult females cause hot
and painful blisters
2. Secondary bacterial infections
3. Nonemergent worms that die
under skin cause allergic reactions that
could lead to death
Pathology
Bacterial infection can cause ulcers and
abscesses to develop, which are very
painful and can cause disability for
extended periods of time
About of the cases are complicated by
bacterial infection of ulcers
Application of antibacterial agents to ulcers
is important in case management
Pathology
Bacterial infection becomes more serious
when the bacteria are drawn under the skin
by a receding worm
In parts of Africa, this is the 3
rd
most common
mode of entry for tetanus spores.
Other complications that can occur are:
synovitis, arthritis, and bubo.

Pathology
Sometimes when worms do not
emerge, they begin to degenerate and
release antigens. Which cause aseptic
abscesses, which can also lead to
arthritis.
Abscesses can be BIG, holding up to
Liter of fluid
More commonly the worms become
calcified.
Pathology
Nonemergent worms can cause
problems within tissues deeper in the
body.
Although many die and become absorbed
or calcified, without much apparent effect
on the host.
Chronic arthritis is common if the worm
is calcified alongside or in a joint.
More serious symptoms, like paraplegia,
result from the worm in the CNS.

Host Immune Response
Allergic reaction occurs due to the release of
metabolic wastes from the worm.

This may cause a rash, nausea, diarrhea,
dizziness, and localized edema.

Reinfection may occur. No immunity.
Clinical manifestations
Pre-patent period: 10-14 months
Asymptomatic until the female worm reaches the skin
surface
Papule which develops into a blister is the first sign
Blisters are usually found on the legs between the
metatarsal bones, on the sole and on the ankles
Intense burning pain at the site of blister
Urticaria, nausea, dyspnoea, giddiness
Secondary bacterial infection



Geographical distribution
Once prevalent in 20 nations of Asia and Africa

But now endemic only in
Sudan, Mali, Ethiopia (Africa)
Saudi Arabia, Iran and Yemen (Middle East)

India was declared free from this disease in 2000 by WHO

In 2010 - < 1800 cases were reported worldwide

94% of the cases are found in South Sudan
Asia, Africa, Indonesia
Diagnosis
Parasitic diagnosis
First stage larvae can be observed in the
discharge fluid
Adult worm can be detected when it appears at
the surface
Serodiagnosis
IHA, IFA, ELISA

Imaging methods
X-ray demonstrates dead and calcified parasites
Treatment
Winding the protruding worm on a stick has been a
successful treatment since antiquity.

Because the worm protrudes only a few centimeters per
exposure to water, this procedure takes, on average,
three weeks to completely remove the worm.

The worm can also be removed surgically, and some
drugs are used, but the evidence for their effectiveness is
dubious.

Thiobendazole or Mebendazole enables rapid emergence
of the worms and quick healing
Control/ Prevention
The most important strategies for the
eradication of Dracunculus have been:
1. Supply of safe drinking water.
Boiled or filtered water
2. Health education.
3. Early case containment.
4. Vector control.
(Temephos, is a chemical that has low toxicity to
mammals and fish, but kills copepods for 4-5 weeks at a
concentration of 1ppm)
Control/Prevention
Onchocerca volvulus
Family Onchocercidae
Causes river blindness
Transmitted by female black flies of the
Simulium damnosum complex
Affects 40 million people mainly in Tropical
Africa and South America.
Second major cause of blindness in the
world.
Onchocerca volvulus
Onchocerca volvulus
Simulium
damnosum
The black fly
Definitive host-Man
Intermediate host- Female black flies of
genus Simulium
They are pool feeders and suck in blood and
tissue fluids
Life-cycle
Life cycle
Life cycle
Microfilariae migrate to thoracic muscles of fly
Develop into filariform (infective stage)
Infective stage migrate to the mouth parts.
Extrinsic incubation period is -6 days.
Life span of adult worm in human host is
about 15 years.
Life span of microfilariae- 1 year.

Diagnosis
Skin snips for
microfilaria with
oculoscleral biopsy
forceps
UN Development Program, World Bank, and
WHO funded the OnchocerciasisControl
Programin 11 West African countries, 1974-
2002 (extended to 2007)
African Program for OnchocerciasisControl in
19 central African countries, 2000-2010
Goal: Disease elimination through drug
therapy
Control of Onchocerciasis

Stop black fly transmission of parasite
to humans
Over time, the human reservoirof
parasites decreases
9-11 year parasite life cycle, 14-20
years of insecticide applications needed
>35,000 miles of river sprayed weekly

Strategy of Vector Control:
Ivermectin is the drug of choice.

DEC causes the Mazzotti reaction- pruritus,
rash, lymphadenopathy, fever, hypotension,
and eye damage.
Treatment
Loa loa
Loa loa
Also called 'eye worm
Causes Calabar swellings
Currently endemic in west and central
Africa.
Adult worm- 30-70x 0.3-0.5mm
Sheathed microfilariae.
Vector- Chrysops


Chrysops
Calabar swellings
Affecting the conjunctiva
Diagnosis
Adult worm- removal from the skin or
the conjunctiva
Microfilaria- peripheral blood collected
during the day.
Treatment Surgical removal of the
adult worms.