Cestode parasites

Medical Parasitology,

Professor Marshall Lightowlers, Principal

Research Fellow, Faculty of Veterinary
Science. He has been striving towards the
parasites eradication for almost 30 years.
http://blogs.unimelb.edu.au/musse/?p=381

Tapeworms: the Cestodes

They are flat in cross

section
Hermaprhoditic
Live in the intestines
with feces
Life cycles are complex
and can include multiple
intermediate hosts
No mouth, no
digestive system
They have suckers and
teeth that grasp the host.
Reproductive structures
http://www.ndpteachers.org/perit/biology_image_gallery1.htm
Behind a short neck are
repeated parts of the worm, each containing reproductive structures with
eggs and sperm, which can be released with the host's feces.
The pieces give the worm a ribbon-like structure, beneficial for absorbing
nutrients from the intestine.

CESTODES
Order pseudophyllidea:

have scolex with bothria; the sperm

whale tapeworm, H. physesteris, can be > 30 m long; the genital pore and
uterine pore are located on the mid-ventral surface, and the ovary is bilobed
("dumbbell-shaped"); each segment has 4-14 complete sets of genitalia, can
be up to 45,000 segments in a worm

Diphyllobothrium sp.
Diphyllobotrium latum

Order cyclophyllidea: most important group of tapeworms of

humans and domestic animals, multiple proglottid, scolex ("head") with four
suckers. Proglottids have genital openings on one side (except the family
Dilepididae, which has them on both sides), and a compact yolk gland or
vitellarium posterior to the ovary; can be small (a few mm's) or large (up to 10
m); mammals serve as intermediate hosts

Family Taeniidae:Taenia saginata, Taenia solium,

taenia multiceps; Echinococcus granulosus, E.
multilocularis
Family Hymenolepididae: Hymenolepis diminuta,
Hymenolepis nana,

HOSTS
The tapeworm life cycle involves a definitive host and one or
more intermediate hosts (IH).
Exception: Hymenolepis nana only uses one
host and D. latum has 2 IHs
INTERMEDIATE: ingests the eggs
which develop into larval forms and
later into encysted forms in
extraintestinal tissues. Each parasite
species has specialized larval forms.
DEFINITIVE: Harbors the mature
forms of the parasite. Carnivorous or
omnivorous mammal that acquires
infection by consuming larval cysts in
the uncooked tissues of an IH

Tapeworms
scolex
neck

strobila

The body plan of adult

cestodes includes a scolex
(looks like the head), a
neck and strobila that can
extend for only a few
proglottids or thousands
The strobila is not truly
metameric though as
several organs like the
excretory system extend
through the entire worm
Proglottid: each individual
segment
Most worms are very long:
occupying the entire length
of small intestine

Morphology of tapeworms:
The scolex

Scolex of Taenia Solium.

http://www.denniskunkel.com/product_info.php
?products_id=813

The scolex is the part of the

worm that anchors it to the
intestinal epithelium and
prevents that the worm is
passed with the digested food

The scolex structure varies

between species of tapeworms.
a. Diphyllobothrium latum has
a scolex with elongated, slit-like
attachment organs (bothria)
b. Taenia saginata has four
muscular SUCKERS.
c. Taenia solium has similar
muscular SUCKERS and a
ROSTELLUM with rows of
chitinous hooks.

Scolex of Diphyllobothrium latum.

Scolex of Taenia Saginata

Strobila
In most cestodes the scolex is tiny when
compared to the strobila which makes up
most of the actual worm
The strobila consists of a linear series of
proglottids
Tape worms are hermaphrodites and each
proglottid carries a set of female and male
reproductive organs
These segments are released and are
eliminated with the feces of the host.

*(Magnifications are based on a 35mm

slide image of 24mm in the narrow
dimension.)
http://www.denniskunkel.com/product_in
fo.php?products_id=813

Strobila

Strobilation: asexual
process of forming
segments
New proglottids are
continuously formed in the
neck just below the scolex
(A)
Along the length of the worm
the proglottids increase in
size and maturity, developing
from premature (B) to mature
(C, carrying fully functional
and active sexual organs), to
the gravid stage (D) in
which essentially the entire
proglottid is filled with the
uterus and eggs

The tegument
Cestodes do not have a
mouth or any form of
intestine
The entire uptake of
nutrients occurs through
multinucleate syncytial
tegument.
In reflection of this
important role in uptake
the absortive surface is
highly enlarged by small
microvilli or microtriches
Microfilaments (actin
polymers) are the
molecular backbone of
microtriches

Developmental stages: the egg

Eggs

larval stages (IH)

adult forms (DH)

Eggs

With very few exceptions vertebrates are the

Diagram of oncosphere of Hymenolepis diminuta, dorsal view

final host harboring the adult tape worms

Many invertebrates and vertebrates are
parasitized as intermediate hosts
The embryonate egg contains the oncosphere
a larva that will penetrate the intestinal wall after
eggs are swallowed by intermediate host
The oncospheres of eucestoda have three
pairs of hooks which makes it easy to identify
them

The egg of the pseudophyllidean

tapeworm (left) has a thin shell wall
and an operculum, which on hatching
opens to release the free swimming
larvae. In contrast, the egg of the
cyclophyllideans tapeworms (right) has
a very thick, resistant egg shell, with no
operculum. The eggs of T. saginata and
solium are similar. CDC

Developmental
stages

The zygote develops into

an oncosphere
In some species with
aquatic hosts the inner
envelope develops into a
ciliated epithelium.
These motile coracidia
have to be taken up by an
intermediate host within a
short time
Once inside the gut of the
host the oncosphere
sheds the ciliated layer
and invades and
differentiates into a
procercoid

Developmental stages
(metacestodes)

(D. latum)

(D. latum)

(T. solium)

(Hymenolepis sp.)

(E. granulosus)

In pseudophyllidean
cestodes the larvae look
fairly similar to the adult.
The first host is infected
by a procercoid which
still carries the larval
hooks
In the second host a
plerocercoid forms (there
is no asexual
amplification)
The cyclophyllidean
larvae are more complex
and come in a quite a
variety
The medically important
larvae are cysticercoid,
cysticercus and hydatid
(some of these larvae
provided amplification)

Developmental stages

The cyst was defined as a hydatid cyst after the

pathological diagnosis. Having been reevaluated
as a primary focus, liver profile and abdominal
ultrasonography findings were normal; and
serological tests results were negative. Hydatid
cyst in inguinal region was accepted as a primary
cyst. Gulten Kiyak, Mehmet Ozer, Recep Aktimur
& Ahmet Kusdemir: Primary Hydatid Disease of
the Soft Tissue: The Internet Journal of Surgery.
2006; Volume 8, Number 2.

Most
cyclophyllidean
cestode larvae (or
metacestodes) are
some form of a liquid
filled bladder with an
invaginated scolex
(and this theme is
the varied in many
ways)
In most cases the
adult is very well
adopted to the host
and causes no
damage, it is the
larvae that are
dangerous
pathogens

Development in the Definitive

host
Eggs
larval stages (IH)
adult forms (DH)
Eggs
In the small intestine of the DH, the juvenile worm excyst,
evaginate, or both.
Digestive enzymes from the host s gut may play a role in the
release of the organisms from their cyst. Temperature is also
important.
Development of the strobila is influenced by size of the
juvenile, worm species, size and diet of the host, presence of
other worms, and immune and/or inflammatory state of the host
Carbohydrates in the diet are important for the growth of the
worm. Polysaccharides able to release glucose are ideal.
Glucose or a disaccharid containing glucose, such as sucrose
are not as good.
As a worm approaches maximal size, growth rate decreases.
T. saginata may live in a human for more than 30 years.

CESTODES
Order pseudophyllidea:

have scolex with bothria; the sperm

whale tapeworm, H. physesteris, can be > 30 m long; the genital pore and
uterine pore are located on the mid-ventral surface, and the ovary is bilobed
("dumbbell-shaped"); each segment has 4-14 complete sets of genitalia, can
be up to 45,000 segments in a worm

Diphyllobothrium sp.
Diphyllobotrium latum

Order cyclophyllidea: most important group of tapeworms of

humans and domestic animals, multiple proglottid, scolex ("head") with four
suckers. Proglottids have a yolk gland or vitellarium posterior to the ovary; can
be small (a few mm's) or large (up to 10 m); mammals serve as intermediate
hosts

Family Taeniidae:Taenia saginata, Taenia solium,

taenia multiceps; Echinococcus granulosus, E.
multilocularis
Family Hymenolepididae: Hymenolepis diminuta,
Hymenolepis nana,

Diphyllobotrium latum - the fish tape

worm-Life cycle
Common in fish
eating carnivores
with little host
specificity. Salmon,
trout, perch, white
fish, eel, pike, etc.
Adults get quite long
(10 m) and shed up
to a million eggs per
day
Eggs must reach
water for
embryonation
After several days a
coracidium hatches
through the
operculum and is
eaten by a copepod

http://www.dpd.cdc.gov/DPDx/HTML/Diphyllobothriasis.htm

Diphyllobotrium
latum - the fish tape
worm

The coracidium is eaten by the

copepod (First Intermediate Host)
It looses its ciliated coat and once
through the intestine and into the
hemocoel, it develops into the
procercoid in 3 weeks ( 500 m)
with a cercomer at the posterior
end
The copepod is weakened by the
parasite and less motile
The procercoid can not develop
any further until is eaten by a fish.
The larvae penetrate the small
fish gut (Second Intermediate
Host) and migrates in the muscle
Here it grows and matures into
the plerocercoid

Diphyllobotrium latum - the fish tape

worm

Mature plerocercoids can be easily seen

as white masses in uncooked fish
If host fish is eaten by other fish
plerocercoids will migrate into muscle of
new fish host (paratenic host)
The plerocercoid develop into immature
and then into mature adult tapeworms in
the small intestine.
About 9 million people infected (was
wide spread in northern Europe and
Japan, more cases in the US due to
sushi, sashimi and ceviche)
Infection occurs through raw fish dishes
or handling (tasting) of fish dishes
before cooking
Infection rate can be locally quite high,
especially when untreated sewer is led
into lakes (there are also reservoirs in
many carnivores)

Diphyllobotrium latum the fish tape worm

Diphyllobothrium latum (broad fish

tapeworm)
http://animaldiversity.ummz.umich.edu/site/reso
urces/Grzimek_inverts/Cestoda/Diphyllobothriu
m_latum.jpg/view. html

Definitive host:fish-eating
carnivores:dogs,bears, humans, etc.
Infection of humans cause no or little
symptoms (abdominal discomfort,
nausea diarrhea are rare)
The parasite takes up large amounts of
Vitamin B12
In patients with genetic deficiencies in
Vit B12 uptake the parasite competes
effectively for the entire vitamin leading
to severe pernicious anemia
Geographic distribution: Northern
Europe, Chile, Japan, Korea North
America

Diphyllobotrium latum - the fish tape

worm
Diagnosis through detection of
characteristic eggs in feces
These eggs are oval or ellipsoidal
an operculum (arrows) at one end
that can be inconspicuous. At the
opposite end there is a small knob
that can be barely discernible
The eggs are passed in the stool
unembryonated. Size range: 58 to
76 m by 40 to 51 m.
Treatment with praziquantel

Proglottids of
Diphyllobothrium
latum. These
proglottids tend to be
passed in strands of
variable length in the
stool. The proglottids
tend to be broader than
long. Image
contributed by Georgia

TAENIA SAGINATA
Beef tapeworm
Ranges in length from 6-30 ft
Geographic distribution:

Taenia
saginata
adult
worm.

cosmopolitan.
Most common where poor sanitation
and no inspection of meat combine
Africa and South America
Transmission: Ingestion of larval
form in undercooked beef
In N. America 1 in 100 is infected. In
third-world nations could be up to 10%
No symptoms or some abdominal
discomfort
Diagnosis: finding eggs or
proglottids in feces

(A) Adult T. saginata in the ileum of a 25-year-old patient. Reflux of barium into the terminal ileum during
a barium enema examination revealed a markedly elongated ribbon-like radiolucent shadow
representing the adult tapeworm. (B) Adult T. saginata recovered intact following its passage after a
vermifuge was administered. Note the extraordinary length of this worm, which may at times reach 20-30

Taenia life cycle

Humans are the only

DHs

The eggs can survive

for days to months in
the environment
The adult worm
attaches by their
scolex to the human
small intestine.
The adults produce
proglottids passed
with stool
The eggs are released
after the proglottids
are passed with the
feces

TAENIA
SOLIUM
The armed
scolex of T.
solium (note
hooks on top
of scolex).
CDC

T. solium has a scolex (A) with four suckers and a double

crown of hooks, a narrow neck, and a large strobila (2-4 m) (B)
consisting of several hundred proglottids.
About 2 months after ingestion, proglottids begin to detach from
the distal end and are excreted in the feces.
Each segment contains 50-60,000 fertile eggs.

The Lancet (2003) 361: 547

Taenia pisiforme, Scolex. Hakenkranz hnlich

dem der T. solium (Mit freundlicher Genehmigung Roche
AG):
http://www.infektionsnetz.at/test/bilder/mikroskop/taenia_pis
iforme_r.jpg

TAENIA SOLIUM

Endemic in less developed countries

where pigs are raised as food source. Latin
America, most of Asia, sub-saharan Africa,
and parts of Oceania.
Infection with the adult forms of the
parasite produces similar symptoms to
infection with T. saginata.

The Lancet (2003) 361: 547

Cysticerci: (A) as seen in infected

pork; (B) excised into a Petri dish.
The white dot in each cyst
corresponds to the scolex. The
Lancet (2003) 361: 547.

Human cysticercosis
When humans plays the role of the
Intermediate Host

Larval stages develop in the human host

Humans acquire cysticercosis through faecal-oral contamination with T. solium

eggs
The oncosphere in the eggs is released by the action of gastric acid and
intestinal fluids
Cross the gut wall and enter the bloodstream
They are carried to the muscles and other tissues
They encyst as cysticerci at small terminal vessels (1 cm) (A) and (B)
Neurocysticercosis and ophtalmic cysticercosis

Racemose Cysticercosis-MRI

MRI of multiple
cysts. Image
courtesy of the
Centers for Disease
Control and
Prevention.

Neurocysticercosis
The parasite infects the CNS
Epileptic seizures (58-80% when parenchymal

brain cysts).
Intracranial hypertension, hydrocephalus, or both.
This syndrome is related to the location of parasites
in the cerebral ventricles or vasal cisterns.
Occasionally a cyst may grow larger (giant cyst)
Racemose form: high mortality. Large translucent
vesicle lobulated without scolex which develops in
the basis of the brain or in the ventricles.
Sometimes several small vesicles surround a
pedicle like a bunch of grapes.
Geographical variation in clinical manifestations

From: NEJM (2001) 345:879

Neuroimaging: MRI of viable (A) and degenerating (B) cysts and CT of calcified cysticerci. The Lancet (2003) 361: 547

Cysticercosis diagnosis
Serologic diagnosis:
Antibody assays for cysticercosis: 8
kDa antigens, GP50, FAST-ELISA
with the 8 kDA antigen
Antigen-detection assays: circulating
antigens means live parasites.
Ongoing viable infection. Monoclonal
antibodies seem to detect AGs in
CSF.
Antibody assays for taeniasis:
TSE33 and TSE38 were recognized
by a panel of taeniasis but not
cysticercocis, patient serum samples.
Neuroimaging diagnosis: CT and
MRI provide objective evidence on
number and location of cysticerci. Also
their viability and the severity of the host
inflammatory reaction.

MRI showing parenchymal (A) and

extraparenchymal (basal ccs) (B) viable NCC.
MRI showing
calcified cyst with
surrounding
edema

Cysticercosis treatment
Treatment should be individualized based on
cyst location, level of inflammation and clinical
presentation
Therapy should include analgesics, antiepileptic
drugs, cysticidal drugs, surgical resection of
lesions and placement of ventricular shunts
Parenchymal cysticercosis with viable cysts:
Albendazole 15 (mg/kg/day) with
dexamethasone (0.1 mg/kg/day). Praziquantel.
Subarachnoid ccs: antiparasitic therapy
No reason to use antiparasitic drugs to treat
dead calcified cysts. Symptomatic therapy.
Surgical therapy: ventricular shunting to resolve
hydrocephalus. Also excision of giant cysts or
intraventricular cysts

Albendazole

Transmission
It is not possible to acquire NCC by eating pork!
Ingestion of infected pork only causes adult
tapeworm infestation: taeniasis. WHY?
Infected pork contains only the larval cysts that
develop into adult worms in the human intestine
What is that transmits CCS?
The eggs
Most common source of infective eggs?
A symptom-free tapeworm carrier in the household

Echinococcosis
Echinococcus multilocularis:
alveolar echinococcosis.

Invasive solid
lesions of firm consistency, full of connective
tissue and a jelly-like material.

Echinococcus granulosus: cystic

echinococcosis.

Produces cystic lesions

Echinococcus granulosus the dog tape worm

Adult E. granulosus adult worms live in the intestine of dogs

They produce eggs which are shed with the feces
Eggs are infective to herbivores (and humans)

Echinococcus granulosus
The oncosphere
penetrate intestine
of intermediate host
and develops into a
hydatid
Hydatides are
spherical fluid-filled
cysts surrounded by
a granuloma formed
by the host

The Hydatid Cyst

The cyst is lined by a multilayer parasite tissue

with the innermost layer being the germinal layer
This layer is a undifferentiated stem cell layer
that can spawn the formation of brood capsules
which are themselves lined by GL
The daughter cysts (the encircled body) "bud"
into the center of the fluid-filled cyst.
This is a very small portion of the cyst which may
become quite large.
Each of the smaller bodies will develop into
diminutive tapeworms should this be eaten by a
definitive or final host such as a canine.

The Hydatid Cyst

Thousands of
protoscolices can fill the
hydatid (hydatide sand)
Protoscolices are the
infective stage for dogs
Hydatides usually grow
slowly but steadily (1-5
cm per year)
They are usually well
tolerated until their size
becomes a problem or
they rupture
Cyst rupture or leakage
can result in allergic
reactions and metastasis

Echinococcosis:
Cystic hydatid disease
Hydatides can be
found in several
organs but are most
frequent in the liver

Hydatid cyst in human:

http://cal.vet.upenn.edu/dxendopar/parasitepages/cestodes/e_granulosus.htm

Echinococcosis:
Cystic hydatid disease
Liver cysts cause liver
swelling, right epigastric
pain, nausea, vomiting
Obstruction of bile ducts and
blood vessels can cause
cholangitis, jaundice,
cirrhosis and portal
hypertension

This upper abdominal CT scan shows multiple cysts in the liver, caused
by echinococcus. Note the large circular cyst (seen on the left side of
the screen) and multiple smaller cysts throughout the liver.
http://www.drkoop.com/ency/93/ImagePages/1177.html

Echinococcosis:
Cystic hydatid disease

Lung cyst are often well tolerated but

obstruction and or rupture can cause
chestpain, cough and dyspnea
The first symptoms of brain cyst is often
focal epilepsy
Diagnosis is by serology, radiology, CT
scans and sonograms.
Treatment is surgical. Prognosis
depends on size and location of
hydatide (mortality is around 5-10%)
Hydatide is often injected with sterilizing
fluids to avoid metastases
Benefit of chemotherapy is inconsistent

Echinococcosis control

Sylvatic and domestic strains.

Strains adapted to dogs &
sheep are more aggressive
upon human infection
Ecchinococcosis can be
locally quite important
Control of feral dogs, limit
access of dogs to sheep offal,
treat pet dogs regularly
Effective control programs in
many countries including
New Zealand, Tasmania,
Cyprus and Iceland

Echinococcus multilocularis - the

fox tape worm

Sylvatic zoonosis in
Europe and northern
America
Fox is final host, life
cycle similar to E.
granulosus
Humans get infected by
eating contaminated
berries and mushrooms
collected in forests
populated by foxes

Hymenolepis nana the dwarf tape worm

Hymenolepis nana
occurs relatively
frequently world
wide and is usually
an infection of
children
An intermediate
host is not required
and autoinfections
occur frequently
Cysicercoids
develop in the
lymphatics of villi
Alternatively
infection through
cysticercoids in
insects that
contaminate grains
or cereal

Hymenolepis nana the dwarf tape worm

Usually asymptomatic (very
high burden can lead to
unspecific gastrointestinal
symptoms
Infections are cleared with
adolescence
Diagnosis by demonstration
of characteristic eggs
(accidental infections with H.
diminuta the rat tape worm)

STAGE FOUND
COMMON
IN HUMANS
NAME
Diphylobothrium lutum Adult
Fish tapeworm

Pernicious anemia

Niclosamide; Praziquantel

Hymenolepis nana

Adult

Dwarf tapeworm

Rarely symptomatic

Niclosamide; Praziquantel

Taenia saginata

Adult

Beef tapeworm

Rarely symptomatic

Praziquantel

Taenia so lium

Adult

Pork tapeworm

Rarely symptomatic

Niclosamide; Praziquantel

Brain and tissue

cysts

Albendazole; Surgery

SPECIES

Larvae

PAT HOLOGY

THERAPY

Echinococcus
granulosus

Larvae

Hydatid cyst
disease

Solitary tissue cysts

Surgery; Albendazole

Echinococcus
multilocularis

Larvae

Alveolar cyst
disease

Multilocular
cysts

Surgery; Albendazole