welcome back let's continue along with
wrong rooms let's talk about the next
parasite now hookworm hookworm is a very
important parasite throughout the world
because it's one of the major causes of
iron deficiency anemia because the worm
basically hooks onto your intestines and
sucks out the blood causing you to lose
a lot of blood in the process the two
main species that affects humans nakida
americanus and a cyclist Summa or an
cyclists amador denali what's the life
cycle of the parasite very similar to
what we talked about in oscar is you can
be infected not by GI or by contaminated
food and drink in this case but through
the skin but it's similar to Oscars in
the in the in in terms of light love in
the lungs so what happens inside you
walking around barefoot in in the area
where hookworm is endemic
the larvae burrows through the the feet
and you can get a rash or a allergic
type reaction where the room Brewers or
the lava bar is through those your soles
of the feet and again like oscar is
there's something what these parasites
that where they really love the lungs
they go to the lungs they affect the
alveolar furs they move from the
alveolar to the bronchial tree from the
bronchial tree they migrate up to the
trachea you swallow it
the larvae mature into adult worms and
the adult worms lay the eggs and then
the cycle continues from the soil etc
but the problem is when you're laying
that when the larvae are in the GI
system and they mature into adults the
adults hook on to the small intestines
and they suck on all this blood and and
as I said it's the most common cause of
iron deficiency anemia in the world
because of these teeth that the hookworm
or plates that the hookworm have as a
hookworm migrate through the lungs like
in oestrus it can also cause pulmonary
symptoms as well so you can diagnose it
by eye on the deficiency anemia as a
clue but mainly over and parasitic no
analysis in
the stool is how we and diagnosed most
of these infections so my foolin
dissection is that one of the most
common causes of iron deficiency anemia
in the world is due to hookworm
infection and here's you can see the
nice hookworm with all these pointy
little teeth here waiting to suck the
blood from your small intestines let's
move on to another case now a related
case this is a case of dog hookworm not
the human hookworm that we talked about
this is a 23 year old returning traveler
with pain on the right foot returning
from Thailand you can see like this is
certainly a worm like object sort of
moving around in this on her feet and
these are the the lateral aspect of her
feet by her fifth toe and and here it is
here so this is what we call visceral
larva migrans visceral because it's on
the viscera and not on the entrails on
the insides really lava because lava is
the life stage at which we're talking
about in terms of this parasite and
migrants because it's migrating so this
is dog hookworm causing visceral larva
migrans it's not human hookworm
so not Nicator or any of the other
species we talked about and this is the
hookworm that dog sket so a lot of vets
are exposed to this particular infection
people you know I had patient ones who
went to Jamaica and she was volunteering
in a dog pound and when she came back
she had what looked like a worm moving
around in her silver feet but actually
it was not human hookworm it was dark
oak causing visceral lava migrants so
what happened as I said you walk around
the dogs the adult worms in the dog have
the adult dog hookworm worms have laid
eggs they infect the soil they walk
around the soil or contaminated feces
etc and the dog will come gets into you
is trying to find the dog lungs but
there are no dog lungs in you so it's
kind of moving around the body trying to
find it
but ultimately it fails and because it
can't complete its life cycle it dies
but you can
from the pictures that you know as it
moves over I can cause this kind of
intense reaction that can be quite et
and an inflammatory but if you don't do
anything they eventually die and you
don't even need antiparasitics for the
most part although many people feel
nervous and they end up taking some sort
of antiparasitics let's move on to the
next case now this is another parasite
and a typical patient is a 55 year old
renal transplant patient presenting with
fever cough and abdominal pain on blood
cultures the patient looks like he or
she is septic and you get two organisms
in a blood culture both of these
organisms come from the gut these are
ecoli Enterococcus and what the picture
shows is this weird rash on the the
abdomen of the patient it kind of looks
very like that there's a lot of you know
inflammatory reaction they are a very
very almost petechial in appearance so
this is strong Louise how do you get
stronger ladies well like hookworm it
comes in through the skin so you walk
around contaminated soil the strong
galati's gets in and like hookworm and
like ascaris it loves along so the first
place that kind of goes to is the lung
goes to the bronchial ego-c alveolar
area then it goes up the bronchial tree
goes up the trachea you swallow it then
the larvae mature into adult worms the
worms lay eggs and this is where strong
galati's is a little bit different so
stronger Louise is the only parasite
where you can actually complete its
entire lifecycle in the human and it
could be a long time between when you
get exposed to strong alloyed ease and
when you get diseased so what happens is
that as a adult worms mature in the GI
tract making lots of eggs these eggs can
hatch into these larvae and the larvae
can actually borrow straight from the
mucosa back to the lungs but it
also if you are in your suppress migrate
to all parts of the body including the
brain the skin and as the eggs come out
through the eggs hatch into larvae and
they come out through the anal area they
can also go through the anal area into
your body again back to the lungs and to
other parts of the body so an
immunocompromised hosts it can be quite
severe with very disseminated disease
and if people become immuno compromised
after not being immuno compromised
initially say like Vietnam vets who in
Southeast Asia many decades ago who
exposed to strong ladies and now they're
immunocompromised maybe because they've
gotten a transplant or maybe because
they have COPD and they're on a lot of
steroids the strong galati's can come
back and it come back comes back in
terms of being having a high rate of
replication and this auto infection can
occur very very frequently and hyper
infection which means a lot more
parasites can also occur affecting many
organs including the lungs of course the
GI tract the skin the brain and other
organs as well so but most people don't
even know they have strong galati's it
causes very mild symptoms of any and
only when you're in your compromised if
you have severe AIDS or HIV disease if
you are iatrogenic Liam you're
compromised because you're
transplantation we've received I mean
your suppression meds if you have a
certain types of malignancies like htlv
those are people who are going to get
this strong alloy teas like crazy which
we call hyper infection syndrome because
you can auto infect yourself in that way
how do you diagnose it well you can
diagnose it by stool onp like many of
these parasites but when somebody has
hyper infection syndrome or and as a
result of auto infection you can get
strong galati's all over the place so
you can get it on the BL sample you can
get it and the urine you can get in the
GI tract and you can see these worms
which make kind of like this S shape s
was for strong Lloyd ease as well
but many times we diagnose it through
serology which is pretty sensitive in
most cases to diagnose this infection if
you haven't reached the stage where
you're making lots and lots of parasites
that going the that are moving all over
the body you treated with ivermectin and
and that's probably one of the the main
power sites that we we see here pretty
often because of our large
immunocompromised population where
people might have been exposed some time
ago you know where if they were born in
another part of the world for example so
the skin rash that strongly
causes is called lava currents so lava
currents is Latin for racing lava or
running lava so remember we talked about
another kind of word with lava in it
cutaneous lava migrants which was
associated with dog hookworm this kind
of rash is called lava currents just
because they move a little bit faster
than the QT Nehemiah grants of dog
hookworm so when you see these strong
Lloyd E's and the skin they generally in
people who are immunocompromised and
they have lots and lots of strong ladies
if you biopsy this rash you see the worm
inside the biopsy so let's review the
transmission so you walk around you get
stronger Lloyd YZ worm or larvae from
the soil that goes still long just like
ascaris and hookworm these three
organisms love the lung and then from
the lungs I you it migrates up to the
trachea you swallow the the larvae and
in the gut they migrate into adult worms
and they lay more eggs so what happens
in strong alloys again it's the only
parasite or one of the few parasites
where you can auto infect yourself and
you don't need some other host or the
parasite doesn't need to leave the body
to then complete its life cycle if it
can complete its life cycle inside of
you so from the gut as the larvae exits
the body you can have larvae burrowing
back into the perianal area and then
going back to the lungs and then you
swallow it again so that
how Auto infection happens but then what
can happen in terms of immunosuppression
is that from the lungs as the lobby
moved to the gut they can move to all
parts of the body and that's really
what's called hyper infection syndrome
so we can get hyper infection syndrome
because we can auto infect ourselves and
when you are in your suppressed you can
get tons and tons of parasites occurring
and as these parasites occur they can
actually put holes in in the gut as they
try to migrate and the gut bacteria can
then go into the bloodstream causing
these super infection with bacteria
because the bacteria come from the gut
so just to just review the case that we
presented in this immunocompromised
patient the patient presented with
bacterial sepsis because the worms were
borrowing through the gut and making
little holes where gut bacteria can then
go into the bloodstream so what the
patient presented with wasn't a worm
issue it seemed like it was a bacterial
issue but it was because the worm caused
the problem in the first place so what
are my pills for this section well first
of all you couldn't diagnose
Strongyloides by serology or by fining
the larvae and not the eggs in the stool
my main pin when we looked for eggs but
in strong galati's we look for larvae
because larvae away all the action
occurs strong Elodie's can completes
life cycle in humans as opposed to many
of the other parasites and you can get
sepsis from enteric bacteria as the
larvae penetrate the gut poking holes in
the gut and having the bacteria that
live in the gut
normally moved from the gut into the
bloodstream so let's move on to the next
case the next parasite in this section
this patient is a 45 year old male
presenting with high fever muscle pain
throg white count is 12
with 55% eosinophils very significant
anything above 20% is particularly
significant in terms of usin affiliate
this guy turns out to be a boar hunter
so this parasite is Trichinella it's a
wrong room how do you get it
well you ingest it typically in its
larval insisted stage so these larvae
like to wall and
Soph and assists these cysts occur in
striated muscle so people are affected
our people are hunters particularly in
hunters of wild pigs for example or
beers of Cougars and and if the meat is
undercooked
you can ingest intact larvae essentially
in the cysts form in the meat what
happens is that the larvae then moved to
the gut they mature into adult worms
they leave the eggs the eggs hatch they
turn into larvae and then the larvae
migrate into muscle where it's its
preferred home and again it Ward's off
itself into the cysts form and this
process really is what causes the
disease and so here's another patient
who's a bear hunter in this case and the
weak one you can get mainly nausea
abdominal pain as they are mainly in the
GI system and as the larvae migrate out
of the GI system to the muscle striated
muscles and to other areas and in that
process of migration you can get some
other symptoms so peeing of the muscles
of Myositis or periorbital edema
particularly prominent symptoms that you
can find with Trichinella how do you
diagnosis whether you can diagnose it by
seeing an increase in CPK is because of
that muscle inflammation as well as well
as is an affiliate like in this case
with this percentage of eosinophils
above 20%
you can also diagnose it by serology and
it's oftentimes diagnosed by biopsy as
well and if you biopsy the muscle you
can find the wrong room in this larval
stage insisting itself and in the muscle
as well so that's the way it's
frequently diagnosed this is periorbital
edema very very notable not common but
notable for in trichinosis again because
of this inflammatory response as a mark
larvae are migrating to muscle let's
move on to another parasite this is a
typical case or a typical case of the
kinds of cases we might see you're
working in Haiti and a 39 year old woman
presencia clinic with six months of
progressive lower extremity swelling so
you can see this particular kind of
swelling or mainly it's lower
extremities here it's very prominent we
call it elephantiasis as well
this is fuller Isis so fuller Isis is
caused by round room called which each
area Bancroft II and what happens is
that the mosquito in this case spreads a
parasite it goes straight to the lymph
nodes and it may take up to a year or so
to develop in the lymph nodes to adults
what happens as the adults meet and they
release the parasites and it's
microfilaria stage this gets into the
bloodstream so you can diagnose the
infection by the microfilaria and the
blood stream and it's particularly
common in parts of Africa Asia and the
Caribbean like Haiti as in this case the
Pacific Islands where I spend some time
for example there are lots of WTO
campaigns eliminate filariasis by
eliminating mosquitoes as well as trying
to find people and diagnose them by
microfilaria and giving them
antiparasitics so again one of these CDC
maps showing you the life cycle but
essentially as in contrast to many of
the other parasites we talked about you
have the mosquito basically being
infected and then infecting the human
these microfilaria go to the lymph nodes
they hang out there
the adults hang out in the lymph nodes
and it's because of this lymph node
granuloma formation inflammation that
happens that's really why the disease
causes because the lymph nodes get
blocked and because the lymph can't get
back up to where it's supposed to be and
the circulation gets compromised you get
a lot of fluid really backed up like a
traffic jam
so you can get screwed Earl edema leg
edema and that's really what causes many
of its symptoms of filariasis so again
like I said clinically you can see
lymphedema particularly in the legs and
scrotum you diagnose it when you see the
microfilaria stage in the
stream you can get a blood thin smear
actually to find these microfilaria or
you can ultrasound the lymphatics to
find the adult forms as well so to
summarize these parasites we've talked
about a lot of wrong rooms in this
section this slide is really meant to be
a review you can see that many of them
love the lungs
you can review hookworm Strongyloides in
this case and ascaris and then some of
the other parasites as well thank you
very much for your attention
you