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GI Week 4 - WLB > GI Parasites - Zimmer > Flashcards

GI Parasites - Zimmer Flashcards

1
Q

What is the main mechanism that parasites cause disease?

A
  • Microbial proliferation and invasion
    • growth and spread of microbes that causes damage that is significant in illness.
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2
Q

What are the basic common features of GI parasites and parasitic infections?

A
  • A worldwide issue
    • Good sanitation in US make us less vulnerable
  • Children hit severely
    • High mobility
    • Poorer standards of hygiene
    • Multiple parasites at the same time
    • Malnutrition makes them more vulnerable
  • Gradual onset of symptoms
  • Infections are commonly long lasting or chronic (or have the potential to become so)
  • Malnutrition a common feature of chronic parasitic GI infections
    • Childhood malnutrition
  • Infected individuals are often asymptomatic
  • Morbidity and mortality depend on
    • parasite burden
    • species
    • preexisting immunity
    • patient comorbidities
  • Rate of parasitic infection is increasing in U.S. due to:
    • international travel
    • immigration
    • children in day care
    • AIDS and the immunocompromised
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3
Q

What is the best way to prevent parasitic infection?

A
  • Whether GI parasites are primarily water-borne, zoonotic, or live in soil, transfer from fecal material or from perianal region is an essential part of transmission
    • Adequate disposal and treatment of human waste
    • Adequate treatment of drinking water
    • Hand washing, food washing
  • Be aware during travel and after
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4
Q

What are the three protozoan (unicellular eukaryotes) parasites that we need to know?

A
  • Entamoeba
  • Giardia
  • Cryptosporidium
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5
Q

What are the Helminths (multicellular eukaryotes) that we need to know?

A
  • Nematodes → Roundworms
    • Ascaris (giant roundworm)
    • Trichuris (whipworm)
    • Enterobius (pinworm)
    • Ancylostoma/Necator (hookworm)
    • Strongyloides
  • Cestode → Tapeworms
    • Diphyllobothrium
    • Echinococcus
    • Taenia
  • Trematodes → Flukes
    • Schistosoma
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6
Q

What are the common symptoms of parasitic infections?

A
  • Stomach/intestinal cramps, gas and nausea
  • Fluid loss/diarrhea lasting longer than one week
  • Often noted upon return from travel
  • Onset gradual
  • Incubation period can be weeks
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7
Q

What are the typical treatments for parasitic infections?

A
  • Often don’t treat with drugs
  • Fluid replacement very important for treatment
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8
Q

What are the common preventions for parasitic infections?

A
  • Avoid contaminated water
  • Live somewhere with good sanitation
  • Practice good personal hygiene, and assume that others do not
  • Wash fruits and veggies
  • Vaccines are not available
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9
Q

What is the common method of diagnosis for parasitic infections?

A

Stool sample

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10
Q

What are the life cycle terminology differences for protozoa, nematodes, and cestodes/trematodes in mammal hosts and in the environment (i.e. excreted fecal matter)?

A
  • Protozoa
    • Host: Motile, replicating form (e.g. Trophozoites, Sporozoites, Trypomastigotes)
    • Environment: Cyst, Oocyst
  • Nematodes
    • Host: Juvenile and adult worms, sexually reproducing (Male and female worms)
    • Environment: Eggs, sometimes larvae
  • Cestodes/Trematodes
    • Host: Juvenile and adult worms, sexually reproducing, hermaphrodite (Schistosome an exception)
    • Environment: Eggs
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11
Q

How are the 3 protozoan GI parasites transmitted?

A
  • Water-borne
  • Or food contaminated with fecal matter
  • Or MSM and oral/anal sex
  • Ingesting cysts or oocysts
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12
Q

Where is Giardia lamblia (intestinalis) infection most likely?

A
  • About 10-fold more common in developing countries
    • 33% of individuals: developing countries
  • Also most common intestinal parasite in US
  • Giardiasis (aka Beaver Fever) is the foe of backpackers/hikers
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13
Q

What is the mechanism of infection for Giardia lamblia (intestinalis)?

A
  • Presence of parasite causes loss of epithelial absorptive surface area.
  • Other factors may play a role, not well understood.
  • Symptoms for 1-2 weeks or more, may seem to resolve and then come back
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14
Q

How is Giardia lamblia (intestinalis) infection diagnosed?

A
  • Ingest cysts
    • Trophozoites: Attachment to epithelials cells but not penetration in small intestines
  • Fecal matter = Cysts
    • cysts survive longer
  • Symptoms useful for diagnosis:
    • Foul-smelling diarrhea
    • Flatulance
    • Stools are greasy, tend to float (fatty)
    • Malabsorption of fat, lipids, some vitamins
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15
Q

What is the best way to prevent Giardia lamblia (intestinalis) infection?

A
  • Filter water in areas where Giardia cysts are likely to exist.
  • Water does not need to be contaminated with human sewage.
  • Wildlife can deposit cysts.
    • “Beaver Fever”
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16
Q

When is Cryptosporidium parvum infection seen?

A
  • Often seen when a sanitation system fails
    • Pool/waterpark chlorination/UV treatment
    • Storms or issues with drinking water
  • Diarrhea symptoms for 1-2 weeks to ~30 days, may seem to resolve and then come back
  • “Crypto” is opportunistic
    • HIV/Immunocompromised individuals
    • Chronic Diarrhea/fluid loss
    • Can be fatal
  • Cannot be immediately infectious → No direct oral-fecal transmission
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17
Q

What is the mechanism of Cryptosporidium parvum infection?

A
  • Absorption impaired and secretion enhanced when intestinal epithelial cells are infected by Cryptosporidium → Cryptosporidiosis
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18
Q

How do you differentiate the diagnosis of Cryptosporidiosis from Giardia?

A
  • Watery, frequent, non-bloody stool
  • Fever, sometimes. Nausea, sometimes.
  • Disrupts epithelial microvilli, slides into host cells, enveloping itself in the host cell membrane
    • Oocysts in feces → very small!
      • can be Acid-fast stained (turn red)
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19
Q

Cryptosporidium parvum belongs to which subclass of Apicomplexan protists?

A

Coccidia

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20
Q

Where is Entamoeba histolytica typically contracted?

A
  • More prevalent in tropical/subtropical climates
  • Only 10-20% of infected individuals will become ill (CDC)
  • Of US population, male homosexuals most vulnerable
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21
Q

What type of infection does Entamoeba histolytica cause?

A
  • Causes Amebiasis
    • AKA Amebic Dysentery, Amebic liver abscesses
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22
Q

How do you differentiate Entamoeba histolytica infection from other GI parasitic infections?

A
  • Bloody, mucus-ey loose stool
    • Relatively mild symptoms
  • Can invade the liver and form an abcess
  • X-ray/ultrasound to detect abscess or tissue damage
  • Must differentiate symptoms from bacillary dysentery!!!
  • Lab diagnosis: Cysts in stool sample.
    • Must differentiate from non-pathogenic entamoeba → takes a specialist
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23
Q

Why is bloody diarrhea/hepatitis common/possible in Entamoeba histolytica infection?

A
  • Cytotoxic
    • maximally tissue-invasive
    • adhere and kill
    • phagocytose
  • Mucosal cell invation
    • results in replication
    • cysts in feces
  • Blood vessel invasion:
    • Amebic hepatitis: single abscess in right lobe
    • should present with right upper quadrant pain, fever, weight loss
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24
Q

What are the antiparasitics targeting GI protozoans?

A
  • Nitroimidazoles
    • Metronidazole
    • Tinidazole
  • Nitazoxanide
  • Iodoquinol
  • Paromomycin
  • TMP-SMX (Trimethoprim Sulfamethoxazole)
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25
Q

What is the MOA of Nitazoxanide?

A
  • Interferes with pyruvate-ferredoxin oxidoreductase enzyme dependent electron transfer
    • essential to anaerobic energy metabolism protein
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26
Q

What is Nitazoxanide used to treat?

A
  • Cryptosporidosis
    • Cryptosporidosis often not treated in immunocompetent hosts
    • but Nitazoxanide effectiveness goes down in the immunocompromised
  • For Crypto, used in combination with retroviral therapy for AIDS patients if at all, because of ineffectiveness
    • HAART with immune reconstitution
  • Anti-peristaltic agents (Loperamide) and oral rehydration is important
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27
Q

What is the MOA of Iodoquinol?

A

Unknown

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28
Q

What are the toxicities of Iodoquinol?

A
  • Loss of visual acuity
  • Use with caution in patients with thyroid disease – its use interferes with certain thyroid tests
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29
Q

Why is the distribution of Iodoquinol beneficial?

A
  • only 10% of the drug is absorbed
    • works locally on the protozoa including cysts in the GI tract
    • luminal antiparasitic (amebicide)
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30
Q

What drug class does Paromycin belong to?

A

Aminoglycoside

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31
Q

What is the MOA of Paromycin?

A

Protein synthesis inhibitor = targets 30S subunit ribosome

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32
Q

What sort of toxicities are associated with aminoglycosides?

A

Ototoxicity, nephrotoxicity

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33
Q

Why can we use Paromycin on GI parasites and avoid the toxicities in patients?

A

It is a luminal antiparasitic

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34
Q

Why we need to consider absorption and tissue distribution in treatment of GI parasitic infections?

A
  • Entamoeba histolytica destroys tissue
  • A symptomatic infection means organism has invaded tissue, but also still at lumen
  • Luminal amebicide
    • Iodoquinol or Paromomycin
  • Tissue amebicide
    • Metronidazole or Tinidazole
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35
Q

What GI parasitic infections is Bactrim effective against?

A
  • Apicomplexans including:
    • Toxoplasma
    • Cystoisospora (formerly Isospora)
    • Cyclospora
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36
Q

When does Enterobius vermicularis (pinworm that is one of the roundworms) infection occur?

A
  • Worldwide distribution, most common helminth infection in US
  • Prevalence can reach 50% in children, caregivers of infected children, and institutionalized individuals.
  • Acquired by ingestion of pinworm eggs
    • Eggs can remain viable on surfaces for 2-3 weeks
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37
Q

Why do infections/outbreaks of Enterobius vermicularis (one of the roundworms) last a very long time?

A
  • Takes 1-2 months from egg ingesion to adult males and females
    • Adults live ~ 2 months
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38
Q

How is Enterobius vermicularis (one of the roundworms) infection diagnosed?

A
  • Hx of anal itching
  • Confirmation:
    • Tape or “pinworm paddle”- obtained eggs
    • Appearance of worms 2-3 hrs after person is asleep
    • A.M. Scotch tape method to pick up eggs from perianal region
    • Sample from under fingernails
    • Eggs will likely NOT be found in stool sample!
39
Q

What are the soil-transmitted roundworms?

A
  • Hookworms (Necator)
    • Southern US
  • Whipworms (Trichuris)
    • Southern US
  • Giant Roundworms (Ascaris)
    • Rarely in US
  • Strongyloides – much less common
    • Large North American Cities, Southern US
40
Q

How is Necator acquired?

A
  • Skin penetration
  • 9-11 mm (small staple size)
41
Q

How is Trichuris acquired?

A
  • Egg ingestion
  • 3-5 cm
42
Q

How is Ascaris acquired?

A

Egg ingestion

15-35 cm (spaghetti, a ruler)

43
Q

How is Strongyloides acquired?

A

Skin penetration

a few mm

44
Q

How does Necator americanus/Ancylostoma duodenale and Strongolides stercoralis cause symptoms?

A
  • Larvae in soil
  • Skin penetrations
    • barefoot
  • Circulatory system
  • Coughing/swallowing
  • Make home in small intestines
45
Q

What type of infection does Necator americanus/Ancylostoma duodenale and Strongolides stercoralis cause?

A

Cause hookworm and strongyloidiasis

46
Q

How are Necator americanus/Ancylostoma duodenale and Strongolides stercoralis diagnosed?

A
  • Stool sample for diagnosis:
    • Necator eggs
    • Strongolides larvae
47
Q

What type of rash does Necator americanus/Ancylostoma duodenale infection cause?

A

Pruritic Papular Erythematous Rash

48
Q

What is a major symptom of hookworms?

A
  • Hookworms are bloodsuckers…
  • Major symptom is iron-deficiency anemia
    • ¼ ml/day/worm
49
Q

What are the symptoms of Strongolides stercoralis (one of the roundworms) infection?

A
  • Stomach and GI complaints
  • Respiratory
    • dry cough
    • throat irritation
  • Skin
    • an itchy, red rash that occurs where the worm entered the skin
    • recurrent raised red rash typically along the thighs and buttocks
  • What makes it different:
    • Autoinfection possible, especially with Immunosuppressed individuals
50
Q

What diseases are caused by Trichuris trichiura (one of the roundworms)?

A

Whipworm or Trichuriasis

—2.2 million cases/yr in U.S.

51
Q

How do you diagnose Trichuris trichiura (one of the roundworms) infection?

A
  • Diagnosis:
    • —Eggs in feces have a characteristic barrel-shaped appearance
    • —Finger clubbing best indicator of severity of infestation
  • Bloody diarrhea = iron deficiency anemia
  • Heavy cases:
    • Frequent, painful stools with mucus, water and blood, tenesmus
    • Rectal prolapse
52
Q

Where does Ascaris lumbricoides (giant roundworm) cause infection?

A
  • About half of the populations in tropical and subtropical areas are infected with this parasite
  • 1 billion/yr affected
53
Q

What are the symptoms of Ascaris lumbricoides infection (Ascariasis)?

A
  • Disease: IF symptoms are experienced, abdominal discomfort
  • If a severe case, intestinal blockages
  • Ultrasonography and radiology to determine
  • Has a lung stage of life cycle, may cause cough
  • Chest radiograph of newly-infected individual may reveal infiltrate
54
Q

How do you diagnose Ascariasis?

A
  • Charcot-Leyden crystals
    • Charcot-Leyden crystals are formed from the breakdown of eosinophils and may be seen in the stool or sputum of patients with parasitic diseases. Cause may or may not be a parasitic infection, may be asthma.
  • Diagnosis: eggs w/thick shells
55
Q

What are the general goals for antiparasitic treatment of GI helminths (roundworm + tapeworm)?

A
  • Remove adult worms from the GI tract
    • Usually can be accomplished with drugs
  • In the case of severe blockages, imaging and surgery may be required
  • Multiple-helminth infections common
  • Mass drug administrations of albendazole and ivermectin to school children in developing nations
  • No vaccines
    • upcoming says NPR
56
Q

What are the selective toxicity strategies used to target/treat GI roundworms?

A
  • Exploit the biochemical differences between the parasite and host
  • Differentially distribute the drug.
    • The parasite is exposed to high concentrations of the drug in its intestinal habitat by the use of orally administered non-absorbable drugs.
  • Mechanisms
    • target worm motor activity or reactions that generate metabolic energy
57
Q

What are the two broad-spectrum benzimidazole drugs used to treat roundworms and tapeworms?

A

Albendazole and Mebendazole

58
Q

What is the drug distribution of Albendazole and Mebendazole?

A
  • Limited oral absorption
  • Albendazole is better absorbed if targeting tissue-migrating larvae is important
59
Q

What is the MOA of Broad-spectrum benzimidazole drugs?

A
  • Binds to parasite β-tubulin and inhibits the formation of microtubules
  • Death can take several days, for some helminths more than one dose may be necessary
60
Q

What are the potential toxicities of Albendazole and Mebendazole?

A
  • Systemic toxic affects on liver/bone marrow rare
  • Abdominal pain, nausea, dizziness, headache
  • Embryotoxic and teratogenic in pregnant rats
  • Evidence suggests safe for use in children when warranted
61
Q

What are the two cholinergic antihelmintics?

A

Pyrantel pamoate and Levamisole

62
Q

What is the MOA of Pyrantel pamoate and Levamisole?

A
  • selectively opens a restricted subgroup of nematode acetylcholine receptor (AChR) ion channels in nematode nerve and muscle
  • depolarization entry of calcium through the opened channels, and an increase in sarcoplasmic calcium
  • produces spastic muscle contraction the parasite is then unable to maintain its location (often in the intestine) and is then swept away
63
Q

What are the toxicities of Pyrantel pamoate and Levamisole?

A

Causes nausea, vomiting, diarrhea

64
Q

What is the macrocyclic lactone that binds to glutamate-gated chloride channels in invertebrate nerve and muscle cells, causing deactivation of channel: worm paralysis and death by starvation?

A

Ivermectin

65
Q

What are the toxicities associated with Ivermectin?

A
  • Generally well-tolerated
  • Itching, swollen lymph glands and rarely dizziness
  • Inflammatory reaction due to death of adult worms
66
Q

What other parasitic infections is Ivermectin used to treat?

A

Nematodes- Ascaris, Strongyloides and Onchocerca

67
Q

What are the three Tapeworms that cause zoonotic disease?

A
  • Taenia: your typical human tapeworm, beef or pork tapeworm
    • 3 – 10 meters in length!
  • Diphyllobothrium fish tapeworm
    • The monster: up to 30 ft in length
  • Echinococcus: causes echinococcocis → a disease of liver, lungs, brain, and other organs
    • Tiny, a few mm in length
68
Q

How is Diphyllobothrium: Fish tapeworm acquired?

A
  • Acquired by eating the musculature of fish where larvae have migrated
  • Adheres to mucosa of small intestine
69
Q

How is Diphyllobothrium: Fish tapeworm diagnosed?

A
  • The standard intestinal “problems”
  • Anemia due to competition for Vitamin B12 in intestine
  • Stool contains eggs and/or proglottids
70
Q

How is Taenia sp: Beef or pork tapeworm acquired?

A
  • Acquired by human when meat containing Cysticeri is consumed
  • Cysticerci grows into tapeworm in small intestines
  • Eggs and broken pieces of mature tapeworm are passed into feces for excretion
71
Q

How is Taenia sp: Beef or pork tapeworm diagnosed?

A
  • The standard intestinal “problems”
  • Stool contains eggs and/or proglottids (mature tapeworm segments)
  • Cysticercosis possible if cysticerci migrate to muscle, brain, or other tissue
72
Q

How does Echinococcus cause Echinococcosis?

A
  • Eggs excreted in feces of definitive host (dog)
  • Oncosphere hatches in small intestines and penetrates the lining
  • Enters circulatory system
  • Causes slow growing cysts in organs
73
Q

How is Echinococcus infection diagnosed?

A
  • Not really a GI illness at all
  • Pain or discomfort in the upper abdominal region or chest
  • Sheep farming + uncontrolled living with canines; trappers
    • common patient profile
74
Q

What are the antiparasitics that target Tapeworms?

A
  • Benzimidazoles
    • Albendazole and Mebendazole
  • Praziquantel
75
Q

What is the MOA of Praziquantel?

A

causes increased permeability of the parasite to divalent cations leading to contraction of the worm’s musculature

76
Q

What are the toxicities of Praziquantel?

A

Generally well-tolerated, but dizziness and nausea are side effects

77
Q

What parasitic infections can be treated with Praziquantel?

A

Cestodes (tapeworms) and trematodes (flukes)

78
Q

What parasite is responsible for the following:

A 38-year-old male who recently spent a month in rural Mexico complained of a spiking fever, malaise, headache, and right upper quadrant abdominal pain. He had bloody diarrhea with mucus and tenesmus. Physical examination revealed a fever of 39.6°C, pallor, slight jaundice, and tender hepatomegaly.

A

Entamoeba hystolytica

(protozoan)

79
Q

What does Giardia trophozoite look like?

A

two nuclei → “eyes”

and Dr. Zimmer thinks it is “cute”

80
Q

What disease is second only to malaria as the most devastating parasitic disease according to the CDC?

A

Schistosomiasis

81
Q

What are the two major forms of schistosomiasis?

A
  • Two major forms of schistosomiasis – intestinal and urogenital – disease incidence numbsecond only to malaria as the most devastating parasitic diseaseers lump both together
    • Urogenital caused by the species Schistosoma haematobium
82
Q

Why is the Schistosoma spp. called the “Valentines Parasite”?

A

Male & female flukes hang out together

83
Q

What is the intermediate and definitive hosts of Schistosoma spp.?

A
  • Intermediate → snail shells
  • Definitive → Humans
    • one in which sexual reproduction can occur
84
Q

What is the mechanism of disease caused by Schistosoma spp.?

A
  • Symptoms are caused by immune response to egg stage of Schistosoma
  • Eggs shed by the adult worms become lodged in the intestine or bladder, causing inflammation, scarring.
  • After years, this damages the liver, intestine, spleen, lungs, and bladder
  • Repeatedly-infected children can develop anemia, malnutrition, and learning difficulties
85
Q

What are the symptoms of Schistosomiasis?

A
  • Within days of infection: rash or itchy skin
  • 1-2 months of infection: fever, chills, cough, and muscle aches
  • Chronic: abdominal pain, enlarged liver, blood in the stool or urine, and problems passing urine.
    • Chronic infection can also lead to increased risk of bladder cancer.
86
Q

How do humans acquire Schistosoma spp.?

A
  • Eggs hatch in water
  • Eggs penetrate snails
  • Maturing form gets deposited in water
  • Humans drink water
  • Mature form develops in human
87
Q

After skin penetration, how do Schistosoma spp. develop in humans?

A
  • After skin penetration → schistosomulae find capillaries (blood)
    • migrate first to lungs
    • second to heart
    • and third to LIVER
88
Q

What is the average lifespan of Schistosoma spp.?

A

Average lifespan is 5 years, but adult worms can live up to 20 years.

89
Q

How is Schistosomiasis diagnosed?

A
  • Stool or urine samples can be examined microscopically for parasite eggs
  • Eggs are passed in small amounts intermittently, it may be necessary to perform a blood (serologic) test.
90
Q

What is the treatment for Schistosomiasis?

A
  • Antiparasitic: praziquantel
    • Low efficacy against immature worms → may need to give a second dose if eggs still present in stool or urine 2-3 months later
    • In acute cases, treatment with praziquantel is usually delayed until three months after infection as this is when it is most effective
  • Steroid medication (corticosteroids) may be used to relieve the symptoms of acute schistosomiasis, as they help control the allergic reaction to the eggs responsible for the symptoms.
91
Q

How are the various GI parasites transmitted?

A
  • Nematodes (roundworms): soil*
  • Cematodes (tapeworms): zoonotic
  • Protozoa: water (food)
  • Trematodes (flukes): water, other flukes: undercooked fish
  • Universal: poor hygiene/sanitation
92
Q

What GI Parasites are you most likely to see in the US?

A
  • Giardiasis
  • “Crypto”
  • Pinworm
93
Q

What patients should you especially suspect parasitic GI infections?

A
  • Children
  • Immigrants
  • World travelers
  • Immunocompromised
  • Chronically “unwell” individuals losing weight

GI Week 4 - WLB (8 decks)

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