Cestodes

Cestodes
Tapeworms - class of Phylum Platyhelminthes Adult tapeworms - all with a flat and ribbon-like body. Cestode body consists of an anterior attachment organ, or scolex, followed by a chain of segments, proglottids also known as strobila. Strobila grows throughout the life of a tapeworm by continuous proliferation of new segments or proglottids in the region immediately posterior to scolex, referred to as the neck. The new segments are immature because they do not contain fully developed internal structures.

Cestodes
Mature segments are larger and found near the middle of the chain and each may contain either one or 2 sets of both male and female reproductive organs. Terminal portion of strobila contains the ripe or gravid segments, usually filled with eggs. Adult tapeworms inhabit the small intestine, where they live attached to the mucosa. Attachment is accomplished by means of scolex, an organ that varies in morphology from species to species. All cestodes of humans have 4 muscular, cup-shaped suckers on the scolex except Diphyllobothrium latum.

Cestodes
In addition to suckers, the scolex may have an elongated and protrusible structure, the rostellum, situated in the center of scolex. Cestodes that parasitize humans have complex life cycles that generally involve both a definitive and intermediate host. Some species utilize humans only as definitive hosts, growing to adulthood in the intestine after ingestion of the infective larvae (e. D. latum, T. saginata, H. diminuta) For some, humans are equally acceptable as definitive or intermediate hosts (T. solium, H. nana) Echinococcus utilize humans as one of their possible intermediate hosts but never as definitive host. In general, extraintestinal infection with the larval forms is a much more serious matter than infection with the adult worm.

Cestodes
Occur in either of two forms: - as mature tapeworms residing in the GIT - as one or more larval cysts (variously called hydatidosis, cysticercosis, coenurosis, or sparganosis) embedded in liver, lung, muscle, brain, eye, or other tissues

Cestode spp
Intestinal tapeworms (e.g., Diphyllobothrium latum, Hymenolepis nana, Taenia saginata, and Taenia solium) Invasive cestode parasites (cysticercosis [T. solium], Hydatid and alveolar cyst disease [Echinococcus spp.], sparganosis, and Coenurosis [Multiceps (Taenia) multiceps]) As mature tapeworms, these parasites reside in the intestinal tract of a definitive host, a carnivorous mammal. Depending on the parasite species, mature tapeworms vary in size from several millimeters (Echinococcus spp.) to 25 m (Diphyllobothrium).

Life Cycle

Cestode Biology
Tapeworm consists of several parts: a head (scolex), a neck, and a tail. The head has two or more suckers and in some cases a rostellum, or knob of small hooks, used to attach to the wall of the hosts intestine.

The scolex is connected by a short neck to the lower portion of the tapeworm, the strobila, which is a ribbon-like chain of independent, but connected, segments called proglottids.

Cestode Biology
Each proglottid has both male and female sexual organs responsible for producing the parasites eggs. Proglottids begin to develop in the neck region of the parasite and then mature and move downward in the strobila as new segments are added from above. The hermaphroditic proglottids become gravid and eventually break free of the tapeworm. Proglottids may degenerate in the stool, releasing eggs (thousands to millions per day) into the feces. Alternatively, intact proglottids may be passed in the stool, with egg release occurring outside the body. In some cases, a section of strobila may be passed in a single day, with no further release of proglottids for several days thereafter. In practical terms, this means that although the number of tapeworm eggs in the stool is usually high, detection of parasite eggs by standard stool examination may be sporadic. It therefore may require multiple stool samples, rectal swabs, and visual examination of stool and perineum for proglottids to detect a tapeworm infection. For some species of tapeworm (e.g., T. saginata), the proglottids are motile. They may migrate within the gastrointestinal tract, causing biliary or appendiceal obstruction, or out of the body, to be found in the perineum.

Diphyllobothrium latum
Common Name: Fish Tapeworm or Broad Tapeworm Human infection acquired by eating pickled or insufficiently cooked/uncooked freshwater fish containing the parasites plerocercoid cysts. Some traditional modes of infection include consumption of dried or smoked fish, which may contain viable cysts if not further cooked, or tasting flavored freshwater fish (e.g., gefilte fish) before cooking; raw bar foods such as ceviche, sushi, and sashimi prepared from freshwater fish, especially salmon, has increased the transmission potential for D. latum in developed areas of North America

Diphyllobothrium latum

Human D. latum tapeworms are large, reaching up to 25 m (3000 to 4000 proglottids) in length. Scolex is elongate, spoon-shaped and characterized by 2 longitudinal grooves; no rostellum/no hooks; neck is thin, unsegmented much longer than the head It takes 3 to 6 weeks after exposure for the tapeworm to mature. Once established, a D. latum parasite may survive 30 years or more. Multiple tapeworms in the same patient are common. Normally, infection is asymptomatic, but a proportion of infected individuals report nonspecific symptoms of weakness (66%), dizziness (53%), salt craving (62%), diarrhea (22%), and intermittent abdominal discomfort.

Diphyllobothrium latum
Some nonspecific abdominal symptoms have been ascribed to this infection but the only significant consequence is result of chance localization in the proximal portion of jejunum. Prolonged (more than 3 or 4 years) or heavy D. latum infection may lead to megaloblastic anemia caused by vitamin B12 deficiency. The vitamin B12 deficiency is a consequence of two factors: parasitemediated dissociation of the vitamin B12intrinsic factor complex in the gut lumen (making vitamin B12 unavailable to the host) and heavy vitamin uptake and use by the parasite. Megaloblastic anemia may be worsened by concurrent folate deficiency, which also occurs as a consequence of D. latum infection. Vitamin B12 deficiency may be sufficiently severe to cause injury to the nervous system, including peripheral neuropathy and severe combined degeneration of the central nervous system (CNS).

Diagnosis
Tapeworm infection may first be suspected based on the patients history or when contrast studies of the intestine show an intraluminal, ribbonlike filling defect. Definitive diagnosis of D. latum infection is made by detection of 45 65-mm operculated parasite eggs on stool examination. Recovery of proglottids (with a characteristic central uterus) also establishes the diagnosis. Eggs of D. latum (55 to 75 m 40 to 50 m) in an iodine-stained wet mount. Note the knob at the abopercular end

Treatment
Treatment is with a single course of praziquantel; for persons unable to take praziquantel, niclosamide is effective and welltolerated. Mild vitamin B12 deficiency reversed by eradicating the tapeworm. Severe vitamin B12 deficiency treated with parenteral vitamin injections. If a patient presents with B12 deficiency and epidemiologic risk factors for fish tapeworm infection, one should maintain a high index of suspicion for possible infection.

Hymenolepis nana
also known as dwarf tapeworm, is a cyclophyllidean tapeworm with embryonated eggs; common parasite of house mouse the most prevalent tapeworm worldwide, and it is the only tapeworm that can be transmitted directly from human to human Ingestion of parasite eggs on fecally contaminated food or fomites allows the initial infection. Once in the small intestine, the eggs hatch to form 6-hooked oncospheres, which penetrate the mucosa to encyst as cysticercoid larvae. Four or five days later, the larval cyst ruptures into the lumen to form the relatively small, adult H. nana tapeworm (15 to 50 mm in length). Internal autoinfection may occur as parasite eggs are released from gravid proglottids (wider than long) in the ileum. In addition, poor sanitary practices promote external (fecal-oral) autoinfection as well as transmission to others sharing the same living quarters. Heavy infection is common among children and may be associated with abdominal cramps, anorexia, dizziness, and diarrhea.

Hymenolepis nana
Scolex
Subglobular 4 suckers Provided with a short retractile rostellum armed with a single row of 20-30 hooklets Rostellar hooklets are shaped like tuning forks

Hymenolepis nana
An H. nana infection is diagnosed by identifying the 30 47-mm parasite eggs (with their characteristic double membrane) in the stool Eggs of H. nana (30 to 50 m) in an unstained wet mount. Note the presence of hooks in the oncosphere and polar filaments within the space between the oncosphere and outer shell.

Hymenolepis nana
Drug of choice is with praziquantel; niclosamide must be given daily for 5 days because of the tissue phase of infection. developing H. nana cysticercoids are not as susceptible to drug therapy as adult tapeworms. Because these cysts can emerge several days later to form new tapeworms, effective therapy of H. nana requires either higher than usual doses of praziquantel to reach cysticidal levels or more prolonged therapy with niclosamide (to eliminate emerging tapeworms) for a period of 5 to 7 days. Nitazoxanide has also been used but still investigational drug to treat infection, appears to be highly effective, and has been used as an alternative therapy after treatment failures with niclosamide

Taenia saginata
known as the beef tapeworm, is transmitted to humans in the form of infectious larval cysts found in the meat of cattle, which serve as the parasites usual intermediate host common in cattle-breeding areas of the world Consumption of measly (i.e., cyst-infected) uncooked or undercooked beef is the usual means of transmission. Rare steak or kebabs and steak tartare are dishes typically associated with T. saginata infection. In the definitive human host, adult T. saginata tapeworms are large (10 m in length) and can contain more than 1000 proglottids (central stem with 15 to 20 lateral branches), each capable of producing thousands of eggs. If, through poor sanitary practices, eggs released in the feces are allowed to reach grazing areas, cattle are subsequently infected with T. saginata cysticerci. Alternative intermediate hosts include llamas, buffalo, and giraffes.

Taenia saginata
Scolex bears 4 muscular suckers and small rostellum without hooks. Presence or absence of hooks may serve to differentiate the 2 species of Taenia Proglottids are wider than long or nearly square, whereas gravid proglottid which are eventually passed in the stool are considerably longer than wide. Gravid proglottids of T. saginata are longer than those of T. solium.

Taenia saginata
Symptoms are absent in most patients with T. saginata infection. A small number report mild abdominal cramps or malaise. The proglottids of T. saginata are motile and occasionally migrate out of the anus, to be found in the perineum or on clothing. The patient may report seeing moving segments in the feces or passing several feet of strobila at one time. These events are often psychologically distressing and are associated with significant anxiety-associated symptoms

Taenia saginata
Ova
Liberated by rupture of ripe proglottids No uterine opening Spherical Thin, outer transparent shell Inner embryophore is brown, thick walled and radially striated Has an oncosphere with 3 pairs of hooklets Does not float in saturated salt solutions Eggs are resistant and remain viable for 8 weeks Infective only to cattle

Taenia saginata
Specific diagnosis of T. saginata infection can be established by recovery of parasite proglottids. If only eggs are found in the stool, it is important to note that T. saginata eggs are morphologically indistinguishable from those of T. solium. With T. solium tapeworms there is potential for autoinfection with cysticercosis; therefore, if any Taenia spp. eggs are detected, treatment should be given without delay for further speciation. Effective oral treatment for either Taenia spp. is obtained with praziquantel or niclosamide

Taenia saginata
Final Host: Man Intermediate Host: cattle, cow buffalo Mode of Infection; eating beef containing Cysticercus bovis Pathogenesis
Taeniasis Passage of proglottids in stool Mild irritation at site of attachment Epigastric pain Hunger fangs Weakness Weight loss Loss of appetite Pruritis Obstruction in intestine but also in bile and pancreatic ducts and appendix because proglottids are actively motile

Taenia saginata
Diagnosis Identifying characteristic eggs, proglottids or scolex Usual specimen is gravid proglottids ( lateral branches 15-20) Concentration techniques for eggs (eggs rarely passed out in stool) Perianal swabs Treatment Praziquantel 5-10mg/kg single dose Criteria for cure Recovery of the scolex Negative stool examination 3 months after treatment

Taenia solium
Humans can serve as either intermediate or definitive hosts for T. solium. The life cycle of this tapeworm requires one intermediate host, the pig. Individuals who ingest T. solium eggs develop tissue infection with parasite cysts, a condition known as cysticercosis Patients who consume raw, cured, or undercooked pork containing infectious larval cysts (cysticerci) acquire the pork tapeworm that is, the adult form of T. solium, which resides in the intestinal tract. These tapeworms develop to approximately 2 to 8 m in length and may survive for 10 to 20 years. Some patients harbor both cysticerci and T. solium tapeworms, and it is possible for a tapeworm-carrying individual to develop cysticercosis by autoinfection.

Taenia solium
Scolex is muscular and bears in addition to the 4 suckers a double crown of prominent hooks, which function in attachment to the intestinal mucosa. Mature segments are wider than long and contain 1 set of male and female reproductive organs.

Taenia solium
Ova
- Same as those of Taenia saginata - Infective to man as well as pigs - Thick brown striated embryophore surrounding a hexacanth embryo

Taenia solium
Infection with T. solium tapeworms is generally asymptomatic unless cysticercosis, caused by autoinfection with parasite eggs, supervenes. If tapeworm infection is diagnosed, one should also have a high index of suspicion for concomitant cysticercosis. The proglottids of T. solium are not motile (unlike those of T. saginata) and do not migrate. Proglottid has a central stem with 7 to 13 main lateral branches. Taenia spp. infection is readily diagnosed by detecting eggs during stool examination, but T. solium eggs are indistinguishable from those of T. saginata

Taenia solium
Taenia spp. eggs (30 to 35 m) in unstained wet mounts. The eggs of T. solium and T. saginata are indistinguishable from each other, as well as from other members of the Taeniid. If a proglottid is recovered, the species can be identified based on the characteristic features of the uterine canals in the segment. Species identification is not required for therapy, which can be achieved with either praziquantel or niclosamide.

Taenia solium
Final Host: Man Intermediate Host: Pig Mode of infection; eating measly pork containing Cysticercus cellulosae Diagnosis: stool examination for proglottids/eggs

Taenia solium
Diagnosis Intestinal
Identifying the characteristic proglottids, eggs or scolex

Cysticercosis
Computed Axial Tomography Magnetic Resonance Imaging

Treatment
Praziquantel: 5-10 mg/kg single dose for children and adults Niclosamide not available locally

Criteria for cure:

Recovery of scolex Negative stool exam 3 months after treatment

Comparison Between T. saginata and T. solium

Taenia saginata Taenia solium
Length Head or scolex Number of proglottids Expulsion 5-10 meters Large, quadrate, no rostellum and hooks 1,000 to 2,000 Expelled singly and may be forced through the anal sphincter Highly branched with 1530 lateral branches on each side; thin; dichotomous 300-400 follicles 2-5 meters Armed; with rostellum; with hooklets Below 1000 Explelled passively in chains of 5 or 6 Lateral branches 5-10 on each side, thin, dendritic and vaginal sphincter is absent 150-200 follicles

Uterus

Testes

Diagnosis of Tapeworm Infection

Because mature tapeworm infection is strictly an intraluminal intestinal infection, the most practical approach to diagnosis is examination of the feces for parasite eggs or proglottids Sensitivity for egg detection may be improved by formyl ethyl acetate or other concentration techniques. Because cestode eggs are relatively heavy, sedimentation procedures (not flotation) provide a more efficient means to isolate tapeworm eggs When handling specimens, it is important to remember that T. solium eggs are infective for humans and cause cysticercosis. For this reason, precautions should be taken to avoid any potential contamination of fingers or clothing with parasite eggs

Diagnosis of Tapeworm Infection

In some cases, intact proglottids are passed in the stool. This is most common with D. latum, T. saginata, T. solium, and D. caninum Expelled proglottids tend to degenerate over time, so fixation and staining of specimens are recommended to allow effective microscopic speciation Although species identification is not essential for treatment, identification of T. solium infection is significant and should prompt consideration of possible cysticercosis in the index patient or among his or her household contacts

Diagnosis of Tapeworm Infection

Proglottids of D. latum (fish tapeworm) often pass as short chains of grayish white connected segments, each 11 3 mm, with a central uterine structure Proglottids of the pork tapeworm, T. solium, are 11 5 mm, with a lateral genital pore and 7 to 13 branches on either side of the central uterine canal Proglottids of T. saginata, the beef tapeworm, have a similar appearance but may be distinguished by the larger number of lateral uterine branches (15 to 20) in the proglottid T. saginata proglottids are motile and may emerge spontaneously from the anus to be found on the perineum, on the legs, or on clothing

Diagnosis of Tapeworm Infection

Proglottids of D. caninum (23 8 mm) are also motile and may be described by the patient (or parent) as whitish, moving cucumber seedlike objects in the stool. D. caninum proglottids may also become adherent to perianal hairs and then dry to form a whitish yellow object resembling a small grain of rice Recently, detection of specific coproantigens in the stool has improved diagnosis of Taenia infection and is genus specific. It carries a specificity of up to 95% to 98%. Newer polymerase chain reaction-based tests also show potential to identify infection at a species level

Treatment of Tapeworm Infection

Tapeworm infection should be treated whenever diagnosed. Safe, effective treatment of intestinal tapeworm infection may be achieved with either praziquantel or niclosamide. Both are well-tolerated oral agents that have direct parasiticidal effects on intraluminal cestode parasites. Although both agents are usually effective and considered first-line, there have been reports of treatment failure, likely secondary to resistance. In some cases, nitazoxanide has been used as an alternative drug and has been found to be safe and effective

Invasive Cestode Infection Cysticercosis

Cysticercosis is a tissue infection with larval cysts of the cestode T. solium in which the patient serves as an intermediate host for the parasite. Infection is acquired by consumption of T. solium eggs by fecal-oral transmission from a T. solium tapeworm carrier. Prevalence is high wherever T. solium tapeworms are common (i.e., Mexico, Central America, South America, the Philippines, and Southeast Asia), and the World Health Organization estimates that there are more than 50,000 deaths per year from neurocysticercosis. Infected subjects normally harbor multiple cysts in many parts of the body. In areas of endemicity, the cumulative infection risk increases with age, frequent consumption of pork, and poor household hygiene. Symptoms may develop because of local inflammation at the site of involvement; however, apart from CNS and cardiac involvement, serious disease is rare. Neurologic symptoms are the most prominent.

Invasive Cestode Infection Cysticercosis

Neurocysticercosis (NCC) is the term used for human CNS involvement with T. solium cysts. Infection may involve any part of the CNS, but symptomatic disease is most often related to intracerebral lesions (causing mass effects, seizures, or both), intraventricular cysts (causing hydrocephalus), subarachnoid lesions (causing chronic meningitis), and spinal cord lesions (causing cord compression syndrome or meningitis). Seizures, occurring in up to 70% of patients with neurocysticercosis, and intracranial hypertension are the most common clinical features

Invasive Cestode Infection Cysticercosis

The most common form of NCC, characterized by presence of living cysts was arachnoiditis, with spinal fluid pleocytosis, increased CSF protein and positive CSF serologic test for cysticercosis. Inactive NCC are calcified parenchymal cysts seen in about 60% of cases, and hydrocephalus secondary to meningeal fibrosis, found in about 4%.

Invasive Cestode Infection Cysticercosis

Cysticerci may be found within the orbit, in either the anterior or posterior chamber or in the retinal tissues; often readily seen with ophthalmoscope. They may give rise to visual difficulties that fluctuate with eye position, generalized decrease in visual acuity, retinal edema, hemorrhage or vasculitis or detachment. Cysts developing along the optic tracts may give rise to visual field defects.

Diagnosis
Surgical removal of subcutaneous or intracranial cysts, with demonstration of the organism, radiographic demonstration of calcified cysts in the muscle or visualization of cysticercus within the orbit, is diagnostic. Signs and symptoms of a space-occuying lesion of CBS may be highly suggestive of cysticercosis. Diagnosis and treatment of cysticercosis depend on the site of involvement and the symptoms experienced. Travel to or residence in an endemic area significantly increases the likelihood of the diagnosis, although transmission has been documented to occur within the United States in people living in the same household as a T. solium-infected immigrant.

Diagnosis
Cysts outside the CNS tend not to be symptomatic. These cysts eventually die and calcify, to be detected incidentally on plain radiographs of the limbs. Although symptomatic cardiac cysticercosis is rarely reported, autopsy reports of cysticercosis patients have shown cysts involving the heart in up to 23% of cases. Symptoms of cardiac cysticercosis can include heart failure or conduction abnormalities Racemose cysts are aberaant cysticerci, which at times are found developing in the ventricles or subarachnoid space

Treatment
Many cases are asymptomatic and require no treatment. All that could be offered are symptomatic like anticonvulsants to relieve seizures. Surgical treatment includes excision of ventricular cysts, shunting procedures to relieve hydrocephalus, and removal of cysts by means of stereotaxic endoscopy. For active parenchymal brain cysts and subarachnoid cysts they recommend albendazole. Alternative drug is praziquantel but less effective than albendazole.

Echinococcus granulosus
Dog Tapeworm Hydatid Worm Man harbors the larval form and not the adult worms which however is found in the intestine of dogs and canines

Echinococcus granulosus
Adult worms are small (3-6 mm in length) It is composed of a Scolex Neck Strobila 3 segments (occasionally 4) Immature Mature Gravid

Echinococcus granulosus
Scolex bears 4 suckers and a protrusible rostellum with 2 circular rows of hooks.

Echinococcus granulosus
Ova
Ovoid in shape Resemble Taenia ova Hexacanth embryo with 3 pairs of hooks

Infective to:
Man Cattle Sheep and other herbivorous animals

Echinococcus granulosus
Definitive Host

Dog Wolf Fox Jackal

Sheep Pig Cattle Horse Goat

Intermediate Host

Echinococcosis
When humans serve as inadvertent intermediate hosts for cestodes of Echinococcus spp., which are carried as tapeworms by canines such as dogs, wolves, and foxes, disease may result from the development of expanding parasite cysts in visceral organs. This condition, termed echinococcosis, has two forms: hydatid or unilocular cyst disease, caused by Echinococcus granulosus, and alveolar cyst disease, caused by Echinococcus multilocularis. In addition, polycystic or neotropical echinococcosis is caused by either Echinococcus vogeli or the much less common Echinococcus oligarthrus, both found in Central or South America. E. vogeli infections are similar to alveolar cyst disease, whereas E. oligarthrus infections appear less aggressive. Sheep, goats, camels, and horses are among the usual intermediate hosts for E. granulosus, but because E. granulosus is transmitted by domestic dogs in livestockraising areas, hydatid disease is prevalent worldwide (Africa, Middle East, southern Europe, Latin America, and southwestern United States). E. multilocularis infections (found in northern forest areas of Europe, Asia, and North America and in the Arctic regions) and E. vogeli infections (found in South American highlands) are transmitted by wild canines and are much less common.

Echinococcosis
Humans acquire echinococcosis by ingesting viable parasite eggs with their food. The parasite eggs are distributed via local environmental contamination by the feces of tapeworm-infected canines. Eggs are partially resistant to desiccation and remain viable for many weeks, allowing delayed transmission to individuals with no direct contact with vector animals. Once in the intestinal tract, the eggs hatch to form oncospheres that penetrate the mucosa and enter the circulation. Oncospheres then encyst in host viscera, developing over time to form mature larval cysts

Hydatid cysts of the liver detected on computed tomographic scan. Note the well-demarcated wall and characteristic septate internal structures (daughter cysts).

Echinococcosis
Infection with E. granulosus, cystic echinococcosis, is estimated to occur in up to 2% to 6% of endemic populations, and the annual incidence in Europe is on the rise in some areas. Risk factors include unsanitary living conditions, slaughter of livestock in close proximity to humans and dogs, and uncontrolled dog populations. Sheep raising, in particular, is associated with a high prevalence of disease. The hydatid cysts of E. granulosus tend to form in the liver (50% to 70% of patients) or lung (20% to 30%) but may be found in any organ of the body, including brain, heart, and bones (<10%). They grow to 5 to 10 cm in size within the first year and can survive for years or even decades. Symptoms are often absent, and in many cases infection is detected only incidentally by imaging studies

Echinococcosis
Hydatid cysts contain a germinal layer that allows asexual budding to form daughter cysts within the primary cyst. If a cyst erodes into the biliary tree or a bronchus, the cyst contents, including daughter cysts, may enter the lumen and cause obstruction or postobstructive bacterial infection.

Multiple thin-walled hydatid cysts, human liver

Echinococcosis
Bacteria may enter the cyst, causing pyogenic abscess formation in the cyst. Cyst leakage or rupture may be associated with a severe allergic reaction to parasite antigens; in the most extreme cases, patients may have anaphylactoid reactions, including hypotension, syncope, and fever, after cyst rupture. A dangerous complication of cyst rupture is secondary seeding of daughter cysts into other areas of the body

Daughter cyst formation from the germinal membrane of a hydatid cyst

Echinococcosis
Infection that is suspected based on imaging studies (ultrasonography, CT, and MRI) may be confirmed by a specific enzyme-linked immunosorbent assay (ELISA) and Western blot serology (available in the United States through the CDC), confirming exposure to the parasite. Serology is 80% to 100% sensitive and 88% to 96% specific for liver cyst infection but less sensitive for lung (50% to 56%) or other organ (25% to 56%) involvement. Additional assays continue to be developed using recombinant Echinococcus antigens and may provide better diagnostic sensitivity and specificity. Eosinophilia is not a consistent or reliable finding. Imaging remains more sensitive (90% with ultrasound and higher with CT and MRI) than serodiagnostic techniques, and a characteristic scan in the presence of negative serologic results still suggests the diagnosis of echinococcosis

Treatment of Echinococcosis
Albendazole; results of therapy are best judged by USG or MRI, repeated at intervals of approximately 3 months. Surgical removal of hydatid cysts Percutaneous aspiration for pulmonary, hepatic, and other cysts PAIR (percutaneous aspiration, injection of hypertonic saline or other scolicidal fluid and reaspiration). Praziquantel has some protoscolicidal effect. Ivermectin injected directly into cysts has ben found to kill all protoscolices in experimental animals.

Prevention of Cestode Infection

Depends on interrupting the parasite life cycle. Transmission can be reduced or eliminated by the following sanitary measures: (1) careful disposal of human sewage to limit environmental spread of parasite eggs; (2) limitation of forage areas and use of safe feed for vector animals such as cattle or swine that serve as common intermediate hosts; (3) meat inspection before marketing to exclude cyst-infested carcasses; and (4) prolonged freezing (at less than 18 C), thorough cooking of meat (at more than 50 C), or both to kill any cysts in the tissues. Control of fish tapeworm is more difficult to achieve because the infected fish can range freely, and there are nonhuman reservoirs for the tapeworm (e.g., bear and seals) that can continue to infect fish despite the presence of good human sanitation

Dipylidium caninum
Double Pored Dog Tapeworm Presence of bilateral genital pores in each segment Common intestinal parasite of dogs Common in dogs and cats all over the world. Occasionally found in humans, particularly in small children Larvae of species is termed cysticercoids Cysticercoid develops when the egg is ingested by a cat or dog flea larva and retained within the adult flea. Infection takes place through accidental ingestion of fleas. Cysticercoids grow into adult worms in the small intestine.

Dipylidium caninum
Scolex Small and globular 4 deeply cupped elliptical suckers Protrusible/retractile rostellum Rostellum has 1-7 rows of rose thorn shaped hooklets

Dipylidium caninum
Strobila 200 proglottids narrow

Dipylidium caninum
Mature proglottids 2 sets of male and female reproductive organs Bilatera genital pores

Dipylidium caninum
Gravid proglottids Have size and shape of pumpkin seeds Filled with capsules or packets of 8-15 eggs enclosed n an embryonic membrane

Dipylidium caninum
Ova
Passed out in the feces along with the proglottids Released by contraction of proglottids or disintegration outside the host Spherical Thin shelled With a hexacanth embryo

Dipylidium caninum
Diagnosis made on finding in the stool the characteristic proglottid or more rarely, egg packets. Proglottids are longer than wide. Light infections are asymptomatic but abdominal pain, diarrhea, and anal pruritus may occur in some individuals. Human infection requires ingestion of infected dog or cat fleas and is thus most likely to occur in small children who kiss or are licked by their infected pets. Treatment: Praziquantel is very effective. Niclosamide is an alternative. Periodic deworming of infected dogs and cats and control of fleas so that the animals do not become reinfected are essential.

Other Species Causing Tapeworm Infection in Humans

Dipylidium caninum: a more frequent parasite of dogs and cats Hymenolepis diminuta: a tapeworm that usually infects rats. Such infections are acquired by consumption of insects (fleas or beetles) containing the larval cysticercoids of these species and are most commonly seen among children. Human infection with tapeworm species related to D. latum Diphyllobothrium klebanovskii, Diphyllobothrium dendriticum, Diphyllobothrium ursi, and Diphyllobothrium dalliaehas been described in the Arctic and areas of Siberia Diphyllobothrium nihonkainse, common in Japan, is another related fish tapeworm that can cause infections in humans, and it has been reported in isolated cases in Europe after ingestion of imported fish. Taenia asiatica, described in 1993 and confused with T. saginata in the past, is found in some countries of Southeast Asia. In contrast to T. saginata and T. solium, this parasite is viscerotropic and is transmissible through ingestion of visceral organs from pigs rather than from muscle

Other Invasive Cestodes

Human tissue infection with plerocercoid cysts of several cestode species is referred to, collectively, as sparganosis. These parasites, like D. latum, pass through several developmental stages in copepods and vertebrates. The definitive hosts for tapeworms of these species are usually canines or felines. Humans acquire inadvertent parasite infection by ingesting copepods (in water) or by consumption of or prolonged exposure to uncooked meat of plerocercoid-infected animals.

Other Invasive Cestodes

Sparganosis has been reported in South America, Japan, China, and other areas of Asia in association with traditional use of frog- or snake-meat poultices. Infection has rarely been reported from Europe and North America. Sparganosis may be the proliferating or nonproliferating type. Infection acquired in the United States is usually due to the species Spirometra mansonoides, which is nonproliferating. In other areas of the world, proliferating forms are more common. These forms branch by lateral division and may detach to spread to other, distal areas of the body. Clinical presentation typically involves local inflammation at the site of invasion (skin and eye are the most common sites for poultice application). Cerebral sparganosis is a rare and severe complication. There is local lymphocytic and eosinophilic inflammation surrounding the parasite(s). Tissue injury may be particularly severe in the eye. Diagnosis is usually by biopsy, although serologic testing has been used in some areas. Treatment is by injection with ethanol, surgical resection, or both. Medical therapy with various anthelmintics has not produced a beneficial effect

Other Invasive Cestodes

Coenurosis is human cyst infection with the cestodes Multiceps multiceps, Taenia crassiceps, and Taenia serialis, which cause tapeworms in dogs. The cysts are unilocular, with multiple protoscolices, but do not contain daughter cysts. Symptomatic disease is usually associated with involvement of the eye or the CNS. Clinically, the cysts may be difficult to distinguish from cysticercosis or hydatid disease. Basal arachnoiditis and hydrocephalus are common. There is no reliable serologic test. Surgical resection is the recommended mode of therapy