Download Ministry of Healthcare of Ukraine

Ministry of Healthcare of Ukraine
N.I. Pirogov Vinnitsya National Medical University
Department of Infectious Diseases
Approved
at the methodical meeting
«__» ___________ 20__
Head of the Department, prof.
Moroz L.V.
WORKBOOK
for practical training on infectious diseases for 5-year students of medical departments ( the topic of
which is included in the plan of classroom training).
Topic 4.2:
CESTODIASIS & TREMATODIASIS.
Prepaired by: assistant Medvedeva L.S.
2009
1. Relevance of the topic:
Cestodiasis - invasions caused by representatives of tapeworms — cestodes:
diphyllobothriasis, teniarinhoze, taeniasis, hymenolepiasis, echinococcosis, alveococcosis and
others.
Diphyllobothriasis is spread around the globe, mainly in the areas with a moderate climate.
In Russia, difilobotriasis is an endemic pathology for pools of northern and Siberian rivers, the
Volga region, the Kola Peninsula, Sakhalin, Far East. In Ukraine, diphyllobothriasis is present in
the Danube Delta and the basin of the Dnieper (Dnieper reservoirs).
Teniarinhoze can be found on all continents of the globe. Areas of high endemicity are the
regions with livestock development. Teniarinhoza cases are recorded to be present in the Caucasus,
Central Asia, Kazakhstan, Yakutia. In Ukraine, there are isolated cases of infestation.
Taeniasis and cysticercosis are registered in the areas of pig breeding development. In
Ukraine, isolated cases of infestation are reported.
Hymenolepiasis is spread all around the globe.
Echinococcosis can be found everywhere, especially in the regions with livestock
development. In Ukraine, echinococcosis is regularly registered in Odessa, Mykolayiv, Donetsk,
Kherson, Zaporozhye and other areas of the Autonomous Republic of Crimea.
Trematodiasis - invasions caused by representatives of flukes - trematodes: opisthorchiasis,
fascioliasis, etc.
Opisthorchiasis - one of the most common human helminthiasis. In Ukraine, a fairly
significant focuses of opisthorchiasis are found in the basins of the Dnieper, Desna, Southern Bug,
Seversky Donets. There are recorded cases of opisthorchiasis infection in 20 regions of Ukraine.
Fascioliasis is usually registered in humans in the form of sporadic cases, however, in tropical
climate zones the number of infected people can reach high level.
2. The aim of the course (with an indicating level of adoption of the
program):
2.1. A student must understand (learn):


have a general understanding of the place of cestodiasis and opisthorchiasis in the structure of
infectious diseases, prevalence in different regions of Ukraine and the world, learn the
statistical data on the sickness rate, lethality, complication rates.
learn the history of the scientific study of cestodiasis and opisthorchiasis, have an
understanding of the scientific contribution of Ukranian scientists in the history of scientific
research in this field.
2.2. A student must know:
–
–
–
–
–
–
–
–
a-1
а-2
rules for hospitalizing patients with cestodiasis and trematodiasis;
etiology of cestodiasis and trematodiasis, pathogen virulence;
epidemiology of cestodiasis and trematodiasis;
life cycle of cestodes and trematodes;
basic processes of pathogenesis of cestodiasis and trematodiasis;
clinical manifestations of the different phases of cestodiasis and trematodiasis;
specific and non-specific laboratory diagnosis of cestodiasis and trematodiasis;
principles of treatment and prevention;
–
–
therapeutic approach for helping a patient in the events of emergency conditions;
convalescent discharge process rules and prophylactic medical examination.
2.3. A student must know how to:
а-3
–
collect medical history with the assessment of epidemiological data;
–
examine the patient and identify the main symptoms and syndromes of cestodiasis and
trematodiasis;
–
make a differential diagnosis of cestodiasis and trematodiasis;
–
make a plan of laboratory and additional inspection of the patient;
–
interpret the results of the laboratory tests;
–
analyze the results of specific diagnostic methods;
–
make an individual treatment plan considering the epidemiological data, stage of disease,
complications, condition severity, allergic history, concomitant pathology;
–
make a plan of antiepidemic and preventive measures in the nidus of infection;
–
give an advise on the treatment, diet, medical examination and the observation in recovery
period.
2.4. Creative level (for most capable and trained students):
а-4
Develop creative abilities of students in the process of conducting clinical researches and
during analysis of scientific sources: get involved in a scientific study group of the faculty; suggest
topics for essays about the most pressing issues, for example: “Perspectives for the study of
helminthiasis as etiological factors of oncological diseases”, etc.
3. Educational aims (personality development):
 Develop a deontological view. Know and be able to follow the principles of medical
deontology. Master the ability to establish psychological contact with the patient and his
family.
 Develop an understanding of the impact of social hygiene factors on the prevalence of
cestodes.
 Develop a sense of responsibility for the timeliness and accuracy of professional activities.
4. Intersubject integration.
Discipline
Biology
Know
Know how to
Foregoing disciplines
The morphology of cestodes and Identify helminths by the shape,
trematodes, their form, means of life, assess the means of invasion
biological life cycle
Physiology
The characteristics of physiological norms Evaluate the results of the laboratory
of human organs and systems; norms of the examination
laboratory examination (CBC, urine,
biochemistry of blood, etc.)
Pathophysiology
The mechanism of organ and system
malfunction in pathological conditions of
various origins
Interpret pathological changes based
on the results of laboratory
examination
Epidemiology
An epidemic process (source, infecting
mechanism,way of transmission) of
cestodiasis and trematodiasis; prevalence
of the disease in Ukraine and in the world.
Immunology and
allergology
The basic concepts of the subject, role of
the immune system in the infectious
process, an effect on the period of
eliminating the helminth from the human
body. Immunological aspects of the
disease course
Collect an epidemiologic evidence,
conduct an antiepidemic and
preventive measures in the nidus of
infection, fill in an emergency
report to SES and epidemiological
survey map.
Evaluate the results of the
immunological research
Surgery
Neurology
Ophthalmology
Clinical and laboratory signs of rupture of
cysts, appendicitis, peritonitis, liver cancer,
intestinal obstruction, first aid tactics
Diagnose these complications,
assign an appropriate examination,
provide emergency care
Pathogenesis, clinical characteristics of Carry out the clinical examination of
toxic
encephalopathy,
meningism, the patient with affection of CNS
eclampsia
Clinical and laboratory characteristics of
eye-lesion, first aid tactics
Diagnose these complications,
assign an appropriate examination,
provide emergency care
Internal diseases Methods and rules for conducting the Obtain the medical history, conduct
propedeutics
clinical examination of the patient for the the clinical examination, determine
detection of cestodes and trematodes
the
presence
of
pathological
symptoms, evaluate the data of the
clinical examination
Pharmacology
Pharmacokinetics and pharmacodynamics Choose an effective drug, prescribe
of drugs used in the treatment of cestodiasis an adequate dose and taking
and trematodiasis, possible side effects.
frequency
Therapeutics
The main clinical symptoms of diseases
that occur with lesions of the
gastrointestinal tract, respiratory tract,
anemia, etc
Evaluate the data of the clinical
examination of the patient, diagnose
the patient, assign a laboratory
examination, make a differential
diagnosis.
Family medicine
Infectious diseases.
Consecutive subjects
Epidemiology, pathogenesis, clinical
course of cestodiasis and trematodiasis,
possible complications, principles of
treatment and prevention
Interdisciplinary integration
Characteristics of infectious diseases.
Principles of diagnosis, treatment and
prevention of infectious diseases.
Epidemiology pathogenesis, clinical
symptoms of various phases of
cestodiasis and trematodiasis
pathogenesis, possible complications.
Criteria for the diagnosis, treatment
principles (etiotropic, pathogenetic and
symptomatic therapy), preventionism.
Make a differential diagnosis of
cestodiasis and trematodiasis with
other nosologies.Idetify cestodiasis
and trematodiasis, complications,
interpret the results of laboratory
tests (blood count, methods of
specific diagnostics); provide
emergency care
Carry out a differential diagnosis of
cestodiasis and trematodiasis with
other infectious and non-infectious
diseases, identify cestodiasis and
trematodiasis, complication, interpret
the results of laboratory tests (clinical
and specific diagnosis). Prescribe the
treatment. Provide emergency care in
the prehospital phase.
5. The content of the course.
1.
Cestodiasis and trematodiasis etiology. Structural features of the worm. Pathogenicity
factors.
2.
Trematodiasis epidemiology at the present stage.
3.
Pathogenesis.
4.
Clinical characteristics, features of modern treatment of cestodiasis and trematodiasis
Pathogenesis and complications.
5.
Laboratory diagnosis. The possibility of early diagnosis. Regulatory documents of MOH
of Ukraine regarding analysis of stool for the presence of helminth eggs. Emphasize the
importance of modern highly sensitive and specific immunological diagnostic methods.
6.
The problem of chronic carriers of the pathogen.
7.
Treatment of patients. Emergency care in case of complications.
8.
Convalescent discharge process rules and prophylactic medical examination.
9.
Principles of prevention.
10.
At the end of the course sort out a number of unsolved problems, their interdisciplinary
significance, emphasize the importance of extracurricular training of students, the use of
independent information search for answers on questions that arose during the practice session.
5.1. The content of the topic
DIPHYLLOBOTHRIASIS
Etiology
Broad tapeworm (Diphylobotrium latum)
Epidemiology
Zoonosis. Oral biogelmintoz
The source of infection and the final host– a human, a dog and other
First intermediate host – freshwater crustaceans
Second intermediate host – freshwater fish (pike, perch, trout)
Infection of humans - not properly heated fish and spawn
Mechanical effect
Toxicoallergic effect
Attachment to the wall of the Metabolic products sensitization
small intestine → mucous of helminth → self-sensitization
membrane bothria suction → → endogenous hypo- and
atrophy and necrosis of the avitaminosis В12 and folic acid →
mucous membrane
Pathogenesis
Clinical picture
Complications
Diagnostics

 asthenia, dizziness
 signs of gastrointestinal tract
affection
 discomfort during meals
 dynamic or obturation
intestinal obstruction
 megaloblastic anemia
 В12 and folate anemia





 Chronic low-grade fever,
stoxicosis symptoms, allergic skin
eruption;
 Tachycardia , hypotension,
dilatation of the heart, systolic
murmur
hyperchromic anemia
hypo- or gastric achylia
bilirubinemia (indirect), hypoproteinemia,
microscopy of faeces: finding eggs or fragments of strobila
Treatment
Causal treatment
 praziquantel
 albendazole,
 phenasalum
Pathogenetic therapy
 treatment of anemia
Prevention
 protection of the environment from faecal contamination
 preventing the fire formation on hydraulic work construction site
 thermal treatment of fish and spawn before food consumption
TENIARINHOZE
Etiology
Epidemiology
Pathogenesis
Clinical picture
Complications
Diagnostics
 praziquantel
 albendazole,
 phenasаlum
Beef tapeworm (Taenairhynchus saginatus)
Anthroponosis. Oral helminthiasis
The source of infection and the final host– a human.
Intermediate host – cattle
Transfer factor – not properly heated meat
small intestine: Finn is released and attached
to the mucous membrane, after 2 months
becomes mature, produces segments with eggs
general signs of toxicity
 right iliac fossa pain – proglottids
pass through Ileocecal valve
 asthenia
 nausea, impaired appetite (anorexia  undue fatigability
replaces bulimia ), weight loss
 sleep disturbance
 flatulence, loose stools
 irritability
 epigastric pain
 headache
 active passing of proglottids, more  dizziness
often at night tim
 acute appendicitis, pancreatitis, cholecystitis
 intestinal obstruction and ileus
 hypo-, anacidic gastritis
 obstructive jaundice
 anaemia
Clinical methods
Specific methods
- eosinophilia, hyperchromic
 microscopy of eggs and segments
anemia
of the helminth in the feces
 contrast x-rays of the digestive
tract
Treatment
Prevention
 preventing the pollution of pastures and water with human feces
 veterinary and sanitary control
 proper thermal processing of beef
TAENIASIS AND CYSTICERCOSIS
Pork tapeworm (Taenia solium)
Anthroponosis.
Oral biogelmintoz
The source of infection and the final host– a human.
Intermediate host – pigs, cats, dogs, human
Transfer factors - raw or half-baked pig meat with Finns
Taeniasis
Сysticercosis
Pathogenesis
pork tapeworm Finns in 2-3
Ingestion of eggs →larvae emerge in
months → mature helminth
the stomach→penetration of the
capillaries→ enters the brain,
myocardium, skeletal muscle,
subcutaneous tissue,
→encapsulation→infiltration, vasculitis
↓
↓
mechanical effect
- mechanical effect on tissue
 mucous membrane damage in the fixing  allergic reactions
place of parasite
 increased signs of toxicity
 irritation of interoceptors
 violation of the absorption process
 intoxication
 sensibilization
↓
↓
Clinical picture
 moderate dyspepsia
 Clinical manifestations depend on
symptoms and toxic syndrome the location (brain, eyes, skin,
subcutaneous tissue, muscles)
Clinical methods
 hemogram: mild eosinophilia
cysticercosis
 ophthalmoscopy
 tissue radiography, CT
 surface biopsy
Taeniasis
 finding segments in the feces
 faecal analysis of helminth
Complications
taeniasis
 praziquantel, albendazole
cysticercosis
 praziquantel, albendazole, surgical
Prevention
 sanitary measures
 pig keeping hygienic requirements
 veterinary control of pork
Etiology
Epidemiology
HYMENOLEPIASIS
Dwarf tapeworm (Hymenolepis nana)
Oral contagious helminthiasis.
Etiology
Epidemiology
The source of infection – a human
Intermediate host – rodents (rats)
Transfer mechanism - fecal-oral
Transfer factors - vegetables, fruits, household things, cockroaches, flies
Pathogenesis
Clinical picture
Complications
Diagnostics
Treatment
Prevention
Larvae leaves the egg → penetrates the small intestine villus →
cysticercoids maturation , falls into the intestinal lumen, hooks to the
mucous membrane → produces eggs in the environment or repeats the
same cycle in the intestine (autoinvasion)
Mechanical effect
 edema, intestinal hyperaemia
 worm
metabolites
cause
 dystrophy,
necrosis
of intoxication and sensitization
epithelium, ulceration
 violation of liver antitoxic funtion
 enzymatic systems affection, and protein synthesis
violation of digestion
 gastric acid secretion
- disbacteriosis





↓
gastrointestinal lesions
nausea, vomiting
salivation
abdominal pain
unstable stool
mild hepatomegaly
 disbacteriosis
 hemogram: mild eosinophilia
 faecal analysis on helminth
 praziquantel,
 albendazole
 phenasаlum
 sanitary-educational work
 personal hygiene
↓
affection of central nervous system
 asthenia, fatigability
 headache, irritability
 dizziness
 epileptiform attacks
sensitization
 pruritus, urticaria
 vasomotor rhinitis, angioedema
 asthmatic bronchitis
ECHINOCOCCOSIS
Etiology
Pathogen - larvae Echinococus granulosus
Epidemiology
Zoonosis. Oral biogelmintoz.
Pathogenesis
Clinical picture
Complications
Diagnostics
2 types of nidus:
1. natural (wild herbivores - deer, roe deer and wild predators - wolves,
foxes)
2. synanthropic - farm animals (sheep and goats) and dogs (final host)
Eggs in food → larvae is released and attached to the mucous membrane of
the duodenum → passes through the wall of blood vessels, enters the liver,
lungs, etc. → cyst formation, local inflammatory response
↓
↓
Toxicoallergic effect
Local tissue damage
-echinococcus metabolites effect,
 compression of the surrounding
-host proteins absorption,
tissue, trophic disorder
development of mimicry,
 necrosis, granulation
-immunosuppression
 connective tissue replacement
of dead cells
 asthenia, fatigability
 headache
 rise of temperature
 dyspeptic symptoms
 skin eruption, pruritus
Latency phase from several months to decades
Liver (localization)
сaudate lobe of liver →
jaundice (bile duct compression)
diaphragmatic surface of liver → pain on the right side of the chest,
shortness of breath
closer to the Glisson capsule → right upper quadrant pain
on the anterior surface of the
during palpation - fixed, dense, tumor
liver →
formation
lungs →
 dyspnea
 chest pain
 cough
brain →
 signs of brain tumor development
Rupture of hydatid cysts → anaphylactic shock
↓
 dissemination of scolices
 acute inflammatory reaction (peritonitis, meningitis, pleurisy)
 cyst suppurating → abscess
 during prolonged invasion → amyloidosis in parenchymal organs
 hydatid disease (50%) – 3 stages: jaundice, cirrhosis, portal hypertension
 liver – massive bleeding
 brain – epileptiform seizures, blindness, paralysis and paresis
 ovaries – fallopian tubes rupture, bleeding
 hemogram: leukocytosis, anemia, eosinophilia, ESR acceleration
 X-ray, CT, MRI
 DS
 angiography, bronchography, cholecystography
Treatment
Prevention
 serological tests (CFT, IHA, immunoelectrophoresis)
 basic method - surgery
 albendazole
 personal hygiene
 helminthological study and dehelmintization of dogs
OPISTHORCHIASIS
Etiology
Epidemiology
Pathogenesis
Clinical picture
Complications
cat liver fluke
Opisthorchis felineus
Naturofocal zoonosis. biogelmintoz
Final host – a human and animals
(cats, dogs, pigs)
Intermediate host – freshwater mollusc Bithynia; cyprinidae
Transfer factor - the fish (raw or salted), which contains live larvae
(metacercariae)
Metacercariae → biliary duct → gallbladder → intrahepatic bile ducts
and pancreatic ducts
↓
↓
Early acute phase
Late chronic phase
The toxic effect of the larvae  allergic effect of helminths
decay products → toxicoallergic (Allergic hepatitis with cholestasis
reactions (increased vascular → telangiectasia, chronic hepatitis
permeability, perivascular edema, → cirrhosis,
impaired trophic tissue) →  cholangitis cholangiocarcinoma
damage of biliary and pancreatic pancreatitis
→
canaliculitis,
ducts
(local
inflammation, fibrosis)
impaired outflow of bile and  toxic effect
pancreatic enzymes)
 mechanical effect (violation of
the secrets outflow caused by
mucus, helminth)
↓
↓
 diarrhea, allergic rash, liver  pain in liver and gall bladder
pain
 dyspeptic symptoms
 asymptomatic disease course
 hepatomegaly
 yellow sclera
 liver abscesses, cellulitis and gallbladder, biliary peritonitis, primary
liver cancer
 chronic cholangitis, cholecystitis, hepatitis
 rupture of the parasitic cyst
 stomach and duodenal ulcers
 sclerosis of the biliary, major duodenal papilla, jaundice
 hemogram: leukocytosis, eosinophilia
 biochemical methods: increased bilirubin, ALT, AST, LF, amylase,
lipase, trypsin, dysproteinemia, hyperglycemia
 increased amylase in urine
 hypo- or gastric achylia желудочного сока
 bile ovoscope
 serological tests (Chronicle opisthorchiasis): IHA, ELISA, etc.
Treatment
 chloxylum
 praziquantel
 pathogenetic therapy
Prevention
 environmental protection (water reservoirs)
 extermination of mollusks
 sanitary control over the manufacture of fish products
Diagnostics
FASCIOLIASIS
Etiology
Epidemiology
Pathogenesis
Common liver fluke (Fasciola hepatica)
Naturofocal zoonosis.
Oral biogelmintoz.
The source of infection and the final host– a human, large and small
cattle, rodents
Intermediate host – freshwater mollusc
Transfer factors - water plants, garden vegetables
Fasciola larvae penetrates mucous membrane of the small intestine
→ liver and bile ducts, pancreas, brain, eyes and other.
↓
↓
Acute migratory phase
Chronic phase
 toxicoallergic effect of  toxicoallergic effect of helminth
helminth metabolic products
metabolic products
→ liver - eosinophilic → mechanical effect
infiltration,
necrosis
of
hepatocytes
↓
 biliary dyskinesia, congestion, bile duct
obstruction, hemorrhage, necrosis →
secondary microflora, inflammation
 cholecystitis, cholangitis
 pancreatitis
 gastrointestinal tract disorders (digestion,
absorption) → increased peristalsis →
malabsorption syndromes
Clinical picture
Acute phase
Subacute phase
(after several weeks)
General toxic and allergic symptoms
 rise of temperature
 skin eruption
 arthralgia
 hepatomegaly, jaundice
↓
Complications
 anemia
 cachexia
Diagnostics
Treatment




Chronic phase
 paroxysmal abdominal pain in
the liver, gallbladder, pancreas
 large liver mass, jaundice
 diarrhea, weight loss, anemia
 secondary microflora
↓
 suppurative cholangitis,
cholecystitis, gallbladder
phlegmon
 liver abscess , jaundice, liver
fibrosis
 acute pancreatitis
 myocarditis
 hemogram: leukocytosis, anemia, eosinophilia
biochemical methods
 increased ALT, AST, bilirubin, dysproteinemia
specific diagnosis
 serological methods (ELISA, TPHA)
 faecal analysis of helminth
 chloxylum
 praziquantel
Prevention
avoid eating aquatic plants
boil water
protection of water sources from faecal contamination
sanitization of infected animals
6. Organizational structure and planning of the course.
Main stages of the course,
functions and content.
1
1. Preparatory stage:
1. Planning a course
2. Goal-setting and
motivation
3. Control of the initial
knowledge
Learn
ing
object
ives in
levels
of
adopti
on
2
Methods of control
and training
3
Contol Interview. Individual
e 2nd survey.
level
Test control.
Methodology
resources (control,
instructions)
4
see. P.1 ”Relevance”;
see. P.2 ”Learning
Objectives”;
Personal interview
questions.
Time
(min.)
5
20 min.
2nd level tests.
Table of contents - see
P.2.1; P.2.2 ”Learning
Objectives”
2. Main stage
Shaping a system of
professional skills.
III
Table of contents see P.2.2; P.2.3 ”Learning
Objectives””
3. Final stage:
 Control and improvement
III
of professional skills
 Summarizing the course
 Homework with the
academic book list
(basic, complementary)
Practical professional
training in dealing with
different (typical and
atypical) clinical tasks.
Patient care supervision.
Anamnesis. Discharge
abstract.
2nd - 3rd
level
situational problems.
Individual control of
practical skills and
professional activities
of the students.
Analysis of common
mistakes.
Test control.
3rd level tests.
60 min.
20 min.