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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.