PARASITIC DISEASES CAUSING ANAEMIA Prof Dr Supargiyono DTMH

PARASITIC DISEASES CAUSING ANAEMIA Prof. Dr. Supargiyono, DTM&H, Ph. D. Sp. Par. K

HABITAT OF THE HUMAN PARASITES l Protozoa l Gastrointestinal l Urogenital l l Blood l l Lymph l Respiratory system l Tissue/body cavity l l l Sarcodina pseudopodia Mastigophora (Flagellata) flagella Ciliophora (Cilliata) cilia Sporozoa ( do not move) PLASMODIUM MALARIA Helminth (Worms) Nemathodes HOOKWORM l Cesthodes l Tremathodes l l Arthropoda

MALARIA Caused by blood protozoa : Plasmodium sp. Infecting human : l P. falciparum malaria; tropical malaria; malignant tertian malaria l P. vivax malaria; benign tertian malaria l P. ovale malaria; tertian malaria l P. malariae quartan malaria l P. knowlesi monkey malaria human

MALARIA LIFE CYCLE Clinical manifestation

Acute attack of malaria l Cold stage l l Hot Stage l l Chill(dingin), rigor(kaku) Fever increased(demam tinggi) Headache(sakit kepala) Flashing face(muka merah) Sweating stage l l l Profuse sweating(banyak keringat) Decrease body temperature(demam turun) Feeling of Relief (fall a sleep) (merasa sehat)

Sporogonic cycle

General Morphol ogy of Malaria Parasite Schufner dots Mature schizont

BLOOD PARASITES: Plasmodium falciparum Mauer cleft Supargiyono 13/07/2011

Thick Smear of Malaria falciparum (heavy infection of young trophozoites) My Picturesfalciparum_thickfilm_1. jpg

Sexual - Gametocyte stages

Plasmodium vivax

Schizont stages P. f. P. m. P. o. P. v.

Sexual - Gametocyte stages

Malaria l P. falciparum causing severe malaria l Clinical manifestation: due to eritrocytic stage l Rupture of IRBC : released Antigens & toxins l Mature trophozoite adhere to endothelial cells l Haemolytic l Periodical anaemia: rupture of mature schizonts l Immune complex INDIRECT rupture of uninfected normal erythrocytes l Marrow suppression by some toxin of malaria parasites Marrow aspirates: dyserythropoiesis, phagocytosis of uninfected red cells

Fig. 3: Schematic representation of resetting and cytoadherence leading to vessel obstruction in P. falciparum infection. Parasites inside red blood cells are depicted as black circle. Arrow shows an infected red blood cell involved in both cytoadherence and resetting. Supargiyono 13/07/2011

Cerebral malaria

Malaria & Pregnancy l Physiological anemia during pregnancy l Microcirculatory arrest in the placenta may cause fetal death, small-for-date babies, and premature stage (mainly in 1 st pregnancy) l Congenital malaria l May occur in all species of malaria but very rare l Progressive hemolytic anemia may accur l

TREATMENT TARGETS

ANTIMALARIALS l TISSUE schizontocides: primaquine (8 aminoquinoline derivatives) l ERYTHROCYTIC schizontocides: l Chloroquine l Sulfadoxine-pyrimethamine l Quinine l Antibiotics l GAMETOCYTOCIDES: primaquine length species dependent l NEW POLICY (2008) ACT l Artemisinine Combination Theraphy

Preparation of thin and thick blood smears

Preparation of thin and thick blood smears

Giemsa staining l l l Thin film were fixed in absolute methanol for 3060 second No fixation for thick smear Prepare 5% Giemsa solution with buffer/destilated water Thick and thin smear were put into 5% Giemsa for 30 minutes Carefully washed off the stain in runing tap water Dry the slides and examined with 100 x objective

Thick & Thin Smear of Malaria heavy infection of young trophozoites of P. f. My Picturesfalciparum_thickfilm_1. jpg

Immuno-chromatographic technology Rapid Diagnostic Test (RDT) RDT for Malaria: detect malaria antigens

Diagnosis Parasitic Infection using Polymerase Chain Reaction (PCR) Every single parasite DNA were amplified thousands time using specific Primers easily detected

Pengobatan malaria falsiparum dengan Dihydroartemisinin+Piperaquin (DHP) dan Primakuin Jumlah tablet perhari menurut kelompok umur Hari Jenis obat 0 -1 Bulan 0 -5 kg 1 2 - 3 DHP ¼ Primakuin ¼ DHP 2 -11 bulan 6 -10 kg ½ ½ 1 -4 5 -9 10 -14 tahun 11 -`7 kg 18 -30 kg 31 -60 kg > 15 tahun >61 kg 1 1, 5 2 3 - 4 ¾ 1½ 2 2– 3 1 1, 5 2 3 - 4 Dihydroartemisinin = 2 -4 mg; Kg BB Piperakuin = 16 -32 mg/Kg BB Primakuin = 0, 75 mg/Kg BB (untuk membunuh gametocyte)

Pengobatan malaria vivak dengan DHP+Primakuin Jumlah tablet perhari menurut kelompok umur Hari Jenis obat 0 -1 Bulan 0 -5 kg 1 -3 1 -14 DHP Primakuin ¼ - 2 -11 bulan 6 -10 kg ½ - 1 -4 tahun 11 -`7 kg 5 -9 tahun 18 -30 kg 10 -14 tahun 31 -60 kg > 15 tahun >61 kg 1 1, 5 2 3 - 4 1/2 3/4 1 Dosis Primakuin = 0, 25 mg/Kg BB selama 14 hari (membunuh gametosit dan hypnozoit dalam sel hati)

Pengobatan Malaria falsiparum dg Artesunat-Amodiakuin Jumlah tablet perhari menurut kelompok umur Hari 1 2 -3 Jenis obat 0 -1 Bulan 0 -4 kg Artesunat ¼ Amodiakuin ¼ Primakuin 2 -11 bulan 4 -10 kg > 15 tahun >60 kg 1 2 3 4 ½ 1 2 3 4 - ¾ 1½ 2 2– 3 Artesunat ¼ 1 2 3 4 Amodiakuin ¼ ½ 1 2 3 4 Artesunat = 4 mg/Kg BB Amodiakuin = 10 mgk. Kg BB Primaquin 0, 75 mg/Kg BB ½ 1 -4 5 -9 10 -14 tahun 10 -20 kg 20 -40 kg 40 -60 kg ½

Pengobatan Malaria vivak dg Artesunat -Amodiakuin dan Primakuin Jumlah tablet perhari menurut kelompok umur Hari Jenis obat Artesunat 1 -3 1 -14 Amodiakuin Primakuin 0 -1 Bulan 2 -11 bulan 1 -4 tahun 5 -9 tahun 10 -14 tahun > 15 tahun 0 -4 kg 4 -10 kg 10 -20 kg 20 -40 kg 40 -60 kg >60 kg ¼ ¼ - ½ 1 2 3 4 - 1/4 1/2 3/4 1 Artesunat = 4 mg/Kg BB Amodiakuin = 10 mgk. Kg BB Primaquin 0, 25 mg/Kg BB selama 14 hari

HOOKWORMS soil transmitted helminth 1. Ancylostoma duodenale 2. Necator americanus 3. Ancylostoma braziliesis 4. Ancylostoma cyelanicum 5. Ancylostoma caninum

Ancylostoma duodenale l ADULT WORM : - CURVED BODY LETTER C FEMALE : 10 - 13 mm 0, 6 mm MALE : 8 - 11 mm 0, 5 mm - MOUTH : 2 PAIRS OF TEETH SAME SIZE - COPULATRIX BURSAE : EXTERNOLATERAL MEDIOLATERAL and POSTEROLATERAL sternum are separated each other - SPICULE MALE: A PAIR, PARALLEL

Necator americanus l ADULT WORM : s - CURVED BODY - MOUTH: A PAIR OF CHITINOUS CUTTING PLATES - FEMALE : 9 -11 mm 0, 4 mm - MALE : 7 -9 mm 0, 3 mm - BURSA COPULATRIX (RAYS) EKSTERNOLATERAL sternum (el) is separated from MEDIOLATERAL st (ml). which is attached to POSTERO- LATERAL st. (pl) - SPICULE IN MALE: A PAIR, POINTED TIP

Life cycle l Definitive host : human/animal EGGS RHABDITIFORM LARVA FILARIFORM LRV DAMP, SHADE, WARM HOST’S SKIN PREPATENT P. 6 – 10 mo FAECES DEFINIT IVE HOST SMALL INTESTINE ADULT WORM SOIL: VENOUS BLOOD RIGHT HEART LUNG PENETRATES ALVEOLI BRONKHUS TRAKHEA PHARYNX

Life cycle of Hookworm

PATHOLOGY & CLINICAL SIGNS l LARVA PENETRATES THE INTACT SKIN hair follicle MACULO PAPULES & ERYTHEMATOUS ITCHY GROUND ITCH / DEW ITCH LARVAE (MANY) MIGRATE TO LUNGS, SENSITIVE INDIVIDUAL BRONCHITIS / PNEUMONITIS l CHRONIC INFECTION iron-deficiency in type + folate deficiency ANAEMIA : MICROCYITIC HYPOCHROMIC l Anaemia does not develop until iron reserves are exhausted, after a prolonged period of negative iron balance.

FACTORS GENERATING ANAEMIA 1. WORM LOAD (N. americanus causes blood loss of 0. 05 ml/day) 2. SPECIES OF WORM (A. DUODENALE CONSUMES 4 -5 TIME than N. a A DAY) (0. 15 vs 0. 05 ml/day/worm) 3. IRON INTAKE (4 -40 MG /DAY) 4. AVAILABILITY OF IRON IN DIETS (high phytic acid intake reduces the iron intake) 5. Disturbance of IRON ABSORPTION 6. THE PRESENCE OF OTHER CONDTION INCREASING IRON DEMANDS (pregnancy, menstruation)

PATHOLOGY & CLINICAL SYMPTOM ARE POSITIVELY ASSOCIATED TO WORM DENSITY & FOOD INTAKE * 50 WORMS SUB CLINICAL * 50 – 125 WORMS CLINICAL SYMPTOM MAY APPEAR * 500 WORMS BODY WEIGHT DEPENDENT SYMPTOMS IN ACUTE INECTION: * APPETITE - / + * NAUSEA, VOMITING * DIARHOEA, CONSTIPATION * HYPERTROPHY OF HEART SOUNDS * QUICK PULSE , EOSINOPHILIA HEAVY INFECTION IN CHILDREN PHYSICAL & MENTALLY DISTURBED ANEMIA

• DIAGNOSIS Clinical : - WEAKNESS (TIREDNESS) - ACHING MUSCLES - SHORT BREATH (BREATHLESSNESS) - OEDEMA (related to heart failure and low serum albumin) - PALE (Pucat) - DYSPHAGIA - KOILONYCHIA (typical of iron deficiency) - SMOOTH RED TOUNGUE AND ANGULAR STOMATITIS (RARE)

RADIOLOGY : - HIPERMOTILITY OF INTESTINE LABORATORY : - FINDING THE EGGS IN FAECES * QUALITATIVE : DIRECT & CONCENTRATION * QUANTITAIVE : KATO METHOD INTENSITY * CULTURE HARADA MORI IDENTIFICATION L. Filariform larvae MORE SENSITIVE

Ancylostoma ceylanicum l ADULT : - BODY: CURVED C FEMALE : 7 mm MALE : 5 mm - MOUTH : ROUND OPENING 2 PAIRS VENTRAL TEETH, 1 PAIR INNER LITTLE TEETH 1 PAIR OUTER BIG TEETH - COPULATORY SEGMENT : EXTERNO LATERAL ST. SEPARATED FROM 2 LATERAL STERNUM SITTING SIDE BY SIDE

Ancylostoma caninum l ADULT : - FEMALE: 14 mm 0, 6 mm - MALE : 10 mm 0, 4 mm - MOUTH : 3 PAIRS OF STRONG TEETH - COPULATORY SEGMENT : ALL THREE STERNUM ARE LONG AND SEPARATED EACH OTHER

CREEPING ERUPTION LARVA FIL HUMAN SKIN STRATUM GERMINATIVUM TUNNEL MOVES FEW mm – cm / DAY WEEKS/MONTHS CUTANEUS LARVA MIGRAN SKIN LESSION : - ERYTEHMA - VESICLE - ITCHY SECONDARY INFECTION PUSTULE SYMPTOM: ITCHY & HOT SKIN DURING LARVA INVASION DIAGNOSIS : - CREEPING SKIN LESION