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The common and uncommon cestodal infestation encountered in routine histo -
pathological practice from a semi-urban population in south India and their public
health importance.
Ramkumar Kurpad R *, Shuba S , Prakash H Muddegowda , Jyothi B Lingegowda
a c a a
A R T I C L E I N F O A B S T R A C T
Keywords:
Case Report
Parasitic infestation
Histopathology
Cestodes
Parasites are encountered uncommonly in routine histopathologic practice. Among them,
cestodes form a major bulk. Cysticercosis heads the list forming the bulk of cases followed by
Hydatidosis and Sparganosis. Microscopic identification of inflammation with surrounding
reactions along with other morphological features forms the mainstay of diagnosis of parasitic
diseases on histopathology. Identification of the parasites on histopathological examination
would reduce the cost-diagnosis ratio avoidingexpensive serological investigation.
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Contents lists available at Direct PublicationsCurrentSci
Journal homepage: www.currentscidirect.com
International Journal of Current Scientific Research
Int J Cur Sci Res. 2011; 1(2): 48 – 51.
CurrentSciDirect
Publication
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* Professor & aAssistant professor, Department of Pathology, VMKV Medical College, Salem, Tamil Nadu, INDIA
Consultant Physician, Vinayaka Missions hi-tech hospital, Salem, Tamil Nadu, INDIA
* Corresponding Author : Dr. Ramkumar Kurpad
Professor, Department of Pathology, VMKV Medical College,
Seeragapadi, Salem – 636 308. Tamilnadu. India.
Email: medicoprakash@yahoo.com
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1. Introduction
1.1.Case details
1.2. Discussion
1.1.Case details
Generally parasitic lesions account for 0.1 to 0.5% of all
histopathological lesions in our country. A majority of these are
cestodal in nature. Tapeworms (cestodes) are segmented worms,
the adult forms of which are encountered in gastrointestinal tract,
whereas the larvae can be seen in almost anyorgan in the body.
The specimen most frequently submitted for detectionof parasites
is stool for the identification of ova or cysts. Specimens are
obtained based on radiological investigations or are usually an
incidental finding. The major advantages of histopathology are
speed, low cost and presumptive identification. Hematological
investigations like presence of eosinophilia in peripheral blood
could give a clue about parasiticinfestation [1,2].
Ours being a semi-urban hospital with many patients coming
from rural areas, wereceive specimens resected as a subcutaneous
nodule, abscess, lymphadenopathy, gynaecomastia or labeled as
soft tissue sarcoma ultimately yielding a cestode with tissue
reaction. This article presents an overview of parasites
encountered in our institution overthe past two years.
Cysticercosis is the commonest cestodal infection encountered
in histopathological practice and forms a major public health
problem worldwide. It occurs due to ingestion of contaminated
vegetables and food or under cooked meat. Auto-infection can also
occur [2].
The life cycle of the cestode, T.solium involves an intermediate
host, normally the pig, for the cystic form of the parasite and a
definitive host, normally man, for the adult form or the tapeworm.
However, persons infected by T.solium eggs can also serve as hosts
for the cystic form, which affects various tissues of the body, most
commonly central nervous system followed by sub-cutaneous
tissue, muscle, eye and rarelyother parts of the body [2,3].
Sex
Female
Male
Male
Male
Male
Female
Male
Female
20
18
22
68
15
28
15
8
Neck
Neck
Thigh
Neck
(Submandibular)
Chest wall
Cervical
lymphnode
NeckChestwall
Intact larva
Degenerated larva
Degenerated larva
Intact larva with
secondaries (SCC)
Intact larva
Intact larva
Intact larva
Intact larva
Age
(in years)
Location Histopathology
The diagnosis of human cysticercosis can be made by radiologic
imaging, tissue biopsy, or serology. Radiologic imaging, including
MRI and CT, currently is the most effective means for diagnosis
[2,3].
Cysticercus forms the commonest parasitic infection of the CNS
(Neurocysticercosis). In the CNS, they cannot grow into worms,
and remain as cysts indefinitely. The cysts are usually found in
Cerbral cortex, but can occur in meninges of the base of the brain,
in the ventricles and rarely in the spinal cord. Compared to other
sites, diagnosis in these cases is not feasible as routine biopsy is
impossible. Diagnosis usually rests on interpretation of patients
symptoms, radiological studies and immunological tests for
dec tection of anti-c ysticercal antibodies (Enzyme- linked
immunoelectrotransfer blot) [2-4].
Definite diagnosis on histopathology (Fig 1 A&B) requires
visualization of the parasite. The live parasite has a single scolex
with four suckers and a double row of hooklets. The cyst wall has
an outer cuticular layer, a middle pseudo epithelial layer, and an
inner reticular layer.In excision biopsies, only the cuticular layer of
deadworm in appreciatedon H&E stain[2].
Rarely can it present in the form of subcutaneous nodules in the
chest, thigh or arms. Histopathology would reveal a cysticerci
larvae with surrounding host response composed of fibrosis,
chronic inflammatory infiltrate with eosinophils and sometimes
giant cells. Sometimes, cysticercosis can coexist with secondaries
2.1. Discussion
Echinococcosis is a zoonotic infection caused by tapeworms of
the Taeniidae family. Human infection is often considered an
occupational public health problem for the sheep (intermediate
host) farmers, ranchers, or shepherds in endemic regions. There is
however, a risk of infection from dog (definitive host) contact, dog
feces, or food contaminated with eggs of E.granulosus.2,5
Fig 1(A and B): Section of Cysticercosis showing inflammatory
host response (A) H&E (10x). Section of cysticercosis (B) H&E
(10x)
Fig 2 (A and B): Gross specimen showing resected lobe of lung
with fragments of laminate membrane (A). Microscopy
showing numerous folded delicate laminate membranes (B).
H&E (10x)
in lymphnode or Hodgkins of mixed cellularity type. Due attention
should be paid to any co-existent disease lest, we miss them. As
similar c hanges are en co untered, it is critical for the
histopathologist to differe nt ia te b et ween i nf la mm at or y
conditions caused by infectious agents from those with non-
infectious etiology [1,3,4].
2. Case details
A 37 year old farm laborer presented with history of cough and
vague chest pain of few months duration. Chest radiograph
revealed irregular masses in right middle zone with specks of
calcification and fluid levels in a few of the cysts. Cyst was excised
with lobectomy of the lung. The cystic mass measured 8x7x5 cm
(Fig 2A). It was opalascent gray white in color. Cut section exuded
about 50 ml of fluid and many daughter cysts with broodcapsules.
Microscopy revealed a lamellated membrane (Fig 2B) with many
scolices diagnostic of Echinococcosis. Surrounding lung showed
granulation tissue and bronchiectatic changes.
Group II
Ramkumar Kurpad R. et al. / Int J Cur Sci Res. 2011; 1(2): 48 – 51.
49
The most common site for hydatidcyst is liver followed by lung and
others. The cyst wall shows contribution from both the cestode as
well as the host and is composed of three layers. The outer host
layer or pericyst is composed of fibroblasts, giant cells and
eosinophils. The middle laminated membrane is a acellular
chitinous layer 2 mm thick. The inner germinal layer is thin and
translucent. Scolices originate from the membrane in the form of
evaginations called brood capsules. Special stains like modified
AFB stain for hooklets and GMS stain for chitinous cellular wall can
be done. Alternately, the hooklets can be visualized as refractile
structures against background debris. It is the commonest cestode
pathogen affecting the lung.2,5,6
The eggs develop into embryos which penetrate intestinal
mucosa and enters various organs via portal circulation. The
larvae develop into fluid filled hydatid cysts. Daughter cysts may
develop from germinal layer giving rise to brood capsules.
Sometimes the cysts may get secondarily infected with
suppuration. Mode of presentation depends on the organ involved
and location of cyst.2
FNAC is contraindicated in a suspected case as the rupture of
cyst could lead to serious anaphylactic shock. Diagnosis of
hydatidosis in man is made by Casoni's test, by detecting
protoscolices in hydatid cyst fluid or by detecting antibodies to
cyst fluid antigen.2,5,6
A mi dd le ag ed man was di agn os ed wi th unil ateral
gynaecomastia which was excised and sent forhistopathology. The
cystic mass was oval, greywhite in color ms 5x3 cm (Fig 3A). C/s
revealed a worm 0.5cm long and 15 ml of turbid fluid. Microscopy
revealed the worm having thick tegmentum with calcospheroites
in sub-tegmentum (Fig 3 B&C) which was surrounded by wall of
granulation tissue diagnostic of Sparganosis.
Fig 3 (A,B and C): Excised specimen showing cut open cyst (A).
Section of Parasite showing Calcareous spherules and muscle
fibres (B &C) – Masson Trichromestain (40x).
Sparganosis are the larvae of Diphyllobothrium species of
genus, spirometra. The parasite has a complex life cycle with dogs
and cats as definitive hosts. Humans are usuallyinvolved as second
intermediate hosts. It is transmitted by consumption of snakesand
frogs (II intermediate host). Transmission to humans usually
occurs through ingestion of water contaminated with infected
Cyclops (I intermediate host) or consumption of contaminated
meat. Sometimes application of frogs as poultice over burns and
wound also transmits the disease. Once a parasite enters the
human body, an aberrant life cycle starts resulting in a cyst like
structure.2,7
The histological features are similar in any tissue being
characterized by a necrotizing and granulomatous inflammation
with or without worm parasite in the lesions. The surrounding
lesion is predominantly composed of eosinophils, plasma cells and
lymphocytes. In the absence of worm, laminated calcospherules
found in the cytoplasm of the proliferating macrophages and giant
cells could be of diagnostic value.7
If the worm is viable, section of the worm would show
dorsoventral flattening, thick, slightly wavy eosinophilic tegument
overlaying a layer of radially oriented subparenchymal cells, well
developed longitudinal bundle of smooth muscles consisted of
dorsoventral and transverse fibres, arranged at right angle to each
other.2,7
The mic roscopi c di fferential diagn osis usually include s
trichinosis, cysticercosis (racemose variant), and visceral larvae
migrans.7
3.1.Discussion
Group III
3. Case details
Ramkumar Kurpad R. et al. / Int J Cur Sci Res. 2011; 1(2): 48 – 51.
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Copyright 2011. CurrentSciDirect Publications. - All rights reserved.IJCSR
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Parasitic infections are endemic in the rural and semi-urban
communities in developing countries. Utility of histopathology in
diagnosis is well established. Histopathological identification of
the parasite based on its morphological features, host tissue
response and in unconfirmed cases, coupled with serology and
molecular diagnosis could help to successfully characterize the
parasite. Effectivecommunication between clinicians, radiologists
and pathologists often lead to correct diagnosis in many difficult to
diagnose diseases.
Public health measures such as good sanitation and personal
hygiene measures such as washing of hands with soap and water.
Washing of utensils and vegetable with clean water, prevention of
sewage contamination of drinking water, safe disposal of waste,
play a vital role in avoiding cestodal infections. Sanitary measures
in abattoirs and treating pet dogs with Anti-helminthics also help.
Even though this article does not actually represent the incidence
of cestodal infections in a population, it should be emphasized that
pathologists play an important role in identifying the parasite.
Information should be passed onto general public and patients
in particular regarding the potential role of cestodes in incidence
of malnutrition and morbidity in populations so that preventive
steps are initiated and appropriate measures are taken given to
prevent spreadof the disease.
[1] Gupta E, Bhalla P, Khurana N, Singh T. Histopathology for the diagnosis of
infectious diseases. IJMM. 2009:27(2):100-106.
[2] Kradin RL. Diagnostic pathology of infectious diseases. Saunder Elsevier,
Philadelphia. 2010.
[3] Diagnosis of Cysticercosis in endemic regions. Garcia HH, Martinez M,
Gi lm an R , He rr er a G, Ts an g VCW, P il ch er J B, e t al . La nc et.
1991;338(8766):549-551.
[4] A Histopathological study on human cysticercosis. Chi HS, Chi JG. The
Koreanjournal of parasitology 1978;16(2):123-33.
[5] Human cystic echinococcosis in a Uruguan Community: A sonographic,
serologic and epidemiologic study. Cohen H, Paolillo E, Bonifacino R, Botta
B, ParadaL, Cabrera P,et al. Am J Trop Med Hyg. 1998;59(4):620-7.
[6] Carmona C, Perdomo R, Carbo A, Alvarez C, Monti J, Grauret R, et al. Risk
factors associated with human cystic echinococcosis in Florida, Uruguay:
Results of a mass screening study using ultrasoundand serology. Am J Trop
Med Hyg. 1998;58(5):599-605.
[7] Chi JG, Chi HS, Lee SH. Histopathologic study on human sparganosis. The
Koreanjournal of parasitology. 1980;18(1):15-23.
4. Conclusion 5. References
Ramkumar Kurpad R. et al. / Int J Cur Sci Res. 2011; 1(2): 48 – 51.
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