DIPHYLLOBOTRIASES (diphyllobothrioses; synonym: bothriocephaloses, dibothriocephaloses) — helminthoses from group of tsestodoz which activators are the lenteets relating to Pseudophyllidea Carus group, 1863, the sort Diphyllobothrium Cobbold, 1858. The person for lentets is a final (definitivny) owner, helminths are localized at it in a small intestine where reach puberty.
Activators D. of the person: Diphyllobothrium latum (Linnaeus, 1758) Liihe, 1910 (synonym: Bothriocephalus latus, DibothriocephaJus latus, Taenia lata) — a tape-worm wide (fig. 1); D. cordatum (Leuckart, 1863) — a tape-worm heart-shaped; D. tungussicum Podjapolskaja et Gnedina, 1932 — a tape-worm Tungus; D. skrjabini Plotnikoff, 1933 — Scriabin's tape-worm; D. giljacicum Rutkewich, 1937 — a tape-worm of gilyatskiya;
D. luxi Rutkewich, 1937 — Luks's tape-worm; D. nenzi Petrow, 1938 — a tape-worm Nenets, D. dendriticum (Nitzsch, 1824) — a tape-worm of seagulls. There are some other types of this sort parasitizing at mammals and birds. A systematics difillobotriid, and the sorts Diphyllobothrium in particular, cannot be considered as finally studied still. Diphyllobothrium latum (Linnaeus, 1758) Luhe, 1910 is known since the beginning of 17 century M. Brown in 1883 proved that infection of the person D. occurs through fishes (a pike and a burbot) who are additional owners of a tape-worm wide. To. Yanitsky and F. Rosen in 1917 established that intermediate owners of this helminth are fresh-water crustaceans — a Cyclops and diaptomusa. The characteristic of some types of the sort Diphyllobothrium is presented in the table.
Belong to natural and focal diseases which spread is connected with a certain environment. Definitivny owners for the majority of activators D. are the person, a dog, a cat, a bear, a fox, sometimes a pig. For some types of lentets (D. dendriticum) the main definitivny owners — fish-eating birds (seagulls, cormorants) though parasitizing at some other birds (a crow, a soroka), and also at the person and mammals is possible. Intermediate owners of lentets are the fresh-water crustaceans belonging to the sorts Cyclops, Diaptomus, etc. Additional owners — a pike, a burbot, a perch, a ruff, a grayling, an omul and some other fishes. With excrements of definitivny owners to the environment eggs of lentets are allocated. At hit of eggs in water in 3 — 5 weeks in them the larvae covered with cilia — koratsidiya which hatch from eggs are created and come to light. In water they are swallowed by crustaceans; from a digestive tract of crustaceans of a koratsidiya get into a cavity of their body and in 2 — 3 weeks develop in a larva of the second stage — procercoid. Crustaceans serve as food for a number of species of fish; the last together with crustaceans swallow procercoids which in their body turn in plerotserkoid. Plerotserkoida of a wide tape-worm are located in a perigastrium of fish, in her muscles, a liver, ovaries and other bodies; plerotserkoida of D. dendriticum are localized a gullet, a stomach, capsular on an outside wall, and intestines of fish. Predatory fishes can be infested by plerotserkoida and from other fishes who are their production, and also during the eating of the fish waste dumped sometimes in water by the fish-processing plants. The person and other definitivny owners catch D. at food the fish containing plerotserkoid of lentets. Thus, epidemiol, the chain consists of the following links: the person and other definitivny owners —> crustaceans (a Cyclops, etc.) —> fish —> the person and other definitivny owners (fig. 2).
Pollution of lakes and rivers invasive material — excrements of sick people — comes from the bathrooms built over water and on coast of reservoirs and also from steamships, barges and other vessels; the particles of excrements containing eggs of lentets communicate in reservoirs from the soil rain and melt waters. Caused by D. dendriticum is connected with wildings, and also fish-eating birds who sometimes become a source of an invasion for crustaceans that can cause developing of diseases and among people (through fishes).
The population living on coast of lakes to a thicket catches D., than living on coast of the large rivers. After mass treatment at non-compliance with preventive actions the prevalence of the population in D.'s centers of lake type quickly (approximately in a year) reaches initial level. In the centers of river type this process is more long. In D.'s distribution, except fecal pollution of reservoirs, insufficient level a dignity. cultures of the population, extent of development of fishery and specific weight of fishes in it (additional owners of lentets), and also feeding habits of the population matters. In particular, D. are especially eurysynusic in those areas where the population eats the crude, poorly salted, slightly frozen fish (stroganina) and insufficiently salted caviar. More often fishermen and their families catch. Population shift, the infected D., to places, free from them, can cause emergence of the new centers.
Lentetsa damage an intestinal wall bodies of an attachment — botridiya, to-rymi they restrain a mucous membrane; in certain cases accumulation of parasites can cause impassability of intestines. The sensitization of an organism metabolic products of helminths leads to development of an allergy (see), the cut is one of manifestations the eosinophilia of blood which is quite often observed at D. most sharply expressed in an early stage of a disease. As a result of mechanical, and it is possible, and toxic irritation dysfunctions of a stomach and other bodies, and in some cases — epileptiform attacks arise lenteets.
S. P. Botkin in 1884 the first revealed communication between parasitizing of a wide tape-worm and development of anemia. G. F. Lang (1940) specified that endogenous avitaminosis — deficit in an organism of vitamin from a complex B is the cornerstone of a pathogeny of difillobotriozny anemia.
Endogenous insufficiency of polyneuramin is the cornerstone of a pathogeny of difillobotriozny anemia 12 and, perhaps, folic to - you (see. Vitamin deficiency ). It is established that polyneuramin 12 is in lenteets in much bigger quantity, than in other helminths. However to explain developing of avitaminosis In 12 only absorption of this vitamin by a tape-worm it is impossible since at some persons anemia does not develop, despite massiveness of an invasion. Perhaps also disturbance of biosynthesis folic to - you in intestines as a result of dysbacteriosis. Developing of endogenous avitaminosis is promoted also by the akhiliya of a stomach and enteritis which are quite often developing at D. Usually it does not lead to development of the expressed anemia, at disturbance of exchange of vitamins and at reduction of receipt them with food absorption In 12 parasite, probably, is that accessory factor which promotes developing of avitaminosis and development of anemia. Are connected with avitaminosis change of normoblastic type of a hemopoiesis megaloblastichesky and development of a glossitis and funicular myelosis.
The pathological anatomy
In rare instances of death at difillobotriozny anemia after opening is noted an anemization of bodies, a hyperplasia of marrow, a hemosiderosis of a liver, kidneys, spleens, marrow, fatty dystrophy of a myocardium, hemorrhage in a pericardium, an endocardium, at the bottom of an eye, in a gullet.
A clinical picture
D. often proceed at a slight wedge, the phenomena. Patients usually complain of nausea, is more rare vomiting, pains in epigastriums or on all stomach, arising out of communication with meal, decrease, increase in appetite, an unstable chair is more rare. At certain patients epileptiform spasms and obturatsionny Ilheus were observed. At development anemias (see) there are a weakness, drowsiness, dizzinesses, falling of working capacity, the burning sensation and pains in language, sometimes paresthesia is frequent. The unpleasant feelings in language which are becoming aggravated at drug intake, acid and salty food often are the main complaint of patients. Occasionally there are pains during the passing of food on a gullet. At a severe form of anemia integuments are pale, with a yellowish shade, the person odutlovato, hypostases standing and a waist sometimes develop. The hypodermic fatty layer is, as a rule, kept. Temperature is usually subfebrile, increases to 38 — 39 ° less often. The research of the alimentary system often establishes existence of a glossitis of Gunter — bright red painful spots and cracks in language (see. Glossitis ). Sometimes the same changes arise on gums, mucous membranes of cheeks, the sky, a throat, a gullet. Later the acute phenomena abate, there is an atrophy of nipples of language which becomes smooth, brilliant, «varnished». The stomach is blown often up, a chair quite often liquid, plentiful. The liver and a spleen are sometimes increased. At 80 — 90% of patients absence free salt to - you is noted, but at some patients contents it can reach high figures. The number of erythrocytes decreases sometimes to 500 000 in 1 mkl blood below, and amount of hemoglobin — to 10 — 15 pieces. A color indicator, as a rule, high, but it is sometimes lower than unit. ROE is accelerated. In blood serum the content of bilirubin which gives indirect reaction is increased. In a blood smear find megaloblasts which quantity is usually small; sometimes normoblasts and erythrocytes meet the remains of nuclear substance — Joly's little bodies and Cabot's rings. Existence of hyperchromic macrocytes and megaloytes is characteristic; there are also poikilocytes, bazofilno punktirovanny and polychromatophilous erythrocytes. As a rule, the leukopenia is observed, but sometimes the number of leukocytes are normal and there is even a leukocytosis; the leukocytic formula is characterized by a relative lymphocytosis and a neutropenia with existence of the big polysegmented neutrophils; the eosinophilia is changeable. Thrombocytopenia is often noted.
At anemia tachycardia, small expansion of borders of heart, the soft, blowing systolic noise at a top of heart, venous noise of «top», decrease in the ABP are observed. Changes from a nervous system in the form of funicular myelosis (see) meet at difillo-botriozny anemia also often, as well as at Addison's disease — Birmera. Byyorkengeym (G. Bjorkenheim, 1951) established existence nevrol. symptoms at 79% of patients with difillobotriozny anemia. Easy manifestations of a myelosis in the form of paresthesias, unsharp disturbance of superficial and deep sensitivity are usually observed.
The expressed forms of anemia of pernicious type meet at D. quite often and are registered both at adults, and at children. Data of different authors on the attitude of number of patients with anemia towards total number of the persons infested by lenteets are not identical: the expressed and severe forms of anemia were noted, according to one authors, at 5,5%, according to others — at 2,9% and, according to the third — at 1,5% of sick. These distinctions are connected with time and the place of inspection, feeding habits and life of the population, with various approach to recognition of anemias. So, in Finland increase in number of patients with difillobotriozny anemia in the years of World War II is noted. In the spring anemia meets more often than in other season. Usually only the expressed and severe forms are registered though N. I. Ragoza in 1913 emphasized that considerably at D. lungs, the erased forms of anemia of pernicious type meet more often. Some patients have a number of erythrocytes and amount of hemoglobin is in limits of norm, but measurement of diameter of erythrocytes shows existence of a makromegalotsitoz (see. Eritrotsitometriya ). This phenomenon was observed at experimental infection of people of D., and the macrocytosis after deworming became considerably less expressed. The number of erythrocytes and amount of hemoglobin remained normal all the time. Almost all cases of anemia are described only at an invasion by a wide tape-worm, and only V. P. Podjyapolskaya (1931) established it and at an invasion by the Tungus tape-worm.
the Diagnosis is established by a research of excrements on eggs of lentets (see. Helmintologic methods of a research ). Often patients complain of an otkhozhdeniye at defecation of fragments of parasites. Allocation of scraps strobiles, but not separate joints, as is characteristic of an invasion lenteets at an invasion a bull tapeworm (see. Teniidoza ). Difillobotriozny anemia is distinguished without effort at a combination of physical inspection of the patient to blood tests too. Changes of language are characteristic, but it is necessary to remember that the glossitis is observed also at Addison's disease — Birmera, to a spr, a pellagra. Clinically and hematologic difillobotrioziy anemia has looking alike Addison's disease — Birmera (see. Pernicious anemia ). The differential diagnosis between them can be carried out by a research of a gastric juice on availability of gastromucoprotein which is absent at Addison's disease — Birmera and is available at difillobotriozny anemia.
Specific treatment at D. is carried out by phenasal, radio extract of a men's fern, pumpkin seeds, quinacrine. Treatment by pumpkin seeds and phenasal can be carried out in house conditions, other drugs — only in a hospital. Phenasal is appointed in doses: to children up to 5 years — 0,5 — 1 g — 9 years — 1 — 1,5 g, 10 — 12 years — 1,5 — 2 g, since 13 years and adult — 2 g. Special training of the patient is not required, only the day before and in day of treatment digestible food is recommended. Drug is given on one of the following schemes.
1. In the evening in 3 hours after an easy dinner give 1/4 chayn. l. dry baking soda, to-ruyu wash down 1/4 glasses of water. In 10 min. the patient drinks carefully stirred suspension of phenasal in 1/2 glasses of warm sweet water or kissel.
2. Phenasal is appointed in the morning on an empty stomach. The patient accepts soda and then phenasal as it is stated above. Laxative after reception of phenasal is not appointed.
3. Phenasal is appointed to night, and in the morning, approximately in 14 hours after its reception, the patient accepts 30 g of laxative salt.
4. Phenasal is appointed to night; in 30 min. after reception of phenasal of the patient accepts 2 g of Pancreatinum.
At treatment phenasal often allocates only scraps of helminth or it does not depart at all and is digested in intestines owing to damage by drug of a cover of a parasite. Therefore the conclusion about efficiency of treatment is possible only on the basis of the analysis a calla on eggs of helminth which should be carried out in 1 — 2 month.
At treatment extract of a fern the night before drink salt laxative, in the morning in day of reception give an enema. Extract of a fern is accepted on an empty stomach capsular or in mix with honey, jam, semolina porridge within half an hour; in an hour laxative; in the absence of a chair in 3 hours give an enema; in case of an exit of a parasite without scolex (head) the enema is done 1 — 3 more time. Efficiency of treatment increases at reception of extract of a fern with 1% solution of bicarbonate soda (0,5 — 1 glass); laxative after reception of extract with soda is appointed in half an hour. At D. it is not necessary to apply high doses of extract of a fern: for adults 3 — 4, at most 5 g there are enough. To children and teenagers appoint the following doses of extract of a fern (in grams): 2 years — 0,5; 3 years — 1,0; 4 years — 1,5; 5 — 6 years — 2,0; 7 — 10 years — 2,5; 11 — 16 years — 3 — 3,5.
Contraindications to purpose of extract of a fern: diseases of cardiovascular system in the period of a decompensation, diseases of a liver, kidneys, cankers of a stomach and intestines, acute went. - kish. diseases, feverish diseases, pregnancy, the first 3 — 4 months of a lactation, menstrual period, exhaustion, senile age.
At treatment pumpkin seeds preparation is carried out 2 days: in the first day for the night — an enema, in the second day — laxative. In the morning in day of deworming — an enema. Seeds can be prepared in two ways: a) the seeds which are carefully pounded in a mortar, cleared of an outside firm shell accept on an empty stomach in the small portions within an hour; in 2 — 3 hours laxative; the dose of the cleared seeds for adult 300 g, to children is 10 years — 150 g, 5 — 7 years — 100 g, 3 — 4 years — 75 g; b) the crude, dried-up on air crude seeds crush in the meat grinder or a mortar, fill in with a double amount of water and mix is heated on the water bath by 2 hours; broth is filtered through a gauze, remove a fat film from its surface, cooled and allowed the patient to accept on an empty stomach within 20 — 30 min.; in 2 hours appoint salt laxative; for adults broth is prepared from 500 g of seeds, children are 10 years old — from 300 g, 5 — 7 years — from 200 g, to small children — from 100 — 150 g. Efficiency of treatment by pumpkin seeds increases at appointment in 30 — 60 min. after their reception of the dose of radio extract of a fern lowered twice.
At treatment quinacrine on the eve of administration of drug appoint salt laxative, in the morning in day of its reception — an enema. Drug is accepted on an empty stomach on 1 — 2 tablets (0,1 — 0,2 g) by each 5 — 10 min. In 1 hour after reception of the last tablet appoint salt laxative. A dose of quinacrine (in grams): for adults 0,8; to children of 3 — 4 years — 0,15 — 0,2; 5 — 6 years — 0,25 — 0,3; 7 — 9 years — 0,35-0,4; 10 — 12 years - 0,45-0,5; 13 — 14 years — 0,6; 15 — 16 years — 0,7.
Contraindications: mental diseases, psychopathies, disorders of secretory function of nights.
Control of efficiency of treatment by extract of a fern, seeds of pumpkin and quinacrine make by a research a calla on existence a strobile and heads of lentets. Existence in Calais of heads of helminths does not demonstrate full treatment since a part of parasites can remain in intestines. Therefore in 1 and 2 months (at the first negative take) it is necessary to make a check analysis a calla on eggs of lentets.
At the expressed difillobotriozny anemia before purpose of anthelmintics carry out pathogenetic therapy by cyanocobalamine (polyneuramin 12 ), which is entered intramusculary daily or every other day on 100 — 200 mkg on an injection during 3 — 4 weeks. At a funicular myelosis the single dose of cyanocobalamine is raised to 500 — 1000 mkg and entered 10 days daily, then 1 — 2 time a week before disappearance of symptoms of a disease. After improvement of composition of blood make deworming. In D.'s centers its combination to Addison's disease — Birmera is possible, at a cut in case of the termination of pathogenetic therapy inevitably there comes a recurrence. Therefore patients with anemia of pernicious type after the carried-out therapy are subject to dispensary observation.
Quality of a diet and specific features of an organism are of great importance. Food rich with polyneuramin 12 (e.g., a crude liver), maybe, it is obvious, to prevent development of anemia. Content of polyneuramin 12 in an organism of various persons fluctuates in very wide limits, and it is possible to assume that difillobotriozny anemia arises at persons with the state close to avitaminosis quicker.
the Forecast at D. if the patient has no expressed anemia, favorable since treatment usually leads to full elimination of an invasion. Before introduction of therapy by polyneuramin 12 the forecast at severe forms of difillobotriozny anemia was very serious; sometimes patients perished before deworming, and in case of purpose of high doses of extract of a fern — and after it. On condition of timely recognition of a disease and use of effective methods of pathogenetic therapy there comes the absolute recovery.
the Possibility of infection of D. is excluded during the cooking of fish and her careful prozharivaniye that affects perniciously plerotserkoida of lentets. Plerotserkoida of a wide tape-worm at a salting pikes in strong brine (24 ° over Baume) depending on the weight of fish perish in 2 — 7 days. Freezing of pikes weighing 450 — 2500 g at t ° — 18 ° causes death of the plerotserkoid which are in them on 2 — the 4th day, at t ° — 6 ° — in 6 — 7 days. The plerotserkoida of D. dendriticum concluded in capsules at a salting of fish keep viability up to 9 days. In caviar of a pike of a plerotserkoida of a wide tape-worm perish at 3% a salting in 2 days, at 5% a salting — through hour and at 10% a salting — in 30 min. Are of great importance in fight against D. protection of the rivers and lakes from fecal pollution (see. Sanitary protection of reservoirs ) and mass planned deworming of the persons infested by lenteets (see. Deworming ), edges it is carried out under the direction of a dignity. - epid. stations. Broad systematic sanitary and educational work among the population is necessary.
Table. Some morphological and epidemiological characteristics of activators of diphyllobotriases of the person
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H. H. Plotnikov; author of tab. B. I. Hodakova.