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Intestinal Capillariasis JOHN H CLINICAL MICROBIOLOGY REVIEWS, Apr. 1992, p. 120-129 Vol. 5, No. 2 0893-8512/92/020120-10$02.00/0 Copyright ©O 1992, American Society for Microbiology Intestinal Capillariasis JOHN H. CROSSt U.S. Naval Medical Research Unit No. 2, Manila, Philippines INTRODUCTION .......................... DESCRIPTION OF THE PARASITE. HISTORY .................................... .120 LIFE CYCLE OF THE PARASITE... .121 CLINICAL PICTURE..................... 1IA symptoms ... Pathology ...................... 124 Diagnosis..................... 125 Treatment ..................... 126 EPIDEMIOLOGY..................... 127 Distribution and Prevalence...................... 127 Transmission ...................... 128 Control .129 REFERENCES. 129 INTRODUCTION widest part of the stichosome, 28 to 36 p.m at the vulva, and 29 to 47 pum postvulva. The vulva is located behind the Although more than 250 Capillaria species have been esophagus, is salient, and is without a flap. The anus is found in fish, amphibians, reptiles, birds, and mammals, subterminal. Figures 1 and 2 illustrate male and female only 4 species have been found in humans: Capillaria worms, respectively, showing some of the features men- C. hepatica, aerophila (Eucoleus aerophilus), C. plica, and tioned above. The female uterus contains numerous thick- C. Reports of human infections with C. philippinensis. shelled eggs (Fig. 2), thin-shelled eggs with or without C. and are rare, reports hepatica, aerophila, C. plica but of embryos (Fig. 2), or larvae (Fig. 3). Eggs found in feces are C. philippinensis infections are increasing and appear to be peanut shaped with a striated shell and inconspicuous flat- spreading geographically. C. philippinensis has been in- tened bipolar plugs, and they measure 36 to 45 by 20 pum volved in epidemics and has been responsible for the death of people in the Philippine Islands and Thailand. (Fig. 4). HISTORY DESCRIPTION OF THE PARASITE Although a number of Capillaria species are known to are related to Trichuris and Trichinella Capillarids closely inhabit the intestinal tract of lower animals, human intestinal species; all are members of the superfamily Trichinelloidea. capillariasis was unknown until Chitwood et al. presented The group is characterized by having a filamentous thin the initial case report at the First International Congress of anterior end and a slightly thicker, and sometimes shorter, Parasitology in Rome in 1964. The patient was a 29-year-old posterior end. The esophagus consists of a short muscular male schoolteacher from Northern Luzon in the Philippines. portion surrounded by rows of secretory cells called sti- He had an intractable diarrhea for 3 weeks prior to admission chocytes. The entire esophageal structure is called a sticho- to the Philippine General Hospital, Manila. He suffered from some. The male worms may or may not have a single chronic recurrent and sheathed spicule. In the female, the vulva is located at the alcoholism, ascites, emaciation, junction of the anterior and posterior ends. cachexia and died a week after hospitalization. At autopsy, a large number of worms were recovered from the intestines, Chitwood et al. (6) described C. philippinensis in speci- but the parasite was not identified to species at the time. mens collected at autopsy from the first person known to have the infection and in material obtained from several In late 1966, a Catholic missionary priest in Tagudin Ilocos Sur, Central Luzon, notified authorities of an unusually large subsequent autopsies. Additional specimens were examined number of deaths due to a chronic gastroenteritis that had by other investigators, and the initial findings were con- been occurring since 1965 in a village called Pudoc West. firmed. The parasite is very small: males range in length from This village is approximately 150 km south of the area where 1.5 to 3.9 mm and in width from 3 to 5 ,um at the head, 23 to the first case was seen. Upon investigation the Philippine 28 ,um at the stichosome, and 18 ,um at the cloaca. The male Department of Health established that C. philippinensis was spicule is 230 to 300 ,um long, and the unspined spicular responsible for the illnesses. The parasitosis soon spread to sheath may extend to 440 p.m. The anus is subterminal, and other villages and towns, and by the end of 1967, more than the tail has ventrolateral expansions containing two pairs of 1,000 people had become infected and 77 had died. papillae. Females are much longer than males, 2.3 to 5.3 The people in the village of Pudoc West were superstitious mm, with widths of 5 to 8 p.m at the head, 25 p.m at the and believed that they were all destined to die of the mysterious disease because of a curse placed on them by a t Present address: Department of Preventive Medicine and Bio- mystical river god. Against the advice of the public health metrics, Uniformed Services University of the Health Sciences, authorities now working in the area, they hired two witch 4301 Jones Bridge Road, Bethesda, MD 20814-4799. doctors to exorcise the village. The witch doctors were 120 VOL. 5, 1992 INTESTINAL CAPILLARIASIS 121 SC S p FIG. 1. Adult male C. philippinensis indicating spicule (Sp), extended spicular sheath (Ss), and stichocyte (Sc). Magnification, x32. retained until one of them died of intestinal capillariasis. parasitosis. Clinical management and treatment regimens Other beliefs and superstitions emerged during the epidemic were established, pathophysiologic studies were done, and until a cure and means of transmission were established (15). epidemiologic information was gathered. One of the most A few years after the Pudoc West outbreak, it was complex challenges, however, was to determine the means determined that during 1963 to 1965 a number of people had of transmission of the parasite and its life cycle. First, died of a chronic gastroenteritis in the area of Northern attempts were made to determine possible reservoir hosts Luzon where the first patient lived. In 1965, the disease began to be seen in Pudoc West, and in the ensuing years for adult and larval stages of the parasite. The Ilocano infections were found in villages along the western and populations of Northern Luzon have unique dietary habits, northern coasts of Central and Northern Luzon. unlike those of other Filipino populations. These eating habits were considered when searching for a source of infection. More than 150,000 specimens of animal life were LIFE CYCLE OF THE PARASITE examined, and although adult Capillana worms were found, Since C. philippinensis was a new human parasite, it was none were C. philippinensis. Capillaria larvae were also essential to obtain knowledge about every aspect of the found, but species determination was not possible (15). SC , 4e.. Vu Eg, I UT it,. (r? Tk Lv FIG. 2. Adult female C. philippinensis indicating stichocyte (Sc), salient vulva (Vu), uterus (Ut), eggs (Eg) in the uterus, and thin-shelled eggs with larvae (Lv). Magnification, x32. 122 CROSS CLIN. MICROBIOL. REV. Lv Vu FIG. 3. Adult female C. philippinensis indicating salient vulva (Vu) and uterus filled with larvae (Lv). Magnification, x 160. Massive stool surveys were undertaken to detect asymp- after 3 weeks (Fig. 5). Several species of fish in the Philip- tomatic infections and to determine whether a relationship pines (8, 10) and other species in Thailand (4) were found to existed between C. philippinensis and other intestinal para- be susceptible to infection. In further studies, one species of sites. More than 7,000 stool samples from 23 village popu- fish (Hypseleotris bipartita) was found naturally infected lations were examined, but there was no correlation between with the larval stage of the parasite, which was recovered C. philippinensis infection and other parasitic infections. from the intestine. Most people (94%) had 1 and, more often, 2 to as many as 10 Larvae from fish were subsequently fed to monkeys different parasites by a single stool examination. Only 2% (Macaca spp.), and patent infections developed (8). Mon- were passing C. philippinensis eggs, compared with 83% keys tolerated the infections well and never manifested passing Trichuris trichiura eggs (12). symptoms. A few of these infections remained patent for as While the above studies were under way, investigations long as 14 months. Three to four months after being given 30 were conducted to establish the life cycle in the laboratory. to 50 larvae from fish, some monkeys were killed and 10,000 At that time the life histories of only a few Capillaria species to 30,000 worms were recovered from their intestines. This were known. Some species had a direct egg-to-egg cycle confirmed the suspicion that autoinfection was part of the whereas others had indirect cycles involving an intermediate life cycle because large numbers of worms in all stages of host. Eggs isolated from patients were found to embryonate development were found at autopsy. In addition, female at ambient temperatures in 5 to 10 days. The eggs were given worms are larviparous. orally to all types of animals, even human volunteers, but did Many other laboratory and wild animals were experimen- not hatch (9). The experiments continued, and eventually tally infected with larvae from fish. Some wild rats (Rattus eggs were found to hatch in the intestines of freshwater and spp.) and multimammate rats (Mastomys natalensis) devel- brackish-water fish from the lagoons in the endemic area. oped transient infections, but Mongolian gerbils (Meriones The eggs hatched within a few hours after ingestion, and the unguiculatus) developed patent infections and died of over- larvae increased in size from 130-150 ,um to 250-300 ,um whelming infections after 6 to 7 weeks. A series of experi- FIG. 4. Two eggs of C. philippinensis, two-cell stage. Note the flattened bipolar plugs and striations in the eggshell; they measure 36 to 45 by 20 p.m. Magnification, x 160. VOL. S, 1992 INTESTINAL CAPILLARIASIS 123 4 Autointecton FIG.
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