Alexandria University Student name: Medical Research Institute Semester: Fall Department of …………….. Academic year: ……………. ………….. Degree Time allowed: … minutes Course title: ………………… Date: ………………. Course code: …………. Total marks: ……………………. ……………. Exam ______Question 1: (21.5 marks,0.5 each)

Choose the correct answer 1- may be presented by all of the following EXCEPT: a. Bronchial asthma b. Malnutrition c. Obstructive jaundice d. Edema of the face @

2- African eye worm : all the following are correct EXCEPT: a. Adult live in subcutaneous tissues b. Eye lesion may lead to blindness @ c. Chrysops is the vector of transmission d. Microfilaria can be detected in CSF

3- Lofflers syndrome is associated with: a. Inflammatory reaction around the migrating larvae in the lung& liver b. Granulomatous reaction followed by fibrosis in the lung c. Adult worm in the lung @ d. Peripheral eosinophilia

4- Untrue regarding Enterobius vermicularis infection. a. Nocturnal irritation around perianal region b. NIH swab for diagnosis c. Auto- infection is common d. One single oral dose of mebendazole is adequate for its treatment @

5- All of the following are correct regarding lymphatic filarial worms EXCEPT: a. They have cylindrical esophagus b. They affect major lymphatic vessels and glands of the lower half of the body

c. There is a relation between vector of transmission & periodicity of microfilaria d. Vector of transmission is day feeding mosquito @

6- Capillaria intestinalis : all of the following are correct EXCEPT: a. Fish eating birds are reservoir of infection b. Eggs with thin shell are responsible for auto-infection c. Maleabsorption and electrolyte imbalance are main symptoms d. Intensity of infection has no role in prognosis of the disease @

7- All of the followings are correct regarding elephantiasis EXCEPT: a. Living adult worms are responsible for the pathogenesis b. Scanty microfialria during chronic stage of the disease c. Immunodiagnostic strip test is specific for diagnosis of infection d. Hetrazan is recommended in treatment than ivermectin @

8- All of the following are incorrect concerning skin manifestations in EXCEPT: a. It is allergic reaction in response to living microfilaria b. Loss of elasticity, atrophy & wrinkling are early manifestations c. Late manifestations differ according geographical distribution of infection @ d. Mazzoti test is recommended to diagnose heavy infection

9- Muscle invasion stage of : all of the following are correct EXCEPT: a. It starts during 2-4 weeks post infection b. Striated & cardiac muscles are invaded & able to develop nurse cell for the larvae @ c. Myocarditis & encephalitis may occur as a complication d. Peripheral eosinophilia

10- Criteria for diagnosis of tropical pulmonary eosinophilia : all of the following EXCEPT: a. Peripheral eosinophilia b. Raised serum IgE c. Peripheral blood positive for microifilaria @ d. Clinical response to hetrazan

11- River blindness occurs as a result of eye invasion by: a. Adult of &their toxins b. Microfilariae of O. Volvulus & their toxins @ c. Adult of & their toxins d. Microfilaria of Loa loa & their toxins

12- Which one of the following microfilariae exhibits diurnal periodicity a. W. bancrofti b. c. Loa loa @ d. Onchocerca volvulu

13- The largest trematode affecting man is a. Fascioloides magna. b. Fasciolopesis buski. @ c. . d. Fasciola gigantic. 14- The snail intermediate host of is a. Bulinus trunchatus b. Biomphalaria alexandrina c. Pirenella conica @ d. Semisulcospira

15- The only snail which ingests the parasite egg is: a. Physa acuta. b. Pirenella conica. @ c. Lymnaea. d. Bulinus truncates.

16- Anaemia of Diphyllobothrium latum is due to: a. Iron deficiency b. Haemolysis of RBCS c. Blood loss d. Vitamin B12 deficiency @

17- ………………….. is the smallest tape worm infecting man. a. @ b. Hymenolepis deminuta c. Ecchinococcus granulosus d. Dipylidium Caninum

18- The diagnosis could depend on detection of proglottids in the following parasites: a. Taenia spp. b. Dipylidium Caninum c. Diphyllobothrium Latum d. All of the above @ e. A &B

19- Organ of attachment in Diphyllobothrium Latum is……………. a. Bothria @ b. Suckers c. Hooks d. B & C

20- Organ of attachment in Hymenolepis nana is……………. a. Suckers b. Hooks c. Bothria d. A & B @

21- Arthropods play a role in the development of…………….. a. Diphyllobothrium Latum b. Dipylidium Caninum c. Ascaris lumbrecoides d. A & B @ e. All of the above

22- Operculated eggs could be recovered in the following infections: a. Fascioliasis b. c. d. A & B @ e. All of the above

23- A diagnostic finding for Diphylobothrium latium a. ovoid, operculated eggs in stoo b. rosette shape segment c. cyst d. A&B

24- The usual infective stage of Trematodes to man is the a. cercariae b. metacercariae @ c. egg d. miracidium 25- The infective stage of the parasite is found in crabs or crayfishes. a. b. Fasciola hepatica c. Echinostoma ilocanum d. @ 26- What parasite produces infection that simulates tuberculosis? a. Clonorchis sinensis b. Fasciola hepatica c. Paragonimus westermani @ d. Opisthorchis felineus

27- Extensive inflammatory response in hydatid disease is due to a. Dead cyst b. Hyalinized cyst c. Degenerating cyst @ d. Calcified cyst

e. Common manifestations of neurocysticercosis a. Loss of vision b. Focal lesion c. Hydrocephalus d. Epilepsy @

28- Man is a blind host of a. mansoni b. @ c. d. Enterobius vermicularis e. 29- Migrating segment of . may cause a. Intestinal obstruction. b. Pernicious anemia. c. Apendicitis @ d. All of the above

30- The cestode which has a very active gravid segment is: a. Taenia saginata. @ b. Taenia solium. c. Hymenolepis nana. d. Hymenolepis diminuta

31- Among clinical presentations of S.hematobium is: a. Hepatic fibrosis. b. Haematemesis. c. Haematuria. @ d. Portal hypertension

32- Incubation period of a. 1 week b. 2 weeks c. 1 month @ d. 2 months

33- Morbidity of cysticerosis is mostly due to affection of: a. Skin b. Liver c. Muscles d. Brain @

34- The cycle from penetration by miracidium to production of mature cercariae takes about a. 4-5 weeks for schistosoma guinesis b. 5-6 weeks for schistosoma haematobium @ c. 3-4 weeks for d. 4-5 weeks for schistosoma haematobium

35- The most pathogenic schistosome is a. Schistosoma haematobium b. @ c. Schistosoma mansoni d. Schistosoma intercalatum

36- Urine precipitin test is used to detect ………… in urine a. Antibodies b. Antigen @ c. Immune complex d. Antigen and antibodies

37- All of the following parasites affect the liver EXCEPT: a. Fasciola b. E. granulosus c. T. saginata @ d. S. mansoni 38- The eggs of the following parasites are infective to man when passed in the faeces EXCEPT : a. Taenia saginata @ b. Taenia solium c. Echinococcus granulosus d. Enterobius vermicularis 39- and can be differentiated by: a. Location of the uterine pore. b. Location of the genital pore. c. Shape of the scolex. d. All of the above. @ e. b & c.

40- egg is the infective stage of: a. Taeniasis. b. . @ c. . d. Hook worms.

41- This nematode is oviparous: a. . b. . @ c. Onchocera volvulus. d. Brugia malayi.

42- The following parasites may cause intestinal obstruction except: a. Taenia saginata. b. Diphyllobothrium latum. c. Ascaris lumbricoides. d. Ancylostoma duodenale. @

43- Terminally spined eggs include all of the following except: a. Schistosoma intercalatum. b. Schistosoma mekongi. @ c. Schistosoma bovis. d. Schistosoma mattheei.

Question no. 2: (2.5 marks,0.5 each)

I. Select one lettered option from the following parasitic infections that are closely associated with one numbered of different clinical manifestations a. W. bancrofti b. Enterobius vermicularis c. Loa loa d. Capillaria intestinalis e. ozzardi

1. Chyluria in chronic obstructive stage ( A) 2. Painful conjunctival granuloma & edema of eye lid ( C) 3. Non- periodic microfilaria ( E) 4. Retro- infection may occur ( B) 5. Increase gut sound with fluid loss (D)

Question no. 3: (6 marks, 0.5 each) III- State whether the following is ( True) or ( False)

1- Myocarditis associated with trichinosis is due to invasion of cardiac muscles ( false) 2- The adult worm of Mansonella ozzardi inhabit the mesentery & fats tissue around the intestine ( True) 3- Ascariasis may presented by acute pancreatitis with raised serum amylase & lipase ( true) 4- Microfilariae of onchocerca volvulus have diurnal periodicity while the microfilariae of W. bancrofti have nocturnal periodicity (false) 5- Simulium is the main vector of African eye worm (false) 6- Frog and fish act as intermediate host for D. renale ( False) 7- Migrating larvae of Trichinella spiralis coincides with acute stage of infection ( true) 8- African eye worm , the microfilaria can be detected in CSF ( true) 9- Auto- infection & hyperinfection in Capillaria intestinalis ( true ) 10- Arthropods are obligatory intermediate hosts in the life cycle of Hymenolepis nana (false) 11- In , Man acts as a definitive host (false). 12- Laurer’s canal in some trematodes is thought to be used in cross fertilization. ( true)

Question no. 4: (30 marks, 3 each) IV- Write short notes on the followings: 1- Pathogenesis and clinical picture of Loa loa Answer Infection with Loa Loa has different clinical manifestations according to the site of the lesion a- Skin - These worms have a tendency to wander through the subcutaneous connective tissues, provoking inflammatory responses as they migrate . - When they remain in one spot for a short period their metabolites provoke a host reaction, resulting in localized allergic reactions called ( Calabar swelling) . This swelling may be dangerous even fatal if the occur in urethra or glottis. b-Eye - When adult worms traverse through the cornea beneath the conjunctiva, granuloma of conjunctiva may occur, edema of the lids & proptosis - The lesion in the eye is only painful d- Cerebral - Loa Loa is the most frequent filarial worms that may invade the central nervous system. - It may causes meningoencephalitis, chorioretnitis & the microfilariae are present in CSF e-Arthritis - Acute arthritis with joint effusion may occur & microfilariae are present in the fluid

2- River blindness Answer - Microfilariae of onchocerca volvolus , live ones cause no reaction, however dead microfilariae cause an immediate tissue reaction which is responsible , eye changes& other complications - The serious sign of the disease is visual damage which is dependent upon the severity of infections. - The early & most common complications occur when microfilariae invade the cornea. There is inflammation & subsequent fibrosis which may lead to blindness.

3- Nurse cell formation in trichinosis Answer - Nurse cell formation in skeletal muscle tissue is mediated by the hypoxic environment which stimulates muscle cells in the surrounding tissue to upregulate and secrete cytokines, such as vascular endothelial growth factor (VEGF). - This allows the migrating T. spiralis larva to enter the myocyte and induce the transformation into the nurse cell. VEGF expression is detected surrounding the nurse cell immediately after nurse cell formation, and the continued secretion of VEGF can maintain the constant state of hypoxia

4- Diagnosis of lymphatic Answer [1] Direct method a) Detection of microfilariae in the blood The presence of microfilariae in peripheral blood or lymphatic fluid is the most definitive diagnosis. The following points should be noted for proper sampling - Micrfilariae appear one year after infection. - They are rarely found where lymphatics have become obstructed. - Blood must collected at right time. The techniques used are:

1- A drop of fresh blood can be examined microscopically to see the movement of microfilariae 2- Thick stained smear (stained with giemsa ) 3- Concentration of microfilaria ( knott ,s technique ) If the microfilariae are scanty, this technique can be used. 2ml of blood + 10 ml of 2% formalin, the mixture left at room temp. for 10 Minutes then centrifuged. The supernatant is decanted & sediment is examined. 5- A more recent concentration technique involves the use of polycarbonate filter Paper which trap the microfilariae after the red cell have been layzed. b) Detection of microfilariae in urine c) Detection of adults * Ultrasound * Biopsy of lymph nodes * X- ray can demonstrate calcified adult. d) Blood picture to demonstrate eosinophilia . [2] Indirect method - Serodiagnosis is of value in late chronic infection when microfilariae Are absent from peripheral blood. Tests used are IFAT, ELISA. - Immunodiagnostic strip test For detection of circulating antigens, it is more accurate than antibody detection.

5- Clinical pictures of Paragonimus westermani infection Answer Symptoms depend on the worm burden and usually insidious in onset and mild in chronic cases.

- The symptoms are fever, chronic cough with blood tinged sputum and increasing chest pain, increasing dyspnea with chronic bronchitis. The most serious complication of is cerebral complication. - In advanced cases lassitude, anorexia, night sweats and clubbing of fingers and toes. - The patient’s sputum may suggest the diagnosis of tuberculosis. Condition may be chronic, as worms are known to live in human lung for as long as 20 years. 6- Differentiate between Hymenolepis nana and Hymenolepis deminuta? Answer

7.Mention one cestode that mainly affects the liver (Name of parasite and its larval stage – Mode of infection – Diagnosis ) Answer Echinococcus granulosus larval stage hydatid cyst Mode of infection accidental ingestion of Echinococcus granulosus egg through contact with dogs Diagnosis  The diversity of clinical manifestations & deeply located cysts often make the diagnosis very difficult.  Hydatid cyst should be considered in patient with abdominal mass& hydatid thrill is present  X- Ray & ultrasound  Hydatid thrill  Eosinophilia is present in 20-25 % of the cases  Exploratory cyst puncture  The test should never attempted unless the surgeon is immediately prepared to perform a radical operation for removal of the cyst.  Freezing the cyst wall for safe aspiration has been done.  Immunological methods: IHA- CFT- ELISA

8. Characteristics of Hook worm infection Answer These are intestinal nematodes, part of their development takes place outside the body – in the soil.  Infection occurs through contact with larvae in contaminated soil.  The pathology is strongly related to the number of worms present (the intensity of infection)

 Individuals who harbor a large worm burden, infection results in :  Anemia  Impaired growth  There morbidity is rapidly reversible by anthelmintic treatment. 9. Diagnosis and treatment of Taenia saginata infection Answer Taenia eggs have a characteristic appearance and can be detected by faecal microscopy. Since all Taenia ova are very similar they are not easily to be differntiated, although they can be distinguished on Ziehl–Neelson staining, or by the use of monoclonal antibodies or molecular techniques. Soluble Taenia antigens can be detected in faeces. Intact proglottids in reasonable condition can be diagnosed by the number of uterine branches. A single dose of at 10 mg/kg is effective therapy 10.Parasitic etiology of creeping eruption Answer Creeping eruptions can be caused by: A. caninum or A. braziliense S. stercoralis (larva currens) Cutaneous myiasis Cutaneous Fasciola hepatica. Ancylostoma larva migrans is usually situated on the foot or toe and lasts for months, moving very slowly. Strongyloides (larva currens) is situated on the buttocks and trunk and lasts for hours only, moving quickly. Non-human Strongyloides is usually situated on the trunk and abdomen and can persist for many months. no eosinophilia.

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