Diphyllobothrium infection

Overview
Also known as:

Tapeworm (broad or fish) infection

Epidemiology and Demographics
Diphyllobothriasis occurs in the Northern Hemisphere (Europe, newly independent states of the former Soviet Union [NIS], North America, Asia) and in Uganda and Chile. Freshwater fish infected with Diphyllobothrium sp. larva may be transported to and consumed in geographic areas where active transmission does not occur, resulting in human diphyllobothriasis. For example, cases of D. latum infection associated with consumption of imported fish have been reported in Brazil.

Pathophysiology & Etiology
The cestode Diphyllobothrium latum (the fish or broad tapeworm), the largest human tapeworm. Several other Diphyllobothrium species have been reported to infect humans, but less frequently; they include D. pacificum, D. cordatum, D. ursi, D. dendriticum, D. lanceolatum, D. dalliae, and D. yonagoensis.



Immature eggs are passed in feces 1. Under appropriate conditions, the eggs mature (approximately 18 to 20 days) 2 and yield oncospheres which develop into a coracidia 3. After ingestion by a suitable freshwater crustacean (the copepod first intermediate host) the coracidia develop into procercoid larvae 4. Following ingestion of the copepod by a suitable second intermediate host, typically minnows and other small freshwater fish, the procercoid larvae are released from the crustacean and migrate into the fish flesh where they develop into a plerocercoid larvae (sparganum) 5. The plerocercoid larvae are the infective stage for humans. Because humans do not generally eat undercooked minnows and similar small freshwater fish, these do not represent an important source of infection. Nevertheless, these small second intermediate hosts can be eaten by larger predator species, e.g., trout, perch, walleyed pike 6. In this case, the sparganum can migrate to the musculature of the larger predator fish and humans can acquire the disease by eating these later intermediate infected host fish raw or undercooked 7. After ingestion of the infected fish, the plerocercoid develop into immature adults and then into mature adult tapeworms which will reside in the small intestine. The adults of D. latum attach to the intestinal mucosa by means of the two bilateral groves (bothria) of their scolex 8. The adults can reach more than 10 m in length, with more than 3,000 proglottids. Immature eggs are discharged from the proglottids (up to 1,000,000 eggs per day per worm) 9 and are passed in the feces 10. Eggs appear in the feces 5 to 6 weeks after infection. In addition to humans, many other mammals can also serve as definitive hosts for D. latum.

History and Symptoms
Diphyllobothriasis can be a long-lasting infection (decades). Most infections are asymptomatic. Manifestations may include abdominal discomfort, diarrhea, vomiting, and weight loss. Vitamin B12 deficiency with pernicious anemia may occur. Massive infections may result in intestinal obstruction. Migration of proglottids can cause cholecystitis or cholangitis.

Laboratory Findings
Microscopic identification of eggs in the stool is the basis of specific diagnosis. Eggs are usually numerous and can be demonstrated without concentration techniques. Examination of proglottids passed in the stool is also of diagnostic value.



A, B: Eggs of Diphyllobothrium latum. These eggs are oval or ellipsoidal, with at one end an operculum that can be inconspicuous. At the opposite (abopercular) end is a small knob that can be barely discernible. The eggs are passed in the stool unembryonated. Size range: 58 to 76 µm by 40 to 51 µm.



C, D: Eggs of Diphyllobothrium latum. These eggs are oval or ellipsoidal, with at one end an operculum (arrows) that can be inconspicuous (D). At the opposite (abopercular) end is a small knob that can be barely discernible (C). The eggs are passed in the stool unembryonated. Size range: 58 to 76 µm by 40 to 51 µm. Figure C contributed by Georgia Division of Public Health.



E: Proglottids of Diphyllobothrium latum. These proglottids tend to be passed in strands of variable length in the stool. The proglottids tend to be broader than long. Image contributed by Georgia Division of Public Health.



F: Proglottids of Diphyllobothrium latum. The species characteristics are: the proglottid is broader than it is long; size 2 to 4 mm long by 10 to 12 mm wide; uterus coiled in rosette appearance; genital pore at the center of the proglottid.

Pharmacotherapy
Praziquantel is the drug of choice. Alternatively, Niclosamide can also be used to treat diphyllobothriasis. (Praziquantel is approved by the FDA, but considered investigational for this purpose).

Acknowledgements
The content on this page was first contributed by: C. Michael Gibson, M.S., M.D.

List of contributors: