TREMATODES

BLOOD FLUKES
Schistosoma japonicum

Adult: have the sexes separate, with the female residing in a gynecophoral canal
within the male. Male worms are robust, tuberculate and measure 6-12 mm in
length. Females are longer (7-17 mm in length) and slender.
Egg: large and more rounded than other species, measuring 70-100 µm long by
55-64 µm wide. The spine on S. japonicum eggs is smaller and less conspicuous
than other species.
Mode of existence: Parasitic
Infective stage: Cecariae
Pathologic stage: Adult worm
Clinical signs and symptoms: Schistosomiasis has three clinical states.
The first stage is characterized by dermatitis and is caused by the
cercariae.
The second stage is marked by fever and constitutional complaints
(Katayama fever)
The third stage results in chronic fibro-obstructive disease which is caused
by the eggs
Acute Clinical Presentation
Dermatitis at the site of penetration
Fever lasting 4-8 weeks
Acute onset: fever, headache, and cough
Heptosplenomegaly and Lymphadenopathy
Symptoms resolve in weeks but death may occur.
Eosinophilia
Chronic Clinical Presentaion
-Often asymptomatic
-Fatigue, colicky abdominal pain
-Intermittent diarrhea
-Liver pre-sinusoidal blockage and increased portal pressure. Earliest sign
Hepatomegaly
-Intestinal granuloma, CNS (3%), Pulmonary (with patent portosystemic
collateral circulation)
Pathologic Pathway: Upon release from the snail, the infective cercariae swim,
penetrate the skin of the human host , and shed their forked tail, becoming
schistosomulae. The schistosomulae migrate through several tissues and stages to
their residence in the veins. Adult worms in humans reside in the mesenteric
venules in various locations, which at times seem to be specific for each species.
For instance, S. japonicum is more frequently found in the superior mesenteric
veins draining the small intestine, and S. mansoni occurs more often in the
superior mesenteric veins draining the large intestine. However, both species can
occupy either location, and they are capable of moving between sites, so it is not
possible to state unequivocally that one species only occurs in one location. S.
haematobium most often occurs in the venous plexus of bladder, but it can also be
found in the rectal venules. The females (size 7 to 20 mm; males slightly smaller)
deposit eggs in the small venules of the portal and perivesical systems. The eggs
are moved progressively toward the lumen of the intestine and are eliminated with
feces or urine, respectively
Mode of Treatment: Praziquantel, a single dose of 40/50 mg/kg, or 25 mg/kg in
two doses or three doses of 20 mg/kg given every 4 hours or even a dose
as low as 10 mg/kg given three times a day for 2 days.

LIVER FLUKES

Fasciola hepatica

Adult: are large and broadly-flattened, measuring up to 30 mm long and 15 mm

wide. The anterior end is cone-shaped.
Egg: broadly ellipsoidal, operculated, and measure 130-150 μm by 60-90 µm.
Mode of existence: Parasitic
Infective stage: Embryonated egg
Pathologic stage: Adult worm
Clinical signs and symptoms: Common signs and symptoms of
the hepatic phase are abdominal pain, fever, eosinophilia, and abnormal liver
function tests.The biliary phase of the disease usually presents with intermittent
right upper quadrant pain with or without cholangitis or cholestasis.
Pathologic Pathway: The cercariae are released from the snail and encyst as
metacercariae on aquatic vegetation or other surfaces. Mammals acquire the
infection by eating vegetation containing metacercariae. Humans can become
infected by ingesting metacercariae-containing freshwater plants, especially
watercress. After ingestion, the metacercariae excyst in the duodenum and migrate
through the intestinal wall, the peritoneal cavity, and the liver parenchyma into the
biliary ducts, where they develop into adult flukes
Mode of Treatment: Triclabendazole, a single 10 mg/kg oral dose following food
Intake
Bithionol is given at 30 to 50 mg/kg body weight on alternate
days to complete 10 to 15 doses.

Fasciola gigantica

Adult: averaging 30 mm in length and 12 mm in width.

Larva/Egg: operculated and average 140 micrometer in length and 75 um in width.
Mode of existence: Parasitic
Infective stage: Egg
Pathologic stage: Adult worms
Clinical signs and symptoms: During the acute phase, the immature worms
begin penetrating the gut, causing symptoms of fever, nausea, swollen liver, skin
rashes, and extreme abdominal pain.
Pathologic Pathway: The cercariae are released from the snail and encyst as
metacercariae on aquatic vegetation or other surfaces. Mammals acquire the
infection by eating vegetation containing metacercariae. Humans can become
infected by ingesting metacercariae-containing freshwater plants, especially
watercress. After ingestion, the metacercariae excyst in the duodenum and migrate
through the intestinal wall, the peritoneal cavity, and the liver parenchyma into the
biliary ducts, where they develop into adult flukes
Mode of Treatment: Triclabendazole, a single 10 mg/kg oral dose following food
Intake
Bithionol is given at 30 to 50 mg/kg body weight on alternate
days to complete 10 to 15 doses.

Clonorchis sinensis

Adult worms: are flattened and measure approximately 10-25 mm long by 3-5 mm
wide. Like other flukes, they are hermaphroditic, with a single ovary situated
anterior to two branches testes.
Egg: eggs are small, ranging in size from 27 to 35 µm by 11 to 20 µm. The eggs
are oval shaped with a convex operculum, that rests on visible “shoulders” at the
smaller end of the egg. At the opposite (larger, abopercular) end, a small knob or
hooklike protrusion is often visible. The miracidium is visible inside the egg.
Mode of existence: Parasitic
Infective stage: Metacercariae
Pathologic stage: Adult worms
Clinical signs and symptoms: Symptoms include fever, chills, epigastric pain,
tender hepatomegaly, diarrhea, and mild jaundice.
Pathologic Pathway Each egg releases a miracidia, which go through several
developmental stages (sporocysts, rediae, and cercariae). The cercariae are
released from the snail and after a short period of free-swimming time in water,
they come in contact and penetrate the flesh of freshwater fish, where they encyst
as metacercariae. Infection of humans occurs by ingestion of undercooked, salted,
pickled, or smoked freshwater fish. After ingestion, the metacercariae excyst in the
duodenum and ascend the biliary tract through the ampulla of Vater. Maturation
takes approximately 1 month. The adult flukes reside in small and medium sized
biliary ducts.
Mode of Treatment: Praziquantel is given at 25 mg/kg, 3 times a day for 2 days or
69 mg/kg in 3 days for 1 day.
Tribendimidine, is given at a single 150 mg/kg of body
weight oral dose.
 LUNG FLUKES

Paragonimus westermani

Adult : 3-10 meters; ivory colored, 3,000-4,000 proglottids

: spoon-shaped scolex with dorsal and ventral median longitudinal sucking groove
: long, unsegmented, attenuated neck
: wider than it is long proglottids with one set of reproductive organ
Egg : oval, operculated with knob at the opposite end
Mode of existence: Parasitic
Infective stage: Metacercaria
Pathologic stage: Adult worm
Clinical signs and symptoms: Symptoms include chronic cough, chest pain,
dyspnea, and hemoptysis.
Pathologic Pathway: transmitted by eating infected crab or crawfish that is either,
raw, partially cooked, pickled, or salted. The larval stages of the parasite are
released when the crab or crawfish is digested. They then migrate within the body,
most often ending up in the lungs.
Mode of Treatment: Praziquantel, 25 mg/kg given 3 times a day for 2-3 days.
Bithionol, given orally at a dose of 15 to 25 mg/kg twice daily
on alternative days for 10 to 15 days.

INTESTINAL FLUKES

Heterophyes heterophyes

Adult: measuring 1.0 to 1.7 mm by 0.3 to 0.4 mm in length.

Mode of existence: Parasitic
Infective stage: metacercariae
Pathologic stage: adult worm
Clinical signs and symptoms: Anorexia, nausea, and vomiting are also common.
The diarrhea persists, becoming greenish-yellow and exceptionally malodorous. In
persons infected with H heterophyes, embolization of the eggs can lead to
myocarditis, chronic heart failure, and/or cerebral emboli.
Pathologic Pathway: The definitive host becomes infected by ingesting
undercooked or salted fish containing metacercariae. After ingestion, the
metacercariae excyst, attach to the mucosa of the small intestine and mature into
adults.
Mode of Treatment: Praziquantel, 25 mg/kg/dose given 3 doses in 1 day.
 THE CESTODES
THE PSEUDOPHYLLIDEAN CESTODES

Diphyllobothrium latum

Adult
: 3-10 meters; ivory colored, 3,000-4,000 proglottids
: spoon-shaped scolex with dorsal and ventral median longitudinal sucking groove
: long, unsegmented, attenuated neck
: wider than it is long proglottids with one set of reproductive organ
Egg
: oval, operculated with knob at the opposite end
Mode of existence: Parasitic
Infective stage: plerocercoid larvae
Pathologic stage: adult worm
Clinical signs and symptoms: D. latum infection results in hyperchromic,
megaloblastic anemia with thrombocytopenia, and leukopenia. Some infected
individuals may experience nervous disturbance, digestive disorders, abdominal
discomfort, and weight loss.
Pathologic Pathway: 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. 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.
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. 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) and are passed in the feces
Mode of Treatment: Praziquantel, 5-10 mg/kg given as a single dose.

THE CYCLOPHYLLIDEAN CESTODES

Diphyllidium caninum

Adult : 10-70 cm with 60-175 proglottids

: mature proglottid : pumpkin-seed shaped
: 2 sets of genital organ on the lateral side
: 2 genital pores on the lateral margin
: gravid proglottid: eggs in pocket or
capsule
: scolex: club-shaped with armed rostellum
Eggs : thin shelled, spherical
Larva : procercoid cystecercoid
Mode of existence: Parasitic
Infective stage: infective cystecercoid
Pathologic stage: Adult worm
Clinical signs and symptoms: Infection is rarely heavy and symptoms are
minimal. Slight intestinal discomfort, epigastric pain, diarrhea, anal pruritus, and
allergic reactions have been reported.
Pathologic Pathway: Humans acquire infection by ingesting the cysticercoid
contaminated flea. This can be promulgated by close contact between children and
their infected pets. In the small intestine of the vertebrate host the cysticercoid
develops into the adult tapeworm which reaches maturity about 1 month after
infection. The adult tapeworms (measuring up to 60 cm in length and 3 mm in
width) reside in the small intestine of the host, where they each attach by their
scolex. They produce proglottids (or segments) which have two genital pores
(hence the name “double-pored” tapeworm). The proglottids mature, become
gravid, detach from the tapeworm, and migrate to the anus or are passed in the
stool
Mode of Treatment: Praziquantel, 5-10 mg/kg given as a single dose.
Hymenolepis nana

Egg: oval and smaller than those of H. diminuta, with a size range of 30 to 50 µm.
On the inner membrane are two poles, from which 4-8 polar filaments spread out
between the two membranes. The oncosphere has six hooks.
Mode of existence: Parasitic
Infective stage: Embryonated eggs
Pathologic stage: adult worm
Clinical signs and symptoms: infections are most often asymptomatic.
Heavy infections with H. nana can
cause weakness, headaches, anorexia, abdominal
pain, and diarrhea.
Pathologic Pathway: When eggs are ingested (in contaminated food or water or
from hands contaminated with feces), the oncospheres contained in the eggs are
released. The oncospheres (hexacanth larvae) penetrate the intestinal villus and
develop into cysticercoid larvae. Upon rupture of the villus, the cysticercoids return
to the intestinal lumen, evaginate their scoleces, attach to the intestinal mucosa
and develop into adults that reside in the ileal portion of the small intestine
producing gravid proglottids. Eggs are passed in the stool when released from
proglottids through its genital atrium or when proglottids disintegrate in the small
intestine
Mode of Treatment: Praziquantel, given at a dose of 25 mg/kg single dose.

Hymenolepis diminuta

Egg: round or slightly oval, size 70 – 85 µm X 60 – 80 µm, with a striated outer

membrane and a thin inner membrane. The space between the membranes is
smooth or faintly granular. The oncosphere has six hooks. There are no polar
filaments extending into the space between the oncosphere and the outer shell.
Mode of existence: Parasitic
Infective stage: cysticercoid larvae
Pathologic stage: Adult worm
Clinical signs and symptoms: infections are most often asymptomatic such as
abdominal pain, loss of appetite, itching around the anus, irritability and diarrhea.
Pathologic Pathway: The cysticercoid larvae persist through the arthropod’s
morphogenesis to adulthood. H. diminuta infection is acquired by the mammalian
host after ingestion of an intermediate host carrying the cysticercoid larvae.
Humans can be accidentally infected through the ingestion of insects in precooked
cereals, or other food items, and directly from the environment (e.g., oral
exploration of the environment by children). After ingestion, the tissue of the
infected arthropod is digested releasing the cysticercoid larvae in the stomach and
small intestine. Eversion of the scoleces occurs shortly after the cysticercoid larvae
are released. Using the four suckers on the scolex, the parasite attaches to the
small intestine wall. Maturation of the parasites occurs within 20 days and the adult
worms can reach an average of 30 cm in length. Eggs are released in the small
intestine from gravid proglottids that disintegrate after breaking off from the adult
worms. The eggs are expelled to the environment in the mammalian host’s feces.
Mode of Treatment: Praziquantel, given at a dose of 25 mg/kg single dose.

Taenia Solium

Adult: 2 to 7 m
Egg: eggs measure 30-35 micrometers in diameter and are radially-striated. The
internal oncosphere contains six refractile hooks.
Mode of existence:
Infective stage: larvae
Pathologic stage: Adult worm
Clinical signs and symptoms: Abdominal pain, anorexia, weight loss, malaise,
and megaly (brain, eye, heart).
Pathologic Pathway: In the human intestine, the cysticercus develops over 2
months into an adult tapeworm, which can survive for years. The adult tapeworms
attach to the small intestine by their scolex and reside in the small intestine. Length
of adult worms is usually 5 m or less for T. saginata (however it may reach up to 25
m) and 2 to 7 m for T. solium. The adults produce proglottids which mature,
become gravid, detach from the tapeworm, and migrate to the anus or are passed
in the stool (approximately 6 per day).
Mode of Treatment: Praziquantel, given at a dose of 5 to 10 mg/kg as a single
dose for both adults and children.
Niclosamide-not available locally

Taenia Saginata

Adult worm: is usually 5 m or less for T. saginata (however it may reach up to 25

m)
Egg: eggs measure 30-35 micrometers in diameter and are radially-striated. The
internal oncosphere contains six refractile hooks.
Mode of existence: Parasitic
Infective stage: larvae
Pathologic stage: adult worm
Clinical signs and symptoms: Abdominal pain, anorexia, weight loss, malaise,
and megaly (brain, eye, heart).
Pathologic Pathway: In the human intestine, the cysticercus develops over 2
months into an adult tapeworm, which can survive for years. The adult tapeworms
attach to the small intestine by their scolex and reside in the small intestine. Length
of adult worms is usually 5 m or less for T. saginata (however it may reach up to 25
m) and 2 to 7 m for T. solium. The adults produce proglottids which mature,
become gravid, detach from the tapeworm, and migrate to the anus or are passed
in the stool (approximately 6 per day).
Mode of Treatment: Praziquantel, given at a dose of 5 to 10 mg/kg as a single
dose for both adults and children.