PARASITOLOGY

Topic: Blood Flukes

References: Old Trans + Belizario

INTRODUCTION Schistosoma japonicum

 Schistosoma is a genus of parasitic blood flukes that infect birds and  7 testes
mammals, including humans  Up to 300 eggs at a time
 5 species of medically important Schistosoma have been identified:  Oval eggs with rudimentary lateral spine
1. S. japonicum (inferior & superior mesenteric veins of SI)  Eggs are deposited in the liver
2. S. mansoni (inferior mesenteric veins of LI)  Habitat: veins of the small intestine, superior mesenteric veins
3. S. haematobium (veins of urinary bladder)  There is a greater chance that eggs can be deposited in the liver
4. S. mekongi  Causes most serious infection
5. S. intercalatum  Intermediate host: Onchomelania hupensis quadrasi
 Disease: Schistosomiasis or Bilharziasis  Liver  Portal vein for maturation
 Common in Middle East, Southeast Asia, Philippines, China and  Eggs expelled in feces
Indonesia, Africa, South America  Morphology:
 Discovered in mid 1800s by Theodore Bilharz o Adult
 Calcified eggs of S. haematobium seen in Egyptian mummies in 1200  Female
BC  Long, slender, with oral and
 They have no 2nd intermediate hosts ventral suckers
 Blood flukes cannot be transmitted through ingestion but through  Ovary is centrally located
skin penetration  Male
 They mature in the vascular system of the host  With oral and ventral suckers
 The species is now called Schistosoma meaning split body  Shorter and stouter with
 Blood flukes are dioecious gynecophoral canal
 The male is shorter and stouter  Cuticle has no tuberculation
 The male has gynecophoral canal where females are lodged during o Egg
copulation  Shape is ovoidal or sub-globular, with thin
 Females are more slender than males shell, rudimentary or abbreviated lateral
 The disease will be produced when female lay eggs spine and cellular debris attached to the shell
 Eggs cause the disease because eggs are deposited to the different  Contains ciliated embryo
tissues causing destruction of the tissues
Schistosoma mansoni
Old Trans Info:  6-9 testes
 1st intermediate host: Snail  Short uterus, fewer eggs
 2nd intermediate host: None  Elliptical eggs with sharp lateral spine
 Definitive host: Human  Habitat: Portal veins draining the large intestine
 Egg: Mature, Non-operculated  Intermediate host: Biomphalaria
 Sex: Dioecious  Large intestine
 Free swimming larva: Fork-tailed cercaria  Eggs expelled in feces
 Development: S1  S2  C  Morphology:
 Infective stage: Cercaria o Adult
 Diagnostic stage: Egg  Female
 Peculiar Flukes  Long and slender with oral and
 Mature in blood vascular system in Definitive Host ventral spines
 Calcified eggs of S. haematobium in Egyptian mummies  Ovary is anterior to the mid-
 “Split Body” – gynecophoral canal of male; where female lodge portion of the organism
during copulation  Male
 S. japonicum – lays the most number of eggs  With oral and ventral suckers
 Male = Shorter, stouter, no pharynx, with strong oral sucker  Shorter and stouter with a
 Female = long, slender gynecophoral canal
 With 6-9 small testes in column or
 “Romancing parasite” – once they copulate they won’t separate
group
anymore
o Egg
 Adult live in veins
 Shape is elongate ovoidal with thin shell and
 Previously called bilharzia
lateral spine
 Adults live in veins that drain certain organs  paired worms go
 Contains ciliated embryo
upstream into smaller veins where female deposit eggs  eggs
traverse wall of venule  eggs traverse intervening tissue  traverse
gut/bladder mucosa  expelled from host  FECES or URINE

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 PARASITOLOGY
Topic: Blood Flukes
References: Old Trans + Belizario

Schistosoma haematobium Life Cycle

 4-5 testes
 20-100 eggs
 Elliptical with sharp terminal spine
 Habitat: Veins of the urinary bladder plexus
 Intermediate host: Bulinus
 Causes least serious infection
 Urinary bladder
 Eggs expelled in urine
 Morphology:
o Adult
 Female
 Long and slender with oral and
ventral suckers
 Ovary is posterior to the mid
portion of the organism
 Male
 With oral and ventral suckers
 Shorter and stouter with a
gynecophoral canal
 Cuticle has fine tuberculation
 With 4-5 large testes in cluster
o Eggs Schistosoma eggs are eliminated with feces or urine, depending on species (1) . Under
 Shape is elongate, ovoidal with thin shell and appropriate conditions the eggs hatch and release miracidia (2) , which swim and penetrate
specific snail intermediate hosts (3) . The stages in the snail include two generations of
terminal spine
sporocysts (4) and the production of cercariae (5) . Upon release from the snail, the
 Contains ciliated embryo infective cercariae swim, penetrate the skin of the human host (6) , and shed their forked
tails, becoming schistosomulae (7) . The schistosomulae migrate via venous circulation to
S. haematobium S. mansoni S. japonicum lungs, then to the heart, and then develop in the liver, exiting the liver via the portal vein
Oriental blood system when mature, (8) (9) . Male and female adult worms copulate and reside in the
Manson’s
Vesical fluke, mesenteric venules, the location of which varies by species (with some exceptions) (10) .
Disease caused intestinal
schistosomiasis Schistosomiasis For instance, S. japonicum is more frequently found in the superior mesenteric veins
schistosomiasis
japonica draining the small intestine (A) , and S. mansoni occurs more often in the inferior
# of testes 4-5 6-9 7 mesenteric veins draining the large intestine (B) . However, both species can occupy either
Uterus Least eggs Few Most eggs ~300 location and are capable of moving between sites. S. intercalatum and S. guineensis also
Rudimentary, inhabit the inferior mesenteric plexus but lower in the bowel than S. mansoni. S.
Short, terminal Sharp, lateral haematobium most often inhabitsin the vesicular and pelvic venous plexus of the
Eggs abbrev. Spine with
spine spine bladder (C) , but it can also be found in the rectal venules. The females (size ranges from 7–
cell debris
Large intestine, Small intestine, 28 mm, depending on species) deposit eggs in the small venules of the portal and perivesical
Urinary bladder systems. The eggs are moved progressively toward the lumen of the intestine (S. mansoni,S.
Habitat inferior superior
plexus japonicum, S. mekongi, S. intercalatum/guineensis) and of the bladder and ureters (S.
mesenteric mesenteric
Biomphalaria haematobium), and are eliminated with feces or urine, respectively (1)
(Africa, KSA,
Bullinus, Pathogenesis & Clinical Manifestations
Middle East), Onchomelania
Snail Biomphalaria,
Physopsis
Tropicorbis quadrasi  Unusual
centrimetralis  Due to eggs, not adult worms
(Brazil)
 Acute Schistosomiasis
Most serious
o Katayama Fever
Infection Least serious (most number of
eggs) o Serum-like sickness that develops several weeks after
Africa, South exposure
Distribution Africa (Egypt) SEA, Philippines
America o Corresponds to the 1st cycle of egg deposition and is
Excreted in Urine Feces Urine and Feces associated with marked peripheral eosinophilia and
Short, stout, Short, stout, circulating immune complexes
gynecophoral Short, stout, gynecophoral o It is most common with S. japonicum and S. mansoni
Male Morphology canal present, gynecophoral canal present, no infection and is most likely to occur in newly infected
cuticle canal present cuticle
individuals after primary infection
tuberculation tuberculation
Female Ovary post-mid Ovary ant-mid Ovary centrally
o Signs and symptoms usually resolve over several weeks
Morphology portion position located but can be fatal to very young and very old
o Mild maculopapular lesion, high grade fever
o Marked dermatitis or swimmer’s itch at the site of
cercaria penetration in primary hosts

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 PARASITOLOGY
Topic: Blood Flukes
References: Old Trans + Belizario

Clinical Manifestations continued…..  Chronic intestinal schistosomiasis (granuloma formation in gut wall,
 Chronic Schistosomiasis most often large intestines)
o More common o Hepatosplenic schistosomiasis (granuloma inflammatory
o Result from egg-induced immune response, granuloma reponse leading to hepatic fibrosis)
formation and associated fibrotic changes o Urogenital schistosomiasis (granulomatous
o Schistosomal eggs are highly immunogenic and induce inflammatory lesion involving urinary tract or genital
vigorous circulating and local immune response organs)
o Malabsorption syndrome  Hematuria often the first sign of established
o Bloody diarrhea disease
o Heavy infections are more likely to produce hepatic o Neuroschistosomiasis (granulomatous response to egg
disease deposition in brain or spinal cord)
o Severe fibrosis leading to portal hypertension  Spinal cord schistosomiasis (an inflammatory
o Splenomegaly myelopathy); most common form
o Hepatosplenomegaly  Pseudotumoral encephalic schistosomiasis;
o Ascites slow growing tumor like mass lesion that
o Esophageal variceal bleeding results in focal neurologic signs and raised
 Egg retention and granuloma formation in the bowel wall (S. mansoni intracranial pressure; symptoms vary
& S. japonicum) according to location of lesion
o Bloody diarrhea
o Cramping  Acute: fever, hepatosplenomegaly, urticaria
o Inflammatory Colonicpolyposis  Chronic: hepatosplenomegaly, abdominal tenderness, ascites, hem
o Increased rate of recurrent Salmonella Infection positive stool, bloody diarrhea, pedal edema, seizures
o Heavy Infection  Hepatic Disease
o Severe Fibrosis  Pipestem pattern Diagnosis
o Periportal Fibrosis  portal HPN S. japonicum and S. mansoni:
o Portal HPN sequelae:  Stool exam
 Splenomegaly  Serology
 Ascites o ELISA – helpful in confirmation of past exposure
 Esophageal varices o Schistosomal antigen test to help distinguish between
 Development of portosystemic collaterals active and inactive infection
 Egg retention (S. haematobium) o Antigen titers from serum and urine correlate with
o Hematuria degree of infection
o Dysuria  Rectal biopsy
o Ulcer  Kato-Katz thick smear clarified with glycerol – for identification and
o Bladder polyp quantification of ova in feces
o Obstructive uropathies  Immunodiagnostic tests
o S. haematobium infections are also associated with o Circum-oval precipitin test (COPT)
development of bladder cancers, usually squamous o Cercaria Huellen Reaction (CHR)
rather than transitional cell CA o Fluorescent Antibody test for cercaria (FAT)
o ELISA
Old Trans Info:  Ultrasound – to detect pipestem fibrosis of the liver and patency of
 Disease Syndrome: the portal splenic and superior mesenteric vessels
o Swimmer’s itch (dermatitis)
o Katayama fever (snail fever) S. haematobium
o Chronic fibro-obstructive disease  Urine Examination – (+) eggs  definitive diagnosis; 24-hour urine
o Bladder carcinoma collection may be recommended
 Dermatitis with pruritus known as “swimmer’s itch”  Micropore filtration for the detection of ova in urine
The manifestation is self-limited and repeated cercarial exposure  Cytoscopy
causes these acute reactions to wane over time  Immunodiagnostic tests
o Circum-oval precipitin test (COPT)
 Katayama fever/Katayama syndrome (“snail fever”) o Cercaria Huellen Reaction (CHR)
o 2-12 weeks following cercarial penetration o Fluorescent Antibody teast for cercaria (FAT)
o Schistosomule migration o ELISA
o Characterized by easy fatigability, respiratory symptoms,  Ultrasound – to detect urinary tract lesion
arthralgias, myalgias, malaise, eosinophilia, fever, and
abdominal pain Treatment
 Chronic colonic schistosomiasis
 Praziquantel
o Ulcerations caused by eggs result in dysentery or diarrhea,
depending on the worm burden

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 PARASITOLOGY
Topic: Blood Flukes
References: Old Trans + Belizario

Complications References:
 End organ disease  Medical Parasitology in the Philippines by
 Pulmonary hypertension Belizario & de Leon (3rd Ed.)
 Lecture Notes
 Cor pulmonale
 Portal hypertension
 Obstructive uropathy
 GI bleeding

Prognosis
 Most patient improve with treatment
 Patients with early disease or without severe end organ complication
recover completely

Old Trans Info:

Schistosoma haematobium
 Female genital schistosomiasis
 Women suffer severe morbidity during their reproductive years
 Infection is transmitted by schistosome eggs that penetrate the
urinary system, migrate to female genital region and form
granulomas in the uterus, fallopian tubes and ovaries, leading to the
development of uterine enlargement
Schistosoma mekongi
 The species 1st recognized in 1978 found in Thailand and Cambodia,
along the Mekong River
 It is closely related to S. japonicum but are slightly smaller and round
 Man and dog are the definitive host
 Man acquires infection in the same way as in S. japoniccum
 Hepatosplenomegaly and ascites are the common clinical finding
Schistosoma intercalatum
 This species, 1st recognized in 1934 is found in West-Central Africa
 The eggs are fully embryonated without any operculum having
terminal spines, but are passed exclusively in stools. The eggs are acid
fast
 It produces few symptoms involving the mesenteric portal system
 Diagnosis is established by detection of the egg in feces and rectal
biopsy
 Praziquantel is the drug of choice
Examine stool for eggs
Use Kato-Katz thick smear method
Eggs: 155 x 66 µm for quantification purposes
S. mansoni Oval with lateral long Rectal biopsy or serologic testing to
spine diagnose stool-negative cases,
particularly in lightly infected
patients
Examine stool for eggs
Found in stool Kato-Katz thick smear ) for
Eggs: 89 x 67 µm quantitative assessment)
S. japnicum Oval or rounded with a Rectal biopsy for those with light
lateral, short, infections especially with less
sometimes curved spine common manifestations (cerebral
schistosomiasis)
Found in stool
Eggs 60 x 32 µm
S. mekongi Examine stool for eggs
Smaller than eggs of S.
japonicum
S. intercalatum Found in stool Examine stool for eggs
Mainly found in urine Obtain urine sample at midday
but maybe found in (when eggs are excreted); more than
stools or rectal biopsy one sample may be needed
specimens Examine urine directly or by filtering
Eggs: 143 x 50 µm 10 mL of urine through a Nucleopore
S. haematobium
Spindle shaped; membrane
rounded anterior, Rectal biopsy in suspected cases
conical posterior, with normal urine
tapering to a terminal Serologic testing to diagnose early or
delicate spine light infection

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