Schistosoma japonicum

I. Morphology

Schistosoma japonicum or the Oriental Blood Fluke causes schistosomiasis japonica. It is

endemic in China, Philippines, and Indonesia. It was first described in Japan but has been
eliminated, with the last human case reported in 1977. For centuries, schistosomiasis has caused
significant morbidity and mortality. S. japonicum eggs have been identified in female corpse
from Western Han Dynasty, 2,000 years ago. While the disease was described while the disease
is described as early as 1847 by Fuji, the adult S. japonicum was described by Katsurada only in
1904.
The first Chinese case diagnosed by Logan in 1905, and Wooley reported case in the
Philippines in 1906. Strains of S. japonicum from different geographic regions are genetically
distinct but all require snails species of Oncomelania as intermediate host. Phenotypic variations
include minor morphological characteristics, ineffectivity to Oncomelania snails from different
areas, periodicity or cercarial emergence, ability to develop in different definitive hosts, groth
rates, egg production, pre-patency period, pathogenicity, and immunogenicity. Injection of
irradiated cercariae of Chinese strain confers resistance against the homologous strain but not
against the Philippines strain. The mouse pathogenecity of Chinese strain is less than that of
Philippines. Differences also seem to exist among various strains (Mindoro, Leyte, Sorsogon,
and Mindanao) in the Philippines.
Schistosoma japonicum egg is ovoid, round, or pear-shaped, and is pale yellow in color. The
longer diameter ranges from 46 to 110 μm, while the shorter diameter ranges from 37 to 90 μm.
It is a thin shell onto residual tissue or red cell may be adherent. A curved hook or spine may be
observes near one polar ends, but only if the egg is properly oriented. Egss are in the
multicellular stage when released from the adult female and require 10 to 12 days to embryonate
and mature. Immature eggs passed out in feces no longer mature in the soil and are not viable.
Mature eggs in feces can survive and still hatched up in a week if dessication is low.
II. Life Cycle

The S. Japonicum life cycle involves an intermediate snail host and a definitive mammalian
host, with free-living stages between. Embryonated eggs in the stool of a definitive host come
into contact in fresh water within 2 to 4 hours in free swimming miracardia. Miricardia seek out
and infect the snail intermediate host, Oncomelania hupensis aquadrasi, and develop into
sporocysts. Sporocysts are able to reproduce asexually and later gave rise to free-swimming
cecariae after 60 to 70 days. The cercariae penetrate the skin of the definitive host when host
comes into contact with infected fresh water. Cercariae then lose their tails and transform into
schistosomula and enter superficial lymphatic vessels or subcutaneous veins and reach the lungs.
Most authors believe that from pulmonary circulation, schistosomules migrate intravascularly
to reach the portal vein where they mature. However, there is some evidence that schistosomules
escape from lungs into pleural cavity and pass through the diaphragm into the liver to reach the
portal veins. In the portal circulation, schistosomules differentiate into male and female then
form and pair up, with the larger female occupying gynecophoric canal on the adult male. Each
female fluke deposits 500 to 2,000 immature eggs/day in the branches of portal vein. These 10 to
12 days to mature and embryonate. Eggs deposited in mucosal or submucosal terminal veins or
capillaries escape through ulcerations into intestinal lumen and are subsequently exported with
the feces. Egg deposition usually begins from the 24th to the 27th day after cercarial penetration.
While the intermediate snail host is specific for each schistosome species, S. japonicum has a
wide range of definitive hosts including domestic mammals such as dogs, cats, pigs, carabaos,
and cows, along with the reservoirs such as rodents and monkeys. Susceptibility to infection can
vary among different definitive host. Some hosts are considered permissive, i.e., S.japonicum
matures and oviposits over an extended period (humans, monkeys, rabbits, and mice); while
others are non-permissive wherein schistosomes are stunned or they may mature but die out
prematurely. Infection rates may also vary between individuals of the same species. This is likely
due to variations in immune activation and response of different genotypes. Some evidence
suggest that in particular endemic island in the Philippines, only one strain is common tp
different definitive host. A large series of experimental crosses of cercariae originating from a
single miracidium obtained from different naturally infected mammalian hosts from Leyte was
made between 1954 and 1957. All of the crosses of flukes of different vertebrae origin was
successful. It is easy to presume that these crossings occur in the transmission sites in the nature
and that only one strain S. japonicum exists in Endemic Island.

Figure 1. Life Cycle of Schistosoma japonicum

 III. Epidemiology
Transmission dynamics vary considerably in different endemic areas due to the many factor
that influence the common environment, behavioral patterns of the definitive host, and the
bionomics of the snail host. Extrapolation of data, whether the nail populations, animal
popu;ations, or socioecomonic activities, may not completely capture the true sanitation.
Understanding the epidemiology of schistosomiasis require the study of the effects of rainfall,
socioeconomic activity, cultural and behavioral patterns, and demographic characteristics of the
human population and animal reservoir host in the transmission of S. japonicum. Occurrence of
the disease in thecommunity should be described in relation toprevalance and intensity of
infection.

In the Philippines, schistosomiasis remains endemic in 12 regions covering 28 provinces, 190

municipalities, 15 cities, and 2,222 barangays. Two additional municipalities, Gonzaga, Cagayan
(Region 2) and Calatrava, Negros Occidental (Region 6), were recently identified
schistosomiasis endemic areas in 2004 and 2006, respectively, through the identification of
indigenous cases, and infected O.h. quadrasi . More recent surveys conducted through active
surveillance by field schistosomiosis teams revealed a national average prevalence of 2.5 %. The
at risk population is approximately 6.8 million. The highest prevalence are children ranging 5 to
15 years old.

S. japonicum is naturally transmitted between humans and other mammalian hosts, with
either humans or animals alone being able to maintain the infection cycle. Prior to application of
intervention measure like mass chemotherapy or program of sanitation, it is important to have
measure how much contamination of environment of schistosome egges is attributable to human
and animal reservoir. This will be the value in predicting sanitary disposal of human feces and
chemotherapy in reducing transmission and complementary measures of control.

IV. Pathology and Symptomatology

Cecarial penetration of skin is usually accompanied by dermitits wit puritus and localized
reaction known as “swimmer’s itch.” This is similar to that seen from non-japonicum and non-
schistosome cercariae that do not lead to chronic disease in humans. The manifestation is self-
limited and repeated cercarial esxposure causes these acute reaction to wane over time. Non-
endemic most likely to experience rhis phenomenon. Typically after 2 to 12 weeks following
cercarial penetration, schistosomule migration can give rise to a syndrome characterized by easy
fatigability, respiratory symptoms, arthralgias, myalgias, malaise, eosinophilia, fever, and
abdominal pain, which has been termed as “snail fever”, Katayama fever of Katayama
Syndrome. The latter term is preffered since not all patients may present with fever.
Hepatosplenomegaly is not uncommon and can be deliberating during the period of infection,
and in rare cases may lead to sever hepatic dysfunction and death. Migration through pulmonary
circulation can cause wheezing and coughing. Aberrant migration of maturing shistosomules
may occlude the circulation of the brain and the spinal cord precipitating seizures, parethiasis,
transient ischemic attacks, and strokes. While the most patient will get better without medication,
treatment with anthelmentics usually leads to faster resolution of symptoms.
The main pathology and chronic disease manifestations of schistosomiasis japonica are due
to the hist granulomatous reaction of the eggs deposited on the liver and other organs. Since S.
japonica does not multiply in the definitive host, initial quantum of cercariae that infect the host
and mature to lay eggs determine the severity of infection, with repeated infection continuing
exposure causing the most sever burden of disease. Correlation between excretal egg-output,
number of resident flukes and egg counts in the liver have been shown in experimentally infected
monkeys.
The clinical course of the infection is arbitrarily divided into three stages naley: a) incubation
(corresponding to the period from cercarial penetration and schistosomular migration to the time
flukes mature) b) period clearly egg deposit and extrusion c) Period of tissue proliferation.Since
there is a significant overlap of the second and third stages of the disease due to repeated
infection, it is usually more useful to organ involvement as the basis for clinical manifestation or
description. Hepatosplenic disease is the most serious consequences of the chronic
schistosomiasis. It is characterized by hepotosplenomegaly, portal hypertension, ascites, and
development of collateral circulation, which can lead to espophagial and gastric varicrd.
V. Diagnosis

Because of S. japonicum is primarily a parasite of a portal vein and its branches, eggs are not
immediately demonstrable in the feces unless they are deposited in the terminal vein or
capillaries of the intestinal mucosa or submucosa, and subsequently escape to the intestinal
lumen. In infections where there is scarring or fibrosis of sites of ulcerations, passage of egss into
the inteastinal lumen can impeded. In cases, stool examinations can give negative results in
active infection. Schistosome eggs can be recovered by rectal or liver biopsy. However, theses
procedures require specialized equipment and are not practical for mass screening or field
surveys. Moreover, tissue diagnosis cannot reliably distinguish active from treated infection.

Microscopic examination techniques are the most specific since these directly visualize
the parasite eggs. Microscopic examination techniques include stool examination and rectal
imprint. S. japonicum eggs tend to clump together, so a small stool sample may turn out falsely
negative. This may also occur in case of light infection. To establish a diagnosis, the
merthiolateiodine-formalin concentration technique (MIFC) has suffeicient sensitivity for
moderate and heavy infections, but it is not inadequate for light infections (<10 eggs per gram of
feces). This technique has certain advantages making it suitable for field surveys. Fecal samples
mixed with mertholate-formalin (MF) solution in screwn-capped cials can be kept indefinitely.
Processing can therefore be resumed in the laboratory or at some latter convenient.

Kato-Katz technique is preffered egg-counting technique considered the most commonly

used stool examination teachnique for evaluating epidemiology, effect of control measures, and
drug trials. The Kato-Katz preparation can be kept for atleast 2 week sfor examination depending
on the workload. Rectal snips and imprints require specialized equipment and personnel, but are
among the most sensitive techniques, it is also the most invasive since biopsy specimen are
required. Locally evaluated immunodiagnostic test include the following a) intradermal test for
immediate cutaneous hypersensitivity using adult worm extacts; b) indirect hemagglutination
using adult worm and egg antigens. c) circumoval precipitin test (COPT) and d) the enzyme-
linked immunosorbent assay or ELISA using antigens of adults and eggs.

VI. Treatment

Praziquantel, a heterocyclic prazinoisoquinoline compound, represents a major breakthrough

in treatment of schistomiasi. It is safe and highly effective in single or divided does against all
the major species of schistosomes. The active substance is hygroscopic, colorless, almost
odorless, crystalline powder a bitter taste, which is very soluble in water. Praziquantel is active
against adult schistosomes both in vitro and in vivo. In vitro experiments have shown that
schistosomes instantly become immobile and undergocontraction on contact with the drug. Acute
toxicity studies conducted in rats, mice, and rabbits have shown that in comparison with other
anti-schistosomal drugs, praziquantel has very low acute toxicity profile. Rats tolerated daily
doses of up to 1 mg/kg for 4 weeks, and 180 mg/kg for 13 weeks without organ damage. No
effects were seen on the whole reproductive process in rats. Teratogenic effects were not
observed in mice rats, and rabbits.

A single dose of 40 to 50 mg/kg, or 25 mg/kg in two doses or three doses of 20 mg/kg

given every 4 hours or even as low as 10 mg/kg given three times a day for 2 days provide cure
rates. A dosage of 30 mg/kg given after breakfast and repeated after lunch has been used in trials
involving more than 6,000 patients with light to moderate S. japonicum infection. Generally, a
single large dose has the same efficacy as several smaller doses at intervals of several hours.
Even the patient is not fully cured, the passage of eggs become significantly reduced.
Improvement after treatment is clinically apparent.

VII. Prevention and Control

In areas of high prevalence and transmission, mass chemotherapy to reduce morbidity

remains main control strategy. School-age children have been identified as target group for
regular chemotheraphy against schistosomiasis since WHO Expert Committee on Bilharziasis
first met in 1953. Treatment in this age group has been shown reduce significant morbidity in the
short term and prevalent the long term sequelae in adulthood associated with the chronic
infection. Continued transmission of schistosomiasis will depend on how rigorously
chemotherapy can be applied, as well as on epidemiological factors. In order to achieve a
sustainable reduction in transmission, health education, attention to the water supply sanitation,
environmental management, and where appropriate, snail control need to be part of an overall
strategy from the very start.

The Primary objective of chemotherapy using praziquantel is the reduction and prevention of
morbidity. Since it is inevitable that prevalence will decrease following treatment, it is important
to measure the effect of chemotherapy on incidence, worm burden, and morbidity of new cases.
Te use of an effective chemotherapeutic agent like praziquantel require efficient case detection
system and diagnostic test in order to optimize priorities for treatment where resources will not
permit treatment of all infected individuals. Consequently, health education must be recognized
as integral part of the control program. Strong effort should made to improve knowledge,
attitudes and perception with respect to transmission, diagnosis, and control of schistosmiasis.
Since behavior is influenced by local culture, knowledge, attitudes, and practices (KAP) of
permit applicable and relevant educational program. Health Education programs should not only
concerned by modifying KAP but also encourage and promote community participation in
schistosomiasis.

The objective of sanitary disposal of human feces is to prevent contamination of

watercourses inhabited by snails. However, this is limited in the value of S. japonicum
transmission if animal reservoir host represent a significant source of miracidia for infecting
snails. The use of properly constructed hygienic latrines should be encouraged at this contributes
to the control water and fecal borne viral, bacterial, and parasitic infections. Latrines use in rural
areas has been regarded as unsatisfactory because of flies, mosquitoes, and maintenance
problems. This should resolve on toilet utilization.
 Lyceum-Northwestern University

College of Medical Laboratory Science

Tapuac District, Dagupan City

REPORT IN CLINICAL
PARASITOLOGY

Schistosoma japonicum

Submitted by:

Soriano, Paullyn Nicole A.

Somera, Jarren Mathew

Submitted to:

Dr. Ike Manuel G. Flores