MEDICAL PARASITOLOGY

TREMATODES
DR. BONI / DUEÑAS / ROX
OLFU • FUMC ½ COLLEGE OF MEDICINE
Ref: Medical Parasitology in the Philippines by: Belizario

§ With integument (outer covering)

OUTLINE: o E.g., spine papillae and tubercle
• Introduction to Trematodes § With holes in the body ® Suckers (oral/ventral) serves
• Liver flukes as attachment and nourishment to host
• Intestinal flukes § Sex: Monoecious Morphology
• Blood flukes § Shape:
• Lung fluke o Flat, leaf-like in shape
o Lanceolate, spatulate
o Anteriorly ® slender
INTRODUCTION TO TREMATODES
o Posteriorly ® broad
• Unsegmented helminths – flat and broad “Leaf-like” appearance
• Fluke – leaf of a tree or a flatfish “flock”
• Trematode – having a large prominent sucker with a hole in the
middle (Greek: Trema, Appearance: Eidos)
• Phylum: Platyhelminthes

Superfamily Family Genus Species

Schistosomatoidea Schistosomatidae Schistosoma S. haematobium
S. mansoni
S. japonicum
S. mekongi
S. intercalatum
Paramphistomatoidea Zygocotylidae Gastrodiscoides G. hominis
Watsonius W. watsoni
Echinostomatoidea Fasciolidae Fasciola F. hepatica
Fasciolopsis F. buski • Cercaria ® Lophocercus
Opisthorchioidea Opisthorchiidae Opisthorchis O. felineus
O. viverrini Simple-tailed Keel-tailed Microcercus Fork-tailed
Clonorchis C. sinensis Fasciola Clonorchis Paragonimus Schistosoma
Heterophyidae Heterophyes H. heterophyes
Metagonimus M. yokogawai hepatica sinensis Westermani japonicum
Plagiorchioidea Paragonimidae Paragonimus P. westermani Fasciolopsis Opistorchis Schistosoma
buski felineus mansoni
Classification Base on Habitat Echinostoma Heterophyids Schistosoma
• All adult Trematodes ® Mesenteric Vein (blood flukes) ilocanum flukes hematobium
• All Paragonimus worms ® Lung Parenchyma
• Fasciola, Clonorchis, Opisthorchis ® Liver and Bile passages
• Fasciolopsis, Echinostoma and Heterophyids ® Intestine Life Cycle
• Oviparous ® all trematodes
Habitat Trematodes § Operculated egg
Blood fluke - S. hematobium (vesical and pelvic venous plexuses) o With lid (operculum)
(Blood) - S. mansoni (inferior mesenteric vein) o Non-embryonated ® F. hepatica, F. buski,
- S. japonicum (superior mesenteric vein) E. ilocanum, P. Westermani
Liver fluke - Clonorchis sinensis o Embryonated ® C. sinensis, O. felineus, O.
(Biliary) - Fasciola hepatica viverini, H. hetorophyes, M. yokogawi
- Opisthorchis spp.
§ Non-operculated egg
GIT
o Without lid (embryonated or spinous) – seen
(Intestinal fluke)
only on Schistosomes
Small intestine - Fasciolopsis buski, Heterophyes heterophyes,
Metagonimus yokogawai, Watsonius watsoni

Large intestine - Gastrodiscoides hominis

Respiratory tract - Paragonimus westermani

(Lung fluke)
• Trematode belong to the subclass of Digenea “Digenetic” ® this
General Characteristics required 2 intermediate host to complete the cycle
• Flat and non-segmented “leaf-like” appearance § 1st Intermediate host: snails or mollusks
• Adult Trematodes are equipped with 3 suckers: § 2nd Intermediate host: fist, crab, crustacean
§ 1st – Oral sucker “distomata” • Infective stage (all trematodes) is Encysted Larva “Metacercaria”
§ 2nd – Ventral sucker “acetabulum” § Except for Blood Fluke (schistosomes) – “Cercaria”
§ 3rd – Genital sucker “gonotyl” – only in heterophyids • Definitive host: Human or Animals or Mammals
• All trematode is hermaphroditic “monoecious” (well-developed • Mature eggs:
reproductive system) § Contain embryo called “Miracidium”
§ Except for Blood Flukes (schistosomes) – which sexes § Eggs passed out by an infected host may be mature
are separated (dioecious) o Schistosoma
• Class: Trematoda o Clonorchis
• General Feature: o Opisthorchis
§ Dorso-ventral flat o Heterophyids
§ Unsegmented

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 MEDICAL PARASITOLOGY
TREMATODES
• Immature eggs: Note:
§ This develops in the aquatic environments • Embryonated eggs (trematodes) immediately hatch to form
o Paragonimus Miracidium or L1 larva
o Fasciola § Schistosoma hematobium
o Fasciolopsis § Schistosoma mansoni
o Echinostoma § Schistosoma japonicum
• Mode of Transmission: • Unembryonated egg of trematode which first embryonated in
§ Ingestion of food infected with metacercaria water and then hatch
§ Skin penetration § Fasciola hepatica
• Larval stage: § Fasciolopsis buski
§ L1 – Miracidium or Miracidia § Paragonimus westermani
§ L2 – Sporocysts • Embryonated eggs (trematode) – which hatch in the body of
§ L3 – Redia the intermediate host
§ L4 – Cercardia § Clonorchis sinensis
• Life stage of Trematode in General: § Opisthorchis felineus
§ Require a snail host to complete the cycle § Opisthorchis viverrini
§ Infective to human § Metagonimus yokogawai
o Free swimming fork-tailed cercaria
§ Trematode infection Morphology
o Required ingestion of improperly cooked • Intestinal Ceca
2nd intermediate host containing the § Highly dendritic
metacercaria o F. hepatica
§ Schistosome § Simple tubular
o 1st intermediate host (snail) produced a o Fasciolopsis buski
“Fork-tailed” cercaria that penetrates intact o E. ilocanum
human skin o H. hetorophyes
o Swimmer’s itch or Farmer’s itch o H. yokogawai
o M. yokogawai
Adult flukes produce eggs, which are shed onto the § Simple zigzag pattern
environment/water o Paragonimus westermani
¯ • Vitelline follicles/Vitellaria
Egg release L1 (Miracidium) and is taken up by the § Where the shell of the ova develops
1st intermediate host (snail) ® L2-L3-L4 § Types:
¯ o Highly dendritic follicles
Intramolluscan development: L1®L2®L3®L4 § Paragonimus westermani
(become free-swimming ® cercaria) § Fasciolopsis buski
[homologous to human sperm]® L4 o Delicate granular follicles
¯ § Clonorchis sinensis
Free-swimming cercaria infects 2nd intermediate host o Medium-sized vitelline follicle
(freshwater brackish fish, crabs, crayfish) § Opisthorchis felineus
¯ o Transverse-compressed follicle
[the tail of the cercaria drops and the head of the cercaria will invade the § Echinostoma ilocanum
2nd intermediate host] o Polygonal follicle
¯ § H. heterophyes
Cercaria encysts to become metacercaria § M. yokogawai
[infective stage to human] § H. yokogawai
¯ • Testes
Human become infected by ingesting the Branched testes in Tandem Clonorchis sinensis
2nd intermediate host containing metacercaria Fasciola hepatica
Fasciolopsis buski
Note: Intramolluscan patterns: - Tandaan mo to! Nimal ka! Branched testes arranged side- Paragonimus westermani [Para ®
• S®R®C by-side side by side and Gonimus ® testis]
o C. sinensis Dumbbell arranged one top of Echinostoma ilocanum
o O. felineus the other
o O. viverrini
o H. hetophyes, H. yokogawai, M. yokogawai
Lobular obliquely equal in size Opisthorchis felineus
• S ® R1 ® R2 ® C
o P. westermani
Lobular obliquely unequal in size Metagonimus yokogawai
o F. hepatica
o F. buski
Spherical arranged side by side H. heterophyes
o H. hetophyes, H. yokogawai, M. yokogawai
• R1 ® R2 ® C
Single spherical testis Haplorchis yokogawai
o E. ilocanum [no sporocysts]
• S1 ® S2 ® C
o S. japonicum
• Ovary
o S. mansoni
§ Branched Ovary
o S. hematobium
o Fasciolopsis buski
o Fasciola hepatica
§ Lobular ovary
o Opisthorchis felineus

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TREMATODES
o Paragonimus westermani (sexually matures 3 to 4 mons)
o Clonorchis sinensis
§ Ovoidal Ovary • Miracidia gets ingested by snails and become cercaria inside the
o Echinostoma ilocanum snails - soon the cercaria are released from the snail
§ Spherical Ovary • They encyst as metacercaria in the 2nd intermediate host which
o Metagonimus yokogawai can be another snail, fish or aquatic plants
o H. heterophyes • Humans become infected by ingestion of 2nd intermediate host
o Haplorchis yokogawai which contains the metacercaria

LIVER FLUKES

Parasite Common name Disease produced

Fasciola Sheep liver fluke Fascioliasis
hepatica Temperate liver fluke Sheep Liver Rot

Fasciola Tropical liver fluke

gigantica
Clonorchis Chinese liver fluke Clonorchiasis
sinensis Oriental liver fluke
Opistrochis Cat liver fluke Opistorchiasis felineus
felineus
Opistorchis Southeast Asian liver Fluke Opistorchiasis
viverrini viverrini

• Minor Liver Flukes

Dicrocoelium Lancet flue (ant*) Dicrocoeliasis • Mode of infection [F. hepatica] 📢📢📢
dendriticum § The definitive host, sheep and man, get infection by
Euretrema Pancreas Fluke (locust*) Euretrematosis ingestion of metacerceriae encysted on aquatic
pancreaticum vegetation
§ Adult worm lives in the biliary passage of sheep or man.
FASCIOLIASIS Eggs are laid in the biliary passages and are shed in feces
• “Hermaphroditic flukes” § The embryo matures in water in about 10 days and the
miracidium escapes. It penetrates the tissues of first
• Causes Fascioliasis – lives in the liver and biliary passages (human
intermediate host, snails of the genus Lymnaea
and herbivorous mammals-ruminants)
§ In snail, the miracidium progresses through the
§ Fasciola hepatica – temperate liver flukes
sporocyst and the first and second generation redia
§ Fasciola gigantica – tropical liver fluke
stages to become the cercariae in about 1-2 months
• Distribution:
§ The cercariae escape into the water and encyst on
§ Central and Latin America, South America,
aquatic vegetation or blades of grass to become
§ Middle East, France, England, etc.
metacercariae, which can survive for long periods
§ Sheep, cattle, or humans eating watercress or other
water vegetation containing the metacercaria become
infected
§ The metacercariae excyst in the duodenum of the
definitive host and pierce the gut wall to enter the
peritoneal cavity
§ They penetrate the Glisson's capsule, traverse the liver
parenchyma, and reach the biliary passages, where they
mature into the adult worms in about 3-4 months

Parasitic Biology
• MOT of Fasciola spp. (hepatica and gigantica)
§ ingestion of metacercaria encysted on aquatic plants
§ drinking water with viable metacercaria

Upon ingestion (metacercaria)

¯
Metacercaria excysted in the Duodenum and Jejunum
(liberating juvenile fluke)
¯
Penetrated the intestinal wall to reach the peritoneal cavity
over the viscera until it penetrates the capsule of Glisson and enters
the liver
¯
The parasite the burrows through the liver parenchyma
feeding and growing until it finally enters the bile ducts where

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TREMATODES
• Adult worm: § 140 to 180um by 63 to 90 um and is released from the
§ Life span of 9 to 13 years worn
§ Lives in biliary passages of the liver § Containing large unsegmented mass of vitelline cells
• Egg:
§ Unembryonated eggs are carried by bile through the
sphincter of Oddi into the intestine and subsequently
voided with feces – egg passes in feces
§ Mature in water (9 to 15 days) at 15 to 250C – to release
viable Miracidium

Note: Fasciola spp.

• 1st intermediate host: Snails
§ F. hepatica – amphibious snails
§ F. gigantica – aquatic snails Fasciola hepatica
• 2nd intermediate host: [aquatic vegetation] 1st intermediate host: snails 2nd intermediate host: plants
§ Trapa spp. ® common in Thailand - Lymnaeidae truncatula - Ipomea obscura (morning
§ Fresh water plants [water cress, kang-kong or - L. bulmoides glory or kangkong)
morning glory] - L. tomentosa - Nasturtium officinale
• Definitive host: Human - L. planorbidae (water cress)
• Infective stage: - L. philippinensis
§ to Snail: Miracidia - L. auricularia rubiginosa
§ to plants/other snails: Cercaria
§ to humans: Metacercaria • Fasciola gigantica worm/egg:
• Diagnostic stage: Unembryonated egg § adult worm is longer than F. hepatica (25 to 75mm)
• In the Philippines – the snails host of Fasciola spp. § less developed shoulder
§ L. philippinensis § shortened cephalic cone
§ L. auricularia rubiginosa § more branched cera
• 1 animal (cow)® can hold an infection up to 300 mature flukes § egg is slight larger than F. hepatica egg
• 150 liver flukes ® each fluke can lay up to 50,000 eggs per day
§ 5 years life span ® animals
§ 10 years ® human
• 50,000 eggs per day ® eggs hatch to form 1st stage flukes
• 7,5000,000 miracidia ® these miracidia multiply inside the snail
to create up to 4,000 cercariae each [

• Fasciola hepatica worm:

§ Large, broad and flat body (18 to 51mm ling and 4 to 14
Fasciola gigantica
inches wide)
1st intermediate host: snails 2nd intermediate host: plants
§ Marked widening at base of the cephalic cone
- Lymnaeidae auricualria - Ipomea obscura (morning
§ Has 2 highly branched testes
- L. acuminate glory or kangkong)
§ Small suckers closely located to each other
- L. natalensis - Nasturtium officinale
§ Vitellaria extended to the lateral field of the whole hind
body - L. planorbidae (water cress)
§ Dendritic ovary in front of anterior testis - L. philippinensis
§ Long and highly branched intestinal ceca - L. auricularia rubiginosa
§ Coiled uterus
Pathogenesis and Clinical Manifestation
• Fascioliasis (F. hepatica) causes more mechanical damage
traversing the liver tissues, leading to parenchymal injury
• Liver involvement
§ Marked destruction and inflammation of liver tissue,
capsular hematoma, and pockets of abscesses to
fibrosis
§ Ductal epithelial hyperplasia, infiltration, dilatation and
periductal fibrosis
• Skin involvement
§ Subcutaneous nodules associated with erratic
migration of juvenile Fasciola hepatica [painful to
touch]

• Fasciola hepatica egg:

§ Large, ovoid, yellowish to brown operculated eggs

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TREMATODES
• Halzoun/Marrara
§ “Pharyngeal fascioliasis” due to ingestion of
improperly cooked [raw liver of infected cattle, sheep]
containing the juvenile forms
§ S/Sx: Edema and congestion ® asphyxia, dysnpnea,
dysphagia
• False fascioliasis
§ Symptomatic form
§ Ingestion of improperly cooked containing Fasciola ova Note:
§ Management: • Halzoun (Lebanon) and Marrara (Sudan)
o Free liver diet 3 to 4 days § Unusual form of fascioliasis occurs after ingestion
o Stool examination ® negative result of raw Fasciola-infected liver
• Biliary obstruction: ® cholecystitis, cholangitis and cholelithiasis § Flukes surviving mastication attach to the posterior
• 2 stages: pharynx, causing hemorrhagic nasopharyngitis and
§ Acute dysphagia
o Larval migration and worm maturation in the
hepatic tissue
o Period of larval migration from intestine ®
liver ® bile ducts (acute symptoms from 2 to
6 weeks to several months)
o Fever, headache, anorexia, nausea,
vomiting, right upper quadrant and
epigastric pain, enlarged and tender liver
• Ectopic Disease
o Severe illness: urticaria, allergy, prostration,
§ Skin: migratory purpuric and painful subcutaneous
wasting, jaundice and anemia
nodules up to 6cms.; abscess formation in the
o Considerations: hypergammaglobulinemia,
brain, orbit, lungs, heart etc.
leukocytosis, eosinophilia, abnormal LFT
§ Halzoun: eating raw liver of infected goat or sheep;
o Eggs (-) in the feces 3 to 4 months after onset
Asphyxia, Dyspnea, Dysphagia and Deafness
§ Chronic
o Persistence of Fasciola worms in the biliary
ducts
o Pain, right hypochondrium and epigastrium
Diagnosis
Hepatomegaly, dyspepsia, diarrhea, nausea
• Clinical history
vomiting and jaundice
§ Timing when to eat a raw meat/water plant containing
o Extrahepatic duct obstruction: Similar to
metacercaria
chronic obstructive symptoms of
§ History of travel or drinking contaminated water
choledocholithiasis
• Stool exam
• Acute stage (Invasive phase)
§ Eggs are not found in feces until 3-4 months
§ Invasion phase
§ Detection of coproantigens (immunologic method –
§ Migration of parasite from the intestine to the liver
ELISA, Western blot)
§ Damage to the intestinal wall is not significant
§ Traumatic and necrotic lesions produced when the • Duodenal or Bile content examination
[parasite burros into the liver parenchyma • Surgical recovery of the worm after autopsy
§ Dyspepsia, fever, RUQ pain • Serologic test:
§ Triad: § Low sensitivity, PCR-restriction fragment Length
o Sudden onset of high fever Polymorphism (RFLP) using Ava II and Dra II
o Hepatomegaly • Radiologic examination or Imaging:
o Marked eosinophilia § CT-Scan ® hepatic phase of disease
o Multiple confluents, hypodense nodule and
tunnel-like branching hypodense tract
o Multiple round clustered hypodense lesion
§ MRI image ® shows mild dilation of the CBD and FH
worms
§ Ultrasound ® linear echogenic material within dilated
• Chronic Stage CHD
§ Asymptomatic § Sonography – biliary phase of disease
§ Parasite has already reached the bile ducts o Small clustered hypoechoic lesion with
§ Obstruction of the biliary epithelium and stimulation of poorly defined contours and hypoechoic
inflammation which results to fibrosis nodular lesions
§ Atrophy of the liver in heavy infection o Oval shape, leaf-like, or snail-like echogenic
§ Associated with cholelithiasis structures with no acoustic shadowing in
§ Complication: the gall bladder or common bile duct
o Obstructive jaundice § Endoscopic Cholangiogram
o Hemobila Treatment
o Biliary cirrhosis • Triclabendazole – DOC [single dose] or Single dose of 10mg/kg
§ Rare complication: oral
o Acute pancreatitis § Heavy infection – twice the 10mg/kg
o Ectopic migration leading to lungs, brain, • Bithionol or Benzimidazole ® alternative [longer use] and V
orbit and subcutaneous tissue § 30-50 mg/kg for 10 to 15 days

Prevention and Control

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TREMATODES
• Control the intermediate host by eliminating it Clonorchis sinensis Opisthorchis Opisthorchis
• Washing and cooking of the vegetables felineus viverrini
• Boiling of water source Shape Leaf-like, with transparent tegument
• Vaccine development for cattle/sheep Size 10-25 mm long and 8-12 mm long and 1.5-3 mm wide
• Symptomatic treatment based on the se 3-5 mm wide
Two large, highly • They have lobate testes,
branched testes which are arranged
OPISTORCHIS and CLONORCHIS Spp.
Arrangement arranged in tandem obliquely.
of the Testes in the posterior half • Opisthorchis viverrini
of the body testes however, are
positioned close to each
other, are more deeply
lobulated
• Yellowish brown, ovoid.
• There is a distinctly
convex operculum that
fits into the thickened
Egg rim of the eggshell, and a
small protuberance at
the abopercular end.
• Small digenetic trematodes • Inside the egg is a well-
• Parasite of the gallbladder and bile ducts developed miracidium that has asymmetrical
§ Clonorchis sinensis (sheep liver fluke) features
§ Opisthorchis felineus (cat liver fluke) • Can produce 10,000 egg/day
§ Opisthorchis viverrini (SE-Asian liver fluke) Parafossarulus, Bithynia
• Distribution: 1st Bulinus,
§ Highly endemic area are China, Korea parts of Japan intermediate Semisulcospira,
and Indo-China Host (genus) Alocinma, Thiara,
• MOT [snails] Melanoides
§ Ingestion of metacercaria of infected raw fish
(salted/dried/pickled freshwater fish) Cyprinidae Cyprinidae and Cobitidae
2nd
Note: Intermediate
• Clonorchiasis [oriental liver flukes] ® chonorchis sinensis Host (family)
§ SEA, China, Korea, Taiwan [salt fish]

• Life cycle:

• Opistorchiasis
§ Central, Eastern and Southern Europe
§ USSR, Siberia
§ Far East: Japan, Korea, Philippines Vietnam, India,
Hongkong

Parasitic Biology
• Morphology:
§ a. O. felineus
§ b. O. viverrini
§ c. C. sinensis

• Definitive host: Humans are the principal definitive host, but dogs
and other fish-eating canines act as reservoir hosts.
• Intermediate hosts: 2 intermediate hosts are required to
complete its life cycle, the first being snail and the second being
fish
• Infective form: Metacercaria larva
• Mode of infection: Man acquires infection by eating undercooked
fresh water fish carrying metacercariae larvae

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Clonorchis eggs although embryonated do not hatch in water, but only when • X-section of the dilated biliary
ingested by suitable species of operculate snails (First intermediate host), duct containing 2 adult worms
such as Parafossarulus, Bulimus, or Alocinma species within the lumen of the duct with
¯ proliferation of the epithelial
The miracidium develops through the sporocyst and redia stages to become lining
the lophocercus cercaria with large fluted tail in about 3 weeks
¯
The cercariae escape from the snail and swim about in water, waiting to get • X-section of the biliary duct with adult worm. Note enlarged,
attached to the second intermediate host, suitable fresh-water fish of the dilated, tortuous thickening of the duct with proliferated
Carp family epithelial lining
¯
The cercariae shed their tails and encyst under the scales or in the flesh of
the fish to become metacercariae, in about 3 weeks, which are the infective
stage for humans
¯
Infection occurs when such fish are eaten raw or inadequately processed by
human or other definitive hosts. Frozen, dried, or pickled fish may act as
source of infection
¯
Infection may also occur through fingers or cooking utensils contaminated
with the metacercariae during preparation of the fish for cooking
¯
The metacercariae excyst in the duodenum of the definitive host
C. sinensis O. felineus O. viverrini
¯
Light Fever and
The adolescaria that come out, enter the common bile duct through the
infection Asymptomatic hepatitis like
ampulla of Vater and proceed to the distal bile capillaries, where they mature
symptoms
in about a month and assume the adult form
Biliary tract
¯ Chronic Liver malfunction, Obstructive, obstruction, liver
Adult worms produce an average of 10, 000 eggs per day, which exit the bile infection calculi, cholecystitis jaundice, cirrhosis, abscess,
ducts and are excreted in the feces. The cycle is then repeated. bile peritonitis suppurative
cholangitis
Hepatocellular
Sequalae carcinoma and Cholangiocarcinoma
cholangiocarcinoma

• Clinical findings:
§ Acute phase
o Appears 10 - 26 days after ingestion of
Pathogenesis and Clinical Manifestation infected fish Low grade fever, anorexia,
• Desquamation of epithelial cells diarrhea, enlarged tender liver, hepatic or
• Hyperplasia, desquamation of epithelial cells and adenomatous epigastric pain
tissue formation o Consideration: Leukocytosis, eosinophilia
• Marked proliferation of the periductal connective tissue with Eggs (-) in the feces 3 to 4 weeks after onset
scattered abortive acini of epithelial cells, and fibrous of the wall of § Chronic phase
the biliary duct o Flatulence and indigestion
• Gross picture of adult o Increasing worm burden:
worms, liver tissue and x- - low grade fever, progressive
section of thickened ducts hepatomegaly, liver area
tenderness, intermittent right
upper quadrant and epigastric
pain, gall bladder dilatation and
dysfunction, weakness, anorexia
and diarrhea

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• Complication:
§ Cholelithiasis Definitive host Human and pigs
§ Pyogenic cholangitis Ingestion of of encysted metacercariae
§ Partial or complete obstruction of the biliary system Mode of transmission from the Aquatic Plants à Attaches to the
§ Abscess formation duodenum à matures for 3 months à
§ Recurrent pyogenic cholangitis Produces Eggs.
§ Mild to severe pancreatitis 1st Intermediate Host The miracidium transforms into
§ Cholangiocarcinoma (SNAIL): Segmentina or sporocysts and mother and daughter redia
§ Hepatocellular carcinoma Hippeutis à Cercaria

Diagnosis Cercaria à Metacercaria à Attaches/

• Identification of parasite egg in stool encysts to Water Plant (TROPA BICORNIS)
• Duodenal or biliary aspiration
• Serology
• Imaging of the liver
• Histopathology of malignant growth
• Cholangiography – “arrowhead sign”
• ELISA
• PCR
2nd Intermediate Hosts: Tropa bicornis
Water Plants Eliocharis tuberosa
Ipomea obscura
Nymphacea lotu

Parasitic Biology
Treatment • Adult worm:
• Praziquantel ® DOC § Shape: Oval
§ 25mg/kg TID for 2 days § Measures: 20-75 mm (Length), 8-20mm (width)
§ 60mg/kg TID for 1 day § Others: No cephalic Cone
• Albendazole ® alternative § Intestinal Ceca: Unbranched and Continuous
§ 7 days treatment coarse • Egg:
• Albendazole + Praziquantel § Largest
§ More effective § Operculated and measures 130 -140 um x 80 – 85 um
§ Treats ascaris and trichiura infection

Note: Treatment
• Clonorchiasis ® Praziquantel, Albendazole
• Opistorchiasis ® Praziquantel

Prevention
• Health education
• Proper hygiene and sanitation
• Cook fish thoroughly, boil water
• Avoid night soil; treat with (NH4)2 S04 [ammonium sulfate]
• Destruction of snail host: CuSO4 [copper sulfate]

INTESTINAL FLUKES
• Fasciolopsis buski
• Echinostomid flukes ® E. ilocanum
• Heterophyids flukes
• Artyfechinostomum

FASCIOLOPSIS BUSKI
• “Giant intestinal fluke”

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Pathogenesis and Manifestation
• Traumatic, Toxic and Obstructive Signs
• Ulceration in the site of attachment
• Gland Abscess can be present
• Generalized Toxic Allergic Reactions and Edema of the Face,
Abdominal Wall and Limbs
• Profound Intoxication (Verminous) à Death

• A. malayanum
§ Worm
o Measures: 5 to 12.0mm by
2-3mm
o Posterior end – composed
of 43-45 collar spines

§ Egg
o Color: Golden Brown
Treatment o Shape: Larger and Operculated
• Praziquantel – Drug of Choice 25mg/Kg of BW x 3 times a day for o Measuring: 120-130 um x 80-90 um
One day

Prevention and Control

• Since metacercariae are very sensitive to dryness, soaking of
aquatic plants in water should be avoided
• Prolong time between harvest and consumption
• Washing of the plants to remove metacercariae, or boiling them
to kill the parasites
• Swamps or ponds where aquatic plants are cultivated should be
protected from pollution by untreated human or pig excreta

ECHINOSTOMID FLUKES
• Classification: Echinostomids – presence of collar spines within the
oral sucker Echinostoma ilocanum adults and eggs detected in our cases from Savannakhet Province, Lao PDR. (A) An adult specimen of
§ Echinostoma ilocanum – “Garrison’s fluke” E. ilocanum showing almost globular testes. (B) Another E. ilocanum specimen showing slightly lobed anterior testis and
oblong posterior testis. (C) Another E. ilocanum specimen showing moderately (anterior testis) or deeply lobed testes
§ Artyfechinostomum malayanum (posterior testis). (D) Head collar showing a total of 51 collar spines, including 5 corner spines on each side, 3 oral and 2 aboral.
Tegumental spines are quite large but smaller in comparison with collar spines. (E) An egg of E. ilocanum in the feces of case
2. The operculum is small and inconspicuous at the anterior end, and abopercular wrinkles are also small and minute. (F)
Another egg of E. ilocanum from case 2 showing similar findings
• Life cycle
§ 1st IH: Gyraulus convexiusculus
§ 2nd IH: Pila luzonica (kuhol)

Parasitic Biology

Infective stage Ingestion of metacercaria encysted in snails

Location Small intestines
Definitive host Human and other mammals (pigs)
Disease Echinostomiasis
• E. ilocanum
§ Worm:
o Color: reddish gray
o Measures: 2.5 to 6.0mm by 1-1.35mm
o Posterior End – composed of 49-51 collar
spines
o Oral Sucker – center of the circumoral disk
o Ventral Sucker – Anterior 5th of the body
§ Egg:
o Color: Straw Colored • Like many trematodes, Echinostomid flukes undergo a multi-host
o Shape: Ovoid and Operculated (indirect) life cycle
o Measuring: 83-116 um x 58-69 um

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• Unembryonated eggs are passed in feces of infected definitive 2nd IH: Fishes (tilapia and mullet)
hosts (1) and develop in water (2) Miracidia usually take about 3 MOT: Ingestion of metacercaria encysted in fish
weeks to mature before hatching (3), after which they swim freely
and penetrate the first intermediate host, a snail (4) • Life cycle:
• The Intramolluscan stages include: § Adult’s release embryonated eggs each with a fully
§ sporocyst stage (4a) one or two generations of rediae developed miracidium, and eggs are passed in the host's
(4b) feces (1)
§ and cercariae (4c), which are released from the snail § After ingestion by a suitable snail (first intermediate
• The cercariae may encyst as metacercariae within the same first host), the eggs hatch and release miracidia which
intermediate host or leave the host and penetrate a new second penetrate the snail's intestine (2)
intermediate host (5) § Genera Cerithidia and Pironella are important snail
• The definitive host becomes infected after eating metacercariae in hosts in Asia and the Middle East respectively
infected second intermediate hosts 6 Metacercariae excyst in the § The miracidia undergo several developmental stages in
duodenum 7 and adults reside in the small intestine (for some the snail, i.e. sporocysts (2a), rediae (2b), and cercariae
species, occasionally in the bile ducts or large intestine) (8) (2c)
§ Many cercariae are produced from each redia.
Pathogenesis and Clinical Manifestation § The cercariae are released from the snail (3) and encyst
• Ulceration of intestinal wall as metacercariae in the tissues of a suitable
• Bloody diarrhea fresh/brackish water fish (second intermediate host) (4)
• Abdominal pains § The definitive host becomes infected by ingesting
undercooked or salted fish containing metacercariae
Diagnosis § After ingestion, the metacercariae excyst, attach to the
• Stool sample – detection of egg by microscope mucosa of the small intestine (6) and mature into adults
• Endoscopy (measuring 1.0 to 1.7 mm by 0.3 to 0.4 mm) (7)
Treatment § In addition to humans, various fish-eating mammals
• Praziquantel – Drug of Choice 25mg/Kg of BW x 3 times a day (e.g., cats and dogs) and birds can be infected by
Heterophyes heterophyes
Prevention and Control
• Avoid improper or ingestion of raw that is infected with 2nd IH –
Pila luzonica (kuhol)

HETEROPHYIDS FLUKES
• Lives in the intestine of the fish-eating hosts – lifespan of 2
months
• Smallest trematodes parasite of man
• 4 types:
§ Heterophyes heterophyes (Von Siebod’s Fluke)
§ Metagomius yokogawai
§ Haplorchis taichui
§ Haplorchis yokogawai

Parasitic Biology
• Adult heterophyids Flukes
§ Elongated to oval or pyriform
§ Measures: 2 mm in length
§ Tegument: Fine scale -like spines
§ Genital Sucker [gonotyl] ® located at left
§ posterior boarder of the ventral sucker The adult worm inhabits the small intestine of the definitive host
¯
Large numbers of eggs are produced and passed out onto the
environment together with feces
¯
The egg hatch into miracidia after ingestion by the 1st snail intermediate
(Inside the snail, the miracidia develop further into sporocyst, which
eventually develop into 1 or 2 generation of redia that give rise to
cercariae)
¯
Cercaria are liberated from the snail encyst as metacercaria
• Egg:
On or under the scales, in the muscles, fins, tails, or gills of the fish
§ Light brown in color
which is 2nd IH
§ Ovoid in shape
§ Measures: 20-30um x
Pathogenesis and Clinical Manifestation
15-17um
• Peptic Ulcer Disease (PUD) or Acid Peptic Disease – most common
§ Operculated – fits to
§ Abdominal discomfort > Gurgling abdomen
eggshell smoothly
§ Colicky pain and Mucoid diarrhea
§ No abopercular
protuberance

Definitive hosts: human, cats, dogs, foxes and other fish eating
mammals
1st IH: Snail (Pironella and Cerithidea)

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• Heart and Cerebral involvement § Sexes ® separate
§ Lead to heart failure and intracerebral hemorrhage § Males shorter & stouter, possess gynecophoric canal
• Sensory and Motor defects § Intermediate host ® snail
§ If the spinal cord is affected depending on the level of
the lesion SCHISTOSOMA JAPONICUM (ORIENTAL BLOOD FLUKE)
• Causes: Oriental schistosomiasis, Katayama disease,
Diagnosis schistosomiasis japonica
• Modified Kato-Thick Method / Stool analysis ® detecting the • Distribution: China, Hong Kong, Indonesia, Japan, Philippines
presence of the eggs (definitive diagnosis) [Difficult Clonorchis (Luzon, Mindanao, Mindoro, Samar, Leyte)
Eggs] • Morphology:
• Clinical history § Adult worm:
§ PUD manifested plus bowel disturbances with history of o Female
eating raw fish - Long, slender, with oral and
ventral suckers
Treatment - Ovary – centrally located
• Praziquantel® DOC o Male
§ 25mg/kg/dose TID in 1 day - With oral and ventral suckers
- Shorter and stouter with
Prevention and Control gynecophoral canal
• Avoiding ingestion of war or improper cooked fish - Cuticle has no tuberculation
• Surveillance on other region where raw fish (kinilaw) is eaten
should be considered

Note: Intestinal Fluke

• Fasciolopsis buski: Giant Intestinal Fluke
• Echinostoma ilocanum: Garrison’s Fluke
• Heterophyes heterophyes: Von’s Seibold’s Fluke
• Metagonimus yokogawai: Yokogawa’s Fluke

BLOOD FLUKES
• Genus – Schistosoma; previously called “Bilharzia”
• 3 Major spp: § Egg:
§ Schistosoma japonicum (Oriental Blood Fluke) o Shape is ovoidal or subglobular, with thin
§ Schistosoma mansoni (Manson’s Blood Fluke) shell, rudimentary or abbreviated lateral
§ Schistosoma haematobium (Vesical Blood Fluke) spine and cellular debris attached to the
• Endemic in China, Philippines and India shell
• Complex life cycle o Contains
§ 1st intermediate host snail ciliated
§ 2nd intermediate host ® varies with species embryo
§ Definitive mammalian host i.e., humans o Lateral knob
§ Live in the vasculature

SCHISTOSOMA MANSONI (MANSON’S BLOOD FLUKE)

• Adult worm:
§ Female
o Long and slender with oral and ventral
spines
o Ovary is anterior to the mid-portion of the
organism
§ Male
o With oral and ventral suckers
o Shorter and stouter with a gynecophoral
canal
o With 6-9 small testes in column or group
1st IH Snail
• Egg:
2nd IH None
§ Shape is elongate ovoidal with thin shell and lateral
Definitive host Man
spine
Egg Mature, non-operculated
§ Contains ciliated embryo
Development S1 – S2 – C
Infective stage Cercaria
Diagnostic stage Egg
Sex Dioecious
Free swimming larva Fork-tailed cercaria

• Schistosomes:
§ Mid 1800s discovery of worms that caused
schistosomiasis hematobia: Theodor Bilharz a German
parasitologist
§ Schistosoma, means "split body"
§ Bodies ® elongated

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SCHISTOSOMA HAEMATOBIUM (VESICAL BLOOD FLUKE)
• Distribution:
§ Africa, Syria, Iran, Iraq, Arabia, Yemen
• Intermediate host: Bulinus, Physopsis, Biomphalaria
• Causes:
§ Vesical schistosomiasis, schistosmal hematuria, urinary
bilharziasis
• Morphology:
§ Egg
o 1 to 4 ova in uterus with alteral spine
§ Adult worm
o Female
- Long and slender with oral and
ventral suckers
- Ovary is posterior to the mid
portion of the organism
o Male
- With oral and ventral suckers
- Shorter and stouter with a
gynecophoral canal OVA in feces
- Cuticle has fine tuberculation ¯
[tegument coarsely MATURE when laid
tuberculated] ¯
- With 4-5 large testes in cluster hatch in water (to look for Intermediate Host)
¯
Release MIRACIDIA
¯
penetrate SNAIL
¯
SPOROCYS
¯
NO REDIA STAGE
¯
CERCARIA goes out into the water
¯
Parasitic Biology SKIN PENETRATION
• Peculiar flukes (Enzyme mediated penetrance to skin)
• Mature in blood vascular system in definitive host ¯
• Calcified egg of S. haematobium in Egyptians mummies Attracted to AA ARGININE
• “Split body” – gynecophoral canal of male, where female lodge ¯
during copulation penetrate skin and disappear in 10-30s
• S. japonicum – lays the greatest number of eggs ¯
• “Romancing parasite” – once they copulate, they won’t separate LEAVES TAIL BEHIND
• Adult worm (3 spp) ¯
§ Female – long and slender SCHISTOSOMULAE (without tail)
§ Male – shorter, stouter, no pharynx with strong oral ¯
sucker enter peripheral circulation
• Eggs (3 spp) ¯
§ Causes infection/symptoms migrate to portal blood in liver and mature into adult paired worm go
§ Form pseudo tubercles microscopically upstream into smaller veins where female deposit egg
§ Marked eosinophilic reaction surrounding eggs ¯
§ Multinucleated giant cells eggs traverse wall of venules (aided by spine)
§ Have antigenic properties – depend on host variability ¯
traverse intervening tissue
– cause granuloma ¯
§ S. japonicum and S. mansonia eggs in the liver and right heart àpulmonary à left heartà systemic à liver and pair up à
intestine travel in pairs à migrate to wall of urinary bladder and GIT and lay eggs
o Intestine: fibrous in mucosa ®
malabsorption ® mucoid, bloody diarrhea • Adults live in veins that drain certain organs à paired worms go
o Liver: fibrous ® cirrhosis upstream into smaller veins where female deposit eggs à eggs
traverse wall of venule à eggs traverse intervening tissueà
traverse gut/bladder mucosa à expelled from host à FECES or
URINE

Pathogenesis and Clinical Manifestation

• Schistosomiasis ® 3 stages:
§ 1st developmental from cercarial penetration to adult
maturation
§ 2nd ® egg deposition and excretion
§ 3rd ® immune response to eggs

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• Sympathology: • Stages of Schistosomiasis
§ 1st evidence of infection: itching & skin rash § Stage 1
§ Then: low grade fever, malaise, transient urticaria o Invasion
§ Inflammatory response develops around dead worms, - Early infection, mild signs and
live species provoke no response symptoms
• Acute schistosomiasis - Skin penetration
§ Katayama Fever or Snail fever - Papulodermatitis due to fork
o Acute schistosomiasis occurring 2-3 weeks tailed cercaria
after exposure to large number of cercaria - Schistosomial dermatitis
characterized by: chills, fever, weakness, o Migration
weight loss, cough, arthralgia, eosinophilia, - ever, cough
abdominal pain, bloody diarrhea - Inflammatory reaction to lungs
§ Schistosome Granuloma and liver
o Develops around the egg, which serves as an o Diagnosis
antigen that provokes an immune response - Cercaria Huellen reaction
o Splendore-Hoeppli phenomenon: an - Skin test (+) at stage
eosinophilic Ag-Ab precipitate around the - Non-specific
egg § Stage 2
§ Serum-like sickness that develops several weeks after o Maturation
exposure - From migration to penetration of
§ Corresponds to the 1st cycle of egg deposition and is egg
associated with marked peripheral eosinophilia and
- Katayama fever: early fever in
circulating immune complexes
schistosomal infection
§ It is most common with S. japonicum and S. mansoni
- Acute febrile response
infection and is most likely to occur in newly infected
§ Stage 3
individuals after primary infection
o Stage of Established infection
§ Signs and symptoms usually resolve over several weeks
- Massive egg laying
but can be fatal to very young and very old
- Early chronic infection, due to
§ Mild maculopapular lesion, high grade fever
granuloma formed by egg
§ Stage 4
o Late infection and complications
o Prolonged infection, marked decrease in egg
production and extrusion of eggs or no eggs
at all
o Possible development of sequelae such as
• Chronic schistosomiasis
cor pulmonale, obstructive uropathy and
§ More common
formation of varices
§ Result from egg-induced immune response, granuloma o Progressive fibrosis relative to infection
formation and associated fibrotic changes o Involves brain in S. japonicum infection
§ Schistosoma eggs are highly immunogenic and induce
o Liver fibrosis ® liver cirrhosis ® portal
vigorous circulating and local immune response
hypertension ® ascites, splenomegaly (due
§ Results from cumulative egg deposition, leading to
to direct invasion of eggs, portal
§ connective tissue deposition, then to periportal fibrosis
hypertension, and granuloma formation
§ Periportal fibrosis > portal hypertension collateral
o Cachexic patient with big abdomen
circulation ›esophageal varices rupture bleeding
• Squamous cell CA
§ Most common cancer in Schistosomiasis

• Egg retention and Granuloma formation in the bowel wall • Transitional cell CA
(S.mansonia and S. japonicum) § Most common type of cancer in bladder CA
§ Bloody diarrhea
§ Cramping
§ Inflammatory Colonic polyposis
§ Increased rate of recurrent Salmonella infection
§ Heavy infection – Hepatic Disease
§ Severe Fibrosis – Pipestem pattern
§ Periportal Fibrosis – Portal HPN • Swimmer’s itch
§ Portal HPN sequelae: § Schistosoma cercarial dermatitis
o Splenomegaly
o Ascites
o Esophageal varices
o Development of portosystemic collaterals
• Egg retention (S. haematobium)
§ Hematuria
§ Dysuria • Birds schistosome
§ Ulcer § Cercaria release allergens
§ Bladder polyp § Inflamed pus-filled pimple
§ Obstructive uropathies

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§ Die in subcutaneous tissue àcause allergy à severe LUNG FLUKE
manifestationàabscess • Other names:
§ Paragonimiasis – Disease causing Paragonimus sp.
§ Pulmonary Distomiasis
§ Endemic Hemoptysis
§ Parasitic Hemoptysis
• Parasites:
§ Paragonimus westermani – Disease causing to Humans
and Other Mammals
§ Paragonimus philippinensis
§ Paragonimus siamensis – Disease causing to Feline
species, seen in cats

Diagnosis PARAGONIMUS WASTERMANI

• S. japonicum and S. mansoni • Also called “Oriental Lung Fluke”
§ Stool Exam • Caused: Pulmonary Paragonimiasis
§ Serology
o ELISA – helpful in confirmation of past 1st Intermediate host Snail
exposure 2nd Intermediate host Grab, cray fish
o Schistosomal antigen test to help distinguish Definitive host/Final host Man
between active and inactive infection
Egg Immature, operculated
o Antigen titers from serum and urine
Sex: Monoecious
correlate with degree of infection
Infective stage Metacercaria
§ Rectal Biopsy
Diagnosis stage Unembryonated egg
o Kato-Katz – thick smear clarified with
glycerol; for identification and quantification Habitat Lungs
of ova in feces
§ Immunodiagnostic tests Parasitic Biology
o Circum-Oval Precipitin Test (COPT) • Adult worm:
o Cercaria Huellen Reaction (CHR) § Reddish brown ® coffee bean
o Fluorescent Antibody Test(FAT) – for o Round anterior
cercaria o Slightly tapered posterior
o ELISA § Measurement:
§ Ultrasound o 7 to 12mm by 4 to 6mm, 3.5 to 5mm in
o to detect pipestem fibrosis of the liver and thickness
patency of the portal, splenic and superior § Shape: Coffee bean/Watermelon
mesenteric vessels shaped
• S. haematobium § Tegument is covered with single-
§ Urine Examination – (+) eggs à definitive diagnosis; 24- spaced spines (skin)
hour urine collection may be recommended § 2 Testes:
§ Micropore filtration for the detection of ova in urine o Irregular, lobulated and situated opposite
§ Cystoscopy each other (side by side), almost midway
§ Immunodiagnostic tests between the ventral sucker and the
§ Ultrasound – to detect urinary tract lesion posterior border of the body
§ Ovary:
Treatment o Located anterior to the testes and posterior
• DOC: Praziquantel (Biltricide) (3rd and 4th of the body) to the ventral sucker
• Anti-inflammatory drugs and has 6 long unbranched lobes
§ Vitellaria:
Prevention and Control o Branched extensively, located at the lateral
side of the entire body
• Mass chemotherapy to reduce morbidity – school age group is the
§ Cercaria
target
o Covered with spines, has ellipsoidal body,
S. hematobium S. mansoni S. japonicum and a small tail
Caused Vesical schistosomiasis Manson’s Oriental blood fluke § Metacercaria
schistosomiasis Schistosomiasis o Round and measures from 381 to 457 um
japonica
Testes 4 to 5 6 to 9 7
Uterus Least egg Few Most egg (<300)
Habitat Urinary bladder plexus Large intestine Small intestine
Inferior mesenteric Superior mesenteric
Snail Bullinus Biomphalaria Oncomelania quadrasi
Biomphalaria Tropicorbis
Physopsis centrimetralis
Infection Least serious Most serious (most
number of eggs) • Egg:
Excreted in Urine Feces Urine and feces
Male Short, stout, Short, stout, Shour, stout,
§ Golden yellowish-brown or chocolate color (thick
morphology gynecophoral can gynecophoral canal gynecophoral canl shelled egg) 80 to 118um by 48 to 60um
present, cuticle present present, no cuticle § Flattened operculum with terminal shell thickening
tuberculation 10-15mm x 0.8-1mm tuberculation
10-15mm x 0.8-1mm 12-20mm x 0.5-
§ Ticked abopercular end portion
0.55mm § Unembryonated at oviposition
Female Ovary post-mid portion Ovary anterior-mid Ovary centrally located § Contains disorganized yolk material (immature when
morphology 20mm x 0.25mm portion 26mm x 0.3mm
20mm x 0.25mm
laid)

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§ For encystment and immune modulation of the
host in metacercaria stage
§ Important role in developing young parasite
because of their environment in metacercarial
excystment, tissue invasion immune modulation of
the host
• Life cycle:
§ 65 - 90 days of completion of development and can
stay 5 - 6 Years

Unembryonated egg Pathogenesis and Clinical Manifestation

(passed in feces) • Granulomatous reaction and Fibro Encapsulation in the lungs
¯ (Pulmonary Paragonimus)
Embryonate in water § Early stage – asymptomatic
¯ § Later stage – Give rise to the development of fibrotic
Miracidia hatch and penetrated Snail cyst containing blood-tinged purulent material, adult
¯ worms and eggs (more pronounced in the Morning)
Sporocyst (L2) ® Redia (L3) ® Cercaria (L4) § Symptoms: less severe after 5 to 6 years
¯ o Chronic cough and hemoptysis
Goes into water and invade Crustacean o Chest pain, dyspnea low-grade fever,
¯ fatigue, generalized myalgia
Encysted in to Metacercaria (L1) § Can sequalae to:
¯ o Chronic bronchiectasis
Man ingested inadequately cooked or pickled crustaceans containing o Flexural fibrosis secondary to severe
Metacercaria parenchymal and pleura damage
¯ • Severe infections:
Excysted in Duodenum § Pulmonary paragonimiasis
¯ § Ectopic Paragonimus – cerebral and cutaneous
Penetrate intestinal wall involvement
¯ • Chest pains and Dyspnea
Diaphragm • Fever, Myalgia, and Fatigue ® Leads to Misdiagnosis of PTB
¯ • Chronic Cough Misdiagnosis of Chronic Bronchitis or Asthma
Adult develop in capsule in cystic cavities in Lungs (middle portion) • IL5 and Eosinophilia ® Pleural Fluid and PBS.
¯ • Other manifestations depending site or lesion (Brain/Abdomen) in
Lay eggs which are excreted in the sputum erratic type forms
(alternately eggs are swallowed and passed with stool)
Diagnosis
• Microscope
§ Detection of eggs in the sputum, stool or aspirated
materials from abscesses or pleural effusion

• Chest radiographs
§ Diagnosing pulmonary paragonimiasis – infiltrative,
nodular, cavitating

• Cerebral radiographs
Note:
§ CT scan and MRI – “grape-cluster” appearance
• 1stIH: Snail
§ Antemelania asperata (previously known as Brotia
asperta
§ Antemelania dactylus
• 2nd IH: Crab or Crayfish
§ Sundathelphusa phuluppina (previously known as
Prathelohysa grapsiodes)
• Cysteine proteases

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• Other:
§ CBC – acute stage
o Reveals eosinophilia and elevated level of
IgE
§ Immunologic methods
o CF testing
o ELISA

Treatment
• Praziquantel – DOC
§ 25mg/kg of BW x #times a day
• Corticosteroids
§ Used in additional drug of cerebral involvement
• Bithionol
§ Alternative drugs. 15 to 25mg/kg BID on alternate days
for 10 to 15 days
• Triclabendazole
§ Damages the nuclear membrane of the parasite

Prevention and Prevention

• Avoid ingestion of raw or insufficiently cooked crabs or cray fish
and other crustacean
• Safe food preparation
• Heath education

END

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