CHAPTER 14 Trematodes

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LEARNING OBJECTIVES
At the end of this chapter, the student should be able to:
1. describe the general characteristics of the medically important trematodes; and
2. characterize and differentiate the different trematodes as to their:
a. general features,
b. source of infection,
c. mode of transmission,
d. clinical manifestations,
e. treatment, and
f. prevention and control of infection.

General Properties of Trematodes

Trematodes, commonly known as flukes, belong to the class Trematoda or Digenea. They may
be hermaphroditic or dioecious (reproduce via separate sexes). Most flukes are hermaphroditic
except Schistosoma spp. (blood flukes). Morphologically, flukes are fleshy, leaf-shaped worms.
Unlike tapeworms, flukes have a digestive tract. In general, flukes have two muscular suckers-an
oral type, which is the beginning of an incomplete digestive system and a ventral sucker which
serves for attachment.

The eggs of the trematodes vary in appearance and are the primary morphologic stage that are
usually recovered from humans. Some eggs may possess a lid-like structure that can flip open to
release its contents. This lid-like structure is called operculum and is present in the eggs of
Fasciolopsis and Fasciola. In Schistosoma spp., the eggs of the various members may be
differentiated based on the presence and location of spines.

Unlike in cestode infections, humans never serve as intermediate hosts for the flukes. In general,
flukes have two intermediate hosts except for the blood flukes where there is only one
intermediate host. Common to all trematodes, the first intermediate hosts are mollusks (snails
and clams) where asexual reproduction takes place. The second intermediate host varies
depending on the parasite. Sexual reproduction of flukes occurs in humans. In most cases,
humans acquire the infection through ingestion of undercooked or raw second intermediate host.
Skin penetration by the infective larvae is the major mode of transmission for blood flukes.

Blood-dwelling Flukes

Schistosoma spp.

Important Properties and Life Cycle

Three schistosomes are frequently associated with human disease, namely: Schistosoma
mansoni, Schistosoma japonicum, and Schistosoma haematobium. Blood flukes are dioecious.
Known as the “romantic parasites,” the male and female worms are usually in a state of
copulation (en copula). Female worms are usually larger than the male worms. The schistosomes
are also obligate intravascular parasites.

The eggs are found In fresh water contaminated with the feces or urine of infected humans. Once
in the water, eggs develop into a miracidium, that will then locate a snail as its host, where it
transforms into cercariae. Infection is acquired through skin penetration by the fork-tailed
cercaria (larval form). The parasite migrates into the bloodstream where they undergo
maturation.

The location of the adults varies by species. For Schistosoma japonicum and Schistosoma
mansoni, after skin penetration, the worms enter the veins surrounding the intestinal tract
(superior and inferior mesenteric and portal vein for S. japonicum; inferior mesenteric for S.
mansoni). Schistosoma haematobium worms localize in the veins surrounding the urinary
bladder. The adult worms lay thousands of eggs per day. The eggs produce enzymes that enable
them to travel through the tissue. The eggs then find their way into the colon (for S. japonicum
and S. mansoni) or into urine (for S. haematobium) from which they are excreted.

Figure 14.1 General life cycle of Schistosoma spp.

Epidemiology and Pathogenesis

Schistosoma mansoni and Schistosoma haematobium are both distributed throughout Africa. S.
mansoni is also found in South America while S. haematobium is also prevalent in the Middle
East. Schistosoma japonicum is endemic in Indonesia, some parts of China, and Southeast Asia,
including the Philippines. It is the only schistosome for which domestic animals (e.g., water
buffalo and pigs) act as important reservoirs.

Most of the findings are caused by the presence of eggs in the liver, spleen, or walls of the gut or
the urinary bladder, depending on which species is causing the infection. Eggs of S. japonicum in
the liver may induce granuloma formation leading to fibrosis and portal hypertension, as well as
damage the walls of the small and large intestines. Eggs of S. mansoni may damage the walls of
the distal colon. Eggs of S. haematobium may induce granuloma and fibrosis in the walls of the
urinary bladder.

Disease: Schistosomiasis (Bilharziasis)

1. Asymptomatic infection - the most common form of the disease. Chronic infection may
become symptomatic.

2. Early acute infection – characterized by pruritic papules seen at the site of entry of the
parasite. This is called “swimmer’s itch” or “clam digger’s itch.” This is followed after 2-
3 weeks by fever and chills, abdominal pain, cough, bloody diarrhea, and weight loss,
Painful urination (dysuria) and blood in the urine (hematuria) may also occur in patients
infected with S. haematobium.

3. Katayama fever- a systemic hypersensitivity reaction to the migrating schistosomes,

usually associated with S. japonicum. It is characterized by a rapid onset of fever,
myalgia, body malaise, cough, diarrhea, and eosinophilia occurring 1-2 months after
exposure to the parasite. Swollen lymph nodes (lymphadenopathy) and enlargement of
the liver and spleen (hepatosplenomegaly) may also occur. It can lead to hepatic
dysfunction, leading to portal hypertension. The most common cause of death in this case
is internal bleeding from ruptured esophageal varices.
 4. Associated conditions - include development of nephrotic syndrome in S. japonicum and
S. haematobium infection. Infection with S. mansoni or S. japonicum may predispose to
repeated Salmonella infections. S. japonicum is associated with the development of
hepatocellular carcinoma or liver cancer while S. haematobium has been implicated in
the development of cancer of the urinary bladder.

Figure 14.2 Swimmer’s itch following skin penetration. By the cercariae of Schistosoma spp.
Source: Cornellier, 2007

Laboratory Diagnosis

Diagnosis relies on demonstration of characteristic eggs in the feces or rectal biopsy specimen
for S. mansoni or S. japonicum, or urine for S. haematobium. S. manioni eggs have a large
lateral spine while S. japonicum eggs have a rudimentary spine. The eggs of S. haematobium
have large terminal spines.

Figure 14.3 Schistosoma ova: a. S. mansoni; b. S. haematobium; and c. S. japonicum

Treatment

The recommended drug for all three species is praziquantel. An alternative drug for S. mansoni is
oxamniquine. Anti-malaria drugs such as artemether and artemisinins have also been proven
effective.

Prevention and Control

There are two objectives of schistosomal control: (a) control of transmission through snail
control, health education, and provision of sanitary facilities and water supply; and (b) control of
disease. Chemotherapy using praziquantel is the main thrust of the Philippine program for
schistosomiasis control (Department of Health). In order to prevent infection, swimming in
endemic areas should be avoided.

Tissue-dwelling Flukes

Clonorchis sinensis (Asian Liver Fluke, Chinese Liver Fluke)

Important Properties and Life Cycle

There are three morphologic stages of the parasite-egg, larva, and adult. The egg have an
operculum surrounded by a thick rim called the shoulder. The first intermediate host is the
freshwater snail while the second intermediate host is a freshwater fish. Within the egg is the
developed miracidium, that is released once the egg comes into contact with fresh water.

The miracidium penetrates the first intermediate host and develops into a sporocyst that contains
numerous larval stages called the rediae. The larvae are then released into the water where they
transform into cercariae. The cercariae enter a freshwater fish where they encyst to become the
metacercariae. The larvae excyst in the duodenum, enter the biliary ducts, and differentiate into
adults. The adult worms produce eggs that are excreted in the feces, Humans acquire the
infection by ingesting raw or undercooked freshwater fish containing the infective metacercariae.

Figure 14.4 Life cycle of Clonorchis sinensis

Epidemiology and Pathogenesis

Clonorchis sinensis is found in Asia including Korea, China, Taiwan, Vietnam, Japan, and Asian
Russia (Center for Disease Control and Prevention). The parasite does not usually cause
significant lesions, however, parasites that inhabit the bile ducts can damage the biliary tract.
Patients who develop infection with the parasite are at higher risk of developing
cholangiocarcinoma or cancer of the bile ducts. The egg has also been associated with the
development of gallstones (stones in the gall bladder or cholelithiasis).
Disease: Clonorchiasis

Most patients are asymptomatic. In heavy worm burden, patients may manifest a fever, upper
abdominal pain, anorexia, hepatomegaly, diarrhea, and eosinophilia. Liver dysfunction may also
occur in chronic infection associated with heavy worm burden.

Laboratory Diagnosis

Diagnosis is established by finding the characteristic eggs in stool specimen or duodenal

aspirates.

Treatment

The drug of choice for treatment is praziquantel. An alternative drug is albendazole.

Prevention and Control

Infection can be prevented by thorough cooking of fish prior to consumption. Other control
measures include health education, proper waste disposal to avoid contamination of bodies of
fresh water, and prompt treatment of infected persons.

Fasciola hepatica (Sheep Liver Fluke)

Important Properties and Life Cycle

The Fasciola hepatica eggs possess an operculum similar to Clonorchis sinensis and is also
equipped with shoulders. The first intermediate host for the parasite is the snail while the second
intermediate hosts are edible aquatic plants (kangkong and watercress). Humans acquire the
infection by ingesting raw edible aquatic plants or by drinking water contaminated by
metacercariae (infective stage). Upon ingestion, the metacercariae excyst in the duodenum or
jejunum, releasing the young flukes. These young flukes wander over the viscera until they reach
the liver capsule. The parasite then burrows through the liver parenchyma until it finally enters
the bile ducts where they mature.

The adult worms (pathogenic stage) live in the biliary passages of the liver. Immature eggs are
carried by the bile into the intestines and subsequently excreted with feces. The eggs mature in
the water and infect the first intermediate host. The cercariae escape the snail host, usually at
night, then encyst on the surface of aquatic plants, forming metacercariae. The natural host for
the completion of the life cycle is the sheep, however the parasite may also be found in cattle. In
sheep-raising countries, ingestion of raw sheep liver containing the adult worm also serves as an
additional mode of transmission. Humans serve as accidental hosts.

Figure 14.5 Life cycle of Fasciola hepatica

Epidemiology and Pathogenesis

The Fasciola hepatica is found worldwide, especially in sheep- and cattle-raising countries, and
where humans consume raw watercress such as Asia, Europe, and the Middle East. The stages of
the disease correspond with the migration of the parasites. The acute or invasive phase
corresponds to the migration of the parasite through the liver parenchyma, which leads to
traumatic and necrotic lesions in the liver. The severity of the destruction is proportional to the
number of metacercariae ingested. The chronic phase corresponds to the localization of the adult
worms to the bile ducts. The worm can obstruct the bile duct and stimulate inflammation. During
migration from the intestines to the liver, the parasite may wander to other sites (e.g., lungs,
subcutaneous tissues, brain, or orbit) where abscesses may develop.

Disease: Fascioliasis or Sheep Liver Rot

Migration of the larval worm through the liver irritates the organ, manifesting as tenderness and
hepatomegaly. Characteristic clinical features include right upper quadrant pain, fever and chills,
and marked eosinophilia. Hepatitis may develop with biliary obstruction. Some worms may
cause necrotic foci in the liver. Ingestion of raw sheep liver may lead to temporary lodgment of
the adult worm in the pharynx leading to suffocation.
Laboratory Diagnosis

Diagnosis rests on finding of eggs in stool specimen, although the appearance of the eggs of F.
hepatica may be indistinguishable from the eggs of another fluke, Fasciolopsis buski.
Examination of a sample of the patient’s bile may aid in the differentiation. If the eggs are
present in bile then this is indicative of F. hepatica. Other tests that can be performed include
ELISA and the Enterotest (discussed in Chapter 11).

Treatment
The treatment of choice is dichlorophenol (bithionol). An alternative drug is triclabendazole.

Prevention and Control

Preventive measures include proper human waste disposal, improvement of hygiene, control of
snail population, and avoidance of consumption of raw aquatic plants and contaminated water. In
endemic areas it is highly recommended to boil water before consumption or use. Avoidance of
ingesting of raw sheep liver is also important, as well as prompt treatment of infected
individuals.

Paragonimus westermani (Oriental Lung Fluke)

Important Properties and Life Cycle

Similar to other trematodes, the first intermediate host for Paragonimus is a snail while the
second intermediate hosts are crabs or crayfish. Humans acquire the infection by ingesting raw
or undercooked crabs or crayfish that contain the infective encysted metacercaria. The larva
excysts in the small intestines, migrate through the intestinal wall, through the peritoneal cavity,
into the diaphragm then into the lung parenchyma where they mature. The adult worms enter the
bronchioles and are then coughed up or swallowed. Eggs in the sputum or feces reach fresh
water, hatch, and penetrate the first intermediate host, where they differentiate into free-
swimming cercariae. The cercariae leave the snail host and encyst in freshwater crabs that are
eaten by humans.

Figure 14.6 Life cycle of Paragonimus westermani

Figure 14.7 A freshwater crab that has been implicated in the transmission of Paragonimus
westermani

Epidemiology and Pathogenesis

P. westermani infection occurs most commonly in Asia, in countries like China, the Philippines,
Japan, Vietnam, South Korea, Taiwan, and Thailand (Centers for Disease Control and
Prevention). Pigs, monkeys, and other animals that eat crayfish and crabs serve as reservoir
hosts. The worms exist in a fibrous capsule within the lung which communicates with a
bronchiole. Within this cyst is blood-tinged purulent material containing eggs. Secondary
bacterial infection frequently occurs.

Disease: Paragonimiasis (Pulmonary distomiasis, Endemic hemoptysis, Parasitic hemoptysis)

The early stages of the disease are usually asymptomatic. Patients may later experience
symptoms related to pulmonary involvement including cough productive of blood-tinged sputum
(hemoptysis), fever, and chest pain. The sputum has a foul, fishy odor and is most pronounced in
the morning. The disease may mimic pulmonary tuberculosis. In rare cases, the immature flukes
may migrate to the brain leading to cerebral paragonimiasis, which may manifest as seizures,
visual disturbances, and reduced motor skill precision.

Laboratory Diagnosis
Diagnosis is made by demonstration of the characteristic eggs in sputum or feces (when sputum
is swallowed). A chest x-ray may be done which may show a ring-shadowed opacity with several
contiguous cavities giving the appearance of a cluster of grapes.

Treatment

The drug of choice for treatment is praziquantel. An alternative drug is bithionol.

Prevention and Control

Preventive measures include adequate and thorough cooking of freshwater crabs or crayfish,
health education, control of snail population, and elimination of reservoir hosts. Prompt
treatment of infected persons is also important to prevent the parasite from spreading.

Fasciolopsis buski (Large Intestinal Fluke)

Important Properties and Life Cycle

The eggs of F. buski and F. hepatica are mophologically identical however they differ only in
size. The adult worms of both parasites are also similar in appearance except that shoulders are
present in F. hepatica and not in F. buski. Similar to the other tissue-dwelling trematodes, the
first intermediate host is a snail while the second intermediate hosts are edible aquatic plants
(e.g., watercress and lotus).

Humans acquire the parasite by ingestion of raw or inadequately cooked aquatic vegetation that
carries the encysted metacercariae. The metacercariae excysts in the duodenum and attaches to
the intestinal wall where they attain maturity. The adult worms lay eggs, that are released
together with the feces into water, where they hatch and infect the first intermediate host. The
eggs develop into cercariae which encyst as metacercariae on the surface of the aquatic plants.
Other animals such as pigs and dogs may also serve as the reservoir hosts.
Figure 14.8 Life cycle of Fasciolopsis buski

Epidemiology and Pathogenesis

F. buski is the largest intestinal fluke that can infect humans. Infection with the parasite is
common in Asia and the Indian subcontinent, particularly in areas where pigs are raised and
where freshwater aquatic vegetation is ingested raw. No locally-acquired cases in humans or pigs
have been reported in the Philippines. Pathologic changes are due to damage to the intestinal
mucosa by the adult fluke.

Disease: Fasciolopsiasis

Most infected persons are asymptomatic. However, with heavy worm burden, patients may
experience abdominal discomfort with inflammation and bleeding in the affected area.
Ulcerations may occur and symptoms may mimic those of duodenal ulcer. Patients may also
suffer from malabsorption. Intoxication may result from absorption of worm metabolites by the
host, leading to allergic symptoms such as edema of the face, abdominal wall, and lower limbs.
Profound intoxication can result in death.

Laboratory Diagnosis

Diagnosis is made by demonstration of the eggs in stool specimen. Examination of bile samples
and duodenal aspirates may help differentiate F. buski eggs from those of F. hepatica.

Treatment

The drug of choice for treatment is praziquantel.

Prevention and Control

Adequate washing and cooking of aquatic plants before consumption can help prevent infection.
Other measures include proper disposal of human waste, control of snail population, and prompt
treatment of infected persons.

CHAPTER SUMMARY

 Trematodes, also known as flukes, are worms that possess a primitive digestive tract.

 Trematodes may be divided into two classes-tissue-dwelling flukes and blood-dwelling

flukes.

 Tissue-dwelling flukes include Clonorchis sinensis, Fasciola hepatica, Paragonimus

westermani, and Fasciolopsis buski.

o All tissue-dwelling flukes have two intermediate hosts.

o The first intermediate host is always a snail.

o Second intermediate hosts include freshwater fish, crabs or crayfish, and edible aquatic
plants.

o All are transmitted by ingestion of raw or inadequately cooked second intermediate host.

o The infective stage is the encysted metacercaria.

 Blood-dwelling flukes are the schistosomes which are composed of three species-
Schistosoma japonicum, Schistosoma mansoni, and Schistosoma haematobium.

 Blood flukes do not have a second intermediate host. The intermediate host is the
freshwater snail.

 The major mode of transmission is skin penetration by the infective fork-tailed

cercaria.

 The pathogenic stage is the adult worm except for S. japonicum where the eggs also
serve as the pathogenic stage.

 S. japonicum has predilection for the superior and inferior mesenteric veins. The adult
female migrates to the portal vein where egg laying may occur. S. mansoni adult
worms localize to the inferior mesenteric veins while S. haematobium worms localize
to the veins around the urinary bladder.

 Patients with S. japonicum infection are at a higher risk for development of liver cancer while
those with S. haematobium infection are more prone to develop cancer of the urinary bladder.

 Clonorchis sinensis and Fasciola hepatica can lead to development of obstructive jaundice.

 Fasciolopsis buski produce disease manifestations that mimic duodenal ulcer.

 Paragonimus westermani produce symptoms that mimic pulmonary tuberculosis.