Lecture 4

TREMATODES

Trematodes (flukes) are flat, fleshy, leaf-shaped worms that are members of
the phylum Platyhelminthes. They differ from cestodes in their gross morphology
and manner of development. Unlike cestodes, flukes have a digestive tract. In
general, flukes have two muscular sucker: an oral type, which is the beginning of
the incomplete digestive system, and a ventral sucker, which serves for
attachment. Most flukes are hermaphroditic, except for Schistosoma spp. (blood
flukes).
Unlike cestodes, trematodes never use human as an intermediate host. Most
of the flukes have two intermediate hosts, except for the schistosomes, which have
only one intermediate host. Without exception, the first intermediate hosts are
mollusks (snails and clams, usually snails), in which asexual reproduction takes
place. The second intermediate host varies depending on the parasite. Sexual cycle
occurs in humans. Transmission to humans occur either by penetration of the skin
by the free-swimming larvae (cercariae) of the schistosomes or by ingestion of cysts
from undercooked or raw second intermediate hosts.
SCHISTOSOMA spp.
Important properties
There are three schistosomes most frequently associated with human
disease, namely: Schistosoma mansoni, Schistosoma japonicum (oriental blood
fluke), and Schistosoma haematobium. The schistosomes differ from other flukes in
that they are not hermaphroditic. They are also obligate intravascular parasites and
are not found in other tissues. The infective stage is the skin-penetrating cercaria.
Humans are infected when the free-swimming fork-tailed cercariae penetrate
the skin. Those that enter the superior mesenteric artery pass into the portal
circulation, where they mature into adult flukes, S. mansoni and S. haematobium
adults migrate against portal flow and reside in the mesenteric venules. S.
haematobium adults reach the bladder veins through the venous plexus between
the rectum and urinary bladder. The eggs are excreted in the stools or urine and
must enter fresh water to hatch.
 Figure 1. Life cycle of Schistosoma japonicum
Pathogenesis & epidemiology
Most of the findings are caused by presence of eggs in the liver, spleen, or
wall of the gut or bladder. Eggs in the liver induce granulomas, which lead to
fibrosis, hepatomegaly, and portal hypertension. S. mansoni eggs damage the wall
of the distal colon (inferior mesenteric venules). S. japonicum eggs damage the
walls of both small and large intestines (superior and inferior mesenteric venules).
The eggs of S. haematobium in the wall of the bladder induce granuloma and
fibrosis.
Schistosoma japonicum is endemic in China, the Philippines and Indonesia.
Schistosoma mansoni is found in Africa and Latin America, whereas Schistosoma
haematobium is found in Africa and the Middle East. S. japonicum is the only one for
which domestic animals act as an important reservoir.
 Figure 2. (a) Adult Schistosoma worms in state of copulation, (b) Schistosoma
infection with ascites and hepatomegaly.
Disease: Schistosomiasis (bilharziasis)
Most patients are asymptomatic. Chronic infection may become
symptomatic. Early infection is 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, chills, diarrhea, lymphadenopathy, and, and in
the case of S. japonicum, hepatosplenomegaly. This stage usually resolves
spontaneously.
Chronic infection can cause significant morbidity and moratality. In patients
with S. mansoni or S. japonicum infection, gastrointestinal hemorrhage,
hepatomegaly, and massive splenomegaly can occur. S. japonicum infection (also
known as Katayama’s disease) specifically can cause hepatic dysfunction, leading to
portal hypertension. The most common cause of death in this case is bleeding from
ruptured esophageal varices. In addition, patients with S. japonicum infection are at
greater risk for developing liver cancer (hepatocellular carcinoma). Patients with S.
haematobium infection (vesical bilharziasis) manifest with hematuria (blood in the
urine). Secondary bacterial infection of the urinary tract can occur, and as
previously mentioned, have a higher risk for development of cancer of the urinary
bladder or bladder carcinoma.
Laboratory diagnosis
Diagnosis rests on finding the characteristic ova if the feces or urine. S.
mansoni eggs have a large lateral spine while S. japonicum eggs have rudimentary
spines. The eggs of S. haematobium lave large terminal spines.
Treatment
The drug of choice for all three species is praziquantil.
Prevention
There are two objectives of schistosoma control: (a) control of transmission
through snail control, health education, and provision of satisfactory sanitary
facilities nd water supply; (b) control of disease. Chemotherapy using praziquantil is
the main thrust of the Philippine program for schistosomiasis control. Swimming in
areas of endemic infection should be avoided.

Clonorchis sinensis (Asian liver fluke)

Important properties
Infection is obtained by ingestion of undercooked or raw freshwater fish
containing the encysted larvae (metacercariae). The larvae excyst in the
duodenum, enter the biliary ducts, and differentiate into adults. The adults produce
eggs, which are excreted in the feces. Once in freshwater environment, the eggs
are ingested by snails (first intermediate host), then hatch into larvae. The larvae
are released from the snails as cercariae, encyst under the scales of certain
freshwater fish (second intermediate host), which are eaten by humans.

Pathogenesis & epidemiology

The parasite does not cause significant lesions. However, those that inhabit
the bile duct cause significant changes in the biliary tract. Patients who developed
infection with the parasite at higher risk of developing cholangiocarcinoma or
cancer of the bile ducts. The egg has been associated with the formation of
gallstones 9stones in the gall bladder or cholelithiasis). C. sinensis is endemic in
China, Japan, Korea, and Indonesia.
Disease: Clonochiasis
Most infections are asymptomatic. Patients with heavy worm burden may
manifest with upper abdominal pain, anorexia, hepatomegaly, and eosinophilia
(increased levels of circuiting eosinophils).

Figure 3. Life cycle of Clonorchis sinensis

Laboratory diagnosis
Diagnosis is made by finding the typical eggs in the stool.
Treatment
The drug of choice is praziquantil.
Prevention
 Infection can be prevented by thorough cooking of fish. Control measures
include education of the population regarding eating habits and stopping the
seeding of fish culture ponds. Proper disposal of human waste must be observed to
avoid contamination of bodies of freshwater.

Fasciola hepatica (sheep liver fluke)

Important properties
Human infection occurs after ingestion of metacercariae (infective stage)
encysted on edible aquatic plants such as kangkong and watercress (second
intermediate hosts) or by drinking water with metacercariae. Upon ingestion, the
metacercariae excyst in the duodenum or jejunum, liberating the young flukes,
which 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 attain sexual maturity.
The adult worm lives in the biliary passages. Immature eggs are carried by
the bile into the intestine and subsequently excreted feces. The eggs mature in
water and infect the first intermediate host (snail). Cercariae develop in the snail
host, escape usually at night, then encyst on surfaces of aquatic plants, forming
metacercariae.
Pathogenesis & epidemiology
The acute or invasive phase of the disease corresponds to the migration of
the parasite through the liver parenchyma, which leads to traumatic and necrotic
lesions. The severity of the injury depends on the number of metacercariae ingested
by the host.
The chronic or latent phase corresponds to the period when he parasite has
already reached the bile ducts. The adult worms cause obstruction in the vessel and
stimulates inflammation. During migration from the intestines to the liver, they
parasite may wander to other sites, such as the lungs subcutaneous tissues, brain
and the orbit, where abscesses may develop.
Disease: Fascioliasis
Migration of the larval worm through the liver can produce irritation of the
organ, manifesting as tenderness and hepatomegaly. Characteristic manifestations
include right upper quadrant pain, chills and fever, with marked eosinophilia. As the
worms lodge in the bile ducts, hepatitis may develop with biliary obstruction. Some
worms may necrotis foci in the liver called liver rot. Ingestion of raw liver of infected
sheep and goats may cause suffocation (halzoun) due to temporary lodgement of
the adult worm in the pharynx.
Laboratory diagnosis
Diagnosis rests on finding of eggs on stool examination, although the
appearance of the eggs of F. hepatica is similar to the eggs of another fluke, F.
buski. For exact identification, examination of a sample of the patient’s bile may be
performed. If the eggs are present in bile, they are F. hepatica and not F. buski.
Treatment
The treatment of choice is bithionol or triclabendazole.

Prevention
Preventive measures include thorough washing and cooking of vegetables,
and boiling of water in areas where the infection is endemic. Control measure
include elimination of the snail intermediate host and killing the parasites in the
reservoir hosts by chemotherapy.

Figure 4. Life cycle of Fasciola hepatica

Paragonimus westermani (lung fluke)

Important properties
Infection is obtained by ingestion of undercooked or raw crab meat (or
crayfish) that contains the encysted larvae (metacercaria). The larvae excyts in the
small intestine, penetrate the intestinal wall and migrate through the diaphragm
into the lung parenchyma, where they attain maturity. The adults produce worms,
which enter the bronchioles and are the coughed up or swallowed. Eggs in either
sputum or feces that reach freshwater hatch and enter the snail (first intermediate
host), where they differentiate into swimming cercariae. The cercariae leave the
snail host and encysts in freshwater crabs (second intermediate hosts), where they
are eaten by humans.
Pathogenesis & epidemiology
The worm exists 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, which accounts for the bloody
sputum. The parasite is endemic in Asia and India.

Figure 5. Life cycle of Paragonimus westermani

Disease: Paragonimiasis (pulmonary distomiasis); endemic hemoptysis;

parasitic hemoptysis)
The early stages of the infection are usually asymptomatic, if symptomatic,
the main symptom is a chronic cough that produces bloody sputum with foul, fishy
odor, most pronounced in the morning. Chest pains and dyspnea are also frequent
symptoms. The disease can resemble tuberculosis.
Laboratory diagnosis
Diagnosis is made by demonstration of the typical eggs in sputum or feces.
Chest radiography may be done, revealing a ring-shadowed opacity with several
contiguous cavities that give the appearance of a bunch of grapes.
Treatment
 The drug of choice is praziquantel. Bithionol may be used as an alternative
drug.
Prevention
Prevention of human infection is by adequate and thorough cooking of crabs.
Control measures involve change in the dietary habits of the population through
health education and promotion. Elimination of reservoir hosts and intermediate
hosts may not be feasible.

Fasciolopsis buski (Intestinal fluke)

Important properties
Humans are infected by eating raw or inadequately cooked aquatic
vegetation that carries the infective stage (metacercariae). They excyst in the
duodenum and attaches onto intestine wall, where they attain maturity. Eggs are
released together with feces into the water, where they hatch and infect the first
intermediate hosts (snail). Inside the snail, they further develop into cercariae,
which emerge from the snail host after several weeks. The cercaria then encyst as
metacercariae on the surface of aquatic plants (second intermediate hosts) such as
watercress or lotus.

Figure 6. Life cycle of Fasciolopsis buski

Pathogenesis & epidemiology

 Pathologic changes are due to damage of the intestinal mucosa by the adult
fluke, Fasciolopsis buski is an intestinal parasite of humans and pigs that is endemic
in Southeast Asia, and China, Korea, and India. No locally-acquired case of
fascioliopsiasis in humans or pigs has been reported in the Philippines.

Disease: Fasciolopsiasis
Most infections are asymptomatic, but ulceration, abscess formation, and
hemorrhage can occur. Intoxication results 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.
Treatment
The drug of choice is praziquantel.
Prevention
Metacercariae are very sensitive to dryness so that soaking of aquatic plants
in water should be avoided. Adequate washing and cooking of the aquatic plants
can also help prevent development of infection. Other control measures include
proper disposal of human sewage.