High Prevalence

of Human Liver
Infection by
Amphimerus spp.
Flukes, Ecuador
Manuel Calvopia, William Cevallos,
Hideo Kumazawa, and Joseph Eisenberg
Amphimerus spp. flukes are known to infect mammals,
but human infections have not been confirmed. Microscopy
of fecal samples from 297 persons from Ecuador revealed
Opisthorchiidae eggs in 71 (24%) persons. Light microscopy
of adult worms and scanning electron microscopy of eggs
were compatible with descriptions of Amphimerus spp. This
pathogen was only observed in communities that consumed
undercooked fish.

he genus Amphimerus Barker 1911 infects mammals

from the Americas, including Canada, the United
States, Costa Rica, Panama, Colombia, Brazil, and Peru.
Eleven species are reported (17). In Ecuador, a trematode
resembling Amphimerus spp. but identified as Opisthorchis
guayaquilensis has been reported (8,9).
Amphimerus spp. are parasitic liver flukes in the bile
ducts of mammals, birds, and reptiles (1). Although these
digenetic trematodes of the Opisthorchiidae family are
closely related to the genera Clonorchis and Opisthorchis,
there are morphologic differences. The vitellaria in adult
Amphimerus spp. trematodes are distributed in 4 groups, 2
anterior and 2 posterior; the latter groups extend beyond the
posterior testis; the ventral sucker is larger than the oral, and
the testes are rounded or slightly lobulated. In contrast, the
vitellaria in Clonorchis and Opisthorchis spp. trematodes
exist only in front of the testes. Additionally, Clonorchis
spp. trematodes have 2 large highly branched testes; testes
in Opisthorchis spp. worms are always lobulated (1,2). The
eggs of the flukes from these genera can be differentiated
only by using scanning electron microscopy (SEM).
Definitive diagnosis using light microscopy of flukes
of the Opisthorchiidae family, therefore, is not possible
unless the adult worm is collected and identified. Through
isolation of adult worms and SEM of eggs, we found a
Author affiliations: Universidad Central del Ecuador Centro de
Biomedicina, Quito, Ecuador (M. Calvopina, W. Cevallos); Kochi
University School of Medicine, Kochi, Japan (H. Kumazawa); and
University of Michigan, Ann Arbor, Michigan, USA (J. Eisenberg)
DOI: http://dx.doi.org/10.3201/eid1712.110373

high prevalence of human infection with a trematode of the

genus Amphimerus in Ecuador.
The Study
In June 2009, during a routine fecal examination
for the parent study, 4 samples tested positive for eggs
of the Opisthorchiidae family in 3 indigenous Chachi
communities along the Cayapas River in the northern
coastal rainforest of Ecuador. In January 2010, a followup survey was conducted in the same 3 communities (total
population 589); all villagers, whether symptomatic or
not, were asked to provide a fecal sample. Specifically,
a community meeting was held in each village, study
objectives were explained, and villagers were asked for
their voluntary participation. Flasks were distributed to
all villagers and collected the next day in the school and
by going house to house. The Chachis, the predominant
group in these 3 communities, represent 13% of the 24,000
inhabitants in the region. Afro-Ecuadorians and mestizos
also reside in this region (10,11).
A total of 297 (50.4%) community members 377
years of age provided samples. To each person providing a
sample, a questionnaire was administered regarding types of
food eaten and cooking practices. Samples were preserved
in 10% formalin, transported to a laboratory in Quito, and
stored at 4C until examination by light microscopy. Eggs
were concentrated by using the formalin-ether technique.
In addition, 120 fecal samples from Afro-Ecuadorian
and mestizo persons were examined. The villagers were
informed of the study in their local Chapalache language
by community health community workers. The ethical
committee of the Central University approved this study.
Duodendoscopy was performed in 4 patients by a
gastroenterology specialist to examine the biliary liquid;
the microscopy of this liquid showed eggs identical to those
found in their feces. These patients received praziquantel
(75 mg/kg in 3 doses/3 d), and were purged with 10 mg
of bisacodilo. Fecal samples were collected and examined
for worms as previously described (12). Recovered
worms were fixed with 10% formalin, stained with DiffQuik fixative (Sysmex, Kobe, Japan), and identified by
comparing their morphologic features to known adult
Clonorchis and Opisthorchis spp. worms. Community
health workers collected and examined the livers of 3
cats and 3 dogs from 1 of the 3 communities. All 6 livers
had eggs and high numbers of adult parasites in the bile
ducts. Adult parasites were stained, and microscopic
studies showed them to be identical to those in the human
specimens.
A total of 71 (24%) of the 297 fecal samples from
the indigenous Chachi were positive for Opisthorchiidae
eggs (Table). In contrast all 120 samples from AfroEcuadorian and mestizo persons were negative. Eggs

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DISPATCHES

were yellow-brown and measured 2833 m 1215 m

(n = 20). The operculum and the shoulders, however, were
not prominent as they are in Clonorchis and Opisthorchis
eggs. Occasionally, a small knob, but most frequently a
curved spine, was seen on the abopercular end. Although,
by light microscopy, the shape and size of the eggs
resembled that of the other liver flukes, the patterns of
the eggshell surface were distinct when viewed with
SEM (Figure 1). This observation is corroborated with
published photographs (3).
After participants were treated with praziquantel, a
total of 8 worms were recovered from 4 human participants
and dozens from cat and dog livers; all were placed in
saline. The worms were delicate, leaf-shaped, elongated,
and red-pink and measured 813.6 mm long (average 10.2
mm) 0.51.1 mm wide (n = 15). After a few minutes,
the worms coiled in an S shape and became transparent
or whitish. Once stained, the following features were
observed: 1) the vitellaria divided into an anterior and
posterior group with the posterior group extending the level
of the posterior testis; 2) a ventral sucker larger than oral
sucker; and 3) 2 rounded testes (Figure 2). On the basis
of these morphologic characteristics of the adults and
the SEM findings of the eggs, the parasite was identified
as Amphimerus spp.
Conclusions
Our study demonstrates that the liver fluke of the
genus Amphimerus can infect humans. We found a high
prevalence (15.5%34.1%) of infection with Amphimerus
spp. trematodes in the surveyed communities (Table).
Samples from the Afro-Ecuadorian and mestizo population
were all negative for Opisthorchiidae eggs. Amphimerus

Table. Prevalence of Amphimerus eggs in feces in 3 villages,

Ecuador
No.
Total
samples
No. (%)
Distance to the
Village population examined
positive
coast, km
1
116
82
28 (34.1)
120
2
248
86
23 (26.7)
91
3
253
129
20 (15.5)
85
Total
617
297
71 (23.9)

spp. trematodes are believed to be transmitted, as are

the other members of the Opisthorchiidae family, by
ingestion of raw or undercooked fish (2). In our survey,
most Chachis reported eating smoked fish caught in the
rivers. Food sharing is more common among Chachi than
Afro-Ecuadorians and mestizo families (13). Notably, the
most remote village (120 km inland from the coast) had the
highest prevalence. Our results suggest that Amphimerus
spp. flukes are zoonotic pathogens of domestic animals
living with humans.
Amphimeriasis should be considered an endemic liver
fluke infection among residents of this Chachi population
in Ecuador. Further studies are needed to determine the
complete epidemiology and geographic distribution of
infection in this region, as well as in other provinces of
Ecuador where freshwater fish is eaten undercooked or
where the same tropical ecology is found. For example,
the Amazonian region has indigenous groups where other
foodborne trematodiasis-like paragonimiasis are endemic
(14). Amphimerus spp. flukes infecting domestic and wild
animals have been reported from Ecuadors neighboring
countries as well as from Central and North America.
The existence of undiscovered foci of human infections is
possible.
Figure 1. Scanning electron
microscopy images of A)
an egg of the Ecuadorian
Amphimerus spp. trematode (original magnification
3) obtained from a
human and B) an egg
of the Asian Clonorchis
sinensis trematode (original
magnification 4). Although
the size is similar, the
pattern of the surface is
different, thus differentiating
the 2 genera.

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Human Liver Infection by Amphimerus spp.

This study was supported by a grant from the US National

Institute of Allergy and Infectious Disease, National Institutes of
Health, grant no. RO1-AI050038.
Dr Calvopia is a professor in the Department of Molecular
Parasitology and Tropical Medicine, Centro de Biomedicina,
Universidad Central del Ecuador, Quito, Ecuador. His major
research interest is parasitic diseases, including leishmaniasis,
paragonimiasis, onchocerciasis, and intestinal parasite infections.
References

Figure 2 . Amphimerus spp. adult trematode (10.1 mm) recovered

from a human, Ecuador.

In 1971, Yamaguti (1) suggested that a parasite

previously reported in Ecuador (8) as O. guayaquilensis
might in fact be Amphimerus spp. Subsequently, publications
referred to this parasite as A. guayaquilensis (5,7); however,
the accuracy of this reclassification is unclear. Molecular
analysis could help clarify the ambiguities in genus/species
identification of O. guayaquilensis parasites and the
conspecific species of Amphimerus (15).
We have much to learn about the pathology and
epidemiology of Amphimerus spp. flukes. For example,
nothing is known about the clinical and pathologic
significance of infections with this parasite. Praziquantel
eliminated the parasites in these patients, but whether
the dose and treatment time were adequate are unknown.
Additionally, little is known about epidemiologic factors
responsible for the differences in the number of infections
among the different population groups. Future studies
can help determine the direct and indirect public health
implications of this new foodborne zoonosis.
Acknowledgments
We thank the community health workers of Borbon and Rio
Cayapas, Esmeraldas, for informing study participants, preparing
and obtaining the consent, and translating to the local language
in the communities surveyed. We also thank Jeyson Abarca for
performing duodendoscopy and Ronald Guderian for revising the
manuscript.

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Address for correspondence: Manuel Calvopia, Department of Molecular

Parasitology and Tropical Medicine, Centro de Biomedicina, Universidad
Central del Ecuador, Sodiro N14-121 e Iquique, Quito, Ecuador; email:
manuelcalvopina@gmail.com

Emerging Infectious Diseases www.cdc.gov/eid Vol. 17, No. 12, December 2011