PARASITOLOGY: Trematodes  Integument plays an important role in the absorption of carbohydrates.

It may also serve for secretion of excess metabolites and mucus.

 One or more muscular suckers on ventral surface. Oral sucker sometimes
has spines or hooklets, found at the anterior end of the worm and in most
species a larger, blind ventral sucker or acetabulum is located on the
ventral surface posterior to the oral sucker.
 Suckers are use for attaching to internal organs or outer surfaces of the
host.
 There is no body cavity.
 Organs and systems –excretory system, nervous system, genital system,
digestive system (incomplete –ends blindly) Alimentary canal ends blindly
– ceca usually unbranched, may be branched.
 Lack a circulatory system and respiratory system.
 Most of the body is occupied by the reproductive organs.
 Trematodes are hermaphrodites or monoecious except genus
Schistosoma which is dieceous.
 Self-fertilization is the common method of fecundation for
hermaphroditic species.
 Trematodes parasitize a wide range of hosts.
 The life cycle is passed in two hosts the sexual (definitive host) and
asexual (intermediate host) phases.
 Require one or more intermediate hosts. The first intermediate host is a
snail.
 Individual flukes can survive in human for more than 40 years.

General Characteristics of Class Nematoda

 Also known as flukes.

 Flat, elongated, leaf shaped but may be ovoid, conical, or cylindrical
depending upon the state of contraction, except for schistosomes which
are elongated.
 Bilaterally symmetrical
 Size vary from less than 1 mm to several centimeters.
 Has a definite anteroposterior axis
 Unsegmented
 Body is covered by cuticle which may be partially or completely covered
with spines, tubercles or ridges.
Trematodes Based on Habitat of Adult Worm

 Blood flukes:
 Schistosoma japonicum
 Schistosoma mansoni
 Schistosoma haematobium
 Lung fluke:
 Paragonimus westermani
 Liver flukes:
 Clonorchis sinensis
 Opistorchis viverrini
 Opistorchis fileneus
 Fasciola hepatica
 Fasciola gigantica
 Intestinal flukes:
 Fascsiolopsis buski
 Echinostoma ilocanum
 Artyfechinostomum malayanum The usual definitive host is sheep or swine but man is sometimes
 Heterophyes heterophyes affected.
 Metagonimus yokogawai Mode of infection:
 Gastrodiscoides hominis
 Skin penetration - cercaria, eg. Schistosomes
 Ingestion of metacercaria - other trematodes
Portal of exit of eggs:
 Sputum - P. westermani
 Urine - S. haematobium
 Feces - all intestinal and liver flukes; S. mansoni, S. japonicum, P.
westermani
Geenral Life Cycle of Trematodes I. BLOOD FLUKE: SCHISTOSOMA SPP.
 A parasitic blood flukes that infect birds and mammals including
1. Egg passes from definitive host and must reach water.
humans.
2. Hatches into a free swimming ciliated larva, the miracidium.
3. Miracidium penetrates tissues of a snail and transforms into  5 medically important species:
sporocysts.  S. japonicum
4. Sporocysts reproduces asexually to form rediae.  S. mansoni
5. Rediae reproduce asexually and form cercaria.  S. haematobium
 S. mekongi
 S. intercalatum

Differentiating Features of Schistosomes:

 Schistosoma japunicum

Schistosoma haematobium

 S. japonicum or Oriental blood fluke

Schistosoma mansoni - causes schistosomiasis japonica
- endemic in China, Philippines, Indonesia
- has been first described in Japan and has been eliminated
since 1977
- its eggs have been identified in a female corpse from Western
han Dynasty.
- First described by Katsurada in 1904.
- intermediate host is Oncomelania
- exist in Mindoro, Leyte, Sorsogon and Mindanao
 Adult Life Cycle of Schistosoma japunicum:
 Adult worms – dioecious Has oral and ventral suckers
 Portal of entry – skin
 Male – 12-20 mm X 0.4-0.5 mm, gynecophoral canal,
 Infective stage – cercaria
testes arranged in one row above the ventral sucker
 Habitat of adult – superior
 Female – 15-26 mm x 0.3 mm, single pyramidal ovary
mesenteric veins
located in the midline
 Portal of exit – feces
 Excretory system made up of flame cells, ingest RBC, absorb nutrients
 Stage excreted –
thru body wall, live for 30 years
fully embryonated ova
Stages – miracidium, 1st and 2nd
 Eggs
generation sporocyst, cercaria
 Ovoidal, rounded or pear shaped
 1 st IH – Oncomelania hupensis
 Thin shell
quadrasi
 Pale yellow
 Definitive hosts - very wide range (dogs, pigs, cats, carabaos, cows,
 Curved hook or spine or lateral
rodents, monkeys)
knob near polar ends
 Laid in multicellular stage and
embryonate within 10-12 days
 Mature eggs in feces can survive and still hatch for up to a week if
desiccation is slow.
 Eggs hatch only in clean fresh water with sufficient oxygen.
 They will not hatch in salinity greater than 0.7% or at mammalian
body temperatures.
 A temperature of between 25 to 31°C in slightly alkaline water is
ideal.
 Most viable eggs will hatch within 2 to 4 hours.

 Miracidia
 Miracidia can survive overnight.
 Cercaria
 Has an apical papilla, epidermal plates covered with cilia, a primitive
gut, a pair of cephalic unicellular penetration glands opening by a Natural release of cercaria is nocturnal but they can survive for 24 hours
duct at the base of the apical papilla, two pairs of flame cells, and so bodies of water remain potentially dangerous at any time. They migrate to
germinal cells. a preferred temperature of 35°C±3°C and penetration is stimulated by skin
 The miracidia are phototactic and swim actively in surface water. lipids. Some chemicals like dimethylate and niclosamide repel cercariae when
 They remain infective for snails for 8 to 12 hours. applied to the skin.
 Embryonated eggs from the stool of a definitive host come into contact The worms ingest red blood cells and possess a protease (hemoglobinase)
with fresh water and hatch within 2 to 4 hours into free-swimming that breaks down globulin and hemoglobin. They utilize glucose at a rapid
miracidia. rate and likely absorb nutrients through the body wall.
 Miracidia seek out and infect the snail intermediate host, Oncomelania
hupensis quadrasi.
 After contact with soft parts of the snail, miracidial penetration is
effected by movement and the lytic action of cephalic gland secretions.
 Factors that influence the infection of snails by miracidia include the age
of the snails and the miracidia, the number of miracidia per snail, the
length of contact time, water flow, and turbulence, later on from
miracidia it will develop into sporocysts.
 Sporocysts are able to reproduce asexually and can later give rise to free-
swimming cercariae after 60 to 70 days.
 The cercariae penetrate the skin of the definitive host when the host
comes into contact with infested 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 the pulmonary circulation, the
schistosomules migrate intravascularly to reach the portal vein where
they mature.
 However, there is some evidence that schistosomules can escape from
the lungs into the pleural cavity and pass through the diaphragm into the
liver to reach the portal vein.
 In the portal circulation, schistosomules differentiate into male and
female forms and pair up, with the larger female occupying the
gynecophoric canal on the adult male
 Each female fluke deposits 500 to 2,000 immature eggs/day in the
branches of the portal vein.
 These require 10 to 12 days to mature and embryonate.
 Eggs deposited in mucosal or sub-mucosal terminal veins or capillaries
escape through ulcerations into the intestinal lumen and are
subsequently exported with the feces.
 Egg deposition usually begins from the 24th to the 27th day after
cercarial penetration.
KEEP IN MIND!!! Clinical Course of Infection

 Acute infection of humans with avian species of schistosomes can  Incubation – from cercarial penetration and schistosomula migration to
result in an allergic skin reaction called swimmer’s itch (cannot maturation of fluke – complaint of itching, chills, fever, cough
mature in human host and die in the skin). No need of anti-parasitic  Period of early egg deposition and extrusion
therapy.  Period of tissue proliferation Due to overlap of 2nd and 3rd stages it is
 Pathogenic adult schistosoma can persist in the human host for best to discuss organ involvement as basis for clinical classification.
decades so infection can present in non-endemic areas among 1. Colonic involvement :
immigrants from endemic regions. a. early stage – ulceration caused by eggs -> dysentery
b. chronic stage –usually asymptomatic with occasional
diarrhea
2. Hepatosplenic disease – most serious consequence of chronic
schistosomiasis -> hepatosplenomegaly, portal hypertension, ascitis,
development of collateral circulation - > esophageal and gastric
varices
3. Pulmonary involvement :
a. During larval migration – coughing and wheezing
b. Chronic stage – lungs next to liver and intestine has the
PATHOLOGY
most number of schistosomal lesions.
 Main pathology and chronic disease manifestations – due to hosts c. Cor pulmonale – due to obstruction of pulmonary
granulomatous reaction to eggs deposited in the liver and other vasculature due to granulomatous formation and fibrosis.
organs Eggs reach the pulmonary circulation via the porto-systemic
 Egg deposition can occur in any organ – most commonly involved are collateral circulation. Pulmonary schistosomiasis is the most
the liver, intestines, lungs and much less the CNS common cause of cor pulmonale in Filipino children
 Primary lesions – granulomatous hypersensitivity reaction around a 4. Cerebral schistosomiasis – the parasite moves from the portal vein -
single egg or cluster of eggs > mesenteric and pelvic veins -> spinal veins
 After egg deposition there is an accelerated formation of larger and a. acute cases - fulminating meningoencephalitis
more destructive granulomas b. chronic cases – clinical picture of tumor with localizing signs
 Chronic infection – granuloma becomes smaller and increase ICP
 Collateral circulation are established -> eggs filtered into pulmonary PATHOGENESIS AND CLINICAL MANIFESTATIONS
microvasculature -> pulmonary hypertension
 Snail fever, Katayama fever, Katayama syndrome - Schistosomule
migration (2-12 weeks after cercarial penetration) -> produce
syndrome: easy fatigability, respiratory symptoms, arthralgia,
myalgia, malaise, eosinophilia, fever and abdominal pain
  Hepatosplenomegaly -> hepatic dysfunction -> death • Migration  Spleen increases in size – mesentery and omentum binding down the
thru pulmonary circulation -> wheezing and coughing colon producing an upper and lower abdominal distension
 Aberrant migration -> occlude the circulation of the brain and spinal  Weaknes, skin pallor, dyspnea on slight exertion
cord -> seizures, ischemic attacks, strokes  Ascitis - may or may not be conspicuous
 May get better without antihelminthics but antihelminthics usually  Granulomatous reaction around the eggs – fibrosis of periportal
lead to faster resolution of symptoms. tissues (pipe-stem fibrosis)
 Main pathology and disease manifestation are due to host  Cerebral involvement
granulomatous reaction to eggs deposited in the liver and other
organs.
 Early schistosomiasis, manifestations, colonic, hepatosplenic,
pulmonary, cerebral manifestations.

3 stages in pathologic processes:

 Incubation
 Dermatitis
 Traumatic infiltrative changes in the lungs DIAGNOSIS
 Acute hepatitis  Finding the eggs in the feces occur when the eggs are deposited in
 Hyperemia in the wall of the small blood vessels the terminal vein or capillaries of the intestinal mucosa or submucosa
 Trauma with hemorrhage – eggs escape from venules to and subsequently escape to intestinal lumen.
intestinal lumen  In cases where there is fibrosis or scarring of sites of ulcerations,
 Eosinophilia passage of eggs into the intestinal lumen can be impeded.
 Cell mediated response of host continues through out the life of
 Stool exam can give negative results even in active infection.
the worms
 Eggs can be recovered by rectal or liver biopsies. This cannot
 Urticarial rash accompanied by fever – 5 th day after exposure
distinguish between active from treated infection.
 4 th week – prodromes – urticaria, edema. Diarrhea
 Egg deposition and extrusion Microscopic examinations techniques are most specific:
 Profuse dysentery with eggs in feces
A. Stool examination and rectal imprint of S. japonicum eggs. Eggs tend
 Secondary anemia, leukopenia, less eosinophil
to clump so a small sample may turn out as false negative. Likewise
 Fever, epigastric pain, enlarged liver and spleen, loss of weight
in light infection.
and appetite – 3-10 weeks
B. A merthiolate-iodine-formalin concentration (MIFC) has moderate
 Infiltration of eggs in tissues – intestine, liver, other organs –
sensitivity for moderate and heavy infections but not for very light
pseudotubercle dev. around the egg
infections (10 eggs/gram of feces). Sample with MIFTC can be kept
 Liver enlarges – miliary lesions around the infiltrated eggs
indefinitely.
 Spleen enlarges – congested
C. Kato-Katz technique:
 Tissue proliferation and repair
 Liver decreases in size – scar tissue
 a. Used for egg counting and the most suitable for quantification of  Complement fixation with adult antigen (CFA)
eggs.  Complement fixation with cercarial antigen (CFC)
b. Used for evaluating epidemiology, effect of control measures and  Slide flocculation with cercarial antigen (SFC))
drug trials.  Cercarial agglutination (CA)
c. Preparation can be kept for 2 weeks  Circumoval precipitin test (COPT)
d. To get 92% sensitivity in stools with <20 eggs/gram of feces –  Intracutaneous test (skin test) – utilizes adult and larval antigens
perform 3 Kato-Katz.  WBC and differential count
D. Rectal snips and imprint
TREATMENT
a. one of the most sensitive technique
b. most invasive (biopsy)  Praziquantel 40-50 mg/kg SD or 25 mg/kg in 2 doses
c. inability to distinguish between untreated and treated infections  Reduce water contact through building foot bridges
E. Immune response in infection: (immunodiagnostic tests)  Health education
a. Intradermal test – for immediate hypersensitivity using adult  Control of Oncomelania snails (clearing vegetation, irrigation
worm extracts. Highly specific but non specific for infection. NO management, control flow of water), chemical control
LONGER USED.  Environmental sanitation: proper waste disposal, control of domestic
b. Indirect hemagglutination using adult worm and egg antigens. animals
c. Circumoval precipitin test (COPT)
 Method of choice for definitive diagnosis in the Praziquantel
Philippines.  Safe and highly effective in a single or divided doses against all
 take more than 2 years to become negative the major species of schistosomes.
 cannot differentiate active from past infection  Active against adult schistosomes in vitro and in vivo.
 not recommended as a screening tool in the  In vitro – when the schistosomes come in contact with the drug
Philippines it becomes immobile and undergo contraction
 Demonstrates the formation of bleb or septate  Has very low acute toxicity profile
precipitates attached to one or more points on the egg  A single dose of 40-50 mg/kg or 25 mg/kg in 2 doses or 3 doses
surface after incubation of schistosome eggs in patient’s of 20 mg/kg given every 4 hours
serum.
 Method of choice for diagnosis of this infection in the Artemisinins
Philippines.  Effective as pre-exposure prophylaxis during the planting season
d. enzyme linked immunosorbent assay or ELISA use soluble  Effective against the juvenile stage of the worm, ideal for non-
antigens of adults and eggs. endemic travelers.
e. Indirect hemagglutination – highly sensitive
f. lateral flow assay – best suited for elimination program. May give the 2 drugs in combination.
Persistence of antibodies long before after active infection has
been treated
• Serologic tests (using adult and cercarial antigens)
TRANSMISSION PREVENTION & CONTROL

Schistosomiasis requires 3 major conditions:  In areas with high prevalence and transmission – mass chemotherapy
reduce morbidity
 Pollution of fresh water with excreta containing schistosome eggs.
 Sustained and appropriate health education
 Presence of the right species of snail Geographic distribution of snail
 Improve knowledge, attitudes and perception with respect to
hosts determines epidemiology of disease.
transmission, diagnosis and control of schistosomiasis
 Human contact with water infested with cercaria - Cercaria must
 Oncomelania h. quadrasi an operculated fresh water amphibious
penetrate human skin or mucosa due to direct contact - No redial stage.
snail, 3-5 mm with separate sexes; habitat is small clear water
EPIDEMIOLOGY streams, water-logged rice fields, swamps and water seepage area.
Snails are found in water and banks, numerous in areas where soil is
 Occurrence of disease in the community should be described in relation
moist.
to prevalence and intensity of infection.
 No outstanding novel molluscide or chemical for killing of snails has
 In the Philippines, schistosomiasis is endemic in 12 regions
been developed 6. Sanitary disposal of human feces
 Highest prevalence of infection are children of 5-25 years of age
 The disease is still endemic in 12 regions affecting 28 provinces, 190
municipalities, 15 cities and 2,230 villages as of 2007
 The total population affected is approximately 12 million, and about 2.5
million are directly exposed to the parasite.
 Schistosoma japonicum is endemic in Mindoro Oriental, Sorsogon,
Bohol, Northern Leyte, Samar, and almost all provinces in Mindanao,
Southwestern Luzon (Belizario et al. 2005).
 A WHO-supported national prevalence survey in Mindanao, the
Visayas, and Luzon was initiated in 2005 and completed in 2007.
 In all of the endemic provinces, the prevalence rate of the disease is
was higher among males than females, suggesting that occupational
hazards of farming and fishing are key risk factors for infection.
 Infection prevalence is also high in adults compared with younger age
groups
 However, the low sensitivity of schistosomiasis screening, particularly
with low-intensity infections, means that the prevalence is likely much
higher (Carabin et al. 2005).
 Endemic in China, Philippines and Indonesia
 Reported in Japan and eliminated in 1977
II. LUNG FLUKE: Paragonimus westermani  A miracidium develops within 2-7 weeks.
 The cercaria is covered with spines, has an ellipsoidal body and a
 Agent: Paragonimus westermani also known as Oriental lung fluke small tail.
 Disease: Paragonimiasis  A stylet is present at the dorsal side of the oral sucker.
 There are 40 species of trematodes (flukes) of the genus Paragonimus  The metacercaraia is round and measures from 381-457 um.
have been reported to infect humans and animals. Among them  Opposite the operculum is a thickened abopercular portion. It is
more than 10 species have been reported to infect humans, the most unembryonated at oviposition.
common is P. westermani which causes 90% of paragonimiasis in  May be seen in the sputum or in feces if the sputum is swallowed.
Asia.
 The fluke is hermaphroditic
 GD: world wide, Philippines – Leyte, Samar, Mindanao (Cotabato),
Sorsogon, Camarines
 Involves two intermediate hosts as well as humans.
 Eggs first develop in water after being expelled by coughing
(unembryonated) or being passed in human feces. In the external
environment, the eggs become embryonated.
 Eggs/Ovum are oval, yellowish-brown, thick shelled egg measures
80-118 um by 48-60 um and has a flattened but prominent
operculum. Immature when laid and matures in water.
 Adults are found in pairs or threes in fibrotic capsules or cysts in the
lungs.
Morphology:
• Adult:
 Egg-shaped, thick and fleshy
 8-12 x 4-5 mm, when alive – resembles a spoon
 The living worms are pinkish/reddish brown in color and coffee bean
shaped (7-15 mm in length 8 mm in width and 3-5 mm in thickness).
 It is rounded anteriorly and slightly tapered posteriorly.
 The tegument is covered with single-spaced spines.
 Two testes are deeply lobed located opposite each other almost
midway between the ventral sucker and posterior border of the
body.
 The ovary is located anterior to the testes and posterior to the ventral
sucker and has 6 long unbranched lobes.
 The vitellaria are branched extensively.
LIFE CYCLE  The definitive host acquires the infection by ingesting raw or
insufficiently cooked crabs harboring metacercariae.
 Infective stage: metacercaria
 Following the ingestion of infected crustacean tissue by the host, the
 Infective mode: eating raw fresh water crabs and crayfish with
metacercariae of Paragonimus excyst in the duodenum of the host.
metacercaria Infective route: by mouth
 The immature worm then traverses through the intestinal wall into the
 Habitat of adult worm: lungs
peritoneal cavity, where it wanders about for several days and embeds
 Intermediate hosts:
itself in the abdominal wall.
 1st IH – Melania, Semisulcospira,Thiara, Brotia asperata
 The parasite then returns to the coelom and migrates through the
Semisulcospira snail
diaphragm into the pleural cavity.
 2nd IH – crab and crayfish
 A juvenile diploid worm wanders in the pleural spaces until it finds one
 Definitive hosts: man, rodents, domesticated animals
or several diploid worms.
 Diagnostic stage – immature egg
 The pair or group then migrates into the lung parenchyma to develop into
 Life span: 5-6 years (persist in man for >20 years)
adults in about 6 weeks, where they mate and lay eggs.
Ingestion of crab/crayfish with metacercaria -> excyst in duodenum -> in 30-  Juvenile triploid worms in Japan, Korea, and Taiwan can establish
60 minutes adolescaria migrate thru intestinal wall -> abdominal cavity -> themselves in the lung parenchyma without a mate.
penetrate diaphragm -> pleural cavity -> grow to adult worms -> self  In the lung parenchyma, a fibrotic capsule forms around the parasite or
fertilization -> Lay eggs -> pass out immature ova which may be: coughed their group. The fibrotic capsule has openings that allow the eggs to
out in sputum, swallowed and passed out with feces -> eggs mature in escape into the respiratory tract where they are moved up and out by the
water, miracidium hatches out -> penetrate snail (S. libertina or Brotia ciliary epithelium along with lung exudates.
asperata) -> sporocyst, redia, ceracria -> cercaria escape and encyst in crabs  In the pharynx, they are either coughed out or swallowed into the
and crayfish. alimentary canal to be passed out with the feces.
 The completion of development in the definitive host takes 65 to 90 days.
 The immature egg embryonates in water, moist soil, or leached feces.
 Adult worms are known to persist in humans for 20 years or longer.
 A miracidium develops within 2 to 7 weeks. It subsequently pushes open
 Cysteine proteases have been found to play an important role in the
the operculum and swims freely in search of its appropriate snail host.
development of young parasites because of their involvement in the
 In the Philippines, the 1st intermediate hosts are Antemelania asperata
metacercarial excystment, tissue invasion, and immune modulation of
and Antemelania dactylus, the former previously known as Brotia
the host.
asperata
 Cysteine proteases with masses of 27 and 28 kD are released from the
 Inside the snail, the miracidium passes through one sporocyst and two
excretory bladder of the metacercariae during excystment. The proteases
redial stages of development.
are most abundant in the tegmentum of newly excysted worms,
 Cercariae subsequently emerge from the snail to seek and infect the
facilitating migration through the tissues of the host.
second intermediate host, the mountain crab Sundathelphusa philippina
 The 27 and 28 kD cysteine proteases are also found to cleave human
(formerly known as Parathelphusa grapsoides).
immunoglobulin G, thereby creating a zone of immune privilege around
 The cercaria penetrates the soft parts of the crustacean and encysts as a
the worm. Protease activity decreases as worm matures.
metacercaria in the gills, body muscles, viscera or legs.
 The crab may also be infected by eating infected snails.
  Worms may localize in: lungs, pleura, pericardium, myocardium,
abdominal wall, omentum, liver, mesenteric lymph nodes, adrenals,
urogenital organs, and eyes
 Heavy infection can cause both pulmonary and ectopic
paragonimiasis.
 Cutaneous paragonimiasis is seen as a slow moving nodular lesion in
the subcutaneous tissue on the abdomen or chest
 Cerebral involvement is the most serious complication of human
paragonimiasis. May present with headache, meningismus, seizures,
hemiparesis,blurring of vision, diplopia, aphasia.

PATHOGENESIS AND CLINCAL MANIFESTATIONS

COMPLICATIONS
 Presence of fluke in lungs provoke a granulomatous reaction and
development of fibrotic cyst containing adults, eggs, blood tinged • Pulmonary complications include:
purulent materials.  Pneumonia
 Most common symptoms: chronic cough and hemoptysis. Chest pain,  Bronchitis
dyspnea, low grade fever, fatigue and generalized myalga may also  Bronchiectasis
occur  Lung abscess
 Early stage – asymptomatic (takes weeks for fluke to migrate and  Pleural effusion
mature)  Empyema
 Clinical symptoms are less severe after 5-6 years s
 Serious sequelae – chronic bronchiectasis, pleural fibrosis, secondary • Cerebral complications include:
to severe parenchymal; and pleural damage  seizures
 Circuitous route of migration allows the worm to mature and be  coma
lodged in different ectopic location.
• Skin complications include:

 migratory allergic skin lesions

DIAGNOSIS  Enzyme linked immunosorbent assay (ELISA) – sensitive from 96-
99% (detect IgG)
 Microscopic examination demonstrating the eggs in the sputum stool
 Loop-mediated isothermal amplification (LAMP) – simple, rapid,
or pleural effusions, materials from abscesses.
cost effective method
 Sputum exam: sensitivity – 37-88% • If negative repeat sputum exam
 An assay that detects worm antigens with monoclonal antibodies is also
3 times on different days with 3% NaOH.
available and can be used in conjunction with the skin test.
 Chest x-ray combined with a high index of suspicion – pulmonary
 Exploratory cyst puncture
lesions which may be infiltrative nodular, cavitating or a combination
 For cerebral paragonimiasis:
of these. Pleural effusion.
 Computer tomography (CT) scan
 PTB and paragonimiasis are usually co-endemic, PTB should be ruled
 Magnetic resonance imaging (MRI)
out.
- Shows lesions described as “grape-like clusters”
 Eosinophilia and elevated IgE
- For chronic disease – skull lesion present specific soap bubble
 Chest x-ray findings: (100 pts)
calcification
 Patchy cloudy infiltration of lungs – 51%
 Nodular shadows – 35% TREATMENT
 Calcified spots – 6%
Praziquantel
 Pleural thickening – 24%
 Interlobular pleuritis – 10% - causes severe spasms and paralysis of the worm’s muscle
 Pleural effusion – 5% - not for pregnant women
 Cerebral involvement requires differentiation from tumors, cysticercosis, - stomach pains, fever, nausea, dizziness, vomiting, headache
cysts, encephalitis, and others .
Bithionol
 Since egg detection rates are low, it would be useful to utilize serological
techniques to detect paragonimus antibodies. - diarrhea
 ELISA are highly sensitive at >92% detection - use is limited due to side effects
 Intradermal skin test using the extract of an adult paragonimus is Triclabendazole
sensitive and has few false positives. The result of the skin test may
remain positive up to 20 years after the infection has been cured - can cure cases where other drugs failed E
 Immunological methods (classic methods): TRANSMISSION
 Complement fixation – high sensitivity for diagnosis and
assessment of cure  Eating raw
 Intradermal test – simple, rapid, cheap, highly sensitive, may give +  Undercooked or pickled crustaceans such as crabs or crayfish
result years after cure  Spitting, a habit in asian countries
 Double diffusion in agar gel  Cultures that eat raw crustaceans:
 Immunoelectrophoresis  drunken crab in china
 More sensitive and specific tests  raw crabs and crayfish with alcohol in the Phils
 Immunoblotting (IB) - sensitivity up to 99%  sushi crab in Japan & Gye Muchim in Korea
EPIDEMIOLOGY

 In the Philippines paragonimiasis is endemic in: Mindoro, Camarines,

Sorsogon, Leyte, Samar, Zamboanga del Norte, Davao Oriental,
Basilan, Cotabato.
 Focal distribution where people eat inadequately cooked crustaceans
and paratenic hosts.
 Unhygienic food preparation also contributes to transmission of
disease.
 Cultural beliefs and tradition influence the age and sex distribution of
paragonimiasis.
 PTB overlaps with paragonimiaisis in endemic areas. Both have the
same symptoms. Misdiagnosis and mismanagement are not
uncommon.

PREVENTION AND CONTROL

 Avoid ingestion of raw or insufficiently cooked crabs and other

crustaceans as well as meat from paratenic hosts like wild pigs.
 Safe food preparation helps reduce the infectivity of the food
 Capacity building of local health staff on the diagnosis and treatment
of this disease is important for early case detection and treatment.
 III. INTESTINAL FLUKE: Fasciolopsis buski  Water spinach (Ipomea aquatica) “kangkong”
 Morning glory (Ipomea obscura)
Disease: Fasciolopsiasis
 Lotus (Nymphaea lotus)
Common name: Giant Intestinal Fluke
 Water hyacinth (Eichhornia crassipes)
 Water bamboos (Dracaena sanderiana)
 Definitive Hosts: Man & Pig
 The egg, which embryonates in water, gives rise to a miracidium in 3 to
7 weeks. The miracidium then seeks out and infects its first intermediate
host, a snail belonging to either the genus Segmentina or Hippeutis.
 Inside the snail, the miracidium transforms into a sporocyst, which
subsequently produces mother rediae, daughter rediae, and finally,
 Largest fluke of humans and pigs. cercariae.
 MOT: ingestion of encysted metacercariae from aquatic plants.  Cercariae leave the daughter rediae and undergo further development
 Metacercaria excysts duodenum and attaches to the intestinal wall, in the snail tissues.
where it becomes sexually mature in about 3 months.  Seven weeks after infection, cercariae emerge from the snails into
 The adult worm lives in the duodenum, attached to the intestinal water.
mucosa by its suckers.  Cercariae attach themselves and encyst as metacercariae on the
 The egg is large, operculated, unembryonated when first passed. It surfaces of seed pods, bulbs, stems, or roots of various aquatic plants.
measures 130 to 140 μm by 80 to 85 μm.
 21,000-28,000 ova per fluke per day
 Adult worm is elongated, oval. Measures 20-75 mm/L
 Testes is highly dendritic in Tandem
 Ovary is single dendritic. Located in midline.
 Gut Is wavy and in lateral projections.
 Brown stain.
 No cephalic cone
 Free like projections of the organ
 Sensitive to dryness

LIFE CYCLE

Intermediate Hosts:

 1st – Snail (Segmentina, Hippeutis)

 2nd – Fresh water/aquatic vegetation
 Water caltrops (Trapa bicornis, Trapa natans)
 Water chestnuts (Eliocharis tuberosa)
PATHOGENESIS AND CLINICAL MANIFESTATIONS IV. INTESTINAL FLUKE: Echinostoma ilocanum

 Pathological changes caused by the worms are traumatic, Disease: Echinostomiasis, Euparyphium ilocanum
obstructive, and toxic. Common name: Garrison’s fluke
 Inflammation and ulceration occur at the site of worm attachment,
producing an increase in mucus secretion, and minimal bleeding.
 Gland abscesses are occasionally formed in the mucosa
 The patient experiences generalized toxic and allergic symptoms,
such as edema of the face, abdominal wall, and lower limbs.
 Profound intoxication can result in death of the host.

DIAGNOSIS

 Detection of parasite eggs in the stool  E. ilocanum is reddish-gray and measures 2.5 to 6.6 mm in length and 1
to 1.35 mm in width.
TREATMENT
 The worm is tapered at the posterior end and has 49 to 51 collar spines.
 Praziquantel  The oral sucker lies in the center of the circumoral disk, and the ventral
sucker is situated at the anterior fifth of the body.
EPIDEMIOLOGY  The two testes are deeply bilobed, arranged in tandem in the third
quarter of the body.
 Endemic in the countries of Southeast Asia, China, Korea, and India.  The ovary is located just in front of the anterior testis.
 Endemicity in the Philippines has not yet been demonstrated.  Follicular vitellaria are located in the posterior half of the body, and
uterine coils are found between the ovary and the ventral sucker.
PREVENTION AND CONTROL
 The E. ilocanum egg is straw-colored, operculated, and ovoid, measuring
 Soaking of aquatic plants in water should be avoided 83 to 116 μm by 58 to 69 μm.
 The time between harvest and consumption could also be prolonged
LIFE CYCLE
to prevent infection
 Washing of the plants to remove metacercariae, or boiling Intermediate Hosts:
 Swamps or ponds where aquatic plants are cultivated should be  1st – Snail (Gyraulus convexiusculus, Hippeutis umbilicalis)
protected from pollution by untreated human or pig excreta  2nd – Snail (Pila luzonica(Kuhol)/conica, Vivipara angularis(Susong
pampang)
 The adult worms live in the small intestine of the definitive host (e.g., DIAGNOSIS
humans, dogs, cats, rats, and pigs).  Diagnosis is by detection of eggs in the stool.
 Immature eggs released by the parasite are transported to the
environment with the feces. TREATMENT
 The egg matures in water, and after 6 to 15 days, a miracidium hatches  Praziquantel
from the egg to infect the first snail intermediate host.
 Inside the snail, the E. ilocanum miracidium develops into mother rediae, EPIDEMIOLOGY
which subsequently produce daughter rediae and cercariae after 42 to 50  These two parasites have been reported in other Southeast Asian
days. and East Asian countries.
 After escaping from the snail, cercariae swim in water to seek out and  E. ilocanum infection is endemic in Northern Luzon, Leyte, Samar,
infect the second snail intermediate host, in which they transform into and the provinces of Mindanao.
metacercariae.  All infected patients had a history of having eaten snails (kuhol and
 The metacercaria is the infective stage to the definitive host. kiambuay) prepared raw with coconut milk and lime juice. The
second snail intermediate hosts are abundant in rice fields especially
during the wet months.
 The rat is probably an important reservoir host of both
echinostomes.

PREVENTION AND CONTROL

 Avoiding ingestion of raw or improperly cooked second intermediate
snail hosts.

V. INTESTINAL FLUKE: Artyfechinostomum malayanum

Disease: Echinostomiasis

PATHOGENESIS AND CLINICAL MANIFESTATIONS

 Inflammation develops at the site of attachment of the adult worm
to the intestinal wall.
 Ulceration, and consequently, diarrhea, which is sometimes bloody,
as well as abdominal pain may also develop.
 The absorption of metabolites from the worms may result in general
intoxication.
 A. malayanum measures 5 to 12 mm in length and 2 to 3 mm in
width.
 It has a rounded posterior end and has 43 to 45 collar spines.
 The two testes are large, each with six to nine lobes arranged in
tandem.
 The ovary is small, rounded or oval, located anterior to the testes,
and pre-equatorial
 A. malayanum egg is larger, golden brown in color, operculated, and
measures 120 to 130 μm by 80 to 90 μm.

LIFE CYCLE
Intermediate Hosts:
 1st – Snail (Gyraulus convexiusculus, Hippeutis umbilicalis)
 2nd – Snail (Lymnaea cumingiana (syn. Bullastra), Ampullarius
canaliculatus (Golden apple snail) & cumingiana (birabid) )
 Definitive hosts: Man, Aquatic birds, Rat

PATHOGENESIS AND CLINICAL MANIFESTATIONS

 Inflammation develops at the site of attachment of the adult worm
to the intestinal wall.
 Ulceration, and consequently, diarrhea, which is sometimes bloody,
as well as abdominal pain may also develop.
 The absorption of metabolites from the worms may result in general
 The adult worms live in the small intestine of the definitive host (e.g., intoxication.
humans, dogs, cats, rats, and pigs).
 Immature eggs released by the parasite are transported to the DIAGNOSIS
environment with the feces.  Diagnosis is by detection of eggs in the stool.
 The egg matures in water, and after 6 to 15 days, a miracidium
hatches from the egg to infect the first snail intermediate host. TREATMENT
 The A. malayanum miracidium first develops into a sporocyst, which  Praziquantel
subsequently produces mother rediae, daughter rediae, and
cercariae. EPIDEMIOLOGY
 After escaping from the snail, cercariae swim in water to seek out and  These two parasites have been reported in other Southeast Asian
infect the second snail intermediate host, in which they transform and East Asian countries.
into metacercariae.  A. malayanum infection in the Philippines was first documented in
 The metacercaria is the infective stage to the definitive host. humans in 1987, and has since been reported in Northern and
 After escaping from the snail, cercariae swim in water to seek out and Central Luzon.
infect the second snail intermediate host, in which they transform  In 2005, a study in Siargao Island, Surigao del Norte, showed A.
into metacercariae. malayanum in 11.4% of individuals suffering from gastrointestinal
disturbance.
  All infected patients had a history of having eaten snails (kuhol and VI. INTESTINAL FLUKE: Heterophyes heterophyes (Heterophyid Fluke)
kiambuay) prepared raw with coconut milk and lime juice.
 All infected patients had a history of having eaten snails (kuhol and Disease: Heterophyiasis
kiambuay) prepared raw with coconut milk and lime juice. Common name: Von Siebold’s fluke (SMALLEST)
 The second snail intermediate hosts are abundant in rice fields
especially during the wet months.
 The rat is probably an important reservoir host of both
echinostomes.

PREVENTION AND CONTROL

 Avoiding ingestion of raw or improperly cooked second intermediate
snail hosts.

NOTE:
 The adult fluke is elongated, oval or pyriform, and it measures less than
 The echinostomids are digenetic trematodes characterized 2 mm in length. The tegument has fine scale-like spines.
by a collar of spines around their oral suckers. There are  Have a gonotyl or a genital sucker that is located near the left posterior
several species which infect humans. border of the ventral sucker.
 When the metacercariae reach the duodenum, they excyst  Testes, variously arranged, are in the posterior end of the body, parallel
and the juvenile fluke attaches to the wall of the small to each other.
intestine, where they develop into sexually mature adult  The ovary, globular or slightly lobed, is located in the submedian, pre- or
post-testicular area
worms.
 The egg is light brown in color, ovoid in shape, operculated, and measures
20 to 30 μm by l5 to 17 μm .
 The operculum fits into the eggshell smoothly, and it does not have an
abopercular protruberance..
 Other stain: yellow-green

LIFE CYCLE
Intermediate Hosts (Heterophyes heterophyes):
 1st – Snail (Family Potamididae)
 2nd – Fish (Mullet fish)
 Definitive Hosts: Man, Cat, Dog, Wolf, Fox (Fish-eating mammals and
birds)
 The mode of transmission of heterophyids is by ingestion of PATHOGENESIS AND CLINICAL MANIFESTATIONS
metacercariae encysted in fish.  There is usually inflammation at the sites where the worm is attached
 When the metacercariae reach the duodenum, they excyst, liberating to or burrowed in the mucosa.
young larvae that attach to the intestinal wall.  Peptic ulcer disease (PUD) or acid peptic disease (APD).
 The larvae subsequently develop into sexually mature adult worms  Colicky abdominal pain and mucoid diarrhea
that have a typically short life span of less than 1 year.  Observed in the heart and brain of Filipino patients who died of heart
 The adult worm inhabits the small intestine of the definitive host. failure and intracerebral hemorrhage
 The eggs hatch into miracidia after ingestion by the first snail  Eggs lodged in the spinal cord may result in sensory and motor losses
intermediate host. at the level of the lesion.
 Inside the snail, the miracidia develop further into sporocysts, which
eventually develop into one or two generations of rediae that give DIAGNOSIS
rise to cercariae.  Detection of eggs in stool using the modified Kato thick method
 Cercariae that are liberated from the snail encyst as metacercariae PCR may be useful as a sensitive diagnostic tool.
on or under the scales, in the muscles, fins, tails, or gills of fish species
that serve as second intermediate hosts. TREATMENT
 The snail hosts can be freshwater, brackish water, or marine species.  Praziquantel
 In the Philippines, the snail hosts of H. taichui and Procerovum
calderoni are the brackish water snails, Melania juncea, and Thiara EPIDEMIOLOGY
riquetti, respectively.  Worldwide in distribution
 In the southern part of the Philippines infection is recognized as
an emerging public health concern

PREVENTION AND CONTROL

 Avoiding ingestion of raw or improperly cooked fish
 Surveillance in other regions where raw fish (kinilaw) is eaten
VII. INTESTINAL FLUKE: Metagonimus yokogawai (Heterophyid Fluke)  The mode of transmission of heterophyids is by ingestion of
metacercariae encysted in fish.
Disease: Metagonimiasis  When the metacercariae reach the duodenum, they excyst, liberating
Common name: Yokogawa’s fluke young larvae that attach to the intestinal wall.
 The larvae subsequently develop into sexually mature adult worms
that have a typically short life span of less than 1 year.
 The adult worm inhabits the small intestine of the definitive host.
 The eggs hatch into miracidia after ingestion by the first snail
intermediate host.
 Inside the snail, the miracidia develop further into sporocysts, which
eventually develop into one or two generations of rediae that give
rise to cercariae.
 Cercariae that are liberated from the snail encyst as metacercariae
 Small, pyriform in shape with rounded posterior and tapering on or under the scales, in the muscles, fins, tails, or gills of fish species
anterior ends that serve as second intermediate hosts.
 Measures 1-2.5 by 0.4 – 0.75 mm  The snail hosts can be freshwater, brackish water, or marine species.
 Ventral sucker is deflected to the right of the midline  In the Philippines, the snail hosts of H. taichui and Procerovum
 2 oval testes are located at the posterior third of the body, arrange calderoni are the brackish water snails, Melania juncea, and Thiara
obliquely. riquetti, respectively.
 Ovary is found at the junction of the middle
 Coarse vitellaria in a fan shaped distribution in the posterior lateral
fields.
 Eggs are ovoidal, operculated with a slight shoulder. Measures 26-28
by 15-17 micro.

Intermediate Hosts (Metagonimus yokogawai):

 1st – Snail (Thiara spp, Semisulcospira libertina)
 2nd – Fish (Mullet fish)
 Definitive Hosts: Man, Cat, Dog, Wolf, Fox (Fish-eating mammals and
birds)

PATHOGENESIS AND CLINICAL MANIFESTATIONS

 There is usually inflammation at the sites where the worm is attached
to or burrowed in the mucosa.
  Peptic ulcer disease (PUD) or acid peptic disease (APD). VIII. LIVER FLUKES: Fasciolo hepatica (Fasciola spp.)
 Colicky abdominal pain and mucoid diarrhea
 Observed in the heart and brain of Filipino patients who died of heart Disease: Sheep Liver Rot, Fascioliasis hepatica Common name: Temperate
failure and intracerebral hemorrhage Liver Fluke, Sheep Liver Fluke, Common Liver Fluke
 Eggs lodged in the spinal cord may result in sensory and motor losses
at the level of the lesion.

DIAGNOSIS
 Detection of eggs in stool using the modified Kato thick method
PCR may be useful as a sensitive diagnostic tool.

TREATMENT
 Praziquantel

EPIDEMIOLOGY
 Worldwide in distribution  F. hepatica has a large, broad, and flat body which measures 18 to 51
 In the southern part of the Philippines infection is recognized as mm in length and 4 to 13 mm in width (near the mid-body).
an emerging public health concern  A distinguishing feature is the cephalic cone which has a marked
widening at the base of the cone (“shoulder”).
PREVENTION AND CONTROL  The suckers are comparatively small and are located close to each other
 Avoiding ingestion of raw or improperly cooked fish in the conical projection.
 Surveillance in other regions where raw fish (kinilaw) is eaten  The two testes are highly branched occupying the second and third
quarters of the body.
 The ovary is dendritic and situated in front of the anterior testis.
 The uterus is coiled and relatively short.
 Vitellaria extend to the whole lateral field of the hind body.
 The intestinal ceca are long and highly branched, extending to the
posterior end of the body.
 The F. hepatica egg is large, ovoidal, operculated, and yellowish to
brownish in color. It measures 140 to 180 µm by 63 to 90 µm in size and
is released from the worm still immature, containing a large
unsegmented mass of vitelline cells.
LIFE CYCLE
Intermediate Hosts:
 1st – Snail (Family Lymnaeidae, Family Planorbidae - sporadically)
 2nd – Fresh water/aquatic vegetation
 Water spinach (Ipomea aquatica) “kangkong”
 Morning glory (Ipomea obscura)
 Watercress (Nasturtium officinale)
 Definitive Host: Man, Sheep, Goat, Cattle
 The mode of transmission of F. hepatica and F. gigantica is through
the ingestion of metacercariae encysted on edible aquatic plants or
by drinking water with viable metacercariae.
 Upon ingestion, the metacercaria excysts in the duodenum or
jejunum, liberating the juvenile fluke, which, in turn, penetrates the
intestinal wall to reach the peritoneal cavity where it wanders over
the viscera until it penetrates the capsule of Glisson and enters the
liver.
 The parasite then burrows through the liver parenchyma, feeding and
growing until it finally enters the bile ducts where it becomes sexually
mature in 3 to 4 months. The life span of the adult worm is 9 to 13
years.
 The adult worm lives in the biliary passages of the liver.
 Unembryonated eggs are carried by the bile through the sphincter of
Oddi into the intestine and subsequently voided with the feces.
 The eggs mature in water within 9 to 15 days optimally at 15 to 25°C,
forming a viable miracidium that escapes through the operculum of
the eggshell to seek out and infect the first intermediate host, a snail
belonging to family Lymnaeidae.
 Snail hosts for F. hepatica are amphibious which are usually found PATHOGENESIS AND CLINICAL MANIFESTATIONS
living on mud. Snail species include Lymnaea truncatula (Europe and Two clinical stages:.
North Asia), L. bulmoides (North America), and L. tomentosa A. Acute stage
(Australia). Snails from family Planorbidae also act as an intermediate - Corresponds to the migration of the juvenile parasite from
host of F. hepatica sporadically. intestine to the liver where it burrows into the liver parenchyma.
 Inside the snail, the miracidium develops into a sporocyst, followed - Traumatic and necrotic lesions are produced when the parasite
by one or two generations of rediae which produce cercariae. burrows through the liver parenchyma.
 Cercariae leave the snail about 5 to 6 weeks after the miracidium - Experience dyspepsia, fever, and right upper quadrant abdominal
entered. pain. Sudden onset of high fever, hepatomegaly, and marked
eosinophilia form a triad of diagnostic significance.
 After escaping from the snail host, usually at night, the cercaria swims
B. Chronic or latent phase
in water, detaches its tail, and encysts in surfaces of aquatic plants
- Asymptomatic and corresponds to the period when the parasite
forming a metacercaria.
has already reached the bile ducts.
 The aquatic plants serve as the second intermediate hosts of the
- The adult worm causes obstruction and stimulates inflammation
parasite.
in the biliary epithelium which subsequently causes fibrosis. T
 These include Ipomea obscura (morning glory or kangkong) and
- The thickened fibrous ducts, in turn, cause less bile to be passed
Nasturtium officinale (watercress).
out building up back pressure.
 Cercariae can also encyst freely in water.
- Atrophy of the liver parenchyma and concomitant periductal
 The metacercaria is the infective stage to the definitive hosts. cirrhosis ensue.
 In the presence of moisture they survive as well as in longer at a - Other complications include obstructive jaundice, hemobilia, and
temperature below 20°C; higher temperatures and desiccation will biliary cirrhosis.
destroy the metacercariae in a short time.
DIAGNOSIS IX. LIVER FLUKES: Fasciolo gigantica (Fasciola spp.)
 Identification of eggs in stool, duodenal contents, or bile, or the Disease: Fascioliasis gigantica
recovery of adult worms during surgical exploration, after treatment, Common name: Tropical Liver Fluke
or at autopsy
 Immunologic methods are preferable to egg examination for the
detection of acute infections
 Radiological examinations may also help in the diagnosis of
fascioliasis

TREATMENT

 Triclabendazole is the drug of choice

 Bithionol may also be used
 Peroxidic compounds, such as semi-synthetic artemisinins and
synthetic trioxolanes (antimalarial and antischistosomal properties)
have been reported to show trematocidal activities
 F.gigantica adult worm is longer (25-75 mm), with about the same
EPIDEMIOLOGY width (3-12 mm), with less developed shoulders, and a shorter
 Fascioliasis has a worldwide distribution cephalic cone.
 The ceca are more branched especially towards the midline of the
PREVENTION AND CONTROL body and the branches of the ovary are longer and more numerous.
 Preventive measures include thorough washing or cooking of  The average distance between the posterior testes and the posterior
vegetables, and boiling of water border of the body is longer.
 Elimination of the snail intermediate host  F. gigantica egg is slightly larger than the F. hepatica egg (160-190 µm
 Spitfill and Dalton in 1998 demonstrated that animals can be by 70-90 µm).
significantly protected against infection by vaccination with defined
Fasciola antigens LIFE CYCLE
Intermediate Hosts:
 1st – Snail (Family Lymnaeidae)
 2nd – Fresh water/aquatic vegetation
 Water spinach (Ipomea aquatica) “kangkong”
 Morning glory (Ipomea obscura)
 Watercress (Nasturtium officinale)
 Definitive Host: Man, Sheep, Goat, Cattle
 The mode of transmission of F. hepatica and F. gigantica is through
the ingestion of metacercariae encysted on edible aquatic plants or
by drinking water with viable metacercariae.
 Upon ingestion, the metacercaria excysts in the duodenum or
jejunum, liberating the juvenile fluke, which, in turn, penetrates the
intestinal wall to reach the peritoneal cavity where it wanders over
the viscera until it penetrates the capsule of Glisson and enters the
liver.
 The parasite then burrows through the liver parenchyma, feeding and
growing until it finally enters the bile ducts where it becomes sexually
mature in 3 to 4 months. The life span of the adult worm is 9 to 13
years.
 The adult worm lives in the biliary passages of the liver.
 Unembryonated eggs are carried by the bile through the sphincter of
Oddi into the intestine and subsequently voided with the feces.
 The eggs mature in water within 9 to 15 days optimally at 15 to 25°C,
forming a viable miracidium that escapes through the operculum of
the eggshell to seek out and infect the first intermediate host, a snail
belonging to family Lymnaeidae.
 First intermediate hosts for F. gigantica are aquatic snails, living in PATHOGENESIS AND CLINICAL MANIFESTATIONS
slow-moving bodies of water, which include L. auricularia (Asia), L. Two clinical stages:.
acuminata (Indian Subcontinent), and L. natalensis (Africa). In the C. Acute stage
Philippines, the snail hosts of Fasciola spp. are L. philippinensis and L. - Corresponds to the migration of the juvenile parasite from
auricularia rubiginosa intestine to the liver where it burrows into the liver parenchyma.
 Inside the snail, the miracidium develops into a sporocyst, followed - Traumatic and necrotic lesions are produced when the parasite
by one or two generations of rediae which produce cercariae. burrows through the liver parenchyma.
 Cercariae leave the snail about 5 to 6 weeks after the miracidium - Experience dyspepsia, fever, and right upper quadrant abdominal
entered. pain. Sudden onset of high fever, hepatomegaly, and marked
eosinophilia form a triad of diagnostic significance.
 After escaping from the snail host, usually at night, the cercaria swims
D. Chronic or latent phase
in water, detaches its tail, and encysts in surfaces of aquatic plants
- Asymptomatic and corresponds to the period when the parasite
forming a metacercaria.
has already reached the bile ducts.
 The aquatic plants serve as the second intermediate hosts of the
- The adult worm causes obstruction and stimulates inflammation
parasite.
in the biliary epithelium which subsequently causes fibrosis. T
 These include Ipomea obscura (morning glory or kangkong) and
- The thickened fibrous ducts, in turn, cause less bile to be passed
Nasturtium officinale (watercress).
out building up back pressure.
 Cercariae can also encyst freely in water.
- Atrophy of the liver parenchyma and concomitant periductal
 The metacercaria is the infective stage to the definitive hosts. cirrhosis ensue.
 In the presence of moisture they survive as well as in longer at a - Other complications include obstructive jaundice, hemobilia, and
temperature below 20°C; higher temperatures and desiccation will biliary cirrhosis.
destroy the metacercariae in a short time.
DIAGNOSIS X. LIVER FLUKES: Clonorchis sinensis
 Identification of eggs in stool, duodenal contents, or bile, or the Disease: Clonorchiasis
recovery of adult worms during surgical exploration, after treatment, Common name: Chinese Liver Fluke, Oriental Liver Fluke
or at autopsy
 Immunologic methods are preferable to egg examination for the
detection of acute infections
 Radiological examinations may also help in the diagnosis of
fascioliasis

TREATMENT

 Triclabendazole is the drug of choice

 Bithionol may also be used
 Peroxidic compounds, such as semi-synthetic artemisinins and
synthetic trioxolanes (antimalarial and antischistosomal properties)
have been reported to show trematocidal activities

EPIDEMIOLOGY
 Fascioliasis has a worldwide distribution

PREVENTION AND CONTROL  leaf-like in shape, with transparent tegument

 Preventive measures include thorough washing or cooking of  C. sinensis adult is 10 to 25 mm long and 3 to 5 mm wide.
vegetables, and boiling of water  vitellaria, which are found in the middle third of the body at the level
 Elimination of the snail intermediate host of the uterus
 Spitfill and Dalton in 1998 demonstrated that animals can be  C. sinensis adults have two large, highly branched testes arranged in
significantly protected against infection by vaccination with defined tandem in the posterior half of the body.
Fasciola antigens  Eggs of these parasites are yellowish brown, ovoid, and measure 26
to 30 µm by 15 to 17 µm.
 There is a distinctly convex operculum that fits into the thickened rim
of the eggshell, and a small protuberance at the abopercular end.
 Inside the egg is a well-developed miracidium

LIFE CYCLE
Intermediate Hosts:
 1st – Snail (Genus Parafossarulus, Bulinus, Semisulcospira, Alocinma,
Thiara, and Melanoides)
 2nd – Fresh water fish (Family Cyprinidae)
 Definitive Hosts: Man, Fish-eating mammals
 The usual mode of transmission is via ingestion of the metacercaria of the
parasite present in infected raw or undercooked fish.
 Viable encysted metacercariae have been reported in salted, dried, or
pickled fresh water fish.
 Metacercariae from decomposing fish could potentially be ingested by
drinking contaminated water.
 The metacercaria excysts in the duodenum, and the young fluke moves
through the ampulla of Vater to the common bile duct, and then to the
distal biliary capillaries where it matures into an adult worm.
 The adult fluke attaches itself to the mucosa of the bile duct by using its
suckers, and by embedding itself in sticky mucus without causing
permanent ulceration of the epithelial lining.
 The flukes may also be found in the pancreatic duct and the gallbladder.
 The worm feeds on tissue fluids, red blood cells, and mucus.
 The egg is fully mature when it is released from the worm.
 It passes with the bile to the intestine, and escapes into the environment
with the feces.
 The miracidium hatches only after the egg is ingested by the first
XI. LIVER FLUKES: Opistorchis felineus (Opistorchis spp.)
intermediate host.
Disease: Opistorchiasis
 The first snail intermediate host of C. sinensis belongs to the following
Common name: Cat Liver Fluke
genera: Parafossarulus (P. manchouricus, P. anomalospiralis, and P.
stratulus), Bulinus (B. striatulus), Semisulcospira, Alocinma (A.
longicornis), Thiara (T. granifera), and Melanoides (M. tuberculatus).
 Upon entry into the snail host, the miracidium transforms into a
sporocyst, which subsequently produces rediae.
 Each redia, in turn, produces cercariae that are released into the
surrounding water.
 Upon contact with the second intermediate host, a fresh water fish, the
cercaria attaches itself to the host epithelium with its suckers, and Intermediate Hosts:
encysts as metacercaria under a scale or in a muscle.
 1st – Snail (Genus Bithynia)
 A total of 31 species in seven families of freshwater fish, and one species
 2nd – Fresh water fish (Family Cyprinidae, Cobitidae)
of freshwater shrimp, have been recorded as second intermediate hosts
of C. sinensis.
 The metacercaria is the infective stage to the definitive host.
 Adult worms are also found in the bile ducts of cats, dogs, pigs, and six
other species of mammals, which can act as reservoir hosts.
  Eggs of the three species of liver flukes are difficult to
XII. LIVER FLUKES: Opistorchis viverrini (Opistorchis spp.) differentiate.
Disease: Opistorchiasis B. Life Cycle

 The usual mode of transmission is via ingestion of the metacercaria

of the parasite present in infected raw or undercooked fish.
 Viable encysted metacercariae have been reported in salted,
dried, or pickled fresh water fish.
 Metacercariae from decomposing fish could potentially be
ingested by drinking contaminated water.
 The metacercaria excysts in the duodenum, and the young fluke
moves through the ampulla of Vater to the common bile duct, and
Intermediate Hosts then to the distal biliary capillaries where it matures into an adult
 1st – Snail (Genus Bithynia) worm.
 2nd – Fresh water fish (Family Cyprinidae (Puntius spp),  The adult fluke attaches itself to the mucosa of the bile duct by
Cobitidae) using its suckers, and by embedding itself in sticky mucus without
causing permanent ulceration of the epithelial lining.
 The flukes may also be found in the pancreatic duct and the
gallbladder.
 The worm feeds on tissue fluids, red blood cells, and mucus.
 The egg is fully mature when it is released from the worm.
 It passes with the bile to the intestine, and escapes into the
environment with the feces.
 The miracidium hatches only after the egg is ingested by the first
OPISTORCHIS SPP. intermediate host.
 O. felineus and O. viverrini require snails belonging to the genus
A. Morphology
Bithynia.
 leaf-like in shape, with transparent tegument
 Upon entry into the snail host, the miracidium transforms into a
 Opisthorchis adults are slightly shorter, being 8 to 12 mm sporocyst, which subsequently produces rediae.
long and 1.5 to 3 mm wide.
 Each redia, in turn, produces cercariae that are released into the
 Opisthorchis adults have lobate testes, which are arranged surrounding water.
obliquely.
 Upon contact with the second intermediate host, a fresh water fish,
 The O. viverrini adult can be differentiated from the O. the cercaria attaches itself to the host epithelium with its suckers,
felineus adult on the basis of testes morphology: the testes and encysts as metacercaria under a scale or in a muscle.
of O. viverrini, which are positioned close to each other, are
 Metacercariae of Opisthorchis spp. Have been recorded in 23
more deeply lobulated.
species and 2 subspecies of Cyprinidae family, and 11 species of
 Eggs of these parasites are yellowish brown, ovoid, and Cobitidae family.
measure 26 to 30 µm by 15 to 17 µm.
 The metacercaria is the infective stage to the definitive host.
 There is a distinctly convex operculum that fits into the
 Adult worms are also found in the bile ducts of cats, dogs, pigs, and
thickened rim of the eggshell, and a small protuberance at
six other species of mammals, which can act as reservoir hosts.
the abopercular end.
 EPIDEMIOLOGY
 sinensis is endemic in China, Korea, Japan, and Vietnam
 O. felineus has been reported in Europe, Turkey, the former USSR
countries, Korea, Japan, Vietnam, and India
 O. viverrini in Thailand, Laos, Malaysia, and in immigrants to North
America
 A case of opisthorchiasis has been reported from the Davao Medical
Center in the Philippines.
 In the Philippines, only two cases of clonorchiasis had been diagnosed
at the College of Public Health, University of the Philippines – Manila

PREVENTION AND CONTROL

The main strategies for liver fluke control consist of three interrelated
approaches:
a) stool examination and treatment of positive cases with praziquantel
b) health education for the promotion of cooked fish consumption
c) proper human waste disposal

OPISTORCHIS SPP. & C. SINENSIS

-end-
DIAGNOSIS
 Detection of the parasite egg in the stool
 Cholangiography is a very useful diagnostic tool
 ELISA with crude extracts of adult C. sinensis has been reported to “I can do everything through Christ, who gives me strength”
have a high degree of sensitivity and a moderate degree of specificity
for the serodiagnosis of clonorchiasis.
Philippians 4:13
 A polymerase chain reaction (PCR) method developed with 100%
sensitivity has been used for detecting a single O. viverrini egg in
artificially inoculated feces Laban future rmt!!!
 A single, one-step multiplex PCR, targeting mitochondrial DNA,
permits the detection and discrimination of Clonorchis sinensis and
Opisthorchis viverrini

TREATMENT
 Praziquantel
 Albendazole
 The artemisinins and synthetic peroxides (i.e., OZ78)
 Tribendimidine