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TREMATODES



    Prepared by FZHapan
CHARACTERISTICS
   Dorso-ventrally flattened
   Unsegmented
   Leaf-like
   Hermaphroditic except blood flukes
   Two radially striated suckers
   Incomplete digestive tract
   Adults are covered with spines, except
   Incomplete digestive tract
   Most of the body is occupied by reproductive
    organs
                        Prepared by FZHapan
BLOOD FLUKES




       Prepared by FZHapan
BLOOD FLUKES
   Characteristics
     – Dioecious
     – Males are shorter and stouter than females
     – Lateral margins of males are folded ventrally to form a
       gynecophoral canal in which females are received
     – Suckers are armed with delicate spines
     – There is no muscular pharynx
     – Eggs are non-operculated
     – Eggs are fully embryonated when laid
     – Embryonated eggs have a ciliated embryo called miracidium
     – Cercariae have bifid tails
     – There is no encysted metacerciarial stage
     – Infective Stage: cercaria penetrating the unbroken skin



                             Prepared by FZHapan
BLOOD FLUKES:
Schistosomes
   Schistosomes
    – Schistosoma japonicum : Oriental blood
      fluke
    – Schistosoma haematobium: Vesical blood
      fuke
    – Schistosoma mansoni: Manson’s blood
      fluke


                   Prepared by FZHapan
Life Cycle




             Prepared by FZHapan
Schistosome Miracidium
   Miracidium
    – Hatches from the egg in
      slightly alkaline clean
      water with a temp.
      between 25 0C to 310C
    – Free swimming cilated
      embryo liberated from
      the egg
    – Photactic
    – Infect snails



                         Prepared by FZHapan
Schistosome Sporocysts
and Cercaria
   Mother sporocysts
    develop from
    miracidium within
    the snail
   Daughter sporocyst
    develops from
    mother sporocyst
   Cercariae develop
    from daughter
    sporocyst
                   Prepared by FZHapan
Schistosome Cercaria
   Cercaria
    – Emerges from
      daughter sporocysts
    – Escapes from the
      snail
    – Has a body and a
      forked tail
    – Infects man by skin
      penetration

                      Prepared by FZHapan
Schistosomulae
   Schistosomule
    – Develops from cercaria
      after skin penetration
    – Adapted to survive in
      serum or physiologic
      saline at 37 0C
    – Enter the pleural
      cavity---diaphragm---
      peritoneal space---
      penetrate the liver to
      reach the intrahepatic
      portions of the portal
      vein
                         Prepared by FZHapan
Schistosoma japonicum
   Schistosoma
    japonicum
    – Life cycle involves
      alternating parasitic
      stages in mammalian
      hosts and free living
      stages
          Egg and miracidium
          First stage (mother)
           sporocyst
          Second stage
           (daughter) sporocyst
          cercaria
          Schistosomulum
          Adult schistosome

                             Prepared by FZHapan
Schistosoma japonicum
   Schistosoma
    japonicum
    – Primarily parasites of
      the portal vein and its
      branches
    – Each female fluke
      deposits 500-2000
      immature eggs/day
    – Embryonation takes
      place within 10-12 days
    – Eggs escape through
      ulcerations in the
      intestinal lumen and are
      passed out with the
      feces
                          Prepared by FZHapan
Schistosoma japonicum
   Schistosoma
    japonicum in
    eternal copula
    – Males have a
      gynecophoral canal
      which receives the
      female during
      copulation



                     Prepared by FZHapan
Schistosoma japonicum
   Schistosoma
    japonicum Ova
    – Ovoidal, rounded or
      pear-shaped
    – Thin shell
    – Pale yellow
    – Curved hook or spine or
      lateral knob
    – Laid in the multicellular
      stage and embryonte
      within 10-12 days

                           Prepared by FZHapan
Schistosoma mansoni
   Schistosoma
    mansoni male and
    female
    – Female inside the
      gynecophoral canal
      of male




                     Prepared by FZHapan
Schistosoma mansoni
   Schistosoma
    mansoni male and
    female
    – Female inside the
      gynecophoral canal
      of male




                     Prepared by FZHapan
Schistosoma haematobium

   Schistosoma
    haematobium adult




                   Prepared by FZHapan
Schistosoma haematobium

   Schistosoma
    haematobium ova
    – Note the presence
      of terminal spine




                     Prepared by FZHapan
Differentiating Features
      of Schistosomes
  Feature        S. japonicum                    S. mansoni           S. haematobium

Testes (male)    6-7 in a single file        8 -9 in a zigzag row        4 -5 in groups


Ovary           In the middle of the      Anterior to the middle of    Behind the middle of
(Female)        body; contains 50 or       the body; contains 1-3     the body; contains 20
                     more eggs                       eggs                   – 30 eggs
Intestine              short                       longest                     long


Egg                Lateral knob                   Lateral spine          Terminal spine


Intermediate       Oncomelania                 Biomphalaria and       Bulimus (Physopsis)
Host                                              Australorbis
Definitive      Man and domestic                        Man
                                        Prepared by FZHapan
                                                                              Man
Host                animals
Blood Flukes:
Pathogenesis and Clinical
Manifestations
   Schistosomiasis
   Host granulomatous reaction to eggs
   Pneumonitis due to schistosomula in
    the lungs
   Hepatosplenic disease
   Colonic schistosomiasis
   Cerebral schistosomiasis
                  Prepared by FZHapan
Blood Flukes:                             Schistosomiasis




                          Prepared by FZHapan

 Distended belly is one of the symptoms of schistosomiasis
Blood Flukes: Diagnosis

   Schistosomiasis
    – Eggs may not be demonstrable in the
      feces

    – Infections where there is scarring prevent
      passage of eggs into the intestinal lumen



                     Prepared by FZHapan
Blood Flukes: Diagnosis

   Schistosomiasis
    – Stool Examination Techniques
         Merthiolate-Iodine Formlin Concentration
          Technique (MIFC)
           – Sensitive for moderate and heavy infections
           – Not adequate for light infections (less than 10
             eggs/gram of stool)
         Kato KatzTechnique
           – For enumeration of eggs
           – Most commonly used for evaluating epidemiology,
             effect of control measures, drug trials
                          Prepared by FZHapan
Blood Flukes: Diagnosis

   Schistosomiasis
         Immunodiagnosis
           – Intradermal tests for immediate cutaneous
             hypersensitivity using adult worm extracts
           – Indirect hemagglutination using adult worm and
             egg antigens
           – Circumoval precipitin test
           – Enzyme-Linked Immunosorbent Assay (ELISA)
             using soluble antigens of adults and eggs



                         Prepared by FZHapan
Blood Flukes: Treatment
   Treatment
    – Praziquantel
      (heterocyclic
      prazinoisoquinolone
      compound)
    – Single dose of 40-
      50 mg/kg
    – 25 mg/kg in two
      doses
    – 20 mg/kg in three
      doses
                      Prepared by FZHapan
Blood Flukes:
Epidemiology

   In the Philippines
    – 24 endemic provinces
        Sorsogon
        Oriental Mindoro

        Samar

        Leyte

        Bohol

        All provinces in Mindanao except Misamis
         Oriental
                      Prepared by FZHapan
Lung Flukes




         Prepared by FZHapan
Lung Flukes
 Paragonimus westermani
 Oriental Lung Fluke



 Paragonimus philippinensis
 Paragonimus siamensis (cats)




               Prepared by FZHapan
Lung Flukes:
Paragonimus westermani
   Paragonimus westermani
    adult
    – Hermaphroditic
    – Body covered with spines
    – Reddish brown
    – Measures 4-6 mm in width
      and 3.5-5 mm in thickness
    – Resembles a coffee bean
    – Adult worms are found in
      pairs or in threes in fibrotic
      capsules or cysts in the
      lungs



                                Prepared by FZHapan
Lung Flukes:
Paragonimus westermani
   Paragonimus
    westermani ova
    – Yellowish brown
    – Thick-shelled
    – Operculated with a
      thickened
      abopercular egg
    – May be seen in the
      sputum or in feces if
      the sputum is
      swallowed
                        Prepared by FZHapan
Lung Flukes:
Paragonimus westermani
Life Cycle




          Prepared by FZHapan
Lung Flukes:
Epidemiology of Paragonimiasis

   First Intermediate Host
    – Brotia asperata (snail)
    – Where miracidium develops into 1
      sporocyst and 2 redial stages of
      development




                   Prepared by FZHapan
Lung Flukes:
Epidemiology of Paragonimiasis

   Second Intermediate Host
    – Sundathelpusa philippina or Parathelpusa
      grapsoides (former name)

    – Harbors the metacercaria that is infective
      to man



                     Prepared by FZHapan
Lung Flukes:
Paragonimus westermani

   Man gets infected
    after ingestion of
    raw or insufficiently
    cooked crabs
    harboring the
    metacercariae




                      Prepared by FZHapan
Lung Flukes:
Pathogenesis and Clinical
Manifestations
   Paragonimiasis
    – Cough
    – Hemoptysis
    – Symptoms
      consistent with
      pulmonary
      tuberculosis
    – Misdiagnosed as
      PTB

                        Prepared by FZHapan
Lung Flukes:
Diagnosis of
Paragonimiasis
   Radiographs aid in
    diagnosis
   Definitive diagnosis is
    based on the finding of
    ova in the sputum,
    stool or less frequently
    in aspirated material
    from abscesses or
    pleural effusions
   Multi-dot ELISA

                         Prepared by FZHapan
Lung Flukes:
Treatment of Paragonimiasis
   Praziquantel
    – Drug of choice
    – 25 mg/kg body
      weight 3x a day for
      three day
   Bithionol
    – 15 – 25 mg/kg / day
      on alternate days
      for a total of 10-15
      days

                       Prepared by FZHapan
Lung Flukes:
Epidemiology of Paragonimiasis
   Has a global distribution
   In the Philippines
    –   Leyte
    –   Sorsogon
    –   Mindoro
    –   Camarines
    –   Samar
    –   Davao
    –   Cotabato
    –   Basilan

                      Prepared by FZHapan
Intestinal Flukes




           Prepared by FZHapan
Intestinal Flukes:
Fasciolopsis buski
   Giant intestinal fluke of man
   Parasite of the intestines of humans and
    pigs

   Mode of transmission is by ingestion of
    encysted metacercariae on aquatic plants
   The viable metacercariae excyst in the
    duodenum and becomes mature in about
    three months
                     Prepared by FZHapan
Intestinal Flukes:
Fasciolopsis buski
   Elongated
   Oval
   20 – 75 mm in length
    and 8 -20 mm in width
   Covered with spines
   No cephalic cone
   Unbranched intestina
    caeca which reach up
    to the posterior end

                       Prepared by FZHapan
Intestinal Flukes:
Life cycle of Fasciolopsis buski




              Prepared by FZHapan
Intestinal Flukes:
Pathogenesis of Fasciolopsis
buski
   Fasciolopsiasis
   Pathological changes caused are:
   Traumati c
    – Inflammation and ulceration
   Obstructive
    – Intestinal obstruction due to heavy infection
   Toxic
    – Due to absorption of worm metabolites by the
      host

                        Prepared by FZHapan
Intestinal Flukes:
Diagnosis Fasciolopsiasis
   Detection of
    parasite eggs in
    stool

   Resemble Fasciola
    eggs
   Provided with an
    operculum

                       Prepared by FZHapan
Intestinal Flukes:
Diagnosis Fasciolopsiasis
   Detection of
    parasite eggs in
    stool
    – Provided with an
      operculum
    – Large
    – Unembryonated
      when laid
   Resemble Fasciola
    eggs
                         Prepared by FZHapan
Intestinal Flukes:
Treatment of
Fasciolopsiasis
   Praziquantel
   25 mg/kg for 3
    doses for one day
   Side effects:
    –   Diziness
    –   Drowsiness
    –   Epigastric pain



                          Prepared by FZHapan
Intestinal Flukes:
Epidemiology of Fasciolopsiasis




              Prepared by FZHapan
Intestinal Flukes:
Epidemiology of Fasciolopsiasis
   Endemic in
    –   Southeast Asia
    –   China
    –   Korea
    –   India

   Endemicity in the Philippines has not been
    demonstrated yet
   Fasciolopsiasis in Filipinos are probably
    imported cases
                         Prepared by FZHapan
Intestinal Flukes:
Echinostoma ilocanum
   Garrison’s fluke
   Echinostomid
   There are several species that infect
    man
   There are 2 identified echinostomids
    that infect man in the Philippines:
    – Echinostoma ilocanum
    – Artyfechinostomum malayanum
                   Prepared by FZHapan
Intestinal Flukes:
Echinostoma ilocanum
   Adult
    – Reddish gray
    – Horse-shape collar of
      spines (circum oral disk)
      around the oral suckers
    – 49-51 collar spines
    – Integument is covered
      by plaque like scales
    – Simple intestinal caeca




                           Prepared by FZHapan
Echinostoma ilocanum showing circum-oral
                  disk
               Prepared by FZHapan
Intestinal Flukes:
Echinostoma ilocanum
      Echinostoma ilocanum Life cycle




                 Prepared by FZHapan
Intestinal Flukes:
Echinostoma ilocanum
   Echinostoma
    ilocanum Ova

    –   Straw-colored
    –   Operculated
    –   Ovoid
    –   Similar to Fasciola
        and Fasciolopsis
        buski ova
                         Prepared by FZHapan
Intestinal Flukes:
Echinostoma ilocanum
   First Intermediate Host:
    – Gyraulus convexciusculus

    – Hippeutis umbilicalis




                     Prepared by FZHapan
Intestinal Flukes:
Echinostoma ilocanum
   Second
    Intermediate Host:
    – Pila luzonica (kuhol)


    – Vivipara angularis
      (susong pampang)




                        Prepared by FZHapan

                                              Pila luzonica
Intestinal Flukes:
Pathogenesis and Clinical
Manifestations Echinostoma ilocanum
   Man gets infected when metacercariae in
    the second intermediate hosts are ingested
   Inflammation at the site of attachment of
    adults
   Ulceration
   Diarrhea (sometimes bloody)
   Abdominal pains
   General intoxication
                    Prepared by FZHapan
Intestinal Flukes:
Diagnosis
Echinostoma ilocanum
   Detection of
    characteristic eggs
    in the stool




                     Prepared by FZHapan
Intestinal Flukes
Treatment
Echinostoma ilocanum
   Praziquantel
    – 25 mg/kg for 3 doses for one day


    – No alcohol; no fats must be taken 24
      hours before and after treatment


    – Only water must be taken within 3 hours
      of medication
                    Prepared by FZHapan
Intestinal Flukes
Epidemiology
Echinostoma ilocanum
   Echinostoma ilocanum is endemic in:
    –   Northern Luzon
    –   Leyte
    –   Samar
    –   Mindanao provinces

   Artyfechinostomum malayanum
    – First reported in 1987
    – Northern and Central Luzon
                       Prepared by FZHapan
Intestinal Flukes
Heterophyids
   Many species live in the intestine of
    fish-eating hosts:
    –   Heterophys heterophyes
    –   Metagonimus yokogawai
    –   Haplorchis taichui
    –   Haplorchis yokogawai


                     Prepared by FZHapan
Intestinal Flukes
Heterophyids
   Mode of transmission is by ingestion
    of metacercariae encysted in fish

   Metacercariae in the abdomen
    excysts, liberating a larva that
    attaches to the intestinal wall


                   Prepared by FZHapan
Intestinal Flukes
Heterophyids
   Heterophyes
    heterophyes Adult
    – Elongated
    – Oval or pyriform
    – Measures less than 2
      mm in length
    – Integument has fine
      scale-like spines
    – Some species have
      gonotyl or genital sucker


                           Prepared by FZHapan
Intestinal Flukes
Heterophyids
   Heterophyes
    heterophyes Ova
    – Light brown in color
    – Ovoid in shape
    – Operculated
    – A fully developed
      symmetrical miracidium
      is already present
    – Operculum fits into the
      egg smoothly
    – No abopercular
      protuberance like that of
      Clonochis sinensis
      ovum

                           Prepared by FZHapan
Intestinal Flukes
Heterophyids




         Prepared by FZHapan
Intestinal Flukes
Heterophyes heterophyes
Pathogenesis and Clinical
Manifestations
   Heterophyiasis
   Inflammation at the site of attachment
   Manifesations are consistent with
    peptic ulcer (observed among infected
    individuals in Compostela Valley)
    –   Upper abdominal discomfort
    –   Gurgling abdomen

                     Prepared by FZHapan
Intestinal Flukes
Diagnosis
Pathogenesis and Clinical
Manifestations
   Detection of eggs in the stool using
    Kato Katz method

   Care must be taken to distinguish
    them from Clonorchis and Opistorchis
    ova


                   Prepared by FZHapan
Intestinal Flukes
Treatment
Pathogenesis and Clinical
Manifestations
   Praziquantel
    – 25 mg/kg in 3 doses for 1 day




                    Prepared by FZHapan
Intestinal Flukes
Epidemiology
Pathogenesis and Clinical
Manifestations
   Found in
    –   Egypt
    –   Greece
    –   Israel
    –   Western India
    –   Central and South China
    –   Japan
    –   Korea
    –   Taiwan
    –   Philippines
            Compostela Valley
            Mindanao
            Emerging public health concern

                               Prepared by FZHapan
Liver Flukes




          Prepared by FZHapan
Liver Flukes
Fasciola species
   Found in the liver and biliary passages of humans
    and ruminants


   Fasciola hepatica
    – Sheep liver fluke
    – Temperate liver fluke

   Fasciola gigantica
    – Giant liver fluke
    – Tropical liver fluke
                             Prepared by FZHapan
Liver Flukes
Fasciola species
   Mode of transmission is by ingestion of
    metacercariae found in edible aquatic plants or by
    drinking water with floating metacercariae

   Metacercariae excsts in the duodenum or jejunum
    and liberate the juvenile fluke
   Juvenile fluke penetrates the intestinal wall and
    reaches the liver capsule
   The parasite burrows into the liver parenchyma
    where it grows and develops
   It becomes sexually mature in the bile ducts
                        Prepared by FZHapan
Liver Flukes
Fasciola hepatica
   Adult Worm
    – Large, broad, flat
      body
    – Anterior end forms a
      prominent cephalic
      cone
    – Small oral and
      ventral suckers
    – Long and highly
      branched intestinal
      caeca
                      Prepared by FZHapan
Liver Flukes
Fasciola gigantica
   Adult Worm
    – Larger
    – More lanceolate
    – Less developed
      shoulders (shorter
      cephalic cone)
    – Larger ventral
      sucker


                       Prepared by FZHapan
Liver Flukes
Fasciola hepatica and gigantica
   Adult Worm




                 Prepared by FZHapan
Liver Flukes
Fasciola hepatica and gigantica
   First Intermediate Host:
    – Lymnea philippinensis
   Second Intermediate Host
    – Watercress
    – grass




                   Prepared by FZHapan
Liver Flukes
Fasciola hepatica
   Fasciola hepatica
    Ova
    –   Large
    –   Ovoid
    –   Operculated
    –   Bile stained
    –   unsegmented



                       Prepared by FZHapan
Liver Flukes
Fasciola hepatica

   Fasciola gigantica
    Ova
    – Larger but very
      similar to Fasciola
      hepatica ova

    *Because of
      similarities, it is just
      safe to say Fasciola
      ova
                          Prepared by FZHapan
Liver Flukes
Fasciola hepatica

   Fasciola gigantica
    Ova
    – Larger but very
      similar to Fasciola
      hepatica ova

    *Because of
      similarities, it is just
      safe to say Fasciola
      ova
                          Prepared by FZHapan
Liver Flukes
Fasciola species




                   Prepared by FZHapan
Liver Flukes
Fasciola species
Pathogenesis and Clinical
Manifestations
   Fascioliasis
   Asymptomatic
   Can produce fever
   Right upper quadrant abdominal pain
   Hypereosinophilia
   Acute or invasive phase
     – Migration from intestine to liver
     – Traumatic and necrotic lesions in liver parenchyma
   Chronic or latent phase
     –   Asymptomatic
     –   Parasite has reached the bile ducts
     –   Obstruction
     –   Stimulates inflammation in the biliary epithelium leading to
         fibrosis

                                 Prepared by FZHapan
Liver Flukes
Fasciola species
Diagnosis
   Microscopy
   Serologic tests
    – Low specificity because of cross reactivity
      with antigens of other parasites
   RFLP
    – PCR restriction Fragment Length
      Polymorphism

                      Prepared by FZHapan
Liver Flukes
Fasciola species
Treatment
   Bithionol
    – 20-50 mg/kg body weight on alternate days to
      complete 10 to 5 doses



   Triclabendazole
    – Also a recommended drug of choice due to:
          Efficacy
          Safety
          Ease of use

                         Prepared by FZHapan
Liver Flukes
Fasciola species
Epidemiology
   Worldwide distribution
   Economic importance n livestock
    raising
   In the Philippines, the dominant
    species is Fasciola gigantica affecting
    cattle and water buffalos
   Few human cases are reported locally
                   Prepared by FZHapan
Liver Flukes
Clonorchis sinensis
   Chinese liver fluke
   Oriental Liver Fluke
   Distome of China
   First intermediate Host:
    – Bulimus fuchsiana (snail not found in the
      Philippines)

   Second Intermediate Host:
    – Ctenopharyngondon idellus (fish)

                       Prepared by FZHapan
Liver Flukes
Clonorchis sinensis
   Adult Worm
    – Narrow, oblong, flat
      worm
    – Oral sucker is slightly
      larger than the ventral
      sucker
    – Blind intestinal caeca
      are simple and extend
      to the caudal region
    – Life span is 20-30 years



                          Prepared by FZHapan
Liver Flukes
Clonorchis sinensis
   Ova
    –   Bile stained
    –   Flask-shaped
    –   Operculated
    –   Contains a miracidium
        when oviposited
    –   Does not hatch in water
        but is ingested with a
        molluscan host
    –   Has a terminal spine
    –   Electric bulb in shape
    –   Infective to snails only

                             Prepared by FZHapan
Liver Flukes
Clonorchis sinensis
Life Cycle




                Prepared by FZHapan
Liver Flukes
Clonorchis sinensis
Pathogenesis and Clinical
Manifestations
 Clonorchiasis
 Provokes intense proliferation of intestinal
  epithelium
 Acute stage (less than 1 month of infection)
    – Chills
    – Fever
   Chronic stage
    – Cirrhosis
    – Portal hypertension

                      Prepared by FZHapan
Liver Flukes
Clonorchis sinensis
Diagnosis
   Detection of parasite egg in stool
   Clonorchis, Opistorchis and
    Hetrophyid ova may not be
    differentiated under ordinary light
    microscope
   ELISA with crude Clonorchis sinensis
    antigen
   Enzyme immunoassay (EIA
   Polymerase Chain Reactions
                  Prepared by FZHapan
Liver Flukes
Clonorchis sinensis
Treatment
   Praziquantel
    – 25 mg/kg three times a day for two days
    – 60 mg/kg in three doses for one day
    – May be used together with albendazole
      for light and moderate infections




                    Prepared by FZHapan
Liver Flukes
Clonorchis sinensis
Epidemiology
   Transmission is due to consumption of raw,
    undercooked fish and salted and dried fish
    harboring the metacercariae
   Over 30 million people are infected in Southeastern
    Asia
   No reported cases in children below 10 years old
   Endemic in:
    –   China
    –   Japan
    –   Korea
    –   Vietnam

                        Prepared by FZHapan
Pancreatic Fluke




          Prepared by FZHapan
Pancreatic Fluke
Eurytrema pancreaticum
   Pancreatic fluke
   Stout worm with
    ruffled margins
   oral sucker is larger
    than the ventral
    sucker



                      Prepared by FZHapan
Pancreatic Fluke
Eurytrema pancreaticum
   First Intermediate
    Host:
    – Macrochlamys
      indica (snail)

   Second
    intermediate Host:
    – Technomyrmex
      deterquens (ant)
                         Prepared by FZHapan
Pancreatic Fluke
Eurytrema pancreaticum
   Ova
    –   Operculated
    –   Thick shelled
    –   Dark brown in color
    –   Embryonated when
        laid




                        Prepared by FZHapan

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Trematodes

  • 1. TREMATODES Prepared by FZHapan
  • 2. CHARACTERISTICS  Dorso-ventrally flattened  Unsegmented  Leaf-like  Hermaphroditic except blood flukes  Two radially striated suckers  Incomplete digestive tract  Adults are covered with spines, except  Incomplete digestive tract  Most of the body is occupied by reproductive organs Prepared by FZHapan
  • 3. BLOOD FLUKES Prepared by FZHapan
  • 4. BLOOD FLUKES  Characteristics – Dioecious – Males are shorter and stouter than females – Lateral margins of males are folded ventrally to form a gynecophoral canal in which females are received – Suckers are armed with delicate spines – There is no muscular pharynx – Eggs are non-operculated – Eggs are fully embryonated when laid – Embryonated eggs have a ciliated embryo called miracidium – Cercariae have bifid tails – There is no encysted metacerciarial stage – Infective Stage: cercaria penetrating the unbroken skin Prepared by FZHapan
  • 5. BLOOD FLUKES: Schistosomes  Schistosomes – Schistosoma japonicum : Oriental blood fluke – Schistosoma haematobium: Vesical blood fuke – Schistosoma mansoni: Manson’s blood fluke Prepared by FZHapan
  • 6. Life Cycle Prepared by FZHapan
  • 7. Schistosome Miracidium  Miracidium – Hatches from the egg in slightly alkaline clean water with a temp. between 25 0C to 310C – Free swimming cilated embryo liberated from the egg – Photactic – Infect snails Prepared by FZHapan
  • 8. Schistosome Sporocysts and Cercaria  Mother sporocysts develop from miracidium within the snail  Daughter sporocyst develops from mother sporocyst  Cercariae develop from daughter sporocyst Prepared by FZHapan
  • 9. Schistosome Cercaria  Cercaria – Emerges from daughter sporocysts – Escapes from the snail – Has a body and a forked tail – Infects man by skin penetration Prepared by FZHapan
  • 10. Schistosomulae  Schistosomule – Develops from cercaria after skin penetration – Adapted to survive in serum or physiologic saline at 37 0C – Enter the pleural cavity---diaphragm--- peritoneal space--- penetrate the liver to reach the intrahepatic portions of the portal vein Prepared by FZHapan
  • 11. Schistosoma japonicum  Schistosoma japonicum – Life cycle involves alternating parasitic stages in mammalian hosts and free living stages  Egg and miracidium  First stage (mother) sporocyst  Second stage (daughter) sporocyst  cercaria  Schistosomulum  Adult schistosome Prepared by FZHapan
  • 12. Schistosoma japonicum  Schistosoma japonicum – Primarily parasites of the portal vein and its branches – Each female fluke deposits 500-2000 immature eggs/day – Embryonation takes place within 10-12 days – Eggs escape through ulcerations in the intestinal lumen and are passed out with the feces Prepared by FZHapan
  • 13. Schistosoma japonicum  Schistosoma japonicum in eternal copula – Males have a gynecophoral canal which receives the female during copulation Prepared by FZHapan
  • 14. Schistosoma japonicum  Schistosoma japonicum Ova – Ovoidal, rounded or pear-shaped – Thin shell – Pale yellow – Curved hook or spine or lateral knob – Laid in the multicellular stage and embryonte within 10-12 days Prepared by FZHapan
  • 15. Schistosoma mansoni  Schistosoma mansoni male and female – Female inside the gynecophoral canal of male Prepared by FZHapan
  • 16. Schistosoma mansoni  Schistosoma mansoni male and female – Female inside the gynecophoral canal of male Prepared by FZHapan
  • 17. Schistosoma haematobium  Schistosoma haematobium adult Prepared by FZHapan
  • 18. Schistosoma haematobium  Schistosoma haematobium ova – Note the presence of terminal spine Prepared by FZHapan
  • 19. Differentiating Features of Schistosomes Feature S. japonicum S. mansoni S. haematobium Testes (male) 6-7 in a single file 8 -9 in a zigzag row 4 -5 in groups Ovary In the middle of the Anterior to the middle of Behind the middle of (Female) body; contains 50 or the body; contains 1-3 the body; contains 20 more eggs eggs – 30 eggs Intestine short longest long Egg Lateral knob Lateral spine Terminal spine Intermediate Oncomelania Biomphalaria and Bulimus (Physopsis) Host Australorbis Definitive Man and domestic Man Prepared by FZHapan Man Host animals
  • 20. Blood Flukes: Pathogenesis and Clinical Manifestations  Schistosomiasis  Host granulomatous reaction to eggs  Pneumonitis due to schistosomula in the lungs  Hepatosplenic disease  Colonic schistosomiasis  Cerebral schistosomiasis Prepared by FZHapan
  • 21. Blood Flukes: Schistosomiasis Prepared by FZHapan Distended belly is one of the symptoms of schistosomiasis
  • 22. Blood Flukes: Diagnosis  Schistosomiasis – Eggs may not be demonstrable in the feces – Infections where there is scarring prevent passage of eggs into the intestinal lumen Prepared by FZHapan
  • 23. Blood Flukes: Diagnosis  Schistosomiasis – Stool Examination Techniques  Merthiolate-Iodine Formlin Concentration Technique (MIFC) – Sensitive for moderate and heavy infections – Not adequate for light infections (less than 10 eggs/gram of stool)  Kato KatzTechnique – For enumeration of eggs – Most commonly used for evaluating epidemiology, effect of control measures, drug trials Prepared by FZHapan
  • 24. Blood Flukes: Diagnosis  Schistosomiasis  Immunodiagnosis – Intradermal tests for immediate cutaneous hypersensitivity using adult worm extracts – Indirect hemagglutination using adult worm and egg antigens – Circumoval precipitin test – Enzyme-Linked Immunosorbent Assay (ELISA) using soluble antigens of adults and eggs Prepared by FZHapan
  • 25. Blood Flukes: Treatment  Treatment – Praziquantel (heterocyclic prazinoisoquinolone compound) – Single dose of 40- 50 mg/kg – 25 mg/kg in two doses – 20 mg/kg in three doses Prepared by FZHapan
  • 26. Blood Flukes: Epidemiology  In the Philippines – 24 endemic provinces  Sorsogon  Oriental Mindoro  Samar  Leyte  Bohol  All provinces in Mindanao except Misamis Oriental Prepared by FZHapan
  • 27. Lung Flukes Prepared by FZHapan
  • 28. Lung Flukes  Paragonimus westermani  Oriental Lung Fluke  Paragonimus philippinensis  Paragonimus siamensis (cats) Prepared by FZHapan
  • 29. Lung Flukes: Paragonimus westermani  Paragonimus westermani adult – Hermaphroditic – Body covered with spines – Reddish brown – Measures 4-6 mm in width and 3.5-5 mm in thickness – Resembles a coffee bean – Adult worms are found in pairs or in threes in fibrotic capsules or cysts in the lungs Prepared by FZHapan
  • 30. Lung Flukes: Paragonimus westermani  Paragonimus westermani ova – Yellowish brown – Thick-shelled – Operculated with a thickened abopercular egg – May be seen in the sputum or in feces if the sputum is swallowed Prepared by FZHapan
  • 31. Lung Flukes: Paragonimus westermani Life Cycle Prepared by FZHapan
  • 32. Lung Flukes: Epidemiology of Paragonimiasis  First Intermediate Host – Brotia asperata (snail) – Where miracidium develops into 1 sporocyst and 2 redial stages of development Prepared by FZHapan
  • 33. Lung Flukes: Epidemiology of Paragonimiasis  Second Intermediate Host – Sundathelpusa philippina or Parathelpusa grapsoides (former name) – Harbors the metacercaria that is infective to man Prepared by FZHapan
  • 34. Lung Flukes: Paragonimus westermani  Man gets infected after ingestion of raw or insufficiently cooked crabs harboring the metacercariae Prepared by FZHapan
  • 35. Lung Flukes: Pathogenesis and Clinical Manifestations  Paragonimiasis – Cough – Hemoptysis – Symptoms consistent with pulmonary tuberculosis – Misdiagnosed as PTB Prepared by FZHapan
  • 36. Lung Flukes: Diagnosis of Paragonimiasis  Radiographs aid in diagnosis  Definitive diagnosis is based on the finding of ova in the sputum, stool or less frequently in aspirated material from abscesses or pleural effusions  Multi-dot ELISA Prepared by FZHapan
  • 37. Lung Flukes: Treatment of Paragonimiasis  Praziquantel – Drug of choice – 25 mg/kg body weight 3x a day for three day  Bithionol – 15 – 25 mg/kg / day on alternate days for a total of 10-15 days Prepared by FZHapan
  • 38. Lung Flukes: Epidemiology of Paragonimiasis  Has a global distribution  In the Philippines – Leyte – Sorsogon – Mindoro – Camarines – Samar – Davao – Cotabato – Basilan Prepared by FZHapan
  • 39. Intestinal Flukes Prepared by FZHapan
  • 40. Intestinal Flukes: Fasciolopsis buski  Giant intestinal fluke of man  Parasite of the intestines of humans and pigs  Mode of transmission is by ingestion of encysted metacercariae on aquatic plants  The viable metacercariae excyst in the duodenum and becomes mature in about three months Prepared by FZHapan
  • 41. Intestinal Flukes: Fasciolopsis buski  Elongated  Oval  20 – 75 mm in length and 8 -20 mm in width  Covered with spines  No cephalic cone  Unbranched intestina caeca which reach up to the posterior end Prepared by FZHapan
  • 42. Intestinal Flukes: Life cycle of Fasciolopsis buski Prepared by FZHapan
  • 43. Intestinal Flukes: Pathogenesis of Fasciolopsis buski  Fasciolopsiasis  Pathological changes caused are:  Traumati c – Inflammation and ulceration  Obstructive – Intestinal obstruction due to heavy infection  Toxic – Due to absorption of worm metabolites by the host Prepared by FZHapan
  • 44. Intestinal Flukes: Diagnosis Fasciolopsiasis  Detection of parasite eggs in stool  Resemble Fasciola eggs  Provided with an operculum Prepared by FZHapan
  • 45. Intestinal Flukes: Diagnosis Fasciolopsiasis  Detection of parasite eggs in stool – Provided with an operculum – Large – Unembryonated when laid  Resemble Fasciola eggs Prepared by FZHapan
  • 46. Intestinal Flukes: Treatment of Fasciolopsiasis  Praziquantel  25 mg/kg for 3 doses for one day  Side effects: – Diziness – Drowsiness – Epigastric pain Prepared by FZHapan
  • 47. Intestinal Flukes: Epidemiology of Fasciolopsiasis Prepared by FZHapan
  • 48. Intestinal Flukes: Epidemiology of Fasciolopsiasis  Endemic in – Southeast Asia – China – Korea – India  Endemicity in the Philippines has not been demonstrated yet  Fasciolopsiasis in Filipinos are probably imported cases Prepared by FZHapan
  • 49. Intestinal Flukes: Echinostoma ilocanum  Garrison’s fluke  Echinostomid  There are several species that infect man  There are 2 identified echinostomids that infect man in the Philippines: – Echinostoma ilocanum – Artyfechinostomum malayanum Prepared by FZHapan
  • 50. Intestinal Flukes: Echinostoma ilocanum  Adult – Reddish gray – Horse-shape collar of spines (circum oral disk) around the oral suckers – 49-51 collar spines – Integument is covered by plaque like scales – Simple intestinal caeca Prepared by FZHapan
  • 51. Echinostoma ilocanum showing circum-oral disk Prepared by FZHapan
  • 52. Intestinal Flukes: Echinostoma ilocanum Echinostoma ilocanum Life cycle Prepared by FZHapan
  • 53. Intestinal Flukes: Echinostoma ilocanum  Echinostoma ilocanum Ova – Straw-colored – Operculated – Ovoid – Similar to Fasciola and Fasciolopsis buski ova Prepared by FZHapan
  • 54. Intestinal Flukes: Echinostoma ilocanum  First Intermediate Host: – Gyraulus convexciusculus – Hippeutis umbilicalis Prepared by FZHapan
  • 55. Intestinal Flukes: Echinostoma ilocanum  Second Intermediate Host: – Pila luzonica (kuhol) – Vivipara angularis (susong pampang) Prepared by FZHapan Pila luzonica
  • 56. Intestinal Flukes: Pathogenesis and Clinical Manifestations Echinostoma ilocanum  Man gets infected when metacercariae in the second intermediate hosts are ingested  Inflammation at the site of attachment of adults  Ulceration  Diarrhea (sometimes bloody)  Abdominal pains  General intoxication Prepared by FZHapan
  • 57. Intestinal Flukes: Diagnosis Echinostoma ilocanum  Detection of characteristic eggs in the stool Prepared by FZHapan
  • 58. Intestinal Flukes Treatment Echinostoma ilocanum  Praziquantel – 25 mg/kg for 3 doses for one day – No alcohol; no fats must be taken 24 hours before and after treatment – Only water must be taken within 3 hours of medication Prepared by FZHapan
  • 59. Intestinal Flukes Epidemiology Echinostoma ilocanum  Echinostoma ilocanum is endemic in: – Northern Luzon – Leyte – Samar – Mindanao provinces  Artyfechinostomum malayanum – First reported in 1987 – Northern and Central Luzon Prepared by FZHapan
  • 60. Intestinal Flukes Heterophyids  Many species live in the intestine of fish-eating hosts: – Heterophys heterophyes – Metagonimus yokogawai – Haplorchis taichui – Haplorchis yokogawai Prepared by FZHapan
  • 61. Intestinal Flukes Heterophyids  Mode of transmission is by ingestion of metacercariae encysted in fish  Metacercariae in the abdomen excysts, liberating a larva that attaches to the intestinal wall Prepared by FZHapan
  • 62. Intestinal Flukes Heterophyids  Heterophyes heterophyes Adult – Elongated – Oval or pyriform – Measures less than 2 mm in length – Integument has fine scale-like spines – Some species have gonotyl or genital sucker Prepared by FZHapan
  • 63. Intestinal Flukes Heterophyids  Heterophyes heterophyes Ova – Light brown in color – Ovoid in shape – Operculated – A fully developed symmetrical miracidium is already present – Operculum fits into the egg smoothly – No abopercular protuberance like that of Clonochis sinensis ovum Prepared by FZHapan
  • 64. Intestinal Flukes Heterophyids Prepared by FZHapan
  • 65. Intestinal Flukes Heterophyes heterophyes Pathogenesis and Clinical Manifestations  Heterophyiasis  Inflammation at the site of attachment  Manifesations are consistent with peptic ulcer (observed among infected individuals in Compostela Valley) – Upper abdominal discomfort – Gurgling abdomen Prepared by FZHapan
  • 66. Intestinal Flukes Diagnosis Pathogenesis and Clinical Manifestations  Detection of eggs in the stool using Kato Katz method  Care must be taken to distinguish them from Clonorchis and Opistorchis ova Prepared by FZHapan
  • 67. Intestinal Flukes Treatment Pathogenesis and Clinical Manifestations  Praziquantel – 25 mg/kg in 3 doses for 1 day Prepared by FZHapan
  • 68. Intestinal Flukes Epidemiology Pathogenesis and Clinical Manifestations  Found in – Egypt – Greece – Israel – Western India – Central and South China – Japan – Korea – Taiwan – Philippines  Compostela Valley  Mindanao  Emerging public health concern Prepared by FZHapan
  • 69. Liver Flukes Prepared by FZHapan
  • 70. Liver Flukes Fasciola species  Found in the liver and biliary passages of humans and ruminants  Fasciola hepatica – Sheep liver fluke – Temperate liver fluke  Fasciola gigantica – Giant liver fluke – Tropical liver fluke Prepared by FZHapan
  • 71. Liver Flukes Fasciola species  Mode of transmission is by ingestion of metacercariae found in edible aquatic plants or by drinking water with floating metacercariae  Metacercariae excsts in the duodenum or jejunum and liberate the juvenile fluke  Juvenile fluke penetrates the intestinal wall and reaches the liver capsule  The parasite burrows into the liver parenchyma where it grows and develops  It becomes sexually mature in the bile ducts Prepared by FZHapan
  • 72. Liver Flukes Fasciola hepatica  Adult Worm – Large, broad, flat body – Anterior end forms a prominent cephalic cone – Small oral and ventral suckers – Long and highly branched intestinal caeca Prepared by FZHapan
  • 73. Liver Flukes Fasciola gigantica  Adult Worm – Larger – More lanceolate – Less developed shoulders (shorter cephalic cone) – Larger ventral sucker Prepared by FZHapan
  • 74. Liver Flukes Fasciola hepatica and gigantica  Adult Worm Prepared by FZHapan
  • 75. Liver Flukes Fasciola hepatica and gigantica  First Intermediate Host: – Lymnea philippinensis  Second Intermediate Host – Watercress – grass Prepared by FZHapan
  • 76. Liver Flukes Fasciola hepatica  Fasciola hepatica Ova – Large – Ovoid – Operculated – Bile stained – unsegmented Prepared by FZHapan
  • 77. Liver Flukes Fasciola hepatica  Fasciola gigantica Ova – Larger but very similar to Fasciola hepatica ova *Because of similarities, it is just safe to say Fasciola ova Prepared by FZHapan
  • 78. Liver Flukes Fasciola hepatica  Fasciola gigantica Ova – Larger but very similar to Fasciola hepatica ova *Because of similarities, it is just safe to say Fasciola ova Prepared by FZHapan
  • 79. Liver Flukes Fasciola species Prepared by FZHapan
  • 80. Liver Flukes Fasciola species Pathogenesis and Clinical Manifestations  Fascioliasis  Asymptomatic  Can produce fever  Right upper quadrant abdominal pain  Hypereosinophilia  Acute or invasive phase – Migration from intestine to liver – Traumatic and necrotic lesions in liver parenchyma  Chronic or latent phase – Asymptomatic – Parasite has reached the bile ducts – Obstruction – Stimulates inflammation in the biliary epithelium leading to fibrosis Prepared by FZHapan
  • 81. Liver Flukes Fasciola species Diagnosis  Microscopy  Serologic tests – Low specificity because of cross reactivity with antigens of other parasites  RFLP – PCR restriction Fragment Length Polymorphism Prepared by FZHapan
  • 82. Liver Flukes Fasciola species Treatment  Bithionol – 20-50 mg/kg body weight on alternate days to complete 10 to 5 doses  Triclabendazole – Also a recommended drug of choice due to:  Efficacy  Safety  Ease of use Prepared by FZHapan
  • 83. Liver Flukes Fasciola species Epidemiology  Worldwide distribution  Economic importance n livestock raising  In the Philippines, the dominant species is Fasciola gigantica affecting cattle and water buffalos  Few human cases are reported locally Prepared by FZHapan
  • 84. Liver Flukes Clonorchis sinensis  Chinese liver fluke  Oriental Liver Fluke  Distome of China  First intermediate Host: – Bulimus fuchsiana (snail not found in the Philippines)  Second Intermediate Host: – Ctenopharyngondon idellus (fish) Prepared by FZHapan
  • 85. Liver Flukes Clonorchis sinensis  Adult Worm – Narrow, oblong, flat worm – Oral sucker is slightly larger than the ventral sucker – Blind intestinal caeca are simple and extend to the caudal region – Life span is 20-30 years Prepared by FZHapan
  • 86. Liver Flukes Clonorchis sinensis  Ova – Bile stained – Flask-shaped – Operculated – Contains a miracidium when oviposited – Does not hatch in water but is ingested with a molluscan host – Has a terminal spine – Electric bulb in shape – Infective to snails only Prepared by FZHapan
  • 87. Liver Flukes Clonorchis sinensis Life Cycle Prepared by FZHapan
  • 88. Liver Flukes Clonorchis sinensis Pathogenesis and Clinical Manifestations  Clonorchiasis  Provokes intense proliferation of intestinal epithelium  Acute stage (less than 1 month of infection) – Chills – Fever  Chronic stage – Cirrhosis – Portal hypertension Prepared by FZHapan
  • 89. Liver Flukes Clonorchis sinensis Diagnosis  Detection of parasite egg in stool  Clonorchis, Opistorchis and Hetrophyid ova may not be differentiated under ordinary light microscope  ELISA with crude Clonorchis sinensis antigen  Enzyme immunoassay (EIA  Polymerase Chain Reactions Prepared by FZHapan
  • 90. Liver Flukes Clonorchis sinensis Treatment  Praziquantel – 25 mg/kg three times a day for two days – 60 mg/kg in three doses for one day – May be used together with albendazole for light and moderate infections Prepared by FZHapan
  • 91. Liver Flukes Clonorchis sinensis Epidemiology  Transmission is due to consumption of raw, undercooked fish and salted and dried fish harboring the metacercariae  Over 30 million people are infected in Southeastern Asia  No reported cases in children below 10 years old  Endemic in: – China – Japan – Korea – Vietnam Prepared by FZHapan
  • 92. Pancreatic Fluke Prepared by FZHapan
  • 93. Pancreatic Fluke Eurytrema pancreaticum  Pancreatic fluke  Stout worm with ruffled margins  oral sucker is larger than the ventral sucker Prepared by FZHapan
  • 94. Pancreatic Fluke Eurytrema pancreaticum  First Intermediate Host: – Macrochlamys indica (snail)  Second intermediate Host: – Technomyrmex deterquens (ant) Prepared by FZHapan
  • 95. Pancreatic Fluke Eurytrema pancreaticum  Ova – Operculated – Thick shelled – Dark brown in color – Embryonated when laid Prepared by FZHapan