Kuliah Parasitologi BMS blok VIII

Trematoda Hati dan Trematoda usus

Forman Erwin Siagian
Email: formanerwin@yahoo.com
Dept. Parasitologi FKUKI
Kamis, 26 juni 2014
Sehat /
sakit
lingkungan
Pelayanan
kesehatan
genetik
perilaku
5 tahap pemenuhan kesehatan
(Leavell dan Clark)
1
Promosi kesehatan
2
Proteksi spesifik
3
Diagnosis dini dan pengobatan
4
Pencegahan kecacatan
5
rehabilitasi
Taxonomy of food-borne
trematodes with emphasis on
species parasitizing humans that
are covered in the current review.
Keizer & Utzinger, 2009
Characteristics..
They are typically found in major viscera such as the bile
ducts, lungs, and gut.
The most important species parasitizing humans include liver
flukes (Clonorchis sinensis, Fasciola gigantica, Fasciola
hepatica, Opisthorchis felineus, and Opisthorchis viverrini),
lung flukes (Paragonimus spp.), and intestinal flukes (e.g.,
Echinostoma spp., Fasciolopsis buski, and the heterophyids).
This list is far from complete. For example, a total of 70
species (14 families and 36 genera) of intestinal flukes have
been reported to have been isolated from humans
map significant patterns and changes in hosts, habitat, morphology,
and distribution. Snail at base of the tree represents the family
Planorbidae, the other snail family is Lymnaeidae. Each illustrated
fluke indicates the intestinal caeca (scale bar: 10 mm).
Lotfy et al, 2008
Life cycles of five different food-borne
trematodes including intestinal flukes
(Echinostoma hortense, Fasciolopsis
buski, and Heterophyes
heterophyes), a liver fluke (Clonorchis
sinensis), and a lung fluke
(Paragonimus westermani)
Keizer & Utzinger, 2009
Scope of the problem:
Approximately 6,000 digenean species have been described, but only a
few are important human parasites. These include:






Infection of humans occurs through the consumption of
contaminated freshwater-fish, frogs, shellfish, snails, tadpoles,
snakes, water plants (e.g., watercress), and other aquatic products
eaten raw or insufficiently cooked .
Hence, fish-borne trematodiases and plant-borne trematodiases are
other common names referred to in text books and the peer-
reviewed literature.
Keiser & Utzinger, 2009

Food-borne
trematodes
Liver flukes
Intestinal flukes
Lung flukes
Scope of the problem:
The zoonotic nature of food-borne trematodiases transmission to
humans occurs via aquatic productsis an important factor
explaining the growing importance of these diseases
not only humans but also other mammals act as definitive hosts;
food-borne trematodiases are therefore an important public health
and veterinary problem.
Additionally, pet animals (e.g., cats and dogs) can act as definitive
hosts, which should be factored into future appraisals of the true
societal impact of food-borne trematodiases
Keiser & Utzinger, 2009
these diseases are among the most neglected of the so-
called neglected tropical diseases .
It should be noted that the neglected tropical diseases
are found predominantly in the worlds poorest
populations in low-income countries, and
where these diseases are common, they exacerbate
poverty.
Characteristics..
Adult
dorsoventral, flattened, bilaterally symmetrical body.
The average size of the flukes varies according to species.
The body surface of trematodes is covered by a syncytial epithelium,
the tegument.
The tegument is implicated in nutrient absorption, synthesis,
secretion, and osmoregulation and has sensory functions. Moreover,
the tegument protects the parasite from the immune system of the
host.
Further typical characteristics of trematodes are the presence of an
oral sucker ( used to attach to the inner surface of the hosts organ),
often a ventral sucker, and a lack of respiratory and circulatory
systems .
The reproductive system is always hermaphroditic
CLINICALLY SIGNIFICANT TISSUE AND INTESTINAL FLUKES
Geographic distribution
The transmission of food-borne trematodiases
is restricted to areas where the first and second
intermediate hosts coexist (which requires
suitable climatic and environmental
factors) and where humans have the habit of
eating raw, pickled, or undercooked fish and
other aquatic products.
These contextual determinants explain why the
distribution of foodborne trematodiases is
focal.
diagnosis
The three main approaches that are currently
available are:






parasitological detection in clinical samples, e.g
eggs in stool, sputum, or other biofluids (Direct)
Immunodiagnosis (Indirect)
Molecular biology
Complementary tools for the diagnosis of
the hepatobiliary (pathology of the bile duct)
caused by parasitic infections are
1. Ultrasound can detect biliary stones, dilatation,
and fibrosis due to liver fluke infections
2. computer tomography (CT) determinations of
the lumen diameter of bile ducts, fibrosis,
calcification, and epithelial hyperplasia
3. magnetic resonance imaging (MRI) as CT
does, and
4. tissue harmonic imaging observation of bile
duct wall trauma and stones
Age prevalence curves for Opisthorchis viverrini at three different locations in the Nam Theun 2
hydroelectric project area in central Lao PDR in the late 1990s.
Keizer & Utzinger, 2009
The global distribution of three major
species of liver flukes, i.e.C. sinensis,
O. viverrini and O. felineus. This map
focuses on the endemicity of C.
sinensis in China, the Republic ofthe
Republic of Korea and the northern
part of Vietnam.
Qian et al. Infectious Diseases of Poverty 2012 1:4
Scanning electron microscope
observations of the anterior part of an
untreated Fasciola hepatica depicting
the oral sucker (OS) and
ventral sucker (VS) (A), a Fasciola fluke
revealing blebbing (b) near the oral
sucker and ventral sucker after
administration of a single oral dose of
200 mg/kg artemether (B), the oral
sucker region of a Clonorchis sinensis
fluke with sensory papillae (SP) visible
(C), sloughing (s) seen on the
oral sucker of an artemether-treated C.
sinensis fluke (D),
oral sucker region of an Opisthorchis
viverrini fluke with sensorypapillae (E),
blebbing and closure of oral sucker
observed on an O. viverrini fluke
treated with a single oral dose of 400
mg/kg tribendimidine (F).

Keizer & Utzinger, 2009


Opisthorchis viverrini is an important food-borne trematode in
Southeast Asia. The infection causes significant morbidity in terms of
hepatobiliary diseases and cholangiocarcinoma.
Humans become infected with O. viverrini through the consumption
of raw or undercooked cyprinoid fish containing metacercariae .
Hence, parasite control should, in part, reduce the risk of morbidity
and cancer development
To date, standard diagnoses of O. viverrini by parasitological
methods are increasingly unreliable because of low sensitivity in
people with light infections and difficulties in discriminating a
mixed infection with intestinal trematodes
Duenggai et al, 2008

Pathogenesis of Liver Fluke-Induced Cholangiocarcinoma (CCA)-
caused by Mechanical injury and fluke metabolic products.
Mechanical injury from the activities of feeding and migrating flukes
contributes to biliary damage in the human host.
Both oral and ventral suckers of the fluke hook onto the biliary
epithelium, resulting in tissue damage even early in infection.
As the parasite matures, the lesion becomes more pronounced and
ulcerates. Fluke eggs become entrapped in the periductal tissue
through the ulcer and induce granulomatous inflammation around
the eggs.
The granulomata are readily visualized in experimental hamster
infections and occasionally in human cases with bile duct
obstruction.
Sripa, et al. 2007
experimental and epidemiologic evidence strongly implicates
liver fluke infection in the aetiology of one of the liver cancer
subtypescholangiocarcinoma (CCA),
or cancer of the bile ducts
Sripa, et al. 2007
Liver fluke infection caused by Opisthorchis viverrini, O. felineus, and
Clonorchis sinensis is a major public health problem in East Asia and
Eastern Europe. Currently, more than 600 million people are at risk of
infection with these trematodes.
O. viverrini is endemic in Southeast Asian countries, including Thailand,
Lao Peoples Democratic Republic, Vietnam, and Cambodia, and C.
sinensis infection is common in rural areas of Korea and China.
Opisthorchiasis has been extensively studied in Thailand, where an
estimated 6 million people are infected with the liver fluke (calculated
from overall 9.4% prevalence within the population in 2001).
Infection with these food-borne parasites is prevalent in areas where
uncooked cyprinoid fish are a staple of the diet.
Due to poor sanitation practices and inadequate sewerage
infrastructure, people infected with O. viverrini and C. sinensis pass
parasite eggs in their faeces into natural water reservoirs, where the
parasite eggs are eaten by intermediate host snails, for example, aquatic
snails of the genus Bithynia,the first intermediate host of O. viverrini
Sripa et al, 2007
A piped water supply with pumps, pit-wells
and taps helps people to stay away from
water that is infected
Fasciola hepatica caused Fascioliasis, a well-known parasitic
disease because of its veterinary importance and the great
losses it causes in livestock production.
However, human fascioliasis was only considered a secondary
disease by public health officials, with only approximately 2,000
cases reported between 1970 and 1990.
Esteban, 2003

Whereas some fasciolids have retained circumscribed geographic
distributions, others such as F. hepatica have become
cosmopolitan.
The spread of this species is in part caused by its adaptability
to different lymnaeid snail hosts and to introduction of
infected livestock or of susceptible snail hosts into new areas.

Lotfy, 2008
Clinical Infectious Diseases 2001; 33:16
Travel related
disease
Immunologically
nave person
Clinical presentation
depend on the stage
of parasitic life cycle
Potential delay in
making diagnoses
(doctor not familiar
with symptom)
Efficacy of treatment
monitored by
improvement of
clinical sign
Preparation of a Meal of Koi-Pla Using Uncooked Cyprinoid Fishes (A) Fluke-infected fi sh are
plentiful in the local rivers such as the Chi River in Khon Kaen province, Thailand. (B) Local
people catch the fish in nets and prepare the fish-based meals with local herbs, spices, and
condiments. (C) The fi nished dish of koi-pla accompanied by rice and vegetables. This dish is a
dietary staple of many northeastern Thai villagers and is a common source of infection with O.
viverrini
PLoS Med 2007; 4(7): e201
Perilaku/gaya
hidup (pola
makan, jenis
makanan)
chronic
Vulnerable
DNA
Endemic
region
Poor
hygiene
practice
Proposed Mechanisms of
Opisthorchis-Derived CCA Initiation
The three proposed pathways
linking the parasite to CCA
initiation are mechanical damage
(in yellow), molecular products (in
blue), and immunopathology (in
green). Combined, these
mechanisms result in several
common elements (purple) that all
lead to DNA damage.
The inhibition of a normal DNA
damage response is the final
oncogenic factor proposed to
dramatically increase the likelihood
of a malignant transformation. This
invariably leads to progression of
CCA
Sripa et al, 2007
Sensitif
&
spesifik
mahal
Bahan
klinis
mudah
Tidak bisa
dilakukan
sembarangan
Potensi
untuk
pmrx
massal
Metode rumit
Hyperendemic region (remote area)
Co-infection
Coprologic study
Parkin, 2006
Parkin, 2006
EPIDEMIOLOGICAL PATTERNS
While contamination of human-made freshwater environments
(inland fish ponds) with food-borne trematode metacercariae is
quite common, human infections occur mainly in areas
characterized by traditional food dishes in specific high-risk
ethnic groups.
Raw, pickled, or undercooked fish and other aquatic products
are prepared in various ways. Such dishes might have been
rooted in traditions for hundreds of years and hence have high
cultural, ethnic, and nutritional significance, making it
exceedingly difficult to change food habits .
Examples of typical traditional preparations include raw crab
meat spiced with soy sauce (ke-jang) in the Republic of Korea,
raw grass carp dishes in China, and fresh uncooked small- or
medium-sized fish, moderately or extensively fermented (lab
pla, koi pla, pla som, and pla ra), in Thailand and in the Lao PDR
PREVENTION, TREATMENT, AND CONTROL
Public health interventions to prevent infections with
foodborne trematodes and to reduce the prevalence and
intensity of infections, and, hence, morbidity and
mortality, include chemotherapy, improved access to
adequate sanitation, and the use of chemical fertilizers,
food inspections, and information, education, and
communication (IEC) campaigns.
The ultimate aim is to change human behavior, because
the consumption of raw or undercooked freshwater fish and other aquatic
products is the key risk factor for acquiring a food-borne trematode infection
Sekian dan terimakasih...
referensi
1. Keiser J, Utzinger J. Food-Borne Trematodiases. Clin. Microbiol. Rev. 2009, 22(3):466.
2. Lotfy WM et al. Evolutionary Origins, Diversification, and Biogeography of Liver Flukes
(Digenea, Fasciolidae). Am. J. Trop. Med. Hyg. 2008; 79(2): 24855
3. Graham CS et al. Imported Fasciola hepatica Infection in the United States and
Treatment with Triclabendazole. Clin Infect Dis 2001; 33:16
4. Sripa B, Kaewkes S, Sithithaworn P, Mairiang E, Laha T, et al. Liver fluke induces
cholangiocarcinoma. PLoS Med 2007; 4(7): e201
5. Duenggai K et al. Improvement of PCR for Detection of Opisthorchis viverrini DNA in
Human Stool samples. J. Clin. Microbiol. 2008, 46(1):366
6. Esteban JG et al. Hyperendemic Fascioliasis Associated With Schistosomiasis In
Villages In The Nile Delta Of Egypt. Am. J. Trop. Med. Hyg. 2003; 69(4): 42937
7. Parkin DM. The global health burden of infection-associated cancers in the year 2002.
Int. J. Cancer 2006; 118: 303044
8. Qian MB, Chen YD, Liang S, Yang GJ, Zhou XN. The global epidemiology of
clonorchiasis and its relation with cholangiocarcinoma. infectious Diseases of Poverty
2012, 1:4
9. Buku ajar Parasitologi Kedokteran FKUI. Edisi ke empat, 2011. Hal 51-9
10. Markel, Voge John. Medical parasitology. WB Saunders, 7
th
ed. 1992. pp 183-223