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S4 L5 SCHISTOSOMA

S4 L5 SCHISTOSOMA

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Published by 2013SecB
Nina Ian John “G” Rachel Mark I Jocelle Edo Gienah Jho Kath Aynz Je Glad Nickay Ricobear Teacher Dadang Niňa Arlene Vivs Paulfie Rico Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung Tope Ag Bien

S4 L5: Schistosoma (Blood Flukes) by Dr. Mary Antonette Madrid
Bulinus sp. SCHISTOSOMIASIS Caused by digenetic blood trematodes. The three main species infecting humans are 1. Schistosoma haematobium ( bilharzia worm) 2. Schistosoma japonicum (Japanese blood fluke) 3. Schistosoma mansoni. (Manson’s blood
Nina Ian John “G” Rachel Mark I Jocelle Edo Gienah Jho Kath Aynz Je Glad Nickay Ricobear Teacher Dadang Niňa Arlene Vivs Paulfie Rico Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung Tope Ag Bien

S4 L5: Schistosoma (Blood Flukes) by Dr. Mary Antonette Madrid
Bulinus sp. SCHISTOSOMIASIS Caused by digenetic blood trematodes. The three main species infecting humans are 1. Schistosoma haematobium ( bilharzia worm) 2. Schistosoma japonicum (Japanese blood fluke) 3. Schistosoma mansoni. (Manson’s blood

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Published by: 2013SecB on Feb 08, 2011
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06/06/2013

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S4 L5:
Schistosoma
(Blood Flukes)
by Dr. Mary Antonette Madrid 
JJJaaannnuuuaaarrryyy222666,,,222000111111 
SCHISTOSOMIASIS
Caused by digenetic blood trematodes.The
three main species infecting humans
are1.
 
Schistosoma haematobium
( bilharzia worm)2.
 
Schistosoma japonicum
(Japanese blood fluke)3.
 
Schistosoma mansoni.
(M
anson’s blood fluke)
 Two other species, more localized geographically, are
S. mekongi 
and
S. intercalatum.
In addition, other species of schistosomes, which parasitize birds andmammals, can cause cercarial dermatitis in humans.
Schistosoma japonicum
 
Oriental blood flukeEndemic in China
, Philippines
, Sulawesi and IndonesiaIn the Phil., the first report of schistosomiasis was made by Woolley in1906Strains from different geographic areas are distinct although ALLrequire
Onchomelania
 
snails as intermediate host
Wide range of host 
o
 
Dogs, pigs, cats, carabaos, cows, rodent, monkeys
 –
 found to be naturally infectedSome hosts such as humans, monkey, rabbits, and mice areconsidered permissive hosts (
S. japonicum
matures and oviposits over extended periods) Adult and female worms are primarily parasites of the portal vein andits branchesFemales: lay up to 200 immature eggs in the branches of the portalvein which require 10-12 days to matureEggs escape through ulcerations into the intestinal lumen
exportedto fecesEmbryonated egg comes in contact with water 
hatches
liberatesmiracidiumMiracidia infect snail (intermediate host:
Oncomelania hupensisquadrasi 
 )
, and develop into sporocystsSporocysts develop into cercariaeCercariae leave snail host and infect definitive hosts who come incontact with water by skin penetration60-70 days from miracidial infection of the snail host to formation of cercariaeCercariae are transformed into schistosomula after skin penetrationand find entry to the superficial lymphatic vessels or subcutanesousveins to reach the lungsFrom pulmonary circulation, schistosomulae migrates to the portal veinwhere they mature.Egg deposition begins from the 24
th
to the 27
th
day after cercarialpenetration
Intermediate hostsOncomelania sp.Bulinus sp. Biomphalaria sp.
-
 
Eggs are eliminated with feces or urine; eggs hatch and release miracidia,which swim and penetrate specific snail intermedicate hosts.-
 
Stages in the snail include 2 generations of sporocysts and the production of cercariae.-
 
Upon release from the snail, the infective cercariae swim, penetrate the skinof the human host and shed their forked tail, becoming schistosomulae.-
 
Schistosomulae migrate through several tissues and stages to their targetresidence in the veins.-
 
 Adult worms in the human reside in the mesenteric venules in variouslocations; females deposit eggs in the small venule of the portal andperivesical systems and are moved progressively toward the lumen of thesmall intestine (
S. mansoni & S. japonicum
) and of the bladder and ureters(
S. haematobium
) and are eliminated with feces or urine, respectively.
ADULT SCHISTOSOMES
 Adult worms in humans reside in the mesenteric venules in variouslocations, which at times seem to be specific for each species.
S. japonicum
is more frequently found in the
superior mesenteric veinsdraining the small intestine
 
S. mansoni 
occurs more often in the
superior mesenteric veinsdraining the large intestine
However, both species can occupy either location, and they are capableof moving between sites
S. haematobium
most often occurs in the
venous plexus of 
 
bladder 
, butit can also be found in the
rectal venules
.Have separate sexes unlike other trematodesWith large sucker capping the anterior end, a ventral sucker and agonophore located posterior to the ventral sucker Suckers aid in movement; enables flukes to maintain position inside theveinsIncomplete digestive systems; excretory system made up of flame cells.These internal structures are surrounded by circular and longitudinalmuscles
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Male
: shorter, sturdier; measures 12-20mm in length by 0.4 to 0.5mmdiameter 
o
 
Has a gynecophoral canal where the longer femaleis held
o
 
Testes arranged in one row above the ventralsucker 
Female:
15 -26 mm by 0.3mm
o
 
Single pyramidal ovary located in the midlineWorms ingest RBC and possess a protease that breaks down globulinand hemoglobinUtilize glucose and are presumed to absorb nutrients through the bodywall
GEOGRAPHIC DISTRIBUTION
S. mansoni 
is found in parts of South America and the Caribbean, Africa,and the Middle East;
S. haematobium
in Africa and the Middle East
S. japonicum
in the Far East.
S. mekongi 
and
S. intercalatum
are found focally in Southeast Asia andcentral West Africa, respectively.In the
Philippines
, there are
24 endemic provinces
 
o
 
Includes Sorsogon, Oriental Mindoro, Samar, Leyte, Bohol and allprovinces in Mindanao island except Misamis Oriental
o
 
Highest prevalence of infection is in
children 5-15 years
of age
PATHOLOGY OF SCHISTOSOMES
S. mansoni 
and
S. japonicum
schistosomiasis
 
includes
:
Katayama fever, hepatic perisinusoidal egg granulomas, Symmers’ pipe
stem periportal fibrosis, portal hypertension, and occasional embolic egggranulomas in brain or spinal cord.
S. haematobium
schistosomiasis includes:
hematuria, scarring, calcification, squamous cell carcinoma, andoccasional embolic egg granulomas in brain or spinal cord
S. japonicum
schistosomiasis includes:
 
Main pathology: due to host granulomatous reaction to eggs deposited inthe liver and other organsQuantity of cercariae determine severity of infectionCercarial penetration may result indermatitis (
cercarial dermatitis
)Schistosomular migration causessuperficial lung petechiae andpneumonitis After egg deposition, there is a granulomatous hypersensitivity reactionaround itMost serious consequence of granuloma formation in liver is obstructionof the intrahepatic portal branches
portal hypertension, splenomegaly,ascites
CLINICAL ASPECTS
S. japonicum
 Course of infection divided into 3 progressive stages1.
 
incubation: corresponds to period from
cercarial penetration
and
schistosomular migration
to maturation
2.
 
period of 
early egg deposition
and
extrusion
3.
 
period of 
tissue proliferation
 
Early schistosomiasis
Itching, chills, fever, cough
Colonic schistosomiasis
Ulceration caused by eggs result in dysentery or diarrheaChronic stage: usually asymptomatic but occasional bouts of diarrheamay occur Occasionally chronic colonic schistosomiasis is associated withmalignancies
Hepatosplenic disease
Hepatosplenomegaly, ascites, collateral circulation
Pulmonary schistosomiasis
 Principal manifestation is cor pulmonale from obstruction of lungvasculature due to granuloma formation and fibrosis
Cerebral schistosomiasis
 Acute stages present with fulminating meningoencephalitis with fever,headache, confusion, lethargy and comaChronic cases: gives a clinical picture of a tumor with localizing signs andinc. intracranial pressure Among Filipinos, cerebral schistosomiasis is associated with pathology inother organs (liver and intestines)
CLINICAL FEATURES
Many infections are asymptomatic. Acute schistosomiasis (Katayama's fever) may occur weeks after theinitial infection, especially by
S. mansoni 
and
S. japonicum
.Manifestations: fever, cough, abdominal pain, diarrhea,hepatospenomegaly, and eosinophilia.Occasionall, central nervous system lesions occur.Continuing infection may cause granulomatous reactions and fibrosis inthe affected organs, which may result in manifestations that include:
o
 
colonic polyposis with bloody diarrhea (
Schistosoma mansoni 
 mostly)
o
 
portal hypertension with hematemesis and splenomegaly (
S.mansoni 
,
S. japonicum
,
S. mansoni 
)
o
 
cystitis and ureteritis (
S. haematobium
) with hematuria, which canprogress to bladder cancer 
o
 
pulmonary hypertension (
S. mansoni 
,
S. japonicum
, more rarely
S.haematobium
)
o
 
glomerulonephritis
o
 
central nervous system lesions.
The abdomen of an 11-year-old boy with intestinal schistosomiasis with the size andextent of the liver and spleen marked. Both are well below the midline, indicating the
 
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3
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severity of infection. The disease has caused a stunting of the boy's growth, he is only120cms tall and weighs 22 kg. WHO/TDR/Crump(Left) A 13-year-old boy with schistosomiasis, hepatosplenomegaly, ascites,muscle atrophy, pyrexia, anaemia and haemorrhage from the gastrointestinal tract.(Right) Two boys, victims of schistosomiasis showing typical distension of theabdomen.
LABORATORY DIAGNOSIS
Microscopic identification of eggs in stool or urine: most practical methodfor diagnosis
Stool
examination:
S. mansoni 
or 
S. japonicum
infection
urine
examination:
S. haematobium
Eggs can be present in the stool in infections with all
Schistosoma
 species.The examination can be performed on a simple smear (1 to 2 mg of fecalmaterial).Enhance detection of eggs by repeated examinations and/or concentration procedures (such as the formalin - ethyl acetate technique)field surveys and investigational purposes: quantify egg output by usingthe
Kato-Katz technique
(20 to 50 mg of fecal material) or the
Ritchietechnique
.Eggs can be found in the urine in infections with
S. haematobium
 (recommended time for collection: between noon and 3 PM) and with
S. japonicum
.Detection will be enhanced by centrifugation and examination of thesediment.Quantification is by using filtration through a Nucleopore® membrane of astandard volume of urine followed by egg counts on the membrane.
Tissue biopsy
(rectal biopsy for all species and biopsy of the bladder for 
S. haematobium
) may demonstrate eggs when stool or urineexaminations are negative.
DIAGNOSIS
S. japonicum
Immunodiagnosis
1.
 
intradermal test for immediate cutaneous hypersensitivity using adultworm extracts2.
 
indirect hemmagglutination using adult worm and egg antigens3.
 
circumoval precipitin test (COPT)4.
 
ELISA using soluble antigens of adults and eggsOnly COPT, ELISA and indirect hemagglutination using egg antigensshould be used because these are more specific
COPT
Demonstrates formation of bleb or septate precipitates attached to one or 
more points on the egg surface after incubation of the eggs in a patients’
serumCurrently regarded as the method of choice for the definitive diagnosis of schistosomiasis in the PhilippinesCOPT may take more than 2 years to become neg.
LABORATORY DIAGNOSISANTIBODY DETECTION
Can be useful in both in clinical management (e.g., recent infections) andfor epidemiologic surveysCan be useful to indicate schistosome infection:1.
 
Patients who have traveled in schistosomiasis endemic areas2.
 
Patients in whom eggs cannot be demonstrated in fecal or urinespecimensTest sensitivity and specificity vary widely among the many tests reportedfor the serologic diagnosis of schistosomiasis and are dependent on boththe type of antigen preparations used (crude, purified, adult worm, egg,cercarial) and the test procedure. At CDC, a combination of tests with purified adult worm antigens is usedfor antibody detection. All serum specimens are initially tested by FAST-ELISA using
Schistosoma mansoni 
adult microsomal antigen (MAMA). A positive reaction (greater than 8 units/µl serum) indicates infection with
Schistosoma
species.
o
 
Sensitivity for 
S. mansoni 
infection:
99%
 
o
 
Sensitivity for 
S. haematobium
infection:
95%
 
o
 
Sensitivity for 
S. japonicum
infection:
<50%
 
o
 
specificity for detecting schistosome infection:
99%
 Because test sensitivity with the MAMA is reduced for species other than
S. mansoni 
, immunoblots of the species appropriate to the patient's travelhistory are also tested to ensure detection of 
S. haematobium
and
S. japonicum
infections.
o
 
Immunoblots with adult worm microsomal antigens are species-specific; a positive reaction indicates the infecting species.
o
 
presence of antibody is indicative only of 
Schistosoma
infection atsome time and cannot be correlated with clinical status, wormburden, egg production, or prognosis.
DIAGNOSTIC FINDINGSMICROSCOPY
S. mansoni 
eggs
These eggs are largeLength: 114 to 180 µmHave a characteristic shape, with a prominent
lateral spine
near theposterior end.The anterior end is tapered and slightly curved.When the eggs are excreted, they contain a mature miracidium (visibleespecially in the first picture).

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