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Parasitology-Lec 7 Lung Flukes

Parasitology-Lec 7 Lung Flukes

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PARASITOLOGY LECTURE 7 \u2013 Flukes (Lungs and Intestines)
Notes from Belizario,V.Y, Malte,B.I., Tiu,W.U.
USTMED \u201907 Sec C \u2013 AsM

PARAGONIMUS WESTERMANI (Oriental Lung Fluke)
\u2022
main species that causes human paragonimiasis in the
Philippines (P.philippinenesis andP.sia mensis [cats] also
cause this disease)
\u2022

patients often complain of cough and hemoptysis, clinical manifestation consistent with pulmonary tuberculosis (PTB); patients with this parasitic infection are often misdiagnosed with PTB

DISEASE
\u2022

Paragonimiasis (lung fluke disease, or pulmonary distomiasis or endemic hemoptysis or parasitic hemoptysis)

MORPHOLOGY
1. Adult
-
Color: reddish brown
-
Dimensions: 7-12mm x
4-6mm
x
3.5-5mm
(lwt)
-
Shape: resembles coffee bean; round anteriorly,
tapers posteriorly
-
Integument: covered with single spaced spines
-
Reproductive organs:
o

2 lobed testes opposite each other midway between ventral sucker and posterior border

o
ovary anterior to testes and posterior to
ventral sucker; w/ six unbranched lobes
-
other: vitellaria extensively branched
2. Cercaria
-
covered with spines
-
has ellipsoidal body and a small tail
-
stylet present at dorsal side of oral sucker
3. Metacercaria
-
round
-
measures 381-457 um.
4. Egg
-
Color: yellowish-brown
-
Shell: thick
-
Shape: oval
-
Operculum: flattened but prominent operculum
-
Aboperculum: thickened
-
Unembryonated at oviposition
-
Dimensions: 80-118um x 48-60 um
LIFE CYCLE
\u2022
Adult worms
-
Found in pairs or in threes in fibrotic capsules or
cysts in lungs of the host
-

Capsules have openings that allow eggs to escape into the respiratory tract where they are moved up and out by ciliary epithelium along with lung exudates

-

In the pharynx, are either coughed out or swallowed into the alimentary canal and passed out with feces

\u2022
Eggs
-
immature egg embryonates in water, moist soil or
leached feces
\u2022
Miracidium
-
develops from eggs w/in 2 to 7 weeks
-
it pushes the operculum and swims in search of an
appropriate snail host
-
1st intermediate host: Antemelania asperata and
Antemelania dactylus
\u2022
Sporocyst and Redia
-
inside the snail the miracidium passes through one
sporocyst and 2 redial stages
\u2022
Cercaria
-
cercariae emerge from the snail to seek a 2nd
intermediate host
-
2nd
intermediate
host:
mountain
crab
(Sundathelphusa philippina)
\u2022
Metacercaria
-

The cercaria penetrates the soft parts of the crustacean and encysts as a metacercaria in the gills, body muscles and viscera or legs

-
crab may also be infected by eating infected snails
-
Infective stage: metacercaria
-
Definitive host: Man
\u2022
Adolescent worm
-
following ingestion, the metacercaria excysts in the
duodenum
-

it traverses the intestinal wall, into the peritoneal cavity where it wanders and embeds itself in the abdominal wall for several days

-

parasite returns to the coelom, migrates throught the diaphragm to the pleural cavity where it penetrates the lungs and develops into adulthood

\u2022
completion of development in the definitive host is 65
to 90 days
\u2022
worms persist for as long as 20 years
\u2022
Reservoir hosts: dogs, cats, field rats, rodents
PATHOGENESIS AND CLINICAL MANIFESTATIONS
\u2022

in the lungs, worms provoke a granulomatous reaction that proceeds to the development of fibrotic encapsulation

\u2022
within the cyst is a blood-tinged purulent material
containing eggs
\u2022
early stages of infection are asymptomatic
\u2022

in heavy infections, patient may suffer from dry cough and later produce bloodstained or rust-colored sputum with foul fish odor (pronounced in the morning)

\u2022
Symptoms: chest pains, dyspnea, hemoptysis, low-grade
fever, fatigue, myalgia
\u2022
often misdiagnosed for PTB
\u2022
symptoms less severe after five to six years
\u2022
complications:
-

lodge in abdominal wall, abdominal cavity, mesenteric lymph nodes, omentum, pericardium, myocardium and intestinal wall causing erratic paragonimiasis

-
cerebral involvement most serious and may cause:
o
Jacksonian epilepsy
o
Cerebral hemorrhage
o
Edema
o
Visual disturbances
o
Meningitis
\u2022
prognosis with light infection is good and chemotherapy
has a high cure rate
DIAGNOSIS
\u2022

based on detection of characteristic eggs in sputum, stool, or less frequently, aspirated material from abscesses or pleural effusions

\u2022
serology helpful; standard test is complement fixation
(CF) \u2013 has advantage to detect rapid decline in antibody
levels
\u2022
EIA and Immunoblot (IB)
TREATMENT
\u2022
*Praziquantel; higher doses required in ectopic
paragonimiasis
\u2022
Bithionol (alternative)
\u2022
Triclabendazole also effective
EPIDEMIOLOGY
\u2022
global distribution in freshwater crabs
\u2022
major endemic areas: Asia (Japan, South Korea,
Thailand, Taiwan, China and Phil.)
PREVENTION AND CONTROL
\u2022
Proper food preparation; the usual\u2026.
FASCIOLOPSIS BUSKI (intestines)
\u2022
a digenetic trematode that parasitizes intestines of
humans and pigs
\u2022

mode of transmission is by ingestion of encysted metacercariae on aquatic plants or when the hull or skin of the fruits of these plants is peeled off between the teeth (?)

DISEASE
\u2022
Fasciolopsiasis
MORPHOLOGY
1. Adult
-
Dimensions: 20-75mm x 8-20mm
(lw)
-
Shape: elongated, oval
-
Reproductive organs:
o
2 testes are dendritic and
arranged in tandem in the
posterior half
o
branched ovary lies to the
right of the midline
-
other:
o
vitellaria (fine)
o
does not have a cephalic cone
and
intestinal
ceca

are unbranched and reach up to posterior

end
(as
compared toF.hepatica
andF.gigantica)
2. Egg
-
Indistinguishable from eggs of
F.hepaticaand F.gigantica
-
Large and operculated
-
Unembryonated at oviposition
-
Dimensions: 130-140um x 80-85um
LIFE CYCLE
\u2022
Adult
-
lives in the duodenum, attached to the intestinal
mucosa by its suckers
\u2022
Egg
-
immature eggs are released together with feces
into the water
-
embryonates in the water and gives rise to
miracidium in three to seven weeks
\u2022
Miracidium
-
seeks out 1st intermediate host
-
1st intermediate host: snail (genusSegmentina or
Hippeutis)
\u2022
Sporocyst and Redia
-

miracidium transforms into sporocyst, which subsequently produces mother rediae, daughter redia and finally cercaria

\u2022
Cercaria
-
leave daughter redia and undergo development in
the snail tissues
-
cercaria emerge 7 weeks after initial infection
-
attach themselves on surfaces of seed pods, bulbs,
stems or roots of various aquatic plants
-
2nd
intermediate host: water caltrop (Trapa
bicornisI), water chestnut (Eliocharis tuberose),
water morning glory (Ipomea obscura), and lotus
(Nymphaea lotus)
\u2022
Metacercaria
-
encyst on the surface of water plants
-

excysts in the duodenum and attaches to the intestinal wall where it becomes sexually mature in 3 months

-
Infective stage: metacercaria
-
Definitive host: Pigs and humans
PATHOGENESIS AND CLINICAL MANIFESTION
\u2022
in heavy infections, worms may be found throughout the
intestinal tract and cause obstruction
\u2022
pathological changes caused by worms are traumatic,
obstructive and toxic
\u2022

inflammation and ulceration occur at site of worm attachement, produces an increase in mucus secretion and minimal bleeding

\u2022
gland abscesses are occasionally formed
\u2022
intoxication results from absorption of worm
metabolites by host
\u2022

patient experiences generalized toxic and allergic symptoms such as edema of face, abdominal wall and lower limbs

\u2022
profound intoxication can cause death
DIAGNOSIS
\u2022
detection of parasite eggs in stool
TREATMENT
\u2022
Praziquantel
EPIDEMIOLOGY
\u2022
endemic in countries of SEA, China, Korea and India
\u2022
not endemic in the Philippines (yet)
PREVENTION AND CONTROL
\u2022
metacercaria are very sensitive to dryness, soaking of
aquatic plants in water should be avoided(eh? \u2026so hindi na
siya aquatic\u2026\ue000)
\u2022
time between harvest and consumption could also be
prolonged to prevent infection
\u2022
washing of plants to remove metacercaria or boiling
them can also prevent infection
HETEROPHYID FLUKES (intestines)
\u2022
heterophyids live in the intestines of fish-eating hosts
\u2022
major
species
are
Heterophyes heterophyes,
Metagonimus yokogawai, Haplorchis taichuiand
Haplorchis yokogawai
DISEASE
\u2022
mode of transmission is via ingestion of metacercariae
encysted in fish
\u2022
intestinal heterophyidiasis
MORPHOLOGY
1. Adult
-
Shape: elongated, oval or pyriform
-
Dimensions: 2mm in length
-
Integument: fine, scale-like spines
-

Some species have gonotyl or a genital sucker that is located near the left posterior border of the ventral sucker

-
Reproductive organs:
o
testes \u2013 variously arranged; in the posterior
part of body
o
ovary \u2013 globular or slightly lobed; located
submedian, pre- or post-testicular
Metagonimus yokogawaia d ult
Heterophyes heterophyesa d ult
2. Miracidium
-

fully developed, symmetrical miracidium is already present w/in the egg when it is deposited by the adult worm

3. Egg
-
color: light brown
-
shape: ovoid
-
operculated; operculum fits into eggshell smoothly
-
does not have abopercular protuberance
-
dimensions: 20-30 um x 15-17 um
Metagoniums yokogawaiegg Heterophyes heterophyesegg
LIFE CYCLE
life cycle of eterophyes heterophyes
\u2022
Adult
-
larva develops into a sexually mature adult that has
a typically short life span of less than one year
-
adult worm inhabits the small intestines of the
definitive host
\u2022
Eggs
-
large numbers of eggs are produced and passed out
with the feces
-
eggs are ingested by 1st intermediate host
-
1st intermediate host: snails (freshwater, brackish
water or marine)
\u2022
Miracidium
-
hatches from the egg inside the snail
-
transforms into a sporocyst
\u2022
Sporocyst and Redia
-
sporocyst develops into one or two generations of
redia that give rise to cercaria
\u2022
Cercaria
-

liberated form the snail and encyst as metacercaria on or under the scales in the muscles, fins, tails or gills of fish

\u2022
Metacercaria
-
often found in the muscles at the base of the fin
-
reaches duodenum and excysts liberating a young
larva that attaches to intestinal wall
-
2nd intermediate hosts: In the Philippines there are
30 species of fish harboring metacercaria
life cycle of Metagonimus yokogawai
PATHOGENESIS AND CLINICAL MANIFESTATION
\u2022
inflammation at the sites where the worm is attached to
or burrowed in the mucosa
\u2022
excessive mucus production and sloughing off of the
superficial layers may occur
\u2022
most common manifestions were consistent with peptic
ulcer disease (PUD) or acid peptic disease (APD)
\u2022
symptoms:
-
upper abdominal discomfort/pain
-
gurgling abdomen
-
colicky abdominal pain
-
mucoid diarrhea
\u2022
In Africa, worms were shown to burrow deep into the
intestinal walls and eventually die
o

Eggs of degenerating worms may be filtered through the intestinal lymphatics and blood vessels and deposited in various tissues

o

Eggs and adults of heterophyids have been observed in the heart and brain of Filipino patients who died of heart failure and intracerebral hemorrhage

o
Eggs can be lodged in the spinal cord and may
result in sensory and motor losses
DIAGNOSIS
\u2022

it is important to consider intestinal fluke infection when dealing with bowel disturbance and a history of consumption of raw fish in cases with same presentation as APD

\u2022
definitive diagnosis: detection of eggs in stool using the
Kato-Katz method
\u2022
hard to distinguish between eggs of heterophyid species
TREATMENT
\u2022
Praziquantel
EPIDEMIOLOGY
\u2022
Egypt, Greece, Israel, western India, Central and South
China, Japan, Korea, Taiwan and the Philippines
\u2022
worldwide distribution due to the fact that they have
adapted to snails belonging to various families and are
not very specific with respect to 2nd intermediate hosts
\u2022
both intermediate hosts may be found in different

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