INTESTINAL FLUKES

Fasciolopsis buski

COMMON NAME

DISEASE

GEOGRAPHICAL DISTRIBUTION
Asia and the Indian subcontinent, especially in areas where humans raise pigs and consume freshwater plants

HABITAT 1st INTERMEDIATE HOST

2nd INTERMEDIATE HOST

Trapa natans, Eliocaris tuberosa (____________)

Fasciolopsis buski

MORPHOLOGY
Adult
Large fleshy or broadly ovate or more often appears as elongately ovoidal, measuring from 20-75 mm Integument is spinose, there is no cephalic cone Oral sucker is about 0.5 mm, and the ventral sucker is 2-3mm Intestinal ceca is unbranched and has characteristic identifications Has a pair of highly dendritic testes which are found one after the other in the posterior half of the fluke Branched ovary lies to the right of the midline and opposite it is the coiled uterus

Ova
Almost identical with the ova of F. hepatica Measure from 130-150u x 80-85 u __________________________________when laid Yolk granules are evenly distributed throughout the egg (In F. hepatica there is___________________________)

Fasciolopsis buski

EPIDEMIOLOGY
Infection in man is through ingestion of infected raw water vegetations

PATHOGENESIS Fasciolopsiasis
Weight loss Anemia Diarrhea Toxic product of this parasite produces the so-called _________________________

Larval stage of F. buski upon escaping from their cysts in the duodenum mature into adult stage within a period of____________ Damaged produced is traumatic, obstructive, and toxic. Adult flukes may obstruct food passages, but what is more important is the sensitization and toxic effects which may result following absorption of the worms metabolite into the system

Fasciolopsis buski

DIAGNOSIS
Ova and sometimes adults are found in feces

TREATMENT
Fasciolopsiasis is treated with praziquantel Other good drugs are mebendazole, thiabendazole, pyrantel pamoate, oxyclozanide, nitroxynil and hexachlorophene. Black walnut green hull is a good natural herb against adult worms whereas wormwood herb kills effectively larvae.

PREVENTION
Freezing vegetables below ___________for a few days or heating them above __________kills most parasites and their eggs. Drinking water can be filtered or boiled (in areas of poor sanitation). Additionally human or pig feces should not be used as a fertilizer in agriculture.

Echinostoma ilocanum

COMMON NAME DISEASE

Echinostomiasis (____________________)

GEOGRAPHICAL DISTRIBUTION
Worldwide, but human cases are seen most-frequently in southeast Asia and in areas where undercooked or raw freshwater snails, clams and fish are eaten.

HABITAT
____________________________________

Echinostoma ilocanum

1ST INTERMEDIATE HOST

Gyraulus convexiusculus (_____________________)

2nd INTERMEDIATE HOST

Pila conics or Pila luzonica (_______________)

MORPHOLOGY
Adult: Colarette spines, coiled uterus, lobate ovary, dumbell testes in tandem, medium sized follicles vitellaria Ova: Straw colored, operculated and immature when laid measuring about 83-116 u, broadly ovoidal in shape with the presence of a distinct germ ball

Echinostoma ilocanum

PATHOGENESIS, PATHOLOGY, AND SYMPTOMATOLOGY

Known to produce inflammatory lesions at the sites of attachment
Abdominal pain and diarrhea have been reported Generally innocuous parasites

Echinostoma ilocanum

DIAGNOSIS
Recovery of unembryonated egg of the parasite in the hosts stool

TREATMENT
Praziquantel

PREVENTION
Refrain from eating raw snails in endemic areas

Echinostoma malayanum

Echinostoma malayanum

MORPHOLOGY
Stool samples from 8 (11.4%) patients had large (120 130 m 8090 m), brownish, operculated eggs; 3 had a total of 13 adult flukes. Microscopy showed small leaflike flukes 89 mm long and 2.53.5 mm wide. After the organisms were processed and stained with aceto-carmine and fast green stains, diagnostic features of Echinostoma malayanum (Leiper 1911) were noted.

Echinostoma malayanum

MORPHOLOGY
Adult trematodes were within known species size range (510 mm 2.53.0 mm) and had elongated bodies and bluntly rounded ends Ventral sucker (acetabulum) was prominent and larger than the anterior oral sucker. Paired testes were deeply branched and positioned high in the posterior half of the body, extending above the midplane with a single anterior globular ovary. Uterus was entirely anterior to the ovary, and vitellaria (glands) were abundant along both lateral portions of the worm, ending just posterior to the esophagus. Oral sucker had a horseshoe-shaped anterior collar with 43 circumoral spines, which differentiates this species from E. ilocanum (4951 collar spines), another trematode species endemic to the Philippines.

Echinostoma malayanum

INVESTIGATION ON TRANSMISSION:
In terms of eating habits, patients reported that fish were commonly eaten raw, after being dipped in a salt and vinegar mixture, locally known as kinilaw. Other methods of fish preparation were tinola (boiled), ginataan (stewed in coconut milk), and sinugba (charcoal-grilled). All echinostome-infected patients had a history of having eaten snails, kuhol and kiambu-ay, prepared raw with coconut milk and lime juice (kinilaw), especially when found in greater abundance during the rainy season.

Echinostoma malayanum

INVESTIGATION ON TRANSMISSION:
Human echinostome infection results from ingestion of metacercariae that encyst in secondary intermediate hosts, usually freshwater snails, tadpoles, or fish. E. malayanum uses various species of gastropod mollusks for primary and secondary intermediate developmental stages Certain species of fish may also serve as secondary intermediate hosts Several mollusks that may serve as primary and secondary intermediate hosts have been identified in the Philippines, including Lymnaea (Bullastra) cumingiana, Radix quadrasi, and Physastra hungerfordiana for E. malayanum, and Pila luzonica for E. ilocanum

THE HETEROPHYIDS

CHARACTERISTICS IN GENERAL
1. 2. 3. 4. 5. 6. 7. 8. 9. Smallest but considered as the ____________of all trematodes _______________ in shape measuring 1-2 mm Rounded posteriorly and attenuated anteriorly with their cuticle surrounded by fine ____________ spines Provided with oral, ventral, and genital sucker With ________________surrounding lip of the genital sucker which is surrounded by spines Endemic in the _________________________ Diagnosis is based on the recovery of the eggs in stool Treatment for all species is tetrachloroethylene Prevention is by abstinence from eating raw or salted mullet or other infected fresh- or salt water fish

THE HETEROPHYIDS

Eggs out in feces

Body of water Ingestion of inadequately cooked fish

Larval development S-R-C

THE HETEROPHYIDS

HETEROPHYIDS OF MEDICAL IMPORTANCE

Heterophyes heterophyes Metagonimus yokogawai

Heterophyes heterophyes

DISEASE GEOGRAPHICAL DISTRIBUTION

Egypt, the Middle East, and Far East

1st INTERMEDIATE HOST 2nd INTERMEDIATE HOST

HABITAT
Adult worm inhabits the

Heterophyes heterophyes

MORPHOLOGY
o Adult
o Pyriform in shape o Oral sucker is small o Ventral sucker is about 3x the size of the oral sucker, thicked walled and muscular, and situated at the ant. 3rd of the body o Genital sucker is situated at the left posterior border of the ventral sucker and is provided with multidigitate spines o 2 oval testes arranged obliquely at the sub-caudal region o Small oval ovary at the anterior portion of the posterior 3rd of the body o 14 large polygonal vitelline follicles at the lateral portions of the worm

o Ova
o 28-30u o Ovoidal, operculated and embryonated when laid o Hatching takes place only upon ingestion of the ova by the intermediate host

Heterophyes heterophyes

Heterophyes heterophyes

PATHOGENESIS, PATHOLOGY AND SYMPTOMATOLOGY

Mild inflammatory reaction at sites where the minute worms become attached to the intestinal mucosa or burrows into the mucosa Worms produce mild irritation, accompanied by colicky pains and mucoid diarrhea, with production of excess mucus and a superficial necrosis of the mucous coat Ova may filter thru the intestinal wall, picked up by the mesenteric lymphatics and are filtered out in cardiac valves and myocardium, where they provoke tissue reactions leading to cardiac failure Ova may also be carried to the brain with the production of fatal cerebral hemorrhage

There is usually a significant diarrhea but no erythropenia in Heterophyes infection

Metagonimus yokogawai

COMMON NAME

DISEASE

GEOGRAPHICAL DISTRIBUTION
Mostly the Far East, as well as Siberia, Manchuria, the Balkan states, Israel, and Spain.

Metagonimus yokogawai

MORPHOLOGY
Adult
Almost similar with H. heterophyes except for FUSION OF THE VENTROGENITAL SUCKERS and DEFLECTED towards on the side of the body, pair of testes, one bigger than the other

Ova
Similar with H. heterophyes

Metagonimus yokogawai

1st INTERMEDIATE HOST

Semisulcospira libertina

2nd INTERMEDIATE HOST

Fresh water fish (Plectoglossus altivelis, Odontobutis obscurus, and Salmo perryi)

PATHOGENESIS
Mild diarrhea due to irritation of the mucosa by the flukes sucker attachments causing excess mucus production, sloughing surrounding mucosal cells, eosinophilic, and neutrophilic infiltration of the wall, granulomatous changes in ectopic foci

LUNG FLUKE

Paragonimus westermani

COMMON NAME

DISEASE
Paragonimiasis,

GEOGRAPHICAL DISTRIBUTION
Paragonimus spp. are distributed throughout the Americas, Africa and southeast Asia. Paragonimus westermani is distributed in southeast Asia and Japan. Endemic in the Philippines particularly in

Paragonimus westermani

MORPHOLOGY
Adult
8-12 mm Coffee bean-shaped Provided with oral sucker, ventral sucker which is situated midway in the body, Simple intestinal ceca with several indentations (zigzag) 2 lobed testes situated side by side in the posterior region Right side of the ventral sucker is a coiled uterus and opposite it is the lobed ovary Vitellaria is highly branched starting from the region of the pharynx down to the posterior end Long excretory bladder extending from below the level of the pharynx down to the posterior end

Ova
Measure about 80u, immature when laid, has

Paragonimus westermani

Paragonimus westermani

EPIDEMIOLOGY
Natural DH other than man includes Infection is obtained through ingestion of inadequately cooked _______________________________________________ in the endemic regions

PATHOGENESIS
PATHOGENIC STAGE: INFECTIVE STAGE: Immature adults
May cause ______________________which lead to abscess production

Mature adults
Produce lesions where they are found In the lungs, they produce an inflammatory reaction which lead to cystic encapsulation filled with blood tinged purulent materials with flecks of reddish brown material containing feces

Paragonimus westermani

PATHOGENESIS
Adult flukes living in the lung cause lung disease that may never be diagnosed or is thought to be_____________________ After ___________days, the initial signs and symptoms may be diarrhea and abdominal pain. This may be followed several days later by fever, chest pain, and fatigue. The symptoms may also include a _____________initially, which later often becomes productive with _______________________ __________sputum on exertion

Paragonimus westermani

DIAGNOSIS
Ova are found in sputum after KOH digestion or in feces after formolether concentration technique Serological tests: CF or ELISA Chest X-ray and lung biopsy

TREATMENT
Praziquantel is the drug of choice: adult or pediatric dosage, 25 mg/kg given orally 3 times per day for 2 consecutive days. Alternatives: Triclabendazole (not available in the U.S.), adult or pediatric dosage, 10 mg/kg orally once or twice; or Bithionol: adult or pediatric dosage, 30-50 mg/kg on alternate days for 10-15 doses. For cerebral disease, a short course of corticosteroids may be given with the praziquantel to help reduce the inflammatory response around dying flukes.

PREVENTION
Never eat raw freshwater crabs or crayfish. Cook crabs and crayfish for to at least 145F (~63C). Travelers should be advised to avoid traditional meals containing undercooked freshwater crustaceans.

DIOECIOUS FLUKES

BLOOD FLUKES

BLOOD FLUKES

Characteristics
1. 2. 3. 4. 5. Elongately cylindroidal in shape with prominent oral and ventral suckers Have separate sexes (dioecious) Abscess of muscular pharynx Intestine bifurcates and unites at a certain level Male adult are provided with gynecophoral canal on the ventral side, the function of which is to cuddle the female throughout its entire life except during oviposition, since they are always in perpetual copula, known as the_______________________ Life span may be as long as __________________ Only trematodes found in_____________________, can also be isolated in urine and/or stool

6. 7.

BLOOD FLUKES

Characteristics
8. Ova are embryonated and _______________________ 9. Only trematodes that require only _________________ 10. Does not have _________________________ 11. Infective stage is _________________ which has a charateristic ___________________ appearance 12. Manner of transmission: _______________________________________ 13. Majority of the schistosomes are parasitic in the lower animals. Only 3 are of medical importance to humans
a. Schistosoma japonicum b. Schistosoma mansoni c. Schistosoma haematobium

Schistosoma japonicum

COMMON NAME SYNONYMS

__________________________________

DISEASE
Schistosomiasis japonica, Oriental schistosomiasis

GEOGRAPHICAL DISTRIBUTION
S. japonicum in the Far East

HABITAT
______________________________________________and occasionally in the inferior mesenteric and portal venous system

Schistosoma japonicum

MORPHOLOGY
Male adult
12-20 mm and 0.5 mm in diameter Oral and ventral suckers are located near the anterior end of the worm Considered as the biggest of all blood flukes Cuticles are smooth and non-tuberculated 6-8 testes arranged in rows Intestinal ceca bifurcates then fuses very posteriorly ( very late union)

Female adult
26mm x 0.3 mm ( longer and more slender) More than one esophageal bulb, with fine cuticles Ovary is located centrally Uterus is long and well-developed with 50-100 eggs, female is usually found held in the gynecophoric canal of the male; females are capable of laying about 1,500 3,000 eggs per day (most destructive)

Ova
73-100 x 50u, broadly ovoidal in shape with very characteristic cellular debris; it has a rudimentary or abbrevated lateral knob, shell is stained with acid fast, sloping shoulder miracidium inside

Schistosoma japonicum

INTERMEDIATE HOST
Onchomelania quadrasi

RESERVOIR HOSTS
Dogs, cats, mice, cattle, pigs, goats

INFECTIVE STAGE
Fork-tailed cercaria

PATHOGENIC STAGE
Ova
Ability to produce irritation and inflammation Ability of microcidia to produce toxic metabolites Lytic property which enable them to penetrate the mucosa and submucosa of the small intestine Possibility of using the spine to penetrate the mucosa

Schistosoma japonicum

PATHOGENESIS, PATHOLOGY, AND SYMPTOMATOLOGY

4 STAGES
1.____________________________________________________ May last up for a few weeks up to several months Initially there is sub-irritation produced at the site of penetration causing dermatitis and rashes (swimmers itch, clam digger ithc, urticarial rash) In the clamdigger itch urticarial hemorrhages, In lungs, produce petechial hemorrhages, causing cough hemoptysis, and chest pain In the liver, may produce hepatitis, growth within interhepatic blood vessels

Schistosoma japonicum

PATHOGENESIS, PATHOLOGY, AND SYMPTOMATOLOGY 4 STAGES

2.___________________________________________________ Initial changes due to eggs causing acute suppurative vascular inflammation leading to small microabscess formation If near the surface, they will rupture into the lumen together with the eggs producing schistosomal colitis or ulcerative colitis depending on the number of worms present and the amount of sensitization produced Characterized by dysenteric syndrome Diarrhea, which last for 6 weeks, is mucoid, scanty, and streaked with blood, it involves the lower GIT, aside from frequent bowel movement, theres also tenesmus, abdominal pains or cramps Diarrhea is not responsive to any anti-diarrheal theraphy Usually no fever, unless secondary bacteria infection occured

Schistosoma japonicum

PATHOGENESIS, PATHOLOGY, AND SYMPTOMATOLOGY 4 STAGES

3.______________________________________________ Initiate fibrotic reaction, scarring of the infected areas S/S of diarrhea disappear, eggs seldom recovered from stool Worms lay their eggs in other areas, can also be carried to the different parts of the body forming tubercle and granuloma Splenomegaly, hepatomegaly and impairment of liver function and marked fibrosis of the affected areas Ascitis Loss of appetite Pedal edema

Schistosoma japonicum

PATHOGENESIS, PATHOLOGY, AND SYMPTOMATOLOGY

4 STAGES 4. ____________________________________________
After a long period, granuloma of the affected portion lead to fibrosis (periportal) leading to portal cirrhosis due to embolic closure of portal radicles with eggs Toxic metabolites secreted by the adults and the continuous infiltration of eggs Cirrhosis later produce portal hypertension causing s/s like ascitis (decrease albumin and decrease oncotic pressure), splenomegaly (hypersplenism decrease platelets, decresease wbc and rbc), distended abdominal veins, hemorrohoids, esophageal varices (hematemesis, hematofezia) Marked abdominal enlargement Liver become small

Schistosoma japonicum

DIAGNOSIS
Incubation stage ________________________ _ Early egg deposition stage________________________ ________________________ Late egg deposition and tissue proliferation stage_____________________ ________________________ ________________________ ________________________ ________________________

Schistosoma japonicum

TREATMENT
Tartar emetic (Potassium Antimony tartrate) Specification essential for successful treatment of S. japonica
Patient should be in a relatively early stage of the disease, before irrepairable damage to the liver and other vital organs has taken place Should be protected from re-exposure Given the benefit of nutritious food to build up resistance Treated thoroughly with tartar emetic and re-treated on slight recurence Liver function tests should be conducted during the course of the treatment to check for any hepatoxic damage caused by the drug Drug of choice is praziquantel for infections caused by all Schistosoma species. Oxamniquine has been effective in treating infections caused by S. mansoni in some areas in which praziquantel is less effective.

PREVENTION
Allow night soil to ripen longer in containers, or to disinfect it with fertilizer salts (ammonium nitrate) in order to kill the eggs before the fertilizer is spread on the fields Use mulusciscides Community sanitation

Schistosoma mansoni

COMMON NAME

DISEASE
Mansons intestinal schistosomiasis or bilharziasis

GEOGRAPHICAL DISTRIBUTION
Schistosoma mansoni is found in parts of South America and the Caribbean, Africa, and the Middle East

HABITAT

Schistosoma mansoni

MORPHOLOGY Male adult

6-12x1mm Coarse tuberculation, Lateral margins interlock and are held in position by accuminate spines which are longer than the other integumentary ones, minute sensory papilles are distirbuted over the surface Tuberosities are provided with microscopic tufts of hair Early union of the intestinal ceca 8-9 small testes arranged in clusters (in some books 3-13 small testes)

Female adult
7-17 x 0.25mm One esophageal bulb, early union of intestinal ceca Ovary located anteriorly with a short uterus containing 4 eggs Females are capable of laying 100-300 eggs per day

Ova
114-175u and has a very prominent lateral spine

Schistosoma mansoni

INTERMEDIATE HOSTS
Australorbis, Biomphalaria, Planorbis

INFECTIVE STAGE
Fork-tailed cercaria

PATHOGENIC STAGE
Ova

Schistosoma mansoni

PATHOGENESIS
Lesions produced similar to S. japonicum except for the much smaller number of eggs and the delay in the ____________________________production around the egg

Organs and tissues most seriously involved are the colon and rectum, but eggs are carried in the mesenteric current into the portal vessel filter in the periportal tissues within the liver and set up the pathologic processes leading to hepatic cirrhosis
Incubation stage- initial papular rash with pruritus, enlarged, and sometimes tender liver; diarrhea Period of egg deposition of extrusion takes place 5-7 weeks after exposure, accompanied by schistosomiasis dysentery, with blood and mucus in feces; later intestinal wall becomes inflamed, thickened and fibrosed, with abscess opening thru the mucosa, and with hyperemia of the peritoneal coat, theres development of paillomata and prolapse of rectum, liver and spleen are enlarged and tender Period of tissue proliferation and repair- tone of the intestinal wall diminished

Schistosoma mansoni

PATHOGENESIS Pulmonary complications

____________________ following migration of the metacercariae thru the lungs _____________________ simulating late TB with endarteritis of pulmonary vessels _____________________ terminating in congestive heart failure

DIAGNOSIS
Recover of eggs from urine or feces (more in feces); COPT, CFT, intradermal test

TREATMENT
Drug of choice is praziquantel for infections caused by all Schistosoma species. Oxamniquine has been effective in treating infections caused by S. mansoni in some areas in which praziquantel is less effective.

PREVENTION
Same as with S. japonicum

Schistosoma haematobium

COMMON NAME DISEASE

Vesical schistosomiasis, schistosomiasis haematobia, vesical or urinary bilharziasis, schistosomal hematuria

GEOGRAPHICAL DISTRIBUTION
S. haematobium in Africa and the Middle East

HABITAT

Schistosoma haematobium

MORPHOLOGY
Male adult
Shorter, stouter, organism 10-15x 0.8-1mm Fine tuberculation, 2 suckers (Ventral is larger) Behind the ventral sucker the body of the male is infolded ventral all the way to the caudal extremity to from the gynecophoral canal There is late union intestinal ceca 4-5 testes arranged in clusters or columns

Female adult
Long and slender 20-0.25mm, suckers are small, subequal and are not conspicuosly muscular Ovary located at the posterior end with a long uterus containing 20-30 eggs, Capable of producing 20-290 eggs per day

Ova
Measures about 120 u and provided with a very characterized terminal spine

Schistosoma haematobium

INTERMEDIATE HOSTS
Bulinus, Planorbis

PATHOGENESIS
Generalized and localized reaction__________________________________ Trauma, with hemorrhage, as eggs_____________________________________ ________________ Pseduo-abscess and pseudo-tubercle formation around eggs lodged in perivascular tissues

DIAGNOSIS
Recovery of eggs from urine and stool ( more in urine), aspirated materials from cystoscope, proctoscope, Fairleys complement fixation test, COPT in chronic areas

TREATMENT AND PREVENTION: Same with the other schistosomal infections

END OF FINALS LECTURE

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