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TREMATODES

Trematodes
Flukes
Belong to Phylum Platyhelminthes class
trematoda
Flat, unsegmented
First Intermediate Host for all Trematodes is
SNAIL
No Coelom, so they are flat
Filled with mesodermal parenchyma
No blood vessels; simple ladder nervous
system
Incomplete digestive and circulatory system
All digenea are parasitic
Digenea has suckers used to attach to the
host; oral sucker contains the mouth and
ventral sucker serves as the passageway
for eggs
Muscular pharynx pumps food into blind
ending gut
Divided into two groups:
Hermaphroditic flukes
o Self-fertilizing
o Infect organs, foodborne
Blood flukes/Schistosomes
o Dioecious
o Infect by direct penetration
Rules:
ALL EXCEPT FOR SCHISTOSOMES:
1. Are hermaphroditic (Schisto: dioecious)
2. Require 2 or more Intermediate Hosts
(Schisto: 1 IH )
3. have metacercaria as the Infective Stage
(S: cercaria)
4. Transmitted through ingestion (S: skin
penetration)
5. have leaf-like appearance
6. have operculated eggs
ALL EXCEPT FOR Heterophyes heterophyes:
7. Have two suckers
(Heterophyes has three suckers: oral, ventral
and genital/gonotyl)
MORPHOLOGY:
Pass through three forms: Eggs, Multiple
Larva stages and adult
EGGS:

Primary form recovered from human


specimen
o Operculum lidlike structure that opens
to release larva
o Some have spines (like Schistosoma spp.)
LARVAE:
o Rarely encountered, occur outside human
hosts
ADULTS:
o Thin, non-segmented, leaf-like in shape
and thickness
o Typically 1 to 5 cm
o Two suckers (oral and ventral)
o Simple digestive system and a genital
tract
o Uses its body surface for absorbing and
excreting nutrients and waste products
o

General Life Cycle for


Hermaphrodites/Organ-dwelling flukes:
1. Egg exits the FH via feces or sputum
At Snail (First IH):
2. Miracidium released by egg when in
contact with fresh water
3. Sporocyst sac-like larval form
4. Rediae larval stages that form inside
sporocyst
5. Cercaria free-swimming, encysts on 2nd
IH
Encysting at 2nd IH (crab, plant, snail, ant,
etc):
6. Metacercaria encysted form of
Trematodes
Ingestion by Final host:
7. Adult
*Schistosomule emerges from cercaria
following penetration of Schistosomes in
humans
*Schistosome eggs are released via urine or
stool
*Testis: appearance may be branching,
simple or lobate. Arrangement may be
oblique, in tandem, or parallel.
TREMATODES
SCIENTIFIC NAME

COMMON NAME

BLOOD FLUKES
Oriental Blood Fluke

Schistosoma
japonicum
Schistosoma
Vesical Blood Fluke
haematobium
Schistosoma mansoni Mansons Blood Fluke
LIVER FLUKES
Fasciola hepatica
Sheep Liver Fluke/
Common Liver Fluke
Fasciola gigantica
Giant Liver Fluke
Clonorchis sinensis
Oriental/Chinese
Liver Fluke
Opisthorchis viverrini
Southeast Asian Liver
Fluke
Dicrocoelium
Lancet Liver Fluke
dendriticum
INTESTINAL FLUKES
Fasciolopsis buski
Giant/Large Intestinal
Fluke
Echinostoma
Garrisons Fluke
ilocanum
Heterophyes
Heterophid Fluke/Von
heterophyes
Siebolds Fluke
Metagonimus
Heterophid Fluke
yokogawai
Haplorchis taichui
--Gastrodiscoides
--hominis
PULMONARY FLUKES
Paragonimus
Oriental Lung Fluke
westermanii
A. LIVER FLUKES
1. Fasciola hepatica
Common Name: Sheep Liver Fluke
FH: Man, Sheep, other vertebrae
IH 1: Snail (Lymnaea species)
IH 2: Aquatic Plants
Habitat: Biliary passages of the liver
Diagnostic Stage: Unembryonated Eggs
*Zoonotic infections may come from
animals
*Take note of rules for MoT and IS
*Found worldwide, particularly in places
where sheep and cattle are raised
*and where humans consume raw
watercress, including Europe, the Middle
East, and Asia

*Natural Host for completion: Sheep.


Accidental Host Man (according to book)
Morphology:
Adult
Cephalic cone: Unique to F. hepatica
Broad shoulder
Intestinal ceca: branching
Testis: Highly branching
Egg
Operculated
Ovoidal, large, brownish-yellow in color
Hens egg appearance
No species differentiation: report simply
as Fasciola egg; information regarding
patient symptoms and travel history is
necessary to diagnose the causative
species
Life Cycle Notes:
Immature eggs are oviposited in the
biliary ducts and released in stool
Embryonated in fresh water
Miracidium penetrates snail IH, develops
into sporocyst, redia and cercaria
Cercaria encysts in aquatic plants and
develop into metacercaria
Ingestion of metacercaria-infected
aquatic plants introduces infection into
humans
Metacercaria excyst into duodenum,
migrate through intestines, peritoneal
cavity and liver parenchyma
Biliary ducts where metacercaria
develop into adults (3-4 months)
Adults reside in LARGE biliary ducts
Pathology:
Halzoun
o Pharyngeal Fascioliasis
o Common in people eating raw liver
Hepatic Fascioliasis
Sheep Liver Rot
Eosinophilia, jaundice, liver tenderness,
anemia, diarrhea, and digestive
discomfort are sometimes seen
Inflammation in the biliary epithelium
Liver atrophy
Concomitant periductal cirrhosis
Diagnosis:

Patient preparation: Three days with liverfree diet to avoid FALSE POSITIVE results
DFS/Kato-Katz/FECT
Duodenal/Bile Aspirate
Recovery of adult worms during surgery
Entero Test (nylon string inside capsule),
gel diffusion
Serology Test Multidot ELISA
Polymerase Chain Reaction/PCR
**WHO Standard: Three negative Kato-Katz
AND three negative FECT to rule out
Fascioliasis
Treatment:
Bithionol, thiabendazole, Praziquantel
Triclabendazole more effective but not
available in the US
2. Clonorchis sinensis
Common Name: Chinese Liver Fluke
FH: Man, Fish-eating mammals
IH 1: Snail (Bulimus fuchsiana and Aloncima
species)
IH 2: Fish (Cyprinidae species)
Habitat: Bile ducts and gallbladder
Diagnostic Stage: Ova in the stool
*Endemic areas are in Asia including Korea,
China, Taiwan, and Vietnam
*Reservoir hosts include carnivores like dogs
and cats
Morphology:
Adult:
Spatulate
Testis: Deeply branching, in tandem
Large oral sucker
Intestine: Simple
Egg:
Comma-shaped abopercular
end/thickening
Opercular shoulders where operculum
rests
Old-fashioned light bulb/pitcher-like
Hard to differentiate with heterophid
eggs, so report as HETEROPHID EGG
Life Cycle Notes:
EMBRYONATED EGGS are discharged in
the biliary ducts and in the stool

Infection of humans occurs by ingestion


of undercooked, salted, pickled, or
smoked freshwater fish
metacercariae excyst in the
duodenum and ascend the biliary tract
through the ampulla of Vater
Maturation takes place in liver (1 month
maturation)
Adults reside in SMALL and MEDIUM sized
biliary ducts
Pathology:
Bile duct obstruction (intensity is
proportional to worm load)
Liver carcinoma
Colangiocarcinoma/Gallbladder carcinoma
*Nitrosamine a compound excreted by
the worm related to development of
cancer
Diagnosis:
Stool Exam (DFS/KK/FECT)
Duodenal Aspirate
Entero Test
PCR
Liver Biopsy
Surgery/Autopsy where rarely
encountered adult worms are seen only
Treatment:
Praziquantel
Albendazole
3. Opistorchis felineus
Common Name: Cat Liver Fluke, Siberian
Liver Fluke
FH: Cat (Man can also be infected)
IH 1: Bithynia spp.
IH 2: Cyprinidae fish
Habitat: Biliary passages, gallbladder
Diagnostic Stage: Ova
*Opistorchis viverrini is similar to this (CN:
Southeast Asian Liver fluke)
Morphology:
Adult:
Lobate Testes , obliquely/diagonally
patterned
Egg:

No abopercular thickening
Life Cycle Notes:
Almost the same as C. sinensis
Pathology:
Opistorchiasis (colangiocarcinoma)
Diagnosis:
Stool Exam, Entero Test, Duodenal
Aspirate
Treatment:
Praziquantel

4. Dicrocoelium dendriticum (old name:


Fasciola lanceolata)
Common Name: Lancet Fluke
FH: Cattle, Sheep, Other vertebrates (Man is
AH)
IH 1: Cionella lubrica (release slime balls:
mass of cercaria)
IH 2: Formica fusca (ant)
Habitat: biliary passages//hepatobiliary
spaces in the liver
Diagnostic Stage: ova
*herbivores are reservoir hosts
Morphology:
Adult:
Lancet shaped
Testis: found on the anterior 1/3 portion;
Lobate in tandem
Egg:
Yellowish/brownish thick-walled with large
operculum, EMBRYONATED
Life Cycle Notes:
Common in herbivores
No redia stage
Pathology:
Enlargement of the bile duct
Portal cirrhosis
Periductal fibrosis
Diagnosis:
Detection of eggs in stool/duodenal fluid
Treatment:
Praziquantel
B. INTESTINAL FLUKES

1. Fasciolopsis buski
Common Name: Giant Intestinal Fluke
FH: Man
IH 1: Snail (Segmentina, Hippeutis, Gyraulus
species)
IH 2: Water Plants (Eliocharis tuberosa/Water
Chestnut, Eichornia species, Trapa species)
Habitat: Small Intestine
Diagnostic Stage: Ova
*Largest Intestinal Fluke of man
*limited to areas of the Far East (China,
Thailand, Taiwan, and Vietnam), India and
Indonesia
*Reservoir hosts: Rabbits, pigs, dogs
Morphology:
Adult:
Largest intestinal fluke
Intestinal ceca: Unbranched
Testis: In tandem branching (2 dendritic
testes)
Egg:
Large, operculated
Indistinguishable from eggs of F. hepatica
and F. gigantica
Life Cycle Notes:
Immature eggs are released via stool
Metacercaria excyst in duodenum
Development into adult is in intestinal
wall (approx. 3 months)
Adults life span = 1 year
Almost the same as F. hepatica; the only
difference is the habitat of adult
Pathology:
Gland abscess
Intestinal obstruction
Patients may also suffer from
malabsorption syndrome, similar in
giardiasis
Diagnosis:
Stool Exam
Eggs are indistinguishable from F.
hepatica
Treatment:
Praziquantel, tetrachloroethylene

Praziquantel should be taken with liquids


during a meal
2. Echinostoma ilocanum
Common Name: Garrisons Fluke
FH: Man, aquatic birds, carnivores, rodents
IH 1: Snail (Gyraulus convexiusculus,
Hippeutis umbicalis)
IH 2: Kuhol (Pila luzonica, Pila conica)
Habitat: Small Intestine
Diagnostic Stage: Ova
Morphology:
Adult:
Equipped with plaque-like scales
instead of spines
Oral sucker is protected by the spine
called circumoral disk (collar spine)
Testis: Lobate, in tandem
Intestinal ceca: unbranched
With structures called vitelline glands or
vitellaria
Egg:
Straw-colored (almost colorless)
Operculated
Structure inside: Germ Ball or Yolk
Can be differentiated from other eggs in
stool exam
Life Cycle Notes:
Unembryonated eggs are released via
feces
May have 1 or 2 generations of rediae
Metacercaria excyst in duodenum, and
adults reside in small intestine
Pathology:
Heavy Infection
General intoxication
Diarrhea
Catarrhal inflammation due to the
penetration of the sharp-spined collar into
the intestinal mucosa
Diagnosis:
Stool Exam
Treatment:
Praziquantel

3. Heterophyes heterophyes
Common Name: Von Siebolds
Fluke/Heterophid Fluke
FH: Man, fish-eating animals and birds
(reservoir)
IH 1: Cerithidia, Pironella species
IH 2: Tilapia and other fresh/brackish water
fish
Habitat: small intestine
Diagnostic Stage: Ova in stool
*smallest fluke infecting man
Morphology:
Adult:
grayish in color
protected by an outer layer of fine spines
(scaly in appearance
Has third sucker: the gonotyl or genital
sucker
Paired testes
Egg:
Operculated
Indistinguishable from Metagonimus
yokogawai; shell is thicker than
Metagonimus yokogawai but is not
enough for species differentiation
similar to Clonorchis sinensis but without
abopercular thickening
Less distinct shoulders compared to
Clonorchis sinensis and lack the small
terminal knob
Life Cycle Notes:
Adults release embryonated eggs passed
through the feces
Infection occurs after ingestion of
raw/uncooked freshwater/brackish water
fish contaminated with metacercaria
Pathology:
Abdominal pain and
chronic mucous diarrhea and eosinophilia
The eggs have the ability to escape into
the lymphatics or venules via intestinal
wall penetration and to migrate to other
areas of the body, such as the heart or
brain which result into granulomas in
these areas

Diagnosis:
Stool exam
Species differentiation is difficult due to
similarities with Clonorchis sinensis and
Metagonimus yokogawai
Treatment:
Praziquantel
4. Metagonimus yokogawai
Common Name: Heterophid fluke
FH: Humans, fish-eating mammals and birds
IH 1: Semisulcospira species
IH 2: Fresh/brackish water fish
Habitat: Small Intestine
Diagnostic Stage: Ova in stool
*smallest human fluke (according to CDC)
Morphology:
Adult:
pyriform in shape
with tapering at the anterior end and
rounding at the posterior end
with a tiny layer of scaly spines heavily
distributed over the anterior end
ventral sucker/genitoacetabulum - to the
side of the midline and closely associated
with the genital pore
Egg:
thinner shell than Heterophyes
heterophyes; no species differentiation
Life Cycle Notes:
Adults release embryonated eggs passed
in the feces
Pathology:
diarrhea and colicky abdominal pain
Same symptoms with Heterophyes
heterophyes
Diagnosis:
Stool exam
Treatment:
Praziquantel
5. Gastrodiscoides hominis

(notes only, wala sa book and CDC)


- Pear-shaped: globular appearance
> Discoid posterior
> Conical Anterior
- Massive acetabulum
- Lay immature eggs
- Habitat: Small intestine
- Life cycle: Not well studied
- Pathology: Mucoid diarrhea, gastritis
- Egg: similar to heterophids
- Treatment: Carbon Tetrachloride (CCl4)
- Praziquantel is ineffective
6. Haplorchis taichui
(wala ako mahanap info tungkol dito!)
From wiki:
Haplorchis taichui is a species of intestinal
flukes in the genus Haplorchis. It is a human
parasite found in the Philippines.
Oxyresveratrol, a stilbenoid found in extracts
of Artocarpus lakoocha is effective against H.
taichui.

C. BLOOD FLUKES
*no metacercaria and redia stages
1. Schistosoma japonicum
Common Name: Oriental Blood Fluke
FH: Man and other vertebrates
IH: Snail (Oncomelania hupensis quadrasi)
Habitat: Superior mesenteric veins of small
intestine
Diagnostic Stage: Ova in stool
*Take note of rules for MoT (skin penetration)
and IS (fork-tailed cercaria)
*Host-permissive: can complete cycle in
other vertebrates
*Reservoir hosts: dogs, cats, carabaos
*Most number of reservoir hosts among the
Schistosomes
*Endemic in the Philippines
Morphology:
Adult:

MALE: Hollow structure called


gynecophoral canal (receives female
during copulation)
Testis: 6 to 7, behind the ventral sucker
FEMALE: slender, with greatest egg
production
When in copulation: described as
Schistosoma in copula (perpetual
copulation); most romantic parasites
No integumentary tuberculation; aspinous
(no spines)
Largest among Schistosoma species in
man
Egg:
Ovoid/round/pear-shaped with minute
lateral knob
Life Cycle Notes:
Eggs are released via feces
Cercaria penetrate human skin and shed
their forked tail, becoming
schistosomule
Females deposit eggs in the small venules
of the portal and perivesical systems
Pathology:
Due to Adult:
Katayama Disease - systemic
hypersensitivity reaction to the
schistosomulae migrating through tissue
Snail Fever
Oriental Schistosomiasis
Due to Larva:
Swimmers Itch
Diagnosis:
Stool Exam
o WHO recommendation: Kato-Katz in
three stool samples for 3 consecutive
days
Rectal Biopsy, Liver Biopsy
Egg-hatching technique
ELISA
Ritchie Technique to quantify eggs
Serological Test: Detects three antigens:
o Circulating Cathodal Antigen (CCA)
o Circulating Anodal Antigen (CAA)
o Soluble Egg Antigen (SEA)
COPT

o
o
o
o

o
o
o

o
o

Sensitive, cannot differentiate present


from previous infections
Confirmatory and definitive test for
Schistosomes in the Philippines
Circumoral Precipitin Test
Reagent: Antigen freezedried/lyophilized Schistosoma
japonicum eggs
Specimen Patient Serum
Positive result: bleb formation
Liquefied petrolatum/wax/paraffin
used to avoid evaporation and to seal
the preparation
Glass beads/nail polish to elevate the
preparation
*Incubate at 36oC for 24 hours and
examine under microscope for blebs

Treatment:
Praziquantel
2. Schistosoma mansoni
Common Name: Mansons Blood Fluke
FH: Man
IH 1: Biomphalaria spp.
Habitat: Inferior mesenteric veins of the
large intestines, colon, rectum
Diagnostic Stage: Ova in stool
* Take note of rules for MoT (skin
penetration) and IS (fork-tailed cercaria)
*Endemic in Africa and South America
Morphology:
Adult:
Male:
o Prominent Integumentation
o 8-9 testes, the most number of testes
among Schistosomes
Female:
o Ovary at the anterior part of the body
o Uterus 1-4 eggs
Egg:
Diagnostic Stage
With lateral spine
Life Cycle Notes:
Same as S. japonicum; the only difference
is the habitat of the adult
Pathology:

Intestinal bilharziasis
Diagnosis:
COPT, Stool Exam, Egg Hatching
Technique
Treatment:
Praziquantel
3. Schistosoma haematobium
Common Name: Vesical Blood Fluke
FH: Man
IH 1: Bulinus spp.
Habitat: Vesical, Prostatic, Uterine, Venous
Plexuses of Urinary Bladder///Vesical
Plexuses of the Venous Circulation
Diagnostic Stage: Ova in urine
*Urine is red in heavy Schistosoma
haematobium infection, unlike in heavy
filarial infections where urine is milky/turbid.
*Endemic in Middle East and Africa
Morphology:
Adult:
Male:
o 4-5 testes
o Fine tuberculations
Female:
o Ovary is in the posterior end
o 20-3o eggs in the uterus
Egg:
With prominent terminal spine
Life Cycle Notes:
Same as S. japonicum and S. mansoni,
except for habitat
Discharged in urine instead of feces
Pathology:
Urinary Bilharziasis, Egyptian
Schistosomiasis
Diagnosis:
Urine Exam, COPT, egg hatching
technique
Centrifuge urine, and look for eggs in the
sediments. Concentration technique
known as Nucleopore Filtration Technique
may be used
Treatment:
Praziquantel

D. LUNG FLUKE
Paragonimus westermani
Common Name: Oriental Lung Fluke
FH: Man
IH 1: Antemelania asperata
IH 2: Sundathelphusa philippina (crab, one
claw is bigger)
Habitat: Lungs (encapsulated in pairs)
Diagnostic Stage: Ova in sputum/stool
*Old name of Antemelania asperata is
Broatia asperata
*Endemic in Bicol, and one is given a direct
sputum smear in addition to Acid Fast
staining when there are TB-like symptoms
*Prawns - paratenic host
Morphology:
Adult:
Reddish, spoon or coffee bean shaped
Rounded anterior, ovoid posterior
Testes Deeply lobed obliquely in tandem
Large, broad and flat body
Wavy intestinal ceca
Spines in the integument
Egg:
Ovoid, with flat, WIDE operculum (unlike
in Heterophid eggs)
With abopercular thickening opposite of
operculum
Brownish operculum
Life Cycle Notes:
Eggs are excreted unembroynated in the
feces and/or sputum
Metacercaria excyst in the duodenum
The worms can also reach other organs
and tissues such as the brain and striated
muscles. However, when this takes place,
completion of the life cycles is not
achieved, because the eggs laid cannot
exit these sites.
Pathology:
TB-like symptoms
Hemoptysis expectorating/coughing
blood which originated from the lungs

(differentiate with hematemesis, in which


blood is from the GI tract)
Jacksonial epilepsy
Pulmonary Distomiasis
Cerebral Paragonimiasis, when there is
migration to the brain

Adult:
Ruffle border
2 notched testes
1 notched ovary
Egg:
Similar to D. dendriticum

Diagnosis:
Sputum Exam
o 3X in different days, preferably in the
morning
o Use NaOH, 10-30% HCl or NAL-C as
mucolytic agent (1 part sputum, 9 parts
digestant)
o Centrifuge, then look for eggs in the
sediment
Stool Exam
o Eggs are present when sputum is
swallowed
o Can also confirm P. westermani
Biopsy and Autopsy the only way to
remove or recover adult worms

Pathology:
Eurytremiasis destruction of pancreas;
diabetes mellitus
Diagnosis:
Same as previous
Treatment:
Praziquantel

Treatment:
Praziquantel, Bithionol (will kill the adult
worm and cause fibrosis)
E. PANCREATIC FLUKE
Eurytrema pancreaticum
(lab notes only, wala sa book and CDC)
Common Name: Pancreatic Fluke
FH: Hogs, cattle (Man is AH)
IH 1: Macrochlamys indica
IH 2: Technomyrmex deterquens (ant) or
grasshopper
Habitat: Pancreatic duct, biliary passages,
gallbladder

Morphology:

---------TEMPLATE (for reviewing)


Common Name:
FH:
IH 1:
IH 2:
Habitat:
Diagnostic Stage:
*
Morphology:
Adult:

Egg:

Life Cycle Notes:

Pathology:

Diagnosis:

Treatment: