MEDICAL HELMINTHOLOGY

PLATYHELMINTHES (Flatworms)

Trematodes (Flukes)
Cestodes (Tapeworms)
Free-living Turbellaria
TREMATODES (Flukes)
Classification of Trematodes

Hepatic Trematodes
Fasciola hepatica
Fasciola gigantica
Clonorchis sinensis
Opisthorchis felineus
Opisthorchis viverrini
Classification

Intestinal Trematodes
Fasciolopsis buski
Echinostoma ilocanum
Echinostoma malayanum
Heterophyes heterophyes
Metagonimus yokogawai
Classification
Blood Trematode
Schistosoma japonicum
Schistosoma mansoni
Schistosoma hematobium
Schistosoma mekongi
Schistosoma intercalatum
Classification

Lung Trematode
Paragonimus westermani
Trematodes
General Characteristics of Adult Worm

Body is dorsoventrally
flattened except
Schistosomes
Trematodes
General Characteristics of Adult Worm
Vary in size
Small, just visible to the naked eye
(Heterophyes)

Large fleshy species (Fasciola and

Fasciolopsis)
Trematodes
General Characteristics of Adult Worm
Acetabula (suckers)
oral, ventral, genital
(gonotyl) suckers
Integument
body covering
provided with spines
underlying
structures are
mesenchymatous
tissue and
musculature
Characteristics of Adult Worm
Alimentary
system
figure of
inverted Y
the 2 intestinal
ceca end blindly
ceca may be
branched or
unbranched
Characteristics of Adult Worm
Excretory system
bilaterally
symmetrical and
opens at the
posterior end of the
body
functional unit are
flame cells
(solenocytes)
series of collecting
tubules and a
bladder
Characteristics of Adult Worm
Nervous System
paired ganglion
cells and nerve
trunks
Characteristics of Adult Worm
Reproductive System
Hermaphroditic (monoecious)
except for Schistosomes
Characteristics of Adult Worm
Male reproductive
system
testes usually
paired
located in the
posterior half of
the body
may be globular,
lobate, tubular or
dendritic
Characteristics of Adult Worm
Female
reproductive
system
single ovary
which may be
rounded, lobed or
dendritic
oviduct, seminal
receptacle,
ootype, uterus,
Mehlis gland,
vitelline glands
Egg or Ovum
Egg shell have an operculum except in
Schistosomes
Operculum or lid or opening

The shape, appearance, and size are constant

and diagnostic for each species
Larval Stages
Miracidium
Sporocyst
Redia
Cercaria
Metacercaria: encysted cercaria
Miracidium
Ciliated larva that is hatched from egg
Penetrates the snail host
In some species the unhatched eggs are
ingested by the snail and hatch in the intestine
Sporocyst
Within the tissues of the snail host, miracidium
metamorphose into an irregular sac-like
sporocyst
Develop into daughter sporocysts or redia
Redia
First generation or may produce second
generation redia
Cercaria develop within redia
Cercaria escape from the snail into the water
Cercaria
Typically has elliptical body, an
elongated tail for swimming
Lytic secretions of the cephalic glands
enable the cercaria to penetrate the
skin of definitive hosts
(Schistosomes)
Encyst in second intermediate hosts
(fish, crabs, snail, aquatic
vegetations) as metacercaria
Trematode Larvae
Hosts
Definitive hosts: man and other vertebrates

Intermediate hosts
1st IH: snail host or mollusc
2nd IH: fish, crabs and crayfish,
snail, water vegetations
Mode of Infection
Direct skin penetration of the cercaria
Schistosomes
Ingestion of metacercaria in 2nd IH
Fresh water fish: Clonorchis,
Opisthorchis, Heterophyes,
Metagonimus
Water vegetations: Fasciola,
Fasciolopsis
Crabs and crayfish: Paragominus
Snail: Echinostoma
Pathology
Lesions produced depend upon their location
and their irritative and toxic actions
Systemic effects are due to the absorption of
toxic substances with allergic reactions
Severity of infection depends on
Worm burden
Invasion of tissues by eggs, larvae
and adult worms
HEPATIC TREMATODES
Fasciola hepatica
Fasciola gigantica
Clonorchis sinensis
Opisthorchis felineus
Opisthorchis viverrini
Fasciola hepatica
Common name
Sheep liver fluke; Temperate liver
fluke
Disease
Sheep liver rot or fascioliasis
hepatica
Geographical distribution (G.D.)
Sheep-raising countries
Fasciola hepatica: Morphology
Adult
30 mm x 13 mm; fleshy, flat and
leaf- like along the
margins
anterior end has distinct conical
projection
oral and ventral suckers
Fasciola
Fasciola hepatica: Adult Worm

Highly branched intestinal ceca

Dendritic pair of testes located in the 2nd and
3rd fourths of the body
Ovary is dendritic located in front of the
anterior testis
vitellaria is highly branched
extending through the lateral
fields
Fasciola hepatica: Egg
Large, ovoid, operculate, light yellowish- brown
130-150 u x 63-90 u
Immature when laid in the biliary tract and are
evacuated with the feces
Embryonate in water
Fasciola hepatica: I.H.
1st I.H. : Snail of the Genus Lymnaea

2nd I.H. : Aquatic vegetations: Ipomea obscura

(kangkong) and Nasturtium officinale (water
cress)
Fascioliasis
2 Clinical Stages
Acute or invasive phase
Corresponds to the migration of
the immature parasite from the
intestine to the liver
Traumatic and necrotic lesions are
produced as worm burrows
through the liver
Triad: high fever, hepatomegaly,
marked eosinophilia
Fascioliasis
2 Clinical Stages
Chronic or latent phase
Asymptomatic and corresponds to
the period when the parasite has
reached the bile duct
Adult worm causes obstruction,
inflammation and fibrosis
Fascioliasis: Ectopic Sites
Lungs
Subcutaneous tissue
Brain
Orbit
Intestinal wall
Halzoun
(Pharyngeal Fascioliasis)
Due to ingestion of infected liver where
livers of sheep and goats are eaten raw
Adult worm temporary lodged in the
pharyngeal mucosa
edematous congestion of the soft palate,
pharynx, larynx, nasal fossae and
Eustachean tube
Dyspnea, dysphagia, deafness,
occasionally asphyxiation
Fascioliasis
Laboratory Dx
Specific diagnosis
recovery of the eggs in the
patients stools or from duodenal
or biliary tract drainage
Serologic diagnosis may be helpful
False fascioliasis is passage of eggs in the feces
due to ingestion of infected livers
Fascioliasis
Treatment
Bithionol
Tricabendazole
Praziquantel is probably effective
Fascioliasis
Prevention and Control
Thorough washing and cooking of vegetables
Boiling of water
Elimination of snail hosts
Killing of parasites in the reservoir hosts by
chemotherapy
Fasciola gigantica

Common name: Tropical liver fluke

Dominant species in the Phil. affecting cattles
and water buffaloes
Fasciola gigantica differs from F.
hepatica based on the following:
Adult worm is larger, more lanceolate
Cephalic cone or shoulder is less developed
Larger ventral sucker
More branched intestinal ceca
Branches of ovary are longer and more
numerous
More anterior position of the testes
Larger eggs (160-190 u x 70-90 u)
Worm found in cystic masses in subcutaneous
or muscles of abdominal or chest wall; liver
abscess
Clonorchis sinensis
Opisthorchis felineus
Opisthorchis viverrini
Common Name and Disease
Clonorchis sinensis
Common name: Chinese liver fluke
Disease: Clonorchiasis
Opisthorchis felineus / O. viverrini
Common name: Cat liver fluke /
Civet liver fluke
Disease: Opisthorchiasis
Geographical Distribution
Clonorchis sinenses: China, Korea, Japan,
Vietnam
Opisthorchis felineus: Europe, Turkey, USSR,
Korea, Japan, Vietnam, India
Opisthorchis viverrini: Thailand, Laos, Malaysia
Clonorchis Adult Worm
Flat, transparent, spatulate, aspinous
integument
10-25 x 3-5 mm
Characteristic features
large deeply branched testes located one
behind the other at the posterior 3rd of the
body
vitellaria are delicate, granular
aggregations in the lateral fields in the
middle 3rd of the body
Opisthorchis Adult Worm
8-12 x 1.5-3 mm
The testes are lobed, are situated obliquely to
each other in the posterior 4th of the worm
Vitellaria consist of numerous transversely
compressed follicles in the lateral field of the
middle 3rd of the body
Clonorchis and Opisthorchis Egg

Yellowish-brown, broadly ovoid provided with a

distinct convex operculum that fits into a
thickened rim of the eggshell
At the posterior end of the shell there is a small
protuberance
26-30 u x 15-17 u
Fully embryonated when laid
Intermediate Hosts
1st I.H.: snail
Clonorchis: Parafossarulus,
Bulimus, Alocinma, Thiara,
Melanoides
Opisthorchis: Bithynia

2nd I.H. : Cyprinidae family of fresh

water fish
Opisthorchiasis and
Clonorchiasis
Development of the parasite in the distal bile
ducts provokes intense inflammatory and
proliferative changes of the biliary epithelium
Periductal fibrosis
Periportal fibrosis
Opisthorchiasis and
Clonorchiasis
Moderate infections cause painful enlargement
of the liver and passive congestion of the
spleen, with icterus
Heavy infections
worms invade the pancreas
causing digestive disturbances
bile stones may form around eggs
as nuclei and cause cholecystitis
with colic
Cholangiocarcinoma
Adenocarcinoma of the bile ducts and
gallbladder
Opisthorchis and Clonorchis have carcinogenic
potentials; can initiate transformation of the
bile duct epithelium
Clonorchiasis and Opisthorchiasis:
Laboratory Dx

Detection of the typical egg in the stool

EIA
PCR
Opisthorchiasis and Clonorchiasis:
Treatment

Praziquantel
Albendazole-Praziquantel
Opisthorchiasis and Clonorchiasis:
Prevention and Control

Stool exam and treatment of (+) cases

Health education
Proper human waste disposal
INTESTINAL TREMATODES
Fasciolopsis buski
Common name: Giant intestinal fluke
Disease: Fasciolopsiasis
G.D. : Parasite of humans and pigs in SEA
countries, China, Korea and India
Endemicity in the Phil. has not been
demonstrated yet
Fasciolopsis Adult Worm
Large, fleshy, elongated, oval
20-75 x 8-20 mm
Unbranched intestinal ceca
Highly dendritic testes which lie one
behind the other at the posterior half of
the body
Branched ovary lies to the right of the
midline; fine vitelline follicles are found
throughout the lateral margins of the
body
Fasciolopsis Egg
Large, operculated, unembryonated when laid
130-140 x 80-85 u
Indistinguishable from Fasciola egg
Fasciolopsis: Intermediate Hosts

1st I.H. : Segmentina or Hippeutis

2nd I.H. : metacercariae on the surfaces of seed
pods, bulbs, stems, or roots of various aquatic
plants like Trapa bicornis (water chestnut),
Eliocharis tuberosa (water caltrop), Ipomera
obscura (water morning glory), Nymphaea
lotus (lotus)
Fasciolopsiasis
Damage produced are traumatic, obstructive and
toxic
At sites of attachment worms cause inflammation
and ulceration of the mucosa producing an
increase in mucus secretion and minimal bleeding
Heavy infection
may cause intestinal obstruction
profound intoxication due to absorption of
worm metabolites which may cause death
Fasciolopsiasis: Lab Dx
and Treatment

Lab diagnosis
recovery of the eggs in the stool

Treatment
Praziquantel
Fasciolopsiasis: Prevention and
Control
Time between harvest and consumption of
water vegetations could be prolonged
Washing of plants or boiling them
Swamps or ponds must be protected from
pollution with feces
Echinostoma ilocanum

Disease: Echinostomiasis

G.D. : Northern Luzon, Leyte, Samar,

and provinces in Mindanao
Echinostoma Adult Worm
Reddish-gray measuring 2.5-6.6 x 1-1.35 mm
Anterior end is provided with a circumoral disk
which is made up of 49-51 collar spines
Testes are deeply lobed lie one behind the
other in the 3rd quarter of the body
Echinostoma Adult Worm
Vitellaria are medium-sized follicles in the
lateral fields located in the posterior of the
body
Uterine coils fill the intercecal field between
the anterior testis and the ventral sucker
Echinostoma Egg

Straw-colored, operculate, unembryonated

83-116 x 58-69 u
Echinostoma I.H.
1st I.H. Phil. : Gyraulus convexiusculus and
Hippeutis umbilicalis

2nd I.H. Pila luzonica (kuhol) and Vivipara

angularis (susong pampang)
Echinostomiasis
In heavy infection
inflammatory lesion occurs at the
site of attachment
ulceration may develop
generalized toxic process
Intestinal colic and diarrhea
Echinostomiasis: Lab Dx and
Treatment
Lab diagnosis
recovery of eggs in the stool
very similar to Fasciola and
Fasciolopsis egg

Treatment
Praziquantel
Echinostomiasis: Prevention and
Control

Avoiding ingestion of raw or improperly cooked

2nd I.H.
Heterophyid Flukes
Heterophyes heterophyes
Metagonimus yokogawai
Heterophyids
Disease: Heterophyiasis
Metagononimiasis

G.D. : Egypt, Greece, Israel, Western India,

Central and South China, Japan, Taiwan,
Philippines
Heterophyid Adult Worm
Elongated, oval or pyriform
1-1.7 x 0.3-0.4 mm
Integument has fine scale-like spines
A genital sucker or gonotyl is located on the left
posterior border of the ventral sucker
Metagonimus ventral sucker is
deflected to the right of the midline
2 oval testes at the posterior end of body
Small subglobose ovary; 14 large polygonal
vitelline follicles
Heterophyid Egg
Minute, ovoid, light brown, operculate
Fully embryonated when laid
28-30 x 15-17 u
Posterior protuberance is absent
Heterophyid I.H.
Heterophyes: 1st I.H. Pironella conica
2nd I.H. mullet

Metagonimus:1st I.H. Semisulcospira

libertina
2nd I.H. trout
Heterophyid: Pathogenesis,
Pathology and Symptomatology
Inflammation at the site of attachment
Excessive mucus production and
sloughing off of superficial layer
Peptic ulcer disease
Eggs may infiltrate blood capillaries and
lymphatics and deposited in various
tissues (myocardium, brain, spinal cord)
where they elicit granulomatous reaction
Heterophyid: Lab Dx and Treatment

Lab Dx
recovery of eggs in the feces

Treatment
Praziquantel
Heterophyid Infection in the Phil.

Eggs and adults of heteropyids have been

observed in the heart and brain of Filipino
patients who died of heart failure and
intracerebral hemorrhage
Stool survey done in Monkayo, Compostela
Valley showed a 31% prevalence rate
Species identified: Haplorchis taichui