TREMATODES

USLS DIVISION OF MICROBIOLOGY AND PARASITOLOGY

 TREMATODES: General Characteristics
PHYLUM PLATYLHELMENTHES
CLASS TREMATODA

OTHER NAME: FLUKES

TREMATODES: General Characteristics

dorso-ventral flattening
bilateral symmetry
hermaphroditic
leaf shaped
tough outer cuticle
two suckers
(anterior/ventral)
acoelomic
TREMATODES: General Characteristics
ORGAN SYSTEMS:
Muscular
Nervous
Excretory
Reproductive
Incomplete digestive tract
TREMATODES: General Characteristics
 THE TEGUMENT:
syncytial;
Distal cytoplasm is continuous
with no intervening cell
membranes;
With an outer anucleate layer:
The outer plasma membranes
possess glycocalyx

TREMATODES: General Characteristics

THE TEGUMENT
 FUNCTIONS OF THE TEGUMENT:
Absorption of nutrients
Synthesis and secretions of various
nutrients
Excretion and osmoregulation
Sensory role

TREMATODES: General Characteristics

THE TEGUMENT
 The main feature of
Trematodes is the presence
of flame shaped cells in
the excretory system of the
worm

TREMATODES: General Characteristics

THE EXCRETORY SYSTEM

 Consists of a system of branched
tubules that end in flame cells
Protonephridium – flame bulb
(functional unit of the excretory system)
Excretion is by osmoregulation and
removal of metabolic wastes
through the protonephridium and by
diffusion across the tegument and the
epithelial lining of the gut

TREMATODES: General Characteristics

THE EXCRETORY SYSTEM

 R
E Reproductive system:
P • Most are monoecious (capable of self-
R
O fertilization) except the schistosomes
D • Testes for spermgenital pore can be found
production
U
C
near the organ
• Cirrus – retractile muscular ventral sucker
T
I
serving as the copulatory organ
V • Fertilized eggs are released via the
E
genital pore
ORGANS

TREMATODES: General Characteristics

Detailed diagram of male (right) and

female (left) genitalia
 Cerebral ganglia are
connected by a commisure
Larval form have
chemoreceptors and
photoreceptors adapted
to finding intermediate hosts

TREMATODES: General Characteristics

THE NERVOUS SYSTEM

 Incomplete (with mouth but no anus)
Undigested wastes are regurgitated into
the mouth and subsequently eliminated

TREMATODES: General Characteristics

THE DIGESTIVE SYSTEM

 LIFE CYCLE:
Usually requires one
or more
intermediate hosts, one of
which is some form of mollusc
(snail or clam)

TREMATODES: General Characteristics

 TREMATODES: Life Cycle Stages
Note:

Miracidium
enters the 1st • Clonorchis sinensis,
Fasiolopsis buski,
IH HERMAPHRODITIC Paragonimys
FLUKES westermani, and
Cercaria Heterophytes
penetrates the heterpphyes
2nd IH and
encysts as
metacercaria • Schistosoma japonicum,
BISEXUAL FLUKES S mansoni, and S
Metacercaria hematobium
are ingested
by DH
 TREMATODES: Life Cycle Stages

Note:
• Clonorchis sinensis,
Miracidium Fasiolopsis buski,
HERMAPHRODITIC Paragonimys westermani,
enters the 1st FLUKES
IH and Heterophytes
heterpphyes
Cercaria
penetrates the
2nd IH and
encysts as
metacercaria • Schistosoma japonicum,
Metacercaria BISEXUAL FLUKES S mansoni, and S
are ingested hematobium
by DH
 Egg: operculated with a smooth
thin shell;
passed embryonated or
unembryonated;
development occurs in water.
Schistosome eggs are not
operculated and are
passed fully
embryonated.

TREMATODES: General Characteristics

Typical Trematode egg
TREMATODES: OVA
 Miracidium: larval stage
released from egg; may
be free swimming form
or remain in the egg until
ingestion by next
intermediate host;
phototactic

TREMATODES: General Characteristics

MIRACIDIUM
 Sporocyst: larval form that
develops within the intermediate
host;
sac-like structure;
rediae (secondary sporocysts)
develop within the primary sporocyst

TREMATODES: General Characteristics

SPOROCYST
 Redia: intermediate larval form
which develops within the
sporocyst;
sac-like structure possessing
mouth and gut;
one miracidium can ultimately
produce up to several hundred
rediae.

TREMATODES: General Characteristics

REDIA
• Final larval form that develops from a
redia.
• May enter the definitive host by direct
penetration of the skin (Schistosomes) or
attach to vegetation or second host and
form a resistant cyst (metacercaria) which
must be ingested by the definitive host.
• Depending on the species of trematode, the
cercaria may enter a second
intermediate host such as a crustacean
or fish where it will encyst.

TREMATODES: General Characteristics

CERCARIA
 • Post-cercarial encysted stage in the
life history of a fluke, prior to transfer
to the definitive host.
• Some cercariae attach themselves to
grass or other vegetation, form
metacercaria, and later are ingested
by herbivores, as in Fasciola and
similar forms;
• Others encyst in muscles of fish, as in
Clonorchis, or in crayfish, as in
Paragonimus.

TREMATODES: General Characteristics

METACERCARIA
 Classified into 4 orders:
• Echinostomatiformes
Fasciolids • Opisthorchiformes
Echinosthomes Opisthorchis
Chlonorchis
• Strigeiformes Heterophyes
(blood flukes)
•Plagiorchiformes
(lung flukes)

TREMATODES OF IMPORTANCE

TAXON DIGENEA
 BLOOD FLUKES
• Dioecious
• Males shorter and stouter than females
• Males with gynecophoral canal where females are received
• Suckers are armed with delicate spines
• Eggs are non-operculated and fully-embryonated when laid
• No metacercarial stage
• Infective stage: cercaria that penetrates intact skin
BLOOD FLUKES
Schistosoma spp.

Five main species infecting humans:

S. mansoni (Oriental blood fluke)
S. haematobium (Vesical blood fluke)
S. japonicum (Oriental blood fluke)
S. intercalatum
S. mekongi
 The eggs are laid at the
multicellular
In the snail,stage and at
normally require 10-
the site
12ofdays to mature
penetration, theand develop
miracidium
Phototactic and swim actively in
into miracidia.
develops into a sac-like structure
surface water.
called a sporocyst, where the
Can survive andlarva
encapsulated hatchbegins
after 1to
Infective for snails within
week in dry, shaded soil then
develop.
8-12 hrs
washed to fresh water lake to
mature.

SCHISTOSOMA: General Characteristics

Left, S. mansoni; Middle, S. haematobium; Right, S. japonicum
Adult worms (female; male)
Cercaria
Sporocyst
Schistosoma miracidium
 Emerge from the sporocyst and
escape from snail
The eggs are laid at the
multicellular
Able
In thetosnail, stage
attach and at
to host
normally require
skin
the 10-
viasite
12ofdays
oral andtoventral
mature
penetration, and develop
suckers,
the then in
miracidium
Phototactic and swim actively
into miracidia.
penetrate
Adult worms
develops via
intoare
secretion
of separate
a sac-like ofstructure
lytic
surface water.
enzymes
sexes
called a from cephalic
sporocyst, whereglands
the
Can survive
encapsulated and hatch
larva begins 1to
after
Infective for snails within
week
Mean inlife
dry, shaded soil then
hrs span: 3-8 years
develop.
8-12
washed to fresh water lake to
mature.

SCHISTOSOMA: General Characteristics

Adult
Left, S. mansoni; Middle, worms (female;
Cercaria
S. haematobium; male)
Right, S. japonicum
Sporocyst
Schistosoma miracidium
Process takes
few months

6-8 weeks
24-27 days
from cercarial
penetration

LIFE CYCLE: SCHISTOSOMA

SCHISTOSOMIASIS: Epidemiology

Schistosomiasis is endemic to over 70 countries world-wide

1997

SCHISTOSOMIASIS: The Philippine Setting

 Oriental blood fluke;
Snail fever
Endemic in China, Philippines
(first reported 1906),
Indonesia (Suluwasi)
Oncomelania snails as
intermediate host

Schistosoma japonicum
 THE BLOOD FLUKES: Pathogenesis
Schistosoma japonicum:
Each female fluke deposits 500-2000 immature eggs per day
Embryonation takes place within 10-12 days
Eggs escape through ulcerations in the intestinal lumen then
passed out to feces
 THE BLOOD FLUKES: Pathogenesis
Due to host granulomatous reactions to eggs deposited in the
liver and other organs (intestines, lungs)
Entry of cercaria: dermatitis
Transmigration of larvae traversing pulmonary vasculature:
pneumonitis, pulmonary hypertension
Obstruction of the intrahepatic portal branches: portal HPN
 THE BLOOD FLUKES: Pathogenesis

Clinical course of infection (stages):

Incubation: cercarial penetration to
maturity
Early egg deposition and extrusion
Tissue proliferation
Acute schistosomiasis Early schistosomiasis
(Katayama's fever) may  itching at entry points
 Fever and chills (Katayama fever)
occur weeks after the Colonic schistosomiasis
initial infection:  Ulcerations with diarrhea
- Abdominal pain Hepatosplenic
- Cough  Most serious consequence,
- Diarrhea  Pulmonary
Occurs in the period of larval migration
-Eosinophilia 

 Principal manifestation is cor pulmonale

-Fever Cerebral
-Fatigue  In 1-5% of infections
-Hepatosplenomegaly

Pathogenesis and clinical manifestations:

 Eggs are frequently not demonstrable in
the feces
 Stool examination techniques:
◼ MIFC (merthiolate-iodine-formalin concentration
technique)
◼ Kato-Katz technique – considered most suitable
for enumeration of eggs; 3x=92% confidence
interval
Rectal imprint/biopsy
Liver biopsy

SCHISTOSOMIASIS: Diagnosis
Immunodiagnosis
 Intradermal test
 Indirect hemagglutination

 COPT (circumoval precipitin test)

◼ Demonstrates formation of bleb or septate precipitates
attached to one or more points on the egg surface after
incubation of the schistosome eggs in a patient’s serum
◼ Method of choice for definitive diagnosis in the Philippines

 ELISA

SCHISTOSOMIASIS: Diagnosis

Parasitology by Belizario
 Praziquantel
 Safe, highly effective in single or divided
doses
 Single dose 40-50mg/kg or

 25 mg/kg in 2 doses, or

 20 mg/kg in 3 doses every 4 hrs

SCHISTOSOMIASIS: Treatment

Parasitology by Belizario
• NO VACCINE IS AVAILABLE.
• NO DRUGS FOR PREVENTING INFECTION ARE AVAILABLE.
• AVOID WADING, SWIMMING, OR OTHER CONTACT WITH
FRESHWATER IN DISEASE-ENDEMIC COUNTRIES
• UNTREATED PIPED WATER COMING DIRECTLY FROM FRESHWATER
SOURCES MAY CONTAIN CERCARIAE, BUT FILTERING WITH FINE-
MESH FILTERS, HEATING BATHING WATER TO 50° C (122° F) FOR
5 MINUTES, OR ALLOWING WATER TO STAND FOR AT LEAST 24
HOURS BEFORE EXPOSURE CAN ELIMINATE RISK OF INFECTION.
• SNAIL CONTROL
• SANITARY WASTE DISPOSAL

SCHISTOSOMIASIS: Prevention

Parasitology by Belizario
THE LUNG FLUKE:
Paragonimus westermani

Paragonimiasis:
Lung fluke disease
Pulmonary
Distomiasis
Endemic hemoptysis
Parasitic
hemoptysis
 Adult is reddish brown
resembling coffee bean
Rounded anteriorly,
tapered posteriorly

THE LUNG FLUKE

Paragonimus westermani
 The diagnostic stage: egg found
in stool or sputum.
• These eggs are yellow-
brown, ovoid, and have a
prominent operculum.
• They measure 80-120 um by
45-70 um and have a
thickened shell at the
abopercular end.

THE LUNG FLUKE

Paragonimus westermani
LIFE CYCLE: Paragonimus westermani
The larvae migrate for ~1
week, then penetrate the
diaphragm, enter the
pleural cavity, and
migrate directly through
Form cystic cavities and develop
lung tissue to reach the
into adult worms in 5-6 weeks.
bronchi.
Adult worms induce an inflammatory
response in the lungs, generating a
fibrous cyst: a purulent, bloody
effusion and eggs released by the
flukes which are passed into the
environment via expectoration, or
may be swallowed and passed with
feces.
• Granulomatous reactions in the lungs -- fibrosis
• Chest pains, hemoptysis, dyspnea are frequent
• Low-grade fever, fatigue, myalgia
• Cerebral involvement --- most serious
complication:
- Jacksonian epilepsy>>> ?
- Cerebral hemorrhage
- Visual disturbances
- Meningitis

THE LUNG FLUKE:

Pathogenesis and Clinical Manifestations

Paragonimus westermani
 Sputum exam for eggs
Chest
Stool xray:
exam for eggs
May not betest
Intradermal able to
distinguish
Serology from
may bePTB
helpful
inRing-shadowed
extra-pulmonary opacity
comprising
diseaseseveral
contiguouseosinophilia
Peripheral cavities (bunch
of grapes)
common
THE LUNG FLUKE: Diagnosis

Paragonimus westermani
 Central nervous system disease
may provide similar
Characteristic
"grapebunch“ findings,
characteristically seen in the
soap bubble
temporal and occipital lobes on
computedappearance
tomography of the in
brain. CNShistologic
involvementfindings
occurs in
up to 25% of hospitalized
patients

THE LUNG FLUKE: Diagnosis

Paragonimus westermani
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 adult or pediatric dosage, 10 mg/kg
orally once or twice
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.

THE LUNG FLUKE: Treatment

Paragonimus westermani
Eating sufficiently cooked crabs and meat
Eliminate reservoir hosts

THE LUNG FLUKE: Prevention

Paragonimus westermani
END OF PART 1: TREMATODES

QUIZ or BREAK?
TREMATODES: Intestinal Flukes

• Fasciolopsis buski
• Echinostoma ilocanum
• Heterophyes heterophyes
Fasciolopsis buski

 the largest intestinal fluke in humans

 Causes fasciolopsiasis
 commonly known as the giant intestinal
fluke
 endemic in China, India, Malaysia, South-
East Asia and Taiwan, especially in areas,
where pigs are raised and fed with
freshwater plants
Fasciolopsis buski

 Intestinal parasite of humans and pigs

 Adult:
 elongated,
 oval in shape,

 ~20–75 mm long and 8–20 mm wide,

 flat, leaf-shaped,

 blunt anterior end, undulating, tandem,

dendritic testes,
 poorly-developed oral and ventral suckers,
branched ovaries, vast vitelline follicles
Fasciolopsis buski

 Mature adults are hermaphroditic and

produce over 25,000 eggs per day.
 No cephalic cone compared to F.
hepatica and F. gigantica
Fasciolopsis buski

 The eggs are large,

operculated and NOT
distinguishable from F.
hepatica and F. gigantica

Egg size: 120 - 197 microns

 2nd intermediate hosts:
water plants

7 weeks

Segmentina or
1st intermediate
Hippeutis
host

3-7 weeks
after
Fasciolopsis buski: pathogenesis and
clinical manifestations

Minor infections are sometimes

asymptomatic.
Symptoms of heavy infections can include:
• allergic reactions
• anemia
• ascites
• diarrhea
• fever
• obstruction of the bowel
• abdominal pain
• edema
• toxemia
Fasciolopsis buski: pathogenesis and
clinical manifestations

 Inflammation and ulceration at the site

of attachment
 Heavy infestation --- intestinal
obstruction
 Intoxication from absorption of worm
metabolites --- generalized toxic and
allergic symptoms (facial edema,etc) ---
may result in death
F. buski: diagnosis

 Detection of parasite eggs in the

stool (embryonated or
unembryonated?)
 Among Filipinos, probably imported.
Endemicity not documented in the
Philippines
F. buski: treatment and prevention
 DOC: Praziquantel 25 mg/kg
3x/day for 2-3 days
 Washing waterplants thoroughly
before consumption
 Freezing vegetables below -10 °C for
a few days or heating them above 60
°C kills most parasites and their eggs
 Drinking water can be filtered or
boiled (in areas of poor sanitation
 human or pig feces should not be used
as a fertilizer in agriculture
 Echinostoma ilocanum

Endemic in Northern Luzon, Leyte,

Samar, Mindanao provinces
Echinostoma ilocanum
 Characterized by a collar of spines
around the oral suckers
 Eggs are stra-colored, operculated and
metacercaria

ovoid

42-50 days

6-15 days
Echinostoma ilocanum
Echinostoma ilocanum
Echinostoma ilocanum: pathogenesis
and clinical manifestation

 Inflammation at site of attachment

 Intoxication due to toxic metabolites

 Heavy infections:

 Diarrhea

 Abdominal pain
Echinostoma ilocanum: diagnosis

 Detection of eggs in stool

Echinostoma ilocanum: treatment
 Praziquantel 25 mg/kg 3x/day
for 1 day
Heterophyes heterophyes
Heterophyidae

 Heterophyds are small intestinal

trematodes (0.5-2 mm in length).
 capable of surviving and reproducing
in a wide range of hosts.
 Many fish eating animals normally
become definitive hosts of the
parasites, where they are able to
reproduce and release eggs.
Heterophyidae

•Their
do not
tegument
have aiscirrus
spined.
pouch
•They
Theirposess
reproductive organs
a small oral
are grouped
sucker, except
pharynx, andfor a
simple
separate
intestinal genital
system sucker with
and caeca.
many chitinous rodlets,
 The ventral sucker is strong
characteristic seminal vesicle,
and has approximately 70
and uterus.
spines
Geographic Distribution:
Egypt, the Middle East, and Far East.
Heterophyidae: pathogenesis and
clinical manifestations
Maayo pa ang  Inflammation at site of attachment
egg. Mi adto
sa heart.  The main symptoms are diarrhea and
colicky abdominal pain.
 Migration of the eggs to the heart,
resulting in potentially fatal
myocardial and valvular damage, has
been reported from the Philippines.
Migration to other organs (e.g., brain)
has also been reported.
Heterophyidae: diagnosis

 Detection of eggs in stools:

indistinguishable from those of
Metagonimus yokogawai and
resemble those of Clonorchis and
Opisthorchis.
Heterophyidae: treatment

 Praziquantel 25 mg/kg 3x/day

for 1 day
LIVER FLUKES
Chlonorchis sinensis
Opisthorchis felineus
Opisthorchis viverrini
Fasciola hepatica
Fasciola gigantica
Chlonorchis sinensis

Parasites of the bile duct and gall

bladder of humans and fish-eating
mammals
Chlonorchis sinensis
Pathogenesis and clinical manifestations
 There is intense proliferation of the biliary epithelium
 walls become thickened,

 lumen dilates 2-3x its diameter (hyperplasia)

 Periductal fibrosis
 Signs and symptoms:
 Fatigue
 Weakness
 Weight loss and poor appetite
 Abdominal distress
Chlonorchis sinensis
Pathogenesis and clinical
manifestations
 Gallstone formation
 Cholangiocarcinoma
 Signs and symptoms (acute infection):
 Fever

 Tender hepatomegaly
 Eosinophilia
Chlonorchis sinensis: diagnosis

 Detection of egg in stools

 Eggs are not distinguishable
from each other
Chlonorchis sinensis: treatment

 Praziquantel 25 mg/kg 3x/day for

2 days
Fasciola hepatica
Fasciola gigantica
Fasciola hepatica
Fasciola gigantica
 Inhabit the biliary passages
of the liver of humans and
herbivores
 Human infection occurs
primarily through the
consumption of
contaminated raw or non-
thoroughly cooked water
vegetables such as
watercress

In the Philippines, F. gigantica is the

dominant parasite
Fasciola hepatica vs Fasciola gigantica

Fasciola gigantica

 Larger and more

lanceolate
 Shorter cephalic cone
 Larger ventral sucker
 More anterior position
of the testes
Fasciola hepatica: ova

 Large, ovoid, operculate, light

yellowish brown
 Laid in immature state in the

biliary passages in the host and

are excreted in the feces
 F. gigantica eggs are larger
 Life span of the adult worm is
9-13 years
4-7 weeks

Once swallowed, the larvae penetrate through the

intestinal wall into the peritoneum and pass
9-14 days through the liver tissue to the biliary tract
Fasciola hepatica
Fasciola gigantica:

Pathogenesis and clinical manifestations

 Traumatic and necrotic lesions are produced when the
parasites burrow through the liver parenchyma
 Acute infection:
 Fever
 Tender hepatomegaly
 eosinophilia
Fasciola hepatica
Fasciola gigantica:

Pathogenesis and clinical

manifestations
Chronic or Latent phase:
The period when the parasite has already
reached the bile ducts
• Obstruction
• Inflammation
• Fibrosis
• Atrophy of the liver
• Periductal fibrotic cirrhosis
Fasciola hepatica
Fasciola gigantica:

Pathogenesis and clinical manifestations

Ectopic sites (during migration from intestines to the liver):

• Lungs
• Subcutaneous tissues
• Brain
• Orbit
Fasciola hepatica
Fasciola gigantica: diagnosis

Detection of eggs in stool, duodenal or

biliary tract drainage
Fasciola hepatica
Fasciola gigantica: Treatment

Bithionol 30-50 mg/kg on alternate

days to complete 10-15 doses
Praziquantel
Fasciola hepatica
Fasciola gigantica: Prevention
 Adequate chemotherapy of infected
animals
 Clean salads properly
 Sanitary disposal of excreta
QUIZ: