MODULE 4 - PHYLUM PLATYHELMINTHES

Unit 2 - Class Trematoda - Monoecious Flukes

Trematoda

- commonly known as flukes (floc - flatfish) Heterophyids

- unsegmented, flat, and broad helminths - provided with genital sucker (gonotyl)
- trematode (trema - hole; eidos - appearance) ● on left posterior boarder of the adult worm’s body
- from having large prominent suckers with a hole in the middle Heterophyes heterophyes
- all adult flukes have 2 cup-shaped muscular suckers (used to attach to host) - has genital sucker separated from the ventral sucker
● oral sucker - in anterior end Metagonimus yokogawai
○ surrounds the oral end or the mouth area - lacks an independent sucker,
● ventral sucker - on one side (ventral surface) - gonotyl is fused with ventral sucker
○ near the center of the adult worm’s body

Subclass Digenea Groups of Flukes

- flukes parasitic to humans Based on their:
- have complex life cycles 1. reproductive system
● alternation of generations 2. system in which they infect their definitive host
○ sexual reproduction in the adult worms in its definitive host (vertebrate) →
asexual reproduction in the larval stages in the intermediate host (mollusc -
snail)

LIFE CYCLE Eggs Larvae

Three morphologic forms:
1. egg - have a smooth, hard shell that is a. Miracidium (pl. miracidia - little boy) d. Cercaria (pl. Cercariae; from e. Metacercaria (pl. metacercariae)
2. larval transparrent - pyriform , ciliagted, first-stage larva which emerges from Gr. kerkos - tail) - A cercaria without a tail
3. adult stages - generally yellow-brown or brown the egg - Consist of: surrounded by a thick cyst
● an elliptical body wall
- opeculated (containing lid-like structure - - Has:
with oral and ventral
operculum) ● anterior secretory glands that discharge suckers,
● opens to release its contents for enzymes for penetrating tissues of susceptible ● Rudimentary
further development host (snail) reproductive system
- When discharged may be: ● Paired excretory system with flame cells ● Excretory and
● Non-embryonated (immature) ● Nervous system with ganglia digestive system
- require further ● Collection of germinal cells similar to that of an
adult worm
development in aquatic
● Tail for swimming
Adult worm or moist conditons b. Sporocyst (a “bladder containing seeds”)
before hatching - A irregular saclike structure containing germinal cells
● Bilaterally symmetrical adult monoecious ● F. hepatica Under cercaria
that bud off internally and continue the asexual process
trematodes are dorsoventrally flattened and ● F. buski of larval multiplication
are non-segmented Simple-tailed cercaria Keel-tailed cercaria Microcercus
● E. ilocanum - Serves as a brood sac for the development and
● Leaf-shaped helminths (knob-shaped tail with
● P. westermani production of a generation of daughter sporocysts or spines)
● Possess:
○ an oral ● Embryonated (mature) many rediae
○ a muscular sucker - containing fully
● Vary in length from a few mm to several cm developed larvae
(Depending on species) ● C. sinensis c. Redia (pl. rediae)
● O. felineus - More complex, elongated, saclike organism, a mouth, oral
● H. heterophyes sucker, a pharynx, a sac-like intestine, an excretory ● P. westermani
● F. hepatica ● C. sinensis
● M. yokogawai system with flame cells and collecting tubules, germinal
● F. buski ● O. felienus
● D. dendriticum cells as well as a birth pore through which the next
● E. Ilocanum ● H. heterophyes
generation escapes ● D. dendriticum ● M. yokogawai
Monoecious flukes
● Heteroxenous parasites
○ Requires 3 hosts to complete their life cycle
■ Definitive host
■ 2 intermediate host
● Typical life cycle of monoecious flukes:
○ Adult worms lives in lumen of biliary tract, intestinal tract, or respiratory tract of
the definitive host (vertebrae, including man)
○ Engages in sexual reproduction → production of operculated eggs

Eggs Immature Eggs Mature eggs

- Escape from the definitive host via feces/sputum - Embryonate → develop a miracidium → hatch in water - Already contain a miracidium, but DO NOT hatch in the
● For intestinal flukes, liver flukes, and sometimes, lung fluke (sputum) environment
- May be mature or immature - Must be ingested by the 1st intermediate host (snail) to hatch

● F. hepatica ● C. sinensis
● F. buski ● O. felineus
● E. ilocanum ● H. heterophyes
● P. westermani ● M. yokogawai
● D. dendriticum

Miracidium Hatches in the environment Unhatched

- Hatches from the egg either in the environment or in the first intermediate snail host
which differs between the flukes ● Swims actively in water through cilia for a few hours ● Embryonated eggs are ingested by the snail → hatch in
- Develops and grows into a sporocyst ● If encounters the appropriate species of snail → penetrates the tegument of the intestines
● Within the snail: snail → cilia is shed as it enters
○ Complex series of generations are formed through asexual reproduction in ● If not → dies
the larval stages by mechanism involving the production of large numbers of
germinal cells follow

Sporocyst Redia Cercariae

- Produces rediae which escape from the ruptured sporocyst - Each develops cercariae - Escape into the tissues and pass through the integument of the
snail into the water
L
A So extensive is the multiplication that thousands of cercariae may develop from one miracidium
R
V Cercaria Aquatic plants: F. hepatica, F. buski
A - Liberated from the snail
E - Swims in water with its tail for a limited time → attaches to/penetrates its appropriate second intermediate host which varies between Freshwater fish: C. sinensis, O. felineus, H. heterophyes, M. yokogawai
flukes
Snail: E. ilocanum

Cab/crayfish: P. westermani

Ant: D. dendriticum

Metacercaria
- Cercaria encysted in the second intermediate host
- Must be ingested by the definitive host, including man
- Ingestion → excysts in the intestine → adolescent worm migrates to its normal habitat (liver, intestine, lung) → grows to adult worm
NOTE:
● Not all monoecious flukes follow the typical eggs → miracidia → sporocysts → rediae → cercariae → metacercariae → adults
F. buski and P. westermani F. hepatica and heterophyids
● Two generations of rediae ● One OR two generations of rediae
○ First-gen rediae from sporocyst become
mother rediae → develop into second-gen,
daughter rediae → cercariae
PARASITES
FASCIOLA HEPATICA CLONORCHIS SINENSIS
● AKA sheep liver fluke ● AKA Chinese liver fluke, oriental liver fluke
● Infective stage: Metacercariae on vegetation ingested ● Classified by the International Agency for Research on
by definitive host Cancer (IARC) as a probable carcinogen (group 2A)
● Diagnostic stage: Unembryonated eggs passed in feces ● Infective stage: Metacercariae in flesh or skin of
freshwater fish ingested by the definitive host
LIFE CYCLE ● Diagnostic stage: Embryonated eggs passed in feces
LIFE CYCLE
PATHOGENESIS AND CLINICAL MANIFESTATIONS
Clonorchiasis
- Symptoms are related to worm burden in the bile ducts
- Flukes may also be found in the pancreatic duct and the
gallbladder
PATHOGENESIS AND CLINICAL MANIFESTATIONS - Most cases are of light burden and asymptomatic
Hepatic fascioliasis - Result from inflammation, intermittent obstruction of
● Recognized by two clinical stages in human biliary ducts, mechanical injury resulting from worms
E. ilocanum
● Two generations of rediae
○ First-gen redia from miracidium become
mother redia → develops into second-gen,
daughter rediae → cercariae
○ Sporocyst stage is OMITTED
OPISTHORCHIS FELINEUS
● AKA cat liver fluke
● Infective stage: Metacercariae in flesh or skin of
freshwater fish ingested by human host
● Diagnostic stage: Embryonated eggs passed in feces
LIFE CYCLE
PATHOGENESIS AND CLINICAL MANIFESTATIONS
Opisthorchiasis
- Usually asymptomatic
- Sometimes cause liver disease resembling
clonorchiasis
- 5 to 10% of infections: Flatulence, fatigue, dyspepsia,
pain in the right upper quadrant of the abdomen,
anorexia, and mild hepatomegaly
- Severe infections
● Rare
● Might cause obstructive jaundice, cirrhosis,
cholangitis, acalculous cholecystitis, or bile
peritonitis
Cholangiocarcinoma
- Most serious complication of infection with O. viverrini
D. dendriticum
● Two generations of sporocysts
○ First-gen sporocyst from miracidium become
mother sporocyst → develops into
second-gen, daughter sporocyst → cercariae
○ Redial stage is OMITTED
DIDROCOELIUM DENDRITICUM
● AKA lancet liver fluke, lanceolate fluke
● Infective stage: Ingestion of infected ants
● Diagnostic stage: Embryonated eggs shed in feces
LIFE CYCLE
PATHOGENESIS AND CLINICAL MANIFESTATIONS
Dicrocoeliasis
- Similar to those of fascioliasis
- Heavy infections in animals:
● Enlargement of the bile ducts, Hyperplasia of
biliary epithelium, Formation of periductal
fibrosis, Eventual portal cirrhosis
- Human infections are almost invariably light and often
asymptomatic
● Biliary colic and digestive disturbances have
been described
 1. Acute form
● Occurs during migration of the metacercariae
from the intestines to the liver → burrows into
the liver parenchyma = traumatic damage,
toxemia, necrosis known as LIVER ROT,
especially in heavy infections
● Presents with fever, right upper quadrant pain,
eosinophilia, tender hepatomegaly
2. Chronic form
● Associated with the development of adults in
the intrahepatic ducts
● Largely associated to their large size, patients
may develop biliary obstruction (may) →
fibrosis
● Thickened fibrous ducts = less bile to be
passed out = back pressure
● Manifestations include biliary cirrhosis,
obstructive jaundice, cholelithiasis, and
anemia
Most important aspect of infections: ability to initiate
cholangiocarcinoma
feeding on mucosal tissue, toxic effects of worms’
metabolic products, and secondary bacterial infections
- Mild cases
● Manifestations: mild abdominal symptoms
● Px with high worm burdens often have other
nonspecific symptoms such as abdominal
pain (in the right upper abdominal quadrant)
and various somatic symptoms (headaches,
dizziness)
- Prolonged infections
● Symptoms can be more severe
● Hepatomegaly and malnutrition may be
present
● Biliary complications include:
○ Cholangitis - inflammation of the
bile duct system
○ Cholecystitis - inflammation of the
gallbladder
○ Cholelithiais - gallbladder stone
disease, when the eggs become
the nuclei of gallstones
○ Pancreatitis
○ Liver abscesses
- Type of cancer that forms in the bile ducts
EPIDEMIOLOGY
EPIDEMIOLOGY
● Endemic in Europe, Turkey, and former USSR countries
(Korea, Japan, Vietnam, and India)
● Reservoir: Cats (most important reservoir host in highly
endemic areas)
○ Include other fish-eating mammals such as
dogs and cats
● Transmission: Similar to that of clonorchiasis
● Cosmopolitan in sheep and other herbivores in Asia,
Africa, Europe, and North and South America
○ Sporadic cases of human infection have
been reported
● Reservoir: Ruminants, especially cattle and sheep
(normal definitive hosts)
○ Aberrant infections in various non-human
primate species and domestic dogs
● Transmission: Spurious (many apparent human
infections) due to consumption of infected liver with
subsequent appearances of the ingested eggs in feces
○ Other reported cases: true dicrocoeliasis
through ingestion of food and drinks
contaminated by ants

EPIDEMIOLOGY
Ectopic fascioliasis
- May result occasionally when immature worms migrate,
(from intestine to the liver), wander and become lost
and carried to ectopic sites (lungs through the
diaphragm), subcutaneous tissues, brain, and/or orbit
of the eyes = abscess of fibrotic lesions
NOTE:
Halzoun (Ar. suffocation) / Pharyngeal fascioliasis
● A parasite of the Far East
○ Endemic areas: Japan, Korea, China, and
Vietnam
● Reservoir: Typically infects fish-eating mammals
○ Found also in dogs, cats, and rats
● Transmission: Humans are infected by eating
uncooked, pickled, smoked, or dried fish containing the
infectious metacercariae
○ Intensity of human infection is dependent
upon eating habits of the population
○ Indiscriminate defecation habits among rural
inhabitants and does not always coincide
with the prevalence of the parasite in animal
reservoir hosts
○ Metacercariae from decomposing fish could
be ingested by drinking contaminated water

- Result from the temporary lodgment of immature worm

in the pharyngeal mucosa
- Immature worm can be acquired by ingestion of
infected liver of the definitive host like sheep
- Immature worm attaches in the pharynx =
inflammation, edema, dysphagia, dyspnea
- Prevalent in sheep-raising countries, dietary habits
include raw liver of sheep and other herbivores in
Middle East countries such as Lebanon and Syria
EPIDEMIOLOGY
● Cosmopolitan throughout the sheep and cattle-raising
countries of the world
○ Human fascioliasis is typically sporadic
● Reservoir: Common disease of ruminants especially
sheep, goats, and cattle
○ Including other domestic and wild animals
that cause serious economic loss in the
animal husbandry industry
● Transmission: Linked to eating raw water-grown
vegetables upon which metacercariae have encysted =
exposure of such vegetation to the feces of infected
animals
○ Washing vegetables with water, vinegar, or
lemon juice is not sufficient to remove the
encysted metacercariae
○ Use of contaminated kitchen tools in
preparing other foods can also transmit
metacercariae

FASCIOLOPSIS BUSKI ECHINOSTOMA ILOCANUM HETEROPHYIDS PARAGONIMUS WESTERMANI

HETEROPHYES HETEROPHYES AND METAGONIMUS
YOKOGAWAI

● AKA giant intestinal fluke ● AKA Garrison’s fluke Heterophyes heterophyes ● AKA human lung fluke or oriental lung fluke
● Infective stage: Metacercariae on water plant ingested ● Infective stage: Metacercariae in second intermediate ● AKA Dwarf intestinal fluke ● Infective stage: Cercariae invade the crustacean and
by humans or pigs causing infection host ingested by definitive host Metagonimus yokogawai encyst into metacercariae
● Diagnostic stage: Unembryonated eggs passed in feces ● Diagnostic stage: Unembryonated eggs passed in feces ● AKA Yokogawa’s fluke, Von Siebold’s fluke ● Diagnostic stage: Unembryonated eggs

LIFE CYCLE LIFE CYCLE ● Infective stage: Ingesting undercooked fish containing LIFE CYCLE
metacercariae
● Diagnostic stage: Embryonated eggs each with
fully-developed miracidium passed in feces

LIFE CYCLE
 PATHOGENESIS AND CLINICAL MANIFESTATIONS
Echinostomiasis
- In heavy infections:
● Characterized by inflammation that develops
at the site of attachment of the adult worm to
the intestinal wall
● Ulceration, consequently, diarrhea
(sometimes bloody), abdominal pain may
also develop
● Absorption of metabolites from worms =
general intoxication

EPIDEMIOLOGY PATHOGENESIS AND CLINICAL MANIFESTATIONS

● Cases are reported in Japan, China, Philippines and
long the Far East
● Reservoir: Aquatic birds, dogs, cats, rats and pigs -
important reservoir hosts
● Transmission: Ingestion of metacercariae encysted in
snails (second intermediate hosts of the parasites)
PATHOGENESIS AND CLINICAL MANIFESTATIONS
Fasciolopsiasis
- Associated with the traumatic, mechanical and toxic
effects of the larvae and adult worms in the host
- Larvae that attach to the duodenal and jejunal mucosa
cause inflammation and local ulceration
- Intoxication and sensitization also account for clinical
illness
- Heavy infections:
● Adult worms cause partial obstruction of the
bowel, malabsorption, protein-losing
enteropathy, and impaired vitamin B12
absorption
● Initial symptoms: diarrhea and abdominal
pain
● Toxic and allergic symptoms: appear as
edema, ascites, anemia, prostration, and
persistent diarrhea
○ Paralytic ileus is a rare
complication
EPIDEMIOLOGY
● An Asiatic trematode and has been reported from
China, Thailand, Malaysia, Korea, India, and other
Oriental regions
○ Endemicity in the Philippines has not yet been
demonstrated
● Reservoir: Pigs and humans - important definitive hosts
● Transmission: Human infections from the ingestion of
Heterophydiasis (and metagonimiasis)
○ In the Philippines, parasite is seen in
Northern Luzon, Leyte, Samar, and the
provinces of Mindanao
○ Snails are abundant in rice fields especially
during wet months
○ All infected px had a history of having eaten
snails prepared raw with coconut milk and
lime juice
EPIDEMIOLOGY
- Similar with other intestinal fluke, adult worms produce
no symptoms unless present in large numbers
- Adult worm’s small size = Intestinal obstruction least
likely to occur, but may erode the intestinal mucosa PATHOGENESIS AND CLINICAL MANIFESTATIONS
- Chronic intermittent diarrhea, nausea, and vague Paragonimiasis
abdominal complaints have been reported Two groups:
- Eggs deposited by the adult worm are filtered by the 1. Pulmonary
capillaries → carried into other organs = ectopic → - In the lungs, Paragonimus worms provoke a
induce formation of granuloma around them granulomatous reaction = development of a
● May cause embolism to the brain, spinal fibrotic cyst containing blood-tinged purulent
material, adult worms, and eggs
cord = seizures, neurologic deficits or
- Most common symptoms: chronic cough and
● To the heart = cardiac insufficiency
hemoptysis
(myocarditis) and/or heart failure
● Chest pain, dyspnea, low-grade
● Reason why heterophyids are “smallest but
fever, fatigue and generalized
deadliest fluke”
myalgia may also occur
2. Extrapulmonary
- Worm may enter any organ of the body (liver,
● H. heterophyes
intestine, peritoneum, and other organs)
○ Reported in Europe: Greece, in Spain; in the
- Clinical manifestation depends on organ
Middle East: Egypt, Israel; in the Far East:
involved
Western India, Central and South China,
- Organs in abdomen: pain, diarrhea, and
Japan, Korea, Taiwan; and in the Philippines
enlargement of liver
○ Infections with M. yokogawai: in the Far East
- Cutaneous and cerebral paragonimiasis
(Korea, Formosa, Japan, and China) as well
● Classic known forms of ectopic
as in Siberia, and in Egypt
infection
● Reservoir: Human infections = fish-eating animals
● Cutaneous: slow-moving, nodular
including dogs, cats, and birds
lesion in the subcutaneous tissue
● Transmission: Humans and other mammals acquire
in the abdomen (characteristic
infection by eating raw infected fish = parasite is
symptom)
common where this custom prevails
● Cerebral involvement: most serious
○ Waters inhabited by susceptible snails and
complication of human
fish are contaminated by fecal discharges of
paragonimiasis
human and other mammals
○ Jacksonian epilepsy and
other symptoms
characteristic of brain
tumor develop[ and may
even terminate fatality
metacercariae on fresh edible aquatic plants that grow
in ponds fertilized by night soil rather than in less
heavily polluted canals
○ Dried plants are not dangerous
■ Desiccation kills metacercariae
EPIDEMIOLOGY
● Cosmopolitan in distribution
● Chiefly confined in the Far East especially in Japan,
Korea, China, Thailand, Taiwan, and Philippines
● Present endemic provinces in PH: Oriental and
Occidental Mindoro, Camarines Sur, Sorsogon, Samar,
Leyte, Zamboanga del Norte, Compostela Valley, Davao
del Norte, Davao Oriental, Cotabato, and Basilan
● Reservoir: Zoonotic disease of carnivorous animals
○ In Asia, canines and felines - reservoir or
definitive hosts
● Transmission: Person is infected by eating uncooked
infected freshwater crabs or crayfish
○ Customary in the Orient to consume these
uncooked crustaceans in brine, vinegar, or
wine as “drunken crabs” → metacercariae
can survive for several hours
○ Metacercariae are killed if crabs are roasted
until muscles turn white or if they are heated
at 55C for 5min
○ Metacercariae dislodged during food
preparation = contaminate eating and
cooking utensils
○ Crushed crab juice, taken orally, and used in
treatment of measles in Korea = source of
infection in children