Clonorchis sinensis

Common name: Chinese liver fluke.

Common associated disease and condition names: Clonorchiasis.
Morphology
EGGS- The typical Clonorchis sinensis egg measures 30 by 15 μm.
The developed miracidium takes up the interior of the egg.
The egg is equipped with a distinct operculum opposite a small knob.
A thick rim is strategically located around the operculum and is referred
to as shoulders.
ADULTS
The average adult C. sinensis
measures 2 by 0.5 cm.
Each end of the adult worm is
narrower than the
midportion of the body.
LIFE CYCLE
Human C. sinensis infection occurs following the ingestion of
undercooked fish contaminated with encysted metacercariae.
Maturation of the immature flukes takes place in the liver.
The adult worms take up residence in the bile duct.
EPIDEMIOLOGY
C. sinensis is endemic in areas of the Far East, including China,
especially the northeast portions, Taiwan, Korea, Vietnam, and Japan.
Reservoir hosts include fish-eating mammals, dogs,and cats.
More than 35 million people are infected, and the numbers have
tripled to 15 million in China alone in the last decade.
Much of this increase may be the result of aquaculture.
CLINICAL SYMPTOMS
Asymptomatic. Light infections typically occur without any obvious
symptoms.
Clonorchiasis. Persons infected with a heavy worm burden often
experience symptoms that include fever, abdominal pain, eosinophilia,
diarrhea, anorexia, epigastric discomfort, and occasional jaundice.
Enlargement and tenderness of the liver and leukocytosis may also
occur.
Liver dysfunction may result in persons severely infected over a long
period of time.
TREATMENT
The treatment for C. sinensis infection is praziquantel or albendazole.
PREVENTION AND CONTROL
Prevention and control measures for halting the spread of C. sinensis
include:
1. Practicing proper sanitation procedures, especially in regard to
fecal disposal by the human and reservoir host (dogs and cats) and
2. Avoiding the ingestion of raw, undercooked, or freshly pickled
freshwater fish and shrimp.
Fasciolopsis buski
Fasciola hepatica
Fasciolopsis buski
Common name: Large intestinal fluke.
Common associated disease and condition names: Fasciolopsiasis.

Fasciola hepatica
Common name: Sheep liver fluke.
Common associated disease and condition names: Fascioliasis, sheep
liver rot.
F. Buski egg
F. Hepatica eggs
ADULTS
• The somewhat oblong, fleshy adult F. buski averages 5 by 1.5 cm in
size.
• The adult F. hepatica is comparable in size to F. buski, measuring
approximately 3 by 1 cm. Unlike F. buski, F. hepatica is equipped with
so-called shoulders.
Laboratory Diagnosis
• The specimen choice for recovery of the eggs of F. buski and F.
hepatica is stool. Because the eggs are indistinguishable, information
regarding patient symptoms and travel history is necessary to
diagnose the causative species. Speciation may also be accomplished
by recovery of the adult Fasciolopsis worm.
• Other methodologies available for the detection of Fasciola include
the Enterotest, ELISA, and gel diffusion.
Life Cycle
• The primary difference in the life cycles of F. buski and F. hepatica is
where the adult worms reside in the human host.
• F. buski adults live in the small intestine—thus, the common name
intestinal fluke.
• The adults of F. hepatica take up residence in the bile ducts—hence,
the common name liver fluke.
EPIDEMIOLOGY
Although the transmission of infection to humans is the same, through
ingestion of raw infected water plants, the geographic distribution of these
two parasites, F. buski and F. hepatica, varies. F. buski is limited to areas of
the Far East, including parts of China, Thailand, Taiwan, and Vietnam, as well
as regions in India and Indonesia.
Several animals, including rabbits, pigs, and dogs, may serve as reservoir
hosts.
The water chestnut, lotus, and water caltrop are common food sources.

F. hepatica is found worldwide, particularly in areas in which sheep and

cattle are raised. The natural host for the completion of the F. hepatica life
cycle is the sheep.
Humans serve as accidental hosts.
Clinical Symptoms
FASCIOLOPSIASIS
Patients suffering from F. buski infection usually develop abdominal
discomfort because of irritation at the site of worm attachment in the
small intestine. This is often accompanied by inflammation and
bleeding of the affected area, jaundice, diarrhea, gastric discomfort,
and edema. These symptoms often mimic those of a person suffering
from a duodenal ulcer. Patients may also suffer from malabsorption
syndrome, similar to that seen in patients with giardiasis. Intestinal
obstruction, and even death, although rare, may result.
CLINICAL SYMPTOMS
Fascioliasis/Sheep Liver Rot
Persons infected with F. hepatica experience symptoms caused by the
presence and attachment of the adult worm to the biliary tract. These
include headache, fever, and chills, and pains in the liver area of the
body (because of tissue damage), some of which may extend to the
shoulders and back.
Eosinophilia, jaundice, liver tenderness, anemia, diarrhea, and digestive
discomfort are sometimes seen. Biliary obstruction may also result.
Treatment
Infections with F. buski may be treated with praziquantel.
Patients suffering from F. hepatica infection have been successfully
treated with dichlorophenol (bithionol).
Triclabendazole is more effective but is not available in the United
States.
Prevention and Control
Prevention of future potential infections with F. buski and F. hepatica
may be accomplished by:

1. Exercising proper human fecal disposal and sanitation practices,

particularly in areas in which animal reservoir hosts reside
2. Controlling the snail population,
3. Avoiding the human consumption of raw water plants or
contaminated water.
Metagonimus yokogawai
Common name: Heterophid fluke.
Common associated disease and condition names: Metagonimiasis.
EGGS
Eggs. The eggs of Heterophyes heterophyes and Metagonimus
yokogawai are basically indistinguishable and may be easily confused
with those of C. sinensis (Table 11-3; see Fig. 11-5).
These eggs measure approximately the same as C. sinensis, 30 by 15
μm. There are only twosomewhat discrete differences among the eggs
of H. heterophyes and M. yokogawai versus those of C. sinensis.
First, although the Heterophyes and Metagonimus eggs have shoulders,
they are less distinct than those of Clonorchis.
Second, the eggs of Heterophyes and Metagonimus may lack the small
terminal knob found on those of Clonorchis.
The eggs of both species consist of a developing miracidium, similar to
those of Clonorchis.
In addition, they both exhibit an operculum like that of Clonorchis.
However, it is important to note that Heterophyes eggs typically have a
much thicker shell than those of Metagonimus.
This is generally not considered enough of a difference to distinguish
between the two species.
ADULTS
The adult Heterophyes worm is small, measuring just over 1.0 by 0.5 mm in
size.
The pyriform organism is grayish in color and is protected by an outer layer
of fine spines that are scaly in appearance.
The adult Metagonimus is similar in size, measuring approximately 1.5 by
0.5 mm.
The worm is also pyriform in shape, with tapering at the anterior end and
rounding at the posterior end.
A tiny layer of scaly spines covers the organism, which is heavily distributed
over the anterior end.
Life Cycle Notes
Human infection of Heterophyes and Metagonimus occurs after the
ingestion of contaminated undercooked fish.
The adult worms of both species reside in the small intestine.
LABORATORY DIAGNOSIS
Identification of Heterophyes and Metagonimus is based on the
recovery of the eggs in stool samples.
Careful microscopic examination is essential to ensure proper species
identification.
This is difficult to achieve because the eggs of Heterophyes,
Metagonimus, and Clonorchis are so similar.
EPIDEMIOLOGY
Metagonimus has been reported in areas of Japan, Siberia, China, the
Philippines, Spain, Greece, and the Balkans.
A number of animals are known to harbor the parasite, including
dogs, cats, hogs, and fish-eating birds such as pelicans.
CLINICAL SYMPTOMS
Asymptomatic. Light infections typically remain asymptomatic.

Heterophyiasis/Metagonimiasis. Heavy infections of H. heterophyes

and M. yokogawai produce similar symptoms. In addition to abdominal
pain and discomfort, patients often experience a chronic mucous
diarrhea and eosinophilia.
The eggs of both organisms have the ability toescape into the
lymphatics or venules via intestinal wall penetration and to migrate to
otherareas of the body, such as the heart or brain.
Granulomas in these areas often result.
TREATMENT
The treatment of choice for Heterophyes and Metagonimus infection is
praziquantel.
PREVENTION AND CONTROL
The easiest and most logistically possible measure to prevent and
control Heterophyes and Metagonimus is the avoidance of consuming
undercooked fish.
In addition, practicing proper fecal disposal is also essential for halting
the spread of disease.
Because of the numerous animal hosts that may harbor both parasites,
control of these populations, as well as that of the snails, is physically
and economically impossible.
Paragonimus westermani
Common name: Oriental lung fluke.
Common associated disease and condition names: Paragonimiasis,
pulmonary distomiasis.
EGGS
The average egg of Paragonimus westermani ranges in size from 78 to 120
μm by 45 to 60 μm (Fig. 11-7; Table 11-4).
The somewhat oval egg consists of an undeveloped miracidium protected by
a thin smooth shell.
An opercular rim (shoulders) surrounds the prominent operculum.
An obvious terminal shell thickening is located on the end opposite the
operculum.

Diphylobothrium latum eggs have similar morphology to P. westermani but

lack opercular shoulders and are more rounded in shape.
D. latum eggs also have an abopercular knob lacking in P. westermani.
Size is also helpful in distinguishing the two eggs in stool specimens.
ADULTS
The typical somewhat oval, red- to brown-colored adult P. westermani
measures 1 by 0.7 cm (Fig. 11-8).
The cuticle of P. westermani possesses spines, similar to the other adult
trematodes.
Laboratory Diagnosis
Diagnosis of P. westermani is accomplished by the recovery of eggs in
sputum specimens.
These eggs are commonly found in bloody samples.
Occasionally, the eggs may be seen in stool samples when sputum is
swallowed.
Serologic tests have also been developed.
LIFE CYCLE
P. westermani is transmitted in undercooked crayfish or crabs.
On ingestion of such freshwater products, the immature flukes (often
occurring in pairs) are released into the body------ where they
migrate through the intestinal wall---- through the peritoneal cavity--
----- into the diaphragm------ and finally into lung tissue, where
encystation occurs.
Migration of immature flukes to other areas of the body, such as the
brain or liver, has been known to take place.
EPIDEMIOLOGY
Infections caused by P. westermani occur in several areas of the world,
including portions of Asia and Africa, India, and South America.
Pigs and monkeys serve as reservoir hosts, as well as other animals
whose diet includes crayfish and crabs.
A number of related species of Paragonimus have also been known to
cause human disease, not only in Central and South America but also in
portions of the United States.
CLINICAL SYMPTOMS
Patients infected with Paragonimus typically experience symptoms
associated with pulmonary discomfort—cough, fever, chest pain, and
increased production of blood-tinged sputum.

Individuals infected with this parasite (the corresponding condition is

known at paragonimiasis and as pulmonary distomiasis) may also
experience chronic bronchitis, eosinophilia, and the production of
fibrous tissue. These symptoms often mimic those seen in persons
infected with tuberculosis.
Patients who develop infections in areas other than the lung
experience symptoms corresponding to the affected organ or tissue.
One area is the brain.

Cerebral Paragonimiasis. Migration of immature P. westermani

organisms to the brain may result in the development of a serious
neurologic condition. Patients experience seizures, visual difficulties,
and decreased precision of motor skills.
TREATMENT
Praziquantel is the medication of choice for the treatment of
Paragonimus.
An acceptable alternative drug is bithionol.
PREVENTION AND CONTROL
The primary prevention and control measures for the eradication of
Paragonimus includes:
1. Avoiding human ingestion of undercooked crayfish and
crabs and
2. Exercising proper disposal of human waste products.
 SCHISTOSOMA SPECIES
Schistosoma mansoni
Schistosoma japonicum
Schistosoma haematobium
Schistosoma mansoni
Common name: Manson’s blood fluke

Schistosoma japonicum
Common name: Blood fluke

Schistosoma haematobium
Common name: Bladder fluke.
Common Schistosoma spp. disease and condition names: Schistosomiasis,
bilharziasis, swamp
fever, Katayama fever.
EGGS
The average Schistosoma egg is com-prised of a developed miracidium (Table 11-5).
The presence of lateral or terminal spines, as well as the organism’s shape and size, aid in species
identification.
Schistosoma mansoni (Fig. 11-9) is relatively large, measuring 112 to 182 μm by 40 to 75 μm.
The organism is somewhat oblong and possesses a prominent large lateral spine.

The somewhat roundish Schistosoma japonicum (Fig. 11-10) is the smallest of the Schistosoma spp., measuring
50 to 85 μm by 38 to
60 μm. The egg is characterized by the presence of a small lateral spine, which is often difficult to detect on
microscopic examination.

Schistosoma haematobium (Fig. 11-11) resembles S. mansoni in size and shape. The somewhat
oblong egg measures 110 to 170 μm by 38 to 70 μm. The presence of a large, prominent, ter-
minal spine distinguishes the egg from that of other Schistosoma spp.
S. Mansoni egg
S. Japonicum egg
S. Haematobium egg
ADULTS
The schistosomes are rounder in
appearance.
Although the typical female
measures 2 cm in length and the
male measures 1.5 cm, the male
surrounds the female almost
completely, facilitating
copulation.
LABORATORY DIAGNOSIS
Laboratory diagnosis of S. mansoni and S. japonicum is accomplished
by recovery of the eggs in stool or rectal biopsy specimens.
The specimen of choice for the recovery of S. haematobium eggs is a
concentrated urine specimen.
In addition, a number of immunodiagnostic techniques, including
ELISA, are also available.
LIFE CYCLE
Human infection with Schistosoma occurs in fresh water
following the penetration of fork- tailed cercariae into the skin-
- The resulting schistosomule migrates into the bloodstream,
where maturation into adulthood is completed.
The location of the adult flukes varies by species. S. mansoni
and S. japonicum reside in the veins that surround the
intestinal tract, as well as in the blood passages of the liver. S.
haematobium resides in the veins surrounding the bladder.
Females lay thousands of eggs daily, which make their way
from the bloodstream through the tissue into the colon (S.
mansoni and S. japonicum) or the urine (S. haematobium).
The eggs produce enzymes that help them travel through the
tissue to be excreted. Once an egg reaches fresh water, the
miracidium is released from the egg and must locate a snail,
where it develops into the cercariae.
EPIDEMIOLOGY
There are a number of reservoir hosts capable of carrying Schistosoma
spp which include monkeys, cattle and other livestock, rodents, and
domesticated animals such as dogs and cats.
The specific geographic distribution of each of the three Schistosoma
spp. vary by species.
S. mansoni originated in the Old World because it is prevalent primarily
in parts of Africa. Transport of the organism to the New World most
likely occurred via the slave trade. Known endemic areas include Puerto
Rico, the West Indies, and portions of Central and South America.
The geographic distribution of S. japonicum is limited to the Far East.
Areas known to harbor the parasite include parts of China, Indonesia,
and the Philippines.

S. haematobium has been known to occur primarily in the Old World.

Almost all of Africa and portions of the Middle East, including Iran, Iraq,
and Saudi Arabia are considered endemic regions.
CLINICAL SYMPTOMS
It is believed that most chronic Schistosoma infections contracted in
known endemic areas remain asymptomatic.
A brown hematin pigment, similar to the pigment seen in persons
infected with malaria, is present in the macrophages and neutrophils
(microphages is not used very often) of these patients.
The first symptom experienced by most symptomatic persons infected with
Schistosoma is inflammation at the cercaria penetration site.
Symptoms of acute infection include abdominal pain, fever, chills, weight loss,
cough, bloody diarrhea, and eosinophilia.
Painful urination and hematuria may also occur in persons infected with S.
haematobium.
The development of necrosis, lesions, and granulomas is common and occurs in the
area(s) infected with the parasite.

Obstruction of the bowel or ureters, as well as secondary bacterial infections and

involvement of the central nervous system and other tissues, may also result.
KATAYAMA FEVER
It is systemic hypersensitivity reaction to the schistosomulae migrating
through tissue.
Rapid onset of fever, nausea, myalgia, malaise, fatigue, cough, diarrhea,
and eosinophilia occur 1 to 2 months after exposure.
Although rare in chronically exposed persons, it is common in people
new to endemic areas, such as tourists and travelers.
TREATMENT
Praziquantel is the drug of choice for the treatment of schistosomal
infections. Oxamniquine is only used for S. mansoni.
The antimalarial artemisinins, artemether and artesunate, have proven
effective for schistosomal infections but, in areasendemic for malaria,
concern for resistance by Plasmodium may limit their usefulness.
Surgery may be necessary for patients in whom obstruction has
occurred.
PREVENTION AND CONTROL
Schistosomiasis may be avoided by proper human waste disposal and control of the
snail population, primarily their breeding areas, prompt diagnosis and treatment of
infected persons, the avoidance of human contact with potentially contaminated
water, and educational programs for the inhabitants of known endemic areas.
Current focus is on anthelminthic chemotherapy with praziquantel because of its
low cost, few side effects, and rapid results.

The World Health Organization (WHO) has recommended the following measures:
mass treatment of everyone in a community in which there is a high prevalence
and/or high risk of schistosomiasis (7 of 15 or more children test positive),
treatment of all children in moderately prevalent areas (2 of 15 children test
positive), and only treating diagnosed cases in low-prevalence areas.
The trematodes (another name for the parasites that belong to
Trematoda) can be divided into two groups:
1. the hermaphroditic (self-fertilizing) flukes that infect organs and are
foodborne,
2. and the blood flukes or schistosomes that are dioecious (para-
sites that reproduce via separate sexes) and infect by direct
penetration.
Common to all trematodes is their complex life cycles, which almost
always include mollusks (snails) as an intermediate host.
MORPHOLOGY AND LIFE CYCLE NOTES
• The trematodes pass through
three morphologic forms during
their life cycle—eggs, multiple
larval stages, and adult worms.
• EGGS- The eggs, which are the
primary morphologic form
recovered in human specimens,
vary in appearance.
- Some contain a lid-like
structure that under the appropriate
conditions flips open to release its
contents for further development,
called an operculum, such as in
Fasciolopsis and Fasciola.
ADULTS
• The rarely seen adult flukes are thin
and non-segmented, resembling
leaves in shape and thickness.
• They typically range in length from 1
to 5 cm.
• Each adult fluke is equipped with two
muscular, cup-shaped suckers, one
oral and the other located ventrally, a
simple digestive system, and a genital
tract.
Like the typical cestode, the average
trematode uses its body surface as a
means for absorbing and releasing
essential nutrients and waste products.
• Based on the organism’s life cycle, the trematodes may be placed into
two categories:
1. those that reside in the intestine, bile duct, or lung (organ-dwelling)
-The organ-dwelling flukes include all trematodes except those
belonging to the genus Schistosoma.
Human infection of such organ-dwelling flukes occurs following the
ingestion of water plants (e.g., water chestnuts), fish, crab, or crayfish
contaminated with the encysted form of the parasite known as
metacercaria.
• On entrance into the intestinal tract, the encysted metacercaria
excysts and migrates to the intestine, bile duct, or lung ------
Developmentinto the adult stage occurs here--- Following self-
fertilization (all organ-dwelling flukes are hermaphroditic), the
resulting eggs exit the host viathe feces or sputum----- On contact
with fresh water,the miracidium (contents of the egg) emerges from
each egg.
Specific species of snails serve as the first intermediate host--- The
miracidium penetrates into the snail, where the development of a
larval form consisting of a saclike structure (sporocyst) occurs.
Numerous rediae (a larval stage that forms in the sporocyst) result and
ultimately produce many cercariae (final-stage larvae)--- The
cercariae emerge from the snail and encyst on water plants or enter a
fish, crab, or crayfish, which serves as the second intermediate host.
Human consumption of these contaminated items initiates a new cycle.
 2. and those that reside in the blood vessels around the intestine and
bladder (blood-dwelling).
The blood-dwelling flukes consist of the Schistosoma spp. Human
infection of these flukesoccurs following the penetration of cercariae
into the skin. This typically happens when an unsuspecting human
swims or wades in contaminated water---- Following penetration, the
resulting schistosomule (the morphologic form that emerges from
cercariae following human penetration)takes up residence in the blood
vessels around the liver, intestinal tract, or urinary bladder,where
maturation into adulthood occurs------
Because sexes are separate, the presence of both an adult male and an
adult female is necessary for copulation to take place- Completion of
this mating process results in numerous eggs----- Passage of the eggs
may take place in the urine or stool, depending on the species- The
development of the miracidium, sporocyst (daughter sporocysts are
produced in place of rediae in this cycle), and cercariae occur in the
same manner as those of the organ-dwelling flukes-- The cercariae
emerge from the snail-> An additional host is not required in this cycle.
The cercariae, on penetrating the skin of a new human host, initiate a
new cycle.
LABORATORY DIAGNOSIS
• The specimen of choice for the recovery of trematode organisms is
species-dependent. Samples include feces, duodenal drainage, rectal
biopsy, sputum, and urine.
• Eggs are the primary morphologic form seen in these specimens.
• Under appropriate conditions, adult worms may be recovered.
• Serologic tests, such as the enzyme-linked immunofluorescence assay
(ELISA), are also available for the diagnosis of the blood flukes
(Schistosoma spp.).