Parasitology Schistosomas February 2008

Schistosomiasis causal Agents Schistosomiasis is caused by digenetic blood trematodes The three main sp. infecting humans are: o S. haematobium o S. japonicum o S. mansoni - Two other sp, more localized geographically are S. mekongi and S. intercalatum In addition, other sp. of schistosomes, which parasitize, bisrds and mammals, can cause cercarial dermatitis in humans Cercariae are transformed into schistosomula after skin penetration and find entry superficial lymphatic vessels or subcutaneous veins to reach the lungs From pulmonary circulation, schistosomulae migrates to the portal vein where they mature Egg deposition begins from the 24th- 27th day after cercarial penetration

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Schistosoma japonicum

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Schistosoma japonicum or oriental blood fluke Endemic in China, Philippines, Sulkawesi, Indonesia In the Phil. the first report of schistosomiasis was made by Woolley in 1906 Strains from different geographic areas are distinct although all require Onchomelania snails as intermediate host

Host Range Wide range of host Dogs, pigs, cats, carabaos, cows, rodent, monkeys- found to be naturally infected - Some hosts such as humans, monkey, rabbits and mice are considered permissive hosts (S. japonicum matures and oviposists over extended periods) Others are non-permissive hosts Life Cycle - Adult male and female worms are primarily parasites of the portal vein and its branches - Females: lay – 200 immature eggs in the branches of the portal veins which require 10-12 days to mature - Eggs escape through ulcerations into the intestinal lumen → exported to feces - Embryonated egg comes in contact with water hatches → liberates miracidium - Miracidia infect small (intermediate host Onchomelania hupensis quadrasi) and develop into sporocysts Sporocysts develop into cercariae - Cercariae leave snail host and infect definitive hosts who come in contact with water by skin penetration 60-70 days from miracidial infection of the snail host to foremation of cercariae

Eggs are eliminated with feces or urine . Under optimal conditions the eggs hatch and release miracidia , which swim and penetrate specific snail intermediate hosts . The stages in the snail include 2 generations of sporocysts and the production of cercariae . Upon release from the snail, the infective cercariae swim, penetrate the skin of the human host , and shed their forked tail, becoming schistosomulae . The schistosomulae migrate through several tissues and stages to their residence in the veins ( , ). Adult worms in humans reside in the mesenteric venules in various locations, which at times seem to be specific for each species . For instance, S. japonicum is more frequently found in the superior mesenteric veins draining the small intestine , and S. mansoni occurs more often in the superior mesenteric veins draining the large intestine . However, both species can occupy either location, and they are capable of moving between sites, so it is not possible to state unequivocally that one species only occurs in one location. S. haematobium most often occurs in the venous plexus of bladder , but it

KIB

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Parasitology – Schistosomas by Dra
can also be found in the rectal venules. The females (size 7 to 20 mm; males slightly smaller) deposit eggs in the small venules of the portal and perivesical systems. The eggs are moved progressively toward the lumen of the intestine (S. mansoni and S. japonicum) and of the bladder and ureters (S. haematobium), and are eliminated with feces or urine, respectively . Pathology of S. mansoni and S. japonicum schistosomiasis includes: Katayama fever, hepatic perisinusoidal egg granulomas, Symmers’ pipe stem periportal fibrosis, portal hypertension, and occasional embolic egg granulomas in brain or spinal cord. Pathology of S. haematobium schistosomiasis includes: hematuria, scarring, calcification, squamous cell carcinoma, and occasional embolic egg granulomas in brain or spinal cord.

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acute stages present with fulminating menigoencephalitis with fever, headache, confusion, lethargy and coma Chronic cases: gives a clinical picture of a tumor with localizing signs and inc. intracranial pressure Among Filipinos, cerebral schistosomiasis is associated with pathology in other organs (liver and intestines)

Pathology Main pathology: due to host granulomatous reaction to eggs deposited in the liver and other organs Quantity of cercariae determine severity of infection cercarial penetration may result in dermatitis Schistosomular migration causes superficial lung petechiae and pneumonitis After egg deposition, there is a granulomatous hypersensitivity reaction around it most serious consequences of granuloma formation in liver is obstruction of the intrahepatic portal branches portal hypertension splenomegaly ascites Clinical Aspects Course of infection divided into 3 progressive stages 1. Incubation: corresponds to period from cercarial penetration and schistosomular migration to maturation 2. period of early egg deposition and extrusion 3. period of tissue proliferation  Early schistosomiasis itching, chills, fever, cough Colonic schistosomiasis Ulceration caused by eggs result in dysentery or diarrhea Chronis stage, it is usually asymptomatic buut occasional bouts of diarrhea may occur Occasionally chronic colonic schistosomiasis is associated with malignancies Hepatosplenic disease hepatosplenomegaly, ascites, collateral circulation Pulmonary schistosomiasis Principal manifestation is cor pulmonale from lung obstruction of lung vasculature due to granuloma formation and fibrosis Cerebral schistosomiasis

Diagnosis Immunodiagnosis 1. intradermal test for immediate cutaneous hypersensitivity using adult worm extracts 2. indirest hemagglutination using adult worm and egg antigens 3. circumoval prepitin test (COPT) 4. ELISA usibg soluble antigens of adults and eggs

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Only COPT, ELISA, and indirect hemagglutination using egg antigens should be used because these were most specific COPT demonstrates formation of bleb or septate ppt attached to one or more points on the egg surface after incubation of the eggs in a patients’ serum Currently regarded as the method of choice for the definitive diagnosis of schistosomiasis in the Phil may take more than 2 years to become neg.

Adult Schistosomes
Adult worms in humans reside in the mesenteric venules in various locations which at times seem to be specific for each sp. S. japonicum is more frequently found in the superior mesenteric veins draining the small intestine S. mansonii occurs more often in the superior mesenteric veins draining the large intestines o However, both sp can occupy either location, and they are capable of moving between sites S. haematobium most often occurs in the venous plexus of bladder but it can be found in the rectal venules Have separate sexes unlike other trematodes With large sucker capping the anterior end, a ventral sucker and a gonophore located posterior to the ventral sucker Sucker aid in movement; enables flukes to maintain position inside the veins Incomplete digestive systems; excretory system made up of flame cells. These internal structures are surrounded by circular and longitudinal muscles worms ingest rbc and pssess a protease that breaks down globulin and hemoglobin

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Parasitology – Schistosomas by Dra

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Utilize glucose and are presumed to absorb nutrients through the body wall Male shorter, sturdier Measures: 1220 mm in length by 0.40.5 mm diameter Has a gynecophoral canal where the longer female is held Testes arranged in one row above the ventral sucker Female 15-26 mm by 0.3 mm Single pyramidal ovary located in the midline

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technique (20-50 mg of fecal material) or the Ritchie technique Eggs can be found in the urine in infections with S. haematobium (recommended time for collection: between noon and 3PM) and with S. japonicum Detection will be enhanced by centrifugation and exam of the sediment Quantification is by using filtration through a Nucleopore membrane of a standard volume of urine followed by egg counts on the membrane Tissue biopsy (rectal biopsy for all sp and biopsy of the bladder for S. haematobium) may demonstrate eggs when stool or urine exam are negative

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Pathology S. mansoni and S. japomicum schistosomiasis: - Katayama fever, hepatic perisinusoidal egg granulomas, Symmers’ pipe stem periportal fibrosis, portal hypertension, and occasional embolic egg granulomas in brain or SC S. Haematobium schistosomiasis: hematuria, scarring, calcification, squamous cell ca, and occasional embolic egg granulomas in brain and spinal cord Clinical Features Continuing infection may cause granulomatous reactions and fibrosis in the affected organs, which may result in manifestations that include: - colonic polyposis with bloody diarrhea (Schistosoma mansoni mostly) - portal hypertension with hematemesis and splenomegaly (S. mansoni, S. japonicum) - cystitis and uretritis (S. haematobium) with hematuria which can progress to bladder cancer - pulmonary hypertension (S. mansoni, S. japoniocum, more rarely S. haematibium glomerulonephritis central nervous system lesion Laboratory Diagnosis Microscopic id of eggs in stool or urine: most practical method of diagnosis - Stool examination for S. mansoni or S. japonicum infection - urine exam foe S. haematobium - Eggs can be present in the stool in infections with all Schistosoma sp. The examination can be performed on a simple smear (1-2 mg of fecal materials) - Enhance detection of eggs by repeated exam and/or concentration procedures (such as the formalin- ethyl acetate technique) Field surveys and investigations purposes: quantify egg output by using the Kajo-Katz

Antibody Detection can be useful in both clinical management (e.g. recent infections) and for epidemiologic surveys can be useful to indicate schistosome infection in patients who have traveled in schistosomiasis endemic areas and in whom eggs cannot be demonstrated in fecal fecal and urine specimens Test sensitivity and specificity vary widely among the many tests reported for the serologic diagnosis of schistosomiasis and are dependent on both the type of antigen preparations used (crude, purified, adult worm, egg, cercarial) and the test procedure At CDC, a combination test with purified adult worm antigens is used for antibody detection - All serum specimens are initially tested by FASTELISA using S. mansoni adult microsomal antigen (MAMA) - A positive reaction (> 8 units/µl serum) indicates infection with Schistosoma sp - Sensitivity for S. mansoni infection is 99%, S. haematobium 95%, S. japonicum, <50% 99% specificity for detecting schistosome infection - Because test sensitivity with MAMA is reduced for sp. other than S. manson, immunoblots of the sp appropriate to the patiens’ travel history are also tested to ensure detection of S. haematobium and S. japonicum infections. immunoblots with adult worm microsomal antigens are sp-specific; a positive reaction indicates the infecting sp - presence of antibody is indicative only for schistosome infection at some time and cannot be correlated with clinical status, worm burden, egg production, or prognosis

Diagnostic Findings Microscopy

Parasitology – Schistosomas by Dra

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Eggs of S. mansoni These eggs are large Length: 114-180 µ - Have a characteristic shape with a prominent lateral spine near the posterior end The anterior end is tapered and slightly curved When the eggs are excreted, they contain a mature miracidium (visible especially in the first picture) - Egg of S. japonicum - Egg is typically oval/subspherical and has a vestigial spine - S. japonicum eggs are smaller (68-100 µ by 4580 µ) than those of the other sp - Eggs of S. haematobium In this sp the eggs are large and have a prominent terminal spine at the posterior end Length 112-170 µ greater magnification shows the miracidium inside the egg
Species Shape Stage of Dev when passed Features & variations

ant end and terminal spine, sometime s “spindle shaped”

miracidium

bent tip, resembles S. haematobium egg except it is longer, thinner and has longer spine, found in feces, debris mat adhere to shell

Characteristics of Schistosoma Eggs

Treatment safe and effective drugs are available DOC: Praziquantel Oxamniquone: tx for S. mansoni in which Praziquantel is less Special effective Geographic Distribution - S. mansoni is found in parts of S. America and the Caribbean, Africa and the Middle East - S. haematobium in Africa and the Middle East - S. japonicum in the Far East - S. mekongi and S. intercalatum are found locally in Southeast Asia and central West Africa, respectively In the Phil, there are 24 endemic provinces: Sorsogon, Oriental Mindoro, Samar, Leyte, Bohol, and all provinces in Mindanao island except Misamis Oriental - Highest prevalence of infection is in children 5-15 y/o

S. mansoni

Elongated , prominent lateral spine near posterior end, ant end tapered and slightly curved Oval with small lateral spine, may appear as small hook or “knob” located in a depressio n in the shell Elongated , rounded anterior ens, terminal spine at post end Elongated with tapered

Embryonat ed, contains mature miracidium

Lateral spine. Found in feces rarely in urine. Eggs discharged at irregular intervals; may not be found in stool. are rare in chronic stages of infection

Summary
Embryonat ed Contains mature miracidium Found in feces.Often coated with debris and maybe overlooked
Organis m S. manson S.japonic um Transmiss ion Symptom Diagno sis Tx

Skin
penetrati on by

cercadia

Eggs in Stool

S. haematobi um S. intercalatu m

Embryonat ed Contains mature miracidium Embryonat ed Contains mature

Terminal spine. Found in urine, occ in feces, egg ofte covered with debris Terminal spine long, slender with

S.
haematobi um

Skin
penetrati on

Dermatitis, urogenital cystitis, urethritris, and bladder Ca

Eggs in urine

woncee.. mjo gnulo ko ng konti ung outline.. pnagsama2 ko ung sa japonicum.. bka mjo mgulo kung ndi macompare no? Ngaun q

Praziquantel

Praziquantel

S. japonicum

Dermatitis, abdominal pain, bloody stool, periportal fibrosis, hepatosplenomeg aly, ascites, CNS

Parasitology – Schistosomas by Dra
lng naisip.. kc knina ampangit tgnan.. aun, kung gs2 nyo nun dti, kau na mag-aus! Hehehe.. tmadz nq.. - malta

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