Parasites in

Genitourinary tract
Schistosoma Sp.

Bagian Parasitologi FK Unisba

Helminths:
 Animalia
 Multicellular
 Clasification :
 Phylum: Platyhelminthes (flatworms)
 Class: Cestodes (tapeworms)
 Class: Trematodes (flukes)
 E.g., Schistosoma
Fasciola sp.
 Phylum: Nemanthelminthes (roundworms)
 Class nematodes
 E.g.,Ascaris, Filaria
Trematodes
 Flukes
 Oral sucker: food uptake
 Incomplete digestive tract
 Ventral Sucker: Attachment
 Mostly hermaphroditic, except
Schistosoma
"Copyright Dennis Kunkel Microscopy, Inc.
(www.denniskunkel.com)"
 Schistosoma
 Schistosome: A parasitic trematode worm that
is capable of causing liver, gastrointestinal tract
and bladder disease.

 Schistosomiasis or bilharzia after the German

physician Theodor Bilharz (1825-1862).
Three main spesies:
 Schistosoma japonicum

 Schistosoma mansoni

 Schistosoma haematobium

Geographic distribution:
 S. mansoni -South America,Caribbean, Africa, Middle
East
 S. haematobium -Africa, Middle East
 S. japonicum -Philippines, Japan,South Asia, Taiwan,
Indonesia
Definitive and Intermediate Host
 Definitive host: Human

 Intermediate host: Snail

Biomphalaria (S. mansoni)

Oncomelania (S.japonicum)
Bulinus (S. haematobium)

 Reservoirs: monkeys, rodents, cats, dogs,

cattle, horses, swine, wild mammals.
Developmental Stages of
Schistosoma
Egg Miracidia

Cercaria Adult male and female

penetrating skin worms
Schistosoma: Life Cycle
Adult Schistosoma ‘s
morphology
 Cover by integument which frequently
provided with spines
 Have two muscular sucker : oral and
ventral
 The alimentary system end blindly
 Not hermaphrodith
 The lifespan of an adult worm averages 3–
5 years, but can be as long as 30 years
 An infected person probably harbours an
average of hundreds (range, 10s–1000s)
of worms
Morphology S. mansoni
The Male
The male S. mansoni is
approximately 1 cm long
(0.6 to 1.4 cm) and is
0.11 cm wide.
It is white and it has a
funnel-shaped oral
sucker at its anterior end.
Have 6-9 testes
have gynecophoral
canal
The female
 has a cilindric body
 longer and thinner
than the male (1.2 to
1.6 cm long by 0.016
cm wide).
 is darker and it looks
gray. The darker color
is due to the presence
of a pigment
(hemozoin) in its
digestive tube
Morphology
Egg’s Morphology

S. mansoni
 Eggs : 114-175µm,
yellowish brown
transparant shell with
lateral spine
S. japonicum
 Eggs : spherical with
minute lateral spine
near one end of the
the egg
S. haematobium
 Eggs : 112-170 m by
40-70 m, contain a
conspicuous
terminal spine.
 *Morphology (eggs)*
A B 

C
Miracidium
 Length ~150 μm
 non-feeding
 Swim rapidly (2mm/s for ~6 h) using cilia
 Swimming behaviour is positively photokinetic, and
possibly chemokinetic towards snail components
 The apical papilla facilitates attachment to the snail
surface; penetration is possibly achieved by
release of proteases from glands (lateral and
apical) and mechanical movement.
Sporocyst
 Inside the snail host the
miracidium sheds its ciliated plates
 A new syncytial tegument is
formed and the larva
differentiates into a mother
sporocyst that produces germ-cell
derived daughter sporocysts that
develop and produce large
numbers of cercariae
 Nutrients from the snail plasma are
absorbed via tegument
Cercaria
 Free-living, non-feeding
 Length~325μm
 emerge from the infected snail
approximately 4 – 5 weeks post
snail-infection
 Host finding isinfluenced by water
turbulence, shadows and certain
skin chemicals including
ceramides,arginine and linoleic acid.
 Cercaria leave the snail at a rate of
thousands per day after a period of weeks.
 Mollusca shed of these cercariae can
continue for months
Schistosoma: Epidemiology
 200 million people infected world wide in over 70
countries
 50% endemic among the local population in high
infested areas
 South America
 Caribbean
 Africa
 Middle East Depends on species
 Far East
 Asia
Schistosomiasis in Indonesia
 Schistosomiasis is endemic in Indonesia in
two isolated areas, Lindu valley and Napu
valley, both located in the Province of Central
Sulawesi.
 In 1940, in Lake Lindu, Schistosoma
japonicum infection prevalence of 56%
among the population of Anca, Tomado and
Langko villages.
 In 1973 in Napu valley, up to 72% were found
among the population in Winowanga village
 In 2006, it was 0.49% in 7 villages in Lindu
valley. In 17 villages Napu valley was1.08%.
 Schistosoma and Affected
Organs
 S. japonicum  superior mesenteric veins
of small intestine

 S. mansoni  superior mesenteric veins

draining of large intestine

 venous plexus of bladder

 S. haematobium
Pathophysiology
 Eggs that do not leave the body are swept
ƒto the pre-`sinusoidal capillaries of the liver
and are trapped there or in the bladder wall
 The immune system responds and walls ƒoff
the eggs with a granuloma, the egg dies 
fibrosis  portal hypertension  collateral
ƒeosophageal varices
 Continuous aggravation in the bladder ƒwall
leads to carcinoma of the bladder
 Schistosoma: Diseases
 Bilharzia/Schistosomiasis
 Often asymptomatic
 Schistosomiasis’s phases:
 24 hours to rash (smimmer’s itch)
 ~1-2 months to acute systemic symptoms 
 ~3-6 months to 1+ year to chronic symptoms
Swimmer’s itch
 an itchy papular skin rash and local swelling
often starts about 24 hrs after the initial
infection and lasts for about 4 days.
Acute schistosomiasis
(Katayama's fever)
 May occur weeks after the initial infection
 S. mansoni and S. japonicum
 Fever, cough, abdominal pain, diarrhea,
hepatospenomegaly, and eosinophilia
 Occasionally central nervous system lesions
occur
 granulomatous lesions around ectopic eggs
 Brain, spinal cord
Chronic infection
 Granulomatous reactions and fibrosis in the
affected organs
 Colonic polyposis with bloody diarrhea
(Schistosoma mansoni mostly)
 Portal hypertension with hematemesis and
splenomegaly (S. mansoni, S. japonicum)
 Cystitis and ureteritis (S. haematobium) with
hematuria, which can progress to bladder
cancer;
Urinary schistosomiasis
 Urinary schistosomiasis is often chronic and
can cause pain, secondary infections, kidney
damage, and even cancer. 
 In Egypt : boys were expected to go
through a “male menarche”—sometime
during adolescence, it was normal for them to
urinate blood. 
Urinary schistosomiasis
 WHO estimates that worldwide, 180 million people live in
endemic areas and 90 million are infected with the
parasites.
 Most of these live in Sub-Saharan Africa.
 70 million persons suffer from schistosomal hematuria
(blood in the urine)
 18 million from associated bladder wall pathology
 10 million from hydronephrosis
 150,000 people die each year from resultant renal failure
 The overall mortality rate is estimated to be at least 2 per
1,000 infected patients per year.
Symptoms
 Early: swimmer’s itch
 Katayama fever :
 lasts for 1-3 weeks.
 Not everyone manifests these early-stage signs
and symptoms.
 Chronic :
 gradual onset
 After months or years
Chronic
 painful or difficult urination (dysuria)
 blood in urine (hematuria),
 urethral obstruction
 kidney damage from obstruction of urine
(obstructive nephropathy),
 no urination (dysuria)
 elephantiasis of penis.
Complication
 Earlier complications (moths-years):
 Chronic bacterial urinary tract infections.
 The bladder may also develop tubercles, polyps,
ulcers, sandy patches, cystitis cystica, and/or
leukoplakia
 Late complication (years):
 Bladder cancer (squamous cell carcinoma)
 Diagnosis
 Microscopic identification of eggs in stool or urine (most
practical)  4-8 weeks after infection
 Tissue biopsy- rectal or bladder biopsy may
demonstrate eggs when stool or urine examinations are
negative.
 Antibody detection
 ELISA and immunoblot

 Schistosomal adult microsomal antigen

 cannot be correlated with clinical status, worm burden,

egg production, or prognosis
 Morphologic comparison with other intestinal parasites
 *Treatment*
 praziquantel -drug of choice, 40mg/kg,
single dose, safe and effective in the
treatment of all forms of schistosomiasis
 Oxamniquine -used exclusively to treat
intestinal schistosomiasis caused by S.
mansoni.
 Metrifonate - effective for the treatment
of urinary schistosomiasis
 Schistosoma: Prevention
 No vaccine
 Avoid wading, swimming or other fresh-water
contact in endemic countries
 Avoid untreated piped water coming directly from
canals, lakes, rivers, streams or springs that may
contain cercariae
 Heating bathing water to 50°C (122°F) for 5 minutes
or filtering water with fine-mesh filters
 Good sanitation practices, control of the snail
population
 Niclosamide, as aprotective barrier to penetration by
schistosome cercariae.
Alhamdulillaah….