CESTODES AND TREMATODES

Fort Salvador
CESTODES
 GENERAL
CHARACTERISTICS

• Part of phylum Platyhelminthes

• Divided into Cestoda and Trematoda
• Two main parts: a scolex and a flat body
made of proglottids
• Scolex is for attachment: suckers, hooks,
grooves
• Germinal center produces proglottids
• Mature and become gravid
• Oldest are gravid; produce eggs
 TAENIA SPP.

• Scolex has four suckers and a circle of hooks (T. solium);

scolex of T. saginata has no hooks
• Gravid proglottids have 5-10 uterine branches (T. solium);
T. saginata proglottids have 15-25 uterine branches
• Infected via ingestion of raw or undercooked pork
containing cysticerci
• Fluid filled bladder with invaginated scolex
• Pigs or cows are intermediate hosts; humans are the
definitive hosts
 LIFE CYCLE

• Larvae attach to SI and grow to 5 m (T. solium) or 10 m (T. saginata) in 3 months

• Gravid proglottids containing eggs detach daily and pass in the feces; eggs eaten by
pigs or cows
• Oncosphere (six-hooked embryo) emerges from each egg in gut
• Burrow into blood vessel to be carried to muscle; mature into cysticerci
• If human ingests eggs; cysticerci are formed in the body
• Eggs are only from humans; pigs do not have adult worms
• Cysticerci can disseminate to many organs (eyes, skin, brain)
• Only T. solium causes cysticercosis
 PATHOGENESIS AND CLINICAL
FINDINGS

• Adult tapeworm causes little damage

• Cysticerci can grow large and can form space-occupying lesions
• Live larvae do not cause inflammation; dead larvae can release
antigens
• Cysticerci calcify
• Patients mostly asymptomatic; anorexia and diarrhea may occur
• Cysticercosis in the brain – headache, vomiting, seizures
• Cysticercosis in the eyes – retinitis, uveitis, floating in vitreous
• Cysticercosis in the skin – subcutaneous nodules
 DIAGNOSIS AND TREATMENT

• Finding eggs in the stool

• Differentiation of proglottids
• Cysticercosis diagnosed via demonstration of cysts
• Treat with praziquantel
 DIPHYLLOBOTHRIUM LATUM

• Fish tapeworm
• Do not have suckers; has sucking grooves
• Proglottids are wider than they are long
• Eggs are oval and have an operculum; unique among tapeworms
• Longest of the tapeworms: 13 m
• Infection starts by ingestion of plerocercoid larvae in raw or
undercooked fish
 LIFE CYCLE

• Larvae attach and mature in the human gut

• Gravid proglottids release eggs via a genital pore
• Eggs hatch into coracidia in fresh water
• Eaten by copepod crustaceans (first intermediate hosts); mature into procercoid larvae
• Crustaceans eaten by freshwater fish (second intermediate hosts); mature into
plerocercoid larvae in fish muscle
• Humans are the definitive hosts
 PATHOGENESIS AND CLINICAL
FINDINGS

• Little damage in the small intestine

• Vitamin B12 deficiency causes megaloblastic anemia

• Endemic in areas where eating raw fish is custom

• Mostly asymptomatic infections; diarrhea and abdominal discomfort may occur
 DIAGNOSIS AND TREATMENT

• Diagnosed via finding operculated eggs in stool

• Treated with praziquantel
 ECHINOCOCCUS
GRANULOSUS

• Causes unilocular hydatid disease

• Composed of a hooked scolex and three proglottids
• One of the smallest tapeworms
• Dogs are the definitive hosts; sheep and humans are
intermediate hosts
• Adult worms in dog’s gut liberate eggs
• Eggs are ingested by sheep or humans; oncosphere emerges
• Migrates to liver (main), lungs, bones, brain
• Matures into hydatid cysts (contains protoscoleces)
• Cycle completed when sheep liver is eaten by the dog
 PATHOGENESIS AND CLINICAL
FINDINGS

• Forms one fluid-filled cyst

• Many individual protoscoleces (hydatid sand) and daughter cysts
• Host forms fibrous capsule outside the cyst
• Space occupying lesions
• If cysts rupture: can lead to anaphylactic shock
• Many individuals are asymptomatic
• May cause hepatic dysfunction (jaundice, portal hypertension); hemoptysis,
headache, focal neurologic signs
 DIAGNOSIS AND TREATMENT

• Brood capsules with multiple protoscoleces

• Treated by albendazole; removal of cysts (irrigation first
with hypertonic saline)
 ECHINOCOCCUS
MULTILOCULARIS

• Definitive hosts are foxes; intermediate

hosts are rodents
• Ingestion of fox feces
• Multiloculated cysts with few
protoscoleces; no outer fibrous capsule
forms
• Form multiple vesicles
• Involves jaundice, weight loss
• Prognosis is poor
 HYMENOLEPIS NANA AND
HYMENOLEPIS DIMINUTA

• Dwarf tapeworm; only 3-5 cm long

• Eggs are directly infectious for humans
• Can have autoinfections; thus many worms can be found in one
person (unlike other tapeworms)
• Rodents are the definitive host; only tapeworm that can be
transmitted from human to human without an intermediate host
• Patients are asymptomatic; may produce weakness,
anorexia, abdominal pain in the heavily-infected
• Find eggs in stool (8-10 polar filaments outside the
hexacanth embryo for H. nana)
 DIPYLIDIUM
CANINUM

• Dog and cat tapeworm

• Infected via ingestion of fleas that have
cysticerci (kids)
• Most human infections are asymptomatic;
diarrhea and pruritus ani may occur
• Diagnosed via finding barrel-shaped
proglottids in the feces
• Treat with niclosamide
TREMATODES
 GENERAL CHARACTERISTICS

• Flukes
• Involves a sexual cycle in humans and asexual reproduction in freshwater
snails
• Ingestion of cysts or skin penetration by cercariae
 SCHISTOSOMA SPP.

• Schistosoma japonicum, Schistosoma mansoni, Schistosoma haematobium

• Only trematode that exists as separate sexes
• Female lives inside the male’s gynecophoric canal
• Schistosoma japonicum and S. mansoni reside in the mesenteric veins
• S. haematobium reside in the bladder veins
• Humans infected by cercariae penetrating skin
 LIFE CYCLE

• Eggs that hatch penetrate the gut or bladder wall

• Leave via the feces or urine
• Differentiate into miracidia (ciliated) in fresh water
• Miracidia penetrate snails and produce many cercariae
• S. japonicum – Oncomelania hupensis quadrasi
• S. mansoni – Biomphalaria
• S. haematobium – Bulinus
 PATHOGENESIS

• Presence of eggs in the liver, spleen, gut, or bladder

• Induce granulomas in the liver – fibrosis, hepatomegaly, portal hypertension
• Liver function tests are normal
• PH leads to splenomegaly and gastroesophageal varices
• Damage wall of the SI and LI (S. japonicum), or just the LI (S. mansoni)
• Proteolytic enzymes and granulomatous inflammation
• Damage wall of bladder – S. haematobium; can predispose to bladder cancer
• Coat their surface with host antigens
• S. japonicum is the endemic species (Samar and Leyte); carabaos and pigs may act as reservoirs
 CLINICAL FINDINGS

• Most are asymptomatic but chronically infected persons

may be symptomatic
• Acute phase: itching, dermatitis at penetration
• 2-3 weeks of fever, chills, diarrhea,
lymphadenopathy, hepatosplenomegaly, eosinophilia
• May resolve spontaneously
• Chronic phase: gastrointestinal hemorrhage,
hepatomegaly, massive splenomegaly in S.
japonicum/mansoni
• Most common cause of death: exsanguination
• Hematuria; superimposed UTIs in S. haematobium
infections
• Swimmer’s itch – nonpathogenic schistosomes
 DIAGNOSIS AND TREATMENT

• Find eggs
• Treat with praziquantel
 CLONORCHIS SINENSIS

• Asian liver fluke

• Humans are infected by eating raw or undercooked fish
• Encysted larvae (metacercariae)
• Excyst in the intestine and migrate to biliary ducts
• Adults lay eggs which are secreted in feces and ingested by snails (first intermediate
hosts)
• Transform into rediae and then into cercariae
• Cercariae differentiate into metacercariae under the scales of freshwater fish (second
intermediate hosts)
 PATHOGENESIS,
DIAGNOSIS, TREATMENT

• May cause hyperplasia and fibrosis of

biliary tract
• May progress to angiosarcoma of the liver
• Most infections are asymptomatic
• May cause Upper abdominal pain, anorexia,
hepatomegaly, eosinophilia
• Diagnosed via finding operculated eggs in
stool (very small)
• Treat with praziquantel
 PARAGONIMUS WESTERMANI

• Lung fluke
• Humans infected by eating raw or undercooked crab meat containing
metacercariae
• After excystation, penetrate intestinal wall and diaphragm to land in the lungs
• Adults produce eggs that are coughed up or swallowed
• Eggs hatch in fresh water to produce miracidia, enters snails (first intermediate hosts)
• Differentiate into rediae then cercariae
• Encyst in Sundathelphusa philippina (endemic in Bicol)
 PATHOGENESIS AND CLINICAL
FINDINGS

• Worms exist in a fibrous capsule

• Secondary bacterial infections – bloody sputum
• Main finding is chronic cough with bloody sputum with bacterial pneumonia
• Resembles tuberculosis
• Diagnosed via finding eggs
• Treated with praziquantel
 FASCIOLA HEPATICA

• Sheep liver fluke

• Humans infected by eating aquatic plants (watercress) that were contaminated by
metacercariae
• Excyst in the gut, penetrate wall, land in the liver
• Adults lay eggs that hatch in fresh water
• Same cycle as in Clonorchis and Paragonimus
• Early infection presents as RUQ pain, fever, hepatomegaly; mostly asymptomatic
• Can present as obstructive jaundice; adult flukes damage liver
• Halzoun – painful pharyngitis (posterior pharyngeal wall) caused by worms
• Diagnosed via finding worms in stool; treat with triclabendazole
 FASCIOLOPSIS BUSKI

• Also transmitted via eating contaminated aquatic vegetation

• Adult flukes damage intestinal wall; most infections
asymptomatic but may progress to ulceration, abscess
formation, hemorrhage
• Diagnosed via finding eggs
• Treatment with praziquantel
 HETEROPHYES
HETEROPHYES

• Cercariae encyst under the scales of fish

• Inflammation of bowel epithelium due to
presence of adult flukes
• Mostly asymptomatic; but pain and non-
bloody diarrhea can occur