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 Pharm
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(2023/2024)
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(PM 906)
(PHM 2202)

Lecture No. (2)

Trematodes
By
Professor
Yasser El Mohammadi
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Lecture’s Aim

To allow the student to discover and obtain a good knowledge about the most
prevalent human trematode worms and their medical importance.

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Lecture’s Competencies

To enable the student to deal with the most important diseases caused by
human trematodes, to know and understand their characteristic clinical
features and methods used for laboratory diagnosis.
The student will also be able to find the measures used to prevent or control
these diseases and how to treat them successfully.

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Lecture’s Contents

- General features of trematodes

1 Schistosoma mansoni
Schistosoma haematobium
2 Fasciola
gigantica Fasciola
hepatica
3 Heterophyes
heterophyes
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I. Helminthes
 HELMINTHES
“Worms”

PLATYHELMINTHES NEMATHELMINTHES
“Flatworms” “Cylindrical Worms”

CESTODA NEMATODA
TREMATODA Round worms
Tapeworms
Flukes (digenetic) Taenia solium Ascaris lumbricoides
Heterophyes heterophyes Enterobius vermicularis
Taenia saginata
Fasciola hepatica Strongyloides sterocoralis
Echinococcus granulosus
Schistosoma haematobium Trichuris tirchiura
Hymenolepis nana
Schistosoma mansoni Diphyllobothrium latum Ancylostoma duodenale
Fasciolopsis buski Wuchereria bancrofti
Brugia malayi
Loa loa
Onchocerca volvulus
Dracunculus medinensis
Trichinella spiralis
 Parasitology

I- Protozoa II- Helminths

1- Intestinal and C- Nematodes
Urogenital Protozoa A- Trematodes(Flukes) (Round worms)

A- Entamoeba 1- Fasciola hepatica 2- Fasciolopsis i- Instestinal

histolytica buski Nematodes

1-Wuchereria bancrofti
3- Heterophyes
B- Balantidium coli
heterophyes

4- Shistosoma sp. 2-Ascaris lumbricoidges

C- Giardia lamblia

D- Trichomonas B- Cestodes 3- Hookworms

vaginalis (Tape worms)
1- Taenia 4- Trichuris
2- Blood and Tissue saginata trichiura
Protozoa
5- Trichinella
A- 2- Taenia spiralis
H solium
e
m 1- Trypanosoma sp. 3- Hymenolepis Ii- Tissue Nematodes
o nana (Filariae)
fl
a 1- Wuchereria
g 2- Leishmania sp. 4- Hymenolepis bancrofti
e diminuta
ll 5- Echinococcus
a B- Sporozoa granulosus
2- Burgia malayi
t
e
1- Plasmoduim sp.
s 3- Dracunculus
medinensis
2- Toxoplasma gondii
4- Loa loa

5- Onchocerca
 Helminthes (Worms) are macroscopic, multicellular organisms
that have microscopic infective forms: eggs and encysted or free-
living larvae.

General Characteristics
• Most parasitic helminthes have at least two hosts: the definitive
host, where sexual reproduction occurs, and the intermediate
host, which supports immature or larval forms.

• The basic patterns of life cycles include: infective stage, mode of

transmission, site of reproduction (infection), portal of exit, and
exiting (mostly diagnostic) stage.
• Chemotherapy usually involves drugs that selectively inhibit worm
metabolism or weaken their attachment.
• Preventive measures are directed to interrupt the cycle
of infection
through improved public health conditions.
 A- Trematodes (Flukes)
• General features
1 Flat, fleshy, leaf-shaped, unsegmented body, except
Schistosoma sp. which is cylindrical.
2 No respiratory nor vascular system.
3 Two muscular suckers for attachment: oral & ventral (except
Heterophyes has a 3 rd genital sucker).
4 Eggs are diagnostic with an operculum, except in case of
Schistosoma sp. the eggs are characterized by presence of a
spine.
5 All are hermaphroditic except Schistosoma sp.
6 The primary intermediate host is a snail.
7 All require 2 intermediate hosts, except Schistosoma sp.
8- Transmission by ingestion of food contaminated with encysted
metacercaria, except Schistosoma sp. through penetration of skin
by cercaria.

• They may be classified into:

I. Liver flukes
II. Intestinal flukes
III. Blood flukes
• General life cycle of trematodes
1. Eggs are released from human (in feces or urine) in fresh water.
2. Eggs hatch into first larval stage (miracidial larva) that invade a
snail as 1ry intermediate host.
3. All trematodes except Schistosoma sp. require a second
intermediate host which is mostly a water plant or animal.
4. The second larval stage (cercarial or metacercarial larva)
comes out of the intermediate host(s).
5. Humans are infected through direct penetration of cercaria
(Schistosoma) or ingestion of encysted metacercaria in water plant
or animal (all other trematodes).
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 Medically important non-hermaphroditic
Pharm
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Species Schistosoma Schistosoma mansoni

Feature
haematobium
Geographical Africa, Middle East, especially West and Central Africa, Egypt, the
Distribution Egypt Arabian Peninsula, South America

Disease all cause bilharzia (after Theodor Bilbarz, a German pathologist,

who first identified the parasite in Egypt in 1851), also known as
bilharziasis, schistosomiasis, snail fever or Katayama fever

Definitive host Human

Intermediate host Bulinus truncatus Biomphalaria alexandrina
(snail)
Transmission
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 Species Schistosoma haematobium Schistosoma mansoni
Feature

Site of Vesical venous plexus surrounding Lower mesentric vein, (small

infection urinary bladder (urinary intestine, colon &
(Habitat) schistosomiasis) liver)

Shape and egg with terminal spine in urine egg with lateral spine in feces
location of
eggs
Symptoms -1st sign is known as swimmer’s itch (cercarial dermatitis)
at penetration site causing pruritic rash
- Acute urinary schistosomiasis (by S. haematobium) is
accompanied by
fibrosis of bladder with hematuria
-Acute intestinal schistosomiasis (mostly by S. mansoni and S.
japonicum) is characterized by fever (Katayama's fever, that occurs after
weeks of initial infection), headache, hepatosplenomegaly and
eosinophilia
 Species Schistosoma haematobium Schistosoma mansoni
Feature

- Manifestations of chronic schistosomiasis include formation of bladder

and urinary stones, bleeding oesophagal varices, hepato- and
splenomegaly & diarrhea (hematuria may progress to cancer)

Diagnosis -Microscopic examination of characteristic eggs in stool (for all

species), or in urine (for S. haematobium)
- Demonstration of egg in rectal or bladder biopsy
- X-rays of urinary tract or intestine
-Serologic tests, and antibody detection by ID injection of
cercarial antigens

Treatment -Praziquantel (Biltricide or Distocide) is the drug of choice for

all schistosomiasis
- Oxamniquine (Vansil) for S. mansoni infections
- Metrofonate for S. haematobium infection
Schistosoma haematobium
Shistosoma mansoni

Female Male
• Life cycle:
• It is basically similar in the two species. Eggs of S. haematobium
pass with urine while that of S. mansoni pass with faeces.

• In water egg hatches giving miracidium which seeks about the

intermediate host which is a snail (Bulinus truncatus for S.
haematobium and Biomphalaria alexandrina for S.
mansoni).

 Inside the snail, miracidium develops into sporocysts then

to cercaria.
 Cercaria penetrates the skin of a human and after losing its tail
it finds its way into a capillary to reach the systemic circulation
and finally the liver and portal circulation.

 After maturation in the liver and hepatic branches of the portal

blood veins, S. haematobium selects the venous plexuses of the
urinary tract, while S. mansoni migrates to branches of the
inferior mesentric veins related to the colon.

 After copulation, the female lay the ova, then the egg break
through the wall of the vessel and escape into the lumen of the
bladder (S. haematobium) or the colon (S. mansoni) together with
blood.
Cercaria of Schistosoma mansoni
Biomphalaria alexandrina
Bulinus truncatus
Schistosoma haematobium Schistosoma mansoni
egg egg
Egg in intestinal wall Egg in hepatic venules

Schistosomiasis
Swimmer’s itch
Schistosomiasis (bilharziasis)- Hepatosplenomegaly
Prevention and Control:
1. Personal prophylaxis:
Avoidance of washing, bathing, swimming in or drinking polluted
water (canals). If this could not be avoided, the following
measures should be done:
A. Wearing protective clothes (boots, gloves, etc...).
B. Water boiled or stored 3 days before use.
C. Quick and thorough drying of exposed skin.
D. The use of repellents.
2. Health education

3. Environmental sanitation:
A. Provision of safe water supply.
B. Proper sewage disposal.

4. Mass treatment:
Detection, treatment and follow up of all infected persons.

5. Snail control:
By chemical & physical methods.
Medically important hermaphroditic trematodes
Fasciola gigantica
Fasciola hepatica
(sheep liver fluke)
Europe, Middle East, Asia (in
sheep & cattle raising areas).
About 2.4 million people
infected worldwide
Heterophyes heterophyes
(Intestinal fluke)
Africa, Middle East, Asia.
In Egypt: Prevalent in North Nile
delta around Bourolos & Manzala
lakes.

Fascioliasis “liver rot” Heterophiasis

Sheep, cattle, man Man (dogs & cats are reservoir
hosts)
Lymnaea cailliaudi Pirenella conica
(F. gigantica)
Lymnaea truncatula
(F. hepatica)
 Fasciola hepatica Heterophyes
heterophyes
Leaves of freshwater plants Freshwater fish (Boury, Bolti)
(watercress)

Transmission Eating wild watercress or other Eating raw or insufficient

water vegetation containing the cooked fish containing the
metacercariae metacercariae

Site of infection Bile ducts (including also liver & Small intestine
(Habitat) gall bladder)
Symptoms Biliary colic, abdominal pain, Abdominal pain,, vomiting &
serious liver cirrhosis (high mucous (non-bloody)
bilirubin), hepatomegaly, diarrhea
inflammation and fibrosis of bile
ducts (Caused by biliary
obstruction
 Species Fasciola hepatica Heterophyes heterophyes
Feature

& inflammation due to presence of

adult worms & their metabolic
wastes in bile ducts).

Laboratory Operculated eggs in stool

diagnosis
Prevention & - Avoiding eating watercress or - Avoiding eating raw or
Control other uncooked water plants insufficient cooked fish
- Destroying snail habitats - destroying snail habitats
- Destruction of eggs or
metacercariae by copper sulfate in
infected waters
- Good washing & cooking of raw
vegetables
Treatment Triclabendazole Praziquantel

Fasciola Fasciola
gigantica hepatica
Fasciola
Fasciola metacercaria
Lymnaea truncatula Lymnaea cailliaudi snail
snail
Intermediate host of
Intermediate host of F. gigantica
F. hepatica
Fasciola hepatica eggs
 Life cycle of Fasciola:
Following ingestion, the metacercariae excyst in the duodenum
and the young flukes migrate through the intestinal wall into the
peritoneal cavity. They reach the bile ducts of the liver.

About 3-4 months after infection, eggs (diagnostic stage) are

excreted in the faeces. To develop they must reach fresh
water. After 9-15 days in water, the eggs hatch miracidia which
enter snails of the genus Lymnaea (first intermediate host).
In the snail, the miracidia develop into sporocysts which produce
generations of rediae and finally cercariae.

After leaving the snail the cercaria encyst (encysted

metacercaria: infective stage) on water vegetation and grass
(second intermediate host).
Life cycle of Heterophyes:
- Following ingestion, the metacercariae excyst and develop into
mature egg-producing flukes in small intestine of man (Definitive
host) and fish-eating animals as dogs & cats (Reservoir hosts).

- Mature eggs pass in the faeces (Diagnostic stage) to

pollute water.

- In water, eggs are ingested by the first intermediate host

Pirenella conica snail in which the miracidium hatches and
develops into a sporocyst which produce rediae and finally
cercariae.
- The cercariae leave the snail and encyst on fish (second
intermediate host) such as Mugil (Boury) and Tilapia (Boulty) and
give encysted metacercariae in their muscles.

- The man (definitive host) is infected by ingestion of raw,

undercooked or undersalted fish (Feseekh) salted for less than a
week containing the encysted metacercariae (infective stage).

- In the small intestine of man, the mateacercaria is liberated and

lodges among the villi to become adult.
 Pear shape

Heterophyes heterophyes adult

Heterophyes heterophyes adult in small intestine
Adult worm is present in intestinal villi
Heterophyes heterophyes encysted metacercaria in Bouri and
Bolti muscles
Heterophyes heterophyes egg
Pirenella conica
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Lecture’s References

- Diagnostic Medical Parasitology, (Elsevier Science Publishing Co.

Inc.) by Garcia, LS & Bruckner, DA.

- Atlas of Medical Helminthology and Protozoology, (E & S Livingstone)

by Jeffrey & Leach

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