Human blood trematodes:

Global status
• People at risk: 600 million
 Number Infected: > 200 million
 Symptomatic patients: 120 million
 Severely infected: 20 million
 Deaths: 14,000 annually
 Disease burden: 1.93 million Disability
Adjusted Life Years (DALY)
 Classification
• Phylum: Platyhelminthes (flatworms)
• Subclass: Digenea
• Order: Strigeida
• Family: Schistosomatidae (blood flukes)
• Subfamily: Schistosomatinae
• Genus: Schistosoma
 Classification

• Species:
• Schistosoma haematobium
• Schistosoma mansoni
• Schistosoma japonicum
• Schistosoma intercalatum
• Schistosoma mekongi
• Schistosoma malayensis
General morphology of
schistosoma
• They have oral and ventral sucker
• Male is samller than female 0/7cm-2/2cm
• Female length :1/2-2/6 cm
• Difference between males in different
spieces :
1-number of testicale
2-with boss or without boss
Difference between females in different
spieces
• 1-Places of ovary
• 2-Length of uterus
• 3-Number of eggs in uterus
• 4-Length of vitelline gland
 Distribution:
• Trematode flatworms (flukes) of the genus Schistosoma.
– S. haematobium is the most prevalent and widespread
species in Africa and the Middle East
– S. intercalatum occurs in 10 countries in the rainforest belt
of Africa
– S. mansoni is found in Africa and is the only species seen
in Latin America
– S. japonicum is restricted to the Pacific region including
China and the Philippines
– S. mekongi is found in limited areas of Laos and Cambodia.
Life Cycle (Basic)
 Life Cycle
1. Parasite eggs released into freshwater
(from human urine, feces)
2. Eggs hatch  ciliated miracidia, free
swimming
3. Miracidia find & infect snail host
(different species prefer diff’t snail sp.)
4. Each miracidia transforms into many
fork-tailed, free swimming forms called
cercariae within 4-6 weeks of entering snail.
5. Cercariae leave snail and move into water at a rate of
15/day for up to 18 days.
 Life Cycle
• Occurs in freshwater when intermediate snail hosts release infective forms of the parasite. People
are infected by contact with water where infected snails live.

Intermediate hosts are molluscs schistosome

• Bullinus globusus S. haematobium
• Bullinus truncatus
• Biomphalaria pfeifferi S. mansoni
• Biomphalaria glabratta
• Onchomelania nosophora S. japonicum

Biomphalaria glabratta Bulinus globosus, Onchomelania nosophora

 Life Cycle
Cercariae find a human host,
penetrate skin, and differentiate into
larval forms called schistosomulae.
7. Migrate through the host’s skin,
gain access to the lymphatic system.
8. Travel to the lungs (stay 3-8 days
and ~70% are eliminated)
9. Migrate to liver portal system, mature into male &
female adults
 Life Cycle
10. In liver, m & f pair up  female inserts
herself into the gynecophoral canal of male
 they are now ‘paired’.
11. Migrate to favoured sites:
S. mansoni – mesenteric venules of
large bowel & rectum
S. japonicum – mesenteric veins of the
small intestine
S. haematobium – perivesical venous plexus
surrounding the bladder
 Life Cycle
12. Females release eggs.
Egg characteristics
- Covered in microbars  cling to vascular
endothelium
- Pores, which allow the release of
1) Antigens
2) Enzymes (aid in passage of eggs
through host tissues)
12. Eggs enter lumen of excretory organs
50%  passed out of body
50%  trapped in tissues, carried away by
blood circulation, lymph
morphology of 3 male & female schistosoma spices
 Schistosoma haemathobium:
• Male :
• 3-5 testicles
• number of tubercle is less than others
• Female:
• place of ovary is 1/3 posterior of worm
• length of uterus is 2/3 length of worm
• length of vitelline is 1/3 posterior of worm
• Number of egg: 30-50 with 120-180 length
and terminal spine
Residence place of S.haematobium
• In the vein of bladder
• Prostate vein
• Ovary vein
• After egg producing in S.haematobium
• Eggs penetrated the bladder wall and
• Appear in the urine
• Urine with blood (hematuria)
• Thicness of bladder wall
• Bladder carcinoma
 S. mansoni:
• Male testicles No:6-9
• Large tubercle
• Ovary in 1/3 anterior
• Uterus length is 1/3 anterior
• No: of eggs=1-2 with lateral spine
• Resident in colon veins
 S.japonicum:
• Male: No of testicles=6-9-13
• with no tubercles
• Place of ovary: ½ body
• Length of uterus: ½ body
• Length of vitellin is ½ body
• No of eggs:50-100 spherical shape with a
small spine `
 Pathogenesis of schistosoma:
• Incubation period

• Egg deposition

• Tissue proliferation and repair

 Incubation period:
• In three species is look like each other
• Cercariae penetrate skin  rash
- called schistosome or swimmer’s itch.
• Katayama fever with more cercaria in S.m,S.j
- fever
- urticaria((‫کهیر‬
- malaise(‫)بیقراری‬
- diarrhea
 Egg deposition
Symptoms of chronic infection caused by eggs that travel to various
parts of body
Eggs remain trapped in host tissues  secrete Ags  granulomatous
inflammatory immune response
 Granulomas: macrophages surrounded by lymphocytes (CD4, CD8
Tcells), which aggregate at site of infection.
Fibroblast cells also at site of infection.
 During late stage of chronic infection, they replace the
granulomas. Their prolif. is stim. by factors produced by the
schistosome egg, & by cytokines from macrophages & CD4 Tcells.
Fibroblasts mediate collagen deposition in the granuloma, leading to
fibrosis (=fibrous connective tissues development
Granuloma
 Chronic Infection
(When eggs meet the GI tract)

• In S. mansoni infections
• Wall of colon is damaged as eggs pass through
• Inflamm. response  ulcers, inflammatory
polyps
• Can lead to fibrosis
• Clinically: diarrhea, abdominal pain
• Eggs can also accumulate in the appendix
• Can lead to appendicitis (inflammation of the appendix)
 Chronic Infection
(When eggs meet the liver/spleen)

• Hepatosplenic schistosomiasis
• Eggs carried by portal circulation  liver
• Granulomatous response
• Granulomas are walled off with fibrous tissue 
fibrosis obstructs portal veins  portal
hypertension
• Esophageal varices (dilated esophageal veins, which drain
the liver bursting can cause bleeding to death. Caused
directly by portal hypertension.)
• Splenomegaly (enlarged spleen, due to fibrosis)
Hepatosplenic schistosomiasis
 Chronic Infection
(When eggs meet the meet the heart)

• In those with severe hepatosplenic schistosomiasis

• Blood gets shunted directly back to the heart (doesn’t pass
through liver).
• Eggs accumulate in heart, sometimes lodged in pulmonary
arterioles.
• Form granulomas  block pulmonary circulation  pulmonary
hypertension.
• Can lead to right ventricular strain, and eventually
cardiovascular collapse.
 Schistosomulae
• Schistosomule
– Develops from cercaria
after skin penetration
– Adapted to survive in
serum or physiologic
saline at 37 0C
– Enter the pleural cavity---
diaphragm---peritoneal
space---penetrate the liver
to reach the intrahepatic
portions of the portal vein

Prepared by FZHapan
 Chronic Infection
(When eggs deposite in the genitourinary areas & CNS)

Genitourinary complications
• Eggs lodge themselves in wall of bladder & can develop into polyps
• Polyps can erode, ulcerate & cause hematuria (blood cells in urine)
• Eggs lodge in ureters and urethra, cause lumps and lesions  kidney
failure
• Eggs lodge into ovaries, the uterus, cervix, fallopian tubes  lumps 
complications incl. infertility
(For the men: eggs can also lodge into the testes and the prostate )

CNS complications
• S. haematobium and S. mansoni can migrate to the spine
• S. japonicum found in the brain and causes encephalopathy (general
brain dysfunction)
 Prevention:
 For travelers it’s easy- don’t swim in fresh, stagnant water (running water is
better, still not safe).

 Harder in endemic areas  people are dependent on nearby freshwater.

 Focused on education, eliminating snail nesting grounds
 Molluscicides can be used to eliminate snails.
 Proper irrigation systems and engineering are key
 There are ways to build irrigation and canalization systems that don’t allow
snails to inhabit the surrounding area
 However, many irrigation/canalization projects since the 50s have
ignored UN instructions, may have contributed to spread of the
parasite
 Treatment
• Swimmer’s itch and Katayama Fever are usually treated
symptomatically.
• Chemotherapy is treatment of choice - Praziquentel is most widely
used drug.

Praziquantel
• Extremely well tolerated, few side effects
• Broad-spectrum antihelminthic drug (antihelminthic= drugs that expel
parasitic worms)
• Cures schistosomiasis in 80–90% of patients, 90% reduction in egg
excretion in those not cured
• Causes worm muscles contract – cannot hold onto human tissues
• Resistance has been reported in Egypt and Senegal
 Treatment:
Others:
 Metrifonate  against S. haematobium
 Niridazole  against S. japonicum
 Oxamniquine  against S. mansoni

 WHO recently approved use of combo of 3 drugs at once (rule is always no more
than 2) to cure a few related diseases (incl. Schistosomiasis) in hopes that
eradication will be faster.

Complications
 Drugs ineffective when fibrosis has developed - treatment is then focused on
managing the complications (e.g. portal hypertension)
 Anticonvulsants may be needed in patients with CNS complications (S.
japonicum).
 Diagnosis
Microscopic Detection
• Take stool or urine sample to detect
eggs
• S. haematobium eggs are oval and have
a spike at the tip
• S. japonicum eggs small and almost
spherical with tiny spine S. mansoni S. japonicum
• S. mansoni eggs have a spike on the
side (spine)

S. haematobium
 Cercarial dermatities :
• Penetration of some birds schistsoma cercaria
to human de
 Other trematodes:

1- intestinal trematodes
2- pulmonery trematodes
 intestinal trematodes
• Fasciolopsis buski ( biggest human
trematodes)
• Heterophyes heterophyes
• Metagonimus yokogawai
 Fasciolopsis buski ( biggest human
trematodes)

Morphology:
Look like the Fasciola heatica leght 7 cm
Without cephalic cone
Cecaum has not any branches
Egg is look like Fasciola´s egg ,25000 daily
Released.open in water 32-37° in 3-7weeks
This worm resides in jojenom & duodenum
Final host human ,pork,dog
Reservoier is pork
Fasciolopsis buski
 Life cycle:
• Egg water miracidium penetrat to
• snail
• Attaches to ceacum plaorbid
• Polypilis hemisphaerula
• Digested in deodenom
• sporocyst
• metacercar on water chest nut
redia
• cercaria
 Fasciolopsis buski
• Pathogenesis:
• Consuming food in ceacum
• Making ulcer in attachment place
• Bloody feces like amebic dysentery
• Disability of cecaum mucosa in
absorbtion of
• High eosinophily
•
 Epidemiology
• Most prevalant area is in far east:
• China
• Thaivan
• Vietnam
• Cambuge
• India
• korea
•
 Diagnosis:
• Observing egg in feces
• Serologic methodes
 Prevention &Treatment:

• Using muluscaside
• Washing vegetables

• Dichlorophen: 2-3 g every 8 hours

• Niclosamid : 100 mg /kg for 7 days
 Heterophyes heterophyes
• Morphology:
• The most samll treamatodes: Length 1-2 mm
• Has 3 sucker: 1 oral ,2 ventral,3 genital sucker
• 2 testicles which places at side by side
• 2 Vitelline glands
• Cecaum has not any branches
• eggs brownish 16-29 mic with opercul
Heterophyes heterophyes
Life cycle:
 Life cycle:
• Egg water
• snail eat
• Attaches to ceacum pyrnella (Japan)
• Tidina (Aegipt)
• Digested in deodenom miracidium
• sporocyst
• metacercar on fish(mullet,salmon)
redia
• cercaria
 Pathogenesis:
• No important problem
• Inflammation at the site of attachment
• Manifesations are consistent with peptic ulcer
• Chronic Mucosa diaharea
Diagnosis:
Observing egg in feces
 Treatment:
• Praziquentel :15mg/kg
• Niclosamide :2g daily for 2 days

Prevention:

Cooking fishes well in 70º c

Nothing use smoky fishes
 Metagonimus ytokogawai
• Morphology:
• 0/6-1/4 mm length
• With spine and 2 large
testicles
• Rough vitellin glands
• Ventral sucker in the right
side of axial cord
 Metagonimus ytokogawai
• Egg is yellowish and has
opercule and miracidium

• Defenite host:
• Human
• Wolf,cat,pork,
 Life cycle:
• Egg water
• snail eat
• Attaches to ceacum semisulcospira
• Thiara
• Digested in deodenom miracidium
• sporocyst
• metacercar on fish(cyprinoid,salmo)
redia
• cercaria
 Treatment ,diagnosis,prevention,

• Treatment ,diagnosis,preventio
n,
• Is look like H.heterophyes
 pulmonery trematodes
• Paragonimus westermane
• Morphology:8-16mm length
• Living tween
• There are a lot of spine which
make irritation
 Lung Flukes: Paragonimus
westermani
• Paragonimus
westermani ova
– Yellowish brown
– Thick-shelled
– Operculated with a
thickened
abopercular egg
– May be seen in the
sputum or in feces if
the sputum is
swallowed
Prepared by FZHapan
 Life cycle:
• lung Egg water miracidium
• snail eat
• Penetrate the ceacum Hoa,semiselcuspira
• Syncera ,Thiara
• Digested in deodenom
• change to metacercar sporocyst
• Penetrated in crabs redia
• cercaria
 Pathogenesis:
• First
• After 6 month to 1 year
• Lung loses the elasticitae
• Making fibrosis capsule with
• blood and eggs.
• Second:
• Making cyst in lung
• Bronchioectasie and mucosa
 Symptoms:
• Coughing

• Coughing with brown sputum

• Chest pain
• Spasm
• Increasing the volume of heart and lung
 Diagnosis:
• Observing eggs in sputum
• Radiologic sign with 5-10 cm diameter like
gripe
• Using serologic methods like CF
•
 Treatment:
• Biothionol 30-50 mgfor 2 days
• Praziquantel 20 mg/kg 2days
• Prevention:
• Control of snail and crabs
• Distribution:
• Far east
• America