Trematodes 13.

Lack a circulatory system and respiratory system

14. Most of the body is occupied by the reproductive organs
General characteristics of Class Trematoda 15. Trematodes are hermaphrodites or monoecious except genus
Schistosoma which is dieceous
1. Also known as flukes
16. Self fertilization is the common method of fecundation for
2. Flat, elongated, leaf shaped but may be ovoid, hermaphroditic species
conical, or cylindrical depending upon the
state of contraction, except for 17. Trematodes parasitize a wide range of hosts
schistosomes which are elongated
18. The life cycle is passed in two hosts the sexual (definitive host) and asexual
3. Bilaterally symmetrical (intermediate host) phases
4. Size vary from less than 1 mm to several centimeters 19. Require one or more intermediate hosts. The first intermediate host is a
snail
5. Has a definite anteroposterioraxis
20. Individual flukes can survive in human for more than 40 years
6. Unsegmented
Basis Schistosomes Other Flukes
7. Body is covered by cuticle which may be
partially or completely covered with spines, Reproductive system Diecious Monoecious
tubercles or ridges
Intestinal ceca Simple Simple
8. Integument plays an important role in the
absorption of carbohydrates. It may also Unite to a single cecum Ends blindly (2)
serve for secretion of excess metabolites and Redia Absent Present
mucus
Cercaria (tail) Forked/bifid Straight, tapered
9. One or more muscular suckers on ventral
surface. Oral sucker sometimes has spines or hooklets, found at the Infective stage Cecaria Metacercaria
anterior end of the worm and in most species
a larger, blind ventral sucker or acetabulum is Portal of entry Skin Mouth
located on the ventral surface posterior to
Ovum Non-operculated Operculated
the oral sucker
Intermediate host Only one (snail) 1st and 2nd
10. Suckers are use for attaching to internal
organs or outer surfaces of the host
11. There is no body cavity Trematode Intermediate Mode of Entry Habitat of Adult
12. Organs and systems –excretory system, nervous system, genital system, Infestation Host/s Worm
digestive system (incomplete –ends blindly) Alimentary canal ends Schistosoma Penetration of skin by Blood vessel of
blindly – ceca usually unbranched, may be branched Snail
haemotobium free swimming cercaria urinary bladder
 Schistosoma Inferior mesenteric Trematodes based on habitat of adult worm
Snail
mansoni veins
Schistosoma Superior
Snail Blood flukes:
japonicum mesenteric veins
1. Schistosoma japonicum
Paragonimus Ingestion of infested crab
Snail/crabs Lungs
westermani meat 2. Schistosoma mansoni
Opistorchis 3. Schistosoma haematobium
Snail/fish Ingestion of infested fish Liver (bile duct)
sinensis
Metagonimus
Snail/fish Ingestion of infested fish Intestine Liver flukes:
yokogawai
Heterophyes 1. Clonorchis sinensis
Snail/fish Ingestion of infested fish Intestine
heterophyes 2. Opistorchis viverrini
Fasciola Ingestion of encysted 3. Opistorchis fileneus
Snail Liver (bile duct)
hepatica* larvae on vegetation
4. Fasciola hepatica
Fasciolopsis Ingestion of encysted
Snail Intestine 5. Fasciola gigantica
buski** larvae on vegetation
Gastrodisciodes Ingestion of encysted
Snail Intestine
hominis** larvae on vegetation
Lung fluke:
* - usual definitive host is sheep but man is sometimes affected 1. Paragonimus westermani
** - usual definitive host is swine but man is sometimes affected
Mode of infection: Intestinal flukes:
 Skin penetration – cercaria, eg. Schistosomes 1. Fascsiolopsis buski
 Ingestion of metacercaria = other trematodes
Portal of exit of eggs:
 Sputum – P. westermani
 Urine – S. haematobium
 Feces – all intestinal and liver flukes; S. mansoni, S. japonicum, P.
westermani
 2. Echinostoma ilocanum  Hatches into a free swimming ciliated larva, the
miracidium
3. Artyfechinostomum malayanum
 Miracidium penetrates tissues of a snail and transforms into
4. Heterophyes heterophyes sporocysts
5. Metagonimus yokogawai  Sporocysts reproduces asexually to form rediae
6. Gastrodiscoides hominis  Rediae reproduce asexually and form cercaria

General life cycle of trematodes

 Egg passes from definitive host and must reach water
Schistosomiasis Thailand, China America Asia, S. Europe
Man,
Man. Rodents,
Natural host domesticated Man
Schistosoma monkeys
animals
 A parasitic blood flukes that infect birds and mammals including humans.
Snail host Oncomelania Biomphalaria Bulinus
 5 medically important species:
Radicals of Mesenteric
Habitat in man Vesical/pelvic
 S. japonicum superior mes. venules - lower
(adult) venous plexuses
venules intestine
 S. mansoni
6-7 in a single 8-9 in a zigzag
 S. haematobium Testes (male) 4-5 in groups
life row
 S. mekongi
 Anterior to  Behind the
 In the middle
 S. intercalatum of the body
the middle of middle of the
Ovary (female) the body body
 S. japonicum or Oriental blood fluke  Contains 20
 Contains 1-3  Contains 20-
 causes schistosomiasis japonica or more eggs
eggs 30 eggs
 endemic in China, Philippines, Indonesia Intestine Short Longest Long
 has been first described in Japan and has been eliminated since 1977 Egg Lateral knob Lateral spine Terminal spine
 intermediate host is Oncomelania 3000 300 239
Egg output/day
 exist in Mindoro, Leyte, Sorsogon and Mindanao
Intermediate Biomphalaria or Bulimus
Oncomelania
host Australobis (Physopsis)
Differentiating features of schistosomes Man and
Definitive host Man Man
domestic animals
Feature S. japonicum S. masoni S. Haematobium
 Found in  Found in
Oriental blood Manson’s blood Vesical blood feces urine
Common name
fluke fluke fluke Ovum Found in feces
 Occasionally  Occasionally
Oriental Intestinal Vesical in urine in feces
Disease
schistosomiasis schistosomiasis schistosomiasis
Ovum shape Oval to rounded Elongated, Spindle shape
Distribution Japan, Phil., Africa, South Africa, Western with short lateral ovoidal with with terminal
 tubercle long lateral spine spine
Adult Grossly Finely
Non tuberculated
integument tuberculated tuberculated
Life span of
20-25 20 30
adult (years)
 S. mansoni

S, haematobium

S. japonicum
Miracidium
 Hatches from the egg in slightly alkaline clean water with a
temp. between 25°C to 31°C
 Free swimming cilated embryo liberated from the egg
 Photactic
 Infect snails

Cercaria
 Natural release of cercaria is nocturnal but they can survive for 24 hours so
bodies of water remain potentially dangerous at any time.
 They migrate to a preferred temperature of 35°C ± 3°C and penetration is
stimulated by skin lipids.

Schistosoma japonicum
 Life cycle:
 Portal of entry – skin
 Infective stage – cercaria
 Habitat of adult – superior mesenteric veins
 Portal of exit – feces
 Stage excreted – fully embryonated ova
 Stages – miracidium, 1st and 2nd generation sporocyst, cercaria
 1st IH – Oncomelania quadrasi
 Adult worms – dioecious
 Has oral and ventral suckers
  Male – 12-20 mm X 0.4-0.5 mm, gynecophoral canal, testes arranged in one  Cercaria
row above the ventral sucker
 Schistosomulum
 Female – 15-26 mm x 0.3 mm, single pyramidal ovary located in the midline
 Adult schistosome
 Excretory system made up of flame cells, ingest RBC, absorb nutrients thru
body wall, live for 30 years
 Primarily parasites of the portal vein and its branches
 Each female fluke deposits 500-2,000 immature eggs/day
 Embryonation takes place in 10-12 days
 Eggs escape thru ulceration in the intestinal wall and are passed out with the
feces
Ova
 Ovoidal, rounded or pear-shaped
 Thin shell
 Pale yellow
 Curved hook or spine or lateral knob
 Laid in the multicellular stage and embryonate within 10-12 days
Definitive hosts:
 very wide range (dogs, pigs, cats, carabaos, cows, rodents,
monkeys)
Snail IH:
 Oncomelania hupensis quadrasi

 Life cycle involves alternating parasitic stages in

mammalian hosts and free living stages
 Egg and miracidium
 First stage (mother) sporocyst
 Second stage (daughter) sporocyst
 Shistosoma in various organs

Blood Flukes
 Infective stage for human - cercariae
 Defenitive host - man
 Intermediate host - snail
  Mode of transmission - penetration of skin by cercariae  Pathogenic adult schistosoma can persist in the human host for decades so
infection can present in non-endemic areas among immigrants from
endemic regions.

Pathology
 Main pathology and chronic disease manifestations – due to hosts
granulomatous reaction to eggs deposited in the liver and other organs
 Egg deposition can occur in any organ – most commonly involved are the
liver, intestines, lungs and much less the CNS
 Primary lesions – granulomatous hypersensitivity reaction around a single
egg or cluster of eggs
 After egg deposition there is an accelerated formation of larger and more
destructive granulomas
 Chronic infection – granuloma becomes smaller
 Collateral circulation are established -> eggs filtered into pulmonary
microvasculature -> pulmonary hypertension

Clinical course of infection (stages)

1. Incubation – from cercarial penetration and schistosomula migration to
maturation of fluke – complaint of itching, chills, fever, cough
2. Period of early egg deposition and extrusion
3. Period of tissue proliferation Due to overlap of 2nd and 3rd stages it is best
to discuss organ involvement as basis for clinical classification.
a. Colonic involvement
 early stage – ulceration caused by eggs ->
dysentery
Keep in mind  chronic stage –usually asymptomatic with occasional
diarrhea
 Acute infection of humans with avian species of schistosomes can result in
an allergic skin reaction called swimmer’s itch (cannot mature in human b. Hepatosplenic disease – most serious consequence of chronic
host and die in the skin). No need of anti-parasitic therapy. schistosomiasis -> hepatosplenomegaly, portal hypertension,
 ascitis, development of collateral circulation > esophageal and
gastric varices
c. Pulmonary involvement
 during larval migration – coughing and wheezing
 chronic stage – lungs next to liver and intestine has the
most number of schistosomal lesions.
 Cor pulmonale – due to obstruction of pulmonary
vasculature due to granulomatous formation and fibrosis.
Eggs reach the pulmonary circulation via the porto-
systemic collateral circulation. Pulmonary
schistosomiasis is the most common cause of cor
pulmonale in Filipino children
d. Cerebral schistosomiasis – the parasite moves from the portal vein
-> mesenteric and pelvic veins -> spinal veins
 acute cases - fulminating meningoencephalitis
 chronic cases – clinical picture of tumor with
localizing signs and increase ICP
Pathogenesis and clinical manifestations
 Snail fever, Katayama fever, Katayama syndrome Schistosomule migration
(2-12 weeks after cercarial penetration) -> produce syndrome: easy
fatigability, respiratory symptoms, arthralgia, myalgia, malaise, eosinophilia,
fever and abdominal pain
 Hepatosplenomegaly -> hepatic dysfunction -> death
 Migration thru pulmonary circulation -> wheezing and coughing
 Aberrant migration -> occlude the circulation of the brain and spinal cord ->
seizures, ischemic attacks, strokes
 May get better without antihelminthics but antihelminthics usually lead to
faster resolution of symptoms
Pathogenesis
 Main pathology and disease manifestation are due to host granulomatous
reaction to eggs deposited in the liver and other organs
 Early schistosomiasis, manifestations, colonic, hepatosplenic, pulmonary,
cerebral manifestations.
 3 stages in pathologic processes
 Incubation
 Dermatitis
 Traumatic infiltrative changes in the lungs
 Acute hepatitis
 Hyperemia in the wall of the small blood vessels
 Trauma with hemorrhage – eggs escape from venules to
intestinal lumen
 Eosinophilia
 Cell mediated response of host continues through out the
life of the worms
 Urticarial rash accompanied by fever – 5th day after
exposure
 4th week – prodromes – urticaria, edema. diarrhea
 Egg deposition and extrusion
 Profuse dysentery with eggs in feces
 Secondary anemia, leukopenia, less eosinophil
 Fever, epigastric pain, enlarged liver and spleen, loss of
weight and appetite – 3-10 weeks
 Infiltration of eggs in tissues – intestine, liver, other organs –
pseudotubercle dev. around the egg
 Liver enlarges – miliary lesions around the infiltrated eggs
  Spleen enlarges - congested
 Tissue proliferation and repair
 Liver decreases in size – scar tissue
 Spleen increases in size – mesentery and omentum binding
down the colon producing an upper and lower abdominal
distension
 Weaknes, skin pallor, dyspnea on slight exertion
 Rectal snips and imprint
 Ascitis - may or may not be conspicuous
 Granulomatous reaction around the eggs – fibrosis of
periportal tissues (pipe-stem fibrosis)
 Cerebral involvement
 Immune response in infection: (immunodiagnostic tests)
Diagnosis
 Finding the eggs in the feces occur when the eggs are deposited in the
terminal vein or capillaries of the intestinal mucosa or submucosa and
subsequently escape to intestinal lumen.
 In cases where there is fibrosis or scarring of sites of ulcerations, passage of
eggs into the intestinal lumen can be impeded. • Stool exam can give
negative results even in active infection.
 Eggs can be recovered by rectal or liver biopsies. This cannot distinguish
between active from treated infection.
 Microscopic examinations techniques are most specific.
 Stool examination and rectal imprint of S. japonicum eggs. Eggs
tend to clump so a small sample may turn out as false negative.
Likewise in light infection.
 A merthiolate-iodine-formalin concentration (MIFC) has
moderate sensitivity for moderate and heavy infections but not for
very light infections (<10 eggs/gram of feces). Sample with
MIFTC can be kept indefinitely.
 Kato-Katz technique
 used for egg counting and the most suitable for
quantification of eggs.
 used for evaluating epidemiology, effect of control
measures and drug trials.
 preparation can be kept for 2 weeks.
 to get 92% sensitivity in stools with <20 eggs/gm of feces
- perform 3 Kato-Katz
 one of the most sensitive technique
 most invasive (biopsy)
 inability to distinguish between untreated and treated
infections
 intradermal test – for immediate hypersensitivity using
adult worm extracts. Highly specific but non specific for
infection. No longer used.
 indirect hemagglutination using adult worm and egg
antigens.
 circumoval precipitin test (COPT).
 Method of choice for definitive diagnosis in the
Philippines.
 take more than 2 years to become negative
 cannot differentiate active from past infection
 not recommended as a screening tool in the
Philippines
 Demonstrates the formation of bleb or septate
precipitates attached to one or more points on the
egg surface after incubation of schistosome eggs in
patient’s serum.
  Method of choice for diagnosis of this infection in
the Philippines.
 Enzyme linked immunosorbent assay or ELISA use soluble
antigens of adults and eggs.
 Indirect hemagglutination – highly sensitive
 Lateral flow assay – best suited for elimination program.
Persistence of antibodies long before after active infection has
been treated
 Serologic tests (using adult and cercarial antigens)
 Complement fixation with adult antigen (CFA)
 Complement fixation with cercarial antigen (CFC)
 Slide flocculation with cercarial antigen (SFC)
 Cercarial agglutination (CA)
 Circumoval precipitin test (COPT)
 Intracutaneous test (skin test) – utilizes adult and larval
antigens
 WBC and differential count
Treatment
 Praziquantel 40-50 mg/kg SD or 25 mg/kg in 2 doses
 Reduce water contact through building foot bridges
 Health education
 Control of Oncomelania snails (clearing vegetation, irrigation management,
control flow of water), chemical control
 Environmental sanitation: proper waste disposal, control of domestic
animals
Praziquantel
 Safe and highly effective in a single or divided doses against all the
major species of schistosomes.
 Active against adult schistosomes in vitro and in vivo.
 In vitro – when the schistosomes come in contact with the drug it
becomes immobile and undergo contraction
 Has very low acute toxicity profile
 A single dose of 40-50 mg/kg or 25 mg/kg in 2 doses or 3 doses of 20
mg/kg given every 4 hours .
Artemisinins
 Effective as pre-exposure prophylaxis during the planting season
 Effective against the juvenile stage of the worm, ideal for non-endemic
travelers
May give the 2 drugs in combination.
  Infection prevalence is also high in adults compared with younger age
groups
Epidemiology
 However, the low sensitivity of schistosomiasis screening, particularly with
 Occurrence of disease in the community should be described in relation to low-intensity infections, means that the prevalence is likely much higher
prevalence and intensity of infection. (Carabin et al. 2005).
 In the Philippines, schistosomiasis is endemic in 12 regions
 Highest prevalence of infection are children of 5-25 years of age
 S. japonicum is normally transmitted between humans and other
mammalian hosts with either humans or animals alone being able to
maintain the infection cycle

Schistosoma japonicum
 Oriental blood fluke
 Causes schistosomiasis japonica
 The disease is still endemic in 12 regions affecting 28 provinces, 190
municipalities, 15 cities and 2,230 villages as of 2007
 The total population affected is approximately 12 million, and about 2.5
million are directly exposed to the parasite.
 Schistosoma japonicum is endemic in Mindoro Oriental, Sorsogon, Bohol,
Northern Leyte, Samar, and almost all provinces in Mindanao,
Southwestern Luzon (Belizario et al. 2005).
 Distribution – Orient (China, Southeast Asia, Philippines, and South
 A WHO-supported national prevalence survey in Mindanao, the Visayas, Pacific Islands)
and Luzon was initiated in 2005 and completed in 2007.
 Adults inhabit the superior mesenteric veins
 Endemic in China, Philippines and Indonesia
 Adult female is prolific egg layer – up to 3,000 eggs are deposited in the
 Reported in Japan and eliminated in 1977 submucosa of the intestine daily
 Snail host Oncomelania spp. (O. quadrasi in Phils)
 Local endemic areas: Mindoro, Leyte, Sorsogon, Mindanao Transmission
 In all of the endemic provinces, the prevalence rate of the disease is was Schistosomiasis requires 3 major conditions:
higher among males than females, suggesting that occupational hazards of
farming and fishing are key risk factors for infection. 1. Pollution of fresh water with excreta containing schistosome eggs
 2. Presence of the right species of snail Geographic distribution of snail hosts  GD: world wide, Philippines – Leyte, Samar, Mindanao (Cotabato),
determines epidemiology of disease Sorsogon, Camarines
3. Human contact with water infested with cercaria  Morphology:
a) Cercaria must penetrate human skin or mucosa due to direct contact  Adult:
b) No redial stage  Egg-shaped, thick and fleshy
 8-12 x 4-5 mm, when alive – resembles a spoon
Prevention and Control  Agent: Paragonimus westermani also known as Oriental lung fluke
1. In areas with high prevalence and transmission – mass chemotherapy reduce  Disease: Paragonimiasis
morbidity
 More than 30 species of trematodes (flukes) of the genus Paragonimus have
2. Sustained and appropriate health education been reported to infect humans and animals. Among them more than 10
species have been reported to infect humans, the most common is P.
3. Improve knowledge, attitudes and perception with respect to transmission, westermani
diagnosis and control of schistosomiasis
 Adults are found in pairs or threes in fibrotic capsules or cysts in the lungs
4. Oncomelania h. quadrasi an operculated fresh water amphibious snail, 3-5
mm with separate sexes; habitat is small clear water streams, water-logged  The fluke is hermaphroditic
rice fields, swamps and water seepage area. Snails are found in water and
banks, numerous in areas where soil is moist.  The living worms are pinkish brown in color and coffee bean shaped (7-15
mm in length 8 mm in width and 3-5 mm in thickness).
5. No outstanding novel molluscide or chemical for killing of snails has been
developed  It is rounded anteriorly and slightly tapered posteriorly.

6. Sanitary disposal of human feces  The body is covered with spines.

 Two testes are deeply lobed located opposite each other almost midway
between the ventral sucker and posterior border of the body
Lung fluke
 The ovary is located anterior to the testes and posterior to the ventral sucker
 The vitellaria are branched extensivel
Paragonimus westermani
 The cercaria is covered with spines, has an ellipsoidal body and a small tail.
 Paragonimus has a quite complex life-cycle that involves two intermediate
 The metacercaraia is round and measures from 381-457 um.
hosts as well as humans. Eggs first develop in water after being expelled by
coughing (unembryonated) or being passed in human feces. In the external  The oval, yellowish-brown, thick shelled egg measures 80-118 um by 48-60
environment, the eggs become embryonated. um and has a flattened but prominent operculum. Opposite the operculum is
a thickened abopercular portion.
 Oriental lung fluke
 It is unembryonated at oviposition.
 May be seen in the sputum or in feces if the sputum is swallowed

Life cycle
 The eggs are excreted unembryonated in the sputum, or alternately they are
swallowed
 Infective stage: metacercaria
 Infective mode: eating raw fresh water crabs and crayfish with metacercaria
 Infective route: by mouth
 Habitat of adult worm: lungs
 Intermediate hosts:
 1st IH – Melania, Semisulcospira, Thiara, Brotia asperata
Semisulcospira snail
 2nd IH – crab and crayfish
 Definitive hosts: man, rodents, domesticated animals
 Diagnostic stage: immature egg
 Life span: 5-6 years (persist in man for >20 years)

Ovum:
 Ovoidal with distinct flattened operculum, thickened posterior end
 Golden brown in color, 80 x 55 u Immature when laid and matures in
water
Life cycle:
 Ingestion of crab/crayfish with metacercaria -> excyst in duodenum -> in
30-60 minutes adolescaria migrate thru intestinal wall -> abdominal cavity
-> penetrate diaphragm -> pleural cavity -> grow to adult worms -> self
fertilization ->
 Lay eggs -> pass out immature ova which may be: 1) coughed out in sputum,
2) swallowed and passed out with feces -> eggs mature in water –
miracidium hatches out -> penetrate snail (S. libertina or Brotia asperata) ->
sporocyst, redia, ceracria -> cercaria escape and encyst in crabs and crayfish
 DH – man and domesticated animals

Symptoms:
 Pulmonary condition – resemble pulmonary tuberculosis – chest pain,
productive cough, night sweats
 abdominal type – associated with dull abdominal pains and diarrhea
 May be lodged in brain - epilepsy
 Lymph nodes - involved

Laboratory Diagnosis:
 Recovery of eggs from sputum or feces
 C-F test
 Skin test
 Chest X-ray findings
  Cultures that eat raw crustaceans: drunken crab in china, raw crabs and
crayfish with alcohol in the Phils, sushi crab in Japan, Gye Muchim in Korea

Pathogenesis and Clinical manifestations

 Presence of fluke in lungs provoke a granulomatous reaction and
development of fibrotic cyst containing adults, eggs, blood tinged purulent
materials.
 Most common symptoms: chronic cough and hemoptysis. Chest pain,
dyspnea, low grade fever, fatigue and generalized myalga may also occur
 Early stage – asymptomatic (takes weeks for fluke to migrate and mature)
 Clinical symptoms are less severe after 5-6 years
 Serious sequelae – chronic bronchiectasis, pleural fibrosis, secondary to
severe parenchymal; and pleural damage
 Circuitous route of migration allows the worm to mature and be lodged in
different ectopic location,
 Worms may localize in: lungs, pleura, pericardium, myocardium, abdominal
wall, omentum, liver, mesenteric lymph nodes, adrenals, urogenital organs,
Lung fluke and eyes

 Clinical disease:  Heavy infection can cause both pulmonary and ectopic paragonimiasis

 chronic cough with bloody sputum, dyspnea, pleuritic chest pain and  Cutaneous paragonimiasis is seen as a slow moving nodular lesion in the
pneumonia subcutaneous tissue on the abdomen or chest

 Laboratory diagnosis  Cerebral involvement is the most serious complication of human

paragonimiasis. May present with headache, meningismus, seizures,
 eggs in the sputum or feces hemiparesis,blurring of vision, diplopia, aphasia
 Prevention:
 cooking crabs and crayfish adequately Pathophysiology
 Once the parasite is in the lung or other organ, the worm stimulates an
inflammatory response that eventually coats tissue.
Transmission
 Eating raw, undercooked or pickled crustaceans such as crabs or crayfish  If worms enter the CSF of the spinal cord it can result in partial or total
paralysis.
 Spitting, a habit in asian countries
  There have also been fatal cases of Paragonimiasis by infection of the
heart.
 Cerebral cases result in cerebral cysticercosis (condition in which fluid-
filled cyst surrounding the worm are present).
Complications
 Pulmonary complications include: - pneumonia, bronchitis, bronchiectasis,
lung abscess, pleural effusion and empyema
 Cerebral complications include: - seizures and coma
 Skin complications include: - migratory allergic skin lesions
Diagnosis
 Cerebral involvement requires differentiation from tumors, cysticercosis,
cysts, encephalitis, and others
 Since egg detection rates are low, it would be useful to utilize serological
techniques to detect paragonimus antibodies
 ELISA are highly sensitive at >92% detection
 Intradermal skin test using the extract of an adult paragonimus is sensitive
and has few false positives. The result of the skin test may remain positive
up to 20 years after the infection has been cured
 Immunological methods (classic methods):
1. Complement fixation – high sensitivity for diagnosis and assessment of
cure
2. Intradermal test – simple, rapid, cheap, highly sensitive, may give +
result years after cure

 Microscopic examination demonstrating the eggs in the sputum stool or 3. Double diffusion in agar gel
pleural effusions, materials from abscesses 4. Immunoelectrophoresis
 Sputum exam: sensitivity – 37-88%  More sensitive and specific tests
 If negative repeat sputum exam 3 times on different days with 3% NaOH 1. Immunoblotting (IB) - sensitivity up to 99%
 Chest x-ray combined with a high index of suspicion – pulmonary lesions 2. Enzyme linked immunosorbent assay (ELISA) – sensitive from 96-99%
which may be infiltrative nodular, cavitating or a combination of these. (detect IgG)
Pleural effusion
3. Loop-mediated isothermal amplification (LAMP) – simple, rapid, cost
 PTB and paragonimiasis are usually co-endemic, PTB should be ruled out. effective method
 Eosinophilia and elevated IgE  An assay that detects worm antigens with monoclonal antibodies is also
 Chest x-ray findings: (100 pts) available and can be used in conjunction with the skin test

 Patchy cloudy infiltration of lungs – 51%  Exploratory cyst puncture

 Nodular shadows – 35%  For cerebral paragonimiasis:

 Calcified spots – 6%  Computer tomography (CT) scan

 Pleural thickening – 24%  Magnetic resonance imaging (MRI)

 Interlobular pleuritis – 10% Shows lesions described as “grape-like clusters”

 Pleural effusion – 5%
 For chronic disease – skull lesion present specific soap bubble  Avoid ingestion of raw or insufficiently cooked crabs and other
calcification crustaceans as well as meat from paratenic hosts like wild pigs. • Safe food
preparation helps reduce the infectivity of the food
 Capacity building of local health staff on the diagnosis and treatment of
Treatment this disease is important for early case detection and treatment.
 Praziquantel
 causes severe spasms and paralysis of the worm’s muscle
 not for pregnant women
 stomach pains, fever, nausea, dizziness, vomiting, headache
 Bithionol
 diarrhea, use is limited due to side effects
 Triclabendazole
 can cure cases where other drugs failed

Epidemiology
 In the Philippines paragonimiasis is endemic in: Mindoro, Camarines,
Sorsogon, Leyte, Samar, Zamboanga del Norte, Davao Oriental, Basilan,
Cotabato
 Focal distribution where people eat inadequately cooked crustaceans and
paratenic hosts
 Unhygienic food preparation also contributes to transmission of disease
 Cultural beliefs and tradition influence the age and sex distribution of
paragonimiasis
 PTB overlaps with paragonimiaisis in endemic areas. Both have the same
symptoms. Misdiagnosis and mismanagement are not uncommon.

Prevention and Control