Trematodes
Organ-dwelling (all but schistosomes)
Intestinal Species
 Fasciolopsis buski – Large Intestinal Fluke
 Heterophyes heterophyes – Heterophyid Fluke
 Metagonimus yokogawai – Yokogawai’s Fluke
Liver Species
 Fasciola hepatica – Sheep Liver Fluke
 Clonorchis sinensis – Chinese Liver Fluke
Lung Species
 Paragonimus westermani – Oriental Lung Fluke
Blood Species
 Schistosoma mansoni – Manson’s Blood Fluke
 Schistosoma japonicum – Blood Fluke
 Schistosoma haematobium – Bladder Fluke
KEY DEFINITIONS
Trematodes
- A group of parasites that in the adult form are
primarily non-segmented, flattened, and leaf
shaped
Dignea
- Another name for the trematodes
Dioecious
- Parasites that reproduce via separate sexes
Distosomiasis
- General term for (human) infection with flukes
MORPHOLOGY AND LIFE CYCLE NOTES
Multiple larval stages
- Typically, not seen in human samples
Adults
- All except the schistosomes
o Leaf-like, hermaphroditic, typically
food-borne
- The schistosomes
o Dioecious, enter humans through direct
penetration
All trematode life cycles require a snail as an
intermediate host.
Two categories:
- Infection after ingestion of contaminated water
plants, fish, crab, crayfish
- Adults found in intestines, bile duct, lung.
- Self-fertilization; eggs passed in stool/sputum
- Eggs make contact with fresh water.
o Miracidium (contents of egg) exit into
water and penetrate specific snail
species.
o Sporocyst containing rediae (larval
stage) forms.
o Cercariae (final stage larvae) emerge
from snail.
o Cercariae enter water plant, fish, crab,
crayfish – ready for next human
infection.
Blood-dwelling (the schistosomes)
- Penetration of cercariae larvae into the skin
while swimming in contaminated water initiates
infection
- Schistosomule form emerges.
- Takes up residence in blood vessels around liver,
intestinal tract, or urinary bladder
- Adult worms form, and eggs are produced
following mating (separate sexes).
- Resulting eggs spill into stool or urine.
- Eggs make contact with fresh water.
- Miracidium (contents of egg) exit into water and
penetrate specific snail species.
- Sporocyst containing rediae (larval stage) forms.
- Cercariae (final stage larvae) emerge from snail,
ready to infect next unsuspecting human.
LABORATORY DIAGNOSIS
Specimen of choice
- Species-dependent:
o Feces
o Duodenal drainage
o Rectal biopsy
o Sputum
o Urine
- Eggs are primary morphologic form seen.
- Serologic tests are available.
PATHOGENESIS AND CLINICAL SYMPTOMS
- Symptoms vary by infection and affected areas
and include:
o Eosinophilia
o Allergic and toxic reactions
o Tissue damage
o Jaundice
 o Diarrhea - Specimen choice for egg recovery – stool
o Eggs are indistinguishable.
TREMATODE CLASSIFICATION
o Symptoms/travel history may be
helpful.
- Speciation may be done via:
o Recovery of adult Fasciolopsis worm
o Perform Enterotest, ELISA, gel diffusion,
or other methodology to recover adult
Fasciola

LIFE CYCLE NOTES

1. Fasciolopsis buski / Fasciola hepatica – Egg - Main life cycle difference:

o Location of adult worm residence
 F. buski – small intestine
 F. hepatica – bile ducts

EPIDEMIOLOGY

- Varies by parasite and is determined by

locations where infected water plants reside
o F. buski – limited to Far East (including
parts of China, Taiwan, Vietnam, others)
 Reservoir hosts include rabbits,
pigs, dogs.
o Food sources:
 Water chestnut
 Lotus
 Water caltrop
o F. hepatica – worldwide
 Natural host is sheep.
 Humans serve as accidental
hosts.

CLINICAL SYMPTOMS

- Fasciolopsis
o Abdominal discomfort
o Inflammation
o Bleeding of affected area
o Jaundice
o Diarrhea
o Gastric discomfort
Fasciolopsis buski /Fasciola hepatica – Adults o Edema
o Malabsorption syndrome
o Intestinal obstruction
o Death (rare)
- Fascioliasis (sheep liver rot)
o Headache
o Fever
o Chills
o Eosinophilia
o Jaundice
Fasciolop Fasciola o Pains in liver area with pain extension
sis buski hepatica that may reach shoulders and back
o Biliary obstruction may occur
LABORATORY DIAGNOSIS
o Anemia
 o Diarrhea Clonorchis sinensis Adult
o Digestive discomfort
LABORATORY DIAGNOSIS
o Liver tenderness
- Recovery of eggs in stool or duodenal aspirates
TREATMENT
- Enterotest may also be performed.
- F. buski – praziquantel - Although rarely encountered, adults may be
- F. hepatica – dichlorophenol (bithionol) removed during surgery or autopsy procedure.
o Success has been documented with
LIFE CYCLE NOTES
triclabendazole, but it is not available in
the U.S. - Human infection follows ingestion of
contaminated undercooked fish with encysted
PREVENTION AND CONTROL
metacercariae (larval form).
- Exercising (especially in areas known to harbor - Adult worm maturation occurs in the liver.
reservoir hosts): - Adult worms reside in the bile duct.
o Proper human fecal disposal
EPIDEMIOLOGY
o Sanitation practices
- Controlling: - Endemic in Far East
o Snail population - Reservoir hosts include fish-eating mammals,
- Avoiding consumption of raw water plants or dogs, cats.
contaminated water
CLINICAL SYMPTOMS

2. Clonorchis sinensis Egg - Asymptomatic

- Clonorchiasis
o Fever
o Abdominal pain
o Eosinophilia
o Diarrhea
o Anorexia
o Epigastric discomfort
o Occasional jaundice
o Enlargement and tenderness of liver
possible
o Liver dysfunction possible

TREATMENT

- Praziquantel
- Albendazole

PREVENTION AND CONTROL

- Proper sanitation procedures

- Avoidance of raw/undercooked fish and shrimp

3. Heterophyes heterophyes/ Metagonimus yokogawai

– Egg
Basically indistinguishable from those of Clonorchis - Proper fecal disposal
sinensis - Control of reservoir host populations if
physically and economically impossible
- Two discrete differences
4. Paragonimus westermani Egg
o Shoulders are less distinct
o Eggs may lack small terminal knob

Heterophyes heterophyes/Metagonimus yokogawai –

Adults

LABORATORY DIAGNOSIS

- Recovery of eggs in stool

- Proper identification may be difficult due to egg
appearance similarities of these parasites and
C. sinensis.

LIFE CYCLE NOTES

- Transmission – ingestion of contaminated

undercooked fish
- Adults reside in small intestine.

EPIDEMIOLOGY Paragonimus westermani - Adult

- H. heterophyes
o Near East and Far East including:
 Japan, Taiwan, the Philippines,
Korea, Israel, Egypt
- M. yokogawai:
o Areas of Japan, Siberia, China, the
LABORATORY DIAGNOSIS
Philippines, Spain, Greece, the Balkans
- Reservoir hosts are known for both parasites. - Recovery of eggs in sputum specimens
- Recovery of eggs in stool is rare and occurs
CLINICAL SYMPTOMS
when sputum is swallowed.
- Asymptomatic - Serologic tests have been developed.
- Heterophyiasis/metagonimiasis
LIFE CYCLE NOTES
o Chronic mucous diarrhea
o Eosinophilia - Human infection initiated after consumption of
o Both parasites may escape intestinal undercooked crayfish or crab.
tract and migrate to other areas (brain, - Immature flukes, often occurring in pairs,
heart). migrate through intestinal wall.
 Granulomas often result. - Ultimately settle in lung tissue
- Infection of brain/liver known to occur
TREATMENT
EPIDEMIOLOGY
- Praziquantel
- Asia
PREVENTION AND CONTROL
- Africa
- Avoidance of consuming undercooked fish - India
- Central and South America
 - Parts of the U.S.
- Reservoir hosts
o Pigs and monkeys
- Also known to cause human disease in Central
and South America and the U.S.

CLINICAL SYMPTOMS

- Paragonimiasis (pulmonary distomiasis)

o Pulmonary discomfort: cough, fever,
chest pain, increased production of
blood-tinged sputum
o May experience chronic bronchitis,
eosinophilia, production of fibrous
tissue
o Symptoms often mimic those seen in
tuberculosis-infected individuals.
- Cerebral paragonimiasis
o When parasite enters the brain:
 Serious neurologic condition Schistosoma species Adults
may result:
 Seizures
 Visual difficulties
 Decreased precision of
motor skills

TREATMENT

- Medication of choice
o Praziquantel
- Alternative choice
o Bithionol

PREVENTION AND CONTROL LABORATORY DIAGNOSIS

- Avoidance of consuming undercooked crayfish - S. mansoni and S. japonicum

or crabs o Stool or rectal biopsy specimens
- Exercising proper disposal of human waste - S. haematobium
products o Concentrated urine specimens
- Immunodiagnostic techniques available
5. Schistosoma species Eggs
LIFE CYCLE NOTES

- Human infection initiated after penetration of

cercariae larvae into the skin when swimming in
contaminated water.
- Schistosomule larvae emerge and migrate into
bloodstream where maturation into adulthood
occurs.
- S. mansoni and S. japonicum adults reside in the
veins that surround intestinal tract.
o Eggs pass into the stool.
- S. haematobium adults reside in the veins
around the bladder.
o Eggs pass into the urine.
- Eggs produce enzymes that help them travel
through the tissue to be excreted.
- When eggs contact fresh water:
 o Egg content (miracidium) is released
into the water.
o Miracidium must locate a snail, where it
develops a cercariae to continue the life
cycle.
EPIDEMIOLOGY
- Numerous reservoir hosts including:
o Monkeys, cattle and other livestock,
rodents, dogs, cats
- S. mansoni
o Africa, Puerto Rico, West Indies,
portions of Central and South America
- S. japonicum
o Far East: parts of China, Indonesia, the
Philippines
o Once considered endemic, parts of
Japan may no longer be considered as
such.
- S. haematobium
o Africa and parts of the Middle East
(Iran, Iraq, Saudi Arabia)
CLINICAL SYMPTOMS
- Asymptomatic (carrier)
- Schistosomiasis (bilharziasis, swamp fever)
o Inflammation at penetration site
o Acute infection
 Abdominal pain, fever, chills,
weight loss, cough, bloody
diarrhea, eosinophilia.
 Painful urination and
hematuria may also occur.
 Necrosis, lesions, and
granulomas are common.
o Other possible symptoms:
o Obstruction of the bowel or
ureters, secondary bacterial
infections, involvement of central
nervous system and other tissues
- Katayama fever
o Systematic hypersensitivity reaction to
schistosomules migrating through tissue
 1-2 months after exposure:
 Rapid onset of fever,
nausea, myalgia,
malaise, fatigue,
cough, diarrhea,
eosinophilia
- Known disease associations:
o Infected patients with S. japonicum
and/or S. haematobium may result in
increased risk of suffering from
nephrotic syndrome.
o S. haematobium has been associated
with bladder cancer.
o S. mansoni and S. japonicum may be
associated with repeated Salmonella
infections.
TREATMENT
- Praziquantel
- Oxamniquine has been used to treat S. mansoni.
- Antimalarial medications have proven effective:
o Artemisinins – artemether and
artesunate
o Concern in endemic areas – increased
malarial resistance may result from
using these medications.
- Surgery may be necessary when obstructions
occur.
PREVENTION AND CONTROL
- Current focus
o Antihelminthic chemotherapy with
praziquantel
 Low cost
 Few side effects
 Rapid results
o WHO (World Health Organization)
recommendations
 Mass treatment of everyone in
high-prevalence/high-risk
communities
 Treatment of all children in
moderately prevalent areas
 Only treating diagnosed cases
in low-prevalence areas
LOOKING BACK
- To accurately diagnose the flukes:
o Careful microscopic examination of
appropriate samples for presence of
eggs
o Consideration of organism shape, size,
and features (such as operculum,
shoulders, spine)
- Eggs of certain flukes are indistinguishable, and,
thus further investigation is required to
speciate.
o Consideration of patient travel history,
signs and symptoms and possible
recovery of adult worms.
- Overall, recovery of adult flukes is rare
o Still important to be familiar with adult
appearance
 Except the schistosomes,
typical adult flukes are leaf-
shaped, flattened worms.
 Schistosomes are round and
elongated.