PARASITOLOGY

2.04 INTESTINAL FLUKES

JENNIFER P. ALVARADO, MD | JUNE 21, 2022

OUTLINE • 1st INTERMEDIATE HOST: snail

I. Fasciolopsis buski II. Echinostomids • 2nd INTERMEDIATE HOST: aquatic plants
A. Morphology A. Morphology
B. Biology B. Biology
C. Life Cycle C. Life Cycle
D. Pathogenesis and D. Pathogenesis and
Clinical Clinical
Manifestations Manifestations
E. Diagnosis E. Diagnosis
F. Treatment F. Treatment
G. Epidemiology G. Epidemiology
H. Prevention and Prevention and Control
Control III. Heterophyid Flukes
B. Biology
• MOT
LEGENDS
→ Ingestion of encysted metacercaria on aquatic
LECTURER BOOK 1 BOOK 2 PPT
plants
→ Hull or skin of the fruits of aquatic plants is peeled
off between the teeth
I. FASCIOLOPSIS BUSKI
→ Infective Stage of Fasciolopsis buski: metacercaria
• Largest intestinal fluke of human and pigs
C. Life Cycle
• Common name: Large intestinal fluke
• Upon ingestion, metacercaria excyst in duodenum
• Common assoc. dse and condition: Fasciolopsiasis
• Attaches to the intestinal wall upon ingestion
A. Morphology
• Becomes sexually mature in about 3 months
• EGG
• Adult worm lives in the duodenum, attached to
→ Large
intestinal mucosa via suckers
→ Operculated
• Immature eggs released together w/ feces into water
→ Unembryonated when first passed
• Eggs embryonates in water (3-7 weeks)
→ Measures 130um-140um by 80um-85 um
• Miracidium infects the 1st intermediate host snail
(genus Segmentina or Hippeutis)
• Inside the snail, miracidium transforms into sporocyst
• Produces mother and daughter rediae then cercariae
• Cercariae leaves daughter rediae and undergo further
development
• 7 weeks after infection, cercariae are released into
water
• Cercaria attach themselves and encyst as
metacercaria on surfaces of the seed pods, bulbs,
• ADULT WORM
stems or roots of various aquatic plants
→ Elongated, oval
→ Trapa bicornis (water caltrop)
→ Measures 20-75mm long and 8-
→ Eliocharis tuberosa (water chestnut)
20mm wide
→ Ipomea obscura (kangkong)
→ No cephalic cone
• Nymphaea lotus (Lotus): 2nd int. host
→ Unbranched intestinal ceca up to
• Primary difference in the life cycles of F. buski and F.
posterior end
hepatica
→ 2 testes dendritic, arranged in
→ F. buski adults live in the small intestine
tandem in posterior half of the
→ F. hepatica live in the bile ducts
body
→ Ovary branched lies to the right of midline
→ Vitelline follicles fine, located at the lateral margin of
the body

TRANS CALUB, GARCIA, L., MACARUBBO, OLUNAN 1 of 4

2.04 Intestinal Flukes
• Exercise proper human fecal disposal and sanitation
practices in areas where animal reservoir hosts reside
• Control snail population
• Avoid human consumption of raw water plants or
contaminated water

II. ECHINOSTOMIDS
• Digenetic
• Collar of spines around oral suckers
A. Morphology
Atryfechinostomum malayum
• ADULT WORM:
→ 5-12mm long, 2-3 mm wide
→ Rounded posterior end
→ 43-45 collar spines
D. Pathogenesis and Clinical Manifestation → 2 testes: large each with 6 to 9 lobes arranged in
tandem
• Pathologic changes: traumatic, obstructive and toxic
• Inflammation and ulceration at site of attachment: → Ovary: small, rounded or oval, located anterior to
testes and pre-equatorial
increase mucus secretion and minimal bleeding
• EGG:
• Gland abscesses: formed in the mucosa
→ Larger, golden brown, operculated
• Intestinal obstruction: heavy infections
(Especially for heavy worm burden) → 120-130 um by 80-90 um
• Intoxication-absorption of worm metabolites • FIRST INTERMEDIATE HOST
→ Not known
GENERALIZED TOXIC AND ALLERGIC SYMPTOMS
• SECOND INTERMEDIATE HOSTS
• Facial edema
→ Lymnaea bullostra
• Bipedal edema
→ Cumingiana (birabid)
• Edema of abdominal wall
• Profound intoxication – death (host)
E. Diagnosis
• Detection of eggs in stools
• Resembles F. hepatica so both are operculated
F. Treatment
• Praziquantel 25mg/kg (3 doses over 1 day)
→ Epigastric pain, dizziness, drowsiness
→ Disappear w/n 48 hrs
→ Patients w/ F. hepatica infection have also been
Echinostoma ilocanum
successfully treated w/ dichlorophenol (bithionol)
• ADULT WORM:
• Central Thailand
→ Reddish gray
→ 100% cure rate for regimens 15mg, 25 mg and 40mg
→ 2.5-6.6 mm long
Praziquantel per kg body weight
→ 1-1.35 mm wide
G. Epidemiology
→ Tapered at posterior end
• Fasciolopsiasis endemic in SEA, China, Korea and India
→ 49-51 collar spines
• Endemicity in Philippines not demonstrated yet
→ Oral sucker lies in the center of circumoral disk
• No locally acquired case has been reported
→ Ventral sucker situated at anterior 5th of the body
H. Prevention and Control
→ 2 testes: deeply bilobed, in tandem at 3rd quarter of
• Avoid soaking aquatic plants in water (metacercaria is
the body
sensitive to dryness)
→ Ovary just in front of anterior testis
• Time interval bet. harvest and consumption should be
→ Follicular vitellaria posterior half of the body
prolonged
→ Uterine coil: found bet. ovary and ventral sucker
• Wash plants to remove metacercaria or boil them to
→ Intestinal ceca: simple
kill the parasite
• Swamps or ponds should be protected from pollution
(by infected humans or pigs)

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2.04 Intestinal Flukes
• Diarrhea (sometimes bloody)
• Abdominal pain
• General intoxication: absorption of metabolites
E. Diagnosis
• Detection of eggs in stool
F. Treatment
• Praziquantel 25mg/kg for 3 doses for one day
• Maximum adult dose: 5ml
• EGGS: • No alcohol nor fat intake 24 hrs before and after
→ Straw colored, operculated and ovoid treatment
→ Measures 83-116 um by 58-69 um • NPO except water within 3 hours of medication
G. Epidemiology
• E. ilocanum infection is endemic in Northern Luzon,
Leyte, Samar, and provinces in Mindanao
• A. malayanum infection is 1st reported in humans only
in 1987, Northern and Central Luzon
• Endemicity is related to eating habits
• Second intermediate host is abundant in rice fields
• Rat: reservoir host
H. Prevention and Control
• 1st INTERMEDIATE HOSTS • Avoid ingesting raw or improperly cooked second snail
→ Gyraulus convexiusculus intermediate host
→ Hippeutis umbilicalis
• 2nd INTERMEDIATE HOSTS III. HETEROPHYID FLUKES
→ Pila luzonica (kuhol) • Lives in the intestines of fish-eating hosts
→ Vivipara angularis (susong pampang) → Heterophyes heterophyes
B. Biology → Metagonimus yokogawai
• MOT → Haplorchis taichui
→ Ingestion of metacercaria encysted in snails → Haplorchis yokogawai
C. Life Cycle • SNAIL HOSTS:
• Egg matures in water → H. taichui: Melania juncea
• After 6-15 days, miracidium hatches from egg to infect → Procerorovum calderoni: Thiara riquetti
first snail intermediate host A. Morphology
• Inside the snail • ADULT:
→ E. ilocanum miracidium develops into mother → Elongated, oval, pyriform
rediae, and produce daughter rediae and cercaria → < 2 mm long
after 42-50 days → Tegument has fine scale-like spines
→ A. malayanum miracidium first develops into → Gonotyl (genital sucker) left posterior border of
sporocyst, then produces mother, daughter rediae ventral sucker
and cercaria → Testes: arranged in the posterior end of the body
• After escaping from the snail, cercaria swim in water to → Ovary: globular or slightly lobed located in the
infect 2nd snail intermediate host w/c transforms into submedian, pre or post testicular area
metacercaria (infective stage) • EGGS:
• Metacercaria reaches duodenum and they will excyst → Light brown
• Juvenile flukes attach to the small intestinal wall → Ovoid
(sexually mature adult worms)
→ Operculated
• Adult worm lives in small intestine of definitive host
→ 20-30 um by 15-17 um
→ Human, dog, cat, rat and pig
→ Fully developed
• Immature eggs are released and transported to the
→ Symmetrical miracidia present in the egg when
environment through feces
deposited
D. Pathogenesis and Clinical Manifestations
B. Biology
• Heavy infections: inflammation develops at the site of
• MOT
attachment of adult worm to intestinal wall
→ Ingestion of metacercaria encysted in fish
• Ulceration

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2.04 Intestinal Flukes
C. Life Cycle E. Diagnosis
• Excyst in the duodenum • Modified Kato thick method
• Liberate young larva → Detection of eggs
• Attach to intestinal villi → Sensitivity 31%
• Develop into sexually mature adult worm (life span < 1 • Formalin ether/ethyl acetate conc. technique
year) → 13.6% sensitivity
• Adult worm inhabits the small intestines of definitive • PCR
host → Sensitive diagnostic tool for low intensity infection
• Produce eggs and passed out in feces F. Treatment
• Eggs hatch into miracidia after ingestion of snail (1st • Praziquantel: DOC; 25mkd TID for 1 day
intermediate host) G. Epidemiology
• Miracidia develop into sporocyst and develop into 1 or • Worldwide distribution
2 generations of rediae giving rise to cercaria • Reservoir host: dogs, cats, birds
• Cercaria liberated from snail encyst as metacercaria • Philippines
on or under scales, in the muscles, fins, tails or gills of → 1980’s - <1% of 30,000 stools examined (+) for ova
fish (2nd intermediate host) → 1998 (Monkayo, Compostela Valley)
▪ 31% prevalence
▪ Majority moderate to heavy worm burden
(Haplorchis taichui)
→ Infection rates
▪ High in both male and female
▪ All age groups
→ Intestinal heterophyidiasis: emerging public health
concern (Southern part of Phil.)
→ 8 provinces in 2 regions of Mindanao: thousand
cases
H. Prevention and Control
D. Pathogenesis and Clinical Manifestations • Avoid ingestion of raw or improperly cooked fish
• Inflammation at site of attachment • Capacity building of laboratory staff for early diagnosis
• Excessive mucus production in routine stool exam to provide appropriate treatment
• Sloughing off superficial layer • Surveillance in other regions where raw fish (kinilaw) is
• Most common manifestations (Compostela Valley) eaten should be considered
→ Peptic Ulcer disease
→ Acid Peptic disease REFERENCES
• Upper abdominal discomfort/pain (42.2%) • Doc Alvarado’s PPT Slides
• Gurgling abdomen (24.1%)
• Colicky abdominal pain
• Mucoid diarrhea
• Africa (1931)
→ Worms tend to burrow deep into the intestinal wall,
trapped and cause disease
→ Eggs of degenerating worms may be filtered
through the intestinal lymphatics and blood vessels
and deposited in various tissues
→ Eggs and adult worms seen in the heart and brain
▪ Died of heart failure and intracerebral
hemorrhage
→ Eggs lodged in spinal cord
▪ Sensory and motor losses at level of lesion

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