CLINICAL PARASITOLOGY LECTURE

TREMATODES • Multiple larval stages

o Typically, not seen in human
Intestinal Flukes samples
• Fasciolopsis buski – Large Intestinal Fluke • Adults
• Heterophyes heterophyes – Heterophyid o All except the schistosomes
Fluke § Leaf-like
• Metagonimus yokogawai - Heterophyid § Hermaphroditic
Fluke § Typically, food-borne
o The Schistosomes
Liver Species § Dioecious
• Fasciola hepatica – Sheep Liver Fluke § Enter humans through direct
• Clonorchis sinensis – Chinese Liver Fluke penetration

Lung Species Life Cycle of Organ Dwelling Trematodes

• Paragonimus westermani – Oriental Lung
Fluke

Blood Species
• Schistosoma mansoni – Manson’s Blood
Fluke
• Schistosoma japonicum – Blood Fluke
• Schistosoma haematobium – Bladder Fluke

Key Definitions
Life Cycle of Blood Dwelling Trematodes
• Trematodes
o A group of parasites that in the adult
form are primarily non-segmented,
flattened, and leaf-shaped
• Digenea
o Another name for the trematodes
• Dioecious
o Parasites that reproduce via separate
sexes
• Distosomiasis
o General term for (human) infection
with flukes Laboratory Diagnosis
Morphology
• Species-dependent
o Feces
• Eggs o Duodenal drainage
o Vary in appearance o Rectal biopsy
o Operculum – lid-like structure o Sputum
present on some fluke eggs o Urine
o Presence and location of spines
• Eggs are primary morphologic form seen
distinguish the Schistosoma spp.
• Serologic tests are available.
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Pathogenesis and Clinical Symptoms Eggs

• Symptoms vary by infection and affected • Mature when laid

areas and include: o Schistosoma
o Eosinophilia o Heterophyes
o Allergic and toxic reactions o Opistorchis
o Tissue damage o Clonorchis
o Jaundice • Operculated and mature when laid
o Diarrhea o Heterophyes
o Opistorchis
Remember!!! o Clonorchis
• Non-operculated and mature when laid
• Eggs are operculated except for Schistosoma o Schistosoma
• Infective stage is metacercaria except • Immature when laid and operculated
Schistosoma (cercaria) o Fasciola
• All requires 2 definitive host except o Echinostoma
Schistosoma (1) o Fasciolopsis
• All Trematodes are hermaphroditic except
Schistosoma Habitat of Trematodes
• All are flat and leaf like except Schistosoma
(elongated) • Liver
• All Trematodes are organ dwelling except o Fasiola hepatica
Schistosoma o Fasciola gigantica
o Clonorchis sinensis
Intermediate Host of Trematodes o Opistorchis felineus
• Small Intestine
• All trematodes o Fasciolopsis buski
o Snail: First IH o Echinostoma ilocanum
• Fish as 2nd IH o Heterophyes heterophyes
o Heterophyes heterophyes • Blood
o Clonorchis sinensis o Schistosoma spp.
o Opistorchis felineus • Lungs
• Crab as 2nd IH o Paragonimus westermani
o Paragonimus westermani
• Plant/Vegetables as 2nd IH
o Fasciola hepatica
o Fasiola gigantica
o Fasciolopsis buski
• Snail as 2nd IH
o Echinostoma ilocanum

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Fasciolopsis buski/Fasciola hepatica Egg

Laboratory Diagnosis

• SOC for egg recovery: stool

o eggs are indistinguishable.
o Symptoms/travel history may be
helpful.
• Speciation may be done via:
o Recovery of adult Fasciolopsis
worm
o Perform
Fasciolopsis buski/Fasciola hepatica Adults § Enterotest
§ ELISA
§ Gel diffusion
§ Other methodology to
recover adult Fasciola
• F. buski
o Small intestine
• F. hepatica
o Bile ducts
Life Cycle

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
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o F. hepatica – worldwide
§ Natural host is sheep
§ Humans serve as accidental
hosts.

Fasciolopsis

• Abdominal discomfort
• Inflammation
• Bleeding of affected area
• Jaundice
• Diarrhea
• Gastric discomfort
• Edema
• Malabsorption syndrome
• Intestinal obstruction
• Death (rare)

Fascioliasis (Sheep Liver Rot)

• Headache
• Fever
• Chills
• Eosinophilia
• Jaundice
• Pains in liver area with pain extension that
may reach shoulders and back
• Biliary obstruction may occur
• Anemia
• Diarrhea
• Digestive discomfort
• Liver tenderness

Treatment

• F. buski
o Praziquantel
• F. hepatica
o Dichlorophenol (bithionol)

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Clonorchis sinensis Egg Laboratory Diagnosis

• Recovery of eggs in stool or duodenal

aspirates
• Enterotest may also be performed.
• Although rarely encountered, adults may be
removed during surgery or autopsy
procedure.

Clonorchiasis

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

Treatment
Clonorchis sinensis Adult
• Praziquantel
• Albendazole

Prevention and Control

• Proper sanitation and control

• Avoidance of raw/undercooked fish and
shrimp

Life Cycle

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Heterophyes heterophyes/Metagonimus yokogawai Heterophyiasis/Metagonimiasis

Egg
• Chronic mucous diarrhea
• Eosinophilia
• Both parasites may escape intestinal tract
and migrate to other areas (brain, heart)
o Granulomas often result.

Treatment

• Praziquantel

Prevention and Control

• Avoidance of consuming undercooked fish

• Proper fecal disposal
• Control of reservoir host populations if
physically and economically impossible

Heterophyes heterophyes/Metagonimus yokogawai

Adults

Epidemiology

• 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
Philippines, Spain, Greece, the
Balkans
• Reservoir hosts are known for both
parasites.

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Paragonimus westermani Egg Life Cycle

Laboratory Diagnosis

• Recovery of eggs in sputum specimens

• Recovery of eggs in stool is rare and occurs
when sputum is swallowed.
• Serologic tests have been developed.

Epidemiology

• Asia
• Africa
Paragonimus westermani Adult • 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 US

Paragonimiasis (Pulmonary Distomiasis)

• Pulmonary discomfort: cough, fever, chest

pain, increased production of blood-tinged
sputum
• May experience chronic bronchitis,
eosinophilia, production of fibrous tissue
• Symptoms often mimic those seen in
tuberculosis-infected individuals.

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Cerebral Paragonimiasis

• When parasite enters the brain:

o Serious neurologic condition may
result:
§ Seizures
§ Visual difficulties
§ Decreased precision of motor
skills

Treatment

• Medication of Choice
o Praziquantel
• Alternative
o Bithionol

Prevention and Control

• Avoidance of consuming undercooked

crayfish or crabs
• Exercising proper disposal of human waste
products

Opistorchis felineus

• Cat liver fluke

Echinostoma ilocanum

• Garrison’s fluke

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Schistosoma spp. Eggs Laboratory Diagnosis

• S. mansoni and S. japonicum

o stool or rectal biopsy specimens
• S. haematobium
o Concentrated urine specimens
• Immunodiagnostic techniques available

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)

Intermediate Hosts

• Schistosoma haematobium
Schistosoma spp. Adults o Bulinus
o Physopsis
o Biomphalaria
• Schistosoma japonicum
o Oncomelania quadrasi
• Schistosoma mansoni
o Biomphalaria
o Australorbis
o Tropicorbis

Schistosomiasis (Bilharziasis, Swamp Fever)

• Inflammation at penetration site

• Acute infection
o Abdominal pain, fever, chills, weight
loss, cough, bloody diarrhea,
eosinophilia.
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o Painful urination and hematuria may Looking Back

also occur.
o Necrosis, lesions, and granulomas
are common.
o Other possible symptoms:
§ Obstruction of the bowel or
ureters, secondary bacterial
infections, involvement of
central nervous system and
other tissues
Katayama Fever
• Systematic hypersensitivity reaction to
schistosomules migrating through tissue
o 1-2 months after exposure:
§ Rapid onset of fever, nausea,
myalgia, malaise, fatigue,
cough, diarrhea, eosinophilia
• Known diseases 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.
• 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.

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.

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