Reported by Ocampo, Eirene Joy Louise N.

BSN110
‡ Parasites of the biliary duct, gall bladder and
liver parenchyma (hepatocyte)

‡ They feed on blood

‡ Adult flukes produce eggs which are passed

into the intestine
Juvenile flukes migrating
through liver tissue:

Juvenile flukes gain entry into

the host after the infectious
metacercariae cysts are
ingested on watercress or algae.
The flukes can spend up to 8-12
weeks migrating through the
liver tissue before it reaches
the bile duct where it begins
sexual reproduction.
Metacercaria - minute cases, usually round or
spherical
- house intermediate stages of
parasites
- ingested by the final stage
host, allowing the lifecycle
to continue.

* Humans acquire Clonorchiasis also known as

biliary trematodiasis by ingesting encysted
metacercaria in undercooked or raw fish.
Fish with metacercariae
‡ Clonorchis sinensis (“Chinese liver fluke” or
the “Oriental liver fluke”)

‡ Opisthorchis felineus (cat liver fluke)

‡ Opisthorchis viverini (Southeast Asian liver

fluke)

‡ Fasciola hepatica (Sheep liver fluke)

‡ Fasciola gigantica (Giant liver fluke)

‡ Dicrocoelium dendriticum (Lancet liver fluke)

‡ Dicrocoelium hospes

‡ Metorchis albidus

‡ Metorchis conjunctus
‡ Protofasciola robusta

‡ Parafasciolopsis fasciomorphae

‡ Opisthorchis guayaquilensis

‡ Fasciola jacksoni
‡ Moderate-sized fluke at
1-2.5X0.3-0.5 cm

‡ Spindle-shaped, have broad

midbodies and tapered ends

‡ The eggs have small comma-

shaped processes at the
abopercular end and measure
29X16 um.
 (1) Embryonated eggs are discharged in the biliary
ducts and in the stool .(2) Eggs are ingested by a suitable
snail intermediate host ; there are more than 100 species
of snails that can serve as intermediate hosts.  Each egg
releases a 2a.miracidia , which go through several
developmental stages (2b.sporocysts , 2c.rediae , and
2d.cercariae ).(3) The cercariae are released from the
snail and after a short period of free-swimming time in
water, they come in contact and penetrate the flesh of
freshwater fish, where they encyst as metacercariae .
(4) Infection of humans occurs by ingestion of
undercooked, salted, pickled, or smoked freshwater fish .
(5) After ingestion, the metacercariae excyst in the
duodenum and (6) ascend the biliary tract through the
ampulla of Vater .  Maturation takes approximately 1
month.  The adult flukes (measuring 10 to 25 mm by 3 to 5
mm) reside in small and medium sized biliary ducts.  In
addition to humans, carnivorous animals can serve as
reservoir hosts.
‡ Causes the disease: Clonorchiasis

Epidemiology of CLONORCHIASIS:
‡ Infection is through undercooked
freshwater fish with encysted
metacercariae

‡ Widespread parasite of humans, dogs &

cats. The last two are considered as
important reservoirs
Epidemiology of CLONORCHIASIS:
‡ Endemic in the Far East, especially in
Korea, Japan, Taiwan, and southern
China, and infection occurs elsewhere
among immigrants and those eating fish
imported from endemic areas.

‡ It occurs in large areas of China

Symptoms of CLONORCHIASIS:

‡ General symptoms = fever

= chills
= epigastric pain
= diarrhea
= mild jaundice
Symptoms of CLONORCHIASIS:
‡ In small quantities = asymptomatic (Light
infection)

‡ In large quantities = acute infection

possibly lasting for less than 1 month

Acute phase irritation of bile ducts dilatation and

deviation liver become enlarged, necrotic, tender
impaired function
Symptoms of CLONORCHIASIS:
‡ Modest infections = indigestion
= epigastric discomfort
= weakness
= loss of weight
‡ Heavier infections = anemia
= liver enlargement
= slight jaundice
= edema
= ascites
= diarrhea
Diagnosis of CLONORCHIASIS:
‡ Occasionally by percutaneous transhepatic
cholangiography

‡ By indentifying eggs in the feces or duodenal

contents by entero test (using a cotton thread fixed to a
very light weight, both of which are enclosed in a capsule, except for
the free end of the thread. The patient swallows the capsule and the
end of the thread is held outside the mouth. After digestion of the
capsule, the weight unrolls the encapsulated part of the thread and
descends to the terminal part of the duodenum. The whole thread and
weight are drawn back after about 3 hours, and all the material sticking
)
to the thread is collected by scraping
Treatment and Control of CLONORCHIASIS:
‡ Administer 25 mg/kg (3x/day for 2 days)
of Praziquantel – 100% cure rate
‡ Sometimes 10 mg/kg (1x/day for 7 days)
of Albendazole is used

‡ Cook fish well

‡ Treat sewage before disposal
‡ Opisthorchis felineus = cat liver
fluke
‡ Opishtorchis viverini = Southeast
Asian liver fluke
‡ Life cycle similar to Clonorchis
sinensis
‡ Adult forms are similar to Clonorchis
sinensis but their eggs are slightly
narrower (30 – 12 um)
‡ Eggs of O. viverini are relatively
short and broad (ave.L = 26.7um;
ave.breadth = 15um)
‡Causes the disease: Opisthorchiasis
("Siberian liver fluke disease" or "cat liver
fluke disease“)
Epidemiology of OPISTHORCHIASIS:
‡ Opisthorchiasis is a parasitic disease that can
infect fish eating mammals, including humans.

‡ Human infection occurs through consumption of

pickled, raw, or poorly cooked fish that contain
the developing worms known as metacercariae.
e.g. Koi-pla (uncooked freshwater fish dish)
Epidemiology of OPISTHORCHIASIS:
‡ Commonly occurs in areas that eat raw or
pickled fish (East Prussia, Poland, Philippines,
Korea, Japan and Vietnam)

‡ O. viverini is a major health problem in

northern Thailand

‡ Prevalence: 85% = rural people

55% = urban people
Symptoms of OPISTHORCHIASIS:
‡ Similar to C. sinensis since it inhabits the
bile ducts as well
‡ Mild to moderate infection = general malaise
to abdominal pain
= upper right
quadrant or
epigastric pain
‡ Heavy & long standing = cholangiocarcinoma
(liver cancer)
Diagnosis of OPISTHORCHIASIS:

‡ Based on the symptoms present

‡ Based on the presence of an endemic infection

in a given area
Treatment and Control of OPISTHORCHIASIS:

‡ Administer 25 mg/kg (3x/day for 1-2 days) of

Praziquantel

‡ Praziquantel has no effect on

cholangiocarcinoma.This indicates that
infection must be entirely avoided to prevent a
future diagnosis of cancer.
Treatment and Control of OPISTHORCHIASIS:

‡ Prevent fecal parasites from reaching the water

supplies

‡ Decreasing snail hosts

‡ Promote adequate cooking methods for the

second intermediate host fish
* Flukes causing Clonorchiasis and
Orthorchiasis are differentiated by the shape
of their testes, which are highly branched in
Clonorchis and only lobed or slightly branched
in Opisthorchis. The parasites also differ in
their larval stage morphology, providing
support for the retention of both Clonorchis
and Opisthorchis genera.
‡ Fasciola hepatica = large (about 3
cm long, 1.5 cm wide)
= “cephalic cone” at anterior end
‡ Fasciola gigantica = 7.4 cm length
= have more attenuated body shape

than the F. hepatica

‡ Eggs are operculated and measure
130 - 150 um in length and 63 – 90
um in breadth
 (1) Immature eggs are discharged into the
intestine and stool . (2) Eggs become embryonated in
water , (3) eggs release miracidia , (4) which invade a
suitable snail intermediate host . In the snail the
parasites undergo several developmental stages
(4a.sporocysts , 4b.rediae , and 4c.cercariae ).
(5) The cercariae are released from the snail (6) and
encyst as metacercariae on aquatic plants .(7) The
mammalian hosts become infected by ingesting
metacercariae on the aquatic plants.  After ingestion,
the metacercariae excyst in the duodenum (8) and
attach to the intestinal wall.  There they develop
into adult flukes (20 to 75 mm by 8 to 20 mm) in
approximately 3 months, attached to the intestinal
wall of the mammalian hosts (humans and pigs).
The  adults have a life span of about one year.
‡ Causes the disease: Fascioliasis

Epidemiology of FASCIOLIASIS:
‡ Humans become infected when they eat
watercress, water chestnuts, or other
plants covered with the encysted
metacercariae.

Metacercariae inflame and destroy tissue of liver

10 – 15 wks after flukes move to bile ducts
produce eggs
Epidemiology of FASCIOLIASIS:

‡ F. hepatica is common among herbivores

and cosmopolitan distribution

‡ F. gigantica is a parasite of herbivores,

particularly camels, cattle, and water
buffalo in Africa and the Orient
Symptoms of FASCIOLIASIS:
‡ Light infection = sign of biliary obstruction

= cholangitis
= fever
= chills
= pain in the RUQ
= jaundice
= enlarged tender liver
= eosinophilia
Symptoms of FASCIOLIASIS:
‡ Adult fluke attaches in pharyngeal mucosa
causing = pain
= bleeding
= edema (interferes with
respiration)
* Halzoun (pharyngeal form of disease)
= common in the Middle East
= from eating raw animal liver
Diagnosis of FASCIOLIASIS:

‡ By recovery of eggs using entero test

‡ By Ultrasonography in visualizing their

presence
Treatment and Control of FASCIOLIASIS:
‡ Administer 30 - 50 mg/kg (every other day for
10 – 15 doses PO) of Bithionol
‡ Watercress should not be grown for human
use in water in which herbivores have access
‡ WHO and Novartis Pharma AG have
negotiated an agreement whereby Novartis
will donate triclabendazole for the treatment
of infected individuals in endemic countries
(free of charge to such countries upon
application from ministries of health)
‡ Also called the Lancet Liver Fluke

‡ 1 cm flukes found in the bile ducts

‡ Causes haepato-biliary damage –

ending in cirrhosis – in sheep, hares
and other herbivores

‡ Rarely in humans
‡ Has a typical life cycle with three
different hosts, but, interestingly, it
clearly alters the behavior of one of
them, making it more likely to reach
the next host (though this type of
behavior control is suspected in
many other parasites, it’s often not
easy to prove)
 The animal in which the adult flukes live is called the
definitive host—the host in which the parasite multiplies sexually:

(1) Adult worms in the liver of the definitive host produce eggs that
are washed out in the bile, mixed with the stool, and passed from
the body.
(2) Land snails feed on decaying animal droppings and ingest the
eggs, whereupon the eggs hatch, releasing miracidia.
(3) Miracidia migrate through the gut wall into the snail’s digestive
gland, where they multiply asexually. Cercariae are produced. The
snail is the first intermediate host for the fluke.
(4) Cercariae exiting the snail’s tissues are encased in a coating of
slime, which is left behind on the vegetation that the snail travels
over. Transforming to metacercariaie, the parasites can be very
numerous (hundreds in one slime ball) and are protected from
drying out by the slime encasing them.
(5) Foraging ants collect the slime balls and carry them back to the
nest, where the slime balls are eaten. Metacercariae encyst in the
ant’s body cavity and become infective to the definitive host. One
metacercaria travels to the ant’s nervous tissue and encysts there,
an event which profoundly influences the ant’s behavior from then
on - scientists are still unsure of how this works.
(6) Infected ants crawl to the tops of blades of grass in the cool
evenings and early mornings and cling there. This is the time when
herbivores are grazing—the ant’s strange behavior makes the insect
much more likely to be eaten by a grazing animal! In the heat of
the day, when the dew dries up and animals rest in the shade, the
ant that has not been eaten resumes its normal activities, only to
ascend again when things cool down.
(7) Metacercariae in ants that have been eaten migrate up the bile
duct into the liver and mature to adult flukes in under two months.
At about three months after infection, the worms begin producing
eggs.
‡ Causes the disease: Dicrocoeliasis

Epidemiology of DICROCOELIASIS:
‡ Unusual

‡ Many suspected cases are simply the result of

the person having eaten the liver of an infected
animal—typical eggs from flukes in the liver
travel through the intestine and are passed in
the stool without actual infection
Epidemiology of DICROCOELIASIS:

‡ True cases of human infection with the Lancet

Fluke arise when people—accidentally or
deliberately—eat ants
‡ Believed to be endemic or potentially endemic in
30 countries (throughout Europe = former
U.S.S.R., Switzerland, Italy, Germany, Spain,
Turkey ; the Middle East = Iran; Asia = China,
Japan, Vietnam; Africa = Ghana, Nigeria, Sierra
Leone; and in North and South America and
Australia
Epidemiology of DICROCOELIASIS:

‡ Tends to be found in areas that favor the

intermediate hosts, such as fields with dry,
chalky and alkaline soils (main reservoirs are
sheep, cows, land snails and ants)

‡ Can also been found in goats, pigs and even

llamas and alpacas.
Symptoms of DICROCOELIASIS:
‡ Infections of the biliary tree (mild) = biliary colic

= general digestive disturbances

(bloating and diarrhea)
‡ Heavier infections = enlarged bile ducts

= enlarged biliary epithelium

= generation of fibrous tissue
surrounding the ducts
= hepatomegaly
= inflammation of the liver
(cirrhosis)
Symptoms of DICROCOELIASIS:

‡ In one unique case, an infection with D.

dendriticum was associated with acute urticaria.
Diagnosis of DICROCOELIASIS:

‡ Involves identification through eggs in the

feces of a human or animal (not very
accurate in humans)

‡ Examination of bile or duodenal fluid for eggs

is a more accurate diagnostic technique
Treatment and Control of DICROCOELIASIS:

‡ Administer 25 mg/kg (3x/day for 1 day) of

Praziquantel
‡ One German patient had 600mg of Praziquantel
3x/day for 3 days = also successful in
eliminating the parasite from the body
‡ Treatment with triclobendazole
‡ Administer 2 capsules of Mirazid (300mg) for 6
days (effective in humans, sheep and goats)
Liver head magnified at 60x
(the bar is 200 microns)
(A) Fasciola gigantica
(B) Fasciola hepatica

Clonorchis sinensis
acetabulum,genital
pore