Trematodes

Dr. Sulaiman Lakoh

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Objectives
• To know the general characteristics of trematodes
• To understand the clinical features, management and
prevention of trematodes

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Characteristics of trematodes (1)
• Trematode (flukes) infections occur worldwide
• Divided based on the tissues they affect: blood, biliary tree,
intestine, and lungs
• Blood flukes: Schitosoma species
• Lung fluke: Paragonimus westermani 
• Liver fluke: Clonorchis sinensis Fasciola
hepatica and Opisthorchis viverrini 
• Intestinal flukes: Fasciolopsis buski, Heterophyes heterophyes
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Characteristics of trematodes (2)
• Adult reside in the gastrointestinal tract (GIT)
• Larvae can be found in almost any organ
• Unsegmented, leaf-shaped worms that are flattened
dorsoventrally
• They bear 2 suckers, one surrounding the mouth
(oral/anterior sucker) and another on the ventral surface of
the body (ventral sucker)
• With the exception of Schistosoma species, they are
hermaphroditic
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Characteristics of trematodes (3)
• Bilaterally symmetrical excretory system with flame cells and
collecting tubes
• The reproductive system consists of male and female
reproductive organs and is complete in each fluke
• An incomplete alimentary canal (absent anus)

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Characteristics of trematodes (4)
• The flukes are oviparous and lay operculated eggs
• An exception is Schistosoma eggs, which are not operculated
• All have complicated life cycles, with alternating asexual and
sexual developments in different hosts

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Characteristics of trematodes (5)
• Two definitive (humans, domestic animals, wild animals) and
intermediate (freshwater snails)
• Adult worms in humans reside in various locations

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General characteristics: schistosomiasis (1)
• Schistosoma are also called blood flukes
• Five species:
• Intestinal species: S. mansoni, S. intercalatum, S. japanicum,
and S. mekongi
• Urinary: S. haematobium

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General characteristics: schistosomiasis (2)
 List of Definitive and Intermediate Hosts and Sources of Infection of Schistosomiasis

Trematodes Definitive host Intermediate host Source of infection

S haematobium Humans Freshwater snails (genus Bulinus) Contact with water contaminated

by cercariae

S mansoni Humans, occasionally baboons Freshwater snails (genus Biomphalaria) Penetration of skin by cercariae
and rodents

S japonicum Humans, dogs, pigs, cattle, mice, Amphibian snails (Oncomelania species) Penetration of skin by cercariae
mustelids, and monkeys

S mekongi Humans and dogs Aquatic snails (Tricula aperta) Penetration of skin by cercariae

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General characteristics: schistosomiasis (3)
• Male adult schistosomes are shorter than females, with
flattened bodies and anteriorly curved, forming the
gynaecophoric canal, in which mature adult females are
usually held
• Females are longer, slender, and round
• Schistosoma species are estimated to infect 200-300 millions
persons
• Prevalent in South America, the Caribbean, Africa, the Middle
East, and Southeast Asia
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General characteristics: schistosomiasis (4)

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Lifecycle: Schistosomiasis (1)
• Infection is initiated by penetration of intact skin with
infective cercariae
• The cercariae are released from infected snails in fresh water
bodies
• It has a ventral and anterior sucker that attached to the skin
• The cercariae transforms into schitosomula in the
subcutaneous tissues

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Lifecycle: Schistosomiasis (2)
• The schistosomula migrate to the lungs via lymphatics or
vessels
• The sexually mature worms descend to specific anatomic
vasculature where they mate
• Intestinal veins (S. mansoni, S. intercalatum, S. japanicum,
and S. mekongi and vesical veins for S. haematonium
• After mating, the gravid adult female travel to small
tributaries where they deposit their ova intravascularly

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Lifecycle: Schistosomiasis (3)
• Ova are excreted in feces or urine
• Ova that reach the fresh body water hatch releasing the free-
living miracidia that seek the snail intermediate host
• Miracidia go through several developmental stages inside the
snail: sporocysts, rediae, with the latter giving rise to many
cercariae
• The infective cercariea are shed from the snails

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Lifecycle: Schistosomiasis (4)

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Pathogenesis: Schistosomiasis (1)
• Cercarial invasion is associated humoral and cell mediated
immune response resulting in cercarial dermatitis
• Serum sickness-like illness may occur causing Katayama fever
• Granulomatous response around these ova is cell-mediated
• Granuloma contribute to the hepatomegaly
• Perisinusoidal portal blockage causes portal hypertension
and its complications
• Periportal fibrosis (Symmers’ clay pipe-stem fibrosis)
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Pathogenesis: Schistosomiasis (2)
• Granuloma formation at the lower end of the ureters
obstruct urinary flow, with subsequent development of
hydroureter and hydronephrosis
• Chronic changes in the urinary bladder is associated with
scarring

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Clinical features: Schistosomiasis (1)
• Cercarial dermatitis (Swimmers’ itch): itchy maculopapular
rash on the affected areas of the skin
• Acute schistosomiasis (Katayama fever): fever, generalized
lymphadenopathy, peripheral-blood eosinophilia, and
hepatosplenomegaly

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Clinical features: Schistosomiasis (2)
• Intestinal disease: Colicky abdominal pain, bloody diarrhea,
fatigue, growth retardation, and anemia
• Hepatosplenic disease: hepatomegaly with right upper
quadrant pain, portal hypertension, bleeding eosophageal
varices, and splenomegaly
• Urinary symptoms: dysuria, frequency, hematuria (which
may be terminal)

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Clinical features: Schistosomiasis (3)
• Lungs: pulmonary hypertension and cor pulmonale manifest
as cough, dyspnea, and fever
• CNS: transverse myelitis, Jacksonian epilepsy

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Diagnosis: Schistosomiasis (1)
• Serology assays
• Kato thick smear
• Urine and stool microscopy
• Imaging: abdominal ultrasound, cranial CT scan, chest x-ray

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Diagnosis: Schistosomiasis (2)

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Treatment: Schistosomiasis
• Cercarial dermatitis: dermatological therapy
• Katayama fever: glucocorticoid treatment
• Specific therapy: praziquantel therapy

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Prevention: Schistosomiasis
• Avoid contact with all freshwater bodies
• Molluscides
• Provision of sanitary water and sewage disposal
• Chemotherapy
• Health education

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General characteristics: Liver and biliary flukes
(1)
• Clonorchis and Fasciola
• They are common in Southeast Asia and Russia
• Clonorchis sinensis ( Chinese or oriental fluke) is endemic
among fish eating mammals in southeast Asia
• Humans are incidental host

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General characteristics: Liver and biliary flukes
(2)
• Prevalence is highest in China, Vietnam, and Korea
• Infection with Opisthorchis viverrini and O. felineus is
zoonotic in cats and dogs
• Transmission to humans occurs occasionally, particularly in
Thailand (O. viverrini) and in Southeast Asia and Eastern
Europe (O. felineus)

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Lifecycle: Liver and biliary flukes (1)
• Infection is established by ingestion of raw or inadequately cooked
freshwater fish habouring metacercariae
• They excyst in the duodenum, releasing larvae that travel through the
ampulla of Vater and mature into adult worms in bile canaliculi
• Mature flukes are flat and enlongated, measuring 1-2cm in length

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Lifecycle: Liver and biliary flukes (2)
• The hermaphroditic worms reproduce by releasing small
operculated eggs, which pass with bile into the intestines
and are voided with stools
• The lifecycle is completed in the environment in specific
freshwater snails (the first intermediate host) and
encystment of metacercariae in freshwater fish

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Lifecycle: Liver and biliary flukes (3)

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Clinical features: Liver and biliary flukes
• Clinical syndromes are not well defined
• Most are asymptomatic
• Right-upper-quadrant pain in heavy infections
• Carcinogenic
• Chronic infections: cholangitis and cholangiohepatitis

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Diagnosis and treatment: Liver and biliary flukes
• Stool microscopy for ova
• Imaging: ultrasound
• Treat with praziquantel and triclabendazole

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General characteristics: Fascioliasis (1)
• Caused by Fasciola hepatica and F. gigantica
• They are worldwide zoonoses
• Particularly endemic in sheep-raising countries
• Humans cases have been reported in South America, Europe, Africa,
Australia, and the Far East
• Recent estimates indicate a worldwide prevalence of 17 million cases
• High endemicity has been reported in certain areas of Peru and
Bolivia

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General characteristics: Fascioliasis (2)
• In most endemic areas, the predominant species is F. hepatica, but in
Asia and Africa a varying degree of overlap with F. gigantica
• Humans acquire fascioliasis by ingestion of metacercariae attached to
certain aquatic plants, such as watercress
• Infection may also be acquired by consumption of contaminated
water or ingestion food items washed with such water
• Ingestion of freshly prepared raw liver containing immature flukes will
also result in infection

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Lifecycle: Fascioliasis (1)
• Infection is initiated when metacercariae excyst, penetrate the gut
wall, and travel through the peritoneal cavity to invade the liver
capsule
• Adult worms finally reach bile ducts, where they produce large
operculated eggs, which are voided in bile through the
gastrointestinal tract to the outside environment

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Lifecycle: Fascioliasis (2)
• The life cycle is completed in specific intermediated snails and
encystment in aquatic plants

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Clinical features: Fascioliasis
• Acute disease: fever, right-upper-quadrant pain, hepatomegaly, and
eosinophilia
• Chronic infections: bile duct obstruction and biliary cirrhosis
• No relationship with hepatic malignancy

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Diagnosis and treatment: Fasciolopsiasis
• Stool microscopy for ova
• Serology
• Treatment: praziquantel or triclabendazole

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General characteristics: Paragonimiasis
• Caused by Paragonimus westermani (lung fluke)
• Endemic in many parts of the world: West Africa, Central and
South America and Southeast Asia
• Reservoir hosts are wild and domestic felines

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General characteristics: Paragonimiasis
• Adult lung flukes, which are 7-12mm in length are found encapsulated
in the lungs of infected persons
• Rarely, flukes are found encysted in the CNS or abdominal cavity

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Lifecycle: Paragonimiasis
• Humans acquire the infection by ingesting the infective
metacercariae encysted in muscles and viscera of crayfish
and freshwater crabs
• The organism excyst in the duodenum, penetrate the gut
wall, and travel through the peritoneal cavity, diaphragm,
pleural space to reach the lungs

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Lifecycle: Paragonimiasis
• Mature flukes are found in the bronchioles surrounded by cystic
lesions
• Parasite eggs are either expectorated with sputum or swallowed and
passed to the outside environment with feces
• The life cycle is completed in snails or and freshwater

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Pathophysiology: Paragonimiasis
• Mature worms cause hemorrhage, necrosis, resulting in cyst
formation
• Inflammatory infiltrate
• Thickened wall and calcification
• Evidence of pneumonia, bronchitis, bronchiectasis, and fibrosis

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Clinical features: Paragonimiasis
• Productive cough with brownish sputum or frank hemoptysis
• Peripheral blood eosinophilia
• Pleurisy
• Bronchiectasis, bronchitis, and lung abscess
• Pleural effusion
• Epilepsy or space occupying lesion

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Diagnosis and treatment: Paragonimiasis
• Sputum/stool microscopy for ova
• Serology
• Full blood count: eosinophillia
• Imaging: chest x-ray, brain imaging
• Treatment: praziquantel

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Prevention: Paragonimiasis
• Avoid ingestion of local plants, fish, or crustaceans
• Wash local plants thoroughly before eating
• Mass chemotherapy
• Adequate cooking of food substance

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General characteristics: Intestinal flukes
• Two species causes intestinal fluke
• Fasciolopsis buski-endemic in Southeast Asia
• Heterophyes heterophyes-found in Nile Delta of Egypt and in the far
East
• Infection is initiated by ingestion of metacercariae attached

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