TREMATODES

LEARNING OBJECTIVES
1. describe the general characteristics of the medically
important trematodes;and
2. characterize and differentiate the different
trematodes as to their: a. generalfeatures,
b. source of infection,
c. mode of transmission,
d. clinical manifestations,
e. treatment,and
f. prevention and control of infection.
General Properties of Trematodes

•commonly known as “flukes”

•Hermaphroditic or dioeciousexcept
Schistosoma spp. (blood flukes)
•Morphologically, flukes are fleshy,
leaf shaped worms. Unlike
tapeworms, flukes have a digestive
tract.
 General Properties of Trematodes
• Eggs: primary morphologic stage
that are usually recovered from
humans.
• operculum -a lid like structure
that can flip open to release its
contents.
• Schistosoma spp., the eggs of the
various members may be
differentiated based on the
presence and location of spines
•Sexual reproduction of flukes occurs in humans
•1 intermediate hosts: mollusks(snails and
ST

clams) where asexual reproduction takes place.

•2ND intermediate host: varies depending on the
parasite.

•MOT: ingestion of undercooked or raw second

intermediate host or skin penetration (blood
flukes)
 Life cycle:
•Organ dwelling or Blood dwelling
•Human infection occurs: ingesting water plants, fish,
crab, or crayfish that contain encysted metacercaria
•adult stage in the host's intestine, bile duct, or lung
(self fertilization)
•Eggs are excreted and hatch in external
environment(fresh water)
PATHOGENESIS AND CLINICAL SYMPTOMS
•Species-dependent symptoms.
•depend on area of the body that is infected.
•Symptoms associated with these infections can
include tissue damage, jaundice, diarrhea,
allergic and toxic reactions, and increased levels
of eosinophils.
1. Fasciolopsis buski
(fa-see’o-lop’sis/bus’kee)
Common name: Large intestinal fluke.
Common associated disease and condition
names: Fasciolopsiasis.

2. Fasciola hepatica
(fa-see’o-luh/he-pat’i-kuh)
Common name: Sheep liver fluke
Common associated disease and condition names:
Fascioliasis, sheep liver rot.
Fasciola spp.
Mode of transmission: ingestion of raw water
plants.
F. buski : China, Thailand, Taiwan, and Vietnam, as
well as regions in India and Indonesia.

Reservoir hosts for F. buskii: rabbits, pigs, and dogs

food sources : water chestnut, lotus, and water
caltrop.
Infective stage: metacercariae
Diagnostic stage: unembryonated eggs
Fasciola spp.
Mode of transmission: ingestion of raw
water plants and sheep liver meat.

F. hepatica is found worldwide,

particularly in areas where sheep and
cattle are raised. natural host:sheep,
humans serve as accidental hosts.
Infective stage: metacercariae
Diagnostic stage: unembryonated eggs
 F. buski
Disease: Fasciolopsiasis
• Most are asymptomatic.
• Heavy worm burden, patients may experience abdominal :
Discomfort with inflammation and bleeding in the
affected area.
Ulcerations may occur and symptoms may mimic those of
duodenal ulcer
Malabsorption.
Allergic symptoms: such as edema of the face, abdominal lwall,
and lowerlimbs.
Profound intoxication can result in death.
F. hepatica
Disease: Fascioliasis or Sheep Liver Rot
• Migration of the larval worm through the liver irritates
the organ, manifesting as tenderness and
hepatomegaly.
• Hepatitis may develop with biliary obstruction.
• Ingestion of raw sheep liver may lead to temporary
lodgment of the adult worm in the pharynx leading to
suffocation.
Adult worms
• F. buski- small
intestine
• F. hepatica- bile
ducts

1st IH: snail

2nd IH: water plant
Laboratory diagnosis
Eggs in stool
patient symptoms and travel history is necessary
to diagnose the causative species
Adult worms
Serology test and Enterotest
Treatment:

•F. buski : praziquantel.

•F. hepatica :dichlorophenol (bithionol).

Triclabendazole is more effective but is
not available in the United States.
Prevention and Control Prevention
proper human fecal disposal and sanitation
practice
snail population,
avoiding consumption of raw water plants
or contaminated water
 3. Clonorchis sinensis
(klo-nor’kis/si-nen’sis)
Common name: Asian Liver Fluke/Chinese liver fluke.
Common associated disease and condition names: Clonorchiasis.
Reservoir hosts include fish-eating mammals, dogs, and cats.

Eggs( 30x15 µm) Reservoir hosts include fish-eating mammals, dogs, and cats.

Adults (2x0.5cm):
Each end of the
adult worm is
narrower than the
midportion of the
body
• Laboratory Diagnosis : recovery of embryonated eggs from stool
specimens or duodenal aspirates, adult worms are only seen when
removed during a surgery or autopsy.

Infective stage:Metacercariae
1st IH: snail
2nd IH: Freshwater fish or
shrimp

Adult habitat: Biliary duct

Treatment :praziquantel or
albendazole.
Heterophyes heterophyes
(het-ur-off’ee-eez)
Common name: Heterophid fluke.
Disease:Heterophyiasis.

Metagonimus yokogawai
(met’uh-gon’imus/yo-ko-gah-wah’eye)
Common name: Heterophid fluke.
Disease : Metagonimiasis.
How to distinguish from C. sinensis

lack the small terminal knob

 Clinical Symptoms
• Asymptomatic.
• Heterophyiasis/Metagonimiasis..
abdominal pain and discomfort
chronic mucous diarrhea and eosinophilia.

The eggs of both organisms have the ability to escape

into the lymphatics or venules via intestinal wall
penetration and to migrate to other areas of the body,
such as the heart or brain. Granulomas in these areas
often result
Transmission: ingestion of contaminated undercooked fish
Adult worms: small intestine

Laboratory Diagnosis: the eggs in stool

Treatment of choice: praziquantel.

 Paragonimus westermani
(par”i-gon-’i-mus/wes-tur-man’eye)
Common name: Oriental lung fluke.
Common associated disease : Paragonimiasis, pulmonary distomiasis.
• occur in several areas of the world, including
portions of Asia and Africa, India, and South
America.
• Pigs and monkeys serve as reservoir hosts, as
well as other animals whose diet includes
crayfish and crabs
• Adults. oval, red- to brown-colored adult
measures 1 by 0.7 cm . The cuticle of P.
westermani possesses spines, similar to the other
adult trematodes.
 Laboratory Diagnosis
• eggs in sputum specimens.
• Occasionally, the eggs may be seen in stool samples
when sputum is swallowed. Serologic tests
 Clinical Symptoms
• Paragonimiasis: Pulmonary Distomiasis.
• cough, fever, chest pain, and increased
production of blood-tinged sputum.
• chronic bronchitis, eosinophilia, and the
production of fibrous tissue.

Cerebral Paragonimiasis.
Migration of immature P. westermani organisms to the
brain may result in the development of a serious
neurologic condition. Patients experience seizures, visual
difficulties, and decreased precision of motor skills
Treatment and Prevention
Praziquantel is the medication of choice.
An acceptable alternative drug is bithionol.

Prevention and Control

avoiding ingestion of undercooked crayfish and crabs
and exercising proper disposal of human waste
products.
 Blood dwelling Flukes

Schistosoma spp.

Schistosoma haematobium ( Bladder fluke)

Schistosoma mansoni (Manson’s blood fluke).
Schistosoma japonicum (Blood fluke)
Schistosoma intercalatum
Schistosoma mekongi
• Blood flukes are parasitic worms that are dioecious and usually
found in a state of copulation.
• eggs are found in fresh water contaminated with the feces or
urine of infected humans..
• Infection is acquired through skin penetration by the cercaria.
The parasite migrates into the bloodstream where they undergo
maturation
• . The adult worms lay thousands of eggs per day, which produce
enzymes that help them travel through tissue. The eggs are
then excreted through the colon or urine.
•Common
. Schistosoma spp. disease
and condition names:
Schistosomiasis, bilharziasis, swamp
fever, Katayama fever.
•Schistosomiasis has recently been
recognized as a major parasite cause
of morbidity and occasional
mortality, especially in sub-Saharan
Africa
• Deaths due to schistosomiasis are
currently estimated at 11,792 globally
per year.
 Clinical Manifestations
• asymptomatic, even in chronic cases.
• Symptomatic: individuals may experience
inflammation at the site of infection,
abdominal pain, fever, chills, weight loss,
cough, bloody diarrhea, and eosinophilia.
• Painful urination and hematuria may also
occur in those infected with S.
haematobium.
 Clinical Manifestations
• The infection can cause necrosis, lesions, and granulomas in the
infected area(s), as well as obstruction of the bowel or ureters
and secondary bacterial infections. It may also affect the central
nervous system and other tissues.
Schistosomiasis, bilharziasis, swamp fever,
Katayama fever
• systemic
hypersensitivity
reaction to the
schistosomulae
 Laboratory Diagnosis
•S. mansoni and S. japonicum :recovery of the eggs in
stool or rectal biopsy specimens
•S. haematobium eggs: concentrated urine specimen.
•immunodiagnostic techniques, including ELISA, are
also available.
 Treatment
•Praziquantel is the preferred drug for treating
schistosomiasis, regardless of the species of
Schistosoma involved.
•Oxamniquine is used specifically for S. mansoni
infections.
• artemether and artesunate have also been found to be effective against
schistosomal infections, but their use may be limited in areas where malaria
is endemic due to the potential for resistance by Plasmodium
 Prevention and Control
• proper waste disposal, snail population control, diagnosis and
treatment of infected individuals, avoidance of contaminated
water, and education.

• The current focus is on the use of anthelminthic chemotherapy

with praziquantel due to its low cost, minimal side effects, and
rapid efficacy.

• The World Health Organization recommends mass treatment for

high-risk communities, treatment of all children in moderately
affected areas, and treatment of diagnosed cases in low-risk areas.