COMMON NAME

• 1st Intermediate host

LIVER TREMATODES o Bithynia sp.
Fasciola hepatica Temperate/sheep liver fluke • 2nd Intermediate host
Opistorchis felineus o Cyprinidae family
Fasciola gigantica Tropical liver fluke Opistorchis viverrini o Cypridae family
o Cobitidae family
Dicrocelium dendriticum Lanceolate fluke • Definitive host
Clonorchis sinensis Chinese liver fluke o Humans, cats, dogs, pigs, etc.

LUNG TREMATODES LUNG TREMATODES

Paragonimus westermani Oriental lung fluke • 1st Intermediate host: freshwater snail
o Hua, Semisulcospira, Syncera, Thiara,
BLOOD TREMATODES
Pomatiopsis, Pomacea spp.
Schistosoma japonicum o Antemelania asperata
o Antemelania dactylus
Schistosoma haematobium Blood fluke
• 2nd Intermediate host: freshwater crab
Paragonimus westermani
Schistosoma mansoni o Eriocher, Potamon, Sesarma,
Camvarus spp.
INTESTINAL TREMATODES o Sundathelpusa philippina (mountain
Fasciolopsis buski Giant intestinal fluke crab)
• Reservoir
Heterophyes heterophyes Von Siebold’s fluke o Pigs, cats, dogs

Metagonimus yokogawai Yokogawa’s fluke BLOOD TREMATODES

Echinostoma ilocanum Garrison’s fluke • Intermediate host

Schistosoma japonicum
o Oncomelania hupensis
INFECTIVE STAGE
LIVER TREMATODES • Intermediate host
Schistosoma haematobium
o Bulinus spp.
Fasciola hepatica Metacercaria

Fasciola gigantica • Intermediate host

Schistosoma mansoni
o Biomphalaria spp.
Dicrocelium dendriticum
• Definitive hosts
Clonorchis sinensis o Domestic:
LUNG TREMATODES ▪ Dogs, cats
▪ Carabaos, cows
Paragonimus westermani
Schistosoma spp. o Sylvatic
BLOOD TREMATODES ▪ Rodents
Schistosoma japonicum Miracidia ▪ Monkeys
o Birds
for snails
Schistosoma haematobium o Humans
Cercaria
Schistosoma mansoni for birds and mammals by direct penetration INTESTINAL TREMATODES

INTESTINAL TREMATODES • 1st Intermediate host: planorbid snails

o Segmentina
Fasciolopsis buski o Hippeutis
o Gyraulus
Heterophyes heterophyes
• 2nd Intermediate host: water plants
Metagonimus yokogawai o Caltrop (Trapa bicornis)
o Hyacinth (Eichonia)
Echinostoma ilocanum Fasciolopsis buski o Chesnut (Eliocharis tuberosa)
o Bamboo (Zizania)
HOSTS o Morning glory (Ipomaea aquatica)
LIVER TREMATODES o Lotus (Nymphaea lotus)
• Definitive host
• 1st Intermediate host: lymneid snails o Humans
o Lymnaea philippinensis o Dogs
Fasciola hepatica o Lymnaea auricularia rubiginosa o Hogs
Not in the PH
• 2nd Intermediate host
o Watercress (Nasturium officionale) • 1st Intermediate host: brackish snails
o Kangkong (Ipomea obscura) o Pirenella (Egypt)
• Definitive host o Cerithidea (Japan)
o Humans, ruminants (cattle, sheep) o H. taichui, Procerovum calderoni
o Horses, goats, buffaloes (hepatica) Heterophyes heterophyes (PH)
Fasciola gigantica
Recorded in the PH o Water buffaloes (gigantica) • 2nd Intermediate host: fish
• Reservoir host: F. hepatica o Mugil (mullet)
o Hares, rabbits o Tilapia (Egypt)
o Acanthogobius (Japan)
• 1st Intermediate host: operculated
• 1st Intermediate host: snails
o Abida, Cochlicopa, Helicella, Zebrina
o Semisulcospira *
spp.
o Hua
• 2nd Intermediate host
Dicrocelium dendriticum o Thiara
o Formica fusca (ants)
Not in the PH • 2nd Intermediate host: freshwater fish
• Definitive host
Metagonimus yokogawai o Salmonoid fish
o Ruminants, sheep, cattle
▪ Plecoglossus
• Accidental definitive host
▪ Salmo
o Humans
o Cyprinoid fish
• 1st Intermediate host ▪ Leuciscus
o Parafossarulus, Thiara, Bulimus, ▪ Odontobutis
Aloncima, Semisulcospira, Melanoides
• 1st Intermediate host
• 2nd Intermediate host o Gyraulus convexiusculus
Clonorchis sinensis
o Cyprinidae family: freshwater fish
o Hippeutis umbilicalis
o Freshwater shrimp
• 2nd Intermediate host
• Definitive host Echinostoma ilocanum o Pila luzonica (kuhol)
o Humans, cats, dogs, pigs, etc.
o Vivipara angularis (susong
pampang)
• Reservoir
o Rats
PATHOLOGY BLOOD TREMATODES
LIVER TREMATODES • Early: itching, chills, fever
• Cerebral: headache
• Acute invasive phase
o Meningoencephalitis
o Burrowing into liver parenchyma
Schistosoma japonicum o Confusion
o Presence of parasite in bile ducts
o Lethargy
o Fever, RUQ pain, hepatomegaly,
Fasciola hepatica o Coma
eosinophilia
• Pulmonary: cor pulmonale
• Chronic phase
• Hepatosplenic: most serious
o Bile ducts: thickening, fibrosis
o Hepatosplenomegaly
o Obstructive inflammation
o Ascites
o Atrophy of the liver
o Portal hypertension
o Periductal cirrhosis Schistosoma haematobium o Esophageal, gastric varices
• Parasitic migration
o Fibrosis in granuloma leads to
o Hematogenous dissemination
pipe stem portal fibrosis
▪ Lungs, brain, orbit, SC tissue
• Intestinal: dysentery, diarrhea
Fasciola gigantica • Pharyngeal fascioliasis (halzoun)
o Due to eggs
o Infected livers of cattle and goat
• Vesicoureteral: hematuria
are eaten raw
• Schistosomal cercarial dermatitis
o Adult worm is consumed
Schistosoma mansoni o Cercarial invasion
o False fascioliasis: eggs in pharynx
▪ Swimmer’s itch
▪ Gulf coast itch
• Most infections involve low numbers ▪ Cercarial itch
o All in all, similar to fascioliasis
• Intense infections ACUTE DISEASES
Dicrocelium dendriticum
o Cholecystitis, liver abscess • Swimmer’s itch: nonendemic travelers
• Erratic migration o Continuous reinfection, sensitized persons may show allergic
o Subcutaneous masses dermatitis
o Wanes over time
• Periductal fibrosis
• Acute schistosomiasis (Katayama fever): jap > man > hae
• Acute o Nonspecific signs
o Chills, fever o Hepatosplenomegaly
• Chronic o Leukocytosis + eosinophilia
o Asymptomatic
o Obstruction: cirrhosis, portal HTN CHRONIC DISEASES
• Nonspecific • Granuloma formation: hypersensitivity around egg
o Fatigue, weakness, weight loss • Hepatosplenic schistosomiasis: MJ
o Abdominal distress, altered o 18 months heavy, 20 years light
appetite • Intestinal schistosomiasis: MJ
o Fever, eosinophilia o Years after infection
o Hepatomegaly + tenderness o Severe anemia from GI blood loss
Clonorchis sinensis
o Chronic stage: asymptomatic, occasional diarrhea
• Changes in whole liver
• Vesicoureteral schistosomiasis: H
o Calculi
o Years after infection
o Acute suppurative cholangitis
o Causes calcifications
o Recurrent pyogenic cholangitis
o Prominent manifestation: hematuria
o Cholecystitis, hepatitis, pancreatitis
o Can cause SCC of bladder
• Pancreatitis with related diffuse
dilation of tributaries of pancreatic INTESTINAL TREMATODES
duct • Due to the toxic products of the worm
• Cancers • At site of attachment
o Carcinoma of the liver o Inflammation
o Adenocarcinoma of gallbladder o Ulceration
o Abscess
• Chronic diseases
o Neurocirculatory dystonia • Heavy infections
Fasciolopsis buski
o Myocardial metabolic changes o Edema, ascites
o Long-term autonomic o Anasarca
o Obstruction
dysregulation
o Progressive imbalance syndrome • Slight anemia
Opistorchis viverrini o Sympathetic hypertonicity • Complete recovery after removal of
• Diabetics are at risk for early and worm
severe complication of diabetes
• No marked symptoms or appreciable
• Carcinoma
injury to intestines, only in heavy
o Cholangiocarcinoma
o Primary CA of liver (hepatocellular • Heavy infections
type) o Chronic intermittent mucoid
diarrhea + colicky pains
LUNG TREMATODES ▪ Irritation of intestinal mucosa
• Lungs o Eosinophilia, but NOT anemia
o Dry cough, bloody sputum, Heterophyes heterophyes • Erratic migration
pulmonary pain, pleurisy, o Granulomatous lesions
hemoptysis ▪ Cardiac beri-beri (heart)
• Aberrant worm + cyst formation ▪ Cerebral hemorrhage (brain)
o Abdominal cavity, mesenteric LN • Most manifestations are consistent
▪ Abdominal pain, rigidity, with PUD or acid peptic disease
Paragonimus westermani
tenderness, diarrhea o Upper abdominal pain
▪ Bloody stools o Gurgling abdomen
o Brain
▪ Jacksonian epilepsy, plegia, • Eggs may enter lymphatics or
paresis, visual disturbances mesenteric venules
o Subcutaneous tissues Metagonimus yokogawai o Granulomatous lesions
▪ Creeping tumors ▪ Cardiac beri-beri
▪ Cerebral hemorrhage

• Heavy infections
o Inflammation at site of attachment
o Ulceration
Echinostoma ilocanum o Diarrhea, sometimes bloody
o Abdominal pain
• General intoxication
o Due to absorption of metabolites
DIAGNOSIS
• Praziquantel
LIVER TREMATODES Dicrocelium dendriticum o Restrain from physical activity 2
hrs after intake
• History: diet, endemic travel
• Stool exam: eggs
• Praziquantel
o Must be repeated; may be o 25, 3/2
Fasciola hepatica negative
o 60, 3/1
o True fascioliasis
• Praziquantel-albendazole
▪ Halting liver diet will still
Clonorchis sinensis o 7 days
have eggs in stool
Opistorchis felineus • Aspen bark
o False fascioliasis
Opistorchis viverrini o Due to salicin
▪ Halting liver diet will have no
• Notes
eggs in stool
o Take soft, liquid diet
• Serology: ancillary tests
Fasciola gigantica o Take drug in the presence of
o Acute or chronic
medical worker
o Limitation: (+) may mean
present or past infection LUNG TREMATODES
• PCR: species differentiation
• Praziquantel (DOC)
• Microscopy o Restrain from physical activituy
o Specimen: stool, duodenum, bile Paragonimus westermani after 2 hours
Dicrocelium dendriticum ▪ But may not be easily • Bithionol, triabendazole
detected in stool • If pregnant, treat after delivery
• Adults are rarely recovered
BLOOD TREMATODES
• Stool: eggs • Praziquantel
o Indistinguishable from Schistosoma japonicum • Artemisinins: vs. juvenile
Clonorchis o Ideal for nonendemic travelers
• Alternatives
Clonorchis sinensis • Praziquantel
o ELISA, EIA Schistosoma haematobium
Opistorchis felineus • Metrifonate
o PCR
o Serum antibody response
• Praaziquantel
▪ For risk of Schistosoma mansoni
• Oxamniquine
cholangiosarrcoma
INTESTINAL TREMATODES
LUNG TREMATODES
• Praziquantel
• Examination: eggs
o 25, 3/1
o Specimen: stool, sputum
o Adverse: epigastric pain, dizziness,
o Sometimes, tissue biopsy
drowsiness
• Serology Fasciolopsis buski
• Niclosamide
o Antibody testing
o 100, single
• Radiographic exams: non-specific
• Diclorophen
o May be misdiagnosed as TB
Paragonimus westermani o 2 – 3 g, 8/3
o CXR: ring-shadowed opacities
▪ Appears as a bunch of • Praziquantel
grapes Heterophyes heterophyes
o 20, 3/2
• Screening tests
o Complement fixation test • Praziquantel
o EIA Metagonimus yokogawai
o 20, TID/2
o Immunoblot test
• Praziquantel
BLOOD TREMATODES
o 25, 1/3
Echinostoma ilocanum
• Stool: MJ • Hexylresorcinol
o Not immediately demonstrable • Tetrachloroethylene
Schistosoma japonicum in feces, unless in terminal vein
or intestinal capillaries PREVENTION
o May give negative results
• Urine: H
LIVER TREMATODES
o Prostatic massage in males
• Immunodiagnosis • Thorough cleaning vegetables
o Circumoval precipitin test o Do not just blanch, or vinegar,
Schistosoma haematobium ▪ Method of choice, not for Fasciola hepatica lemon juice
screening • Boil drinking water
▪ Adjuct for stool (-), but • Eliminate snails
remain highly suspicious o CuSO4
o ELISA o Chemotherapy
▪ Limited to banked specimen, • Vaccination
cannot be POC Fasciola gigantica o Fh12
Schistosoma mansoni o FAST-ELISA: M o Glutathione-S-transferase
▪ MAMA antigen o Cathepsin L proteinase
• Biopsy o Hemoglobin

INTESTINAL TREMATODES • Destroy metacercaria in ants

• Clinical symptoms in endemic area • Cook liver well before eating
Dicrocelium dendriticum
• Stool: eggs • Proper disposal of feces
Fasciolopsis buski o Resemble Fasciola • Control of snails is not practical
• Adult flukes vomited or passed in
feces Clonorchis sinensis • Stool exam and treat positive cases
o To eliminate host reservoir
Heterophyes heterophyes • Kato-thick: eggs • Education of cooked fish
Opisthorchis spp. • Proper human waste disposal
Metagonimus yokogawai • Modified Kato-thick: eggs
BLOOD TREMATODES
Echinostoma ilocanum • Stool: eggs
• Mass chemotherapy (PRZ)
Schistosoma japonicum o School-age children: target
TREATMENT • Health education
LIVER TREMATODES • Control IH
Schistosoma haematobium o Focal approach
Fasciola hepatica • Bithionol (10 – 15 doses)
▪ Limited transmission sites
o Alternating days
▪ Need water contact studies
Fasciola gigantica • Triclabendazole Schistosoma mansoni o Area wide approach
▪ More cost effective
 • Environmental sanitation Clonorchis sinensis, Opisthorchis viverrini
• Long-term solution • Can cause cancer
o Sustained education o Cholangiocarcinoma
o Strong community participation o Primary CA of liver
INTESTINAL TREMATODES • Pathologic changes in bile ducts
• Mucin-producing activity
• Avoid raw aquatic plants
o Neoplasm of goblet cells
o Cook in boiling water
o Metacercariae are sensitive to
Paragonimus westermani
dryness – DO NOT SOAK
• Leyte, Sorsogon
• Prolong time from harvest and
• Hemoptysis
consumption
Fasciolopsis buski • If si Leni nagkaroon ng hemoptysis, think paragonimiasis
• Treat human sources of infection
• Reduce infestation
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o Avoid using night soil
BLOOD TREMATODES
o Use unslaked lime or CuSO4
• Restrain hogs from area • Snail: (2) sporocyst generations → productiion of cercariae
• Destroy snail hosts • Schistosomulae: veins → lungs → heart → liver → portal system

• Avoid raw or uncooked or recently • Adults reside in mesenteric venules

salted fish in endemic areas o S. japonicum : SMV (from SI) **
• Sanitary disposal of waste
o S. mansoni : IMV : (from colon) **
• General measures are impractical
Heterophyes heterophyes o S. haematobium: vesicular + pelvic venous plexus of bladder; rectal
o Cannot detect and treat human
carriers venules
o Animal reservoirs
o Difficulty enforcing measures • Eggs are moved in:
o Intestinal lumen (except haematobium)
• Avoid eating poorly cooked fish o Bladder (haematobium)
Metagonimus yokogawai
• Dispose excreta
• Unembryonated, or embryonated eggs : feces or urine
• Avoid eating snails in endemic area • Embryonated eggs only : feces
Echinostoma ilocanum
• Boil drinking water
• Miracidial penetration affected by movement and lytic action of
cephalic gland secretions
LIFE CYCLE o Ciliated surface of miracidium disappears after penetration
• Egg contains miracidium
• Germ cells (early daughter sporocyts) migrate to loose CT of liver
o Often in water sources :: hatches to release miracidium
o Limiting factor for number of cercariae
ASEXUAL REPRODUCTION • Release of cercariae : nocturnal
• Miracidium → 1st stage larva
o Larva contains sporocyst o Sunlight can destroy cercariae
▪ Redia multiply into other daughter redia • Dimethylate and niclosamide repel cercariae
o Redia matures into cercaria
• Egg deposition most commonly involved
• Cercaria develops shell → metacercaria
o Metacercaria is ingested by host to become adult o Liver
o Lungs
LIFE CYCLE: Fasciola
• Duodenum: cysteine proteinases → jejunum → peritoneum → liver → o Intestines
bile ducts: MATURE (3-4) → intestine

LIFE CYCLE: Dicrocelium

• Duodenum → jejunum → peritoneum → liver → bile ducts: MATURE

LIFE CYCLE: Clonorchis

• Duodenum: no penetration → ampulla of Vater: CBD → distal biliary
capillaries: MATURE → embed in sticky mucus w/o permanent
ulceration → pancreatic duct, gallbladder: ducts dilate

LIFE CYCLE: Paragonimus

• Duodenum: cysteine proteinases → jejunum → peritoneum: embed →
diaphragm → pleural cavity → lungs: MATURE (2-3.... 20 years)

SEXUAL REPRODUCTION
• Adult

HOSTS
• 1st IH: SNAIL: egg → larva 1
• 2nd IH: metacercariation
• 3rd H: 2nd larva → adult

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• Treatment: Fasciola vs. Fasciolopsis
o Praziquantel

Dicrocelium dentriticum
• Slime ball

Clonorchis sinensis
• Phase 1
o Hyperplasia of epithelial cells
• Phase 2
o + Desquamation of epithelial cells
• Phase 3
o ++ Adenomatous tissue formation
• Phase 4
o Proliferation of periductal CT with scattered abortive acini of
epithelial cells
o Fibrosis of wall of biliary duct