TREMATODES 1.

Adult fluke
 Upon reaching maturity, fertilized eggs are laid &
General morphology & physiology of Flukes: released into the environment thru:
a. Feces = for liver/intestinal flukes
 Flukes belong to Phylum Platyhelminthes, Class
b. Sputum = for lung flukes
Trematoda, and Subclass Digenea.
 2nd only to nematodes in abundance & distribution.
2. Fertilized egg requires “water” to undergo further
 Their body form exhibits a variety of sizes & shapes
development.
but most are leaf-like & range from 0.16mm-5.7cm
If the right conditions (temperature, oxygen &
long.
concentration) are present, “embryonation”
takes place within 1-2 weeks.
Essential Body Parts: The developing zygote is transformed into a
1.Suckers = as organs of attachment. ciliated motile larval stage called the
a. Oral sucker = located at the anterior “MIRACIDIUM”.
end surrounding the mouth.
b. Ventral sucker/Acetabulum = situated Eggs passed out with feces >>>> Miracidium
on the mid-ventral anterior 3rdof the develops within the egg >>>> miracidium released
body which is the typical “distome”
(two-mouth) form. Miracidium penetrates appropriate Snail host ----
2.Integument = the entire external surface of Sporocyst, Redia, and Cercaria develops
flukes that functions as:
A. Cuticle Cercaria leaves snail host >>>> enters the 2 IH
B. Nutrition/Absorption
3.Mouth = surrounded by the oral sucker. In the 2ndIH, metacercaria develops ------
4.Esophagus = lined by a muscular organ, the Metacercaria ingested by Man
“pharynx”.
5.Intestinal branches GENERALITIES/CHARACTERISTICS
6.Blind pouches 1.All flukes appear flat and leaf-like except for
7.Muscular system Schistosomes (blood flukes) – elongated/cylindrical
8.Nervous system = typically ganglionic & “ladder 2.All are hermaphroditic (monoecious) except for
type”. Schistosomes – separate sexes (dioecious)
9.Excretory system & No circulatory system. 3.All eggs are operculated except for Schistosomes –
10. Reproductive system non-operculated
All are “hermaphroditic” except 4.Life Cycle of Trematodes
Schistosomes. Egg >> Larva >> Adult
A. Male reproductive tract = testes, cirrus Larva: Miracidium >> Sporocyst >> Redia >>
(penis). Cercaria >> Metacercaria
B. Female reproductive tract = ovary, *Except for Schistosomes: No Metacercaria
seminal receptacle, uterus, vitellaria 5.Infective Stage to the Final Host: Metacercaria
(yolk glands). except for Schistosomes: Cercaria
C. Genital pore = common opening where 6.Mode of Transmission: Ingestion except for
the male & female reproductive systems Schistosomes: Skin Penetration (Forked tail
connect to the external environment. Cercaria)
7.Require 2 Intermediate Host
 Morphology (shape & arrangement) of the 1st IH: Snail (Cercaria)
reproductive system is very useful for the 2nd IH: Fish, Crab, Plant, Snail, Ant (Metacercaria)
classification & identification of flukes. Fish: Heterophyes heterophyes, Clonorchis
 Flukes infecting man are found in a variety of sinensis, Opisthorchis felineus
habitats inside their hosts: Crab: Paragonimus westermani
1. Liver flukes = reside in the bile ducts. Plant/Vegetation: Fasciola hepatica, Fasciola
2. Intestinal flukes = found in the lumen of the SI. gigantica, Fasciolopsis buski
3. Lung flukes = encapsulated on lung parenchyma. Snail: Echinostoma ilocanum
Ant: Dicrocoelium dendriticum, Eurytrema
 All flukes follow an indirect cycle. pancreaticum
 Mature (adult) fluke resides in man. *Except for Schistosomes – only 1 Intermediate
 Immature larvae occur in various IH. Host: Snail (Cercaria)
8.Adults attach themselves to the host by means of 2 - Infective Stage: Metacercaria
sucker: oral sucker, ventral sucker (acetabulum) - MOT: Ingestion of 2nd IH
except for Heterophyes heterophyes having 3 - Egg: large, operculated, unembryonated, yellowish
suckers – 3rd sucker: Genital sucker / Gonotyle brown egg resembling F. gigantica and F. buski egg
9. Egg Fasciola egg: resembling Hen’s egg shape
a. Mature when laid (embryonated) - Adult: Cephalic cone, well developed shoulder
Schistosoma
Heterophyes
Opisthorchis
Clonorchis
b. Immature when laid
Fasciola
Fasciolopsis
Paragonimus
Echinostoma
10. Possess Alimentary Canal without Anus
(incomplete)
Possess complex reproductive structures: Testis,
Ovary, Uterus Fasciola gigantica
11. Treatment: Praziquantel - CN: Giant Liver Fluke / Tropical Liver Fluke
- Infects cattles in the
LUNG, INTESTINAL & LIVER FLUKES Philippines
 Hermaphroditic - Common in tropical areas
 Body of adult worm is leaf like (oral and ventral - Dominant species affecting
sucker) cattle and water buffaloes in
 Infective stage: Metacercaria the Philippines
 Mode of transmission: Ingestion - Habitat: Biliary Passages of
 Requires 3 hosts:DF –man; 2 IH Liver
1st IH: snails/mollusks - FH: Cattle
2nd IH: may vary - 1st IH: Snail
 Operculated egg 2nd IH: Plant/Vegetation E.g.
Kangkong/Water Spinach
Intermediate Host - Infective Stage: Metacercaria
 P.westermani – Sundathelpusaspp, - MOT: Ingestion of 2nd IH
Parathelpusaspp. - Egg: Fasciola egg
 E.ilocanum – Pila luzonica/ Vivipara angoralis - Adult: Longer cephalic cone, less developed
 F. hepatica – ipomea obscura shoulder. Almost same w/ F. hepatica but is bigger
 F. buski – water chestnuts, bamboo shoots, water --Largest fluke to infect man; easily recognized by its
caltrop large size, presence of cephalic cone or shoulder,
 C. sinensis, O.felineus, M. yokogawai, highly dendritic intestines, ovary & testes.
H.heterophyes - Fishes --RH: cattle & water buffaloes (carabaos).

 Fasciola is unique in utilizing freshwater or semi-

A. LIVER FLUKES aquatic snails of the family Lymnacidae as 1stIH.
 Lymnaea philippinensisis the snail species found
Fasciola hepatica in the Phils.
- CN: sheep liver fluke  Man is the accidental DH in certain parts of the
- Sheep liver fluke causing sheep world where infected aquatic plants like “morning
liver rot glory” or “kangkong” are eaten raw as salads or
- Prevalent in sheep raising garnishing to other foods.
counties  Acute inflammation eventually leads to
- Habitat: Biliary duct / Passages of “pipesteam fibrosis” & “obstruction of bile ducts”
liver in chronic infections.
- FH: Sheep
- 1st IH: Snail
2nd IH: Plant/Vegetation E.g. Kangkong/Water
Spinach
 Laboratory diagnosis:
Laboratory Diagnosis: 1.DFS
1.DFS = presence of a large bile-stained golden-brown 2.Serologic testing
ova. Patient must abstain from ingesting liver for 3
days. Treatment:
2.Concentration techniques 1.Praziquantel
3.Serologic testing
•Chlonorchiasishave been reported in mainland
China, Taiwan, Hongkong, Korea, Japan & Vietnam.
Treatment:
1. Emetine HCl •Not endemic in the Phils. because of the absence
2. Bithionol of the appropriate 1stIH.
3. Hexachloroparaxylene
4. Chloroquine Opisthorchis felineus
- CN: Cat Liver Fluke / Siberia Liver Fluke
Prevention & Control: - Habitat: Liver, Bile Passages of Liver
1.Thorough washing & cooking of vegetables, - FH: Cats
especially those of aquatic origin. - Accidental Host: Man
2.Boiling of drinking water - 1st IH: Snail
3.Treatment of domesticated RH by chemotherapy. 2nd IH: Fish
4.Health education - Infective Stage: Metacercaria
- MOT: Ingestion of 2nd IH
- Egg: Operculated Mature
Clonorchis sinensis - Additional: Opisthorchis viverrini – Southern Asian
- CN: Chinese Liver Fluke / Oriental Liver Fluke liver fluke
- Most important liver fluke of man
- Habitat: Bile duct / Gall Bladder
- FH: Man Opisthorchis viverrini
- 1st IH: Snail - Can be differentiated from
2nd IH: Fish Chlonorchis by the presence of
- Infective Stage: Metacercaria lobulated testes arranged
- MOT: Ingestion of 2nd IH obliquely (1 after the other in
- Egg: Operculated, Mature diagonal position).
Eggs are like an old- - Occur mostly in Thailand, Laos &
fashioned electric light Malaysia.
bulb, Pitcher-like - RH: cats & other fish-eating
appearance carnivores.
Adults are medium sized & - Opisthorchis felineus= a closely related species
morphologically distinguished
found in Europe, Turkey, USSR, Korea, Japan,
by the presence of dendritic
Vietnam & India.
(highly branched) testes in
- 1st IH: snails of the genus Bithynia.
tandem arrangement (1 after the other in vertical
fashion). - 2nd IH: cyprinoid fish.
The 2 lateral branches of the intestinal cecum are
simple (unbranched) & extend to the posterior end.
Dicrocoelium dendriticum / lanceolatum
A unique feature in its life cycle is that the - CN: Lanceolate / Lancet Fluke
embryonated eggs in the water must - Cirrhosis / Fibrosis of the liver
first be ingested by the snail, - Habitat: Biliary Passages of Liver
Parafossarulus manchouricus , - FH: Cattles/Sheep
before they can release the miracidia - Accidental Host: Man
inside the snail’s body. - 1st IH: Snail (Mass of Cercaria: Slime ball/Germ ball)
RH: dogs & cats 2nd IH: Ants
- Infective Stage: Metacercaria
- MOT: Ingestion of 2nd IH Ant w/ Metacercaria
- Egg: Brownish, Thick walled, operculated,
Embryonated
- Adult: Lancet-shaped
B. INTESTINAL FLUKES (SMALL INTESTINE) Echinostoma ilocanum & Echinostoma
malayanum
Fasciolopsis buski - Characterized by the unique
- CN: Giant Intestinal Fluke morphology of a collar of
- Largest fluke parasitizing man spines around the oral sucker
- Habitat: Small Intestine (echino= spiny; stoma =
- FH: Man mouth).
- Reservoir Host: Pigs, Dogs, Rabbits - 1st IH: snail = Gyraulus convexiusculus.
- 1st IH: Snail - 2nd IH: snail = Pila luzonica or Pila conica “kuhol”;
2nd IH: Plants/Vegetation (chestnuts, caltrop) ginataang kuhol
- Infective Stage: Metacercaria - RH: wild rats for E. ilocanum; pigs for E. malayanum
- MOT: Ingestion of 2nd IH
- Egg: Operculated, Immature; Eggs are
indistinguishable from eggs of Fasciola: Fasciola egg

Characterized by the absence

of a cephalic cone/shoulder,
presence of simple but wavy
intestinal cecum & tandem Laboratory diagnosis:
dendritic testes. 1. DFS = eggs resemble Fasciola & Fasciolopsis.
1st IH: snails = Segmentina trochoideus& Hippeutis 2. Concentration techniques
umbilicalis. Treatment:
2nd IH: aquatic plants 1. Praziquantel
DH: mans & pigs which get infected when infected
plants with metacercariae are eaten raw. Prevention & Control:
Most common sources of human infections are the 1. Proper cooking of snail 2ndIH.
edible fruits “water chestnut” & “water caltrop”. 2. Health education.
3. Treatment of confirmed cases.
3 types of Pathology in fasciolopsiasis:
1.Traumatic = when adult flukes attach to the
intestinal mucosa & cause tissue damage & blood
Echinostoma ilocanum
loss. - CN: Garrison’s fluke
2.Obstructive = when there is malabsorption due to Discovered among Bilibid Prisoners
large numbers of adults that become barriers to - Habitat: Small Intestine
normal absorptive processes. - FH: Man
3.Toxic = evidence of periorbital edema & systemic - Reservoir Host: Rat
allergic reactions due to the metabolites & other - 1st IH: Snail
excretory by-products of the adult worms being 2nd IH: Snail
absorbed by the host. - Infective Stage: Metacercaria
- MOT: Ingestion of 2nd IH
Laboratory diagnosis: - Egg: Operculated, Immature; Germ Ball egg
1. DFS = eggs resemble Fasciola.
2. Concentration techniques Heterophyes heterophyes
- CN: Von Siebold’s fluke
- Teardrop-shaped fluke
- Smallest Fluke of Man
but deadliest fluke
- Habitat: Small Intestine
- FH: Man
- 1st IH: Snail
2nd IH: Fish
- Infective Stage:
 Difficult to differentiate the two. Metacercaria
 Broadly ellipsoidal. - MOT: Ingestion of 2nd IH
 Operculated.
- Egg: Operculated, Mature; Resembles Clonorchis - Egg: Operculated w/ shoulders, Immature /
sinensis egg; Appears Old-fashioned light bulb Umembryonated; Opposite the operculum is an
- Adult: presence of genital sucker (Gonotyle) abopercular thickening; With thickened abopercular
end opposite the operculum; Similar to
Gonotyle Diphyllobothrium latum egg
3 common species reported in the Phils: - Adult: resembles coffee bean
a.Heterophyes heterophyes - Laboratory: Specimen for diagnosis – Sputum/Stool
b.Haplorchis taichui Diagnosis is based on sputum and stool
c.Metagonimus yokogawai examination for the characteristic eggs;
Same life cycle & egg morphology with that of Charcot-Leyden crystals may be
Clonorchis & Opistorchis. observed in sputum or lung tissue
1st IH: fresh & brackish water snails = Pironella specimens
conica& Cerithidia cingula. - Additional: Paragonimus mexicanus - found in areas
2nd IH: fresh & brackish water fishes: tilapia, bangus of Mexico and South America; formation of
& dalag. subcutaneous or lower abdominant nodules
RH: cats & other carnivores. Egg: operculated w/ shoulders, thick shelled,
DFS = eggs are difficult to distinguish from brownish-yellow, unembryonated
Clonorchis & Opistorchis .
Treatment: Praziquantel Adults are fat, coffee bean shaped & encapsulated
Prevention & Control: in lung parenchyma.
1. Avoid ingestion of raw or improperly cooked Fever, sweating, chest & back pains & hempotysis
fish. Adults are unique in displaying branched testes
which are arranged side by side.
Eggs are also unique for having a thickening of the
abopercular end.
1st IH: snail = Brotia asperata
2nd IH: freshwater crustaceans = crabs & crayfish.
Metacercariae are usually found embedded in the
viscera, muscles, heart & gills of the fish

Metagonimus yokogawai Laboratory diagnosis:

1.For presence of eggs
a.Sputum exam
b.Stool exam
c.Aspirates from lung abscesses or pleural effusions
2. Radiographs = cannot differentiate from
paragonimiasis & TB.
3. Serologic testing

D. PANCREATIC FLUKE

Eurytrema pancreaticum
C. LUNG FLUKE - CN: Pancreatic Fluke
- Cholecystitis, Pancreatitis
Paragonimus westermani - Habitat: Pancreatic ducts
- CN: Oriental Lung Fluke - FH: Sheep, Cattle
- Causing Endemic Hemoptysis - Accidental Host: Man
- TB like symptoms - 1st IH: Snail
- Common in Sorsogon 2nd IH: Ant, Grasshopper, Mantis, Crickets
- Habitat: Lungs FH: Man - Infective Stage: Metacercaria
- 1st IH: Snail 2nd IH: Crab, Crayfish - MOT: Ingestion
- Infective Stage: - Egg: Operculated, Embryonated (Mature)
Metacercaria
- MOT: Ingestion of 2nd IH
Crab w/ Metacercaria
 E. BLOOD FLUKES Comparison of Schistosoma eggs:

Schistosomes
- Adult stages are in the blood vessels
- Most Romantic Parasites “Perpetual Copulation”
- Adult male with gynecophoral canal where the
female is held
- Diagnosis: Demonstration of eggs in feces,rectal or
liver biopsies,urine (S.haematobium)
Faust and Maleneys egg hatching techniques
Circumoval Precipilin Test (COPT) of Oliver and
Gonzales

Blood Flukes: “Schistosomes”

 Cause Schistosomiasis consisting of digenetic flukes
that live in the blood vessels of the host.
 Common species infecting humans:
1. Schistosoma japonicum
2. Schistosoma mansoni
3. Schistosoma hematobium
4. Schistosoma intercalatum
5. Schistosoma mekongi

 Non hermaphroditic/Dioecious
 Body of adult is not leaflike (oral and ventral sucker
and male has schist)
 Mode of Transmission: Skin Penetration
 Adult Female blood fluke produces NON
OPERCULATED EGG.
 Require 2 hosts: DH Man; One IH: Snails/Mollusk
S. japonicum - Oncomelania quadrasi
S. mansoni - Biomphalaria, Planorbis, Tropicorbis
S. haematobium - Bulinus, Physopsis

Species Habitat Integument Size of

Adult
S. japonicum Superior Smooth Largest
mesenteric integument
veins
S. mansoni Inferior Coarse Smallest
mesenteric tuberculations
veins
S. Vesical Fine Medium
haematobium veins tuberculaltions -sized

Eggs passed out with feces/urine >>>> Miracidium

develops within the egg >>>> on contact with H20,
miracidium released

Miracidium penetrates appropriate Snail host ----

Sporocyst, cercaria (fork tail) develops

Cercaria leaves snail host >>>> free swimming

Cercaria penetrates the human skin.

(schistosomule)
 S. mansoni S. hematobium S. japonicum d. Eggs in the brain result in motor & sensory
Elongated Elongated Round disturbances; Jacksonian epileptic seizure.
Large lateral Terminal spine Small, Laboratory diagnosis:
spine rudimentary •DFS is not applicable.
lateral spine 1. Rectal/Liver biopsy
Profile of a Found in urine 2. Concentration technique
man 3. Kato-Katz technique = most suitable method for
enumeration of eggs.
Cercaria/Cercariae = infective stage. 4. Serologic testing
a. Intradermal test = for immediate hypersensitivity
using adult worm extracts.
b. IHA = using adult worm & egg antigens.
c. ELISA = using soluble antigens of adults & eggs.
d. COPT = method of choice for definitive diagnosis.
(Circum-oval Precipitin Test) –freeze dried egg of
S.japonicum(Ag) –37C ;(+) bleb formation/septate
ppt.)
Oncomelania quadrasi = snail IH. e. Faust and Meleney’s egg hatching technique
(strip)

How is COPT done?

• Patient’s serum(ab) added to schistosome eggs (ag)
for incubation (37c).
• Demonstration of bleb formation or septate
precipitates attached to 1 or more points on the egg
Pathogenesis of Schistosomiasis: surface indicates a positive result.
There are 4 schistosome developmental stages of the
disease in the human host: Treatment: Praziquantel
1. Cercaria stage
Cercarial dermatitis = inflammatory response Prevention & Control:
occuring in the skin at the site of cercarial 1. Snail control
penetration. (swimmer’s itch) a. Vegetation removal
b. Drainage
c. Earth filling
d. Ponding
e. Improved rice culture
f. Mollusciciding
2. Schistosomule stage 2. Health education
Migration of schistosomules in the lungs = fever, 3. Environmental sanitation
malaise, cough & wheeze. 4. Case detection & chemotherapy
3. Adult stage 5. Elimination of the snail IH = most basic of all control
Katayama syndrome = fever, cough, diarrhea, measures.
hepatomegaly & generalized lymphadenopathy.
4. Egg stage Schistosoma japonicum
The stage of major pathology. - CN: Oriental Blood Fluke
a. Eggs trapped in the tissues induce granuloma - Causes Oriental Schistosomiasis or Katayama’s
formation & subsequent fibrosis around the egg. Disease
b. Eggs in the liver lead to obstruction of blood - Habitat: Superior Mesenteric; Vein in the Small
flow resulting in portal hypertension, Intestine
hepatosplenomegaly & development of porto - FH: Man
systemic collateral circulation & abdominal - Reservoir Host: Dogs, Cats, Carabaos
enlargement. - IH: Snail (Oncomelania hupensis quadrasi)
c. Eggs in the lungs result in obstruction of - Infective Stage: Cercaria (Forked tail Cercaria)
pulmonary circulation leading to “cor - MOT: Skin Penetration >> Allergic Reaction:
pulmonare”. Swimmer’s itch
- Egg: Unoperculated, Embryonated (Mature)
 Smallest egg among blood flukes
With a small knob-like or small lateral spine
(recurved back on one side)
Schistosoma mansoni Treatment
- CN: Manson’s Blood Fluke - The drug of choice for schistosome infections is
- Smallest Adult Blood Fluke praziquantel, given in two or three doses in a single
- Habitat: Superior Mesenteric Vein of the colon and day
rectum - Infection with S. mansoni may require a larger dose
- FH: Man than that for the other species.
- Reservoir Host: Nonhumsn primates - An alternative treatment for S. haematobium
- IH: Snail (Biomphalaria spp.) infections is metrifonate (Bilarcil), an
- Infective Stage: Cercaria organophosphorus compound, given once every
- MOT: Skin Penetration other week in a total of three doses.
- Egg: Unoperculated, Embryonated
With prominent lateral spine In summary:
a. Liver, Lung, & Intestinal Flukes
Schistosoma haematobium  METACERCARIA is the infective stage.
- CN: Vesical Blood Fluke  Adults are leaf like in shape.
- Causes Urinary Bilharziasis, Urinary Schistosomiasis  Operculated egg.
(Bloody Urine), Egyptian Haematuria  Transmission is thru ingestion of raw or poorly
- Habitat: Vesical/Urine plexus near the Urinary cooked fish or plants (IH).
Bladder b. Blood Flukes (schistosomes)
- FH: Man  CERCARIA is the infective stage.
- IH: Snail (Biomphalaria spp.)  Rediae & Metacercariae are lacking. (life cycle)
- Infective Stage: Cercaria  Unoperculated egg with a unique spine.
- MOT: Skin Penetration  Transmission is thru skin penetration.
- Egg: Unoperculated, Embryonated
With prominent terminal spine
- Specimen: 24-hour Unpreserved Urine Sample
- Optimize recovery in urine between moon and 2pm

Additional:
Schistosoma intercalatum
- Egg: resembles egg of S. haematobium, but Acid-
Fast Positive
- Adult: located in the venules of colon (large
intestine)

Schistosoma mekongi
- Egg: resembles egg of S. mansoni, but much smaller
- Adult: located in the venules of small intestine

Laboratory Test for Schistosoma

- DFS, Kato Katz, FEACT: Stool exam for eggs of
Schistosoma japonicum and Schistosoma mansoni
- Urine Analysis using 24-hour unpreserved urine
(centrifugation) for Schistosoma haematobium
- Circumoval Precipitin Test (COPT): Confirmatory test
for Schistosomiasis | (+) Result: Bleb Formation
(bulge)
Reagent: Lyophilized Schistosoma japonicum
eggs from a Rabbit (Reservoir Host)
Specimen: Serum
Principle: Detection of Antibodies that reacts
with the eggs
- Alkaline phosphatase Immuniassay for Schistosomes