Trematodes (flukes)

objectives
• Explain the general feature of Trematode
• Explain the general morphology of Adult, larvae & ova
• Explain the geographical distribution Morphology,
differential characteristics, and life Cycles of each
Trematode
• laboratory procedures
 Trematodes (flukes)
 leaf shaped except schistosomes – cylinderical
Unsegmented, flattened dorsoventrally
Hermaphroditic (except blood flukes (Bisexual)

• The life cycle is passed in two hosts

–Definitive host: Man (DH) and other animals
–Intermediate host: Snail (molluscan host)
 Require one or more intermediate hosts except schistosomes
 Helmin… Flukes

• Adult Trematode
 Helmin… Flukes

• Types:
a. Blood dwelling
b. Organ dwelling
I. Organ dwelling:
 Liver flukes
• Fasciola hepatica
• Opisthorchis viverini
• Clonorchis sinensis
• Metorchis conjunctus

 Intestinal flukes (Fasciolopsis buski )

 Lung flukes (P. westermani)

 CLASSIFICATION BASED ON HABITAT
HABITAT TREMATODES
Blood (Blood fluke) Schistosoma haematobium (vesical & pelvic
venous plexus)
Schistosoma mansoni (inferior mesentric
vein)
Schistosoma japonicum (superior mesentric
vein)

Biliary tract (Liver fluke) Clonorchis sinensis

Fasciola hepatica
Opisthorchis spp.

Gastrointestinal tract (Intestinal fluke)

Small intestine Fasciolopsis buski
Heterophyes heterophyes
Metagonimus yokogawai
Watsonius watsoni

Large intestine Gastrodiscoides hominis

Respiratory tract (Lung fluke) Paragonimus westermani

 Helmin… Flukes

• Trematodes have three morphologic stages

1) The egg (ova) – the excretory stage
2) Larvae (Miracidium, metacercariae,
cercariae)- the infective stage
3) Adult worms.
- Eggs ( have operculum or spine)
- Larvae (miracidium)sporocyst
radiae cercariae
In some spp the cercariae encyst into
metacercariae
Adult: Most leaf like with two suckers &
are hermaphrodite
 FEATURES DISTINGUISHING SCHISTOSOMES FROM
OTHER TREMATODES

• They are unisexual:DIECIOUS

• Lack a muscular pharynx

• They produce non-operculated eggs

• They have no redia & metacercaria stages

• The cercariae have forked tails and infect by penetrating the

unbroken skin of definitive hosts
Adult morphology

Male : 0.6 to 2.2 cm long

-it looks cylindrical, incurved
ventrally to form a gynecophoral
canal in which the female
reposes
-the body is covered by coarse
tubercles
- It has 6-9 testes
Female
• 1.2 to 2.6 cm
-slender, with a body almost
circular in cross section

-The ovary is present in the

anterior third and Vitelline glands
occupy the posterior two-thirds.

-It lays about 100-300 eggs

daily.

-The uterus is short containing

few ova.
 Cercaria

Miracidium – Little Boy

Schistosomulum

14
 Predisposing & Risk Factors

• Defaecation and
urination near water
sources
• Presence of snails
• Bathing
• Household works
• Fishing
• Rice fields

04/07/23 09:46 PM 15
 Schistosomiasis or Bilharziasis

– It is estimated that about 600 million people in 79

countries suffer from schistosomiasis.
– Clinical Presentation of schistosomiasis
 Intestinal Urinary- S. hematobium
– S. mansoni
– S. japonicum
– S. intercalatum
– S. mekongi
– S. mansoni & S. haematobium are prevalent in
Ethiopia.
 Geographical distribution
S. mansoni
•It is found in Africa, South America, Middle East
(some Arab countries) etc.
•S.mansoni is reported from all regions with
altitude between 1000 and 2000 meters
•More prevalent in the northern areas like Tigray
(Adwa), Wollo (Bati, Kemissie, and Dessie),
Gojjam (Jiga, Bahir Dar) and, Jimma and Agaro.
S. haematobium
•Low lands of Ethiopia with altitudes between
300 and 700 meters above sea level.
•Endemic areas include the swampy flood plains
of the Awash and Wabe Shebele valleys
•Areas with irrigation projects have the highest
risk of infection.
S. mansoni
• This species lives in the veins of the intestine

•The snail hosts that harbor S. mansoni are the genera:

Biomphalaria (B. glabrata)

S. haematobium
-the veins of the bladder of humans.

-the genera Bulinus (Bulinus africanus, B. truncatus) .

 Helmin… Flukes

a. In man
1. Cercaria penetrate intact skin while
in contact with cercaria infested
water.
2. Via the blood stream it resides in:
2.1. the veins surrounding the intestine or the
bladder.
 Helmin… Flukes

3. The female lays eggs in the veins, the eggs penetrate the wall
& enter the lumen of the intestine & leave the host via the
feces.
b. In snail:
- Development & multiplication result
in formation of cercaria which infest
the water body.
- Cercaria infect anybody in contact with
water.
 Symptoms and complications
• Patients infected with S. haematobium suffer
from terminal haematuria and painful
micturition.
• There is inflammation of the urinary bladder
(cystitis), and enlargement of spleen and liver.
• Patients infected with S. mansoni
– dysentery (mucus and blood in stool with
tenesmus)
– enlargements of the spleen and liver.
 Pathogenesis
• Cercaria dermatitis/ skin rash (swimmer itching)
• Migration & maturation of schistosomule
 Toxic and allergic rxn including uriticaria
 Eosiniphilia
 acute schistosomiasis: Patients may have diarrhea,
abdominal cramp, tenesmus, fever and chills. .
egg
• Depends on the load of parasite inflammatory
granuloma , fibrosis finally result calcification.
• Intestinal Schistosomiasis
– portal hypertension with splenomegaly
oesophagial varices
– hypersplenism (an overactive spleen)
– ascitis
• Egg deposition in the lungs leads to fibrosis
• CNS lesions: cerebral – seizures (S.
japonicum)
• intestinal polyposis: both sessile and
pedunculated contractures, intussusception
 S. mansoni
• Manson’s blood fluke
• Africa and South America
• Snails – Biomphalaria and Australorbis glabratus
• Intestinal bilharziasis
• Eggs - Faeces

04/07/23 09:46 PM 28
 S. japonicum
• Oriental blood fluke: anything belonging to the Orient or
"East" (for Asia)
• Asian schistosomiasis
• Intestinal and Hepatic Schistosomiasis
• Snails – Oncomelania species
• Habitat
Superior mesenteric veins – Ileum, Caecum
Intrahepatic portal vein
Rectal or haemorrhoidal veins
• Eggs - Faeces

04/07/23 09:46 PM 29
 Pathogenesis
• Similar to S. mansoni, But more pronounced.
Due to larger egg load
Proximity to liver
• Liver – Clay pipe stem cirrhosis
Not true cirrhosis, Due to fibrosed granulomas
Hepatic fibrosis & Calcification
• Splenomegaly

30
31
• Urinary schistosomiasis (S.hematobium)
– hematuria (terminal)
– Urinary frequency pyuria (pus in urine)
– Pyelonephritis: a bacterial infection causing inflammation
of the kidneys
– Obstructive uropathy
– Cancer of bladder (squamous cell)
– Distant metastases (spinal column) (pulmonary
hypertension)
 Laboratory diagnosis

• Microscopic identification of eggs in stool or urine is the most

practical method for diagnosis. 

– Stool examination should be performed when infection

with S. mansoni or S. japonicum is suspected, and urine
examination should be performed if S. haematobium is
suspected.

33
 Laboratory diagnosis

– Eggs can be present in the stool in infections with all

Schistosoma species. 
The examination can be performed on a simple smear (1 to 2
mg of fecal material). 
Since eggs may be passed intermittently or in small amounts,
their detection will be enhanced by repeated examinations
and/or concentration procedures (such as the formalin-ethyl
acetate technique). 

34
 Lab…
 In addition, for field surveys and investigational purposes, the
egg output can be quantified by using the Kato-Katz
technique (20 to 50 mg of fecal material).
 Laboratory diagnosis
• Eggs can be found in the urine in infections with S. haematobium and
with S. japonicum. 

 Detection will be enhanced by centrifugation and

examination of the sediment. 
 Quantification is possible by using filtration through a
Nucleopore® membrane of a standard volume of urine
followed by egg counts on the membrane.

36
Species Egg Infectious Clinical Symptoms Areas of the
Morphology Location World

Mansoni Lateral Inferior Hepatic Fibrosis

spine mesenteric Portal Hypertension South
veins Katayama Fever
CNS damage due to
deposition of eggs in spinal
column
Cor Pulmonare
Japonicum No spine Hepatic Fibrosis South East
(lateral knob) mesenteric Portal Hypertension (historically,
veins Katayama Fever now rare)
CNS damage due to
deposition of eggs in brain
Cor Pulmonare
Haematobium Terminal Bladder Calcified bladder only
spine venous Squamous cell epithelioma
plexus UTIs
Hematuria in males
Hydronephrosis
37
 Laboratory diagnosis
• Antibody detection can be useful in both in clinical management
(e.g., recent infections) and for epidemiologic surveys.
Antibody detection can be useful to indicate schistosome
infection in patients who have traveled in schistosomiasis
endemic areas and in whom eggs cannot be demonstrated in
fecal or urine specimens.
Serologic diagnosis of schistosomiasis are dependent on both
the type of antigen preparations used (crude, purified, adult
worm, egg, cercarial) and the test procedure
38
 Diagnosis

• Tissue biopsy (rectal biopsy for all species and

biopsy of the bladder for S. haematobium)
may demonstrate eggs when stool or urine
examinations are negative.
Treatment
• The drug of choice is praziquantel

• Effective against all species of schistosomes

Prevention and control

• Eradicating the snail

• Avoid swimming and bathing in rivers

• Use of tap water

• Mass treatment of the community

Organ flukes
Definition:
• It is an acute or chronic disease of human/ruminants,
caused by fasciola spp.,characterized by sudden
death, bottle jaw, emaciation and chronic digestive
disturbance.
• Etiology:
• Fasciola hepatica and F. gigantica
• Predisposing factors:
1. Common in swampy area
2. In area subjected to frequent flood-irrigation
 Liv. Conti.
 Include
Fasciola hepatica
Fasciola gigantica
Clonorchis(opisthorchis) sinensis
Opisthorchis viverrini
Opisthorchis felineus
 MORPHOLOGY
• Adult worms: F. hepatica relatively is a large,
flat and leaf-shaped brown coloured fluke

• The fluke measures 2.5 cm to 3 cm in length

and 1.5 cm in breadth

• The anterior end shows a distinct conical

projection while the posterior end is rounded
 Contd….
• Egg: The eggs are large, ovoid and bile-stained and
have a small, but distinct operculum

• They measure 130-150 µm by 63-90 µm

• These are unembryonated when freshly passed

• The eggs are excreted in the bile into the duodenum,
from where they are excreted out in the faeces

• Further development of the eggs take place only in

water
 INFECTIVE FORM
• Metacercaria: It is the infective form for
man and other definitive hosts.
• It is found on the surfaces of aquatic
vegetations and water cress.
 LIFE CYCLE
• DEFINITIVE HOST: Sheep is the principal
definitive host

• Goat, cattle and other herbivorous

animals and humans are the other
definitive hosts
 INTERMEDIATE HOSTS

• First intermediate host: Amphibian snails of

the family Lymnaeidae are the first
intermediate hosts

• Second intermediate host: Aquatic

vegetations and water cress are the second
intermediate hosts. They harbour
metacercaria

• Pre-patent period is 4 to 6 months.

 Fa. gi. conti.
Life cycle
 similar to the life cycle of F.hepatica except
the species of snail hosts infected by
F.gigantica are aquatic not amphibious
Clinical feature and pathology
 Light infections are usually asymptomatic

 In heavy infection
Local irritation during migration of the young
worms to the liver
Fever, Sweating, abdominal pain

In chronic infection: obstructive jaundice

Persistent diarrhea, anemia

• Postmortem lesions in animal
• Acute form
– Congested, swollen and damaged liver
– Liver capsule showed perforation with
subcapsular hemorrhage
– Small liver fluke can be seen on slicing
apiece of liver
• Chronic form
– Large leaf liver flukes present in bile
duct and protruded above liver surface
– Calcification of bile ducts wall
– Liver parenchyma is extensively
fibrosed
• Diagnosis
1.Fecal examination by direct and sedimentation
– Oval, operculated greenish yellow in color and embryonic
cell well demarcated
2.Eggs in aspirates of the duodenal fluid

3. Serum biochemical changes: Hypoproteinemia due to

increase protein leakage into the gut
4. Hematological changes: PCV, Hb and RBCs may be decrease
with Sever normochromic anemia, and hypochromic anemia
in chronic form with eosinophilia
5. Histopathology of liver
 Fasciola giagantica

 Common name: Large or Giant liver fluke

Geographical Distribution
 Widely distributed in tropical Africa including
Ethiopia, and Far East, south and south East
Asia
 Fa. gi. conti.
Habitat
Adult: In the bile duct of sheep, goat , cattle
& man

Egg: In faeces

All larva stages: Fresh water snail: Lymanae

Metacercaria: on water vegetations

 Fa. gi. conti.

Morphology
 Similar to F.hepatica
Adult:-Size 25-75 mm by 12 mm, larger
Egg: 160-190 m by 70-90m, operculated
& non-embryonated, larger
Prevention &Control F. hepatica & F. giagantica
1.Treatment of infected patients and animals
also
2.Hygienic measurements
– Infected pasture should not use for grazing
– Wet pasture or floody areas are avoided
– Regular removing of manure
3.Snails control
 Clonorchis(opisthorchis)
sinensis
 Common name: Chinese Liver fluke

Geographical Distribution
 Far east- China, Japan, Korea, Taiwan
 
 Cl. si. Conti.
Habitat
Adult: bile duct of man and fish eating
animals including cat , dog, pig

Eggs: In the faeces

Metacercariae: under the scale of fresh

water fish
 Cl. si. Conti.
Morphology:
Adult- Size: 10-25 mm by 3-5 mm; Boat
shaped
 Cl. si. Conti.
Egg: Size: 25-30m;shape like electric bulb
Colour: shell; yellowish brown; contents pale yellow
Operculum: At the narrow end of the egg,
 Cl. si. Conti.
Life cycle
 Embryonated eggs are discharged in the biliary ducts
and in the stool

 Eggs are ingested by a suitable snail intermediate

host
miracidia sporocysts rediae cercariae

 The cercariae are released from the snail

 
 Cl. si. Conti.
 Then, they come in contact and penetrate the flesh
of freshwater fish, where they encyst as
metacercariae
 
 humans acquire infection by ingestion of
undercooked, salted, or smoked freshwater fish

 After ingestion, the metacercariae excyst in the

duodenum and ascend the biliary tract
Life cycle of C.sinesis
 Cl. si. Conti.
Clinical feature and pathology
 Major symptoms are diarrhea, jaundice,
cirrhosis, biliary obstruction, hepatomegally

Laboratory Diagnosis
1.Finding the eggs in the faeces

2. Finding the eggs in aspirates of duodenal

fluids
 Cl. si. Conti.
3. Serological diagnosis
Antibody or antigen detection

Treatment : praziquantel

Prevention and Control

1.Avoid eating raw fish
 Cl. si. Conti.
2.Sanitary disposal of faeces and not using faeces
as a night soil

3. Destroy the snails

4. Inspection of fish

5.Treating infected person and giving health

education
 Opisthorchis viverrini
 Endemic in mekong River basin in Thailand,
Cambodia ,Ukraine & Russia

 Transmission & life cycle are similar to C.sinensis

 Fish eating animals like dogs & cats serve as

reservoir host

 Mature fluke live in biliary and pancreatic duct

 Op. vi. conti
 The fluke and deposited egg causes
inflammation & fibrosis around the bile duct

 Diarrhea , flatulence , abdominal

pain ,enlargement of liver , jaundice

 Laboratory diagnosis , prevention & control

are similar to C.sinensis
 Opisthorchis felineus
 Common parasites of cats , dogs , fish eating
wild animals & also infects humans

 Mainly found in Russia Kazakhstan, Ukraine

& Poland

 The life cycle ,clinical features, laboratory

diagnosis , prevention &control are similar to
C. sinensis
Op. fe. conti

Egg
 Intestinal Flukes

General Characteristics
 Adults live in the intestine

 Eggs are large and contain undeveloped

ovum when passed in the faeces

 They are hermaphrodite

 Intestinal Flukes
 Include
Fasciolopsis buski
Heterophyes heterophyes
Metagonimus yokogawai
Gastrodiscoides homines
 Fasciolopsis buski
 Common name: Giant intestinal fluke

Geographical Distribution :China, Taiwan, Thailand,

Vietnam, Indonesia

Habitat
Adults: small intestine of man , pig, dog,
Eggs: In the faeces of man, Pig, dog,
Larval forms: Fresh water snails
Metacercariae: encysted on certain aquatic
vegetation
 Fa. bu. conti.

Morphology
Adult

Size: 20-75mm by 8-20mm

Large, fleshy, flat worm

Has no cephalic cone &

shoulder
 Fa. bu. conti.
Egg
Size: 130-140m by 80-85m
Colur : Pale yellow-brown
Shape: oval
Small operculum
Unembroynated
 
Fa. bu. conti.

Egg
 Fa. bu. conti.
Life cycle
 Immature eggs are discharged into the
intestine and stool

 Eggs become embryonated in water , eggs

release miracidia , which invade a suitable
snail intermediate host
sporocysts rediae cercariae
 Fa. bu. conti.
  The cercariae are released from the snail and encyst
as metacercariae on aquatic plants

 The mammalian hosts become infected by ingesting

metacercariae on the aquatic plants

 after ingestion, the metacercariae excyst in the

duodenum and attach to the intestinal wall

 There they develop into adult flukes  

Life cycle of Fasciolopsis buski
 Fa. bu. conti.
Clinical feature and Pathology
 Epigastric pain, nausea and diarrhea

 In heavier infections, generalized edema and

ascites occur

 The fluke attaches itself to the intestinal

mucosa where inflammation, ulceration and
abscesses occur
 Fa. bu. conti.
Laboratory Diagnosis
1.Finding eggs in the faeces
2. Finding adult worms in the faeces
occasionally

Treatment
Praziquantel
 Fa. bu. conti.
Prevention and Control
1.Avoid eating uncooked water plants which may
be infected

2.Construction of latrine

3. Avoid use of human faces as a fertilizer

 Fa. bu. conti.
3. Destroy snails and their habitat

4. Treating infected individuals and giving

health education
 Heterophyes heterophyes
Geographical Distribution: China, Japan, Egypt, Korea,
Taiwan

Habitat
Adult: In small intestine of man, cat, dog, fox
Egg : In the faeces
Larval forms: In fresh water snails
Metacercariae: fresh water fish
 Het. he. Conti.
Morphology
Adult: Size: 1-2mm;has three suckers :oral,
ventral & genital suckers
Egg: Size: 25-30m
Colour: shell; yellowish brown; contents pale
yellow
the egg, Similar to Clonorchis sinensis
the shell Slightly thicker
 Het. he. Conti.
Life Cycle
 embryonated eggs ,each with a fully-
developed miracidium, are passed faeces

 After ingestion by a suitable snail , the eggs

hatch and release miracidia which penetrate
the snail’s intestine  
 sporocysts rediae cercariae  
 Het. he. Conti.
 The cercariae are released from the snail &encyst as
metacercariae in the tissues of a fresh water fish

 The definitive host becomes infected by ingesting

undercooked or salted fish containing metacercariae

 After ingestion, the metacercariae excyst, attach to

the mucosa of the small intestine & mature into
adults
Life cycle of H.hetrophyes
 Het. he. Conti.
Clinical features and pathology
 Light infection usually asymptomatic
 Heavy infection may cause diarrhea,
abdominal pain and eosinophilia

Laboratory Diagnosis
 Finding of eggs in the faeces
 Het. he. Conti.
 Treatment
Praziquantel

Prevention and Control

 Similar as Clonorchis sinensis
• Avoid eating raw fish
• Use of latrine
• Use chemicals for killing the snails
• Treating infected person and HE
 Lung Fluke
Paragonimus westermani

 Common name: Oriental lung fluke

Geographical Distribution
 Extensively distributed in the Far East & West African
countries : Zaire, Nigeria, Cameroon & South
America
 Par. we. Conti.

Habitat
Adults: In the lung of man
Eggs: In the sputum of man
Larval forms: Fresh water snails
Metacercariae: Fresh water crabs &
crayfish
 Par. we. Conti.
Morphology
Adult: Size: 7.5mm-12mm by 4-6mm

Egg
Size: 70-100m by 50-65m
Colour: Yellow-brown or brown
Shape: oval but asymmetrical
Has flattened operculum
MORPHOLOGY
Paragonimus westermani egg
 Par. we. Conti.
Life cycle
 eggs are excreted unembryonated in the sputum, or
alternately they are swallowed & passed with stool

 In the external environment, the eggs become

embryonated & miracidia hatch & penetrate its soft
tissues snail
sporocysts rediae cercariae

The cercariae invade a crustacean such as a crab or

crayfish, where they encyst & become metacercariae
 Par. we. Conti.
 Human infection with P. westermani occurs by eating
inadequately cooked crab or crayfish that harbor
metacercariae

 The metacercariae excyst in the duodenum , penetrate

through the intestinal wall into the peritoneal cavity

 then through the abdominal wall & diaphragm into the

lungs, where they become encapsulated & develop into
adults
 Par. we. Conti.
 The worms can also reach other organs and
tissues, such as the brain and striated muscles
 when this takes place completion of the life
cycles is not achieved, because the eggs laid
cannot exit these sites

 Animals such as pigs, dogs, and a variety of

feline species can also harbor P. westermani.
 
Life cycle of P.westermani
 Par. we. Conti.
Clinical feature and pathology
 Light to moderate infection are asymptomatic

 Symptoms sever pulmonary paragonimiasis:

chest pain , cough, night sweets, pleural
effusion, & coughing up blood

 Worms may migrate to the brain where they

lay eggs and cause a granulomatous abscess
resulting in symptoms similar to epilepsy
 Par. we. Conti.
Laboratory Diagnosis
1. Finding of eggs in the sputum
 sputum is usually bloody, mucoid &rusty brown

2. Finding of eggs in aspirates of pleural fluid &

occasionally in faeces

Treatment
Praziquantel
 Par. we. Conti.
Prevention and Control
1.Avoid eating raw or uncooked crabs & crayfish

2.Avoid contamination of water with sputum or

faeces

3.Destroy snails & their habitat

 Par. we. Conti.
4.Inspecting crabs & crayfish for
metacercariae

5.Treating infected individuals & giving

health education