CHAPTER 14:

TREMATODES
Learning Objectives
At the end of this chapter, the student should be
able to:
1. describe the general characteristics of the medically
important trematodes; and

2. characterize and differentiate the different trematodes

as to their:
• a. general features,
• b. source of infection,
• c. mode of transmission,
• d. clinical manifestations,
• e. treatment, and
• f. prevention and control of infection.
General Properties
of Trematodes
 TREMATODES
Trematodes, They may be
Most flukes are
commonly known as hermaphroditic or
hermaphroditic
flukes, belong to the dioecious
except Schistosoma
class Trematoda or (reproduce via
spp. (blood flukes).
Digenea. separate sexes).

Flukes have two

muscular suckers—
Morphologically, Unlike tapeworms,
an oral type and a
flukes are fleshy, flukes have a
ventral sucker which
leaf shaped worms. digestive tract.
serves for
attachment.
 TREMATODES
Some eggs may
possess a lid like
The eggs of the structure In Schistosoma
trematodes vary in (operculum) that spp., the eggs of
appearance and can flip open to the various
are the primary release its members may be
morphologic stage contents. differentiated
are usually This operculum is based on the
recovered from present in the presence and
humans. eggs of location of spines.
Fasciolopsis and
Fasciola.
 TREMATODES
Common to all trematodes, the
first intermediate hosts are Sexual reproduction
mollusks (snails and clams) of flukes occurs in
where asexual reproduction humans.
takes place.

Skin penetration by
In most cases, humans acquire
the infective larvae
the infection through ingestion
is the major mode of
of undercooked or raw second
transmission for
intermediate host.
blood flukes.
Blood-welling Flukes
 Schistosoma spp.
Important Properties and Life Cycle
Three schistosomes are frequently associated with
human disease, namely: Schistosoma mansoni,
Schistosoma japonicum, and Schistosoma haematobium.
Blood flukes are dioecious.
Known as the “romantic parasites,” the male and female
worms are usually in a state of copulation (en copula).
Female worms are usually larger than the male worms.
The schistosomes are also obligate intracellular
parasites.
 Schistosoma spp.
Important Properties and Life Cycle
The eggs are found in fresh water contaminated with the
feces or urine of infected humans.
Once in the water, eggs develop into a miracidium, that
will then locate a snail as its host, where it transforms
into cercariae.
Infection is acquired through skin penetration by the fork
tailed cercaria (larval form).
The parasite migrates into the bloodstream where the
undergo maturation.
 Schistosoma spp.
Important Properties and Life
Cycle
For Schistosoma japonicum and Schistosoma
mansoni, after skin penetration, the worms
enter the veins surrounding the intestinal tract
(superior and inferior mesenteric and portal
vein for S. japonicum; inferior mesenteric for S.
mansoni).
Schistosoma haematobium worms localize in
the veins surrounding the urinary bladder.
 Schistosoma spp.
Important Properties and Life
Cycle
The adult worms lay thousands of eggs per
day.
The eggs produce enzymes that enable
them to travel through the tissue.
The eggs then find their way into the colon
(for S. japonicum and S. mansoni) or into
urine (for S. haematobium) from which they
 Schistosoma spp.
Epidemiology and Pathogenesis
Schistosoma mansoni and Schistosoma haematobium
are both distributed throughout Africa.
S. mansoni is also found in South America while S.
haematobium is also prevalent in the Middle East.
Schistosoma japonicum is endemic in Indonesia, some
parts of China, and Southeast Asia, including the
Philippines.
It is the only schistosome for which domestic animals
(e.g., water buffalo and pigs) act as important
 Schistosoma spp.
Epidemiology and Pathogenesis
It is the only schistosome for which domestic
animals (e.g., water buffalo and pigs) act as
important reservoirs.
Most of the findings are caused by the
presence of eggs in the liver, spleen, or walls
of the gut or the urinary bladder, depending
on which species is causing the infection.
 Schistosoma spp.
Epidemiology and Pathogenesis
Eggs of S. japonicum in the liver may induce
granuloma formation leading to fibrosis and portal
hypertension, as well as damage the walls of the
small and large intestines.
Eggs of S. mansoni may damage the walls of the
distal colon.
Eggs of S. haematobium may induce granuloma
and fibrosis in the walls of the urinary bladder.
 Disease: Schistosomiasis
(Bilharziasis)
Asymptomatic infection
– The most common form of the disease.

- Chronic infection may become

symptomatic.
 Disease: Schistosomiasis
(Bilharziasis)
Characterized by pruritic papules seen at the site of
entry of the parasite.
Early This is called “swimmer’s itch” or “clam digger’s itch.”
acute
infectio This is followed after 2–3 weeks by fever and chills,
n abdominal pain, cough, bloody diarrhea, and weight
loss.
Painful urination(dysuria) and blood in the urine
(hematuria) may also occur in patients infected with
S. haematobium.
 Disease: Schistosomiasis
(Bilharziasis)
A systemic hypersensitivity reaction to the migrating schistosomes,
usually associated with S. japonicum.

It is characterized by a rapid onset of fever, myalgia, body malaise,

cough, diarrhea, and eosinophilia occurring 1–2 months after exposure
to the parasite.
Swollen lymph nodes and enlargement of the liver and spleen may
Katayam also occur.
a fever
It can lead to hepatic dysfunction, leading to portal hypertension.

The most common cause of death in this case is internal bleeding from
ruptured esophageal varices.
 Disease: Schistosomiasis
(Bilharziasis)
Include development of nephrotic syndrome in S.
japonicum and S. haematobium infection.

Associate Infection with S. mansoni or S. japonicum may predispose

to repeated Salmonella infections.
d
condition
s
S. japonicum is associated with the development of
Hepatocellular carcinoma or liver cancer while S.
haematobium has been implicated in the development of
cancer of the urinary bladder.
 Schistosoma spp.
Laboratory Diagnosis
Diagnosis relies on demonstration of
characteristic eggs in the feces or rectal biopsy
specimen for S. mansoni or S. japonicum, or
urine for S. haematobium.
S. mansoni eggs have a large lateral spine, S.
japonicum eggs have a rudimentary spine,
while the eggs of S. haematobium have large
terminal spines.
 Schistosoma spp.
Treatment
The recommended drug for all three
species is praziquantel.
An alternative drug for S. mansoni is
oxamniquine.
Anti malaria drugs such as artemether
and artemisinins have also been proven
effective.
 Schistosoma spp.
Prevention and Control
There are two objectives of schistosomal control: (a)
control of transmission through snail control, health
education, and provision of sanitary facilities and
water supply; and (b) control of disease.
Chemotherapy using praziquantel is the main thrust
of the Philippine program for schistosomiasis control
(DOH).
In order to prevent infection, swimming in endemic
areas should be avoided.
Tissue-dwelling Flukes
 Clonorchis
sinensis
There are The egg The first Within the
(Asian Liver three have an intermediat egg is the
Fluke, morphologic operculum e host is developed
Chinese Liver stages of the surrounded the miracidium
parasite— by a thick freshwater , that is
Fluke) egg, larva, rim called snail while released
Important and adult. the the second once the
Properties shoulder. intermediat egg comes
and Life e host is a into
freshwater contact
Cycle fish. with fresh
water.
 Clonorchis
sinensis
(Asian Liver
Fluke, The miracidium The larvae are The cercariae
Chinese Liver penetrates the then released enter a
Fluke) first intermediate into the water freshwater fish
host and where they where they
Important develops into a transform into encyst to
Properties sporocyst that cercariae. become the
and Life contains metacercariae.
Cycle numerous larval
stages (rediae).
 Clonorchis Humans
The larvae The adult
sinensis excyst in worms
acquire the
(Asian Liver infection by
the produce
Fluke, ingesting raw
duodenum, eggs that
or
Chinese Liver enter the are
undercooked
Fluke) biliary excreted in
freshwater fish
ducts, and the feces.
Important containing the
differentiate
Properties infective
into adults.
and Life metacercariae
Cycle .
 Clonorchis sinensis is found in Asia
including Korea, China, Taiwan, Vietnam,
Clonorchis Japan, and Asian Russia (CDC).
sinensis The parasite does not usually cause
(Asian Liver significant lesions, however, parasites that
Fluke, inhabit the bile ducts can damage the
biliary tract.
Chinese Liver Patients who develop infection with the
Fluke) parasite are at higher risk of developing
Cholangio carcinoma or cancer of the bile
Epidemiology ducts.
and The egg has also been associated with the
Pathogenesis development of gallstones (stones in the
gall bladder or cholelithiasis).
Disease: Clonorchiasis
Most patients are asymptomatic.

In heavy worm burden, patients may manifest a fever, upper

abdominal pain, anorexia, hepatomegaly, diarrhea, and
eosinophilia.

Liver dysfunction may also occur in chronic infection

associated with heavy worm burden.
 Clonorchis sinensis
(Asian Liver Fluke, Chinese Liver Fluke)

Laboratory Diagnosis
Diagnosis is established by finding the characteristic eggs in stool
specimen or duodenal aspirates.

Treatment
The drug of choice for treatment is praziquantel.
An alternative drug is albendazole.
 Clonorchis sinensis
(Asian Liver Fluke, Chinese Liver Fluke)

Prevention and Control

Infection can be prevented by thorough cooking of
fish prior to consumption.
Other control measures include health education,
proper waste disposal to avoid contamination of
bodies of fresh water, and prompt treatment of
infected persons.
 Fasciola hepatica
(Sheep Liver Fluke)
The Fasciola hepatica eggs possess an
operculum similar to Clonorchis sinensis and is
also equipped with shoulders.
Importa
nt The first intermediate host for the parasite is
Properti the snail while the second intermediate hosts
are edible aquatic plants (kangkong and
es and watercress).
Life Humans acquire the infection by ingesting raw
Cycle edible aquatic plants or by drinking water
contaminated by metacercariae (infective
stage).
 Fasciola hepatica
(Sheep Liver Fluke)
Upon ingestion, the metacercariae excyst in
the duodenum or jejunum, releasing the young
flukes.
Importa
nt These young flukes wander over the viscera
Properti until they reach the liver capsule.
es and
Life The parasite then burrows through the liver
Cycle parenchyma until it finally enters the bile ducts
where they mature.
 Fasciola hepatica
(Sheep Liver Fluke)
The adult worms (pathogenic stage) live in
the biliary passages of the liver.
Importa
nt Immature eggs are carried by the bile into
Properti the intestines and subsequently excreted
es and with feces.
Life The eggs mature in the water and infect the
Cycle first intermediate host.
 Fasciola hepatica
(Sheep Liver Fluke)
The cercariae escape the snail host, usually at
night, then encyst on the surface of aquatic
plants, forming metacercariae.
Importa
nt The natural host for the completion of the life
Properti cycle is the sheep, however the parasite may
also be found in cattle.
es and
Life In sheep raising countries, ingestion of raw
Cycle sheep liver containing the adult worm also
serves as an additional mode of transmission.
 Fasciola hepatica
(Sheep Liver Fluke)
Epidemiology and Pathogenesis
The Fasciola hepatica is found worldwide, especially in sheep
and cattle raising countries, and where humans consume raw
watercress such as Asia, Europe, and the Middle East.
The stages of the disease correspond with the migration of the
parasites.
The acute or invasive phase corresponds to the migration of the
parasite through the liver parenchyma, which leads to traumatic
and necrotic lesions in the liver. The severity of the destruction
is proportional to the number of metacercariae ingested.
 Fasciola hepatica
(Sheep Liver Fluke)

Epidemiology and Pathogenesis

• The chronic phase corresponds to the localization of
the adult worms to the bile ducts. The worm can
obstruct the bile duct and stimulate inflammation.
• During migration from the intestines to the liver, the
parasite may wander to other sites (e.g., lungs,
subcutaneous tissues, brain, or orbit) where
abscesses may develop
 Disease: Fascioliasis or
Sheep Liver Rot
Migration of the larval worm through the liver irritates the organ, manifesting as
tenderness and hepatomegaly.

Characteristic clinical features include right upper quadrant pain, fever and
chills, and marked eosinophilia.

Hepatitis may develop with biliary obstruction.

Some worms may cause necrotic foci in the liver.

Ingestion of raw sheep liver may lead to temporary lodgment of the adult worm
in the pharynx leading to suffocation.
 Fasciola hepatica
(Sheep Liver Fluke)
Laboratory Diagnosis
Diagnosis rests on finding of eggs in stool specimen,
although the appearance of the eggs of F. hepatica may
be indistinguishable from the eggs of another fluke,
Fasciolopsis buski.
Examinationof a sample of the patient’s bile may aid in
the differentiation.
If the eggs are present in bile, then this is indicative of F.
hepatica.
 Fasciola hepatica
(Sheep Liver Fluke)

Treatment
The treatment of choice is
dichlorophenol (bithionol).
An alternative drug is triclabendazole.
 Fasciola hepatica
(Sheep Liver Fluke)
Prevention and Control
Preventive measures include proper human waste
disposal, improvement of hygiene, control of snail
population, and avoidance of consumption of raw aquatic
plants and contaminated water.
In endemic areas it is highly recommended to boil water
before consumption or use.
Avoidance of ingesting of raw sheep liver is also
important, as well as prompt treatment of infected
individuals.
 Paragonimus westermani
(Oriental Lung Fluke)

The first intermediate host for Paragonimus is a

snail while the second intermediate hosts are
crabs or crayfish.
Importa Humans acquire the infection by ingesting raw
nt or undercooked crabs or crayfish that contain
Properti the infective encysted metacercaria.
es and The larva excysts in the small intestines, migrate
Life through the intestinal wall, through the peritoneal
Cycle cavity, into the diaphragm then into the lung
parenchyma where they mature.
 Paragonimus westermani
(Oriental Lung Fluke)

The adult worms enter the bronchioles

Importa and are then coughed up or swallowed.
nt
Properti Eggs in the sputum or feces reach fresh water,
hatch, and penetrate the first intermediate host,
es and where they differentiate into free swimming
Life cercariae.
Cycle The cercariae leave the snail host and
encyst in freshwater crabs that are eaten
by humans.
 Paragonimus westermani
(Oriental Lung Fluke)
P. westermani infection occurs most commonly in Asia, in
countries like China, the Philippines, Japan, Vietnam,
South Korea, Taiwan, and Thailand (CDC).

Epidemiolo Pigs, monkeys, and other animals that eat

gy and crayfish and crabs serve as reservoir hosts.
Pathogenes
is The worms exist in a fibrous capsule within the
lung which communicates with a bronchiole.
Within this cyst is blood-tinged purulent
material containing eggs.
 Disease: Paragonimiasis (Pulmonary
distomiasis, Endemic hemoptysis, Parasitic
hemoptysis)

The early stages of the disease are usually asymptomatic.

Patients may later experience symptoms related to

pulmonary involvement including cough productive of blood-
tinged sputum (hemoptysis), fever, and chest pain.
 Disease: Paragonimiasis (Pulmonary
distomiasis, Endemic hemoptysis, Parasitic
hemoptysis)
The sputum has a foul, fishy odor and is most pronounced in the
morning.

The disease may mimic pulmonary tuberculosis.

In rare cases, the immature flukes may migrate to the brain

leading to cerebral paragonimiasis, which may manifest as
seizures, visual disturbances, and reduced motor skill precision.
 Paragonimus westermani
(Oriental Lung Fluke)

Diagnosis is made by demonstration

of the characteristic eggs in sputum
or feces (when sputum is swallowed).
Laborator
y
Diagnosis A chest x ray may be done which may
show a ring shadowed opacity with several
contiguous cavities giving the appearance
of a cluster of grapes.
 Paragonimus westermani
(Oriental Lung Fluke)

The drug of choice for treatment is

praziquantel.

Treatme
nt An alternative drug is bithionol.
 Paragonimus westermani
(Oriental Lung Fluke)
Preventive measures include adequate
and thorough cooking of freshwater crabs
or crayfish, health education, control of
Preventio snail population, and elimination of
n and reservoir hosts.
Control Prompt treatment of infected persons
is also important to prevent the
parasite from spreading.
 Fasciolopsis buski
(Large Intestinal Fluke)
Important Properties and Life Cycle
The eggs of F. buski and F. hepatica are
morphologically identical however they differ only in
size.
The adult worms of both parasites are also similar in
appearance except that shoulders are present in F.
hepatica and not in F. buski.
The first intermediate host is a snail while the second
intermediate hosts are edible aquatic plants (e.g.,
watercress and lotus).
 Fasciolopsis buski
(Large Intestinal Fluke)
Important Properties and Life Cycle
Humans acquire the parasite by ingestion of raw or
inadequately cooked aquatic vegetation that carries the
encysted metacercariae.
The metacercariae excysts in the duodenum and attaches to
the intestinal wall where they attain maturity.
The adult worms lay eggs, that are released together with
the feces into water, where they hatch and infect the first
intermediate host.
The eggs develop into cercariae which encyst as
 Fasciolopsis buski
(Large Intestinal Fluke)
Epidemiology and Pathogenesis
F. buski is the largest intestinal fluke that can infect
humans.
Infection with the parasite is common in Asia and the
Indian subcontinent, particularly in areas where pigs are
raised and where freshwater aquatic vegetation is
ingested raw.
No locally acquired cases in humans or pigs have been
reported in the Philippines.
Pathologic changes are due to damage to the intestinal
 Disease: Fasciolopsiasis

Most infected persons are asymptomatic.

However, with heavy worm burden, patientmay experience abdominal

discomfort with is inflammation and bleeding in the affected area.

Ulcerations may occur and symptoms may mimic those of duodenal ulcer.
Patients may also suffer from malabsorption.

Intoxication may result from absorption of worm metabolites by the host,

leading to allergic symptoms such as edema of the face, abdominal wall, and
lower limbs.
 Fasciolopsis buski
(Large Intestinal Fluke)
Laboratory Diagnosis/Treatment
Diagnosis is made by demonstration of the
eggs in stool specimen.
Examination of bile samples and duodenal
aspirates may help differentiate F. buski eggs
from those of F. hepatica.
The drug of choice for treatment is
praziquantel.
 Fasciolopsis buski
(Large Intestinal Fluke)

Prevention and Control

Adequate washing and cooking of aquatic
plants before consumption can help prevent
infection.
Other measures include proper disposal of
human waste, control of snail population,
and prompt treatment of infected persons.