MONOECIOUS FLUKES LIVER FLUKES Fasciola hepatica and Fasciola gigantica Chlonorchis sinensis Opistorchis felineus and Opistorchis

viverrini Dicrocoelium dendriticum INTESTINAL FLUKES Fasciolopsis buski Echinostoma ilocanum Heterophyes heterophyes Metagonimus yokogawai LUNG FLUKE Paragonimus westermani DIOECIOUS FLUKES BLOOD FLUKES Schistosoma japonicum Schistosoma mansoni Schistosoma haematobium

CLASS TREMATODA

GENERAL CHARACTERISTICS

Broadly oval or _________________ in shape with an oral sucker, a prepharyngeal tube, a pharynx, an esophagus, and a bifurcated intestinal ceca which ends blindly except in the ___________________ They vary in size and shape. The most characteristic external structure are the _______________________ (suckers) Digestion is predominantly an _______________________ Respiration is essentially ____________________

Excretory system is bilaterally symmetrical and open at the posterior end of the body with ____________________________
Nervous system is composed of a group of ______________________ disposed like saddle on the dorsum of the pharynx or esophagus, and a main pair each of posteriorly and anteriorly directed nerve trunks in the dorsal, ventral and lateral fields

GENERAL CHARACTERISTICS

They are hermaphrodites (monoecious) except for HUMAN BLOOD FLUKES The _______________________________ trematode is found in the DEFINITIVE HOST Both male and female reproductive organ system have one common opening known as the ________________________ Male reproductive system is composed of the prostate enclosed by ____________________________________ followed by dilatation known as SEMINAL VESSICLE, leading to ONE VAS DEFERENS the bifurcate into 2 vas deferens which ends into a PAIR OF TESTES Female reproductive system consists of a sac-like structure called the UTERUS which opens into the ____________________, then the OOTYPE, then the OVIDUCT ending in a single ovary

GENERAL CHARACTERISTICS

All trematodes lay eggs which upon embryonation, give rise to a ciliated embryo known as MIRACIDIUM. All eggs to trematodes are provided with a lid called an OPERCULUM except for the BLOOD FLUKES whose eggs are NON OPERCULATED Trematodes need BODY OF WATER to complete the life cycle. All require 2 INTERMEDIATE hosts except the BLOOD FLUKES which only has one I.H.

GENERAL CHARACTERISTICS

LIFE CYCLE OF TREMATODES

________________ adult fluke _________________-larva _________________ free swimming stage, ciliated embryo which hatches in water to penetrate the 1st IH __________________ sac-like structure with GERM BALLS which proliferate, found in snail host ________________ sac-like structure containing ORAL SUCKER, a pharynx, a birth pore, carcaria germ balls, and another generation of redia, also found in the snail host (1st IH) ___________________ stage in the life cycle which emerges from the snail host; all possess tail, therefore they are free swimming ___________________ found in 2nd IH

GENERAL CHARACTERISTICS

TYPES OF CERCARIA
Lephocerous
A. Simple tailed

B. Keeled tailed

Microcerous Fork-tailed bifurcated at its dorsal end

GENERAL CHARACTERISTICS

IMPORTANT DIFFERENCES IN DEVELOPMENTS

1) Egg embryonated when laid----hatches on contact with water---miracidium actively enters appropriate mollusk----develops into 1st generation sporocyst (S1)-----produce 2nd generation sporocyst (S2) ----produce cercaria

2) Egg not embryonated when laid but matures in water and then hatches----miracidium, after entering the mollusk, develops into 1st generation sporocyst (S1)----produces redia----which then produce cercaria

GENERAL CHARACTERISTICS

IMPORTAN DIFFERENCES IN DEVELOPMENTS

3) Egg not embryonated when laid but mature in water and h hatches---miracidium, after actively entering the mollusk, develops into redia---produces 2nd generation rediae----which then produce cercariae.

4)

Egg embryonated when laid but hatches only when ingested by appropriate snail----miracidium develops into 1st generation sporocyst (S1)----produces rediae----which then produce cercariae

GENERAL CHARACTERISTICS

INTESTINAL CECA
Branched: Simple: Simple but arranged in a zigzag fashion:

TESTES
Branched and arranged in tandem: Deeply lobulated testes arranged in tandem or dumbell testes: Lobulated testes arranged side by side: Oval or round testes arranged side by side or slightly oblique: Lobular testes obliquely arranged:

GENERAL CHARACTERISTICS

OVARY
Branched: Lobulated: Oval or round:

VITELLARIAE
Highly branched: Finely granular vitelline follicles: Medium sized vitelline follicles: Polygonal:

GENERAL CHARACTERISTICS

MANNER OF TRANSMISSION
Ingestion of ______________________through improperly cooked 2nd IH Skin penetration by __________________in flukes

CONTROL AND PREVENTION

Chemotherapy of cases discovered in the human population Disinfection of excreta or their sanitary disposal Anti-molluscal campaigns Education of the population to refrain from bathing in infected water and from eating improperly prepared foods

MONOECIOUS FLUKES

LIVER FLUKES

Fasciola hepatica

COMMON NAME
________________________________

DISEASE
Fascioliasis, _________________

GEOGRAPHICAL DISTRIBUTION
Fascioliasis occurs worldwide. Human infections with F. hepatica are found in areas where sheep and cattle are raised, and where humans consume raw watercress, including Europe, the Middle East, and Asia.

Fasciola hepatica

MORPHOLOGY

Fasciola hepatica

PATHOGENESIS, PATHOLOGY, AND SYMPTOMATOLOGY

IMMATURE ADULTS
Ectopic lesions in the intestinal _____________________

MATURE ADULTS
Irritation and inflammation of the bile duct including biliary obstruction due to pressure toxic metabolites Development of parenchymal atrophy and periportal cirrhosis Enlarged tender liver, jaundice, diarrhea, and anemia S/S: sever headache, irregular fever, chills, diarrhea, urticarial rashes, stabbing substernal pain, right upper quadrant pain that radiate to back and shoulder, vomitting. In the latter course, there is tenderness and enlargement of the liver with jaundice, which is hepato-cellular and obstructive in type, leukocytosis, with 60% eosinophilia

Fasciola hepatica

_________________________________________
Laryngopharyngitis due to eating raw infected sheep or goat liver; the young adullt flukes attached to the pharynx, larynx, eustachian tube and palate; S/S include dyspnea, dysphagia, deafness, and asphyxia

_________________________
An ectopic foci wherein the flukes lodged themselves in the subcutaneous tissue causing an oval or round reddish-brown discoloration with associated pain and itchy sensation

_________________________
Due to ingestion of infected liver with passage of eggs in the feces. Ruled out by keeping patient on a liver-free diet fro at least 3 days. If eggs continue to pass out, infection is probably genuine

Fasciola hepatica

DIAGNOSIS
DFS Concentration and sedimentation methods Biliary drainage

TREATMENT
Triclabendazole is the treatment of choice

PREVENTION
Eliminate molluscan host with 1: 50,000 solution of cupric sulfate Proper drainage of pasture Sanitary protection of water beds Eradication of parasite in reservoir host which is the sheep Avoid eating raw salad (water cress)

Fascioliasis is endemic in the Philippines, and is common among_________________

Fasciola gigantica

DISEASE
Fascioliasis

GEOGRAPHICAL DISTRIBUTION
Infections with F. gigantica have been reported, more rarely, in Asia, Africa, and Hawaii

MORPHOLOGY
Refer to laboratory manual

Fasciola gigantica

INTERMEDIATE HOST
The species of Fasciola can become adapted to new intermediate hosts under certain conditions based on laboratory trials. It has been reported that the most important intermediate host for Fasciola gigantica is Radix auricularia Lymnaea rufescens and Lymnaea acuminata are the host snails in the Indian Subcontinent Radix rubiginosa and Radix natalensis are the hosts in Malaysia and in Africa respectively; and the synonymous Lymnaea cailliaudi is the intermediate host in east Africa

Fasciola gigantica

DEFINITE HOSTS

Fasciola gigantica is a causative agents (together with Fasciola hepatica) of fascioliasis in ____________________________________________ worldwide The parasite infects ________________________ and can also be seen regionally in goats, sheep, and donkeys.

Fascioliasis
Disease

Most of the clinical knowledge about fascioliasis is based on cases caused by Fasciola hepatica. However, the same principles and clinical features are thought to apply to F. gigantica. Fasciola parasites do not multiply in people. Therefore, the parasite burden depends on the inoculum, including the potential for reinfection. Clinical manifestations reflect host factors and the parasite burden, the large sizes of Fasciola eggs and of adults flukes in and of themselves can be problematic. They can compound the tissue damage and increase the abdominal pain when larval flukes migrate through the liver and can predispose to biliary obstruction during the chronic phase.

Fascioliasis

Both the acute and chronic phases of infection can be symptomatic or symptom free. Nonspecific clinical features of both phases can include:
fever, which can be intermittent
malaise abdominal pain, in the right upper quadrant, epigastrium, or more diffuse/generalized other abdominal symptoms (such as anorexia, nausea, vomiting, diarrhea, change in bowel habits, and weight loss) and signs (such as hepatomegaly and jaundice) eosinophilia, which is more prominent and less variable during the acute phase than in the chronic phase anemia, especially in children; and

transaminitis (during the chronic phase, laboratory testing also can indicate hepatobiliary obstruction)

Fascioliasis
_________________________________
The _________________ is also referred to as the ________________________________________________ Immature larval flukes migrate through the intestinal wall, the peritoneal cavity, the liver capsule, and hepatic tissue and, ultimately, to the bile ducts. Lasts up to 2 to 4 months and ends when the larvae reach and mature in the bile ducts. Larval migration, especially through the liver, can result in tissue destruction, inflammation, local or systemic toxic/allergic reactions, and internal bleeding. Symptoms, in addition to those listed above, can include urticaria, cough, and shortness of breath. This phase can be life-threatening in sheep infected with large inocula of parasites. However, severe illness is uncommon in people, although some young children may have intense abdominal pain.

Fascioliasis
__________________________________________
The chronic phase is also referred to as ___________________________________________________The chronic phase begins when immature larvae reach the bile ducts, mature into adult flukes, and start producing eggs. The eggs are passed from the bile ducts into the intestine and then into feces. During this phase, the patient may be asymptomatic for months, years, or indefinitely. The only finding on routine blood testing may be peripheral eosinophilia, which typically is less prominent than during the acute phase. Some experts differentiate between an asymptomatic latent phase and a symptomatic obstructive phase, which only some patients experience. The symptoms, if any, may be similar to those during the acute phase or may be more focal/discrete, reflecting:

cholangitis and biliary obstruction, which can be intermittent; cholecystitis and gallstones; pancreatitis; and cirrhosis.

On the basis of limited data, the life span of adult flukes in people may be 5 to 10 years, perhaps even longer.

Fascioliasis
__________________________________

Fasciola parasites usually go to the liver and bile ducts. However, larval flukes also can migrate to ectopic (aberrant) sites, such as the lungs, subcutaneous tissue, genitourinary tract, or brain. Fasciola parasites at ectopic sites may or may not mature into adult flukes. For example, subadult worms may emerge through the skin. In addition, Fasciola hepatica and F. gigantica have been reported to cause pharyngeal infection in people who ate raw sheep or goat liver that contained immature flukes. In this unusual scenario, the larval flukes emerge from the liver and attach to the pharyngeal mucosa. Pharyngeal fascioliasis (and other parasitic infections) acquired in this manner from raw liver is also known as halzoun (a local, Middle Eastern term). The clinical features can include dysphagia, dyspnea, bleeding, and airway obstruction.

Chlonorchis sinensis

COMMON NAME
_________________________________________

DISEASE
Chlonorchiasis

GEOGRAPHICAL DISTRIBUTION
Endemic areas are in Asia including Korea, China, Taiwan, and Vietnam.

Clonorchiasis has been reported in non endemic areas (including the United States). In such cases, the infection is found in Asian immigrants, or following ingestion of imported, undercooked or pickled freshwater fish containing metacercariae.

HABITAT _________________________________ passages

Chlonorchis sinensis

MORPHOLOGY
Adult
Measure from 10-25 mm, spatulate organism, attenuated anteriorly and rounded posteriorly Integument is ASPINOSE Oral sucker is slightly larger than the ventral sucker Most characteristic feature: _________________________________________which are situated one behind the other in the posterior 3rd of the body, with large branches extending into the lateral fields Vitellaria are delicate, granular aggregrates in the lateral field

Eggs
Measure about 27-35 u Broadly ovoidal with a moderately thick light yellow brown shell provided with a distinct convex operculum which fits into a rimmed extension of the shell Thick posterior and with a ____________________________________________________ __________________when laid Contain mature __________________

Chlonorchis sinensis

Chlonorchis sinensis

MODE OF TRANSMISSION
Ingestion of __________________through improperly cooked infected freshwater fish

1ST INTERMEDIATE HOST

Melanoides tuberculatus, Corithidia, Thiara, and Bulimus

2ND INTERMEDIATE HOST

Fresh water fishes (Bangus, tilapia, Kanduli, etc)

Chlonorchis sinensis

EPIDEMIOLOGY AND PATHOGENESIS

Human infection is characterized by proliferation of the bile duct epithelium and of the surrounding connective tissue due to irritation, inflammation of the biliary passages resulting in liver cirrhosis, destroying liver parenchyma and obstructing portal blood flow Toxemia is due to decreased detoxifying ability of the liver Symptoms are divided into 3 stages:
1) _______________________ mild infection 2) _________________________ epigastric pain, producing GIT disturbances like diarrhea, indigestion, anorexia, irregular appetite, fullness of abdomen, hepatomegaly and tenderness, abdominal pain, leukocytes with 40% eosinophilia 3) ______________________ producing portal cirrhosis, jaundice, anemia, edema, and ascitis

Chlonorchis sinensis

DIAGNOSIS
DFS Duodenal aspirate Non-specific immunological tests

TREATMENT
Praziquantel

PREVENTION
Prevention centers on adequate cooking of fish and proper disposal of human waste Add __________________as sterilizing agent in fresh night soil endemic areas

Opistorchis felineus

COMMON NAME
__________________

DISEASE
Opistorchiasis

GEOGRAPHICAL DISTRIBUTION
O. felineus is found mainly in _______________________________

HABITAT
Distal ___________ passages

Opistorchis felineus

MORPHOLOGY
Adult:
Measures from 7-12 mm ________________in shape with a subterminal oral sucker Ventral sucker is almost of equal size as the oral sucker Diagnostic feature: ________________________arranged obliquely to each other On the lateral field of the worm are transversely compressed vitelline follicles Simple intestinal ceca

Ova/ Egg:
Measures 30 x 10 u Elongatedly oval in shape and resembles the C. sinensis ova in shape Absence of prominent shoulder rim

Opistorchis felineus

Opistorchis felineus

1st INTERMEDIATE HOST

Melanoides tuberculatus

2nd INTERMEDIATE HOST

Fresh water fish (_____________)

PATHOGENESIS
30-60 worms No serious damage If _________: enlargement of liver with tenderness, passive congestion of the spleen, gastric disturbances, pancreatic involvement, cystic dilatation of biliary duct and thickening due to increase fibrous growth leading to cirrhosis and portal hypertension _________ can be built in the egg Simulate _________with subsequent __________ S/S include: anemia, abdominal fullness, diarrhea, vomitting, urticaria, enlargement of the liver, jaundice, flatulence, leukocytosis with eosinophilia

Opistorchis felineus

DIAGNOSIS
DFS Duodenal aspirate

TREATMENT
Praziquantel

PREVENTION
Same with C. sinensis

***** ___________ is associated more with O. felineus than with C. sinensis ****_____________ is associated more with C. sinensis than with O. felineus

Opistorchis viverrini

COMMON NAME

DISEASE
Does not cause nay specific symptoms

GEOGRAPHICAL DISTRIBUTION
O. viverrini is found mainly in northeast

MORPHOLOGY
Similar with O. felineus except for its greater proximity of the ovary and testes, fewer clusters of aggregated vitellaria

Opistorchis viverrini

LIFE CYCLE: Same with the O. felineus

Dicrocoelium dendriticum

COMMON NAME DISEASE

Dicrocoeliasis

GEOGRAPHICAL DISTRIBUTION
Europe, northern Asia, America and northern Africa

MORPHOLOGY
Refer to laboratory manual

Dicrocoelium dendriticum

PATHOGENESIS
Most infections are light and asymptomatic. In heavier infections, symptoms may include cholecystitis, liver abscesses and upper abdominal pain.

DIAGNOSIS
Microscopic identification of eggs in the stool or duodenal fluid. If eggs are found only in stool, it could represent spurious passage following the ingestion of infected animal liver. Additional specimens should be collected to confirm a true infection.

TREATMENT
In humans, the diagnosis of dicrocoeliasis is typically spurious based on parasite eggs that are passed in the feces after consumption of infected animal liver. True infections are rare. Infection has been treated successfully with praziquantel, 25 mg/kg three times orally daily for 2 days. Praziquantel is not approved for treatment of children less than 4 years old. Niclosamide is effective but is not available in the United States.