 TREMATODES

1
 Class Trematoda
 Trematode parasites of man belong to Order Digenea
 Characters:
 Flattened dorsoventrally / leaf like (Schistosomes – cylinderical)
 Bilaterally symmetrical
 Unsegmented
 Has no body cavity
 Cuticle covered with spines (help in fixation)
 Organs of fixation in the form of suckers

2
 Class Trematoda

1. Oral sucker – at anterior end surrounding the mouth

2. Ventral sucker (acetabulum)– blind on the ventral surface

posterior to the oral sucker

3. Genital sucker – present in some species

3
Hermaphroditic (A) and Bisexual (B) flukes

4
 Class Trematoda

 Digestive system:
 Mouth at anterior end surrounded by the oral sucker
 It leads to an oesophagus having a muscular pharynx
 This divides infront of the ventral sucker into 2 intestinal
caeca ending blindly at the posterior end

Mouth (Oral sucker) ____ Oesophagus ___ Intestinal caeca

5
 Class Trematoda

 Excretory system:
 Flame cells derive products, by the activity of their cilia,
into collecting tubules to a bladder, and are finally
discharged from an excretory pore at the posterior end

Flame cells (Cilia) ___ Collecting tubule ___ Bladder ___ Excretory
pore __ Discharged

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 Genital system:
 Hermaphroditic except blood flukes (Bisexual)
 The male system comprises:
 Testes (usually two)
 Vas deferens which dilates into a seminal vesicle and ends in
a muscular copulatory organ, the cirrus, which may be
enclosed in a cirrus sac.
 The cirrus opens in the common genital pore anterior to the
female opening

Testes ____ Vas deferens ______ cirrus _____ Common genital pore
7
  The female system comprises:
 The ootype receives the secretions of two glands, the
vitelline (yolk) glands and Mehli’s (shell) gland
 One ovary from which the oviduct arises and ends in
the ootype

8
 Fem...
 Uterus proceeds from ootype & ends in the vagina
which opens in the common genital pore posterior to the
male opening

Ovary____ Oviduct ______ Ootype_____ Uterus _____Common

genital pore

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 Sexes of flukes

10
 Trematodes - schistosomes

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 Class Trematoda
 The life cycle is passed in two hosts (alternation of hosts)

1. Final host: harbour the sexual stage of the parasite (adult

worm)
 Man (DH)
 Other animals (RH)

2. Intermediate host: harbour the asexual stages of the

parasite

 Snail (molluscan host).

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 General life cycle

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 Classification
1. Blood flukes:

1. Schistosoma spp. (S. mansoni, S. hematobium, S.

japonicum, S. intercalatum, S. mekongi)

2. Liver flukes:

1. Clonorchis sinensis,

2. Opistorchis spp.,

3. Fasciola spp. (F. hepatica, F. gigantica)

3. Lung flukes

1.
14 Paragonimus westermani
 Classification

4. Intestinal flukes

1. Fasciolopsis buski

2. Heterophyes heterophyes

15
 Clas...
• Classification is based on the body site where they resides on
the hosts body:

1. Liver flukes – in the liver and biliary duct

2. Intestinal flukes – in the intestine

3. Lung flukes – in the lung

• The trematodes that infect liver, lung, and intestine are all
food-borne.
 Freshwater fish, crustaceans, and aquatic vegetation are the
sources of human infection.
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 ES
UK
FL
OD
LO
B
 Blood flukes (Schistosomes)
 General feature:
 Develop in the portal venous system (df. Other flukes)
 The adult live in the veins that drain the intestine or the
urinary bladder (species dependent)
 Sexes are separate (Diecious - bisexual)
 Cylinderical
 No redia and metacercaria stages.

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Blood flukes (Schistosomes)

 Males broader & females filiform and larger than male

 Male has gynaecophoric canal where the female
resides after mating
 Freshwater snails serve as interemediate host.
 Humans the most significant DHs, cercaria is the
infective stage
 The immature stage that migrates in the body after
infection by cercaria is called schistosomulum.

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 Blood flukes (Schistosomes)

 Schistosomiasis is caused by digenetic blood trematodes.

 The three main species infecting humans are
Schistosoma haematobium, S. japonicum, and S.
mansoni.
 Two other species, more localized geographically, are S.
mekongi (Southeast Asia) and S. intercalatum (central
West Africa).

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 Blood flukes (Schistosomes)

 Adult worms reside in venous system

 S. haematobium resides in veins of urinary tract
 S. japonicum in superior mesenteric veins of small intestine
 S. mansoni in inferior mesenteric veins of large intestine
 worms move upstream to smaller venules to lay eggs
 Eggs traverse tissue to exit in gut or bladder

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 S. Mansoni (manson’s blood fluke)
 Distribution: Nile delta, Africa, S. America
 Disease: Intestinal bilharziasis
 Morphology:
 Adults:
 Male: marked tuberculated integument, 6 – 9 testes,
intestinal caeca reunite in the anterior half of the body
 Female: longer and thicker than male, ovary in the
anterior half of the body, lay 100 – 300
eggs/day/female
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S. Mansoni (manson’s blood fluke)

 Egg: oval with one rounded pole and one conical pole, large
triangular lateral spine, contains fully embryonated
(developed miracidium) when discharged with feces

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S. Hematobium (urinary schistosomiasis)
 Also called vesical blood fluke
 Distribution: Africa, middle East, S. Europe
 In ethiopia – Awash, Wabeshebele, Asossa

 Morphology:
 Adults:
 Male: finely tuberculated integument, 4 – 5 testes, the ventral sucker is
larger, intestinal caeca reunite in the middle body of the worm

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S. Hematobium (urinary schistosomiasis)
 Female: ovary in the posterior half of the body, uterus
– 20 – 200 ova/day/female, suckers are subequal
 Egg: oval with one well rounded pole, terminal spine at
one pole, contains fully developed miracidium when laid

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S. Japonicum (intestinal schistosomiasis)
 Also called oriental blood fluke
 Distribution: China, Phillipins, Indonesia, Thailand
 Not in ethiopia

 Morphology:
 Adults:
 Male: non tuberculated (smooth), intestinal caeca reunite in the posterior body
of the worm

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S. Japonicum (intestinal schistosomiasis)

 Female: ovary in the middle part of the body, uterus – 50 or more ova/day/female
 Egg: oval almost round, spine very small hook like spine laterally, contains fully
developed miracidium when laid

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 S. Intercalatum
 Also called vesical blood fluke
 Distribution: West and Central Africa
 Not in Ethiopia

 Morphology:
 Adults:
 Male: body covered with tubercules and fine spines, 4 – 6 testes
 Female: ovary lies at the midddle part of the body, uterus – 5– 50ova/day/female

 Egg: resembles S. Hematobium but acid fast positive

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General life cycle of Schistosoma spp.
 Embryonated egg (urine, feces of DH)
 Miracidium - swims (penetrate snail IH)
 Sporocyst (two generations in the same snail host &
cercaria released)
 Forked cercariae – swims (penetrate DH – sheds the fork)
 Schistosomulum (migrate till their residence – veins)

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 General life cycle of Schistosoma spp.
 Adult
S. Mansoni (mesentric vein draining large Intestine)
S. Japonicum (mesentric vein draining small intestine)
S. Hematobium (Venous plexus of bladder)
Females lay eggs in small venules (egg moves to lumen)
Intestinal lumen (mansoni & japonicum) & bladder lumen
in hematobium.
Life cycle of Schistosoma species

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 Pathology
Immunopathology
 Host immune response against adult worm is minimal
 Eggs induce intense inflammatory reaction ,leading to
granuloma formation
 Granuloma consists of egg at center surrounded by
eosinophils , macrophages and lymphocytes
 Larvae inside the egg produce enzymes that aid in tissue
destruction and allow the eggs to pass through the mucosa
and in to lumen of bowel and bladder
 Clinical feature

 Many infections are asymptomatic.

 S. mansoni causes
 Acute schistosomiasis (Katayama's fever) may occur weeks
after the initial infection, especially by S. mansoni and S.
japonicum.
 Manifestations include fever, cough, abdominal pain,
diarrhea, hepatospenomegaly, and eosinophilia.
 There may be irritation & skin rash at the site of cercarial
penetration (swimmer’s itch)
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 S. haematobium and S. mansoni …
Cont’d

 In less than 10% of cases,

granulomas can cause
blockage of blood flow in
liver causing enlargement
of the spleen and fluid
retention in abdomen.

34
 Clinical feature
 Host reaction to eggs lodged in the intestinal/bladder
mucosa leads to the formation of granulomata, ulceration,
thickening of the wall
 Occasionally central nervous system lesions occur:
 Cerebral granulomatous disease may be caused by
ectopic S. japonicum eggs in the brain, and
 Granulomatous lesions around ectopic eggs in the spinal
cord from S. mansoni, and S. haematobium infections
may result in a transverse myelitis with flaccid paraplegia
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…paralysis of the leg
 Clinical feature

 Continuing infection may cause granulomatous reactions

and fibrosis in the affected organs, which may result in
manifestations that include:
 Colonic polyposis with bloody diarrhea (Schistosoma
mansoni mostly);
 Portal hypertension with hematemesis and
splenomegaly (S. mansoni, S. japonicum);

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Clinical feature

 Cystitis and ureteritis (S. haematobium) with hematuria,

which can progress to bladder cancer;
 Pulmonary hypertension (S. mansoni, S. japonicum, more
rarely S. haematobium);
 Glomerulonephritis

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 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.

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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).

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 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
 Antibody detection can be useful in both in clinical
management (e.g., recent infections) and for epidemiologic
surveys.

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 Prevention and control
 Avoid contact with water
 Construction of bridges on streams and rivers
 Providing safe recreational bathing & swimming sites
 Avoid contamination of water with the feces/urine of man
 Latrine construction and sanitary disposal of feces and urine
 Destroying snail hosts
 Treatment of infected individuals
 Health education

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 1. Liver flukes
 Human liver flukes are members of two families, the
Opisthorchiidae and the Fasciolidae, distinguished by
differences in life cycle and pathogenesis.
 In human Opisthorchiidae there are three major species:
 Clonorchis sinensis in East Asia,
 Opisthorchis viverrini in Southeast Asia, and
 Opisthorchis felineus in countries of the former Soviet Union
 In the Fasciolidae the species are:
 Fasciola hepatica, which has a worldwide distribution, and

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Fasciola gigantica in South Asia, Southeast Asia, and Africa.
 Liver flukes
 Opisthorchiidae:
 The three major Opisthorchiidae species have similar life
cycles and pathogenic processes.
 Differentiation among species is usually based on adult
fluke morphology or geographic distribution, as differences
in egg morphologies are small.

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 a) Clonochis sinensis
 It is also called the Chinese liver fluke.
 Endemic in Asia including China, Korea, Taiwan and Vietnam.
 The primary intermediate host is a snail and the secondary
intermediate host is a crap (a fish).
 Dogs and cats are reservoirs.
 Morphology:
 Adult: boat shaped with smooth cuticle
 Oral sucker larger than ventral sucker
 Simple un-branched caeca

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 Clonorchis sinensi

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 Clonorchis sinensi
 Eggs:
 Small operculated eggs.
 Size 27 to 35 µm by 11 to 20 µm.
 The operculum, at the smaller end of the egg, is convex
and rests on a visible "shoulder."
 At the opposite (larger, abopercular) end, a small knob or
hook-like protrusion is often visible.
 The miracidium is visible inside the egg.

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Life Cycle of Clonorchis sinensi

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Pathology of C. sinensis/ O. Felinus/viverni
 There is consensus that the biologic and pathologic
characteristics of Opisthorchis and Clonorchis are the same.
 The pathologic changes seen in the liver and biliary system
in clonorchiasis and opisthorchiasis are believed to be the
result of mechanical injury by the suckers of the flukes and
host interactions with their secreted metabolic products.
 The worm causes irritation of the bile ducts which become
dilated and deviated.
 The liver may enlarge, become necrotic and tender and its
function may be impaired.
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 Path...
 Modest infections results in indigestion, epigastric
discomfort, weakness and loss of weight.
 Heavier infections produce anemia, liver enlargement, slight

jaundice, edema, ascites and diarrhea.

Laboratory Diagnosis
 Eggs in feces
 Eggs in aspirates of duodenal fluid

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 Prevention and control

 Avoid eating raw fish

 Sanitary disposal of feces and not using feces as a night soil
 Destroy the snails
 Inspection of fish
 Treating infected individuals and giving health education

51
 Fasciola
 Among the Fasciolidae there are two human flukes:
 Fasciola hepatica, the most common and widely
distributed, and
 Fasciola gigantica, a fluke of much more focal
distribution.
 Both have similar life cycles and produce similar human
disease, but F. gigantica can be recognized by its larger
adult and egg sizes.
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 Fasciola hepatica

 It is also called as sheep liver fluke

 Distribution : cosmopolitan (esp. In cattle and sheep raising
countries, including the highlands of Ethiopia
 Morphology:
 Adult: fleshy, flat, leaflike
 Cone shaped prominent two ”shoulders”

 Genital pore anterior to the ventral sucker

 Highly branched testes

 Branched and fan-shaped ovary

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 Fasciola hepatica
 Eggs:
 Oval with rounded poles
 Have a small, barely distinct operculum.
 The operculum can be opened, for example when a
slight pressure is applied to the cover-slip.
 Have a thin shell which is slightly thicker at the
abopercular end.
 Passed unembryonated.
 Size range: 120 to 150 µm by 63 to 90 µm.
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Life cycle of Fasciola hepatica

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 Pathogencity
 Light infections are usually asymptomatic
 In heavy infection:
 Local irritaion during migration of the young worms to the
liver
 Fever, sweating and abdominal pain
 Obstructive jaundice
 Acute epigastric pain and abdominal tenderness
 Persistent diarrhoea
56  Inflammation of the bile duct
 Fasciola hepatica in the bile duct

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 Laboratory diagnosis

 Eggs in the feces in chronic infection

 Eggs in aspirates and in bile if eggs are absent in feces
 Serological diagnosis by testing serum for antibodies
 Especially In the early stages of infection when the
immature flukes are migrating through the liver and
causing serious symptoms but before egg production.

58
 Laboratory diagnosis
 False fascioliasis: due to ingestion of animal liver containing
Fasciola egg, with the passage of eggs in stool.
 This may be ruledout by keeping the patient on a liver
free diet for three days or more.
 If eggs continue to be passed in Fasciolopsis-free areas,
the infection is probably genuine (True fascioliasis).

59
 Prevention and control
 Avoid eating uncooked water plants
 Treating infected animals
 Destroying snail hosts
 Sanitary disposal of feces
 Treating infected individuals and giving health education

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
Fasciola gigantica
The giant liver fluke
 Morphology similar to F. Hepatica
 Difference:
Features F. Gigantica F. Hepatica
Size 6x1.5cm 3x1cm
Anterior cone Small Large
Lateral Parallel Converging
margins
Shoulders Less prominent More prominent
Suckers Oral smaller than Equal
ventral
Snail host Lymnaea cailliaudi Lymnaea
truncatula
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 2. Intestinal flukes
 Fasciolopsis buski
 Heterophyes heterophyes
 Metagonimus yokogawi

62
 Fasciolopsis buski

 Also called the giant intestinal fluke

 Distribution: Thailand, Taiwan, Vietnam, Indonesia
 Morphology:
 Adult: large, fleshy flat worm
 Has no cephalic cone and shoulder
 Oral sucker is smaller than the ventral sucker
 Testes highly branched

63
 Fasciolopsis buski
 Adult fluke of Fasciolopsis buski:
 The adult flukes range in size: 20 to 75 mm by 8 to 20
mm.

64
 Fasciolopsis buski
 Eggs:
 Practically indistinguishable from those of Fasciola
hepatica.
 The eggs are ellipsoidal, with a thin shell, and a usually
small, indistinct operculum.
 The operculum is open.
 Eggs range in size: 130 to 159 mm by 78 to 98 mm.

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Life cycle of Fasciolopsis buski

66
 Pathology

 Diarrhea
 Ulceration and inflammation of the intestine
 Malabsorption

Laboratory Diagnosis
 Eggs in feces
 Adult worms in the feces (occasional)

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 Prevention and control
 Avoid eating uncooked water plants
 Latrine construction
 Avoid use of human feces as fertilizers
 Destroy snail and their habitat
 Treating infected individuals and giving health education

68
Heterophyes heterophyes
 Description of the Organism
 H. heterophyes is a minute trematode
 The adult worm measures 1-1.7mm in length X 0.3-0.4mm in
width
 The adult flukes reside in the intestine
 They secret eggs that are passed in human feces.
 Mammalian and avian hosts acquire by ingesting raw or
undercooked fish
 Reservoir of infection are dogs, cats foxes and some birds
 Life Cycle
 The eggs are ingested by the intermediate snail host
 Hatch to miracidia
 Develop into sporocysts and then rediae
 This latter stage produces cercariae
 Which encyst in various fish and develop into
metacercariae
Life cycle of Heterophyes heterophyes

71
Egg and larval developmental stages other tissue flukes

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 Het…
Pathogenesis
 Heterphyid flukes cause a mild inflammatory reaction
with some necrosis
 The lesions contained lymphocytes, plasma cells and
eosinophils with erosions, goblet cell depletion and
edema
 The eggs may gain access to the bloodstream and
cause disseminated disease
Epidemiology

 Heterophyid infections are found worldwide

 H. heterophyes found in Egypt, Korea, China, Taiwan,
Africa, Japan, Philippines and the Mediterranean
 Het…
Clinical Features
 The majority of infections are mild and asymptomatic
 Heavier infections possibly causing chronic diarrhea,
abdominal discomfort, nausea and malaise
 Occassionally appendicitis
 Eggs can be found in the heart , brain, spinal cord, liver,
lungs and spleen
 Lesion in the myocardium led to heart failure
 Brain involvement cause seizures
 Het…
Laboratory Diagnosis
 Stool microscopy remains the cornerstone of diagnosis
 It is difficult to distinguish the small, operculated ova of the
different heterophyid from each other and
 also from Chlonorchis sinensis and Opistochis spp.

Treatment
Praziquantel is the first-line drug for heterophyid
infections-20mg/kg

Other drugs, niclosamide and piperazine

 Het..
 Prevention and Control
 Heterophyid infections can be prevented by avoiding the
ingestion of raw or undercooked fish
 Metagonimus yokogawai
 Adult fluke:
 These minute intestinal flukes (1 mm to 2.5 mm by 0.4 mm to
0.75 mm) resemble Heterophyes heterophyes.
 An important distinctive feature is the position of the ventral
sucker, which is to the side of the midline with its axis in a
diagonal line.

77
Life cycle of Metagonumus yokogawai

78
Other tissue flukes and their eggs

79
 3. Lung flukes
 Paragonimus westermani:
 It is also called the lung fluke.
 It is endemic to the Far East, but other species of
Paragonimus are found elsewhere.
 P. heterotremus, P. miyazakii, P. uterobilateralis, P.
mexicanus.
 The first host is a snail, and the second host is a crab.
 Domestic and wild animals are reservoirs for Paragonimus
westermani.

 Morphology:
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 Paragonimus westermani

Adult: reddish brown and resembles one half of a pea,
testes are side by side
 Integument covered with toothed spines

 Eggs:
 The average size is 85 µm by 53 µm (range: 68 to 118 µm
by 39 to 67 µm).
 Yellow-brown, ovoidal or elongate, with a thick shell, and
often asymmetrical with one end slightly flattened.
 At the large end, the operculum is clearly visible. The
opposite (abopercular) end is thickened.
 The eggs of P. westermani are excreted unembryonated.

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Life cycle of Paragonimus westermani

82
 Pathology
 Causes paragonimiasis or endemic haemoptysis
 Major symptoms are fever, chronic coughing, haemoptysis,
diarrhoea and enlargement of liver

83
 Laboratory diagnosis
 Eggs in sputum
 The sputum is usually bloody, mucoid and rusty brown
 Eggs in aspirates of pleural fluid and occasionally in feces

84
 Prevention and control
 Avoid eating raw or uncooked crabs and crayfish
 Avoid contamination of water with sputum or feces
 Destroy snails and their habitat
 Inspecting crabs and crayfish for metacercaria
 Treating infected individuals and giving health education

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