Introduction to tromatodes

Phylum Platyhelminthes
Class Trematoda
Order Digenea
Morphology
Adult worm
Flattened (flatworm) and leaf like
Sucker: oral & ventral (fluke)
Body wall: musculo-tegumental sac
Parenchyma (structure between body wall and
internal organs): connective tissue fibers, cells
and space between them
Digestive tract: not intact
i.e. no anal opening, caecum
Reproductive system: hermaphrodite
(monoecious) exception of schistosome
Muscular system
Nervous system
Excretory system
Egg
Size divergent
Ovoid
Operculum (exception of that of schistosome)
Content: ovum , vitelline cells, or miracidium
Egg of Clonorchis sinensis
Egg of Paragonimus westermani
Egg of Fasciolopsis buski
S. japonicum S. Mansoni S. haematobium
Schistosome egg
Features Reflecting
Adaptation to Parasitism
Organs of attachment highly developed
Retardation of digestive system
Highly developed reproductive system
Life Cycle
Complex
Alteration of generation
sexual generation and asexual generation alter in
the life cycle of parasite
Asexual multiplication in larval stage in snail host
Multiple hosts transfer and having reservoir hosts
in majority
Water environment is essential
Important Species
Liver fluke: Clonorchis sinensis
Intestinal fluke: Fasciolopsis buski
Lung fluke: Paragonimous westermani
P. skrjabini
Blood fluke: Schistosoma spp.
The Liver Fluke

Clonorchis sinensis

Introduction
Parasite of biliary passage
Cause clonorchiasis
A common trematode in Far East
First report
1874 oversea Chinese in India
Morphology
Adult worm
Size & Shape
like the seed of sunflower
Sucker: oral = ventral
2 dendritic testes lie in tandem to each other in
the posterior region (clonorchis)
Adults of Clonorchis sinensis
Cross section of Clonorchis sinensis adult in the hepatic bile duct
Egg
Size: smallest
Shape: just like sesame
Color: yellowish brown
Operculum distinct: shoulder, knob
Content: miracidium
Clonorchis sinensis egg. These are small operculated
eggs. Size 27 to 35 m by 11 to 20 m. 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 hooklike protrusion is often visible
(as is the case here). The miracidium is visible inside the
egg.
Egg of Clonorchis sinensis
Life cycle of Clonorchis sinensis
Life Cycle
A model pattern of trematode
Main points
Definitive host: human being
Reservoir host: dog, cat, etc.
Residing: hepatic bile duct
Discharge of eggs with feces
Hatching in the host small intestine
2 intermediate host
I: snails, such as Bithynia,Parafossarulus
II: freshwater fishes, such as Cyprinus
2 generation of asexual proliferation
Infective stage: metacercaria in fish
Infective route: oral consumption
Pathogenesis
Due to adult worm
Mechanism
Mechanical: sucker
Chemical: excretions, secretions, metabolite
Biological: nutrition deprivation
Pathological process
Inflammation Proliferation
ThickeningOcclusion
Extensive involvementFibrosis of the liver
Clinical Manifestations
Acute stage: allergic reaction
Chronic stage: functional impairment of
liver (Cholangitis, Cholecystitis, Bile stone,
Jaundice, etc)
Advanced stage: portal cirrhosis &
malignancy
Laboratory Diagnosis
Etiological
Examination of egg in feces by sedimentation
method
Duodenal aspiration
Immunological
ELISA to detect antiboby or antigen
Epidemiology
Distribution
Far East
(China, South Korea, Japan, etc.)
24 provinces in China
(Guangdon: 5 million infected etc.)
Endemic Factors
Source of infection: mainly wild carnivores
I,II intermediate host in the same water-
field
Mode of fish breeding
Dinning habit & Customs
Principle of Control
Cure patients & carrier
praziquantel:25mg/kg, tid, 2 days
Control reservoir host
Carry out scientific fish-breeding
Hygienic education
not eating raw or undercooked fishes
Paragonimus westermani

Paragonimus skrjabini
(Paragonimus szechuanensis)

The Lung Fluke
Genus paragonimus
Zoonotic parasite (cause zoonosis)
Animal infection> human infection
2 major species in China
Introduction
Pathogen of lung disease
Endemic hemoptysis
Favorite lodging site: lung
Ectopic site: brain, abdomen, muscle, etc.
Morphology
Adult worm
Body thick (a half piece of a bean grain)
Tegument: spinous
Sucker: oral = ventral
Parallel arrangement of reproductive organ
lobular testes (posterior)
lobular ovary & uterus (anterior)
Cross section of lung containing adult Paragonimus westermani.
Egg
Median size, ovoid (water pot)
Golden yellow
Distinctive & wide operculum
Contain 1 germ cell & several yolk cells
Egg of Paragonimus westermani.
Life cycle of Paragonimus westermani.
Crab or
crayfish
Life cycle
Definitive host: human being
Reservoir host: carnivorous animals
Habitation: lung & ectopic site
Intermediate host:
I: Melania snails
II: stream crabs, crayfish
Infective stage: metacercaria
Infective mode: oral route, may via
paratenic host (swine)
Migration & Preadult wondering
Ectopic parasitism: cerebral, abdominal,etc.
Eggs discharged with sputum & feces
3 generation of asexual multiplication
Pathogenesis
Stage take responsibility: adult & preadult
Pathological processes
Abscess stage()
Cystic stage()
Scar formation stage()
4 clinical types
Thoracic (pulmonary type):chest pain,
coughing, blood-tinged sputum(hemoptysis)
Abdominal (hepatic type):hepatomegaly
Cranial type: dizzy, headache, epilepsy
Musculocutaneous type: migratable subskin
nodule
Laboratory diagnosis
Disease history + physical examination
Etiological diagnosis
eggs in sputum or feces by sedimentation
Immunological diagnosis
for ectopic infections
Epidemiology
Global
main continent except Europe
China
23 provinces
Paragonimus westermani infection occurs in Asia
(especially in China (Taiwan), Corea, India, Japan,
Laos, Philippines, Sri Lanka, Thailand, Viet-Nam),
Central-West Africa, South America (Ecuador, Peru
Venezuela).
Principle of control
Treat patient: praziquantel
Hygienic education
Social construction, economic refinement
The Ginger Fluke

Fasciolopsis buski

Intestinal fluke

Morphology
Adult worm
Like a ginger piece
Big muscular trematode
Have strong suckersventral >> oral
Adult fluke of Fasciolopsis buski The adult flukes
range in size: 20 to 75 mm by 8 to 20 mm
Fasciolopsis buskii adult worm
Egg
Biggest
Ovoid
Minute operculum
Yellowish
Germ cell inclusions
F.buski eggs are released in feces unembryonated.
The operculated eggs are oval, brown and measure 130-150 by
78-100 um
Life cycle of Fascilopsis buski
Life Cycle
Definitive host: human being
Reservoir host: swine, etc.
Intermediate host: Planorbis snails
Aquatic plant vectors: caltrops, water
chestnut, etc.
Habitation: small intestine
Infective stage: metacercaria
Infective route: oral
Developmental stages: as Paragonimus
3 generation of asexual proliferation
Pathogenesis Factors
Traumatic (suckers)
Obstructive (due large size)
Toxic (excretion, secretion, metabolite)
Clinical Manifestation
Abdominal pain
Acute intestinal obstruction
Anemia
Generalized edema
Laboratory Diagnosis
Examination of egg in feces by
sedimentation method
Epidemiology
Aquatic plant raising districts
Fasciolopsis buski: is endemic in China
(Taiwan), South-East Asia,
Malaysia and India.
Principle of Control
Drug for treatment: praziquantel
Water & nightsoil control; Scientific swine
raising
Hygienic education
Introduction
6 species of human schistosomes
Schistosoma japonicum
S. mansoni
S. haematobium
S. intercalatum
S. mekongi
S. malayi
Schistosoma japonicum

Distribution and Epidemic Situation
Worldwide
200 million of population infected in 74
countries
(S.m. 55; S.h. 55; S.j. 4;
S.i. 10; S.me. 2; S.ma. 1)
China
11 million in 12 provinces 0.7 million in 8
provinces
50 years
Before control After control (1996)
Regional distribution of S. japonicum infection in China
Morphology
Difference from other trematodes
Dioecious adults
Non-opeculate egg
Bifurcated (forked) cercaria invades the final
host by skin
Adults parasitize blood vessels
Adult
Male (15 mm length) < female (22 mm)
Oral sucker < ventral sucker
2 paralleled guts form a blind caecum in the
posterior ends
7 testes in male and single ovary with a tubule
uterus in female
Gynecophoric canal (male) in which female
repose




Egg
Ovoid and non-opeculate
74~106 m 55~80 m
Contains one miracidium
Bear a minute lateral knob.
Miracidium
Cercaria
S. japonicum S. Mansoni S. haematobium
Schistosome egg
Schistosome miracidium


Schistosome cercaria




Life Cycle
Eggs discharged fresh water (hatch) miracidia
penetrate oncomelania(I.H.)mother sporocysts
(multiplication) daughter sporocysts (multiplication)
cercariae (infective form) skin penetration of D.H.
schistosomulum right heart lungs left heart
systemic circulation portal system pairing and
sexual maturation mesenteric veins lay eggs eggs
develop and live in tissue for 21 days( 23% in liver tissue,
60% in intestinal tissue, 17% discharged)
Cercarial dermatisis due to avian schistosome
Main Points of Life Cycle
Residing site: mesenteric vein
I.H.(Only one): Oncomelania hupensis
No metacercaria and redia stage
Two generation of sporocyst
Infective stage: cercaria
Route of infection: skin penetration










Adult of Schistosome in mesenteric veins of hamster


Onchomelania hupensis




Skin penetration of cercaria first
appearance of eggs: 30~35 days
Life spans in human: 4~5 years, longest: 35
years

Tissue egg
The egg which can develop and live in tissue
Significance of tissue egg
Major pathogenic stage, inflammation and
granuloma around the egg
Diagnosis and evaluation of therapeutic
efficacy
Immunity
Concomitant immunity
Host carrying an initial infection of adult
schistosomes shows the protection to a cercarial
challenge infection (and this
protective immunity will disappear with
eradication of schistosomes in the host
Immuno-evasion: Its an ability by which
the schistosome adult can evade the host
immune response. The possible mechanism
of evasion.
Acquire host antigen on it surface
Host-like antigen produced by parasite
Changing of tegument very quickly
Parasite may inactivate or down-regulate
immune effectors
Pathogenesis
Schistosomiasis at each stage of the life
cycle in human body
Cercaria (skin-penetration)
Dermatitis
Schistosomula (migration)
Larva migrans
Adult: (immunocomplex)
Immuno-nephropathy
Tissue egg: principal pathogenic stage
Miracidium within eggSEASensitization of T Cell
Th1IL-2, INF-, TNF activate macrophage, induce
cell-mediated immunity
Th2IL-4, IL-5 stimulate IgE production or eosinophilia
inflammation and granuloma fibrosis portal hypertension
intestinal polyp
Clinical Form
Acute schistosomiasis
Fever, diarrhea, abdominal pain, enlargement of liver or
spleen
Chronic schistosomiasis
asymptomatic or diarrhea, abdominal pain, enlargement
of liver or spleen
Advanced schistosomiasis
Ascites; splenomegaly;collateral circulation; dwarfism;
Ectopic lesion: encephalitis; focal epilepsy








Advanced schistosomiasis patient
with portal hypertension and ascites
A patient with S. j has marked ascites, splenomegaly,
umbilical hernia and distended superficial abdominal veins.
Diagnosis
Parasitological diagnosis (etiological,
definitive diagnosis)
Demonstrating eggs by stool examination
Stool examination after concentration
(sedimentation)
*Miracidium-hatching from eggs
Rectal biopsy eggs-demonstration
Miracidium-hatching from eggs
Necessity: tissue ova;
low egg burden due to mass treatment
Possibility:
Hatch quickly (T:25; limpid water; free of
Cl
2
;light; pH=6.8-7.8)
Three tropism:limpidity, phototrophic, ascendancy
Swimming in a zigzag way
Immunodiagnosis (indirect diagnosis)
Detection of antibodies in serum, urine, saliva
by ELISA, but is impossible to distinguish
current infection from past infection.
Detection of antigens (circulation anodic and
cathodic antigen)
Combined diagnosis: including
epidemiological antecedent, symptoms and
signs, parasitological and immunological
examination.
Treatment
Praziquantel 60 mg/kg divided in 3 doses.
Factors of Transmission and
Prevention
Factors
Source of infection: patients and reservoir host
Intermediate host: Oncomelania
Contact with cercaria-infected water
Preventive measures
Detection and treatment of patients and reservoir
host
Elimination or control of oncomelania
Protection of susceptible population and
avoidance of contact with cercaria-infected water
Prevention of water contamination by human
night soil
Distinguishing of 3 major
schistosomes
(see page 54, Table 3-1)