PARASITOLOGY

Topic: Introduction to Trematodes and Liver Flukes

References: Old Trans + Belizario

INTRODUCTION TO TREMATODES General Life Cycle

 Common name: Flukes 1. Adult flukes produce eggs, which are shed into the
o Derived from the word ‘floc’, meaning ‘flatfish’ environment/water
 All require 2 intermediate hosts (IH) 2. Egg releases L1 (miracidium) and is taken up by the 1st intermediate
EXCEPT: Schistosomes  require only 1 intermediate host host (snail)
3. Intramolluscan development: L1  L2  L3  L4: becomes free-
o 1st IH: Snail swimming cercaria
o 2nd IH: Variable: fish, another snail, or freshwater plants 4. Free-swimming cercaria infects 2nd intermediate host
(It depends on the species) (freshwater/brackish fish, crabs, crayfish)
5. Cercaria encyst to become metacercaria
General Features 6. Humans become infected by ingesting the 2nd intermediate host
 Flat and unsegmented (Leaf-like) containing metacercaria
o With the exception of schistosomes  they are a little
cylindrical NOTE:
 Characterized by the presence of holes, which are strong muscular o In Schistosomes, the 1st intermediate host produces a fork-
structures, for attachment and nutrition: tailed cercaria that penetrates intact human skin
o Oral sucker (swimmer’s itch/farmer’s itch)
o Ventral sucker (Acetabulum)  for attachment
o Genital sucker (Gonotyl)  seen only in heterophyids Intramolluscan Metamorphosis Pattern
 With integument  SRC
 Shape: leaf-like (broad, spatulate, lanceolate)  S  R1  R2  C
 All are Monoecious (hermaphroditic)  R1  R2  C
o With the exception of schistosomes  they are diecious  S1  S2  C
(separate sexes)
 Oviparous Morphologic Features
Morphologic features:  Adult digenetic trematodes are usually flat, elongated, leaf-shaped
o Operculated (embryonated or non-embryonated) worms, but they may be ovoid, conical or cylindrical depending upon
o Non-operculated (embryonated or spinous) – seen only the state of contraction
on schistosomes  They vary in size from less than 1 mm to several centimeters
 Larval Stages:  The worm is enveloped by a noncellular homogenous tegument,
o L1 – miracidium/miracidia which may be partially or completely covered with spines, tubercles,
o L2 – sporocyst(s) or ridges
o L3 – redia(e)  The tegument plays an important role in the absorption of
o L4 – cercaria(e) carbohydrates
Infective to the 2nd intermediate host EXCEPT for  The worms are attached to the host by cup-shaped muscular suckers,
schistosoma sometimes bearing spines or hooklets
L2-L4 develop inside the 1st intermediate host  An oral sucker is situated at the anterior end of the worm, while in
most species a larger ventral sucker or acetabulum is located on the
Classification According to Habitat ventral surface posterior to the oral sucker
 Liver flukes  in the biliary tract; but present with hepatic  An outer circular, middle oblique, and an inner longitudinal layer of
manifestations muscles lie beneath the tegument, while bands of the worm
o Fasciola hepatica  There is no body cavity
o Clonorchis sinensis  The intervening space between the various organs is filled with fluid
o Opisthorchis felineus and a network of connective tissue cells and fibers
o Opisthorchis viverrini  Intestinal ceca – homologous to human GIT
 Intestinal Flukes o Branched – F. hepatica
o Fasciolopsis buski o Simple (tubular) – F. buski, E. ilocanum, C. sinensis
o Echinostoma ilocanum Opisthorchis spp., Heterophyes spp.
o Heterophyes heterophyes o Simple (zigzag) – P. westermani
o Metagonimus yokogawai  Vitelline follicles – seen on the lateral margins; where the egg shell
o Haplorchis yokogawai develops
 Lung Flukes  Testes – paired
o Paragonimus westermani  Ovary – found on top of the testes
 Blood Flukes o Branched – F. hepatic, F. buski
o Schistosoma japonicum o Lobular – C. sinensis, Opisthorchis spp. P. westermani
o Schistosoma haematobium o Ovoidal – E. ilocanum
o Schistosoma mansoni o Spherical – Heterophyes spp.

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 PARASITOLOGY
Topic: Introduction to Trematodes and Liver Flukes
References: Old Trans + Belizario

Old Trans Information: o Suckers are small and are located close to each other in
INTRODUCTION TO TREMATODES the conical projection
 Non-segmented Flatworms o Two testes are highly branched occupying the second and
 Adults are equipped with an oral sucker, a ventral sucker third quarters of the body
(acetabulum) and genital sucker (gonotyl) – only seen in Heterophyes o Ovary is dendritic and situated in front of the anterior
 Hermaphroditic/Monoecious testis
 Requires intermediate host in the life cycle o Uterus is coiled and relatively short
 First intermediate host is always a Snail o Vitellaria extend to the whole lateral field of the hind body
 Second intermediate host will either be a fish, crustaceans, another o Intestinal ceca are long and highly branched, extending to
snail or fresh water plants the posterior end of the body
 Have an operculated eggs
 Fasciola gigantica
 Infective stage: Metacercaria (in the 2nd intermediate host) or
Encysted larva o The adult worm is longer, with about the same width with
Fasciola hepatica
 Properties (for Schistosomes/Blood flukes)
o Less developed shoulder
o Dioecious
o Shortened cephalic cone
o Snail as single host
o Ceca are more branched especially towards the midline of
o Non-operculated eggs
the body and the branches of the ovary are longer and
o Infective stage: Cercaria (fork-tailed)
more numerous
 They are grouped based on their habitat
o The average distance between the posterior testes and
o Schistosome – Mesenteric veins
the posterior border of the body is longer
o Paragonimus – Lung parenchyma
o Fasciola, Clonorchis, and Opsthorchis – Liver & Bile
 Egg
passages
o Fasciola hepatica egg
o Fasciolopsis, Echinostoma, and Heterophyes - Intestine
 Large, ovoidal, operculated, and yellowish to
 Mature egg containing embryo (Embryonated ova)  Miracidium
brownish in color
o Schistosomes
 It is released from the worm still immature,
o Clonorchis
containing a large unsegmented mass of
o Opisthrochis
vitelline cells
o Heterophyes
o Fasciola gigantica egg
 Immature eggs  Will embryonate in water environment
 It is slightly larger than the Fasciola hepatica
o Paragonimus
egg
o Fasciola
o Fascilopsis
Life Cycle
o Echinostoma

LIVER FLUKES
Fasciola spp.
 These large digenetic trematode species belong to family Fasciolidae
 They are parasites found in the liver and biliary passages of humans
and herbivorous mammals
o Fasciola hepatica (temperate liver fluke)
o Fasciola gigantica (tropical liver fluke)
 Causative agents of Fascioliasis

Parasite Biology
Mode of Transmission:
 Ingestion of metacercariae encysted on edible aquatic plants or by
drinking water with viable metacercariae
o Upon ingestion, the metacercaria excysts in the
duodenum or jejunum, liberating the juvenile fluke,
which, in turn, penetrates the intestinal wall to reach the
peritoneal cavity where it wanders over the viscera until
it penetrates the capsule of Glisson and enters the liver
o The parasite then burrows through the liver parenchyma, Immature eggs are discharged in the biliary ducts and passed in the stool (1) . Eggs become
feeding and growing until it finally enters the bile ducts embryonated in freshwater over ~2 weeks (2) ; embryonated eggs release miracidia (3) ,
where it becomes sexually mature in 3 to 4 months which invade a suitable snail intermediate host (4) . In the snail, the parasites undergo
o The life span of the adult worm is 9 to 13 years several developmental stages (sporocysts (4a) , rediae (4b) , and cercariae (4c) ). The
cercariae are released from the snail (5) and encyst as metacercariae on aquatic vegetation
or other substrates. Humans and other mammals become infected by ingesting
Morphology:
metacercariae-contaminated vegetation (e.g., watercress) (6) . After ingestion, the
 Fasciola hepatica metacercariae excyst in the duodenum (7) and penetrate through the intestinal wall into
o Large, broad and flat body the peritoneal cavity. The immature flukes then migrate through the liver parenchyma into
o Cephalic cone – has a marked widening at the base of the biliary ducts, where they mature into adult flukes and produce eggs (8) . In humans,
cone maturation from metacercariae into adult flukes usually takes about 3–4 months;
development of F. gigantica may take somewhat longer than F. hepatica.

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 PARASITOLOGY
Topic: Introduction to Trematodes and Liver Flukes
References: Old Trans + Belizario

Based on Belizario: o The severity of the injury depends on the number of

 The adult worm lives in the biliary passages of the liver metacercariae ingested by the host
 Unembryonated eggs are carried by the bile through the sphincter of o Though this invasive phase can be asymptomatic,
Oddi into the intestine and subsequently voided with the feces patients have been known to experience dyspepsia,
 The eggs mature in water within 9 to 15 days optimally at 15 to 25°C, fever, and right upper quadrant abdominal pain
forming a viable miracidium that escapes through the operculum of o Sudden onset of high fever, hepatomegaly, & marked
the eggshell to seek out and infect the first intermediate host, a snail eosinophilia form a triad of diagnostic significance
belonging to family Lymnaeidae  Chronic or Latent Phase
o Coincides with the persistence of Fasciola worms in the
Intermediate Host: (Snails) biliary ducts
 Snail hosts for F. hepatica are amphibious which are usually found o Asymptomatic
living on mud. Snail species include: o Corresponds to the period when the parasite has already
o Lymnaea truncatula (Europe and North Asia) reached the bile ducts
o L. bulmoides (North America) o The adult worm causes obstruction and stimulates
o L. tomentosa (Australia) inflammation in the biliary epithelium which
o Snails from family Planorbidae also act as an subsequently causes fibrosis
intermediate host of F. hepatica sporadically o The thickened fibrous ducts, in turn, cause less bile to be
 On the other hand, the first intermediate hosts for F. gigantica passed out building up back pressure
are aquatic snails, living in slow-moving bodies of water, which o In heavy infections, atrophy of the liver parenchyma and
include: concomitant periductal cirrhosis ensue
o L. auricularia (Asia) o The wall of the bile duct may be eroded allowing the
o L. acuminata (Indian Subcontinent) worms to re-enter the liver parenchyma and cause large
o L. natalensis (Africa) abscesses to develop
 In the Philippines, the snail hosts of Fasciola spp. are: o Other complications include obstructive jaundice,
o L. philippinensis hemobilia, & biliary cirrhosis
o L. auricularia rubiginosa o Associated lithiasis of the bile ducts or gallbladder is also
common, as the eggs or fragments of dead parasites can
 Inside the snail, the miracidium develops into a sporocyst, followed form nuclei for calculi
by one or two generations of rediae which produce cercariae o Another rare complication of fascioliasis is acute
pancreatitis
Cercariae leave the snail about 5 to 6 weeks after the miracidium o In some cases, this phase is only diagnosed during a
entered surgery
 During the migration from the intestine to the liver, the parasite may
 After escaping from the snail host, usually at night, the cercaria swims wander or be carried hematogenously (after it had penetrated a
in water, detaches its tail, and encysts in surfaces of aquatic plants blood vessel) to ectopic sites such as the lungs, subcutaneous tissue,
forming a metacercaria the brain, and the orbit where abscesses or fibrotic lesions may also
 The aquatic plants serve as the 2nd intermediate hosts of the parasite result
These include:  Another unusual form of fascioliasis can occur after ingestion of raw
o Ipomea obscura (morning glory or kangkong) Fasciola-infected liver. Flukes surviving mastication attach to the
o Nasturtium officinale (watercress) posterior pharynx, causing hemorrhagic nasopharyngitis and
dysphagia, known as halzoun in Lebanon and marrara in Sudan
 Cercariae can also encyst freely in water  Spurious or False fascioliasis – Eggs may also be transiently present
 The metacercaria is the infective stage to the definitive hosts in the stool after the ingestion of poorly cooked liver from the
infected animals
In the presence of sufficient moisture, the metacercariae will
remain alive for many weeks, depending on the temperature Diagnosis
 Identification of eggs in stool, duodenal contents or bile
They survive longer at a temperature below 20°C; higher
temperatures and desiccation will destroy the metacercariae in a  Recovery of adult worms during surgical explorations
short time  Eggs are not found in feces until 3-4 months
 Immunologic methods are recommended for the detection of
Pathogenesis & Clinical Manifestations coproantigens – seen in the stool
o ELISA, Western blot
2 Clinical stages that are recognized in Human Fascioliasis:
 Radiologic examination:
 Acute or Invasive Phase
o CT scan  Hepatic phase of the disease
o Coincides with larval migration and worm maturation in
 Multiple confluent, hypodense nodule and
the hepatic tissue
tunnel-like branching hypodense tracts
o Corresponds to the migration of the juvenile parasite
o Sonography  Biliary phase of the disease
from intestine to the liver where it burrows into the liver
 Small clustered hypoechoic lesions with
parenchyma
poorly defined contours and hypoechoic
o The damage caused by the parasite penetrating through
nodular lesions
the intestinal wall and migrating towards the liver is not
 Oval shaped, leaf-like, or snail-like echogenic
significant
structures with no acoustic shadowing in the
o However, traumatic and necrotic lesions are produced
gall bladder or common bile duct
when the parasite burrows through the liver parenchyma
 Endoscopic retrograde cholangiopancreatography (ERCP)  Biliary phase also

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 PARASITOLOGY
Topic: Introduction to Trematodes and Liver Flukes
References: Old Trans + Belizario

Treatment Life Cycle

 Triclabendazole (DOC)
o Single 10 mg/kg oral dose following food intake
o Heavy infection: Two doses of 10 mg/kg spaced by 12 hrs.
 Bithionol
o 30-50 mg/kg body weight on alternate days to complete
10 to 15 doses

Epidemiology
 Worldwide distribution
 In the Philippines, the dominant species affecting cattle and water
buffaloes is F. gigantica
 Examination of cows, carabaos, and horses in South Cotabato in 2007
showed a fascoliasis prevalence of 89.5%
 Human fascioliasis is typically sporadic
 Fascioliasis due to F. gigantica is typical of rural areas of Vietnam
 No human fascioliasis documented in the Philippines
 France is considered an important human endemic area

Prevention & Control

Clonorchis sinensis eggs are discharged in the biliary ducts and in the stool in an
 Thorough washing or cooking of vegetables, and boiling of water in embryonated state (1) . Eggs are ingested by a suitable snail intermediate host (2) . Eggs
areas where the infection is endemic release miracidia (2a) , which go through several developmental stages (sporocysts (2b) ,
 Elimination of the snail intermediate host rediae (2c) , and cercariae (2d) ). The cercariae are released from the snail and, after a short
 Killing the parasite in the reservoir host by chemotherapy period of free-swimming time in water, they come in contact and penetrate the flesh of
freshwater fish, where they encyst as metacercariae (3) . Infection of humans occurs by
 Vaccination of animals with defined Fasciola antigens
ingestion of undercooked, salted, pickled, or smoked freshwater fish (4) . After ingestion,
the metacercariae excyst in the duodenum (5) and ascend the biliary tract through the
Clonorchis sinensis, Opisthorchis felineus, Opisthorchis viverrini ampulla of Vater (6) . Maturation takes approximately one month. The adult flukes
 Family Opisthorchiidae (measuring 10 to 25 mm by 3 to 5 mm) reside in small and medium sized biliary ducts.
 They are parasites of the bile duct and gallbladder of human and fish-
eating mammals
 MOT: Ingestion of metacercaria in raw and undercooked fish
 Egg is mature Embryonated  Miracidium

Parasite Biology
Morphology:

Clonorchis Opisthorchis Opisthorchis

sinensis fileneus viverrini
Shape Leaf-like, with transparent tegument
10-25 mm long
Size 8-12 mm long and 1.5-3 mm wide
and 3-5 mm wide
Location of
Found in the middle third of the body at the level of the uterus
vitellaria
Two large, highly
branched testes They have lobate testes, which are
Arrangement of arranged in arranged obliquely. Opisthorchis viverrini
the Testes tandem in the testes however, are positioned close to
posterior half of each other, are more deeply lobulated
the body
Yellowish brown, ovoid. There is a distinctly convex operculum
that fits into the thickened rim of the eggshell, and a small
Egg
protuberance at the abopercular end. Inside the egg is a well-
developed miracidium that has asymmetrical features The adult flukes deposit fully developed eggs that are passed in the feces(1). After ingestion
Parafossarulus, by a suitable snail (first intermediate host) (2), the eggs release miracidia (2a), which
Bulinus, undergo in the snail several developmental stages (sporocysts (2b), rediae (2c),
1st IH (Genus) Semisulcospira, Bithynia cercariae (2d)). Cercariae are released from the snail (3) and penetrate freshwater fish
Alocinma, Thiara, (second intermediate host), encysting as metacercariae in the muscles or under the
Melanoides scales (4). The mammalian definitive host (cats, dogs, and various fish-eating mammals
2nd IH (Family) Cyprinidae Cyprinidae and Cobitidae including humans) become infected by ingesting undercooked fish containing
metacercariae. After ingestion, the metacercariae excyst in the duodenum (5) and ascend
through the ampulla of Vater into the biliary ducts, where they attach and develop into
adults, which lay eggs after 3 to 4 weeks (6). The adult flukes (O. viverrini: 5 mm to 10 mm
by 1 mm to 2 mm; O. felineus: 7 mm to 12 mm by 2 mm to 3 mm) reside in the biliary and
pancreatic ducts of the mammalian host, where they attach to the mucosa

Opisthorchis viverrini (Southeast Asian liver fluke)

Opisthorchis felineus (Cat liver fluke)

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 PARASITOLOGY
Topic: Introduction to Trematodes and Liver Flukes
References: Old Trans + Belizario

Based on Belizario: Correlation of Clonorchiasis & Opisthorchiasis with Cholangiocarcinoma:

 MOT: Ingestion of the metacercaria of the parasite present in  Chronic irritation and inflammation caused by the fluke can result in
infected raw or undercooked fish hyperplasia and adenomatous changes of the biliary epithelium
Metacercariae from decomposing fish could potentially be  Hyperplastic cells are vulnerable to carcinogens that can easily induce
ingested by drinking contaminated water DNA damage during active cell proliferation
 Liver fluke infection results in endogenous formation of N-nitroso
 The metacercaria excysts in the duodenum, and the young fluke compounds in the area around the bile ducts, which in turn may lead
moves through the ampulla of Vater to the common bile duct, and to neoplastic transformation
then to the distal biliary capillaries where it matures into an adult  Furthermore, macrophages and other inflammatory cells, activated
worm by parasite-specific T-cells, synthesize nitric oxide, which is a
 The adult fluke attaches itself to the mucosa of the bile duct by using potential carcinogen
its suckers, and by embedding itself in sticky mucus without causing  Mucin-producing activity is also a frequent feature reflecting the
permanent ulceration of the epithelial lining neoplastic transformation of goblet cells in the bile duct lining
 The flukes may also be found in the pancreatic duct and the
gallbladder. Diagnosis
 The worm feeds on tissue fluids, red blood cells, and mucus  Detection of parasite egg in the stool
 The egg is fully mature when it is released from the worm  Cholangiography  Saccular dilation of the intrahepatic bile ducts,
It passes with the bile to the intestine, and escapes into the and rapid ductal tapering toward the periphery (referred to as
environment with the feces “arrowhead sign”)
 ELISA
 The miracidium hatches only after the egg is ingested by the 1st  EIA
intermediate host  PCR
 Upon entry into the snail host, the miracidium transforms into a
sporocyst, which subsequently produces rediae Treatment
 Each redia, in turn, produces cercariae that are released into the  Praziquantel
surrounding water o 25 mg/kg, 3x a day for 2 days
 Upon contact with the 2nd intermediate host, a fresh water fish, the o 60 mg/kg in 3 doses for 1 day
cercaria attaches itself to the host epithelium with its suckers, and  Albendaole
encysts as metacercaria under a scale or in a muscle o Seven days treatment course
 The metacercaria is the infective stage to the definitive host  Albendazole + Praziquantel
o More effective than Praziquantel alone
Pathogenesis & Clinical Manifestation o Treating coinfection with Ascaris, Trichuris, Hookworms
 In clonorchiasis, metacercariae reaching the biliary system mature
and provoke pathological changes as a result of local trauma and Epidemiology
irritation  Transmission of clonorchiasis and opisthorchiasis is by consumption
 Although the morphologic features vary with duration and severity of of raw, undercooked, salted, dried, or pickled freshwater fish that
the infection, they are sufficiently distinctive and characteristic to harbor encysted metacercariae
allow classification into phases:  Reservoir hosts are fish-eating mammals such as dogs, cats, and rats
o Desquamation of epithelial cells  The distribution of liver fluke disease is related, in part, to the
o Hyperplasia and desquamation of epithelial cells distribution of intermediate hosts and animal reservoir hosts
o Hyperplasia, desquamation of epithelial cells, and  Traditional consumption of improperly cooked fish, and
adenomatous tissue formation indiscriminate defecation habits among rural inhabitants are
o Marked proliferation of the periductal connective tissue significant factors that determine the high prevalence of liver fluke
with scattered abortive acini of epithelial cells, and infection in an area
fibrosis of the wall of the biliary duct
Prevention & Control
Clonorchis sinensis Opisthorchis fileneus Opisthorchis viverrini
Asymptomatic
 Stool examination and treatment of positive cases with praziquantel
Fever and hepatitis- in order to eliminate human host reservoir
Light Infection (or diarrhea, abdominal Asymptomatic
like symptoms
pain)  Health education for the promotion of cooked fish consumption in
Fever, diarrhea, loss of Flatulence, fatigue,
appetite, rash, edema, dyspepsia, RUQ RUQ abdominal pain,
order to prevent infection
Moderate
night blindness, swollen abdominal pain, nausea, &  Proper human waste disposal in order to interrupt transmission
Infection
abdomen, & enlargement anorexia, & mild emesis
of the liver hepatomegaly
Acute pain in the RUQ
Liver malfunction: Biliary tract References:
 Calculi Obstructive jaundice obstruction  Medical Parasitology in the Philippines by
 Acute suppurative Cirrhosis Inflammation Belizario & de Leon (3rd Ed.)
Chronic stage/
cholangitis Cholangitis Fibrosis
Severe
 Recurrent pyogenic Acalculous Liver abscess
 Lecture Notes
Infections
cholangitis cholecystitis Pancreatitis
 Cholecystitis Bile peritonitis Suppurative
 Hepatitis cholangitis
 Pancreatitis
Hepatocellular carcinoma
Sequelae Cholangiocarcinoma
Cholangiocarcinoma

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