BS

3 MT CLINICAL
Nickson Cammayo, RMT
PARASITOLOGY(lec)
TREMATODES
• The intestinal trematodes (flukes) are members of
the phylum Platyhelminthes (flatworms), are According to location/habitat:
dorsoventrally flattened, and require at least one 1. Mesenteric veins- blood flukes/schistosomes
intermediate host (a freshwater snail). Human 2. Lung parenchyma- Paragonimus (e.g.
infection occurs by ingestion of metacercariae Westermanii)
(tailless encrusted larvae) encysted on freshwater 3. Liver -Fasciola
4. Bile duct- Chlonorchis, Opistorchis
vegetation or fish.
4. Small intestines- Fasciolopsis, Echinostoma,
• Most trematodes are hermaphroditic (both ovaries
Heterophyids
and testes are contained within each adult worm).
The parasites are typically identified from eggs Types of cercarial larvae of Trematodes
shed in the feces. 1. Furcocercus cercaria- Elongated body with
• The adult worms are located in the small intestine, forked tail (e.g. Schistosoma)
where they lay eggs that may be embryonated or 2. Microcercus cercaria- Oval body with short
remain unembryonated until they are shed from the stumpy tail (e.g. Paragonimus)
body via feces. 3. Lophocercus cercaria- Cercaria is armed with
• The egg continues developing after reaching the spines and has a large fluted tail andconspicuous
water, and a ciliated, free-swimming ciliated eye spots, (e.g.Clonorchis, Metagonimus and
miracidium larva is released. The miracidium enters Heterophyes)
a snail host and develops into a redia (cylindrical 4. Pleurolophocercus cercaria- Cercaria is armed
with spines and has a pigmented eye spots with a
larvae), followed by development into tailed
long keeled tail, (e.g. Opisthorchis)
cercariae.
• The cercariae emerge from the snail and encyst as a PPT/VIDEO
metacercariae on water plants or fish. A human host Nematodes – Roundworms
ingests raw or undercooked plants Cestodes – tapeworms
(Fasciolopsisbuski) or fish (Heterophyes, Trematodes – flatworms
Metagonimusyokogawai) containing the - Class Digenea
metacercariae, which excyst in the intestinal tract, - Commonly known as Flukes
attach, and mature into adults. - Flukes is digenetic means can be able to
multiply and reproduce to both sexual and
GENERAL CHARACTERISTICS asexual cycles
(MAIN TREMATODES/FLUKES) - The worms appear flat in cross section and non-
segmented and leaf-shaped
• Other group of flatworms
• Adult worms are provided with an oral sucker and Life cycle of Trematodes
ventral sucker (acetabulum) • Humans who have adult worms
o Oral sucker surrounding the mouth, • Adult’s worm will lay eggs
anterior • The egg produce miracidium (First larva
o Ventral sucker is in the middle ventrally stage is miracidium hatches from the egg in
o Adult flukes possess one oral sucker the fresh water and enters the first
which open the digestive tract and one intermediate host, the freshwater snail)
ventral sucker for attachment • First intermediate host: Fresh water snail
• Third sucker- genital sucker/gonotyl (present • Several stages of asexual reproduction
only in heterophyids) occurring in this snail and the final larval
• All are hermaphrodite – both sexes present except stage known as Cercaria leave the snail
for Schistosoma • Hundreds of Cercaria form from each
• Requires 2 intermediate hosts to complete cycle miracidium that enters the snail
• All have operculated eggs • Dermatophytic cercariae then encyst
• Infective stage is metacercaria (encysted larva) metacercariae
• Immature egg when passed (develops in aquatic • Second intermediate host: freshwater fish,
environment): PEFF- Paragonimus, Echinostoma, crustacean, and water plants
Fasciola, Fasciolopsis • Metacercariae develop into adult worms
• Mature egg when passed: Schistosoma, • Metacercariae secretes a protective wall and
Heterophyids, Opistorchis, Clonorchis encyst in water plant or 2nd intermediate
o CHOS host.

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 BS
3 MT CLINICAL
Nickson Cammayo, RMT
PARASITOLOGY(lec)
• Metacercariae then encyst in human • Humans serve only as good/permissive hosts
intestinal tract migrate to various site • Most require Oncomelania snails to develop
depending on the species Special Laboratory Procedures:
• Faust and Meleney’s egg hatching
technique
• Circumoval precipitin test (COP) of Oliver
and Gonzales
o Used to detect serum antibodies to
S. mansoni and S. haematobium or
both species using eggs of either
specie of Schistomosomes

SCHISTOSOMA JAPONICUM

• (Oriental blood fluke)

• During World War II, large numbers of
Adult worm Trematodes American and Australian troops were infected
in Leyte
I. MORPHOLOGY
• Egg: spherical and oval in shape, has a
minuteLateral knob
BLOOD FLUKES • Adult: smooth tegument

I. GENERAL CHARACTERISTICS II. PATHOGENESIS:

• Diecious (separate sexes) a. Cercarial dermatitis / swimmer’s itch

o Schistosomes are blood flukes, agents b. chronic infection- hepatic(most serious) and
of schistosomiasis, bilharziasis, and pulmonary cirrhosis
swamp fever c. CNS involvement may also occur
o Three species that cause most d. Katayama’s disease – formation of immune
infections in humans are S. complexes and serum sickness like illness
japonicum, S. mansonii, and S. brought by antigens released by eggs and
haematobium stimulation of humoral response of adult
o Less frequent species are S. mekongi worms. Fever, lymphadenopathy and
and S. intercalatum hepatosplenomegaly are seen
e. Secondary bacterial infection with Salmonella
• Females are long and slender, with body f. Colorectal and liver carcinoma
circular in section g. infection with few worms can be serious
• Males are flattened behind ventral sucker,
cylindrical and incurved ventrally to form • Location: branches of superior mesenteric
gynecophoral canal in which female reposes. vein adjacent to small intestine
• Suckers are armed with delicate spines • Diagnostic stage: eggs in stool
• Infective stage: fork tailed cercaria Procedures:
(nocturnal activity) o Acute- eggs in stool (kato thick/katokatz),
• Medication:Praziquantel also stained by Modified ZiehlNeelsen
• MOT: skin penetration o Chronic- hatching test,
• Schistosomule: cercaria minus tail concentration/sedimentation, rectal biopsy
• Remains in subcutaneous tissue for 2 days o Antigen detection- Circulating Cathodic
• Adapted to survive in serum/saline at 37°C Antigen (urine), Circulating Anodic
• In laboratory, artificial schistosomule may be Antigen (serum)
done (passing in small syringe, application of o Antibody detection- ELISA
surface with skin lipids/lecithin, passage SCHISTOSOMA HAEMATOBIUM
through isolated skin) • (Bladder fluke)
• Worms dilate vessels when they penetrate
them for oviposition I. MORPHOLOGY
• Definitive hosts: dogs, pigs, carabaos,cows.

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3 MT CLINICAL
Nickson Cammayo, RMT
PARASITOLOGY(lec)
• Egg: contain fully developed miracidium when PPT/VIDEO
deposited. Has a conspicuous terminal spine
II. PATHOGENESIS:

• Acute- cercarial dermatitis, cough, fever

• Chronic- dysuria, hematuria, obstructive
uropathies, bladder carcinoma, also
granuloma/fibrous damage can be seen in liver,
lungs, spinal cord, urogenital tract and intestines
• Snail intermediate hosts: Bulinus, Physopsis, Fig. 7: Schematic diagram to show distinguishing
Biomphalaria features of eggs of S. mansoni, S. haematobium, and S,
• Location: vesical, prostatic and uterine plexuses japonicum
• Diagnostic stage: eggs in stool, urine
• Possible to find eggs from biopsy material from Schistosoma mansoni – Lateral spine
uterine, cervical wall and vagina - Latera spine = letters from the word manSoni

Procedure: Schistosoma haematobium – Terminal spine

• Acute- eggs in stool (kato thick/katokatz) - “T” from the word haematobium = Terminal
• Chronic- hatching test, concentration/
sedimentation Schistosoma japonicum– Lateral knob
• Histopathology- biopsy (bladder)
• Antigen detection- Circulating Cathodic Antigen
(urine), Circulating Anodic Antigen (serum) ADDITIONAL SCHISTOSOMES:
• Antibody detection- ELISA
PPT
SCHISTOSOMA MANSONI

• (Profile of a man, Manson’s blood fluke) 1. Schistosoma mekongi: schistosome from mekongi
• Brought as consequence of slave trade, smallest river, closely resembles S. japonicum but is smaller
schistosomes in terms of adult worms 2. Schistosoma malayensis: found in peninsular
Malaysia, resembles also S. japonicum
I. MORPHOLOGY 3. Schistosoma intercalatum:acid fast positive;
• Egg: light yellowish brown, has a large lateral terminal spine (resembles S. haematobium) and has
spine, shaped like rose thorns. a diamond body.

II. PATHOGENESIS
• 1st stage- Cercarial dermatitis
• 2nd stage- Katayama’s disease
• 3rd stage/Chronic- Fibrosis/granuloma of
intestines, Symmers pipe stem fibrosis, Pulmonary
emboli & hypertension, Right sided heart failure,
Spinal cord schistosomiasis, Kidney failure
• Snail intermediate hosts: Biomphalaria,
Australorbis, Tropicorbis
• Location: inferior mesenteric vein of lower colon
• Diagnostic stage: eggs
Procedures:
• Acute- eggs in stool (kato thick/katokatz), also
stained by Modified ZiehlNeelsen
• Chronic- hatching test,
concentration/sedimentation
• Histopathology- rectal biopsy
• Antigen detection- Circulating Cathodic Antigen
(urine), Circulating Anodic Antigen (serum)
• Antibody detection- ELISA

Cariño, E., Gumatay J., Damagon I. | 3

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3 MT CLINICAL
Nickson Cammayo, RMT
PARASITOLOGY(lec)
LUNG FLUKE

LMS / PPT VIDEO

1. Paragonimuswestermani
• (Lung fluke, oriental lung fluke, pulmonary
distomiasis, endemic hemoptysis, parasitic
hemoptysis)
• Other species: Paragonimusphilippinensis,
Paragonimussiamensis
Egg of Paragonimuswesterman
MORPHOLOGY
• Egg: oval, yellowish brown, thick shaped egg has Life cycle: Immature egg embryonates inwater/soil/feces,
a flattened but prominent operculum, miracidum develops within 2- 7 weeks. It develops into
• Adult: reddish brown resembles coffee bean. miracidium, 2 redial stages and emerges the cercaria to
Rounded anteriorly and flattened posteriorly. seek the 2nd intermediate host. Definitive host acquires
• Cercaria: covered with spines and has an infection through ingestion.
ellipsoidal body and tail, stylet is present at dorsal Pathogenesis:
site. 1. Causes granulomatous reaction that proceeds into
Metacercaria- round shaped. fibrotic encapsulation.
• 1st Intermediate host: snails 2. Dry cough that progresses into rust-colored
sputum with foul fish odor most pronounced in
(Antemelaniaasperata&Antemelania
morning (misdiagnosis of tuberculosis)
dactylus/Brotiaasperata, Semiculcospira).
3. If chronic cough is only present, it is confused
• 2nd Intermediate host: crab with chronic bronchitis.
(Sundathelpusaphilippina formerly 4. Cerebral involvement is the most serious
Parathelpusagrapsoides). complication, causes jacksonian epilepsy
5. Ectopic infections- peri- & myocardium,
abdominal wall, liver, lymph nodes,
adrenals,urogenital organs, eyes, even in skin
(subcutaneous nodular lesions in chest)
- Abdominal paragonimiasis: Occasionally the fluke
migrates to liver and intestinal wall resulting in
enlarge liver, abdominal tenderness and bloody
diarrhea.
- Cerebral paragonimiasis: Encapsulated cyst of
Paragonimus is found in brain and spinal cord.
Symptoms include headache, fever, paralysis, visual
70-100 um x 40-60 um
disturbances and convulses seizures.
Diagnostic stage embryonated egg
Life cycle and egg of Paragonimuswestermani • Note- cysteine protease excreted by the
metacercaria helps in immunemodulation and
migration of worms
• Diagnostic stage: detection of eggs in
sputum/stool/pleural effusions
• (3% NaOH is added into sputum to enhance
recovery)
• Classic immunoserologic- CF, Intradermal,
Double diffusion, Immunoblot,ELISA, LAMP
• CT scan/MRI- “grape cluster” appearance on
posterior part of brain, soapbubble calcifications
• Medication: Praziquantel, Triclabendazole,
Bithionol-alternative.

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3 MT CLINICAL
Nickson Cammayo, RMT
PARASITOLOGY(lec)
INTESTINAL FLUKES

PPT VIDEO/ LMS

1. Fasciolopsisbuski (giant intestinal fluke)
- Digenetic trematode that is a parasite of humans and
pigs
- Largest fluke infecting human

Morphology
• Egg: large, operculated, unembryonated when
first passed
• Indistinguishable from Fasciola hepatica,
Fasciola gigantica&Echinostomids Enchinostomailocanum
• Adult: elongated, compared to Fasciola hepatica Horse shoe shape
& Fasciola gigantica,Fasciolopsis also does not
have cephalic cone and its intestinal ceca
areunbranched and reaches posterior end
• 1st intermediate host: snail (Segmentina or
Hippeutis)
• 2nd intermediate host: plants (Trapa bicornis-
water caltrop, Eliocharistuberosa-water chestnut,
Ipomea obscura-water morning glory, Nymphaea
lotus- lotus). Artyfecchinostomummalayanum
• Life cycle: Adult worm thrives in duodenum,
immature eggs are released into water, INTERMEDIATE HOSTS:
itembryonates maturing into miracidium that I. E. ilocanum
seeks out 1st intermediate host. Insidesnail, • 1st (snail): Gyraulusconvexiusculus,
miracidium develops into sporocyst and produces Hippeutisumbicalis
redia, and cercaria. Thecercaria will dislodge • 2nd (snail):Pila luzonica- “kuhol”, Vivipara
itself from snail and encyst as metacercaria on angularis- “susongpampang”
various 2ndintermediate host. II. A. malayanum
• Pathogenesis: pathological changes involve • 1st (snail): unknown
trauma, obstruction and toxication. • 2nd (snail):Lymnaeacumingiana- “birabid”
• Diagnostic stage: eggs in stool • Life cycle: Adult worm lives in small intestines
• Medication: Praziquantel of definitive host. Immatureeggs are released by
parasite and released into environment, egg
2. Echinostomids maturesin water and develops in miracidium
• Digenetic trematodes characterized by horse shoe which infects 1st intermediate host, asnail
shaped collar of spinesaround their oral suckers. Miracidium develops into redia which produces
Rats are reservoir hosts. cercaria after 50 days,after escaping from snail
Species: cercaria seeks out 2nd intermediate host,a
• Echinostomailocanum (Garrison’s fluke) secondsnail.
• Artyfechinostomummalayanum • Pathogenesis: bloody diarrhea, abdominal pains,
Morphology intoxication, ulceration
• Egg: straw colored, operculated and ovoid - E. • Diagnostic stage: eggs in stool
ilocanum • Fasciola, echinostomes spp. and
• Larger, golden brown, operculated - A. Fasciolopsisbuskieggs look very much alike
malayanum • Medication: Praziquantel

3. Heterophyid flukes
• species: Heterophyesheterophyes,
Metagonimusyokogawai, Haplorchistaichui,
Haplorchisyokogawai
• 1st intermediate host: snail (Melania juncea,
brackish water snails, Thiarariquetti).

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3 MT CLINICAL
Nickson Cammayo, RMT
PARASITOLOGY(lec)
• 2nd intermediate host: fishes (Oreochromis
niloticus- tilapia, Clariasbatrachus- hito) LIVER FLUKES
• Heterophyesheterophyes- smallest trematode
PPT Video/ LMS
parasite of man 1. Fasciola spp
• Parasites found in liver and biliary passages of
MORPHOLOGY humans and herbivorous mammals (ruminants)
• Egg: fully developed symmetrical miracidium is • Species:
alreadyplaced in egg, operculum fits into eggshell Fasciola hepatica
smoothly anddoes not have abopercular (Temperate liver fluke, sheep liver fluke, common liver
protuberance in comparison toClonorchis and fluke)
Opistorchis.
• Adult: elongated, oval, pyriform.Testes variously Fasciola gigantica
(Tropical liver fluke, giant liver fluke)
arranged(posterior part). Ovaries are globular.
• Reservoir hosts- dogs, cats, birds Morphology
• Life cycle: Adult worm inhabits into small ▪ Egg: large, ovoidal, operculated, yellowish to
intestine, miracidium hatcheswhen egg is ingested brownish in color, released immature from adult
by 1st intermediate host. Miracidium hatches worm, containing a large unsegmented mass of
intocercaria that encyst into its 2nd intermediate vitteline cells. F. gigantic egg is bigger.
host ▪ *Fasciola hepatica- with cephalic cone that has a
• Pathogenesis: Excessive mucus production. Most widening/shoulder, Leaf-like hermaphrodite
▪ In humans, species identification cannot be
common clinicalmanifestations are Peptic Ulcer
achieved by clinical, pathological, coprological or
Disease and Acid Peptic disease. Gurgling immunological methods. Differential diagnosis
ofstomach. Can be lodged in spinal cord, heart (PCR) is very important because of their
and brain. epidemiological characteristics.
• Diagnostic stage: eggs in stool using katokatz ▪ Adult (F. hepatica): large, broad and flat body, 20-
• Medication: Praziquantel 50 mm in length, presence of cephalic cone which
has a marked widening at base of cone –“shoulder”
▪ Adult (F. gigantica): longer and its shoulders are
less developed.
▪ 1st intermediate host: snail (Lymnaea
philippinensis & Lymnaea auricularia rubiginosa).
▪ 2nd intermediate host: aquatic plant (Ipomea
obscura- “kangkong”, Nasturtium officinale-“water
cress”)

Life cycle: Adult worm lives in biliary passages of liver,

immature eggs are carried by bile into
intestine and voided with feces. Eggs mature in
water, forming a miracidium and infects 1st
intermediate host. Follows the usual order of maturity
from miracidium to redia to cercaria. Cercaria infects
2nd intermediate host.
▪ Pathogenesis: “sheep liver rot”
▪ Acute stage- larval migration in hepatic tissue,
traumatic and necrotic lesions are produced.
▪ Chronic stage- persistence of filarial worms in biliary
ducts, causes fibrosis
▪ Hepatic fascioliasis- right upper quadrant abdominal
pain, fever/asymptomatic
▪ Rare complication- acute pancreatitis
▪ In some Mediterranean countries where liver of sheep
and goats are eaten raw, ingestion of infected liver
may cause suffocation (halzoun in arabic) as a result

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3 MT CLINICAL
Nickson Cammayo, RMT
PARASITOLOGY(lec)
of temporary lodgement of worm in pharynx ▪ Cholangiography- arrowhead sign saccular dilatation
▪ F. hepatica- induces Th1 and Th2 cytokines. ▪ Medication: Praziquantel (25 mg)
▪ Cause of evasion (suppression of proliferated ▪ Additional: Hazard Analysis Critical Control Point
response mediated by cytokines IL-4 and IL (HACCP)-concept: recommended by WHO to control
▪ Diagnostic stage: to differentiate two species, use of foodborne trematode infections
PCR (polymerase chain reaction). Eggs in stool,
duodenal contents, recovery of adults during surgical
exploration. UNCOMMON HUMAN TREMATODES
▪ Confirmatory – Western blot/ ELISA
▪ Medication: Triclabendazole, Bithionol 1. Nanophyetus salmincola: causes “salmon poisoning”- a
fatal disease of dogs, wolves and
FAMILY Opistorchiiidae foxes. It harbors the ricketssia “Neorickettsia helminthoeca”.
2. Philophthalmus: “eyeflukes”
3. Acanthoparyphium: intestinal parasite of ducks
4. Alaria- acquired through ingestion of frogs/infected meat
5. Gymnophalloides- parasite of shore birds
6. Metorchis conjunctus- parasite of sled dogs

• Parasites of gall bladder and bile duct

• Species:
1. Clonorchis sinensis (oriental liver fluke,
Chinese liver fluke)- Most important liver fluke of
man
2. Opistorchis felineus (cat liver fluke)

3. Opistorchis viverrini

Morphology
▪ Egg: yellowish brown, ovoid. Eggs of these 3 flukes
are difficult to differentiate
▪ Main similarity between Clonorchis sinensis &
Opistorchis spp. Is the location of vittelaria, which
are found in middle third of the body at level of uterus
Clonorchis Opistorchis Opistorchis
sinensis felineus viverrini
Difference Branched Slightly Deeply
(testes) testes lobulated lobulated
testes testes

▪ Life cycle: Adult fluke attaches into mucosa of bile

duct using its suckers and embedding itself in sticky
mucus without causing permanent ulceration in
epithelial lining. It feeds on tissue fluids, RBCs and
mucus.
▪ Egg is fully matured when it is released, passes into
bile to intestine and escapes to environment.
Miracidium hatches only after the egg is ingested by
1st intermediate host: snail.
▪ Follows the usual order of maturity from miracidium
to redia to cercaria. Cercaria infects 2nd intermediate
host: a freshwater fish.
▪ Reservoir hosts- dogs, cats, rats
▪ Pathogenesis: Proliferation of walls if biliary
epithelium (walls of ducts become thickened)
Clonorchis sinensis- (1) desquamation of epithelial
cells (2) hyperplasia (3) adenomatous tissue formation
(4) pancreatitis
▪ Opistorchis spp.- cholangiocarcinoma
▪ Diagnostic stage: demonstration of eggs in stool
▪ Staining with Potassium permanganate- distinct
melon-like ridges on surface of O. viverrini eggs and
light striae pattern on Haplorchis taichui eggs.

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