TREMATODES

EUKARYOTES

UNICELLULAR MULTICELLULAR

Helminths

Nematodes Cestodes Trematodes

(roundworms) (Tapeworms) (leaf-like)

Liver Intestinal Lungs Blood

 TREMATODES
• LIVER FLUKES
• Fasciola hepatica
• Fasciola gigantica
• Clonorchis sinensis
• Opistorchis felineus
• Opistorchis viverinii
• Dicrocoelium dendriticum
 TREMATODES
A. Liver Flukes
EGG LARVA 1 LARVA 2 ADULT

HOST 1 HOST 2 HOST 3

Hatches Develops in Eaten by the Eaten by the

in water the first second Final host
to release the Intermediate host Intermediate host (Humans)
MIRACIDIUM (SNAILS) (water plants,
Fish or snails
Adult Trematodes
• Flat, elongated, leaf-shaped

• Ovoid, conical or cylindrical

depending on state of
contraction

• Integument may be
covered with spines,
tubercles or ridges
(partially or completely)
 Adult Trematodes (Prototype)
Oral sucker

Esophagus
Ventral sucker

Intestinal cecum
Vitellaria
1 ovary

2 testes

All trematodes are hermaphroditic EXCEPT the blood flukes (Schistosoma sp.)
Trematode Egg (Prototype)
• Contains a fertilized
ovum

• Shape, appearance and

size – depending on the
species

• Contains a cap-like
operculum, EXCEPT
Schistosoma sp.
 TREMATODES
EGG LARVA 1 LARVA 2 ADULT
Hatches FIRST SECOND
in water INTERMEDIATE INTERMEDIATE
to release the HOST HOST FINAL HOST
Fish ,
MIRACIDIUM SNAIL crustaceans
Snails
Sporocyst
Aquatic plants

Redia I Metacercaria Adult

(encysted cercaria)
Redia II

Cercaria

All follow the above cycle, EXCEPT Schistosoma sp.

 LIVER FLUKES
EGG LARVA 1 LARVA 2 ADULT
Hatches FIRST SECOND
in water INTERMEDIATE INTERMEDIATE
to release the HOST HOST FINAL HOST
MIRACIDIUM Fish ,
SNAIL crustaceans
Snails

Aquatic plants
Adult liver flukes that live
In the biliary passages irritate
the ducts. Adenomatous
proliferation can result to
partial obstruction.
 Clonorchis sinensis
(Chinese Liver Fluke)
Oral sucker

Ventral sucker
smaller than oral sucker
uterus

Testes deeply lobulated

in tandem

Small lobate ovary

Intestinal ceca up
to the posterior end
 Clonorchis sinensis
(Chinese Liver Fluke)

operculum

rimmed

Small protuberance

Thicker posterior end

 Clonorchis sinensis
(Chinese Liver Fluke)
EGG LARVA 1 LARVA 2 ADULT

FIRST SECOND FINAL

INTERMEDIATE
HOST
operculate snails of several
genera, including Alocinma
and Parafossarulus,
Bithynia ( Bulimus),
Semisulcospira,
Melanoides tuberculatus
INTERMEDIATE HOST
HOST
fresh water fish
of the family Cyprinidae , Humans get infected by:
Ctenopharyngodon idellus >eating uncooked fish
containing the infective
metacercaria
> ingestion of the cysts
in drinking water
 Clonorchis sinensis
(Chinese Liver Fluke)
• PATHOLOGY • bile ducts thicken and become
dilated and tortuous
• distal bile ducts are irritated
mechanically and by its toxic • adenomatous proliferation of
secretions the biliary epithelium

• slight leukocytosis and • fibrosis and destruction of

eosinophilia in early infection hepatic parenchyma

• enlarged tender liver • liver function is impaired

although SGPT and SGOT are
normal
 Clonorchis sinensis
(Chinese Liver Fluke)
• SYMPTOMATOLOGY

• Light Infections • Heavy infections

– produce only mild symptoms or – complicated by cholelethiasis
go unnoticed and bouts of pyogenic cholangitis
• Moderate Infections
– indigestion
– Epigastric discomfort unrelated
to meals
– weakness
– loss of weight
 Clonorchis sinensis
(Chinese Liver Fluke)
• CLINICAL DIAGNOSIS • LABORATORY DIAGNOSIS
• suggestive in patients from • finding the characteristic
endemic areas with: eggs in the feces or biliary
– history of eating uncooked drainage or duodenal
fish aspiration
– symptoms of biliary tract
disease
• intermittent jaundice • eggs to be differentiated
• bouts of fever from opistorchid and
• right upper quadrant pain
heterophyid flukes
 Clonorchis sinensis
(Chinese Liver Fluke)
• TREATMENT • PREVENTION AND CONTROL
• chloroquine diphosphate
• thorough cooking of all
• praziquantel freshwater fish

Heavy infections complicated • sterilization of human feces by

by obstructive jaundice:
1. cholecystectomy with
2. choledocholithotomy
3. exploration of the common
duct
4. drainage procedure such as
sphincteroplasty or
choledochoduodenostomy
storage or by the addition of
ammonium sulfate
• Human and animal feces should
not be disposed in bodies of
water.
Opistorchis felineus
(Cat Liver Fluke)
Oral sucker
subterminal

Ventral sucker
Same size as
oral sucker

2 testes lobed
Oblique to each other
 Opistorchis felineus
(Cat Liver Fluke)

operculum

rimmed

Small protuberance

Resembles Clonorchis sinensis but:

1. is narrower and has more tapering ends

2. a pointed terminal knob
3. a less conspicuous operculum
 Opistorchis felineus
(Cat Liver Fluke)
EGG LARVA 1 LARVA 2 ADULT

FIRST SECOND FINAL

INTERMEDIATE INTERMEDIATE HOST
HOST HOST
amnicolid snail fresh water fish
Bithynia(Bulimus) leachi (cyprinoid fish) Humans get infected by:
>eating uncooked fish
Tinca tinca, Idus melanotus, containing the infective
Barbus barbus, Cyprinus metacercaria
Carpio, Abramis brama,
A. sapa, Alburnus lucidus,
> ingestion of the cysts
Aspius aspius, Blicca in drinking water
bjorkna, Leuciscus rutilis
Scardiinius erythopthalmus

Bithynia funiculata
 Opistorchis felineus
(Cat Liver Fluke)
• PATHOLOGY

• inflammatory and proliferative

changes of the biliary
epithelium

• fibrosis of the distal biliary

vessels

• pathologic changes may extend

to the proximal
bile ducts and gallbladder 
periportal fibrosis
 Opistorchis felineus
(Cat Liver Fluke)
• SYMPTOMATOLOGY
• Light Infections • Heavy Infections
– • invade the pancreas with digestive
Asymptomatic
disturbances
• bile stones may form around eggs as
• Moderate Infections nuclei and cause cholecystitis with
– moderate, painful colic
enlargement of the liver • loss of appetite as patient becomes
– passive congestion of the toxic
spleen • scar tissue around the bile ducts
– Icterus encroaches on liver cells and portal
– local eosinophilia in the wall vessels ---- collateral venous
of the bile ducts circulation, edema of the face and
limbs and at times ascitis
 Opistorchis felineus
(Cat Liver Fluke)
• CLINICAL DIAGNOSIS • LABORATORY DIAGNOSIS
• suggestive in patients from • finding the characteristic
endemic areas with: eggs in the feces or biliary
– history of eating uncooked drainage or duodenal
fish aspiration
– symptoms of biliary tract
disease
• intermittent jaundice
• bouts of fever
• right upper quadrant pain
 Opistorchis felineus
(Cat Liver Fluke)
• TREATMENT • PREVENTION AND CONTROL
• praziquantel
• thorough cooking of all
freshwater fish

• sterilization of human feces by

storage or by the addition of
ammonium sulfate

• Human and animal feces should

not be disposed in bodies of
water.
Opistorchis viverinii
Oral sucker
subterminal

Ventral sucker
Same size as
oral sucker

2 testes deeply lobulated

Oblique to each other
 • Eggs are relatively short
operculum
and broad

rimmed

protuberance
 Opistorchis viverinii
EGG LARVA 1 LARVA 2 ADULT

FIRST SECOND FINAL

INTERMEDIATE INTERMEDIATE HOST
HOST HOST
Snails : fresh water fish
Bithynia goniomphalus Humans get infected by:
Punteus orphoides >eating uncooked fish
Bithynia funiculateB Hampala dispar
ithynia laevis containing the infective
Cyclocheilichthys siaja
metacercaria
> ingestion of the cysts
in drinking water

Natural definitive hosts:

civet cat, cat, dog
and other fish- eating
mammals
MAN IS AN ACCIDENTAL HOST.
 Opistorchis viverinii
• PATHOLOGY
• dilatation and thickening of
bile duct walls
• presence of stones and
sludge in the gallbladder
• hyperplastic biliary
epithelium from presence
of worms
• further stimulated by
nitrosamines in local
fermented foods or by
nitrosocompounds
produced by activated
• macrophages in chronically
affected tissues
• striking association with
cholangiocarcinoma
 Opistorchis viverinii
• SYMPTOMATOLOGY
• Light to Moderate Heavy Infections
• abdominal distress
Infections
• epigastric pain
a few symptoms
• generalized malaise
 Opistorchis viverinii
• CLINICAL DIAGNOSIS
• suggestive in patients from
endemic areas with:
– history of eating uncooked
fish
– symptoms of biliary tract
disease
• intermittent jaundice
• bouts of fever
• right upper quadrant pain
• LABORATORY DIAGNOSIS
• finding the characteristic
eggs in the feces or biliary
drainage or duodenal
aspiration
• Ultrasonography to screen
the presence of
cholangiocarcinoma
 Opistorchis viverinii
• TREATMENT • PREVENTION AND CONTROL
• praziquantel
• thorough cooking of all
freshwater fish

• sterilization of human feces by

storage or by the addition of
ammonium sulfate

• Human and animal feces should

not be disposed in bodies of
water.
 Opistorchis viverinii
• TREATMENT • PREVENTION AND CONTROL
• praziquantel
• thorough cooking of all
freshwater fish

• sterilization of human feces by

storage or by the addition of
ammonium sulfate

• Human and animal feces should

not be disposed in bodies of
water.
 Fasciola hepatica
(Sheep Liver Fluke)
Sheep liver rot, Pharyngeal fascioliasis,Halzoun
Flat, leaf shaped with characteristic
shouldered appearance
from its cephalic cone

Highly branched
intestinal ceca
and testes
 Fasciola hepatica
(sheep liver fluke)

operculated
oval
 Fasciola hepatica
(sheep liver fluke)
EGG LARVA 1 LARVA 2 ADULT

FIRST SECOND FINAL

INTERMEDIATE INTERMEDIATE HOST
HOST HOST
Lymneid snails aquatic vegetation
a. Lymnaea philippinensis watercress FASCIOLIASIS
b. Lymnea swinhoe Humans get infected by:
>eating uncooked watercress
containing the infective
metacercaria
> ingestion of the cysts
in drinking water

Natural definitive
herbivorous animals like sheep.
PHARYNGEAL FASCIOLIASIS
(HALZOUN)
Humans get infected by:
hosts: >eating raw sheep or goat liver

MAN IS AN ACCIDENTAL HOST.

PATHOLOGY

Acute Or Invasive Phase

period during which the fluke migrates from the intestine
to the liver and its burrowing through the liver parenchyma

no significant change from the intestine to the liver

Parasite may wander or be carried by blood after penetrating

a blood vessel to ectopic sites such as lungs, subcutaneous
Tissues, brain and the orbit ---- abscesses or fibrotic lesions

Migration to the liver parenchyma

traumatic and necrotic lesions
Chronic Or Latent Phase
period when the parasite has already reached the bile ducts

a. obstruction in the vessel

b. inflammatory and adenomatous changes of the biliary epithelium

c. fibrosis of the ducts

d. pressure atrophy of the liver parenchyma

e. intensive periductal fibrosis

f. Heavy infections
1. erosion of the epithelium
2. young worms wander back into the liver to produce
abscess pockets and to seed the vital liver tissue
with their eggs
Symptomatology

1. colic and obstructive jaundice

2. coughing and vomiting
3. generalized abdominal rigidity
4. acute epigastric pain and tenderness
5. urticaria
6. early leukocytosis and eosinophilia
7. irregular fever
8. more or less persistent diarrhea
9. marked anemia
10.hemoglobinuria
11.cholelithiasis – common complication
PHARYNGEAL FASCIOLIASIS OR HALZOUN

due to ingestion of infected raw sheep and goat livers

Adult worm lodges temporarily in the pharyngeal mucosa causing:

>edematous congestion of the soft palate, pharynx, larynx,

nasal fossae, Eustachian tube ------ suffocation

>dyspnea

>deafness

>asphyxiation
DIAGNOSIS

Clinical – based on
1. biliary symptoms
2. moderate to high eosinophilia
3. eating watercress as a green salad
(metacercaria in vegetation)

Laboratory
1. recovery of the eggs in the patient’s stool or
from duodenal or biliary tract drainage
2. serodiagnosis – helpful but not adapted for
routine diagnosis
DIFFERENTIAL DIAGNOSIS

1. acute hepatitis of other etiology

2. cholecystitis
3. cholelithiasis
4. cirrhosis resulting from other causes

False fascioliasis – due to ingestion of infected livers

with passage of eggs in the feces

Keep the patient on a liver free diet for 3 days or more

False fascioliasis – eggs no longer seen
True fascioliasis – eggs can still be seen
Treatment

1. bithionol (dichlorophenol)
2. dehydroemetine hydrochloride
3. emetine hydrochloride
4. hexachloroparaxylene
5. praziquantel
PREVENTION AND CONTROL

1. thorough washing or cooking of vegetables

2. boiling of water in areas where the infection is endemic

(metacercaria in vegetation)

3. elimination of the snail intermediate hosts

4. killing the parasites in the reservoir hosts by

chemotherapy
Fasciola gigantica
(Giant Liver Fluke)
Flat, leaf shaped more elongated

cephalic cone is shorter and less

prominent

shoulders are practically lacking

ventral sucker is larger

Highly branched
intestinal ceca
and testes (more anterior)
 Fasciola gigantica
(Giant liver fluke)

operculated
oval

Eggs are larger.

 Fasciola gigantica
(Giant Liver fluke)
EGG LARVA 1 LARVA 2 ADULT

FIRST SECOND FINAL

INTERMEDIATE INTERMEDIATE HOST
HOST HOST
snails aquatic vegetation
watercress Humans get infected by:
>eating uncooked watercress
containing the infective
metacercaria
> ingestion of the cysts
in drinking water

Natural definitive hosts:

Cattle, buffaloes, camels
Wild hogs and other herbivores

MAN IS AN ACCIDENTAL HOST.

Pathology
Symptomatology (same as Fasciola hepatica
Diagnosis
Prevention and Control
Dicrocoelium dendriticum
(Lancet Fluke)
Morphology 1. slender, lancet shaped, flat transparent,
aspinous body 5 to 15 mm by 1.5 to
2.5 mm

2. acetabulum lies at the beginning of the

second fifth of the body

3. two large, slightly lobed testes situated

obliquely to each other anterior to the
small subglobose ovary just behind the
ventral sucker

4. voluminous uterine coils in the posterior

thirds of the worm

5. subglobose ovary lies to the right of the

midline and somewhat anterior to the
equator of the worm

6. discrete vitelline follicles occupy lateral

fields in the middle of the body
Eggs are deep golden- brown
thick shelled, distinctly
operculated, measuring
38 to 45 u by 22 to 30 u
containing a fully developed
miracidium.
 Dicrocoelium dendriticum
(Lancet fluke)
EGG LARVA 1 LARVA 2 ADULT
FIRST SECOND FINAL
INTERMEDIATE INTERMEDIATE HOST
HOST HOST
land snails of the genera Ants
Abida, Cochlicopa, (Formica fusca) Humans get infected by:
Helicella and Zebrina > ants harboring the metacercaria
Eggs are deep golden- brown
thick shelled, distinctly
operculated, measuring
38 to 45 u by 22 to 30 u
containing a fully developed
miracidium.
Pathology- same as Fasciola hepatica

1. in animals
a. enlargement of the bile ducts
b. hyperplasia of the biliary epithelium
c. formation of the periductal fibrous connective
tissue
d. atrophy of the liver cells
e. portal cirrhosis in heavy infections

2. in humans
a. hepatic changes are less pronounced
Symptomatology

In Humans
a. digestive disturbances
b. flatulence
c. vomiting
d. biliary colic
e. chronic constipation or diarrhea
f. enlarged liver
g. systemic toxemia less pronounced that in
fascioliasis
LABORATORY DIAGNOSIS

1. finding the eggs consistently in the feces and

duodenal drainage

2. eliminate spurious infections from eating livers

containing the eggs
TREATMENT – same as Clonorchis sinensis

1. praziquantel – 25 mg per kg TID for 2 consecutive

days

PREVENTION AND CONTROL

2. no effective measures of control

3. Fresh herbs collected from grazing areas
for use as food for humans should be washed
to remove the ants.
________________________________________________________________
Scientific name Common name Infective Diagnostic
stage stage
___________________________________________________________________________
Fasciola hepatica sheep liver fluke metacercaria unembryonated ova
___________________________________________________________________________
Fasciola gigantica giant liver fluke metacercaria unembryonated ova
___________________________________________________________________________
Clonorchis sinensis Chinese liver fluke metacercaria embryonated ova
___________________________________________________________________________
Opistorchis felineus cat liver fluke metacercaria embryonated ova
___________________________________________________________________________
Opistorchis metacercaria embryonated ova
viverrini
___________________________________________________________________________
Dicrocoelium lancet fluke metacercaria embryonated ova
dendriticum
______________________________________________
_______________________________________________________________
Scientific name 1ST IH 2ND IH FH AFH
_______________________________________________________________________
Fasciola hepatica snail aquatic vegetation herbivorous animals man
like sheep
_______________________________________________________________________
Fasciola gigantica snail aquatic vegetation camels, wild hogs, man
cattle and water
buffalo
_______________________________________________________________________
Clonorchis sinensis snail fresh water fish man
_______________________________________________________________________
Opistorchis felineus snail fresh water fish cats, dogs,fox,wolves
seals man
_______________________________________________________________________
Opistorchis snail fresh water fish civet cat, cat,dog man
viverrini and other fish eating
mammals
_______________________________________________________________________
Dicrocoelium snail ants sheep man
dendriticum
_______________________________________________________________________
 TREMATODES
A. Liver Flukes
EGG LARVA 1 LARVA 2 ADULT
Hatches Develops in Develops in
in water The first The second Eaten by the
to release the Intermediate host Intermediate host Final host
Larva. (SNAILS) (water plants, (Humans)
Fish or snails

LIVER FLUKES
Eating Goes to the liver, bile duct
Fasciola hepatica
watercress Causing destruction

Opistorchis felineus Eating raw Can cause bile stones.

(cat liver fluke) Fresh water destruction of the bile
fish ducts and liver

Clonorchis sinensis Eating raw Can cause liver cancer

(Chinese liver fluke) Fresh water
fish