The Platyhelminthes (Flatworms): Flukes Class Digenea (Trematoda) - the flukes. • Trematodes are parasites of vertebrates. They have complex life cycles requiring one or more intermediate hosts. Most are hermaphroditic and capable of selffertilization. • Eggs shed by the adult worm pass outside to the environment, and a larva (called a miracidium) hatches and swims away to infect the intermediate host. • Each species requires a certain species of mollusk (snail, clam, etc) as an intermediate host. A series of generations occurs in the mollusk, resulting in the liberation of larvae known as cercariae. The Platyhelminthes (Flatworms): Flukes Class Digenea (Trematoda) - the flukes. To reach the vertebrate host, depending upon species, cercariae : • Penetrate directly through skin and develop into adults. • Enter a second intermediate host, and wait to be ingested (they are now called metacercariae). • Attach to vegetation, secrete a resistant cyst wall, and wait to be eaten (now called metacercariae). The Platyhelminthes (Flatworms): Flukes Class Digenea (Trematoda) - the flukes. Intestinal: • Fasciolopsis buski • Heterophyes heterophyes • Metagonimus yokogawai Liver / Lung • Fasciola hepatica • Clonorchis sinensis • Paragonimus westermani Blood • Schistosoma mansoni • Schistosoma haematobium • Schistosoma japonicum The Platyhelminthes (Flatworms): Flukes Class Digenea (Trematoda) - the flukes. General appearance of adult flukes: • Body is non-segmented, flattened dorsal-ventrally, and covered with a cuticle which may be smooth or spiny. • Attachment organs are two cup-shaped suckers, oral and ventral. Tegument is metabolically active. • Oral cavity leads to muscular esophagus; intestine branches into 2 cecae, which end blindly near the posterior end of the worm. • Simple digestive system, no anus - waste products are regurgitated. The Platyhelminthes (Flatworms): Flukes Class Digenea (Trematoda) - the flukes. Reproductive system: • Uterus is the largest organ; a single ovary, two testes & a series of glandular structures that produce egg shell materials. • Uterus may be filled with thousands of eggs. The Platyhelminthes (Flatworms): Flukes Class Digenea (Trematoda) - the flukes. Trematode eggs: • Trematode eggs usually have a smooth, hard, transparent, yellow-brown shell and may have "shoulders" and/or spines. • Size varies greatly, ranging from less than 30 microns to 175 microns or more. • Most have an operculum (escape hatch for the miracidium). • Larger trematode eggs cannot be concentrated successfully using flotation techniques (due to size and weight). Sedimentation procedures are recommended. The Platyhelminthes (Flatworms): Flukes Fasciolopsis buski - The Giant Intestinal Fluke • Epidemiology - Found in China, Taiwan, Vietnam, Thailand, Indonesia, Malaysia, and the Indian subcontinent. Infection rate may be as high as 40%. It is the most common intestinal fluke in the orient. • Life cycle - Humans infected through ingestion of metacercaria on uncooked water plants. Encysted metacercariae hatch & attach to intestinal wall, develop into adult worms; eggs pass in feces miracidium hatches, penetrates snail cercariae emerge and encyst on aquatic plants. The Platyhelminthes (Flatworms): Flukes Fasciolopsis buski - The Giant Intestinal Fluke Diagnosis - Demonstrating eggs in feces specimens. Eggs are difficult to differentiate from those of Fasciola hepatica. Morphology of eggs: • Oval, yellow-brown eggs measure 150 x 90 microns. • Operculum - the transparent shell has an operculum (sometimes seen “popped open”). Major pathology - adult worms attach to the intestinal wall, producing local inflammation possibly leading to hemorrhage, ulceration and abscess formation. Absorption of worm metabolites can produce toxic or allergic reactions (edema, ascites). The Platyhelminthes (Flatworms): Flukes Fasciola hepatica - The Sheep Liver Fluke Epidemiology - rare in the USA, probably due to our diet not including the plants (wild grown) containing metacercariae. Common in sheep, cattle, & goats around the world. Life cycle - similar to F. buski; the difference being that hatching metacercariae do not attach to wall of intestine, rather, they penetrate the intestinal wall and migrate through peritoneal cavity until coming in contact with liver. They penetrate the liver & migrate to bile ducts where they grow to adult worms. The Platyhelminthes (Flatworms): Flukes Fasciola hepatica - The Sheep Liver Fluke Pathology and Clinical Manifestations - Migration through liver causes damage and symptoms proportionate with worm burden. Fever, abdominal pain, diarrhea, and eosinophilia may be experienced. Heavy worm burdens later result in extensive inflammation, epithelial hyperplasia, and fibrosis around the adult worms. This can lead to obstruction of the bile ducts. Distribution - Cosmopolitan distribution in sheepand cattle-raising countries. The Platyhelminthes (Flatworms): Flukes Clonorchis sinensis - The Chinese Liver Fluke Life cycle: • Humans eat undercooked fish containing the metacercaria. • Immature worms migrate to liver and bile duct, mature and produce eggs. • Eggs in fresh water are consumed by 1st intermediate host (snail). Cercariae develop in snail. • Released cercariae penetrate the second intermediate host (fish) and migrate to muscles to transform into the infective metacercariae. The Platyhelminthes (Flatworms): Flukes Clonorchis sinensis The Chinese Liver Fluke • Diagnosis - detection of eggs in feces. • Morphology of eggs - Eggs are small (15 x 35 microns), flask-shaped, with a small operculum on the narrow end. A small “comma-shaped” extension can often be seen on the abopercular end. They cannot be easily distinguished from eggs of Heterophys or Metagonimus. The Platyhelminthes (Flatworms): Flukes Clonorchis sinensis - The Chinese Liver Fluke Pathology and Clinical Significance: • Light infections are usually asymptomatic. • Heavy infections can result in jaundice, hepatomegaly, abdominal pain, diarrhea and anorexia. • Patients may have severe hepatic complications in chronic cases with heavy worm burdens from repeated infections. • Distribution - Far East, especially China. The Platyhelminthes (Flatworms): Flukes Heterophyes heterophyes & Metagonimus yokogawai Life cycle: • Humans eat undercooked fish containing the metacercaria. • Adults develop in the intestine, mature and lay eggs. • Eggs in water are consumed by first intermediate host (snail). Cercariae develop in the snail. • Released cercariae penetrate the second intermediate host (fish), migrate to muscles and transform into infective metacercariae. The Platyhelminthes (Flatworms): Flukes Heterophyes heterophyes & Metagonimus yokogawai Diagnosis: • Recovery and identification of eggs in feces. • Difficult to differentiate from each other and from C. sinensis unless adult worms are recovered. • A patient history is helpful since the infections are more common in one country or another. These are intestinal flukes, therefore, no liver involvement and symptoms would be expected. Treatment is similar for all. Pathology - Asymptomatic in light infections. Chronic mucous diarrhea and abdominal pain in heavy infections. Eggs may travel into tissue causing granulomas and other tissue disorders. The Platyhelminthes (Flatworms): Flukes Paragonimus westermani - The Oriental Lung Fluke Life cycle – • Eggs in sputum or feces get into fresh water. • The miracidium hatches from the egg within 2 weeks, penetrates a snail. Cercariae develop and escape the snail. • Cercariae penetrate freshwater crabs or crayfish and encyst, becoming metacercaria. • Man eats metacercaria present in undercooked crab or crayfish. • Immature fluke penetrates intestine, migrates through peritoneal cavity, penetrates diaphragm and burrows into the lung. • Worms gather around bronchioles, discharge eggs into bronchial secretions. Eggs are found in sputum or, if sputum is swallowed, in feces. • Infections may persist for years. The Platyhelminthes (Flatworms): Flukes Paragonimus westermani The Oriental Lung Fluke Morphology: • Adults are 6 x 10 mm, plump, usually reddish-brown. • Eggs are 80 to 125 x 45 to 65 microns, opercular end is broader than the other end and has “shoulders,” abopercular end often has marked thickening of egg shell. The Platyhelminthes (Flatworms): Flukes Paragonimus westermani - The Oriental Lung Fluke Pathology • Chronic chest pain, cough, blood tinged sputum, lung infiltration, nodules, abscesses. • X-ray may resemble tuberculosis. • Abdominal paragonimiasis is usually asymptomatic but common. The Platyhelminthes (Flatworms): Flukes Schistosoma spp. - The Blood Flukes General • Separate male and female worms exist in this group of flukes. • The female is long and slender, the male is shorter, cylindrical and characteristically in-curved to form a gynecophoral groove in which the female reposes. Adult males are 7 - 20 mm long; females are a bit longer. • The female leaves the male to lay eggs in the small veins close to lumen of the intestine or bladder. • Eggs are firmly wedged in, and spines present on the eggs facilitate their retention. • The release of enzymes along with necrosis of tissue results in release of eggs into the intestine or bladder. Expansion and contraction of affected organs aid eggs in crossing the tissue barrier into the lumen for discharge. The Platyhelminthes (Flatworms): Flukes Schistosoma spp. - The Blood Flukes Life cycle • Eggs are released into fresh water; miracidia hatch. • Miracidia penetrate snails and undergo essential developmental stages, leaving the snail as free-swimming cercariae. • Free-swimming cercariae penetrate the skin of humans while they are swimming or bathing. • Cercariae lose their tails upon penetration, travel through body via the bloodstream and develop to adults in blood vessels of the host. The Platyhelminthes (Flatworms): Flukes Schistosoma mansoni - Manson's blood fluke Life cycle (follows general life cycle) • After penetration of the skin immature worm (schistosomule) travels through the blood vessels. • Most adults will develop in smaller branches of the inferior mesenteric vein in the region of the lower colon (but can be found elsewhere). • S. mansoni lives on ingested blood. The female can ingest up to 330,000 rbc’s/hour, the male 39,000/hour. • Eggs are non-operculate; measure 114 to 180 x 45 to 75 microns, and exhibit a prominent lateral spine. 100 - 300 eggs per worm per day are normally shed. The Platyhelminthes (Flatworms): Flukes Schistosoma mansoni - Manson's blood fluke Diagnosis: • Recovery and identification of eggs in stool or rectal biopsy (best to get 4 rectal snips in different areas of the bowel). • Most of the eggs are swept into the liver where granulomas form. Periportal pipestem fibrosis may result in cirrhosis with little hepatocellular regeneration. • Travels history as well as clinical signs and symptoms are important aids in determining possibility of infection. • Distribution - Africa, South and Central America, with foci in the Caribbean and West Indies. The Platyhelminthes (Flatworms): Flukes Schistosoma mansoni - Manson's blood fluke Major pathology and symptoms • Mostly due to the reaction to eggs in the liver. • Dermatitis at the site of cercarial penetration. • Acute phase of first infection resembles typhoid fever. • Cirrhosis of the liver, bloody diarrhea, bowel obstruction, hypertension, and toxic reactions due to granulomas around eggs in the liver. The worm secretes metabolites, resulting in a hepatitis syndrome; acute cases experience a serum sicknesslike syndrome (Katayama syndrome). • Many chronic cases are asymptomatic. The Platyhelminthes (Flatworms): Flukes Schistosoma japonicum – The Oriental Blood Fluke Life cycle - follows general life cycle. • Found in virtually all mammals exposed to infested water in endemic areas. • After penetration, the parasite inhabits the branches of the superior mesenteric vein adjacent to the small intestine. • The inferior mesenteries and caval system may also be invaded. Over time, worms will migrate farther and farther from the liver. • Produces more & smaller eggs than the other schistosomes; eggs free in the circulation are filtered out in the liver, lungs or other organs. The Platyhelminthes (Flatworms): Flukes Schistosoma japonicum – The Oriental Blood Fluke • Morphology of eggs - measure 55 to 95 x 40 to 60 microns; exhibit a very small lateral spine (may not be apparent). • Diagnosis - based upon recovery and identification of eggs in stool samples or rectal biopsies. The Platyhelminthes (Flatworms): Flukes Schistosoma japonicum – The Oriental Blood Fluke Major Pathology and Symptoms • Infection with even a few worms may be very serious. Cerebral atrophy can occur due to eggs becoming trapped in the brain. • Hepatic and pulmonary cirrhosis are seen in the chronic stage of this infection; CNS symptoms occur due to lodgment of eggs in nerve tissue. Distribution - the Far East. The Platyhelminthes (Flatworms): Flukes Schistosoma haematobium - The Bladder Fluke Life cycle – (see general life cycle) • Adult worms mature in the sinusoids of the liver, and migrate from that organ reaching vesicle, prostatic and uterine plexuses by way of the hemorrhoidal veins. • Eggs are deposited in the walls of the bladder, uterus, vagina & prostate. • Eggs in the bladder break into the lumen and escape with urine. The spine and contraction & expansion of the bladder aids movement of eggs through tissue. The Platyhelminthes (Flatworms): Flukes Schistosoma haematobium - The Bladder Fluke Morphology of the eggs • Measure 112 to 170 x 40 to 70 microns, & exhibit a prominent terminal spine. Diagnosis • Eggs in urine. • Eggs may be in feces due to worm rarely inhabiting intestinal mesenteric vessels. The Platyhelminthes (Flatworms): Flukes Schistosoma haematobium - The Bladder Fluke Major pathology and symptoms • The bladder wall becomes increasingly infiltrated with eggs. • Bleeding occurs from the bladder wall as it contracts. As it becomes more involved ulceration occurs. • Hematuria becomes more severe and calcification of the bladder and obstruction of ureters and the neck of the bladder lead to bacterial infections. • Death from renal failure may occur but damage is reversible if treated early enough. • Clinical correlation exists between S. haematobium infection and bladder cancer. Distribution - epidemic in the Nile Valley. Present across Africa and the Middle East.