Trematodes

(Flukes/ flatworms)
Schistosoma spp.
(Blood flukes /"Snail Fever"/ "Bilharziasis")

Paragonimus westermani
(Lung fluke)

Tropical areas (including Mexico & Caribbean)

Second only to malaria in incidence

SE Asia (primarily)
Africa, Latin America

All cases in U.S. are imported (Travelers & Immigrants)

Exception: Swimmers itch (Great lakes)

High incidence rate

Free-living Cercariae
penetrate skin directly in fresh water (also beachs/ shallow water)

Raw/ Undercooked Seafood (crustaceans

especially)

Epidemiology

Fasciolopsis buski
(Giant intestinal fluke)

Fasciola hepatica
(Liver fluke)

Opisthorchis sinesis
(Chinese Liver fluke)

Endemic in SE Asia

Worldwide

Endemic in SE Asia

Eating aquatic plants

(especially water chestnuts)

Eating aquatic plants

Undercooked fish
(Intermediate host = freshwater fish)

Similar life cycle to Schistosoma

(except for skin penetration)

Similar life cycle to Schistosoma

(except for skin penetration)

Eggs excreted in human feces or urine

Eggs hatch in fresh water & form miracidia that penetrate snails
Snails = intermediate host****
Pathophysiology

Larval migration and growth in lung

In snails sporocysts form then become cercariae (infectious form)****

Cercariae penetrate skin and lose their tail to become schistosomulae.

Destruction of lung tissue occurs

Freshwater fish is intermediate host

Rarely invades CNS

Similar life cycle to Schistosoma

(except for skin penetration)

Enter blood, mature in liver

Adults mate in characteristic circulatory sites (worms bisexual)
-Worms are not immunogenic due to molecular mimicry (eggs are though)
Schistosomiasis
Many asymptomatic

Symptoms

Paragonimiasis
Cough, fever
"Rusty sputum"- colored with w/ blood & eggs

Acute Schistosomiasis (Katayaman's Fever) [few weeks after exposure]

Fever, cough, abdominal pain, diarrhea
Rash @ penetration site
Hepatosplenomegaly, eosinophilia
Liver granulomas****

Chronic infection:
Bronchitis & pleural effusions

S. hematobium: [urinary localization]

-Urinary frequency, hematuria, bacteriuria (and GI symp. still)

CNS spread:
Seizures, visual defects, motor weakness

Chronic Schistosomiasis
Deposited eggs cause granulomatous immunologic response
Fibrosis and obstruction also occur

Mnemonic: cowboys/ westerners smoke so

therefore westermani = lung fluke

Increased susceptibility to bacterial infection

Heavy worm burden:

Abdominal pain
Diarrhea
Malabsorption
Intestinal obstruction

Hepatomegaly
RUQ pain
Fever, Chills
Eosinophilia
Hepatitis & Biliary obstruction if worms
occlude bile duct

Usually asymptomatic
In severe infections:
Epigastric pain
Fever
Diarrhea
Hepatomegaly
Jaundice

****Mnemonic: hepatica = liver

Swimmer's Itch (Schistosomal or Cercarial Dermatitis)

Skin rash from larval penetration
Species can't reproduce in humans
Larvae penetrate skin & cannot progress further & die
Great lakes region*****

Detect eggs in feces

Detect eggs in urine for S. hematobium
Diagnosis

S. mansoni: Lateral spine (Charles Manson dagger on SIDE)

Detect eggs in sputum****

Detect eggs in stool

Detect eggs in stool

Detect eggs in stool

Praziquantel

Triclabendazole

Praziquantel

S. hematobium: Terminal spine at end, circular, small

S. japonicum: Circular & small (like a ying-yang symbol)

Praziquantel
Treatment

Praziquantel

Alternative:
Bithionol