Nina Ian John “G” Rachel Mark I Jocelle Edo Gienah Jho Kath Aynz Je Glad Nickay Ricobear

Teacher Dadang Niňa Arlene Vivs Paulfie Rico Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung Tope Ag Bien

S4 L5: Schistosoma (Blood Flukes) by Dr. Mary Antonette Madrid JJaannuuaarryy 2266,,22001111

Bulinus sp. Biomphalaria sp.

SCHISTOSOMIASIS
Caused by digenetic blood trematodes.
The three main species infecting humans are
1. Schistosoma haematobium ( bilharzia worm)
2. Schistosoma japonicum (Japanese blood fluke)
3. Schistosoma mansoni. (Manson’s blood fluke)
Two other species, more localized geographically, are S. mekongi and
S. intercalatum.
In addition, other species of schistosomes, which parasitize birds and
mammals, can cause cercarial dermatitis in humans.

Schistosoma japonicum

Oriental blood fluke

Endemic in China, Philippines, Sulawesi and Indonesia
In the Phil., the first report of schistosomiasis was made by Woolley in
1906
Strains from different geographic areas are distinct although ALL
require Onchomelania snails as intermediate host
Wide range of host
o Dogs, pigs, cats, carabaos, cows, rodent, monkeys –
found to be naturally infected
Some hosts such as humans, monkey, rabbits, and mice are
- Eggs are eliminated with feces or urine; eggs hatch and release miracidia,
considered permissive hosts (S. japonicum matures and oviposits over
extended periods) which swim and penetrate specific snail intermedicate hosts.
- Stages in the snail include 2 generations of sporocysts and the production of
Adult and female worms are primarily parasites of the portal vein and
cercariae.
its branches
- Upon release from the snail, the infective cercariae swim, penetrate the skin
Females: lay up to 200 immature eggs in the branches of the portal
of the human host and shed their forked tail, becoming schistosomulae.
vein which require 10-12 days to mature
- Schistosomulae migrate through several tissues and stages to their target
Eggs escape through ulcerations into the intestinal lumen  exported
residence in the veins.
to feces
- Adult worms in the human reside in the mesenteric venules in various
Embryonated egg comes in contact with water  hatches  liberates
locations; females deposit eggs in the small venule of the portal and
miracidium
perivesical systems and are moved progressively toward the lumen of the
Miracidia infect snail (intermediate host: Oncomelania hupensis
small intestine (S. mansoni & S. japonicum) and of the bladder and ureters
quadrasi), and develop into sporocysts
(S. haematobium) and are eliminated with feces or urine, respectively.
Sporocysts develop into cercariae
Cercariae leave snail host and infect definitive hosts who come in
contact with water by skin penetration ADULT SCHISTOSOMES
60-70 days from miracidial infection of the snail host to formation of
cercariae Adult worms in humans reside in the mesenteric venules in various
Cercariae are transformed into schistosomula after skin penetration locations, which at times seem to be specific for each species.
and find entry to the superficial lymphatic vessels or subcutanesous S. japonicum is more frequently found in the superior mesenteric veins
veins to reach the lungs draining the small intestine
From pulmonary circulation, schistosomulae migrates to the portal vein
S. mansoni occurs more often in the superior mesenteric veins
where they mature.
Egg deposition begins from the 24th to the 27th day after cercarial draining the large intestine
penetration However, both species can occupy either location, and they are capable
of moving between sites
Intermediate hosts S. haematobium most often occurs in the venous plexus of bladder, but
Oncomelania sp. it can also be found in the rectal venules.
Have separate sexes unlike other trematodes
With large sucker capping the anterior end, a ventral sucker and a
gonophore located posterior to the ventral sucker
Suckers aid in movement; enables flukes to maintain position inside the
veins
Incomplete digestive systems; excretory system made up of flame cells.
These internal structures are surrounded by circular and longitudinal
muscles

Page 1 of 5
 Male: shorter, sturdier; measures 12-20mm in length by 0.4 to 0.5mm 2. period of early egg deposition and extrusion
diameter 3. period of tissue proliferation
o Has a gynecophoral canal where the longer female
is held Early schistosomiasis
o Testes arranged in one row above the ventral Itching, chills, fever, cough
sucker
Female: 15 -26 mm by 0.3mm Colonic schistosomiasis
o Single pyramidal ovary located in the midline Ulceration caused by eggs result in dysentery or diarrhea
Worms ingest RBC and possess a protease that breaks down globulin Chronic stage: usually asymptomatic but occasional bouts of diarrhea
and hemoglobin may occur
Utilize glucose and are presumed to absorb nutrients through the body Occasionally chronic colonic schistosomiasis is associated with
wall malignancies

GEOGRAPHIC DISTRIBUTION Hepatosplenic disease

S. mansoni is found in parts of South America and the Caribbean, Africa,
and the Middle East;
S. haematobium in Africa and the Middle East
S. japonicum in the Far East.
S. mekongi and S. intercalatum are found focally in Southeast Asia and
central West Africa, respectively.
In the Philippines, there are 24 endemic provinces
o Includes Sorsogon, Oriental Mindoro, Samar, Leyte, Bohol and all
provinces in Mindanao island except Misamis Oriental
o Highest prevalence of infection is in children 5-15 years of age
PATHOLOGY OF SCHISTOSOMES
S. mansoni and S. japonicum schistosomiasis includes:
Katayama fever, hepatic perisinusoidal egg granulomas, Symmers’ pipe
stem periportal fibrosis, portal hypertension, and occasional embolic egg
granulomas in brain or spinal cord.
S. haematobium schistosomiasis includes:
hematuria, scarring, calcification, squamous cell carcinoma, and
occasional embolic egg granulomas in brain or spinal cord
S. japonicum schistosomiasis includes:
Main pathology: due to host granulomatous reaction to eggs deposited in
the liver and other organs
Quantity of cercariae determine severity of infection
Cercarial penetration may result in
dermatitis (cercarial dermatitis)
Schistosomular migration causes
superficial lung petechiae and
pneumonitis
After egg deposition, there is a granulomatous hypersensitivity reaction
around it
Most serious consequence of granuloma formation in liver is obstruction
of the intrahepatic portal branches  portal hypertension, splenomegaly,
ascites
Hepatosplenomegaly, ascites, collateral circulation
Pulmonary schistosomiasis
Principal manifestation is cor pulmonale from obstruction of lung
vasculature due to granuloma formation and fibrosis
Cerebral schistosomiasis
Acute stages present with fulminating meningoencephalitis with fever,
headache, confusion, lethargy and coma
Chronic cases: gives a clinical picture of a tumor with localizing signs and
inc. intracranial pressure
Among Filipinos, cerebral schistosomiasis is associated with pathology in
other organs (liver and intestines)
CLINICAL FEATURES
Many infections are asymptomatic.
Acute schistosomiasis (Katayama's fever) may occur weeks after the
initial infection, especially by S. mansoni and S. japonicum.
Manifestations: fever, cough, abdominal pain, diarrhea,
hepatospenomegaly, and eosinophilia.
Occasionall, central nervous system lesions occur.
Continuing infection may cause granulomatous reactions and fibrosis in
the affected organs, which may result in manifestations that include:
o colonic polyposis with bloody diarrhea (Schistosoma mansoni
mostly)
o portal hypertension with hematemesis and splenomegaly (S.
mansoni, S. japonicum, S. mansoni)
o cystitis and ureteritis (S. haematobium) with hematuria, which can
progress to bladder cancer
o pulmonary hypertension (S. mansoni, S. japonicum, more rarely S.
haematobium)
o glomerulonephritis
o central nervous system lesions.

CLINICAL ASPECTS

S. japonicum
Course of infection divided into 3 progressive stages
1. incubation: corresponds to period from cercarial penetration and The abdomen of an 11-year-old boy with intestinal schistosomiasis with the size and
schistosomular migration to maturation extent of the liver and spleen marked. Both are well below the midline, indicating the

Page 2 of 5
severity of infection. The disease has caused a stunting of the boy's growth, he is only
120cms tall and weighs 22 kg. WHO/TDR/Crump
(Left) A 13-year-old boy with schistosomiasis, hepatosplenomegaly, ascites,
muscle atrophy, pyrexia, anaemia and haemorrhage from the gastrointestinal tract.
(Right) Two boys, victims of schistosomiasis showing typical distension of the
abdomen.
LABORATORY DIAGNOSIS
Microscopic identification of eggs in stool or urine: most practical method
for diagnosis
Stool examination: S. mansoni or S. japonicum infection
urine examination: S. haematobium
Eggs can be present in the stool in infections with all Schistosoma
species.
The examination can be performed on a simple smear (1 to 2 mg of fecal
material).
Enhance detection of eggs by repeated examinations and/or
concentration procedures (such as the formalin - ethyl acetate technique)
field surveys and investigational purposes: quantify egg output by using
the Kato-Katz technique (20 to 50 mg of fecal material) or the Ritchie
technique.
Eggs can be found in the urine in infections with S. haematobium
(recommended time for collection: between noon and 3 PM) and with S.
japonicum.
Detection will be enhanced by centrifugation and examination of the
sediment.
Quantification is by using filtration through a Nucleopore® membrane of a
standard volume of urine followed by egg counts on the membrane.
Tissue biopsy (rectal biopsy for all species and biopsy of the bladder for
S. haematobium) may demonstrate eggs when stool or urine
examinations are negative.
DIAGNOSIS
S. japonicum
Immunodiagnosis
1. intradermal test for immediate cutaneous hypersensitivity using adult
worm extracts
2. indirect hemmagglutination using adult worm and egg antigens
3. circumoval precipitin test (COPT)
4. ELISA using soluble antigens of adults and eggs
Only COPT, ELISA and indirect hemagglutination using egg antigens
should be used because these are more specific
COPT
Demonstrates formation of bleb or septate precipitates attached to one or
more points on the egg surface after incubation of the eggs in a patients’
serum
Currently regarded as the method of choice for the definitive diagnosis of
schistosomiasis in the Philippines
COPT may take more than 2 years to become neg.
LABORATORY DIAGNOSIS
ANTIBODY DETECTION
Can be useful in both in clinical management (e.g., recent infections) and
for epidemiologic surveys
Can be useful to indicate schistosome infection:
1. Patients who have traveled in schistosomiasis endemic areas
2. Patients in whom eggs cannot be demonstrated in fecal or urine
specimens
Test sensitivity and specificity vary widely among the many tests reported
for the serologic diagnosis of schistosomiasis and are dependent on both
the type of antigen preparations used (crude, purified, adult worm, egg,
cercarial) and the test procedure.
At CDC, a combination of tests with purified adult worm antigens is used
for antibody detection.
All serum specimens are initially tested by FAST-ELISA using
Schistosoma mansoni adult microsomal antigen (MAMA).
A positive reaction (greater than 8 units/µl serum) indicates infection with
Schistosoma species.
o Sensitivity for S. mansoni infection: 99%
o Sensitivity for S. haematobium infection: 95%
o Sensitivity for S. japonicum infection: <50%
o specificity for detecting schistosome infection: 99%
Because test sensitivity with the MAMA is reduced for species other than
S. mansoni, immunoblots of the species appropriate to the patient's travel
history are also tested to ensure detection of S. haematobium and S.
japonicum infections.
o Immunoblots with adult worm microsomal antigens are species-
specific; a positive reaction indicates the infecting species.
o presence of antibody is indicative only of Schistosoma infection at
some time and cannot be correlated with clinical status, worm
burden, egg production, or prognosis.
DIAGNOSTIC FINDINGS
MICROSCOPY
S. mansoni eggs
These eggs are large
Length: 114 to 180 µm
Have a characteristic shape, with a prominent lateral spine near the
posterior end.
The anterior end is tapered and slightly curved.
When the eggs are excreted, they contain a mature miracidium (visible
especially in the first picture).
Page 3 of 5
S. japonicum eggs
DETOX CORNER

Try answering the situation below.

MIDNIGHT CALLER

As you fall asleep, you enter what could be called another world, as far from
this one as any distant star. In that remote space, even familiar voices and sounds seem
alien and strange. It is a world utterly removed from the one where we spend our waking
hours, a world where the mind is free to roam.
You are lying in bed in that foggy zone between consciousness and sleep,
when the telephone at your bedside rings. It takes you a tremendous effort to reach out
The egg is typically oval or subspherical, and has a vestigial spine,
for the receiver, almost as if you were moving underwater. You fumble to get the right
which is better shown in picture below
ends aligned with your mouth and ear and manage to mumble, “Hello?” Who is the voice
Schistosoma japonicum eggs are smaller (68 to 100 µm by 45 to 80 µm) on the other end of the line, and what does that person say to you?
than those of the other species
..........
S. haematobium eggs .........
........
.......
......
.....
....
...
..
.

 In this species, the eggs are large and have a prominent terminal
spine at the posterior end.
 Length 112 to 170 µm.
 greater magnification shows the miracidium inside the egg.
TREATMENT
Safe and effective drugs are available
Drug of choice: Praziquantel
Oxamniquine has been effective in treating infections caused by S.
mansoni in some areas in which praziquantel is less effective.
---------------------------------------------end of trans-------------------------------------------
Siret na?
KEY TO MIDNIGHT CALLER
Being awakened suddenly from a slumber is disorienting and
sometimes a little bit scary. It’s a natural instinct to turn to others for help when
you’re confused or afraid. So although the ringing phone is the cause of your
confusion, the voice you hear on the line is actually someone you depend on in
difficult times.
Whom did you name,and what words of reassurance did they offer
you?
Was it a familiar voice saying, “Hello? It’s your mother. How come you
never call me?” Well, you can always depend on mothers for that.
Or was it a friend calling to talk for no special reason? Sometimes,
that’s the best kind of reassurance when you’re feeling scared.

-Kokology, the game of self discovery

Na-detox ka ba? O lalo ka natoxican? Hehehe 

Page 4 of 5
 Criteria S. japonicum S. mansoni S. haematobium
Geographical distribution China, Indonesia, Japan and Philippines (Mindoro, Samar, Leyte, Africa, South America Africa, Middle East
Sorsogon, Mindanao)
Common name Oriental Blood Fluke Manson’s Blood Fluke Vesical Blood Fluke
Habitat Superior mesenteric veins Inferior mesenteric veins Vesical veins (venous plexus of the bladder)
Disease Caused Oriental Schistosomiasis/ Katayama’s disease Intestinal Bilharziasis/ Schistosomal Dysentery Urinary Bilharziasis/ Schistosomal hematuria
Symptoms Dermatitis, abdominal pain, bloody stool, peri-portal fibrosis, Dermatitis, abdominal pain, bloody stool, peri-portal Dermatitis, urogenital cystitis, urethritis and bladder
hepatosplenomegaly, ascites, CNS fibrosis, hepatosplenomegaly, ascites, CNS carcinoma
Mode of transmission Skin penetration of cercariae in infected water
Snail intermediate host Oncomelania quadrasi Biomphalaria spp., Planorbis, Tropicorbis Bulinus, Physopsis
Infective stage Cercariae
Diagnostic stage Eggs in stool
Ova Oval; w/ small lateral spine; may appear as a small hook or Elongated; prominent lateral spine near posterior end; Elongated; rounded anterior end; terminal spine at
“knob” located in a depression in the shell; tissue or red cekks may anterior end tapered and slightly curved posterior end.
be adherent
Size: 55-65 x 70-100 um Size: 45-70 x 115-175 um Size: 55-65 x 110-170 um
Adult skin Smooth With course tuberculations With fine tuberculations
Number of testes in adult 6-7 4-5 8-9
males
Location of the ovary in Median Anterior Posterior
adult female
Number of eggs produced by 50-100 20-30 1-4
adult female
Uterus in adult females Long and well developed Short Long
Specimen for diagnosis Feces/ Stool Feces/ Stool urine
Specific features and Often coated with debris and may be overlooked Eggs discharged at irregular intervals; may not be found in eggs often covered with debris
varieties stool. Are rare in chronic stages of infection
Stage of Development when Embryonated. Contains mature miracidium
passed
Treatment Praziquantel
Prevention and control Chemotherapy in high prevalence areas, health education, control of Oncomelania quadrasi snails, sanitary disposal of feces

Additional:
SPECIES SHAPE STAGE OF SPECIFIC
DEVELOPMENT FEATURE AND
WHEN PASSED VARIETIES
Schistosoma Elongated; w/ Embryonated. Terminal spine long,
intercalatum tapered anterior end Contains mature slender with bent tip;
& terminal spine; miracidium resembles S.
sometiimes “spindle- Haematobium egg
shaped” except it is longer,
thinner and has
longer spine; found
in feces; debris may
adhere to shell

** Source: From the Lecture, Laboratory notes and CEU College of Medical Technology Parasitology Review Notes by Ma. Cristina Liwanag

Page 5 of 5