CHAPTER

13 Cestodes

LEARNING OBJECTIVES

At the end of this chapter, the student should be able to:

1. describe the general characteristics of the medically important cestodes; and
2. characterize and differentiate the different cestodes as to their:
a. general features,
b. source of infection,
c. mode of transmission,
d. clinical manifestations,
e. treatment, and
f. prevention and control of infection.

General Properties of Cestodes

Cestodes are classified under the subkingdom Metazoa, phylum Platyhelminthes. These
parasites are considered as primitive worms. They do not possess a digestive system nor a
nervous system. They absorb nutrients and eliminate waste products through their outer
surface called the tegument. Commonly known as tapeworms, these parasites are flat and
consist of three distinct regions—the head, neck, and body (proglottids). The head contains
an organ of attachment called the scolex, which may consist of either hooks, suckers, or sucking
grooves. In some species, the scolex has a fleshy extension called a rostellum to which hooks may
be attached.
The body is divided into multiple segments (hence, the name tapeworm) called proglottids.
A series of proglottids is called strobila (plural strobili). All cestodes are hermaphroditic
(self fertilizing) with each proglottid containing both male and female reproductive organs
208 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Each proglottid, therefore, is capable of laying eggs (now called a pregnant proglottid
or gravid segment).
The neck serves as the region of growth and connects the head to the body of the worm.
The worm grows by adding new proglottids from the neck. The oldest proglottids are found at
the most distal part of the body of the parasite.
A typical cestode life cycle is divided into three stages—egg, larva, and adult worm. For the
majority of cestodes, the egg contains an embryo called the oncosphere, which represents the first
larval or motile stage. It is equipped with small hooks (called hooklets) that eventually enable the
parasite to pierce the wall of the intestines. The eggs are excreted in the feces of infected hosts
and are transmitted to the intermediate hosts (cattle, pig, or fish). Infection in humans is usually
acquired through ingestion of the undercooked or raw flesh of the intermediate host containing
the infective larvae. After ingestion, the ingested larvae are transformed into adult worms in
the intestines of the infected host. The adult worm then undergoes self impregnation with the
gravid segment rupturing to release the eggs in the intestines. These eggs are then passed out to
the external environment during defecation.

Intestinal Cestodes
Taenia saginata (Beef Tapeworm)
Important Properties and Life Cycle
The intermediate host is cattle where the eggs enter the blood vessels within the cattle’s
intestines. The eggs are then transported to the skeletal muscles of the cattle where they
develop into cysticerci (larvae). Infection with the beef tapeworm is acquired by ingestion of
improperly cooked or raw beef containing the infective larva (called cysticercus). These larvae
then mature into adult worms (pathogenic stage) in the small intestines within a period of
approximately three months. These tapeworms are known to achieve a length of as much as
10 meters. Humans serve as the definitive hosts.
The eggs of Taenia saginata are usually indistinguishable from the eggs of the pork
tapeworm Taenia solium. Both species may be differentiated by the appearance of their scolices
and the structures of their proglottids. The scolex of Taenia solium contains a rostellum while
that of Taenia saginata does not. Taenia saginata proglottid is rectangular and contains more
uterine branches (about 15–30) in comparison with Taenia solium which is square in appearance
containing about 7–15 uterine branches
 Cestodes 209

Intermidiate Host
(Cattle)

Infection by ingestion of
Definitive Host undercooked contaminated meat
(Man) containing the cysticercus larvae.
Figure 13.1 Life cycle of the beef tapeworm Taenia saginata

Epidemiology and Pathogenesis

Taenia saginata infection is common in areas of the world where beef is routinely eaten,
especially undercooked beef. It has been found to be endemic in Eastern Europe, Russia,
Eastern Africa, and Latin America (Centers for Disease Control and Prevention). The adult
worms do not produce significant damage in the small intestines.

Disease: Taeniasis
Majority of patients are asymptomatic. Those with high worm burden may complain
of diarrhea, abdominal pain, loss of appetite with resultant weight loss, and body malaise.
The gravid proglottids may reach the anus where egg laying may occur resulting in itchiness in
the anal region (pruritus ani).

Laboratory Diagnosis
Examination of fecal specimen from infected patients is the procedure of choice. Eggs
or gravid proglottids may be recovered from the stool although eggs are less often found than
the proglottids
210 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Treatment
The drug of choice against the adult worm is praziquantel.

Prevention and Control

Proper waste disposal and sanitation practices as well as the adequate cooking of beef
are the main preventive measures for taeniasis. Freezing of beef meat for approximately
10 days may kill the encysted larvae. Prompt treatment of infected persons help prevent spread
of the disease.

Taenia solium (Pork Tapeworm)

Important Properties and Life Cycle
Infection with the pork tapeworm is acquired through ingestion of improperly cooked
or raw pork meat which contains the infective larva called cysticercus cellulosae. Unlike the
beef tapeworm, Taenia solium infection can also occur following the ingestion of food or
water contaminated with human feces that contain the eggs of the parasite. Therefore, unlike
the beef tapeworm, Taenia solium has two infective stages—eggs and larvae. Autoinfection
may also occur. Pigs serve as the intermediate host while humans serve as both intermediate
and definitive hosts.
There are two scenarios that can occur depending on which infective stage entered the
human host. In cases where infection is acquired through ingestion of undercooked or raw
pork meat, the infective stage is the larval form which transforms into adult worm in the
intestines of infected individuals. In this instance, humans serve as the definitive hosts. On the
other hand, ingested worm eggs hatch in the small intestines, burrow through the wall of the
intestines into a blood vessel, and disseminate to various organs. In this instance, humans serve
as intermediate hosts.

Table 13.1 Comparison of scolex and gravid segments of Taenia saginata and Taenia solium
Characteristic Taenia saginata Taenia soliu
Scolex
Number of suckers Four Four
Rostellum Absent Present
Hooks Absent Present; double crown
Gravid Proglottid
Appearance, shape Rectangular Somewhat square
Number of uterine branches 15–30 7–15
on each side of uterus
 Cestodes 211

Epidemiology and Pathogenesis

T. solium infection is more prevalent in underdeveloped communities with poor sanitation
and where people eat raw or undercooked pork. Higher rates of illness have been seen in people
in Latin America, Eastern Europe, sub Saharan Africa, India, and Asia (Centers for Disease
Control and Prevention).
Adult worms produce little damage in the intestines. Encysted larvae may produce
damage in the tissues where they disseminate. For instance, in the brain, they may manifest as
space occupying lesions. Although the larvae may encyst in various tissues of the body, they
evoke little inflammatory response. However, when the encysted larvae die, they may release
substances that may induce an allergic reaction in the host which may potentially be fatal due
to the development of anaphylactic shock.

Cysticercus in
Scolex lungs, brain, eyes
attaches
to intestine Circulation

Humans Onchosphere

Gravid Autoinfection
Egg Embryonated
Cysticercus in muscle eggs or
proglottids
ingested
in feces
Proglottid
Circulation Swine

Embryonated eggs
Onchosphere or proglottids ingested

Figure 13.2 Life cycle of the pork tapeworm Taenia solium

Disease
1. Taeniasis – the disease produced by the adult worm. Most cases are asymptomatic
but in the presence of high worm burden, manifestations may be similar to beef
tapeworm infection.
2. Cysticercosis – the result of larval encystation in various tissues of the body. The most
common involvement is that of the skeletal muscles where patients may complai
212 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

of muscle pain. Cyticercosis of the brain (neurocysticercosis) is the most feared and
most severe involvement. It may present with symptoms associated with increased
intracranial pressure such as seizures, headache, and vomiting. Ocular cysticercosis may
lead to visual disturbances due to development of inflammation of the uvea (uveitis) and
retina (retinitis).

Laboratory Diagnosis
Microscopic examination of stool specimen from infected persons is the diagnostic
procedure of choice in patients with taeniasis. Demonstration of ova or proglottids may
help establish the diagnosis. The demonstration of the typical morphology of the scolex can
differentiate pork tapeworm from beef tapeworm. For cysticercosis, diagnostic procedure
depends on demonstration of the cyst in tissue, through biopsy or CT scan.

Treatment
The drug of choice for treatment of intestinal infection is praziquantel. For cysticercosis,
praziquantel may also be effective but it is usually not recommended for ocular and
CNS involvement. Alternative drugs include albendazole, paromomycin, and quinacrine
hydrochloride. Surgical removal of the larvae may be necessary. Anti convulsants may be given
in cases of neurocysticercosis.

Prevention and Control

Important preventive measures for pork tapeworm infection are the same as that for beef
tapeworm and include proper waste disposal and sanitary measures, thorough cooking of pork
meat, and the prompt treatment of infected persons to prevent the spread of the parasite.

Diphyllobothriumlatum (Broad Fish Tapeworm)

Important Properties and Life Cycle
The longest of the tapeworms, the fish tapeworm can reach a length of about 13 meters. Its
eggs consist of ciliated larvae called coracidia (s. coracidium). One end of the egg is occupied by
a lid structure called an operculum. Its scolex contains a pair of long sucking grooves. The gravid
segments contain a uterine structure that is centrally located and assumes a rosette formation.
Human infection with D. latum is through ingestion of improperly cooked or raw fish
containing the plerocercoid (infective stage), the precursor larval stage. After ingestion, the
plerocercoid attaches to the intestinal mucosa and matures into the adult worm. The adul
 Cestodes 213

worm self fertilizes and the eggs are passed out with the stool. If the eggs come to contact
with fresh water, the coracidium hatches and is ingested by the first intermediate host, a
tiny crustacean called a copepod (Cyclops sp.). After ingestion, the coracidium develops into
the larval stage called the procercoid. The copepod is then eaten by a freshwater fish (second
intermediate host) where the procercoid develops into the plerocercoid. Definitive hosts for the
parasites are humans and other fish eating mammals such as dogs, cats, bears, and seals.

Figure 13.3 Life cycle of Diphyllobothrium latum

Epidemiology and Pathogenesis

D. latum infection occurs in countries where raw freshwater fish is consumed. Little damage
is produced in the small intestines of the human hosts. In some individuals, the parasite may
compete with the host for vitamin B12, leading to a deficiency of this vitamin
214 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Disease: Diphyllobothriasis
1. Asymptomatic disease – the most common presentation among most individuals infected
with the parasite.
2. Diphyllobothriasis – may manifest with symptoms of gastrointestinal involvement, which
may include diarrhea and abdominal discomfort. When the adult worm attaches itself to
the jejunum and ileum, the patient may develop deficiency of vitamin B12, leading to
anemia similar to pernicious anemia and is characterized as megaloblastic anemia resulting
from lack of maturation of red blood cells.

Laboratory Diagnosis
Diagnosis is based on finding of the characteristic eggs and/or the proglottids (less
frequent) in a stool specimen.

Treatment
The drug of choice for the treatment of diphyllobothriasis is praziquantel. An alternative
drug is niclosamide.

Prevention and Control

Preventive measures include proper sanitary procedures, thorough cooking of fish prior
to consumption, and the prompt treatment of infected individuals to prevent spread of the
parasite. Freezing of the fish for 24–48 hours at –18 °C can kill all larvae.

Hymenolepis nana (Dwarf Tapeworm)

Important Properties and Life Cycle
H. nana is different from the other tapeworms because it does not require an obligatory
intermediate animal host. The eggs are directly infectious and humans get the infection
after the accidental ingestion of the eggs of the parasite. This may occur after ingestion
of fecally contaminated food or water. One may also acquire the eggs by touching one’s
mouth with contaminated fingers or through ingestion of contaminated soil. Accidental
ingestion of rice or flour beetles containing the infective larvae and that may have gotten
into food is another way by which the infection may be acquired. Rodents serve as additional
source of infection
 Cestodes 215

Once the eggs (infective stage) gain entrance into the human host after ingestion of
contaminated food and water, the eggs transform into cysticercoid larvae. The larvae mature
into adult worms capable of self reproduction. Eggs are released after disintegration of the
gravid segments. There are two pathways for the eggs—the eggs may be passed to the outside
environment through the feces or some of the eggs may remain inside the human host. Those
that remain inside the human host hatch into larvae and mature into adult worms, thereby
starting a new cycle within the human host. This type of re infection is called autoinfection.

Epidemiology and Pathogenesis

The dwarf tapeworm is the most common tapeworm recovered in the United States. It has
a worldwide distribution and is also found in East Asia and the Philippines. It is common in
areas with inadequate sanitation and hygiene. Children and persons living in crowded areas are
at risk of developing infection. The parasite produces little damage in the small intestines.

= Infective Stage
= Diagnostic Stage

Oncosphere hatches
5 Cysticercoid develops
3 Humans and rodents are
infected when they ingest in intestinal villus
cysticercoid infected arthropods.

Cysticercoid
develops in
9 Autoinfection can occur
if
insect eggs remain in the intestine.
The eggs then release the
4 Scolex
hexacanth embryo, which
Embryonated egg penetrates the intestinal villus
ingested by humans continuing the cycle.
from contaminated
food, water, or hands

Adult ileal 7
portion of small
Egg ingested
by insect intestin
2

Eggs can be released through the

8 genital atrium of the gravid proglottids.
Gravid proglottids can also disintegrate
1 Embryonated egg in feces releasing eggs that are passed in stools.

Figure 13.4 Life cycle of Hymenolepis nana

216 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Disease: Hymenolepiasis
Most patients are asymptomatic. In cases of high worm burden, patients may complain of
nausea, weakness, loss of appetite, diarrhea, and abdominal pain. In young children with heavy
infection, anal itchiness (pruritus ani) may occur leading to headaches due to difficulty sleeping.
It can be confused with a pinworm infection. Autoinfection may lead to hyper infection
syndrome which can result in secondary bacterial infection and spread of the worms to other
tissues of the body.

Laboratory Diagnosis
Diagnosis is established by finding of the characteristic eggs in stool specimen.

Treatment
Praziquantel is the drug of choice. Niclosamide can be an alternative drug.

Prevention and Control

Important preventive measures include proper hygiene and waste disposal, control of
transport host population, and rodent control. Proper storage of grains and flour must be
observed to prevent infestation with flour and grain beetles. Prompt treatment of infected
individuals must be instituted to prevent the spread of the parasite.

Extra Intestinal Cestode

Echinococcusgranulosus
(Dog Tapeworm or Hydatid Tapeworm)
Important Properties and Life Cycle
Infection with E. granulosus is primarily a zoonotic type of infection. Dogs are the most
important definitive hosts while sheep are usually the intermediate hosts. Humans are
considered as accidental and dead end hosts. The eggs of E. granulosus are identical to those of
Taenia spp. and are thus not diagnostic. The diagnostic stage of the parasite is its larval form,
which is encased in a cyst wall and is called the hydatid cyst.
Infection is acquired after ingestion of eggs (infective stage) from food and water
contaminated by dog feces or through contact with contaminated dog feces. Eggs transform
into larvae in the intestines, penetrate the intestines, and migrate through the bloodstrea
 Cestodes 217

to different tissues in the body, particularly the liver and the lungs. The hydatid cyst
(pathogenic stage) then develops in the infected tissues. Dogs acquire the parasite by eating the
visceral organs of the intermediate host.

4
Adult flea harbours
the infective cysticercoid. Humans, normally children,
7 acquire the infection by
5 ingesting the infected flea.
Cysticercoid
Host is infected
by ingesting fleas
Infected larval containing cysticercoid.
stage develop
into adult flea.

Oncosphere Cysticercoid
Scolex attaches
Oncospheres hatch from in intestine
the eggs and penetrate Animals can transmit the
the intestinal wall of the 3 infected fleas to humans.
larvae. Cysticercoid larvae
develop in the body cavity. Gravid proglottids are
passed intact in the feces
or emerge from perianal
1 region of either animal
or human hosts. 8 Adult in small intestin
2
Egg packets containing Each proglottid contains egg packets
embryonated eggs that are held together by an outer
are ingested by larval embryonic membrane (see 2 ).
stage of flea. The proglottids disintegrate and
release the egg packets.
= Infective Stage
= Diagnostic Stage

Figure 13.5 Life cycle of Echinococcus granulosus

Epidemiology and Pathogenesis

E. granulosus infection is common in Africa, Europe, Asia, the Middle East, Central and
South America, and in rare cases, North America (Center for Disease Control and Prevention).
The embryos develop into large, fluid filled hydatid cysts, which act as space occupying lesions.
In addition, the cyst fluid contains antigens that can sensitize the host. Rupture of the cyst,
either spontaneously or during trauma or surgical removal, may lead to the release of these
antigens leading to anaphylaxis and widespread dissemination of the parasite.
218 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Disease: Echinococcosis, Hydatid Cyst Disease,

Hydatid Disease, Hydatidosis
Most patients are asymptomatic during the early stages of the disease. However, as the cysts
enlarge, necrosis of the infected tissues occur. Involvement of the liver may result in obstructive
jaundice. Patients with lung involvement may manifest with cough, chest pain, and shortness of
breath. Other organs that may be infected include the spleen, kidneys, heart, bone, and central
nervous system, including the brain and eyes (Center for Disease Control and Prevention). Cyst
rupture may lead to anaphylactic shock leading to death of the patient.

Laboratory Diagnosis
There are several ways by which E. granulosus infection can be diagnosed. These
include (1) examination of biopsy specimen; (2) serologic tests (e.g., ELISA or indirect
hemagglutinationtest); and (3) radiography to demonstrate the hydatid cysts (e.g., CT scan or
ultrasound). Care should be exercised when doing biopsy to prevent rupture of the cyst.

Treatment
In cases when surgery is possible, removal of the cyst has been considered as the treatment
of choice. However, medical management alone may prove effective, especially if the cyst is
located in inaccessible areas. Drugs that have been proven effective include mebendazole,
albendazole, and praziquantel.

Prevention and Control

Improvement of personal hygiene practices, prevention of contamination of food and
water with dog feces, avoidance of feeding pet dogs with contaminated viscera, and the
prompt treatment of infected canines and humans are some measures to prevent the spread of
the parasite. Chemoprophylaxis should be given to dogs in endemic areas. Health education
is essential
 Cestodes 219

CHAPTER SUMMARY

• Cestodes are primitive worms that do not possess a digestive system nor a nervous
system. They absorb nutrients and eliminate wastes through their outer covering called
the tegument.

• Aandtypical cestode consists of a head containing the organ of attachment (scolex), a neck,
the body which is divided into segments called proglottids.

• All cestodes are hermaphroditic and capable of self reproduction. Eggs are released
disintegration of the gravid proglottids and are released to the outer environment with
by

the feces.

• The major mode of transmission for all cestodes is through ingestion of the infective
stage, usually the eggs, found in contaminated water, soil, or food.

• The major intestinal cestodes are Taenia saginata (beef tapeworm), Taenia solium
(pork tapeworm), Diphyllobothrium latum (broad fish tapeworm), and Hymenolepis nana
(dwarf tapeworm).

• Both beef and pork tapeworm infections are acquired through ingestion of raw or
undercooked beef or pork meat.
» Cattle serve as the intermediate hosts for the beef tapeworm while pig or swine serve
as the intermediate hosts for the pork tapeworm.
» The infective stage for T. saginata is the cysticercus larva while for T. solium both the
egg and the larva (cysticercus cellulosae) serve as the infective stages.
» The adult worms serve as the pathogenic stage for both beef and pork tapeworms.
Larvae may also serve as the pathogenic stage for pork tapeworm if the infective stage
is the egg.
» The adult worm for both tapeworms produces the disease taeniasis. The larval form
of the pork tapeworm encysts in tissues leading to the development of cysticercosis,
the most severe form of which is neurocysticercosis.

• [Link]
latum is unique among the tapeworms because it has two intermediate hosts. The
host is the copepod, a tiny crustacean which is ingested by the second
first

intermediate host, the freshwater fish.

• There is no obligatory animal intermediate host for E. granulosum. Unlike the other
tapeworms, humans only serve as accidental and dead end hosts for the parasite
 Cestodes 221

SELF ASSESSMENT QUESTIONS

Name: Score:
Section: Date:

Matching Type.

Column A Column B
1. Dogs serve as the definitive host a. Taenia saginata
2. Has two intermediate hosts b. Taenia solium
c. Diphyllobothrium
3. Autoinfection can occur latum
4. Acquired through ingestion of raw beef d. Hymenolepis nana
5. Has no obligatory intermediate host e. Echinococcus
granulosu
6. Obstructive jaundice may occur
7. A tiny crustacean serves as intermediate host
8. Megaloblastic anemia may develop
9. Cysticercosis develops after ingestion of eggs
10. Humans serve as dead end hosts

Identification.

11. The infective stage for D. latum.

12. The organ of attachment of cestodes.
13. The usual intermediate host for E. granulosus.
14. The most commonly recovered tapeworm in the U.S.
15. Anal itchiness occurs in infection with this cestode.
 CHAPTER

14 Trematodes

LEARNING OBJECTIVES

At the end of this chapter, the student should be able to:

1. describe the general characteristics of the medically important trematodes; and
2. characterize and differentiate the different trematodes as to their:
a. general features,
b. source of infection,
c. mode of transmission,
d. clinical manifestations,
e. treatment, and
f. prevention and control of infection.

General Properties of Trematodes

Trematodes, commonly known as flukes, belong to the class Trematoda or Digenea.
They may be hermaphroditic or dioecious (reproduce via separate sexes). Most flukes are
hermaphroditic except Schistosoma spp. (blood flukes). Morphologically, flukes are fleshy,
leaf shaped worms. Unlike tapeworms, flukes have a digestive tract. In general, flukes have two
muscular suckers—an oral type, which is the beginning of an incomplete digestive system and a
ventral sucker which serves for attachment.
The eggs of the trematodes vary in appearance and are the primary morphologic stage
that are usually recovered from humans. Some eggs may possess a lid like structure that can
flip open to release its contents. This lid like structure is called operculum and is present in the
eggs of Fasciolopsis and Fasciola. In Schistosoma spp., the eggs of the various members may be
differentiated based on the presence and location of spines
224 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Unlike in cestode infections, humans never serve as intermediate hosts for the flukes.
In general, flukes have two intermediate hosts except for the blood flukes where there is
only one intermediate host. Common to all trematodes, the first intermediate hosts are
mollusks (snails and clams) where asexual reproduction takes place. The second intermediate
host varies depending on the parasite. Sexual reproduction of flukes occurs in humans.
In most cases, humans acquire the infection through ingestion of undercooked or raw second
intermediate host. Skin penetration by the infective larvae is the major mode of transmission
for blood flukes.

Blood dwelling Flukes

Schistosomaspp.
Important Properties and Life Cycle
Three schistosomes are frequently associated with human disease, namely: Schistosoma
mansoni, Schistosoma japonicum, and Schistosoma haematobium. Blood flukes are dioecious.
Known as the “romantic parasites,” the male and female worms are usually in a state of
copulation (en copula). Female worms are usually larger than the male worms. The schistosomes
are also obligate intravascular parasites.
The eggs are found in fresh water contaminated with the feces or urine of infected
humans. Once in the water, eggs develop into a miracidium, that will then locate a snail as
its host, where it transforms into cercariae. Infection is acquired through skin penetration by
the fork tailed cercaria (larval form). The parasite migrates into the bloodstream where they
undergo maturation.
The location of the adults varies by species. For Schistosoma japonicum and Schistosoma
mansoni, after skin penetration, the worms enter the veins surrounding the intestinal tract
(superior and inferior mesenteric and portal vein for S. japonicum; inferior mesenteric for
S. mansoni). Schistosoma haematobium worms localize in the veins surrounding the urinary
bladder. The adult worms lay thousands of eggs per day. The eggs produce enzymes that enable
them to travel through the tissue. The eggs then find their way into the colon (for S. japonicum
and S. mansoni) or into urine (for S. haematobium) from which they are excreted
 Trematodes 225

Figure 14.1 General life cycle of Schistosoma spp.

Epidemiology and Pathogenesis

Schistosoma mansoni and Schistosoma haematobium are both distributed throughout
Africa. S. mansoni is also found in South America while S. haematobium is also prevalent in
the Middle East. Schistosoma japonicum is endemic in Indonesia, some parts of China, and
Southeast Asia, including the Philippines. It is the only schistosome for which domestic
animals (e.g., water buffalo and pigs) act as important reservoirs.
Most of the findings are caused by the presence of eggs in the liver, spleen, or walls of
the gut or the urinary bladder, depending on which species is causing the infection. Eggs of
S. japonicum in the liver may induce granuloma formation leading to fibrosis and portal
hypertension, as well as damage the walls of the small and large intestines. Eggs of S. mansoni
may damage the walls of the distal colon. Eggs of S. haematobium may induce granuloma and
fibrosis in the walls of the urinary bladder
226 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Disease: Schistosomiasis (Bilharziasis)

1. Asymptomatic infection – the most common form of the disease. Chronic infection may
become symptomatic.
2. Early acute infection – characterized by pruritic papules seen at the site of entry of the
parasite. This is called “swimmer’s itch” or “clam digger’s itch.” This is followed after
2–3 weeks by fever and chills, abdominal pain, cough, bloody diarrhea, and weight loss.
Painful urination (dysuria) and blood in the urine (hematuria) may also occur in patients
infected with S. haematobium.
3. Katayama fever – a systemic hypersensitivity reaction to the migrating schistosomes,
usually associated with S. japonicum. It is characterized by a rapid onset of fever, myalgia,
body malaise, cough, diarrhea, and eosinophilia occurring 1–2 months after exposure to
the parasite. Swollen lymph nodes (lymphadenopathy) and enlargement of the liver and
spleen (hepatosplenomegaly)may also occur. It can lead to hepatic dysfunction, leading
to portal hypertension. The most common cause of death in this case is internal bleeding
from ruptured esophageal varices.
4. Associated conditions – include development of nephrotic syndrome in S. japonicum
and S. haematobium infection. Infection with S. mansoni or S. japonicum may predispose
to repeated Salmonella infections. S. japonicum is associated with the development of
hepatocellular carcinoma or liver cancer while S. haematobium has been implicated in the
development of cancer of the urinary bladder.

Figure 14.2 Swimmer’s itch

following skin penetration
by the cercariae of Schistosoma spp.
Source: Cornellier, 200
 Trematodes 227

Laboratory Diagnosis
Diagnosis relies on demonstration of characteristic eggs in the feces or rectal biopsy
specimen for S. mansoni or S. japonicum, or urine for S. haematobium. S. mansoni eggs have a
large lateral spine while S. japonicum eggs have a rudimentary spine. The eggs of S. haematobium
have large terminal spines.

a b c

Figure 14.3 Schistosoma ova: a S. mansoni; b S. haematobium; and c S. japonicum

Treatment
The recommended drug for all three species is praziquantel. An alternative drug for
S. mansoni is oxamniquine. Anti malaria drugs such as artemether and artemisinins have also
been proven effective.

Prevention and Control

There are two objectives of schistosomal control: (a) control of transmission through snail
control, health education, and provision of sanitary facilities and water supply; and (b) control
of disease. Chemotherapy using praziquantel is the main thrust of the Philippine program for
schistosomiasis control (Department of Health). In order to prevent infection, swimming in
endemic areas should be avoided.

Tissue dwelling Flukes

Clonorchis sinensis (Asian Liver Fluke, Chinese Liver Fluke)
Important Properties and Life Cycle
There are three morphologic stages of the parasite—egg, larva, and adult. The egg have
an operculum surrounded by a thick rim called the shoulder. The first intermediate host is
the freshwater snail while the second intermediate host is a freshwater fish. Within the egg
is the developed miracidium, that is released once the egg comes into contact with fresh water
228 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

The miracidium penetrates the first intermediate host and develops into a sporocyst that
contains numerous larval stages called the rediae. The larvae are then released into the water
where they transform into cercariae. The cercariae enter a freshwater fish where they encyst
to become the metacercariae. The larvae excyst in the duodenum, enter the biliary ducts,
and differentiate into adults. The adult worms produce eggs that are excreted in the feces.
Humans acquire the infection by ingesting raw or undercooked freshwater fish containing the
infective metacercariae.

Metacercariae in flesh or
skin of fresh water fish are
ingested by human host. = Infective Stage
4 = Diagnostic Stage

Free swimming cercariae

encyst in the skin or flesh
of fresh water fish. 3
5 Excyst in
duodenum

Eggs are ingested

by the snail. 2

6 Adults in
biliary duc

Miracidia Sporocysts Rediae Cercariae 1 Embryonated eggs

2a 2b 2c 2d passed in feces

Figure 14.4 Life cycle of Clonorchis sinensis

Epidemiology and Pathogenesis

Clonorchis sinensis is found in Asia including Korea, China, Taiwan, Vietnam, Japan, and
Asian Russia (Center for Disease Control and Prevention). The parasite does not usually
cause significant lesions, however, parasites that inhabit the bile ducts can damage the
biliary tract. Patients who develop infection with the parasite are at higher risk of developing
cholangiocarcinoma or cancer of the bile ducts. The egg has also been associated with the
development of gallstones (stones in the gall bladder or cholelithiasis).
 Trematodes 22

Disease: Clonorchiasis
Most patients are asymptomatic. In heavy worm burden, patients may manifest a fever,
upper abdominal pain, anorexia, hepatomegaly, diarrhea, and eosinophilia. Liver dysfunction
may also occur in chronic infection associated with heavy worm burden.

Laboratory Diagnosis
Diagnosis is established by finding the characteristic eggs in stool specimen or duodenal
aspirates.

Treatment
The drug of choice for treatment is praziquantel. An alternative drug is albendazole.

Prevention and Control

Infection can be prevented by thorough cooking of fish prior to consumption. Other control
measures include health education, proper waste disposal to avoid contamination of bodies of
fresh water, and prompt treatment of infected persons.

Fasciola hepatica (Sheep Liver Fluke)

Important Properties and Life Cycle
The Fasciola hepatica eggs possess an operculum similar to Clonorchis sinensis and is also
equipped with shoulders. The first intermediate host for the parasite is the snail while the
second intermediate hosts are edible aquatic plants (kangkong and watercress). Humans acquire
the infection by ingesting raw edible aquatic plants or by drinking water contaminated by
metacercariae (infective stage). Upon ingestion, the metacercariae excyst in the duodenum or
jejunum, releasing the young flukes. These young flukes wander over the viscera until they reach
the liver capsule. The parasite then burrows through the liver parenchyma until it finally enters
the bile ducts where they mature.
The adult worms (pathogenic stage) live in the biliary passages of the liver. Immature eggs
are carried by the bile into the intestines and subsequently excreted with feces. The eggs mature
in the water and infect the first intermediate host. The cercariae escape the snail host, usually at
night, then encyst on the surface of aquatic plants, forming metacercariae. The natural host for
the completion of the life cycle is the sheep, however the parasite may also be found in cattle.
In sheep raising countries, ingestion of raw sheep liver containing the adult worm also serves as
an additional mode of transmission. Humans serve as accidental hosts.
230 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Figure 14.5 Life cycle of Fasciola hepatica

Epidemiology and Pathogenesis

The Fasciola hepatica is found worldwide, especially in sheep and cattle raising countries,
and where humans consume raw watercress such as Asia, Europe, and the Middle East.
The stages of the disease correspond with the migration of the parasites. The acute or invasive
phase corresponds to the migration of the parasite through the liver parenchyma, which leads
to traumatic and necrotic lesions in the liver. The severity of the destruction is proportional to
the number of metacercariae ingested. The chronic phase corresponds to the localization of the
adult worms to the bile ducts. The worm can obstruct the bile duct and stimulate inflammation.
During migration from the intestines to the liver, the parasite may wander to other sites
(e.g., lungs, subcutaneous tissues, brain, or orbit) where abscesses may develop
 Trematodes 23

Disease: Fascioliasis or Sheep Liver Rot

Migration of the larval worm through the liver irritates the organ, manifesting as
tenderness and hepatomegaly. Characteristic clinical features include right upper quadrant pain,
fever and chills, and marked eosinophilia. Hepatitis may develop with biliary obstruction. Some
worms may cause necrotic foci in the liver. Ingestion of raw sheep liver may lead to temporary
lodgment of the adult worm in the pharynx leading to suffocation.

Laboratory Diagnosis
Diagnosis rests on finding of eggs in stool specimen, although the appearance of the
eggs of F. hepatica may be indistinguishable from the eggs of another fluke, Fasciolopsis buski.
Examination of a sample of the patient’s bile may aid in the differentiation. If the eggs are
present in bile then this is indicative of F. hepatica. Other tests that can be performed include
ELISA and the Enterotest (discussed in Chapter 11).

Treatment
The treatment of choice is dichlorophenol (bithionol). An alternative drug is
triclabendazole.

Prevention and Control

Preventive measures include proper human waste disposal, improvement of hygiene, control
of snail population, and avoidance of consumption of raw aquatic plants and contaminated
water. In endemic areas it is highly recommended to boil water before consumption or use.
Avoidance of ingesting of raw sheep liver is also important, as well as prompt treatment of
infected individuals.

Paragonimus westermani (Oriental Lung Fluke)

Important Properties and Life Cycle
Similar to other trematodes, the first intermediate host for Paragonimus is a snail while
the second intermediate hosts are crabs or crayfish. Humans acquire the infection by ingesting
raw or undercooked crabs or crayfish that contain the infective encysted metacercaria. The
larva excysts in the small intestines, migrate through the intestinal wall, through the peritoneal
cavity, into the diaphragm then into the lung parenchyma where they mature. The adult worms
enter the bronchioles and are then coughed up or swallowed. Eggs in the sputum or feces reach
fresh water, hatch, and penetrate the first intermediate host, where they differentiate into free
swimming cercariae. The cercariae leave the snail host and encyst in freshwater crabs that are
eaten by humans.
232 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Cercariae invade the crustacean

5
and encyst into metacercariae.
4a 4b 4c

Sporocysts Rediae Cercariae

Humans ingest 6
inadequately
cooked or pickled
4 crustaceans containing
metacercariae.
7

Excyst in
3 duodenum
Miracidia hatch
and penetrate snail 8

Adults in cystic
cavities in lungs
lay eggs which
are excreted
in sputum.
2 Embryonated eggs Alternately, eggs
are swallowed
= Infective Stage
1 Unembryonated eggs and passed
with stool.
= Diagnostic Stage
Figure 14.6 Life cycle of Paragonimus westermani

Figure 14.7 A freshwater crab that has

been implicated in the transmission of
Paragonimus westerman
 Trematodes 23

Epidemiology and Pathogenesis

P. westermani infection occurs most commonly in Asia, in countries like China, the
Philippines, Japan, Vietnam, South Korea, Taiwan, and Thailand (Centers for Disease Control
and Prevention). Pigs, monkeys, and other animals that eat crayfish and crabs serve as reservoir
hosts. The worms exist in a fibrous capsule within the lung which communicates with a
bronchiole. Within this cyst is blood tinged purulent material containing eggs. Secondary
bacterial infection frequently occurs.

Disease: Paragonimiasis (Pulmonary distomiasis, Endemic hemoptysis,

Parasitic hemoptysis)
The early stages of the disease are usually asymptomatic. Patients may later experience
symptoms related to pulmonary involvement including cough productive of blood tinged
sputum (hemoptysis), fever, and chest pain. The sputum has a foul, fishy odor and is most
pronounced in the morning. The disease may mimic pulmonary tuberculosis. In rare cases,
the immature flukes may migrate to the brain leading to cerebral paragonimiasis, which may
manifest as seizures, visual disturbances, and reduced motor skill precision.

Laboratory Diagnosis
Diagnosis is made by demonstration of the characteristic eggs in sputum or feces (when
sputum is swallowed). A chest x ray may be done which may show a ring shadowed opacity
with several contiguous cavities giving the appearance of a cluster of grapes.

Treatment
The drug of choice for treatment is praziquantel. An alternative drug is bithionol.

Prevention and Control

Preventive measures include adequate and thorough cooking of freshwater crabs or crayfish,
health education, control of snail population, and elimination of reservoir hosts. Prompt
treatment of infected persons is also important to prevent the parasite from spreading.

Fasciolopsis buski (Large Intestinal Fluke)

Important Properties and Life Cycle
The eggs of F. buski and F. hepatica are mophologically identical however they differ only
in size. The adult worms of both parasites are also similar in appearance except that shoulders
234 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

are present in F. hepatica and not in F. buski. Similar to the other tissue dwelling trematodes,
the first intermediate host is a snail while the second intermediate hosts are edible aquatic
plants (e.g., watercress and lotus).
Humans acquire the parasite by ingestion of raw or inadequately cooked aquatic vegetation
that carries the encysted metacercariae. The metacercariae excysts in the duodenum and
attaches to the intestinal wall where they attain maturity. The adult worms lay eggs, that are
released together with the feces into water, where they hatch and infect the first intermediate
host. The eggs develop into cercariae which encyst as metacercariae on the surface of the
aquatic plants. Other animals such as pigs and dogs may also serve as the reservoir hosts.

6 Metacercariae
on water plant
4a 4b 4c ingested by
Sporocysts Rediae Cercariae 5 Free swimming
cercariae
humans or pigs,
causing infection

in snail tissue

4 Snail
7 Excyst in
duodenum

3
7
Miracidia hatch,
penetrate snail 8

2 Embryonated eggs
in water
8
= Infective Stage 1 Unembryonated eggs Adults in
passed in feces small intestin
= Diagnostic Stage

Figure 14.8 Life cycle of Fasciolopsis buski

 Trematodes 23

Epidemiology and Pathogenesis

F. buski is the largest intestinal fluke that can infect humans. Infection with the parasite
is common in Asia and the Indian subcontinent, particularly in areas where pigs are raised
and where freshwater aquatic vegetation is ingested raw. No locally acquired cases in humans
or pigs have been reported in the Philippines. Pathologic changes are due to damage to the
intestinal mucosa by the adult fluke.

Disease: Fasciolopsiasis
Most infected persons are asymptomatic. However, with heavy worm burden, patients
may experience abdominal discomfort with inflammation and bleeding in the affected area.
Ulcerations may occur and symptoms may mimic those of duodenal ulcer. Patients may also
suffer from malabsorption. Intoxication may result from absorption of worm metabolites by the
host, leading to allergic symptoms such as edema of the face, abdominal wall, and lower limbs.
Profound intoxication can result in death.

Laboratory Diagnosis
Diagnosis is made by demonstration of the eggs in stool specimen. Examination of bile
samples and duodenal aspirates may help differentiate F. buski eggs from those of F. hepatica.

Treatment
The drug of choice for treatment is praziquantel.

Prevention and Control

Adequate washing and cooking of aquatic plants before consumption can help prevent
infection. Other measures include proper disposal of human waste, control of snail population,
and prompt treatment of infected persons.
236 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

CHAPTER SUMMARY

• Trematodes, also known as flukes, are worms that possess a primitive digestive tract.
• Trematodes
flukes.
may be divided into two classes—tissue dwelling flukes and blood dwelling

» Tissue dwelling flukes include Clonorchis sinensis, Fasciola hepatica, Paragonimus

westermani, and Fasciolopsis buski.

› All tissue dwelling flukes have two intermediate hosts.

› The first intermediate host is always a snail.
› Second intermediate hosts include freshwater fish, crabs or crayfish, and edible
aquatic plants.
› All are transmitted by ingestion of raw or inadequately cooked second intermediate
host.

› The infective stage is the encysted metacercaria.

» Blood dwelling flukes are the schistosomes which are composed of three
japonicum, Schistosoma mansoni, and Schistosoma haematobium. species—Schistosoma

› Blood flukes do not have a second intermediate host. The intermediate host is the
freshwater snail.

› The major mode of transmission is skin penetration by the infective fork tailed
cercaria.

› The pathogenic stage is the adult worm except for S. japonicum where the eggs also
serve as the pathogenic stage.

› [Link] has predilection for the superior and inferior mesenteric veins.
adult female migrates to the portal vein where egg laying may occur. S. mansoni
adult worms localize to the inferior mesenteric veins while S. haematobium worms
localize to the veins around the urinary bladder.

• Patients with S. japonicum infection are at a higher risk for development of liver cancer
while those with S. haematobium infection are more prone to develop cancer of the
urinary bladder.

• sinensis and Fasciola hepatica can lead to development of obstructive jaundice.

Clonorchis

• buski produce disease manifestations that mimic duodenal ulcer.

Fasciolopsis

• Paragonimus westermani produce symptoms that mimic pulmonary tuberculosis

 Trematodes 237

SELF ASSESSMENT QUESTIONS

Name: Score:
Section: Date

Multiple Choice.

1. The first intermediate host common to the trematodes is the:

a. Fish c. Snail
b. Crab d. Water plant
2. Which among the following is the second intermediate host of P. westermani?
a. Fish c. Snail
b. Crab d. Water plant
3. Which among the following schistosomes has predilection for the urinary
bladder?

a. S. japonicum c. S. mansoni
b. S. haematobium d. A and C only
4. Which among the following is a characteristic of blood flukes?
a. Transmitted by skin penetration
b. Second intermediate host is a snail
c. Capable of self reproduction
d. A, B, and C
e. A and C only

5. Cholangiocarcinoma is associated with which among the following flukes?

a. Clonorchis sinensis c. Paragonimus westermani
b. Fasciola hepatica d. Schistosoma japonicum
238 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

6. The lid like structure seen on the eggs of F. buski and F. hepatica is called:
a. Miracidium c. Rediae
b. Operculum d. Shoulder
7. The specimen of choice for diagnosis is the sputum for which among the
following?

a. F. buski c. P. westermani
b. F. hepatica d. S. japonicum
8. Katayama fever is associated with:
a. S. japonicum c. F. hepatica
b. P. westermani d. C. sinensis
9. Schistosoma japonicum is associated with development with cancer of the:

a. Bile ducts c. Liver

b. Colon d. Urinary bladder
10. The drug of choice for most trematode infection is:
a. Bithionol c. Praziquantel
b. Mebendazole d. Triclabendazol