Liver Flukes

Bien AgNina Ian John “G” Rachel Mark Jocelle Edo Gienah Jho Kath Aynz Je Glad Nickie Ricobear Teacher Dadang Niňa Arlene Vivs Paul F. Rico F. Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung Tope

S4 L7: TREMATODES (LIVER FLUKES) by Maria Cielo B. Malijan, MD, DPPS, FPSDBP Liver Flukes Clonorchis sinensis Opistorchis felineus Opistorchis viverinii Fasciola hepatica Fasciola gigantica Dicrocoelium dendriticum Life Cycle All trematodes follow the above cycle, EXCEPT Schistosoma sp. Adult liver flukes that live in the biliary passages irritate the ducts. Adenomatous proliferation can result to partial obstruction.

Clonorchis sinensis Common Name: CHINESE LIVER FLUKE Diseases Clonorchiasis Liver Cancer Geographic Distribution an important parasite of humans in the Far East a parasite of fish eating mammals and humans in Japan, China, South Korea, Formosa and Vietnam Morphology Flat, spatulate, aspinous, flabby, transparent gray worm tapering anteriorly and somewhat rounded posteriorly Measures 12 to 20 mm (10 to 25 mm) by 3 to 5 mm Ventral sucker smaller than oral sucker Long intestinal ceca extending to the posterior end Large deeply lobulated or branched testes in tandem formation in the posterior third of the body Small, slightly lobate ovary anterior to the testes in the midline Loosely coiled uterus arising from the ootype ending in the common genital pore Minutely follicular vitellaria in the lateral midportion of the body

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) All trematodes are hermaphroditic EXCEPT the blood flukes (Schistosoma sp.) Ovum Broadly ovoid, 29 x 16 u Has a moderately thick, light yellowish brown shell At the smaller end is a distinct convex operculum which fits into a rimmed extension of the shell. At the thicker posterior end is a small median protuberance. Life Cycle

Trematode Egg (Prototype) Contains a fertilized ovum Shape, appearance and size – depending on the species Contains a cap-like operculum, EXCEPT Schistosoma sp.

Page 1 of 7

Praziquantel o 25 mg/kg TID for 2 consecutive days or 75 mg/kg in 3 doses 4 to 6 hours apart o no treatment failure and only mild side effects – headache and dizziness Heavy infections complicated by obstructive jaundice o cholecystectomy with choledocholithotomy o exploration of the common duct o drainage procedure such as sphincteroplasty or o choledochoduodenostomy Prevention and Control 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 felineus Common Name: CAT LIVER FLUKE Disease: Opistorchiasis felineus Geographic Distribution prevalent in eastern and southeastern Europe and Asiatic areas of the former USSR found in humans in the highly endemic areas of Poland and the Dnieper, Donetz and Desna basins Pathology distal bile ducts are irritated mechanically and by its toxic secretions slight leukocytosis and eosinophilia in early infection enlarged tender liver bile ducts thicken and become dilated and tortuous adenomatous proliferation of the biliary epithelium fibrosis and destruction of hepatic parenchyma liver function is impaired although SGPT and SGOT are normal Symptomatology Light infections o produce only mild symptoms or go unnoticed Moderate infections o indigestion o epigastric discomfort unrelated to meals o weakness o loss of weight Heavy infections o complicated by cholelethiasis and bouts of pyogenic cholangitis

Morphology lancet in shape 7 to 12 mm by 2 to 3 mm rounded posteriorly and attenuated anteriorly thin and transparent; reddish bile colored has a smooth integument two suckers equal in diameter; oral sucker subterminal two testes lobed and situated obliquely to each other in the posterior fourth of the worm ovary small, oval or slightly lobed is median in position just in front of the anterior end of the bladder vitellaria consist of numerous transversely compressed follicles disposed in the lateral fields in the middle third of the body uterus – an intricately coiled tubule from the ootype that proceeds anteriad

Diagnosis Clinical Diagnosis o 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 o finding the characteristic eggs in the feces or biliary drainage or duodenal aspiration o eggs to be differentiated from opistorchid and heterophyid flukes Treatment Chloroquine Diphosphate o 250 mg TID for 6 weeks o with treatment failure and side effects including optic neuropathy

Ovum resembles Clonorchis sinensis but: o is narrower and has more tapering ends o a pointed terminal knob o a less conspicuous operculum elongate, ovoid in shape with an operculum that fits into a thickened rim of the shell proper

Page 2 of 7

light yellowish brown and are about three times as long as broad a minute tubercular thickening at the posterior end has a miracidium when laid Life Cycle

o o

loss of appetite as patient becomes toxic scar tissue around the bile ducts encroaches on liver cells and portal vessels  collateral venous circulation, edema of the face and limbs and at times ascitis

Diagnosis Clinical Diagnosis o 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 o finding the characteristic eggs in the feces or biliary drainage or duodenal aspiration Treatment Intermediate snail hosts are infected by feces deposited on sandy shores and washed into streams. Definitive hosts – cats, dogs, fox, wolves, seals Accidental final host – man Can cause bile stones, destruction of the bile ducts and liver

Praziquantel o 40 mg/kg body weight in a single dose after a meal o Side effects – abdominal pain, vomiting, diarrhea, lassitude, myalgia, headache and rashes Prevention 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 Disease: Opistorchiasis viverrini Geographic Distribution an important human parasite in northeastern Thailand and in the northernmost province of Udorn Morphology It can be distinguished from Opistorchis felineus: o greater proximity of its ovary and testes, both of which are deeply lobulated o aggregation of its vitellaria into a few clusters of glandular material o esophagus is elongated

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 Symptomatology Light infections o asymptomatic Moderate infections o moderate, painful enlargement of the liver o passive congestion of the spleen o icterus o local eosinophilia in the wall of the bile ducts Heavy infections o invade the pancreas with digestive disturbances o bile stones may form around eggs as nuclei and cause cholecystitis with colic

Ovum Eggs are relatively short and broad, 26.7 x 15 um.

Page 3 of 7

Family Dicrocoellidae small to medium-sized flukes that live in the bile or pancreatic ducts of birds and mammals elongate with well developed suckers notable feature – position of the testes anterior to the ovary eggs are small, with a thick brown shell and embryonated when laid

Diagnosis Clinical Diagnosis o 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 o finding the characteristic eggs in the feces or biliary drainage or duodenal aspiration o Ultrasonography to screen the presence of cholangiocarcinoma

Life Cycle

Treatment Praziquantel o 25 mg per kg body weight TID for two days Natural definitive hosts - civet cat, cat, dog and other fish- eating mammals Accidental host – man

Prevention and Control 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 Common Name: SHEEP LIVER FLUKE Diseases Fascioliasis hepatica Sheep Liver Rot Pharyngeal Fascioliasis or Halzoun Geographic Distribution: has a cosmopolitan distribution and prevalent in sheep raising countries Morphology Large size, 20 to 30 mm by 8 to 13 mm Flat, leaf shaped with characteristic shouldered appearance from its cephalic cone Oral and ventral suckers of equal size on the cephalic cone Intestine with numerous diverticula Highly dendritic testes in tandem formation Diffusely branched vitellaria in lateral and posterior portions of the body Short convoluted uterus

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 Symptomatology mild to moderate infections o few symptoms heavy infections o abdominal distress o epigastric pain o generalized malaise

Ovum large, oval, yellowish brown operculated egg measures 130-150 u x 63-90 u unsegmented at oviposition

Page 4 of 7

Life Cycle

o

Natural definitive hosts - herbivorous animals like sheep o Herbivorous or ominivorous animals acquire the infection in low, damp pastures, where the vegetation is infested with metacercaria. Accidental host – man Goes to the liver and bile duct, causing destruction

Heavy infections  erosion of the epithelium  young worms wander back into the liver to produce abscess pockets and to seed the vital liver tissue with their eggs

Symptomatology colic and obstructive jaundice coughing and vomiting generalized abdominal rigidity acute epigastric pain and tenderness urticaria early leukocytosis and eosinophilia irregular fever more or less persistent diarrhea marked anemia hemoglobinuria 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: o edematous congestion of the soft palate, pharynx, larynx, nasal fossae, Eustachian tube  suffocation o dyspnea o deafness o asphyxiation Diagnosis Clinical Diagnosis – based on: o biliary symptoms o moderate to high eosinophilia o eating watercress as a green salad (metacercaria in vegetation) Laboratory Diagnosis o recovery of the eggs in the patient’s stool or from duodenal or biliary tract drainage o Serodiagnosis – helpful but not adapted for routine diagnosis Differential Diagnosis acute hepatitis of other etiology cholecystitis cholelithiasis cirrhosis resulting from other causes 

Pathology Acute or Invasive Phase o period during which the fluke migrates from the intestine to the liver and its burrowing through the liver parenchyma o no significant change from the intestine to the liver o 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 o Migration to the liver parenchyma o traumatic and necrotic lesions Chronic or Latent phase o period when the parasite has already reached the bile ducts o obstruction in the vessel o inflammatory and adenomatous changes of the biliary epithelium o fibrosis of the ducts o pressure atrophy of the liver parenchyma o intensive periductal fibrosis



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

Treatment bithionol (dichlorophenol) o 30 to 50 mg/kg per o body weight on alternate days to complete 10-15 doses dehydroemetine hydrochloride o 1 mg per kg daily intramuscularly for 10 days emetine hydrochloride o 30 mg daily for 17 or 18 days intramuscularly or 40 mg daily to a total of 5 mg per kg body weight hexachloroparaxylene o favorable results as reported from Russia praziquantel o probably effective as in other liver fluke infections

Page 5 of 7

Prevention and Control thorough washing or cooking of vegetables boiling of water in areas where the infection is endemic (metacercaria in vegetation) elimination of the snail intermediate hosts killing the parasites in the reservoir hosts by chemotherapy

Fasciola gigantica Common Name: GIANT LIVER FLUKE Disease: Fascioliasis gigantica Geographic Distribution: parasite of herbivorous mammals particularly camels, wild hogs, cattle and water buffalo in Africa, Asia and Hawaii Differences from Fasciola hepatica more elongated or lanceolate cephalic cone is shorter and less prominent ventral sucker is larger testes are more anterior in position shoulders are practically lacking eggs are larger

Dicrocoelium dendriticum Common Name: LANCET FLUKE Disease: Dicrocoeliasis Geographic Distribution: has a cosmopolitan distribution in sheep and other herbivors in Asia, Africa, Europe and North and South America Morphology slender, lancet shaped, flat transparent, aspinous body 5-15 mm x 1.5-2.5 mm acetabulum lies at the beginning of the second fifth of the body two large, slightly lobed testes situated obliquely to each other anterior to the small subglobose ovary just behind the ventral sucker voluminous uterine coils in the posterior thirds of the worm subglobose ovary lies to the right of the midline and somewhat anterior to the equator of the worm discrete vitelline follicles occupy lateral fields in the middle of the body

Ovum Family Opistorchiidae parasites of the bile ducts and gall bladder small to medium-sized, usually elongate and relatively delicate with weakly developed suckers testes located posteriorly may be branched or lobed ovary is near midbody coiled uterus fills the area between the ovary and ventral sucker eggs are small and are fully embryonated

deep golden-brown thick shelled, distinctly operculated, measuring 38 to 45 u by 22 to 30 u containing a fully developed miracidium. Life Cycle

Life Cycle

1. Principal definitive host – sheep and other herbivorous mammals 2. Accidental final host – man

Natural definitive hosts - Cattle, buffaloes, camels, wild hogs and other herbivores Accidental host - man Pathology Symptomatology Treatment Prevention and Control

same as Fasciola hepatica

Page 6 of 7

o o

enlarged liver systemic toxemia less pronounced that in fascioliasis

Laboratory Diagnosis finding the eggs consistently in the feces and duodenal drainage eliminate spurious infections from eating livers containing the eggs Treatment – same as Clonorchis sinensis Praziquantel – 25 mg per kg TID for 2 consecutive days Prevention and Control no effective measures of control fresh herbs collected from grazing areas for use as food for humans should be washed to remove the ants. -----------------------------------------END OF TRANS-----------------------------------------

Pathology – same as Fasciola hepatica in animals o enlargement of the bile ducts o hyperplasia of the biliary epithelium o formation of the periductal fibrous connective tissue o atrophy of the liver cells o portal cirrhosis in heavy infections in humans o hepatic changes are less pronounced

--Ayna Due

Symptomatology in humans o digestive disturbances o flatulence o vomiting o biliary colic o chronic constipation or diarrhea Scientific Name Clonorchis sinensis Opistorchis felineus

CN

Morphology

Chinese Liver Fluke Cat Liver Fluke

Highly dendritic or deeply lobulated testes in tandem

Opistorchis viverinii

Testes are lobed and oblique to each other

Ang trans na ito ay inihahandog ng... MiCrObIoMaN

Ovum Rimmed, With small protuberance Rimmed, With small protuberance

Infective Stage Metacercaria

Diagnostic Stage Embryonated ova

1st IH

2nd IH

Snail

Freshwater Fish

Man

Metacercaria

Embryonated ova

Snail

Freshwater Fish

Cat, Dog, Fox, Wolf, Seal

Man

Civet cat, Cat, Dog, other Fish-eating mammals Herbivorous Animals like Sheep

Man

Testes are lobed and oblique to each other

Rimmed, With small protuberance

Metacercaria

Embryonated ova

Snail

Freshwater Fish

Final Host

AFH

Fasciola hepatica

Sheep Liver Fluke

Cephalic cone, (+)Shoulder, Dendritic intestinal ceca & testes

Oval

Metacercaria

Unembryonated ova

Snail

Aquatic Vegetation

Fasciola gigantica

Giant Liver Fluke

Cephalic cone is shorter & less prominent, ()Shoulder, Dendritic intestinal ceca & testes

Oval

Metacercaria

Unembryonated ova

Snail

Aquatic Vegetation

Camels, Wild hogs, Cattle, Water buffalo

Man

Dicrocoelium dendriticum

Lancet Fluke

Uterine coils in posterior 1/3, Vitelline follicles in middle 1/3

Oval, Deep golden brown

Metacercaria

Embryonated ova

Snail

Ants

Sheep

Man

CN – Common Name

1st IH – First Intermediate Host

2nd IH – Second Intermediate Host

Man

AFH – Accidental Final Host

Page 7 of 7