This document provides an overview of schistosomiasis and other fluke infections. It describes the lifecycles and clinical manifestations of Schistosoma mansoni, S. japonicum, S. haematobium, Clonorchis sinensis, Opisthorchis species, and Fasciola hepatica. Schistosomiasis remains a major public health problem, infecting over 200 million people globally. Chronic infection can lead to liver and intestinal disease, portal hypertension, and genitourinary complications. Diagnosis involves finding parasite eggs in stool, urine, or biopsy samples, and serology can also be used. Praziquantel is the treatment of choice for

1. Schistosomes and
other flukes
Rahajeng N. Tunjungputri, MD, MSc
Department of Parasitology
Faculty of Medicine Diponegoro University - 2012

2. Case
 A 22-year-old student from Sulawesi presented at
the hospital with acute haematemesis
 Physical examination revealed marked
hepatosplenomegaly
Oesophageal and gastric
varices were identified at
upper gastrointestinal
endoscopy  portal
hypertension

3. S. mansoni
Human schistosomiasis/
Schistosomes S. japonicum bilharziasis
S. hematobium
Clonorchis
sinensis
Trematodes
Liver flukes Opistorchis sp.
Fasciola hepatica
Intestinal Fasciolopsis buski, Metagonimus
flukes yokogawai, Heterophyes heterophyes

4. Human schistosomiasis: epidemiology
 200 million persons infected with schistosomes in 74 countries
 120 million persons have symptoms, 20 million have severe
disease, and 100,000 die each year
 Higher infection rate and infection burden in children
 amount of water exposure, partial acquired immunity, age,
and genetic susceptibility

5.  Water resource development projects and population
movements have spread the disease to non-endemic areas

6. Global distribution

7. Schistosomiasis in Indonesia
 1975: highest prevalence  72%
 Domestic and wild animals maintain
transmission cycle: eg deer, cow, buffalo, rats
 2001: increased prevalence due to Poso unrest
 population movement

8. Snail habitat

9. Schistosomes morphology
 Male
 9,5mm x 19,5 mm
 Canalis gynecophorus
 Female : 16 mm x 26 mm
 Thin-shaped

10. S. mansoni
 Habitat
 Mesenteric and portal veins
 V. mesenterica inferior

11. S. mansoni

12. S. mansoni male adult: tegument

13. S. japonicum
 Habitat
 Mesenteric and portal veins
 V. mesenterica superior

14. S. haematobium
 Habitat
 V. vesicalis

15. Life cycle
Video

16. Cercariae
penetration
Intensity of
infection
Severity of
disease
In snails: sporocyst I 
sporocyst II  cercaria

17.  Transmission

18. Clinical manifestation
Period Affected organ Manifestation
Immediate Skin Dermatitis: A maculopapular eruption at the site of penetration
In migrants or tourists: skin reactions (hours), a rash (up to one
week later)
Acute Systemic A history of contact with contaminated water 2-6 weeks before
Schistosomiasis Gastrointestinal (in travellers)
Lungs Mediated by the immune complex
Katayama fever Liver, spleen Majority of cases begin with the deposition of an egg into host
tissues
Fever, headache, generalized myalgias, right-upper-quadrant
pain, and bloody diarrhea, respiratory symptoms
Tender hepatomegaly, splenomegaly, aseptic meningitis.
Not all patients shed eggs, but all have eosinophilia and most
have positive serologic tests
Chronic Especially in people with longstanding infection in poor areas
shistosomiasis Gastrointestinal and Liver Disease
Genitourinary Disease
Neurologic and Other Manifestations

19. Pathogenesis
 Egg production commences four to six weeks after infection
and continues for the life of the worm — usually three to five
years.
Shed in feces
Eggs in blood Pass the
Tissue (S.m, S.j) and
vessels mucosa
urine (S.h)

20. Gastrointestinal and liver disease
 Intestinal disease: Eggs in the gut wall  inflammation,
hyperplasia, ulceration, microabscess formation, and polyposis
 Light infections: fatigue, intermittent abdominal pain, and
diarrhea
 Heavy infections: anemia, intestinal polyps
 Liver disease
 presinusoidal inflammation, periportal fibrosis & collagen
deposits, progressive obstruction of blood flow, portal
hypertension, hepatomegaly
 Early chronic: granuloma infiltration around eggs in small venulae
 In 5-10%: periportal fibrosis in years after infection

21. Adult in
mesenteric
veins
Eggs in
venulae/ tissue
Inflammation

22. Portal hypertension,
variceal bleeding
 Hepatomegaly
 Varices
 Variceal bleeding
 Splenomegaly

23. Genitourinary Disease
 Dysuria and hematuria (early and late disease)
 Late manifestations:
 proteinuria (often in the nephrotic range)
 calcifications in the bladder
 obstruction of the ureter
 renal colic
 hydronephrosis
 renal failure
 associated risk of bladder cancer
 Secondary bacterial infection is frequent
 Genital disease in 1/3 women: vulval and
perineal hypertrophic, ulcerative, fistulous, or
wart-like

24. Schistosomal dermatitis
http://img.medscape.com/pi/emed/ckb/pediatrics_general/996090-999469-98.jpg

25. Schistosomal dermatitis
 http://upload.wikimedia.org/wikipedia/commons/5/5a/Cercarial_dermatitis_lower_legs.jpg

26. GU disease
 27-year-old man with hematuria and left-sided loin
pain who had S. haematobium eggs in his urine

27. Liver disease
 ultrasonogram showing gross hepatic fibrosis
(arrows) in a 45-year-old man with severe hepatic
schistosomiasis

29. Diagnosis: Schistosomiasis
 Eggs in stool
 Multiple samples
 Others:
 PCR
 Serology - ELISA

30. Schistosomiasis control
 Indonesia
 2 times /year: Human stool survey, Snails survey, Reservoir host
survey
 Control activity
 MDA  Selective drug administration using praziquantel
 Snail control: Chemical molluscicide in limited area
 Environment: drying / flooding of snails habitats, cleaning of
irrigation channels (drainage)
 Education
 Vaccination of reservoir host  research
 Host population control  satellite tracking

31. Other liver flukes

32. Clonorchis sinensis
 flattened
 10-25 mm long by 3-5 mm wide
 ovary
 two branches testes
 habitat: bile ducts

33. Opistorchis spp.
 Testes: 2, lobular shape
 Eggs often indistinguishable
from C. sinensis
 Habitat: bile ducts

34. Opisthorchiasis and Clonorchiasis
 2-3 weeks after exposure
 Fever, abdominal pain, hepatomegaly, urticaria, and
eosinophilia
 Chronic infection
 inflammation and thickening of bile duct walls and
localized obstruction in about 10% of persons with heavy
chronic infections
 right upper quadrant discomfort, anorexia, and weight loss
 Heavy infection
 Gall stones, recurring cholangitis with bacterial sepsis,
cholecystitis, liver abscess, and occasionally pancreatitis

35.  Infection:
 ingesting the
metacercariae in
raw or
inadequately
cooked fish

37. Fasciola hepatica
 large and broadly-flat
 up to 30 mm x 15 mm
 The anterior end is cone-
shaped
 Habitat: bile duct

38.  ingesting
uncooked
aquatic
vegetation

39. Clinical syndromes of F. hepatica infection
• In 6-12 weeks after infection: Marked
eosinophilia, abdominal pain,
Acute/ Migratory intermittent high fever, weight loss,
phase urticaria
• Tender hepatomegaly, jaundice,
anemia
• eosinophilia
• inflammation and intermittent
Chronic phase
obstruction of bile ducts, cholecystitis,
ascending cholangitis

40. Diagnosis: other liver flukes
 Finding eggs in stool
 Multiple samples

41. Treatment
 Schistosomiasis: Praziquantel repeated dose after 4-6 weeks in Katayama fever
 Niridazol for schistosomiasis due to toxicity

42. Case: Examination of stool specimens

43. Serology
 Enzyme immunoassay high levels of serum
antibodies to S. mansoni were subsequently
detected

44. Therapy
 Endoscopy sclerotherapy
 Pharmacotherapy

45. Reference
 Mandell GL, Bennet JE, Dolin R. Principles and practice of
infectious diseases. 2010 Ed. 7 pp. 3595-3605.
 Ross AG, Bartley PB, Sleigh AC, Olds GR, Li Y, Williams
GM, McManus DP. Schistosomiasis. N Engl J Med. 2002 Apr
18;346(16):1212-20.
 Gryseels B, Polman K, Clerinx J, Kestens L. Human
schistosomiasis. Lancet. 2006 Sep 23;368(9541):1106-18.