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S4 L5: Schistosoma (Blood Flukes) by Dr. Mary Antonette Madrid JJaannuuaarryy 2266,,22001111
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
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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
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
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severity of infection. The disease has caused a stunting of the boy's growth, he is only Currently regarded as the method of choice for the definitive diagnosis of
120cms tall and weighs 22 kg. WHO/TDR/Crump 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
(Left) A 13-year-old boy with schistosomiasis, hepatosplenomegaly, ascites, specimens
muscle atrophy, pyrexia, anaemia and haemorrhage from the gastrointestinal tract. Test sensitivity and specificity vary widely among the many tests reported
(Right) Two boys, victims of schistosomiasis showing typical distension of the for the serologic diagnosis of schistosomiasis and are dependent on both
abdomen.
the type of antigen preparations used (crude, purified, adult worm, egg,
cercarial) and the test procedure.
LABORATORY DIAGNOSIS
At CDC, a combination of tests with purified adult worm antigens is used
for antibody detection.
Microscopic identification of eggs in stool or urine: most practical method
All serum specimens are initially tested by FAST-ELISA using
for diagnosis
Schistosoma mansoni adult microsomal antigen (MAMA).
Stool examination: S. mansoni or S. japonicum infection
A positive reaction (greater than 8 units/µl serum) indicates infection with
urine examination: S. haematobium
Schistosoma species.
Eggs can be present in the stool in infections with all Schistosoma o Sensitivity for S. mansoni infection: 99%
species. o Sensitivity for S. haematobium infection: 95%
The examination can be performed on a simple smear (1 to 2 mg of fecal o Sensitivity for S. japonicum infection: <50%
material). o specificity for detecting schistosome infection: 99%
Enhance detection of eggs by repeated examinations and/or Because test sensitivity with the MAMA is reduced for species other than
concentration procedures (such as the formalin - ethyl acetate technique) S. mansoni, immunoblots of the species appropriate to the patient's travel
field surveys and investigational purposes: quantify egg output by using history are also tested to ensure detection of S. haematobium and S.
the Kato-Katz technique (20 to 50 mg of fecal material) or the Ritchie japonicum infections.
technique. o Immunoblots with adult worm microsomal antigens are species-
Eggs can be found in the urine in infections with S. haematobium specific; a positive reaction indicates the infecting species.
(recommended time for collection: between noon and 3 PM) and with S. o presence of antibody is indicative only of Schistosoma infection at
japonicum. some time and cannot be correlated with clinical status, worm
Detection will be enhanced by centrifugation and examination of the burden, egg production, or prognosis.
sediment.
Quantification is by using filtration through a Nucleopore® membrane of a DIAGNOSTIC FINDINGS
standard volume of urine followed by egg counts on the membrane.
Tissue biopsy (rectal biopsy for all species and biopsy of the bladder for MICROSCOPY
S. haematobium) may demonstrate eggs when stool or urine
examinations are negative. S. mansoni eggs
DIAGNOSIS
S. japonicum
Immunodiagnosis
1. intradermal test for immediate cutaneous hypersensitivity using adult
worm extracts
2. indirect hemmagglutination using adult worm and egg antigens
These eggs are large
3. circumoval precipitin test (COPT)
Length: 114 to 180 µm
4. ELISA using soluble antigens of adults and eggs
Have a characteristic shape, with a prominent lateral spine near the
Only COPT, ELISA and indirect hemagglutination using egg antigens
posterior end.
should be used because these are more specific
The anterior end is tapered and slightly curved.
COPT When the eggs are excreted, they contain a mature miracidium (visible
especially in the first picture).
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
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S. japonicum eggs
DETOX CORNER
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 Siret na?
spine at the posterior end.
Length 112 to 170 µm.
KEY TO MIDNIGHT CALLER
greater magnification shows the miracidium inside the egg. 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
TREATMENT 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
Safe and effective drugs are available difficult times.
Drug of choice: Praziquantel Whom did you name,and what words of reassurance did they offer
Oxamniquine has been effective in treating infections caused by S. you?
Was it a familiar voice saying, “Hello? It’s your mother. How come you
mansoni in some areas in which praziquantel is less effective. 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,
---------------------------------------------end of trans------------------------------------------- that’s the best kind of reassurance when you’re feeling scared.
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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
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