Parasitology

Schistosomas
February 2008

Schistosomiasis causal Agents - Cercariae are transformed into schistosomula

- Schistosomiasis is caused by digenetic blood
trematodes
- The three main sp. infecting humans are:
o S. haematobium
o S. japonicum
o S. mansoni
- Two other sp, more localized geographically are S.
mekongi and S. intercalatum
- In addition, other sp. of schistosomes, which
parasitize, bisrds and mammals, can cause
cercarial dermatitis in humans
after skin penetration and find entry superficial
lymphatic vessels or subcutaneous veins to reach
the lungs
- From pulmonary circulation, schistosomulae
migrates to the portal vein where they mature
- Egg deposition begins from the 24th- 27th day
after cercarial penetration

Schistosoma japonicum
- Schistosoma japonicum or oriental blood fluke
- Endemic in China, Philippines, Sulkawesi,
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

Host Range
- Wide range of host
- Dogs, pigs, cats, carabaos, cows, rodent,
monkeys- found to be naturally infected
- Some hosts such as humans, monkey, rabbits and
mice are considered permissive hosts (S.
japonicum matures and oviposists over extended
periods)
- Others are non-permissive hosts

Life Cycle
- Adult male and female worms are primarily
parasites of the portal vein and its branches
- Females: lay – 200 immature eggs in the
branches of the portal veins which require 10-12
days to mature
- Eggs escape through ulcerations into the
intestinal lumen → exported to feces
- Embryonated egg comes in contact with water
hatches → liberates miracidium
- Miracidia infect small (intermediate host
Onchomelania hupensis quadrasi) and develop
into sporocysts
- Sporocysts develop into cercariae
- Cercariae leave snail host and infect definitive
hosts who come in contact with water by skin
penetration
- 60-70 days from miracidial infection of the snail
host to foremation of cercariae
Eggs are eliminated with feces or urine . Under optimal
conditions the eggs hatch and release miracidia , which
swim and penetrate specific snail intermediate hosts . The
stages in the snail include 2 generations of sporocysts and
the production of cercariae . Upon release from the snail,
the infective cercariae swim, penetrate the skin of the human
host , and shed their forked tail, becoming schistosomulae
. The schistosomulae migrate through several tissues and
stages to their residence in the veins ( , ). Adult worms
in humans reside in the mesenteric venules in various
locations, which at times seem to be specific for each species
. For instance, S. japonicum is more frequently found in the
superior mesenteric veins draining the small intestine ,
and S. mansoni occurs more often in the superior mesenteric
veins draining the large intestine . However, both species
can occupy either location, and they are capable of moving
between sites, so it is not possible to state unequivocally that
one species only occurs in one location. S. haematobium
most often occurs in the venous plexus of bladder , but it

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 Parasitology – Schistosomas by Dra
can also be found in the rectal venules. The females (size 7
to 20 mm; males slightly smaller) deposit eggs in the small
venules of the portal and perivesical systems. The eggs are
moved progressively toward the lumen of the intestine (S.
mansoni and S. japonicum) and of the bladder and ureters (S.
haematobium), and are eliminated with feces or urine,
respectively . Pathology of 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. Pathology of
S. haematobium schistosomiasis includes: hematuria,
scarring, calcification, squamous cell carcinoma, and
occasional embolic egg granulomas in brain or spinal cord.
Pathology
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
- Schistosomular migration causes superficial lung
petechiae and pneumonitis
- After egg deposition, there is a granulomatous
hypersensitivity reaction around it
- most serious consequences of granuloma
formation in liver is obstruction of the
intrahepatic portal branches portal
hypertension splenomegaly ascites
Clinical Aspects
Course of infection divided into 3 progressive stages
1. Incubation: corresponds to period from
cercarial penetration and schistosomular
migration to maturation
2. period of early egg deposition and extrusion
3. period of tissue proliferation
 Early schistosomiasis
- itching, chills, fever, cough
 Colonic schistosomiasis
- Ulceration caused by eggs result in dysentery
or diarrhea
- Chronis stage, it is usually asymptomatic buut
occasional bouts of diarrhea may occur
- Occasionally chronic colonic schistosomiasis is
associated with malignancies
 Hepatosplenic disease
- hepatosplenomegaly, ascites, collateral
circulation
 Pulmonary schistosomiasis
- Principal manifestation is cor pulmonale from
lung obstruction of lung vasculature due to
granuloma formation and fibrosis
 Cerebral schistosomiasis
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- acute stages present with fulminating
menigoencephalitis 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)
Diagnosis
Immunodiagnosis
1. intradermal test for immediate cutaneous
hypersensitivity using adult worm extracts
2. indirest hemagglutination using adult worm
and egg antigens
3. circumoval prepitin test (COPT)
4. ELISA usibg soluble antigens of adults and eggs
- Only COPT, ELISA, and indirect hemagglutination
using egg antigens should be used because these
were most specific
COPT
- demonstrates formation of bleb or septate ppt
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 Phil
- may take more than 2 years to become neg.
Adult Schistosomes
- Adult worms in humans reside in the mesenteric
venules in various locations which at times seem
to be specific for each sp.
- S. japonicum is more frequently found in the
superior mesenteric veins draining the small
intestine
- S. mansonii occurs more often in the superior
mesenteric veins draining the large intestines
o However, both sp can occupy either
location, and they are capable of moving
between sites
- S. haematobium most often occurs in the venous
plexus of bladder but it can 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
- Sucker 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
- worms ingest rbc and pssess a protease that
breaks down globulin and hemoglobin
 Parasitology – Schistosomas by Dra
- Utilize glucose and are presumed to absorb
nutrients through the body wall
Male Female
- shorter, - 15-26 mm by
sturdier 0.3 mm
- Measures: 12- - Single
20 mm in pyramidal
length by 0.4- ovary located in
0.5 mm the midline
diameter
- Has a
gynecophoral
canal where the
longer female is
held
- Testes arranged
in one row
above the
ventral sucker
Pathology
S. mansoni and S. japomicum schistosomiasis:
- Katayama fever, hepatic perisinusoidal egg
granulomas, Symmers’ pipe stem periportal
fibrosis, portal hypertension, and occasional
embolic egg granulomas in brain or SC
S. Haematobium schistosomiasis:
- hematuria, scarring, calcification, squamous cell
ca, and occasional embolic egg granulomas in
brain and spinal cord
Clinical Features
Continuing infection may cause granulomatous
reactions and fibrosis in the affected organs, which
may result in manifestations that include:
- colonic polyposis with bloody diarrhea
(Schistosoma mansoni mostly)
- portal hypertension with hematemesis and
splenomegaly (S. mansoni, S. japonicum)
- cystitis and uretritis (S. haematobium) with
hematuria which can progress to bladder cancer
- pulmonary hypertension (S. mansoni, S.
japoniocum, more rarely S. haematibium
- glomerulonephritis central nervous system lesion
Laboratory Diagnosis
- Microscopic id of eggs in stool or urine: most
practical method of diagnosis
- Stool examination for S. mansoni or S. japonicum
infection
- urine exam foe S. haematobium
- Eggs can be present in the stool in infections with
all Schistosoma sp.
- The examination can be performed on a simple
smear (1-2 mg of fecal materials)
- Enhance detection of eggs by repeated exam
and/or concentration procedures (such as the
formalin- ethyl acetate technique)
- Field surveys and investigations purposes:
quantify egg output by using the Kajo-Katz
Page 3 of 5
technique (20-50 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 3PM) and with S.
japonicum
- Detection will be enhanced by centrifugation and
exam 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 sp and biopsy
of the bladder for S. haematobium) may
demonstrate eggs when stool or urine exam are
negative
Antibody Detection
- can be useful in both clinical management (e.g.
recent infections) and for epidemiologic surveys
- can be useful to indicate schistosome infection in
patients who have traveled in schistosomiasis
endemic areas and in whom eggs cannot be
demonstrated in fecal fecal and 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 test with purified adult
worm antigens is used for antibody detection
- All serum specimens are initially tested by FAST-
ELISA using S. mansoni adult microsomal antigen
(MAMA)
- A positive reaction (> 8 units/µl serum) indicates
infection with Schistosoma sp
- Sensitivity for S. mansoni infection is 99%, S.
haematobium 95%, S. japonicum, <50%
- 99% specificity for detecting schistosome
infection
- Because test sensitivity with MAMA is reduced for
sp. other than S. manson, immunoblots of the sp
appropriate to the patiens’ travel history are also
tested to ensure detection of S. haematobium and
S. japonicum infections.
- immunoblots with adult worm microsomal
antigens are sp-specific; a positive reaction
indicates the infecting sp
- presence of antibody is indicative only for
schistosome infection at some time and cannot be
correlated with clinical status, worm burden, egg
production, or prognosis
Diagnostic Findings Microscopy
 Parasitology – Schistosomas by Dra Page 4 of 5

Eggs of S. mansoni bent tip,

These eggs are large resembles S.
- Length: 114-180 µ haematobium
ant end
- Have a characteristic shape with a prominent egg except it
and
lateral spine near the posterior end is longer,
terminal
- The anterior end is tapered and slightly curved thinner and
spine, miracidium
- When the eggs are excreted, they contain a has longer
sometime
mature miracidium (visible especially in the spine, found
s “spindle
first picture) in feces,
shaped”
- Egg of S. japonicum debris mat
- Egg is typically oval/subspherical and has a adhere to
vestigial spine shell
- S. japonicum eggs are smaller (68-100 µ by 45-
80 µ) than those of the other sp
- Eggs of S. haematobium
- In this sp the eggs are large and have a Characteristics of Schistosoma Eggs
prominent terminal spine at the posterior end
- Length 112-170 µ Treatment
- greater magnification shows the miracidium - safe and effective drugs are available
inside the egg - DOC: Praziquantel
Oxamniquone: tx for S. mansoni in which Praziquantel is less
Stage of Special
effective
Species Shape Dev when Features &
passed variations
Geographic Distribution
Lateral spine.
Elongated - S. mansoni is found in parts of S. America and the
Found in
, Caribbean, Africa and the Middle East
feces rarely
prominent - S. haematobium in Africa and the Middle East
in urine. Eggs
lateral
Embryonat discharged at - S. japonicum in the Far East
spine near
ed, irregular - S. mekongi and S. intercalatum are found locally
posterior
S. mansoni contains intervals; in Southeast Asia and central West Africa,
end, ant
mature may not be respectively
end
miracidium found in - In the Phil, there are 24 endemic provinces:
tapered
stool. are rare Sorsogon, Oriental Mindoro, Samar, Leyte, Bohol,
and
in chronic and all provinces in Mindanao island except
slightly
stages of Misamis Oriental
curved
infection - Highest prevalence of infection is in children 5-15
Oval with y/o
small
lateral Summary
spine,
may Found in Organis Transmiss Diagno
appear as Embryonat feces.Often Symptom Tx
m ion sis
S. small ed Contains coated with Dermatitis,
japonicum hook or mature debris and abdominal pain, Praziquantel
“knob” miracidium maybe S. Skin
bloody stool, Eggs
located in overlooked manson penetrati
periportal in
a S.japonic on by
um fibrosis, Stool
depressio cercadia
hepatosplenomeg
n in the aly, ascites, CNS
shell
Praziquantel

Elongated Dermatitis,
Terminal Skin urogenital Eggs
, rounded S.
Embryonat spine. Found haematobi penetrati cystitis, in
S. anterior
ed Contains in urine, occ um on urethritris, and urine
haematobi ens,
mature in feces, egg bladder Ca
um terminal
miracidium ofte covered
spine at
with debris
post end
S. Elongated Embryonat Terminal
intercalatu with ed Contains spine long, woncee.. mjo gnulo ko ng konti ung outline.. pnagsama2 ko ung
m tapered mature slender with sa japonicum.. bka mjo mgulo kung ndi macompare no? Ngaun q
 Parasitology – Schistosomas by Dra Page 5 of 5

lng naisip.. kc knina ampangit tgnan.. aun, kung gs2 nyo nun dti,
kau na mag-aus! Hehehe.. tmadz nq..
- malta