Dr. Tri Baskoro(UGM) - Cestode & Trematode_dr. Tridjoko

8/19/2019 Dr. Tri Baskoro(UGM) - Cestode & Trematode_dr. Tridjoko

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30. Cestoda and trematoda in Gastrointestinal Disorder dr. Tridjoko Hadianto, DTM&H

CESTODE (Tape-worm)

Causal Agents:The cestode Diphyllobothrium latum (the fish or broad tapeworm ), the largest human tapeworm .Several other Diphyllobothrium species have been reported to infect humans, but less frequently;they include D. pacificum, D. cordatum, D. ursi, D. dendriticum, D. lanceolatum, D. dalliae, and D.yonagoensis.

Life Cycle:

Geograp ic Distri!ution:Diphyllobothriasis occurs in areas where la es and rivers coe!ist with human consumption of rawor undercoo ed freshwater fish . Such areas are found in the "orthern #emisphere ($urope,

newly independent states of the former Soviet %nion ("&S), "orth 'merica, 'sia), and in %gandaand hile.

Clinical "eatures:Diphyllobothriasis can be a long lasting infection (decades). *ost infections are asymptomatic .*anifestations may include abdominal discomfort, diarrhea, vomiting, and weight loss. +itamin

- deficiency with pernicious anemia may occur. *assive infections may result in intestinalobstruction . *igration of proglottids can cause cholecystitis or cholangitis.

Block 11, April 30, 200 !eek " #nternational $ro%ramme


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La!oratory Diagnosis:*icroscopic identification of eggs in the stool is the basis of specific diagnosis. $ggs are usuallynumerous and can be demonstrated without concentration techniques. $!amination ofproglottids passed in the stool is also of diagnostic value.

Treatment:/ra0iquantel 1 is the drug of choice. 'lternatively, "iclosamide can also be used to treatdiphyllobothriasis.

Causal Agents:The cestodes (tapeworms) Taenia saginata (beef tapeworm ) and T. solium (por tapeworm ).Taenia solium can also cause cysticercosis .

Life Cycle:

Life cycle of Taenia saginata an# Taenia solium. #umans are the only definitive hosts forTaenia saginata and Taenia solium .

Geograp ic Distri!ution:oth species are worldwide in distribution. Taenia solium is more prevalent in poorer

communities where humans live in close contact with pigs and eat undercoo ed por and in veryrare in *uslim countries .



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Clinical "eatures:Taenia saginata taeniasis produces only mild abdominal symptoms. The most stri ing featureconsists of the passage (active and passive) of proglottids. 2ccasionally, appendicitis orcholangitis can result from migrating proglottids. Taenia solium taeniasis is less frequentlysymptomatic than Taenia saginata taeniasis. The main symptom is often the passage (passive)of proglottids. The most important feature of Taenia solium taeniasis is the ris of development of

cysticercosis .

La!oratory Diagnosis:*icroscopic identification of eggs and proglottids in feces is diagnostic for taeniasis, but is notpossible during the first 3 months following infection, prior to development of adult tapeworms.4epeated e!amination and concentration techniques will increase the li elihood of detecting lightinfections. "evertheless, speciation of Taenia is impossible if solely based on microscopice!amination of eggs, because all Taenia species produce eggs that are morphologically identical .$ggs of Taenia sp. are also indistinguishable from those produced by cestodes of the genusEchinococcus (tapeworms of dogs and other canid hosts). *icroscopic identification of gravidproglottids (or, more rarely, e!amination of the scole!) allows species determination.

Treatment:Treatment is simple and very effective. /ra0iquantel 1 is the drug of choice.

Causal Agents:#ymenolepiasis is caused by two cestodes (tapeworm) species, Hymenolepis nana (the dwarftapeworm , adults measuring -5 to 67 mm in length) and Hymenolepis diminuta (rat tapeworm ,adults measuring 7 to 87 cm in length). Hymenolepis diminuta is a cestode of rodentsinfrequently seen in humans and frequently found in rodents.

Life Cycle: Hymenolepis nana



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Hymenolepis diminuta

Geograp ic Distri!ution:Hymenolepis nana is the most common cause of all cestode infections , and is encounteredworldwide. &n temperate areas its incidence is higher in children and institutionali0ed groups.Hymenolepis diminuta , while less frequent, has been reported from various areas of the world.

Clinical "eatures:Hymenolepis nana and H. diminuta infections are most often asymptomatic. #eavy infectionswith H. nana can cause wea ness, headaches, anore!ia, abdominal pain, and diarrhea .

La!oratory Diagnosis:The diagnosis depends on the demonstration of eggs in stool specimens. oncentrationtechniques and repeated e!aminations will increase the li elihood of detecting light infections.

Treatment:/ra0iquantel 1 is the drug of choice.

Causal Agent:Dipylidium caninum (the double pored dog tapeworm ) mainly infects dogs and cats , but isoccasionally found in humans.



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Life Cycle:

Geograp ic Distri!ution:9orldwide. #uman infections have been reported in $urope, the /hilippines, hina, :apan,

'rgentina, and the %nited States.

Clinical "eatures:*ost infections with Dipylidium caninum are asymptomatic . /ets may e!hibit behavior to relieveanal pruritis (such as scraping anal region across grass or carpeting). *ild gastrointestinaldisturbances may occur. The most stri ing feature in animals and children consists of thepassage of proglottids. These can be found in the perianal region, in the feces, on diapers, andoccasionally on floor covering and furniture. The proglottids are motile when freshly passed andmay be mista en for maggots or fly larvae.

La!oratory Diagnosis:The diagnosis is made by demonstrating the typical proglottids or egg pac ets in the stool or theenvironment.

Treatment:Treatment for both animals and humans is simple and very effective. /ra0iquantel is given eitherorally or by in ection (pets only). The medication causes the tapeworm to dissolve within theintestines. Since the worm is usually digested before it passes, it may not be visible in the dog


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Causal Agent:#uman echinococcosis ( hydatidosis , or hydatid disease ) is caused by the larval stages ofcestodes (tapeworms) of the genus Echinococcus . Echinococcus granulosus causes cystic

echinococcosis , the form most frequently encountered; E. multilocularis causes alveolarechinococcosis; E. vogeli causes polycystic echinococcosis; and E. oligarthrus is an e!tremelyrare cause of human echinococcosis.

Life Cycle:

Geograp ic Distri!ution:E. granulosus occurs practically worldwide, and more frequently in rural, gra0ing areas wheredogs ingest organs from infected animals. E. multilocularis occurs in the northern hemisphere,including central $urope and the northern parts of $urope, 'sia, and "orth 'merica. E. vogeli and E. oligarthrus occur in entral and South 'merica.

Clinical "eatures:Echinococcus granulosus infections remain silent for years before the enlarging cysts causesymptoms in the affected organs. #epatic involvement can result in abdominal pain, a mass inthe hepatic area, and biliary duct obstruction. /ulmonary involvement can produce chest pain,cough, and hemoptysis. 4upture of the cysts can produce fever, urticaria, eosinophilia, andanaphylactic shoc , as well as cyst dissemination . &n addition to the liver and lungs, other organs(brain, bone, heart) can also be involved, with resulting symptoms. Echinococcus multilocularis affects the liver as a slow growing, destructive tumor, with abdominal pain, biliary obstruction, andoccasionally metastatic lesions into the lungs and brain. Echinococcus vogeli affects mainly theliver, where it acts as a slow growing tumor; secondary cystic development is common.



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clothing, furniture, etc., or drop to the ground, such contamination could occur in the absence ofany visible source of @fecal@ contamination.

2nce the eggs hatch in the human


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T$E+ATODE ("lu,es)

Causal Agents:The trematodes Fasciola hepatica (the sheep liver flu e ) and Fasciola gigantica , parasites ofherbivores that can infect humans accidentally .

Life Cycle:

Geograp ic Distri!ution:?ascioliasis occurs worldwide. #uman infections with F. hepatica are found in areas where sheepand cattle are raised, and where humans consume raw watercress , including $urope, the *iddle$ast, and 'sia. &nfections with F. gigantica have been reported, more rarely, in 'sia, 'frica, and#awaii.

Clinical "eatures:During the acute phase (caused by the migration of the immature flu e through the hepaticparenchyma), manifestations include abdominal pain, hepatomegaly, fever, vomiting, diarrhea,urticaria and eosinophilia, and can last for months. &n the chronic phase (caused by the adultflu e within the bile ducts), the symptoms are more discrete and reflect intermittent biliaryobstruction and inflammation. 2ccasionally, ectopic locations of infection (such as intestinal wall,lungs, subcutaneous tissue, and pharyngeal mucosa) can occur.

La!oratory Diagnosis:*icroscopic identification of eggs is useful in the chronic (adult) stage. $ggs can be recovered inthe stools or in material obtained by duodenal or biliary drainage. They are morphologicallyindistinguishable from those of Fasciolopsis buski . ?alse fascioliasis (pseudofascioliasis) refersto the presence of eggs in the stool resulting not from an actual infection but from recent ingestion



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of infected livers containing eggs. This situation (with its potential for misdiagnosis) can beavoided by having the patient follow a liver free diet several days before a repeat stoole!amination. 'ntibody detection tests are useful especially in the early invasive stages, when theeggs are not yet apparent in the stools, or in ectopic fascioliasis.

Anti!o#y DetectionThe acute manifestations of human fascioliasis may precede the appearance of eggs in the stoolby several wee s; immunodiagnostic tests may be useful for early indication of Fasciola infectionas well as for confirmation of chronic fascioliasis when egg production is low or sporadic and forruling out @pseudofascioliasis@ associated with ingestion of parasite eggs in sheep or calves< liver.The current tests of choice for immunodiagnosis of human Fasciola hepatica infection areen0yme immunoassays ($&') with e!cretory secretory ($S) antigens combined with confirmationof positives by immunoblot. Specific antibodies to Fasciola may be detectable within to 6wee s after infection, which is 5 to E wee s before eggs appear in stool. Sensitivity for the ?'ST$F&S' format of $&' was reported to be G5>, while sensitivity for the immunoblot using - , -E ,and 83 Da antigens appeared to be -77>. #owever, some cross reactivity occurs in the ?'ST$F&S' with serum specimens of patients with schistosomiasis. 'ntibody levels decrease tonormal 8 to - months after chemotherapeutic cure and can be used to predict the success oftherapy.

Treatment:%nli e infections with other flu es, Fasciola hepatica infections may not respond to pra0iquantel .The drug of choice is triclabenda0ole with bithionol as an alternative.

Causal Agent:The trematode Fasciolopsis buski, the largest intestinal flu e of humans .

Life Cycle:



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Geograp ic Distri!ution: 'sia and the &ndian subcontinent, especially in areas where humans raise pigs and consumefreshwater plants .

Clinical "eatures:*ost infections are light and asymptomatic. &n heavier infections, symptoms include diarrhea,abdominal pain, fever, ascites, anasarca and intestinal obstruction.

La!oratory Diagnosis:*icroscopic identification of eggs, or more rarely of the adult flu es, in the stool or vomitus is thebasis of specific diagnosis. The eggs are indistinguishable from those of Fasciola hepatica .

Treatment:/ra0iquantel 1 is the drug of choice.

Causal Agents:Schistosomiasis is caused by digenetic blood trematodes . The three main species infectinghumans are Schistosoma haematobium, S. japonicum, and S. mansoni. Two other species, morelocali0ed geographically, are S. mekongi and S. intercalatum. &n addition, other species ofschistosomes, which parasiti0e birds and mammals, can cause cercarial dermatitis in humans.

Life Cycle:



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Geograp ic Distri!ution:Schistosoma mansoni is found in parts of South 'merica and the aribbean, 'frica, and the*iddle $ast; S. haematobium in 'frica and the *iddle $ast; and S. japonicum in the ?ar $ast.Schistosoma mekongi and S. intercalatum are found focally in Southeast 'sia and central 9est

'frica, respectively.

Clinical "eatures:*any infections are asymptomatic. 'cute schistosomiasis ( Hatayama

Dr. Tri Baskoro(UGM) - Cestode & Trematode_dr. Tridjoko

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