Liver and biliary tree parasites (69)

LIVERLIVERANDAND

BILIARY TREEBILIARY TREEPARASITESPARASITES

CESTOIDEA CESTOIDEA Order:Order: CyclophyllideaCyclophyllidea

                            Echinococcus granulosus Echinococcus granulosus EchinococcusEchinococcus multilocularismultilocularisEchinococcus vogeliEchinococcus vogeli

ECHINOCOCCUSECHINOCOCCUSGRANULOSUSGRANULOSUS

Echinococcus granulosus infection has a world-Echinococcus granulosus infection has a world-wide distribution with a higher prevalence in wide distribution with a higher prevalence in South-America (Argentina, Uruguay), Europe South-America (Argentina, Uruguay), Europe (mediterranean bassin), Northern Africa, Middle (mediterranean bassin), Northern Africa, Middle East, South-Central and East Asia.East, South-Central and East Asia.

Echinococcus granulosus: Echinococcus granulosus: hydatidosis is caused by hydatidosis is caused by the larval stage of the larval stage of E.granulosus.E.granulosus. After ingestion of eggs the onchospheres After ingestion of eggs the onchospheres penetrate the intestinal mucosapenetrate the intestinal mucosa and reach host and reach host organs (mainly liver and lung) where they encyst organs (mainly liver and lung) where they encyst within a week reaching 1 cm in diameter in about 5 within a week reaching 1 cm in diameter in about 5 months.months.

Echinococcus granulosus: Echinococcus granulosus: the cysts (2 to 30 cm) the cysts (2 to 30 cm) are constituted by an externalare constituted by an external acellular cuticule acellular cuticule and an inner cellular "germinal" layer (10-25 µ) and an inner cellular "germinal" layer (10-25 µ) that producesthat produces the brood capsules containing 6-12 the brood capsules containing 6-12 protoscolices or single protoscolices. (Germinal protoscolices or single protoscolices. (Germinal layer with a protoscolex).layer with a protoscolex).

Echinococcus granulosus: the larvae (scolices) Echinococcus granulosus: the larvae (scolices) develop from the germinal layer. develop from the germinal layer. The protoscolices are at first evaginated and The protoscolices are at first evaginated and measure 120-220 by 70-120 µ.measure 120-220 by 70-120 µ.

Echinococcus granulosus: the mature rotoscolices Echinococcus granulosus: the mature rotoscolices have 4 suckers and a rostellumhave 4 suckers and a rostellum with hooklets and with hooklets and can be observed in the hydatid fluid.can be observed in the hydatid fluid.

Echinococcus granulosus: detail of the rostellum.Echinococcus granulosus: detail of the rostellum.

Echinococcus granulosus: Echinococcus granulosus: the protoscolices then the protoscolices then become invaginated andbecome invaginated and measure 90-140 by 70-120 measure 90-140 by 70-120 µm.They can transform into daughter cysts. µm.They can transform into daughter cysts. These cysts can proliferate both internally and These cysts can proliferate both internally and externally giving exogenous cysts.Spontaneous or externally giving exogenous cysts.Spontaneous or surgical rupture of the cyst can originate a surgical rupture of the cyst can originate a secondary hydatidosis.secondary hydatidosis.

Echinococcus granulosus: Echinococcus granulosus: the liver is the most the liver is the most common site of development of cysts (50-75%). common site of development of cysts (50-75%). Lesions can be detected by CT scan or Lesions can be detected by CT scan or echography;a septate structure is a characteristic echography;a septate structure is a characteristic of active cysts. of active cysts. Treatment is based on surgical and/or medical Treatment is based on surgical and/or medical therapy (albendazole)therapy (albendazole)

Echinococcus granulosus: Echinococcus granulosus: definitive diagnosis is definitive diagnosis is obtained by meansobtained by means of serologic tests (EIA, IHA, of serologic tests (EIA, IHA, CIEP/Western Blot);the last two are confirmatory CIEP/Western Blot);the last two are confirmatory teststests and are useful for the follow-up of treated and are useful for the follow-up of treated patients.patients.--Detail of liver lesion, CT-scan with septa. Detail of liver lesion, CT-scan with septa. --Western blot analysis: both Ag5 (55 and 65 Kd) Western blot analysis: both Ag5 (55 and 65 Kd) and AgB (8, 16, 24 Kd) bands are present.and AgB (8, 16, 24 Kd) bands are present.

Echinococcus granulosus: Echinococcus granulosus: pulmonary infection is pulmonary infection is observed in about 20-30% of patients. observed in about 20-30% of patients. RoentRoentggenografic examination shows round mass enografic examination shows round mass lesionslesions and CT scan demonstrates the fluid and CT scan demonstrates the fluid content of the lesion. content of the lesion. Serology has a lower sensitivity in extrahepatic Serology has a lower sensitivity in extrahepatic hydatidosis.hydatidosis.

Echinococcus granulosus: Echinococcus granulosus: any other organ can be any other organ can be affected:nervous system, heart, bones, spleen affected:nervous system, heart, bones, spleen eyes, muscles are the most common sites. eyes, muscles are the most common sites. Multiple involvement is frequent.Symptoms and Multiple involvement is frequent.Symptoms and signs depend on the size,the site and the signs depend on the size,the site and the pressure of the cyst on host structures.pressure of the cyst on host structures.--CT scan of a spleen cyst.CT scan of a spleen cyst.--MRI scans of a muscular cyst.MRI scans of a muscular cyst.

Echinococcus granulosus: Echinococcus granulosus: medullary hydatidosis medullary hydatidosis is a severe form of the infection.In this case the is a severe form of the infection.In this case the mechanical pressure of host tissues caused mechanical pressure of host tissues caused paraplegia.The surgical treatment allowed paraplegia.The surgical treatment allowed resolution of symptoms.The infection relapsed resolution of symptoms.The infection relapsed and responded partially to medical treatment.and responded partially to medical treatment.

Echinococcus granulosus: Echinococcus granulosus: MRI imaging can MRI imaging can demonstrate the relationshipdemonstrate the relationship between the cyst between the cyst and the medulla on the longitudinal axis. and the medulla on the longitudinal axis. The serology is often negative in infections in The serology is often negative in infections in sites other than liver or lung.(Medullary sites other than liver or lung.(Medullary hydatidosis) hydatidosis)

ECHINOCOCCUS MULTILOCULARIS ECHINOCOCCUS MULTILOCULARIS

( 1 )( 1 ) E.multilocularis E.multilocularis is a small tapeworm (1,2-4,5 mm in is a small tapeworm (1,2-4,5 mm in lenght)that parasites red and arctic foxes (dogs  and cats  are lenght)that parasites red and arctic foxes (dogs  and cats  are the definitive hosts).Definitive hosts are always carnivores.the definitive hosts).Definitive hosts are always carnivores. ( 2 )( 2 ) In the definitive hosts the adult tapeworm, consisting of 2 In the definitive hosts the adult tapeworm, consisting of 2 to 6 proglottids, lives attached to the luminal surface of the to 6 proglottids, lives attached to the luminal surface of the small intestine.The terminal proglottid contains mature eggs small intestine.The terminal proglottid contains mature eggs (ovoid, 30-40 µm in diameter). (ovoid, 30-40 µm in diameter). ( 3 )( 3 ) The embryonated eggs, the infectious stage, are long-lived The embryonated eggs, the infectious stage, are long-lived and highly  resistant to high and low temperature (more than and highly  resistant to high and low temperature (more than 50° C and down to -40° C).The mature eggs are shed with faeces 50° C and down to -40° C).The mature eggs are shed with faeces and are spread in the environment.It is assumed that the and are spread in the environment.It is assumed that the intermediate host acquires the infectionsintermediate host acquires the infections through the ingestion through the ingestion of contaminated fruits and vegetables.of contaminated fruits and vegetables.( 4 )( 4 ) When the intermediate hosts (predominantly rodents When the intermediate hosts (predominantly rodents or other small mammals, or, accidentaly, humans) ingest or other small mammals, or, accidentaly, humans) ingest eggs,the onchosphere hatches from the egg in the duodenum. eggs,the onchosphere hatches from the egg in the duodenum. ( 5 )( 5 ) The activated oncosphere penetrates the small intestine, The activated oncosphere penetrates the small intestine, enters blood vessels and reaches primarly the liver via the enters blood vessels and reaches primarly the liver via the portal vein;In the liver the oncosphere proliferates into the portal vein;In the liver the oncosphere proliferates into the metacestode surrounded by an inner germinative membrane metacestode surrounded by an inner germinative membrane and an outer laminated layer.and an outer laminated layer.( 6 )( 6 ) The lifecycle is completed when an intermediate host, The lifecycle is completed when an intermediate host, carrier of viable protoscolices within the cysts, is devoured by a carrier of viable protoscolices within the cysts, is devoured by a definite host. definite host.

Geographical distributionGeographical distribution

Human AE is prevalent in North America (Alaska Human AE is prevalent in North America (Alaska and northern Canada), in Europe (France, and northern Canada), in Europe (France, Switzerland, Austria and Germany),in Asia (from Switzerland, Austria and Germany),in Asia (from the White Sea to the Behring strait in the north the White Sea to the Behring strait in the north and from Turkey, through Afghanistan, Iran, India, and from Turkey, through Afghanistan, Iran, India, China, Mongolia to north Japan in the south).China, Mongolia to north Japan in the south). The annual incidence of human disease varies from The annual incidence of human disease varies from

28 cases/100.000 inhabitants in Western Alaska 28 cases/100.000 inhabitants in Western Alaska (St. Lawrence Island included),to 0.18-4,4/100.000 (St. Lawrence Island included),to 0.18-4,4/100.000 in Central Europe. in Central Europe.

The diseaseThe disease

The liver is the organ primarily affected;metastases The liver is the organ primarily affected;metastases are mainly observed in cases of advanced disease are mainly observed in cases of advanced disease and may affect almost any organ. and may affect almost any organ. The disease either spreads via direct contact or via The disease either spreads via direct contact or via blood vessels.Secondary AE mostly affects the brain, blood vessels.Secondary AE mostly affects the brain, the lungs, soft tissue, the spine and other bony the lungs, soft tissue, the spine and other bony structures.The disease is primarily characterized by structures.The disease is primarily characterized by an expansive and infiltrative growth in the liver. an expansive and infiltrative growth in the liver. Clinical features may be absent for many years Clinical features may be absent for many years and mostly become apparent in advanced disease. and mostly become apparent in advanced disease. They may include hepatomegaly, jaundice, They may include hepatomegaly, jaundice, abdominal pain, weight loss,fever and abdominal pain, weight loss,fever and manifestations of secondarily affected organs. manifestations of secondarily affected organs.

Diagnosis Diagnosis For diagnosing AE the clinician mainly relies on For diagnosing AE the clinician mainly relies on morphological criteria together with serology and morphological criteria together with serology and epidemiological aspects.epidemiological aspects.

On ultrasound a typical lesion demarcates as On ultrasound a typical lesion demarcates as a heterogeneous hypoechoic lesion with irregularly a heterogeneous hypoechoic lesion with irregularly shaped margin and often contains focal areas of shaped margin and often contains focal areas of calcification ( 50% of cases). The appearance on calcification ( 50% of cases). The appearance on ultrasound is highly variable between cases as can ultrasound is highly variable between cases as can be appreciated on the images above.It is the ideal be appreciated on the images above.It is the ideal method for screening purposes and short-term method for screening purposes and short-term follow-up.follow-up.

Computed Computed tomography (CT) and tomography (CT) and magnetic-resonance-magnetic-resonance-imaging (MRI)are imaging (MRI)are used forused for further further characterization of characterization of the lesion.They are the lesion.They are indispensable for the indispensable for the evaluation ofevaluation of extrahepatic extrahepatic affection in AE and affection in AE and they are used for a they are used for a preoperative preoperative evaluation.CT best evaluation.CT best depicts the typical depicts the typical calcifications and it is calcifications and it is usedused for follow-up for follow-up examinations at examinations at longer intervalls. For longer intervalls. For serology an ELISA serology an ELISA was established was established based on the purified based on the purified E.multiloculariE.multilocularis s carbohydrate antigen carbohydrate antigen Em2 (derived from Em2 (derived from the laminated layer). the laminated layer). It is the reference It is the reference test for diagnosis test for diagnosis and it may allow and it may allow discrimination of AE discrimination of AE from from E.granulosusE.granulosus infection.However, in infection.However, in a significant a significant percentage of cases percentage of cases the two speciesthe two species cancan not be differentiated not be differentiated simply by serological simply by serological means. means.

TreatmentTreatment

The only curative treatment for AE to date The only curative treatment for AE to date is total surgical resection combined with is total surgical resection combined with chemotherapy. Drugs used for the treatment chemotherapy. Drugs used for the treatment of AE are benzimidazoles (mebendazole of AE are benzimidazoles (mebendazole 50mg/KG and albendazole 10-15mg/KG). 50mg/KG and albendazole 10-15mg/KG). Chemotherapy is mainly parasitostatic and Chemotherapy is mainly parasitostatic and may therefore not be considered curative. may therefore not be considered curative. In inoperable or incompletely resected cases In inoperable or incompletely resected cases chemotherapy has to be administered for chemotherapy has to be administered for extended periods of time and often results in extended periods of time and often results in life-long treatment. life-long treatment.

ECHINOCOCCUS VOGELIECHINOCOCCUS VOGELI

Echinococcus vogeli:Echinococcus vogeli: E.vogeliE.vogeli is the agent of the is the agent of the polycystic hydatidosis.The larval stage proliferates polycystic hydatidosis.The larval stage proliferates externally from the germinal layerexternally from the germinal layer and forms septa and forms septa within the cyst generating microcysts.Endemic in within the cyst generating microcysts.Endemic in Central and South America.(Cysts, macro)Central and South America.(Cysts, macro)

Echinococcus vogeli:Echinococcus vogeli: protoscolices similar to that protoscolices similar to that of of E.granulosusE.granulosus are present in the cyst's fluid. are present in the cyst's fluid.

TREMATODATREMATODA Order:Order: StrigeataStrigeata --Schistosoma japonicum Schistosoma japonicum --Schistosoma mansoni Schistosoma mansoni

SCHISTOSOMA JAPONICUM SCHISTOSOMA JAPONICUM

Schistosoma Schistosoma spp.: cercarae are the infectivespp.: cercarae are the infective forms. forms. They measure about 500 micron. AfterThey measure about 500 micron. After encountering encountering the skin,the cercariae penetrate and lose the tail the skin,the cercariae penetrate and lose the tail transforming into schistosomulae.transforming into schistosomulae.

S.japonicun:S.japonicun: geographic distribution. geographic distribution. S.japonicumS.japonicum occurs in Southeast Asia and western occurs in Southeast Asia and western Pacific countries(including China, the Philipines Pacific countries(including China, the Philipines and Indonesia).and Indonesia).S.mekongiS.mekongi has been reported from has been reported from Cambodia and Laos.Cambodia and Laos.

S.japonicumS.japonicum: adult schistosomes live in pairs: adult schistosomes live in pairsin the portal system and in mesenteric venules; in the portal system and in mesenteric venules; adults of adults of S.japonicumS.japonicum are bigger than adults of are bigger than adults of S.mansoniS.mansoni..MMales are 12-20 mm in lenght and 0,5 ales are 12-20 mm in lenght and 0,5 wide,and have a ventral infolding from the ventral wide,and have a ventral infolding from the ventral sucker to the posterior end forming the sucker to the posterior end forming the gynecophoric canal.Adult male with female in the gynecophoric canal.Adult male with female in the copulatory groove.copulatory groove.

Females are slender ( 0,3 mm in diameter) Females are slender ( 0,3 mm in diameter) and longer (up to 26 mm in lengand longer (up to 26 mm in lengtth),and are held h),and are held in the gynecophoric canal during copulation.Each in the gynecophoric canal during copulation.Each female may lay up to 2.000-3.000 eggs per day. female may lay up to 2.000-3.000 eggs per day.

S.japonicumS.japonicum egg: eggs measure 70-90 my 55-60 egg: eggs measure 70-90 my 55-60 µm in diameter,are oval to round in shape with µm in diameter,are oval to round in shape with subterminal spine.(Formol-ether concentration).subterminal spine.(Formol-ether concentration).

S.japonicum S.japonicum egg: eggs are usually round and egg: eggs are usually round and have a small spine or no spine.Other small have a small spine or no spine.Other small knobby-spined or not spined schistosomes that knobby-spined or not spined schistosomes that affect humans areaffect humans are S.mekongi S.mekongi and and S.malaysiensisS.malaysiensis..

S.japonicum: intermediate host of S.japonicum are S.japonicum: intermediate host of S.japonicum are snailssnails of the genus Onchomelania, hupensis spp. of the genus Onchomelania, hupensis spp.

SCHISTOSOMA MANSONI SCHISTOSOMA MANSONI

SchistosomaSchistosoma spp.: cercarae are the infective spp.: cercarae are the infective forms. forms. They measure about 500 micron. AfterThey measure about 500 micron. After encountering encountering the skin,the cercariae penetrate and lose the tail the skin,the cercariae penetrate and lose the tail transforming into schistosomulae.transforming into schistosomulae.

Cercaria of Cercaria of Schistosoma mansoniSchistosoma mansoni from snail. from snail.

S.mansoni: intermediate host of S. mansoni S.mansoni: intermediate host of S. mansoni are snails of the genus Biomphalaria. are snails of the genus Biomphalaria.

S.mansoni:S.mansoni: geographical distribution. geographical distribution.S.mansoniS.mansoni is endemic in 43 countries in Africa and occurs in is endemic in 43 countries in Africa and occurs in the americas in Brazil,Suriname, Venezuela and the americas in Brazil,Suriname, Venezuela and in the Caribbean.in the Caribbean.

S.mansoni: S.mansoni: adult schistosomes live in pairsadult schistosomes live in pairs in the in the portal system and in the mesenteric venules;males portal system and in the mesenteric venules;males are shorter (7-12 mm in lenght and 2 mm wide)and are shorter (7-12 mm in lenght and 2 mm wide)and have a ventral infolding from the ventral sucker have a ventral infolding from the ventral sucker to the posterior end forming the gynecophoricto the posterior end forming the gynecophoric canal. canal. Adult male with female in the copulatory groove. Adult male with female in the copulatory groove. 

Adult male and female of Adult male and female of S.mansoni.S.mansoni.

S.mansoniS.mansoni : Females are slender (1 mm in : Females are slender (1 mm in diameter)and longer (9-17 mm in lengdiameter)and longer (9-17 mm in lengtth),and are h),and are held in the ginecophoric canal during copulation. held in the ginecophoric canal during copulation. Each female lays about 300 eggs per day. Each female lays about 300 eggs per day. Adult male with female in the copulatory groove. Adult male with female in the copulatory groove. Adult of Adult of S.mansoniS.mansoni in mesenteric veins of in mesenteric veins of hamster.hamster.

S.mansoniS.mansoni egg: egg: S.mansoniS.mansoni eggs measure 110-175 eggs measure 110-175 by 45-70 µm;the colour is yellow, with a thin by 45-70 µm;the colour is yellow, with a thin transparent shell and a strong lateral spine.Fresh transparent shell and a strong lateral spine.Fresh examination of intestinal biopsy with one egg in examination of intestinal biopsy with one egg in the mucosa.the mucosa.

S.mansoniS.mansoni egg: viable eggs contain the motile egg: viable eggs contain the motile larva, the miracidium.After breaking the shell the larva, the miracidium.After breaking the shell the ciliated miracidium moves in the waterciliated miracidium moves in the water and and reaches the mollusca. reaches the mollusca. Fresh examination.Fresh examination.

S.mansoniS.mansoni egg: egg with typical spine in stools egg: egg with typical spine in stools (formol-ether concentration). Demonstration of (formol-ether concentration). Demonstration of eggs in faeces and urine is the standard method eggs in faeces and urine is the standard method of diagnosis of schistosomiasis.Sensitivity of one of diagnosis of schistosomiasis.Sensitivity of one stool examination does not exceed 60%.stool examination does not exceed 60%.

S.mansoniS.mansoni egg: lateral spine at higher egg: lateral spine at higher magnification. magnification. Other diagnostic methods include intestinal or liver Other diagnostic methods include intestinal or liver biopsy.Serology is useful in travellers from endemic biopsy.Serology is useful in travellers from endemic areas before sheddingareas before shedding of eggs or in extraintestinal of eggs or in extraintestinal forms (spinal) but not in natives. forms (spinal) but not in natives.

S.mansoni:S.mansoni: hepatosplenic schistosomiasis occurs hepatosplenic schistosomiasis occurs in in S.mansoniS.mansoni and and S.japonicumS.japonicum infections; it infections; it results by eggs embolization in hepatic venules results by eggs embolization in hepatic venules with formation of granulomas and portal fibrosis. with formation of granulomas and portal fibrosis. Epatosplenomegaly, bleeding oesophageal Epatosplenomegaly, bleeding oesophageal varices and hepatic insufficiency are the more varices and hepatic insufficiency are the more severe manifestations. Praziquantel is the drug of severe manifestations. Praziquantel is the drug of choice. choice. Liver biopsy: egg surrounded by granuloma and Liver biopsy: egg surrounded by granuloma and fibrosis of portal space.fibrosis of portal space.

Polyposis due to Polyposis due to S.mansoniS.mansoni infection. infection.

Egyptian with Egyptian with splenomegaly due to splenomegaly due to infection with infection with S.mansoni.S.mansoni.

Brazilian with portal Brazilian with portal hypertension and hypertension and ascites due to ascites due to S.mansoni.S.mansoni.

S.mansoni: S.mansoni: different schistosome stages are different schistosome stages are used as antigen source(cercariae, schistosomula, used as antigen source(cercariae, schistosomula, adults, eggs) for standard immunodiagnostic adults, eggs) for standard immunodiagnostic tests:enzyme linked immunosorbent assay tests:enzyme linked immunosorbent assay (ELISA), indirect immunofluorescence test (IFAT), (ELISA), indirect immunofluorescence test (IFAT), radioimmunoassay (RIA), indirect radioimmunoassay (RIA), indirect haemoagglutination (IHA), circumovale precipitin haemoagglutination (IHA), circumovale precipitin assay.Serological tests may be useful for assay.Serological tests may be useful for travellers returning from endemic areastravellers returning from endemic areas and in and in patients with light or ectopic infection, with no patients with light or ectopic infection, with no detectable eggs in the faeces,urine or intestinal detectable eggs in the faeces,urine or intestinal biopsies (i.e. hepatic, CNS infections).On the biopsies (i.e. hepatic, CNS infections).On the contrary, in patients living in endemic areas, the contrary, in patients living in endemic areas, the positive test maypositive test may reflect previous exposure to reflect previous exposure to the agent rather than an active infection;a slow the agent rather than an active infection;a slow decrease in titer after effective treatment is decrease in titer after effective treatment is usually observed.Recently, new tests for the usually observed.Recently, new tests for the detection of schistosome antigensdetection of schistosome antigens have been have been prepared using monoclonal antibodies.The larval prepared using monoclonal antibodies.The larval stage of stage of S.mansoniS.mansoni used as antigen in the used as antigen in the indirect fluorescence test.indirect fluorescence test.

TREMATODA TREMATODA Order:Order: EchinostomataEchinostomata

--FASCIOLA HEPATICA FASCIOLA HEPATICA

FASCIOLA HEPATICA FASCIOLA HEPATICA

F.hepaticaF.hepatica infection is found in rural areas of infection is found in rural areas of temperate and tropical regions, related to cattle temperate and tropical regions, related to cattle herding.High prevalence is described in Europe herding.High prevalence is described in Europe and Latin America.and Latin America.

F.hepatica,F.hepatica, adult worm, macroscopic examination: adult worm, macroscopic examination: adults measure 2-5 cm by 8-13 mm, are flat, oval adults measure 2-5 cm by 8-13 mm, are flat, oval in shape with a cephalicin shape with a cephalic cone containing the oral cone containing the oral sucker.The adults live in biliary ducts for up to 10 sucker.The adults live in biliary ducts for up to 10 years.years.

Fasciola hepaticaFasciola hepatica, living adult in bile duct of sheep. , living adult in bile duct of sheep.

F.hepaticaF.hepatica, adult worm, macroscopic, adult worm, macroscopic examination: examination:

higher magnification: particular of the cephalichigher magnification: particular of the cephalic cone with the oral sucker.cone with the oral sucker.

F.hepaticaF.hepatica, adult worm, liver biopsy: after , adult worm, liver biopsy: after excistationexcistation in the small intestine, metacercariae in the small intestine, metacercariae penetrate the intestinal wallpenetrate the intestinal wall and the Glisson and the Glisson capsule, cross the liver parenchima to the bile capsule, cross the liver parenchima to the bile ducts.Eggs can be found in faeces 3-4 months ducts.Eggs can be found in faeces 3-4 months after penetration.after penetration.

F.hepaticaF.hepatica, adult worm: the diagnosis is, adult worm: the diagnosis is confirmed by the presence of eggs in confirmed by the presence of eggs in faeces.Repeated examinations and concentration faeces.Repeated examinations and concentration techniques are recommended.Serology is useful techniques are recommended.Serology is useful when the clinical picture is compatible and eggs when the clinical picture is compatible and eggs are not found.are not found.

F.hepaticaF.hepatica, egg: eggs measure 140 by 80 µm and , egg: eggs measure 140 by 80 µm and are operculated. The colour is yellow to brown. are operculated. The colour is yellow to brown. (Formol-ether concentration).(Formol-ether concentration).

F.hepaticaF.hepatica, egg: the opercular end is more visible , egg: the opercular end is more visible at higher magnification;sometimes it can present a at higher magnification;sometimes it can present a shell irregularity.shell irregularity.

F.hepaticaF.hepatica, egg: the operculum can be open.Eggs , egg: the operculum can be open.Eggs are unembrionated and contain a granular are unembrionated and contain a granular material. material.

F.hepaticaF.hepatica, egg: the open , egg: the open operculum at higher operculum at higher magnification. magnification.

Fasciola hepatica: Fasciola hepatica: although direct diagnosis by although direct diagnosis by observation of eggs in faecal smearsobservation of eggs in faecal smears it the it the reference method, indirect diagnostic tests such reference method, indirect diagnostic tests such as IF may allow diagnosisas IF may allow diagnosis when direct observation when direct observation is negative.is negative. Immunodiagnosis by indirect mmunofluorescence. Immunodiagnosis by indirect mmunofluorescence. Antigen: frozen sections of Antigen: frozen sections of Fasciola hepatica.Fasciola hepatica.

TREMATODA TREMATODA Order:Order:OpisthorchiataOpisthorchiata

--Clonorchis sinensis / Opisthorchis Clonorchis sinensis / Opisthorchis viverrini viverrini --Opisthorchis felineus Opisthorchis felineus

CLONORCHIS SINENSIS / CLONORCHIS SINENSIS / OPISTHORCHIS VIVERRINIOPISTHORCHIS VIVERRINI

Clonorchis sinensis/Opisthorchis viverrini: Clonorchis sinensis/Opisthorchis viverrini: geographic distribution.geographic distribution.

Clonorchis sinensisClonorchis sinensis, liver biopsy:  , liver biopsy:  Clonorchis sinensisClonorchis sinensis adults adults areare 10-25 mm by 3-5 10-25 mm by 3-5 mm,mm,O.viverriniO.viverrini is 5,4-10 by 0,8-1,9 mm.The adults is 5,4-10 by 0,8-1,9 mm.The adults live in the distal bile ducts and may survive for 30-live in the distal bile ducts and may survive for 30-40 years, causing irritation to biliary cells and 40 years, causing irritation to biliary cells and inflammation. inflammation. 

Clonorchis sinensis adult. Clonorchis sinensis adult.

Clonorchis sinensis, liver biopsy: most infections Clonorchis sinensis, liver biopsy: most infections are asymptomatic.Clinical manifestations can be are asymptomatic.Clinical manifestations can be observed in adults due to obstructionobserved in adults due to obstruction and and dilatation of biliary ducts, cholangitis and in dilatation of biliary ducts, cholangitis and in some cases cholangiocarcinoma.some cases cholangiocarcinoma.

Cholangiocarcinoma caused by chronic infection Cholangiocarcinoma caused by chronic infection with with C.sinensis.C.sinensis.

Clonorchis sinensis/ O.viverrini Clonorchis sinensis/ O.viverrini egg: eggs of the egg: eggs of the two species are similar.They measure 30-35 by 12-two species are similar.They measure 30-35 by 12-20 µm, are operculated at one end20 µm, are operculated at one end and have a and have a small knob on the other end. The colour is yellow.small knob on the other end. The colour is yellow.

OPISTHORCHIS FELINEUS OPISTHORCHIS FELINEUS

Opisthorchis felineus:Opisthorchis felineus: an estimated 17 million of an estimated 17 million of people on our planet are infected with fishborne people on our planet are infected with fishborne Opisthorchiidae trematode infections: Opisthorchiidae trematode infections: Opisthorchis felineus, O.viverrini, Clonorchis Opisthorchis felineus, O.viverrini, Clonorchis sinensissinensis [1].Despite being preventable fishborne [1].Despite being preventable fishborne trematode infectiontrematode infection Opisthorchis felineusOpisthorchis felineus is is widespread in the Russia.widespread in the Russia.Opisthorchis felineus:Opisthorchis felineus: adult fluke adult fluke

Opisthorchis felineus was first found in 1884 in cat liver in the Northern Italy by Rivolta and in 1891 in man in Siberia by the Russian scientist K.N.Vinogradov who named it “Siberian liver fluke” Opisthorchis felineus: adult fluke, detail

Opisthorchis felineusOpisthorchis felineus (Rivolta, 1884) is the most (Rivolta, 1884) is the most prevalent food-borneprevalent food-borne liver-fluke infection of man liver-fluke infection of man in the Russia, Ukraine and Kazahstan. in the Russia, Ukraine and Kazahstan. Estimated number of persons infected with Estimated number of persons infected with O.felineusO.felineus in Russia is about 1,500,000 [2]. in Russia is about 1,500,000 [2]. Opisthorchis felineus:Opisthorchis felineus: adult fluke, detail adult fluke, detail

Opisthorchis felineus:Opisthorchis felineus: opisthorchiasis is most opisthorchiasis is most prevalent in Western Siberian region in the Ob prevalent in Western Siberian region in the Ob and Irtish river valleys where the prevalence and Irtish river valleys where the prevalence amongst local natives (Hanti, Mansi, Nensi - amongst local natives (Hanti, Mansi, Nensi - Mongoloid race)in some settlements of this region Mongoloid race)in some settlements of this region reaches 100% and upreaches 100% and up to 80 amongst nonaborigene to 80 amongst nonaborigene indigenous population [3,4].In the European indigenous population [3,4].In the European Russia the endemic area is located between Russia the endemic area is located between Volga and Kama rivers and in some other regions Volga and Kama rivers and in some other regions where prevalence of this infection varies from where prevalence of this infection varies from sporadic cases to 10% [2]. sporadic cases to 10% [2]. Opisthorchis felineus:Opisthorchis felineus: adult fluke, detail adult fluke, detail

Opisthorchis felineus:Opisthorchis felineus:  first intermediate hosts are   first intermediate hosts are freshwater snails - Bithyniidae; second freshwater snails - Bithyniidae; second intermediate hosts are freshwater fish -Cyprinidae. intermediate hosts are freshwater fish -Cyprinidae.

In Russia the most important second intermediate In Russia the most important second intermediate hosts arehosts are Leuciscus idus L., Leuciscus leuciscus L.Leuciscus idus L., Leuciscus leuciscus L. and and Rutilus rutilus L..Rutilus rutilus L..Main second intermediate Main second intermediate hosts from Ob and Irtish river valleys: hosts from Ob and Irtish river valleys: Leuciscus idus LLeuciscus idus L. (in the middle); . (in the middle); Leuciscus Leuciscus leuciscus L.leuciscus L.(at the bottom) (at the bottom) and and Rutilus rutilus LRutilus rutilus L. (at the top).. (at the top).

Opisthorchis felineus:Opisthorchis felineus: final hosts are dogs, cats and final hosts are dogs, cats and other fish-eating mammals.People in Siberia and some other fish-eating mammals.People in Siberia and some European regions acquire infectionEuropean regions acquire infection by consumption of by consumption of raw, slightly salted and frozen fish (a locally so-called raw, slightly salted and frozen fish (a locally so-called “stroganina”)because of it natural availability and “stroganina”)because of it natural availability and because freezing is the most easybecause freezing is the most easy and cheap method of and cheap method of preserving fish in the North [3].Metacercaria in muscle preserving fish in the North [3].Metacercaria in muscle tissue of tissue of Leuciscus idusLeuciscus idus;compression between two ;compression between two slides. slides. (o.s.- oral suker; v.s.- ventral suker; e.v. - excretory (o.s.- oral suker; v.s.- ventral suker; e.v. - excretory visicle).visicle).

Opisthorchis felineus:Opisthorchis felineus: pathological manifestations pathological manifestations of initial phaseof initial phase of of O.felineusO.felineus infection are multiple infection are multiple and vary in both quality and intensity from non-and vary in both quality and intensity from non-apparent form and acute cases with clinical apparent form and acute cases with clinical manifestations.The major pathology in manifestations.The major pathology in O.felineusO.felineus infection is chronic inflammation of the bile ducts. infection is chronic inflammation of the bile ducts.

Opisthorchis felineusOpisthorchis felineus. Metacercarias in culture . Metacercarias in culture (artificial digestion procedure).(artificial digestion procedure).

Opisthorchis felineus:Opisthorchis felineus: opisthorchiasis varies in severity from opisthorchiasis varies in severity from asymptomatic infection to severe illness with appreciable asymptomatic infection to severe illness with appreciable morbidity and mortality.In heavily infected patients recurrent morbidity and mortality.In heavily infected patients recurrent pyogenic cholangitis, liverpyogenic cholangitis, liver a abscesses,cholecystitis,bscesses,cholecystitis, pancreatitis, biliary stones may occur.The absence ofpancreatitis, biliary stones may occur.The absence of pathognomic clinical manifestations and confoundingpathognomic clinical manifestations and confounding of of diagnosis with other prevalent diseases lead to under-diagnosis with other prevalent diseases lead to under-reporting [3,5].Opisthorchiasis is linked toreporting [3,5].Opisthorchiasis is linked to holangiocarcinoma,holangiocarcinoma, but the pathogenesis is still unclear and liver cancer is onebut the pathogenesis is still unclear and liver cancer is one of of most common malignancies that occurs in endemic areas [1]. most common malignancies that occurs in endemic areas [1]. The outcome in patients with opisthorchiasis is dependent on The outcome in patients with opisthorchiasis is dependent on early treatmentearly treatment and hence the early detection of infection is and hence the early detection of infection is important.Opisthorchiasis parasitological techniques: important.Opisthorchiasis parasitological techniques: - stool and duodenal fluid surveys , - stool and duodenal fluid surveys , examination of suspected fish examination of suspected fish - artificial digestion procedure ,tissue compression between - artificial digestion procedure ,tissue compression between two slides .Praziquantel is the drug of choice for treatment of two slides .Praziquantel is the drug of choice for treatment of opisthorchiasis and clonorchiasis.opisthorchiasis and clonorchiasis.Opisthorchis felineusOpisthorchis felineus eggs eggs (at x 400 magnification) in duodenal fluid(at x 400 magnification) in duodenal fluid on the transparent on the transparent polycarbonate Nucleopore membranepolycarbonate Nucleopore membrane (arrow indicates a filter (arrow indicates a filter pore (8 mm) ) pore (8 mm) ) Duodenal fluid was obtained by duodenal aspiration.Duodenal fluid was obtained by duodenal aspiration.