Trematodes, or flatworms, are a group of morphologically and biologically heterogeneous organisms that belong to the phylum Platyhelminthes. Human infection with trematodes occurs in many geographic areas and can cause considerable morbidity and mortality. The dependence on one drug—praziquantel—for treatment of most infections caused by trematodes raises the specter of developing resistance in these worms; several instances of reduced drug efficacy have already been reported. The widespread use of oxamniquine in the 1970s to reduce the impact of schistosomiasis resulted in the development of significant resistance. Recently, a single quantitative trait locus on schistosomal chromosome 6 was identified as the genetic basis for resistance.
ETIOLOGIC AGENTS AND THEIR LIFE CYCLES
For clinical purposes, significant trematode infections of humans may be divided according to the tissues invaded by the adult stage of the fluke, whether bloodstream, biliary tree, intestines, or lungs (Table 134-1). Trematodes share some common morphologic features, including macroscopic size (from one to several centimeters); dorsoventral, flattened, bilaterally symmetric bodies (adult worms); and the prominence of two suckers. Except for schistosomes, all human parasitic trematodes are hermaphroditic. Their life cycles involve a definitive host (mammalian/human), in which adult worms initiate sexual reproduction, and an intermediate host (snail), in which asexual multiplication of larvae occurs. More than one intermediate host may be necessary for some species of trematodes. Human infection is initiated either by direct penetration of intact skin or by ingestion. Upon maturation within humans, adult flukes initiate sexual reproduction and egg production. Helminth ova leave the definitive host in excreta or sputum and, upon reaching suitable environmental conditions, they hatch, releasing free-living miracidia that seek specific snail intermediate hosts. After asexual reproduction, cercariae are released from infected snails. In certain species, these organisms infect humans; in others, they find a second intermediate host to allow encystment into metacercariae—the infective stage for humans.
TABLE 134-1MAJOR HUMAN TREMATODE INFECTIONS |Favorite Table|Download (.pdf) TABLE 134-1 MAJOR HUMAN TREMATODE INFECTIONS
|TREMATODE ||TRANSMISSION ||ENDEMIC AREA(S) |
|Blood Flukes |
|Schistosoma mansoni ||Skin penetration by cercariae released from snails ||Africa, South America, Middle East |
|S. japonicum ||Skin penetration by cercariae released from snails ||China, Philippines, Indonesia |
|S. intercalatum ||Skin penetration by cercariae released from snails ||West Africa |
|S. mekongi ||Skin penetration by cercariae released from snails ||Southeast Asia |
|S. haematobium ||Skin penetration by cercariae released from snails ||Africa, Middle East |
|Biliary (Hepatic) Flukes |
|Clonorchis sinensis ||Ingestion of metacercariae in freshwater fish ||Eastern Asia |
|Opisthorchis viverrini ||Ingestion of metacercariae in freshwater fish ||Eastern Asia, Thailand |
|O. felineus ||Ingestion of metacercariae in freshwater fish ||Eastern Asia, Europe |
|Fasciola hepatica ||Ingestion of metacercariae on aquatic plants or in water ||Worldwide |
|F. gigantica ||Ingestion of metacercariae on aquatic plants or in water ||Sporadic, Africa |
|Intestinal Flukes |
|Fasciolopsis buski ||Ingestion of metacercariae on aquatic plants ||Southeast Asia |
|Heterophyes heterophyes ||Ingestion of metacercariae in freshwater or brackish-water fish ||Eastern Asia, North Africa...|
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