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Tropical medicine - All clinical images copyright Gorgas course - : Instituto de Medicina Tropical Alexander von Humboldt > Trematodes - Schistosoma, Fasciola, Paragonimus... > Flashcards

Trematodes - Schistosoma, Fasciola, Paragonimus... Flashcards

1
Q

Schisto species and geography + targeted pathology

A
  • S haematobium - urogenital- Africa and Middle east. Haem / albumin urea [Eventually fibrosis and obstructive uropathy]
  • S mansoni bowel and LIVER- Africa and South America (due to slave trade) diarrhoea and blood
  • S japonicum - bowel and liver + CNS in 4% - China, and South East Asia
    -S mekongi (similar to japonicum only found in Laos / cambodia)
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2
Q

Shisto appearance

A

Worms 1-2cm long look like a rolled leaf

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3
Q

Basic life cycle of all shisto? How does this affect where eggs are found

A
  • Eggs released from human stool / urine
  • Hatches in FRESHwater after 1-3 weeks to release a miracidium (L1 stage)
  • Snails which live in water - intermediate hosts
  • Sporocyst in snail release cercariae (L3) into water (0.2mm long) in response to light
  • Penetrates through skin [Days 0-2]
  • Reaches lungs Day 3-10 then to liver [3+ days]
  • liver -> mature fluke (L5) in mesenteric vein [4+ weeks] where mature males and females couple (forever)

haematobium - lives vesicle plexus and eggs pass through wall into bladder
Mansori / japonicum - Live in portal veins and eggs pass through bowel wall into stool

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4
Q

Which shisto is most zoonotic?

A

Japonicum- reservoirs in farmed mammals

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5
Q

Transmission of schisto usually very local. Who has most egg output

A

Children 10-15 Years
[They the ones swimming most]

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6
Q

Bar lakes where is other key water for shisto to infect humans

A

Domestic if water supplied contaminated

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7
Q

Acute shisto also called? What happens? when?

A
  • Katayama fever
  • Diarrhoea, hepato/splenomegaly, cough/wheeze, urticaria fever and eosinophilia

Approx 4-8 weeks after infection

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8
Q

What is swimmers/fisherman’s itch cased by? real name and how long does it last?

A

Shitsto occasionally occurs where cercariae enter skin

Cercarial dermatitis - can last several days

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9
Q

4 complications with s haematobium?

A

Eggs may cause fibrosis and calcification
-> May lead to ureteric obstruction

Increased risk of bladder squamous cell Ca

Female sterility

Eggs obstructing pulmonary arterioles -> R heart failure

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10
Q

S mansori/ japonicum key issue? Seen on imaging?

A
  • Periportal fibrosis -> varices
  • ‘Pipe stem fibrosis’ on US
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11
Q

Definitive dx shisto? How to work out which species

A
  • Microscopy of eggs
  • Gives an idea of degree of infection eg >50 eggs /g of stool

-Western blot for species (but Rx the same)

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12
Q

Dx of neuro shisto

A

Brain imaging with serodiagnosis

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13
Q

Shisto rx

A

Praziquantel single dose 40mg/kg
- add steroids if katayama fever

[Artemisinin can be used as ‘morning after pill’ as need to wait 8 weeks for prazi]

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14
Q

Shisto control

A
  • Kill snails by eg draining water, or use a molluscuside eg niclosamide
  • Health education
  • Mass chemo with praziquantel - targeting kids
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15
Q

How can you monitor shisto haematobium incidence rates without having to use blood tests

A
  • Prevelance of haematuria
  • Point of care urine antigen dipstick
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16
Q

What do all trematodes have in life cycle

A

Snail

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17
Q

Which snail for 3 types

A

Too hard don’t care

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18
Q

What is the infectious L3 form of schisto

A

Cercariae - this is the infectious stage
[Full mature adult is never the infectious stage]

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19
Q

Whats cute about schisto

A

Males and females mate for life

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20
Q

S mansori egg in liver what happens

A

When egg breaks down -> proteins causes immune reaction (IL-2/5 -> granuloma -> fibrosis

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21
Q

Buzzword for mansoni pathology cauing morbidity

A

symmer’s periportal fibrosis [pipestem firbrosis]

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22
Q

Key difference between Katayama fever and malaria in returning traveller

A

Katayama - eosinophilia

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23
Q

Neuroschisto caused by which? Paraplegia?

A

S Japonicum in 4% of untreated cases -> neuro

S. Haematobium - due to backflow of eggs into spinal cord -> paraplegia

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24
Q

Variceal bleeding in which schisto

A

Mansoni and Japonicum

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25
Q

Swimmers itch in the US due to

A

Avian schisto (only causes local cutaneous infection)
The cercariae looking for ducks and doesn’t cause more issues for humans

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26
Q

Katayama fever how to make dx of schisto

A

Eosinophilia + clinical and Hx (fresh water exposure 4-8 weeks ago)

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27
Q

Katayama fever how to make dx of schisto

A

Eosinophilia + clinical and Hx (freshwater exposure 4-8 weeks ago)

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28
Q

Whos got big eggs

A

Trematode Eg Schisto

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29
Q

Japonicum and mejongi eggs differ from mansori by?

A

Smaller, rounder with a little knob on the side

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30
Q

Praziquantel kills what stages of schito ? Relevance of this

A

Adult worms only
[Therefore in pre-patent phase would not clear schisto infection]

Need to wait 8 weeks after exposure

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31
Q

Rx Katayama fever

A

Short course high dose pred - for 3-6 days

Praziquantel after 6 weeks [when worms are mature]

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32
Q

What common co-infection associated with schisto

A

Salmonella in urine = schisto

[Hepatitis
HIV (especially if genital disease]

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33
Q

trematodes are known as? Usual Rx?

A

Flukes
Praziquantel
[If Fasiciola hepatica or F. Gigantica (both liver flukes)- Triclabendazole]

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34
Q

what are trematodes? Usual rx?

A

Flukes
Praziquantel

[if liver flukes - Triclabendazole]

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35
Q

2 main types of liver fluke? Geography and life cycle?

A

Fasciola hepatica: worldwide where there are sheep, Peru esp in highlands

Fasiola gigantica: africa, west Asia, South America

2intermediate hosts
snail (lymnae snail)
Plants (which are eaten by human eg watercress)
Infectious state: metacercariae

Consumption of these plants eg watercress or contaminated water
Enter through duodenum and migrate to liver into bile ducts where they mature

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36
Q

Liver fluke clinical features? when?

A

Fasciola hepatica

6-12 weeks after infection
General abdo symptoms and tender hepatomegaly
-Increased risk of cholangitis or intermittent biliary obstruction
-marked eosinophilia
-leukocytosis
-pulmonary infiltrates

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37
Q

Ix liver flukes

A

Eosinophilia
CT - multiple hyperdense lesions
EIA, Immunoblot
Lateral flow
Serology - eg Fas2-ELISA
Fasciola excretory-secretory (FES) antigen in faeces

[Stool eggs only present in chronic disease usually]

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38
Q

Rx Fasciola hepatica or F. Gigantica? key side effect?

A

Triclabendazole 10mg/kg single dose

Get biliary colic after 3-7 days due to expulsion of dead flukes

[fashion trick]

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39
Q

Which oriental liver fluke china? Thailand? - diffence in their life cycle to other liver flukes? Complication?

A

Clonorchis sinensis (china)
Opistorchis viverrini (Laos Thailand)
Opistorchis felineous (Russia)

Infect fresh water fish (carp) rather than plants -> transmitted by eating fish

Ascend the bile ducts, eosinophilia, chronic obstructive picture, cholangiocarcinoma

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40
Q

Oriental liver fluke dx? rx?

A

Characteristic eggs in faeces / biliary aspirate
Can use US / ERCP

Praziquantel 40mg/kg single dose

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41
Q

Key intestinal fluke? Geography ? sx? Rx

A

Fasciolopsis Buski
India through to SE asia especially pig rearing
Cause ulceration / chronic Gi Sx

Praziquantel ….

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42
Q

Clinical features paragonimus ? Seen on imaging? Common complications?

A

Malaise, shivers, sweats and rash
-Key is chronic cough with haemoptysis
-Peripheral nodules / ring shadows on XR
-Prominent eosinophilia

Subcut migratory nodules common
Effusion/empyema
Cerebral/spinal disease**
[Can get egg granulomas in many organs]

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43
Q

Paragonismus dx? Rx?

A

Sputum / faeces microscopy
Eosinophilia
ICT test - rapid
ELISA, Immunoblot [if available]

Praziquantel for 2-3 days
[Or Triclabendazole]

-Surgical removal of extrapulmonary lesions

44
Q

Most common paragonimus species worldwide?

A

Paragonimus westermani

45
Q

Life cycle of hermaphroditic trematodes

A

Eggs hatch in water -> miracidium
Enters snail -> sporocyst
sporocyt develop into redia
Redia turn into cercariae which enter water and either
-Infect fish
-Crustacean
-Attach to plant

Become metacercariae

46
Q

41 yo male
* 30 d of chills, fever at night, moderate sweating
*Abdominal pain in epigastrium and RUQ, increases with
meals
*Wt Loss 5 Kg
Distended, diffuse tenderness to superficial palpation; pain and muscular guarding in epigastrium and RUQ to deep palpation

A

Fasciola hepatica or gigantica

47
Q

Fasciola hepatica gigantica definitive host

A

: Sheep, cattle

48
Q

Fasciola life cycle

A
49
Q
A

fAsciola egg

50
Q

Fasciola what are these

A

Redia on left, cercaria on right

51
Q

Most common sx fasciola? Blood finding?

A

Abdo pain
Significant eosinophilia

52
Q

Most important complications fasciola?

A

Sclerosing Cholangitis (fever, jaundice)
Biliary sclerosis

[Pancreatitis, haemobilia / anaeemia
-Migrating Blood vessels, lung, peritoneum, intestinal wall, Muscles, eyes, brain, testes]

53
Q

Diagnosis chronic phase fasciola

A

Serology: CIEF for copro-antigens (3-4 w before eggs)
Fas2 serology
Western blot
Eggs in stool

54
Q

Clonorchis sinensis and Opistorchis viverrini / felineus life cycle

A
55
Q

Clonorchis sinensis and Opistorchis viverrini / felineus key blood finding in acute infection

A

Raised ALP

56
Q

Clonorchis sinensis and Opistorchis viverrini / felineus key complications

A

Same as fasciola

  • Obstructive jaundice
    -Recurrent ascending cholangitis
    -Cholecystitis
  • Pancreatitis
  • Gallbladder or intrahepatic stones

Specific to Clonorchis sinensis and Opistorchis viverrini
- Night blindness
- Cholangiocarcinoma

57
Q

Clonorchis sinensis and Opistorchis viverrini Dx? Rx?

A

Eggs in stools
ELISA - fecal antigen / antibodies

Praziquantel

58
Q

Which is the biggest intestinal fluke? Definitive host?

A

Fasciolopsis buski

Pigs

59
Q

Fasciolopsis buski life cycle

A

Basically same as fasciola
[Pigs implicated instead of other livestock]

60
Q

Fasciolopsis buski Key pathology?

A

Small bowel mucosa: Inflammation, mucus,secretion, ulceration.

Bleeding, abscess formation.

[fowl smelling diarrhea, undigested food
* severe abdominal pain
* fever, eosinophilia
* malabsorption, hypoalbuminemia, low
serum levels of vitamin B12
* oedema, ascites, anasarca]

61
Q

Fasciolopsis buski Ix Rx

A

Stools - Eggs

Praziquantel

62
Q
A

Paragonimus westermani egg

63
Q

Which paragonimus in Latin america?

A

P. mexicanus

Westermani more in asia

64
Q

Paragonimus Intermediate vs definitive host

A

1st intermediate - snails
2nd - crayfish

Definitive - animals eating

65
Q

Paragonimus life cycle

A
66
Q

How do you get infected with paragonimus

A

Consume uncooked crab/crayfish with metacercariae

67
Q

CXR sign in paragonimus called?

A

Soap bubble appearance

68
Q
A

Paragonimus egg

69
Q

Schisto life cycle

A
70
Q

Found in stool =

A

Schistosoma mansoni - has a lateral spine

71
Q
A

Schistosoma mansori

72
Q
A

S. Hematobium Ova in Stool
Terminal spine

73
Q

Which schisto

A

S. Japonicum or S. Mekongi;
smaller, round, with small lateral knob

74
Q

Only trematode which isn’t eaten by a snail (directly infects)

A

Fasciola

75
Q

Acute vs chronic fasciola ix?

A

Acute - hypereosinophilia >1500
-no eggs in stool
- serology positive after 2-3 weeks (Fas2 ELISA)

Chronic - mild eosinophilia
- Microscopy positive after 3-4 months

76
Q

Spell 2 liver, 1 lung, 1 blood and 1 intestinal fluke

A

Liver fluke
-Fasciola hepatica / gigantica
-Clonorchis sinensis
- Opistorchis viverrini

Lung
- Paragonimus westermani

Blood
-Schistosoma mansori

Intestinal
-Fasciolopsis buski

77
Q

What are all flukes? bar?

A

Hermaphrodites
-Bar schisto

78
Q

How do humans get infected by trematodes

A

Eating host/plants with metacercariae (except schisto)

79
Q

Fasciola life cycle?
Infective vs diagnostic? Name the hosts?

A

Infective stage : metacercariae
Diagnostic stage : unembryonated egg

Intermediate host : snail
Definitive host : ruminants , humans

80
Q

Key food for fasciola hepatica

A

watercress

81
Q
A

Fasciola hepetica - note CEPHALIC cone
[herpetic cone of shame]

82
Q
A

Fasciola hepatica - note CEPHALIC cone
[herpetic cone of shame]

83
Q

130um big

A

Faciola hepatica

84
Q

How big am I?

A

Fasciola hepatica
120-140um

85
Q

Faciola hepatica vs fasciolopsis buski
Cephalic cone?
Which one can be 7cm?
Oral and ventral suckers distance?

A
86
Q

fasciolopsis buski life cycle

A
87
Q

Clonorchis sinensis life cycle?

A
88
Q
A

Clonorchis sinensis
or O. viverreni

Knob on side

89
Q
A

Clonorchis sinensis
-Lateral branches

[S - wavey side to side]

90
Q
A

opisthorchis viverrini
- No lateral branches

[V - remains straight line down middle]

91
Q

Paragonimus life cycle? Infective vs diagnostic?
Hosts?

A

Infective stage: metacercariae
Diagnostic stage : unembryonated egg
(sputum or stools if swallowed)

1 - intermediate host : snail
2 -intermediate host : crustacean
Definitive host : human

92
Q
A

Paragonimus metacercariae
- note the central (ventral) sucker

93
Q
A

Paragonimus
no cephalic cone
oral and ventral suckers

94
Q
A

Paragonimus
no cephalic cone
oral and ventral suckers

95
Q
A

Paragonimus egg
‘shoulders, thickened end (no knob)

96
Q
A

Paragonimus egg - its in sputum obvs.
‘shoulders, thickened end (no knob)

97
Q

Schistosoma life cycle? Infective vs diagnostic? Hosts?

A

Infective stage : cercariae
-penetrate skin)
Diagnostic stage: egg
-in feces or urine

Intermediate host: snail
Definitive host : human

98
Q

Where would you find me?

A

Faeces - Schistosoma mansoni
-Lateral spine

99
Q

Where would you find me?

A

Urine - Schistosoma haematobium
-Your willy is in the middle = mid line spine for urine]

100
Q

Where would you find me?

A

Faeces - Schistosoma japonicum
Rounded, small lateral spine

[Lateral spine = poo idk]

101
Q
A

Male and female Schistosoma
[male is bigger]

102
Q
A

Schistosoma cercaria (infective stage)

103
Q

Fasciola vs paragonimus vs Dyphillobothrium egg sizes? other distinguishing features?

A

Fasiola - 130um
-often ‘open’

Paragonimus - 100um
-‘Shoulders’, asymetrical and thickened end

Dyphillobothrium - 60um
-Little knob

104
Q

Freshwater exposure lake Malawi now eosinophilia and urticarial rash ix? Rx? What are the most common symptoms?

A

Steroids - Katayama fever
Serology - eggs undetectable this early

Praziquantel 6 weeks after exposure

Eosinophilia
Fever
Cough
(rash)

105
Q

Paragonimus incubation time after infection -> chest sx

A

4-6 weeks

Tropical medicine - All clinical images copyright Gorgas course - : Instituto de Medicina Tropical Alexander von Humboldt (26 decks)

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