FASCIOLA HEPATICA - Shahid Sadoughi University of Medical ...

FASCIOLA HEPATICA - Shahid Sadoughi University of Medical ...

FASCIOLA HEPATICA MUZAFFAR KHAN ALAM KHAN Student of TSMU Parasite A Parasite is an organism that spends a significant portion of its life in or on the living tissue of a host organism & which causes harm to the host without immediately killing it. Every free-living species has its own unique species of parasite, so the number of PARASITOLOGY & MEDICAL PARASITOLOGY:

It is the study of parasites, their hosts & the relationship between them. One of the largest fields in parasitolgy, medical parasitology is the subhect which deals with the parasites that infect humans, the diseases caused by them, clinical picture and the response generated by humans against them. It is also concerned with the various methods of their diagnosis, treatment & finally their prevention & control. Scientific Classification

Kingdom: Animalia Phylum: Platyhelminthes Class: Trematoda Subclass: Digenea Order: Echinostomida Family: Fasciolidea Genus: Fasciola Species: hepatica TREMATODES-FLAT WORMS(FLUKES) Schistosoma S. mansoni S. hematobium

O. sinensis O. felineus S. japonicum O. viverini Fasciolopsis Opisthorchis Paragonimus P. westermani P. kellicotti Fasciolopsis buski

Fasiola Fasiola hepatica Fasiola gigantica Echinostoma Trematodes: Morphological Features Near anterior end, mouth is surrounded by muscular

oral sucker Mouth connects to pharynx, leads to esophagus, bifurcates into 2 ceca No anus: releases cecal contents back through mouth into tissue it infects Cecal contents can be seen in

histopathologic section and are colloquially referred to as fluke puke Also possess and acetabulum, or ventral sucker holdfast organ not associated with feeding Trematodes: Reproduction With exception of schistosomes (blood flukes) all flukes are

hermaphroditic Each fluke possesses both sex organs Self-fertilization usually takes place, but crossfertalization can also occur Fasciola hepatica Fasciola hepatica, also known as the common liver fluke or sheep liver fluke.

Is a parasitic flatworm of the class Trematoda, phylum Platyhelminthes that infects liver of various mammals, including humans. The disease caused by the fluke is called fascioliasis (also known as fasciolosis).

F. hepatica is world-wide distributed and causes great economic losses in sheep and cattle. Definitive host: Sheep Cattle Humans (Accidental) Other Mammals Intermediate host:

Fresh Water Snail Geographic Range: Cosmopolitan; anywhere sheep and cattle are raised Morphology of adult Fasciola hepatica acetabulum Morphology: (Angus, 1978) Specie Size Shape F.hepatica

5cm length/1.5cm wide Leaf shape with prominent shoulders F.gigantica 7.5cm length/1.2cm wide Leaf shape with scarcely perceptible shoulders DR.T.V.RAO MD

13 Life cycle outside the animal Eggs hatch in spring (>10 C) to release miracidia which must penetrate a mud snail (Lymnaea [syn. Galba] truncatula) within 3 hours Develop inside snail Cercariae emerge from snail

Encyst on grass (metacercariae) Infection of a snail with one miracidium can produce over 600 metacercariae Life cycle inside the animal Once ingested metacercariae excyst in SI and immature fluke migrate through the gut wall to penetrate the liver

Tunnel through liver for 6-8 weeks before entering bile ducts where they reach maturity Time from infection of cattle/sheep to adult egg-laying fluke is 10-12 weeks Little or no development of immunity Cycle of Events in Fasciola hepatica The life cycle of Fasciola hepatica

starts when a female lays eggs in the liver of an infected human. Immature eggs are discharged in the biliary ducts and taken out in the feces. If landed in water, the eggs become embryonated and develop larvae called miracidia. A miracidium invades an aquatic snail and develops into cercaria, a larva that is capable of swimming with its large tail. DR.T.V.RAO MD 16 Cycle of events in infection

DR.T.V.RAO MD The cercaria exits and finds aquatic vegetation where it forms a cyst called Metacercariae. A human eats the raw freshwater plant containing the cyst. The Metacercariae excysts in the first part of the small intestine, duodenum. It then penetrates

the intestinal wall and gets into the peritoneal cavity. 17 Cycle of events in infection DR.T.V.RAO MD It finds the liver and starts eating liver cells. This happens only a few days after the initial contact with the parasite. Usually the larva spends a few weeks just browsing and eating the liver. Then it

relocates to the bile duct where it begins its final stage and becomes an adult. It takes about three months for the Metacercariae to develop into an adult. Adults are about 3 cm long and 1 cm wide. 18 Progress of Infection Ingestion Metacercariae

Ex-cyst in Duodenum Burrows through Intestinal Wall Enters Peritoneal Cavity Migrates to Liver

DR.T.V.RAO MD 19 MACROSCOPIC & MICROSCOPIC EXAMINATION Egg capsule with emerging miracidium of Fasciola hepatica. 400x F.hepatica, egg: eggs measure 140 by 80 m and are operculated.

The colour is yellow to brown. (Formolether concentration). unembryonated egg capsule of F. hepatica. earlier stage of development. 400x embryonated egg capsule of Fasciola hepatica. So-named because the miracidium is fully formed and ready to emerge. The

operculum can be seen to the left. 400x egg capsule with emerging miracidium of Fasciola hepatica. 400x Redia and cercaria of Fasciola hepatica Miracidium of Fasciola hepatica. This ciliated, non-feeding larval stage, has about 24 hours to find its specific snail host, such as Fossaria modicella or Stagnicola bulimoides. 400x

The ova Length 130-145 m Width 70-90 m Regular ellipse Thin shell Operculum at one pole Granular yellowish-brown contents filling whole egg The Adult

one of the largest flukes in the world. 20 -30mm in length and 13 mm in width Leaf shape characteristic with the anterior end broader than the posterior end and an anterior coneshaped projection. Possesses a powerful oral sucker at the anterior cone and a ventral sucker at the base of the cone attach to the lining of the biliary ducts. monoecious - possesses ovaries and testes which are highly branched and allow for individual flukes to produce eggs independently.

A stained adult Fasciola hepatica; approximate length = 20 mm. The internal organs are highly branched, thus making it very difficult to differentiate the various internal organs All of their major systems are branched, including the intestine, testes, and ovary. F.hepatica, adult worm, macroscopic examination: adults measure 2-5 cm by 8-13 mm, are flat, oval in shape with a cephalic cone

containing the oral sucker.The adults live in biliary ducts for up to 10 years. Fasciola hepatica, living adult in bile duct of sheep. F.hepatica, adult worm, liver biopsy: after excistation in the small intestine, metacercariae penetrate the intestinal wall and the Glisson capsule, cross the liver parenchima to the bile ducts.Eggs can be found in faeces 34 months after

penetration. F.hepatica, adult worm, macroscopic examination: higher magnification: particular of the cephalic cone with the oral sucker. SYMPTOMS: Symptoms

The first stage: prepatent or larval period: Abdominal Pain Fever Backache, headache Chills Weight loss Urticaria Eosinophilia, elevation of AST, ALT

Cough and chest discomfort The second stage: patent or biliary period: Intermittent right upper quadrant pain Enlarged, tender liver Diarrhea Eosinophilia Complications: Anemia, cholangitis, biliary obstruction, subcapsular liver hematomas, hemoperitoneum

Condemned Liver Annual condemnatio n of livers of 3-4% of cattle at $3-5 each due to parasites. Adult-Biliary hyperplasia, dilatation, fibrosis, calcification Migration-Diffuse

fibrosis, shrunken ventral lobe The course of infection passes through three phases: The acute phase The chronic phase The obstructive phase Pathology / clinical manifestations are related to the phase

Acute Phase: Rarely seen in humans and occurs only when a large number of metacercariae are ingested at once. Fever, tender hepatomegaly, and abdominal pain are the most frequent symptoms of this stage of infection vomiting, diarrhea, urticaria (hives), anemia, may be present.

Caused by the migration of the F. hepatica larvae throughout the liver parenchyma. The larvae penetrate the liver capsule and begin to produce symptoms 4-7 days after ingestion. Migration and acute phase continues for 6-8 weeks until the larvae mature and settle in

The acute phase: Coincides with migration of the immature flukes through the peritoneal cavity, penetrating liver capsule then through liver parenchyma till they reach the bile ducts. liver Symptoms : Acute dyspepsia Prolonged high fever

Acute symptoms Asymptomatic (unusual) Severe illness (prostration & jaundice) (unusual) Hepatomegaly/ abdominal pain in the right hypochondrium

Urticaria Peripheral eosinophilia, 80%. Anaemia up to Cont.. Chronic Phase:

more common in human include biliary cholic, abdominal pain, tender hepatomegaly, and jaundice. In children, severe anemia - common result of infection biliary obstruction and inflammation caused by the presence of the large adult worms and their metabolic waste in the bile ducts. Inflammation of the bile ducts leads to fibrosis and a condition called "pipestem liver",

(white appearance of the biliary ducts after fibrosis). The final outcome portal cirrhosis and even death. The chronic phase, coincides with the presence of the flukes in the bile ducts The life span of the

parasite is 10-13 years Pathology tends to be mild Symptoms : Asymptomatic Few gastrointestinal symptoms Intermittent fever with persistent

prominent eosinophilia Recurrences of the acute signs & symptoms Recurrent cholangitis Obstructive phase (heavy / prolonged infection) Coincides with epithelial changes in the bile ducts due to irritation of the epithelium by the spines

& the activity of proline Diagnosis Eggs are large, operculated and golden in color Fasciola is diagnosed by fecal sedimentation examination DIAGNOSIS: Laboratory diagnosis

The definitive and most widely used form of diagnosis is the directly observed presence of Fasciola hepatica eggs either in a stool sample, duodenal aspirate or biliary aspirate. However, the flukes do not begin to produce eggs until roughly 4 months after infection. Until this time and in the case of ectopic infections where eggs are not present in the stool, serological tests can be used, the FASTELISA being the most popular. It has a sensitivity of 95% and can detect specific F. hepatic

antibodies as early as 2 weeks after infection . Ultrasound can be used to visualize the adult flukes in the bile ducts CT scan may reveal the burrow tracts made by the worms and dilation of the bile ducts. Computed tomography (CT) and magnetic-resonance-imaging (MRI)are used for further characterization of the lesion.They are indispensable for the evaluation of extrahepatic affection in AE and they are used for a preoperative evaluation.CT best depicts the typical calcifications and it is used for follow-up examinations at longer intervalls. For serology an ELISA was established based on

the purified E.multilocularis carbohydrate antigen Em2 (derived from the laminated layer). It is the reference test for diagnosis and it may allow discrimination of AE from E.granulosus infection.However, in a significant percentage of cases the two species can not be differentiated Halzoun : worm settles in the pharynx. Occurs when an individual consumes infected raw liver The young adult worms then attach themselves to the pharyngeal mucosa causes considerable pain, edema, and bleeding that can interfere with respiration.

The adults can live in the biliary ducts, causing symptoms for up to 10 years. Ectopic Infection: Ectopic infections through normal transmission are infrequent but can occur in the peritoneal cavity, intestinal wall, lungs, subcutaneous tissue, and very rarely in other locations. Fasciola hepatica: although direct diagnosis by

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

Infection begins when Metacercariae infected aquatic vegetation is eaten or when water containing Metacercariae is drunk. Humans are often infected by eating watercress. Human infections occur in parts of Europe, northern Africa, Cuba, South America, and other locales. It is one of the most important disease agents of domestic stock throughout the world and shows promise of 49

Treatment Bithional Highly Effective Large Dose High Cost Long Treatment Period Triclabendazole

Easier to Use 1-2 Oral Doses in 24 hrs Virtually 100% Effective Surgery 50 Prevention The presence of a substantial reservoir - keep domestic animal herds separate from the growing sites of aquatic. This limits the risk of contaminating the vegetation and thus decreases both human infection

and the animal reservoir The presence of the intermediate host, the Lymanaea snails - application of molluscicides to decrease the population of Lymnaea snails. The opportunity for water source contamination by human and non-human hosts Dietary practices that include the consumption of raw, untreated aquatic vegetation.

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