بسم الله الرحمن الرحیم

1. بسم الله الرحمن الرحیم

2. Platyhelminthes • Class: • 1- Trematoda • 2-Cestoda • 3-Turbellaria (planaria)

3. Classification of Trematoda • Trematoda: sub cl. 1-Monogenea • 2- Digenea • 3- Aspidogastrea • Digenea: 1- liver flukes • 2- Intestinal ″ ″ • 3-Lung ″ ″ • 4- Blood ″ ″

4. Trematoda (Flukes) • Morphology: • Biology • General characters: • - size • - digestive tract • - reproductive system • - excretory system • Life cycle

8. F: Fasciolidae • Genus:The trematodes; Fasciola hepatica(the sheep liver fluke) • Fasciola gigantica, parasites of herbivores that can infect humans accidentally. • F.indicum parasites of herbivores: is reported in sheep from Iran

9. Fasciola hepatica • Morphology: • - Size: adult fluke measures 20-30 * 8-13mm wide and is flat and leaf like, with a spiny tegument.

10. Adult form of Fasciola hepatica

11. Egg of Fasciola The egg is large, 130-150µm x 60- 90µm. Unembryonated, filled with yolk cells in which an indistinct germinal cell is imbedded.

12. Geographic Distribution Fascioliasis occurs worldwide: specially in areas where sheep and cattle are raised, and where humans consume raw watercress, including Europe, the Middle East, and Asia. Infections withF. gigantica and F.indicum have been reported, more rarely, in Asia, Africa, and Hawaii.

13. فاسيوليازيس طغيان ناگهاني و بروز بزرگترين همه گيري آن طي دهه گذشته با فراواني حدود ده هزار مورد در استان گيلان، به عنوان يك بيماري بازپديد و با عنايت به اينكه تا سال 1379 موارد انساني آن در صفحات غرب كشور به اثبات نرسيده است اوّلين همه گيري آن در كرمانشاه به عنوان يك بيماري نوپديد، تلقي، مي گردد.

18. Clinical Features Acute phase manifestations Chronic phase manifestations   Ectopic locations of infection

19. پاتوزنزیس و علائم بالینی مکانیسم باتوژنز: • تورم ,نکروزو فیبروز کبدی و آتروفی پارانشیم کبدی • هیپرپلازی,آدنوماتوز و فیبروز و انسداد مجاری صفراوی ناشی از متابولیتهای سمی کرم وتحریکات مکانیکی کرمهای بالغ علائم بالینی: لرز,تب ,درد ناحیه سمت راست و فوقانی شکم ,درد شانه راست, درد ناحیه پشت, بزرگی کبد, زردی ,اختلالات گوارشی , کهیر , کاهش وزن,آسیت, اسهال, کم خونی همراه باهیپرائوزنیونیلی( گاهی تا 90%)

21. يافته‌ هاي باليني بيماران مبتلا به فاسيوليازيس در كرمانشاه

22. ـ شكايات بيماران مبتلا به فاسيوليازيس در كرمانشاه

23. Laboratory Diagnosis *Microscopic identification of eggs in the stools * or in material obtained by duodenal or biliary drainage.  They are morphologically indistinguishable from those ofFasciolopsis buski.  *False fascioliasis (pseudo-fascioliasis) Antibody detection tests are useful especially in the early invasive stages or in ectopic fascioliasis.

24. تشخیص تشخیص پاراکلینیک: • انجام سی تی اسکن ( CTS ) • سونوگرافی کبد تشخیص یارازتیولوژیک: • آزمایش مدفوع و جستجوی تخم انگل در فاسیولوزیس مزمن • توباژ دوازدهه و جستجوی تخم در ترشحات دوازدهه تشخیص سرولوژیک: • تستهای ELISA, IFA (با حساسیت 75/96% و ویژگی 77/96% ) • C.C.I.E ( جهت بررسی رو ند درمان)

25. Antibody Detection • Immunodiagnostic tests may be useful for: • - early indication ofFasciolainfection as well as for -confirmation of chronic fascioliasis - for ruling out "pseudofascioliasis“ • The current tests are enzyme immunoassays (EIA) with excretory- secretory (ES) antigens combined with confirmation of positives by immunoblot.   • Antibody levels decrease to normal 6 to 12 months after chemotherapeutic cure and can be used to predict the success of therapy.

26. Treatment Unlike infections with other flukes, Fasciola hepaticainfections may not respond to praziquantel. The drug of choice is Triclabendazole with bithionol as an alternative. Bithionol: 30-50mg/kg ; 10-15 intermittent days  Triclabendazole: 10mg/kg 1-2 days

27. کرم بالغ در کبد تخم کرم کرم بالغ

28. F.hepatica, adult worm, liver biopsy

29. Laboratory diagnosis Fasciola hepatica: observation of eggs in faecal smearsImmunodiagnosis by indirect immunofluorescence. Antigen: frozen sections of Fasciola hepatica.

30. Dicrocoelium dendriticum( D. lanceolatum)

31. Life cycle of • D. lanceolatum

35. Clonorchis sinensis The trematode Clonorchis sinensis (Chinese or oriental liver fluke ). • Size: 10 to 25 mm by 3 to 5 mm reside in small and medium sized biliary ducts. • (There can be a wide variation in the size of adults, depending upon the intensity of infection and on the diameter of the bile ducts in which they are living.) •   In addition to humans, carnivorous animals can serve as reservoir hosts.

36. Adult worm The tegument has no spines. The ventral sucker is smaller than the oral and is situated about a quarter of the length from the anterior end. Cercaria

37. Geographic Distribution • Endemic areas : in Asia including Korea, China, Taiwan, and Vietnam. • in non endemic areas : including the United States • In such cases, the infection is found in Asian immigrants, or following ingestion of imported, undercooked or pickled freshwater fish containing metacercariae.

38. Life Cycle of Clonorchis Snail: Bulimus parafossarulus B.Semisulcospira Melanoides

40. Clinical Features • Most pathologic manifestations result from inflammation and intermittent obstruction of the biliary ducts.  • In the acute phase, abdominal pain, nausea, diarrhea, and eosinophilia can occur.  • In long-standing infections, cholangitis, cholelithiasis, pancreatitis, and cholangiocarcinoma can develop, which may be fatal.

41. Section of Clonorchis in liver

42. Laboratory Diagnosis Microscopic demonstration of eggs in the stool or in duodenal aspirate is the most practical diagnostic method.  The adult fluke can also be recovered at surgery Microscopy:

43. Opisthorchis spp. Opisthorchis viverrini (Southeast Asian liver fluke) and O. felineus (cat liver fluke). The mammalian definitive host : cats, dogs, and various fish-eating mammals including humans The adult size: O. viverrini: 5 mm to 10 mm by 1 mm to 2 mm; O. felineus: 7 mm to 12 mm by 2 mm to 3 mm reside: in the biliary and pancreatic ducts of the mammalian host, where they attach to the mucosa.

44. O. felineus O. viverrini

45. Geographic Distribution O. viverrini is found mainly in northeast Thailand, Laos, and Kampuchea.  O. felineus is found mainly in Europe and Asia, including the former Soviet Unio

46. Life Cycle Life Cycle: Snails involved in Thailand are subspecies of Bithynia siamensis,

47. Clinical Features Most infections are asymptomatic.   In mild cases, manifestations include dyspepsia, abdominal pain, diarrhea or constipation.   In chronic infections the symptoms can be more severe, and hepatomegaly and malnutrition , cholangitis, cholecystitis, and chlolangiocarcinoma may develop.  • In addition, infections due to O. felineus may present an acute phase resembling Katayama fever (schistosomiasis), with fever, facial edema, lymphadenopathy, arthralgias, rash, and eosinophilia.  • Chronic forms of O. felineus infections present the same manifestations as O. viverrini.

48. Laboratory Diagnosis: • Diagnosis is based on microscopic identification of eggs in stool specimens.  • However, the eggs of Opisthorchis are practically indistinguishable from those of Clonorchis. • Treatment:Praziquantel ( 25mg/kg 3 time daily/2 days)is the drug of choice to treat Opisthorchiasis.