Intestinal Helminths (worms)

Transcription

1 Intestinal Helminths (worms) I. Platyhelminths (Flat worms): 1- Cestodes (Tape-worms). 2- Trematodes (Flukes). II. Nematihelminths (Round worms/ Nematodes). 19-Nov-15 NM Kaplan 1

2 Cestodes (Tape worms) 19-Nov-15 NM Kaplan 2

3 Taenia solium & Taenia saginata Cosmopolitan. Human is the only definitive host. incidence is higher in developing countries. Infection rate: as low as 1 per as high as 10%. 19-Nov-15 NM Kaplan 3

4 Adults 19-Nov-15 NM Kaplan 4

5 19-Nov-15 NM Kaplan 5

6 19-Nov-15 NM Kaplan 6

7 Taeniid eggs indistinguishable morphologically between spp. rounded or subspherical, 35 x 45 µm. brown thick shell with peripheral radial striations eggs survive days-months in environment. Mature (embryonated): oncosphere hexacanth embryo with 3 pairs of hooklets. 19-Nov-15 NM Kaplan 7

8 Injection of India ink in uterus: Gravid proglottids with genital pores in mid-lateral position T. solium T. saginata 19-Nov-15 NM Kaplan 8

9 Life cycle Human infection by ingestion of larval cysts (cysticerci) in raw or undercooked infected meat (pork or beef) larvae excyst, pass to small intestine, attach to mucosa by their scolex suckers, mature in 3-4 months into adults w pass both detached gravid proglottids ( 6/ day) & eggs extruded from them with feces (eggs may be released after proglottids are passed with feces). Infection of intermediate host (pigs for T. solium or cattle for T. saginata) by ingestion of vegetations contaminated with gravid proglottids or eggs w hatch in small intestine hexacanth oncospheres w invade intestinal wall & migrate to striated muscles, where they develop into cysticerci w can survive for several years. 19-Nov-15 NM Kaplan 9

10 Taeniasis Light infections: asymptomatic. Heavier infections: mild GI symptoms as abdominal discomfort, epigastric pain, nausea, vomiting, diarrhea & weight loss. 19-Nov-15 NM Kaplan 10

11 Lab Dx Taeniasis: eggs or gravid proglottids in stool or from perianal area. Rx DOC: Praziquantel or niclosamide: single oral dose. Expulsion of scolex must be assured to assume satisfactory Rx. Control Thorough inspection of meat (pork & beef). Adequate cooking (internal temp. >56 C / 5min) or freezing of meat (cysticerci do NOT survive temps <-10 o C & >50 o C. Adequate sewage disposal. 19-Nov-15 NM Kaplan 11

12 Cysticercosis Human (intermediate host) infection by T. solium eggs larval cysts in S/C tissue, muscle, heart, lungs & liver. CNS meningo-encephalitic syndrome with eosinophilia & neurological disorders as epilepsy, psychiatry!. Eye pain & visual disturbances & blindness. Dx: Hx of travel to endemic area, O&P in stool, immunology assays for specific Abs (useful epidemiological tools), Radiology & Biopsy. Rx: Prolonged praziquantel or albendazole + steroids, surgery?. 19-Nov-15 NM Kaplan 12

13 Diphyllobothrium latum Worldwide, endemic in subarctic & temperate regions in association with eating of raw or undercooked fresh water fish. Definitive hosts: human & many other mammals. 19-Nov-15 NM Kaplan 13

14 Adults Longest tapeworm (3->10 meters in length with >3000 proglottids). reside in small intestine & attach to mucosa by only 2 bilateral longitudinal sucking groves (bothria) of their scolex w resembles two almondshaped leaves. Scoelx 19-Nov-15 NM Kaplan 14

15 Gravid proglottids passed in stool in strands of variable length. size: mm wide X 2-4mm long (Broader/wider than longer Broad tapeworm). with ccc centrally positioned, rosetteshaped coiled uterus. genital uterine pore at center of proglottid. 19-Nov-15 NM Kaplan 15

16 Eggs Immature (unembryonated): discharged in small intestine from gravid proglottids (up to 1,000,000 eggs/ worm/ day). pass in feces 5-6 weeks after infection. yellow-brown, oval or ellipsoidal, (58-76X40-51µm) with: 1- At one end, operculum (arrows) w can be inconspicuous. 2- At opposite (abopercular) end, small knob w can be barely discernible. mature under appropriate conditions ( days). 19-Nov-15 NM Kaplan 16

17 Life cycle Mature eggs with oncospheres hatch in fresh water ciliated coracidia (free-swimming larvae) w are ingested by small freshwater crustacean (First intermediate host; copepod, cyclop, water flea) procercoid larvae in body cavity of infected crustacean w is then ingested by fresh water fish (Second intermediate host; trout, perch, walleyed pike), released from crustacean, penetrate fish intestinal wall, migrate into fish muscles plerocercoid larvae (sparganum; 15 x 2 mm) (IS) w are ingested by human or animals eating raw, salted, pickled or undercooked freshwater fish immature adult mature adults (in 3-5 weeks). 19-Nov-15 NM Kaplan 17

18 Diphylobothriasis Light infections: asymptomatic, nonspecific as loss of appetite, epigastric pain, abdominal cramps, vomiting, weight loss & some malnutrition. Heavier infections: ccc vitamin B12 Megaloblastic anemia & neurological problems. 19-Nov-15 NM Kaplan 18

19 Dx Eggs & empty proglottids in stool. Rx DOC: Praziquantel. Control Freezing at -10 C for 48 hours, thorough cooking or pickling of fish kills larvae. Sanitary sewage disposal to keep fish reservoirs free of raw sewage. 19-Nov-15 NM Kaplan 19

20 Echinococcus granulosus common in Asia, Australia, Eastern Africa, southern Spain, southern parts of South America & northern parts of North America. incidence of human infection is 1-2 per 1000 population & higher in rural areas of endemic regions. 19-Nov-15 NM Kaplan 20

21 Adults smallest of all tapeworms (3-9 mm long) with only 3 proglottids. reside in small intestine of definitive hosts; domestic & wild carnivorous animals (dogs). 19-Nov-15 NM Kaplan 21

22 Eggs indistinguishable morphologically from other Taeniid eggs. 19-Nov-15 NM Kaplan 22

23 Hydatid cyst Round, 1-7 cm in diameter (although it may grow up to 30 cm). consists of outer anuclear hyaline cuticula & inner nucleated germinal layer containing clear yellow fluid. Daughter cysts attach to germinal layer, although some cysts (Brood cysts) may have only many larvae (Protoscolices or Hydatid Sand). 19-Nov-15 NM Kaplan 23

24 Hydatid sand Fluid aspirated from hydatid cyst show multiple protoscolices: 1- size 100 µm. 2- Ccc dagger-like hooklets. 3- normally invaginated (Lt), & evaginate (middle, then Rt) when put in saline. 19-Nov-15 NM Kaplan 24

25 Life cycle Eggs (IS), released from gravid proglottids, passed in feces of infected definitive host animals, ingested by intermediate host (grazing farm animals as sheep, goat, swine, cattle, horses, camel) or man (accidental or dead-end host), hatch in small intestine oncospheres (embryos) released, penetrate intestinal wall, migrate through circulation to various organs (liver, lungs, bones & brain) hydatid cysts w enlarge gradually, producing protoscolices & daughter cysts w fill cyst interior. Definitive hosts are infected by ingesting cyst-containing organs of infected intermediate host protoscolices escape cysts, evaginate, attach to intestinal mucosa adult worms in days. 19-Nov-15 NM Kaplan 25

26 Echinococcosis (Hydatid disease) Causative agents: E granulosus & E multilocularis. Symptoms of slow-growing tumor with eosinophilia, depend upon location of cyst: Large abdominal cysts increasing discomfort. Liver cysts obstructive jaundice. Peribronchial cysts pulmonary abscesses. Brain cysts intracranial pressure & Jacksonian epilepsy. Kidney cysts renal dysfunction. Release of contents of cyst anaphylactic responses. 19-Nov-15 NM Kaplan 26

27 Dx Intradermal (Casoni) test using hydatid fluid. Radiology: for pulmonary cysts & calcified cysts. Serology: ELISA or indirect hemagglutination test for Abs against hydatid fluid Ags. 19-Nov-15 NM Kaplan 27

28 Rx surgical removal of cyst or inactivation of hydatid sand by injecting cyst with 10% formalin & its removal within few (4-5) minutes. Praziquantel: effective in many cases. Albendazole, in high doses,: alternative. Control Avoid contact with infected dogs & cats and elimination of their infection. 19-Nov-15 NM Kaplan 28

29 E. multilocularis In northern parts of Asia & North America. very similar morphology ( mm) & life cycle with the following differences: definitive hosts are foxes, & to lesser extent dogs, cats, coyotes & wolves; intermediate hosts are rodents; cysts are multilocular (many chambers) & larval growth (in liver) remains indefinitely in proliferative stage invasion of surrounding tissues. 19-Nov-15 NM Kaplan 29

30 Rx R to praziquantel; doses of Albendazole has some anti-parasitic effect. Surgery to remove the cyst. Control Rodent control. 19-Nov-15 NM Kaplan 30

31 Hymenolepis nana most common cause of all cestode infections. Worldwide. In temperate areas its incidence is higher in children & institutionalized groups. Reservoir: Rodents. Infection is by oro-fecal route. 19-Nov-15 NM Kaplan 31

32 Adult worms Small X 0.7 cm, with small rounded scolex at anterior end & proglottids at posterior wider end. resides in ileal portion of small intestine for 4-6 weeks. 19-Nov-15 NM Kaplan 32

33 Eggs released from gravid proglottids through its genital atrium or when proglottids disintegrate in small intestine Mature (embryonated) immediately infective when passed in stool. cannot survive >10 days in external environment. round or slightly oval, smaller than those of H. diminuta, X µm. with striated outer shell & thin inner membrane. The space between membranes is smooth or faintly granular. two poles, on inner membrane, from w 4-8 polar filaments spread out between two membranes. Embryo (larva): Hexacanth oncosphere with six hooklets. 19-Nov-15 NM Kaplan 33

34 Life cycle 1- Arthropod intermediate host (various spp of beetles & fleas) ingestion of eggs cysticercoids (IS) humans or rodents ingestion of arthropod adults in small intestine. 2- Direct ingestion of eggs (IS) (NO intermediate host): w hatch oncospheres w penetrate intestinal villus cysticercoids larvae w, upon rupture of villus, return to intestinal lumen, evaginate their scoleces, attach to intestinal mucosa & develop into adults. * Cross human-to-human infection (infective cycle with passage through external environment) in contaminated food or water or from fecally-contaminated hands. * Internal autoinfection (infective cycle without passage through external environment) persistence of infection for years. 19-Nov-15 NM Kaplan 34

35 C/P: Light infections vague abdominal disturbances. Heavier infections enteritis (diarrhea, abdominal cramping & anorexia). Dx: eggs in feces. DOC: Praziquantel. Control: Hygiene. 19-Nov-15 NM Kaplan 35

36 H. diminuta Worldwide; cestode of rodents (frequently found in rodents) but infrequently seen in humans. Adults: cm in length with slightly bigger eggs (with no polar filaments) & proglottids than H. nana. 19-Nov-15 NM Kaplan 36

37 Life cycle Intermediate host (various arthropod/ insect adults or larvae) ingestion of mature eggs w hatch oncospheres released, penetrate intestinal wall cysticercoid larvae w persist through arthropod's morphogenesis to adulthood. Mammalian definitive host (rodents, man) ingestion of cysticercoid larvae in intermediate host either directly from environment or indirectly in precooked cereals, or other food items tissue of infected arthropod is digested cysticercoid larvae released in stomach & small intestine, eversion of scoleces, attach to small intestine wall by four scolex suckers, maturation within 20 days into adults gravid proglottids break off from adult worms & disintegrate mature eggs released in small intestine & passed in feces to external environment. 19-Nov-15 NM Kaplan 37

38 Dipylidium caninum most common tapeworm infection in dogs & cats in US. Adults: 19-Nov-15 NM Kaplan 38

39 Proglottids White, flat, amorphous rice-like bodies in stool & motile upon release into environment. small, can vary in size but longer than they are wide (ccc barrel-shaped cucumber tapeworm) with ccc 2 genital pores (dipylos = two gates) double-pored tapeworm. Carmine-stain 19-Nov-15 NM Kaplan 39

40 Eggs Embryonated & contain hexacanth oncosphere with 6 hooklets. round to oval (average size X 27-48µm). often found in packets, with 5-15 eggs vs. eggs of many cestode spp. 19-Nov-15 NM Kaplan 40

41 Life cycle Infection of humans, most often children, by ingestion of infected intermediate host (flea or louse) infective larval stages attach to small intestine adults. 19-Nov-15 NM Kaplan 41

42 C/P Light infections: often asymptomatic. Heavier infections: non-specific symptoms as weight loss, abdominal pain, & failure to thrive. Rx DOC: praziquantel. Niclosamide is also effective. Control examination & Rx of household pets. aggressive flea abatement. 19-Nov-15 NM Kaplan 42

43 19-Nov-15 NM Kaplan 43

44 19-Nov-15 NM Kaplan 44

45 Trematodes (Flukes) 19-Nov-15 NM Kaplan 45

46 19-Nov-15 NM Kaplan 46

47 Schistosomes 1 intermediate host snail (vs. other trematodes with 2 intermediate hosts) restricted geographical distribution 3 spp:. 1- S. hematobium in Africa. (S. intercalatum in SE Asia) 2- S. mansoni in Africa & America. 3- S. japonicum in far east (S. mekongi in central Africa). Various animals as dogs, cats, rodents, pigs, horses & goats, serve as reservoirs for S. japonicum, and dogs for S. mekongi. 19-Nov-15 NM Kaplan 47

48 Adults reside in mesenteric venules in various locations (specific for each sp) in humans. separate sexes (vs. other hermaphroditic trematodes): * : 7-20 mm long with slender shape. * : slightly smaller with 2 marginal long folds forming (Gynaecophoric canal) in w is held. ccc eggs w often contain fully-developed mature miracidium when excreted. 19-Nov-15 NM Kaplan 48

49 & schistosomes 19-Nov-15 NM Kaplan 49

50 S. haematobium Adult Eggs in section of bladder 19-Nov-15 NM Kaplan 50

51 S. haematobium; Eggs large (55-65 X µm) in urine with terminal spine at posterior end. DD: S. intercalatum. 19-Nov-15 NM Kaplan 51

52 S. Mansoni Adult & Adult & in copula 19-Nov-15 NM Kaplan 52

53 S. Mansoni; eggs large (45-70 X µm) in feces, with lateral spine near posterior end. Anterior end is tapered & slightly curved. 19-Nov-15 NM Kaplan 53

54 S. japonicum Adult & Adult & in copula 19-Nov-15 NM Kaplan 54

55 S. japonicum; eggs smaller (55-65 X µm), typically oval or subspherical, with knob (vestigial spine) on side. DD: S. mekongi. 19-Nov-15 NM Kaplan 55

56 Life cycle No vehicle of infection w occurs in fresh water by intact skin penetration by free-swimming bifurcated-tail cercaria (IS) w shed their forked tail schistosomulae w travel through venous circulation to heart, lungs & portal circulation (liver) adults in 3 weeks w reach mesenteric (S. mansoni & S. japonicum) or bladder (S. haematobium) venous vessels where they live & ovulate for D of host's life. Adult deposit eggs in small venules of rectum or bladder. Eggs germinate as they pass through vessel wall into lumens of intestine or bladder & are excreted in feces (S. mansoni & S. japonicum) or urine (S. haematobium) & hatch under optimal conditions larval miracidia released, swim & penetrate specific snail intermediate hosts in w developmental stages inc 2 asexual multiplication generations of sporocysts cercariae. 19-Nov-15 NM Kaplan 56

57 bifurcated-tail Cercaria 19-Nov-15 NM Kaplan 57

58 Pathology Adult worms are innocuous & coat themselves with host Ags to evade immune responses. Deposition of eggs granulomata & fibrotic lesions of liver, bladder or other organs malignant changes: 1- Urinary; (S. haematobium): Haematuria, scarring, calcification, squamous cell carcinoma, occasional embolic egg granulomas in brain or spinal cord. 2- Intestinal; (S. mansoni & S. japonicum): Katayama fever, hepatic perisinusoidal egg granulomas, Symmers pipe stem periportal fibrosis, portal hypertension & occasional embolic egg granulomas in brain or spinal cord. 05/04/2013 NM Kaplan 58

59 Katayama fever )Katayama syndrome) Esp. by S. mansoni & S. japonicum. Acute (as early as 3 weeks after initial exposure) egg-laying phase of schistosomiasis, a toxemic syndrome in heavy primary infections, rarely seen in chronic cases. form of immune complex disease or serum sickness-like condition. 05/04/2013 NM Kaplan 59

60 Schistosomiasis (Bilharziasis) 250 million infected & 600 million at risk. Penetration of cercariae transient dermatitis (swimmers' itch). Symptoms are primarily due to reaction against deposited eggs In bladder: granulomatous lesions, hematuria & sometimes urethral occlusion. chronic infection in endemic areas most bladder cancers. In intestine: polyp formation w in severe cases life threatening dysentery. In liver: periportal fibrosis & portal hypertension HSM & ascites. Gross enlargement of esophageal & gastric veins (varices) rupture & hematemesis. S. japonicum eggs are sometimes carried to (1) CNS headache, disorientation, amnesia & coma. (2) heart arteriolitis & fibrosis enlargement & Rt. ventricle failure. 19-Nov-15 NM Kaplan 60

61 Dx *ccc eggs *Tests for viability of eggs after Rx Ova hatched in water & motile miracidia seen by hand-lens. Eggs examined microscopically for ccc flickering movement of excretory flame cells. *Other serodiagnostic tests ELISA for Ab detection. Methods for Ag detection. 05/04/2013 NM Kaplan 61

62 Rx Generic Praziquantel DOC (effective against all spp). Lack of toxicity. Simple administration. Specific Metriphonate (organophosphate compound S hematobium. Oxamniquine S mansoni. 05/04/2013 NM Kaplan 62

63 Control Avoid contaminated water. sanitary disposal of sewage. destruction of snails. No vaccine is available. 19-Nov-15 NM Kaplan 63

64 Fasciolopsis buski (Giant intestinal fluke) Adult endemic in central & southeast Asia. life span one year. elongate oval, X cm. Lives attached to small intestinal mucosa of mammalian hosts (humans & pigs) inflammation, ulceration & abscesses. Adult; anterior end, carmine stain 19-Nov-15 NM Kaplan 64

65 Eggs X μm). Immature eggs are discharged into intestine & passed in stool to mature & become embryonated in water. 19-Nov-15 NM Kaplan 65

66 Life cycle Infection by ingesting water plants (water chestnuts) contaminated with encysted metacercaria w excyst in duodenum, attach to intestinal mucosa & mature into adults in days eggs passed in feces & hatch in fresh water miracidia w must penetrate suitable snail intermediate host within hours & undergo several developmental stages (sporocysts, rediae & cercariae) cercaria released in fresh water & encyst as metacercariae on acquatic vegetations. 19-Nov-15 NM Kaplan 66

67 C/P Light infectons: epigastric pain, nausea & diarrhea, esp. in morning. Heavier infections: generalized edema & ascites. Dx Eggs in faeces. Rx DOC: Praziquantel. Control Avoid water chestnuts from contaminated waters. Sewage ttt before disposal. 19-Nov-15 NM Kaplan 67

68 Heterophyes heterophyes (Minute intestinal fluke) Adult Middle East, & Far East. infects & lives in small intestine of humans, various fish-eating mammals (e.g., cats & dogs) & birds. one of the smallest, X mm. Adult stained with carmine oral sucker (OS), pharynx (PH), intestine (IN), ventral sucker, or acetabulum (AC), & eggs within uterus (UT). 19-Nov-15 NM Kaplan 68

69 Life cycle Infection by ingesting raw, undercooked or salted fish containing metacercariae w excyst, attach to mucosa of small intestine & mature into adults embryonated eggs (each with fully-developed miracidium) passed in feces, ingested by suitable snail (first intermediate host) & hatch miracidia released, penetrate snail s intestine & undergo several developmental stages (i.e. sporocysts, rediae & cercariae) cercariae released from snail & encyst as metacercariae in tissues of suitable fresh/brackish water fish (second intermediate host). 19-Nov-15 NM Kaplan 69

70 C/P Intestinal main symptoms: diarrhea & colicky abdominal pain. Ectopic: eggs may penetrate small intestine mucosa, enter PB & migrate to extraintestinal sites as heart, liver, spinal cord & brain, where they can cause serious disease. 19-Nov-15 NM Kaplan 70

71 Dx: eggs in stool; indistinguishable from those of C.sinensis. DOC: Praziquantel. 19-Nov-15 NM Kaplan 71

72 Metagonimus yokogawai minute intestinal fluke (smallest human fluke; X mm.). Mostly Far East, Siberia, Manchuria, Balkan states & Spain. Similar to H. heterophyes in all aspects. Adult stained with carmine. oral sucker (OS), pharynx (PH), intestine (IN), genitoacetabulum (GA), ovary (OV), large paired testes (TE), eggs within the uterus (EG). 19-Nov-15 NM Kaplan 72

73 Liver flukes Fasciola hepatica: worldwide, infect grazing animals (sheep & cattle) & man. Opisthorchis (Clonorchis) sinensis (Chinese/ oriental liver fluke): widespread in southeast Asia (extraordinarily common in China and is also found in Korea & Japan), infects man & carnivorous animals as dogs & cats w can serve as reservoir hosts. Related Opisthorchis spp parasitizing European cats (O. felineus; Cat liver fluke) & SE Asian dogs (O. viverini ; Southeast Asian liver fluke) infect humans in endemic areas. 19-Nov-15 NM Kaplan 73

74 19-Nov-15 NM Kaplan 74

75 Fasciola hepatica (Sheep liver fluke) Adult: leaf shaped, 1x3 cm. 19-Nov-15 NM Kaplan 75

76 Eggs Embryonated eggs in stool: 80 x 150 µm, indistinguishable from those of F. buski. 19-Nov-15 NM Kaplan 76

77 Life cycle Humans infection by ingesting raw or undercooked fresh water plants as watercress w harbor encysted larval metacercariae w excyst in duodenum, penetrate through intestinal wall, migrate to peritoneal cavity, penetrate liver capsule, wander through liver parenchyma for up to 9 weeks & migrate into bile duct where it matures into adult embryonated eggs in stool w hatch in water miracidia w penterate appropriate snail intermediate host & divide (sporocysts, redia & cercaria) cercariae w exit snail & encyst as metacercariae attached to acquatic vegetations leaves. 19-Nov-15 NM Kaplan 77

78 C/P Adults do NOT multiply in human parasite burden depends on inoculum). Adults live in biliary ducts symptoms for up to 10 years: 1- Physical presence irritation hyperplasia of epithelium & bile obstruction. 2- Toxic metabolic by-product secretions most damage in liver parenchyma (hepatitis). Adult worms may invade liver & cause necrotic foci (Liver Rot). Passage of larva through liver tenderness & hepatomegaly. upper quadrant pain, chills & fever accompanied with eosinophilia. 19-Nov-15 NM Kaplan 78

79 Rx Praziquantel: NOT effective (vs. F. buski,) Triclabendazole: effective. 19-Nov-15 NM Kaplan 79

80 Halzoun (local, Middle Eastern term) pharyngeal infection (initially attributed to Fasciola hepatica) by ingestion of raw or undercooked sheep or goat liver w contained immature flukes larval flukes emerge, attach to pharyngeal mucosa Adult. C/P: dysphagia, dyspnea, edema, bleeding & airway obstruction. All pts presented with immune allergic-like symptoms of eyes, ears, nose, or throat. 19-Nov-15 NM Kaplan 80

81 Opisthorchis (Clonorchis) sinensis (Chinese liver fluke) spindloid mm X 3-5 mm. reside in small & medium sized biliary ducts. Adults 19-Nov-15 NM Kaplan 81

82 Clonorchis sinensis Adults in section of liver (H&E) Eggs: CCC operculated brownish small 29 x 16 µm 19-Nov-15 NM Kaplan 82

83 Life cycle Human infection by ingestion of raw or undercooked, salted, pickled, or smoked freshwater fish w carries encysted metacercariae (IS) w excyst in duodenum, migrate ascending up biliary tract (through ampulla of Vater) to liver & mature into adults in 1 month embryonated eggs deposited in biliary ducts, pass in feces, find their way to fresh water, ingested by suitable freshwater operculate snails (first intermediate hosts; >100 spp) & hatch miracidium w undergoes several developmental stages (sporocysts, rediae & cercariae) cercaria released in water, penetrate flesh of freshwater fish (second intermediate hosts) where they encyst as metacercariae. 19-Nov-15 NM Kaplan 83

84 Chlonorchiasis Light infections indigestion, epigastric discomfort, loss of appetite & weakness. Heavier infections nausea, vomiting, diarrhoea, anemia, loss of weight, jaundice, hepatomegaly & tenderness & ascites. Hyperplasia, fibrosis of bile ducts & cholangiocarcinoma. 19-Nov-15 NM Kaplan 84

85 Lab Dx: ccc eggs in feces or biliary drainage. Rx:Praziquantel. Control: Proper cooking of fish before consumption. Sewage ttt before disposal. 19-Nov-15 NM Kaplan 85

86 05/04/2013 NM Kaplan 86

87 19-Nov-15 NM Kaplan 87

88 19-Nov-15 NM Kaplan 88