TREMATODES: Fasciola hepatica ECCMID LONDON ABRIL 2012 EDUARDO GOTUZZO,A M.D.FACP.FIDSA UNIVERSIDAD PERUANA CAYETANO HEREDIA HOSPITAL NACIONAL© by CAYETANO author HEREDIA THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia HERMAPHRODITIC TREMATODES - BILIARY TRACT: • Fasciola hepatica • Clonorchis sinensis - INTESTINAL CANAL: • Fasciolopsis buski - LUNG: • Paragonimus© by westermani author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia HERMAPHRODITIC TREMATODES CLASSIFICATION - BILIARY TRACT: Liver flukes • Fasciola hepatica, F. gigantica • Clonorchis sinensis • Opistorchis felineus, O. viverrini • Dicrocoelium dendriticum © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia HERMAPHRODITIC TREMATODES CLASSIFICATION - INTESTINAL CANAL: Intestinal flukes • Fasciolopsis buski • Heterophyes heterophyes • Metagonimus yokogawai • Echinostoma • Gastrodiscoides© by authorhominis THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia HERMAPHRODITIC TREMATODES CLASSIFICATION - LUNG : Lung flukes • Paragonimus westermani • P. miyazakii, P. skrjabini, P. heterotremus • P. africanus, P. uterobilateralis • P. mexicanus, P. caliensis, P. amazonicus, P. inca © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia © by author ESCMID Online Lecture Library HERMAPHRODITIC TREMATODES LIFE CYCLE • Adult fluke: vertebrate host • Eggs water miracidium • Miracidium snail (1st. IH) sporocysts • Sporocyst 1st and 2nd generation rediae fish • Rediae cercariae water crustacean metacercariae plant (encyst) © by author(2nd IH ) THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Fasciola hepatica © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Fasciola hepatica and F. gigantica • F. hepatica : Adult: 20-30 mm by 8-13 mm Worldwide Definitive Host: Sheep, cattle • F. gigantica : Adult: 20-75 mm by 8-20 mm Africa, western Asia, South America Definitive Host: Cattle, sheep • 1st Int. Host : Lymnaea snails © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Fasciola hepatica and F. gigantica • Metacercariae in 2nd intermediate host: Watercress, alfalfa, lettuce (or water) → excyst (duodenum) → penetrate the intestinal wall → peritoneal cavity → penetrate Glisson's capsule → traverse liver parenchyma → large bile ducts → adults • Incubation period to adult flukes: 3-4 months • Life span: 9-13 years © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia FASCIOLA LIFE CYCLE © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Fasciola Hepatica Infection • High prevalence – Bolivia (Altiplano) - Peru (Andean Valleys) • New endemic area: South east Asia • (THAILAND.LAOS.CAMBODIA,VIETNAM) • Endemic in some AREAS TURKEY ,IRAN Mas-Coma 2010 © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia FASCIOLA Egg Miracidium © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia FASCIOLA Redia Cercaria © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Fasciola hepatica and F. gigantica CLINICAL MANIFESTATIONS ACUTE PHASE (INVASIVE or MIGRATORY) Asymptomatic or Symptomatic: IP: 6-12 weeks Last: 2-4 months Sym: - Abdominal pain (65%) in RUQ, epigastrium - Anorexia, nausea, vomiting, diarrhea - Fever (60%), headache, night sweats, weight loss (35%) PE: - Tender hepatomegaly, splenomegaly, jaundice unusual, ascites - Urticaria, wheezing - Cough, pleural effusion,© by pulmonary author infiltrates Lab: - Leukocytosis, marked eosinophilia (95%) THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Fasciola hepatica and F. gigantica PATHOLOGY • Migrating larva: - Liver parenchimal destruction and dilatation of bile ducts - Fibrosis and calcification with necrosis - Abscess formation and hemorrhage. • Adult flukes: - Hiperplasia, desquamation, thickening and dilatation of bile ducts - Fibrosis and calcification. • Granulomas and abscesses© aroundby author eggs trapped in the parenchimal tissue. THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Fasciola hepatica-induced liver abscess © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Foreign body reaction against the ovum (pseudotubercle) © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Fascioliasis NEJM 2002;346(16):1232-1239 7 cm lesion 1,5 months later 1,5 months later Serpiginous yellow nodules © by author ESCMID Online Lecture Library Fascioliasis Marcos LA et al. Am J Trop Med Hyg 2008;78(2):222-227. Less 1 week of symptoms: Thickened 2 weeks of symptoms: Hypodense, tract- Glisson`s capsule and hypodense lesion. like, serpiginous lesion. © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Fascioliasis Marcos LA et al. Am J Trop Med Hyg 2008;78(2):222-227. 2 mo of symptoms: Subcapsular hematoma; 5 mo of symptoms: Lesions are more thickening and enhancing of Glisson`s capsule. central, nodular, serpiginous; splenomegaly. © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Fasciola Hepatica Acute Phase Subcapsular Hematoma © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Fasciola hepatica and F. gigantica CLINICAL MANIFESTATIONS CHRONIC PHASE (LATENT or OBSTRUCTIVE) Asymptomatic or symptomatic Sym: - Intermittent abdominal pain in RUQ, epigastrium, biliary colic - Anorexia, nausea, vomiting - Cholangitis (fever, jaundice) - Calculous or acalculous cholecystitis PE: - Tender hepatomegaly - Severe: Ascites with© blood, by author severe anemia Lab: - Abnormal LFT, eosinophilia THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Fascioliasis Palmer PES and Reeder MM. The Imaging of Tropical Diseases, Springer-Verlag 2001. Gallbladder with sludge and vermiform Dilated comon duct nonshadowing images © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Fascioliasis. Multiple linear, crescent-shaped lucencies in the distal common duct (flukes). Palmer PES and Reeder MM. The Imaging of Tropical Diseases, Springer-Verlag 2001. © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Fasciola hepatica and F. gigantica COMPLICATIONS CHRONIC PHASE - Hemobilia - Anemia - Hematemesis and melena - Bile duct and gallbladder stones - Sclerosing cholangitis - Biliary cirrhosis © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Fascioliasis-liver fluke (trematode) Hx: 62-year old female with 3m. of fever, severe general malaise, loss of appetite, 10 kg weight loss, right upper quadrant pain and initially some icterus. No meds. Evaluation 1 m. earlier had shown an eosinophil count of 7,500, Alk P. 8X normal, transaminases 2X normal, and 3 neg stools. CXR was normal and an abdominal ultrasound showed numerous small (<15mm) lesions throughout the liver. Empiric Rx with 7 days of praziquantel without effect. No past med Hx. Epi: Farmer. Her husband, who had a history of chronic alcoholic liver disease,© had by become author ill at the same time and died with icterus, ascites, and hypereosinophilia. Just prior to the illness the husband had heard of beneficial health effects of watercress which was consumed on only once. THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Case continued PE: Pale. Afebrile. Liver non-tender 3 cm below costal margin. No splenomegaly. Lab: Hct 31. WBC 15,600 21 PMN, 18L, and 56 eos. Blood cultures neg. LFTs not repeated. Hepatitis A, B, C, negative. Stool O & P and serological tests were ordered. Available CT image is from 3 months later. © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia © by author THE UNIVERSITYESCMID OF Online Lecture LibraryUniversidad Peruana ALABAMA AT BIRMINGHAM The Gorgas Course Cayetano Heredia Clinical presentation and management of Fasciola