Kuliah Parasitologi BMS blok VIIITrematoda Hati dan Trematoda usus

Forman Erwin SiagianEmail: formanerwin@yahoo.com

Dept. Parasitologi FKUKIKamis, 26 juni 2014

5 tahap pemenuhan kesehatan

(Leavell dan Clark)

Taxonomy of food-borne trematodes with emphasis on

species parasitizing humans that are covered in the current review.

Keizer & Utzinger, 2009

Characteristics..• They are typically found in major viscera such as the bile

ducts, lungs, and gut. • The most important species parasitizing humans include liver

flukes (Clonorchis sinensis, Fasciola gigantica, Fasciola hepatica, Opisthorchis felineus, and Opisthorchis viverrini), lung flukes (Paragonimus spp.), and intestinal flukes (e.g., Echinostoma spp., Fasciolopsis buski, and the heterophyids).

• This list is far from complete. For example, a total of 70 species (14 families and 36 genera) of intestinal flukes have been reported to have been isolated from humans

map significant patterns and changes in hosts, habitat, morphology, and distribution. Snail at base of the tree represents the family Planorbidae, the other snail family is Lymnaeidae. Each illustrated fluke indicates the intestinal caeca (scale bar: 10 mm).Lotfy et al, 2008

Life cycles of five different food-borne trematodes including intestinal flukes (Echinostoma hortense, Fasciolopsis buski, and Heterophyesheterophyes), a liver fluke (Clonorchis sinensis), and a lung fluke (Paragonimus westermani)

Keizer & Utzinger, 2009

Scope of the problem:• Approximately 6,000 digenean species have been described, but only a few are

important human parasites. These include:

• Infection of humans occurs through the consumption of contaminated freshwater-fish, frogs, shellfish, snails, tadpoles, snakes, water plants (e.g., watercress), and other aquatic products eaten raw or insufficiently cooked .

• Hence, fish-borne trematodiases and plant-borne trematodiases are other common names referred to in text books and the peer-reviewed literature.

Keiser & Utzinger, 2009

Scope of the problem:• The zoonotic nature of food-borne trematodiases— transmission to

humans occurs via aquatic products—is an important factor explaining the growing importance of these diseases

• not only humans but also other mammals act as definitive hosts; food-borne trematodiases are therefore an important public health and veterinary problem.

• Additionally, pet animals (e.g., cats and dogs) can act as definitive hosts, which should be factored into future appraisals of the true societal impact of food-borne trematodiases

Keiser & Utzinger, 2009

these diseases are among the most neglected of the so-called neglected tropical diseases .

It should be noted that the neglected tropical diseases are found predominantly in the world’s poorest

populations in low-income countries, andwhere these diseases are common, they exacerbate

poverty.

Characteristics..Adult •dorsoventral, flattened, bilaterally symmetrical body. •The average size of the flukes varies according to species. •The body surface of trematodes is covered by a syncytial epithelium, the tegument.•The tegument is implicated in nutrient absorption, synthesis, secretion, and osmoregulation and has sensory functions. Moreover, the tegument protects the parasite from the immune system of the host. •Further typical characteristics of trematodes are the presence of an oral sucker ( used to attach to the inner surface of the host’s organ), often a ventral sucker, and a lack of respiratory and circulatory systems . •The reproductive system is always hermaphroditic

CLINICALLY SIGNIFICANT TISSUE AND INTESTINAL FLUKES

Geographic distribution• The transmission of food-borne trematodiases is

restricted to areas where the first and second intermediate hosts coexist (which requires suitable climatic and environmental factors) and where humans have the habit of eating raw, pickled, or undercooked fish and other aquatic products.

• These contextual determinants explain why the distribution of foodborne trematodiases is focal.

diagnosisThe three main approaches that are currently available are:

Complementary tools for the diagnosis of the hepatobiliary

(pathology of the bile duct) caused by parasitic infections are

1. Ultrasound can detect biliary stones, dilatation, and fibrosis due to liver fluke infections

2. computer tomography (CT) determinations of the lumen diameter of bile ducts, fibrosis, calcification, and epithelial hyperplasia

3. magnetic resonance imaging (MRI) as CT does, and

4. tissue harmonic imaging observation of bile duct wall trauma and stones

Age prevalence curves for Opisthorchis viverrini at three different locations in the Nam Theun 2 hydroelectric project area in central Lao PDR in the late 1990s.

Keizer & Utzinger, 2009

The global distribution of three major species of liver flukes, i.e.C. sinensis, O. viverrini and O. felineus. This map focuses on the endemicity of C. sinensis in China, the Republic ofthe Republic of Korea and the northern part of Vietnam.

Qian et al. Infectious Diseases of Poverty 2012 1:4

Scanning electron microscope observations of the anterior part of an untreated Fasciola hepatica depicting

the oral sucker (OS) andventral sucker (VS) (A), a Fasciola fluke

revealing blebbing (b) near the oral sucker and ventral sucker after

administration of a single oral dose of 200 mg/kg artemether (B), the oral

sucker region of a Clonorchis sinensis fluke with sensory papillae (SP) visible

(C), sloughing (s) seen on theoral sucker of an artemether-treated C.

sinensis fluke (D), oral sucker region of an Opisthorchis

viverrini fluke with sensorypapillae (E), blebbing and closure of oral sucker

observed on an O. viverrini fluke treated with a single oral dose of 400

mg/kg tribendimidine (F).

Keizer & Utzinger, 2009

• Opisthorchis viverrini is an important food-borne trematode in Southeast Asia. The infection causes significant morbidity in terms of hepatobiliary diseases and cholangiocarcinoma.

• Humans become infected with O. viverrini through the consumption of raw or undercooked cyprinoid fish containing metacercariae .

• Hence, parasite control should, in part, reduce the risk of morbidity and cancer development

• To date, standard diagnoses of O. viverrini by parasitological methods are increasingly unreliable because of low sensitivity in people with light infections and difficulties in discriminating a mixed infection with intestinal trematodes

Duenggai et al, 2008

• Pathogenesis of Liver Fluke-Induced Cholangiocarcinoma (CCA)- caused by Mechanical injury and fluke metabolic products.

• Mechanical injury from the activities of feeding and migrating flukes contributes to biliary damage in the human host.

• Both oral and ventral suckers of the fluke hook onto the biliary epithelium, resulting in tissue damage even early in infection.

• As the parasite matures, the lesion becomes more pronounced and ulcerates. Fluke eggs become entrapped in the periductal tissue through the ulcer and induce granulomatous inflammation around the eggs.

• The granulomata are readily visualized in experimental hamster infections and occasionally in human cases with bile duct obstruction.

Sripa, et al. 2007

experimental and epidemiologic evidence strongly implicatesliver fluke infection in the aetiology of one of the liver cancer

subtypes—cholangiocarcinoma (CCA), or cancer of the bile ducts

Sripa, et al. 2007

• Liver fluke infection caused by Opisthorchis viverrini, O. felineus, and Clonorchis sinensis is a major public health problem in East Asia and Eastern Europe. Currently, more than 600 million people are at risk of infection with these trematodes.

• O. viverrini is endemic in Southeast Asian countries, including Thailand, Lao People’s Democratic Republic, Vietnam, and Cambodia, and C. sinensis infection is common in rural areas of Korea and China.

• Opisthorchiasis has been extensively studied in Thailand, where an estimated 6 million people are infected with the liver fluke (calculated from overall 9.4% prevalence within the population in 2001).

• Infection with these food-borne parasites is prevalent in areas where uncooked cyprinoid fish are a staple of the diet.

• Due to poor sanitation practices and inadequate sewerage infrastructure, people infected with O. viverrini and C. sinensis pass parasite eggs in their faeces into natural water reservoirs, where the parasite eggs are eaten by intermediate host snails, for example, aquatic snails of the genus Bithynia,the first intermediate host of O. viverrini

Sripa et al, 2007

A piped water supply with pumps, pit-wells and taps helps people to stay away from water that is infected

• Fasciola hepatica caused Fascioliasis, a well-known parasitic disease because of its veterinary importance and the great losses it causes in livestock production.

• However, human fascioliasis was only considered a secondary disease by public health officials, with only approximately 2,000 cases reported between 1970 and 1990.

Esteban, 2003

• Whereas some fasciolids have retained circumscribed geographic distributions, others such as F. hepatica have become cosmopolitan.

• The spread of this species is in part caused by its adaptability to different lymnaeid snail hosts and to introduction of infected livestock or of susceptible snail hosts into new areas.

Lotfy, 2008

Clinical Infectious Diseases 2001; 33:1–6

Preparation of a Meal of Koi-Pla Using Uncooked Cyprinoid Fishes (A) Fluke-infected fi sh are plentiful in the local rivers such as the Chi River in Khon Kaen province, Thailand. (B) Local people catch the fish in nets and prepare the fish-based meals with local herbs, spices, and condiments. (C) The fi nished dish of koi-pla accompanied by rice and vegetables. This dish is a dietary staple of many northeastern Thai villagers and is a common source of infection with O. viverrini

PLoS Med 2007; 4(7): e201

Proposed Mechanisms of Opisthorchis-Derived CCA InitiationThe three proposed pathways linking the parasite to CCA initiation are mechanical damage (in yellow), molecular products (in blue), and immunopathology (in green). Combined, these mechanisms result in several common elements (purple) that all lead to DNA damage. The inhibition of a normal DNA damage response is the final oncogenic factor proposed to dramatically increase the likelihood of a malignant transformation. Thisinvariably leads to progression of CCA

Sripa et al, 2007

Parkin, 2006

Parkin, 2006

EPIDEMIOLOGICAL PATTERNS• While contamination of human-made freshwater environments (inland fish

ponds) with food-borne trematode metacercariae is quite common, human infections occur mainly in areas characterized by traditional food dishes in specific high-risk ethnic groups.

• Raw, pickled, or undercooked fish and other aquatic products are prepared in various ways. Such dishes might have been rooted in traditions for hundreds of years and hence have high cultural, ethnic, and nutritional significance, making it exceedingly difficult to change food habits .

• Examples of typical traditional preparations include raw crab meat spiced with soy sauce (ke-jang) in the Republic of Korea, raw grass carp dishes in China, and fresh uncooked small- or medium-sized fish, moderately or extensively fermented (lab pla, koi pla, pla som, and pla ra), in Thailand and in the Lao PDR

PREVENTION, TREATMENT, AND CONTROL• Public health interventions to prevent infections with

foodborne trematodes and to reduce the prevalence and intensity of infections, and, hence, morbidity and mortality, include chemotherapy, improved access to adequate sanitation, and the use of chemical fertilizers, food inspections, and information, education, and communication (IEC) campaigns.

• The ultimate aim is to change human behavior, because the consumption of raw or undercooked freshwater fish and other aquatic products is the key risk factor for acquiring a food-borne trematode infection

Sekian dan terimakasih...

referensi1. Keiser J, Utzinger J. Food-Borne Trematodiases. Clin. Microbiol. Rev. 2009, 22(3):466.2. Lotfy WM et al. Evolutionary Origins, Diversification, and Biogeography of Liver Flukes

(Digenea, Fasciolidae). Am. J. Trop. Med. Hyg. 2008; 79(2): 248–553. Graham CS et al. Imported Fasciola hepatica Infection in the United States and Treatment

with Triclabendazole. Clin Infect Dis 2001; 33:1–64. Sripa B, Kaewkes S, Sithithaworn P, Mairiang E, Laha T, et al. Liver fluke induces

cholangiocarcinoma. PLoS Med 2007; 4(7): e2015. Duenggai K et al. Improvement of PCR for Detection of Opisthorchis viverrini DNA in

Human Stool samples. J. Clin. Microbiol. 2008, 46(1):3666. Esteban JG et al. Hyperendemic Fascioliasis Associated With Schistosomiasis In Villages In

The Nile Delta Of Egypt. Am. J. Trop. Med. Hyg. 2003; 69(4): 429–377. Parkin DM. The global health burden of infection-associated cancers in the year 2002. Int.

J. Cancer 2006; 118: 3030–44 8. Qian MB, Chen YD, Liang S, Yang GJ, Zhou XN. The global epidemiology of clonorchiasis and

its relation with cholangiocarcinoma. infectious Diseases of Poverty 2012, 1:49. Buku ajar Parasitologi Kedokteran FKUI. Edisi ke empat, 2011. Hal 51-910. Markel, Voge John. Medical parasitology. WB Saunders, 7th ed. 1992. pp 183-223