Fluke Infections

Definition

Fluke infections are diseases of the digestive tract and other organ systems caused by several different species of parasitic flatworms (Trematodes) that have complex life cycles involving hosts other than human beings. Trematode comes from a Greek word that means having holes and refers to the external suckers that adult flukes use to draw nourishment from their hosts. Fluke infections are contracted by eating uncooked fish, plants, or animals from fluke-infected waters. Symptoms vary according to the type of fluke infection.

Description

In humans, fluke infections can be classified according to those diseases caused by liver flukes and those caused by lung flukes. Diseases caused by liver flukes include fascioliasis, opisthorchiasis, and clonorchiasis. Cases of liver fluke infection have been reported in Europe and the United States, as well as the Middle East, China, Japan, and Africa. Diseases caused by lung flukes include paragonimiasis. Paragonimiasis is a common infection in the Far East, Southeast Asia, Africa, Central and South America, Indonesia, and the Pacific Islands. It is estimated that between 40 million and 100 million people worldwide suffer from either liver or lung fluke infections.

In their adult stage, liver and lung flukes are symmetrical in shape, ranging between 1/4-1 in in length, and look somewhat like long, plump leaves or blades of grass. They enter through the mouth and can infect any person at any age.

Causes and symptoms

The symptoms of fluke infection differ somewhat according to the type of fluke involved. All forms of liver and lung fluke infection, however, have the following characteristics:

• most persons who get infected do not develop symptoms (asymptomatic)
• the early symptoms of an acute fluke infection are not unique to these diseases alone (nonspecific symptoms)
• infection does not confer immunity against re-infection by the same species or infection by other species of flukes
• infection is usually associated with eating uncooked fish, plants, or animals that live in fresh water

Fascioliasis

Fascioliasis is caused by Fasciola hepatica, the sheep liver fluke. The fluke has a three-part life cycle that begins when eggs from a host's feces are deposited in water. The eggs release free-swimming larvae (miracidia) that infect snails. The snails then release free-swimming larvae with tails (cercariae) that form cysts containing larvae in the infective stage (metacercariae) on vegetation growing in fresh water. Humans become infected when they eat watercress, water chestnuts, or other plants covered with the encysted metacercariae.

When a person eats contaminated plants, the cysts are broken open in the digestive system, and the metacercariae leave their cysts, pass through the wall of the intestine, and enter the liver, where they cause inflammation and destroy tissue. After a period of 10-15 weeks in the liver, the adult flukes move to the bile ducts and produce eggs. Acute fascioliasis is marked by abdominal pain with headache, loss of appetite, anemia, and vomiting. Some patients develop hives, muscle pains, or a yellow-color to the skin and whites of the eyes (jaundice ). Chronic forms of the disease may produce complications, including blockage of the bile ducts or the migration of adult flukes to other parts of the body.

Opisthorchiasis and clonorchiasis

These infections are caused by Clonorchis sinensis, the Chinese liver fluke, and Opisthorchis viverrini or O. felineus. The diseases are widespread, affecting more than 20 million people in Japan, China, Southeast Asia, and India. The life cycle of these liver flukes is similar to that of F. hepatica except that the etacercariae are encysted in freshwater fish rather than on plants. Dogs, cats, and other mammals that eat raw fish can be infected with opisthorchiasis and clonorchiasis.

The symptoms of opisthorchiasis and clonorchiasis are similar to those of fascioliasis and include both acute and chronic forms. In acute infection, the patient may be tired, have a low-grade fever, pains in the joints, a swollen liver, abdominal pain, and a skin rash. The acute syndrome may be difficult to diagnose because the fluke eggs do not appear in the patient's stool for three to four weeks after infection. Patients with the chronic form of the disease experience a loss of appetite, fatigue, low-grade fever, diarrhea, and an enlarged liver that feels sore when the abdomen is pressed.

Paragonimiasis

Paragonimiasis is caused by a lung fluke, either Paragonimus westermani or P. skrjabini. These flukes are larger than liver flukes and infect meat- or fisheating animals as well as humans. Their life cycle is similar to that of liver flukes except that their encysted larvae infect crabs and crayfish rather than plants or fish. Humans can ingest the encysted metacercariae from drinking contaminated water or eating raw or undercooked crabs and crayfish.

In humans, the metacercariae are released from their cysts in the small intestine and migrate to the lungs or the brain in 1% of cases. In the lungs, the flukes lay their eggs and form areas of inflammation covered with a thin layer of fibrous tissue. These areas of infection may eventually rupture, causing the patient to cough up fluke eggs, blood, and inflamed tissue. The period between the beginning of the infection and the appearance of the eggs during coughing is about six weeks. Patients with lung infections may have chest pain and fever as well as rust-colored or bloody sputum. Lung infections can lead to lung abscess, pneumonia, or bronchitis. Patients with fluke infections of the brain may experience seizures or a fatal inflammation of brain tissue called encephalitis. Some patients also develop diarrhea and abdominal pain or lumps under the skin that contain adult flukes.

Diagnosis

Diagnosis of fluke infections is based on a combination of the patient's history, particularly travel or residence in areas known to have flukes, and identification of the fluke's eggs or adult forms. In some patients, the eggs are found in fluid from the lungs, bile duct, or small intestine. Samples of these fluids can be obtained with a suction instrument (aspirator). Because most types of fluke infections are rare in the United States, stool specimens or body fluid samples may need to be sent to a laboratory with experts in unusual diseases or conditions to identify the specific parasite. In some cases, adult flukes may be found in the patient's stools, vomit, sputum, or skin lumps (for lung flukes). In the case of lung flukes, it is important for the doctor to rule out tuberculosis as a possible diagnosis. A tuberculosis skin test and chest x ray will usually be sufficient to do this.

Blood tests may be useful in diagnosing fluke infections, but their usefulness is limited because of cross-reactions. A cross-reaction occurs in blood testing when a particular disease agent reacts with antibodies specific to another disease agent. This result means that the doctor may know that the person is infected by flukes but cannot tell from the blood test alone which specific type of fluke is causing the disease. In addition, blood tests for fluke infections cannot distinguish between past and current infections. In some cases, sophisticated imaging techniques, such as computed tomography scans (CT scans) or ultrasound scans of the patient's chest or brain (for lung flukes) or abdomen (for liver flukes), are useful in confirming a diagnosis of fluke infection.

KEY TERMS

Aspirator— A medical instrument that uses suction to withdraw fluids from the lungs, digestive tract, or other parts of the body for laboratory testing.

Asymptomatic— Persons who carry a disease and are usually capable of transmitting the disease but, who do not exhibit symptoms of the disease are said to be asymptomatic.

Cercaria (plural, cercariae)— An intermediate-stage of the fluke larva, released into water by infected snails.

Cross-reaction— A reaction that occurs in blood testing when a disease agent reacts to the specific antibody for another disease agent. Cross-reactions are common in blood tests for fluke infections because the different species are closely related.

Encysted— Enclosed in a cyst or capsule. Flukes spend part of their life cycle as encysted larvae.

Fluke— A parasitic flatworm that has external suckers. Flukes are sometimes called trematodes.

Host— The living animal that supplies nutrition to a parasite.

Jaundice— Yellowing of the skin and the whites of the eyes as a result of excess bile in the blood due to an improperly functioning liver.

Metacercaria (plural, metacercariae)— The encysted stage of a fluke larva that produces infection in human beings.

Miracidium (plural, miracidia)— The free-swimming larval form in the life cycle of the liver fluke.

Parasite— An organism that lives on or inside an animal of a different species and feeds on it or draws nutrients from it.

Trematode— Parasitic flatworms or another name for fluke, taken from a Greek word that means having holes.

Treatment

Liver and lung fluke infections are treated with medications. These include triclabendazole, praziquantel, bithionol, albendazole, and mebendazole. Praziquantel works by paralyzing the flukes' suckers, forcing them to drop away from the walls of the host's blood vessels. In the United States, bithionol is available only from the Centers for Disease Control (CDC). Depending on the species of fluke and the severity of infection, the course of treatment can vary from several days to several weeks. Cure rates vary from 50-95%. Most patients experience mild temporary side effects from these drugs, including diarrhea, dizziness, or headache.

Prognosis

The prognosis for recovery from liver fluke infections is good, although patients with serious infections may be more vulnerable to other diseases, particularly if significant liver damage has occurred. Most patients with lung fluke infections also recover, however, severe infections of the brain can cause death from the destruction of central nervous system or brain tissue.

Prevention

No vaccines have been developed that are effective against lung or liver fluke infections. Prevention of these infections includes the following measures:

• boiling or purifying drinking water
• avoiding raw or undercooked fish or salads made from fresh aquatic plants; all food eaten in areas with fluke infestations should be cooked thoroughly; pickling or smoking will not kill fluke cysts in fish or shellfish
• control or eradication of the snails that serve as the flukes' intermediate hosts

Resources

BOOKS

Goldsmith, Robert S. "Infectious Diseases: Protozoal & Helminthic." Current Medical Diagnosis and Treatment, 1998, edited by Stephen McPhee, et al., 37th ed. Stamford: Appleton & Lange, 1997.