eMedicine Specialties > Infectious Diseases > Parasitic Infections

Trematode Infection: Treatment & Medication

Author: Subhash Chandra Parija, MBBS, MD, PhD, FRCPath, Director-Professor of Microbiology, Head of Department of Microbiology, Jawaharlal Institute, Postgraduate Medical Education and Research, India
Coauthor(s): Thomas J Marrie, MD, Chair, Professor, Department of Medicine, Division of Infectious Diseases, University of Alberta College of Medicine; Shekhar Koirala, MD, Vice Chancellor, Department of Medicine, BP Koirala Institute of Health, Dharan, Nepal
Contributor Information and Disclosures

Updated: Nov 13, 2009

Treatment

Medical Care

  • Causes of mortality include recurrent pyogenic cholangitis in persons with schistosomiasis; hemiplegia, cephalgia, and paresis in those with cerebral paragonimiasis; cholangiocarcinoma in those with clonorchiasis; and intercurrent bacterial infections in those with fascioliasis and/or intestinal fluke infections.
  • Praziquantel remains the drug of choice for all trematode infections except fascioliasis, for which bithionol is the drug of choice. Praziquantel is recommended when bithionol is not available.
  • Bithionol is the drug of choice for Fasciola infections.
  • Emetine, dehydroemetine, chloroquine, albendazole, and mebendazole were once used in many trematode infections; however, this practice is now discontinued because these drugs are associated with toxicity and their efficacy is in doubt.
  • When trematode infections are complicated by intercurrent bacterial infections, institute antibiotic therapy.

Surgical Care

  • Surgical management may be needed for complications of trematode infection, which include bladder carcinoma in patients with urinary schistosomiasis, fibrosis and thickening of the intestinal wall in those with intestinal schistosomiasis, ascending cholangitis in those with fascioliasis, and cholangiocarcinoma in those with clonorchiasis.

Consultations

  • Intestinal and liver trematode infections - Infectious diseases specialist
  • Urinary schistosomiasis - Infectious diseases specialist, gastroenterologist, and urologist
  • Pulmonary paragonimiasis - Chest disease specialist
  • Ectopic fluke infections (eg, abdominal and cerebral paragonimiasis; ectopic schistosomiasis in intestine, lung, brain, or spinal cord; ectopic clonorchiasis) - Consultations with appropriate specialists as required per particular manifestations

Diet

  • To prevent paragonimiasis and clonorchiasis, avoid eating raw or undercooked fish.
  • To prevent infection with intestinal flukes and fascioliasis, properly clean and thoroughly wash raw vegetables, watercress, and other water-grown vegetables before eating.
  • Cook water-grown vegetables thoroughly before eating.

Activity

The patient should be given adequate bed rest supplemented with an adequate protein-rich diet.

Medication

Chemotherapy objectives in trematode infections are to cure the disease, to reduce morbidity, and to prevent transmission of parasitic infection in endemic areas.

Bithionol (Lorothidol, Bitin) is the drug of choice for Fasciola infections; however, it is an investigational drug with distribution limited to physicians with patients who are unable to take praziquantel. Doses of 30-50 mg/kg/d PO for 5-15 days have been used to treat Fasciola infections. Repeat doses may be administered to some patients. Pediatric patients have been administered the same weight-based dosing used in adults. Adverse effects include nausea, vomiting, diarrhea, and abdominal pain.

Anthelminthics

Parasite biochemical pathways are different enough from the human host to allow selective interference by relatively small doses of chemotherapeutic agents.


Praziquantel (Biltricide)

DOC in most trematode infections. Safe and effective (less effective against Fasciola infections; reserved for situations in which bithionol is not available).
Increases cell membrane permeability in susceptible worms, resulting in loss of intracellular calcium, massive contractions, and paralysis of musculature. In addition, produces vacuolization and disintegration of schistosome tegument. This is followed by attachment of phagocytes to parasite and death.
Tab should be swallowed whole with some liquid during meals. Keeping tab in mouth may reveal bitter taste, which can produce nausea or vomiting.

Adult

Schistosomiasis: S haematobium and S mansoni, 40 mg/kg/d PO tid for 1 d; S japonicum, 60 mg/kg/d PO tid for 1 d
Fasciolopsiasis, metagonimiasis, echinostomiasis, heterophyiasis, and lung trematodes: 15-40 mg/kg PO tid for 1 d
Liver flukes: Fasciolopsis/clonorchiasis, 25 mg/kg PO tid for 1 d

Pediatric

<4 years: Not established
>4 years: Administer as in adults

Hydantoins may reduce serum concentrations, possibly leading to treatment failures

Documented hypersensitivity; ocular cysticercosis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Destruction of parasite within eyes can cause irreparable lesions (ocular cysticercosis should not be treated with praziquantel); caution while driving or performing other tasks requiring alertness on the day of and following treatment; minimal increases in liver enzymes reported; when schistosomiasis or fluke infection is associated with cerebral cysticercosis, hospitalize patient for duration of treatment

More on Trematode Infection

Overview: Trematode Infection
Differential Diagnoses & Workup: Trematode Infection
Treatment & Medication: Trematode Infection
Follow-up: Trematode Infection
Multimedia: Trematode Infection
References
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References

  1. Lun ZR, Gasser RB, Lai DH, Li AX, Zhu XQ, Yu XB, et al. Clonorchiasis: a key foodborne zoonosis in China. Lancet Infect Dis. Jan 2005;5(1):31-41. [Medline].

  2. Dainichi T, Nakahara T, Moroi Y, et al. A case of cutaneous paragonimiasis with pleural effusion. Int J Dermatol. Sep 2003;42(9):699-702. [Medline].

  3. Hong ST, Choi MH, Kim CH, et al. The Kato-Katz method is reliable for diagnosis of Clonorchis sinensis infection. Diagn Microbiol Infect Dis. Sep 2003;47(1):345-7. [Medline].

  4. Massoud AA, Hussein HM, Reda MA, el-Wakil HS, Maher KM, Mahmoud FS. Schistosoma mansoni egg specific antibodies and circulating antigens: assessment of their validity in immunodiagnosis of schistosomiasis. J Egypt Soc Parasitol. Dec 2000;30(3):903-16. [Medline].

  5. Obeng BB, Aryeetey YA, de Dood CJ, Amoah AS, Larbi IA, Deelder AM, et al. Application of a circulating-cathodic-antigen (CCA) strip test and real-time PCR, in comparison with microscopy, for the detection of Schistosoma haematobium in urine samples from Ghana. Ann Trop Med Parasitol. Oct 2008;102(7):625-33. [Medline].

  6. Wongratanacheewin S, Pumidonming W, Sermswan RW, et al. Development of a PCR-based method for the detection of Opisthorchis viverrini in experimentally infected hamsters. Parasitology. Feb 2001;122:175-80. [Medline].

  7. Wongratanacheewin S, Pumidonming W, Sermswan RW, Pipitgool V, Maleewong W. Detection of Opisthorchis viverrini in human stool specimens by PCR. J Clin Microbiol. Oct 2002;40(10):3879-80. [Medline].

  8. King CH. Ultrasound monitoring of structural urinary tract disease in Schistosoma haematobium infection. Mem Inst Oswaldo Cruz. 2002;97 Suppl 1:149-52. [Medline].

  9. Echenique-Elizondo M, Amondarain J, Liron de Robles C. Fascioliasis: an exceptional cause of acute pancreatitis. JOP. Jan 13 2005;6(1):36-9. [Medline].

  10. Anuracpreeda P, Wanichanon C, Chawengkirtikul R, Chaithirayanon K, Sobhon P. Fasciola gigantica: Immunodiagnosis of fasciolosis by detection of circulating 28.5kDa tegumental antigen. Exp Parasitol. Dec 2009;123(4):334-40. [Medline].

  11. Marcos LA, Terashima A, Gotuzzo E. Update on hepatobiliary flukes: fascioliasis, opisthorchiasis and clonorchiasis. Curr Opin Infect Dis. Oct 2008;21(5):523-30. [Medline].

  12. Parija SC. Protozoology and helminthology. In: Textbook of Medical Parasitology: Textbook and Color Atlas. 3rd ed. Chennai, India: AIPD; 2006:237-80.

  13. Xu J, Rong R, Zhang HQ, Shi CJ, Zhu XQ, Xia CM. Sensitive and rapid detection of Schistosoma japonicum DNA by loop-mediated isothermal amplification (LAMP). Int J Parasitol. Sep 6 2009;[Medline].

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Further Reading

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Keywords

trematode infection, trematodiasis, parasites, parasitemia, flukes, blood fluke, lung fluke, liver fluke, intestinal fluke, species, schistosomes, Oriental lung fluke, giant intestinal fluke, schistosomiasis, pulmonary paragonimiasis, paragonimiasis, swimmer's itch, swimmer itch, cercarial dermatitis, Katayama syndrome, fascioliasis, clonorchiasis, schistosomal infection, fasciolopsiasis, heterophyiasis, metagonimiasis, pyogenic cholangitis, hemiplegia, cephalgia, paresis, cholangiocarcinoma, bilharzia, fasciolosis

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Contributor Information and Disclosures

Author

Subhash Chandra Parija, MBBS, MD, PhD, FRCPath, Director-Professor of Microbiology, Head of Department of Microbiology, Jawaharlal Institute, Postgraduate Medical Education and Research, India
Subhash Chandra Parija, MBBS, MD, PhD, FRCPath is a member of the following medical societies: Indian Academy of Tropical Parasitology, Indian Association of Biomedical Scientists, Indian Association of Medical Microbiologists, Indian Association of Pathologists and Microbiologists, Indian Medical Association, Indian Society for Parasitology, National Academy of Medical Sciences, India, and Royal College of Pathologists
Disclosure: Jawaharlal Institute of Postgraduate Medical education & Research , Pondicherry , India Salary Employment

Coauthor(s)

Thomas J Marrie, MD, Chair, Professor, Department of Medicine, Division of Infectious Diseases, University of Alberta College of Medicine
Thomas J Marrie, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society for Microbiology, Canadian Infectious Disease Society, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Shekhar Koirala, MD, Vice Chancellor, Department of Medicine, BP Koirala Institute of Health, Dharan, Nepal
Disclosure: Nothing to disclose.

Medical Editor

Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus
Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist  Speaking and teaching

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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