Malaria 瘧疾 Filariasis 血絲蟲症 Leishmaniasis 利什曼原蟲症 Trypanosomiasis 錐蟲症 Schistosomiasis 血吸蟲症 Leprosy 痲瘋

Schistosomiasis 血吸蟲症 Schistosoma mansoni 曼氏血吸蟲 Schistosoma intercalatum 間插血吸蟲 Schistosoma japonicum 日本血吸蟲 Schistosoma mekongi 湄公血吸蟲 Intestinal 腸道 Schistosomiasis Urinary 尿道 Schistosomiasis Schistosoma heamatobium 埃及血吸蟲 Dr.Theodor Bilharz discovered the parasite in 1851 in Cairo One-sixth of the world’s population is at risk Endemic in 74 countries 200 million persons are infected Highest prevalence and severity in children

Distribution of S. mansoni and S. intercalatum 血吸蟲症分佈 ( 曼氏血吸蟲及間插血吸蟲 ) 非洲 馬達加斯加. 中東. 南美 ( 巴西 ). 加勒比海. S. mansoni 曼氏血吸蟲 非洲中西部 S. intercalatum 間插血吸蟲

Distribution of S. japonicum, S. mekongi and S. haematobium 血吸蟲症分佈 ( 日本血吸蟲，湄公血吸蟲及埃及血吸蟲 ) 非洲，阿拉伯，中東， 馬達加斯加，糢里斯 S. heamatobium 泰國湄公河流域 S.mekongiS. japonicum 中國大陸，印尼， 菲律賓。

雌雄異體 蟲體呈細柱狀 具口吸盤及腹吸盤 生殖孔在蟲體前端的腹側 腸在腹吸盤前分成兩支以後又匯合成一單管盲腸

雄蟲呈灰白色 圓柱狀 10~20×0.5~0.55 ㎜ 腹面具有抱雌溝 (gynecophoric canal) 圓形睪丸呈串狀排列 於腹吸盤下方 血吸蟲雄蟲形態 S. mansoni ( 睪丸 6~9) S. haematobium ( 睪丸 4~5 ) S. japonicum ( 睪丸 6~7)

表皮之 結節 (nodules) 及棘 (spines) S. japonicum 日本血吸蟲 S. mansoni 曼森血吸蟲 血吸蟲雄蟲表皮構造

呈暗褐色，體細長 12~28×03 ㎜ 卵巢長橢圓形位於蟲體腸支匯合處前 子宮長管狀，內含蟲卵。後端由葉狀卵黃腺組成 血吸蟲雌蟲形態 卵巢位於 子宮 蟲卵數 蟲體後半 長 20~30 曼森血吸蟲 卵巢位於 子宮 蟲卵數 蟲體前半 短 1~4 埃及血吸蟲 卵巢位於 子宮 蟲卵數 蟲體中央 長 50~100 日本血吸蟲

血吸蟲成蟲形態比較 表皮上之結節 盲腸連接處 睪丸數目 埃及血吸蟲曼森血吸蟲日本血吸蟲雄蟲 雌蟲 卵巢位置 子宮 蟲卵數 細 中 4~5 粗 前 1/3 處 6~9 無 後 1/3 處 6~7 蟲體後半 長 20~30 蟲體前半 短 1~4 蟲體中央 長 50~100

Intermediate hosts for Schistosomes: Freshwater snalis Biomphlaria spp. 扁捲螺 Flat without a spire up to 20 wide Aquatic 水生。 Hermaphroditic S. haematobium S.intercalatum S. mansoni S. japonicum S.mekongi Bulinus spp. 浦螺 Ovoid with short spires 尖頂。 9~18 mm in length Aquatic 水生。 Hermaphroditic Oncomelania spp. 釘螺 Oval and operculated with a steep spine. <10 mm Amphibious 兩棲 。 Unisexual Tricula aperta An aquatic snail lives in water on soil debris ? 血吸蟲中間宿主 : 淡水螺螄

移行至最終寄生部位 －靜脈叢 雌雄交配產卵 ( 有性生殖期 ) Cercaria 尾動幼蟲 Schistosome Life Cycle 血吸蟲生活週期 Miracidum 纖毛幼蟲 Egg 蟲卵 Mother Sporocyst 母胞子幼蟲 Daughter Sporocyst 子胞子幼蟲 ( 無性生殖期 ) Schistosomula 血吸蟲幼蟲 Eggs/Day/Fluke 埃及 曼氏 日本 中間宿主 － 淡水螺螄 診斷期 穿透皮膚 感染期 蟲卵穿過血管壁 進入組織中 ( 膀胱，大腸 ) 蟲卵隨糞便或尿液排出體外

Migration of Schistosomules 血吸蟲幼蟲內臟移行 Veins 進入周邊靜脈及淋巴 Right side of the heart Lung 肺血管 Left side of the heart Abdominal aorta 腹主動脈 Hepatic portal vessels 肝臟 Schistosomules 血吸蟲幼蟲 S. haematobium vesical venous plexus 膀胱，攝護腺及子宮靜脈叢 S.mansoni inferior mesenteric vein 下腸系膜靜脈叢 S.japonicum superior mesenteric vein 上及下腸系膜靜脈叢 Paired Mature Worms

Clinical Diseases Effect of cercariae penetration Stage 1 Formation of immune complexStage 2 Reaction to eggsStage 3

Stage 1 Site of cercariae penetration Clinical Disease Swimmer’s itch (Fisherman’s itch ) itch papular rash 發癢丘疹 within 24 hours Penetration of cercariae of animal schistosomes can cause severe dermatitis 皮膚炎

Clinical Disease Formation of immune complex Stage 2 soluble excretory-secretory worm antigens (2~6 weeks post infection) + host antibody Katayama Fever Y Y Y Y Y Y Y Y Circulating immune complex ( 免疫複合體 ) Fever ( 發燒 ) Uritcaria ( 蓴麻疹 ) Eosinphilia ( 嗜伊紅性白血球增加 ) Diarrhoea ( 腹瀉 ) Cough and wheeze ( 哮喘 )

Clinical Disease The eggsStage 3 S. haematobium Eggs passed in urine Haematuria Proteinuria Dysuria S. mansoni & S. japonicum Eggs passed in feces Diarrhea with blood and mucus Granuloma Formation ( 血吸蟲肉芽腫 ) Eggs passed 蟲卵排出體外 Eggs retained in tissue 蟲卵留在組織中

The cellular contents diminishes with time to be replaced by fibroblasts and collagenous scar Tissue reaction to eggs Stage 3 Epithelioid and gaint cells Lymphocytes Eosinophils Egg Egg Granuloma ( 血吸蟲肉芽腫 ) results from the combined humoral and cell mediated immunity against the egg

Granulomatous reaction 血吸蟲肉芽腫 S.haematobium埃及血吸蟲 Obstructive uropathy 阻塞性泌尿道病變 Schistosomal cor pulmonale 血吸蟲心肺症 Calaification of the bladder 膀胱鈣化 → Bladder cancer 膀胱癌 除重度感染或異位感染大多數病人無明顯症狀 症狀與日本血吸蟲相似但比較輕 S.mansoni曼氏血吸蟲 S. japonicum 日本血吸蟲 Intestinal diseases 腸道疾病 Liver diseases 肝臟疾病 MED & MT

Granulomatous reaction 血吸蟲肉芽腫 S.haematobium埃及血吸蟲 Obstructive uropathy 阻塞性泌尿道病變 Schistosomal cor pulmonale 血吸蟲心肺症 Calaification of the bladder 膀胱鈣化 → Bladder cancer 膀胱癌 除重度感染或異位感染大多數病人無明顯症狀 症狀與日本血吸蟲相似但比較輕 S.mansoni曼氏血吸蟲 S. japonicum 日本血吸蟲 Intestinal diseases 腸道疾病 Colon pseudopdplyposis 大腸性假息肉症 Ulcerate 潰瘍, bleeding and dysentery 血痢 Liver diseases 肝臟疾病 Periportal (Symmers clay pipestem) fibrosis Enlargement of liver and spleen 肝脾腫大 Bleeding from oesphageal varices 食道靜脈曲張出血 NUR

Obstructive Uropathy Obstructive Uropathy 阻塞性泌尿道病變 in S. haemtobium infection in S. haemtobium infection ● Eggs escape from the pelvic veins → Reached the ureters 輸尿管 and ureteric orifces 輸尿管出口 → Granuloma formation 形成肉芽腫 → Obstruction of ureteres 輸尿管阻塞 → Hydrourter 輸尿管水腫 → Hydronephrosis 水腫 → Uraemia 尿毒症 ● Pseudopapilloma 假性乳頭狀瘤 Egg granuloma formed in the bladder mucosa which resemble tumors. Cystitis 膀胱炎 Ureteritis 輸尿管炎 Bladder cancer 膀胱癌

Schistosomal cor pulmonale 血吸蟲心肺症 in S. haemtobium infection in S. haemtobium infection Eggs that reach the lungs by metastatic-blood spread lead to periarteritis. This is followed by fibrosis of the pulmonary arterioles with pulmonary hypertension and, finally, enlargement of the right heart (cor pulmonale) 蟲卵經由血液循環從入肺小動脈引起肺性高血壓， 右心室肥寸及鬱血性心衰竭。

Colon pseudopolyposis 大腸性假息肉症 Egg granulomata in the large intestine develop into a papilloma － like outgrowths of the mucosa 大腸中的肉芽腫在黏膜形成乳頭狀突出物 Hoepp;I reaction: The fibrotic granuloma around the dead ovum in colon.

Hepatosplenomegaly Hepatosplenomegaly 肝脾腫大 Granulomata in periportal regions leads to gradual occulsionof the intrahepatic portal veins → Enlargement of liver and spleen 肉芽腫阻塞肝門靜脈引至肝臟及脾臟腫大

Ectopic Mansoni Schistosominiasis 曼氏血吸蟲異位感染 ● CNS-paravertebral venous plexus 脊髓旁靜脈叢 ● Cerebral cortical veins 大腦皮質靜脈 ● Spinial cord compression 脊髓壓迫 ● Cauda equiba lesion 在脊髓尾形成病兆 ● Subserosal veins of the abdomen 腹部臟膜下靜脈 ● Peritoneal granulomata 腹膜肉芽腫 ● Female genital tract → Sterility 不孕症 ● Cutaneous → Itchy, punctate skine eruption 皮膚疹

Schistosome Eggs All Schistosomes eggs are pale yellow-brown to colorless and contains a fully developed Miracidium S. haematobium Large & oval 145 x 55 um Terminal Shape Size Spine S. japonicum Round to oval 90 x 65 um Rudimentary S. mansoni Large & oval 150 x 60 um Lateral

Laboratory Diagnosis S. heamatobium Finding eggs in urine Finding eggs in urine 檢查尿液中之蟲卵 收集尿液時間： ~ 以靜置, 離心或過濾法濃縮蟲卵 取出鏡檢 S. haematobium Large & oval 145 x 55  m Terminal spine 尾刺

Laboratory Diagnosis S. mansoni and S. japonicum Finding eggs in feaces Finding eggs in feaces 檢查糞便中之蟲卵 必須先以濃縮法提高靈敏度 Formol - ether Thiomersal -iodine -formol (TIF) Kato smear S. japonicum Round to oval 90 x 65  m Rudimentary spine 不明顯側剌 S. mansoni Large & oval 150 x 60  m Lateral spine 側刺