Diagnosis of Parasitic Infections 1.

saturated sodium chloride (ascaris, hookworms)

1. Clinical 2. Zinc sulphate centrifugation floatation (cyst, nematodes).
2. Laboratory • Sedimentation (solution of low specific gravity):
Purpose of laboratory diagnosis : formol ether
• Confirmation of clinical suspicion Egg count in 1 gram
• Identification of unsuspected infection

SPECIMENS:
❖ Stool
❖ Blood
❖ Serum and plasma
❖ Others (anal swab, duodenal aspirate, sputum, urine, urogenital specimen)
❖ Tissues and aspirates
Stool examination
Sample collection:
• Sample is collected in clean, dry container
• Handled carefully
• Sometimes use preservative (10% formalin) Immunodiagnostic (antigen detection)
• Samples in some cases fresh(amoeba, ciliates) • Fresh or preserved stool samples are the appropriate specimens
• Liquid and soft stool examined within 15 min Amebiasis
• Not mixed with urine or disinfectant (as they will kill trophozoites) • EIA kits are commercially available for detection of fecal antigens for the diagnosis
• Specimens obtained by enema or laxatives are often positive for worm eggs or of intestinal amebiasis.
adult worm. • These assays use monoclonal antibodies that detect the galactose-inhibitable
Examination of the stool sample: adherence protein in the pathogenic E. histolytica.
Gross examination: • Several EIA kits for antigen detection of the E. histolytica/E. Dispar (non-pathogenic
• Mucoid blood stained (acute amoebic dysentry), Parasites can be detected amoeba) group are available , but only the TechLab kit is specific for E. histolytica.
(nematodes, cestodes) Cryptosporidiasis
Microscopic examination: Several kits are combined tests for Cryptosporidium, Giardia, and E. histolytica.
- Saline mount DFA test identifies oocysts in concentrated or unconcentrated fecal samples by using a
- Iodine Mount fluorescein isothiocyanate (FITC)-labeled monoclonal antibody is the most sensitive.
- Thick smears – not commonly used Giardiasis
- Permanent stained smears DFA assays may be purchased that employ FITC-labeled monoclonal antibody for
Iron hematoxylene detection of Giardia cysts.
Whearley’s trichrome stain Molecular diagnosis
• Concentration methods (using stool sample)
- Floatation techniques If an unequivocal identification of the parasite can not be made, the stool
- Sedimentation techniques specimen can be analyzed using molecular techniques such as polymerase chain reaction
• Antigen detection (PCR). PCR amplified fragments can be analyzed by using restriction fragment length
• Molecular diagnosis polymorphisms (RFLP) or DNA sequencing if further characterization is needed.
Microscopic examination Sample :
Direct wet mount: Fresh stool should be kept cold or frozen till DNA extraction.
• Thin emulsion of small amount of faeces Samples collected in a preservative should be compatible with molecular
• Few drops of saline detection (TotalFix, Unifix, modified PVA (Zn- or Cu-based), and Ecofix)
• Sometimes add lugol’s iodine (nuclear details, glycogen vacuole in cyst) • DNA Extraction better using commercially available kits (Qiagen)
• Protozoa (trophozoite), cyst, eggs and larva of helminths, crystals (charcot
leyden) PCR analysis:
Concentration methods Conventional PCR:
• Scanty parasites in the sample DNA is tested by PCR with diagnostic primers. Amplified DNA fragments are
• Floatation (eggs and cyst float , solution of high specific gravity) electrophoretically resolved on an agarose gel for analysis of results.
Real-Time PCR Molecular diagnosis
The DNA amplification is monitored by measuring the fluorescence signal generated in (using blood sample)
the reaction vessel. The fluorescence signal is measured every cycle and is proportional to • Collect a 1-5 ml blood sample in tube with EDTA.
the amount of accumulated PCR product. • Blood can be collected on filter papers (e.g Whatman)
Blood examination • DNA is extracted using DNA extraction kits
• Fresh capillary blood of finger or ear lobe
• Venous blood collected in EDTA (anticoagulant) Species-specific diagnosis of malaria
Blood sample will be used for : Detection and speciation of Plasmodium is done with a two step nested PCR using the
• Microscopic examination(Thin Smear, Thick smear, Wet mount for microfilaria). primers of Snounou et al 1993.
• Molecular diagnosis
• Detection of parasite antigen
• Isolation of organisms
• Special tests

Detection of parasite antigens

(in blood sample)
• Rapid diagnostic tests for malaria employing immunochromatographic methods
based on the detection of malarial antigens present in peripheral blood.
• only diagnose only P. falciparum malaria.
• Currently, the only available RDT for malaria in the United States is the
BinaxNOW® Malaria Test.

Isolation of Organisms
(from blood)
❑ The diagnosis of Leishmania spp. is made by microscopic identification of the
nonmotile, intracellular form (amastigote) in stained sections from lesions, and
Microfilaria by culture of the motile, extracellular form (promastigote) on suitable media.
• Sample collection according to periodicity of microfilaria ❑ Slides should be fixed and stained before they are sent unless reagents are not
• Concentration by sedimentation or membrane filtration (examine the filter) available.
• DEC provocation method ❑ Serologic tests are also available to detect for anti-leishmanial antibodies;
however, these tests are often not sensitive, particularly for diagnosing cutaneous
leishmaniasis.
 Special Tests: MQ Testing ❑ Sputum specimens should be collected first thing in the morning.
➢ Mefloquine is recommended by CDC as a prophylactic against malaria. A sputum sample can be examined in several ways:
➢ When individuals who are on mefloquine prophylaxis exhibit signs of malaria, ❑ The unfixed specimen may be centrifuged and then the sediment examined as a
blood samples are collected and analyzed for the presence of the drug. direct wet mount.
➢ The drug is extracted from the blood and the concentration is determined by high- ❑ If the sputum is too viscous, an equal volume of 3% sodium hydroxide may be
performance liquid chromatographic (HPLC) methods. added, then centrifuge, and examine the sediment.
➢ Determining the level of mefloquine in the blood helps assess if the individual ❑ The specimen can be preserved in 10% formalin and a formalin-ethyl acetate
was adherent with his/her medication. ❑ The specimen can be preserved in PVA if protozoa are suspected and stained
➢ This procedure is also useful to determine treatment failure due to a mefloquine with trichrome stain.
resistant form of malaria. Vaginal swabs
Serum, plasma and others ▪ Demonstration of Trichomonas vaginalis trophozoites is usually done by
Specimen Requirements preparing wet mounts made from vaginal swabs or scrapings.
o Serum/plasma is required for all parasitic disease immunodiagnostic tests. ▪ If the specimen cannot be examined immediately, it should be preserved in PVA
o A single sample is sufficient; acute and convalescent specimens are not and stained smears examined later.
necessary.
o CSF and eye fluids (vitreous or aqueous) are acceptable for selected diseases) but
MUST be accompanied by a serum specimen.
Serum for all tests: 0.5 ml serum/plasma separated from RBCs .
CSF: 0.5 ml. Acceptable only for cysticercosis and baylisascariasis testing.
Eye fluids: 0.1 ml neat fluid (no washings). Acceptable only for toxocariasis
Serology – All tests available Tissue Specimens for Free-living Amebae (FLAs)
- IHA – ELISA – CIEP – IF - CFT Tissue specimens, including biopsy, surgical or necropsy specimens, may be collected for
More useful in the detection of free-living amebae (Naegleria, Balamuthia, and Acanthamoeba).
- Amoebiasis - Leishmaniasis - Malaria - Toxoplasmosis The desired specimens include:
- Trichinosis - Filariasis - Echinococcosis • Tissue slides stained with hematoxylin and eosin (H&E).
Skin Tests • Unstained slides (for indirect Immunofluorescence, or IIF).
Specificity low, cross reactions common • Unfixed brain tissue or CSF for PCR.
Examples: • Unfixed corneal scrapings (for Acanthamoeba).
Casoni’s test
Acanthamoeba cyst
Leishmanin test
Cultivation of parasites • Paraffin-embedded tissue block.
Culture methods are used for : Cellulose Tape or Swube Tube Procedure for Demonstration of Pinworm Eggs
• Amoeba • The most reliable and widely used technique for demonstrating pinworm eggs
• Leishmania (Enterobius vermicularis) is the cellulose tape or swube tube procedure.
• Trypanosoma • The adhesive part of the swube tube or tape is applied to the perianal area first
• Malarial parasite thing in the morning.
Animal inoculation • Specimens should be collected on three consecutive mornings prior to bathing.
• Leishmania (young hamester) • If an infection is present, eggs and sometimes adult
• Trypanosomes (rat, mouse) worms
• Toxoplasma (all lab animals) of Enterobius vermicularis will be present E. Vermicularis egg

Xenodiagnosis: on the tape and can be seen under the microscope

In chagas’ disease
Vector infected experimentally
Sputum examination Urine Specimens
Microscopic examination of sputum can identify: Urinary schistosomiasis
➢ Paragonimus westermani eggs • Presence of S. haematobium eggs in urine is diagnostic
➢ Strongyloides stercoralis larva • Eggs usually shed in the urine around midday, so an
➢ Ascaris lumbricoides larvae optimum urine specimen for diagnosis should be
➢ hookworm larvae, and rarely Entamoeba histolytica. collected at noon.
❑ Sputum should be obtained from the lower respiratory passages not saliva. • The specimen should be immediately centrifuged at 400
× g and the sediment examined by a wet mount.
Trichomonas vaginalis
❑ Motile trophozoites may also be found in the urine, especially in infected male
patients.
❑ Urine specimen should be centrifuged at 400 × g, the sediment mixed with a drop
or two of saline, and examined by wet mount.
❑ Temporary stains, such as methylene blue is helpful to see T. vaginalis

Artifacts
• Cysts and trophozoites must be examined carefully in different fields of view and
measurement is often essential. Objects such as epithelial cells and macrophages
are around the same size as amoebic trophozoites: the latter may also move and
contain red blood cells.
• White blood cells, plant and vegetable cells, fat globules, muscle fibers, pollen
grains, yeasts cells and air bubbles may be confused with cysts or eggs.
• Air bubbles trapped under adhesive tape often resemble Enterobius eggs.
• Plant hairs and fibers are easily confused with larvae
• Earthworms may resemble roundworms.
• Eggs of Heterodera, a parasitic nematode of root vegetables, may resemble
;hookworm eggs.
• Eggs originating from harmless mites in cereals or flour could be confused with
hookworm ova
• A patient complaining of hematuria: we suspected Schistosoma haematobium
but, on closer analysis, the eggs contained unidentified insects
•
Artifacts should be considered on the basis of size, shape, lack of organelles and defining
feature, and variable reactivity with common
Artifacts
 MEDICAL PARASITOLOGY
Morphology
• includes size, shape, color, and position of different organelles in different
parasites at various stages of their development.
• This is especially important in laboratory diagnosis, which helps identify the
different development stages and differentiate between pathogenic and
commensal organisms. For example, Entamoeba histolytica and Entamoeba coli

Geographical distribution
Even though revolutionary advances in transportation have made geographical isolation no
longer a protection against many of the parasitic diseases, many of them are still found in
abundance in the tropics

Distribution of parasites depends upon:

➢ The presence and food habits of a suitable host:
• Host specificity, for example, Ancylostoma duodenale requires a man as a
host whereas Ancylostoma caninum requires a dog.
• Food habits, e.g. consumption of raw or undercooked meat or vegetables
predisposes to Taeniasis
➢ Easy escape of the parasite from the host
❑ the different developmental stages of a parasite which are released from the
body along with feces and urine are widely distributed in many parts of the
world as compared to those parasites which require a vector or direct body
fluid contact for transmission.
➢ Environmental conditions favoring survival outside the body of the host, i.e.
temperature, the presence of water, humidity, etc.
➢ The presence of an appropriate vector or intermediate host
❑ parasites that do not require an intermediate host (vector) for transmission
are more widely distributed than those that do require vectors
Life cycle of parasites
the route followed by a parasite from the time of entry to the host to exit, including
the extracorporeal (outside the host) life. It can either be simple, when only one host is
involved, or complex, involving one or more intermediate hosts.
 A parasite’s life cycle consists of two common phases one phase involves the route Indirect evidence
a parasite follows inside the body. This information provides an understanding of the ✓ changes indicative of intestinal parasitic infections are:
symptomatology and pathology of the parasite. a. Cytological changes in the blood
In addition, the method of diagnosis and selection of appropriate medication may – eosinophilia often gives an indication of tissue invasion by helminths, a
also be determined. The other phase, the route a parasite follows outside of the body, reduction in white blood cell count is an indication of kala-azar, and anemia is a
provides crucial information pertinent to epidemiology, prevention, and control. feature of hookworm infestation and malaria.
b. Serological tests
Host-parasite relationship - infection is the result of entry and development within the – are carried out only in laboratories where special antigens are available.
body of any injurious organism regardless of its size. Treatment
a. Carrier state - a perfect host-parasite relationship where tissue destruction by a parasite • many parasitic infections can be cured by specific chemotherapy.
is balanced with the host’s tissue repair. (parasite and host live harmoniously, i.e. they are The greatest advances have been made in the treatment of protozoal diseases.
at equilibrium.)
b. Disease state - this is due to an imperfect host-parasite relationship where the parasite For the treatment of intestinal helminthiasis, drugs are given orally for direct action on
dominates the upper hand. It can result either from lower resistance of the host or higher the helminths. To obtain the maximum parasiticidal effect, it is desirable that the drugs
pathogenicity of the parasite. administered should not be absorbed and the drugs should also have a minimum toxic
c. Parasite destruction – occurs when the host takes the upper hand. effect on the host.

Laboratory diagnosis Prevention and Control

a) Blood – in those parasitic infections where the parasite itself in any stage of its • measures may be taken against every parasite infecting humans. Preventive
development circulates in the bloodstream, examination of blood film forms one of the measures designed to break the transmission cycle are crucial to successful
main procedures for specific diagnosis. parasitic eradication.
For example, in malaria, the parasites are found inside the red blood cells. In Such measures include:
Bancroftian and Malayan filariasis, microfilariae are found in the blood plasma. • Reduction of the source of infection- the parasite is attacked within the host,
b) Stool – examination of the stool forms an important part in the diagnosis of intestinal thereby preventing the dissemination of the infecting agent. Therefore, a prompt
parasitic infections and also for those helminthic parasites that localize in the biliary tract diagnosis and treatment of parasitic diseases is an important component in the
and discharge their eggs into the intestine. prevention of dissemination.
In protozoan infections, either trophozoites or cystic forms may be detected; the former • Sanitary control of drinking water and food.
during the active phase and the latter during the chronic phase. Examples: Amoebiasis, • Proper waste disposal – through establishing safe sewage systems, use of
Giardiasis, etc. screened latrines, and treatment of night soil.
In the case of helminthic infections, adult worms, their eggs, or larvae are found
• The use of insecticides and other chemicals used to control the vector population.
in the stool.
• Protective clothing that would prevent vectors from resting in the surface of the
c) Urine – when the parasite localizes in the urinary tract, examination of the urine will be
body and inoculate pathogens during their blood meal.
of help in establishing the parasitological diagnosis.
For example, in urinary Schistosomiasis, eggs of Schistosoma haematobium are • Good personal hygiene.
found in the urine. In cases of chyluria caused by Wuchereria bancrofti, • Avoidance of unprotected sexual practices.
microfilariae are found in the urine.
GENERAL CHARACTERISTICS OF MEDICALLY IMPORTANT PARASITES
Medically important protozoa, helminths, and arthropods, which are identified as causes
d) Sputum – examination of the sputum is useful in the following:
and propagators of disease have the following general features. These features also differ
❑ In cases where the habitat of the parasite is in the respiratory tract, as in
among parasites in a specific category.
Paragonimiasis, the eggs of Paragonimus westermani are found.
❑ In an amoebic abscess of the lung or in the case of an amoebic liver abscess
(1) PROTOZOA
bursting into the lungs, the trophozoites of E. histolytica are detected in the
Reproduction
sputum.
- the methods of reproduction or multiplication among the parasitic protozoa are of the
e) Biopsy material - varies with different parasitic infections.
following types:
For example, spleen punctures in cases of kala-azar, muscle biopsy in cases of
1. Asexual multiplication:
Cysticercosis, Trichinelliasis, and Chagas’ disease, and Skin snip for
(a) Simple binary fission – in this process, after the division of all the structures, the
Onchocerciasis.
individual parasite divides either longitudinally or transversely into two more or less equal
f) Urethral or vaginal discharge – for Trichomonas vaginalis
parts.
(b) Multiple fission or schizogony – in this process, more than two individuals are
produced, e.g. asexual reproduction in Plasmodia.
 (3) ARTHROPODS
2. Sexual reproduction: Arthropods, which form the largest group of species in the animal kingdom, are
(a) Conjugation – in this process, a temporary union of two individuals occurs during characterized by having a bilaterally symmetrical and segmented body with jointed
which time the interchange of nuclear material takes place. Later on, the two individuals appendages.
separate. They have a hard exoskeleton, which helps enclose and protect the muscles and other
(b) Syngamy – in this process, sexually differentiated cells, called gametes, unite organs. An open circulatory system, with or without a dorsally situated heart pumps the
permanently and a complete fusion of the nuclear material takes place. The resulting blood (hemolymph) via arteries to the various organs and body tissues.
product is then known as a zygote. Blood is returned to the heart through body spaces known as hemocoeles. In addition,
respiratory, excretory, and nervous systems are present.

Based on their organs of locomotion. Arthropods affect the health of humans by being either direct agents for disease or agents
for disease transmission.
Table 1. Classification of the Pathogenic Protozoa: The arthropods of medical importance are found in Classes Insecta, Arachnida, and
Crustacea which have their own distinguishing features.
In Class Insecta, the body is divided into the head, thorax, and abdomen, with one pair of
antennae. Diseases like malaria, yellow fever, onchocerciasis, and trypanosomiasis are
primarily transmitted by insects.

MEDICAL PROTOZOLOGY
Protozoa (singular, protozoan), from the Greek ‘protos’ and ‘zoon’ meaning “first
animal”, are members of eukaryotic protists.
They may be distinguished from other eukaryotic protists by their ability to move at some
stage of their life cycle and by their lack of cell wall.

Occurrence of protozoa
✓ Protozoa are found in all moist habitats. They are common in the sea, in soil, and
in freshwater. These organisms occur generally as a single cell.
✓ Colonies of protozoa might also occur in which individual cells are joined by
(2) HELMINTHS: cytoplasmic threads and form aggregates of independent cells.
• The helminthic parasites are multicellular, bilaterally symmetrical animals having ✓ However, distinct types of protozoa, include a resistant cyst (non-motile) stage to
three germ layers. survive adverse environmental conditions, such as desiccation, low nutrient
• The helminths of importance to human beings are divided into three main groups supply, and even anaerobiosis.
with the peculiarities of the different categories described in Table 2. ✓ For example, the soil amoeba, Naegleria is a resistant cyst in dry weather, a
naked amoeba in moist soil, and becomes flagellated when flooded with water.
Table 2. Differentiating Features Of Helminths
Morphology of protozoa
❑ Protozoa are predominantly microscopic, ranging in size from 2 to more than
100μm.
❑ Morphologically, they are within a mass of protoplasm, consisting of a true
membrane–bound nucleus and cytoplasm.
❑ The nucleus contains clumped or dispersed chromatin and central nucleolus or
karyosome, which are useful structures to distinguish protozoan species from one
another based on the shape, size, and distribution of these structures.
Importance of protozoa
➢ serve as an important link in the food chain and ecological balance of many
communities in wetland & aquatic environments.
➢ important in biological sewage treatment, which involves both anaerobic
digestion and/or aeration.
➢ important laboratory organisms in research areas, by which their asexual
reproduction enables clones to be established with the same genetic makeup.
 ➢ useful in the study of cell cycles and nucleic acid biosynthesis during cell Classification of Protozoa
division. Protozoa of medical importance are classified based on their morphology and
Medical concern about protozoa locomotive system as described below:
✓ Protozoa are ubiquitous in moist areas, including the human alimentary canal. ✓ Amoebas - Entamoeba histolytica
From an ecological standpoint, protozoa may be divided into free-living forms ✓ Flagellates - Giarda lamblia, Trichomonas vaginalis, Trypanosoma spp,
and symbiotic forms. Some of the symbiotic ones are parasitic and may cause Leishmania spp
disease. ✓ Cliliophora - Balantidium coli
✓ Although most amoebas are free-living, several are found as commensal ✓ Coccidian - Isospora belli, Cryptosporidium parvum, Toxoplasma gondii,
inhabitants of the intestinal tract in humans. One of these organisms Entamoeba Plasmodium species
histolytica may invade tissue and produce disease. Protozoan pathogens can also be grouped according to the location in the body where they
Ciliates – the majority are free-living and seldom parasitize humans. most frequently cause disease.
Flagellates - of the genus Trypanosomes and Leishmania are capable of invading the AMOEBIASIS
blood & tissue of humans, where they produce severe chronic illnesses. Amoebas primitive unicellular microorganisms with a relatively simple life cycle which
Others such as Trichomonas vaginalis and Giardia lamblia, inhabit the urogenital can be divided into two stages:
and gastrointestinal tracts and initiate disease characterized by mild to moderate morbidity • Trophozoite – actively motile feeding stage.
but no mortality. • Cyst – quiescent, resistant, infective stage.
✓ Sporozoan organisms produce two of the most potentially lethal diseases of Their reproduction is through binary fission, e.g. splitting of the trophozoite or
humankind: malaria and toxoplasmosis. through the development of numerous trophozoites with in the mature multinucleated cyst.
✓ With the advent of HIV a new and important chapter has been opened; i.e. Motility is accomplished by extension of pseudopodia (“false foot”)
‘opportunistic’ parasitosis. Most of the parasitic incidents belong to endocellular Entamoeba histolytica - Morphological features
protozoa of different genera or species. (a) Trophozoites
Reproduction and regeneration of protozoa ✓ Viable trophozoites vary in size from about 10-60μm in diameter. Motility is
❑ As a general rule, protozoa multiply by asexual reproduction. rapid, progressive, and unidirectional, through pseudopods.
❑ This is not to say that sexual processes are absent in the protozoa. Some parasitic ✓ The nucleus is characterized by evenly arranged chromatin on the nuclear
forms may have an asexual phase in one host and a sexual phase in another host. membrane and the presence of a small, compact, centrally located karyosome.
Transmission ✓ The cytoplasm is usually described as finely granular with few ingested bacteria
In most parasitic protozoa, the developmental stages are often transmitted from or debris in vacuoles. In the case of dysentery, however, RBCs may be visible in
one host to another within a cyst. The reproduction process is also related to the formation the cytoplasm, and this feature is diagnostic for E. histolytica.
of the cyst. (b) Cyst
Asexual reproduction of some ciliates and flagellates is associated with cyst ✓ Cysts range in size from 10-20μm.
formation, and sexual reproduction of Sporozoa invariably results in a cyst. ✓ The immature cyst has inclusions namely; glycogen mass and chromatoidal bars.
Pathogenic protozoa can spread from one infected person to another by: ✓ As the cyst matures, the glycogen completely disappears; the chromatoidials may
• Fecal – oral transmission of contaminated foods and water. also be absent in the mature cyst.
• Insect bit inoculums or rubbing infected insect feces on the site of the bite. Life cycle
• Sexual intercourse Intestinal infections occur through the ingestion of a mature quadrinucleate
Pathogenesis infective cyst, contaminated food or drink, and also by hand-to-mouth contact.
Protozoan organisms are virtually always acquired from an exogenous source, It is then passed unaltered through the stomach, as the cyst wall is resistant to gastric juice.
and as such, they have evolved numerous ways to enter the body of the human host. In the terminal ileum (with alkaline pH), excystation takes place.
Factors that are important for pathogenecity include: Trophozoites being actively motile invade the tissues and ultimately lodge in the
• Attachment to the host tissue followed by replication to establish colonization. submucous layer of the large bowel. Here they grow and multiply by binary fission.
• Toxic products released by parasitic protozoa.
• Shifting of antigenic expression to evade the immune response and inactivate host Trophozoites are responsible for producing lesions in amoebiasis.
defenses. Invasion of blood vessels leads to secondary extra-intestinal lesions.
Gradually the effect of the parasite on the host is toned down together with a
concomitant increase in host tolerance, making it difficult for the parasite to continue its
Antiprotozoal agents life cycle in the trophozoite phase.
Generally, the antiprotozoal agents target relatively rapidly proliferating, young,
growing cells of the parasite.
Most commonly, these agents target nucleic acid synthesis, protein synthesis, or
specific metabolic pathways (e.g. folate metabolism) unique to the protozoan parasites.
 A certain number of trophozoites come from tissues into the lumen of the bowel
and are first transformed into pre-cyst forms.
Figure 1. Life Cycle of E. histolytica
Pre-cysts secrete a cyst wall and become a uninucleate cyst.
Eventually, mature quadrinucleate cysts form. These are
the infective forms.
Both mature and immature cysts may be passed in feces.
Immature cysts can mature in external environments and
become infective.
Pathogenesis
✓ Trophozoites divide and produce extensive local necrosis in the large Extraintestinal amoebiasis
intestine.
✓ Diagnosed by the use of scanning procedures for the liver and other organs.
✓ Invasion into the deeper mucosa with extension into the peritoneal
✓ Specific serologic tests, together with a microscopic examination of the abscess
cavity may occur. This can lead to secondary involvement of other material, can confirm the diagnosis.
organs, primarily the liver but also the lungs, brain, and heart.
Treatment
✓ Extraintestinal amebiasis is associated with trophozoites. Amoebas
✓ Acute, fulminating amebiasis is treated with metronidazole followed by
multiply rapidly in an anaerobic environment because the trophozoites iodoquinol, and asymptomatic carriage can be eradicated with iodoquinol,
are killed by ambient oxygen concentration.
diloxanide furoate, or paromomycin.
Epidemiology
✓ The cysticidal agents are commonly recommended for asymptomatic carriers
✓ E. histolytica has a worldwide distribution. Although it is found in cold areas, the who handle food for public use.
incidence is highest in tropical and subtropical regions that have poor sanitation
✓ Metronidazole, chloroquine, and diloxanide furoate can be used for the treatment
and contaminated water. of extra intestinal amoebiasis.
✓ About 90% of infections are asymptomatic, and the remaining produces a Prevention
spectrum of clinical syndrome.
✓ Introduction of adequate sanitation measures and education about the routes of
✓ Patients infected with E. histolytica pass non-infectious trophozoites and transmission.
infectious cysts in their stools. ✓ Avoid eating raw vegetables grown by sewerage irrigation and night soil
✓ Therefore, the main source of water and food contamination is the symptomatic
OTHER AMEBAE INHABITING THE ALIMENTARY CANAL
carrier who passes cysts. Symptomatic amebiasis is usually sporadic. The Most of these amoebae are commensal organisms that can parasitize the human
epidemic form is a result of direct person-to-person fecal-oral spread under gastrointestinal tract.
conditions of poor personal hygiene.
Entamoeba hartmanni
Clinical features ✓ In all of its life–cycle stages, resembles E. histolytica except in size, yet there is a
✓ The outcome of infection may result in a carrier state, intestinal amebiasis, or
slight overlap in the size range.
extraintestinal amebiasis.
✓ The trophozoites do not ingest red blood cells, and their motility is generally less
✓ Diarrhea, flatulence, and cramping are complaints of symptomatic patients. More vigorous than that of E. histolytica. As in other amebae, infection is acquired by
severe disease is characterized by the passing of numerous bloody stools in a day.
ingestion of food or water contaminated with cyst-bearing feces.
✓ Systemic signs of infection (fever, leukocytosis, rigors) are present in patients
✓ Identification is based on the examination of small amebae in unstained or
with extraintestinal amebiasis. iodine-stained preparations.
✓ Usually, no treatment is indicated, measures generally effective against fecal-
✓ The liver is primarily involved, because trophozoites in the blood are removed
borne infections will control this amoebic infection.
from the blood by the portal veins. Entamoeba coli
✓ The right lobe is most commonly involved, thus pain over the liver with
✓ the life cycle stages include; trophozoite, precyst, cyst, metacyst, and metacystic
hepatomegaly and elevation of the diaphragm is observed. trophozoite.
Immunity ✓ Typically the movements of trophozoites are sluggish, with broad short
E. histolytica elicits both the humeral and cellular immune responses, but it is not yet
pseudopodia and little locomotion, but at a focus, the living specimen cannot be
clearly defined whether it modulates the initial infection or prevents reinfection. distinguished from the active trophozoite of E. histolytica.
Laboratory diagnosis - In intestinal amoebiasis: ✓ However, the cysts are remarkably variable in size.
• Examination of a fresh dysenteric fecal specimen or rectal scraping for the trophozoite
✓ Entamoeba coli is transmitted in its viable cystic stage through fecal
stage. (Motile amoebae containing red cells are diagnostic of amoebic dysentery). contamination. Ε. coli as a lumen parasite is non-pathogenic and produces no
• Examination of formed or semiformed feces for cyst stage. (Cysts indicate infection with symptoms.
either a pathogenic E. histolytica or non-pathogenic E. dispar.)
 ✓ The mature cyst (with more than four nuclei) is the distinctive stage to ✓ There are thin–walled cysts involved in autoinfection, and thick–walled cysts
differentiate [Link] from the pathogenic E. histolytica. responsible for external transmission via the fecal-oral route.
✓ Specific treatment is not indicated since this amoeba is non-pathogenic. The ✓ The presence of large numbers of these parasites (five or more per oil immersion
presence of [Link] in stool specimens is evidence of fecal contamination. microscopic field) in the absence of other intestinal pathogens indicates disease.
✓ Prevention depends on better personal hygiene and sanitary disposal of human ✓ The organism may be detected in wet mounts or trichome–stained smears of fecal
excreta. specimens.
Entamoeba polecki ✓ Treatment with iodoquinol or metronidazole has been successful in eradicating
✓ A relatively cosmopolitan parasite of hog and monkey. the organism from the intestine and alleviating symptoms.
✓ It can cause human disease but is rarely isolated. The disease is manifested as ✓ However, the definitive role of B. hominis in disease remains to be demonstrated.
mild, transient diarrhea. ✓ The incidence and apparent worldwide distribution of the infection indicate
✓ The diagnosis of E. polecki infection is confirmed by the microscopic detection preventive measures to be taken, which involve improving personal hygiene and
of cysts in stool specimens. sanitary conditions.
✓ Treatment is the same as for E. histolytica infection. Prevention is achieved by
good personal hygiene.
Endolimax nana
✓ is a lumen dweller in the large intestine, primarily at the cecal level, where it
feeds on bacteria.
✓ The life cycle is similar to E. histolytica. Motility is typically sluggish (slug-like)
with blunt hyaline pseudopodia,
✓ Human infection results from the ingestion of viable cysts in polluted water or
contaminated food.
✓ Typical ovoid cysts of E. nana are confirmative. Rounded cysts and living
trophozoites are often confused with E. hartmanni and E. histolytica.

✓ No treatment is indicated for this nonpathogenic infection. Prevention can be

achieved through personal cleanliness and community sanitation
Iodamoeba buetschlii
✓ the natural habitat is the lumen of the large intestine, the principal site probably
being the caecum.
✓ The trophozoite feeds on enteric bacteria; it is a natural parasite of man and lower
primates. It is generally regarded as a nonpathogenic lumen parasite.
✓ No treatment is ordinarily indicated. Prevention is based on good personal
hygiene and sanitation in the community.
Entamoeba gingivalis
✓ only the trophozoite stage presents, and encystation probably does not occur.
✓ E. gingivalis is a commensal, living primarily on exudate from the margins of the
gums, and thrives best on unhealthy gums.
✓ No specific treatment is indicated. However the presence of E. gingivalis
suggests a need for better oral hygiene.
✓ The infection can be prevented by proper care of the teeth and gums.
Blastocystis hominis
✓ is an inhabitant of the human intestinal tract previously regarded as non-
pathogenic yeast. Its pathogenicity remains controversial.
✓ The organism is found in stool specimens from asymptomatic people as well as
from people with persistent diarrhea.
✓ B. hominis is capable of pseudopodia extension and retraction and reproduces by
binary fission or sporulation.
✓ The classic form that is usually seen in the human stool specimen varies
tremendously in size, from 6-40μm.
 Naegleria, Acanthamoeba, and Balamuthia organisms are opportunistic pathogens.
Naegleria fowleri causes acute primary amoebic meningoencephalitis.
Acanthamoeba & Balamuthia organisms are responsible for granulomatous amoebic
encephalitis and single or multiple brain abscesses, primarily in immunocompromised
individuals.
Keratitis (eye) and skin infection by Acanthamoeba may also occur.
For the diagnosis of Naegleria, Acanthamoeba, and Balamuthia infections, specimens of
nasal discharge and cerebrospinal fluid; and in cases of eye infections corneal scraping
should be collected.
The clinical specimen can be examined with saline wet preparation and Iodine stained
smear. Treatment of free-living amoebic infections is largely ineffective.
PATHOGENIC FLAGELLATES
Flagellates are unicellular microorganisms. Their locomotion is by lashing a tail-like
appendage called a flagellum or flagella and reproduction is by simple binary fission.
There are three groups of flagellates:
✓ Luminal flagellates
Giardia lamblia
Dientamoeba fragilis
✓ Hemoflagellates
Trypanosoma species.
Leishmania species.
✓ Genital flagellates
Trichomonas vaginalis
LUMINAL FLAGELLATES
Giardia lamblia - Important features
✓ The life cycle consists of two stages, the trophozoite and cyst. The trophozoite is
9-12 μm long and 5-15μm wide anteriorly.
✓ It is bilaterally symmetrical, and pear-shaped with two nuclei (large central
karyosome), four pairs of flagella, two axonemes, and a suction disc with which
it attaches to the intestinal wall.
PATHOGENIC FREE-LIVING AMOEBAE ✓ The oval cyst is 8-12μm long and 7-10μm wide, thick-walled with four nuclei
- Among the numerous free-living amoebae of soil and water habitats, certain and several internal fibers. Each cyst gives rise to two trophozoites during
species of Naegleria, Acanthamoeba, and Balamuthia are facultative parasites of excystation in the intestinal tract.
man. ✓ Transmission is by ingestion of the infective cyst.
- Most human infections of these amoebae are acquired by exposure to
contaminated water while swimming. Inhalation of cysts from dust may account
for some infections.
Naegleria fowleri
the trophozoites occur in two forms. Amoeboid forms
with single pseudopodia and flagella form with two
flagella, usually appearing a few hours after flooding
water or in CSF.
Acanthamoeba species
- the trophozoites have an irregular appearance with
spine-like pseudopodia and acanthopodia.
Balamuthia species
- the trophozoite extends broad, flat lamellipodia or
sub-pseudopodia from it. The trophozoite may be bi-nucleated. Unlike most amoebae, the
nuclear envelope breaks down during mitosis.
Pathogenesis - Proper waste disposal and use of latrine.
✓ Infection with G. lamblia is initiated by ingestion of cysts. Gastric acid stimulates Trichomonas vaginalis - Important features
excystation, with the release of trophozoites in the duodenum and jejunum. ✓ It is a pear-shaped organism with a central nucleus and four anterior flagella; and
✓ The trophozoites can attach to the intestinal villi by the ventral sucking discs an undulating membrane that extends about two-thirds of its length.
without penetration of the mucosa lining, but they only feed on the mucous ✓ It exists only as a trophozoite form and measures 7-23μm long & 5-15μm wide.
secretions. ✓ Transmission is by sexual intercourse.
✓ In symptomatic patients, however, mucosa-lining irritation may cause increased Pathogenesis
mucous secretion and dehydration. ❑ The trophozoite is found in the urethra & vagina of women and the urethra &
✓ Metastatic spread of disease beyond the GIT is very rare. prostate gland of men.
Epidemiology ❑ After the introduction of sexual intercourse, proliferation begins which results in
✓ Giardia lamblia has a worldwide distribution, particularly common in the tropics inflammation & large numbers of trophozoites in the tissues and the secretions.
and subtropics. ❑ The onset of symptoms such as vaginal or vulval pruritus and discharge is often
✓ It is acquired through the consumption of inadequately treated contaminated sudden and occurs during or after menstruation as a result of the increased
water, ingestion of contaminated uncooked vegetables or fruits, or person-to- vaginal acidity.
person spread by the fecal-oral route. ❑ The vaginal secretions are liquors, greenish or yellowish, sometimes frothy, and
✓ The cyst stage is resistant to chlorine in concentrations used in most water foul smelling.
treatment facilities. Infection exists in 50% of symptomatic carriage and reserves ❑ Infection in the male may be latent, with no symptoms, or may be present as self-
the infection in endemic form. limited, persistent, or recurring urethritis.
Clinical features - Clinical disease: Giardiasis ❑ Epidemiology
✓ Symptomatic giardiasis ranges from mild diarrhea to severe malabsorption ❑ This parasite has worldwide distribution, and sexual intercourse is the primary
syndrome. mode of transmission.
✓ Usually, the onset of the disease is sudden and consists of foul-smelling, watery ❑ Occasionally, infections can be transmitted by fomites (toilet articles, clothing),
diarrhea, abdominal cramps, flatulence, and steatorrhea. although this transmission is limited by liability of the trophozoite.
✓ Blood & pus are rarely present in stool specimens, a feature consistent with the ❑ Rarely Infants may be infected by passage through the mother’s infected birth
absence of tissue destruction. canal.
Immunity ❑ The prevalence of this flagellate in developing countries is reported to be 5% –
✓ The humoral immune response and the cellular immune mechanism are involved 20% in women and 2% –10% in men.
in giardiasis. Clinical features - Clinical disease - Trichomoniasis.
✓ Giardia–specific IgA is particularly important in both defense against and ✓ Most infected women at the acute stage are asymptomatic or have a scanty,
clearance of parasites. watery vaginal discharge.
Laboratory diagnosis ✓ In symptomatic cases, vaginitis occurs with more extensive inflammation, along
✓ Examination of diarrheal stool- trophozoite or cyst, or both may be recovered in with erosion of the epithelial lining, and painful urination, and results in
wet preparation. In examinations of formed stool (e.g. in asymptomatic carriers) symptomatic vaginal discharge, vulvitis, and dysuria.
only cysts are seen. Immunity
✓ Giardia species may occur in “showers”, i.e. many organisms may be present in The infection may induce humoral, secretory, and cellular immune reactions, but they are
the stool on a given day and few or none may be detected the next day. Therefore of little diagnostic help and do not appear to produce clinically significant immunity.
one stool specimen per day for 3 days is important. Laboratory diagnosis
✓ If microscopic examination of the stool is negative in a patient in whom • In females, T. vaginalis may be found in urine sediment, wet preparations of vaginal
giardiasis is highly suspected duodenal aspiration, string test (entero-test), or secretions, or vaginal scrapings.
biopsy of the upper small intestine can be examined. • In males it may be found in urine, wet preparations of prostatic
✓ In addition to conventional microscopy, several immunologic tests can be secretions, or following massage of the prostate gland.
implemented for the detection of parasitic antigens. • Contamination of the specimen with feces may confuse T.
Treatment vaginalis with T. hominis.
For asymptomatic carriers and diseased patients, the drug of choice is quinacrine Treatment
hydrochloride or metronidazole. Metronidazole is the drug of choice. If resistant cases occur, re-
treatment with higher doses is required.
Prevention Prevention
- Asymptomatic reservoirs of infection should be identified & treated. - Both male & female sex partners must be treated to avoid
- Avoidance of contaminated food and water. reinfection
- Drinking water from lakes and streams should be boiled, filtered and/or iodine-treated. - Good personal hygiene, avoidance of shared toilet articles & clothing.
- Safe sexual practice. - Mucocutaneous leishmaniasis
Dientamoeba fragilis
✓ Initially classified as an amoeba; however, the internal structures of the The species of leishmania exist in two forms, amastigote (aflagellar) and promastigote
trophozoite are typical of a flagellate. No cyst stage has been described. (flagellated) in their life cycle.
✓ The life cycle and mode of transmission of D. fragilis are not known.
✓ It has worldwide distribution. They are transmitted by certain species of sand flies (Phlebotomus & Lutzomyia)
✓ The transmission is postulated, via helminth eggs such as those of Ascaris and Figure 8. The life cycle of Leishmania species
Enterobius species. Transmission by fecal-oral routes does occur.
✓ Most infection with D. fragilis is asymptomatic, with colonization of the cecum Visceral leishmaniasis
and upper colon. However, some patients may develop symptomatic disease,
consisting of abdominal discomfort, flatulence, intermittent diarrhea, anorexia, Leishmania donovani
and weight loss.
✓ The therapeutic agent of choice for this infection is iodoquinol, with tetracycline Important features
and paromomycin as acceptable alternatives.
the natural habitat of L. donovani in man is the reticuloendothelial system of the viscera,
✓ The reservoir for this flagellate and its lifecycle is unknown. Thus, the specific
recommendation for prevention is difficult. However, the infection can be in which the amastigote multiplies by simple binary fission until the host cells are
avoided by the maintenance of adequate sanitary conditions. destroyed, whereupon new macrophages are parasitized.
Other flagellates inhabiting the alimentary canal
In the digestive tract of appropriate insects, the developmental cycle is also simple by
Trichomonas hominis
longitudinal fission of promastigote forms. The amastigote stage appears as an ovoidal or
✓ The trophozoites live in the cecal area of the large intestine and feed on bacteria.
✓ It is considered to be non-pathogenic, although it is often recovered from rounded body, measuring about 2-3μm in length; and the promastigotes are 15-25μm
diarrheic stools. Since there is no known cyst stage, transmission probably occurs lengths by 1.5-3.5μm breadths.
in the trophic form. There is no indication of treatment.
Figure 9
Trichomonas tenax
✓ first recovered from the mouth, specifically in tartar from the teeth. Pathogenesis
✓ There is no known cyst stage. The trophozoite has a pyriform shape and is
smaller and more slender than that of T. hominis. In visceral leishmaniasis, the organs of the reticuloendothelial system (liver, spleen, and
✓ Diagnosis is based on the recovery of the organism from the teeth, gums, or bone marrow) are the most severely affected organs.
tonsillar crypts, and no therapy is indicated.
Chilomastix mesnili Reduced bone marrow activity, coupled with cellular destruction in the spleen, results in
✓ has both a trophozoite and cyst stage. anemia, leukopenia, and thrombocytopenia.
✓ It normally lives in the cecal region of the large intestine, where the organism
feeds on bacteria and debris.
✓ It is considered to be non-pathogenic, and no treatment is recommended.
This leads to secondary infections and a tendency to bleed.

MEDICAL PROTOZOLOGY
Part Deux The spleen and liver become markedly enlarged, hypersplenism contributes to the
development of anemia and lymphadenopathy also occurs.
Hemoflagellates & Ciliates

Hemoflagellates
Increased production of globulin results in hyperglobulinemia, and reversal of the
Leishmania Species albumin-to-globulin ratio.

Clinical disease Epidemiology: L. donovani donovani infection

- Visceral leishmaniasis An infection of the classic kala-azar (“black sickness”) or dumdum fever type occurs in
many parts of Asia, Africa, and Southeast Asia.
- Cutaneous leishmaniasis
Kala-azar occurs in three distinct epidemiologic patterns. In the Mediterranean basin - Culture of blood, bone marrow, and other tissue often demonstrates the promastigote
(European, Near Eastern, and Africa) and parts of China and Russia, the reservoir hosts stage of the organisms.
are primarily dogs & foxes; in sub-Saharan Africa, rats & small carnivores are believed to
be the main reservoirs. - Serologic testing is also available.

Figure 10. Sandfly

In India and neighboring countries (and Kenya), kala-azar is anthroponosis, i.e. there is no Treatment
other mammalian reservoir host other than humans.

The vector is the Phlebotomus sand fly.

The drug of choice is sodium stibogluconate, a pentavalent antimonial compound.

Alternative approaches include the addition of allopurinol and the use of pentamidine or
amphotericin B.

Other variants of L. donovani are also recognized:

Prevention

L. donovani infantum with similar geographical distribution, reservoir host, and vector to
L. donovani donovani.
• Prompt treatment of human infections and control of reservoir hosts.
L. donovani chagasi is found in South America, Central America, especially Mexico, and
the West Indies. • Protection from sand flies by screening and insect repellents.

Reservoir hosts are dogs, foxes, and cats, and the vector is the Lutzomiya sand fly Old World Cutaneous Leishmaniasis (Oriental sore)

Clinical features Clinical disease

Symptoms begin with intermittent fever, weakness, and diarrhea; chills and sweating that
may resemble malaria symptoms are also common early in the infection. L. tropica minor - dry or urban cutaneous leishmaniasis
As organisms proliferate & invade cells of the liver and spleen, marked enlargement of the L. tropica major - wet or rural cutaneous leishmaniasis
organs, weight loss, anemia, and emaciation occur.
L. ethiopica - cutaneous leishmaniasis
With the persistence of the disease, a deeply pigmented, granulomatous lesion of the skin,
referred to as post-kala-azar dermal leishmaniasis, occurs. Important features

Untreated visceral leishmaniasis is nearly always fatal as a result of secondary infection. These are parasites of the skin found in endothelial cells of the capillaries of the infected
site, nearby lymph nodes, within large mononuclear cells, in neutrophilic leukocytes, and
Immunity free in the serum exuding from the ulcerative site.

Host cellular and humoral defense mechanisms are stimulated

Laboratory diagnosis Metastasis to other sites or invasion of the viscera is rare.

Figure 13. Lesions

- Examination of tissue biopsy, spleen aspiration, bone marrow aspiration, or lymph node Pathogenesis
aspiration in a properly stained smear (e.g. Giemsa stain).
In neutrophilic leukocytes, phagocytosis is usually successful, but in macrophages, the
- The amastigotes appear as intracellular & extracellular L. donovani (LD) bodies. introduced parasites round up to form amastigotes and multiply.
In the early stage, the lesion is characterized by the proliferation of macrophages that Clinical disease:
contain numerous amastigotes.
Leishmania mexicana complex- Cutaneous leishmaniasis.
There is a variable infiltration of lymphocytes and plasma cells.
Leishmania braziliensis complex- mucocutaneous or cutaneous leishmaniasis
The overlying epithelium shows acanthosis and hyperkeratosis, which is usually followed
by necrosis and ulceration. Figure 14. Geographical distribution of New World Leishmaniasis

Epidemiology Important features

Cutaneous leishmaniasis produced by L. tropica complex is present in many parts of Asia, The American cutaneous leishmaniasis is the same as the oriental sore.
Africa, Mediterranean Europe, and the southern region of the former Soviet Union. But some of the strains tend to invade the mucous membranes of the mouth, nose,
Urban cutaneous leishmaniasis is thought to be an anthroponosis while rural cutaneous pharynx, and larynx either initially by direct extension or by metastasis.
leishmaniasis is a zoonosis with human infections occurring only sporadically. The metastasis is usually via lymphatic channels but occasionally may be in the
The reservoir hosts in L. major are rodents. L. ethopica is endemic in Ethiopia and Kenya. bloodstream.

The disease is a zoonosis with rock & tree hyraxes serving as reservoir hosts. Pathogenesis

The vector for old-world cutaneous leishmaniasis is the Phlebotomus sand fly. The lesions are confined to the skin in cutaneous leishmaniasis and to the mucous
membranes, cartilage, and skin in mucocutaneous leishmaniasis.
Clinical features
A granulomatous response occurs, and a necrotic ulcer forms at the bite site. The lesions
The first sign, a red papule, appears at the site of the fly’s bite. tend to become superinfected with bacteria.

This lesion becomes irritated, with intense itching, and begins to enlarge & ulcerate.
Gradually the ulcer becomes hard and crusted and exudes a thin, serous material.
Secondary lesions occur on the skin as well as in mucous membranes.
At this stage, secondary bacterial infection may complicate the disease. In the case of
Ethiopian cutaneous leishmaniasis, there are similar developments of lesions, but they may
also give rise to diffuse cutaneous leishmaniasis (DCL) in patients who produce little or no Nasal, oral, and pharyngeal lesions may be polypoid initially, and then erode to form
cell-mediated immunity against the parasite. ulcers that expand to destroy the soft tissue and cartilage about the face and larynx.
This leads to the formation of disfiguring nodules over the surface of the body.

Immunity Regional lymphadenopathy is common.

Both humoral and cell mediated immunity (CMI) are involved

Treatment Epidemiology

The drug of choice is sodium stibogluconate, with an alternative treatment of applying Most of the cutaneous & mucocutaneous leishmaniasis of the new world exists in enzootic
heat directly to the lesion. cycles of infection involving wild animals, especially forest rodents. Leishmania mexicana
occurs in South & Central America, especially in the Amazon basin, with sloths, rodents,
Treatment of L. ethiopica remains to be a problem as there is no safe and effective drug. monkeys, and raccoons as reservoir hosts.
Prevention
- Prompt treatment & eradication of ulcers
- Control of sand flies & reservoir hosts.

New World Cutaneous and Mucocutaneous Leishmaniasis (American cutaneous

leishmaniasis)
Mucocutaneous leishmaniasis is seen from the Yucatan peninsula into Central & South Trypanosoma cruzi – American trypanosomiasis (Chagas’ disease)
America, especially in rainforests where workers are exposed to sandfly bites while
invading the habitat of the forest rodents. Important features

These species may have amastigote, promastigote, epimastigote, and trypomastigote

stages in their life cycle.
There are many jungle reservoir hosts, and domesticated dogs also serve as reservoirs.

In human trypanosomes of the African In their life cycle, these species may have
The vector is the Lutzomyia sand fly. amastigote, promastigote, epimastigote, and trypomastigote stages form, however, the
amastigote and promastigote stages of development are absent.

Clinical features
A typical trypanosome structure is an elongated spindle-shaped body that more or less
The types of lesions are more varied than those of oriental sore and include Chiclero ulcer, tapers at both ends, a centrally situated nucleus, a kinetoplast posterior to the nucleus, an
Uta, Espundia, and Disseminated Cutaneous Leishmaniasis. undulating membrane arising from the kinetoplast and proceeding forward along the
margin of the cell membrane and a single free flagellum at the anterior end.

Laboratory diagnosis African trypanosomiasis

• Demonstration of the amastigotes in properly stained smears from touch preparations of Trypanosoma gambiense & Trypanosoma rhodesiense are causative agents of the
an ulcer biopsy specimen. African trypanosomiasis, transmitted by insect bites.
• Serological tests based on fluorescent antibody tests.
The vector for both is the tsetse fly.
• Leishman skin test in some species.
Figure 20. Comatose state
Fig. 17. Drug of choice
Pathogenesis
Immunity

The humoral and cellular immune systems are involved

The trypomastigotes spread from the skin through the blood to the lymph node and the
brain.

Treatment The typical somnolence (sleeping sickness) usually progresses to a coma as a result of
demyelinating encephalitis. In the acute form, a cyclical fever spike (approximately every
The drug of choice is sodium stibogluconate. 2 weeks) occurs that is related to antigenic variation.

As antibody-mediated agglutination and lysis of the trypomastigotes occurs, the fever

subsides.
Prevention
With a few remains of antigenic variants new fever spike occurs and the cycle repeats
• Avoid endemic areas, especially during times when local vectors are most active.
itself over a long period.
• Prompt treatment of infected individuals.
Figure 22. Eastern & Western African sleeping sickness
Trypanosomiasis
Epidemiology
Etiologic agents
T. brucei gambiense is limited to tropical west and central Africa, correlating with the
Trypanosoma brucei complex – African trypanosomiasis (sleeping sickness) range of the tsetse fly vector.
The tsetse flies transmitting T. b. gambiense prefer shaded stream banks for reproduction
and proximity to human dwellings.
In T. rhodesiense, the disease caused is a more acute, rapidly progressive disease that is
People who work in such areas are at greatest risk of infection. usually fatal. This more virulent organism also develops in greater numbers in the blood.

An animal reservoir has not been proven for this infection. Lymphadenopathy is uncommon, and early in the infection, CNS invasion occurs,
resulting in lethargy, anorexia, and mental disturbance.

The chronic stages described for T. gambiense are not often seen, because, in addition to
T. brucei rhodesiense is found primarily in East Africa, especially the cattle-raising rapid CNS disease, the organism produces kidney damage & myocarditis, leading to death.
countries, where tsetse flies breed in the brush rather than along stream banks.
Immunity

Both humoral and cellular immunity involve in these infections.

T. b. rhodesiense also differs from T. b. gambiense in that domestic animal hosts (cattle
and sheep) and wild game animals act as reservoir hosts. The immune responses of the host to the presence of these parasites, however, are faced
with antigenic variation, in which organisms that have changed their antigenic identity can
escape the host immune response and initiate another disease process with the increased
This transmission and vector cycle makes the organism more difficult to control than T. b. level of parasitemia.
gambiense. Laboratory
Clinical features Examination of thin and thick films, in concentrated anticoagulated blood preparations,
Although both species cause sleeping sickness, the progress of the disease is different. and in aspiration from lymph nodes and concentrated spinal fluid.

Methods for concentrating parasites in the blood may be helpful approaches including
centrifugation of heparinized samples and ion–exchange chromatography.
T. gambiense-induced disease runs a low-grade chronic course over a few years. One of
the earliest signs of disease is an occasional ulcer at the site of the fly bite. Levels of parasitosis vary widely, and several attempts to visualize the organism over a
number of days may be necessary.

As the reproduction of organisms continues, the lymph nodes are invaded, and fever,
myalgia, arthralgia, and lymph node enlargement result.
The same treatment protocol is applied for these parasites.

Swelling of the posterior cervical lymph nodes is characteristic of Gambian sleeping For the acute stages of the disease, the drug of choice is suramin with pentamidine as an
sickness and is called Winterbottom’s sign. alternative.

In chronic disease with CNS involvement, the drug of choice is melarsoprol.

The chronic disease progresses to CNS involvement with lethargy, tremors, Alternatives include tryparsamide combined with suramin.
meningoencephalitis, mental retardation, and general deterioration. Prevention

• Control of breeding sites of tsetse flies and use of insecticides.

In the final stages, convulsions, hemiplegia, and incontinence occur. The patient becomes • Treatment of human cases to reduce transmission to flies.
difficult to arouse or obtain a response from, eventually progressing to a comatose state.
• Avoiding insect bites by wearing protective clothing & use screens, bed netting, and
insect repellants.
Death is the result of CNS damage and other infections, such as pneumonia.
American trypanosomiasis (Chagas’ disease) The amastigotes can kill cells and cause inflammation, consisting mainly of mononuclear
cells.
Trypanosoma cruzi is a pleomorphic trypanosome that includes an additional form of
amastigote in its life cycle. The cardiac muscle is the most frequently and severely affected tissue.

In addition, neuronal damage leads to cardiac arrhythmias and loss of tone in the colon
The vector for transmission is reduviid bugs. (megacolon) and esophagus (megaesophagus).

In the chronic phase, the organism persists in the amastigote form.

Laboratory diagnosis
First described by Carlos Chagas in 1909 Examine thin or thick stained preparations for trypomastigotes.
Mostly occurring in Latin America

Vector is also known as the “kissing bug” Wet preparations should also be examined to look for motile organisms that leave the
bloodstream and become difficult to find.

Clinical features Biopsy of lymph nodes, liver, spleen,

Chagas’ disease may be an asymptomatic acute or chronic disease. or bone marrow may demonstrate

One of the earliest signs is development at the site of the bug bite of an erythematous and organisms in amastigote stage.
indurated area called a chagoma.

This is often followed by a rash and edema around the eyes and face; in young children
frequently an acute process with CNS involvement may occur.

Acute infection is also characterized by fever, chills, malaise, myalgia, and fatigue.
Figure 29. Amastigote stage of T. cruzi in skeletal muscle

Chronic Chagas’ disease is characterized by hepatosplenomegaly, myocarditis, and

enlargement of the esophagus and colon as a result of the destruction of nerve cells (E.g.
Auerbach’s plexus) and other tissues that control the growth of these organs.

Involvement of the CNS may produce granulomas in the brain with cyst formation and
meningoencephalitis.
Xenodiagnosis - which consists of allowing an uninfected, laboratory-raised reduviid bug
Death from chronic Chagas’ disease results from tissue destruction in the many areas
to feed on the patient and, after several weeks, examining the intestinal contents of the bug
invaded by the organisms, and sudden death results from complete heart block and brain
for the organism.
damage

Pathogenesis Immunity

During the acute phase, the organism occurs in the blood as a typical trypomastigote and
in the reticuloendothelial cells as a typical amastigote.
Unlike African trypanosomiasis, the antigenic variation is less common in [Link]
infection. Therefore, the humoral and cellular immune responses function in the immune
system.
Treatment

Treatment

The drug of choice is nifurtimox. Alternative agents include allopurinol & benzimidazole. The drug of choice is tetracycline; iodoquinol and metronidazole are alternative agents.

Prevention

• Bug control, eradication of nests

• Treating infected persons & exclusion of donors by screening blood.

• Development of vaccine.

MEDICALLY IMPORTANT CILIATES

Balantidiasis

The intestinal protozoan Balantidium coli is the only member of the ciliate group that is
pathogenic for humans.

Disease produced by B. coli

is similar to amebiasis,

because the organisms

elaborate proteolytic and

cytotoxic substances that

mediate tissue invasion and

intestinal ulceration.

Fig. 30. Epidemiology and life cycle of B. coli

Clinical features

As with other protozoan parasites, asymptomatic carriage of B. coli can exist.

Symptomatic disease is characterized by abdominal pain, tenderness, tenesmus, nausea,

anorexia, and watery stools with blood and pus.

Ulceration of the intestinal mucosa, as with amebiasis, can be seen; a secondary

complication caused by bacterial invasion into the eroded intestinal mucosa can occur.

Extraintestinal invasion of organs is extremely rare in balantidiasis.