PROTOZOA 1

PROTOZOA  The cyst of E. histolytica contains one, two, or four nuclei because
- A subkingdom consisting of unicellular eukaryotic animals. The various nuclear divisions accompany cyst maturation.
life are carried out by specialized intracellular structures known as  The nuclear structure in stained cysts and in trophozoites is the same. The
ORGANELLES. Each group exhibits morphologic differentiation by cyst of the pathogenic E. histolytica is round and is 10 to 20 µm. It may also
which it can be identified. Most protozoa multiply by BINARY contain cigar-shaped chromatoid bars.
FISSION. However, certain groups have more specialized modes of  E. hartmanni is nonpathogenic and may be confused with E. histolytica. It
reproduction, which are individually discussed. forms cysts of less than 10µm and trophozoites are less than 12 µm in size. A
- Parasites have along coevolution with their host species have evolved calibrated cyst diameters to differentiate these species.
adaptations, such as antigenic variations of their surface proteins, that  Another nonpathogenic species is Entamoeba dispar. Cysts and
permit evasion of the host’s immune recognition and response trophozoites are morphologically identical to E. histolytica, except that E.
mechanism. dispar is noninvasive and never ingests RBCs. Beacuase patients harboring E
- dispar are asymptomatic and may not require treatment, when not trophozoites
THERE ARE THREE MAJOR METHODS OF TRANSMISSION with ingested RBCs are found in submitted specimens, the laboratory report
1) ingestion of the infective stage of the protozoa should say “Entamoeba histolytica/E. dispar – unable to differentiate unless
2) via an arthopod vector trophozoites are seen containing ingested RBCs.”
3) transmitted by sexual contact  Pathology caused by E. histolytica includes flask-shaped ulcerations of
the intestinal wall and bloody dysentery.
THE FOLLOWING GROUPS OF PROTOZOA ARE CONSIDERED:  Liver abscesses are most common and lung invasion usually results from
1. Amebae that move by means of pseudopodia erosion of the liver abscess. Any of these extraintestinal infections can be
2. Protozoa that possess one to several flagella. fatal.
3. Protozoa that move by means of many cilia on the cell surface  The infection can be transmitted sexually by homosexual males and is one
4. Protozoa that have no mode of mobility but can glide cause of the disease known as “gay bowel syndrome.” Up to 30% of some
nonetheless. (This same group uses sexual reproduction during populations of this at-risk group can harbor E. histolytica/E. dispar.
the life cycle.)  Entamoeba coli (a nonpathogenic ameba) is most commonly confused
with E. histolytica.
CLASS LOBOSEA  The nucleus of E. coli differs from E. histlytica; it has a large eccentric
karyosome and irregular peripheral chromatin clumping along the nuclear
 AMEBAE in the order Amoebida, which include parasites of humans, membrane.
can be found worldwide.  Entamoeba polecki, found primarily in pigs and monkeys, is occasionally
found in humans. It closely resembles both E. histolytica and E. coli
STAGES OF AMOEBA: morphologically. Great care is needed when identifying this organism because
it is not pathogenic and unnecessary treatment results if it is incorrectly
1) TROPHOZOITE (feeding stage)- motile, reproducing, feeding stage differentiated as E. histolytica.
lives most commonly in the lower gastrointestinal tract.  Entamoeba gingivalis, found in the mouth in soft tartar between teeth or
2) CYSTIC STAGE (non-feeding stage)- non motile, non feeding stage in tonsillar crypts, is considered nonpathogenic, but occasionally it can be
and is the infective stage for humans. found in sputum and must be differentiated from E. histolytica. Two important
features help in this regard: E. gingivalis has no cyst stage and it is the only
MODE OF TRANSMISSION: is generally by ingestion of cysts in contaminated species known to ingest white blood cells.
food or water. When cysts are swallowed and pass to the lower intestine, they excyst  Two common nonpathogenic species also found in the intestinal tract
and begin to multiply as feeding trophozoites. include Endolimax nana and lodamoeba butschlii. These organisms must be
 Cysts of amebae may have varying numbers of nuclei, depending on their differentiated from pathogens to avoid misdiagnosis and mistreatment.
stage of development; therefore, it is critical to look at nuclear structure as  Blastocystis hominis is a strictly anaerobic intestinal protozoa that has
well as numbers for correct identification. been variously classified since its discovery in 1912. Fetal-oral transmission
through contaminated food or water is probably the route of infection.
DIAGNOSIS: A permanent stain-such as the trichrome stain used on a thin, fixed  Blastocystis hominis’s variable pathogenicity may be explained by
fecal smear-is particularly helpful in allowing identification of nuclear and other variations in the different strains, each causing different symptoms.
intracellular structures and is highly recommended as a ROUTINE PROCEDURE Metronidazole is the drug of choice when treatment is needed.
IN A DIAGNOSTIC LABORATORY.  When present, B.hominis protozoa are easily recovered and are identified
using the trichrome stain. The organism is round and varies greatly in size
OTHER DIAGNOSTIC FEATURES: from 6 to 40 µm in diameter. When fecal samples are being processed, only
A. TROPHOZOITES features: saline or formaline should be used to wash the specimen because water
1) size 2) cytoplasmic inclusions 3) type of motility exhibited by the destroys B. hominis, causing a false-negative report. Organisms are reported as
pseudopodia formed by trophozoites in a water-mount preparation “rare, few, moderate, many or packed” as viewed on the stained smear.
 Several species of free-living amebae may become opportunistic parasites
B. CYST features: of humans. These organisms are found in fresh or salt water, moist soil, and
1) size decaying vegetation.
2) shape of the cyst  The notable potential pathogens are Naegleria fowleri and, less
3) the number of nuclei commonly, Acanthamoeba spp.Naegleria is an ameboflagellate because in the
4)other inclusion bodies present. free-living state it alternates from an ameboid phase to a form possessing two
flagella. Only the ameboid phase is found in host tissues.
EXAMPLES OF AMOEBA:  The disease caused by N. fowleri occurs most often during the summer
1.ENTAMOEBA HISTOLYTICA months (see N. fowleri life cycle).
- is the major pathogen in this group  It then migrates along the olfactory nerves and, within several days,
- the cause of amebic dysentery in humans invades the brain.
- It can occur in other primates, dogs, cats, and rats.  This parasites is highly thermophilic and survives at water temperatures
 The nucleus of E. histolytica has a small central karyosome (endosome) up to 113°F.
and uniform peripheral chromatin granules lining the nuclear membrane.  It also tolerates chlorinated water and has even been found in an indoor
swimming pool. Infections have been acquired by drinking unfiltered,
PATHOGENESIS: chlorinated tap water.
 Upon infection, the clinical symptoms are dramatic and the disease runs a
1. Entamoeba histolytica – a pathogenic species that in invasive and penetrates rapid and usually fetal course.
the tissues wall and multiplies in the mucosal tissue.  Symptoms of primary amebic meningoencephalitis (PAM) begin with
- In the cytoplasm of the trophozoite – visible are the Red Blood Cells headache, fever, nausea, and vomiting within 1 or 2 days.
(RBCs);  Typical symptoms meningoencephalitis follow, leading to irrational
the trophozoite voraciously feeds on RBCs when it is invasive in tissue. behavior, coma and death. The clinical course rarely lasts more than 6 days.
 The trophozoite of E. histolytica extends thin, pointed pseudopodia and Because of the rapid course of this disease, all examinations of fluids should
exhibits active, progressive motility in a saline wet mount. be considered stat (high priority) procedures.
 2 PROTOZOA

 Diagnostic is often made on autopsy; however, a purulent spinal fluid

containing high numbers of neutrophils (200 t0 20,000/µL) without bacteria
should add amebic meningoencephalitis to the differential diagnostic.
 A drop of unrefrigerated spinal fluid sediment should be examined on a
clean glass slides for parasite motility because the organism resembles a
leukocyte when observed on a counting chamber.
 Trophozoites may also be seen in Wright-stained cytospin preparations.
 Its ameboid form is elongated with a tapered posterior and ranges from 7
to 20 µm.
 The rounded form is 15 µm with a large central nuclear karyosome and
granular, vacuolated cytoplasm.
 Treatment is usually unsuccessful; however, when given promptly,
amphotericin B and sulfadiazine have been effective in a very few cases.
 At least six species of Acanthamoeba are known to cause granulomatous
amebic encephalitis (GAE), a more chronic form of meningoencephalitis (see
Acanthamoeba spp. Life cycle).
 Infected patients often have compromised immunologic systems.
 Onset of symptoms is slow – usually weeks to months or even years.
 Chronic granulomatous lesions in brain tissue may contain trophozoites
and cysts.
 Acanthamoeba have been isolated from the upper respiratory tract of
healthy individuals and seem to grow best in the upper airways of susceptible
patients.
 infections occur through either inhalation of contaminated dust or
aerosols or through invasion of broken skin or mucous membranes.
 These parasites have been found in the lungs, nasal and sinus passages,
eyes, ears, skin lesions, and vagina.
 There have also been several hundred cases of Acanthamoeba keratitis
related to poor contact lens care. Direct examination of a patient’s cornea using a
confocal microscope can aid in diagnosing A. keratitis. Direct examination and
culture of corneal scrapings can also lead to a correct diagnosis.
 A related ameba, Balamuthia mandrillaris, has been reported as another
causative agnet of GAE. It is rare, however, it as also been found in
immunocompetent children. This parasite has been found in many primates (e.g.,
gorillas, gibbons, monkeys) and sheep and horse. One-third of the few cases
reported in the United States were in patients with AIDS.
 Cysts of Acanthamoeba spp., like Naegleria spp., are also resistant to
chlorination and drying Acanthamoeba spp. trophozoites have spinelike ACANTHAMOEBIA SPP. (GRANULOMATOUS AMEBIC ENCEPHALITIS)
pseudopodia but are rarely seen motile. They average 30 µm and have a large
central karyosome in the nucleus. The 10- to 25-µm cyst is round with a single
nucleus and has a double wall; the outer cyst wall may be slightly wrinkled with
a polyhedral inner wall. Acanthamoeba spp. vary in sensitivity to antimicrobial
agents. Treatment of Acanthmoeba keratitis is often successful but only rare
cases of central nervous system (CNS) infections have responded to therapy. In
vitro studies suggest that B. mandrillaris is susceptible to pentamidine
isothiocyanate.

PROTOZOA

ENTAMOEBA HISTOLYTICA (AMEBA)

 PROTOZOA 3

ENTAMOEBA HISTOLYTICA (AMEBA) Comparative Morphology of Intestinal Amebae and Others

Method of Diagnosis:
Recover and identify trophozoites or cysts in feces or intestinal mucosa.
Specimen Requirements:
1. At least three fresh stool specimens should be examined for the presence of
parasites. A permanently stained smear and a concentration procedure must be
performed on each specimen submitted for examination. A saline mount may be
performed on a fresh liquid or very soft stool to observe trophozoite motility.
Successful interpretation of saline mounts requires immediate examination of the
specimen. Because this may not be convenient, it is often preferable to place a fresh
stool into a preservative and transport the sample to the laboratory.

2. Six permanent smears from different sites should be prepared while a

sigmoidoscopy is being performed.

3. Antigen-based immunoassays on fresh or frozen fecal samples provide a useful

and direct method of demonstrating infections with this parasites.

4. Serologic methods are most useful in extraintestinal diseases.

Diagnostic Stage:

Disease Names:
 Amebiasis
 Amebic dysentery
 Amebic hepatits (if liver is involved)

Major Pathology and Symptoms:

Patient may be asymptomatic or exhibit vague abdominal discomfort,

malaise, diarrhea alternating with constipation, or bloody dysentery and fever (in
cases of acute illness). The pathogen invades the intestinal submucosa via lytic
enzymes in 2% to 8% of infections; lateral extension leads to typical flask-shaped
lesions. In amebic hepatitis, there is an enlarged liver, fever, chills, and leukocytosis.

Treatment:
Depending on the location of infection, iodoquinol, paromomycin,
metronidazole, dehydroemetine, and combinations. All positive cases should be
treated.

Distribution: Comparative Morphology of Opportunistic Amebic Pathogens of the Central

Distribution is worldwide. Nervous System
Of Note:
1. Chronic infection may last for years.

2. Although the pathogenic E. histolytica and the non-pathogenic species E. dispar

can be differentiated definitively using appropriate fecal immunoassay methods or by
using DNA probes, it is acceptable to use the finding of ingested RBCs as a means of
identifying E. histolytica.

3. Onset of invasive disease may be gradual or sudden and is characterized by blood-

tinged mucous dysentery with up to 10 stools per day. Severe, sudden-onset cases
may mimic appendicitis.
4. It must be differentiated from ulcerative colitis, carcinoma, other intestinal
parasites, and diverticulitis. Also, the hepatic form must be differentiated from
hepatitis, hydatid cyst, various gallbladder problems, cancer, and lung disease.
SUPERCLASS MASTIGOPHORA
5. Amebae can invade the lungs, brain, skin, and other tissues. Amebic hepatitis is
the most common and gravest complication. Usually, only a single abscess develops
in the right lobe of the liver. Any of the various imaging techniques reveals the Falgellates in the class Zoomastigophorea include the pathogenic protozoa that
abscess. inhabit the gastrointestinal tract, atria, bloodstream, or tissues of humans. The
6. This parasite has been added to the list of sexually transmitted diseases. pathogenic gastrointestinal flagellates include two species: Giardia lamblia and
Comparative Morphology of Intestinal Amebae and Others Dientamoeba fragilis. Two common nonpathogenic species also found in the
 4 PROTOZOA

intestinal tract are Chilomastix mesnili and Pentatrichomonas hominis. These 3. Be sure to examine areas of mucus in feces for the possible presence of
organisms must be differentiated from the pathogens to avoid misdiagnosis and parasites.
mistreatment. Trichomonas vaginalis is the only pathogenic atrial protozoan that 4. The string test may be helpful if fecal examinations are negative.
inhabits the vagina and urethra. 5. Antigen-based immunoassays on fecal samples provide a useful and direct method
of demonstrating infections with this parasite. Fecal immunoassays provide more
G. lamblia is the most common intestinal flagellates, it is important to differentiate sensitive detection of this parasite than conventional diagnostic methods, but the
G. lamblia from the several nonpathogenic flagellates that can be found in the limitation is that only Giardia will be detected and other parasites would be missed if
intestinal tract. The cyst and the trophozoite are illustrated on pages 83 and 84. The stained slides are not examined.
trophozoite of G. lamblia (10 to 20 µm x 5 to 15 µm) is bilaterally symmetric and PROTOZOA: GIARDIA LAMBLIA (FLAGELLATE)
has two anterior nuclei and eight flagella. A sucking disk concavity on the ventral
side is the means of attachment to the intestinal mucosa.

The cysts oval, with two or four nuclei located at one end. The clustered nuclei and
the central axoneme give the cyst the appearance of a little old lady wearing glasses.
The cytoplasm of the cyst stage is often retracted from the cyst wall, leaving a clear
space under the wall. This parasites has often been associated with traveler’s
diarrhea, and trophozoites and cysts can be found in the diarrhea feces along with
unusual amounts of mucus. These are not tissue invaders; however, prolonged heavy
infection may result in malabsorption by the intestinal mucosa. Transmission is by
ingestion of the cyst stage fecally contaminated water or food.

D. fragilis also has been associated with cases of diarrhea. It lives in the cecum
and colon and does not form cysts; the method of transmission is uncertain. The
trphozoite has two nuclei connected by a division spindle filament. It has no
observable flagella but is classified in the flagellate order Trichomonadida. It moves
by means of pseudopodia when seen in feces. The trophozoite is 6 to 20 µm and
exhibits sluggish nondirectional motility. D. fragilis may occasionally have more or
fewer than two nuclei in the trophozoite stage; therefore, it could be confused with
developing cysts of Endolimax nana or other ameba.

T. vaginalis multiplies in the genitourinary atrium of both men and women. Usually,
only women exhibit symptoms, whereas men serve as asymptomatic carriers.
Transmission of T. vaginalis is direct and generally by sexual intercourse.
Trichomonad species do not form cysts. Motile trophozoites may be identified in
fresh urine or in a saline preparation of urethral or vaginal discharge by its Disease Names:
characteristic structure, jerky motility, and the “rippling” motion of its undulating  Giardiasis
membrane. It has a large anterior nucleus, four anterior flagella, an axostyle, and an  Traveler’s diarrhea
undulating membrane. Men are usually asymptomatic; thus, all sex partners should
be treated to prevent reinfection. Major Pathology and Symptoms:
Symptoms include abdominal pain, foul-smelling diarrhea, foul-smelling gas
(known as the “purple burps” and smells like rotten eggs), and mechanical irritation
of intestinal mucosa with shortening of villi and inflammatory foci. Malabsorption
syndrome may occur in heavy infections. People with an IgA deficiency may be
more susceptible. Unlike bacillary dysentery, stool does not contain re or white blood
cells.

Treatment:
1. Quinacrine
2. Metronidazole or furazolidone

Distribution:
Distribution is worldwide

Of Note:
1. Outbreaks have been related to cross-contamination of water and sewage
systems and contamination of streams by wild animals, such as beavers,
that serve as reservoir hosts.
2. Travelers to endemic areas (e.g., St. Petersburg, Russia; some areas of the
United States) experience severe diarrhea on infection, but permanent
residents of the endemic areas generally do not exhibit symptoms.
3. Increased numbers of gay men harbor this infection.

PROTOZOA: GIARDIA LAMBLIA (FLAGELLATE)

Method of Diagnosis:
Recover and identify trophozoites or cysts in feces or duodenal contents.

Specimen Requirements:
1. At least three stool specimens should be examined for possible parasites.
Because trophozoites adhere to the duodenal intestinal mucosa via their
sucking disk, there may be intermittent shedding of organisms; therefore,
more than three specimens may be required to diagnose this infection.
2. A permanently stained smear for each specimen should be prepared and
examined.
 PROTOZOA 5

DIENTAMOEBA FRAGILIS (INTESTINAL FLAGELLATE)

Method of Diagnosis:
TRICHOMONAS VAGINALIS (ATRIAL FLAGELLATE)
Identify trophozoites in feces (no cyst stage known).
Method of Diagnosis:
Recover and identify motile trophozoites in fresh urethral discharge, vaginal
smear, or urine. T. vaginalis can be recognized in a Papanicolaou-stained cervical
smear. Rapid point-of-care testing is available. These tests are
immunochromatographic capillary flow assays.

Specimen Requirements:
1. At least three stool specimens should be examined for parasites.
2. A permanently stained smear for each specimen should be prepared and
examined for trophozoites.
3. Trophozoites can be found in formed stools

Diagnostic Stage:
Dientamoeba fragilis

Specimen Requirements:
1. Fresh vaginal or urethral discharges or prostatic secreations are examined
as a wet mount diluted with a drop of saline. Note jerkey, “rippling”
pattern of motility.
Major Pathology and Symptoms: 2. Several specimens may be needed before diagnosis is confirmed.
Disease is usually asymptomatic but it may be associated with diarrhea, anorexia,
and abdominal pain. Disease Names:
 Trichomonad vaginitis
Treatment:  Urethritis
Iodoquinol,  Trich
Tetracycline,
or Paromomycin Major Pathology and Symptoms:
1. In women, the following symptoms are common:
Distribution: a. Persistent, vaginal inflammation
Distribution is worldwide. b. Yellowish, frothy, foul-smelling vaginal discharge
c. Burning on urination
Of Note: d. Itching and irritation in the vaginal area
1. A fairly high association between Enterobitus vermicularis and D. 2. In men, the disease is generally asymptomatic.
fragilis infections has been noted. These findings suggest that D. fragilis
may also be transmitted via pinworm eggs. PROTOZOA:
2. No cyst stage is known for this parasite. TRICHOMONAS VAGINALIS (ATRIAL FLAGELLATE)
3. Most organisms (60% to 80%) have two nuclei and 20% to 40% will have
only one nucleus. Treatment:
4. This parasites may be difficult to identify because the nuclear chromatin Metronidazole
may appear as fragmented dots, which in turn may cause it to resemble
other organisms such as E. nana, E. hartmanni, or Chilomastix mesnili, Distribution:
leading to misidentification. Distribution is worldwide
5. In some geographic areas (even within the United States), D. fragilis is
more common than G. lamblia and the infection is no limited to the Of Note:
pediatric population. T. hominis may be found as a fecal contaminant in urine samples being examined
for the presence of T. vaginalis. Care must be exercised in correctly identifying these
organisms, especially in samples from children, so that issues such as potential child
abuse can be correctly managed.
 6 PROTOZOA

internal organs and eventually causing death if the patient is untreated. In

tissue sections (e.g., liver, spleen), L. donovani can be seen as an
intracellular multiplying amastigote form (L.D. body). All species of
NONPATHOGENIC INTESTINAL FLAGELLATES Leishmania that infect humans are zoonotic; the usual host is a vertebrate,
such as a dog, fox, or rodent.

Trypanosoma brucei rhodensiense (east african sleeping sickness) and

trypanosoma brucei gambiense (west african sleeping sickness)

Method of Diagnosis:
Examine fluid from bite site chancre or buffy coat of blood for trypomastigotes
during febrile period. Thick blood smears increase the chance of diagnosis. Multiple
whole-blood specimens may be needed. Thick and thin blood smears are stained with
Giemsa or Wright’s stain. Late in the infection, trypomastigotes are best found in the
KINETOPLASTIDA lymph nodes or cerebrospinal fluid (CSF). Concentrating CSF by centrifugation may
 In the order Kinetoplastida, the pathogenic Trypanosoma and Leishmania increase the chance of recovering parasites. Animal inoculation (mice or young rats)
flagellates are found multiplying in the blood (hemoflagellates) or tissue may be helpful; trypomastigotes in patient’s blood multiply in the animal and then
of humans. All species require an arthropod intermediate host. These may be detected more easily.
hemoflagellates exhibit varying morphology in specific locations in both
humans and arthopods. Diagnostic Stage:
 In the genus Trypanosoma, two subspecies – T. brucie rhodesiense and T. Trypomastigote
brucei gambiense – cause East and West African sleeping sickness, Form in plasma
respectively. These disease are transmitted by the tsetse fly intermediate
host (Glossina spp.). Organisms are injected when the infected fly takes a
blood meal. The trypomastigote form can be found extracellularly in a
human blood smear in the plasma, in tissues such as lymph-node biopsies,
or in the CNS late in the disease.
 The species T. cruzi, primarily found in Central and South America and
more recently in the southwestern United States and Mexico, causes a
debilitating condition known as Chagas’ disease. T. cruzi is transmitted
by the Triatoma spp. bug (also known as the kissing bug, reduviid bug,
cone nose bug or in South America the vinchuca bu) intermediate host.
When the Triatoma takes a blood meal, infective organisms are deposited
on the skin in the feces of the bug and are rubbed into the wound when
the itching bite site is scratched. T. cruzi organisms multiply in
macrophages of the reticuloendothelial system and are found multiplying
as the amastigote form in tissues such as the heart. However, Note:
trypomastigote forms may be found in the bloodstream early during the Trypomastigote form may be seen dividing in peripheral blood
infection. Chagas’ disease can result in an enlarged heart, esophagus, and
colon. Eventually, death may occur if the disease is untreated. In children, Major Pathology and Symptoms:
an acute fatal disease course is not uncommon. Pathology and symptoms for both parasites include the following:
 In the genus Leishmania, there are four pathogenic “species complexes” 1. Lesion at bite site (chancre), usually seen in non-Africans
with subspecies in each complex: L. tropica (Old World), L Mexicana 2. Enlarged lymph nodes, especially posterior cervical chain
(new World), L. braziliensis, and L. donovani. Specification has (Winterbottom’s sign)
traditionally been based on clinical symptomology, geographic location, 3. Fever, headache, night sweats
and case history. All Leishmania species are transmitted by the sandfly 4. Joint and muscle pain
intermediate host, Phlebotomus spp. The bite of an infected sandfly 5. CNS impairment in 6 months to 1 year with T.b. gambiense or in 1 month
initially results in a self-healing skin lesion at the bite site; the lesion may with T. b. rhodesiense
last up to 1 year and may be a wet or dry ulcer, depending on the species. 6. Lethargy and motor changes
Amastigote forms can be found multiplying intracellularly in local 7. Coma and death; death from cardiac failure may precede CNS symptoms
macrophages of the lesion. L. tropica and L. Mexicana cause cutaneous, in T.b. rhodesiense
spontaneously healing ulcers, although some subspecies of L. Mexicana
spread to cause a disfiguring form, diffuse cutaneous leishmaniasis Treatment:
(DCL). L. braziliensis affects the mucosa of the nasopharynx and mouth. Treatment depends on the phase of the disease:
In addition, L. braziliensis can become subpatent and flare up years later, 1. Early: suramin or pentamidine
resulting in subsequent erosion of cartilage in the nose and ears. 2. Late: melarsoprol or tryparsamide, when CNS involvement has occurred
 Unlike the others, L. donovani does not stay localized in the skin lesion; 3.
the organisms spread to the viscera, multiplying in macrophages of all Distribution:
 PROTOZOA 7

Distribution is primarily East or West Africa as noted. 2. Symptoms may include fever, weakness, and enlarged spleen, liver, and
lymph nodes.
Of Note: 3. Acute infection (most common in children) results in initial chagoma
1. RBC autoagglutination is commonly observed in vitro. reaction at bite site with periorbital edema if bitten near the eye
2. High levels of both IgM and spinal fluid proteins are characteristic. (Romaña’s sign), cardiac ganglia destruction, megacolon, and often rapid
3. IgM in spinal fluid is diagnostic. death.
4. Enzyme-linked immunosorbent assay (ELISA) method to detect antigen Treatment:
in serum and CSF is useful for clinical staging of the disease and Nifurtimox
evaluating therapy.
Distribution:
Distribution is primarily in Mexico, Central America, and South America;
Trypanosoma cruzi (Chagas’ disease) seropositivity rates range from 60% to 70% in Brazil and Bolvia. It may be the cause
of 30% of adult in Brazil and Bolivia. Increasingly, more cases are being reported in
Methods of Diagnosis: Texas, California, and other parts of the Southwest.
1. Find amastigotes in stained tissue scraoing of skin lesion (chagoma) at
bite site. Of Note:
2. Identify C-shaped trypomastigotes in blood smear during acute 1. Many animals serve as resrvior hosts in the warmer southwestern states of
exacerbation of symptoms. north America
3. Allow uninfected bugs to feed on patient, then later examine bug feces for 2. Triatoma spp. feed at night on warm-blooded hosts, frequently on the
parasite (xenodiagnosis). conjunctiva of the eye.
4. Perform Machado complement fixation test, intradermal test, or indirect 3. T. cruzi can cross the placenta and cause the disease prenatally.
hemagglutination test (serology); endocardial, vascular, and interstitial 4. Autoimmune reaction by antibodies that cross-react with EVI antibodies
(EVI) antibodies present; chemiluminescence, ELISA. may play a role in heart, colon, and esophagus dilation and atony.
5. L.D. bodies (amastigotes) appear in heart muscles postmortem. 5. Donor blood must be tested using two different serologic tests for
6. Culture for epimastigotes in diphasic novy-MacNeal-Nicolle (NNN) evidence of T. cruzi infection.
medium. 6. Nonphatogenic T. rangeli trypomastigotes may be present in humans in
7. Polymerase chain reaction (PCR) using T. cruzi DNA is being used to Central and South America and may confuse diagnosis.
detect the presence of the parasite in chronic cases.

LEISHMANIA TROPICA, L. MEXICANA, L. BRAZILIENSIS, AND

L. DONOVANI SPECIES COMPLEXES (LEISHMANIASIS)

Method of Diagnosis:
 L. tropica and L. Mexicana: identify amastigotes in macrophages of skin
lesion.
 L. braziliensis: identify amastigotes at the periphery of the lesion.
 L. donovani: identify amastigotes in early skin lesion and L.D. bodies
later in reticuloendothelial system, spleen, lymph nodes, bone marrow,
and liver. They are also present in feces, urine, and nasal discharges. The
clinical symptoms of a person in an endemic area are presumptive; bone
marrow smears are helpful. A striking increase in gamma globulin should
be noted; serology, skin testing, culture, and animal inoculations are
helpful.

PROTOZOA:
Trypanosoma cruzi (Chagas’ disease)

Diagnostic Stage:
Pseudocyst containing amastigote stages in heart muscle

Specimen Requirements:
1. Fine-needle aspiration from the base of the lesion using the aseptic
technique is recommended. Several slides should be made and staines
with Giemsa stain.
2. Cultures should be attempted for a complete diagnosis using aspirated
Disease Names: material and a suitable medium, such as NNN
 Chagas’ disease Diagnostic Stage:
 American trypanosomiasis

Major Pathology and Symptoms:

1. In chromic cases, usually in adults, there may be no history of acute
illness, but an enlarged, weakened heart may cause sudden death.
 8 PROTOZOA

Organisms in the Kinetofragminophorea class (phylum, Ciliophora) are

characterized by ectoplasmatic cilia covering the surface, two different kinds of
nuclei (a large kidney-shaped macronucleus and a small micronucleus), and other
well-developed organelles, such as an oral cytostome. Ciliates multiply asexually by
binary fission and also sexually reproduce by conjugation, with exchange of
micronuclei.
Balantidium coli is the largest parasitic protozoom (60 µm x 40 µm) and is the
only ciliate that is pathogenic for humans. B. coli cause dysentery in severe intestinal
infections and can be found in feces in either the trophozoite or cyst state. It is
Disease Names: probable that human infections are directly acquired through ingestion of cysts in
 L. tropica: cutaneous or Old World leishmaniasis, Oriental boil, Baghdad fecally contaminated food or water.
or Delhi boil this parasites is a tissue invader and produces intestinal lesions along the
 L. braziliensis: mucocutaneous or New World leishmiasis, uta, espundia submucosa. There are also reports of vaginal infections with this organism, probably
 L. donovani: visceral leishmaniasis, kala-azar, Dumdum fever acquired by fecal contamination of the vaginal atrium.
Major Pathology and Symptoms:
The type of illness results from immunopathology in specific tissue sites.
1. L. tropica complex: incubation period is several months (L.tropica) or as BALANTIDIUM COLI (CILIATE)
short as 2 weeks (L. major). One or more ulcerated, pus-filled lesions
appear on the body (indurated with macrophages) and are self-healing. Method of Diagnosis:
Lesions often are moist and short-term in rural areas (infection by L Identify trophozoites or cysts in feces or intestinal mucosa.
major lasting 3 – 6 months) or dry and long-lasting in urban areas
(infection by L. tropica lasts 12 to 18 months).
2. L. Mexicana: Symptoms are similar to L. tropica. Two subspecies may cause
DCL.
3. L. braziliensis: Symptoms include a red, itchy, indurated ulcer; lesions may
metastasize along lymphatics and sequester; lesion is self-healing.
Disfigurement of nose and ears may occur years later from chronic
mucosal ulceration. DCL, seen mainly in Brazil, has an absence of cell-mediated
immune reactively. Note: the cause may be L.pifanoi.
4. L. donovani: The incubation period is long. With the initial lesion, short-term,
small papules are at the bite site. Malarialike spiking chills and fever
ensure (however, double fever spikes occur), along with sweating,
diarrhea, dysentery, and weight loss. Splenomegaly and hepatomegaly develop
after leishmania disseminate and multiply in visceral reticuloendothelium.
Hyperplasia of tissue and organs occurs, along with progressive anemia.
Death often occurs within 2 years if untreated (75% to 95% mortality).

Treatment: Sepcimen Requirements:

1. L. tropica complex: (1) antimony (as sodium stibogluconate [Pentostam]), 1. One to three stool specimens are usually sufficient. The large organisms
(2) local heat (three 30-second treatments of 122°F at weekly intervals on can be noted easily under low power (100x).
chancre) 2. Wet mounts of fresh or voncentrated specimens are best. The organisms
2. L. Mexicana: (1) antimony (as sodium stibogluconate [Pentostam]), (2) stain very darkly in permanently stained preparations.
pentamidine isethionate
3. L. braziliensis: (1) antimony (as sodium stibogluconate [Pentostam]), (2) Disease Names:
pentamidine isethionate  Balantidiasis
4. L. donovani: (1) antimony (as sodium stibogluconate [Pentostam]), (2)  Balantidial dysentery
pentamidine isethionate

Distribution:
 L. tropica complex is found in the Mediterraneanarea, southwestern Asia,
central and northwest Africa, Central America, and South America; recent
cases have been seen in Texas (may be L. mexicana).
 L. braziliensis occurs in Central America and South America; the highest
concentration is in Brazil and the Andes. The disease is rural.
 L. donovani occurs primarily in young children in North Africa and East
Africa, Asia, the Mediterranean area, and South America. In India and
Bangladesh, the disease is found primarily in adults.

Of Note:
1. Cutaneous lesion may appear as ulcers, cauliflower like masses, or
nodules.
2. Host’s genetic, nutritional, and immunologic status plays a large role in
pathology.
3. Various animals serve as reservoir hosts (e.g., gerbils and other rodents,
monkeys, and in the New World, dogs). Major Pathology and Symptoms:
4. Vaccination against L. tropica is common in the former Soviet Union. Disease may be asymptomatic. When symptoms occur, they are usually
5. Leishmanin (Montenegro) skin test becomes positive in DCL and kala- abdominal discomfort with mild no moderate chromic recurrent diarrhea or acute
azar only after cured; positive reactions are usually found in cutaneous dysentery. A healthy person is less likely to develop illness.
and mucocutaneous leishmaniasis.
6. Elevated globulin levels are present in visceral leishmaniasis. Treatment:
7. L. tropica is generally transmitted from humans; other parasites in the 1. Tetracycline
complex are primarily zoonoses. 2. Iodoquinol or metronidazole

Distribution:
Distribution is worldwide, especially in the tropics, but the disease is rare in the
CLASS KINETOFRAGMINOPHOREA United States.
 PROTOZOA 9

Of Note: enter the bite site via the saliva of the mosquito and travel to the liver; the
1. Pig feces are regarded as potential source if infection because pigs can life cycle begins again. Malaria can also be transmitted via blood
harbor this parasite. transfusion and from contaminated needles of intravenous drug users.
2. B. coli may invade the intestinal mucosa, spreading horizontal lesions and
causing hyperemia and hemorrhage of the bowel surface. However, the  Drug resistant strains of Plasmodium species and insecticide-resistant
organism does not spread via the bloodstream. strains of mosquitoes have recently and rapidly evolved, posing major
3. This is the largest protozoa and the only ciliated protozoa to infect problems in controlling the spread of this disease worldwide. Control
humans. measures have essentially eliminated the disease from some countries,
including the United States, but it is still a major problem in Africa, Asia,
Central and South America, and areas of Europe, and it could be
CLASS SPOROZOA reintroduced into controlled areas.

 Of the four species included in the life-cycle diagram. P. falciparum is the

most deadly; these parasites promote physiologic changes of the red cell
(which develops a “knobby” surface), which cause agglutination and
lysis. Schizogony takes place in the capillaries and blood sinuses of the
brain, visceral organs, and placenta, with infected cells tending to adhere
to one another and to the surrounding vessel walls. Vessels become
blocked, causing local infaction damage to the regional tissue. Symptoms
vary according to the degree of tissue amoxia and rupture of blocked
capillaries. Many uninfected red cells also lyse during a paroxysm. Host
responses to red-cell also lyse during a paroxysm. Host responses to red-
cell remnant and other parasitic debris lead to more RBC lysis and
enlargement of the spleen and liver. Another complication is renal failure
caused by renal amoxia. The sudden massive intravascular lysis of RBCs,
followed by hemoglobin passage in urine (blacwater fever, or
hemoglobinuria) is related to treatment with quinine in susceptible
individuals. The most severe complication---cerebral malaria---occurs
when blood vessels in the brain become affected. Coma and death may
follow.
 Pathology caused by the other Plasmodium species is less severe,
primarily because these parasites are unable to invade both young and old
 Sporozoan parasites are obligate endoparasitic protozoa with no apparent red cells as are P. falciparum parasites.in addition, the other species do
organelles of locomotion. This class includes some of the most important not cause changes to the red-cell membrane such as those seen with P.
and wide-spread parasites of humans, including those that cause malaria falciparum. Merozoites of P. malariae can invade only older cells; those
and toxoplasmosis 9Table 5-5). Most species produce a spore form that is of P. vivax and P. ovale infect primarily reticulocytes ( immature RBCs).
infective for the definitive host after it is ingested or injected by a biting Inasmuch as these young red-cell populations are small at any given time,
arthropod vector. All genera have a life cycle that includes both sexual the infection is limited.
(gametocyte production and sporogony) and asxual (schizogony) phases  P. vivax is the most widely disseminated and most prevalent parasites
of reproduction. Most have a two-host life cycle. causing malaria. There is repeated exoerythrocytic development in the
liver; therefore P. vivax can caused a relapse, with erythrocytic cycles
 The genus Plasmodium includes the sporozoon than causes human starting again years after the initial infection sequence. This is thought to
malaria. The asexual cycle (schizogony) begins when the infected female result from sequestered hypnozoites in the liver. P. ovale can also cause
Anopheles mosquito (the definitive host) bites a human and injects relapses, but infections with this parasite are usually less severe and often
infective sporozoites, which then enter cutaneous blood vessels. The resolve themselves within 6 to 10 paroxysms.
sporozoites travel via blood and invade liver cells. Each becomes a  A fifth malaria species, known as P. knowlesi, is emerging as an
cryptozoite, reproducing intracellularly by asexual division and forming important parasite. This zoonosis, found in forests of southeast Asia,
many merozoites. This is the exoerythrocytic cycle and is completed in 1 especially Malaysian Borneo, is transmitted from long-tailed (Macaca
to 2 weeks. fasicularis) and pig-tailed (M. nemestrina) macaques to humans by
Anopheles latens mosquitoes. The parasite’s morphology resembles that
 The mecrozoites escape from the lver cells and invades circulating RBCs. of P. malariae, but some forms may also appear similar to ring
Merozoites entering RBCs become trophozoites (also known as ring trophozoite forms of P. falciparum. Rapid diagnostic assays cannot
forms), which then mature through the schizont stage in 36 to 72 hours. distinguish this parasite from other parasitic species so the final diagnosis
Each schizont produces 6 – 24 new mecrozoites. The timing to maturation relies on careful observation of blood smears. Correct identification is
of the scizont and the number of new mecrozoites produced differentiate important because P. malaria generally produces mild or benign disease
the species of Plasmodium. When the schizont is mature, the RBC and P. knowlesi may produce very high parasitemias leading to severe or
ruptures, releasing the merozoites, which invade newRBCs. The cylcle of fatal pulmonary and hepatorenal symptoms.
RBC invasion, schizogony, and cell rupture continually repeats itself,
producing symptoms. This is the erythrocytic cycle: merozoite enters
RBC trophozoite schizont production RBC rupture merozoites
PLASMODIUM SPECIES (MALARIA)
released to penetrate ne RBCs. Each cycle includes a paroxysm when
toxic materials are released from the many ruptured RBCs. The paroxysm
begins suddenly and is characterized by a 10- to 15- minute (or longer)
period of shaking chills, followed by a high fever lasting from 2 to 6
hours or longer. The patient begins sweating profusely as the temperature
returns to normal. The paroxysm is in part an allergic response to released
parasitic antigens.

 Later in the infection, some merozoites develop into microgametocytes

(male sex cells) and macrogamecytes (female sex cells). The sexual cycle
(sporogony) begins when a female Anopheles mosquito (definitive host)
ingests gametocytes as she takes a blood meal from an infected person.
The gametes unite in the stomach of the mosquito, forming a motile
zygote (the ookinete), which then moves through and encysts on the
mosquito’s stomach wall. After further maturation to an oocyst
containing many infective sporozoites, the sporozoites are released from
the oocyst and migrate to the mosquito’s salivary glands. The mosquito
bite is now infective for the next human victim. Infective sporozoites Method of Diagnosis:
 10 PROTOZOA

 Demonstrate and identify trophozoites, schizonts or gametocytes in

peripheral blood. Blood should be drawn immediately when the patient
arrives at the hospital. The initial test must be considered a stat request,
and because early infections may be synchronized, subsequent specimens
should be drawn at 6- to 12- hour intervals. Both thick and thin smears
should be examined. Negative morning and afternoon thick-stained
smears for 3 consecutive days during symptoms indicated absence of
infection. When infections are synchronized, more parasites may be
visible when blood is obtained between paroxysms. Serology is helpful
but is not readily available.
 Although the thick film examination is still considered the gold standard
for malaria diagnosis, several other techniques are used in different parts
of the world.
1. Rapid immunochromatographic dipstick antigen detection assays have Note: Single ring, one-third diameter of RBC. RBC is oval, shows Schuffner’s dots
been developed and may be useful in detecting parasitemia. Once of these
tests is FDA approved in the United States. The disadvantage of this
methodology is that it may not detect early infections with low
parasitemia; therefore, thick film examination should still be performed
before ruling out infection.
2. Fluorescent DNA/RNA stained films using Acridine orange offers a rapid
method to detect parasites but species identification may be difficult.
3. (MERASE) Polymerase chain reaction (PCR) methods have been
available for some time but are not commonly used due to the complexity
and expense of the procedure. These methods provide an excellent
method for detecting and resolving mixed infections.

Specimen Requirements:
Ethylene-diamine-tetraacetic (EDTA) acid preserved whole blood is preferred if
anticoagulants are used for collection but smears should be made within 1 hour
because true stippling of immature RBCs may not be retained (e.g., P. vivax).
Giemsa stain is preferred but parasites are visible when stained with Wright-Giemsa
stain.
MAJOR PATHOLOGY AND SYMPTOMS
Diagnostic Stages: Plasmodium falciparum  All cause splenic enlargement, fever and chill paroxysms, pain in the
joints, and anemia from red-cell destruction. Nausea, vomiting, and
diarrhea often are among the initial symptoms seen on admission to the
hospital. Malaria pigment is deposited in tissues. P. falciparum infection
can cause high fever, bloody urine, massive hemolysis, brain damage
from clumping of RBCs, resultant blocking of capillaries, and subsequent
rapid death. P. falciparum infection also can result in severe blackwater
fever and renal failure. A sudden life-threatening respiratory distress
syndrome may also occur with P. falciparum. High IgM and IgG levels
suggest current or recurrent malaria infection; elevated IgG alone
indicates past infection. Quartan malaria nephropathy is
immunopathological from immune complex deposition in kidneys.
 Suspicion must be high and response must be rapid for the diagnosis of
malaria when a patient who has visited or lived in a malarious area shows
Diagnostic Stages: Plasmodium malariae symptoms of this disease. Death can occur quickly if treatment is delayed.

Treatment:
Chloroquine, quinine, pyrimethamine, sulfadiazine, and tetracycline

Distribution:
 P. falciparum and P. malariae are found in the tropics.
 P. vivax is found in the tropics, subtropics, and some temperate regions; it
is the most prevalent malaria species.
 P. knowlesi is found in southeastern Asia.
 P. vivax and P. falciparum account for more than 95% of infections.

Diagnostic Stages: Plasmodium vivax Of Note:

1. P. vivax and P. ovale may cause relapses years later because of secondary
exoerythrocytic cycles (hypnozoites in liver); primaquine is used to kill
the liver-phase organisms of malaria.
2. P. vivax and P. ovale invade reticulocytes preferentially; therefore,
counterstaining blood for reticulocytes can aid identification.
3. As many as 70% of African Americans and West Africans are negative
for the Duffy blood group, which may be related to resistance to P. vivax
infection in the indigenous people. Inherited glucose-6-phosphate
dehydrogenase deficiency and hemoglobin gene alterations (e.g., sickle
cell inheritance) may play an evolutionary role in survival o humans in
endemic areas, inasmuch as these genetic variants are incompatible with
parasite survival.

Note: Single ring, one-third diameter of an RBC; invades only immature RBCs so
that large bluish-staining cells are parasitized, RBC shows red-stained Schuffner’s
dots, which become visible between 15 and 20 hours following invasion of the cell. 4. Presence of P. falciparum schizonts in peripheral blood indicates very grave
Trophozoite is very ameboid and assumes bizarre shapes during early schizogony. prognosis.
 PROTOZOA 11

5. P. malariae infections may cause a recrudescence or series of recrudescences 2. Patients may acquire concomitant infection with Borrelia burgdorferi
for many years because of low-grade parasitemia. (Lyme disease) or Ehrlichia spp. (human granulocytic ehrlichiosis)
6. Malaria is primarily a rural disease; its incidence is significantly increasing because these organisms are transferred by the same insect vector.
because of drug-resistant malaria strains, insecticide-resistant mosquitoes, and
inadequate resources to prevent infection from spreading. PROTOZOA: SUBCLASS COCCIDIA
The next three genera of sporozoa belong to the subclass Coccidia. Schizogony
PROTOZOA: BABESIA SPECIES occurs in various nucleated cells of many species of mammals and birds, and
 Ticks, especially Ixodes dammini in the northeastern United States, are sporogony occurs in the intestinal mucosa of the definitive host. Infective oocysts are
the definitive hosts for the sporozoa of the Babesia species (subclass passed in feces. Infection occurs when a susceptible host ingests mature oocysts
Piroplasmia). Occasional tick-transmitted human infections have been containing sporozoites.
reporte. In the human intermediate host, the organisms multiply in RBCs.
Trophozoites are generally pear-shaped (2 to 4 µm), lying in pairs or PROTOZOA: COCCIDIAN PARASITES
tetrads. Unlike malarias, extracellular trophozoites may occasionally be
observed. Clinical signs follow the bite of an infected tick in about 2 to 3
weeks and resemble symptoms of malaria, including nonsynchronous
fever, chills, sweats, anorexia, and myalgia. There may also be hemolytic
anemia and mild spleen and liver disease. Although most infections are
subclinical, more severe cases may exhibit renal failure, disseminated
intravascular coagulation, and respiratory syndrome.
 Studies comparing disease symptoms found in patients in the northeastern
United States with those found in patients in California indicate that more
than one species of Babesia causes disease in humans. Cases in the
Northeast are usually caused by B. microti and commonly produce mild
or subclinical disease, although several patients have died. Infected
individuals in California and in other parts of the world often present
fulminant, febrile, hemolytic symptoms, especially in splenectomized or
immunocompromised patients. Babesia spp. infections have been
transmitted through blood transfusions.
 Two other species, B. bovis and B. divergens, found in cattle have
infected humans in the United States and Europe and have been
associated with the infections in splenectomized or immunocompromised
patients. An unknown number of wild animals may also serve as reservoir
hosts for these and other species of this parasite. Human carriers probably Toxoplasma gondii
exist as indicated by cases related to transmission through blood

transfusions.
 Toxoplasma gondii is a sporozoan parasites that infects and undergoes
schizogony in all nucleated cells of almost all animals and birds. The
Method of Diagnosis:
domestic cat and other members of Felidae, however, have been cited as
The diagnosis is made by examination of multiple thin and thick blood smears.
the only definitive host for this parasites. In the cat, it is an intestinal
Parasites in RBCs usually lie in pairs at an acute angle or as a tetrad in a Maltese
parasite, with both schizogony and sporogony occurring in the intestinal
cross formation, although they are rarely observed. As many as four of five ring
mucosa (the enteric cycle). The cat becomes infected by eating infective
forms per erythrocyte may be seen in babesiosis. Care must be taken not to confuse
oocysts (viable for up to 1 year in moist soil), by eating tissues of infected
Babesia spp. with malarial ring forms of Plasmodium, especially P. falciparum,
small animals, or by being infected transplacentally. Oocysts are shed in
which often has multiple small ring forms in RBCs. When absolute species
cat feces and these become infective within several days for a variety of
identification is impossible, it is advisable to add the statement that “Plasmodium
vertebrate intermediate hosts, including humans. Humans become
falciparum cannot be excluded” to the laboratory report. Blood samples from
infected by ingesting the infective oocyst in contaminated food or drink or
infected patients can be injected into hamsters or gerbils; the animal’s red cells will
by accidental hand-to-mouth transmission of contaminated soil or cat
show infection. Paired sera tested against infected hamster RBCs using an indirect
litter.
fluorescent antibody method can be helpful in diagnosing chronic infections as well.
 Initially, toxoplasma divides mitotically in the tissues of humans as
tachyzoites, which assume a crescent-like appearance when seen in tissue
fluids. Infected tissue cells die, releasing free tachyzoites that invade new
BABESIA MICROTI cells. In late or chronic infections, cysts (formerly called pseudocysts)
form in brain and other tissues. These cysts contain Toxoplasma
bradyzoites and may remain viable for long periods, being held in check
by the host’s immune system.
 The infection in humans is usually asymptomatic; however, it may be
highly symptomatic in early infections and can mimic several other
infections, such as infectious mononucleosis. A serious concern is that
Toxoplasma may be transmitted across the placenta to the fetus in a
woman who acquires her first infection during the pregnancy. It can cause
death of the fetus or mental retardation or blindness later in the child’s
life.
 In addition to ingestion of oocysts from cat feces or from transplacental
infecton, the most common source of infection for humans is ingeastion
Specimen Requirements:
of under-cooked meat (especially sheep, pigs, and rabbits) containing
 Whole blood or capillary blood may be used.
calcified cysts. Rarely, goat’s milk containing tachyzoites can be a source
 Giemsa stain is preferred but parasires are visible when stained with
of infection. Transmission can also occur through blood transfusions and
Wright’s stain.
organ transplantation. The letter event is more serious because the organ
Treatment:
recipient will be immunocompromised and unable to respond to the
1. Clindamycin and quinine
disease.
2. Chloroquine phosphate, which provides symptomatic relief but does not
 Toxoplasma gondii
reduce the eparasitemia.
Method of Diagnosis:
Of Note:
1. Serologic testing: Sabin-Feldman dye test, latex agglutination, various
1. Automated differential counting instruments can lead to diagnostic
fluorescent antibody methods, ELISA. A 16-fold increase in IgG antibody
problems because these machines are not designed to detect bloodborne
in a second sample taken 21 days later indicates an acute infection.
parasites such as malaria or Babesia spp. Therefore, infections may be
Differentiatetion of acute and chronic infections is complex and requires
missed, especially if the affected individual is asymptomatic.
testing for both IgG and IgM antibodies.
 12 PROTOZOA

2. Tissue biopsy or impression smears stained with Giemsa stain. microgametocytes join to become mature gametes. Sexual unionforms an
Bradyzoites are strongly periodic acid-Schiff (PAS) positive. oocyte, which then develops into an oocyst.
3.  The entire life cycle can occur within a single host because oocysts are
Treatment: auto-reinfective. External infection is probably acquired from food or
1. Pyrimethamine and sulfadiazine (add folinic acid in an water contaminated with oocysts from feces of animal reservoir hosts,
immunosuppressed host) such as calves. Human-to-human transmission occurs and nosocomial
2. Spiramycin infections have also been reported. The oocysts are immediately infective
when passed in feces. The oocyst is 4 µm and contains four sporozoites.
Sarcocystic spp  Human infection, first reported in 1976, was though to be uncommon and
 Two species of Sarcocystis (formerly known as Isospora hominis in was found primarily in patients with compromised immune systems.
humans) --- S. hominis (from cattle) and S. suihominis (from pigs) --- Since then, many more cases have been reported in many populations
have a life cycle similar to that of Toxoplasma. Humans, dogs, or cats can worldwide. In 1987, an estimated 13,000 cases of gastroenteritis were
become definitive hosts if they eat uncooked intermediate-host beef or reported in a 2-month period in Carroll Country, Georgia. Of the patients
pork tissue containing sarcocysts. Bradyzoites released from the tested, 34% were found to have Crytosporidium oocysts. Follow-up
sarcocyst invade intestinal cells in these definitive hosts and undergo studies suggested that this parasites caused as many as 54% of these
gametogony, producing infective oocysts. These oocysts can be cases. The source of infection was found to be the country’s public water
recovered from feces. When infected with this parasite, supply.
immunocompromised humans may have severe diarrhea, fever and  Outbreaks in 1993 and 1996 were associated with drinking unpasteurized
weight loss. Oocysts ingested from fecally contaminated food by the apple cider. The apple were probably tainted by exposure to contaminated
intermediate host (cattle or pigs) release sporozoites that go to muscle soil in the first outbreak and by washing apples in fecally polluted water
tissue and form sarcocysts. in the second case. Another outbreak in 1995 was linked to chicken salad
 Humans can also be accidental intermediate hosts by ingesting oocysts that may have been contaminated by a food handler in a home day care
and forming sarcocysts in muscle. Other species of Sarcocystis are found center. Unwashed contaminated green onions were the probably source of
in wild animal reservoir hosts. another earlier outbreak. These events indicate that infections caused by
 The broadly oval oocyst contains two sporocysts, each of which contains this parasite are not rare and often are associated with improperly washed,
four mature sporozoites. The sporocysts, measuring 9 to 16 µm by 8 to 12 fecally contaminated fruits and vegetables.
µm, are commonly seen free in feces. Intact oocysts and individual  The symptom common to all reported cases is acute diarrhea. The disease
sporozoites are rarely seen. is self-limited in patients with normal immune systems and lasts from 1 to
PROTOZOA: COCCIDIAN PARASITES 2 weeks; however, oocysts may be shed intermittently for up to 60 days
 There is one pathogenic coccidian for which the human is the only after the diarrhea has entered. Meticulous handwashing after infection
definintive host and in which both schizogony and sporogony, will reduce further transmission of oocysts. Immunodeficient patients,
accompanied by mild pathology, occur. This species is Cystoisospora such as those with AIDS or people receiving immunosuppressant drugs,
belli. There are no known intermediate hosts in this parasite’s life cycle. often develop chroni diarrhea after infection with Cryptosporidium spp.
Characteristics oocysts can be found in infected human feces. The oocysts Patients with AIDS have also developed respiratory cryptosporidiosis.
of C. belli in a fresh fecal specimen are transparent, measuring 30 µm x
12 µm, and are immature (containing a single mass of protoplasm called Cyclospora cayetanensis
the sporoblast) or, rarely, developing (containing two sporoblasts). Within
18 to 36 hours after feces are passed, each of the two sporoblasts develops  Another coccidian parasite that resembles Crytosporidium spp. is
a sporocyst wall and contains four sausage-shaped infective sporozoites. Cyclospora cayetanensis (formerly called cyanobacterium-like body).
Full maturation takes 4 to 5 days. Infection by this parasite causes a self-limiting diarrhea that may last 3 or
 This parasite is found worldwide and transmission to humans is direct via 4 days; however, relapses often occur over 2 -3 weeks. Antidiarrheal
sporulated oocysts in fecally contaminated food or water. Human preparations provide relief of symptoms and treatment with TMP-SMX
infection can cause anorexia, nausea, abdominal pain, diarrhea, and will reduce the possibility of relapse. Tranmission of this organism
possible malabsorption. appears to be indirect, through contaminated water or food rather than by
direct transfer from person to person. People of all ages can contact this
Cystoisospora (Isospora) belli disease.
 Since 1990, several notable outbreaks have occurred in the United States.
Method of Diagnosis: The first occurred among 21 staff members at a Chicago hospital. The
1. Oocysts are recoverable with zinc sulfate flotation technique and they source of this outbreak was associated with drinking tap water that was
stain well with iodine. possibly contaminated by stagnant polluted water stored in a rooftop
2. Oocysts in polyvinyl alcohol-preserved sediment are difficult to see reservoir.
because the cyst wall is very thin and refractile.  The infection was confirmed in 11 of the 21 cases and symptoms lasted
3. Oocysts of C. belli are undeveloped in fresh feces and retrain the oocyst up to 9 weeks. Later outbreaks reported from 1995 through 1997 were
wall. Although oocysts of Sarcocystis oocysts are smaller and often lose associated with imported raspberries raised on farms in Guatemala.
the cyst wall; single free sporocysts, each containing four mature Although the true cause of the contamination was not conclusively
sporozoites, can therefore be seen in stool samples in Sacrocystis spp. proven, there were definite links between contaminated soil and water and
infections. the fruit. Other cases have been associated with vegetables, such as
Mesclun lettuce and fresh basil. Further study is needed to completely
Specimen Requirements: clarify this parasite’s epidemiology and life cycle.
several routine fecal specimens are usually sufficient.  It is important to differentiate this parasite from Cryptosporidium spp. and
other sporozoa by careful measurement and observation of oocysts
Treatment: recovered in fecal specimens. Oocysts of C. cayetanesis measure 8 to 10
Trimethoprim-sulfamethoxazole (TMP-SMX) µm and are undeveloped, taking 5 to 14 days for sporozoites to develop in
vitro.
Cryptosporidium spp.
Method of Diagnosis:
 Cryptosporidium spp. Has two recognized species C. parvum, found in 1. Oocysts can be recovered using sedimentation techniques but are most
both animals and humans, and C. hominis, found only in humans. The easily recovered by flotation methods and can be observed using phase-
fecal oocysts of these two species are indistinguishable by routine contrast (preferred) or bright-field microscopy. Unstained Cyclospora
microscopy. Crytosporidium spp. differ from other coccidian protozoa spp. appear as glassy, wrinkled spheres. C. cayetanensis does no stain
because they form an intracellular parasitophorous vacuole bounded by well with iodine, trichrome, or iron-hematoxylin. Oocysts autoflouresce
the host-cell membrane near the outer surface of a host intestinal cell. when viewed under a fluorescent microscope; this is a useful diagnostic
These parasites invade the gastrointestinal mucosal surface of many characteristic.
vertebrate hosts, including humans. Both trophozoites and schizonts are 2. Acid-fast stained smears of fecal material are also useful. Stained cells
attached to the host-cell membrane. Eight merozoites develop within the containing Cryptosporidium spp. appear as red spherical bodies
scizont and, on maturation, are released to begin a new schizontic cycle or measuring 3 to 6 µm in diameter, whereas those of Cyclospora spp. (8 to
to initiate a sexual cycle in the intestinal mucosa. Macrogametocytes and
 PROTOZOA 13

10 µm in diameter) range from pink to red and some may contain Method of Diagnosis:
granules or have a bubbly appearance. 1. Diagnosis is accomplished by histology on respective tissues using acid-
Method of Diagnosis: fast and PAS stains or electron microscopy.
3. Antigen-based immunoassays on fresh, frozen, or preserved fecal 2. Modified acid-fat trichrome-stained thin fecal smears may reveal spores.
samples (no PVA) provide a direct method of demonstrating infections Positive controls are necessary.
with Cryptosporidium spp. These assays have high specificity but 3. Chromotrophic and chemiflourescent stains are useful as well.
variable sensitivity; even with this limitation they may be helpful Specimen Requirements:
screening tools during outbreaks. 1. Tissue biopsy materials for processing in histology (best staining with
4. PCR methods are useful in subtyping various Cryptosporidium spp. during PAS, methenamine silver, or acid-fast stains)
outbreaks. 2. Three fecal collections on alternate days; thin smears of unconcentrated
5. Trophozoites, schizonts, microgametocytes, and macrogametocytes of C. fecal material are preferred.
parvum can be distinguished when using the electron microscope to examine Treatment:
smears of biopsy material from the jejunum. No satisfactory treatment is generally available, except for Encephalitozoon
(septata) intestinalis. Albendazole has been used successfully to treat these
Diagnostic Stage of Intestinal Coccidia: infections.
Table 5-7 summarizes the diagnostic features of the intestinal coccida.
Distribution:
Distribution is worldwide.

Of Note:
1. Double infections with Cryptosporidia and Microsporidia are common.
2. Table 5-8 compares that clinicalmanifestations of microsporididal species
in immunocompetent and immunoincompetent patiens.

Specimen Requirements:
Three fecal specimens collected on alternate days are usually sufficient.

Treatment:
 C. belli: TMP-SMX
 C.parvum: paromomycin (experimental)
 Sarcocystis spp.: none for tissue disease; antidiarrheal for intestinal
infection
 C. cayetanensis: TMP-SMX

Distribution:
Distribution is worldwide

PNEUMOCYSTIS CARINII
MICROSPORIDIA
 Pneumocystis carinii is the causative agent of atypical interstitial plasma-
The microsporidia have recently been recognized as tissue parasites in cell pneumonia (PCP). This organism has been included in parasitology
immunocompromised patients. In humans, they are small (1 to 2.5 µm), obligate texts for some time because it was long thought to be a protozoon.
intracellular parasites that can inhabit all body tissues. They consist of seven named  Pneumocystic is now classified as a fungus in the phylum Ascomycota,
genera and one “catch-all” genus (Microsporidium spp.), which is currently used for class Archiascomycetes, order Pneumocystidales. The reader should
species that have not yet been fully described. Other genera include Brachiola spp., consult recent literature for details on this organism.
Enterocytozzon bieneusi, Encephalitozoon cuniculi, Encephalitozoon hellem,
Encephalitozoon (Septata) intestinalis, Nosema connori, Pleistophora spp.,
vittaforma corneae, and Trachipleistophora hominis. These organisms inject
infective contents (sporoplasm) from the spore into the host cell through a small
polar tube. The organism multiplies inside the host cell by binary fission (merogony)
or multiple fission (schizogony) and sexual reproduction (sporogony).

Spores are produced with thick walls and, for E. bieneusi, are released into the
intestine and passed in stool. Other hosts become infected by ingesting spores.
Spores are resistant to the environment and some infections may be acquired by
inhaling spores. Microsporidia have been found in the CNs, eyes, lungs, kidney,
myocardium, liver, and adrenal cortex and have been associated with other diseases,
such as leprosy, tuberculosis, schistosomiasis, malaria, and Chagas’ disease.
Infection be E. bieneusi is the most common microsporidial infection found in
patients with AIDS. E. bieneusi infections are also found in immunocompetent
individuals, causing a self-limited diarrheal disease that resolves within 2 weeks.
Encephalitozoon cunticuli and E. hellum are most frequently associated with eye
infections.
14 PROTOZOA