 Structure

Protozoa  Cytoplasm
 Ectoplasm – outer homogenous part that serves as the organ for locomotion and
for engulfment of food by producing pseudopodia
General Characteristics  Endoplasm - the inner granular portion of cytoplasm that contains nucleus.
 Protozoa comes from the Greek words protos = first; and zoon = animals  Nucleus
 Single-celled eukaryotic microorganisms belonging to kingdom Protista  The nucleus contains one or more
 Most are completely pathogenic, but few may cause major diseases such as malaria, nucleoli or a central karyosome
leishmaniasis, and sleeping sickness.  The chromatin may be distributed
 Some are considered opportunistic pathogens along periphery or as a condensed
 It exhibits wide range of size (1-150µm), shape, and structure; yet all possess essential mass around the karyosome
common features  Karyosome - a DNA-containing body,
situated peripherally or centrally
within the nucleus and found in
intestinal amoeba

 Reproduction
 Asexual Reproduction
 Binary fission – method by which a single parasite divides either longitudinally or
transversally into two or more equal number of parasites.
 Multiple fission (schizogony) – method in which nucleus undergoes several
successive divisions within the schizont to produce large number of merozoites
 Endodyogeny – method in which some protozoa multiply by internal budding,
resulting in the formation of two daughter cells
 Sexual Reproduction
 Conjugation – method in which two organisms join together and reciprocally
exchange nuclei material
 Gametogony (syngamy) - male and female gametocyte are produced, which after
fertilization form the zygote, which gives rise to numerous sporozoites by
sporogony
Protozoa Metazoa
Morphology Unicellular; single-cell-like unit Multicellular; a number of cells,  Life Cycle
making up a complex individual  Single host - Protozoans like flagellates and ciliates require only 1 host, within which
Physiology A single cell performs all the Each special cell performs a they multiply asexually in trophic stage and transfer from one host to another by the
functions: reproduction, digestion, particular function cystic form
respiration, excretion, etc.  Second host - In some protozoans, like Plasmodium, asexual method of reproduction
Example Amoeba Tapeworm occurs in one host (man) and sexual method of reproduction in another host
(mosquito).

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 Sarcomastigophora  Life Cycle
 Modes of Transmission:
 It has been subdivided into 2 subphyla based on their locomotion:  Ingestion of cyst from fecal-contaminated material
 _______________________ - it includes parasites which have no permanent locomotory  Venereal transmission through fecal-oral contact
organs, but move about with the aid of temporary prolongations of the body called  Direct colonic inoculation through contaminated enema equipment
pseudopodia
1. Cysts and trophozoites are passed
Amoeba
in feces.
Intestinal Amoeba Entamoeba histolytica
2. Infection with E. histolytica (and E.
Commensal Amoeba Entamoeba coli
dispar) occurs via ingestion of
Entamoeba hartmanni mature cysts from contaminated
Entamoeba polecki
food, water, or hands. Exposure to
Entamoeba gingivalis
infectious cysts and trophozoites in
Iodamoeba bütschlii fecal matter during sexual contact
Endolimax nana
may also occur.
Pathogenic Free-living Amoeba Naegleria fowleri 3. Excystation occurs in the small
Acanthamoeba spp. intestine and trophozoites are
released, which migrate to the large
 _______________________ - includes those protozoa which possess whip-like flagella intestine.
Atrial Flagellates Hemoflagellates 4. Trophozoites may remain confined
Giardia lamblia Trypanosoma brucei gambiense to the intestinal lumen (A:
Trichomonas vaginalis Trypanosoma brucei rhodesiense noninvasive infection) with
Trichomonas hominis Trypanosoma cruzi individuals continuing to pass cysts
Trichomonas tenax Leishmania brasiliense in their stool (asymptomatic
Dientamoeba fragilis Leishmania donovani
carriers).
Chilomastix mesnili
5. Trophozoites can invade the
intestinal mucosa (B: intestinal
Intestinal Amoeba disease), or blood vessels, reaching
extraintestinal sites such as the
Entamoeba histolytica liver, brain, and lungs.
 It is the most invasive of the Entamoeba parasites, and the only member of the family to 6. Trophozoites multiply by binary fission and produce cysts, and both stages are passed
cause colitis and liver abscess in the feces.
 E. histolytica, E. dispar and E. moshkovskii are morphologically identical and of the same 7. Cysts can survive days to weeks in the external environment and remain infectious in
size; can only be differentiated using PCR and monoclonal antibody typing. the environment due to the protection conferred by their walls.
 E. hartmanni, formerly referred to as “small race” of E. histolytica, is differentiated 8. Trophozoites passed in the stool are rapidly destroyed once outside the body, and if
primarily on the basis of size ingested would not survive exposure to the gastric environment.
 The life cycle consists of two stages: an infective cyst and an invasive trophozoite form

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 Morphology  Laboratory Diagnosis
Entamoeba histolytica trophozoite  Method of Choice: microscopic detection of trophozoites and cysts in stool specimen
 E. histolytica trophozoite with ingested RBCs = diagnostic of amebiasis
Size range 8-65 µm
 Presence of Charcot-Leyden crystals
Motility Progressive and directional
 Formalin Ether/Ethyl Acetate Concentration Test and Merthiolate Iodine Formalin
Number of nuclei One
Concentration Test = more sensitive than DFS for the detection of cysts.
Peripheral chromatin Fine, evenly distributed
 Stool culture using Robinson’s and Inoki medium is more sensitive than stool
Cytoplasm Finely granular (ground microscopy but is not routinely available.
(endoplasm) glass appearance)
Cytoplasmic Ingested red blood cells
 PCR and ELISA can be performed to differentiate E. histolyitica and E. dispar
inclusions  Serologic tests may also be performed if E. histolytica is suspected but was not seen in
Karyosome Small and central the stool specimen.

Entamoeba histolytica cyst  Treatment

Size range 10-20 µm  Drug of Choice (Invasive): Metronidazole
Shape Spherical to round  Drug of Choice (Asymptomatic): Diloxanide furoate
Number of nuclei 1-4  Alternative drug: Tinidazole and Secnidazole
Karyosome Small and central  Percutaneous drainage of liver abscess = indicated to patients who do not respond to
Peripheral chromatin Finely and evenly distributed metronidazole.
Cytoplasm Finely granular
 Prevention and Control
 Clinical Manifestations  Integration and improvement of environmental sanitation to provide safe drinking water,
 Asymptomatic carrier state safe food, and sanitary disposal of human feces.
 Parasite is a low-virulence strain  Proper use of latrines and practice of proper hygiene, such as washing of hands, should be
 The inoculation into the host is low emphasized.
 Patient’s immune system is intact  If potable water is not available. Drinking water should be boiled and filtered.
 Amoebic colitis – an intestinal infection caused by the presence of amoeba exhibiting  Vegetables and fruits should be washed thoroughly before consumption.
symptoms.
 Amoebic dysentery – a condition characterized by blood and mucus in the stool
specimen.
 Amoebic liver abscess – most common extraintestinal form of amoebiasis.
 Amoebic pneumonitis – trophozoite extension into the diaphragm
Commensal Amoeba
 Secondary amebic meningoencephalitis  Also known as non-pathogenic amoeba
 Activated T-lymphocytes kill Entamoeba histolytica by:  Human infection is due to ingestion of viable cyst in water or food.
 Directly lysing trophozoites in a contact-dependent process  Reproduction is by binary fission of the trophozoites
 Producing cytokines which activate macrophages and other effector cells  Encystation occurs as amoebae pass through the lower colon where colonic contents are
(neutrophils and eosinophils) more dehydrated.
 Providing helper effect for B-cell antibody production  Excystation occurs in the alkaline environment of the lower small intestines

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 Entamoeba coli
 Non-invasive protozoa that exists in the human GIT as a commensal parasite
 They never enter into the mucosa or sub-mucosa layers or other tissues of the intestine.
 Cosmopolitan in distribution and is considerably more common than other human
amoebae.
Entamoeba hartmanni
 Commensal in man, colonizing the colon.
 A non-pathogenic protozoa that may be found during stool examination and need to be
differentiated from potentially pathogenic E. histolytica.
 Differentiated from E. histolytica on the basis of size. E. hartmanni is smaller.
Entamoeba polecki
 It is a parasite found in the intestines of pigs and monkeys.
 Rarely, it can infect humans, though a high prevalence in some parts of Papua New Guinea
Endolimax nana
 Occurs with the same frequency as Entamoeba coli
 No common associated disease because it is considered as nonpathogenic.
Iodamoeba bütchlii
 No common associated disease because it is considered as nonpathogenic.
 Characterized by its large, vesicular nucleus with a large, central karyosome, surrounded
by achromatic granules.
 No peripheral chromatin granules on the nuclear membrane.
Entamoeba gingivalis
 Can be found in the mouth
 Trophozoite measures 10-20 um and moves quickly because of numerous blunt
pseudopodia.
 Lives on the surface of the gum and teeth, in gum pockets, and sometimes in tonsillar
 Life Cycle
crypts.
1. After ingestion of cysts, they pass through the acidic stomach and remain viable because
 Transmission is direct: kissing, droplet spray, or by sharing utensils.
of protective cyst wall
2. Excystation occurs in the lower small intestine. Entamoeba dispar
3. Metacystic trophozoites colonize the large intestines and live on the mucus coat covering  It is morphologically similar to Entamoeba histolytica; but their DNA and ribosomal RNA
the intestinal mucosa. are different
4. These amebae are noninvasive and do not cause disease.
Entamoeba moshkovskii
 All the species have the following stages, EXCEPT E. gingivalis (no cyst stage)
 It is a nonpathogenic species and is morphologically indistinguishable from E. histolytica
 Trophozoite > Precyst > Cyst > Metacystic trophozoite and E. dispar but differs biochemically and genetically.

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Trophozoite Morphology
E. coli E. hartmanni E. polecki E. nana I. bütchlii E. gingivalis

Size Range 18-27 µm 3-12 µm 8-25 µm 5-12 µm 4-20 µm 10-20 µm

Motility Sluggish, undirected Non-progressive Sluggish, non-progressive Sluggish Sluggish; progressive Active
Number of nuclei One One One One One One
Peripheral chromatin Unevenly distributed Fine, evenly distributed Fine, evenly distributed Absent Absent Fine; evenly distributed
Cytoplasm Coarse granular Finely granular Granular, vacuolated Granular, vacuolated Coarsely granular; vacuolated Finely granular
Cytoplasmic inclusion Bacteria and debris Bacteria Bacteria; food particles Bacteria Bacteria, yeast, debris WBC, Bacteria, ECs
Karyosome Large irregular shape Small and central Small and central Large, irregular Large Small and central

Cyst Morphology
E. coli E. hartmanni E. polecki E. nana I. bütchlii

Size Range 12-25 µm 5-12 µm 10-20µm 4-12 µm 6-16 µm

Shape Round to spherical Spherical Spherical or oval Spherical, ovoid, ellipsoid Ovoid, ellipsoid, triangular
Number of nuclei 1-8 1-4 1 1-4 (mostly 4) 1
Karyosome Large irregular shape Small and central Small and central Large, blot-like; central Large
Peripheral chromatin Unevenly distributed Fine; evenly distributed Fine; evenly distributed Absent Absent
Cytoplasm Coarse granular Finely granular Granular Granular Coarsely granular, vacuolated

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 Laboratory Diagnosis  Morphology
 Method of Choice: Stool examination Acanthamoeba spp. trophozoite
 DFS: best demonstrate trophozoites
Size range 12-45 µm
 FECT and zinc sulfate flotation: useful in recovering cysts
Motility Sluggish
 FECT and iodine stain are useful in differentiating the species.
Number of nuclei One
 For E. gingivalis, a swab between the gums and teeth is examined for trophozoites.
Peripheral chromatin Absent
Cytoplasm Granular, vacuolated
 Treatment Karyosome Large, peripheral
 No treatment is necessary because these amoebae do not cause disease.
Acanthamoeba spp. cyst
 Prevention and Control
 Contraction of organism may be prevented through proper disposal of human waste and Size range 8-25 µm
good personal hygiene Shape Round (rugged edges)
Number of nuclei 1
Karyosome Large and central
Peripheral chromatin Absent
Free-living Pathogenic Amoeba Cytoplasm Disorganized,
granular, vacuolated
 Among the numerous types of free-living amoebae found in water and soil, a few are
potentially pathogenic and can cause human Infections.
 Primary amoebic meningoencephalitis (PAM) – caused by amoeba- flagellate
Naegleria (the brain eating amoeba).
 Granulomatous amoebic encephalitis (GAE) and chronic amoebic keratitis
(CAK) – caused by Acanthamoeba
 Amphizoic – term used to define organisms that can multiply both in the body of a host
(endozoic) and in free-living (exotoic) conditions.

Acanthamoeba spp.
 It is characterized by an active trophozoite stage with prominent “thorn-like” or “spine-
like” appendages (acanthopodia)
 Motile trophozoites feed on gram-negative bacteria, blue-green algae, or yeasts and
reproduce by binary fission.
 It can also adapt to feed on corneal epithelial cells and neurologic tissue through
phagocytosis and secretion of lytic enzymes.
 Acanthamoeba spp. are ubiquitous in the environment and have been found in a variety
of sites, including soil; water; sewage; swimming pools; contact lens supplies; medicinal
pools; dental treatment units; dialysis machines; heating, ventilating, and air
conditioning systems; and tap water; mammalian cell cultures; and vegetables.

Review Notes in Clinical Parasitology by RMDM 60

 Life Cycle  Laboratory Diagnosis
1. Acanthamoeba has two stages; cysts and trophozoites in its life cycle and lacks a  Acanthamoeba Keratitis (AK)
flagellate stage.  Epithelial biopsy or corneal scrapings
2. The trophozoites replicate by mitosis (nuclear membrane does not remain intact).  Isolation of amoebae from contact lens and lens solutions
3. The trophozoites are the infective forms, although both cysts and trophozoites can  Culture and molecular analysis through PCR
enter the body through various means.  Granulomatous Amebic Encephalitis (GAE)
4. Entry can occur through the eye, the nasal passages to the lower respiratory tract, or  It is more difficult to diagnose and is often at advanced stages when they are
ulcerated or broken skin. diagnosed.
5. When Acanthamoeba spp. enters the eye, it can cause severe keratitis in otherwise  Recovery of ameba from cerebrospinal fluid is exceedingly rare, and imaging results
healthy individuals, particularly contact lens users. are generally nonspecific.
6. When it enters the respiratory system or through the skin, it can invade the central
nervous system by hematogenous dissemination causing granulomatous amebic
encephalitis (GAE) or disseminated disease, or skin lesions in individuals with
 Treatment
compromised immune systems.
 Early recognition coupled with aggressive combination of anti-amebic agents can
preclude the need for extensive surgery
7. Both Acanthamoeba spp. cysts and trophozoites are found in tissue.
 Anti-amebic agents: clotrimazole combined with pentamidine, isethionate, and
Neosporin.
 Clinical Manifestations
 Advanced AK usually requires debridement
 Acanthamoeba Keratitis (AK)
 Procedure of choice: Deep lamellar keratectomy
 An infection of the eye that typically occurs in healthy persons and can result in
permanent visual impairment or blindness.
 Associated with the use of improperly disinfected soft contact lenses, particularly  Prevention and Control
those which are rinsed with tap water or contaminated lens solution  Since Acanthamoeba is ubiquitous, it makes exposure unavoidable.
 Symptoms: severe ocular pain and blurring of vision  A robust immune system is able to prevent infection, except in relatively
 Corneal ulceration with progressive corneal infiltration may occur immunocompromised site such as the cornea.
 Granulomatous Amebic Encephalitis (GAE)  Meticulous contact lens hygiene is essential; avoid using tap water to rinse contact lenses.
 A serious infection of the brain and spinal cord that typically occurs in persons with
a compromised immune system.
 Systemic manifestation: fever, malaise, and anorexia
 Neurologic symptoms: increased sleeping time, severe headache, mental status
changes, epilepsy, and coma. Naegleria fowleri
 Others: hemiparesis, blurring of vision, diplopia, cranial nerve deficits, ataxia,  Naegleria spp. are thermophilic organisms that thrive best in hot springs and other
increased intracranial pressure. warm aquatic environments.
 Disseminated Infection  Only Naegleria fowleri has been reported to consistently cause disease in humans,
 A widespread infection that can affect the skin, sinuses, lungs, and other organs although some non-fowleri species may be opportunistic.
independently or in combination. It is also more common in persons with a  N. fowleri occurs in 3 forms:
compromised immune system.  Cyst
 Involves inflammation of the lungs or sinuses, and/or skin infections and has the  Amoeboid trophozoite form
potential to spread to the brain.  Ameboflagellate trophozoite form

Review Notes in Clinical Parasitology by RMDM 61

 Morphology
Amoeboid trophozoite form
Size range 10-35 µm
Motility Sluggish
Number of nuclei One
Peripheral chromatin Absent
Cytoplasm Granular, vacuolated
Karyosome Large and central

Amoeboflagellate trophozoite form

Size range 7-15 µm
Motility Jerky; spinning
Number of nuclei One
Peripheral chromatin Absent
Cytoplasm Vacuolated
Karyosome Large and central

Cyst form
Size range 9-12 µm
Cell wall Present
Number of nuclei 1
Karyosome Large and central
Peripheral chromatin Absent
Cytoplasm Contains vacuoles

 Life Cycle
1. The trophozoites replicate by promitosis (nuclear membrane remains intact).
2. Trophozoites can turn into temporary non-feeding flagellated forms which usually
revert back to the trophozoite stage.
3. Trophozoites infect humans or animals by penetrating the nasal mucosa, usually during
swimming or sinus irrigation, and migrating to the brain via the olfactory nerves causing
primary amebic meningoencephalitis (PAM).
4. Naegleria fowleri trophozoites are found in cerebrospinal fluid (CSF) and tissue, while
flagellated forms are occasionally found in CSF. Cysts are not seen in brain tissue.

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 Clinical Manifestations Atrial Flagellates
 Primary Amebic Meningoencephalitis (PAM)
 A rare but rapidly destructive and fatal meningoencephalitis Giardia lamblia
 Symptoms: fever, nausea, vomiting, headache, nuchal rigidity, and mental status  Also known as Giardia intestinalis or Giardia duodenalis
changes; rapid progression to coma and death  It is one of the earliest protozoan parasites to have been recorded.
 CSF: increased WBC count, elevated neutrophils, high protein and low glucose  It is the most common protozoan pathogen and is worldwide in distribution.
 Initial symptoms of PAM start about 5 days (range 1 to 7 days) after infection. Later  Endemicity is very high in areas with low sanitation, especially tropics and subtropics.
symptoms can include stiff neck, confusion, lack of attention to people and Visitors to such places frequently develop traveler's diarrhea caused by giardiasis
surroundings, loss of balance, seizures, and hallucinations. through contaminated water.
 After the start of symptoms, the disease progresses rapidly and usually causes death  G. lamblia lives in the duodenum, jejunum, and upper ileum of humans.
within about 5 days (range 1 to 12 days).  Asexual life cycle: trophozoite and quadrinucleated infective cyst stages
 Infection of this parasite destroys brain tissue causing brain swelling and death.

 Morphology
 Laboratory Diagnosis
 Specimen of Choice: Cerebrospinal fluid Trophozoite form
 Saline and Iodine wet preparations of the CSF is done to scan for presence of the Size range 9-12 µm by 5-15 µm
parasite Motility Falling leaf
 Aspirates from suspected infections, when introduced into bacteria seeded agar Shape Pear-shaped; teardrop
culture medium, will exhibit active trophozoites within 24 hours. Appearance Bilaterally symmetrical
 Serology utilizing ELISA is less useful in diagnosing active infection since healthy Nuclei Two ovoid-shaped, each with a
individuals (in endemic areas) have been shown to have positive antibody titers large karyosome
No peripheral chromatin
 Treatment Flagella Four pairs, origination of each:
One pair, anterior end
 Medication of Choice: Amphotericin B in combination with clotrimazole
One pair, posterior end
 Amphotericin B has deleterious effects in the nucleus and mitochondria of the ameba, Two pair, central, extending
decreases the number of food vacuoles, and increases the formation of autophagic laterally
vacuoles.
 Ameba has decreased pseudopod formation Cyst form
 Alternative drugs: Azithromycin and voriconazole (effective against N. fowleri) Size range 8-12 µm by 7-10 µm
Shape Ovoid
 Prevention and Control Nuclei Immature cyst, two
 Infection is rare and typically occurs when people go swimming or diving in warm Mature cyst, four
freshwater places, like lakes and ponds. Central karyosomes
 Avoid immersing the head and accidental inhalation of water especially in endemic areas Cytoplasm Retracted from cell wall
and in hot springs. Others Median bodies: two in
 Appropriate decontamination of swimming water should be followed since N. fowleri is immature cyst or four in
fully mature cyst
easily killed by chlorination of water at 1 ppm or higher.
Interior flagellar structures

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 Life Cycle  Clinical Manifestations
1. Cysts are resistant forms and are responsible for transmission of giardiasis. Both cysts  Giardiasis
and trophozoites can be found in the feces (diagnostic stages).  Parasite attaches to the intestinal cells causing irritation in the affected tissues.
2. The cysts (infective stage) are hardy and can survive several months in cold water.  G. lamblia has the ability to alter mucosal intestinal cells once it has attached to the
Infection occurs by the ingestion of cysts in contaminated water, food, or by the fecal- apical portion of the enterocyte.
oral route (hands or fomites). ▪ These alterations lead to decreased electrolyte, glucose, and fluid absorption,
3. In the small intestine, excystation releases trophozoites (each cyst produces two and cause deficiencies in disaccharides
trophozoites). ▪ Result in malabsorption and maldigestion
4. Trophozoites multiply by longitudinal binary fission, remaining in the lumen of the  Signs and symptoms: abdominal pain (cramping) associated with diarrhea;
proximal small bowel where they can be free or attached to the mucosa by a ventral excessive flatus with an odor of “rotten egg” due to hydrogen sulfide
sucking disk.  Chronic infection: steatorrhea, or the passage of greasy, frothy stools.
5. Encystation occurs as the parasites transit toward the colon. The cyst is the stage found
most commonly in nondiarrheal feces.
 Laboratory Diagnosis
6. Because the cysts are infectious when passed in the stool or shortly afterward, person-
 Method of choice: Stool examination
to-person transmission is possible. While animals
 Demonstration of G. lamblia trophozoites and/or cysts in stool samples
 Concentration techniques are recommended to detect cysts
 At least 3 stool exams on alternate days are recommended
 Duodenal aspiration – examination of the duodenal content for trophozoite, if not
found in the feces.
 Enterotest – may demonstrate Giardia trophozoite
 Antigen detection tests

 Treatment
 Drug of Choice: Metronidazole (250 mg; 3x a day for 5-7 days)
 Alternative drugs: tinidazole and furazolidone; nitazoxanide has been used in drug-
resistant cases
 Albendazole is an alternative and has shown equal effectiveness as metronidazole.

 Prevention and Control

 Proper or sanitary disposal of human excreta to prevent contamination of food and
water supply.
 Normal water chlorination will not destroy the cysts, but usual water treatment
modalities should be adequate.

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Trichomonas vaginalis  Clinical Manifestations
 Trichomonas differs from other flagellates, as they exist only in trophozoite stage. Cystic  Trichomoniasis in Females
stage is not seen.  Inflammation of the vaginal mucosa several days after inoculation.
 Genus Trichomonas has 3 species, which occur in humans: ▪ Liquid vaginal secretions, greenish or yellow in color
 T. vaginalis, T. hominis and T. tenax  Proliferation of the parasite causes degeneration and desquamation of the vaginal
 Trichomonas vaginalis causes a sexually transmitted disease called trichomoniasis that epithelium followed by leukocytic inflammation of the tissue layer.
has a worldwide distribution.  Symptoms: vulvitis, and dysuria; trichomonads appear to be associated with an
 It is now often described as the most prevalent non-viral sexually transmitted infection. increased incidence of postpartum endometritis
 Strawberry cervix – punctate hemorrhages of the cervix
 Trichomoniasis in Males
 Morphology  Latent and essentially asymptomatic
Trophozoite form  It is responsible for an irritating persistent and recurring urethritis.
Size range 7-23 µm  Prostatitis is the most common complication
Motility Rapid, jerky, twitching
Shape Pyriform  Laboratory Diagnosis
Nuclei One, ovoid, nondescript  Saline Preparation of vaginal fluid / urethral discharge
Flagella All originating anteriorly:  Quickest and most inexpensive, but 60-70% sensitivity only
Four extending anteriorly  Examined for characteristic jerky and twitching movement and shape
One extending posteriorly  Culture
Other Undulating membrane extending  Considered as gold standard and most sensitive (95%)
features: half of body length
Prominent axostyle that often  Uses Diamond’s modified medium, and Feinberg and Whittington culture medium
curves around nucleus;  Pap smear
granules may be seen along  Polymerase Chain Reaction (PCR)
axostyle  Antigen detection in vaginal smear
 InPouchTM TV Test

 Life Cycle  Treatment

1. Trichomonas vaginalis resides in the female  Drug of choice: Metronidazole or Tinidazole
lower genital tract and the male urethra and  May also be recommended in pregnant women
prostate, where it replicates by binary fission.  Sexual partners must be treated concomitantly to prevent reinfection
2. The parasite does not appear to have a cyst
form and does not survive well in the external
environment.  Prevention and Control
3. Trichomonas vaginalis is transmitted among  Limit the number of sexual partners, and proper use of protective devices such as
humans, its only known host, primarily by condoms and spermicidal foams may help prevent infection
sexual intercourse.
 Prompt follow-up of patients and their contacts, as well as health and sex education are
also important.

Review Notes in Clinical Parasitology by RMDM 65

Dientamoeba fragilis
 It was initially classified as an ameba because this organism moves by means of
pseudopodia and does not have external flagella.
 Dientamoeba fragilis is a flagellate that lacks external flagella and therefore must be
morphologically differentiated from the small nonpathogenic amebae (e.g., Endolimax
nana, Entamoeba hartmanni).
 It has been identified in practically all regions of the world in which satisfactory iron-
hematoxylin stained films have been carefully examined.
 It is a flagellate with only the trophozoite stage known.

 Morphology
Trophozoite form
Size range 7-12 µm
 Clinical Manifestations
Motility Progressive
 Patients who suffer symptoms associated with D. fragilis infections often present with
Shape Irregularly shaped
diarrhea and abdominal pain
Nuclei 1 or 2; rosette-shaped
Karyosome (4-6 discrete  Bloody or mucoid stools, flatulence, nausea or vomiting, weight loss, and fatigue or
granules) weakness.
Cytoplasm Bacteria-filled vacuoles  Some patients experience diarrhea alternating with constipation, low-grade eosinophilia,
Other Broad hyaline pseudopodia and pruritus.
features: allows the movement of this
parasite
The nucleus typically has a  Laboratory Diagnosis
fragmented karyosome with  Method of choice: examination of multiple and fixed fresh stool samples
discrete chromatin granules,  Fresh samples are necessary since the trophozoites degenerate after a few hours of
and a thin nuclear membrane stool passage
may be visible.  Multiple samples increase the sensitivity
 Purged stool specimens provide more suitable material for examination
 Life Cycle  Polyvinyl alcohol fixative or Schaudinn’s fixative
1. The complete life cycle of Dientamoeba fragilis has not yet been elucidated; assumptions
have been made
 Treatment
2. Trophozoites are found in the lumen of the large intestine, where they multiply via binary
 Antimicrobial therapy – resolves symptoms and eradicates D. fragilis
fission, and are shed in the stool.
 Drug of choice: Iodoquinol (650 mg, 3x a day for 20 days)
3. Transmission: fecal-oral route; transmission via helminths (E. vermicularis) has been
 Alternative drugs: Tetracycline and metronidazole
postulated.
4. Animal reservoirs (macaques, gorilla, and swine) may also be potential sources of human
infections  Prevention and Control
 Proper sanitation and disposal of human waste are essential.

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 Non-Pathogenic Flagellates Chilomastix mesnili
 Chilomastix mesnili is a flagellated protozoan generally regarded as nonpathogenic in the
Trichomonas hominis human host.
 As with other Trichomonas species, T. hominis occurs only as a trophozoite.  It inhabits the cecal region of the large intestine
 Transmission occurs rapidly through fecal contamination of food and drinks.
 Its habitat is the cecal area of the large intestine of human and other primates. Trophozoite form
 It is non-invasive.
Size range 6-10 µm
Trichomonas tenax Motility Boring; spiral forward
 It is a harmless commensal of the human mouth, living in the tartar around the teeth, in Shape Pear-shaped; asymmetrical
cavities of carious teeth, and in mucosal cells of gingival margins. Nuclei One with small central
 Transmission: through droplet spray from the mouth, kissing, or common use of karyosome
contaminated dishes and drinking glasses Flagella 3 anterior flagella
1 extending posteriorly
 Diagnosis: made by swabbing the tartar between the teeth, the gingival margin, or
Others Prominent cytostome extending
tonsillar crypts. 1/3 to 1/2 body length
Trophozoite T. hominis T. tenax Spiral groove
Size range 7-13 µm 5-12 µm
Shape Pear-shaped; Pyriform Oval; pear-shaped Cyst form
Motility Nervous, jerky movement Size range 5-10 µm
Nuclei One, with a small central One, ovoid nucleus Shape Lemon- or Pear-shaped
karyosome With chromatin granules With a clear hyaline knob
No peripheral chromatin extending from anterior end
Flagella 3-5 anterior flagella 4 free equal flagella Nuclei 1 large vestibular nucleus
1 posterior flagellum projecting 1 on the margin of an undulating Others Well-defined cytostome located
from undulating membrane membrane on one side of the nucleus
Others Axostyle that extends beyond the Undulating membrane extending
posterior end of the body two thirds of body length with
Full body length undulating accompanying costa
membrane Thick axostyle curves around  The cyst stage is resistant to
Conical cytostome cleft in nucleus; extends beyond body
environmental pressures and is
anterior region ventrally length
located opposite the undulating Small anterior cytostome responsible for transmission
membrane opposite undulating membrane of Chilomastix
 Chilomastix resides in the cecum
and/or colon; it is generally
considered a commensal whose
contribution to pathogenesis is
uncertain.

Review Notes in Clinical Parasitology by RMDM 67

Hemoflagellates Trypomastigote
Size range 12-35 µm long by 2-4 µm wide
 These protozoans live in the blood and tissues of man and other vertebrate hosts and in Shape Long and slender
the gut of the insect vectors. Nucleus One, located anterior to the
 All members of the family have similar life cycles. They all require an insect vector as an kinetoplast
intermediate host. Others Kinetoplast, located in the
 Multiplication in both the vertebrate and invertebrate host is by binary fission. No sexual posterior end
cycle is known. Undulating membrane
Free flagellum
 Morphologic forms: amastigote, promastigote, epimastigote, and trypomastigote
Amastigote
Size range 5 by 3 µm
Leishmania spp.
Shape Round to oval
Nucleus One, usually off center  It is associated with a vector-borne disease Leishmaniasis that is transmitted by
Others Kinetoplast present, consisting of sandflies.
dotlike blepharopast from  Though it is not yet documented in the Philippines, organisms in this genus and their
which emerges a small respective vectors have made successful migrations and adaptations to many
axoneme environments.
Parabasal body located adjacent  Philippines has a number of Phlebotomus spp. that can serve as vectors for Leishmania
to blepharoplast
spp.

Promastigote
Size range 9-15 µm long
Shape Long and slended
Nucleus One, in or near the center
Others Kinetoplast, located in anterior
end
Single free flagellum, extending
from anterior end

Epimastigote
Size range 9-15 µm long
Shape Long; slightly wider than
promastigote
Nucleus One, in posterior end
Others Kinetoplast, located anterior to
the nucleus
Undulating membrane
Free flagellum

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 Life Cycle
1. The sandflies inject the infective stage (promastigotes) from their proboscis during blood  Laboratory Diagnosis
meals  Microscopic demonstration
2. Promastigotes that reach the puncture wound are phagocytized by macrophages and  Specimen: lesion and tissue scrapings, aspirates, or biopsy
other types of mononuclear phagocytic cells.  Giemsa and hematoxylin-eosin stains are often used
3. Promastigotes transform in these cells into the tissue stage of the parasite (i.e.,  Demonstration of amastigotes confirms the diagnosis of leishmaniasis
amastigotes)  Leishmanin Skin Test (Montenegro skin test)
4. Amastigotes then multiply by simple division and proceed to infect other mononuclear  Immunologic assays
phagocytic cells.
5. Sandflies become infected by ingesting infected cells during blood meals.
6. In sandflies, amastigotes transform into promastigotes in the gut  Treatment
7. And eventually migrate to the proboscis of the insect.  Pentavalent antimonials: sodium stibogluconate and n-methyl-glucamine
 Primary pharmacologic treatment
 Clinical Manifestations  Amphotericin B
 Cutaneous Leishmaniasis  Drug of choice in cases of treatment failure with antimonials
 Most common form of the disease  Miltefosine
 Incubation period: 2 weeks to several months  Only oral drug currently given to VL patients
 Produces an erythematous papule or nodule called oriental button  Pentamidine
 During the course of several weeks, the papule forms a violaceous ulcer as it  Another second-line drug for CL as well as VL
enlarges in size  Topical paromomycin
 It may heal spontaneously after a few months  Used for the cutaneous form of leishmaniasis
 Diffuse Cutaneous Leishmaniasis  Combination therapy
 Aka anergic or lepromatous leishmaniasis  Sodium stibogluconate + paromomycin
 Characterized by a localized, non-ulcerating papules; developing numerous diffuse  Liposomal amphotericin B + miltefosine or sodium stibogluconate
satellite lesions
 Usually affects the face and extremities  Prevention and Control
 Mucocutaneous Leishmaniasis  Preventive measures include usage of insect repellants containing DEET and permethrin,
 Involvement of the mucus membranes of the nasal and oral cavities which results in insecticide clothing, and fine-mesh bed nets.
nasal stuffiness, discharge, epistaxis, and destruction of the nasal septum
 However, interval spraying predisposes sandflies to resistance to the insecticides, and
(Espundia)
also the impact of insecticides on the environment
 Dysphonia, dysphagia, and aspiration pneumonia – results due to the progression
into the pharynx and larynx  Regulation of reservoir hosts
 Visceral Leishmaniasis  Insecticide-treated dog collars, mass testing of domestic dogs, and even extermination of
 Aka ala-azar infected dogs are strategies to avoid zoonotic transmission
 Manifestation stems from the spread of parasite into the bone marrow, spleen,  Commercial vaccines are currently under development.
and liver
 Incubation period: 2 to 8 months; but symptoms usually appear during
immunocompromised states
 If left untreated, VL has a greater than 95% mortality rate
Review Notes in Clinical Parasitology by RMDM 69
Trypanosoma cruzi
 It is the only parasite that was discovered and studied before it was known to cause a
disease.
 T. cruzi is the etiologic agent of Chagas disease (American Trypanosomiasis).
 Carlos Chagas found that the trypanosomes he dissected from the intestine of a
triatomid bug were the same parasites found in the blood of a child suffering from fever
and enlargement of the lymph nodes.
 It is an intracellular parasite, with myocytes and cells of the reticuloendothelial system
being the most heavily infected cells.
 Other tissues that get infected include the skin, gonads, intestinal mucosa, and placenta.
 T. cruzi trypomastigotes are the only stage found in the blood of an infected person.
 Arthropod vector: “kissing bug” from the genera Triatoma, Panstrongylus, and Rhodnius
 Zoonotic mammalian reservoir hosts: domestic animals, armadillos, raccoons,
rodents, marsupials, and even some primates
 T. cruzi exhibits all four stages of development:
 Amastigote – found in the tissue cells of human
 Promastigote
 Epimastigote  Clinical Manifestations
 Trypomastigote – infective stage; found in the bloodstream of human  Chagas disease (Acute Phase)
 Characterized by a focal or diffuse inflammation mainly affecting the myocardium
 Cutaneous manifestation: localized inflammatory reaction near or at the site of
 Life Cycle inoculation
1. An infected vector takes a blood meal and releases trypomastigotes in its feces near the  Chagoma – furuncle-like lesions associated with induration, central edema, and
site of the bite wound. lymphadenopathy
2. Inside the host, the trypomastigotes invade cells near the site of inoculation, where they  Romaña’s sign – swelling of the eyelid caused if the parasite penetrates through
differentiate into intracellular amastigotes the conjunctiva
3. The amastigotes multiply by binary fission.  After 1-2 months, symptoms resolve, and the patient goes into a latent or
4. Amastigotes differentiate into trypomastigotes and are released in the circulation. indeterminate, but usually asymptomatic phase
5. Trypomastigotes infect cells from a variety of tissues and transform into intracellular  Chagas disease (Chronic Phase)
amastigotes in new infection sites.  Manifested by fibrotic reactions that cause injury to the myocardium, cardiac
6. The “kissing” bug becomes infected by feeding on human or animal blood that contains conduction network, and enteric nervous system
circulating parasites.
 Heart is the primary organ affected during this phase
7. The ingested trypomastigotes transform into epimastigotes in the vector’s midgut.
 Cardiomegaly, congestive heart failure, thromboembolism, arrhythmias
8. The parasites multiply and differentiate in the midgut and differentiate into infective
metacyclic trypomastigotes in the hindgut.

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 Laboratory Diagnosis Ciliophora
 Specimen of choice: Giemsa-stained blood smear
 Detection of trypomastigotes  These protozoa are motile by means of cilia, which cover their entire body surface.
 Epimastigotes are primariliy found only in the arthropod vector  The only human parasite in this group is Balantidium coli, which rarely causes dysentery.
 Lymph node biopsy Giemsa-stained slides, as well as blood culture, may reveal the
typical amastigotes.
 Serologic tests: Complement fixation test, DAT, and indirect immunofluorescence Balantidium coli
 PCR and ELISA test  Also known as Neobalantidium coli / Balantioides coli
 It is a large ciliated protozoan; the only ciliate known to be capable of infecting humans.
 Treatment  It is often associated with swine, the primary reservoir host.
 Drug of Choice: Nifurtimox and Benznidazole  B. coli is considered as the largest protozoan parasite affecting humans
 It is capable of attacking the intestinal epithelium, resulting in ulcer formation which, in
 Allopurinol and Itraconazole
turn, causes bloody diarrhea
 Newer drugs
 Triazole derivatives
 Cruzipain inhibitors Cyst form
Size range 40-60 µm in diameter
 Prevention and Control Nuclei Two
 Vector control and blood transfusion regulations have resulted in positive outcomes Kidney-shaped macronucleus
usually present
 Spraying of insecticides, use of insecticide-treated bed nets, and house improvements. Small spherical microcnucleus;
 Vaccine development has not yet been successful. may not be observable
Others One or two visible contractile
vacuoles in young cysts
Trypanosoma brucei complex Double cyst wall
Row of cilia visible in between
 Two subspecies that are morphologically indistinguishable cause distinct disease cyst wall layers of young cysts
patterns in humans:
 Trypanosoma brucei gambiense - chronic African trypanosomiasis (“West African
Trophozoite form
sleeping sickness”)
 Trypanosoma brucei rhodesiense - acute African trypanosomiasis (“East African Size range 30-150 µm long
25-120 µm wide
sleeping sickness”)
Motility Rotary; boring
 Another subspecies, T. brucei brucei, primarily affects wild and domestic animals
Nuclei One
 Arthropod vector: blood-sucking tsetse fly (Glossina spp.)
Kidney-shaped macronucleus
 HAT cases are localized in regions of sub-Saharan Africa, primarily remote rural areas Small spherical micronucleus
where tsetse fly habitats are located Others One or two visible contractile
vacuoles
Cytoplasm may contain food
vacuoles and/or bacteria
Small cytostome present
Layer of cilia around organism

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 Life Cycle  Laboratory Diagnosis
1. Human infection results from  Diagnosis is made by microscopic demonstration of trophozoites and cysts in feces using
ingestion of food and/or water direct examination or concentration techniques.
contaminated with B. coli cyst.  Repeated stool examinations may be done to increase sensitivity.
2. Ingested cyst excyst in the small  Sigmoidoscopy – demonstrate the presence of trophozoites in biopsy specimens
intestine and become trophozoites.  Bronchoalveolar washings may also contain B. coli trophozoites in the case of
3. Trophozoites colonize the large pulmonary infection
intestine where they replicate by
binary fission.
 Treatment
4. Trophozoites undergo encystation to
 Drug of Choice: Tetracycline (500 mg or 40mg/kg/dose, 4x for 10 days) or
produce infective cysts.
Metronidazole
 Alternative drugs: Iodoquinol; doxycycline and nitazoxanide
 Infective stage: cysts; remain viable
for several weeks
 Incubation period: 4 to 5 days  Prevention and Control
 Encystation occurs during intestinal  Proper sanitation, safe water supply, good personal hygiene, and protection of food from
transport or after evacuation of contamination.
semi-formed stools.  Limiting the contact of pigs with water sources and food crops
 Use of pig feces as fertilizer should also be avoided
 Cysts are inactivated by heat and by 1% sodium hypochlorite.

 Clinical Manifestations
 Asymptomatic carriers
 Patients do not present with diarrhea or dysentery, but may serve as parasite
reservoir
 Acute form (fulminant balantidiasis/balantidial dysentery)
 Involves diarrhea with bloody and mucoid stools
 May have 6-15 episodes of diarrhea per day accompanied by abdominal pain,
nausea, and vomiting
 Chronic form
 Diarrhea may alternate with constipation accompanied by abdominal pain or
cramping, anemia, and cachexia.
 Extraintestinal Infection
 A rare but potentially serious and typically occurs secondary to intestinal infection.
 B. coli can spread to mesenteric nodes, appendix, liver, genitourinary sites, pleura,
and lungs.

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