MODULE IN CLINICAL PARASITOLOGY (LECTURE)

TOPIC: “FLAGELLATED GROUP”

Lesson Title: “Whipped Animal-like Protists”

I. OBJECTIVES:
This module aims to provide an understanding of the protozoan flagellates, with emphasis on
the clinically significant species.

Specifically, at the end of the module, students are expected to be able to:
a. recall the taxonomic classification of flagellated group
b. diistinguish the pathogenic flagellates from the non-pathogenic species.
c. differentiate the gross and microscopic characteristics of each flagellates, especially the
pathogenic ones..
d. iIllustrate the developmental stage or life cycle of Giardia lamblia, Trichomonas vaginalis and
the hemoflagellates
e. recognize the infective stages of pathogenic flagellated species and discuss their modes of
transmission;
f. identify the henoflagellates and how humans can get infected with these protozoans
g. discuss the pathophysiology and symptomatology of pathogenic flagellates
h. enumerate some preventive measure on how to control Giardiasis, Trichomonaisis, and
hemoflagellate infections.

II. INTRODUCTION:
Taxonomic Classification

Phylum Sarcomastigophora

Subphylum Mastigophora

Atrial Flagellates Hemoflagellates

Non-pathogenic: Pathogenic: Leishmania Trypanosoma

Chilomastix mesnili Giardia intestinalis

Dientamoeba fragilis (digestive tract)
Trichomonas hominis Trichomonas
Trichomonas tenax vaginalis
(genitalia)
III. *PRE-QUIZ/ Activity:

Before we go further, try to answer the questions under Quizzes in Canvas regarding Flagellates.

IV. General Characteristics of Flagellates:

Giardia lamblia
o a.k.a. Giardia intestinalis or G. duodenalis
o Disease: Giardiasis or Lambliasis
o Classically described as “old man with eyeglass” or an “old man’s face”
o lives In the duodenum, jejunum, and upper ileum of humans
o double walled organism
o with rigid axostyle and a pair of parabasal bodies
o infective stage: matured cyst (quadrinucleated)
o Divides by longitudinal binary fission or asexual life cycle that includes trophozoites and
quadrinucleated infective cyst stages.
o non-tissue invading but pathogenic causing gastrointestinal disease.
o transmission: ingestion of matured cyst through food and water
o The disease may be asymptomatic (cyst passers)
= fat malabsorption causing steatorrhea (fats in stool)

Nice to know: It was first discovered by Anton von Leeuwenhoek in his own stool in 1681.
Lambl described it later in 1859, and called it Cercomonas intestinalis.
Stiles renamed it later as Giardia lamblia in 1915.

o Trophozoite: old man’s face

 9 to 12 um by 5 to 15 um wide.
 Pyriform or teardrop shaped, pointed posteriorly, with a pair of nuclei, one on each
side of the midline
 Dorsal side of the flagellate is convex, while the ventral side is concave with a large
adhesive disc.
 Bilaterally symmetrical, with a distinct medial line called the axostyle.
 Motility is likened to a floating, falling leaf motion
 Has 4 pairs of flagella.
 Found in diarrheic stools.
 o Cyst
 Ovoid, measures 8 to 12 um by 7 to 10 um wide.
 Flagella retracted into axonemes
 Median, parabasal body
 Deeply stained curved fibrils surrounded by a tough hyaline cyst wall
 Found in semi=formed or formed stools
 Immature cyst contain 2 nuclei, while the mature, Infective stage cyst contains 4
nuclei.

Life Cycle:
Infection starts in humans when humans ingest the mature, quadrinucleated cysts from
contaminated food or water or hands.
Excystation takes about 30 minutes and this happens in the duodenum developing into
trophozoites that rapidly multiply and attach to the intestinal villi.
As the feces enters the colon and dehydatres, the flagellate undergoes encystations
(encystment). Thus, the parasite leaves the human body as mature cycts are passed out in the
feces.

Pathogenicity:
Due to attachment of the sucking disc on the epithelial cells lining, the duodenum
provokes intense inflammation resulting in the secretion of abundant mucus and causes
hyperperistalsis leading to malabsorption of fat and starch and finally dehydration of the patient.

Acute cases:
s/sx: Diarrhea , body malaise and flatulence
abdominal pain, cramping associated with diarrhes
excessive flatus with an odor of “rotten eggs” due to hydrogen sulfide.
Other s/sx may include:
Abdominal bloating, nausea and anorexia.
Clinincal incubation is about 1 to 4 weeks (average 9 days). Spontaneous recovery occurs within 6
weeks in mild to moderate cases.

Chronic infections:
s/sx: Steatorrhea – passage of greasy, frothy stools.
Some patients complain of alternating bouts of diarrhea and constipated bowel
movements. Weight loss, profound malaise and low grade fever.

Diagnosis:
1. Stool exam
2. Duodenal aspirate
3. Entero test – A patient swallows a gelatine capsule attached to a nylon string and the other
end of the string attached to the patient’s cheek. After about 4 to 6 hours, the string is
retrieved. Any adherent fluid is placed on the slide and examined microscopically.
4. Serologic tests:
Antigen detection tests and imminofluorescent tests
Immunochromatographic tests
CWP1 (Cell wall protein 1) test – detects antigen of G. lamblia
Treatment: Metronidazole : 250 mg three times a day for 5 to 7 days
Pediatric dose: 15 mg/kg BW/day in three divided doses.
Tinidazole
Furazolidone
Albendazole
Nitrazoxanide

Trichomonas

o They exist only in trophozoite stage and there is no cystic stage

o pyriform organism, less prominent cytostome axostyle that extends the body parasite
usually another flagella.

Trichomonas vaginalis:

o Causative agent of Trichomoniasis; most prevalent non-viral STI (sexually transmitted

infection)
o infective stage: Trophozoite stage
o pyriform shape, measuring 7 to 23 um with four free anterior flagella and a fifth flagellum
embedded in the undulating membrane.
o Has median axostyle and a single nucleus
o Movement: jerky tumbling motion

Trichomonas is sexually transmitted disease

Pregnant mothers = pH alkaline = favors Trichomonas growth
Normal pH of vagina = acidic

Manner of transmission or infection is through sexual intercourse

Male is asymptomatic who is the carrier of this parasite and women are reservoir. Urine and
prostatic secretion from male should be examined.

Pathogenicity:
 Early stage = multiplication of bacteria without damaging the mucosa
Later stage = increase in number of symbiotic bacteria; increase in leukocyte.
= appearance of thin, greenish or yellowish frothy, foul smelling vaginal discharge
Classical Symptom: intense burning sensation and itchiness of vagina, strawberry cervix;
In Male, it is chronic urethritis.

Prevention:
1. avoidance of sexual intercourse during infection
2. 0.5% acetic acid can kill the organism

Culture media: Diamond’s modified medium, Feinberg & Whittington culture

IDENTIFYING FEATURES: T. hominis T. tenax T. vaginalis

1. habitat Intestine oral cavity genitalia
2. size of parasite Medium smallest largest
3. nucleus Ovoidal rounded ovoidal
2
4. undulating membrane as long as the /3 of the costa less than 1/2 the
costa costa
5. inclusion bodies None none siderophil
granules
6. pathogenicity Commensal commensal non-specific
7. specimen for diagnosis Stool oral scrappings urine, vaginal
swab, vaginal
discharge
NON-PATHOGENIC FLAGELLATES:

Chilomastix mesnilli
o commensal organism
o have only one nucleus and is already mature
o have a characteristic projection in the cyst wall which is described as
lemon shape cyst or nipple like projection
o trophozoite stage: asymmetrically pear because it has a very prominent
cytostome.
o movement: corkscrew motion
o infective stage: mononucleated cyst

Dientamoeba fragilis

o now correctly classified as flagellate, a trichomonad flagellate

o causes a disturbing gastroenteritis
o lacks a cyst stage thus, differs from the true amoeba
o trophozoite stage is destroyed after leaving the body of host
o measures 5 - 15µ
o possess a leaf like pseudopodium. Its movement is similar to Entamoeba histolytica
trophozoite, endoplasm contains food vacuoles with WBC, epithelial cells or bacteria but
rarely RBC
o possession of similar nuclei which refer to particulate nuclei
o transmission occurs by way of pinworm ova.
 Hemoflagellates
(Blood and Tissue Flagellates)
The Blood Sucking Flagellates; arthropod transmitted parasite

Family Trypanosomatidae
Class Kinetoplastidea
Order Trypanosomatida
Family Trypanosomatidae (6 genera)
2 Clinically significant : Leishmania and Trypanosoma

Intracellular stage (development stage) = Leishmania

Stages:
Amastigote will go out and develop and develop on elongated organisms. Also known as stage of
Leptomonad-Kinetoplast nucleus.
Leptomonad stage (promastigote)
Kinetoplast = anterior to the nucleus Crithidia stage (epimastigote)
Kinetoplast = posterior to the nucleus (trypomastigote)

Trypanosoma = long undulating membrane

I. Trypanosoma brucei complex

o They cause African Trypanosomiasis, said to be the ancestral form of the 2 human forms

1. Trypanosoma brucei brucei = animal parasite which causes Nagana diseases

2. Trypanosoma brucei gambiense = Gambian Sleeping Sickness = West, Central
Africa
3. Trypanosoma brucei rhodesiense = Rhodesian Sleeping Sickness = East, Central
Africa

This sleeping sickness involves the central nervous system. The patient undergoes lethargic
condition, then, followed by coma and eventually death due to malnutrition and concurrent
infection.
There is only one stage of this parasite which is Trypanosomal stage.
Three stages of tissue involvement:
1. parasitemia = parasites are numerous in the blood
2. lymphadenitis = parasites are concentrated in lymph nodes
3. CNS = numerous in the brain substance and arachnoid spaces.

There is no point of difference between Trypanosoma gambiense and

Trypanosoma rhodesiense as far as morphology is concerned. They are both
pleomorphic parasite. They differ only in their vectors.

The vector is tse tse fly (Glossina)

Vector of Trypanosoma gambiense = Glossina palpalis, Glossina tacinoides

Vector of Trypanosoma rhodesiense = Glossina morsitans, Glossina swynnerteni
The parasite is described as long & slender, short & slumpy, and twins

LIFE CYCLE
Trypanosoma ----------- >arthropod (tse-tse fly)

metacyclic forms in intestine

deposited in saliva

= Infective stage: metacyclic form

= Diagnostic stage: trypanosome

Diagnosis:
1. muscle tissue wherein biopsy is performed
2. xenodiagnosis is not advisable, culture is not very easy to do
3. infected blood is administered to experimental animal like guinea pig and young dogs after
2-3 weeks, the blood of this animal is positive to trypanosomes.
During febrile stage, the parasites are found in the blood and lymph node stained with giemsa.
They divide by means of binary fission. During lethargic stage, the patient is unconscious or
sleeping parasites are found in the CSF causing meningoencephalitis.

Antigenic variation of African trypanosomes = The changing antigenicity makes it difficult to

develop long term protective substance such as vaccines. The parasite can change their antigenic
composition, hence, evade a host’s immune response.

Concentration techniques:
1. Zinc sulfate technique
2. Acid ether concentration technique

Immunologic techniques:
IFA, IHA, ELISA (there is marked increase in the IgM level)

II. Trypanosome cruzi

It causes America Trypanosomiasis or South American Trypanosomiasis or Chaga’s disease

The vital organs involved are the heart muscle, the reticuloendothelial system, the central nervous
system
It differs from African trypanosomes in the sense that it has an intracellular phase involving
cells not only the lymphoid – macrophage system but also myocardium, endocrine glands and
brain cells.

The trypanosomes when stained are described as C-shaped or S-shaped Vectors: the
reduviid bugs like kissing bugs, assassin bugs, (triatomid) cone-nosed bugs

Triatoma infestans, Panstrongylus megistus, Rhodnius sp.

Triatoma rubiafasciata = genus of kissing bug present in the Philippines.
The vectors are allowed to take the blood with suggestive patient and after an interval, the
manure of the bug is examined for developing stages of parasites.
Feces of bugs have the metacyclic form. Biting and at the same time defecating of the feces.

Diagnosis:
Specimen to examine: blood puncture, CSF, lymph juice
Stain used: Giemsa Stain
Culture media: Nicolle, Novy, MacNeal (NNN) = reveal the epimastigote, trypomastigote forms
Chang’s medium. Tissue culture
Xenodiagnosis = allow laboratory-bred reduviid bug to feed on infected patient/
Bug -----> fed on the patient’s blood ----->dissect the bug after 3 weeks = and the result : look for
metacylic form
If metacylic form is in the posterior gut = Trypanosoma cruzi
If metacylic form is in the salivary gut = Trypanosoma rangeli

Serodiagnosis: CF, immunodiffusion, IHA

There is no elevation of IgM, slight increase in IgG level

Trypanosoma rangeli
= commensal, non-pathogenic
= no extravascular stages
= twice as long as Trypanosoma cruzi

Leishmania
= also arthropod transmitted disease.
= a flagellates which live inside the macrophage.

The 3 species are:

Leishmania tropica
Affects the skin (cutaneous) so, it is the causative agent of Oriental sore or Old World Cutaneous
Leishmaniasis
=endemic in Saudi Arabia

Leishmania braziliensis
Affects the skin and the mucus membrane, mucocutaneous type known as Espundia = Chiclero’s
disease, the New World Cutaneous Leishmaniasis or American Mucocutaneous Leishmaniasis

Leishmania donovani
Affects the internal organs ( liver and spleen)
The causative agent of Visceral Leishmaniasis, Kala-azar, Dum dum Fever, Death Fever, Tropical
splenomegaly
Stages:
Leishmania  arthropod (sandfly = phlebotomus flies, also lutzomyia)
Leptomonad
 LIFE CYCLE

Sandflies fed on blood, tissue juices from infected human

containing amastigote form

Promastigote stage
Injection to next individual

Migration to pharynx and mouth Multiplication in the midgut

V. Additional Readings and References:

Related videos/ websites:
*Uploaded Files: (see Files under Canvas)
Atrial flagellates PPT
Hemoflagellates PPT

VI. Post-Activity: Prepare 5 scholarly made questions about flagellates. Include rationalization
of the answer and reference. (Submission is through AUFmyClass)

REFERENCES:

Belizario, Vicente Y. Jr & Solon, Juan Antonio A. PHILIPPINE TEXTBOOK OF MEDICAL PARASITOLOGY.
Manila: University of the Philippines. C2015.

Beaver, Paul Chester, Jung, Rodney Clifton & Cupp, Eddie Wayne CLINICAL PARASITOLOGY, latest
Edition. Philadelphia: Lea & Febigez.
Brown, Harold W. and Neva, Franklin A. BASIC CLINICAL PARASITOLOGY. United States of America:
Appleton & Lange.
Garcia, Lynne Shore DIAGNOSTIC MEDICAL PARASITOLOGY 5th Edition. ASM Press.
Heelan, Judith S and Ingerson, Frances W. ESSENTIALS OF HUMAN PARASITOLOGY, 4TH Edition.
Delmar Cengage Learning, 2001.
John, David T., Edward K. Markell and Voge’s MEDICAL PARASITOLOGY; 9th Edition. Philadelphia:
Elsevier Saunders, c2011.
Henry,John Bernard CLINICAL LABORATORY DIAGNOSIS and MANAGEMENT BY LABORATORY
METHODS. Philadelphia: W.B. Saunders Company, c2017.
Roberts, Larry S.and John Janovy Jr. Larry S. Roberts’ FOUNDATIONS OF PARASITOLOGY; 8TH Edition.
New York: McGrow Hill Science/Engineering/Math. c2005.