FLAGELLATES

LEARNING OBJECTIVES

➢ Classify the individual flagellates as intestinal or extraintestinal.

➢ Construct, describe, and compare and contrast the life cycle of the
different flagellates.
➢ Identify and describe the factors responsible for the asymptomatic carrier
state of an infected patient, treatment options and prevention and contrast
measures
➢ Determine the specimen choice, alternative specimen type where
appropriate, collection protocol and laboratory diagnostic technique
required for recovery of each of the flagellates.
➢ Briefly identify and describe the populations prone to contracting clinically
significant disease processes and clinical signs and symptoms associated
with each pathogenic flagellate.
 REVIEW
• All Protozoa fall under Kingdom Protista which is a diverse group of
eukaryotic microorganisms.
• Divided into 6 phyla but the major organisms causing disease in man belong
to Phylum Sarcomastigophora and Apicomplexa.

• Under Phylum Sarcomastigophora are 2 subphyla:

1. Subphylum Mastigophora
2. Subphylum Sarcodina

• Subphylum Mastigophora
- Whose organelles of locomotion are whip-like structures arising from the ectoplasm
called flagella.
• These are the flagellates:
I. Parasitic (Pathogenic Flagellates): (flagellates with medical and public health
importance)
> Intestinal Flagellates
Giardia lamblia
Dientamoeba fragilis
> Genital flagellate
Trichomonas vaginalis
> Blood and Tissue flagellates
Trypanosoma cruzi
Trypanosoma brucei gambiense
Trypanosoma brucei rhodesiense
Leishmania spp.
II. Non-Pathogenic Flagellates:
* Trichomonas hominis
* Trichomonas tenax
* Chilomastix mesnili
 I. INTESTINAL FLAGELLATES
• GIARDIA LAMBLIA
- This protozoan is also known as Giardia intestinalis or Giardia duodenalis.
- worldwide distribution; more prevalent in warm climates and in children.
- cause epidemic and endemic diarrhea.
- disease called giardiasis, and this manifests as a significant but not life-threatening
gastrointestinal disease.
- lives in the duodenum, jejunum, and upper ileum of humans.
- a simple asexual life cycle: trophozoites and quadrinucleated infective cyst stages.
- bilaterally symmetrical, 2 median bodies, 2 axostyle, 2 nuclei, and 4 pairs of
flagella.
• propelled into an erratic tumbling motion by four pairs of flagella arising from
superficial organelles in the ventral side of the body.
• divide by longitudinal binary fission.
LIFE CYCLE OF GIARDIA LAMBLIA
CLINICAL MANIFESTATIONS:
• Half of infected patients may be asymptomatic.
• For acute cases: abdominal pain, described as cramping, associated with
diarrhea.
• excessive flatus with an odor of “rotten eggs” due to hydrogen sulfide.
• Diarrhea in 89% of cases; malaise and flatulence. Spontaneous recovery
occurs within 6 weeks in mild to moderate cases.
• Chronic infection: steatorrhea
• There may be weight loss, profound malaise, and low-grade fever.
• In developing countries, it has been described as a cause of the failure-to-
thrive syndrome.
 DIAGNOSIS
Diagnostic Techniques are:

I. Demonstration of G. lamblia/duodenalis trophozoites and/or cysts in stool

specimens.
- Direct fecal smears - trophozoite as having a floating leaf-like motility.
- Concentration technique is recommended to detect cysts in stools.
II. If the parasite is not found in the feces, duodeno-jejunal aspiration may be
done.
- Examination of the duodenal contents for trophozoites gives a higher
percentage of positive findings compared to examination of feces.
• - In patients with chronic diarrhea, suspect Giardiasis.
 III. Enterotest (String test) another test that may demonstrate Giardia
trophozoites.
IV. Antigen detection tests and immunofluorescent tests are already
available as commercial kits.
A. Immunochromatographic assays detect the presence of Giardia
antigen in stool. Cyst wall protein 1 (CWP1) is one of the antigens used for
these diagnostic tests.
B. Direct fluorescent antibody assays
- the gold standard in diagnosis as such assays have the highest
combination of sensitivity and specificity.
•
 TREATMENT
• Metronidazole
- 250 mg three times a day for 5 to 7 days
- Pediatric dose: 15 mg/kg/day in three divided doses).
- usually well tolerated in adults and has a cure rate of 90%.
• Alternative Drugs:
a. Tinidazole - single dose of 2 g for adults; 50 mg/kg in children)
b. Furazolidone - 100 mg four times daily for 10 days for adults; Pediatric
dose: 6 mg/kg/day in four divided doses for 7 to 10 days).
c. Albendazole - 400 mg/day for 5 days in adults and 10 mg/kg/day for 5
days in children.
- is equally effective as metronidazole at the above doses; not available
in the Philippines.
• Nitazoxanide - has likewise been used effectively in drug-resistant cases.
• Prompt treatment of asymptomatic - reduce cyst passage and possible
transmission;
• high risk groups:
- food handlers, institutionalized patients, children attending day-care,
and day-care workers.

EPIDEMIOLOGY
• Giardia has a worldwide distribution.
• In the Philippines, the prevalence: 1.6 to 22.0%; groups in areas with poor
sanitation and hygiene practices - higher prevalence of giardiasis.
• higher in male adults than females, also in other countries.
• Direct oral-anal sexual contact : men who have sex with men
• Outbreaks of giardiasis : reported outside the Philippines. In water-borne
(recreational water or drinking water).
• Foodborne outbreaks.
• The low infective dose, prolonged communicability, and relative resistance
to chlorine - transmission of Giardia through drinking and recreational water,
food, and person-to-person contact.

PREVENTION AND CONTROL

• Methods of prevention and control include:
- proper or sanitary disposal of human excreta,
- avoid contaminated water,
- avoid risky sexual behaviors/ practices
- wash hands with soap and water after bathroom use and before eating,
This Photo by Unknown Author is licensed under CC BY-SA
DEMONSTRATION OF GIARDIA LAMBLIA/DUODENALIS
 DIENTAMOEBA FRAGILIS

• originally described as amoeba but is actually a flagellate with only the

trophozoite stage known.
• No cyst stage; Except for the absence of a flagellum, this protozoan is
closely related to and resembles Trichomonas.
• lives in the mucosal crypts of the appendix, cecum and the upper colon.
• The exact life cycle is unknown
• Direct human to human transmission: via the fecal-oral route or via
transmission of helminth eggs particularly that of Enterobius vermicularis.
• stools from macaques, gorillas, and swine were found to carry D. fragilis, thus
animal reservoirs may also be potential sources of human infections.
 PATHOGENESIS AND CLINICAL MANIFESTATIONS

• Dientamoeba fragilis does not invade tissues

• usually asymptomatic but if symptomatic. the onset of infection is usually
accompanied by loss of appetite, colicky abdominal pain, and intermittent
diarrhea with excess mucus, abdominal tenderness, a bloating sensation, and
flatulence.
• Another symptom in 11% of patients was anal pruritus. This is due to co-infection
with Enterobius.
• Chronic infection of this organism can mimic the symptoms of diarrhea-
predominant irritable bowel syndrome (IBS), and some experts have suggested
ruling out infection with this organism first before diagnosing a patient as having
IBS.
LIFE CYCLE OF DIENTAMEOBA FRAGILIS
 DIAGNOSIS

• by observation of binucleate trophozoites in multiple fixed and stained fresh

stool samples.
• Fresh stool samples are necessary
• Purged stool specimens provide more suitable material for examination than
the average formed stool.
• Even when formed, D. fragilis may be misdiagnosed as other amebae. This
organism is not detected by stool concentration methods.
• Prompt fixation of the fresh specimen with polyvinyl alcohol fixative or
Schaudinn’s fixative has been found to be helpful.
 TREATMENT, EPIDEMIOLOGY AND PREVENTION AND
CONTROL
TREATMENT
• Iodoquinol at 650 mg three times daily for 20 days. The pediatric dose is 40
mg/kg/day in three doses, also for 20 days. Tetracycline and metronidazole
have also been found to be effective.
EPIDEMIOLOGY
• The organism has a world-wide distribution with varying infection rates
ranging from 0.4 to as high as 42%.
• high prevalence rates of D. fragilis have been reported from developed
countries with high sanitation standards.
PREVENTION AND CONTROL
• Specific recommendations for prevention and control cannot be made until
there is more specific information concerning the method of transmission.
Proper sanitation and disposal of human waste are essential.
 II. GENITAL FLAGELLATES
TRICHOMONAS VAGINALIS

• causes a sexually transmitted disease called trichomoniasis which has a

worldwide distribution.
• correlates strongly with the number of sexual partners.
• most prevalent non-viral sexually transmitted infection.
• Trichomonas vaginalis exists only in the trophozoite stage.
• pyriform shape with four free anterior flagella that appear to arise from a
simple stalk, and a fifth flagellum embedded in the undulating membrane.
• It has a median axostyle and a single nucleus.
• found in the urogenital tract. In women, in the vagina but may ascend as far
as the renal pelvis.
• can be isolated from the urethra, prostate, and less frequently, in the
epididymis in men.
• mode of transmission: by sexual intercourse.

• PATHOGENESIS AND CLINICAL MANIFESTATIONS

• The acute inflammation caused by the parasite results in the characteristic

liquid vaginal secretions, greenish or yellow in color, that cover the mucosa
down to the urethral orifice, vestibular glands, and clitoris.
• The vaginal secretions are very irritating; cause intense itchiness and burning
sensation.
• associated with an increased incidence of postpartum endometritis.
• Complications in women : secondary bacterial infection of the urogenital
tract.
• 2% of cases is the so called strawberry cervix described as punctate
hemorrhages of the cervix on speculum examination.
• In males may be latent and essentially asymptomatic. In some cases, it is
responsible for an irritating persistent and recurring urethritis.
• Most common complication is prostatitis.
 DIAGNOSIS

I. Saline preparation of vaginal fluid

- is the quickest and most inexpensive way to diagnose trichomoniasis, but
the sensitivity of this technique is low at 60 to 70%.
II. Culture
- is the accepted gold standard and it takes 2-5 days.
III. The unstained wet drop preparations may be fixed and stained by
Giemsa, Papanicolau, Romanowsky, and acridine orange stains.
IV. Culture using Diamond’s modified medium, and Feinberg and Whittington
culture medium.
V. Pap smear may also show trichomonads (sensitivity 60%; specificity 95%).
VI. Antigen detection tests and polymerase chain reaction (PCR) assays
- are commercially available, but not widely used locally. PCR among
females does not seem to offer an added diagnostic advantage. Among
males, however, diagnosis is more difficult. For culture, the best results are seen
with a combination of cultures of urethral swabs and urine sediment. PCR
appears to detect more cases than culture among males.
VII. InPouchTM TV Test
- is a novel transport and culture test system.
- This test has a comparable sensitivity to Diamond’s modified medium
culture.
 TREATMENT

• Metronidazole or tinidazole
- to be given 2 g as a single dose.
- Reported cure rate range from 86% to 100%.
- Sexual partners must be treated concomitantly to prevent reinfection.
- If treatment fails and reinfection is ruled out, a seven-day regimen of 500
mg metronidazole three times a day may be considered.
- If either this regimen fails, a 2 g daily dose for 5 days of either
metronidazole or tinidazole can be used.
- In pregnancy, metronidazole remains the drug of choice for
trichomoniasis.
 EPIDEMIOLOGY

• Trichomonas infection occurs worldwide and estimate of 170 to 190 million

are infected with Trichomonas.
• Prevalence is higher among women of child-bearing age.
• 5 to 20% of women and 2 to 12% of men in developed countries are
infected.
• Higher prevalence is associated with greater frequency of sexual intercourse
with multiple partners and with commercial sex workers.
• is often associated with other sexually transmitted infections.
• In the U. S. study, in the United States, 70% of male partners of women with
trichomoniasis were likewise infected and the majority of the infected male
partners were asymptomatic (77%).
• In the Philippines, the prevalence among sex workers varies according to the
method of diagnosis used. 15% studied with microscope and 37% studied
with culture. One study surveyed 421 male sex workers and there were no
positive cases among them based on microscopy.
• In Zimbabwe and South Africa, trial participants diagnosed with
trichomoniasis were more likely to test positive for HIV in their next visit.
• Perinatal transmission of HIV was likewise more likely if the mother had
vaginal infections.
 PREVENTION AND CONTROL

• Prevention is best achieved by reducing the risk of exposure, like:

• Limiting the number of sexual partners, and proper use of protective devices
such as condoms and spermicidal foams
• To prevent “pingpong” or recurrent infections, there should be simultaneous
treatment of sexual partners.
• Prompt follow-up of patients and their contacts,
health and sex education about venereal disease are also important.
This Photo by Unknown Author is licensed under CC BY
This Photo by Unknown Author is licensed under CC BY
 III. BLOOD AND TISSUE FLAGELLATES
• TRYPANOSOMA CRUZI

• is the etiologic agent of Chagas disease or American trypanosomiasis.

• This was discovered more than 100 years ago by Carlos Chaga when 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.
• belongs to the trypanosome group Stercoraria.
• multiply within the mammalian host in a discontinuous manner.
• it is an intracellular parasite, with myocytes (particularly myocardial tissues)
and cells of the reticuloendothelial system being the most heavily infected
cells.
* arthropod vector: are the reduviid bugs, belonging to the genera Triatoma,
Panstrongylus, and Rhodnius; thrive under squalid housing conditions such as
thatched roofs and mud walls, commonly seen in poor rural communities.
• Zoonotic mammalian reservoir hosts:
- domestic animals, armadillos, raccoons, rodents, marsupials, and
even some primates.

4 STAGES OF DEVELOPMENT:
a. Amastigote
- found in human tissue cells and are usually found in small groups of cyst-
like collections in tissues.
b. Promastigote
c. Epimastigote
c. Trypomastigote

- are found in the bloodstreams of humans.

- The posterior end - pointed. The undulating membrane is narrow with two
to three undulations; single thread-like flagellum originating near the
kinetoplast provides the parasite with mobility. In stained specimens,
trypomastigotes are characteristically C-shaped; also been described as U- or
S-shaped with a prominent kinetoplast, characteristic of the species.

• Inside its insect vector, the amastigote, epimastigote, and promastigote

forms occur in the midgut, while the infective metacyclic trypomastigote
appear in the hindgut.
LIFE CYCLE OF T. CRUZI
 PATHOGENESIS AND CLINICAL MANIFESTITIONS

• Chagas disease can be divided into:

A. acute phase
B. chronic phase
Acute Phase
• is characterized by a focal or diffuse inflammation mainly affecting the myocardium.
• Nonspecific signs and symptoms, such as fever, malaise, nausea, vomiting, and
generalized lymphadenopathy.
• Cutaneous manifestations of the disease can sometimes appear during this phase,
usually associated with a localized inflammatory reaction at or near the site of
inoculation.
• Appearance of Chagomas which are furuncle-like lesions associated with
induration, central edema, and regional lymphadenopathy. These lesions represent
the site of entry of the parasite.
• If the parasite penetrates through the conjunctiva, eyelid swelling called
Romaña’s sign may form; characterized by unilateral painless bipalpebral
edema and conjunctivitis, and may involve the lacrimal gland and
surrounding lymph nodes.
• Symptoms resolve after 1 o 2 months and the patient goes into a latent
phase.
• During this phase, infected patients are still capable of transmitting it to
others through insect vectors, blood transfusion, or organ transplantation.
Chronic phase
• Heart is the primary organ affected
• is manifested by fibrotic reactions that cause injury to the myocardium,
cardiac conduction network, and enteric nervous system (decrease in nerve
ganglia leading to megasyndromes).
• result in cardiomegaly, congestive heart failure, thromboembolism, and
even arrhythmias.
• Less severe signs and symptoms are chest pain, palpitations, dizziness,
syncopal episodes, abnormal electrocardiogram findings, achalasia
associated with megaesophagus, and chronic constipation associated with
megacolon.
 DIAGNOSIS
> Complete patient history – is the primary tool for diagnosing Chagas disease. Like:
• Establishing possible exposure to T. cruzi and risk factors such as place of residence
or work, recent blood transfusion in an endemic area, and contact or exposure to T.
cruzi intermediate host should be evaluated.
Acute phase
> Direct visualization of the parasites in thick and thin blood smears using Giemsa
stain.
- definitive diagnosis of Chagas disease.
- Cerebrospinal fluid (CSF), tissue samples, or lymph can also be used for parasite
visualization.
- only in the first two months of acute disease can T. cruzi trypomastigotes be seen
by direct examination.
> Concentration methods (microhematocrit)
> Blood culture
> polymerase chain reaction (PCR)
 > Xenodiagnosis, wherein laboratory-reared triatomine bugs are allowed to
feed on suspected patients and are later examined for the presence of T. cruzi
metacyclic trypomastigotes.

Chronic phase:

> Enzyme-linked immunosorbent assay (ELISA)

> Indirect hemagglutination
> Indirect immunofluorescence
> PCR
• The WHO recommends using at least 2 techniques with concurrent positive
result before a diagnosis of Chagas disease is made.
Cardiac Form:

• ECG and echocardiography may show atrial fibrillation/flutter, low QRS voltage,
dilated cardiomyopathy, and tricuspid and mitral regurgitation.

Gastrointestinal Form:
• usually diagnosed by barium esophagogram (esophageal dilatation) and barium
enema (megacolon of the sigmoid and rectum).

• TREATMENT

• For acute phase of Chagas Dse:

• Nifortimox
• Benzdinazole
• These 2 drugs are associated with severe side effects.
Side effects:
> Nifurtimox : may cause weight loss, anorexia, behavioral changes, and
an antabuse effect.
> Benzdinazole : may cause rashes, bone marrow suppression, and
peripheral neuropathy.
Other drugs:
> Allopurinol
> Itraconazole
• These 2 have been shown to halt the progress into cardiomyopathy.
• No form of treatment has been shown to reverse the damage caused by the
disease.
Newer drugs: which are currently under development.
• Triazole derivatives:
> Posaconazole
> Ravuconazole
• Cruzipain inhibitors (a parasite protease)

• Symptom-specific management is used to treat patients with chronic

manifestations.
• Cardiac manifestations:
- are controlled by pacemakers and antiarrhythmic drugs, such as
amiodarone.
• Megasyndromes:
- are managed with special diets, laxatives, and surgical procedures.
 EPIDEMIOLOGY

• Chagas Disease is estimated to have infected more than 10 million people

worldwide.
• Mostly in Latin America where more than 25 million people are at risk for the
disease.
• Estimated 10,000 – 12,000 people die of the disease annually.
• In America, the prevalence and distributions has been continually shifting.
Endemic regions include most of Central America and the southern cone of
South America.
• Chagas disease is included in the WHO list of Neglected Tropical Diseases
(NTDs), and is the leading cause of parasite-related deaths in Latin America.
In 2003, it ranked 3rd as the leading cause of parasitic infection in the world,
behind malaria and schistosomiasis.
 PREVENTION AND CONTROL

• There have been major breakthroughs in the control and prevention of

American trypanosomiasis, particularly by Brazil, Chile, and Uruguay. Vector
control and blood transfusion regulations have delivered positive outcomes,
in terms of disease prevention in these countries.
• Spraying of insecticides, use of insecticide-treated bed nets, and house
improvements to prevent vector infestation have been proven cost-
effective.
• Vaccine development has not yet been successful, but the advent of newer
technologies and characterization of the T. cruzi genome may aid in future
vaccine research.
 TRYPANOSOMA BRUCEI GAMBIENSE
TRYPANOSOMA BRUCEI RHODESIENSE

• Human African trypanosomiasis (HAT), also known as African sleeping

sickness, is a highly fatal disease caused by two subspecies of Trypanosoma
brucei: T. brucei gambiense and T. brucei rhodesiense. A third subspecies, T.
brucei brucei, primarily affects wild and domestic animals; collectively, the
three subspecies represent the Trypanosoma brucei complex.
• 2 types of HAT: East African trypnosomiasis and West African Trypanosomiasis.
• Members of the T. brucei complex belong to the trypanosome family
Salivaria.
• is usually transmitted via the bite of the bloodsucking tsetse fly (Glossina
spp.) feeding from an infected mammalian host.
• HAT cases are localized in regions of sub-Saharan Africa, primarily in remote
rural areas where tsetse fly habitats are located.
T. brucei gambiense:
- localized mostly in the western and central regions of sub-Saharan
Africa.
- It primarily affects humans, but utilizes dogs, pigs, and sheep as
reservoir hosts.
- It is responsible for the chronic type of sleeping sickness, (West African
sleeping sickness) and accounts for 95% of all HAT cases.
T. brucei rhodesiense
- is found in east Africa.
- is primarily a zoonosis of cattle and wild animals, with humans being
accidental hosts.
- It causes the more acute and rapidly fatal form of sleeping sickness,
(East African sleeping sickness) and accounts for the remaining 5% of HAT
cases.
• Only the epimastigote and trypomastigote forms are exhibited by the T.
brucei complex.
- Though mostly transmitted through its insect vector, the disease can
also be transmitted through mechanical methods (accidental needle pricks,
other blood sucking insects), as well as vertically, via mother-to-child
infection through the placenta.

PATHOGENESIS AND CLINICAL MANIFESTATIONS

• Two types of Human African trypanosomiasis, depending on the subspecies
causing the disease:
a. Acute (East African Trypanosomiasis) – caused by T. b. rhodisiense
b. Chronic (West African Trypanosomiasis) – caused by T. b. gambiense
• Trypanosoma brucei gambiense sleeping sickness manifests months or years
after initial infection.
• Trypanosoma brucei rhodesiense sleeping sickness may appear just weeks
after infection.

Initial Lesion:
• begins as a local, painful, pruritic, erythematous chancre located at the bite
site, progressing it to a central eschar, and resolving after 2 to 3 weeks.
• Trypanosomal chancre is more common in Gambian sleeping sickness.

• Both types of HAT undergo two stages:

• early phase called the hemolymphatic stage
• late phase known as the meningoencephalitic stage
Hemolymphatic stage:
- the parasites proliferate in the bloodstream and lymphatics
• Manifestations:
- irregular bouts of fever, headache, joint and muscle pain, and malaise.
- Anemia, myocardial inflammation, disseminated intravascular
coagulation, and renal insufficiency.
- in Gambian trypanosomiasis, the posterior cervical lymph nodes are
enlarged, non-tender, and rubbery in consistency (Winterbottom’s sign).
- In both types of sleeping sickness, axillary and supraclavicular lymph
nodes may also be involved.
- These signs and symptoms are due to tissue damage, either from parasitic
toxins or immune complex reactions that target organs and RBC’s.
• Meningoencephalitic stage: marks the involvement of the central nervous
system.
- The brain and meninges become involved as the parasites find their way
into the CNS through the bloodstream.
- In Gambian infection, this usually occurs 3-10 months after initial
infection, whereas in Rhodesian trypanosomiasis, it can manifest after just a
few weeks.
• Neurologic symptoms:
- apathy, behavioral changes, headache, and sleep pattern changes;
more severe symptoms, such as convulsions, tremors, speech defects,
disturbances in speech and reflexes, and even paralysis.
- Kerandel’s sign may manifest as a deep, delayed hyperesthesia
(delayed bilateral pain out of proportion to the extent of tissue injury).
• In the later stages, somnolence manifests, followed by a deep coma. Death
eventually follows either from the disease itself, or from intercurrent infection
due to immunosuppression.

• Areas of the CNS involved:

> Frontal lobe
> Pons
> Medulla
> Perivascular areas
• Parasites may also be seen in the CSF.
• Autopsy of HAT patients reveals:
- edema and numerous, small, and confluent hemorrhages.
DIAGNOSIS
• Diagnostic techniques:
> demonstration of highly motile trypomastigotes in expressed fluid from a
chancre, lymph node aspirate, and CSF. Thick and thin blood films can be
stained with Giemsa.
> Buffy coat concentration method is recommended to detect parasites
when they occur in low numbers. Examination for trypomastigotes is usually
done during the hemolymphatic stage of the disease, and is more useful for
the diagnosis of T. brucei rhodesiense.
- Serial examinations may be necessary due to varying levels of
parasitemia.
 > Other diagnostic techniques include:
- enzyme-linked immunosorbent assay
- immunofluorescence,
- indirect hemagglutination test,
- mini-anion exchange centrifugation technique,
- PCR
• CSF examination is mandatory in patients with suspected HAT to detect CNS
involvement.
Abnormal CSF findings include:
- increase in cell count, opening pressure, protein concentration, and IgM
levels.
- This is considered pathognomonic for the meningoencaphalitic stage of
the disease.
 > Card agglutination test for trypanosomiasis (CATT) detecting circulating
antigens in persons infected with T. brucei complex is available commercially
and can be used in the field setting to screen at-risk populations.
- This technique provides a rapid and highly specific method of screening
for HAT cases.
- the method has low sensitivity for certain strains of T. brucei gambiense
in certain areas of West Africa.

TREATMENT
- depends on the stage of the disease.
First stage:
> Intravenous Suramin sodium for both T. brucei gambiense and T. brucei
rhodesiense.
> Intramuscular Pentamidine for the Gambian form.
Side Effects:
> For Suramin: include fever, rash, renal insufficiency, muscle pain, and
paresthesia.
> For Pentamidine: include tachycardia, hypotension, and hypoglycemia.
• These drugs do not cross the blood-brain barrier, and so, they cannot be
used for the CNS stage of the disease.
For CNS involvement:
> Intravenous Melarsoprol
- is the drug of choice for both types of sleeping sickness.
• This arsenic-containing drug can cause fatal arsenic encephalopathy
(usually prevented by co-administration of corticosteroids), and resistance to
the drug has also been observed.
• Jarisch-Herxheimer reaction – a febrile episode due to trypanosome lysis
following melarsoprol treatment.
• For Melarsoprol treatment failure:
> A second-line drug, Nitrofurazone, is used.
> A newer drug, eflornithine, less toxic than melarsoprol, and can also be
used during the hemolymphatic stage; it is only effective against T. brucei
gambiense.
• a combination treatment of oral nifurtimox and intravenous eflornithine is of
similar efficacy compared to longer intravenous monotherapy with either
agent.
• Combination therapy is advantageous due to the relative ease in
administration, and a decreased risk of developing drug resistance.
• Nifurtimox is currently registered as a drug against American
trypanosomiasis, its use in the nifurtimox-eflornithine combination treatment
(NECT) has been included in the WHO List of Essential Medicine.
 EPIDEMIOLOGY

• Sleeping sickness affects around 300,000 to 500,000 people in 36 countries within

subSaharan Africa. It is estimated that more than 50 million people are at risk of
infection.
• In the last 10 years, most reported cases came from the Democratic Republic of
Congo (DRC), followed by the Central African Republic.
• Other countries:
- Angola, Cameroon, Chad, Congo, Côte d’Ivoire, Equatorial Guinea, Gabon,
Guinea, Kenya, Malawi, Nigeria, Sudan, Uganda, United Republic of Tanzania,
Zambia, and Zimbabwe.
• Newer data from the WHO has estimated more recently that new cases have
dropped below the 10,000 mark, a first in 50 years.
• Tsetse flies live near the banks of rivers and streams, therefore transmission can
readily occur when people frequent these areas to swim and do their laundry.
• Rhodesian trypanosomiasis is an occupational hazard for persons working in game
reserves, and may also be a threat to visitors of game parks.
• Cattle and game animals like antelopes can serve as reservoir hosts for the parasite.
PREVENTION AND CONTROL
• Vector control is the primary method used in the control and prevention of African
sleeping sickness.
Control methods:
> Tsetse fly trapping is the main strategy employed to decrease the vector
population.
> Use of insecticides and protective clothing are recommended to prevent
contact with the insect vector.
> Regulation and treatment of reservoir hosts such as cattle and game animals are
also being looked upon as an effective means of preventing disease transmission.
* The WHO has established partnerships with private companies such as Aventis
Pharma (Sanofi-Aventis) and Bayer HealthCare to provide surveillance and
management support to endemic countries.
This Photo by Unknown Author is licensed under CC BY-SA
 TRYPANOSOMA BRUCEI GAMBIENS

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 LEISHMANIA SPP.

• Early descriptions of leishmaniasis have been found as early as the first

century A.D., where American Indians documented the disease in pottery
figures.
• Leishman had properly identified the intracellular parasites in 1903.
• Leishmania braziliensis was later identified in 1911 by Gaspar Viana, as was
the insect vector which transmitted the parasite in 1922 by Henrique Aragao.
• Leishmaniasis is a disease caused by infection of the diploid protozoa
belonging to the genus Leishmania.
• This genus is actually divided into two subgenera, differentiated from one
another by the location of their development inside the insect vector, as well
as the areas in which they are endemic.
Epidemiologically, the Leishmania spp. are divided into:
1. Old World leishmaniasis
2. New World leishmaniasis

Old World, the common species involved are:

a. L. tropica – Asia and Eastern Europe
• B. L. aethiopica and L. major – Africa

• New World leishmania:

a. L. mexicana
b. L. amazonensis
c. L. guyanensis
d. L. braziliensis
e. L. chagasi.
• These affects Mexico, Central America, and some parts of South America, as well as
the Amazon rain forest,
• Insect vector for these parasites are Arthropods, particularly sandflies of the
following genera:
1. Phlebotomus – for Old World
2. Lutzomyia – for New World

• Dogs are the primary reservoir in urban areas

• Rodents act as reservoirs in both urban and rural areas

Leishmania spp. Produce:

> Amastigotes intracellularly in the mammalian host,
> Promastigotes in the hindgut (Viannia subgenus), midgut (Viannia and
Leishmania subgenera), and proboscis (Viannia and Leishmania subgenera)
of the insect vectors.
Amastigotes:
• ovoid or rounded bodies measuring 2 to 3 µm in length and live intracellularly
in monocytes, polymorphonuclear leukocytes, or endothelial cells. The
nucleus is large, while an axoneme arises from the kinetoplast and extends to
the anterior tip.

Promastigotes
• have a single free flagellum arising from the kinetoplast at the anterior end
measuring 15 to 20 µm in length and 1.5 to 3.5 µm in width.
• Leishmania spp. may also be transmitted congenitally, through blood
transfusion, by contamination of bite wounds, and by direct contact with
contaminated specimens.
 PATHOGENESIS AND CLINICAL MANIFESTATIONS
Clinically, leishmaniasis are divided into four categories:
A. Cutaneous leishmaniasis (CL)
B. Diffuse cutaneous leishmaniasis (DCL)
C. Mucocutaneous leishmaniasis (MCL)
D. Visceral leishmaniasis (VL)
- The wide spectrum of symptoms manifested by leishmaniasis is often
compared to leprosy, where the localized CL is similar to tuberculoid leprosy,
and DCL is similar to lepromatous leprosy.

A. Cutaneous leishmaniasis (CL)

• is the most common form of the disease, and is caused by several species of
Leishmania, including:
a. L. tropica (dry or urban oriental sore)
b. L. major (moist or rural oriental sore)
c. L. mexicana (chiclero ulcer, usually affecting the ears)
• Incubation period: two weeks to several months.
• An erythematous papule or nodule, called an “oriental button,” is produced
at the inoculation site. It has raised edges and a central crater.
• the papule forms a violaceous ulcer as it enlarges in size during the course of
several weeks.
• lesion may heal spontaneously after a few months, leading to a disfiguring
scar.
• in the case of New World leishmaniasis, CL may progress to other forms of
leishmaniasis.
B. Diffuse cutaneous leishmaniasis (DCL)

• The manifestation of DCL, also called anergic or lepromatous leishmaniasis,

is characterized by a localized, non-ulcerating papule, eventually
developing numerous diffuse satellite lesions that affect the face and
extremities.
• This type may be initially diagnosed as lepromatous leprosy.
C. Mucocutaneous leishmaniasis (MCL)

• develops in about 2 to 5% of persons infected with L. braziliensis, either

concurrently or even several years after the resolution of skin lesions.
• also due to the contiguous spread of cutaneous leishmaniasis caused by L.
tropica.
• This produce the so called Espundia, due to the Involvement of the mucous
membranes of the nasal and oral cavities results in nasal stuffiness,
discharge, epistaxis, and destruction of the nasal septum.
• Progression into the pharynx and larynx may threaten the airway passage,
and may lead to dysphonia, dysphagia, and even aspiration pneumonia.
• Systemic Th1 response is strong with increased levels of peripheral
mononuclear cells in the blood.
D. Visceral leishmaniasis (VL) ( or Kala Azar)
• disseminated parasitosis primarily caused by L. donovani complex: L.
donovani, L. chagasi, and L. infantum.
• Incubation period: 2 to 8 months, but clinical symptoms in previously infected
but asymptomatic persons may appear during immunocompromised states.

In the acute phase:

• twice-daily fever spikes (double quotidian), with accompanying chills may
be present, which might be mistaken for malaria.

During the subacute and chronic course

• common signs and symptoms include fever, weakness, loss of appetite,
weight loss, hemorrhage, and abdominal enlargement associated with
hepatosplenomegaly
• Small number of Phagocytosed amastigotes are present in the blood and
numerous in reticuloendothelial cells of the spleen, liver, lymph nodes, bone
marrow, intestinal mucosa, and other organs.

Leishmania-specific Th1 response is usually low or absent.

If VL is left untreated, has a greater than 95% mortality rate.

Post-kala azar dermal leishmaniasis (PKDL) is a sequela of visceral

leishmaniasis, usually seen in endemic areas.
- manifests as a cutaneous eruption resulting in hypopigmented macules,
malar erythema, nodules, and ulcerations. manifest a few months to several
years after treatment.
 DIAGNOSIS

> Diagnosis of active leishmaniasis is based on the microscopic

demonstration of Leishmania from lesion and tissue scrapings, aspirates, or
biopsy.
- Giemsa and hematoxylin-eosin stains are often used in microscopic and
histologic samples, and the demonstration of amastigotes confirms the
diagnosis of leishmaniasis.
> Cultures are unreliable due to the difficulty of isolating the parasites,
especially in old lesions.
> reports of successful primary isolation of the New World cutaneous
leishmania using the Novy, MacNeal, and Nicolle medium (NNN).
> The Schneider’s medium found useful.
> The leishmanian skin test (Montenegro skin test) can be used to identify
exposure to the parasite; usually positive in cases of CL and MCL, but is
negative in cases of DCL and kala azar.
 > Immunologic assays such as ELISA and rk39 antigen dipstick test have
demonstrated high sensitivity and specificity for VL in certain
immunocompetent patient populations.
> Direct agglutination, urine antigen assays, and newer techniques such as
flow cytometry and molecular diagnostic modalities (polymerase chain
reaction, RFLP analysis) are also being used and it may be may be used to
identify the species of Leishmania.

TREATMENT

Primary pharmacologic treatment is based on antimony compounds:

• the Pentavalent Antimonials:
> sodium stibogluconate
> n-methyl-glucamine (meglumine)
 - still being used in areas where susceptibility is still good, due to its low cost.
- primary treatment failure and relapses are often observed using these
drugs. especially in patients with AIDS.

Side effects:
- abdominal pain, nausea, arthralgia, and even fatal arrhythmias are high.
• Treatment should only be done after consultation with infectious disease
experts.
• daily intramuscular or intravenous administration for up to 4 weeks, and
hospital confinements are necessary.
For treatment failure or where resistance is high:
> Intravenous Amphotericin B is the drug of choice.
- high cure rate; the associated side effects, as well as the cost and
availability of the drug are significant limiting factors.
 > Lipid-based preparations of the drug (AmBisome) - highly effective, better
tolerated, and overall cost-effective drug formulation for cutaneous and
visceral leishmaniasis.
In India, sodium pentavalent antimony resistance is high,
> Antineoplastic drug Miltefosine was introduced in 2002 to treat VL; only
oral drug currently given to VL patients.
> Pentamidine is another second-line drug for cutaneous as well as the
visceral form of the disease; due to side-effects and the development of drug
resistance, pentamidine use has been limited.
> Topical Paromomycin – used for the cutaneous form of leishmaniasis
which has shown efficacy in certain areas.
• Combination therapy using two or more of the anti-leishmanial drugs is being
studied.
• Combination drugs: sodium stibogluconate plus paromomycin, and
liposomal amphotericin B plus either miltefosine, or sodium stibogluconate.
 EPIDEMIOLOGY
• Leishmaniasis is a global disease distributed across 88 countries in four
continents.
• New cases of cutaneous leishmaniasis number between 1 to 1.5 million per
year, the majority of which occur in Afghanistan, Brazil, Iran, Peru, Saudi
Arabia, and Syria.
• American soldiers deployed in Afghanistan and Iraq have also
demonstrated cases of CL.
• Mucocutaneous leishmaniasis occurs in Bolivia, Brazil, and Peru, while half a
million new cases annually of visceral leishmaniasis occur primarily in
Bangladesh, Brazil, India, Nepal, and Sudan.
• In 2009, there was upsurge in VL cases in Sudan affecting mostly poor and
malnourished children below 15 years old.
• Leishmaniasis is primarily a disease of poverty; affects people living in squalid
conditions, and is associated with poor housing, malnutrition, a weak
immune system, and lack of resources.
• Visceral leishmaniasis is an important opportunistic infection in AIDS patients.
• VL/ HIV co-infection is currently a major threat in the control and prevention
of either disease.
• Immunosuppression from HIV predisposes to VL, while VL infection
accelerates HIV replication and progression to AIDS.
• Most cases of VL/ HIV co-infection are coming in from Ethiopia, southern
Europe (Spain, Italy, France, and Portugal), and Brazil.
• In the Philippines, there have been imported cases of cutaneous lesions
referred to the University of the Philippines—College of Public Health, where
amastigotes were identified from the patients.

PREVENTION AND CONTROL

Preventive measures against leishmaniasis include:
> usage of insect repellants containing DEET and permethrin, insecticide-
treated clothing, and fine-mesh bed nets.
 > Use of fine mesh screens and spraying of houses and buildings are also
being done in certain areas. However, interval spraying predisposes to
resistance of sandflies to the insecticides, not to mention the impact of
insecticides on the environment
> Regulation of reservoir hosts is another important aspect in the control and
prevention of leishmaniasis.
> Insecticide-treated dog collars, mass testing of domestic dogs, and even
extermination of infected dogs are current strategies that address zoonotic
transmission of the disease.

At present, there is no commercially available form of either active or passive

chemoprophylaxis against leishmaniasis.

• Commercial vaccines are currently under development.

This Photo by Unknown Author is licensed under CC BY
 NON-PATHOGENIC FLAGELLATES
Namely: 1. Trichomonas hominis
2. Trichomonas tenax
3. Chilomastix mesnili

TRICHOMONAS HOMINIS
> a harmless commensal found in the caecum and colon of man, other
primates, dogs and cats.
> only as a trophozoite
> pyriform shape and measures 7 to 13 µm; five anterior flagella and a
posterior flagellum projecting from an undulating membrane; cytostome and
the nucleus are situated at the anterior end; axostyle extends from anterior
to posterior along the mid-axis.
 > less common in temperate climates; prevalence in the Philippines is less
than 1%.
> Transmission: occurs rapidly through fecal contamination of food and
drinks.
> associated with Entamoeba histolytica.

TRICHOMONAS TENAX
> also known as oral trichomonas; species commonly found in oral cavity of
humans.
> a pyriform flagellate; only in trophozoite form
> measures 5 to 12 µm, and is smaller and more slender than T. vaginalis.
> smallest of the 3 genus Trichomonas.
 > has four free equal flagella and a fifth one on the margin of an undulating
membrane which does not reach the posterior end of the body, and lacks a
free posterior extension.
> has a single nucleus and a cytostome.
> a commensal in human mouth; tartar around the teeth or defects of carious
teeth; not found on the gums of healthy patients.
> no evidence of direct pathogenesis, but it is frequently associated with
pyogenic organisms in pus pockets or at the base of teeth.
> in necrotizing ulcerative gingivitis and necrotizing ulcerative periodontitis,
worsening preexisting periodontal disease.
> also implicated in some chronic lung diseases.
> Transmission : through saliva, droplet spray, and kissing or use of
contaminated dishes or drinking water; divide by binary fission.
 > patients with poor oral hygiene and advanced periodontal disease.
> Signs Symptoms:
- not known to cause symptoms if alone.
- rare bronchopulmonary infections mainly in cancers or other
underlying lung disease.
> Diagnosis
- is made by swabbing the tartar between the teeth, the gingival
margin, or tonsillar crypts.
> Treatment:
- For Pulmonary Trichomoniasis, Metrinidazole.
 CHILOMASTIX MESNILI
> is a flagellated protozoan generally regarded as nonpathogenic in the
human host.
> inhabits the cecal region of the large intestine.
> exist in 2 forms: trophozoite and cystic stages.
> Trophozoite:
- asymmetrically pear-shaped; spiral groove extending through the
middle half of the body.
- movement: boring and spiral forward by 3 anterior free flagella and a
more delicate one within the prominent cytostome.
> Cyst:
- pear- or lemon-shaped; single large vestibular nucleus and the
cytostome by hematoxylin and eosin stained film.
> Life cycle similar to Giardia lamblia. . Both trophozoites and cysts are
passed in the feces; only cysts can survive outside of the host.
> Transmission: ingestion of cysts ( the infective stage) in food and drinks.
> Prevalence: < 1% in the Philippines; more prevalent in areas with
inadequate sanitation.
> The presence of cysts and/or trophozoites in stool specimens - an indicator
of fecal contamination of a food or water source,
> No treatment is indicated.
> Preventive and control measures include improved sanitation and personal
hygiene.
This Photo by Unknown Author is licensed under CC BY-NC-ND