Hemoflagellates

- Found in blood and tissues

- Movement: by means of flagella

Two genera:

- Leishmania
- Trypanosoma

Leishmania braziliensis

Causative agent of:

 Mucocutaneous leishmaniasis
 Chiclero ulcer
 Espundia
 Forest yaws
 Plam Bois
 Uta

Epidemiology:

 L. braziliensis – Mexico Argentina

 L. panamensis – Panama, Colombia
 L. peruviana – Peruvian Andres
 L. guyanensis – Guana, Brazil

Vector: Sandfly Lutzomyia

Notes:

 Sandfly vectors transmit promastigotes thru skin bite

 Promastigotes invade reticuloendothelial cells
 Proma transform into Amastigotes (Infective stage)

Clinical symptoms (Mucocutaneous)

 Incubation period: within a few weeks to months

 Large ulcers in oral and nasal mucosa
 Cutaneous skin lesions
 If untreated nasal lesions – destruction of nasal septum
 Secondary bacterial infectiom
 Disfigurement of face

Clin symptoms caused by other members of Leishmania

 Espundia – L. brazieliensis
  Forest yaws – “Pian bois” Guianas
 Uta- peruviana

Lab Diagnosis

 Specimen – biopsy of infected ulcer

 Method – microscopy
 Giemsa stain
 Look for: Amastigotes

Treatment

 Antimony compounds: Sodium stibogluconate (pentosam)

 Alt: Ampo B, Fluconazole, Ketoco, Itraco

Leishmania donovani

Causative agent of:

 Visceral leishmaniasis
 Kala-azar
 Dum Dum fever

Epidemiology:

 Chagasi – Mexico
 Donovani – Africa, Thailand, China, Pakistan
 Infantum- Europe, Hungary

Vectors:

 L. donovani chagasi – Lutzomyia

 L. donovani donovani – Phlebotomus
 L. donovani infantum – Phlebotomus

Notes:

 Similar with braziliensis with only 2 exceptions:

- Sandlfy vary with each species
- Donovani mainly infect visceral tissue

Clinical Symptoms of Visceral Leishmaniasis

 Incubation period: 2 weeks – 8 months

 Hepatosplenomegaly
 Early stage may resemble malaria
 Diarrhea
 Anemia
 Glomerulonephritis
  Kala-azar (Black fever due to darkening of the skin)
 Chronic: death in 1-2 yrs Acute: Lethal in weeks

Lab Diagnosis

 Montenegro Skin Test – Same with tuberculin skin test; Not good for diagnosing active disease
 Giemsa Stain
 Possible specimens: blood, bone marrow, lymph node aspirats, biopsies
 Other methods: IFA, ELISA

Treatment

 Ampo B
 Sodium stibogluconate (alternative)

Leishmania Mexicana

Causative agent of:

 New world cutaneous L.

 Chiclero ulcer
 Bay sore

Vector: Lutzomyia sandfly

Notes: Same with braziliensis

Clinical Symptoms (New world cutaneous L.)

 Incubation: varies with each species

 Single pus containing ulcer
 40% infections affect the ear; can damage surrounding cartilage
 Red papule at bite site : 2cm of size, has red itching (Pruritis)

Lab diagnosis

 Giemsa stained slides

 Specimen: lesion biopsy material
 To look for: Amastigotes
 Other tests: Culture in NNN medium, Nuclear DNA hybridization, Monoclonal Anti bodies

Treatment

 Na stibo
 Ampo B (alternative)

Leishmania tropica

Causative agent of:

 Old world cutaneous L.

 Dry/ urban cutaneous L.
  Oriental sores
 Delhi boils
 Baghdad boils

Epi

 Aethiopica – Kenya
 Major – Soviet, Iran Israel
 Tropica – Afghanistan, India, Kenya

Vector: Phlebotomus sandfly

Notes: Same with braziliensis, Attacks human lymphoid tissue

Clinical symptoms (World cutaneous L.)

 Incubation varies with each subspecies

 One or more pus-containing ulcer
 Red papule at bite site; 2cm, intense itching

Lab diagnosis

 Giemsa stained slides

Specimen: Aspiration fluid from ulcer bed (look for amastigotes)
 Culture
Specimen: Ulcer tissue (look for Promastigotes)
 Other methods: Serology, IFA, Nuclear Hybrid

Treatment

 Na stibogluconate
 Alt: Ketoconazole, steroids, application of heat to infected lesions

Trypanosoma brucei gambiense

Causative agent:

 West African sleeping sickness

 Gambian trypanosomiasis

Epi

 Found in West and Central Africa

Vector: Tsetse fly (Glossina palpalis and tachinoides)

Notes

 Trypomastigotes enter Lymphatic system thru blood meal

- Multiply via binary fission
 CNS invasion ensues
 Trypo are transmitted back to the fly after feeding from an infected human
  Trypo migrate to salivary glands of tsetse fly and become Epimastogotes
 Epi transform back into trypo

Clinical symptoms (Gambian sleeping sickness)

 Asymptomatic incubation period: days to weeks

 Painful chancre develops, surrounded by white halo at bite site
 Fever, malaise, headache
 Lymphadenopathy
 Winterbottom’s sign – enlargement of cervical lymph nodes
 Kerandel’s sign – delayed pain sensation

Lab diagnosis

 Giemsa stained slides

Specimen: blood, lymph nodes aspirates (Look for trypo)
 CSF examination
Check for trypo using IgM detection

Treatment

 Eflornithine
 Melarsoprol
 Pentamidine
 Suramin

Trypanosoma brucei rhodesiense

Causative agent of:

 East African sleeping sickness

 Rhodesian trypanosomiasis

Epi

 Found in central Africa

Vector: Tsetse fly (glossina morsitans and pallipides)

Clinical symptoms (East African or Rhodesian)

 More virulent than gambiense

 Fever, malaria, rigors
 NO WINTERBOTTOM; NO LYMPHADENOPATHY
 Rapid weight loss, mental disturbance, lethargy
 Death in 9-12 months via glumerulonephritis and myocarditis

Trypanosoma cruzi

Notes:

1. Trypo are defecated near the site of blood meal

 2. Bite site causes itching sensation
3. Host scratches bite area
4. Trypo gain entry
5. Other MOT: blood transfusion, sex, transplacental and mucous membranes
6. Trypo transform into amastigotes
7. Amastigotes destroy cells
8. Amastigotes convert into trypo
9. Trypo are ingested via reduviid bug
10. Trypo convert into epi
11. Epi reproduce inside bug
12. Epi convert back into trypo

Clincial symptoms (Chaga’s disease)

 Chagoma – erythematous nodule at site of infection

 Romana’s sign – conjunctivitis, unilateral edema of eyelids
 Myocardities
 Megacolon
 Megaesophagus
 CNS involvement
 Cardiomegaly

Lab diagnosis

 Giemsa stained slides

Specimen: Blood (look for trypo)
Lymph node biopsy (look for amas)
 Other methods: Complement fixation, IIF, PCR, ELISA

Treatment

 Nifurtimox
 Alt: Beznidazole, Allopurinol, Ketoco

Trypanosoma rangeli

 NO disease associated; benign to asymptomatic

Epi – same with cruzi

Notes – same life cycle with cruzi

Vector: reduviid bug and Rhodius prolixus

Lab diagnosis

 Giemsa stained blood films (look for trypo)

 Other methods: Serologic testing, PCR, Xenodiagnosis

Treatment
Nifurtimox and Benzimizadole