Parasitology

Ciliates and Flagellates

Presentors:
Ilaji, Fatima Nurshiba
Olayres, Vince Dave
Dabay, Sanjie
 Ciliates
Balantidium coli
• a.k.a Paramecium coli
• Largest protozoa
• Pathogenic
‑ Balantidiasis (pig as major host)
‑ Balantidiosis
‑ Balantidial dysentery
‑ Explosive diarrhea
• Zoonotic –came from animals
 Balantidium coli

• Cilia –locomotor apparatus

• Capable of attacking the intestinal epithelium
‑ result: ulcer formation
‑ cause: bloody diarrhea (similar to amebic
dysentery)
• Hyaluronidase –virulence factor
• Encystation –not result in increasing the number of
nuclei
 Balantidium coli

• Incubation period - 4 to 5 days

• Infective stage – cyst stage
‑ inactivated by heat and by 1% sodium
hypochlorite
‑ Chlorination of water is not effective
• Reproduction:
‑ Asexual: asymmetric binary fission
‑ Sexual: conjugation
Balantidium coli
BALANTIDIUM COLI CYST
Size range 40-60 μm
Motility None
Shape Spherical to slightly ovoidal
Number and Nuclei Two kidney-shaped
macronucleus small spherical
micronucleus.
Peripheral Chromatin Granulated
Membrane Thick double cell walls
Other features One or two visible contractile
vacuole
Balantidium coli
BALANTIDIUM COLI TROPHOZOITE
Size range 30-150 x 25-120 μm
Motility Thrown ball or rolling ball rotary /
boring movement longitudinal
pattern extending from the oral to
the caudal region
Shape Pointed & broadly rounded
posterior
Number of nuclei Two kidney-shaped macronucleus
small spherical micronucleus; may
not be observable
Peripheral chromatin None
Membrane Covered with cilia
Balantidium coli

BALANTIDIUM COLI TROPHOZOITE

Other features One or two visible contractile
vacuoles (mucocusts) in young
cysts, double cysts wall row of
cilia visible in between cyst wall
layers of young cysts.
Balantidium coli
Life Cycle
 Balantidium coli
Pathogenesis and Clinical Manifestations

1. Ulcers
• Capable of attacking the intestinal epithelium and creating a
characteristic ulcer with a rounded base and wide neck.
• Caused by the lytic enzyme hyaluronidase secreted by the
trophozoite.
2. Balantidiasis
• Aggravated by presence of Salmonella
 Balantidium coli
Pathogenesis and Clinical Manifestations
Three Forms of Clinical Manifestations:
a. Asymptomatic carriers
• Do not present with diarrhea or dysentery, but may serve as reservoir
b. Fulminant balantidiasis/Balantidial dysentery
• 6 to 15 episodes of diarrhea with bloody and mucoid stools accompanied by
abdominal pain, nausea, and vomiting.
• Often associated with immunocompromised and malnourished states.
c. Chronic balantidiasis
• Diarrhea may alternate with constipation, and may be accompanied by
nonspecific symptoms such as abdominal pain or cramping, anemia, and
cachexia
 Balantidium coli
Laboratory Diagnosis

1. Direct examination or concentration techniques

• microscopic demonstration of trophozoites and cysts.
- Increased sensitivity –repeated stool examinations
2. Biopsy
• Trophozoites in lesions obtained through sigmoidoscopy
3. Bronchoalveolar washings
• trophozoites in pulmonary infection
 Balantidium coli
Treatment

Drug of choice: tetracycline & metronidazole

o Tetracycline
• Older children and adults: 500 mg or 40 mg/kg/dose divided
in four doses for 10 days.
• Contraindication: children < 8 years old and pregnant women
o Metronidazole
• 750 mg three times daily, or 35 to 50 mg/kg body weight/
day in three divided doses for 5 days.
 Balantidium coli
Treatment
o Iodoquinol
• 650 mg, or 40 mg/kg/dose, divide in three doses for 20 days

o Doxycycline and nitazoxanide

• are 2 antibiotics that their use together with quinolones was
suggested as a successful alternative therapy.
• Nitazoxanide, a benzamide thiazolide derivative, has been shown to
be effective against many bacteria as well as helminthes and
protozoa (8-10).
Balantidium coli
Treatment
Balantidium coli
Treatment
Balantidium coli
Treatment
 Flagellates
Species
Pathogenic Non-Pathogenic
1. Giardia lamblia 1. Chilomastix mesnili
2. Trichomonas vaginalis 2. Trichomonas hominis
3. Trichomonas tenax
• All trichomonas spp. Doesn’t have
their cysts form
 Flagellates
Giardia lamblia

• Describe by Dr. Lamb (French) and Dr. Giard (Czechoslovakian)

• Specimen of choice: Stool & Duodenal contents
• Lives in duodenum, jejunum, and upper ileum of humans.
• Incubation period: 1 to 4 weeks (average of 9 days)
• Infective stage: Mature cyts
• Risk Factor: direct oral-anal sexual contact among men who
have sex with men
Giardia lamblia
 Giardia lamblia
Morphology
Giardia lamblia cyst
Size Range 8-12 x 7-10 um
Motility
Shape Ovoidal
Number of Nuclei Immature cyts, two
Mature cyst, Four
Appearance
Membrane Double wall ( inner and outer)
Cyst wall protein 1
Cytoplasm Retracted
Flagella Retracted into axonemes, the median or
parabasal body, and deeply stained
Giveaway Football Shaped
 Giardia lamblia
Giardia lamblia Trophozoite
Size Range 9-12 x 5-15 um
Motility Falling or floating leaf and erratic tumbling
motion
Shape Pyriform or tea- drop
Number of Nuclei Two, Ovoidal
Appearance Bilaterally symmetrical
Membrane
Cytoplasm
Flagella Four pairs, origination of each
One pair, anterior end
One pair, posterior end
Two pair, central, attached to median bodies
extending laterally to axostyle
Giveaway Old-man with eyeglasses
 Giardia lamblia
Pathogenesis and Clinical Manifestations

• Infection occurs when the host ingests food or water

contaminated with the mature cysts.

• Attachment was observed to be maximal at body temperature

and stable at a pH of 7.8 to 8.2.
Giardia lamblia
Life Cycle
 Giardia lamblia
Diagnosis
• Trophozoites in direct fecal smears may be characterized as
having a floating leaf-like motility.
 Giardia lamblia
Diagnosis
•To detect cysts in stools, concentration techniques are
recommended. At least three stool examinations on alternate days
are recommended because of spotty shedding of cysts.
 Trichomonas vaginalis
• Only pathogenic Trichomonas spp.
• Largest trichomonas
• Does not form cyst, only trophozoite
• Habitat: Urogenital tract (vagina to renal pelvis)
• Reproduction: binary fission
• Incubation period: 4 to 8 days
 Trichomonas vaginalis
Morphology
TRICHOMONAS VAGINALIS TROPHOZOITE
Size Range 7-23 um
Motility Jerky tumbling
Shape Pyriform
Number of Nuclei One
Appearance
Undulating Membrane Half costa
Cytoplasm
Flagella Four free anterior flagella arising in a
single stalk 5th along the margin of the
undulating membrane/ 1 in the
posterior

Giveaway Knob- like or nipple-shaped

protuberance
 Trichomonas vaginalis
Pathogenesis and Clinical Manifestations

• Inflammation of the vaginal mucosa occurs several days

after the inoculation of T. vaginalis trophozoites.
• T. vaginalis cannot live without close association with the
vaginal, urethral, or prostatic tissues.
• Four to 28 days after introduction of viable T. vaginalis
into the vagina
Trichomonas vaginalis
Life cycle
 Trichomonas vaginalis
Diagnosis
Specimens
• Urine sample
• Vaginal discharge
• Prostatic or seminal fluid- heavily infected male
• Cervical Scrapings

Microscopy
• Saline preparation- detection of motility, quickest and most in
expensive
• Unstained wet drop in Giemsa, Papanicolaou (PAP smear ., 25 yr
old)
Chilomastix mesnili

• Largest flagellate

• Habitat: cecal region of the large intestine

Chilomastix mesnili
CHILOMASTIX MESNILI CYST
Size range 7-10 x 4.5-6 μm
Motility
Shape Lemon shaped
Number of nuclei One to two
Appearance
Membrane
Cytoplasm
Flagella
Chilomastix mesnili

CHILOMASTIX MESNILI CYST

Other structure Cytostome

Giveaway Knob-like or nipple shaped

Protuberance
Hematoxylin and eosin:
Single large vestibular
Nucleus and the Cytostome
Chilomastix mesnili
CHILOMASTIX MESNILI TROPHOZOITE
Size range 6-10 μm
Motility Boring or spiral forward
Movement
Cork-screw motility
Shape Pear-shaped
Number of nuclei One (large, spherical)
Appearance Asymmetrical
Membrane
Cytoplasm
Flagella Three anterior, free
Chilomastix mesnili

CHILOMASTIX MESNILI CYCT

Other structure Longitudinal spiral groove
Extending through the
Middle half of the body
Prominent Cytostome
Giveaway Cytostomal fibril or
Shepherds crook
Chilomastix mesnili
Life Cycle
 Chilomastix mesnili
Mode of Transmission

• Ingestion of cysts in food and drinks

Diagnosis
• Examination of feces and demonstration of either
trophozoites or cysts
 Trichomonas
hominis/Pentatrichomonas
hominis
• Does not have cystic stage
• Smaller than vaginalis
• Most common intestinal flagellate
• Really difficult to identify
• Habitat: cecal area of the large intestine
• Infective stage: Trophozoite stage
 Trichomonas
hominis/Pentatrichomonas
hominis
TRICHOMONAS HOMINIS TROPHOZOITE
Size 7 – 13 µm
Shape Pyriform
No. of nuclei One with small central
karyosome, anterior end
Undulating Membrane As long as the costa
Flagella Five interior flagella and a
posterior flagellum
Other structures Conical cytostome cleft,
anterior end
Giveaway Axostyle extend from
anterior to mid-axis
Flagella is not visible
 Trichomonas
hominis/Pentatrichomonas hominis
Life Cycle
 Trichomonas
hominis/Pentatrichomonas
hominis
Mode of Transmission

• Fecal contamination of food and drinks

 Trichomonas tenax

• a.k.a Trichomonas buccalis – inhabit buccal cavity/

mouth
• Harmless ommensal of the mouth
• Does not form cyst
• Smaller and more slender than T. vaginalis
• Resistant to changes in temperature and will
survive for several hours in drinking water
Trichomonas tenax
TRICHOMONAS TENAX
Size 5-12 µm
Shape Pyriform
No. of nuclei One
Undulating Membrane Two-thirds of costa
Flagella Four free equal flagella 5th on
the margin of the undulating
membrane
Other structures Small cytostome
Giveaway Knob-like or nipple-shaped
protuberance
 Trichomonas tenax

Mode of Transmission
• Droplet spray from the mouth, kissing, or common
use of contaminated dishes and drinking glasses
 Trichomonas tenax
Pathogenesis and Clinical Manifestations

• Pulmonary trichomoniasis – not alone

Diagnosis
• Swabbing the tartar between the teeth, the gingival
margin, or tonsillar crypts
Trichomonas tenax
Treatment
• Metronidazole
 Trichomonas tenax
Differentiation of Trichomonas

Features T. hominis T. tenax T. vaginalis

Habitat Large intestine Mouth Genitalia
Size Small Smallest Largest
Nucleus Ovoidal Rounded Ovoidal
UM As long as costa Two-thirds of the Half of the costa
costa
Inclusions Siderophil granules
Specimen Stool Oral scrapping Urine, vaginal
swab/ secretions,
prostatic secretions
Blood and
Tissue
Flagellates
 Blood and Tissue
Flagellates
Atrial flagellates: large intestine
Hemoflagellates: blood and reticuloendothelial system/cells
consisting of:
• Blood
• Bone marrow
• Esophagus
• Colon
• Heart
• Liver
• Spleen
• Lymph nodes
 Blood and Tissue
Flagellates
Two species of hemoflagellates
1. Trypanosoma spp.
2. Leishmania spp
• Unicellular
• Flagellated
• Arthropod borne
 Blood and Tissue
Flagellates
Morphologic Forms
Amastigote (Leishnan-Donovan body)
• Doesn’t have flagella
• Posterior and anterior end cannot be
defined
• Has axoneme
 Blood and Tissue
Flagellates
Morphologic Forms

2. Promastigote
• The flagella is found at the anterior
end
• Nucleus lies in the center
 Blood and Tissue
Flagellates
Morphologic Forms

3. Epimastigote
• Has an undulating membrane extending
from the anterior end to blepharoplast
• The flagella is found at the anterior end
• Nucleus is almost at the posterior
beside kinetoplast
 Blood and Tissue
Flagellates
Morphologic Forms

4. Trypomastigote
• Nucleus is almost at the center
• Found in the bloodstream
• In stained specimens, C-shaped
 Blood and Tissue
Flagellates

Mode of Transmission
• Vector borne
• Vertical transmission- from mother to child
through birth
• Accidental needle prick
• Blood transfusion
• Organ transplant
 Blood and Tissue
Flagellates
Trypanosoma and Leishmania:
Stages seen Most often (in the blood film)
Stage Description Common Name: Found in (Infective
stage)
Amastigote No Flagella Leishmanial form L. Donovan
L. Tropica
L. Braziliensis
T. cruz
Trypomastigote Flagella Originates at Trypanosomal form T. Rhodesien
Posterior end of T. Gambiense
organism T. cruzi

Disease Chagas Disease West African East African

South American Sleeping Sleeping
Sleeping Sickness sickness
Sickness
 Blood and Tissue
Flagellates
Trypanosoma cruzi
• Etiologic agent of chagas
disease or American
trypanosomiasis
• Intracellular parasite
• 3rd as the leasing cause of
parasitic infection in the
world, behind malaria and
schistosomiasis
Trypanosoma cruzi
Vectors

Kissing Bugs
Trypanosoma cruzi
Life Cycle
 Trypanosoma cruzi
Pathogenesis and Clinical
Manifestations

1. American Trypanosomiasis (Chaga’s Disease)

• Endemic to America
• Presents 2 phases
 Trypanosoma cruzi
Pathogenesis and Clinical
Manifestations
2 Phases of Chaga’s Disease
Acute Trypanosomiasis
• More dangerous
• Characterized by focal or diffuse inflammation
mainly affecting the myocardium
• Chagonia
• Romaña’s sign
 Trypanosoma cruzi
Pathogenesis and Clinical
Manifestations
2 Phases of Chaga’s Disease

Chronic Trypanosomiasis
• More grave
• Mya last for 20 years or more
• Heart – primary organ affected during this phase
 Trypanosoma cruzi
Pathogenesis and Clinical Manifestations
Characteristics of American Trypanosamiasis
Characteristics Trypanosoma cruzi Trypanosoma rangeli
Vector Reduviid bug Reduviid bug
Primary Reservoirs Opossums, dogs, cats, Wild rodents
wild, rodents
Illness symptomatic Asymptomatic
Diagnostic stage
Blood trypomastigote Trypomastigote
Tissue Amastigote (intercellular None
morphological form)
Recommended Specimens Blood, lymph nide Blood, but organisms
aspirate, chagoma rarely recovered
 Trypanosoma cruzi
Diagnosis

• Patient history – primary diagnosis

• Giemsa staining - definitive diagnosis
• Blood cultures – NNN (Novy-MCNeal-Nicolle) medium
• Serologic test
• Molecular testing
• ECG (cardiac form)
• Gastrointestinal form – barium esophagogram and barium enema
 Trypanosoma cruzi
Treatment

• Nifurtimox and Benznidazole – acute phase

• Symptom-specific management – chronic phase
 Trypanosoma
•
brucei
Human African trypanosomiasis (HAT) or
African sleeping sickness
• Trypanosome family Salivaria
• Mode of transmission: Bite of vector
 Trypanosoma
brucei
Morphological Forms

• Only the epimastigote and trypomastigote

forms are exhibited
 Trypanosoma
Morphological
brucei Forms

1. Trypomastigote
• Polymorphic
• Flattened and fusiform in shape
• Reproduction: longitudinal binary fission
• Able to evade the immune response of the
host through antigenic variation
 Trypanosoma
Morphological
brucei Forms

2. Epimastigotes
• Multiplying for 15 to 20 days -> migrate
to the foregut into the insect’s salivary
glands -> mature into metacylic
trypomastigotes
Trypanosoma
Life
bruceiCycle
 Trypanosoma
Life Cycle
brucei
• Vector: Tsetse fly
• Mode of transmission: Not through defecation but
through injection of metacylic trypomastigote
• Multiplies in body fluids
• Infective stage of human: Metacylic trypomastigote
• Infective stage of vector: Trypomastigote
 Trypanosoma
Pathogenesis and Clinical Manifestations
brucei
1. Trypanosoma brucei gambiense
• Glossina palpalis
• Glossina tachnoides
• Reservoir host: dogs, pigs, and sheep
• Manifests months or years after initial
infection
 Trypanosoma
Pathogenesis and Clinical Manifestations
brucei
West African (Gambian) Sleeping sickness
Hemolymphatic stage (early stage)
• Invades blood and lymphatic fluids
• Fever, headache, joint and muscle pain, malaise,
tachycardia, dizziness & rashes
• Chancre (hard painful lesion at the site of inoculation)
 Trypanosoma
Pathogenesis and Clinical Manifestations
brucei
2. Trypanosoma brucei rhodesiense
• Glossina morsitans
• Glossina swynnertoni
• Zoonosis of cattle and wild animals
• Accidental hosts: Humans
• Appear just weeks after infection
 Trypanosoma
Pathogenesis and Clinical Manifestations
brucei
East African (Rhodesian) Sleeping sickness
• Rhodesian trypanosomiasis
• More rapid and fatal
• CNS involvement appear early
• Neurologic deterioration is rapid
 Trypanosoma
Diagnosis
brucei
1. Microscopic examination (Thick and thin blood films
by Giemsa)
• Usually done during the hemolymphatic stage of
the disease
2. Serologic tests – IFAT, ELISA, IHAT, CATT & CIATT
 Trypanosoma
Diagnosis
brucei
Card Agglutination Test for Trypanosomes
CATT
Type of test Antibody test
Reagent Fixed, stained, intact
trypanosomes (Antigen)

Detects Previous exposure

Advantages High sensitivity and specificity and
is simple and quick to perform

Species Trypanosoma brucei gambiense

 Trypanosoma
Diagnosis
brucei
Card Indirect Agglutination Test for Trypanosomes
CIATT
Type of test Antigen test
Reagent Specific antibodies coupled to
latex beads (Antibody)

Detects Active infection

Advantages High sensitivity and specificity and
is simple and quick to perform

Species Trypanosoma brucei gambiense &

Trypanosoma brucei rhodesiense
 Trypanosoma
Diagnosis
CHARACTERISTICS
brucei
East and West African trypanosomiasis
EAST AFRICAN WEST AFRICAN
Organism Trypanosoma brucei Trypanosoma brucei gambiense
rhodesiense
Vector Tsetse fly, Glossina morsitans Tsetse fly, Glossina palpalis
group group
Primary reservoir Animal (wild and domestic) Humans
Illness Acute (early CNS invasion) <9 Chronic (late CNS invasions)
mo months to years
Lymphadenopathy Minimal Prominent
Parasitemia High Low
Epidemiology Anthropozoonosis, game parks Antroponosis, rural populations
Diagnostic stage Trypomastigote Trypomastigote
Recommended specimen Chancre aspirate, lymph node Chancre aspirate, lymph node
aspirate, blood, CSF aspirate, blood
Leishmania
spp.
• Intracellular parasites
• Diploid protozoa
 Leishmania spp.
Species

Old world New world

1. L. tropica (Asia and Eastern 1. L. Mexicana

Europe) 2. L. amazonensis
• Phlebotomus papatasii 3. L. guyanensis
• Phlebotomus sergentii 4. L. braziliensis
• Phlebotomus spp. (sand-fly) • Phlebotomus peruensis
2. L. aethiopica (Africa) • Phlebotomus verrucarum
3. L. major • Phlebotomus argentipes
5. L. chagasi
• Lutzomyia
 Leishmania spp.
Species

TROPICA BRAZILIENSIS DONOVANI

• Old world leishmaniasis • New world • Visceral leishmaniasis
• Cutaneous leishmaniasis • Kala-azar fever
leishmaniasis • American leishmaniasis • Dumdum fever
• Oriental sore • Mucocutaneous
• Jericho boil leishmaniasis
• Baghdad boil
• Aleppo button
Leishmania spp.
Life Cycle
 Leishmania spp.
Life Cycle

• Macrophages
o Largest WBC
o Parasitized cell
• Infective stage of human: Promastigote
• Infective stage of vector: Amastigote
 Leishmania spp.
Pathogenesis and Clinical
Manifestations
1. Cutaneous Leishmaniasis (CL)
• Most common form
• Superficial
• Skin ulcer, painless lesions “leprematous leprosy” &
lesions do not heal spontaneously and tend to relapse
after treatment
• Caused by
o L. tropica (dry or urban oriental sore
o L. major (moist or rural oriental sore)
o L. Mexicana ( chiclero ulcer, usually affecting the
ears)
• Incubation period: 2 weeks to months
 Leishmania spp.
Pathogenesis and Clinical
Manifestations

2. Diffuse Cutaneous Leishmaniasis (DCL)

• Anergic or lepromatous leishmaniasis
• Localized , non-ulcerating papule
• Developing numerous diffuse satellite lesions that
affect the face and extremities
• Initially diagnosed as lepromatous leprosy
 Leishmania spp.
Pathogenesis and Clinical
Manifestations

3. Mucocutaneous Leishmaniasis (ML)

• 2 to 5% of persons infected with L. braziliensis
• Deeper (nose, mouth, ears)
• Involvement of the mucous membranes of the nasal
and oral cavities -> nasal stuffiness, discharge,
epistaxis, and destruction of the nasal septum
 Leishmania spp.
Pathogenesis and Clinical
Manifestations

4. Visceral Leishmaniasis (VL)

• “Kala-azar or Dumdum fever”
• Caused by L. donovani complex: L. donovani, L.
chagasi, L. infantum
• Incubation period: 2 to 8 months
 Leishmania spp.
Diagnosis

1. Biopsy
2. Serologic test: CH, IFAT, Counter current electrophoresis
techniques
3. Montenegro test – skin test, positive in cases of CL and
MCL, but is negative in cases of DCL and kala-azar
4. Formol – gel test
5. TPAG ratio – Total protein, Albumin-Globulin (A/G)
6. Giemsa and hematoxylin-eosin stains
7. Culture: Novy,MacNeal, and Nicolle (NNN) and
Schneider’s medium only in New world
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