HEMOFLAGELLATES

Flagellates e) Choanomastigote
• Intestinal and reproductive tract f) Amastigote
o Giardia g) Paramastigote
** bold: not seen in the species

Two Hosts
• Humans and their domestics (animals they interact with) are
definitive host
• Insect are vectors, the intermediate host

o Trichomonas Four Life Stages

• Not all life stages occur in all species
• Certain stages are found in specific hosts
- Epimastigotes and Promastigotes in insect
intermediate hosts
- Trypomastigotes and Amastigotes in definitive host

• Blood and Tissue

- Trypanosoma
- Leishmania

Hemoflagellates – Trypanosoma
• Kingdom: Protista Fig. (left to right): Trypomastigote, Epimastigote, Promastigote, Amastigote
• Phylum: Sarcomastigophora
• Class: Zoomastigophora a) Amastigote
• Order: Kinetospladia -Rounded or oval forms devoid of
• Family: Trypanosomatidae external flagellum
• Genus: Trypanosoma - Has nucleus and kinetoplast
• Species: cruzi, brucei, rangeli - Example: Leishmania
b) Promastigote
Structure of Leishmania and Trypanosoma - Elongated form
• Include the following: - Kinetoplast anterior to nucleus
o Body - Flagellum arising near it and
o Nucleus emerging from the anterior end
o Kinetoplast of the body
o Flagellum - No undulating membrane
o Undulating - Visible nucleus and kinetoplast
membrane - Example: Leptomonas
• Structure of Leishmania and Trypanosoma in general c) Epimastigote
- Elongated form with a juxta nuclear kinetoplast
Anatomy and Life Stages - Flagellum arising near it and
• 7 ontogenetic stages, but not all species have all seven. emerging from the side of the
These stages are continuous. body to run along short
• For Trypanosoma and undulating membrane
Leishmania, only 4 - Example: Blastocrithidia
a) Promastigote - Magkatabi yung nucleus at kinetoplast
b) Ophistomastigote d) Trypomastigote
c) Epimastigote - “true” trypanosome type
d) Trypomastigote - Postnuclear kinetoplast

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 Hemoflagellates

- Flagellum arising near it to run along a long undulating Life Cycle of T. brucei Subspecies
membrane
- Nucleus and kinetoplast are separated

• Intermediate Host: Tsetse Fly → in their midgut

Species of Flagellate Protozoa that Inhabit the • Can pass onto humans thru a bite (saliva), parasite will
Bloodstream and Tissues of Man enter the human (metacyclic trypomastigotes)
• Trypanosoma brucei (difference • Multiplies via binary fission → migrate to blood, lymph or
of the subspecies: location) spinal fluid
- T. b. rhodesiense (East • Trypomastigotes in blood – diagnostic stage; infective stage
African) • Two stages for Trypanosoma brucei: trypomastigote and
- T. b. gambiense (West epimastigotes
African)
• Trypanosoma cruzi
• Can be seen in CSF, liver,
spleen
• Kung nasaan ang blood:
nagmimigrate dun yung
parasites

Trypanosoma brucei Subspecies

• Trypanosoma brucei gambiense (West African)
• Trypanosoma brucei rhodesiense (East African)
• Definitive host:
- Humans
- not pathogenic to any other species
- native ruminates serve as reservoirs for T. b.
rhodesiense, but not T. b. gambiense
• Intermediate host:
Pathogenesis - Tsetse fly (Glossina)
• T. brucei primarily invades the blood, lymph, and spinal fluid • Mode of Transmission:
• The course of T. brucei infections depend on the - Bite of infected tsetse fly
susceptibility of the animals involved - Trypomastigotes divide rapidly and
• Horses, mules and dogs are acute sufferers; can die within spread throughout the body
2 weeks of infection • Location:
• Symptoms include: - Throughout the body in the blood and tissues
- Anemia • Pathology:
- Edema - Both subspecies cause African Sleeping Sickness
- Fever - Gambiense: chronic, long-term form
• Cattles suffer the same kinds of symptoms but often live a - Rhodesiense: acute form
few extra months - Starts with a small sore at bite
• Pigs can recover from the infection - Trypomastigotes divide rapidly and spread throughout
the body

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 Hemoflagellates

Geographic Distribution Treatment

• T.b. gambiense found in west • Trypan blue and trypan red
central and central Africa • Suramin sodium
• T.b. rhodesiense found in central • Melarsoprol
and east central Africa • Difluoromethylornithine
• Why do we need to study? • Eflornithine
o Migration
o Intermediate host are found in
the PH (reduviid kissing bugs, Prevention
tsetse flies) • Bug control
• Eradication of nests
• Treating infected person and exclusion of donors by
screening blood
• Development of vaccine
• Using dichlorodiphenyltrichloroethane (DDT)
• We don’t screen for Trypanosomes and Leishmania in the
Philippines, only Malaria

Trypanosoma cruzi
American Trypanosomiasis (Chaga’s Disease)
• Definitive host
- Humans
- Dogs
- Cats
- Opossums
- Armadillos
Clinical Disease of Trypanosoma brucei Subspecies - Wood rats
• T. b. gambiense (West African) • Intermediate host
- Frequently goes to CNS - Reduviid bugs (kissing bugs
- Causes chronic sleepiness associated with African or assassin bugs)
Sleeping Sickness • Location in the definitive host
- S&S: Apathy, mental dullness, disturbance of - Throughout the body
coordination, increase in sleepiness, finally to coma - Trypomastigotes in blood
and death sleeping beauty sickness - Amastigotes most common in spleen, liver, and
- Death may also occur from malnutrition, falling or other muscles including heart
infections • Mode of transmission
• T. b. rhodesiense (East African) - Invertebrate hosts
- Rarely invade the CNS, but causes death much faster - Blood transfusion
(usually due to the invasion of heart tissue) - Sexual and congenital transmission (transplacental)
- Both subspecies produce intermittent periods of fever,
particularly in the early stages Geographic Distribution
o Due to the antigen shifts of the parasite • Throughout much of central and south
o Can also take antigens from host body and put them America
on their body • 12-19M affected annually
o Much pathology may be due to heightened immune • 2-3M with chronic symptoms
response killing uninfected body cells • 45,000 die every year
o Serologic testing can be used • Few cases in US in Maryland, Georgia,
Florida, Texas, California, Alabama
and Louisiana

Life Cycle
• Same with other trypanosoma but with invasion of organs
• Amastigotes: found in tissues (liver, spleen, heart)

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 Hemoflagellates

Clinical Syndrome Hemoflagellates – Leishmania

• Acute stage • At least 4 different major species of Leishmania parasite are
- Immediate reaction to infection responsible for leishmaniasis which are similar in
- Only occurs in about 1% of people infected morphology but differing in:
- Swelling of the eye, tiredness, fever, rash, loss of - Cultural characteristic
appetite - Clinical feature (chronic, acute, which organ it invades)
- Can be fatal for infants, young children and - Geographical distribution
immunocompromised recipients
• Intermediate Leishmania spp.
- 8-10 weeks after infection with no symptoms 1. L. donovani
• Chronic o Causes visceral leishmaniasis (Kala Azar), involving
- 10-20 years after infection liver, spleen, and bone marrow
- Enlarged heart and digestive tract 2. L. tropica and L. major
- Can result in heart failure o Causes old world cutaneous leishmaniasis (oriental
- Little effective therapy (toxic drugs/low cure rates) sore)
3. L. braziliensis complex
Lab Diagnosis for T. cruzi o Cutaneous and mucocutaneous leishmaniasis in
• Examination of blood America, involving mucous membranes of the
- Thick and thin blood films mouth and nose after spread from a nearby
- Buffy coat examination cutaneous lesion (very rare)
- T. cruzi can often be seen in C, U or S shapes in 4. L. mexicana complex
stained films o Cutaneous leishmaniasis in America, involving the
• Xenodiagnosis skin at the site of a sandfly bite
• Blood culture
• Serology tests • Leishmaniasis – involves permanent disfiguration
- Indirect fluorescence antibody test (IFAT)
- Complement fixation test (CFT) Introduction – Leishmaniasis
- Indirect hem agglutination test (IHAT) • Leishmaniasis is a parasitic disease transmitted by the bite
- Enzyme linked immunoabsorbent assay (ELISA) of sand flies
• Found in parts of at least 88 countries including the Middle
east
• Different spp. of Leishmania cause different forms of
disease
• Middle east: L. major and L. tropica are the most common
species
o L. major: causes skin infection
o L. tropica: causes skin and visceral infection and
rarely causes mucocutaneous infection

• Amastigotes (right pic): no flagella; kinetoplast and Route of Transmission

nucleus present • Insect bite (sand fly) → most common
route
• Blood transfusion
• Rarely transplacental
• Human: chief host in most areas,
some areas: dogs and foxes

Morphology – Leishmania
• Amastigotes:
o Small, oval
o Contains nucleus
o Rod-shaped kinetoplast
o No flagellum
Treatment for T. cruzi • Promastigote
• Nifurtimox o Found in the vector
• Allupurinol o Spindle in shape
• Benznidazole o Contains nucleus
o Anterior free flagella arise
• Diuretic treatment
from a kinetoplast at the
• Surgical intervention
anterior end
• Leishmania
Control of T. cruzi
o Intracellular in macrophages
• Bug control
o Inhabit the blood and RES
• Eradication of nests
• Treating infected person and exclusion of donors by
screening blood
• Development of vaccine
• Using dichlorodiphenyltrichloroethane (DDT)

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 Hemoflagellates

or years and can leave significant scars and be disfiguring

on the skin
• L. tropica infection can spread to
contagious mucus membrane
(upper lip to nose)
• Swollen lymph nodes may be
present near the sored (under
the arm if the sores are on the
arm or hand)

Mucocutaneous Leishmaniasis
• Amastigote is engulf by a macrophage • Caused by L. braziliensis complex and L. Mexicana
complex
Life Cycle - Leishmania • Mucocutaneous; American
leishmaniasis (new world)
• Identical to oriental sore but may
produce later mucous membrane
involvement
o Occurs if a cutaneous lesion
on the face spreads to involve the nose or mouth
(Disfiguration is permanent not just scarring)
o This rare mucosal involvement may occur if a skin
lesion near the mouth or nose is not treated
• Painful, can cause great deformity with erosion of the nose
palate or larynx or ear
• Edema, tissue destruction & secondary bacterial infection
may occur
• May occur months to years after original skin lesion and can
be very disfiguring

Visceral Leishmaniasis
• L. donovani infection
• Visceral leishmaniasis, kala-azar,
• Promastigotes in the saliva of the sandfly is injected into the dum dum fever, Black dis
skin through skin bite • Transmitted by sand fly
• Promastigotes are eaten or phagocytized by macrophages
(WBC)
• Inside the macrophages, promastigotes will transform into
amastigotes
• Macrophage will be eaten by the sandfly, once macrophage
is inside the sandfly, it will burst then it will liberate Pathology and Symptoms
amastigotes • Phagocytosed parasites are present in blood and numerous
• Amastigote will turn into promastigotes, go up in the midgut in spleen, liver, lymph nodes, bone marrow and intestinal
of the sandfly and can infect again mucosa
• Incubation Period: 1-4 months
Cutaneous Leishmaniasis • Intermittent fever (40C), often with 2 peaks daily; chills and
• Caused by L. tropica and L. major sweating may be present
• Other names: oriental sore, • Hepato-splenomegaly (enlargement of the abdominal area)
Baghdad boil, Delhi ulcer • Lymph adenopathy
• Two types: • Bleeding from gum, lips, nose, and intestinal mucosa
o L. tropica: dry (urban), chronic • Anemia (low RBC), leukopenia (low WBC),
course, late ulceration thrombocytopenia (low platelets)
o L. major: moist, (rural), acute • Post kala-azar dermal
course, early ulceration, and leishmaniasis
exudation o Nodular skin lesion, containing
• Characterized by 1 or more many organisms, usually over
sores, papules or nodules on the the dorsum of the hands and
skin, develop within few weeks of face; appear 1-2 years after cure of the disease
the sand fly bite, however they o Once leishmaniasis is treated, post kala-azar dermal
can appear up to months later leishmaniasis may develop; parasites in the
• Sores can change in size and appearance over time tissues/blood go out to the skin creating nodules (when
• Sore looking like volcano with a raised scraped, you can see many parasites)
edge and central crater usually painless
but can become painful if secondary Diagnosis
infected • Early diagnosis and treatment is critical to avoid
• If ni-scrape: amastigotes can be seen disfigurement
• Skin sores of cutaneous leishmaniasis • Patients with any of the following findings should be referred
can heal on their own; can take months early to avoid long term complications:

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 Hemoflagellates

o Big lesions (greater than an inch in size)

o Many lesions (3 or more)
o Sores on the face, hand, and feet over joints
o Sores that will not heal have to be referred for
evaluation—even if not “typical” for leishmaniasis
• Biopsies should be done for diagnosis but require special
treatment to avoid further disfigurement
• Scrapings of the lesion margin and make an impression
smear to see the amastigote stage
• Direct visualization of the parasite (amastigote in liver and
spleen)
- Make a slide stained with Leishman or Giemsa stain for
20 min to see the amastigote in monocyte,
macrophages, less commonly in neutrophil (they are
the WBC that phagocytized amastigotes)
• Find the parasite in the tissue biopsy: L.N, spleen, liver, skin
lesion
• Serology test: IFA and ELISA
• Molecular test: PCR
• Culture in NNN media (Novy-MacNeal-Nicolle medium)

Prevention
• Suppress the vector (Prevent sand fly bite)
o Most important at night
o Sleeves down
o Screening of doors and windows by fine mesh
o Insect repellent with DEET
• Suppress the reservoir: dogs, rats, gerbils, other small
mammals and rodents

Pader, Juliene Andrei B.