Pre cyst stage

PROTOZOA
- 10-60 X 15-30u average (15-20u)
PATHOGENIC PROTOZOA - Round or oval with a blunt pseudopodia
- Protozoa that exist in human body and cause harm to - Absent cyst wall
infected human (E. histolytica, G. lamblia, B. coli) - Single nucleus present.

COMMENSAL PROTOZOA Cyst stage

- Protozoa that exist human body but does not cause harm
- 10-20u average (15u)
to infected human ( e.g. E. coli, E. dispar, E. hartmanni) -Responsible for - Four nuclei are present in mature
food storage
quadrinucleated cyst
OPPORTUNISTIC PROTOZOA
-Disappears - Glycogen mass & chromatoid bodies are present
- weak protozoa that cause minimal effect to infected during
in immature cysts –disappear in mature ones.
healthy man but has severe effect on infected excystation
immunocompromised man ( e.g. Cryptosporidium parvum) LIFE CYCLE (CHRONOLOGICAL ORDER)

POTENTIALLY PATHOGENIC FREE-LIVING PROTOZOA - Pre-cyst

- Free-living in nature away from man but some of them - Uninucleate cells
may cause disease if they enter the human body by certain - Binucleate cells
route. - Quadrinucleate cells
- - Trophozoites
CLASSIFFIED ACCORDING TO ITS LOCATION:
Pathogenesis
INTESTINES:
- Depends on the:
 Amoeba : Entamoeba  Virulence
 Flagellates : Giardia  Host resistance
 Sporozoa : Cryptosporidium  Condition of the Intestinal tract
 Ciliates : Balantidium coli - How will E. histolytica burrow the intestinal
lumen?
UROGENITAL  Answer: Due to the presence of
histolytic enzyme that is used to
 Trichomonas
destroy the intestinal mucosa leading
BLOOD AND TISSUES to the formation of flask-shaped ulcer.

 Trypanosoma Factors Determining Pathogenicity

 Leishmania (Flagellates)
- Strain
 Plasmodium
 E. dispar similar to E. histolytica only
 Toxoplasma
that E. dispar is non-invasive.
- Virulence
TROPHOZOITE CYST - Host Factors
Active / Vegetative Dormant  Immunity
Feeding stage Infectious Stage  Nutrition
Sensitive Highly resistant  Drugs
Causes symptoms of the body  Debilitating state
 Intestine
- Followed by:
INTESTINAL PROTOZOAS (AMOEBA)  Proliferation of connective tissue
 Intensive Ulcerations
 Entamoeba histolytica  Extra-intestinal invasion to brain, liver,
- Pathogenic lung or skin.
- Ingests RBC
- Pseudopod forming non-flagellated protozoan Since the parasite’s habitat is the caecum area, there will
parasite be chances where during the burrowing of the
- Most invasive of the Entamoeba parasites trophozoites, it would affect the liver area since it is
- The only member of the family to cause COLITIS closest to the region. The patient will then have the extra-
and LIVER ABSCESS. intestinal amoebiasis.
- Habitat: Caecum and Sigmoidorectal region
Clinical Pictures
(Large Intestine)
- Infective stage: Quadrinucleate cyst 2 forms: Asymptomatic and Symptomatic
- Mode of reproduction: Binary Fission
- Mode of Infection: - Asymptomatic – are cyst carriers only. They are
 Eating raw vegetables non-infective to the parasites. (More than 75%
 Drinking water of our asymptomatic cases are healthy cyst
 Flies and food handlers (cyst passer) passers)
 Faeco oral (autoinfection) - Symptomatic
 Acute Intestinal Amoebiasis – (gradual
Morphology of Trophozoite onset), fever (low grade), diarrhea,
dysentery, abdominal pain, localized
- 10-60 X 15-30u average (20-25 u)
abdominal tenderness, tenesmus &
- Cytoplasm is clearly differentiated into:
strain, painful spasm of anal sphincter
 ECTOPLASM: is clear with well-
 Chronic Intestinal Amoebiasis -
developed pseudopodia.
Recurrent attacks of dysentery with
 ENDOPLASM: dense & fine granular
intervening periods of constipation,
enclosing:
abdominal distension & Flatulence,
- NUCLEUS: spherical containing centrally located
weight loss and cachexia.
karyosome & peripheral evenly distributed small
 Extra Intestinal Amoebiasis - Amoebic
chromatin dots.
hepatitis or amoebic abscess, lung
- FOOD VACUOLES: contain leukocytes/RBC
abscess, brain abscess or skin abscess.
 Complications  Very effective in killing amoebas in the
wall of the intestine, in blood, and in
- Amoeboma (localized granulomatous mass liver abscesses.
misdiagnosed with carcinoma) - Luminal Amoebicide
- Hemorrhage  Used if the infection is mild
- Perforation of Ulcer (secondary peritonitis - rare
 Diluxanide furoate
but fatal)
- Stricture of colon
- Asymptomatic patients: are given luminal
- Appendicitis
amoebicide as Diluxanide furoate.
Diagnosis (Intestinal Amoebiasis) - Symptomatic patients: are given tissue
amoebicide as Metronidazole followed by
- Clinically presents with Dysentery luminal amoebicide as Diluxanide furoate.
 Painful frequent evacuation of small - Percutaneous drainage of liver abscess is
quantities of stool containing mucus indicated for patients who do not respond to
tinged with blood. metronidazole.
- Laboratory Preparation: Direct Stool Examination
 Wet Preparation Epidemiology
 Iodine Stained - Cyst passers are the main source of infection.
 Permanent stain with iron - Cysts remain viable in faeces for few days, in
haematoxylin or trichrome. water for longer periods.
 Stain used for the - Cysts are killed by dryness, heat (over 55ºC) and
visualization of E. histolytica by chlorine.
 Trophozoites are found in diarrhoeic
stool Control
 Cysts are found in formed stool.
- Treatment of patients.
- Concentration Techniques for cysts
- Examination and treatment of food handlers.
- Environmental sanitation.
Typical Amoebic Dysentery Stool Typical Bacillary Dysentery Stool - Personal prophylaxis.
Bulky Scanty - Human faeces should not be used as fertilizers.
Acidic Alkaline
Scanty Exudate Massive Exudate
Pus Cells + Pus +++ CHECH FOR UNDERSTANDING!
Blood + Blood + Multiple choices
Presence of Charcot-Leyden Absence of Charcot-Leyden
Crystals Crystals 1. Entamoeba histolytica trophozoites are found in:
Presence of Amoebae Absence of Amoebae a) Duodenum of infected human.
Trophozoites Trophozoites b) Jejunum of infected human.
c) Caecum of infected human.
d) All of the above.
- Indirect Diagnosis
 Serological tests in chronic
2. Infection with Entamoeba histolytica occurs through eating
amoebiasis.
green salad contaminated with:
 Detection of copro-antigen using
a) Trophozoites of Entamoeba histolytica.
monoclonal antibodies.
b) Cysts of Entamoeba histolytica.
 Copro-antigen is a specific
c) Both trophozoites and cysts of Entamoeba
antigen found in the stool.
histolytica.
- Molecular techniques
 Polymerase Chain Reaction (PCR)
3. Pathogenicity of Entamoeba histolytica depends on:
- Radiological Examination using Barium Enema
a) Parasite virulence.
 For the visualization of the Large
b) Host resistance.
Intestine
c) Condition of intestinal tract.
- Sigmoidoscopy
d) All of the above.
 To visualize the ulcer, scrap, aspirate or
take biopsy to see the trophozoites.
4. Patients with chronic intestinal amoebiasis suffer from:
Diagnosis (Extra-intestinal Amoebiasis) a) Dysentery, tenesmus with painful spasm of anal
sphincter.
- Clinical: according to the organ affected. b) Recurrent attacks of dysentery alternating with
- Laboratory: constipation.
 Examination of aspirate from lung or c) Fever, diarrhea and tenesmus.
liver abscesses for trophozoites. d) None of the above.
 Color of liver abscess:
Anchovy sauce 5. The following findings in stool suggest amoebic not
 Liver scanning bacillary dysentery infection:
 Radiology of diaphragm level and a) Acidic pH and presence of Charcot Leyden
pulmonary lesions. Crystals.
 Serology b) Alkaline pH and presence of Charcot Leyden
 Leukocytosis due to 2ry bacterial Crystals.
infection. c) Massive exudate with presence of many pus
- Amebic liver abscess is the most common extra- cells.
intestinal form of amebiasis
True or False
Treatment
1. Cyst passers are the main source of Entamoeba histolytica
- Tissue Amoebicide infection.
 Used if the infection is severe and 2. Trophozoites of Entamoeba histolytica produce ulcers with
already has luminal destruction. indurated margin in intestinal mucosa.
 Metronidazole, Tinidazole. 3. Examination and treatment of food handlers is very
important to control Entamoeba histolytica infection.
 4. Infection with Entamoeba histolytica is totally localized to  Usually spherical
the gastrointestinal tract.  mature cyst: 4-8 nuclei, sometimes 16
5. Both trophozoites and cysts of Entamoeba histolytica are  Immature cyst: 2 or more nuclei
infective to man.  Karyosome is large, may/may not be
compact and/or eccentric
BONUS QUESTION:
- Cytoplasm: coarsely granular chromatoidal
bodies: Splinter-shaped or broom-shaped with
rough, pointed end
Rounded quadrinucleate cysts (20μ) seen in stool of patients should
be reported:
 Entamoeba gingivalis
a) Entamoeba histolytica cyst - a common inhabitant of the mouth of man
a) Entamoeba dispar cyst - lives on the surface of teeth and gums, in gum
b) Entamoeba histolytica / dispar cyst pockets and sometimes in the tonsillar crypts
c) Entamoeba coli cyst - Organisms are more common in persons with
pyorrhea (gum disease) but they are not the
cause of the condition
- Hosts: Humans, other primates, dogs and cats
 Entamoeba dispar
- Prevalence is from 50 to 95%
- formerly designated as non-pathogenic E.
- Mode of transmission:
histolytica
 Kissing
- 9x more prevalent than E. histolytica
 Droplet spray
- Morphologically identical with E. histolytica
 Sharing of utensils
- their DNA and ribosomal RNA are different
- No cyst stage
- Diagnosis: negative serologic tests
 Trophozoites have no ingested RBCs Morphology of Trophozoites

 Entamoeba hartmanni - 10-20μm

- Morphologically indistinguishable from E. - Moves quickly
histolytica/E. dispar - Non pathogenic
- Has numerous blunt pseudopodia
Morphology of Trophozoite - Has numerous food vacuoles that contain
cellular debris and bacteria
- similar to E. histolytica except that it is much - has ingested leukocytes
smaller (5-12 μm)
- ingest bacteria but does not ingest RBCs
 Endolimax nana
- 1 nucleus w/ small and compact, central
- Second most common endo commensal of
karyosome
humans
- more sluggish, non-progressive motility
- worldwide distribution 30%
Morphology of Cysts - Lives in the large intestine mainly near the
cecum
- 5-10μm, spherical in shape - feed on bacteria
- Mature: 4 nucleus with a coarse cytoplasm - non pathogenic
- immature cysts - Usually have chromatoidal bars - Outstanding feature:
- (short with tapered ends, or thin and bar-like)  larger karyosome than those of the
genus Entamoeba
 Entamoeba coli  absent peripheral chromatin
- most common endo-commensal of humans
- has a worldwide distribution Morphology of Trophozoites
- Feeds on bacteria and any other cells available to
- small size of 6 to 15 μm
it
- Cytoplasm is granular and vacuolated
- does not invade tissues
- nucleus exhibits a large irregularly shaped
- common inhabitant of the lumen of the cecum
karyosome
and colon of man and other animals
- (may appear “blot-like”) with no peripheral
- Has the typical Entamoeba nucleus
chromatin
Morphology of Trophozoites - on the nuclear membrane
- Pseudopodia are blunt and hyaline
- Usually 15-25 μm in diameter (range 10-50 μm) - Sluggish, non-progressive motility
- Cytoplasm:
 More vacuolated or granular Morphology of Cysts
endoplasm with bacteria and debris - Spherical or ovoid in shape
but no RBCs - Mature cyst:
 Dirty-looking or honeycomb  5 – 14 μm in diameter
appearance
 4 nuclei when mature
 Narrower, less differentiated
 A refractile cyst wall present
ectoplasm
 Chromatoidal bodies are not usually
- Pseudopodia: Broader and Blunter
found
 function more to ingest food
 sluggish, non-directional motility
 Iodameba butschlii
- Nucleus
- Not very common endocommensal in people
 1 nucleus
- non-pathogenic
 Thicker, irregular, coarsely granular
- Lives in the large intestine, predominantly in the
peripheral chromatin with a large
cecal areas
eccentric karyosome (not compact,
- Has a very high prevalence in pigs
may/may not be eccentric.
 50% of pigs are infected with this
Morphology of Cysts ameba in France and Egypt
 pigs are probably its normal host
- size: 10-35 μm
- Nucleus
 Morphology of Trophozoites
- Usually 9-14 μm long (range 6-20 μm)
- Single large vesicular nucleus with large
chromatin- rich karyosome, surrounded by a
layer of achromatic granules globules and
anchored to nuclear membrane by achromatic
fibrils (described as “basket nuclei”)
- Cytoplasm appears granular, containing vacuoles
with ingested bacteria and debris
- Hyaline pseudopodia with sluggish progressive
motility
Morphology of Cysts
Morphology of Trophozoites
- Average size 15 X 8 μ
- Pear shaped (broad anteriorly –tapering
posteriorly)
- Convex dorsally –flat ventrally with bi-lobed
anterior concavity (sucking discs) for attachment
- Motility by 4 pairs of flagellae (similar to a falling
leaf)
- Two oval nuclei with central karyosome.
- Two axostyle traversing the body
- Two rod-shaped parabasal bodies across the
axostyle

- 5-20 μm , oval-round in shape Morphology of Cyst

- uninucleated “basket nuclei” - Average size 12 X 7 μ
- Prominent characteristic: large glycogen vacuole - Oval with well-defined cyst wall
- which stains deeply w/ iodine - Four nuclei present usually at one pole.
- Includes: axostyle – parabasal bodies – remnants
 Diantamoeba fragilis of flagella
- LIFE CYCLE - it does not form cysts and
trophozoites cannot survive passage through the Pathogenesis
small intestine. - Determined by:
- Humans probably get infected by this  Strain Virulence
endocommensal when they ingest pinworm  Host susceptibility
eggs! (Enterobius vermicularis) - Predisposing factors- determines the disease
severity.
 Hypogammaglobulinaemia – Low
antibodies
 Achlorhydria – No Hydrochloric acid
(ph 1-3)
- Pathogenicity is directly related to the
attachment of Trophozoite and surface area
affected.
- Mechanism of disease development
 Mechanical Irritation
 Enterotoxin
 Blunting of brush border
 Malabsorption syndrome

Pathogenesis and Clinical pictures

- Trophozoites feed on mucus = NO SYMPTOMS
- Trophozoites cause hyperaemia and
inflammation of duodenal wall (Duodenitis).
Symptoms include:
 Epigastric pain
 digestive disturbances
 Steatorrhoea (fatty diarrhea- Stool is
light-colored and greasy)
 Flatulence
- In patients with impaired immunity as:
 Hypogammaglobulinaemia.
 Diminished secretory IgA in small
intestine.
 Diminished gastric acidity or
achlorohydria; severe symptoms will
occur such as:
 Persistent diarrhea
 Steatorrhoea,
INTESTINAL PROTOZOAS (FLAGELLATES)  Malabsorption
 Anemia.
 Giardia lamblia  Hypoproteinemia
 Fat-soluble vitamin
- Causes Giardiasis in man, especially children deficiency.
- Geographic distribution: Cosmopolitan  Jaundice and biliary colic.
- Habitat: duodenum, upper part of small
intestine, bile ducts and gall bladder as Diagnosis
trophozoites attached to the mucosa. - Direct Fecal Smear (DFS)
- Definitive Host: Man - If negative stool samples is strongly suspected
- Reservoir Host: Animals (excretion is irregular), the test must me
- Infective Stage: Cyst repeated.
- No flagella on the cyst stage - String Test
- Mode of infection: - Serological tests: for copro antigen detection
 Contaminated food or water
 Flies and food handlers Treatment
(Heteroinfection) - Metronidazole or Tinidazole, recently
 Faeco oral (Autoinfection) Albendazole
 - 8 - 10 μ
INTESTINAL OPPURTUNISTIC PROTOZOAS - Geographic distribution: worldwide
- Takes the shape of oocyst containing sporozoites
(SPOROZOA) - Infective stage: Sporulated oocyst
- AUTOINFECTION DOES NOT OCCUR
- HABITAT: Microvilli of the small intestine
- Unsporulated oocyst is excreted in the stool of
- Complains of mostly infected humans is watery the patient.
diarrhea - Same life cycle with Cryptosporidium but instead
- THE ONLY PROTOZOA CAPABLE OF SEXUAL OR of thick or thin walled oocyst, it produces
ASEXUAL REPRODUCTION unsporulated oocysts.
- Commonly associated from raspberries, basils.
OOCYST CYST - Oocyst sporulation happens in the environment
CASING (THICK SHELL) WITH PART OF THE NATURAL LIFE CYCLE specifically in the soil.
SPOROCYSTS INSIDE - Mode of infection: Ingestion of sporulated
oocysts in contaminated food or drink.
 Cryptosporidium parvum
- Causes cryptosporidiosis  Isospora belli (Cytoisospora belli)
- 4-6μ - Causes isosporiasis
- Only sporozoa with no sporocyst inside oocyst, - 30 X 12 μ
only sporozoite - Geographic distribution: worldwide
- Geographic distribution: worldwide - Takes the shape of oocyst containing sporozoites
- Takes the shape of oocyst containing sporozoites - Infective stage: Sporulated oocyst
- Resistant to chlorine - Same process with Cyclospora cayetanensis
- Infective stage: Sporulated oocyst - Same life cycle with Cryptosporidium but instead
- Mode of infection: of thick or thin walled oocyst, it produces
 Ingestion of thick-walled oocyst unsporulated and sporulated oocysts.
 Contaminated food and water (hetero - AUTOINFECTION MAY OCCUR
infection) - Mode of infection: Ingestion of sporulated
 Faeco oral route in already infected oocysts in contaminated food or drink.
patient (external autoinfection)
Diagnosis of Cyclospora and Isospora
 Thin-walled oocysts in intestinal lumen
- Stool examination to detect unstained oocysts
of already infected patient cause
- Stained oocyst by Modified Ziehl Neelsen (MZN)
internal autoinfection.

Development in human body PATHOGENESIS OF INTESTINAL PROTOZOA (SPOROZOA)

- For sexual reproduction, zygote can either - Intestinal villi show:
become thick-walled or thin-walled oocyst.  Inflammatory changes
 Thick-walled oocyst – External  Atrophy
autoinfection
 Crypt hyperplasia
 Infective to man
- In immunosuppressed patients:
 Thin-walled oocyst – Internal
 Dissemination of the parasite to:
autoinfection
 Esophagus
- Sporozoite attack brush borders of the epithelial
 gall bladder
cells.
 respiratory tract
- LIFE CYCLE
 urinary bladder
 Oocyst
 Sporocyst
CLINICAL PICTURE OF INTESTINAL PROTOZOA (SPOROZOA)
 Trophozoite
 Type I Meront - In immunocompetent subject
 Merozoite  Mild self-limited diarrhea for 2 weeks
 If ASEXUAL REPRODUCTION, - In children
Merozoites can develop  Abdominal discomfort
again into Trophozoites.  Diarrhea
 If SEXUAL REPRODUCTION,  Anorexia
Merozoites can be  fever
differentiated into male and  nausea
female gametocytes. Both  weight loss
gender then merges, - In immunocompromised patients
producing a zygote.  Sever life-threatening diarrhea
- Thin wall oocyst is formed(endogenous  Dehydration
autoinfection)  Malabsorption
- Thick walled oocysts are excreted in stool
TREATMENT OF INTESTINAL PROTOZOA (SPOROZOA)
Diagnosis - For immunocompetent:
- Clinical Picture: diarrhea
 Self-limited
- Stool analysis
- For immunocompromised:
 Direct Fecal Smear (DFS)
 Concentration method using  Paromomycin (for Cryptosporidium)
Shaether’s sugar floatation technique.  Trimethoprim + Sulphamethoxazole
Oocysts are seen by: (for Cyclospora and Isospora)
 Staining stool smear with  Fluid and Electrolyte replacement
modified Ziehl Neelsen stain.
 Immunofluorescence assay. EPIDEMIOLOGY AND CONTROL
- Intestinal Biopsy – to detect meronts and - Cryptosporidiosis is a zoonotic disease
gamonts - Oocysts are highly resistant to chemicals
- Faeco-oral infection occurs (external
 Cyclospora cayetanensis autoinfection)
- Proper washing of green vegetables
- Causes cyclosporiasis
 - Pure water supply c. Disseminated Cut
Haemoflagellates (Blood flagellates) Leishmaniasis (L. aethiopica)
d. Chronic (Recidivan) Relapsing
General characteristics: Cut Leishmaniasis (L. tropica)
Present in blood and tissues B. New World Cutaneous leishmaniasis
Move by flagellum (mastigote) then invade their host (N.W.C.L.)
Transmitted to man through arthropod bites a. Relapsing skin lesion
Require vector (blood sucking insect) for transmission (Chiclero’s Ulcer) – (L.
Alternate cycles and acquire 2 interchangeable stages in mexicana)
host and vector
Multiply by simple binary fission - Mucocutaneous Leishmaniasis “ESPUNDIA”
a. L. braziliensis

T. gambiense T. rhodesiense - Visceral Leishmaniasis “Kala-azar”

a. L. donovani
T. brucei b. L. infantum
Trypanosoma c. L. chagasi
Flagellates Haemoflagellates T. cruzi
Leishmania

Sporozoa Blood Sporozoa Plasmodium spp.

(P. falciparum, P. ovale, P.vivax, P.
malariae)

GEOGRAPHICAL DISTRIBUTION

- Usually, disease Leishmania (Old World) is in the

Middle East and Africa. South America cases
 Leishmania spp. possess the Leishmania species (New World)
- Disease caused by Leishmania spp. is - Leishmania attacks the Human Viscera (Soft
Leishminiasis which is divided into: organs of the body)
 Cutaneous - Mode of infection: Through the bite of FEMALE
 Mucocutaneous sandflies
 Visceral Lesions (most severe) - Rarely, Leishmaniasis is spread from a pregnant
- Leishmania established everywhere in Forest, woman to her baby
desert, mountains, towns, countries
PATHOGENESIS AND CLINICAL PICTURE OF CUTANEOUS
- Leishmania spp. are strictly obligatory
LEISHMANIASIS
intracellular parasite of macrophages/monocyte
series (Histiocytes – Epitheloid cells – Kupfer - Causes BLACK FEVER
cells – R.E.Cs) - NODULE forms at the site of bite due to
- Multiply by binary fission within macrophages of: multiplication of Leishmania in skin macrophages
SKIN – RETICULOENDOTHELIAL SYSTEM & other and granulomatous reaction around them.
VISCERA - ULCER
- Acquire interchangeable stages: - Healing occurs leaving a DISFIGURING SCAR
 Amastigotes (Diagnostic stage): in - THE PATIENT DEVELOPS SOLID IMMUNITY
Man- Dogs –Rodents. - Morphology of wound: somewhat like a volcano
 Promastigotes (Infective stage): in with a raised edge and central crater
vector & culture
- Transmission of the disease is seasonal – mainly LESIHMANIA SPECIES CAUSING ULCER IN THE NEW WORLD
zoonotic. Exceptions are L. donovani in india & L.
SPECIES DISEASE LOCATION
tropica….. Whereas man is the only source of
L. peruviana Dry Ulcer (Uta) Peru, and
maintaining infection (Anthroponotic) Brazil
- Ca be transmitted through contaminated L. pifanoi Diffuse lesion and resembles Brazil
syringes lepromatous leprosy (does not
- Vector of transmission is SANDFLY under the heal or ulcerate)
genus of “Phlebotomus” (Old world) L. braziliensis Spread along lymphatics to Guyana, and
(Espundia) mucous membrane producing Brazil
erosion of nasal septum, palate,
DISEASES
and larynx
L. mexicana Chiclero’s ulcer or Bay sore Mexico, Belize,
- Cutaneous Leishmaniasis (Oriental Sore)
Single ulcer affects the ear Guatemala,
A. Old World Cutaneous Leishmaniasis causing destruction of the Panama,
(O.W.C.L.) cartilage Honduras, etc.
a. Single Dry Non-Exudative
Lesion (L. tropica)
b. Multiple Wet Exudative  Trypanosoma
Lesion (L. major) -