BLOOD AND TISSUE FLAGELLATES
MODE OF TRANSMISSION
Trypanosoma cruzi
DISEASE: Chagas’ Disease or American Trypanosomiasis
 the ONLY trypanosome that has an intracellular
amastigote stage
VERTEBRATE HOST: humans, domesticated and wild
animals
VECTOR/INTERMEDIATE HOST: Reduviid bug/ Kissing
bug/Triatomid bug/Assasin bug
 Triatoma infestans
 Triatoma sordida
 Panstrongylus megistus
 Rhodnius prolixus
GEOGRAPHIC DISTRIBUTION
 Southern part of United States, Mexico, Brazil
Central America, South America
4 STAGES OF DEVELOPMENT
1. Amastigote or leishmania form - found
intracellularly in a human host. No free
flagellum
2. Promastigote or leptomonas form – elongated
spindle-shaped with pointed ends and a short
free flagellum that arises from the kinetoplast
at the anterior end
3. Epimastigote or Crithidia –elongate spindle-
shaped with the free flagellum from the
anterior continuing backwards along the margin
of the undulating membrane and ends at the
kinetoplast which is situated anterior to the
nucleus
4. Trypomastigote or Trypanosoma form – found
in the human host bloodstream as well as
infective stage metacyclic trypomastigote in the
fly vector. In trypomastigotes the kinetoplast is
near the posterior end of the body, and the
flagellum lies attached to the cell body for most
of its length by an undulating membrane.
 Bite of an infected Reduviid bug
(Infective metacyclic trypomastigotes found in
the feces of reduviid bug penetrates the skin as
the bite wound is rubbed/scratched)
 Blood transfusion
 Transplacental route
 Accidental ingestion of infected insect
STAGE: TRYPOMASTIGOTE
 Found in the peripheral blood
 Length: 16 -20 um
 Pointed posterior end with large kinetoplast
 Centrally located nucleus
 Undulating membrane runs the entire length of
the parasite and extends as a free flagellum
 In stained specimens, they are C-shaped/U-
shaped/ S-shaped
 Cork-screw-like motility
STAGE: AMASTIGOTE
 Develops in cardiac muscles, brain tissue,
visceral tissue (INTRACELLULAR)
 Round or ovoid in shape
 1.4 um – 4 um in diameter
 Large red nucleus
 Has a dark-staining rod-shaped kinetoplast
LIFE CYCLE
All hemoflagellates are dimorphic.
2 phases of the Life Cycle:
1. within humans
2. Within insect vector or the intermediate host
 ACUTE FORM

 4 days – 2 wks after the insect bite

 High fever, lymphadenopathy, swelling of the
entire body
 Severe symptoms are seen in young children
with CNS involvement early in the infection.
Amastigotes are seen in the meningeal tissues.
Leads to death within a few days or weeks
LIFE CYCLE IN MAN  Meningoencephalitis in neonates
Infected reduviid bug partakes a mealdefecates  Romaña’s Sign – conjunctivitis and unilateral
passing out metacyclic trypomastigotepenetrates the edema of the eyes
skin via mucus membranestrypomastigotes engulfed
by histiocytesdevelops into amastigote
intracellularly multiply by binary fissionmay
transitionally pass through a promastigote
stageepimastigotetrypomastigoteinfected
histiocyte ruptures in 4-5 days releasing
 Some patients will experience complete
trypomastigotes in the bloodstreaminfects new
recovery after the acute stage but most will
histiocytes and replicate again as
progress to Chronic Chagas’ Disease
amastigotestrypomastigote in bloodstream is
CHRONIC FORM
ingested by reduviid bug as it takes a blood meal
 More common in adults
LIFE CYCLE IN THE INSECT VECTOR
 More common than the acute form
Trypanosomes pass through the posterior portion of the
 Cardiac damage– most common serious form of
midgut of reduviid bug develop into
the disease
epimastigotemultiplies by longitudinal binary
fissiondevelop into infective metacyclic  CHF (Congestive Heart Failure)
 Mega syndrome
trypomastigoteappears in the insect’s rectum 8-10
 Megaesophagus
days after infectionexcreted in the bug’s
fecesenters human host via scratch on skin or  Megacolon
 Cardiomegaly
through mucous membranes that are rubbed with
 CNS involvement - signs of agitation,
fingers contaminated with bug’s feces
INFECTED CELLS disorentiation, aphasia, comadeath if left
untreated
Frequently infects:
DIAGNOSIS
1. Reticuloendothelial cells of spleen, liver, cardiac
 Patient history – being in an endemic area
muscles, smooth and skeletal muscles
 Clinical Presentation: Febrile episodes,
2. Skin
enlargement of the lymph nodes, Chagoma,
3. Gonads
Romaña’s sign, myocarditis, CNS and digestive
4. Intestinal mucosa
problems
5. Placenta
 Demonstration of parasites in blood, CSF, and
PATHOGENESIS AND CLINICAL MANIFESTION
tissue  Giemsa staining
 Chagoma – localized inflammation at the site of
 Centrifugation – examination of the buffy coat
infection (usually in the face)
layer
 Small, painful, reddish nodule that takes
 Blood cultures – if parasites are scanty
2-3 months to resolve
 Animal inoculation
 Trypomastigotes and amastigotes may
be aspirated from Chagoma  Xenodiagnosis – successful even in the later
part of the disease when blood films are
negative
  Has a chronic course which ends with
CNS involvement leading to death after
Xenodiagnosis several years
 Parasite can be found in the wet lowlands and
rainforest of West and Central Africa
MODE OF TRANSMISSION
 Bite of an infected Tsetse fly (Intermediate host
and vector)
(Riverine tsetse flies of the palpalis group)
 Glossina palpalis
 Glossina tachinoides (tsetse fly)
 Glossina fuscipes
 Day biters
 Blood transfusion
 Organ transplant
SEROLOGIC TESTS  Transplacental route
 Complement fixation
 Direct and Indirect Hemagglutination LIFE CYCLE
 Indirect Immunofluorescent Antibody Test
(IFAT)
 PCR
 ELISA – directs T. cruzi antigen in urine
TREATMENT
 Nifurtimox (aka Lampit or Bayer 2502) – DOC
 Allupurinol
 Benznidazole
 Megaesophagus and Megacolon –surgical
intervention
PREVENTION
 Education of the endemic population to raise
awareness about the disease
Trypomastigotes are ingested by tsetse fly when it takes
 Insect control – application of insecticide on the
a blood meal on infected humans  develop into
roof and walls
epimastigotemultiplies within the fly in the gut and
 Housing improvement to eliminate cracks and
salivary glands. As tsetse fly takes another blood meal,
crevices where the insect resides
saliva containing metacyclic trypomastigotes is
 Screening of blood for transfusion
transmitted to the human hosttrypomastigotes
 Routine addition of gentian violet dye
multiply in the bloodstream (may be ingested by
to blood bottles in final concentration
fly)goes to CNS causing sleeping sickness
of 0.025% to kill T. cruzi
CLINICAL MANIFESTATIONS AND PATHOGENESIS
______________________________________________
1st Stage
Trypanosoma brucei complex
 Asymptomatic incubation period
 Both sp. are morphologically indistinguishable
 Trypanosomal chancre at the insect bite
 Same life cycle nd
2 Stage
 Both are pathogenic for humans in Africa
 Trypomastigotes found in the bloodstream and
 “brucei-gambiense-rhodesiense complex”
lymphatic system
 Disease: African Sleeping Sickness
 1st distinct symptom: fever followed by afebrile
STAGES OF DEVELOPMENT
periods
 Polymorphic trypanosomes – seen in blood and
 Headache, malaise, anorexia, night sweats,
CSF
weakness, joint and muscle pain, tachycardia
 Epimastigotes – seen in vector
 Lymphadenopathy and glandular enlargement
Trypanosoma brucei gambiense
 Winterbottom’s sign – enlargement of the post-
 Disease: West African Sleeping Sickness/
cervical chain of lymph nodes
Gambian Trypanosomiasis
  Somnolence – indicates CNS involvement
 Entire course of the disease takes 9-12 months
MODE OF TRANSMISSION
 Bite of an infected tsetse fly
 Glossina pallidipes
 Glossina morsitans
 Erythematous (red )rash, pruritus, edema
 Glossina swynnertoni
 Kerandel’s sign – delayed sensation to pain
RD Reservoir host: antelopes, game animals, domesticated
3 Stage
cattle, waterbuck, impala, and warhog
 Takes 6 mos. – 1 yr after the onset of first
LABORATORY DX
symptoms
 Same as gambian trypanosomiasis
 Meningoencephalitic stage
______________________________________________
 Increased fatigue, mental dullness, apathy,
Leishmania spp.
diminished motor control
Basis of differentiation of Leishmania sp:
 Somnolence (excessive sleepiness)
 Geographic distribution
 Demonstration of trypomastigotes in px’s CSF
 Pathogenesis
 Sleepiness progresses to coma death
Stages of Development:
LABORATORY DIAGNOSIS
Promastigoteamastigote
 Demonstration of trypomastigotes in:
Serologic tests to differentiate the species:
 blood, lymph node aspirates, bone
 Kinetoplast DNA (kDNA)
marrow – early stage
 DNA hydridization
 CSF – late stage
______________________________________________
 Direct wet mounts examined for motile
Leishmania tropica complex
trypanosomes
 L. tropica
 Concentration techniques - Trypanosomes can
 L. aethiopica
be found in the buffy coat layer of blood after
 L. major
centrifugation
Vector
 Serologic Tests: Card Agglutination
 Sand fly (Phlebotomus spp.)
Trypanosomiasis Test (CATT)
Infective Stage
TREATMENT
 Promastigote
 Pentamidine –2nd stage
Diagnostic Stage
 Suramin – for 1st and 2nd stage
 Amastigote (intracellular in mononuclear
 more toxic than pentamidine
phagocytic cells)
 May be prescribed during pregnancy
MODE OF INFECTION
 Melarsoprol – 3rd stage; CNS involvement
 Bite of infected sand fly
 Eflornithine - the resurrection drug
 Blood transfusion
PREVENTION
DISEASE
 Control, management, and avoidance of insect
 Old World Cutaneous Leishmaniasis
vector
 Recidivans
 Wearing protective clothing against tsetse fly
 Chronic Relapsing Cutaneous Leishmaniasis
 Application of repellents
 Oriental Sore
 Clearing of vegetation where tsetse fly breeds
 Aleppo or Baghdad or Delhi boil
 When traveling to endemic areas, wear khaki or
 Dry or Urban Cutaneous Leishmaniasis
olive drab clothing
EPIDEMIOLOGY
Trypanosoma brucei rhodesiense
Areas bordering Mediterranean, Middle East, Republic
 East African Sleeping Sickness/Rhodesian
of Georgia, and India
Trypanosomiasis
LIFE CYCLE IN THE VECTOR
 Geographical distribution: Central and Eastern
sand fly ingests amastigote from infected human after
Africa
taking a blood meal within the insect, amastigote
 Pathology is similar to Gambian form but more
transforms into promastigotemultiply
severe and fatal (terminating within 1 yr)
promastigotes migrate to the pharynx of sand
 More common in males than in females
flyTransmits the promastigote to humans
 Trypomastigotes are found in the peripheral
LIFE CYCLE IN HUMAN HOSTS
blood during febrile periods
Promastigotes are engulfed by phagocytestransform
 Glomerulonephritis
into amastigotesmultiply inside cellcell ruptures
 Myocarditis
releasing amastigotes which invade other macrophages
then multiply intracellularly leading to tissue  Uta – form of the disease with mucosal features
destruction  Mucocutaneous Leishmaniasis
CLINICAL MANIFESTATIONS AND PATHOGENESIS  Pain bois (forest yaws)
 Incubation period: 2-24 months VECTOR: Lutzomyia sandfly
 First Sign/Early Lesion: Oriental sore MODE OF TRANSMISSION
 Late Lesion: multiple on exposed surface of the  Contamination of the bite wound
body  By contact
 Healing occurs over 1-2 yrs without treatment GEOGRAPHIC DISTRIBUTION
leaving a depigmented scar  From Mexico to Argentina
 Diffuse Cutaneous Leishmaniasis occurs in CLINICAL MANIFESTATIONS
patients with impaired immunity  Mucocutaneous lesions - Growth of polyp-like
 Lesions are loaded with parasites appendages in the nasal cavity
COMPLICATIONS
 Secondary bacterial infections
 Leishmania recidiva – due to an exaggerated
delayed hypersensitivity response to parasite
antigen
 Facial lesions with scanty parasites
LABORATORY DX
 Characteristic feature of lesion: elevated and  Development of ulcers on or around the oral
indurated margin of the ulcer and nasal mucosa
 Demonstration of amastigotes from lesions or  Needs to be differentiated with lepromatous
biopsy leprosy
 Giemsa or Wright’s stain  Tapir nose – destruction of oropharyngeal
 Presence of promastigotes from specimen mucosa
cultured on NNN media  Chiclero ulcer erosion of the pinna of ear of
 Montenegro (Leishmanin) Skin Test – delayed forest workers
hypersensitivity reaction
 Promastigotes are administered
intradermally
 (+) result: induration and erythema of
4-5 mm or more in diameter
SEROLOGIC TESTS
 Indirect fluorescent Antibody Assay (IFAT)
 Complement Fixation
 Immunoperoxidase test LABORATORY DX
 Direct/Indirect Hemagglutination  Same for Leishmania sp.
TREATMENT TREATMENT
 Sodium stibogluconate (Pentostam) – DOC  Pentostam – DOC
 Meglumine antimonate (Glucantime)  Camolar and Amphoterecin B
 Amphoterecin B and ketoconazole ______________________________________________
 Prompt TX for individuals with active lesions to Leishmania donovani complex
prevent autoinfection  L. donovani, L. infantum, L. chagasi
PREVENTION MORPHOLOGY
 Vector and reservoir control  In Mammalian tissues
______________________________________________ - Amastigotes (leishmania stage)
Leishmania mexicana complex  In the gut of sandflies or in cultures
Leishmania brasiliensis, L. panamensis, L. peruviana, L. - promastigote form (leptomonas stage)
guyanensis DISEASE (fatal if not treated)
STAGES OF DEVELOPMENT  Visceral Leishmaniasis
 Amastigote  Kala azar or Black Disease
 Promastigote  Dum-dum fever
DISEASE  Death Fever
 New World Cutaneous Leishmaniasis  Ponos
 American Leishmaniasis  Tropical splenomegaly
 Espundia
GEOGRAPHIC DISTRIBUTION
 India, Pakistan, Thailand, parts of Africa, China
VECTOR
 Phlebotomus sandflies
 Lutzomyia
RESERVOIR HOST
 Humans, dog, wild animals
CLINICAL MANIFESTATIONS
 More common in males
 Affects the spleen, liver, bone marrow,
peripheral blood, lymphatics
 Most prominent symptoms:
 Fever
 Splenomegaly
 Cachexia
 Anemia
 Recovery from kala-azar leads to lasting
immunity
 Butterfly rash
LABORATORY DIAGNOSIS
 History and PE
 Demonstration of the parasites from the blood
and tissues
 Culture using Novy-MacNeal-Nicolle Medium –
promastigotes
 Bone marrow aspirate and splenic puncture
SEROLOGIC TESTS
 Indirect hemagglutination test
 ELISA
 Formol-gel aldehyde test of Napier
 Direct Agglutination Test
TREATMENT
 Pentostam and Lomidine – DOC
 Amphoterecin B
 Allopurinol or gamma intervention + Pentostam
PREVENTION
 Avoid and destroy infected dogs
 Destroy breeding places
 Use repellents
 Vector control
 Health education