Paniker'sTextbook of Medical Parasitology
KEY POINTS OF GIARD/A LAMBLIA
• Giardia is the only protozoan parasite found in the lumen of
the human small intestine (duodenum and jejunum).
• Trophozoites a re pear-shaped, bilaterally symmetrical with
two nuclei, fo ur pairs of flagella and a ventral concave
sucking disk. They exhibit motility resembling a "falling leaf".
• Ellipsoid cysts contain four nuclei with remnants of flagella.
• Infective form: Ellipsoid cysts.
• Clinical features: Mostly asymptomatic but in some cases
may cause diarrhea, dull epigastric pain and malabsorption.
Stool contains excess mucus but no blood.
• Diagnosis: By microscopic demonstration of trophozoites
or cysts in stool, enterotest a nd s e rodiagnosis by ELISA
(ProSpecT/Giardia antigen assay).
• Treatment Metronidazole and tinidazole are the drugs of
choice.
• TRICHOMONAS
Trichomonas differs from other flagellates, as th ey exist only
in rrophozoite stage. Cysti c stage is not seen .
Genu s trichomonas has th ree species, which occur in
hum ans (Figs 4A to C) :
l. T. vaginalis (Fig. 4A)
2. T. hominis (Fig. 4B)
3. T. tenax (Fig. 4C)
Trichomonas Vagina/is
History and Distribution
T: vaginalis was fi rst o bserved by Donne (1836) in vagi nal
secretion.
Prevalence of trichomoniasis varies from 5% patients at
hospitals to 75% in sexual workers.
Figs 4A to C: Trichomonas species. (A) T. vagina/is; (B) T. hominis; and (C) T. tenax
Morphology
It is pear-shaped or ovoid and measures 10-30 µm in length
a nd 5-10 µmin breadth with a short undulating membrane
reaching up to the m iddle of the body (Fig. 4A) .
• It h as four an terior flagella a nd fi fth running along the
outer margin of the u ndulati ng membrane, which is
supported at its base by a flexi ble rod, costa.
• A prom inent axostyle runs throughou t the length of the
body and projects posteriorly like a tail.
• the cytoplasm shows prominent siderophilic granu les,
which are most numerous alo ngside the axostyle and
costa.
• It is motile with a rapidj erky or twitch ing type movement.
Habitat
In fe males, it lives in vagina and cervix and m ay also b e fo und
in Bartholin 's gland s, urethra and urinary bladder. Ln males,
it occurs mainly in the an terior ureth ra, but may also be
fou nd in the pros tate and prep utial sac.
Life Cycle
Life cycle of T. vaginalis is com pleted in a single host eithe r
male or female.
Mode oftransmission:
• The trophozoite cannot survive outside and so infection
has to be tra ns mi tted d irectly from perso n-to-p erson.
Sexual transmission is th e usual mode of infect ion
( Box 3).
• Trichomoniasis often coexists wilh other sexually trans-
mi tte d d iseases like ca ndidiasis, gon orrhea, syph ilis, or
human immunodeficiency vi rus (HIV).
• Babies may get infected d uring birth.
• Vaginal pH of more than 4.5 facilitates infection.

Box 3: Protozoa transmitted by sexual contact
, Trichomonas vagina/is
, Giardia Iambi/a
, Entamoeba histolytica
Fomites such as towels have been implicated in trans-
mission.
• Trophozoites divide by binary fission.
As cysts are not formed, the lrophozoite itself is the
infective form.
• Incubation period is roughly 10 days.
Pathogenesis
T. vaginalis particularly infects squam ous epithelium and not
columnar epithelium. It secretes cysteine proteases, adhesins,
lacti c acid and acetic acid, which disrupt the glycogen levels
and lower the pH of Lhe vaginal fluid.
It is an obligate parasite and cannot live witho ut close
association with the vaginal, urethral, or prostatic tissues.
Parasite causes petechial hemorrhage and mucosa!
capillary dilation (strawberry mucosa), m etaplastic
changes and desquamation of the vagi nal epithelium.
Intracellular edema and so called chicken-like epithelium,
is the characteristic feature oftrichomoniasis.
Clinical Features
Infec tion is ofte n asymptomatic, particularly in males,
although some m ay develop uret hritis, epididymitis and
prostatitis.
• In females, it may produce severe pruritic vaginitis
with an offensive, yellowish green, often frothy dis-
charge, dysuria and dyspareun ia. Cervical erosion is
common. Endometritis and pyosalpingitis are infrequent
complications.
• Ra rely, neo natal pneumonia and conj uncti vitis h ave
been reported in infants born to infected mothers.
The incubati on period of trichomoniasis is 4 days to
4 weeks.
Laboratory Diagnosis
Microscopic examination
Wet mount :
Vaginal or urethral discharge is examined microscopically
in saline wet mount preparation for characteristic jerky
and twitchi ng motility and shape. In males, trophozoites
may be found in urine or prostatic secretions. An
abundance of leukocytes is seen.
Permanent stain:
Fixed sm ears may be stained with acridin e orange,
Papanicolaou and Giemsa stains.
Intestinal, Oral and Genital Flagellates
Direct fluorescent antibody:
• Direct fluorescen t antibody (DFA) is another method of
detection of parasite and is more sensitive than the wet
mount.
Culture: Culture is recommended when direct microscopy is
negative and is considered as a "gold standard" as well as the
most sensitive (95%) method for the diagnosis of T. vagina/is
infection.
• It grows best at 35-37°C under anaerobic conditions. The
optimal pl I for growth is 5.5-6.0.
• It can be grown in a va ri ety of solid or liquid media,
tissue culture and eggs. Cysteine-peptone-liver-maltose
(CPLM) medium and plastic envelope medium (PEM) are
often used.
Serology: Enzyme-linked immunosorbenl assay is used for
demonstration of T. vagina/is antigen in vaginal smear using
a monoclonal antibody for 65 kDA surface polypeptide of
T. vaginalis.
Rapid immunochromatographic tests (lCTs) are now
avai lable for detection of Antigen like OSOM Trichomonas
rapid test, Xenostrip-Tv.
Molecular method: Deoxyribonucleic acid hybridization and
PCR are also highly sensitive (97%) and specific (98%) tests
for the di agnosis of trichomoniasis.
Sensitive and specific commercially available ucleic
acid amplification test (NAAT) has been developed (Aptima
Trichomonas vagina/is assay).
Treatment
Simultaneous treatment of both partners is recommended as
it is an STD.
Metronidazole 2 g orally as a single dose or 500 mg orally
twice a day for 7 days is the drug of choice.
In patients not responding to treatm ent with standard
regime, the dose ofmetronidazole may be increased or it
may be administered parenterally.
• In pregnancy, m etronidazole is safe in 2nd and 3rd
trimesters.
Prophylaxis
Prevention is same as for other sexually tran smitted d iseases.
• Avoida nce of sexual contact with infected partners and
use of barrier m eth od during intercourse prevent the
disease.
Patient's sexual partner should be tested for T. vagina/is
when necessary.
Trichomonas Tenax
T. tenax, also known as T. buccalis, is a harmless commensal
which lives in mouth, in the periodontal pockets, carious
tooth cavities and, less often, in tonsillar crypts.