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(C-03) The Flagellates
(C-03) The Flagellates
(C-03) The Flagellates
LABORATORY DIAGNOSIS
CHAPTER OUTLINE
I. Morphology and Life Cycle • Stools submitted for parasite study that contain
flagellates may reveal trophozoites and/or
II. Laboratory Diagnosis
cysts.
III. Pathogenesis and Clinical Symptoms
MUST KNOW
MORPHOLOGY
Trophozoite Cyst
Size Range 8-20 µm long; 5-16 µm wide Size Range 8-17 µm long; 6-10 µm wide
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GIARDIA INTESTINALIS
LIFE CYCLE
Cycle Notes
Infective Stage • Mode of Transmission: ingestion of cyst from
1. Giardia cysts can contaminate food, water, and contaminated food, water, surfaces, and objects
surfaces. A person swallows Giardia cysts from • Diagnostic Stage: cyst, trophozoite
contaminated water, food, hands, surfaces, or objects. • Infective Stage: cyst
Excystation • It has a simple asexual life cycle that includes
2. When Giardia cysts are swallowed, they pass through trophozoites and quadrinucleated infective cyst stages.
the mouth, esophagus, and stomach into the small • Cysts from animals or human feces are transferred to
intestine where each cyst releases two trophozoites the mouth via contaminated hands, food, or water.
through excystation. The Giardia trophozoites then feed
off and absorb nutrients from the infected person. • On ingestion, the infective G. intestinalis cysts enter the
stomach.
Longitudinal Binary Fission
• The digestive juices, particularly gastric acid, stimulate
3. Giardia trophozoites multiply by splitting in two in a the cysts to excyst in the duodenum. The resulting
process called longitudinal binary fission, remaining in trophozoites become established and multiply
the small intestine where they can be free or attached approximately every 8 hours via longitudinal binary
to the inside lining of the small intestine. fission.
Encystation • The trophozoites feed by attaching their sucking disks to
4. The Giardia trophozoites then move toward the colon the mucosa of the duodenum.
and transform back into cyst form through encystation. • Trophozoites may also infect the common bile duct and
The Giardia cyst is the stage found most commonly in gallbladder.
stool.
• Changes that result in an unacceptable environment
Diagnostic Stage for trophozoite multiplication stimulate encystation,
5. Both Giardia cysts and trophozoites can be found in the which occurs as the trophozoites migrate into the large
stool of someone who has giardiasis and may be bowel.
observed microscopically to diagnose giardiasis. • The cysts enter the outside environment via the feces
Giardia cysts are immediately infectious when passed and may remain viable for as long as 3 months in water.
in the stool or shortly afterward, and the cysts can Trophozoites entering into the outside environment
survive several months in cold water or soil. quickly disintegrate.
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GIARDIA INTESTINALIS
CLINICAL SYMPTOMS
• Asymptomatic • Severe Cases
→ Infections with G. intestinalis are often completely → produce light-colored stools with a high fat content
asymptomatic. that may be caused by secretions produced by the
• Depending on the strain involved, infection can occur irritated mucosal lining
with one ingesting as few as 10 cysts. → fat-soluble vitamin deficiencies, folic acid
deficiencies, hypoproteinemia with
• The ability of the parasite to cause disease can be traced hypogammaglobulinemia, and structural changes
to its ability to alter mucosal intestinal cells once it has of the intestinal villi
attached to the apical portion of the enterocyte.
• Blood rarely, if ever, accompanies the stool in these
• In monolayer studies, it was noted that attachment was patients.
influenced by certain physical factors such as
temperature and pH. • The typical incubation period for G. intestinalis is 10 to
36 days, after which symptomatic patients suddenly
• The parasite may also produce a lectin which, when develop watery, foul-smelling diarrhea, steatorrhea,
activated by duodenal secretions, is able to facilitate flatulence, and abdominal cramping.
attachment. Once attached, the organism is able to
avoid peristalsis by trapping itself in between the villi or • In general, Giardia is a self-limiting condition that
within the intestinal mucus. typically is over in 10 to 14 days after onset.
• Most Common Symptom: Diarrhea • Chronic Cases and Reoccurence
→ ranges from mild diarrhea, abdominal cramps, → In chronic cases, however, multiple relapses may
anorexia, and flatulence to tenderness of the occur.
epigastric region, steatorrhea, and malabsorption → Patients with intestinal diverticuli or an
syndrome immunoglobulin A (IgA) deficiency appear to be
particularly susceptible to reoccurring infections.
• Acute Case
→ abdominal pain, described as cramping, associated • Spontaneous recovery occurs within 6 weeks in mild to
with diarrhea moderate cases.
→ excessive flatus with an odor of “rotten eggs” due to • In untreated cases, patients may experience diarrhea
hydrogen sulfide with varying intensities, for weeks or months
EPIDEMIOLOGY
Who? • The first recorded water outbreak of G. intestinalis occurred in St. Petersburg, Russia,
→ people in childcare and involved a group of visiting travelers.
→ travelers within areas • In the Philippines, the prevalence of giardiasis ranges from 1.6 to 22.0% depending on
of poor sanitation the population group being studied.
Where? • Notably, Giardia is not commonly found in patients with diarrhea.
→ worldwide • Direct oral-anal sexual contact among men who have sex with men may increase the
→ areas with poor risk of giardiasis and infection with other intestinal protozoans.
sanitation and hygiene • Outbreaks of giardiasis are more frequently reported outside the Philippines.
practices → Most of these are water-borne (recreational water or drinking water).
→ Foodborne outbreaks have also been reported.
How? • The low infective dose, prolonged communicability, and relative resistance to chlorine
→ person to person facilitate the transmission of Giardia through drinking and recreational water, food, and
→ through contaminated person-to-person contact.
water, food, surfaces, • Giardia was also recognized during World War I as being responsible for diarrheal
or objects epidemics that occurred among the fighting soldiers.
• Giardia trophozoites have often been referred to as resembling an old man with
whiskers, a cartoon character, and/or a monkey’s face.
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CHILOMASTIX MESNILI
MUST KNOW
→ considered a nonpathogen
→ inhabits the cecal region of the large intestine
→ has well-defined trophic and cystic stages
→ Prevalence in the Philippines is less than 1%.
→ a harmless commensal
→ Diagnostic Stage: cyst, trophozoite
→ Infective Stage: cyst
MORPHOLOGY
Trophozoite Cyst
Size Range 5-25 µm long; 5-10 µm wide Size Range 5-10 µm long
• Average Length: 8 to 15 µm
• The broad anterior end tapers toward the posterior end
of the organism.
• Stiff rotary motility in a directional pattern
• cytostome: a rudimentary mouth from which the fourth
flagellum, which is shorter than the others, extends
posteriorly
• The structure bordering the cytostome resembles a
shepherd’s crook and is the most prominent of several
supporting cytostomal fibrils found in this area.
• The ventral surface indentation located toward the
center of the body that extends down toward the
posterior end of the trophozoite is known as a typical
spiral groove.
• The presence of this spiral groove results in a curved
posture at the posterior end.
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CHILOMASTIX MESNILI
LIFE CYCLE
Cycle
Diagnostic Stage
1. Both cysts and trophozoites can be found in the feces.
Infective Stage
2. Infection occurs by the ingestion of cysts in contaminated water, food, or by the fecal-oral route (hands or fomites).
Excystation
3. In the large (and possibly small) intestine, excystation releases trophozoites.
Commensalism
4. Chilomastix resides in the cecum and/or colon; it is generally considered a commensal whose contribution to
pathogenesis is uncertain.
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DIENTAMOEBA FRAGILIS
MUST KNOW
→ causes Dientamoeba fragilis infection
→ initially classified as an ameba because this organism
moves by means of pseudopodia and does not have
external flagella
→ first discovered by Wenyon in 1909 but was first
described in the scientific literature by Jepps and
Dobell in 1918
→ Diagnostic Stage: trophozoite
→ Infective Stage: trophozoite
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DIENTAMOEBA FRAGILIS
LIFE CYCLE
Cycle EPIDEMIOLOGY
Diagnostic Stage Who?
1. Trophozoites are found in the lumen of the large intestine, where they → patients who were also infected with
multiply via binary fission, and are shed in the stool. E. vermicularis (pinworm)
→ children,
Infective Stage
→ homosexual men
2. Historically, only the trophozoite stage of D. fragilis had been detected. → those living in semicommunal groups
However, rare putative cyst and precyst forms have been described in → persons who are institutionalized
human clinical specimens; whether and in what settings transmission to
humans occurs via ingestion of such forms in contrast or in addition to Where?
other fecal-oral transmission routes is not yet known. → worldwide distribution
Transmission via Helminth Eggs → distributed in cosmopolitan areas
3. Transmission via helminth eggs (e.g., via Enterobius vermicularis eggs) How?
has been postulated. → fecal-oral and anal-oral routes
(ingestion of putative cyst and
Notes precyst form)
→ hypothetical transmission via
• Mode of Transmission: fecal-oral route (ingestion of putative cyst and helminth eggs
precyst form); hypothetical transmission via helminth eggs
• Diagnostic Stage: trophozoite NOTES OF INTEREST
• Infective Stage: trophozoite
• In contrast to many pathogenic
• D. fragilis lives in the mucosal crypts of the appendix, cecum and the protozoa, which have a high prevalence
upper colon. in developing countries, high
• The exact life cycle is unknown, although several assumptions have prevalence rates of D. fragilis have been
been made from clinical data. reported from developed countries with
• Direct human to human transmission is probably via the fecal-oral high sanitation standards.
route or via transmission of helminth eggs particularly that of Enterobius • D. fragilis differs from the amebic
vermicularis. trophozoites when mounted in water
• Dientamoeba-like mononucleated and binucleated forms have been preparations.
observed in the lumen of Enterobius adults and eggs present in the • Although both types of organisms swell
intestines. and rupture under these conditions,
• More recently, stools from macaques, gorillas, and swine were found to only D. fragilis returns to its normal size.
carry D. fragilis, thus animal reservoirs may also be potential sources of • Numerous granules are present in this
human infections. stage and exhibit Brownian motion. This
• There is no evidence to suggest that D. fragilis trophozoites invade their is known as the Hakansson
surrounding tissues. D. fragilis has only rarely been known to ingest red phenomenon; it is a feature diagnostic
blood cells. for the identification of D. fragilis.
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TRICHOMONAS HOMINIS
MUST KNOW
→ considered a nonpathogen
→ occurs only as a trophozoite
→ Diagnostic Stage: trophozoite
→ Infective Stage: trophozoite
MORPHOLOGY
Trophozoite
Size Range 7-20 µm long; 5-18 µm wide
Shape pear-shaped
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ENTEROMONAS HOMINIS
MORPHOLOGY
Trophozoite
Size Range 3-10 µm long; 3-7 µm wide
Motility jerky
Flagella four:
3 directed anteriorly
1 directed posteriorly
• Average Length: 7 to 9 µm
• In this case, the body is flattened on one side.
• The nucleus is located in the anterior end of the
trophozoite.
LABORATORY DIAGNOSIS
• These trophozoites are simple, relatively speaking, in that Specimen of Choice stool
structures such as an undulating membrane, costa,
cytostome, and axostyle are absent. • Unfortunately, this organism is difficult to identify
accurately because of its small size.
Cyst • Careful screening of samples is recommended to
Size Range 3-10 µm long; 4-7 µm wide prevent missing an E. hominis organism.
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RETORTAMONAS INTESTINALIS
MORPHOLOGY
Trophozoite
Size Range 3-7 µm long; 5-6 µm wide
Shape Ovoid
Motility jerky
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LIFE CYCLE OF NON-PATHOGENIC FLAGELLATES
ENTEROMONAS HOMINIS | RETORTAMONAS INTESTINALIS | PENTRATRICHOMONAS HOMINIS
Cycle
Diagnostic Stage
1. Both cysts and trophozoites of Enteromonas hominis and Retortamonas intestinalis are shed in feces; only trophozoites
of Pentatrichomonas hominis (no known cyst stage) are shed in feces
Infective Stage
2. Infection occurs after the ingestion of cysts (E. hominis, R. intestinalis) or trophozoites (P. hominis) image in fecally
contaminated food or water, or on fomites.
Excystation
3. Excystation of E. hominis and R. intestinalis releases trophozoites into the large intestine; P. hominis is found as a
trophozoite throughout its life cycle.
Replication
4. These three species colonize and replicate in the large intestine, where they are regarded as commensal organisms
and are not known to cause disease.
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TRICHOMONAS TENAX
MUST KNOW
→ considered a nonpathogen
→ a pyriform flagellate which has been observed only
in the trophozoite stage
→ Diagnostic Stage: trophozoite
→ Infective Stage: trophozoite
MORPHOLOGY
Trophozoite
Size Range 5-14 µm long
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TRICHOMONAS VAGINALIS
MUST KNOW
MORPHOLOGY
Trophozoite
Size Range up to 30 µm long
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TRICHOMONAS VAGINALIS
LIFE CYCLE
Cycle Notes
Infective Fission • The growing trophozoites multiply by longitudinal binary fission and feed on local
bacteria and leukocytes.
3. Trichomonas vaginalis is
transmitted among • T. vaginalis trophozoites thrive in a slightly alkaline or slightly acidic pH environment,
humans, its only known such as that commonly seen in an unhealthy vagina.
host, primarily by sexual • The most common infection site of T. vaginalis in males is the prostate gland region
intercourse and the epithelium of the urethra.
• The detailed life cycle in the male host is unknown.
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TRICHOMONAS VAGINALIS
EPIDEMIOLOGY PREVENTION & CONTROL
Who? Individual Level
→ people with more sexual partners ✓ limiting the number of sexual partners
Where? ✓ avoidance of unprotected sex
→ worldwide ✓ prompt diagnosis and treatment of asymptomatic
How? men
→ sexual intercourse ✓ avoidance of sharing douche equipment, as well as
close contact with potentially infective underclothing,
• Infections with T. vaginalis occur worldwide. toilet articles, damp towels, and wet sponges
• These trophozoites may also migrate through a mother’s
Community Level
birth canal and infect the unborn child.
✓ avoidance of communal bathing
• Under optimal conditions, T. vaginalis is known to be ✓ Prompt follow-up of patients and their contacts
transferred via contaminated toilet articles or ✓ health and sex education about venereal disease
underclothing. However, this mode of transmission is rare.
• The sharing of douche supplies, as well as communal NOTES OF INTEREST
bathing, are also potential routes of infection.
• Infections with T. vaginalis are generally considered to
• T. vaginalis trophozoites, which are by nature hardy and
be a nuisance and not a major pathogenic process.
resistant to changes in their environment, have been
known to survive in urine, on wet sponges, and on damp • There is evidence to suggest a connection between T.
towels for several hours, as well as in water for up to 40 vaginalis infections and cervical carcinoma.
minutes. • Saline preparation of vaginal fluid is the quickest and
• Prevalence is higher among women of child-bearing age. most inexpensive way to diagnose trichomoniasis, but
the sensitivity of this technique is low at 60 to 70%.
• About 5 to 20% of women and 2 to 12% of men in
developed countries are infected. Higher prevalence is • The accepted gold standard is culture which takes 2 to
associated with greater frequency of sexual intercourse 5 days.
with multiple partners and with commercial sex workers. • The unstained wet drop preparations may be fixed and
• In the Philippines, the prevalence of trichomoniasis stained by Giemsa, Papanicolau, Romanowsky, and
among commercial sex workers varies with the method of acridine orange stains.
diagnosis used, from 15% in studies using only • Trichomonas can also be cultured using Diamond’s
microscopic examination of vaginal swabs to 37% in modified medium, and Feinberg and Whittington
studies using culture. culture medium.
REFERENCES
➢ Belizario, et. al. (2013). Medical
Parasitology in the Philippines. The
University of The Philippines Press
➢ Zeibig. (2013). Clinical Parasitology: A
Practical Approach. Elvisier Inc.
TRANSCRIBED BY
➢ Bautista, MD
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