Protozoa

Entamoeba histolytica
Distinguishing features
Amoeba: move with pseudopodia
Trophozoite with ingested RBC in stool
with active disease
4-nuclei cyst in stool with carrier state
Pathogenesis
Fecal-oral transmission from
contaminated food/water cyst
ingested trophozoite invades colon
with extension to liver, lungs
Diseases
Asymptomatic carriage (most common)
Intestinal amebiasis: dysentery (bloody
diarrhea)
Invasive amebiasis: flask-shaped ulcers
in colon, liver abscesses RUQ pain,
pulmonary abscesses
Treatment
Metronidazole
Trophozoites with ingested RBCs with active state
Colonic flask-shaped ulcer
Cyst of carrier state showing 3 of 4 nuclei
Protozoa
Giardia lamblia
Distinguishing features
Flagellate: move with flagella
Tear-shaped flagellated trophozoites in
stool with active disease
4-nuclei cyst in stool with carrier state
Most common enteric parasite in the U.S.
Leading infectious agent in waterborne
outbreaks of diarrhea
Pathogenesis
Fecal-oral transmission from contaminated
food/water cyst ingested trophozoite
attaches to duodenum (no invasion)
malabsorption
Diseases
Asymptomatic carrier
Fatty diarrhea: non-bloody & foul-smelling
Treatment
Metronidazole
Binucleated trophozoite with 4
pairs of flagella
Cyst of Giardia lamblia
Protozoa
Cryptosporidium parvum
Distinguishing features
Sporozoan: obligate intracellular
parasites
Acid-fast oocysts in stool
Pathogenesis
Fecal-oral transmission from
animals/humans oocysts
ingested inhabit microvilli of
the SI
Diseases
Watery diarrhea
Severe, prolonged diarrhea in IC
hosts
Also caused by Isospora belli, which
is distinguished by having elliptical
acid-fast oocysts in the stool, and is
treated with TMP/SMX


Acid-fast oocysts of Cryptosporidium
Elliptical oocysts of Isospora belli
Protozoa
Trichomonas vaginalis
Distinguishing features
Flagellate: move with flagella
Lacks a cyst form: does not survive
in external environment
Trophozoites on wet mount of
discharge
Pathogenesis
Sexually-transmitted
Diseases
Vaginitis: greenish, frothy, foul-
smelling vaginal discharge, itching
Urethritis (males): mostly
asymptomatic
Treatment
Metronidazole to patient and
patients sexual partners
Trophozoites with 5 flagella, 1 nucleus
Protozoa
Plasmodium species
Distinguishing features
Sporozoan: obligate intracellular parasites
Characteristic trophozoite in RBC (small rings in
P. falciparum)
Pathogenesis
Transmitted by bite of Anopheles mosquito
sporozoites in bloodstream migrate to liver
hepatocytes burst releasing merozoites that
invade the RBCs infected RBCs lyse releasing
merozoites that can invade other RBCs
immune response fever, chills, sweats, anemia
Hepatosplenomegaly from phagocytosis of
destroyed RBCs
Diseases
Malaria
Plasmodium falciparum (most severe): irregular fever
spikes, blackwater fever = hemoglobinuria, sticky
RBCs cause vessel occlusion in kidney, lung, brain
cerebral malaria (seizures, coma), kidney failure, lung
edema
Plasmodium vivax/ovale: 48-hour fever spikes (tertian
form), dormant hypnozoites in liver may relapse
Plasmodium malariae: 72-hour fever spikes (quartan
form)
Treatment
Chloroquine, mefloquine for chloroquine-resistant
P. falciparum, primaquine for hypnozoites
Small ring-shaped
trophozite of P. falciparum
Banana-shaped gametocyte of
P. falciparum
Schuffners dots and
ameboid trophozoites of
P. vivax
Bar/band form of P.
malariae trophozoite
Rosette schizont of P.
malariae
Jagged RBC of P.
ovale
Protozoa
Toxoplasma gondii
Distinguishing features
Sporozoan: obligate intracellular
parasites
Crescent-shaped trophozoites within
macrophage
Cat is definitive host
Pathogenesis
Cysts ingested from cat feces,
undercooked meat (pork)
mononucleosis-like symptoms
invasive forms become dormant
Host becomes IC reactivation
Diseases
Leading cause of CNS disease in AIDS
patients = encephalitis, chorioretinitis
Ring-enhancing lesions on brain scan
Congenital toxoplasmosis: mental
retardation, chorioretinitis, other birth
defects, from transplacental fetal
infection
Treatment
Sulfadiazine + pyrimethamine

Ring-enhancing lesions on MRI =
toxoplasmic encephalitis
Crescent-shaped trophozoites in a
bronchoalveolar lavage
Protozoa
Trypanosoma cruzi
Distinguishing features
Flagellate: move with flagella
Flagellated protozoan (trypomastigote) in
blood
Nonflagellated protozoa (amastigote) in
tissue
Pathogenesis
Reservoir in South/Central American
animals transmitted by reduviid bug
chagoma (inflammatory nodule) @ bite
site infects blood, tissue
Romanas sign (swelling around eye)
when protozoan enters through
conjunctiva
Diseases
Chagas Disease (American
Trypanosomiasis)
Acute phase: myocarditis
Chronic phase: dilated cardiomyopathy,
megacolon, megaesophagus
Treatment
Nifurtimox, benznidazole for acute cases

Trypomastigote in blood smear
Amastigotes in heart muscle
Romanas sign: swelling around eye
Protozoa
Trypanosoma brucei
Distinguishing features
Flagellate: move with flagella
Antigenic variation of surface coat:
causes recurring fevers
Trypomastigotes in blood, CSF,
lymph nodes
Pathogenesis
Transmitted by tsetse fly
Diseases
African Sleeping Sickness (African
Trypanosomiasis): hard red ulcer @
bite site recurring fevers CNS
invasion (encephalitis, somnolence,
coma)
T. b. rhodesiense (EASS) is more severe
than T. b. gambiense (WASS)
Treatment
Suramin (if no CNS involvement)
Melarsoprol (with CNS involvement)

Trypomastigotes in blood smear
Protozoa
Leishmania species
Distinguishing features
Flagellate: move with flagella
Nonflagellated protozoans within
macrophages
Pathogenesis
Dog/rodent reservoir transmitted by
sandfly
Diseases
Cutaneous leishmaniasis: single skin
ulcer with intact CMI, diffuse nodular
lesions with deficient CMI
Mucocutaneous leishmaniasis:
nasal/oral mucosal ulcers erosion of
nasal septum/buccal cavity
Visceral leishmaniasis (Kala-Azar):
invasion of reticuloendothelial system
hepatosplenomegaly, anemia,
leukopenia
Caused by L. donovani
Treatment
Stibogluconate

Protozoa
Amastigotes within a macrophage
Skin ulcer due to leishmaniasis
Babesia microti
Distinguishing features
Sporozoan: obligate intracellular
parasites
Maltese-cross on blood smear
Pathogenesis
Transmitted by Ixodes tick, same
tick that spreads Lyme Disease =
coinfections with Borrelia
Diseases
Babesiosis: invades RBCs
malaria-like illness with fever
and mild hemolytic anemia
Treatment
Clindamycin + quinine


Protozoa
Pathognomonic maltese-cross
Platyhelminthes (flatworms)
Schistosoma species
Distinguishing features
Trematode (fluke)
Eosinophilia
Adult forms evade immune system with
molecular mimicry
Pathogenesis
Snails as intermediate host larvae (cercariae)
released into fresh water penetrate human
flesh (dermatitis) eggs released acute
inflammation Katayama fever
Diseases
S. mansoni (South America, Africa), S.
japonicum (East Asia): eggs released in
intestinal veins eggs deposited in stool
Eggs carried to liver chronic inflammation
granulomas, periportal fibrosis portal HTN
Eggs carried to lung chronic inflammation
fibrosis pulmonary HTN
Eggs carried to intestine chronic inflammation
polyps
S. haematobium (Africa): eggs released in
bladder veins eggs deposited in urine
Eggs lodge in bladder wall chronic inflammation
hematuria, association with bladder (squamous
cell) carcinoma
Treatment
Praziquantel

Egg of S. haematobium: prominent terminal spine
Egg of S. japonicum: non-specific
Egg of S. mansoni:
lateral spine
Female resides in groove
of male
Platyhelminthes (flatworms)
Taenia saginata (beef tapeworm)
Distinguishing features
Cestode (tapeworm)
Eosinophilia
No hooks on scolex
Proglottids, eggs in feces
Pathogenesis
Ingested as cysticerci in
undercooked beef adult scolex
adheres to intestine consumes
host food malnutrition
Diseases
Usually asymptomatic
Abdominal discomfort, weight
loss, diarrhea
Treatment
Praziquantel

Gravid proglottid: 15-20
branches of the uterus on
each side
Egg:
undistinguishable
from T. scolia
Scolex: no hooks
Platyhelminthes (flatworms)
Taenia solium (pork tapeworm)
Distinguishing features
Cestode (tapeworm)
Eosinophilia
Hooks on scolex
Proglottids, eggs in feces
Calcified cysticerci in brain, muscle on
CT, biopsy
Diseases
Intestinal infection: ingestion of
cysticerci in undercooked pork adult
scolex adheres to intestine
consumes host food malnutrition
Cysticercosis: ingestion of eggs from
feces larvae form cysticerci in brain,
eye, skeletal muscle neurological
defects (seizures, hydrocephalus, focal
deficits), blindness
Treatment
Praziquantel
Proglottid: 7-13 branches
of uterus on each side
Scolex: hooks
Cysticerci on muscle biopsy Platyhelminthes (flatworms)
Diphyllobothrium latum (fish tapeworm)
Distinguishing features
Cestode (tapeworm)
Eosinophilia
Proglottids, eggs in feces
Pathogenesis
Ingestion of larvae in poorly
cooked freshwater fish
absorbs vitamin B12
megaloblastic anemia
Treatment
Praziquantel

Egg: ellipsoidal with operculum @ 1 end
Proglottid: broader than it is long Platyhelminthes (flatworms)
Echinococcus granulosus (dog tapeworm)
Distinguishing features
Cestode (tapeworm) with only 3
proglottids
Eosinophilia
(Calcified) cysts on CT, X-RAY
Presence of daughter cysts within
hydatid cyst is pathognomonic
Pathogenesis
Eggs ingested from dog feces
larvae form hydatid cysts in liver,
lung
Diseases
Hydatid Cyst Disease
Cysts enlarge mass effect
abdominal pain, biliary obstruction
Cysts rupture severe anaphylaxis,
cough, chest pain
Treatment
Surgical removal of cysts
Albendazole

Gross: hydatid cysts in liver
Micro: hydatid cysts
3 proglottids
CT: hydatid cysts of the liver and left kidney
Platyhelminthes (flatworms)
Nematodes (roundworms)
Enterobius vermicularis (pinworm)
Distinguishing features
Most common helminth infection in
the U.S.
Primarily infects children
Diagnose with Scotch tape test:
adhere tape to perianal region and
examine for eggs
Pathogenesis
Fecal-oral transmission eggs
ingested
Diseases
Perianal itching: females migrate to
perianal area @ night to lay eggs
Treatment
Pyrantel pamoate
Albendazole, mebendazole

Egg: flattened side
with larvae inside
Nematodes (roundworms)
Trichuris trichiuria (whipworm)
Distinguishing features
Barrel-shaped eggs with
bipolar plugs in stool
Pathogenesis
Eggs incubate in moist soil
for 3-6 weeks ingested
Diseases
Diarrhea
Abdominal pain
Rectal prolapse
Treatment
Mebendazole, albendazole

Egg: football-shaped with bipolar bumps
Whipworm
Nematodes (roundworms)
Ascaris lumbricoides
Distinguishing features
Most common worldwide helminth
infection
Common in tropical climates and in the
Southern U.S.
Eggs with rough surface in stool
Eosinophilia
Pathogenesis
Fecal-oral transmission egg ingested
larvae migrate through lungs
(pneumonia) swallowed mature in
small intestine consumes host food
malnutrition
Diseases
Asymptomatic
Abdominal cramping
Intestinal occlusion by a mass of worms
Biliary obstruction
Treatment
Pyrantel pamoate
Albendazole, mebendazole



Knobby eggs
Nematodes (roundworms)
Necator americanus, Ancylostoma duodenale
(hookworm)
Distinguishing features
Eggs in stool
Eosinophilia
Pathogenesis
Filariform larvae penetrate skin of
bare feet (local itching) lung
migration (pneumonia)
swallowed attach to SI
Diseases
Pneumonia
Gastroenteritis
Iron-deficiency anemia:
bloodsucking from SI
Treatment
Mebendazole, pyrantel pamoate

Eggs in stool: oval,
transparent, with 2-8 cell-
stage visible inside
Nematodes (roundworms)
Strongyloides stercoralis (threadworm)
Distinguishing features
Larvae in stool
Eosinophilia
Pathogenesis
Filariform larvae penetrate skin
of bare feet (local itching)
lung migration (pneumonia)
swallowed eggs hatch in
intestinal wall inflammation
Diseases
Pneumonia
Gastroenteritis
Severe autoinfection (in IC)
Treatment
Thiabendazole, ivermectin

Larvae in stool
Nematodes (roundworms)
Trichinella spiralis
Distinguishing features
Eosinophilia, serum muscle enzymes
Cysts with larvae on muscle biopsy
Pathogenesis
Encysted larvae in undercooked meat
ingested
Diseases
Gastroenteritis: worms penetrate intestinal
mucosa
Splinter Hemorrhages
Periorbital swelling
Myalgia: larvae encyst in skeletal muscle
Severe infections
Myocarditis: most common parasitic cause
Larvae migrate to heart
Encephalitis: larvae migrate to brain
Treatment
Mebendazole against worms in SI
Encysted larva in striated muscle
Nematodes (roundworms)
Wuchereria bancrofti (Pacific Islands, Africa), Brugia
malayi (Southeast Asia)
Distinguishing features
Microfilariae in blood @ night
Eosinophilia
Pathogenesis
Transmitted by mosquito
carried to lymph nodes of
genitals, lower extremities
Diseases
Recurrent fever and swollen
lymph nodes
Elephantiasis: edema, scaly skin
in legs, scrotum
Fibrosis around dead worms in
lymph nodes lymphatic
obstruction
Treatment
Diethylcarbamazine against
microfilariae
Nematodes (roundworms)
Microfilaria of W. bancrofti on blood smear
Elephantiasis of the leg and hydrocele
Onchocerca volvulus
Distinguishing features
Found in Africa, Central & South
America
Microfilariae on skin biopsy
Pathogenesis
Transmitted by black fly near rivers
Diseases
Skin nodules: fibrosis around adults
Hyperpigmented pruritic rash:
inflammation as microfilariae migrate
Lizard skin: dry, scaly skin from
intraepithelial granulomas
River blindness: microfilariae migrate
to the eye
Treatment
Ivermectin against microfilariae


Nematodes (roundworms)
Microfilariae on skin biopsy
Adults in nodules
Fibrotic skin nodules