Trichomonads

- Generally non-pathogenic commensals & only a few species are of

importance to humans

3 species of trichomonads infect humans:

- Trichomonas vaginalis

- Trichomonas tenax (non pathogenic & inhabits oral cavity)

- Trichomonas hominis (non pathogenic & inhabits the illeocaecal region)

- These species are highly site specific & typically morphologically similar to
each other

Trichomonas vaginalis is the most common curable sexually transmitted

disease worldwide!
 Why is it so important?

Trichomoniasis is a sexually transmitted disease that accounts for 25%

of vaginitis

* 7.4 million cases reported annually

* 180 million people infected worldwide
* 50% asymptomatic carriers

HABITAT:

* T. vaginalis trophozoite affects both males & females

Females: vagina & urethra

Males: urethra, prostate & seminal vesciles
 Trichomonas vaginalis
Trichomonas is the simplest of all the protozoan parasties because it only exists
as a trophozoite (infective stage of parasite)

- They infect the urogenital tract unlike other members of the Trichomonadida
which affect the intestinal tract
I’m the most common
pathogenic parasite infecting
humans in industrialized
countries!
- Facultative anaerobic parasite

- produces energy by fermentation of sugars in a structure

called hydrogenosome – a modified mitochondria in which
enzyme of oxidative phosphorylation is replaced by enzyme of anaerobic
fermentation

Causative agent of sexually transmitted infection Trichomoniasis

Structure of Trichomonas Vaginalis

Important characteristics:
- 5 flagella arise near the anterior portion
* 4 immedicately extend out of the cell from a periflagellar canal = 4 free flagella
* anterior tuft of flagella
* 1 wraps backwards along the undulating membrane = recurrent flagellum
* Contribute to motility
- Just under the undulating membrane = rigid filamentous cord
“Costa”
- An axostyle = hyaline rod like structure
* runs throughout the entire length & comes out through the posterior
end of the parasite)
* It helps anchor the protozoan to the vaginal epithelial cells
- Cytoplasm contains a large number of hydrogenosomes

- Exist only in trophozoite stage

* Lacks cystic stage
* it can survive outside the body up to 48 hours at temperatures as low as 15 degrees
How do can you get it?

Primary mode of transmission: Sexual Intercourse

Reservoir for this species – human gential tract

Other modes of transmission:

- toilet seats
- swimming pools
- sharing sex toys
- mother to child vaginal delivery
Life Cycle

Life cycle of T. vaginalis is quite simple

In females…
parasite gets the nourishment from:
* vaginal mucosa
* ingested bacteria
* RBC
- It reproduces by longitudinal binary fission
- Division of nucleus  division of neuromuscular apparatus
- Separation of cytoplasm into 2 daughter trophozoites
- Trophozoites are the infective stages
- Trophozoites are transmitted to males on sexual contact & become
localized in the urethra & prostate gland
* In those specific site they replicate in the same way
 Pathogenesis & Pathology
- It is not an invasive parasite
- It remains adherent to the squamous epithelium but not columnar
epithelium

Virulence Factors:

- Protein liquid & proteases – help in adherence

- Lactic acid & Acetic acid – lowers the vaginal pH (low pH is cytotoxic
to vaginal epithelial cells)
- Enzyme Cysteine proteases CP39 – responsible for hemolytic activity
of the parasite

Pathology:

* Intracellular edema and “chicken like epithelium” (characteristic

feature)
 Biological Mechanism
Vaginal epithelial cell

Ligand

Adhesion Protein
(Receptor)

Flagellum

- Adhesion proteins on the surface of flagella

- Ligand/receptor Cytoadherence – 11 to 23 different cysteine

proteinases (CP’s)

- CP’s play an important role in the pathogenicity of the parasite

 Characteristics of CP39
Important characteristics:

- present in vaginal secretions in patients with trichomoniasis

- Its optimal temperature is 37 degrees & a pH range of 3.6 to 7

- Suggested to be involved in tissue damage

- Broad substrate specificity

- Plays a role in parasite survival & immune evasion by degrading hemoglobin

& immunoglobins

* Indicative that CP39 plays a role in Trichomonal infection

Clinical Manifestations in women

- Urethritis, Vaginitis & Cervicitis

- Inflammation of the vaginal canal
- Vulvar itching leading to edema
- Painful urination = Dysuria
- Painful sexual intercourse = Dyspareunia
Vaginal Discharge
* Purulent – 60%
* Gray – 45%
* Yellow/Green – 35%
* Frothy – 10% to 30%
- Punctuate hemorrahages on the cervix = colpitis macularis
- Also known as strawberry or “flea-bitten” cervix
* symptoms usually appear in women within 5 to 28 days of exposure
Clinical manifestations in men

- Usually asymptomatic

- dysuria, urethral discharge

- Non purulent discharge (fish-like odour)

- Irritation inside the penis or slight burning after urination or ejaculation

- painful intercourse & inflammation of the external genitals

Why are women usually symptomatic?

High incidence of symptomatic infection occurs in women because of

the following reasons:

- Natural flora (bacteria) keep the pH of the vagina at 4-4.5 & this
discourages infections
- However, T. vaginalis can survive at a low pH
- Once established it causes a shift towards alkalinitiy (pH 5-6) which
encourages further growth

- Presence of zinc & inhibitory substances in prostatic secretions are

harmful to T. vaginalis
… there may be complications

- In women, PID (Pevlic Inflammatory Disease) is most common

- Women have a higher prevalence of invasive cervical cancer when

they have trichomoniasis

- During pregnancy, increased risk of preterm & low weight babies

- In men, the infection has been found to be associated with prostate

cancer, prostatitis & epididymitis

- In both sexes, there is a higher susceptibility to HIV & infertility

Specimen: Laboratory Diagnosis
- vaginal secretions
- urethral discharge
- urine sediment
- prostatic secretions

Methods:

- Microscopic examination
1) Direct wet mount
2) Giemsa stain
3) Acridine orange fluorescent stain

- PAP smear

* Fast, inexpensive & gives immediate identification of organisms

* Both of these methods have low sensitivity to the parasite

Culture:

- Gold standard: Diamond media

* inefficient in detecting low numbers of parasites or defective parasites
- PCR (expensive)

- Real Time PCR – much more sensitive than culture & direct microscopy
* Specificity & positive predicative values are also very high

Findings: Trophozoite
Specimens
In women:
- vaginal discharge
- endocervical specimens
* Endocervical specimens are not used for wet mount preparations
because of small number of parasites – can be collected for culture
In men:
- urine sediment (test of choice for diagnosing males)
- urethral discharge
- prostatic fluid
- urethral swab before voiding urine
- semen
* Cultures or urethral scrapings/urine are the most effective method
for diagnosis of the condition
Direct Microscopy - Wet Saline Mount

- Specimen is collected by a swab from lateral & anterior fornices of the

vagina
- Put a drop of saline & place a cover slip on top

Microscopy shows:
* Jerky & twitching motility
* Flagellated protozoa in a background of many polymorphonuclear
leukocytes

- Sensitivity of a wet mount prep with vaginal secretion is about 60%

Permanent Staining Wet Mount Giemsa Stain
T. vaginalis

T. vaginalis
1) Acridine Orange Staining
– Rapid & accurate method
Pus cell
2) Papinicolaou Staining Epithelial
T. vaginalis

– Sensitivity is the same as wet mount Bacteria cell

3) Giemsa Staining
Acridine Orange Acridine Orange
Stain Stain
4) Leishman Staining

5) Direct Fluorescent Antibody Staining

– It is more sensitive than wet mount
– Rapid method
– Disadvantage: requires fluorescent microscope
 Culture
- Culture is the gold standard
- It is the most sensitive method (>90%)

- Specimens are inoculated immediately into appropriate medium:

* Modified Diamond’s medium
* Trichosel/Hollander’s medium
* Trussel & Johnson medium
* Trypticase serum medium

- Cultures are incubated aerobically

- In a positive culture, actively motile trophozoites are demonstrates

after 48 hrs of incubation at 37C
 Antigen Detection

* ELISA

Rapid Tests:

- Latex Agglutination Test

- Immunofluorescent Assay

* Serologic testing is NOT useful for diagnosis of Trichomoniasis

 Molecular Diagnosis

1) DNA Probes – use synthetic oligonucleotide probes for detection of

Trichomonas vaginalis DNA in vaginal secretions

* Affirm VPIII – is a direct DNA probe test & tests for 3 most common syndromes
associated with increased vaginal discharge:

- Bacterial vaginosis (Gardenerella vaginalis)

- Candidiasis (Candida albicans)
- Trichomoniasis (T. vaginalis)

* Sensitivity is 90% & specificity is 98%

2) PCR

* not FDA cleared

 Other Tests

1) Determination of Vaginal pH:

- vaginal pH is usually above 4.5 in Trichomoniasis & bacterial vaginosis but not in
Candidiasis

- Measured by Nitrazine paper method

2) Whiff Test/Amine Odor Test:

- This test is positive in Trichomoniasis & Bacterial vaginosis

- Vaginal swab is collected from the patient & is mixed with 10% KOH for the
presence of polyamines

- Presence of Trichomoniasis = fishy odor is released due to production of amines

 Treatment

Trichomoniasis
* preferred treatment is a single 2g dose of Metronidazole
* Alternatively, 500 mg bid for 7 days
* Alternative drug = Tinidazole
- the symptoms in infected men may disappear within a few weeks without
treatment
- pregnant women utilize metronidazole with caution especially in the
early stages of pregnancy (usually given only after first trimester)
- Sexual partners, even if asymptomatic, should be treated
- There is a 30% treatment failure when the male partner is not treated
 Prevention

- Monogamous relation with partners

- Personal hygiene

- Use Protection during sexual intercourse

- Avoid intercourse during treatment

- Notify partners immediately so they can be treated to avoid

reinfection

* No vaccine is available