Intestinal Protozoa

Flagellates and Ciliates

Giardia lambla

BY

Okweny David
Flagellates and Ciliates
Intestinal protozoans with flagella and cilli include the following;
i. Giardia lamblia
ii. Balantidium coli
 Historical background
• The flagellate Giardia lamblia (syn. Giardia intestinalis, Giardia
duodenalis ) was first discovered by Leeuwenhoek in 1681.

• The organism was named after Professor A. Giard of Paris and Dr.
F. Lambli of Prague in 1859.

• During the 1980s, the name G. duodenalis was supported and in the
1990s G. intestinalis was supported by various investigators.

• Despite disagreement concerning the various species names, all

three continue to be used to describe this organism.
 Giardia

• Giardiasis is the most common small intestinal

protozoal infection and is found worldwide.
• Giardia lamblia is a flagellated protozoan that
infects the duodenum and small intestine.
• Range from asymptomatic colonization to acute or
chronic diarrhea and malabsorption.
• More prevalent in children
 Giardia Epidemiology
 Usually occurs sporadically
 One of the most prevalent human parasites in the U.S.A. .
 Many animals are major reservoirs: dogs, beaver, muskrat, elk,
deer, voles, mice, horses and sheep.
Transmission
 Fecal-oral route.
 Transmission by contaminated water and food is common
 Person-to-person spread also occurs .
 Transmission in day-care centers, refugee camps, jails and
other crowded facilities with poor hygiene and sanitation.
General Characteristics

Geographical distribution:
Worldwide; found in the soil, water or surfaces
contaminated with feces of infected human/animal.

Habitat: 
Lives in the upper part of the small intestine
(duodenum, jejunum, and upper ileum).
Here the trophozoites attach to the epithelial cells.
Feeds on mucous that forms in response to irritation.
• Giardia trophs are attracted to bile salts: so
sometimes you can get infections in bile ducts
and gall bladder, causing jaundice and colic.

• This is irritating but not life threatening

infection like E. histolytica.
 Cyst and Trophozoite of Giardia lamblia showing
Encystation-excystation cycle

Morphology: Exists in two form

Cyst: Oval cyst is thick walled with four nuclei and several
internal fibers. Each cyst gives rise to two trophozoites during
excystation in the intestinal tract.


Trophozoite: Pear-shaped with two nuclei, four pairs of flagella
and a suction disk.

Giardia is protected by an outer shell that allows it to survive outside
the body for long periods of time and makes it tolerant to chlorine
disinfection
 Giardia duodenalis Trophozoite
 Trophozoites are binucleated
(looks like a face). 12-15 μm.

 Ventral surface bears adhesive

disk to adhere to surface of
intestinal cell.

 8 flagella (2 anterior, 2
posterior, 2 ventral, and 2
caudal) - all arise from
kinetosome.

 Median bodies occur behind

adhesive disk - function is
unknown.
Giardia duodenalis Trophozoite

Light microscope photos of trophozoites

 Cyst of Giardia duodenalis
The cyst forms as trophozoites become
dehydrated when they pass through the large
intestine.

Morphology:

ovoid in shape; 8-12 µm long x 7-10 µm

widethin cyst wall.
Four nuclei present, often concentrated at on
end.
Flagella shorten and are retracted within cyst.
Axonemes provide internal support.
 Cyst of Giardia duodenalis

Cyst may remain viable in the external

environment (usually water) for many months.

-14 billion cysts can be passed in 1

stool sample

-Moderate infections: 300 million

cysts.
Cyst of Giardia duodenalis
 Life cycle of G. lamblia
 life cycle of G. lamblia is composed of 2
stages:
 trophozoites
 cysts
 Life cycle of G. lamblia cont’d…
 Giardia cysts are the infective stage of G. intestinalis.  As few as 10
cysts can cause infection.
 Cysts are ingested by consuming contaminated food or water, or
fecal-orally. 
 They can survive outside the body for several months, and are also
relatively resistant to chlorination, UV exposure and freezing.
 When cysts are ingested, the low pH of the stomach acid produces
excystation, in which the activated flagella breaks through the cyst
wall.
 This occurs in the small intestine, specifically the duodenum.
 Excystation releases trophozoites, with each cyst producing two
trophozoites.
 Life cycle of G. lamblia cont’d…
 Within the small intestine, the trophozoites reproduce asexually
(longitudinal binary fission) and either float free or are attached to
the mucosa of the lumen.
 Some trophozoites then encyst in the small intestine.
 Encystation occurs most likely as a result of exposure to bile salts
and fatty acids, and a more alkaline environment.
 Both cysts and trophozoites are then passed in the feces, and are
infectious immediately or shortly afterward
 Person-to-person transmission is possible
 Animals can also be infected with Giardia, and beavers have been
associated with giardia outbreaks, although not definitively
 Clinical Illness and Pathogenesis
• Incubation period :1–2 wk
• Duration of illness varies: few days to months.
• Ingested cysts excyst in response to stomach acidity.
• Trops. attach (via their sucking disk) to microvilli of epithelium in
small intestine, causing epithelial damage and interfering with gut
transport processes.
• Epithelial mucus is thinned, lymphocytes and other inflammatory
cells infiltrate, physical blocking of absorption may occur, and
enterobacteria may proliferate, causing more epithelial damage.
• clinical manifestations :asymptomatic . acute infectious diarrhea,
chronic diarrhea with failure to thrive and abdominal pain or
cramping.
 Pathogenesis and Pathology

Its in two ways;

I.Nutrient malabsorption and physical blockage

and damage to microvilli.

II.Trophs attach to small intestine cause

damage (mechanical and toxins).
 Pathogenesis and Pathology
It occurs in the following two ways;

1) Fat/CHO digestion decreases and causes maldigestion.

2) Absorption decreases due to villus blunting causing

malabsorption.

3) Malabsorption and maldigestion causes diarrhea.

4) Physical damage: clubbing of villi; decreases villus-to-

crypt ratio; brush borders of cells are irregular.
 Pathogenesis of G. Lamblia
• The mechanisms by which Giardia duodenalis (= G. lamblia)
produces chronic diarrhoea and malabsorption have still not been
clearly defined.
• Possible mechanisms include direct physical injury, release of
parasite products such as proteinases or lectin, and mucosal
inflammation associated with T cell activation and cytokine release.
• Other possible mechanisms of malabsorption include associated
bacterial overgrowth and bile salt deconjugation, bile salt uptake by
the parasite with depletion of intraluminal bile salts, and inhibition
of pancreatic hydrolytic enzymes.
• Thus, there is no single mechanism to explain the diarrhoea and
malabsorption caused by Giardia, which currently should be
regarded as a multifactorial process.
Most symptomatic patients have;
-profuse and watery to semisolid, greasy, bulky and foul- smelling
diarrhea;
-abdominal cramps; -nausea;
-vomiting; -anorexia;
-low-grade fever and flu-like headache.
-General malaise, -weakness,
-Distention and flatulence can occur. -weight loss,

Note
•stools may be profuse and watery and later become greasy and foul
smelling
•Stools do not contain blood, mucus, or fecal leukocytes
•Varying degrees of malabsorption may occur.
• Malabsorption of sugars, fats, and fat-soluble vitamins has been
well documented and may be responsible for substantial weight
loss.

• Giardiasis has been associated with growth stunting and repeated

Giardia infections with a decrease in cognitive function in
children in endemic areas.
 Laboratory Diagnosis
Stool examination
1. Ova and parasite (O+P) examination
– Giardia cysts can be excreted intermittently, so many cases
(>50%) of giardiasis will be missed with a single O+P
examination, resulting in under diagnosis.
– Multiple stool collections (i.e., three stool specimens collected
on separate days) increase test sensitivity
– Use of concentration method increases sensitivity.
– Microscopical examination of freshly passed stools is used for
the demonstration of Giardia trophozoite and cysts.
-Fresh diarrhoeic specimen: find Giardia
lamblia trophozoites. Generally difficult to detect as they attach
themselves to the wall of the intestine. 

-A Giemsa or Field’s stained faecal smear should be examined

if giardiasis is suspected but no trophozoites are detected in a
wet mount of the faeces.

-Formed faecal specimen: Look for the Giardia lamblia cyst.

2. Fecal immunoassays that are more sensitive and specific can be
used:
– An ELISA test that detects a Giardia cyst wall antigen in the stool
can be used
– Antibody Detection. serum antibody responses to giardiasis
revealed that antigen recognition bimmunoglobulin M (IgM), IgA,
IgG1, and IgG3 of these patients, determined by immunoblotting,
3. String test (Entero-Test)
- Swallowing a weighted piece of string until it reaches a duodenum.
– The trophozoite adhere to the string and can be visualized after
withdrawal of the string.
4. Polymerase Chain Reaction (PCR); can be used to identify the
subtypes of Giardia lamblia. 
 Treatment of Giardiasis
 Tinidazole: >3 yr: 50 mg/kg/day once daily
 Nitazoxanide
 Metronidazole: 15 mg/kg/day in 3 divided doses for 5–7
days
• Second line alternatives:
-furazolidone 6 mg/kg/day in 4 divided doses for 10 days
-albendazole: >6 yr: 400 mg once a day for 5 days
-paromomycin, and quinacrine :6 mg/kg/day in 3 divided
doses for 5 days
 PREVENTION
• Handwashing
• Purify public water supplies adequately include
chlorination and filtration.
• Travelers to endemic areas are advised to avoid uncooked
foods that might have been grown, washed, or prepared
with water that was potentially contaminated.
• Purification of drinking water can be achieved by a filter
or by brisk boiling of water for at least 1 min
 Environmental Control of Giardia
Water: physical and chemical treatment (coagulation-
flocculation, sedimentation, filtration and disinfection) will
reduce Giardia by 3+ log10
– 2 to 2.5 log10 by typical physical-chemical treatment
– ~0.5 log10 by chemical disinfection (chlorine, ozone or
chlorine dioxide)
– Extensive >4 log10 reductions by membrane filtration
• Sewage: ~99% reductions by conventional 1o+2o sewage
treatment
– Infectivity of cysts in treated effluent is uncertain
• Relatively resistant to chemical disinfection but relatively
sensitive to physical disinfection by UV radiation or heat
– Pasteurization and thermal treatments effective for foods