[PROTOZOANS BY DR DOMANTAY] Aug.

19-20, 2014

[PROTOZOANS BY DR DOMANTAY] Aug. 19-20, 2014

Parasitic infections are either due to

a:
o Unicellular protozoan
o Multicellular metazoan
Protozoan parasites are parasites provided
with:
1. Nucleus
2. Cytoplasm
3. Outer limiting membrane
4. Organelles
*Organelles of locomotory
apparatus
a)
b)
c)

Feeding
Locomotion
Osmoregulation
Reproduction

Infective stages: CYSTS which are resistant to

environmental changes
o

abscess (extra intestinal dse)

E. histolytica Trophozoite

Many require a wet environment for:

1.
2.
3.
4.

Cilia: short processes found on the

surface
Flagella: longer, whip-like appendages
Pseudopodia: false feet

cause
colitis
and
liver

Other modes of transmission include:

o Venereal transmission (STD)
o Direct colonic inoculation

Cyst undergoes nuclear followed by

cytoplasmic division to form 8 trophozoites.
Excystation (release of trophozoites) then
occurs in the small or large bowel. The
trophozoites have the ability to colonize and
invade the large bowel.

E. histolytica trophozoites multiply by binary

fission.
They undergo encystation producing
uninucleate cysts, which undergo two
successive nuclear divisions to form the
characteristic quadrinucleate cysts (found in
stool).

able to thrive/survive even in the harshest

conditions

Vegetative stages: TROPHOZOITES

All protozoa fall under kingdom Protista

Major protozoan organisms causing disease in
man belong to:
o Phylum Sarcomastigophora
o Phylum Ciliophora
o Phylum Apicomplexa
o Phylum Microspora

Life cycle (two stages)

1. infective cyst
2. invasive trophozoite
Infection occurs when cysts are ingested from
fecally contaminated material

INTESTINAL AMEBAE: Entamoeba histolytica

E. histolytica is currently classified within

o
Subphylum Sarcodina
o
Superclass Rhizopoda
o
Class Lobosea
o
Order Amoebida
o
Genus Entamoebidae
o
Family Entamoeba

There are two generally distinct but

morphologically identical species, E. histolytica
and E. dispar
o E. histolytica = cause invasive
intestinal and extraintestinal dse
(histolytic)
o E. dispar = harmless commensal

Parasite Biology

E. histolytica is a pseudopod-forming nonflagellated protozoan parasite. It is the most

invasive of the parasites in the Entamoeba
family, and the only member of the family to

Pathogenesis & Clinical Manifestations

Signs & Symptoms

Majority of cases are asymptomatic infections

with cysts being passed out in the stools
1. Amebic colitis

presents as gradual onset of abdominal pain &

diarrhea with or without blood and mucus in
the stools.

Fever occurs only in 1/3 of patients (not

common).

[PROTOZOANS BY DR DOMANTAY] Aug. 19-20, 2014

2.

Ameboma presents as a mass-like lesion with

abdominal pain and a history of dysentery.

Name one differential diagnosis: carcinoma

Amebic liver abscess (ALA)

most common extra-intestinal form of

amebiasis.

cardinal manifestations of ALA are: (1) fever;

and
(2) right upper quadrant (RUQ) pain.

liver is tender & hepatomegaly is present in

50% of cases.

Chronic disease is found in older patients and it

involves wasting

Pathology
1. Trophozoite invasion is facilitated by the
expression of virulence factors:
a. Gal/GalNac lectin: mediates adherence
of trophozoite to host cells/ mucosa
b. Amebapores: form pores or holes in the
host membrane (lysed)
c. Cysteine proteinases: cytopathic for
host tissues, and they act by:
i. Thinning of mucin layer - allows
trophozoite to enter
submucosa
ii. Shortening of villi - indicates
malabsorption syndrome
iii. Breakdown of extracellular
matrix - aids in ability of
trophozoite to penetrate

Trophozoites attach to mucosal cells facilitated

by lectin.

They lyse cells through amebapores and

stimulate release of IL-8 which attracts and
activates neutrophils. (inflam.)
2. The trophozoites finally erode through the
lamina propria and extend laterally producing
the characteristic flask-shaped ulcer.
3.

The most common sides of amebic ulcer are

Cecum

Ascending colon

Sigmoid

E. Histolytica is the only protozoan that has an

extrainstestinal infection causing Amebic Liver Abscess
(ALA). How do trophozoites reach the liver?

4.

From the primary site in the colon, E.

histolytica trophozoites reach the liver through
a. portal vein = trophozoite penetrate the
submucosa (rich in blood vessels) thus
having a hematogenous route leading
to the Portal Vein then Liver.
b. may also occur through direct extension
(hepatic flexure of the ascending colon)

5.

Amebic Liver Absces (ALA):

Once in the liver, the trophozoites lyse

both inflammatory and liver cells

The abscess becomes filled with

necrotic, proteinaceous debris.

The aspirate is described as anchovysauce like. It is odorless and

bacteriologically sterile, although
secondary bacterial invasion may
occur.

If present, trophozoites are found at

the edge of the abscess.

*(middle of abscess only contain

necrotic cells)

Complications of E. HISTOLYTICA if left untreated:

1. Amebic Colitis
-it may cause perforations and secondary
bacterial peritonitis because colon is not
sterile.
2. Amebic Liver Abscess
-it can rupture to the pericardium, pleura or
into the peritoneal cavity.
3. Secondary Amebic Meningoencephalitis
-affects the meninges of the brain
-found in immunocompromised patients
causing abnormal mental state.

IMMUNITY TO E. HISTOLYTICA

Natural / Innate Immunity (non-specific)

Mucin from intestine prevents attachment
Complement-mediated killing in the
Systemic Circulation

Acquired Immunity
Cell mediated responses (T-cell)
Activated T-cell kills by:
a Directly lysing trophozoites in a
contact-dependent process
b Producing cytokines which attracts
macrophages and other effector
cells.
c Provides helper effect for B-cell
Antibody production
DIFFERENTIAL DIAGNOSIS
1. Amebic Colitis should be differentiated from:

[PROTOZOANS BY DR DOMANTAY] Aug. 19-20, 2014

Bacillary Dysentery of Shigella, Salmonella,

Campylobacter, Yersinia and Enteroinvasive E.
Coli

Inflammatory Bowel Disease- 2 entities:

o Crohns Disease
o Ulcerative Colitis.

Difference between Bacillary and Amebic

BACILLARY
DYSENTERY
Bacterial
Maybe Epidemic
Acute Onset
Prodromal Fever and
malaise common
Vomiting Common
Patient is prostrate or
weak
Watery, Bloody
diarrhea
Odorless stool
Stool microscopy:
numerous bacilli, pus
cells macrophages, red
cells, no CharcotLeyden Crystals
Abdominal cramps
common and severe
Tenesmus* common
Natural history:
spontaneous recovery
in a few days, weeks or
more. No relapse

AMEBIC DYSENTERY
Parasitic
Seldom Epidemic
Gradual Onset
No Prodromal Features
No Vomiting
Patient usually
ambulant or
asyptomatic
Bloody Diarrhea
Fishy odor stool
Stool microscopy: few
bacilli, red cells,
trophozoites with
ingested RBC, Charcotleyden crystals
Mild abdominal cramps
Tenesmus* uncommon
Natural history:
Lasts for weeks;
dysentery returns after
remission; infection
persists for years.

Dysentery:
*Tenesmus= feeling of incomplete defecation

2. ALA should be differentiated from:

Pyogenic Liver abscess (pus formation by S.

aureus)

Tuberculosis of the Liver

Hepatic Carcinoma
3. Genital Amebiasis should be differentiated from:

Carcinoma

Tuberculosis

Chancroid (H. ducreii)

Lymphogranuloma Venereum (STD by

Chlamydia trachomatis
LABORATORY DIAGNOSIS
STANDARD METHOD: Fecalysis
Dont rule out with just 1 negative result
Minimum of 3 stool specimens collected at
different days because trophozoite/cyst release
is intermittent (released in batches)

DFS (Direct Fecal Smear)

- Use either: Saline, Iodine, Methylene Blue

-enhances visibility of organisms under the
microscope
-Charcot Leyden Crystals may be seen but rarely
(usual in asthma patient)
Concentration Techniques
-demonstrates cyst stage of protozoans
-techniques:
a) Zinc sulfate floatation- kills trophozoites
b) FECT- Formalin Ether Concentration Test
c) MIFC- Merthiolate Iodine Formalin
Concentration Test
Stool Culture
-Medium: Robinsons and Inokis
-usually done for research studies

E. histolytica vs E. dispar Laboratory Differentiation

o
PCR = determine genetic make-up
o
ELISA
o
Isoenzyme Analysis
SEROLOGY (for ALA)
Usually for ALA (detecting trophozoite in the liver is
hard)
Detects Antibody in Serum to positive infection
a) IHAT- Indirect Hemagglutination Test
Can direct past Antibody as long as 10 yrs*
b) CIE- Counter Immunioelectrophoresis
c) AGD- Agar Gel Diffusion
d) IFAT- Indirect Fluorescent Antibody Test
e) ELISA- Enzyme-linked Immunosorbent Assay
RADIOGRAPHIC STUDIES (for ALA)

UTZ

CT Scan

MRI
TREATMENT
2 Objectives:
a) Cure the invasive disease: Trophozoite
b) Eliminate the passage of the cyst (prevent further
infection)
1.

Invasive Amoebiasis Treatment:

o Metronidazole = DRUG OF CHOICE
o Other 5-nitroimidazole derivatives are also effective:

Tinidazole

Secnidazole
o
For asymptomatic cyst passers:

Diloxanide Furoate = DRUG of CHOICE

may also be given after a course of

metronidazole for invasive amebiasis

2.

ALA Treatement:
o
Percutaneous Drainage of Liver Abscess is indicated
for patients who do not respond to IV metronidazole.

EPIDEMIOLOGY
Distribution and Determinants of the Disease
Distribution:
At present, the epidemiology of E. histolytica is not certain
because of its similarities with E. dispar
E. Histolytica infects 50 million people worldwide
And about 100,000 infection ends fatally (ex.
Meningioencephalitis)

[PROTOZOANS BY DR DOMANTAY] Aug. 19-20, 2014

2nd to Malaria in terms of mortality caused by protozoans.
Increased cases of Amebiasis infection has been reported
from:
Indian subcontinent, Indonesia, Subsaharan &
Tropical Africa, Central & South America, Philippines
Determinants: Who are at risk of severe infection?

Children and neonates

Pregnant Women

Post-partum Patients

Those taking corticosteroids

Those with malignancy

Those with malnutrition

High risk groups in developed counties include

Recent travelers and immigrants

Inmates of mental institutions

Asexually active male homosexuals

Life Cycle of Entamoeba histolytica:

Cysts
and
trophozoites
are
passed
in
feces .
Cysts are typically
found
in
formed
stool,
whereas
trophozoites
are
typically found
in diarrheal stool.
Infection
by Entamoeba
histolytica occurs by
ingestion
of
mature
cysts
in
fecally
contaminated food, water, or hands. Excystation
occurs in the small intestine and trophozoites
are
released, which migrate to the large intestine. The trophozoites multiply by binary fission and produce
cysts , and both stages are passed in the feces . Because of the protection conferred by their walls,

[PROTOZOANS BY DR DOMANTAY] Aug. 19-20, 2014

the cysts can survive days to weeks in the external environment and are responsible for transmission.
Trophozoites passed in the stool are rapidly destroyed once outside the body, and if ingested would not
survive exposure to the gastric environment. In many cases, the trophozoites remain confined to the
intestinal lumen ( : noninvasive infection) of individuals who are asymptomatic carriers, passing cysts in
their stool. In some patients the trophozoites invade the intestinal mucosa ( : intestinal disease), or,
through the bloodstream, extraintestinal sites such as the liver, brain, and lungs ( : extraintestinal
disease), with resultant pathologic manifestations. It has been established that the invasive and
noninvasive forms represent two separate species, respectively E. histolytica and E. dispar. These two
species are morphologically indistinguishable unless E. histolytica is observed with ingested red blood cells
(erythrophagocystosis). Transmission can also occur through exposure to fecal matter during sexual
contact (in which case not only cysts, but also trophozoites could prove infective).
Note takers:
Marco Paulo Naoe
Geas-Ann Kho
Mary Anne Kua