PROTOZOA

Unicellular organisms

Intestinal Protozoa
Amoeba: Entamoeba histolytica
Flagellates: Giardia lamblia & Trichomonas

parvum/hominis
Ciliates: Balantidum coli
Sporozoa:
Isospora belli
Cyclospora cayetanensis
Cryptosporidium parvum/hominis
Sarcocystis hominis

Entamoeba histolytica - Amoebiasis

World wide distribution 3rd after malaria and

schistosomiasis
Hand-mouth; fecal-oral; sexual transmission
Increasing in homosexuals
Resistant to chlorine
Major complications: amoebic abscesses in
liver, brain, lung
Amoebic pericarditis (rare) is most dangerous

complication of amoebic liver abscess

Clinical Classification of Amoebiasis

Asymptomatic infection
Colonization without invasion
Symptomatic infection
Invasion with mild symptoms
Intestinal disease
Dysentery, colitis, amoeba
Extraintestinal amoebiasis
Liver, skin, lung, pleura, brain

Pathogenesis of Amoebiasis
Ingested cysts trophozoites in large intestine

75% remain in lumen 15% invasive disease;

adherence/digestion of epithelium; formation of
flask-shaped ulcers bacterial superinfection
may occur dissemination liver abscess
rupture pericardial disease

Clinical Presentation of Amoebiasis

Asymptomatic
Mild GI discomfort
Diarrhea, pain, blood, mucus
Weight loss
Organ specific symptoms
Dx: history, cysts/trophozoites, ELISA/PCR

Intestinal Flagellates
Giardia lamblia
Giardia intestinalis
Giardia duodenalis
Trichomonas hominis
Epidemiology: worldwide
Travelers/backpackers diarrhea: hikers/campers
Day care centers
Zoonotic; water, food (fecal-oral)

Life Cycle of Giardia

Ingestion of cysts trophozoites attach to

duodenal brush border causing irritation and

obstruction of absorption cysts in colon;
passed in feces
See them moving in stool

Clinical Presentation of Giardia

Watery diarrhea, abdominal cramps
Weight loss
No blood, no pus, no fever
Steatorrhea fatty and foul-smelling
Lactose intolerance
Antibody deficiency
Dx: fecal cysts/trophozoites; enterotest;

ELISA; duodenal aspiration

Comparison of Clinical
Presentations
Amoebiasis

Giardiasis
Non-inflammatory watery

Asymptomatic
Mild GI discomfort
Inflammatory Diarrhea,

pain, blood, mucus

Weight loss, fever
Organ specific symptoms
Dx: history,
cysts/trophozoites,
ELISA/PCR
History: international travel

diarrhea, abdominal cramps

Steatorrhea fatty and foulsmelling
No blood, no pus, no fever
Weight loss
Lactose intolerance
Antibody deficiency
Dx: fecal cysts/trophozoites;
enterotest; ELISA; duodenal
aspiration
History: Camping in Northern US
wilderness; drink mountain water

Oral Flagellate
Trichomonas tenax

Intestinal Ciliate
Balantidum coli Balantidiasis
The only ciliated protozoa!
Common parasite of animals
No extraintestinal spread
Easily treated, not very common
Seen in ppl who are around animals all the time

Farmers, zoo workers

Tx: tetracycline

Intestinal Sporozoa
Isospora belli
Cyclospora cayetanesis water or produce
Cryptosporidium parvum/hominis water and food
Non-inflammatory diarrhea
Infection by ingestion of oocyst infection of

intestinal epithelium
Sexual & asexual stages sporogony/schizogony
Self-limiting in immunocompetent; Severe in AIDS
or other immunocompromised individuals
Dx: acid-fast oocysts in stool & history

Urogenital Flagellate
Trichomonas vaginalis
Sexual transmission

Amoeboflagellates
Primary CNS pathogens
Naegleria fowleri
Enter thru olfactory neuroepithelium causing primary

amoebic meningoencephalitis (PAM) in healthy ppl

Trophozoites in CSF and tissue

Acanthamoeba culbertsoni
Balamuthia mandrillaris
Acanthamoeba and Balamuthia enter thru lower

respiratory tract or thru broken skin causing

granulomatous amoebic encephalitis (GAE) in
immunocompromised individuals
Trophozoites and cysts in tissue

Haemoflagellates
Trypanosoma & Leishmania
Insect borne
Found in blood, tissue, lymph and CSF
Amastigote and trypomastigote most imp forms

Trypanosomiasis
T. Gambiense
Tsetse fly; West Africa
T. Rhodesiense
Tsetse fly; East Africa
T. Cruzi
Reduviid bug, Americas

T. Cruzi American trypanosomiasis

Chagas disease
Vector: reduviid bug (triatomine bug)
Zoonotic
South/Central America
Infection thru eyes or open cuts, transplacental, at
parturition or breastfeeding, blood, uncooked or
contaminated food
Patho: bug feces infection of local tissue ulceration

& inflammation spread localization in mesenchymal

tissues of heart, GI, esophagus, etc markedly
enlarged heart, esophagus, and megacolon
tachycardia, chest pain, ECG changes, constipation

Chagas Disease
Chagoma, Romanas sign
Hepatosplenomegaly, lymphadenopathy
Myocarditis w/ CHF; Meningoencephalitis
Tx: nifurtimox, benznidazole

Leishmaniasis
Vector Phlebotomine sand fly
3 forms
Leishmania tropica: dermal/cutaneous form
Leishmania brasiliensis: mucocutaneous form
Leishmania donovanii: visceral form
Most severe form (KALA AZAR) 100% fatality if
untreated
Hypoalbuminemia; hypergammaglobulinemia
Irregular fever, marked weight loss, anemia,
hepatosplenomegaly
Amastigotes in deep tissue liver, spleen, bone
marrow

Drug: Sodium stibogluconate

Visceral leishmaniasis
Patho: Parasite localization in macro of RES

PANCYTOPENIA high output heart failure

myocarditis/pericarditis
Leishmania HIV coinfection on the rise

Tissue Sporozoa
Plasmodium (blood & tissue)
Malaria; Vector: female anopheles mosquito
Babesia (blood)
Babesiosis; Vector: Ixodes scapularis
Ixodes also carries lyme disease and human granulocytic
anaplasmosis

Toxoplasma gondii (tissue)

Toxoplasmosis; Vector: cat
Most commonly reported parasitic disease following heart
transplantation
Two life cycles, two hosts: sexual (sporogony) definitive

host; Asexual (schizogony) intermediate host

Malaria

Plasmodium
P. falciparum, ovale, vivax, malariae

Parasite detection: HRP2 detection,

parasite LDH ... Dipstick tests

Complications of Malaria

Parasitized RBCs adhere fibrin thrombi

microinfarcts in brain, heart CHF,

encephalopathy death
Phagocytosis by macro macro hyperplasia
hepatosplenomegaly nephrosis death

Pathology of Malaria
Fever, anemia, jaundice
Hepatosplenomegaly, hepatorenal syndrome
Pulmonary edema, CHF
Blackwater fever dark urine
Encephalopathy cerebral malaria

Protection against
Malaria
Absence of receptor (duffy antigen Fy aFyb)
G6PD deficiency
HbS
Thal

Malaria hypnozoites
P. vivax & P. Ovale
Use primaquin against hypnozoites
Chloroquine against severe malaria
Quinine in severe parasitemia and resistant

malaria
Metronidazole for amoebic liver abscesses
Also for giardiasis, trichomoniasis, dracunculis

medinensis

Babesiosis
Similar to malaria; co-infection w/ Lyme

disease; Ixodes scapularis

Fever, chills, sweating, myalgias, fatigue,
hepatosplenomegaly, hemolytic anemia

Toxoplasmosis
Infection flu-like latency reactivation if

pt becomes immunocompromised
myocarditis, pericarditis, CHF

HELMINTHES METAZOA

Helminthology
Platyhelminthes
Cestodes tapeworms Tx: Praziquantel,
Niclosamide
Trematodes flukes Tx: Praziquantel
Nemathelminthes (Nematodes)
Intestinal worms Tx: Mebendazole
Tissue worms - filaria

Trematodes
Hermaphroditic flukes
Mammals definitive hosts
Snails 1st intermediate hosts
Fish, crustacea, vegetable 2nd intermediate
hosts
Schistosomes
Mammals definitive hosts
Snails intermediate hosts

Clinical Classification
Lung fluke
Paragonimus westermanii CRAB
Liver fluke
Clonorchis sinensis FISH
Fasciola hepatica PLANT/VEGETABLE

Intestinal fluke
Heterophyes heterophyes FISH
Fasciolopsis buski PLANT/VEGETBALE
Tx: Praziquantel for all trematodes

Schistosomiasis (blood fluke)

Direct skin penetration by cecariae
S. Mansoni intestinal (side spine)
S. Japonicum intestinal (no spine)
S. Hematobium urinary (terminal spine)
Tx: Praziquantel
Picture:
Left, S. mansoni
Middle, S. Haematobium
Right, S. japonicum

Diphylobothrium Latum
Broad or fish tapeworm
Very big
From ingestion of larvae in RAW fish
Clinical:
Low serum B12, eosinophilia
Atrophic gastritis
Megaloblastic anemia

Dx: history, presentation, eggs in stool

Tx: Praziquantel, Niclosamide

Taeniasis
Beef tapeworm T. Saginata
Ingestion of larvae in undercooked/raw beef
Pork tapeworm T. Solium
Ingestion of eggs in undercooked/raw pork
Associated w/ heart problems
Dx eggs/proglottids in human feces; adult in

intestines
Tx: Praziquantel, Niclosamide

Nemathelminthes
Intestinal nematodes
Ascaris lumbricoides Roundworm
Strongyloides stercoralis Threadworm
Ancylostoma duodenale Hookworm
Necator americanus Hookworm
Enterobius vermicularis Pinworm
Trichuris trichiura Whipworm
Trichinella spiralis Porkworm
Infections characterized by eosinophilia and high

IgE levels; hygiene and lifestyle is important

Ascaris lumbricoides - Roundworm

One of the most common human infections

worldwide
Patho:
Stage 1: infective eggs ingested larval migration

cough, hemoptysis (bloody sputum), dyspnea,

hemorrhagic pneumonia, asthma attacks, pulmonary
infiltration, urticaria
Stage 2: adult in intestine dependent on worm load
pain, distension, nausea, anorexia, malnutrition
(growth stunting in children), intestinal obstruction
Stage 3: adult migration acute pancreatitis or
obstruction, biliary obstruction, jaundice,
appendicitis, peritonitis

Dx: larvae in sputum; ova & parasites in stool

Tx: Mebendazole

Strongyloides stercoralis Threadworm

Direct skin penetration
2 distinct adult forms
Filariform (infective form): larvae penetrate

intact skin initiating infection enter

circulatory system lungs penetrate alveolar
spaces reach small intestine mature to
adult female (not male) produce uninfective
larvae autoinfection
Uninfective infective in intestine and stool
Uninfective adults in soil or become infective

Rhabditiform (uninfective form)

Strongyloides Clinical Features

Acute disease:
Ground itch, cough, dyspnea, wheezing, fever,
epigastric pain
Chronic disease:
Abdominal cramping, diarrhea, pain

Severe disease
Hyperinfection syndrome
Extraintestinal spread (CNS, etc)
**dissemination in AIDS pts**
Dx: larvae in stool, urine, duodenum, enterotest
Tx: Ivermectin

Enterobius Vermicularis - Pinworm

Common in US; children
Eggs on perianal folds perianal itching
Pricking anal pain, restlessness,
sleeplessness
Dx: see them around anus, eggs on

scotch tape
Tx: pyrantel pamoate or mebendazole

Enterobius vermicularis

Necator Americanus & Ancylostoma

Duodenale Hookworms
Worldwide distribution; Enter thru FEET
Clinical stages:
Cutaneous Stage: ground itch
Pulmonary Stage: pulmonary hemorrhage

Cough, wheezing, pneumonitis

Intestinal Stage: GI discomfort, blood loss

Hookworm Infection Complications

Protein losing enteropathy
Fe deficiency anemia
Tachycardia
Stillbirth
Poor physical development
Dx: history and eggs in stool
Tx: mebendazole + dietary supplements
Wear shoes!!

Trichuris Trichura - Whipworm

Fecal-oral transmission; rare
Clinical:
Light infection: asymptomatic
Moderate infection:

Discomfort, gas, diarrhea/constipation

Heavy infection
Distension, vomiting, diarrhea, weight loss
**RECTAL PROLAPSE**

Dx: history & eggs in stool

Tx: mebendazole

Trichinella Spiralis - Porkworm

No eggs
No external phase
Dead end transmission! ingestion of

undercooked meat larvae turn to adults in

intestinal cells migrate to muscle encyst

Clinical Presentation of Trichinella

Spiralis
Diarrhea, constipation
Fever, myalgia, fatigue
Macular or petechial rash
Periorbital edema, conjunctivitis/retinal

hemmorrhage
Splinter hemmorhage; heart problems
Dx: muscle biopsy, positive serology,
presentation symptoms
Tx: Thiabendazole before tissue invasion
Rest + analgesics for after invasion

Tissue Nematodes =
Filaria
Adults in tissue
Eggs not produced; microfilaria produced
Wuchereria bancrofti mosquito
Brugia malayi/timori mosquito
Loa loa deer fly
Onchocerca volvulus simulium black fly
Dracunculus medinensis Cyclops (water

flea)

Elephantiasis/Lymphatic filariasis
Wuchereria bancrofti
Brugia malayi & Brugia timori
Patho: microfilaria adult worms in lymphatics

more microfilariae lymphoedema inflammatory

reaction elephantiasis
Early: acute inflammation, hypereosinophilia, massive

lymphatic dilatation, bacterial and fungal infections,

infection by wolbachia bacteria (tx: tetracycline)
Late: lymphoedema/elephantiasis; chyluria (lymph in
urine)

Tx: DEC + Albendazole or Albendazole + Ivermectin

Elephantiasis
Dx: presentation, very high increase in eosinophils, IgE,

IgG4, and specific antifilarial Ab; microfilariae in blood

(nocturnal periodicity)
Sheath = pathogenic; no sheath = nonpathogenic

Onchocerca Volvulus
River blindness/onchocerciasis
Vector: Simulium Black Fly
Larvae in subcutaneous tissue
Patho: adult in onchocercoma millions of

migrating microfilariae death due to

immune response onchodermatitis/keratitis
Dx: Skin biopsy nodules tons of little worms
Tx: DEC or Ivermection (single dose)

Dracunculiasis
Dog, horse, cow, monkey
Vector: Cyclops (Water Flea)
Debilitatin skin eruptions worms come

out of them!!
Tx: metronidazole/thiabendazole
Dracunculus medinensis

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