Other tissue dwelling

Protozoans

Toxoplasma
Pneumocystis
Microsporidia
Babesia

Dr. R. E.
 Genus Toxoplasma
 Toxoplasma gondii
 one of the most common protozoan parasites in the world
 toxoplasma, form the Greek "toxon" meaning arc or crescent
shape
 The species name is derived from the rodent, Ctenodactylus
gondii from which the T. gondii was first isolated
 T. gondii is classified into:
 phylum Apicomplexa
 class Sporozoa
 subclass Coccidia

 It is related to the parasites Plasmodium (the agents of

malaria), Cryptosporidium, Isospora, Neospora and Sarcocystis
 T. gondii is an obligate intracellular parasite
 which means that it is only able to reproduce inside cells

 Maybe found in many kinds of tissues including muscles and

intestinal epithelium

 definitive hosts: domestic & wild cats and certain members of

the Felidae family
 intermediate hosts: humans, many mammals, rodents, pigs,
herbivores and birds
 cosmopolitan distribution
 able to infect a wide variety of vertebrate hosts (warm-
blooded animals)
 human infection common in many parts of the world
 Most common congenitally acquired parasitic infection
 most infection benign and asymptomatic
Morphology

Trophozoite
 motile
 size 4-6μm L X 2-3μm W
 cresent or banana-shaped with pointed anterior and rounded
posterior end
 nucleus single, spherical-shaped situated near the more
rounded end
 In human host, the asexual cycle produces:
 Slender tachzoites which infect cells which is responsible
for acute disease - toxoplasmosis
 Shorter, broader, dormant, bradyzoites which form large
tissue cysts
Cyst
 5-50 µm in diameter
 Appears - spherical in the brain
- elongated in cardiac and skeletal
muscles
 Tissue Cysts - may be found in various sites
throughout the body of the host, but are most
common in the brain and skeletal and cardiac
muscles

Oocyst
 ovoidal in shape
 9-11μm (width) X 11-14μm (length)
 Mature oocyst contains 2 sporocyst with 4
sporozoite inside each sporocyst
 cyst develop into sporulated oocysts shed by
infected cats in the environment
Life Cycle of T. Gondii
 asexual cycle involves
mammals (including
humans) and various
strains of birds and other
intermediate hosts
 It consists of 2 forms:
 tachyzoites (the rapidly
dividing form observed
in the acute phase of
infection)
 bradyzoites (the slowly
growing form observed
in tissue cysts)
 Both the oocyst and tissue
cysts transform into
tachyzoites shortly after
ingestion
 Tachyzoites localize in the
neural and muscle tissue
and develop into tissue
 sexual cycle occurs only among
cats
 begins in the GIT of the cat
 Bradyzoites are released in the
intestines where it infect cells;
forms trophozoites and undergoes
schizogony
 Macrogametocytes and
microgametocytes develop from
ingested bradyzoites and fuse to
form zygotes
 zygotes then become encapsulated
within a rigid wall and are shed as
oocysts
 The zygote sporulates and divides
to form sporozoites within the
oocyst
 Sporozoites become infectious 24
hours or more after the cat sheds
the oocyst. During a primary
Modes of Transmission

 cats acquires the infection by feeding on infected animals

such as mice or eating infected uncooked household meat
 Humans acquire the infection thru:
 Handling or ingestion of undercooked or raw meat
containing tissue cysts (bradyzoites)
 Infection can occur by ingestion of oocysts following the
handling of contaminated soil or cat litter or the
consumption of contaminated water or food sources (eg,
unwashed garden vegetables)
 Fetus acquire infection thru:
 congenital transmission (Transmission of tachyzoites to
the fetus can occur via the placenta following primary
maternal infection)
 Disease: Toxoplasmosis

 T. gondii infects a large proportion of the world's population but

uncommonly causes clinically significant disease
 high risk individuals for severe or life-threatening disease:
 Fetuses

 Transplacental transmission rate: 45%

 60% are subclinical; 30% may suffer severe damage; 9%
may die
 Stillbirths and spontaneous abortion may result
 Newborns

 immunodeficient individuals

 pts with defects of T-cell–mediated immunity, such as

those with hematologic malignancies, bone marrow and
solid organ transplants, or AIDS
 Acute toxoplasmosis in immunocompetent host

 Approximately 80-90% of patients are asymptomatic

 Lymphadenitis is the most common manifestation
 Infected nodes are tender and discrete but not painful

 the infection resolves spontaneously in weeks or months

 Lymphadenopathy may be accompanied by fever,

malaise, fatigue, muscle pains, sore throat, and
headache
 Retroperitoneal and mesenteric lymphadenopathy with
abdominal pain may occur
 Chorioretinitis is reported
Acute toxoplasmosis in hosts who do not have AIDS
but are immunodeficient

 Disease may be newly acquired or may be a reactivation

 CNS disease occurs in 50% of patients
 Patients may have encephalitis, meningoencephalitis, or
mass lesions
 Encephalitis is an important and severe manifestation in
immunosuppressed patients including patients with
AIDS
 Symptoms may include headache, disorientation,
drowsiness, hemiparesis, reflex changes, and
convulsions
 Coma and death may ensue

 Patients report visual changes

 They may have signs and symptoms similar to those
observed in immunocompetent hosts
 Toxoplasmosis in AIDS patients

 Brain involvement is the most common manifestation, with or

without focal CNS lesions
 Clinical findings are altered mental state, seizures, weakness,
cranial nerve disturbances, sensory abnormalities, cerebellar
signs, movement disorders, and neuropsychiatric
manifestation
 Pneumonitis - being increasingly recognized in AIDS patients
who are not receiving appropriate anti-HIV drugs or primary
prophylaxis for toxoplasmosis; primarily manifests as a
prolonged febrile illness with cough and dyspnea
 Toxoplasmic chorioretinitis - observed infrequently in AIDS
patients; it commonly manifests with ocular pain and loss of
visual acuity
 Panhypopituitarism and diabetes insipidus are reported
 Multiple organs may be involved, and findings manifest as acute
respiratory failure and hemodynamic abnormalities similar to
 Congenital toxoplasmosis

 This is most severe when maternal infection occurs early in

pregnancy
 Approximately 67% of patients have no signs or symptoms of
infection
 Mild disease may consist of slightly diminished vision
 severely diseased children may exhibit classic manifestations:
- chorioretinitis (15% ; most common
sequela)
- intracranial calcifications (10%)
- microcephaly
- convulsions
- psychomotor disturbances
- mental retardation
- blindness and other visual defects
- hydrocephalus (least common sequela but most severe)
 Other sign of congenital toxoplasmosis present at birth
includes:
Laboratory Diagnosis
 Clinical signs of toxoplasmosis are nonspecific and cannot be
depended on for a definite diagnosis
 Definitive diagnosis: demonstration of the parasite at autopsy or
biopsy from lymph nodes and involved
organ
 Serology - demonstration of specific antibodies
 indirect hemagglutination test, latex agglutination test, ELISA

 indirect fluorescent antibody test

 Sabin-Feldman dye test

- gold standard for serological diagnosis of Toxoplasma

- Live virulent tachyzoites of T. gondii are used as antigen
and are exposed to dilutions of the test serum and to a
complement accessory factor resembling complement
that is obtained from Toxoplasma-antibody free-human
serum
Treatment

 combination of:
 Pyrimethamine 20-25mg daily x 1 month

 Trisulfapyrimedine or Sulfonamides 2-6gms daily x 1 month

 Spiramycin 300mg/kg x 3-4 weeks given to pregnant women

to prevent transmission in utero
Prevention and Control

• raw meat
• cook thoroughly
• wear gloves when handling
• wash hands after handling
• wash cutting boards, counter tops, utensils, etc

• cat feces
• clean litter box promptly (<24 hr)
• wear gloves while gardening
• wash hands after gardening or cleaning litter box
• wash and peal fruits and vegetables
• always keep cat away from the house
• control strays
• do not acquire new cats during pregnancy
 Genus Pneumocystis
 Pneumocystis jirovecii
 previously classified as Pneumocystis carinii

 was previously classified as a protozoa

 Currently, it is considered a fungus based on nucleic acid and

biochemical analysis
 Pneumocystis is a genus of unicellular fungi found in the
respiratory tracts of many mammals and humans
 The organism was first described in 1909 by Chagas then a few
years later by Delanöes who ultimately named the organism in
honor of Dr. Carinii after isolating it from infected rats
 Years later, Dr. Otto Jirovec and his group isolated the organism
from humans, and it is after him that the organism responsible
for PCP (pneumocystis carinii pneumonia) was renamed
 Geog. Dist.: Worldwide
Morphology Trophozoites (trophic form)
 1-5 µm, pleomorphic and contain a single
nucleus
 found in the lungs and many other
extrapulmonary specimens, especially in
immunocompromised pts

Cysts
 thick-walled, cup-shaped, rounded, 5-8 µm in
size
 contain up to eight “intracystic bodies” also
known as spores which are infective young
trophozoites
 Also found in the lungs and many other
extrapulmonary specimens, especially in
immunocompromised patients

Precysts (sporozoites)
 Disease: Pneumocystis carinii pneumonia (PCP)
Interstitial plasma cell pneumonitis

 Mode of transmission:
 acquired by inhalation (aerosol droplets)

 Direct contact

 Congenital transmission is possible

 human are reservoir host

 the most common opportunistic infection in HIV-infected patients
 disease more prevalent among patient who extensively use
immunosuppressive drugs, irradiation for cancer treatment and
following organ transplant and in patients who have undergone
bone marrow transplantation
 incubation period 3-4 weeks
 occurs almost exclusively in immunocompromised host
 acute and fatal especially among infants and adults
 The symptoms of PCP are very nonspecific
 The symptoms include dyspnea, nonproductive cough, and fever,
chest discomfort, weight loss, chills and rarely hemoptysis
 Extrapulmonary manifestations:
 Hepatomegaly

 Skin lesions

 Bone marrow (may have necrosis with resultant pancytopenia)

 Lymphadenopathy

 Eyes (may have retinal cotton-wool spots)

 Thyroid (may present as a rapidly enlarging thyroid mass)

 GIT
Pathogenesis

 It is relatively rare in people with normal immune systems but

common among people with AIDS
 In infected lungs, the epithelium becomes desquamated and
alveoli filled with foamy exudate containing parasite
 The disease has a rapid onset associated with fever, cough,
rapid breathing, and cyanosis
 both lungs are inflamed and enlarged
 presence of macrophages with hyperplasia of the alveolar
epithelium with round cell infiltration
 lobes consolidated and septa appears gray surface and airless
 Mortality rate: 100% in untreated pts
 Laboratory Diagnosis

 definitively confirmed by pathologic identification of the

causative organism in induced sputum or bronchial washings
obtained by:
characteristic cysts
 bronchoscopy with coloration by toluidine blue

 immunofluorescence assay

 In situations where these two techniques cannot be used,

transbronchial biopsy or open lung biopsy may prove
necessary
 Microscopic identification of P. jiroveci trophozoites and cysts
is performed with stains that demonstrate either the nuclei of
trophozoites and intracystic stages or the cyst walls
 immunofluorescence microscopy using monoclonal antibodies
can identify the organisms with higher sensitivity than
conventional microscopy
  The most commonly employed cell wall stain is the
silver stain. This stain, and its modifications, is
considered the "gold standard" stain for P. carinii since
it is more sensitive and specific than other stains

The cyst walls readily take up stain, but individual trophozoites do

not stain
 Chest radiographs should be obtained in
any immunocompromised patient with fever
and/or respiratory signs or symptoms
 Findings include the following:
 Diffuse bilateral infiltrates extending from
the perihilar region
 Less common findings include patchy
asymmetric infiltrates and
pneumatoceles
 Pleural effusions and intrathoracic
adenopathy
 The chest radiographic findings may be
normal in patients with early mild disease
 Pneumothorax may occur in patients
using aerosolized pentamidine
 The clinical diagnosis can be confirmed
by the characteristic appearance of the
chest x-ray which shows widespread
pulmonary infiltrates and an arterial
 Treatment

 Trimethoprim-sulfamethoxazole is the drug of choice

 Recommended alternatives
 Pentamidine

 trimethoprim plus dapsone

 atovaquone

 primaquine plus clindamycin

 Supportive
 Genus Microsporidia
 are obligate intracellular protozoan parasites belonging to the
phylum Microspora 
 are characterized by the production of resistant spores that vary
in size, depending on the species
 are ubiquitous organisms with an extensive host range, including
honeybees, fish, mosquitoes, ticks, grasshoppers, rodents,
rabbits, and other fur-bearing mammals
 Currently, most cases are associated with HIV infection or other
forms of immunosuppression, particularly in organ transplant
recipients; however, cases have been reported in
immunocompetent individuals
 Cases of microsporidiosis have been reported in Argentina,
Australia, Botswana, Brazil, Canada, Czech Republic, France,
Germany, India, Italy, Japan, The Netherlands, New Zealand,
Spain, Sri Lanka, Sweden, Switzerland, Thailand, Uganda, United
 They possess a unique
organelle, the polar tubule
or polar filament, which is
coiled inside the spore as
demonstrated by its
ultrastructure
 The presence of polar
tubes/filaments of the spores
distinguishes Microsporidia
from all other intracellular
protozoans
 Transmission

 transmission of microsporidia is still unclear, but the most

common way is thought to involved inhaling, ingesting or
otherwise contracting spores
 Spores of microsporidia may also be transmitted in water as
species of Encephalitozoon, Enterocytozoon
 Significant contact with infected animals may also transmit
the disease (zoonoic infection) but cases are rare
 Disease: Microsporidiosis
- The phylum Microspora contains over 1000 species

Microsporidian species Clinical manifestation

Infection of the GI tract causing
Encephalitozoon intestinalis diarrhea, and dissemination to ocular,
(formerly known as Septata intestinalis) genitourinary and respiratory tracts
esp. among
Diarrhea AIDSpts,
in AIDS pts acalculous
Enterocytozoon bieneusi
cholecystitis
Keratoconjunctivitis, infection of
Encephalitozoon cuniculi and
respiratory and genitourinary tract,
Encephalitozoon hellem
disseminated infection
Microsporidium
Infection of the cornea
(M. ceylonensis and M. africanum)
Nosema sp. (N. ocularum), Brachiola
Ocular infection
connori
Pleistophora sp. Muscular infection
Trachipleistophora anthropophthera Disseminated infection
Muscular infection, stromal keratitis,
Trachipleistophora hominis
(probably disseminated infection)
Vittaforma corneae (syn. Nosema
Ocular infection, urinary tract infection
corneum)
Keratoconjunctivitis, skin and deep
Brachiola algerae
muscle infection
 Intestinal maniifestations: Chronic diarrhea (loose, watery,
nonbloody) weight loss, abdominal
pain, nausea and vomiting
 Disseminated infection
 Symptoms of cholecystitis, renal failure, and respiratory
infections
 Headache, nasal congestion or discharge, ocular pain, and
loss
of taste may indicate sinus involvement
 Patients with urinary tract involvement frequently are
asymptomatic
 Ocular disease
 Foreign body sensation, eye pain, or both; light sensitivity,
ocular redness, excessive tearing, blurred or decreased vision
 Musculoskeletal: Myalgia, generalized muscle weakness, and
fever are common in patients with myositis and
severe immunodeficiency states
 Diagnosis

 Light microscopic examination of the stained clinical smears,

especially the fecal samples, is an inexpensive method of
diagnosing microsporidial infections even though it does not
allow identification of microsporidia to the species level
 The most widely used staining technique is the trichrome
stains (Chromotrope 2R method) or its modifications or
Giemsa stain
 This technique stains the spore and the spore wall a bright
pinkish red
 Transmission electron microscopy (TEM) - the gold standard and
is necessary for the identification of the
microsporidian specie
 expensive, time consuming, and not feasible for routine
diagnosis
  

 
Treatment
         
Drug Category Drug Treatment for Dose Precautions
Gastro, muscle, 400mg PO Avoid pregnancy
Anthelmintics Albendazole disseminated bid for 2-4
and ocular weeks
Antibiotics infections.
Keratoconjunctivi 3 mg/ml
tis and ocular drops 1 Thrombocytopenia
Fumagillin –
lesions week
Topical
(Encephalitozoon topical use
Oral
spp. B. algarae, +
E. hellum, E. manageme
cuniculi, V. nt
corneae) Unknown
500mg PO
Metronidazo E. bieneusi and
Antiprotozoals E. bieneusi bid for 2
le others
weeks.
Diarrhea when Unknown Toxic, only as last
Immunomodulato other drugs have resort.
Thalidomide
ry failed Severe birth
defects; avoid
pregnancy.
 Genus Babesia
 are protozoan parasites of domestic and wild animals
 belong to the subclass Piroplamsia and are commonly referred
to as ‘piroplasms’ due to the pear-like shaped merozoites
which live as small intra-erythrocytic parasites
 characterized by its round, rod or abstract shape and lack of
any mobility structures such as cilia or flagella

Species Host Vector Distribution

B. Yugoslavia, Russia, Ireland,
Man Ticks
divergens
B. Scotland
Man Ticks Subtropics and Tropics
bigemina
B. equi Man Ticks South America
Ticks North America (Eastern US,
B. microfti Man (Ixodes Wisconsin), Asia, Russia,
dammini) India, Africa
 commonly infect mammals, particularly cattle, sheep, goats,
horses, pigs, dogs and cats
 only recently found to cause human infection
 severe cases seen among asplenic patient

 the white-footed mouse appears to serve as the primary

reservoir host for the infection
 endemic in rodents along the eastern coast of U.S.
 MOT: bite of a tick (Ixodes dammini)
Life Cycle infected tick injects sporozoites (infective stage)
into a mouse while taking a blood meal

In the RBC, these sporozoites mature to the trophozoite stage and then
rapidly undergo the process of merogany to produce merozoites

merozoites then burst out of the RBC and infect other cells and continue
to multiply
However, some merozoites stay in the red blood cells and wait for the
next host. This next host is usually a tick that is infected when biting
the animal

merozoites then differentiate into gametes

The gametes are once again ingested by the tick , where they join and
undergo the sporogony, producing sporozoites

When an infected tick bites a human for a blood meal, Babesia

sporozoites are introduced into the human 

Just as in the mouse, sporozoites then go into erythrocytes , where they

asexually reproduce by budding

As the parasites multiply within the blood, the disease begins to be

manifested
Morphology
 Merozoites - pear-shaped and appear as small ringform within
the rbc arranged parallel to each other
 The organism frequently occur in:
 Ring-form

 Pairs

 Tetrads (“maltese cross” forms)

 pathognomonic tetrads of

budding trophozoites
 may appear like P. falciparum
 Can be differentiated from malarial parasite by the
absence of hemozoin pigment in the infected erythrocyte
 These different types may be found in red blood cells,
lymphocytes, and histiocytes as well as other blood cells
Disease: Redwater fever / Babesiosis

 hemolytic disease characterized by destruction of erythrocyte

 Anemia due to loss of red blood cells becomes very severe

 because these red blood cells are being lysed (bursting)

 jaundice (a yellowing of the skin and eyes)

 hemoglobinuria - massive destruction of the rbc allows
hemoglobin to escape together with
urine
 Urine may appear red and internal organs may become
damaged
 Patients report a history of travel to an endemic area
 incubation period: 1-4 weeks
 Presents as fever which persists for weeks associated with chill,
malaise, arthalgia, myalgia, hepatosplenomegaly, fatigue and
weakness

 Diagnosis
 In individuals who are asymptomatic, laboratory studies may be
unremarkable
 Wright or Giemsa-stained peripheral blood smear shows
microscopic demonstration of intra-erythrocytic parasite
 Serological: indirect immunoflouresence test
 CBC may demonstrate mild-to-severe hemolytic anemia,
leukopenia thrombocytopenia and atypical lymphocytes
 Liver function test results often reveal mildly elevated hepatic
transaminase levels, erythrocyte sedimentation rate (ESR), lactic
dehydrogenase (LDH) level, alkaline phosphatase level, and
serum bilirubin level
 Urinalysis may reveal hemoglobinuria, proteinuria, and a dark
color may be present
 Babesia Plasmodium falciparum

clumped extracellular intra-erythrocytic forms

forms

intra-erythrocytic maltese cross

vacuolated forms forms
Treatment
 combination of :
 Clindamycin 1.2gm IV 2x a day // 600mg orally 3x a day

 oral quinine 650mg 3x a day x 1wk

 Pentamidine
 Chloroquine

 Alternative: atovaquone plus azithromycin

 Exchange transfusions have been used in severely ill patients
with high parasitemia

Prevention and Control

 avoidance of animal contact which are susceptible to tick
attack
 avoid staying long in animal barns which are herded with cow,