Intestinal protozoa & Genital protozoa...๐Life cycle ๐Epidemiology ๐Pathology/...

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Intestinal protozoa & Genital protozoa

Dr. Oranuch SanpoolDepartment of Parasitology, Faculty of Medicine, KKU

อีเมล:์ oransa@kku.ac.th

MD641 304 Parasitology for Pharmaceutical science students (1st year)

Join Zoom Meeting ID: 937 9234 5794 Password: 7096227 Aug 2020, 08.00-10.00 AM

Intestinal Protozoa

Genital protozoa

Blood and tissue protozoa

Unclassified protozoa

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Amoebae

Intestinal Protozoa

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Flagellate

Ciliate

Apicomplexa

Amoebae:

-Entamoeba histolytica

-Entamoeba coli

- Entamoeba gingivalis

- Iodamoeba buetschlii

- Endolimax nana

- Dientamoeba fragilis

Intestinal Protozoa

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Flagellate : - Giardia lamblia

- Chilomastix mesnili

- Trichomonas hominis

Ciliate : - Balantidium coli

Apicomplexa : - Isospora species

- Cryptosporidium species

Intestinal Protozoa (cont.)

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Giardia lambliaBalantidium coli

๐ Common Name

๐ Scientific Name

๐ Diseases

๐ Morphology

๐ Geographic

distribution

๐ Life cycle

๐ Epidemiology

๐ Pathology/ pathogenesis

๐ Symptoms and signs

๐ Diagnosis

๐ Treatment

๐ Prevention and control

Entamoeba histolytica

Blastocytis hominis

Entamoeba coli

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Balantidium coli (Malmsten, 1857) Stein, 1863

Ciliate Protozoa

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Balantidium coli

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Ciliate protozoa

Causing Balantidiasis in human

Habitat : large intestine colon

Reservoir host : pig

Infective stage : Cyst

Epidemiology : Tropic, sub-tropic zone

Large intestinal protozoa in human body

Size 60-70 um

Surrounded with cilia

Anterior cytostome (mouth)

Food vacuole in cell

Contractile vacuole for water balance

Trophozoite contained 2 nucleus :

Macronucleus & Micronucleus

Posterior cytopyge for excrete waste product

Stage :Trophozoite

Balantidium coli

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Oval shape

Size ~ 55 um

2 layers of thick cyst wall;

cilia attached in inner cyst wall

Finding Macronucleus & Contractile vacuole

Finding undigested food in food vacuole

Stage : Cyst

Balantidiumcoli

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Sexual reproduction: 2 types

1. Asexual (transverse binary fission)

2. Sexual (conjugation)

Life cycle: similar to Entamoeba histolytica

Diagnostic stage: Cyst, trophozoite in feces

Balantidium coli

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Balantidiasis

Cinical signs: No symptoms dysentery

Mild infection : Chronic intermittent symptom

- Abdominal symptoms

- Diarrhea / constipation

- Mucus and bloody stool

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Dysentery form: - Massive intestinal movement

- Mucus and bloody feces

- Abdominal pain, weight loss

Fulminant : - Finding in poor immunity

- Death in 3-5 days

Extra-intestinal balantidiasis: Low incidence

Balantidiasis

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Pathogenesis of Balantidium coli

Balantidium coli (cyst)

Excystation in small intestine

Large intestinal mucosa

Multiplication (conjugation & transvers binary fission)

Ulcer in mucosa - submucosa

(lytic action of hyaluronidase)

Large opening wound14

-Tetracycline 500 mg, 4 times x 10 days or

- Diiodohydroxyquin, 650 mg, 3 times x 21 days or

- Metronidazole, 400-600 mg, 3 times x 5 days

Prevention and controls

- Like as Entamoeba histolytica

- Good personal hygiene

- Good sanitation

Balantidiasis

Treatment :

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Flagellate protozoa

Giardia lambliaStiles, 1915

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Giardia lamblia

Giardiasis / Giardial dysentary

- Active movement

- Blunt anterior and sharp end posterior (21 x 15 x 4 um)

- Sucking disc

- 2 nuclei

- 4 pair of flagellum

- 2 axonemes

- 2 median body

Stage:Trophozoite

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- No movement

- Oval shape, size 8-12 x 7-10 um

- Thin cyst wall

- 2-4 nuclei

- 2 axonemes

- 2 median body

Giardia lamblia

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Stage:Cyst

G. lamblia cyst in iodine

G. lamblia cyst in normal saline

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Classification : Duodenum (crypt, villi)

Infective stage: 4 nuclei cyst

Multiplication: Longitudinal binary fission

Incubation period : 12-15 days

Giardia lamblia

Epidemiology:

Worldwide (nursery, mental retard nursery, gay, lesbian)

Symptoms : Diarrhea and malabsorption

severity : Depend on age, immunity and history of exposure

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Pathologic feature

- Normal mucosa

- Catarrhal inflammation

- Damage of mucosa

- Loss of Brush border

- Flatten villi

- Incresed Globlet cells , WBC infiltration

Giardia lamblia

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Clinical signs

Acute :

- Similar food poisoning (2-3 days)

- Anorexia, nausea

- Abdominal pain

- Diarrhea, Foul smelling

- Greasy stool

Giardiasis

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Chronic : - Abdominal cramp

- Chronic abdominal pain in child

(celiac disease)

- Malabsorption

- Lipid in feces (steatorrhea)

- Jaundice, ampulla of water swelling

Giardiasis

Clinical signs

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Diagnosis : finding cyst, trophozoite in samples

Specimens: - Feces

- Duodenal aspirate

- Intestinal biopsy

Treatment: Metronidazole (200-400 mg, tid, after meal,

5-10 days)

Giardiasis

Prevention and controls :

- Good sanitation

- Good personal hygiene24

4 forms of Blastocystis hominis

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- Diarrhea

- Abdominal pain and cramp

- Nausea

- Flatulence

- Fever

- Irritable Bowel Syndrome (IBS)

Clinical symptoms of Blastocystosis

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- Stool examination

- Finding vacuolar form

- Trichrome stain

Treatment:

- Metronidazole

- Cotrimoxazole

Balastocystosis

Laboratory diagnosis:

Prevention & controls:

- Good personal hygiene

- Good sanitation27

Genus Trichomonas

• 4 free flagella, equally in size

- 5th flagellum at rim of undulating membrane

Trophozoite only

No cyst stage

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Trichomonas spp.

Trichomonas tenax Trichomonas hominisTrichomonas vaginalis

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Trichomonas tenax(O.F. Muller, 1773) Dobell, 1939

• Pear shape, living in mouth

• Trophozoite only, 5-12 um in size

• More slender shaped than T. vaginalis

• 4 Free flagella, equally in size

• The 5th flagellum at the rim of undulating membrane

• Can not live in intestine but can in vagina

• Longitudinal binary fission30

Trichomonas hominis(Davaine, 1860) Leuckart, 1879

• Trophozoite, 5-14 um x 7-10 um in size

• 3-5 Free flagella

• Living in large intestine, commensalism, ingested bacteria

• Transmission by contaminated food or insect

• Diagnosed by movement of trophozoite in fresh feces

• No need for treatment31

- Trophozoite only, pear shape

- Undulating membrane no longer than body

- Size 7-27 um x 5-18 um in size

- 4 Free flagella, equally in size

- 5th Flagellum at rim of undulating membrane

- Longitudinal binary fission

Trichomonas vaginalis, Donne, 1837

Origin of name: firstly found in vaginal secretion

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Habitat:

Vagina

Prostate gland or ureter

Sexual transmitted disease (STD)

Infective stage trophozoite

Incubation period 4-28 day

Epidemiology

Trichomonas vaginalis

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Pathology:

- Degeneration and desquamation

- Inflammation of vagina and uterus

Clinical symptoms

- Vulvovaginitis, itching

- Liquid, greenish-yellow down to urethral orifice, foul-smelling

- Spot hemorrhage, red spotted lesion (call “strawberry vagina”)

- Dysuria - Symptom less

- Frequency of urination

- prostatitis

Male

Trichomonas vaginalis

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- Centrifuged urine

- Vaginal swab

- Vaginal scrap

- Vaginal discharge

Trichomonas vaginalis

Diagnosis: Wet preparation

& finding trophozoite under microscope

Male: Prostate secretion examination

Other methods : Culture, PCR technique35

- Metronidazole

-Tinidazole

- Clotrimazole Vagina supposition

Prevention

- Avoidance of unprotected sexual experiences

- Avoidance of sharing equipment and communal bathing

Treatment

Trichomonas vaginalis

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Blood & tissue protozoaFungi-likes protozoa

Haemoflagellate

Many stage, small size, 1 nucleus

Migration by flagellum, some stage can not see flagellum

Living in blood, plasma, cerebrospinal fluid,

cells of visceral organ

Longitudinal binary fission

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Family Trypanosomatidae

- Trypanosoma brucei gambiense

- T. b. rhodesiense

- T. cruzi

Genus Trypanosoma species

Genus Leishmania species

- Leishmania donovani

- L. tropica

- L. braziliensis 39

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Morphological stage of haemoflagellates

Leishmania Trypanosoma brucei

Trypanosoma cruzi

Amastigote(leishmanial form)

Promastigote(leptomonad form)

Epimastigote(crithidial form)

Trypomastigote(trypanosomal form)

** Promastigote form or Leptomonas form (Infective stage of Leishmania)

** Metacyclic trypanosomal form (Infective stage of Trypanosoma)

Trypanosoma brucei gambiense Dutton, 1902 (T.b.gambiense)

Trypanosoma brucei rhodesiense Stephens & Fantham, 1910 (T.b.rhodesiensi)

Biology & life cycle

2 Hosts: human and insect vectors

Insect vectors : Glossina spp. (Tsetse flies)

Extracellular parasite

Human stage: Trypomastigote form

Insect stages: - Critidial or epimastigote: intestine

- Metacyclic trypanosome: salivary gland

Caused of African trypanosomiasis or African sleeping sickness

African trypanosomes

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Sleeping sickness

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Epidemiology and Transmission of African trypanosomes

No report in Thailand

Insect bite transmittedmetacyclic trypomastigote

(biological transmission)

* Mechanical transmission

* Blood transfusion

* Congenital transmission

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Incubation period 5 to 20 (~ 14 day)

Swelling at biting site

Clinical manifestation of

African trypanosomes

Parasite multiply in circulation

- Vasculitis at infected organ

- Splenomegaly

- Joint and muscular pain, fever, chill,

lymphadenopathy (postcervical gland)

namely Winterbottom’ sign

I. Acute stage :

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II. Chronic stage (2-3 year) :

- Parasite invade central nervous system

- Headache, stiffness of neck and paralysis

- African sleeping sickness

Laboratory diagnosis 1. Blood examination

2. CSF examination

3. Animal inoculation

4. Serological methods

Clinical manifestation of

African trypanosomes

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Treatment Suramin

Pentamidine isothionate

Melasoprol

Prevention and control

Elimination breeding place of vector

Avoidance to visit endemic area

Mass treatment

African trypanosomes

Trypanosoma cruzi Chagas 1909

American trypanosome

Caused American trypanosomiasis or Chagas disease

Stage in human and vertebrate

Trypanosomal Extracellular protozoa in blood circulation (C-shape)

Leishmanial Intracellular protozoa in RE cell of spleen, liver, lymphoid gland

Leptomonas

Critidial

Interstitial spaces of organ

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Stage of Trypanosoma cruzi

in Triatomine bugs

Critidial (Epimastigote) : middle part of intestine

Metacyclic trypanosomal : anal area (Posterior stationary)

(infective stage)

Epidemiology

America

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Trypanosoma cruzi

Chagas’ disease

1. Incubation period 1-2 weeks

- Local inflammation, chagoma

- Romana’ s sign

2. Acutes stage

- Degeneration of liver and spleen

- Inflammation of cardiac muscle

3.Chronic stage

- Myocarditis heart failure

Pathology of Trypanosoma cruzi

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Prevention and control

Elimination of insect with BHC

Elimination of reservoir host

1. Blood examination

2. Biopsy

3. Xenodiagnosis

4. Serological test

Treatment: Suramin, Diamidins, Nifurtimox,

D0870 inhibitor of sterol biosynthesis

Laboratory diagnosis of Trypanosoma cruzi

o Visceral leishmaniasis or

o Kala-azar

Leishmania tropica,

L. major,

L. aethiopica

o Cutaneous leishmaniasis or

o Oriental sore

Leishmania braziliensis complex,

L. mexicana complex,

L. peruviana

o Mucocutaneous leishmaniasis or

o Espundia

Leishmania donovani

Leishmania species

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Cutaneous & Mucocutaneous Leishmaniasis

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Cutaneous leishmaniasis(Oriental sore)

Mucocutaneous leishmaniasis(Espundia)

amastigote

promastigote

Multiply in stomach

promastigoteinfective stage

Migrate to mouth

Amastigotemultiply inmacrophage

Sand fly

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Amastigote

Change to promastigote

Multiply in intestine

Migrate to mouth

Sand fly

Migrate from brokenmacrophageMultiply

Ingestion by macrophage at skin

Human, dog

Macrophage migrate to visceral organs: (RE system) spleen, liver, bone marrow

Change to amastigote Ingestion by macrophage

Leishmania donovani caused Visceral leishmaniasis

HumanAmastigote founded in RE cell

(macrophage, lymphoid cells)

Promastigote founded in Phlebotomus spp.

(Sand flies)

EpidemiologyImported cased in Thailand,

Africa, Middle East, South Asia

Insect

Leishmania spp.

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Clinical manifestation of Leishmaniasis

Cutaneous leishmaniasis: found parasite in phagocytic cell

Chronic wound of skin

Mucocutaneous leishmaniasis :

Chronic wound of junction between skin and mucous tissue of mouth, nose, anus, sexual organs

Visceral leishmaniasis : Destroy liver, spleen, bone marrow, RE cell

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Cutaneous leishmaniasis

* Skin Biopsy, Culture, Serological test

Mucocutaneous leishmaniasis

* Biopsy, Serological test

Visceral leishmaniasis

- Parasite exam in RE cells

- Spleen or bone marrow biopsy

- Serological test57

Laboratory diagnosis of Leishmaniasis

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Sodium or potassium antimoyl tartate

Sodium stibogluconate

Amphotericin B

Treatment of Leishmaniasis

1. Mass treatment

2. Elimination of vector Phlebotomus spp.

3. Elimination of reservoir host

Prevention and control of Leishmaniasis

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- Cause by Pneumocystis jiroveci (carinii)

- Atypical fungus, yeast like characteristic

- Both cyst & trophozoite found in alveoli

Pneumocystosis

Pneumocystis cariniiSyn. Pneumocystis jiroveci

Pneumocystis pneumonia (PCP)

Pneumocystis jiroveci

Opportunistic organism

Natural habit : Lung

Important cause of pneumonia in immunocompromised host

Taxonomy status argument between Protozoa and Fungus

Unclassified protozoa

Molecular identification related to Fungus than Protozoa

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Trophozoite :

- Pleomorphic trophozoite like amoeba

- 1-4 um

- 1 nucleus

Cyst : - Oval shape and thick cyst wall- 5-8 um- Mature cyst contained 8 intracystic bodies

Pneumocystis jiroveci

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Pneumocystis jiroveci Giemsa stained

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Haploid intracystic bodies disrupt from cyst

Trophozoite develop in alveolar cavity

Binary fission / budding or endodyogeny or combined to diploid trophozoite

Miosis I------> II

mitosis

Encystation contained intracystic up to 8 cysts

Pneumocystis jiroveci

Disease : Pneumocystosis / Interstitial plasma cell pneumonia (PCP)

Endemic area : worldwide in human and animals

Genetic diversity and host diversity

Serology study : in children

Transmission : respiration (airborne route), placenta

90,000 AIDS patients in USA has infected at least 1 time

Pneumocystosis is the main cause of death in AIDS patients

Extrapulmonary : lymph node, spleen liver bone marrow 64

Pneumocystis jiroveci

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Caused by CMIR & HMIR abnormality

Principal host effector cell : Alveolar macrophage

Risk group: HIV, immunosuppressive Rx,

malnourished infants

Pathogenesis & Pathology

Pneumocystis jiroveci

Increase alveolar capillary permeability and destroy type I alveolar cell

surfactant abnormality

: Decrease bronchoalveolar lavage (BAL) fluid phosholipids

: Increase surfactant proteins A & D

Pneumonia

Increase alveoli fluid , increasing of rbc, histiocyte, lymphocyte, plasma cell

Thick alveolar septum, gas exchange abnormality

Foamy alveoli, vacuolated exudates, interstitial edema, fibrosis

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Pathogenesis & Pathology

Pneumocystis jiroveci

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1. Demonstration of organisms from lungs

- Gomori’s methenamine silver stain

- Giemsa stain

- Modified acid fast

- Hematoxylin

Laboratory diagnosis for PCP

Staining

- Lung / Transbronchial Biopsy

- Bronchoalveolar lavage

- Sputum

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2. Antigen detection using MAb

3. Molecular techniques :

- Conventional PCR (Torres et al., 2000)

- Real-time PCR (~ 3 hr), 100% sensitivity,

85-99 % sensitivity (Flori et al. 2004)

Laboratory diagnosis for PCP

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Trimethoprim-sulfamethazole (TMP-SMX) or Bactrim

Dose: TMP 15-20 mg/kg/day,

SMX 75 -100 mg/kg/day; oral or IV

Divide to 3-4 times/day

(x 14 day for non-HIV, x 21 day for HIV)

Treatment

Pneumocystis jiroveci

Primary prophylaxis HIV pateints at risk of PneumocystosisThere are indications for the drug

- CD4+ cell count less than 200 cell / ul

- Fever of unknown origin (37.8 oC) more than2 wk or

- Had history of oral Candida infection

Secondary prophylaxis in recovered pneumocystosis pateints

Primary or Secondary prophylaxis for pneumocystosisTMP 160-SMX 800 (double strength) one time/day orTMP 80-SMX 400 (single strength) one time/day x 3 days for1 weeks

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Prevention

Pneumocystis jiroveci

Phylum Microspora

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Small size intracellular /Class Microsporea :

Microsporidia

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SEM of a microsporidian spore with an extruded polar tubule inserted into a eukaryotic cell

https://www.cdc.gov/dpdx/microsporidiosis/index.html

Encephalitozoon intestinalis disseminated patients

- fever. Diarrhea sinusitis cholangitis

Enterocytozoon bieneusi & Encephalitozoon intestinalis

- Chronic diarrhea weight loss in Aids patients (10-40%)

- Bile ducts

Microsporidiosis – found in AIDS more than other

opportunistic patients

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Transmission by drinking contaminated water

or from human to human

Found in HIV patients with diarrhea = 27%

Chiang Mai feces > 100 cases found 1 case

Siriraj and Bumradnaradul Hospital positive 18/22 cases

Enterocytozoon bieneusi

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Symptom-Sign-Pathology

Similar cryptosporidiosis & misosporidiosis

Chronic diarrhea, nausea, GI absorption defect, weight loss

Diarrhea 4-8 times/days No bloody mucus

No fever

Detatchment and atrophy of intestinal villi 75

Enterocytozoon bieneusi

Treatment:

No effective drugs

- Supportive treatment: octreotide 100-500 ug (sc)

- Albendazole : have effective reports

Prevention:

- Drinking cleaned water and cooked food

- Good personal hygiene76

Enterocytozoon bieneusi

o Habitat enterocyte , lamina propria, macrophage,

fibroblast, endothelial cell of small intestine

Pathology & Symptom

o Chronic diarrhea intestinal inflammation

o Malabsorbtion

o Distribute to Gall bladder Lung Respiratory tract

Encephalitozoon intestinalis

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Diagnostics : intestinal biopsy & Electronmicroscopy

Treatment : Albendazole 400 mg oral bid x 2-4 week

Prevention : Personal hygeine

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Encephalitozoon intestinalis

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References / Books

• https://www.ncbi.nlm.nih.gov/pubmed

(search under parasites specific name)

• https://www.cdc.gov/dpdx (search under parasites specific name)

• วันชัย มาลีวงษ์ ผิวพรรณ มาลีวงษ์ และนิมิตร มรกต. ปรสิตวิทยาทางการแพทย์: โปรโตซัวและ

หนอนพยาธ.ิ ขอนแก่น : โรงพิมพ์คลังนานาวิทยา. 2544.

• Etc.

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“ Only fill a glass of water half full, you will learn to

always seek for more knowledge”

The guidance of his majesty the 9th king