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Intestinal protozoa & Genital protozoa
Dr. Oranuch SanpoolDepartment of Parasitology, Faculty of Medicine, KKU
อีเมล:์ [email protected]
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
49
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.
55
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
58
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
59
- 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
63
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
69
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
74
http
s://w
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.cdc.go
v/dp
dx/
micro
sporid
iosis/
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.htm
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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
78
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.
80
“ 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
