Intestinal Parasitism 1

Microbiology and Parasitology

Rachelle P. Mendoza, mD

Intestinal Parasites

Protozoans Metazoans/Helminths

Sarcodina Mastigophora Ciliata Sporozoa Nematoda Platyhelminthes

Trematoda Cestoda

ENTAMOEBA Morphology

Taxonomy

 Kingdom: Protozoa
 Phylum Sarcomastigophora
 Class: Lobosa
 Order: Amoebida
 Family: Entamoebidae

Epidemiology

 10% worldwide (2006)

 14 per 1000 travellers (1996-2005)
 10-20% of infected becomes symptomatic
 Size: 10-60 μm
 Transmission: fecal-oral
 Host: humans, primates

Note: E. histolytica is the only pathogenic organism among

the Sarcodina subphylum Note: The cyst is 10-20 μm in size while the trophozoite is 10-
60 μm. The cytoplasm of the trophozoite consists of two
parts, the endoplasm (granular) and the ectoplasm
(hyaline). The ectoplasm is one that first forms the
pseudopod when the trophozoite is moving.

Life Cycle

Note: Excystation occurs in the terminal ileum or the colon while encystation occurs in the rectum. A mature trophozoite can yield
4 mature trophozoite

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 Virulence Factors  Amoebapores – cell lysis and necrosis
 Cysteine proteases – digest ECM, induce IL-1,
 Epithelial galactose/N-acetylgalactosamine- cleave IgA and IgG
specific lectin (gal-lectin) binding protein –
adhesion, complement resistance

Pathogenesis

Asymptomatic Symptomatic

Shedding of cyst through feces Adhesion to intestinal epithelium

Invasion of intestinal epithelium by lytic necrosis Metastasis thru the portal circulation

Perforation into peritoneal cavity Secondary intestinal lesions Ameboma Amebic hepatitis,
leading to chronic infection liver abscess Lungs, Brain

Direct extension to skin

Note: Direct extension to the skin may cause abdominal tenderness, dysentery, dehydration, nausea, vomiting, malaise and
weight loss. The characteristic morphology of abscesses formed by E. histolytica infection is anchovy paste.

 Factors that determine invasion of amoeba  Trophozoite

 Number of amoeba ingested  Distinction must be done from other non-
 Pathogenic capacity of the parasite strain pathogenic intestinal protozoa
 Host factors  Proctoscopy often shows characteristic flask-
 Presence of suitable enteric bacteria shaped ulcers in the mucosa
 Tissue biopsy (recto-sigmoid)
Spectrum of Diseases  Antibody detection

 Asymptomatic infection
 Diarrhea and dysentery
 Fulminant colitis
 Peritonitis
 Extraintestinal amoebiasis
 Liver (4% of clinical infection)
 Lung
 Brain
 Spleen

Diagnosis

 Symptoms, history and epidemiology

 Fecalysis
 Cyst

Cyst Nucleus Cytoplasm

Size Peripheral Karyosomal Chromatoid
Species Shape Number Glycogen
(diameter/length) Chromatin Chromatin bodies
Peripheral Usually diffuse.
4 in mature
chromatin Present. Concentrated
cyst, Small,
present. Elongated mass often
immature discrete,
Entamoeba 10-20 μm, usual Usually Fine, bars with present in
cysts with 1 usually
histolytica range: 12-15 μm spherical uniform bluntly young cysts.
or 2 centrally
granules, rounded Stains reddish
occasionally located
evenly ends brown with
seen
distributed iodine
Present.
4 in mature
Elongated
cyst,
Entamoeba 5-10 μm, usual Usually Similar to E. Similar to E. bars with Similar to E.
immature
hartmanni range: 6-8 μm spherical histolytica histolytica bluntly histolytica
cyst with 1 or
rounded
2 often seen
ends
8 in mature Peripheral
cyst. chromatin
Occasionally present. Present, but Usually samll,
Large,
Usually super- Coarse less diffuse, but
discrete,
spherical, nucleated granules frequently occasionally
usually
occasionally cysts with 16 irregular in seen than in well-defined
Entamoeba 10-35 μm, usual eccentric
oval, or more are size and E. histolytica. mass in
coli range: 15-25 μm but
triangular or seen. distribution, Usually immature
occasionally
other Immature but often splinter-like cysts. Stain
centrally
shapes cyst with 2 or appear with pointed reddish brown
located
more more ends with iodine
occasionally uniform
seen than in

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 trophozoites
Usually small,
diffuse masses
Present. stain reddish
Many small brown with
bodies with iodine. A dark
Rarely
Usually fine angular or are called an
Occasionally Usually small
Entamoeba 9-18 μm, usual Spherical or granules pointed “inclusion
visible in and
polecki range: 11-15 μm oval evenly ends, or few mass” (possibly
unstained eccentric
distributed large ones. concentrated
preparations
May be oval, cytoplasm) is
rod-like or often also
irregular present. Mass
stains lightly
with iodine
Occasionally
Usually diffuse.
granules or
Concentrated
small oval
mass seen
Spherical, 4 in mature Large (blot- masses seen,
Endolimax 5-10 μm, usual occasionally in
ovoidal or cyst are None like), usually but bodies
nana range: 6-8 μm young cysts.
ellipsoidal rarely seen central as seen in
Stains reddish
Entamoeba
brown with
spp. Are not
iodine
present
Large,
usually Occasionally
eccentric. granules
Ovoidal, Refractile, present, but Compact,
ellipsoidal, achromatic chromatoid well-defined
Iodamoeba 5-20 μm, usual 1 in mature
triangular or None granules on bodies as mass. Stains
buetschlii range: 10-12 μm cyst
other one side of seen in dark brown
shapes karyosome. Entamoeba with iodine
Indistinct in spp. Are not
iodine present
preparations

Trophozoite Nucleus Cytoplasm

Peripheral Karyosomal
Species Size (length) Motility Number Appearance Inclusions
Chromatin Chromatin
10-60 μm.
Small, Red blood
Usual range:
Fine granules. discrete. cells
15-20 μm Progressive
1. Not visible in Usually evenly Usually occasionally.
Entamoeba commensal with hyaline, Finely
unstained distributed centrally Non-invasive
histolytica form. Over finger-like granular
preparations and uniform in located, but organisms
20 μm pseudopods
size occasionally may contain
invasive
is eccentric bacteria
form
Usually non- Small,
5-12 μm. 1. Not visible in
Entamoeba progressive Simiilar to E. discrete, Finely
Usual range: unstained Bacteria
hartmanni but may be histolytica often granular
8-10 μm preparations
occasionally eccentric
Coarse
Sluggish, non- Large,
15-50 μm. 1. Often visible granules, Coarse, Bacteria,
Entamoeba progressive, discrete,
Usual range, in unstained irregular in size often yeast, other
coli with blunt usually
20-25 μm preparations and vacuolated materials
pseudopods eccentric
distribution
Usually fine
1. May be
Usually granules
slightly visible
sluggish, evenly
in unstained Coarsely,
similar to E. distributed. Small,
preparations. granular,
coli. Occasionally discrete,
10-25 μm. Occasionally may
Entamoeba Occasionally granules may eccentric. Bacteria,
Usual range: may be resemble E.
polecki in diarrheic be irregularly Occasionally yeast
15-20 μm irregularly coli. Contains
specimens, arranged. large, diffuse
distorted by numerous
motility may Chromatin or irregular
pressure from vacuoles
be sometimes in
vacuoles in
progressive plaques or
cytoplasm
crescents
Sluggish,
6-12 μm. 1. Visible Large,
usually non-
Endolimax Usual occasionally in irregularly Granular,
progressive None Bacteria
nana range:8-10 unstained shaped, blot- vacuolated
with blunt
μm preparations like
pseudopods
Large, usually
central.
Surrounded
1. Not usually
8-20 μm. Sluggish, by refractile Coarsely Bacteria,
Iodamoeba visible in
Usual range: usually non- None achromatic granular, yeast or other
buetschlii unstained
12-15 μm progressive granules. Are vacuolated material
preparations
often not
distinct even
in stained

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 slides
 Family: Hexamitidae
 Genus: Giardia
Treatment  Species: Intestinalis

 Metronidazole 750-800 mg TID for 5-10 days Epidemiology

 Tinidazole 2g daily for 3-5 days
 Paromomycin 25-35 mg/kg per day, divided into 3  The only pathogenic protozoan found in the
doses, for 7 days (8-11 mkd for asymptomatic) duodenum and jejunum of humans
 Diloxanide furoate 500 mg TID for 10 days  2% of adults and 6-8% of children in developed
 Iodoquinol 650 mg p.o. TID in adults (10-13 mg/kg countries
TID in children) for 20 days  33% of people in developing countries
 Size: 12-15 μm
Amoebic  Transmission: fecal-oral, water, food
Antimicrobial Intestinal Asymptomatic
liver  Host: humans, cats, dogs, birds
Therapy Amoebiasis Infection
abcess  Incubation: 1-14 days
Metronidazole + + -
Tinidazole + + - Morphology
Paromomycin - + +
Diloxanide
- + +
furoate
Iodoquinol - - +

Prevention and Control

 Proper excreta disposal

 Boiling of water (kills E. histolytica cysts)
 Chemical disinfection with iodine- or chlorine-
containing compounds
 Water filtration
 Vaccine is not available yet

GIARDIA LAMBLIA

Taxonomy
G. lamblia trophozoite (center) and cyst (lower right).
 Kingdom: Protista Trophozoite ranges from 12-15 μm while cyst ranges from 8-
 Subkingdom: Protozoa 14 μm
 Phylum: Sarcomastigophora
 Subphylum: Mastigophora
 Class: Zoomastigophora
 Order: Diplomonadida

Life Cycle

Virulence Factors  Ventral adhesive disk

 Mannose-binding lectin
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  Proteinases  Thiol-independent
 Thiol-dependent  Flagella
Pathogenesis

Intake of infectious dose (10-25 cyst)

Excystation at the duodenum and jejunum and trophozoite release

Adhesion to enterocytes and invasion of microvilli of duodenum and jejunum

Loss of epithelial tight junction/barrier function

Activation of T-lymphocytes Enterocyte apoptosis via arginine starvation

Induced loss of intestinal brush border surface area:

1. Villus flattening
2. Inhibition of disaccharidase activities
3. Eventual overgrowth of enteric bacterial flora

Note: Doubling time is 9-12 hours. Characteristics of diarrhea are as follows: greasy, bulky and foul-smelling. Malabsorption may
lead to weakness and weight loss

Spectrum of Diseases  Abdominal distention

 Flatulence
 Asymptomatic  Malabsorption
 Gastrointestinal distress  Weakness
 Greasy, bulky and foul-smelling stool  Weight loss
 Abdominal cramps

Flagellates

Size Number of Number of

Species Shape Motility Other features
(length) Nuclei Flagella
1 rosette shaped No cyst form. Fragmented
Dientamoeba
3-22 mm Amoeboid Sluggish nuclei contain 3- 0 karyosome usually in form of cluster
fragilis
5 granules of 4-8 granules
Chilomastix Pear- Stiff, 1 3 anterior, 1 Prominent cytosome. Spiral groove
6-24 mm
mesnili shaped rotary Not visible in cytosome across ventral surface
Sucking disk occupying ½-3/4 of
4 lateral
Giardia 10-20 Pear- “Falling 2 ventral surface. Median bodies lying
2 ventral
intestinalis mm shaped leaf” Not visible horizontally or obliquely in lower part
2 caudal
of body

Cyst

Number of
Species Size Shape Other features
Nuclei
Chilomastix 6-10 Lemon shaped with anterior 1 Cytosome with supporting fibrils. Usually visible in
mesnili μm hyaline knob Not visible stained preparations
Giardia 8-19 Usually 4 Fibrils or flagella longitudinally. Cytoplasm often
Oval or ellipsoidal
intestinalis μm Not visible retracts from a portion of cell wall

Treatment

 Metronidazole 750-800 mg TID for 5-10 days

BALANTIDIUM COLI
Prevention and Control
Taxonomy
 Improved sanitation
 Proper excreta disposal
 Kingdom: Protista
 Water filtration and boiling
 Subkingdom: Protozoa
 Phylum: Ciliophora
 Class: Kinetofragminophorea
 Order: Trichostomatida
 Family: Balantidiidae

Epidemiology

 Largest protozoan parasite of humans

 Occurs in less than 1%

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  Size: 50-130 μm Note: Macronucleus controls the overall function of the cell
 Transmission: fecal-oral while the micronucleus is for sexual conjugation. The
 Vehicle: water trophozoite has a prominent mouth (cytostome) and an
 Host: pigs, humans anus (cytopyge). The vacuole is used for osmoregulation.
The size of the cyst is 45-55 μm.

Virulence Factors
Morphology
 Cilia
 Hyaluronidase – used to invade the intestine
 Proteolytic enzymes

Life Cycle

Pathogenesis

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 Asymptomatic Symptomatic

Shedding of cyst through

feces Adhesion to intestinal epithelium

Hyaluronidase/Proteolytic enzyme degrade

intestinal tissue

Penetration of
mucosa

Secondary bacterial Ulceration and Chronic

infection perforation infection

Abscess

Note: Adhesion to intestinal epithelium occurs in the cecum and colon. Ulceration and perforation may lead to bloody, mucoid
stools, weight loss and severe abdominal pain. Chronic infection may present as chronic diarrhea, colitis and foul breath.

Spectrum of Diseases  Proper sanitation, proper excreta disposal and

boiling of water are three most important
 Asymptomatic infection preventive measures
 Chronic infection
 Non-bloody diarrhea END
 Cramping
 Halitosis This transcription includes two tables which are not found in
 Abdominal pain the given handout. Also, some pictures of the species are
 Fulminant balantidiosis passing mucoid, bloody not included. You can search for them over the net using
stools (30% case fatality) the site that Dr. Mendoza gave.

Treatment Good luck and God bless 2016!

Antimicrobial
Dosage Notes
therapy
Contraindicated
in pregnant
500 mg QID for 10 women and
Tetracycline
days children younger
than 8 years of
age
Contrainidicated
750 mg TID for 5
Metronidazole in 1st trimester of
days
pregnancy
640 mg TID for 20
Iodoquinol
days

Prevention and Control

Risk factors Public Health Intervention

Close contact between pigs
and humans
Lack of appropriate waste
disposal
Improper excreta disposal
(swine and human
excrement contaminate
water)
Tropical climatic condition
Pig habitat should be
separated from human
habitation and demarcated
by fencing
Proper disposal of human
waste and animal waste
Personal hygiene
Create potable water
sources
Boil water
Asymptomatic carriers
should be treated with
antibiotics
Improve the overall health
of a population

Summary

 Protozoans causing intestinal disease can be

transmitted via fecal-oral route
 They exist as trophozoites and cysts
 They often cause diarrhea (watery, mucoid,
bloody, greasy, chronic)
 Treatment includes Metronidazole

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