Ciliates

Taxonomy of Protozoans
Kingdom Protista
Phylum Sarcomastigophora
Subphylum Sarcodina
Subphylum Mastigophora
Phylum Ciliophora
Phylum Apicomplexa
Phylum Microspora
 Balantidium coli
• Largest protozoan parasite affecting humans
• Disease: balantidiasis, balantidiosis, or balantidial
dysentery
• Normal host : pigs, man
• MOT: Ingestion of Cysts
• Habitat: Colon (cecum)
(anterior/ mouth) and cytophage or
cytopyge (posterior/ anus),
micronucleus (small and bean- • CYST: ovoid, rounded with cilia
for
reproduction,
Balantidium coli
shape)
macronucleus (big bean shape) for covered with cystic wall, with two
Organisms
vegetation, with CILIA
Thrown Ball as locomotor
Motility nuclei (macro- and micronucleus)
apparatus

%!%*&!
%!%*&!
• Paramecium coli (Pandemic)
• Common to pigs (Balantidium suis)
• Biggest intestinal protozoan
• TROPHOZOITE: ovoid or bean
• PATHOLOGY: Ulcer (hyaluronidase-
shaped, ciliated, with cytostome histolytic enzyme); Diarrhea, Ciliary
(anterior/ mouth) and cytophage or dysentery
cytopyge (posterior/ anus), • Lab Test: Direct Fecal Smear-
micronucleus (small and bean- Saline Wet Mount
shape) for reproduction,
 Pathogenesis
• Attacks intestinal epithelium
• Ulcers: rounded base and wide neck
• Ulcerations are due to hyaluronidase
 Pathogenesis
Balantidiasis has 3 forms of clinical
manifestations:

1. Asymptomatic
2. Fulminant balantidiasis/balantidial
dysentery
3. Chronic form
 Pathogenesis
• Can spread to extraintestinal sites
• Complications/fatal cases include
intestinal perforations, intestinal
hemorrhage, shock, sepsis, and acute
appendicitis
 Diagnosis
• DFS
• Concentration techniques
• Biopsy
• Bronchoalveolar washings
 Treatment
• Tetracycline or metronidazole
• Alternative treatment:
doxycycline and nitazoxanide
 Epidemiology
Prevalent in:
• areas with poor sanitation
• abbatoir, farms (close contact w/
pigs)
• overcrowded institution
• Warm/humid climates
Prevention and Control
• Proper sanitation
• Safe water supply
• Good personal hygiene
• Proper food preparation
• Cysts are easily inactivated by heat
and 1% sodium hypochlorite
Flagellates
Flagellates
 PARTS
• Axoneme
• Axostyle
• Costa
• Cytostome
• Parabasal Body/Median Body
• Undulating Membrane
• Ventral Sucking Disk
 FLAGELLATES
SUBPHYLUM MASTIGOPHORA
Class Zoomastigophora
1.Intestinal and Urogenital Flagellates
2.Hemoflagellates
INTESTINAL/UROGENITA
L FLAGELLATES
 INTESTINAL/UROGENITAL
FLAGELLATES
Generalities
• All inhabit the large intestine except Giardia lamblia,
Trichomonas vaginalis, Trichomonas tenax

• All undergo encystation except Trichomonas species

• All are commensals except Giardia lamblia,

Dientamoeba fragilis and Trichomonas vaginalis
 Giardia duodenalis
• Other name: G. intestinalis, G, lamblia,
Cercomonas intestinalis

• MOT: Ingestion of infective cysts

• Causative agent of Giardiasis, Traveller’s

Diarrhea, Backpacker’s Diarrhea, Beaver
Fever
G. duodenalis
G. duodenalis
G. duodenalis
 PATHOGENESIS
• Parasite attaches to the intestinal cells via
an adhesive sucking disc located on its
ventral side
• Once attached, the parasites cause villous
flattening and crypt hypertrophy
(Malabsorption and Maldigestion)
 PATHOGENESIS
• Half of the patients may be
asymptomatic
• Acute cases: excessive flatus with rotten
egg (due to hydrogen sulfide) odor,
diarrhea, malaise, abdominal pains,
anorexia
• Chronic cases: steatorrhea, weight loss,
profound malaise, low-grade fever
 PATHOGENESIS
• Low Infective Dose
• Alteration of the mucosal lining
• Ventral Sucker
• Lectin
• Presence of VSPs
 Giardiasis:
Differential diagnosis

Giardiasis is different from amebiasis and

bacterial dysentery:

No mucus, blood or PMN in stool

No granulocytosis and no fever
 DIAGNOSIS
• DFS
• Concentrations techniques : cysts
• Duodenal-jejunal aspiration
• Enterotest
• Antigen detection test (CWP1)
• Direct fluorescent Ab test
 TREATMENT

• Metronidazole
• Alternative drugs : tinidazole,
furazolidone, abendazole
 EPIDEMIOLOGY
• Prevalent worldwide
• Areas with poor sanitation and poor
hygiene
• Direct oral-anal sexual contact among
MSM increase the risk
• Zoonotic disease
• Reservoir host: beavers
 PREVENTION AND CONTROL

• Proper or sanitary disposal of human

excreta
• Normal water chlorination will not affect
cysts, but usual water treatment
modalities should be adequate.
Chilomastix mesnili
Chilomastix mesnili – cyst
 Chilomastix mesnili
• MOT: ingestion of cysts in food and drinks
• Diagnosis: DFS
• No treatment is indicated (commensal
parasite)
• Preventive and control measures: improved
sanitation & personal hygiene
 Dientamoeba fragilis
• Originally described as ameba
• Trophozoite and Cyst (newly
discovered)
• 1 or 2 nuclei
• Nuclear membrane has no
peripheral chromatin
• Karyosome: 4-6 discrete
granules
 Classification: AMEBOFLAGELLATE infection or pyorrhea
• Does not undergo encystation and
does not follow typical amoebae life &,-& #'2
#'2
cycle.
Dientamoeba fragilis
• With prefix Di- because trophozoite
• Small or minute E. histolytica found
has 2 nuclei in pigs
• Resembles flagellates, in particular • Swine Amoeba
is Trichomonas (same antigenic
properties)

CYST TROPHOZOITE
 Dientamoeba fragilis
• MOT: fecal-oral route or via transmission of
helminth eggs (eg E. vermicularis)
 Pathogenesis
• Usually asymptomatic
• Common symptoms: intermittent diarrhea
w/ excess mucus
 Diagnosis
• DFS
• Not detected by concentration techniques
• Prompt fixation of fresh stool w/ PVA
fixative or Schaudinn’s fixative has been
helpful.
 Trichomonas vaginalis

• Causes trichomoniasis
• Habitat: Urogenital Area
• MOT: Intimate Contact; Infant Delivery;
Contaminated Towels and Underwear
  



Trichomonas vaginalis
Collect Specimen:
&" "%
"%
Discharge, Prostatic
Flagellates without encystations Stain: hematoxylin

Trichomonas vagin

LIFE CYCLE:

(1,'"')'#"
(1,'"')'#"
• PATHOLOGY: Trichosomiasis
Trichomonas vaginalis
Trichomonas vaginalis
 Pathogenesis
• Common symptoms: vaginal discharge (frothy
green/yellow color), vulvitis, dysuria,
postpartum endometritis
• Lower abdominal pain
• Atypical Pelvic Inflammatory Disease
• Strawberry Cervix 2% of the cases)
• Males: asymptomatic, some cases:
• non-gonoccocal urethritis, epididymitis, and
prostatitis can occur.

• May also cause neonatal pneumonia

 Trichomonas vaginalis
• Binding to vaginal epithelial cells using
ADHESINS
• Immune evasion – surface coating with
host proteins; shedding of parasite
proteins,
• Cysteine Proteinases
• Cell Detaching Factor – cytopathic effect
• Alkaline pH
Strawberry cervix
 Diagnosis
• Saline preparation of vaginal fluid
• Culture: gold standard
• Diamond Modified Medium, Feinberg
Whittington, Cysteine Peptone Liver Maltose,
Simplified Trypticase Serum Semen Culture
• Pap’s smear
• Ag detection test
• PCR
 Treatment

• Metronidazole
• Tinidazole
 Epidemiology

• Occurs worldwide
• High prevalence is associated with
greater sexual activity with multiple
partners
 Prevention and Control

• Reduce the risk of exposure

• Proper use of protective devices such as
condoms and spermicidal foams
• Simultaneous treatment of infected
sexual partners
• Health and sex education
 Non-pathogenic Flagellates

• Pentatrichomonas (Trichomonas) hominis

• Trichomonas tenax
• Chilomastix mesnili
Trichomonas hominis
 end. Four of the flagella extend anteriorly and one extends poste
An undulating membrane that extends two thirds of the body length
accompanying costa typically lie next to the posterior flagellum. A thick a
runs along the entire body length, curving around the nucleus, and e
Trichomonas tenax
posteriorly beyond the body of the organism .a small anterior cytoso
located next to the axostyle opposite the undulating membrane.

Cytosome
Flagella Nucleus
Axostyle

Posterior Costa
Posterior
flagellum
Axostyle

Undulating membrane
(Two thirds of body length)

Fig. (2): Trichomonas tenax trophzoite.

ar flores
BLOOD AND TISSUE FLAGELLATES
BLOOD AND TISSUE FLAGELLATES
• Flagellates that are found in the blood
and other fluids (CSF) and in tissues
• Vector borne parasites
• Medically important genera
1. Trypanosoma
2. Leishmania
BLOOD AND TISSUE FLAGELLATES
GENERALITIES
• Only Trypanosoma and Leishmania
infect humans
• Transmitted by a bite of an infected
vector
• There are four morphological forms
• Amastigote – (Donovan Leishman)
• Promastigote – (Leptomonas)
• Epimastigote – (Crithidia)
• Trypomastigote
BLOOD AND TISSUE FLAGELLATES
BLOOD AND TISSUE FLAGELLATES

!
 prominent
Sidero-iron
containing
granules

mallest
BLOOD AND TISSUE FLAGELLATES
Long; lace-like Prominent



UE
S
vector
ppines

mania)

PROMASTIGOTE EPIMASTIGOTE
(Leptomonas) (Crithidia)
 *5
BLOOD AND TISSUE
 FLAGELLATES
 


 
• MODE OF TRANSM
lesion, skin capillarie
• LIFE CYCLE:

TRYPOMASTIGOTE
(Trypanosome)
 BLOOD AND TISSUE FLAGELLATES
• All forms are found in Trypanosoma cruzi
infections
• Only the epimastigote and trypomastigote are
seen in Trypanosoma brucei infections
• Only the amastigote and promastigote are seen in
Leishmania infections
• Diagnostic Stages (found in humans) include
amastigote and/or trypomastigote
 Trypanosoma cruzi
• Causative agent of Chagas disease or
American trypanosomiasis
• Habitat: RES, cardiac muscle, CNS
• Intermediate host Vector: Reduviid Bug,
(kissing bug)
• MOT: Feces of vector entering bite wound;
blood transfusion, organ transplants;
transplacentally
 Trypanosoma cruzi
• Exhibits all 4 stages of development
• Humans
• Trypomastigotes: bloodstream
• Amastigotes: tissue cells

• Vector
• Amastigote, Epimastigote, Promastigote: midgut
• Metacyclic trypomastigote: hindgut
Life cycle
Trypanosoma cruzi
Trypanosoma cruzi in blood smear
(Giemsa stain)

Triatomine bug, Trypanosoma cruzi

vector, defecating on the wound after
taking a blood meal
 66

 Trypanosoma cruzi
• Humans
• Trypomastigotes:
bloodstream
• Amastigotes:
tissue cells
 Pathogenesis
• Acute phase
• Non specific S/S: fever, malaise, nausea,
vomiting, lymphadenopathy, cutaneous
inflammation
• Chagomas
• Romaña’s sign
• Chronic phase
• Enlargement of vital organs
(myocardium, megaesophagus)
Chagoma
Chagasʼ disease:
Romana's sign
Chagasʼ disease:
mega colon
Chagasʼ disease:
megacardium
 Diagnosis
ACUTE PHASE
• Thick and thin blood smear using Giemsa
• CSF, tissue samples, lymph examination
• Concentration methods
• Blood culture : Chang’s , NNN (Novy-MacNeal Nicolle
Medium)
• PCR
• Xenodiagnosis

CHRONIC PHASE
• ELISA
• Indirect hemagglutination
• Indirect immunofluorescence
• PCR
 Treatment
ACUTE PHASE
• Nifurtimox
• Benznidazole
CHRONIC PHASE – symptom specific
management
• Pacemakers
• Antiarrhythmic drugs (amiodarone)
• Megasyndromes are managed w/ special
diets, laxatives, surgery
 Epidemiology
• Most cases : Latin America
• Other cases reported in Mexico, USA,
Canada, France, Switzerland, Japan,
and Australia
 Prevention and Control
• Vector control
• Blood transfusion regulations
• No vaccines available
 Trypanosoma brucei complex
• Etiologic Agents of African Sleeping Sickness
Trypanosoma brucei rhodesiense
Causes Rhodesian or East African Sleeping Sickness
Endemic in East and South Africa

Trypanosoma brucei gambiense

Causes Gambian or West African Sleeping Sickness
Endemic in West and Central Africa

Trypanosoma brucei brucei

affects wild and domestic animals
 Trypanosoma brucei complex
• Vector: Tsetse fly (Glossina sp.)
• Only epimastigote and trypomastigote
are exhibited
 Trypanosoma brucei
morphological forms

Epimastigote (crithidial
form) in the insect

Trypomastigote
(trypanosomal form) in
the mammalian host
Tsetse Fly
Trypanosoma brucei complex
• Vector Transmitted Parasitic Infections
• Vector: Tsetse Fly (Glossina spp.)
• T. b. rhodesiense – G. pallidipes, G. morsitans
• T. b. gambiense – G. palparis
• Infective Stage to Humans: Metacyclic Trypomastigote
 Pathogenesis
• Initial lesion: local, painful, pruritic, erythematous chancre
• Early HAT
• Hemolymphatic stage
• Fever, joint and muscle pain, malaise
• Winterbottom’s sign

• Late HAT
• Meningoencephalitic stage
• Neurologic symptoms
• Convulsions, tremors, speech and reflexes defects, paralysis
• Kerandal’s sign
• Death
Winterbottom’s Sign
 Diagnosis
• Demonstration of trypomastigote in chancre,
lymph node aspirate, CSF
• Thick and thin blood smear (Giemsa)
• Buffy coat concentration
• ELISA
• IFA
• Indirect hemagglutination
• Mini-anion exchange centrifugation technique
• PCR
• CATT
• Animal Inoculation and Culture
 Treatment
• Intravenous suramin solution: first stage of the
disease
• Intravenous melarsoprol: if w/ CNS involvement
 Prevention and Control
• Vector control
• Protective clothing
• Regulation and treatment of reservoir host
(cattle and game animals)
 Leishmania spp
• Divided into:
• Old World: L. tropica, L. aethiopica, L. major
• New World: L. mexicana, L. amazonensis, L.
guyanensis, L. braziliensis, L. chagasi
• Vector-borne
• Old World: Phlebotomus sandfly
• New World: Lutzomyia
• Obligate intracellular parasite
• Primarily a zoonotic disease
Leishmania
• Leishmania tropica
• Leishmania braziliensis
• Leishmania donovani
Leishmania
• Leishmania tropica
• Habitat: Endothelial Cells of skin capillaries; phagocytic monocytes
• Leishmania braziliensis
• Habitat: Mucocutaneous junctions (nasal septum, mouth, pharynx)
• Leishmania donovani
• Habitat: Endothelial Cells of the RES
Leishmania
• Leishmania tropica
• Vector: Phlebotomus papatasii; P. sergenti
• Leishmania braziliensis
• Vector: Phlebotomus peruensi; P. verrucarum
• Leishmania donovani
• Vector: Phlebotomus argentipes
Phlebotomus
vector
 Leishmania spp
• MOT: congenitally, blood transfusion
,contamination of bite wounds, direct
contact with contaminated specimens
• Infective stage: promastigote
Leishmania
morphology

Ø Amastigote (leishmania)
seen in the mammalian
host
Ø Promastigote
(leptomonad) seen in sand
fly
 Pathogenesis
• 4 categories
• Cutaneous Leishmaniasis (CL)
• Diffuse Cutaneous Leishmaniasis (DCL)
• Mucocutaneous Leishmaniasis (MCL)
• Visceral Leishmaniasis (VL)
Cutaneous leishmaniasis
Leishmania
Disease: Leishmaniasis
• Cutaneous Leishmaniasis (Old World Leishmaniasis, Aleppo Button,
Delhi Boil, Baghdad Boil, Jericho Boil))
• Etiology: Leishmania tropica
• Disease Manifestation
• Elevated Skin Ulcers (Painless)
• Leaves an Ugly Scar; Highly Disfiguring
Mucocutaneous
leishmaniasis
Leishmania
• Mucocutaneous Leishmaniasis (American, New World Leishmaniasis)
• Etiologic Agent: Leishmania braziliensis
• Disease manifestation
• Spread to Oronasal and Pharyngeal Mucosa
• ESPUNDIA
• TAPIR NOSE
• CHICLERO ULCER
 Pathogenesis
• Visceral Leishmaniasis (VL)
• L. donovani complex (L. donovani, L.
chagasi, L. infantum)
• Acute phase: may be mistaken for
malaria
• Post- Kala-azar dermal leishmaniasis:
cutaneous eruption resulting in
hypopigmented macules, malar
erythema, nodules, and ulcerations
 Diagnosis
• Microscopic demo of Leishmania form
lesions and tissue scrapings, aspirates,
and biopsy
• Culture: NNN medium, Schneider’s
medium
• Animal inoculation (hamster)
• Montenegro skin test
• Immunologic assays
• ELISA
 Diagnosis
• Immunologic assays
• ELISA
• rk39 Ag test (for VL)
• Direct agglutination
• Urine Ag test
• Flow cytometry
• PCR
• RFLP analysis
 Treatment
• Antimony compounds: IM or IV for
up to 4 weeks; primary treatment
• IV Amphotericin B
• Antineoplastic drug miltefosine
• Pentimidine: second-line drug for CL
& VL
• Combination therapy
 Epidemiology
• Primarily a disease of poverty
• VL is an important opportunistic
infection in AIDS
 Prevention and Control
• Use of insect repellant (DEET &
permethrin)
• Insecticide-treated clothing
• Fine-mesh bed nets
• Screens and sprays in houses
• Regulation of reservoir hosts