Contents:

Intestinal amebae E. histolytica

Commensal amebae E.coli
E. hartmanni
E. poleckii
E. gingivalis
E. nana
I. butschlii
Free-living pathogenic amebae Acanthamoeba
N.fowleri
N. Gruberi
Ciliates B.coli
Intestinal flagellates G. lamblia
D. fragilis
Urogenital flagellates T. vaginalis

Nonpathogenic flagellates T. tenax

T. hominis
C.mesnelli
Partially acid fast coccidians C. hominis
C. cayetanensis
I. belli
Other coccidians T.gondii
S.hominis
Other intestinal protozoan B. hominis

Belizario,V.Y., & de Leon,W.U.(2013). Medical Parasitology in the Philippines(Third edition).Diliman,Quezon City: The University of the Philippine Press
Shelley Lee, RMT
 INTESTINAL AMEBAE
Entamoeba histolytica Bacillary dysentery Amebic dysentery
- a peudopod-forming nonflagellated protozoan parasite Causative agent Shigella, Salmonella, E. histolytica
- eukaryotic organism but has unusual features Campylobacter,
- only pathogenic intestinal amebae Yersinia, EIEC
- the only member of the Entamoeba family to cause colitis and Onset acute gradual
liver abscess Fever present absent
Cyst Trophozoite Vomiting common no vomiting
Nucleus Quadrinucleated Single nuclei (with Stool watery, bloody, bloody, fishy odor
centrally located odorless
karyosome) Leukocyte count significantly increased increased result is less
Chromatin Fine Fine peripheral common
Motility Non-motile Motile
(unidirectional, progressive) DIAGNOSIS
Others - cigar-shaped - ingested RBCs can be Microscopic standard method
chromatoidal bars found detection of
- resistant to gastric acid - multiply by binary fission trophozoite and - minimum of 3 stool samples collected in
and dessication different days
cyst in stool
Stool Watery Formed
Direct fecal smear - detection of trophozoite and its motility
consistency (with saline) - detection of ingested RBCs is diagnostic of
amebiasis

(stool examined within 30 minutes from

defecation)
FECT and MIFC Morphologic structures being noted:
1. size of the cyst
2. number of nuclei
Host man 3. location and appearance of karyosome
MOT - ingestion of cysts from fecally-contaminated 4. appearance of chromotoidal bodies
material 5. presence of cytoplasmic structures
- venereal transmission through fecal-oral contact PCR, ELISA, Differentiates E. histolytica from E. dispar
- direct inoculation isoenzyme analysis
Habitat large bowel Serology gold standard
Infective stage cyst and trophozoite
Diagnostic quadrinucleated cyst Detects antibodies in the serum (key in
diagnosis of ALA)
stage
Radiographic studies
DOC Metronidazole

DISEASE MANIFESTED
Amebic colitis gradual onset of abdominal pain and diarrhea
with or without blood and mucus in the stool

Flask-shaped ulcers

Complications:
1. Perforation
2. Secondary bacterial peritonitis
Ameboma mass-like lesion with abdominal pain and a
history of dysentery
Amebic liver - anchovy sauce-like aspirate
abscess Cardinal manifestations:
a. fever
b. right upper quadrant pain

▪ Acute cases (<2 weeks)

▪ Chronic cases (>2 weeks) - wasting
disease involved

Complications:
1. Rupture in pericardium
2. Rupture in pleura
3. Superinfection
4. Intraperitoneal rupture
Secondary amebic meningoencephalitis

Virulence factors Action

1. Cysteine proteinases tissue destruction
2. Gal/Gal NAc lectin cytoadherence
3. Amebapores formation of spores

Belizario,V.Y., & de Leon,W.U.(2013). Medical Parasitology in the Philippines(Third edition).Diliman,Quezon City: The University of the Philippine Press
Shelley Lee, RMT
 COMMENSAL AMEBAE
Three genera of intestinal amebae differentiated by its nuclei:
Entamoeba Endolimax Iodamoeba Entamoeba gingivalis
Nucleus Spherical (distinct Vesicular - can be found in the mouth (gum, teeth surface, gum pockets,
nuclear and sometimes in tonsillar crypts
membrane lined
- trophozoite: blunt pseudopodia, food vacuoles that contain
with chromatin
granules) cellular debris and bacteria
Karyosome Small,center of Large, Large, - no cyst stage
the nucleus irregularly- chromatin-rich,
shaped surrounded by a layer
of achromatic
Endolimax nana
globules - smallest intestinal amebae
Trophozoite: sluggish movement, large irregular karyosome, no
chromatin
Host man Cyst: quadrinucleated, cross eyed cyst
MOT ingestion of viable cysts in food or water
Stages trophozoite, precyst, cyst, metacystic trophozoite Iodamoeba butschlii
Excystation lower small intestine Trophozoite: large vesicular nucleus, large endosome surrounded by
Encystation lower colon achromatic granules, sluggish and nonprogressive motility
Cyst: uninucleated, large glycogen body, stains deeply with iodine

Entamoeba coli DIAGNOSIS

- largest amebae Swab between the gums and teeth for detection of E. gingivalis
Cyst Liquid stool detection of cyst
E.coli E. histolytica Formed stool detection of trophozoites
No. of nuclei 8 4
Chromatoidal splinter-like sausage-shaped
body
Size larger

Trophozoite
E.coli E. histolytica
Cytoplasmic bacteria, no RBCS RBCs
inclusions
Motility sluggish, progressive, unidirectional
undirected
Karyosome eccentric centrally located
Chromatin thick,peripheral fine, peripheral
Pseuodopodia broader and finger-like
blunter

Entamoeba hartmanni
Cyst
E.hartmanni E. histolytica
Chromatoidal body tapered ends or thin and sausage-shaped
bar-like

Trophozoite
E.hartmanni E. histolytica
Cytoplasmic no ingested RBCS ingested RBCS
inclusions
Motility sluggish progressive, unidirectional
Size smaller

Entamoeba polecki
- a parasite of pigs and monkeys
- cysts is uninucleated

Belizario,V.Y., & de Leon,W.U.(2013). Medical Parasitology in the Philippines(Third edition).Diliman,Quezon City: The University of the Philippine Press
Shelley Lee, RMT
 TROPHOZOITE
E.histolytica E.coli E.hartmanni E. polecki E. gingivalis E. nana I. butschlii
Number of 1 1 1 1 1 1 1
nucleus
Karyosome Central Eccentric Cental/eccentric Central Central Blot-like Central
(achromatic
granule)
Cytoplasmic Ingested RBCs Bacteria No ingested RBCs Vacuolated Bacteria Vacuolated Vacuolated
inclusion Ingested RBCs Debris, WBCs Bacteria Bacteria, Yeast
Chromatin Fine, uniformly Thick/coarse Fine, uniformly Evenly Fine None None
distributed distrbitued distributed
Motility Progressive, Sluggish, Sluggish, Progressive, Progressive Sluggish Sluggish,
unidirectional undirected nonprogressive unidirectional nonprogressive

CYST

E.histolytica E.coli E.hartmanni E. polecki E. gingivalis E. nana I. Butschlii

Number of 4 8 4 1 No cyst stage 4 1
nucleus
Others Cigar-shaped Splinter-like Tapered end or Cross eyed Stains deeply
chromatoidal chromatoidal bar-like with iodine
body body chromatoidal
body

Belizario,V.Y., & de Leon,W.U.(2013). Medical Parasitology in the Philippines(Third edition).Diliman,Quezon City: The University of the Philippine Press
Shelley Lee, RMT
 FREE-LIVING PATHOGENIC AMOEBA
Acanthamoeba Naegleria fowleri
- active trophozoite and a dormant cyst Two vegetative forms:
- feed on gram negative bacteria, algae, and yeast 1. ameba: trophozoite form
- ubiquitous organims (air, bottled mineral water, soil, 2. flagellate: swimming form
swimming pools, contact lens cleaning solutions)
- high incidence in AIDS patients with low CD4+ T-lymphocyte Two forms of trophozoite:
counts 1. Ameboid: in humans
2. Ameboflagellate
Acanthamoeba cyst: double-walled (outer: wrinkled, inner:
polyglonal-shaped) - trophozoite can transform reversibly into a non-reproductive
flagellate or a resistant cyst
TROPHOZOITES - trophozoites replicate by promitosis (nuclear membrane
Nucleus single, large, centrally-located intact)
Cytoplasm finely granulated - growth is inhibited by 0.2% NaCl and KCl
Movement sluggish, polydirectional (acanthopodia - small,
spiny filaments) TROPHOZOITE
1. Centrally-located nucleus
2. Prominent monopseudopodium
3. A pair of flagella originating from the tip of a pear-shaped cell
body (ameba →biflagellated organism)
4. Blunt, lobose pseudopodia
5. Directional motility

Host man
Habitat skin/lungs
Other sites CNS
MOT - entry through eyes, nasal passage, broken skin
- use of contaminated contact lens solution
Infective stage trophozoite
Diagnostic stage cyst and trophozoite

Host man, mice

DISEASE MANIFESTED
MOT intranasal or oral entry
Granulomatous amebic Nonspecific manifestations: fever, chills, Infective stage trophozoite
encephalitis (GAE) fatigue, and weight loss
Neurologic symptoms: focal hemiparesis, Diagnostic stage trophozoite and flagellated form
cranial nerve palsies, visual disturbances, Can survive at high temperatures(up to 46℃) and
ataxia hyprchlorinated water
Skin lesions Habitat brackish water, soil (preferred)
Amebic keratitis Treatment Amphotericin B

DIAGNOSIS DISEASE MANIFESTED

1. Demonstration of trophozoites and cysts in tissues using Primary amebic characterized by fever, headache, vomiting,
histopathologic stains and microscopy meningoencephalitis signs of meningeal irritation and encephalitis,
2. Culture using CSF sample (PAM) with rapid progression to coma and death
3. Epithelial biopsy - for Acanthamoeba keratitis
4. PCR DIAGNOSIS
1. Trophozoite in brain and CSF
2. CSF findings of pleocytosis with a high precentage of PMN cells,
hypoglycorrhachia, and elevated protein levels
3. Active trophozoites in bacteria-seeded agar culture medium
4. PCR and ELISA

Naegleria gruberi
- most commonly studied non-pathogenic species
- susceptible to cyanuric acid

Belizario,V.Y., & de Leon,W.U.(2013). Medical Parasitology in the Philippines(Third edition).Diliman,Quezon City: The University of the Philippine Press
Shelley Lee, RMT
 CILIATES AND FLAGELLATES
CILIATES Trophozoite
Balatindium coli 1. Shape Pyriform/teardrop
- largest protozoan parasite affecting humans 2. Nuclei A pair of ovoidal nuclei (one on each side of the
- only ciliate known to cause human disease midline)
- is found in association with pigs in the tropics 3. Dorsal side Convex
- easily inactivated by heat and 0.1% sodium hypochlorite 4. Ventral side Concave with large adhesive disc
5. Motility Erratic, tumbling (4 pairs flagella)
Cyst 6. Bilaterally symmetrical with a distinct medial line called
1. Spherical and ovoid, covered with thick walls axostyle
2. Encystation does not result in an increase number of nuclei 7. Entire surface of the parasite has variant-specific surface
proteins (VSPs)
Trophozoite
1. Nuclei 2 (macro- and micronucleus)
2. Contractile 2
vacuoles
3. Bean-shaped macronucleus
4. Contains an extrusive organelle called mucocysts
5. Has a cytosome through which it acquires food
6. Has a cytophage through which it secretes waste
Host man
MOT ingestion of food contaminated with cyst
Habitat duodenum, jejunum, upper ileum
Infective stage cyst
Diagnostic stage cyst and trophozoite
DOC Metronidazole

DISEASE MANIFESTED
Host man 1. Malabsorption and maldigestion
MOT ingestion of food and water contaminated 2. Excessive flatus with an odor of rotten eggs
with fecal material containing B. coli cysts 3. Chronic infection: steatorrhea
Habitat colon 4. Failure to thrive syndrome
Infective stage cyst 5. Giardiasis/Traveller’s diarrhea/Bever fever/Backpacker’s
Diagnostic cyst and trophozoite diarrhea/Gay bowel syndrome
stage
Treatment Tetracycline/metronidazole/iodoquinol Virulence factors Action
1. Ventral adhesive discs attachment (influenced by
DISEASE MANIFESTED temperature and pH)
Balantidiasis or - indistinguishable from amebic dysentery 2. Lectin attachment
balantidial Common complaint: diarrhea with bloody and
dysentery mucoid stool DIAGNOSIS
Acute: 6-15 episodes of diarrhea/day
Microscopy demonstration of cyst and trophozoite
(floating leaf-like motility)
Chronic: diarrhea may alternate with
constipation Duodeno-jejunal biopsy if not found in feces
Enterotest/Beale’s string demonstrate Giardia trophozoites
Complications: Direct fluorescent gold standard
intestinal perforation and acute appendicits
antibody assays
Ulcer in the - characteristic rounded base and wide neck
intestinal flask-shaped ulcer
epithelium - caused by hyaluronidase Dientamoeba fragilis
- uses iron-hematoxylin stained films for examination
- trophozoite stage only (1-2 rosette-shaped nuclei)
DIAGNOSIS
- resembles Trichomonas but with flagella
Microscopy demonstration of cyst and trophozoite in stool
- mononucleate and binucleate forms of Dientamoeba have
Sigmoidoscopy presence of trophozoite in biopsy
been observed in the lumen of E. vermicularis adults in the
intestines
INTESTINAL FLAGELLATES Habitat mucosal crypts of the cecum and the upper
Giardia lamblia colon
- also known as Giardia instetinalis, G. duodenalis, Lamblia MOT - fecal-oral route
duodenalis, L. intestinalis, Cercomonas intestinalis - transmission of helminth eggs particularly
that of Enterobius vermicularis
- intestinal parasitic flagellate
(co-infection)
Cysts
Clinical manifestation - colicky abdominal pain
1. Nuclei: 2 (young), 4 (mature) - pruritus ani
2. Median body Diagnosis observation of binucleate trophozoites in
multiple fixed and stained fresh stool

Belizario,V.Y., & de Leon,W.U.(2013). Medical Parasitology in the Philippines(Third edition).Diliman,Quezon City: The University of the Philippine Press
Shelley Lee, RMT
 UROGENITAL FLAGELLATES AND NONPATHOGENIC
FLAGELLATES
Trichomonas spp - no cyst stage Disease diarrhea diarrhea, diarrhea,
T. vaginalis T.hominis T. tenax cholera-like D-xylose
jejunal infections malabsorption
Habitat genitals colon oral cavity
MOT - sexual ingestion of direct contact,
intercourse trophozoite kissing, Diagnosis - microscopy - Sheather’s sugar - autofluoresence under
- infant delivery contaminated - concentration flotation UV light
- contaminated dish or techniques - acid fast staining - safranin staining
- acid fast - PCR
underwear and glasswares
staining
towels - enterotest
Size largest medium smallest
Nucleus ovoid ovoid round
Undulating 1/2 the length whole body 2/3 of the
membrane body OTHER COCCIDIANS
Inclusion siderophil none none Toxoplasma gondii
bodies granules - intracellular parasite which infects nucleated cells
Motility jerky motility Definitive host cat
Pathogenecity Pathogenic Nonpathogenic Nonpathogenic Intermediate host birds, rodents, pigs
Accidental host/ man
T.vaginalis dead end host
- Pingpong disease MOT - ingestion of contaminated food and water
Trichomonal vaginitis: yellow green, frothy, foul smelling - vertical transmission
discharge and strawberry cervix - organ transplant/blood transfusion
- ingestion of infected meat
Infective stage Intestinal stage: oocysts
Extraintestinal: tachyzoite and bradyzoite

TROPHOZOITES
Shape Crescent-shaped
(pointed anterior, round
posterior)
Nucleus Spherical
Chilomastix mesnelli
- nonpathogenic flagellate
Habitat cecal region of the colon
Trophozoite asymetrically pear-shaped CYSTS
Cyst pear/lemon-shaped Oocysts 8 sporozoites (2
Movement spiral forward sporocysts with 4
MOT ingestion of cysts in food and drinks sporozoites each)
Location CNS and muscles
PARTIALLY ACID FAST COCCIDIANS
Three sequential stages:
1. Asexual reproduction/schizogony: produce merozoites Endodyogeny: formation of the plasma membrane by the two
2. Sexual reproduction/sporogony: produce oocysts new daughter parasites even before the division of the nucleus
3. Gametogony: produce male(micro) and female(macro)
gametocytes DISEASE MANIFESTED
1. Asymptomatic Healthy individuals
Host man 2. Encephalitis Most common in immunocompromised patients
MOT ingestion of cyst 3. Stillbirth and abortion
Stages sexual and asexual 4. In babies: chorioretinitis, epileptic seizures, jaundice,
Habitat small intestine hydrocephaly, and microcephaly
Infective stage oocysts 5. Newborn death: anemia with pneumonia

Cystoisospora Cryptosporidium Cyclospora DIAGNOSIS

belli hominis cayetanensis 1. Sabin-Feldman very sensitive and specific but requires
a.k.a Isospora belli Cyanobacterium-like methylene blue dye test the maintenance of live organisms
body
Oocsyt thin-walled Thin-walled: autofluorescent + result: non-uptake of the dye
autoinfection, 2. Serodiagnostic methods
Thick-walled: 3. ELISA, indirect HAT, indirect FAT
contaminate food 4. PCR
and water
Once immature infective immature
released

Belizario,V.Y., & de Leon,W.U.(2013). Medical Parasitology in the Philippines(Third edition).Diliman,Quezon City: The University of the Philippine Press
Shelley Lee, RMT
Sarcocystis hominis OTHER INTESTINAL PROTOZOANS
- causative agent of Sarcosporidiosis/sarcocystosis Blastocystis hominis
- lacks cell wall but has a mitochondrion with protozoan
Definitive host (DH) man, carnivores (dogs) morphology
Intermediate host (IH) herbivores, omnivores - reproduction is asexual (binary fission) or sporulation under
MOT DH: strict anaerobic conditions
- consumption of uncooked or - optimal growth at 37℃ in the presence of bacteria
undercooked meat of an intermediate
host that contains sarcocysts Host man
- accidental ingestion of sporocysts
MOT fecal-oral route
Habitat lower intestinal tract
IH:
DOC Metronidazole
- ingestion of sporocysts
Habitat DH: intestine
IH: brain, muscle, kidney MORPHOLOGICAL FORMS
Infective stage cyst with bradyzoites 1. Vacuolated - most predominant forms in fecal specimen
- the prominent central vacuole has bee found to
be a reproductive organelle
Zoite- simplest form; banana-shaped (pointed end is entering
- considered to be the main type of Blastocystis
the host cell) causing diarrhea
SPOROCYST 2. Ameba-like - exhibit active extension and retraction of
1. Composed of 4 zoites (long teardrop-shaped) pseuodopodia
2. Oblong/cylindrical in shape - this stage allows the parasite to ingest bacteria
3. Capable of retaining their infectivity months in water at 4-10℃ in order to enhance encystment
3. Granular - multinucleated; mainly found in old cultures
SARCOCYST 4. Multiple - arise from vacuolated forms
Macrocysts - sarcocysts that can be seen by the naked eye fission
- described as grayish/whitish streaks runnning 5. Cystic - has a very prominent and thick osmophilic
lengthwise along the muscle fibers electron dense wall
Microcysts The same width as a muscle fiber (microscopic) - oval/circular, dense body surrounded by a loose
membranous layer (is the easiest diagnostic
feature easiest to identify)
DISEASE MANIFESTED
Human sarcocystosis gastroenteritis with diarrhea, eosinophilic Thick-walled: external transmission
enteritis, myalgia, weakness, mild increase of Thin-walled: cause of reinfection
creatine kinase
In IH - weakening of the limbs, muscle wasting,
head tilt, move in circles
- cause of abortion in animals (cows)
- paralysis/death
NOTE: the number of clinical signs that appear is proportional to the number of
sarcocystis organism paralyzing the host

DIAGNOSIS
Diagnosis: detection of organism from stool sample
1. Fecal flotation methods DH: sporocysts
2. Muscle biopsy (definitive) IH: schizonts
3. Western blot Useful for the detection of antibodies
In blood serum and CSF
4. Complement fixation
5. Dermal sensitivity tests
6. Periodic Acid Schiff (PAS) positive: confirmatory

Belizario,V.Y., & de Leon,W.U.(2013). Medical Parasitology in the Philippines(Third edition).Diliman,Quezon City: The University of the Philippine Press
Shelley Lee, RMT