Protozoa - GI Infections

1. Giardia lamblia

General characteristics

- Flagellated protozoa

Clinical features

- Poop and brown water = fecal-oral transmission  cysts (bubbles in the river) found in
water contaminated with animal or human feces  commonly affects hikers and
campers that drink unfiltered or unpurified water (guy filling his bottle with river water)
from a river or stream in an area endemic to Giardia
- Flagellated shields = ingested cysts differentiates into trophozoites (distinctive shape) in
the proximal small bowel  trophozoites attach but do not invade the intestinal wall
(Giardia doesn’t cause bloody diarrhea) by a ventral sucking disk trophozoites can be
passed into the stools (many of them become cysts as they transit through the colon)
- Symptoms  bloating, flatulence and foul-smelling (guys covering their nose) and fatty
diarrhea (yellow stool = steatorrhea) due to fat malabsorption (excessive mucus
production that impairs the absorptive capacity of the intestine)  can lead to
significant weight loss and health problems for malabsorption (deficiency of vitamins A,
D, E and K)
- Diagnosis  stool ova & parasites (O&P) test will show the presence of trophozoites or
cysts (guy pointing the shields in the water) / ELISA stool antigen detection

Treatment

- Metro train = metronidazole

2. Entamoeba histolytica

General characteristics

- Intestinal amoeba

Clinical features

- Transmission  ingestion of cysts found in contaminated water (archeologists drinking

dirty water) / anal-oral transmission associated with men who have sex with men
(archeologists holding hands)  in the small intestine cysts differentiates into
trophozoites  trophozoites migrate and invade the colon mucosa and spread via the
portal circulation to the liver
- Amebiasis:
 Liver abscess formation with anchovy paste exudate (anchovy paste truck)
commonly affects the right lobe of the liver (tomb)  up to 80% of this lesions are
solitary (map with CT)  causes RUQ pain and tender hepatomegaly (archeologist
clutching his RUQ)
 Ulcerations along the colonic mucosa (drainage pipe with rust spots) with a flask-
shaped appearance on biopsy (flask-shaped bottles)
 Bloody diarrhea (red stools)
- Diagnosis  cysts (with up to 4 nuclei) or trophozoites (with endocytosed RBC in the
cytoplasm) on stool O&P / ELISA antigen test on stool or serum / serology / flask-
shaped lesions on colon biopsy

Treatment

- Metro train = metronidazole

- Luminal agents  paramycin (pair of mice) and iodoquinol (Queen Iodo’s tomb) 
eliminate cysts in the lumen of the colon  for asymptomatic cyst passers
- No surgical approach needed for liver abscess (in contrast to hydatid cysts)
3. Cryptosporidium spp.

General characteristics

- Unicellular and partially acid fast organism (pink poncho)

Clinical features

- Brown water = watery diarrhea (mild disease) in immunocompetent hosts

- Cane = severe diarrhea in immunocompromised patients  most common organism
identified in HIV patients with diarrhea
- Transmission  fecal-oral  oocysts in contaminated water with feces (bubbles on
water)  each oocyst is composed of 4 motile sporozoites that are release in the small
intestine (narrow pipe)  sporozoites attach to the epithelial cells of the small intestine
where they convert to trophozoites and undergo asexual and the sexual multiplication
causing mucosal damage and diarrhea
- Diagnosis  oocysts on acid fast staining of stool O&P (gems in the water) / antigen
detection

Treatment and prevention

- Water dripping down from the sock = filtration can remove oocysts from contaminated
water (highly resistant to chlorination)
- Treatment is mainly supportive
- Needle sock = nitazoxanide exclusively in immunocompetent hosts
- Spirit crows = spiramycin (macrolide) not FDA approved
Protozoa – CNS Infections

1. Toxoplasma gondii

General characteristics

- Intracellular protozoa that can infect almost any warm-blooded animal

Clinical features

- Transmission  consumption of raw or undercooked meat (bowl with bubbly looking

meat) that contains tissue cysts (most common) / ingestion of water or vegetables
contaminated with oocysts shed in the feces of infected animals especially cats (eggs
in cats’ feces) / transplacental transmission if the mother is first exposed to the parasite
during pregnancy (pregnant women cleaning the poop)
- Approximately 30% of the world’s population carries Toxoplasma gondii  mostly
asymptomatic or mononucleosis-like symptoms in immunocompetent hosts
- Cat with a cane = immunocompromised patients (especially those with HIV) are a high
risk population (reactivation)  CNS toxoplasmosis  encephalitis (red turban) + brain
abscesses seen as multiple ring enhancing lesions on CT or MRI (shiny round multi-lens
 glasses)  brain biopsy (pin sticking out of the turban) is required to differentiate it
from CNS lymphoma  HIV patients can also develop chorioretinitis
- Cat dressed like the Statue of Liberty = congenital toxoplasmosis is one of the TORCH
infections  deafness (cat dressed like Beethoven) + classic triad: chorioretinitis (giant
camera’s flashbulb) / hydrocephalus (cat with bowl stuck on his head) / intracranial
calcifications (cat with milk on the head)  seizures
- Diagnosis  serology or biopsy (intramuscular cysts or tachyzoites)

Treatment and Prevention

- Dyed rotten eggs with pyramid shapes = sulfadiazine + pyrimethamine for active
infection
- Cat with a cane dressed like Benjamin Franklin = prophylaxis in HIV patients should be
given when CD4 count < 100 (hundred dollar bill) and IgG(+) for Toxoplasma gondii (key
tied to the kite)  TMP-SMX (rotten egg)
2. Trypanosoma brucei

General characteristics

- Single pink ribbon = motile parasite with a single flagella

- African map = endemic to western and southeastern Africa

Clinical features

- Transmission  via the painful bite of the tsetse fly (vector)

- Pearl neckless and ruffles around the shoulders = metacyclic trypomastigotes enter the
lymphatic system and causes cervical and axillary lymphadenopathy  it spreads to
the bloodstream where they transform to trypomastigotes and travels to other body
fluids
- Multicolored tents = recurrent fevers (mountains) due to antigenic variation of surface
glycoproteins  leads to evasion of the immune system and chronic infection
- Sleeping princess = penetration to the CNS via the CSF causes somnolence and comma
 African sleeping sickness
- Diagnosis  trypomastigotes (goat on the bed) seen on blood smear (also can be found
in lymph nodes and CSF)
Treatment

- Bottle of serum = suramin for peripheral blood infection

- Bar of soap = melarsoprol for CNS infection
3. Naegleria fowleri

General characteristics

- Free-living amoeba found in warm freshwater

Clinical features

- Transmission  trophozoite enters to the CNS via the cribiform plate (cribs) when
swimming in freshwater  rapidly fatal meningoencephalitis
- Windsurfing dude = associated with water sports
- Water bottles = also associated with nasal irrigation systems and contact lens solutions
- Symptoms  nuchal rigidity (neck brace) + fever + altered mental status from
encephalitis (red turban)  primary amebic meningoencephalitis (high mortality and
poor prognosis)
- Diagnosis  lumbar puncture (bottle of champagne with spinal needle) and
visualization of amoebas (trophozoites) in the CSF under microscopy

Treatment
- Frogs (amphibians) = amphotericin B
Protozoa – Hematologic Infections

1. Trypanosoma cruzi

General characteristics

- Protozoa located predominantly in South America that produces Chagas disease

Clinical features

- Transmission  triatomine insect (kissing bug) bites and defecates around the mouth
or eyes (Che kissing his girlfriend)  scratching causes fecal transmission of metacyclic
trypomastigotes into the bite site or mucosa  parasite tunnels into tissue and feeds in
the blood and lymph of the host
- Acute infection: asymptomatic / local inflammation around the bite site  unilateral
periorbital swelling (Romaña sign)
- 10-20 years after inoculation Chagas disease develops with the following symptoms:
 Megacolon (gas line looking like a swollen colon)  extreme constipation or acute
abdomen due to perforation
 Dilated cardiomyopathy (bag shaped as floppy heart)  from the blood the parasite
burrows into the endocardium (mole)  main cause of mortality
 Megaesophagus (snake with dilated throat)
- Diagnosis  visualization of motile trypomastigotes in blood smear (blood on the
ground) in active infection / clinical symptoms + serology in chronic infection /
visualization of intracellular amastigotes within cardiac myocytes in heart biopsy

Treatment

- Knee high furry moccasins = nifurtimox for acute infection

- No effective treatment for chronic infection
2. Babesia spp.

General characteristics

- Apicomplexan protozoa with intracellular replication within RBC

- NE = geographic distribution is predominantly in northeast US along with Borrelia
burgdorferi

Clinical features

- Robin of Ixodes = transmission to humans (dead-end hosts) occurs via the Ixodes tick
(deer tick is the definitive host) containing sporozoites  the longer the attachment of
the tick the higher the likelihood of transmission  coinfection with Lyme disease is
common
- Vampire babes = babesiosis causes blood related symptoms  hemolytic anemia (red
broken glass windows) + hemoglobinuria + jaundice (yellow clothes)  also causes
irregularly cycling fevers (bottom of Robin’s shirt)
- In 25% to 50% patients the infection is subclinical or mild
- Sickle = higher risk of severe disease in sickle cell disease and asplenic patients (hole in
Robin’s clothes)
- Diagnosis  thick blood smear (red carpet) will show merozoites with a Maltese cross
appearance (cross in the carpet) within infected RBC
Treatment

- Ato-vampire queen = atovaquone + azithromycin (crows)

3. Plasmodium spp.

General characteristics

- Member of the phylum Apicomplexa with intracellular replication within hepatocytes

and RBC

Clinical features

- Transmission  via Anopheles mosquitoes (vector) carrying sporozoites (mushrooms)

in their saliva  sporozoites mature to schizonts in the liver (cow with liver spot) 
schizonts cause the rupture of hepatocytes (burst spot) and release of merozoites 
merozoites infect RBC and mature to trophozoites which can form schizonts or
gametocytes (♀♂)
- General symptoms  fever, headache, anemia and splenomegaly
- Diagnosis  Giemsa stain on blood smear to see parasites (trophozoites, schizonts,
gametocytes) inside RBC
- Species:
 Plasmodium malariae (smelly warlord)  quartan fever cycle (buttons on tunic =
every 72 hours)
  Plasmodium vivax and Plasmodium ovale (warlord with oval shield and ax) 
produce dormant hypnozoites (hypnosis) in the liver (liver spot on the shield) 
tertian fever cycle (pendulums = every 48 hours)
 Plasmodium falciparum (false mask warlord)  severe malarial illness  irregular
fever pattern (bottom of torn shirt) + cerebral malaria (red headdress) as the
parasitized RBC occlude capillaries of the brain + occlusion of kidney (gold belt) and
pulmonary (gold chest plates) vessels  P. falciparum gametocytes are banana-
shaped in the peripheral blood smear (banana-shaped headdress)
- Sickle = sickle cell disease is protective against P. falciparum

Treatment

- Color queen = chloroquine  blocks plasmodium’s heme polymerase (color polymers

on dress)  nowadays chloroquine sensitive species are uncommon
- Primal queen = primaquine  effective against hypnozoites in the liver  causes
severe anemia in patients with G6PD deficiency
- Me-fly queen = mefloquine  reserved for chloroquine resistant species and used as a
prophylactic agent for travelers (luggage) to chloroquine resistant areas
- Ato-vampire queen = atovaquone in combination with proguanil (iguana) can be used
as prophylaxis (luggage) or treatment even for severe infections (painting)
- Artist = IV artemisinin (artesunate or artemether) for severe infections caused by P.
falciparum
- Dining queen = IV quinidine is also used for resistant and severe infections 
cinchonism (headache and tinnitus) is a related side effect (tin cans)
4. Leishmania spp.
General characteristics

- Obligate intracellular protozoa

Clinical features

- Transmission  vertebrates (mainly humans) are the hosts and sandflies are the
vectors (flies around the zombie)  promastigotes in the vector are phagocytized by
host’s macrophages where they transform into amastigotes (goats in cages)
- Brazilian zombie = Leishmania braziliensis  causes cutaneous and mucocutaneus
leishmaniasis  disfiguring skin ulcers
- Donovan = Leishmania donovani  visceral leishmaniasis (black fever or kala-azar) 
hyperpigmented skin spots, spiking fevers (sweating), hepatosplenomegaly (cow with
liver and spleen spots), pancytopenia due to bone marrow affection (meat on the plate)
- Diagnosis  visualization of macrophages containing amastigotes (spots on goats) in
aspirates from the bone marrow, spleen or skin lesions

Treatment

- T-bone steak = stibogluconate for cutaneous leishmaniasis

- Frogs (amphibian) = amphotericin B for visceral leishmaniasis
Protozoa – Other Tissue Infections
1. Trichomonas vaginalis

General characteristics

- Flagellate protozoa which doesn’t have a cyst form

Clinical features

- Couple kissing = sexually transmitted infection (humans are the only hosts)
- Symptoms: vaginitis  itching and burning (fire) + foul-smelling yellow-greenish
discharge (street color) / cervicitis  strawberry cervix due to severe inflammation
with areas of punctate hemorrhages / Men are usually asymptomatic (but contagious)
- Diagnosis  motile trophozoites (moving car) seen on wet mount (water) / vaginal
fluid pH is > 4.5 (paintings price) / strawberry cervix on speculum examination

Treatment

- Metro train = metronidazole for both partners

Helminths – Nematodes

1. Intestinal Nematodes

Enterobius vermicularis (pinworm)

- At night time the female pinworm migrates to the anus (round hole in the wall) and lays
its eggs (round rocks)  causes anal pruritus
- Fecal-oral transmission (rats eating near the rocks)  commonly infection occurs via
self-inoculation (transferring eggs to the mouth with hands that have scratched the
perianal area)  typically affects children
- Diagnosis  tape test (scotch cape)  touch the perianal skin with transparent tape to
collect pinworm eggs around the anus first thing in the morning  visualization of the
eggs on the tape (rocks on the cape) under a microscope
- Treatment  pyrantel pamoate (pam!) or albendazole (bend metal bars)
Ancylostoma duodenale / Necator americanus (hookworms)

- Transmission  filariform larvae penetrate the skin especially of soles of the feet
when walking barefoot (red boots = cutaneous larva migrans  pruritic serpiginous
rash)  in the bloodstream they travel to the lungs and ascend the bronchial tree until
they get coughed up and swallowed (ascending arrow on chest)  in the small intestine
they mature to adults  they attach to the intestinal wall and suck the blood from the
capillaries of the villi  patients develop severe iron deficiency anemia (iron on the
hook)
- Slingshot boy = eosinophilia (white blood cells with pink granules and bilobed nuclei)
- Diagnosis  visualization of eggs in the stool (grenades on water)
- Treatment  pyrantel pamoate (pam!) or albendazole (bend metal bars)
Ascaris lumbricoides (giant roundworm)

- Fecal-oral transmission  ingestion of eggs from contaminated food or water  eggs

hatch in the small intestine and the larvae migrates through the gut wall into the
bloodstream  larvae reach the lungs and ascend through the bronchial tree until they
are swallowed back to the GI tract (ascending arrow on the chest)  they mature into
adults in the small intestine where they multiply and their eggs are passed through the
feces
- Symptoms  respiratory symptoms (tree on chest) as the worms migrate into the
bronchi / biliary or intestinal obstruction at the ileocecal valve (tunnel obstruction) or
perforation
- Pink granules from slingshot boy = eosinophilia
- Diagnosis  visualization of knobby-coated oval eggs in the stool (corns on water)
- Treatment  albendazole (bend metal bars)
Strongyloides stercoralis (threadworm)

- Transmission  filariform larvae in the soil penetrate the skin of soles of the feet
(reed boots)  in the bloodstream they travel to the lungs and ascend to through the
bronchial tree until they are swallowed back to the GI tract (ascending arrow on the
chest)  larvae mature in the small intestine into adults
- Hyperinfection syndrome  caused by autoinfection in immunocompromised hosts
when adults lay their eggs in the intestinal wall and filariform larvae reenter the
bloodstream (eggs in the hole kicked by strong guy)
- Symptoms  GI (duodenitis) / respiratory (dry cough and hemoptysis) / cutaneous
(pruritus)
- Pink granules = eosinophilia
- Diagnosis  visualization of rhabditiform larvae in the stool (eggs don’t get pass to the
stool)
- Treatment  albendazole (bend metal bars) or ivermectin (river sign)
Trichinella spiralis

- Transmission  ingestion of cysts in undercooked meat (especially pork)  larvae

enter the bloodstream (red pipes) and encyst (cyst-shaped explosives) in striated
muscle (brick wall) causing myositis (fire in the wall)
- Trichinosis  fever (sweating pork), nausea and vomiting (green vomit on mouth),
periorbital edema (red glasses), myalgia due to myositis
- Pink granules = eosinophilia
- Treatment  albendazole (bend metal bars)
2. Tissue Nematodes

Dracunculus medinensis

- Transmission  ingestion of contaminated water (water cooler) with copepods (tiny

crustaceans found in the sea and freshwater) containing larvae (paper cups)  once the
copepods die (intermediate hosts) the larvae penetrates the host’s stomach and
intestinal wall  after maturation in the abdominal cavity the females migrate to the
surface of the skin (usually the lower extremities) and generate a painful skin ulcer
- Pink granules = eosinophilia
- Diagnosis  visualization of adult female worms emerging from the skin ulcers (untied
shoe laces)
- Treatment  slow extraction of the worm with a small stick (shoe lace wrapped
around the leg of the water cooler) + metronidazole
Onchocerca volvulus

- Transmission  female blackfly (found around rivers in Africa and Central and South
America) bites the human host and deposits filarial larvae in the skin  larvae
penetrates down into the skin and mature into adult filariae in subcutaneous tissue 
adults produce microfilariae that migrate throughout the body
- Symptoms  scattered pruritic skin papules that become hyper or hypopigmented
(dark and light stains on lab coat) / river blindness (second most common cause of
infectious blindness) due to migration of microfilariae to the eyeball (fly covering his
eye)
- Pink granules = eosinophilia
- Diagnosis  microfilariae seen in skin biopsy (microscope)
- Treatment  ivermectin (river sign)
Wuchereria bancrofti

- Transmission  female mosquito (mosquitos flying around) bites and deposits filarial
larvae on the host’s skin  larvae penetrate the skin and enter the lymphatics where
they mature into adults  adults produce microfilariae that travel though the
lymphatics system and peripheral blood
- Causes elephantiasis (large pants)  lymphatic filariasis due to long standing
lymphedema mainly of the lower extremities (ruffles)  spread of microfilariae causes
inflammation and disruption of the lymphatic system
- Coughing witch = microfilariae that travel to the lungs cause a hypersensitivity reaction
- Pink granules = eosinophilia
- Diagnosis  visualization of microfilariae in thick blood smear (blood on the hat)
- Treatment  diethylcarbamazine (diet & carb magazine)
Toxocara canis

- Fecal-oral transmission  contamination of food with dog or cat feces (poop bag)
containing eggs  larvae hatch inside humans (incidental hosts) but never mature into
adults  larvae circulates from the intestinal wall to the bloodstream and through the
body  visceral larva migrans
- Sleep mask covering eyes = ocular larva migrans causes visual impairment and blindness
 T. canis can also affect the liver, CNS (seizures and comma) and heart (myocarditis) as
it migrates
- Pink granules = eosinophilia
- Bend legs of the chair = albendazole
Loa loa

- Transmitted by the deer fly bite (surrounding flies)  introduction of filarial larvae into
the skin of the human host and maturation into adult worms  adult worms reside in
subcutaneous tissue and produce microfilariae
- Lumps over the body = as the adult worm migrates through the subcutaneous tissue
causes transient angioedema (local subcutaneous swellings)
- Red eyes = adult worms can migrate across the conjunctiva causing transient
inflammation and edema
- Pink granules = eosinophilia
- Diagnosis  visualization of the adult worm in the conjunctiva / visualization of
microfilariae on blood smear (blood across the face)
- Treatment  diethylcarbamazine (diet & carb magazine) or albendazole (bend legs of
the chair)
Helminths – Cestodes and Trematodes

1. Cestodes (tapeworms)

Taenia solium and Taenia saginata

- Cow = intermediate host for T. saginata is cattle (sagging tent)

- Pig = intermediate host for T. solium are pigs (sun on pig’s tent with meat hooks) 
hooks on proglottid heads (segment of a tapeworm containing male and female
reproductive organs)
- Taeniasis  ingestion of encysted larvae (cysticerci) in undercooked meat  adult
tapeworms develop and reside in the small intestine  GI symptoms
- Cysticercosis  ingestion of T. solium eggs or gravid proglottids in food or water
contaminated with human feces (eggs on poop water)  larvae (oncospheres) hatch in
the intestine and invade the intestinal wall  larvae enter the bloodstream and
migrate to multiple tissues and organs where they mature into cysticerci  if the
parasite goes to the brain it can develop cystic CNS lesions leading to neurocysticercosis
and causing seizures and hydrocephalus (girl crushing into the cheese stand) which
looks like swiss cheese on head CT (cheese on girl’s head)
- Treatment  praziquantel (pretzels) + albendazole (bending a bar) for
neurocysticercosis
Diphyllobothrium latum (fish tapeworm)

- Transmission  ingestion of (plerocercoid) larvae in undercooked freshwater fish (guy

running to the bathroom after eating fish)
- Long piece of toilet paper stuck to shoe = longest tapeworm (can grow up to 10 meters
long)
- Must B12 sign = adult tapeworms competes for B12 in the small intestine causing
vitamin B12 (cobalt firework) deficiency leading to megaloblastic anemia (blasting
fireworks in the sky)
- Diagnosis  visualization of eggs on stool O&P (pieces of toilet paper on the mud)
- Treatment  praziquantel (pretzel) or niclosamide (1 nickel for the bathroom)
Echinococcus granulosus

- Dog show = dogs are the definitive hosts and sheep are the intermediate hosts of the
parasite
- Transmission  ingestion of eggs in food or water contaminated with dog feces (pile
of poop)  humans are incidental hosts  larvae are released in the small intestine
and migrate through the circulatory system into various organs where they develop into
a thick-walled hydatid cysts
- Ribbon on liver-shaped spot = hydatid cyst formation in the liver eggshell
calcifications (egg cup) visualized inside a cyst-like mass on liver CT  cyst rupture can
cause anaphylaxis (red and puffy price giver’s face) and acute abdomen  injection of
ethanol or hypertonic saline to kill the cells before surgical removal
- Pink granules = eosinophilia
- Treatment  albendazole
2. Trematodes (flukes)

Schistosoma spp.

- Transmission  free living cercariae penetrate the skin of humans in contact with
contaminated fresh water (swimmer)  in the bloodstream they travel to the liver
where they mature into adults  adults migrate against the portal blood flow (red
fishes swimming against the current) to other parts of the body (depending on the
species)  eggs are passed through feces and urine  snails (intermediate hosts)
swimming in water sources contaminated with human feces become infected (miracidia)
- Species:
 S. mansoni (merman with dorsal fin = egg with large lateral spine) and S. japonicum
(Japanese tourist with flag = egg with small spine)  primarily reside in mesenteric
veins  cause portal hypertension (crack on port hole) that can lead to GI
hemorrhage, cirrhosis (fibrotic coral) and liver failure (yellow clothes of Japanese
tourist)
 S. haematobium (Swordfish = egg with large terminal spine)  resides on the veins
of the bladder  hematuria (swordfish piercing a jellyfish) and squamous cell
carcinoma of the bladder (swordfish piercing a crab)
- Diagnosis  visualization of the eggs on stool O&P
- Treatment  praziquantel (pretzel)
Clonorchis sinensis

- Transmission  snails (intermediate hosts) release cercariae that infect freshwater fish
 humans eat undercooked infected fish containing encysted metacercariae 
metacercariae excyst in the duodenum and travel to the biliary system where they
mature into adults  inflammation leads to biliary tract fibrosis (seagull with fibrous
rope), pigmented gallstones (black rocks) and cholangiocarcinoma (crab)
- Diagnosis  visualization of operculated eggs (eggs with caps) on stool O&P
- Treatment  praziquantel (pretzel)
Paragonimus westermani

- Transmission via ingestion of raw or undercooked crab meat (crab legs on plate)
carrying encysted metacercariae  metacercariae excyst in the duodenum and travel
to the lungs where they mature into adults
- Snails are the intermediate hosts
- Penguins with white and red lung spots = chronic cough with bloody sputum
- Diagnosis  visualization of operculated eggs (eggs with caps) on stool O&P
- Treatment  praziquantel (pretzel)