ARTIFACTS AND CONFUSERS – common in stool and blood samples

-due to disease processes, medications, and/or dietary habits.

Artifact Confused for: Illustration

White Blood Cell Entamoeba histolytica cyst
- Average size of 15um ( Neutrophil)
- with 2-4 nuclear lobes Entamoeba histolytica trophozoite
( Macrophage and Monocyte)

Pollen Grains ( Thick Walled) Taenia spp.

- no notable interior structure Unfertilized egg of Ascaris lumbricoides
- spine like structure outside

Vegetable Cell
- large to roundish oval; Helminth eggs
unorganized interior portion
with large vacuole
Vegetable Spiral
- doesnt have head or tail region Helminth Larva
- Ladder like appearance

Yeast Cyst of Entamoeba hartmani

- oval to spherical that exhibits Cyst of Endolimax nana
budding and without internal Oocyst of Cryptosporidium
structure
Plant Hair
-doesn’t have diagnostic structures Helminth Larva

Epithelial Cell
- does not have internal structure Trophozoite of Amoeba
- smooth cytoplasm
- single nucleus with distinct cell wall
Starch Granules
- no internal structure; dark blue- Cyst of Entamoeba hartmani
black color when stained with iodine. Cyst of Endolimax nana

Stain Precipitate
- bluer in color and varies in size Plasmodium
and shape

OTHER ARTIFACTS ( CDC)

Fungal Spore (Stool) Eggs of Hookworms

Giardia lamblia
Chilomastix mesnili
Mite Eggs ( Stool) Hookworm eggs
Elongated and Degenerating Platelet ( Blood) Trypanosoma
Fungal spore of Helicosporium ( Blood) Microfilaria
Seed ( Intestinal Biopsy) Balantidium coli
 NEMATODES
Intestinal Nematode
Ascaris lumbricoides adult male and female Distinguishing Features
Important pictures Largest Intestinal
Nematode
With trilobite lips

Ascaris lumbricoides ova

Unfertilized Corticated ( Fertilized) Decorticated ( Fertilized)
Elliptical; w/o embryo Round; w/ embryo Round; w/ embryo
Amorphous mass of cytoplasm 3 layers: outer albuminous, middle 2 layers: w/o outer albuminous coat
transparent, inner lipoidal

Trichuris trichiura adult male and female Distinguishing Features

Important pictures Whiplike structure
Prominent/Thickened Posterior
Male equipped with prominent
coiled tail
 Trichuris trichiura ova Distinguishing Features
Diagram Microscopic Barrel of Football shape
w/ Embryo
w/ prominent bipolar plugs

Enterobius vermicularis adult male and female Distinguishing Features

Important pictures Cervical Alae
Prominent Double
Esophageal Bulb

Enterobius vermicularis ova Distinguishing Features

Diagram Microscopic Lopsided or D-shape
With larva inside the ova
( Embryonated)
Outer thicked walled shell
 Ancyclostoma duodenale Necator americanus
4 ventral teeth Semilunar cutting plate

Shape C S
Copulatory
Bursa

Ancylostoma braziliensi – 1 pair of teeth Ancylostoma caninum – 3 pairs of teeth

HOOKWORMS
Rhabditiform Larva Filariform Larva

Hookworms ova Distinguishing Features

Diagram Microscopic Clear thin shell
w/ blastomeres that resemble
morula balls ( 4-8)
 Soil Transmitted Helminthes – Embryonated Ova in the SOIL ( presence of larva inside the ova)
Ascaris lumbricoides Trichuris trichiura Hookworms

Strongyloides stercoralis adult Presence of copulatory spicule in male

Strongyloides stercoralis
Rhabditiform Larva Filariform Larva

Strongyloides stercoralis ova Distinguishing Features

Diagram Microscopic Rarely seen in stool with will
developed larva inside but also
resembles hookworm at early
stage
 Hookworms Strongyloides stercoralis
Rhabditiform
Larva

Filariform
Larva

Trichinella spiralis adult Distinguishing Features

Diagram Microscopic Presence of claspers

Trichinella spiralis encysted larva Distinguishing Features

Diagram Microscopic Coiled larva encysted in the
nurse cell of striated muscle
Dracunculus medinensis L1 and
Adult
Release after H20 exposure
Capillaria philippinensis
Ova
Peanut shape; Flattened bipolar
plugs with embryo or larva
inside
Angiostrongylus cantonensis
adult
Barber’s pole apperance

Microfilaria

Sheathed
Wuchereria bancrofti Brugia malayi Loa loa

Non- Sheathed
Onchocerca volvulus ( skin snips) Mansonella ozzardi Mansonella perstans

OVA SIZES ( Length)

um

90

75

60

45

30

15
0 Pudoc worm Whipworm Pinworm Eelworm Hookworms Eelworm
( 35-45um) ( 50-55um) ( 48-60um) Fertilized (50-75um) Unfertilized
(40-75um) ( 85-95um)
ADULT SIZE ( Length)

Eelworm Whipworm Hookworm Pinworm Pudoc Worm Trichina Threadworm

( ↑) Worm (↓)
 Blood Flukes
Diagnostic Stage - Embryonated ova
S. japonicum S. mansoni S. haematobium
Stool Stool Urine
50-85um by 38-60um 112-182um by 40-75um 110-170um by 38-70um
Somewhat roundish Oblong Somewhat oblong
Developed miracidium Developed miracidium Developed miracidium
Small lateral knob Large Terminal spine Large Lateral Spine

Blood Flukes
Adult
S. japonicum S. mansoni S. haematobium
Superior Mesenteric Vein Inferior Mesenteric Vein Vesical Vein
Smooth Tegument Grossly Tuberculated Tegument Finely tuberculated tegument
Lays 50-100 eggs Lays 1-4 eggs 20-30 Eggs
 Cercaria – Infective stage to man Miracidium – Infective stage to snail

LEAF FLUKES
A. OVA
Parasite/s Illustration Distuinguishing Features
Clonorchis sinensis and With Developed Miracidium
Opistorchis felineus With operculum and small
( 30 by 15um) abopercular knob
STOOL - SPECIMEN With thick shoulders
C. sinensis – broadly ovoid
O. felineus – elongately ovoid

Fasciola hepatica, With Undeveloped miracidium

Fasciolopsis buski and Distinct operculum
Echnistoma ilocanum Oblong
STOOL - SPECIMEN F. hepatica –128-150 by 60-90um
F. buski – 128-140 by 78-85um
E. ilocanum - 80-135um by 55-
80um)

Heterophyes Developing miracidium

heterophyes and With operculum, shoulder
Metagonimus yokogawai With or without small
( 30-15um)
STOOL - SPECIMEN
knob
H. heterophyes – thick shell
M. yokogawai – thin shell

Paragonimus Undeveloped miracidium

Westermani Somewhat oval with thin
(78-120 by 45- smooth shell
60um) Prominent operculum
STOOL AND With Shoulders
SPUTUM Prominent Terminal
- SPECIMENT abopercular knob
 LEAF FLUKES
B. ADULT
Parasite/s Illustration Distuinguishing Features
Clonorchis sinensis and C. O. felineus
Opistorchis felineus sinensis
Shape Narrow Lancet
anterior
and
posterior
Size 10-20x 7-12x
3-4mm 2-3mm
Vitellaria Granular Transverse
Testes Branched Lobed

Fasciola hepatica,
Fasciolopsis buski and
Echnistoma ilocanum

F. hepatica F. buski
Habitat Liver Intestine
Size 3 by 1 cm 5 by 1.5 cm
Cephalic cone Present Absent
Intestine, testes and ovary Branched Not branched
 Echinostoma ilocanum – presence of crown spike circum oral disk

Parasite/s Illustration Distuinguishing Features

Heterophyes heterophyes H. M.
and Metagonimus Heterophyes yokogawai
yokogawai Shape Pyriform Pyriform with
tapered
anterior and
round
posterior
Size 1 by 0.5mm 1.5 by 0.5mm
Spine Fine Scaly
( Anterior)
Gonotyl Present Absent

Paragonimus westermani Habitat – LUNGS

1 by 0.7cm
Coffee Bean Shape
Outer spikes
Paralobate Testes

Metacercaria Cercaria Miracidium

Infective stage to man Infective stage to 2nd IH Infective stage to 1st IH
SAME WITH BLOOD FLUKES

NOT FORKED TAIL

 CESTODES
SCOLEX – attachment in the intestinal mucosa
Parasite ILLUSTRATION/ Picture
Diphyllobothrium
latum
With 2 false cuplike
suckers or sucking
grooves ( bothria);
Almond shape or
spatulate

Taenia spp. T. solium T. saginata

Rostellum with hooks Without rostellum nor hooks
( Double Crown)

Hymenolepis diminuta
With four suckers;
small (rudimentary)
apical rostellum
without hooks
 Hymenolepis nana
With four suckers;
small rostellum with
one row of hooks

Dipylidium caninum
With four suckers;
club shaped armed
rostellum with up to
seven circlets

Proglottid – segments and part where reproductive organs are found

Parasite ILLUSTRATION/ Picture
Diphyllobothrium
latum
Wider than they
are long;
Rosette gravid
proglottid (
central uterine);
Bilobed ovary

Taenia spp. T. solium T. saginata

W/ accessory ovarian lobe With vaginal sphincter
Hymenolepis diminuta
and Hymenolepis nana
Rectangular; Saclike
uterus filled with
eggs; Often difficult
to see

Dipylidium caninum
Pumpkin Seed
mature and gravid
proglottid; Two sets
of reproductive
organs; With two
genital pores; full
eggs enclosed in
embryonic membrane

OVA – diagnostic stage for cestodes

( Except: Echnicoccus granulosus: Hydatid Cyst)
Parasite ILLUSTRATION/ Picture
“ Fried Egg Appearance”
 Echinococcus granulosus also known as Dog Tapeworm or Hydatid Tapeworm
Definitive Host: Dogs; Intermediate Host: Sheep and Man
Adult scolex, small neck, and three proglottids, one at each developmental stage—
immature, mature, and gravid. The scolex contains four suckers and has
approximately 36 hooks. This form is not typically seen in humans but is commonly
found in canines, which serve as definitive hosts. With twisted or coiled uterus

Hydatid Cyst

Ova Indistinguishable to Taenia eggs; cannot be recovered in human

PROTOZOA
Intestinal Amoeba
Entamoeba histolytica trophozoite Distinguishing Features
DIAGRAM MICROSCOPIC Uninucleated
Clear Cytoplasm ( Fine Granules)
Bull’s Eye karyosome
Finger Like Pseudopodia
Rapid unidirectional progressive motility
With Ingested RBC

Entamoeba dispar: without ingested RBC ( DNA probes and electrophoresis)

Entamoeba hartmani: non-progressive without ingested RBC ( just smaller with E. histolytica)
Entamoeba histolytica cyst Distinguishing Features
DIAGRAM MICROSCOPIC Quadrinucleated ( up to 4)
Clear Cytoplasm ( Fine Granules)
Bull’s Eye karyosome
Cigar shape Chromatoidal
Body
 Entamoeba coli trophozoite Distinguishing Features
DIAGRAM MICROSCOPIC Uninucleated
Trashy Cytoplasm ( Coarse Granules)
Large Eccentric Karyosome
Blunt Like Pseudopodia
Sluggish Non-progressive motility

Entamoeba coli cyst Distinguishing Features

DIAGRAM MICROSCOPIC 1-8 nuclei
Clear Cytoplasm ( Fine Granules)
Large Eccentric Karyosome

Splintered/ Broomstick
Chromatoidal Body

Entamoeba polecki ( non-pathogenic)

Trophozoite Cyst

NOTE TO DIFFERENTIATE: Uninucleated cyst and inclusion mass

Endolimax nana trophozoite Distinguishing Features

DIAGRAM MICROSCOPIC Uninucleated
Large Irregular blotlike
karyosome
SMALL SIZE
 Endolimax nana cyst Distinguishing Features
DIAGRAM MICROSCOPIC Up to 4
Absence of chromatoidal body
Large Irregular blotlike
karyosome

Iodameoba butschlii trophozoite Distinguishing Features

DIAGRAM MICROSCOPIC Uninucleated
Central karyosome with achromatic
granules

Iodamoeba butschlii cyst Distinguishing Features

DIAGRAM MICROSCOPIC Uninucleated
Central karyosome with
achromatic granules
Prominent Glycogen mass

Extraintestinal Amoeba

Entamoeba gingivalis trophozoite Distinguishing Features

DIAGRAM MICROSCOPIC Uninucleated
With ingested WBC, bacteria and
epithelial cell
Source – Buccal Cavity/ Sputum or
Vaginal crevices

Without CYSTIC STAGE

 Free Living Amoeba

Naegleria fowleri – sample is CSF

Amoebic Trophozoite Amoebic Cyst Flagellate
Elongated with broad Uninucleated with thick cell Pear shape flagellate with two
wall whiplike structure; Jerky or
anterior and tapered spinning movement
posterior
- ONLY IN HUMAN

Acanthamoeba – sample is CSF or Corneal Scrapings

Amoebic Trophozoite Amoebic cyst
Spinelike pseudopods known as Double cell wall with outer ragged edges
Large central karyosome
acanthapodia
Large Eccentric karyosome
- ONLY IN HUMAN
 Isolation of Free Living Amoeba
1. Isolation on media with Escherichia coli – (+) feeding amoeba on bacteria
2. Calcofluor white – apple green color
3. Indirect Immunofluorescent Antibody Staining – to speciate Acanthamoeba species
Ciliates

Balantidium coli trophozoite Distinguishing Features

DIAGRAM MICROSCOPIC Largest Intestinal Protozoa
Rotary Boring or Directional Tumbling
Motility ( With cilia)
Kidney bean Macronucleus with dot
shaped micro nucleus
Cytostome – cell mouth
Cytopyge – cell anus

Balantidium coli cyst Distinguishing Features

DIAGRAM MICROSCOPIC Kidney bean Macronucleus with dot
shaped micro nucleus
Double Protective Cyst wall

Atrial Flagellates

Giardia intestinalis trophozoite Distinguishing Features

DIAGRAM MICROSCOPIC Presence of sucking disk, two
axonemes and two median bodies
Pear-shaped or teardrop which is
bilaterally symmetrical
Fallen Leaf like motility
4 pairs of Flagella ( 8 ☺ )
One pair anterior
One pair posterior
Two pairs central extending lateral

Giardia lamblia are still being used nowadays

 Giardia intestinalis cyst Distinguishing Features
DIAGRAM MICROSCOPIC Ovoid in Shape
Two – immature cyst Four – mature
Cytoplasm retracted in cell wal
Median bodies ( 2-4)

Chilomastix mesnili trophozoite Distinguishing Features

DIAGRAM MICROSCOPIC Pear shape
Stiff rotary movement
4 flagella:
3 anterior extending
1 extending to posterior
Prominent cytostome with fibrils
Spiral Groove
Curved posterior

Chilomastix mesnili cyst Distinguishing Features

DIAGRAM MICROSCOPIC Ovoid in Shape
Lemon shape with clear hyaline knob on
its anterior end
Well defined cytostome at side of
nucleus

Dientamoeba fragilis trophozoite Distinguishing Features

No cystic stage ( Amoeboflagellate)
DIAGRAM MICROSCOPIC Irregularly Round
Broad Hyaline Leaflike Pseudopodia
Fragmented karyosome ( 4 to 8)
Binucleate condition
 Trichomonas – no cystic stage
Trichomonas tenax Trichomonas hominis Trichimonas vaginalis
Non-Pathogenic ( Buccal Cavity) Non-pathogenic Pathogenic
( Large Intestine) ( Vagina or Urethra)

Pear shape; Five anterior flagella and one posterior flagellum

Nervous jerky ( non-pathogenic); Rapid jerky ( pathogenic)
One ovoid Nucleus filled with Spherical nucleus with central Ovoid nucleus filled with chromatin
chromatin granules karyosome granules
Undulating membrane extending Full body undulating Undulating membrane ½ of the
2/3 membrane body
Thick axostyle curved around Axostyle extends beyond the Prominent axostyle
nucleus posterior Absence of cytostome but granules
Small cytostome Conical cytostome cleft along axostyle is present

Trichomonas can be differentiated from sample used

Enteromonas hominis Distinguishing Features

Trophozoite Cyst Trophozoite:
Body flattened on one side
Four flagella
3 anterior ; 1 posterior

Cyst:
Quadrinucleated with two at
each opposite side
 Retortamonas intestinalis Distinguishing Features
Trophozoite Cyst Trophozoite:
Two Anterior flagella
Cytostome extending halfway with
well defined fibril border
Cyst:
Lemon shaped
Two fused fibrils resembling bird’s
beak near nucleus

Hemoflagellates
Leishmania Forms
Amastigote ( Human) Promastigote

Round to oval Long and Slender

Kinetoplast is present with dot like One near center
blepharoblast Kinetoplast present
Parabasal body adjacent to blepharoblast Free single flagella
No visible flagella
Trypanosoma gambiensi and rhodisiensi forms

Epimastigote Trypomastigote ( Human)

Long and Wider than promastigote Long and Slender ( C, S or U shape)

Undulating membrane half of body length Undulating membrane whole body length
Free flagellum Free flagellum

Forms found in human sample

Amastigote Trypomastigote
 Sporozoa

Plasmodium vivax

Ring surrounds the vacuole Irregular ameboid appearance

Accole form possible Ring remnants
 Plasmodium ovale – with distorted ragged cell walls

Same with vivax just larger Not ameboid as vivax ( Compact)

Rosette arrangement of merozoite

 Smaller than vivax

Plasmodium malariae

1/6 of RBC size; Heavy chromatin dot Band or band shape cytoplasm
6-12 merozoites that may resemble fruit pie with possible brown green pigment

Trophozoite Schizont Gametocyte

 Plasmodium falciparum

Circle configuration; Headphone appearance Heavy rings

Multiple rings Fine pigment

Cluster arrangement merozoites

Sausage or Crescent Shape

 Babesia microti
Trophozoite – ring form without granules Merozoite – four trophozite attached with maltese
Blue cytoplasmic circle with red chromatin dot cross appearance

Miscellanous protozoa

Parasite Diagram Picture

Isospora belli
Oocyst
Transparent and
Oval
 Sarcocystis
Oocyst
Sausage shape
sporocyst

Cryptosporidium
parvum
Oocyst
Thick cell wall
1-6 dark granules

Blastocystis hominis
Centrally located
large vacuole
2 to 4 nuclei at the
periphery
Vacuolated
form
Microsporidia
SPORE
Polar filaments
“ Extruding”

Toxoplasma gondii
Tachyzoite –
crescent shape
Bradyzoite –
Enclose to form cyst

Pneumocystis
jirovecii
Trophozoite
Four to eight
unorganized nuclei in
rosette

GOODLUCK