Blood and Tissue Flagellates • four stages of development:

Introduction 1. Amastigote
2. Promastigote
• Locally acquired infections due to the
3. Epimastigote
blood and tissue flagellates have not yet
4. Trypomastigote.
been documented in the Philippines.
• In humans, trypomastigotes are found
• Imported cases from endemic countries
in the bloodstream, and amastigotes in
may become future sources of local
tissue cell
infection
Amastigotes
• The vectors of T.cruzi: Triatoma and
Rhodnius bugs, are found in the • round or ovoid in shape and
country. measure from 1.5 to 4 µm in
diameter.
• The Philippines has a number of
Phlebotomus spp., which can serve as • usually found in small groups of
vectors for Leishmania spp. cyst-like collections in tissues.

TRYPANOSOMA CRUZI

• the etiologic agent of Chagas disease or

American trypanosomiasis.

• the only parasite that was discovered

and studied before it was known to
cause a disease.

Parasite Biology

• belongs to the trypanosome group

Stercoraria.

• Unlike other trypanosomes, it is an

intracellular parasite,

• arthropod vector: reduviid bugs

Figure 1. Four Stages of T. Cruzi Development
• thrive under squalid housing conditions
such as thatched roofs and mud walls

• Zoonotic mammalian reservoir hosts:

armadillos, raccoons, rodents,
marsupials, and even some primates
 Trypomastigote
• has
– usually pointed posterior end
– narrow undulating membrane
with 2 to 3 undulations, and
– a single thread-like flagellum
originating near the kinetoplast.
• C-shaped in stained specimen
• U- or S-shaped with a prominent
kinetoplast, characteristic of the
species.
Figure 2. Trypomastigote stage
Life Cycle of Trypanosoma cruzi
1. An infected triatomine insect vector (or
“kissing” bug) takes a blood meal and
releases trypomastigotes in its feces
near the site of the bite wound.
Trypomastigotes enter the host through
the bite wound or intact mucosal
membranes, such as the conjunctiva
2. Inside the host, the trypomastigotes
invade cells near the site of inoculation,
where they differentiate into
intracellular amastigotes
3. The amastigotes multiply by binary
fission
4. And differentiate into trypomastigotes,
and then are released into the
circulation as bloodstream
trypomastigotes
5. The “kissing” bug becomes infected by
feeding on human or animal blood that
contains circulating parasites
6. The ingested trypomastigotes transform
into epimastigotes in the vector’s
midgut
7. The parasites multiply and differentiate
in the midgut
8. And differentiate into infective
metacyclic trypomastigotes in the
hindgut
Mode of Transmission:
• Vector transmission (infected feces of
blood-sucking triatomine bugs)
Less common routes of transmission include:
• blood transfusions,
• organ transplantation,
• transplacental transmission, and
• foodborne transmission (via food/drink
contaminated with the vector and/or its
feces).
Pathogenesis and clinical Manifestation:
Acute Phase
• characterized by a focal or diffuse
inflammation mainly affecting the
myocardium.
• Nonspecific signs and symptoms:
• fever, malaise, nausea,
vomiting, and generalized
lymphadenopathy and
sometimes cutaneous
manifestations
(FEMALNAUVOGELYMSOCU)
• Chagomas -furuncle-like lesions
associated with induration,
central edema, and regional
lymphadenopathy.
(ICE EDRELY)
• represent the site of entry of
the parasite
• Romaña’s sign
• characterized by unilateral
painless bipalpebral edema and
conjunctivitis, and may involve
the lacrimal gland and
surrounding lymph nodes.
Latent Phase
• after 1 or 2 months, symptoms resolve
• patients infected are still capable of
transmitting it to others through insect
vectors, blood transfusion, or organ
transplantation.
Chronic Phase
• initially thought to be autoimmune in
nature
• newer evidence shows it is
multifactorial, and dependent on the
interaction between parasite and host.
• The heart is the primary organ affected
• About one-third of patients in the latent
stage develop some manifestation of
chronic Chagas disease after several
years or decades.
• The majority of symptomatic, chronic
patients manifest with the cardiac form,
while the rest develop the
gastrointestinal form
Diagnosis
• complete patient history
• the primary tool for diagnosing
Chagas disease.
• Establish possible exposure to T. cruzi
• Evaluate risk factors:
• place of residence or work,
• recent blood transfusion in an
endemic area, and
• contact or exposure to T. cruzi
intermediate host .
• definitive diagnosis of Chagas disease Epidemiology
during its acute phase
• Chagas disease is estimated to have
• relies on direct visualization of infected more than 10 million people
the parasites in thick and thin worldwide
blood smears using Giemsa
• Most cases are reported in the Latin
stain.
Americas
• only in the first two months of
• included in the WHO list of Neglected
acute disease can T. cruzi
Tropical Diseases (NTDs)
trypomastigotes be seen by
direct examination. • the leading cause of parasite-related
deaths in Latin America.
• During the chronic phase:
• ranked 3rd as the leading cause of
• enzyme linked immunosorbent
parasitic infection in the world, behind
assay (ELISA)
malaria and schistosomiasis in 2003
• indirect hemaglutination
Prevention and Control
• indirect immunofluorescence
• Vector control and blood transfusion
and
regulations have delivered positive
• PCR. outcomes

• The WHO recommends using at least • Spraying of insecticides, use of

two techniques with concurrent insecticide-treated bed nets, and house
positive results before a diagnosis of improvements to prevent vector
Chagas disease is made infestation

Treatment

• Recommended for the treatment of

acute phase Chagas disease:

• Nifurtimox and Benznidazole.

• usually associated with severe

side effects:

• Nifurtimox -may cause weight

loss, anorexia, behavioral
changes, and an antabuse
effect;

• Benznidazole- may cause

rashes, bone marrow
suppression, and peripheral
neuropathy
 Trypanosoma brucei gambiense
Trypanosoma brucei rhodesiense
• Human African trypanosomiasis (HAT)
– aka African sleeping sickness
– highly fatal disease caused by 2
subspecies
• T. brucei brucei
– primarily affects wild and
domestic animals;
• Trypanosoma brucei complex-
– the 3 subspecies collectively
Parasite Biology
• belong to the trypanosome family
Salivaria.
• usually transmitted via the bite of the
bloodsucking tsetse fly (Glossina spp.)
feeding from an infected mammalian
host
T. brucei gambiense
• localized mostly in the western and
central regions of sub-Saharan Africa.
• primarily affects humans, but utilizes
dogs, pigs, and sheep as reservoir hosts.
• responsible for the chronic type of
sleeping sickness
• accounts for 95% of all HAT cases
T. brucei rhodesiense
• found in east Africa
• primarily a zoonosis of cattle and wild
animals, with humans being accidental
hosts.
• causes the more acute and rapidly fatal
form of sleeping sickness, and
• accounts for the remaining 5% of HAT
cases.
Life Cycle of Trypanosoma brucei
1. When an infected tsetse fly bites
a person (or animal), it injects a
form of the protozoa that can cause
infection (called trypomastigotes)
into the skin. The protozoa move to
the lymphatic system and
bloodstream.
2. Inside the person, they change
forms and travel to organs and
tissues throughout the body,
including lymph and spinal fluid.
3. The protozoa multiply in the
bloodstream and other body fluids.
4. They circulate in the
bloodstream.
5. A fly ingests the protozoa when it
bites an infected person.
6. Inside the fly, the protozoa
change forms and multiply.
7–8. The protozoa travel to the fly's
salivary glands, multiply, and
change into trypomastigotes—the
form that is injected when the fly
bites a person.
 Pathogenesis and Clinical • the posterior cervical lymph nodes are
Manifestation: enlarged, non-tender, and rubbery in
consistency
Human African Trypanosomiasis
Late Phase
• 2 types:
• aka meningoencephalitic stage
– acute and
• marks the involvement of the central
– chronic,
nervous system.
– depending on the subspecies
• brain and meninges become involved as
causing the disease.
the parasites find their way into the
• Trypanosoma brucei gambiense CNS through the bloodstream.
sleeping sickness
• usually occurs 3 to 10 months after
– manifests months or years after initial infection in Gambian infections
initial infection,
• can manifest after just a few weeks in
• T. brucei rhodesiense sleeping sickness Rhodesian trypanosomiasis.

– may appear just weeks after • Kerandel’s sign

infection.
• trypanosomal chancre
– initial lesion, begins as a local,
painful, pruritic, erythematous
chancre located at the bite site,
progressing into a central
• the ability of the trypomastigote to
eschar, and resolving after 2 to
3 weeks
– more common in Gambian
sleeping sickness.
Early phase
• Aka Hemolymphatic stage
• deep, delayed hyperesthesia
(delayed bilateral pain out of
proportion to the extent of
tissue injury
Antigenic Variation
continuously change its surface coat,
composed of variant surface
glycoproteins, so that the host’s
antibodies cannot recognize the
parasite in subsequent recurrent waves
of parasitemia.

• the parasites proliferate in the

bloodstream and lymphatics.

• patient may manifest with irregular

bouts of fever, headache, joint and
muscle pain, and malaise

• Winterbottom’s sign

• Seen in Gambian trypanosomiasis

Trypanosomes are able to evade the immune
response of the host through this process
 Diagnosis
• demonstration of highly motile
trypomastigotes in expressed fluid from
a chancre, lymph node aspirate, and
CSF.
• Thick and thin blood films can be
stained with Giemsa.
• Buffy coat concentration method
– recommended to detect
parasites when they occur in
low numbers.
• usually done during the hemolymphatic
stage of the disease
• CSF examination
– mandatory in patients with
suspected HAT to detect CNS
involvement.
• Abnormal CSF findings:
– increase in
• cell count,
• opening pressure,
• protein concentration,
and
• IgM levels.
– pathognomonic for the
meningoencaphalitic stage of
the disease
• Card agglutination test for
trypanosomiasis (CATT)
– detects circulating antigens in
persons infected with T. brucei
complex
– available commercially and can
be used in the field setting to
screen at-risk populations.
– provides a rapid and highly
specific method of screening for
HAT cases
– method has low sensitivity for
certain strains of T. brucei
gambiense in certain areas of
West Africa.
Treatment
• depends on the stage of the disease.
• For the first stage,
– Suramin sodium IV- for both T.
brucei gambiense and T. brucei
rhodesiense
– Pentamidine IM- for the
Gambian form .
– drugs side effects:
– Suramin: fever, rash, renal
insufficiency, muscle pain, and
paresthesia
– Pentamidine: tachycardia,
hypotension, and hypoglycemia
• they do not cross the blood-brain
barrier, and so, they cannot be used for
the CNS stage of the disease
• Melarsoprol IV
– the drug of choice for both
types of sleeping sickness once
CNS involvement occurs.
– arsenic-containing drug can
cause fatal arsenic
encephalopathy
– usually prevented by co-
administration of
– corticosteroids resistance to
the drug has also been
observed.
• Jarisch-Herxheimer reaction
– febrile episode due to
trypanosome lysis may occur
following melarsoprol
treatment
• Nitrofurazone- used in cases of
melarsoprol treatment failure.
• Eflornithine
• newer drug less toxic
than melarsoprol,
• can also be used during
the hemolymphatic
stage
• only effective against T.
brucei gambiense
Epidemiology
• Sleeping sickness affects around
300,000 to 500,000 people in 36
countries within subSaharan Africa.
• estimated that more than 50 million
people are at risk of infection
Prevention and Control
• Vector control -the primary method
used in the control and prevention .
• Tsetse fly trapping -the main strategy
employed to decrease the vector
population.
• Use of insecticides and protective
clothing are recommended to prevent
contact with the insect vector.
Old World
• Regulation and treatment of reservoir
hosts such as cattle and game animals
are also being looked upon as an
effective means of preventing disease
transmission.
Leishmania spp
• Early descriptions of leishmaniasis have
been found as early as the first century
A.D.,
– American Indians documented
the disease in pottery figures.
• Cunningham studied the “Delhi boil” in
India in 1885
• Leishman -properly identified the
intracellular parasites in 1903.
• Leishmania braziliensis was later
identified in 1911 by Gaspar Viana, as
was the insect vector which transmitted
the parasite in 1922 by Henrique
Aragao
Parasite Biology
• Leishmaniasis
– disease caused by infection of
the diploid protozoa belonging
to the genus Leishmania.
• genus is divided into two subgenera
• differentiated from one another by
– the location of their
development inside the insect
vector
– the areas in which they are
endemic.
Leishmania spp: epidemiologic
classification:
• common species :
• L. tropica (Asia and
Eastern Europe),
• L. aethiopica (Africa)
and
 • L. major.
New World
• affect Mexico, Central
America, and some
parts of South America,
as well as the Amazon
rain forest
• usually caused by
• L. mexicana,
• L. amazonensis,
• L. guyanensis,
• L. braziliensis, and
• L. chagasi
• Leishmania spp
• Arthropods:
• Sandflies of the genera
Phlebotomus (Old World) and
Lutzomyia (New World),
2. Promastigotes that reach the puncture
wound are phagocytized by
macrophages
3. and other types of mononuclear
phagocytic cells. Promastigotes
transform in these cells into the tissue
stage of the parasite (i.e., amastigotes)
4. which multiply by simple division and
proceed to infect other mononuclear
phagocytic cells
5,6. Parasite, host, and other factors affect
whether the infection becomes
symptomatic and whether cutaneous or
visceral leishmaniasis results. Sand flies
become infected by ingesting infected cells
during blood meals
7. In sand flies, amastigotes transform into
promastigotes, develop in the gut
8. (in the hindgut for leishmanial organisms
in the Viannia subgenus; in the midgut for
organisms in the Leishmania subgenus), and
migrate to the proboscis

• act as the insect vector

for these parasites.

• Dogs

• the primary reservoir in urban

areas

• Rodents

• act as reservoirs in both urban

and rural areas.

Mode of Transmission: Vector transmission

(bite of infected female phlebotomine sand
flies)

Life Cycle of Leishmania

1. The sand flies inject the infective stage

(i.e., promastigotes) from their
proboscis during blood meals
 Pathogenesis and Clinical Diffuse Cutaneous Leishmaniasis
Manifestation
• aka Anergic or lepromatous
• Clinically, leishmaniasis 4 categories: leishmaniasis

– cutaneous leishmaniasis (CL), • characterized by a localized, non-

ulcerating papule, eventually
– diffuse cutaneous
developing numerous diffuse satellite
leishmaniasis (DCL),
lesions that affect the face and
mucocutaneous leishmaniasis
extremities.
(MCL), and
• this type may be initially diagnosed as
– visceral leishmaniasis (VL).
lepromatous leprosy.
• wide spectrum of symptoms manifested
Mucocutaneous Leishmaniasis
by leishmaniasis is often compared to
leprosy, where the localized CL is similar • develops in about 2 to 5% of persons
to tuberculoid leprosy, and DCL is infected
similar to lepromatous leprosy.
with L. braziliensis, either concurrently or
Cutaneous Leishmaniasis even

• the most common form of the disease several years after the resolution of skin
lesions.
• caused by several species
• Espundia-
– L. tropica (dry or urban oriental
sore), – disfiguration involvement of the

– L. major (moist or rural oriental mucous membranes of the nasal and

sore), and
oral cavities results in nasal stuffiness,
– L. mexicana (chiclero ulcer,
discharge, epistaxis, and destruction
usually affecting the ears).
of the nasal septum.
• incubation period ranges from two
weeks to several months.

• Oriental button Visceral Leishmaniasis( Kala Azar)

– an erythematous papule or • a disseminated parasitosis primarily
nodule caused by L. donovani complex L.
infantum.
– produced at the inoculation
site. • incubation period: o2 to 8 months

• clinical symptoms in previously infected

but asymptomatic persons may appear
during immunocompromised states.

Acute phase:
 • twice-daily fever spikes (double
quotidian) with accompanying
chills may be present, which
might be mistaken for malaria.
Subacute and chronic course
• common signs and symptoms:
fever, weakness, loss of appetite, weight
loss, hemorrhage, and abdominal
enlargement associated with
hepatosplenomegaly
Diagnosis
• based on the microscopic
demonstration of Leishmania from
lesion and tissue scrapings,
aspirates, or biopsy.
• Giemsa and hematoxylin-eosin
stains
– often used in microscopic
and histologic samples
– demonstration of
amastigotes-
• confirms the
diagnosis of
leishmaniasis.
• Cultures -unreliable due to the
difficulty of isolating the parasites,
especially in old lesions
• The leishmanin skin test
(Montenegro skin test)
– can be used to identify
exposure to the parasite.
– usually positive in cases of
CL and MCL, but is negative
in cases of DCL and kala
azar
Treatment
• Primary pharmacologic treatment
– Sodium stibogluconate
and
– n-methyl-glucamine
(meglumine).
• antimony
compounds, (
pentavalent
antimonials)
– still being used in areas
where susceptibility is still
good, due to its low cost
• primary treatment failure and
relapses are often observed
especially in patients with AIDS
• Intravenous amphotericin B
– the drug of choice for
treatment failure with
antimonials, or in areas
with high resistance
Epidemiology
• Leishmaniasis is a global disease
distributed across 88 countries in
four continents.
• affects more than 12 million
people worldwide, and more than
350 million are at risk for the
disease
• Visceral leishmaniasis -an
important opportunistic infection
in AIDS patients
 Prevention and Control

• Usage of insect repellants

containing DEET and permethrin,

• insecticide-treated clothing

• fine-mesh bed nets/screens

• spraying of houses and buildings

• no commercially available form of

either active or passive
chemoprophylaxis