CHAPTER 2: Protozoan Infection

HEMOFLAGELLATES
CASTRO, DALAYGON, GABITOYA, MERCADO A, NGOHO, RELATIVO, VICENTE
HEMOFLAGELLATES

- Blood and tissue parasites that propels by means

of flagella
- Belong to the genera Leishmania and
Trypanosoma
 4 Morphological Forms

Amastigote
no flagellum; found in
tissue cells, muscle, and
CNS within macrophages

Promastigote
seen only in freshly
collected blood sample
after transmission
 4 Morphological Forms

Epimastigote
found primarily in the
arthropod vector

Trypomastigote
visible in the peripheral
blood
 01
Trypanosoma
cruzi
Trypanosoma cruzi
● Trypanosome group: Stercoraria
● Only parasite discovered and studied before known to
cause disease
● Causative agent of Chagas disease
● found in southern portions of the United States, Mexico,
and Central and South America.

FORMS
● Contains the 4 morphological forms
○ Humans: trypomastigotes are found in the
peripheral blood, and amastigotes in tissue cells,
muscle, and CNS within macrophages
○ Inside the insect : amastigote, promastigote, and
epimastigote (midgut); trypomastigote (hindgut)
 LIFE CYCLE
Mode of Transmission: Bite of reduviid
bug (kissing bug), blood transfusions,
sexual intercourse, transplacental
transmission, and entry through mucous
membrane

Intermediate Host: Triatomine bug

Reservoir Host: domestic animals,

armadillos, raccoons, rodents,
marsupials, and some primates.

Infective Stage: Metacyclic trypomastigote

Diagnostic Stage: Amastigote and Trypomastigote
 CLINICAL MANIFESTATION

Chagas Disease (American trypanosomiasis)

● Discoverer : Carlos Chagas
● Common Initial Symptom: development of erythematous
nodule (chagoma) lasting for 2-3 months where edema
and rash around the eyes and face may occur

● Romaña’s sign
○ When T. cruzi penetrates through ocular
mucosa, it may develop conjunctivitis
and eyelid swelling
 CLINICAL MANIFESTATION
● 3 Phases:
○ Asymptomatic
○ Chronic- myocarditis, hepatosplenomegaly,
and enlargement of the colon and esophagus
○ Acute: fever, chills, fatigue, myalgia, and
malaise
■ May result in:
● Recovery
● Transition to the chronic stage of
disease
● Death (usually happens a few
weeks after the attack of acute
infection)
● Common in children < 5y.o (experiences most
severe form)
 DIAGNOSIS
Complete patient history
primary tool for Chagas disease diagnosis.

Giemsa-stained blood slides

specimen of choice for T.cruzi detection

Serologic Tests:
Complement fixation (CF), DAT, and indirect immunofluorescence (IIF)

Polymerase chain reaction (PCR) and ELISA

testing methods
 TREATMENT
Acute phase Chronic phase

Nifurtimox and Benznidazole Symptom-specific

Severe side effects: management
(a) nifurtimox: weight loss,
anorexia, behavioral changes,
and an antabuse effect;
(b) benznidazole: rashes, bone
marrow suppression, and
peripheral neuropathy.

Other medications: Allopurinol and

itraconazole
 02
Trypanosoma
brucei
gambiense
Trypanosoma brucei
gambiense

● Is regarded as a human parasite that can infect

domestic cats through the bite of a tsetse fly.
● T. b. gambiense
Trypanosoma brucei
gambiense
FORMS

● stumpy non-dividing infectious (metacyclic) forms

or long,
● slender dividing forms (with a long free flagellum)
(with no free flagellum).
● The epimastigotes, which have an anterior
kinetoplast and a short,
● undulating membrane,
● vary in size as well, measuring between 10 and 35
millimeters long by 1 to 3 millimeters wide.
 LIFE
CYCLE
CLINICAL MANIFESTATION
● Sleeping sickness frequently manifests as a fever,
excruciating headaches, irritability, extreme
exhaustion, swollen lymph nodes, and aching
muscles and joints.

● Some individuals get a skin rash. Once an infection

has spread to the central nervous system, it can
cause progressive confusion, personality changes,
and other neurological issues.
 DIAGNOSIS
microscopic examination
of lymph node aspirate,
blood, or CSF
offers concrete proof of trypanosome
infection and enables a firm
diagnosis.
TREATMENT
● Pentamidine is the
treatment of choice for
stage T. b. Gambiense
disease
● NECT stands for
nifurtimox-eflornithine
combination therapy
(Seen to be more effective
and less toxic)
 03
Trypanosoma
brucei
rhodesiense
Trypanosoma brucei
rhodesiense
● Human African Trypanosomiasis (HAT)
○ African sleeping sickness
○ T. brucei gambiense & T. brucei
rhodesiense

● Family Salivaria
● Reservoir Host: Cattle
● MOT: bite of tsetse fly ● Accidental Host: Human
● East Africa
Trypanosoma brucei
rhodesiense
● Tryptomastigote:
○ Polymorphic
○ Flattened and fusiform
○ Undulating membrane
○ Single flagellum
● FLY
○ Glossina mortisans
○ Glossina pallipides
 LIFE
CYCLE
 CLINICAL DIAGNOSIS
MANIFESTATION
Gemsia
● Human African Trypanosomiasis (HAT)
○ East African sleeping sickness
○ fever, myalgia, and rigors
○ Rapid weight loss
○ Myocarditis
■ 9 to 12 months in untreated
TREATMENT
patients
● IV Suramin sodium
● Nitrofurazone
 04
Leishmania
braziliensis
complex
 Leishmania
braziliensis complex
● Mucocutaneous leishmaniasis
○ found in Mexico, Argentina,
Panama, Colombia

● MOT: blood meal, resulting in a skin

bite

● Genera: Lutzomyia and

Psychodopygus
 LIFE
CYCLE
 CLINICAL DIAGNOSIS
MANIFESTATION
● Mucocutaneous Leishmaniasis ● Gemsia
○ Large ulcers in the oral or nasal ● Biopsy of the infected
mucosa areas ulcer
○ large cutaneous lesions, mucosal ● Enzyme analysis and
lesions molecular techniques
○ Untreated- destruction of the nasal

TREATMENT
septum

● Antileishmanial agent
● Resistance: sodium
stibogluconate (Pentosam)
● Alternative: liposomal
amphotericin B (Ambisome)
 05
Leishmania
donovani
complex
Leishmania donovani
complex
 LIFE CYCLE

L. donovani complex is identical

to that of L. braziliensis, with only two
exceptions
1. specific sandfly species
responsible for L. donovani
transmission vary with
each of the three
subspecies
2. primarily affects the
visceral tissue of the
infected human
 CLINICAL MANIFESTATION
● Visceral Leishmaniasis
○ kala-azar or dum dum fever
○ present with a nondescript abdominal illness and
hepatosplenomegaly (enlargement of the spleen and
liver)
○ Early stages of disease may resemble malaria
○ Incubation: 2 weeks to 18 months
Treatment
○ weight loss and emaciation, parasitic invasion of the
● Liposomal amphotericin B
liver
(Ambisome) - drug of choice
○ Advanced stage: kidney damage (e.g.,
● Sodium stibogluconate
glomerulonephritis, inflammation of the glomeruli of
(Pentosam)
the kidney)
● paramomycin and miltefosin
○ Chronic cases: lead to death in 1 or 2 years
○ acute disease: debilitates the patient and becomes
lethal in a matter of weeks.
 06
Leishmania
mexicana
complex
 Leishmania mexicana
complex
The Leishmania mexicana
complex can be found in:
● Belize
● Guatemala
● Yucatan Peninsula
● Amazon River Basin
● Venezuela
● Brazil
● Venezuelan Andes
 FORMS

Amastigote form
● ovoid or rounded bodies measuring 2 to 3 μm Promastigote form
in length ● Single free flagellum arising from
● lives intracellularly in monocytes, the kinetoplast at the anterior
polymorphonuclear leukocytes, or endothelial end
cells ● 15 to 20 μm in length and 1.5 to
● large nucleus, axoneme arises from the 3.5 μm in width
kinetoplast and extends to the anterior tip
LIFE CYCLE
Vector
● Lutzomyia sandfly

Reservoir Hosts
● Forest rodents

Mode of Transmission
● Skin penetration
○ injection of infective promastigotes in the
proboscis of sandflies to skin during feeding
● Congenital transmission
● Blood transfusion
● Contamination of bite wounds
● Direct Contact
 CLINICAL MANIFESTATION
Diffuse Cutaneous Leishmaniasis
New World Cutaneous Leishmaniasis
● Bay sore, chiclero ulcer
● Characterized by single-pus containing
ulcer ; generally self healing
● 40% infects the ear, causing serious
damage to surrounding cartilage
● Small red papule at the bite site (typically
≥ 2 cm in diameter) at the bite site
● May cause pruritis (intense itching)
● Incubation time and appearance vary
with each subspecies
● Rare in the New World; incidents with all
species in the complex has been
reported
● L. pifanoi: initial lesion appears, ulcerates
or disappears and, after a period of time,
appears in local and distant areas from
the bite site with lepromatous-appearing
lesions.
● L. amazonensis: infections have been
known to progress to an incurable diffuse
cutaneous form of the disease. (occurs
when patient is anergic)
 DIAGNOSIS
● Demonstration of amastigote form in
Giemsa-stained preparations of lesion
biopsy material
● Demonstration of promastigote stage
in cultures on NNN medium
● Diagnostic Tests:
○ Serologic testing using
monoclonal antibodies
○ Schizodeme analysis,
zymodeme analysis, nuclear
DNA hybridization (research
basis)
TREATMENT
● Pentavalent amonials
○ Sodium stibogluconate
(Pentosam)
● Antimony combined with
pentoxifylline
● Amphotericin B & Liposomal
ampothericin B (Ambisome)
PREVENTION
● Repellents, protective clothing,
screening
● Prompt treatment of human infection
● Control of sandfly and reservoir host
populations
 06
Leishmania
tropica
complex
Leishmania tropica
complex
- Causative agent of Old World Cutaneous Leishmaniasis, oriental sore, and
Baghdad or Delhi boil, dry or urban cutaneous leishmaniasis
LIFE CYCLE

- L. tropica complex is basically identical to

that of L. braziliensis with the exception of
the specific sandfly species and the area
of the body most affected.
- All three subspecies are transmitted by
the Phlebotomus sandfly
- L. tropica complex is primarily attacks the
human lymphoid tissue of the skin
CLINICAL MANIFESTATION
Old World Cutaneous Leishmaniasis
- Old World leishmaniasis, oriental
sore, and Baghdad or Delhi boil,
cutaneous leishmaniasis
- Characterized by 1 or more
ulcers containing pus that
generally self-heal.
- Infected patients: develop
an initial small red papule
located at the bite site, which
is typically 2 cm or larger in
diameter and may cause
intense itching
 DIAGNOSIS
- Giemsa-stained slides:
microscopic examination of
aspirated fluid underneath the ulcer
for typical amastigotes - specimen of
choice
- Amastigote - most common
morphologic form
- Culture of the ulcer tissue: may
reveal promastigote forms
- Serologic tests (IFA testing)
- Schizodeme analysis
- Zymodeme analysis
- Nuclear DNA hybridization
TREATMENT
- Sodium stibogluconate
(Pentosam)
- Steroids, application of heat to
the infected lesions,
meglumine antimonate
(Glucantime), pentamidine,
and oral ketoconazole
- Paromomycin ointment