AL – Mustafa University College – Baghdad Dept.

of pharmacology - Medical microbiology

theory course 2 – stage 2

I- Parasitology
Lec.3
Phylum: Ciliophora
Class: Kinetofragminophorea (Litostomatea)
Order: Trichostomatida (Vestibuliferida)
Family: Balantiididae
Genus: Balantidium
Species: Balantidium coli

Geographical distribution
B. coli is worldwide in distribution. Because pigs are an animal reservoir, human
infections occur more frequently in areas where pigs are raised.
Habitat
B. coli inhabits the large intestine of man, monkeys and pigs. It is generally believed that
pigs act as the main reservoir for human infections.

Morphology
B. coli is the only pathogenic ciliate and is the largest protozoal parasite inhabiting the large
intestine of man. It has a trophozoite and a cyst stage (Fig.1). The trophozoite is found in
dysenteric stool. It is actively motile and is the invasive stage. On the other hand, the cyst
is found in chronic cases and carriers. It is the resistant form and the infective stage.
Trophozoite
It is an oval organism, measuring 60 × 45 μm or more. The anterior end is somewhat
pointed and has a groove (peristome) leading to a mouth (cytostome) terminating in a short
funnel-shaped gullet (cytopharynx) extending up to anterior one-third of the body. There
is no intestine. The posterior end is broadly rounded and has an excretory opening known
as cytopyge (Fig.1) through which the residual contents of food vacuoles empty
periodically. The body is covered with a delicate pellicle showing longitudinal striations.
Embedded in the pellicle are short cilia of relatively uniform length that, in the living
organism, maintain a constant synchronized motion that vigorously propels the protozoan

1 Medical microbiology (theory) course -2

forward. The cilia that line the mouth part are longer and are called adoral cilia. These are
used for propelling food into the cytopharynx. The cytoplasm of the trophozoite has:
1. Two nuclei: A macronucleus which is large and situated near the middle of the body.
It may be kidney-shaped, spherical, curved or elongate. The micronucleus is small,
round and lies in close proximity to the macronucleus.
2. Two contractile vacuoles: Which may lie side by side or one above the other. These
vacuoles are responsible for maintaining the proper osmotic pressure in the cell by
drawing excess water from the cytoplasm and ejecting it to the exterior.
3. Numerous food vacuoles: The food particles on being ingested become surrounded by
a vacuolar membrane and digestion takes place inside the vacuoles. The parasite is
capable of ingesting a variety of food particles, such as bacteria, starch grains, fat
droplets, cell debris of the intestinal wall, red blood cells, etc
Cyst
The cyst of B. coli is spherical or oval measuring 40– 60 μm in diameter. It is surrounded
by a thick and transparent double-layered wall. Newly formed cyst shows movement,
but as the cyst matures the cilia are absorbed and the movement ceases. The
macronucleus, micronucleus and vacuoles are present in the cyst also. Unlike
encystation in amoebae, in B. coli this is not preceded by complete discharge of
undigested foods.

Figure 1: Morphological forms of Balantidium coli.

2 Medical microbiology (theory) course -2

Culture
B. coli can be cultured in all the media that support the growth of E. histolytica.

Life cycle
B. coli passes its life cycle in two stages, but in one host only. Pig is the natural host and
man is incidental host. Transmission occurs from pig-to-pig, pig-to-man, man-to-man and
man-to-pig. Pig-to-pig transmission is very common. The cyst is the infective form of the
parasite. Man acquires infection by ingestion of food or water contaminated with the faeces
containing the cysts of B. coli (faecal-oral route). Excystation occurs in the small intestine
and multiplication occurs in the large intestine. From each cyst, a single trophozoite is
formed (Fig.2). The trophozoites feed on bacteria and faecal debris which may remain
either in the lumen or invade submucosa of the large intestine.

Figure 2: Life cycle of Balantidium coli.

3 Medical microbiology (theory) course -2

Reproduction:
B. coli reproduces by transverse binary fission. First the micronucleus divides into two,
then the macronucleus and finally the cytoplasm separates into two daughter organisms by
a transverse partition in the middle of the body. The daughter organism formed from the
anterior half retains the cytostome of the original parasite but develops a new excretory
pore, whereas the one formed from the posterior end develops a new mouth. Successive
divisions produce a large number of trophozoites (Fig.2).
Sexual Reproduction:
Sexual union (syngamy) is an important aspect of this parasite’s life cycle. It occurs by a
process of conjugation, in which two cells come in contact with each other at their anterior
ends and exchange nuclear material. Conjugation lasts for a few moments, after which the
cells detach. There is no increase in numbers as a result of conjugation (fig.2).
Encystation of the trophozoite occurs as it is being transported down the intestine.
In this process, the organism partially rounds up, then, without completely retracting the
cilia, it secretes a tough cyst wall. In the infected person the parasite may be passed in the
faeces as a trophozoite or a cyst. The trophozoite does not encyst outside the body and
disintegrates. The passed cyst survives and may contaminate food and water and, as a
result, may then be passed to other humans or animals.
Pathogenicity
Most infections with B. coli are apparently harmless. However, rarely, the trophozoites
invade the mucosa and submucosa of the large intestine and terminal ileum and produce
ulcers or subsurface abscesses in the mucous or submucous coats that sometimes extend to
the muscular layer. The ulcers are round, ovoid, or irregular in shape with undermined
edges. The floor of the ulcer is covered with pus and necrotic material. The abscesses are
usually small and, when incised, are found to be filled with a mucoid material containing
numerous balantidia. The intervening mucosa may or may not be inflamed.

4 Medical microbiology (theory) course -2

 Note:
On microscopic examination, parasites are frequently seen in clusters in the
submucosa or at the bases of the crypts. They can easily be recognized because of
the presence of the macronucleus which stains deeply with haematoxylin and eosin.
The cellular response is mainly lymphocytic with some plasma cells being present.
Neutrophils are few unless there is a superimposed bacterial infection. Sometimes
the parasites may invade the regional lymph nodes and then they may be detected
inside the lymphatic tissues. B. coli can produce hyaluronidase, which probably
helps it in its invasion of the host tissues by dissolution of the intercellular ground
substance.

Chronic recurrent diarrhea, alternating with constipation, is the most common clinical
manifestation, but there may be bloody mucoid stools, tenesmus, anorexia, nausea,
epigastric pain, vomiting and intestinal colic. In a majority of patients, recovery occurs in
3–4 days even without treatment but extreme cases may mimic severe intestinal
amoebiasis. In patients with acute infection, Extraintestinal involvement such as liver
abscess formation, peritonitis, pleuritis and pneumonia may occur.
Laboratory diagnosis
1. Stool examination: Diagnosis is based on faecal examination, which reveals mainly

trophozoites in acutely infected patients and cysts in chronic cases and carriers.
2. Biopsy: Diagnosis can also be made by the examination of biopsy specimens taken

with the help of a sigmoid scope or by examination of scrapings of an ulcer.

Treatment
Tetracycline 500 mg four times a day for 10 days or metronidazole 750 mg three times a
day may be used for the treatment of B. coli infection.

5 Medical microbiology (theory) course -2

Blood and tissue flagellates:
Leishmania spp.
Leishmania spp. caused Leishmaniasis disease spread by the bite of certain types of
sandflies. Geographical distribution divided the disease to
1- Old world leishmaniasis caused by L. donovani, L. infantum, L. tropica, L. major,
L. aethiopica are transmitted by the sandflies genus Phlebotomus;
2- New world leishmaniasis caused by L. mexicana, L. braziliensis and etc... Are
transmitted by the sandflies genus Lutzomyia. Risk factors include poverty,
malnutrition, deforestation, lack of sanitation and urbanization.
Morphology and Life cycle
The life cycle of Leishmania is completed in two hosts, humans and sandflies. Two stages
are known; the amastigote which is spherical or subspherical and the promastigote which
is pyriform or spindle shape with flagellum (fig.1).

Figure 1: Morphological forms of Leishmania donovani.

6 Medical microbiology (theory) course -2

Life cycle
L. donovani passes its life cycle in two hosts – man and also dog in some areas are the
vertebrate hosts, and female sandfly of the genus Phlebotomus is the invertebrate host.
Life cycle in sandfly:
Amastigotes of the parasite are present in the blood stream of the patient, both free as well
as phagocytosed by polymorphonuclear leucocytes and monocytes. These are taken up by
the sandfly in a blood meal and reach midgut of the insect. Here the parasite transforms
into promastigotes and multiplies producing enormous numbers. The parasites then
proceed forwards to the pharynx and buccal cavity which they block between the 6th and
9th day of its infective blood meal.
Life cycle in human:
Because of the blockage of pharynx and buccal cavity, the sandfly has difficulty in
getting a blood meal, nevertheless, it pricks the skin of the victim and regurgitates the
promastigotes in the wound caused by its proboscis. These are engulfed by nearby fixed
macrophages and change into amastigotes within the cytoplasm of these host cells. Here
the amastigotes multiply slowly and may remain more or less quiescent for weeks or
months. Thereafter, parasitized macrophages are set free into the blood stream and are
carried from the skin to spleen, liver, bone marrow, and other centers of reticuloendothelial
activity. The amastigotes are now taken up by fixed macrophages such as Kupffer’s cells
in the liver, and multiply by simple binary fission till the cells become packed with the
parasites (50–200 or more in the cytoplasm of the infected cell).
The infected cell ruptures and the parasites are liberated into the circulation. These are
taken up by other reticuloendothelial cells followed by multiplication of the parasites and
rupture of the cells. In this way the entire reticuloendothelial system becomes progressively
infected. In the blood stream, some of the free amastigotes are phagocytosed by
polymorphonuclear leucocytes and monocytes. A blood-sucking insect draws these free
amastigotes, as well as those within the cells during its blood meal and the cycle is
repeated.

7 Medical microbiology (theory) course -2

 Old world leishmaniasis
1. Cutaneous leishmaniasis (oriental sore) is the most common form caused by L.
tropica, L. major, L. aethiopica, found in 88 tropical and subtropical countries which
causes an open sore at the bite sites, which heals in a few months to a year and half, leaving
an unpleasant-looking scar. Diffuse cutaneous leishmaniasis produces widespread skin
lesions which resemble leprosy, and may not heal on its own.
Pathogenesis:
Leishmania invades human macrophages and replicates intracellularly. A raised, red
lesion develops at the site of the bite (often weeks or sometimes years afterwards). The
lesion then ulcerates and may become secondarily infected with bacteria.
Diagnosis
1. A skin scraping with microscopic analysis using Wright or Giemsa stain is the best
test.
2. Needle aspiration of tissue fluid from the margin of a lesion can yield fluid for culture
to isolate the organism and identify the species.
3. DNA testing (PCR). -Leishmanin skin test (Montenegro test) delayed-type
hypersensitivity reaction.

8 Medical microbiology (theory) course -2

2. Visceral leishmaniasis
(Kala-azar) Also known as black fever, and Dumdum fever, is the most severe form of
leishmaniasis and, without proper diagnosis and treatment, is associated with high fatality.
Caused by obligate intracellular parasite Leishmania donovani, L. infantum (infantile
visceral leishmaniasis) Habitat: reticuloendothelial cells, predominately of liver, spleen,
bone marrow and lymph nodes of man and dogs.
Pathogenesis:
The parasite spreads from the site of inoculation to multiply in reticuloendothelial cells,
especially in the liver, spleen, bone marrow and lymph nodes. This leads to progressive
enlargement of these organs. The most typical symptoms are fever and the enlargement of
the spleen, liver and lymph nodes, anemia, leucopenia, and skin changes. Death is due to
secondary infections.
Sometime after successful treatment—generally a few months with African Kala-
azar, or as much as several years with the Indian strain—a secondary form of the disease
may set in, called post kala-azar dermal leishmaniasis, or PKDL. This condition caused by
the reversal of L.donovani from viscerotropic to dermatotropic, manifests first as small,
measle-like skin lesions on the face, which gradually increase in size and spread over the
body.
Diagnosis
1. Nonspecific tests: blood count, haemoglobin and serum protein estimation.
2. Parasitological diagnosis: blood film stained with Leishman or Giemsa stain, culture
in specific media, visualization of the amastigotes in splenic or bone marrow aspirate,
PCR (polymerase chain reaction) tests for the detection of Leishmania DNA.
3. Immunological tests: Serological testing is much more frequently used in areas
where leishmaniasis is endemic.

9 Medical microbiology (theory) course -2

New world leishmaniasis
1. Mucocutaneous leishmaniasis (espundia)
It causes both skin and mucosal ulcers with damage primarily of the nose and mouth. It
can be highly disfiguring if not promptly treated. Caused by L. mexicana, L. braziliensis,
which are mainly found in certain South American nations. Severe cases can diminish the
ability to eat and can be fatal.
Pathogenesis:
Leishmania invades human macrophages and replicates intracellularly. A raised, red lesion
develops at the site of the bite. The lesion may spontaneously heal with scarring, but then
reappear elsewhere (especially as destructive mucocutaneous lesions).
Diagnosis: as in cutaneous leishmaniasis.
Treatments:
The treatment needed is determined by where the disease is acquired, the species of
Leishmania, and the type of infection. Some possible medications used for visceral disease
include liposomal amphotericin B, a combination of pentavalent antimonials and
paromomycin, and miltefosine. For cutaneous disease, paromomycin, fluconazole, or
pentamidine may be effective.
Prevention
Leishmaniasis can be partly prevented by:
1. Sleeping under nets treated with insecticide.
2. Spraying insecticides to kill sandflies.
3. Treating people with the disease early to prevent further spread.
4. Reservoir control programs.
Vaccination: leishmania is an intracellular pathogen since it requires strong cell mediated
immunity to be controlled. However most of vaccines trials provide humoral response

10 Medical microbiology (theory) course -2