PROTOZOAN INFECTIONS - PATHOGENIC

Pathogenic Amoeba Amebae Species Found In Human

• Amoebida – pseudopoda
• Protomonadida – flagellates • Entamoeba histolytica (pathogenic)
• Eucoccidia – spores • E. dispar
• Cillatea – cillia • E. moshkovskii
• E. hartmanni
• E. coli
• Endolimax nana
• Iodamoeba butschlii
• Entamoeba polecki (pigs, monkey but occasionally
detected in humans)

Amebae

• Intestinal Amoeba
o Pathogenic
▪ E. histolytica
o Non- Pathogenic
▪ E. dispar
▪ E. moshkovskii
▪ E. coli
▪ E. gingivalis
• Free living Amoeba
o Acanthamoeba
o Naegleria fowleri
o Balamuthia madrillaris
Intestinal Protozoa
Entamoeba Histolytica
• Pseudopods are extensions of cytoplasm providing
motility unique to amebae • Subphylum Sarcodina
• Trophozoite and cyst stages are part of the amebae life • Superclass Rhizopoda
cycle • Class Lobosea
• Most amebic infections are spread to humans through • Order Amoebida
contaminated water • Family Entamoebidae
• Cyst is the infective stage, whereas the trophozoite is the • Genus Entamoeba
active reproductive stage destroyed by stomach acid
• Laboratory identification: microscopic identification of Description
cysts (in formed stools) and trophozoites(in liquid stools)
• Pseudopod forming non-flagellated protozoan parasite
based on size, nuclear characteristics, and inclusions
• We can differentiate the different protozoans based on • Most invasive (not only in one place where it invades like)
the size of the trophozoites and the cysts, nuclear (E. dispar, E. moshkovskii. E. hartmanni, E. polecki, E.
characteristics and inclusions coli, and E. gingivalis)
• Size is one of the most important criteria for o Causes liver abscess and colitis
identification. • Habitat
• Morphologic terms associated with protozoa o Mucosa
o Karyosome: Area of chromatin within the o Submucosa of large intestine
nucleus o Near the ilium and cecum
o Peripheral chromatin: Nucleic acid combined
with protein found along the nuclear membrane
o Excystation: Development of a cyst into a
trophozoite
o Encystation: Development of a
trophozoite into a cyst
o Chromatoid bar: Rod-shaped, RNA
containing structure found in the cytoplasm

Pader, Juliene Andrei B.

 Protozoan Infections

3 Stages of E. Histolytica • Trophozoites are highly motile and possess pseudopodia

• 12 to 60 micrometer in diameter (about 20 micrometer in
• Trophozoite average)
• Pre-cyst • Progressive and directional movement
• Cyst • The hyaline pseudopodium is formed when the clear,
glasslike ectoplasm, or outer layer is extruded, and the
granular endoplasm flows into it.
• Ingested red blood cells are observed as pale, greenish,
refractile bodies in the cytoplasm of the ameba
Trophozoite • Trophozoites have the ability to colonize and/or invade
the large bowel
• Invasive form of the parasite, passed only in the
• Multiply by binary fission
patients with active dysentery
• Invasive, feeding and reproductive form
• It measures 08-30 um
• Cytoplasm has a clear ectoplasm (outer) and a
granular endoplasm (inner)
• Inner part is more granular
• Endoplasm contains RBC and food vacuoles
• Why is RBC important? It is a diagnostic feature for E.
histolytica. The only amoeba that has RBC ingested in it.
• It will die once it is outside

• Nucleus
o Single, spherical 4-6um size, contains central do
like compact karyosome surrounded by
peripheral chromatin
• Pseudopodia
o Long finger like projections of endoplasm Pre-Cyst
through ectoplasm (organ of locomotion) • It is the intermediate stage between trophozoite and cyst
• Trophozoites are motile with active unidirectional • It is oval with blunt pseudopodia
progressive and purposeful movement • Immature cysts; usually has only 1 nucleus or less than 4
nucleus with prominent chromatoid bodies

Pader, Juliene Andrei B.

 Protozoan Infections

E. histolytica – Cyst Life cycle

• Infective form if the parasite found in formed stools • Simple and completed in single host
• Spherical • INFECTIVE FORM
• And the size may vary from 10 to 20 micrometer o Mature quadrinucleated cyst
• Highly refractile hyaline cyst wall, one to four nuclei, and • MODE OF TRANSMISSION
rod-shaped (or cigar-shaped) chromatoidal bars o Fecal-oral route – most common
• Never found within invaded tissues o Sexual contact – rare
• Covered with smooth chitinous wall that makes them o Vector – more rare
resistant to gastric acid and other adverse conditions
• Chromatoid bodies are best seen in Iodine solution
• In DFS, we should separate Iodine and Saline solution

• Acidic content of stomach will not destroy the mature

Cyst cysts
• Nuclear structures are same as trophozoites • Trypsin in the small intestine will allow the cysts to
o Uninucleated – chromatid body and large glycogen lose its wall → excystation → trophozoite
mass
• 1 cysts = 4 trophozoite
o Quadrinucleated – mature
cyst present only in the gut • The trophozoites will multiply inLarge intestine and
lumen, they never invade invade the different organs
intestinal wall • Cyst cannot invade because only trophozoites contain
pseudopods
• Trophozoites can infect through active dysentery but if
it reaches stomach, it dies
• Sa number 4, it implies that we canobserve trophozoite at
stool
• Cyst is the infective agent

Pathogenesis

• Virulence
o Trophozoites play a majorrole in the pathogenesis
ofintestinal as well as extra intestinal amoebiasis

1. Amoebic Lectin Antigen

o Present in the surface oftrophozoites
o Lectin is a 260kDa surface protein that consists of
170-and 35-kDa subunits
o It mediates
▪ Adhesion
▪ Cytotoxicity
▪ Complementresistance

Pader, Juliene Andrei B.

 Protozoan Infections

2. Amoebic pore forming protein • Pleuropulmonary amoebiasis

3. Cysteine proteinases o Direct extension from liveror from metastatic foci
o Degrade IgA and IgG • Cerebral amoebiasis
4. Hydrolytic enzymes • Cardiac amoebiasis
o RNAse, neutral proteasesand phosphatase • Genital-urinary amoebiasis
• Cutaneous amoebiasis

Complications of Amoebic Liver Abscess

• Secondary bacterial infection

• Rupture into pleural space – Empyema
• Rupture into pericardium – pericarditis
• Rupture into peritoneum (peritonitis),
esophagus and stomach

Differential Diagnosis Amebic Colitis

• Acute amoebic colitis should bedifferentiated from

Pathogenesis Intestinal Amoebiasis bacillary dysentery:
o Shigella
• Produces characteristic ulcerative o Salmonella
lesion
o Campylobacter
o Flask shapes (broad base and
o Yersinia, and
narrow neck)
o Round in shape o Enteroinvasive Escherichia coli
o Vary in size from pin head to • Inflammatory bowel disease
an inch
o Ragged edges and
undermined margins
o They may be localized to
ileocecal region or generalized
o They may be superficial or
deep and are scattered with
intervening normal mucosa
• Profuse bloody diarrhea (amoebic
dysentery)

Complications of Intestinal Amoebiasis

• Fulminant amoebic colitis

• Intestinal perforation and amoebicperitonitis
• Toxic mega colon andintussusception
• Amoebic appendicitis
• Perianal skin ulcers
• Chronic amoebiasis
• Amoeboma (amoebic granuloma)

Pathogenesis Extra-intestinal Amoebiasis

• Amoebic liver abscess

o Single or multiple abscess found most commonly in
postero-superior surface inright lobe of liver

• Liver abscess has three zones

o Inner central zone – necrotic and consists of lysed
hepatocytes but no amoebae
o Intermediate zone – degenerated liver cells, tissue
cells, RBCs and occasional trophozoites
o Outer zone – layer of normal liver tissue invaded by
amoebic trophozoites

Differential Diagnosis of Amoebic Liver Abscess

• Pyogenic liver abscess

• Tuberculosis of the liver
• And hepatic carcinoma

Pader, Juliene Andrei B.

 Protozoan Infections

Differential Diagnosis of Genital Amebiasis • Ultrasound and CT scan

• Carcinoma
• Tuberculosis
• Chancroid
• Lymphogranuloma venereum

Immunity to E. histolytica

• What our body produces to fight E. histolytica

• Mucin inhibition of amebic attachment to the
underlying mucosal cells
• Complement-mediated killing
• Cell mediated response
o Activated T-cell, cytokines,TNF
• Humoral mediated response

Diagnosis of E. histolytica

• Molecular – gold standard; very specific

• Microscopic detection of the trophozoites and cysts in
stool specimens
• Trophozoites must be examined within 30 minutes
• DFS

o Saline (observe unidirectional motility)

o Methylene blue (entamoeba sp. stains blue) Treatment and Prognosis
▪ Differentiates from WBC
o Iodine (nucleus and karyosome are observed) A. To cure invasive disease at both intestinal and
▪ Differentiates from E. hartmanni, E. coli, extraintestinal sites
Endolimax nana B. To eliminate the passage of cysts from the intestinal
• E. histolytica trophozoites with ingested RBC is diagnostic lumen.
of amebiasis
• Charcot Leyden crystal can be seen 1. Metronisadle
• FECT is more sensitive in detection of cyst 2. 5-nitroimidazole derivatives such as tinizadole
o Size of the cyst and secnidazole
o Number of nuclei
3. Diloxanide furoate
o Location and appearance of the karyosome,
o The characteristic appearance of chromatoid bodies, *** good to know lang pero di tayo focus sa treatment
o And presence of cytoplasmic structures such as
glycogen vacuole *** Metronizadole is used as a prophylaxis
• Stool culture using Robinson’s and Inoki medium is more
sensitive than stool microscopy, but is not routinely Prevention and Control
available
• Differentiation of E. histo and E. dispar is possible by PCR, • The prevention and control ofamebiasis depends
ELISA and Isoenzyme analysis on
• Detection of antibodies in the serum is still the key in the o Integrated and community-based efforts to
diagnosis of ALA improve environmental sanitation
• Serological tests available for antibody detection include: o And to provide for sanitarydisposal of human
o Indirect Hemagglutination (IHAT) feces, safe drinking water, and safe food
o Counter Immunoelectrophoresis (CIE) • Vaccination
o Agar Gel Diffusion (AGD_
o Indirect Fluorescent Antibody Test (IFAT)
o ELISA

Pader, Juliene Andrei B.