PARASITES LIFE CYCLE

DIRECT INDIRECT
E. Hystolytica Trypanosoma
Malpighamoeba mellificae Histomonas melleagridis
Giardia Sarcocystis
Eimeria Neospora
Isospora Toxoplasma
Cryptosporidium Leishmania
Klossiella Hemogregarina
Hepatozoon

REPRODUCTION

ASEXUAL SEXUAL
Binary fission Gametogony

Internal budding Conjugation

- Endodiogeny
- Endopoliogeny

Schizogony
- Merogony
- Sporogony
BOTH : SPOROGONY RESULTS IN OOCYSTSPOROZOIT (EIMERIA) AND
FECUNDATION-SYNGAMY RESULTS IN ZYGOTE

ASEXUAL SEXUAL BOTH

Class Sarcodina Apicomplexa
- E.hystolytica - Eimeria
- Malpighamoeba - Isospora
mellificae
Class mastigophore Cryptosporidium
- Trichomonas Toxoplasma
Class mastigophora-ordre Neospora
diplomonadida Besnoitia besnoiti
- Giardia Klossiella
Sarcocystis
Trypanosoma amastigotes Babesia
Theileria
Trypanosoma brucei Balantidium
typomastigotes and procyclic
trypomastigotes Fam Hemagregarinid

TROPHOZOITES CYSTS SPOROZOITES MEROZOITES

Amoeba
Malpighamoeba
Trypasnosoma
Leishmania
 Trichomonas
Histomonas
Giardia Motile stage in
small intestine
Eimeria
Isospora
Cryptosporidium
Toxoplasma +BRADYZOITES &
TACHYZOITES
Neospora + BRADYZOITES
& TACHYZOITES
Sarcocystis
Klosiella
Hepatozoon
Babesia
Theileria
Besnoita

EXTRA INTESTINAL PROTOZOAN PARASITES

- African trypanosomiasis
- Babesiosis
- Chagas diseases
- Leishmaniasis
- Malaria
- Toxoplasmosis

INTESTINAL

- Giardiasis
- Amebiasis
- Cryptosporidiosis
- Coccidiosis
- Cystoisosporiasis
- Cyclosporiasis

PARASITES CLINICAL SIGNS

E.histolytica - diarrhea

The formalin-ethyl acetate sedimentation concentration procedure for feces

is used to: demonstrate protozoan cysts and helminth eggs.
 ANSWER: The formalin-ethyl acetate concentration procedure
cannot be used to demonstrate any type of motility since the
organisms have already been preserved in formalin prior to being
concentrated. This procedure is designed to recover helminth eggs
and protozoan cysts. Accurate identification of many of the protozoan
cysts should be confirmed using a permanent stained smear that can
be examined using the oil immersion lens for a total magnification of
1,000X. The correct answer is B.

A direct saline mount of fresh feces is most often used to

demonstrate: motility of protozoan trophozoites

The permanent stained smear (trichrome stain) within the ova and
parasite examination is designed to: demonstrate protozoan cysts
and trophozoites

The most sensitive method for the recovery of Acanthamoeba spp. from

lens care solutions or corneal biopsies is: the use of non-nutrient agar
cultures seeded with Escherichia coli.

The sodium-acetate/acetic acid/formalin (SAF) fixative for stool collection

and preservation provides the capacity to do: concentration, permanent
stain, and fecal immunoassay.

ANSWER: The SAF collection system gives the user the capability to

perform the fecal concentration, the permanent stained smear, and
some of the fecal immunoassays for Giardia
lamblia and Cryptosporidium parvum. The correct answer is C.

When staining coccidian oocysts with modified acid-fast stains (either hot or
cold), the important difference between these methods and the acid-fast
stains used for AFB is:

the decolorizer used in the modified methods is weaker than

the regular acid alcohol used for AFB decolorization.

The modified trichrome stains are used primarily to demonstrate:

microsporidian spores

No diarrhea in trichomonas vaginalis

Because Balantidium coli trophozoites and cysts are so large, they tend to

overstain on the permanent stained smear and can be confused with
helminth eggs and/or artifacts. The best approach to identification is the
examination of the concentration wet preparation, where the morphology
(including cilia on the trophozoite) can be easily seen. Therefore, the
correct answer is C.

If Entamoeba spp. trophozoites are seen in a permanent stained smear (no

ingested RBCs, 13 µm, nucleus with evenly arranged chromatin and small,
compact karyosome), they should be reported as: Entamoeba
histolytica trophozoites

The following organisms are immediately infectious when passed in the

stool (regardless of the stool consistency): cryptosporidium parvum
OOCYSTS

Occasionally, structures can be seen within the Cryptosporidium

parvum oocysts that are stained with the modified acid-fast stain; they are:
Sporozoites/ Cryptosporidium oocysts measure approximately 4 to 6
microns, are immediately infective when passed in the stool and contain
four sporozoites. Although these sporozoites are not visible within every
oocyst, the oocyst is still infective. Therefore, the correct answer is A

The horizontal "stripe" or "bar" seen in microsporidial spores is actually the:

polar tubule

In the human, microsporidian spores generally measure approximately:1 to

4 µm

The presence of nonpathogenic protozoa in the intestinal tract

indicates:The patient has ingested something contaminated with fecal
material containing infective cysts

If a patient has watery diarrhea, the stage in the life cycle of the intestinal
protozoa that is most likely to be seen in the permanent stained smear is
the: Trophozoite

If amebic trophozoites measuring 13 µm and containing red blood cells

within the cytoplasm are seen in a permanent stained smear, the correct
report would indicate the presence of: Entamoeba histolytica trophozoites

AMOEBIASIS
In prior years, fecal smears and visual identification were used to detect Amebiasis. However,
upon the realization that the morphologies of E. dispar and E. histolytica were identical,
better methods needed to be used. Current methods are:
 
1) Antigen detection (ELISA assays)
 
2) Antibody detection (Indirect hemagglutination):
 

ASCARISIS

if Ascariasis is suspected, diagnostic tests can be run to confirm the disease.  Ultrasounds and
endoscopes can be used to attempt to image the worms.

Yet, the most reliable means to diagnose the disease is the simple stool sample.  Because of
the high volume of eggs produced in the duodenum by the adult worm, a stool sample can
often be placed under a microscope in a formalin wet mount, allowing a physician or lab
technician to make a diagnosis.  (On the left, you can find several images of Ascaris eggs in
stool samples that can be used to help diagnose a patient)

Lastly, immunoserology can be used, as the worms often cause elevated IgG and IgE levels in
the blood stream.
DIAGNOSIS — The diagnosis of ascariasis is usually made via stool microscopy. Other forms of
diagnosis are through eosinophilia, imaging, ultrasound, or serology examination.
 
Microscopy — Characteristic eggs may be seen on direct examination of feces or following
concentration techniques. However, eggs do not appear in the stool for at least 40 days after
infection; thus, the main drawback of relying upon eggs in feces as the sole diagnostic marker for
Ascaris infection is that an early diagnosis cannot be made, including during the phase of respiratory
symptoms. In addition, no eggs will be present in stool if the infection is due to male worms only.
Sometimes an adult worm is passed, usually per rectum. If an Ascaris worm is found in the feces, a
stool specimen can be checked for eggs to document whether or not additional worms are present
prior to instituting therapy [10].
 
Eosinophilia — Peripheral eosinophilia can be found, particularly during the phase of larval migration
through the lungs but also sometimes at other stages of Ascaris infection [34]. Eosinophil levels are
usually in the range of 5 to 12 percent but can be as high as 30 to 50 percent. Serum levels of IgG and
IgE are also often elevated during early infection.
 
Imaging — In heavily infested individuals, particularly children, large collections of worms may be
detectable on plain film of the abdomen. The mass of worms contrasts against the gas in the bowel,
typically producing a "whirlpool" effect [8]. Radiologic detection of adult worms is sometimes made
by detecting elongated filling defects following barium meal examinations of the small bowel. The
worms also sometimes ingest barium, in which case the alimentary canal appears as a white thread
bisecting the length of the worm's body [8]. Radiographs will also show when there is associated
intestinal obstruction.
 

Ultrasound — Ultrasound examinations can help to diagnose hepatobiliary or pancreatic ascariasis.

Single worms, bundles of worms, or a pseudotumor-like appearance may be seen [35]. Individual
body segments of worms may be visible, and on prolonged scanning, the worms will show curling
movements [36]. Computed tomographic (CT) scanning or magnetic resonance imaging (MRI) may
also be used to identify worm(s) in the liver or bile ducts, but this is not usually necessary. Imaging
the worm in cross-section gives a "bull's eye" appearance. When ascariasis involving the biliary tree
or pancreatic duct is suspected, an ERCP will not only establish the diagnosis but also allows for the
direct removal of the worm [32,37].
 
Serology — Infected individuals make antibodies to A. lumbricoides which can be detected. However,
serology is generally reserved for epidemiologic studies rather than in the diagnosis in a particular
individual [2]. IgG antibodies are not protective against infection [38]. Antibodies to Ascaris also often
cross react with antigens from other helminths.
 
TREATMENT — Treatment consists of choosing the right drugs, therapy, follow-up, and supportive
care for each patient.
 
Choice of Drugs — A number of drugs can be used in the treatment of ascariasis. These include:
pyrantel pamoate, mebendazole, albendazole, ivermectin, piperazine citrate, and levamizole.
 
 

Ascaris lumbricoides expelled following effective drug treatment. Source: Courtesy of Dr. Tom
Nutman, NIH.
 
 * Pyrantel pamoate — Pyrantel pamoate (11 mg/kg up to a maximum of 1 g) is administered as a
single dose. Adverse effects include gastrointestinal (GI) disturbances, headaches, rash, and fever.
Parasite immobilization and death occur, although this happens slowly and complete clearance of the
worm from the GI tract may take up to three days. Efficacy varies with worm load, but single dose
therapy is approximately 90 percent effective in eradicating adult worms [6].
* Mebendazole — Mebendazole (100 mg BID for 3 days or 500 mg as a single dose) is an alternative.
Adverse effects include transient GI discomfort, headache, and rarely leukopenia. The three-day
regimen is approximately 95 percent effective, and the single dose seems to have similar results.
 
* Albendazole — A single dose of albendazole (400 mg) is effective in almost 100 percent of cases,
although reinfection commonly occurs [39]. Albendazole causes the same adverse effects as
mebendazole.
 
* Ivermectin — Ivermectin causes paralysis of adult worms and is approximately as effective as other
available therapies but is not generally used.
 
* Piperazine citrate — Piperazine citrate (50 to 75 mg/kg QD up to a maximum of 3.5 g for 2 days)
was a frequent treatment regimen, but it is now being withdrawn from the market in many
developed countries because the other alternatives are less toxic and more efficacious. However, it
may still be recommended when there is suspected intestinal or biliary obstruction since this drug
paralyzes worms to aid expulsion.
 
* Levamisole — Levamisole (150 mg for adults and 5 mg/kg for children) is safe and is effective in 77
to 96 percent of cases of ascariasis.
 
Choice of therapy — The mainstays of treatment currently are the benzimidazoles, mebendazole and
albendazole. However, they should not be given during pregnancy because of possible teratogenic
effects. Thus, pyrantel pamoate should be used in pregnancy. In a randomized study conducted
among 2,294 children aged 6 to 12 years in Zanzibar, single dose mebendazole and albendazole were
both found to have efficacies greater than 97 percent [40]. Similar results with both drugs and good
tolerability have also been observed in other studies [41-43].
 
Follow-up — All of these therapies act against the adult worm but not the larvae. Following therapy,
patients should be reevaluated at two to three months to ensure that no eggs are detectable, either
because of inadequate elimination of adult worms or because of reinfection. Reinfection occurs
frequently; more than 80 percent of individuals in some endemic areas become reinfected within six
months [1]. Evaluation of other family members should be entertained whenever the diagnosis is
made because of the propensity of the infection to cluster in families [10,12].
 
Supportive care — In addition to specific anthelminthic therapy, supportive therapy for complications
of ascariasis may be required, including potential surgical intervention for intraabdominal
complications. In biliary infections, conservative therapy with anthelminthics, often combined with
antispasmodics, is often successful. However, surgical or endoscopic interventions may be required.
 
Since pulmonary ascariasis is a self-limited disease, symptomatic alleviation of wheeze and cough
with inhaled bronchodilators can be instituted. Occasionally, systemic corticosteroids may be required
for symptoms. Following symptomatic therapy, standard therapy for intestinal ascariasis can be given
after the worms have developed to maturity in the small intestine [6]. Anthelminth therapy is not
usually given at the time of pulmonary symptoms because dying larvae may do more harm than
migrating ones.
 

TRICHOMONASIS
Diagnostic Tests
Microscopic examination of discharge from vagina or urethra (wet mounts)
Pelvic/vaginal internal exam to check for discharge and inflammation
Urine test
Cervical smear test
Fluorescent antibody assay (staining)
Polymerase Chain Reaction (PCR)
In mounts, look for highly motile organisms; darting motion
Management
Antibiotic treatment
Avoid vaginal, oral, and anal sex until antibiotic treatment has eliminated the parasite
Treat all sexual partners to avoid re-infection
Avoid unprotected sex
Prioritize sexual safety:
Talk about protection methods with all partners
Use condoms and other protective measures consistently and properly
Seek medical advice upon first signs of infection

Therapy
Trichomoniasis is usually treated with Metronidazole, an antibiotic and antiparasitic drug.
Metronidazole eliminates T. vaginalis by inhibiting nucleic acid synthesis. It is classified as a
nitroimidazole.
The structure of Metronidazole:
 http://en.wikipedia.org/wiki/Metronidazole
Brand names of Metronidazole include: Flagyl, Metryl, Protostat, Satric, Neo-Tric
Dosing: Metronidazole 2 grams by mouth (usually 4, 500 mg tabs) or 500 mg twice a day by mouth
for 7 days. The single dose has a high success rate (90%+) and good compliance.
Resistance: Intravagical application of nonoxynol-9, a spermicide, may be somewhat effective against
metronidazole-resistant strains. Mebendazole and furazolidone may also be effective. Topical
metronidazole is not absorbed sufficiently well to eliminate T. vaginalis.
Implications for HIV Transmission

Trichomoniasis is one of the most prevalent sexually transmitted infections. Although it is not fatal
and symptoms are typically mild or non-existant, it increases susceptibility to HIV infection upon
exposure to the virus. Individuals with trichomoniasis are also more likely to pass on HIV to sexual
partners. Thus, trichomoniasis has significant public health implications in the context of HIV.
Implications for Pregnant Women

Some cases of premature birth and low birth weight have been reported in pregnant women with
trichomoniasis. It may also be possible to transmit the infection to a baby during birth.
Prevention Techniques

Like other sexually transmitted infections, Trichomoniasis is best prevented through safer sex
practices. The use of condoms with the spermicide nonoxynol-9 is the single best preventative
technique. It is also critical to stop all sexual activity until the parasite has been eliminated by
antibiotic treatment. High rates of re-infection occur in those who do not put off sex.

GIARDIASIS
Diagnostic Tests
 Identification of cysts in stool sample, using trichrome or iron hematoxylin staining
 More than one sample is recommended (at least 3 stool samples with two days between each), since the presence of cysts
in the stool can be highly irregular, and cysts may not be present until a week after symptoms appear.
 Trophozoites break up rapidly in the stool, and should not be relied upon to measure an infection
 An Enzyme-Linked Immunosorbent Assay (ELISA) may be used to detect Giardia antigens in the stool, and is commercially
available (highly sensitive)
 String Test: a patient swallows a capsule with a string attached, and when it is passed into the small intestine, trophozoites
stick to the string. The string is then removed and examined for the trophozoites.
 A duodenal biopsy may also be useful to detect trophozoite presence, although trophozoites may be hard to distinguish in
the sample
 Seropositivity tests are not recommended, since they cannot distinguish between current and previous infections.
 A CBC (complete blood count) is not helpful, because eosinophilia is not present, and the white blood cell count should be
normal.
Treatment
   Metronidazole (also known as Flagyl) is a first-line treatment
Contraindications: if patient has documented hypersensitivity, or pregnancy (there are potential risks, must outweigh
risks).
 Tinidazole (Tindamax) is also a first-line treatment
Contraindications: documented hypersensitivity, first trimester pregnancy

 Nitazoxanide (also know as Alinia) inhibits trophozoite growth by disrupting their energy metabolism
Contraindications: documented hypersensitivity

 Paromomycin (Humatin) may be used to treat severe infections in pregnant women, but has worse side effects and
long term use is not recommended.
Contraindications: intestinal obstruction, hypersensitivity (14)

 Furazolidone (Furoxone) is available in liquid form, although is less effective than other
treatments
Contraindications: documented hypersensitivity
Also effective: albendazol and mebendazole(9)

BABESIOSIS

Diagnosis
 There are three main methods of diagnosis:
Hematology diagnosis of human babesiosis relies on finding the erythrocytic stage of the
parasite.  A peripheral blood smear, stained with a Wright's or Giemsa stain, is examined. The
organisms appear as dark ring forms with light clue cytoplasm within red blood cells, and can
be confused with ring-stage Plasmodium falciparum. Though it is subjective, hematology is the
most commonly used diagnostic technique.

(Image 13)
Serology and Immunology IFAT test uses Babesia antigens derived from laboratory rodents.
Antibodies in the patients can be detected soon after infection, and antibody titers last from
13 months to 6 years. This test is sensitive and specific, but may eleicit false-positives with
other protozoal parasites. Immuno-suppressed patients also could have false negative
results.
Molecular Diagnostic Approaches involve PCR assays which amplify certain conserved
sequenced. Analysis and comparison of these fragments allows for an identification of the
agent. This test is sensitive for even mild cases, but is only useful for active infections (8).
CRYPTOSPORIDIUM

The most common method of diagnosing Cryptosporidiosis is acid-fast staining methods,

with or without a stool sample. Acid-fast staining, or the Ziehl-Neelsen stain, is used to
detect acid-fast mycobacteria. Because Cryptosporidium is acid-fast, it retains a red color as
depicted in the picture below:

12

This photo is described by the CDC as, "Using a modified cold Kinyoun acid-fast staining
technique, and under an oil immersion lens the Cryptosporidium sp. oocysts, which are acid-
fast stain red, and the yeast cells, which are not acid-fast stain green."

The stool sample, on the other hand, may be more difficult to attain and several samples
over several days may be needed to get accurate results and diagnosis. The CDC also
suggests immunofluorescence microscopy, followed by enzyme immunoassays and
distinguishes molecular methods as research tools. However, there are no commercially
available serologic assays that detect Cryptosporidium-specific antibodies.2

The official 5 laboratory-confirmed signs of the presence of Cryptosporidium, as defined by

the CDC's 1998 case definition is as follows:

1. oocysts in stool by microscopic examination, or

2. in intestinal fluid or small-bowel biopsy specimens, or
3. oocyst or sporozoite antigens by immunodiagnostic methods, e.g., ELISA, or
4. by PCR techniques when routinely available, or
5. demonstration of reproductive stages in tissue preparations.

ISOSPORIASIS
- Stool examinations:
Bright field microscopy
Differential interference contrast
UV fluorescence microscopy
Acid-fast stain
- Blood count may indicate mild eosinophilia

Treatment
 - Drug treatment involves primarily a combination of the antibiotics, sulfamethoxazole and
trimethoprim, but alternative drugs are also effective. In immunocompetent individuals, the
symptoms disappear in 2-3 days with treatment and longer without treatment. In either case,
the illness disappears completely. Side effects of antibiotic treatment are uncommon and
generally mild. They include sore throat, skin rash, and, the most severe, anemia due to folic
acid deficiency.
- In immunocompromised patients, symptoms will disappear after a few days but the illness
may return after as little as 2 months.
Control and Prevention
The most effective means of prevention is improved sanitation standards and practices. Increased
awareness and attention should be given in areas of higher Isosporiasis occurence and with
immunocompromised patients (5).

SARCOCYSTOSIS
Diagnoses for both intestinal and muscular sarcocystosis are made through the discovery of
cysts. Cyst sizes vary depending on the species.

For intestinal sarcocystosis, initial diagnoses can be made after a history of exposure has
been established and symptoms reported. Stool samples are usually taken in order to find
cysts in the feces for clinical diagnosis of an intestinal infection. Oocysts in the feces typically
present as two sporocysts without a surrounding oocyst wall. S. hominis sporocysts are
expelled 2 weeks after ingestion, and S. suihominis sporocysts are excreted 11-13 days after
consumption (2).

For muscular sarcocystosis, initial diagnosis can be made based on reported symptoms as
well as an exposure history of travel to an at-risk locale. Sarcocysts in muscle tissue can be
found using CT scans, MRIs and through microscopic examinations. Blood work up can be
performed to detect eosinophilia. Immunofluorescent antibody test and immunoblotting are
examples of serologic tests that can be performed. PCR can be performed to help identify
particular Sarcocystis species (2).