Introduction to
symbiosis:
Parasitology
Parasitology The area of biology is
concerned with the
phenomenon of
dependence of one living
organism on another.
Medical Parasitology Concerned primarily with
parasites of humans and
their clinical significance as
well as their importance in
human communities.
Tropical Medicine Branch of medicine that
deals with tropical diseases
and other special medical
problems of tropical
regions.
Tropical Disease An illness, which is
indigenous to or endemic
in a tropical area but may
also occur in sporadic or
epidemic proportions in
areas that are not tropical.
Endemic – refers to a
disease of frequency that
occurs in a certain location
for almost the entire time.
Ex, the Philippines is a
dengue-endemic area.
Sporadic – occur only in a
certain period of time, it
would usually pop up in a
certain amount of time.
The disease does not
occur all throughout the
year.
Epidemic – disease
occurrence that is at a
level higher than that of the
population. Ex. Covid 19
epidemic.
Biological Relationships
Symbiosis Living together of unlike
organisms; it may also
involve the protection of
other advantages to one or
both organisms.
Different forms of
-
-
Commensalism
Mutualism
- Parasitism
Commensalism one species benefits from
the relationship without
harming or benefiting the
other.
Mutualism Two organisms mutually
benefit from the other.
Parasitism One organism, the
parasite, lives in or on
another, depending on
the latter for its survival
and usually at the expense
of the host.
Parasites Are often described
according to their habitat
or mode of development.
• Endoparasite Living inside the body of a
host; Infection
Ex.
Ascaris Lumbricoides
(giant roundworm) -
causing ascariasis that
lives inside the host
specifically in our
gastrointestinal tract.
• Ectoparasite Living outside the body of
a host; Infestation
Ex.
Arthropods (some of your
mollusk) – live outside of
the body, and attach to
your skin, hair, or through
your nails (mucous
membranes).
Infested by lice.
Obligate parasites Needs a host at some
stage of their life cycle to
complete their
development and to
propagate their species.
Facultative parasite May exist in a free-living
state or may become
parasitic when the need
arises.
Either way, they can
survive with/without the
host.

Being facultative means
you are adaptable in any
situation. Ex. Facultative
anaerobes – organisms
that can survive in a
hypoxic environment or in
an environment full of
oxygen.
Accidental or Establishes itself in a host
incidental parasite where it does not ordinarily
live.
Temporary parasite lives on the host only for a
short period of time.
completed its development
within the host. (Example:
mosquito)
Malaria is caused by
plasmodium falciparum,
and its vector is the
anopheles (female)
mosquito, the plasmodium
species also transmit the
parasite and undergoes
sexual reproduction.
Mechanical or phoretic Only transports the
vector parasite. (Example: fleas,
cockroaches)

Spurious parasite A free-living organism that No asexual or sexual

passes through the reproduction would take
digestive tract without place inside that vector.
infecting the host

Host
Definitive or final host Parasite attains sexual
maturity.

Undergoes sexual
reproduction. Example in
Ascaris lumbricoides, the
definitive host is the
human, meaning it is
where specifically in the GI
tract, the parasite
undergoes sexual
reproduction, its
production is an ova or a
fertilized ovum.

Intermediate host Harbors the asexual or

larval stage of the parasite.

Paratenic host Parasite does not develop

further to later stages.

Reservoir host Harbor the parasite other

than definitive,
intermediate, and paratenic
hosts. (i.e. pigs, field rats,
cats)

The medical importance of

this host, they are potential
sources of this parasitic
disease.

Vectors – are responsible for transmitting the parasite

from one host to another.
Biologic vector Transmits the parasite only
after the latter has
 Application of Terms

• Definitive Host: Man

• Intermediate Host: Snail
• Diagnostic Stage: Ova
• Infective Stage: Cercariae (Larva)
• Definitive Host: Man – where the parasite Exposure and Infection
undergoes sexual maturity or sexual
Carrier Harbors a particular
reproduction.
pathogen without
• Intermediate Host: None manifesting signs and
• Diagnostic Stage: Ova or Adult symptoms.
• Infective Stage: Ova/ Embryonated ova or
Eggs – have already undergone development Exposure the process of inoculating
within the soil, without embryonation an infective agent.
transmission cannot take place.
Infection Connotes the
In the small intestine, it is where encystation takes
establishment of the
place. This means the conversion or the hatching of
infective agent in the host.
the infected embryonated egg to form a larva. That
larva would enter the intestinal wall of our small
Incubation period Period between infection
intestines and it goes into the portal circulation
and evidence of
entering the liver, the hepatic vein, the inferior vena
symptoms. This is also
cava, enters the heart, and entering the lung. Once
known as the clinical
the larva goes into the lung, goes into our terminal
incubation period.
alveoli in our lungs, and it migrates to our bronchioles
and then to our trachea, and to our larynx. Once it is in
Initial infection until the
our larynx, we swallow the larva, once it is swallowed it
evidence of symptoms,
reenters again in our GI tract, and that larva now can
such as symptoms of
be converted to an adult worm.
abdominal pain, vomiting
diarrhea, and nausea, that
Now male and female adult worm undergoes sexual
time is the patient is still
reproduction in the small intestines, and the product of
symptom-free but the
the sexual reproduction is the formation of a fertilized
parasite is already doing
egg. Therefore, once the fertilized egg is formed, is
something inside your
excreted out of the GI tract through the feces and
body.
enters the soil. And inside the soil, the fertilized egg
will undergo development to form the embryonated
egg.
 Clinical means the patients
signs and symptoms, what
you observe to the patient.
Pre-patent period the period between
infection or acquisition of
the parasite and evidence
or demonstration of
infection. This is also
known as biologic
incubation period.
Evidence or demonstration
of infection means there
are the presence of ovum
adult worms, or whatever
form of that parasite can
be diagnosed through
laboratory means.
Autoinfection Results when an infected
individual becomes his
own direct source of
infection.
Ex. Enterobius vermicularis
(pinworm) and
Strongyloides stercoralis
(threadworm).
Superinfection or Happens when the already
hyperinfection infected individual is
further infected with the
same species leading to
massive infection with the
parasite.
Usually happens in soil-
transmitted helminths
(STH). We have
superinfection with Ascaris
lumbricoides together with
hookworms, Trichuris
trichiura, sometime with
Enterobius vermicularis.
Sources of Infection
• Contaminated soil and water
• Contaminated food
• Lack of sanitary toilets and the use of night
soil or human excreta as fertilizers.
• Consumption of undercooked or raw
freshwater fish.
• Arthropods and mosquitoes
• Dogs, cats, and rats
• Infected person
• Beddings and clothing
Mode of Transmission
Oral of feco-oral route it is the most common
mode of transmission of
parasites. Infection is
transmitted orally by
ingestion of food, water or,
vegetables contaminated
with feces containing
infective stages of the
parasite. (e.g., cysts of E.
histolytica, and ova of
Ascaris lumbricoides).
Penetration of the skin Infection is transmitted by
and mucous the penetration of the
membranes larval forms of the parasite
through unbroken skin or
by the introduction of the
parasites through blood-
sucking insect vectors.
Helminth or worm - Egg or ova
parasite usually exist - Adult worm
in 3 major forms: - Larval form –
usually invasive,
can travel or
migrate to other
areas of the body,
they metastasize.
Sexual contact Trichomonas vaginalis is
the most frequent parasite
to be transmitted by sexual
contact. However,
Entamoeba, Giardia, and
Enterobius are also
transmitted rarely by
sexual contact among
homosexuals.
Bite of vectors Many parasitic diseases
are transmitted by insect
bites such as malaria
(female anopheles’
mosquito), filariasis (culex),
leishmaniasis (sandfly),
Chagas’ disease (reduviid
bug), and African sleeping
sickness (tsetse fly).
Vertical transmission Mother-to-fetus
transmission is important
for a few parasitic
infections like Toxoplasma
gondii, Plasmodium spp.,
and Trypanosoma cruzi.
Blood transfusion Certain parasites like
Plasmodium species,
 Babesia species,
Toxoplasma species,
Leishmania species and
Trypanosoma species can
be transmitted through
transfusion of blood or
blood products.

Autoinfection Few intestinal parasites

may be transmitted to the
same person by
contaminated hand
(external autoinfection) or
by reverse peristalsis
(internal autoinfection). It is
observed by
Cryptosporidium parvum,
Taenia solium, Enterobius
vermicularis, Strongyloides
stercoralis and,
Hymenolepsis nana.

Nomenclature Life Cycle - Needs to establish

- Animal parasites are classified according to itself in a host for
the International Code of Zoological survival.
Nomenclature. - Study of life cycle
- Phylum, classes, orders, families, genera and of parasites of its
species. development,
- Genera and species are italicized or starting by one
underlined when written. Example Ascaris stage ending to
lumbricoides or Ascaris lumbricoides. where the cycle
repeats.
Life Cycle – the life cycle of the parasite may be direct
(simple) or indirect (complex)
Direct/simple life cycle A parasite requires only
one host to complete its
development.

Ex. Ascaris lumbricoides

Indirect/complex life A parasite requires two
cycle hosts (one definitive host
and another intermediate
host) to complete its
development.
Fields of Medical 1. Medical Protozoology –
Parasitology more on unicellular
parasites such as
amoebas, flagellates, and
Sarcodina.
2. Medical Helminthology -
worms
3. Medical Malacology -
mollusk
4. Medical Entomology –
arthropods of medical
importance.

Immune Response
to Parasitic
Infections

The first line of defense would always come from the

innate immune system.

Blood is comprised of two components: plasma and

formed elements (erythrocyte and leukocyte)
Macrophages (tissues) originated from monocyte
(blood).

Humoral immunity also is known as antibody-mediated

immunity.
B-cell immunity is dependent on T-cell immunity Resistance to - Polymerization of sickle
because the activation of your humoral immunity Plasmodium hemoglobin (HbS) is
requires you to have activation as well of cell-mediated falciparum in responsible for the
immunity. sickle cell trait growth arrest of
erythrocytes is intraerythrocytic P.
2 Major factors in the Immune Response to driven by falciparum parasites.
Parasitic Infections oxygen- - HbS polymerization-
Host factors Immune status, age, underlying dependent induced growth inhibition
disease, nutritional status, genetic growth following cytoadherence
constitution, and various defense inhibition. is the critical driver of the
mechanisms of the host. reduced parasite
densities observed in
Parasitic factors Size, route of entry, frequency of malaria infections of
infection, parasitic load, and individuals with AS.
various immune evasion - the protective effect of
mechanisms of the parasites. AS derives largely from
effective sequestration of
Outcomes of Parasitic Infection infected RBCs into the
- Parasite fails to become established in the hypoxic microcirculation.
host.
- Parasite becomes established and the host Components of Innate Immunity
eliminates the infection. Anatomic skin is an important barrier for
- Parasite becomes established, and the host barriers (skin the parasites that enter by
begins to overcome the infection but is not and Mucosa) cutaneous routes like
totally successful. Schistosomes, hookworm and
- Parasite becomes established and the host, in Strongyloides.
trying to eliminate the organism, becomes
damaged itself. Physiologic It includes temperature, pH, and
- Parasite becomes established and kills the barriers various soluble molecules like
host. lysozyme, interferon, and
complement. Gastric acidity acts
Innate Immunity Innate immunity is the resistance as a physiologic barrier to Giardia
that an individual possesses by and Dracunculus.
birth, due to genetic and
constitutional make-up. Phagocytosis Phagocytes like macrophages
and microphages (neutrophils,
Factors - Age of the host basophils, and eosinophils – if
influencing - Sex elevated can be a sign of the
innate immunity - Nutritional status patient having a parasitic
- Genetic constitution of infection but not all the time, it
the individuals. can be other types of etiology
• People with such as Acute interstitial nephritis
hemoglobin S which is a type of acute kidney
(sickle cell injury) act as the first line of
disease), fetal defense against the parasites.
hemoglobin and
thalassemia Complements They play an important role for
hemoglobin are killing the extracellular parasites
resistant to by forming membrane attack
falciparum complexes; that leads to the
malaria whereas formation of holes in the parasite
Duffy blood membrane.
group negative
red blood cells Natural killer Natural killer cells (NKs) are
(RBCs) are cells another important mediator of
resistant to vivax innate immunity. They play a
malaria. central role in killing few of the
helminthic parasites.

Toll-like Receptors: Initiators of Innate Immunity
- Type-I integral transmembrane receptors
- Recognize specific molecules called
pathogen-associated molecular patterns
(PAMPs) that are non-native to the body. 2
- TLRs are expressed on various types of cells.
- Ten functional human and 12 mouse TLRs
have been identified.
Receptors – membrane-bound proteins that receive
signals from the outside (you may have an infection
and you need to initiate your immune response).
PAMPs come from microorganisms, for example from
a parasite or a bacteria. They would try to detect a
sample of that microorganism so that it can in so that
our toll-like receptors will initiate a cascade of
information telling our immune system that “hey we
have an infection”.
- TLRs activate antigen-presenting cells (will get
the sample of the parasite and present it to an
1 acquired immune system, it now forms
adaptive immunity against that
microorganism) and bridge innate and
adaptive immunity by coordinating responses
of T cells and B cell.
- Some parasites, for example, Leishmania,
Entamoeba, and Trypanosoma can down-
regulate TLRs (meaning we have lesser
capacity of recognizing PAMPs then you have
lesser capacity in activating your immune
system and lesser activation of inflammatory
cascade, so no one will ever your body from
this infection) expression as an important part
of immune evasion strategies.

- TLR types 1,2,4,5,6, and 10 are expressed on

the cell surface to recognize extracellular
PAMPs.
- TLR types 3,7,8, and 9 are expressed in
compartments such as the endoplasmic
reticulum, endosomes, and lysosomes.

TLRs signaling pathways

- Parasite ligands activate Toll-like receptors
(TLRs) and mediate signals through either
myeloid differentiation factor 88 (MyD88) or
Toll-interleukin 1 receptor (TIR) domain–
containing adaptor inducing interferon- b
pathways.

- TLRs initiate inflammation through the

activation of NF-kB and other transcription
factors → subsequent production of pro-
inflammatory cytokines and reactive oxygen
and nitrogen intermediates (this specie are
highly active and easily kill microorganism).
We want inflammation to kill the parasite.
 Therapeutic role of TLR in parasitic infections - The antigen presenting cells also secrete
- TLR antagonists or agonists of their negative interleukin-1 (IL-1) that activates the resting T
regulators play a novel therapeutic role for helper cells.
parasitic infection or as an adjuvant for
vaccines as in malaria and leishmaniasis. - Activated T helper cells differentiate into Th-1
and Th-2 cells.
- Interference with TLRs function likely to
prevent their aberrant activation and the
excessive release of inflammatory mediators.

We do not want excessive or sublevel

inflammation, we needed balance. If excessive
inflammation happens, it can promote further
tissue damage of the normal cell surrounding
the parasite or even in the entire body system.
In some parasitic infection in each we have
excessive inflammatory response, we can also
down regulate the toll like receptors, example
of which is the E6446.

Example:
E6446, a small molecule that acts as an
antagonist for nucleic acid-sensing TLRs,
decreased the activation of TLR9 and reduced
the levels of pro-inflammatory cytokines;
however it did not affect parasitemia. It can be
Green (APC) – Antigen presenting cell, usually found
a potential drug for cases of malaria because
on the epithelial surfaces such as the epithelial lining
you have an excessive inflammatory response
of our skin, in the gastrointestinal tract, as well as in
aside from that of the damage caused by a
the respiratory tract. Examples of antigen presenting
parasite.
cells are macrophages, Langerhans cells, dendritic
cells, microglial cells, in the liver it’s the Kupffer cells.
- TLRs are therefore largely responsible for
They are monocyte derivatives.
triggering the initial inflammatory response.
Function: somewhat get a sample, in the form of a
- They function as pyrogens and synthesize
parasitic antigen, and it now presents the antigen to
inflammatory response proteins, which then
the helper T cells. Telling you that “hey we have here
increase the number and function of
the sample of an intruder, try to get rid of this one, if
phagocytic cells.
you would see this kind of pattern you better kill it”.
Also secrete Interleukin 1 that will activate the T cell to
differentiate into either Th1 or Th2.
Adaptive - This is the resistance
Immunity acquired by an individual
TH1 Response
during life following
- T helper cell-1 secrete interleukin-2 (IL-2)
exposure to an agent.
and interferon gamma (IFN-g)
- It is mediated by antibody
- Inerleukin-2 activates the cytotoxic T cells
produce by B
and NKs, which are cytotoxic to the target
lymphocytes (humoral
parasitic cells. They produce perforin and
immune response) or by
granzyme that pores and lyse the target cells.
T cells (cell-mediated
immune response).
- IFN-g activates the resting macrophages
which in turn become more phagocytic and
Cell-Mediated Immunity
release free radicals like reactive oxygen
- When parasite enters, the parasitic antigens
intermediate (ROI) and nitric oxide (NO) that
are processed by the antigen presenting cells,
kill the intracellular parasites.
(e.g., macrophages) which present the
antigenic peptides to T helper cells.
TH2 Response
- T helper cells-2 release IL-4, IL-5, IL-6 and IL-
10 which are involved in activation of B cells
to produce antibodies [immunoglobin E (IgE)
by IL-4].
- IL-4: stimulates B cells to differentiate into IgE-
secreting plasma cells.
- IL-5: acts as chemoattractant for the
eosinophils.
- Eosinophilia is common finding in various
helminthic infections.
Humoral Immune Response
Th-2 response activates the B cells to produce
antibodies which in turn have various roles against
parasitic infections. They are:
- Neutralization of parasitic toxins (mediated by
IgA and IgG).
- Preventing attachment to the gastrointestinal
tract (GIT) mucosa (mediated by secretory
IgA).
- Agglutinating the parasitic antigens thus
preventing invasion (mediated by IgM).
- Complement activation (by IgM and IgG):
Complements bind to the Fc portion of the
antibody coated to the parasitic cells.
Activation of the complements leads to
membrane damage and cell lysis.
- Antibody dependent cell-mediated
cytotoxicity (ADCC) is important for killing of
the helminths. NKs bind to the Fc portion of
the IgG antibody coated to the helminths.
Activation of NKs leads to release of perforin
and granzyme that in turn cause membrane
damage and cell lysis.
- Mast cell degranulation: IgE antibodies
coated on mast cells when get bound to
parasitic antigens, the mast cells become
activated and release a number of mediators
like serotonin and histamine.
Hypersensitivity Reactions in Parasitic Infections
- Immune responses may be exaggerated or
inappropriate in the sensitized individuals on
re-exposure to the same antigen.
- Such type of immunopathologic reactions are
called as hypersensitivity reactions that may
be harmful to the hosts causing tissue
damage.
Type I Hypersensitivity Reactions
- These are allergic or anaphylactic reactions,
occurring within minutes of exposure to
parasitic antigens due to IgE mediated
degranulation of mast cells.
- Examples: Cercarial dermatitis (Swimmer’s
Itch) in schostosomiasis, Loeffler’s syndrome
in ascaris, Ground itch (hookworm infection),
Anaphylaxis due to leakage of hydatid fluid
(Echinococcus granulosus), Cason’s test
(done in the diagnosis of hydatid disease),
Tropical pulmonary eosinophilia (occult
filariasis).
Type II Hypersensitivity Reactions
These are mediated by IgG or rarely IgM antibodies
produced against the antigens on surfaces of the
parasitic cells causing antibody mediated destruction
of the cells by:
- i) the complement activation or
- ii) by the NK cell activation (ADCC – antibody
dependent cell mediated cytotoxicity)
Examples: Anemia in malaria, Black water fever in
malaria following quinine therapy, Myocarditis in
Chagas’ disease, Killing of the helminths by NK cells.
Type III Hypersensitivity Reactions
- Immune complexes are formed by the
combination of parasitic antigens with the
circulating antibodies (IgG) which get
deposited in various tissues.
- Examples: Nephrotic syndrome in
Plasmodium malariae, Katayama fever in
schistosomiasis, African trypanosomiasis,
Onchocerciasis.
Type IV Hypersensitivity Reactions
- This is T-cell mediated delayed type of
hypersensitivity reaction. Previously sensitized
T helper cells secrete a variety of cytokines,
on subsequent exposure to parasitic antigens.
Usually, the pathogen is cleared rapidly with
little tissue damage. However, in some cases,
it may be destructive to the host resulting in
granulomatous reaction.
 - Examples: Elephantiasis (in filariasis), (do not cause
Granulomatous disease in schistosomiasis harm to their
and other helminthic infections, Leishmaniasis. host, however
if the immune
Parasite Evasion Mechanism system is
weak they
- Resistance to Immune Response may cause a
- Immune Suppression disease, for
- Antigenic Variation example of
- Host Mimicry which are
- Intracellular Sequestration those patient
infected with
HIV infection,
diabetes
Protozoan: Amoeba mellitus and
other
illnesses so
Amoeba - Single-celled protozoa they are
- Greek word “amoibe” prone to
meaning “change”. having
- Constantly change their infection).
shape due to presence of an
organ locomotion: Taxonomal Classification
Pseudopodium - 1980s : Phylum Sarcomastogophora,
- Classification: Habitat or Subphylum Sarcodina, Superclass Rhisopoda,
Taxonomical. Class Lobosea, Sublcass Gymnamoebia,
Order Amoebida, Family Endamoebidae

- Last 30 years, the taxonomy is changed and

currently the new molecular classification is
followed

Pathogenic Intestinal Amoeba

Classification Based on Habitat

1. Intestinal - Entamoeba histolytica (only
amoebae: pathogenic)
large intestine - E.dispar
of humans - E. moshkovski
Entamoeba - Worldwide in
and animals. - E. coli
histolytica distribution but more
- E. polecki
common in tropical
- E. hartmanni
and subtropical
- E. gingvalis
countries.
- Endolimax nana
- 3 subspecies:
- Iodamoeba butschli
histolytica, dispar, and
moshkovskii.
2. Free – - Acanthamoeba species
- Cysts and
living - Naegleria fowleri
trophozoites of all
amoeba: - Balamuthia mandrillaris
three subspecies are
small free - Sappinia diploidea
morphologically
living and
indistinguishable.
opportunistic
pathogens
 - It causes amoebic
dysentery, amoebic Feeding and replicating form
liver abscess. of the parasite found in the
feces of patients with active
disease.
History of - First described by
Entamoeba Fedor Losch (1875) 12-60um (average 15-20 um)
histolytica from Russia. diameter.
- The species name
was first coined by Cytoplasm: clear ectoplasm
Fritz Schaudinn in and granular endoplasm
1903.
- Brumpt: described Glandular endoplasm:
and designed the ground glass appearance and
nonpathogenic form contains RBCs, EBCs and
of E. histolytica as E. food vacuoles (contains tissue
dispar in 1993. debris and bacteria).

Epidemiology - The largest burden of Pseudopodia: longer finger

the disease occurs in like projections; exhibits
tropics of China, active, unidirectional rapid
Central and South progressive and purposeful
America, and Indian movement.
subcontinents
affecting 10% of the Nucleus
world’s population. - Single and spherical.
- Third most common - 4-6 um in size
parasitic cause of - Contains central dot
death in the world. like compact
- Approximately 50 karyosome
million cases and surrounded by a clear
110,000 deaths are halo.
reported annually by
the World Health Nuclear membrane
Organization. - Thin and delicate
- Lined by a layer of the
Morphology E. histolytica has three stages: chromatin granules.
(1) trophozoite, (2) precyst, - Number of
(3) cyst (immature and chromosomes varies
mature) between 30 and 50.

Cart-wheel appearance:
- Space between the
karyosome and the
nuclear membrane is
traversed by spoke
like radial
arrangement of
achromatic fibrils.

Anaerobic parasites:
- No mitochondria,
endoplasmic
reticulum and golgi
apparatus.

Precyst Intermediate stage between

trophozoite and cyst.
Trophozoites Invasive form
 Smaller to trophozoite but
larger to cyst (10 – 20 um)
Oval with a blunt
pseudopodia.
Food vacuoles and RBCs
disappear.
Nuclear structures are same
as that of trophozoite.
Cyst Infective form and diagnostic
form.
Measures 10-20 um (average
12-15 um) diameter.
Nuclear structures are same
as in trophozoites.
- 1st: Uninucleated
- 2nd: binucleated
- 3rd: quadrinucleated
Life Cycle - Host: complete life
cycle in one host like
humans.
- Infective form:mature
quadrinucleated cyst.
Mode of Feco-oral route: ingestion of
Transmission contaminated food or water
with mature quadrinucleated
cyst
Sexual Contact: anogenital or
orogenital tract.
Vector: flies and cockroaches
Development in Man (small intestine)
Asymptomatic cyst Trophozoites don’t cause any
passers lesion, transform into cysts
and are excreted in feces.
Amoebic dysentery Proteolytic enzymes causes
destruction and necrosis of
tissue and produces flask
shaped ulcers on the intestinal
mucosa.
Amoebic Liver Extensive erosions and
Abscess necrosis of small intestine ->
entrance into the radicals of
portal veins -> multiply in liver.
Development in Man (large intestine)
Encystation The trophozoites transform
into precyst then into
quadrinucleated cysts which
are liberated into the feces.
Factors that induce 1. food deprivation
cyst formation: 2. overcrowding
3. dessication
4. accumulation of waste
products.
5. cold temperatures
Pathogenesis of Intestinal Amebiasis
Trophozoite of E. Histolytica is the major invasive form
and possesses many virulence factors that play role in
the pathogenesis of intestinal as well as extraintestinal
amoebiasis.
Virulence factors of - Amoebic lectin
Entamoeba antigen: principle
histolytica virulent factor.
 - Amoebapore: inserts Chronic amoebiasis Characterized by thickening,
ion channels in the fibrosis, and stricture
target cell membrane. formation with scarring and
- Cysteine proteases: amoeboma formation.
secreted by
trophozoites of Pathogenesis of Extraintestinal Amoebiasis
Entamoeba histolytica.
- Hydrolytic enzymes: 5-10% develop extra-intestinal amoebiasis following 1-
destruction of the 3 months of intestinal amoebiasis.
target tissue.
- Neuraminidase and Liver: most common site (lungs, brain, genitourinary
metallocollagenase: tract and spleen).
help in invasion.
Amoebic Liver Abscess
Amoebic Ulcer - Flask-shaped ulcer: - Most common group affected are adult
classical ulcer (broad males. (9:1 M to F ratio)
base with a narrow - Posterior-superior surface of the right lobe of
neck) liver.
- Ileocecal region: - Abscess: single or rarely multiple
most common site
(sigmoidorectal Amoebic Liver Abscess
region or
generalized)
- Scattered with
intervening normal
mucosa.
- Superfical or Deep
Ulcer
- Size: pin head to
inches
- Shape: round to oval
- Margin: ragged and
undermined
- Base: formed on
muscle coat.

Complication of Intestinal Amoebiasis

Fulminant amoebic Generalized necrotic
colitis involvement of entire large
intestine commonly in
immunocompromised
patients.
Amoebic Infection involves the
appendicitis appendix.
Intestinal Ulcer progress beyond the
perforation and serosa.
amoebic peritonitis
Toxic megacolon Segment of intestine
and invaginates into adjoining
intussusception intestinal lumen, causing
bowel obstruction.
Amoeba (amoebic A diffuse pseudotumor like
granuloma) mass of granulomatous tissue
found in rectosigmoid colon.
Complication of Amoebic Liver Abscess
- Granuloma cutis: right sided liver abscess
may rupture externally to the skin.
- Pulmonary amoebiasis: rupture of right sided
liver abscess into the lungs.
- Amoebic pleuritis: rupture of right sided liver
abscess into the right pleura.
- Subphrenic abscess and generalized
peritonitis
- Amoebic pericarditis
- Hematogenous spread: brain, lungs, spleen,
and genitourinary organs.
Clinical Manifestation of Amoebiasis
Asymptomatic - 90% of infected
amoebiasis individual
- 10% of infected
people produces a
spectrum of disease
varying from intestinal
amoebiasis to
 amoebic liver - 50-7-% sensitivity
abscess. - 100% specificity
- Other culture medias used are:
Intestinal - IP: 1 to 4 weeks 1. National Institute of Health (NIH) media
amoebiasis - Characterized by four 2. Boeck and Drbohlav egg serum medium
clinical forms: containing Locke’s solution
1. Amoebic 3. Balamuth’s medium
dysentery 4. Nelson’s medium
2. Amoebic 5. Robinson’s medium
appendicitis - Axenic culture: lacks bacterial supplement.
3. Amoeboma - Examples of an axenic culture: Diamond’s
4. Fulminant colitis medium
- Advantages: useful when the bacterial flora
Amoebic liver interferes with the test results.
abscess
Stool Antigen Detection
Laboratory Diagnosis - Counter current immune electrophoresis
- Stool microscopy: wet mount, permanent (CLEIP)
stains. - Enzyme-linked immunosorbent assay (ELISA
- Stool culture: polyxenic and axenic culture - Immunochromatographic test (ICT)
- Stool antigen detection (copro-antigen): CIEP,
ELISA, ICT Remember: antigens get denatured by stool
- Serology preservatives, only fresh and frozen stoo sample
1. Amoebic antigen – ELISA should be used.
2. Amoebic antibody – IHA, ELISA, and IFA
- Isoenzyme (zymodene) analysis ELISA detecting - 95% sensitivity and
- Molecular diagnosis: Nested multiplex PCR 170 kDa of lectin specificity.
and real time PCR. antigen - Differentiates
pathogen Entamoeba
Sample Collection histolytica and
- Stool: specimen of choice nonpathogenic
- Minimum of three samples should be Entamoeba dispar
collected on consecutive days. (lectin antigen
- Stool specimen should be collected wide negative)
mouthed clean container before
administration of interfering substances. Immunochromatogr - Simultaneous
- Other sample: rectal exudates and rectal ulcer aphic Test detection of antigens
tissues. specific for Giardia
- Examined within 1-2 hours of collection or lamblia, Entamoeba
preserved in polyvinyl alcohol or Merthiolate hostolytica/
iodine or formalin. Entamoeba dispar and
Cryptosporidium
Stool Microscopy parvum from stool
- Direct examination of the stool by saline and - 83-96% sensitivity
iodine mount. - 99-100% specificity
- Motility of trophozoites: saline mount
- Internal structures of cyst: iodine mount Serology
- Stool or colonoscopy guided biopsy samples: Amoebic antigen: presence in serum indicates recent
stains like trichrome, periodic acid Schiff and and active infection.
hematoxylin and eosin stains.
- Entamoeba histolytica indistinguishable from ELISA: done using monoclonal antibody specific for
that of Entamoeba dispar and moshkovskii lectin antigen; sensitivity of 65%
with an exception.
Stool Culture Various other antigens: serine rich Entamoeba
- Culture methods are not routinely used for histolytica protein (SREHP), lysine rich surface antigen
diagnosis. and lipophosphoglycan (LPG).
- Polyxenic culture: culture media contains
bacterial supplement, starch and serum Other older methods for antigen detection:
providing nourishment to amoeba. 1. CIEP
2. Coagglutination test
3. Slide agglutination test
Amoebic antibody: appear only in the later stages of
intestinal amoebiasis
Various tests include:
1. ELISA
2. Indirect fluorescent antibody (IFA) test
3. Indirect hemagglutination (IHA) test
ELISA detecting antibody against lectin antigen shows
90% sensitivity in convalescent stage and 75-85% in
early stage.
Isoenzyme (zymodeme) analysis: hexokinase, malic
enzyme, isomerase, and phosphoglucomutase.
Differentiate Entamoeba histolytica and Entamoeba
dispar.
Entamoeba Dispar
It is morphologically indistinguishable (both cyst and
trophozoite) from Entamoeba histolytica.
It can be distinguished from Entamoeba histolytica by:
1. Zymodeme study
2. Molecular methods, PCR amplifying small subunit
rRNA gene
3. Detection of lectin antigen in stool.
4. RBC inside trophozoites – present only in
Entamoeba histolytica.
It was described by Brumpt in 1993
It was nonpathogenic, usually colonizes in the large
intestine but doesn’t invade intestinal mucosa.
Grows well in polyxenic media.
It does not induce antibody production.

Disadvantages: difficulty of performing the test, time-

consuming and difficulty in preparing the antigens by
culture.

Molecular Diagnosis
Polymerase Chain - Targeting small
Reaction (PCR) subunit ribosomal
ribonucleic acid
(rRNA) genes
- Differentiate
Entamoeba histolytica,
Entamoeba dispar,
and Entamoeba
moshkovskii.
- Sensitivity nearing
90%
- Specificity 90-100%
- Real-time PCR and
Conventional PCR.

Treatment
Metronidazole: drug of choice for intestinal
amoebiasis and amoebic liver abscess.

Other measures include fluid and electrolyte

replacement and symptomatic treatment.

Prevention
Preventive measures are as follows:
- Avoidance of the ingestion of food and water
contaminated with human feces.
- Treatment of asymptomatic person who pass
Entamoeba histolytica cysts in the stool.

**No effective vaccine licensed for human use.

Notes: