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[NOTES] PROTOZOA (2nd Year BS Medical Technology)

Clinical Parasitology (Centro Escolar University)

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CLINICAL PARASITOLOGY • May adopt in a different host and transfer themselves

Module 5 - Protozoa passively in the cystic stage
✓ Digenetic protozoa
Transcribed by PORPION • Require two hosts to complete their life cycles
References: Canvas introduction, PowerPoint presentation, • Leishmania spp, Trypanosoma spp., and
and video discussion Plasmodium spp.
o In malarial infection, man is the
TABLE OF CONTENTS secondary/intermediate host, but the mosquito
Introduction is the primary/definitive host
Taxonomy o In trypanosomiasis, the tsetse fly is the
Locomotory Organ Distinctions intermediate host and man is the definitive host
Phylum Sarcomastigophora ✓ Amoeba o In leishmaniasis, the sandfly is the intermediate
– Subphylum Sarcodina ✓ Commensal Amoeba host and man is the definitive host
Free-Living Amoebas ✓ Naeglaria fowleri
✓ Acanthamoeba spp. TAXONOMY
✓ Other Free-living Kingdom Protista -> Subkindgom Protozoa -> Phlyum
Amoeba Sarcomastigaphora, Phylum Ciliophora, Phylum
Phylum Ciliophora ✓ Balantidium coli Apicomplexa, and Phylum Microscopa
Phylum Sarcomastigophora ✓ Atrial Flagellates
– Subphylum Mastigophora ✓ Giardia lamblia LOCOMOTORY ORGAN DISTINCTIONS
✓ Trichomonas vaginalis ✓ Differences in locomotory organs
✓ Non-Pathogenic Atrial • Subphylum Sarcodina has pseudopodium (false
Flagellates feet)
✓ Blood and Tissue • Subphylum Mastigophora has flagella
Flagellates • Phylum Ciliophora has cilia
✓ Trypanosoma spp.
✓ Leishmania spp. PHYLUM SARCOMASTIGAPHORA – SUBPHYLUM
✓ Pathogenesis of the SARCODINA
Leishmania spp. All organisms under Subphylum Sarcodina are known as
Phylum Apicomplexa – ✓ Plasmodium spp. ‘amoebas’
Plasmodium spp. and ✓ Life Cycle
Babesia spp. ✓ Pathology: Classical AMOEBA
Malaria Paroxysms ✓ Have pseudopodium (hyaline foot-like protrusion for
✓ Diagnosis locomotion)
✓ Treatment ✓ All amoebas are commensal (non-pathogenic unless the
✓ Resistance to Malaria host is immunocompromised) except for Entamoeba
✓ Plasmodium knowlesi histolytica
✓ Babesia spp. ✓ All are intestinal dwellers (specifically the large intestine)
except Entamoeba gingivalis (found in the mouth)
INTRODUCTION ✓ All undergoes encystation (trophozoite -> cyst stage
✓ Need a microscope to view, unlike metazoans which occurs in the large intestine) except for
✓ The science of the study of the protozoa is called Entamoeba gingivalis and Dientamoeba fragilis
protozoology ✓ Multiplies through binary fission (trophozoite)
✓ They are the first group of organized but simplest animals ✓ Life cycle (Process of encystation)
in the animal kingdom 1. Trophozoite form
✓ They are unicellular without any tissue grade of 2. Pre-cystic form
organization 3. Cystic form (with hyaline cystic wall)
✓ They generally multiply asexually 4. Metacystic form
• By binary or multiple fission, budding, and in some
cases, sexual reproduction by conjugation. NOTE: Excystation is cyst -> trophozoite which occurs in the
• May switch to sexual method or undergo cystic small intestine
change to its host
• Parasitic protozoa perform asexual and sexual Entamoeba histolytica
reproduction in different hosts (alternation of ✓ First described by Loesch in 1880
generation) ✓ Direct life cycle
✓ They are very minute and microscopic animals ✓ Multiplies by binary fission
✓ The structure of a protozoan “cell” consists of
• Nucleus NOTE: Refer to the PowerPoint presentation for the life cycle
• Cytoplasm body
o Differentiated into two parts Infective stage Cyst
- Outer hyaline portion, the ectoplasm Mode of transmission Ingestion of food/water with
(locomotive, for protection, and for sensory E. histolytica cyst
purposes) Phoretic vectors Cockroach and flies
- Inner granular portion, the endoplasm Pathology Amoebiasis
(nutritive and reproductive function) Treatment Metronidazole
✓ Generally possess definite locomotory organs
• Flagella, cilia, or pseudopodia Comparison of E. histolytica Trophozoite and Cyst
• A contractile vacuole is present in many protozoans Trophozoite Cyst
• Some form cysts in extreme conditions Motile Non-motile
✓ Can be free-living, parasitic, or symbiotic in nature NOTE: Because only
✓ Monogenetic protozoa trophozoites have
• Require one host to complete their life cycle pseudopods
• Amoeba, intestinal flagellates, and B. coli
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Feeding stage
Vegetative state
Found in watery, soft, or
semi-formed stool
Fragile
Non-feeding stage ✓ The 1st image shows the I. butschlii cyst while not stained
Infective stage with iodine, the 2nd image shows the cyst stained with
Found in soft to formed stool iodine
Resistant to acidic pH

NOTE: Due to its cystic wall

NOTE: They are destroyed which contains chitin and
by gastric juices hence they lectins (Jacob and Jessie
are the non-infective stage lectins)
Cannot encyst if excreted Morphologic Comparison of E. histolytica and E. coli
from body TROPHOZOITE STAGE
E. histolytica E. coli
NOTE: Encystation only Movement Unidirectional, active Sluggish, non-
occurs in the large intestine progressive progressive
Pseudopodi Finger-like Blunt
NOTE: Once the cyst is in the small intestine, it undergoes a shape
excystation which involves nuclear division. The nuclei of the Release of Explosive/one at a Slow
cyst divides from 4 to 8 nucleus. After nuclear division, it pseudopodi time manner/several at
undergoes cytoplasmic division. Excystation yield 8 a a time
trophozoites due to E. histolytica cyst being quadri-nucleated
Nucleus Uninucleated with Uninucleated with
(it can have 4 nuclei).
central karyosome eccentric
karyosome
COMMENSAL AMOEBA
Cycoplasm Clean-looking Dirty-looking
Entamoeba coli
(endoplasm
Harmless inhabitant of the colon )
Inclusion RBCs Bacteria, yeast,
Entamoeba dispar cell debris
✓ Morphologically similar with E. histolytica but with a Size Bigger (12- Smaller (15-
different genome 60micrometers) 50micrometers)
✓ Distinguished from E. histolytica by PCR Image

Entamoeba hartmanni
✓ Similar with E. histolytica but smaller and has no RBC
inclusion
✓ Known as the “small race” of E. histolytica
✓ Their cysts are quadrinucleated with coarse cytoplasm;
immature cyst has chromatoidal bars

Entamoeba polecki
✓ Parasite of pigs and monkeys; rarely infect humans
✓ Distinguished from E. histolytica by Cyst
✓ Their cysts are consistently uninucleated

Entamoeba gingivalis
✓ Can be found in the mouth (gum and teeth surface)
✓ Abundant in cases of oral disease
✓ No cyst stage
✓ Transmitted through kissing, droplet spray, sharing
utensils
NOTE: The four morphologically similar amoebas are the E.
Entamoeba moshkovskii histolytica, E. dispar, E. moshkovskii, and E. 2angladeshi.
✓ Morphologically similar with E. histolytica and E. dispar
CYST STAGE
✓ Classified as free-living amoeba (rarely infect humans)
E. histolytica E. coli
✓ Osmotolerant
Number of Quadrinucleated (< > 4 (mature: 8)
✓ Able to survive at temperature range of 0-41°C
nuclei or = 4)
Endolimax nana Chromatoid Cigar-shaped/rod- Witch-
al bars shaped/Coffin-lod broom/splintered/
✓ Smallest protozoa needle-like
✓ Its trophozoite form is sluggish and Nuclear Thin Thick
mononuclear membrane
✓ Its cyst form is quadrinucleated with
Size 10-20micrometers 8-35micrometers
eccentric karyosome (Cross-eyed cyst)
Image

Iodamoeba butschlii
✓ Has an iodine cyst (cyst which has affinity to iodine)
✓ Has a large glycogen vacuole/body which stains deeply
✓ with iodine
✓ Uninucleated

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o Entamoeba spp. stained blue

• Saline + Lugol’s Iodine
o Only nucleus of E. histolytica cyst can be
observed
✓ Concentration Techniques (FECT, MIFT)
✓ Culture:
• To isolate E. histolytica
• Robinson’s & Inoki medium
• Balameth Monophasic medium
• Boeck & Dorbolav’s Diphasic medium
Pathogenesis (Amoebiasis)
• TYS-S-33
✓ Intestinal amoebiasis ✓ Serologic Tests (ELISA, IHAT, CIE, AGD, IFAT)
• Most common pathology ✓ Liver aspirate biopsy
• Amoebic dysentery • Checks for presence of E. histolytica trophozoite in
o Caused by E. histolytica case of extraintestinal infections
o Differentiated from bacillary dysentery (caused ✓ Radiographic techniques (X-Ray, MRI, CT-Scan)
by the Shigella dysenteriae bacteria) by the ✓ Molecular Tests (PCR)
presence of Charcot-Leyden crystals • Differentiates morphologically similar amoeba
• Amoebic colitis
o Ulceration of intestine (cecum, rectosigmoid) NOTE: IHAT can detect past infections up to 10 years. In
o Caused by E. histolytica terms of Lugol’s iodine, only cysts can be observed because
o The ulcer is flask-shaped iodine destroys trophozoites due to their fragility

Other Intestinal Amoeba

✓ Blastocystis hominis
• No exact taxonomic
classification (stramenophile)
• Ovoid or spherical, vacuole-like
structure
• May cause diarrhea to some
patient (immunocompromised)
• Commensal
Pathogenesis (Extraintestinal Amoebiasis) ✓ Dientamoeba fragilis
✓ Occurs due to its motility • Commensal
✓ Hepatic amoebiasis • Ameboflagellate
• Most common • No cyst stage
extraintestinal amoebiasis • Rosette-shaped nuclei (1-
• Amoebic liver abscess has 2); no peripheral chromatin
an anchovy sauce-like • Can be transported by
appearance pinworm to man
✓ Pulmonary amoebiasis • Chronic infection may
✓ Cerebral amoebiasis mimic Irritable Bowel
✓ Amebic pericarditis Syndrome
✓ Cutaneous amoebiasis
✓ Genital amoebiasis FREE-LIVING AMOEBAS

Naeglaria fowleri
Virulence Factors ✓ Causative agent of Primary Amoebic
✓ Pathogenic determinants Meningoencephalitis (PAM)
✓ Gal/Gal Nac Lectin ✓ Thermophilic organisms (up to 30°C)
• Galactose/N-acetyl galactosamine ✓ Multiplies through promitosis (intracellular mitosis)
• Cytoadherence • The nuclear membrane doesn’t break down
o Attachment to large intestine
✓ Caspase-3 Mode of Transmission
• Causes apoptotic death of mucosal cells Oral and intranasal routes while swimming in contaminated
✓ Myosin IB lakes, pools, and rivers
• Ingestion of RBC
• Results in presence of RBCs in E. histolytica Diagnosis
✓ Amebapores ✓ Uses cerebrospinal fluid
• Pore-formers • Collected through spinal tap
• Causes ulceration of tissues/cells of the host ✓ Culture
✓ Cysteine proteinase • Non-nutrient medium with Page’s saline seeded with
• The most virulent factor living Escherichia coli
• Tissue invasiveness ✓ PCR
o Leads to extraintestinal amoebiasis ✓ ELISA

Laboratory Diagnosis Ways to Eliminate

✓ Direct Fecal Smear ✓ 1mg/L chlorine solution
• Saline solution (0.85-0.95 NSS) ✓ pH 8-8.01
o Trophozoite motility is observed ✓ Place in 38°C water
• Saline + Methylene Blue
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Morphologic Forms OTHER FREE-LIVING AMOEBA

CYST TROPHOZOITE Balamuthia mandrillaris
AMOEBOID FLAGELLATE Pathology is similar with GAE
D
Uninucleated with ✓ Only form ✓ With two CYSTS TROPHOZOITES
rounded recognized flagella at ✓ Spherical Finger-like pseudopodia
chromatoidal bars in humans broad end ✓ Three layered
✓ With single ✓ Spinning or cystic walls (visible
pseudopod jerky through electron
✓ Uninucleate motility microscopy)
d with large ✓ (directional) ✓ Two layers (visible
central ✓ Does not through light
karyosome divide microscopy)
without
peripheral
nuclear
chromatin

Sappinia diploidea
Acanthamoeba spp. ✓ Newly recognized human
✓ Most common is A. castellani pathogen causing amoebic
encephalitis
Pathology ✓ Trophozoite
✓ Granulomatous Amebic Encephalitis (GAE) • With two nuclei attached
together by connecting
• Destructive encephalopathy and associated
perpendicular filaments
meningeal irritation
✓ Amebic Keratitis (AK)
• Associated with improperly
disinfected contact lenses
PHYLUM CILIOPHORA
(when cleaned with tap
Known as ciliates
water or impure lens
solution)
Balantidium coli
✓ Only member of the Phylum Ciliophora
Mode of Transmission
✓ Largest intestinal protozoan
✓ Intranasal
✓ Entrance of pathogen through cuts, wounds. First name Paramecium coli
Former name B. coli
Diagnosis New name Neobalantidium coli
✓ Specimen Infective stage Cyst
• Discharges, exudates, tissue secretions. Reservoir host Pigs
✓ Culture Mode of transmission Ingestion of infective stage
• PYGC medium with antibiotics
o Peptone yeast glucose cysteine Morphologic Forms
o The antibiotics remove unwanted bacterial
CYSTS TROPHOZOITES
growth
✓ Ovoid, rounded ✓ “Thrown ball/Rolling” motility
Morphologic Forms with well- defined ✓ Ovoidal, bean-shaped
cystic wall (cilia ✓ Prominent cytostome (for
CYSTS TROPHOZOITES enclosed in cystic food entry)
✓ Double-walled ✓ With large nucleus with wall) ✓ Indented cytopyge (for waste
✓ With ostioles (pores in centrally located ✓ Binucleated exit)
between the cyst walls) nucleolus ✓ 2 nuclei
✓ With acanthopodia ✓ Macronuclei
(spiny-filaments or (vegetative)(bigger/kidney-
“thorn-like”) shaped)
✓ appendages for ✓ Micronuclei
locomotion (reproductive)(smaller/round-
✓ Replicates by mitosis shaped)

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Pathology ✓ Chronic infection is seen with steatorrhea (passage of

✓ Balantidiasis/Balantidial Dysentery/Ciliary Dysentery fats in stool)
• Similar with Amoebic dysentery • Fats are nonpolar so they float in water
• Characteristic of the diarrhea is blood stool with
mucous Morphologic Forms
CYSTS TROPHOZOITES
Virulent Factors ✓ Ovoid, football ✓ Bilaterally symmetrical
✓ Hyaluronidase (lytic enzyme that causes ulceration) shaped ✓ Pear/tear drop shaped,
• Lytic enzymes cause cell destruction ✓ Quadrinucleated pyriform
✓ Ulceration (rounded base and wide neck) (mature cyst) ✓ With Large ventral
✓ Young cyst has 2 sucking disc (for
Laboratory Diagnosis nucleus attachment)
✓ Thick shell (double- ✓ “Old man with
✓ Specimen used is stool
walled) eyeglasses”
✓ Direct Fecal Smear
✓ Flagella retracted to ✓ 4 pairs of flagella
✓ Concentration techniques
axoneme (median - One pair – anterior
body) - One pair – posterior
Treatment
✓ Deeply stained curved - 2 pairs – central,
Tetracycline or Metronidazole fibril extending laterally
✓ 2 nuclei with distinct
PHYLUM SARCOMASTIGOPHORA – SUBPHYLUM karyosome (bilaterally
MASTIGOPHORA ✓ symmetrical)
✓ Present axostyle with
ATRIAL FLAGELLATES parabasal body (energy)
General Structure ✓ “Falling-leaf motility”
✓ Flagella (locomotor apparatus) ✓ Multiplies by
✓ Kinetoplast (provides energy) Longitudinal Binary
• Blepharoplast Fission
• Parabasal Body ✓ Covered with variant-
✓ Cytostome (cell mouth) specific surface proteins
• For food entry (VSPs)
✓ Undulating membrane (membrane laterally projecting
from the body of certain flagellates, participates in active
motility of the flagella)
✓ Axostyle/axial rod (supports locomotion)
✓ Costa (rib-like structure within the cytostome)

Giardia lamblia
✓ First described by Antoine van Leeuwenhoek using his
own stool
✓ Multiplies by binary fission
NOTE: VSPs are surface antigens present around the
NOTE: Refer to the PowerPoint presentation for the life cycle trophozoite

Old name G. lamblia Diagnosis

Other names G. intestinalis, Lamblia ✓ Specimen used are stool and duodenal aspirates
duodenalis, L. intestinalis, ✓ Stool Exam
Cercomonas intestinalis ✓ Duodenal Aspirates
New name Giardia duodenalis ✓ Beale String Test/Entero-Test
Habitat Duodenum (where it ✓ Immunochromatography
performs excystation for • For antigen detection in stool
~30mins.), jejunum, and • Utilizes the VSPs
upper ileum ✓ Direct Fluorescent Antibody Assay
Diagnostic stage Trophozoite and cyst • Gold standard for detection
Infective stage Mature cyst
Mode of transmission Ingestion of infective stage Trichomonas vaginalis
Treatment Metronidazole ✓ The ONLY pathogenic Trichomonas spp.
✓ Most prevalent non-viral sexually transmitted infection
Pathology ✓ No cyst stage
✓ Can be transferred from the pregnant woman to their child
✓ Giardiasis, Traveller’s Diarrhea, Gay-bowel syndrome
through the birth canal
✓ Acute infection has a “rotten egg” odor of stool
✓ Multiplies by binary fission
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NOTE: Refer to the PowerPoint presentation for the life cycle ✓ “Boring/spiral” or “cork-
screw” motility
Diagnostic stage Trophozoites
Infective stage Trophozoites
Mode of transmission Sexual intercourse
Habitat ✓ Urogenital tract
- Female (Vulva/vagina
where pH is 5.2-6.4)
- Male (prostate gland)
Treatment ✓ Oral Metronidazole
✓ Acidic douche (10%
vinegar) Retortamonas intestinalis
CYSTS TROPHOZOITES
Pathology ✓ Lemon-shaped/Pear- ✓ Single large nucleus in
✓ Female (Trichomoniasis, Ping-pong disease) shaped the anterior portion of
• Non-specific vaginitis ✓ Uninucleated with the organism
central karyosome ✓ Cytostome opposite to
• Itchiness, burning
✓ With two fused fibrils the nucleus
sensation
anterior to the nuclear
• Vulvovaginitis
region
• Greenish-yellow
leukorrheic discharge
• Inflammation of cervix
(“strawberry cervix”)
✓ Male (often asymptomatic)
• Non-specific prostatitis, UTI

Morphologic Forms
✓ Trophozoite:
• Pear-shaped/pyriform shaped
• 4 anterior flagella Enteromonas hominis
• Short Undulating membrane (with one flagella) CYSTS TROPHOZOITES
• “Rapid Jerky/Jerky-tumbling motility” ✓ One to four nuclei ✓ Single nucleus with
located at the opposite large central
ends karyosome
✓ With central ✓ 4 flagella: 3 directed
karyosome anteriorly, 1 directed
✓ With well defined posteriorly
cystic wall

Diagnosis
✓ Microscopy (can be stained with Giemsa or Wright)
• Female: Urine, Vaginal Discharge, Vaginal
Scrapping
• Male: Urine, Prostatic Fluid, Seminal Fluid Trichomonas hominis
✓ Culture: ✓ Usually found in the intestines
• Medium: ✓ Commensal
o Diamond’s Modified Culture Medium ✓ Relatively smaller than T. vaginalis
o Feinberg-Whittington Culture Medium
o Trypticase Liver Serum Medium CYSTS TROPHOZOITES
NO CYST STAGE ✓ Pear-shaped
NON-PATHOGENIC ATRIAL FLAGELLATES ✓ Full body-length
Chilomastix mesnili undulating membrane
✓ Largest flagellate in man ✓ Uninucleated with
small central
CYSTS TROPHOZOITE karyosome
✓ “Nipple-like cyst” ✓ Asymmetrical ✓ Motility: Jerky motility
✓ Uninucleated with ✓ Pear shaped
distinct anterior ✓ 3 anterior flagella
protuberance ✓ 1 flagellum inside
cytostome –
cytostomal fibril
“shepherd’s crook”
(safety-pin
appearance)
✓ Prominent spiral
groove in the
midportion of the body
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Trichomonas tenax Trypanosoma cruzi

✓ Usually found in the mouth ✓ Infective stage
• Man: Metacyclic trypomastigote
CYSTS TROPHOZOITES • Vector: Trypomastigote
NO CYST STAGE ✓ Four anterior flagella ✓ Mode of transmission: Vector-borne
✓ One posterior flagella
Pathology of T. cruzi (Chaga’s Disease)
✓ “American trypanosomiasis”
✓ Fatal in young children
✓ CHAGOMA – inflammation a the site of inoculation
✓ Phases:
• Acute Trypanosomiasis
o Generalized
lymphadenopathy
o ROMAÑA’S SIGN –
BLOOD AND TISSUE FLAGELLATES edema of eyelid and
conjunctiva
Morphologic Form of Trophozoites
AMASTIGOTE PROMASTIGOTE EPIMASTIGOTE TRYPOMASTIGOTE
SHAPE
Round to oval Long and slender Long and slightly wider than C, S, or U shaped
promastigote

NUCLEUS LOCATION
Off center In or near center Posterior end Anterior to the kinetoplast
KINETOPLAST (Energy provider)
With dot-like blepharoplas Located in anterior end Located anterior to the Located in the posterior end
and parabasal body adjacent nucleus
to it
FLAGELLA
None (with axoneme) One which extends from the One which extends from the One which extends from the
anterior end to the posterior anterior end to the posterior anterior end to the posterior
end end end
UNDULATING MEMBRANE (Support for mobility of the flagellates)
None None Extending half of the body Extends entire body length
length

Trypanosoma spp. • Chronic Trypanosomiasis

o No characteristic symptoms; may last for 20
ETIOLOGIC VECTOR DISEASE STAGES years or more
AGENT ASSOCIATION EXHIBITED o Cardiomyopathy, megaesophagus and
T. cruzi See Chaga’s All forms megacolon (can lead to death)
below disease or
American
trypanosomiasis
Treatments for T. cruzi
T. Tsetste Gambian or Epimastigote Nifurtimox and Benznidazole
gambiense fly West African and
(Glossina Sleeping trypomastigote Life Cycle of T. cruzi
spp.) Sickness only
✓ Contains two stages
T. Rhodesian or
rhodesiense East African • Triatomine bug stages
Sleeping • Mammalian stages
Sickness
NOTE: Refer to the PowerPoint presentation for the life cycle
NOTE: T. gambiense and T. rhodesiense are part of the T.
bruzei complex which causes African sleeping sickness Laboratory Diagnosis of T. cruzi
✓ Specimen used are blood, CSF, fixed lymph nodes
Trypanosoma cruzi Vectors tissues, and lymph juices
✓ Cone-nose bug ✓ Laboratory tests
✓ Assassin bug • Stained Smear (Giemsa staining which
✓ Reduviid bug demonstrations trypomastigote)
✓ Triatomine bug • Blood Cultures (NNN medium/Novey-McNeal-
✓ Triatoma rubrofasciatica Nicolle medium)
✓ Rhodnius • Xenodiagnosis
✓ Panstrongylus • Serologic Test (IFA, IHAT, ELISA)

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✓ Molecular Testing (PCR) L. Visceral In the vector:

• Amplification of DNA from kinetoplast donovani Leishmaniasis Promastigote
(midgut and
Trypanosoma brucei Complex proboscis)

Involves T. gambiense and T. rhodesiense Life Cycle

Pathogenesis of the Trypanosoma brucei Complex ✓ Involves two stages
• Sandfly stages
✓ Chancre
• Human stages
• Earliest sign of African Trypanosomiasis
• Hard, painful lesion at the site of inoculation Pathogenesis of the Leishmania spp.
Infective Stage
✓ In man: Promastigote
✓ In the vectors: Amastigote

Mode of Transmission
Vector-borne

Cutaneous Leishmaniasis
✓ Gambian trypanosomiasis ✓ Other names are Jericho boils, Aleppo button, Baghdad
boils, Oriental sore, Delhi fever
• Known as West African Sleeping Sickness
✓ Symptoms
• Has 2 phases:
• Skin ulcer (leaves ugly scar on the skin)
• Acute: Fever, headache, joint and muscle pain,
• Painless lesions
tachycardia, dizziness and rashes
✓ In diffuse cases, it resembles Lepromatous leprosy
o Winterbottom’s
(which is caused by Mycobacterium leprae)
sign –
✓ Lesions do not heal spontaneously and tend to relapse
enlargement of
after treatment
the posterior
cervical lymph
American Leishmaniasis
node and have a
ripe plum ✓ Also known as Mucocutaenous Leishmaniasis
consistency ✓ ESPUNDIA – metastatic spread of lesion to oronasal and
pharyngeal mucosa
• Chronic: with CNS ✓ TAPIR NOSE – disfiguring leprosy-like tissue destruction
invasion and swelling
• Severe headache, ✓ CHICLERO ULCER – erosion of the pinna of the ear
alternately morose and
excitable, and lack Visceral Leishmaniasis
interest in work ✓ Also known as Kala-azar or the Dumdum fever
• Tremors and “Kerandel’s sign” – hyperesthesia and ✓ Twice daily elevation of fever (prominent finding)
inversion of sleep cycle can be observed. ✓ Splenomegaly and cachexia
✓ Rhodesian Trypanosomiasis ✓ Parasites are numerous in reticuloendothelial cells of the
• Known as East African Sleeping Sickness spleen, liver, lymph nodes, bone marrow and other
• More rapid and fatal than Gambian Trypanosomiasis organs
• CNS involvement appear earlier • Makes it fatal
• Neurologic deterioration is rapid
Laboratory Diagnosis
Laboratory Diagnosis for the T. brucei Complex ✓ Specimen used are blood and tssue Sample
✓ Specimen used are blood, CSF, and lymph juices ✓ Laboratory Tests:
✓ Laboratory Tests: • Biopsy:
• Wet Smear: presence of live parasite o Cutaneous (skin)
• Stained Smear o Visceral (bone marrow, spleen; for L. donovani)
o Giemsa staining which demonstrates • Serologic Tests:
trypamastigote o Complement Fixation Test
• Serologic Tests (IFA, ELISA, IHA) o IFA
o Counter current electrophoresis technique
Treatment for the T. brucei Complex
Treatment
✓ Only effective on early stages
✓ Suramin and Pentamidine ✓ Pentavalent antimonials
✓ Melasorprol and Tryparsamide (with CNS involvement) • Sodium stibogluconate & n-methyl-glucamine
✓ DL-alpha-difluoromethylornithine (DFMO, Eflornithine) antimonite
✓ Second-line Drugs
Leishmania spp. • Amphotericin B, Pentamidine (Kala-azar),
Metronidazole, and Nifurtimox
ETIOLOGI VECTOR DISEASE STAGES
C AGENT ASSOCIATIO EXHIBITED PHYLUM APICOMPLEXA – Plasmodium spp. AND
N Babesia spp.
L. tropica Sandfly Cutaneous In humans: Also known as coccidian
vectors Leishmaniasis Amastigotes
L. (Phlebotomu American (reticuloendotheli Coccidian
braziliensis s spp.) Leishmaniasis al system)

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✓ Spore forming , single-celled obligate intracellular Pre-Erythrocytic Cycle (Schizogony)

parasites Occurs inside the liver of man
✓ Habitat: Intestine
✓ Pathology: They are generally opportunistic pathogens SPOROZOITES INFECTS THE LIVER PARENCHYMAL
CELLS -> FORMS SCHIZONTS (balloon-like merozoites) ->
Coccidian Life Cycle SCHIZONTS MULTIPLY UNTIL LIVER CELLS CANNOT
✓ Sporogony CONTAIN THEM -> LIVER CELLS RUPTURE (releasing
• Sexual cycle producing oocysts (outside human merozoites) -> RELEASED MEROZOITES ENTER
host) ERYTHROCYTIC CYCLE
• Occurs in the vector
✓ Schizogony Erythrocytic Cycle
• Asexual cycle producing merozoites (inside human Occurs inside man
host)
• The human host acts as the intermediate host MEROZOITES INVADE THE RBCS -> ONCE INVADED,
✓ Gametogony THEY FORM RING FORMS (young trophozoites)* ->
• Development of male and female gametocytes DEVELOP TO MATURE TROPHOZOITES -> DEVELOP TO
SCHIZONTS (RBC) -> MULTIPLIES CAUSING RBC TO
Plasmodium spp. RUPTURE AND RELEASE MEROZOITES** -> DEVELOPS
✓ Causative agent of Malaria (Mal’aria = bad air) INTO MICRO OR MACRO GAMETOCYTES
✓ Leading parasitic disease that causes mortality worldwide
✓ 4 species (in order of frequency in the Philippines): * These ring form or young trophozoites may become
• Plasmodium falciparum (most common in the gametocytes which are gendered, though the male and
Philippines) female are indistinguishable
• Plasmodium vivax (most common worldwide) ** The released merozoites may invide RBCs again through
• Plasmodium malariae the RBC glycophorins
• Plasmodium ovale (exclusively rare)
✓ Possible mixed infection with P. vivax and P. falciparum RBC Glycophorins
✓ Glycoproteins in the RBCs
Mode of transmission Vector-borne ✓ Responsible for antigenic determinants of the RBCs
Vectors in the Philippines ✓ Female Anopheles • E.g. blood type
mosquito ✓ Can serve as ligands
✓ Principal vector is the ✓ Serves as entrance of merozoites
Anopheles minimus var
flavirostris Sporogony and Schizogony Lenghts
✓ Secondary vectors are SPECIES SPOROGONY SCHIZOGONY
the A. litoralis, A. LENGHT LENGTH
maculates, A. P. falciparum 9-10 days 36-48 hours
mangyamus P. vivax 8-9 days 48 hours
Final host Female Anopheles P. malariae 15-20 days 72 hours
mosquito P. ovale 14 days 48 hours
Intermediate host Man
Periodicity or Febrile Cycle
NOTE: The final host is where sporogony occurs while the
Cycle of fever or the interval of occurrence of fever
intermediate host is where schizogony occurs

Vectors TYPE OF
SPECIES FEBRILE CYCLE INTERVAL RBC
✓ Their habitats are slow flowing shaded streams INFECTED
✓ Their biting time is at night, both indoor and outdoor
P. Malignant 36-48 All
✓ Their resting place is inside walls
falciparum Tertian/Subterian hours
Infective Stage P. vivax Benign Tertian 48 hours Young
P. Quartan 72 hours Old
✓ Man: Sporozoites (which are from mosquitos) malariae (Senescent)
✓ Mosquito: Gametocyte (which are from man)
P. ovale Ovale Tertian 48 hours Young
LIFE CYCLE
✓ Has three stages Morphology
• Mosquito stage (Sporogonic cycle) See next page
• Human liver stage (Exo-erythrocytic cycle/pre-
erythrocytic cycle)
• Human blood stage (Erythrocytic cycle)

NOTE: Refer to the PowerPoint presentation for the life cycle

Sporogony (Sporognic Cycle)

✓ Occurs inside the mosquito
✓ Sexual cycle

MICROGAMETE ENTERS MACROGAMETE -> ZYGOTE ->

OOKINETE -> OOCYST (which is filled with sporozoites) ->
OOCYST RUPTURES -> SPOROZOITES (are released and
are injected into man, leading to the next cycle)

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P. falciparum P. vivax P. malariae P. ovale

RBC size Normal Enlarged Normal Normal to slightly
enlarged
Trophozoite Usually not present Amoeboid Band form Fimbriated, round,
compact
No. of merozoites in 12-32 (24) 12-24 (16) 6-12 (8) Usually 8 (6-12(
schizont In a rosette-formation,
flowerlike, fruit pie,
daisy head
Stipplings Maurer’s, Stephen- Schuffner’s dots Ziemann’s dots Jame’s dots
Christopher, Cuneiform
dots
Ring forms/RBC Single/multiple Single Single Single
Chromatin dot Single/double Single/densed Single Single
Applique or accole Present Not present Not present Not present
Gametocytes Macro is crescent- Round/oval Round/oval Round/oval
shaped; Micro is
banana/sausage-
shaped
Asexual stages in Not all stages All stages All stages All stages
peripheral blood

NOTE: Stipplings are the dots in the RBCs

Plasmodium falciparum
✓ Most dangerous Plasmodium spp.
• Can infect multiple RBC at the same time
• Can invade old and/or young RBC TROPHOZOITES
✓ Can cause:
• Cerebral Malaria
• Blackwater Fever (Sudden massive intravascular
hemolysis resulting to hemoglobinuria)
o Hemoglobuniria is the presence of hemoglobin
in urine

GAMETOCYTE

RING FORMS

SCHIZONT

GAMETOCYTE

Plasmodium malariae

RING FORMS
SCHIZONT

Plasmodium vivax

TROPHOZOITES

RING FORMS

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✓ May last for 2-6 hours

Sweating Stage
✓ Known as Defervescence or Diaphoresis
GAMETOCYTE ✓ Profuse sweating, temperature lowers and symptoms
diminishes
✓ May last for 2-4 hours

Pathology
✓ Recrudence
• Renewal of parasitemia or its clinical features arising
from persistent undetectable asexual parasitemia in
the absence of exo-erythrocytic cycle
SCHIZONT ✓ Relapse
• Reinfection after treatment
• Common to P. vivax and P. ovale infections, as a
result of the reactivation of hypnozoites/cryptozoites
form of the parasite in the liver
• Hypnozoites/cryptozoites are a malarial stage that is
Plasmodium ovale left in the liver which may be reactivated after
treatment, leading to reinfection
✓ Cerebral Malaria
• Caused by P. falciparum
• Diffuse symmetric encephalopathy, retinal
hemorrhage, bruxism, mild neck stiffness
RING FORMS • If left untreated, may lead to coma and death

Pathological Process of RBCs

✓ The RBCs are altered
✓ Poikylocytosis (variation in RBC shape) and anisocytosis
(variation in RBC count/numbers)
✓ Altered RBC membrane transport
✓ RBC stiffness and cytoplasmic viscosit
• RBC lose stiffness due to presence of parasite in the
TROPHOZOITES
RBC which alters their exoskeleton

DIAGNOSIS
Microscopy
✓ The gold standard for diagnosis
✓ Involves thick and thin blood smear
• The thin smear uses the two-slide method
• The thick smear involves the emulsification of 1 drop
of blood and 1 drop of water (to dehemoglobinize the
GAMETOCYTE
RBCs)
✓ Stained with Giemsa or Wright’s stain
✓ Manner of reporting:
• Qualitative
+ 1-10 parasites/100 thick
field
++ 11-100 parasites/100
thick field
+++ 1-10 parasites/thick field
SCHIZONT
++++ More than 10/thick field

• Quantitative

PATHOLOGY: CLASSICAL MALARIA PAROXYSMS

These happen in every febrile cycle
Quantitative Buffy Coat (QBC)
Cold Stage ✓ Uses special capillary tubes with acridine orange (a
fluoroscent stain)
✓ Sudden coldness and apprehension
✓ POSITIVE RESULT: Bright green and yellow under
✓ Mild shivering turns to teeth chattering and shaking of
fluorescent microscope
whole body
✓ May last for 50-60 minutes
Rapid Diagnostic Test (RDT)
Hot Stage/Flush Phase ✓ Detects plasmodium-specific antigens
✓ Best stage to collect blood sample • Histidine-rich Protein II (HRP II)
✓ High temperature (40-41°C) o Water soluble protein produced by trophozoites
and young gametocytes
• Due to invasion of merozoites in the RBCs
o Specific for P. falciparum
✓ Patient is confused and delirious

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• Plasmodium LDH • Early Trophozoite – similar with P. falciparum

o Produced by both sexual and asexual stages
and can distinguish between P. falciparum and
non-P. falciparum
o Produced by all species of malaria
• Mature Trophozoite – similar with P. malariae
✓ Diagnosis:
• PCR - most reliable method for detecting and
diagnosing P. knowlesi infection since they are
morpholigcally similar to other Plasmodium spp.

Babesia spp.
Blood parasites that cause malaria-like infections

Babesia microti
✓ Parasites divide through binary fission or budding
✓ Cycle in the tick is still uncertain

Vector Ticks (Ixodes scapularis)

Serologic Tests
IHA, IFAT, and ELISA

Molecular Methods
Infective stage Sporozoites
PCR for low cases and mixed infections Diagnostic stage ‘Maltese cross’
arrangement of merozoites
TREATMENT
Prophylactic
✓ Mefloquine and Doxycycline
✓ Used for persons who might become exposed to the
disease (e.g. People going to endemic areas)

Therapeutic Pathology Babesiosis

✓ Arthemether-Lumefantrine
• First line drug for P. falciparum cases
✓ Quinine (plus Tetracycline or Doxycycline)
• Second line drug for P. falciparum if AL fail or not
available.
✓ Quinine IV Drip
• Drug of choice for complicated or severe P.
falciparum malaria
✓ Primaquine
• Given on the 4th day as single dose to prevent
transmission

RESISTANCE TO MALARIA
✓ People with the Duffy null phenotype/Fy (a-b-)
• A blood group system
• Characterized by the lack of duffy antigen on the
RBC surface
• Most Africans and African Americans are resistant
• Resistant to P. vivax and P. knowlesi
o Because the Duffy antigens are glycophorins,
which means the lack of these antigens mean
the P. vivax and P. knowlesi have no way of
entering
✓ Hemoglobinopathies
• Sickle-cell anemia
o Characterized by HbC or HbS
o Shape of the RBC is unfavorable for parasitic
entry
✓ G6PD Deficiency
• Resistant to P. falciparum
✓ Infants (First year of life)
• High level of HbF(fetal hemoglobin)

Plasmodium knowlesi
✓ A primate malarial parasite
✓ Causes malaria in long-tailed macaques (Macaca
fascicularis)
✓ May also infect man
✓ Described in humans in the Philippines and Southeast
Asia
✓ Morphology:

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