Prepared by:

Dr. kholoud Baraka

Lecturer of Microbiology and Immunology.
Faculty of Pharmacy, Damanhour University.
2. LEISHMANIA

 Is the causative agent of leishmaniases.

 Leishmanias are transmitted by sandflies (female
mosquitoes of the genera Phlebotomus) and cause the
following main forms of leishmaniases in warm regions:
Visceral leishmaniases (VL)
Cutaneous leishmaniases (oriental sore) (CL)
Mucocutaneous leishmaniases (MCL)
 Leishmania species are unicellular eukaryotes having a
well-defined nucleus and other cell organelles and
flagella.
 They exist in two structural forms:
1. The amastigote form: is found in the mononuclear phagocytes and
circulatory systems of humans. It is an intracellular, oval and non-
motile form, being devoid of external flagella.
2. The promastigote form: is found in the alimentary tract of sandflies.
It is an extracellular and motile form. It is larger and highly
elongated. It is spindle-shaped, tapering at both ends. A long
flagellum is projected externally at the anterior end.
Life cycle
 The sand fly injects promastigote into human blood.
leishmanias parasitize in mononuclear phagocytic
cells (macrophages, monocytes) and are converted to
the amastigote form and multiply.
 The amastigote stages of the parasite ingested by the
insect with a blood meal are transformed in its
intestine into slender, flagellate promastigote forms,
which multiply and migrates to the fly's proboscis
and the cycle is repeated.
 Clinical manifestations
1- Visceral leishmaniasis (Kala azar or Dumdum fever)
 The visceral disease, the most devastating and fatal form of
leishmaniasis, is classically known as kala-azar or “black fever/disease,”
which is a reference to the characteristic darkening of the skin caused
by L. donovani in patients with this condition.
 It involves the liver, spleen, and bone marrow. The spectrum of illness
ranges from asymptomatic infection to fulminant, severe, life-
threatening infection.
 Symptoms: Fever, splenomegaly,
hepatomegaly, lymphadenopathy, progressive
anemia, leucopenia, fever and characteristic
hyperpigmentation of skin.
2- Cutaneous leishmaniasis (oriental sore)
 Cutaneous leishmaniasis can be simple or diffuse (disseminated). The
hallmark of cutaneous leishmaniasis is skin lesions, which can
spontaneously heal in 2-10 months. Incubation occurs over weeks to
months after a sandfly bite, followed by the appearance of an
erythematous papule, which can evolve into a plaque or ulcer. These
lesions are usually painless.

Oriental sore

3- Mucocutaneous leishmaniasis
 Skin and mucosa are involved. Skin changes similar to oriental sore.
Some forms tend to spread to mucosa and cause severe tissue
destruction involving: nose, mouth, oropharynx, and trachea
resulting in symptoms of nasal obstruction and bleeding.
 Diagnosis
 Direct parasite detection in aspirate from lymph nodes and bone
marrow or liver biopsy (in case of Visceral leishmaniasis) or
from the edges of the skin lesions (in case of Cutaneous &
Mucocutaneous leishmaniasis) in Giemsa-stained smears, then
cultured. However, confirmation of diagnosis by culture may
take two to four weeks but it's useful in case of the presence of
small amount of parasites, as it gives them the opportunity to
grow to detectable levels.
 Physical examination to look for an
enlarged spleen or liver is performed.
 PCR.
 Serological Antibody tests.
 Treatment
 Antimony-containing compounds are the main drugs used to
treat leishmaniasis. They're given either systemically or
injected into the lesions. These include:
Meglumine antimoniate.
Sodium stibogluconate.
 Other drugs that may be used include:
Amphotericin B.
Ketoconazole.
Miltefosine.
 Plastic surgery may be needed to correct the disfigurement
caused by sores on the face (cutaneous leishmaniasis).
 Prevention
*Preventing sandfly bites is the most immediate form of
protection. They can be prevented by:
 Putting fine mesh netting around the bed (in areas
where the disease occurs).
 Wearing insect repellent.
 Wearing protective clothing.
 Using insecticides and elimination of breeding places.
 IV- Blood sporozoa
PLASMODIUM SPECIES
 They are the causative agent of malaria.
 The infection is caused by several plasmodium species and is
transmitted by the bite of Anopheles mosquitoes.
 There are four parasite species that cause different types of
malaria in humans:
*Plasmodium falciparum: malignant tertian malaria (malaria
tropica).
*Plasmodium vivax and Plasmodium ovale: tertian malaria
(malaria tertiana).
*Plasmodium malariae: quartan malaria (malaria quartana).
• In addition to Plasmodium knowlesi which has recently been
recognized to be a cause of zoonotic malaria in humans.
 Plasmodium falciparum and Plasmodium vivax are the most
common. However, Plasmodium falciparum is the most deadly.
 They are differentiated from each other by light microscope in
stained blood smears during the erythrocytic phase of the infection in
humans.
 Various stages of the organism (sporozoite, merozoite, ookinete) can
be recognized on the electron microscopic level.
 According to the latest estimates, released in December 2014, there
were about 198 million cases of malaria in 2013 and an estimated 584
,000 deaths.
Life cycle
 The parasite always has two hosts in its life cycle: a mosquito vector
(in which sexual reproduction and formation of sporozoites occur)
and a vertebrate host (in which asexual multiplication occurs). The
life-cycle is very complex, involving a sequence of different stages
both in the vector and the host.

In human:
1- Exoerythrocytic development
 Humans are infected through the bite of an infected female Anopheles
mosquito that inoculates sporozoites into the bloodstream.
 Within about 15–45 minutes of inoculation, the sporozoites reach the liver
through the bloodstream and infect hepatocytes, in which asexual
multiplication takes place. In this process, the sporozoite develops into a
multinuclear, large schizont described as a tissue schizont which divides
producing merozoites.
 The released merozoites will then infect erythrocytes, however some remain
dormant for extended periods in the liver, causing relapses weeks or months
later.
2- Erythrocytic development
 The merozoites infect erythrocytes, in which they reproduce
asexually.
 When the plasmodium has recently infected an erythrocyte (<12
hours), it appears ring-shaped. The ring forms develop into
schizonts, which feed on glucose and hemoglobin and will be broken
down to a brownish-black pigment (malaria pigment).
 The schizont undergoes multiple divisions to produce merozoites.
The merozoites enter the plasma when the erythrocyte is destroyed;
they infect other erythrocytes and begin a new asexual cycle .
 Some of the merozoite-infected blood cells leave the cycle of asexual
multiplication. Instead of replicating, the merozoites in these cells
develop into sexual forms of the parasite, called male and female
gametocytes that circulate in the bloodstream. These sexual forms
(gametocytes) are taken up by blood sucking Anopheles females.
In Mosquito:
 In the mosquito midgut, fusion of a microgamete (male) and
macrogamete (female) to form a motile zygote (ookinete). The
ookinetes occupy the intestinal wall then transformed into
oocysts .
 In oocyst, nuclear proliferation and production of thousands of
sporozoites will occur. The sporozoites migrate through the body
cavity to the salivary glands, from where they can be
transmitted to a new host.
 Clinical manifestations
A- Classic malarial paroxysm:
 Fever is induced when the schizonts burst and when many red blood
cells are destroyed at once, causing the typical, intermittent fever
attacks (“malarial paroxysm”).
 Three stages separated by symptoms free periods (3 days, so-called
“tertian malaria” and 4 days, so-called “quartan malaria”.
1. Initial rise in temperature to about 39 °C, peripheral vasoconstriction
causes a period of chills (lasting for about 10 minutes to one hour).
2. Temperature once again rises to 40–41°C (febrile stage two to six
hours).
3. Peripheral vasodilatation, the patient sweats and fever drops.
 More commonly, the patient presents with a combination of the
following symptoms:
Fever, chills, sweats, headaches, nausea and vomiting, body aches and
general malaise.
B- Symptoms of different types of malaria
 Tertian malaria: is characterized by daily bouts of fever.
 Quartan malaria: is characterized by nephrotic syndrome,
especially in African children.
 Malignant tertian malaria: is characterized by severe
complications:
Cerebral malaria (e.g., convulsions, disturbed vision and
coordination, altered states of consciousness, coma).
Severe anemia, pulmonary edema and respiratory and renal
insufficiency, gastrointestinal disturbances, circulatory
collapse, hypoglycemia, spontaneous hemorrhage,
hemoglobinuria (blackwater fever), hyperpyrexia (39.5–42°C).
 Diagnosis
 Microscope examination of patient's blood smears stained with
Giemsa stain to give the parasites a distinctive appearance. This
technique remains the gold standard for laboratory confirmation of
malaria.
 Rapid diagnostic tests (using monoclonal antibody to detect specific
Plamodium antigens).
 PCR.
Treatment
 Drug of choice is chloroquine or quinine.
 In case or resistance to chloroquine: primaquine and
atovaquone are used.
Spectrum of efficacy

Drug Asexual Gametocytes Liver Hy

blood schizonts of
stages
Chloroquine + + -

Quinine + + -

Primaquine + + +

Atovaquone + + +
 Prevention

1.Mosquito bite prevention:

 Wear clothing (long sleeves, long trousers). Spray clothing with
a fast-acting insecticide (pyrethrines).
 Apply an insect repellent to uncovered skin.
 Screen off rooms to keep mosquitoes out, fit fine-meshed
screens on doors and windows and use bed nets.
 Impregnating bed nets with an insecticide.

2. Chemoprophylaxis: regular intake of antimalarial drugs

before, during and after a trip for a malarious area.