PARASITOLOGY

MIDTERMS/LECTURE SECOND SEMESTER

PROTOZOAN INFECTIONS

PLASMODIUM 4 SPECIES THAT ARE MEDICALLY IMPORTANT TO

● Plasmodium vivax HUMANS
● Plasmodium ovale ● P. falciparum
● Plasmodium malariae ● P. vivax
● Plasmodium falciparum ● P. ovale
● Plasmodium knowlesi ● P. malariae
● P. knowlesi
BABESIA
● Babesia microti
● Babesia divergens ★ P. knowlesi described humans in the Philippines and
most of Southeast Asia.
○ The fifth human malaria parasite is normally
a parasite of long-tailed macaques (Macaca
fascicularis).

MALARIA ★ The first naturally acquired human infection was

● Remains the leading parasitic disease that causes
mortality worldwide.
● Young children and pregnant women are the
population groups mostly affected by malaria.
● Groups of parasites causing malaria belong to the
genus Plasmodium.
reported in 1965 in Sarawak, Malaysia; other foci of
infection have been reported in Thailand and China
as late as 2008.
★ In the Philippines, the first reported case of P.
knowlesi was described in 2006.
● Asexual cycle: HUMANS
● Sexual cycle: Anopheles mosquito

MORPHOLOGY

● Ring forms
○ Early trophozoite
○ Stained with Giemsa, it consists of a blue
cytoplasmic circle or red chromatin dot
referred to as nucleus.

● Immature schizonts
○ Pigment granules, often brown in color, are
commonly seen.

● Mature schizonts
○ Fully developed stage of the asexual
sporozoa trophozoite known as merozoites.
○ Cytoplasmic material:
■ Not visible, presumed to be absent.

● Microgametocytes
○ Shape: Roundish
○ Consists of large diffuse chromatin mass that
stains pink to purple and is surrounded by a
Plasmodium spp. colorless to pale.

● Transmitted by the bite of an infected female ● Macrogametocytes

mosquito belonging to the genus Anopheles. ○ Shape: Round to oval
○ Chromatin mass is partially to completely
surrounded by cytoplasmic material.

RORRY 1
LIFE CYCLE ● Hepatomegaly
● Liver Dysfunction
3 STAGES
● Exo-erythrocytic cycle (inside liver)
● Erythrocytic cycle (inside RBC)
● Sporogonic cycle Plasmodium ovale
INFECTIVE STAGE:
● Sporozoites 1. INFECTED RED BLOOD CELLS
● Larger than normal
● Fringed or irregular edge
DIAGNOSTIC STAGE ● Oval in shape
● Trophozoites ● Stains more readily and deeply than in P. vivax

2. TROPHOZOITE
Small Trophozoite
Plasmodium vivax ● Small
● Darker in color
● BENIGN TERTIAN VIVAX MALARIA ● Generally, more solid than those of P. falciparum
● Infects RBCS: YOUNG CELLS
● Stipplings: SCHUFFNER’S DOTS Growing Trophozoite
● 48 hours ● Resembles closely same stage of P. malariae but is
considerably larger
● Pigment is lighter
● Irregular ameboid appearance
● Ring remnants common Large Trophozoite
● Seldom present
HEMOZOIN
● Brown pigment 3. SCHIZONT (MATURE)
● Rosette arrangement of merozoites
Immature Schizont ● Parasite occupy 75% of RBC
● Multiple chromatin bodies ● Usually eight merozoites arranged around a central
● Often contains clumps of brown pigment block of pigment
● Has fewer chromatin bodies

Mature Schizont 4. SCHIZONT (IMMATURE)

● 12 to 24 merozoites occupy most of infected red Schizont (Presegmenting)
blood cell ● Many cells with indefinite fringed outline; pigment
● Merozoites surrounded by cytoplasmic material lighter and less coarse than in P. malariae
● Brown pigment may be present
5. GAMETOCYTE
● Distinguished from P. malariae by size of infected
CLINICAL MANIFESTATION cells and by Schüffner's dots

Stages in Peripheral blood:

Type of malaria or fever: Benign tertian malaria
● All stages present
- Age of infected RBCs: Young RBCs or reticulocytes
LENGTH OF ASEXUAL CYCLE:
- PRE-PATENT PERIOD:
● 48 hours
- 11 DAYS – 4 WEEKS
- 11 – 15 DAYS

- INCUBATION PERIOD: CLINICAL MANIFESTATION

- 8-40 DAYS
- 12-20 DAYS
Type of malaria or fever:
● ovale tertian malaria
SYMPTOMS Age of infected RBCs:
● Fever ● Young RBCs or reticulocytes
● Chills Rare Case
● Headache Average pre-patent period:
● Muscle Aches and Joint Pain ● 14-26 days
● Fatigue and Weakness
● Sweating
● Anemia
● Nausea and Vomiting
SEVERE CASES
● Splenomegaly

RORRY 2
 Plasmodium falciparum
Plasmodium malariae
RING FORMS
Associated disease and condition names: ● Typical small, delicatering
● Quartan Malaria/ malarial malaria ● Consist of scanty cytoplasm to one (circle
Found in subtropic and temperate regions configuration) or two (headphone configuration) small
chromatin dots
★ OLD RBC
★ ZIEMANN'S DOTS DEVELOPING TROPHOZOITES
● Consists of one or two rings that each possess a
● Occupies approximately one sixth of the infected RBC heavy cytoplasmic ring
● Usually smaller than P. vivax
● Connected by heavy chromatin dot IMMATURE SCHIZONTS
● The immature schizont phase of P. falciparum is not
DEVELOPING TROPHOZOITES routinely seen in the peripheral blood
● Formation of non amoeboid solid cytoplasm
potentially assuming a band, bar, oval, or roundish
shape. MATURE SCHIZONTS
● Consist of coarse dark brown pigment often masking ● The mature schizont is only visible in the peripheral
the chromatin material blood of patients
● Vacuoles are absent in mature stages ● Contains 24 merozoites, 8 to 36 merozoites

IMMATURE SCHIZONTS
Similar to P. vivax: MICROGAMETES
● P. malariae immature schizonts are characteristically ● Assumes a characteristic sausage or crescent shape
smaller than those of P. vivax with larger and darker
peripheral or central granules
MACROGAMETES
MATURE SCHIZONTS ● Typically sausage- or crescent-shaped, just like the
● Contains 6-12 merozoites, usually arranged in corresponding microgametocyte form described
rosettes or irregular clusters earlier
● Central arrangement of brown-green pigment may be
visible
● Infected RBC may not be seen
CLINICAL MANIFESTATION

MICROGAMETOCYTE aND MACROGAMETOCyTES MOT:

● Similar to p. vivax but smaller in size ● Bite of infected Anopheles mosquito
● Pigment is darker and coarser than the pigment of P.
vivax PRE-PATENT PERIOD: 11-14 days
● Older forms are typically oval in shape INCUBATION PERIOD: 8-15 days

SYMPTOMS:
CLINICAL MANIFESTATION ● Black water fever and Malignant Tertian Malaria

Black Water Fever

● The infection is caused by the presence of P. malariae ● It is a manifestation of falciparum malaria occurring in
typically experience an previously infected individuals and is characterized by
● Incubation period: 18-40 days sudden intravascular hemolysis followed by fever and
hemoglobinuria.
STAGES
1. Cold stage Black Water Fever
2. Hot stage ● Symptoms:
3. Sweating stage ○ high fever, haemoglobinaemia,
hemoglobinuria, circulatory collapse, and
renal failure.
Cyclic paroxysms - occur every 72 hrs.
● No relapses however repeated attack may occur for Malignant Tertian Malaria
20 yrs or more (moderate to severe) ● A fulminating disease results and the intestinal
symptoms
SHORT INCUBATION PERIOD: 7-10 days
● Early Symptoms:
○ Chills, fever, diarrhea, nausea, vomiting
○ 36-48 hours

RORRY 3
 ● Histidine-rich protein (HRP II)
● Plasmodium lactate dehydrogenase (pLDH).
● Plasmodium aldolase
Plasmodium knowlesi ● Panmalaria antigen (PMA)

● Parasite of Old World Monkeys SEROLOGIC TEST

● Causes Malaria to humans and other primates ● Indirect hemagglutination (IHA)
● Requires infection of both mosquito and a warm ● Indirect Fluorescent Antibody Test (IFAT)
blooded host ● Enzyme-linked Immunosorbent Assay ( ELISA)
● Intermediate host (macaque monkeys, genus ● POLYMERASE CHAIN REACTION (PCR)
Macaca)
● P. knowlesi causes quotidian malaria
FIRST NATURALLY ACQUIRED HUMAN INFECTION TREATMENT
● Reported in 1965 in Sarawak, Malaysia

OTHER FOCI OF INFECTION Antimalarial Drugs

● Thailand and China as late as 2008 Main Uses:
● Protective (prophylactic)
FIRST REPORTED CASE OF P. knowlesi ● Curative (therapeutic)
● Philippines ● Preventive
● Describe in 2006
Antimalarial Drugs
LIFE CYCLE Types:
The life cycle of P. knowlesi is microscopically indistinguishable ● Prophylactic drugs
from P. malariae ● Blood Schizonticidal drugs
● Gametocytocidal drugs
● Sporonticidal drugs
MORPHOLOGY
RING FORM Types:
● The early trophozoite form with a ret chromatin dot ● Chloroquine
● Artemisinin-based Combination Therapies (ACTs)
TROPHOZOITE FORM ● Parental Antimalarial Treatment
● Has a large chromatin mass and a prominent
ameboid cytoplasm Recommended Antimalarial Drugs
● Artesunate Intravenous (IV) Injection
SCHIZONT ● Intramuscular Injection (IM)
● When the chromatin with small amounts of cytoplasm, ● Artemether IM
the so- called merozoites. ● Antipyretics and Sponging

CLINICAL MANIFESTATION
DIAGNOSTIC TEST/S
P. knowlesi produces an acute illness and relatively
high parasitemia. FOR P. falciparum & knowlesi
● Paroxysms of fever occur daily (quotidian malaria)
● Clinical features of infected individuals range from Serologic Test
respiratory distress, acute renal or multi-organ failure, ● Indirect hemagglutination (IHA)
to shock. ● Indirect Fluorescent Antibody Test (IFAT)
● Incubation period: 9-12 days ● Enzyme-linked Immunosorbent

Rapid Diagnostic Test

● Histidine rich protein II (HRP)
DIAGNOSTIC TEST/S FOR P.knowlesi
Diagnostic Test
FOR P. ovale, vivax, malariae ● Serologic Test
● DNA Extraction
MICROSCOPIC IDENTIFICATION ● Nested PCR Examination
● Thick and thin blood smears
● Giemsa or Wright’s stain
TREATMENT
IMMUNOCHROMATOGRAPHIC METHOD
● Detect Plasmodium-specific antigens
● Aretemether plus Lumefantrine
RAPID DIAGNOSTIC TESTS (RTSs) ● Artesunate plus Amodiaquine

RORRY 4
 ● Artesunate plus Mefloquine - Babesiosis is a disease caused by microscopic
● Artesunate together with Sulfadoxine Pyrimethamine parasites that infect red blood cells and are spread by
certain ticks.
FOR P. knowlesi - In the United States, tick borne transmission is most
● Quinine common in particular regions and seasons. It mainly
● Chloroquine occurs in parts of the Northeast and upper Midwest
● Artemether Lumefantrine and usually peaks during the warm Months.

In the Philippines, malaria has not been included among the 10

leading causes of morbidity since 2006. Cases have been MORPHOLOGY
notably decreasing as reported in 2009.
- Sporozoites and Trophozoite form
As of 2009, the provinces of - Pleomorphism-ring form, pear shaped/pyriform
● Cagayan (Round 2–3 μm in diameter)
● Isabela, - "Maltese cross" or tetrad form
● Palawan
● Sulu
● Tawi-Tawi
comprise the five provinces having the highest number of
malaria cases reported. CLINICAL MANIFESTATION

- Asymptomatic (mild to severe)

★ Anopheles minimus var. flavirostris, “a night - Fatigue
biter”, which prefers to breed in slow flowing. - Malaise
- Anorexia
★ Anopheles litoralis is associated with malaria - Weight loss (1-6 weeks)
transmission in the coastal areas of - Intermittent fever (38-40 degrees Celsius)
- Emotional liability
Mindanao, particularly in Sulu.
- Depression
- Hyperesthesia
★ Anopheles maculatus coexists with A.
flavirostris in the portion of streams exposed - Severe Cases
to sunlight. - Hemolytic anemia and hemoglobinuria
- Pulmonary edema
★ Anopheles mangyanus has the same
breeding habitats and seasonal prevalence as - Worse Infection: (ELDERLY)
- Splenectomized and Immunocompromised
A. flavirostris but appears to prefer habitats
patients Individuals with Lyme disease
located in forest fringe.

DIAGNOSTIC TEST/S
Babesia spp.

- Blood smears (acute stage)

- Babesiosis - Direct microscopy examination (Giemsa stained PBS)
- Zoonotic infection: Wild & Domestic Animals - Serological test (IFA) -widely used molecular gene
- Redwater, Texas, or Nantucket fever analyses, epidemiologic data (epizootiological)
- 1888 - First discovered by Dr. Victor Babes - GOLD STANDARD: PCR
- Definitive host: hard ticks (Ixodidae)
- Intermediate host: Mammals - cattle and rodents
- Accidental host: Humans- blood transfusion, organ
transplantation, and transplacental route
- Babesia microti (Theileria microti) & Babesia TREATMENT
divergens
- Infective stage: Sporozoites
- Combination of drugs such as:
- Diagnostic stage: Trophozoites
- Clindamycin (1.2g/600 mg 3 times a day) and Quinine
(650 mg 3 times a day) or Atovaquone and
Azithromycin

Babesia microti

EPIDEMIOLOGY

RORRY 5
 - neck stiffness,
- Asia Pacific - sore throat,
- 1956 in Europe - First human case - abdominal pain,
- 1970- Discovery of transmission to humans - jaundice
- CDC confirmed more than 40 human cases - anemia.
contracted the disease from transfusion of packed
RBC Severe infection include:
- Human cases common among farmers living in close - Splenectomized
habitation with wild animals, and where ticks are - Immunocompromised
abundant
- Most common vector: Ixodes dammini/Ixodes - INCUBATION PERIOD: 1-4 weeks and can last
scapularis several weeks
- Definitive host: Black-legged ticks
- Reservoir host: Peromyscus leucopus
- Accidental host: Humans
DIAGNOSTIC TEST/S

- Giemsa-stained peripheral blood films specimen of

PREVENTION AND CONTROL choice
- Wright's stain
- Thick and Thin blood films
- Avoid tick-infected areas - Serologic test
- Wear covered clothing - PCR techniques
- Application of bug repellent
- Screening procedures for blood & organ donors in
high risk areas
TREATMENT

- Combination of drugs such as:

- Clindamycin (600 mg every 6 hours) and Quinine
Babesia divergens
(650 mg every 8 hours)
- Atovaquone (750mg every 12 hours) and
- An intraerythrocytic protozoan parasite Azithromycin (500-600 mg on the 1st day, and
- Commonly found in European countries 250-600 mg on the following days).
- Vector: Ixodes ricinus
- Reservoirs host: cattle and rabbits - Other combination of drugs: Diminazene and
- Also described in the Nantucket area Pentamidine
- Pyrimethamine and Quinine

MORPHOLOGY

EPIDEMIOLOGY
- Trophozoites are pleomorphic 2-5 µm in diameter
found inside the red cells.
- Shape: pyriform, ameboid, or spindle - Europe
- Usually in pairs and are often mistaken as ring form of - Cattle
Plasmodium. - vector: ixodes ricinus (castor bean tick)
- Merozoites may be spherical or oval or pyriform
bodies, found in pairs.

PREVENTION AND CONTROL

CLINICAL MANIFESTATION
- avoiding tick-infested areas
- subclinical or mild self-limiting or acute illness - covered with clothing
- spray repellent containing DEET on your shoes,
Manifestation diseases: socks, and exposed areas.
- Fever - wear long pants and long sleeved shirt
- Sweating
- Fatigue
- Depression
- Weight loss

Less common syndromes

RORRY 6
RORRY 7