The Flagellates

LABORATORY DIAGNOSIS
CHAPTER OUTLINE
I. Morphology and Life Cycle • Stools submitted for parasite study that contain
flagellates may reveal trophozoites and/or
II. Laboratory Diagnosis
cysts.
III. Pathogenesis and Clinical Symptoms

• Flagellate trophozoites are typically seen in

IV. The Flagellate Classification
loose, liquid, or soft stool specimens, whereas
V. Intestinal Species flagellate cysts are more common in formed
i. Giardia intestinalis
stools.
ii. Chilomastix mesnili
iii. Dientamoeba fragilis
iv. Trichomonas hominis • Nuclear characteristics, such as number of
v. Enteromonas hominis
nuclei present and the presence and
vi. Retortamonas intestinalis
positioning of the nuclear structures, are helpful
VI. Extraintestinal Species in differentiating the flagellates.
i. Trichomonas tenax
ii. Trichomonas vaginalis
• Proper identification of structures specific to
select flagellates, such as a finlike structure
MORPHOLOGY AND LIFE CYCLE connected to the outer edge of some
flagellates known as an undulating membrane
• Movement of the flagellates is accomplished
and axostyle, is often even more crucial in
by the presence of whiplike structures known as
determining proper parasite identification.
flagella in their trophozoite form.
▪ Axostyle
→ a rodlike support structure found in some
• All flagellate life cycles consist of the flagellates
trophozoite form.
• The use of saline and iodine wet preparations,
• The general characteristics of the flagellate as well as permanent stains, results in the same
trophozoites are similar to those of the amebic benefits in flagellate identification as those
trophozoites, with one major exception. described for the amoebas.
▪ In those flagellate life cycles with no known
cyst stage, the trophozoite is considered to be
more resistant to destructive forces, surviving
passage into the stomach following ingestion.

• In flagellate life cycles that consist of both the

trophozoite and cyst, the processes of
encystation and excystation occur, similar to
those of the amoebas.

• Flagellates reside mainly in the small intestine,

cecum, colon and, in the case of Giardia
intestinalis, the duodenum.

30 PADAYON, FUTURE RMT, MD! | BS Public Health – Batch LEVIS

 CHAPTER 03: The Flagellates PH 201
SECOND YEAR – SECOND TERM | Para

PATHOGENESIS AND NEMATODES

CLINICAL SYMPTOMS Subphylum Mastigophora
Class Zoomastigophora
• Flagellates are often recovered from patients INTESTINAL SPECIES
suffering from diarrhea without an apparent Giardia intestinalis
Chilomastix mesnili
cause.
Dientamoeba fragilis
Trichomonas hominis
• There are a number of asymptomatic flagellate Enteromonas hominis
infections. Retrotamonas intestinalis
EXTRAINTESTINAL SPECIES
Trichomonas tenax
• Pathogenic flagellates have transmission Trichomonas vaginalis
routes similar to those of the non-pathogenic
variety.

• It is important to note that there is only one

intestinal flagellate, G. intestinalis, that is
considered pathogenic.

THE FLAGELLATE CLASSIFCATION

• The flagellates belong to the subphylum

Mastigophora, class Zoomastigophora.

• Like the amebas, the flagellates may be

separated into two categories, intestinal and
extraintestinal.

31 PADAYON, FUTURE RMT, MD! | BS Public Health – Batch LEVIS

 GIARDIA INTESTINALIS
Cercomonas intestinalis (former)
Other Names Giardia lamblia
Giardia duodenalis

MUST KNOW

→ causes Giardiasis, traveler’s diarrhea

→ an intestinal parasitic flagellate of worldwide distribution
→ the only known pathogenic intestinal flagellate
→ known to cause epidemic and endemic diarrhea
→ was first discovered in 1681 by Antoine van Leeuwenhoek
in his own stools and was first described by Lambl in 1859
who called it Cercomonas intestinalis
→ renamed Giardia lamblia by Stiles in 1915 manifests as a
significant but not life-threatening gastrointestinal
disease
→ Diagnostic Stage: cyst, trophozoite
→ Infective Stage: cyst

MORPHOLOGY
Trophozoite Cyst
Size Range 8-20 µm long; 5-16 µm wide Size Range 8-17 µm long; 6-10 µm wide

Shape pear-shaped, teardrop, pyriform Shape ovoid

Motility falling leaf Nuclei immature cyst: two

mature cyst: four
Appearance bilaterally symmetrical central karyosomes
no peripheral chromatin
Nuclei two ovoid-shaped, each with a large
karyosome Cytoplasm retracted from cell wall
no peripheral chromatin
Other median bodies: two in immature cyst or
Flagella four pairs, origination of each: Structures four in fully mature cyst
1 pair - anterior end interior flagellar structures
1 pair - posterior end
2 pair - central, extending laterally • The colorless and smooth cyst wall is prominent and
distinct from the interior of the organism.
Other two median bodies
• The cytoplasm is often retracted away from the cyst wall,
Structures two axonemes
creating a clearing zone. This phenomenon is especially
sucking disk
possible after being preserved in formalin.
• Giardia duodenalis is a flagellate that lives in the • Mature cysts contain twice as many interior flagellar
duodenum, jejunum, and upper ileum of humans. structures.
• Average Size: 10 to 15 µm long • Cysts are characterized by flagella retracted into
• axonemes - the interior portions of the flagella axonemes, the median or parabasal body, and deeply
stained curved fibrils surrounded by a tough hyaline cyst
• median bodies - slightly curved rodlike structures wall secreted from condensed cytoplasm.
believed to be associated with energy, metabolism, or
support
• The dorsal side of the organism is convex, while the
ventral side is concave with a large adhesive disc used
for attachment.
• Covering 50% to 75% of the ventral surface, the sucking
disk serves as the nourishment point of entry by
attaching to the intestinal villi of an infected human.

32
 GIARDIA INTESTINALIS
LIFE CYCLE
Cycle
Infective Stage
1. Giardia cysts can contaminate food, water, and
surfaces. A person swallows Giardia cysts from
contaminated water, food, hands, surfaces, or objects.
Excystation
2. When Giardia cysts are swallowed, they pass through
the mouth, esophagus, and stomach into the small
intestine where each cyst releases two trophozoites
through excystation. The Giardia trophozoites then feed
off and absorb nutrients from the infected person.
Longitudinal Binary Fission
3. Giardia trophozoites multiply by splitting in two in a
process called longitudinal binary fission, remaining in
the small intestine where they can be free or attached
to the inside lining of the small intestine.
Encystation
4. The Giardia trophozoites then move toward the colon
and transform back into cyst form through encystation.
The Giardia cyst is the stage found most commonly in
stool.
Diagnostic Stage
5. Both Giardia cysts and trophozoites can be found in the
stool of someone who has giardiasis and may be
observed microscopically to diagnose giardiasis.
Giardia cysts are immediately infectious when passed
in the stool or shortly afterward, and the cysts can
survive several months in cold water or soil.
33
Notes
• Mode of Transmission: ingestion of cyst from
contaminated food, water, surfaces, and objects
• Diagnostic Stage: cyst, trophozoite
• Infective Stage: cyst
• It has a simple asexual life cycle that includes
trophozoites and quadrinucleated infective cyst stages.
• Cysts from animals or human feces are transferred to
the mouth via contaminated hands, food, or water.
• On ingestion, the infective G. intestinalis cysts enter the
stomach.
• The digestive juices, particularly gastric acid, stimulate
the cysts to excyst in the duodenum. The resulting
trophozoites become established and multiply
approximately every 8 hours via longitudinal binary
fission.
• The trophozoites feed by attaching their sucking disks to
the mucosa of the duodenum.
• Trophozoites may also infect the common bile duct and
gallbladder.
• Changes that result in an unacceptable environment
for trophozoite multiplication stimulate encystation,
which occurs as the trophozoites migrate into the large
bowel.
• The cysts enter the outside environment via the feces
and may remain viable for as long as 3 months in water.
Trophozoites entering into the outside environment
quickly disintegrate.
 GIARDIA INTESTINALIS
CLINICAL SYMPTOMS
• Asymptomatic • Severe Cases
→ Infections with G. intestinalis are often completely → produce light-colored stools with a high fat content
asymptomatic. that may be caused by secretions produced by the
• Depending on the strain involved, infection can occur irritated mucosal lining
with one ingesting as few as 10 cysts. → fat-soluble vitamin deficiencies, folic acid
deficiencies, hypoproteinemia with
• The ability of the parasite to cause disease can be traced hypogammaglobulinemia, and structural changes
to its ability to alter mucosal intestinal cells once it has of the intestinal villi
attached to the apical portion of the enterocyte.
• Blood rarely, if ever, accompanies the stool in these
• In monolayer studies, it was noted that attachment was patients.
influenced by certain physical factors such as
temperature and pH. • The typical incubation period for G. intestinalis is 10 to
36 days, after which symptomatic patients suddenly
• The parasite may also produce a lectin which, when develop watery, foul-smelling diarrhea, steatorrhea,
activated by duodenal secretions, is able to facilitate flatulence, and abdominal cramping.
attachment. Once attached, the organism is able to
avoid peristalsis by trapping itself in between the villi or • In general, Giardia is a self-limiting condition that
within the intestinal mucus. typically is over in 10 to 14 days after onset.
• Most Common Symptom: Diarrhea • Chronic Cases and Reoccurence
→ ranges from mild diarrhea, abdominal cramps, → In chronic cases, however, multiple relapses may
anorexia, and flatulence to tenderness of the occur.
epigastric region, steatorrhea, and malabsorption → Patients with intestinal diverticuli or an
syndrome immunoglobulin A (IgA) deficiency appear to be
particularly susceptible to reoccurring infections.
• Acute Case
→ abdominal pain, described as cramping, associated • Spontaneous recovery occurs within 6 weeks in mild to
with diarrhea moderate cases.
→ excessive flatus with an odor of “rotten eggs” due to • In untreated cases, patients may experience diarrhea
hydrogen sulfide with varying intensities, for weeks or months

LABORATORY DIAGNOSIS TREATMENT

Specimen of Choice stool • metronidazole: usually well-tolerated in adults
• Alternative Drugs: tinidazole, furazolidone,
• Trophozoites in direct fecal smears may be characterized as
albendazole
having a floating leaf-like motility.
• Cysts: concentration techniques are recommended PREVENTION & CONTROL
• At least three stool examinations on alternate days are
recommended because of spotty shedding of cysts. Individual Level
✓ exercising good personal hygiene
• Duodeno-jejunal aspiration: if parasite is not found in stool ✓ proper cleaning and cooking of food
• Enterotest: may demonstrate Giardia trophozoites, wherein the ✓ avoidance of unprotected oral-anal sex
patient swallows a gelatin capsule attached to a nylon string, with
one end of the string attached to the patient’s cheek Community Level
• Antigen detection tests and Immunofluorescent Tests ✓ proper or sanitary disposal of human excreta
to prevent contamination of food and water
• Immunochromatographic assay: detect the presence of Giardia supply
antigen in stool ✓ proper water treatment: chemical therapy &
▪ Cyst Wall Protein 1 (CWP1) - one of the antigens used for these filtration
diagnostic tests ✓ guarding water supplies against
• Direct fluorescent antibody assays: the gold standard in diagnosis contamination by potential reservoir hosts

EPIDEMIOLOGY
Who? • The first recorded water outbreak of G. intestinalis occurred in St. Petersburg, Russia,
→ people in childcare and involved a group of visiting travelers.
→ travelers within areas • In the Philippines, the prevalence of giardiasis ranges from 1.6 to 22.0% depending on
of poor sanitation the population group being studied.
Where? • Notably, Giardia is not commonly found in patients with diarrhea.
→ worldwide • Direct oral-anal sexual contact among men who have sex with men may increase the
→ areas with poor risk of giardiasis and infection with other intestinal protozoans.
sanitation and hygiene • Outbreaks of giardiasis are more frequently reported outside the Philippines.
practices → Most of these are water-borne (recreational water or drinking water).
→ Foodborne outbreaks have also been reported.
How? • The low infective dose, prolonged communicability, and relative resistance to chlorine
→ person to person facilitate the transmission of Giardia through drinking and recreational water, food, and
→ through contaminated person-to-person contact.
water, food, surfaces, • Giardia was also recognized during World War I as being responsible for diarrheal
or objects epidemics that occurred among the fighting soldiers.
• Giardia trophozoites have often been referred to as resembling an old man with
whiskers, a cartoon character, and/or a monkey’s face.

34
 CHILOMASTIX MESNILI
MUST KNOW
→ considered a nonpathogen
→ inhabits the cecal region of the large intestine
→ has well-defined trophic and cystic stages
→ Prevalence in the Philippines is less than 1%.
→ a harmless commensal
→ Diagnostic Stage: cyst, trophozoite
→ Infective Stage: cyst

MORPHOLOGY
Trophozoite Cyst
Size Range 5-25 µm long; 5-10 µm wide Size Range 5-10 µm long

Shape pear-shaped Shape lemon-shaped, with a clear hyaline knob

extending from the anterior end
Motility stiff, rotary, directional
Nuclei one, with large central karyosome
Nuclei one with small central or eccentric no peripheral chromatin
karyosome
no peripheral chromatin Other well-defined cytostome located on one side
Structures of the nucleus
Flagella four:
3 extending from anterior end • The cysts of C. mesnili are usually lemon-shaped and
1 extending posteriorly from cytostome possess a clear anterior hyaline knob.
region • The average cyst measures 7 to 10 µm long and 3 to 7 µm
in width.
Other prominent cytostome extending from 1/3 to
Structures 1/2 body length
spiral groove

• Average Length: 8 to 15 µm
• The broad anterior end tapers toward the posterior end
of the organism.
• Stiff rotary motility in a directional pattern
• cytostome: a rudimentary mouth from which the fourth
flagellum, which is shorter than the others, extends
posteriorly
• The structure bordering the cytostome resembles a
shepherd’s crook and is the most prominent of several
supporting cytostomal fibrils found in this area.
• The ventral surface indentation located toward the
center of the body that extends down toward the
posterior end of the trophozoite is known as a typical
spiral groove.
• The presence of this spiral groove results in a curved
posture at the posterior end.

LABORATORY DIAGNOSIS PREVENTION & CONTROL

Specimen of Choice stool Individual Level
✓ exercising proper personal hygiene
• Traditional examination of freshly passed liquid stools
typically reveals only trophozoites. Community Level
• Formed stool samples from these patients usually ✓ proper public sanitation practices
reveal only cysts.
• Samples of semi-formed consistency may contain
EPIDEMIOLOGY
trophozoites and cysts.
Who?
• Encystation has been known to occur in unformed → people in childcare
samples, particularly during the process of centrifuging → travelers within areas of poor sanitation
the sample.
Where?
• Iodine Wet Preparations: often demonstrate the → worldwide; warm climates
organism’s features most clearly → areas with poor sanitation and hygiene practices
How?
CLINICAL SYMPTOMS TREATMENT → ingestion of infective cysts through hand-to-mouth
Typically Asymptomatic Organism is a nonpathogen. contamination via contaminated food or drink

35
 CHILOMASTIX MESNILI
LIFE CYCLE

Cycle
Diagnostic Stage
1. Both cysts and trophozoites can be found in the feces.

Infective Stage
2. Infection occurs by the ingestion of cysts in contaminated water, food, or by the fecal-oral route (hands or fomites).

Excystation
3. In the large (and possibly small) intestine, excystation releases trophozoites.

Commensalism
4. Chilomastix resides in the cecum and/or colon; it is generally considered a commensal whose contribution to
pathogenesis is uncertain.

36
 DIENTAMOEBA FRAGILIS
MUST KNOW
→ causes Dientamoeba fragilis infection
→ initially classified as an ameba because this organism
moves by means of pseudopodia and does not have
external flagella
→ first discovered by Wenyon in 1909 but was first
described in the scientific literature by Jepps and
Dobell in 1918
→ Diagnostic Stage: trophozoite
→ Infective Stage: trophozoite

MORPHOLOGY CLINICAL SYMPTOMS

Trophozoite • Asymptomatic Carrier State: most people with D. fragilis infection
remain asymptomatic
Size Range 5-18 µm • In symptomatic individuals, the onset of infection is usually
accompanied by loss of appetite, colicky abdominal pain, and
Shape irregularly round intermittent diarrhea with excess mucus, abdominal tenderness, a
bloating sensation, and flatulence.
Motility progressive, broad hyaline
pseudopodia • Another common symptom was anal pruritus, which may partially
be due to the co-infection with Enterobius.
Number of two, each consisting of massed • Common Symptoms: diarrhea and abdominal pain
Nuclei clumps of four to eight
• Other Documented Symptoms: bloody or mucoid stools,
chromatin granules
flatulence, nausea or vomiting, weight loss, and fatigue or
no peripheral chromatin
weakness
Cytoplasm bacteria-filled vacuoles • Some patients experience diarrhea alternating with constipation,
common low-grade eosinophilia, and pruritus.
• Dientamoeba fragilis does not invade tissues, but its presence in
• The nuclei are generally only observable with
the intestines produces irritation of the mucosa with secretion of
permanent stain.
excess mucus and hypermotility of the bowel.
• The stain of choice for distinguishing the
• Chronic Infection: can mimic the symptoms of diarrhea-
individual chromatin granules is iron
predominant irritable bowel syndrome (IBS), and some experts
hematoxylin.
have suggested ruling out infection with this organism first before
• Although most trophozoites are binucleated— diagnosing a patient as having IBS
hence, the name Dientamoeba—
mononucleated forms may also exist. TREATMENT
• Except for the absence of a flagellum, this
protozoan is closely related to and resembles • Iodoquinol
Trichomonas. • Tetracycline: alternative treatment
• Paromomycin (Humatin): used in cases when the treatments listed earlier,
Cyst for whatever reason, are not appropriate

• There is no known cyst stage of D. fragilis. PREVENTION & CONTROL

LABORATORY DIAGNOSIS Individual Level • If the unproven
✓ exercising proper personal transmission theory is
Specimen of Choice stool hygiene valid, the primary
✓ avoidance of unprotected prevention and control
• Multiple samples may be necessary to rule out homosexual practices measure would be the
the presence of this organism because the eradication of the
amount of parasite shedding may vary from Community Level helminth eggs,
day to day. ✓ proper public sanitation especially those of the
• Fresh stool samples are necessary since the practices pinworm.
trophozoites degenerate after a few hours of ✓ proper disposal of human waste
stool passage.
• The organism has the ability to blend in well
with the background material in the sample.
• Purged stool specimens provide more suitable
material for examination than the average
formed stool.
• Real-Time Polymerase Chain Reaction (RT-
PCR): shown to be the most sensitive of all
diagnostic methods
• Prompt fixation of the fresh specimen with
polyvinyl alcohol fixative or Schaudinn’s fixative
has been found to be helpful.

37
 DIENTAMOEBA FRAGILIS
LIFE CYCLE

Cycle EPIDEMIOLOGY
Diagnostic Stage Who?
1. Trophozoites are found in the lumen of the large intestine, where they → patients who were also infected with
multiply via binary fission, and are shed in the stool. E. vermicularis (pinworm)
→ children,
Infective Stage
→ homosexual men
2. Historically, only the trophozoite stage of D. fragilis had been detected. → those living in semicommunal groups
However, rare putative cyst and precyst forms have been described in → persons who are institutionalized
human clinical specimens; whether and in what settings transmission to
humans occurs via ingestion of such forms in contrast or in addition to Where?
other fecal-oral transmission routes is not yet known. → worldwide distribution
Transmission via Helminth Eggs → distributed in cosmopolitan areas
3. Transmission via helminth eggs (e.g., via Enterobius vermicularis eggs) How?
has been postulated. → fecal-oral and anal-oral routes
(ingestion of putative cyst and
Notes precyst form)
→ hypothetical transmission via
• Mode of Transmission: fecal-oral route (ingestion of putative cyst and helminth eggs
precyst form); hypothetical transmission via helminth eggs
• Diagnostic Stage: trophozoite NOTES OF INTEREST
• Infective Stage: trophozoite
• In contrast to many pathogenic
• D. fragilis lives in the mucosal crypts of the appendix, cecum and the protozoa, which have a high prevalence
upper colon. in developing countries, high
• The exact life cycle is unknown, although several assumptions have prevalence rates of D. fragilis have been
been made from clinical data. reported from developed countries with
• Direct human to human transmission is probably via the fecal-oral high sanitation standards.
route or via transmission of helminth eggs particularly that of Enterobius • D. fragilis differs from the amebic
vermicularis. trophozoites when mounted in water
• Dientamoeba-like mononucleated and binucleated forms have been preparations.
observed in the lumen of Enterobius adults and eggs present in the • Although both types of organisms swell
intestines. and rupture under these conditions,
• More recently, stools from macaques, gorillas, and swine were found to only D. fragilis returns to its normal size.
carry D. fragilis, thus animal reservoirs may also be potential sources of • Numerous granules are present in this
human infections. stage and exhibit Brownian motion. This
• There is no evidence to suggest that D. fragilis trophozoites invade their is known as the Hakansson
surrounding tissues. D. fragilis has only rarely been known to ingest red phenomenon; it is a feature diagnostic
blood cells. for the identification of D. fragilis.

38
 TRICHOMONAS HOMINIS
MUST KNOW

→ considered a nonpathogen
→ occurs only as a trophozoite
→ Diagnostic Stage: trophozoite
→ Infective Stage: trophozoite

MORPHOLOGY
Trophozoite
Size Range 7-20 µm long; 5-18 µm wide

Shape pear-shaped

Motility nervous, jerky

Nuclei one, with a small karyosome

no peripheral chromatin

Flagella three to five anterior

one posterior extending from the
posterior end of the undulating
membrane
LABORATORY DIAGNOSIS
Other axostyle that extends beyond the
Structures posterior end of the body Specimen of Choice stool
full body length undulating
membrane CLINICAL SYMPTOMS TREATMENT
conical cytostome cleft in anterior
region ventrally located opposite Generally asymptomatic Organism is a nonpathogen.
the undulating membrane
LIFE CYCLE NOTES
• The rodlike structure located at the base of the
undulating membrane, known as the costa, connects • Mode of Transmission: ingestion of trophozoite; fecal-oral
the undulating membrane to the trophozoite body. transmission
• The single nucleus, not visible in unstained • Diagnostic Stage: trophozoite
preparations, is located in the anterior region of the • Infective Stage: trophozoite
organism.
• Transmission occurs rapidly through fecal contamination
of food and drinks.
Cyst
• Its habitat is the cecal area of the large intestine of human
• There is no known cyst stage of D. fragilis. and other primates.
• It is noninvasive.
EPIDEMIOLOGY
• Trophozoites pass out with diarrheic stools.
Who?
→ children PREVENTION & CONTROL
→ travelers within areas of poor sanitation
Individual Level
Where? ✓ exercising proper personal hygiene
→ worldwide; cosmopolitan areas of warm and
temperate climates Community Level
→ areas with poor sanitation and hygiene practices ✓ proper public sanitation practices
How?
→ ingestion of trophozoite
→ fecal-oral transmission

• It is interesting to note that the frequency of infections

is higher in warm climates and that children appear
to contract this parasite more often than adults.
• Contaminated milk is suspected of being one of the
sources of infection.
• It is suspected that in patients suffering from
achlorhydria, the milk acts as a shield for the T.
hominis trophozoites upon entry into the stomach.
This may account for the organism’s ability to survive
passage through the stomach area and to settle in
the small intestine.
• The prevalence in the Philippines is less than 1%.

39
 ENTEROMONAS HOMINIS
MORPHOLOGY
Trophozoite
Size Range 3-10 µm long; 3-7 µm wide

Shape oval; sometimes half-circle

Motility jerky

Nuclei one with central karyosome

no peripheral chromatin

Flagella four:
3 directed anteriorly
1 directed posteriorly

• Average Length: 7 to 9 µm
• In this case, the body is flattened on one side.
• The nucleus is located in the anterior end of the
trophozoite.
LABORATORY DIAGNOSIS
• These trophozoites are simple, relatively speaking, in that Specimen of Choice stool
structures such as an undulating membrane, costa,
cytostome, and axostyle are absent. • Unfortunately, this organism is difficult to identify
accurately because of its small size.
Cyst • Careful screening of samples is recommended to
Size Range 3-10 µm long; 4-7 µm wide prevent missing an E. hominis organism.

Shape CLINICAL SYMPTOMS TREATMENT

oval, elongated
Typically asymptomatic Organism is a nonpathogen.
Nuclei one to four
binucleated and quadrinucleated nuclei EPIDEMIOLOGY
located at opposite ends
central karyosome Who?
no peripheral chromatin → people warm and temperate climates
Where?
• On first inspection of these organisms, yeast cells may → worldwide; warm and temperate climates
often be suspected. → areas with poor sanitation and hygiene practices
• When more than one nucleus is present, these structures How?
are typically located at opposite ends of the cell. → ingestion of infected cysts
• The nuclei resemble those of the trophozoites in
• that each consists of a well-defined nuclear membrane PREVENTION & CONTROL
surrounding a central karyosome.
Individual Level
• The cysts of E. hominis are protected by a well-defined ✓ exercising proper personal hygiene
cell wall.
• Fibrils and internal flagellate structures are also not seen Community Level
in the cyst form. ✓ proper public sanitation practices
• It is important to note that the size range of E. hominis
cysts overlaps that of Endolimax nana cysts. A high LIFE CYCLE NOTES
frequency of binucleated cysts seen on a stained
preparation indicates probable E. hominis because the • Mode of Transmission: ingestion of infected cyst; fecal-
probability of finding binucleated E. nana cysts is oral transmission
extremely rare. • Diagnostic Stage: cyst, trophozoite
• Infective Stage: trophozoite

40
 RETORTAMONAS INTESTINALIS
MORPHOLOGY
Trophozoite
Size Range 3-7 µm long; 5-6 µm wide

Shape Ovoid

Motility jerky

Nuclei one, with small central karyosome

ring of chromatin granules may be on
nuclear membrane

Flagella two; anterior LABORATORY DIAGNOSIS

Other cytostome extending halfway down body Specimen of Choice stained stool
Structures length with well-defined fibril border
opposite the nucleus in the anterior end • Unfortunately, accurate identification is difficult, in part
because of the small size of this organism.
• Average Length: 3 to 5 µm long
• In addition, the small number of diagnostic features
may sometimes not stain well enough to recognize.
Cyst
• Stools suspected of containing R. intestinalis, as well as
Size Range 3-9 µm long; up to 5 µm wide the other smaller flagellates, should be carefully
screened before reporting a negative test result.
Shape lemon-shaped, pear-shaped
CLINICAL SYMPTOMS TREATMENT
Nuclei one, located in anterior-central region with
central karyosome Typically asymptomatic Organism is a nonpathogen.
may be surrounded by a delicate ring of
chromatin granules EPIDEMIOLOGY
Other two fused fibrils resembling a bird’s beak in Who?
Structures the anterior nuclear region, only visible → select group of individuals, including patients in
in stained preparations psychiatric hospitals and others living in crowded
conditions
• This structure, along with the nucleus itself, is often
difficult to see, especially in unstained preparations. Where?
→ warm and temperate climates throughout the world
LIFE CYCLE NOTES → areas with poor sanitation and hygiene practices
How?
• Mode of Transmission: → ingestion of infected cysts
ingestion of infected
cyst PREVENTION & CONTROL
• Diagnostic Stage: cyst,
trophozoite Individual Level
• Infective Stage: ✓ exercising proper personal hygiene
trophozoite
Community Level
✓ proper public sanitation practices

41
 LIFE CYCLE OF NON-PATHOGENIC FLAGELLATES
ENTEROMONAS HOMINIS | RETORTAMONAS INTESTINALIS | PENTRATRICHOMONAS HOMINIS

Cycle
Diagnostic Stage
1. Both cysts and trophozoites of Enteromonas hominis and Retortamonas intestinalis are shed in feces; only trophozoites
of Pentatrichomonas hominis (no known cyst stage) are shed in feces

Infective Stage
2. Infection occurs after the ingestion of cysts (E. hominis, R. intestinalis) or trophozoites (P. hominis) image in fecally
contaminated food or water, or on fomites.

Excystation
3. Excystation of E. hominis and R. intestinalis releases trophozoites into the large intestine; P. hominis is found as a
trophozoite throughout its life cycle.

Replication
4. These three species colonize and replicate in the large intestine, where they are regarded as commensal organisms
and are not known to cause disease.

42
 TRICHOMONAS TENAX
MUST KNOW

→ considered a nonpathogen
→ a pyriform flagellate which has been observed only
in the trophozoite stage
→ Diagnostic Stage: trophozoite
→ Infective Stage: trophozoite

MORPHOLOGY
Trophozoite
Size Range 5-14 µm long

Shape oval, pear-shaped

Nuclei one, ovoid nucleus; consists of

vesicular region filled with
chromatin granules

Flagella five total, all originating anteriorly:

4 extend anteriorly
1 extends posteriorly
Other undulating membrane extending two
Structures thirds of body length with
accompanying costa
thick axostyle curves around nucleus;
extends beyond body length
small anterior cytostome opposite
undulating membrane
• T. tenax is smaller and more slender than T. vaginalis.
• The organism multiplies by binary fission and thrives
on the microorganisms found in its environment.
Cyst
• There is no known cyst stage of D. fragilis.
LABORATORY DIAGNOSIS
Specimen of Choice mouth scrapings
• Microscopic examination of tonsillar crypts and
pyorrheal pockets of patients suffering from T. tenax
infections often yields typical trophozoites.
• Tartar between the teeth and gingival margin of the
gums are the primary areas of the mouth that may
also potentially harbor this organism.
• Samples suspected of containing T. tenax may also
be cultured onto appropriate media.
• Diagnosis is made by swabbing the tartar between
the teeth, the gingival margin, or tonsillar crypts.
CLINICAL SYMPTOMS
• The typical T. tenax infection does not produce any
notable symptoms.
• On a rare occasion, T. tenax has been known to
invade the respiratory tract, but this appears to have
mainly occurred in patients with underlying thoracic
or lung abscesses of pleural exudates.
• Pulmonary trichomoniasis has been reported among
those with underlying chronic pulmonary disease,
entering the lungs most probably by aspiration.
• The parasite is probably unable to cause disease on
its own. The presence of bacteria most probably
allows it to proliferate profusely.
TREATMENT
• T. tenax is considered to be a nonpathogen and no
chemical treatment is normally indicated.
• The T. tenax trophozoites seem to disappear in infected
persons following the institution of proper oral hygiene
practices.
• In most of these cases, treatment with metronidazole results
in rapid improvement.
EPIDEMIOLOGY
Who?
→ patients with poor oral hygiene
Where?
→ worldwide
→ areas with poor sanitation and hygiene practices
How?
→ use of contaminated dishes and utensils
→ droplet contamination through kissing
• The exact mode of transmitting T. tenax trophozoites is unknown.
• The trophozoites appear to be durable, surviving several hours in
drinking water.
• Exposure results from droplet spray from the mouth, kissing, or
common use of contaminated dishes and drinking glasses.
• Trichomonas tenax is a harmless commensal of the human mouth,
living in the tartar around the teeth, in cavities of carious teeth, and
in necrotic mucosal cells in the gingival margins.
• It is quite resistant to changes in temperature and will survive for
several hours in drinking water.
PREVENTION & CONTROL
Individual Level
✓ exercising proper personal hygiene
Community Level
✓ proper public sanitation practices
LIFE CYCLE NOTES
• Mode of Transmission: ingestion of infected cyst
• T. tenax trophozoites survive in the body as mouth scavengers that
feed primarily on local microorganisms.
• Located in the tartar between the teeth, tonsillar crypts, pyorrheal
pockets, and gingival margin around the gums, T. tenax
trophozoites multiply by longitudinal binary fission.
• These trophozoites are unable to survive the digestive process.

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 TRICHOMONAS VAGINALIS
MUST KNOW

→ causes trichomoniasis (sexually transmitted

disease), persistent urethritis, persisten vaginitis
→ first observed by Donne in 1836 in purulent
secretions of male and female urogenital tracts
→ the most prevalent non-viral sexually transmitted
infection
→ Diagnostic Stage:
→ Infective Stage:

MORPHOLOGY
Trophozoite
Size Range up to 30 µm long

Shape ovoid, round or pear-shaped

Motility rapid, jerky CLINICAL SYMPTOMS

Nuclei one, ovoid, nondescript • Inflammation of the vaginal mucosa occurs several days after the
inoculation of T. vaginalis trophozoites.
Flagella all originating anteriorly: • T. vaginalis cannot live without close association with the vaginal,
3-5 extending anteriorly urethral, or prostatic tissues. Four to 28 days after introduction of
1 extending posteriorly viable T. vaginalis into the vagina, proliferating colonies of the
flagellate cause degeneration and desquamation of the vaginal
Other undulating membrane extending two epithelium followed by leukocytic inflammation of the tissue layer.
Structures half of body length • The acute inflammation caused by the parasite results in the
prominent axostyle that often curves characteristic liquid vaginal secretions, greenish or yellow in color,
around nucleus; granules may be that cover the mucosa down to the urethral orifice, vestibular
seen along axostyle glands, and clitoris
• As the acute condition changes to the chronic stage, the secretion
• Trichomonas vaginalis exists only in the trophozoite loses its purulent appearance due to a decrease in the
stage. trichomonads and leukocytes, an increase in epithelial cells, and
the establishment of a mixed bacterial flora.
• The flagella may be difficult to find on specimen
• Aside from the common symptoms of vaginal discharge, vulvitis,
preparations.
and dysuria, trichomonads appear to be associated with an
increased incidence of postpartum endometritis. Complications in
women include secondary bacterial infection of the urogenital
tract.
• Strawberry Cervix: speculum examination reveals punctate
hemorrhages of the cervix
• Trichomonas infection in males may be latent and essentially
asymptomatic.
• In some cases, it is responsible for an irritating persistent and
recurring urethritis. Prostatitis is the most common complication.
• Asymptomatic Carrier State: most frequently occur in men
• Persistent Urethritis: recurring urethritis is the condition that
symptomatic men experience
→ Involvement of the seminal vesicles, higher parts of the
urogenital tract, and prostate may occur in severe cases of
Cyst
infection.
→ Symptoms of severe infection include an enlarged tender
• There is no known cyst stage of D. fragilis. prostate, dysuria, nocturia, and epididymitis.
→ These patients often release a thin, white urethral discharge
LABORATORY DIAGNOSIS that contains the T. vaginalis trophozoites.
• Persistent Vaginitis: found in infected women, is characterized by a
Specimen spun urine, vaginal discharges, urethral foul-smelling, greenish-yellow liquid vaginal discharge after an
of Choice discharges, and prostatic secretions incubation period of 4 to 28 days
→ Vaginal acidity present during and immediately following
• prompt examination of saline wet preparations menstruation most likely accounts for the exacerbation of
symptoms.
• Additional Diagnostic Tests: phase contrast → Burning, itching, and chafing may also be present. Red punctate
microscopy, Papanicolaou (Pap) smears, fluorescent lesions may be present upon examining the vaginal mucosa of
stains, monoclonal antibody assays, enzyme infected women.
immunoassays, and cultures → Urethral involvement, dysuria, and increased frequency of
urination are among the most commonly experienced
• A DNA-based assay has been developed for T.
symptoms.
vaginalis detection using Affirm VPIII (BD Diagnostics, → Cystitis is less commonly observed but may occur.
Sparks, MD).
• Infant Infections
• InPouch TV (BioMed Diagnostics, White City, OR) → T. vaginalis has been recovered from infants suffering from both
culture system: used with vaginal swabs from women, respiratory infection and conjunctivitis.
urethral swabs from men, urine sediment and semen
→ These conditions were most likely contracted as a result of T.
sediment; requires incubation time and takes up to 3 vaginalis trophozoites migrating from an infected mother to the
days before a result is determined infant through the birth canal and/or during vaginal delivery.

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 TRICHOMONAS VAGINALIS
LIFE CYCLE

Cycle Notes

Diagnostic Stage • Mode of Transmission: sexual intercourse

1. Trichomonas vaginalis • Diagnostic Stage: trophozoite
resides in the female lower • Infective Stage: trophozoite
genital tract and the male • The parasite is found in the urogenital tract.
urethra and prostate, ▪ In women, it is found in the vagina but may ascend as far as the renal pelvis.
where it replicates by ▪ The parasite can be isolated from the urethra, prostate, and less frequently, in the
binary fission. epididymis in men.
2. The parasite does not • The trophozoites multiply by binary fission in the host and are transferred passively
appear to have a cyst from person to person.
form, and does not survive
well in the external • T. vaginalis trophozoites reside on the mucosal surface of the vagina in infected
environment. women.

Infective Fission
3. Trichomonas vaginalis is
transmitted among
humans, its only known
host, primarily by sexual
intercourse
• The growing trophozoites multiply by longitudinal binary fission and feed on local
bacteria and leukocytes.
• T. vaginalis trophozoites thrive in a slightly alkaline or slightly acidic pH environment,
such as that commonly seen in an unhealthy vagina.
• The most common infection site of T. vaginalis in males is the prostate gland region
and the epithelium of the urethra.
• The detailed life cycle in the male host is unknown.

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 TRICHOMONAS VAGINALIS
EPIDEMIOLOGY
Who?
→ people with more sexual partners
Where?
→ worldwide
How?
→ sexual intercourse
• Infections with T. vaginalis occur worldwide.
• These trophozoites may also migrate through a mother’s
birth canal and infect the unborn child.
• Under optimal conditions, T. vaginalis is known to be
transferred via contaminated toilet articles or
underclothing. However, this mode of transmission is rare.
• The sharing of douche supplies, as well as communal
bathing, are also potential routes of infection.
• T. vaginalis trophozoites, which are by nature hardy and
resistant to changes in their environment, have been
known to survive in urine, on wet sponges, and on damp
towels for several hours, as well as in water for up to 40
minutes.
• Prevalence is higher among women of child-bearing age.
• About 5 to 20% of women and 2 to 12% of men in
developed countries are infected. Higher prevalence is
associated with greater frequency of sexual intercourse
with multiple partners and with commercial sex workers.
• In the Philippines, the prevalence of trichomoniasis
among commercial sex workers varies with the method of
diagnosis used, from 15% in studies using only
microscopic examination of vaginal swabs to 37% in
studies using culture.
PREVENTION & CONTROL
Individual Level
✓ limiting the number of sexual partners
✓ avoidance of unprotected sex
✓ prompt diagnosis and treatment of asymptomatic
men
✓ avoidance of sharing douche equipment, as well as
close contact with potentially infective underclothing,
toilet articles, damp towels, and wet sponges
Community Level
✓ avoidance of communal bathing
✓ Prompt follow-up of patients and their contacts
✓ health and sex education about venereal disease
NOTES OF INTEREST
• Infections with T. vaginalis are generally considered to
be a nuisance and not a major pathogenic process.
• There is evidence to suggest a connection between T.
vaginalis infections and cervical carcinoma.
• Saline preparation of vaginal fluid is the quickest and
most inexpensive way to diagnose trichomoniasis, but
the sensitivity of this technique is low at 60 to 70%.
• The accepted gold standard is culture which takes 2 to
5 days.
• The unstained wet drop preparations may be fixed and
stained by Giemsa, Papanicolau, Romanowsky, and
acridine orange stains.
• Trichomonas can also be cultured using Diamond’s
modified medium, and Feinberg and Whittington
culture medium.

REFERENCES
➢ Belizario, et. al. (2013). Medical
Parasitology in the Philippines. The
University of The Philippines Press
➢ Zeibig. (2013). Clinical Parasitology: A
Practical Approach. Elvisier Inc.

TRANSCRIBED BY
➢ Bautista, MD

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