Parasitology (dra Madrid

)

Coccidians
20 February 08 November 07
Coccidians Isospora belli (Life cycle)

▪At time of excretion, immature oocyst contains usually 1
Coccidian Parasites sporoblast

▪Members of the class Sporozores (Phylum Apicomplexa) ▪Obligate intracellular protozoans ▪Gliding motility ▪Reproduction
o o Sexual phase: sporogony, gametogony Asexual phase: schizogony, merogony (trophozoites, schizonts, merozoites) Isospora Sarcocystis Cryptosporidium Cyclospora Toxoplasma Pneumocystis

▪Sporoblast divides into two, secrete a cyst wall sporocysts ▪Sporocyst divide to produce sporozoites ▪Infection occurs in ingestion of sporocyst containing
oocyst(oocyst containing 2 sporocyst with each containing 4 sporozoites)

▪Sporocyst excyst in small intestinerelease sporozoites
enter epithelial cells of distal duodenum and proximal ileum o Invade new epithelial, continue asexual multiplication

▪Species included:
o o o o o o

▪Trophozoites develop into schizonts which contain multiple
merozoites

o

Rupture of schizonts  release of merozoites  invade new epithelial cells and continue of asexual multiplication

▪After 1 wk, sexual stage begins – male and female
gametocytes o Microgametocytes fertilize macrogametocytes

Isospora belli

▪Fertilization product: oocyst excreted in stool
o
o Oocyst mature in 48 hrs  oocyst initially has 1 sporoblast  divides into 2 sporoblast  develop into sporocysts (2) 4 long and slender sporozoites develop within each sporocyst

▪Coccidian parasite ▪Infects epitheial cells of the small intestine ▪Infections usually in immunocompromised patients ▪Geographic distribution
o o Worldwide, in tropical and subtropical areas High prevalence: Haiti and other tropical areas with poor sanitary conditions

▪Oocyst of isospora contains 2 sporocysts, each with 4
sporozoites Isospora belli: Clinical Manifestations

▪Transmission: food and water ▪Dse common in children and male homosexuals especially
those with AIDS

▪Infections often asymptomatic even with excretion of
oocysts

▪Definitive hosts: human and animals
Pathogenesis

▪Symptomatic infections:
o o o o o o o o Diarrhea: intermittent for months Fever, malaise, anorexia, abdominal pain, flatulence Malabsorption along with weight loss and rarely death In immunocompromised hosts, severe diarrhea Eosinophilia Mucosal lesions of shortened villi Hypertrophied crypts Infiltration of lamina propria with pmn leucocytes especially eosinophils

▪Parasites develop and multiply in the epithelial cells of the
small intestine

▪Trophozoites develop into schizonts(contain merozoites);
rupture of schizonts release the merozoites  invade new epithelial cells, and continue the cycle of asexual multiplication

▪Intestinal biopsies show:

▪After 1 week sexual stage begins: devt of male and female
gametocytes fertilization  devt of oocysts excreted in the stool

▪Immature oocyst contains usually 1 sporoblast  further
maturation  sporolast divides in 2 (oocyst now contains 2 sporoblasts); sporoblasts secrete a cyst wall and becomes sporocysts  sporocysts divide 2x to produce 4 sporozoites each

▪Dissemination to other organs: seen in AIDS patients ▪Prognosis is good but infection may last for months
Isospora belli: diagnosis

▪Infection occurs by ingestion of sporocyst-containing
oocysts; sporocysts excyst in small intestine, release their sporozoites  invade epithelial cells and initiate schozogony

▪Detection of oocysts in feces ▪Oocysts in stools: ellipsoidal shape
1 of 7

YNA, joy, cams, shar – 2B1

Parasitology – Coccidians by Dra Madrid
Isospora belli: treatment

Page 2 of 7

▪In humans,
o Gastroenteritis, myalgia, weakness, mild increase of creatine kinase

▪Asymptomatic infections: bed rest and a bland diet ▪Trimethoprim-sulfamethoxazole: drug of choice
Sarcocystis

▪In the intermediate hosts, the brain, muscle, and kidney
tissues can be damaged o Loss of appetite, fever, weight loss, and anemia; o Gait abnormalities, weakening of limbs, muscle wasting, and head tilt o Infected animals have been observed to move in circles

▪Worldwide: infects humans and animals ▪Disease: sarcosporidiosis and sarcocystosis ▪Complex life cycle – involves intermediate hosts ▪Definitive hosts: man and carnivores (dog) ▪Human definitive hosts for 2 species:
o o Sarcocystis hominis Sarcocystis suihominis

▪Accidental ingestion of sporocysts results in direct infection
of humans without the intermediate host o Occurs rarely and is called human intramuscular sarcocystis

▪Humans can also act as intermediate hosts ▪Take several forms ▪Simplest is called the zoite
o Banana shaped cell with a pointed end equipped for entering host cells Oval; can survive on ground and infect intermediate hosts

Sarcocystis (diagnosis)

▪In the definitive host, demonstration of sporocysts in the
fecal material using flotation method

▪In the intermediate host, detection of schizonts in the
skeletal muscle or in brain tissue during autopsy

▪Sporocysts are composed of 4 zoites
o

▪Detection of antibodies in serum or CSF using Western blot,
IFA and ELISA

▪Sporozoites are formed from sporocysts ▪Sarcocysts are formed from sporozoites
o o o Composed of large numbers of zoites surrounded by a cyst wall Those that can be seen by the naked eye are called macrocyst Microcysts are sarcocysts that remain about the same width as the muscle fiber and can be seen only under the microscope

Sarcocystis (treatment and prognosis)

▪No effective treatment known ▪Corticosteroid – to decrease muscular inflammation ▪Trimethoprim-sulfamethoxazole – effective in treating
intestinal infections

▪In most animal infections due to this parasite do not cause
serious pathologic changes

Sarcocystis (Life cycle) Sarcocystis (Epidemiology) Definitive hosts are infected when they eat undercooked meat w/c contains sarcocyst  sarcocyst wall digested  release of zoites  enter intestinal cells and change into male and female forms fertilization sporocysts passed out in the feces of the host (definitive host)

▪Worldwide geographic distribution ▪Few human cases, most from SE Asia ▪Prevalence may be high due to numerous asymptomatic
infections

▪Other animals w/c may be infected: cattle, horses, dogs,
cats, rabbits, mice, and chicken

Sporocysts ingested by intermediate hosts  sporozoites (w/c are formed from sporocysts) penetrate intestinal epithelial tissues hematogenous spreadbrain, muscles and other tissues

▪Infections in avian species have no known human threat ▪Sporocysts remain infective for many months in water at 410C; infectivity prolonged during the cooler months of the year

▪Infected carcasses left unburied on farmland can remain
infective for cats and dogs for weeks on cool weather

** sporozoites enter muscle cells, and encyst and develop into sarcocysts ** in other tissues, sporozoites become schizonts and then encyst

▪Freezing does not prevent spread ▪Macrocysts from sheep have to be heated for 20 mins to kill
them

Sarcocystis (prevention and control)

Sarcocystis (Clinical Manifestations)

▪No known control methods ▪Uncooked dead animal should not be fed to other animals ▪Good sanitation and hygiene

Parasitology – Coccidians by Dra Madrid

Page 3 of 7

Cryptosporiosis Cryptosporidium

Immunocompetent:

▪Causal agent:
o o Many species exist that infect humans and a wide range of animals Although Cryptosporidium parvum and Cryptosporidium hominis (formerly known as C. parvum anthroponotic genotype or genotype 1) are the most prevalent species causing disease in humans, infections by C. felis, C. meleagridis, C. canis, and C. muris have also been reported

▪Acute self-limiting diarrheal illness ▪1-2 week duration ▪Frequent, watery diarrhea ▪N/V, abdominal cramps, low grade fever
Immunocompromised

▪C. parvum – now considered a parasite of bovines w/c can
infect humans

▪C. hominis – infect only humans ▪Prevalence in the Philippines has been reported to be low at
2.6%

▪Debilitating, cholera-like diarrhea (upto 20L/day) ▪Severe abdominal cramps ▪Malaise ▪Low grade fever ▪Weight loss ▪Anorexia
**Pa-add ng Cryptosporidosis epidemiology at yung persons likely to be infected

▪Coocidian protozoan ▪1907 – discovery of the organism ▪1976 – first case of human cryptosporidiosis ▪Infect several different hosts, can survive most
environments for long periods of time (“hard cysts”); inhabits all climates and locales

▪Taxonomically classified as Sporozoa – oocyst releases 4
sporozoites

Cryptosporidium: Transmission

▪Monoxenous life cycle – completes entire cycle w/in a single
host

▪Ingestion of fecally contaminated food and water
o Drinking water taken from surface water sources such as lakes and river; swimming pools and water park wave pools, untreated water Cyst is resistant to various drinking water filtration treatments such as chlorination Food can get contaminated; oocyst do not survive cooking but can occur in foods not heated or in foods not cooked after handling From household pets is rare Definite correlation between calves shed oocysts and pathogen present in 90% of all dairy farms Occurs at a high frequency in day-care centers; clustered population Nosocomial settings

▪Sexual and asexual cycles ▪Six distinct developmental stages
Cyptosporidium (Life cycle)

o o

▪6 distinct developmental stages:
o o o o o o Excystation of the orally ingested oocyst in the small bowel with the release of 4 sporozoites Invasion of intestinal epithelial cells; initiation of asexual intracellular multiplication stage Differentiation of the microgametes (males) and macrogametes (females) Fertilization initiating sexual replication Development of oocysts Formation of new, infectious sporozoite w/in the oocyst, excreted in the stool

▪Animal to person transmission
o o

▪Person to person
o o

▪Sporulated oocysts, containing 4 sporozoites, are excreted
thru feces (and possibly respiratory secretions)

Cryptosporidium: Pathogenesis

▪Following ingestion, excystation occurs sporozoites are
released and parasitize epithelial cells of GIT (or other tissues) undergo asexual (schizogony or merogony) and then sexual multiplication (gametogony)

▪Upon excystation, sporozoites released
o o

▪Fertilization of macrogamonts (female) by microgametes
(male)  oocysts develop  sporulate in host, and excreted o Because oocysts sporulate inside host, autoinfection can occur

o

▪Oocysts are infective upon excretion, thus permitting direct
and immediate fecal-oral transmission Cryptosporidiosis (Clinical Manifestations)

Adhere to the surface of the intestinal mucosa Sporozoite-specific lectin adherence factor: agent of attachment to the intestinal surface Release of cytokines by mucosal cells  activate phagocytes to release soluble factors that increase intestinal secretion of water and chloride; inhibit absorption Direct result of parasite invasion Damage through T cell-mediated inflammation, producing villus atrophy and crypt hyperplasia

▪Epithelial cells damaged via:
o o

Parasitology – Coccidians by Dra Madrid
Cryptosporidium: diagnosis

Page 4 of 7

▪Staining methods eg. Modified acid-fast stain to detect
oocysts in stool specimen

▪PCR
Cryptosporidium: treatment

When ingested, sporozoites are released  enter intestinal cells  undergo schizogony and gametogony ** pa insert ng picture n life cycle, first slide sa page 10 ng trans ng 2B

o

Cyclospora: Clinical Manifestations ** hindi ulit mabasa…ito yung secnd slide sa page 10

▪No safe and effective therapy ▪Immunocompetent individuals – supportive care ▪Pharmacologic therapies:
o o Immunocompromised patients, spiramycin and dicalzuril sodium have produced partial responses Paromomycin, a promising drug…decreases severity of infection and improve intestinal function Feeding of bovine colostral immunoglobulin  ameliorate symptoms; release of intestinal IgA w/c clears infection

Cyclospora: diagnosis

▪Direct microscopic examination of fecal specimens using
concentration techniques and acid-fast staining (Kinyoun’ stain)

▪Immunologic therapies
o

▪Fluorescent microscopy
o Appear blue or green circles

Cyclospora: treatment Cryptosporidium: prevention

▪Practice good hygiene
o o Wash hands thoroughly Protect others: don’t go swimming if have diarrhea Do not swallow recreational water Do not drink untreated water (shallow wells, lakes, rivers, ponds and streams) Do not use untreated ice or drinking water during travel to areas with unsafe water supply Wash and/or peel raw vegetables and fruits with clean water Avoid uncooked foods during travel to countries with minimal water treatment and sanitation systems

▪Avoid possibly contaminated water
o o o

▪Self-limiting disease ▪Treatment not necessary if symptoms are mild ▪The only effective drug is cotrimoxazole ▪No alternative drug if not tolerated ▪Oocyst disappear from the stools a few days after
treatment

Cyclospora: epidemiology

▪Avoid possibly contaminated foods
o o

▪Epidemics reported: Haiti, Peru and Nepal ▪Raspberries from Guatemala were incriminated in infections
in the US

▪Leafy vegetables were found to contain oocysts Peru and
Nepal

▪Lettuce and basil pesto-salad incriminated in other cases in
the US

Cyclospora cayetanensis

▪Originally called a cyanobacterium-like body (CLB) ▪Life cycle presumed to be similar to other intestinal
coocidia

▪Contaminated water: main source of infection ▪No animal reservoirs found; cyclosporidiosis is considered a
human disease

Cyclospora: prevention and control

Cyclospora: parasite bology

▪The oocyst
o o o Formed after asexual and sexual cycles Passed in feces Are unsporulated when passed (after 5 or more days, 2 sporocysts develop, each containing 2 sporozoites w/in oocyst) Sporulated Contains 2 sporozoites Considered infective stage

▪Follow good sanitary practices ▪In most endemic areas: boiling water seems to be the best
method since chlorination is not effective

▪Wash fruits and vegetables with clean water
Pneumocystis carinii

▪Mature oocyst
o o o

▪Causal agent
o P carinii is now considered a fungus based on nucleic acid and biochemical analysis

Parasitology – Coccidians by Dra Madrid
o However, it has morphologic and biologic characteristics that, while incompletely understood, place it close to the protozoa

Page 5 of 7

▪Diffuse type of pneumonia in immunocompromised hosts ▪New name: Pneumocystis jiroveci ▪Exist in ______________________________ (hindi mabasa: 4
th

Toxoplasmosis

slide, page 11)

Toxoplasma gondii

▪Painsert na rin ng slide 5 (picture naman to) at slide 6 sa
page 11

P carinii: structure

▪Worldwide distribution ▪Infects humans and many species of animals ▪Definitive host: cat
o o o Complete cycle occurs in this host Cats get infected by ingestion of infective oocyst from soil or tissue of infected animals (mice) In cat intestines, undergoes schizogony, gametogony and sporogony

▪Cyst: thick walled; spherical to ovoid;
o 4-6 um in diameter; contains up to 8 pleomorphic sporozoites

▪Sprozoites: intracystic structure ▪Trophozoite: thin walled extracystic cell; represents
excysted sporozoite

T gondii (parasite biology)

▪Organism does not enter the host cell but attaches to its
surface during replicative cycle; no evidence of toxin production

▪In the cat
o In intestinal epithelium of the cat, merozoites multiply (schizogony), followed by differentiation into microgametocytes and macrogametocytes (gametogony) Fertilization of the macrogamete gives rise to an oocyst Oocyst passed out with cat feces in unsporulated stage

P carinii: clinical features

o o

▪Dyspnea ▪Nonproductive cough ▪Fever ▪Diffuse infiltrates on CXR ▪Extrapulmonary lesions (< 3%):
o LN, spleen liver, and bone marrow

o

▪Complete sporulation: 3-4 days In mature oocyst: 2 sporocysts, each with sporozoites are formed ▪Can be ingested with contaminated food
or water by another host In humans or other hosts:

▪Illness may last from 4-6 weeks ▪Pneumocystis pneumonia (PCP) occurs in
immunosuppressed individuals and in premature malnourished infants

o

▪Mature oocyst excysts (inside intestine of
new host)  release 4 sporozoites  penetrate lamina propria

▪Parasites enter lymphatics different
o organs, tissues and body fluids Following entry of sporozoite into a new cell, t transforms into a tachyzoite

P carinii: Pathogenesis

▪Portal of entry, not established ▪Likely mode of transmission: inhalation ▪In most individuals, dormant and dispersed in the lung eith
no apparent host response o P carinii: diagnosis o

▪Tachyzoites: formed during initial and
acute phase of infection • Fast multiplying tachyzoites give rise to slow multiplying bradyzoites that form cysts Only these 2 stages are present in humans and other animal intermediate hosts Asexual multiplication is by a variation of binary fission called endodyogeny

▪Id of organism in pulmonary tissue or lower airway fluids
through lung biopsy, inducement of sputum, bronchoalveolar lavage, needle aspiration of lung o

▪Formation of plasma membrane by the 2
new daughter parasites even before the division of the nucleus Cells in w/c endodyogeny occur eventually burst releasing trophozoites w/c invade other cells Pa-add ng toxoplasma life cycle (1st 2 slides sa page 14)

P carinii: treatment

o

▪Trimethoprim-sulfamethoxazole: DOC ▪Alternative drugs:
o o o o Pentamidine Atovaquone Primaquine + clindamycin Trimthoprim + dapsone

T gondii: intermediate hosts

▪Man, rodents, farm animals

Parasitology – Coccidians by Dra Madrid
o T gondii: parasite biology Does not have a well-defined wall Usually contain bradyzoites Seen during chronic infections Well-formed wall Can be found in muscles and CNS

Page 6 of 7

▪The cyst
o o o o

▪Infective stages:
o o o Oocyst Tachyzoites Bradyzoite Ovoidal, thin walled Mature cyst in intestine of the new host  excystsrelease 4 sporozoites, penetrates intestinal mucosa; can also gain entry to the lymphatics and spread to other organs The transformed stage when sporozoite enters a new cell Found during initial and acute stage of infection  Rapidly multiplying  Present in humans and other animal intermediate hosts  Can be transmitted to other humans by blood transfusion, transplacental and organ transplantation Formed after tachyzoite Encysted form Found during chronic latent (asymptomatic) infections Persists for years in human tissue (brain, retina, muscles, etc) Can also be found in other animal intermediate hosts Can be transmitted by organ transplantation and eating meat of infected animals

▪The oocyst
o

T gondii: clinical manifestations

o

▪Asymptomatic – majority of cases ▪Acute toxoplasmosis – fever, lymphadenopathy (infectious
mononucleosis-like picture)

▪The Tachyzoite
o o

▪Reactivation toxoplasmosis – in immunocompromised
patients (AIDS, cancer, drug immunosuppression, organ transplant recipients); presents with specific organ involvement o Encephalitis: most common manifestation o Myocarditis, focal pneumonia

▪Choreoretinitis
o o Occurs later in life in those who acquired toxoplasma congenitally Retinal focal lesions: dec visual acuity, dec vision, retinal lesions on retinoscopy Mother to fetus Increased transmission rate in third trimester but increased severity of fetal disease in the 1st trimester Presents as hydrocephaly Hepatomegaly, cerebral calcifications, mental retardation Stillbirth and abortion may result when mothers acquire infection during the 1st trimester of pregnancy

▪The bradyzoite
o o o o o o

▪Congential toxoplasmosis
o

o
o o

o

T gondii: diagnosis T gondii: Multiplication

▪Observation of parasites in patient specimens s.c.
bronchoalveolar lavage for immunocompromised or lymph node biopsy

▪Sexual phase – occurs in cat ▪Asexual replication
o o Occurs in both definitive and intermediate hosts Endodyogeny – variation of binary fission  Formation of the plasma membrane by the 2 new daughter parasites before nuclear division

▪Isolation of parasites from blood or other body fluids, by
intraperitoneal inoculate into mice or tissue culture

▪Detection of parasite gamete material by PCR, esp in
detecting congenital infection

▪Serologic test – routine method of diagnosis; detect
presence of o o o antibodies against T gondii Sabin-Feldman methylene blue dye test IgM indirect fluorescent antibody technique IgM enzyme immunoassay

Cells burst trophozoites

T gondii: parasite forms T gondii: treatment

▪The trophozoite
o o o o o o o 4-8 um in length; 2-3 um in width Crescent-shaped Pointed anterior end; rounded posterior end Rhoptries and micronemes found on the anterior end; for cell penetration Nucleus: spherical on the posterior end Usually contains proliferating tachyzoites Can be taken in tissue sections of patients with acute infections

▪Regimen: pyrimethamine+sulfadiazine x 1month ▪Other drugs: clindamycin, azithromycin, clarithromycin,
dapsone, and atovaquone

▪The pseudocyst

▪Corticosteroids – prevent hypersensitivity reactions ▪Trimethoprim-sulfamethoxazole – prophylaxis for
immunocomromised

T gondii: Epidemiology

Parasitology – Coccidians by Dra Madrid

Page 7 of 7

▪Endemic worldwide both in humans and animals ▪Dse usually not manifested except in immunodeficiency or
immunosuppression

▪Infection more common in warm climates and at lower
altitudes than in cold climates and mountainous regions

▪Only 2% of human population is seropositive for T gondii
T gondii: prevention and control

▪Food should be protected from being contaminated with cat
feces

▪Cook eggs and meat well ▪Avoid unpasteurized milk.
END OF TRANS