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CHAPTER THREE

MEDICAL
PROTOZOLOGY

Protozoan
The

protozoa are a microscopic, one celled


(unicellular) organism. They are the simplest forms of
animal life.
Several species of protozoa are found in to intestinal
tract and few of them invade different part of human
body. E.g. blood, tissue, internal organs.
The protozoa are classified biologically according to
their type of locomotory organelles or according to
their habitat in the body of the host
Locomotory organelles
Habitat
Ameba- pseudopodia
- Intestinal protozoa
Flagellate
- Tissue protozoa
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Ciliate
- Blood protozoa

Contd

Intestinal protozoa
A number of protozoa are capable of living in the

Intestinal tract of man.


Some of the intestinal protozoa of medical importance
are
Amoebae
Flagellates
Ciliates and
sporozoan

PROTOZOA
Intestinal
Protozoa

Blood and
tissue
protozoa

INTESTINAL PROTOZOA

Amoeba:
Entamoeba
histolytica
Entamoeba dispar
Entamoeba coli
Entamoeba
hartmanni
Endolimax nana
Apicomplexa:
Iodamoeba
Cryptosporidium
btschlii
hominis
Cryptosporidium
parvum
Cyclospora
cayetanensis
Isospora belli

Flagellates:
Giardia lamblia
Dientamoeba fragilis
Chilomastix mesnili
Trichomonas hominis
Enteromonas hominis
Retortamonas
intestinalis
Other(Cilliate):
Balantidium coli
Blastocystis hominis

COMMON CHARACTERSTICS
TYPICAL FECAL-ORAL LIFE CYCLE

Fecal-Oral Transmission Factors


Poor personal hygiene
Food handlers
Institutions
Children in day care
centers
Developing countries
Highly endemic
Poor sanitation
Travelers diarrhea

Water-borne epidemics
Male homosexuality
Oral-anal contact
Zoonosis
Entamoeba = no
Cryptosporidium = yes
Giardia = controversial

Control/Prevention
Improve personal
hygiene
Especially institutions
Treat asymptomatic
carriers
Eg, family members
Health education
Hand-washing
Sanitation
Food handling
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Protect water supply


Treat water if
questionable
Boiling
Iodine
chlorine

Taxonomy
Phylum Sarcomastigophora
Sub-Phylum Sarcodina
Class Lobosea
Order Amoebida
Suborder Tubulina
Genera: Entamoeba, Iodamoeba, Endolimax- parasitic
Species- Entamoeba histolytic
-- Suborder Acanthopodina
Genera: Acanthamoeba - Free living
Order Schizopyrenida
Genera: Naegleria - Free living

Taxonomy
Phylum Sarcomastigophora
Sub-Phylum Sarcodina
Class Lobosea
Order Amoebida
Suborder Tubulina
Genera: Entamoeba, Iodamoeba, Endolimax- parasitic
Species- Entamoeba histolytic
-- Suborder Acanthopodina
Genera: Acanthamoeba - Free living
Order Schizopyrenida
Genera: Naegleria - Free living

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Classification.

The Amoeba

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Parasitic and
commensal Amoeba:
Intestinal
Entamoeba histolytica
Entamoeba dispar
Entamoeba coli
Entamoeba hartmanni
Endolimax nana
Iodamoeba btschlii
Mouth
E. gingivalis

Free living Amoeba:


Pathogenic
Naegleria fowleri
Acanthamoeba spp

Entamoeba histolytica
EPIDEMIOLOGY
Cosmopolitan distribution principally
In tropical countries with warm climates and bad sanitary
conditions (fecalism).
It is more frequent in poorest areas with;
Contaminated water,
Poor management of waste,
Poor drainage system.

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FREQUENCY
Amebiasis- is the 3rd leading cause of death worldwide,

~ 10% of worlds population may be


infected with E. histolytica / E. dispar.
worldwide incidence = 0.2-50%(tropics)
500 million people worldwide infected

100 million people suffer acute symptoms


100,000 people die every year
Note

Since more survey to determine the prevalence are made on stool examination which
includes E. dispar

Therefore, the current epidemiology of amoebiasis doesnt show the true prevalence of E
histolytica
Transmission
Ingestion of mature cyst

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Classification.
1. pathogenic:
intestinal amoeba: E- histolytica.
2. non pathogenic/Commensal:
Mouth amoeba: E.gingivalis
intestinal amoeba: E.coli, endolimax nana,
butschlii
3.Free living amoeba
Naegleria fowleri
Acanthamoeba spp

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iodamoeba

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Pathogenic Free-Living Amebae


There are only two genera of Free-Living amoebae
Naegleria fowleri
Acanthamoeba spp
General characteristics
Usually free living
Rarely infect humans
Acquired by soil/water contact
No human to human or vector borne transmission
Causes Acute/chronic amebic
meningoencephalitis
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Naegleria fowleri
Distribution: worldwide
Habitat: Free living
Fresh water/lakes and ponds
Moist soil
Parasitic
Nasal cavity and CNS
Causes: primary amebic meningoencephalitis
(PAM)
PAM first recognized by Fowler (1965)
~ 200 documented cases worldwide
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Transmission
Infection:- through nasal cavity by aspiration of

water(especially
warm)
trophozoites while;-

contaminated

with

bathing in stagnant fresh water/lakes/pools contaminated with

sewage/decaying matter
under chlorinated swimming pool
Snuffing water from lakes/ponds etc

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Acanthameoba
sp.
Geographic Distribution:
Cosmopolitan
Found in freshwater almost everywhere Cannot survive in thermal

pools
Has trophozoite and cyst forms
Definitive Host: Usually Free-living
Facultative parasite of humans
Mode of transmission:.
Cyst and trophozotes are infective
portal of entry unknown, possibly respiratory tract (inhalation of
cysts)
invades body through cuts and abrasions or wounds in skin/eye
contaminated with soil
The brain is probably infected by trophozoites via blood stream from
infected skin or lung
Location in Host: Most common in eye and skin. Rarely invades
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brain/lung

Morphology & life cycle


Typical protozoan life cycle
Exist as trophozoites and Cyst

cyst & trophozoit


are infective

Angular in shape
with three
layared wall
Wrinkled
appearance
Several yrs in soil
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-Slow motility
-spiky
projection

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Acanthameoba

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Acanthameoba sp: Pathology:


Rarely causes damage in people with intact immune systems
Most common cause of corneal ulcers and keratitis in contact lens wearers

Mainly causes
A- Amebic Keratitis
B- chronic Granulomates meningoencephalitis
Amebic Keratitis-A vision threatening chronic inflammation of the
cornea
predisposing factors
ocular trauma & contact lens (contaminated cleaning solutions)
symptoms
ocular pain and corneal lesions (refractory to usual treatments)
diagnosis
demonstration of amoebas in corneal scrapings
Treatment- difficult, limited success
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chronic Granulomates meningoencephalitis

AIDS Patients and other immune suppressed individuals cannot fight the

amoeba
May cause skin ulcerations, keratitis, and corneal ulcerations
In rare cases, it can cause problems in the central nervous system of
immune suppressed individuals.
Can cause meningoencephalitis like N. fowleri

associated with immunosuppression


onset is insidious with headache, personality changes, slight fever
Prolonged clinical course, weeks to months to progresses to coma and death
amoebas not yet detected in spinal fluid
In contrast to naegleria, both trophozoites and sometimes cysts are detected in

histological examination
no human cures documented
Diagnosis is difficult usually done at autopsy
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Flagellates

Luminal intestinal,
urogenital& oral)
flagellates

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Haemoflagellates
(blood & tissue)

Luminal (intestinal,urogenital& oral) flagellates

Intestinal Flagellates:
Giardia lamblia
Dientamoeba fragilis
Chilomastix mesnili
Trichomonas hominis
Enteromonas hominis
Retortamonas intestinalis
Urogenital flagellates
Trichomonas vaginalis
Oral flagellates
Trichomonas tenax

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Luminal (intestinal,urogenital& oral) flagellates


General characteristis
Usually posses 2-6 flagella(~ 8 flagella.)
Inhabit the intestinal, urogenital and oral cavity
Direct life cycle/no biological vector
All have trophozoites and cyst stage except the

Trichomonas species
All are commensal/ non-pathogenic/except G.lamblia

and T. vaginalis
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Synonyms:
Cercomonas
intestinalis
Megastoma enterica
Lamblia intestinalis
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Giardia duodenalis

Giardia
lamblia

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Epidimology
Worldwide distribution
higher

prevalence in tropical or developing


countries (20%)
1-6% in temperate countries
most common and easily recognized protozoa in stools
~200 million cases/yr
Giardiasis
often asymptomatic
acute or chronic diarrhea

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G. lambliaTransmission
the cyst is the infective stage

1- ingestion of faecally contaminated food


or water with cyst
2- Person to person
3- sexually among homosexual (feco-oral
contact)

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Fecal-Oral Transmission Factors


Poor personal hygiene
Children (e.g. day care centers)
Food handlers
Developing countries
Poor sanitation
Endemic
Water-borne epidemics
Male homosexuality
Oral-anal contact
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Giardia intestinalis in culture.


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Other Flagellates Found in Human Feces

Chilomastix mesnili
Pentatrichomonas hominis
formerly called Trichomonas hominis
Enteromonas hominis
Retortamonas intestinalis
Dientamoeba fragilis

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Ciliates
General features
have trophozoites and cyst
The trophozoites are covered with short hairs (cilia ) by which

they move
They reproduce asexually by binary fission and sexually by

conjugation
They posses two dissimilar nuclei (Macro and micronucleus ) &

large contractile vacuole


Genus that cause disease Blantidium coli
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Blantidium coli
The largest protozoan parasite of man

Epidemiology
World wide being more commonly found amongst those who
keep pigs, and uses pig faeces as fertilizer especially in warmer
climates
In Ethiopia it was reported from Debre Berhan.

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Transmission and life cycle


Human acquires through ingestion of contaminated food
or water or hands contaminated with pig faeces
containing cyst.

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Blood

and

Tissue

flagellates

belonging to the family Trypomastidae


six genera but only two of them are responsible to cause

disease to man
Genus Leishmania
Genus Trypanosoma

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PROTOZOA

EUGLENOZOA

KINETOPLASTIDEA
LEISHMANIA
TRYPANOSOMATIDAE

TRYPANOSO
MES
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General

Characteristics

blood

&

tissue

Reproduces by simple longitudinal binary fission


Transmission occurs through biological insect

flagellates

vectors as

intermediate hosts & human as definitive host


The species are morphologically indistinguishable, but they can be
differentiated on the basis of their
clinical features,
geographical distribution,
serologic tests,
immunological tests, etc.

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The

1.

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following

are

the

the

main

developmental

Amastigote (Leishmanial form)


Rounded body, central nucleus and eccentric kinetoplast visible
no free flagellum,
No undulating membrane,
The only intracellular forms of all leishmania species and Trypanosome
cruzi.

forms

2.

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Promastigote (Leptomonad form)slender form


Elongated body, central nucleus, anterior kinetoplast
Single anterior flagellum arises from kinetoplast
found in the invertebrate host, and in culture media (of all Leishmania
species) and in man for Tryponosoma cruzi

3.Epimastigote /crithidial/ forms


Elongated body, single free flagellum, single nucleus
Has undulating membrane,
kinetoplast is just anterior to the nucleus

found in the invertebrate host and in culture media (of


Trypanosome species)

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4.

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Trypomastigote
Pleomorphic, it can be as U or C shaped,
Central nucleus, posterior kinetoplast
single Flagellum arises posteriorly
Has undulating membrane
found in the peripheral blood of vertebrates and is the diagnostic stage of
Trypanosome species.

5.

Metacyclic Trypomastigote /Trypanosomal/ Forms.


Morphologically similar to trypomastigote stage but it is
short and stumpy
final developmental stage in the gut of the insect vectors
infective stage of Trypanosomes species

Epimastigote

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Leishmania species
Causative agent of Leishmaniasis
obligate intracellular protozoa of the genus Leishmania
In the human host, Leishmania are intracellular parasites that infect the

mononuclear phagocytes
Human infection is caused by about 21 of 30 species that infect
mammals. These include:
L. donovani complex with 3 sub species
L. donovani,
L. infantum,
L. chagasi;

L. mexicana complex with 3 main sub species


L. mexicana
L. amazonensis
L. venezuelensis;
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L. braziliensis complex
L. braziliensis
L. Peruviana

L. Guyanensis complex
L. Guyanensis
L. panamensis
L. tropica; L. major & L. aethiopica

Leishmania is classified based on the disease it cause, Leishmaniasis ca

easily classified clinically as


Visceral leishmaniasis
Cutaneous leishmaniasis
Mucocutaneous leishmaniasis
Diffuse cutaneous leishmaniasis
These different forms of the disease is caused by the different species o
Leishmania

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Cutaneous leishmaniasis(CL)
L. tropica
L. major
L. aethiopica
L. panamensis
L. guyanensis
L. peruviana

Visceral leishmaniasis(VL)
L. donovani
L. infantum
L. Chagasi

Mucocutaneous leishmaniasis(MCL)
L. panamensis
L. guyanensis
L. Brazilliensis

Diffuse cutaneous leishmaniasis(DCL)


L. amzonensis
L. aethiopica
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Epidemiology

350 million people are at risk in 88 countries around the world


72 of which are developing countries
an estimated 12 million cases world wide ;1.5 to 2 million new cases occur every year
CL form representing 50 to 75% of all new cases
Most of the affected countries are in tropics and sub tropics
90% of all VL cases occur in Bangladesh, Brazil, India, Nepal and Sudan;
90% of all MCL cases occurs in Bolivia, Brazil and Peru
90% of all CL cases occur in Afghanistan, Brazil, Iran, Peru, Saudi Arabia and Syria
Geographical distribution of leishmaniasis is limited by:
The distribution of the sandfly,
Its tendency to take blood from humans or animals only, and
Its capacity to support the internal development of specific species

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Transmission and life cycle


Common mode of transmission.

Bite of sandfly
Genera

Phlebotomus

in

Old

world
Lutzomyia in New world
Uncommon

routes

transmission:
Congenital transmission,
Blood transfusion,
Rarely, inoculation of cultures.
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of

The
Trypanosomes

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Trypanosomes
General Feature
actively

motile
flagellated
protozoa that live in blood and
lymph node
Vector:- tsetse fly, bug

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Classified in to two groups based on the type of development in


the insect vector and mode of transmission

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Genus Trypanosoma
Two distinct forms occur in humans
African Trypanosomiasis
Trypanosoma brucei gambiense
Trypanosoma brucei rhodesiense
Transmited by the Tsetse fly

American Trypanosomiasis
Trypanosoma cruzi
Transmited by the tritomine bug

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Human African Sleeping


Sickness
It is caused by the flagellate protozoan, Trypanosoma brucei
exists in 2 morphologically identical subspecies:
Trypanosoma brucei gambiense
Disease: West African or Gambian African trypanosomiasis
Geographical Dist: Central & West Africa

Trypanosoma brucei rhodesiense


Disease: East African or Rhodesian African trypanosomiasis
Geographical Dist : Central and East Africa

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Habitat : blood, Lymph channel throughout the body,


CSF, Connective tissue, Intracellular space, brain
Mode of Transmission:
1. bite of infected tse-tse fly
2. congenital
3. sexual contact
4. human-fly-human transmission
Vector : Tse-Tse fly Glossina spp.
1. G. palpalis
T. b. gambiense
2. G. tachinoides
3. G. morsitans
T. b.
4. G. pallidipes
rhodesiense
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APICOMPLEX
A

Intestinal
coccidian

Blood and
tissue
coccidian

APICOMPLEXA(Phylum)
Sporozoa (subphylum)
Coccidia and haematozoa (Class)
Single-celled parasitic organism: a single-celled parasitic protozoan
organism that has alternating sexual and asexual generations and
reproduces by means of spores.
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contd
1. Intestinal coccidian
Cryptosporidium
Isospora
Cyclospora
2. Blood and tissue coccidian
Plasmodium
Toxoplasma
Babesia
Sarcocystis

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Intestinal

coccidian

General characteristics
Considered as opportunistic parasite in immunocompromised

person

Complete entire life cycle in single host

Within the intestinal epithelial cells of the host

Characterized by production of a thick walled oocyst excreted in


faeces
Are transmitted by the fecal-oral route

Note-Oocyst (a fertilized gamete of sporozoan enclosed


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in thick wall)

Fresh Stool

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Acid Fast

Blood and tissue sporozoa


Found inside blood , blood forming

organs or tissues
Blood and tissue sporozoa include
Plasmodium species
Toxoplasma gondii
Babesia species
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PERCOLOZOA

PARABASAL
A

EUGLENOZOA

PROTOZOA

LEISHMANIA

KINETOPLASTIDEA

TRYPANOSOMATIDA
E

TRYPANOSOME
S

CILIOPHORA
COCCIDEA

EIMERIIDA

TOXOPLASM
A

HAEMOSPOR
IDA

PLASMODIU
M

PIROPLASMI
DA

BABESIA

APICOMPLEXA

RHIZOPODA

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HEMATOZOE
A

Malaria
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Plasmodium

species

Causative agent of Malaria: an acute and/or

chronic infection caused by protozoans of the genus


Plasmodium
Five plasmodium species causing human malaria
Plasmodium falciparum (P. falciparum)
P. vivax
P.malariae
P.ovale
P.knowlesi
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General

feature

of

Plasmodium

species

obligate Intracellular parasites. (liver cell & RBC)


Life cycle,

Alternation of generation ~ alternation of hosts


Sexual and asexual reproduction
Requires two hosts:
Man (IH)
Female Anopheles mosquitoes (DH)
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General

feature

of

Plasmodium

species

obligate Intracellular parasites. (liver cell & RBC)


Life cycle,

Alternation of generation ~ alternation of hosts


Sexual and asexual reproduction
Requires two hosts:
Man (IH)
Female Anopheles mosquitoes (DH)
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Epidemiology
Widespread species
P. falciparum: most prevalent in the
hotter and more humid regions of the
world.
P. vivax: more common in temperate
region than in the tropics
Less widespread species
P. malariae: confined mainly to tropical
Africa (25%)
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P. Ovale: Low & restricted distribution

Burden of malaria in Ethiopia

landmass malarious
68% of the population at risk
Annual clinical cases estimated 4-5 million
10-40% of all outpatient consultations
13-26% of all inpatient admissions

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Plasmodium species
P.falciparum =60%
P.vivax = nearly 40%
P.malariae

=1%

cases

,focal

distribution like in Humera


P.ovale = less than 1% cases , found in
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Setit Humera , Gambela & Arbaminch

Transmission and life cycle of Malaria


Principal mode Transmission

bites

of
mosquito

female

anopheles

bites between 5 PM and 7 AM,


with maximum intensity at
midnight.

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Anopheles

Toxoplasma gondii
Causative agent of toxoplasmosis
Tissue or extraintesinal coccida
infects most species of warm blooded animals

, including humans

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Epidemiology- World wide


About 47% of African , more than 50% adult
population in north America and west Europe shows
antibodies to T. gondii
Only about 1% of persons showing antibody to T.

gondii have signs and symptoms of diseases


In Ethiopia : few studies indicated the disease found

in Ethiopia
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Habitat
In the skeletal muscle, heart, lymph nodes, lungs, spleen,
bone marrow, mononuclear leukocytes, brain, CSF,
Spleen, etc. of man, domestic and wild animals
Morphology
has five main developmental forms
only trophozoite and cyst stages are found in man
but all occur in the feline (cats family)
Toxoplasm(trophozoite):-has two forms
Tachyzoite/endozoite
Bradyzoites/cryptozoites
Occurs in the chronic stage of infection, develops slowly and

multiplies in the tissues to form a true cyst

Cyst:-10-100m
& may contain about 3,000 trophozoites
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Transmission and life cycle


Human infection may be acquired by
A) ingestion of undercooked infected meat
containing Toxoplasma cysts.
B) ingestion of the oocyst from fecally
contaminated hands or food (in cat feces)
C) organ transplantation or blood transfusion;
D) transplacental transmission;
E) accidental inoculation of tachyzoites.

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