Mastigophora/Flagellates

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 Parasitic flagellates
• possess whip-like flagella (organs of locomotion)
• Phylum: Sarcomastigophora
• Subphylum: Mastigophora
• Class: Zoomastigophora (mastix: whip)
• Depending on their habitat:
– Lumen-dwelling flagellates: Flagellates found in the
alimentary tract and urogenital tract
– € Hemofl agellates: Flagellates found in blood and
tissues
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 Parasite species Habitat
Intestinal G. lamblia Duodenum and jejunum
Dientamoeba fragilis Large intestine
Pentatrichomonas Large intestine
hominis
Chilomastix mesnili Large intestine
Enteromonas hominis Large intestine
Retortamonas Large intestine
intestinalis
Oral Trichomonas tenax Oral cavity
Genital Trichomonas vaginalis Vagina and urethra
Blood/tissue Leishmania spp. Reticuloendothelial cells
Trypanosoma brucei Connective tissue and blood
Trypanosoma cruzi Reticuloendothelial cells and
blood

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 Flagellates cont’d
• Most luminal flagellates are nonpathogenic
• Two of them cause clinical diseases
– Giardia lamblia
– Trichomonas vaginalis
• they posses different life cycle stages and modes
• Transmission
– Faeco-oral route
– Biological vectors
– Sexual contact
– Kissing
• Some species don’t posses resistant stages
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 Intestinal flagellates
Giardia lamblia
• also called G. duodenalis/ G. intestinalis
• First described in 1681 by Antony van Leeuwenhoek
• named 'Giardia' (Prof Giard) &'lamblia' (Prof Lamble)
• It is the most common protozoa with ww
distribution
• Endemic in areas with low sanitation (tropics &
subtropics)
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 Description of the organism
• Habitat
– G. lamblia lives in the duodenum and upper jejunum
• Posses two life cycle stages:
– Trophozoite
• Tear-drop shaped ; 9-21µm length x 5-15µm width
• Dorsally convex & ventrally concave
• Ventral disc- attachment
• It is bilaterally symmetrical and possesses;
–€ 1 pair of nuclei
–€ 4 pairs of flagella
–€ 1 pair of axostyles running along the midline 6
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Description cont’d .…
• Cyst:
– small and oval, measuring 12 μm x 8 μm and
– is surrounded by a hyaline cyst wall
– includes 2 pairs of nuclei grouped at one end
– The axostyle lies diagnonally, forming a dividing line
within cyst wall
– Remnants of the flagella and the sucking disc may
be seen in the young cyst

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 Giardia lamblia: life cycle
• Giardia passes its life cycle in 1 host
• Infective form: Mature cyst
• Mode of transmission:
– Man acquires infection by ingestion of cysts in
contaminated water and food
• € Direct person to person transmission
– Children
– mentally ill persons
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 Life cycle cont’d
• Within half an hour of ingestion, the cyst
hatches out into two trophozoites, which
multiply successively by binary fission and
colonize the duodenum
• The trophozoites live in the duodenum and
upper part of jejunum, feeding by pinocytosis
• During unfavorable conditions, encystment
occurs usually in colon

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 Giardia lamblia: Pathogenesis

• Pathogenesis
(i)Mechanical blockage of intestinal mucosa
(ii) Enterocytic apoptosis

(iii) Loss of epithelial barrier function

(iv) Shortening of epithelial microvilli

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Mechanical blockage

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 Pathogenesis cont’d…
• Enterocytic apoptosis
– Consumption of local arginine
– pro-apoptotic caspase-3
– down-regulation of anti-apoptotic Bcl-2
– increased expression of pro-apoptotic Bax
• Loss of epithelial barrier function
• Apoptosis
• Caspase-3
– disruptions of tight junctional ZO-1
 Pathogenesis cont’d…
• the parasite also affects epithelial claudin
proteins, which are critical components of the
sealing properties of tight junctions
• Increased epithelial permeability allows luminal
antigens to activate host immune-dependent
pathological pathways
– these alterations disrupt intestinal barrier
function in human giardiasis
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 Pathogenesis cont’d…
• Shortening of epithelial microvilli
– Giardia duodenalis causes malabsorption of
glucose, sodium, and water, and reduced
disaccharidase activity
– malabsorption and maldigestion are due to
a diffuse shortening of epithelial microvilli
– The parasite may also induce chloride
secretion
Shortening of epithelial microvilli cont’d…

• A combination of malabsorption and

hypersecretion of electrolytes results in fluid
accumulation in the intestinal lumen
– diarrhea
 Clinical manifestation
• Majority are asymptomatic
• Incubation period varies from 1-3 weeks
• Steatorrhoea accompanied by epigastric pain
• Stool: voluminous, foul-smelling & greasy in
appearance
• Flatulence, bloating & sulphuric belching
• Typically no blood/mucus is present
• Less common: anorexia, nausea, vomiting and fever

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Clinical feature con’d

• Distinguish from viral & bacterial diarrhea

– Pre-hospital illness is longer- 7-10 days

(hallmark)
– Viral (vomiting)
– Bacterial(inflammatory stool changes)

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Clinical features con’d
• Extra intestinal giardisis_ much rare
– Biliary tract
Achlohydria
– Stomach
Chronic giardisis: co-infection with
Helicobacter Pylori (cytotoxin VacA- HCO3-
efflux )

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Clinical features con’d
• Chronic giardiasis
– Malabsorption of:
• Fat
• Vitamin A & B12
• Iron
• Lactose (lactase deficiency)
• Protein
– Failure to thrive in children
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 Diagnosis
• Clinical findings
– A patient with prolonged diarrhea associated with
Wt loss, but usually have NO (fever, significant
vomiting, tenesmus or blood in stool)
– Travel, camping, having child
• Parasitological examination
– Microscopy
• Trophozoites
– Leaf falling mov’t
• Cyst _iodine
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 Laboratory diagnosis

Stool Serological Molecular

examination Enterotest/
string test tests diagnosis
•Macroscopic Ag detection •PCR
•Microscopic •ELISA
•IIF test
Ab detection
•ELISA
•IIF test

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Duodenal sampling
• String Test/Entero test
– a gelatin capsule is swallowed attached to a long
string
– The end of the string remains outside the mouth
and is taped to Pts cheek
– The capsule dissolves in the stomach and the string
passes into the upper part of the small intestine (
duodenum)
– The string is left in place for 4 to 6 hours or overnight
– withdrawn and the end is examined under the
microscope
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Treatment

Drug Dosage
Adult Child
Metronidazole 250 mg t.i.d x5-7 5 mg/kg t.i.d x 5-7
days days
Tinidazole 2g x 1 dose 50mg/kg (max. 2
g)
Paromomycin 30mg/kg/day
tidx5-10 days

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Prevention & control
• Proper waste disposal

• Provision of potable water_ community

setting
• Fecal-oral hygiene_ individual level

• Chlorination (0.4mg/L)

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