Phylum

Apicomplexa
Plasmodium spp
Stage of development
1. Ring Forms
– Early Trophozoites
– as the name implies, refers to a ring like appearance of
the malarial parasite following invasion into a previously
healthy RBC
– space inside the ring is known as a vacuole
2. Developing/Growing Trophozoites
– remnants of the cytoplasmic circle and chromatin dot
are still intact until late development
– the parasite is actively growing during this stage, the
amount of RBC space invaded is significantly more than
that of the ring form
Stage of development
3. Immature/Presegmenting Schizonts
– active chromatin replication is seen
– expands and occupies more space within the RBC
4. Mature Schizonts
– Merozoites: emergence of the fully developed stage of the
asexual sporozoa trophozoite
5. Microgametocytes
– typical microgametocyte is roundish in shape (except P.
falciparum, which is crescent-shaped)
– large diffuse chromatin mass that stains pink to purple and
is surrounded by a colorless to pale halo
– pigment is usually visible
Stage of development
6. Macrogametocytes
– round to oval (except P. falciparum, which is crescent-
shaped)
– pigment is also present, and its color and distribution in this
morphologic form vary by individual Plasmodium species
Plasmodium falciparum
■ Disease: malignant malaria, aestivo-autumnal, falciparum
malaria, subtertian malaria, pernicious malaria, Black water
fever malaria
■ It is most prevalent in the tropics and subtropics
– It causes the most severe form of malaria
– It still remains almost unchallenged as the greatest
killer of the human race over most parts of Africa and
elsewhere in the tropics.
Plasmodium falciparum
■ Size of Erythrocytes: normal, multiple-infected RBC are
common
■ Maurer’s dots occasionally seen
■ Young rings are small, delicate, often with double chromatin
dots, accole, applique
■ > 1 ring form can be found in 1 RBC (multiple infection)
■ Gametocytes are 🌛 crescent or elongated
■ Pigment: black, coarse and conspicuous in parasite
■ Number of merozoites: 6-32, average is 20-24
■ Schizonts: bad prognosis
■ Stages found in Circulating Blood: Young, growing
trophozoites (ring forms) and gametocytes
 Plasmodium falciparum

 numerous rings  crescent-shaped

without mature gametocytes
forms
 slightly smaller
 marginal forms
 trophozoites and schizonts
 not normally seen in
peripheral circulation
 severe disease
 compact parasite
 6-32 merozoites
Plasmodium vivax
■ Disease: vivax malaria or benign tertian malaria
■ Most widespread, found in most endemic areas including some
temperate zones
■ It is more common in temperate than in tropical region.
■ It is the second common Malaria in the Philippines.
Plasmodium vivax
■ Size of Erythrocytes: enlarged, maximum size may be 1 ½ - 2 times
normal (attained with mature trophozoites and schizonts)
■ Ring forms occupies 1/3 diameter of RBC
■ Schuffner’s dots present in all stages except early young forms
■ Irregular, ameboid trophozoites, has spread-out appearance
■ Pigment: Golden brown, inconspicuous
■ Number of merozoites: 12-24, average is 16
■ Stages found in circulating blood: all stages
 Plasmodium vivax

• enlarged erythrocyte
• Schüffner’s dots
• ‘ameboid’ trophozoite
• 12-24 merozoites
Plasmodium malariae
■ Disease: malariae or quartan malaria
■ Similar range as P. falciparum, but less common and patchy
distribution
■ Common in tropical Africa, Burma, Sri lanka, India, Malaysia
and Indonesia.
■ It is occasionally seen in the Philippines.
Plasmodium malariae
■ Size of erythrocytes: normal
■ Ziemann’s dots rarely seen
■ Rounded, compact trophozoites with dense cytoplasm.
■ Band form trophozoites occasionally seen
■ Pigment: dark brown, conspicuous
■ Rosette schizonts occasionally seen
■ No. of merozoites: 6-12, average is 8
■ Stages found in circulating blood: all stages
 Plasmodium malariae
 compact trophozoite
 'band' form
 6-12 merozoites in mature schizont
 🌺 ‘rosette’
Plasmodium ovale
■ Disease: ovale malaria, Benign tertian malaria
■ It is the least common Plasmodium infecting man.
■ It occurs mostly in tropical Africa, principally on the west coast
and is endemic in Ethiopia.
Plasmodium ovale
■ Size of erythrocytes: enlarged, maximum size may be 1 ¼ - 1 ½
times normal, approximately 20% or more infected RBC are oval
and fimbriated (border has irregular projections)
■ Schuffner’s dots present in all stages except early ring forms
■ Rounded, compact trophozoites, occasionally slightly ameboid
■ Growing trophozoites have large chromatin mass
■ Pigment: dark brown, conspicuous
■ No. of merozoites: 6-14, average is 8
■ Stages found in circulating blood: all stages
 Plasmodium ovale

 similar to P. vivax
 enlarged erythrocyte
 Schüffner’s dots
 subtle differences
 ‘compact’ trophozoite
 fewer merozoites (8)
 elongated erythrocyte
Plasmodium knowlesi
■ a primate malaria parasite commonly found in Southeast Asia.
■ It causes malaria in 🐵 long-tailed macaques (Macaca
fascicularis), but it may also infect humans, either naturally or
artificially.
■ The fifth major human malaria parasite
■ This is an emerging infection that was reported for the first
time in humans in 1965.
■ It accounts for up to 70% of malaria cases in South East Asia
where it is mostly found
Plasmodium knowlesi
■ In developing trophozoites of P. knowlesi, band forms may
appear that are similar in appearance to P. malariae. 
■ As the vacuole is lost during maturation of the trophozoite stage,
the parasite becomes smaller and more compact. 
■ The pigment appears as dark grains and the red nucleus
increases in size. 
■ Stippling appears, often referred to as 'Sinton and Mulligan's'
stippling
Plasmodium knowlesi

Developing trophozoites Mature trophozoites

Plasmodium knowlesi
■ In developing schizonts of P. knowlesi, Sinton and Mulligan's
stippling may be observed. 
■ The nucleus continues to divide until there are up to 16 (average
10) merozoites. 
■ As the schizont matures, it fills the host RBC and the pigment
collects into one or a few masses. 
■ In the mature schizont, the merozoites may appear 'segmented'
and the pigment has collected into a single mass.
Plasmodium knowlesi
■ It may cause severe malaria as indicated by its asexual erythrocytic
cycle of about 24 hours.
■ The typical fever becomes quotidian
Plasmodium knowlesi

Mature schizont
Life cycle
Invertebrate Phase
■ 4-15 days after ingestion of gametocyte
■ Female Anopheles mosquito takes a blood meal containing
gametocytes from infected person
o Microgametocytes – male
o Nuclear division and exflagellation
o Macrogametocytes – female
o Shifting of nucleus to the surface to form a projection
o Microgamete penetrates macrogametes producing an
ookinete
Vertebrate Phase
■ Mosquito injects sporozoites to man
■ Sporozoites disappear from the blood
– Some are destroyed by the host immune system
– Enters liver parenchymal cells (hypnozoites in P. vivax and
P. ovale)
Insect Vectors in the Philippines
■ Anopheles flavirostris – primary vector in the Philippines, night biter,
breeds in slow-flowing clean water mountain streams
■ Anopheles balabacensis - rest either indoors or outdoors, in puddles,
pools, ponds, and in shades.
■ Anopheles lesteri - rest either indoors or outdoors, in pools, ponds, lakes,
and in ricefields.
■ Anopheles philippinensis - rest either indoors or outdoors, in pools ponds
or lakes.
■ Anopheles umbrosus - rest out of doors, in pools, ponds, lakes, running
streams and canals in shades.
■ Anopheles leucosphyrus – vector of Plasmodium knowlesi, typically
found in forest areas in South East Asia but with a greater clearing of
forest areas for farmland
■ Anopheles litoralis, Anopheles maculates, Anopheles mangyanus
 Malaria Transmission
 🦇 natural (sporozoites/Anopheles)
 💉 blood transfusions
 shorter incubation period
 fatality risk (P. falciparum)
 relapses possible (P. vivax/ovale)
 💉 syringe sharing
 👶 congenital
 relatively rare although placenta is heavily infected
 Clinical features
 characterized by acute febrile attacks (malaria paroxysms)
 periodic episodes of fever alternating with symptom-free periods
 manifestations and severity depend on species and host status
 immunity, general health, nutritional state, genetics
 recrudescences and relapses can occur over months or years
 can develop severe complications (especially P. falciparum)
 Chilly sensations that progresses to a teeth-
chattering, frankly shaking chill. The
peripheral blood vessels are constricted and
the lips and nails are cyanotic.
 The body temperature begins to mount rapidly as
the blood vessels dilate. Temperature peaks at 39-
41 C, skin is hot and the face flushed. Sign and
symptoms includes nausea, vomiting headache and
rapid pulse. High fever may produce convulsion in
children.
 The patient perspires profusely, temperature
falls and the headache disappears. The patient is
exhausted but symptomless. And the next day the
patient can feel quite well, before the next
paroxysm occurs.
 Malarial paroxysms
■ Periodicity varies according to species
■ Depends on the length of the asexual cycle
■ Plasmodium falciparum
– Malignant tertian malaria (36 hours or less)
■ Plasmodium vivax and P. ovale
– Benign tertian malaria (48 hours)
■ Plasmodium malariae
– Quartan malaria (72 hours)
Pathogenicity of Malaria
■ In P. falciparum infections, as the parasite begins to grow, the
red cell membrane becomes sticky and cells adhere to the
endothelial lining of the capillaries of the internal organs
■ thus, only ring forms and gametocytes appear in the peripheral
blood
Anemia
■ More pronounced in P. falciparum
■ Hemolytic, normochromic, normocytic anemia
■ Decrease Oxygen carrying capacity leading to anoxia
Splenomegaly
■ Caused by an increase in splenic activity
■ Parasitized red cells pass through the spleen, loss their
deformability, thus destroyed in the process
■ Normal RBC’s are destroyed due to increase activity of
macrophages
Nephrotic Syndrome
■ Seen in Plasmodium malariae infection
■ Deposition of antigen – antibody complexes causes thickening of
the capillary walls of the basement membrane
■ Presence of focal hyalinizing lesions of the tuft of the glomerulus and
segmental endothelial cell proliferation progressing to glomerular
sclerosis
Blackwater Fever
■ Sydrome of acute intravascular hemolysis, accompanied by
hemoglobinemia and hemoglobinuria
■ Abrupt onset, passage of dark red or almost black urine, vomiting
of bile stained fluid, jaundice
■ High mortality
■ Rapid and severe hemolysis of both parasitized and non – parasitized
red cells
■ Presence of the parasite changes the antigenic structure of individual
erythrocytes and stimulates the production of antibodies
Disseminated Intravascular
Coagulation (DIC)
■ Most serious hematologic complication
■ Activation of the clotting system resulting to thrombin generation
and intravascular coagulation
Severe Falciparum Malaria
■ Prostration: first probable symptom, a condition characterized by confusion or
drowsiness with extreme weakness
■ Unarousable coma (Cerebral malaria)
■ Generalized convulsions
■ Severe normocytic anemia
■ Hypoglycemia
■ Metabolic acidosis with respiratory distress
■ Fluid and electrolyte disturbances
■ Acute renal failure
■ Acute pulmonary edema and Adult Respiratory Distress Syndrome (ARDS)
■ Circulatory collapse, shock, septicemia (algid malaria)
■ Abnormal bleeding
■ Jaundice
■ Hemoglobinuria
■ High fever
■ Hyperparasitemia
Relapse
■ Present in P. ovale and P. vivax
■ Activation of hypnozoites (liver stages) resulting to renewal of
malarial infection.
Recrudescence
■ Renewal of parasitemia or clinical features arising from persistent
undetectable asexual parasitemia in the absence of an exo-
erythrocytic cycle
■ P. falciparum: Due to infected RBC sequestered by the spleen
Diagnosis
■ Prompt and adequate diagnosis is necessary
■ Clinical diagnosis: symptoms
■ History of being in endemic area
Diagnosis
■ 🔬Microscopic identification of the malarial parasites
■ 💉Thick and thin blood smear
• thick film: screening for positivity and parasite count
• thin film: species identification easier
■ Stained with Giemsa or Wright’s stain
■ Gold standard for malarial diagnosis
■ Taken at the before height of the fever (schizogony) and before
antibiotic administration, highest number of parasite in the blood
■ repeat smears every 12 hours for 48 hours if negative
Diagnosis
■ 🔬Quantitative Buffy Coat (QBC)
– Usually prepared capillary tube coated with acridine orange
– Malaria parasites take up the stain and appear bright green
and yellow under a fluorescent microscope
Diagnosis
■ 🖥Rapid Diagnostic Tests (RDT)
– Detects parasitic antigens:
o Pan malaria: p-LDH (Diamed Optimal IT)
o Falciparum malaria: HRP-II (Paracheck Pf Test, ParaHIT f Test)
– Makes use of immunochromatographic methods in order to detect
Plasmodium-specific antigens in a finger-prick blood sample
– Advantages: Can be performed in 15-30 mins, 90% specific
– Disadvantages: lack of sensitivity at low levels of parasitemia,
inability to quantify, more costly
Diagnosis
 🖥 Serological Tests
– Cannot differentiate current and past infections
– Most helpful in epidemiological studies
o Indirect Hemagglutination (IHA)
o Indirect Fluorescent Antibody Test (IFAT)
o Enzyme-linked Immunosorbent Assay (ELISA)
■ 🖥 Polymerase chain reaction (PCR)
– To significantly enhance the microscopic diagnosis of
malaria especially in cases of low parasitemia and in cases
of mixed infection
 Malaria Control
💁Reduce Human-Mosquito Contact
• Insecticide treated bed nets (ITN)
• repellants, protective clothing
• screens, house spraying

🦇Reduce Vector
• environmental modification
• larvacides/insecticides
• biological control

🦍Reduce Parasite Reservoir

• diagnosis and treatment
• chemoprophylaxis
Treatment
■ 💊 Most drugs used in the treatment are active against the parasite forms in
the blood
– Chloroquine: drug resistance with P. falciparum
– sulfadoxine-pyrimethamine (Fansidar®)
– mefloquine (Lariam®)
– atovaquone-proguanil (Malarone®)
– quinine
– doxycycline
– artemisin derivatives
■ In addition, primaquine is active against the dormant parasite liver forms
(hypnozoites) and prevents relapses.
Babesia spp
Babesia Taxonomy
■ Phylum Apicomplexa
■ Class Sporozoea
■ Subclass Coccidia
■ Subclass Piroplasmia – no oocyst
■ Order Piroplasmida
■ Genus Babesia
 Babesia spp.
 Common tick-borne parasite of domestic and wild animals
 Parasites of red blood cells, causes malaria-like infections
 No intracellular pigment in developmental stages
 Rare zoonotic human infection, natural host are the rodents and deers
 white-footed mouse (Peromyscus leucops)
Geographic Range
■ Worldwide, especially in:
– Europe (although, mostly Babesia divergens)
– Asia
– United States
■ Particularly in the Northeast: Especially New
England, New York & other coastal regions
■ Has been spotted in other parts of the U.S., such as
the mid-west
 Human Babesiosis

B. microti B. divergens
Location United States Europe
Reservoir field mice, voles cattle, ruminents
Ixodes scapularis Ixodes ricinus
Vector (black-legged tick)
Ixodes dammiini
Cases ~300 ~30
Fatality 5% 50%
Mode of Transmission

■ 🐞 Tick-bite
■ 👶 Transplacental
■ 💉 Blood transfusion
Babesia microti
 Common species diagnosed in human.
 Small rings within the red blood cell, very
much like Plasmodium falciparum with a
darkly staining nucleus and very little
cytoplasm.
 It do not have associated pigment in the red
blood cell.
 Asexual multiplication by binary fission in
the RBC with production of merozoite that
invade other RBC.
 When taken up by the ticks, there is
complex cycle of multiplication that
includes a sexual stage, resulting ultimately
in the presence of the parasites in the
salivary gland of the tick.
 Definitive Host
■ A tick is the definitive host
■ Transmission occurs from an animal Female Ixodes scapularis tick
to a human, normally using the
northern deer tick or black-legged
tick (Ixodes scapularis) as the vector.
Babesia divergens
■ transmitted by the tick Ixodes ricinus
■ main agent of bovine babesiosis, or redwater fever in Europe
■ it can also infect immunocompromised humans, causing medical
emergencies characterized by rapid fulmination and parasitemias
that may exceed 70%.
Life cycle
Human Babesiosis
 Clinical disease
 asymptomatic to fatal
 more severe in splenectomized persons, elderly, or
immunocompromised
 characterized by fever, chills, sweating, myalgia, fatigue,
nausea, loss of appetite
 moderate to severe hemolytic anemia
 Renal failure, jaundice and hepatosplenomegaly
Diagnosis
 💉 parasite in thin or thick blood smear
 Tetrad-forms or Maltese-cross arrangement of merozoites
 🗺 no travel history
 🖥 Serology
 IFA
 lack of response to anti-malarials
Treatment
 no generally effective drugs
 Clindamycin (DOC) + quinine is recommended
 reduces duration of parasitemia
 high level of adverse side affects
 atovaquone + azithromycin
 as effective as clindamycin + quinine
 fewer adverse affects
 blood transfusions for severe anemia
Prevention
■ 🙌 Skin checks for ticks after being in wooded areas
■ 🐞 Check animals for ticks
■ 🕺 Wear long clothing
■ Find a good tick repellant
Coccidians
Coccidia
■ Class Sporozoea.
■ Coccidian parasites infect the intestinal tracts of animals
■ The largest group of apicomplexan protozoa.
■ obligate, intracellular parasites, which means that they must live and
reproduce within an animal cell.
■ with no definite organ of locomotion
■ It may have body flexion, gliding or undulating of longitudinal ridges.
Coccidia
 characterized by thick-walled oocysts excreted in feces

In Humans

• Cryptosporidium
• Isospora
• Cyclospora
• Toxoplasma
• Sarcocystis
Coccidia
■ In Isospora, Cyclospora and Cryptosporidium only a single direct
cycle of transmission occurs, both the asexual and sexual stages of
multiplication occurs in a single host and that is to man.

■ In Sarcocystis and Toxoplasma, the sexual stages are usually in the

intestinal mucosa of a carnivorous host (the predator). The result in an
oocyst or sporocyst that passes out in the feces to infect an intermediate
host (the prey) in which asexual multiplication of the parasite occur.
 Life Cycle
 Merogony
 schizogony
 produce merozoites
 Gametogony
 gamogony or
gametocytogenesis
 produce micro- and
macrogametes
 Sporogony
 produce sporozoites
 completed on host cell
 thin (autoinfection) or thick
walled oocysts
Toxoplasma gondii
Toxoplasma gondii
 cosmopolitan distribution
 seropositive prevalence rates vary
 generally 20-75%
 generally causes very benign disease in
immunocompetent adults
 tissue cyst forming coccidia
 predator-prey life cycle
 felines are definitive host
 Infects wide range of birds and
mammals (intermediate hosts)
Typical Life Cycle in Felines
Typical Life Cycle in Felines

• fertilization within infected host cells

• immature oocysts in feces
• sporulation in environment (1-4 days)
Merozoites: Tachyzoites vs. Bradyzoites
 Tachyzoites has been coined for the
first, actively multiplying merozoites
that develop within the intermediate
host, irrespective of whether infection
is from oocysts or tissue cysts

Tachyzoites in peritoneal macrophage

 Metrocytes (noninfectious) and

bradyzoites (infectious) are merozoites
that develop within tissue cysts Pseudocyst: filled with bradyzoites
 Tachyzoite Stage

 ingestion of oocysts
 sporozoites penetrate intestinal
epithelium
 rapid intracellular replication (any
cell)
 dissemination via macrophages

• 2 sporocyst
• 4 sporozoite
 Tachyzoite Stage

 merogony  'merozoites'
 typical apicomplexan
 motile invasive stages
 intracellular replication
 'binary fission' = endodyogony
 Tachyzoite Stage

 repeated rounds of merogony

 acute stage infection
 primarily in reticulo-endothelial
cells
 Bradyzoite Stage
 dormant, slowly replicating
 due to host immune response
 chronic or latent infection
 tissue cysts primarily in brain and
muscle
 Human
Transmission
 😿 ingestion of sporulated
oocysts (cat feces +
incubation)
 🍗 ingestion of zoites
(tachyzoite & bradyzoites
(undercooked meat)
 👼 congenital infection (only
during acute stage)
 😰 organ transplants
 chronic infection in donor
 immunosuppression
 💉 blood transfusions (only
during acute stage)
Pathogenesis

■ The organisms can grow in any organs or tissues, developing in the

brain, eyes and skeletal muscles
■ There is localized proliferation of the organisms and immunologic
hypersensitivity reaction.
■ Multiplication of the organisms within the infected cell leads to
death and rupture of the cell.
 Clinical Manifestations
■ Most of the cases are
asymptomatic.
■ Congenital toxoplasmosis is
often severe and even fatal.
■ Sabin syndrome (tetrad of
signs)
– Chorioretinitis
– Cerebral calcification
– Convulsion or
psychomotor disturbances
– Hydrocephalus or
microcephalus
Other Forms of Toxoplasmosis
■ Typhus-like exanthematous form
– may produce myocarditis, meningoencephalitis and atypical
pneumonia
■ Cerebrospinal form
– There is involvement of the CNS and the CSF is xanthochromic.
■ Non-congenital retinochoroiditis infection
– The ocular lesion originates in the retina and spread to the
choroids.
 Ocular Toxoplasmosis

 retinochoroiditis: likely due to both

active parasite proliferation and immune
hypersensitivity
 generally a recrudescence--rarely from
primary infection
 congenital infection
 20% exhibit ocular symptoms at birth
 82% by adolescence
 most lesions are focal and self-limiting
 rapidly destructive in AIDS patients
Diagnosis
 🔬 Identification of the organism in smears of
lymph nodes, bone marrow, spleen or brain or
other materials.
 🐭 Inoculation into mice or cell culture (only
acute stage)
 🔬 Sabin-Feldman methylene blue dye test:
very sensitive and specific but requires
maintenance of live organism
 🖥 Serological test: to detect antibodies
 Polymerase chain reaction (PCR) :
detection of the parasites DNA
 ELISA
 IFA
 EIA
 Latex agglutination
Treatment
■ Pyrimethamine and sulfadiazine
– controls Toxoplasma but do not kill it.
– Leucovorin (folic acid): pyrimethamine can cause lower
blood counts
– Sulfadiazine: causes allergic reaction but can be substituted
by clindamycin
■ Corticosteroids: prevent occurrence of hypersensitivity
■ Trimethoprim-sulfamethoxazole: prophylaxis for
immunocompromised
Prevention and Control
■ 🍖 Proper cooking of meat (66oC, 150oF)
– wear gloves when handling
– wash hands after
■ ⛺ Environmental sanitation
■ 🙀 Careful attention to cat feces
– clean litter box promptly (<24 hr)
– wear gloves
– keep cat in house
– cover sand box
– no cats in home
– control strays
Isospora belli
Isospora belli
■ 🌍 Though rare, it has a wide geographical distribution (higher
prevalence in warmer climates)
■ The least common of the intestinal coccidia that infect humans
■ Can cause severe disease with fever, malaise, persistent diarrhea and
even death in AIDS patients
■ Monoxenous (required one host) , probably not zoonosis: Asexual
and sexual multiplication occurs in man
Isospora belli

■ Mode of Transmission: Human are probably infected by

accidental hand-to-mouth ingestion of mature oocyst in food
and water.
■ Habitat: Distal duodenum and proximal jejunum
Pathology

 invades intestinal epithelial cells

 often asymptomatic (seldom reported)
 symptoms range from mild gastro-intestinal distress to severe
dysentery
 often self-limiting, but can become chronic (wasting, anorexia)
 symptoms more severe in AIDS patients
Isospora belli
 30 x 12 mm oocyts
 2 sporocysts
 4 sporozoites each
Pathogenesis
■ Infection is confined to intestinal epithelial cells.
■ Destruction of the surface layer of the intestine.
■ There is malabsorption markedly abnormal intestinal mucosa
with short villi, hypertrophied crypts and infiltration of the
lamina propia with eosinophilia, neutrophils and round cells.
Clinical Manifestations
■ Infections are often asymptomatic and self -limiting.
■ It may be from mild gastrointestinal distress to severe dysentery.
■ The loose, pale yellow and foul-smelling stools are suggestive of
malabsorption process.
■ There may be chronic diarrhea, vague or crampy abdominal
pain, weight loss, weakness, malaise and anorexia.
■ There may be diarrhea over a period of several months to 15
years.
Diagnosis
■ 🔬 Stool examination to demonstrate the immature oocyst from
the feces
– Iodine stain which facilitates identification.
■ 🔬 Modified acid fast stain (Kinyoun’s stain/Auramine-
rhodamine) wherein oocyst wall does not stain and sporoblast
is deep red stained.
■ 🎈 Enterotest™
■ 🛢 Concentration technique
– zinc sulfate flotation method
– Formalin-ether sedimentation method
– Sheather’s sugar flotation
Treatment and Prevention
■ For mild or asymptomatic infection, non specific measures such as rest
and bland diet mat be sufficient.
■ AIDS patients: trimethoprim-sulfamethoxazole
■ Prevention: same as Entamoeba histolytica
Sarcocystis spp.
 Sarcocystis
 The name is dervived from Greek: sarx = flesh and cystis = bladder
 rare human infection
 heteroxenous parasite
 predator-prey life cycle
 humans support both stages
 originally identified as 2 species
 intestine ~ Isospora
 tissue ~ Sarcocystis
 taxonomic confusion
 generally named after host species
 Sarcocystis hominis
 Sarcocystis suihominis
 Intestinal Disease
 ingest undercooked meat
 transient mild to severe diarrhea
 excrete sporulated sporocysts
 13x10 mm
 4 sporozoites

Sarcocystis
 Muscle Disease

 ingest sporocysts
 develop sarcocysts
 several 100 mm
 compartments
 sometimes thick striated wall
 muscle tenderness
 episodic inflammation
Pathology and Clinical Manifestation
■ Human sarcocystosis/sarcosporidiosis
– gastroenteritis with diarrhea
– eosinophilic enteritis
– myalgia and weakness
– mild increase of creatine kinase
■ Intermediate host
– gait abnormalities
– muscle wasting
– head tilt
– animals observed to move in circles
– abortion in pregnant animals
Diagnosis
■ Fecal floatation methods
■ Brain tissue biopsy in animals: 🐮 bradyzoites
■ Serological methods:
– IFA
– ELISA
– PCR
– Western blot
Treatment
■ No effective treatment known
■ Corticosteroids: treating muscular inflammation
Cryptosporium spp.
Cryptosporidium
 fecal-oral transmission (monoxenous)
 wide range of animal hosts (C. parvum)
 several host-adapted species
 C. hominis for human species
 first human case reported in 1976
 self-limiting diarrhea in immunocompetent persons
 profuse, watery diarrhea associated with AIDS (life threatening)
Cryptosporidium
■ C. baileyi (birds)
■ C. felis (cat)
■ C. meleagridis (turkeys)
■ C. muris (mouse)
■ C. nasorum (fish)
■ C. serpentis (snakes)
■ C. wrairi (guinea pigs)
■ C. parvum (mammals)
■ C. hominis (humans)
Cryptosporidium hominis
■ Disease: Cryptosporidiosis
■ World wide in distribution
■ Common cause of diarrhea among travelers and in day care
centers.
■ Can occur as water-borne outbreaks
■ Zoonosis from domestic animals.
■ More common in children than adult.
Cryptosporidium hominis

 4-5 mm oocysts
 4 sporozoites
 no sporocysts
Cryptosporidium hominis
■ Habitat:
– Brush border of the mucosal epithelium of the stomach or
intestine.
– May involved the gallbladder and pancreatic duct.
■ Pathogenesis:
– Destruction of the host cells
– villi of intestine: infiltration of inflammatory cells into
the lamina propia and elongated crypts
Clinical Manifestations
■ Self-limiting in person with sound immune function
■ Nausea and vomiting, abdominal cramps, weight loss and fever
■ Diarrhea
■ Severe fluid loss from diarrhea and vomiting can lead to fatal
outcome in children
Diagnosis
■ 🔬 Stool examination to identify the oocyst.
■ 🎈 Enterotest™: to recover oocyst.
■ 🔬 Kinyoun’s modified acid fast stain: red-pink doughnut shaped
circular organism in a blue background
■ 🛢 Concentration test
– Sheather’s sugar flotation
■ 🖥 Serological test:
– EIA
– DNA probes specific for C. hominis
Treatment and Prevention
■ 💊Treatment:
– Spiramycin
– Pyrimethamine and sulphadiazine
– Somatostatin
■ 🛀 Preventive Measures:
– Environmental sanitation
– Personal hygiene
Cyclospora cayetanensis
Cyclospora cayetanensis
 first human case in 1979
 named in 1993
 initially called ‘cyano-bacteria
like body’ (CLB) or large
Cryptosporidium
 no known animal reservoir
 more common in tropical and sub-
tropical areas
 Infection most common in
HIV/AIDS patients.
Cyclospora cayetanensis
 In freshly passed in stools, the oocyst is not
infective (direct fecal-oral transmission cannot
occur; this differentiates from
Cryptosporidium).
 In the environment, sporulation occurs after
days or weeks at temperatures between 22°C to
32°C, resulting in division of the sporoblast into
two sporocysts, each containing two elongate
sporozoites.
 8-10 mm oocyts
 2 sporocysts
 2 sporozoites each
 Fresh produce and water can serve as vehicles
for transmission
Pathogenesis
■ Onset of symptoms may occur 12-24 hrs after exposure
■ Chronic and intermittent diarrhea alternating with constipation
■ Fatigue, anorexia, weight loss, nausea, vomiting, abdominal
pain, flatulence, bloating, dyspnea
Pathology
■ Cyclospora infects enterocytes of the
small bowel where various stages,
sexual and asexual stages have been
observed.
■ Villous blunting, mild crypt
hyperplasia and variable increased
chronic inflammatory cells in the
lamina propria.

Duodenal biopsy showing immature

schizonts (broad arrow) and merozoites
(arrow) in a parasitophorous vacuole of
C. cayetanesis in surface enterocytes.
(HE STAIN)
Pathology
 In the immunocompromised patient, severe diarrhea can last up
to 4 months or longer even if treated thus producing a disease
syndrome that is debilitating and life threatening
 Extra-intestinal infection appears to be more common in
AIDS patients
Transmission
 🍽 associated with food-borne outbreaks
 luncheons, social events, weddings, etc.
 possible source always involved foreign country and fresh fruit or
vegetables
 🍒 raspberries from Guatemala
 🥗 leafy vegetables from Peru and Nepal
 🥗 lettuce and basil pesto in US
 presumed source: contaminated water or human waste as fertilizer
Diagnosis and Treatment
Diagnosis
• 🔬 demonstration of oocysts in feces
• acid-fast stain (kinyoun’s stain)
• safranin staining and microwave heating
• Autofluorescence: blue or green circles
• 🖥 Serologic methods:
• PCR: to differentiate with closely related Eimeria species

💊 Treatment
• Self-limiting, immunity may result with repeated infection
• Trimethoprim-sulfamethoxazole: only effective drug
Comparison: Oocyts of
Different Genera

Sporocyst Sporozoites
Cryptosporidium 0 4
Cyclospora 2 2
Isospora 2 4
Toxoplasma 2 4
Sarcocystis 2 4
 Pneumocystis jiroveci