MEDICAL

MICROBIOLOGY II

DR. KELI, MBChB.

 Parasitology
Scope: description of parasites, general characteristics, classification and
transmission; parasites of medical importance; occurrence, lifecycle,
morphology, transmission and control – protozoa, helminths, (blood and
tissue nematodes, platyhelminths), arthropods (pediculus humanus,
sarcoptes scabei, tunga penetrans
Parasitism
• A parasite refers to organisms that are physiologically dependent
upon their host for survival.
• A parasite is an organism living in or on another organism, obtaining
from it part or all of its organic nutriment, commonly exhibiting some
degree of adaptive structural modification, and causing some degree
of real damage to its host.
• Parasitism, therefore, denotes a relationship in which one organism,
the parasite, usually benefits at the expense of the other, the host.
• 3 major taxonomic groupings: Protozoa, Platyhelminthes, and
Nemathelminthes
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Symbiosis
• ‘living together’
• Coined by DeBary (1876) to describe two species of organisms that
lived together, with no implication regarding the length or outcome of
the association.
• Encompasses all ranges of interractions including mutualism,
commensalism and parasitism.

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Mutualism
• Association between 2 organisms where both derive mutual benefit
• Highly interdependent association; if separated neither will survive
• Examples: ruminants and ruminant protozoa (protozoa have enzymes
to convert cellulose to glucose; host provides ideal environment for
protozoa)

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Commensalism
• “eating together at the same table”
• Facultative association between 2 organisms of which is beneficial to
one but not to the other. (one benefits and the other derives neither
benefit nor harm.)
• Examples: Entamoeba coli in man

• Phoresis - Specialised form of commensalism

• Smaller organism (phorant) uses the larger organism as transport host

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Parasitology terms
• Facultative parasite: host not necessary for the completion of life
cycle
• Obligate parasite: host necessary
• Definitive (final) host: where parasite reaches sexual maturity
• Intermediate host: usually where asexual reproduction takes place.
-parasite undergoes morphological or physiological changes
-required by the parasite to complete its life cycle

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Parasitology terms cont…
• Paratenic (transport) host: parasite lives on host but no morphological changes take place
• Incidental host: Accidental host
-not obligatory
-parasite may or may not complete its life cycle
-zoonotic
• Ectoparasite: lives on surface e.g. mites
• Endoparasite: lives inside host e.g. hookworms
• Mesoparasite: penetrates external openings (ear, nose, buccal cavities)
• An epiparasite is one that feeds on another parasite. This relationship is also
sometimes referred to as hyperparasitism which may be exemplified by a
protozoan (the hyperparasite) living in the digestive tract of a flea living on a
dog.
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Parasitology terms cont…
• Vector: host that plays active role in transmission
• Biological vector: where parasite undergoes development stages
• Mechanical vector: no development
• Anthropophilic vector: prefers human blood
• Zoophilic vector: prefer animal blood
• Endophilic vector: feed indoors
• Exophilic vectors: feed outdoors

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Life cycles
• Monoxenous : life cycles with one host only
• Heteroxenous: life cycles with more than one host
• Direct life cycles: involve only one host
• Indirect life cycles: involve intermediate host
• Horizontal life cycle: where parasite is transmitted from one infected
host to its neighbour
• Vertical life cycles: where parasite is transmitted from mother to
offspring

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Host Parasites Relationship
• The word infection (derived from Latin) means to mix with or corrupt.
• The term refers to the relationship between the host and the parasite and the
competition for supremacy that takes place between them.
• If the host has upper hand, due to increased host resistance it remains healthy
and the parasite is either driven away or assumes a benign relationship with the
host.
• On the contrary, if the host loses the competition (may be due to increased
pathogenicity), disease develops

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Classification of parasites

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Gen. properties of protozoa
• Eukaryotic microorganisms
• No cell walls
• Most have heterotrophic metabolisms
• A few protozoa (eg Euglena) are photosynthetic.
• Many are free-living in soil or aquatic environments; a few are parasitic.
• Most protozoa reproduce by asexual methods, sexual reproduction has
been observed in several species.
• Most protozoal species are aerobic, but some anaerobic species have
been found in the human intestine

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AMOEBIASIS
• Phylum Sarcomastigophora include both the amebas and flagellate
groups.
• two genera, Naegleria and Acanthamoeba – free living. Implicated
occasionally as causes of meningoencephalitis and keratitis.
• Several genera of amebas, including Entamoeba, Endolimax, and
Iodamoeba, are obligate commensalistic parasites of the human
alimentary tract
• Passed as cysts from host to host by the fecal–oral route.
• 2 major species of Entamoeba: E.histolytica and E. dispar.

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 Entamoeba histolytica lifecycle

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Entamoeba histolytica
Mechanism/factors of tissue damage:
• Secretion of proteolytic enzymes (protease breaks down proteins)
• Release of cell free cytotoxins
• Contact dependent cytolysis
• Phagocytosis

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Entamoeba histolytica cont…
• E. histolytica trophozoites contains surface adhesions that allow
attachment to colonic epithelium
• Adherence of trophozoites to host cells and colonic mucins is
mediated by lectin-activity expressed on the amoebas surface
• Contact between Entamoeba sp. trophozoites & host cells results in
lysis of target cells
• They also contain a number of proteolytic enzymes
• Tissue damage begins as small foci of necrosis in the large intestinal
mucosa without the involvement of caecum, appendix or
descending colon
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Entamoeba histolytica cont…
• These foci coalesce to form ulcers, some small discrete, others merge
to form large ulcers
• Polymorphonuclear leukocytes constitute initial host response to E.
Histolytica
• On contact with trophozoites, these neutrophils also undergo lysis
releasing more proteolytic enzymes resulting further tissue destruction
• Inflammatory cells in the lesions are thus characteristically found in the
periphery
• Amoebic lesions may be disseminated throughout the colon, but
commonly in caecum
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Entamoeba histolytica cont…
• Typical amoebic ulcer is undermined & is sharply defined without ragged
edges
• Crater of the ulcer contains gray necrotic tissue composed of fibrin,
cellular debris & amoebic trophozoites
• Amoebic ulcers are typically flask shaped due to the exudate raising the
undermined mucosa
• Once deep tissue invasion occurs, trophozoites invade blood vessels
causing vasculitis with subsequent thrombosis & infarction
• As ulcers widen, secondary bacterial infection occurs leading to
accumulation of neutrophils, histiocytes, plasma cells & eosinophils in
the ulcer crater & surrounding tissues
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Entamoeba histolytica cont…
• Lesions may reach the muscularis mucosa leading to:
-Perforation of intestine with or without peritonitis
-Intra-abdominal pericolic abscess formation
-Amoebic appendicitis
-Massive haemorrhage
-Amoebic strictures
-Acute necrotizing colitis
-Toxic megacolon
• Disseminated infections: Amoebic liver abscess, Lung abscess, Empyema
thoracis, Pericarditis, Brain abscess etc
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Amoebiasis dx (E. histolytica)
• Diagnosis:
- History & Physical Exam
- Lab.
• Specimen: Stool, Blood/serum, Hepatic aspirate
• Methodology:
Stool Microscopy for trophozoites/cysts; (direct; iodine; FECT)
Culture
Sygmoidoscopic exam
Rectal snip – histology.
Serology – ELISA, PCR.
Radiology.
Hematology
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Amoebiasis Rx
• Treatment:
- Metronidazole
- Tinidazole
- Aminosidine
- Diloxanide furoate/ Paramomycin – for carriers.
- Dehydroemetine

• Surgery.

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Amoebiasis Prevention & Control
• Health education
• Hand washing
• Sanitary measures – Toilets & utilization
• Health education
• Avoid uncooked food
• Boil drinking water

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Leishmaniasis
• Leishmaniasis is a disease caused by intracellular protozoan parasite
of the genus leishmania
• Transmitted by the bite of sandfly.
• Clinical spectrum of leishmaniais ranges from a self limiting cutaneous
ulcer to mutilating mucocutaneous disease and even to lethal
cutaneous illnesses

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Reservoir hosts include:
• Humans
• Dogs
• Wild canines (foxes, jackals, sloths)
• Multiple hosts/rodents
Unusual routes of transmission:
• Blood transfusion
• Sexual contact
• Congenital transmission
• Occupational exposure

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Leishmaniasis life cycle

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Leishmaniasis Clinical syndromes
• Classification based on clinical disease
1. Cutaneous leishmaniasis- localized, diffuse, leishmaniasis recidivans,
and post-kala-azar dermal leishmaniasis
2. Mucocutaneous
3. Visceral leishmaniasis

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Leishmaniasis Diagnosis (L. donovani; L. brazilliennsis etc)

• Specimen:
• Splenic aspirate and biopsy- 96-98% sensitive but not commonly done due to the risk of splenic rupture
and hemorrhage.
• Bone marrow aspirate (Sternum or iliac crest)-is 60-80% sensitive.
• Skin biopsy and scrapings of the ulcer in cutaneous disease.
• Blood/serum
• Techniques:
• Microscopy; staining for amastigotes
• Culture for promastigotes- NMN medium
• Serology for Ab
• Leishman skin test (LST)
• PCR
• Biochemical tech
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Leishmaniasis Treatment
1. Sodium Stibogluconate (Pentavalent antimonial) - 20 mg/kg/day IV
or IM for 28 days, dose mixed with 50ml of 5% dextrose in water
and infused over 10 mins.
2. Alternative 1st line drug - Amphotericin B: 0.5-1 mg/kg IV slow
infusion (6-8 hrs) dissolved in 500mls of dextrose 5%, on alternate
days. 14-20 infusions for a total dose of 1.5gms.
3. Pentamidine
4. Alternative agents: Miltefosine, Ketoconazole, Paramomycin,
Sitamaquine

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SUPPORTIVE MEASURES
• Transfusion
• Wound care
• Rest
• High protein high calorie diet
• I/V fluids
• Dermatology consults
• Antimicrobial cover if necessary

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Trypanosomiasis
• Two subspecies that cause distinct disease patterns in humans:
• T. brucei. gambiense, causing chronic African trypanosomiasis (“West
African sleeping sickness”) and
• T. brucei. rhodesiense, causing acute African trypanosomiasis (“East
African sleeping sickness”).
• The third subspecies T. b. brucei is a parasite primarily of cattle and
occasionally other animals,
• Chagas disease, also known as American trypanosomiasis, is a tropical
parasitic disease caused by Trypanosoma cruzi.

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Trypanosomiasis cont’d
• Humans are considered the main reservoir for Trypanosoma brucei
gambiense,
• Domestic cattle are thought to be the most epidemiologically-relevant
animal reservoir of T. b. rhodesiense.
• The only known vector for each is the tsetse fly (Glossina spp.).

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Clinical Presentation
• First-stage disease (haemolymphatic) involves nonspecific signs and
symptoms such as intermittent fever, pruritus and lymphadenopathy.
• In the second-stage disease (meningoencephalitic), invasion of the
central nervous system causes a variety of neuropsychiatric
manifestations including sleep disorders, hence the common name
“African sleeping sickness”.
• The course of infection is much more acute and rapid with T. b.
rhodesiense than T. b. gambiense, and both infections are almost
invariably fatal without treatment.

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Trypanosoma (HAT) dx (T. rhodensiense; T. gambiense)

• Specimen: • Methodology:
• Concentration techniques:-
• chancre fluid, • Haematocrit centrifugation tech for buffy
• lymph node aspirates, coat
• mini anion-exchange/centrifugation
• blood/serum • Quantitative Buffy Coat (QBC) technique
• bone marrow • Giemsa staining of blood-
trypamastigotes
• cerebrospinal fluid. • sediment Isolation of the parasite by
inoculation of rats or mice for spinal fluid
• Antibody detection has sensitivity and
specificity

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Chagas disease dx (T. cruzi)

• Specimen:
• Blood
• Serum
• Techniques:
• Microscopy for amastigotes; thin/thick smears
• Buffy coat for motile parasites
• Culture (NNN/LTI media)
• Innoculation in mice
• Xenodiagnosis
• Ab serodiagnosis

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Trypanosomiasis Rx
• Treatment:
- Medical - Nifurtimox, Benznidazole
- Supportive management
- Surgical - Balloon dilatation
- Open/Lap cardiomyotomy
- Cardiac pacemaker
- Heart transplant
- Sigmoidectomy

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Giardiasis
• Giardiasis is a diarrheal disease caused by Giardia intestinalis
• The flagellate protozoan Giardia intestinalis­­(previously known as G
lamblia or G duodenalis),
• Feco-oral transmission
• Can cause asymptomatic colonization or acute or chronic diarrheal
illness
• Treatment: Metronidazole (Flagyl®), Tinidazole (Tindamax®),
Nitazoxanide (Alinia®).

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Giardia intestinalis
• Mechanism of parasite adhesion:
i) Mechanical; through beating of flagella & contractile elements in
ventral sucker disk
ii) Lectin mediated process leading to mannose –dependent adhesion
of parasite to enterocyte

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Giardia intestinalis cont….
Mechanism of diarrhoea:
i) During movement of parasite in small intestine surface lectin adhesion to
enterocyte are continuous with subsequent breaking of adhesion sites;
• disrupt enzymes & surface membranes of microvilli leading to failure to absorb
nutrients leading to diarrhoea
ii) Active uptake of bile salts by trophozoites may cause malabsorption of fats
iii) Trophozoites may interfere with pancreatic lipase function leading to steatorrhea
iv) Giardiasis may lead to bacterial overgrowth which could secrete enterotoxins
causing intestinal damage
v) G. intestinalis infection can lead to reduction of villus height, villus atrophy &
increase in villus crypt depth
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Giardiasis dx (G. intestinalis)

• Specimen: • Technique:
• Stool • Microscopy (trophozoites/cysts):
• Serum -Formalin acetate
• Duodenal biopsy -Haematoxylin/eosin stain
• Duodenal fluids • Ag detection: serology: enzyme
immunoassays
• PAR detection via
immunofluorescent assays
• PCR

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Balantidium coli
• A rare, large ciliated protozoan that causes the disease balantidiasi
• Transmitted thr’ fecal-oral route by contaminated food and water.
• Trophozoites penetrates mucosa in caecum & ileum aided by action of
hyaluridase
• This leads to necrosis, ulceration & small abscesses
• Following mucosal invasion, bacterial invasion may occur leading to
cellular infiltration
• Multiplication of balantidia in tissues leads to ulcers or subsurface
abscesses. Gross appearance resembles amoebic ulceration
• Leads to mild diarrhoea, rarely bloody.
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Cryptosporidiosis
• A self-limited diarrheal illness in otherwise healthy adults
• Caused by at least 15 different species.
• Commonest: Cryptosporidium hominis, for which humans are the only
natural host, and Cryptosporidium parvum, which infects a range of
mammals, including humans.
• Cryptosporidiosis mainly affects children.
• Cryptosporidium is the most common parasite identified in
HIV/AIDS patients with diarrhea.

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Cryptosporidium parvum
• Transmission is through ingestion of sporulated oocysts
• Sporozoites emerge from oocysts & attach to intestinal epithelial cells.
• In contrast to other coccidia species, sporozoites do not invade enterocytes
• Instead, they induce the fusion & expansion of microvilli, resulting in the
parasite being surrounded by double membrane of the host’s origin
• Thus, Cryptosporidium sp. infection is unusual in that it barely invades epithelial
cells, remaining in an intracellular but extracytoplasmic location just beneath
the host cell’s plasma membrane, where it can derive nutrition while
minimizing immunologic recognition.

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Cryptosporidium parvum cont…..
• Because the organism derives sustenance from the cells to which it
attaches rather than from the host’s food stream, it can survive on
any mucosal epithelial surface.
• Trophozoites have been identified on mucosa in the pharynx,
oesphagus, stomach, duodenum, jejunum, ileum, appendix, colon,
rectum.
• Other sites are surfaces of the biliary tract, lung, eye, and
nasopharynx.

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Cryptosporidium parvum cont…..
• Due to watery nature of diarrhoea, it is thought parasite-produced enterotoxins
may be involved.
• However, there is no evidence for a toxin-mediated secretory diarrhea despite
efforts to identify such a toxin
• Diarrhea can have osmotic, inflammatory, or secretory components
• Experimental evidence does suggests that glucose-coupled Na+ absorption is
decreased and Cl- secretion is increased.
• Therefore, the diarrhea associated with Cryptosporidium sp. appears to be
primarily osmotic in nature

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Cryptosporidium parvum cont…..
• Associated with this disruption of enterocyte (i.e., intestinal epithelial cells)
function is a blunting of the villi and crypt cell hyperplasia.
• A possible mechanism of pathogenesis is that the infection of intestinal
epithelial cells with Cryptosporidium sp. damages the enterocytes and
eventually leads to their death.
• This triggers cell division in the crypt region (i.e., hyperplasia) to replace the
damaged cells.
• The combination of destruction of absorptive cells at the tips of the villi and the
increase in the Cl--secreting crypt leads to an overall enhanced secretion

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Cryptosporidiasis dx (C. parvum)

• Specimen:
• Stool (care infective oocyst)
• Serum
• Biopsy
• Technique:
• Acid fast staining for oocysts: Kinyoun;Ziel-Neelsen
• Centrifugation
• Enzyme immunoassays
• PCR
• Ab detection

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Cyclospora cayatenensis
• Causes a diarrheal disease called cyclosporiasis
• The infection is acquired through the ingestion of sporulated oocysts.
• Lifecycle: Sporozoites are release in the intestinal lumen and invade intestinal epithelial cells.
• Within the epithelial cells the parasite undergoes a round of merogony leading to the
production of merozoites.
• The released merozoites reinvade intestinal epithelial cells and can undergo additional rounds
of merogony or develop into either micro- or macrogamonts. Microgametes will fertilize the
macrogametes to form a zygote which develops into the oocyst.
• Immature oocysts are passed in the feces and maturation into infectious sporulated oocysts
occurs in the environment.
• Recognizable stages during this maturation (ie, sporogony) include oocysts with a single
sporoblast, oocysts with two sporoblasts, and the mature oocyst with two sporocysts, each of
which contains four sporozoites
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Cyclosporiasis; Pathogenesis
• Cyclospora cayatenensis transmission is faeco-oral; treated (Clˉ) & untreated water,
food-borne (raspberries, basil, cilantro, snow peas, lettuce etc.)
• Infection more severe in immunocompromised individuals
• Cyclospora primarily infects epithelial cells in the upper portion of the small intestine
• Ingestion of oocysts may lead to
1. Upper gastrointestinal symptoms (nausea, eructation with absence of tenesmus &
dysentery
2. Malabsorption of D-xylose leading to weight loss
3. erythema of distal duodenum,
4. epithelial disarray with acute & chronic inflammation,
5. partial villus atrophy
6. crypt cell hyperplasia
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Isospora belli
• Cystoisospora belli, previously known as Isospora belli, is a parasite
that causes an intestinal disease known as cystoisosporiasis.
• Isospora belli is believed to be a valid species which only infects
humans.
• It has a worldwide distribution but is more common in tropical
regions and areas with poor sanitation
• Infections are more common and the symptoms more severe in AIDS
patients that in immuno-competent persons.

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Isospora belli
• Symptoms associated with I. belli infection include diarrhea, steatorrhea,
headache, fever, abdominal pain, nausea, dehydration and weight loss.
• In general, the symptoms are similar to those of cryptosporidiosis.
• The disease is often self-limiting.
• However, it can become chronic with oocysts being detected in the feces for
months to years and recrudescences of the symptoms.
• The disease tends to be more severe in infants and young children than adults.
• Pathology associated with I. belli infections are primarily villous atrophy, or
blunting, and crypt hyperplasia.

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 • The diarrhea in AIDS patients is often very watery and can lead to
dehydration requiring hospitalization.
• Fever and weight loss are also a common finding. Another common
finding among AIDS patients is a chronic intermittent diarrhea
lasting for months to years.
• The resulting excessive weight loss and electrolyte imbalance can
lead to wasting and even death.
• There have also been a few reports of disseminated extra-intestinal
isosporiasis in AIDS patients.

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Trichomoniasis
• Is a common sexually transmitted infection caused by a parasite.
• Worldwide, at least 250 million new cases of STDs occur each year.
• Trichomoniasis, caused by Trichomonas vaginalis - 120 million cases a
year.
• Chlamydia 50 million cases a year.
• Human papilloma virus, gonorrhea, and herpes simplex virus 20-30
million cases a year.

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Trichomonas vaginalis
• Flagellated protozoans
• Prevalence 2-10 % in populations
• Infects epithelium, ectocervix and vaginal epithelium and male
urethra
• Diagnosis: wet mount, culture
• Treatment: metronidazole ( or other imidazoles)

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Trichomoniasis Signs and symptoms:
• Females: About 50% of women who harbor the org are asymptomatic
• S/s often peak just after the menses
• Vaginal discharge (75%, usually copious, which may be frothy, yellowish
green and alkaline, watery and pooling), Vaginal odor (10%), Vulvovaginal
irritation (50%), Dysuria (50%), Dyspareunia, Vaginal hyperemia, Cervical
erosion, A "strawberry cervix" from punctate hemorrhages (5% of cases),
Suprapubic discomfort

• Males: About 80% are asymptomatic.

• Urethral discharge (It may be gray, white, or yellow-green), Dysuria,
Epididymitis (rare)
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Trichonomiasis dx (T. vaginalis)

• Specimen:
• High vaginal swabs (HVS)
• Urethral discharge
• Urine
• Serum
• Prostatic secretions
• Technique:
• Microscopy (direct) for trophozoites (no cysts!)
• Direct immunofluorescent test (IFAT)
• Culture
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Plasmodium
• Plasmodium is a malaria causing parasite.
• (Blood and tissue protozoa)
There are four types of plasmodia that cause malaria:-
• Plasmodium vivax
• Plasmodium ovale
• Plasmodium malariae
• Plasmodium falciparum

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Malaria ETIOLOGY
Species of plasmodium shown to infect humans;
• P. falciparum – found in Africa, Haiti, Papua New Guinea
• P. vivax – Central and South America, North Africa, Middle East, Indian
subcontinent; rare in Sub-Saharan Africa.
• P. ovale – in West Africa
• P. malarial – everywhere but especially Africa
• P. knowlesi – S.East Asia, similar to p. malariae
• P. simium – Brazil, resembles P. vivax

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Malaria EPIDEMIOLOGY
• 2018 - 219 million cases of malaria worldwide (WHO)
• 92% African region, 5% South-East Asia & 2% Eastern Mediterranean
region
• Male : female – equally affected.
KENYA
• Malaria incidence/1,000 population at risk: 166 (MOH 2015)
• Under-five mortality rate: 52/1,000 live births (MOH 2014)
• Estimated 3.5 million new clinical cases and 10,700 deaths each year
CDC/GoK 2018

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 KENYA MALARIA ZONE MAP

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Lifecycle of plasmodia
• The vector and definitive host for plasmodia is the female anopheles
mosquito (only the female takes a blood meal).
• There are two phases in the lifecycle of plasmodia
• Sexual circle - which occurs primarily in the mosquitoes
• The asexual circle which occurs in humans(the intermediate host)
• The sexual cycle is called sporogony because sporozoites are
produced.
• The asexual cycle is called schizogony because schizoints are made.

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Lifecycle Cont’d
• Lifecycle in humans
• The lifecycle in humans begins with the introduction of sporozoites
into the blood from the saliva of the biting mosquito.
• The sporozoites are taken up by hepatocytes within 30 minutes.
• This "exoerythrocytes“ phase consists of cell multiplication and
differentiation into merozoites . p.vivax and p.ovale produce a latent
form(hypnozoite) in the liver; this form is the cause of relapses seen
with vivax or ovale malaria.

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Lifecycle Cont’d
• Merozoites are released from the liver cells and infect red blood cells.
• During the erythrocytic phase, the organism differentiates into ring-
shaped trophozoite.
• After release, the merozoites infect other erythrocytes. This cycle in
the red blood cells repeats at regular intervals typical for each
species.
• The periodic release of merozoites causes a typical recurrent
symptoms of chills, fever, and sweats seen in malaria patient.

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Lifecycle Cont’d
• The asexual cycle begins in human red blood cells when some
merozoites develop into male and others into female gametocytes.
• The gametocyte containing red blood cells are ingested by the female
anopheles mosquito and, within her gut, produce a female
macrogamete and eight sperm like male microgametes.
• After fertilization, the diploid zygote differentiates into a motile
ookinate that burrows into gut wall, where it grows into an oocyst
within which many haploid sporozoites are produced.
• The sporozoites are released and migrate to the salivary glands ready
to complete the cycle when the mosquito takes her next meal.
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 LIFECYCLE

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TRANSMISSION
• Mainly by bite from infected female anopheles spp mosquito.
Others (rare);
• Blood transfusion
• Organ transplant
• Sharing contaminated needles
• Congenitally acquired disease

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 CLINICAL FEATURES:
a)Uncomplicated malaria - Characterized by fever in the presence of
peripheral parasitaemia ˂4% & absence of signs of severe malaria.
Fever and febrile paroxysms Irritability, refusal to eat.
Rigors. Nausea
Chills Vomiting.
Headache Profuse sweating
Yellowness of eyes History of travel to endemic zone.
Muscle aches and joint pains.
Abdominal pain and diarrhea.

11/24/2023 Dr. Keli 72

b) Severe Malaria (WHO criteria)
P. falciparum in peripheral blood in presence of any of these defining clinical/lab features;
• Coma
• Repeated generalized convulsions (> 2 in 24 hrs)
• Circulatory collapse (shock, supervening bacterial septicemia)
• Pulmonary oedema
• Acidotic breathing
• Spontaneous bleeding (DIC)
• Acute Renal failure (oliguria, anuria), Hemoglobinuria (black water fever)
• Acidosis < 7.35 (Hyperlactatemia=Lactic acidosis)
• Severe anemia Hb < 5. hematocrit <15%
• Hypoglycemia < 2.2 mmol/L, <45 mg/dl)
11/24/2023 Dr. Keli 73
DIAGNOSTIC APPROACHES
1. Clinical (presumptive) diagnosis

2. Parasite based diagnosis – laboratory evaluation

• Microscopy – is the gold standard
-Thin and thick blood smears, giemsa stain
• Rapid Diagnostic Tests (RDT) - Immunochromatographic tests based on
detection of specific parasite antigens. e.g. plasma LDH
• Polymerase Chain reaction-detection parasite DNA or mRNA; used in efficacy
studies for antimalarial drugs, vaccines
• Quantitative Buffy Coat (QBC) - more sensitive than the conventional thick
smear, but unreliable for the differential dx of parasite species
11/24/2023 Dr. Keli 74
 Reporting/Interpretation
• Plasmodium parasite seen Species seen ( pf, pv, po, pm)

• Developmental stages seen (trophozoites, schizonts and gametocytes)

• plus system
• + represents 1-10/100 thick blood films
• ++ represents 11-100/100 thick blood films
• +++ represents 1-10 per single thick blood film
• ++++ > 10 parasites per single thick blood film

11/24/2023 Dr. Keli 75

TREATMENT:
(i) Chloroquine-resistant uncomplicated malaria
1st line: ACT(Artemesinin based Combination Therapy).
• Artemether-lumefantrine
• Artesunate-amodiaquine
• Artesunate-mefloquine
• Dihydroartemisinin-piperaquine

Total artemisinin dose (10 to 12 mg/kg) is given over three days.

11/24/2023 Dr. Keli 76
TREATMENT cont..:
• Artemether-Lumefantrine (Coartem): Typically 4 tabs every 12 hours
for 3 days

11/24/2023 Dr. Keli 77

Take away assignment
Toxoplasmosis (T. gondii)
 Hosts / transmission
 Lifecycle
 Clinical presentation
 Diagnosis
 Treatment
 Prevention & Control

11/24/2023 Dr. Keli 78

11/24/2023 Dr. Keli 79
 (B) HELMITHS

11/24/2023 Dr. Keli 80

11/24/2023 Dr. Keli 81
Trematodes(flukes)
• Trematoda(flukes) and cestoda(tapeworm) are the two large classes of
parasites in the phylum platyhelminthes.
• The most important trematodes are:-
Schistosoma species -blood flukes(schistosomiasis) e.g schistosoma
mansoni (blood vessels -mesenteric veins), schistosoma japonicum
(gastro-intestinal tract), schistosoma haematobium (urinary tract).
Clonorchis sinensis -liver fluke (causes clonorchiasis)
Paragonimus westermani -lung fluke(causes paragonimiasis)
• Schistosomiasis have the greatest impact in terms of the number of
people infected, morbidity, and mortality.
11/24/2023 Dr. Keli 82
Trematodes(flukes) cont’d
• The lifecycle of the medically important trematodes involves asexual
cycle in humans (definitive host) and sexual reproduction in fresh
water snails (intermediate host).
• Transmission to humans takes place either through penetration of the
skin by the free-swimming cercariae of the schistosomes or through
ingestion of undercooked (raw) fish or crabs in clonorchis and
paragonimus infection, respectively.

11/24/2023 Dr. Keli 83

Schistosomiasis
• Schistosomiasis or bilharzia is a parasitic disease caused by trematode
flukes of the genus schistosoma.
• The adult male and female worms live within the veins of their human
hosts where they mate and produce fertilized eggs
• 3 main species of schistosoma infect humans: S. haematobium, S.
mansoni and S. japonicum.
• 2 minor species include: S.mekongi & S.intercalatum
• The prevalence of schistosomiasis is highest in sub-saharan Africa.
• Worldwide, its has been estimated that 200 million people are infected
and schistosomiasis may cause up to 200,000 deaths annually.
11/24/2023 Dr. Keli 84
• Snail is the intermediate host for the schistosoma parasite.
• Certain schistosoma spp prefer certain species of snails:
• S.mansoni – Biomphilaria spp
• S. haematobium – Bulinus spp
• S.japonicum – Oncomelania spp
• S.mekongi – Tricula spp

11/24/2023 Dr. Keli 85

Lifecycle of schistosoma.

11/24/2023 Dr. Keli 86

Pathogenesis.
• Eggs induce morbidity caused by schistosoma infections.
• Many eggs are not excreted and become lodged in the intestines or
liver (mansoni, japonicum and mekongi)
• Eggs induce a granulomatous immune response largely characterized
with lymphocytes (Th2 cytokines 4, 5, 13).
• Process of granuloma formation induces a chronic inflammation that
lead to disease manifestations of schistosomiasis.

11/24/2023 Dr. Keli 87

• Acute schisto’ is sometimes referred to as katayama syndrome
• with clinical presentation of sudden onset of fever, malaise, myalgia,
headache, eosinophilia, fatigue and abdominal pain lasting 2-10wks.
• Occurs often in immigrants and travelers to schistosome-endemic
areas (occurs weeks to months after infection)
• Overtime the granulomatous response to eggs is downregulated thr’
several mechanisms, leading to chronic intestinal form of the disease
and this presents with non-specific intermittent abdominal pain,
diarrhea and rectal bleeding

11/24/2023 Dr. Keli 88

• Some people with intestinal schisto’ only poorly immunoregulate their response
to parasite egg antigens and develop extensive fibrosis and subsequent
hepatosplenic dse with periportal fibrosis
• Pts with periortal fibrosis also called symmer’s pipe-stem fibrosis retain
hepatocelllular function (this differentiates the disease from cirrhosis and other
liver dses)
• Clinical features include upper abdominal discomfort with palpable nodular and
hard hepatomegaly often with splenomegaly
• Ascites and hematemesis from esophageal varices as a complication of portal
hypertension can rapidly lead to death
• Substantial pulmonary hptn caused by granulomatous pulmonary arteritis can
occur in pts with advanced hepatic fibrosis disease.
11/24/2023 Dr. Keli 89
• The defining symptom of urogenital schisto(S. haematobium) is hematuria,
often presenting with urinary frequency, burning micturition & suprapubic
discomfort.
• Severe urogenital schistosomiasis leads to chronic fibrosis of the urinary
tract presenting as an obstructive uropathy (hydroureter & hydronephrosis)
which along with bacterial superinfection and renal dysfxn can have lethal
consequences
• SCC of the bladder is strongly associated with S. haematobium infxn.
• Female genital schisto (FGS) causes inflammatory lesions of the ovaries,
fallopian tubes, cervix, vagina and vulva and has been associated with
stress incontinence, infertility and increased risk of abortion.
11/24/2023 Dr. Keli 90
Clinical Features
• Disease manifestations of schistosomiasis occur in three stages
• 1st Phase- Cercarial Dermatitis/Swimmer’s Itch
• Most often with S. mansoni and S. japonicum infections,
• Manifesting within 1 day of invasion as an itchy maculopapular rash on the
affected areas of the skin.
• Mostly in the feet and lower legs

11/24/2023 Dr. Keli 91

Clinical Features Cont…
2nd Phase-Acute Schistosomiasis/Katayama Fever
• Begins 4–8 weeks after skin invasion as a result of systemic hypersensitivity
rxn to schistosome antigen and circulating immune complexes.
• Onset of symptoms coincide with egg production when the antigen burden is
increased . Mostly in non immune patients.
• a serum sickness–like syndrome with fever, chills,
utricaria,angioedema ,myalgias, arthalgias, dry cough ,abd pain ,diarrhoea,
headache-generalized lymphadenopathy, and hepatosplenomegaly

11/24/2023 Dr. Keli 92

Clinical Features Cont…
3rd Phase- Chronic Schistosomiasis- insidious onset of symptoms
depend on infested organ.
• Intestinal Species - chronic, intermittent, colicky abdominal pain, poor
appetite, colonic ulceration ,bleeding, bloody diarrhea which cause iron
deficiency anemia, strictures and bowel obstruction post inflammatory and
fibrosis.
• Hepatosplenic schistosomiasis- can lead to 2 distinct syndromes.
1. Inflammatory hepatic schistosomiasis- hepatomegaly and severe
splenomegaly
2. Chronic hepatic schistosomiasis

11/24/2023 Dr. Keli 93

Clinical Features Cont…
• Urinary Tract Species
• Up to 80% of children infected with S. haematobium have dysuria, frequency,
and hematuria due to bladder ulceration. Some present with pyuria
• In females,genital lesions, vaginal bleeding, pain during intercourse or vulvar
nodules
• Pulmonary Schistosomiasis
• Portal hypertension lead to eggs being embolized which then lodge in small
arterioles, producing acute necrotizing arteriolitis and granuloma formation
• Subsequent fibrous tissue deposition leads to endarteritis obliterans,
pulmonary hypertension, and cor pulmonale (cardiomegally and pulmonary
artery dilatation). The most common symptoms are cough, fever, dyspnea and
milliary nodules.
11/24/2023 Dr. Keli 94
Clinical Features Cont…
• CNS Schistosomiasis
• Migratory worms deposit eggs in the brain and induce a
granulomatous response
• Jacksonian epilepsy due to S. japonicum infection
• S. mansoni and S. haematobium infections have been associated
with transverse myelitis.

11/24/2023 Dr. Keli 95

Diagnosis:
• Lab. - Urine microscopy – terminal urine sample.
- Stool microscopy – eggs in stool –kato katz technique
- Rectal snip for biopsy – ova detection
• Radiology - Abdominal U/S, IVU
• Endoscopy
• Serology-96%
• Falcon assay screening test-ELISA (FAST-ELISA)
• Enzyme-linked immunoelectrotransfer blot (EITB)
• Peripheral Blood Film- Eosinophillia
• Others-FHG, LFT, U/E/Cs, U/A, fecal occult blood test
11/24/2023 Dr. Keli 96
Treatment
• Treatment of schistosomiasis depends on stage of infection and
clinical presentation
• 1st phase- Cercarial Dermatitis
• Topical dermatologic applications for relief of itching. No specific
treatment is indicated
• 2nd phase- Acute Schistosomiasis/Katayama Fever
• Glucocorticoids for symptomatic treatment-prednisone 40mg OD
for 5 days
• Also in neuroschistosomiasis

11/24/2023 Dr. Keli 97

Treatment cont…
Medical - Oxamniquine
- Metrifonate
- Praziquantel
SurgicalLaparotomy
Banding, injection, stapling, shunting procedures
Cystectomy
Pyeloplasty

11/24/2023 Dr. Keli 98

Prevention & Control:
(1) Snail : - Molluscisides
- Biologically competing spp
- Predators – Gambusia (mosquitofish)
- Environmental hygiene
(2) Man – water contacts :- Provide safe water, Bridges, Recreational pools,
protect workers.

(3) Man :- Health education, proper sanitation, personal hygiene,

chemotherapy, large-scale treatment of at-risk population groups,
• No vaccines
11/24/2023 Dr. Keli 99
Fasciolepsis buskii
• Giant intestinal fluke
• Transmission thro’ ingestion of fresh water plants with
metacercariae
• Metacercariae excyst in duodenum & attach to mucosa, developing
to adult
• Adult flukes attach to duodenal & jujenal mucosa but may be found
in pylorus, ileum, colon
• May cause inflammation, mucus secretion & ulceration at
attachment site followed by deep erosions & hemorrhage

11/24/2023 Dr. Keli 100

Fasciolepsis buskii cont….
• Heavy infestation may lead to:
• Intestinal obstruction
• Profound intoxication & sensitization from absorption of fluke
metabolites
• Hypoabuminemia secondary to malabsorption or protein losing
enteropathy may result in oedema of face & extremities
• Impaired vitamin B12 absorption & reduced serum vitamin B12 levels
may occur
• Thus diarrhoea, excessive appetite, anorexia, stool with undigested
food, vomitus etc. common
11/24/2023 Dr. Keli 101
CESTODES (tapeworms)
• Tapeworm consist of two main parts
 A rounded head called a scolex
 Flat body of multiple segments called proglottids
• The scolex has specialized means of attaching to the intestinal wall-
suckers, hooks, or sucking grooves
• The worm grows by adding new proglottids from its germinal centre
next to the scolex.
• The oldest proglottids at the distal end are gravid and produce many
eggs ,which are excreted in the feces and transmitted to various
intermediate hosts such as cattle, fish, and pigs.
11/24/2023 Dr. Keli 102
Cestodes (tapeworm) cont’d
• Humans acquire the infection when undercooked flesh containing the larvae is
ingested.
• Two important diseases caused by cestodes:
Hydatid disease
Cystercosis
• There are four medically important cestodes
 Taenia solium-causes cystercosis(human)
 Taenia saginata-cause cystercosis(in other animals)
 Diphyllobothrium latum(lives in fish)-causes diphyllobothriasis
 Echinococcus granulosus(dogs definitive host, sheep intermediate host)-causes
echinococcosis(hydatid cyst).
11/24/2023 Dr. Keli 103
TAENIA SOLIUM (Pig tape worm)-
Cysticercosis
• INFECTION: Pig to human (oral - pork).
Human to human (feacal oral)
• DIAGNOSIS – EITB (Enzyme linked Immuno-Electrotransfer blot),
Subcutaneus/muscle biopsy. CT/MRI. ELISA.
• MEDICAL Rx. Albendazole. Praziquantel.
• SURGICAL COMPLICATIONS - Neurocysticercosis. Spinal cysticercosis.
Intra-occular cysticercosis
• SURGICAL RX. Neuroendoscopy. Ventricular shunts. Open surgery

11/24/2023 Dr. Keli 104

Hydatid disease
• Also called Hydatidosis, Echinococcosis
• Two main types of the disease: cystic echinococcosis and alveolar echinococcosis
• Commonest disease-causing species of Echinococcus :
- E. granulosus
- E. multilocularis
• All are transmitted to intermediate hosts via the ingestion of eggs and are
transmitted to definitive hosts by means of eating infected, cyst-containing
organs.
• Humans are accidental intermediate hosts that become infected by handling soil,
dirt or animal hair that contains eggs
• Dog- human. Feacal oral
11/24/2023 Dr. Keli 105
Clinical features
 Types of hydatid cysts: - Unilocular hydatid cyst, Multivesicular cyst,
Alveolar hydatid cyst, Multilocular hydatid cyst
• Many are asymptomatic.
- Pressure symptoms - depending on the cyst's location and size.
- Severe anaphylactic reaction to hydatid fluid.
• Liver – 67% - abd pain. Weight loss, jaundice
• Lung – 16% - chest pain, cough, shortness of breath
• Peritoneal cavity – 8% - ascites
• Kidneys – 7%, Brain & Spinal cord – 0.5%, Bone – 1.5%
11/24/2023 Dr. Keli 106
Hydatid disease dx (E. granulosus)

• Specimen:
• Fine needle biopsy
• Serum
• Techniques:
• Microscopy for protoscolisces
• Ab detection techniques (serology)
• Imaging tech
- Plain CXR, Chest CT Scan
- Liver US, Abdominal CT Scan
- Brain CT Scan, MRI
- Bone X-rays
11/24/2023 Dr. Keli 107
Hydatid disease Tx
• Treatment:
Medical
- Albendazole 10-15mg/Kg/day
- High dose Mebendazole 40-50 mg/Kg/day
- Praziquantel 40mg Kg/day
Surgical Rx:
• Liver Cysts - PAIR (Percutaneous Aspiration Injection & Re-aspiration).
• Other surgical options e.g. resection, partial hepatectomy, Lobectomy
etc
11/24/2023 Dr. Keli 108
NEMATODES (NEMATHELMINTHES)
• Nematodes are round worms with acylindrical body and complete
digestive tract including the mouth and an anus.
• The body is covered with a noncellular, highly resistant coating called a
cuticle.
• Nematodes have separate sexes;-female usually larger than male. The
male typically has a coiled tail.
• Medically important nematodes are divided into two categories
according to their primary location in the body.i.e
 Intestinal nematodes
 Tissue nematodes
11/24/2023 Dr. Keli 109
Intestinal nematodes
Intestinal nematodes include
• Ascaris(giant round worm)-causes ascariasis(human)
• Necator & Ancylostoma (the two hookworm)
• Strongyloides(small roundworm)-causes strongoloidiasis
• Enterobius(pinworm)-causes enterobiasis(human)
• Trichuris(whipworm)-causes trichuriasis(human);may cause diarrhea
and rectal prolapse in children.
• Trichinella.

11/24/2023 Dr. Keli 110

Tissue nematodes
The important tissue nematodes include:-
• Wuchereria- causes filariasis(elephantiasis);-transmitted by female mosquitoes
anopheles and culex.
• Onchocera -causes onchoceriasis;-transmitted by black fly
• Loa -causes loasis;-transmitted by deer fly (mango fly)
• The three are called filarial worms because they produce motile embryos
called microfilariae in blood and tissue fluids.
• A fourth species is the guinea worm-dracunculus whose larvae inhabit tiny
crustaceans(copepods) and are ingested in drinking water.
• Nematodes cause disease as a result of presence of adult worms within the
body.
11/24/2023 Dr. Keli 111
Ascariasis
• Caused by Ascaris lumbricoides, a large roundworm of humans,
growing to a length of up to 35 cm
• 1 billion humans – infected worldwide, 60,000 deaths p.a. Mainly
tropical Africa.

11/24/2023 Dr. Keli 112

11/24/2023 Dr. Keli 113
Ascaris lumbricoides; Pathogenesis
• Pathogenesis in the GIT can be due to the migrating larvae or
presence of adult
• Migrating larva may lead to obstruction and perforation of the bile
ducts
• Also lead to pancreatic duct obstruction with peritonitis
• Adults could cause severe intestinal obstruction and/or Intestinal
perforation
• Adult infestation may lead to malabsorption of lactose, nitrogen &
vitamin A

11/24/2023 Dr. Keli 114

Clinical manifestations
Signs caused by the larval Caused by the mature worms:
stage: • Abdominal distension
• Intestinal obstruction
• Asthma • Intestinal intussusception
• Eosinophilia • Intestinal perforation
• Appendicitis
• Rash • Peritonitis
• Conjunctivitis • Pancreatitis
• Volvulus
• Cholangitis
• Jaundice
• Liver abscesses
• Respiratory tract obstruction
11/24/2023 Dr. Keli 115
Ascariasis dx (A. lumbricoides)

• Specimen:
• Stool
• Technique:
• Microscopy for ova:
• FECT/FEACT (ether/ethyl acetate)
• Radiology - U/S (biliary). X-ray (I.O).
• Barium meal
• Duodenoscopy
• Macroscopy (adults)

11/24/2023 Dr. Keli 116

ASCARIS LUMBRICOIDES Treatment
• MEDICAL Rx : Mebendazole. Albendazole. Piperazine phosphate. pyrantel
parmoate.

• SURGICAL Rx:
- Intestinal Obsruction - Laparotomy.
- Partial intestinal obstruction - Conservative. Hypertonic saline enema.
- Pancreato-biliary ascariasis - Removal: Sphincteromy(ERCP),
Choledochotomy

 Prevention & Control

11/24/2023 Dr. Keli 117
Strongyloides stercoralis; Pathogenesis
• Larvae found in the submucosa & mucosal crypts
• Cause mechanical trauma, ulceration
• Infection associated with increased epithelial turnover leading to
malabsorption
• Involvement of larva/adults may lead to flattened villi, thus
malabsorption
• Rarely larvae is seen in biliary or pancreatic ducts causing obstruction

11/24/2023 Dr. Keli 118

Strongyloidiasis dx (S. stercoralis)

• Specimen:
• Stool
• Duodenal aspirates
• Serum
• Technique:
• Microscopy for ova/larvae:
• Direct/conc FECT/FEACT
• Culture for L2 larvae:
-harada-mori
-damp charcoal
-agar plate culture
• Serology for Ab
11/24/2023 Dr. Keli 119
11/24/2023 Dr. Keli 120
Filariasis
• Filarial worms – tissue nematodes (Filarioidea)
• Pathogenic forms:
- Wuchereria bancrofti
- Brugia malayi & B. timori
- Loa loa
- Onchocerca volvulus
 Non-pathogenic forms:
- Mansonella spp.
 Oncocerciasis – subcutaneous filariasis affecting skin & eye – O. volvulus.
 Loa loa – eye worm
11/24/2023 Dr. Keli 121
• General features of filarial worms:
- Use arthropods as vectors of their transmission- Anopheles, Culex,
Aedes, Mansonia mosquitoes.
- Females produce larvae – microfilariae.
- Adult worms live in lymphatics, subcutaneous tissues, muscles &
body cavities.
- Humans – only significant hosts

11/24/2023 Dr. Keli 122

Lymphatic filariasis
• W. bancrofti, B. malayi, B. timori
• Tropical Africa – E. Africa. Kenya – coastal regions, Lake Victoria
• Forms:
- Adult worms – lymphatics in the upper & lower limbs, groin.
- Microfilariae – blood especially at night. 6p.m then rising slowly –
peak 10p.m & 2 a.m.
• Periodicity – adaptation to biting habits of mosquitoes

11/24/2023 Dr. Keli 123

11/24/2023 Dr. Keli 124
Filariasis Clinical manifestations:
Clinical manifestations:
- Asymptomatic amicrofilaraemics – not yet infected, pre-patent
infection, adult worms only, apparent clearance of infection.
- Asymptomatic microfilaraemics – microfilariae in blood but no
symptoms or signs.
Acute presentations – filarial fevers.
- Chronic presentation – Hydrocele, Lympoedema, Chyluria.
- Tropical pulmonary eosinophilia syndrome.

11/24/2023 Dr. Keli 125

Lymphatic filariasis

11/24/2023 Dr. Keli 126

Filariasis dx (W. bancrofti; L. loa; O. volvulus; D. immitis; B. malayi; M. pertsans)

• Specimen:
• Blood: note periodicity
• Serum
• Tissue
• Techniques:
• Microscopy for microfilaria; staining (Giemsa/Wrights)
• Knotts concentration technique
• Filtration techniques (nucleophore membrane)
• Ag detection (Immunoassays; rapid test)
• PCR
• Ab
• Macroscopy

11/24/2023 Dr. Keli 127

Treatment:
Medical
– DEC (Diethylcarbamazine) – mainstay antifilarial therapy.
The drug kills the microfilariae and some of the adult worms

- Single-dose combination therapy - Albendazole + ivermectin or

Albendazole + DEC.
- Skin care
- Treat secondary bacterial infection
- Manage lymphedema
11/24/2023 Dr. Keli 128
• SURGICAL COMPLICATIONS: Chronic lymphoedema. Hydrocoele.
Abscesses. Chyluria.
• SURGICAL Rx:
 Pneumatic compression.
 Reconstructive surgery debulking.
 Hydrocoelectomy.
 Chyluria - Renal pedicle lymphatic disconnection.
 Limb reduction procedures
• Prevention & control – vector control

11/24/2023 Dr. Keli 129

 C: ARTHROPODS

11/24/2023 Dr. Keli 130

Classification of Arthropods
Phylum: Arthropoda
1) Class: Arachnida
i) Order: Acariae
a) Family: Ixodidae (hard ticks)
Amblyomma americanum (lone star tick)
Boophilus microplus (southern cattle tick)
Dermancetor sp. (dog tick)
Ixodes scapularis (deer tick)
Rhipicephalus sp.(dog tick)
11/24/2023 Dr. Keli 131
Phylum: Arthropoda cont….
b) Family: Argasidae (soft ticks)
Ornithodoros moubata (tick borne (endemic) relapsing fever)

ii) Order: Astigmata

Sarcoptes scabei (human itch-mite; scabies)

11/24/2023 Dr. Keli 132

Phylum: Arthropoda cont….
2) Class: Insecta
i) Order: Dictyoptera
Periplenata americana (American cockroach)
Blatta germanica (German cockroach)
ii) Order: Anoplura
Pediculus humanus capitis (head louse)
Pediculus humanus corporis (body louse)
Phthiuris pubis (pubic louse)

11/24/2023 Dr. Keli 133

Phylum: Arthropoda cont….
iii) Order: Hemiptera
a) Family: Cimicidae
Cimex hemiptera (tropical bedbug);
Cimex lectularius (common bedbug; Hepatitis A,B)

b) Family: Reduviidae
Triatoma infestans (kissing bug)

11/24/2023 Dr. Keli 134

Phylum: Arthropoda cont….
iv) Order: Siphonaptera
a) Family: Siphonaptera
Ctenocephaledes felis (cat flea)
Ctenocephaledes canis (dog flea; Dipylidium canium)
Xenopsilla cheopis (rat flea)
Pulex irritans (human flea)

b) Family: Tungidae
Tunga penetrans (jigger flea)

11/24/2023 Dr. Keli 135

Phylum: Arthropoda cont….
v) Order: Diptera
a) Family: Tabanidae
Chrysops sp. (horse flies; loa loa)
b) Family: Glossinidae
Glossina sp (tsetse fly; trypanosomiasis)
c) Family: Ceratopogonidae
Culicoides sp.(biting midge; Mansonella perstans;
Mansonella streptocerca [ filariasis])

11/24/2023 Dr. Keli 136

Phylum: Arthropoda cont….
Order: Diptera cont…
d) Family: Culicidae
Anopheles sp. (mosquitoes)
Aedes sp.
Culex sp.
e) Family: Phlebotominae
Phlebotomus sp.; Sergentomyia sp.
(sandflies; leishmaniasis; sand fly fever; Oroya fever
f) Family: Muscidae
Musca domestica (house fly)
g) Family: Simuliidae
Simulium damnosum; S. neavei (black flies; onchocerciasis
11/24/2023 Dr. Keli 137
Phylum: Arthropoda cont….
3) Class: Crustacea
Order Copepoda
Cyclops (Water fleas; Druncaculiasis)

11/24/2023 Dr. Keli 138

Fleas
Common name Scientific name Pathogen Disease Control
transmitted
Human flea Pulex irritans Pruritus
Pruritic lesions
Cat flea Ctenocephalides Rickettsia sp Flea borne murine
felis endemic typhus

Dog flea C. canis Diphilydium canium Dog tapeworm

Hymenolepis Rat tapeworm
deminuta

Rat flea Xenopsylla Yersinia pestis Bubonic plague

cheopis
Jigger flea Tunga penetrans Orienta Scrub typhus
tsutsugamushi
11/24/2023 Dr. Keli 139
Lice
Common name Scientific name Pathogen transmitted Disease

Body louse Pediculus humanus Rickettsia prawzeskii Endemic louse borne

corporis typhus
Brill-Zinsser disease

Borellia sp. Epidemic louse borne

relapsing fever
Trench fever
Rickettsia quintata

Head louse P. h. capitis Pruritic lesions

Macules &
pigmentation
Pubic louse Phthirus pubis Irritating papules
11/24/2023 Dr. Keli 140
Bugs
Common name Scientific name Pathogen Disease

Tropical bedbug Cimex hemipterus Hepatitis A

Allergy
Anaemia
Common bedbug C. lectularius Irritation

Kissing bug Triatoma infestans Trypanosoma cruzi Chagas disease

(American
trypanosomiasis)

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Mites
Common name Scientific name Pathogen Disease

Trumbuculid mite Leptotrombidium sp Rickettsia Scrub typhus

tsutsugamushi

Scabies mite Sarcoptei scabiei Scabies

Hair follicle mite Demodex folliculorum Hair lose

House dust mite Dermatophagoides sp. House dust mite

allergies (asthma)

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Common name Scientific name Pathogen Disease
Mosquitoes Culex sp. Alphaviruses Onyong-nyong fever
Aedes sp. Yellow fever
Flavivirus Rift Valley fever
Phleboviruses Wuchereriasis
W. Bancrofti Malaria
Plasmodium sp.

Sandflies Phlebotomus sp. Leishmania sp. Leishmaniasis

Bartonella sp. Oroya fever
Phlebovirus Sandfly fever

Blackflies Simulium damnosum Oncocerca volvulus Onchocrciasis

Tsetseflies Glossina sp. Trypanosoma sp. HAT
Deerflies Chrysops sp. Loa loa Loiasis
Biting midges Culicoides sp. Mansonella sp. Filariasis

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Tungiasis
• Tungiasis is an inflammatory skin disease caused by infection
with the female Tunga penetrans.
• Also known as; Jigger flea, Sand flea, Funza, Ndutu, Dudu or
Chigoe.
• First case described in 1526 in Haiti then spread to Africa thr’
shipping expeditions in 17th & 19th centuries.
• Found in the tropical parts of Africa, the Caribbean, Central &
South America, and India.

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Epidemiology
• Kenya - 4% total popn suffer from jigger infestation
• Highest prevalence rates - Central, Nyanza, Western, Coast & Rift
valley
• Most at risk population cohorts; children 5-14 yrs, the elderly, and
physically & mentally disabled persons in the affected areas, approx
10M Kenyans (MOH, 2013).
• Humans act as both biological vectors and definitive hosts.
• Other reservoir hosts include chickens, pigs, dogs, cats and rats.

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Etiology / Risk Factors
• Tunga penetrans
• Poor hygiene
• Travel to endemic areas
• Walking barefeet

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Clinical Features
• Severe pruritus
• Pain
• Inflammation and swelling
• Lesions and ulcerations, with black dots in the center
• Secondary infxns - bacteremia, tetanus & gangrene

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MANAGEMENT
• Surgical extraction of the fleas followed by the application of a topical
antibiotic.
• Dress the sore appropriately then admin tetanus vaccination.
• The T. penetrans flea can also be suffocated using occlusive
petrolatum / Vaseline.
• Pharmacotherapy - no proven effective drug but topical Ivermectin,
thiabendazole and metrifonate are in use.
• Pain management.

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Scabies
• A transmissible ectoparasite infection, caused by the mite Sarcoptes
scabiei var hominis .
• The impregnated female mite tunnels into the stratum corneum and
deposits her eggs along the burrow.
• The female mite burrows through the skin, leaving behind a trail of
debris, eggs, and feces.
• The larvae hatch within a few days.
• Induces an intensely itchy allergic response

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SCABIES (Sarcoptes scabei) Symptoms
Clinical findings result from hypersensitivity and irritation to the mite and mite
products.
• Itching
• Worse when warm or hot bath
• Particularly at night
• May interfere with sleep
• Family history (other family members complain of itching)

• A delayed hypersensitivity reaction (an intensely itching papular eruption) is

characteristic beginning 30 - 40 days after the infestation is acquired.

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Typical distribution of inflammatory papules
in adults.
• .

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Scabies Dx/ Tx

• Diagnosis
• History and typical clinical features
• Extraction of a mite
• The black dot at end of burrow

• Treatment
• gamma benzene hexachloride
• benzyl benzoate emulsion
• permethrin
• Ivermectin
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 REFERENCES
• Sherri’s Medical Microbiology 7th edition
• Medscape
• www.cdc.gov

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 THANK YOU!

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