Luminal Flagellates

(Intestinal, Urogenital & Oral)

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 Classification of Luminal Flagellates

Flagellates

Luminal Flagellates
Blood & Tissue Flagellates

Intestinal Urogenital Oral Leishmania Trypanosoma

G. lamblia T. vaginalis T. tenax

T. hominis
 General characteristics of Luminal Flagellates

• Usually posses 2-6 flagella ( 8 flagella)

• Inhabit the intestinal, urogenital and oral cavity

• Direct life cycle/no biological vector

• All have trophozoites & cyst stage except the

Trichomonas species

• All are commensals/non-pathogenic/ except G.

lamblia & T. vaginalis

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 Important Terms Used In Relation To Flagellates
• Flagellum:
– An elongated hair-like organelle used for locomotion.
– At ultrastructure level it reveals one pair of central
tubules and nine pairs of peripheral tubules.
• Undulating membrane:
– Is a membranous structure which connects the
flagellum to the body of the parasite.
– It is thrown into folds as the parasite moves, giving
itan undulating appearance.
• Costa:
– A cytoplasmic thickening seen at the base of the
undulating membrane in some flagellates
• Axostyle:
– A central supporting rod seen in some flagellates.
• Axoneme:
– A delicate filament extending from the region of the
kinetoplast to the cell membrane.
– It represents the cytoplasmic part of the flagellum.
Giardia lamblia
 Introduction to Giardia lamblia
• It is the only intestinal flagellate known to cause
endemic & epidemic diarrhea.

• It was initially named Cercomonas intestinalis by

Lambl in 1859 and

• Renamed Giardia lamblia by Stiles in 1915, in honor

of Professor A. Giard of Paris and Dr. F. Lambl of
Prague.
 Introduction to …….
• Synonyms:
 Lamblia intestinalis
 Giardia duodenalis

• History of diagnosis
 First cultured in 1960’s
 Confirmed as pathogen 1970’s

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 Morphology of G. lamblia
1. Cyst
– Infective stage in the environment

– Persist in cold water up to several months

– Egg-shaped, 8-14 x 7-10µm

– Organelle duplication with out cytokinesis results

in four nuclei

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 Morphology ……
2. Trophozoite
– Cannot survive in the environment

– It is motile with 4 pairs of flagella

– It is Pear shaped, or tear-drop shape with

bilateral symmetry when viewed from the top

– Relatively flattened, 10-12µm long & 5-7µm wide

– It has a large sucking disk on the anterior ventral

side

– It has two nuclei

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 Trophozoites
• Have
– 2 nuclei & each nucleus contains a prominent karyosome, giving the
parasite its characteristic face-like appearance.
– 4 pairs of flagella,
– an axostyle (a microtubule-containing organelle to which the
flagella attach & support troph),
• Axostyle made up of two axonemes, defined as the interior portions of
the flagella.
– a ventral disk and
– 2 median bodies:- slightly curved rod-like structures, it is
believed to be associated with energy, metabolism, or support.
• Giardia is an aerotolerant anaerobe that metabolizes glucose and
scavenges cholesterol, phospholipids, purines, pyrimidines and
amino acids.
• Giardia does not contain classical mitochondria but does make ATP
in double-membraned organelles called mitosomes, which may
 Trophozoites
• G. intestinalis trophozoite has four pairs of flagella.
– One pair of flagella originates from the anterior end and one
pair extends from the posterior end.
– The remaining two pairs of flagella are located laterally,
extending from the axonemes in the center of the body.
• The G. intestinalis trophozoite is equipped with a sucking
disc, covering 50% to 75% of the ventral surface., the
sucking disk serves as the nourishment point of entry by
attaching to the intestinal villi of an infected human.
 Trophozoites
• Cysts, which are slightly smaller than trophozoites, have
a carbohydrate-rich cell wall which protects them from
the environment and two to four nuclei.
• The cytoplasm is often retracted away from the cyst wall,
creating a clearing zone.
• This phenomenon is especially possible after being
preserved in formalin.
• The immature cyst contains two nuclei and two median
bodies.
• Four nuclei, which may be seen in iodine wet
preparations as well as on permanent stains, and four
median bodies are present in the fully mature cysts.
 Habitat of G. lamblia

• It inhabits in small intestine mainly in the

duodenum & upper jejunum
 Epidemiology of G. lamblia
• G. lamblia has ww distribution, common in the
tropics & subtropics including Ethiopia.

• It is acquired through drinking contaminated water,

eating uncooked vegetables/fruits, or person-to-
person by faecal-oral route.

• The cyst stage is resistant to chlorine used in water

treatment facilities.

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 Life Cycle of Giardia lamblia
• It is simple & completed in a single host, the man

Infective form: Large intestine:

Cysts encyst

Ingestion: Faeco-
oral Steatorrhoea

Stomach: Resist Mucus Diarrhoea

acid

Small Intestine: Abnormal villous

excyst architecture

Binds to mucosa by
ventral sucking disc No invasion
Life Cycle …..
 Pathogenesis of Giardia lamblia
• Infection occurs by the ingestion of cysts in contaminated water,
food, or by the fecal-oral route (hands or fomites).

• Cysts pass through the stomach & excyst to trophozoites in the

duodenum within 30 minutes of ingestion, inhabits in the
duodenum & upper ileum.

• The trophozoites may remain attached to the intestinal mucosa.

• As few as 10-25 cysts can cause giardiasis

 Pathology
• Trops. attach (via their sucking disk) to microvilli of
epithelium in small intestine, causing epithelial damage
and interfering with gut transport processes.
• Epithelial mucus is thinned, lymphocytes and other
inflammatory cells infiltrate, physical blocking of
absorption may occur, and enterobacteria may
proliferate, causing more epithelial damage.
•
• There is shortening of microvilli & elongation of crypts
which result Villus blunting
• The brush border of the absorptive cells are damaged
which induces mal-absorption of fats.
 Clinical Features of Giardia lamblia
• IP .... 5 - 6 days & usually lasts 1 -3 weeks
• Clinical manifestations vary from asymptomatic carrier to severe
diarrhoea & malabsorption of fat & carbohydrates, with no clear
mechanism.
• Symptoms include profuse & watery to semi-solid, greasy,
bulky & foul- smelling diarrhea; abdominal cramps; nausea;
vomiting; anorexia; low-grade fever, bloating, flu-like
headache, general malaise, weakness, weight loss, and
flatulence can occur.
• In some patients, the infection progress to a chronic disease with
recurrent symptoms & debilitation may occur.
• The condition frequently is associated with malnutrition and
stunted growth in pre-school children.
 Clinical Features of Giardia lamblia

– The pathogenic mechanisms may be

• mechanical blockage of the intestinal mucosa,
• competition for nutrients, or
• inflammation of the intestinal mucosa, or
 Laboratory Diagnosis of Giardia lamblia
1. Fecal examination
– It is diagnosed by the identification of cysts or
trophozoites in the feces,
• Using direct wet mount or concentration
procedures.
• Motile trophozoites are demonstrated in the direct
wet mount as falling leaf motility
• The cysts are demonstrated in the semi-formed
stool.
 Diagnosis….
• Fecal examination……
– The stool specimens are examined either fresh

– In case of delay, preserve by formalin or polyvinyl alcohol,

& subsequent staining by trichrome or iron-haematoxylin
method.

– Concentration of stool by formalin-either or zinc sulphate

method increase the yield of parasites.

– In chronic giardiasis cysts often are excreted intermittently.

• Hence examination of at least three stool specimens

collected at an interval of 2 days, helps in the detection
of parasites.
 Diagnosis……
2. Duodenal contents
– Microscope examination of duodenal contents,

– when the repeated stool examination is negative but

giardiasis is still suspected.

– String test or Entero test method is used in collecting

duodenal contents
 String test or Entero test
• It is a gelatin capsule which contains a nylon string at one end.

• The capsule is swallowed by the patient and the free end of the
string is fixed at the mouth.

• In the stomach, the capsule is dissolved & the string remains in

duodenum and jejunum.

• After overnight incubation (4 to 8 hours ), the string is removed,

• The bile-stained mucous on the end of the string is collected on

the glass side & examined microscopically by wet mount or
permanent staining for trophozoites.
 Treatment of Giardia lamblia
• Patients & carriers:
– Metronidazole /
– Tinidazole

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 Prevention of Giardia lamblia
• Personal hygien
• Health education
• Avoid food & water contamination
• Insect vector control (fly, cockroach)
• Drink safe water
• Chlorination of water is not adequate to kill the cysts.
• Main prevention is filtering (<1µm pore) or boiling.

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Trichomonas species

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 Introduction to Trichomonas species
• A group of flagellated protozoa that infect humans &
animal.

• There are 3 species of trichomonads found in human.

1. T. hominis: inhabit in large intestine & non-

pathogenic.

2. T. tenax: inhabit oral cavity & it is commensal

3. T. vaginalis: inhabit urogenital tract & it is

pathogenic flagellate

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central skeletal rod
or axostyle
Trichomonas vaginalis
 1. Introduction to T. vaginalis
• It is the most common pathogenic flagellate of
humans.

• The parasite is first described from purulent vaginal

discharge in 1836

• It causes trichomoniasis.
 2. General Characteristics of T. vaginalis

– Inhabit the urogenital tract of male & female

– Has only trophozoite stage

– Most frequent STD pathogen

– Reproduce by longitudinal binary fission

 3. Morphology of T. vaginalis
• Size: 15-25 X 5-12m, is the largest Trichomonas.
• Shape: pear-shaped organism with a central nucleus
• Motility: Jerky (on-spot), non-directional in fresh
specimen

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 Morphology .......
• Flagella: 4 anterior flagella & a fifth single lateral
flagellum attached to pellicle form the outer edge of a
short undulating membrane.

• Undulating membrane extends about two-thirds of its

length.

• The inner margin of this membrane is supported by a

filament.

• There is also a central skeletal rod or axostyle.

• The cytoplasm contains a large numbers of

hydrogenosomes & sometimes viral particles. 36
 4. Habitat of T. vaginalis
• Trichomonas vaginalis only exists in trophozoite
stage
• Trophozoite inhabit
– The vagina of female,
– The prostate & seminal vesicles in male and
– Urethra in both sexes.

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 5. Epidemiology of T. vaginalis
• This parasite has ww distribution.

• Trophozoite is the infective form of the parasite.

• Transmission:
– Sexual intercourse,

– Non-sexual contact possibly by babies during

passage through an infected birth canal, and fomites
(toilet articles, clothing),

– This transmission is limited by liability of the

trophozoite. 38
• Trophozoite of T. vaginalis is facultative anaerobic

• The optimum pH range for the organism to reproduce

is approximately 5 or 6.

• While the normal pH of the vagina is 4 to 4.5, when

the level of acidity is disturbed, an environment is
created in which T. vaginalis thrives.

• Normally, the pH of the vagina is maintained by the

activity of a group of lactic acid-producing bacteria,
but T. vaginalis can disrupt such bacteria, causing
the pH to rise above 4.9.
6. Life cycle of T. vaginalis
 Life Cycle....
• Life cycle of Trichomonas vaginalis is simple.

• It is completed in a single host either male or female.

• T. vaginalis replicates by binary fission.

• The parasite does not appear to have a cyst form, &

does not survive well in the external environment.

• T. vaginalis is transmitted among humans, its only

known host, primarily by sexual intercourse.
 7. Pathologenesis of T. vaginalis
• It is an obligate parasite which cannot live without the
host tissues.

• It causes degeneration & desquamation of the vaginal

epithelium through contact-dependent damage.

• Sometimes, it is associated with small blisters or

granules.

• The mucosa & superficial submucosa are infiltrated by

lymphocytes, plasma cells & polymorphonuclear
leucocytes.
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 8. Clinical symptoms of T. vaginalis
• In males:
– symptomless or may be responsible for an irritating,
persistent or recurring urethritis.

• In females:
– It ranges from asymptomatic to mild or moderate
irritation, to extreme vaginitis

– or have a scanty, watery vaginal discharge, but can be

yellow or green & occasionally blood tinged (50-
75% )

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Clinical manifestations

Females Males

 Asymptomatic (15-20%*)  Asymptomatic (50-90%*)

 Vaginal discharge (50-  Urethral discharge (50-
75%*) 60%**)
 Dyspareunia (50%*)  Dysuria (12-25%**)
 Pruritus (25-50%*)  Urethral pruritus (25%**)

*% Of infected; **% of symptomatic

 Clinical symptoms .......
• Symptomatic cases develop
– Painful urination (dysuria),
– Profuse odorous (foul-smelling) discharge,
– Itching (25-50%)
– Dyspareunia (50%)
– Frequency of urination.
– Vaginal erythema,:‘strawberry cervix’ (~2%)

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 8. Laboratory diagnosis of T. vaginalis
• Specimen:
– In females:
• wet preparations of vaginal discharge collected
using speculum
– In males:
• wet preparations of prostatic secretions or following
massage of the prostate gland.
– Both sex: Urethral discharge, urine sediment

– Contamination of the specimen with feces may confuse

T. hominis.

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1. Microscopy

• Finding the trophozoites in unstained (wet

mounts) or stained preparation

• Giemsa, field stained or Acridine orange stained

• It is identified by its characteristic jerky motility in

wet mounts.

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 9. Treatment of T.vaginalis

• Metronidazole cures 95% of cases

• If resistant cases occur, re-treatment with higher doses

is required.

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 10. Prevention of T.vaginalis
1. Detection & treatment of cases.

– Simultaneous treatment of partner! (85-90% cure

rate)

2. Practice sexual abstinence, or limit sexual contact to

one uninfected partner.

3. Avoidance of sexual contact with infected partners

4. Use of condoms.

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Trichomonas tenax
 Trichomonas tenax
• Habitate:
– Crevices of the gingiva, the gum tissue that surrounds
the neck of the teeth.
– The T. tenax organism is considered a harmless
commensal and is frequently found in the tartar
(plaque) that has hardened around the teeth.
• Morphology:
– Trophozoites are very small (5-16 mm by 2-15 mm),
– Has 4 free flagella & a 5th flagellum re-curved as an
undulating membrane that extends about two-thirds of
the length of the cell.
 Trichomonas tenax……
• Transmission:
– it is by direct contact, usually kissing or using
contaminated eating utensils.

– Drinking contaminated water from a community source

since this flagellate can live in drinking water for several
hours.

• Symptoms
• Generalized inflammation may occur &

• It is most prevalent in smokers & those with poor dental

hygiene.

• The condition is predominantly asymptomatic, however.

 Trichomonas tenax……
• Laboratory Diagnosis
• Direct observation of motile trophozoites in
• wet preps,
• hanging drop suspensions, &
• surgically obtained gum scrapings.
 Trichomonas tenax……
• Treatment
– The parasite is considered to be a nonpathogenic.

• Therefore, no medication is generally prescribed

for the condition.

• Prevention:

– It can be avoided through proper oral hygiene.

Pentatrichomonas (Trichomonas) hominis
 Pentatrichomonas (Trichomonas) hominis

• Habitat:- intestine

• Commensal:- must differentiate from pathogens.

• Transmission:- direct person-to-person; fecal-oral

transmission; no cyst stage.

• Morphology:- exhibits a unstable, jerky motility.

– Must differentiate from T. vaginalis:- in instances

where feces is contaminated with urine.
Dientamoeba fragilis
 Introduction to Dientamoeba fragilis
• Despite its name, Dientamoeba fragilis is not an ameba but an
intestinal flagellate, most closely related to trichomonads.

• Historically Dientamoeba has been considered as a non-

pathogenic commensal.

• However, clinical symptoms often correlate with the presence

of large numbers of trophozoites and treatment of the infection
resolves the symptoms. .
 Introduction .....

• In human stool specimens, D. fragilis is almost always

found solely as a trophozoite.

• However, the rare presence of putative cyst & precyst

forms in clinical specimens has been reported; their
transmission potential is being investigated.

• Other aspects of the transmission & pathogenicity of D.

fragilis also are poorly understood
 Epidemiology of Dientamoeba
• Geographic Distribution
– Dientamoeba fragilis is found worldwide. Infection
appears to be more common

• Hosts
– Dientamoeba fragilis is primarily a parasite of
humans.
– Trophozoites have been identified in some other
mammals (e.g., non-human primates, swine), but the
epidemiologic significance of these hosts is unknown.
• Transmission
– As other trichomonads, Dientamoeba only exhibits a
trophozoite stage.
– This raises some questions about the mode of transmission
in that a cyst stage is usually involved in fecal oral
transmission.
– In addition, the trophozoites of Dientamoeba survive
outside of the body for a very short time.
– It is proposed that Dientamoeba is transmitted via helminth
eggs.
– Epidemiological & experimental evidence tends to
incriminate the pinworm E. vermicularis as the carrier
for Dientamoeba.
 Pathogenesis of Dientamoeba
• Little is known about the pathogenesis &

• It probably acts as a low-grade irritant of intestinal mucosal

surfaces that may lead to some inflammation.
Life Cycle
 Clinical Presentation

• Both asymptomatic and symptomatic infection have been

reported.

• The reported clinical manifestations have sometimes been

described as similar to those of colitis, appendicitis, or irritable
bowel syndrome, intermittent diarrhea, abdominal pain,
flatulence, nausea and fatigue.
 Treatment
• Iodoquinol is generally the drug of choice for the treatment
of Dientamoeba.

• Paromomycin & metronidazole are also effective.