Introduction to Parasitology

The basics are just the beginning

Marc Roger Couturier Ph.D., D(ABMM) Blaine A. Mathison B.S., M(ASCP)

Medical Director, Parasitology – ARUP Laboratories Research and Development Scientist, Parasitology Specialist – ARUP Laboratories
Professor of Pathology – University of Utah Adjunct Instructor – University of Utah

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 Objectives for Learning
Understand parasite diversity/taxonomy

Recognize clinically relevant parasites found in humans and

how to test for them

Understand the impact and role of parasites in human health

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 Parasitology Structure
• Basic overview of all sites
• Focus on:
» Brain/Central nervous system
» Skin/Soft tissue
» Lungs
» Liver
» GU
» Blood (See separate video)

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 What is a parasite?

An organism that derives a survival benefit from a host at the expense of the host.

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 Key Concepts in Parasitism
• Definitive Host –where sexual maturity and reproduction occur for
completion of transmission cycles
• Intermediate Host – where asexual or developmental stages occur (e.g.
larvae development, excystation, etc). Not competent for development to
final lifecycle stages
• Paratenic Host – a host which harbors an immature stage but no further
development of the parasite occurs; used for further transmission
• Reservoir Host – a primary host that maintains a parasite in nature
• Dead-end or Accidental Host – where various levels of parasite life cycle
can occur, but the parasite cannot complete the entire life cycle and fails to
perpetuate gametes/fully mature.

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 Broad (Medical) Classification of Parasites
• Helminth – worm
» Flatworms – Platyhelminths (only 2 parasitic classes)
▪ Cestoda – tapeworms
▪ Trematoda – flukes Taenia

» Roundworms – Nematoda

Paragonimus
Ascaris

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 Broad (Medical) Classification of Parasites
• Protozoa – unicellular eukaryotic free-living or parasitic organisms
» Ameba
» Coccidia
» Flagellates
» Ciliates
» Stramenopiles
Entamoeba Giardia Cyclospora Balantioides

» Microsporidia*

* Fungi, not protozoa

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 Broad (Medical) Classification of Parasites
• Arthropods –eukaryotic free-living or parasitic organisms
» Mites
» Lice
» Fleas Scabies mites
» Ticks
» Fly larvae (myiasis)
» True bugs
Pubic louse

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 Diagnostics
• Specimen dependent/organism dependent
» Each organism discussed in more detail within body systems
• Broad types of tests include:
» Stool parasite examinations
» Body fluid parasite examinations and cytology
» Histopathology of tissue
» Antigen detection
» Antibody detection (serology)
» Nucleic acid amplification tests (NAAT)
» Culture (very limited use)

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 Diagnostics - Microscopy
• Stool examination
» Wet mount and permanent stain (trichrome)
» Other special stains

• Body fluid examination

» Aspirates

• Tissue
» H&E stains

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 Diagnostics – Antigen detection
• Detection of antigen (immuno-stimulatory component) from a
parasite in a patient specimen

• Variable in performance and specimen types

» Blood & stool

• Rapid time to result

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 Diagnostics – Antibody detection
• Detection of antibody from a patient that recognizes antigen(s) from
a parasite

• Variable in performance and specimen types

» Serum and CSF

• Moderate time to result, limited availability

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 Diagnostics – NAAT
• Detection of nucleic acid from a parasite in a patient specimen

• Variable in specimen types, excellent specificity

» Sensitivity depends on organism and biology

• Long time to result for rare parasites, limited availability

» Stool parasites can be faster and readily available

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 Diagnostics – Culture
• Limited utility in parasitology

• Insensitive

• Not routinely performed in most labs

• Can be biosafety risk

Acanthamoeba in culture

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 Organ Systems
• Brain/Central nervous system
• Skin/Soft tissue
• Lungs
• Liver
• GU

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 Parasites of the Brain/Central Nervous
System

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 Toxoplasmosis (Toxoplasma gondii)
• Caused by apicomplexan parasite, Toxoplasma gondii
• Transmission occurs via:
» Eating undercooked meat of animals harboring tissue cysts
» Food, water, fomites contaminated with cat feces containing infectious
oocysts
▪ Contaminated soil or changing cat litter box
» Blood transfusion
» Organ transplantation
» Transplacentally from mother to fetus.

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 Toxoplasmosis (Toxoplasma gondii)
• Cats are definitive hosts
• Humans are dead-end hosts

Tachyzoites in brain tissue

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 Toxoplasmosis (Toxoplasma gondii)
• Common sites of human infection are skeletal
muscle, myocardium, brain, eyes.
• Symptoms
» Acute disease often asymptomatic; cervical
lymphadenopathy and flu-like illness
» Immunodeficient patients will have localized
symptoms based on body site
» Ocular disease: vision loss
Peripheral
» AIDS patients: toxoplasmic encephalitis. retinochoroiditis

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 Toxoplasmosis (Toxoplasma gondii)
• Diagnosis is primarily by serology (IFA, IgG/IgM
EIA); PCR of aspirates; tissue cysts & tachyzoites
may be observed in biopsy specimens & aspirates.
» Radiologic findings of: “ring enhancing lesions”
▪ Not specific to toxoplasmosis, but supports serology

• Treatment: pyrimethamine, folinic acid

(leucovorin), & sulfadiazine in
immunocompromised patients & congenitally- CT Scan showing ring
infected newborns. enhancing lesions

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 Primary Amebic Meningoencephalitis (PAM)
• Caused by the free-living ameba, Naegleria fowleri
• Not a “true parasite”: human infection is incidental & most cases fatal.
Part of natural fauna of warm, fresh water.
• Route of infection is through the nasal mucosa
• Typically in children, teens, and young adults
• Symptoms
» Hemorrhagic-necrotizing meningoencephalitis
-> severe CNS dysfunction
» Rapid onset
» High case-fatality rate

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 Life Cycle of
Naegleria fowleri
• Cyst: environmentally
hardy stage

• Trophozoite:
replication and
feeding

Trophozoites in CSF

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 Primary Amebic Meningoencephalitis (PAM)

• Diagnosis usually made on autopsy by histopathology examination of

brain tissue
» Observation of live trophozoites in fresh wet mount of CSF; confirm with
Giemsa, trichrome
» PCR of CSF (CDC, large reference labs)
» Culture [delay issues]

• Treatment: Miltefosine + medically controlled hypothermia

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 Granulomatous Amebic Encephalitis (GAE)

• Caused by free-living amebae Balamuthia mandrillaris &

Acanthamoeba spp.
• Not ‘true parasites’; part of normal soil and water fauna.
Humans are accidental hosts.
• Route of infection: lower respiratory tract or ulcerated
or broken skin.
» Acanthamoeba species can also enter the eye, causing
amebic keratitis (AK)
• Symptoms
» Meningoencephalitis/encephalitis
» More chronic than PAM

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 Life Cycle of Acanthamoeba/Balamuthia

Balamuthia in brain tissue, H&E stain

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 Granulomatous Amebic Encephalitis (GAE)

• More commonly seen in immunocompromised patients

• Diagnosis usually made on autopsy by histopathology examination of

brain tissue
» Giemsa and calcofluor white stain of specimens
» Culture
» PCR (CDC, large reference labs)

• Treatment: None. Most cases are fatal

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 Free-living Amebic Infections
Primary Amebic Granulomatous Amebic Encephalitis
Meningoencephalitis
Causal Agent(s) Naegleria fowleri Acanthamoeba spp., Balamuthia mandrillaris
Source of Infection Inhalation when water forced into Inhalation to lower respiratory tract; cuts and abrasions
nasal cavity
Route to brain Olfactory nerve Hematogenous
Risk groups Children, teens, young adults Usually immunocompromised
Diagnosis Wet mounts/Giemsa stain, PCR, Giemsa/Calcoflour white stains; PCR; histopathology;
histopathology, [culture] [culture]
Stage(s) in human tissue Trophozoites only Trophozoites, cysts
Treatment Amphotericin B, Mitefosine + Combos of pentamidine, sulfadiazine, flucytosine, AND
therapeutic hypothermia fluconazole or itraconaconazole (Acanthamoeba) or
azithromycin or clarithromycin (Balamuthia)

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 Neurocysticercosis
• Caused by the larval stage (cysticercus) of Taenia
solium (the ‘pork’ tapeworm).
» Latin America, SE Asia
• Acquired: eating T. solium eggs in food, fomites
contaminated with human stool.
• Clinical manifestations: vary by number, size, & state of
cysticerci & inflammatory response to degenerating
cysts.
» Epilepsy most-common manifestation, also intracranial
hypertension, hydrocephalus, chronic meningitis, & cranial
nerve abnormalities

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 Life Cycle of Taenia solium

Degrading cysticercus in brain biopsy

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 Neurocysticercosis
• Diagnosis primarily by imaging, confirmed w/ antibody detection
» EIA for initial screening
» CDC immunoblot recommended by WHO & PAHO for confirmation

• Larval worms may be seen in biopsy specimens, but undesirable to biopsy

the brain

• Treatment: control of symptoms; antihelminthic therapy might increase

symptoms!
» Corticosteroids usually co-administered to combat these effects.
» Albendazole may be better than praziquantel; combined
albendazole/praziquantel with corticosteroids if >2 active parenchymal cysts

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 Angiostrongyliasis
• Caused by the nematode, Angiostrongylus cantonensis.
» Human infection in Asia/South Pacific; Africa, Latin America,
Caribbean, Hawaii
• Natural definitive hosts are rats; intermediate hosts are
mollusks
• Human infection: ingesting raw or undercooked snails and
slugs containing infectious (third stage, L3) larvae
• Clinical symptoms: bi-temporal headache, nausea,
vomiting, stiff neck, & eosinophilic pleocytosis of the CSF
» Symptoms related to death of larvae in brain and directly
proportional to parasite load

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 Life Cycle of Angiostrongylus
cantonensis

L4/young adult in brain autopsy

specimen

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 Angiostrongyliasis
• Diagnosis:
» PCR (CDC, HI DOH)
» Observations of L4 larvae in CSF or brain biopsy/autopsy specimens
» Antibody detection not available in the US

• Treatment usually limited to analgesics for pain and corticosteroids

for inflammation; removal of CSF to relieve headache and pressure

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 Parasites of the Skin and Soft tissue

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 Leishmaniasis
• Caused by hemoflagellate protozoa, Leishmania
• Infect many mammals
» 21 of 30 known species infect humans
• Vectored to humans by the phlebotomine sand fly
• Geographically dispersed:
» Tropic/sub-tropics
▪ C. & S. America
▪ Africa
▪ Asia
▪ Middle East
▪ S. Europe

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 Leishmaniasis
• Clinical manifestations
» Cutaneous (pizza lesion)
▪ Painless or painful
» Mucocutaneous
▪ Disemination of cutaneous
» Visceral (kala-azar)
▪ Fever, weight loss, hepatosplenomegaly
▪ Anemia
▪ Thrombocytopenia
▪ Leukopenia

• Different species w/ different

clinical manifestations

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 Leishmaniasis
• Diagnosis:
» Histopathologic examination of tissue
(biopsy, aspirate)
» Serology
» PCR
H&E stained skin biopsy

• Treatment:
» Pentavalent antimony (investigational from CDC)
» Liposomal amphotericin B (visceral only)
» Miltefosine (cutaneous, mucocutaneous, visceral)

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 Trichinellosis
• Caused by nematode,Trichinella

• Acquired: ingestion of undercooked meat

containing encysted larvae

• Geographically dispersed:
» Worldwide with bias towards
▪ Europe
▪ N. America

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 Trichinellosis
• Symptoms: Encysted larvae in muscle H&E stain
» May be asymptomatic
» Initially GI: diarrhea, cramping, emesis
» >1 Week: Muscle invasion
▪ Periorbital & facial edema
▪ Fever, myalgias, rashes
▪ Peripheral eosinophilia
» Larvae encyst in muscle: myalgia & weakness →
cessation of symptoms
• Diagnosis:
» Social history
» Serology
» Tissue stain & microscopy

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 Onchoceriasis
• Caused by the nematode Onchocerca volvulus
• Acquired via the bite of Simulium (black fly)
• Geographically constrained:
» Africa (Sub-Saharan)
» Latin America (focal)
» Middle East (Yemen)

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 Onchoceriasis
• Symptoms:
» Most symptoms are result of inflammatory reactions to dead or dying worms
▪ Itchy skin rash
▪ Subcutaneous nodules
▪ Vision change
» Continued inflammation of cornea and optic nerve results in blindness
▪ River blindness
• Diagnosis: skin snip and histology
• Treatment:
» Ivermectin

[Link]

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 Scabies
• Sarcoptes scabiei (itch mite)
• Acquired by direct contact with mite infected surfaces
• Symptoms: Severe pruritius serpiginous burrows
» Common between digits and behind large joints
• Geographically distributed worldwide
» Low socioeconomic status
» Institutional settings
• Diagnosis: macroscopic identification of mite
• Treatment:
» Permethrin (human)
» Cleaning (environment)

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 Lice
• Pediculus humanus (head and body louse)
• Pthirus pubis (pubic louse)
• Symptoms: Itching of infected site
» Can transmit serious human diseases Pubic louse Head louse
▪ Epidemic typhus, relapsing fever, trench fever

• Diagnosis: macroscopic identification of louse

• Treatment:
» Ivermectin lotion (human)
» Nit combing (human)
» Environmental cleaning

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 Parasites of Lung and Liver

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 Paragonimiasis
• Caused by lung flukes in the genus Paragonimus.
» Paragonimus westermanni & P. heterotremus in
southeast Asia
» Paragonimus kellicotti in the United States.
• Infections occur from the ingestion of raw or
undercooked freshwater crustaceans.
• Symptoms:
» Acute: diarrhea, abdominal pain, fever, cough, urticaria,
eosinophilia
» Chronic: cough, expectoration of discolored sputum
(“iron fillings”), hemoptysis
‘crab martini’

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 Life Cycle of Paragonimus spp.

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 Paragonimiasis
• Diagnosis
» morphology
(eggs in respiratory specimens & stool)
» Serology

• Treatment: praziquantel

Eggs of Paragonimus in respiratory specimen

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 Echinococcosis
• Caused by cestodes in the genus Echinococcus.
» Echinococcus granulosus (complex) – cystic echinococcosis
» Echinococcus multilocularis - alveolar echinococcosis
• Infection caused by the ingestion of tapeworm eggs in food and
fomites contaminated with dog feces.
• Parasites cannot mature in human host (humans are dead-end hosts)
• Symptoms:
» Cystic: dependent on size, number, and location of cysts (hepatic,
pulmonary most common)
▪ Cyst rupture: anaphylaxis, urticarial, eosinophilia
» Alveolar: slow-growing, destructive tumor; abdominal pain and biliary
obstruction (high case fatality rate untreated).

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 Life Cycle of Echinococcus granulosus

Protoscoleces in ‘hydatid sand’ in

liver aspirate

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 Echinococcosis
• Diagnosis
» Imaging (CT, MRI)
» Antibody detection
» Morphology (e.g. hydatid sand in aspirates)

• Treatment:
» Albdendazole (praziquantel preoperative)
CT image of hepatic hydatid cyst
» Surgical removal of cyst (as indicated)
» PAIR (percutaneous aspiration, injection, reaspiration)
» Nothing (as indicated)

50 Korean J Radiol. 2007 Nov-Dec; 8(6): 531–540.

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 Visceral Larval Migrans
• Caused by larvae of nematodes of animals:
» Toxocara canis & T. cati (dogs and cats)
» Baylisascaris procyonis (raccoons) [predilection for CNS]
• Humans ingest fully-embryonated eggs
» Soil, food, & on fomites contaminated with feces of natural definitive
host or eating paratenic hosts.
• Humans are dead-end hosts
• Symptoms: fever, myalgia, weight loss, cough, rashes,
hepatosplenomegaly, hypereosinophilia
» Eosinophilic meningoencephalitis uncommon
» Ocular – uveitis, retinitis, endophthalmitis

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 Life Cycle of Toxocara spp.

Cross sections of larvae in liver

biopsy

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 Visceral Larval Migrans
• Diagnosis: antibody detection

• Treatment:
» Visceral: albendazole or mebendazole with steroids
» Ocular: albendazole or mebendazole with topical steroids

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 Clonorchiasis/Opisthorchiasis

• Caused by liver flukes Opisthorchis viverrini, O. felineus,

and Clonorchis sinensis (Chinese liver fluke).
» Clonorchis: parts of Asia incl. China, Japan, Korea, Taiwan, &
Vietnam.
» Opisthorchis viverrini: mainly in NE Thailand & Laos
» O. felineus: Eastern Europe and Russia.

• Infection: ingestion of raw or undercooked fish

‘koi ‘ – raw fish dish eaten in
containing metacercariae. Laos and Thailand

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 Life Cycle of Clonorchis sinensis

Egg in wet mount of stool

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 Clonorchiasis/Opisthorchiasis
• Symptoms related to worm burden
» Inflammation, intermittent obstruction of biliary ducts; abdominal
pain (RUQ)
» Toxicity (metabolic products of worms), secondary bacterial
infections
» Leading cause of cholangiocarcinoma; also cholangitis,
cholecystitis, pancreatitis.
• Diagnosis: detection of eggs in feces.
• Treatment: praziquantel

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 Parasites of Genitourinary tract

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 Trichomoniasis
• Caused by the protozoa Trichomonis
vaginalis
• Acquired by direct sexual contact with
infected human
• Worldwide distribution
» Increased prevalence among populations
w/multiple sexual partners

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 Trichomoniasis
• Symptoms:
» Women: vaginitis w/purulent discharge
▪ Can lead to adverse pregnancy outcomes
▪ Rarely cervical lesions, abdominal pain, dysuria
» Men: Typically asymptomatic
▪ Rarely urethritis, prostatitis, epididymitis
• Diagnosis:
» NAAT testing (preferred clinically)
» Wet mount exam (obsolescence)
• Treatment: single dose metronidazole

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 Microsporidia
• Obligate intracellular fungal parasites of most animal phyla
» Thought to be ingested
• Most-commonly seen in immunocompromised patients.
» May disseminate

• Numerous species are known to be involved in human infections

• Treatment: Albendazole (for most species)

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 Human Microsporidiosis
CNS microsporidiosis: Ocular microsporidiosis:
E. cuniculi Encephalitozoon spp. (E.
cuniculi, E. hellem, E.
E. intestinalis intestinalis)
Trachipleistophora Vittaforma corneae
anthropopthera
Anncaliia algerae

Skin lesions Disseminated microsporidiosis:

Anncaliia algerae E. hellem
E. cuniculi
E. intestinalis
Gastrointestinal and biliary Trachipleistophora anthropopthera
tract microsporidiosis:
Trachipleistophora hominis
E. bieneusi
Tubulinosema acridophagus
E. intestinalis

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 Microsporidiosis - Diagnosis

• Not readily detected by traditional stool O&P

» Very small & do not retaining trichrome stain
» Require special stains

• PCR and DNA sequencing typically used for species-level

identification
» PCR not practical for routine screening.

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 Microsporidia stained with Modified trichrome

BAL Stool

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 Key Points
• Toxoplasma – cats, congenital infections, & immunocompromised hosts

• Angiostrongylus – eosinophilic meningitis

• Cysticercosis – Caused by the pork tapeworm but not acquired from

eating pork! Brain lesions

• Naegleria – Diving into fresh warm water, rapidly fatal

meningoencephalitis

• Acanthamoeba – brain and cornea infections, often fatal

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 Key Points
• Leishmania – disfiguring lesions, severe visceral form (kala azar)

• Trichinella – undercooked pork/bear, larvae in muscles

• Onchocerca – River Blindness, subcutaneous nodules

• Paragonimus – Iron fillings → hemoptysis, raw crustaceans

• Echinococcus – liver cysts, sheep dog exposures

• Chlonorchis – cholangiocarcinoma, raw fish

• Trichomonas – Vaginitis w/discharge (♀), asymptomatic (♂)

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