INTESTINAL PROTOZO

Dr. Faliha Habeb AL-Karaawy

Intestinal protozoa
unicellular eukaryotic organisms
a. Amebas
b. Flagellates
c. Ciliates
d. Sporozoa

Ameba: Entamoeba histolytica

Flagellates: Giardia lamblia
Entamoeba histolytica

 Causes : Amoebiasis which is spread between humans by

its cysts. It is one of the leading parasitic causes of
morbidity and mortality in the tropics and is occasionally
acquired in non-tropical countries.

 Two nonpathogenic Entamoeba species (E. dispar and E.

moshkovskii) are morphologically identical to E. histolytica,
and are distinguishable only by molecular techniques,
isoenzyme studies or monoclonal antibody typing. However,
only E. histolytica causes amoebic dysentery or liver
abscess.
Geog.Distribution: Parasite has worldwide distribution but is
most common in the tropical and subtropical areas of the world.
Natural Habitat : Mucosa and submucosaof L.I of
human(duodenum)
Infective stage : cyst.
The organism exists both as a motile trophozoite and as a cyst
that can survive outside the body.
Transmission
 Contaminated water.
• Most people in the world don’t have indoor plumbing/running water.
• Get water by ground/surface water.

 Contaminated food.
• human excrement used as fertilizer.
• Defecation in vegetable gardens, fields.
• The practice of humans using their bare hands to clean toilet

 Mechanical contamination.
• Medical Equipment
• Flies, roaches, etc.
• Hand to mouth (finger nails, contaminated objects, toys, etc.)
• Hand to eye (ectopic)
• Hand to open sore (ectopic)
• Anal sex (ectopic)
Morphology
Parasite occurs in three stages; trophozoite, precyst and
cyst
Trophozoite:

1- Its size (12-30 µm), Clear ectoplasm.

2- Large finger – like pseudopodia
3- The endoplasm is granular and may contain RBCs.
4- It has one nucleus, contain small central karyosome and fine
chromatin granules arranged regularly beneath nuclear membrane.
2. pre cyst (immature cyst):

• It is the intermediate stage between trophozoite and cyst

• It is smaller in size; 10-20μ
• It is round or slightly ovoid with blunt pseudopodium
projecting from periphery
• No RBC or food materials are found on its endoplasm.
Cyst (mature cyst):

• Dormant/resistant stage (form in response to unfavorable

(deteriorating) environmental conditions).
• Cysts are susceptible to heat (above 40 C.),freezing (below –
5 C.), and drying.
• Cysts remain viable in moist environment for 1 month.
• 1- Small (10 – 20 µm) , spherical in shape,
• containing 1 - 4 nuclei (4 in mature cysts) is usually found in
feces .
• Bluntly rounded chromatoidal bars
• Found and released in formed feces
Life cycle :
Infection by E. histolytica occurs by ingestion of mature cysts in fecally
contaminated food, water, or hands. Excystation occurs in the small
intestine and trophozoites are released which migrate to the large
intestine. The trophozoites multiply by binary fission and produce cysts,
which are passed in the feces.
Because of the protection conferred by their walls, the cysts can
survive days to-weeks in the external environment and are responsible
for transmission of infection. Trophozoites can also be passed in
diarrheal stools, but are rapidly destroyed once outside the body, and if
ingested rapidly destroyed by gastric juice. In many cases, the
trophozoites remain in intestinal lumen as noninvasive infection of
individuals who are asymptomatic carriers, passing cysts in their stool
only.
In some patients the trophozoites invade the intestinal mucosa and
cause intestinal disease or developed perforated ulcer and the
trophozoites migrate through the blood stream to invade the
extraintestinal organs such as the liver, brain, and lungs and it will
cause amoebic infection in these organs.
Virulence factors:
•i. Cyst wall: cyst wall is resistant to low pH and gastric
juice of stomach.
•ii. Lectin: Surface of trophozoite contains lectin that
is specific to link to (N-acetyl-galactosamine and
galactose sugar) present in surface of intestinal
epithelium.
•iii. Ionophore like protein: It causes leakage of ions
such as Na+, K+, Ca++ from target cells.
•iv. Hydrolytic enzymes: Phosphatase, proteinease,
glycosidase and RNase causes tissue destruction and
necrosis.
•v. Toxin and haemolysin
Pathology
Cysts of E. histolytica are ingested in water or uncooked foods
contaminated by human faeces. Infection may also be
acquired through anal/oral sexual practices. In the colon,
trophozoite forms emerge from the cysts. The parasite
invades the mucous membrane of the large bowel, producing
lesions that are maximal in the caecum but extend to the
anal canal. These are flaskshaped ulcers, varying greatly in
size and surrounded by healthy mucosa. A localised
granuloma (amoeboma), presenting as a palpable mass in
the rectum or a filling defect in the colon on radiography, is a
rare complication that should be differentiated from
carcinoma. Amoebic ulcers may cause severe haemorrhage
but rarely perforate the bowel wall.
Amoebic trophozoites can emerge from the
vegetative cyst from the bowel and be carried to
the liver in a portal venule. They can multiply
rapidly and destroy the liver parenchyma, causing
an abscess. The liquid contents at first have a
characteristic pinkish colour, which may later
change to chocolate-brown (said to resemble
anchovy sauce).
Cutaneous amoebiasis, though rare, causes
progressive genital, perianal or peri-abdominal
surgical wound ulceration.
Clinical features
Intestinal amoebiasis – amoebic dysentery
Most amoebic infections are asymptomatic. The
incubation period of amoebiasis ranges from 2 weeks to
many years, followed by a chronic course with abdominal
pains and two or more unformed stools a day. Offensive
diarrhoea, alternating with constipation, and blood or
mucus in the stool are common. There may be
abdominal pain, especially in the right lower quadrant
(which may mimic acute appendicitis). A dysenteric
presentation with passage of blood, simulating bacillary
dysentery or ulcerative colitis, occurs particularly in older
people, in the puerperium and with super-added
pyogenic infection of the ulcers.
Amoebic liver abscess
The abscess is usually found in the right hepatic lobe. There
may not be associated diarrhoea. Early symptoms may be only
local discomfort and malaise; later, a swinging temperature
and sweating may develop, usually without marked systemic
symptoms or signs. An enlarged, tender liver, cough and pain
in the right shoulder are characteristic but symptoms may
remain vague and signs minimal. A large abscess may
penetrate the diaphragm, rupturing into the lung, and may be
coughed up through a hepatobronchial fistula. Rupture into
the pleural or peritoneal cavity, or rupture of a left lobe
abscess in the pericardial sac, is less common but more
serious
Lab Diagnosis:

Specimen: stool, pus or liver abscesses, sputum and biopsy samples, blood ,
CFS.
in amoebic dysentery stool is offensive, semi-solid, dark brown color and
acidic in nature, mixed with blood, mucus and faecal materials.
 Direct method :
The stool and any exudate should undergo prompt microscopic examination
for motile trophozoites containing red blood cells. Movements cease rapidly as
the stool preparation cools. Several stools may need to be examined in
chronic amoebiasis before cysts are found.
(with iodine and microscopically examined for cysts
with saline and microscopically examined for motile trophozoite)
 Stool culture: Robinson’s medium and NH polyxenic culture medium are
used to culture E. histolytica

 Sigmoidoscopy : may reveal typical flaskshaped ulcers, which should be

scraped and examined immediately for E. histolytica.

 Biopsy : fluid from large intestine aspirates also be examined

microscopically for trophozoites .

 Radiological finding : X-rays, MRI, CT scan, ultrasonography etc for

extra intestinal amoebiasis
 Serology : is very important for the diagnosis of extraintestinal
amoebiasis, serum antibodies are detectable by immunofluorescence
in over 95% of patients with hepatic amoebiasis and intestinal
amoeboma, but in only about 60% of dysenteric amoebiasis.

 PCR test : It is sensitive test, DNA detection by Polymerase Chain

Reaction has been shown to be useful in diagnosis of E. histolytica
infections but is not generally available

 Blood test: blood count, Liver function test, Kidney function test

 Intradermal skin test

Management
 Patients should remain in bed and receive a high protein
and high vitamin with adequate fluids.
 Chemotherapy for sever amoebiasis
 Intestinal and early hepatic amoebiasis responds quickly
to oral metronidazole (800 mg 3 times daily for 5–10
days) or other long-acting nitroimidazoles like tinidazole
or ornidazole (both in doses of 2 g daily for 3 days).
Nitazoxanide (500 mg twice daily for 3 days) is an
alternative drug. Either diloxanide furoate or
paromomycin, in doses of 500 mg orally 3 times daily for
10 days after treatment, should be given to eliminate
luminal cysts.
 If a liver abscess is large or threatens to burst, or if the
response to chemotherapy is not prompt, aspiration is
required and is repeated if necessary. Rupture of an
abscess into the pleural cavity, pericardial sac or
peritoneal cavity necessitates immediate aspiration or
surgical drainage. Small serous effusions resolve without
drainage.
Prevention & Control:
1- All human infections should be treated
2- A symptomatic carriers should be treated especially
those working in restaurants.
3- Effective environmental sanitation is necessary to
prevent water, food, and vegetable contamination, e.g.
Sewage disposal should be treated with chemical before
used as fertilizer in gardens.
4- Chlorination & filtered water supply are important to kill
the cyst of E.histolytica.
5- Insects should be controlled by insecticides.
6- Uncooked vegetables should be washed with running
water.
Giardia lamblia
 Giardia lamblia
Causes : Giardiasis in man especially children.
Geog.Distribution: cosmopolitan.
Habitat : duodenum, upper part of small intestine, bile ducts
and gall bladder as trophozoites attached to the mucosa.
D.H: man R.H: animals
Infective stage : the cyst.
trophozoite : replicative stage in small intestine
Epidemiology: Worldwide in its distribution especially in
chilidren.It is present in Iraq.
Mode of transmission:
 Man is the main reservoir of Giardia.
Infection is acquired due to-
 Ingestion of contaminated food and water
 Person to person transmission due to poor hygiene in
day care centers, nursing homes, mental asylums
 Sexual transmission-oral-anal and oral-genital sex
 Immunocompromised individuals such as AIDS patients,
X-linked gammaglobulinaemia, patients with protein
energy malnutrition are more susceptible for giardiasis
 Giardia lamblia
Morphology of Trophozoite stage (diagnostic stage) :
* Average size 15 X 8 µ
* Pear shaped (broad anteriorly –tapering posteriorly)
* Convex dorsally –flat ventrally with bilobed
anterior concavity (sucking discs) for attachment.
*Motility by 4 pairs of flagellae.
* Two oval nuclei with central karyosome.
* Two axostyle traversing the body
*Two rod-shaped parabasal bodies across the
axostyle diagnostic stage)
Giardia lamblia
 Giardia lamblia
Morphology of Cyst stage:
* Average size 12 X 7 µ
* Oval with well defined cyst wall
* Four nuclei present usually at one pole.
*Includes: axostyle – parabasal bodies – remnants
of flagella
Life cycle :

Human being is the natural host of Giardia lamblia inhabit the upper
part of small intestine especially duodenum . Multiplication occurs by
mitotic division during cyst formation, which pass with feces into soil
outside the host and can remain viable for months under moist
conditions .

Man especially children acquired the infection through the ingestion of

cysts via contamineted food, these cysts passes through the stomach
into duodenum where excystation takes place & within 30 minutes after
emerging from the cyst resulting in two binucleated trophozoites .
 Life Cycle of Giardia inside human body

Pass in stool cyst

Binary fission
Enter with food

trophozoite

Duodenal mucosa
Life Cycle of Giardia inside human body
Pathogenesis is determined by:
 Strain virulence
 Host’s susceptibility

Predisposing Factors: that determine disease severity

1- Hypogammaglobulinaemia.
2- Achlorhydria.

Pathogenicity: is directly related to

Attachment of Trophozoite & Surface area affected
Clinical manifestation :
 Incubation varies from 1-3 weeks
 In majority of cases infection remains asymptomatic.
 Symptomatic infection is more common in children than
adults because of their lower immunity.
Acute giardiasis:
 It is characterized by acute watery diarrhea, abdominal
cramp, bloating and flatulence. Occasionally nausea,
vomiting, fever, rashes or constipation in some.
 Pus, blood and mucus are not seen in stool.
 The condition lasts for 5-7 days.
Chronic giardiasis:
 Symptoms includes chronic diarrhea with
malabsorption of fat (steatorrhoea) and malabsorption
of vitamin A, protein and D-xylose, weight loss,
malaise, nausea, anorexia
 Protuberance of abdomen, spindly extremities and
stunted growth are most common sign in children.
 It lasts for several weeks
Extra-intestinal are rare and sometimes urticarial and
reactive arthritis are seen in rare case
Complication:
 In adults, malabsorption syndrome and weight loss
 In children, growth retardation, delayed milestones
achievements
 Giardiasis is self-limited disease and progression to
chronic state is only 5% of infected people and
death is rare.
 Source: Gallery of histology Woods and Ellis2000

Giardia Lamblia clinging to the wall of a duodenal villus.

Diagnosis :
Specimen:
Stool, duodenal contents, bile stained mucus,
duodenal/jejunal biopsy
Stool examination:
 Microscopy:
 Direct wet mount preparation: trophozoites are
identified by their characteristic falling leaf motility
 Iodine wet mount preparation: cyst can be observed
 Examination of stained stool smear for demonstration of
trophozoitse
 Stool antigen detection: ELISA, IFA.
 Stool culture
Cysts in Trophozoite in
formed stool diarrhoeic stool
Entero-test:
 In entero-test, a gelatin capsule containing a nylon string with a
weight attached to it is swallowed by patients.
 When it reaches to stomach, the gelatin capsule is diddolved and
nylon string moves down to duodenum and jejunum due to its
attached weight.
The string is allowed to remain there for 4-6 hours or overneight.
After removal of string, bile stained mucus is collected on glass slide
and examined for living trophozoites.

Serology

Molecular methods
Giardia lamblia
Treatment for giardiasis:
 Metronidazole, trinidazole, nitroimidazole
derivatives
 Nitrofurans- furazolidine
 * metronidazole is drug of choice. Dose- orally
250mg, 3 times daily for adults, 15mg/kg /day in
three divided dose for children for 7 days
Prevention and control :
Is just like that of E.histolytica.
1- All human infections should be treated because human being is the
only chief source of infection .
2- A symptomatic carriers should be treated especially those working in
restorants .

3- Effective enviromental sanitation is necessary to prevent water ,food ,

and vegitable contamination, e.g. Sewage disposal should be treated
with chemical before used as fertiliser in gardens.

4- Chlorination & filtered water supply are important to kill the cyst of
G.lamblia.

5-Flies and Insects should be controlled by insecticides because they

transmit the infective stage by mechanical methods.

6- Uncooked vegetables should be washed with running water. .

 Check for understanding
State True or False
• G.lamblia infection is common in children. T

• G.lamblia trophozoites are attached to caecal F

mucosa.
G.lamblia trophozoites are attached to duodenal mucosa.
• Stool of Giardia infected patients contains mucus F
tinged with blood. Stool is light-coloured and greasy.

• Giardia infected patients complain of diarrhoea and

flatulence. T

• Both trophozoites and cysts of Giardia are infective to

man. Only Giardia cysts are infective to man. F
 Case
A young youth took a sandwich in a restaurant. Later, he
complained of sudden abdominal pain together with anorexia
and diarrhoea. Stool analysis revealed protozoan parasite.

a- What are the protozoa that may cause such condition?

G. lamblia, C.parvum, C.cyaetenensis, I.belli
b- If the patient noticed that his stool became light-coloured and
greasy, what is the probable causative protozoa?
Giardia lamblia.
c- Name the habitat of the parasite in this condition?
Duodenum and upper part of small intestine
also bile duct and gall bladder.
d-Draw the diagnostic and infective stages?