Phylum protozoa

Introduction

• Protozoa are single celled eukaryotic organisms that exhibit considerable

variation in size, shape, locomotory organelles and methods of reproduction.
• Considered as the oldest forms of animal life, these organisms have become
adapted to practically all types of environment, except those that are
extremely dry.
• The protoplasmic units that constitute the organism consists essentially of a
nucleus, or nuclear material surrounded by cytoplasm limited by an
ectoplasmic membrane which may be rigid or pliable. The relatively viscous
nucleus, which is the important organelle, contain the chromosomes,
essential to life, reproduction and transmission of the genetic constituent of
the organism.
 Introduction

• A single mass or aggregate of of granules referred to as karyosome

• ( endosomes or nucleolus ) may be found near the center of the cell, surrounded by
chromatin particles that appear to be arranged in an achromatic network.
• Locomotion of protozoa is accomplished by organelles arising from the ectoplasm.
• In subphylum Mastigophora , a thread or whip-like projections called flagella serve
as organelle for locomotion.
• In Rhizopoda, crawling movement is accomplished by a foot-like projections from
the cytoplasm called pseudopodia.
• In phylum, Ciliophora, short-hair like cilia distributed on the surface of the
organism propel the parasite.
• Class sporozoa have no definite organelles for locomotion
Introduction

• The process of reproduction among protozoa is accomplished by simple

binary fission.
• All protozoa are included under the kingdom Protista.
• Four major groups: Sarcomastigophora; Apicomplexa; Microsporida;
and Ciliophora.
• In phylum Sarcomastigophora, both sexual and asexual reproduction
may occur; however among medically important members of the
phylum ( amebas, intestinal and muminal flagellates ) asexual
reproduction is the rule.
• Phylum Ciliophora undergoes transverse binary fission
Introduction
of protozoan
• All protozoan follows a pattern of asexual schizogony followed by sexual sporogony.
These cycles may occur in the same host ( e.g. crystoporidium )or in different host
( e.g. Toxoplasma, plasmodium spp. )
• The trophozoites of sporozoan are intracellular.
• The parasites undergo schizogony, a process of repeated nuclear and cytoplasmic
division which results in the production of a schizont filled with merozoites.
• Merozoites undergo sporogony and develop into microgametocytes ( male ) and
macrogametocytes ( female )
• Fertilization produce a zygote and eventually an oocyst.
• The germinal mass within the oocyst become sporoblast which may have a cyst wall
called sporocyst, differentiation of the sporoblast results in sporozoites- infective
stage of protozoan
 Introduction

subphylum mastigophora

• A. Species which inhabits the digestive tract

1. Giardia lamblia
2. trichomonas hominis
3. chilomastiz mesnili.
4. retrtomonas intestinalis
5. enteromona hominis
B. Species which inhabits the oral cavity
1. trichomonas tenax
C. Species that inhabits the genitalia
1. trichomonas vaginali
Subphylum Sarcodina
Class Rhizopoda

• A. Species that colonize the large intestine

1. Entamoeba histolytica
2. Entamoeba coli
3. Endolinax nana
4. Iodamoeba butschlii
5. Dientamoeba fragilis
B. Species that inhabits the oral cavity
1. Entamoeba gingivalis
C. Species that inhabit the brain
1. Naegleria spp
2. Acanthamoeba spp
Phylum Apicomplexa
subclass coccidia
• Zygote not motile; sporozoites typically enclosed in sporocyst within oocyst
1. Cryptosporidium spp
2. Isospora spp
3. Sarcocystis spp
4. Toxoplasma gondii
Zygote motile ( ookinite ) sporozoite naked with three membrane wall
1. Plasmodium vivax
2. Plasmodium ovale
3. Plasmodium malariae
4. Plasmodium falciparum
5. Plasmodium knowlesi
Ciliophora
Balantidium coli
Entamoeba histolytica

• Introduction
• Common associated disease or condition names
• Intestinal amebiasis; amebic colitis; amebic dysentery; extraintestinal amebiasis.
• What is the common acceptance of the genetic distinction between the pathogenic E.
histolytica and commensal E. mescohkovskii and E. dispar, and the finding that E. dispar is much
more frequently encountered, the true prevalence of E. histolytica is closer to 1% - 5%
worldwide.
• E. histolytica principally inhabits the large intestine where trophozoites or active forms,live in
the intestinal lumen and sometimes invade the mucosal crypts, where they feed on red blood
cells and form ulcers.
• Ulceration of the intestinal wall give rise to amebic dysentery.
• The invading ameba at times find their way into capillaries to the bloodstream to the liver or
other organs, where abscess formation may occur
Morphology

• Trophozoites :exhibits rapid, unidirectional, progressive movements, achieved with finger-like

hyaline pseudopods.
• The single nucleus typicallycontains a small central mass of chromatin known as karyosome
( karyosomal chromatin )
• The karyosome of this ameba is surrounded by chromatin material, a morphological structure
called peripheral chromatin which is typically fine and evenly distributed around the nucleus
in a perfect circle.
• It contains a finely granular cytoplasm, which is often to as having a ground glass appearance.
• RBC in the cytoplasm are considered diagnostic; E. histolytica is the only intestinal ameba to
exhibit this characteristic.
• Bacteria, yeast or other debris may also reside in the cytoplasm, but their presence is not
diagnostic.
Morphology

• Cysts : the spherical to round cysts are typically smaller than the trophozoite. Presence of a
hyaline cyst wall helps in the recognition of the morphologic form.
• One-four nuclei are present.
• These nuclei appear basically the same as those of the trophozoite.
• Nuclear variation do occur, karyosome being eccentric, thin plaques of peripheral chromatin
or a clump of peripheral chromatin at one side of the nucleus that appear crescent shaped.
• The chromatoidal bars generally appear as elongate with rounded or squared ends but may
occasionally be ovoid or cigar shaped.
• Chromatoidal bars of this characteristic morphology are seen in E. histolytica, E. dispar and
E. hartmanni but may occur also in E. polecki.
• Chromotoidals are more frequently encountered in the mono and binucleate cysts and a
large proportion of mature quadrinucleate cysts do not possess them
Valuable characteristics in the identification of E. histolytica, E. dispar
and E. meshkovskii

• Trophozoites unstained
• suggestive: progressive motility, hyaline pseudopodia no ingested
• bacteria; nuclei not visible
• diagnostic: ingestion of rbc
• Trophozoite, stained
• suggestive : clear differentiation of ectoplasm and endoplasm; no ingested
• bacteria
• Diagnostic : fine, uniform granules of peripheral chromatin and small central
karyosome in nucleus; rbc ave.size over 12 micron.
• Cyst , unstained ; suggestive 4 nuclei, rod-like chromatin
• Cysts, stained ; suggestive; maximum of 4 nuclei having both karyosome and
peripheral chromatin, dm over 10 micron
diagnostic : typical nuclear structure, chromatoidal bars with
rounded or squared ends; dm over 10 micron
Symptoms and pathogenesis
WHO classification
• I. Assymptomatic infections
• II. Symptomatic infections
• A. Intestinal amebiasis
• 1. dysenteric
• 2. non dysenteric colitis
• B. extraintestinal amebiasis
• 1. hepatic
• A. Acute non-suppurative
• B. Liver absces
• 2. pulmonary
• 3. other extra-intestinal foci
Symptoms

• Symptoms depends on the following

1. large measure of tissue invasion
2. infection is confined to the intestinal tract
3. spread to other organs
Amebic dysentery – all patients with symptoms of intestinal amebiasis
and who actually have dysentery or blood and mucus in the stool.
Amebic colitis is term that can be used to denote any symptomatic
intestinal symptoms.
Symptoms and pathogenesis

• Ameba may penetrate the muscularis mucosa into the submucosa where they spread out
into classic flask-shaped ulcers and blood vessels to give rise into the intra-luminal
bleeding.
• Sigmoidoscopic examination may demonstrate an almost normal mucosal pattern or one
that is indistinguishable from those seen in ulcerative or granulomatous s colitis.
• There may be scattered ulceration up to a few millimeters in diameter characterized by an
erythematous border and yellowish center.
• Presence of grossly normal mucosa between ulcers serves to differentiate amebic from
bacillary dysentery.
• As the amebic infection progresses, coalescence of the ulcers may produce irregularly
wandering ulcer trenches, sometimes with hair-like remains of the more resistant
supportive structures projecting from their bases ( “ buffalo skin “ or “ djak hair “ ulcers ).
Symptoms and pathogenesis

• Abdominal palpation may reveal tenderness of the cecum, transverse

colon or sigmoid.
• Fever is not characteristic of uncomplicated amebic colitis
• A chronic granulomatous lesion known as ameboma develops most
frequently in the cecal or rectosigmoid region.
• It may produce a so called napkin-ring constriction of the bowel wall
indistinguisale on X-ray examination from an annular carcinoma or it
may give rise to a characteristic ( though ) nonspecific conical
configuration of the cecum.
Symptoms and pathogenesis
• Hepatomegaly and tenderness may occur in amebic colitis w/o an evidence
of hepatic infection.
• Hepatic infection is characterized by liver tenderness and enlargement,
fever, weight loss and sometimes cough with evidence of pneumonitis
involving the right lower lung field.
• A typical liver abscess consist of; central zone of necrosis; a median zone of
stroma only; an outer zone of normal tissue just being invaded by ameba.
• Most of the amebic liver abscesses are in the right lobe.
• Next to the liver in frequency as the site of extra-intestinal amebiasis is the
lungs.
Life cycle
• E. histolytica passes through trophozoite, pre-cyst, cyst.
• Trophozoites are found in lesion-like ulcer in the intestines or in an abscess of the liver. Inside the
tissue, they divide by binary fission.
• The trophozoite is the vegetative feeding stage
• Locomotion is achieve bt pseudopodia which are finger-like extrusion of the cytoplasm.
• Pre-cyst is transitory stage from trophozoites to the formation of cysts. Cyst are rounded with a
distinct cyst wall.
• Encystation occur in infected individual whose rate of bowel ecvacuation is not increased so that
there is adequate time of dehydration of colonic mucosa which induces the trophozoites to encyst.
• Cyst , the usual transfer or infective stage are ingested with food or drink contaminated with fecal
material.
• They survive in acid gastric juices.
• Cysts are usually seen in semi-formed stool; trophozoites are seen in watery or diarrheic stool.
Epidemiology

• Amebiasis is cosmopolitan and country wide in distribution.

• Man get infected through ingestion of food or drink contaminated with fecal material
containing mature cysts.
• This may occur as a result of pollution of water supply, use of night soil as fertilizer for
vegetative farms, droppings of flies and infected food handlers.
• Treatment
• Amebic colitis or amebic liver disease
• Tinidazole; 2g/d PO for 3 days
• Metronidazole ; 750mg tid PO or IV for 5-10 days
• Entamoeba histolytica luminal infection
• Paromomycin ; 30 mg/kg qd PO in 3 divided doses for 5-10 days
• Iodoquinol : 650mg PO tid
The non-pathogenic amoeba of man

1. entamoeba dispar
2. entamoeba hartmanni
3. entamoeba coli
4. entamoeba gingivalis
5. endolinax nana
6. iodamoeba butschlii

• apabl
• Entamoeba dispar and E. moshkovskii
• Entamoeba dispar is approximately nine times more prevalent than E.
histolytica and together they infect about 10% of the world population.
• Because E.histolytica, E. dispar and E. moshlovskii are morphologically
indistinguishable, one can no longer rely on microscopic alone for the
unequivocal detection of E. histolytica infection.
Entamoeba dispar

• Microscopic identification of E. histolytica can be made if ingested

erythrocytes are present in its trophozoites.
• However, regardless of symptoms, the presence of what appear to be
E. histolytica-like forms in the stool along with positive serologic
response, indicates the presence of true histolytica.
• Conversely a negative serologic test and E. histolytica-like amoeba in
the stool indicates E. dispar
• There are specific test for ID of both amoebas; ELISA and EIA
Entamoeba hartmanni

• Synonym “ small race” E. histolytica

• E. hartmanni and E. histolytica have similarities in morphology, only difference is their sizes.
• Upper limits of the size of the trophozoites of E. hartmanni to be 12micron and the cysts to be 10
micron; these measurements are likewise the lower size range of E. histolytica.
• Characteristics of E. hartmanni
• Trophozoites unstained : not characteristic
Trohozoites stained: diagnostic : nuclear structure similar to that of E.
histolytica; ingested bacteria dm <12
micron
Cyst, unstained : suggestive : 4 nuclei, rounded form
Cysts, stained; diagnostic : typical nuclear structure; chromatoidal bars with rounded or
square ends; dm < 10 micron
Entamoeba coli

• The following are of value in the ID of Entamoeba coli

• The cytoplasm is granular, frequently containing many vacuoles.
• Red blood cells are not ingested by this amoeba; sluggish in its movement.
• Pseudopodia are short and blunt, never long and finger-like as in E. histolytica.
• No striking differenciation of the cytoplasm into ectoplasm and endoplasm.
• Motility not progressive; pseudopodia appear to function more to ingest food
than to produce directional movements.
• The nucleus is usually easily discerned.
• A ring of refractile granules representing the peripheral chromatin encloses
another eccentric refractile mass, the karyosome.
E. Coli

• Stained : peripheral chromatin is irregular both in size and its

arrangement on the nuclear membrane
• The karyosome is large, frequently irregular in shape, eccentric in position
• The cysts of E. coli; the cyst wall is highly refractile and cytoplasm granular
in appearance; food vacuoles are absent
• Nucleus usually number 1 – 8.
• Iodine stain ; glycogen may be seen in the cysts of E. coli, often masses of
dark-staining material completely surround the nuclei.
• The chromatoidals are seen to be composed of splinter-shaped or ribbon
or tread-like bodies; heavier bodies with irregular ends are seen.
Entamoeba gingivalis

• E. gingivalis is often found in pyorrheal pockets and between the teeth

and gums and in the tonsillar crypts.
• It may multiply in bronchial mucus and to appear in the sputum, where
it may be mistaken for E. histolytica from pulmonary abscess.
• The cytoplasm contain bacteria and occasional red blood cells but more
frequently is filled with portions of ingested leukocytes.
• Nuclear fragment from the leukocytes are usually recognizable in
stained specimen and serve to identify the amoeba, as E. gingivalis is
the only specie that ingest these cells.
• E. gingivalis form no cyst.
Entamoeba polecki
• It was first reported as an intestinal parasite of pigs and monkeys.
• E. polecki has been found occasionally in humans
• In parts of Papua, New Guinea, it is apparently most common intestinal amoeba
of humans.
• Although pig-human transmission is considered to be likely route of human
infection, this possibility of human-human transmission exist where prevalence
of infection is high.
• E. polecki resembles those of E. histolytica but can be fifferentiated in culture
and reaction to various therapeutic agents.
• Trophozoites of E.polecki resemble those of E. coli in motility; granularity and
degree of vacuolization of cytoplasm and ingestion of bacteria
Entamoeba polecki
• The following characteristics are of value in ID of E. polecki
• Trophozoite, stained : suggestive: nucleus with minute central
karyosome, peripheral chromatin eve enly
distributed or massed at one end or both poles;
ingested bacteria
Cyst, unstained : suggestive; uniform mononuclear condition
Cyst, stained ,suggestive: mononucleate cyst; large central karyosome
with evenly distributed peripheral chromatin or
peripheral chromatin massed at one end or both
ends
diagnostic ; inclusion masses, chromatoidal bars with angular of pointed ends
thank you
Endolinax nana

• Most common of the smaller intestinal amoeba

• Is usually encountered same frequency as in Entamoeba coli
• It has both trophozoites and cysts
• Pseudopodia are blunt and hyaline; they are extruded rapidly as in
E. histolytica but fais to produce the directional locomotion
Cytoplasm contain food vacuoles with ingested bacteria
Characteristics in the ID of Endolinax nana
Trophozoite, stained : diagnostic: a nucleus w/ large karyosome,
generally, w/ little or no peripheral chromatin
Cyst, stained : diagnostic : 4 nuclei w/ large karyosome and little or no
peripheral chromatin
Iodamoeba butschlii
• The Iodamoeba butschlii receives its generic name from the characteristics glycogen vacuoles of the
cystic stage.
• The single nucleus is seen at one side of the glycogen vacuole.
• It has sluggishly progressive movement with hyaline pseudopods.
• Bacteria is scattered throughout the cytoplasm, red blood cells are never ingested
• Unstained cyst is seldom is surrounded by a refractile wall, glycogen vacuole is prominent in
unstained cyst due to its refractility.
• Nucleus is seldom distinct in unstained cysts
• Stained cysts, the chromatin granules which surrounds the karyosome in the trophic stage. Usually
form crescent aggregates between karyosome and nuclear membrane.
• In well stained specimen, linin fibrils may seen running between karyosome and chromatin granules.
• Nuclei exhibiting this structure have been likened to basket of flowers, the karyosome forming the
basket, the linin fibrils the stem and the granules the blossoms.
Free living pathogenic amoeba of man
naegleria fowleri and acanthamoeba spp are free living pathogenic
amoeba of medical importance.
• Naegleria fowleri “ brain-eating amoeba “
• Introduction
• Primary amoebic meningoencephalitis ( PAM ) causes by Naegleri mimics
bacterial meningitis; it is often fatal
• The amoeba has been isolated in several water sites in the Philippines but
only one case of PAM has been documented.
• Diagnosis rest on the neurologic manifestation coupled with history of
contact with water plus definite identification of the amoeba in CSF of in
tissue section
• Early diagnosis is essential because of the rapid course of the infection
Morphology of naegleria
• Trophozoites of naegleria fowleri occur in 2 forms, ameboid and flagellates
• The ameboid form; has blunt pseudopodia ( lobopodia )
vesicular nucleus w/ large central karyosome
Flagellated from : bear two long flagella at one end are rather elongated
and do not form pseudopodia
Cysts are round and uninucleate, the cyst wall is smooth and heavy; nucleus
is similar to that of the trophozoites but smaller.
Life cycle of naegleria
• The amoeboid trophozoites of N. fowleri are the only form known to exist in humans.
• Replication of the amoeboid trophozoites occur by simple binary fission.
• The amoeboid trophozoites transform into flagellate trophozoite in vitro after being
transferred to water from a tissue or culture.
• The flagellate trophozoites do not divide but rather lose their flagella and convert
back into the amoeboid form, in which reproduction resumes. The cyst form is known
to exist only in the external environment
• Humans primarily contract this ameba by swimming in contaminated water
• The amoeboid trophozoites enter the human body through the nasal mucosa, often
migrates to the brain, causing rapid tissue destruction.
• Some infection may be caused by inhaling dust infected w/ N. fowleri.
Epidemiology of N. fowleri
• Naegleria fowleri is found in warm bodies of water, including lakes,
streams, ponds and swimming pools.
• Prevalence is higher in the summer months of the year.
• In addition to water sources, there have been cases of contaminated dust.
• The ameboid trophosoites enter the human body through the nasal
mucosa.
• Inhalation of contaminated dust has accounted for other documented
infections.
• There is also some evidence to suggest that sniffing contaminated water
may transmit this ameba.
Clinical symptoms

• Asymptomatic : patients who contract N. fowleri resulting from colonization of the

nasal passages are usually asymptomatic.
• Primary amebic meningoencephalitis ( PAM ) occur when the ameboid
trophozoites invade the brain, causing rapid tissue destruction.
• Patients may initially complain of fever, headache, sore throat, nausea and
vomiting.
• Symptoms of meningitis rapidly follow, including stiff neck and seizures.
• Patients also experience smell and taste alterations, blocked nose and Kernig’s
sign .
• In untreated patients, death usually occur 3 – 6 days after onset.
• Post mortem brain tissue samples reveal the typical ameboid trophozoites,
Treatment of N. fowleri
• Unfortunetely, medications used to treat meningitis and amebic infections are
ineffective against N. fowleri.
• However, prompt and aggressive treatment with amphotericin B may be of benefit to
patients suffering from infections of N. fowleri.
• Amphotericin B in combination with rifampin or miconazole also proved to be an
effective treatment.
• Amphotericin B and miconazole, inhibiting the biosynthesis of ergosterol and resulting
in increased membrane permeability, which causes nutrients to leak out of the cells.
• Rifampicin inhibits RNA synthesis jn the amoeba by binding to beta subunits of DNA
dependent RNA polymerase, which in turn blocks RNA transcriptase.
• a person can survive if signs are recognized early.
Prevention and control
• Because of the numerous bodies of water that may be potentially be infected, total
eradication is unlikely to be totally eradicated.
• Posting of signs around known sources of contamination, as well as educating the
medical community and public, may help curb infection rates.
• Chlorination of swimming pools and hot tubs is important.
• The first case of PAM was reported by Carter and Fowleri for whom the ameba is named,
in Australia in 1965 and by Butt and Patras in 1966 in the US.
• A specie od Naegleria that could possibly infect human in the future is known as
Naegleria australiensis.
• This organism exist in the environment in Asia, Australia, Europe and USA.
• Laboratory techniques include PCR assay, monoclomal antibody testing, flow cytometer,
DNA hybridization.
Acanthamoeba species
• Common associated disease: Ganulomatous Amebicencephalitis ( GAE ); acantamoeba keratitis
• Morphology:
• Trophozoites : motility is sluggish; spindle-like pseudopodia known as acanthopodia, which
project outward from the base of organism.
• Acanthamoeba trophozoites contain only one nucleus, consisting of a large karyosome similar to
that of N. fowleri; peripheral chromatin is absent.
• Cytoplasm appear granular and vacuolated.
• Cysts : is equipped with a double cell wall; inner smooth cell wall is surrounded by an outer
rugged cell wall, this appearance is characteristic and aids in acanthamoeba cyst identification.
• The single nucleus is similar in appearance to that of the trophozoite form, a large karyosome
and no peripheral chromatin.
• A disorganized, granular and vacuolated cytoplasm surrounds the nucleus.
Laboratory diagnosis of acanthamoeba
• A specimen of choice is CSF for acanthamoeba trophozoites and cyst
• Brain tissue may also be examined. Corneal scrapings are also used for the
detection of acanthamoeba infection of the eye.
• Suspected corneal scrapings may be cultured on non-nutrient agar plates seeded
with gram negative bacteria ( Escherichia coli or Enterobacter aerogenes ) which
serves as a source of food for the amoeba.
• As the Acanthamoeba organisms feed, they produce a set of marks known as
( tracks ) on the agar.
• Calcofluor white is also used to stain the cysts present in corneal scrapings.
• Indirect immunofluorescent antibody staining is the technique of choice for
speciating Acanthamoeba.
Life cycle of Acanthamoeba

• The trophozoites and cyst of Acanthamoeba convert between these two morphologic
forms in the external environment.
• Humans may acquire in one or two ways; one route consist of aspiration or nasal
inhalation of the amoeba.
• Trophozoites and cysts enter via the lower respiratory tract or through ulcers in the
mucosa or skin---migrate via hematogenous spread --- invade the CNS causing serious
CNS infection
• The second route of infection consist of direct invasion of the amoeba in the eye.
• Patients who are at risk for direct invasion are contact lens wearers and those whose
cornea are traumatized.
• Contact lens wearers who use homemade, non-sterile saline solution that are
contaminated with Acanthamoeba typically suffer a serious eye infections.
Acanthamoeba species
• 10 species currently known to infect human
• Acanthamoeba castellanii has been identified as the species responsible for most CNS and eye infections in human.
Species name CNS infection eye infection
A.astronyxis X
A. castellanii X X
A. culbertsoni X X
A. divionensis X
A. griffin X
A. healy X
A. hatchetti X
A. lugdunensis X
A. polyphaga X
A. rhysodes X X
Epidemiology

• Infections often occur in persons who are debilitated or

immunosuppressed and fatal cases have been reported in patients
with AIDS.
• In one of the AIDS patients, the feature of the disease were more like
PAM than GAE, presumably because of the immunosuppression.
Symptoms and pathogenesis

• Granulomatous amebic encephalitis ( GAE ) is not as well-defined as the

disease caused by N. fowleri.
• The course of infection is sub-acute or chronic, lasting for weeks or
months and is characterized by focal granulomatous lesions of the brain.
• The onset of GAE is insidious, with prolong clinical course.
• The incubation period of GAE is not known but probably takes weeks or
months, during which single or multiple space-occupying lesions develop.
• A prominent feature of GAE is an altered mental state.
• Symptoms like headache, seizures and stiff neck occurs in some cases; also
nausea and vomiting.
Symptoms and pathogenesis

• Acanthamoeba CNS is focal in contrast with Naegleria infections

which diffuse meningoencephalitis
• Acanthamoeba keratitis is a chronic infection of the cornea.
• Infection is by direct contact of the cornea caused by species of
Acanthamoeba, which may be introduced through minor corneal
trauma or by exposure to contaminated water or to contaminated
contact lenses.
• Acanthamoeba keratitis usually develops over a period of weeks or
months and is characterized by severe ocular pain, often out of
proportion to the degree of inflammation observed
Symptoms and pathogenesis
• Acanthamoeba keratitis, affected vision and stromal infiltrates that
frequently is a ring a shaped and composed of predominantly neutrophils.
• Acanthamoeba keratitis is a serious ocular infections and if not properly
managed can lead to loss of vision and of the eye.
• Ocular infection is characterized by chronic progressive ulcerative keratitis;
corneal ulceration may progress to perforation.
• A case of endophthalmitis in which Acanthamoeba was recovered from
aqueous and vitreous specimen has been recovered in a patients with AIDS.
• Trophozoites and cysts of Acanthamoeba was found in the infected corneal
tissue.
Epidemiology
• Fewer cases of acanthamoeba CNS infections have been reported
than that of Naegleria.
• CNS infections primarily occur in patients who are debilitated or
immunocompromised.
• Contact lens wearer, particularly whose wearing soft contacts may be
at risk of contracting acantamoeba eye infections.
• Poor hygiene practices, especially the use of home made saline
rinsing solutions is the major risk factor that may lead to these
infections.
Treatment

• As with Naegleria infections, there is no satisfactory treatment for GAE

because most cases have been diagnosed after death.
• There is some evidence to suggest that sulfamethazine might be suitable
treatment.
• Cases of acanthamoeba keratitis have successfully been treated with
itraconazole, ketoconazole, miconazole, propamidine, isethionate and
rifampin.
• Of all these agents, propamidine appears to have the best documented
success record.
• The key to successful treatment to eye infections is to begin treatment once
infection has been diagnosed.
Notes of interest and new trends

• Acanthamoeba shares many characteristics with the gram negative

Pseudomonas aeruginosa, which frequently occurs in standing water as an eye
pathogen.
• It is believed that P. Aeruginosa inhibits the activity of Acanthamoeba species.
• An interesting case involved the cutaneous lesions filled with acathamoeba
trophozoites and cysts on the trunks, legs and arms of a patients suffering from
AIDS
• The patient also presented with brain lesions that did not show acanthamoeba
organisms.
• Another case involved acanthamoeba invasion of bone following a graft
procedure, patient subsequently developed osteomyelitis.
Flagellates

• There are four common species of intestinal flagellates

1. giardia lamblia
2. chilomastix mesnili
3. trichomonas hominis
4. dientamoeba fragilis
In addition two small flagellates are sometimes incountered; enteromonas hominis and
retartamonas intestinalis.
Only giardia and dientamoeba may cause disease.
The flagellates other than dientamoeba are readily recognized by their characteristic
rapid motility.
Trichrome stain is used for staining flagella
Giardia lamblia
• Giardia lamblia ( also referred to as Giardia duodenalis or Giardia
intestinalis ) is the causative agent of giardiasis and is the only common
pathogenic protozoan found in the duodenum and jejunum of humans.
• Giardia exists in 2 forms; trophozoites and cysts.
• Giardiasis is a cosmopolitan disease in humans characterized by broad
clinical spectrum of acute to chronic symptoms ranging from diarrhea
and mal-absorption syndrome.
• This flagellates was first discovered by Antone van Leeuwenhock
( 1681 ) who found it in his own stool.
• It was first recognized and described by Lambl ( 1859 )
Introduction G. lamblia
• It is frequently tagged as the primary cause of traveler’s diarrhea and the etiologic agent in
sporadic outbreaks of water-borne transmitted disease.
• Giardiasis occurs worldwide with highest prevalence observed in places where sanitary are
poor.
• People of all ages are affected with infants and children are more frequently affected in
endemic areas.
• Humans are the natural host of the parasite although a variety of animal specie also harbor
the parasite.
• Giardia does not appear consistently in the stool of all patients.
• Three patterns of excretion has been described as; high, with parasites in nearly all stools;
low, with small numbers of parasites present in only 40% of stool specimen; and a mixed
pattern, with 1-3 weeks of a high excretion rate alternating with a shorter period of low
excretion.
Morphology of G. duodenalis
• Giardia is a flagellate that resides in the upper part of the small intestines.
• It has a simple asexual life cycle that include a binucleate flagellated trophozoites
that attaches to the upper intestinal tract by a ventral sucking disc and
quadrinucleate cyst that are passed in the stool.
• Trophozoite s are bilaterally symmetrical, each structure being paired, two nuclei;
4 pairs of flagella- anterior, lateral, ventral and posterior.
• Two nuclei lie in the area of the sucking disc in the anterior portion of the body.
• Two curved rods are seen posterior to the sucking disc- these rods known as
median bodies.
• The sucking disc is bordered by the curved intracytoplasmic portion of the anterior
flagella, axonemes which divide the body into throughout most of its length.
Morphology

• The cysts are ovoid and contain flagella retracted into axonemes; four
median bodies as well as twice as the number of intracytoplasmic
flagellar structures seen in trophozoites, all dispersed in a seemingly
helter-shelter fashion.
• The nuclei are spherical or ovoid and contain a large, usually eccentric
karyosome and no peripheral chromatin.
• Young cysts have two nuclei while mature cysts have four nuclei.
• Motility is somewhat erratic, with slow oscillation along the long axis.
• This type of motility has been likened to the motion of “ falling leaf “.
Life cycle

• Tophozoites are found in the upper intestinal tract where optimum pH

of survival is 6.4- 7.0.
• Trophic stage multiplies rapidly by binary fission causing pathologic
changes in giardiasis. This phase is found only in the small intestines
and in watery stools.
• The parasites encysted in the colon; cyst is the infective stage and
when swallowed by the host in contaminated water or food, pass
safely in the stomach and excyst in the duodenum immediately
completing the division of the cytoplasm.
Symptoms and pathogenesis

• Children are more frequently affected than adults, although all ages may exhibits
symptoms ranging from mild diarrhea, flatulence, anorexia, crampy abdominal
pain and epigastric tenderness to steatorrhea and full-blown mal-absorption
syndrome.
• Like celiac disease in children and its adult counterpart, non-tropical sprue,
severe giardiasis may be marked by the production of copious light-colored, fatty
stools, hypoproteinemia with hypogammaglobulinemia, folic acid and fat soluble
vitamin deficiencies.
• Giardia lamblia pathogenicity and invasiveness as well as host resistance
revealed that changes in the microvilli ( crypt hypertrophy, villus atrophy or villus
flattening, and epithelial cell damage and villus enzyme response ) may be
immune mediated.
Symptoms and pathogenesis
• The typical incubation period of giardia is 10-36 days, after which
symptomatic patients suddenly develop watery, foul-smelling
diarrhea, steatorrhea, flatulence and abdominal cramping.
• In general giardia is a self-limiting condition that typically is over in 10-
14 days after onset.
• Patients with intestinal diverculitis, or in IgA deficiency appear to be
particularly susceptible to reccuring infections
• Hypogammaglobulinemia may predispose to giardia as well as
achlorhydria.
Epidemoplogy

• Giardia intestinalis may be found worldwide– lakes, streams other water

sources.
• It is interesting to note that giardia cysts are resistant to the routine chlorination
procedure carried out at most water plant facilities.
• Filtration as well as chemical treatment as well as chemical treatment of water is
crucial to obtain adequate drinking water.
• Giardia may transmitted by eating contaminated fruits or vegetables.
• Person-to-person contact through oral-anal sexual practices or via fecal-oral
route may also transfer giardia
• Sexual practices, particularly anal-oral contact favor transmission of this parasites
and there is increased prevalence among homosexual males.
Treatment, prevention and control

• Treatment with quinacrine or metronidazole usually effects complete cure within a few days.
• Metronidazole is typically issued with strong warnings against concurrent consumption of
alcoholic beverages.
• Tinidazole is as effective as metronidazole and shows to be well tolerated by patients.
• Nitazoxanide is very efficient in treating adults and children.
• The steps necessary to prevent and control of G. intestinalis are similar to those of E. histolytica.
• 1. proper water treatment that includes combination of chemical treatment and filtration.
• 2. guarding water supply against contamination by potential reservoir host
• 3. exercising good personal hygiene
• 4. proper cleaning and cooking of food
• 5. avoidance of unprotected oral-anal sex
• Pls study the characteristic of value in the identification of Giardia lamblia
Chilomastix mesnili
• As far as is known, chilomastix mesnili is not pathogenic to humans
• However, it must be differentiated from giardia and other flagellates occasionally seen in the stool.
• Trophozoites are elongate, tapering towards the posterior end.
• At the anterior, broad end of the body are three flagella, by means of which the parasite moves in a
directional manner.
• In fresh specimen one readily distinguishes the flagella and a groove running in spiral along the length of
the body.
• The stained trophozoites are characterized by a single nucleus near the origin of the anterior flagella; the
cytostome, or oral depression, bordered by cytostomal fibrils and a short flagellum.
• The most prominent of the cytostomal fibrils, curving posterior ly around the cytostome, resembles a “
shepherd’s crook “
• Cysts of chilomastix mesnili, at the anterior pole of the cysts is a nipplelike protuberance that gives this
stage a characteristic lemon-shape not seen in any of the other intestinal protozoa.
• Pls study the characteristics of chilomastix mesnili
Dientamoeba fragilis

• Until recently, dientamoeba was considered by most parasitologist to be an amoeba.

• It is unique among the intestinal ameba in its binucleate condition and in the absence of a cyst
stage.
• It is initially classified as an amoeba because this organism moves by means of a pseudopodia and
does not have external flagella.
• By using an electron microscope, D. fragilis does have flagellate characteristic.
• Trophozoites is irregular and rounded in shape, progressive motility seen primarily in fresh stool
sample, is accomplished by broad hyaline pseudopodia that possess characteristic serrated margin
• The trophozoite has two nuclei, each consisting of four to eight centrally located massed
chromatin granules.
• Peripheral chromatin is absent
• Trophozoites are binucleated
Life cycle and epidemiology

• The complete life cycle of D. fragilis is not well understood.

• It resides in the mucosal crypts of the large intestines and trophozoites does
not invade the surrounding tissue.
• The exact mode of transmission remains unknown but some suggestion that
D. fragilis is transmitted via the eggs of helminth parasites such as
Enterobius vermicularis and Ascaris lumbricoides.
The following individuals appear to be at risk of contracting D. fragilis: children,
homosexual men, those living in a semi-communal groups and persons who are
institutionalized.
D. fragilis transmission may occur by fecal-oral and anal-oral routes, as well as
person-person routes.
Clinical symptoms and treatment

• Patients who suffer symptoms associated with D. fragilis infections

often present with diarrhea, abdominal pain, bloody or mucoid stools,
flatulence, nausea or vomiting, weight loss, fatigue or weakness.
• Treatment of choice is iodoquinol
• Tetracycline is an acceptable alternate treatment,
• Paromomycin ( Humatin ) may be used .
• Pls study the characteristics of D. fragilis
Enteromonas hominis

• Trophozoites : body is broadly oval anteriorly and somewhat attenuated posteriorly;

three anterior flagella, by which the organisms move in a rapid, jerky fashion; fourth
flagellum is directed posteriorly.
• In living specimen one may observed the general body shape, anterior flagellar
movement and trailing flagellum.
• In stained specimen; the single nucleus is seen near the anterior end, a distinct nuclear
membrane and a large central karyosome.
• Cysts; are inconspicuous , usually ellipsoidal, in fresh specimen, they are likely
mistaken for yeast.
• Stained cysts : possess one to four nuclei, generally with predominance of binucleate
condition.
• A predominance of binucleate cysts of small size is highly suggestive of Enteromonas.
Characteristics of identifying Enteromonas
hominis
• Trophozoites, unstained : diagnostic : anterior flagella; trailing
flagellum but no undulating membrane.
Trophozoites, stained : suggestive : absence of costa, axostyle or
cytosome fibrils; single nucleus with large
central karyosome
Cysts, stained : suggestive : oval shape; one to four nuclei; with
predominance of binucleate cysts of small size
Retartamonas intestinalis

• Trophozoites : ovoid or tear-shaped and move rapidly by means of two anterior flagella.
• Cytosome extends from near the anterior end to half the length of the organism.
• trophozoites, unstained, diagnostic: presence of cytosome; two
anterior flagella only.
Trophozoites, stained, diagnostic: large nucleus with small central
karyosome, fine granules of peripheral chromatin;
cytosomal fibrils.
Cysts, stained suggestive : pear-shaped, contain a single relatively large nucleus frequently
near the center. Two fibrils extend from the nuclear region to the attenuated end of the cysts.
The fibrillary arrangement “ bird’s beak “ appearance is characteristic