Introduction to Parasitology PDF 2021-2022

OLFU Introduction to Parasitology 2021 – 2022 CLINICAL PARASITOLOGY...

OLFU Introduction to Parasitology 2021 – 2022 CLINICAL PARASITOLOGY LEC 1 1st Semester RMT 2023 Instructor: Prof. Sherlyn Joy P. Isip, RMT, MSMT Date: September 14, 2021 TRANS 1 PARA311 LEC  Tropical Disease At the end of the session, the student must be able to learn:  An illness, which is indigenous to or endemic in tropical area I. Parasitology but may also occur in sporadic or epidemic portions in areas A. Divisions of Parasitology that are not tropical. II. Host Parasite Relationship  Parasite A. Symbiosis  Lives on or in the host usually on a larger organism, which B. Parasites according to the Mode of Living provides physical protection and nourishment. C. Parasites according to Duration of Parasitism  Host D. Parasites according to Pathologic Conditions  Harbours parasite and gives nourishment. III. Types of Host IV. Sources of Exposure to Infection II. HOST PARASITE RELATIONSHIP A. Contaminated soil and water B. Food containing immature infective stage of parasite  The organisms may develop unique relationship due to their C. Arthropods, blood sucking insects and other wild or habitual and long associations with each other. domesticated animals D. Another Person A. Symbiosis E. One’s self V. Types of Vectors  Living together of unlike organisms, protection or other advantages VI. Modes of Transmission to one or both partners. VII. Portal of Entry  Mutualism VIII. Portal of Exit  Relationship is beneficial to both organisms. IX. Nomenclature  Termites X. Types of Life Cycle  Commensalism A. Life stage of a parasite  Parasite derives benefit without reciprocating and without XI. Mode of Reproduction injury to the host or both. XII. Epidemiologic Measures  Entamoeba coli can be found in intestinal lumen XIII. Distribution of Diseases and is being supplied with nourishment without XIV. Pathophysiology and Symptomology of Parasitic causing any damage to the tissue of the host. Infections  Parasitism XV. Factors that determine the Intensity of Parasitic  Relationship where one organism, the parasite, lives in or Infection another, depending on the latter for its survival and usually at XVI. Treatment the expense of the host. XVII. Prevention and Control  Entamoeba histolytica derives nutrition from XVIII. Eradication and Elimination human host at the same time it causes amoebic dysentery. I. PARASITOLOGY B. Parasites according to the Mode of Living  An area of science, which deals with the study of organisms living  Ectoparasites permanently or temporarily on or within another organism.  Living outside the body of the host.  The branch of biology or medicine concerned with the study of  Infestation parasitic organisms  Endoparasites  It is the study of parasites, their hosts, and the relationship between  Living inside the body of the host. them.  Infection  Concerned with the phenomena of dependence of one living  Facultative parasites organism on another.  Able to live outside or inside the host and lead both to a free and parasitic existence. A. Divisions of Parasitology  Obligate parasite  Completely dependent to the host for its existence throughout  Protozoology its life.  Protozoans: small, unicellular organisms, which contain  Accidental/Incidental parasite nucleus and functional organelles.  Establishes itself in the host in which it does not ordinarily live.  Helminthology  Occasional/Periodic  Worms: larger, multicellular organisms normally visible to the  Seeks its host intermittently to obtain nourishment. naked eye in their adult form.  Saprophytes  Medical Entomology  Live in organic substances in state of decomposition.  Insects and arthropods  Erratic  Those that live in an organ different from the one it usually parasitize. OTHER TERMINOLOGIES  Zoonotic  Animal parasites, non-human parasites that may cause  Medical Parasitology human infections.  Concerned primarily with the parasite that affects humans and their medical significance, as well as their importance in human communities.  Tropical Medicine  Branch of medicine, which deals with tropical diseases and other special medical problems of tropical regions. Gurrea, A.N, Ortiz, M.J - TRANSCRIBER [PARA311] 1.01 Introduction to Parasitology I Prof. Sherlyn Joy P. Isip, RMT, MSMT C. Parasites according to Duration of Parasitism  Autoinfection  Infected individual becomes his own direct source of infection.  Temporary parasites  Enterobius vermicularis  Free living during part of existence, larval stage has different  Superinfection or Hyperinfection host from its adult stage.  already affected individual is further infected with the same  Permanent parasites species leading to the massive infection with the parasite  Remain on the body of the host in all stages of its life cycle.  Co-infection  simultaneous infection of a host by two or more parasite  Presence of Ascaris lumbricoides and Trichuris D. Parasites according to Pathologic Conditions trichiura in the stool sample.  Spurious/Coprozoic parasite  Passes digestive tract of humans without infecting them. A. Contaminated soil and water  Coprophilic parasite  Parasite multiply in fecal matter outside the human body.  lack of sanitary toilets and use of night soil  Hematozoic parasite  Soil: Ascaris lumbricoides, Trichuris trichiura, Hookworm,  Lives inside the red blood cells Strongyloides stercoralis  Cytozoic parasite  Water: Amoeba, Flagellates, Blood flukes  Lives inside the cells or tissues  Coelozoic parasite  Lives in the body cavities B. Food containing immature ineffective stage of parasite  Enterozoic parasite  Lives in the intestine  consumption of undercooked or raw freshwater fish, crab, snail, beef and pork III. TYPES OF HOST C. Arthropods, blood sucking insects and other wild or domesticated animals  Definitive host  final host, harbours the adult and sexually mature form  If infected with Taenia saginata and Taenia solium,  Mosquitoes (Filaria and Malaria) humas are considered as definitive host.  Triatoma bugs ( Trypanosoma cruzi)  These helminths develop into adult form inside the  Sandflies (Leishmania) human body.  Cats, dogs and house rats  Intermediate host  harbours the larvae or asexual stage of the parasite D. Another Person  In some Helminths, their first intermediate host can be plants. While their second intermediate host can be snail or fish.  Beddings and clothing  Reservoir host  Immediate environment he has contaminated  Animal that harbours the same parasite of man  Pigs are reservoir of Balantidium coli E. One’s self  Paratenic host  harbours a stage of the parasite where in no further development in parasite takes place.  Autoinfection: self is the source of infection  Angiostrongylus cantonensis is in larva form when  Enterobius vermicularis, Hymenolepis nana, and resided in the human body and will not develop into Strongyloides stercoralis adult form. Their definitive host is the house rats while humans are considered as their paratenic host. V. TYPES OF VECTORS  Vector is responsible for transmitting the parasite from one host to IV. SOURCES OF EXPOSURE TO INFECTION another.  Pathogens A. Biological vector  can be animal parasites that are harmful and frequently cause mechanical injury to their host  the parasite is seen inside the body of this organism and the  Carrier parasite needs this organism for its development. Ex:  harbours a particular pathogen without manifesting signs and mosquitoes, tsetse flies symptoms  Exposure  process of inoculating an infective agent B. Mechanical vector  Infection  establishment of the infective agent in the host  Responsible only for transporting the parasite, the parasite is  Incubation period only seen on the surface of this organism and there will be no  period between infection and evidence of symptoms development on the parasite. Ex: cockroaches, house flies  Pre-patent period  Biological incubation period, period between infection and acquisition of the parasite and evidence or demonstration of VI. MODES OF TRANSMISSION infection.  Soil transmitted  Arthropod/ Vector transmitted  Food-borne Gurrea, A.N, Ortiz, M.J - TRANSCRIBER [PARA311] 1.01 Introduction to Parasitology I Prof. Sherlyn Joy P. Isip, RMT, MSMT  Water-borne  Skin penetration A. Sexual  Congenital transmission  Direct contact  Oviparous: "egg birth", give birth to eggs that must develop before hatching  Ovoviviparous: ones that produce eggs but retain them inside the female body until hatching occurs, so that "live" offspring are born VII. PORTAL OF ENTRY  Larviparous/ Viviparous: being born alive without eggs  By mouth: most common area of invasion, entrance for intestinal protozoa B. Asexual  Skin penetration  Intranasal: inhalation of eggs  Binary fission: division in half  Transplacental infection  Parthenogenesis: unfertilized ovum develops directly into a new  Transmammary individual, natural form of asexual reproduction in which growth and  Sexual intercourse development of embryos occur without fertilization by male sex cell VIII. PORTAL OF EXIT XII. EPIDEMIOLOGIC MEASURES  Stool  Epidemiology  Urine  science concern with the propagation of the disease,  Sputum study of patterns, distribution and occurrence of  Blood disease  Tissue aspirates and biopsy  Orifice swab  Incidence  Discharge  number of new cases of infection appearing in a population in a given period of time  Absolute number IX. NOMENCLATURE  Prevalence  usually expressed in percentage, number of  Classified according to the International Code of Zoological individuals in a population estimated to be infected Nomenclature with a particular parasite at a certain time  Scientific name are Latinized  Names of genera and species are italicized or underlined when  Cumulative prevalence written.  percentage of individuals in the population infected with  Generic names consist of a single word written in initial at least one parasite capital letter, the specific name always begins with a small letter.  Intensity of infection Kingdom: Animalia  number of worm per infected person (worm burden)  Direct: counting expelled worms during treatment Phylum: Nematoda  Indirect: counting helminth egg excreted in feces, Class: Secernentea expressed in egg per gram Order: Ascaridida Family: Ascarididae XIII. DISTRIBUTION OF DISEASES Genus: Ascaris  Sporadic  appears only occasionally in one or at most a few members of Species: Ascaris lumbricoides the community  eg. Tetanus and rabies  Endemic X. TYPES OF LIFE CYCLE  there is a steady moderate level of disease in human population  Simple or complicated  eg. Malaria in Palawan  Most parasitic organisms attain sexual maturity at the  Epidemic definitive host.  there is a sudden outbreak or rise of incidence in human  Larval stage of parasite may pass through different population stages in an intermediate host.  SARS-CoV and MERS-CoV  As life cycle becomes complicated, the lesser chances are for the individual parasite to survive.  Pandemic  when the disease have been disseminated in extensive area of the world A. Life Stage of a Parasite  COVID-19, AIDS and HIV 1. Ova 2. Egg 3. Larva XIV. PATHOPHYSIOLOGY AND SYMPTHOMOLOGY OF 4. Trophozoite PARASITIC INFECTIONS 5. Cyst 6. Adult  Traumatic or physical damage  when parasites invade the skin and other tissues causing destruction XI. MODE OF REPRODUCTION Gurrea, A.N, Ortiz, M.J - TRANSCRIBER [PARA311] 1.01 Introduction to Parasitology I Prof. Sherlyn Joy P. Isip, RMT, MSMT  the parasite competes with its host for the available supple of vitamin.  Diphyllobothrium latum competes on vitamin b12 Creeping eruption, a skin infection caused by hookworms  Lytic necrosis  secretory and excretory products elaborated by many parasites allow them to metabolize nutrients obtained from the host and store these for energy production.  Entamoeba histolytica secretes enzyme cysteine proteinase to digest cellular materials and degrade epithelial basement Hookworms membrane facilitating tissue invasion. XV. FACTORS THAT DETERMINE THE INTENSITY OF PARASITIC INFECTION  Topography of locality  Social condition  Age  Hygienic measure  Sewage disposal  Water supply Entamoeba histolytica in rectal biopsy XVI. TREATMENT  Tissue reactions  There are several options for treating parasitic infections. Many of  Cellular proliferation, white cell infiltration at the side of the these drugs are toxic to the host and care should be exercised parasite when selecting the proper course of treatment.  Antiparasitic medications  Change in diet  Vitamin supplements  Fluid replacement  Blood transfusion bed rest  Deworming  Use of anti-helminthic drugs in an individual or public health program.  Cure rate: usually expressed in percentage, Filarial larvae of Strongyloides stercoralis number of previously positive subjects found to be  Toxic allergic phenomena egg-negative in examination of a stool or urine  When proteins or other metabolites of the parasites are sample using a standard procedure at a set time introduced into the body, there is sensation to the foreign after deworming. substance, which may produce hypersensitization to  Egg reduction rate: percentage fall in egg counts anaphylactic shock. after deworming based on examination of a stool or urine sample using a standard procedure at a set time after deworming  Selective Treatment  Individual-level deworming with selection of treatment based on a diagnosis of an infection or based on presumptive grounds  Targeted Treatment  Group-level deworming where the risk group to be treated (with or without prior diagnosis) may be defined by age, gender or other social characteristics irrespective of infection Punctuate keratitis status.  Universal treatment  Population-level deworming in which the community is treated irrespective of age, gender, infection status or other social characteristics.  Coverage  Proportion of target population reached by an intervention.  Deprivation of the host’s essential nutrients and substances  Drug resistance Gurrea, A.N, Ortiz, M.J - TRANSCRIBER [PARA311] 1.01 Introduction to Parasitology I Prof. Sherlyn Joy P. Isip, RMT, MSMT  Genetically transmitted loss of susceptibility to a drug in a worm population that was previously sensitive to the appropriate therapeutic dose.  Efficacy  Effect of a drug against an infective agent in deal experimental conditions and isolated form of any context.  Performance of intervention under ideal or control circumstances mostly used in research or in trial.  Is the drug working or not?  Effectiveness  Measure of the effect of a drug against infective agent in a particular host, living in a particular environment with specific ecological, immunological, and epidemiological determinants.  Is the drug working or not? Is it effective or safe? XVII. PREVENTION AND CONTROL  Morbidity Control  Avoidance of illness caused by infections, may be achieved by periodically deworming individuals or groups, known to be at risk of morbidity.  Targeted treatment may be given  Information-education-communication (IEC)  health education strategy that aims to encourage people to adapt and maintain healthy life practices  Environmental management  planning, organization, performance and monitoring of activities for the modification and/or manipulation of environmental factors or their interaction with human beings  preventing or minimizing vector and intermediate host propagation  reducing contact between humans and the infective agent  Environmental sanitation  intervention to reduce environmental health risk  safe disposal and hygienic management of human and animal excreta, refuse and waste water  control of vectors, intermediate host and reservoir of diseases  provision of safe drinking water and food safety  housing that is adequate in terms of location, quality of shelter and indoor living conditions  facilities for personal and domestic hygiene  safe and healthy working conditions  Sanitation  provision to access to adequate facilities for safe disposal of human excreta, usually combined with access to safe drinking water XVIII. ERADICATION AND ELIMINATION  Disease eradication  Permanent reduction to zero of the worldwide incidence of infection caused by a specific agent, as a result of deliberate effort. Once this is achieved, continued measures are no longer needed.  Small pox  Disease elimination  Disease elimination: reduction to zero of the incidence of a specified disease in a defined geographical area as a result of deliberate effort. Continued intervention and surveillance are still required. Gurrea, A.N, Ortiz, M.J - TRANSCRIBER  OLFU Intestinal and Extraintestinal Amoebae 2021 – 2022 CLINICAL PARASITOLOGY LEC 2 1st Semester RMT 2023 Instructor: Prof. Sherlyn Joy P. Isip, RMT, MSMT Date: October 01, 2021 TRANS 2 PARA311 LEC OUTLINE B. Classification of Protozoan Parasites At the end of the session, the student must be able to learn: I. Protozoa A. Composition B. Classification of Protozoan Parasite C. General Rule for Amebae II. Entamoeba histolytica A. Life Cycle of E. histolytica B. Morphologic comparison between E. histolytica and E. coli C. Pathogenesis D. Pathology E. Pathogenic Determinants/Virulence Factor F. Laboratory Diagnosis G. Treatment H. Prevention and Control III. Non-Pathogenic species A. Entamoeba coli B. Entamoeba dispar C. Entamoeba hartmanni D. Entamoeba polecki E. Entamoeba gingivalis F. Entamoeba moshkovskii G. Endolimax nana H. Iodamoeba butschlii IV. Free Living Pathogenic Amoeba A. Acanthamoeba spp. (Acathamoeba castellani) B. Naegleria fowleri V. Phylum ciliophora cilates A. Balantidium coli I. PROTOZOA  Proto ( first), Zoa (animals) Encystation  Unicellular organism that performs all the functions: reproduction, digestion, respiration, excretion, etc.  Stage forming a cyst or becoming enclosed to a capsule, this event takes place in the rectum of the host as feces are dehydrated A. Composition or soon after the feces have been excreted 1. Nucleus  usually single but may be double or multiple; contains one or Excystation more nucleoli or a central karyosome; DNA containing body 2. Cytoplasm  Escape from cyst or envelope, produces a trophozoite from the  Endoplasm: inner (often granulated), dense part. cyst stage, and it takes place in the large intestine of the host after  Granulated because it shows number of structures such the cyst has been ingested. as golgi bodies. endoplasmic reticulum, food vacuoles, and contractile vacuoles  Contractile vacuoles regulate osmotic pressure between the parasite and its environment  Ectoplasm: outer (non-granulated), typically watery  Homogenous and serves as an organ for motility and engulfment of food by producing pseudopodia  Helps in respiration, discharging waste material and providing protective covering 3. Structures for locomotion  Psuedopodia: fingerlike  Flagella: Tail-like  Cilla: Hair-like  Undulating membrane 4. Plasma membrane  controls secretions and excretions 5. Cytosome  cell mouth 6. Chromatoidal bodies  storage for glycogen protein GURREA, A.N - TRANSCRIBER [PARA311] 1.02 Intestinal and Extraintestinal Amoebae I Prof. Sherlyn Joy P. Isip, RMT, MSMT C. General Rules for Amebae A. Life Cycle of E. histolytica  All Entamoeba are commensal except for Entamoeba histolytica.  With pseudopodium (false feet): finger-like structures for movement formed by sudden jerky movements of the ectoplasm in one direction.  Undergoes ENCYSTATION except for E. gingivalis and Dientamoeba fragilis.  E. gingivalis and Dientamoeba fragilis do not have a cyst form and stays in trophozoite form.  Inhabits the large intestine except for E. gingivalis (gums)  Amebiasis— presence of amoeba in any part of the body (exclusively applied to E. histolytica)  Asexually multiplies through binary fission. II. Entamoeba histolytica Morphologic forms 1. Tropozoite: divides through "binary fission", capable of encystation (overpopulation, pH change, food supply, availability of oxygen)  Trophozoite undergo encystation in intestinal lumen or rectum 2. Precyst: contains large glycogen vacuole and two chromatid bars and then secretes a highly retractile cyst wall around it and becomes cyst. 3. Cyst: with protective thick cell wall (hyaline), capable of excystation  Cyst found on contaminated food and water could withstand the acidic pH of our stomach because of its thick cell wall made up of hyaline. 4. Metacyst: liberated quadrinucleate amoeba during excystation  No morphologic difference among other Entamoeba spp. such as E. moshkovskii and E. dispar. However, they can be differentiated through isoenzyme analysis, PCR, and monoclonal antibody typing. Infective Stage  mature quadrinucleate cyst passed in feces Mode of Transmission  Ingestion of contaminated food and/or water with E. histolytica cyst.  Primary route is fecal-oral  Venereal transmission  Direct colonic inoculation through contaminated enema equipment. enema - test sa pwet TROPHOZOITE CYST Vegetative and motile stage Non-motile, feeding stage (feeding stage) Found in fresh watery, soft or Found in soft to formed stool semi-formed stool B. Morphologic comparison between E. histolytica and E. coli Fragile Resistant to acidic pH A. Trophozoite Point of E. histolytica E. coli Differentiation Movement Unidirectional, Sluggish, non- progressive progressive and non- directional Shape of Finger-like Blunted pseudopodia Manner of One at a time/explosive Several at a time release of pseudopodia Nucleus Uninucleated Uninucleated (central karyosome) (eccentric karyosome) Inclusion RBC Bacteria, yeast, debris Cytoplasm Clean looking Dirty looking Size Bigger Smaller GURREA, A.N - TRANSCRIBER [PARA311] 1.02 Intestinal and Extraintestinal Amoebae I Prof. Sherlyn Joy P. Isip, RMT, MSMT B. Cyst C. Pathogenesis Point of E. histolytica E. coli Differentiation  Symptoms No. of nuclei Quadrinucleated More than 4  Gradual onset of abdominal pain  Diarrhea (with or without blood) Chromatoidal bar Sausage, rod, cigar- Broomstick,  In children: bloody diarrhea, fever and abdominal pain shaped splinter-like  Abscess formation > Amoebic liver abscess Manner of Thin Thick release of  Pathology (Intestinal amebiasis) pseudopodia  Amoebic dysentery vs. Bacillary Dysentery  Presence of Charcot-Leyden crystals, product from metabolism of eosinophils, found microscopically in the stool in cases of amoebic dysentery Amoebic dysentery Bacillary dysentery Onset Gradual Acute Signs/ No significant fever or Fever and usually Symptoms vomiting vomiting Odor of feces Offensive, Fishy odor Odorless Blood and Often watery and (+) mucus bloody pH 12-60 um 15-50 um Acidic Alkaline Pus cell/ PMN/ Neutrophils Few Numerous Cellular exudates Scant Massive Pyknotic residues Numerous Few Charcot Leyden crystals Present Absent Pathogenic amoeba Present Absent Bacteria Few Numerous Macrophages Absent Present 10-15 um 10-35 um D. Pathology  Common associated disease: Intestinal amebiasis, amebic colitis, amebic dysentery, extraintestinal amebiasis  Amebic colitis- gradual onset of abdominal pain and diarrhea with or without blood and mucus on the stool  Ameboma – mass-like lesions with abdominal pain and history of dysentery. It may be mistaken for carcinoma or malignant tumor. GURREA, A.N - TRANSCRIBER [PARA311] 1.02 Intestinal and Extraintestinal Amoebae I Prof. Sherlyn Joy P. Isip, RMT, MSMT  Can cause ulceration "flask-shaped ulcer" in the intestines (cecum, ascending colon and sigmoid) F. Laboratory Diagnosis  Microscopic detection of cyst and trophozoite is the standard method of parasitological diagnosis.  Minimum of 3 stools specimen on different days should be examined (one stool sample for each day)  For the detection of trophozoite, fresh stool specimen should be examined 30 mins after defecation.  Detection of E. histolytica trophozoite with ingested RBC under saline solution is diagnostic of amebiasis. E. Pathogenic Determinants/Virulence Factor 1. Direct Fecal Smear  saline solution: trophozoite motility 1. Galactose-inhibitable adherence lectin (Gal Lectin): receptor mediated adherence of amoeba to target cells  saline + methylene blue: Entamoeba spp. stain blue 2. Amoeba ionophore: cell lysis and tissue invasion (differentiate Entamoeba spp. from WBC)  Ionophore can attract calcium (anion), the calcium helps the  saline + iodine: nucleus of E. histolytica can be Gal lectin so the parasite can adhere on the target cells observed (differentiate E. histolytica from 3. Cystein proteinase: most important, tissue invading factor nonpathogenic amoeba) 2. Concentration Techniques Extraintestinal amoebiasis  In case of light infection, cyst and trophozoite may not be detected in direct fecal smear.  Through the portal vein (liver), trophozoite reach other parts of the  Formalin Ether/ Ethyl Acetate Concentration body (liver, brain, lungs and kidneys). Technique (FECT) Merthiolate Iodine Formalin  Metastatic amoebiasis- involvement of distant organs by Concentration (MIFC) – Sedimentation technique hematogenous spread or through lymphatic resulting to abscesses in the kidney, brain, spleen, and adrenals 3. Culture  Amoebic hepatitis – repeated invasion in the  More sensitive than stool microscopy but not routinely liver can cause inflammation available (Ex: Robinson's and Inoki medium, Boeck  Amoebic liver abscess – most common and Drbohlav media, NIH polygenic media, Craig's extraintestinal form of amoebiasis; fever, upper medium and Nelson's medium right quadrant pain; thick chocolate brown pus (liquefied necrotic liver tissue) 4. Serologic Testing  Amoebic appendicitis and peritonitis  ELISA (Enzyme-linked Immunosorbent Assay), CIE  Pulmonary amoebiasis (Counter Immunoelectrophoresis), AGD (Agar Gel  Cerebral amoebiasis Diffusion), IHAT (Indirect Hemeagglutination Test)  Splenic abscess and IF-AT (Indirect Fluorescent Antibody Test)  Cutaneous amoebiasis  IHAT and IFAT considered as gold standard in  Genitourinary amoebiasis –destructive detecting E. histolytica infection ulcerative lesions may resemble carcinoma 5. Molecular Testing : PCR  Asymptomatic carriers: cysts becomes unnoticed, ameba  In case of extraintestinal amoeba, CT-scan and MRI reproduce but infected individual shows no clinical symptoms. may be used to detect amebic liver abscess.  Diagnostic Stage: identification of the cyst or trophozoite  Sample for ID: stool (examined within 30 minutes from collection) G. Treatment  To cure invasive disease at both intestinal and extraintestinal site and to eliminate passage of cyst from intestinal lumen  Metronidazole: drug of choice for invasive amebiasis (Tinidazole and secnidazole are also effective)  Diloxanide furoate: drug of choice for asymptomatic cyst passers  Percutaneous drainage of the liver abscess: Patients who do not respond to metronidazole and need prompt relief of severe pain H. Prevention and Control  Proper hygiene  Provision for sanitary disposal of human feces  Improve access to clean and safe drinking water  Good food preparation practices  Avoid using "night soil"  Food handler should be examined for cyst carriage  Health education and promotion GURREA, A.N - TRANSCRIBER [PARA311] 1.02 Intestinal and Extraintestinal Amoebae I Prof. Sherlyn Joy P. Isip, RMT, MSMT III. Non-Pathogenic species 4. Entamoeba polecki 1. Entamoeba coli  Parasite of the pigs and monkeys (rarely infect humans)  Humans are accidental/incidental host  Harmless inhabitant of the colon  Entamoeba chattoni: found in apes and monkeys, identical to E.  Cysts: Size (10 — 35 microns) polecki, identification via isoenzyme analysis  Larger than E. histolytica  Consists of 8 nuclei with very diffuse karyosomes  May become hypernucleated with 16-32 nuclei  May also contain needle-like chromatoidal bodies with irregular fragmented/sharp/splintered ends  Trophozoites: Size (15-50 microns)  Smaller than E. histolytica  Has one nucleus containing large, diffuse karyosomes  Peripheral chromatin is usually dense and irregular  Cytoplasm is usually rough and contain few to many ingested debris Entamoeba polecki 5. Entamoeba gingivalis  Not capable of encystation. Trophozoite form only  Can be found in the mouth (gum and teeth surfaces)  Abundant in cases of oral diseases  No cyst stage, does not inhabit the intestines  Transmission through kissing, droplet spray, sharing utensils 2. Entamoeba dispar  May ingest RBC (rarely), associated on lesions inside the mouth  Morphologically similar to E. histolytica, but with different DNA and RNA. 3. Entamoeba hartmanni  Similar to E. histolytica except much smaller and no RBC inclusions  "small-race E. histolytica” Entamoeba gingivalis 6. Entamoeba moshkovskii  Morphologically indistinguishable from those of the disease causing species E. histolytica and the non-pathogenic E. dispar, but differs from them biochemically and genetically. Although sporadic cases of human infection with E. moshkovskii have been reported, the organism is considered primarily a free-living amoeba.  physiologically unique: osmotolerant, able to grow at room temperature and able to survive at 0-41 o c 7. Endolimax nana  "Smallest amoeba"  "Cross eyed cyst" — 4 eccentric nuclei Entamoeba hartmanni  Blot-like karyosome GURREA, A.N - TRANSCRIBER [PARA311] 1.02 Intestinal and Extraintestinal Amoebae I Prof. Sherlyn Joy P. Isip, RMT, MSMT Mode of Transmission  Aspiration or nasal inhalation: use of contaminated swimming pools, deep well, etc.  Direct invasion of the eye: contaminated saline Endolimax nana 8. Iodamoeba butschlii  "iodine-cyst" because of its affinity to iodine Acanthamoeba spp.  Large glycogen vacuole/ body which stains deeply with iodine  Uninucleated — resembling a "basket of flowers" shape Specimen  Discharges, exudates and tissue secretions Pathogenesis  Granulomatous Amoebic Encephalitis (GAE)  destructive encephalopathy and associated meningeal irritation  Disease of immunocompromised (AIDS)  Laboratory diagnosis: made by demonstration of trophozoites and cysts in brain biopsy (post-mortem in most cases), culture, and immunofluorescence microscopy-using monoclonal antibodies.  CSF shows lymphocytic pleocytosis (abnormal increase in the number of lymphocyte in the CSF), slightly elevated protein levels, and normal or slightly decreased glucose levels.  CT scan of brain provides inconclusive findings. Iodamoeba butschlii Acanthamoeba spp. cycst  Amoebic keratitis (contact lens users) IV. FREE LIVING PATHOGENIC AMOEBA  perforation of the cornea and results to subsequent loss of vision 1. Acanthamoeba spp. (Acathamoeba castellani)  Laboratory diagnosis: made by demonstration of the cyst in corneal scrapings by wet mount, histology, culture (growth can be obtained from corneal scrapings inoculated on nutrient  Ubiquitous, free-living ameba agar, overlaid with live or dead Escherichia coli and incubated  With an active trophozoite stage with characteristic prominent at 300 C), demonstration of cyst and trophozoites in stool and "thorn-like" appendages (acanthopodia) and resilient cyst stage PCR.  Aquatic organism, can survive in contact lens cleaning solutions  Most common ameba of freshwater and soil  No flagellate state GURREA, A.N - TRANSCRIBER [PARA311] 1.02 Intestinal and Extraintestinal Amoebae I Prof. Sherlyn Joy P. Isip, RMT, MSMT 2. Naegleria fowleri Laboratory diagnosis  Free-living protozoan with two vegetative forms: an ameba  CSF examination (trophozoite form) and a flagellate (swimming form)  cloudy to purulent  "brain-eating amoeba"  neutrophilic leukocytosis  Thermophilic organism that thrive best in hot springs and other  elevated protein and low glucose warm aquatic environment  resembling pyogenic meningitis  True pathogen  Wet film examination of CSF: (+) trophozoites  Incubation period varies from 2 days to 2 weeks.  Autopsy: (+) trophozoites in immunofluorescent staining  Disease almost ends fatally within a week  Culture: can be grown in several kinds of liquid axenic media or non-nutrient agar plates coated with Escherichia coli, (+) both trophozoites and cysts.  Molecular Diagnosis: Polymerase chain reaction (PCR) Prevention  Frequent cleaning  Chlorination  Salination V. PHYLUM CILIOPHORA CILATES 1. Balantidium coli  Causative agent of "balantidiasis or balantidial dysentery", similar to amoebic dysentery Naegleria fowlei  Largest protozoan parasite  Only parasitic ciliate  Primarily associated with pigs Pathogenesis  Fatal Primary amoebic encephalitis (PAM)  patients initially complain of fever, headache, sore throat, nausea and vomiting  Hemorrhagic necrosis in post mortem examination of infected brain Balantidium coli Morphology  "Kernig's sign"  Has trophozoite and cyst stage  diagnostic sign for meningitis where the patient is unable to  Parts: fully straighten his or her leg when the hip is flexed at 90  Cytosome: entry of food degrees because of hamstring stiffness  Cytophyge: excretes waste  Two dissimilar nucleus: Large kidney-shaped macronucleus and micronucleu  One or two contractile vacuoles Mode of Transmission  Oral and intranasal routes while swimming in contaminated pools, rivers and lakes Balantidium coli GURREA, A.N - TRANSCRIBER [PARA311] 1.02 Intestinal and Extraintestinal Amoebae I Prof. Sherlyn Joy P. Isip, RMT, MSMT Pathogenic determinant  Hyaluronidase: causes the ulceration, secreted by trophozoite  Ulceration is described as flask-shaped ulcer but with rounded base and wider neck.  Unlike like Entamoeba histolytica, Balantidium coli does not invade the liver or other extraintestinal site. Laboratory diagnosis  Stool examination: microscopic demonstration of cyst and trophozoite in direct  Biopsy: specimens and scrapings from intestinal ulcers can be examined for presence of trophozoites and cysts.  Culture: can also be cultured in vitro in Locke's egg albumin medium or NIH polyxenic medium like Entamoeba histolytica, but it is rarely necessary. Mode of Transmission  ingestion of food/water contaminated with B. coli cyst Infective stage  Cyst Treatment  Tetracycline is the drug of choice. Alternatively Doxycycline can be given.  Metronidazole and nitroimidazote have also been reported to be useful in some cases. Prevention  Avoidance of contamination of food and water with human or animal feces.  Prevention of human-pig contact.  Treatment of infected pigs.  Treatment of individuals shedding B. coli cysts. GURREA, A.N - TRANSCRIBER  OLFU Intestinal and Reproductive Organ Flagellates 2021 – 2022 CLINICAL PARASITOLOGY LEC 3 1st Semester RMT 2023 Instructor: Prof. Sherlyn Joy P. Isip, RMT, MSMT Date: October 07, 2021 TRANS 3 PARA311 LEC OUTLINE  Microscopy and direct fecal smear  Purged stool- provides more suitable material for examination than At the end of the session, the student must be able to learn: the average formed stool. We use laxatives in purged stool. I. Other Intestinal Protozoan  Suitable specimen for detecting Dientamoeba flagilis. A. Dientamoeba fragilis II. Pathogenic flagellates 5. Treatment A. Giardia lamblia B. Trichomonas vaginalis  Iodoquinol (Tetracycline and Metronidazole are also effective) III. Non-pathogenic atrial flagellates A. Chilomastix mesnili 6. Prevention and Control B. Trichomonas hominis C. Trichomonas tenax  Proper sanitation D. Enteromonas hominis  Proper disposal of human waste E. Retortamonas intestinalis 7. Basic Structure of Flagellates I. OTHER INTESTINAL PROTOZOAN  Flagellum/Flagella- locomotor apparatus  Kinetoplast- provides energy A. Dientamoeba fragilis  blepharoplast  parabasal body  Despite of its name, it is not an amoeba but an intestinal flagellate.  Cytostome- cell mouth  No cyst stage identified, only the trophozoite stage is known.  Undulating membrane- a membrane laterally projecting from the  Originally described as an amoeba (based on EM and immunologic body of certain flagellates, participate in active motility of the and molecular phylogenic findings it is actually a flagellate) flagella.  Resembles Trichomonas  Axostyle or axial rod- for support in locomotion  Costa- rib-like structure within the cytostome for support 1. Morphology of the trophozoite  Rosette shaped nuclei (1 to 2)  Cytoplasm may contain vacuoles with ingested debris  Shows progressive motility  Broad hyaline pseudopodia that possess characteristic "serrated margin” 2. Mode of Transmission  fecal-oral route via transmission of helminth eggs (eg., Enterobius vermicularis)  It has been observed that some of Dientameoba flagillis are found in the lumen of the Enterobius vermicularis adult. 3. Pathogenesis  Infections are asymptomatic because it does not invade the tissues compare to E. histolytica. The presence of this parasite in GIT only produces irritation of the mucosa with secretion of excess mucus and hypermotility of the bowel.  In chronic infections, it may only mimic the irritable bowel II. PATHOGENIC FLAGELLATES syndromes but primarily the infection is asymptomatic because the parasite is not invading the tissues. A. Giardia lamblia  Possible co-infection with E. vermicularis and A. lumbricoides  Chronic infections may mimic Irritable Bowel Syndrome (IBS)  Causes diarrhea  Cercomonas intestinalis : Initial name (Dr. F. Lambl) 4. Diagnosis and Specimen  Giardia lamblia : (by Stiles > Dr. Giard and Dr. Lambl)  Giardia intestinalis: synonymous to Giardia duodenalis  observation of binucleate trophozoites in multiple fixed and stained  Habitat: duodenum, jejunum and upper ileum of humans fresh stool Gurrea, A.N - TRANSCRIBER [PARA311] 1.03 Intestinal and Reproductive Organ Flagellates I Prof. Sherlyn Joy P. Isip, RMT, MSMT 1. Life Cycle of Gardia lamblia  Ingested mature cyst will pass safely through the stomach; it will undergo excystation in the duodenum for about 30 mins, developing into trophozoites that rapidly multiply (binary fission) and attach to intestinal villi causing pathologic changes.  As the feces dehydrates, the parasite will undergo encystation.  The mature cyst will pass through the feces (infectious)  Trophozoites may be isolated on the fecal sample. Diagnostic stage are cyst and trophozoites. 2. Morphology 4. Pathogenicity  Trophozoite: "Old-man with eyeglasses", "Monkey Face"  pear/tear drop shaped, pyriform, shape of a tennis racket  Parasite attach to intestinal walls via adhesive sucking disc located  Bilaterally symmetrical with large ventral sucking disc- on the ventral side, it causes mechanical irritation in the affected pathogenic determinant. tissue.  ventral sucking disc- attachment for intestinal villi  It produces lectin for attachments.  4 pairs of flagella, 2 ventral sucking disc  The parasite is able to avoid peristalsis by trapping itself between the villi or within the intestinal mucosa.  2 ovoidal nuclei with distinct karyosome (symmetrically  Villous flattening and crypt hypertrophy- may lead to decrease bilateral) glucose, electrolytes, fluid absorption, and deficiency in  "falling leaf motility"- movement disaccharide (malabsorption and maldigestion).  Covered with variant-specific surface proteins (VSPs)- function is not fully elucidated but it is used as resistance for intestinal proteases attributing to the survival of the parasite.  Cyst  Ovoidal in shape  Thick shell (double wall), surrounded by a hyaline cyst wall  Nuclei: 2 (young), 4 (mature)  Presence of axostyle 2. Infective Stage  Mature cysts (resistant to routine chlorination)  Ovoidal, composed of double-wall thick shell surrounded by hyaline cyst wall.  Can be mature (4 nuclei) or immature (2 nuclei)  Presence of axostyle on cyst 3. Mode of Transmission  Ingestion of contaminated food and water with G. lamblia mature cyst Gurrea, A.N - TRANSCRIBER [PARA311] 1.03 Intestinal and Reproductive Organ Flagellates I Prof. Sherlyn Joy P. Isip, RMT, MSMT 5. Pathology 1. Morphology of the trophozoite  The onset is between 1-4weeks on an average of 9 days. Half of  Pyriform shape patients are asymptomatic.  4 free anterior flagella and one posterior flagellum beside  causative agent of Giardiasis or Lambliasis undulating membrane  "Traveler’s diarrhea" - St. Petersburg, Russia (first recorded  Prominent axostyle and single nucleus water outbreak and involved a group of visiting travelers) Gay  Presence of undulating membrane bowel syndrome, Failure to thrive syndrome  "rapid jerky tumbling" or "twitching"  Acute infections : "rotten eggs" odor (hydrogen sulfide)  Chronic infections: steatorrhea (malabsorption of fats) > passage of greasy, frothy stools that may float on toilet water 6. Diagnosis  Specimen: Stool and Duodenal contents  Diagnostic Stage: Trophozoite and Cyst  Lab Test:  Direct Fecal Smear  Entero test/Enterotube test/string test/ Beale  String's test (non-invasive)  Aspirate and Biopsy (invasive)  Concentration techniques in low level of light infections  Antigen detection test and immunofluorescence commercial test kit- Cyst wall protein 1 (Giardia antigen found in the stool)  Direct fluorescent antibody testing- Gold standard because it provides high sensitivity and high specificity. Trichomonas vaginalis 2. Infective and Diagnostic stage  Trophozoite 7. Treatment 3. Pathology  Metronidazole: (3x a day of 1 week): drug of choice Tinidazole, Albendazole, Furazolidone, Quinacrine and Paromomycin as  Correlates strongly with the number of sexual partners alternative.  Trichomoniasis (persistent urethritis, persistent vaginitis, infant infections) 8. Prevention and Control  Most prevalent non-viral sexually transmitted infection  Coinfection with Candidiasis, Gonorrhea, Syphilis, and  Proper disposal of human excreta HIV  Improve access to clean and safe drinking water - (Proper water treatment that includes combination of chemical therapy and 4. Symptoms filtration)  Good food preparation practices  Males  Avoid using "night soil”  asymptomatic  Health education and promotion  (less persistent, self-limiting)  Females:  Greenish-yellow discharge B. Trichomonas vaginalis  Edema, itching, burning sensation  "Strawberry cervix"  The only pathogenic Trichomonas  No cyst stage.  Infects squamous epithelium  Habitat: Urogenital tract  Secretes cysteine proteases, lactic acid, acetic acid  Female: Vulva (vagina) and may ascend to renal pelvis which disrupts the glycogen level and lowers the ph of (pH 5.2-6.4) vaginal fluid  Male: prostate gland, urethra, prostatic tissue  Low pH may cause infertility. High pH prone to fungal or bacterial infection. Gurrea, A.N - TRANSCRIBER [PARA311] 1.03 Intestinal and Reproductive Organ Flagellates I Prof. Sherlyn Joy P. Isip, RMT, MSMT 4 pairs (anterior, mid, Flagella sucking disc, extreme 4 anterior posterior) Nuclei 2 nuclei Uninucleated Symmetry Symmetrical Asymmetrical Motility Falling-leaf Rapid Jerky Tumbling B. Cyst Point of Giardia lamblia Trichomonas vaginalis Comparison Shape Ovoid Thick shell, axostyle 5. Mode of Transmission Characteristic No cyst stage present Nuclei 2 to 4  Sexual intercourse  Can be passed through newborns through the birth canal  Contaminated underwear or towels, or sitting at contaminated toilet bowl II. NON-PATHOGENIC ATRIAL FLAGELLATES 6. Specimen A. Chilomastix mesnili  Male: urine sample, prostatic fluid or seminal fluid  Largest flagellates in man  Female: urine sample, vaginal discharge, cervical scrapings 1. Trophozoite 7. Laboratory Test  Asymmetrical  Microscopy — wet smear or wet mount. Sensitivity of Microscopy  Pear-shaped is between 60-70%  Spiral groove on midportion  Saline preparation- quickest and most inexpensive way but may be  3 anterior flagella subjective.  1 flagellum within the cytostome > Cystostomal fibril (shepherds  Fixed and stained wet drop: Giemsa, Papanicolaou, crook, safety pin appearance) Romanowsky and Acridine Orange  “Boring/spiral movement or Cork-screw movement”  Culture  Gold standard  Culture between 2-5 days  Feinberg-Whittington medium  Diamond Modified medium  Trypticase Luver Serum medium  lnPouch TV Test- novel transport and culture system (sealed pouch with culture media) 2. Cyst 8. Treatment  Pear or lemon shaped  Oral Metronidazole (Tinidazole)  Conical anterior with knob-like or "nipple-shaped" protuberance  Acidic Douche (10% vinegar) – Dilute with distilled water 9. Prevention and Control  Both the male and female must be treated  4 Cs (Counselling, Compliance, Contact Tracing, Correct and Consistent use of Condom)  Case Finding  Choice and number of sexual partner  ABSTINENCE C. Morphologic Comparison of the Cyst and Trophozoite A. Trophozoite Point of Giardia lamblia Trichomonas vaginalis Comparison Shape Pear, tear-drop, pyriform Pyriform Round anterior, pointed Prominent axostyle, Characteristic posterior, with undulating membrane large sucking disc Gurrea, A.N - TRANSCRIBER [PARA311] 1.03 Intestinal and Reproductive Organ Flagellates I Prof. Sherlyn Joy P. Isip, RMT, MSMT B. Trichomonas hominis  Usually found in cecal area of large intestine  Commensal, occurs only in trophozoite  Pyriform shape  5 anterior flagella and a posterior flagellum  Relatively smaller than T. vaginalis III. SUMMARY C. Trichomonas tenax  Usually found in the mouth living in tartar around teeth and cavities of carious teeth, occurs only in trophozoite  Pyriform shape  smaller and slender than T. vaginalis  4 free equal flagella and a 5th one on the margin of the undulating membrane D. Enteromonas hominis  Demonstrates "jerky motility"  Very small like Endolimax nana E. Retortamonas intestinalis  Demonstrates "jerky motility", 2 anterior flagella  Stained stool preparation is the best sample to examine its presence Gurrea, A.N - TRANSCRIBER  OLFU Blood and Tissue Flagellates 2021 – 2022 CLINICAL PARASITOLOGY LEC 3 1st Semester RMT 2023 Instructor: Prof. Sherlyn Joy P. Isip, RMT, MSMT Date: October 09, 2021 TRANS 4 PARA311 LEC OUTLINE At the end of the session, the student must be able to learn: I. General Characteristics A. Morphologic forms II. Trypanosoma spp. A. Life Cycle of Trypanosoma spp. B. Pathology 2. PromastigoteI. SUMMARY C. Infective stage D. Specimen  lanceolate E. Laboratory Test  Elongated flagellum F. Treatment G. Prevention and Control III. Trypanosoma brucei complex A. Life Cycle of Trypanosoma brucei complex B. Pathogenesis C. Specimen D. Laboratory test E. Treatment F. Prevention and Control 3. Epimastigote IV. Leishmania spp. A. Life Cycle of Leishmania spp. B. Pathology  Elongated C. Infective stage  Undulating membrane D. Specimen E. Diagnostic test F. Treatment G. Prevention and Control I. GENERAL CHARACTERISTICS  Unique morphologies  They live in the blood and tissues of man and other vertebrate hosts and in the gut of the insect vectors. 4. Trypomastigote  To transmit these parasites, you need an insect vector. Those vectors are biological vectors because they are included in the  Elongated, spindle shape lifecycle of the parasite.  Long slender or short stumpy  Habitat: humans - blood and tissues. Vectors-Gut of vectors  C, U, S-shaped  Members of this family have a single nucleus, a kinetoplast, and a single flagellum  Nucleus is round or oval and is situated in the central part of the body  Kinetoplast consists of a deeply staining parabasal body and adjacent dotlike blepharoplasty  Flagellum is a thin, hairlike structure, which originates from the blepharoplast. A. Morphologic forms 1. AmastigoteIII. SUMMARY  round, ovoid  usually found in small groups of cyst-like collection in tissues Gurrea, A.N - TRANSCRIBER [PARA311] 1.04 Blood and Tissue Flagellates I Prof. Sherlyn Joy P. Isip, RMT, MSMT II. Trypanosoma spp. B. Pathology Etiologic Disease Vector Stages  "Chagas' disease" or American trypanosomiasis Agent exhibited  usually serious and fatal in young children T. cruzi Chaga's Disease Assassin bug,  "Chagoma" or Kissing bug,  furuncle-like lesions, inflammation at the site of inoculation American Cone nose bug,  small, painful, reddish nodule Trypanosomiasis Triatomine bug, (Reduviid bug) ALL Triatoma, Rhodnius, Panstrongylus T. brucei Gambian or West Tsetse fly, gambiense African Sleeping Glossina spp. Epimastigote Sickness and T. brucei Rhodesian or East Trypomastig rhodesiense African Sleeping ote only Sickness 1. Acute trypanosomiasis A. Trypanosoma cruzi  generalized lymphadenopathy  focal or diffuse inflammation mainly affecting the myocardium  Belongs to the group Stercoraria (multiplies within the mammalian  "Romaña's sign" — edema of the eyelid if the parasite penetrates host in a continuous manner) through the conjunctiva. May involve lacrimal gland or surrounding  Stercoraria- the trypanosome to be transmitted is found in the tissues feces of the vector. The reduviid (vector) will take a blood meal on a host, the bite wound will be contaminated with feces. The feces 2. Chronic trypanosomiasis of reduviid bug contains the infective stage of parasite.  The metacyclic trypanosomes being transmitted are found on the  no characteristic symptom and may last for 20 years or more feces cof vector.  cardiomyopathy, megaesophagus and megacolon (chronic  Infected cells (intracellular parasite): constipation)  Skin  Cardiomegaly, congestive heart failure, thromboembolism, and  Gonads arrhythmia  Intestinal mucosa  Primary organ affected: heart  Placenta  these advanced conditions can lead to death  Myocytes (particularly myocardial tissues)  Achalasia-lower part of esophageal sphincter fails to open up  Reticuloendothelial system cells during swallowing > leads to back up of food. Associated with  The myocytes and reticuloendothelial system cells are the megaesophagus heavily infected cells A. Life Cycle of Trypanosoma cruzi C. Infective stage  to vector : trypomastigote  to man : metacyclic trypomastigote D. Specimen  blood, CSF, fixed lymph node tissues and lymph juices E. Laboratory Test  Complete patient history is the primary tool for diagnosing Chaga’s disease. Signs and symptoms of Chaga’s disease are nonspecific.  Establish possible exposure to the parasite base on complete patient history.  Stained smear -Giemsa staining (stain in diagnosing blood parasite: demonstration of trypomastigote  Concentration methods (Micro hematocrit- capillete with acridine orange stain)  Blood Cultures - NNN medium (Novy-MacNeal-Nicolle)  Xenodiagnosis - use of laboratory animal to isolate parasite (negative bugs > feed on suspective patients > examine for the presence of Trypanosoma cruzi metacyclic trypomastigote  Serologic test - IFAT, CFT (Machado Guerreiro test), IHAT, ELISA Gurrea, A.N - TRANSCRIBER  [PARA311] 1.04 Blood and Tissue Flagellates I Prof. Sherlyn Joy P. Isip, RMT, MSMT  Dot-immunobinding: small amounts of sample is used  Molecular— testing (PCR) amplify DNA from kinetoplast A. Life Cycle of Trypanosoma brucei complex  The WHO recommends using at least two techniques with concurrent positive results before diagnosis of Chaga’s disease is made. F. Treatment  Nifurtimox and Benznidazole G. Prevention and Control B. Pathogenesis  vector control (