Medical Parasitology Lecture Notes PDF

LECTURE NOTES Degree and Diploma Programs For Health Science Students Medical Parasitology Dawit Assafa, Ephrem Kibru, S. Nagesh, Solomon Gebreselassie, Fetene Deribe, Jemal Ali Jimma...

LECTURE NOTES Degree and Diploma Programs For Health Science Students Medical Parasitology Dawit Assafa, Ephrem Kibru, S. Nagesh, Solomon Gebreselassie, Fetene Deribe, Jemal Ali Jimma University Debub University University of Gondar In collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education 2004 Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00. Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Important Guidelines for Printing and Photocopying Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty. All copies must retain all author credits and copyright notices included in the original document. Under no circumstances is it permissible to sell or distribute on a commercial basis, or to claim authorship of, copies of material reproduced from this publication. ©2006 by Dawit Assafa, Ephrem Kibru, S. Nagesh,, Solomon Gebreselassie, Fetene Deribe, Jemal Ali All rights reserved. Except as expressly provided above, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission of the author or authors. This material is intended for educational use only by practicing health care workers or students and faculty in a health care field. PREFACE This lecture note is useful to students of health science, medicine and other students and academicians. It is believed to provide basic knowledge to students on medical parasitology. It also serves as a good reference to parasitologists, graduate students, biomedical personnel, and health professionals. It aims at introducing general aspects of medically important parasites prevalent in the tropics and in Ethiopia in particular. It is our belief that this note will contribute much in alleviating the shortage of Parasitology texts. Students preparing to provide health care in their profession need solid foundation of basic scientific knowledge of etiologic agents of diseases, their diagnosis and management. To face the fast growing trends of scientific information, students require getting education relevant to what they will be doing in their future professional lives. Books that are of manageable size are increasingly important in helping students learn the seemingly overwhelming amount of information they must absorb. i ACKNOWLEDGEMENTS The writers are indebted to the Ethiopian Public Health Initiative (EPHI) for encouragement and financial support. We thank all who contributed in the write up of this lecture note and those involved in giving the secretarial service in all colleges and Universities. Included in the acknowledgment are also the reviewers of the draft material, Dr. Habtamu and Ato Asrat Hailu who are currently staffs of AAU-MF, Microbiology, Immunology, and Parasitology department. Their comments were quiet constructive and well taken up. ii TABLE OF CONTENTS Topic Page Preface...................................................................................................... i Acknowledgement......................................................................................ii Table of Contents...................................................................................... iii About the Authors.................................................................................... vii List of Boxes and Tables........................................................................ viii Abbreviations and Acronyms....................................................................ix UNIT ONE: General Parasitology........................................................... 1 Association between parasite and host................................................ 1 Effect of parasites on the host.............................................................. 4 Basic concepts in medical parasitology............................................... 5 Classification of medical parasitology.................................................. 8 General characteristics of medically important parasites................... 11 (1) Protozoa.................................................................................. 11 (2) Heliminths................................................................................ 13 (3) Arthropods............................................................................... 14 UNIT TWO: Medical Protozology......................................................... 17 Introduction............................................................................................. 17 Classification of protozoa........................................................................ 20 UNIT THREE: Amoebiasis.................................................................... 22 Introduction............................................................................................. 22 1.1. Entamoeba Histolytica................................................................ 22 1.2. Other Amebae inhabiting the alimentary canal........................... 27 1.3. Pathogenic free-living amoebae.................................................. 35 UNIT FOUR: Pathogenic Flagellates................................................... 37 Introduction........................................................................................ 37 2.1 Luminal Flagellates...................................................................... 37 iii 2.1.1. Giardia Lamblia.................................................................... 37 2.1.2 Trichomonas vaginalis.......................................................... 41 2.1.3 Dientamoeba Fragilis............................................................ 43 2.1.4 Other flagellates inhabiting the alimentary canal................... 44 2.2. Haemoflagelates.......................................................................... 47 2.2.1 Leishmania Species.............................................................. 47 2.2.1.1 Visceral Leishmaniasis.................................................. 47 2.2.1.2 Old world cutaneous leishmaniasis (Oriental sore)....... 50 2.2.1.3 New world cutaneous and mucocutaneous leishmaniasis52 2.2.2 Trypanosomiasis................................................................... 53 2.2.2.1 African trypanosomiasis................................................ 54 2.2.2.2 American trypanosomiasis............................................ 57 UNIT FIVE: Medically important ciliates.............................................. 61 Balantidiasis........................................................................................ 61 UNIT SIX: COCCIDIA (SPOROZOA)..................................................... 63 4.1 Malaria.......................................................................................... 63 4.1.1 Plasmodium falciparum......................................................... 66 4.1.2 Plasmodium vivax................................................................. 69 4.1.3 Plasmodium malariae............................................................ 70 4.1.4 Plasmodium ovale................................................................. 71 4.2 Other cocidian parasites............................................................... 74 Review Questions............................................................................... 80 UNIT SEVEN: Medical heminthology................................................... 82 UNIT EIGHT: Medically important treatodes (Flukes)........................ 84 1.1. Blood Flukes................................................................................ 84 1.1.1. Schistosomiasis (Bilharziasis).............................................. 84 Schistosoma Mansoni.................................................................... 85 Urinary Scistosomiasis................................................................... 85 Schistosoma Japonium.................................................................. 86 Schistosoma Intercalatum.............................................................. 86 1.2. Intestinal Flukes........................................................................... 89 iv 1.3. Liver Flukes.................................................................................. 89 1.4. Lung Flukes................................................................................. 89 UNIT NINE: Nematodes (Round Worms)............................................. 89 General Characteristics of nematodes................................................ 90 2.1. Intestinal nematodes with tissue stage........................................ 91 2.1.1. Ascaris lumbricoides............................................................ 91 2.1.2. Hook worms......................................................................... 93 2.1.2.1. Ancylostoma duodenale............................................... 93 2.1.2.2. Necator Americanus..................................................... 94 2.1.3 Larva migrans....................................................................... 96 A. Cutaneous larva migrans (creeping eruption)....................... 96 B. Visceral larva migrans.......................................................... 96 2.1.4 Strongyloides stercoralis....................................................... 98 2.2. Intestinal nematodes without tissue stage................................. 100 2.2.1. Enterobius vermicularis (Pin worm or thread worm).......... 100 2.3. Tissue nematodes...................................................................... 104 2.3.1. Filarial worms..................................................................... 104 2.3.1.1. Wuchereria Bancrofti.................................................. 105 2.3.1.2. Onchocerca Volvulus................................................. 107 2.3.1.3. Loa Loa...................................................................... 110 2.3.2. Dracunculus Medinensis (Guinea Worm or Medina Worm) 111 2.3.3. Trichinosis.......................................................................... 113 UNIT TEN: Cestodes (Tapeworms).................................................... 116 Introduction....................................................................................... 116 3.1. Hymenolepis nana (Dwarf Tapeworm)....................................... 116 3.2. Hymenolepis Diminuta (Rat tapeworm)..................................... 117 3.3. Echinococcus............................................................................. 118 3.3.1 Echinococcus Granulosus (Dog Tape Worm)..................... 118 3.3.2. Echinococcus multilocularis............................................... 120 3.4. Taenia Saginata (Beef Tape Worm).......................................... 120 3.5. Taenia Solium (Pork Tape Worm).............................................. 123 v 3.6. Diphylobotrium Latum (Fish Tapeworm or Broad Tape Worm)... 124 UNIT ELEVEN: Medical Entomology................................................. 127 Introduction....................................................................................... 127 Arthropods....................................................................................... 127 Biology of Arthopods.................................................................... 128 Development of Arthropods......................................................... 130 Importance of Arthropods in Parasitology.................................... 130 Classification of Arthropods......................................................... 132 Medical conditions related to arthropods..................................... 134 A. Fly related conditions.......................................................... 134 B. Mosquito related conditions................................................ 135 C. Flea related conditions....................................................... 135 D. Lice related conditions........................................................ 135 E. Bug related conditions........................................................ 136 F. Tick related conditions........................................................ 136 G. Mite related conditions....................................................... 136 Vector control measures.............................................................. 136 (1) Mechanical Methods.......................................................... 136 (2) Ecological control.............................................................. 136 (3) Chemical methods............................................................. 137 (4) Biological methods............................................................ 137 (5) Genetic control.................................................................. 137 Summary............................................................................................. 138 Learning Activity................................................................................. 138 References.......................................................................................... 138 Glossary.............................................................................................. 139 vi ABOUT THE AUTHORS Solomon Gebreselassie (M.D., M.Sc): assistant professor of and department head of Microbiology, Parasitology, and Immunology, Jimma University Dawit Assefa(M.D): Lecturer and department head of Biomedical and Behavioral Sciences, Awassa College of Health Sciences. Ephrem Kibru(M.D): Assistant Lecturer of Microbiology and Parasitology, Awassa College of Health Sciences. Nagesh S. (MSc.): Lecturer of Microbiology and Parasitology, Awassa College of Health Sciences. Fetene Deribe(MSc): Lecturer of Microbiology and Parasitology, Jimma University Jemal Ali (BSc in MLT): Gondor University College vii LIST OF BOXES AND TABLES Box 1: different kinds of parasites --------------------------------------------------------2 Box 2: different kinds of Hosts ------------------------------------------------------------3 Table 1: classification of pathogenic protozoa-----------------------------------------12 Table 2: differentiating features of helminthes------------------------------------------13 viii ABBREVIATIONS AND ACRONYMS CNS: Central nervous system CSF: Cerebro-spinal fluid DEC: Diethyl carbamazine ELISA: Enzyme linked immunosorbent assay PO: Per Os (through mouth) HIV: Human Immunodeficiency Virus AIDS: Acquired Immune Deficiency Syndrome ix UNIT ONE GENERAL PARASITOLOGY LEARNING OBJECTIVES At the end of this section the student is expected to: Discuss the various types of parasites and hosts. Explain the relationship between a parasite and the host and their effects. Discuss in detail the classification of medically important parasites. Explain the difference between the Cestodes, Nematodes, Trematodes and protozoa INTRODUCTION Man and other living things on earth live in an entangling relationship with each other. They don’t exist in an isolated fashion. They are interdependent; each forms a strand in the web of life. Medical parasitology is the science that deals with organisms living in the human body (the host) and the medical significance of this host-parasite relationship. ASSOCIATION BETWEEN PARASITE AND HOST A parasite is a living organism, which takes its nourishment and other needs from a host; the host is an organism which supports the parasite. The parasites included in medical parasitology are protozoa, helminthes, and some arthropods. (See box 1 for broader classification of parasites). The hosts vary depending on whether they harbor the various stages in parasitic development. (See box 2) 1 BOX 1. DIFFERENT KINDS OF PARASITES Ectoparasite – a parasitic organism that lives on the outer surface of its host, e.g. lice, ticks, mites etc. Endoparasites – parasites that live inside the body of their host, e.g. Entamoeba histolytica. Obligate Parasite - This parasite is completely dependent on the host during a segment or all of its life cycle, e.g. Plasmodium spp. Facultative parasite – an organism that exhibits both parasitic and non-parasitic modes of living and hence does not absolutely depend on the parasitic way of life, but is capable of adapting to it if placed on a host. E.g. Naegleria fowleri Accidental parasite – when a parasite attacks an unnatural host and survives. E.g. Hymenolepis diminuta (rat tapeworm). Erratic parasite - is one that wanders in to an organ in which it is not usually found. E.g. Entamoeba histolytica in the liver or lung of humans. Most of the parasites which live in/on the body of the host do not cause disease (non-pathogenic parasites). In Medical parasitology we will focus on most of the disease causing (pathogenic) parasites. However, understanding parasites which do not ordinarily produce disease in healthy (immunocompetent) individuals but do cause illness in individuals with impaired defense mechanism (opportunistic parasites) is becoming of paramount importance because of the increasing prevalence of HIV/AIDS in our country. 2 BOX 2. DIFFERENT KINDS OF HOSTS Definitive host – a host that harbors a parasite in the adult stage or where the parasite undergoes a sexual method of reproduction. Intermediate host - harbors the larval stages of the parasite or an asexual cycle of development takes place. In some cases, larval development is completed in two different intermediate hosts, referred to as first and second intermediate hosts. Paratenic host – a host that serves as a temporary refuge and vehicle for reaching an obligatory host, usually the definitive host, i.e. it is not necessary for the completion of the parasites life cycle. Reservoir host – a host that makes the parasite available for the transmission to another host and is usually not affected by the infection. Natural host – a host that is naturally infected with certain species of parasite. Accidental host – a host that is under normal circumstances not infected with the parasite. There is a dynamic equilibrium which exists in the interaction of organisms. Any organism that spends a portion or all of its life cycle intimately associated with another organism of a different species is considered as Symbiont (symbiote) and this relationship is called symbiosis (symbiotic relationships). The following are the three common symbiotic relationships between two organisms: Mutualism - an association in which both partners are metabolically dependent upon each other and one cannot live without the help of the other; however, none of the partners suffers any harm from the association. One classic example is the relationship between certain species of flagellated protozoa living in the gut of termites. The protozoa, which depend entirely on a carbohydrate diet, acquire their nutrients from termites. In return they are capable of synthesizing and secreting cellulases; the cellulose digesting enzymes, which are utilized by termites in their digestion. 3 Commensalism - an association in which the commensal takes the benefit without causing injury to the host. E.g. Most of the normal floras of the humans’ body can be considered as commensals. Parasitism - an association where one of the partners is harmed and the other lives at the expense of the other. E.g. Worms like Ascaris lumbricoides reside in the gastrointestinal tract of man, and feed on important items of intestinal food causing various illnesses. Once we are clear about the different types of associations between hosts and parasites, we can see the effect the parasite brings to the host and the reactions which develop in the host’s body due to parasitic invasion. EFFECT OF PARASITES ON THE HOST The damage which pathogenic parasites produce in the tissues of the host may be described in the following two ways; (a) Direct effects of the parasite on the host Mechanical injury - may be inflicted by a parasite by means of pressure as it grows larger, e.g. Hydatid cyst causes blockage of ducts such as blood vessels producing infraction. Deleterious effect of toxic substances- in Plasmodium falciparum production of toxic substances may cause rigors and other symptoms. Deprivation of nutrients, fluids and metabolites -parasite may produce disease by competing with the host for nutrients. (b) Indirect effects of the parasite on the host: Immunological reaction: Tissue damage may be caused by immunological response of the host, e.g. nephritic syndrome following Plasmodium infections. Excessive proliferation of certain tissues due to invasion by some parasites can also cause tissue damage in man, e.g. fibrosis of liver after deposition of the ova of Schistosoma. 4 BASIC CONCEPTS IN MEDICAL PARASITOLOGY In medical parasitology, each of the medically important parasites are discussed under the standard subheadings of morphology, geographical distribution, means of infection, life cycle, host/parasite relationship, pathology and clinical manifestations of infection, laboratory diagnosis, treatment and preventive/control measures of parasites. In the subsequent section some of these criteria are briefly presented. Morphology - includes size, shape, color and position of different organelles in different parasites at various stages of their development. This is especially important in laboratory diagnosis which helps to identify the different stages of development and differentiate between pathogenic and commensal organisms. For example, Entamoeba histolytica and Entamoeba coli. Geographical distribution - Even though revolutionary advances in transportation has made geographical isolation no longer a protection against many of the parasitic diseases, many of them are still found in abundance in the tropics. Distribution of parasites depends upon: a. The presence and food habits of a suitable host: Host specificity, for example, Ancylostoma duodenale requires man as a host where Ancylostoma caninum requires a dog. Food habits, e.g. consumption of raw or undercooked meat or vegetables predisposes to Taeniasis b. Easy escape of the parasite from the host- the different developmental stages of a parasite which are released from the body along with faeces and urine are widely distributed in many parts of the world as compared to those parasites which require a vector or direct body fluid contact for transmission. c. Environmental conditions favoring survival outside the body of the host, i.e. temperature, the presence of water, humidity etc. d. The presence of an appropriate vector or intermediate host – parasites that do not require an intermediate host (vector) for transmission are more widely distributed than those that do require vectors. 5 Once we are clear about the geographical distribution and conditions favoring survival in relation to different parasites, effective preventive and control measures can more easily be devised and implemented. Life cycle of parasites - the route followed by a parasite from the time of entry to the host to exit, including the extracorporeal (outside the host) life. It can either be simple, when only one host is involved, or complex, involving one or more intermediate hosts. A parasite’s life cycle consists of two common phases one phase involves the route a parasite follows inside the body. This information provides an understanding of the symptomatology and pathology of the parasite. In addition the method of diagnosis and selection of appropriate medication may also be determined. The other phase, the route a parasite follows outside of the body, provides crucial information pertinent to epidemiology, prevention, and control. Host parasite relationship - infection is the result of entry and development within the body of any injurious organism regardless of its size. Once the infecting organism is introduced into the body of the host, it reacts in different ways and this could result in: a. Carrier state - a perfect host parasite relationship where tissue destruction by a parasite is balanced with the host’s tissue repair. At this point the parasite and the host live harmoniously, i.e. they are at equilibrium. b. Disease state - this is due to an imperfect host parasite relationship where the parasite dominates the upper hand. It can result either from lower resistance of the host or a higher pathogenecity of the parasite. c. Parasite destruction – occurs when the host takes the upper hand. Laboratory diagnosis – depending on the nature of the parasitic infections, the following specimens are selected for laboratory diagnosis: a) Blood – in those parasitic infections where the parasite itself in any stage of its development circulates in the blood stream, examination of blood film forms one of the main procedures for specific diagnosis. For example, in malaria the parasites are found inside the red blood cells. In Bancroftian and Malayan filariasis, microfilariae are found in the blood plasma. 6 b) Stool – examination of the stool forms an important part in the diagnosis of intestinal parasitic infections and also for those helminthic parasites that localize in the biliary tract and discharge their eggs into the intestine. In protozoan infections, either trophozoites or cystic forms may be detected; the former during the active phase and the latter during the chronic phase. Example, Amoebiasis, Giardiasis, etc. In the case of helmithic infections, the adult worms, their eggs, or larvae are found in the stool. c) Urine – when the parasite localizes in the urinary tract, examination of the urine will be of help in establishing the parasitological diagnosis. For example in urinary Schistosomiasis, eggs of Schistosoma haematobium are found in the urine. In cases of chyluria caused by Wuchereria bancrofti, microfilariae are found in the urine. d) Sputum – examination of the sputum is useful in the following: In cases where the habitat of the parasite is in the respiratory tract, as in Paragonimiasis, the eggs of Paragonimus westermani are found. In amoebic abscess of lung or in the case of amoebic liver abscess bursting into the lungs, the trophozoites of E. histolytica are detected in the sputum. e) Biopsy material - varies with different parasitic infections. For example spleen punctures in cases of kala-azar, muscle biopsy in cases of Cysticercosis, Trichinelliasis, and Chagas’ disease, Skin snip for Onchocerciasis. f) Urethral or vaginal discharge – for Trichomonas vaginalis Indirect evidences – changes indicative of intestinal parasitic infections are: a. Cytological changes in the blood – eosiniphilia often gives an indication of tissue invasion by helminthes, a reduction in white blood cell count is an indication of kala-azar, and anemia is a feature of hookworm infestation and malaria. b. Serological tests – are carried out only in laboratories where special antigens are available. 7 Treatment – many parasitic infections can be cured by specific chemotherapy. The greatest advances have been made in the treatment of protozoal diseases. For the treatment of intestinal helminthiasis, drugs are given orally for direct action on the helminthes. To obtain maximum parasiticidal effect, it is desirable that the drugs administered should not be absorbed and the drugs should also have minimum toxic effect on the host. Prevention and control - measures may be taken against every parasite infectiving humans. Preventive measures designed to break the transmission cycle are crucial to successful parasitic eradication. Such measures include: Reduction of the source of infection- the parasite is attacked within the host, thereby preventing the dissemination of the infecting agent. Therefore, a prompt diagnosis and treatment of parasitic diseases is an important component in the prevention of dissemination. Sanitary control of drinking water and food. Proper waste disposal – through establishing safe sewage systems, use of screened latrines, and treatment of night soil. The use of insecticides and other chemicals used to control the vector population. Protective clothing that would prevent vectors from resting in the surface of the body and inoculate pathogens during their blood meal. Good personal hygiene. Avoidance of unprotected sexual practices. CLASSIFICATION OF MEDICAL PARASITOLOGY Parasites of medical importance come under the kingdom called protista and animalia. Protista includes the microscopic single-celled eukaroytes known as protozoa. In contrast, helminthes are macroscopic, multicellular worms possessing well- differentiated tissues and complex organs belonging to the kingdom animalia. Medical Parasitology is generally classified into: Medical Protozoology - Deals with the study of medically important protozoa. 8 Medical Helminthology - Deals with the study of helminthes (worms) that affect man. Medical Entomology - Deals with the study of arthropods which cause or transmit disease to man. Describing animal parasites follow certain rules of zoological nomenclature and each phylum may be further subdivided as follows: Super class Super family Phylum Subphylum Class Order Family Genus Species Subclass Subfamily 9 FIGURE 1. CLASSIFICATION OF MEDICALLY IMPORTANT PARASITES PROTOZOA METAZOA (HELIMINTHS) Sarcodina (Amoebae): Platyhelminthes: (a) Genus, Entameba: Trematodea: E.g. Entameba histolytica (a) Genus Schistosoma (b) Genus Endolimax E.g. S. mansoni E.g. Endolimax nana (b) Genus Fasciola (c) Genus Iodameba E.g. F. hepatica E.g. Iodameba butchlii Cestoda: (d) Genus Dientmeba (a) Genus Diphylobotrium E.g. Dientameba fragilis E.g. D. latum Mastigophora (Flagellates): (b) Genus Taenia (a) Genus Giardia E.g. T. saginata E.g. G. lamblia (c) Genus Echinococcus (b) Genus Trichomonas E.g. E. granulosus E.g. T. vaginalis (d) Genus Hymenolepsis (c) Genus Trypanosoma E.g. H. nana E.g. T. brucci Nemathelminthes: (d) Genus Leishmania (a) Intestinal Nematodes E.g. L. donovani E.g. A. lumbricoides Sporozoa (b) Somatic Nematodes (1) Genus Plasmodium E.g. W. bancrofti E.g. P. falciparum (2) Genus Toxoplasma E.g. T. gondi (3) Genus Cryptosporidum E.g. C. parvum (4) Genus Isospora E.g. I. beli Ciliates E.g. Balantidium coli 10 Parasitology GENERAL CHARACTERISTICS OF MEDICALLY IMPORTANT PARASITES Medically important protozoa, helminthes, and arthropods, which are identified as causes and propagators of disease have the following general features. These features also differ among parasites in a specific category. (1) PROTOZOA Protozoan parasites consist of a single "cell-like unit" which is morphologically and functionally complete and can perform all functions of life. They are made up of a mass of protoplasm differentiated into cytoplasm and nucleoplasm. The cytoplasm consists of an outer layer of hyaline ectoplasm and an inner voluminous granular endoplasm. The ectoplasm functions in protection, locomotion, and ingestion of food, excretion, and respiration. In the cytoplasm there are different vacuoles responsible for storage of food, digestion and excretion of waste products. The nucleus also functions in reproduction and maintaining life. The protozoal parasite possesses the property of being transformed from an active (trophozoite) to an inactive stage, losing its power of motility and enclosing itself within a tough wall. The protoplasmic body thus formed is known as a cyst. At this stage the parasite loses its power to grow and multiply. The cyst is the resistant stage of the parasite and is also infective to the human host. Reproduction – the methods of reproduction or multiplication among the parasitic protozoa are of the following types: 1. Asexual multiplication: (a) Simple binary fission – in this process, after division of all the structures, the individual parasite divides either longitudinally or transversely into two more or less equal parts. (b) Multiple fission or schizogony – in this process more than two individuals are produced, e.g. asexual reproduction in Plasmodia. 11 2. Sexual reproduction: (a) Conjugation – in this process, a temporary union of two individuals occurs during which time interchange of nuclear material takes place. Later on, the two individuals separate. (b) Syngamy – in this process, sexually differentiated cells, called gametes, unite permanently and a complete fusion of the nuclear material takes place. The resulting product is then known as a zygote. Protozoa are divided into four types classified based on their organs of locomotion. These classifications are: amoebas, ciliates, flagellates, and sporozoans. TABLE 1. CLASSIFICATION OF THE PATHOGENIC PROTOZOA: PROTOZOA ORGAN OF IMPORTANT HUMAN LOCOMOTION PATHOGENS 1. Rhizopoda Pseudopodia Entamoeba histolytica (Amoeba) 2. Mastigophora Flagella Trypanosomes (Flagellates) Leishmania Trichomonas Giardia 3. Sporozoa None, exhibit a slight Plasmodium.Spp Amoeboid movement 4. Ciliates Cilia Balantidium coli 12 (2) HELIMINTHS: The heliminthic parasites are multicellular, bilaterally symmetrical animals having three germ layers. The helminthes of importance to human beings are divided into three main groups with the peculiarities of the different categories described in table 2. TABLE 2. DIFFERENTIATING FEATURES OF HELMINTHES CESTODE TREMATODE NEMATODE Shape Tape like, segmented Leaf like, Unsegmented Elongated, Cylindrical Sexes Not separate Not separate Separate. (monoecious) (monoecious) (diecious) Except blood flukes which are dioecious "Head" End Suckers: with hooks Suckers: no hooks No suckers, and hooks Alimentary Absent Present Present and canal but incomplete complete Body cavity Absent Absent Present 13 (3) ARTHROPODS Arthropods, which form the largest group of species in the animal kingdom, are characterized by having a bilaterally symmetrical and segmented body with jointed appendages. They have a hard exoskeleton, which helps enclose and protect the muscles and other organs. An open circulatory system, with or without a dorsally situated heart pumps the blood (hemolymph) via arteries to the various organs and body tissues. Blood is returned to the heart through body spaces known as hemocoeles. In addition, respiratory, excretory, and nervous systems are present. Arthropods affect the health of humans by being either direct agents for disease or agents for disease transmission. The arthropods of medical importance are found in Classes Insecta, Arachnida, and Crustacia which have their own distinguishing features. In Class insecta the body is divided into head, thorax, and abdomen, with one pair of antennae. Diseases like malaria, yellow fever, onchocerciasis, and trypanasomiasis are primarily transmitted by insects. FIGURE 2. CLASSIFICATION OF ARTHROPODS Kingdom Animalia Phylum Arthropoda Class Class Class Class Class Crustacia Arachnida Insecta Chilopoda Pentastomida e.g. Scorpion e.g. Ticks e.g. Mosquito e.g. Centipedes e.g. tongue worms N.B. Crustacia, Arachnida, and Insecta are the three most common classes of arthropods of medical significance, which need closer attention 14 SUMMARY A parasite is an organism which lives in/on the body of a host. A host is that which harbors the parasite. There is usually some association such as mutualism, commensalisms, or parasitism between the parasite and the host. This association may produce a variety of effects and the host usually tends to react to it. Understanding the various structural and behavioral components of parasites assists classification. In general, the protozoa, helminthes and arthropods are the most commonly studied and the most important parasites in medical parasitology. They are further sub classified considering many parameters. 15 REVIEW QUESTIONS 1. Explain briefly the various types of parasites and hosts. 2. Explain the three types of symbiotic relationships and give examples. 3. Discuss the mechanisms by which parasites impose their effect on the host. 4. Give examples of reactions that occur in the body of the host following parasitic invasion. REFERENCES: 1. Robert F. Boyd, Basic medical microbiology, third edition, 1986 2. K.D. Chaterjee, protozoology and helminthology, twelfth edition, 1980 3. Brown, H.W. and Neva. F.A. Basic clinical Parasitology (5th edn) New York: 1982. 4. Zaman, V. scanning electron microscopy of medically important parasites. Littleton, MA: Johnwright PSG, 1983. 5. Belding, D., Text book of clinical parasitology, 2nd edition, New York, 1952. 16 UNIT TWO MEDICAL PROTOZOLOGY LEARNING OBJECTIVES: At the end of the lesson, the student should be able to: Discuss the classification of medically important protozoa. Discuss the pathogenesis and clinical aspects of infections. Describe the general epidemiological aspects and transmission patterns of diseases caused by protozoa. Identify the methods and procedures of laboratory diagnosis of pathogenic protozoa in clinical specimens. Discuss treatment options for protozoan infections. Implement the preventive and control measures of protozoan infection. INTRODUCTION Protozoa (singular, protozoan), from the Greek ‘protos’ and ‘zoon’ meaning “first animal”, are members of eukaryotic protists. They may be distinguished from other eukaryotic protists by their ability to move at some stage of their life cycle and by their lack of cell wall. Occurrence of protozoa Protozoa are found in all moist habitats. They are common in sea, in soil and in fresh water. These organisms occur generally as a single cell. Colonies of protozoa might also occur in which individual cells are joined by cytoplasmic threads and form aggregates of independent cells. However, distinct types of protozoa, include a resistant cyst (non-motile) stage to survive adverse environmental conditions, such as desiccation, low nutrient supply, and even anaerobiosis. For example, the soil amoeba, Naegleria is a resistant cyst in dry 17 weather, a naked amoeba in moist soil, and becomes flagellated when flooded with water. Morphology of protozoa Protozoa are predominantly microscopic, ranging in size from 2 to more than 100μm. Morphologically, they are within a mass of protoplasm, consisting of a true membrane – bound nucleus and cytoplasm. The nucleus contains clumped or dispersed chromatin and central nucleolus or karyosome, which are useful structures to distinguish protozoan species from one another based on the shape, size and distribution of these structures. Importance of protozoa Protozoa serve as an important link in the food chain and ecological balance of many communities in wetland & aquatic environments. They are also important in biological sewage treatment, which involves both anaerobic digestion and/or aeration. In addition, protozoa are important laboratory organisms in research areas, by which their asexual reproduction enables clones to be established with the same genetic make-up. These are useful in the study of cell cycles and nucleic acid biosynthesis during cell division. Medical concern of protozoa Protozoa are ubiquitous in moist areas, including the human alimentary canal. From an ecological standpoint, protozoa may be divided into free-living forms and symbiotic forms. Some of the symbiotic ones are parasitic and may cause disease. Although most amoebas are free-living, several are found as commensal inhabitants of the intestinal tract in humans. One of these organisms Entamoeba histolytica may invade tissue and produce disease. The majority of ciliates are free living and seldom parasitize humans. Flagellates of the genus Trypanosomes and Leishmania are capable of invading the blood & tissue of humans, where they produce severe chronic illness. Others such as Trichomonas vaginalis and Giardia lamblia, inhabit the 18 urogenital and gastrointestinal tracts and initiate disease characterized by mild to moderate morbidity but no mortality. Sporozoan organisms, in contrast, produce two of the most potentially lethal diseases of humankind: malaria and toxoplasmosis. With the advent of HIV a new and important chapter has been opened; i.e. ‘opportunistic’ parasitosis. Most of the parasitic incidents belong to endocellular protozoa of different genera or species. Reproduction and regeneration of protozoa As a general rule, protozoa multiply by asexual reproduction. This is not to say that sexual processes are absent in the protozoa. Some parasitic forms may have an asexual phase in one host and a sexual phase in another host. (refer to page 18 for details on reproduction of protozoans) Transmission In most parasitic protozoa, the developmental stages are often transmitted from one host to another within a cyst. The reproduction process is also related to the formation of the cyst. Asexual reproduction of some ciliates and flagellates is associated with cyst formation, and sexual reproduction of Sporozoa invariably results in a cyst. Pathogenic protozoa can spread from one infected person to another by: Faecal – oral transmission of contaminated foods and water. Insect bit inoculums or rubbing infected insect faeces on the site of bite. Sexual intercourse Pathogenesis Protozoan organisms are virtually always acquired from an exogenous source, and as such, they have evolved numerous ways to enter the body of the human host. Factors that are important for pathogenecity include: Attachment to the host tissue followed by replication to establish colonization. 19 Toxic products released by parasitic protozoa. Shifting of antigenic expression to evade the immune response and inactivate host defences. Antiprotozoal agents Generally the antiprotozoal agents target relatively rapidly proliferating, young, growing cells of the parasite. Most commonly, these agents target nucleic acid synthesis, protein synthesis, or specific metabolic pathways (e.g. folate metabolism) unique to the protozoan parasites. CLASSIFICATION OF PROTOZOA Protozoa of medical importance are classified based on their morphology and locomotive system as described below: Amoebas - Entamoeba histolytica Flagellates - Giarda lamblia, Trichomonas vaginalis, Trypanosoma spp, Leishmania spp Cliliophora - Balantidium coli Coccidian - Isospora belli, Cryptosporidium parvum, Toxoplasma gondii, Plasmodium species Protozoan pathogens can also be grouped according to the location in the body where they most frequently cause disease. 20 Table-1 Important pathogenic protozoa and commonly caused diseases. Type and location Species Disease Intestinal tract Entamoeba histolytica Ambiasis Giardia lamblia Giardiasis Cryptosporidium parvum Cryptosporidiosis Balantidium coli Balantidiasis Isospora belli Isosporiosis Cyclospora cayentanensis Cyclosporiasis Urogenital tract Trichomonas vaginalis Trichomoniasis Blood and tissue Plasmodium species Malaria Toxoplasma gondii Toxoplasmosis Trypanasoma species Trypanosomiasis Leishmania species Leishmaniasis Naegleria species Amoebic Meningoencephalitis Acanthamoeba species Amoebic Meningoencephalitis Babesia microti Babesiosis 21 UNIT THREE AMOEBIASIS INTRODUCTION Amoebas primitive unicellular microorganisms with a relatively simple life cycle which can be divided into two stages: Trophozoite – actively motile feeding stage. Cyst – quiescent, resistant, infective stage. Their reproduction is through binary fission, e.g. splitting of the trophozoite or through the development of numerous trophozoites with in the mature multinucleated cyst. Motility is accomplished by extension of pseudopodia (“false foot”) 1.1. Entamoeba histolytica Morphological features (a) Trophozoites Viable trophozoites vary in size from about 10-60μm in diameter. Motility is rapid, progressive, and unidirectional, through pseudopods. The nucleus is characterized by evenly arranged chromatin on the nuclear membrane and the presence of a small, compact, centrally located karyosome. The cytoplasm is usually described as finely granular with few ingested bacteria or debris in vacuoles. In the case of dysentery, however, RBCs may be visible in the cytoplasm, and this feature is diagnostic for E.histolytica. (b) Cyst Cysts range in size from 10-20μm. The immature cyst has inclusions namely; glycogen mass and chromatoidal bars. As the cyst matures, the glycogen completely disappears; the chromotiodials may also be absent in the mature cyst. 22 Life cycle Intestinal infections occur through the ingestion of a mature quadrinucleate infective cyst, contaminated food or drink and also by hand to mouth contact. It is then passed unaltered through the stomach, as the cyst wall is resistant to gastric juice. In terminal ileum (with alkaline pH), excystation takes place. Trophozoites being actively motile invade the tissues and ultimately lodge in the submucous layer of the large bowel. Here they grow and multiply by binary fission. Trophozoites are responsible for producing lesions in amoebiasis. Invasion of blood vessels leads to secondary extra intestinal lesions. Gradually the effect of the parasite on the host is toned down together with concomitant increase in host tolerance, making it difficult for the parasite to continue its life cycle in the trophozoite phase. A certain number of trophozoites come from tissues into lumen of bowel and are first transformed into pre-cyst forms. Pre-cysts secret a cyst wall and become a uninucleate cyst. Eventually, mature quadrinucleate cysts form. These are the infective forms. Both mature and immature cysts may be passed in faeces. Immature cysts can mature in external environments and become infective. 23 Figure-1 life cycle of Entamoeba histolytica Pathogenesis Trophozoites divide and produce extensive local necrosis in the large intestine. Invasion into the deeper mucosa with extension into the peritoneal cavity may occur. This can lead to secondary involvement of other organs, primarily the liver but also the lungs, brain, and heart. Extraintestinal amebiasis is associated with trophozoites. Amoebas multiply rapidly in an anaerobic environment, because the trophozites are killed by ambient oxygen concentration. Epidemiology E.histolytica has a worldwide distribution. Although it is found in cold areas, the incidence is highest in tropical and subtropical regions that have poor sanitation and contaminated water. About 90% of infections are asymptomatic, and the remaining produces a spectrum of clinical syndrome. Patients infected with E.hisolytica pass non- 24 infectious trophozotes and infectious cysts in their stools. Therefore, the main source of water and food contamination is the symptomatic carrier who passes cysts. Symptomatic amebiasis is usually sporadic. The epidemic form is a result of direct person-to-person faecal-oral spread under conditions of poor personal hygiene. Clinical features The outcome of infection may result in a carrier state, intestinal amebiasis, or exteraintestinal amebiasis. Diarrhoea, flatulence, and cramping are complaints of symptomatic patients. More severe disease is characterised by the passing of numerous bloody stools in a day. Systemic signs of infection (fever, leukocytosis, rigors) are present in patients with extraintestinal amebiasis. The liver is primarily involved, because trophozoites in the blood are removed from the blood by the portal veins. The right lobe is most commonly involved, thus pain over the liver with hepatomegaly and elevation of the diaphragm is observed. Immunity E.histolytica elicits both the humeral and cellular immune responses, but it is not yet clearly defined whether it modulates the initial infection or prevents reinfection. Laboratory diagnosis In intestinal amoebiasis: Examination of a fresh dysenteric faecal specimen or rectal scraping for trophozoite stage. (Motile amoebae containing red cells are diagnostic of amoebic dysentery). Examination of formed or semiformed faeces for cyst stage. (Cysts indicate infection with either a pathogenic E.histolytica or non-pathogenic E.dispar.) 25 Figure 2-, E.histolytica trophozoite (A) E. histolytica Cyst (B) Extraintestinal amoebiasis Diagnosed by the use of scanning procedures for liver and other organs. Specific serologic tests, together with microscopic examination of the abscess material, can confirm the diagnosis. Treatment Acute, fulminating amebiasis is treated with metrondiazole followed by iodoquinol, and asymptomatic carriage can be eradicated with iodoquinol, diloxanide furoate, or paromomycin. The cysticidal agents are commonly recommended for asymptomatic carriers who handle food for public use. Metronidazole, chloroquine, and diloxanide furoate can be used for the treatment of extra intestinal amoebiasis. Prevention Introduction of adequate sanitation measures and education about the routes of transmission. Avoid eating raw vegetables grown by sewerage irrigation and night soil 26 1.2. OTHER AMEBAE INHABITING THE ALIMENTARY CANAL Most of these amoebae are commensal organisms that can parasitize the human gastrointestinal tract. Entamoeba hartmanni in all of its life–cycle stage, E.hartmanni resembles E.histolytica except in size, yet there is a slight overlap in the size range. The trophozoites do not ingest red blood cells, and their motility is generally less vigorous than that of E.histolytica. As in other amebae, infection is acquired by ingestion of food or water contaminated with cyst-bearing faeces. Identification is based on examination of small amebae in unstained or iodine-stained preparations. Usually no treatment is indicated, measures generally effective against faecal-borne infections will control this amoebic infection. Entamoeba coli the life cycle stages include; trophozoite, precyst, cyst, metacyst, and metacystic trophozoite. Typically the movements of trophozoites are sluggish, with broad short pseudopodia and little locomotion, but at a focus the living specimen cannot be distinguished from the active trophotozoite of E.histolytica. However, the cysts are remarkably variable in size. Entamoeba coli is transmitted in its viable cystic stage through faecal contamination. Ε.coli as a lumen parasite is non-pathogenic and produces no symptoms. The mature cyst (with more than four nuclei) is the distinctive stage to differentiate E.coli from the pathogenic E.histolytica. Specific treatment is not indicated since this amoeba is non-pathogenic. The presence of E.coli in stool specimen is evidence for faecal contamination. Prevention depends on better personal hygiene and sanitary disposal of human excreta. Entamoeba polecki- arelatively cosmopolitan parasite of hog and monkey. It can cause human disease but is rarely isolated. The disease is manifested as mild, transient diarrhoea. The diagnosis of E.polecki infection is confirmed by the microscopic detection of cysts in stool specimens. Treatment is the same as for E.histolytica infection. Prevention is achieved by good personal hygiene. 27 Endolimax nana is a lumen dweller in the large intestine, primarily at the cecal level, where it feeds on bacteria. The life cycle is similar to E.histolytica. Motility is typically sluggish (slug-like) with blunt hyaline pseudopodia, Projects shortly. Human infection results from ingestion of viable cysts in polluted water or contaminated food. Typical ovoid cysts of E.nana are confirmative. Rounded cysts and living trophozoites are often confused with E.hartmanni and E.histolytica. No treatment is indicated for this non- pathogenic infection. Prevention can be achieved through personal cleanliness and community sanitation. Iodamoeba buetschlii: - the natural habitat is the lumen of the large intestine, the principal site probably being the caecum. The trophozoite feeds on enteric bacteria; it is a natural parasite of man and lower primates. It is generally regarded as a non- pathogenic lumen parasite. No treatment is ordinarily indicated. Prevention is based on good personal hygiene and sanitation in the community. Entamoeba gingivalis - only the trophozoite stage presents, and encystation probably does not occur. E.gingivalis is a commensal, living primarily on exudate from the margins of the gums, and thrives best on unhealthy gums. No specific treatment is indicated. However the presence of E.giingivalis suggests a need for better oral hygiene. The infection can be prevented by proper care of the teeth and gums. Blastocystis hominis- is an inhabitant of the human intestinal tract previously regarded as non-pathogenic yeast. Its pathogenecity remains controversial. The organism is found in stool specimen from asymptomatic people as well as from people with persistent diarrhoea. B.hominis is capable of pseudopodia extension and retraction, and reproduces by binary fission or sporulation. The classic form that is usually seen in the human stool specimen varies tremendously in size, from 6-40μm. There are thin – walled cysts involved in autoinfection, and thick–walled cysts responsible for external transmission via the faecal-oral route. The presence of large numbers of these parasites (five or more per oil immersion microscopic field) in the absence of other intestinal pathogens indicates disease. The organism may be detected in wet mounts or trichome –stained smears of faecal specimens. Treatment with iodoquinol or metronidazole has 28 been successful in eradicating the organism from intestine and alleviating symptoms. However, the definitive role of B.hominis in disease remains to be demonstrated. The incidence and apparent worldwide distribution of the infection indicates preventive measures to be taken, which involve improving personal hygiene and sanitary conditions. 29 Parasitology Table 2: Morphology of Trophozites of intestinal Amoebae Nucleus Cytoplasm Size (diameter Motility Number Peripheral Karyosomal Appearance Inclusions Species or length) Chromatin chromatin Entamoeba 10-60μm: usual Progressive with One: not Fine granules: Small, discrete: Finely Erythrocytes histolytica range. 15- hyaline, finger- visible in usually evenly usually centrally granular occasionally: 20μm- like pseudopods unstained distributed and located, but non-invasive commensal preparations uniform in size occasionally organisms may form- over eccentrically located contain bacteria 20μm-invasive form Entamoeba 5-12μm:usual Usually One: not Similar to E. Small, discrete, often Finely Bacteria hartmanni range, 8-10μm non progressive: visible in histolytica eccentrically located granular may be unstained progressive preparations occasionally Entamoeba 15-50μm: usual Sluggish, non One: often Coarse Large, discrete, Coarse, Bacteria yeasts, coli range, 20-25μm progressive, visible in granules, usually eccentrically often other materials with blunt unstained irregular in located vacuolated pseudopods preparations size and distribution 30 Entamoeba 10-25μm: usual Usually One:may be Usually fine Small, discrete, Coarsely Bacteria yeasts ploecki range, 15 -20μm sluggish, similar slightly granules eccentrically located: granular, to E.coli; visible in evenly occasionally large, may occasionally in unstained distributed, diffuse, or irregular resemble diarrheic preparations: occasionally E.coli; speciments, occasionally irregularly vacuolated may be distorted by arranged, progressive pressure chromatin from sometimes in vacuoles in plaques or cytoplasm crescents Endolimax 6-12μm: usual Sluggish, usually One: visible None Large, irregularly Granular, Bacteria nana range, 8 -10μm non- progressive, occasionally shaped, blotlike vacuolated with blunt in unstained psedopods preparations Iodamoeba 8-20μm: usual Sluggish usually One: not None Large, usually Coarsely Bacteria, yeasts, buetschlii range, 12 -15μm non-progressive usually centrally located, granular, or other material visible in surrounded by vacuolated unstained refractile, achromatic preparations granules: granules often not distinct even in stained slides 31 Table 3: Morphology of cysts of intestinal Amoebae Nucleus Cytoplasm Species Size Shape Peripheral Karyosomal Chromatoid Glycogen and Number Chromatin chromatin bodies other features Entaboeba 10-20μm: Usually Four in mature Peripheral Small, discrete, Present: elongated Usually diffuse: histolytica usual spherical cyst: immature chromatin usually centrally bars with bluntly concentrated range, 12 cysts with 1 or present: fine, located rounded ends mass often in –15μm 2 occasionally uniform young cysts; seen granules, evenly stains reddish distributed brown with iodine Entaboeba 5-10μm: Usually Four in mature Similar to E. Similar to E. Present: elongated Similar to E. histolytica usual spherical: cyst: immature histolytica hisolytica bars with bluntly hisolytica range, 6 cysts with 1 or rounded ends; –8μm 2 often seen may be rounded and grapelike Entaboeba 10-35μm: Usually Eight in Peripheral Large, discrete, Present, but less Usually diffuse, coli usual spherical: mature cyst: chromatin usually frequently seen but occasionally range, sometimes occasionally, present: coarse eccentrically, than in E. well-defined 15 – oval, super nucleate granules but occasionally histolytica; usually mass in 25μm triangular, cysts with 16 irregular in size centrally, splinterlike with immature cysts; or of or more are and distribution, located pointed ends stains reddish 32 another rarely seen; but often appear brown with iodine shape immature more uniform cysts with 2 or than in more trophozoite occasionally seen Endolimas 5-10μm: Spherical, Four in mature None Large (blotlike), Granules Usually diffuse; nana usual ovoid, or cysts: usually centrally occasionally or concentrated range, ellipsoidal immature located small oval masses mass 6 -8μm cysts with lees present, but bodies occasionally in than 4 rarely as seen in young cysts; seen Entamoeba stains reddish species are not brown with iodine present Iodamoeb 5-20μm: Ovoid One in mature None Large, usually Granules Compact, well- a usual ellipsoidal, cyst eccentrically occasionally defined mass; buetschlii range, triangular, located; present, but bodies stains dark brown 10 – or of refractile, as seen in with iodine 12μm another achromatic Entamoeba shape granules on species are not 33 one side of present karyosome; indistinct in iodine preparations 34 1.3. PATHOGENIC FREE-LIVING AMOEBAE Among the numerous free-living amoebae of soil and water habitats, certain species of Naegleria, Acanthamoeba and Balamuthia are facultative parasites of man. Most human infections of these amoebae are acquired by exposure to contaminated water while swimming. Inhalation of cysts from dust may account for some infections. Naegleria fowleri- the trophozoites occur in two forms. Amoeboid forms with single pseudopodia and flagella forms with two flagella which usually appear a few hours after flooding water or in CSF. Figure 3. Naegleria trophozoites in a section of spinal cord from a patient with amoebic meningoecephalitis Acanthameba species- the trophozoites have an irregular appearance with spine-like pseudopodia, and acanthopodia. Balamuthia species- the trophozoite extends a broad, flat lamellipodia or sub pseudopodia from it. The trophozoite may be bi-nucleated. Unlike most amoebae the nuclear envelope breaks down during mitosis. Naegleria, Acanthamoeba, Balamuthia organisms are opportunistic pathogens. Naegleria fowleri causes acute primary amoebic meningoencephalitis. Acantamoeba & Balamuthia organisms are responsible for granulomatous amoebic encephalitis and single or multiple brain abscesses, primarily in immunocompromised individuals. Keratitis (eye) and skin infection by Acanthamoeba may also occur. For the diagnosis of Naegleria, Acanthamoeba, and Balamuthia infections, specimens of nasal 35 discharge and cerebrospinal fluid; and in cases of eye infections corneal scraping should be collected. The clinical specimen can be examined with saline wet- preparation and Iodine stained smear. Treatment of free-living amoebic infections is largely ineffective. These infections are rare in Ethiopia. 36 UNIT FOUR PATHOGENIC FLAGELLATES INTRODUCTION Flagellates are unicellular microorganisms. Their locomotion is by lashing a tail-like appendage called a flagellum or flagella and reproduction is by simple binary fission. There are three groups of flagellates: Luminal flagellates Giardia lamblia Dientmoeab fragilis Hemoflagellates Trypanosoma species. Leishmania species. Genital flagellates Trichomonas vaginalis 2.1. Luminal flagellates 2.1.1. Giardia lamblia Important features – the life cycle consists of two stages, the trophozoite and cyst. The trophozoite is 9-12 μm long and 5-15μm wide anteriorly. It is bilaterally symmetrical, pear-shaped with two nuclei (large central karyosome), four pairs of flagella, two axonemes, and a suction disc with which it attaches to the intestinal wall. The oval cyst is 8-12μm long and7-10μm wide, thick-walled with four nucleus and several internal fibera? Each cyst gives rise to two trophozoites during excystation in the intestinal tract. Transmission is by ingestion of the infective cyst. 37 Figure 4; Life cycle of Giardia lamblia. Pathogenesis Infection with G.lamblia is initiated by ingestion of cysts. Gastric acid stimulates excystation, with the release of trophozoites in duodenum and jejunum. The trophozoites can attach to the intestinal villi by the ventral sucking discs without penetration of the mucosa lining, but they only feed on the mucous secretions. In symptomatic patients, however, mucosa-lining irritation may cause increased mucous secretion and dehydration. Metastatic spread of disease beyond the GIT is very rare. Epidemiology Giardia lamblia has a worldwide distribution, particularly common in the tropics and subtropics. It is acquired through the consumption of inadequately treated contaminated water, ingestion of contaminated uncooked vegetables or fruits, or person-to-person spread by the faecal-oral route. The cyst stage is resistant to chlorine in concentrations used in most water treatment facilities. Infection exists in 50% of symptomatic carriage, and reserves the infection in endemic form. 38 Clinical features Clinical disease: Giardiasis Symptomatic giardiasis ranges from mild diarrhea to severe malabsorption syndrome. Usually, the onset of the disease is sudden and consists of foul smelling, watery diarrhea, abdominal cramps, flatulence, and streatorrhoea. Blood & pus are rarely present in stool specimens, a feature consistent with the absence of tissue destruction. Immunity The humoral immune response and the cellular immune mechanism are involved in giardiasis. Giardia – specific IgA is particularly important in both defense against and clearance of parasite. Laboratory diagnosis Examination of diarrhoeal stool- trophozoite or cyst, or both may be recovered in wet preparation. In examinations of formed stool (e.g. in asymptomatic carriers) only cysts are seen. Giardia species may occur in “showers”, i.e. many organisms may be present in the stool on a given day and few or none may be detected the next day. Therefore one stool specimen per day for 3 days is important. 39 Figure 5; Giardia lamblia tphozoite (A), cyst (B) If microscopic examination of the stool is negative in a patient in whom giardiasis is highly suspected duodenal aspiration, string test (entero-test), or biopsy of the upper small intestine can be examined. In addition to conventional microscopy, several immunologic tests can be implemented for the detection of parasitic antigens. Treatment For asymptomatic carriers and diseased patients the drug of choice is quinacrine hydrochloride or metronidazole. Prevention - Asymptomatic reservoirs of infection should be identified & treated. - Avoidance of contaminated food and water. - Drinking water from lakesand streams should be boiled, filtered and/or iodine- treated. - Proper waste disposal and use of latrine. 40 2.1.2. Trichomonas vaginalis Important features- it is a pear-shaped organism with a central nucleus and four anterior flagella; and undulating membrane extends about two-thirds of its length. It exists only as a trophozoite form, and measured 7-23μm long & 5-15μm wide. Transmission is by sexual intercourse. Figure 6; Life cycle of Trichomonas vaginalis Pathogenesis The trophozoite is found in the urethra & vagina of women and the urethra & prostate gland of men. After introduction by sexual intercourse, proliferation begins which results in inflammation & large numbers of trophozoites in the tissues and the secretions. The onset of symptoms such as vaginal or vulval pruritus and discharge is often sudden and occurs during or after menstruation as a result of the increased vaginal acidity. The vaginal secretions are liquors, greenish or yellowish, sometimes frothy, and foul smelling. Infection in the male may be latent, with no symptoms, or may be present as self limited, persistent, or recurring urethritis. 41 Epidemiology This parasite has worldwide distribution, and sexual intercourse is the primary mode of transmission. Occasionally, infections can be transmitted by fomites (toilet articles, clothing), although this transmission is limited by liability of the trophozoite. Rarely Infants may be infected by passage through the mother’s infected birth canal. The prevalence of this flagellate in developing countries is reported to be 5% –20% in women and 2% –10% in men. Clinical features Clinical disease - trichomoniasis. Most infected women at the acute stage are asymptomatic or have a scanty, watery vaginal discharge. In symptomatic cases vaginitis occurs with more extensive inflammation, along with erosion of epithelial lining, and painful urination, and results in symptomatic vaginal discharge, vulvitis and dysuria. Immunity The infection may induce humoral, secretory, and cellular immune reactions, but they are of little diagnostic help and do not appear to produce clinically significant immunity. Laboratory diagnosis In females, T.vaginalis may be found in urine sediment, wet preparations of vaginal secretions or vaginal scrapings. In males it may be found in urine, wet preparations of prostatic secretions or following massage of the prostate gland. Contamination of the specimen with faeces may confuse T.vaginalis with T.hominis. 42 Figure 7; Trichomonas vaginalis Treatment Metronidazole is the drug of choice. If resistant cases occur, re-treatment with higher doses is required. Prevention - Both male & female sex partners must be treated to avoid reinfection - Good personal hygiene, avoidance of shared toilet articles & clothing. - Safe sexual practice. 2.1.3. Dientamoeba fragilis Dientamoeba fragilis was initially classified as an amoeba; however, the internal structures of the trophoziote are typical of a flagellate. No cyst stage has been described. The life cycle and mode of transmission of D. fragilis are not known. It has worldwide distribution. The transmission is postulated, via helminthes egg such as those of Ascaris and Enterobius species. Transmission by faecal- oral routes does occur. Most infection with D. fragilis is asymptomatic, with colonization of the cecum and upper colon. However, some patients may develop symptomatic disease, consisting of abdominal discomfort, flatulence, intermittent diarrhea, anorexia, and weight loss. The therapeutic agent of choice for this infection is iodoquinol, with tetracycline and 43 parmomycine as acceptable alternatives. The reservoir for this flagellate and lifecycle are unknown. Thus, specific recommendation for prevention is difficult. However, infection can be avoided by maintenance of adequate sanitary conditions. 2.1.4. Other flagellates inhabiting the alimentary canal Trichomonas hominis – The trophozoites live in the caecal area of the large intestine and feed on bacteria. It is considered to be non-pathogenic, although it is often recovered from diarrheic stools. Since there is no known cyst stage, transmission probably occurs in the trophic form. There is no indication of treatment. Trichomanas tenax – was first recovered from the mouth, specifically in tartar from the teeth. There is no known cyst stage. The trophozoite has a pyriform shape and is smaller and more slender than that of T.hominis. Diagnosis is based on the recovery of the organism from the teeth, gums, or tonsillar crypts, and no therapy is indicated. Chilomastix mesnli – has both a trophozoite and cyst stage. It normally lives in the cecal region of the large intestine, where the organism feeds on bacteria and debris. It is considered to be a non-pathogenic, and no treatment is recommended. 44 Parasitology Table 4: Morphology of Trophozoites of intestinal Flagellates Number of Species Length Shape Motility Number of Nuclei Flagella Other features Dientamoe 5-15μm: usual Ameboid; Sluggish 1 or 2; in None Karysome usually in form ba fragilis range, 9 - pseudopodia approximately 40% of cluster of 4-8 grnules; 12μm are angular, of organisms only 1 no peripheral chromatin; serrated, or nucleus is present; cytoplasm is finely broad-lobed nuclei not visible in granular, vacuolated, and and hyaline, unstained may contain bacteria; almost preparations organism formerly transparent classified as an ameba Trichomon 8-20μm: usual Pear-shaped Rapid, 1; not visible in 3-5 anterior; 1 Undulating membrane as hominis range, 11 - jerking unstained mounts posterior extending length of body 12μm Trichomon 7-23μm: usual Pear-shaped Rapid, 1; not visible in 3-5 anterior; 1 Undulating membrane as range, jerking unstained mounts posterior extends ½ length of body: Vaginalis 10 -15μm no free posterior flagellum; does not live in intestinal 45 tract; seen In vaginal smears and urethral discharges Chilomasti 6-24μm: usual Pear-shaped Stiff, rotary 1; not visible in 3 anterior; 1 Prominent cytostome x mesnili range, unstained mounts cytostome extending 1/3 – ½ length of 10 -15μm body; spiral groove across ventral surface Giardia 10-20μm: Pear-shaped “ Falling leaf” 2;not visible in 4 lateral; 2 Sucking disk occupying ½ lamblia usual range, unstained mounts ventral; 2 - ¾ of ventral surface 12 –15μm caudal 46 2.2. Haemoflagelates 2.2.1. Leishmania Species Clinical disease - Veseral leishmaniasis - Cutaneous leishmaniasis - Mucocutaneous leishmaniasis The species of leishmania exist in two forms, amastigote (aflagellar) and promastigote (flagellated) in their life cycle. They are transmitted by certain species of sand flies (Phlebotomus & Lutzomyia) Figure 8; Life cycle of Leishmania species 2.2.1.1. Visceral leishmaniasis Leishmania donovani Important features- the natural habitat of L.donovani in man is the reticuloendothelial system of the viscera, in which the amastigote multiplies by 47 simple binary fission until the host cells are destroyed, whereupon new macrophages are parasitized. In the digestive tract of appropriate insects, the developmental cycle is also simple by longitudinal fission of promastigote forms. The amastigote stage appears as an ovoidal or rounded body, measuring about 2-3μm in length; and the promastigotes are 15-25μm lengths by 1.5-3.5μm breadths. Pathogenesis In visceral leishmaniasis, the organs of the reticuloendothelial system (liver, spleen and bone marrow) are the most severely affected organs. Reduced bone marrow activity, coupled with cellular distraction in the spleen, results in anaemia, leukopenia and thrombocytopenia. This leads to secondary infections and a tendency to bleed. The spleen and liver become markedly enlarged, and hypersplenism contributes to the development of anaemia and lymphadenopathy also occurs. Increased production of globulin results in hyperglobulinemia, and reversal of the albumin-to-globulin ratio. Epidemiology L. donovani donovani, infection of the classic kala-azar (“black sickness”) or dumdum fever type occurs in many parts of Asia, Africa and Southeast Asia. Kala-azar occurs in three distinct epidemiologic patterns. In Mediterranean basin (European, Near Eastern, and Africa) and parts of China and Russia, the reservoir hosts are primarily dogs & foxes; in sub-Saharan Africa, rats & small carnivores are believed to be the main reservoirs. In India and neighboring countries (and Kenya), kala-azar is anthroponosis, i.e. there is no other mammalian reservoir host other than human. The vector is the Phlebotomus sand fly. Other variants of L. donovani are also recognized: L. donovani infantum with similar geographical distribution, reservoir host and vector; with L. donovani donovani. L. donovani chagasi is found in South America, Central America, especially Mexico, and the West Indies. Reservoir hosts are dogs, foxes, and cats, and the vector is the Lutzomiya sand fly. 48 Clinical features Symptoms begin with intermittent fever, weakness, and diarrhea; chills and sweating that may resemble malaria symptoms are also common early in the infection. As organisms proliferate & invade cells of the liver and spleen, marked enlargement of the organs, weight loss, anemia, and emaciation occurs. With persistence of the disease, deeply pigmented, granulomatous lesion of skin, referred to as post-kala-azar dermal leishmaniasis, occurs. Untreated visceral leishmaniasis is nearly always fatal as a result of secondary infection. Immunity Host cellular and humoral defence mechanisms are stimulated. Laboratory diagnosis Examination of tissue biopsy, spleen aspiration, bone marrow aspiration or lymph node aspiration in properly stained smear (e.g. Giemsa stain). The amastigotes appear as intracellular & extra cellular L. donovan (LD) bodies. Figure 9; Giemsa-stained amastigotes (LD bodies) Culture of blood, bone marrow, and other tissue often demonstrates the promastigote stage of the organisms. Serologic testing is also available. 49 Treatment The drug of choice is sodium stibogluconate, a pentavalent antimonial compound. Alternative approaches include the addition of allopurinol and the use of pentamidine or amphotercin B. Prevention Prompt treatment of human infections and control of reservoir hosts. Protection from sand flies by screening and insect repellents. 2.2.1.2. Old World Cutaneous Leishmaniasis (Oriental sore) Clinical disease L.tropica minor - dry or urban cutaneous leishmaniasis L.tropica major - wet or rural cutaneous leishmaniasis L.aethiopica - cutaneous leishmaniasis Important features These are parasites of the skin found in endothelial cells of the capillaries of the infected site, nearby lymph nodes, within large mononuclear cells, in neutrophilic leukocytes, and free in the serum exuding from the ulcerative site. Metastasis to other site or invasion of the viscera is rare. Pathogenesis In neutrophilic leukocytes, phagocytosis is usually successful, but in macrophages the introduced parasites round up to form amastigote and multiply. In the early stage, the lesion is characterized by the proliferation of macrophages that contain numerous amastigotes. There is a variable infiltration of lymphocytes and plasma cell. The overlying epithelium shows acanthosis and hyperkeratosis, which is usually followed by necrosis and ulceration. 50 Epidemiology Cutaneous leishmaniasis produced by L.tropica complex is present in many parts of Asia, Africa, Mediterranean Europe and the southern region of the former Soviet Union. The urban Cutaneous leishmaniasis is thought to be an anthroponosis while the rural cutaneous leishmaniasis is zoonosis with human infections occurring only sporadically. The reservoir hosts in L. major are rodents. L.aethopica is endemic in Ethiopia and Kenya. The disease is a zoonosis with rock & tree hyraxes serving as reservoir hosts. The vector for the old world cutaneous leishmaniasis is the Phlebotomus sand fly. Clinical features The first sign, a red papule, appears at the site of the fly’s bite. This lesion becomes irritated, with intense itching, and begins to enlarge & ulcerate. Gradually the ulcer becomes hard and crusted and exudes a thin, serous material. At this stage, secondary bacterial infection may complicate the disease. In the case of the Ethiopian cutaneous leishmaniasis, there are similar developments of lesions, but they may also give rise to diffuse cutaneous leishmaniasis (DCL) in patients who produce little or no cell mediated immunity against the parasite. This leads to the formation of disfiguring nodules over the surface of the body. Immunity Both humoral and cell mediated immunity (CMI) are involved Treatment The drug of choice is sodium stibogluconate, with an alternative treatment of applying heat directly to the lesion. Treatment of L.aethopica remains to be a problem as there is no safe and effective drug. 51 Prevention - Prompt treatment & eradication of ulcers - Control of sand flies & reservoir hosts. 2.2.1.3. New World Cutaneous and Mucocutaneous Leishmaniasis (American cutaneous leishmaniasis) Clinical disease: Leishmania mexicana complex- Cutaneous leishmaniasis. Leishmania braziliensis complex- mucocutaneous or cutaneous leishmaniasis Important features: The American cutaneous leishmeniasis is the same as oriental sore. But some of the strains tend to invade the mucous membranes of the mouth, nose, pharynx, and larynx either initially by direct extension or by metastasis. The metastasis is usually via lymphatic channels but occasionally may be the bloodstream. Pathogenesis The lesions are confined to the skin in cutaneous leishmaiasis and to the mucous membranes, cartilage, and skin in mucocutaneous leishmaniasis. A granulomatous response occurs, and a necrotic ulcer forms at the bite site. The lesions tend to become superinfected with bacteria. Secondary lesions occur on the skin as well as in mucous membranes. Nasal, oral, and pharyngeal lesions may be polypoid initially, and then erode to form ulcers that expand to destroy the soft tissue and cartilage about the face and larynx. Regional lymphadenopathy is common. Epidemiology Most of the cutaneous & mucocutaneous leishmaniasis of the new world exist in enzootic cycles of infection involving wild animals, especially forest rodents. Leishmania mexicana occurs in south & Central America, especially in the Amazon 52 basin, with sloths, rodents, monkeys, and raccoons as reservoir hosts. The mucocutaneous leishmaniasis is seen from the Yucatan peninsula into Central & South America, especially in rain forests where workers are exposed to sand fly bites while invading the habitat of the forest rodents. There are many jungle reservoir hosts, and domesticated dogs serve as reservoirs as well. The vector is the Lutzomyia sand fly. Clinical features The types of lesions are more varied than those of oriental sore and include Chiclero ulcer, Uta, Espundia, and Disseminated Cutaneous Leishmaniasis. Laboratory diagnosis Demonstration of the amastigotes in properly stained smears from touch preparations of ulcer biopsy specimen. Serological tests based on fluorescent antibody tests. Leishman skin test in some species. Immunity The humoral and cellular immune systems are involved Treatment The drug of choice is sodium stibogluconate. Prevention Avoiding endemic areas especially during times when local vectors are most active. Prompt treatment of infected individuals. 2.2.2. Trypanosomiasis Etiologic agents Trypanosoma brucei complex – African trypanosomiasis (sleeping sickness) Trypanosoma cruzi – American trypanosomiasis (Chagas’ disease) 53 Important features These species may have amastigote, promastigote, epimastigote, and trypomastigote stages in their life cycle. In human trypanosomes of the African form, however, the amastigote and promastigote stages of development are absent. Typical trypanosome structure is an elongated spindle-shaped body that more or less tapers at both ends, a centrally situated nucleus, a kinetoplast posterior to nucleus, an undulating membrane arising from the kinetoplast and proceeding forward along the margin of the cell membrane and a single free flagellum at the anterior end. 2.2.2.1. African trypanosomiasis Trypanosoma gambiense & Trypanosoma rhodesiene are causative agents of the African typanosomiasis, transmitted by insect bites. The vector for both is the tsetse fly. Figure 10; Life cycle of Trypanosoma brucei 54 Pathogenesis The trypomastigotes spread from the skin through the blood to the lymph node and the brain. The typical somnolence (sleeping sickness) usually progresses to coma as a result of demyelinating encephalitis. In acute form, cyclical fever spike (approximately every 2 weeks) occurs that is related to antigenic variation. As antibody mediated agglutination and lysis of the trypomastigotes occurs, the fever subsides. With a few remains of antigenic variants new fever spike occurs and the cycle repeats itself over a long period. Epidemiology T.burcei gambiense is limited to tropical west and central Africa, correlating with the range of the tsetse fly vector. The tsetse flies transmitting T.b. gambiense prefer shaded stream banks for reproduction and proximity to human dwellings. People who work in such areas are at greatest risk of infection. An animal reservoir has not been proved for this infection. T.burcei rhodeseinse is found primarily in East Africa, especially the cattle-raising countries, where tsetse flies breed in the brush rather than along stream banks. T.b. rhodeseines also differs from T.b. gambiense in that domestic animal hosts (cattle and sheep) and wild game animals act as reservoir hosts. This transmission and vector cycle makes the organism more difficult to control than T.b. gambiense. Clinical features Although both species cause sleeping sickness, the progress of the disease is different. T.gambiense induced disease runs a low-grade chronic course over a few years. One of the earliest signs of disease is an occasional ulcer at the site of the fly bite. As reproduction of organisms continues, the lymph nodes are invaded, and fever, myalgia, arthralgia, and lymph node enlargement results. Swelling of 55 the posterior cervical lymph nodes is characteristic of Gambian sleeping sickness and is called winterbottom’s sign. Chronic disease progresses to CNS involvement with lethargy, tremors, meningoencephalitis, mental retardation, and general deterioration. In the final stages, convulsions, hemiplegia, and incontinence occur. The patient becomes difficult to arouse or obtain a response from, eventually progressing to a comatose state. Death is the result of CNS damage and other infections, such as pneumonia. In T.rhodesiense, the disease caused is a more acute, rapidly progressive disease that is usually fatal. This more virulent organism also develops in greater numbers in the blood. Lymphadenopathy is uncommon, and early in the infection, CNS invasion occurs, resulting in lethargy, anorexia, and mental disturbance. The chronic stages described for T.gambiense are not often seen, because in addition to rapid CNS disease, the organism produces kidney damage & myocarditis, leading to death. Immunity Both the humoral and cellular immunity involve in these infections. The immune responses of the host to the presence of these parasites, however, is faced with antigenic variation, in which organisms that have changed their antigenic identity can escape the host immune response and initiate another disease process with increased level of parasitemia. Laboratory Examination of thin and thick films, in concentrated anticoagulated blood preparations, and in aspiration from lymph nodes and concentrated spinal fluid. Methods for concentrating parasites in blood may be helpful approaches including centrifugation of heparinized samples and an ion–exchange chromatography. 56 Levels of parasitosis vary widely, and several attempts to visualize the organism over a number of days may be necessary. Figure 11; Trypomastigote stage of Trypanosoma burcei complex Treatment The same treatment protocol is applied for these parasites. For the acute stages of the disease the drug of choice is suramin with pentamidine as an alternative. In chronic disease with CNS involvement, the drug of choice is melarsoprol. Alternatives include trypars amide combined with suramin. Prevention Control of breeding sites of tsetse flies and use of insecticides. Treatment of human cases to reduce transmission to flies. Avoiding insect bite by wearing protective clothing & use of screen, bed netting and insect repellants. 2.2.2.2 American trypanosomiasis Trypanosoma cruzi is a pleomorphic trypanosome that includes an additional form

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