[FLAGELLATES-2 BY DR GALLARDO] Aug.

27-28, 2014
Cont..(Giardia)

For difficult cases:

1. Duodenal String test
2. Duodenal aspiration
3. Duodenal biopsy
- Require touch preparations, Giemsa
staining, and a careful search of
trophozoites.
- May identify a histologic abnormality
not caused by giardiasis and may
detect other pathogens
Other tests:
1. Detection of Giardia nucleic acid by PCR or
gene probes highly sensitive but
experimental technique
2. WBC count usually normal, absence of
eosinophilia
3. Barium studies non-specific irregular
thickening of small bowel folds
Differential Diagnosis
Other Diarrheal syndromes caused by
viruses, noninvasive bacteria, and
protozoans (e.g. Cryptosporidium and
Cyclospora)
Tropical Sprue = find steatorrhea
Treatment
o DOC: Metronidazole 250mg 3x a day for
5-7 days p.o. (pediatric dose:15mg/kg in 3
divided doses)
Nitroimidazole drug- binds to
parasite DNA causing damage and
trophozoite death
Side effects: metallic taste in
mouth, nausea, dizziness,
headache, reversible
neutropenia(rare)
o Alternative:
o Tinidazole 2gm SD (50mg/kg in
children)
o Furozolidone 100mg 4x daily for 7
to 10 days(pediatric dose:
6mg/kg/day in 4 divided doses for 710 days) *except for G6PD positive
patient
o Quinacrine
For pregnant women: therapy should be delayed
until after delivery, or at least until after the 1st
trimester
-Paromomycin

-Metronidazole
*givesupportive care for 1st trimester

Prevention and Control

o Proper or sanitary disposal of human
excreta (night soil) to prevent
contamination of food and water supply
o Proper handling and treatment of public
water supplies(chlorination, flocculation,
sedimentation and filtration)
o Avoidance of oral-anal and oral-genital sex
o Breastfeeding protective
- Milk is cytotoxic to trophozoites
- Human and animal breastmilk
contain anti-Giardia antibodies
Treatment of asymptomatic carriers
generally not recommended
No immune- or chemoprophylactic
strategy for humans
Veterinary vaccine has been developed

Trichomonas spp.
3 Trichomonas
Flagellated protozoan
3 human species
- T. vaginalis vagina
- T. hominis intestine
- T. tenax mouth

Disease: Trichomoniasis
:Trichomonad vaginitis
:Urethritis
:Prostatovesiculitis
a) Trichomonas tenax
- Resides in the anaerobic,
periodontal crevices of some
patients with pyorrhea
- Occasionally appears to cause
respiratory tract infection in
patients with underlying
pulmonary disease
b) Trichomonas hominis
- Can be recovered from the
lower GI tract
- Usually from patients with
symptomatic bowel disease

[FLAGELLATES-2 BY DR GALLARDO] Aug. 27-28, 2014

Differs dramatically compared to
chlamydial and gonococcal
infections
o Infection rates are high or higher in
middle-aged women compared to
adolescents
o Having a sexual partner who is
more than 4 yrs. Older ->
important risk factor for
Trichomoniasis among adolescents
Incidence is highest among women with
multiple sexual partners
Also in groups with high rates of other
STDs
o Neisseria gonorrhoeae
o Chlamydia trachomatis
o HIV
Recovered from 66- 100% of female
partners of infected men and from 2280% of the male sexual partners of
infected women
Infection may be self-limited in about 20%
of women but in at least 40% of men
Commonly co-exists with other conditions,
particularly infection with Neisseria
gonorrheae and bacterial vaginitis
Predisposes individuals to HIV/AIDS and a
cervical cancer
Has also been reported in the urinary
tract, fallopian tubes and pelvis, and can
cause pneumonia, bronchitis and oral
lesions
o

Parasite Biology
Colorless, pyriform/ pear-shaped flagellate
15 to 18 m in fresh preparations, smaller
when fixed
Trophozoite only stage in life cycle
Habitat: vagina of female;
urethra, epididymis and prostate of male
Possesses 5 flagella, four of which are
located at its anterior portion. The fifth
flagellum is incorporated within the
undulating membrane of the parasite.
T. vaginalis is anaerobic -> contains no
mitochondria in its cytoplasm
Generates metabolic energy via
specialized granules or organelles called
hydrogenosomes -> distributed
throughout the region of the cytoplasm
adjacent to the hyaline, pointed axostyle
that protrudes from the posterior of the
parasite.

In cultures, it has been observed to ingest

bacteria, starch, and even erythrocytes
Reproduces by longitudinal binary fission,
with mitotic division of the nucleus
Cannot live in normally acid vaginal
secretions(pH 3.8 to 4.4) of healthy adults

Epidemiology
Most common non-viral sexually
transmitted disease worldwide
Infection often leads to vaginitis and acute
inflammatory disease of the genital
mucosa
Associated with preterm delivery, low birth
weight, and increased infant mortality
Age Distribution:

Modes of Transmission
Sexual intercourse- most important
Direct contact with infected females,
contaminated toilet articles, and toilet
seats
Mother with Trichomoniasis could transfer
it to the neonate from passage to an
infected birth canal(NSVD)
Trichomoniasis and HIV
Trichomonas vaginalis is emerging as one
of the most important co-factors in
amplifying HIV transmission, particularly in
African-American communities of the
United States
Individuals infected with T. vaginalis have
a significantly increased incidence of HIV
transmission

[FLAGELLATES-2 BY DR GALLARDO] Aug. 27-28, 2014

T. vaginalis elicits an aggressive local

cellular immune response with a heavy
influx of target cells for HIV
This response may increase the chance of
portal entry of HIV in a seronegative
individual
Conversely, in an HIV-seropositive
individual, punctuate hemorrhages that
are frequently associated with T. vaginalis
infection, increase shedding and
subsequent transmission of the virus

Most infected males- asymptomatic

Symptomatic males:
o Urethritis
o Epididymitis
o Prostatitis

Complications
Vaginitis emphysematosa- rare
- Gas-filled blebs in vaginal wall
Gestational trichomoniasis
o Premature labor
o Low birth weight
o Post-abortional infection

Pathology
Responsible for low-grade inflammation of
the vagina ->vaginitis
Vaginal walls- tender and injected with
hyperemia and petechial hemorrhages
Advanced cases- granular areas
Erosion and necrosis may be observed at
times
Males: urethritis, prostatovesiculitis
Clinical Manifestations
Infection commonly asymptomatic
- 10-50% of infected women
Incubation period in women
- Range 5-28 days
Symptomatic postmenarcheal females:
o Vaginal discharge- frothy, pale
yellow to gray-green, musty or
fishy odor
o Mild vulvovaginal itching and
soreness
o Dysuria; dyspareunia
o Lower abdominal pain or
discomfort rare
Symptoms more severe just before or
after menstruation
Vaginal mucosa often deeply
erythematous
Cervix friable and deeply inflamed,
sometimes covered with numerous
petechiae(strawberry cervix)

o Premature rupture of membranes

DIAGNOSIS
1. Direct microscopic examination of vaginal
secretions using
Wet - mount technique
= preparation of vaginal discharge lashing
of
flagella and distinctive jerky motility of
organisms
- (+) in only 60 - 70% of cases
- also reveals large numbers of WBCs
2. Culture for T. vaginalis in liquid or semi-solid
artificial media
- (+) in >80% of cases
- Gold standard

Intense erythema in the

cervix & punctuate
hemorrhages, thus the
term strawberry cervix

[FLAGELLATES-2 BY DR GALLARDO] Aug. 27-28, 2014

3. Enzyme Immunoassay and
Immunofluorescence
Techniques more sensitive but generally not
required for
diagnosis
TREATMENT
DOC: Metronidazole
- 2 g single oral dose
- 500 mg BID x 7 days
Sexual partner should also be treated, even
if
asymptomatic
Asymptomatic infected women shall be
treated
important reservoir of the disease
Infection during pregnancy
- single 2 g dose of Metronidazole in
any stage of pregnancy
CAUSES OF RECURRENT INFECTION
1. Reinfection from an untreated sexual
partner
most common cause
2. Noncompliance with multi-dose regimens
3. True Metronidazole resistance
Evaluate for presence of other
Transmitted
Diseases:
- Syphilis
- Gonorrhea
- Chlamydia infection
- Hepatitis B
- HIV infection

C. mesnili trophozoites
live in the cecum and
colon
pear-shaped, teardrop shaped
measure 6 - 24 by 3 10 m
have a long, prominent
cytostome (1/3 to 1/2
length of the body)
1 anterior nucleus and 4 anterior flagella
C. mesnili cysts
excreted with feces and constitute the
transmission
uninucleated, lemon-shaped
measure 6 - 10 by 4 - 6 m with a little
protuberance at one end and a prominent
cytostome

Sexually

PREVENTION AND CONTROL

1. Attention to personal hygiene
2. Detection and treatment of infected males
3. Periodic vinegar douches to restore normal
acid pH of the vagina
4. Measures to prevent STIs:
- use of condoms
- avoidance of sexual activity until
patient and sexual
partners are cured

Dientamoeba fragilis
Chilomastix mesnili

commensal or non-pathogenic flagellate of

the intestinal tract
Transmission: fecal-oral route
presence of the flagellate in feces is a sign
of fecal contamination and poor
alimentary hygiene
infected humans: asymptomatic

PARASITE BIOLOGY
Originally described as an ameba but is actually a
flagellate

[FLAGELLATES-2 BY DR GALLARDO] Aug. 27-28, 2014

Only trophozoite stage is known
Live in mucosal crypts of cecum and upper colon
Resembles Trichomonas antigenically and
ultrastructurally
except for absence of a flagellum
Measures about 7 - 12 m with 1 or 2 (rarely 3 or
4) rosette-shaped nuclei
Nuclear membrane does not have peripheral
chromatin
Karyosome consists of 4 - 6 discrete granules
Cytoplasm may contain vacuoles with ingested
debris
Undergoes binary fission
Exact life cycle unknown
Direct human to human transmission is probably via
fecal-oral route or via transmission of helminth eggs
particularly that of Enterobius vermicularis
Mononucleated and binucleated forms of
Dientamoeba have been observed in the lumen
of Enterobius adults present in the intestines
EPIDEMIOLOGY

D. fragilis and E. vermicularis are reported to be

highly prevalent companion parasites of preschool children in Germany

Prevalence rates: 18% in Israel, 36% in Holland,

41.5% in Germany

Increased rates noted in mental institutions and

crowded areas with poor personal hygiene (fecooral)
PATHOGENESIS

D. fragilis does not invade tissues

occupies mucosal crypts of large intestine

presence in intestines produces irritation of the

mucosa with secretion of excess mucus and
hypermotility of the bowel

infections are usually asymptomatic

CLINICAL MANIFESTATIONS

Onset of infection is usually accompanied by

colicky abdominal pain and loss of appetite

Intermittent diarrhea with excess mucus,

abdominal tenderness, bloating sensation, and
flatulence

Anal pruritis may be partially due to coinfection with Enterobius vermicularis (nocturnal
pruritus)

Peripheral eosinophilia observed in 50% of cases

Chronic infection can mimic the symptoms of

diarrhea predominant irritable bowel syndrome
(IBS)
DIAGNOSIS
o Binucleated trophozoite in multiple fixed strained
fresh stool
o Organism is not detected by stool concentration
methods
o Prompt fixation of fresh specimen with polyvinyl
alcohol fixative or Schaudinns fixative may be
helpful

TREATMENT
Iodoquinol 650 mg 3x a day for 20 days
(Pediatric dose: 40 mg/kg/day)
Alternative:
Tetracycline
Metronidazole
PREVENTION AND CONTROL
Specific recommendations cannot be made
Proper method of sanitation and disposal of human
waste
(like other focally transmitted disease)

Blastocystis hominis
-

inhabitant of lower intestinal tract of humans and

other
animals
Infection: Blastocystosis
formerly classified as a yeast
was considered to be related to dimorphic fungus,
Blastomyces
reclassified as a protozoan
lacks a cell wall but has a mitochondrion with
protozoan morphology
capable of pseudopodial extension and retraction
asexual reproduction through binary fission or
sporulation under strict anaerobic conditions
optimal growth at 37C in the presence of bacteria
does not grow on fungal media

EPIDEMIOLOGY

overall prevalence: 1.5-10%

Philippine prevalence: 20-44%

recovered from 1-20% of stool specimens

examined for ova and parasites

presence of organism may be a marker for the

presence of other pathogens spread by fecal
contamination
Transmission

believed to be fecal-oral route

water-borne transmission

may be transmitted from animals (pigs,

monkeys, poultry, and rodents)

also present in house lizard and cockroaches

contamination of food and water by fecal droppings

PARASITE BIOLOGY
Morphological Forms:
1. Vacuolated/vacuoles
2. Amoeba-like/amoeboid
3. Granular
4. Multiple fission
5. Cyst
6. Avacuolar

1. Vacuolated / Vacuolar Form

Most predominant form in fecal specimens

Main type of Blastocystis causing diarrhea

Spherical shape, 5 to 10 m in diameter

Large central vacuole

May sometimes be seen with thick capsule

[FLAGELLATES-2 BY DR GALLARDO] Aug. 27-28, 2014

Vacuole Reproductive growth

2. Amoeba-like/Amoeboid Form

Occasionally observed

Irregular, active pseudopod

Peripheral clamping of nuclear chromatin

Intermediate stage between vacuole and precystic form allows parasite to ingest bacteria
so as to enhance encystment
3. Granular Form

Mainly observed from old culture

Measure from 10 to 60m

Granular contents develop into daughter cells

of amoeboid form when cell ruptures (4.
multiple fission)
5. Cyst form

Measures about 3 to 55m

Very prominent and thick cell wall (thick-walled

cyst are responsible for external transmission)

Most resistant form and is able to survive in

harsh conditions because of thick cell wall

thin-walled cysts responsible for re-infection

within a hosts intestinal tract
6. Avacuolar Form
Sharply demarcated polymorphic, but mostly
oval or circular dense body surrounded by a
loose outer membranous layer

Lacks a central vacuole but few nuclei, multiple

vacuoles, and food storage deposits were
observed

Note taker:
Jamailah Rafael
Raz Ramos

[FLAGELLATES-2 BY DR GALLARDO] Aug. 27-28, 2014