PARASITOLOGY LECTURE 11 – Ciliates and Flagellates weeks)

Notes from Belizario,VY , Solon,JAA

USTMED ’07 Sec C – AsM

CILIATES

BALANTIDIUM COLI

• largest protozoan parasite affecting humans

• only ciliate known to cause human disease
• capable of attacking the intestinal epithelium resulting
in ulcer formation which, in turn, causes bloody
diarrhea similar to amebic dysentery
• primarily associated with pigs

DISEASE

• causative agent of balantidiasis or balantidial dysentery

MORPHOLOGY

- Trophozoite

• Dimensions
o 30 to 300 um long
o 30 to 100 um wide
• has a cytosome – acquisition of food
• cytopyge – excretion of waste
PATHOGENESIS AND CLINICAL MANIFESTATION
• 2 dissimilar nuclei (macro- and micronucleus)
o macronucleus
 bean-shaped
• B. coli is a tissue invader
• 2 contractile vacuoles • Trophozoites are capable of attacking the intestinal
• mucocysts – extrusive organelles which are located epithelium and creating characteristic ulcer with a
beneath the cell membrane rounded base and wide neck (vs. flask-shaped, narrow
o adhesion of parasitic ciliates (not proven) necked ulcers of amebiasis)
o Ulceration caused by hyaluronidase = enzyme
secreted by trophozoite
o Trophozoites are abundant in exudates on
mucosal surfaces
o Inflammatory cells and trophozoites are
numerous in the base of the ulcers
• Trophozoites also invade the submucosa and the
muscular coat, including the blood vessels and
lymphatics
o May spread to mesenteric nodes, pleura or the
liver
• many infected individuals are asymptomatic
- Cysts
• most common symptoms presented:
o diarrhea
o dysentery
• acute infection
o abdominal discomfort/pain associated with
nausea and vomiting
o 6 to 15 episodes of diarrhea per day
• Balantidial dysentery is indistinguishable from amebic
dysentery
• Dimensions o Diarrhea with bloody, mucoid stools
o 40 to 60 um in diameter • Chronic cases
• spherical and ovoid o Diarrhea may alternate with constipation
• covered with thick cell walls o Accompanied by anemia and cachexia
• unlike amoeba, encystations does not result in an o Associated with non-specific abdominal
increase in number of nuclei symptoms
• Fulminant disease occur in immunocompromised or
malnourished patients
LIFE CYCLE • Complications
o Intestinal perforation
• exhibits both trophozoite and cyst stages o Acute appendicits
• ingested cysts excyst in the small intestines and become
trophozoites
• trophozoites inhabit the lumen, mucosa and submucosa
of the large intestines, primarily the cecal region
• multiply by binary fission and cause pathologic changes
in the colonic wall and mucosa
• cysts formed as protection for survival outside host
• parasites encyst during intestinal transport or after
evacuation of semi-formed stools
• infective stage: cysts (remains viable for several
 • Dimensions
o 9 to 12 um long
o 5 to 15 um wide
• pyriform or teardrop shaped
• pointed posteriorly
• pair of ovoidal nuclei
• dorsal is convex, ventral is concave with large adhesive
disc for attachment
• bilaterally symmetrical
• axostyle - distinct medial line
• erratic tumbling motion – propelled by 4 pairs of flagella
arising from superficial organelles in the ventral side
DIAGNOSIS
• divide by longitudinal binary fission
• microscopic demonstration of trophozoites and cysts in • covered with variant-specific surface proteins (VSPs) =
feces (DFS or concentration techniques) resistant to intestinal proteases
• sigmoidoscopy – biopsy specimens of lesions that show - cysts
presence of trophozoite

Sigmoidoscopy

TREATMENT
• dimensions
• tetracycline (adults and children) 500 mg 4x daily for 10 o 8 to 12 um long
days o 7 to 10 um wide
o contraindicated for children < 8 y/o and • young cysts have 2 nuclei
pregnant women • mature cysts have 4 nuclei
• Metronidazole 750 mg 3x daily for 5 days
• characterized by flagella retracted into axonemes
o Pediatric dose 35 to 50 mg/kg/day in 3 divided
(median body)
doses for 5 days
o Contraindicated in early pregnancy • deeply stained curved fibrils surrounded by a touch
• Iodoquinol 650 mg 3x daily for 20 days hyaline cyst wall secreted from condensed cytoplasm
o Pedia – 20 mg/kg/day in 3 divided doses for 20
LIFE CYCLE
days

EPIDEMIOLOGY AND CLINICAL COURSE

• thrives in the duodenum, jejunum and upper ileum of
humans
• simple asexual life cycle
• human infection results from ingestion of food or water
o binucleated flagellated trophozoite
contaminated with fecal material containing B. coli
o quadrinucleated infective cyst stage
cysts
• infective stage: mature cysts
• incubation period is 4 to 5 days
• once mature cysts are ingested, they pass safely through
• Balantidiasis is uncommon in temperate climates
the stomach and excyst in the duodenum (30mins)
• Associated with pigs in the tropics
• develop into trpophozoites which rapidly multiply and
• Due to poor environmental sanitation
attach to intestinal villi
PREVENTION AND CONTROL
• trophozoites are found in jejunum
• feces enters the colon and dehydrates, the parasite then
• the usual (hygiene, sanitation, etc) encysts
• cysts may be resistant to environmental conditions • mature cysts are passed out in the feces
o inactivated by heat and 1% sodium
hypochlorite

FLAGELLATES

GIARDIA LAMBLIA

• Intestinal parasitic flagellate of worldwide distribution.

• a.k.a. Giardia intestinalis, G. duodenalis, Lamblia
duodenalis or L. intestinalis
• mode of transmission – fecal-oral route

DISEASE

• Cause epidemic and endemic diarrhea

• Disease caused is called giardiasis or lambliasis –
significant but not life-threatening GI disease

MORPHOLOGY

- Trophozoites (found in diarrheic stools)

 • demonstration of G. lamblia trophozoites and/or cysts
in stool specimens
• trophozoites
PATHOGENESIS AND CLINICAL MANIFESTATION o floating leaf-like motility
• duodeno-jejunal aspiration or biopsy done if parasite is
• ability to cause disease can be traced to its ability to not found in feces (higher percentage of positive
alter mucosal intestinal cells once it has attached to the findings)
apical portion of the enterocyte • Entero-test – demonstrates trophozoites (accurate,
• attachment is via adhesive disc located on ventral side inexpensive option for diagnosis)
o causes mechanical irritation • IF and antigen detection test kits considered as tests of
o influenced by physical factors such as choice
temperature (body temp) and pH (7.8 to 8.2)
o also produce a lectin, when activated by TREATMENT
duodenal secretions is able to facilitate
attachment • oral metronidazole 9250 mg 3x daily for 5-10 days)
o attachment enables parasite to avoid • alternative drugs
peristalsis o tinidazole
o furazolidone
o quinacrine
o paromomycin

EPIDEMIOLOGY AND CLINICAL COURSE

• from ingestion, it takes 1 to 4 weeks for disease to

manifest
• associated w/ poor environmental sanitation
• worldwide distribution
• outbreaks are almost exclusively water-borne
• risk factors
o poor hygiene
o poor sanitation
o overcrowding
o immunodeficiency
o bacterial and fungal overgrowth in SI
o homosexual practices (“gay bowel syndrome”)
• once attached, it causes alteration in the villi
PREVENTION AND CONTROL
o villous flattening
o crypt hypertrophy
• same
• alterations causes
• normal water chlorination will not affect cysts
o decreased electrolyte, glucose and fluid
absorption
o cause deficiencies in disaccharides TRICHOMONAS VAGINALIS
• G. lamblia also rearranges cytoskeleton in human
colonic and duodenal monolayers DISEASE
o Cytoskeleton is essential for proper cell
attachment to extracellular matrix • Trichomoniasis - a sexually transmitted disease caused
o Disruption will lead to structural disintegration by T. vaginalis
and detachment from the substrate (observed • Mode of transmission – sexual intercourse
in apoptotic cells)
o Causes enterocyte apoptosis MORPHOLOGY
• 50% are asymptomatic
• acute cases • a protozoan flagellate that exists only in the trophozoite
o abdominal pain (cramping associated w/ stage
diarrhea) • body
o excessive flatus with an odor of hydrogen o pyriform in shape
sulfide (rotten eggs) o measures 15-20 um long and 5-15 um in width
o abdominal bloating • motion
o nausea o jerky movements provided by four free
o anorexia anterior flagella
o diarrhea (most common 89%) o a 5th flagellum embedded in the undulating
o spontaneous recovery w/in 6 weeks in mild to membrane extends half the organism’s length
moderate cases
• chronic infection
• morphologically similar to T. tenax (trichomonad
o steatorrhea (passage of greasy, frothy, stools species found in the mouth) except for the
that float on toilet water) following:
o periods of diarrhea alternated w/ normal or
constipated bowel movements T. vaginalis T. tenax
o weight loss Size Larger Smaller
o profound malaise Undulating Shorter longer
o low grade fever membrane
Siderophil More less
granules in the
cytoplasm
Cytosome Less conspicuous
conspicuous

Trophozoites on bowel wall Small bowel villus atrophy

DIAGNOSIS

LIFE CYCLE
• exists only in the trophozoite stage like all trichomonads
• inhabits the surface of the vaginal epithelium of females
and the epithelium of the urethra, epididymis and
prostate gland of males where pH ranges from 5.2 to 6.4
(optimal for survival)
• the trophozoite thrives on the mucosal surface of the
vagina feeding on bacteria and leukocytes
• they are sometimes phagocytosed by macrophages
• reproduction is by binary fission
• transmission is by sexual intercourse
• can also be contracted by direct contact w/ infected
females (thru contaminated toilet articles)
• in babies, infection may be acquired by passing through
the birth canal
PATHOLOGY AND CLINICAL MANIFESTATION
• the infection is often symptomatic in females but can
also produce mild to severe vulvovaginitis
• rarely produces urethritis or other symptoms in males
• the normal acid vaginal secretions (pH 3.8 to 4.4) deter
its survival
• inflammation of the vaginal mucosa occurs several days
after the inoculation of T. vaginalis trophozoites
• trophozoites infect the surface but do not appear to
invade the mucosa
• acute inflammation caused by the parasites results in
the characteristic vaginal discharge
o contains polymorphonuclear cells and
desquamated epithelial cells
• Vaginal secretions
o Liquid
o Greenish to yellow
o Very irritating (cause intense itchiness and
burning sensation)
• Speculum exam
o Punctuate hemorrhages of the cervix
(“strawberry cervix”)
 Observed only in 2% but are
diagnostic of trichomoniasis
• T. vaginalis infections in females presents as
symptomatic vaginitis, chronic infection may be
asymptomatic
• In males, trichomoniasis is asymptomatic during the
acute stage
o Becomes a chronic urethritis
DIAGNOSIS
• demonstration of trophozoites in:
o urine
o urethral secretions
o vaginal secretions
o cervical secretions and scrapings (swabs)
o semen
o prostatic secretions
• avoid contamination of sample w/ feces so as not to
misdiagnose T. hominis for T. vaginalis
• Microscopy: Giemsa, Papanicolou, Romanowsky, acridine
orange
• Culture: Diamond’s modified medium or Feinberg and
Whittington culture medium
EPIDEMIOLOGY
• worldwide distribution with incidence correlating
strongly with the number of sexual partners
• most commonly acquired sexually transmitted infections
• prevalent in societies where there is more sexual
permissiveness
• frequent in ages between 30 to 49 y/o, especially in
groups where feminine hygiene is lacking
• In the Philippines:
o Among hospitality girls – 24%
o Other groups of women – 3-8%
TREATMENT, PREVENTION AND CONTROL
• involve both sexual partners to avoid reinfection
• sexual intercourse discouraged during treatment period
• Drug of Choice: Oral Metronidazole (250 mg, 3x for 7
days = 90-98% cure rate)
• Suppositories and acid douches to promote acid pH of
vagina
• Limit number of sexual partners
• Protective devices such as condoms and spermicides
DIENTAMOEBA FRAGILIS
• identified in all regions of the world in which
satisfactory iron-hematoxylin stained films have been
carefully examined
MORPHOLOGY
• originally described as an ameba, is actually a flagellate
with only the trophozoite stage known (like
trichomonads)
• measures 7-12 um
• w/ 1 or 2 (rarely 3 or 4) rosette-shaped nuclei
• nuclear membrane does not have peripheral chromatin
• karyosome consists of 4-6 discrete granules
• vacuoles found in cytoplasm with ingested debris
• no flagellum
Trophozoite w/ rosette nuclei Trophozoite w/ 2 nuclei
LIFE CYCLE
• lives in the crypts of the cecum and upper colon
• exact life cycle is unknown
• direct human to human transmission via the fecal-oral
 route or via transmission of helminth eggs (particularly
that of E. vermicularis) • proper sanitation and human waste disposal
• mononucleated and binucleated forms of Dientamoeba
were observed in lumen of Enterobius adults in the
LEISHMANIAS
intestines

• mode of transmission : vector bite, congenital, blood

transfusion, contamination of wound by contact

DISEASE

• Leishmaniases – caused by 3 large species complexes

w/c differ in clinical manifestation, geographic
distribution and sand fly vectors

MORPHOLOGY

• produce amastigotes intracellularly in the mammalian

host
• promastigotes in the midgut and proboscis of the insect
vector

• Amastigotes
o Ovoid or rounded bodies
o 2 to 3 um in length
o lives intracellularly in the
monocytes,
polymorphonuclear leukocytes
or endothelial cells
o nucleus is large
o axoneme arises from the
kinetoplast and extends to the
anterior tip
PATHOGENESIS AND CLINICAL MANIFESTATIONS
• Promastigotes
• does not invade tissues but presence in the intestines o Single free flagellum
produces irritation of the mucosa arising from kinetoplast
o secretion of excess mucus at the anterior end
o hypermotility of the bowel o Measure 15 to 20 um in
• infections are usually asymptomatic length and 1.5 to 3.5 um
in width
• in symptomatic patients, onset of infection is
accompanied by colicky abdominal pain and loss of
appetite
o also complain of intermittent diarrhea w/ LIFE CYCLE
excess mucus
o abdominal tenderness • infective stage : promastigotes in the proboscis of the
o bloating sensation sand fly
o flatulence o injected into host skin during feeding
o anal pruritis (11% of patients) = may be due to • invade the reticuloendothelial cells
co-infection with Enterobius • become amastigotes
• peripheral eosinophilia observed in 50% • multiply by binary fission
• chronic infection • the parasitized cell ruptures
o mimic symptoms of diarrhea-predominant o amastigotes are released to invade new cells
irritable bowel syndrome (IBS)
o rule out infection with this protozoan before
 L. tropica = lymphoid tissue of the
skin
diagnose patient as IBS
 L. donovani = visceral organs
DIAGNOSIS  L. braziliensis = skin and mucous
membranes
• observation of binucleate trophozoites in multiple fixed
and stained fresh stool samples • vector : sand fly Phebotomus spp.
• fresh stool since trophozoites degenerate after few o Takes up amastigotes during feeding
hours of stool passage • Amastigotes transforms into promastigotes in the gut
• Multiply by binary fission
• number of samples = rate of identification
• Migrate to pharynx
• easily overlooked by the examiner if he is not aware of
D. fragilis infection
• purged stool specimens are more suitable
• may be misdiagnosed for other amoebae
• prompt fixation with polyvinyl alcohol fixative or
Schaudinn’s fixative

TREATMENT

• Iodoquinol at 650 mg 3x for 20 days

o Pedia dose 40 mg/kg 3x for 20 days
• Tetracycline and metronidazole

EPIDEMIOLOGY

• presence of D. fragilis in eggs or lumen of E.

vermicularis
• companion parasites of pre-school children in Germany,
Israel and Holland

PREVENTION AND CONTROL

 - phagocytosed parasites are present only in small
numbers in blood; more in reticuloendothelial cells of
spleen, liver, lymph nodes, bone marrow, intestinal
mucosa and other organs
- marked hyperplasia of reticular cells
- marked increase in vascularity of tissues

Promastigote Amastigote

PATHOLOGY AND CLINICAL MANIFESTATION
1. Cutaneous leishmaniasis (Leishmania tropica)
- incubation period ranges from 2 weeks to months
- skin ulcer with elevated and indurated margins
leaves ugly scar on healing
- lesions may be local or metastatic
- lesions are painless and do not result in
lymphadenopathy
- appearance of subcutaneous nodules
- no systemic signs and symptoms
- parasites found in macrophages and histiocytes
- ulceration secondary to anoxia or to an
immunoathologic reaction
- diffuse cutaneous leishmaniasis causes widespread
thickening of the skin with lesions resembling
lepromatous leprosy
- lesions do not heal spontaneously and tend to relapse
after treatment
- New World cutaneous leishmaniasis more severe and
chronic than Old World cutaneous leishmaniasis
DIAGNOSIS
• demonstration of Leishmania in tissue biopsies, skin for
cutaneous leishmaniasis; bone marrow, spleen or lymph
nodes for visceral leishmaniasis
• serology – used for supportive diagnosis when parasites
are difficult to demonstrate
• delayed hypersensitivity reaction to Leishmania antigen
usually develops in late stages of infection or following
cure and lasts for life
EPIDEMIOLOGY
• occur in southern regions of North America,
Mediterranean Basin, East and North Africa, The Caspian
Littoral, Arabian Peninsula, Persian Gulf, Indian
subcontinent, China, Southern Soviet Union
• most severe forms found in Africa, Latin America and
India (yay! Wala sa pinas!  )
• incidence of 400,000 cases per year, 12 million
prevalence

leishmania skin lesion

2. American or Mucocutaneous leishmaniasis
(Leishmania braziliensis)

- initially there are lesions resembling cutaneous
leishmaniasis
- after several decades, metastatic spread to the
oronasal and pharyngeal mucosa
 causes highly disfiguring leprosy-like
tissue destruction and swelling
(“Tapir nose”)
- chiclero ulcer refers to the erosion of the pinna of the
ear of forest workers
TREATMENT, PREVENTION AND CONTROL
• antimony compounds
o pentavalent antimonials sodium stiboglyconate
and n-methyl-glucamine antimonite
• second-line drugs (antimicrobials)
o Amphoterecin B
o Pentamidine (for Kala-azar)
o Metronidazole
o Nifurtimox

• protection against sand flies and avoidance of contact

infection

NON-PATHOGENIC FLAGELLATE PROTOZOA

3. Visceral leishmaniasis or Kala-azar
donovani)
- incubation period is long (1-3 months)
- prominent findings:
 fever (2x daily elevations)
 splenomegaly
 cachexia
- other signs and symptoms
 skin darkening
 hepatomegaly
 lyphadenopathy
 malaise
 weight loss
 loss of apetite
 cough
 diarrhea
 anemia
(Leishmania • the presence of such organisms in the man serve as an
indicator of fecal contamination of ingested food or
water
• treatment is not necessary
• mode of transmission :
o Cysts = Chilomastix
o Trophozoites = Trichomonas
• Trichomonads are easily recognized because of their
anterior tuft of flagella, stout median rod (axostyle) and
undulating membrane. 3 species found in man
o T. tenax
o T. hominis
o T. vaginalis
TRICHOMONAS TENAX
• harmless commensal found in the oral cavity
 • more frequently associated with people with poor dental o found in formed or semi-formed stools
hygiene and oral disease o pear or lemon-shaped, round at one end and
• found exclusively in mouth of humans and other conical at the other
primates; often associated with Entamoeba gingivalis o w/ knob-like protruberance (not always
visible)
• mode of transmission: direct by droplets, kissing or use o 7 to 16 um
of contaminated dishes and drinking glasses o w/ cytostome and 1 nucleus
MORPHOLOGY

• pyriform in shape
• measures 5 to 12 um
• organelles
o 4 free flagella
o undulating membrane that does not reach the
posterior end of the body
o 1 nucleus
o 1 cytosome
EPIDEMIOLOGY

• cosmopolitan distribution
• more prevalent in warm climates
• < 1% prevalence in the Philippines

disclaimers:

these are not notes from the lecture given by dr. pascual, these
were taken from various parasitology books. it’s up to you if you
LIFE CYCLE want to study this. 

• lives in the tartar around the teeth, cavities of carious
teeth, gingivalis margins of the gums, in pus pockets in
tonsillar follicles
• multiplies by binary fission
• thrives on organisms found in its environment
the same goes for lectures 7, 9 and 10… gawa ko lang po iyon…
bahala na kayo mag fill-in ng mga kulang na details… tao lang po!
Good luck!
Only 1 lecture to go!

Auds

audsmartinez@gmail.com
ustmedc3@yahoogroups.com

DIAGNOSIS

• swabbing
o tartar between the teeth
o gingival margin of the gums
o tonsillar crypts
CHILOMASTIX MESNILI

• normal inhabitant of the cecal region of the large

intestine
• well defined trophic and cystic stages
• mode of transmission: ingestion of cysts in food and
drinks contaminated with human feces (fecal-oral)

MORPHOLOGY

• trophozoites
o found in diarrheic or liquid stools
o pear-shaped and asymmetrical
o with spiral grooves extending through middle
portion
o size 6-10 um
o movement: boring or spiral forward movement
 possible by 3 anterior free flagella
 1 delicate flagellum w/in the
prominent cytostome

• cysts