PARASITOLOGY LECTURE 12 – Trypanosomes and Coccidia

Lecture and Notes by Dr. Llanera/Dr. Lagamayo

USTMED ’07 Sec C – AsM

TRYPANOSOMOA SPECIES

Trypanosoma species responsible for human diseases

TRYPANOSOMA BRUCEI sspp RHODESIENSE (East African sleeping sickness)

• No morphologic difference with T. gambiense

• Lower over all prevalence
• Rates of infectious to non-infectious fly vector
1:534(host valleys); 1:1312 (cool plateau) with suspicion
Group Complex of other blood sucking insects as transmitters
• Reservoir in game animals
• Toxic – characteristically more rapid and fulminant,
reaches climax before any considerable nervous system
involvement

PATHOGENESIS

• Local infiltration from area of bite to the lymphatics and

endothelial cells to arachnoid spaces and CNS
• Chronic inflammation of the lymphatics and perivascular
TRYPANOSOMA BRUCEI sspp GAMBIENSE infiltration and with pressure and hemorrhage creating
atrophy of dendrons in ganglion cells
• Habitat – blood and various tissues
• Vector and Intermediate host SYMPTOMATOLOGY
o Glosina flies (palpalis) both males and females
• Incubation period – asymptomatic (2-23 days)
LIFE CYCLE OF TRYPANOSOMA BRUCEI • Invasion of lymph nodes – (variable duration) ,
Winterbottoms sign, Kerandels sign, localized edema,
alternating febrile attacks
• Invasion of the nervous system – headaches, gradual
development of mental dullness, apathy, initially
excitable or morose then eventually asthenia and death

DIAGNOSIS

• Characteristic symptoms in endemic areas

• Demonstration of parasite in blood tissues on CSF
• Serology (for large scale screening) ELISA, IF

PROGNOSIS

• Good if diagnosed early

• Poor with CNS involvement

TREATMENT

• General supportive measures

• Drug Treatment
o Pentamidine
o Suramin
o Melarsopenol
o Tryparsamide
o Melarsen

PREVENTION

• Treatment of cases
• Elimination of vectors
o Spray
EPIDEMIOLOGY o Clearing of vegetations
o Application of mass treatment and prophylaxis
• Limited to tropical West and Central Africa correlating • Development of good control programs by trained
to the range of fly vector (shaded stream banks) personnel

TRYPANOSOMA CRUZI (Chaga’s Disease, S. American Trypanosomiasis)

• Workers in such areas are at risks
• Mode of transmission
• Less than 10% of flies become infective after biting an o From feces of arthropod containing metacyclic
infected patients trypomastigotes
• Congenital transmission possible o Transplacental
• Reservoir host – domestic animals, no proof in game o Accidental ingestion
animals, though experimental infection have been o Blood transfusion
proven
EPIDEMIOLOGY
Trypanosoma Brucei Gambiense
• Zoonosis in moist warm regions of Western hemisphere
• Reservoir in wild mammals
• Vectors – triatomid bugs (Panstrongylus, Triatomid,
Rhodnius)
• Affects low income groups in suburban and rural
localities
 • Most frequent in children
• Elimination of bugs – insecticides – gammexane
PATHOGENESIS • Education of families in endemic areas

• Engulfed by histiocytes and multiply as amastigotes and Trypanosoma cruzi in skeletal muscle Trypanosoma cruzi
invade adipose tissues. An inflammatory response
follows with infiltration of PMNs, monocytes and
lymphocytes with eventual fibrotic encapsulation to
form a primary lesionà chagoma. From primary site –
metastasize to regional lymph nodes later to the blood
stream and multiples in fixed histocytes in various
organs

PATHOLOGY

• Destruction of RE and other tissue cells with

COCCIDIA
predilection to mesenchynol cells (adipose, myocardial,
RE, neurologlial)
• Early 1970s- first discovery of Toxoplasma gondii
LIFE CYCLE OF TRYPANOSMA CRUZI parasite as a coccidia and the cat was the definitive
host
• Sexual stage in the life cycle of this parasite had an
important epidemiologic implication
• Early 1980s- Cryptosporidia causes an opportunistic
infection causing diarrhea

COMMON FEATURES OF COCCIDIA

• Sexual stage in the intestinal mucosa of a carnivorous

definitive host
• Oocyst or sporocyst passes out of the feces to infect the
intermediate host asexual multiplication of parasite
• Cryptosporidium, Isospora, and Eimeria
o Single host - both sexual and asexual stages of
multiplication occurs

TOXOPLASMA GONDII

HISTORY

• 1908 - T. gondii was first found in African rodent

Ctenodactylus gondii
• 1923 - Janku described toxoplasmic chorioretinitis
• 1939 - Wolf et al isolated the parasite and established
the cause of congenital neonatal disease

MORPHOLOGY OF T. GONDII

• In Man
o Bradyzoites - collection of tachyzoites in the
SYMPTOMATOLOGY host cell with parasite membrane
 measures 10 to 100 um in diameter
• Acute form – high fever, generalized or local edema
o Cyst - contains 50 to several thousands of
(Romana’s sign) lipochagomas)
bradyzoites
• Sub-acute stage – hepatosplenomegaly, general
glandular enlargement
• In CATs’ intestinal epithelium:
• Chronic stage – mostly in adults myxedema,
o male and female gametocytes
megaesophagus, dyshagia, paraphlegia, etc.
o fertilized gametocytes spherical oocysts (10-
DIAGNOSIS 13 u) rupture out of the intestinal epithelial
cells passed out of the cats’ feces
• Blood smear o oocyst develop into 2 sporocysts
• Serology – complement fixation (specific and practical) o each sporocyst contains 4 sporozoites
• Xenodiagnosis
• Excision biopsy of chagomas
Toxoplasma gondii
• Differential Diagnosis
o Primary lesions – allergic skin lesions
o Acute stage – typhoid, rheumatic fever, acute
leukemoid, etc.
o Chronic stage – primary cardiomyopathy,
ASHD, CA of colon, hypothyroidism

TREATMENT

• 8-amino quinolones – primaquine reduce parasitemia but

with no evidence of its effect on the ultimate course of
disease
• Bayer 2502 (Nifurtomax)
• Symptomatic and supportive treatment
• Surgery

PROGNOSIS

• 11.7% fatality in acute cases

LIFE CYCLE OF T. GONDII
PREVENTION
 o Hydrocephaly
o Microcephaly
o Psychomotor disturbances
o Convulsions
o Visceral and muscular lesions
• Acquired or Reactivated Toxoplasmosis
Clinical types of acquired post-natal toxoplasmosis:
1. Mild lymphatic form
- resembles Infectious Mononucleosis
- cervical and axillary lymphadenopathy
- malaise, muscle pain, irregular low grade fever,
slight anemia, low BP, leukopenia, lymphocytosis,
slightly altered liver function
2. Acute Fulminating, disseminated Infections
- skin rash
- meningoencephalitis
- high grade fever
- hepatitis
- pneumonitis
• Endodygeny- a tachozoite forms 2 daughter cells within - chills
a mother cell - myocarditis
• Tachozoite: - prostration
o consume O2 PATHOLOGY AND SYMPTOMATOLOGY
o respiration is cyanide sensitive
1980’s
o Use dextrose
o evolve CO2 • Toxoplasmic encephalitits as a complication of AIDS
o grows in mammalian or avian organs or tissues • CNS infection with Toxoplasma:
(brain, eye, skeletal muscles) o headache
o cannot synthesize purines o altered mental status
o fever
Transmission cycle of Toxoplasma gondii o lethargy
o focal neurologic deficits
o convulsions

DIAGNOSIS OF TOXOPLASMOSIS

• Serologic Tests:
o IgM antibodies by double-sandwhich ELISA
o Indirect fluorescent antibody (IFA) for IgG and
IgM determination
o ELISA and IHA
o PCR detection of Toxo DNA
o Mice / tissue inoculation with clinical
specimens

Toxoplasma gondii.
Cyst in H & E stained tissue Giemsa stained cyst in
section of mouse brain an impression smear

Giemsa – stained trophozoites in peritoneal

fluid of mouse called Tachyzoites found in
tissues and
fluids during
the acute
stage of
infection.

Giemsa –
stained
trophozoites in tissue culture
EPIDEMIOLOGY
Macrophage infected with Toxoplasma
• Toxoplasmosis is cosmopolitan gondii: tachyzoites form rosette in the
• Antibody vs. T.gondii: 20% to 75% of various populations parasitophorous vacuole within the infected cell
are chronically ill but asymptomatic
• France: Raw meat as a gourmet and “health food” for
children – serology rate is higher in both adults and
children
• Congenital infection is acquired by transplacental
transmission from mothers who were infected during
pregnancy

PATHOLOGY AND SYMPTOMATOLOGY

• Congenital Toxoplasmosis
o 1-5/1000 pregnancies
o Intracerebral calcification
o Chorioretinitis
TREATMENT OF TOXOPLASMOSIS

• Symptomatic infections:
o pyrimethamine (Daraprim)
 Adult: 25-50 mg per day orally x 3-4
weeks
o trisulfapyrimidines, 2-6 g per day orally x 3-4
weeks
• Pregnant women:
o spiramycin
o clindamycin
• AIDS patients:
o Atovaquone- toxoplasmic encephalitis
PREVENTIVE MEASURES FOR TOXOPLASMOSIS

• Thorough cooking of all meats

• Careful attention to cats’ feces (sporozoites remain
infective up to 18 months in the soil)
• Avoid tasting raw meat and wash hands with soap and
water after handling meat
• Keep cats in houses where there are no rodents ( feed
cats dry or cooked canned cat food)
• Empty litter box daily; disinfect with boiling water and
wash hands after
ISOSPORA BELLI

• Only known coccidial parasite for which MAN is the

DEFINITIVE HOST
• Sexual multiplication takes place in the intestinal
mucosa PATHOLOGY AND SYMPTOMATOLOGY
• Geographic distribution:
• excretion of oocysyts in healthy and symptomatic
Central and South America, Africa,
(diarrhea) individuals
Southeast Asia, Chile
• An opportunistic infection in AIDS patients • Malabsorption syndrome, weight loss, even fatal
outcome
• Biopsy: shortened villi, hypertrophied crypts, infiltration
MORPHOLOGY of lamina propria, with eosinophils, polys, and round
cells
• Oocysts : forms found in the stool
o elongated or ovoid DIAGNOSIS
o 25 to 33 u by 12 to 16 u in size
o in fresh feces: granular cytoplasm with • oocysts in the feces
smooth, colorless, two-layered wall, • oocysts and/or sporocysts in duodenal contents
unsegmented or unsporulated • Intracellular stages of the parasite in intestinal
biopsies
Isospora belli
Isospora belli, immature oocyst (Diagnostic stage in stool specimens)

Unicellular oocyt Oocyst w/ 2 Oocyst with 2 spores each

Sporoblasts containing 4 sporozoites TREATMENT

• Mild and asymptomatic infections:

LIFE CYCLE OF ISOSPORA BELLI
o rest
o bland diet
• Combined: pyrimethamine( 75 mg) and sulfadiazide (4 g)
or Trimetoprim- sulfamethoxazole (160 mg with 800
mg, respectively) for 10 days
• for AIDS pxs: low doses for longer period

CRYPTOSPORIDIUM

• Protozoa parasite of the subclass Coccidia (C. parvum)

• Human cryptosporidiosis is worldwide in distribution
• Causes diarrhea in travelers, in day care centers and in
water-borne outbreaks

SIGNS AND SYMPTOMS

• Diarrhea
• Nausea
• Vomiting
• abdominal cramps
 • fever up to 100/min; cyanosis
• Older children and adults: rapid onset with fever, rapid
PATHOLOGY
respiration, non-productive cough, and cyanosis.
• Small intestines; stomach and colon may also be • Radiographs show diffuse infiltrates, bilateral, has a
involved ground glass appearance
• Death due to asphyxia
DIAGNOSIS
DIAGNOSIS
• stool exam: basic and modified Acid Fast stain
• Surgical open lung biopsy for tissue imprints and tissue
• Concentration procedures: sections
o sucrose flotation • Bronchoalveolar lavage fluid
o formalin-ether method • Bronchoscopy for brush biopsy specimen
o formalin-ethyl acetate method • Aspiration lung biopsy; tracheal aspirates
LIFE CYCLE OF CRYPTOSPORIDIUM PARVUM • Laboratory tests
o Toluidine or methenamine silver stains
o Monoclonal antibodies
o Serologic tests for antibody to P.carinii

Pneumocystis carinii
Gomori methenamine-silver nitrate
stain: Cysts in human lung section:
cup-shape appearance due to
partial collapse of the cyst wall

Cysts in human lung impression

smear

Carinii (silver nitrate)

H & E section of human lung.
Alveioli appear to be filled with pink-
TREATMENT staining, foamy material.

• Long list of antibiotics are ineffective Neither cysts nor organisms can be seen
in this stain
• Spiramycin(?) 1g TID x 2 weeks

PREVENTION

• avoid contact with infected materials

• use gloves, gowns and hand washing
• full strength commercial bleach(5% NaHypochlorite) or 5
to 10% household NH4
PNEUMOCYSTIS CARINII

• An extracellular organism causing interstitial pneumonia

(protozoa-?) TREATMENT
• By sequence analysis of ribosomal RNA, it is closely
related to fungi
• Combination of trimethoprim - sulfamethoxazole
• Morphology: unicellular, pleomorphic, 1-2 u in diameter; (Bactrim)
tropozoites up to 5 u; cysts -spherical or crescentic, o 120 mg per kg per day, every 6 hrs x 14 days
thick-walled structure, 4-6 u in diameter for adults and children
• Exact multiplication of the organism is unknown • Prophylaxis in high risk pxs.: 5 and 25 mg per kg per
• Transmission: droplet to close contacts day divided into 2 equal doses at 12 hrs intervals
EPIDEMIOLOGY • AIDS patients: inhalation of aerosolized pentamidine

• cosmopolitan in humans, rodents, dogs, and other

domestic animals HAPPY HEARTS’ DAY! ♥♥♥♥♥
• Fatal pneumonia in premature and malnourished infants
-auds-
• In older children and adults: associated with
hypogammaglobulinemia, leukemia, Hodgkin’s
lymphoma, malignancies,use of corticosteroids AIDS audsmartinez@gmail.com
patients ustmedc3@yahoogroups.com

PATHOLOGY

• Lungs- firm ; cut surface areas are gray and airless

• Microscopic: thickened alveolar septa, infiltrated with
plasma cells (interstitial plasma cell pneumonia)
o alveolar epithelium- partially desquamated
o alveoli- filled with fat laden cells, parasites
and foamy, vacuolated material

SYMPTOMATOLOGY

• Infantile disease: insidious onset for over weeks with

poor feeding
o failure to thrive; rapid respiratory rate of