PARASITOLOGY

MIDTERMS/LECTURE SECOND SEMESTER

TITLE

THE COCCIDIANS ● Cryptosporidium parvum MOT:

● Cryptosporidium hominis ○ Zoonotic or anthroponotic (humans)
● Cryptosporidium parvum ○ All stages of development in C. hominis
● Cyclospora cayetanensis completed in the GASTROINTESTINAL
● Cystoisospora belli TRACT of the host.
● Toxoplasma gondii
● Sarcocystis spp.
TYPES OF OOCYST:
OTHER INTESTINAL PROTOZOANS ● Thick walled cysts (commonly excreted by host)
● Thin walled cysts (primarily involved in autoinfection)
● Blastocystis hominis
● Dientamoeba fragilis LIFE CYCLE

COCCIDIANS

● Considered as opportunistic in immunocompromised

and immunodeficient individuals.

LIFE CYCLE OF COCCIDIANS

● SPOROGONY
○ Sexual cycle
○ Producing oocysts
○ Sporozoites: inside the oocysts

● SCHIZOGONY (Merogony)
○ Asexual cycle
○ Producing merozoites
○ Merozoites: inside the meronts

● GAMETOGONY
○ Development of male (micro) and female
(macro) to produce micro and macro
gamonts
○ Micro and macro gamonts produce micro
and macro gametocytes
○ Gametocytes: inside the gamonts
○ Fertilized to produce Zygote

THE COCCIDIANS

Cryptosporidium hominis

● Causes CRYPTOSPORIDIOSIS
● Cryptosporidium parvum: the only specie that is Cryptosporidium parvum
known to infect mammals and believe to infect
humans.
● Oocyst:
INFECTIVE/DIAGNOSTIC STAGE ○ Typical Characteristics at a glance
● Thick walled Oocysts: contains 4 sporozoites ○ Often confused with yeast.
● Cryptosporidium hominis MOT: ● Size: 4-6 um
○ Through contact with contaminated water ● Shape: Roundish
and food with oocysts (only HUMANS) ● No. of sporocysts: NONE
● No. of sporozoites: 4 (small)
● Other features: thick cell wall, one to six dark granules
may be visible

RORRY 1
SCHIZONTS & GAMETOCYTES Cyclospora cayetanensis
● Schizonts contains
○ 4-8 merozoites ● Causes CYCLOSPORIASIS
○ Microgametocytes ● Originally called cyanobacterium-like body (CLB)
○ Macrogametocytes ● Believed to be under the family of CYANO BACTERIA
○ 2-4 µm ● Cyanobacteria gives off color (florists)
● Cyclospora cayetanensis showed organelle that
photosynthesis and auto-florist particle (to cause light)
CLINICAL MANIFESTATIONS which is a characteristic of blue-green algae
microorganisms

● Immunocompetent host
○ Self-limiting diarrhea lasting for 2 to 3 weeks INFECTIVE/DIAGNOSTIC STAGE
(most common) ● Excretion of an unsporulated (not infective) oocyst in
○ Abdominal pain, anorexia, fever, nausea and the human feces (diagnostic stage)
weight loss ● Sporulation undergo within the environment
(infective stage)
● Immunocompromised host ● 22-32 degree Celsius the unsporulated oocyst will
○ More severe, progressive diarrhea (life undergo sporulation
threatening)
○ Acute and gangrenous cholecystitis
○ Chronic coughing, dyspnea, bronchiolitis, LIFE CYCLE
and pneumonia 1. Excretion of unsporulated oocyst.
○ Villi will become blunted – infiltration of UNSPORULATED OOCYST: no sporozoites
■ parasite, can cause present.
MALABSORPTION 2. Environmental contamination. External factors (20 -
32 degrees Celsius temp) trigger the sporulation or
the formation of sporozoites.
DIAGNOSTIC TEST/S 3. Sporulated oocyst enters the food chain
4. Ingestion of contaminated food and water
5. Undergoes excystation.
● Sheather’s sugar flotation and the formalin ether/ethyl 6. Invasion of intestinal epithelium
acetate concentration technique 7. Undergoes merogony/asexual > Type I Meront >
● Kinyoun’s modified acid-fast stain (oocyst will appear Type II Meront
RED/PINK DONUT SHAPE) 8. Undergoes gametogony producing unsporulated
● Intestinal biopsy material, sputum, transbronchial and oocyst
broncheo-alveolar lavage
● Indirect fluorescent antibody, enzyme immunoassay,
and DNA probes specific
● Acid-fast staining (MORE SIMPLE, QUICKEST AND
CHEAPEST

TREATMENT

● THERE IS NO SPECIFIC TREATMENT FOR

C. hominis
● Nitazoxanide
○ Prescribed to help alleviate
symptoms
● Spiramycin
● Bovine colostrum, paromomycin, and
clarithromycin
● Chemotherapy, body fluid replacement and
symptomatic treatment (RECOMMENDED
FOR IMMUNOCOMPETENT &
IMMUNOCOMPROMISED PATIENTS)

RORRY 2
Cyclospora cayetenensis
● Mature Oocyst: Typical Characteristics at a glance Isospora belli Oocyst
● Size: 7-10 um in diameter ● Size range: 25-35 um long, 10-15 um wide
● No. sporocyte: 2 ● Appearance: transparent
● Contents of sporocysts: each sporocyst contains 2 ● Shape: oval
sporozoites (a total of 4 sporozoites) ● Cell wall: two layered, colorless and smooth
● Developing sporoblast: Unicellular with granular
cytoplasm
CLINICAL MANIFESTATIONS ● Young oocyst: two sporoblast
● Mature oocyst: two sporocysts, each containing four
● Initial symptoms: malaise and low grade fever (occur sausage-shaped sporozoites (8 sporozoites)
12-24 hrs. after exposure)
● Early infection: chronic and intermittent watery
diarrhea (6 to 7 weeks with six or more stools per
day) LIFE CYCLE
● D-xylose malabsorption

DIAGNOSTIC TEST

● Direct microscopic examination (HPO)

● Concentration techniques
● Acid-fast staining (Kinyoun’s stain)
● Oocysts under fluorescent microscopy: blue or green
circles
● Safranin staining and microwave heating
● Polymerase chain reaction (PCR)

TREATMENT

● Trimethoprim-sulfamethoxazole: 160/800 mg twice

daily for 7 days

Cystoisospora belli

● Causative agent of a medical condition affecting small

bowel called CYSTOISOSPORIASIS
● Isospora hominis
○ Other known specie; now taxonomically
grouped under the genus Sarcocystis
CLINICAL MANIFESTATIONS
● HUMANS only known host
● Immunocompetent
INFECTIVE STAGE:
○ Generally asymptomatic or self-limiting
● Sporulated oocyst (2 sporocysts) contains 4
gastroenteritis
sporozoites
○ More severe infections, Severe diarrhea &
● Oocysts will release the sporozoites and evade the
Fat Malabsorption
epithelial cells and initiates schizogony
○ Stools contain undigested food, mucus, and
Charcot-Leyden crystals (distinct
ASEXUAL STAGE or SCHIZOGONIC PHASE:
characteristics of C. belli (severe infection)
● sporozoites excyst in the small intestine
● penetrate the epithelial cells
● schizont
● Immunocompromised
● liberating merozoites into the lumen
○ Self-limiting enteritis to severe diarrheal
illness
SEXUAL STAGES:
○ Mucosal bowel biopsy may reveal flattened
● merozoites undergo GAMETOGONY (to produce
mucosa and damaged villi
MACROGAMETES & MICROGAMETES)
○ Infiltration of the lamina propria w/
● form a zygote; form an unsporulated oocyst
lymphocytes, plasma cells, and eosinophils.

RORRY 3
 CAT'S INTESTINAL EPITHELIUM:
DIAGNOSTIC TEST ● Merozoites (schizogony) - microgametocytes &
● Direct microscopy or formalin-ether/ethyl acetate macrogametocytes (gametogony)
concentration (Zinc sulfate or sugar floatation)
● Stains OOCYST
○ Modified Ziehl-Neelsen method (granular red ● Shape: Ovoidal, thin wall
color against a green background) ● Unsporulated stage: passed out with the feces of
○ Phenol-auramine: Iodine the cat
○ Kinyoun’s stain or auramine-rhodamine stain (MOT: contaminated food or water by another host)
● Presence of Charcot-Leyden crystals ● Complete sporulation: 1-5 days
● Blood examination: peripheral eosinophilia ● Inside the mature oocyst: 2 sporocysts are formed
● Molecular based techniques (each have 4 sporozoites - penetrate the lamina
propria)
● Intermediate hosts: Birds and rodents (infected after
TREATMENT ingesting soil, water or plant contaminated with
oocysts)
● Asymptomatic infections
○ Bed rest and a bland diet LIFE CYCLE
● Oocyst will transform into tachyzoites (initial and
● Symptomatic infections acute stage of the infection)
○ Trimethoprim-sulfamethoxazole (160/800 mg
4x/day for 10 days, then 2x/day for 3 weeks) CATS
○ With Pyrimethamine and Sulfadiazine for 7 ● Become infected after consuming intermediate hosts
weeks harboring tissue cysts.
● May also become infected directly by ingestion of
sporulated oocysts.
Toxoplasma gondii
Humans can be infected by:
● Eating undercooked meat of animals harboring tissue
● Belongs to the Phylum Apicomplexa
cysts
● causes TOXOPLASMOSIS, CONGENITAL
● Consuming food or water contaminated with cat feces
TOXOPLASMOSIS, CEREBRAL TOXOPLASMOSIS
or by contaminated environmental samples (such as
● Can infect all animals
fecal-contaminated soil or changing the litter box of a
● Definitive host: members of the casts (Felidae)
pet cat).
● Intermediate host: birds and rodents
● Blood transfusion or organ transplantation .
● Accidental host: humans
● Tachyzoites can be transferred from the newly
infected mother to the fetus.
INFECTIVE STAGES:
● HUMANS: the parasites form tissue cysts, most
● Tachyzoite, Bradyzoite, and Oocyst
commonly in skeletal muscle, myocardium, brain, and
eyes; these cysts may remain throughout the life of
EXTRAINTESTINAL STAGES (ASEXUAL):
the host
● Tachyzoites and Bradyzoites
TROPHOZOITE
LIFE CYCLE
● SHAPE: Crescent w/ pointed anterior and rounded
posterior
● Nucleus: Spherical, posterior end

PSEUDOCYSTS
● Contain proliferating tachyzoites are seen in tissue
sections taken for patients suffering from acute
infection
● SHAPE: do not have well-formed walls

CYSTS
● Contains many bradyzoites that are seen during
chronic infections.
● Found in muscles, and the central nervous system

Toxoplasma gondii Tachyzoites

● General comment: Actively multiplying morphologic
form
● Size: 3-7 x 2-4 um
● Shape: Crescent-shaped, often more rounded on one
end
● No. of nuclei: 1
● Other features: contains a variety of organelles that
are not readily visible

RORRY 4
Toxoplasma gondii Bradyzoites LIFE CYCLE
- General comment: Slow-growing morphologic form
- Size: smaller than tachyzoites IN INTERMEDIATE HOST (COWS, PIGS)
- Physical appearance: similar to that of tachyzoites 1. After ingestion of oocysts/sporocysts, these pass to
- Other features: Hundreds to thousands of the small intestine and release four sporozoites.
bradyzoites enclose themselves to form a cyst that 2. Sporozoites migrate through the gut epithelium and
may measure 12-199 um in diameter enter endothelial cells where they undergo asexual
reproduction (merogony)
CLINICAL MANIFESTATIONS 3. After three generations of producing merozoites,
merozoites then form metrocytes and encyst in
muscles initiating sarcocyst formation.
● Cysts: found in the brain, skeletal and heart muscles, 4. Sarcocysts begin as unicellular bodies but with
and retina continued asexual multiplication, metrocytes
● Encephalitis: most common manifestation among the accumulate and sarcocyst increases in size.
immunocompromised patients 5. As sarcocysts mature, the small, rounded,
● Stillbirth (having anemia or pneumonia) and abortion non-infectious metrocytes give rise to infectious,
during the first trimester of pregnancy (jaundice, crescent-shaped bradyzoites.
microcephaly, and epileptic seizure)
IN DEFINITIVE HOSTS (HUMANS, OTHER ANIMALS)
1. Once the intermediate host is eaten by the definitive
host, sarcocysts are digested and bradyzoites
DIAGNOSTIC TEST
become motile.
2. Active bradyzoites enter intestinal cells and change
● Examination of tissue imprints stained with Giemsa into male and female gametocytes
● Serodiagnostic methods: detect antibodies against T. 3. Fusion of a male and a female gametocyte creates a
gondii (positive titer or a four fold increase in titers) zygote which develops into an oocyst; oocyst is then
● Sabin-Feldman methylene blue dye test passed through the feces of the definitive host
● IgM indirect fluorescent antibody technique or double
sandwich IgM enzyme immunoassay INFECTIVE STAGE:
● Polymerase chain reaction ● Cyst with Bradyzoites (for humans);
● Sporocyst and thin-walled oocyst (for pigs and cattle)
● DIAGNOSTIC STAGE:
TREATMENT ○ Sporocyst and thin-walled oocyst (for
humans)
● Pyrimethamine ● Cyst with Bradyzoites (for pigs and cattle)
○ (lower blood counts of humans) (25-100 mg ● DEFINITIVE HOST: Humans
daily) ● INTERMEDIATE HOST:
○ Sulfadiazine (cause allergic reaction) (1-1.5 ○ Cattle for S. hominis
g 4x daily) – mode of action: keep under ○ Pigs for S. suihominis
control the parasites ● MOT:Ingestion of undercooked meat of pigs and
● Combination for one month Cows
○ Spiramycin, azithromycin, clarithromycin, ● HABITAT: intestinal walls
dapsone, and atovaquone
○ Corticosteroids
○ Prophylaxis with trimethoprim
sulfamethoxazole (given to
immunocompromised patient)

Sarcocystis spp.

● Causes SARCOSPORIDIOSIS or SARCOCYSTOSIS

● Definitive host: humans
● Intermediate host: cattle (S. hominis) and pigs (S.
suihominis)
● 1843
○ Parasite was first reported by Miescher as
white threadlike cysts in striated muscles of
a house mouse.

● 1899
○ Referred to as Miescher’s tubules

● Sarcocystis miescheriana
○ Proposed name to identify this parasite.

RORRY 5
Sarcocystis spp. mature oocyst
● Shape: Oval OTHER INTESTINAL PROTOZOANS
● Appearance: Transparent
● No. of sporocysts: 2
● Size of each sporocysts: 10-18 um long Blastocystis hominis
● Contents of each sporocysts: Four sausage-shaped
sporozoites ● found in animals and humans
● Oocyst cell wall appearance: Clear, colorless, double ● previously classified as yeast under the genus
layered Schizosaccharomyces and was related to
● In many cases, only single or double sporocysts Blastomyces
cemented together may be visible in stool samples ● 1996: Silberman et al. completed a study of the small
subunit rRNA (SSUrRNA) gene, showing it belongs to
the informal group Stramenophiles.
● ZOITE (other form) ● lacks cell wall
○ The simplest form. ● undergoes asexual reproduction (binary fission or
○ banana shaped cell, associated with the sporulation) under strict anaerobic conditions
penetration to the Intestine ● Optimal Growth: 37°C in the presence of bacteria.

CLINICAL MANIFESTATIONS LIFE CYCLE (Proposed)

● Life cycle is unclear
● Not fully understood.
● 2 types ● B. hominis Four Morphological Forms:
○ Invasive form: presents with vasculitis and ○ Vacuolated
myositis (invasion of blood vessel and ○ Ameba-like
muscle) ○ Granular
○ Intestinal form: presents with nausea, ○ Multiple Fission
abdominal pain, and diarrhea (mild and last
for 48 hours) 4 MORPHOLOGICAL FORMS
● VACUOLATED
● Associated with acute fever, myalgias, ○ Easiest to recognize
bronchospasm, pruritic rashes, lymphadenopathy, ○ Most predominant form
subcutaneous nodules with concurrent eosinophilia, ○ 5-23 um
elevated erythrocyte sedimentation rate, and elevated ○ NUCLEI: 2-4 LOCATED IN CYTOPLASM
creatine kinase levels ○ Main type of Blastocystis that causes
diarrhea
DIAGNOSTIC TEST ○ Spherical and has a 5 - 10 um diameter
○ thick capsule

● Sporocysts ● AMEBA-LIKE
○ S. hominis: 14 to 18 days after ingesting ○ Intermediate stage between vacuolar and
beef precystic form
○ S. suihominis: 11 to 13 days after ingesting ○ 2.5 - 8 um
pork ○ Predominated in isolates from symptomatic
cases (Tan and Suresh)
● Direct fecal smear or Fecal flotation wet mount ○ Rarely seen; appears to be an intermediate
(visualize the sporocysts) using bright-field stage
microscope
● Biopsy of an infected muscle ● GRANULAR
○ S. hominis: muscles of cattle ○ Multinucleated
○ S. suihominis: muscles of swine ○ 10 - 60 um
○ develop into daughter cells of the ameba
● Stain form
○ Hematoxylin and eosin ○ Observed from old cultures
○ Periodic acid-Schiff (PAS)
● MULTIPLE FISSION
○ Produces many vacuolated forms.
TREATMENT
○ Resistant cystic form:
■ oval or circular
● Myositis: Albendazole, Metronidazole, and ■ 3 -10 um with 1-2 nuclei
Co-trimoxazol\e ■ thick, osmophilic, electron
● Corticosteroids for symptomatic relief ■ dense wall
● Trimethoprim-sulfamethoxazole or pyrimethamine
plus sulfadiazine for typically given to treat these
disease
● No known chemotherapy if humans are the
intermediate host.

RORRY 6
 EPIDEMIOLOGY

● HOW: Infects via the fecal-oral route: contaminated

food and water, in crowded and unsanitary conditions
● WHERE: Common in tropical, subtropical, and
developing countries BUT may also occur in
temperate countries.
● WHO: Infects all ages BUT more often in children and
people with weak immune systems

★ Food and water contaminated by fecal-dropping of

“home visitors” may transmit blastocyst.

ANIMALS THAT MAY HARBOR THAT IS

SIMILAR TO HUMANS:
● pig-tailed macaques, chickens, dogs, and ostriches,
house lizards and cockroaches.

PREVENTION AND CONTROL

● Consume safe food and drinking water
● Follow provisions for sanitary preparation

Dientamoeba fragilis

● Iron-hematoxylin stained films

★ Blastocystis hominis was given its current name in ● Originally described as an ameba but is actually a
1912 by Emile Brumpt. flagellate with only the trophozoite stage (no cyst
stage)
● 7-12 um
CLINICAL MANIFESTATIONS ● One or two (rarely three or four) rosette shaped nuclei
● No peripheral chromatin
● Karyosome consists of four to six discrete granules
● Gastrointestinal pathology ● Cytoplasm may contain vacuoles with ingested debris
● Symptoms: 3-10 days or weeks up to months ● Closely related to and resembles Trichomonas
● Immunosuppression ● Mucosal crypts of the appendix, cecum and the upper
colon
DIAGNOSIS 1909
● First discovered by Wenyon
1918
● Stool is the specimen of choice ● First described in the scientific literature by Jepps and
● Microscopic Examination using Direct fecal smear Dobell
● Hematoxylin or Trichrome staining
● Boeck and Drbohlav and Nelson and Jones Media Dientamoeba fragilis TROPHOZOITE
● 5-18 um
● Shape: Irregularly round
● Motility: Progressive, broad hyaline pseudopodia
TREATMENT ● Nuclei: 2, each consisting of massed clumps of four to
eight chromatin granules
● Metronidazole - 750 mg (3x daily for 10 days) ● NO PERIPHERAL CHROMATIN
○ Pediatric dose - 35-50mg/kg/day in three ● Cytoplasm: Bacteria-filled vacuoles common
doses for 5 days)
● Iodoquinol - 650 mg (3x daily for 20 days) LIFE CYCLE
○ The exact life cycle is unknown
● Drug resistance:
○ Trimethoprim-sulfamethoxazole (TMP-SMX) Clinical Assumptions:
○ Nitazoxanide 1. Fecal-oral route
■ Clinically tested on patients with 2. Transmission of helminth eggs particularly that of
Blastocystis Enterobius vermicularis (vector)
■ Resolve 86% of patients after 3 a. Mononucleated and binucleated forms
days of admission. 3. Animal reservoirs
a. Macaques, gorillas, and swine

RORRY 7
 TREATMENT

● Antimicrobial therapy
● Iodoquinol: 650 mg three times daily for 20 days
○ Pediatric dose: 40 mg/kg/day in three doses,
also for 20 days
● Alternatives:
○ Tetracycline
○ Metronidazole
○ Paromomycin (Humatin)

EPIDEMIOLOGY

● The organism has a world-wide distribution with

varying infection rates ranging from 0.4 to as high as
42%
● High prevalence rates of D. fragilis have been
reported from developed countries with high
sanitation standards
● Using adequate culture techniques, the rates were as
high as 18% in Israel, 36% in Holland, and 41.5% in
CLINICAL MANIFESTATIONS
Germany

● Does not invade tissues Prevention & Control

● Produces irritation of the mucosa with secretion of ● Proper sanitation and disposal
excess & hypermotility of the bowel
● Usually asymptomatic
● In symptomatic individuals: ★ D. fragilis has only rarely been known to ingest red
○ Loss of appetite blood cells.
○ Colicky abdominal pain
○ Intermittent diarrhea with excess mucus
○ Abdominal tenderness ★ Numerous granules are present in this stage and
○ Bloating sensation exhibit Brownian motion. This is known as the
○ Flatulence Hakansson phenomenon; it is a feature diagnostic
○ Anal pruritus for the identification of D. fragilis.
■ Peripheral eosinophilia can be
observed
★ D. fragilis were identified in patients who were also
infected with E. vermicularis (pinworm).
DIAGNOSIS

● Diagnosis of this organism is by observation of

binucleate trophozoites in multiple fixed and stained
fresh stool samples
● Fresh stool samples are necessary
● Multiple samples increase the sensitivity of detecting
the organism
● Purged stool specimens provide more suitable
material for examination than the average formed
stool

★ Real time polymerase chain reaction (RT-PCR)

○ Shown to be the most sensitive of all
sensitive of all diagnostic methods

Dientamoeba fragilis may be diagnosed as other

amebae when formed:
● Not detected by stool concentration methods
● Prompt fixation of the fresh specimen with polyvinyl
alcohol fixative or Schaudinn's fixative has been found
helpful

RORRY 8