CLINICAL PARASITOLOGY LECTURE

CILIATES AND COCCIDIANS • Micronucleus

o Small
Miscellaneous Protozoa Classification o Dot-like nucleus
o Often not readily visible
• Phylum Ciliophora o Located adjacent to the
o Class Kinetofragminophorea macronucleus
§ Intestinal Species: • Sporoblast
• Balantidium coli o Developing morphologic form
• Phylum Apicomplexa within the oocyst
o Class Sporozoa o Roundish, immature sac
§ Intestinal Species o Contains a small, discreet nucleus
• Isospora belli and granular cytoplasm
• Sarcocystis species • Sporocyst
• Cryptosporidum o Mature form of the sporoblast
parvum o Roundish, mature sac
§ Tissue Species o Containing four sausage-shaped
• Toxoplasma gondii sporozoites
• Order Blastocystida • Gametogony
o Class Blastocystea o Formation of macrogametocytes and
§ Intestinal Species microgametocytes in which the
• Blastocystis hominis resulting gametocytes develop to
form oocysts
• Others
o Cyclospora cayetanensis • Tachyzoite
o Microsporidia (species) o Actively multiplying form of
o Pneumocystis jiroveci trophozoites in humans where the
§ Classified now as a fungus internal organelles are readily visible
• Bradyzoite
o Slow-growing viable form of
Key Definitions trophozoites in humans in which
hundreds to thousands enclose
themselves to form a cyst
• Cilia
o Hairlike cytoplasmic extensions
• Ciliate
Balantidium coli trophozoite
o Parasites that move by means of cilia
• Size:
• Coccidia
o 28-152 microns (length)
o Asexual reproduction occurs outside
o 22-123 microns (width)
human host
o Sexual reproduction occurs inside • Motility:
human host o Rotary, boring
o Often referred to as coccidian • Number of nuclei:
protozoans o 2
• Macronucleus § Kidney-shaped macronucleus
o Large § Small spherical micronucleus
o Kidney bean-shaped molecules • Other features:
o Appear as a hyaline mass (esp. in o 1 or 2 visible contractile vacuoles
unstained preparations) o Cytoplasm: food vacuoles and/or
bacteria
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o Small cytostome present Balantidiasis

o Layer of cilia around organism • Mild colitis and diarrhea to full-blown
disease that mimics amoebic dysentery
Balantidium coli cyst • Abscesses and ulcers followed by secondary
• Size bacterial infection
o 43-66 microns • Acute infections
• Number of nucleus o Up to 15 liquid stools per day
o 2 containing pus, mucus, and blood
§ Kidney-shaped macronucleus • Chronic infections
usually present o Tender colon, anemia, cachexia,
§ Small spherical occasional diarrhea alternating with
micronucleus; may not be constipation
observable • Spread outside of intestine to liver, lung,
• Other features pleura, mesenteric nodules, urogenital tract
o 1 or 2 visible contractile vacuoles in
young cysts Treatment
o Double cyst wall • Asymptomatic patients have good chance of
o Row of cilia visible in between cyst recovery
wall layers of young cysts o Oxytetracycline (Terramycin)
o Iodoquinol
Laboratory Diagnosis o Metronidazole (Flagyl)
• Stool samples for trophozoites and cysts
• Sigmoidoscopy Isospora belli cyst
• Multiple samples may be required to • Size:
confirm parasite presence or absence o 25-35 microns (long)
o 10-15 microns (wide)
Life Cycle Notes • Appearance:
• Similar to that of E. histolytica o Transparent
• Multiplication does not occur in cyst phase • Shape
• Trophozoites reside in ileum and large o Oval
intestine and divide via • Cell Wall
o Transverse binary fission o 2 layered, colorless and smooth
• Excystation occurs in lumen • Developing sporoblast
• Once outside of host, cysts may survive for o Unicellular with granular cytoplasm
weeks • Young oocyst
o 2 sporoblast
Historic MOT • Mature oocyst
• Ingesting contaminated food (pork mainly) o 2 sporocysts
and water with infective cysts § Each contains four sausage-
• Oral-fecal route shaped sporozoites
• Person-to-person
Laboratory Diagnosis
New Evidence Suggests: • To recover oocysts
• Pigs may not be primary infection source o Fresh stool
• Food handlers appear to be person-to-person o Duodenal contents
spreading source o Enterotest

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• To recover intracellular stages • Eosinophilia may be visible in stool samples

o Intestinal biopsies • Charcot-Leyden Crystals
• Wet prep examination o May form and be seen in stool
o Iodine preferred samples in response to eosinophilia
o May be missed in saline preps due to • Severe infection
oocyst transparency o Malabsorption syndrome possible
• Concentration procedures o Increased fecal fat levels and death
o Sheather’s sugar flotation procedure may result
• Permanent stains
o Auramine-rhodamine permanent Treatment
stain • For asymptomatic or mild infections
o Modified acid-fast stain o Consume bland diet
o Plenty of rest
Life Cycle Notes • For more severe infections
• IH: pigs and cattle o Chemotherapy
• DH: humans § Combination of
o Sexual and asexual replication trimethoprim and
occurs here sulfamethoxazole or
• MOT: ingestion of infected mature oocysts pyrimethamine and
• Sporozoites emerge in small intestine sulfadiazine
• Asexual reproduction occurs and results in • For AIDS patients
merozoites o Low dose chemotherapy for
• Formation of gametocytes also occurs that extended time may be necessary
unite and form oocysts
• Immature oocysts pass into outside
environment via feces Sarcocystis species oocyst
• Shape
• Oocysts mature in outside environment
o Oval
• Oral-anal sexual contact may also be a
transmission route • Appearance
o Transparent
Remember: • Number of sporocysts
• Patients suffering from AIDS via o 2
unprotected oral-anal sexual contact • Size of each sporocyst
o Resulting infections now considered o 10-18 microns long
opportunistic • Contents of each sporocyst
o Four sausage-shaped sporozoites
Isosporiasis • Oocyst cell wall appearance
• Mild to gastrointestinal discomfort to severe o Clear, colorless, double layered
dysentery
• Common symptoms
o Weight loss Laboratory Diagnosis
o Chronic diarrhea • SOC: stool for presence of oocysts
o Abdominal pain o Sometimes oocysts have already
o Anorexia ruptured upon examination and only
o Weakness sporocysts are visible singly or in
o Malaise pairs that appear cemented together

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• Routine histologic methods Laboratory Diagnosis

o For striated muscle specimens • For detection of oocysts in stool
o Iodine wet preps
Life Cycle Notes o Modified acid-fast stain
• IH required for asexual reproduction o Formalin-fixed smears stained with
• MOT to humans: Giemsa
o Ingestion of contaminated pig/cattle • Enterotest, ELISA, indirect
meat immunofluorescence
§ Humans definitive host; • Zinc flotation or Sheather’s sugar flotation
oocysts in stool o Proven successful
o Accidental ingestion of oocysts from
animals other than pigs/cattle Life Cycle Notes
§ Humans intermediate host; • MOT: ingestion of infected oocysts
sarcocysts in human striated • Sporozoites emerge in upper GIT
muscle • Asexual and sexual reproduction occurs
• Sporozoites rupture from resulting oocysts
Clinical Symptoms o Capable of initiating autoinfection by
• Signs of invasion of intestinal tract invading new epithelial cells
o Fever • Intact oocysts pass through feces
o Severe diarrhea o Serves as IS for the new host
o Weight loss • Two forms of oocysts:
o Abdominal pain o Thin-shelled
• Muscle tenderness § Presumed to initiate
• Local symptoms autoinfections
o Sign of invasion of striated muscle o Thick-shelled
§ Capable of new infections out
Treatment of host; only occasionally
• Infection of intestinal tract autoinfections
o Sulfamethoxazole or pyrimethamine
plus sulfadiazine Other Information
• Infection of striated muscle • 20 species known to exist
o No known specific chemotherapy o Only C. parvum known to infect
humans
Cryptosporidum parvum oocyst • Infection presumed to be initiated via:
• Size o Ingestion of contaminated water or
o 4-6 microns food
• Shape o Person-to-person transmission
o Roundish • Populations at risk:
• Number of sporocysts o Immunocompromised
o None o Immunocompetent children in
• Number of sporozoites tropical areas
o 4 (small)
• Other features Cryptosporidiosis
o Thick cell wall • Symptoms
o 1 to 6 dark granules may be visible o Diarrhea
§ Self-limiting
§ Lasts about 2 weeks
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§ Episodes of diarrhea lasting Laboratory Diagnosis

1-4 weeks reported in day • SOC: stool
care centers • Iodine wet prep preferred
o Fever o Saline usually lyses vacuolated
o Nausea forms
o Vomiting
o Weight loss Life Cycle Notes
o Abdominal pain • Reproduces by sporulation or binary fission
• May be fatal in children if fluid loss is great • Passes through numerous morphologic
• Infected immunocompromised individuals forms
(AIDS) • Participates in sexual and asexual
o Severe diarrhea and one or more reproduction
symptoms identified in previous • Exhibits pseudopod extension and
slide; malabsorption possible contraction
o Migration of infection to other body • Pathogenicity not clear
areas possible
• Patients with B. hominis in absence of other
o Death may result
intestinal pathogens (B. hominis considered
as a pathogen)
Treatment
o Diarrhea
• Most are proven ineffective o Vomiting
• Spiramycin, although still experimental, o Nausea
shows promising results o Fever
o Abdominal pain
Prevention and Control o Cramping
• Proper water supply treatment
• Proper handling of infected material Treatment
(handwashing) • Iodoquinol or metronidazole
• Properly disinfecting equipment o In cases where there is no other
o Commercial bleach or 5-10% obvious reason for symptoms
household ammonia (diarrhea)
• Proper precautions when working with
known infected persons Prevention and Control
• Proper treatment of fecal material
• Proper handling of food and water
Blastocystis hominis vacuolated form
• Size Cyclospora cayetanensis oocyst
o 5-32 microns • Size
• Vacuole o 7-10 microns (diameter)
o Centrally located • Number of sporocysts
o Fluid-filled structure o 2
o Consumes almost 90% of organism § Each contains 2 sporozoites
• Cytoplasm
o Appears as ring aroung periphery of Laboratory Diagnosis
organism • Stool samples concentrated without formalin
• Nuclei fixative
o 2 to 4 located in cytoplasm • Oocysts to sporulate best at room temp.

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• Addition of 5% potassium dichromate • Only using treated water when handling and
allows sporocysts to become visible processing food
• Flotation by examination using
o Preferred phase contrast or
brightfield microscopy Microsporidia spore
o Modified acid-fast stain • Size
• Oocysts to autofluoresce under UV light o 1 to 5 microns
microscopy • Other features
o Equipped with extruding polar
Life Cycle Notes filaments (or tubules) that initiate
• Human infection infection by injecting sporoplasm
o Ingestion of oocyst form (infectious material) into host cell
• Sporozoites emerge in small intestine where • A protozoa
asexual reproduction of sporozoites results • DNA testing reveals that Microsporidia are
in merozoites fungi
• Sexual reproduction results in macro – and • Microsporidia known to cause human
microgametocyte production. disease in AIDS patients:
• Male and female gametocytes unite to form o Enterocytozoon bieneusi
oocysts, which are passed in stool where o Encephalitozoon species
• In optimal conditions, oocysts develop and o Pleistophora species
mature outside of body
o May take 1 or more weeks to Laboratory Diagnosis
complete • Varies by species
• Resultant oocysts capable of initiating new • Serologic tests available for some species
infections • Cell cultures grow some species
• No animal reservoir hosts exist

Other Information: • Stains to detect all or part of spore

• Contaminated water considered to be source o Thin smears with trichrome or acid-
of 1990 Chicago mini-outbreak in fast stain
physician’s dormitory o Appearance on stains
• Contaminated lettuce and fruit (raspberries) § Positive on gram stain
also known to be infection source § Partially positive on acid-fast
or histologic stain periodic
Clinical Symptoms acid-Schiff (PAS)
• Cases in children are similar to those seen in o Speciation requires transmission
cases of cryptosporidiosis with 2 notable electron microscopy
differences • Molecular methods being developed
o Cyclospora infections produce
longer duration of diarrhea Life Cycle Notes
o No connection in known between • Transmission may be direct or may involve
Cyclospora and intermediate host
immunocompromised patients • Human infection initiation:
o When infective spores inject
Prevention and Control sporoplasm into host cells
• Proper water treatment prior to use § Complex reproductive
process occurs
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§
New spores emerge that • Bradyzoites
typically infect new cells o General comment
• Human infection initiation: § Slow-growing morphologic
o In the direct transmission cycle form
§ Spores are dispersed into o Size
outside environment via § Smaller than tachyzoites
feces, urine, and death of host o Appearance
o In intermediate host cycle § Similar to that pf the
§ Spores may be ingested by a tachyzoites
carnivorous animal o Other features
§ Hundreds to thousands of
Clinical Symptoms bradyzoites enclose
• Infected patients may develop: themselves to form a cyst that
o Enteritis may measure 12-100 microns
o Keratoconjuctivitis in diameter
o Myositis
• The occurrence of these conditions are rare: Laboratory Diagnosis
o Peritonitis • Serologic methods performed on blood
o Hepatitis samples
• In congenital infections
Treatment o IgM – double-sandwich ELISA
• Species dependent • Tests for IgM and IgG – (IHA and ELISA)
• Enterocytozoon bieneusi • Examination for presence of tachyzoites and
o Albendazole bradyzoites not practical
o Suitable alternative
§ Oral fumagillin Life Cycle Notes
• Nosema infection – albendazole + • Natural life cycle simple
fumagillin eye drops • Accidental cycle more complex
• DH: cat
• IH: rats or mice
Toxoplasma gondii tachyzoites and bradyzoites • Natural Cycle
• Tachyzoites o Cats ingest rats or mice contaminated
o General comment with cysts in brain or muscle tissue
§ Actively multiplying o Cysts release bradyzoites in cat that
morphologic form transform to tachyzoites
o Size o Sexual and asexual replication
§ 3-7 by 2-4 microns occurs in cat gut where the sexual
o Shape cycle
§ Crescent-shaped o Production of immature oocysts pass
§ Often more rounded on one in cat feces
end o Rats/mice ingest infected oocysts as
o Number of nuclei they forage for food
§ 1 o Sporozoites emerge from ingested
o Other features oocysts and transformation of
§ Contains a variety of tachyzoites occurs in rodent intestine
organelles that are not readily o Tachyzoites migrate to brain or
visible muscle and form cyst
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o Ready for passage to cats Congenital toxoplasmosis

• Severe, often fatal
Human Infection • Mild infections possible
• 4 Possible Routes • Years later retinochoroiditis may develop
o Ingestion (via hand-to-mouth o Infected child may experience:
transmission)of infected oocysts § Hydrocephaly
during handling of infected cat feces § Microcephaly
o Ingestion of contaminated cattle, pig, § Intracerebral calcification
or sheep meat (obtained via ingestion § Chorioretinitis
of infected oocysts present in cat § Convulsions
feces) § Psychomotor disturbances
o Transplacental infection § Mental retardation
§ Expectant mothers come in § Severe visual impairment
contact with contaminated cat § Blindness
feces
o Blood transfusion Cerebral toxoplasmosis in AIDS patients
§ Very rare • Early symptoms
o Headache
Once inside human: o Fever
• Tachyzoites emerge and replicate resulting o Altered mental status (confusion)
in tissue damage and initial infection o Lethargy
• Tachyzoites migrate to numerous sites • Subsequent possible symptoms
(tissues and organs) where cysts with o Focal neurologic deficits, brain
bradyzoites form lesions, convulsions
o Infection stays in CNS
Toxoplasmosis § Rise in CSF IgG is diagnostic
• General symptoms § Demonstration of tachyzoites
o Mimic those of infectious in CSF on microscopic
mononucleosis examination is also
o Acute form diagnostic
§ Fatigue
§ Lymphadenitis Treatment
§ Chills • For symptomatic cases (except pregnant
§ Fever women)
§ Headache o Combination of trisulfapyrimidines
§ Myalgia and pyrimethamine (Daraprim)
o Chronic form • For pregnant women
§ All symptoms from acute o Pyrimethamine is not appropriate
form plus: o Alternative is spiramycin (currently
• Maculopapular rash considered experimental in the U.S.)
• Evidence of • Other possible treatments
encephalomyelitis o Corticosteroids
• Myocarditis o Folinic acid (leucovorin)
• Hepatitis o Atovaquone
§ Rarely:
• Retinochoroiditis with
subsequent blindness
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Prevention and Control • Now classified as a fungus

• Avoidance of contact with cat feces via: • Because of morphologic and biologic
o Wearing protective gloves characteristics
o Disinfecting litter box with boiling
water and thorough handwashing Laboratory Diagnosis
afterward • Method of Choice
o Placing protective cover over o Histologic procedures
children’s sandboxes when not in use § Gomori’s methenamine silver
(to keep cats out) nitrate stain
• Avoidance of ingesting contaminated o Giemsa and iron hematoxylin stains
meat via • Serologic Tests
o Thorough handwashing after o Not considered appropriate for
handling contaminated meat clinical diagnosis
o Avoidance of consuming raw meat • SOC may vary:
o Thorough cooking of meat o Sputum
• Keep cats away from potentially infective o Bronchoalveolar lavage
rodents o Tracheal aspirate
• Feed cats only dry or cooked canned cat o Bronchial brushings
food o Lung tissue
• Not having cats at all
• Especially important that pregnant women Life Cycle Notes
practice these measures when around cat • Takes up residence in alveolar spaces in
feces and potentially contaminated meat lung tissue
• Mature cysts rupture producing growing,
multiplying, and feeding trophozoites
Pneumocystis jiroveci trophozoite • Trophozoites convert into precysts and cysts
• Size • Cycle repeats itself
o 2 to 4 microns • Parasite may migrate to other body sites,
• Shape including:
o Ovoid, ameboid o Spleen
• Number of nuclei o Lymph nodes
o 1 o Bone marrow

Pneumocystis jiroveci cyst Other information:

• Presumed route of transmission:
• Size o Transfer of pulmonary droplets
o 4 to 12 microns (diameter) through direct person-to-person
• Shape contact
o roundish • Populations at risk:
• Number of nuclei o AIDS patients
o 4 to 8 o Children (infants and those with
§ Unorganized or arranged in a predisposing conditions)
rosette • Transfer from mother to child via the
placenta has been known to occur
Pneumocystis jiroveci o Results in infection as well as
• Once considered as a parasite stillbirth

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Clinical Symptoms
• Pneumocystosis
o Interstitial plasma cell pneumonia
o In immunocompromised adults and
children:
§ Non-productive cough
§ Fever
§ Rapid respirations
§ Cyanosis
o AIDS patients often develop
Kaposi’s sarcoma (malignant skin
disease)
• All infected patients exhibit:
o Infiltrate on x-ray, breathing
difficulties
• Prognosis is usually poor
o Lack of proper oxygen and carbon
dioxide exchange in lungs is primary
cause of death

Treatment
• Trimethoprim/sulfamethoxazole (Bactrim) –
first line
• Alternates: Pentamidine isethionate,
Cotrimoxazole

Prevention and Control

• Difficult to define since life cycle is poorly
understood
• Based on presumed person-to-person
transmission route
o Personal protection from pulmonary
droplets
o For example, wearing mask

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