Coccidia

Rogelio Junior B. Rivera, MD

Microbiology and Parasitology
Introduction
Coccidia are a subclass of single-celled obligate
intracellular parasites that are spore-formers
• Belong to Phylum Apicomplexa and Class Conoidasida

They infect the intestinal tracts of most classes of

invertebrates and all classes of vertebrates

Considered to be opportunistic pathogens in humans

Life Cycle

The sexual cycle (sporogony) produces oocysts

The asexual cycle (schizogony* or merogony*)

produces merozoites

Gametogony produces male (micro) and female

(macro) gametocytes
*Schizogony and merogony are interchangeable
Cryptosporidium spp
General Information
Several species of this genus can cause cryptosporidiosis

Many species and genotypes are host-adapted but reports of human cases
from species that usually infect other animals have been reported

Cryptosporidium parvum and Cryptosporidum hominis are the leading

causes of human cryptosporidiosis

Zoonotic subtypes of C parvum that are implicated in human infections are

commonly associated with cattle
Life Cycle
Infective and diagnostic stages: sporulated oocyst

Excystation occurs following ingestion, also probably through

inhalation, releasing four sporozoites

The sporozoites then parasitize epithelial cells of the GI tract, and

probably the respiratory tract
• Inside these cells, usually within the brush border, the parasites undergo schizogony
• They then undergo gametogony, producing micro and macrogamonts
Life Cycle
Microgamonts then produce microgametes, which fertilize the
macrogamonts.

Upon fertilization, zygotes give rise to two types of oocysts

• Thick-walled oocyst: excreted into the environment and are recovered in

stools
• Thin-walled oocyst: involved in internal autoinfection. Not recovered in stools
• Oocysts are infectious upon excretion
Life Cycle
Pathogenesis and Clinical Manifestations
Infections have been linked to exposure to contaminated water; unpasteurized cider, juice,
and milk; contact with animals; unhygienic childcare settings; camps; and ill food handlers

In the immunocompetent host

• Self-limiting diarrhea, usually resolving within 2-3 weeks

In the Immunocompromised

• Severe diarrhea leading to malabsorption, which can be life-threatening, and wasting

• Intestinal villi become blunted
• Inflammatory infiltration is seen into the lamina propria and crypts
• Extraintestinal cryptosporidiosis can involve the bile duct and gallbladder, the respiratory tract and the lungs
Diagnosis
Acid-fast staining methods with or without stool concentration are the
most frequently used diagnostic method

Immunofluorescence has the greatest sensitivity and specificity

Enzyme immunoassays are also sensitive and specific

Molecular methods (e.g. PCR) allow for species level identification

Parasite
morphology
Oocysts are both the diagnostic and infective
stage

Size is 4.2-5.3 µm

On acid fast stain, oocysts appear as red-pink

circles in a blue background

Sporozoites may be visible within the oocysts,

indicating that sporulation has occurred

Non-acid fast oocysts can also occur,

especially in resolving infections
Treatment
There currently is no antiprotozoal against Cryptosporidium

Most immunocompetent patients will recover without need for treatment other than symptomatic
treatment and rehydration

Immunocompromised, the pregnant, and young children are susceptible to severe disease. Rapid fluid
loss is especially life-threatening to babies.

Nitazoxanide can be given to help with diarrhea in healthy adult and pediatric patients. It presently is not
recommended for the PLHIV and immunodeficient patients due to non-superiority compared to placebo

Cryptosporidiosis is often not curable and, even if symptoms disappear, they can recur once immunity
weakens again
Prevention and Control
Practice good hygiene

Avoid swallowing water from pools, lakes, or other swimming areas.

• Chlorination does not affect the parasite

Safe eating and drinking

• Boil water before consumption
• Pasteurize milk and juices
• Avoid eating raw fruits and vegetables that might be contaminated

Safe sex
• Wait to have sex for two weeks after resolution of diarrhea
• Reduce contact with fecal matter during sex
Cyclospora cayetanensis
General Information
Cyclospora cayatenensis is the only known causative agent of
cyclosporiasis

The protozoan was previously thought to be a member of cyanobacteria

because it has photosynthesizing organelles and autofluorescing particles
characteristic of blue green algae

Cyclosporiasis is more commonly seen in the tropics and subtropics

Life Cycle
Infective stage: Sporulated oocyst

Diagnostic stage: Unsporulated oocyst

Unsporulated oocysts are passed in stools and sporulation occurs after several days to weeks at
22-32C in the environment.
• The sporont consists of two sporocysts with each sporocyst containing two elongate sporozoites

Sporulated oocysts contaminate fresh produce and water, which are then ingested

Excystation occurs in the GI tract

Life Cycle
Sporozoites then invade the epithelial cells of the small intestine

Asexual reproduction into type I and type II meronts

• Type I merozoites: more likely to remain in the asexual cycle
• Type II mermzoites: undergo sexual development into macrogametocytes and microgametocytes upon
invasion of another host cell. Fertilization then occurs

After fertilization, an oocyst is then released from the host cell and is shed into stool

Several aspects of intracellular replication and development area still unknown

Mechanisms surrounding contamination of food and water are also still under study
Life Cycle
Pathogenesis and Clinical Manifestations
Average incubation period is one week

Can be asymptomatic, especially in endemic retgions

Symptoms are typically watery diarrhea with varying severity

Other manifestations
• Weight loss
• Abdominal symptoms
• Sometimes, non-specific systemic symptoms

Natural history is that they cyclosporiasis can last for 10-12 weeks or become a relapsing infection

Duration of symptoms and associated weight loss is greater in the immunodeficient

Deaths have not been reported with this infection

Diagnosis
Microscopy with or without concentration techniques

• Direct microscopy
• Stained smears using modified acid fast or modified safranin. Oocysts will appear pink to brilliant
red
• Giemsa or trichrome stains are not reliable
• Under fluorescent microscopy, oocysts are autofluorescent and appear as blue or green circles

Conventional and real-time PCR can provide species-level identification

Oocysts may not be shed during every bowel movement. Submitting specimens
on different days may have to be done
Parasite
Morphology
On wet mount, oocysts appear
spherical. An infective oocyst will
contain two sporocysts which
each contain two sporozoites

Size is 7.5-10 µm
Treatment
The disease is usually self-limiting and
treatment is not necessary when symptoms are
mild

If Pharmacologic treatment is warranted,

trimethoprim-sulfamethoxazole (TMP/SMX) is
the only effective drug
Prevention and Control

Good Hygiene

Cyclospora is resistant to treatment of food or water

through chemical disinfection or sanitizing methods
• Wash all fruits and vegetables thoroughly under running water
• Cook food properly
Cystoisospora belli
Introduction
Cystoisospora belli, formerly known as Isospora belli,
causes an intestinal disease called cystoisosporiasis

The parasite is spread through fecal oral transmission

The parasite has worldwide distribution but is more

common tropically and subtropically
Life Cycle
Infective stage: Mature oocyst

Diagnostic stage: Immature oocyst

Immature oocysts are shed during defecation

• Immature oocysts usually contain one sporoblast

Upon maturation
• the sporoblast divides into two
• Sporoblasts also secrete a cyst wall, becoming sporocysts

Infection occurs upon ingestion of oocysts containing sporocysts

• Sporocysts excyst in the small intestine, releasing sporozoites
• Sporozoites then invade the intestinal epithelial cells, initiating schizogony
Life Cycle
Upon rupture of the schizonts
• Merozoites are released and they invade new epithelial cells
• They then continue asexual reproduction
• Trophozoites develop into schizonts, which contain multiple merozoites

After a minimum of one week, sexual stage begins

• Merozoites infecting the epithelial cells undergo gametogenesis,
producing microgametocytes and macrogametocytes
• Fertilization results in the development of immature oocysts
• Immature oocysts are then shed in stool
Life Cycle
Pathogenesis and Clinical Manifestations
Infection causes acute, nonbloody diarrhea with crampy abdominal pain

Symptoms may last for weeks

Complications
• Malabsorption
• Weight loss
Diarrhea is severe with immunodeficiency and in infants and children

Eosinophilia may be present

Diagnosis
Microscopy with concentration techniques is typically the basis for diagnosis

• Oocysts are large and ellipsoidal

• Size is 25-30 x 10-19 µm
• Sporulated (mature) oocysts can e observed if the specimen is kept in potassium dichromate at room
temperature for more than 2 days
• Oocysts have intense blue autofluorescence on UV fluorescence
• On modified acid-fast stain, oocysts appear light pink to deep purple in a blue background. Some are
unstained.
• On safranin stain, oocysts stain uniformly from red to reddish orange
• Multiple stool samples on different days may be needed

If examinations are negative, examination of duodenal specimens by biopsy or string

test may be needed
Parasite
Morphology
Large (25-30 µm in length)

Ellipsoid in shape

Immature oocyst: contain one

sporoblast
Mature oocyst: two sporoblasts
containing four sporozoites each
Treatment
Trimethoprim-sulfamethoxazole (TMP-SMX is the drug of choice in symptomatic
patients

• In the immunosuppressed, treatment duration can be longer and with higher doses
• Patients with AIDS may also need secondary prophylaxis with TMP-SMX

Patients who are allergic to TMP-SMX can be given pyrimethamine, however,

pyrimethamine can suppress the bone marrow so leucovorin is also given along with
pyrimethamine

Ciprofloxacin is a second-line alternative

Prevention and Control

Good hygiene

Washing and cooking food