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Characteristics & Concepts of Medically Important Fungi
Candida: 3 -4 most common cause of blood
rd th
What is a fungus?
Eukaryotic (hard to treat; close relationship to other euk) stream infection
Heterotrophic: feed off of other sources Aspergillis: most common cause of infectious
pneumonic mortality in BMT recipients
Polymorphic: different shapes/forms
PCP/PJP, crytococcus: among most common
Cell wall: complex, heteropolysaccharides/peptides, target of AIDS-defining infections in HIV pts
antimicrobial therapy
Cell membrane: contains sterols, commonly ergosterol (target of ampho B)
Reproduction: all reproduce asexually, 75% have sexual cycle
Morphologic Forms
Yeast: unicellular fungus, reproduces by asexual budding (generation time = hours)
o Budding: create daughter cell, leave mother cell
Filamentous: fungus whose vegetative form is a mass of individual hyphae (mold)
o Hyphae: characteristics used for dx in laboratory
Branching Septation
dichotomous = “Y-shaped” septate, e.g. Apergillus,
right-angled = “T-shaped” non-septate, zygomycetes, e.g. rhizopus)
If NON-SEPTATE, think ZYGOMYCOSIS AMPHOTERICIN is immediate response
BRANCHING SEPTATE hyphae in immuncompromised with PNEUMONIA Aspergillus
Pseudohyphae: look like hyphae but not filamentous (yeast elongating)
If HYPHAE, PSEUDOHYPHAE, and YEAST forms present: CANDIDA
Structure of a fungus
Encapsulated: only CRYPTOCOCCUS NEOFORMANS!
Protects against host response
Cryptococcal antigen: capsular antigen can be detected from LP in CSF via latex agglutination assay or ELISA.
Extremely sensitive test, targets glucuronxylomannan, produced in huge amounts in cryptococcal infections
Cell Wall:
Rigid, heteropolysaccharide wall, very resistant to hydrolysis, strength & stability
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NOT a barrier to environment (cell membrane): like a chain link fence
Multi-layered: glucans: inner fibrillar/inner matrix of cell wall; glycopeptides: inner/outer layers.
o 90% polysaccharide, 10% peptides
o 1,3-β-glucans: enchinocandins target this specific component of cell wall (Candida, Aspergillus)
o Also mannans, chitin, 1,6-β-glucans
Can monitor mannans or glucans as markers in detection of invasive fungal infections
Composition varies between different forms of fungi; target of cell/humoral immune response
Important receptors for cells, intracellular matrices, and HARDWARE (catheters!)
Other structural features: ER/ribosomes, unstacked Golgi, simple mitochondria, membrane bound vacuoles,
most haploid in vegetative form
Reproduction
Sexual reproduction: via fusion of hyphae (see picture on right)
Asexual reproduction:
asexual spores, germinate colony with identical genetic composition to parent
strain
more resistant to organism, better dispersion
can be infective respiratory inoculum in patients (esp. immunocompromised e.g.
AIDS pt, raking leaves aspergillosis)
Sporangiospores: asexual spores, produced in sac-like cell called
sporangium by zygomycetes
Condida: asexual spores (not sporangium) by all other major
groups (e.g. Aspergillus)
Virulence factors:
Cell surface receptors (epithelial cells, endothelial cells, caths, etc.)
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Hydrolytic enzymes, host mimicry
Polysaccharide capsule (Cryptococcus)
Melanin production: inhibits oxidative response (dampens host response)
Stains:
STAIN FEATURES
H&E Differentiate host response, not sensitive for fungi detection
PAS (periodic acid-Schiff) Stains acid polysaccharide cell wall of fungi
GMS (Gomorri’s methenamine silver) Deposits silver on fungal cell wall, better sensitivity of detection
Mucicarmine / Alcican blue Specific for Cryptococcus capsule
(Fontana Masson) Melanin in cell wall of some fungi
IMPORTANT TO REMEMBER:
Diagnosis: key features of certain organisms
FEATURE ORGANISM
Zygomycosis / Rhizopus
Non-septate hyphae
(give ampho B)
Branching septate hyphae
Aspergillus
(pneumonia in immunocomp pt)
Hyphae + pseudohyphae + yeast form Candida
Capsule Cryptococcus
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Superficial / Cutaneous Fungal Infections
1. Dermatophytosis
2. Onchomycosis (nail infection)
3. Tinea versicolor (superficial, variable color, nape of shoulder across chest)
1. Tinea pedis:
a. most common (70% adults worldwide); often Trichophyton rubrum
b. 3 clinical forms: interdigital, moccasin, vesiculobullous (can treat topically)
c. Can have 1 hand + 2 feet: tinea pedis et manuum
d. Can have onychomycosis along with tinea pedis (need to treat systemically)
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2. Tinea corporis:
a. non-glabrous skin (trunk, extremities)
b. “Ringworm” – erythematous, round, scaly patch; red, raised, advancing border +/- papules/pustules
c. Itchy (pruritic)
3. Tinea cruris:
a. Invasion of hair follicles (can confuse with cutaneous candida)
b. Predisposition: tinea pedis/onchyomycosis at same time (transfer?)
4. Tinea capitus:
a. Infants, children, young adolescents, in US mostly urban (AA/Hispanic preschoolers)
b. Can transmit child-child or animals/humans
c. Usually Trichophyton (T. tonsurans especially) in US; Microsporum canis most common worldwide
d. Variety of manifestations (pustles/papules/etc) on scalp
i. Inflammation scaling, alopecia, erythema/exudate/edema
ii. Ectothrix: “black dot alopecia” (some patches preserved)
iii. Endothrix: total hair loss
iv. Kerion (scalp condition; thickened raised area with set of spongy lesions) forms
1. increased cell-mediated immune response; all Mϕ & mono not PMNs)
2. Severe inflammation, hair loss, cervical lymphadenopathy
e. Need to hit hair follicles: systemic + cutaneous treatment
Onchyomycosis
Onchyomycosis: infection of nail plate and/or nail bed that interferes with normal nail function
Epidemiology: mostly dermatophytes (T. rubrum, others)
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Clinical classifications: PSO/DSO/WSO
DISTAL SUBUNGUAL (DSO) PROXIMAL SUBUNGUAL (PSO) WHITE SUPERFICIAL (WSO)
Immunocompromised hosts
PREVALENCE Most common (90%) 10%
(early HIV infection indicator)
Distalproximal
Proximaldistal Dorsal surface of nail
(hyphae under nail plate, spread
INVASION (starts at cuticle, spreads to
proximally, digest stratum plate attacked
entire nail bed)
corneum of nail bed & nail plate)
Whole nail involved / Minimal inflammation
PRESENTATION Proximal parts relatively intact
obliterated (not attacking viable tissue)
HOST RESPONSE Cell-mediated immunity
T. rubrum (most common)
SPECIES T. tonsurans, T. mentagrophytes, E. T. rubrum T. mentagrophytes
floccosum)
Tinea Versicolor
Superficial mycotic infection
Young, middle-aged adults
Upper trunk/neck/arms; often manifests as depigmentation (“ sun spots” because they don’t tan)
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Opportunistic Mycoses
Candida, Aspergillus, Zygomycetes, Cryptococcus, Pneumocystis
Mycoses: 2 groups based on ability of host’s non-immune cells to phagocytose & kill the challenging fungal spore/yeast
Mucocutaneous candidiasis
Altered T-cell function
Cryptococcus
(e.g. AIDS)
Opportunistic compromised Pneumocystosis
mycoses hosts only Altered phagocytic Invasive candidiasis
activity (quantitative or Aspergillosis
qualitative defects) Zygomycosis
Histoplasmosis (Histoplasma capsulatum)
Blastomycosis (Blastomyces dermatitidis)
Pathogenic,
Coccidiomycosis (Coccidioides immitis)
deep, systemic normal hosts Cellular/T=cell function
Paracoccidiomycosis (Paracoccidoides brazilensis)
mycoses – Latin America, N. Brazil
Penicilliosis (Penicillium marneffei)
Candidiasis
Opportunist (causes wide range of infection)
Candida is genus, albicans is most common member
o Albicans is Germ tube POSITIVE, others aren’t
Hyphae + pseudohyphae + yeast
Components of normal flora on mucosal surfaces (skin/oral/GI tract/female GU)
Causes infection only in compromised hosts
Infections
Mucocutaneous Deeply invasive
THINK NORMAL MUCOSAL DISTRIBUTION. Candidemia: #3-4 for blood infections overall
oropharyngeal (thrush), esophageal Endocarditis, hepatosplenic candidiasis
Clinical
candidiasis, candida epiglottis (chronic/disseminated),
presentation cutaneous, onchyomycosis, keratitis, Acute disseminated candidiasis (high burden septic shock)
vulvovaginal. Renal candidiasis (filtering out candida sets up shop)
Altered barriers (vascular/urinary cath, peritoneal dialysis,
Underlying disease (HIV/diabetes)
trauma, burns, cytotoxic drugs)
Corticosteroids
Risk factors Neutropenia, BMT/solid transplants, surgery
Pregnancy, elderly (↓ immune)
Broad spectrum Abx
Antibacterial Abx (kill normal flora)
Hyperalimentation, hemodialysis
Topical if not serious
Clotrimazole, etc. Need SYSTEMIC Tx (Fluconazole, etc.)
Treatment
Systemic if serious (e.g. if esophageal) (Ampho B as salvage b/c of toxicity)
IV if needed
Mucocutaneous candidiasis
Smear / scrape:
Mucosal: mucosal surfaces; white pseudomembranous placque
hyphae + pseudohyphae
Cutaneous: intertriginous (where 2 areas of skin rub together) areas: scalded
+ budding yeast
lesions, punctuate satellite lesions
o Diaper dermatitis, paronychial/onchyomycosis, moist areas
o Diabetes
Chronic mucocutaneous candidiasis: genetic inherited disorder, big scarring; disfiguring
o ↓ cellular immunity to Candida + polyendocrinopathies
(DM I, adrenal insufficiency, hypothyroid/gonad/parathyroid/etc.)
o Intractable candida: mucocutaneous surfaces (oropharynx, face, toes, fingers, intertriginous areas)
o “Autoimmune-polyendocrinopathy-candidosis-ectodermal dystrophy” (APCED)
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o Tx: fluconazole but worry about resistance in long term use
Invasive candidiasis
Pathogenesis:
1. Adherence/colonization
2. Penetration through mucosa angioinvasion / access to venous caths
3. Hematogenous dissemination
4. Replication in tissues (necrosis +/- abscess formation) Dx in Tissues:
Host response: hyphae + pseudohyphae
1. Immune competent: acute + chronic inflammatory cells + budding yeast
2. Neutropenic: no abscesses form, lots of hyphae
If you suspect invasive candidiasis:
GET A FULL OPHTHALMIC EXAM
Candida Albicans (to check for involvement of vitriol –
GERM TUBE POSITIVE species (form hyphae; others are negative) candida endophthalmitis)
Virulence factors:
o surface receptors (epithelial/endothelial cells; extracellular matrices, hardware)
can act as immunomodulator
sticky for cardiac valves, caths, etc.
o Hydrolytic enzymes, host mimicry
o dimorphic (yeast in environment colonizes sets up shop as hyphae)
Invasive Aspergillosis
Risk factor: PMN FUNCTION depression Conidia = asexual spores
o Quantitiative (neutropenia)
o Qualitiative (function: CGD, post-BMT, high dose corticosteroids, HIV)
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2. Immunosuppresion: inflammatory necrosis, local invasion
Radiology: (not specific for aspergillus – anything that invades a large blood vessel - but commonly present)
1. Halo sign (dense nodule = infarction; delicate structure of local ischemia around it)
2. Air crescent sign (e.g. in recovery; infarcted area
where aspergillus was, separated by a crescent of air
from surrounding parenchyma)
Aspergillus fumigates
Aspergillus niger
Commonly saprophytic (in fungus balls; lives off of dead tissue)
Black color; commonly found in environment
Zygomycosis (mucormycosis)
Opportunistic; caused by several zygomycetous fungi (Rizopus is most
common species)
Pathology: wide, non-septate hyphae that branch at right angles
o Key: NON-SEPTATE; T-SHAPED
o Invasion of blood vessel walls/nerves; extensive necrosis in
advance of fungus
Rapid-growing “LID-LIFTERS” (both in lab and in vivo!)
Sporangiophores have large “sporangia” sacs filled with sporangiospores
(asexual spores)
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Cryptococcus neoformans
At risk: T-cell-compromised (corticosteroids, transplants, HIV with CD4 < 100)
Pathogenesis:
1. inhale yeast (environment) lung replication CD4/CD8 recruited usually cleared (specific response)
2. If immunocompromised (T-cells)
a. Progressive pulmonary infection
b. Hematogenous dissemination (cross BBB to BRAIN)
Pathology:
Normal host: chronic inflammation +/- granulomatous response; resolve w/o calcification
Compromised: mild to non-inflammatory response
Gelatinous lesion (ENCAPSULATED) Diagnosis of cryptococcus
Spherical yeast cells with: Antigen test or direct
o clear area (capsule), obs. in CSF
o narrow/pinched mother-daughter attachment
Need PAS/GMS (H&E doesn’t really work) Clinically:
confusion, decreased
Radiography: disseminated infection concentration, headache
(increased ICP)
Virulence factor: CAPSULE
Glucuronxylomannan with different side chains (different serotypes) Treatment:
o Produced in excess: detectable as ANTIGEN FOR RAPID Dx AMPHO B + 5FC
Inhibits phagocytosis; poor in vivo antigen
Others: phenoloxidase (produces melanin, which inhibits oxygen-dep killing & is stainable)
Pneumocystis carinii/jiroveci
Opportunistic
o CELL-MEDIATED IMMUNITY is key (not neutropenia) Diagnosis of PCP
Alveolar-interstitial pneumonia (fever, dyspnea, non-productive cough) Bronchioalveolar lavage:
o Extrapulmonary dz is uncommon cysts of trophozoites
o Tachypnea + hypoxia DFA (mAb available)
Risk factors: immunosuppresion, corticosteroids, HIV infection, elderly PCR
Radiography Treatment:
No nodules or infarcts TMP+SMX
Interstitial / alveolar involvement, multilobar
Delicate proteinaceous debris in alveoli, blocks oxygen exchange (alveolar / interstitial disease)
o Trophozoites from cyst damage & create interstitial rxn / debris
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Pathogenic Mycoses
Histoplasma, Coccidiodes, Blastomyces, Paracoccidiodes
Can cause infection in normal host; all are endemic dimorphic fungi
o Contact with organism in well-defined ecological niches
Organism Niche Geography
Histoplasma capsulatum Soil, caves (bird/bat feces) Ohio/Mississippi Valley regions
Coccidiodes immitus Desert soil SW USA (Sonora desert)
Blastomyces dermatitidis Water North/Central, SE USA
Paracoccidiodes brasiliensis unknown South America (Venezuela, N. Brazil)
General features:
Entry = inhalation (asexual spores from environment); NOT PERSON-PERSON (even if mimics TB)
Asymptomatic or mild in most hosts
Disseminated progressive infection: 1/1000 infections Dermatophytes are
o More frequent in T-CELL COMPROMISED transmissible, others
Pathology: chronic inflammation, granuloma formation generally aren’t
Disease:
Pulmonary entry
o Acute: (90-95% have asx or mild resp sx; 5%: moderate mild to severe resp dz)
o 1/1000: disseminated infections (more common in T-cell compromised);
Severity/progression: related to host status
Disease of the reticuloendothelial system: Mϕ lining lung, spleen, LN, bone marrow
Pathology
Early / active infection: intracellular budding yeast cells (in Mϕ & monocytes)
Normal hosts: Granulomas (fibrosis, calcification in old lesions); Few intracellular yeasts
Immunocompromised (e.g. HIV+): poorly formed granulomas; Many intracellular yeasts
In vivo yeasts
Diagnosis: DNA probes Cell response Location Disease
Histoplasmosis Monocytes Intracellular Lung dz
Culture: SLOW; takes weeks. Molecular Candida glabrata Lymphocytes Extracellular UG / bloodstream opportunist
probes are faster.
See conversion to yeast at 37C (reverse of candida); macroconidia + hyphae
Organism is HIGHLY TRANSMISSIBLE in this form (careful! Advise!)
Virulence factors: evades killing by phagocytes; replicates in phagolysosome (neutralize acid environment?)
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Blastomycosis (Blastomyces dermatitidis)
Pneumonia + other presentations
Water in NE/central USA
Less propensity for reticuloendothelial system than histoplasmosis
Hyphae (25C) large yeast, double wall, broad-based budding (in vivo, 37C)
Characteristic structure
Hyphal form at room temperature
o Arthrocondia: little boxcar units
hydrophobic & easily transmitted (room temp)
Dispersed throughout environment
Spherules in tissues (very characteristic); invasive
Virtual Rounds
PATIENT DIAGNOSIS TREATMENT PLAN
Little boy with itching scalp; hair falling out. Exam: Tinea capitis: High temp cycle for clothes, systemic Tx +
small areas of inflammation/erythema/scratching; pull Trichophyton spp ketoconazole shampoo, selenium sulfide
hair out including bulb. shampoo for other kids
Migratory farm worker, was working with moss. sporotrichosis Azole
Multiple cutaneous lesions, draining.
sICU pt: came back from surgery starting to spike high Candida (if germ tube +, Fluconazole. If liver enzymes elevated,
temperatures, came back as yeast. albicans) can’t use (use echinocandins) Think of
eyes (call ophthalmologist); think of cath
(make sure it’s clean)
Oncology: AML pt in high dose chemo; cough/high Aspergillus Voriconazole; if liver enzymes elevated,
spiking temperature / pleuritic pain. See halo sign on maybe ampho B
radiography. See branching septate hyphae from
bronchioalveolar lavage
14 year old diabetic girl. Acidotic, sinus infiltration that Zygomycosis Ampho B. Debride, correct underlying
shows black, darkened, necrotic nasal turbinate on immune deficit
biopsy. Broad, non-septate hyphae
24 yo IV drug user; minimal access to medical care. Cryptomycosis Ampho + 5 FC. Worried about
Headache. Get LP with antigen test, positive meningitis, increased ICP
Pt with high risk for HIV. Shortness of breath, 85% Pneumocystis (PCP/PJP) TMP+SMX
O2Sat, diffuse interstitial infiltrate with no nodules.
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Introduction to Parasitology
Parasite: organism living in complete dependency in or on another living organism (host)
Host shields parasite from outer world; provides food (parasite’s “restaurant”) Major themes of
Generally protozoa, worms, arthropods parasitology
Host: Attachment/invasion
Host cell invasion
Definitive: host where sexual reproduction of parasite occurs
Host-parasite
Intermediate: host for immature parasite stage / asexually-reproducing stage interaction
Vector: disease-causing parasite is conveyed from this host to another host Obtaining nutrients
Immune evasion
Parasitism: most common way of life (>50% all spp); Encystation/eggs
all living creatures have parasites (tiny viruses to big tapeworms) Behavioral changes
Humans: found in variety of tissues/organs
man-made ecological changes responsible for perpetuating/intensifying most infectious/parasitic diseases
Epidemiology: huge burden; most morbidity from chronic infection; mortality figures high (malaria in Africa > CVD in US)
Attachment/invasion of host
Attatchment: Parasite needs mechanism to interact with host & prevent its expulsion
Molecular (receptor-ligand)
o e.g. Plasmodium & RBC molecules; falciparum/vivax use different molecules
Physical interaction:
o e.g. hookworm, attach with sharp teeth/hooklets
o Feces eggs in soilstepped on footlungaspirate (weird!) GI tract
Invasion: Obligate intracellular parasites need host cell to survive & replicate Mechanisms of invasion
Helminths: different modes of invasion 1. receptor/ligand interaction
1. Direct from environment– worms penetrate skin directly, go to 2. subvert host cell transmembrane
blood (shistosomes, hookworm) signaling pathway
2. Along vector bite path – bite bloodstream (brugia) 3. modify host cytoskeleton
3. Dispersed from vector bite – enter skin, then go all around through tissue (onchocerca)
Host cell invasion
Apicomplexan invasion (Toxoplasma gondii)
o glides along surface apical tip (rhoptry neck) invades; forms
moving junction rest of parasite pulled in behind (like boat in
Panama canal) – see picture to right
o Result: parisotophorous vacuole. Parasite proteins not
expressed in vacuole, but later help it survive
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Obtaining nutrients
By definition, parasites obtain nutrients from their hosts
E.g. plasmodium digests Hb from RBC; some protozoa (Toxoplasma) can’t synthesize purines on own
Immune evasion
1. Interfere with host immune system to co-exist
Block Ag processing by inhibiting protease cleavage in APC; induce suppressor Mϕ & Treg cells, induce tolerance,
use superantigens, inhibit T/B activation
Clearing: Ab / CMI can be important, or innate/Mϕ can be important (Depends on parasite; intracellular = more innate)
Worms: EOSINOPHILS & IgE RESPONSE
Encystation: eggs/cysts
Environmentally stable forms (good for transitioning between hosts) Good for diagnosis:
o Thick walled cysts (protozoa, esp. intestinal) stool ova & parasite exams
o Eggs (worms) (“stool O&P”)
Can be signature forms:
o oocysts in cryptosporidium
o Schistosome eggs
lateral spur = mansoni; end-spur = haematobium, round = hepatica)
Host behavior
Parasites can alter host behavior
E.g. Toxoplasma gondii: from cat feces; rats eat it, stop being afraid of other animal
scents (makes it easier for cat to catch them!)
Mechanisms of Pathogenesis
1. Direct cellular damage
Need to balance host cell damage & needs from host cell
Direct damage from lysing cell during egress; secreting pore-forming How do parasites cause disease?
peptides, secreting proteolytic enzymes 1. Direct cellular damage
E.g. Toxoplasma lyses cells during egress – necrotic cell death; invades 2. Mechanical
adjacent cells during the process obstruction/compression
3. Host immunological response
2. Mechanical obstruction/compression 4. Other disease mechanisms
Helminths are prototype: obstruct GI tract or lymphatics
o e.g. Ascaris intestinal obstruction in kids in developing countries
o e.g. lymphatic filariasis: block LN, backup of lymph elephantiasis
Parasite-filled abscesses/cysts compress vital organs
o e.g. pork tapeworm: brainmass effect seizures
o Encephalitis/brain abscesses in HIV cerebral Toxo
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Eosinophilia (helminths) irritate GI lining, increase bowel permeability, produce more eosinophils
Granulomas (around destroyed larvae or eggs) colon/rectum walls, elsewhere (back up fluids, damage)
Cytokines: IL-8, TNF-α, etc.
Damage from parasite itself can be minimal; host immune reaction extreme & harmful
o Schistosomiasis: eggs in bladder granulomatous rxn fibrosis obstruction; carcinoma!
Other
Anemia, fever, organomegaly, malnutrition, diarrhea, rash, etc.
Intestinal protozoa
Fecal-oral route; cyst-tryphozite stages (Giardiasis, amebiasis, crytptosporidiois)
o Cyst: resistant wall (infective, found in feces)
o Trophozoite: metabolically active & mobile (non-
infective)
Diarrhea:
Secretory: small intestine, ↑Cl- secretion from crypt cells
o E.g. giardia (cyst ingested, releases trophozites, differentiates
into cyst again in gut lumen in response to bile shed in
watery diarrhea infective).
Villus blunting, infiltrating lymphocytes, secretory diarrhea
Invasive / malabsorptive: esp. colon
o Normally need brush border, good epithelium
o Damage to brush border (break junctions/ulcerate) malabsorption
o Dysentery: diarrhea + blood/mucus in stool
E.g. Entamoeba histiolytica: protozoa; common cause of dysentery in developing countries;
Trophozoite / cyst life cycle
invades host intestinal mucosa; can spread to liver to make abscesses (lung, brain too)
Can cause colitis (flask-shaped ulcers – spread laterally)
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Tx: need early treatment (otherwise could cross BBB CNS involvement; white matter encephalitis
o Early stage: without CNS involvement
Suramin (rhodesiense) or Pentamidine (gambiense), good prognosis
o Late stage: CNS involvement
Melarsoprol – arsenical; HIGH TOXICITY: 4-12% MORTALITY
Eflornithine – expensive, injections x14d; phase III trials for oral underway (good for preventing
unwanted hair growth in women too!)
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