PARASITOLOGY LECTURE 11 – Ciliates and Flagellates

Notes from Belizario,VY , Solon,JAA

USTMED ’07 Sec C – AsM

CILIATES

BALANTIDIUM COLI

 largest protozoan parasite affecting humans

 only ciliate known to cause human disease
 capable of attacking the intestinal epithelium resulting
in ulcer formation which, in turn, causes bloody
diarrhea similar to amebic dysentery
 primarily associated with pigs

DISEASE

 causative agent of balantidiasis or balantidial dysentery

MORPHOLOGY

- Trophozoite

 Dimensions
o 30 to 300 um long
o 30 to 100 um wide
 has a cytosome – acquisition of food
 cytopyge – excretion of waste PATHOGENESIS AND CLINICAL MANIFESTATION
 2 dissimilar nuclei (macro- and micronucleus)
o macronucleus  B. coli is a tissue invader
 bean-shaped  Trophozoites are capable of attacking the intestinal
 2 contractile vacuoles epithelium and creating characteristic ulcer with a
 mucocysts – extrusive organelles which are located rounded base and wide neck (vs. flask-shaped, narrow
beneath the cell membrane necked ulcers of amebiasis)
o adhesion of parasitic ciliates (not proven) o Ulceration caused by hyaluronidase = enzyme
secreted by trophozoite
o Trophozoites are abundant in exudates on
mucosal surfaces
o Inflammatory cells and trophozoites are
numerous in the base of the ulcers
 Trophozoites also invade the submucosa and the
muscular coat, including the blood vessels and
lymphatics
o May spread to mesenteric nodes, pleura or the
liver
 many infected individuals are asymptomatic
 most common symptoms presented:
- Cysts o diarrhea
o dysentery
 acute infection
o abdominal discomfort/pain associated with
nausea and vomiting
o 6 to 15 episodes of diarrhea per day
 Balantidial dysentery is indistinguishable from amebic
dysentery
o Diarrhea with bloody, mucoid stools
 Dimensions  Chronic cases
o 40 to 60 um in diameter o Diarrhea may alternate with constipation
 spherical and ovoid o Accompanied by anemia and cachexia
 covered with thick cell walls o Associated with non-specific abdominal
 unlike amoeba, encystations does not result in an symptoms
increase in number of nuclei  Fulminant disease occur in immunocompromised or
malnourished patients
 Complications
LIFE CYCLE o Intestinal perforation
o Acute appendicits
 exhibits both trophozoite and cyst stages
 ingested cysts excyst in the small intestines and become
trophozoites
 trophozoites inhabit the lumen, mucosa and submucosa
of the large intestines, primarily the cecal region
 multiply by binary fission and cause pathologic changes
in the colonic wall and mucosa
 cysts formed as protection for survival outside host
 parasites encyst during intestinal transport or after
evacuation of semi-formed stools
 infective stage: cysts (remains viable for several
weeks)

DIAGNOSIS
 microscopic demonstration of trophozoites and cysts in
feces (DFS or concentration techniques)
 sigmoidoscopy – biopsy specimens of lesions that show
presence of trophozoite
Sigmoidoscopy
TREATMENT
 tetracycline (adults and children) 500 mg 4x daily for 10
days
o contraindicated for children < 8 y/o and
pregnant women
 Metronidazole 750 mg 3x daily for 5 days
o Pediatric dose 35 to 50 mg/kg/day in 3 divided
doses for 5 days
o Contraindicated in early pregnancy
 Iodoquinol 650 mg 3x daily for 20 days
o Pedia – 20 mg/kg/day in 3 divided doses for 20
days
EPIDEMIOLOGY AND CLINICAL COURSE
 human infection results from ingestion of food or water
contaminated with fecal material containing B. coli
cysts
 incubation period is 4 to 5 days
 Balantidiasis is uncommon in temperate climates
 Associated with pigs in the tropics
 Due to poor environmental sanitation
PREVENTION AND CONTROL
 the usual (hygiene, sanitation, etc)
 cysts may be resistant to environmental conditions
o inactivated by heat and 1% sodium
hypochlorite
FLAGELLATES
GIARDIA LAMBLIA
 Intestinal parasitic flagellate of worldwide distribution.
 a.k.a. Giardia intestinalis, G. duodenalis, Lamblia
duodenalis or L. intestinalis
 mode of transmission – fecal-oral route
DISEASE
 Cause epidemic and endemic diarrhea
 Disease caused is called giardiasis or lambliasis –
significant but not life-threatening GI disease
MORPHOLOGY
- Trophozoites (found in diarrheic stools)
 Dimensions
o 9 to 12 um long
o 5 to 15 um wide
 pyriform or teardrop shaped
 pointed posteriorly
 pair of ovoidal nuclei
 dorsal is convex, ventral is concave with large adhesive
disc for attachment
 bilaterally symmetrical
 axostyle - distinct medial line
 erratic tumbling motion – propelled by 4 pairs of flagella
arising from superficial organelles in the ventral side
 divide by longitudinal binary fission
 covered with variant-specific surface proteins (VSPs) =
resistant to intestinal proteases
- cysts
 dimensions
o 8 to 12 um long
o 7 to 10 um wide
 young cysts have 2 nuclei
 mature cysts have 4 nuclei
 characterized by flagella retracted into axonemes
(median body)
 deeply stained curved fibrils surrounded by a touch
hyaline cyst wall secreted from condensed cytoplasm
LIFE CYCLE
 thrives in the duodenum, jejunum and upper ileum of
humans
 simple asexual life cycle
o binucleated flagellated trophozoite
o quadrinucleated infective cyst stage
 infective stage: mature cysts
 once mature cysts are ingested, they pass safely through
the stomach and excyst in the duodenum (30mins)
 develop into trpophozoites which rapidly multiply and
attach to intestinal villi
 trophozoites are found in jejunum
 feces enters the colon and dehydrates, the parasite then
encysts
 mature cysts are passed out in the feces
PATHOGENESIS AND CLINICAL MANIFESTATION
 ability to cause disease can be traced to its ability to
alter mucosal intestinal cells once it has attached to the
apical portion of the enterocyte
 attachment is via adhesive disc located on ventral side
o causes mechanical irritation
o influenced by physical factors such as
temperature (body temp) and pH (7.8 to 8.2)
o also produce a lectin, when activated by
duodenal secretions is able to facilitate
 attachment  alternative drugs
o attachment enables parasite to avoid o tinidazole
peristalsis o furazolidone
o quinacrine
o paromomycin

EPIDEMIOLOGY AND CLINICAL COURSE

 from ingestion, it takes 1 to 4 weeks for disease to

manifest
 associated w/ poor environmental sanitation
 worldwide distribution
 outbreaks are almost exclusively water-borne
 risk factors
o poor hygiene
o poor sanitation
o overcrowding
o immunodeficiency
o bacterial and fungal overgrowth in SI
o homosexual practices (“gay bowel syndrome”)

PREVENTION AND CONTROL

 once attached, it causes alteration in the villi
o villous flattening  same
o crypt hypertrophy  normal water chlorination will not affect cysts
 alterations causes
o decreased electrolyte, glucose and fluid
absorption TRICHOMONAS VAGINALIS
o cause deficiencies in disaccharides
DISEASE
 G. lamblia also rearranges cytoskeleton in human
colonic and duodenal monolayers
 Trichomoniasis - a sexually transmitted disease caused
o Cytoskeleton is essential for proper cell
by T. vaginalis
attachment to extracellular matrix
 Mode of transmission – sexual intercourse
o Disruption will lead to structural disintegration
and detachment from the substrate (observed MORPHOLOGY
in apoptotic cells)
o Causes enterocyte apoptosis  a protozoan flagellate that exists only in the trophozoite
 50% are asymptomatic stage
 acute cases  body
o abdominal pain (cramping associated w/ o pyriform in shape
diarrhea) o measures 15-20 um long and 5-15 um in width
o excessive flatus with an odor of hydrogen  motion
sulfide (rotten eggs) o jerky movements provided by four free
o abdominal bloating anterior flagella
o nausea o a 5th flagellum embedded in the undulating
o anorexia membrane extends half the organism’s length
o diarrhea (most common 89%)  morphologically similar to T. tenax (trichomonad species
o spontaneous recovery w/in 6 weeks in mild to found in the mouth) except for the following:
moderate cases
 chronic infection T. vaginalis T. tenax
o steatorrhea (passage of greasy, frothy, stools Size Larger Smaller
that float on toilet water) Undulating Shorter longer
o periods of diarrhea alternated w/ normal or membrane
constipated bowel movements Siderophil More less
o weight loss granules in the
o profound malaise cytoplasm
o low grade fever Cytosome Less conspicuous
conspicuous

Trophozoites on bowel wall Small bowel villus atrophy

DIAGNOSIS

 demonstration of G. lamblia trophozoites and/or cysts

in stool specimens
 trophozoites
o floating leaf-like motility
 duodeno-jejunal aspiration or biopsy done if parasite is
not found in feces (higher percentage of positive
findings) LIFE CYCLE
 Entero-test – demonstrates trophozoites (accurate,
inexpensive option for diagnosis)  exists only in the trophozoite stage like all trichomonads
 IF and antigen detection test kits considered as tests of  inhabits the surface of the vaginal epithelium of females
choice and the epithelium of the urethra, epididymis and
prostate gland of males where pH ranges from 5.2 to 6.4
TREATMENT (optimal for survival)
 the trophozoite thrives on the mucosal surface of the
 oral metronidazole 9250 mg 3x daily for 5-10 days) vagina feeding on bacteria and leukocytes
  they are sometimes phagocytosed by macrophages  prevalent in societies where there is more sexual
 reproduction is by binary fission permissiveness
 transmission is by sexual intercourse  frequent in ages between 30 to 49 y/o, especially in
 can also be contracted by direct contact w/ infected groups where feminine hygiene is lacking
females (thru contaminated toilet articles)  In the Philippines:
 in babies, infection may be acquired by passing through o Among hospitality girls – 24%
the birth canal o Other groups of women – 3-8%

TREATMENT, PREVENTION AND CONTROL

 involve both sexual partners to avoid reinfection

 sexual intercourse discouraged during treatment period
 Drug of Choice: Oral Metronidazole (250 mg, 3x for 7
days = 90-98% cure rate)
 Suppositories and acid douches to promote acid pH of
vagina
 Limit number of sexual partners
 Protective devices such as condoms and spermicides

DIENTAMOEBA FRAGILIS

 identified in all regions of the world in which

satisfactory iron-hematoxylin stained films have been
carefully examined

MORPHOLOGY

 originally described as an ameba, is actually a flagellate

with only the trophozoite stage known (like
trichomonads)
 measures 7-12 um
 w/ 1 or 2 (rarely 3 or 4) rosette-shaped nuclei
 nuclear membrane does not have peripheral chromatin
 karyosome consists of 4-6 discrete granules
PATHOLOGY AND CLINICAL MANIFESTATION
 vacuoles found in cytoplasm with ingested debris
 no flagellum
 the infection is often symptomatic in females but can
also produce mild to severe vulvovaginitis Trophozoite w/ rosette nuclei Trophozoite w/ 2 nuclei
 rarely produces urethritis or other symptoms in males
 the normal acid vaginal secretions (pH 3.8 to 4.4) deter
its survival
 inflammation of the vaginal mucosa occurs several days
after the inoculation of T. vaginalis trophozoites
 trophozoites infect the surface but do not appear to
invade the mucosa
 acute inflammation caused by the parasites results in
the characteristic vaginal discharge
o contains polymorphonuclear cells and
desquamated epithelial cells
 Vaginal secretions
o Liquid LIFE CYCLE
o Greenish to yellow
o Very irritating (cause intense itchiness and  lives in the crypts of the cecum and upper colon
burning sensation)  exact life cycle is unknown
 Speculum exam  direct human to human transmission via the fecal-oral
o Punctuate hemorrhages of the cervix route or via transmission of helminth eggs (particularly
(“strawberry cervix”) that of E. vermicularis)
 Observed only in 2% but are  mononucleated and binucleated forms of Dientamoeba
diagnostic of trichomoniasis were observed in lumen of Enterobius adults in the
 T. vaginalis infections in females presents as intestines
symptomatic vaginitis, chronic infection may be
asymptomatic
 In males, trichomoniasis is asymptomatic during the
acute stage
o Becomes a chronic urethritis

DIAGNOSIS

 demonstration of trophozoites in:

o urine
o urethral secretions
o vaginal secretions
o cervical secretions and scrapings (swabs)
o semen
o prostatic secretions
 avoid contamination of sample w/ feces so as not to
misdiagnose T. hominis for T. vaginalis
 Microscopy: Giemsa, Papanicolou, Romanowsky, acridine
orange
 Culture: Diamond’s modified medium or Feinberg and
Whittington culture medium

EPIDEMIOLOGY

 worldwide distribution with incidence correlating

strongly with the number of sexual partners
 most commonly acquired sexually transmitted infections
  Promastigotes
o Single free flagellum
PATHOGENESIS AND CLINICAL MANIFESTATIONS
arising from kinetoplast
at the anterior end
 does not invade tissues but presence in the intestines
o Measure 15 to 20 um in
produces irritation of the mucosa
length and 1.5 to 3.5 um
o secretion of excess mucus
in width
o hypermotility of the bowel
 infections are usually asymptomatic
 in symptomatic patients, onset of infection is
accompanied by colicky abdominal pain and loss of LIFE CYCLE
appetite
o also complain of intermittent diarrhea w/  infective stage : promastigotes in the proboscis of the
excess mucus sand fly
o abdominal tenderness o injected into host skin during feeding
o bloating sensation  invade the reticuloendothelial cells
o flatulence  become amastigotes
o anal pruritis (11% of patients) = may be due to  multiply by binary fission
co-infection with Enterobius  the parasitized cell ruptures
 peripheral eosinophilia observed in 50% o amastigotes are released to invade new cells
 chronic infection  L. tropica = lymphoid tissue of the
o mimic symptoms of diarrhea-predominant skin
irritable bowel syndrome (IBS)  L. donovani = visceral organs
o rule out infection with this protozoan before  L. braziliensis = skin and mucous
diagnose patient as IBS membranes
 vector : sand fly Phebotomus spp.
DIAGNOSIS o Takes up amastigotes during feeding
 Amastigotes transforms into promastigotes in the gut
 observation of binucleate trophozoites in multiple fixed  Multiply by binary fission
and stained fresh stool samples
 Migrate to pharynx
 fresh stool since trophozoites degenerate after few
hours of stool passage
  number of samples =  rate of identification
 easily overlooked by the examiner if he is not aware of
D. fragilis infection
 purged stool specimens are more suitable
 may be misdiagnosed for other amoebae
 prompt fixation with polyvinyl alcohol fixative or
Schaudinn’s fixative

TREATMENT

 Iodoquinol at 650 mg 3x for 20 days

o Pedia dose 40 mg/kg 3x for 20 days
 Tetracycline and metronidazole

EPIDEMIOLOGY

 presence of D. fragilis in eggs or lumen of E.

vermicularis
 companion parasites of pre-school children in Germany,
Israel and Holland

PREVENTION AND CONTROL

 proper sanitation and human waste disposal

LEISHMANIAS

 mode of transmission : vector bite, congenital, blood

transfusion, contamination of wound by contact

DISEASE

 Leishmaniases – caused by 3 large species complexes

w/c differ in clinical manifestation, geographic
distribution and sand fly vectors

MORPHOLOGY
PATHOLOGY AND CLINICAL MANIFESTATION
 produce amastigotes intracellularly in the mammalian
host 1. Cutaneous leishmaniasis (Leishmania tropica)
 promastigotes in the midgut and proboscis of the insect
vector - incubation period ranges from 2 weeks to months
- skin ulcer with elevated and indurated margins  leaves
 Amastigotes ugly scar on healing
o Ovoid or rounded bodies - lesions may be local or metastatic
o 2 to 3 um in length - lesions are painless and do not result in
o lives intracellularly in the lymphadenopathy
- appearance of subcutaneous nodules
monocytes,
- no systemic signs and symptoms
polymorphonuclear leukocytes
- parasites found in macrophages and histiocytes
or endothelial cells
- ulceration secondary to anoxia or to an immunoathologic
o nucleus is large
reaction
o axoneme arises from the
- diffuse cutaneous leishmaniasis causes widespread
kinetoplast and extends to the thickening of the skin with lesions resembling
anterior tip lepromatous leprosy
- lesions do not heal spontaneously and tend to relapse
 after treatment
- New World cutaneous leishmaniasis more severe and
chronic than Old World cutaneous leishmaniasis

leishmania skin lesion

2. American or Mucocutaneous leishmaniasis TREATMENT, PREVENTION AND CONTROL
(Leishmania braziliensis)
 antimony compounds
- initially there are lesions resembling cutaneous o pentavalent antimonials sodium stiboglyconate
leishmaniasis and n-methyl-glucamine antimonite
- after several decades, metastatic spread to the oronasal  second-line drugs (antimicrobials)
and pharyngeal mucosa o Amphoterecin B
 causes highly disfiguring leprosy-like
o Pentamidine (for Kala-azar)
tissue destruction and swelling
o Metronidazole
(“Tapir nose”)
- chiclero ulcer refers to the erosion of the pinna of the o Nifurtimox
ear of forest workers
 protection against sand flies and avoidance of contact
infection

NON-PATHOGENIC FLAGELLATE PROTOZOA

 the presence of such organisms in the man serve as an

indicator of fecal contamination of ingested food or
water
3. Visceral leishmaniasis or Kala-azar (Leishmania  treatment is not necessary
donovani)  mode of transmission :
o Cysts = Chilomastix
- incubation period is long (1-3 months) o Trophozoites = Trichomonas
- prominent findings:
 fever (2x daily elevations)  Trichomonads are easily recognized because of their
 splenomegaly anterior tuft of flagella, stout median rod (axostyle) and
 cachexia undulating membrane. 3 species found in man
- other signs and symptoms o T. tenax
 skin darkening o T. hominis
 hepatomegaly
o T. vaginalis
 lyphadenopathy
 malaise TRICHOMONAS TENAX
 weight loss
 loss of apetite
 harmless commensal found in the oral cavity
 cough
 more frequently associated with people with poor dental
 diarrhea
hygiene and oral disease
 anemia
 found exclusively in mouth of humans and other
- phagocytosed parasites are present only in small
primates; often associated with Entamoeba gingivalis
numbers in blood; more in reticuloendothelial cells of
spleen, liver, lymph nodes, bone marrow, intestinal  mode of transmission: direct by droplets, kissing or use
mucosa and other organs of contaminated dishes and drinking glasses
- marked hyperplasia of reticular cells
MORPHOLOGY
- marked increase in vascularity of tissues

Promastigote Amastigote  pyriform in shape

 measures 5 to 12 um
 organelles
o 4 free flagella
o undulating membrane that does not reach the
posterior end of the body
o 1 nucleus
o 1 cytosome

DIAGNOSIS

 demonstration of Leishmania in tissue biopsies, skin for

cutaneous leishmaniasis; bone marrow, spleen or lymph
nodes for visceral leishmaniasis
 serology – used for supportive diagnosis when parasites
are difficult to demonstrate
 delayed hypersensitivity reaction to Leishmania antigen
usually develops in late stages of infection or following
cure and lasts for life
LIFE CYCLE
EPIDEMIOLOGY
 lives in the tartar around the teeth, cavities of carious
 occur in southern regions of North America, teeth, gingivalis margins of the gums, in pus pockets in
Mediterranean Basin, East and North Africa, The Caspian tonsillar follicles
Littoral, Arabian Peninsula, Persian Gulf, Indian  multiplies by binary fission
subcontinent, China, Southern Soviet Union  thrives on organisms found in its environment
 most severe forms found in Africa, Latin America and
India (yay! Wala sa pinas!  )
 incidence of 400,000 cases per year, 12 million
prevalence
 Auds

audsmartinez@gmail.com
ustmedc3@yahoogroups.com

DIAGNOSIS

 swabbing
o tartar between the teeth
o gingival margin of the gums
o tonsillar crypts
CHILOMASTIX MESNILI

 normal inhabitant of the cecal region of the large

intestine
 well defined trophic and cystic stages
 mode of transmission: ingestion of cysts in food and
drinks contaminated with human feces (fecal-oral)

MORPHOLOGY

 trophozoites
o found in diarrheic or liquid stools
o pear-shaped and asymmetrical
o with spiral grooves extending through middle
portion
o size 6-10 um
o movement: boring or spiral forward movement
 possible by 3 anterior free flagella
 1 delicate flagellum w/in the
prominent cytostome

 cysts
o found in formed or semi-formed stools
o pear or lemon-shaped, round at one end and
conical at the other
o w/ knob-like protruberance (not always
visible)
o 7 to 16 um
o w/ cytostome and 1 nucleus

EPIDEMIOLOGY

 cosmopolitan distribution
 more prevalent in warm climates
 < 1% prevalence in the Philippines

disclaimers:

these are not notes from the lecture given by dr. pascual, these
were taken from various parasitology books. it’s up to you if you
want to study this. 

the same goes for lectures 7, 9 and 10… gawa ko lang po iyon…
bahala na kayo mag fill-in ng mga kulang na details… tao lang po!

Good luck!

Only 1 lecture to go!