Dr.

SUHAEMI, SpPD, FINASIM

P R O TO Z O A

PEN D AH U LU AN

Protozoans
Protozoans are more diverse than all

other eukaryotes.
No longer classified in a single kingdom.
Recently shown that there are at least

seven or more clades.

May be more than 60 monophyletic
eukaryotic clades.

Protozoa is now used informally

without implying phyletic
relationship.

Protozoans
Protozoa
Lack a cell wall
Have at least one motile stage in life cycle
Most ingest their food

Carry on all life activities within a single cell.

Can survive only within narrow

environmental ranges.
Very important ecologically.
At least 10,000 species of protozoa are
symbiotic in or on other plants or animals.

Relationships may be mutualistic, commensalistic,

or parasitic.

Cladogram ofthe M ajor D ivisions ofO rganism s

C lassif c
iation
Phylum:

Sarcomastigop
hora

Apicomplexa

Ciliophora

Class

Genera:

Zoomastigophor
a

Trypanosoma, Leishmania, Giardia,

Trichomonas

Lobosea

Entamoeba,
Acanthamoeba

Sporozoea

Plasmodium,Toxoplasma,
Cryptosporidium, Isospora

Kinetofragminopho
rea

Balantidium

Naegleria,

Life C ycle Stages

The stages of parasitic protozoa

that actively feed and multiply are

frequently called trophozoites; in
some protozoa, other terms are
used for these stages. Cysts are
stages with a protective membrane
or thickened wall. Protozoan cysts
that must survive outside the host
usually have more resistant walls
than cysts that form in tissues.

EcologicalN iches in the H um an B ody:

1. Skin: Leishmania
2. Eye: Acanthamoeba
3. Mouth: Amoebae and flagellates

(usually non-pathogenic)
4.Gut: Giardia, Entamoeba
invasion to
liver), Cryptosporidium,
Isospora, Balantidium
5. G.U. tract: Trichomonas

(and

Protozoans
Protozoans are an extremely diverse

assortment of unicellular eukaryotes.

leishm ania

giardia

trichom onas

am oeba

M A LA R IA O R G A N IS M S

Malaria Pathogenesis and

Clinical Presentation

M alaria Burden
Malaria kills 1.5 to 2.7 m people

world wide every year

95% are due to P.falciparum
In India P.falciparum up to 34%
Case fatality rate is up to 9%
Chloroquine resistance is major
concern
Multi drug resistance emerged in
India

Plasm odium
Causative agent of malaria bad air
Been around since ~3550 BC
General life cycle
2 hosts
Invertebrates mosquitoes; technically the
definitive host because of sexual reproduction
Vertebrates reptiles, mammals or birds; asexual
reproduction here, intermediate host

Gametocytes form in the blood of

vertebrates but fertilization occurs in the

gut of the mosquito in the blood of the
vertebrate, so vertebrates are the definitive
host

Relapsing m alaria
P. vivax and P. ovale hypnozoites

remain dormant for months

They develop and undergoe preerythrocytic sporogeny
The schizonts rupture, releasing
merozoites and produce clinical
relapse

Life
Cycle

M alaria Transm ission Cycle

Exo-erythrocytic (hepatic) Cycle:
Sporozoites infect liver cells and
develop into schizonts, which release
merozoites into the blood

Sporozoires injected
into human host during
blood meal

Parasites
mature in
mosquito
midgut and
migrate to
salivary
glands

MOSQUITO

Parasite undergoes
sexual reproduction in
the mosquito

HUMAN

Some merozoites
differentiate into male or
female gametocyctes

Dormant liver stages

(hypnozoites) of P.
vivax and P. ovale
Erythrocytic Cycle:
Merozoites infect red
blood cells to form
schizonts

Com ponents ofthe M alaria Life Cycle

Sporogonic cycle

Infective Period
Mosquito bites
uninfected
person
Mosquito bites
gametocytemic
person

Mosquito Vector
Parasites visible

Prepatent Period

Human Host

Symptom onset
Recovery

Incubation Period
Clinical Illness

plasm odium

Life Cycle
Life Cycle (mosquito stages in orange):
sporozoite in mosquito salivary glands injected
during feeding sporozoite in blood invades
hepatocyte trophozoite in hepatocyte mitotic
division schizont in hepatocyte hepatocyte
bursts merozoites in blood invade RBC
trophozoite in RBC mitotic division schizont
in RBC RBC bursts merozoites in blood
reinvade RBC schizont or gametocyte in RBC
gametocytes ingested by mosquito gametes in
midgut fertilization zygote elongation
ookinete penetrates midgut epithelium, meiotic
and mitotic division oocyst containing
sporozoites sporozoite migration in hemolymph
sporozoites in salivary glands

Anopheles H ead

Female

200m

Male

O ocyst

500 m

Oocysts of Plasmodium sp. on the surface

of an Anopheles sp.

Plasm odium Species

4 human plasmodium
P falciparum
P vivax
P malariae
P ovale

Plasm odium vivax

43% of the malaria world wide; not

usually life threatening

Causes benign tertian malaraia, vivax
malaria or tertian ague fever every 48
hours
Found in temperate zones; mostly in
Asia 40% of American soldiers in
Vietnam had this type
Blacks in tropical Africa are resistant
May remain as hypnozoites in the liver,
relapse of up to 8 years later

P vivax (cont.)
Merozoites only infect young RBC called

reticulocytes because they contain the right

receptors on the surface
After the ring stage, they become active
amoeba
Schffners dots are stippling in the RBCs
Hemozoin accumulated in RBC when
trophozoite is present
12-24 nuclie in mature schizont
Some merozoites develop into gametocytes

Ratio of 2 macrogametocytes to 1 microgametocyte

Macrogametocyte is almost is large as RBC
Microgametocyte is not nearly as large
Mature in about 4 days

Sporozoites of Pl
asm odium
Squash prep of an oocyst
from an infected
vivax
mosquito
Sporozoites develop in

10 m

oocysts, migrate in the

hemolymph to the
salivary glands
Several thousand may
be injected into the host
by one mosquito during
feeding
In host liver, each will
penetrate into an
hepatocyte and develop
into an exoerythrocytic
schizont by way of a
trophozoite

Exoerythrocytic Schizonts
Liver cells
Exoerythrocytic schizont,

which is a single
multinucleate cell

Cytokinesis occurs, and

thousands of merozoites burst

from the hepatocyte within 1-2
weeks post infection

Merozoites then infect

erythrocytes
P. vivax and P. ovale, some
schizonts develop into
dormant hypnozoites
May become active and cause a
10 m

relapse of the disease years after

a supposed cure

Trophozoites of P.vivax

Identified as P.

vivax by the
following features:
Enlarged,

10 m

decolorized infected
erythrocytes
Prominent
Schffners dots
Amoeboid shape of
the troph

Erythrocytic Schizonts of P.vivax

Merozoites invade

10 m

host erythrocytes,
most undergo
schizogony
New merozoites burst
out of the cell and
immediately infect
new cells
Large numbers of
infected erythrocytes
burst more or less
simultaneously,
causing a rapid rise in
body temperature at
48-hour intervals

Plasm odium falciparum

50% of malaria world wide; most

virulent strain
Causes malignant tertian, subtertian or
estivoautumnal malaria
Concentrated in the tropics and
subtropics
Exoerythrocyte stage in liver, more
irregularly shaped
No relapse but can have recrudescence
develop symptoms years later due to
resurgence of previously low,
nondetectable levels of parasitemia
(not to be confused with relapse)

P.falciparum (cont.)
Merozoites can infect any RBC, not age

dependent

Usually see early ring stage/gametocytes in the

blood smear
Smallest ring stage of the 4

Can also bind uninfected RBC forming a

rosettes, can be hard to find in blood smears

RBC develop irregular blotches called Mauers
clefts that are larger than Schffners granules
Mature schizont is less symmetrical than
others
Gametocytes take 10 days to develop and
then can be seen in large numbers
Cresent shaped and very distinct

Troph of P.falciparum
Young signet ring

stage
Diagnostic
features are:

High parasitemia
Presence of only

signet ring
trophozoites;
Double chromatin
dots
Multiple infections
in some cells
Absence of
Schffners dots
10 m

Schizogony

results in new
infected
erythrocytes

 This
Erythrocytic schizont
s of
P.usually is
stage
not observed in
peripheral blood,
falciparum

10 m

except in very heavy

infections
Each schizont
produces from 6 to 32
merozoites, with an
average of 20 to 24,
every 48 hours
Hemozoin pigment is
clumped in the center
of the infected RBC
Note that the
merozoites are very
small, and that the
schizont usually does
not fill up the RBC

G am etocytes of P.falciparum

10 m

Macrogametocytes are elongate; nucleus less than one-half the length of the cell
Microgametocytes may be shorter and more blunt-ended; lighter blue cytoplasm;
nucleus that is greater than one-half the length of the cell
Gametes not produced until in the midgut of a mosquito

D iff
erentiation offalciparum

P.falciparum
gametocyte

P.vivax gametocyte

D iff
erentiation offalciparum

P.falciparum shizont

P.vivax shizont

D iff
erentiation offalciparum

P.falciparum
trophozite

P.vivax trophozite

D iff
erentiation offalciparum

P.falciparum
gametocyte

P.vivax gametocyte

Falciparum gam etocytes

Male

Female

Electron M icrographs

P.falciparum EM

P.vivax EM

Falciparum invading RBC

D rug Rx.offalciparum
Chloroquine is not the drug of choice
Should not be treated with single

drug
Combination therapy is a must
Weaker drugs like Proguanil are of no
avail
Artemisinin based CT ACT is the Rx.
of choice

The Anti-m alarialD rugs

Artesunate, Artether, Artemether
Mefloquine, Amodiaquine
Quinine, Chloroquine
Lumefantrine, Halofantrine,
Proguanilchlor (chlorguanide)
Sulfadoxin+Pyrimethmine, Dapsone
Tetracyclines, Doxycyclin, Clindamycin

Todays W atch W ord

Combination Therapy
(CT)
Artemisinin based
Combination Therapy
(ACT)

W hat is CT ?
Anti-malarial combination therapy

(CT) is the simultaneous use of two

or more blood schizonticidal drugs
with different biochemical targets in
the parasites and independent
modes of action.

W hat is ACT ?
Artemisinin-based combination

therapy (ACT) is an antimalarial

combination therapy with an
artemisinin derivative as one
component of the combination given
for at least 3 days.

W hat are Artem isinins ?

Artemisinin derivatives
Dihydroartemisin

Qinghaosu
("ching-how-soo")

Ethyl Ether

Methyl Ether

Arteether

Artemether
Hemisuccinate
Artesunate

W hy Artem isinins ?
Short half-life; hence good for

combination
Rapid substantial reduction of the
parasite biomass
Rapid resolution of clinical symptoms
Effective action against multi-drug
resistant P. falciparum
Reduction of gametocyte carriage
No documented parasite resistance
yet

N o M onotherapy
No Chloroquine for P.falcipatum
No Monotherapy with

Artemisinin

ACT -W H O G uidelines
Technical Consultation on Anti-

malarial Combination Therapy:

Geneva, April 2001
Guidelines for the treatment of
Malaria
WHO document 266 page book
February 2006

Recom m ended Com binations

1. Artemether + Lumefantrine

(Lumether)
2. Artesunate (3 days) + Amodiaquine
3. Artesunate (3 days) + Mefloquine
4. Artesunate (3 days) + SP
5. Amodiaquine + SP (as interim option)

 Artem ether
Methyl ether of Artemisinin
Effective Schizonticidal and

gametocidal drug
Short half life 2 - 6 hours
Interferes with the conversion of
Haem to non toxic hemozoin in the
parasite
Not indicated in 1st trimester of preg.

 Artem ether
side eff
ects

Very few and less troublesome

Cough
Body aches
Abd pain, Nausea, Vomiting,

Anorexia
Palpitations
Dizziness, weakness
Skin rash, itching

AL D osage Schedule

COARTEM PREFERENTIAL PRICING FOR PUBLIC

SECTOR: PRICE CHANGES BY 2005
PUBLIC SECTOR

PRIVATE SECTOR

Second line Com binations

1. Artesunate (7 days) + Tetracycline

(7)
2. Artesunate (7 days) + Doxycycline

(7)
3. Artesunate (7 days) + Clindamycin

(7)
or
4.

Quinine in place of AS + any of the

above antibiotics for 7 days

W hat to give in pregnancy ?

In 1st trimester

In 2nd and 3rd trimesters

Quinine + Clindamycin 7 days

Any ACT combination as per rec. or
Artesunate + Clindamycin 7 days or
Quinine + Clindamycin 7 days

Lactating women same ACT

Com plications offalciparum m alaria

Coma - cerebral malaria, convulsions
Renal failure black water fever
Hyperpyrexia, acute pulmonary

edema
Hemolytic Jaundice, severe bleeding
Hypovolemic shock, Hypoglycemia
Metabolic acidosis, Coagulopathy,
Severe anaemia, hyperparasitemia

Artem isinins parenteral

Arteether 150 mg (2ml) i.m od x 3

days or 3 mg/kg od i.m. x 3 days

Artesunate 2.4 mg/kg i.v. or i.m. given
on admission (time = 0), then at 12 h
and 24 h, then once a day
Artemether 3.2 mg/kg i.m. given on
admission then 1.6 mg/kg per day is an
acceptable alternative to quinine i.v
infusions
Rectal artemisinins are not as effective

Q uinine parenteral
A loading dose of quinine of 20 mg

salt/kg bw. 10 mg/kg 8th hrly i.v

infusion
Rate-controlled i.v. infusion is the
preferred route of quinine admin.
If this cannot be given safely, then
i.m. injection is a satisfactory
alternative.
Rectal admin. is not effective
Quinidine can substitute quinine

Q uinine parenteral
A loading dose of quinine of 20 mg

salt/kg bw. 10 mg/kg 8th hrly i.v

infusion
Rate-controlled i.v. infusion is the
preferred route of quinine admin.
If this cannot be given safely, then
i.m. injection is a satisfactory
alternative.
Rectal admin. is not effective
Quinidine can substitute quinine

The time of poor drugs for poor people is over

 ARTEETH ER
150 mg (2 ml amp.)
O.D.
intramuscular x 3 days
=
Total 3 ampoules in a
box
To be given I.M