This document discusses the clinical presentation, laboratory diagnosis, and most common pathogens involved in parasitology. It describes the symptoms, life cycles, microscopic appearance, and diagnostic methods for protozoan parasites commonly found in stool, blood, and tissues. These include Entamoeba histolytica, Giardia lamblia, Cryptosporidium, and Trypanosoma among others.
2. Clinical presentation
Travel history or poor sanitation put you at
the highest risk for parasitic infection
Sporadic symptoms,
Poor immune status higher risk
Dysentery not common (amebiasis)
Most usual symptoms:
• Abdominal pain, cramping, long term nausea,
and malaise, mucous in stool, and +/- fever
3. Laboratory Diagnosis
Limited
Currently based on
microscopic exam, however utility/availability of:
molecular panels are in the
• Serology
near future
• Stool
• Fluorescent stains
• Non-stool
• PCR
Perianal specimen
•
•
Sigmoidoscopic specimen
Duodenal aspirates
Liver abscess
Sputum
Urine
Urogenital
Blood
Tissue
4. Two-vial collection kit for Stool
10% formalin
Concentration with
ethyl acetate to
eliminate fecal debris
Wet mount and DFA
staining
Helminth eggs, larvae,
microsporidia, and
protozoan cysts
PVA with fixative
Polyvinyl alcohol
Permanent stained
smear
• Trichrome stain
Protozoan
trophozoites and cysts
Mercury based
fixatives being phased
out for safety – Zinc
fixatives are now used
10. Entamoeba histolytica/dispar
E. histolytica is a pathogen and E. dispar is a
nonpathogenic species that can also occur in the
large intestine. Morphologically indistinguishable
E histolytica
• Cysts = infectious form
• trophozoites = invasive form
• Contaminated water and poor sanitation
• Colon biopsy shows “flask-shaped” ulcer
• Non-intestinal disease = extraintestinal
amebiasis (liver abscess)
Serology
13. Amebic abscess
Amebic liver abscess
Entamoeba histolytica
Serology – high %
positive in extraintestinal cases
Flask-shaped ulcer of intestinal amebiasis
14. Entamoeba coli cyst and trophozoite
Trophozoite is the form
that invades intestines
Cyst >=15 mm
Up to 8 nuclei
Shed from host
Lives in environment
Nucleus has a chromatin ring
The cytoplasm appears dirty
16. Endolimax nana trophozoite
Mostly thought to be a non-pathogen,
Seen in HIV/AIDS patients,
Some literature suggesting it can cause
intermittent or chronic diarrhea
17. Iodamoeba butschlii cysts with starch
Staining inclusion
Iodine preparation – name from
appearance with iodine staining
20. Giardia lamblia
Contaminated water,
undercooked foods
Mild diarrhea to severe
malabsorption
Foul, watery diarrhea
Day-care center outbreaks
Cysts/trophozoites may be
seen in stool, but can be
hard to find; Fluorescent
stains available
Duodenal aspirations
CYSTS
TROPHOZOITE
“falling leaf” motility
21. Giardia lamblia trophozoite
Waxing and waning
symptoms
Can be irregularly
Shed in stool material
& can be difficult to find
Russia & Mexico
-Hot beds
Only invades intestine
Flagyl (Metronidazole)
is drug of choice
31. Ciliates
Balantidium coli
• Mainly in swine
• Contact with swine & poor hygiene
• Only ciliate that’s pathogenic to humans
• Similar disease as amebiasis, but
extraintestinal invasion rare
• Largest (50-200 um) trophozoite;
surface covered with cilia; macronucleus
• Cyst 40-60 um
• Readily identified in fresh, wet mounts
32. Only protozoa with cilia
50 microns
In intestine can cause flask-shaped ulcers like those
caused by E. histolytica
36. Cryptosporidium parvum
Contaminated water
Resistant to usual water-purification
procedures (chlorination, ozone)
Daycare center outbreaks (fecal-oral)
Watery diarrhea; more severe in
AIDS
38. Enzyme immunoassay for the antigen
Direct Fluorescence Antibody stain –
of C. parvum is also available.
Cryptosporidium parvum
False negatives may result due to low
organisms numbers (Asymptomatic
carriers) in both the EIA and DFA
assays
Combo stain for Cryptosporidium
And Giardia lamblia
C. parvum
Giardia
39. C. Parvum in intestine
C. Parvum in intestine
just below the plasma
membrane
40. Cyclospora cayetanensis
Contaminated fruits and vegetables
Watery diarrhea; more sever in
HIV/AIDS
Infects upper small bowel
Found in vacuoles in cytoplasm of
jejunal epithelium, villous atrophy,
crypt hyperplasia
43. Microsporidia
-Common in HIV/AIDS
-Watery persistent diarrhea
Positive on modified Trichrome
and Calcofluor white stains
-Longer staining time will eventually
allow for it to work its way into the spore
44. Blastocystis hominis cysts
Nuclear blobs
Around the periphery
Can be a pathogen
Small #s: can be commensal
Large #s: pathogenic
Dirty H20 Traveler’s diarrhea
Trichrome
stain
Iodine wet mount
45. Blood-Borne Protozoa
Organism
Transmission
Disease/Symptoms
Diagnosis
Treatment
Trypanosoma
brucei
Tsetse fly
African
trypanosomiasis;
Sleeping sickness
Encephalitis; cardiac
failure
Hemoflagellate in
blood or lymph
node
Blood stage:
Suramin or
petamidine
isethionate
T. cruzi
Reduvid (kissing)
bug
American
trypanosomiasis;
Chagas disease:
megacolon, cardiac
failure.
Hemoflagellate in
blood or tissue.
C- or commashaped
CNS:
melarsoperol
Nifurtimox and
Benzonidazole.
Leishmania
donovani
Phlebotomine
sandfly
Visceral leishmaniasis
(Kala-azar),
granulomatous skin
lesions
Iraq/Iran/Afghanistan
Intracellular
(macrophages)
leishmanial bodies
with kinetoplast
Pentosam;
Pentamidine
isethionate.
Babesia microti
Ixodes tick
Hemolytic anemia,
Jaundice, fever,
hepatomegaly
Maltese cross in rbc
None;
self resolving.
47. Trypanosoma brucei Sleeping
sickness (African trypanosomiasis)
Vector: Tsetse fly
The two T. brucei species that cause
African trypanosomiasis are
indistinguishable morphologically
• T. b. gambiense
• T. b. rhodesiense
A typical trypomastigote has:
• A small kinetoplast located at the posterior
end
• A centrally located nucleus
• An undulating membrane, and
• A flagellum running along the undulating
membrane, leaving the body at the
anterior end
• 14 to 33 µm in length
Trypomastigotes are the only stage found
in patients.
50. Trypanosoma cruzi Chagas
(American trypanosomiasis)
Vector: Reduvid/Triatoma (kissing) bug
Trypomastigotes are the only stage found in
the blood of an infected person; may be seen in
CSF in CNS infections
Motile circulating trypomastigotes are readily
seen on slides of fresh anticoagulated blood in
acute infection but are rarely detectable by
microscopy in chronic T. cruzi infection.
A typical trypomastigote has:
•
•
•
•
A large, subterminal or terminal kinetoplast,
A centrally located nucleus,
An undulating membrane, and
A flagellum running along the undulating
membrane, leaving the body at the anterior end.
• 12 to 30 µm in length.
Amastigote stage parasite may be seen in
histopathology specimens from affected organs.
C-shape
54.
Leishmania amastigotes
• Macrophages filled with
amastigotes (arrows), several
of which have a clearly visible
nucleus and kinetoplast
• Amastigotes are being freed
from a rupturing macrophage
55. Leishmania – Clinical Disease
Cutaneous
• Single or few chronic, ulcerating
lesions; many species
• Latin America, southern Europe,
Middle east, southern Asia,
Africa
• Mucocutaneous in Latin America
Visceral
• primarily L. donovani complex
(Asia), L. infantum/chagasi
(Africa and Latin America),
others
• Hepatosplenomegaly, anemia,
cytopenias, systemic symptoms
• India, Bangladesh, Nepal,
Sudan, and Brazil
• Important OI in HIV infection
56. Leishmania
Diagnosis
• Biopsy of infected tissue (skin, bone marrow)
Multiple, tiny 2-5 um amastigotes within histiocytes
Distinct kinetoplast (bar-like structure adjacent to
nucleus)
• PCR
• Urinary antigens (visceral)
DDx of multiple tiny intracellular
organisms
•
•
•
Leishmania – kinetoplast
Histoplasma – budding
Toxoplasma – somewhat curved, mostly
extracellular
58. Babesia
Ixodes tick
Protozoan: B. microti, B. divergens
Zoonosis (deer, cattle, rodents; humans accidental host)
Transmission by Ixodes tick bite
Infects red blood cells
Found world-wide
B. microti along the Northeast US
• Nantucket Island, Martha’s vineyard, Shelter Island
Malaria-like syndrome
• Fever but without periodicity, “B-symptoms”, hemolytic
anemia, hemoglobinuria, renal failure
Dx:
• Blood smear examination
Ring form only (mimics P. falciparum)
Tetrads (unlike P. falciparum)
Maltese cross
(tetrads)
63. Malaria
Physical exam findings
•
•
•
Fever
Splenomegaly
P. falciparum
Jaundice
Hepatomegaly
Increase in respiratory rate
CNS involvement
Diagnosis: peripheral blood smear (gold
standard)
Molecular tests are available but not yet
widely used
64. Malaria
Distinction is between P. falciparum and
non-falciparum
• P. falciparum = rapidly progressive and
LETHAL (malignant tertian fever), often
chloroquine-resistant
• Non-falciparum = rarely cause severe
manifestations, often chloroquine sensitive
Relapsing malaria
• Dormant hepatic phase
Hypnozoites of P. vivax and P. ovale
65. Two in the Liver/Two Not!!
Two types of malaria that don’t recur from
the liver:
• P. falciparum – high incidence and severity
• P. malariae – lower incidence and severity
Two types of malaria that do recur from the
liver:
• P. vivax – high incidence, most of the world
except Western Africa
• P. ovale – lower incidence, occupies the niche in
Western Africa
69. P. falciparum
P. vivax, P.
ovale
P. malariae
Babesia
Vector
Mosquito
Mosquito
Mosquito
Ixodes tick
RBC
Any RBC
Young RBC;
enlarged
Mature RBC;
Not enlarged
Ring
Multiple can
be seen;
delicate;
“appliqué”
Rarely >1;
thickened
Schizont
Rarely seen
Commonly seen
Bananashaped
Round
none
None
None
Present
No
Yes
No
Brown
No
5-10%
Gametocyte
Extra-RBC
form
Schüffner dots
Pigmentation
Infection rate
>2%
<2%
Protective
polymorphism
s
Hemoglobin S,
C,E, alpha and
beta thal, G6PD
Duffy negative
(P. vivax)
1-12
Tetrads
(Maltese
cross)
Delicate
Rings only
“rosette”
none
70. Malarial Preparations
Thick smear
Drop of blood on slide
Water rinse to
eliminate rbc’s
Stain with Giemsa
stain (not WrightGiemsa) with proper
pH
Concentrated to spot
malaria parasites
Thin smear
Feather edge smear
For optimal
morphology, stain
with Giemsa (not
Wright-Giemsa) stain
with proper pH
Speciation of malaria
Parasitemia (%)
77. P. vivax
Amoeboid ring form
P.Vivax – benign tertian malaria (every 48 hours), Duffy negative RBC is protective
Africans lack Duffy rbc antigen and this prevents rbc invasion.
Untreated infections last several years; dormant in the liver for years
Patients can survive years without treatment, but chronic infection can lead to brain, kidney and liver damage
92. Amoebic meningoencephalitis
Most commonly caused by Naegleria
fowleri
Granulomatous amoebic encephalitis
or brain abscess(es) caused by
Acanthamoeba and Balamuthia
Clinical scenario: swimming or
diving in fresh-water pools
93. Naegleria fowleri
-Found in warm fresh water
-Breath-in through nose-> brain
Brain tissue with Naegleria fowleri
trophozoite
95. Contact-lens keratitis
Caused by Acanthamoeba
Can be cultured on a “lawn of E. coli”
• Take corneal scapings
• Visible trail of ameba moving across
plate ingesting E. coli
100. Enterobius vermicularis (pinworm)
Humans considered only host
Females 8-13mm, males 2-5 mm
Dwell in the cecum
¼-1/2 inch in thickness, white, lloks like
string in stool
Lay up to 15,000 eggs
• Oval with a flattened side: 50-60um by 20-30um
Diagnosis- Scotch tape test or anal swab
Most common helminth in US
103. Ascaris lumbricoides (roundworm)
1-1.2 billion people infected
• More common in children
20,000 death
Largest helminth to affect humans
Females 20-35cm long, males 1530cm with a curved tale
• Can cause intestinal obstruction
106. Ascaris eggs
Unfertilized eggs-large & oval, mammillated
layer is pronounced
Fertilized eggs- smaller, rounder,
mammillated layer is less obvious
107. Trichuris Trichiura (whipworm)
Soil transmitted
Can be similar to amebiasis
PVA preserved samples inferior to formalin
Adults attach to large intestine and are
rarely recovered
Thinnest part- head
Males are smaller than females
109. Necator americanus, Anclyostoma
duodenale (Hookworms)
Soil transmitted
2nd most common helminth infection
Enter via exposed skin
Necator or Ancylostoma – Hookworm egg
114. Microfilariae
Sheathed
• Wucheria bancrofti and Brugia malayi
Elephantiasis (lymphangitis/lymphedema)
• Loa loa
Calabar swellings & migrating worms in the
conjunctiva
Not sheathed
• Onchocerca volvulus
• Mansonella species
Allergic skin reactions, edema, Calabar swellings
115.
116. How to tell them apart
Are they sheathed?
• Yes: Wucheria, Brugia, Loa loa
• No: Onchocerca, Mansonella
How far do nuclei extend?
• Terminal and subterminal nucleus:
Brugia
• To the end: Loa loa
117. Identification of microfilariae is based on the presence of a sheath covering the larvae, as
well as the distribution of nuclei in the tail region
A, W. bancrofti. B, B. malayi. C, L. loa. D, O. volvulus. E, Mansonella
perstans. F, Mansonella streptocerca. G, Mansonella ozzardi.
139. Diphyllobothrium latum
Poorly-cooked fresh-water fish(salmon)
Scandinavian, Russia, Canada, N. USA,
Alaska
Broad fish tapeworm
Longitudinal sucker
Eggs have non-shouldered operculum and
knob
• They are not embryonated
Causes Vit B12 deficiency
142. Taenia Species – two species
Outstanding characteristics
Taenia saginata
Taenia Solium
Beef tapeworm
4 suckers on scolex
>13 uterine branches in
proglottids
Ingestion of cysticerci in
beef
Intestinal infestation
Ingestion of eggs ->
Non-human pathogen
Pig tapeworm
Ring of thorns/crown on
scolex
<13 uterine branches in
proglottids
Ingestion of cysticerci in pork
Intestinal infestation
Ingestion of eggs ->
Cysticercosis
151. Larger outer shell
No radial striations
Hooklets inside
Hymenolepis nana
Most common cestode recovered in USA
Worm is 2-4 cm
Egg has inner & outer shell separated
space
Water /food contaminated by rodent
droppings
Particularly difficult to differentiate from falciprium
Hallmark of babesiosis is the tetrad (Maltese cross; cruciform body)
Blackwater fever (falciprium and think black pee)
Microscopic examination
Exception for non-falcirpium is P. vivax where chlorquine resistance is seen in Papua New Guinea and Indonesia
The malaria parasite life cycle involves two hosts. During a blood meal, a malaria-infected female Anopheles mosquito inoculates sporozoites into the human host. Sporozoites infect liver cells and mature into schizonts, which rupture and release merozoites. (Of note, in P. vivax and P. ovale a dormant stage [hypnozoites] can persist in the liver and cause relapses by invading the bloodstream weeks, or even years later.) After this initial replication in the liver (exo-erythrocytic schizogony ), the parasites undergo asexual multiplication in the erythrocytes (erythrocytic schizogony ). Merozoites infect red blood cells . The ring stage trophozoites mature into schizonts, which rupture releasing merozoites. Some parasites differentiate into sexual erythrocytic stages (gametocytes). Blood stage parasites are responsible for the clinical manifestations of the disease. The gametocytes, male (microgametocytes) and female (macrogametocytes), are ingested by an Anopheles mosquito during a blood meal . The parasites’ multiplication in the mosquito is known as the sporogonic cycle . While in the mosquito's stomach, the microgametes penetrate the macrogametes generating zygotes . The zygotes in turn become motile and elongated (ookinetes) which invade the midgut wall of the mosquito where they develop into oocysts . The oocysts grow, rupture, and release sporozoites , which make their way to the mosquito's salivary glands. Inoculation of the sporozoites into a new human host perpetuates the malaria life cycle .
Presence of absence of various stages in the blood
Morphology of the gametocyte
Size of the infected RBC
Most prevalent
Widest geographical distribution
Enlarged RBC; fimbriated/ragged rbc
Fever cycle every 72 hours (quartan), can remain dormant in the blood for years.
Untreated infections may last as long as 20 years