C H A P T E R

5
Visceral Protistans II
Flagellates
Chapter 5 introduces eight species of flagellated protistans that infect the human digestive
and reproductive systems. In the ensuing discussion, this group of organisms is divided into
two groups, the nontrichomonad flagellates and the trichomonad flagellates. Within these
two groups, eight species of flagellates inhabit the aforementioned sites, but only two organ-
isms are usually considered pathogenic, Giardia lamblia and Trichomonas vaginalis. The former
infects the small intestine of humans, while the latter infects the reproductive system. The
epidemiology of G. lamblia is discussed emphasizing the wide variety of wild animals that
can serve as reservoir hosts for the organism. Backpacker’s disease is presented as an exam-
ple of the role that wild animals can play in transmitting the organism to humans. The host’s
immune response is considered as is the current chemotherapeutic regimen. Of the tricho-
monads, only T. vaginalis is considered pathogenic to humans. Following a brief overview of
the trichomonad morphology, the physiology and epidemiology of T. vaginalis is discussed in
detail. In considering the latter, the roles of males and females in the spread of the infection
is considered. A brief discussion of the host’s immune response is followed by a paragraph
outlining the current chemotherapeutic regimen for T. vaginalis.
Members of the phyla Retortamonada and Parabasalia, the flagellates infecting the digestive
and reproductive systems of humans, belong to seven genera. As in the case of amoebae, only
a few are pathogenic, but it is important to distinguish the nonpathogenic from the pathogenic
forms. The nonpathogenic organisms are Chilomastix mesnili, Retortamonas intestinalis, Enteromo-
nas hominis, Trichomonas tenax, Pentatrichomonas hominis, and Dientamoeba fragilis; forms patho-
genic in humans are G. lamblia and T. vaginalis. Of the eight organisms listed above, all but two
species, T. tenax (mouth) and T. vaginalis (reproductive tract), are intestinal parasites.

NONTRICHOMONAD FLAGELLATES

Giardia Lamblia (=G. Duodenalis)

The bilateral symmetry of members of this genus (Figs. 5.1 and 5.2) is distinctive among
the protistans. The trophozoite is rounded at the posterior end, tapered posteriorly, and flat-
tened dorso-ventrally. It is 14-µm long (range, 8–16 µm) by 10-µm wide (range, 5–12 µm)

Human Parasitology. http://dx.doi.org/10.1016/B978-0-12-813712-3.00005-9

Copyright © 2019 Elsevier Inc. All rights reserved.

71
FIGURE 5.1  Giardia lamblia. (A) Trophozoite. (B) Cyst.

FIGURE 5.2  Giardia. (A) Trophozoite of the Giardia intestinalis type. Scanning electron micrograph of the ventral
surface showing the attachment organelle. Bar = 1 mm. (B) Transmission electron micrograph of a cross section of a
Giardia muris trophozoite in the small intestine of an infected mouse. The marginal groove is the space between the
striated rim of cytoplasm and the lateral ridge of the adhesive disc. This specimen bears endosymbionts, which ap-
parently are bacteria. (X 15,350) (C) Scanning electron micrograph of an intestinal villus. The microvillus border of
the epithelial cells is almost obscured by attached trophozoites.

 
 NONTRICHOMONAD FLAGELLATES 73
(Fig. 5.1). The dorsal surface is convex; the ventral surface is usually concave but occasionally
flat and is dominated by a large, binucleate adhesive disc with a nucleus in the center of each
half (Fig. 5.2A). The rim of the adhesive discs is supported by microtubules and clusters of
microfilaments (Fig. 5.2B), and four pairs of flagella arise from basal bodies clustered between
the two nuclei. One pair extends down the midline of the cell, emerging posteriorly as trailing
flagella; the ventral pair emerges at the posterior edge of the adhesive disc. Of the remaining
two pairs, one emerges anteriolaterally and one laterally. Two prominent, slightly curved
median bodies are distinctive to the genus Giardia. Their function is unknown, although it
has been suggested that they may act as supportive structures.

Life Cycle (Fig. 5.3)

The trophozoite of G. lamblia reproduces by longitudinal fission. Its organelles undergo divi-
sion in the following order: nuclei, adhesive disc, and cytoplasm. In the duodenum and bile
duct of its host, the trophozoite can either maintain position by attaching its large adhesive disc
to the epithelial cells (Fig. 5.2C) or use its flagella to swim rapidly in the lumen. Attachment is
facilitated by the two ventral flagella working with the flexible rim of the disc. As trophozoites
pass through the digestive tract, they usually encyst in the colon. The cystic transmission stage
is typically ovoid and averages 11-µm long (range, 9–12 µm) (Fig. 5.1). In saline smears, refrac-
tile granules can be seen in the cysts, and, at times, the cytoplasm appears to be detached from
the cyst wall in several places. In cysts stained with iodine or hematoxylin, two to four nuclei
are visible in addition to numerous fibrils (probably flagellar remnants) and median bodies.
In victims of giardiasis, massive infection is common. The presence of up to several billion
trophozoites in a single diarrheic stool sample is not unusual. Cysts are rarely encountered in
such stools, being found instead in either formed or partially formed stools. Infection results

FIGURE 5.3  Life cycle of Giardia lamblia. Credit: Image courtesy of Gino Barzizza.

 
74 5.  Visceral Protistans II

from ingestion of cyst-contaminated food or water or from direct hand-to-mouth contact.

Ingestion of 100 or more cysts is considered infective. Following ingestion, cysts pass through
the stomach to the small intestine where they excyst and begin the cycle anew.

Epidemiology
Giardia is the most prevalent intestinal parasite in humans. It is cosmopolitan and is common
in children 6–10 years of age but is also seen often in older children and adults, with a high inci-
dence in homosexual males. Outbreaks are frequent in daycare nurseries and other institutions
where sanitation may be inadequate. An outbreak of giardiasis occurred in the ski resort town
of Aspen, Colorado, when a water supply line was inadvertently crossed with a sewage line,
and 11% of the skiers present that season became infected. Among 59 persons whose stools were
positive, 56 experienced clinical symptoms of the disease. Giardiasis is common among tourists
(an infection rate of approximately 23%) returning from Russia. An increase in Giardia infection
has been noted among wilderness campers in the United States, probably due to drinking water
polluted beyond the line above which human contamination is unlikely. The term “Backpackers
Disease” has been coined in reference to the disease contracted by this group. Such outbreaks
have led epidemiologists to suspect that wild animals may harbor species of Giardia capable of
infecting humans. Surveys have implicated beavers, dogs, and sheep as potential reservoirs for
human infections. Significant differences in size and structure among species of the genus Giar-
dia have led to the assumption that each different host species has a different parasite species. It
now appears more likely that the variable morphology of Giardia is due to host diet rather than
genetic variation, so that many of the described “species” are invalid distinctions.

Symptomatology and Diagnosis

G. lamblia infection causes severe intestinal disorders, most commonly diarrhea and related
symptoms due to malabsorption. Attachment of the trophozoite to the mucosal surface by
means of its adhesive disc (Fig. 5.2C) causes shortening of the villi of the small intestine,
inflammation of the crypts and lamina propria, and lesions on mucosal cells. Occasionally,
trophozoites penetrate the mucosa, but this is rare. Since Giardia has not been known to pro-
duce toxins, it appears that symptoms result from combined mechanical and chemical factors.
Severe Giardia infections produce a malabsorption syndrome characterized by the inability
of the small intestine to absorb such essential, fat-soluble substances as carotene, vitamin
B12, and folate. These absorptive abnormalities may be accompanied by reduced secretion of
a number of small-intestinal digestive enzymes, such as disaccharidase. Additional symp-
toms of infection are diarrheic stools, steatorhea, abdominal distension, nausea, flatulence,
and eventual weight loss. Occasionally, bile duct and gall bladder involvement may produce
jaundice and colic. These symptoms may become evident as early as 3–25 days (average 10
days) after ingestion of cysts.
Identification of characteristic cysts in the stool is used in diagnosis of this parasite. Either
saline or iodine smears can be employed for initial diagnosis, but a concentration method is
commonly used to enhance detection. Examination for trophozoites is rare since their detec-
tion depends upon almost immediate inspection or fixation of diarrheic stool samples. Duo-
denal aspiration, either by intubation or by the enteric capsule method, is an alternate, more
satisfactory technique for trophozoite detection, especially in early stages of infection. An
enzyme-linked immunosorbent assay to detect salivary IgA antibodies to G. lamblia has been
used successfully to test school children.

 
 NONTRICHOMONAD FLAGELLATES 75
Chemotherapy
Treatment with either metronidazole, tinidazole, or quinacrine is recommended. Complete
cure is usually effected within a week after treatment begins. The limitations regarding metro-
nidazole usage are discussed on page 58. If the bile duct or gall bladder is infected, “relapses”
may occur for years. Because of the ease with which the cyst is transmitted, all members of
the household should be treated simultaneously. Untreated patients can pass cysts from a few
weeks to months postinfection.

Physiology
Little is known of the physiology of Giardia, due in large measure to the inadequancy of in
vitro culture methods. An in vivo study to determine the method of uptake of macromolecular
markers such as ferritin by Giardia indicates rapid transfer of the marker from the host’s intestinal
lumen into vacuoles close to the surface of the organism, suggesting a means by which Giardia
obtains nutrients. Other studies using radiolabeled sugars show Giardia capable of incorporating
certain monosaccharides into glycogen. Giardia has no mitochondria but can use oxygen when
available. There is no evidence of either an electron transport system or a Krebs cycle. The organ-
isms rely on a flavin-dependent substrate-level phosphorylation as their major means of obtain-
ing adenosine triphosphate (ATP), metabolizing carbohydrates to ethanol, CO2, and acetate as
principal end products. This pathway is blocked by quinacrine and chloroquine. In the presence
of oxygen, excretion of acetate is favored, while ethanol is favored in the absence of oxygen.

Host Immune Response

In the majority of human giardia infections, the disease appears to be self-limiting, although
reoccurrences do occur. While specifics of the immune defense are not well understood, both
humoral and cellular mechanisms appear to be important for parasite clearance. Human
G. lamblia infections result in the production of antigiardial antibodies from mucosal secretions
and serum, and IgA-dependent host defenses are central for eradicating Giardia trophozoites.
IgA is believed to bind to the surface of the trophozoite, inhibiting attachment to the intestinal
epithelium as opposed to direct killing. Specific IgA has been detected bound to trophozoite
surfaces in human jejunal biopsies and jejunal fluid.
G. lamblia trophozoites display surface antigenic variation mediated by a unique family of
cysteine-rich proteins, variant-specific surface proteins (VSPs). Unlike the variant surface
glycoproteins of trypanosomes (see pp. 106–107), the expression of G. lamblia trophozoite
VSPs do not involve gene movement but may be influenced by epigenetic mechanisms. Evi-
dently, variations can occur spontaneously and selections for and against different variations
may be determined by physiological and immunological factors of the host.

Prevention
Generally, preventive measures recommended for Entamoeba histolytica are applicable to
G. lamblia as well. The prescribed amount of iodine added to drinking water should be doubled
to ensure killing of G. lamblia cysts.

Chilomastix Mesnili
Cosmopolitan in distribution, this organism (Fig. 5.4) infects about 6% of the world’s human
population. Usually considered nonpathogenic, C. mesnili, like most protistan parasites, when

 
76 5.  Visceral Protistans II

FIGURE 5.4  Chilomastix mesnili. (A) Trophozoite. (B) Cyst.

present in sufficient numbers may cause intestinal disorders, most commonly diarrhea. The
stage found in the human colon, the motile, pyriform trophozoite, averaging 12-µm long
(range, 5–20 µm), has a blunt anterior end from which extend three free flagella. A spiral groove
extends the length of the cell, terminating at the pointed posterior end. A prominent cytostome
enclosing a fourth, recurrent flagellum is located in the anterior portion of the cell, as is the
large nucleus. A prominent, curved, supporting fibrillar structure, the so-called Shepherd’s
Crook, lies just under the cytostome wall.
The parasite utilizes a resistant cyst stage for transmission. The lemon-shaped, relatively
thick-walled cyst, approximately 8 µm in diameter, is identifiable by its single nucleus and the
cytostome containing the remnant of the recurrent flagellum and Shepherd’s Crook. When
the cyst is stained, basal bodies, one for each of the four flagella, may be seen.

Retortamonis Intestinalis
Although only about one-third its size, this nonpathogen (Fig. 5.5) closely resembles
C. mesnili. The trophozoite has one free, anterior flagellum and a recurrent, cytostomal fla-
gellum that emerges as a free, posteriorly trailing flagellum. As in C. mesnili, the trophozoite
resides in the colon, and a cyst, approximately 6-µm long by 3-µm wide, serves as the trans-
mission stage.

Enteromonas Hominis
This rare human intestinal parasite (Fig. 5.6) also has trophozoite and cyst stages, but
human hosts experience no clinical symptoms with the infection. The pyriform trophozoite,
4–10-µm long by 3–6-µm wide, has three anterior flagella and one recurrent flagellum, the
latter extending posteriorly along one side and trailing free. The mature cyst, approximately
7 by 4 µm, is ovoid with two to four nuclei, which are usually situated at the ends of the cyst.
Most cysts are binucleate.

Dientamoeba Fragilis
The current system of classification of the Protista places D. fragilis (Fig. 5.7) with certain
amoeboid forms that may or may not possess flagella. Although D. fragilis exists only in the

 
 NONTRICHOMONAD FLAGELLATES 77

FIGURE 5.5  Retortamonas intestinalis. (A) Trophozoite. (B) Cyst.

FIGURE 5.6  Enteromonas hominis. (A) Trophozoite. (B) Cyst.

FIGURE 5.7  Binucleate form of Dientamoeba fragilis. Credit: Image courtesy of the Center for Disease Control.

 
78 5.  Visceral Protistans II

amoeboid form, it is assigned to this group on the basis of ultrastructural and immunological
affinities.
D. fragilis occurs worldwide infecting about 4% of the world population. While the organ-
ism is often considered nonpathogenic and intestinal lesions attributed to the organism have
never been demonstrated, patients with gastrointestinal disturbances experience relief from
discomfort when the organism is destroyed by chemotherapy. Fibrosis of the appendiceal
wall in all D. fragilis infections of the appendix constitutes further strong evidence of the
pathogenic potential of D. fragilis. Also, D. fragilis shows a decided preference for erythrocytes
when they are available.
The trophozoite, 6–12 µm in diameter, lives in the cecal area of the large intestine and
moves sluggishly by means of thin, leaflike pseudopodia. It is frequently binucleate, with
a thin nuclear envelope visible only after staining. The prominent endosome is surrounded
by minute clumps of chromatin, giving it a beaded appearance. Since no cyst form has been
reported, the mechanism of transmission is unknown, although the eggs of the intestinal
nematode Enterobius have been suggested as possible carriers. While the trophozoite is highly
viable and is capable of motility up to 48 h after leaving the host in feces, it cannot survive the
digestive juices in the upper regions of the digestive tract.
From 20% to 80% of the trophozoites recovered from human feces are binucleate, a condi-
tion that may represent merely an arrested telophase stage of mitosis. Identification of the
trophozoite in the feces serves as diagnosis of infection. When placed in water, the tropho-
zoite swells and then returns to normal size. In the swollen state, numerous cytoplasmic
granules exhibit Brownian movement. This feature, called the “Hakansson Phenomenon,” is
peculiar to D. fragilis and occasionally is used in its identification.

THE GENUS TRICHOMONAS AND RELATED FORMS

Of the trichomonads that infect humans, two species, T. tenax and T. vaginalis, possess
four free, anterior flagella. A third species, formerly called T. hominis, has five free, anterior
flagella and is accordingly placed in the genus Pentatrichomonas. All trichomonads possess
certain common features (Fig. 5.8), among which are three to five anterior flagella and a
recurrent flagellum in the form of an undulating membrane. All flagella in these forms
originate from anteriorly situated basal bodies. The costa also originates from the region of
the basal bodies and extends along the base of the undulating membrane. In all three spe-
cies, associated with the costa and/or axostyle is a row of granules, the hydrogenosomes
(paracostal or paraxostylar granules). An axostyle extending the length of the trichomonad
appears to protrude from its posterior end although it is covered by the plasma membrane.
A prominent Golgi complex (parabasal body) lies anteriorly near the single nucleus. There
are no known cyst stages in the life cycles of these organisms; while venereal or oral con-
tact are obvious methods of transmission for T. vaginalis and T. tenax, that of P. hominis
remains obscure.

Trichomonas Tenax
This flagellate (Fig. 5.9A) is commonly found in the tartar and gums of the mouth, as well
as in the nasopharyngeal region. Trophozoites are very small (5–16 by 2–15 µm), with four

 
 THE GENUS TRICHOMONAS AND RELATED FORMS 79

FIGURE 5.8  Ultrastructural morphology of a generalized trichomonad.

FIGURE 5.9 (A) Trichomonas tenax. (B) Trichomonas vaginalis. (C) Pentatrichomonas hominis.

free flagella and a fifth flagellum recurved as an undulating membrane that extends about
two-thirds of the length of the cell. The costa runs parallel to the undulating membrane.
Transmission is necessarily by direct contact, usually kissing or using contaminated eating
utensils. Drinking contaminated water from a community source may be another means
of transmission since some investigators have shown that this flagellate can live in drink-
ing water for several hours. The organism is not considered pathogenic and can be avoided

 
80 5.  Visceral Protistans II

through proper oral hygiene. Like Entamoeba gingivalis, it tends to flourish in unhealthy envi-
ronments fostered by poor oral hygiene and is most easily found in patients who practice
poor hygiene.

Trichomonas Vaginalis
Of the three human-infecting trichomonads, T. vaginalis (Fig. 5.9B) is the only pathogen,
although a heavy infection of P. hominis may cause diarrhea. T. vaginalis inhabits the vagina
in the female and the urethra, epididymis, and prostate gland in the male. Morphologically, it
is distinguishable from the other two trichomomads by its larger size (7–32 by 5–12 µm) and
its shorter undulating membrane, which extends only one-third the length of the cell. The
trophozoite occasionally produces pseudopodia. Clusters of hydrogenosomes extend along
both the costa and the axostyle.

Life Cycle
Typical of flagellates, T. vaginalis reproduces by longitudinal binary fission. The optimum pH
range for the organism to reproduce is approximately 5 or 6. While the normal pH of the vagina
is 4–4.5, when the level of acidity is disturbed, an environment is created in which T. vaginalis
thrives. Normally, the pH of the vagina is maintained by the activity of a group of lactic acid-
producing bacteria, but T. vaginalis can disrupt such bacteria, causing the pH to rise above 4.9.

Epidemiology
The prevalence among women is approximately 10%–25%, varying inversely with the
level of hygiene practiced. While about 15% of women with trichomoniasis complain of
symptoms, altered vaginal secretions are evident in many more. In infected households, the
recorded incidence of infection among men is much lower than among women from the same
household. This statistic is misleading, however, since the flagellate is much more difficult
to detect in men; in fact, positive identification sometimes requires the examination of pros-
tate exudate. Transmission is by direct contact, usually through sexual intercourse. Damp
washcloths and similar items also are sources of infection among children and adults, viable
trophozoites having been recovered from wet washcloths 24 h after contamination. Tricho-
moniasis among newborns indicates that the fetus can acquire the organism while passing
through the birth canal.

Symptomatology and Diagnosis

T. vaginalis produces deterioration of the cells of the vaginal mucosa, resulting in low-
grade inflammation and persistent vaginitis. The condition is characterized by a yellowish
discharge accompanied by persistent itching and burning. In males, symptoms are much less
noticeable, although there may be urethritis and swelling of the prostate gland. These symp-
toms are sometimes confused with gonorrhea.
Diagnosis in females is confirmed by microscopical identification of motile trophozoites in
vaginal discharge smears. Examination of the urine of both sexes and examination of prostate
secretions of the male following prostate massage are also helpful diagnostic procedures.

 
 THE GENUS TRICHOMONAS AND RELATED FORMS 81
Chemotherapy
Metronidazole or tinidazole are the most effective drugs, although they are contraindi-
cated in pregnant patients. Restoration of the normal pH of the vagina by periodic douches
with a dilute solution of vinegar is an effective preventive method and can control mild infec-
tions. It is recommended that sexual partners be treated simultaneously.

Physiology
While trichomonads are anaerobic organisms, deriving much of their energy from the
incomplete degradation of simple sugars accompanied by the production of short chain
organic acids such as lactic and acetic acids, the presence of oxygen has little effect on this
process. Glucose and maltose are the most effective growth stimuli in vitro. One of the prod-
ucts of carbohydrate metabolism is acetic acid, which is anaerobically produced in the hydro-
genosome from part of the pyruvic acid pool. Pyruvic acid is produced in the cytoplasm via
glycolysis, and a portion enters the hydrogenosome while the remainder is reduced in the
cytoplasm to lactic acid and excreted. ATP is formed in the cytoplasm and in the hydrogeno-
some by substrate level phosphorylation. Trichomonads lack mitochondria; however, it has
been suggested that the hydrogenosome may be a modified mitochondrion since it shows
morphological and functional similarities to such organelles, such as a double membrane
and regulation of cell calcium. This organelle is also considered by some to be a specialized
microbody.
In culture, T. vaginalis feeds on bacteria and, occasionally, erythrocytes. The predilection for
bacteria suggests a mechanism for the breakdown of the normal pH of the infected vagina,
since the lactic acid bacilli act to maintain normal pH levels.

Pentatrichomonas (Trichomonas) Hominis

This trichomonad (Fig. 5.9C) is a smaller (5–14 by 7–10 µm), highly motile organism with
an anterior cytostome and three to five free flagella. Typically, four flagella beat synchro-
nously, while the fifth beats independently. A sixth, a recurrent flagellum, is associated with
the undulating membrane and extends the length of the cell, the flagellum protruding beyond
the posterior end as a trailing flagellum. P. hominis is generally considered a nonpathogen of
the human colon, and while it is often associated with diarrhea, there is no definite evidence
that it causes the condition. P. hominis has no cyst stage; so, transmission must occur via
trophozoites, and flies may be implicated as mechanical vectors. The ability of trophozoites
to survive for at least 24 h in feces-contaminated milk suggests that transmission may occur
through contaminated food and drink and that trophozoites are able to withstand the acidic
environment of the stomach en route to the intestine. Reproduction is by longitudinal fission.
P. hominis infects dogs, cats, and mice and other rodents, with such hosts serving as reservoirs
in nature.
Identification of trophozoites in fresh fecal preparations provides the most accurate means
of diagnosis. It is important that only fresh samples be used since old stools may contain
atypical or degenerating trophozoites resembling amoebae, which could result in their mis-
identification.

 
82 5.  Visceral Protistans II

Suggested Readings
Adam, R. D. (1991). The biology of Giardia spp. Microbiology Reviews, 55, 706–732.
Camp, R. R., Mattern, C. F. T., & Honigberg, B. M. (1974). Study of Dientamoeba fragilis Jepps and Dobell. I. Electron-
microscopic observations of the binucleate stages. II. Taxonomic position and revision of the genus. Journal of
Protozoolgy, 21, 69–82.
Flanagan, P. A. (1992). Giardia diagnosis, clinical course and epidemiology: a review. Epidemiology and Infection,
109, 1–22.
Honigberg, B. M. (1978). Trichomonads of importance in human medicine. In J. P. Kreier (Ed.), Parasitic protozoa (Vol 3).
New York: Academic Press.
Kabnick, K. S., & Peattie, D. A. (1991). Giardia: a missing link between prokaryotes and eukaryotes. American Scientist,
79, 34–43.
Mirhaghani, A., & Warton, A. (1996). An electron microscope study of the interaction between Trichomonas vaginalis
and epithelial cells of the human amnion membrane. Parasitology Research, 82, 43–47.