SOUTHWESTERN UNIVERSITY PHINMA

SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

Ciliates and Flagellates

Balantidium coli

⚫ It is the causative agent of the zoonotic disease called balantidiasis, balantidiosis, or balantidial
dysentery.
⚫ It is considered as the largest protozoan parasite affecting humans and is the only ciliate known
to cause human disease.
⚫ It is capable of attacking the intestinal epithelium, resulting in ulcer formation which, in turn,
causes bloody diarrhea similar to that of amebic dysentery.
⚫ This organism is primarily associated with pigs, its normal host.

⚫ Balantidium coli trophozoite measures 30 to 150 μm long and 25 to 120 μm wide. For
locomotion, trophozoites are covered with cilia arranged in a longitudinal pattern extending
from the oral to the caudal region.

⚫ It has a cytostome, an oral apparatus at the tapered anterior end, through which it acquires food,
and a cytopyge at the rounded posterior end through which it excretes waste.
⚫ It has two dissimilar nuclei. The macronucleus is usually bean-shaped and can easily be identified
in stained specimens, while the micronucleus is round and lies in the concavity vacuoles that act
tas osmoregulatory organelles.
⚫ B. coli cysts are spherical to slightly ovoid in shape and measure 40 to 60 μm in diameter.
⚫ They are covered with thick cell walls (doublewalled). Unlike amebae, encystation does not
result in an increase in number of nuclei.
⚫ Human infection results from ingestion of food and/or water contaminated with B. coli cysts.
The incubation period is normally from 4 to 5 days

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

⚫ Trophozoites inhabit the lumen, mucosa, and submucosa of the large intestines, primarily the
cecal region. They cause pathologic changes in the colonic wall and mucosa.
⚫ Cysts are formed principally as protection for survival outside the host. The parasites encyst
during intestinal transport or after evacuation of semi-formed stools. Cysts are the infective
stage, and they may remain viable for several weeks
Pathogenesis and Clinical Manifestations
⚫ Balantidium coli trophozoites are capable of attacking the intestinal epithelium and creating a
characteristic ulcer with a rounded base and wide neck, in contrast to the flask-shaped,
narrow necked ulcers of amebiasis
⚫ Ulceration is caused by the lytic enzyme hyaluronidase which is secreted by the trophozoite.
The trophozoites are abundant in exudates on mucosal surfaces; while inflammatory cells
and trophozoites are numerous in the base of the ulcers. Trophozoites also invade the
submucosa and the muscular coat, including blood vessels and lymphatics.

⚫ Intrinsic host factors including nutritional status, intestinal bacteria flora, achlorhydria,
alcoholism, and presence of chronic disease contribute to host susceptibility to and severity of B.
coli infection
⚫ Co-infection with other organisms may also contribute to severity of B. coli infection. The
presence of Salmonella in the intestines has been shown to aggravate balantidiasis by
invadingthe ulcers caused by the protozoan.
⚫ Balantidiasis has three forms of clinical manifestations.

◼ Asymptomatic carriers are those who do not present with diarrhea or dysentery, but may
serve as parasite reservoir in the community.
◼ Fulminant balantidiasis, or balantidial dysentery involves diarrhea with bloody and mucoid
stools, which is sometimes indistinguishable from amebic dysentery. Acute cases may have
6 to 15 episodes of diarrhea per day accompanied by abdominal pain, nausea, and vomiting.
This form of balantidiasis is often associated with immunocompromised and malnourished
states.
◼ The third form is the chronic form wherein diarrhea may alternate with constipation, and
may be accompanied by nonspecific symptoms such as abdominal pain or cramping,
anemia, and cachexia.
⚫ B. coli can spread to extraintestinal sites including the mesenteric nodes, appendix, liver,
genitourinary sites, pleura, and lungs.
⚫ Complications of balantidiasis include intestinal perforation and acute appendicitis.
⚫ Cases of mortality related to balantidiasis were reported to be associated with intestinal
hemorrhage and shock, intestinal perforation, or sepsis.

Diagnosis
⚫ Diagnosis is made by microscopic demonstration of trophozoites and cysts in feces using direct
examination or concentration (sedimentation or flotation) techniques.
⚫ Repeated stool examinations may be done to increase sensitivity.
⚫ Demonstrating the presence of trophozoites in biopsy specimens from lesions obtained through
sigmoidoscopy is likewise diagnostic.

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

⚫ Bronchoalveolar washings may also contain B. coli trophozoites in the case of pulmonary
infection.

Treatment

⚫ The treatment of choice for balantidiasis is tetracycline or metronidazole.

Epidemiology

⚫ The distribution of B. coli is cosmopolitan and is more prevalent in areas with poor
sanitation, close contact with pigs or pig feces (e.g., farms, abattoirs), and in overcrowded
institutions (e.g., asylum, orphanages, prisons). There is an estimated 1% worldwide
prevalence of human B. coli infection. Pigs are the major host of balantidiasis, although
primates have been reported to harbor infection.
Prevention and Control
Control measures for balantidiasis include proper sanitation, safe water supply, good personal
hygiene, and protection of food from contamination. Measures to limit contact of pigs with water
sources and food crops may also contribute to reducing transmission and infection

Giardia duodenalis

⚫ Giardia duodenalis is an intestinal parasitic flagellate of worldwide distribution. It is known to

cause epidemic and endemic diarrhea.

⚫ This protozoan is also known as Giardia intestinalis or G. lamblia

⚫ The disease caused by this parasite is called giardiasis, and this manifests as a significant but not
life-threatening gastrointestinal disease.Giardia duodenalis is a flagellate that lives in the
duodenum, jejunum, and upper ileum of humans.

⚫ The trophozoites measure 9 to 12 µm long by 5 to l5 µm wide. They are pyriform or teardrop

shaped, pointed posteriorly, with a pair of ovoidal nuclei, one on each side of the midline. The
dorsal side of the organism is convex, while the ventral side is concave with a large adhesive disc
used for attachment.
⚫ It is bilaterally symmetrical, with a distinct medial line called the axostyle. The parasite is
propelled into an erratic tumbling motion by four pairs of flagella arising from superficial
organelles in the ventral side of the body.

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

⚫ Cysts are ovoid and measure 8 to 12 µm long by 7 to 10 µm wide. The young cysts have two
nuclei, while the mature cysts have four. Cysts are characterized by flagella retracted into
axonemes, the median or parabasal body, and deeply stained curved fibrils surrounded by a
tough hyaline cyst wall secreted from condensed cytoplasm.
⚫ Cysts from animals or human feces are transferred to the mouth via contaminated hands, food,
or water. Once mature cysts (infective stage) are ingested, they pass safely through the stomach
and excyst in the duodenum (in about 30 minutes) developing into trophozoites which rapidly
multiply and attach to the intestinal villi causing pathologic changes. The trophozoites may then
be found in the jejunum.
Pathogenesis and Clinical Manifestations
⚫ Infection with G. duodenalis occurs when the host ingests food or water contaminated with
the mature cysts.
⚫ The ability of the parasite 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.
⚫ The parasite attaches to the intestinal cells via an adhesive sucking disc located on its
ventral side, causing mechanical irritation in the affected tissues.

⚫ Upon attachment to the intestinal cells, G. duodenalis is able to cause alterations in the villi such
as villous flattening and crypt hypertrophy. These alterations lead to decreased electrolyte,
glucose, and fluid absorption, and cause deficiencies in disaccharidases.

⚫ The physiologic disturbances subsequently result in malabsorption and maldigestion, which in

turn cause the signs and symptoms experienced by the patient. Bacterial colonization of the area
may further worsen the damage already caused by the parasite
⚫ Cytoskeleton is essential for proper cell attachment to the extracellular matrix and the other
neighboring cells.
⚫ From ingestion of the cysts, it takes about 1 to 4 weeks (average of 9 days) for the disease
to manifest.
⚫ Half of the infected patients may be asymptomatic. For acute cases, patients
experience abdominal pain, described as
cramping, associated with diarrhea.

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

⚫ There is also excessive flatus with an odor of “rotten eggs” due to hydrogen sulfide.
⚫ Diarrhea is the most common symptom, occurring in 89% of cases. It is followed by malaise
and flatulence. Chronic infection is characterized by steatorrhea, or the passage of greasy,
frothy stools.
Diagnosis
⚫ Diagnosis is made by demonstration of G.
duodenalis trophozoites (Plate 2.11) and/or cysts
(Plate 2.12) in stool specimens. Trophozoites
in direct fecal smears may be characterized as
having a floating leaf-like motility. To detect cysts in stools, concentration techniques are
recommended.
⚫ At least three stool examinations on alternate days are recommended because of spotty
shedding of cysts. If the parasite is not found in the feces, duodeno-jejunal aspiration may
be done.
⚫ Examination of the duodenal contents for trophozoites gives a higher percentage of positive
findings compared to examination of feces.

⚫ Aside from duodenal aspiration, the

Enterotest® (HDC Mountain View, CA) may
demonstrate Giardia trophozoites.

Presently, antigen detection tests and

immunofluorescent tests are already available
as commercial kits.
Treatment
⚫ Giardiasis may be treated with metronidazole 250 mg three times a day for 5 to 7 days
(pediatric dose: 15 mg/kg/day in three divided doses). Metronidazole is usually
welltolerated in adults and has a cure rate of 90%.
⚫ Prompt treatment of asymptomatic individuals reduce cyst passage and possible transmission
especially among high risk groups such as food handlers, institutionalized patients, children
attending day-care, and day-care workers
Epidemiology
Giardia has a worldwide distribution. In
the Philippines, the prevalence of giardiasis
ranges from 1.6 to 22.0% depending on the
population group being studied. From the local
data, it can be clearly seen that the groups in
areas with poor sanitation and hygiene practices
have a higher prevalence of giardiasis.
Prevention and Control
Methods of prevention and control include
proper or sanitary disposal of human excreta
to prevent contamination of food and water

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

supply

Trichomonas vaginalis

Trichomonas vaginalis causes a sexually

transmitted disease called trichomoniasis
which has a worldwide distribution. Its
incidence correlates strongly with the number
of sexual partners.
It is now often
described as the most prevalent non-viral
sexually transmitted infection.
Trichomonas vaginalis exists only in the
trophozoite stage. It has a pyriform shape,
measuring 7 to 23 µm with four free anterior
flagella that appear to arise from a simple
stalk, and a fifth flagellum embedded in the
undulating membrane.
The parasite is found in the urogenital
tract. In women, it is found in the vagina but
may ascend as far as the renal pelvis. The parasite
can be isolated from the urethra, prostate, and
less frequently, in the epididymis in men. The
trophozoites multiply by binary fission in the
host and are transferred passively from person
to person. The usual mode of
transmission is by sexual intercourse.

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

Pathogenesis and Clinical Manifestations

⚫ Inflammation of the vaginal mucosa occurs several days after the inoculation of T. vaginalis
trophozoites. T. vaginalis cannot live without close association with the vaginal, urethral, or
prostatic tissues.
⚫ Four to 28 days after introduction of viable T. vaginalis into the vagina, proliferating colonies of
the flagellate cause degeneration and desquamation of the vaginal epithelium followed by
leukocytic inflammation of the tissue layer. The trophozoites infect the surface but do not
appear to invade the mucosa.
⚫ The acute inflammation caused by the parasite results in the characteristic liquid vaginal
secretions, greenish or yellow in color, that cover the mucosa down to the urethral orifice,
vestibular glands, and clitoris.
⚫ The vaginal secretions are very irritating and may cause intense itchiness and burning
sensation. As the acute condition changes to the chronic stage, the secretion loses its
purulent appearance due to a decrease in the trichomonads and leukocytes, an increase in
epithelial cells, and the establishment of a mixed bacterial flora
⚫ Aside from the common symptoms of vaginal discharge, vulvitis, and dysuria, trichomonads
appear to be associated with an increased incidence of postpartum endometritis.
Complications in women include secondary bacterial infection
⚫ Trichomonas infection in males may be latent and essentially asymptomatic. In some cases,
it is responsible for an irritating persistent and recurring urethritis. Prostatitis is the most
common complication
Diagnosis
Saline preparation of vaginal fluid is the quickest and most inexpensive way to diagnose
trichomoniasis, but the sensitivity of this technique is low at 60 to 70%. The accepted gold standard is
culture which takes 2 to 5 days. The unstained wet drop preparations may be fixed and stained by
Giemsa, Papanicolau, Romanowsky, and acridine orange stains The Pap smear may also show
trichomonads (sensitivity 60%; specificity 95%).
Treatment
⚫ Trichomoniasis can be treated with metronidazole or tinidazole 2 g as a single dose. The
reported cure rates of these drugs range from 86 to 100%. Sexual partners must be treated
concomitantly to prevent reinfection.

Epidemiology
⚫ Trichomonas infection occurs worldwide. It is estimated that there are 170 to 190 million
individuals with trichomoniasis.
⚫ Higher prevalence is associated with greater frequency of sexual intercourse with multiple
partners and with commercial sex workers. Trichomoniasis is often associated with other
sexually transmitted infections.
Prevention and Control

⚫ Prevention is best achieved by reducing the risk of exposure. Limiting the number of sexual
partners, and proper use of protective devices such as condoms and spermicidal foams may help
prevent infection. To prevent “pingpong” or recurrent infections, there should be simultaneous
treatment of sexual partners.

Non-Pathogenic Flagellates
Trichomonas hominis
⚫ As with other Trichomonas species, T. hominis occurs only as a trophozoite which has a pyriform
shape and measures 7 to 13 µm. It has five anterior flagella and a posterior flagellum projecting
from an undulating membrane. The cytostome and the nucleus are situated at the anterior end.
An axostyle extends from anterior to posterior along the mid-axis. Transmission occurs rapidly
through fecal contamination of food and drinks.
⚫ Its habitat is the cecal area of the large intestine of human and other primates. It is non
invasive. Trophozoites pass out with diarrheic stools. The prevalence in the Philippines is less than 1%.

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

Trichomonas tenax

⚫ Trichomonas tenax is a pyriform flagellate which has been observed only in the trophozoite
stage. It measures 5 to 12 µm, and is smaller and more slender than T. vaginalis. It has four free
equal flagella and a fifth one on the margin of an undulating membrane which does not reach
the posterior end of the body, and lacks a free posterior extension. It has a single nucleus and a
cytostome. The organism multiplies by binary fission and thrives on the microorganisms found in
its environment.
⚫ Exposure results from droplet spray from the mouth, kissing, or common use of contaminated
dishes and drinking glasses.
⚫ Trichomonas tenax is a harmless commensal of the human mouth, living in the tartar around the
teeth, in cavities of carious teeth, and in necrotic mucosal cells in the gingival margins. It is quite
resistant to changes in temperature and will survive for several hours in drinking water
⚫ Diagnosis is made by swabbing the tartar between the teeth, the gingival margin, or tonsillar
crypts.
⚫ Pulmonary trichomoniasis has been reported among those with underlying chronic pulmonary
disease, entering the lungs most probably by aspiration. The parasite is probably unable to cause
disease on its own. The presence of bacteria most probably allows it to proliferate profusely.
⚫ In most of these cases, treatment with metronidazole results in rapid improvement.

Chilomastix mesnili

⚫ This organism inhabits the cecal region of the large intestine. It has well-defined
trophic and cystic stages. The trophozoite is asymmetrically pear-shaped as a result of a
spiral groove extending through the middle half of the body. Its size ranges from 6 to 10 µm.
⚫ The characteristic boring and spiral forward movement is made possible by the three anterior
free flagella and a more delicate one within the prominent cytostome.
⚫ The cyst is pear- or lemon-shaped, broadlyrounded at one end and somewhat bluntly
conical at the other end which has a knob-like protruberance that is visible occasionally.
Internally, hematoxylin and eosin stained films clearly demonstrate the single large vestibular nucleus
and the cytostome, which is almost as long as the encysted organism. Good preparations reveal a
fibril on either side of the cytostome.
⚫ Transmission occurs through ingestion of cysts in food and drinks. Prevalence in the Philippines
is less than 1%. This is a harmless commensal diagnosed by microscopic examination of feces
and demonstration of either trophozoites or cysts. No treatment is indicated. Preventive and
control measures include improved sanitation and personal hygiene.

Coccidians
⚫ The coccidian parasites are the largest group of apicomplexan protozoa falling under Class
Conoidasida. Coccidia is a subclass of microscopic, spore-forming, single-celled obligate
intracellular protozoanCoccidians infect the intestinal tract of most phyla of invertebrates and all
classes of vertebrates including humans
⚫ The disease called coccidiosis is recognized as one of the major problems in animal farming and
in zoo management. Among humans, they are considered to be opportunistic in
immunocompromised and immunodeficient individuals.
⚫ Species with medical and veterinary significance include Cryptosporidium, Cyclospora,
Cystoisospora, Sarcocystis, and Toxoplasma.In the coccidian life cycle, there is an alternation of
sexual and asexual multiplication. It is typically characterized by three sequential stages, namely:
sexual cycle or sporogony producing oocysts, asexual cycle or schizogony (merogony) producing
merozoites (meronts), and gametogony resulting in the development of male (micro) and female
(macro) gametocytes (gamonts).
⚫ Cryptosporidium hominis There are several species of Cryptosporidium that are currently
recognized. molecular tools, especially DNA analysis, described the existence of another species,
Cryptosporidium hominis found mainly in humans.All stages of development are completed in
the gastrointestinal tract of the host.

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

⚫ Oocysts when passed out are already infective. Oocysts produced by C. hominis are found in the
feces of humans and other animals.

⚫ The oocysts are round and measure 4 to 5 µm in diameter. Each oocyst contains four sporozoites,
which are present at the time of passage into the feces.
⚫ The oocyst is infectious and when ingested, the sporozoites attach to the surface of epithelial
cells of the gastrointestinal tract.
⚫ The sporozoites develop into small trophozoites and become intracellular but extracytoplasmic,
and attach to the brush borders.
⚫ The trophozoites divide by schizogony producing merozoites that infect other cells.
⚫ Macro- and microgametocytes are eventually produced, and the macrogamete is fertilized by
the microgamete to produce a zygote.
⚫ There are two types of oocysts resulting from the zygote: the thin-walled and the thick-walled
oocysts.
⚫ The thin-walled oocysts infect other enterocytes thus resulting in autoinfection, which is possibly
responsible for the chronicity of the infection among the immunocompromised.
⚫ On the other hand, the thick-walled oocysts are passed out with the feces that may contaminate
food and water, which are ingested by the same or another host
Pathogenesis and Clinical Manifestations

⚫ Cryptosporidiosis hominis was not well recognized prior to the occurrence of acquired immune
deficiency syndrome (AIDS). In the immunocompetent host, the disease may present as a self-
limiting diarrhea lasting for 2 to 3 weeks, and less commonly, abdominal pain, anorexia, fever,
nausea, and weight loss.
⚫ In immunocompromised persons, the diarrhea becomes more severe, progressive, and may
become life-threatening. The bile duct and gall bladder may become heavily infected and lead to
acute and gangrenous cholecystitis. Respiratory infections lead to chronic coughing, dyspnea,
bronchiolitis, and pneumonia.

Diagnosis

There are several methods of stool examination that will reveal C. hominis oocyst. Sheather’s sugar
flotation and the formalin ether/ethyl acetate concentration technique are commonly used. Kinyoun’s
modified acidfast stain is routinely used with the oocysts appearing as red-pink doughnut-shaped
circular organisms in a blue background. Intestinal biopsy material may also be examined under a
light microscope and stages of the parasite can be seen at the microvillus region of the infected
enterocyte. In cases of pulmonary involvement, the parasite may be recovered from the sputum,
although transbronchial and broncheo-alveolar lavage can yield a better result

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

Indirect fluorescent antibody, enzyme

immunoassay, and DNA probes specific for C.
hominis have been developed. Acid-fast staining
is probably the quickest and cheapest method
of diagnosis.
Treatment
There is presently no acceptable treatment
for cryptosporidiosis.
Epidemiology
Cryptosporidiosis hominis has a universal
distribution with infections reported worldwide.
Swimming in contaminated recreation
water may result in accidental ingestion of
infective oocysts. Swimming pool disinfection
with 3 to 5 mg/L of chlorine does not kill
the oocysts. The most common mode of
transmission is from one person to another.
Infected food handlers may likewise transmit
oocysts during handling of beverages, raw
vegetables, and other food that may be eaten
raw. Unpasteurized milk, freshly pressed apple
cider, potato salad, and sausages were found
sources of infection. Nosocomial infections have
also been reported among health workers caring
for AIDS patients.
Prevention and Control
Water-borne transmission is the most
common source of cryptosporidiosis.
Chlorination does not affect the parasite. The
synergistic effect of multiple disinfectants and
combined water treatment processes may reduce
C. hominis oocysts in drinking water. Natural
water and swimming pool water should not be
swallowed. Contamination of drinking water by
human and animal feces should be prevented.
Cyclospora cayetanensis
When first associated with diarrhea,
this organism was thought to be a
member of cyanobacteria because it
showed photosynthesizing organelles and
autofluorescing particles characteristic of the
blue green algae.
Parasite Biology
Cyclospora cayetanensis was originally called a cyanobacterium-like body (CLB) but upon careful study,
it was found to be a coccidian parasite. Similar to the other intestinal coccidians, the life cycle begins
with the ingestion of sporulated oocyst, which contains two sporocysts with two sporozoites
each. The released sporozoites invade the epithelial cells of the small intestines, although the site of
predilection was found to be the jejunum. Multiple fissions of these sporozoites take place inside the
cells to produce meronts, which contain 8 to 12 merozoites during the first generation, and only four
merozoites in the second generation. Some of the merozoites
develop into male (micro) and female (macro)gametes. The microgametes fertilize the macrogametes
to produce oocysts, which are passed out with feces when the host cells are sloughed off from the
intestinal wall. The oocysts undergo complete sporulation within 7 to 12 days in a warm environment

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

Pathogenesis and Clinical Manifestations

Initial symptoms include malaise and low
grade fever, which may occur 12 to 24 hours
after exposure. Chronic and intermittent watery
diarrhea occurs early in the infection and may
alternate with constipation. The diarrhea
may continue for 6 to 7 weeks with six or
more stools per day
Infections are usually self-limiting
and immunity may result with repeated
infections.
Diagnosis
⚫ Direct microscopic examination of fecal smears under high magnification (400x) is recommended.
Various concentration techniques and acid-fast staining (Kinyoun’s stain) are also useful. Oocysts
are autofluorescent and under fluorescent microscopy, they appear as blue or green circles
depending on the filter (365-450 DM). This technique is useful for screening. Safranin staining
and microwave heating are also helpful. A polymerase chain reaction (PCR) technique has been
developed to differentiate Cyclospora from closely related Eimeria species

Treatment
⚫ The disease is self-limiting and treatment is not necessary if the symptoms are mild. If
pharmacologic treatment is warranted, the only effective drug is trimethoprim-sulfamethoxazole
160/800 mg twice daily for 7 days.

Epidemiology
⚫ Cyclosporidiosis has been described in many countries, with epidemics reported in Nepal, Peru,
Haiti, and the United States.

Prevention and Control

⚫ Since the direct source of C. cayetanensis is unknown, good sanitary practices should be
followed to prevent the infection. Only water that has been subjected to adequate treatment
procedures should be consumed. In most endemic areas, boiling water seems to be the best
method since chlorination is not effective
⚫ Fruits and vegetables should be washed with clean water, but it would be prudent to avoid
eating fruits and vegetables that have been exposed to natural untreated water.

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

Cystoisospora belli

⚫ This is the causative agent of a medical condition affecting the small bowel called
cystoisosporiasis. The other known species Isospora hominis is now taxonomically grouped
under the genus Sarcocystis.

⚫ The sporulated oocyst contains two sporocysts each containing four sporozoites (infective stage).
When ingested via contaminated water or food, the sporozoites excyst in the small intestine
releasing sporozoites, which penetrate the epithelial cells, thus starting the asexual stage or the
schizogonic phase of the life cycle
⚫ The sporozoites develop in the epithelial cell to form a schizont, which ruptures the host
epithelial cell liberating merozoites into the lumen. These merozoites will then infect new
epithelial cells and the process of asexual reproduction in the intestine continues.
⚫ This process may continue for weeks or monthsSome of the merozoites undergo gametogony to
produce macrogametes and microgametes (sexual stages), which fuse to form a zygote that
eventually matures to form an unsporulated oocyst. Sporulation usually occurs within 48 hours
after passage with the stool.

Pathogenesis and Clinical Manifestations

⚫ Among the immunocompetent, infection is generally asymptomatic or may present as a

selflimiting gastroenteritis. However, in more severe infections, severe diarrhea and fat
malabsorption can occur. Symptoms include low-grade fever, anorexia, vomiting, general body
malaise, anorexia, weight loss, and flatulence. Stools usually contain undigested food, mucus,
and Charcot-Leyden crystals.
⚫ Infection in immunocompromised individuals ranges from a self-limiting enteritis to severe
diarrheal illness resembling that of cryptosporidiosis, giardiasis or cyclosporiasis.
⚫ Mucosal bowel biopsy may reveal flattened mucosa and damaged villi. Infiltration of the lamina
propria with lymphocytes, plasma cells, and eosinophils has been reported. However, the
mechanism by which the parasite produces these lesions is still not clear.

Diagnosis

⚫ The oocysts of C. belli may be detected in the feces by direct microscopy or formalin
ether/ethyl acetate concentrationOther concentration techniques that can also be used include zinc
sulfate and sugar flotation. Oocysts are thin walled, transparent, and ovoid in shape. They appear as
translucent, oval structures measuring 20 to 33 μm by 10 to 19 μm. Alternatively, oocysts can be seen
in a fecal smear stained by a modified Ziehl-Neelsen method, where they stain granular red color
against a green background. Phenol-auramine, as well as iodine staining of the specimen can help
visualize the organism. Acid-fast stain, such as Kinyoun’s stain or an auraminerhodamine stain, is also
useful. A considerable amount of stool may have to be examined because oocysts in the samples are

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

often few in number. Charcot-Leyden crystals may be seen in the stool specimen. In blood
examination, peripheral eosinophilia is common. String capsule (Enterotest®) and duodenal aspirate
examinations may be of value. Molecular based techniques may prove useful as an additional
diagnostic tool.

Treatment

⚫ Asymptomatic infections may be managed with bed rest and a bland diet, while symptomatic
infections, such as those occurring in AIDS patients, can be treated with trimethoprim-
sulfamethoxazole 160/800 mg four times per day for 10 days, then two times per day for 3
weeks. Combination therapy with pyrimethamine and sulfadiazine for 7 weeks has also been
used successfully.

Epidemiology

⚫ Unlike the other coccidians, humans are the only known hosts of C. belli, which has a worldwide
distribution. It is however more common in tropical and subtropical countries with poor sanitary
conditions. The actual incidence of cystoisosporiasis is not known but C. belli has been tagged as
the causative agent of diarrheal episodes in day care centers and mental institutions. The
disease is common among patients with AIDS

Toxoplasma gondii

⚫ Toxoplasma gondii is a coccidian that belongs to the Phylum Apicomplexa. It is a parasite that
has a worldwide distribution and that infects humans and many species of animals.

⚫ The infective stages include the tachyzoite, the bradyzoite, and the oocyst. The complete life
cycle occurs only in the members of the cat family (Felidae), which serve as definitive hosts. It
follows a typical coccidian life cycle consisting of schizogony, gametogony, and sporogony in the
intestinal epithelium. The extraintestinal stages are the asexual stages: tachyzoites and
bradyzoites.

⚫ In the intestinal epithelium of the cat, merozoites multiply (schizogony) and then
differentiate into microgametocytes and macrogametocytes (gametogony). Fertilization of
the macrogamete by the microgamete gives rise to an oocyst. The oocyst is ovoidal in shape,
has a thin wall, and measures 10 to 13 μm by 9 to 11 μm.
⚫ These oocysts are passed out with the feces of the cat in the unsporulated stage. These can be
ingested together with contaminated food or water by another host. The oocysts complete
sporulation within three to four days. Inside the mature oocyst, two sporocysts are formed, each
having four sporozoites.

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SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

⚫ When the mature oocyst reaches the intestine of the new host, it excysts and releases four
sporozoites which can penetrate the lamina propria. The parasites gain entry to the lymphatics
then spread to the different organs, tissues, and fluids of the body Toxoplasma is an
intracellular parasite, which infects different kinds of nucleated cells including macrophages.
Following the entry of the sporozoite into a new cell, it transformsinto a tachyzoite.
Tachyzoites are found during the initial and acute stage of the infection, but as host
immunity to the parasite is developed, the fast multiplying tachyzoites give rise to slow
multiplying bradyzoites that form cysts. Only these two stages are present in humans and
other animal intermediate hosts.

⚫ It is possible that tachyzoites can be transferred from one person to another by granulocyte
blood transfusion. Tachyzoites can be transferred from the newly infected mother to the fetus
during the first trimester of pregnancy by passing through the placental barrier. Tachyzoites and
bradyzoites can be transferred by organ transplant especially bone marrow, and bradyzoites can
be acquired by eating meat of infected animalsThe trophozoite measures 4 to 8 μm in length, 2
to 3 μm width. It is crescentshaped with a pointed anterior and a rounded posterior end.
Organelles, such as rhoptries and micronemes, which are associated with cell penetration, are
found in a short conoid on the anterior end. A spherical nucleus is found in the posterior end. In
the infected macrophage, the parasites prevent the fusion of the parasitophorous vacuole that
contains the parasites, with the lysosome and are, thus, not killed by the lysozyme. Pseudocysts
containing proliferating tachyzoites are seen in tissue sections taken from patients suffering
from acute infection. These do not have well-formed walls unlike cysts containing many
bradyzoites that are seen during chronic infections. Cysts are found in muscles and in the central
nervous system.

Pathogenesis and Clinical Manifestations

⚫ Toxoplasmosis is commonly asymptomatic as long as the immune system of the patient is

functioning well. Clinical manifestations become apparent when the immune system is
suppressed as in old age, drug-induced immunosuppression after organ transplantation, or in
the case of AIDS
⚫ Among the immunocompromised patients, the most common manifestation is encephalitis.
Myocarditis and focal pneumonia have also been reported

Diagnosis

⚫ Identification of the parasite can be done through examination of tissue imprints stained with
Giemsa. Tissue sections can be processed and stained with hematoxylin and eosin.
Serodiagnostic methods are used to detect antibodies against T. gondii. A seroconversion to a
positive titer or a four-fold increase in titers is indicative of an infection. The Sabin-Feldman
methylene blue dye test is very sensitive and specific but it requires the maintenance of live
organisms in the laboratory
⚫ Handling of live trophozoites may result in accidental infection of the laboratory personnel

Treatment

⚫ Treatment consists of pyrimethamine (25-100 mg daily) and sulfadiazine (1-1.5 g four times daily)
used in combination for one month. These drugs keep the Toxoplasma under control but do not
kill it.

Epidemiology

⚫ Toxoplasmosis is endemic worldwide in humans and in domestic and wild animals as well.
Disease due to this parasitic infection is not manifested except in cases of immune deficiency or
suppression.

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

Prevention and Control

⚫ Food should be protected from contamination with cat feces. Meat and eggs should be well
cooked. Unpasteurized milk should be avoided. Pregnant women should avoid contact with cats.
Laboratory workers should be very careful in handling the parasite.

Sarcocystis spp.
⚫ Sarcocystisis a genus of intracellular protozoa reported to infect humans and animals worldwide.
Infection with this parasite is known as sarcosporidiosis or sarcocystosis.

⚫ There are about 130 recognized species under Sarcocystis including S. hominis and S. suihominis.
Humans serve as definitive hosts for the two species, but occasionally, humans can act as
intermediate hosts. There is an ongoing revision of the taxonomy of this genus, and it is possible
that all the currently recognized species may be fewer or may in fact be a single species that can
infect multiple hosts.
⚫ Sarcocystis can take several forms. The simplest form is called a zoite. It is a bananashaped cell,
with a pointed anterior end, also known as the apical complex, which possesses micronemes,
micropores, and rhoptries, and believed to be associated with host cell penetration and creation
of an intracellularenvironment suitable for parasite growth and development.
⚫ Sporulated oocysts and individual sporocysts can be passed out in the feces of an infected
definitive host. The sporulated oocyst undergoes sporogony creating two sporocysts.
⚫ Once sporogony is complete, the oocyst itself undergoes lysis, releasing the sporocysts into the
environment. Sporocysts of most species measure 15 to 19 µm by 8 to 10 µm, and contain four
sporozoites and a discrete refractile residual body. Sporocysts are capable of surviving on the
ground and infecting intermediate hosts
⚫ After oocysts and/or sporocysts are ingested by a susceptible intermediate host (usually cows or
pigs), the sporocysts pass to the small intestine. The plates forming the sporocyst wall separate,
releasing the four sporozoites into the intermediate host’s body.
⚫ The sporozoites migrate through the gut epithelium and eventually enter the endothelial cells in
small arteries where they undergo the first two generations of asexual reproduction (called
schizogony or merogony). These cycles result in the development of meronts.
⚫ This stage lasts about 15 to 16 days after ingestion of sporocysts. Merozoites emerge from the
second generation meronts and enter the mononucleate cells where they develop. Subsequent
generations of merozoites develop in the direction of blood flow to arterioles, capillaries,
venules, and veins throughout the body. The third asexual generation appears as multinucleate
schizonts in capillaries throughout the body. Merozoites from this generation form metrocytes
and encyst in the muscles, initiating sarcocyst formation.
⚫ Sarcocysts begin as unicellular bodies containing a single metrocyte. Through repeated asexual
multiplication, numerous metrocytes accumulate and the sarcocyst increases in size.

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SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

⚫ Humans, as well as other definitive hosts, are infected by consumption of uncooked or

undercooked meat of intermediate host that contains sarcocysts. Once the intermediate host is
eaten by a definitive host such as dog or human, the parasite undergoes sexual reproduction
within the intestines. After sarcocysts are ingested and the wall is digested, bradyzoites become
motile. Active bradyzoites enter intestinal cells and change into the male and female forms,
microgamonts and macrogamonts, respectively.

Pathology and Clinical Manifestations

⚫ The pathology is of two types: a rare invasive form that presents with vasculitis and myositis, and
an intestinal form that presents with nausea, abdominal pain, and diarrhea.
⚫ The invasive form may involve a wide variety of tissues including lymph nodes, muscles, and the
larynx.
⚫ Sarcocystosis has also been associated with acute fever, myalgias, bronchospasm, pruritic rashes,
lymphadenopathy, subcutaneous nodules with concurrent eosinophilia, elevated erythrocyte
sedimentation rate, and elevated creatine kinase levels.
Diagnosis

⚫ Presumptive diagnosis of human intestinal sarcocystosis is based on symptoms manifested by

infected individuals and a history of recent consumption of raw or undercooked meat
Identification of sporocysts in feces may
require several stool examinations done on
separate days during the infection. Sporocysts
of S. hominis are first excreted 14 to 18 days
after ingesting beef, and those of S. suihominis
are excreted 11 to 13 days after ingesting
pork. A fecal flotation wet mount is usually
done to visualize sporocysts using bright-field
microscopy. Flotation methods based on
high-density solutions incorporating sodium
chloride, cesium chloride, zinc sulfate, sucrose,
Percoll, Ficoll-Hypaque, and other density
gradient media are preferred over formalin
ether/ethyl acetate and other sedimentation
methods. Species cannot be distinguished
from one another solely by microscopy because
sporocysts of different species overlap in size
and shape.
Definitive diagnosis can be made through
biopsy of an infected muscle. Sarcocysts of S.
hominis are microscopic in muscles of cattle,
whereas those of S. suihominis are macroscopic
in muscles of swine. Sarcocysts are identifiable
with hematoxylin and eosin stain. Confirmatory
staining with the periodic acid-Schiff (PAS) can
be performed as the walls stain positively
Treatment
Because infection is often asymptomatic,
treatment is rarely required
Epidemiology
There are very few large-scale population
surveys that have been conducted for Sarcocystis
in humans. Prevalence data for Sarcocystis
infections often come from case reports and
findings of physicians, public health workers,
and scientists with specific interests.

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

Human infection is considered rare with

less than 100 published cases of invasive
disease
Prevention and Control
Intestinal sarcocystosis can be prevented
by thoroughly cooking or freezing meat to kill
bradyzoites in the sarcocysts. Alternatively,
freezing the meat at –5°C for several days
will kill the sporocysts. Where contaminated
drinking water is suspected, boiling should be
considered to ensure disinfection.
Other Intestinal Protozoans
Blastocystis hominis
B
lastocystis hominis is an intestinal protozoan
found in a vast array of animals, including
humans.
The life cycle is unclear. It has been
proposed that the life cycle begins with ingestion
of cysts from contaminated food or water. Upon
ingestion, the cyst possibly develops into other
forms, which may in turn re-develop into cyst
forms. When excreted with stools, the cysts
contaminate the environment and are eventually
transmitted to humans and other animals
through the fecal-oral route, repeating the cycle.
B. hominis is known to occur in four
morphological forms: (a) vacuolated, (b) ameba
like, (c) granular, and (d) multiple fission. More
recently, additional cyst and avacuolar forms
have been recognized
Vacuolated forms are the most predominant
forms in fecal specimens. These are spherical in
shape, measuring 5 to 10 μm in diameter. A
large central vacuole pushes the cytoplasm and
the four nuclei to the periphery of the cell.
Sometimes, a very thick capsule surrounds
the vacuolated forms. The prominent central
vacuole has been found to be a reproductive
organelle. The vacuolar forms are considered
to be the main type of Blastocystis that cause
diarrhea
Ameba-like forms, usually measuring
between 2.5 to 8 μm, are occasionally observed
in stool samples
Granular forms are multinucleated and
are mainly observed from old cultures. The
diameter of the cell varies from 10 to 60 μm.
The granular contents develop into daughter
cells of the ameba-form when the cell ruptures.
Multiple fission forms arise from vacuolated
forms. It is believed that these multiple fission
forms produce many vacuolated forms

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

Pathogenesis and Clinical Manifestations

Infection with B. hominis is called

blastocystosis. B. hominis as a cause of
gastrointestinal pathology is controversial.

Diagnosis

⚫ Specific diagnosis based on clinical presentation alone may prove difficult, because the spectrum
of symptoms is seen in other intestinal infections. Laboratory detection of the organism from
stool is needed to confirm the diagnosis. Multiple stool samples should be collected from
patients showing clinical signs and symptoms. Microscopic examination using direct fecal smear
is useful, but sensitivity is increased when concentration techniques are used

Treatment

⚫ Blastocystis is difficult to eradicate. It hides in the intestinal mucus, as well as sticks and
holds on to intestinal membranes. The drug of choice is metronidazole given orally, 750 mg three
times daily for 10 days

Epidemiology

⚫ Blastocystis hominis has been reported virtually worldwide, with infections occurring most
commonly in tropical, subtropical, and developing countries
⚫
Dientamoeba fragilis

⚫ Dientamoeba fragilis was first discovered by Wenyon in 1909. this protozoan, which was
originally described as an ameba, is actually a flagellate with only the trophozoite stage known
⚫ The organism measures about 7 to 12 µm with one or two (rarely three or four) rosetteshaped
nuclei. The nuclear membrane does not have peripheral chromatin, and the karyosome consists
of four to six discrete granules. The cytoplasm may contain vacuoles with ingesteddebris. No cyst
stage has been identified.
⚫ Except for the absence of a flagellum, this protozoan is closely related to and resembles
Trichomonas.
⚫ D. fragilis lives in the mucosal crypts of the appendix, cecum and the upper colon. The exact life
cycle is unknown, although several assumptions have been made from clinical data.

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SOUTHWESTERN UNIVERSITY PHINMA
SCHOOL OF MEDICINE
DEPARTMENT OF MICROBIOLOGY and PARASITOLOGY

⚫ Direct human to human transmission is probably via the fecal-oral route or via transmission of
helminth eggs particularly that of Enterobius vermicularis.
⚫ Dientamoebalike mononucleated and binucleated forms have been observed in the lumen of
Enterobius adults and eggs present in the intestines.
⚫ More recently, stools from macaques, gorillas, and swine were found to carry D. fragilis, thus
animal reservoirs may also be potential sources of human infections.

Pathogenesis and Clinical Manifestations

⚫ Dientamoeba fragilis does not invade tissues, but its presence in the intestines produces
irritation of the mucosa with secretion of excess mucus and hypermotility of the bowel.
Infections are usually asymptomatic.
⚫ In symptomatic individuals, the onset of infection is usually accompanied by loss of appetite,
colicky abdominal pain, and intermittent diarrhea with excess mucus, abdominal tenderness, a
bloating sensation, and flatulence. Chronic infection of this organism can mimic the symptoms of
diarrhea-predominant irritable bowel syndrome (IBS)
Diagnosis

⚫ Diagnosis of this organism is by observation of binucleate trophozoites in multiple fixed and

stained fresh stool samples. Fresh stool samples are necessary since the trophozoites degenerate
after a few hours of stool passage. Multiple samples increase the sensitivity of detecting
the organism. Unless the laboratory examiner is aware of the possibility that D. fragilis may be
present in the fresh fecal films, the protozoan is easily overlooked. Purged stool specimens provide
more suitable material for examination than the average formed stool. Even when formed, D. fragilis
may be misdiagnosed as other amebae. This organism is not detected by stool concentration methods.

Treatment

Antimicrobial therapy is followed by resolution of symptoms and eradication of D. fragilis. Treatment

is done with iodoquinol at 650 mg three times daily for 20 days. The pediatric dose is 40 mg/kg/day in
three doses, also for 20 days

Epidemiology

⚫ The organism has a world-wide distribution with varying infection rates ranging from 0.4 to
as high as 42%. In contrast to many pathogenic protozoa, which have a high prevalence in
developing countries, high prevalence rates of D. fragilis have been reported from developed
countries with high sanitation standards. Using adequate culture techniques, the rates were as
high as 18% in Israel, 36% in Holland, and 41.5% in Germany.
Prevention and Control

⚫ Specific recommendations for prevention and control cannot be made until there is more
specific information concerning the method of transmission. Proper sanitation and disposal of
human waste are essential.

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