Lecture 4

Mastigophora/ Flagellates

a) Intestinal/luminal flagellates
Giardia lamblia
Giardia lamblia has a worldwide distribution, particularly common in the tropics and subtropics.
It is acquired through the consumption of inadequately treated contaminated water, ingestion of
contaminated uncooked vegetables or fruits, or person-to-person spread by the faecal-oral route.
The cyst stage is resistant to chlorine in concentrations used in most water treatment facilities
Important features – the life cycle consists of two stages, the trophozoite and cyst. The
trophozoite is 9-12 μm long and 5-15μm wide anteriorly. It is bilaterally symmetrical, pear-
shaped with two nuclei (large central karyosome), four pairs of flagella, two axonemes, and a
suction disc with which it attaches to the intestinal wall. The oval cyst is 8-12μm long and7-
10μm wide, thick-walled with four nucleus. Each cyst gives rise to two trophozoites during
excystation in the intestinal tract. Transmission is by ingestion of the infective cyst.

Pathogenesis
Infection with G.lamblia is initiated by ingestion of cysts. Gastric acid stimulates excystation,
with the release of trophozoites in duodenum and jejunum. The trophozoites can attach to the
intestinal villi by the ventral sucking discs without penetration of the mucosa lining, but they
only feed on the mucous secretions. In symptomatic patients, however, mucosa-lining irritation
may cause increased mucous secretion and dehydration. Metastatic spread of disease beyond the
GIT is very rare.

Clinical features
It causes giardiasis. Symptomatic giardiasis ranges from mild diarrhea to severe malabsorption
syndrome. Usually, the onset of the disease is sudden and consists of foul smelling, watery
diarrhea, abdominal cramps, flatulence, and streatorrhoea. Blood & pus are rarely present in
stool specimens, a feature consistent with the absence of tissue destruction.
Immunity
The humoral immune response and the cellular immune mechanism are involved in giardiasis.
Giardia – specific IgA is particularly important in both defense against and clearance of parasite.

Laboratory diagnosis
Examination of diarrhoeal stool- trophozoite or cyst, or both may be recovered in wet
preparation.
In examinations of formed stool only cysts are seen.

Treatment
The drug of choice is quinacrine hydrochloride or metronidazole.

- Asymptomatic reservoirs of infection should be identified & treated.

- Avoidance of contaminated food and water.
- Drinking water from lakes and streams should be boiled, filtered and/or iodine treated.
- Proper waste disposal and use of latrine.
- Health education

Dientamoeba fragilis
Dientamoeba fragilis was initially classified as an amoeba; however, the internal structures of
the trophozoite are typical of a flagellate. No cyst stage has been described. The life cycle and
mode of transmission of D. fragilis are not known. It has worldwide distribution. The
transmission is postulated, via helminthes egg such as those of Ascaris and Enterobius species.
Transmission by oral faecal routes does occur. Most infection with D. fragilis is asymptomatic,
with colonization of the caecum and upper colon. However, some patients may develop
symptomatic disease, consisting of abdominal discomfort, flatulence, intermittent diarrhea,
anorexia, and weight loss. The therapeutic agent of choice for this infection is iodoquinol, with
tetracycline and parmomycine as acceptable alternatives. The reservoir for this flagellate and
lifecycle are unknown. Thus, specific recommendation for prevention is difficult. However,
infection can be avoided by maintenance of adequate sanitary conditions/hygiene.
Trichomonas hominis – The trophozoites live in the caecal area of the large intestine and feed
on bacteria. It is considered to be non-pathogenic, although it is often recovered from diarrheic
stools. Since there is no known cyst stage, transmission probably occurs in the oral faecal form.
There is no indication of treatment.

Trichomanas tenax – was first recovered from the mouth, specifically in tartar from the teeth.
There is no known cyst stage. The trophozoite has a pyriform shape and is smaller and more
slender than that of T.hominis. Diagnosis is based on the recovery of the organism from the teeth,
gums, or tonsillar crypts, and no therapy is indicated.

Chilomastix mesnili – has both a trophozoite and cyst stage. It normally lives in the caecal
region of the large intestine, where the organism feeds on bacteria and debris. It is considered to
be a non-pathogenic, and no treatment is recommended.

b) Urogenital flagellates

Trichomonas vaginalis
This parasite has worldwide distribution, and sexual intercourse is the primary mode of
transmission. Occasionally, infections can be transmitted by fomites (toilet articles, clothing),
although this transmission is limited by liability of the trophozoite.
Important features- it is a pear-shaped organism with a central nucleus and four anterior
flagella and undulating membrane extends about two-thirds of its length. It exists only as a
trophozoite form, and measured 7-23μm long & 5-15μm wide.
Pathogenesis
The trophozoite is found in the urethra & vagina of women and the urethra & prostate gland of
men. After introduction by sexual intercourse, proliferation begins which results in inflammation
and large numbers of trophozoites in the tissues and the secretions. The onset of symptoms such
as vaginal or vulval pruritus and discharge is often sudden and occurs during or after
menstruation as a result of the increased vaginal acidity. The vaginal secretions are liquors,
greenish or yellowish, sometimes frothy, and foul smelling. Infection in the male may be latent,
with no symptoms, or may be present as self limited, persistent, or recurring urethritis.
Clinical features
This is the causative agent of trichomoniasis. Most infected women at the acute stage are
asymptomatic or have a scanty, watery vaginal discharge. In symptomatic cases vaginitis occurs
with more extensive inflammation, along with erosion of epithelial lining, and painful urination,
and results in symptomatic vaginal discharge, vulvitis and dysuria.

Laboratory diagnosis
• In females, T.vaginalis may be found in urine sediment, wet preparations of vaginal secretions
or vaginal scrapings.
• In males it may be found in urine, wet preparations of prostatic secretions or following massage
of the prostate gland.

Treatment
Metronidazole is the drug of choice. If resistant cases occur, re-treatment with higher doses is
required.
Prevention
- Both male & female sex partners must be treated to avoid re-infection
- Good personal hygiene, avoidance of shared toilet articles and clothing.
- Safe sexual practice.