MACROSCOPIC AND

LUMINAL PROTOZOAN
INFECTIONS

DR.MEHRU NISHA
[email protected]
Intestinal Protozoa
 Learning Outcome

 Discuss the classification of medically important

protozoa.
 Discuss the pathogenesis and clinical aspects of
infections.
 Describe the general epidemiological aspects and
transmission patterns of diseases caused by protozoa.
 Identify the methods and procedures of laboratory
diagnosis of pathogenic protozoa in clinical specimens.
 To implement the preventive and control measures
Point to focus on:-
a. Types of parasites
b. Type of host
c. Sources of infection
d. Portal of Entry
e. Life Cycle of Parasite
f. Laboratory Diagnosis
 Introduction to Protozoa
• What is Protozoa??
“Proto” means primitive
“Zoa” means animal
 Unicellular eukaryotic cells, measuring 1-50µm
 Protozoa cell consist of plasma membrane, cytoplasm,
endoplasmic reticulum, mitochondria, Golgi body,
ribosomes, nuclear membrane, nucleus and
chromosomes
 They may possess pseudopodia, flagella or cilia as
organelles of locomotion.
Intestinal Protozoa
 Important Pathogenic Protozoa
& Commonly Caused Diseases
Type and location Species Disease
Intestinal tract Entamoeba histolytica Amebiasis
Giardia lamblia Giardiasis
Cryptosporidium parvum Cryptosporidiosis
Blastocystis hominis Blastocyctis
Balantidium coli Balantidiasis
Isospora belli Isosporiosis
Cyclospora cayentanensis Cyclosporiasis

Urogenital tract Trichomonas vaginalis Trichomoniasis

Blood and tissue Plasmodium species Malaria
Toxoplasma gondii Toxoplasmosis
Trypanasoma species Trypanosomiasis
Leishmania species Leishmaniasis
Naegleria species Amoebic Meningoencephalitis
Acanthamoeba species Amoebic Meningoencephalitis
Babesia microti Babesiosis
 Amoebae
 Belong to the phylum Sarcomastigophora
 They form pseudopodia which constitute organelles of
locomotion
 Due to constant extension & retraction of pseudopodia-
they don’ have constant shape
 Common species of amoebae found in human
gastrointestinal tract Entamoeba spp, Iodamoeba butchii,
Endolimax nana and Dientamoeba fragilis.
 Among this, Entamoeba histolytica is medical importance.
 Entamoeba histolytica
Different stages:
Geographic distribution
Tropozoite - Prevalence is high in Asia
 Measures about 10-60µm countries like
Trophozoites are motile with Bangladesh, Myanmar,
active, unidirectional motility China, India, Iraq
 Only present in tissues and - Poor hygiene
only appear in diarrhoeic
faeces in active cases & only
survives for few hours Habitat
Trophozoites of
Precyst E.histolytica reside in
 It is smaller in size, varying musoca & submucosal of
10-20µm in diameter large intestine of man
Food vacuoles disappear

Cyst
10-15µm in diameter
Surrounded by a thick Morphology
The parasite exists in 3
chitinous wall which makes it
morphological forms:
highly resistant to the gastric
 Trophozoite
acid
Precyst
Cysts are present only in
Cyst
the lumen of the colon and in
formed faeces
Amoeba
Cysts and trophozoites are passed in
feces

(1).Cysts are typically found in formed

stool, whereas trophozoites are typically
found in diarrheal stool.
Infection by Entamoeba histolytica occurs
by ingestion of mature cysts.
(2) In fecally contaminated food, water, or
hands.
(3) Excystation occurs in the small
intestine and trophozoites .
(4) Trophozoites are released, which
migrate to the large intestine. The
trophozoites multiply by binary fission and
produce cysts.
(5) Both stages are passed in the
 It has been established that the invasive and
noninvasive forms represent two separate species,
respectively E. histolytica and E. dispar.

 These two species are morphologically

indistinguishable unless E. histolytica is observed with
ingested red blood cells (erythrophagocystosis).

 Transmission can also occur through exposure to fecal

matter during sexual contact (in which case not only
cysts, but also trophozoites could prove infective).
 Pathogenicity
Clinical symptoms associated with amebiasis
Intestinal Disease Extra intestinal Disease

Asymptomatic cyst Liver abscess

passer
Symptomatic Pleuropulmonary
nondysenteric infection amebiasis
Amebic dysentery Brain and other organs

Perianal ulceration Cutaneous & genital

diseases
Amoebic liver abscess (ALA
 Laboratory Diagnosis
How to diagnosis Intestinal amoebiasis?

a) Stool examination
b) Blood examination

c) Serological examination
Stool examination
Intestinal Amoebasis
• Performed by microcopy screening. The stool
sample is emulsified in a drop of saline and
viewed under microscope
• Common stain used are iodine, Trichrome
stain, Iron hematoxylin
Hepatic amoebasis
• Diagnostic amoebiasis
Trophozoite of E.histolytica may be demonstrated by
microscopy of pus aspirated from amoebic liver
abscess
• Liver biopsy
Trophozoites of E.histolytica can be demonstrated in
the specimen of liver biopsy from wall of liver
abscess.
• Blood examination
It shows leukocytosis (above normal range) with
total leucocyte count of 15,000-30,000/µl
• Serological tests
Serological test like IHA, IFA, coagglutination
test & ELISA are of immense value in the
diagnosis of hepatic amoebiasis

• Histology
Haematoxylin and eosin are used to stain the
tissues
Nitroimidazole Di-iodohydroxyquin

Paromomycin
Drug treatment for
amoebic infection

Metronidazole Emetine

Dehydroemetine
 Prevention

• Amoebic infection can be prevented by

avoiding fecal contamination of food & water
• Contamination may result from discharge of
sewage into rivers
• Purified water should be distributed through
pipelines, boiled water should be consume
and clean food handling should be practiced.
 NonPathogenic
Nonpathogenic Amoebae
Amoebae
Entamoeba dispar Non-invasive nonpathogenic species.
Similar morphology to E.histolytica

Entamoeba hartmanni Worldwide parasite. It lives freely in the

lumen of large intestine of man & is
nonpathogenic.

Entamoeba coli It’s a worldwide parasites. Lives freely in

the lumen of large intestine of man and is
nonpathogenic.

Entamoeba polecki Common parasite of the caecum & colon

of pigs. Can also be found in human.

Entamoeba gingivalis First parasitic amoeba to be reported.

Found in between the teeth and not in
bowel. Only have trophozoite around 10-
25µm & actively motile by multiple
pseudopodia.
 Entamoeba gingivalis
• Small amoeba 10 – 20µm in diameter.
• Actively motile by multiple pseudopodia.
• It has only TROPHOZOITE stage, no cystic phase.
• A parasite of human mouth.
• Commensal in gingival tissue around the teeth,
particularly in the unhealthy tissues – pyorrhoea
alveolaris.
• Also occur in healthy mouths and dental plates if not
cleaned properly.
• Found in the crypts and histologic sections of tonsils.
• Transmitted by close contact like kissing / contaminated
drinking utensils
• Lab diagnosis: demonstration of E. gingivalis in the
material removed from gingival margin of gums / from
denture.
Entamoeba gingivalis
 Cryptosporidium
 First reported in 1907 in the gastric crypts of a
laboratory mouse (Tyzzer).
 Subsequently, it has been found in chickens,
turkeys, mice, rhesus monkeys, dogs, cats &
human.
 Transmission is via:-
Feacal-oral route
 Cryptosporidiosis is one of the most
opportunistic infections in patients with AIDS
Human cryptosporidiosis is caused by infection with apicomplexan protozoans of
genus Crytosporidium.

More than one species are in Crytosporidium group (>15 species)

Among the more common species are Cryptosporidium hominis, for which humans
are the only natural host, and C.parvum, which infects bovines as well as humans

Cryptosporidiosis mainly affects children-prolongned diarrhea in persons with 

acquired immunodeficiency syndrome (AIDS).

Cryptosporidium species are able to infect and reproduce in the epithelial cell

lining of the GI and respiratory tracts without causing cytopathic effects C.hominis
and C.parvum cause most human infections.
In immunocompetent individuals, the organisms are primarily localized to the distal small intestines,
whereas in immunocompromised hosts, the parasites have been identified throughout the gut, biliary
tract, and respiratory tract.
 Morphology of
Crytosporidium oocyct

The It contains four

parasites in crescent –
stool called shaped naked
oocyst sporozoite

It is colorless, It contains four

spherical or oval crescent –
and measures, shaped naked
4-5 µm in sporozoite
diameter
 Fecal oral route from infected
host

T
R Transmission can also occur following
A animal contact, ingestion of water
N (mainly during swimming), or through
S food. Extensive waterborne outbreaks
M have resulted from contamination of
I municipal water and recreational waters
S (eg, swimming pools, ponds, lakes)
S
I
O
Animal contact can also be associated with
N
transmission of zoonotic species
 Life cycle of Cryptosporidium sp.
Sporulated oocysts, containing 4 sporozoites, are
excreted by the infected host through feces and
possibly other routes such as respiratory
secretions. Following ingestion (and possibly
inhalation) by a suitable host, excystation (a)
occurs. The sporozoites are released and
parasitize epithelial cells
(b,c) of the gastrointestinal tract or other tissues
such as the respiratory tract. In these cells, the
parasites undergo asexual multiplication
(schizogony or merogony)
(d,e,f) and then sexual multiplication
(gametogony) producing microgamonts (male)
(g) and macrogamonts (female)
(h) . Upon fertilization of the macrogamonts by
the microgametes
(i), oocysts
(j,k) develop that sporulate in the infected host.
Two different types of oocysts are produced, the
thick-walled, which is commonly excreted from
the host
(SOURCE: PHIL 3386 - CDC/Alexander J. da Silva,
PhD/Melanie Moser)
Laboratory Diagnosis
 Stool samples; usin Ziehl –Neelsen staining method

Fully sporulated forms can be seen in which the red staining sporozoites
are within an unstained oocyst wall.

 Using specific polyclonal or monoclonal antibodies

Detection of the oocysts can also be achieved by using specific

polyclonal or monoclonal antibodies conjugated to fluorescein.  These
tests are now commercially available and offer a high degree of
sensitivity.

Oocysts in stool specimens (fresh or in storage media) remain infective

for extended periods. Thus stool specimens should be preserved in 10%
buffered formalin or sodium acetate-acetic acid-formalin (SAF) to render
oocysts non-viable.
 Treatment

• Antimicrobial-Co-trimoxazole
• Spiramycin
• Letrauril
• Nitazoxanide
Giardia lamblia

 Giardia lamblia is a cosmopolitan parasite, mainly

occurs in tropics & subtropics
 Giardiasis infects 200 million people worldwide &
may produce 500,00 individuals every year.
 Habitat-duodenum & upper part of jejunum
 Morphology of giardia:-
- Trophozoite
- Cyst
 Giardia duodenalis cyst
G. duodenalis in a wet mount stained
trophozoite stained with with iodine
trichrome
G. duodenalis cyst stained with
trichrome.
 Giardia (also known
as Giardia
intestinalis, Giardia
lamblia, or Giardia
duodenalis) is found
on surfaces or in
Giardia is a soil, food, or water
microscopic that has been
parasite that contaminated with
causes diarrheal feces (poop) from
illness and named infected humans or
as giardiasis animals.
Giardia is protected by an outer shell that allows it to
survive outside the body for long periods of time and
makes it tolerant to chlorine disinfection. While the
parasite can be spread in different ways, water
(drinking water and recreational water) is the most
common mode of transmission.
• Cysts are resistant forms and are
responsible for transmission of giardiasis.
Both cysts and trophozoites can be found
in the feces (diagnostic stages)
• 1. The cysts are hardy and can survive
several months in cold water. Infection
occurs by the ingestion of cysts in
contaminated water, food, or by the fecal-
oral route (hands or fomites) The number
2. In the small intestine, excystation
releases trophozoites (each cyst produces
two trophozoites)
• 3. Trophozoites multiply by longitudinal
binary fission, remaining in the lumen of
the proximal small bowel where they can
be free or attached to the mucosa by a
ventral sucking disk
• 4. Encystation occurs as the parasites
transit toward the colon. The cyst is the
stage found most commonly in
nondiarrheal feces
• 5. Because the cysts are infectious when
passed in the stool or shortly afterward,
person-to-person transmission is possible.
While animals are infected with Giardia,
their importance as a reservoir is unclear
 Intestinal Protozoa (con’t)
Life cycle of Giardia lamblia
Cysts are resistant forms and are responsible for transmission of giardiasis

Both cysts and trophozoites can be found in the feces (diagnostic stages)

Infection occurs by the ingestion of cysts in contaminated water, food, or by the

fecal-oral route (hands or fomites)

In the small intestine, excystation releases trophozoites (each cyst produces two
trophozoites) . Trophozoites multiply by longitudinal binary fission, remaining in
the lumen of the proximal small bowel where they can be free or attached to the
mucosa by a ventral sucking disk
 Life cycle of Giardia lamblia (con’t)

Encystation occurs as the parasites transit toward the colon. The cyst is the
stage found most commonly in nondiarrheal feces

Because the cysts are infectious when passed in the stool or shortly
afterward, person-to-person transmission is possible

While animals are infected with Giardia, their importance as a reservoir is

unclear
 Intestinal Protozoa (con’t)
• Pathogenicity of G.lamblia

With the help of sucking dics, the parasite

attaches itself to the surface of the epithelial cells
in duodenum & jejunum. This may lead to
duodenitis and jejunitis
Patients may complain of dull epigastric pain,
flatulence & chronic diarrhoe.
Due to malabsorption, patients stool may be
voluminous, foul smelling & containing large
amount of mucus and fat.
Parasitology FSE 1332 Semester 2
Laboratory diagnosis

Wet mount In bright-field microscopy, cysts appear ovoid to

ellipsoid in shape and usually measure 11 to
14μm (range: 8 to 19μm)

Trichrome stain Trophozoites appear as pear-shaped organisms,

measuring 12 to 15 μm (range: 10 to 20 μm).
Cysts appear ovoid to ellipsoid in shape.

Direct fluorescent antibody For commercial DFA kits, it is recommended that

a concen­trated stool specimen be used to in
(DFA) assay crease the probability of detec­tion of low
numbers of cysts

Enzyme immunoassay (EIA) Antigens of Giardia are detected in the feces

using this method; therefore, specimens should
not be concentrated prior to testing. However,
special equipment (microplate reader) and
commercially available test kits are required

Entero-Test Detection of G.lamblia trophozoites from bile

aspirated from duodenum using duodenal
capsule technique
 Intestinal Protozoa (con’t)
• Treatment
Metronidazole, tinidazole, furazolidone

• Prevention
Improved water supply, proper disposal
of human feces, improved personal
hygiene, routine hand washing, proper
storage of food & water, control of insects
which may carry parasites
 Blastocystis hominis
Classification

 Strict anaerobic protozoan found in

human intestine

 Over the years , it was considered

related to funges spp, but it is
considered as protozoan after knowing
its SSUrRNA gene profile
Knowledge of the life cycle and transmission is
still under investigation, Therefore this is a
proposed life cycle for B. hominis. The classic
form found in human stools is the cyst, which
varies tremendously in size from 6 to 40 μm.

(1) The thick-walled cyst present in the

stools.
(2) Cyst is believed to be responsible for
external transmission, possibly by the
fecal-oral route through ingestion of
contaminated water or food
(3) The cysts infect epithelial cells of the
digestive tract and multiply asexually
(4) Vacuolar forms of the parasite give origin
to multi vacuolar
(5a) and ameboid
(5b)The multi-vacuolar develops into a pre-cyst
(6a) That gives origin to a thin-walled cyst
(7a) Thought to be responsible for
autoinfection.
(6b) The ameboid form gives origin to a pre-
cyst, which develops into thick-walled
cyst by schizogony

The number 7b.

The thick-walled cyst is excreted in feces (1).
 Pathognicity
• Non-pathogen
• But may cause diarrhoea, nausea, abdominal
pain, cramps and discomfort
• Increasingly reported among HIV patients
 Diagnosis
• Permanently stained smears are preferred
over wet mount preparations because fecal
debris may be mistaken for the organisms in
the latter.  :
• Different morphological forms of Blastocystis spp. Vacuolar
forms: (a) wet mount, (b) iodine stain, (c) iodine stain
with the vacuole darkly stained, (d) trichrome stain, (e) trichrome
stain with the vacuole stained red. Granular forms: (f) wet mount, (g)
iodine stain, (h) trichrome stain. Amoeboid forms: (i, j)
wet mount showing pseudopodia (arrowheads).
Multivacuolar forms: (k) wet mount, (l) iodine stain. ×1000.
Treatment of Blastocystis hominis

• Many believe that this disease is self-

limiting and therefore should not be
treated.
• However, upon diagnosis with the disease,
patients are usually treated with
Metronidazole, which has been effective,
but studies have also suggested
resistance to this drug
 Trichomonas

Contains 3 species:-

 T. tenax (non-pathogenic)
 T. hominis (non-pathogenic)
 T. vaginalis (pathogenic)

These flagellates exist only in trophozoite stage

Cysts stage is absent in Trichomonas spp
Intestinal Protozoa (con’t)
 Have 4 anterior
flagella & one lateral
flagellum which is
attached to the
surface of the parasite
to form undulating
membrane

 This undulating
membrane is
supported at the base
by a rod-like structure
known as costa the
axostyle runs in the
middle of the body &
ends in the pointed
tail-like structure
Parasitology FSE 1332 Semester 2
Trichomonas vaginalis

 First observed by Donne in 1836

 It has worldwide distribution with higher prevalence
among persons with multiple sexual partners or other
venereal disease
 Size around 7-23µm in length and 5-15µm width
 Normal habitat is the vagina & urethra of
women & the urethra, seminal vesicles and
prostrate of man.
Pathogenicity
The exact
mechanism of
pathogenesis is still
not elucidated yet

T.vaginalis is an
obligate
parasite
Responsible for a mild
Vaginitis with discharge.
Vaginal discharge
It cannot live without close contains
association with the large amount of
vaginal, urethral or parasites &
prostatic tissues leucocytes

Male patients usually

have mild or
asymptomatic
 Laboratory Diagnosis
 Microscopy
Trophozoites can be observed in wet mount of the
sedimented urine, vaginal secretions or vaginal scrapings
by bright-field, dark-field or phase-contrast microscopy
 Fluorescent microscopy
 ELISA
 PCR
• Prevention

Since infection is contracted through sexual

intercourse, therefore, the preventative measures
include
(i) detection & treatment of cases
(ii) avoidance of sexual contact with infected
persons
(iii) use of condoms
 Treatments

 Metronidazole is highly effective

therapeutic agent. 250mg, 3x daily for
7 days
 Clotrimazole- 100mg for 7 days
Parasitology FSE 1332 Semester 2
Trichomonas tenax

• Discovered inside the mouth (in tartar) from the teeth.

• No known cyst stage
• Has a pyriform shape and more slender than T. hominis.
• Diagnosis: T. tenax from teeth, gums, or tonsillar crypts.
• No therapy indicated.
 Trichomonas hominis

 Habitat: trophozoite live in the caecal area

and feed on bacteria.
 Non-pathogenic, often discovered from
diarrheic stools.
 No indication of treatment
THANK YOU