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Agnes Kurniawan, dr. PhD.

SpParK
Dept. Parasitologi Fakultas Kedokteran
Universitas Indonesia

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AREA PROGRAM
PERAWATAN, DUKUNGAN DAN PENGOBATAN ODHA

Orang dengan
HIV/AIDS
(ODHA)

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HIV / AIDS
Gejala :
-

berat badan menurun > 10% dalam 1 bulan


diare kronis > 1 bulan
demam lama > 1 bulan
gangguan neurologis
batuk menetap > 1bulan
Gangguan makan/minum  OPC

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Gejala AIDS di RS. Dr. Cipto Mangunkusumo

Gejala
Demam Lama
Batuk
Penurunan berat badan
Sariawan dan nyeri menelan
Diare
Sesak napas
Pembesaran kelenjar getah bening
Penurunan kesadaran
Gangguan penglihatan
Neuropati
Ensefalopati

Frekuensi
100 %
90,3 %
80,7 %
78,8 %
69,2 %
40,4 %
28,8 %
17,3 %
15,3 %
3,8 %
4,5 %

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Manifestasi klinis :
- CNS : Toxoplasmosis
- GIT : diare (Parasit patogen & oportunistik)
- Respiratory tract : Cryptosporidium, Strongyloides
stercoralis, Toxoplasmosis
- Mata : Toxoplasmosis

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Pre antiretroviral therapy

Age : 5 months 55 years old

94.5% : males (2140 years)

CD4+ counts <50 cells/mm3.

Parasites positive samples : 84.3%

protozoan pathogens are most commonly

Intestinal protozoan pathogens were detected


more frequently in cases CD4+ 200/mm3
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CNS opportunistic infection in


RSCM, Jakarta
(2004 2006), n= 203
Undetermined
24%
CMV
0%

Bacterial
5%
Krypto
13%

Cerebral Toxoplasmosis
31%

TBC
27%

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26%

43%

8%
1%
5%
17%

TB = 229

Hepatitis C = 69

Toksoplasmosis = 26

Pneumonitis carinii = 31

Herpes Zoster = 19

Candidiasis Oral = 144

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Single parasitic infection: 71.4%


Polyparasitism: 12.9%

Type of Parasites found:








Blastocystis hominis (72.4%)


Cryptosporidium 11.9%,
Cyclospora cayetanensis 7.8%
Giardia duodenalis 3.4%
stercoralis, Ascaris
Isospora belli, Strongyloides stercoralis
lumbricoides, Entamoeba
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Kurniawan A, et al. Trans R Soc Trop Med Hyg2009, doi:10.1016/j.trstmh.2009.02.017

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Intestinal Parasitic Infection among


the HIV/AIDS in Jakarta (n=328)
80
60
% 40
20
0
Blastocystis

Cryptosp

Cyclospora

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Giardia

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Collection :
Formed stool : thumb size
Liquid stool
: 5 ml
Container : plastic, clean, dry , wide mouthed,
screw capped
Free of urine, antiseptic, soil
Transport :
Distant place : fixative 10% formalin , PVA,
SAF

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Liquid stool, blood +, mucus +



examined within 30 of voiding
Semi-liquid  examined within 1 hour of
voiding so that motile forms of the
protozoans can be examined, permit the
culture of low infections

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Parasit patogen
Parasit oportunistik

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Preservation of trophozoites and cysts : use


PVA : stool = 3:1 in a vial with a plastic cap
For trichrom staining
DO NOT USE VIALS WITH ALLUMINIUM CAPS
Other Staining ??

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Faeces contains magnesia, powdered


aluminium salts, barium, bismuth, oil, or
antibiotics may be unsatisfactory for
identification of protozoans.

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Visual examination

Colour : black (occult blood), brown, pale


yellow (fat), white (obstructive jaundice).

consistency : formed (normal shape), soft


formed, unformed or liquid (watery).

Macroscopic blood ? Exudate?

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 Saline

suspension : to detect motile


trophozoites; and cysts; erythrocytes,
cellular debris or excess fat.
 Lugol solution : stain the nucleus
 Eosin solution : stain the whole field
except the protozoa (eg) amoebae

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Microscopic ExaminationAttention :
Select unformed or liquid faeces when using
direct microscopy for detection of trophozoites
and direct examination of any external blood or
mucus.
Formed stools : take from the centre and the
surface
Stools with mucus / liquid: take the portion from
the surface of mucus / liquid
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Examine the whole area with 10 X objective,


then with 40X

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Protozoa is a single cell microorganism


 Maybe found in stool as :
- vegetative / trophozoite form OR
- cysts
 Classification :
1. pathogenic : E. histolytica, G. intestinalis,
B. coli, Cyclospora
2. non pathogenic : Entamoeba coli
3. opportunistic: Cryptosporidium,
Microsporidia, Isospora


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Motile :
1. slow movement  amoebae
2. rapid movement 
flagellate, cilliate

note : size, shape, motility,


cytoplasm, nucleus, presence
of erythrocytes
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Non motile, well-defined shells

eosin sol : can be seen as transparent shiny


globules standing out clearly against a red
background.

40 X objective : size ~ 13 erythrocytes.

Note: size, shape, membrane, nuclei,


karyosome, cytoplasm
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Can be found in vegetative form as well as cyst


stage in stool
Method :
1. detection of trophozoite : wet mount with
saline / eosin solution  trophozoite movement
2. detection of cyst : wet mount with eosin, lugol
or MIF solution. Mature cysts are infective. Cysts
bearer do not show any clinical signs  carrier
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Entamoeba histolytica cyst:


 should be differentiated from E. coli cyst
 cannot be differentiated from E. dispaar cyst

Definitive diagnosis :
stool antigen detection
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Trichrome

Lugol

Lugol

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It is an opportunistic parasite
Formerly : AIDS defining disease
Clinical manifestations in immune competent
individuals are not obvious, light diarrhoea
Immunocompromised : chronic diarrhoea, profuse
diarrhoea, abdominal cramps, wasting, (fever)
Mode of infection : oro-fecal, food and water borne
Infective form : mature oocyst
Severe immune deficiency: extraintestinal lungs,
billiary
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EPIDEMIOLOGY
 Common
 May

in tropical countries

cause travellers diarrhea

 Endemic

in children, may cause epidemic


in community/institution

 Several

outbreak due to contamination of


drinking water sources
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Standard :
1. Modified Acid Fast (mAF) / Safranin
Staining on Direct smear of stool or after
concentration with ether-formaldehyde/ ethylacetate
2. lugol solution for Isospora and Cyclospora

Advance : fluorescence microscope  UV


excitation, Auramine phenol stain, mAb
labelling, PCR
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Direct wet smear : helminth eggs, larvae


Culture : Strongyloides, Hook worm

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Always include a positive control

Always put on face mask and gloves

Cryptosporidium oocysts excreted in stool may


have been sporulated and infectious

Cryptosporidium oocysts are resistant to most


desinfectant except hypochlorite sol.

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Choice of diagnostic technique depends on


available equipment, reagents, experience,
time & cost
 Battery tests :
- direct wet smear stool examination
- concentrated stool
- acid fast staining from direct / concentrated
stool


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Hot / fresh stool: check immediately for the


trophozoites form

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