Protozoa

Dr Mohieddn M Abdul Fattah

Luminal protozoa
1. Intestinal amoebae: Entamoeba histolytica and E.dispar. 2. Intestinal flagellates: Giardia intestinalis. 3. Urogenital flagellates: Trichomonas vaginalis 4. Intestinal (apicomplexans) coccidia : Cryptosporidium parvum and C hominis 5. Intestinal ciliates: Balantidium coli

Patterns of protozoan life cycle

Blood and Tissue protozoa

1.Blood flagellates: Trypanosoma and Leishmania. 2.Blood apicomplexans (coccida): Plasmodium (malaria parasites) and Toxoplasma
game tocyte s
GAMETOGONY

zygote
SPOROGONY

me rozoite s
MEROGONY

sporozoite s

Amoebae: E. histolytica and dispar

A. Biology:
Final host: Human. Habitat: Colon Exit stage: trophozoites, precysts, binucleate and Quadrinucleate cysts in feces. Basic morphology: trophozoite;15-20 m amoeboid, and round cyst 12-15 m.

what is amoeboid about amoebae?

Pseudopodium
Hyaline ectoplasm (gel)

Endoplasm (sol)

While the endoplasm (sol) is liquid and filled with organelles the ectoplasms appears more solid (gel) and clear.

Amoebae: Basic Morpology and Life Cycle

Entamoeba histolytica : (large intestine) but can invade extraintestinal sites

Amoebae Life cycle

1. Trophozoites colonize large intestine feed on bacteria and debris replicate by binary fission 2. Trophozoite rounds up to form cyst secretion of cyst wall aggregation of ribosomes (= chromatoid bodies) 2 rounds of nuclear division occur (14 nuclei) survive weeks to months

Amebae: E. histolytica and dispar

B. Epidemiology: Distribution: both are worldwide
10% of E. histolytica cases are symptomatic, severe infections occurs in pregnant women, young children, the malnourished and people on steroids.

Transmission:
1. Intermediate host: none 2. Reservoir host: none 3. Infective stage: 4 nuclei cyst. It remains viable in damp cool conditions up to 2 months 4. Mode of infection: ingestion of food and drinks contaminated by the infective stage

C. Host parasite relationship Immune responses

1. Serum antibodies (IgG1; used in ADCC via M), (IgG4& IgG2; blocking). 2. Mucosal IgA against amebic lectin (protective). 3. Classical and alternative activation of complement. 4. Intestinal epithelium secretes nuclear factor, proinflammatory cytokines (IL6 IL8) and IFN. 5. These enhance amebicidal effect of M and Neutrophils 6. They also enhance neutrophil resistence to killing by ameba trophozoites.

 Virulence factors of Entamoeba histolytica:

A. Resistance to host response (evasion from it): 1. complement resistance: amebic lectin cross react with CD59 on human leucocyte to prevent assembly of C5b-C9 and lysis of amoeba by complement. 2. Antigen shedding B. Adherence properties (galactose inhibitable adherence protein GIAP). This GIAP allows amoeba to adhere to epithelial cells. C. Cytolytic properties (adherence + 'amoebapore') D. Ability to breakdown tissues (eg, secreted cysteine proteases)

1. 2. 3. 4.

penetration of mucus layer contact-dependent killing of epithelial cells breakdown of tissues (extracellular matrix) contact-dependent killing of neutrophils, leukocytes, etc.

C.Host-parasite relationship:
The non-pathogenic E. dispar is non invasive. Only E histolytica is invasive and symptomatic, but under certain condition it is non invasive and non symptomatic. Non-invasive condition: 1. Amebae colonize on mucosal surface without inducing symptoms Asymptomatic cyst passer or it induces 2. Non-dysenteric diarrhea .

Invasive amebiasis
Invasive condition:
a) Amebae invade mucosa ulcer Dysentery. b) Hematophagous trophozoites ulcer enlargement peritonitis c) Ameboma occasionally occurs. d) Via blood invasion or by direct extension Metastasis extraintestinal amebiasis. 1. Primarily liver amebic abscess

2. Other sites: skin, lung and brain.

Ameba-free stools are common in such situations.

Colitis is the most common form of disease associated with amoebae

Amoeba invade mucosa and erode through laminia propria causing characterisitic flask shaped ulcers contained by muscularis

Invasive intestinal phase; continued

ulcer enlargement severe dysentery perforation of intestinal wall peritonitis local abscesses 2o bacterial infections occasional ameboma (=amebic granuloma) cessation of cyst production
ameboma = inflammatory thickening of intestinal wall around the abscess (can be confused with tumor)

Ulceration can lead to secondary infection and extraintestinal lesions

Extraintestinal Amebiasis
metastasis via blood stream primarily liver (portal vein) other sites less frequent ameba-free stools common high antibody titers

Amebic Liver Abscess

chocolate-colored pus necrotic material usually bacteria free lesions expand and coalesce further metastasis, direct extension or fistula

Cutaneous Amebiasis
intestinal or hepatic fistula mucosa bathed in fluids containing trophozoites perianal ulcers urogenital (eg, labia, vagina, penis)

D. Diagnosis
D.Intestinal stool examination: To detect cysts and/or trophozoites by microscopy Or to detect antigen in stool (specific E. histolytica lectin) by ELISA. This differentiates histolytica from dispar Lower endoscopy to see lesions, take aspirate, or biopsy ii.Extraintestinal (hepatic) Serology to detect amobic lectin antigen or its antibodies but the latter do not tell is it current or past infection? Imaging: CT, MRI, Sonar Abscess aspiration: non suppurative reddish brown liquid full of trophozoites. Only applied on clinical cases to differentiate between amoebic and bacterial abscesses

1. Trophozoite

imaging: CT, MRI, Sonar: They do not differentiate between bacterial and amoebic abscess

2. Precyst 3. Binucleate cyst. 4. Quadrinucleate cyst

E.Treatment
1. Asymptomatic cyst pasers: dilxanide furoate 500 mg tds for 10 days, iodoquinol or paromomycin (500 mg tds for 10 days) endemic areas? Mass treatment. 2. symptomatic metronidazole 750 mg tds for 10 days or tinidazole followed by lumenal agents (dilxanide furoate 500mg tds for 10 days 3. drain liver abscess only with high probability of rupture!

Amoebae: E. histolytica
F.Control: Personal hygiene, Food sanitation proper disposal of human sewage.

Ciliates: Balantidium
Characterized by having two distinct nuclei. The large kidney-shaped macronucleus is involved in the 'housekeeping' or somatic functions of the cell, The smaller spherical micronucleus contains the complete genome. The macronucleus contains thousands of copies of transcriptionally active 'minichromosomes' representing 10-20,000 different DNA molecules.

Biology of Balantidium coli

Final hosts: Pigs,and monkeys. Man is infected occasionally. Habitat: large intestine. Exit stage: Trophozoites and mature cyst in stools Life cycle:

Biology: Morphology of Balantidium

Epidemiology
Distribution 1. world-wide; human infections occur more frequently in areas where pigs are raised. 2. especially prevalent in tropics 3. rarely exceeds 1% Reservoir hosts: pigs . monkeys and rodents unlikely to be reservoirs No intermediate hosts. Infective stage: mature cysts Mode of infection: once human gets the infection; human to human transmission is the rule

Host-parasite relationship
Pathogenesis: Usually non-pathogenic commensal in large intestine. Can invade intestinal epithelium and cause ulceration with dysentery like symptoms. symptoms: acute diarrhea with mucus and blood, and with cramps.

Diagnosis
identify trophozoite in feces. Cysts are less likely to be detected. Balantidium coli is passed intermittently and once outside the colon is rapidly destroyed. Repeated samples are required, to enhance detection of the parasite

Treatment and control

Treatment: tetracycline or iodoquinol. Prevention: same as other fecal-oral diseases

Pathogenic Free Living Amoebae

Mohiedden M Abdul-Fattah

Classification
Schizopyrenida (Amoeboflagellates)
Naegleria fowleri

Acanthpodina:
Acanthamoeba culbertsoni.

Ecology of Naegleria fowleri

It grows fastest at 42oC, in water piped above ground, swimming and medicinal pools, acquarium, and in sewage. 3 stages in the life cycle 1. Trophozoite is an amoeboid feeding stage 2. Flagellate is a rapidly swimming . 3. The dormant cyst survives low temperature. Cysts have poor resistance to desiccation. It rarely occurs in soil. Chlorine kills all life-cycle stages.

Biology in the human host

Naegleria is pathogenic to human host when gets access to him. Habitat in man: brain tissues and meninges. Exit stage: None, but trophozoites can be recovered from brain tissue biopsy and CSF. Flagellated form from CSF only. Three stages exist in its life cycle: amoeboid trophozoite, flagellate and cyst. Cysts exist only in the environment

1. All stages are characterized by a single nucleus with a large karyosome and no visualised peripheral chromatin. 2. The ameboid transforms into a pear-shaped flagellate with two flagella at the end if placed in distilled water or CSF
3. In desiccation or low nutrients, amoeboid encysts. 4. The cyst reverts back to trophozoite in favorable cases. 5. Cysts exist only outside human.

Epidemiology
Distribution: freshwater habitats and rarely moist soil throughout the world. Human infections are quite rare and are acquired directly from the environment. Transmission: No human-to-human transmission or vector transmission. 1. Intermediate host: no 2. Reservoir host: no 3. Infective stage: Trophozoites. 4. Mode of infection: During swimming in warm or heated waters, the trophozoites enter through the olfactory neuroepithelium in the nasal cavity; migrate along the olfactory nerves into the brain.

Host-parasite relationship
Naegleria produces a fulminate, almost always fatal, acute meningoencephalitis (primary amoebic meningoencephalitis; PAM) in healthy children and young adults. The symptoms of PAM resemble bacterial meningoencephalitis, characterized by a sudden onset of headache, neck rigidity and fever. Nausea, vomiting and others related to intracranial tension. There is a rapid progression from headache and fever to coma, seizures and death.

Diagnosis
Unless diagnosed, treated early, infection is fatal. CT scan of head. Not diagnostic for PAM May be normal early in disease Later, may show signs of elevated ICP, leptomeningeal enhancement Cloudy CSF shows neutrophils, glucose, and proteins. Wet microscopy of CSF: motile amoebae without bacteria. Biopsy from brain tissues stained by Wright or by monoclonal PAP stains may help, but it is almost

always too late.

Wet microscopy

a trophozoite, b flagellated form from CSF

c. cyst (only in environment). Scale bar = 10 m

Stained microscopy
CSF Brain biopsy

Flagellated form

Wright stain (or Geimsa stain) positive for blue vacuolated amoebas slightly larger than a polymorph leukocytes

N. Fowleri in biopsy from brain tissue

Treatment
(only 7 documented survivors)
Amphotericin B 1.5mg/kg IV daily for 3d and 1mg/kg/d for 6d or intrathecally by lumbar catheter; 1.5 mg for 2d then 1mg every other day for 8d.

Health education to avoid bathing in: 1.stagnant fresh water lake, 2.pools contaminated with sewage, 3.under-chlorinated swimming pools. Chloramination, (ammonia and chlorine) to the water, is more effective in practice.

control

Acanthamoeba
Acanthamoeba is group of amoebae unrelated to Naegleria, but also free-living. It is infectious, causing two diseases: 1.Granulomatous amoebic encephalitis (GAE): It occurs in immune-suppressed patients, usually secondary to infection elsewhere in the body (e.g. skin ulceration). 2.Amoebic Keratitis (AK) is a severe corneal infection, among the immune competent hosts

Biology
It is free living, but can infects man Habitat in human nostrils and throats; skin, lung tissues, and brain. Exit (diagnostic) stage: No... But trophozoites and cyst can be found in histological sections No flagellated form.
Acanthamoeba have a role in the dispersal of Legionella pneumophila that grows inside the acanthamoebae, This enables the bacteria to thrive in soil and to spread by air

Morphology and life cycle

Trophozoite 25-40um with spine like pseudopodia. Cyst: double walled, polygonal or spherical 15-20um

Epidemiology:
Distribution Throughout the world. 1.In soil; fresh, brackish, and sea water; sewage; swimming pools; 2.Contact lens equipment and in medicinal pools 3.Dental treatment units; 4.Dialysis machines; 5.Heating, ventilating, and air conditioning systems;

Transmission
Transmission: No human-to-human transmission or vector transmission.
Intermediate host: no. Reservoir host: no. Infective stage: Trophozoites and cysts. Mode of infection: The trophozoites and cysts can enter human through eye, nasal passages to the lower respiratory tract, or through ulcerated or broken skin and can reach the central nervous system and other organs by hematogenous dissemination.

 Amoebae enter lungs via the nasal route. Next, amoebae traverse the lungs into the bloodstream Or amoebae enter directly through skin lesions, followed by haematogenous spread. Finally, amoebae cross the blood-brain barrier and enter into the central nervous system (CNS) to produce disease.

Autopsy of GAE
The autopsy revealed extensive necrotizing granulomatous encephalitis with subependymal necroinflammatory process.
Tissue section (c) of the brain were made and stained with (H&E).

Host parasite relationship, continued

Disseminated infections of various other tissues including lung (pneumonitis) and skin ulceration.

In healthy individuals, The prominent disease is Acanthamoeba keratitis (AK), A potentially sight-threatening eye infection, especially in patient with contact lens.

Lesions in acanthamoebic infection

Acanthamoebic skin ulceration

Acanthamoebic keratitis

Acanthamoebic granuloma in brain tissues

Diagnosis
1. It is difficult 2. Amebas not yet detected in spinal fluid 3. Cysts and trophozoites are detected in brain biopsy (GAE) or in corneal scrapings (keratitis).

Diagnosis, cont.
The brain imaging; (CT) or (MRI) scan may show: 1. multifocal areas of signal intensities 2. or lesions indicating brain abscesses or tumours . CSF findings, although not confirmatory of GAE, are of value in diagnosing the CNS involvement. Pleocytosis with lymphocytic predominance is an important feature with PMNL, protein concentrations, glucose concentrations.

Treatment 1.Some success in treating amebic keratitis has been obtained with propamidine isethionate (Brolene). 2.Surgery is often needed to correct the loss of vision.

Control
1. Health education 2. Care of skin lesions, 3. use of sterilized saline for contact lens.

Luminal flagellates: Basic morphology and life cycle

Urogenital flagellate: Trichomonas vaginalis Intestinal flagellates (small inrtestine) Giardia lamblia

Giardia lamblia
A. Biology:
Final host: man Habitat: small intestine. Exit (diagnostic) stage: Trophozoite and cyst. Basic morphology and life cycle:

B. Epidemiology of Giardiasis
Distribution: Worldwide, more prevalent in warm climates, and in children. Transmission:. Intermediate host: no. Reservoir host: no. Infective stage: cyst. Mode of infection: By the ingestion of cysts in contaminated water, food, or by the fecal-oral route (hands or fomites, autoinfection) .

C. Giardiasis: Host-parasite relationship

Giardia never invade intestinal mucosa Asymptomatic infection to severe diarrhea and malabsorption. Acute infection develops after ~7 days and usually lasts to 3 weeks: Diarrhea, abdominal pain, bloating, nausea, and vomiting occur. Chronic infection: Symptoms recur with malabsorption and debilitation.

D. Diagnosis of Giardiasis:
Identification of cysts or trophozoites in the feces or in duodenal aspirate (Enterotest). Detection of antigens in stool by ELISA, or parasites by immunofluorescence.

E. Treatment of Giardiasis:
Metronidazole (flagyl) ,tinidazole (Fasygin) or Nitazoxanide (cryptonaz).
F. Control: Environmental sanitation and personal hygiene

Trichomonas vaginalis
A. Biology Final host: man Habitat: In the female, lower genital tract and the male urethra and prostate. Exit (diagnostic) stage: Trophozoite (no cyst stage). Basic morphology and Life cycle:

B. Epidemiology of Trichomoniasis
Distribution: Worldwide. Higher prevalence among persons with multiple sexual partners. Transmission: Intermediate host: no. Reservoir host: no. Infective stage: trophozoite. Mode of infection: By direct contact during sexual intercourse.

C. Host-parasite relationship: 1. In female: Vaginitis with a purulent discharge is the prominent symptom. It can be accompanied by vulvar and cervical lesions, abdominal pain, dysuria and dyspareunia. 2. In men, the infection is frequently asymptomatic; occasionally, urethritis, epididymitis, and prostatitis can occur.

D. Diagnosis:
Detecting actively motile organisms in wet smears from vaginal, urethral or prostatic secretions. Direct immunofluorescent antibody staining (more sensitive) and Culture of the parasite (most sensitive). for both parteners; Metronidazole (250mg t.d.s.-10 days), tinidazole (2gm single dose).

E. Treatment:

F. Control:
Condom limits transmission.

Hemoflagellates : Leishmania: Trypanosoma cruzi: amastigote and promastigote Amastigote, trypomastigote Trypanosoma brucei: epimastigote and trypomastigote and epimastigote

Leishmania life cycle

A. Biology of Leishmania organisms

1. 2. 3. 4.

Organisms: Old world cutaneous: L.tropica, L. major New world cutaneous: L mexicana New world muco-cutaneous:L. braziliense. Visceral: L. donovani, and L. infantum Final host: Man only in L.donovani and L. tropica. Man and animals in the others Habitat: Reticulo-endothelial cells of skin or viscera. Exit (diagnostic) stage: Amastigotes within macrophages. Life cycle:

B. Epidemiology of Leishmania infection

1. Intermediate host (vector): phlebotomus (old world) and

Lurzomyia (new world).

2. Reservoir host: arboreal mammal; monkeys (New.World). Rodents in African donovani and L. major. Dogs in L.infantum Transmission cycles: Zoonotic in all except Indian L. donovani, and L. tropica. 3. Infective stage: Metacyclic promastigotes regurgitated from pharynx 4. Mode of infection: During vector feeding metacyclic promastigotes are regurgitated into the bite wound (not in the salivary gland)

C. Host-parasite relationship:
1. Ulcerative cutaneous lesions: self healing, painless, nonpruritic ulcer; dry (tropica) wet (major). 2. Scaly non ulcerated lesions i. Anergic diffuse cutaneous: (L.mexicana and ethiopica) with abundant amstigotes . ii. Hypersensitive leishmaniasis recidivans (L. tropica): with rare amstigotes. 3. Mucocutaneous lesion in 5% of cutaneous leishmaniasis braziliense. 4. Visceral leishmaniasis (Kala-azar): fever, anaemia, hepatosplenomegaly in L. donovani. 5. Post kala-azar dermal leishmaniasis: lesion that resembles leprosy. It occurs months or years after successful treatment

D. Diagnosis of leishmaniasis:
Cutaneous types: Detecting amastigotes in the raised border of the lesion and positive leishmanin skin test. Visceral type: Detecting amastigotes in bone marrow, lymph nodes or spleen aspirates and serotesting to detect; specific IgG (anti K39 antigen anti-IgG ), Intradermal leishmanin test is usually negative

E. Treatment:
Pentostam (20mg/kg/d IM or IV for 30 ds), Pentamidine 4 mg/kg on alternate days for 10 doses. Amphotericin B (parenteral) and orally aminosidine (paromomycin). Protective clothing, insect repellents, insecticides and control of reservoirs.

F. Control:

African trypanosomes: Basic morphology and life cycle

Trypanosoma brucei
A. Biology:
Two organisms; Trypanosoma gambiense in West and T. rhodesiense in East Africa Final host: 1. Man and domestic animals for T. gambiense. 2. Game animals and sometimes man for T. rhodesiense. Habitat: Blood lymphatics CNS vessels. Exit (diagnostic) stage: Blood stream short stumby trypomastigotes Basic morphology and Life cycle:

Trypanosoma brucei life cycle

B.Epidemiology:
Distribution: T. gambiense in rainforest, riverine and lakes in West Africa. T. rhodesiense in dry bush and woodland in East africa Transmission: Intermediate host (vector): o Glossina palpalis in West and G morsitans in East. Infective stage: metacyclic trypomastigotes in saliva Mode of infection: o Glossina injects saliva with metacyclic trypomastigotes into skin. o Congenital transmission and o Accidental lab inoculation are recorded.

C. Host-Parasite relationship:
1. 2. 3. The parasite in skin: Chancre (swelling) in the bite site The parasite in blood: fever and headache lymphadenopathy (posterior cervical L.N. (Winterbottom sign) The parasite in CNS: anorexia & apathy severe sleep disturbance. neurological signs; delayed pain sensation (Kerandle' sign). Coma and death.

D. Diagnosis:

Detecting trypanosomes in blood, lymph nodes or spinal fluid (CSF). IgM in serum, CSF.

E. Treatment:
Pre CNS: o Pentamidine (gambiense), or o suramin for rhodesiense & gambiense CNS: o Melarsoprol. o Difluoromethyornithine (DFMO.

F. Control:
Treat cases and reduce the vector

American trypanosome: Basic morphology and Life Lycle

American trypanosomes Trypanosoma cruzi

A. Biology:
o o Final host: Man and armadillo. Habitat: Free trypomastigotes in blood (low parasitaemia) and Intracellular amastigotes in spleen, liver, lymph nodes and muscles. Exit (diagnostic) stage: o Blood stream short stumpy trypomastigotes Basic morphology and Life cycle:

Trypanosoma cruzi: life cycle

B. Epidemiology:
Distribution: South and central America Transmission: Intermediate host (vector): Kissing bugs (Triatoma) via infected feces Reservoir hosts: various mammals Transmission cycles: sylvatic and human cycles. Infective stage: metacyclic trypomastogotes. Mode of infection: 1. During vector feeding metacyclic trypomastigotes are released into feces. They enter via the bite wound near the mouth or the eyes. 2. Blood transfusion, 3. congenital, and 4. accidentally by ingestion of contaminated food

C.Host-Parasite relationship:
Pathogenesis is parasite mediated damage, or by autoimmunity. Acute stage: 1. Chagoma (Rmana sign) in the bite site; periorbital edema and conjunctivitis (few days postinfection and persists for 2-3 months). 2. Fever, malaise, lymphadenopathy and/or acute myocarditis for 3-4 months. Chronic stage: o After decades of latency, it is manifested as cardiomyopathy and autonomic neural dysfunction (mega-esophagus and megacolon).

D. Diagnosis:
Detecting trypanosomes: 1. In blood smear, 2. In buffy coat layer during the acute stage. 3. In Culture (NNN media). 4. By xenodiagnosis. 5. By PCR. Detection of specific serum IgG by Elisa in chronic stage.

E. Treatment:
o o o Acute stage: Nifurtimox: (2mg/kg/6h Po for 90 ds) or Benznidazole: (3.7 mg/kg/8h for 60 ds). Chronic stage: No specific drug in the chronic stage is useful. Treat symptoms.

F. Control:
improve housing conditions. Insecticides. screening blood donors.

Life cycle of Plasmodium

Plasmodium species
1. 2. 3. 4. Benign malaria Plasmodium vivax: tertian malaria Plasmodium ovale. Oval tertian malaria Plasmodium malariae: quartan malaria malignant malaria Plasmodium falciparum: malignant sutertian malaria

1.Final host: Female Anopheles mosquitoes 2.Habitat in FH: stomach lumen then stomach wall. 3.Exit stage from FH :Sporozoites. 4.Exit stage from IH (man); diagnostic: ring, schizont and gametocytes; in all species except falciparum: ring and gametocytes only.

A. Biology

B. Epidemiology
Distribution: Tropical and subtropical areas. Formerly throughout temperate areas. Transmission: Intermediate host: human. Commonly in liver cells and RBCs. Reservoir host: None except P. malariae ; monkeys.. Infective stage: sporozoites in mosquitos saliva or merozoites in RBCs. Mode of infection: 1. mosquito injects sporozoites into blood vessels percutaneously. 2. Transmission of merozoite in RBCs via blood

transfusion or transplacentally.

C. Host-parasite relationship
Clinical features
Fever (cold, shivers hot; up to 41 oC sweating; hypopyrexia sleep). Anemia due to hemolysis and cytokine suppression on erythropoiesis (severe in falciparum), Splenomegaly and hypersplenism anemia. Jaundice due to massive and repeated hemolysis (severe in falciparum). Abortion, stillbirth in pregnant women;esp primigravidae infected with P falciparum.

complications
Falciparum malaria: 1.cerebral malaria and death 2.Persistent anaemia exists because recrudescence of blood forms that survive the immune attacks 3.Algid malaria is characterized by rapid development of shock due to sudden hypotension and fall of temperature. 4.Blackwater fever: It results from massive intravascular hemolysis and consequent hemglobinuria.

Plasmodium vivax and ovale: relapse up to 5 years due to latent liver hynozoites. P. malariae: glomerulonephritis and nephrotic syndrome. P. vivax: Splenic rupture is rare complication but with high mortality (80%). Hyper-reactive malarial splenomegaly may develop with recurrent infections.

D. Malaria diagnosis
1.Light microscopy of thin and thick blood films: to detect ring, schizont and gametocytes in all species and only ring and gametocytes in falciparum species 25-100% sensitive in field and 100% specific 2.Rapid diagnostic strip or cassette format tests based on pLDH (OptiMal). 84-97% sensitive. It Differentiates flaciparum from others based on PfHRP-II: 81-100% sensitive 3.Fluorescent microscopy Acridin orange (AO) stained thick blood film 42-93%sensitive and 52-93% specific 4.Quantitaive buffy coat (QBC) 90% sensitive and > 95% specific

Differentiation of plasmodium sp

E. Treatment: 1. Benign malaria: Cloroquine base PO for 3 days. If vivax/Ovale give primaquin; for 14 days after chloroquine to treat liver stage and prevent relapse. 2. Falciparum malaria: If can swallow and has no complications, give quinine salt PO for 7d + tetracycline, doxycyclin or clindamycin for 7 days. If seriously ill take to ITU give quinine IV. F. Control: 1. Avoid the major sources of infection; mosquito. 2. Chemical prophylaxis: chloroquine base or (proguanil, PO). Take drug one week before travel and continue for 4 weeks after return.

Outline of Txoplasma life cycle

A. Biology of Toxoplasma
Final host: Cats Habitat: Intracellular in enteroepithelial cells of gut. Exit stage from FH : Immature oocyst. No exit stage from IH Basic morphology and Life cycle:

B. Epidemiology of Toxoplasma
Distribution: Worldwide. . Transmission: Intermediate host: mammals including human. commonly in skeletal muscle, myocardium, and brain Reservoir host: cats, rodents and domestic animals. Infective stage: mature oocysts, tissue cysts, tachyzoites. Mode of infection: 1.Ingestion of undercooked infected meat containing Toxoplasma cysts. 2.Ingestion of the oocyst from fecally contaminated food; 3.Organ transplantation or blood transfusion. 4.Transplacental transmission. 5.Accidental inoculation of tachyzoites.

C. Host-parasite relationship
1. Adymptomatic infection. 2. Fever and lymphadenopathy (10-20%). 3. Encephalitis, acquired retinochoroiditis or pneumonitis in the immune compromised. 4. Congenital toxoplasmosis: 5. abortion, stillbirth, hydrocephalus and/or congenital retino-choroiditis. The latter may manifest early or later up to 20 years after birth.

D.Diagnosis of toxoplasmosis:
Observation of parasites in LN biopsy. Isolation of parasites from blood (BCL) by intra-peritoneal inoculation into mice. Detection of parasite genetic material by PCR, in congenital infections in utero. Serologic testing: Acute infection is confirmed by by a 4fold rise in specific IgG antibody titer over 4 weeks. IFA, ISAGA, IHAT and ELISA are the routine methods of diagnosis to detect specific IgM, IgG, IgE and IgA.

Immunofluorescent antibody test (IFA)

Positive test Negative test

E.Treatment:
Often none is used except in: 1. If the eye is involved or in the immunecompromized: Pyrimethamine (Daraprim); for 4 weeks,+ sulfadiazine. 2. Women with seroconversion during pregnancy: spiramycin; 1g/6h daily for 21 days.

F.Control:
Avoid the two major sources of infection: raw meat and cont. cat feces.

Outline of Cryptosporidium life cycle

A.

Biology of Cryptosporidium

2 species; hominis and parvum Final host: man and cattle Habitat: intra-cellular extracytoplasmic within the brush borders of the enterocytes of whole GIT, biliary and respiratory epithelia. Exit (diagnostic) stage: mature Oocyst (asporocystic tetrazoic) in human and calves feces. Basic morphology and Life cycle:

B. Epidemiology of Cryptosporidium
Distribution: About 30% of the adult population in developed counties and 90% in developing C. Transmission: 1. Intermediate host: no. 2. Reservoir host: cattle in C parvum. No reservoir host in C. hominis. 3. Infective stage: Oocyst. 4. Mode of infection: Human-to-human fecal-oral transmission. Animal-to-person transmission. Waterborne transmission

C. Host-parasite relationship
Incubation period of 5-10 days The patient develops watery diarrhea, This may be associated with abdominal cramps and a low-grade fever Stool microscopy: Modified acid-fast staining of stool shows red-stained round oocysts against a bluegreen background. Antigen-detection assays are more sensitive and include IFA assays, ELISA, and IC tests. Polymerase chain reaction (PCR) assays, more sensitive than others.

D. Diagnosis of cryptosporidiosis:

E. Treatment: Nitazoxanide (Cryptonaz). For 3 days with food F. Control: Using a home micro-straining water filter, to remove particles 1 m in size.