Flagellates: Giardia lamblia Dientamoeba fragilis Chilomastix mesnili Trichomonas hominis Enteromonas hominis Retortamonas intestinalis Ameba: Entamoeba

tamoeba histolytica Entamoeba dispar Entamoeba coli Entamoeba hartmanni Endolimax nana Iodamoeba btschlii Apicomplexa: Cryptosporidium parvum Cyclospora cayetanensis Isospora belli Microsporidia: Enterocytozoon bieneusi Encephalitozoon intestinalis Other: Blastocystis hominis Balantidium coli

INTESTINAL PROTOZOA

monoxenous vs heteroxenous
Other Lumen-Dwelling Protozoa
Trichomonas vaginalis (urogenital) Trichomonas tenax (oral) Entamoeba gingivalis (oral)

Giardia lamblia
worldwide distribution higher prevalence in tropical or developing countries (20%) 1-6% in temperate countries most common protozoa in stools ~200 million cases/yr giardiasis Historical Notes often asymptomatic 1681 van Leeuwenhoek acute or chronic diarrhea observed 1859 Lambl documented Taxonomy 1920s clinical symptoms, one human species, aka: but controversial G. duodenalis 1954 Rendtorff fulfilled G. intestinalis Kochs postulate morphologically similar forms in other mammals

Fecal-Oral Transmission Factors

poor personal hygiene
children (eg, day care centers) food handlers

developing countries
poor sanitation endemic travelers diarrhea

water-borne epidemics Is giardiasis a zoonosis? male homosexuality no definitive documentation

oral-anal contact

zoonosis?
Entamoeba =no Cryptosporidium =yes Giardia =controversial

transmission between humans and dogs rare (J.Parasit. 83:44, 1997) person-to-person transmission is most prevalent

Giardia Life Cycle

CYST TROPHOZOITE

Infective stage passed in feces

Replicative stage inhabiting sm. intestine

In Vitro Culture of Giardia

Excystation
brief exposure to acidic pH (~2) flagellar activity within 5-10 min after return to neutral pH breakdown of cyst wall (proteases) trophozoite emerges from cyst cytokinesis within 30 min

Encystation
exposure to pH 7, no bile exposure to pH 7.8, high bile cyst wall secretion (appearance of vesicles) loss of disk and flagella nuclear division

Adhesive Disk Components

microtubules tubulin microribbons giardins lateral crest actin-myosin
Attachment Mechanisms? contractile ring hydrodynamic force receptor mediated

microtubules + microribbons

lateral crest

Clinical Features and Symptoms

Subacute/Chronic Range of Outcomes recurrent diarrheal asymptomatic/latent episodes acute short-lasting diarrhea cramps uncommon chronic/nutritional disorders sulfuric belching, anorexia, nausea frequent Acute Symptoms can lead to weight loss and failure to thrive 1-2 week incubation sudden explosive, watery diarrhea bulky, frothy, greasy, foul-smelling stools no blood or mucus upper gastro-intestinal uneasiness, bloating, flatulence, belching, cramps, nausea, vomiting, anorexia usually clears spontaneously (undiagnosed), but can persist or become chronic

Pathogenesis
epithelial damage villus blunting crypt cell hypertrophy cellular infiltration malabsorption enzyme deficiencies lactase (lactose intolerance)

Possible Mechanisms
mechanical irritation obstruction of absorption

Diagnosis
suspect: acute or chronic symptoms confirmed: detection of parasite in feces or duodenal aspirate or biopsy parasite easy to identify parasite can be difficult to detect inconsistent excretion in feces patchy loci of infection

Parasite Detection
Stools 3 non-consecutive days wet mounts or stained IFA, copro-antigens Aspirate or Biopsy Enterotest (or string test)

Treatment
Drug of Choice metronidazole (Flagyl) 750 mg/tid/5d >90% cure rate

Control

avoid fecal-oral transmission improve personal hygiene especially institutions treat asymptomatic carriers eg, family members Alternatives health education tinidazole (single dose) hand-washing paromomycin (pregnancy) sanitation quinicrine food handling furazolidone protect water supply treat water if questionable boiling Prognosis is good iodine with no sequelae not chlorine

TRICHOMONADS
3-5 anterior flagella one undulating membrane axostyle hydrogensome (EM)

Human Trichomonas Species T. tenax oral cavity T. hominis* intestine T. vaginalis uro-genital
*aka: Pentatrichomonas

Trichomonas vaginalis
trophozoite stage transmitted during sexual intercourse
non-sexual contact possible

common STD
co-infection w/other STDs more prevalent in at risk groups
sexual intercourse

associated with epithelium of uro-genital tract

females: vagina males: urethra, prostate, epididymis

both sexes equally susceptible symptoms more common in females

In females:

Trichomoniasis

ranges from asymptomatic, to mild or moderate irritation, to extreme vaginitis

50-75% abnormal discharge (frothy, yellowish or greenish) 25-50% pruritis 50% painful coitus

onset or exacerbation often associated with menstruation or pregnancy vaginal erythema, strawberry cervix (~2%)

In males:
50-90% are asymptomatic mild dysuria or pruritus minor urethral discharge

DIAGNOSIS
demonstration of parasite direct observation or in vitro culture
vaginal discharge urine sediment prostatic secretion

PREVENTION
limit # of sexual partners condoms

TREATMENT
metronidazole (Flagyl)
250 mg (3/d) for 5-7 days single 2 g dose

simultaneous treatment of partner! (85-90% cure rate)

Key Features of Cysts

oval shape 11-14 x 6-10 m distinct cell wall set apart from cytoplasm 4 nuclei at anterior end large karyosome, no peripheral chromatin fibrils (axonemes) evident median bodies

Key Features of Trophozoites

pear shape 12-15 x 5-10 x 2-4 m 2 nuclei large karyosome, no peripheral chromatin fibrils (axonemes) evident bilateral symmetry pair of median bodies adhesive disk (not always evident) 4 pair flagella motility likened to falling leaf

Other Flagellates Found in Human Feces

Dientamoeba fragilis
no flagella (discuss with amebas)

Pentatrichomonas hominis
formerly called Trichomonas hominis

Chilomastix mesnili Enteromonas hominis Retortamonas intestinalis

Non-Pathogenic Intestinal Flagellates

Trichomonas hominis
7-15 mm trophozoite no cyst single nucleus axostyle 4 free flagella + undulating membrane costa

Non-Pathogenic Intestinal Flagellates

Chilomastix mesnili
10-20 mm trophozoite 6-20 mm cyst single nucleus 4 flagella cytostome

T. hominis

Chilomastix mesnili