Pneumocystis Paragonimus spp. Echinococcus spp.

. . Tel. 043-348387, 3434 E-mail psomec@kku.ac.th

Parasitic infection causes pneumonia

Objectives
Pneumocystis, Paragonimus Echinococcus :
Disease Morphology life cycle Transmission Pathogenesis Diagnosis Treatment Prevention & control

Pneumocystis jiroveci, Frenkel 1999 or Pneumocystis carinii

Causes Pneumocystis jiroveci (carinii) Pneumonia (PCP) P. jiroveci is ascomycetelike fungi

Does not cause illness in healthy people.

An opportunistic parasite

Pneumocystis jiroveci, Frenkel 1999 or Pneumocystis carinii

It can cause a lung infection in people with a weakened immune system due to:
Cancer Chronic use of corticosteroids or other medications that weaken the immune system HIV/AIDS Organ or bone marrow transplant The most serious disease in AIDS

Morphology
Cyst: spherical, 4-8 um, contained intracystic body or sporozoite inside < 8 intracystic bodies; pre-cyst 8 intracystic bodies; Mature cyst Rupped cyst; cup- or cresent- shaped Trophozoite: 2-4 um

Life cycle of Pneumocystis

Live in the surface of epithelial cell in alveoli & alveolar space
Asexual and sexual stage Infective stage is cyst stage
Bogitsh BJ et al, 2005: p162

Mode of transmission
Is not known but presumed to be via inhalation of infective stage Airborne transmission Direct: person-to-person

Mother-to-infant
Indirect: environmental Human may infection early in life but pneumocystis develops only when the host has low immunity

Pathogenesis & symptoms of PCP

Causes an interstitial plasma cell pneumonia (inflammation of alveoli) Thickening of alveolar septa from fibrosis Alveolar space filled with a foamy vacuolated material Foamy exudate or honeycomb pattern related to the disease progression Death due to respiratory failure

Pathogenesis & symptoms of PCP

The heavy interstitial cellular infiltration causes
the alveolar-capillary block and severe anoxia. Pneumocystosis granulomatous present epithelioid cells and multinucleated giant cells. Interstitial fibrosis, emphysema and pulmonary

calcification may progress.

Rare an extrapulmonary pneumocystis: liver, spleen, heart, etc.

Pathogenesis & symptoms of PCP

The incubation period, based on animal model,

is between 4-8 weeks

Symptoms tend to progress slowly over weeks to months In non-AIDS immunosuppressed children and adults occur over a period of day

Infant failure to thrive leading to a rapid

respiratory rate (> 100 respiration/min), cyanosis

The clinical symptoms of PCP

1. Shortness of breath, dyspnea (difficultly in breathing) 2. Dry non-productive cough
(but smokers tend to produce some sputum)

3. Fever 4. Fatigue, malaise 5. Night sweats 6. Cyanosis

Possible Complications of PCP

1. Pleural effusion (extremely rare) 2. Pneumothorax (collapsed lung) 3. Respiratory failure (may require breathing support)

Pathogenesis of PCP
Fibrosis in septal walls Bilateral-diffused

H&E staining of lung

Radiography by X-ray

biopsy or section

Diagnosis

Specimens
1. Induced sputum

Efficiency
30-90%

2. Bronchoalveolar lavage (BAL)

3. Transbronchial biopsy

50-95%
>90%

Diagnosis
1. Staining
(Speciment; sputum or bronchio-alveolar lavage)

Gomeris methenamine silver staining : cyst wall

Toluidine blue O : cyst wall Giemsa : intracystic bodies, trophozoite Periodic-acid schiff

Immunofluorescent or Histochemical staining

2. Chest x-ray; diffuse bilateral pulmonary infiltrates 3. Serologic test: Indirect Fluorescence Technique

4. Molecular technique: PCR

Staining
Giemsa stain
Papanicolaou stain

Gomeris methenamine silver

Grocott methenamine silver nitrate

cast stained positive with 3F6 antibody

Wazir JF, Ansari NA. Pneumocystis carinii infection.. Arch Pathol Lab Med 2004;128:1023-7.

Chest x-ray
Bilateral upper-lobe pneumatoceles

Medrano FJ et al. (2005). Emerg Infect Dis 11 (2): 245250

18

Treatment of PCP
Co-administration of oxygen is recommended in severe PCP cases. The 2 major drugs for PCP are: trimethoprim-sulfamethoxazole (co-trimoxazole), first drug of choice Pentamidine isothionate, alternative drug

Corticosteroids reduce the risk of respiratory

failure and death.

Prevention of PCP
Prophylaxis
Preventive therapy is recommended for:
Patients with AIDS who have CD4 counts below 200 Bone marrow transplant recipients Organ transplant recipients People who take long-term, high-dose corticosteroids People who have had previous episodes of this infection


4 1. (Intestinal fluke)
2. (Liver fluke) 3. (Lung fluke) 4. (Blood fluke)

 (LUNG FLUKES) Paragonimus spp.

paragonimiasis
Pulmonary paragonimiasis Extrapulmonary paragonimiasis

Paragonimus westermani

Paragonimus heterotremus


P. heterotremus

Paragonimus heterotremus
Adult
~ 7.5-12 X 4-6 . Oral sucker ventral sucker (zigzag) Ovary Testes 1 (side by side) Uterus Vitelline glands 2

Paragonimus heterotremus egg

~ 80-118 X 48-60

Echinostome

 Paragonimus heterotremus

 paragonimiasis

Egg

 paragonimiasis
Acute Paragonimiasis (Early-Stage Disease)
: Abdominal pain, fever, - 2-15 and diarrhea Chronic Pleuropulmonary Paragonimiasis (Late-Stage Disease): - (pulmonary paragonimiasis):

 paragonimiasis
- (pulmonary paragonimiasis)

CT scan of a patient with paragonimiasis shows Chest roentgenogram of a patient with bilateral pleural effusions and thickening of the paragonimiasis shows bilateral pleural left pleura with possible cystic change (arrow). effusions and an infiltrate in the lower lobe of the left lung (arrow).

Clinical Microbiology Reviews, July 2009, p. 415-446, Vol. 22, No. 3

Pulmonary paragonimiasis

Chest radiograph shows cavitated areas of increased opacity in the middle lobe and left upper lobe (arrows).

CT scan shows a cavitated area of consolidation in the middle lobe

Chest radiograph shows a soft-tissue nodule in the middle lobe (arrows)

CT scan more clearly demonstrates the nodule (arrows).

 paragonimiasis
- (Extrapulmonary paragonimiasis)

Paragonimus egg in the brain

Clinical manifestations of paragonimiasis:

Cough Hemoptysis 83% 70%

tan- to brown pigmented paragonimus egg: sputum presents Iron filings

Chest pain or discomfort Dyspnia Fever and/or Chills Asymptomatic 65% 42% 37% 2%

Clinical Microbiology Reviews, July 2009, p. 415-446, Vol. 22, No. 3

 paragonimiasis

Praziquantel

Echinococcus spp.
E. granulosus E. multilocularis E. vogeli E. oligarthrus
The adult worm live in small intestine of carnivor, such
as dog, wolves, jackals, foxes, coyotes, rarely in cat. Human is an accidental host, which found hydatid cyst (metacestode) in tissues.

Geographic Distribution
E. granulosus occurs practically worldwide, and more frequently in rural, grazing areas where dogs ingest organs from infected animals. E. multilocularis occurs in the northern hemisphere, including central Europe and the northern parts of Europe, Asia, and North America. E. vogeli and E. oligarthrus occur in Central and South America.

Morphology of E. granulosus
Scolex with rostellar hook

Adult:
E. granulosus

Immature proglottid Mature proglottid

Gravid proglottid

Consist of 3 segments: immature, mature & gravid proglottid. Mature proglottid: Testes; follicle 45-65, Ovary 2 lobes, Vitelline gland; cluster at the posterior. Gravid proglottid: the most widest, length > of body, small sac of uterus 12-15 sac.

Morphology of Echinococcus spp.

E. multilocularis

E. granulosus

E. multilocularis

E. oligarthrus E. vogeli E. granulosus

Morphology; larva

E. granulosus E. multilocularis
Fluid-filled mostly solitary cyst, unilocular or multichambered , diam 1->15 cm; often with protoscoleces Masses of numerous small cyst (diam up to 3 mm), often interconnected, surrounded by connective tissue, no cyst fluid, rarely a few protoscoleces

E. vogeli
Polycystic; fluid-filled cysts (diam up to 4-6 mm), solitary, but often aggregated, thick laminated layer protoscoleces frequently present

E. oligarthrus
Fluid-filled cysts, laminated layer thinner than E. vogeli, protoscoleces formed

Hydatid cyst of E. granulosus

Laminated membrane Germinal layes Laminated membrane

Germinal layes

Brood capsule
Protoscolices Brood capsule Protoscolices

Hydatid sand
Neva FA, & Brown HW, 1994

Echinococcus spp.
Species
E. granulosus

Disease
cystic echinococcosis or unilocular hydatidosis

Host
dog

IH
herbivores

E. multilocularis alveolar or multilocular

echinococcosis

fox

rodent

E. vogeli & E. Oligarthrus

Polycystic echinococcosis

sylvatic animal

rodent

Life cycle of Echinococus spp.

Transmission
Human cause echinococcosis by eating

Echinococcus spp. egg contaminated in

food and drinking water.

Pathogenesis and Clinical disease

The incubation period of echinococcosis

varies from months to years.

It can be as long as 20-30 years.

Pathogenesis and Clinical disease

Cystic echinococcosis (Cyst of E. granulosus)
Symptoms and signs depend on the size, the location and the pressure of the cyst on host structures. 1. Hydatid cyst is not a problem as a single cyst in liver, since it is immunologically silent. 2. If it ruptures however, no matter which organ it occupies, anaphylaxis usually ensues. This may be fatal. 3. In other organs (e.g., brain, lung, bone marrow), an hydatid cyst may range from being asymptomatic to fatal, depending on its effect as a space-occupying lesion.

Distribution of hydatid cyst

Liver: 63%
Lungs: 25% Muscles: 5% Bone marrow: 3% (usually fatal) Kidney: 2% Spleen: 1% Brain: 1% (usually fatal)

Pulmonary hydatid disease from E. granulosus

Pulmonary hydatid disease from E. granulosus

CT scan of the lung shows a hypoattenuating crescent sign (meniscus sign)

The inner germinal layer, to which several daughter protoscolices of E. granulosus are attached.

Hydatid capsule, inner surface,

isolated from lung of a Korean woman

inner surface,

Hydatid sand in human lung H&E, X100

A section of human lung shows multiple protoscoleces

Diagnosis
A. Direct
Detect circulating antigens Microscopic examination of fluid from hydatid cyst after surgical removal, see hydatid sand DO NOT BIOPSY!

B. Indirect
ELISA-based serology MRI or CT scanning, x-ray Accurate case history (ownership of dogs, living on a farm, etc.)

Prevention and Control

Regularly treat all dogs with niclosamide that have contact with sheep. This drug kills the adult parasites. Avoid feeding hydatid cyst material to dogs. Public health education of sheep farmers.

Treatment
Drug of Choice:
Albendazole or mebendazole Mode of Action: De-polymerizes invertebrate microtubules, only Spontaneous or surgical rupture of the cyst can originate a secondary hydatidosis.

Mammomonogamus laryngeus

References
Wilkin A and Feinberg J. Pneumocystis carinii pneumonia: a clinical review. Am Fam Phys 1999;60:1699-1714. John G Bartlett and Stefano Vella. Textbook-Atlast of Intestinal Infections in AIDS Medrano FJ et al. "Pneumocystis jirovecii in General Population". Emerg Infect Dis 2005; 11 (2): 245250 Wazir JF, Ansari NA. Pneumocystis carinii infection. Update and review. Arch Pathol Lab Med 2004; 128:1023-7. Markell EK et al. Medical Parasitology. 1999 www.google.co.th(search image under scientific name/life cycle) www.google.co.th (search under scientific name/lecture, power point or review)

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