HNS 212: MEDICAL PARASITOLOGY

INTRODUCTION TO MEDICAL
PROTOZOOLOGY

 A parasite is an organism that obtains food and shelter
from another organism and derives all benefits from this
association. The parasite is termed obligate when it can
live only in a host; it is classified as facultative when it can
live both in a host as well as in free form. Parasites that live
inside the body are termed endoparasites whereas those
that exist on the body surface are called ecto-parasites.
Parasites that cause harm to the host are pathogenic
parasites while those that benefit from the host without
causing it any harm are known as commensals.
INTESTINAL AND LUMINAL PROTOZOA


 The organism that harbors the parasite and suffers a loss
caused by the parasite is a host. The host in which the
parasite lives its adult and sexual stage is the definitive
host whereas the host in which a parasite lives as the larval
and asexual stage is the intermediate host. Other hosts
that harbor the parasite and thus ensure continuity of the
parasite's life cycle and act as additional sources of human
infection are known as reservoir hosts. An organism
(usually an insect) that is responsible for transmitting the
parasitic infection is known as the vector.
Background…. (WHO report).

Access to sanitation facilities and safe water is a

fundamental right that safeguards health and
human dignity
 2.3 billion people live without access to sanitation
facilities and access to safe water.
 Morbidity & mortality rates due to diseases related to
poor sanitation and water are high
For example…:
 1 billion people have sanitation related infections
 300 million suffer from associated severe morbidity
 155,000 deaths are reported annually due to sanitation &
water related disease mainly diarrhoea
85% are found in Africa (Children are the most
vulnerable are the most affected).
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Amoebae- of alimentary canal
 These are protozoa parasites associated with human
poor excreta disposal in the communities
 They cause diarrhea or dysentery
 Mode of amebic infection is ingestion of food stuff or
water contaminated with infected human stool.
 These intestinal parasites because of their amoeboid
motion (Trophozoites).
Amoeba of the elementary tract
Amoebae- of alimentary canal
 Intestinal amoeba significant to human health
include
 Entamoeba histolytica
 (Entamoeba coli,
 Entamoeba hartmanni,
 Dientamoeba fragilis, commensals
 Endolimax nana,
 Iodamoeba buetschlii, etc.)
Amoebae- of alimentary canal and other protozoa:
 Balantidium coli (Ciliate)
 Giardia lamblia and Trichomonas vaginalis
(Flagellates)
 Cryptosporidium parvum and Isospora belli (Sporozoa-
incidence is high in immuno-depressed individuals)
Entamoeba histolytica

Morphology/cycle; E. histolytica cyst Mature

 They have cyst stage and

Trophozoites stages.
 Cysts resists hard
environment
 Trophozoites are free living
and they feed from human Trophozoit of E. histolytuca with
digestive or tissue fluids phagocytized erythrocytes
ENTAMOEBA HISTOLYTICA
Morphology/cycle;

 Cyst are ingested from contaminated environment

 Excystation takes place in small intestine to produce
trophozoites
 Trophozoites- responsible for pathology in
amoebiasis / living stage
Epidemiology of E. histolytica
 Distribution is cosmopolitan in template and tropical
climates
 It is a disease due to poor sanitation and hygiene
 Tropical countries are mostly affected
 Poor habit of excreta disposal cause transmission
 Mode of transmission- Ingestion of faeces
contaminated water / foodstuff
Methods of transmission

 Epidemics of E. histolytica may develop due to gross water

pollution
 Food and water become contaminated by cyst due to:
 Polluted water
 Food handlers who are carriers
 Dropping of flies etc
 Use of human excreta in vegetable gardens
Incidence
 Adults have higher prevalence of infection than
children mainly due to exposure.
 Incidence of infection may require numerous
specimen test due to high rate of under diagnoses in
diarhoeal cases and the presence of other none
pathogenic amoeba (commensals)
Pathogenesis and Pathology
 It is associated with; dysentery and Invading of tissue
(Histo-lysis).
 May cause disease on the wall of colon (colonizing
mucosa) resulting in ulcers
 Trophozoites can phagocytize erythrocytes
 Trophozoites can disseminate through bloodstream to
cause hepatic amoebiasis
 May infiltrate kidney skin and brain etc.
Symptomatology
Amoebic dysentery:
 In children this may be acute febrile illness with
passage of bloody dysentery stool
Hepatic amoebiasis-
 Trophozoites digest the walls of mesenteric venules
and are carried in to hepatic portal system to the liver
 Necrosis of the liver tissue takes place and finally
development of liver abscesses
 Liver is tender and enlarged,
 Chills and fever are common
E. HISTOLYTICA
Diagnosis:
 Demonstration of cyst or trophozoite in stool under a
microscope
 Trophozoites found in Diarrhoeic stool wet
saline stool preparation
 Cyst or trophozoites found in semi-formed stool and
cyst only in formed stool
 Mature cyst has 2 –6 spherical nuclei
Cyst must be differentiated from that of Entamoeba coli,
by size and the number of nuclei,and other amoebic
cysts.
Entamoeba histolytica

E. histolytica cyst Mature

Trophozoit of E. histolytuca with

phagocytized erythrocytes
Other Amoebae- of alimentary canal

 (Entamoeba coli,
 Entamoeba hartmanni,
 Dientamoeba fragilis,
 Endolimax nana,
 Iodamoeba buetschlii, etc.)
 Balantidium coli (Ciliate)
 Giardia lamblia (Flagellates)
ENTAMOEBA
1. This is a none COLI
pathogenic commensal
2. It is a good indicator of the level of faecal
contamination in drinking water

Morphology
 Trophozoites, and cyst are the major stages of the
parasite-trophozoite in the human body and cysts both in
the body and outside in the faeces.
 Mature cyst has 6 – 8 spherical nuclei
 Excystation takes place in small intestine which pass to
colon
 Metacystic trophozoites to trophozoites establish in
coecum
 Trophozoites feed on erythrocytes, bacteria etc
E. COLI
 Epidemiology
 Transmission is cosmopolitan
 Incidence is high in countries with primitive hygiene
and sanitation
E.COLI
 Pathogenesis, pathology and Symptomatology:
 None pathogenic lumen parasite but
 Heavy intensity of infection may cause diarrhoea.
 Early stages of cyst are not easily differentiated from E.
histolytica
Entamoeba coli cyst

Entamoeba coli trophozoite

ENDOLIMAX NANA

Endolimax nana cysts

IODAMOEBA BUETSCHLII

Iodamoeba buetschlii cysts Iodamoeba buetschlii Trophozoit

ENTAMOEBA GINGIVALIS
MorphologyBiology/life cycle
 The first parasitic amoeba to be described
 It is a parasite of the oral cavity living in gingival
tissue around the teeth

 It is found in trophozoite stage with one nucleus

 Karyosome is small and well defined
 Trophozoites may have partly digested phagocytes
and epithelial cells
Entamoeba gingivalis trophozoite
 ENTAMOEBA GINGIVALIS
 Epidemiology:
 Transmission is closely associated with poor oral
hygiene
 With no cyst, transmission in believe to be by contact,
droplet sprays of mouth
 Drinking glasses or dishes
 In unhygienic mouths, incidence may be 70 to 95%
 In healthy mouths incidence of 10% or more have been
reported
 ENTAMOEBA GINGIVALIS

 Pathogenicity, pathology, symptomology

 This is a commensal living in the margins of human
gums
 It thrives best in unhealthy mouths
 Diagnosis:
 Identification of the amoeba trophozoite in materials
removed from the margins of the gum
ENDOLIMAX NANA

 This is a small amoeba and it is cosmopolitan in

distribution
 It is as prevalent as E. coli
ENDOLIMAX NANA

Endolimax nana cysts

ENDOLIMAX NANA
 Morphology:
 Has all stages described for E. coli and E. histolytica
 It dwells in the coecum where it feeds on bacteria
 Epidemiology:- As in E. Coli
 Pathogenesis: None pathogenic
 Diagnosis: Identification of the ovoidal cyst in the
stool
IODAMOEBA BUETSCHLII
Cosmopolitan in distribution but less common than
E. coli and E. nana
Morphology:
 Trophozoite, precyst, cyst, metacystic
 Trophozoite small to medium size, fairly active
 Endoplasm may contain bacteria, yeast and food
vacuoles
 Natural habitat is coecum
 Epidemiology:
 From man to man when viable cyst are ingested
through contamination
IODAMOEBA BUETSCHLII

 Pathogenesis:
 Generally considered none pathogenic…

Diagnosis: Identification of typical cyst or trophozoites

in stool
 Fresh iodine stain to detect glycogen vacuole
IODAMOEBA BUETSCHLII

Iodamoeba buetschlii cysts Iodamoeba buetschlii Trophozoit

DIANTAMOEBA FRAGILIS

Distribution- All regions of the world

Morphology: No cyst found
 Trophozoites actively motile with one or two
nucleus (Binucleate)
 It is lodged in mucus secretions in large intestine
coecum
 Passed in stool, it is found in clumps of mucous in
coecum
Epindemiology:
 Fecal contamination of foodstuff and water
 Incidence is low- -Less than 5% but may be higher
in congested institutions
 OTHER INTESTINAL PROTOZOA
 Balantidium coli and Cryptosporidium (parvum)
are both zoonotic protozoan intestinal infections
with some health significance. Isospora belli is an
opportunistic human parasite.

 Balantidium coli
This is a parasite primarily of cows, pigs and
horses. The organism is a large (100 x 60
micrometer) ciliate with a macro- and a micro-
nucleus (Figure 8). The infection occurs mostly in
farm workers and other rural dwellers by ingestion
of cysts in fecal material of farm animals. Man-to-
man transmission is rare but possible.
 Symptoms and pathogenesis of balantidiasis are
similar to those seen in entamebiasis, including
intestinal epithelial erosion. However, liver, lung
and brain abscesses are not seen. Metronidazole
and iodoquinol are effective.
 Balantidium coli trophozoites. These are
characterized by: their large size (40 µm to more
than 70 µm) the presence of cilia on the cell
surface - particularly visible in (B) a cytostome
(arrows) a bean shaped macronucleus which is
often visible - see (A), and a smaller, less
conspicuous micronucleus CDC
0PP0RTUNISTIC AMOEBA
Opportunistic amoebiasis
Causal Agents:
Acanthamoeba,
Naegleria fowleri,
and Sappinia Spp
 Free-living amoebae belonging to three genera
Acanthamoeba, Naegleria, Balamuthia are known to
affect humans. Sappinia are important causes of disease
in humans and animals.
 These amoebas live freely in soil and in fresh and coastal
waters.
 The resistant cysts can be transported in dust.


 - Naegleria fowleri causes an acute and almost invariably
fatal encephalitis,
 Several species of Acanthamoeba can cause lung and
skin infections, and insidious encephalitis, in
immunocompromised patients.
 Acanthamoeba may cause an ulcerative keratitis,
which is usually associated with improper sterilization
of soft contact lenses.
 These amebas live freely in soil and in fresh and
coastal waters.
 The resistant cysts can be transported in dust.
Naegleria fowleri
 Life Cycle
 Trophozoites infect humans or animals by
penetrating the nasal mucosa and migrating
to the brain via the olfactory nerves causing
primary amebic meningoencephalitis
 N. fowleri trophozoites are found in cerebrospinal
fluid (CSF) and tissue,
 Flagellated forms of trophozoites are occasionally
found in CSF but Cysts are not seen in brain tissue.
Naegleris Fowleri

 Diagnosis
 Diagnosis relies on identifying trophozoites by
microscopic examination of fresh cerebrospinal fluid
specimens or histologic sections of CNS tissue, and on
culturing, if necessary.
 Control
 Only three patients have survived primary these
patients, the disease was diagnosed early and
treated aggressively with high doses of
amphotericin B.
 Amphotericin B and miconazole appear to be the
drugs of choice.
 The chance of catching the disease can presumably
be reduced by properly chlorinating swimming
pools, whirlpools, and Jacuzzis, and by not diving
or splashing in warm water ponds.
Naegleris Fowleri
Epidemiology
Naegleris fowleri is found worldwide in soil, warm
fresh water, thermal discharges of power plants,
heated swimming pools, hydrotherapy and medicinal
pools, aquariums, and sewage.
 Infectious cysts may be carried in dust as
cysts.
Naegleris Fowleri
Pathogenesis
 Amoeba splashed or inhaled onto the
olfactory epithelium migrate up the
olfactory nerve to the brain and spread
via the subarachnoid space.
Acanthamoeba Spp
Clinical Manifestation
 Acanthamoeba species usually act as opportunistic
pathogens in immunocompromised or debilitated
individuals
 They cause pneumonitis or dermal ulcerations.
 From these lesions the amebas may spread to the
brain to cause an insidious, slowly progressive, and
usually fatal encephalitis called granulomatous
amebic encephalitis.
 In healthy individuals, Acanthamoeba spp can
cause an ulcerating keratitis, which is often
associated with the use of improperly sterilized
contact lenses.
Control

 No effective treatment is known for opportunistic

Acanthamoeba and B mandrillaris infections in
debilitated and immunosuppressed individuals.
 The incidence of keratitis may be reduced by
properly cleaning and sterilizing contact lenses.
 Keratitis may respond to treatment with
propamidine (often combined with neomycin),
followed if necessary, by keratoplasty.
Acanthamoeba Spp & Balamuthia mandrillaris

 Pathogenesis
 Encephalitis is caused by the hematogenous spread
from superficial or pulmonary lesions to the brain.
 Keratitis results from contamination of superficial
corneal abrasions.
 Host Defenses
 Except in the case of keratitis, the defenses of a healthy
host seem sufficient to prevent infection.
 Acanthamoeba
 Epidemiology
 The organisms live worldwide in soil and fresh and salt water.
 They may contaminate contact lens solution, physiotherapy
pools, air-conditioning units, etc.
 Diagnosis
 Diagnosis is usually by microscopic examination of biopsy
specimens from lesions;
 both trophozoites and cysts may be seen. Amebas may also
can be cultured.
Acanthamoeba
 Acanthamoeba castellanii, A culbertsoni, and other
Acanthamoeba species as well as the recently described B
mandrillaris, can cause opportunistic lung and skin
infections in immunocompromised or otherwise
debilitated individuals.
 The amebas may spread hematogenously from such
lesions to the brain, where they cause a subacute, slowly
progressive, and usually fatal encephalitis.
 In addition, Acanthamoeba can cause an ulcerating
keratitis in healthy individuals, usually in association
with improperly sterilized contact lenses.
Acanthamoeba and B mandrillaris
 Infections of the Lungs and Skin
 Acanthamoebic pneumonitis and dermatitis,
characterized by the presence of cysts and
trophozoites in alveoli or in multiple nodules or
ulcerations of the skin, are opportunistic diseases
that usually affect immunosuppressed or debilitated
individuals.
 In acanthamoebic pneumonitis, chest radiographs
may show areas of consolidation.
 Granulomatous amebic encephalitis usually develops
as a result of hematogenous spread from lesions in
the lungs, upper respiratory tract, or skin.
 Multiple skin nodules may represent "terminal"
dissemination in cases of granulomatous amebic
encephalitis.
 Acanthamoeba Keratitis
 Painful corneal ulcerations that fail to respond to the usual antibacterial,
antiviral, and antifungal treatments may be caused by Acanthamoeba.

 The disease is a nonsuppurative keratitis that characteristically follows a waxing

and waning clinical course.

 The damaged corneal tissue may show a characteristic annular infiltrate and
congested conjunctivae or there may be a dendriform epitheliopathy and patchy
stromal infiltrate with lacunar areas.

 If not successfully treated, the disease progresses to corneal perforation and loss
of the eye or to a vascularized scar over thinned cornea, with impaired vision.

 The disease is quite rare. It is usually associated with contaminated contact

lenses.
 Figure 81- 3 Pathogenesis of Acanthamoeba infection.
 Acanthamoeba keratitis usually results from direct invasion of ocular
tissue by the amebas through a break in the corneal epithelium.
 In most cases, the portal of entry is a minor corneal lesion, such as
those caused by a previous episodes of herpes simplex or by abrasion
from hard or soft contact lenses.
 The amebas are often introduced in the eye by an individual's use of
contaminated contact-lens cleaning solutions or by swimming in
contaminated water.
 The incubation period is unknown. Amebic trophozoites and cysts are
usually located deep in the corneal stroma, with moderated
granulomatous inflammation and negligible acute inflammatory
response.
INTESTINAL FLAGELLATES
 Giardia lamblia and Dietamoeba fragilis are
the two medically important flagellates:
 They are flagellates because they use flagella for
locomotion unlike amoeba which use
pseudopodia.
 HUMAN GIADIASIS

Caused by Giardia lamblia

Giardia lamblia (Intestinalis)

 Phylum (Protozoa)

Class: ZOOMASTIGOPHOREA

 Order: Diplomonadidae

 Family Hexamitidae--- (Two nuclei lying side

by side)

Genus GIARDIA
 Species Giardia lamblia (Intestinalis)
 Hosts
 Giardia affects humans, but is also one of the most
common parasites infecting cats, dogs and birds .
Mammalian hosts also include cows, beavers, deer, and
sheep.
Major characteristics
 Distinguishing features of the trophozoites
 Two nuclei
 Large karyosome and no peripheral chromatin, giving
the two nuclei a halo appearance.
 Cysts are distinguished by a retracted cytoplasm.
 The protozoan lacks mitochondria,

 The life cycle begins with a non-infective cyst being
excreted with the faeces of an infected individual.
 Distinguishing characteristic of the cyst is four nuclei and a
retracted cytoplasm.
 Once ingested by a host, the trophozoite emerges to an
active state of feeding and motility.
 Trophozoite undergoes asexual replication through
longitudinal binary fission.
 The resulting trophozoites and cysts then pass through the
digestive system in the faeces.
 While the trophozoites may be found in the faeces, only
the cysts are capable of surviving outside of the host.
Giardia lamblia (Lamblia intestinalis, Giardia
duodenalis) Life cycle
 Giardia lamblia is a flagellated protozoan parasite
It colonises and reproduces in the small intestine, causing
giardiasis.
 It attaches to the epithelium by a ventral adhesive disc,
 Reproduction is by binary fission longitudinally.
 Giardiasis does not spread via the bloodstream, nor does it
spread to other parts of the gastro-intestinal tract, but
remains confined to the lumen of the small intestine
 Giardia trophozoites absorb their nutrients from the lumen
of the small intestine, and are anaerobes.
 If the organism is split and stained, it has a very
characteristic pattern that resembles a smiley face.
Life cycle
Cyst of G. lamblia
 Giardia infection can occur through ingestion of dormant cysts in
contaminated water, food, or by the fecal-oral route (through poor
hygiene practices).
 The Giardia cyst can survive for weeks to months in cold water[3], and
therefore can be present in contaminated wells and water systems, and
even clean-looking mountain streams.
 They may also occur in city reservoirs and persist after water treatment,
as the Giardia cysts are resistant to conventional water treatment
methods such as chlorination
 Zoonotic transmission is also possible, and therefore Giardia infection
is a concern for people camping in the wilderness or swimming in
contaminated streams or lakes,
 As well as waterborne sources, fecal-oral transmission
can also occur, for example in day care centres, where
children may have poor hygiene practices. Those who
work with children are also at risk of being infected, as
are family members of infected individuals. Not all
Giardia infections are symptomatic, and many people
can unknowingly serve as carriers of the parasite.
 Manifestation of infection
 Nomenclature for Giardia species are difficult, as
humans and other animals appear to have
morphologically identical parasites.
 Colonization of the gut results in inflammation
and villous atrophy, reducing the gut's absorptive
capability. In humans, infection is symptomatic
only about 50% of the time, and protocol for
treating asymptomatic individuals is
controversial.[3]
 Symptoms of infection include (in order of
frequency) diarrhea, malaise, excessive gas (often
flatulence or a foul or sulphuric-tasting belch,
which has been known to be so nauseating in taste
that it can cause the infected person to vomit),
steatorrhoea (pale, foul smelling, greasy stools),
epigastric pain, bloating, nausea, diminished
interest in food, possible (but rare) vomiting which
is often violent, and weight loss.[3] Pus, mucus and
blood are not commonly present in the stool.
 It usually causes "explosive diarrhea" and while unpleasant,
is not fatal. In healthy individuals, the condition is usually
self-limiting, although the infection can be prolonged in
patients who are immunocompromised, or who have
decreased gastric acid secretion.[3]
 People with recurring Giardia infections, particularly those
with a lack of IgA, may develop chronic disease.
 Lactase deficiency may develop in an infection with
Giardia, however this usually does not persist for more than
a few weeks, and a full recovery is the norm[citation
needed].
 Some studies have shown that giardiasis should be
considered as a cause of Vitamin B12 deficiency, this a
result of the problems caused within the intestinal
absorption system. [5]
 Giardia lamblia infection in humans is frequently misdiagnosed.
 Accurate diagnosis
 an antigen test or, if that is unavailable,
 an ova and parasite examination of stool.
 Multiple stool examinations are recommended, since the cysts and
trophozoites are not shed consistently.
 Given the difficult nature of testing to find the infection, including many false
negatives, some patients should be treated on the basis of empirical evidence;
treating based on symptoms.[10]
 Human infection is conventionally treated with
 1) metronidazole,
 2) tinidazole or
 3) nitazoxanide.
 Although Metronidazole is the current first-line therapy, it is mutagenic in
bacteria and carcinogenic in mice, so should be avoided during pregnancy.[ [11]
 DrugTreatment durationPossible Side
EffectsMetronidazole5-7 daysMetallic taste;
nausea; vomiting; dizziness; headache; disulfiram-
like effect; neutropeniaTinidazoleSingle
doseMetallic taste; nausea; vomiting; belching;
dizziness; headache; disulfiram-like
effectNitazoxanide3 daysAbdominal pain;
diarrhea; vomiting; headache; yellow-green
discolouration of urineTable adapted from Huang,
White
Prevention
 Chlorine treatment of drinking water for Giardia is
not very successful in killing the organism though
quoted in many studies.
 Reliable prevention of outdoor water typically
involves filtration with a filter that has a nominal 1-
micrometer pore size.
 Most chemical treatment methods, including
common point-of-use treatments such as iodine
and chlorine dioxide, are considered unreliable in
inactivating Giardia cysts.
 Water parameters such as temperature, turbidity,
and dissolved solids may also affect the
effectiveness of such treatments.
Giardia lamblia & Giardiasis
Giardia lamblia parasitizes the small intestines
 Its Characteristic location is in the crypts at duodenal level of small
intestine
 Incubation period 5-20 days
 It is a clinical disease of mainly infants and children
 There is Intermittent shedding of cysts
 Clinical Disease is Self limiting in 4-7 weeks

Clinical manifestations-
 Acute diarrhoea- 5 -7days, abdominal cramps & bloating
Anorexia & fever, May damage villi
 Fat malabsorption in Chronic diarrhoea- (mechanical obstruction)
 Asymptomatic- (carrier spreading cysts in environment)

 Giardia infection occurs through the ingestion of cysts in

contaminated water, or food or by the faecal-oral route
Giardia
 Giardia has trophozoite and cyst stages
 Trophozoite stage is pear shaped (10-20µm long,
Rounded anteriorly and pointed posterioly)
 Has two nuclei with central karyosome and single
dense chromatine mass and
 8 flagellum (Four on lateral surface
 Two vertical and two posteriorly (tail)
 Sucking disk (Bow shaped depression) ventral
anteriorly located used to attach to the columnar
cells of the intestine.
 Giardia lamblia Infections.
Cysts are resistant forms and are responsible for
transmission of Giardiasis (Infective stages)
 Both cysts and trophozoites can be found in the feces .

The cysts are hardy and can survive several months in cold
water.
Infection occurs by the ingestion of cysts in contaminated

water, or food or by the fecal-oral route.

In the small intestine, excystation releases trophozoites

(each cyst produces 2 trophozoites).

Trophozoites multiply by longitudinal binary fission and

remain in the lumen of the small intestines free or attached

to the mucosa by a ventral sucking disk

Copyright ©2003 American Academy of Pediatrics

Giardia trophozoite:
 note the 2 anterior nuclei (“eyes”), the
 ventral adhesive disc, the axostyle and the 8 flagella.
Giardia Cyst

Encystation occurs as feces gradually become

dehydrated in transit down the colon
The trophozoites retract their fragella into axonemes
and assume the appearance of 4 pairs of curve bristles
Cytoplasm becomes thin
Tough hyaline membrane is secreted.
Giardia lamblia Cyst
 Importance of cyst formation.
 Forms protective coat that is resistant to environment.
 Allows parasites to exist outside host. Required for
disease transmission
 Cyst wall composed of carbohydrates, proteins,
 glycoprotein's polymers of galactosamine or N-
acetylgalactosamine.
 Survives in cold water.
 Resistant to Chlorine, disinfectant .
 Removed from water by filtration.
 Killed by heat, freezing and desiccation.
Giardia lamblia Cyst
 Mechanism of encystation:
 In vivo it occurs in small intestine.
 Invitro it is induced by high pH and high bile
concentration.
 Synthesis of the cyst wall requires specific secretions of cyst
wall components.
 Encystation specific secretion vesicles are induced at the
beginning of encystation
 Encystation specific secretions deliver cyst wall
components to the surface of trophozoites
 Inhibition of encystation would block transmission of
Giardiasis and this is a possible target for chemotherapy.
 Cysts are passed in faeces..
 They have no visible flagella and have 4 nuclei
 Life cycle of Giardia lamblia
 Infection is acquired by ingestion of mature cysts
 Cysts have rigid cell walls and are non-dividing. They can survive
in water and are resistant to desiccation.
 Cysts pass through the stomach, where they are exposed to gastric
acid/low pH and emerge in the lower stomach or upper small
intestine as a trophozoite.
 The trophozoite colonize the small intestine and are the disease-
causing stage.
 The trophozoite adheres to the epithelia, using a ventral adhesive
disc, and can cause maladsorption from the intestines and
diarrhea.
 Trophozoites that migrate to the distal small intestine undergo a
process of encystation, triggered by high pH and bile salts.
Encystation requires the synthesis of a cell wall.
 Cysts are passed in the feces of the host and mature and survive
externally until they are ingested by another host.

Copyright ©2003 American Academy of Pediatrics
Diagnosis

 Giardia lamblia infection in humans is frequently

misdiagnosed.
 Diagnosis of Giardiasis is done by observation of
cysts and/or trophozoites in faeces or duodenal
aspirates under a microscope
 Multiple microscope stool examinations are
recommended, since the cysts and trophozoites
are not shed consistently.
 Accurate diagnosis may require an antigen test
 Given the difficult nature of testing to find the
infection, including many false negatives, some
patients should be treated on the basis of
empirical evidence;
trophozoite:
using the trichrome stain the nuclei
and the flagella are clearly visible.
Trophozoites obtained by duodenal aspiration,
trichrome stain
Giardia lamblia Infections

● Cysts are resistant forms and are responsible for transmission of

giardiasis.
● Both cysts and trophozoites can be found in the feces (diagnostic
stages)
● The cysts can survive several months in cold water.
● Infection occurs by the ingestion of cysts in contaminated water, or
food or by the fecal-oral route
● Excystation:
● Excystation takes place in small intestine to releases trophozoites (each
cyst produces 2 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
Encystation

Encystation
 Encystation occurs as the parasites moves
toward the colon.
 The cyst is the stage found most commonly in
non-diarrheal 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
Giardiasis- Summary
 Giardia lamblia (also called G. intestinalis and G. duodenalis)
 This organism is unicellular and infection of the host results when
environmentally resistant cysts are ingested. Growing, motile stages of
the parasite, referred to as trophozoites, emerge from the cyst (a
process called excystation) in the proximal small intestines and
colonize the intestines. A certain number of these trophozoites travel
to the more distal intestines and will encyst, and will be passed back
into the environment in the feces of the host. The life cycle is
completed when a new host ingests these cysts.
 This fecal-oral route of infection may result from person-to-person
contact but also often involves ingesting cysts that contaminate natural
waters. Because G. lamblia infects many animals in addition to human
(i.e. it has many reservoir hosts), mountain and forest streams are often
contaminated with cysts that are deposited there by wildlife that
inhabit these areas. It is important to either filter, boil or chemically
treat water from these streams before drinking it to avoid possible
infection with G. lamblia.
 A Giardia trophozoite: note the 2 anterior nuclei
(“eyes”), the
 ventral adhesive disc, the axostyle and the 8 flagella.
Giardia lamblia (Lamblia intestinalis, Giardia
duodenalis) Life cycle
 Giardia lamblia is a flagellated protozoan parasite
It colonises and reproduces in the small intestine, causing
giardiasis.
 It attaches to the epithelium by a ventral adhesive disc,
 Reproduction is by binary fission longitudinally.
 Giardiasis does not spread via the bloodstream, nor does it
spread to other parts of the gastro-intestinal tract, but
remains confined to the lumen of the small intestine
 Giardia trophozoites absorb their nutrients from the lumen
of the small intestine, and are anaerobes.
 If the organism is split and stained, it has a very
characteristic pattern that resembles a smiley face.
 The life cycle begins with a noninfective cyst being excreted
with the faeces of an infected individual.
 Distinguishing characteristic of the cyst is four nuclei and a
retracted cytoplasm.
 Once ingested by a host, the trophozoite emerges to an
active state of feeding and motility.
 Trophozoite undergoes asexual replication through
longitudinal binary fission.
 The resulting trophozoites and cysts then pass through the
digestive system in the faeces.
 While the trophozoites may be found in the faeces, only
the cysts are capable of surviving outside of the host.
Life cycle
Cyst of G. lamblia
Major characteristics
 Distinguishing features of the trophozoites
 Two nuclei
 Large karyosome and no peripheral chromatin, giving
the two nuclei a halo appearance.
 Cysts are distinguished by a retracted cytoplasm.
 The protozoan lacks mitochondria,

 Hosts
 Giardia affects humans, but is also one of the most
common parasites infecting cats, dogs and birds .
Mammalian hosts also include cows, beavers, deer, and
sheep.
 Giardia infection can occur through ingestion of dormant cysts in
contaminated water, food, or by the fecal-oral route (through poor
hygiene practices).
 The Giardia cyst can survive for weeks to months in cold water[3], and
therefore can be present in contaminated wells and water systems, and
even clean-looking mountain streams.
 They may also occur in city reservoirs and persist after water treatment,
as the Giardia cysts are resistant to conventional water treatment
methods such as chlorination
 Zoonotic transmission is also possible, and therefore Giardia infection
is a concern for people camping in the wilderness or swimming in
contaminated streams or lakes,
 As well as waterborne sources, fecal-oral transmission
can also occur, for example in day care centres, where
children may have poor hygiene practices. Those who
work with children are also at risk of being infected, as
are family members of infected individuals. Not all
Giardia infections are symptomatic, and many people
can unknowingly serve as carriers of the parasite.
 Manifestation of infection
 Nomenclature for Giardia species are difficult, as
humans and other animals appear to have
morphologically identical parasites.
 Colonization of the gut results in inflammation
and villous atrophy, reducing the gut's absorptive
capability. In humans, infection is symptomatic
only about 50% of the time, and protocol for
treating asymptomatic individuals is
controversial.[3]
 Symptoms of infection include (in order of
frequency) diarrhea, malaise, excessive gas (often
flatulence or a foul or sulphuric-tasting belch,
which has been known to be so nauseating in taste
that it can cause the infected person to vomit),
steatorrhoea (pale, foul smelling, greasy stools),
epigastric pain, bloating, nausea, diminished
interest in food, possible (but rare) vomiting which
is often violent, and weight loss.[3] Pus, mucus and
blood are not commonly present in the stool.
 It usually causes "explosive diarrhea" and while unpleasant,
is not fatal. In healthy individuals, the condition is usually
self-limiting, although the infection can be prolonged in
patients who are immunocompromised, or who have
decreased gastric acid secretion.[3]
 People with recurring Giardia infections, particularly those
with a lack of IgA, may develop chronic disease.
 Lactase deficiency may develop in an infection with
Giardia, however this usually does not persist for more than
a few weeks, and a full recovery is the norm[citation
needed].
 Some studies have shown that giardiasis should be
considered as a cause of Vitamin B12 deficiency, this a
result of the problems caused within the intestinal
absorption system. [5]
 Microscopy


 This picture shows multiple views of a single Giardia lamblia (intestinalis) cyst
as imaged at different instrument settings by confocal microscopy.Bar = 10
micrometres.
(A) is the cyst imaged by transmission (differential interference contrast), only.
(B) is the cyst wall selectively imaged through use of fluorescent-labelled
(TRITC) antibody that is cyst wall specific.
(C) is the cyst imaged through use of carboxy fluorescein diacetate, a viability
stain.
(D) is a composite image of (B) and (C).
(E) is a composite image of (A), (B), and (C).
 Under a normal compound light microscope, Giardia often looks like a "clown
face," with two nuclei outlined by adhesive discs above dark that form the
"mouth." Cysts are oval, have four nuclei, and have clearly visible axostyles. In
spite of the common belief that all Eukaryotes have mitochondria, Giardia is
one of the few that lack these organelles
 Giardia lamblia infection in humans is frequently misdiagnosed. Accurate
diagnosis requires an antigen test or, if that is unavailable, an ova and parasite
examination of stool. Multiple stool examinations are recommended, since the
cysts and trophozoites are not shed consistently. Given the difficult nature of
testing to find the infection, including many false negatives, some patients
should be treated on the basis of empirical evidence; treating based on
symptoms.[10]
 Human infection is conventionally treated with metronidazole, tinidazole or
nitazoxanide. Although Metronidazole is the current first-line therapy, it is
mutagenic in bacteria and carcinogenic in mice, so should be avoided during
pregnancy.[3] One of the most common alternative treatments is (found in
Oregon grape root, goldenseal, yellowroot, and various other plants).[citation
needed] Berberine has been shown to have an antimicrobial and an antipyretic
effect.[citation needed] Berberine compounds cause uterine stimulation, and so
should be avoided in pregnancy.[citation needed] High doses of berberine can
cause bradycardia and hypotension. [11]
 Treatment in animals
 Cats can be cured easily, lambs usually simply lose weight, but in calves
the parasites can be fatal and often are not responsive to antibiotics or
electrolytes. Carriers among calves can also be asymptomatic. Dogs
have a high infection rate, as 30% of the population under one year old
are known to be infected in kennels. The infection is more prevalent in
puppies than in adult dogs. This parasite is deadly for chinchillas, so
extra care must be taken by providing them with safe water. Infected
dogs can be isolated and treated, or the entire pack at a kennel can be
treated together regardless. Kennels should also be then cleaned with
bleach or other cleaning disinfectants. The grass areas used for exercise
should be considered contaminated for at least one month after dogs
show signs of infection, as cysts can survive in the environment for long
periods of time. Prevention can be achieved by quarantine of infected
dogs for at least 20 days and careful management and maintenance of a
clean water supply.
 DrugTreatment durationPossible Side
EffectsMetronidazole5-7 daysMetallic taste;
nausea; vomiting; dizziness; headache; disulfiram-
like effect; neutropeniaTinidazoleSingle
doseMetallic taste; nausea; vomiting; belching;
dizziness; headache; disulfiram-like
effectNitazoxanide3 daysAbdominal pain;
diarrhea; vomiting; headache; yellow-green
discolouration of urineTable adapted from Huang,
White
Prevention
 Treatment of drinking water for Giardia is ordinarily indicated in
wilderness regions in North America,[citation needed], although at
least four researchers disagree with this statement, including Robert
W. Derlet, a professor at the University of California-Davis School of
Medicine, Timothy P. Welch and Thomas R. Welsh of Tulane Medical
School and the Children's Hospital of Cincinnati respectively, and
Robert Rockwell, a widely quoted writer who is an engineer by
training.[6][7][8][9]
 In other areas frequented by hikers and campers, as well as places
where many residents rely on untreated surface water, reliable
prevention typically involves filtration with a filter that has a nominal 1-
micrometer pore size. Most chemical treatment methods, including
common point-of-use treatments such as iodine and chlorine dioxide,
are considered unreliable in inactivating Giardia cysts. Water
parameters such as temperature, turbidity, and dissolved solids may
also affect the effectiveness of such treatments.
 Opportunistic amibiasis
Causal Agents: Acanthamoeba spp. Naegleria fowleri &
Balamuthia mandrillaris
 Free-living amebae belonging to the genera Acanthamoeba,
Naegleria,
 Balamuthia and Sappinia are important causes of disease in
humans and animals.
 Naegleria fowleri produces an acute, and usually lethal, central
nervous system (CNS) disease called primary amebic
meningoencephalitis (PAM).
 Acanthamoeba spp. and Balamuthia mandrillaris are
opportunistic free-living amebae capable of causing
granulomatous amebic encephalitis (GAE)
 This is common in individuals with compromised immune
systems.
 Sappinia diploidea has been implicated in a case of amebic
encephalitis.
 : Opportunistic amibiasis
 Naegleria fowleri and Acanthamoeba spp, are commonly
found in lakes, swimming pools, tap water, and heating
and air conditioning units.
 Only one species of Naegleria, (N. fowleri,) is known to
infect humans,
 Several species of Acanthamoeba are implicated in
human disease, Viz:
 Acanthamoeba culbertsoni,
 Acanthamoeba polyphaga,
 Acanthamoeba castellanii,
 Acanthamoeba astronyxis
 Acanthamoeba hatchetti,
 Acanthamoeba rhysodes,
 Acanthamoeba divionensis,
 Acanthamoeba lugdunensis,
 Acanthamoeba lenticulata
Balamuthia Spp and Sappinia Spp,
 An additional agent of human disease,
Balamuthia mandrillaris,
 It is related morphologically to
Acanthamoeba in tissue sections in
light microscopy.
 Sappinia Spp are free-living amoeba
rarely isolated from humans;
 cysts and trophs have been found in
the feces of many animals, including
mammals and reptiles.
 Balamuthia mandrillaris has only recently been isolated from the environment
and has also been isolated from autopsy specimens of infected humans and
animals.
 B. mandrillaris has only two stages, cysts and trophozoites , in its life
cycle. No flagellated stage exists as part of the life cycle.
 The trophozoites replicate by mitosis (nuclear membrane does not remain
intact) .
 The trophozoites are the infective forms, although both cysts and trophozoites
gain entry into the body through various means.
 Entry can occur through the nasal passages to the lower respiratory tract , or
ulcerated or broken skin .
 When B. mandrillaris enters the respiratory system or through the skin, it can
invade the central nervous system by hematogenous dissemination causing
granulomatous amebic encephalitis (GAE)
 or disseminated disease , or skin lesions in individuals who are immune
competent as well as those with compromised immune systems.
 B. mandrillaris cysts and trophozoites are found in tissue.
 Naegleria fowleri has three stages, cysts , trophozoites , and flagellated forms , in its life
cycle. The trophozoites replicate by promitosis (nuclear membrane remains intact) . N.
fowleri is found in fresh water, soil, thermal discharges of power plants, heated
swimming pools, hydrotherapy and medicinal pools, aquariums, and
sewage. Trophozoites can turn into temporary non-feeding flagellated forms which
usually revert back to the trophozoite stage. Trophozoites infect humans or animals by
penetrating the nasal mucosa and migrating to the brain via the olfactory
nerves causing primary amebic meningoencephalitis (PAM). N. fowleri trophozoites are
found in cerebrospinal fluid (CSF) and tissue, while flagellated forms are occasionally
found in CSF.
 Naegleria fowleri Cysts are not seen in brain tissue. Naegleria fowleri has three stages,
cysts , trophozoites , and flagellated forms , in its life cycle. The trophozoites replicate
by promitosis (nuclear membrane remains intact) . N. fowleri is found in fresh water,
soil, thermal discharges of power plants, heated swimming pools, hydrotherapy and
medicinal pools, aquariums, and sewage. Trophozoites can turn into temporary non-
feeding flagellated forms which usually revert back to the trophozoite
stage. Trophozoites infect humans or animals by penetrating the nasal mucosa and
migrating to the brain via the olfactory nerves causing primary amebic
meningoencephalitis (PAM). N. fowleri trophozoites are found in cerebrospinal fluid
(CSF) and tissue, while flagellated forms are occasionally found in CSF. Cysts are not
seen in brain tissue.
 Naegleria fowleri
 Cysts are not seen in brain tissue. Naegleria fowleri has
three stages, cysts , trophozoites , and flagellated forms
, in its life cycle. The trophozoites replicate by
promitosis (nuclear membrane remains intact) . N.
fowleri is found in fresh water, soil, thermal discharges of
power plants, heated swimming pools, hydrotherapy and
medicinal pools, aquariums, and sewage. Trophozoites
can turn into temporary non-feeding flagellated forms
which usually revert back to the trophozoite
stage. Trophozoites infect humans or animals by
penetrating the nasal mucosa and migrating to the
brain via the olfactory nerves causing primary amebic
meningoencephalitis (PAM). N. fowleri trophozoites are
found in cerebrospinal fluid (CSF) and tissue, while
flagellated forms are occasionally found in CSF. Cysts
are not seen in brain tissue.
 Free-living amebae belonging to the genera Acanthamoeba,
Balamuthia, Naegleria and Sappinia are important causes
of disease in humans and animals. Naegleria fowleri
produces an acute, and usually lethal, central nervous
system (CNS) disease called primary amebic
meningoencephalitis (PAM). Acanthamoeba spp. and
Balamuthia mandrillaris are opportunistic free-living
amebae capable of causing granulomatous amebic
encephalitis (GAE) in individuals with compromised
immune systems. Sappinia diploidea has been implicated
in a case of amebic encephalitis.
 Acanthamoeba spp.Balamuthia mandrillarisNaegleria
fowleri
Causal Agents:
Naegleria fowleri
 Causal Agents:
Naegleria fowleri and Acanthamoeba spp., are commonly found in
lakes, swimming pools, tap water, and heating and air conditioning
units. While only one species of Naegleria, N. fowleri, is known to
infect humans, several species of Acanthamoeba, including A.
culbertsoni, A. polyphaga, A. castellanii, A. astronyxis, A. hatchetti, A.
rhysodes, A. divionensis, A. lugdunensis, and A. lenticulata are
implicated in human disease. An additional agent of human disease,
Balamuthia mandrillaris, is a related free-living ameba that is
morphologically similar to Acanthamoeba in tissue sections in light
microscopy. Sappinia is a genus of free-living amebae rarely isolated
from humans; cysts and trophs have been found in the feces of many
animals, including mammals and reptiles.
Comparison of morphology of Opportunistic amoeba
 Balamuthia mandrillaris has only recently been isolated from the
environment and has also been isolated from autopsy specimens of
infected humans and animals. B. mandrillaris has only two stages,
cysts and trophozoites , in its life cycle. No flagellated stage exists as
part of the life cycle. The trophozoites replicate by mitosis (nuclear
membrane does not remain intact) . The trophozoites are the infective
forms, although both cysts and trophozoites gain entry into the body
through various means. Entry can occur through the nasal passages to
the lower respiratory tract , or ulcerated or broken skin . When B.
mandrillaris enters the respiratory system or through the skin, it can
invade the central nervous system by hematogenous dissemination
causing granulomatous amebic encephalitis (GAE) or disseminated
disease , or skin lesions in individuals who are immune competent as
well as those with compromised immune systems. B. mandrillaris cysts
and trophozoites are found in tissue.
 : Opportunistic amibiasis

 Naegleria fowleri and Acanthamoeba Spp, are commonly

found in springs, lakes, swimming pools, tap water, and
heating and air conditioning units.
 Only one species of Naegleria, (N. fowleri,) is known to
infect humans,
 Several species of Acanthamoeba are implicated in
human disease, Viz:
(Acanthamoeba culbertsoni,Acanthamoeba polyphaga, Acanthamoeba
castellanii, Acanthamoeba astronyxisAcanthamoeba hatchetti,
Acanthamoeba rhysodes, Acanthamoeba divionensis, Acanthamoeba
lugdunensis and Acanthamoeba lenticulata)
Balamuthia Spp and Sappinia Spp,
 An additional agent of human disease,
Balamuthia mandrillaris,
 It is related morphologically to
Acanthamoeba in tissue sections in
light microscopy.
 Sappinia Spp are free-living amoeba
rarely isolated from humans;
 cysts and trophozoites have been found
in the feces of many animals, including
mammals and reptiles.
Naegleris Fowleri

 Clinical Manifestation
 Naegleria fowleri causes primary amoebic
meningoencephalitis, a rare, rapidly fatal disease with
sudden onset of headache, fever, stiff neck, lethargy,
and coma in otherwise healthy people.
Table