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INTESTINAL FLAGELLATES

Common intestinal flagellates


Giardia lamblia , Chilomastrix mesneli , Trichomonas hominis,
Deintamoeba fragilis

Occasionally encountered intestinal flagellates


Enteromonas hominis, Retortamonas intestinalis
= no evidence that any of this organism can cause disease
except G. lamblia and D. fragilis
= Pathogenic Trichomonads:
1. Trichomonas vaginalis - found in the urogenital tract
2. Trichomonas tenax - commensal found in the mouth

Giardia lamblia Life Cycle:


• a protozoan flagellate considered as one of the more Ingestion of viable cyst (infective stage) → cyst undergo
common cause of infectious diarrhea throughout the excystation in duodenum → becomes a trophozoit → colonize
world mucosa of duodenum →
• Synonym: Cercomonas intestinalis Reproduce by binary fission → encystations in the large
Megastoma enterica intestine → cyst in feces
• Geog. Dist: Worldwide (tropical and subtropical region)
• Disease: Giardiasis, Lambliasis, Traveler’s diarrhea Epidemiology:
Giardiasis
• Morphology: exhibit the trophozoite and cyst stages • most prevalent disease in areas with poor
• Trophozoite: environmental sanitation and personal hygiene
- found in diarrheic stool • one of the most common cause of travelers and
- pear or pyriform shaped epidemic diarrhea
- rounded anteriorly and pointed posteriorly • considered to be a major cause of diarrheal outbreak
- bilaterally symmetrical from contaminated water supplies
- size 9-20um L X 5 - 15um W
• transmitted by fecal-oral route
- sucking disc occupying 1/2 - 3/4 of the ventral
surface (used for attachment of organism) • foods and drinks may be a source of infection

- axoneme (axostyle) found at the anterior end • all age group are affected, but attack rate is more
terminating posteriorly common in children (90%) than adult
- 4 pairs of lateral flagella, 2 ventral and 2 caudal
(enhance erratic jerky motion) or falling leaf Pathologenesis:
movement • disease may be asymptomatic or may manifest as a
self-limiting acute onset of diarrhea associated with
• 2 pairs of blepharoplast: 1 pair at anterior end 1 pair at
nausea, anorexia and crampy abdominal pain
caudal end
• 2 oval-shaped nuclei with large central karyosome on • diarrheic stool is non-bloody, foul smelling and
each side near the anterior end steatorrheic (fatty stool) containing large amount of
• 2 deeply stained (parabasal bodies) found posterior to fats and mucus → Malabsorption syndrome
the sucking disc
Lab. Diag:
1. Stool examination (unstained preparation)
• demonst. pear-shaped body with progressive
falling leaf motility - trophozoite
2. Intestinal biopsy
• shortening and blunting of intestinal villi due to
mucosal invasion of the organism
3. String test (Entero test); Fecal antigen test
4. Serological – ELISA, Immunofluorescence test

Treatment: Metronidazole (Flagyl) - DOC 40mg TID for 7


days

Prevention and Control:


• proper disposal of human excreta to prevent
contamination of water supply
• protect food from contamination (from infected food
handlers and flies)

Dientamoeba fragilis
Geog. Dist: Cosmopolitan
Cystic stage: Morphology:
= ovoidal/ellipsoidal – shaped • only trophozoite stage known
= thick wall and doubly contour • very small with an ave. size of 5-12um dia.
= size 8-12um L X 7 - 10um W • nuclear membrane without peripheral chromatin
= contains 2-4 nuclei located at one end • majority are binucleated (2 nuclei) with large central
= axoneme, parabasal bodies and other remnant organelles karyosome composed of 4-8 chromatin granules
of the trophozoite are also found inside the cyst arranged symmetrically
• Habitat: duodenum and jejunum • motility non-progressive and very active in a freshly
passed stools
• cytoplasm finely granular and vacuolated with
ingested bacteria and other debris

Epidemiology:
• habitat: mucosal crypt of large intestine
• oral transmission not established
• commonly associated with ova of E. vermicularis
• infective stage Trophozoite
Cyst:
Pathogenesis and Symptomatology: • found in formed or semi-formed stools

• pathogenicity disputed
pear/lemon-shaped rounded anteriorly with anterior
hyaline knob/nipple-like protuberance (very prominent)
• does not invade tissue but causes superficial irritation • measures 7 – 10um L X 4.5 – 6um W
of the intestinal mucosa resulting in excess secretion of
• cyst wall thicker at the anterior end
mucus, hypermotility of bowel and diarrhea
• rudimentary cytostome with prominent cytostomal
• abdominal ternderness and pain are also present
fibrils curving posteriorly around the cytostome which
• anal pruritus has been observed
resembles a “shepherd crook”
• all manifestation are referred to as Dientamoebiasis or • single spherical nucleus with central karyosome
Hakanssons syndrome

Diagnosis: Direct fecal smear of diarrheic stool stained with


iron-hematoxylin

Treatment: Iodoquinol
Tetracycline (alternate drug)

Prevention: Same with amoebiasis

NON – PATHOGENIC FLAGELLATES

Chilomastix mesnili

Synonym: Cercomonas intestinalis


Macrostoma mesnili
Pathogenesis and Epidemiology:
Geog. Dist: Worldwide (more prevalent in warm than in) cool • considered as normal inhabitant of cecal region of the
climate large intestine (harmless parasite)
• transmission thru ingestion of cyst in food or drinks
Morphology: exhibit both trophozoite and cyst stage contaminated with human feces
Trophozoite: • prevalence rate in the Phil. is less than 1%
• found in diarrheic or liquid stools
• assymetrically pear-shaped/elongate rounded flattened Lab. Dx: Stool examination
anterior end and pointed posterior end measures 6 – - diarrheic stool – trophozoite
20um L X 3-10u W - formed stool – cyst
• body marked externally by a spiral groove across the - semi-formed – both
ventral surface (diagnostic feature) Treatment: None
• cytoplasm finely granular and vacuolated
• cytostome large, cleft-like and occupies the anterior Prevention: Good sanitation and personal hygiene reduce
half of the body incidence of infection
• single nucleus with minute central or eccenteric
Trichomonas hominis
karyosome
Synonym: Cercomonas hominis
• 3 pairs of blepharoplast near the anterior pole of Trichomonas confusa
nucleus from where the flagellae arises
• 2 short anterior flagella and 1 short posterior flagellum Geog. Dist: = Worldwide; most common intestinal flagellates
lying near the cytostome found in humans; has little evidence of
pathogenicity for human
• motility is progressive and boring spiral forward Morphology:
movement • exhibit trophozoite stage only
• no undulating membrane and axostyle • pear-shaped, rounded anterior and pointed posteriorly
• size 7-15um L X 3-4um W
• cytostome at ventral side near the ant. end of the
body
• single nucleus with small central karyosome near the
• 2 blepharoplast adjacent to the nucleus which gives
• anterior end close to the margin of the anterior flagella
rise to 3 anterior flagella w/c enhance jerky forward
• chromatin granules unevenly distributed movement and 1 posterior flagellum
• cytoplasm finely granular and vacuolated • no cytostome
• blepheroplast lying between the nucleus and anterior
end of the body giving rise to the flagella, axostyle and • entire cytoplasm vacuolated and contains numerous
undulating membrane bacteria
• 4 anterior flagella (serves for propulsion) and recurrent
flagellum that runs to the posterior end and forms the Cyst:
outer edge of the undulating membrane  elongate-ovoidal shaped
• axostyle (slender rod) extend through the body from  6-8um W X 5um L
anterior to the posterior end and protrudes as a sharp  cyst wall well-defined
pointed tail (diagnostic)  contains 1-4 nuclei usually 2 lying at opposite end
• undulating membrane at the dorsal surface of the body  resembles E. nana cyst
and impart the rotatory motion of the organism (jerky
non-directional)

Pathogenesis and Epidemiology:


• parasites is a commensal in the cecal region of the
large intestine
• no proof provided of its pathogenicity
• infection is the result of ingestion of cyst from
contaminated food and drink

Lab. Diag.: Demonstration of characteristic trophozoite and


Pathogenesis and Epidemiology: cyst by stool exam
 evidence of pathogenicity insufficient, however
organism is always associated with diarrhea Treatment: = None (no therapy indicated)
 acquired through ingestion of food and drinks
contaminated with the trophozoite Prevention: Good personal and community hygiene

Lab. Diag.: Stool Examination Retortamonas intestinalis


• demonstration of trophozoite from diarrheic stool Synonym: Waskia intestinalis
Embadomonas intestinalis
(jerky, non-directional movement of the undulating)
membrane and protrusion of the axostyle
Geog. Dist.: China, Malaysia, Philippines, Egypt, Brazil, USA
and probably cosmopolitan in warm climates
Rx: No indication for specific treatment
= harmless commensal of the intestine of man
Prevention:
Morphology: exhibit both trophozoite and cyst stage
1. Improvement of community sanitation
2. Personal hygiene
Trophozoite:
Enteromonas hominis • pear/oval shaped attenuated posteriorly
Synonym: Trichomonas intestinalis • size from 4 – 10um L X 3-4um W
• nucleus, single and large at the anterior end with
Geog. Dist: Worldwide; more widely distributed central karyosome
throughout tropical • lateral to the nucleus is a pair of blepharoplast giving
areas and temperate region rise to 2 flagella (1 long anterior and 1 short) posterior
flagellum
Morphology: exhibit both stages: Trophozoite and Cyst • cytoplasm finely granular and vacuolated
• prominent cleft-like cytostome at the anterior end of
Trophozoite: the body about half of the length of the organism
• pear/oval shaped with one side flattened
• measures 4-10uL X 3-6u W (small flagellate)
• single nucleus near the anterior end of the body with
central karyosome
troph

cyst

Cyst:
• pear/pyriform shaped
• cyst wall thick and doubly contoured
• measures 4-7um L X 5um W
• contain a single large nucleus with central karyosome
• 2 fibrils extending from the nuclear region to the
attenuated end giving a characteristic bird beak fibrillar
arrangement (diagnostic)

Pathogenesis and Epidemiology:


Disease: Trichomoniasis
Pathogenesis and Epidemiology: • one of the most common sexually transmitted
• no evidence of its pathogenicity infection seen in women worldwide
• commonly discovered in diarrheic stool • acquired sexually, direct contact with infected person,
• transmission is from hand to mouth thru contaminated contaminated toilet seats, passage through an infected
food or drinks birth canal
• often asymptomatic but frequency of symptomatic
Diagnosis: Direct microscopy of fresh stool specimen disease is highest among sexually active women in
their 30’s and lowest in post menopausal women
Treatment: None (no indication for treatment parasite is
commensal)
• habitat: vagina and urethra (female), prostate, seminal
vesicle and urethra (male)
Prevention: Good personal and community hygiene
Clinical Manifestation:
Trichomonas vaginalis (Female)
• a urogenital flagellate • profuse watery to creamy foul smelling greenish
• closely related to T. hominis vaginal discharge accpd. with burning and itching
sensation
• differ from T. hominis by having a short undulating
• vaginal mucosa and cervix diffusely hyperemic with
membrane that extend about half of the distance to the
bright red punctate lesion (strawberry cervix)
posterior end
• urinary frequency and dysuria are common symptoms
• produce a cell detaching factor that causes
detachment and sloughing of vaginal epithelial cell
(Male)
Morphology: • usually asymptomatic
• exhibit the trophozoite stage only • about 10% of infected men have urethritis with thin
• pear-shaped, measures 8-30um L X 3-17um W urethral discharge
• prostate enlarged and tender associated with
• single, elongated nucleus with large central karyosome
inflammation of the epididymis
• 4 anterior flagella & 1 posterior flagellum which forms
the free margin of the undulating membrane (no free Lab. Diag.:
flagellum beyond the undulating membrane) 1. Direct microscopy of wet mount preparation
• axostyle slender and project posteriorly = demonstrate the pear-shaped trophozoite in typical
• parabasal body well-defined jerky motion
• small cytostome at anterior end 2. Culture (Feinberg – Whittington or Modified Diamond’s
• cytoplasm contains large amount of siderophil med.)
granules 3. Serological - DOT - blot DNA hybridization assay (more
• motility jerky, non-directional effective than microscopic exam) PCR

Rx: Metronidazole for both partners to prevent re-infection


= restoration of the normal acid pH of vagina
= periodic vaginal douches

Prevention:
• good personal hygiene
• detection and treatment of infected males
• condom limits transmission
• no prophylactic drug or vaccine available

Trichomonas tenax
Synonym: Trichomonas buccalis
Trichomonas elongata

Geog. Dist.: Worldwide


Morphology: exhibits trophozoite stage only

Trophozoite:
• pear/pyriform-shaped
• size 5-12um L (smaller & slender than T. vaginalis)
• single nucleus with few chromatin granules
• possesses 4 anterior flagella of equal length and 5th
flagellum runs along the margin of the undulating
membrane (resp. jerky rapid motility)
• presence of costa with the same length as the
undulating membrane
 a single blepharoplast
 parabasal apparatus lies near the nucleus
 thick axostyle protrudes beyond the posterior end
 cytoplasm is delicately granular

Pathogenesis and Epidemiology:


• considered as harmless commensal of the human
mouth feeding on microorganisms and cellular debris
• most abundant between the teeth and gums, tooth
cavities, pyorrheal pockets and tonsillar crypt.
• can also be found in the trachea and lungs
• MOT: through kissing, use of utensil during eating or
drinking water (parasite can live for several) hours in
drinking water

Lab. Diagnosis: Direct microscopy

Treatment: None (no specific treatment)


= directed to the underlying condition if any

Prevention: Good oral hygiene (eliminate/decrease infection)