2.

Medical Protozoology

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 2.1. introduction to protozoa
Definition
protozoa:
• Single celled eukaryotic organisms
• Vary in size ( 1 - 150µm)

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Protozoa are extremely diverse organisms and found
in a variety of niches
Most species are free-living in
 Freshwater
 marine environments
 decaying organic matter and soil
Few are adapted to a parasitic life
Adapted to life in a wide range of sites within the host

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Ecological Niches of protozoa
Skin: Leishmania

Eye: Acanthamoeba

Mouth: Amoebae and flagellates (usually non-

pathogenic)

Gut: Amoeba, Giardia, Cryptosporidium, Isospora,

Balantidium

Urogenital tract: Trichomonas

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Ecolo…

Bloodstream: Plasmodium, Trypanosoma

Spleen: Leishmania

Liver: Leishmania, Amoeba

Muscle: Trypanosoma

CNS: Trypanosoma, Toxoplasma, Plasmodium

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Basic properties of protozoa
A. Locomotion
Structures that mediate movement:

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 Basic Prop…
B. Reproduction

Binary Fission
Asexual
Reproduction Multiple Fission

Endodyogeny

Conjugation
Sexual
Reproduction

Singamy

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Basic Prop…
C. Feeding
Most parasitic protozoa are heterotrophic
Phagocytosis
Engulfment of solid material
predation on bacteria or other protozoa
Pinocytosis
Invagination of membrane surrounding liquids
Peristome or cytostomal feeding
Food is ingested at a definite site, using a specialized
feeding structure
Diffusion =absorb solutes (osmotrophy) through cell
membrane

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 Basic Prop…

D. Excretion
• Undigested particles and wastes are extruded at the
cell surface by mechanisms that are the reverse of
those used in ingestion

– diffusion (primary mechanism)

– contractile vacuole

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 Taxonomy of protozoa

Protozoa Organ of Important

Locomotion example
1.Sarcodina(amoeba) Pseudopodia E.histolytca…

2. Mastigophora Flagella Giardia,

(flagellates) Trypanosomes…

3. Apicomplexa None Plasmodium spp.

(sporozoa)

4. Ciliophora Cilia Balantidium coli

(ciliate)
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 Sarcodina (Amoeba)
Classification of Amoeba
Amoeba (plural amoebae)= Moves by means of pseudopodia
I - pathogenic:
 Intestinal amoeba: Entamoeba histolytica (E. histolytica)

II - non pathogenic:
 Amoeba resides in the oral cavity : E. gingivalis
 Intestinal amoeba: E. coli, E. Dispar, E. hartmanni, E. polecki
Iodamoeba buetschlii , Endolimax nana

III -Free living pathogenic Amoeba

 Naegleria species, Acanthamoeba species 11
 Pathogenic amoeba

Entamoeba histolytica

 Causes amoebic(amebic) dysentery

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Geographical distribution
• Cosmopolitan distribution
• More frequent in poorest areas:
- bad management of waste, and drainage systems

• Worldwide incidence = 0.2-50%(tropics)

500 million people infected worldwide

100,000 deaths annually

The third most common cause of death from parasitic

disease 13
• In Ethiopia
 Amoebic (Amebic) dysentery is one of the most
commonly reported infections
 However, this data was obtained based on non-
specific and non-sensitive diagnosis

 In 50 rural school populations in the highlands of

Ethiopia : mean infection rate 19%

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 Habitat:

• Trophozoites
– dwell in the lumen or wall of the colon, liver and
other extra intestinal organs
– feed on bacteria and tissue cells
– When diarrhea occurs, the trophozoites are passed in
the liquid stool

 Cyst
 Found in the colon (in the stool of chronic
patients & carriers)
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Characteristics:
Trophozoite
 Motile , actively feeding , multiplying form
 Susceptible to destruction outside the host
 Pathogenic form
Cyst
 Non-motile form, non feeding or dormant stage
 Protected by a distinct membrane or a cyst wall (resistant
stage)
 infective or transmissible form
(Infective stage)

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Distribution of protozoa in relation to stool consistency

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 Transmission

• Ingestion of mature cyst (tetranucleated cyst)

from contaminated hands ,food or water

Humans are the only reservoir excreting

up to 15- 45 million cysts per day
Mature cysts can survive in environment:
• temp up to 55°C,
• Normal Chlorine concentration,
• gastric acid
 Life cycle
 Ingestion of tetranucleated cyst (infective stage),

• In response to gastric acid, ingested cysts release

metacyst trophozoites(Excystation)
 in the small intestine

• Trophozoites migrate to large intestine

 feed, grow & multiply by binary fission

• Produce cysts, which are passed in the feces.

Amoeba

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Important terms used in relation to amoeba

Encystation
 The process of formation of the cyst from the
trophozoite
Excystation
The process of emergence of the trophozoite from
the cyst
Metacyst
The trophozoite which emerges from the cyst

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 Life cycle…

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PATHOGENESIS AND PATHOLOGY OF AMEBIASIS

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 Patho…
INVASIVE
 Trophozoites invade tissues by:
Penetration of mucus layer

Contact-dependent killing of epithelial cells

Breakdown of tissues (extracellular matrix)

Contact-dependent killing of, leukocytes

 necrosis of mucosa  ulcers, dysentery

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 Patho…
NON-INVASIVE
Trophozoites colonize , adhere to the mucus layer and
ingest bacteria and cellular debris from the lumen
Usually asymptomatic
Exhibits symptoms ranging from mild abdominal
discomfort to non-dysenteric diarrhea and cramps

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 Patho..

• The first evidence of amebic pathology is depletion of

intestinal mucus and disruption of the epithelial
barrier, which results from the action of cysteine
proteinases.

• Cysteine proteinases degrade the extracellular matrix

( collagen, elastin, laminin.. ) in order to cause invasive
disease

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 Patho…
 The cytolytic effect of amebas appears to require
direct contact with target cells and may be linked to
the release of phospholipase A and pore-forming
peptides.

• Pore-forming peptides can insert in to the lipid bilayers

of target cells, forming ion channels

• Target cells die due to necrosis with cell swelling,

rupture of plasma membranes, and release of cell
contents including nucleic acids.
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 Patho…
• Ulcers are usually
- raised,
- a small opening on the mucosal surface and
- a large area of destruction below the surface,
i.e., “flask shaped.’’

• The mucosal lining may appear normal between

ulcers
• Invasion of the colonic intestinal epithelium by
trophozoites leads to the formation of the flask
shaped ulcers.
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• ulcers with raised borders
• The mucosal lining may appear normal between
ulcers

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Ulcer Enlargement can lead to secondary bacterial
infection and extraintestinal infection

•Ameoba lesion expand laterally and downward

•Localized sloughing
•Perforation of intestinal wall
- Peritonitis
- 2o bacterial infections
• Ameboma (amebic granuloma)
( Rarely, intestinal infection results in the formation ameboma )
Ameboma = inflammatory thickening of intestinal wall around
the abscess (can be confused with tumor colonic cancer in
appearance)
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Lateral and downward expansion of amoeba
- Localized sloughing

- Perforation of intestinal wall

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Gross pathology of large intestine due to Entamoeba
histolytica

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Extraintestinal amebiasis
• Metastasis via blood stream
• Primarily liver (portal vein)

• Amoeba-free stools common

• High antibody titers

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Amebic liver abscess
• The most common form of
extraintestinal amebiasis

• Symptoms are right upper

quadrant pain and fever

• Fast growing abscess filled

with:
• chocolate-colored ‘pus’
• necrotic material
• usually bacteria free
• amoebae are found
only at borders

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Amoebic liver abscess
• 30-50% of patients with liver
abscess show also
pneumonic involvement

• Rupture is again a major

threat, especially rupture
into the pericardium

• Draining abscesses is today

only performed in extreme
cases when rupture is feared
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Pulmonary Amebiasis

• rupture of liver abscess

through diaphragm
• fever, cough, dyspnea,
pain

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Cutaneous amebiasis and recto-vaginal fistulas

• From intestinal or hepatic fistula

• mucosa bathed in fluids containing trophozoites
• perianal ulcers
• urogenital (eg, labia, vagina, penis)
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CLINICAL MANIFESTATION
• Intestinal Symptoms
• range
• mild to intense, transient to long lasting
• Non dysenteric
• Diarrhea, - cramps,
• Flatulence, - nausea

• Dysenteric
• blood/mucus in stools
• cramps/pain, tenesmus
• Ameboma
• palpable mass, obstruction

• Liver symptoms
– Symptoms are similar to hepatitis

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 Clinical Syndromes
Associated with Amebiasis
Intestinal Disease
 asymptomatic cyst passer
 symptomatic nondysenteric
infection
 amebic dysentery
 fulminant colitis
 + perforation (peritonitis)
 ameboma (amebic granuloma)
 perianal ulceration

Extraintestinal Disease
 liver abscess
 pleuropulmonary amebiasis
 brain and other organs
 cutaneous and genital diseases
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• Differential diagnosis of acute amebic colitis
- shigellosis
- salmonellosis
- envasive Escherichia coli
- Campilobacter sp. …
Laboratory diagnosis
1. Microscopic examination of faecal specimens
Trophozoite: motile in fresh stool specimen (diarrhea)
Cyst : in formed and Semi- formed stool

2. Immunodiagnosis
 Antigen detection
 Antibody detection
3. Molecular techniques
4. Culture

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 1.Microscopic examination of faecal specimen
 Examination of fresh diarrheic or dysenteric faecal
specimen for motile trophozoites
- Saline wet mount

 Examination of formed or semi-formed faecal specimen for cysts

- Iodine wet mount

- Saline wet mount
(To maximize recovery of cyst stool samples
should be concentrated prior to microscopic
examination).

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Cysts of amoeba

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 Treatment
Asymptomatic carrier (cyst passer )
- luminal agents:
 Iodoquinol
 Paromomycin
 Diloxanide furoate
Colitis and liver abscess should be treated with:
- metronidazole plus luminal agent or
- Tinidazole plus luminal agent

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 Prevention and Control
• Prevention and control of amebiasis requires
interruption of the fecal-oral spread of the
infectious cyst stage of the parasite by improved
hygiene, sanitation and water treatment.

• Cysts are normally removed by

- Sand filtration
• Destroyed by
- 200 ppm of iodine
- Boiling
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Prevention and Control
1. Avoid consumption of raw vegetables or other uncooked foods which
main contain cysts, usually as a result of fertilization with untreated
human faeces
2. Hand washing after defecation and before eating
3. Preventing water supplies from becoming faecally contaminated
4. Control of mechanical vectors
5. Avoid use of night soil as a fertilizer and proper sanitary disposal of
faeces
6. Treatment of infected individuals and health information dissemination

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 • Non pathogenic amoebae in the human intestine

Entamoeba dispar
Entamoeba coli
Entamoeba hartmanni
Entamoeba polecki
Endolimax nana
Iodamoeba bütschlii

• Non pathogenic amoeba in the oral cavity

Entamoeba gingivalis

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 Entamoeba dispar

• A non-invasive protozoan
• Has recently been separated from E. histolytica
• Morphologically identical with E. histolytica but
genetically distinct species

• The predominant cause of colonization in many

asymptomatic 'cyst-passers'

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Free-Living Pathogenic
Amoeba

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 Free-Living Pathogenic Amoebae

Are large and diverse group, inhabiting fresh,salt

water, moist soil, and decaying vegetation

Usually free living

Include:
Naegleria fowleri
Acanthamoeba spp

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Free-Living…

• Naegleria and Acanthamoeba cause diseases mainly of the

central nervous system of humans and animals, leading
almost always to death

• Naegleria Fowleri is known to cause the disease, primary

amebic meningoencephalitis (PAM) in humans

• Acanthamoeba species have been identified as agents of the

granulomatous amebic encephalitis (GAE) in humans and
other animals

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 Naegleria Fowleri

Transmission
Infection:- through nasal cavity by inhalation or aspiration of
water contaminated with trophozoites while:
- bathing or swimming in stagnant water/lakes/pools

 The organism then penetrate the nasal mucosa and migrate via
the olfactory nerves to the brain
 Causes Primary Amoebic Meningoencephalitis (PAM)

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Naeg…
Laboratory Diagnosis
Definitive diagnosis: demonstration of trophozoites
in CSF or biopsy specimens

CSF analysis shows:

- Leukocytosis

- Increased protein concentration

- Decreased glucose concentration

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Naeg…
Prevention and Control
-No easy solution for controlling:
- Because of its extensive distribution and its ability to
withstand adverse environmental conditions

1. Avoiding contact, swimming and sniffing in waters of ponds,

lakes
2. Treatment of water
3. Proper sewage disposal
4. Treatment of infected individuals and health education

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 Acanthamoeba spp
Transmission

 Trophozoites ( sometimes cysts) are believed to gain entry into

the body through:
- lower respiratory tract
- ulcerated or broken skin

 Infection usually reaches the CNS hematogenously from the

primary site, the skin or lung

 Entry can also occur through the eye

(direct invasion of the eye )

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Causes:
A- Granulomatous amebic encephalitis (GAE)
B- Amebic Keratitis

 Deeper corneal invasion and loss of vision may follow

Laboratory diagnosis
Finding trophozoites in
- CSF specimens

Finding trophozoites and cysts in

- stained smears of biopsy specimens
brain tissue, corneal scrapings

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• Prevention and Control
- As described for Naegleria