INTESTINAL & UROGENITAL SYSTEM

PROTOZOA
(AMOEBA, FLAGELLATES & CILIATES)

Dr. Cemile Bagkur

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Intestinal and Urogenital System Protozoa
• Pathogenic Commensal

• Entamoeba histolytica Entamoeba hartmanni

• Balantidium coli Entamoeba coli

• Giardia lamblia Entamoeba dispar

• Dientamoeba fragilis Endolimax nana

• Cryptosporidium parvum Iodamoeba bütschlii

• Enterocystozoon bieneusi Chilomastix mesnil

Cyclospora cayetenensis Blastocystis hominis

• Isospora belli Trichomonas hominis

• Trichomonas vaginalis
AMOEBA
Entamoeba histolytica
• Causative agent of the disease Amoebiasis (Amoebic Dysentery).

• Dogs, cats and primates may be infected.

• Parasite is primarily a human parasite and can be transmitted from human to human.

Epidemiology
• 10% world population is infected with Entamoeba histolytica/dispar.

• Majority with non invasive E. dispar

• 90% infections are asymptomatic

• 10%  symptomatic

• Amoebiasis is the fourth most common cause of death from parasite disease.
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Entamoeba histolytica
Transmission
• Two forms;

• Cyst

• Trophozoite

• Infective form is the cyst.

• Fecal-oral route!

• Ingestion of food & water contaminated with cyst.

• Sometimes through arthropods.

Entamoeba histolytica
Cysts
• Infective form.

• Cyst wall is resistant to environmental conditions.

• Can be detected in hard stool, can not be detected in watery diarrhea.

Entamoeba histolytica
Trophozoite
• Motile form.

• Causes ameobiasis (disease causing form).

• Can spread to the body.

• Rarely can be responsible of transmission.

• Motile in diarheal stool.

• Trophozoites colonize the large intestine and

invade the mucosa.
• Trophozoites may live and multiply
indefinitely within the crypts of the large
intestine mucosa feeding on starches and
mucous secretions.
Entamoeba histolytica
Cyst Trophozoite

Thick walled Plasmalemma (Thin)

1-4 circular nucleus 1 circular nucleus

Spherical (14 – 20 µm) Irregular (12 – 17 µm)

Entamoeba histolytica
Clinical features
• Three clinical forms of amoebiasis

1. Asymptomatic amoebiasis

2. Intestinal amoebiasis

3. Extraintestinal amoebiasis
• hepatic

• pulmonary

• cerebral

• genitourinary
Entamoeba histolytica
Patogenesis
• Trophozoites settle in the colonic epithelium, secret enzymes that cause

ulcers and necrosis.

• Causes dysentery (Bloody diarrhea).

• Spreads via blood and lymphatic system

• Causes abscess in extra-intestinal sites

Entamoeba histolytica
• Asymptomatic infection (Cyst spreaders)

• Most frequent

• Asymptomatic for weeks to months

• Self-limited

• Two species

• E. histolytica (pathogen)

• E. dispar (non-pathogen)
Entamoeba histolytica
• Intestinal Amoebiasis

• Two types;

• Acute dysenteric

• Chronic non-dysenteric (self-limited, porter state)

• Colitis is the most common form of disease associated with amoebae.

Entamoeba histolytica

• Chronic amoebiasis (carrier)

• Intermittent diarrhea, mucus, abdominal pain and/or weight loss

• Trophozoites in stool (rarely cyst).

• Ulceration can lead to secondary infection and extraintestinal

lesions.
Entamoeba histolytica
• Extraintestinal amoebiasis

• Amoebic liver abscess (ALA)

• Amoebic pulmoner abscess

(APA)

• Cerebral amoebiasis

• Spleen and cutaneous

amoebiasis

• Amoebiasis of the skin

• …
Entamoeba histolytica
Diagnosis
• Trophozoite, cyst examination (stool)

• Should be differentiated from non-

pathogenic amoeba.
• Concentration methods; cyst

• Trichrome staining

• Sigmoidoscopy

• Serologic tests (for chronic cases)

• Stool Antigen Test (ELISA E.

histolytica adhesine)
• Molecular (PCR, Real time PCR)
Entamoeba histolytica
Treatment
• For asymptomatic infections,

• iodoquinol, paromomycin, or diloxanide furoate (limits the spread

of cysts).
• For symptomatic intestinal disease, or extraintestinal infections (e.g.,
hepatic abscess),
• metronidazole or tinidazole,

• immediately followed by treatment with iodoquinol, paromomycin,

or diloxanide furoate.
Entamoeba histolytica
Prevention & Control
• Diagnose and treat patients

• Wash hands with soap & water at least 10 seconds after using toilet or
changing baby diaper
• Clean bathroom & toilets often

• Avoid sharing towels

• Avoid eating raw vegetables or wash them well

• Boil water or treat with iodine tablets or filter (0.22 filtration)

• Prevent food contamination with stool

FLAGELLATES
Giardia intestinalis
• Giardia lamblia
Giardia intestinalis Same organism
Giardia duodenalis

• Intestinal flagellate

• Inhabit duodenum, jejunum of humans

• Trophozoit and cyst forms

• Multiplies by binary fission.

Giardia intestinalis

Epidemiology
• Worldwide distribution, ~200 million/year

• More prevalent in warm climates and children

• Transmitted by contaminated food and water

• Most common identified cause of water-borne disease

• Causes diarrhea and malabsorption.

Giardia intestinalis
• Trophozoite

• Symetrical

• Resembles a “badmington racket”

• Two oval nuclei, four pairs of flagella

• Attaches to host tissue with a disc-like structure

• Cysts

• Oval shaped

• Four nuclei usually located at the anterior end

• The flagella and adhesive disk are lost as the cyst

matures
• Infective stage
Giardia intestinalis
Patogenesis
• Cysts are infective.

• Transmission through contaminated

water or food.

• Trophozoite emerges in the small

intestine, rapidly multiplies and

attaches to the small intestinal villi.

• Infective cysts pass in feces and

spread.
Giardia intestinalis
Clinical features
• Varies from asymptomatic carriage (90%) to severe diarrhea and malabsorption.

• Acute giardiasis: 1 to 14 days incubation period and usually lasts 1 to 3 weeks.

• Watery diarrhea (no blood in the stool)!

• Epigastric pain, bloating, anorexia, nausea and vomiting could be seen.

• In chronic giardiasis the symptoms are recurrent and malabsorption and

debilitation may occur.
• Villous atrophy may interfere with the absorption of food, deficiency of fat and
fat soluble vitamins
• Steatorrhea (fatty stool).
Giardia intestinalis
Laboratory Diagnosis
• Identification of cysts or trophozoites in the feces using direct mounts as
well as concentration.
• Trophozoites may be found in fresh watery stool.

• Repeated samplings may be necessary (6 times)!

• Duodenal biopsies may demonstrate trophozoites.

• Antigen detection tests by ELISA and immunofluorescence can be

alternatives.
Treatment
• Human infection is conventionally treated with metronidazole, tinidazole
or nitazoxanide.
 Human Trichomonas Species
• T. vaginalis uro-genital tract
• T. tenax oral cavity
• T. hominis large intestine

• Tissue flagellate
• Inhabit genitourinary tract
• Only trophozoite form!
• Multiply by binary fusion.
• Trophozoite is sensitive to external conditions.
• Only in humans; no animal reservoir.
Trichomonas vaginalis
Epidemiology
• Cosmopolitan, found in 3-5% of female

• Transmitted by sexual contact and direct contact with contaminated

urine.

• Sharing clothing/linens; sharing of wash cloth, etc.

• Can live in moist clothing for one day!

• Increased in STD clinics and prostitutes.

• Males are the main “vectors”.

• Can persist for 2 years in host.

Trichomonas vaginalis
Clinical Features
• Causes degeneration and desquamation of local tissues.

• It is more common in women and hard to find in men, because most are
asymptomatic.
• In men

• Rarely pathogenic

• May produce mild urethritis and prostatitis

• In women

• Experience symptoms;

• Ranges from chaffing, itching to frothy, yellow-green creamy vaginal discharge

with a strong odor (leukorrhea)
• Discomfort during intercourse and urination
Trichomonas vaginalis
Diagnosis
• From vaginal and urethral secretion in
women
• From anterior urethral or prostatic
secretions in men
• Stained or unstained microscopic
examination
• With wet mounts detecting actively
motile organisms
• Culture is the most sensitive method, but
results in 3 to 7 days and not available in
every lab.
Trichomonas vaginalis

Treatment
• Flagyl- 3 times a day for 4-5 days.

• Reinfection can happen almost immediately.

• Partners must be treated together.

CILIATES
Balantidium coli
• Large protozoa (40-70 µm).

• Presence of cilia on the cell surface.

• Presence of a cytostome.

• Presence of a macronucleus, which is often visible and a smaller micronucleus.

Epidemiology
• Worldwide

• Pigs are reservoir.

• Human infected in areas where pigs are raised.

• Rodents and non human primates are other potential reservoirs.

• Only ciliate that infect human!

Balantidium coli
• Cysts are responsible for transmission

through contaminated food and water.

• Excystation occurs in the small intestine.

• Trophozoites colonize in the large

intestine.

• Replicate by binary fission, during

conjugation.

• Trophozoites undergo encystation to

produce infective cysts.

• Mature cysts are passed with feces.

Balantidium coli
Clinical Features
• Most cases are asymptomatic.

• Indistinguishable from amoebic dysentery.

• Similar flask-shaped ulcers in submucosa.

• Persistent diarrhea, occasionally dysentery, abdominal pain, and weight

loss.
• Symptoms can be severe in debilitated people.

• Ileum, colon and rectum are the mostly affected parts.

• Not found in any other visceral organs.

• Main complication is perforation!

Balantidium coli
Laboratory Diagnosis
• Detection of trophozoites and cysts in stool.

• Stool specimens should be collected repeatedly, and

immediately examined or preserved to enhance detection
of the parasite.
• Trophozoites could be seen in tissue collected during
endoscopy or biopsy.
Pay attention to:
• Cilia on the cell surface and a cytostome

• Bean shaped macronucleus which is often visible

• Smaller, less conspicuous micronucleus

Blastocystis hominis
• Blastocystis is a genetically diverse unicellular
parasite of unclear pathogenic potential that colonizes
the intestines of humans and a wide range of non-
human animals.
• On the basis of molecular data, the organism has been
classified as a stramenopile. Organisms such as
diatoms, water molds are other examples of
stramenopiles.
• Inhabits the large bowel and is frequently found in
stool specimens of asymptomatic individuals.
• Some studies have linked heavy infection to
symptomatic intestinal diseases to this organism,
although this remains controversial.
Blastocystis hominis
• Blastocystis can be found in these three
forms: vacuolated (seen most commonly),
ameboid, or granular.
• The vacuolated form

• usually is spherical and variable in size

(5–20 μm).
• has a central clear area and two to four
peripheral nuclei.
• Ameboid forms with bizarre shapes may
predominate in heavy infections.
• The presence of Blastocystis should be
reported, especially when they are
numerous in the sample.
Free Living Amoeba
• Naegleria, Acanthamoeba,
Balamuthia and Sappinia are
inhabitants of soil, water and other
environmental substrates.

• They feed on other microscopic

organisms, especially bacteria and

yeasts.

• All four genera have been associated

with opportunistic infection of the

central nervous system and
Acanthamoeba causes keratitis.
Primary Amebic Meningoencephalitis
• Caused by the ameboflagellate Naegleria
fowleri.
• Typically affects children and young adults
who have been swimming or diving in
warm, freshwater lakes or pools.
• Enters the brain via the cribriform plate and
olfactory bulbs and reaches the frontal lobes.
• It produces an acute hemorrhagic
meningoencephalitis that is usually fatal
within 1 week of onset of symptoms.
• Extremely poor prognosis.

• Diagnosis is usually established at autopsy.

Primary amebic meningoencephalitis
• Trophozoites measure 10–35 μm;
have large, round, central
karyosomes.
• If exposed to warm distilled water,
convert to flagellated forms in 1–2
hours.
• Cysts are spherical, measuring 7–15
μm in diameter.
• Culture usually is performed on non
nutrient agar plates seeded with a
lawn of heat-killed or living
Escherichia coli.
Granulomatous Amebic Meningoencephalitis
• (GAE) may be caused by several species of Acanthamoeba.

• Subacute or chronic opportunistic infection of chronically ill,

debilitated, and immunosuppressed individuals.
• Leading to death in weeks to months following onset of the
symptoms.
• Spread hematogenously from primary foci in skin, pharynx or the
respiratory tract.
• Systemic infections occur in individuals with AIDS.

• May present as ulcerative skin lesions, subcutaneous abscesses, or

erythematous nodules.
Granulomatous Amebic Meningoencephalitis

• Diagnosis usually is established at autopsy.

• Culture technique could be used.

• Acanthamoeba trophozoites are larger than Naegleria, and display

needle-like filamentous projections from the cell known as

acanthopodia.

• Cysts measure 10–25 μm and are double-walled, displaying a

wrinkled outer wall (ectocyst) and a polygonal, stellate, or round

inner wall (endocyst).
Thank you for listening…