CHAPTER

12 Protozoa

LEARNING OBJECTIVES

At the end of this chapter, the student should be able to:

1. describe the general characteristics of the medically important parasitic protozoa; and
2. characterize and differentiate the parasitic protozoa as to their:
a. general features,
b. source of infection,
c. mode of transmission,
d. clinical manifestations,
e. treatment, and
f. prevention and control of infection.

Definition of Terms
Infective stage – refers to the stage of the parasite that enters the host or the stage that is
present in the parasite’s source of infection.
Pathogenic stage – refers to the stage of the parasite that is responsible for producing the organ
damage in the host leading to the clinical manifestations.
Encystation – process by which trophozoites differentiate into cyst forms.
Excystation – process by which cysts differentiate into trophozoite forms
170 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

General Properties of Protozoa

The Kingdom Protozoa consists of single celled eukaryotic organisms that are spherical to
oval or elongated in shape. The classification of these organisms is mainly based on the organ
of locomotion utilized. Not all protozoa are parasitic. Some are facultative parasites capable of
a free living state (e.g., Acanthamoeba and Naegleria). These normally reside in the soil or water
but can cause severe illness when they gain entrance into the central nervous system or the eyes.
Reproduction among the protozoa is relatively simple. Majority of protozoa divide by
means of binary fission (flagellates, ciliates, and amebae). Sporozoans reproduce through both
sexual and asexual means. Asexual reproduction is achieved through a process called merogony
or schizogony. Sexual recombination can occur, leading to antigenic and genomic variation.
Due to their small size, protozoan infections are most often diagnosed through
microscopic examination of body fluids, tissue specimens, or feces. Special stains may be used
to demonstrate the different protozoa. Most of the parasitic protozoa infections are diagnosed
by demonstrating the motile, feeding, dividing stage of the parasite called trophozoite, or the
dormant, non motile form called the cyst. The trophozoite is the motile (with pseudopods or
“false feet”) and feeding form and is the pathogenic stage. The cyst is the non motile form and
is the infective stage for most intestinal protozoan parasites, except for Trichomonas vaginalis
where cyst forms are not found.

Intestinal and Urogenital Protozoa

Subphylum Sarcodina: Entamoeba histolytica
Important properties and life cycle
Entamoeba histolytica is an intestinal and tissue ameba and is the only known pathogenic
intestinal ameba. Its life cycle consists of two stages—the non motile cyst (infective stage)
and the motile trophozoite (pathogenic stage). The trophozoite is found within the intestinal
and extra intestinal lesions, and in diarrheal stools. Cysts are usually found in non diarrheal,
formed stools
 Protozoa 171

a b
Ingested RBC Chromatoidal body
Nucleus Karyosome
Karyosome

Nucleus
Trophozoite Cyst

Figure 12.1 a Trophozoite of Entamoeba histolytica, as well as b comparison of trophozoite

and cyst morphology

Table 12.1 Comparison of E. histolytica trophozoite and cyst forms

Parameter Trophozoite Cys
Size range 8–65 μm 8–22 μm
Shape Irregular Spherical to round
Motility Yes (with finger like pseudopodia) No
Number of nuclei One One to four
Karyosome Small and central Small and central
Peripheral chromatin Fine and evenly distributed Fine and evenly distributed
Cytoplasm Finely granular Finely granular
Cytoplasmic inclusions Ingested red blood cells Chromatoid bars and diffuse
glycogen mass in young cysts

Epidemiology and Pathogenesis

Infection with Entamoeba histolytica is found worldwide but is more common in tropical
countries, especially in areas with poor sanitation. The parasite is primarily transmitted by the
fecal oral route through ingestion of the cyst from contaminated food and water. Water serves
as the major source of infection of the parasite. Sexual transmission may also occur when a man
has unprotected sex with a woman who has vaginal amoebiasis or through anal intercourse.
The ingested cyst undergoes excystation in the ileum where it differentiates into
a trophozoite (pathogenic stage). It then proceeds to colonize the cecum and colon.
The trophozoites may then undergo encystation and become converted into cysts, which are
then passed out with the feces. Trophozoites are usually recovered in the feces of patients
with active infection (diarrheic stools) while cysts are found in formed, non diarrheic stools.
The trophozoites of E. histolytica secrete enzymes that cause local necrosis producing the typical
“flask shaped” ulcer associated with the parasite. Invasion of the portal circulation may occur
leading to the development of abscess in the liver.
172 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Human ingests infective cyst

in contaminated food or water

Trophozoite
Organism excysts
in intestine—asexual
reproduction in colon
Encyst

Trophozoite passed
in liquid or soft
stool—not infective

Infective cyst Entamoeba histolytica

Hepatic abscess in formed stool only erodes intestinal wall

To liver via
circulatory system

Figure 12.2 Life cycle of Entamoeba histolytica

Disease: Amoebiasis
1. Acute intestinal amoebiasis – presents as bloody, mucus containing diarrhea (dysentery)
accompanied by lower abdominal discomfort, flatulence (release of gas), and tenesmus
(feeling of incomplete defecation). Chronic infection may occur, with symptoms such as
occasional diarrhea, weight loss, and fatigue. In some patients, a lesion called an amoeboma
may form in the cecum or in the rectosigmoid area of the colon, which may be mistaken
for a malignant tumor in the colon.
2. Extraintestinal amoebiasis – occurs when the parasite enters the circulatory system.
The most common extraintestinal form of amoebiasis is the amoebic liver abscess. This
is characterized by right upper quadrant pain, weight loss, fever, and a tender, enlarged
liver. Abscess found on the right lobe of the liver may penetrate the diaphragm and cause
lung disease (amoebic pneumonitis). Other organs that may become infected include the
pericardium, spleen, skin, and brain (meningoencephalitis)
 Protozoa 173

a b

Figure 12.3 a Solitary amebic liver abscess (arrow) and b resection of the abscess showing its
characteristic “anchovy sauce” appearance

3. Asymptomatic carrier state – occurs under the following conditions: (a) if the parasite
involved is a low virulence strain; (b) if the parasite load is low; and (c) if the patient’s
immune system is intact. In these cases, the patient presents with no symptoms but the
parasite reproduces and is passed out with the patient’s feces.

Laboratory Diagnosis
Diagnosis of intestinal amoebiasis is confirmed by the finding of trophozoites in diarrheic
stools or cysts in formed stools. The trophozoites characteristically contain ingested red blood
cells. The stool specimen should be examined within one hour of collection to see the motility
of the trophozoites. Serologic testing may be useful for the diagnosis of invasive amoebiasis.

Treatment
The drug of choice for symptomatic intestinal amoebiasis or hepatic abscess is
metronidazole. The alternative drug tinidazole is for both intestinal and extraintestinal
amoebiasis. Asymptomatic carriers should be treated with diloxanide furoate, metronidazole,
or paromomycin. Surgical drainage of amoebic liver abscess may be necessary if there is no
improvement with medical therapy.

Prevention and Control

The most important preventive measure is the observance of good personal hygiene.
This includes proper hand washing, especially for food handlers. Proper waste disposal should
be observed to avoid fecal contamination of water sources. The use of “night soil” (human feces)
for fertilization of crops must be avoided. Adequate washing and cooking of vegetables should
be observed
174 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Subphylum Mastigophora:
Giardia lamblia (Giardia intestinalis)
Important Properties and Life Cycle
Giardia lamblia is an intestinal protozoan that was initially known as Cercomonas intestinalis.
At present, the name Giardia intestinalis has gained popularity. Another name used is
Giardia duodenale.
The parasite also exists in a cyst form and a trophozoite form. The trophozoite is
pear shaped or teardrop shaped with four pairs of flagella and has a motility likened to a falling
leaf. The trophozoite has been described as resembling an old man with whiskers (“old man
facies”). It also possesses a sucking disc which the parasite uses to attach itself to the intestinal
villi of the infected human.
The cyst is typically oval and thick walled with four nuclei. The fully mature cyst contains
four nuclei with four median bodies. It divides through binary fission. Each cyst gives rise to
two trophozoites during excystation in the intestinal tract.

a b

Figure 12.4 a A typical trophozoite with four pairs of flagella and b an oval shaped cyst is
shown on the right photo

Epidemiology and Pathogenesis

Giardia lamblia has a worldwide distribution through contaminated water sources. The
disease can thus occur in outbreaks related to contaminated water supplies. About 50% of
infected individuals do not present with symptoms and serve as carriers. Other than humans,
many species of mammals may act as reservoirs. The infection is also common among
individuals engaging in oral anal contact. High incidence has been seen in daycare centers and
among patients in mental hospitals.
The parasite is primarily transmitted through ingestion of the cyst from fecally
contaminated water and food. The cyst enters the stomach and is stimulated by the gastric
acid to undergo excystation in the duodenum. The trophozoites then attach themselves to th
 Protozoa 175

duodenal mucosa through the sucking disks. Damage to the intestines is not due to invasion
of the parasite but because of inflammation of the duodenal mucosa, leading to diarrhea with
malabsorption of fat and proteins. The trophozoites may also infect the common bile duct
and gallbladder.

Figure 12.5 Life cycle of Giardia lamblia

Disease: Giardiasis
1. Asymptomatic carrier state – infection with the parasite is usually completely
asymptomatic. The infected individual unknowingly passes out the parasite with the feces
which can then contaminate water
176 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

2. Giardiasis (Traveler’s diarrhea) – infection is characterized by a non bloody, foul

smelling diarrhea accompanied by nausea, loss of appetite, flatulence, and abdominal
cramps. The symptoms may persist for weeks or months. Malabsorption of fat may
lead to the presence of fat in the stool (steatorrhea). Patients are usually afebrile.
Manifestations may vary depending on which nutrient becomes deficient due to the
resulting malabsorption. These may include deficiencies in fat soluble vitamins, folic acid,
and proteins. It is a self limiting infection, lasting one to two weeks. Relapses may occur,
especially in patients with IgA deficiency.

Laboratory Diagnosis
Diagnosis is made by the demonstration of the cyst or trophozoite (or both) in diarrheic
stools. Only cysts are isolated from the stools of asymptomatic carriers. If microscopic
examination of the stool is negative, string test may be performed which consists of making
the patient swallow a weighted piece of string until it reaches the duodenum. The trophozoites
adhere to the string and can be visualized after withdrawal of the string.

Treatment
As per recommendation of the Centers for Disease Control and Prevention in the United
States, the primary choice of treatments for G. lamblia infection are metronidazole, tinidazole,
and nitazoxanide.

Prevention and Control

The main preventive measure involves avoidance of fecal contamination of water supplies
through proper waste disposal. Drinking water should be boiled, filtered, or iodine treated
especially in endemic areas. Improvement of personal hygiene such as proper hand washing is
also recommended.

Subphylum Mastigophora:
Trichomonas vaginalis
Important Properties and Life Cycle
The parasite is a pear shaped organism
with a central nucleus, four anterior flagella,
and an undulating membrane. It exists Figure 12.6
Trophozoite of
only in the trophozoite form (infective and Trichomonas vaginalis
pathogenic). Source: Beards, 201
 Protozoa 177

Epidemiology and Pathogenesis

Trichomonas vaginalis is not an intestinal pathogen. It causes urogenital infections and
the main mode of transmission is through sexual intercourse. It has been isolated from the
urethra and vagina of infected women as well as the urethra and prostate gland of infected
men. Infection is highest among sexually active women in their thirties and lowest in post
menopausal women. Occasionally the parasite may be transmitted through toilet articles and
clothing of infected individuals. Infants may be infected as they pass through the infected birth
canal during delivery.
The parasite invades the vaginal mucosa of infected women, where they multiply through
binary fission. The trophozoites feed on local bacteria and leukocytes. In men, the most
common infection site is the prostate gland and the urethral epithelium.

Figure 12.7 Life cycle of Trichomonas vaginali

178 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Disease: Trichomoniasis
Infection in men – usually asymptomatic and men serve as the reservoir for infection in
women. In men who develop symptoms, the manifestations are those related to development of
prostatitis (inflammation of the prostate), urethritis (manifest as discharge), and other urinary
tract involvement. Persistent or recurring urethritis is the most common symptomatic form of
the infection.
Infection in women – also asymptomatic, some women may present with scant, watery
vaginal discharge. In more severe cases, the discharge may be foul smelling and greenish yellow
in color. This may be accompanied by itching (pruritus) and a burning sensation in the vagina.
The cervix appears very red, with small punctuate hemorrhages, giving rise to a strawberry
cervix. Other common symptoms include dysuria and increased frequency of urination.
Infection in infants – occurs as the infant passes through the infected birth canal of the
mother during vaginal delivery. The infected infants may manifest conjunctivitis or respiratory
infection.

Laboratory Diagnosis
Diagnosis is made by the finding of the characteristic trophozoite in a wet mount of vaginal
or prostatic secretions, urine, and urethral discharges.

Treatment
The drug of choice for treatment of trichomoniasis is metronidazole. All sexual partners
of an individual with the infection must be simultaneously treated to prevent “ping pong”
infections.

Prevention and Control

The best way to prevent infection is to practice safe sex. The use of condoms can limit the
transmission of the parasite. Health and sex education are important. Maintenance of the acidic
pH of the vagina may also be helpful.

Phylum Ciliophora: Balantidium coli

Important Properties and Life Cycle
Balantidium coli is morphologically more complex than E. histolytica. It has a primitive
mouth called a cytostome, a nucleus, food vacuoles, and a pair of contractile vacuoles.
The infective stage is the cyst and the pathogenic stage is the trophozoite, which invade
 Protozoa 179

the mucosal lining of the terminal ileum, cecum, and colon. It is the largest protozoan to
infect humans.
The trophozoites typically exhibit a rotary, boring motility (through cilia) and contain two
nuclei (a small dot like micronucleus adjacent to a kidney bean shaped macronucleus). The cyst
also contains two nuclei although the micronucleus may not be readily observable.

Epidemiology and Pathogenesis

The parasite has a world wide distribution. The most common and most important
reservoir is the pig. Monkeys may occasionally act as reservoirs of the parasite. The main
source of infection is water contaminated by pig feces and the mode of transmission is through
the fecal oral route. Person to person transmission via food handlers has been implicated
in outbreaks.
The cysts are found in contaminated water, which when ingested, undergoes excystation
in the small intestines. From there, the trophozoites travel to the large intestines where they
produce ulcers similar to those seen in amoebiasis. However, extra intestinal involvement is
not seen.

a b

Cytostome

Figure 12.8 Balantidium coli trophozoites characterized by their

large size (40 μm to more than 70 μm), and the presence of cilia
on the cell surface, which is particularly visible in a . The large
macronucleus is seen in b and a cytostome. The micronucleus is
less conspicuous.

Disease: Balantidiasis
Most infected individuals are asymptomatic. A dysenteric type of diarrhea resembling
amebic dysentery may occur in patients with high parasite load. Acute infections may manifest
with liquid stools containing pus, blood, and mucus while chronic infections may manifest
with a tender colon, anemia, wasting (cachexia), and alternating diarrhea and constipation.
Extraintestinal infection is rare and may involve the liver, lungs, mesenteric nodes, and
urogenital tract
180 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Laboratory Diagnosis
Diagnosis is based on the finding of trophozoites and cysts in the stool specimen. Due to
its large size, the parasite can be readily detected in fresh, wet microscopic preparations.

Treatment
The current recommended treatment of patients with balantidiasis involves two
and iodoquinol. Metronidazole may also be used as alternative to treat infecteddrugs—oxytetracycline

patients.

Prevention and Control

Preventive measures are similar to those for amoebiasis. These include maintenance of
sanitary hygiene, proper disposal of pig feces, and boiling of drinking water.

Blood and Tissue Protozoa

Subphylum Sarcodina: Acanthamoeba (Free living Amoeba)
Important Properties and Life Cycle
Acanthamoeba castellani, together with Naegleria, is a minor protozoan pathogen but unlike
Naegleria, Acanthamoeba usually causes infection in immunocompromisedpatients. It is a
free living amoeba that causes inflammation of the brain substance and its meningeal coverings
(meningoencephalitis). The parasite is found widely in soil, contaminated freshwater lakes, and
other water environment. It is able to survive in cold water. Like E. histolytica, the infective stage
is the cyst while the pathogenic stage is the trophozoite.

Epidemiology and Pathogenesis

There are two ways by which the parasite can be acquired—through aspiration or nasal
inhalation or through direct invasion in the eye. People acquire the infection usually while
swimming in contaminated water. Inhalation of the cysts from dust has also been shown to
occur. The trophozoites enter through the lower respiratory tract or through ulcers in the
mucosa or skin. The parasite then migrates through the bloodstream and invade the central
nervous system.
Eye infection with Acanthamoeba occurs primarily in patients who wear contact lenses.
The parasite has been recovered from contact lenses, lens cases, and contact lens solutions.
Tap water contaminated with the parasite is the source of infection for contact lens users
 Protozoa 18

Disease
1. Granulomatous amebic encephalitis – infection occurs primarily in immunocompromised
individuals. The parasite produces a granulomatous amebic encephalitis and brain
abscesses in immunocompromisedpatients. Symptoms develop slowly and may include
headache, seizures, stiff neck, nausea, and vomiting. The brain lesions may contain both
the trophozoites and the cysts. In rare instances, the parasite may spread and produce
granulomatous lesions in the kidneys, pancreas, prostate, and uterus.
2. Keratitis – infection of the cornea of the eye. Symptoms include severe eye pain and vision
problems. Loss of vision may occur due to perforation of the cornea.

Laboratory Diagnosis
Diagnosis is made by finding of both trophozoites and cysts in the cerebrospinal fluid as
well as brain tissue and corneal scrapings. Histologic examination of corneal scrapings may
also be done. Calcofluor white, a stain usually used to demonstrate fungi, may be used to
demonstrate the parasite in corneal scraping specimens.

Treatment
Pentamidine, Ketoconazole, or Flucytosine may be effective in the treatment of infection,
however, prognosis is poor even with treatment. For eye and skin involvement, topical
miconazole, chlorhexidine, itraconazole, ketoconazole, rifampicin, or propamidine may be used.
Propamidine has been documented to have the best success record.

Prevention and Control

Infection can be prevented through adequate boiling of water. Regular disinfection of
contact lenses is also advised. Contact lens wearers are also advised to avoid using homemade
non sterile saline solutions.

Subphylum Sarcodina: Naegleria

Important Properties and Life Cycle
Similar to Acanthamoeba, the parasite Naegleria is also classified as a free living protozoan.
It shares many characteristics with Acanthamoeba. The parasite is also found worldwide in
soil and contaminated water environment. Unlike Acanthamoeba, Naegleria can survive in
thermal spring water. The known pathogen worldwide is Naegleria fowleri, which is the only
amoeba with three identified morphologic forms—trophozoite, flagellate, and cyst forms.
182 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

The trophozoite exhibits the typical amoeboid motility which is described as “slug like.”
The flagellate form is pear shaped and is equipped with two flagella that is responsible for
the parasite’s jerky or spinning movement. The non motile form is the cyst. The amoeboid
trophozoite form is however the only form that is known to exist in humans.

Epidemiology and Pathogenesis

Naegleria infection is usually acquired transnasally when swimming in contaminated
water. The parasite penetrates the nasal mucosa and cribriform plate, enters the central
nervous system, and produces a rapidly fatal meningitis and encephalitis (primary amoebic
meningoencephalitis). Unlike Acanthamoeba, the parasite produces infection in otherwise
healthy individuals, usually children. In some instances, the parasite may be acquired through
inhalation of dust containing the parasite. The entire life cycle of the parasite (amoeboid
trophozoite → flagellate trophozoite → amoeboid trophozoite → cyst form) occurs entirely in
the external environment.

Disease
1. Asymptomatic infection – the most common clinical presentation in patients with
colonization of the nasal passages.
2. Primary amoebic meningoencephalitis(PAM) – the result of colonization of the brain by
the amoeboid trophozoites leading to rapid tissue destruction. Patients initially complain
of sore throat, nausea, vomiting, fever, and headache. Patients eventually develop signs of
meningeal irritation (e.g., Kernig’s sign) as well as alterations in their senses of smell and
taste. If untreated, the patients may die within one week after onset of symptoms.

Laboratory Diagnosis
Diagnosis is based on the finding of the amoeboid trophozoites in the cerebrospinal fluid.

Treatment
Treatment is ineffective because of its rapidly fatal course. However, some patients
have been shown to recover from infection due to early detection and initiation of
treatment. Treatment of choice is Amphotericin B in combination with miconazole and
rifampicin (Murray, 2014)
 Protozoa 18

Prevention and Control

There is no known means of preventing Naegleria infection other than the prevention
of contamination of water sources. Adequate chlorination of swimming pools and hot
tubs is recommended.

Subphylum Mastigophora:
Hemoflagellates Leishmania spp.
Important Properties and Life Cycle
The life cycle of the parasite involves a vector, the female sandfly of the Phlebotomus
and Lutzomyia genera. Leishmania spp. are obligate intracellular parasites. It has three
morphologic forms—the amastigote, promastigote, and epimastigote. The infective stage is
the promastigote. The promastigote form may be seen only if a blood sample is collected and
examined immediately after transmission. Epimastigotes are found primarily in the vector.
The pathogenic stage and diagnostic form is the amastigote which is found primarily in tissue
and muscle, as well as the central nervous system within macrophages and in cells of the
reticuloendothelial system.
The typical amastigote is round to oval in shape and contains a nucleus, a basal
body structure called a blepharoblast, and a small parabasal body located adjacent to the
blepharoblast. Both the blepharoblast and parabasal body are collectively known as the
kinetoplast. The promastigote is long and slender, with a kinetoplast located in its anterior end,
and a single free flagellum extending from the anterior portion.

Epidemiology and Pathogenesis

The parasite has a worldwide distribution. Natural reservoirs include rodents, ant eaters,
dogs, and cats. In endemic areas, the parasite may be transmitted in a human vector human
cycle. There are three major strains of Leishmania which differ in the tissues affected
and the resulting clinical manifestations. These are Leishmania donovani (visceral
leishmaniasis), Leishmania tropica (cutaneous leishmaniasis), and Leishmania braziliensis
(mucocutaneous leishmaniasis).
184 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Figure 12.9 Life cycle of Leishmania spp.

Leishmania donovani complex

L. donovani is the causative agent of visceral leishmaniasis (also known as kala azar
or dumdum fever). The complex consists of (1) L. donovani chagasi which is mainly seen in
Central America (mainly Mexico, West Indies, and South America) and is transmitted by
the Lutzomyia sandfly; (2) L. donovani donovani found in parts of Africa and Asia (Thailand,
India, China, Burma, and East Pakistan) and is transmitted by the Phlebotomus sandfly;
and (3) L. donovani infantum, also transmitted by the Phlebotomus sandfly and is found mainly
in Mediterranean Europe, Near East, and Africa.
The promastigote is injected into the human host through bite of the sand fly. After entry
into the host, it loses its flagella, is engulfed by macrophages, and transforms into amastigotes.
The organs of the reticuloendothelialsystem (liver, spleen, and bone marrow) are the most
severely affected
 Protozoa 18

Disease: Visceral Leishmaniasis(Kala azar, Dumdum Fever)

After an incubation period of 2 weeks to 18 months, the disease begins with intermittent
fever, weakness, and weight loss. Massive enlargement of the spleen (splenomegaly) is
characteristic, leading to hypersplenism and resulting anemia. Hepatomegaly or enlargement
of the liver also occurs. In light skinned patients, hyperpigmentation of the skin may be seen
(kala azar means “black sickness” or “black fever”). Involvement of the bone marrow leads
to destruction of the cellular components with the corresponding clinical effects—anemia
due to destruction of red blood cells, bleeding tendencies due to reduction of platelets
(thrombocytopenia), and increased risk for secondary infection because of reduction of white
blood cell (leukopenia). Glomerulonephritis or inflammation of the glomeruli of the kidney
may also occur. The disease may be fatal if untreated.

Laboratory Diagnosis
The screening test is called the Montenegro skin test. This test is similar to the tuberculin
skin test for the diagnosis of tuberculosis. It is used as screening for large populations at
risk but is not used for diagnosis. Definitive diagnosis is done by demonstration of the
amastigote from Giemsa stained slides of specimen from blood, bone marrow, lymph nodes,
and biopsies of infected areas. Culture of blood, bone marrow, and other tissues may also be
done, which will show the promastigote forms. Serologic tests are now also available such as
indirect fluorescent antibody (IFA), enzyme linked immunosorbent assay (ELISA), or direct
agglutination test (DAT).

Treatment
The present recommended drug of choice is liposomal amphotericin B (Ambisome).
Sodium stibogluconate has also been found to be effective but the development of resistance
may occur. Other patients have shown favorable responses to gamma interferon in combination
with pentavalent antimony.

Prevention and Control

Control of the vector population is important in the prevention of infection. The use of
insect repellents, protective clothing, and installation of screens may be helpful. Prompt
treatment of infected humans is essential to help halt the spread of the disease.
186 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Leishmania braziliensis complex

L. braziliensis is the causative agent of mucocutaneous leishmaniasis which involves
skin, cartilage, and mucous membranes. Infection with L. braziliensis occurs most commonly
in Brazil and Central America, primarily in construction and forestry workers. The
complex consists of L. panamensis (Panama and Colombia), L. peruviana (Peruvian Andes),
and L. guyanensis (The Guianas, parts of Brazil and Venezuela).
Infection is transmitted by sandflies (Lutzomyia and Psychodopigus) through skin bite.
The promastigotes invade the reticuloendothelial cells where they transform into amastigotes
(diagnostic stage). Reproduction of the amastigotes result in tissue destruction. The amastigotes
are taken up by the vector during a blood meal and are transformed into promastigotes.

Disease: MucocutaneousLeishmaniasis
Mucocutaneous leishmaniasis, also called espundia, begins with a papule at the site of insect
bite, then forms metastatic lesions, usually at the mucocutaneous junction of the nose and
mouth. Disfiguring granulomatous, ulcerating lesions destroy the nasal cartilage (tapir nose)
but not the adjacent bone. Death can occur from secondary infections.

a b c

Figure 12.10 Clinical manifestations of infection with Leishmania: a cutaneous leishmaniasis by

L. tropica; b mucocutaneous leishmaniasis by L. braziliensis; and c enlarged spleen in patient
with visceral leishmaniasis caused by L. donovani.

Laboratory Diagnosis
Diagnosis is confirmed by demonstration of amastigotes in clinical specimen. Ulcer biopsy
specimens are used for the diagnosis of mucocutaneous leishmaniasis. Microscopic examination
of Giemsa stained ulcer biopsy specimens reveals the diagnostic amastigotes. Culture of
infected material may show the promastigotes. Serologic testing may also be done
 Protozoa 18

Treatment
At present, the most widely used drug for the treatment of mucocutaneous leishmaniasis
is sodium stibogluconate, although resistance has been shown to develop. Alternative drugs
include liposomal Amphotericin B and oral anti fungal drugs (fluconazole, ketoconazole,
and itraconazole).

Prevention and Control

The most important preventive measure is the control of the insect vector. If this cannot be
done, measures should be undertaken to protect individuals from sandfly bites by using netting,
window screens, protective clothing, and insect repellents. Prompt treatment can also help
prevent spread of the disease.

Leishmania tropica complex

Important Properties and Life Cycle
The complex consists of L. tropica, L. aethiopica, and L. major. These are the causative
agents of what is referred to as Old World cutaneous leishmaniasis. The life cycle of L. tropica
is similar to that of L. braziliensis. All three members of the complex are transmitted by the
Phlebotomus sandfly and primarily attacks the human lymphoid tissue of the skin.

Disease: Old World Cutaneous Leishmaniasis

The disease is also known as oriental sore, and Baghdad or Delhi boil. It is characterized
by one or several pus containing ulcers that may heal spontaneously. The initial lesion is a
small, pruritic red papule at the bite site. In patients with anergy and hypersensitivity responses,
spontaneous healing does not occur. Thick skin plaques with multiple nodules may develop,
especially on the limbs and face.

Laboratory Diagnosis
Microscopic examination of Giemsa stained slides of fluid aspirated from beneath the
ulcer bed is the usual diagnostic procedure of choice. Microscopic examination reveals the
typical amastigotes. Culture of specimen will show the promastigote form. Serologic tests are
also available.
188 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Treatment
The drug of choice is sodium stibogluconate. Steroids with application of heat to the
infected lesions may be used. Other alternative drugs are meglumine antimonite, pentamidine,
and oral ketoconazole. Paromomycin ointment may be helpful in the healing of the ulcers.

Prevention and Control

Preventive measures are the same as those for the different forms of leishmaniasis.
However, unlike the other Leishmania, a vaccine has been developed against L. tropica which is
currently undergoing clinical trials.

Trypanosomaspp.
Important Properties and Life Cycle
The trypanosomes are also hemoflagellates like Leishmania. The major difference
between the two lies in their diagnostic stages, which is the amastigote for Leishmania and the
trypomastigote for the trypanosomes. The trypomastigotes are curved, assuming the shape of
the letters C, S, or U. Unlike Leishmania, the kinetoplast of the trypomastigote is posteriorly
located, with the single large nucleus located anterior to it. The trypomastigotes are visible in
the peripheral blood.

Trypanosomacruzi
Epidemiology and Pathogenesis
The parasite is found primarily in South and Central America and is transmitted by
the bite of the reduviid or triatomid bud (Triatoma or “cone nose” bug or “kissing bug”).
It is usually transferred to a human host when the feces of the bug containing the infective
trypomastigotes is deposited near the bite site. The feces are then introduced into the bite site
when the host scratches the bite area. Other routes of transmission include blood transfusion,
sexual intercourse, transplacental transmission, and through the mucous membranes when
the bite site is near the eye or mouth. Humans and animals (domestic cats and dogs, and wild
species such as armadillo, raccoon, and rat) serve as reservoir hosts.
The trypomastigotes invade the surrounding cells and transform into amastigotes.
The amastigotes then reproduce leading to destruction of host cells. These are then transformed
back into trypomastigotes, which invade the blood, penetrate other cells in the body, and
transform back into amastigotes
 Protozoa 189

Different cell types may be affected. However glial cells, reticuloendothelialcells,

and especially myocardial cells are the most frequently affected. The disease is primarily seen
in rural areas because the reduviid bug lives in the walls of rural huts and feeds at night. Acute
infection is rarely seen in the United States. Chronic infection is now seen with increasing
frequency among immigrants from Latin America.

Disease: Chagas Disease (American Trypanosomiasis)

The acute phase of the disease begins with a nodule (chagoma) near the bite site and
unilateral swelling of the eyelid with conjunctivitis (Romana’s sign). The eyelid swelling may be
due to the bug feces being accidentally rubbed into the eye. This is accompanied by fever, chills,
malaise, myalgia, and fatigue. Patients may recover or may enter the chronic phase.
Hepatosplenomegaly,enlargement of lymph nodes (lymphadenopathy), and myocarditis
with cardiac arrhythmia characterize the chronic phase of Chagas disease. Cardiac muscle is the
most frequently and most severely affected tissue. Loss of tone of the colon and esophagus due
to destruction of the Auerbach’s plexus may lead to abnormal dilatation of these organs, called
megacolon and megaesophagus, respectively. CNS involvement may also be seen in the form of
meningoencephalitisand cysts. Death may occur due to cardiac failure and arrhythmias.

a b c

Figure 12.11 a A patient with chagoma on the lower lip, b the reduviid bug, and c Romana's sig
190 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Figure 12.12 Life cycle of Trypanosoma cruzi

Laboratory Diagnosis
Acute disease is diagnosed by the finding of trypomastigotes in thick or thin films of the
patient’s blood. Other diagnostic methods that can be used include bone marrow aspiration,
muscle biopsy, culture on special medium, and xenodiagnosis. Xenodiagnosis entails allowing
an uninfected laboratory raised reduviid bug to feed on an infected patient. After several weeks,
the intestinal contents of the bug are examined for the presence of the parasite. Serologic tests
can also be helpful. Both xenodiagnosis and serologic tests are useful in the chronic form of the
disease.

Treatment
The drugs of choice for treatment are benznidazole and nifurtimox but these are less
effective during the chronic phase of the disease. Alternative agents are allopurinol and
ketoconazole
 Protozoa 19

Prevention and Control

Prevention involves protection from the bite of the reduviid bug, improvement of housing
conditions, and insect control. Education regarding the disease and its transmission is
also helpful.

Trypanosomabrucei gambiense
and Trypanosomabrucei rhodesiense
Epidemiology and Pathogenesis
The two species are similar in morphology and life cycle. Their life cycles involve the tsetse
fly (Glossina) as the vector. Humans are the reservoir for T. brucei gambiense, while domestic
animals (especially cattle) and wild animals serve as the reservoir for T. brucei rhodesiense.
The infective and pathogenic stage is the trypomastigote.
The trypomastigotes spread from the skin to the blood then to the lymph nodes and the
brain. A demyelinating encephalitis occurs leading to the characteristic manifestations of the
disease. T. gambiense infection (West African or Gambian Sleeping Sickness) is chronic while
T. rhodesiense infection (East African or Rhodesian Sleeping Sickness) is more rapidly fatal.
The disease is endemic in sub Saharan Africa which is the natural habitat of the tsetse fly.
T. gambiense causes disease along the water courses in West Africa while T. rhodesiense causes
disease mostly in the arid regions of East Africa.

Disease: African Sleeping Sickness

The initial lesion is an indurated ulcer called chancre at the site of the insect bite.
Intermittent weekly fever and lymphadenopathy then develop. Enlargement of the posterior
cervical lymph nodes (Winterbottom’s sign) is commonly seen. Other manifestations seen
during this stage include red rash accompanied by pruritus, localized edema, and a delayed
pain sensation (Kerandel’s sign). The encephalitis is characterized by headache, insomnia, and
mood changes. Muscle tremors, slurred speech, and apathy follow, progressing to somnolence
(sleeping sickness) and coma. Untreated disease is fatal.
Trypanosoma brucei rhodesiense is more virulent than Trypanosoma brucei gambiense. Infection
with the parasite has a shorter incubation period. Winterbottom’ssign may not be seen.
There is no lymphadenopathy and CNS involvement occurs early in the course of the disease.
A rapid and fulminating disease may follow with the parasite spreading in the blood. Death is
seen usually within 9–12 months following infection in untreated patients and may be due to
glomerulonephritis and myocarditis.
192 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Laboratory Diagnosis
Microscopic examination of Giemsa stained slides of the blood, lymph node aspirations
and CSF will reveal the trypomastigotes during the early stages of the disease. Aspiration of the
chancre or enlarged lymph nodes may also reveal the parasites. Parasites are isolated from the
CSF of patients with CNS involvement. Serologic tests can also be helpful as well as detection
of the presence of IgM and proteins in the CSF of patients. The presence in the serum and/or
CSF of IgM is considered diagnostic.

a b c

Figure 12.13 a Typical trypanosomal chancre seen at bite site, b the tsetse fly, and c enlarged
cervical lymph nodes
Source: International Atomic Energy Agency, 2015 and Hudson, 2014

Figure 12.14 Life cycle of Trypanosoma bruce

 Protozoa 19

Treatment
Several drugs are available for the treatment of both East African and West African
Sleeping Sickness, which include melarsoprol, suramin, pentamidine, and eflornithine
(Zeibig, 2013). The choice of drug will depend on whether the patient is pregnant or not,
the age of the patient, and the stage of the disease.

Prevention and Control

Preventive measures involve protection against the bite of the fly. Use of netting and
protective clothing are recommended. Use of fly traps and insecticides may be helpful. Clearing
the forest around the villages are also helpful measures.

Subphylum Apicomplexa: Plasmodium spp.

Important Properties and Life Cycle
Malaria is caused by five plasmodia species: Plasmodium vivax, Plasmodium malariae,
Plasmodium ovale, Plasmodium knowlesi, and Plasmodium falciparum. The vector and definitive
host is the female Anopheles mosquito. The sexual cycle (sporogony) occurs primarily in
mosquitoes, and the asexual cycle (schizogony) occurs in humans (intermediate hosts).
The infective stage is the sporozoite from the saliva of the biting mosquito, which is taken up
by the liver cells. This is called the exoerythrocytic phase. Multiplication and differentiation
of sporozoites into merozoites occur during this stage. P. vivax and P. ovale produce a latent
form (called hypnozoite or sleeping form) in the liver, which is the cause of the relapse or
recrudescence seen in vivax and ovale malaria.
Merozoites (pathogenic stage) are released from liver cells and infect the red blood cells.
The parasite’s life cycle now enters the erythrocytic phase. These merozoites multiply and are
eventually released to infect other red blood cells. The periodic release of merozoites causes
the typical recurrent symptoms seen in malaria patients. Some merozoites then develop
into microgametocytes (male gametocytes) and macrogametocytes (female gametocytes).
The gametocyte containing red blood cells are ingested by the mosquito during feeding. Sexual
reproduction then ensues.
194 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Table 12.2 Comparison of morphological forms and characteristics of the different Plasmodium
species
P. falciparum P. malariae P. vivax P. ovale
Young • fine ring • thick ring; one • thick ring, • thick ring; one
trophozoite chromatin dot often irregular chromatin dot
• multiple infection amoeboid
• crescent shaped • similar
P. vivax
to
but appearance; • circular shape
mass at outer one chromatin
smaller
edge of RBC dot
(accole form);
1 to 2 small
chromatin dots
• only detected in
severe infection
Mature • ring enlarged; • round with • irregular, • round, compact
trophozoite slightly irregular central amoeboid
chromatin and
band forms;
pigment
(hemozoin)
distinct
Schizont 8 to 36 merozoites 6 to 12 merozoites 12 to 24 8 to 14 merozoites
in cluster or rosette arranged in merozoites with rosette
arrangement; ring rosettes or arranged arrangement
enlarged; only irregular clusters; irregularly
detected in severe central location
infections of brown green
pigment
Gametocyte • crescentic • oval or rounded • oval or rounded • oval or rounded
• male: reddish • male: diffuse • male: diffuse • male: diffuse
with diffuse chromatin chromatin chromati
chromatin
• female: bluish
with compact
chromatin
Size of Unchanged Unchanged or Enlarged Enlarged
infected smaller
red cell
Shape of Sometimes Unchanged Unchanged Often irregular
red cell irregular and with jagged
crenated edges
Stippling Sometimes present Rarely present Often present Always present
(Maurer’s dots) (Zieman’s dots) (Shuffner’s dots) (Shuffner’s dots)
 Protozoa 195

a b c d

Figure 12.15 Comparison of the trophozoite forms of the different Plasmodium species:
a P. falciparum; b P. vivax; c P. malariae; and d P. ovale

P. Vivax P. Ovale P. Malariae P. Falciparum

Ring Stage

Trophozoite

Schizont

Segmenter

sequestered
Gametocytes

Figure 12.16 Comparison of morphological forms of the different Plasmodium specie

196 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Epidemiology and Pathogenesis

Infection with plasmodia occurs worldwide. It occurs primarily in tropical and subtropical
areas, especially in Asia, Africa, and Central and South America. Sixty nine percent (69%) of
cases in the Philippines are due to Plasmodium falciparum while the remaining 31% are due to
Plasmodium vivax (World Malaria Report 2013). The primary vector is Anopheles flavirostris,
which breeds in clear, slow flowing streams near foot hills and forests. In the 2014 Asia Pacific
Malaria Elimination Network (APMEN) VI held in Makati City, Philippines, then Secretary
of Health Doctor Enrique Ona reported an 83% reduction in malaria cases from 2005 to 2013,
with a 92% decrease in malarial deaths. Secretary Ona also reported that of 53 known provinces
that are endemic for the disease, 27 have already been declared malaria free, which are: Cavite,
Batangas, Marinduque, Catanduanes, Albay, Masbate, Sorsogon, Camarines Sur, Iloilo, Aklan,
Capiz, Guimaras, Bohol, Cebu, Siquijor, Western Samar, Eastern Samar, Northern Samar,
Northern Leyte, Southern Leyte, Biliran, Camiguin, Surigao del Norte, Benguet, Romblon,
Batanes, and Dinagat Islands.
The main mode of transmission of malaria is the bite of the female mosquito vector.
However, the parasite can also be transmitted through blood transfusion (transfusion malaria),
intravenous drug abuse with sharing of IV needles (“main line malaria”), and transplacental
transmission (congenital malaria). Most of the pathologic findings result from the destruction
of red blood cells. P. falciparum and P. knowlesi can infect both young and old red blood cells
leading to high levels of parasitemia. P. vivax and P. ovale mainly infects young red blood cells,
while P. malariae infects old red blood cells.
Plasmodium knowlesi is a natural parasite of macaque monkeys throughout the Southeast
Asia region. Cases of infection have been noted in Thailand, Singapore, Brunei, Indonesia,
Myanmar, Vietnam, and the Philippines (Murray, 2014). The red blood cells infected
by P. knowlesi have normal morphology. All developmental stages of the parasite may be seen in
the peripheral blood
 Protozoa 197

Figure 12.17 Life cycle of Plasmodium spp.

Disease: Malaria
Paroxysms of malaria are divided into three stages: cold stage, hot stage, and the sweating
stage. These paroxysms are considered partially as allergic responses to the schizonts and to the
antigens released following the release of the merozoites. A malarial paroxysm presents with
abrupt onset of chills (rigors) accompanied by headache, muscle pain (myalgia), and joint pains
(arthralgia). This stage lasts for approximately 10–15 minutes or longer. Spiking fever lasting
2–6 hours follows, reaching up to 41 °C, accompanied by shaking chills, nausea, vomiting, and
abdominal pain. This is then followed by drenching sweats. Patients usually feel well between
febrile episodes. Splenomegaly is often present and anemia is prominent.
The timing of the fever cycle is 72 hours for P. malariae, in which symptoms recur every
4th day (quartan malaria). Malaria caused by P. vivax, P. ovale, and P. falciparum recur ever
198 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

3rd day (tertian malaria). P. falciparum causes malignant tertian malaria since it causes severe
infection which is potentially life threatening due to extensive brain (cerebral malaria) and
kidney damage. The dark color of the patient’s urine is due to kidney damage giving rise to the
term “black water fever.” P. vivax and P. ovale cause benign tertian malaria that is characterized
by relapses that can occur up to several years after the initial illness and is due to the latent
hypnozoites in the liver.
Most cases of P. knowlesi infection resembles infection in patients by other malarial
parasites. A small number of cases of patients develops severe infection. The severity of the
infection is due to the high parasitemia levels produced due to its ability to infect all stages of
red blood cells and its 24 hour erythrocyte cycle (quotidian malaria).

Laboratory Diagnosis
The diagnosis of malaria is based on examination of Giemsa stained or Wright stained
thick and thin smears of the blood. The thick blood smears are used for screening purposes
while the thin blood smears are used to differentiate the various Plasmodium species. The best
time to take blood films is midway between paroxysms of chills and fevers or before the onset
of fever. This is the time when the greatest number of intracellular organisms are present.
Characteristic trophozoites will be seen within the infected red blood cells. P. falciparum will
show characteristic crescent shaped or banana shaped gametocytes. Infection with P. falciparum
is highly considered if there are > 10 infected red blood cells consisting only of ring forms. For
P. malariae and P. knowlesi, demonstration of the characteristic rosette schizont is diagnostic.
P. knowlesi should be suspected if there is a higher average merozoite count of 16/red blood cell
as compared to 10–12/red blood cell of P. malariae. The presence of early trophozoite forms
and two to three parasites per red blood cell (similar to P. falciparum) is more suggestive of
P. knowlesi infection.

Treatment
The drugs of choice for acute malaria infection are chloroquine or parenteral quinine.
However, chloroquine does not affect the hypnozoites of P. vivax and P. ovale. For vivax and
ovale malaria, primaquine is given to destroy the hypnozoites. For chloroquine resistant strains
of P. falciparum other agents may be used including mefloquine + artesunate, artemether
lumafantrine, atovaquone proguanil, quinine, quinidine, pyrimethamine sulfadoxine
(Fansidar), and doxycycline (Murray, 2014). Artemisin based combination therapies (ACTs)
are now recommended for uncomplicated malaria and for chloroquine resistant vivax malaria.
Artesunate is the drug of choice for severe malaria, in combination with either amodiaquine,
mefloquine, or sulfadoxine pyrimethamine. P. knowlesi infection is managed similar to
P. falciparum due to its potential to produce severe infection
 Protozoa 19

Prevention and Control

Chemoprophylaxis of malaria for travelers to endemic areas consists of mefloquine or
doxycycline. Travelers to areas where the other plasmodia are found should take chloroquine
starting two weeks before arrival and continued for 6 weeks after departure, followed by a
2 week course of primaquine if exposure was high.
Other preventive measures include avoidance of the bite of the vector through the use of
mosquito netting, window screens, protective clothing, and insect repellants. The mosquitoes
usually bite from dusk to dawn, so protection is important during the night. Reduction of
mosquito population is also helpful, including the use of insecticide sprays, as well as drainage
of stagnant water in swamps and ditches.

Phylum Apicomplexa: Toxoplasma gondii

Important Properties and Life Cycle
The definitive host of the parasite is the domestic cat or other felines while humans and
other mammals serve as the intermediate hosts. The parasite develops in the intestinal cells of
the cat and passes to the tissues through the bloodstream. These are then passed in the cat’s
feces and mature into infective oocysts in the external environment. Infection in humans begins
with the ingestion of oocysts (infective form) in undercooked meat or from contact with cat
feces. In the small intestines, the oocysts rupture into trophozoites (tachyzoites or bradyzoites).
Tachyzoites are the rapidly multiplying forms responsible for the initial infection while
bradyzoites are shorter, slow growing forms seen in chronic infections.
200 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

Conoid
Aprical polar ring

a Micronemes

Rhoptries

Dense granules b
Subpellicular microtubules
Inner membrane
complex with
underlying subpellicular
network (not shown)
Mitochondrion
Apicoplast
Nucleus

Endoplasmic reticulum

Plasma membrane

Posterior pole

Figure 12.18 a Tachyzoite and b bradyzoite of Toxoplasma gondii

Epidemiology and Pathogenesis

Infection by T. gondii occurs worldwide. Infection is usually sporadic but outbreaks
associated with ingestion of raw meat or contaminated water can occur. Individuals who are
severely immunocompromisedare more likely to develop severe disease.
The parasite can be transmitted in two ways: (1) ingestion of improperly cooked meat of
animals that serve as intermediate hosts, and (2) ingestion of oocyst from contaminated water.
Transplacental transmission may occur, with severe consequences on the fetus. Sharing of
needles by IV drug abusers as well as blood transfusion are less common modes of transmission
of the parasite
 Protozoa 201

Human ingests raw

Human ingests meat containing
infective cyst with
oocyst from bradyzoites
cat feces

Sporozoite
Congenital toxoplasmosis
released
penetrates
intestinal Formation of "cysts"
Infect fetus cell containing bradyzoites
in various organs

Tachyzoite
formed
Tachyzoites
cross
placental barrier Asexual Immune system response
reproduction
in cells
Other tissue
cells invaded
by tachyzoites

Pregnant woman Cells rupture

Hematogenous spread

Figure 12.19 Life cycle of Toxoplasma gondii

Disease: Toxoplasmosis
1. Infection in immunocompetentindividuals – usually asymptomatic. Acute infection may
manifest non specific symptoms such as chills, fever, headache, and fatigue. This may
be accompanied by inflammation of lymph nodes (lymphadenitis). Chronic infection
may manifest with lymphadenitis, hepatitis, myocarditis, and encephalomyelitis.
Chorioretinitis leading to blindness may also occur
202 Microbiology and Parasitology: A Textbook and Laboratory Manual for the Health Sciences

2. Congenital infection – occurs in infants born to mothers who were infected during
pregnancy. The manifestations vary depending on when the infection was acquired.
Infection during the first trimester of pregnancy may result to miscarriage, stillbirth,
or severe infection (encephalitis, microcephaly, hydrocephalus, mental retardation,
pneumonia). If the infant acquires the infection during the last trimester, symptoms may
not develop until months to years after delivery. The most common manifestation is
chorioretinitis with or without blindness.
3. Infection in immunocompromisedhosts – usually manifest with neurologic symptoms
similar to patients with diffuse encephalopathy, meningoencephalitis,or brain tumors.
Reactivation of latent toxoplasma infection is common. Other sites of infection include
the lungs, eye, and testes.

Laboratory Diagnosis
Demonstration of high antibody titers through immunofluorescence assay is essential for
the diagnosis of toxoplasma infection. Microscopic examination of Giemsa stained preparations
will show the crescent shaped trophozoites during the acute infection. Cysts may be seen in the
tissues. Prenatal diagnosis can be done through ultrasonographyand amniocentesis with PCR
analysis of the amniotic fluid (method of choice).

Treatment
Infection in immunocompetenthosts is usually self limiting and does not require specific
therapy. The regimen of choice for immunocompromisedpatients, especially those with AIDS,
is initial high dose pyrimethamine plus sulfadiazine given for an indefinite period. Alternative
regimen for those who develop symptoms of drug toxicity is clindamycin plus pyrimethamine.
For pregnant women, clindamycin or spiramycin may be given.

Prevention and Control

The most effective preventive measure is through adequate cooking of meat. Pregnant
women should refrain from eating undercooked meat and should avoid contact with cats and
refrain from handling litter boxes. Cats should not be fed raw meat
 Protozoa 203

CHAPTER SUMMARY

• Protozoa are unicellular organisms that are spherical or elongated in shape.

• The classification of protozoa into phyla is based in part on their mode of locomotion,
namely: Sarcodina (pseudopods or false feet), Apicomplexa (no organ of locomotion),
Mastigophora (flagella), and Ciliophora (cilia).

• Important human pathogens of Subphylum Sarcodina are Entamoeba histolytica,

Acanthamoeba, and Naegleria.

• Subphylum Mastigophora is composed of flagellated members—the intestinal parasite

Giardia lamblia, the urogenital parasite Trichomonas vaginalis, and the hemoflagellates
Leishmania and Trypanosoma.

• Important members of the Subphylum Apicomplexa are Toxoplasma gondii and the
malarial parasite Plasmodium.

• There is only one significant human pathogen in the Subphylum Ciliophora which
is Balantidium coli. It produces infection similar to Entamoeba histolytica but does not
produce extraintestinal infection.

• Some protozoa are capable of a free living state. These are Acanthamoeba and Naegleria,
both of which can cause infection of the central nervous system.

• For most protozoa, reproduction is means of binary fission. In some, it is accomplished

by
through union of two cells (syngamy), while in others, sexual reproduction may be seen
(e.g., Plasmodium).

• The mode of transmission of protozoa may be varied. Intestinal and luminal protozoa
can be transmitted by person to person or through fecal oral means. Blood and tissue
protozoa may be spread through direct contact or through vectors (e.g., Anopheles
mosquito for malaria or reduviid bug for Trypanosoma). Congenital or transplacental
transmission may occur in infection with Toxoplasma gondii and Plasmodium.

• The infective stage for most protozoa is the trophozoite while the pathogenic stage is the
cyst, except for Trichomonas vaginalis which exists only in the trophozoite form.

• Diagnosis of protozoal infection is usually through microscopic examination of

Giemsa stained specimens. Diagnosis is confirmed by detecting the diagnostic forms of
the parasites