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giardia & coccidia

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CLASS- ZOOMASTIGOPHERA
• The parasites belonging to this group of
protozoa possess one or more flagella giving
them the power of motility.
FLAGELLATES
• These are classified according to their habitat
into TWO groups:
1.Intestinal,oral & genital flagellates.
2.Blood & tissue flagllates.
Giardiasis
Giardia intestinalis =(lamblia)
Class Zoomastigophorea
Order Diplomonadida
Family Hexamitidae
– Giardia lamblia (intestinalis, duodenalis) humans, mammals
– Giardia muris - mammals
– Giardia ardeae - birds
– Giardia psittaci - birds
– Giardia agilis - amphibians
Habitat
•
Duodenum and the
upper part of the
jejunum of the man.
Morphology
• Exits in two phases:
A) Trophozoite
B) Cyst
TROPHOZITE
• When viewed flat,the shape of the trophozoite is like
that of badminton racket.
• The dorsal surface is convex & the ventral surface is
concave like a sucking disc.
• The size of the trophpzoite is 14 micrometer long & 7
micrometer broad.
• All organs of the body are paired.
• There are 2 axostyles,2 nuclei and 4 pairs of flagella.
CYST
• It is oval in shape and
measures 12
micrometer long and 7
micrometers in breadth.
Giardia intestinalis
Epidemiology
Presumed to be zoonotic, but new evidence indicates that
strains may be species specific.
Host can be humans, primates, cats, dogs, calves,
beavers, rabbits, etc.
World wide distribution
Highest incidence in children, young adults in late summer.
Transmission
Person to person transmission
Water sports, surface contamination, watershed contamination
Sexually active male homosexuals and persons in custodial
institutions.
PATHOGENICITY
• With the help of the sucking disc the parasites
attach itself on the epithelial cells of the
intestine and may cause disturbance, leading
to malabsorption of fat.
• The patient may complain of persistent
looseness of bowels , and mild steatorrhoea.
Pathogenesis and Immune response
•The production of diarrhea, and occasionally malabsorption, is the
result of a complex interaction of Giardia with the host,
•Infection occurs after oral ingestion of as few as 10 to 25 cysts.
•After excystation, trophozoites colonize and multiply in the upper
small bowel
•Adherence of G. lamblia in the human gut may be via the disk,
but may also involve specific receptor-ligand interactions
Pathogenesis and Immune response
Several pathogenic mechanisms have been postulated
•Disruption of the brush border
•Mucosal invasion
•Elaboration of an enterotoxin
•Stimulation of an inflammatory infiltration leading to fluid and
electrolyte secretion and occasionally to villous changes
Source: Gallery of histology Woods and Ellis2000
Giardia Lamblia clinging to the wall of a duodenal villus.
Immune Response
Partially protective immunity may develop to Giardia
Immune response involves both cellular and humoral immunity
Ig A, serum Ig G and Ig M are detected in patients: Role of Ig A
is not completely understood, probably inhibits trophozoite attachment
IgA deficiency lead to chronic giardiasis
Cell mediated immune response may also play a role
Human milk may also play a role in protection of the host against
Giardia : Free fatty acids and IgA antibodies
Infection with G. lamblia includes
•Asymptomatic cyst passage (5 to 15% )
•Acute self-limited diarrhea (25 to 50% )
•Chronic syndrome of diarrhea, malabsorption and weight loss
Symptomatic giardiasis is characterized by (Travelers Diarrhea)
•Acute onset of diarrhea
•Abdominal cramps, bloating, and flatulence
•Malaise, nausea, and anorexia
•May complain of sulfuric belching
•Vomiting, fever, and tenesmus occur less commonly.
•Stools may be profuse and watery, but later they are commonly
greasy, and foul-smelling.
Diagnosis
• Giardia should be identified 50 to 70% of the time after one stool, and
90% identification after three stools
• Wet, saline mounts: falling leaf motion, fibrils present, and nucleic
characteristics.
• Biopsy tissue/duodenal aspirate /Enterotest stained by trichrome or
Giemsa stain.
• Enzyme immunoassay and fluorescent monoclonal antibody antigen
detection systems
• Sensitivity & specificity: 90-100%
( ProSpec T, GiardEIA, MeriFluor, Color Vue, and DD System)
Drug
Adult
Pediatric
Metronidazole
250mgtidX 5-7 d
5mg/kg/tid x 7 d
Quinacrine
100mgtidX5-7d
2mg/kg tidX7d
Furazolidone
100 mg qid × 7–10 d 2 mg/kg qid × 10
Paromomycin
25–30 mg/kg/d in 3 doses × 5–10 d
Tinidazole
2 g × 1 dose
PREVENTION
The prevention of giardiasis requires proper handling and treatment of
water
Good personal hygiene on an individual basis
Chlorination alone is sufficient to kill G. lamblia cysts, important
variables, such as water temperature, clarity, pH, and contact time, alter
the efficacy of chlorine, and higher chlorine levels (4 to 6 mg/liter) may
be required.
Bringing water to a boil is sufficient to kill all protozoal cysts; at high
altitudes, boiling for longer periods may be necessary
Cryptosporidium, Cyclospora, and Isospora
•Secretory diarrhea without RBC or WBC in the
stool.
•None are easily found in routine “stool for ova and
parasites.”
•Modified acid-fast staining is
useful for all of the Coccidians.
Isospora belli
Cyclospora
Cryptosporidium
COCCIDIA
Thick-walled oocysts excreted in feces
In Humans
• Cryptosporidium
• Cyclospora
• Isospora
• Sarcocystis
• Toxoplasma
Classification
• Kingdom : Animalia
• Sub kingdom : Protozoa
• Phylum : Apicomplexa
• Class : Sporozoa
• Sub class : Coccidia
• Order : Eucoccidia
• Sub order : Eimeriidae
• Family: Eimeriidae
Cryptosporidium parvum
History :
• Tyzzer -1907 1st reported by
in gastric crypts of
laboratory mouse
• 1971-C.parvum as
pathogenic causing micro
organism.
• 1976-1st case of human
infection of diarrhea
• 1993-Massive outbreak of
cryptosporidiosis in
Milkwaukee affected
4,00,000 people
Species of Cryptosporidium
C. parvum
C. hominis (previously C. parvum genotype 1)
C. canis,
C. felis,
C. muris
Habitat of C.parvum
• In the form of
trophozoite.
• It is present in the
intestinal
epithelial cell.
• Remaining just
within brush
border.
MORPHOLOGY
TROPHOZOITE
OOCYST
THICK WALLED
THIN WALLED
Trophozoite
• Measures 1micro
meter in diameter.
• They are found on
brush border (micro
villous surface) of small
intestine.
• They grow into
schizonts.
OOCYST
These oocyts are either:
• 1.Thickwalled-80% passed in feces
THICKWALLED OOCYST
• 2. Thin walled -20% excyst endogenously
causing internal autoinfection
• Oocyst contain 4 sporozoites. NO
SPOROCYSTS PRESENT
• Size - 4-5µm
THIN WALLED OOCYST
Modes of infection
Reservoir host- Live stock, cats,
dogs, birds etc.
Portal of entry- occurs by
ingestion of oocysts usually
with
• contaminated water
• fecal-oral and
• anal oral transmission from
person to person
Susceptibility- Veterinary
personnel animal handlers
are at high risk
Transmission
• The 50% infective dose (ID50) of C. parvum is
only 132 oocysts for healthy persons with no
previous serological immunity to
cryptosporidiosis
• Outbreaks result from drinking water of surface water sources
-lakes and rivers .
• Swimming pools and water park wave pools
• Also, untreated groundwater or well water public drinking
water supplies.
• The highly environmentally resistant cyst of C. parvum survive
various drinking water filtrations and chemical treatments
such as chlorination.
• Food can be contaminated by either an infected person or an
asymptomatic carrier . The oocysts do not survive cooking, but
food contamination can occur
Person-person transmission
• Day-care centers, where infants or younger children are
clustered within classrooms, share toilets and common play
areas
• Day-care employees through careless diaper-changing or
through washing the laundry of infected children.
• Nosocomial settings
• Aerosol infection is fairly likely, since Cryptosporidium oocysts
are shed in large numbers during acute infection and are
immediately infective to others
Persons most likely to be infected by
Cryptosporidium are:
• Infants and younger children in day-care centers
• Those whose drinking water is unfiltered and untreated
• Involved in farming practices such as lambing, calving, and
muck-spreading
• Engaging in sexual practices that brings a person into oral
contact with feces of an infected individual
• Patients in a nosocomial setting with other infected
patients or health-care employees
• Veterinarians who come in contact with farm animals
• Travelers to areas with untreated water
• Living in densely populated urban areas
• Owners of infected household pets (rare)
MONOXENOUS LIFE CYCLE
OF C.parvum
1)INTRA CELLULAR
2)EXTRA CYTOPLASMIC
3)PRESENT IN PARASITOPHOROUS VACUOLE
Life cycle of C.parvum(monoxenous)
Modes of infection
LIFE CYCLE
Large reservoir of wild animals and
livestock(Cattles, rodents, puppies, kittens)
Life cycle is completed within a single host
Lacks host specificity-Capable of infecting many
different mammalian species
Zoonotic- from animals to humans
Life Cycle
Complex -sexual and asexual cycles, and distinct developmental stages
Excystation of the ingested oocyst in the small bowel with release of the
four sporozoites
Invasion of intestinal epithelial cells via apical end of the sporozoite within a
vacuole formed of both host and parasite membranes and the initiation of
the asexual intracellular multiplication stage (parasitophorous vacuole)
Differentiation of microgametes and macrogametes
Fertilization - sexual replication
Development of oocysts
Formation of sporozoites within the oocyst, which is then excreted in the
stool
The cycle begins anew when these oocysts are ingested by a new host.
Pathogenesis
• Sporozoite-specific lectin adherence factor has been identified
• After sporozoite attachment, epithelial mucosa cells release
cytokines that activate resident phagocytes . These activated cells
release soluble factors that increase intestinal secretion of water and
chloride and also inhibit absorption. They act on various substrates,
including enteric nerves and on the epithelial cells themselves
1. Cell death is a direct result of parasite invasion, multiplication, and
extrusion
2. Cell damage could occur through T cell-mediated inflammation,
producing villus atrophy and crypt hyperplasia
3. Either model produces distortion of villus architecture and is
accompanied by nutrient malabsorption and diarrhea
Clinical manifestations in
immunocompetent
 The incubation period - Two days - week.
 In immunocompetent patients, it is an acute, yet
self-limiting diarrheal illness (1-2 week duration),
and symptoms include :
• Frequent, watery diarrhea
• Nausea
• Vomiting
• Abdominal cramps
• Low-grade fever
Immunocompromised persons
CD4 counts of <200 cell/cubic mm
 The illness is much more severe
 Debilitating, cholera-like diarrhea (up to 20
liters/day)
• Severe abdominal cramps
• Malaise
• Low-grade fever
• Weight loss
• Anorexia
Detection and Diagnosis
• Stool Conc. Technique:
Sheather’s sugar solution in Zn SO4
Saturated Nacl
):
Formalin ether conc.
Formalin ethyl acetate
• By a biopsy of intestinal tissue . -"patchy" nature of
parasitic infection
• The modified acid-fast stain is traditionally used to
detect –oocysts(4.2-5.4 um) have sporozoites (dd
from Cyclospora-larger and unsporulated)
Cryptosporidium
• 4-5 mm oocysts
• 4 sporozoites
• no sporocysts
Cyclospora
• 8-10 mm oocyts
• 2 sporocysts
• 2 sporozoites each
Isospora belli
• 30 x 12 mm oocyts
• 2 sporocysts
• 4 sporozoites each
OTHER DIAGNOSTIC METHODS
• Anti-cryptosporidial IgM, IgG, and IgA can be
detected by ELISA or by the antibody
immunofluorescence assay (IFA), but neither
of these assays can provide a direct diagnosis
of cryptosporidiosis.
• Recently, new genetic methods of detecting C.
parvum have been developed, using PCR or
other DNA-based detection methods.
TREATMENT
 Since cryptosporidiosis is a self-limiting illness in
immunocompetent individuals, general, supportive
care is the only treatment for the illness.
 Oral or intravenous rehydration and replacement of
electrolytes may be necessary for particularly
voluminous, watery diarrhea.
 Antibiotics such as spiramycin and dicalzuril sodium
have produced partial responses in patients. However,
one particular antimicrobial agent, paromomycin, has
shown promise
Cyclospora cayetenisis
• Cyclospora is associated
with diarrhea.
• 1990- virtually unknown
before about
• 1996 -Contaminated
Guatemalan raspberry,
cause of a United States
outbreak of Cyclospora in.
• “yuppie disease” .
MORPHOLOGY
• OOCYST
DEFINATIVE HOST – REPTILES,BIRDS,
HUMAN BEINGS
• 8-10micro meter in
diameter
• Contains 2 sporocysts
each containing 2
sporozoites
• Sporozoite contain
membrane bound
nucleus and
micronemes
Gametogony
Oocyst
Sporozoites penetrate epithelium
Producing merozoites
Invade other epithelial cell
Excystation In
small intestine
Unsporulated Oocyst
Passed in feces 7-13 days
mature
oocyst(4sporozoites)
Human Infection Through
Water(oocyst)
Modes of infection
• Ingestion of
contaminated food with
sporulated oocyst.
• Contaminated water
• Contaminated
raspberries.
• Contaminated basil
leaves.
Clinical disease
• Acute infective diarrhea
• Incubation period: 2 to 11 days
Immuno competant individual:
1)Rapid onset of watery diarrhea 7 to 8 stools per day
2)Nausea,anorexia,abdominal cramps
3)Low grade fever and malaise
4)Self limiting remission in 3-4 days followed by relapses
from 4-7 weeks
Immuno compromised individual
1)Diarrhea is prolonged 8-7 weeks and severe.
2)Biliary diseases have been reported
lab diagnosis
Light microscopy
Auto florescence
Concentration
methods
Normal light miscroscopy.
Three mature, living oocysts
sporozoites (sp)
sporocystic residuum(sr)
Stieda body (st).
Bar = 10 µm.
Direct wet preparation with no staining (x1650).
• The outer wall is
distinct and thick.
• Each body contains
several refractive
granules.
• 2 sporocysts in one
oocyst
Cyclospora cyst taking zeihl neelson
staining
AUTO FLUORESCENCE
• Cyclospora organism
flouresce when examined
with an UV flourescent
microscope.
• This factor should be
taken into consideration
SEE WHETHER THE RASPBERRY ARE NOT
CONTAMINATED BEFORE YOU EAT
SEE THAT THE WATER IS NOT CONTAMINATED
Isosopora belli
• Apicomplexa
• Coccidia
• Monoxenous life cycle.
• Coccida parasites are identified based on the
structure of the oocyst.
•Sporulated oocyst is the infective stage
•Invades intestinal epithelial cells
•Often asymptomatic
•Symptoms mild gastro-intestinal distress to
severe dysentery
•Often self-limiting, but can become chronic
•Symptoms more severe in AIDS patients
•
•
•
•
HABITAT:
Inside human beings.
In form of trophozoites.
Resides in epithelial cell of
small Intestine
Here schizogony and
sporogony occurs
Morphology
• OOCYST
2 types:
Immature oocyst
Mature oocyst
DEFINATIVE HOST – HUMAN BEINGS
Immature oocyst:
• Size- 15µm× 20µm
• Shape – rugby ball
• Develop inside
epithelial cell of small
intestine.
• Central individual mass
of protoplasm.
• They are unsporulated.
• They are shed in feces
Immature
oocyst
Mature oocyst
•
•
•
Mature
oocyst
Size – 20µm × 10µm
Shape- rugby shape
It is elongated and narrow
at one pole with neck like
restricted area.
2 sporocyst with 4
sporozoites each
Modes of infection
• Reservoir host: NIL
• Source : contaminated
food and water.
• Portal of entry:
ingestion of oocyst
Infection by Oocyst
Gametogony, Fertilisation oocyst
Merozoites
Undergo
Schizogony
In epithelial cell
Sporocyst Invade epithelium
Of small intestine-trophozoite
Trophozoite
Undergo
schizogony
ISOSPORA BELLI LIFE CYCLE
Clinical disease
• Acute infective diarrhea
• Incubation period: 2 to 11 days
immunocompetant individual:
1) Rapid onset of watery diarrhea 7 to 8 stools per day
2) Nausea,anorexia,abdominal cramps
3) Low grade fever and malaise
4) Self limiting remission in 3-4 days followed by relapses
from 4-7 weeks
Immuno compromised individual
1)Diarrhea is prolonged 8-7 weeks and severe.
2)Biliary diseases have been reported
LAB DIAGNOSIS
DIRECT
MICROSCOPY
(FAECES)
DUODENAL
ASPIRATE
BIOPSY
Diagnosis-Mod acid fast staining
Autofluorescence
Biopsy of Intestinal mucosa
PCR
20-33 um x 10-19 um
PREVENTION
Wash food such as green salads and fruits,
especially if it is to be eaten uncooked.
WASH YOUR HANDS BEFORE
YOU EAT YOUR FOOD
Eat meat only when it is cooked to "well
done". For example, do not eat meat
tartare or "rare" meat.
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