Intestinal Flagellates

PATHOGENIC INTESTINAL FLAGELLATES

Giardia lamblia
= a protozoan flagellate considered as one of the more common cause of infectious diarrhea throughout the world
= most easily recognized human parasite of the gastrointestinal tract
= lives in the doudenum, jejunum and upper ileum
= known to cause epidemic and endemic diarrhea
= most commonly diagnosed intestinal infection in US

Synonym: Cercomonas intestinalis / Giardia duodenalis

Megastoma enterica
Geog. Dist: Worldwide (tropical and subtropical region)

Morphology: = exhibit both trophozoite and cyst stages

Trophozoite:
= found in diarrheic stool
= pear or pyriform shaped with a broad anterior and attenuated posterior end, bilaterally symmetrical
= size 9-20um L X 5 - 15um W
= possess 2 large oval shape nuclei near the anterior end, each with a distinct central karyosome giving
smiling face appearance, no peripheral chromatin
= found at the anterior portion of the lateral surface is the sucking disc
(used for attachment of organism)
= running along the center of the body and terminating posteriorly is the axostyle (axoneme)
= provided with 4 pairs of flagella which enhances erratic jerky or falling leaf motility
1 pair at the anterior end of sucking disc
1 pair lateral portion of sucking disc
1 pair ventral from sucking disc itself
1 pair at the posterior end of axostyle
= 2 pairs of blepharoplast: (1 pair at anterior end and) 1 pair at caudal end
= 2 deeply stained curved rod found posterior to the sucking disc, parabasal/median bodies

Cystic stage:
= ovoidal/ellipsoidal shaped
= thick wall and doubly contour
= size 8-12um L X 7 - 10um W
= young cyst contains 2 nuclei, mature cyst 4 nuclei
= axoneme, parabasal bodies and other remnant organelles of the trophozoite are also found inside
the cyst

Habitat: duodenum, jejunum and upper ileum

Life Cycle:
infection occurs by ingestion of mature viable cyst (infective stage)
from contaminated hand, food and drinks

pass through the stomach and
excyst in the duodenum

develop into trophozoites
mature cyst
passed out w/ feces encyst in the reproduce by binary fission
large intestine
Disease: Giardiasis
= a form of travelers diarrhea prevalent in areas with poor environmental sanitation and personal hygiene
= considered to be a major cause of diarrheal outbreak from contaminated water supplies
= man gets infected by ingestion of viable cyst in contaminated food and water
= all age group are affected, but attack rate is more common in children (90%) than adult

Pathologenesis:
= disease may be asymptomatic or may manifest as sudden onset of acute diarrhea, nausea, anorexia, crampy abdominal pain, bloating and
weight loss.
= stool is loose, non-bloody, malodorous and fatty
= infection is self-limiting and may last for 10-15 days following a 10-35 incubation period.
= diarrhea may become persistent, chronic and associated with malabsorption syndrome
= spontaneous recovery occur within six weeks for mild to moderate cases
= non-invasive

Lab. Diag:
1. Stool examination (unstained preparation) = demonst. pear-shaped body with progressive falling-leaf motility - trophozoite
2. Intestinal biopsy/Duodenal fluid aspiration shortening and blunting of intestinal villi due to mucosal invasion of the organism
3. String test (Entero test)
4. Immunofluorescence test
5. Immunochromatography assay (detect giardia antigen in stool)
6. Direct fluoresencent antibody assay - gold standard for laboratory diagnosis for giardiasis
- have highest sensitivity and specificity

Treatment: Metronidazole (Flagyl) - DOC 250mg TID for 5-10 days - cure rate 90%
Prevention and Control:
= proper disposal of human excreta to prevent contamination of water supply
= protect food from contamination (from infected food handlers and flies)

Dientamoeba fragilis
= originally describe as an amoeba but actually a flagellate
Geog. Dist: Cosmopolitan
Morphology:
= only trophozoite stage known (Infective stage)
= very small with an average size of 5-12um dia.
= possess 2 rosette-shaped nuclei without peripheral chromatin and clumps of nuclear granules arranged symmetrically
= motility non-progressive and very active in a freshly passed stools
= cytoplasm finely granular and vacuolated with ingested bacteria and other debris
Epidemiology:
= habitat: mucosal crypt of large intestine (cecum and upper colon)
= oral transmission not established
= commonly assoc. with infection caused by E. vermicularis
= life cycle not well-defined
Pathogenesis and Symptomatology:
= pathogenicity disputed
= infection usually asymptomatic
= does not invade tissue
= causes superficial irritation of the intestinal mucosa resulting in excess secretion of mucus, hypermotility of bowel,
diarrhea, abdominal pain, tenderness and anal pruritus (itching)
= more commonly seen among individual living in close quarter such as: inmates, students & military recruits
= all manifestation are referred to as Dientamoebiasis or Hakanssons syndrome
Diagnosis:
= Trichrome stained smear of stool specimen demonstrating binucleate trophozoite (best technique for identification)
Treatment: Iodoquinol (650mg TID for 20 days)
Tetracycline/Metronidazole (alternate drug)
Prevention: Same with amoebiasis
NON PATHOGENIC INTESTINAL FLAGELLATES

Chilomastix mesnili
Synonym: Cercomonas intestinalis
Macrostoma mesnili
Geog. Dist: Worldwide (more prevalent in warm than in cool climate )
Morphology: = exhibit both trophozoite and cyst stage
Trophozoite:
= found in diarrheic or liquid stools
= assymetrically pear-shaped with rounded flattened anterior and pointed posterior end
= size ranges from 6 20um L X 3-10u W
= spiral groove divide the body externally into 2 unequal sides
= single nucleus near the anterior end without peripheral chromatin
= karyosome minute and eccenteric
= cytostome large, cleft-like and occupies the anterior half of the body
= cytoplasm finely granular and vacuolated
= possess 3 pairs of blepharoplast near the anterior pole of nucleus where 6 flagellae arises
3 short anterior flagella
2 flagella laterally located
1 flagellum within the cytostome
= no undulating membrane and axostyle
= motility progressive and boring spiral forward movement

Cyst:
= found in formed or semi-formed stools
= pear/lemon-shaped rounded anteriorly with anterior hyaline
knob/nipple-like protuberance (very prominent)
= measures 7 10um L X 4.5 6um W
= cyst wall thicker at the anterior end
= prominent cytostomal fibrils curving posteriorly which resembles a
shepherd crook
= contain single spherical nucleus without peripheral chromatin
= karyosome large and centrally located
= cytostome well-defined

Pathogenesis and Epidemiology:

= considered as normal inhabitant of cecal region of the large intestine
= generally non-pathogenic but has been associated with disease in immunosuppressed patient
= infection is acquired thru ingestion of food or drinks containing the cyst, which is infective
= prevalence rate in the Phil. is less than 1%

Lab. Dx: Microscopic examination of stool sample

Treatment: None
Prevention: = Good sanitation and personal hygiene reduce incidence of infection
Trichomonas hominis
Synonym: Cercomonas hominis /Trichomonas confusa
Geog. Dist:
= Worldwide
= one of the most common intestinal flagellates found in humans
= believed to be a harmless commensal, and is not associated with disease

Morphology:
= exhibit trophozoite stage only and seen in diarrheic stool
= pear-shaped, rounded anterior and pointed posteriorly
= size 7-15um L X 3-4um W
= cytostome at ventral side near the ant. end of the body
= single nucleus with small central karyosome near the anterior end
= chromatin granules unevenly distributed
= cytoplasm finely granular and vacuolated
= one pair of blepheroplast at the anterior end giving rise to the flagella, axostyle and undulating membrane
= 4 anterior flagella (serves for propulsion) and a recurrent flagellum that runs to the posterior end forming the outer edge of the undulating
membrane which impart the rotatory motion of the organism (jerky non-directional)
= axostyle which runs from the anterior to the posterior end along the midaxis and protrudes as a sharp pointed tail (diagnostic)

Pathogenesis and Epidemiology:

= common habitat in the cecal area of the large intestine
= evidence of pathogenicity insufficient, however organism is always associated with diarrhea
= acquired through ingestion of food and drinks contaminated with the trophozoite

Lab. Diag.: Stool Examination ,demonstration of trophozoite from diarrheic stool

(jerky, non-directional movement of the undulating) membrane and protrusion of the axostyle
Rx: = No indication for specific treatment
Prevention: 1. Improvement of community sanitation 2. Personal hygiene

Enteromonas hominis
Synonym: Trichomonas intestinalis
Geog. Dist: Worldwide = more widely distributed throughout tropical and temperate region
Morphology: = exhibit both stages: Trophozoite and Cyst

Trophozoite:
= pear/oval shaped with one side flattened
= measures 4-10uL X 3-6u W (small flagellate)
= single nucleus near the anterior end with central karyosome
= 1 pair of blepharoplast adjacent to the nucleus which gives rise to 3 anterior flagella enhancing the jerky Forward movement and
1 posterior flagellum
= no cytostome
= entire cytoplasm vacuolated and contains numerous bacteria
Cyst:
= elongate-ovoidal shaped
= 6-8um W X 5um L
= cyst wall well-defined
= contains 1-4 nuclei usually 2 lying at opposite end
= resembles E. nana cyst
Pathogenesis and Epidemiology:
= parasites is a commensal in the cecal region of the large intestine
= no proof provided of its pathogenicity
= infection is the result of ingestion of cyst from contaminated food and drink
Lab. Diag.: = Stool Exam - demonstrate morphological characteristic of trophozoite and cyst
Treatment: = None (no therapy indicated)
Prevention: Good personal and community hygiene
Retortamonas intestinalis
Synonym: Waskia intestinalis /Embadomonas intestinalis
Geog. Dist.: Cosmopolitan (China, Malaysia, Philippines,Egypt, Brazil, USA)
= harmless commensal of the intestine of man
Morphology: = exhibit both trophozoite and cyst stage

Trophozoite:
= pear/oval shaped, rounded anteriorly and attenuated posteriorly
= size from 410um L X 3-4um W
= single nucleus at the anterior end with large central karyosome
= lateral to the nucleus is a pair of blepharoplast giving rise to 2 flagella (1 long anterior and 1 short) posterior flagellum
= cytoplasm finely granular and vacuolated
= prominent cleft-like cytostome at the anterior end of the body about half of the length of the organism

Cyst:
= pear/pyriform shaped
= cyst wall thick and doubly contoured
= measures 4-7um L X 5um W
= contain a single large nucleus with central karyosome
= 2 fibrils extending from the nuclear region to the attenuated end giving a characteristic bird beak fibrillar arrangement
(diagnostic)
Pathogenesis and Epidemiology:
= no evidence of its pathogenicity
= commonly discovered in diarrheic stool
= transmission is from hand to mouth thru contaminated food or drinks
Diagnosis: Direct microscopy of fresh stool specimen
Treatment: None (no indication for treatment parasite is commensal)
Prevention: Good personal and community hygiene

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

Pathogenesis and Epidemiology:

= considered as harmless commensal of the human mouth feeding on microorganisms and cellular debris
= most abundant between the teeth and gums, tooth cavities, pyorrheal pockets and tonsillar crypt.
= can also be found in the trachea and lungs
= MOT: through kissing, use of utensil during eating or drinking water (parasite can live for several) hours in drinking water
= associated with pulmonary trichomoniasis
Lab. Diagnosis: Direct microscopy of materials taken from teeth, gingival margin of the gums, pyorrheal pockets and tonsillar crypt.
Treatment: None (no specific treatment)
= directed to the underlying condition if any
Prevention: Good oral hygiene (eliminate/decrease infection)
Trichomonas vaginalis
= most important pathogen of the urogenital tract especially among women with vaginitis
= also found in the urinary tract of both male and female
= closely related to T. hominis
= produce a cell detaching factor that causes detachment and sloughing of vaginal epithelial cell

Morphology:
= trophozoite infective stage
= pear-shaped, measures 8-30um L X 3-17um W
= single nucleus with large central karyosome
= possess 4 anterior flagella and 1 flagellum directed posterorly forming the margin of the
undulating membrane supported by a flexible rod Costa
= undulating membrane short and extend about half the distance to the posterior end
= axostyle slender and project posteriorly
= parabasal body well-defined
= small cytostome at anterior end
= cytoplasm contains large amount of siderophil granules
= motility jerky, non-directional

Pathogenesis and Epidemiology:

Disease: Trichomoniasis
= one of the most common sexually transmitted infection seen in women worldwide
= sexually through direct contact with infected person, contaminated toilet seats, mother to child transmission through an infected birth canal
= 50% of infected individual are often asymptomatic but frequency of symptomatic disease is highest
among sexually active women in their 30s and lowest in post-menopausal women
= habitat: vagina, urethra and cervix (female),
prostate, seminal vesicle and urethra (male)

Clinical Manifestation:
(Female) = vaginal discharge most common complaints associated with vaginal trichomoniasis:
> profuse frothy creamy foul smelling greenish to yellow discharge accompanied with burning and itching sensation
> vaginal mucosa and cervix diffusely hyperemic with bright red punctate lesion (strawberry cervix)
= urinary frequency and dysuria are common accompanying symptoms
(Male) = infection is frequently asymptomatic
= about 10% of infected men have urethritis with thin milky urethral discharge
= prostate enlarged and tender associated with inflammation of the epididymis
Life Cycle:
Definitive host: Human
= trophozoite passes from person to person by sexual contact
= transmission in female also occurs by the exchange of contaminated towels, under clothing or other toilet articles
Lab. Diag.:
1. Direct demonstration of wet film preparation
= demonstrate the pear-shaped trophozoite in typical jerky motion (basis for ID)
2. Culture (Feinberg Whittington or Modified Diamonds med.)
3. Serological - DNA hybridization assay (more effective than microscopic exam)
Enzyme immunoassay (EIA)
Direct Fluorescent Antibody (DFA)
Polymerase Chain Reaction (PCR)

Rx: Metronidazole (flagyl) drug of choice for vaginal trichomoniasis

= since infection can be transmitted through SI both partners should be treated to prevent pingpong infection
= for females: restoration of the normal acid pH of vagina and periodic vaginal douches
Prevention:
= good personal hygiene
= detection and treatment of infected males
= condom limits transmission
= no prophylactic drug or vaccine available