INTRODUCTION TO PARASITOLOGY In any field of study, it is important that the learner is presented with the basic terminology used

as well as application and limitation of the different terms used. This will enable the reader an easier way of understanding matters the concerns a particular subject matter. The following text aims to acquaint the reader of the various terms and basic information in the field of medical parasitology. TERMINOLOGY Parasitology is a branch of biology that deals with the phenomenon of dependence of one living organism to another. Clinical (or Medical) Parasitology primarily deals with animal parasites of man and their medical significance and importance in human communities. Parasites are organisms that depend onto another living creature, referred to as the host, for survival. Obligate parasites are those that cannot survive without the assistance of the host. This means that the parasite is totally dependent and unable to multiply if it is not in the body of a host. Some parasites, however, are able to adapt to a free-living or parasitic existence depending upon the condition. These organisms are called facultative parasites or opportunists. In nature, there are some free-living organisms that are parasitic to other creatures but not to humans. Man may ingest these organisms and they pass through the alimentary canal, excreted in the feces, alive or dead, in the unchanged state. These organisms are referred to as spurious parasites. Parasites, like other living creatures, undergo different stages of development before reaching full maturity. Each set of metamorphosis results to a distinct stage of development. Some parasites may need a particular kind of host for a particular stage of development. The transformation and survival of a certain stage of development may not occur if the organism is in the body of a non-appropriate host. This phenomenon is called host specificity. There are some parasites that do not inhabit only a single host throughout their lifetime. Some organisms, while undergoing development, inhabit a host different from the one where the adult forms are found. An intermediate host is the one that harbors the immature or larval forms of the parasite. Some parasites undergo both asexual and sexua| reproduction. In these organisms, the asexual process takes place in the body of the intermediate host. On the other hand, the mature or adult forms of the parasites are found in the body f the definitive or final host. This is also the host where the sexua| cycle of some organisms takes place. Some animals, domestic or wild, may serve as respiratory host to a parasite. These are referred to as reservoir hosts. Man, in this case, is only incidentally involved but not a natural host. Reservoir hosts are of epidemiologic importance in the spread of some infection since they have served as the ready and constant source of the infectious organisms to the community. Some parasites require passage through an intermediate host before the infective stage (i.e. the specific developmental form capable of causing infection to man) is developed. The infective stage may not be transferred directly from an intermediate to the definitive host. Instead, it may be passed to a transport host, whereby no development or transformation of the parasite takes place but infectivity is preserved. Some animals serve as transport (or parathenic) host. They are not essential in the life cycle of the parasite but may serve as another source of infection to man aside from the natural intermediate host of the organism. Interrelationship of Organisms Different organisms exhibit various kinds of association with one another throughout their entire life. Close association of two organisms, whereby a give-and-take relationship exists is called symbiosis. If the relationship is beneficial to both associates, it is referred to as mutualism.

If the parasite derives benefits without reciprocating and/or without causing injury to the host, the relationship is called commensalism. Some big animals attack, kill, and use smaller ones for food. In this form of existence, the bigger animal is referred to aspredator while the smaller is called prey. There are animals that derive their nourishment from already dead ones either by devouring those that died of natural causes or taking the leftovers of the predators. These kind of animals subsisting in such manner are calledscavengers. The Process of Infection Parasites that live on the surface of the hosts body are called ectoparasites and their condition is referred to as infestation.Those parasites found inside the body of their host are referred to as endoparasites in which the condition is called infection. Prior to the development of an infection, a person must be in a situation considered at risk of acquiring it. Such risk situation is called exposure, which simply means that the organism is given the chance to enter the body of the individual. The process of introducing the organism into the body of the host (e.g. man) is called inoculation. Parasites that successfully enter the body of a person may establish a colony through reproduction. These organisms, inside the persons body, may be recovered in body fluids like blood, urine, CSF, or tissues at that times that the organisms are still unable to produce signs and/or symptoms of the infection. The period of time from the entry of the organism until they may be recovered in body fluids, tissues, or excreta, without any manifestation yet, is referred to as the biologic incubation period (also calledpre-patent period). Disease producing organisms, as may be expected, will be able to produce signs and/or symptoms of the infection later after inoculation. The period of time from the entry of the organism into the body of the host until the earliest sign and/or symptom of the infection appear is referred to as the clinical incubation period. Disease-producing organism (also called pathogen or pathogenic organism), in certain conditions may not be able to cause damage to the host and therefore unable to produce signs and/or symptoms of the infection. This condition is referred to asinapparent infection, and the person who harbors such pathogenic organism but without manifestation of the infection (i.e. the person is asymptomatic) is called a carrier. Other susceptible individuals, who later manifest the infection, may acquire the infection from carriers. Parasites have specific developmental forms with the ability to enter the human body to initiate an infection process. The developmental form of the parasite capable to doing so is called infective stage. On the other hand, the pathogenic stage is the developmental form may or may not be able to cause pathologic damage but is the only stage that can enter the body of the host. There are some parasites whose infective form, as well as their mature stages, can cause pathologic damage or disease to man. In certain species, the infective stage may also be the pathogenic form and vice versa. Some animals serve to transfer the infective stage of an organism from one source to another. The transfer may be from one person to another, from an animal to a human being, or from inanimate objects into a person. Commonly, the animals that transfer the organism or parasite are various kinds of insects. These animals that transfer the infective form may be referred to asvectors (also called transmitters). Vectors, which are essential or needed in the life cycle of the parasite, are called biologic vectors. The life cycle of some parasite will not be completed without the participation or involvement of a particular biologic vector. On the other hand, some vectors are not necessarily needed in the life cycle and they merely act as mechanical transmitters of the organism these are called phoretic or mechanical vectors.

An organism coming from the body of a person and transferred to another individual is undergoing horizontal transmission. Man acquires many parasites, pathogenic and commensal ones, through horizontal transmission. An unborn baby may be infected with a parasite that came from the mother via placental transfer and this process may also be called vertical transmission. This process is responsible for congenital infection. Most parasites that cause infection to man originated from animals thus, commonly referred to as zoonotic infections. A person may excrete the infective form of an organism and this stage of development may re-enter the persons body in the process ofautoinfection. Autoinfection may occur via retrograde migration of the infective form (retroinfection) or through the outside part of the body (external autoinfection). This process may lead to a severe type of infection in an individual without necessarily acquiring infective forms from another person or other sources. Infective stages coming from another source of the same species, e.g. human-to-human, is called heterofection. An already infected individual and has been re-infected with the same species of the parasite is suffering from a condition called superinfection. On the other hand, a person may be harboring more than one species of organism at the same time and this condition is called mixed infection. There are some individuals who may think they are infected with some bizarre parasite but in reality, no such parasite exists in their bodies. Psychiatrists referred to this situation as delusional parasitosis. Sources of Parasite Infections An individual may acquire parasite infection from a variety of sources. The infective cyst of some protozoa such asEntamoeba histolytica, Giardia lamblia, etc. may be present in unclean foods or water (or drinks) contaminated with fecal matter that came from an infected person. The infective egg of some worms like Ascaris lumbricoides, Trichuris trichiura, etc. may also be present in food and water, aside from being deposited in the soil around human habitation. People, who will be eating such food or drink such water contaminated by soil containing the infective eggs, may easily acquire the infection with these organisms. Some individuals may ingest contaminated soil, accidentally or intentionally (geophagia), which may contain the infective forms of organisms such as Ascaris lumbricoides. Trichuris trichiura, Toxocara sp., Strongyloides stercoralis, hookworms, etc. Various animals that serve as food to humans, if infected and eaten raw or inadequately cooked may also be the source of infections. Echinostoma ilocanum, a kind of fluke, is acquired from certain species of snails. Parasites such as Capillaria philippinensis, Diphylobothrium latum, and Opistrochis viverrini are know to come from certain species of fish that man eats. Individuals who are fond of eating raw beef or pork have higher chances of acquiring infections with Taenia saginata and Taenia solium, respectively.

Mosquitoes of the genus Anopheles serve as vectors for malaria and some filarial worms such as Wuchereria bancrofti andBrugia malayi. Insects like fleas, which may be present on domestic pets, are known source of infections with Diplydium caninumand Hymenolepis diminuta. sexual contact with an infected individual is a known source of infection with Trichomonas vaginalis. Portals of Entry The specific site in the human body where the parasites enter is referred to as portal of entry. Some species of organisms may not be able to effectively cause infection if they enter the wrong portals thus in most instances each species has its own entry point in the hosts body.
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Internal parasites that inhabit the intestinal tract, expectedly, enter through the mouth. Examples of species that make use of the mouth as portal of entry include Ascaris lumbricoides, Trichuris trichiura, Taenia species, Enterobius vermicularis, Entamoeba histolytica, Giardia lamblia, Trichinella spiralis, Capillaria philippinensis, etc. Some parasites such as hookworms (Necator americanus, Ancylostoma duodenale) threadworm (Strongyloides stercoralis), and blood flukes (e.g. Schistosoma japonicum) gain access to the body via the skin. Parasites causing malaria, the filarial worms, leishmania, and the trypanosomes are introduced into the human bodypercutaneously by blood-sucking insects that serve as vectors or transmitters. The infective eggs of pinworm (Enterobius vermicularis), aside from using the mouth as portal of entry, may also enter through the nose through inhalation. The infective larvae of Strongyloides stercoralis and species of Ancylostoma may cause infection among babies of infected mothers through the milk (i.e. transmammary transfer) Trichomonas vaginalis enters the body of an individual through the genital organs during unprotected sexual intercourse. Pathogenesis of Parasitic Infections Each pathogenic parasite utilizes different mechanisms (pathogenesis) of causing disease among humans or other animals. These mechanisms maybe one or a combination of the following: 1. 2. 3. 4. trauma or physical damage lytic (liquefaction) necrosis stimulation of hosts tissue reaction (cellular or immunologic), and toxic and/or allergic response.

Ectoparasites, such as Sarcoptes scabiei causing scabies, produce intense pruritus (itchiness) due to local irritation of the persons skin. The infective larvae of blood flukes, hookworms, and threadworm cause local damage as they enter the hosts skin. The adult worm of Ascaris lumbricoides may cause obstruction o the appendix, common bile duct, gall bladder, and the intestine. Entamoeba histolytica and Balantidium are examples of species that secrete proteolytic enzymes that can produce lysis (liquefaction) of the hosts tissues. The lytic process may occur in any organ that the parasite is able to invade such as the brain, lungs, liver and other organs. Obligate intracellular parasites, such as species causing malaria, can produce lysis of red blood cells that they infect. Eggs of schistosomes (i.e. Schistosoma japonicum), once in contact with the tissues of organs such as the liver, stimulate the tissues that eventually lead to production of fibrosis or scar tissue. Adults of filarial worms (e.g. Wuchereria bancrofti) cause stimulation and proliferation of the cells of the lymphatic channels reaching to the obstruction in the flow of lymph fluid and later on producing lymphedema that manifests with swelling of the affected part of the body such as the lower extremities. Leishmania donovani stimulates the bone marrow to produce plenty of phagocytes but reducing the ability to produce red cells at the same time. Thus, persons who suffer from leishmaniasis manifests with anemia with increase number of some of the white blood cells. Host tissue reaction to Entamoeba histolytica infection may result to granuloma (consists of fibrous tissues), which may stimulate a tumor that maybe mistaken for a cancer.

Some species of parasites, while inhabiting the hosts body, excrete waste or toxic substances, which may be absorbed and later produce systemic toxic effects. Adult worms of the intestinal fluke, Fasciolopsis buski, that inhabit the duodenum can produce obstruction and also secrete metabolic wastes, which when absorbed may lead toxicity to the host. The larvae of Ascaris lumbricoides pass through the lungs sometime in its life cycle. This larvae can stimulate the immune system of the host and subsequent infections may lead to the development of allergic responses similar to bronchial asthma or urticaria. The cyst of a tapeworm, Echinococcus granulosus, aside from its ability to cause mechanical pressure on surrounding tissues where it is located, may spontaneously rupture resulting to the release of its fluid content. The fluid contained in this cyst is a very potent anaphylatoxin, which when systemically absorbed may end with shock. Diagnosis of Parasitic Infections The medical technologist plays a very important role in the diagnosis of infections with parasites. Diagnosis of parasitic infection is, oftentimes, based on identification of organism in specimen submitted to the laboratory. The technologist, therefore, should be very accurate in the identification of the organisms. Different diagnostic tests in Parasitology may be classified as either direct or indirect. The direct approach is to demonstrate the organisms where they can be recovered. Patients who are infected with Ascaris lumbricoides, Trichuris trichiura, Capillaria philippinensis, Taenia saginata, Taenia solium, Schistosoma japonicum, and many other parasites are easily diagnosed by finding the eggs of the organism in the patients feces. Larval forms of threadworm and some species of hookworm may also be recovered in fecal specimen. Patients infected with Trichinella spiralis are diagnosed through recovery of the larval stage in biopsy material of muscle tissues. Malaria, filariasis, trypanosomiasis, and similar diseases are usually diagnosed by finding the causative parasites in blood films. Not infrequently, people who are infected with tapeworms may evacuate segments of the worms in their feces. The segments may be examined and identified with or without stain. Trichomonas vaginalis infection is easily diagnosed by finding the trophozoites of the parasite in the patients urine. Examination of CSF will also be of great help in the diagnosis ofNaegleria fowleri and Acanthamoeba culbertsoni infections. In quite a number of instances, recovery of parasites in body fluids may not be that easy or impractical. Also, there are some conditions whereby the location of the organism is quite inaccessible or trying to get them, such as in biopsy, may entail more damages that benefits. In such situations, the indirect approach may be resorted to instead. These diagnostic procedures, however, are not readily available, more likely to be less accurate, and are of limited application. If the organism is able to stimulate the immune system of the host, antibodies may be detected in the blood such as in the case of schistosomiasis, where the patients blood will contain antibodies against the eggs of the parasite. This is the basis of the so-called Circumoval Precipitin Test (COPT), which may be used in the diagnosis of schistosomiasis. Serologic tests are also available, although expensive, for the diagnosis of human infections with Echinococcus granulosus, Trichinella spiralis, Leishmania donovani, etc. A certain laboratory technique called Xenodiagnosis may be used to diagnose infection with some parasites such asTrypanosoma cruzi. In this method, a laboratory-bred insect, the one that serves as vector to the organisms, is allowed to feed on the blood of individuals suspected to be infected with the parasite. The feces of the insect is then examined for the presence of the organism after sometime.

Some parasites may also be grown in artificial culture media such as rice-starch agar for Entamoeba histolytica, as well as other protozoa parasites. Coproculture (i.e. stool or soil culture) will enable the recovery of the larval forms of hookworms and threadworms. Animals such as rabbits, hamsters, and monkeys may also be used to grow parasites in the laboratory to produce more parasites and therefore, make the diagnosis easier, more accurate, and to have high yield of positive result. Treatment of Parasitic Infections Infections with parasites may be treated with chemotherapy (i.e. the use of commercially available drugs) or through surgical intervention or a combination of the both. Hydatid disease due to the larvae of Echinococcus granulosus is treated by surgical removal of the cyst. Cysticorcus larvae of Taenia solium located in the eye of a patient are also removed through surgical procedure. Infections with organisms such as Entamoeba histolytica, Ascaris lumbricoides, Trichuris trichiura, Giardia lamblia, Trichomonas vaginalis, etc. are effectively treated through the administration of specific drug for the particular organism. Vaccination against parasite infection is not yet perfect at the present time. Researches are still ongoing for the development of vaccine that may effectively protect humans from acquiring infection with some parasites. At the present time, vaccines are being developed and tested for organisms such as Plasmodium species (causing malaria), Schistosoma japonicum, Entamoeba histolytica, etc.