CILIATES AND FLAGELLATES
region)
BALANTIDUM COLI
• Balantidiasis/balantidial dysentery
• Largest protozoan parasite affecting
humans
• Only ciliate known to cause human
disease
• Attacks INTESTINAL
EPITHELIUM>ULCER
FORMATION>BLOODY DIARRHEA
(similar to amebic dysentery)
• Primarily associated with PIGS
PARASITE BIOLOGY
• Exhibits both trophozoite and cyst
stages
• Cytosome-acquires food
• Cytopyge-excretes wastes
• With two dissimilar nuclei (macro
and micronucleus) and two
contractile vacuoles; micronucleus-
bean shaped
• Mucocysts-extrusive organelles
beneath the cell membrane;fxns in
the adhesion of parasitic ciliates
• Unlike amebae, enecystation dos not
result in an increase no. of nuclei
• Infection from ingestion of
contaminated food or water (B. coli
cysts)
• IC: 4-5 days
• Small intestine-where cysts excysts
and become trophozoites
• Large intestine’s lumen, mucosa and
submucosa-where trophozoites
inhabit (primarily in the cecal
• Multiply by binary fission
• Pathologic changes in colonic wall
and mucosa
• Cysts-protection for survival outside
the host; INFECTIVE STAGE (viable
for several weeks)
• Encystment-during intestinal
transport or after evacuation of
semi-formed stools
PATHOGENESIS AND CLINICAL
MANIFESTATIONS
• Tissue invader
• Trophozoites!attacks intestinal
epithelium!ulcer formation
(rounded base and wide neck, in
contrast to amebiasis which is flask-
shaped, narrow neck)
• Ulceration-due to hyaluronidase
secreted by trophozoites
• Troph. are abundant in exudates on
mucosal surfaces
• Inflamm. Cells and trophozoites
abundant in the base of the ulcers.
• Also invades the submucosa,
muscular coat, blood vessels and
lymphatics
• Also spreads to the mesenteric
nodes, pleura or liver
• Many are asymptomatic
• Diarrhea and dysentery –most
common complaint
• Acute infection-abdominal
discomfort or pain with N/V.
• BALANTIDIAL DYSENTERY IS
INDISINGUISHABLE FROM AMEBIC
DYSENTERY.
• Acute episodes-6-15 diarrhea/day
• Chronic disease-diarrhea alternating
with constipation and accompanied
with anemia and cachexia
• Fulminant dse.-in
immunocompromised and
malnourished
• Intestinal perforation and acute
appendicitis-complications
DIAGNOSIS
• Through microscopic demonstration
of troph. and cysts in feces using
direct exam. or concentration
techniques.
• Presence of the troph. in biopsy
specimens from lesions-can be
diagnostic
TREATMENT
• Adults and older children
o Tetracycline 500 mg, QID, for 10
days
o Metronidazole 750 mg, TID, for 5
days (alternative)
o Iodoquinol 650 mg, TID, for 20
days
• Pediatric dose
o Metronidazole 35-50 mg/kg/day
in 3 individual doses for 5 days
o Iodoquinol 40 mg/kg/day in 3
divided doses for 20 days
• Tetracycline-C/I in children less than
eight years old and in pregnant
women
• Metronidazole-C/I in early pregnancy
EPIDEMIOLOGY
• Uncommon in temperate climates
• Associated with PIGS throughout the
tropics
• Prevalence is associated with poor
environmental sanitation
• 25% of human cases-exposure to
swine
• Human infxns. In the Phil. Has been
few and sporadic (prevalence is less
than 1%)
• Local porcine strain may not be
infective
PREVENTION AND CONTROL
• Proper sanitation
• Safe water supply
• Protection of food from
contamination
• Cysts-easily inactivated by heat and
1% sodium hypochlorite
• Ordinary clorination may not be
effective
GIARDIA LAMBLIA
• Causes giardiasis/lambliasis
(significant but not life-threatening
GI dse.)
• Intestinal flagellate
• Causes epidemic and endemic
diarrhea
• A.k.a G. intestinalis, G. duodenalis,
Lamblia duodenalis, or L. intestinalis
• First discovered by Antoine van
Leeuwenhoek in his own stools in
1681
PARASITE BIOLOGY
• Lives in the duodenum, jejunum and
upper ileum
• Simple asexual life cycle that
includes binucleated flagellated
trophozoites and quadrinucleated
infective cyst stages.
• Genotypes A and B-classification of
the parasite that infects humans
based on the specific sequences in
the small subunit of their ribosomal
RNA.
• Trophozoites-pyriform or teardrop
shaped, pointed posteriorly, with a
pari of ovoidal neuclei, one on each
side of the midline.
• Dorsal side-convex
• Ventral side-concave with a large
adhesive disc used for attachment
• Bilaterally symmetrical
• Axostyle-distinct medial line
• Erratic tumbling motion-4 pair of
flagella arising from superficial
organelles in the ventral side of the
body.
• Divide by binary fission and found in
diarrheic stools.
• VSPs (variant-specific surface
proteins)-cover the entire surface;
resistant to intestinal proteases
• Cysts are ovoid
• Young-2 nuclei
• Mature-4 nuclei
• Characterized by flagella retracted
into axonemes, the median body,
and deeply stained curved fibrils
surrounded by a tough hyaline cyst
wall secreted from condensed
cytoplasm
• Cysts are transferred to the mouth
via contaminate hands, food, or
water.
• Mature cysts (infective stage)-pass
safely through the stomach!excysts
in the duodenum (30
min)!trophozoites!rapidly multiply
and attach to the intestinal
villi!found in the jejunum!feces
enters the colon (dehydrates),
encystment occurs!newly formed
cysts have 2 nuclei, mature ones
have four!passes out of the stool
(mature cyst:infective)
PATHOGENSIS AND CLINICAL
MANIFESTATION
• Infection-ingestion of mature cysts;
occurs with one ingesting as few as
10 cysts
• Has the ability to alter mucosal
intestinal cells once it has attached
to the apical portion of the
enterocyte (adhesive disc in the
ventral side)!mechanical irritation
• Attachment is maximal at body temp
and stable at a pH of 7.8-8.2
• Produces lectin, which is activated
by duodenal secretions and
facilitates adhesion
• Attachment to the villi or intestinal
mucous will not expose the parasite
to the peristaltic movement
• Attachment to the villi causes villous
flattening and crypt
 hypertrophy!decreased electrolyte,
glucose, and fluid absorption and
deficiencies in
disaccharidases!malabsorption and
maldigestion
• The parasite can rearrange human
colonic and duodenal
monolayers!structural
disintegration and detachment from
the substrate, observed in apoptotic
cells (enterocyte apoptosis)
• Also causes increase in epithelial
permeability!leading to the loss of
epithelial barrier fxn!luminal
contents penetrate submucosal
layers!more damage in intestinal
tissue
• It takes 1-4 wks. for dse. to manifest
after ingestion of the cyst (ave. 9
days)
• 50% are asymptomatic
• Acute cases-abdominal pain
(cramping) associated with diarrhea;
“rotten egg” flatus due to hydrogen
sulphide
• Diarrhea-most common symptom,
89% of cases, followed by malaise
and flatulence
• Within 6 weeks-spontaneous recover
in mild to moderate cases
• Untreated cases-diarrhea with
varying intensities for weeks or
months
• Chronic infection-steatorrhea,
diarrhea alternating with
constipation, weight loss, profound
malaise, and low grade fever.
• Underdeveloped countries-this
parasite causes failure to thrive
syndrome
DIAGNOSIS
• Troph. and cysts in stool specimens
• Troph. in direct fecal smear-floatig
leaf-like motility
• Spotty sheddings-requires at least 3
examinations on alternate days
• Duodeno-jejunal aspiration-if
parasites are not found in the feces
• Duodenal contents examination
higher percentage of positive
findings than fecal exam
• Protracted diarrhea-suspect
giardiasis
• Entero-test-gelatin capsule
containing nylon string is swallowed
(attached to the patient’s
cheek)!after 6-8 hrs. string is
removed!adherent fluid is
examined under the microscope (this
test is accurate and inexpensive)
• Antigen detection tests and
immunofluorescence tests are
available-stools should not undergo
concentration procedures
• Direct fluorescent antibody-gold
standard
TREATMENT
• Oral metronidazole 250 mg, TID for
5-10 days
• Pedia dose: 15 mg/kg in 3 divided
doses)
• Cure rate is 90%
EPIDEMIOLOGY
• Prevalence-associated with poor
environmental sanitation
• Worldwide distribution
• Phil. Prevalence 6%
• Infection more prevalent under 9 y/
o, 14%
• Institutionalized-16.9%
• Higher prevalence in homosexual
oro-anal practices
• Zoonotic
• Water-borne-exclusive outbreak
source of giardiasis
• Does not reproduce in food
• Risk factors: poor hygiene, poor
sanitation, overcrowding,
immunodefiency, bacterial and
fungal overgrowth in the small
intestine, and homosexual practices
• “Gay-bowel syndrome”
PREVENTION AND CONTROL
• Proper sanitary disposal of human
excreta
• Chlorination does not affect cysts
Coccidians
Juan Ismael G. Sumagaysay, MD, FPCP Epidemiology
• Universal
• Member of the class Sporozoea • 3-20% prevalence in developing
• Phylum apicomplexia countries
• Alternation of generations • Waterborne
(asexual and sexual)
• Asexual –schizogony
• Sexual –sporogony

Class Coccidia
• Isospora
• Sarcocystis
• Cryptosporidium
• Cyclospora
• Toxoplasma

Toxoplasma gondii
• Worldwide distribution
• Infects humans and many species
of animals

Parasite Biology
• Infective stages: tachyzoites,
bradyzoites, oocyst
• Cat family –definitive host, where
the complete life cycle occurs
• Intestinal epithelium of the cat !
Merozoites multiply !
Differentiation into
microgametocytes,
macrogametocytes ! Oocyst
!Passed out with feces
• Oocyst ! intestines of the new
host ! Sporocyst ! sporozoites
! lymphatics ! spread to
different organs tissues and fluids
• As soon as sporozoites enter the
new cell it transforms into
tachyzoites ! bradyzoites ! cyst
Pathogenesis and Clinical
Manifestations
• Immunocompetent host: self
limiting diarrhea of 2-3wks, less
commonly abdominal pain,
anorexia, fever, nausea and
weight loss
• Asymptomatic when immunity is
intact
• Factors that may activate the
disease: old age, drug induced
immunosuppression after organ
transplantation, AIDS
Manifestations
• Encephalitis
• Myocarditis
• Pneumonia
• Hepatitis, retinochoroiditis,
lymphoreticular hyperplasia
 • Splenomegaly • Indirect hemagglutination test
• Stillbirth • Indirect fluorescent Ab test
• Enzyme linked immunosorbent
assay
• Latex agglutination test
• PCR

Treatment
• Pyrimethamine
• Sulfadiazine
• Clindamycin
• Spiramycin, azithromycin,
clarithromycin, dapsone, atova

Epidemiology
• Worldwide in humans and other
domestic and wild animals
• 2.4% seropositive in the
population

Prevention and Control

• Thorough cooking
• Avoidance of unpasteurized milk
• Pregnant women should avoid
cats
• Lab workers should be careful in
handling the parasites

Cryptosporidium Hominis
• Oocysts are the infective stage
found in the feces

Pathogenesis and Clinical

Manifestations
• Immunocompetent host: self
limiting diarrhea of 2-3wks, less
commonly abdominal pain,
anorexia, fever, nausea and
weight loss
• Immunocompromised host: more
severe maybe life-threatening
Diagnosis diarrhea, acute and gangrenous
• Tissue examination –giemsa stain cholecystitis, respiratory
• Serology -4x increase in titer infections, excessive fluid loss
Diagnosis
• Stool exam
• Kinyoun’s modified acid fast stain

Treatment
• Nitazoxadine
• Paromomycin
• Clarithromycin
• Azithromycin