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 1. A 34-year-old woman living on Martha’s Vineyard,

a small island off the New England coast, develops
the sudden onset of chills and fever. Microscopic
examination of a peripheral blood smear reveal
inclusions within the red blood cells, some of which
form distinctive Maltese cross forms. What is the
best diagnosis?
a. Babesiosis
b. Leishmaniasis
c. Lyme disease
d. Atypical malaria
e. Toxoplasmosis
2. Soon after returning from a trip to Costa Rica, a
41-year-old woman develops recurrent chills
and high fever that recur every 48 h.
Examination of her peripheral blood reveals red
granules (Schüffner’s dots) in enlarged, young
erythrocytes. Which of the following organisms
is most likely to have produced her signs and
a. Afipia felis
b. Ancyclostoma duodenale
c. B. microti
d. P. ovale
e. Toxoplasma gondii
 Four species, all cause different types of malaria Life cycle split
between man and mosquito.
 When infected into skin by bite of a carrier female mosquito,
sporozoites travel to liver, enter hepatocytes, grow and
transform to merozoites which reenter the blood and RBC’s,
and grow to become trophozoites.
 Some undergo sexual division into gametes which can then
again be picked up by mosquitoes and transform into
 Infected individuals show relapsing high fever with chills, rigor,
headache, body ache, delirium; then sweating, break in fever,
and lassitude
 Parasites can be found in the blood, and brown-black malarial
pigment (hemozoin) can be found in histiocytes in the spleen
and in Kupffer cells in the liver
 HbS carriers limit parasitemia by forcing parasite to leave the
red cell as its heme starts sickling
P. vivax, P. ovale
 Benign tertian malaria: fever spikes 48
hrs apart; rarely fatal
 Vivax can only infect RBCs with the
Duffy blood group factor
P. malariae
 Benign quartan malaria: fever spikes 72
hrs apart – long latency periods
P. falciparum
 Malignant tertian malaria: fever spikes at
48 hr intervals, progressive damage to
RBC’s, high parasitemias, can spread to
CNS, accounts for most of the fatalities
 Tiny <3μm intracellular parasite - on
smears, two basophilic dots (nucleus
and kinetoplast)
 Limited cutaneous infection or
generalized visceral infection
Babesia microti
 Babesiosis: acute, sometimes prolonged
illness with headache, fever, chills,
myalgia, fatigue
 Commonly seen on Eastern seaboard,
especially Nantucket and Martha’s
 Transmitted by tick
T. rhodesiense, T gambiense
 Acute febrile attack with purpura and
DIC, then chronic episodic fever with
lymphadenopathy and splenomegaly,
then progressive brain dysfunction,
“sleeping sickness”, cachexia and death
 Transmitted by insect (Tsetse flies) - live
in bloodstream
 Genetically programmed antigenic
Strongyloides stercoralis
 Very small (1mm long) intestinal luminal
 Burrow into mucosal crypts; can
damage absorptive surface of gut
leading to chronic enteritis
 Only intestinal nematode which can
reproduce within host
 Larvae can invade and migrate to lung,
liver, CNS
 Ingestion of undercooked meat - larvae
excyst and mature into adults - attach to
bowel wall by scolex - can grow to great
 Can obstruct GI tract or lead to B12
 Diagnose by finding proglotids or eggs
in stool
 To cure, must remove scolex; a
vermifuge can be used
 Usually Taenia solium
 Acquired by consumption of eggs;
invade through gut and disseminate to
brain, muscles, skin, heart
 Can block spinal fluid reabsorption
 Ovoid, white to opalescent
 Often calcify or degenerate
 Minimal inflammation when alive,
extensive when die
Echinococcus granulosus
 Main host is dog
 Human ingestion of eggs leads to hatching
in duodenum and invasive embryos which
go usually to liver (66%) but also to lung (5-
15%) or bones, brain, etc.
 In target site, lodge within capillaries, incite
an inflammatory reaction, and if survive
encyst; this “hydatid cyst” grows in size
over years and can reach 10cm or more
 Cysts unilocular (E. multilocularis causes
multilocular cysts)
Trichinella spiralis
 Trichinosis acquired by eating improperly
cooked contaminated meat (pork, bear, wild
game) – larvae released into stomach by
digestion of cyst wall - attach to duodenal
mucosa - mature to adult worms – produce
numerous new larvae which invade
bloodstream and spread to skeletal muscles
where convert muscle cell to a nurse cell -
encyst - in time, may die and calcify
 Most common muscles: diaphragm, eye
muscles, laryngeal muscles, deltoid,
gastrocnemius, intercostals
 6 species, including S. mansoni, S. japonicum, S.
 Infective form burrows through skin of feet into
blood-stream; pause in lung at 4-14 days until reach
liver; mature in intrahepatic portal radicals;
eventually descend to mesenteric or pelvic venules
where mate and lay eggs
 Hypersensitivity granulomas in liver can lead to
 Generally minimal host tissue reactions to adults
until die
 Eggs produce significant inflammation; often calcify
 Predisposes to squamous cell carcinoma of the
 Long string-like nematodes whose
fertilized females release tiny
microfilariae into the lymph, blood, and
 Can survive for many years, producing
 Mosquito borne
Wuchereria bancrofti
 10 cm long; invade lymphatics
producing lymphedema of scrotum,
penis, vulva, leg, breast, or arm
Onchocerca volvulus
 Largest of human filaria (50 cm)
 Transmitted by black flies
 Lives in skin - discharges microfilariae
into subcutaneous tissue
 In addition to skin lesions, can get
blindness from millions of microfilariae
accumulating in eye chambers
Entamoeba histolytica
 15-40μm trophozoite with small nucleus, foamy cytoplasm
 Often ingests red cells; very motile on wet preps
 Infects cecum and ascending colon;sometimes whole
 Can cause mild to very bloody diarrhea
 Invade lamina propria from deep in crypts; do not go past
muscularis mucosa; spread out, undermining site of
invasion (flask shaped lesion); as spread, cut into blood
supply of overlying mucosa, causing liquefactive necrosis
with minimal inflammatory response
 In ~40% cases, enter blood vessels and travel to liver
where can form a unilocular cyst, often large, often
hemorrhagic (chocolate colored anchovy paste; NOT
 Lung and brain abscesses can also be formed
Naegleria fowleri
 Free-living ameboflagellate; large
 Enters arachnoid space through the
cribriform plate while swimming in
infected waters: causes
 Organism has large nucleus - easily
mistaken for human cell
Pneumocystis carinii
 4-6μm cysts
 Ubiquitous opportunistic parasite -
essentially all children have acquired
antibodies to it by age 2
 In protein malnourished children and
immunosuppressed adults, can cause
an interstitial pneumonia
 Foamy alveolar exudate with
proliferating parasites
Trichomonas vaginalis
 Most frequent venereal parasitic infection
 15-18μm long turnip shaped flagellate
 Lives in postpubertal vaginas and male
urethra (prepubertal vagina has wrong
bacterial flora)
 Only small fraction of patients are
symptomatic (itching, burning, especially
during micturition)
 May be asymptomatic, even when present
in large numbers