Post on 28-Apr-2015
Clinical Parasitology
Dr. Mohieddīn Abdul-Fattah
Introduction -Definitions• Parasitism :(التطفل) a relationship in which one organism
(parasite) lives at the expense of another (host).
• Endoparasite :( داخلى a parasite which lives within the (طفيلbody of the host, e.g. protozoa and helminthes
• Ectoparasite :( خارجى lives on the body surface of the (طفيلhost e.g. insects
• Habitat:( العائل داخل الطفيل the organ in which the (مقرparasite exists in the body of the host.
• Final host:( النهائى harbors the adult or sexually mature(العائلparasite.
• Intermediate host : ( الوسيط harbors the immature (العائلstages or asexual stages of a parasite that show significant development.
Definitions• Reservoir host : ( المخزن the animal that holds the (العائل
same stage of the same species of a parasite that man holds and contributes to the perpetuation of the parasite life cycle in nature.
• Transport host (Paratenic): the intermediate host that carries the larva of the parasite without significant development (with arrested development).
• Vector مخزن غير موجه an arthropod or a snail IH that ( :(ناقلdirects a parasite to a certain host within certain conditions.
• Exit stage ( الخروج The stage that gets out of the host :(طورand aids in diagnosis (diagnostic stage).
• Inlet stage or infective stage ( المعدى الطور أو االدخول :(طورThe stage that enters the host and causes the infection.
• Auto-infection ( الذاتية when a host infects himself; this :(العدوىoccurs when the infective stage is the exit stage.
• Patent infection: infection with an exit stage out of the host in clinical sample and which contributes to perpetuation of the life cycle.
• Non patent infection: infection without exit stage out of the host. • Routes of infection or entry of the infective stages:1. By ingestion of: larva, egg, cyst or oocyst in contaminated foods & drinks.2. Entry of larva, trophozoites, sporozoites or cysts through contact with skin ulcer
and abrasion, or by active penetration, or via inoculation by an insect.3. Through epithelia of mucosal surfaces, of the eye, olfactory epithelium ,
respiratory, or via urogenital tracts.4. Congenital transmission.5. Blood transfusion.
Host-Parasite Relationship1. Infection: means establishment of a parasite existence within
the host accompanied or not with its development and reproduction.
This means host parasite interaction passes through 4 stages: initial contact (contamination), establishment within suitable habitat, development and lastly reproduction.
2. Immune response:• When a parasite antigens come into contact with the host
immune system (cells), these cells interact with the parasite antigens (structures or excretion and secretions) to induce:
A. Parasite immune-evasion,
B. Host immune-protection (immunity or resistance)
C. Host immune-pathogenesis
D. or aid in immune-diagnosis.
Host-Parasite Relationship3. Disease (Pathogenesis):• The occurrence of infection does not necessarily
imply the occurrence of disease. • Disease only occurs if the anatomical and/or the
physiological integrity of the host were broken down. • If infection leads to this breakdown it induces disease.
Disease is usually presented by signs and symptoms.• Opportunistic infection: infection that does not
cause disease in immune competent host, but if the host immunity is impaired it does.
Host-Parasite Relationship
• How do Parasites damage their hosts?
1.Competing for nutrients (e.g. Hookworms and D. latum).
2.Disrupting tissues (e.g. Hydatid disease, myiasis and Tungiasis).
3.Destroying cells (e.g. malaria, hookworm, and schistosomiasis).
4.Mechanical blockage (e.g. Ascaris).
5.Severe disease often is induced by immune / inflammatory response.
Parasites studied in this course
• Helminthes:
1.Platyhelminthes• Trematoda• Cestoda
2.Nemathelminthes• Nematoda
3.Protozoa• Amebas• Flagellates• Coccidia
4.Arthropodes
• Every endoparasite will be studied through these points
1. Biology: Brief life cycle:• Which type of host man acts as? Are
there reservoir hosts?• Habitat in man• Exit stage
2. Epidemiology:• Geographical Distribution• Transmission: Reservoir and intermediate hosts Infective stages and Modes of infection
3. Host-parasite relationship• The induced disease:
4. Diagnosis
5. Treatment
6. Control
Trematoda
Dr. Mohieddīn Abdul-Fattah
Trematodes According to Habitat
• Intestinal Trematodes:
1. Heterophyes
2. Metagonimus
3. Fasciolopsis
4. Echinostoma• Liver trematodes:
1. Fasciola.
2. Clonorchis
3. Opistorchis
• Lung trematodes:
1. Paragonimus.• Blood trematodes:
1. Schistosoma
Heterophyes heterophyes
• Final host: Man, dogs and cats
• Habitat : between villi in small intestine
• Exit stage: mature egg in stool of FH.
• Morphology: 1.5 x 0.5 mm, pear like trematode.
I. Biology
II. Epidemiology• Geographical distribution: Egypt around Borollos and
Menzella lakes , Palestine Europe and Far East..• Transmission:
1. Intermediate host (I.H.): Pirenella conica is 1st I.H. and Bolty and Boory fish are 2nd I.H.
2. Reservoir hosts: dogs and cats act as final reservoir hosts.
3. Infective stage: Encysted metacercaia in fish muscles
4. Mode of infection: Ingestion of insufficiently cooked or under salted fish infected with Encysted metacercaria
Host parasite relationship 1. Mild infection is almost asymptomatic
2. Heavy infection induces local intestinal inflammation and intermittent diarrhea
3. The small eggs may be inoculated into the blood vesels and migrate to heart and brain resulting in embolic manifestations.
4. Myocarditis and neurological complications are reported
IV. Diagnosis
• Detection of eggs in stool.
• Egg charcteristics:
1.30 x 15 µm,
2.oval, thick shelled,
3.yellowish brown, operculated
4.mature (contains developed larva [miracidium]).
V. Treatment
• Praziquantel; 25 mg/kg/8h PO for one day
VI. Control • Adequate salting and cooking of fish and
snail control.
• Proper disposal of human waste and eradication of stray dogs.
• Mass examination and treatment of fishermen and health education
Trematodes (flukes)
wormHeterophyes
ManFinal host
ReservoirCats, dogs and birds
HabitatIn between villi of small intestine
Exit stageEgg: mature, operculate, thick-shelled, ovoid, golden yellow, 30X15 µm
Intermediatehost
1st : Pirenella snail in brackish water2nd : fish (Bolty & Boury)
Infective stage
Encysted meatcercaria fish muscles underneath scales
Mode of infection
Ingestion of encysted metacercaria in under-salted or under-cooked fish
Disease1. Enetritis 2. Myocarditis due to embolised eggs
diagnosis1. Detection of eggs in stool.
TreatmentPraziquantel
Control1. Thorough cooking of fish 2. sanitary disposal of fishermen excreta.04/11/2317
Fasciola hepatica and F. giganticaI. BIOLOGY• Man, sheep and cattle act as final hosts. • Diagnostic morphology: A. 3-6 x1.2 cm, leaf like hermaphrodite B. with anterior conical part and posterior
elongated part C. having parallel lateral borders in F. gigantica
or converging in F. hepatica.• Habitat in the final host: The biliary tracts
of the liver. • Exit stage: Immature egg.
Lymnaea snail
Fasciola egg
Fasciola hepatica
Simple tailed cercaria
E. metacercaria on
grass
II. Epidemiology• Geographical distribution: Egypt and
sheep and cattle raising countries.• Transmission: 1. Intermediate host (I.H.): Lymnaea is
1st I.H. and vegetable is 2nd I.H.2. Reservoir hosts: Sheep and cattle act
as final reservoir hosts3. Infective stage: Encysted metacercaia4. Mode of infection: Ingestion of raw
vegetable contaminated with encysted metacercaia
III. Host-Parasite Relationship• Immune responses:Humoral: Early development of IgM, IgE, IgG1 and IgG2 to
ES Fasciola Ags. These are of limited role in protection.Cellular: Peripheral eosinophilia and lymphocytosis. The response in the invasive phase is due to Th1
cytokines.Th2 type cytokines predominate when the worms reside in
the bile canaliculi. • Effector protective mechanisms against JF : The toxic NO produced by IFNγ activated macrophages. ADCC; IgG1, IgE, IgA, IgG2a dependent macrophage,
eosinophil, and platelet cytotoxicity This leads to release of the killing granules: ECP, MBP and
eosinophil peroxides.
III. Host-Parasite Relationship• Pathogenesis:• Acute fasciolitic hepatitis during the migratory phase in
liver. It is manifestecd by fever, eosinophilia and allergic features.
• Chronic biliary fascioliasis when the worm resides in the biliary passages causing duct hyperplasia due to excessive proline secretion and biliary obstruction
• This→ jaundice and haematobilia → anaemia. The worm secreted proline also contributes to anaemia via its inhibitory effect on erythropioesis.
• Fasciolitic pharyngitis (Halzoun) caused by the presence of adult in the pharynx after eating infected raw sheep liver infectd with adults..
Pathogenesis
The surface spines of Fasciola damage the biliary epithelium during chronic stage
Juvenile Fasciola migrating in liver parenchyma during invasive stage
IV. Diagnosis• Detection of eggs in stool.
Direct and conc.• Egg charcteristics: 1. thin walled, 2. 140 x 70 µm, 3. ovoid, 4. yellowish brown,
Operculated, 5. immature (does not contain
developed larva [miracidium]).
Indirect diagnosis
Serodiagnosis (sp. during invasive stage)
• IFAT (T.S of adult worm) or ELISA (ES ags).
Imaging: CT sonography
V. Treatment• Triclabendazole (10 mg/kg PO for one dose)
or Mirazid.
VI. Control1. Adequate washing of vegetable.
2. Mass treatment of Reservoirs.
3. Sanitations of slaughter houses.
4. Control of snails.
5. Proper disposal of human waste.
Trematodes (flukes)wormFasciola
ManFinal host
ReservoirSheep and cattle
HabitatBiliary passages
Exit stageEgg: Immature, operculate, thin-shelled, yellowish brown, 140 X70 µm
Intermediatehost
1st : Lymnaea snail in fresh water2nd : vegetable (watercress)
Infective stage
Encysted meatcercaria on vegetable
Mode of infection
Ingestion of encysted metacercaria in vegetable
Disease1. Acute stage: fever 2. chronic stage: jaundice, anemia 3. Halzoon
diagnosis1. Detection of eggs in stool & in duodenal aspirate (DA), 2. Detection of specific abs & ags in serum
TreatmentTriclabendazol orally.
Control1. Thorough wash of vegetable 2. snail control 3. cooking of liver04/11/2328
Paragonimus westermani
Final host: Humans, dogs, cats, rodents and pigs.
Habitat: Encapsulated in the bronchioles of the lung
Exit stage: immature eggs passed in feces and sputum. Basic morphology and life
cycle: adult thick bodied 4 mm x 8 mm.
I. Biology
Adult
Egg in sputum
II. Epidemiology Distribution: worldwide but more confined
in oriental countries such as Japan. Reservoir hosts: Dogs, cats, rodents and
pigs. Intermediate hosts: 1st IH snail;
Semisulcospira or Thiara and 2nd fresh water cructaceans.
Infective stage: Encysted metacercaria in gills and muscles of crustaceans (crabs).
Mode of infection: ingestion of encysted metacercaria in undercooked crustacean.
III. Host Parasite Relationship Early symptoms cough with blood tinged sputum.Low grade fever Difficult
to distinguish from pneumonia and
tuberculosis.Ectopic sites may
include: abdominal wall, heart, lymph nodes and
nervous system.
T.S. of lung containing encapsulated adult
Eggs in m. LN with granulomas abundant with esosinophils
IV. Diagnosis
Clinical picture with eosinophila in endemic
areas.Detection of eggs in
sputum or feces.Serology for ectopic
sites DIG or ELISA.Imaging: plain x-ray.
V.Treatment
• Praziquantel; 25mg/kg/8h PO for 2 days
• Bithionol ; 20 mg/kg/12h Po daily for 14 ds.
VI.Control• Health education.
• proper cooking of crabs and crayfish .
Schistosoma mansoni & S. hematobium• BIOLOGY Man only acts as final hosts.
Diagnostic morphology: sex separate flukes.
Male is ~ 20 mm covered with tubercle, flattened dorso-ventrally and folded on it self to form gynecophoric canal.
Female is ~ 26 mm cylindrical and smooth carried by the male. Habitat in the final host:
Inf. mesenteric veins draininnig large intestines in S. mansoni. vesical plexus draining urinary bladder in S. hematobium.
Exit stage: mature egg in stool (S.mansoni) and in urine (S. hematobium).
II. Epidemiology Geographical distribution: Africa, south America,
Middle East and Portugal. Transmission:
1. Intermediate host (I.H.): The snails; Biomphalaria is I.H. of S.mansoni and Bulinus is I.H. of S
hematobium.
2. Reservoir hosts: No animal reservoir hosts.
3. Infective stage: Free swimming cecaria in fresh water
4. Mode of infection: free cercaria penetrates skin
III. Host-Parasite Relationship
A. Early cell mediated immunity before egg laying.
B. Late humoral antibody dependent cell mediated cytotoxicity (ADCC).
• Immune responses:
• Pathogenesis1. Cercarial dermatitis (swimmer's itch): maculo-papilar rash in areas of skin exposed to cercaria S.
haematobium, S.mansoni and to avian schistosome infection.
– It is due to immediate or late hypersensitivity reaction that begins 1-2 days after exposure. It
more common among the newcomers to endemic areas.
2. Acute schistosomiasis (Takayama fever): fever occurs weeks after the primary infection.
– It is due to massive IFN-γ and TNF-α cytokines of TH1 response priming for granuloma formation
around the eggs.
• Pathogenesis1. Chronic schistosomiasis: occurs due to TH2
cytokine response that strongly expands the granuloma size.
2. The cellular components of this granuloma are plenty of eosinophils plus macropages,
fibroblasts and lymphocytes. Eosinophil mediated chronic inflammatory reactions predispose to
fibrosis around the eggs in tissues of the affected organs.
3. Downregultion of fibrosis is associated with diminshed TH2 cytokines and increased TH1
cytokines.
Pathogenesis
Cercarial dermatitis
Adult in lung
Planorbis
granulomas in lung Egg granuloma in liver
• Pathogenesis• The manifestations in the chronic stage include:
In S. mansoni:a) Colonic polyps with bloody diarrhea
b) Periportal fibrosis → portal hypertension with hematemesis and splenomegaly.
In S. hematobium:a) Cystitis (sq cell carcinoma), ureteritis with hematuria.
b) Ureteric stricture induces hydronephrosis
c) CNS disorders and core pulmonale occur earlier in S.hematobium due to direct passages of eggs from
bladder and ureteral veins into systemic veins than in S. japonicum and mansoni.
d) In the latters they occur later after the onset of portosystemic shunts.
Portosystemic shunts1. esophageal varices;
2. paraesophageal varices;
3. gastrorenal shunt; 4. splenorenal shunt; 5. inferior
mesenteric, hemorrhoidal, & internal iliac veins
6. mesocaval shunt; 7. intrahepatic
portosystemic shunt;
8. Sappey's veins
Pathogenesis
Colonic polyps endoscopy
Polyposis post mortem
Eggs in C. polyp biopsy
B splenomegalyPeriportal fibrosis
Periportal fibrosis
Esophageal varices
Pathogenesis (hematobium)
Ureteral dilatation due to calcified stenosis of orifices
Rt unilateral hydronephrosis
Squamous cell carcinoma of bladder. Ova of hematobium are often found in such tumour
Fetal head appearnce due to intense calcification of bladder→
IV. Diagnosis Detection of eggs in stool (S.mansoni) or in urine
(S.hematobium).
Egg characteristics:
o S. mansoni: Ovoid non-operculated, 140 x 70 µm, yellowish brown with lateral spine and mature (contains
miracidium).
o S. hematobium: spindle shaped, non-operculated, 140 x 70 µm, yellowish brown with terminal spine and mature
(contains miracidium).
o Serology in prepatent and chronic infection to detect specific schistosome antigens and antibodies
V. Treatment• Praziquantel; 40 mg/kg PO with food divided
into 2 doses separated by 4-6 hours for S. mansoni and hematobium .
VI. Control
1. Avoiding swimming in fresh water.
2. Proper disposal of human waste.
3. Control of snails and health education.
4. Mass treatment
Trematodes (flukes)wormSchistosoma mansoniSchistosoma hematobium
ManFinal host
Reservoirnone
HabitatVeins draining large intestinesVeins draining urinary tracts
Exit stagemature, ovoid egg with lateral spine 150X70µm
Mature, ovoid, egg with terminal spine,150X70µm
Intermediate hostBiomphalaria snailBulinus snail
Infective stageFree swimming cercaria
Mode of infectionFree cercaria penetrate skin immediately after bathing in water
Disease1.Cercarial dermatitis, 2.Katayama fever3.Bloody diarrhea, 4.Anemia5.Periportal fibrosis:a)Portal hypertension, b)Splenomegalyc)Esophageal varices., d)Ascites
1.Cystitis, ureteritis2.Dysuria and hematuria.3.Anemia4.Carcinoma of U. bladder
diagnosisDetection of egg in stool, detection of specific abs & ags in serum
Detection of egg in urine, detection of specific abs & ags in serum
TreatmentOral Praziquantel
Control1.Mass treatment of human cases. 2.Snail control3.Sanitary disposal of sewage04/11/2348