AUST

Clinical Parasitology
CLS 450

Dr. Renée Zakhia

[email protected]

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Course Outline
 Introduction to  Naegleria species  Clonorchis sinensis
parasitology and  Acanthamoeba species  Paragonimus westermani
laboratory diagnostic  Nematodes  Cestodes (tapeworms)
 Intestinal and urogenital (roundworms)  Taenia solium
Protozoa  Trichuris trichiura  Taenia saginata
 Entamoeba histolytica  Enterobius vermicularis  Hymenolepis nana
 Balantidium coli  Ascaris lumbricoides  Diphyllobothrium latum
 Giardia lamblia  Toxocara canis  Echinococcus granulosus
 Dientamoeba fragilis  Ancylostoma duodenale  Echinococcus multilocularis
 Trichomonas vaginalis Necator americanus
  Arthropods
 Cryptosporidium parvum  Strongyloides stercoralis  Insects
 Cyclospora cayetanensis  Trichinella spirallis  Pediculus humanus
 Isospora belli  Wuchereria bancrofti  Pediculus capitis
 Sarcocystis species  Dracunculus medinensis  Phthirus pubis
 Blood and tissue  Loa Loa  Mites
Protozoa  Onchocerca volvulus  Sarcoptes scabiei
 Plasmodia species  Trematodes (flukes)
 Babesia species  Schistosoma species
 Toxoplasma gondii  Fasciola hepatica
 Leishmania species  Fasciolopsia buski
 Trypanosoma species
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 Blood and tissue Protozoa

Toxoplasma gondii
(Toxoplasmosis)

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 Outline
 Causative agent
 Parasitic cycle
 Mode of transmission
 Epidemiology
 Clinical aspects
 Diagnosis
 Treatment
 Prevention

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 Causative agent
 Domain: Eukaryota
 Phylum: Apicomplexa (sporozoa)

 Class: Conoidasida
 Subclass: Coccidia
 Family: Sarcocystidae

 Genus: Toxoplasma
 Species: T. gondii

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 Causative agent (2)
Toxoplasma gondii exists in 3 different evolutionary forms
 A vegetative form called tachyzoite or trophozoite
(Intermediate host)

 The bradyzoite that results from the tachyzoite stage

during its evolution in the intermediate host.

 The sporozoite is the result of sexual reproduction that

takes place in the cells of the intestinal epithelium of the
definitive host.

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Causative agent

Tachyzoite or trophozoite
 Obligate intracellular parasite (macrophages)
 6 to 8 μm long and 3 to 4 μm arcuate, with tapered ends
 Rapid multiplication
 Very fragile, destroyed by HCl
 Characterized by the P30 protein

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Causative agent

Tachyzoite or trophozoite (2)

 Conoid: apical end of the parasite, penetration into the

host cell
 Micronemes, rhoptries and dense granules: main
organelles of secretion and invasion
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Causative agent

Bradyzoite or cystozoite
 Morphologically very close to the tachyzoite
 distinguished by a slow metabolism (slow multiplication)

 They are grouped within 100μm cysts containing 2 to

3000 bradyzoites
 inaccessible to immune defences and treatments

 They sit mainly in neurons, astrocytes, muscle cells and

retinal cells.

 More resistant than tachyzoites

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Causative agent

Bradyzoite or cystozoite (2)

Ruptured Toxoplasmic cyst

Toxoplasmic cyst in smear of bone

marrow, Giemsa stain
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Causative agent

Sporozoite
 Result of sexual reproduction in the cells of the intestinal
epithelium of the definitive host (cat)

 Morphologically little different from other infectious

stages

 Maturation in the environment

 sporulated oocysts can survive in the environment more than
one year in a humid climate

 Very resistant in the environment

 HCl resistant
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Causative agent

Sporozoite (2)

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 Parasitic life cycle
 Indirect life cycle
 Definitive hosts: cats and wild felidae (sexual reproduction)
 Intermediate hosts: warm-blooded animals = homeotherms
(terrestrial and marine mammals, birds) (asexual forms)

 Felids are infected by hunting infected intermediate hosts

(birds, mammals)
 Intermediate hosts get infected from oocysts in the
environment
 on the ground, plants or in drinking water

 Toxoplasma has an incomplete cycle that does not involve DH

 the parasite moving from one IH to another by ingestion of cysts
present in the flesh of carnivorous or herbivorous animals

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 Parasitic life cycle (2)
 Unsporulated oocysts are shed in the cat’s feces

 Although oocysts are usually only shed for 1-3 weeks,

large numbers may be shed.

 Oocysts take 1-5 days to sporulate in the environment

and become infective.

 Cats become infected after consuming intermediate hosts

harboring tissue cysts.

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Parasitic life cycle

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 Mode of transmission to humans
Transmission by oocyst absorption
 mainly indirect by consumption of raw fruits and vegetables
poorly washed or contaminated drinking water
 insufficient hand hygiene after contact with soil (gardening) or
animals

Transmission by cysts
 consumption of smoked or undercooked meat (sheep)
 cysts destroyed only by cooking the meat at 67°C (for 15min) or
freezing below -12°C for at least 3 days
 cysts can survive for several days at room temperature, and several
months at 4°C
 organ transplantation from a toxoplasmosis seropositive
donor to a seronegative recipient before the transplant

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 Mode of transmission to humans (2)
Transmission by tachyzoites
 the tachyzoite is a fragile form, destroyed in the external
environment and by the gastric juice.

 agents of transplacental transmission, responsible for

congenital toxoplasmosis

 responsible for exceptional cases of transfusion

transmission
 possible if the donor was in the full parasitemic phase of
toxoplasmosis

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Transmission to humans

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 Mode of transmission in pregnant women
 The intake of a meal outside Home
 an occurrence that does not allow careful control of raw
vegetables washing or cooking meat

 The presence of a cat in the entourage does not appear

as a high risk factor
 the only cats that pose a risk are young animals that hunt for
food outside houses
 cats eliminate oocysts for only a few weeks during their
lifetime, during the primary infection
 these oocysts must remain for a certain time (24-48 hours) in
the external environment to become infective
 they are emitted non sporulating (immature)

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 Epidemiology
 Toxoplasmosis is cosmopolitan
 its prevalence increases with age and varies with environment and
dietary habits
 In developed countries, contamination is mainly related to the
consumption of infected meat.
 Low prevalence <25% in countries where meat is eaten well cooked
(Scandinavia, North America).
 In Southeast Asia and Japan the prevalence is very low <10%
 20 to 30% in the Indian subcontinent and the Middle East
 In the tropical countries of Africa and America, the
contamination is rather related to the absorption of oocysts.
 low prevalence in areas where the climate is hot and dry, unfavorable
for survival of oocysts on the ground
 high prevalence 80% in humid regions

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 Clinical aspects
 The clinical expression of toxoplasmosis is related to host-
parasite interactions and will be different depending on the
immune status of the patient and the parasite strain involved.

 There are three main clinical aspects

Toxoplasmosis of
immunocompetent subject
Toxoplasmosis of
immunocompromised
subject
Congenital toxoplasmosis

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Clinical aspects

Toxoplasmosis of immunocompetent subject

Asymptomatic forms (> 80% of cases)
 Perceptible cervical glands for 1 week
 No fever
 Persistence of cysts (immunity detectable by IgG)

Sub-acute forms (15 to 20% of cases)

 Incubation of a few days
 Symptoms: fever, lymphadenopathy and asthenia
 prolonged fever for a few days/weeks, disappear spontaneously
 adenopathies especially cervical, not very bulky
 asthenia can be deep and persist for several months
 Evolution is usually benign with spontaneous healing
 Persistence of cysts (immunity detectable by IgG)
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Clinical aspects
Toxoplasmosis of immunocompetent
subject (2)
Rare acute forms
 Fever
 Ocular, cardiac, pulmonary, neurological lesions

 The sepsis phase is prolonged

 virulent excretions allowing direct contagion
 urine, tears, milk, saliva

 Persistence of cysts (immunity detectable by IgG)

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Clinical aspects
Toxoplasmosis of immunocompromised
subject
 Serious disease, constantly fatal without treatment
 except isolated ocular forms that can lead to blindness
 Classical descriptions distinguish

Disseminated forms Localized forms

The problem is that of an isolated fever

whose diagnosis is sometimes made only
on secondary visceral locations.
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Clinical aspects
Toxoplasmosis of immunocompromised
subject (2)
Localized toxoplasmosis
 The most common location is cerebral
 one or more abscesses (persistent headache, fever, ...)
 an epilepsy is possible

 The second most frequent location is ocular

 decreased visual acuity, redness of the eyes, ...
 Pulmonary toxoplasmosis is defined as febrile dyspneumatic
pneumonia suggestive of pneumocystosis.

 T. gondii tachyzoite can enter any type of cells, resulting in

severe cases in the most diverse locations
 diagnosis is made by anatomic/pathological examination

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Clinical aspects
Toxoplasmosis of immunocompromised
subject (3)

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Clinical aspects

Congenital toxoplasmosis
 Generally, if a woman has been infected before becoming
pregnant, the unborn child will be protected because the
mother has developed immunity.
 If a woman becomes newly infected with Toxoplasma during or
just before pregnancy, she can pass the infection to her unborn
baby (congenital transmission).

 In early pregnancy (before the 4th month)

 risk of fetal infection is low
 risk of severe congenital toxoplasmosis (death, cranial deformation,
ocular infections …)

 In late pregnancy (4th month to 9th month)

 greater risk of fetal infection
 risk of benign or latent congenital toxoplasmosis (ocular lesions …)
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Clinical aspects

Congenital toxoplasmosis (2)

IgM, IgA and IgE

first antibodies IgG antibodies
synthesized; their produced after
persistence varies IgM antibodies
according to the and last years
subjects

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 Diagnosis
Toxoplasmosis of immunocompetent subject
 Orientation made by the clinical and epidemiological
arguments (origin, habit of life, ...)
 Almost impossible to detect the parasite
 Detection of persistent serum antibodies that will reveal
the immunity status of the subject

 Active toxoplasmosis: seroconversion

 2 sera samples spaced 15 to 20 days
 1st negative serum, 2nd positive serum
 the presence of IgM with a significant elevation of IgG titer
between the 1st and the 2nd serum

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 Diagnosis
Pregnant women
 Knowledge of her immune status before/early pregnancy
 Detection of possible seroconversion during pregnancy
 Assessment of the risk of fetal transmission and fetal
monitoring
 Postnatal surveillance for several years

 Serology results
 If negative: monthly sero-diagnosis + prophylaxis measures
 Seroconversion: immediate treatment of the mother and
monitoring of the fetus; no risk for the next pregnancy
 If positive: no risk

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Diagnosis
Toxoplasmosis of immunocompromised
subject
 Little or no detectable serum antibody due to immune
deficiency
 Use of clinical arguments and imaging

 Direct methods of diagnosis (parasite search)

 The search for tachyzoites would be possible only during the
septicemic phase of the disease, their scarcity makes their
detection unlikely.

 Optical staining, labeling with monoclonal antibodies, PCR

of a biological sample (BAL, CSF, peripheral blood,
marrow ...)

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 Treatment
 Most healthy people recover from toxoplasmosis without
treatment.

 Persons who are ill can be treated with a combination of drugs

 pyrimethamine and sulfadiazine, folinic acid

 Pregnant women, newborns, and infants can be treated,

although the parasite is not eliminated completely.

 The parasites can remain within tissue cells in a less active

phase; their location makes it difficult for the medication to
completely eliminate them.
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 Prevention
Congenital toxoplasmosis
 Well cooked meat (beef, sheep, pork, horse) (at least 65°C)
 Wash vegetables and aromatic plants thoroughly, especially if
they grow on ground and are eaten raw
 Good hygiene of hands and cooking utensils

 In the presence of a cat

 avoid direct contact with objects that may be contaminated by cat
feces (litter boxes, earth)
 wear gloves
 disinfect cat litters and boxes with boiling water frequently

 Avoid direct contact with soil and wear gloves while gardening
 wash hands after gardening even if they are protected by gloves

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