C H A P T E R 61

Medical parasitology

QUESTIONS
•Q1
The optimal blood specimen is not often provided for malaria smears. State what
this specimen is and also what the second choice is in terms of anticoagulant.
(p. 1121)

•Q2
What is the only stain that allows visualization of erythrocyte stippling in malaria
smears? (p. 1121)

•Q3
Which two fecal matter fixatives contain mercury and are thus difficult to dispose
of safely in the laboratory? (p. 1122)

•Q4
What are the three types of microscopic examination routinely performed on stool
specimens? (p. 1123)

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 384
•Q5
What three organisms may be better visualized with either a modified iron
hematoxylin or modified acid-fast stain? Discuss the sensitivity and specificity of
the acid-fast stain for these organisms. (p. 1123)

•Q6
Several human cells and types of organic material resemble parasites and can make
diagnosis challenging. What do Entamoeba histolytica trophozoites look like?
(Table 61–4, p. 1124)
Medical parasitology

•Q7
Review the lifecycle of Plasmodium species by stating whether the following events
or parasite forms are found in the mosquito or in humans. (Fig. 61–1,
pp. 1128–1130)
Fertilization of macrogamete: ––––––––––––––––––––––––––––––––––––––––––––––––––––––
Immature schizont: ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Release of merezoites: ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Liberation of sporozoites: ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Mature schizont: –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
61
•Q8
CHAPTER

Differentiate between true disease relapse and recrudescence in malaria and state
which Plasmodium species exhibit each. (pp. 1128–1129)

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 385
•Q9
Clinical Consultation: A 23-year-old female returned from a 1-week trip to West
Africa 3 months ago and has complained of fevers and chills for the past week. She
is now hospitalized and is noted to have fevers to 102.5°F every other day at about
2:00pm. The clinician suspects malaria. Based on her history and fever curve, what
two species are now unlikely or at least less likely? (Table 61–8, pp. 1130–1133)
––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––
Using what you learned from question 1 in this chapter and the guidance on
page 1121, what do you recommend for collection of a blood sample?
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
What age of red blood cells (RBCs) will you pay particular attention to in your
microscopic examination?
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
You find several intracellular parasites on the thick smear, and note ameboid forms,
Shüffner’s dots, and 13–16 merozoites in the few mature schizonts you find. You

QUESTIONS
diagnose:
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
The woman then reveals to the clinician that her brother had an episode of
hemolytic anemia when he was treated for vivax malaria last year. She wonders if
she is at risk for hemolysis. Is she? Explain your answer.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

• Q 10
Are both trophozoites and gametocytes seen in humans with babesiosis? (p. 1134)

• Q 11
Review the morphologic forms of the two important genera of hemoflagellates,
stating which form is found in which vector or host. (pp. 1134–1135)
Leishmania spp. in humans: ––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Trypanosoma cruzi tissue in humans: ––––––––––––––––––––––––––––––––––––––––––––––––
Leishmania spp. in insect vector: ––––––––––––––––––––––––––––––––––––––––––––––––––––
Trypanosoma in insect vector: –––––––––––––––––––––––––––––––––––––––––––––––––––––––
Trypanosoma in bloodstream in humans: –––––––––––––––––––––––––––––––––––––––––––

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 386
• Q 12
Compare and contrast the trypanosomiases. (p. 1135)

East African West African American

Hemoflagellate

Vector

Illness severity (describe)

Length of parasite (blood)

• Q 13
Review the major hemoflagellates causing the various forms of leishmaniasis.
(pp. 1135–1136)
Medical parasitology

L. donovani causes ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

L. braziliensis causes the aggressive ––––––––––––––––––––––––––––––––––––––––––––––––––
L. mexicana and L. braziliensis cause the less severe New World –––––––––––––––––––––
L. tropica and L. major cause Old World ––––––––––––––––––––––––––––––––––––––––––––

• Q 14
How will you distinguish Leishmania spp. from Histoplasma capsulatum in a tissue
biopsy? (p. 1136)

61
CHAPTER

• Q 15
What three types of serologic tests are employed to diagnose toxoplasmosis?
(p. 1137)

• Q 16
What is the etiologic agent of primary amebic meningoencephalitis? (p. 1137)

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 387
• Q 17
What genus causes granulomatous amebic meningoencephalitis, and keratitis in
contact lens wearers? (p. 1138)

• Q 18
List the three genera of ameba that inhabit the intestinal tract of humans. (p. 1138)

QUESTIONS
• Q 19
The only amebic species that is invasive and causes disease in humans is Entamoeba
histolytica. What nonpathogenic species looks identical to E. histolytica in stool
specimens? (p. 1139)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
What commercially available test will discriminate between the two?

• Q 20
How useful is the serologic test for diagnosing amebic liver abscess if stool samples
are negative? (p. 1139)

• Q 21
Differentiating between Entamoeba histolytica and the nonpathogenic Entamoeba
coli is challenging. Erythrophagocytosis by a trophozoite, if present, is diagnostic
for E. histolytica. Otherwise, cyst forms may be compared and contrasted. Review
these. (Table 61–10, p. 1142)

E. histolytica E. coli

Usual size

No. of nuclei (mature cyst)

Appearance of chromatid bodies

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 388
• Q 22
Dientamoeba fragilis is an ameboid flagellate which causes diarrhea, often in
young children. Trophozoites are roughly 10 μm, with binucleation being the
predominant form. A positive specimen should raise suspicion for what other
intestinal parasite? (p. 1142)

• Q 23
Describe in the box below how you can differentiate between Giardia lamblia and
Chilomastix mesnili. (Figs. 61–13 and 61–14, pp. 1143–1144)

G. lamblia C. mesnili

Nuclei in trophs
Medical parasitology

Nuclei in cysts
Patient symptoms

• Q 24
Clinical Consultation: A 48-year-old male pig farmer has had diarrhea for 1 week.
Colonoscopy showed ulcerations, and a biopsy was performed. List some of the
morphologic features that will help you diagnose Balantidium coli. (p. 1144)

61
CHAPTER

• Q 25
List the four coccidian parasite genera that infect humans. (p. 1144)

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 389
• Q 26
State how the size of the organism will distinguish oocysts of Cryptosporidium
parvum from those of Cyclospora cayetanensis on an acid-fast preparation of a stool
specimen. (pp. 1145–1146)

• Q 27
Describe the appearance of microsporidia on a modified trichrome stain. (p. 1146)
Color: ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Size: –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Shape: –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

QUESTIONS
• Q 28
The Cellophane test is the method of choice for diagnosing Enterobius vermicularis.
Adult females measuring up to –––––––––––––––––––––––––– in length and colorless
ovoid eggs –––––––––––––––––––––––– long are easily identified. (Fig. 61–16, p. 1147)

• Q 29
How does pneumonitis occur in ascariasis if ova are ingested orally, and the adults
live in the duodenum and jejunum? (p. 1148)

• Q 30
Describe how the buccal chamber morphology can be used to distinguish
between rhabditoid larvae of hookworms and Strongyloides stercoralis. (Fig. 61–19,
pp. 1149–1150)

• Q 31
Like Ascaris lumbricoides, Strongyloides stercoralis adults live in the duodenum and
may cause Löffler syndrome/pneumonitis in the migration stage. They differ from
A. lumbricoides in several ways. Outline these by reviewing the life cycle of
S. stercoralis. (pp. 1149–1150)
How parasite enters host (human): ––––––––––––––––––––––––––––––––––––––––––––––––
Form found in stool specimens: ––––––––––––––––––––––––––––––––––––––––––––––––––––
Variant of life cycle in immunosuppressed host: ––––––––––––––––––––––––––––––––––––

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 390
• Q 32
How may the number of lateral branches of a gravid uterus differentiate between
Taenia saginata and T. solium? (Fig. 61–21, p. 1150)

• Q 33
Infection with the pork tapeworm and cysticercosis are not acquired in the
same way and are not interchangeable terms. Distinguish between the two.
(pp. 1150–1151, 1157)
Medical parasitology

• Q 34
The common first intermediate host of all trematodes is: (p. 1152)

• Q 35
Differentiation between the ova of Fasciolopsis buski and those of Fasciola hepatica is
not usually possible. What clinical symptoms or laboratory tests would suggest one
fluke over the other? (pp. 1152–1153)
61
CHAPTER

• Q 36
Longstanding infection with Clonorchis sinensis is linked to what malignancy?
(p. 1153)

• Q 37
Both Fasciola hepatica and the lung fluke Paragonimus westermani have
unembryonated, operculated ova. Describe the size difference that distinguishes the
two. (Fig. 61–16, pp. 1147, 1153)

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 391
• Q 38
What form/stage of the schistosome penetrates the skin of humans? (p. 1154)

• Q 39
Which two species of Schistosoma have a lateral spine? (p. 1154)

• Q 40

QUESTIONS
Review the periodicity of the common filarial worms by stating the optimal time to
draw blood for examination. (p. 1155)
Wuchereria bancrofti: ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Brugia malayi: ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Loa loa: –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Mansonella spp: ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

• Q 41
Differentiation of the filarial worm is based on morphology, but there may be
other clues to their identity on an exam question, such as the insect vector. Review
both of these features. (Figure 61 –25, pp. 1155–1156)

Sheath Nuclei in tail tip Vector(s)

Wuchereria bancrofti

Brugia malayi

Loa loa

Onchocerca volvulus

Mansonella spp.

• Q 42
Clinical Consultation: A 10-year-old boy whose parents are sheep farmers develops
abdominal pain and is found to have a single, unilocular, 9 cm cyst filled with
clear fluid in his liver. His primary chore at home is to clean up after the family’s
Australian shepherd dog. Give three species of cestode, from two genera, that are
diagnostic possibilities. (pp. 1158–1159)

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 392 ANSWERS
A1. A drop of fresh blood, directly from a finger stick or syringe, is preferred
because it does not distort the parasite. If anticoagulant must be used, then
ethylenediaminetetraacetic acid (EDTA) is preferred.
A2. Giemsa stain will allow for visualization of the Shüffner’s dots.
A3. Schaudinn’s and polyvinyl alcohol (PVA) both contain mercury. The modified
PVA fixatives replace mercury with either zinc sulfate or copper sulfate.
A4. The three basic examinations are the direct wet mount with a drop of saline
or iodine, the wet mount of a concentrate, and the permanent stain. The
direct mount is best for identifying motility, the concentration method is
more sensitive if few organisms are present, and the stains can bring out small
organisms such as amebae.
A5. The oocysts of Cryptosporidium, Cyclospora, and Isospora are better visualized with
Medical parasitology

these stains than with Wheatley’s trichrome, so this is a more sensitive method.
It is not, however, specific, and careful attention must be paid to size and
comparison with positive controls.
A6. E. histolytica trophozoites resemble macrophages, which are likely to be present
in the specimen along with parasites.
A7. Fertilization of the macrogamete and liberation of sporozoites occur in the
mosquito. Both schizont forms and the release of merozoites occur in humans.
A8. True disease relapse occurs when there is a renewal of exoerythrocytic schizony
by latent hepatic sporozoites, called hypnozoites. This occurs with P. vivax and
P. ovale.
Recrudescence does not involve the liver. It is a rise in parasitemia from
61 undetectable to clinically detectable levels. It occurs with P. falciparum and
P. malariae.
CHAPTER

A9. P. falciparum usually presents within 1 month, and P. malariae has quartan
periodicity, so these are less likely.
Collect blood by syringe or fingerstick near 2:00 pm on a ‘febrile’ day.
Examine the smear for younger red blood cells (reticulocytes).
Diagnosis: P. vivax.
If this woman is a heterozygote with a dual population of red blood
cells, she may experience some degree of hemolysis, but not as severe as her
brother’s.
A10. No, just trophozoites. As P. falciparum often shows only the ring forms,
distinguishing between the two with no travel history can be tough.
A11. Leishmania and T. cruzi in humans are in the amastigote form.
The promastigote is found in the insect vector for Leishmania.
The epimastigote form is in the insect vector for Trypanosoma.
The trypomastigote is found in the bloodstream of humans.

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 A12. East African trypanosomiasis is caused by Trypanosoma brucei rhodesiense, 30 μm 393
long, carried by the tsetse fly, Glossina spp. It is rapidly fatal.
West African trypanosomiasis is caused by T. brucei gambiense, 30 μm long,
also carried by Glossina spp. flies. It is more chronic, but can be fatal.
American trypanosomiasis (Chagas disease) is caused by Trypanosoma cruzi,
20 μm long, carried by the reduviid bug. It may have an acute or chronic
course.
A13. L. donovani – visceral form.
L. braziliensis – mucocutaneous.
L. mexicana and L. braziliensis – New World cutaneous.
L. tropica and L. major – Old World cutaneous.
A14. Leishmania have a kinetoplast but lack a cell wall. H. capsulatum lacks the
kinetoplast but its cell wall may stain with Gomori’s methenamine silver or
periodic-acid–Schiff.

ANSWERS
A15. Sabin–Feldman (an antibody titer), indirect fluorescent antibody (IFA), and
enzyme immunoassay (EIA).
A16. Naegleria fowleri. This is nearly always fatal.
A17. Acanthamoeba spp. are classically associated with keratitis in contact lens
wearers.
A18. These are Entamoeba, Endolimax, and Iodamoeba.
A19. E. dispar is the nonpathogen. EIA antigen detection can help distinguish the
two.
A20. Very useful. It has a 95% sensitivity if one has a liver abscess. By contrast,
serologies are much less often positive (10%) in asymptomatic carriers.
A21. E. histolytica and E. coli cysts are nearly the same size, with E. coli a little larger
(15–25 μm vs 12–15 μm). E. histolytica cysts have four nuclei and blunt or
rounded chromatoidal bodies. E. coli cysts have eight nuclei and splintered or
pointed chromatoidal bodies.
A22. Enterobius vermicularis, the agent of pinworms.
A23. G. lamblia has two nuclei in the trophozoite and four in the cyst stage. It also
causes diarrhea. C. mesnili, in contrast, has just one nucleus in either stage and
is nonpathogenic. If a person is symptomatic, and one finds only C. mesnili,
one must continue to search for a cause.
A24. B. coli is the largest parasite one will see under the microscope. The trophozoite
is 50–100 μm, and the cyst is 50–70 μm. It is ciliated, another feature that
makes it unique among pathogens. It has a large macronucleus and many
cytoplasmic food vacuoles.
A25. Isospora, Sarcocystis, Cryptosporidium, and Cyclospora are the four coccidians that
infect humans.
A26. C. parvum is just 4–6 μm in diameter, while C. cayetanensis is 8–10 μm.
A27. Microsporidia are extremely small, but the modified trichrome stain helps
bring them out. They are elliptical in shape, just 1.5–3 μm in size, and red with
this stain.

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 394 A28. Adults are up to 13 μmm long, and ova are 50–60 μm in length.
A29. Ingested eggs hatch in the intestine and migrate through the wall of the bowel
as larvae to enter the bloodstream. They travel to the lungs and mature briefly
in the alveolar capillaries before being coughed up, swallowed, and returning
to the intestines, where they mature into adults. A large load of larvae in a
person previously sensitized to Ascaris lumbricoides can lead to an allergic
reaction.
A30. Strongyloides has a short buccal cavity, about as long as the (narrowed) anterior
tip is wide. Hookworms have a longer buccal cavity, about as long as the body
is wide.
A31. Humans are infected by penetration of the skin by infective (third-stage) larvae.
They pass first-stage larvae in their stool, and rarely pass ova. Autoinfection can
occur in the debilitated host.
A32. T. saginata has 15–20 branches, while T. solium has 7–13.
Medical parasitology

A33. Ingestion of undercooked pork containing cysticerci results in the tapeworm

developing in the gut and passage of T. solium ova in the feces. This is mildly
debilitating. Ingestion of T. solium eggs, from one’s own tapeworm or from
poor hygiene, with spreading of the ova to others, causes cysticercosis. This is a
serious, often fatal illness.
A34. The snail is the common intermediate host. Many trematodes have a second
intermediate host, such as a fish or crab.
A35. F. buski causes diarrhea and nausea. The geographic range is south-east Asia,
China, and India and is found in people who eat water chestnuts (and possibly
have contact with pigs). Peripheral blood eosinophilia may be seen even
in asymptomatic persons. F. hepatica, with a wider geographic distribution
61 and acquired by ingestion of watercress, causes biliary colic and obstructive
jaundice, so an elevated direct bilirubin or alkaline phosphatase might be
helpful. Eosinophilia would be seen with F. hepatica as well, so this would not
CHAPTER

be a useful discriminator.
A36. Cholangiocarcinoma is an adverse outcome associated with chronic Clonorchis
infestations.
A37. F. hepatica is about 140 μm long, while P. westermani is about 90 μm.
A38. The cercaria stage penetrates the intact skin of humans.
A39. Both S. mansoni and S. japonicum have lateral spines, but they are often poorly
visible in S. japonicum.
A40. Both W. bancrofti and B. malayi are nocturnal, so 10:00 pm to 2:00 am is the
recommended time to draw blood. L. loa is best harvested at noon. Mansonella
spp. lack periodicity and can be found any time.
A41. W. bancrofti have a sheath, have no nuclei in the tail, and are transmitted by
several mosquito vectors – Culex, Aedes, and Anopheles.
B. malayi have a sheath, have two nuclei in the tail, and are transmitted by
Aedes, Anopheles, and Mansoni spp. mosquitos.
L. loa has a sheath, has some nuclei in the tail, and is transmitted by the
Chrysops deer fly.

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 O. volvulus lacks a sheath, has no nuclei in the tail, and is transmitted by the 395
Simulium black fly.
Mansonella spp. lack a sheath, have nuclei in the tail, and are transmitted by
Culicoides gnats.
A42. Echinococcus granulosus is associated with sheep and is probably the first choice.
Also consider the dog or cat tapeworms Taenia multiceps or Taenia serialis in this
case.

ANSWERS

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