Trypanosomiasis

Etiologic agents
• Trypanosoma brucei complex – T. brucei gambiense and T. brucei
rhodeseinse African trypanosomiasis (sleeping sickness). The third
subspecies T. brucei brucei is a parasite primarily of cattle and occasionally
other animals, and under normal conditions does not infect humans.
• Trypanosoma cruzi – American trypanosomiasis
Important features

These species may have amastigote, promastigote, epimastigote, and trypomastigote

stages in their life cycle. In human trypanosomes of the African form, however, the
amastigote and promastigote stages of development are absent. Typical trypanosome
structure is an elongated spindle-shaped body that more or less tapers at both ends,
a centrally situated nucleus, a kinetoplast posterior to nucleus, an undulating
membrane arising from the kinetoplast and proceeding forward along the margin of
the cell membrane and a single free flagellum at the anterior end.

• Amastigote: Non-flagellated, intracellular form (e.g., in macrophages).

• Promastigote: Flagellated, extracellular form with anterior flagellum (e.g., in
sandfly gut).
• Epimastigote: Flagellated form with flagellum forming an undulating
membrane, kinetoplast near the nucleus (e.g., in tsetse fly midgut).
• Trypomastigote: Flagellated form with flagellum forming an undulating
membrane, kinetoplast near the posterior end (e.g., in vertebrate bloodstream).
African trypanosomiasis

Trypanosoma gambiense & Trypanosoma rhodesiene are causative agents of the

African trypanosomiasis, transmitted by insect bites. The vector for both is the tsetse
fly.
Life cycle of Trypanosoma brucei
Pathogenesis

The trypomastigotes spread from the skin through the blood to the lymph node and
the brain. The typical somnolence (sleeping sickness) usually progresses to coma as
a result of demyelinating encephalitis. Demyelinating encephalitis is a type of brain
inflammation that involves damage to the myelin sheath, which is the protective
covering that surrounds nerve fibers in the central nervous system (CNS). This
condition can lead to severe neurological symptoms due to the disruption of normal
nerve signal transmission. In acute form, cyclical fever spike (approximately every
2 weeks) occurs that is related to antigenic variation. As antibody mediated
agglutination and lysis of the trypomastigotes occurs, the fever subsides. With a few
remains of antigenic variants new fever spike occurs and the cycle repeats itself over
a long period.

Epidemiology

T. burcei gambiense is limited to Tropical West and Central Africa, correlating with
the range of the tsetse fly vector. The tsetse flies transmitting T.b. gambiense prefer
shaded stream banks for reproduction and proximity to human dwellings. People
who work in such areas are at greatest risk of infection. An animal reservoir has not
been proved for this infection. T. burcei rhodeseinse is found primarily in East
Africa, especially the cattle-raising countries, where tsetse flies breed in the brush
rather than along stream banks. T.b. rhodeseines also differs from T.b. gambiense in
that domestic animal hosts (cattle and sheep) and wild game animals act as reservoir
hosts. This transmission and vector cycle make the organism more difficult to
control than T.b. gambiense.

Clinical features
Although both species cause sleeping sickness, the progress of the disease is
different. T. gambiense induced disease runs a low-grade chronic course over a few
years. One of the earliest signs of disease is an occasional ulcer at the site of the fly
bite. As reproduction of organisms continues, the lymph nodes are invaded, and
fever, myalgia, arthralgia, and lymph node enlargement results. Swelling of the
posterior cervical lymph nodes is characteristic of Gambian sleeping sickness and is
called interbottom’s sign. Chronic disease progresses to CNS involvement with
lethargy, tremors, meningoencephalitis, mental retardation, and general
deterioration. In the final stages, convulsions, hemiplegia, and incontinence occur.
The patient becomes difficult to arouse or obtain a response from, eventually
progressing to a comatose state. Death is the result of CNS damage and other
infections, such as pneumonia. In T. rhodesiense, the disease caused is a more acute,
rapidly progressive disease that is usually fatal. This more virulent organism also
develops in greater numbers in the blood. Lymphadenopathy is uncommon, and
early in the infection, CNS invasion occurs, resulting in lethargy, anorexia, and
mental disturbance. The chronic stages described for T. gambiense are not often
seen, because in addition to rapid CNS disease, the organism produces kidney
damage & myocarditis, leading to death.

Immunity

Both the humoral and cellular immunity involve in these infections. The immune
responses of the host to the presence of these parasites, however, is faced with
antigenic variation, in which organisms that have changed their antigenic identity
can escape the host immune response and initiate another disease process with
increased level of parasitemia.
Laboratory Examination of thin and thick films, in concentrated anticoagulated
blood preparations, and in aspiration from lymph nodes and concentrated spinal
fluid.

Treatment

The same treatment protocol is applied for these parasites. For the acute stages of
the disease the drug of choice is suramin with pentamidine as an alternative. In
chronic disease with CNS involvement, the drug of choice is melarsoprol.
Alternatives include trypars amide combined with suramin.

Prevention

• Control of breeding sites of tsetse flies and use of insecticides.

• Treatment of human cases to reduce transmission to flies.
• Avoiding insect bite by wearing protective clothing & use of screen, bed
netting and insect repellants.

COCCIDIA (SPOROZOA) INTRODUCTION

Coccidia are members of the class sporozoa, Phylum Apicomplexa. Apical complex
is present at some stage and consists of elements visible with electron microscope.
The life cycle is characterized by an alternation of generations, i.e. sexual
(gametogony) and asexual (schizogony) reproduction and most members of the
group also share alternative hosts. The locomotion of a mature organism is by
body flexion, gliding, or undulation of longitudinal ridges.

The genus Plasmodium that are the causes of malaria is the prototype of this class.

Malaria

There are four species normally infecting humans, namely, Plasmodium falciparum,
Plasmodium vivax, Plasmodium ovale, and Plasmodium malariae.
Life cycle

The life cycle of malaria is passed in two hosts (alternation of hosts) and has sexual
and asexual stage (alternation of generations). Vertebrate host - man (intermediate
host), where the asexual cycle takes place. The parasite multiplies by schizogony
and there is formation of male and female gametocytes (gametogony). Invertebrate
host - mosquito (definitive host) where the sexual cycle takes place. Union of male
and female gametes ends in the formation of sporozoites (sporogony). The life cycle
passes in four stages: Three in man: - Pre - erythrocytic schizogony, Erythrocytic
schizogony and Exo- erythrocytic schizogony, One in mosquito - Sporogony
Introduction into humans

When an infective female Anopheles mosquito bites man, it inoculates saliva

containing sporozoites (infective stage).

• Pre- Erythrocytic schizogony - sporozoites reach the blood stream and

within 30 minutes enter the parenchymal cells of the liver, initiating a cycle
of schizogony. Multiplication occurs in tissue schizonts, to form thousands of
tiny merozoites.
• Erythrocytic schizogony - Merozoites are then liberated on rupture of
schizonts about 7th – 9th day of the bites and enter into the blood stream.
These merozoites either invade the RBC’s or other parenchymal liver cells. In
case of P. falciparum and possibly P. malariae, all merozoites invade RBC’s
without re-invading liver cells. However, for P. vivax and P. ovale, some
merozoites invade RBC’s and some re-invade liver cells initiating further
Exo-erythrocytic schizogony, which is responsible for relapses. Some of the
merozoites remain dormant (hypnozoites) becoming active later on.
Erythrocytic schizogony (blood phase) is completed in 48 hrs in P. vivax, P.
ovale, and P. falciparum, and 72 hrs in P. malariae. The merozoites reinvade
 fresh RBC’s repeating the schizogonic cycles. Erythrocytic merozoites do not
reinvade the liver cells. So, malaria transmitted by blood transfusion
reproduces only erythrocytic cycle.
• Gametogony - Some merozoites that invade RBC’s develop into sexual
stages (male and female gametocytes). These undergo no further development
until taken by the mosquito. Sporogony (extrinsic cycle in mosquito) When
a female Anopheles mosquito vector bites an infected person, it sucks blood
containing the different stages of malaria parasite. All stages other than
gametocytes are digested in the stomach. The microgametocyte undergoes
ex-flagellation. The nucleus divides by reduction division into 6-8 pieces,
which migrate to the periphery. At the same, time 6-8 thin filaments of
cytoplasm are thrust out, in each passes a piece of chromatin. These filaments,
the microgametes, are actively motile and separate from the gametocyte. The
macrogametocyte by reduction division becomes a macrogamete.
Fertilization occurs by entry of a micro gamete into the macro gamete forming
a zygote. The zygote changes into a worm like form, the ookinete, which
penetrates the wall of the stomach to develop into a spherical oocyst between
the epithelium and basement membrane. The oocysts increase in size.
Thousands of sporozoites develop inside the oocysts. Oocysts rupture and
sporozoites are liberated in the body cavity and migrate everywhere
particularly to the salivary glands. Now the mosquito is infective.
• The sporogonous cycle in the mosquito takes 8-12 days depending on
temperature
The malaria parasite life cycle involves two hosts. During a blood meal, a
malaria-infected female Anopheles mosquito inoculates sporozoites into the
human host . Sporozoites infect liver cells and mature into schizonts ,
 which rupture and release merozoites . (Of note, in P. vivax and P. ovale a
dormant stage [hypnozoites] can persist in the liver and cause relapses by
invading the bloodstream weeks, or even years later.) After this initial
replication in the liver (exo-erythrocytic schizogony ), the parasites undergo
asexual multiplication in the erythrocytes (erythrocytic schizogony ).
Merozoites infect red blood cells . The ring stage trophozoites mature into
schizonts, which rupture releasing merozoites . Some parasites differentiate
into sexual erythrocytic stages (gametocytes) . Blood stage parasites are
responsible for the clinical manifestations of the disease.
The gametocytes, male (microgametocytes) and female (macrogametocytes),
are ingested by an Anopheles mosquito during a blood meal . The parasites’
multiplication in the mosquito is known as the sporogonic cycle . While in
the mosquito’s stomach, the microgametes penetrate the macrogametes
generating zygotes . The zygotes in turn become motile and elongated
(ookinetes) which invade the midgut wall of the mosquito where they
develop into oocysts . The oocysts grow, rupture, and release sporozoites
, which make their way to the mosquito’s salivary glands. Inoculation of the
sporozoites into a new human host perpetuates the malaria life cycle.
Life cycle of Plasmodium species
Plasmodium falciparum demonstrates no selectivity in host erythrocytes, i.e. it
invades young and old RBCs cells. The infected red blood cells also do not enlarge
and become distorted. Multiple sporozoites can infect a single erythrocyte, and show
multiple infections of cells with small ring forms. The trophozoite is often seen in
the host cells at the very edge or periphery of cell membrane at accole position.
Occasionally, reddish granules known as Maurer’s dots are observed. Mature (large)
trophozoite stages and schizonts are rarely seen in blood films, because their forms
are sequestered in deep capillaries, liver and spleen. Peripheral blood smears
characteristically contain only young ring forms and occasionally crescent shaped
gametocytes.
Epidemiology
P. falciparum occurs almost exclusively in tropical and subtropical regions.
Weather (rainfall, temperature & humidity) is the most obvious cause of seasonality
in malaria transmission. To date, abnormal weather conditions are also important
causes of significant and widespread epidemics. Moreover, drug-resistant infection
of P. falciparum is the commonest challenge in many parts of the world.

Plasmodium vivax is selective in that it invades only young immature erythrocytes.

Infections of P. vivax have the following characteristics: Infected red blood cells
are usually enlarged and contain numerous pink granules or schuffner’s dots. The
trophozoite is ring-shaped but amoeboid in appearance. More mature trophozoites
and erythrocytic schizonts containing up to 24 merozoites are present. The
gametocytes are round.

Epidemiology
P. Vivax is the most prevalent of the human plasmodia with the widest geographic
distribution, including the tropics, subtropics, and temperate regions.

P. malariae can infect only mature erythrocytes with relatively rigid cell
membranes. As a result, the parasite’s growth must conform to the size and shape of
red blood cell.

P. ovale is similar to P. vivax in many respects, including its selectivity for young,
pliable erythrocytes. As a consequence, the classical characteristics include: The
host cell becomes enlarged and distorted, usually in an oval form. Schiffner’s dots
appear as pale pink granules. •The infected cell border is commonly fimbriated or
ragged. Mature schizonts contain about 10 merozoites.
Epidemiology
P. ovale is distributed primarily in tropical Africa. It is also found in Asia and South
America

Clinical Presentation of Plasmodia sp

The symptoms of uncomplicated malaria can be rather non-specific and the
diagnosis can be missed if health providers are not alert to the possibility of this
disease. Since untreated malaria can progress to severe forms that may be rapidly
(<24 hours) fatal, malaria should always be considered in patients who have a history
of exposure (mostly: past travel or residence in disease-endemic areas). The most
frequent symptoms include fever and chills, which can be accompanied by headache,
myalgias, arthralgias, weakness, vomiting, and diarrhea. Other clinical features
include splenomegaly, anemia, thrombocytopenia, hypoglycemia, pulmonary or
renal dysfunction, and neurologic changes. The clinical presentation can vary
substantially depending on the infecting species, the level of parasitemia, and the
immune status of the patient. Infections caused by P. falciparum are the most likely
to progress to severe, potentially fatal forms with central nervous system
involvement (cerebral malaria), acute renal failure, severe anemia, or acute
respiratory distress syndrome. Other species can also have severe manifestations.
Complications of P. vivax malaria include splenomegaly (with, rarely, splenic
rupture), and those of P. malariae include nephrotic syndrome.

Treatment
Because chloroquine – resistant strains of P.falciparum are present in many parts of
the world, infection of P.falciparum may be treated with other agents including
mefloquine, quinine, guanidine, pyrimethamine – sulfadoxine, and doxycycline. If
the laboratory reports a mixed infection involving P.falciparum and P.vivax, the
treatment must eradicate not only P.falciparum from the erythrocytes but also the
liver stages of P.vivax to avoid relapses provided that the person no longer lives in a
malaria endemic area. Chloroquine is the drug of choice for the suppression and
therapeutic treatment of P.vivax, followed by premaquine for radical cure and
elimination of gametocytes. Treatment for P. ovale and P. malariae is similar to P.
vivax
Prevention
• Chemoprophylaxis and prompt diagnosis and treatment.
• Control of mosquito breeding
• Protection of insect bite by screening, netting and protective clothing
• Use of insect repellents.
Other Coccidian parasites
• Toxoplasma gondii – causes toxoplasmosis.
• Isospora belli - is an intestinal protozoan that causes diarrhea, especially in
immunocompromized patients, e.g., those with AIDS. Its life cycle parallels
that of other members of the Coccidia.
Revision questions
1. Explain the reproductive process, transmission route and pathogenesis of
protozoan parasites.
2. How are medically important protozoa classified?
3. Describe the pathogenesis of E.histolytica. and G. lamblia
4. Describe the Life cycle of P. vivax or T. brucei
5. What are the causative protozoa for African tryponosomiasis?
6. What are the common characteristics of the class sporozoa?
: Romanowsky stained thin malaria films and their different stages.
Patrick. R. Murray, Ken. S. Rosenthal, George S. Kabayashi, Michael A. P. Faller. Medical microbiology 4th
ed USA: Mosby, 2002.