‫جامعت االنبار‬

‫ الصيدلة‬: ‫كليت‬
‫ الصيدلة‬: ‫قسم‬
‫ الطفيليات الطبية‬:‫اسم المادة باللغت العربيت‬
Medical Parasitology :‫اسم المدة باللغت اإلنكليزيت‬
‫ الثانية‬:‫المرحلت‬
‫ مهند عبدالمجيد محمد‬.‫د‬.‫م‬.‫ أ‬:‫التدريسي‬
‫ النسيج العصبي‬:‫عنوان المحاضرة باللغت العربيت‬
Intestinal protozoa (Amoeba) :‫عنوان المحاضرة باللغت اإلنكليزيت‬

:‫محتوى المحاضرة‬
Intestinal protozoa (Amoeba)
Features of protozoa:
 Protozoa (from the Greek words proto, meaning "first", and
zoa, meaning "animals") is a grouping of eukaryotes many of
which are motile.
 The most important protozoans range usually from 10 to 52
micrometers, but can grow as large as 1 mm, and are seen easily
by microscope
 They move by a variety of organs pseudopodia, flagella and
cilia.
 They are found in different parts of the body intestine, blood
and tissues, cavities like mouth, Uro-genital system.
 Most intestinal protozoa have direct life cycle. They have
either: Trophozoit and cyst or Trophozoit only.

Life stages of intestinal Protozoa

A- Cyst stage: It is non motile, none feeding, non active stage, it is the
infective stage if the parasite has trophozoite and cyst stage in the life cycle.

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It is diagnostic stage in case of chronic infection. Transmitted to the human
by contamination of food and water.
B- Trophozoite stage: It is active, motile, feeding stage of parasite. *it is
the pathogenic stage of parasite. *it is the diagnostic stage in case of acute
infection.
C- Or It has only Trophozoite without cyst stage:
(Trophozoite stage will be the pathogenic, diagnostic and infective stage if
the parasite has no cyst stage).

1.1 Pathogenic Intestinal Amoeba: AMOEBIASIS

Intestinal Protozoa Amoeba: Entamoeba histolytica
Diseases: Entamoeba histolytica causes amebic dysentery and liver abscess.
Important Properties: The life cycle has two stages:
the motile (trophozoite) the nonmotile (cyst)
These cysts are killed by boiling but not by chlorination of water supplies.
They are removed by filtration of water.
The mature trophozoite has a single nucleus with lining of peripheral
chromatin and a central nucleolus (karyosome).
The cyst has four nuclei, an important diagnostic criterion

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Entamoeba histolytica:

Morphological features
a- Trophozoites: Viable trophozoites vary in size from about 10-60μm in
diameter. Motility is rapid, progressive, and unidirectional, through
pseudopods. The nucleus is characterized by evenly arranged chromatin on
the nuclear membrane and the presence of a small, compact, centrally
located karyosome. The cytoplasm is usually described as finely granular
with few ingested bacteria or debris in vacuoles. In the case of dysentery,
however, RBCs may be visible in the cytoplasm, and this feature is
diagnostic for E.histolytica.

(b)- Pre Cyst: Smaller to trophozoite but larger to cyst (10-20µm),

oval with blunt pseudopodia. Food vacuoles and RBCs are
disappear. Single rounded nucleus, absence of digested materials
and lack of a cyst wall.

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(c)- Cyst: Cysts range in size from 10-20μm. The immature cyst has
inclusions namely; glycogen mass and chromatoidal bars. As the cyst
matures, the glycogen completely disappears; the chromotiodials may also
be absent in the mature cyst. Mature Entamoeba histolytica cysts have 4
nuclei that characteristically have centrally-located karyosomes and fine,
uniformly distributed peripheral chromatin.

Info before the life

cycle:
 Habitat: Trophozoite in:
1-Large intestine
2- Extraintesinal infection. Cyst only in large intestine Life cycle: direct no
intermediate host.
 Infective stage: Is mature quadrinucleated cyst.
 Pathogenic stage: Only Trophozoite which seen in diarrheic acute
dysentery stool.
 Diagnostic stage: Cyst in chronic infection and trophozoite in acute
diarrhic infection.
 Mode of infection: Contamination of food and water. Humans are the
principal host, although dogs, cats and rodents may be infected
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Life cycle of Entamoeba histolytica:
Intestinal infections occur through the ingestion of a mature quadrinucleate
infective cyst, contaminated food or drink and also by hand to mouth
contact. It is then passed unaltered through the stomach, as the cyst wall is
resistant to gastric juice.

In terminal ileum (with alkaline pH), excystation takes place. Trophozoites

being actively motile invade the tissues and ultimately lodge in the
submucous layer of the large bowel. Here they grow and multiply by binary
fission.

Trophozoites are responsible for producing lesions in amoebiasis. Invasion

of blood vessels leads to secondary extra intestinal lesions. Gradually the
effect of the parasite on the host is toned down together with concomitant
increase in host tolerance, making it difficult for the parasite to continue its
life cycle in the trophozoite phase.

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A certain number of trophozoites come from tissues into lumen of bowel and
are first transformed into pre-cyst forms. Pre-cysts secret a cyst wall and
become a uninucleate cyst. Eventually, mature quadrinucleate cysts form.
These are the infective forms. Both mature and immature cysts may be
passed in faeces. Immature cysts can mature in external environments and
become infective.

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Reproduction of E. histolytica

The Reproduction occurs in three stages:

- Excystation
- Encystation
- Multiplication
 Excystation: This is the process of transformation of cyst to trophozoites.
During excystation a quadrinucleate cyst give rise to eight amoebulae
each one of which is being capable of developing into trophozoites.
 Encystation: This is the process of transformation of trophozoite to cyst
and occurs inside the lumen of the intestine of an infected individual.
 Multiplication: This occurs only in the trophozoite forms of the
entamoeba histolytica , growing and multiplication takes place inside the
tissue. Reproduction of trophozoites occurs by simple binary fission.

Pathogenesis & Epidemiology:

1. The organism is acquired by ingestion of cysts that are transmitted by the
fecal-oral route in contaminated food and water.
2. The ingested cysts differentiate into trophozoites in the ileum but tend to
colonize the cecum and colon.
3. The trophozoites invade the colonic epithelium and secrete enzymes that
cause localized necrosis. As the lesion reaches the muscularis layer, a
typical "flask-shaped" ulcer forms.
4. Progression into the submucosa leads to invasion of the portal circulation
by the trophozoites. By far the most frequent site of systemic disease is
the liver, where abscesses containing trophozoites form.

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Clinical Findings:
1. Acute amebiasis presents as dysentery (i.e., bloody, mucus-containing
diarrhea) accompanied by lower abdominal discomfort, flatulence, and
tenesmus.
2. Chronic amebiasis: diarrhea, weight loss, and fatigue also occur. Roughly
90% of those infected have asymptomatic infections, but they may be
carriers, whose feces contain cysts that can be transmitted to others. In
some patients, a granulomatous lesion called an ameboma may form in
the cecal or rectosigmoid areas of the colon. These lesions can resemble
an adenocarcinoma of the colon.
3. Amebic abscess of the liver is characterized by right-upper-quadrant pain,
weight loss, fever, and a tender, enlarged liver. Right-lobe abscesses can
penetrate the diaphragm and cause lung disease.

Immunity:
E.histolytica elicits both the humeral and cellular immune responses, but it is
not yet clearly defined whether it modulates the initial infection or prevents
reinfection.

Laboratory Diagnosis:
1. Intestinal amebiasis: finding either trophozoites in diarrheal stools or
cysts in formed stools. Diarrheal stools should be examined within 1 hour of
collection. Trophozoites contain ingested red blood cells, because cysts are
passed intermittently.
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-E. histolytica can be distinguished by two criteria:
(1) The nature of the nucleus of the trophozoite (has a small central
nucleolus and fine chromatin granules along the border of the nuclear
membrane). (2) The second is cyst size and number of its nuclei.
2. A complete examination for cysts includes a wet mount in saline, an
iodine-stained wet mount, and a fixed, trichrome-stained preparation. These
preparations are also helpful in distinguishing amebic from bacillary
dysentery.
3. Serologic testing ex. indirect hemagglutination test.
4. Detects nucleic acids of the organism in a PCR-based assay.
Treatment:
Acute, fulminating amebiasis is treated with metrondiazole followed by
iodoquinol, and asymptomatic carriage can be eradicated with iodoquinol,
diloxanide furoate, or paromomycin. The cysticidal agents are commonly
recommended for asymptomatic carriers who handle food for public use.
Metronidazole, chloroquine, and diloxanide furoate can be used for the
treatment of extra intestinal amoebiasis.

Prevention:
1. Avoiding fecal contamination of food and water. 2. Good personal
hygiene such as hand washing. 3. Purification of water supplies. 4. In areas
of endemic infection, vegetables should be cooked.

1.2 Nonpathogenic Intestinal Amoeba:

Most of these amoebae are commensal organisms that can parasitize the
human gastrointestinal tract.

Entamoeba coli the life cycle stages include; trophozoite, precyst, cyst,
metacyst, and metacystic trophozoite. Typically the movements of
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trophozoites are sluggish, with broad short pseudopodia and little
locomotion, but at a focus the living specimen cannot be distinguished from
the active trophotozoite of E.histolytica. However, the cysts are
remarkably variable in size. Entamoeba coli are transmitted in its viable
cystic stage through faecal contamination. Ε.coli as a lumen parasite is non-
pathogenic and produces no symptoms. The mature cyst (with more than
four nuclei 8-nuclei) is the distinctive stage to differentiate E.coli from the
pathogenic E.histolytica. Specific treatment is not indicated since this
amoeba is non-pathogenic. The presence of E.coli in stool specimen is
evidence for faecal contamination. Prevention depends on better personal
hygiene and sanitary disposal of human excreta.

Trophozoites of Entamoeba coli usually measure 15–50 µm.

The trophozoites have a single nucleus with a characteristically large,
eccentric karyosome and coarse, irregular peripheral chromatin. The
cytoplasm is usually coarsely granular and vacuolated (often described as
“dirty” cytoplasm).

Cysts of Entamoeba coli are usually spherical but may be elongated and
measure 10–35 µm. Mature cysts typically have 8 nuclei but may have as
many as 16 or more. Entamoeba coli is the only Entamoeba species found
in humans that has more than four nuclei in the cyst stage.

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Entamoeba dispar: A common noninvasive parasite, is indistinguishable
in its cysts and trophozoite forms from Entamoeba histolytica, the cause of
invasive amebiasis, by microscopy.
Trophozoites in trichrome stained smears usually measure 15 to 20 µm.
Presence of one nucleus with evenly arranged chromatin on the nuclear
membrane and a small, centrally located karyosome are morphological
features of trophozoites. The cytoplasm is finely granular and few ingested
bacteria or debris may be present. Presence of red blood cells within the
cytoplasm of trophozoites is a diagnostic feature for the identification of E.
histolytica. Ingested RBCs are not frequently seen; in the absence of this
diagnostic characteristic E. histolytica/E. dispar should be reported. Cysts
usually measure 12 to 15 µm and have 1 to 4 nuclei. Chromatoid bodies with
bluntly rounded ends may also be present.

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 Cyst Trophozoites

Entamoeba hartmanni in all of its life-cycle stage, E.hartmanni resembles

E.histolytica except in size, yet there is a slight overlap in the size range. The
trophozoites do not ingest red blood cells, and their motility is generally less
vigorous than that of E.histolytica. As in other amebae, infection is acquired
by ingestion of food or water contaminated with cyst-bearing faeces.
Identification is based on examination of small
amebae in unstained or iodine-stained preparations. Usually no treatment is
indicated, measures generally effective against faecal-borne infections will
control this amoebic infection.
Endolimax nana: Is a lumen dweller in the large intestine, primarily at the
cecal level, where it feeds on bacteria. The life cycle is similar to
E.histolytica. Motility is typically sluggish (slug-like) with blunt hyaline
pseudopodia, Projects shortly. Human infection results from ingestion of
viable cysts in polluted water or contaminated food. Typical ovoid cysts of
E.nana are confirmative. Rounded cysts and living trophozoites are often
confused with E.hartmanni and E.histolytica. No treatment is indicated for
this nonpathogenic infection. Prevention can be achieved through personal
cleanliness and community sanitation.

Iodamoeba buetschlii: The natural habitat is the lumen of the large intestine,
the principal site probably being the caecum. The trophozoite feeds on
enteric bacteria; it is a natural parasite of man and lower primates. It is
generally regarded as a nonpathogenic lumen parasite. No treatment is

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ordinarily indicated. Prevention is based on good personal hygiene and
sanitation in the community.

Entamoeba gingivalis: Only the trophozoite stage presents, and encystation

probably does not occur. E.gingivalis is a commensal, living primarily on
exudate from the margins of the gums, and thrives best on unhealthy gums.
No specific treatment is indicated. However the presence of E.giingivalis
suggests a need for better oral hygiene. The infection can be prevented by
proper care of the teeth and gums.

1.3.

PATHOGENIC FREE-LIVING AMOEBAE:

Among the numerous free-living amoebae of soil and water habitats, certain
species of Naegleria, Acanthamoeba and Balamuthia are facultative parasites
of man. Most human infections of these amoebae are acquired by exposure
to contaminated water while swimming. Inhalation of cysts from dust may
account for some infections.

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Naegleria fowleri: The trophozoites occur in two forms. Amoeboid forms
with single pseudopodia and flagella forms with two flagella which usually
appear a few hours after flooding water or in CSF.

Acanthameba species: Are free-living amebae that inhabit a variety of air,

soil, and water environments. However, these amebae can also act as
opportunistic as well as nonopportunistic pathogens. Acanthamoeba has two
forms, the metabolically active trophozoite and a dormant, stress-resistant
cyst. The trophozoites have an irregular appearance with spine-like

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pseudopodia. Acanthamoeba causes three main types of illness involving the
eye (Acanthamoeba keratitis), the brain and spinal cord (Granulomatous
Encephalitis), and infections that can spread throughout the entire body
(disseminated infection). Naegleria fowleri causes acute primary amoebic
meningoencephalitis.

Balamuthia species: The trophozoite may be bi-nucleated. Unlike most

amoebae the nuclear envelope breaks down during mitosis. Naegleria,
Acanthamoeba, Balamuthia organisms are opportunistic pathogens.
Acantamoeba & Balamuthia organisms are responsible for granulomatous
amoebic encephalitis and single or multiple brain abscesses, primarily in
immunocompromised individuals. For the diagnosis of Naegleria,
canthamoeba, and Balamuthia infections, specimens of nasal discharge and
cerebrospinal fluid; and in cases of eye infections corneal scraping should be
collected. The clinical specimen can be examined with saline wet
preparation and Iodine stained smear. Treatment of free-living amoebic
infections is largely ineffective.

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