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Tropical medicine - All clinical images copyright Gorgas course - : Instituto de Medicina Tropical Alexander von Humboldt > Protozoal infections - Coccidia, Toxoplasma, Giardia, Amoeba > Flashcards

Protozoal infections - Coccidia, Toxoplasma, Giardia, Amoeba Flashcards

1
Q

What is giardia? Appearance? Lifecycle

A
  • Flagellate protozoan
  • Pear shaped 15um long
  • Attaches to small intestine with sucker but does not invade -> not bloody diarrhoea
  • Produces a small 4 nucleus cyst (expelled in stool)
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2
Q

Giardia incubation? Who has high risk?

A

7-10 days (occasionally months)

Children
MSM

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3
Q

Giardia Rx completed and test negative but ongoing diarrhoea probably due to?

A

Lactose intolerance

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4
Q

Giardia dx?

A
  • Stool microscopy for Characteristic small 4 nuclei cyst (may require 3 samples)
  • Also now ELISA / EIA and point of care tests
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5
Q

String test is used for? How does jt work

A

Giardia / stronglyotides
- Patient shallows some string which is attached to cheek with gelatin on end. Left overnight and then examined for trophozoites

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6
Q

Giardia small bowel biopsy?

A

Villlous flattening, crypt deepening and inflam infiltrate in lamina propria

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7
Q

Giardia rx? 2nd line (especially in HIV)

A

tinidazole
[Metronidazole / albendazole ]

Nitazoxanide

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8
Q

Prevention giardia

A

Boil water, sedimentation, flocculation

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9
Q

Prevention giardia

A

Boil or filter water, chlorination, flocculation, sedimentation

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10
Q

Main protective factor against giardia

A

IgA

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11
Q

Amoeba most common presentation? Geography

A
  • Dysentery
  • Then liver abscess
    [Only 4-10% of infected with E histolytica develop sx]

Found throughout tropics

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11
Q

Entamoeba which one causes issues? Which is much more common but doesn’t cause significant disease?

A
  • E Histolytica
  • E dispar - more common
  • Issue is that both cysts look the same on microscopy but no need to treat dispar
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12
Q

Confirm dx of amoebic dysentery? Stain? Differentiate from dispar?

A
  • Amoebic trophozoites containing ingested RBCs in a fresh Stool sample
  • Should be within 15 minutes of sample
    -iron haematoxylin / trichrome stain

Non-virulent Eg E Dispar would not have ingested RBCs

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13
Q

E histolytica life cycle

A
  • Four-nucleated cyst ingested following consumption of contaminated food / water
  • -> digested by gut releasing 8 trophozoites which continue to replicate through fission
  • Produce cysts which are excreted in stool and can survive weeks in water
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14
Q

Incubation of amoeba?

A

Few days to several years

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15
Q

Most common location amoebic abscess? What’s often seen on CXR? LFTs

A
  • Single one in right lobe of liver in 70%
  • Raised right hemidiaphragm or effusion (communication with abscess)
  • LFTs often unremarkable bar raised ALP
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16
Q

Stool microscopy makes mainstay of dx for Amoeba in resource poor settings - what about in richer? GOld standard?

A

[Egg microscopy]

  • ELISA Stool antigen testing - most common
  • PCR - gold standard
    -Serum IgG - does not differentiate from past infection
  • Enzyme immunoassay (EIA)
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17
Q

What does amoebic colitis look like on endoscopy?

A
  • Mimicks IBD with ulcers
  • Can take biopsies of these if other tests inconclusive
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18
Q

Amoeba rx?

A

Metronidazole for 5-10 days or single dose tinidazole (2g)

Followed by a course of luminal amoebicides to eradicate cysts
- Eg diloxanide furoate, paromomycin, iodoquinol

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19
Q

Prevention amobea

A
  • Improved hygiene/ sanitation and clean drinking water
  • Boil / peel / cook food and water
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20
Q

amoebic cysts resistant to?

A

Chlorination
Sensitive to iodine

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21
Q

How many people infected with amoeba develop the disease when infected?

A

4-10% in first year

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22
Q

Describe entamoeba

A

Non-flagellate protozoan

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23
Q

2 Main parts of life cycle entamoeba

A

Noninvasive, infective cysts
Invasive trophozoite

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24
Q

Which receptor allows amoeba to attach to the intestinal mucosa

A

Galactose lectin
[Can test for this]

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25
Q

amoebic colitis usual incubation? sx? risk of progression to?

A

sx after 1-2 weeks and lasts 4-6 weeks
The pain is usually the worst LLQ
Bloody diarrhoea

Risk of fulminant colitis/NEC/Megacolon in risk groups (Immunosupressed, malnourished, pregnant)

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26
Q

Mass in caecum in amoeba is?

A

Ameoboma- inflammatory reaction in cecum

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27
Q

Ameoboma differentials

A

Intestinal TB, typhoid fever, appendiceal mass and colonic cancer

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28
Q

72 yo with AML
Hx of chronic diarrhea
develops bloody diarrhea
on day 12 of chemotherapy
multiple ulcers plus a
4cm mass in the ascending
colon =

A

Ameboma

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29
Q

Which LFT most derranged in amebic liver abcess

A

ALP

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30
Q

Women or men more likely to have an amebic liver abscess

A

Men make up 90%

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31
Q

25 yo male from Lima
Hx: 3 week history of fever,
weight loss, RUQ pain
no diarrhea
PE: T 39C, pulse 120
chronically ill, pale
no jaundice, tenderness
over RUQ
Labs: mild anemia, leukocytosis
elevated alkaline phosphatase

A

Amebic liver abscess

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32
Q

2 complications of amebic liver abscess spread

A

Pericarditis
Empyema

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33
Q

Where do you get cutaneous amoeba histolytica lesions? Due to? What does it look like?

A

ano-genital, perianal region

▪ direct inoculation from cysts in the stools

▪ well-demarcated, round-oval ulcer
with heaped-up borders

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34
Q

Only way to diagnose ameoboma

A

Colonoscopy + biopsy

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35
Q

Ix gold standard for amebic liver abscess

A

PCR + imaging (US fine)

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36
Q

Positive amoeba but no dystentery or liver abscess Rx

A

Luminal agent - paromomycin,
[ diloxanide furoate, iodoquinol]

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37
Q

Appearance of aspirate from amoebic abscess

A

Yellow-brown’
‘anchovy paste’

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38
Q

Name 3 situations you would perform diagnostic tap amebic abscess

A

-Left lobe - risk of pericardial spread
->10cm
-Not responding to medical therapy
-Unclear diagnosis ?pyogenic

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39
Q

▪ 18 yo female from rural Trujillo
▪ 3 week history of diarrhea
▪ admitted with acute abdomen and sepsis
▪ multiple colonic perforations?
What is it?
Usual host?
Dx?
RX?

A

Balantidiasis
-Balantidium coli is the largest intestinal protozoan of humans and the only ciliate
[Massive oval with fluffy edge kidney-shaped nuclei]

-Pigs usual hosts (humans accidental)
-trophozoites in a fresh stool sample or in scrapings from a colonic ulcer

Tetracycline or Metronidazole

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40
Q
A

TROPHOZOITE OF ENTAMOEBA HISTOLYTICA

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41
Q
A

CYST OF ENTAMOEBA HISTOLYTICA
-one to four nuclei identical to that of trophozoites

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42
Q

Abscess in right lobe of liver + dysentery and now this on colonoscopy

A

Amoebic colitis

multiple flask-shaped ulcers; extensive areas of hemorrhage and necrosis

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43
Q

Cryptosporidium which type for humans? Animals and humans? Life cycle.

A
  • C hominis
  • C parvum

Feacal oral - oocyst releases 4 sporozoites which invades epithelium
- Can either produce thin-walled oocysts which auto-infect same host. Or thick walled which are excreted

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44
Q

Cryptosporidiosis dx? Stain that can be used?

A

Acid fast oocysts in faeces/ luminal aspirate using kinyoun acid fast stain
[I was fucKinyoun when I had it]

Most have PCR assays now

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45
Q

Unusual finding of eosinophilia in which protozoan infection? Rx?

A

cystoisospora infection

Co-trimoxazole

[CystoEYEsospora - egg looks like eye and has Eosinopholia]

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46
Q

Cryptosporidiosis rx?

A
  • Usually self limiting
  • Nitazoxide
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47
Q

Cyclospora rx?

A

Co-trimox

[or cipro]

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48
Q

2 main stages of protazoa? Which are infective? which are feeding?

A

Trophozoite : feeding/vegetative stage. May cause damage

Cyst: non replicative, resistance stage. Spherical shape. Infective stage

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49
Q

Compare nucleus of histolytica vs dispar vs E coli

A
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50
Q

Compare Chromatid bars of histolytica vs dispar vs E coli

A

Histolytica and dispar - the blunt bois

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51
Q

Entamoeba histolytica Life cycle
Infective vs diagnostic stage

A

Infective stage : mature cyst.
Diagnostic stage : cysts, trophozoites.

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52
Q
A

Dispar / histolytica

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53
Q
A

Histolytica trophozoite

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54
Q
A

Hitolytica / dispar trophozoite

even peripheral chromatin , central karyosome

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55
Q
A

ingested RBCs - E. histolytica nucleus (1),
even peripheral chromatin , central karyosome

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56
Q
A

Ingested RBCs - E. histolytica nucleus (1),
even peripheral chromatin , central karyosome

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57
Q
A

Ingested RBCs - E. histolytica nucleus (1),
even peripheral chromatin , central karyosome

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58
Q
A

ingested RBCs - E. histolytica nucleus (1),
even peripheral chromatin , central karyosome

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59
Q
A

E. histolytica / E. dispar - Pre cyst
nucleus (1), even peripheral chromatin , central karyosome,
chromatid bars ( blunt ends

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60
Q
A

E. histolytica / E. dispar - Pre cyst
nucleus (1), even peripheral chromatin , central karyosome,
chromatid bars ( blunt ends

61
Q
A

E. histolytica / E. dispar - Pre cyst
nucleus (1), even peripheral chromatin , central karyosome,
chromatid bars ( blunt ends

62
Q
A

E. histolytica / E. dispar - Premature cyst
nuclei (2-3), even peripheral chromatin , central karyosome ,
chromatoidal bars ( blunt ends)

63
Q
A

E. histolytica / E. dispar - Premature cyst
nuclei (2-3), even peripheral chromatin , central karyosome ,
chromatoidal bars ( blunt ends)

64
Q
A

E. histolytica / E. dispar - Premature cyst
nuclei - 4, even peripheral chromatin , central karyosome ,
chromatoidal bars ( blunt ends

65
Q
A

Entamoeba coli - Trophozoite
nucleus (1), uneven peripheral chromatin ,

66
Q
A

Entamoeba coli - Trophozoite
nucleus (1), uneven peripheral chromatin ,

67
Q
A

Entamoeba coli - Trophozoite
nucleus (1), uneven peripheral chromatin ,

68
Q
A

Entamoeba coli - Imature cyst
central vacuole , nuclei (1-7, usually~2 )

69
Q
A

Entamoeba coli - Imature cyst
central vacuole , nuclei (1 7, usually~2 )

70
Q
A

Entamoeba coli - Mature cyst
nuclei 8 , rarely 16,
uneven peripheral chromatin
chromatoidal bars ( sharp ends)

71
Q
A

Entamoeba coli - Mature cyst
nuclei 8 , rarely 16,
uneven peripheral chromatin
chromatoidal bars ( sharp ends)

72
Q
A

Entamoeba coli - Mature cyst
nuclei 8 , rarely 16,
uneven peripheral chromatin
chromatoidal bars ( sharp ends)

73
Q

Entamoeba coli - Trophozoite vs immature vs Mature cyst number of nuclei

A

Trop - 1
Immature - 2 (1-7)
Mature 8 (or 16)

74
Q
A

Giardia Trophozoite

75
Q
A

Giardia Cyst

76
Q
A

Giardia cyst

77
Q
A

Giardia cyst

78
Q
A

Endolimax nana

[Looks like a little di]

79
Q
A

Iodamoeba butschlii
[Od shape]

80
Q
A

Iodamoeba butschlii
[Od shape]

81
Q
A

Chilomastix mesnili
[Chilled to the max ‘dont make a mess’ lemonade]

82
Q
A

Chilomastix mesnili
[Chilled lemonade]

83
Q
A

Blastocystis hominis - Central vacuole - peripheral nuclei
(nuclei blasted to edge)

84
Q
A

Blastocystis hominis- Central vacuole - peripheral nuclei
(nuclei blasted to edge)

85
Q
A

Balantidium coli Trophozoite
kidney shaped micronucleus,
Cilia - fast moving

86
Q
A

Balantioides coli Trophozoite
kidney shaped micronucleus,
Cilia - fast moving

87
Q
A

Balantioides coli cyst
kidney shaped nucleus

88
Q

What are the 3 free-living amoeba that can cause meningitis in humans

A

naegleria fowleri
Acanthamoeba
Balamuthia mandrillaris

89
Q

Which amoeba causes acute Haemorrhagic Meningitis? How does it get to brain?

A

naegleria fowleri - via olfactory nerve

90
Q

Which ameoba sometimes produces cutaneous granulomatous lesions but may involve CNS with chronic granulomatous encephalitis (similar to chronic meningitis)? Spread to CNS

A

Acanthamoeba
Haematogenous (from lungs)

91
Q

2 ameba which cause granulomatous amebic encephalitis

A

Acanthamoeba spp.
Balamuthia mandrillaris

92
Q

cause of severe keratitis among contact lens wearers? Rx?

A

Acanthamoeba
Pentamidine
+Fluconazole
+Miltefosine

93
Q

Cause of acute, and usually lethal, central nervous system (CNS) disease called primary amebic meningoencephalitis (PAM).

A

Naegleria fowleri
-penetrating the nasal mucosa, usually during swimming and travels up olfactory nerves

94
Q

5 days after swimming -> severe CNS dysfunction with rapid degeneration caused by hemorrhagic-necrotizing meningoencephalitis.

A

Naegleria fowleri:

95
Q
A

Naegleria fowleri - trophozoite

large single nucleus with large and densekaryosome, no peripheral chromatin, granular cytoplasm with many vacuoles

96
Q
A

Naegleria fowleri - trophozoite
[nae good, fowl bug]

large single nucleus with large and densekaryosome, no peripheral chromatin, granular cytoplasm with many vacuoles

97
Q

Granulomatous amebic encephalitis (GAE) / Keratitis =? Infective vs diagnostic stage?

A

Acanthamoeba spp.

Infective stage: trophozoites
Diagnostic stage: trophozoites, cysts.

98
Q
A

Acanthamoeba spp. - Trophozoite
spine-like pseudopodia, single nucleus with large karyosome, vacuoles

99
Q
A

Acanthamoeba spp. - Trophozoite
spine-like pseudopodia, single nucleus with large karyosome, vacuoles

100
Q
A

Acanthamoeba - cyst
double wall (exocyst and endocyst), single nucleus

101
Q
A

Acanthamoeba - cyst
double wall (exocyst and endocyst), single nucleus

102
Q
A

Acanthamoeba - cyst
double wall (exocyst and endocyst), single nucleus

103
Q

Cause of Granulomatous amebic encephalitis (GAE) + lesions on nose?
Infective vs diagnostic stage?

A

Balamuthia mandrillaris

Infective stage: trophozoites
Diagnostic stage: trophozoites, cysts

104
Q
A

Balamuthia mandrillaris - trophozoite
pleomorphic, long/slender pseudopodia (broader than Acanthamoeba), large single nucleus.

105
Q
A

Balamuthia mandrillaris - trophozoite
pleomorphic, long/slender pseudopodia (broader than Acanthamoeba), large single nucleus.

106
Q
A

Balamuthia mandrillaris - cyst
3 layered wall , single nucleus

107
Q
A

Balamuthia mandrillaris - cyst
3 layered wall, single nucleus

108
Q

a 2-week medical mission trip to a village in Honduras. One week after returning, she developed bloating, epigastric discomfort, and diarrhea. The diarrhea consisted of watery and soft stools that are foul smelling.
Name 4 protozoa that it might be and their Rx

A

Giardia lamblia – metronidazole
Cryptosporidium – Nitazoxanide
Cystoisospora belli - co-trimoxazole
Cyclospora cayetanensis – Co-trimoxazole

109
Q

Metronidazole side effects

A

-GI upset, metallic taste
-Avoid alcohol
-chronic use -> peripheral neuropathy

110
Q

Name 3 uses of Nitazoxanide

A

cryptosporidium, giardia, backup for Fasciola herpetica

111
Q

Pt had amoeba histolytica - treated with single dose of 1 drug - what was it? Why did they relapse

A

tinidazole

Need to treat with luminal agent as well eg . paromomycin

112
Q
A

Cystoisospora belli
1 oval oocyst with 1 or 2 sporoblasts (no sporozoites inside).

113
Q
A

Cystoisospora belli
1 oval oocyst with 1 or 2 sporoblasts (no sporozoites inside).

114
Q

Cystoispora belli infective vs diagnostic stage

A

Infective stage: mature oocysts with sporozoites.
Diagnostic stage: immature oocysts in feces.

115
Q

What is this? which stain?

A

Cystoisospora belli
Ziehl-Neelsen / Kinyoun

116
Q

Cyclospora cayetanensis infective vs diagnostic

A

Infective stage: mature oocysts with sporozoites.

Diagnostic stage: immature oocysts in feces.

117
Q

Cyclospora cayetanensis key implicated food

A

Raspberries
[basil / cilantro]

118
Q
A

Cyclospora cayetanensis
1 round oocyst (no sporozoites inside), thick wall, dark granules.

119
Q

What protozoa has acid fast variability

A

Cyclospora cayetanensis
kinyoun stain used

120
Q

Cryptosporidium infective vs diagnostic

A

Both are mature oocysts with sporozoites
Its the only one that does autoinfection

121
Q
A

Cryptosporidium trophozoite - on outside of gut vili

122
Q

2 types of cryptosporidium oocyst

A

Thick-walled mature oocysts (80%)
-Survive in outside

Thin-walled mature oocysts (20%)
Internal autoinfection (not recovered from stools).

123
Q
A

cryptosporidium
1 round oocyst with 4 sporozoites, dark granules.

Ziehl-Neelsen / Kinyoun

124
Q
A

cryptosporidium

125
Q

Cryptosporidium vs Cyclospora vs Cystoisospora
Size?
Which one has a mature cyst as diagnostic stage?
rX?
Which can auto-reinfect?
Which common cause of travellers diarrhoea?
Which causes eosinophilia?

A

Cystoisospora - Eye shaped + E for eosinophilia

126
Q

2 key species of Cryptosporidium

A

Cryptosporidium hominis
Cryptosporidium parvum

127
Q

Cryptosporidium survives in domestic water in low income countries why?

A

Resistant to chlorination

128
Q

Long term impact of childhood diarrhoea

A

Early childhood diarrhea with:
-decreased fitness (aged 6-9) and
-Cognitive impairment (ages 6-10)

Effects likely primarily due to stunting

129
Q

Cryptosporidium Dx?

A

Routine stool exam
AFB stains
IFA
Ag detection
PCR
Multiplex molecular

130
Q

Name 3 things Nitazoxanide works for

A

Cryptosporidium,
Entamoeba , Giardia
helminths (also bacteria)

131
Q

27 yo F with 4 wks of watery diarrhea,
>5x per day. No mucus, blood
Also, fatigue, nausea, anorexia, cramps, bloating sensation
Travelling around Nepal for 4 mo
Antibiotics, metronidazole no response
-Eggs 9um

dx?
Rx?
Key countries

A

Cyclospora cayetanensis
co-trimoxazole

Highly endemic in Peru, Haiti, Nepal

132
Q
A

Cyclospora cayetanensis showing acid-fast variability

133
Q

Chronic watery diarrhoea, mild eosinophilia ? rx?

A

Cystoisospora belli
co-trimoxazole

134
Q

Rx A/b/c

A

Cryptosporidium - Rx nitazoxanide
Cyclospora - co-trimox
Cystoisospora - co-trimox

135
Q

Name 1 microsporidia species

A

Enterocytozoon bieneusi - diarrhoea + biliary in AIDs

Encephalitozoon intestinalis - Diarrhoea in AIDs

E. hellem -Systemic infection
E Tachypleistophora - Myositis
E Nosema Keratoconjunctivitis

136
Q

AIDs with Diarrhoea, wasting, keratoconjunctivitis and myositis

A

microsporidia

137
Q

Toxoplasma full name? Infective vs diagnostic stage?

A

Toxoplasma gondii
Infective stage: bradyzoites, mature
oocysts with sporozoites, tachyzoites.

Diagnostic stage: tissue cysts with
bradyzoites (biopsy), tachyzoites

138
Q

Toxoplasma life cycle? Name 3 methods of infection and the form

A

Undercooked meat Tissue cysts with bradyzoites

Organ transplantation (tissue cysts with bradyzoites)

Contaminated food/water with cat feces
(Mature oocysts)

Blood transfusion (Tachyzoites)

Transplacentary (Tachyzoites)

139
Q
A

Toxoplasma gondii (Tachyzoite
Crescent shaped with a prominent nucleus

140
Q
A

Toxoplasma gondii (Bradyzoite)
Spherical in brain (may be elongated in muscle)

141
Q

Name the parts of toxoplasma here

A

A - tachyzoite
B - pseudocyst
c- tissue cyst
D/E - sporulated oocyst

142
Q

2 most common presentations of toxoplasma gondii

A

*Lymphadenopathy and “Mononucleosis like”

*Chorioretinitis

143
Q
A

Toxoplasma gondii

144
Q
A

Toxoplasma gondii

145
Q

AIDs. Most likely?

A

Toxoplasma gondii

146
Q

Key side effects of Pyrimethamine + Sulfadiazine? How to reduce?

A

Anaemia (35%)
Leukopenia (15%)
Thrombocytopenia (5%)

Add folic acid

147
Q

Toxoplasma Ix?

A

Serology - IgM

148
Q

Prevention of fetal toxoplasmosis when mum is positive Eg IgM?

A

Spiramycin

149
Q

Diagnosis and Treatment of confirmed congenital toxoplasma

A

Amniotic fluid PCR
-US aslso used

pyrimethamine/sulfadiazine

150
Q

Diagnosis and Treatment of confirmed congenital toxoplasma

A

Amniotic fluid PCR
-US also used

pyrimethamine/sulfadiazine

Tropical medicine - All clinical images copyright Gorgas course - : Instituto de Medicina Tropical Alexander von Humboldt (26 decks)

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