Walden- GI Parasites X4- Melissa** Flashcards
Naegleria:
Pathogenesis of infection?
Symptoms?
How is it diagnosed?
Swimming in stagnant fresh water/heated pool–>
Invades nasal mucosa–> cribriform plate–>
Ollfactory N.–> Brain + Meninges–>
Primary Amoebic Meningoencephalitis (PAM)
Sx: Severe Frontal HA, N/V, meningitis sx.–> FATAL coma within 1 week
Dx: Motile Amoebas on wet prep of CSF
Where is Naegleria found in the US?
-VA, GA, FL, TX, CA (warm/ costal US states)
Acanthamoeba: Two mechanisms of infection? What two infections does this cause?
Where is this amoeba found?
How is infection prevented?
1) Skin lesion, Eye infection, Inhalation–> Hematogenous spread–>
Granulomatous Amoeboid ENCEPHALITIS
Sx: FATAL progressive brain disease
2) Soft contacts/ corneal trauma/ contaminated water–>
** Chronic Amoebic KERATITIS**
Sx: Ocular pain + corneal lesions w diffuse, indolent, inflam.
Tx: Successful treatment with drugs
Note: both diseases found in US
Px: Avoid warm stagnant fresh water, especially around power plants…
Onchocerciasis:
What disease does this amoeba cause?
Vector?
River blindness, Simulium Fly (Black)
Onchocerciasis:
Describe the pathogenesis of river blindness.
What are 4 clinical manifestations of the disease?
(Remember: location of nodules in Africa vs Guatemala)
Simulium flies breed in riffles of rapid flowing streams–>
Female fly bites human–>
Inoculates larvae into skin–> mature–> adult worms form NODULES –>MICROFILARIAE released by female–>
Migrate to eye–> RIVER BLINDNESS
Clinical Manifestations:
- Itching–> scratching–> depigmented lizard/ leopard skin
- Lymphadenitis–> “Hanging groin”
- pelvic (Africa) or head (Guatemala) nodules
- Blindness
Onchocerciasis:
3 ways to dx?
Tx (DOCs and management)?
How is it prevented?
Dx:
1) Tenting (microfilarieae in skin)
2) Mazzotti Test (admin DEC, intense itching in 24 hours)
3) slit lamp exam of eye
Tx: -Surgical removal of nodules -NO DRUG TO TREAT ADULT WORMS Ivermectin= DOC for microfilariae Doxy = Wolbach Bacteria* (endosymbiotic bacteria)
Px: Premetherin, Deet, avoid rapidly flowing streams in endemic areas I.e. Ferry crossings
What are wolbach bacteria?
Endosymbiotic bacteria that live in microfilariae of onchocerciasis; they are responsible for primary inflammatory response in the cornea that leads to river blindness **Tx w doxy
Bancroftian Filariasis:
3 worms and disease caused?
Wuchereria bancrofti
Brugia Malawi
Mansonella Filariasis **asx
**ELEPHANTITIS
Describe the pathogenesis of Bancroftian Filariasis induced elephantiasis. What are the early and late manifestations of disease?
Infected MOSQUITO bites human–>
Microfilariae transmitted into human–>
Migrate through lmyphatics–>
Immunologic Reaction–>
**Early: Inflammation
(fever, erythema, swelling, +/- lofflers in lung)
**Late: Elephantiasis w/ prolonged exposure + repeat infxn.
(Enlarged legs, arms, genetalia) +/- Chyluria (pee lymph)
3 ways to dx Bancroftian Filariasis?
DOC for treatment/ management procedures?
Prevention?
DX:
1) Microfilariae (+) in NIGHT-time blood draw (“Bancroft=elephants’ bedtime”)
2) Mazotti (DEC itch) test
3) antifilarial IgG4-ELISA in blood w active infection
* Lab tests ~ negative in patients with elephantitis
TX:
Ivermectin = DOC
Surgery for hydrocele in scrotum or breast, not effective for general elephantitis
Px: Prometherin soaked nets at night, deet, etc.
Mansonella Filariasis infections are typically…
asymptomatic
Loiasis: Microbe the pathogenesis and three manifestations of disease?
Day biting Chrysops fly bite–> hypersensitivity reaction–>
1) Calabar (Transient) swellings +/- pain and itching, arthritis
2) Migration to eye–> Ocular pain/ conjuncitivitis/ eyelid edema; noticed when looking in mirror
“‘Lo’ and behold you have a Loa Loa in your eye”
3) rarely CNS manifestations (encephalitis + seizure)
How do we diagnose Loiasis?
How do we treat it (DOC)?
Dx:
microfilariae (+) in DAYTIME (noon) blood draw
(Contrast with elephantitis = NIGHT)
“if you suspect Loa, draw blood in the ‘L’ight”
Tx:
DEC = DOC (can cause encephalopathy, Ivermectin») + Surgical removal of worms
Where is Loiasis endemic?
Rainforest of west and central Africa: Congo River Basin
Describe the lifecycle of Draculus medinensis–
With what is this infection associated?
Lifecycle: Human drinks Cyclops (STEP WELL**)--> Larvae freed from Cyclops in stomach--> Penetrate intestine--> Migrate in SQ tissue to legs--> Mature, copulate, males dies--> Females form blisters on skin--> Blister ruptures in water--> new larvae released--> Larvae ingested by Cyclops **Infectious for 2-3 weeks inside Cyclops**
Symptoms of Dracunulus medinensis infection:
- Red itchy blister + n/v/ fever; allergic rxn
- Ulceration–> possible cellulitis or septicemia if worm is broken during removal
Dracunulus medinensis: Dx/ Tx/ Px
Dx:
See worm coming out of blister; calcified worms on X-ray
Tx:
**Wrap worm around stick (+/- Metronidazole for inflam.)
Px:
Temphos in existing step wells (insecticide); eradicate step wells; boil step well water before drinking
Where is Dracunculiasis endemic?
Sudan; war-torn African countries
Toxoplasmosis: Which animal is the only living host?
Cats
What are 5 ways to get toxo?
To which two populations is this disease particularly relevant?
Important infection for Preggos and AIDS 5 ways to get it: 1) Undercooked meat with cysts 2) Fecal oral ingestion of cysts 3) Blood transfusion/ organ transplant 4) Transplacentally 5) Lab accident
Describe:
- congenital toxo
- ocular toxo
- AIDS toxo
- How toxo can infect immunosuppressed patient
- How does it present in healthy patients?
How does toxo infection typically manifest in otherwise healthy individuals?
- Congenital Toxo: not apparent at birth; sequelae apparent as child grows (intellectual disability)
- Ocular Toxo: chorioretinitis (congenital or after birth)
- AIDS Toxo: ring enhancing lesions; encephalitis
Immunosuppressed: newly acquired OR reactivated latent infection
Typically asx in healthy people; possibly flu sx w cervical lymphadenopathy
How common is toxo in the US?
USA 23% population seropositive;
Most NOT symptomatic
Describe the lifecycle for fresh water shistosomas:
SNAIL –> MAN –> SNAIL
Cerariae in contaminated water–>
Penetrate skin–> Lung–> Liver–>
Mature + mate in liver–> portal circ–> mesenteric venules (can live here up to 30 yrs!)–>
Females lay eggs containing MIRACIDIUM–>
Miracidium eggs migrate to intestine–> Pooped out–>
Miracidium eggs hatch in fresh water–>
Free miracidium penetrates snail–>
Cerariae formed–> released to fresh water to go to humans again
What are the manifestations of shistosoma mansioni disease (2)?
How is infection diagnosed?
How is it treated?
Diseases: LIVER AND INTESTINE
- Liver fibrosis, Portal HTN, chronic SALMONELLA infection
- Katayama Fever (acute typhoid-like illness)
Dx: Oval eggs with prominent lateral spine in stool or intestine/ liver biopsy
Tx: Praziquantel (DOC for all GI/GU shistosomaisis)
Katayama Fever: what is it and what causes it?
Acute typhoid-like illness w ^ EOS
- immune complex mediated
- shistosoma mansioni or japonicum infection in patients without prior immunity
Schistosoma Mansoni: endemic areas
Classically: PUERTO RICO!
(But can appear in many other countries)
“MAN it’s SONI in puerto rico”
Where do shistosoma mansioni lay their eggs?
Inferior mesenteric vessels (large intestine)
Describe manifestations of shistosoma japonicum infection.
Where do these guys lay eggs?
Dx and Treatment?
Same as shistosoma mansioni, except lays eggs in superior mesenteric vessels (large and small intestine)!!
DX and TX the same way as well.
Shistosoma Haematobium:
Where do these guys lay eggs?
What are 3 sequelae of disease?
How is the disease diagnosed and treated?
Lays eggs in urinary bladder
Diseases:
- Painful, frequent urination w/ terminal hematuria
- Chronic obstructive disease + salmonellosis
- ^^^ risk bladder ca.
Dx:
Oval eggs with terminal spine in urine or bladder mucosa
Tx: Praziquantel
Shistosoma Haematobium: Endemic areas?
Africa, Middle East
Salt water Avian Schistosomes:
Endemic areas and infection caused?
Pathogenesis and treatment?
Cape Cod
-Clam Digger’s Itch—transient dermatitis
-Does not mature in humans
-Cerariae in contaminated water penetrate skin
Tx: Antihistamine
Fresh Water Avian Schistosomes:
Endemic areas and infection caused?
Pathogenesis and treatment?
Great Lakes
**Worse w hydro-dams and agricultural irrigation
-Swimmer’s Itch—transient dermatitis
-Does not mature in humans
-Cerariae in contaminated water; ingested or penetrate skin
Tx: Antihistamine
Taenia Saginata: Animal Reservoir?
Taenia Solium?
Saginata: Cow Tapeworm (“SAGgy Utter’s”)
Solium: Pig
Tania Solium: Animal Reservoir?
Pig tapeworn
Lifecycle for Tanea Saginata and Solium?
(Humans = only definitive hosts)
Eggs (gravid proglottids) pooped out by human–>
Proglottid contaminated grain eaten by pig or cow–>
Infected Pig or cow meat ingested by humans
Clinical manifestation of Tanea Saginata infection?
Dx and Tx?
Typically asx; mild GI upset; eggs not directly infectious to humans; emotional trauma from shitting worms
Dx: Eggs in stool; not distinguishable from solium
Tx: Prazaquantel
(“if you see worms in your poop, prazaquantel will cure in one swoop”)
Clinical manifestation of Tanea Solium infection?
Same as Saginata or Neurocysticercosis
Human ingests eggs shed from human feces–> Oncopsheres released in intestine–>
Penetrate intestinal wall–>
Cysts lodge in MSK + BRAIN–>
Mental disturbance, seizures
**Suspect infxn in Latin American migrant workers w/ new onset seuzures and strong bx!!!
Dx and Tx for Tanda Solium Infection?
Dx:
- Ab detection w immunoblot assay + purified T. sodium Ag
- CT or MRI for brain cysts
Tx:
Prazaquantel or Albendazole +/- anticonvulsant, steroids
Where are Tanea solium and saginata found?
worldwide
Diphyllobothriasis: Réservoir?
Fish tapeworm of cold water
Describe the Diphyllobothriasis Lifecycle
Eggs pooped out (human= definitive host)–>
Eggs in freshwater–>
Eggs hatch–> larvae eaten by water fleas–>
Waterfleas grow into crustadeans–>
Crustaceans w infectious larvae eaten by fish–>
Undercooked fish eaten by humans–>
Larvae grow into tapeworms in SMALL INTESTINE –> spread and create cysts (liver, lung, brain)
Clinical manifestation, Dx + Tx for Dihyllobothriasis Infection
Clinical:
Asx.»>; Diarrhea + fatigue; B12 deficiency anemia
Dx:
Characteristic egg w/operculum ; Megaloblastic Anemia
Tx: Praziquantel
Hymenolpiasis: Vector? Prevalence?
Fleas and Beetles in GRAIN: #1 HUMAN TAPEWORM WW
Where is Hyminolpiasis found?
WW; mostly hot places like SE rural US
Hymenolpiasis Nana (dwarf tapeworm): Two modes of infection, clinical manifestations of infection, and how it's diagnosed?
Modes of transmission:
1) Human poops eggs eggs immediately infectious Fecal oral transmission
2) Human poops eggseggs ingested by flea or beetle insect consumed in contaminated grain
Clinical: Asx»; abdominal pain, diarrhea
Dx: Eggs in stool
H. diminuta (rat tapeworm): Describe the route of infection.
Human infection swallowing infected insect in grains or flour; typically a rat infection
Dipylidium Caninum: What are the reservoir and vector?
Dog Tapeworm; Flea = vector
Dipylidium Caninum:
Describe the route of infection and its clinical manifestations.
How is it treated?
Dog infected –> passes to flea– > Flea bite–> Human infected
Clinical: Perianal itching, diarrhea/ belly pain/ restlessness CUCUMBER SEEDS (parglottids—pieces of worm) in poops
Tx: Prazaquantel
“Dogs and FLEAS and cucumber Seeds” (that rhymes, right?)
Echinococcus granulosus:
Describe the lifecycle; what disease does the worm cause in humans?
Human CYSTIC ECHINOCOCCUS (more common version)
Lifecycle:
Dogs eat infected sheep viscera w heated cysts–>
Adult worms mature in dog intestine–> Eggs exit in dog poop–>
Humans somehow eat dog poop –> Larvae penetrate human intestinal wall–>
Travel to liver + brain + lung = hyatid cysts
(‘ECH= shEEp, Canine, human’- if you see this then pick ECHinococcus granulosus)
Echinococcus granulosus:
What’s the disease?
How is the disease diagnosed (2)?
Treatment (2)?
**HYATID CYSTS OF LIVER + LUNGS (Cystic echinococcosis)
Dx:
- Imaging + Hx
- Serologocally: EIH/ IHA screen–> Echinococcal “Arc5”
Tx:
- Surgery—careful removal of cysts to prevent ANAPHYLAXIS + seeding of more cysts
- Albendazole or Prazaquantel
Where is Echinococcus granulsus endemic?
Rural herding areas, classically Greece
Echinococcus multilocuaris:
Disease caused in humans and route of infection
Human ALVEOLAR ECHINOCOCCUS
Eggs ingested by rodents–> larvae released in rodent stool & eaten by fox/dog –> Human ingests veggies/ raw fruit w/ dog or fox feces–> Larvae form vesicles that invade + destroy tissues–>
LIVER FAILURE
Paragonimus westermani:
Where is it found and what kind of infection does it cause?
What do the eggs look like?
Found in asia; causes infection that mimics TB w/ “rustier” colored sputum
Like TB, can infect the lungs + brain (as well as GI tract)
Operculated eggs MINUS knob (compare to opisthorchiasis)
Paragonimus westermani:
Describe the lifecycle
(MAN–> SNAIL–>CRAB–MAN)
Human eats raw/ undercooked crayfish/ crab w/ cercariae--> Larvae penetrate intestinal wall--> Migrate to lungs--> lay eggs--> Cough up, swallow eggs--> Poop eggs out--> Eggs mature in FRESHWATER--> LARVAE (miracidium) Penetrate SNAILS--> CERCARIAE emerge from snail--> Encyst in freshwater CRUSTACEANS
***Clonorchiasis/ Opisthorchiasis: Describe the lifecycle
(MAN–> SNAIL–> FRESHWATER FISH–> MAN)
Human eats fish w encysted larvae–>
LARVAE Migrate to BILE DUCTS–>
Mature, lay EGGS containing MIRACIDIA–>
MIRACIDIA into bile–> pooped out in feces–>
Eaten by snails–> CERCARIAE released to water–>
Penetrate fish –> encyst in fish muscle
***Clonorchiasis/ Opisthorchiasis:
Clinical presentation (acute vs. chronic)
Diagnosis
Prophylaxis
Clinical:
Acute–>epigastric pain, tenderness in RUQ
Chronic–> jaundice w/ diarrhea, fever, HSM, RUQ pain, cirrhosis, ^ risk CHOLANGIOSARCOMA*
Dx:
Tiny ovoid eggs w ‘knob’ in feces or duodenal asparate; ELISA
Px: Night soil (human waste) should not be used to fertilize fish ponds; cook fish well
***Clonorchiasis/ Opisthorchiasis:
Where is this found?
What do the eggs look like?
Asia, especially SE—
US in refugees** from endemic areas
Operculated eggs + knobs
Fascioliasis:
What kind of infection does this cause?
How does one get infected?
Where is it found?
-liver abscesses; chronic infection NOT Asstd. w cholangiosarcoma (liver rot!!) (Think of it as being named after “fasciitis” so its just causing rot but be careful not to confuse with fasciolopsiasis)
Infection caused by eating contaminated freshwater plants in areas where cattle and sheep herding is common
WATERCRESS!!!!=FASCIOLIASIS/LIVER ROT
Fasciolopsiasis What kind of infection does this cause? Basic life cycle? How does one get infected? Where is it found?
- Heavy infection will cause alternating diarrhea and constipation
- Pig –> snail –> plant –> human
Associated with eating contaminated water chestnut/ bamboo shoots/caltrop in SE asia; look for giant worms in poops or vomit
“fascioloP(ig)S(nail)I(ngest chest…nut)A(human)sis”
Entamoeba histolytica:
Where are entamoeba found?
What three infections do they cause?
Poor countries (Africa, C/S America, India) **Immigrants and travelers in US
Infections:
1) BLOODY MUCOID DYSENTARY DIARRHEA, +/- flu sx, necrotizing colitis
2) Liver abscesses = right elevated diaphragms
3) LUNG INFECTION (liver abscess rupture seed through diaphragm):pleuritic + RUQ pain, red-brown sputum, SOB
**Note: don’t typically see these conditions all together! May not even see worms in stool! (Only 20% + for worms!)
Entamoeba histolytica, dispar, or moshkovskii: Describe the organisms. How is it transmitted during epidemics? What is the natural reservoir? Which cause asx. colonization?
Pseudopod forming non-flagellate protozoan
Transmitted from fly feet (cysts) to water during epidemics
Humans are only significant reservoir
- E. dispar & moshkovskii infection is asx even in immunocompromised
- E. histolytica can be asx for years
Etatmoeba histolytica, dispar, or moshkovskii:
Describe the life cycle
Ingestion of contaminated food, H2O/ Oral-anal sex–> Trophozoites multiply (binary fission), form cysts + invade (flask shaped large bowel)–>
Trophozoites migrate to liver, lung, brain via portal circ.
What are the two ways we diagnose Entamoeba infection?
1) OPx3 (examine stool w/in 30 min, look for charcot-leyden crystals, gliding amoeba w pseudopods, not sensitive or specific)
2) Colonoscopy + Biopsy, Ag testing (15-30min; invasive trophozoites + cysts) + observe multiple flask shaped ulcerations
How do we differentiate E. Histolytica from its non-infectious counterparts? (2)
E. histolytica:
- Cysts = 1-4 nuclei (more nuclei = noninfectious)
-Trophozoites = single nucleus, central karyosome, INGESTED RBCs, rounded chromatidal bars (frayed chromatin, eccentric karyosome = non infectious types)
Blastocystis hominis
How common is this? What disease does it cause? Where is it found and how its it treated?
- Over 50% MSM have this
- Causes n/v/d abdominal pain, anorexia, malaise
- WW esp in tropics
- Treatment is typically supportive care
What two diseases will have chariot-leyden crystals?
- Enteric amoebiasis (E. Histolytica)
- Isospora Belli
Giardia Lamblia: Where is this found? Describe the organism. Two commonly assc animal carriers? Tx? Px?
Worldwide; WV, CO, St Petersburg
Motile protozoan 4 flagella (trophozote pic)
Beavers, dogs
Tx: tinidazole (Metronidozole =disulfiram-like rxn)
Px: Chloride resistant (filtration is needed)
Giardia Lamblia: Describe the transmission of infection
Waterborne», person-person contact, food–>
Ingest 10-20 cysts–>
Excyst in stomach acid–>
Trophozoite colonization of duodenum/ upper small intestine (form cysts as they move down the intestine)–>
Pass cysts + trophozoites in stool
Describe the clinical manifestations of Giardia infection:
Wha tis the course like and what are three possible sequelae?
Clinical:
**1-2 wk incubation (Shorter think ETEC)–>
Bloating, cramping, yellow/frothy/floaty STANKY DIARRHEA–> ~Malabsorption (ADEK), B12 deficiency
Possible sequelae include LACTOSE INTOLERANCE, RECURRENT sx., REACTIVE ARTHRITIS, failure to thrive in kids
*B12 def also seen with Diphyllobothrium Latum (fish tapeworm)
What is the #1 Human pathogenic protozoan in the developed world?
How does the infection present?
Trichomoniasis vaginalis
NOT AN INTESTINAL PROTOZOAN (STI)
- Infects female lower GU and male urethra + prostate
- Presents with itchy lady parts, frothy/ fishy/ STANKY yellow-green discharge, strawberry cervix
- Girls symptomatic, boys not
- TX with metronidazole
- ^ risk HIV transmission, preterm birth
- See motile trichomonads on saline slide; serious fishy stank w KOH prep (diff.from candida)
Dientamoeba fragilis
Where is it located? describe the organism.
Worldwide; rare infection
HAS NO FLAGELLA BUT STILL CONSIDERED FLAGELLATE!!!
Dientamoeba fragilis
Describe the pathogenesis.
Fecal oral transmission alone or within PINWORM and ASCARIS eggs–>
Trophozoites from ONLY (no cysts)–>
Diarrhea, farts, abdominal pain
Balantidium Coli: Describe one important structural fact about the parasite + the infection.
LARGEST INTESTINAL PROTOZOAN IN HUMANS!
Incidental human infection–>
Intermittent diarrhea/ acute dysentery w crater like colon ulcers
” LARGEST GI protozoa, from LARGE bowels of pigs, causing LARGE amounts of diarrhea, LARGE crater ulcers”
Balantidium Coli:
Where is it found? Describe the organism.
Tropics (large bowel of pigs)
CILIATE—only ciliate infectious to humans
List the 4 intestinal coccoidal infections that can be stained w acid fast. What kind of infection do these organisms generally cause?
- Cryptosporidium parvum
- Isospora belli
- Cyclospora cayetanensis
- Sarcocystis
Cause severe protracted diarrhea in immunocompromised patients and travelers to the third world
What are two factors that make Cryptosporidium parvum exceptionally infectious?
- Chlorine resistant**
- Small oocysts= pass through H2O filters
Describe the Cryptosporidium parvum mode of infection and three diseases caused:
Infection: waterborne (pools), animal –> person, person –> person, food borne all possible
1) Endemic childhood watery diarrhea (third world)
2) Traveler’s diarrhea (Immunocompetent= 2-3 days)
3) Protracted diarrhea in AIDS patients (cholera-like diarrhea for mos)
How do we diagnose cryptosporidium parvo?
How do we treat it?**
Dx: Acid fast stain feces; EIA test more sensitive + specific
Tx:
- REHYDRATION/SUPPORTIVE CARE ONLY for immunocompromised (RX QUESTION)
- Immunocompetent patients get Nitazoxanide (classically but in real life walden says it isn’t effective)
What random animal is associated with CRYptosporidium parvo infection? Where is this infection generally found?
pre-weened calves; infection is found ww
“the CRYing pre-weened cow”
Isospora belli: Where is infection found? Describe mode of transmission. What kind of infection does it cause? How is it diagnosed and treated?
Found in US; humans= only host
Fecal oral spread to immunocompromised patients–> Acute non-bloody diarrhea +/- EOSINOPHILIA, CHARCOT-LEYDEN CRYSTALS in stool
Dx: bright ted cysts on acid fast
Tx: TMP-SMX even for AIDS patients
Cyclospora cayetanensis:
Where is this disease found?
Describe the infection caused–high yield mode of transmission?
How do we dx and treat it?
Found WW:
Ingest sporulated oocysts in water or food–>
N/V/ prolonged watery diarrhea +/-flu sx–>
Poop out unsporulated oocysts–> contaminate food
**Raspberries, mesclun lettuce, snow peas = commonly contaminated foods
Dx: UV microscopy of stool; PCR
Tx: TMP-SMX
Sarcocystis: High yield points regarding lifecycle
Require 2 hosts for life cycle
Sexual dvlpmt/ definitive host: carnivore
Intermediate host: herbivore
Sarcocystis: two infections caused?
Two manifestations of human disease:
1) Intestinal infection; human = definitive host
(Tx w TMP-SMX)
2)Muscle infection; human = intermediate host
Microspora: what kind of organism is this?
Obligate intracellular parasitic fungus!
Microspora:
Describe the lifecycle + 2 high yield infections caused.
Who does it typically infect?
Typically infects immunocompromised patients
Ingestion or Inhalation of infectious spores–>
Coiled polar filament extrudes infective spore into host cells–> Replication within host cell–>
Many systems affected…
1) Keratoconjunctivitis
2) Chronic diarrhea
Microsporidia:
How is infection treated?
Fumagillin/ albendazole
What 4 have snail interaction in their lifecycle?
- liver fluke (man-snail-freshwater fish-man)
- lung fluke (man-snail-crab-man)
- intestine fluke (pig-snail-plant/water chestnut-man)
- Schistosomiasis (man-snail-man)
which two acid-fast staining parasites cause chronic diarrhea in immunocompromised?
- microsporidia
2. cryptosporidium parvum
