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Parasites (Identifying Factors (Diarrhea (Watery Diarrhea Giardia
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Parasites
Identifying Factors
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Ring Enhancing Brain Lesions
Intracellular
- Cryptosporidum parvum
- Leishmania
- Plasmodium
- Toxoplasma gondii
- Trypanosoma
Butt Stuff
Stool
Parasite Eggs
- Schistosoma mansoni
- Schistosoma japonicum
- Ascarasis lumbroides
Proglottids (intestinal tapeworm segments)
- Taenia Solium
- Taenia Saginata
- Diphyllobothrium latum
Trophozoites and cysts
- Giardia lamblia
- Entamoeba histolytica
Rhabditiform (non-infective) Larvae
- Strongyloides stercoralis
(Filariform are infectious larvae)
Perianal
Perianal Eggs
- Enterobius vermicularis (Pinworms)
Protozoa of the blood
Babesia
("Vampire Babes")Special
- Ixodes Ticket (like Borrelia) - North East USA
- You can also get Borrelia
- 25% of folks in Rhodes island have been exposed
Intraerythrocytic Ring Inclusions (Maltese cross)
- Asplenic patients will have more severe disease
Virulence Factors
Transmitted via Ixodes ticket in the North East
25% in Rhodes Island have been exposed to Babesia
Lab Identifiers
- Thick blood smear with maltese cross representing an infected red blood cell
- cross formed by a tetrad of trophozoites
Management
Atovaquone ("Vampire Queen Atova")
Azithromycin ("Her Macrolide crow")
Diseases
Typically silent but can present similarly to malaria.
- Fever, fatigue, myalgia, headache, flulike symptoms
- Severe : ARDS, CHF, DIC, Splenic Rupture
- Hemolytic Anemia
- Hemoglobinuria
- Jaundice
Irregularly cycling fevers
- Like Brucella (undulating fever with hepatomegaly)
- Like T. Brucei (sleeping fever)
- Higher risk of Severe disease in Sickle Cell Disease
- b/c they are unable to request it in the endothelium of the spleen
Trypanosoma Cruzi
("Che's Gas")Special
- Intracellular
- Megacolon
- Megaesophagus
- Dilated Cardiomyopathy
Virulence Factors
- Transmitted when "Reduviid Kissing Bug" bites around vitcim's mouth
- The bite itches so scratching creates an avenue for kissing bug feces which contains the bacteria to enter into the bloodstream. It then tunnels into tissue and feeds on the blood and lymph of victim.
- At the heart it burrows into the endocardium
Lab Identifiers
- Blood smear to visual mobile trypanosomes during active infection
- Can be found on cardiac myocytes on heart biopsy
Management
Nifurtimox ("knee high moccasins")
- No treatment for chronic infection
Diseases
Chagas Disease
- T Cruz is an intracellular protozoan that localizes mainly in the heart and nerve cells of the myenteric plexus leading to myocarditis and dysmotility of hollow organs such as the esophagus, colon, and ureters
- Megacolon - extreme constipation or acute abdomen
- destruction of myenteric plexus
- Dilated Cardiomyopathy (same as coxsackie virus)
- biventricular dilation
- myocyte necrosis and fibrosis leads to ventricular dilatation and congestive heart failure
- Mega-esophagus
- causes achalasia which is due to the loss of innervation to the lower esophageal sphincter prevention relaxation of the sphincter leading to dilation of the distal third of the esophagus
Plasmodium
("Plasmodium Warloads")Special
- Intracellular
- P. Malariae - fever every 72 hours
- Chloroquine - only in Caribbean and Central America
- Mefloquine everywhere else
- Atovaquone + Proguanil everywhere else
- P. vivax/ovale - fever every 48 hours + dormant hypnozoites in liver
- Primaquine for the dormant form of the 48 hour guys
- P. falciparum - irregular fever - banana shape on blood smear
Sickle Cell Patients are resistant to P. falciparum
- Merozoites infect RBCs
- Artemisins for severe P. Falciparum
Virulence Factors
- Malaria transmitted via anopheles mosquito which carry sporozoites in saliva
- Sporozoites travel to liver to mature into trophozoites
- Trophozoites become Schizonts which rupture the hepatocyte while releasing merozoites
- Merozoites infect the RBCS**
trophozoite --> schizont --> merozoites --> infect RBC --> produce gametocytes --> blood taken up by mosquito where gametocytes become trophozoites in the mosquito's gut --> cycle continues
Lab Identifiers
- Blood stain
- Giemsa Stain
- P. falciparum is banana shaped
- Schizonts are immature and will show "ring" in RBC
Management
-quin Rx for P. Malariae in Central America or Caribbean
- Chloroquine ("color queen") - blocks plasmodium heme polymerase. ("Can be hypnotized so cannot kill hypnozoites")
- Only works in Caribbean and Central America
Rx for P. vivax/ovale Liver Hypozoites
- Primaquine ("Primal queen") - kills hypnozoites in the liver
- careful with G6PD deficiency as you can get malaria
Rx for P. Malariae in Chloroquine resistant countries
- Mefloquine ("Me-fly-Queen") - prophylactic medicine for travellers
- Atovaquone + Proguanil ("Ato-vampire Queen and her Iguana") - prophylactic medicine for travellers
Rx for P. falciparum
- Artemisins for severe P. falciparum infections ("Artesian defending her queen")
- sickle cell is protective against P. falciparum
Rx for Severe Infection with any type
- IV Artesunate - severe malaria infections
- IVQuinidine ("Dining Queen") - for resistant species - treatment for serious infections
- quinidine can cause cinchoism --> headaches and tinnitus
Diseases
Each strain causes a different fever patternPlasmodium malariae
Fever: Every 72 hours (day 1 and then day 4)Plasmodium vivax/ovale
Fever: Every 48 hours (day 1 and then day 3)
- Produce dormant hypnozoites in liver
Plasmodium falciparum
Fever: Irregular fever
- Cerebral Malaria : Neurologic symptoms due to parasitized RBCs occluding vessels to brain
- Renal Malaria : kidney failure due to parasitized RBCs occluding vessels to the kidneys
- Pulmonary Malaria : lung failure due to parasitized RBCs occluding vessels in the lungs
Fever Cycle
Irregular Fever
- Likely P. Falciparum
- Banana shaped
- Sickle Cell is productive
Artemisins
- Artesonates
- For P. Falciparum
Disseminated Infection
Artesunate
Quinidine
SE:
Cinchoism
In Central America
In Caribbean
- Chloroquine Sensitive P. Malariae
Chloroquine
- Blocks plasmodium heme polymerase
Anywhere Else
- Chloroquine Resistant P. Malariae
Atovaquone + Proguanil
- Also to treat Babeiosis
- Likes Igunas
Mefloquine
- Given as prophylactic for travelers
48 Hour Fever
- Likely P. Vivax/Ovale
- Need to Kill Dormant Hypnozoites Forms in Liver
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Leishmania donovani and braziliensis
("Desert Mania")Special
- Intraceullar
- Sandfly vector
- Stibugluconate for treatment
- Pancytopenia
- Macrophages full of amastigotes
Virulence Factors
Leishmania donovani
- Mediterranean, Middle East, Africa
Leishmania braziliensis
- Sandfly is the vector (with promastigote)
- Vertebrates are host (with amastigote - intracellular (inside macrophages) form)
Lab Identifiers
- Marcophages full of amastigotes from biopsy from spleen, skin lesions, or lymph nodes
Management
Rx Cutaneous Leishmanias - Braziliensis
Stibugluconate - treatment for cutaneous leishmaiasis ("Steve-O-T-bone")
Rx Visceral Leishmanias - donovani
Amphotericin B
Diseases
Leishmania donovani 100% Fatal
- Visceral Leishmaniasis
- Scattered hyperpigmented spots - black fever
- Pancytopenia due to bone marrow infection
- Hepatosplenomegaly due to liver and spleen involvement
Leishmania braziliensis
- Cutaneous Disfiguring Ulcers
- Sandflies are the vector
- Mastigote is what's in the fly
- Amgastigote is the intracellular form
- Usually in macrophages
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Protozoa of the CNS
Toxoplasma gondii
("Crazy Pregnant Cat Lady's Backyard")Special
- Intracellular
From Oocysts in cat Poop
Cysts in Undercooked Meat
- Congenital Toxoplasmosis : Chorioretinitis, hydrocephalus, Intracranial Calcifications, Deafness
- Cause ring enhancing lesions on MRI
Virulence Factors
- Intracellular parasitic protozoan
- From consumption of raw or undercooked meat with Toxo cysts
- From consumption of water with oocytes from the feces of infected animals
- Cross-placental transfer if the mother is exposed to Toxoplasmosis during pregnancy (Toxoplasmosis ORCH)
Lab Identifiers
- Ring enhancing lesions in brain
- Brain biopsy needed to differentiate from CNS lymphoma
- Biopsy or serology - looking for intramuscular cysts
Management
Sulfadiazine and Pyrimethamine ("dyed sulfa eggs with pyramids")
- TMP-SMX Prophylactic drugs should be given to HIV patients with CD4+ <100 when they are (+) IgG for Toxo Antigens
Diseases
- Affects Pregnant women
- Affects immunocompromised
- Flu symptoms in Normal people
- Can infect fetus via transplacental transmission
- chorioretinitis
- hydrocephalus
- intracranial calcifications
- seizures
- deafness
Immunocompromised
- Can cause brain abscesses seen as multiple ring-enhancing lesions on imaging
- CNS Lymphoma in HIV will be a single Ring Enhancing lesion
Trypanosoma Brucei
("Prince Bruce and the Sleeping Princess")Special
- African Sleeping Sickness
Testes Fly
Recurrent Fevers
Brucella also causes undulating fever but has hepatosplenomegaly
- Cervical/Axillary Lymphadenopathy
- Trypomastigotes on blood smear
Motile with Single Flagella
Virulence Factors
- Transmitted via bite from Tetse fly.
- After bite the parasite moves from the blood into the lymph nodes
- Variable surface glycoprotein undergoing antigenic variation
- Motile with Single flagella
Lab Identifiers
- Western Africa
Trypomastigotes in blood smear
- Motile - Single Flagella
Management
Melarsoprol - CNS infection treatment ("bar of soap")
Suramin - Peripheral blood infection ("live saving serum")
Diseases
- Cervical and Axillary Lymphadenopathy
- Recurrent Fevers (like Brucella)
- Coma
Naegleria fowleri
("Niagara (Fresh Water) Falls")
- Leptospirosis is also associated with fresh water
Special
- Amoebas in freshwater lakes that cause Encephalitis - associated with water sports and can contaminate water supplies
- Amoebas in CSF
- Water skiing, water sports
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Lab Identifiers
- Amoebas in CSF via Lumbar Puncture
Management
- Amphotericin B
Diseases
- Meningoencephalitis
- nuchal rigidity
- fevers
- altered mental status
- Rapidly fatal with poor prognosis
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Helminths
Nematodes
Intestinal Nematodes
1. Enterobius vermicularis (Pinworm)
2. Ancyclostoma duodenale (Hookworm)
3. Necator americanus (Hookworm)
4. Ascariasis lumbricoides (Giant Roundworm)
5. Strongyloides stercoralis (Auto-infecting Hookworm)
6. Trichinella spiralis
("Scary worm lady escaping through wall fighting superheroes")Special
- Pyrantel Pamoate for Pinworm and Hookworm
- Albendazole for Pinworm, Hookworm, and Giant Roundworm
- Eosinophilia
Virulence Factors
Enterobius vermicularis
1. Female worms lay eggs around the anus
- Fecal oral route
- Have really itchy butt hole
Ancyclostoma duodenale**
Necator americanus**
Strongyloides stercoralis**
- Larvae penetrate skin of soles of feet
- Travel to the lungs
- Ascend bronchial tree.
- Coughed up and expelled into the mouth
- Swallowed and they mature as adults in the small intestine
Strongyloides stercoralis
Rhabditiform larva in stool
1. Autoinfects host. Lays eggs in intestinal wall, larvae hatch, repenetrate the intestinal wall and then travel to the lung. Ascariasis lumbricoides
- Transmitted by eating eggs in food or water
- Eggs mature in small intestine and the larvae will migrate through gut wall and into the blood stream.
- Migrates in the blood stream to the lungs
- Travel from capillaries into alveoli
- Are coughed up in the mouth
- Swallowed again in larvae form and now they can mature into adults in the small intestine
- Adults multiply and eggs are deposited into the feces
Trichinella spiralis
- Cysts found in undercooked pork or bear
- Larvae mature in the small intestine
- Larvae enter blood stream and form cysts in striated muscle cells
- This leads to muscle inflammation, and eventual muscle destruction
Lab Identifiers
All
- High Eosinophil count
Enterobius vermicularis
- Scotch Tape Test
Ancyclostoma duodenale & Necator americanus
- Eggs in Stool
Ascariasis lumbricoides
- Eggs in Stool
Strongyloides stercoralis
- Eggs in Intestinal Wall. Not in the stool.
- Larvae in the stool
Management
- Pyrantel Pamoate ("PAM")
- Enterobius vermicularis
- Ancyclostoma duodenale
- Necator americanus
- Albendazole - inhibit microtubule function and render the worms immobile. Can actually precipitate obstruction as all the worms stop moving. Also, don't use microtubule inhibitors in pregnant women.
- Ascariasis lumbricoides
- Strongyloides stercoralis
- Trichinella spiralis
- Ivermectin ("river-mectin")
- Strongyloides stercoralis
Diseases
Enterobius vermicularis
- Perianal itching due to eggs on the anus
Ancyclostoma duodenale & Necator americanus Hookworm in Southern US - Hookworm in Southern US
- Iron Deficiency Anemia
- due to blood sucking of the hookworms
Ascariasis lumbricoides
- Build up of worms can cause malnutrition
- Respiratory Problems as worms migrate to bronchus
- Intestinal Obstruction at ileocecal valve
Strongyloides stercoralis
- Inflammation from wall penetration by larvae can lead to hyperinfection and dissemination of the worms
Trichinella spiralis
- Fever, vomiting, periorbital edema
- Severe myalgia
Necator americanus
- Penetrate the basement of the food and spread from dermis to blood stream. Cause iron deficiency anemia
- Pruritic rash with wavy margins
Tissue Nematodes
1. Dracunuculus medinensis
2. Onchocerca volvulus
3. Wuchereria banfrofti
4. Toxocara canis
5. Loa Loa
("Screamatodes III: Return of the Flesh Eaters")Special
1. Dracunuculus medinensis
- worms in skin ulcers remove with twig
- Rx with Metronidazole
2. Onchocerca volvulus
- hyper/hypo pigmented papules
- river blindness
- Rx with Ivermectin
3. Wuchereria banfrofti
- Elephantiasis
- Rx with Diethylcarbamazine
4. Toxocara canis
- Ocular Larval Migrans --> blindness
- Rx with Albendazole
5. Loa Loa
- Angioedema subcutaneous swellings
- Worm in the eye
- Rx with Diethylcarbamazine or Albendazole
Virulence Factors
Dracunuculus medinensis
- Drinking contaminated water with copepods which are little sea creatures that live in fresh water. Copepods contain larvae.
- Once copepods die the larvae penetrate the host's intestinal wall
- Mature in small intestine
- Once mature migrate to the surface of the skin to create skin ulcers
Onchocerca volvulus
- Transmitted by river black flies which bite host and deposit larvae in the skin.
- Larvae penetrate into skin and mature into adults.
- Adults produce microfilariae which migrate throughout body
- Causes scattered hyperpigmented pruritic papules
Wuchereria banfrofti
- Mosquitos transmitted W. bancrofti which when the bite deposit larvae on the skin.
- Larvae penetrate the skin and enter lymphatics where they produce microfilariae
- Microfilariae proliferate in the lymphatics and prevents proper lymphatic drainage.
- Lymphedema accumulates in the lower extremities
- Microfilariae migrate to the lungs causing a hypersensitivity reaction
Toxocara canis
- Contaminated food with dog or cat feces
- Parasitic larvae don't mature in the human, but continually circulate in body
- as larvae circulate Visceral Larval Migrans
- larvae in the eye Ocular Larval Migrans
Loa Loa
- Transmitted by deer flies (L. Ioa) which when they bite deposit larvae on the skin.
- The larvae then migrate through subcutaneous tissue.
- Migration causes transient angioedema leading to subcutaneous swellings (Calibar Swellings)
- The worm can enter the eye and is seen moving in the eye
Lab Identifiers
ALL
- Peripheral Eosinophilia
Onchocerca volvulus
- Microfilariae seen in skin biopsy under microscope
Wuchereria banfrofti
- Thick blood smear to see organisms
Loa Loa
- Blood smear
- Eye exam
Management
Dracunuculus medinensis
- Wrap worm around little twig and slowly pull it out of the ulcer
- Metronidazole
Onchocerca volvulus
- Ivermectin ("river-mectin")
Wuchereria banfrofti
- Diethylcarbamazine ("Witch Reading Diet and Carb Magazine")
Toxocara canis
- Albendazole
Loa Loa
- Diethylcarbamazine ("River Monster Reading Diet and Carb Magazine")
- Albendazole
Diseases
Dracunuculus medinensis
- Skin ulcers and worms coming out of the ulcer.
Onchocerca volvulus
- Onchodermatitis : Causes scattered hyperpigmented pruritic papules
- Hypopigmented spots appear on the shins of older patients
- Riverblindness - caused by microfilariae which proliferate in the eye
- (#2 cause of infectious blindness after C. trachomatis)
Wuchereria banfrofti
- Elephantiasis due to chronic lower extremity lymphedema
- Lymphadenopathy
- Microfilariae penetrate lungs causing inflammation and cough
Toxocara canis
- Blindness due to perpetual larval migration
Loa Loa
- Local subcutaneous swellings
- Worm can enter eye and will move beneath conjunctiva
Trematodes
(FLUKES)
Schistosoma mansoni
Schistosoma japonicum
Schistosoma haematobium
Clonorchis sinensis (Chinese River Fluke)
Paragonimus westermani (Lung Fluke)
Flukes
("San Franschisto Ocean Park")Special
Swimmers at risk
Snails are intermediate host
- Schistosoma mansoni
- portal hypertension
- Large Lateral spine on egg
- Schistosoma japonicum
- portal hypertension
- Smooth round egg (no spine)
- Schistosoma haematobium
- Clonorchis sinensis
- Biliary fibrosis & Pigmented gallstones
- Operculated eggs
- Paragonimus westermani
- Bloody cough
- Operculated eggs
Virulence Factors
- Free living circari that can penetrate the skin usually in the water and enter the bloodstream.
- Carried to the liver where they mature as adults
- Adults lay eggs in the humans and they are transmitted to others via pooping in shared water sources
- Snails exposed to the excrement and become intermediate host completing the cycle
Once mature adults in the liver will travel to different places depending on the species. All will migrate upstream like salmon against portal flow to reach venous destination. Schistosoma mansoni
- Travel to Mesenteric Veins
Schistosoma japonicum
1.Travel to Mesenteric VeinsSchistosoma haematobium
- Travel to bladder
Clonorchis sinensis - Chinese liver Fluke - Sushi
- Snail intermediate hosts transfer to fluke to fish
- Undercooked fish in sushi will mature inside the biliary system
- Will lead to biliary tract fibrosis and pigmented gallstones.
Paragonimus westermani
- Snails are the intermediate host
- Raw or undercooked crab meat
- Larvae mature in GI then travel to GI
Lab Identifiers
Travel To GI
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Have Spine
Go to Portal Vein
Small Spine
Schistosoma japonicum
- ("smooth and round like sun on Japanese flag")
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Diseases
ALL
- Swimmer's Itch where larvae penetrate the skin
Schistosoma mansoni & Schistosoma japonicum
- Portal hypertension
- GI hemorrhage
- abdominal pain
- cirrhosis
- liver failure
Schistosoma haematobium
- Hematuria
- bladder cancer
Clonorchis sinensis
- Biliary tract Fibrosis
- Can progress to Cholangiocarcinoma
Paragonimus westermani
- Chronic cough with bloody sputum
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