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Coccidia and Pneumocystis
Nimit Morakote, Ph.D.
2016
1
Learning objectives
• After class, students will be able to: • Describe morphology, life cycle, signs and symptoms, prevention and
control, laboratory diagnosis and treatment of coccidian of man and Pneumocystis
• Differentiate oocysts of coccidian causing human infection
2
Coccidia
• Collectively intracellular organisms in suborder Eimeriorina in Phylum Apicomplexa
• 10 families, at least 42 genera, and over 2,000 named species
• Life history has both asexual and sexual phase of development
3
Asexual reproduction
• From one cell to 2 or many cells
• Multiple fission = one cell → many cells • Termed “Merogony” or “schizogony”
• Internal budding = one cell → 2 or many cells • Termed “Endodyogeny” and “Endopolygeny”
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Replication by the Apicomplexa.
Morrissette N S , and Sibley L D Microbiol. Mol. Biol. Rev. 2002;66:21-38
Endodyogeny
Schizogony or merogony
Meront or schizont
Merozoites
Sexual reproduction
• Sex cell production termed “Gametogony” Merozoite
Macrogamont
(macrogametocyte)
Many
microgametes
Microgamont
(microgametocyte)
Microgamete
(macrogamete)
fertilization Zygote
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• Sporogony: production of sporozoites
Zygote
Oocyst (immature or unsporulated)
Oocyst (mature or sporulated, infective) sporozoite
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Taxonomy of coccidia
• Based on number of sporocysts and sporozoites in sporulated oocyst
Unsporulated oocyst
Sporulated oocyst
sporozoites
sporocysts
8
Taxonomy- coccidia of medical importance
0+4 Cryptosporidium Naked sporozoites
2+4 Cyclospora
2+8 Cystoisospora Toxoplasma Sarcocystis
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Coccidia of medical importance Life cycle Opportunist Affected organs/
Disease in man
Toxoplasma gondii Complex
Cat=DH
+ Brain-Toxoplasmic
encephalitis
Developing organs-
Congenital
toxoplasmosis
Sarcocystis bovihominis,
S. hominis
Complex
Cattle, pig=IH
- Small intestine-
Eosinophilic enteritis
S. nesbitti or other spp. Cobra=DH - Muscle
Cystoisospora belli Simple + Small intestine-Diarrhea
Cryptospridium Simple + Small intestine-Diarrhea
Cyclospora
cayetanensis
Simple + Small intestine-Diarrhea
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Toxoplasma gondii
• Disease: toxoplasmosis • Congenital toxoplasmosis
• Toxoplasmic encephalitis in AIDS
• Stages in life cycle • Tachyzoites, 6 x 2 µm: during acute stage of
infection
• Bradyzoites, during chronic stage of infection
• Oocyst, 10 x 12 µm
tachyzoite
Sporulated oocyst
11
Life cycle
rowdysites.msudenver.edu
PP=3-10 d
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Enteroepithelial cycle • Merogony • Gametogony • Fertilization
Sporulation
Asexual phase
tachyzoites
Bradyzoites In tissue cysts
sporozoites
Human infection
• Man acquires infection from • Consumption of improperly cooked
meat (tissue cysts)
• Drinking unfiltered water (oocysts)
• Contaminated hand (oocysts)
• Organ transplant, blood transfusion (tachyzoites)
Medical-labs.net
13
Pathogenesis, Signs, Symptoms
• Acute phase- tachyzoites invade and destroy host cells
• Lymphadenopathy, flu-like symptoms
• Chronic phase • Immune pressure: Tachyzoites bradyzoites
(tissue cysts) in brain, muscle, liver
• Symptomless
• Reactivate in AIDS toxoplasmic encephalitis
• Congenital toxoplasmosis: chorioretinitis, hydrocephalus, intracerebral calcification
Medical-labs.net
14
Diagnosis, prevention & treatment
• Isolation of parasite impractical
• Primarily diagnosed by serology (antibody detection)
• Serological survey shows worldwide distribution including Thailand
• Prevention by • Properly cook meat,
• Proper handling of cat’s faeces
• Treatment: pyrimethamine and sulfadiazine, plus folinic acid.
15
Sarcocystis spp.
• Affect intestine
• Human as definitive host • S. hominis: bovine = IH
• S. suihominis: porcrine = IH
• Intestinal sarcocystosis
• Usually no signs and symptoms, a few cases of segmental eosinophilic enteritis
• Not opportunistic parasite
• Affect muscle
• Man as accidental host • S. nesbitti of snake (cobra)
• Muscular sarcocystosis
• Fever, and/or myalgia, arthralgia, headache, fatigue
• Later myositis: pain and swelling. Eosinophilia, high CPK
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S. hominis and S. suihominis
• Oocysts: thin-walled, sporulated when come out in faeces; “8”-like
• Sporocyst size: • 15 x 9 m (S. hominis); 13 x 9 m (S. suihominis)
• Sarcocysts with septa • Bradyzoites (banana shape)
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Humans as definitive (final) hosts for Sarcocystis species.
Ronald Fayer et al. Clin. Microbiol. Rev. 2015;28:295-311
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Humans as aberrant intermediate hosts for Sarcocystis species.
Ronald Fayer et al. Clin. Microbiol. Rev. 2015;28:295-311
19
Diagnosis
• Intestinal sarcocystosis • Microscopic observation of
oocysts or sporocysts in fecal smear
• Wet fecal smear- sporulated oocysts
• Acid fast stain- irregular staining (some stained, some don’t)
• Muscular sarcocystosis • Tissue biopsy, section and
stained.
20
From: Parasite.czu.cz
From: jcm.asm.org
Cystoisospora belli
• Only in human and primate
• Asexual and sexual reproduction in epithelial cell of the small intestine
• Oocyst sporulation outside host: 1-5 days
• Acute infection: diarrhea, self-limited
• Immunodeficient person: severe diarrhea
• Diagnosis: unsporulated oocyst, 20-23 x 10-19 m
• Treatment: trimethoprim and sulfamethoxazole
Fresh faecal smear
Acid fast stained smear
21
Cryptosporidium
• Parasite of mammals, birds, reptiles, fish, amphibians: rather host-nonspecific
• Human: mostly C. parvum, C. hominis
• Oocyst 5 µm in diameter, smallest of all human coccidian
• 4 naked sporozoites
Acid-fast stained smear (getfor.4t.com)
Unstained faecal smear (marvistavet.com)
22
• Life cycle similar to Cystoisospora belli (development occurs in GI epithelium) except:
• Organism is intracellular, extracytoplasmic
• Sporulation in host cells- • thick-wall oocysts
• thin-wall oocysts (autoinfective)
• PP app. 2 days, IP app. 7-10 days
Electron micrograph (phoenixwaterfilter.com.au)
23
• Emerging infectious disease
• Impaired intestinal absorption + enhanced secretion
• Watery diarrhea, abdominal cramp, fever
• In immunocompetent persons, self-limited in 2 wk.
• In immunocompromised persons, severe diarrhea and malabsorption syndrome
24
• An important opportunist in AIDS patients
• 4 Clinical patterns: • < 4 stool/day
• diarrhea < 2 mo.
• Diarrhea > 2 mo.
• Fulminant infection, 2L watery stool daily (CD4 < 50/microliter)
• Extraintestinal dissemination can occur, most common= biliary tract
25
• Infection worldwide including Thailand • Account for 5% of patient diarrhea
• Contaminated drinking water, food, direct contact
• Clam
• Outbreak involving 403,000 persons in Milwaukee associated with drinking water
• No effective, specific chemotherapy
• Diagnosis by stool exam for oocysts
26
Cyclospora cayetanensis
• Man is the only host
• Infect the small intestine, similar life cycle with C. belli diarrhea
• Unsporulated when come out with faeces
• Sporulation requires 7-15 days in external environment
• 2 sporocysts, each with 2 sporozoites
• IP app. 7 days
27
• Diarrhea (5-15 times/day)
• Self-limited (19-57 days), recurrent,
• More severe in AIDS patients
• Traveler's diarrhea • Implicated in Europeans returning
from Asian/South American countries
• Indonesia, Nepal, Thailand, Guatemala, Mexico
• Imported vegetables, salad & fruits = most frequent source of infection
• Oocysts survive a week at 4 C
28
• Diagnosis • Stool exam for oocysts
• Acid fast stain- must differentiate from Cryptoporidium
• Oocyst slightly bigger than Cryptosporidium oocyst, i.e., 8.6 m
• Staining not uniform: dark red, unstained
• Prevention & control: avoid exotic salad & vegetable or wash well
• Treatment: Trimethoprim, sulfamethoxazole
Cyclospora oocyst
Unsporulated: cdc.gov
29
Pneumocystis jirovecii
• First identified in 1909 in rat lung, named Pneumocystis carinii of uncertained taxonomy
• Cause infantile pneumonia
• Recently classified as atypical fungus Renamed Pneumocystis jirovecii to be distinctive from rat’s species
30
Morphology
• Extracellular, obligate, host-specific, yeast-like parasitic fungi
• Live in alveoli
• Trophic forms (1-4 µm) adhere to alveolar epithelium
• Precyst stages (early, intermediate, late)
• Mature cyst or ascus (8-10 µm) with 8 intracystic bodies (spores)
31
Putative life cycle of Pneumocystis.
Beck J M , and Cushion M T Eukaryotic Cell 2009;8:446-460
Disease and treatment
• Pneumocystis pneumonia, interstitial plasma cell pneumonia
• Premature infants • AIDS • Organ transplant subjects • Malignancies • Steroid treatment, long term
• Fever, cough, dyspnea
• Radiograph: bilateral, diffuse, reticular, or granular opacities
• Trimethoprimsulfamethoxazole (TMP-SMX) • Chemoprophylaxis when CD4 < 200
cells/microliter
Histogical picture:
Alveolar spaces filled with
eosinophilic, vacuolated or
foamy exudate containing 4-
5um cysts
33
Epidemiology
• Niches uncertain, airborne transmission
• Human acquires infection during infancy, asymptomatic, latent infection
• Reactivated when immunocompromised or primary infection is still a debate
34
Diagnosis
• Specimen from lungs • Induced sputum
• Bronchoalveolar lavage (BAL)
• Stain for cysts • Methenamine silver nitrate
• Toluidine Blue O
• Stain for trophics forms and intracystic bodies
• Giemsa stain
Beck J M , and Cushion M T Eukaryotic Cell 2009;8:446-460
Finish
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