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Intestinal protozoa & Genital protozoa
Dr. Oranuch SanpoolDepartment of Parasitology, Faculty of Medicine, KKU
อีเมล:์ [email protected]
MD641 304 Parasitology for Pharmaceutical science students (1st year)
Join Zoom Meeting ID: 937 9234 5794 Password: 7096227 Aug 2020, 08.00-10.00 AM
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Intestinal Protozoa
Genital protozoa
Blood and tissue protozoa
Unclassified protozoa
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Amoebae
Intestinal Protozoa
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Flagellate
Ciliate
Apicomplexa
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Amoebae:
-Entamoeba histolytica
-Entamoeba coli
- Entamoeba gingivalis
- Iodamoeba buetschlii
- Endolimax nana
- Dientamoeba fragilis
Intestinal Protozoa
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Flagellate : - Giardia lamblia
- Chilomastix mesnili
- Trichomonas hominis
Ciliate : - Balantidium coli
Apicomplexa : - Isospora species
- Cryptosporidium species
Intestinal Protozoa (cont.)
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Giardia lambliaBalantidium coli
๐ Common Name
๐ Scientific Name
๐ Diseases
๐ Morphology
๐ Geographic
distribution
๐ Life cycle
๐ Epidemiology
๐ Pathology/ pathogenesis
๐ Symptoms and signs
๐ Diagnosis
๐ Treatment
๐ Prevention and control
Entamoeba histolytica
Blastocytis hominis
Entamoeba coli
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Balantidium coli (Malmsten, 1857) Stein, 1863
Ciliate Protozoa
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Balantidium coli
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Ciliate protozoa
Causing Balantidiasis in human
Habitat : large intestine colon
Reservoir host : pig
Infective stage : Cyst
Epidemiology : Tropic, sub-tropic zone
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Large intestinal protozoa in human body
Size 60-70 um
Surrounded with cilia
Anterior cytostome (mouth)
Food vacuole in cell
Contractile vacuole for water balance
Trophozoite contained 2 nucleus :
Macronucleus & Micronucleus
Posterior cytopyge for excrete waste product
Stage :Trophozoite
Balantidium coli
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Oval shape
Size ~ 55 um
2 layers of thick cyst wall;
cilia attached in inner cyst wall
Finding Macronucleus & Contractile vacuole
Finding undigested food in food vacuole
Stage : Cyst
Balantidiumcoli
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Sexual reproduction: 2 types
1. Asexual (transverse binary fission)
2. Sexual (conjugation)
Life cycle: similar to Entamoeba histolytica
Diagnostic stage: Cyst, trophozoite in feces
Balantidium coli
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Balantidiasis
Cinical signs: No symptoms dysentery
Mild infection : Chronic intermittent symptom
- Abdominal symptoms
- Diarrhea / constipation
- Mucus and bloody stool
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Dysentery form: - Massive intestinal movement
- Mucus and bloody feces
- Abdominal pain, weight loss
Fulminant : - Finding in poor immunity
- Death in 3-5 days
Extra-intestinal balantidiasis: Low incidence
Balantidiasis
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Pathogenesis of Balantidium coli
Balantidium coli (cyst)
Excystation in small intestine
Large intestinal mucosa
Multiplication (conjugation & transvers binary fission)
Ulcer in mucosa - submucosa
(lytic action of hyaluronidase)
Large opening wound14
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-Tetracycline 500 mg, 4 times x 10 days or
- Diiodohydroxyquin, 650 mg, 3 times x 21 days or
- Metronidazole, 400-600 mg, 3 times x 5 days
Prevention and controls
- Like as Entamoeba histolytica
- Good personal hygiene
- Good sanitation
Balantidiasis
Treatment :
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Flagellate protozoa
Giardia lambliaStiles, 1915
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Giardia lamblia
Giardiasis / Giardial dysentary
- Active movement
- Blunt anterior and sharp end posterior (21 x 15 x 4 um)
- Sucking disc
- 2 nuclei
- 4 pair of flagellum
- 2 axonemes
- 2 median body
Stage:Trophozoite
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- No movement
- Oval shape, size 8-12 x 7-10 um
- Thin cyst wall
- 2-4 nuclei
- 2 axonemes
- 2 median body
Giardia lamblia
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Stage:Cyst
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G. lamblia cyst in iodine
G. lamblia cyst in normal saline
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Classification : Duodenum (crypt, villi)
Infective stage: 4 nuclei cyst
Multiplication: Longitudinal binary fission
Incubation period : 12-15 days
Giardia lamblia
Epidemiology:
Worldwide (nursery, mental retard nursery, gay, lesbian)
Symptoms : Diarrhea and malabsorption
severity : Depend on age, immunity and history of exposure
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Pathologic feature
- Normal mucosa
- Catarrhal inflammation
- Damage of mucosa
- Loss of Brush border
- Flatten villi
- Incresed Globlet cells , WBC infiltration
Giardia lamblia
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Clinical signs
Acute :
- Similar food poisoning (2-3 days)
- Anorexia, nausea
- Abdominal pain
- Diarrhea, Foul smelling
- Greasy stool
Giardiasis
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Chronic : - Abdominal cramp
- Chronic abdominal pain in child
(celiac disease)
- Malabsorption
- Lipid in feces (steatorrhea)
- Jaundice, ampulla of water swelling
Giardiasis
Clinical signs
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Diagnosis : finding cyst, trophozoite in samples
Specimens: - Feces
- Duodenal aspirate
- Intestinal biopsy
Treatment: Metronidazole (200-400 mg, tid, after meal,
5-10 days)
Giardiasis
Prevention and controls :
- Good sanitation
- Good personal hygiene24
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4 forms of Blastocystis hominis
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- Diarrhea
- Abdominal pain and cramp
- Nausea
- Flatulence
- Fever
- Irritable Bowel Syndrome (IBS)
Clinical symptoms of Blastocystosis
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- Stool examination
- Finding vacuolar form
- Trichrome stain
Treatment:
- Metronidazole
- Cotrimoxazole
Balastocystosis
Laboratory diagnosis:
Prevention & controls:
- Good personal hygiene
- Good sanitation27
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Genus Trichomonas
• 4 free flagella, equally in size
- 5th flagellum at rim of undulating membrane
Trophozoite only
No cyst stage
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Trichomonas spp.
Trichomonas tenax Trichomonas hominisTrichomonas vaginalis
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Trichomonas tenax(O.F. Muller, 1773) Dobell, 1939
• Pear shape, living in mouth
• Trophozoite only, 5-12 um in size
• More slender shaped than T. vaginalis
• 4 Free flagella, equally in size
• The 5th flagellum at the rim of undulating membrane
• Can not live in intestine but can in vagina
• Longitudinal binary fission30
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Trichomonas hominis(Davaine, 1860) Leuckart, 1879
• Trophozoite, 5-14 um x 7-10 um in size
• 3-5 Free flagella
• Living in large intestine, commensalism, ingested bacteria
• Transmission by contaminated food or insect
• Diagnosed by movement of trophozoite in fresh feces
• No need for treatment31
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- Trophozoite only, pear shape
- Undulating membrane no longer than body
- Size 7-27 um x 5-18 um in size
- 4 Free flagella, equally in size
- 5th Flagellum at rim of undulating membrane
- Longitudinal binary fission
Trichomonas vaginalis, Donne, 1837
Origin of name: firstly found in vaginal secretion
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Habitat:
Vagina
Prostate gland or ureter
Sexual transmitted disease (STD)
Infective stage trophozoite
Incubation period 4-28 day
Epidemiology
Trichomonas vaginalis
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Pathology:
- Degeneration and desquamation
- Inflammation of vagina and uterus
Clinical symptoms
- Vulvovaginitis, itching
- Liquid, greenish-yellow down to urethral orifice, foul-smelling
- Spot hemorrhage, red spotted lesion (call “strawberry vagina”)
- Dysuria - Symptom less
- Frequency of urination
- prostatitis
Male
Trichomonas vaginalis
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- Centrifuged urine
- Vaginal swab
- Vaginal scrap
- Vaginal discharge
Trichomonas vaginalis
Diagnosis: Wet preparation
& finding trophozoite under microscope
Male: Prostate secretion examination
Other methods : Culture, PCR technique35
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- Metronidazole
-Tinidazole
- Clotrimazole Vagina supposition
Prevention
- Avoidance of unprotected sexual experiences
- Avoidance of sharing equipment and communal bathing
Treatment
Trichomonas vaginalis
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Blood & tissue protozoaFungi-likes protozoa
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Haemoflagellate
Many stage, small size, 1 nucleus
Migration by flagellum, some stage can not see flagellum
Living in blood, plasma, cerebrospinal fluid,
cells of visceral organ
Longitudinal binary fission
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Family Trypanosomatidae
- Trypanosoma brucei gambiense
- T. b. rhodesiense
- T. cruzi
Genus Trypanosoma species
Genus Leishmania species
- Leishmania donovani
- L. tropica
- L. braziliensis 39
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Morphological stage of haemoflagellates
Leishmania Trypanosoma brucei
Trypanosoma cruzi
Amastigote(leishmanial form)
Promastigote(leptomonad form)
Epimastigote(crithidial form)
Trypomastigote(trypanosomal form)
** Promastigote form or Leptomonas form (Infective stage of Leishmania)
** Metacyclic trypanosomal form (Infective stage of Trypanosoma)
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Trypanosoma brucei gambiense Dutton, 1902 (T.b.gambiense)
Trypanosoma brucei rhodesiense Stephens & Fantham, 1910 (T.b.rhodesiensi)
Biology & life cycle
2 Hosts: human and insect vectors
Insect vectors : Glossina spp. (Tsetse flies)
Extracellular parasite
Human stage: Trypomastigote form
Insect stages: - Critidial or epimastigote: intestine
- Metacyclic trypanosome: salivary gland
Caused of African trypanosomiasis or African sleeping sickness
African trypanosomes
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Sleeping sickness
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Epidemiology and Transmission of African trypanosomes
No report in Thailand
Insect bite transmittedmetacyclic trypomastigote
(biological transmission)
* Mechanical transmission
* Blood transfusion
* Congenital transmission
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Incubation period 5 to 20 (~ 14 day)
Swelling at biting site
Clinical manifestation of
African trypanosomes
Parasite multiply in circulation
- Vasculitis at infected organ
- Splenomegaly
- Joint and muscular pain, fever, chill,
lymphadenopathy (postcervical gland)
namely Winterbottom’ sign
I. Acute stage :
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II. Chronic stage (2-3 year) :
- Parasite invade central nervous system
- Headache, stiffness of neck and paralysis
- African sleeping sickness
Laboratory diagnosis 1. Blood examination
2. CSF examination
3. Animal inoculation
4. Serological methods
Clinical manifestation of
African trypanosomes
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Treatment Suramin
Pentamidine isothionate
Melasoprol
Prevention and control
Elimination breeding place of vector
Avoidance to visit endemic area
Mass treatment
African trypanosomes
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Trypanosoma cruzi Chagas 1909
American trypanosome
Caused American trypanosomiasis or Chagas disease
Stage in human and vertebrate
Trypanosomal Extracellular protozoa in blood circulation (C-shape)
Leishmanial Intracellular protozoa in RE cell of spleen, liver, lymphoid gland
Leptomonas
Critidial
Interstitial spaces of organ
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Stage of Trypanosoma cruzi
in Triatomine bugs
Critidial (Epimastigote) : middle part of intestine
Metacyclic trypanosomal : anal area (Posterior stationary)
(infective stage)
Epidemiology
America
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Trypanosoma cruzi
Chagas’ disease
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1. Incubation period 1-2 weeks
- Local inflammation, chagoma
- Romana’ s sign
2. Acutes stage
- Degeneration of liver and spleen
- Inflammation of cardiac muscle
3.Chronic stage
- Myocarditis heart failure
Pathology of Trypanosoma cruzi
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Prevention and control
Elimination of insect with BHC
Elimination of reservoir host
1. Blood examination
2. Biopsy
3. Xenodiagnosis
4. Serological test
Treatment: Suramin, Diamidins, Nifurtimox,
D0870 inhibitor of sterol biosynthesis
Laboratory diagnosis of Trypanosoma cruzi
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o Visceral leishmaniasis or
o Kala-azar
Leishmania tropica,
L. major,
L. aethiopica
o Cutaneous leishmaniasis or
o Oriental sore
Leishmania braziliensis complex,
L. mexicana complex,
L. peruviana
o Mucocutaneous leishmaniasis or
o Espundia
Leishmania donovani
Leishmania species
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Cutaneous & Mucocutaneous Leishmaniasis
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Cutaneous leishmaniasis(Oriental sore)
Mucocutaneous leishmaniasis(Espundia)
amastigote
promastigote
Multiply in stomach
promastigoteinfective stage
Migrate to mouth
Amastigotemultiply inmacrophage
Sand fly
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Amastigote
Change to promastigote
Multiply in intestine
Migrate to mouth
Sand fly
Migrate from brokenmacrophageMultiply
Ingestion by macrophage at skin
Human, dog
Macrophage migrate to visceral organs: (RE system) spleen, liver, bone marrow
Change to amastigote Ingestion by macrophage
Leishmania donovani caused Visceral leishmaniasis
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HumanAmastigote founded in RE cell
(macrophage, lymphoid cells)
Promastigote founded in Phlebotomus spp.
(Sand flies)
EpidemiologyImported cased in Thailand,
Africa, Middle East, South Asia
Insect
Leishmania spp.
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Clinical manifestation of Leishmaniasis
Cutaneous leishmaniasis: found parasite in phagocytic cell
Chronic wound of skin
Mucocutaneous leishmaniasis :
Chronic wound of junction between skin and mucous tissue of mouth, nose, anus, sexual organs
Visceral leishmaniasis : Destroy liver, spleen, bone marrow, RE cell
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Cutaneous leishmaniasis
* Skin Biopsy, Culture, Serological test
Mucocutaneous leishmaniasis
* Biopsy, Serological test
Visceral leishmaniasis
- Parasite exam in RE cells
- Spleen or bone marrow biopsy
- Serological test57
Laboratory diagnosis of Leishmaniasis
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Sodium or potassium antimoyl tartate
Sodium stibogluconate
Amphotericin B
Treatment of Leishmaniasis
1. Mass treatment
2. Elimination of vector Phlebotomus spp.
3. Elimination of reservoir host
Prevention and control of Leishmaniasis
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- Cause by Pneumocystis jiroveci (carinii)
- Atypical fungus, yeast like characteristic
- Both cyst & trophozoite found in alveoli
Pneumocystosis
Pneumocystis cariniiSyn. Pneumocystis jiroveci
Pneumocystis pneumonia (PCP)
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Pneumocystis jiroveci
Opportunistic organism
Natural habit : Lung
Important cause of pneumonia in immunocompromised host
Taxonomy status argument between Protozoa and Fungus
Unclassified protozoa
Molecular identification related to Fungus than Protozoa
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Trophozoite :
- Pleomorphic trophozoite like amoeba
- 1-4 um
- 1 nucleus
Cyst : - Oval shape and thick cyst wall- 5-8 um- Mature cyst contained 8 intracystic bodies
Pneumocystis jiroveci
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Pneumocystis jiroveci Giemsa stained
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Haploid intracystic bodies disrupt from cyst
Trophozoite develop in alveolar cavity
Binary fission / budding or endodyogeny or combined to diploid trophozoite
Miosis I------> II
mitosis
Encystation contained intracystic up to 8 cysts
Pneumocystis jiroveci
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Disease : Pneumocystosis / Interstitial plasma cell pneumonia (PCP)
Endemic area : worldwide in human and animals
Genetic diversity and host diversity
Serology study : in children
Transmission : respiration (airborne route), placenta
90,000 AIDS patients in USA has infected at least 1 time
Pneumocystosis is the main cause of death in AIDS patients
Extrapulmonary : lymph node, spleen liver bone marrow 64
Pneumocystis jiroveci
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Caused by CMIR & HMIR abnormality
Principal host effector cell : Alveolar macrophage
Risk group: HIV, immunosuppressive Rx,
malnourished infants
Pathogenesis & Pathology
Pneumocystis jiroveci
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Increase alveolar capillary permeability and destroy type I alveolar cell
surfactant abnormality
: Decrease bronchoalveolar lavage (BAL) fluid phosholipids
: Increase surfactant proteins A & D
Pneumonia
Increase alveoli fluid , increasing of rbc, histiocyte, lymphocyte, plasma cell
Thick alveolar septum, gas exchange abnormality
Foamy alveoli, vacuolated exudates, interstitial edema, fibrosis
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Pathogenesis & Pathology
Pneumocystis jiroveci
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1. Demonstration of organisms from lungs
- Gomori’s methenamine silver stain
- Giemsa stain
- Modified acid fast
- Hematoxylin
Laboratory diagnosis for PCP
Staining
- Lung / Transbronchial Biopsy
- Bronchoalveolar lavage
- Sputum
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2. Antigen detection using MAb
3. Molecular techniques :
- Conventional PCR (Torres et al., 2000)
- Real-time PCR (~ 3 hr), 100% sensitivity,
85-99 % sensitivity (Flori et al. 2004)
Laboratory diagnosis for PCP
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Trimethoprim-sulfamethazole (TMP-SMX) or Bactrim
Dose: TMP 15-20 mg/kg/day,
SMX 75 -100 mg/kg/day; oral or IV
Divide to 3-4 times/day
(x 14 day for non-HIV, x 21 day for HIV)
Treatment
Pneumocystis jiroveci
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Primary prophylaxis HIV pateints at risk of PneumocystosisThere are indications for the drug
- CD4+ cell count less than 200 cell / ul
- Fever of unknown origin (37.8 oC) more than2 wk or
- Had history of oral Candida infection
Secondary prophylaxis in recovered pneumocystosis pateints
Primary or Secondary prophylaxis for pneumocystosisTMP 160-SMX 800 (double strength) one time/day orTMP 80-SMX 400 (single strength) one time/day x 3 days for1 weeks
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Prevention
Pneumocystis jiroveci
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Phylum Microspora
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Small size intracellular /Class Microsporea :
Microsporidia
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SEM of a microsporidian spore with an extruded polar tubule inserted into a eukaryotic cell
https://www.cdc.gov/dpdx/microsporidiosis/index.html
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Encephalitozoon intestinalis disseminated patients
- fever. Diarrhea sinusitis cholangitis
Enterocytozoon bieneusi & Encephalitozoon intestinalis
- Chronic diarrhea weight loss in Aids patients (10-40%)
- Bile ducts
Microsporidiosis – found in AIDS more than other
opportunistic patients
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Transmission by drinking contaminated water
or from human to human
Found in HIV patients with diarrhea = 27%
Chiang Mai feces > 100 cases found 1 case
Siriraj and Bumradnaradul Hospital positive 18/22 cases
Enterocytozoon bieneusi
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Symptom-Sign-Pathology
Similar cryptosporidiosis & misosporidiosis
Chronic diarrhea, nausea, GI absorption defect, weight loss
Diarrhea 4-8 times/days No bloody mucus
No fever
Detatchment and atrophy of intestinal villi 75
Enterocytozoon bieneusi
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Treatment:
No effective drugs
- Supportive treatment: octreotide 100-500 ug (sc)
- Albendazole : have effective reports
Prevention:
- Drinking cleaned water and cooked food
- Good personal hygiene76
Enterocytozoon bieneusi
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o Habitat enterocyte , lamina propria, macrophage,
fibroblast, endothelial cell of small intestine
Pathology & Symptom
o Chronic diarrhea intestinal inflammation
o Malabsorbtion
o Distribute to Gall bladder Lung Respiratory tract
Encephalitozoon intestinalis
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Diagnostics : intestinal biopsy & Electronmicroscopy
Treatment : Albendazole 400 mg oral bid x 2-4 week
Prevention : Personal hygeine
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Encephalitozoon intestinalis
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References / Books
• https://www.ncbi.nlm.nih.gov/pubmed
(search under parasites specific name)
• https://www.cdc.gov/dpdx (search under parasites specific name)
• วันชัย มาลีวงษ์ ผิวพรรณ มาลีวงษ์ และนิมิตร มรกต. ปรสิตวิทยาทางการแพทย์: โปรโตซัวและ
หนอนพยาธ.ิ ขอนแก่น : โรงพิมพ์คลังนานาวิทยา. 2544.
• Etc.
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“ Only fill a glass of water half full, you will learn to
always seek for more knowledge”
The guidance of his majesty the 9th king