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Aula 3 Giardia E Crypto 2020

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Aula 3 Giardia E Crypto 2020 DISCIPLINA PARASITOLOGIA 2020 20 de fevereiro GIARDÍASE E CRIPTOSPORIDIOSE Docente: Profa. Dra. Juliana Q. Reimão • PROTOZOÁRIOS INTESTINAIS • Mais comuns em imunocompetentes • Entamoeba histolytica e Giardia duodenalis • Emergentes e Oportunistas • Causam doença principalmente em imunocomprometidos • Foram recentemente caracterizados como patógenos humanos • Cryptosporidium parvum e Cryptosporidium hominis GIARDÍASE Giardíase • Generalidades • Infecção causada por parasitas flagelados que se prendem à parede do intestino delgado provocando diarreia e desconforto abdominal. • Agente etiológico • Giardia duodenalis • (= Giardia lamblia e Giardia intestinalis) • Parasita monoxênico eurixeno • Exige apenas um hospedeiro • Variedade de hospedeiros vertebrados • Homem e alguns animais • Mamíferos, aves e répteis • Formas de vida • Trofozoíto e cisto Epidemiologia Precárias • 200 milhões de indivíduos sintomáticos condições de higiene, educação • 500 mil casos/ano sanitária e • Distribuição mundial alimentação • Parasita intestinal mais comum em países desenvolvidos Morfologia • Trofozoíto • Corpo piriforme Núcleo Flagelo Disco • Simetria bilateral suctorial • 2 núcleos • 4 pares flagelo Corpo Flagelo basal • 1 disco suctorial • Corpo basal = aparelho de Golgi Flagelo Flagelo • Axóstilo = feixe de microtúbulos Morfologia • Trofozoíto • Achatamento dorsoventral • Disco suctorial • Adesão ao epitélio intestinal Vista dorsal Vista lateral Morfologia • Cisto • Oval • Núcleo e corpo basais duplicados • Cada cisto produz 2 trofozoítos Núcleos Corpo basal • Forma de resistência Parede cística • Viáveis na água por até 3 meses • Resistentes ao processo de cloração da água • São eliminados nas fezes → milhões/dia Ciclo de vida Trofozoítos Cistos Ciclo de vida • Cães e gatos podem ser fontes de infecção → eliminam cistos! • Sua importância como reservatórios não é clara Aspectos clínicos • Em imunocompetentes • Em geral é assintomático • Diarreia • Manifestação mais comum (90% casos) • 2 a 4 semanas • Raramente contém sangue • Esteatorreia • Presença de gordura nas fezes • Desconforto abdominal/cólicas • Náuseas e vômitos • Perda de peso • Autolimitada ou recorrente • Em imunodeprimidos • A infecção pode ser grave, com longa duração (> 7 semanas) Patogenia • Efeito citotóxico • Células epiteliais • Destruição das vilosidades • Contato com a margem dos discos suctoriais Patogenia vilos cripta microvilosidades enterócito Atrofia de vilos e hiperplasia das criptas Mucosa normal Mucosa alterada Patogenia • Consequências do parasitismo Disco suctorial • Redução da produção de enzimas (ex. lactase) • Redução da absorção de carboidratos, gorduras e vitaminas • Inflamação da mucosa e apoptose dos enterócitos • Aumento da secreção de cloretos → acúmulo de líquidos no lúmen intestinal Disco suctorial Vilosidades Patogenia Virulência das cepas Número de cistos ingeridos Infecção assintomática Síndrome da má absorção Idade Estado imune do hospedeiro Exposição prévia ao parasito Diagnóstico • Parasitológico • Exame de fezes (EPF) • Sensibilidade • 1 amostra: 60 a 80% • 3 amostras: 90% • Menos usados • Aspiração intestinal • Biópsia duodenal • Sorológico • ELISA, RIFI, hemaglutinação indireta • Molecular cisto trofozoíto • PCR Reação de imunofluorescência indireta (RIFI) Teste imunoenzimático (ELISA) Teste de aglutinação PCR Tratamento • Nitroimidazóis Metronidazol secnidazol tinidazol metronidazol Medicamento Adulto Criança Secnidazol 2g, VO, dose única 30 mg/kg, dose única Tinidazol 2 g, VO, dose única - 15 mg/kg/dia 250 mg, VO, 2 vezes Metronidazol (máximo de 250 mg), VO, ao dia por 5 dias dividida em 2 tomadas, por 5 dias • Controle de cura: • 3 exame de fezes (1 por semana) Prevenção e controle • Principais veículos • Água e alimentos crus • Pessoas infectadas • Vetores mecânicos • Moscas e baratas • Moluscos bivalves • Profilaxia • Fervura da água • Saneamento básico • Educação sanitária • Tratamento • Manipuladores de alimentos • Creches e asilos CRIPTOSPORIDIOSE Coccídios intestinais • Generalidades • Parasitas intracelulares obrigatórios • Possuem semelhanças com os apicomplexos • Parasitas monoxênicos • Exigem apenas um hospedeiro • Criptosporidiose • Cryptosporidium hominis • Cryptosporidium parvum • Ciclosporíase • Cyclospora cayetanensis • Cistoisosporíase • Cystoisospora belli Importância • Emergentes • Recentemente descritos como patogênicos • Avanço nas técnicas diagnósticas • Globalização • Alteração HIV positivo • Do meio ambiente (%) • Dos hábitos alimentares HIV negativo • Oportunistas Prevalência • Indivíduos imunossuprimidos Cyclospora Cryptosporidium Cystoisospora • Aumento crescente de incidência cayetanensis parvum belli Criptosporidiose • Importância • Segunda causa de morte por diarreia em crianças no mundo • 30 a 50% das mortes até 5 anos de idade • Consequências letais em imunodeprimidos Epidemiologia • Cosmopolita • Mais frequente em países em desenvolvimento • Prevalência de 0,5 a 10% → subestimada • Crianças 1 a 5 anos • Em Fortaleza: uma pesquisa mostrou que todas as crianças avaliadas apresentavam anticorpos contra C. parvum → exposição prévia ao parasito • AIDS • Prevalência de até 50% • Surtos de transmissão hídrica • Ex.: Milwaukee (EUA): 400 infectados e 100 mortes Aspectos biológicos • Parasito intracelular • Apresenta fusão com a membrana do enterócito • Forma um vacúolo parasitóforo • Extracitoplasmático • Se localiza fora do citoplasma da célula hospedeira • Localização epicelular • Sobrevive em biofilmes • Ambiente aquático • Habitat • Intestino delgado Ciclo de vida Ingestão ou inalação RESERVATÓRIOS de oocistos Cryptosporidium parvum Cryptosporidium Liberação de hominis oocistos nas fezes Ciclo de vida Merogonia Esporozoíto Ingestão ou Meronte tipo I inalação Trofozoíto Meio exterior Auto-infecção Merozoíto Oocisto esporulado parede espessa Oocisto esporulado Microgameta Meronte tipo II parede fina Macrogameta Merozoítos Zigoto Esporogonia Gametogonia Patogenia • Alterações histológicas • Invadem as células epiteliais do intestino • Não atingem as camadas mais profundas da mucosa • Causam atrofia das vilosidades e inflamação • Redução da absorção • Redução da produção de enzimas • Diarreia Oocistos de Cryptosporidium sp. na mucosa intestinal Aspectos clínicos • Em imunocompetentes • Sintomas ausentes ou autolimitados • Diarreia aquosa • Vômitos • Dores abdominais • Perda de peso • Em imunocomprometidos • Diarreia grave, com várias evacuações/dia • Evolução crônica ou fulminante • Perda diária de mais de 20 litros de líquido Cryptosporidium sp. Diagnóstico laboratorial Às bactérias que possuem esta propriedade • Exame parasitológico de fezes (EPF) • Encontro de oocistos Oocistos • Visualização microscópica a fresco nas fezes • Coloração de Ziehl-Neelsen • Coloração usada para microrganismos EPF, coloração de Ziehl-Neelsen álcool-ácido resistentes • Outros exames • Pesquisa de antígenos nas fezes • PCR de fezes • Biópsia ou aspirado intestinal Trofozoítos nas células epiteliais Biópsia intestinal Tratamento • Nitazoxanida • Bem tolerado, com poucos efeitos colaterais • Ação contra outros patógenos intestinais • Pouco efetivo em imunocomprometidos • Cuidados gerais • Hidratação • Tratamento sintomático • Tratamento antiviral em pacientes HIV+ • Restauração da imunidade Os oocistos • São resistentes ao cloro e à maioria Prevenção dos desinfetantes • Viáveis por vários meses no ambiente • Medidas de prevenção • São sensíveis: • Saneamento básico • À altas temperaturas (60 °C) • Educação sanitária • Ao congelamento e à dessecação • Ao H O • Filtração ou fervura da água 2 2 • Controle de contaminação ambiental com fezes • Evitar contato direto com animais infectados • Evitar o consumo de moluscos bivalves crus (ex. ostras) Curiosidades • Se uma pessoa com criptosporidiose defeca na piscina: • 50 milhões de oocistos por mL de fezes x 150 mL fezes = 7.5 bilhões de oocistos na piscina • Em uma piscina padrão de 25 x 12 m (450 m3) teria uma média de 20.000 oocistos por litro = 20 oocistos/mL • Uma criança de 6-18 anos em média ingere 37 mL da água da piscina = 740 oocistos • Alto risco: • Áreas recreacionais com contami- nação por esgoto humano ou animal • Água de irrigação Dúvidas? [email protected] Vídeos relacionados • Surto de diarreia deixa 95 mortos em Pernambuco: • https://www.youtube.com/watch?v=6hZym-EJ5SA • Vídeo Criptosporidium (Monsters inside me – Discovery Channel) • https://www.youtube.com/watch?v=7Rfu235rT6A Discussão de caso clínico Paciente com diarreia crônica • Objetivos a serem atingidos neste estudo: • Identificar os modos de transmissão, os sinais clínicos e os exames diagnósticos empregados no diagnóstico da giardíase e criptosporidiose; • Correlacionar o ciclo biológico do parasito com as principais áreas do corpo humano que podem ser afetadas por este parasitismo; • Conhecer o tratamento e as medidas profiláticas a serem empregadas frente a estas parasitoses; • Discutir informações relevantes com o grupo de estudo e investigar os processos patológicos observados neste caso. Socrative Salas JULIANA2020 e GATTI7970.
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