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Visceral Leishmaniasis (Kala-Azar): Caused by Leishmania Donovani

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Visceral Leishmaniasis (Kala-Azar): Caused by Leishmania Donovani تابع 2 أ.د / فاطمة إبراهيم سنبل أستاذ الميكروبيولوجيا الصيدلية • (Plate 2) • Life cycle of Balantidium coli Mastigophora • General characters : • This subphylum includes those protozoa that move actively by means of a Flagellum (or several flagella) during all or part of their life. In addition, the body has a definite form (not irregular as in amoebae) maintained by a firm pellicle on its outer surface. Some flagellates are devoid of a mouth opening but some have an opening or Cytostome through which food is ingested. They reproduced by longitudinal binary fission (not transverse fission as in case of B. coli). • Some have undulating membrane which appear to consist of highly modified flagellum. Flagellates have vesicular type of nucleus . • The parasitic flagellated protozoa fall into two categories with respect to the type of disease produced in humans : • a) Intestinal and genital flagellates : these are found only in the intestinal or genital tracts and their transmission does not require a biological vector and so pass directly from man to man usually enclosed in a cyst. They include : • - Giardia intestinalis (lamblia) • - Enteromonas hominis • - Trichomonas hominis • - Trichomonas tenax • - Trichomonas vaginalis • - Dientamoeba fragilis (amoeba-like flagellate) • The parasites are nearly all harmless commensals but two species, Giardia intestinalis and Trichomonas vaginalis are associated with inflammatory lesions in heavy infections and for practical purposes may be regarded as pathogenic . • b) Blood and tissue flagellates (haemoflagellates) : these infect the vascular system and various tissues and their transmission requires a biological vector. usually an arthropod (insect) in which they undergo a fresh cycle of alteration and multiplication before they can again infect man. This class contains : • -Genus Leishmania . • -Genus Trypanosoma . • (A) Intestinal and genital flagellates • Giardia intestinalis • Geographical distribution: Universal • Morphology : The trophozoite is bilaterally symmetrical, pear shaped with a broad rounded anterior end and a tapering posterior end. The usual length is 12-15u. The dorsal surface is convex, the sucking disc appears as an ovoid concavity with raised margins and used for attachment. There are two nuclei (containing central karyosome but no chromatin), two axostyles, four pairs of flagella and two median (parabasal) bodis . There is no mouth . • The cyst is ovoid with highly refractile wall. It measures about 12μ in length. Two or four nuclei may be detected (according to the stage of maturity), 4 median bodies and also parts of flagella . • Life cycle : (Plate 3) • Man is infected by swallowing the cyst which pass safely through the stomach and hatches in the upper part of the small intestine liberating 2-4 trophozoites. The organism starts dividing into two by longitudinal division, and attach to the mucosa by their suckers. They become encysted in the lower part of the small intestine. Cysts are passed in the faeces and the cycle is repeated . • Plate (3) • Giardia intestinalis life cycle • Pathogenicity : • Giardiasis is transmitted through food and water containing cysts after contamination by sewage, flies or by food handlers. The parasite is weakly pathogenic but its attachment to the intestinal mucosa may cause • -Irritation and inflammation with consequent Epigastric pain and acute or chronic diarrhea and digestive disturbances. • -Steatorrhoea (fatty diarrhea- Stool is light-coloured and greasy due to malabsorption of vitamin A and fats, and • - Flatulence • - Occasionally, the parasites are found in the bile ducts and even in the • gall bladder leading to cholangitis and cholecystitis . • Predisposing Factors: that determine disease severity • 1- Hypogammaglobulinaemia. • 2- Achlorhydria. • Laboratory diagnosis : • Microscopical examination of faeces to find the characteristic cysts or more rarely the trophozoites Duodenal biopsy may be necessary for diagnosis by demonstrating trophozoites . • N.B. : In giardiasis the stools are usually greasy or fatty (steatorrhoea) due to malabsorption of fats and there is no blood or mucus . • Treatment : • -Metronidazole OR Tinidazole • -Recently Albendazole. • -Correction of the resulting nutritional deficiency from • malabsorption . • Giardiasis is often a family infection, (because it doesn't need intermediate host) so other members should be screened and treated as necessary . • Prevention & control : • Transmission depends on the swallowing of mature cysts (in feaces). Prevention therefore depends on a high level of sanitation • Trichomonas vaginalis • Geographical distribution : Cosmopolitan. • Habitat : • The genital tract of man, both in the male and in the female but particularly the latter . • Morphology : • It is the largest trichomonad found in human being. The parasite is fusiform or oval, 20 u x l0u and has 4 flagella. However, the number of flagella vary from 3-5. The nucleus is elongated. An axostyle originates near the nucleus and extends to the posterior end. An undulating membrane is also present which does not extend beyond two thirds of the body length. There is a well developed parabasal body lying close to the nucleus. Cysts are not known . • Transmission : (Plate 4 ) • T. vaginalis lives in the vagina and urethra of women and in the prostate, seminal vesicles and urethra of men. It is transmitted primarily by sexual intercourse. • Its presence occasionally in young children including virginal females suggests that the infection can be contracted from soiled washcloths, towels & clothing. • Pathogenicity : • The acidity of the normal vagina (pH4-5) ordinarily discourages infection, but once established, the organism itself cause a shift toward alkalinity (pH 5-6) which further encourages its growth. A few days after infection, there is a degeneration of the vaginal epithelium followed by an intense inflammation which lead to itching and a copious white discharge (characteristic) containing trophozoites. Infection of men is usually asymptomatic but there may be an irritating urethritis or prostitis . • Laboratory diagnosis : • Microscopical : depends on recognizing the trichomonad in secretions which may be vaginal, prostatic or urethral or sedimented urine . • The vaginal secretions are likely to be more alkaline than normal, we may use a strip of pH paper. The pH is likely to exceed 5.0. • Treatment : • - Systemic treatment using oral drugs such as Metronidazol cure infection in about 5 days. Treatment of both partners simultaneously is necessary to avoid reinfection . • - Local treatment by (a) promoting an acid pH of the vagina using lactic acid douche or douche containing 4 tablespoons of vinegar (b) Flagyl vaginal insert (c) Clotrimazole (canestine) vaginal cream or tablets . • Plate ( 4) • Trichomonas vaginalis • Prevention & control : • - Personal hygiene. • - Disinfection of W C. seats. • - Boiling of underwear . • - Treating cases and both partners simultaneously . • -Condom use • (B) The blood and tissue flagellates • (Haemoflagellates) • These parasites include two genera : Leishmania and Trypanosoma which belong to an order of protozoa called Kinetoplastida as they are characterized by the presence of a structure unique to the order, the kinetoplast, which contain the mitochondrial DNA . • General characters of order kinetoplastida : • 1- The flagellum of these flagellates arises from the kinetosome. The kinetoplast and kinetosome are always closely associated, sometimes so close that they appear as a single body under the light microscope. However, most electron micrographs show no physical connection between kinetosome and kinetoplast . • 2- These species are heteroxenous. Part of their life cycle is spent in the gut of a fly where they assume the form of a promastigote and the remainder of their life cycle is completed in vertebrate tissues (amastigate). • 3- The species of kinetoplastida usually pass through different morphological stages, depending on the phase of their life cycle and the host they are parasitizing. These stages include • Genus Trypanosoma • Members of this genus have been found parasitizing all types of vertebrates, both worm and cold - blooded and have a world-wide distribution (Cosmopolitan). • General characters • 1- A trypanosome (Tripomastigote form) is elongated, flattened organism having a single nucleus of the vesicular type and containing a large central karyosome near the kinetosome there is a round or rod-shaped organelle known as kinetoplast. There are a single flagellum and undulating membrane both serve to propel the trypanosome in the same way as a fin propel a fish. • 2- Multiplication of trypanosomes is asexually by longitudinal binary fission . • 3- All trypanosomes are divided into two broad categories or "Sections:" based on characteristics of their development in their invertebrate host. When a species develops in the front portions of the digestive tract it is said to undergo anterior station development and is placed under section salivaria. In this case transmission is inoculative through insect saliva. On the other hand when a species develops in the hind gut of its invertebrate host (insect), it is said to undergo posterior station development and is placed under section . Stercoraria In this case transmission of infection is contaminative through the insect faeces. • 4- Some trypanosomes e.g. those occurring in animals in temperate countries cause only unapparent infection and appear to cause little disturbances to their hosts. On the other
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