.
- =ay be used, however, for the detection and cultivation of
e~f9
MEDICAL PARASITOLOGY
The field of parasitology in its broadest sense is con-
cerned with those organisms, either animal or plant, living on
or in other organisms which serve as their hosts. Although it
is true that bacteria, rickettsiae, fungi, spirochetes, and
filtrable viruses are also parasites, parasitology in its re-
stricted sense includes only animal parasites which, by their
residence in or attachment to the body of the host, serve as
agents or vectors of disease. Some parasites may cause little
or no damage to the host. These should not be ignored, how-
ever, since careful differentiation of pathogenic from non-
pathogenic types is necessary if diagnostic confusion and
mistakes are to be avoided.
Importance of Morphologic Identification:
The recognition and differentiation of the animal parasites
of man demands primarily a knowledge of their morphology.
Except in a comparatively few instances the diagnostic cul-
tural, biochemical, and serologic procedures so commonly
utilized by the bacteriologist are not available to the parasi-
tologist. Inasmuch as the diagnosis of a parasitic infection
rests upon the demonstration of the parasite - and since this
demonstration depends upon morphologic recognition - it is
essential that those responsible for the handling of clinical
specimens be well-trained microscopists. Proficiency in this
phase of laboratory work is gained only by extensive practical
experience with properly collected clinical specimens. The
diagnosis and differentiation of the diseases caused by proto.-
zoa, whether intestinal or systemic, present particular
difficulties. This is especially true with respect to the dif-
ferentiation of the intestinal amebas. These difficulties may
be overcome only if the microscopist entrusted with the
examinations has a thorough knowledge of the morphology and
the habitat of the various organisms parasitizing man and
animals.
Cultivation Technics:
The use of cultivation procedures as a means of diagnosis
in parasitology is limited. Effective methods are available
*Associate Professor of Parasitology, University of Puerto
Rico School of Medicine, San Juan, Puerto Rico.
- :::::estinal amebas and flagellates (Entamoeba histolytica,
=_=:amoeba fragilis, Trichomonas hominis, etc.) and the
and tis sue flagellates (Leishmania donovani,
-" ;>aDo soma cruzi, etc.).
- _::, .opc Technics:
-erologic tests are often of practical value in demonstra-
·-:l:e presence of a particular protozoan or helminthic
-:-a.site. The complement fixation test for amebiasis; the
- -.: ~ement fixation. agglutination, and precipitin tests for
aniasis; the complement fixation test for Trypanosoma
, infections; and the dye test for toxoplasmosis have
- ••ed of distinct diagnostic benefit. Serologic tests as well
; ..;:~adermal tests may help in the diagnosis of certain he1-
- -:hic infections, such as trichinosis, echinococcosis, and
.' tosomiasis, where it is difficult and sometimes impos-
- e to demonstrate the causative organisms.
~: patho10gic Technics:
Certain parasites produce characteristic tissue changes
cl::make possible a histopathologic diagnosis. Biopsy of
" rectum and/ or the urinary bladder and liver is often the
re 'able method of diagnosis in schistosomiasis. Muscle
;sy is indicated for trichinosis.
:::-_"emiology:
T::e solution of problems associated with the epidemi-
- - -' prevention, and control of parasitic diseases of man
::':::'res a knowledge of the geographic distribution, life
;:-::-:es, and habits not only of parasites but of their vectors
--:. ::os s as well. The elimination of parasitic infections
-=. a community thus depends upon the combined efforts of
-~ '-' oratory worker, the field investigator, and the
~:-'an.
Or: the following pages information pertinent to the more
--~ant parasites of man is presented, as well as a con-
~=:ion of the diseases produced by them and a description
-" :aboratory methods and procedures employed for their
-~on in clinical specimens. For more extensive informa-
this subject the following references should be consulted:
:aust, E. C., Animal Agents and Vectors of Human
:>:'sease. Lea and Febiger, 1955.
_ :aust, E. C., and Russell, P. F., Craig and Faust's
..inical Parasitology, 6th ed. Lea and Febiger, 1957.
·ckie, T.T., Hunter, G.W., and Worth, C.B., A
ual of Tropical Medicine, 2nd ed. Saunders, 1954.
?essoa, S. B., Parasitologia Medica, 5th ed. Livraria
:::Gt, Guanabara, Koogan. Rio de Janeiro, 1958.
 Saliva from Pre- erythrocytic and
~ Sporozoites ,~ mosquito injected _________ _ exo-erythrocytic
•• cycle
_____ (Through coelomic cavity into hu an host in the liver
Oocyst reach salivary glands)
t
(Penetrates EXOGENOUS ENDOGENOUS
MeroLites~
(Enters
stomach wal1
of mosquito
PHASE
IN MOSQUITO
PHASE
IN MAN
/
Segmenter j
red cell)

and encysts)
t
Ookinete
Sexual Cycle
(Sporogony)
Asexual Cycle
(Schizogony)
i
Schizont
CLINICAL
MALARIA

'- Signet Ring

~ Mature /Trophozoite
Trophozoite

1 ~Microgamete
Zygote (fertilization) (in stomach)
(r:f) A<
Human
blood _Microgametocyte
enters
(r:f)
(differentiation)
~----- Macrogamete (" ) ~. mosquito __ Macrogametocyte (" )

Species Length of Sexual Cycle Incubation (Prepatent) Period Length of Asexual Cycle
(in mosquito) (in man) (in man)
Pre-erythrocytic Cycle

P. vivax (tertian) 7 - 10 days 8 - 15 days 48 hours

P. malariae (Quartan 18 - 21 days 23 days (averaf!e) 72 hours
P. falciparum (malignant tertian) 7 - 10 days 8 - 15 days 36 - 48 hours

P .L-as;.~ed
Erythrocyte
Has a predl:'eCUQIl for reucu;.o-
Enlarged pale cell; All forms in cytes but does Dot attack
Plasmodium vivax
SchUffner's dots peripheral mature erythrocytes. This
(benign tertian, vivax
malaria).
World-wide. Prevalent
(eosinophilic)
mature forms.
in blood.
(0
.'.
limits the parasitemia to
8.000 to 20,000 per cu. mm .
in temperate zones. Multiple infections of blood.
Commonest type. common.

Attacks primarily older ery-

Not enlarged; All forms in throcytes which already are
Plasmodium malariae
calor normal. peripheral about to be removed by the
(quartan malaria).
Comparatively rare. Multiple infections blood. normal process of blood de-
Temperate zone and rare. struction. Parasitemias less
subtropics. than 10,000 per cu. mm. of
blood.

Invades all erythrocytes re-

Not enlarged; Only rings gardless of age. Parasitemias
Plasmodium falciparum
color normal. and game- may reach 500,000 per cu. mm.
{malignant tertian.
Maurer's dots red, tocytes in P. falciparum also causes red
estivo-autumnal
larger and fewer peripheral cells to agglutinate, forming
malaria}.
Predominates through- than SchUffner's. blood. thrombi and emboli. and
out tropical regions. Multiple infections causing them to adhere to the
very common. capillary walls, with resulting
capillary obstruction and
Ring
Trophozoite Macrogametocyte Microgametocyte severe ischemia.

*The invasive characteristics of the different plasmodia parallel the marked variations in the severity of the disease.
 Found world-wide, incidence depending on the sanitation level. Entamoeba histolytica and Dientamoeba fragilis,
9-50% of population. Giardia lamblia, 15"/0. Balantidium coli, comparatively rare; mainly an infection of swine.

Parasite Enters Man Infective Life CyC'1ein Man Exit Reservoir Host
Form
May invade mucosa Man, dog*, cat*.
Entamoeba Becomes and/or other organs rat*. pig*,
histolytica Mouth <ofbody Cysts andlor monkey*.
Giardia trophoz cite- Duodenum and bile trophozoites Man.
Cyst
lamblia by passages in feces
Balantidium in May invade mucosa of Man, pig, monkey.
coli contamination large intestine
Dientamoeba intestine Tissue invasion Trophozoites ? - Probably man.
fragilis ?
questionable in feces

Non-pathogenic protozoa are commonly found in the feces of man. They are of diagnostic interest only because they
must be distinguished from. the pathogenic forms. The commoner organisms: Amoebae - Entamoeba coli, Endolimax
can a, Iodamoeba biitschlii; Flagellates - Chilomastix mesnili, Trichomonas hominis.

Trichomonas vaginalis (Trichomonas genitalisJ, known only in the trophozoite stage, inhabits the human vagina and
urethra of male and female. It is thought to produce a vaginitis, with severe itching and mucopurulent discharge.
Some workers believe the streptococci usually associated with the parasite cause the infection. T. vaginalis is world-
wide in distribution, occurring in 10-40"/0 of women examined. It is transferred probably by coitus. A flagellate
identical with T. vaginalis is found in the vagina of monkeys.

Glardiasis. Diarrhea. abdominal pain, dis comfo rt. Exam.u:e feces by

G. lamblia smear, cancentratlOD.
Balantidiasis. Limited to intestine where parasites localize .. with pathology and symptoms re- Examine feces by
Bal. coli sembling amebic dysentery. smear .. concentra-
tion, culture.
Dientamoeba Not proved to invade tissues. Diarrhea, abdominal pain, discomfort as in mild Examine feces by
diarrhea. amebiasis. smear, culture.
D. fralZilis
Amebiasis. F lask- shaped ulcers formed in mucosa of large bowel which appear as pinpoint Examine feces by
E. histolytica dots on surface, with little inflammation but extensive undermining below surface. smear, concentra-
Localize in cecum and appendix. Blood: Leukocytosis, anemia. There is no tion, culture.
eosinophilia in uncomplicated protozoan infections. Symptoms: Dysentery, bloody Abscess and ulcer
diarrhea, or constipation; abdominal pain and discomfort, gas distention; appetite material (as for
disturbance, weight loss, headache, nervous manifestations, localized tenderness. feces ).
Complications: 'Liver abscess (single or multiple) with liver enlargement and con-
gestion. Pain, swelling, leukocytosis, anernia, fever. Lung abscess primary or
secondary to liver abscess. Peritonitis (bacterial) with usual manifestations.
Ulcerations and abscesses of other organs or tissues, manifestations depending up-
on site infected. (lncubation Period: Acute~ 8- 10 days; chronic, 2 mos. -years. )
Prevention: Protect food and water supply. Find and treat carriers.
Toxoplasma gondii is a crescent-shaped protozoon found intracellularly in tissues and free in body fluids~ which causes
toxoplasmosis. Method of transmission to adults is unknown. The fetus in utero is infected across the placenta. May
be symptomatic or latent. Acute form involves all the viscera and is usually quickly fatal. Subacute or chronic toxo-
plasmosis shows predominantly C.N.S. manifestations and eye signs. Diagnostic laboratory methods: Isolation of the
organism from C.S.F. or autopsy material. The complement fixation test and the Sabin-Feldman dye test are the most
reliable serologic procedures. C. S. F. protein in subacute and chronic forms is high. usually over 500 mg./! 00 m!.
 Parasite and Fly Host Enters Man Life Cycle in Man I Exit Cycle in Fly Reservoir
Distribution Host
Leishmania donovani. Phlebotomus Becomes leishmania Man, dog,
Asia, Africa, Brazil, (sandfly) Plug of in cells of reticulo- cat, monkey,
Middle East. Mediter- endothelial system. rodents.
ranean basin. leptomonas Sucked Becomes
Leishmania tropica. Phlebotomus Becomes leishmania Man, dog,
Asia. S. and Cent. Am. , (sandfly) injected in endothelial cells of into leptomonas cat, monkey.
Middle East. Europe. skin. rodents.
Leishmania Phlebotomus with bite Becomes leishmania fly in the Man, dog,
brasiliensis. (sandfly) in endothelial cells of cat, monkey,
Central and of fly. skin and (secondary) with intestine rodents.
S. America. mucous membranes
of nasopharynx .. blood of the fly.
Trypanosoma "Glossina Fly bites; Trypanosome in Becomes Man,
gambiense. palpalis metacyclic lymph and blood; of crithidia and domestic
Central and W. Africa. (tsetse flv) trypanosome later in spinal metacyclic animals.
Trypanosoma Glossina injected with fluid. host. trypanosome Man,
rhodesiense. morsitans saliva. in the intestine wild game
Central and E. Africa. (tsetse fly) and salivary animals.
!!lands of fly.
Trypanosoma cruzi. Panstrongylus Metacyclic Becomes leishmania Sucked Becomes Man, dog,
Central and megistus trypanosome in tissue cells and into bug crithidia and cat, fox.
S. America, (kissing bug) in feces trypanosome in blood with metacyclic armadillo.
United States. and other contaminates stream. blood of trypanosome opossum
reduviid bugs skin. host. in the intestine (Dide lphis),
of the bue. rodents.

Disease and
BLOOD FLAGELLATE

Clinical Features
-----
D.FECTIONS OF iAC

Lab. Diagnosis
Etioloe:v
Chronic febrile disease, causing hyperplasia of cells of the reticulo- Blood: Thick and thin smears.
Kala-azar
endothelial system. particularly spleen and liver. Irregular fever culture. Napier and Chopra
(visceral
(spiking twice a day) with chills, sweating, diarrhea, edema, serum tests. Sternal marrow
le ishmaniasis).
cachexia, leukopenia. anemia. (Incubation Period: 2-9 months.) and splenic aspirate: Stained
L. donovani.
smears.
Endothelial cells and lymphoid tissue of skin parasitized. Itching Ulcer curettings: Stained
Oriental sore
red papule ~ scaling ----.. crusted ulcer ~enlargernent of smears, culture.
(cutaneous
leishmaniasis ). ulcer ----..healing. May be multiple. (Incubation Period: Several
L. trooica. davs to months. I-
Initial lesions similar to oriental sore, but this enlarges, producing Ulcer curettings: Stained
American
a weeping "saucer" ulceration. Destructive and deforming secon- smears, culture.
leishmaniasis
(espundia, uta. dary lesions occur at mucocutaneous junctions. Have fever, pain,
forest yaws; malaise, and anemia. lnoculable and auto-inoculable.
mucocutaneous (Incubation Period: Unknown.)
leishmaniasis) .
L. brasiliensis.
Sleeping sicknesS. Local lesion at fly bite followed by fever. adenitis, rash, transitory Blood: Thick and thin smears.
edemas. May fulminate (T. rhodesiense) or go on to meningo- concentration, culture. Spinal
West African -
encephalitis and meningomyelitis, with mental and physical wasting fluid: Smears of sediment.
T. gambiense;
leading to coma and death (T. gambiense). (Incubation Period: Lymph node fluid: Smears,
East African -
T. !!ambiense. 1-3weeks;T. rhodesiense, 1-2 weeks.) culture.
T. rhodesiense.
Acute (children) and chronic (adult) disease. with tissue cell degen- Blood: Thick and thin smears,
Chagas' disease.
eration leading to fibrosis (heart. brain, live-r), enlarged liver and concentration, culture.
T. cruzi.
May end in cardiac failure and death. (Incubation Period: Xenodiagnosis: See p. 322.
spleen.
1-2 weeks.) _.
 Parasite and Man Ingests After Liberation in Duodenum Adult Goes To Exit Reservoir Host
Distribution
Enterobius Egg Larvae become adult in ileum or Periana region -'"ggs on perIanal Man
vermicularis. lower bowel. to lay eggs. skin; in feces.
World-wide.
Trichuris Larvae attach to villi and mature. Cecum to lay Eggs in feces. Man
trichiura. eggs.
World-wide.
Trichinella Larvae in Larvae penetrate mucosa, mature, (Cycle ends in Feeding of un- Hog, rat,
spiralis. raw pork females produce larvae; enter blood man.) cooked garbage flesh-eating
Pork - eating (ingested stream; travel over body; encap- to hogs perpet- mammals.
countries. also by sulate in striated muscles (dia- uates the
rats). phragm, intercostals. eye, etc. ). organism.
Ascaris Egg Duodenum and Eggs in feces. Man
lumbricoides. right heart jejunum to lay
World-wide. .J.
eggs .. (Strongy-
Necator Filariform Larvae alveoli of lungs Ioicles penetrates Man
americanus, * larvae pene- .enter wall to lay eggs
Ancylostoma trate skin. blood~ up trathea to esophagus which hatch to
duodenale. *§ Egg (rare). stream ,rhabditiform
Strongyloides swall}wed ~ intestine larvae. ) Rhabditiformt Man, dog
stercoralis. t larvae in feces.

*Hookworm Soil Cycle: Rhabditiform larva-+ filariform larva~enter man under favorable conditions.
tStrongyloides larvae may become filariform larvae in the bowel or perianal surface and reinfect directly (hyper-
infection). Usually pass to soil: Rhabditiform larva---+- adult or filariform (infective) larva ~ man (under
t(Soil Cycle) t favorable conditions).
adult ---+- egg_ rhabditiform larva
§Found in tropical and subtropical climates where sanitation is poor and favorable conditions exist for the parasite.

Disease and Eliology C!.icical Features Lab. D"agnosis

Enterobiasis. pin- Symptomless to slight s)'IDptoms oi nervousness, insomnia. perianal Cellulose tape swab:
worm infection. itching and irritation. Eosinophilia. Secondary bacterial infection may p. 321. Feces: Direct
Enterobius occur. smear, concentration.
vermicularis
Trichuriasis. Depend on worm load. Symptomless to protracted, debilitating diarrhea, Feces: Direct, standard-
Trichuris resulting in cachexia. ized smear to count
trichiura eggs (see p. 318) .
Trichinosis. Worms: Irritate and inflame intestinal mucosa, with nausea, vomiting, Biopsy material: Di-
Trichinella
---
diarrhea, pain. Larvae: Muscu1ar pains, edema of eyes, face, hands. gestion and examination.
spiralis Irregular, persistent fever; breathing, swallowing, speech difficulties, Feces: Direct smear
rash, eosinophilia. Encysted larvae: Cachexia, toxic edema, dehydration, (rarely), concentration,
collapse. intradermal test.
Ascariasis. Larvae: Pneumonitis with cough, hemorrhages. lung consolidation. Feces: Direct smear,
Ascaris Adults: Symptomless to serious intllstinal complications (obstruction, concentration.
lumbricoides perioration). Nausea, pain, vomitin~, systemic toxemia, eosinophilia. Sputum: Direct smear.
Hookworm infection. Larval ground itch with edema, erythema, vesicular or papular eruption. Feces: Direct standard-
Necator americanus, Lung: Reaction similar to but milder than Strongyloides or Ascaris types. ized smear to count
Ancylostoma Intestine: Heavy infections cause hypochromic microcytic anemia and eggs (see p. 318).
duodenale eosinophilia.
Strongyloidiasis. Skin: Petechial hemorrhages, congestion, edema. Intense pruritus, no Feces: Direct smear,
Strongyloides inflammation. Lung: Larvae cause hemorrhage, cellular iniiltration, concentration.
stercoralis bronchial pneumonitis. Intestine: Catarrhal inflammation of mucosa;
watery, mucoid diarrhea. Abdominal pain, tenderness, nervous m ani -
festations, eosinophilia. Hyperinf'ection may cause dea th or chronic
invalidism (see next page).
Prevention: Trichinella - Proper meat handling. The U. S. GOZJer'7'.J11ent does not ~nspect jor' Tr'~ch~nella.
Hookworm, Ascaris, Strongyloides - Protect food and water supplies. Prevent soil pollution by proper disposal oi feces.
Eliminate infection reservoirs. Enterobius - Personal cleanliness, prevent dispersion of eggs, clean surroundings,
mass treatment of family.
in U. S. ; Echinococcus l!ranulosus, 3-160/0in endemic areas; Taenia solium, hiJ:(hwhere pork is eaten (rare in the U. S.).

Parasite and Intermediate Host Definitive Hos t

Distribution Entry of Egg In Inte s tine Entry of Larva Maturation of Worm Exit Reservoir Hosts
Hymenolepis Ingestion Into duodenal villi, (Entire cycle in one Eggs Man; rats and mice;
nana (dwarf (man). becoming cysti- host.) Larva leaves in gerbille in Africa.
tapeworm). $:ercoid larva. villi, attaches to lower feces
World-wide. Hatches to intestine, becomes adult.
Taenia Ingestion Into blood stream, Man ingests larva liber- Grav- Definitive: Man.
saginata (cattle). onc ho- over body to encyst ated in intestine from raw id Intermediate: Cattle.
(beef tapeworm). in muscles or organs beef; larva attaches to seg- buffalo, giraffes,
World-wide. sphere (cysticercus). intestine, becomes adult. ments llamas, goats.
per
Taenia solium Ingestion (1st As for T. saginata. As for T. saginata. anus Man.
(pork tapeworm~ (hogs, (Cycle ends in man.)
World-wide. man). stage
Echinococcus ngestion Into blood stream, Sheep dog ingests from Eggs Definitive: Dogs,
granulosus (sheep, larva). over body to muscles sheep carcass. Worm in cats, wolves, ja.okals.
(hydatid worm). accidental and organs (forms heads attach to intestinal feces Intermediate: Man,
Sheep-raising ingestion hydatid cys t). (Cycle wall; become adult. sheep, hogs, cattle.
countries. in man). ends in man.)
Diphyllobothrium Water flea Larva en- Fresh-water fish Man ingests raw fish with Eggs Definitive: Man,
Iatum (fish tape- ingests free- cysts in eats water flea; sparganum; larva liber- in fish-eating mammals.
worm). North swimming hemal larva escapes in ated in intestine, attaches feces Intermediate:
Europe, Great larva cavity, intestine, enters to intestinal wall, becomes Diaptomus, various
Lakes region of (coracidium) becomes muscles, becomes adult. "pike" fish.
North America. hatched procercoid 3rd stage larva
from el!l!. larva. sparl!anum\.

Disease and Clinical Features Lab. Diagnosis

Etiology

Hymenolepiasis. Symptomless to severe systemic toxeroia, depending on worm load. Feces: Direct smear,
Hymenolepis Eosinophilia, nervous manifestations, with or without diarrhea, and pain. concentration.
nana. May produce convulsions, insomnia, dizziness.
Taeniasis Abdominal and hunger pains, chronic indigestion, weight loss, persistent Feces: Direct smear
saginata. diarrhea or alternating with constipation; nervous manifestations. not reliable. Recovery
Taenia saJ:(inata. Eosinophilia. (Incubation Period: 10-12 weeks.) of gravid segments.
Taeniasis solium. Intestinal: Same as T. saginata. Cysticercosis: Symptoms may vary with Feces: Direct smear
Taenia solium. number of larvae and site in tissues. Foreign body response with inflam- not reliable. Recovery
mation followed by fibrosis and necrosis of parasite, later calcification. of gravid segments. Re-
If in brain, epilepsy and convulsions. (Incubation Period: 10-12 weeks.) covery of larva by exci-
sion' and identification.
Hydatid disease. Symptoms depend on location and type of cyst: Unilocular cysts usually Cyst contents, urlne,
Echinococcus cause inflammatory and fibrous tissue response, eosinophilia; pressure sputum: Direct smear.
granulosus. symptoms if large. Hydatid fluid, escaping, can produce allergic reaction. Blood: Complement
Alveolar cysts produce metastases wlth secondary cyst formation; a fixation and precipitin.
malignant growth. Osseous cysts cause rapid erosion of bone. Spontaneous Intradermal test.
cyst rupture mav cause violent reaction reScultinl! in death. X-rays.
Diphyllobothriasis Symptomless to marked systemic toxemia. Pain, weight loss, diarrhea. Feces: Direct smear,
(fish tapeworm Severe macrocytic anemia like pernicious anemia found in a small number concentration.
disease). of cases; 700/0 from Finland where there is a tendency to this type of
Diphyllobothrium anemia; eosinophilia. (Incubation Period: 10-12 weeks.)
latum.
 Parasite and Definitive Host Intermediate Host
Distribution Habitat Exit Cvcle Outside Man
Schistosoma Vesical and pelvic venous Egg in Egg hatches to mi-
haematobium. plexuses draining bladder. urine racidium in water.
Asia Minor, Trop- or .Invades appropriate
ical and N. Africa. feces. snail. (Clonorchis
larva ingested by
snail.)
Schistosoma Branches of inferior mesenteric Man, monkeys.
mansoni. Cercaria veins draining rectum and Mouse, hamster
P. Rico, Brazil, penetrates sigmoid. (experimental).
Venezuela, N. skin. In snail, becomes
and Cent. Africa. sporocyst, redia
Schistosoma Branches of superior mesenteric in (except Schisto- Man, horses, cows
japonicum. veins draining intestine. soma), cercaria. dogs, cats, mice,
Japan, E. Asia,
P.!. ~ water- buffalo.
Cercaria swarms
Fasciolopsis from snail.
buski. Ingested
E. and S. Asia. metacercaria +
Encysts on water
Fasciola hepatica. on water Intestinal wall, abdominal cavi- Egg in plants (Fasciola and Sheep, cattle.
World-wide, sheep- plant. ty, diaphragm and liver capsule Fasciolopsis), other herbi-
raising countries. to distal bile caoillaries. bile to or vores.
Clonorchis Ingested Bile ducts. Invades fish (Clon- Man, dogs, cats.
sinensis. metacercaria orchis), crayfish, or
S. Asia. in raw fish. crab (Paragonimus),
Paragonimus Ingested Encysted in lungs, pleural Egg in or Man~ wildcats,
westermani. metacercaria cavity, liver. sputum directly attacks man foxes~ wolves,
America~ Asia, N. in crayfish, or (Schistosoma) . dogs, rats, pigs,
and Cent. Africa. crab. feces. weasels.

Etiology
esical )!un penetrallon: yractlcauy symp omless; 1 cnmg, erytnema, petectuae. Urine: Direct smear,
schistosomiasis Migration: Acute clinical episode with visceral and cutaneous hemorrhages; urti- sedimentation for
Schistosoma caria, asthma, transient pneumonic infiltrations of lungs. Deposition of eggs: S. haematobium.
haematobium. Foreign body reaction; inflammation with fibrosis~ calcification or cyst formation Feces: Direct smear,
Intestinal with ulceration which may produce polyps or malignant changes. Bacterial infec- concentration for S.
schistosomiasis. lion often follows. Eosinophilia. S. haematobium eggs in bladder wall cause mansoni or japonicurn.
Schistosoma pain~ urinary frequency~ hematuria. S. mansoni and S. japonicum eggs in Rectal biopsy.
mansoni, intestines cause abdominal pain, diarrhea with blood, mucus, and pus (schisto- Blood: Precipitin
Schistosoma somal dysentery). If eggs go to secondary sites, they cause urethritis, (circumoval or CHR)
japonicum. cirrhosis, splenomegaly, infection of other organs or tissues. (Incubation test (see p. 321).
Period: 1-3 months.)
Fasciolopsiasis. Localized inflammation of jejunum or duodenum, followed frequently by ulcera- Feces: Direct smear,
Fasciolopsis tion at sites of worm attachment. Diarrhea with foul- smelling stools; abdominal concentration.
buski. pain. In severe infections eosinophilia, ascites, anorexia, nausea, vomiting,
toxemia, prostration. (Incubation Period: 3-4 months.)
Fascioliasis Worm migrations cause tissue necrosis and fibrosis. Vomiting, coughing, Feces: Direct smear,
hepatica. Fasci- generalized abdominal pain. Urticaria, diarrhea, jaundice, irregular fever, concentration.
ola hepatica. edema, anemia, and eosinophilia. (Incubation Period: 3-4 months.) Duodenal drainage:
Clonorchiasis. Parallel degree of infection. Vast numbers of parasites cause diarrhea, jaundice. Direct smear.
Clonorchis cachexia, eosinop~lia. Proliferation and desquamation of biliary epithelium.
sinensis. dilatation and thickening of the wall occur. Severe symptoms of liver d)rsfunction,
recurring icterus with hepatomel!aly follow. (Incubation Period: 3 months.)
Paragonimiasis. Lung: Parasites are embedded in subpleural cysts (eggs act as foreign bodies) Sputum: Direct
Paragonimus with inflammation and fibrous capsule formation. Chronic cough with fever, smear.
westermani. brown sputum, hemoptysis, severe chest pain, bronchopneumonia or pleural fluid. Feces: Direct smear~
May enter any organ to produce symptoms, e.g., abdominal pain, diarrhea, concentration.
eosinophilia. Similar lesions in other tissues. (Incubation Period: 3 months.l
 Parasite and Insect Enters Matures to Microfilaria Exit Fly Cycle Reser-
Distribution Host MaI\ Adult Goes to voir
Wuchereria bancrofti. Culex and Filariform In lymph vessels Blood stream Micro- Becomes in-
Tropics and sub- other mos- and nodes becomes (nocturnal or no filaria fective larva
tropics. quitoes. larva .in- adult filaria. periodicity). is taken in fly thoracic
Loa loa. Chrysops In subcutaneous Blood stream (di- up by muscles.
Tropical Africa. I (de.er fly). jected with tissues becomes urnal periodicity). fly when Migrates to
Onchocerca volvulus. Simulium adult filaria. (Remains in biting. proboscis. Man
Tropiclll Africa and (buffalo insect bite. subcutaneous
Central A~erica. I gnat). tissues.)
Dracunculus Cyclops Cyclops con- Digested out of (Adult female worm dis- lnf ecti ve larva
medinensis. (water taining larva Cyclops in intes- char ges larva through develops in
Afrioa, India, Middle flea). ingested by tines; migrates skin "blister" Cyclops.
East, East Indies. host. intb tissues. into water. )

Disease and
Etiology
Bancroft's Filaria in afferent lymphatics or lymph nodes (of lower extremity, vulva, scrotum,
filariasis. epididymis, mammary gland) cause inflammation followed by intensely fibrotic re·
W. bancrofti. action involving whole area in a maSs of scar tissue. Pain, fever, chills, toxemia.
eosinophilia. Chronic stage varies from microscopic lesion to lymph varicosity to 'Blood: Thick
marked elephantiasis. Non·pitting edema on pressure. (Inc. Per. : Months to years.) and thin smears,
Loaiasis. Fugitive swellings of skin due to migration of worm and edema. Common over nose. concentration
Loa loa. Eosinophilia. May have albuminuria. (Inc. Per.: Months to years.) (see p. 322).
Onchocerciasis. Small cutaneous fibrous skin nodules with filariae in center. Microfilariae may io- Nodule aspirate;
O. volvulus. vade eye, cause inflammation and blindness. Eosinophilia. IInc. Per. : Mos. to vrs.) skin section.
Dracontiasis. Asymptomatic until reddish papular lesion appears on skin. Becomes a blister which Smear or ulcer
D. medinensis. bursts, liberating larvae. Itching, rash, asthma-like symptoms develop. Eosino· washing. X-ray
Iphilia. (Inc. Per.: 8-12 months.) of worm in tissue.
Preventlon: f>rotectlOn agamst fly blte (Dracunculus: agamst Cyclops mgestlOn). EradlcatlOn of arthropods.
Chemoprophylaxis and/or chemotherap of i abitants in e demic a.reas. __ ~ _
 LABORA TOR Y EXAMINA TION
FOR PARASITES

FECES
(See also p. 267.)

I"••.lmen Collection:
ollect specimen in a clean, dry container and examine
loon as possible, preferably while still warm. Specimens
hollowing administration of oil, bismuth, or barium are un-
til factory. Repeated examinations are advisable; at least
1111'( • la six should be examined on consecutive days since the
Ilml' of appearance of parasites in the feces is variable. If
1I\\I1'UH or blood streaks are present these must be examined
111"(' trophozoites or cysts may be' distributed irregularly
IIIl ollghout the specimen.

1"'(' 'rvation and Shipment of Specimens to Be Examined for

Trophic and Encysted Protozoa (Method of Brooke and
Goldman):
1\ Iteagent: Modified Schaudinn's solution is prepared by
,nlxing 5 ml. of glacial acetic acid, 1. 5 ml. glycerol, and
03.5 ml. Schaudinn's solution (two parts saturated aqueous
on re uric chloride and one part ~5"!o ethyl alcoho'1).
Heat the above solution to 75° C. ;. while stirring, slowly
cleI 5 Gm. polyvinyl alcohol (PVA) powder (Dupont's
l~lvanol®, Grades 71-24 or 71-30). This final solution
Hhould be clear and free of lumps after cooling. It is
LIB d at room temperature, and lasts for several months.
11. I>reparation of Specimens:
1. ne specimen should be sent without above fixative to
be used for detection of protozoan cysts and helminthic
ova. This specimen can be used for temporar.y or
permanent smears or for concentratioJ:! procedures
(see p. 318).
2. Second specimen is pr'epared by thoroughly mixing
with three or more parts of fixative in a small vial.
To prepare slides a small amount of this fecal mixture
(recent or months old) is spread thinly over about one-
third of the slide. After drying for three or more
hours at 37° C. or overnight at room temperature, the
smear is stained by the iron hematoxylin method (see
p. 319). This procedure is particularly suitable for
the preservation and staining of the trophic forms of
the intestinal protozoa. To obtain satisfactory stained
fecal smears containing cystic s·tages the excess clear
PVA solution is decanted from the vial and a small
amount of the remaining fixed fecal material is placed
on a piece of facial tissue or toilet paper. The excess
PVA solution is allowed to absorb for five to ten min-
utes, leaving a moist fecal residue. Gently scrape up
 a small amount of the residue with the sharp edge of
a broken applicator stick and smear with gentle
brushing strokes on a slide. Drop smear immediately
into 700/0 alcohol to which iodine has been added to pro-
duce a port wine color, and stain by the iron hema-
toxylin method (see p, 319), To insure satisfactory
preparations of both cystic and trophic forms, the
preparation of the two types of smears is recommended.
Standardized Direct Fecal Smear Examination:
Follow directions given by Beaver strictly (J. Parasito!.,
35:125-135, 1949; 36:451-456, 1950). Place a glass slide over
a calibrated photometer (a Weston Master is just as good) and
set the reading at 20 f. c. Add a drop of saline and with the
tip of an applicator comminute feces progressively until the
needle moves down to the preset reading. A 2 mg. prepara-
tion is preferable. Cover with a coverglass and examine all
the microscopic fields, counting the various eggs and looking
for cysts and trophozoites of protozoa. A drop of iodine
solution (Lugol's, Craig's, or D'Antoni's) may help identify
some of the protozoa. This method thus replaces the ordi-
nary direct saline smear, permitting the quantitation of worm
loads as well as examination for all signs of parasites.
Concentration:
Parasites are often so few in number that they cannot be
detected WIthout employing a concentration procedure.
A. Formalin-Ether Sedimentation Technic (Ritchie):
1. Emulsify portion of stool (a mass 2 to 3 cm. in di-
ameter) in 30 to 50 ml. saline. (For specimens that
have previously been preserved in formalin, start
with 2, below. Tap water may be used instead of
saline in this case if desired. )
2. Strain about 10 ml. of the emulsion through two layers
of wet gauze into a 15 ml. centrifuge tube with a
conical tip. The remainder of the emulsion may be
used for other concentration technics, direct smears,
or for preservation.
3. Centl'ifuge at moderate speed for a few minutes and
then decant supernatant.
4. Resuspend sediment in' fresh saline, centrifuge, decant
as before. Repeat as necessary, if supernatant is
particularly cloudy.
5. Add 10 ml. of 100/0formalin to the sediment, mix
thoroughly, and allow to stand for five minutes.
6. Add 3 ml. of ether, stopper the tube, and shake
vigorously.
7. Centrifuge at low speed for about two minutes. Four
layers should result: (1) at the bottom, small amount
of sediment containing most of the parasites and eggs;
(2) a layer of formalin; (3) a plug of fecal debris on
top of the formalin; and (4) at the top, a layer of ether.
8. Free the plug of debris from the sides of tube by
ringing with an applicator stick, and decant the top
three layers.
9. Mix the remaining sediment with the small amount of
fluid that drains back from the sides of the tube and
prepare iodine or unstained mounts in the usual
manner for microscopic examination.
B. Zinc Sulfate Centrifugal Flotation Technic (Faust,
D'Antoni, and Sawitz):
1. Emulsify 1 ml. of feces in 10 ml. of tap water.
2. Filter through two layers of gauze.
3. Centrifuge mixture for one minute at 2600 r. p. m. and
pour off supernatant fluid.
4. Add fresh saline, mix well, and centrifuge again.
Repeat this process three or four times.
5. For the final emulsification, substitute 33"10 zinc sulfate
solution (sp. gr. 1.80) for the saline.'
6. Centrifuge the suspension for one minute at top speed.
7. Eggs and cysts rise to surface (trophozoites destroyed).
8. Disturbing the supernatant as little as possible, trans-
fer several loopsful of the surface film to a glass
slide. Add a drop of iodine, mix, cover with cover-
glass, and examine microscopically.
He'denhain's Iron Hematoxylin Staining Method For Intestinal
Protozoa:
There are numerous modifications of the iron-hema-
-oxylin stain, anyone of which will give good results if
properly handled. The process of decolorization is the most
n.a. step. This can be mastered only by experience.
A. Staining Solutions:
1. Schaudinn's fixative - Two parts saturated mercuric
chloride in water, one part 950/0 ethyl alcohol. Be-
fore using add 4 ml. glacial acetic acid to 100 ml. of
the stock solution.
2. Hematoxylin stain (stock solution) - Dissolve 10 Gm.
hematoxylin powder in 100 ml. absolute ethyl alcohol.
Let stand several weeks to ripen before use. For use,
5 ml. of the ripened hematoxylin is added to 95 ml.
distilled water.
3. Mordant (iron alum) - Dissolve 2 Gm. ferric ammoni-
um sulfate in 100 ml. distilled water.
B Procedure:
1. ~l1akethin fecal smear on glass sI ide with toothpick or
applicator.
2, Before drying occurs, immerse slide in Schaudinn's
fluid which has been heated to 45° C. Fix for five to
15 minutes at this temperature or for 30 minutes at
room temperature.
 3. Staining-
700/0 iodine alcohol 5 minutes
70"/0 alcohol 2 minutes Examine centrifugate directly under the microscope.
500/0 alc-ohol 2 minutes e smears, stain with Giemsa's stain, and examine. Cul-
Tap water (running) 2 minutes -e some of the sediment, as for blood. Inoculate guinea
Distilled water Rinse ?:gs or mice if necessary.
20/0aqueous alum (mordant) 10 minutes at 30·C.
Tap water (running) 5 minutes
Distilled water Rinse
O. 50/0hematoxylin 10 minutes at 3D·C. Wet preparation may be examined directly for Trichomo-
Differentiate in cold 20/0 z= vaginalis. Cultures can be made by experienced tech-
aqueous iron alum (a =i :ans.
critical step)
Tap water (running) 15 to 20 minutes
500/0 alcohol 2 minutes GRAHAM CELLULOSE TAPE TECHNIC FOR
70"/.alcohol' 2 minutes DIAGNOSIS OF ENTEROBIASIS
950/0 alcohol 2 minutes
1000/0 alcohol 2 minutes The adhesive side of a small strip or loop of cellulose
Carbol xylol 5 minutes :..a;>e e. g., Scotch Tape®j is pressed over the anal and peri-
Xylol 5 minutes a.::.a: surfaces with the help of a tongue depressor. Then place
:a;;e with adhesive side down in a drop of toluene on a micro-
Mount in xylol-balsam, xylol-Damar or Permount® 5:: .:c slide. Examine for eggs or worms which have ad-
with a coverglass of No. 1 thickness. e~eC.to the tap e.

Cultivation of Intestinal Protozoa:

Numerous types of special media have been developed IMMUNOLOGIC TESTS
for the cultivation of the intestinal amebas and flagellates as (See p. 342.)
well as for the ciliate Balantidium coli. Among these are
Boeck-Drbohlav's Locke-egg-serum medium, Nelson's egg tradermal tests for Trichinella spiralis (Bachmann
yolk-alcoholic extract medium, and Balamuth's egg yolk in- • S' and Echinococcus granulosus (Casoni test) are specific,
fusion-liver extract medium. Consult standard texts for =c some diagnostic laboratories are prepared to make them.
details of preparation. -":gen for the former is made from extracts of larvae
=--;;ested from muscles of laboratory-infected rats, whlle the
~-er antigen consists of fluid obtained from hydatid cysts
,. :.n man or sheep ..
r::e circumoval and CHR (cercarien-hiillen-reaktion) tests
Collect urine in clean, dry container, avoiding fecal con- =e soecific in the diagnosis and follow-up of schistosomiasis.
tamination. Study centrifuged sediment. Trophozoites of _- ,,~living eggs or cercariae of the species under suspi-
Trichomonas vaginalis, eggs of Schistosoma haematobium, are incubated overnight in blood serum from the patient.
and intact scolices or hooklets of Echinococcus granulosus -",:>e ~ precipitate will form around them. The circumo-
may appear in the urine. ~ :e . is species-specific and becomes negative several
after successful therapy. Intradermal tests with
s: '-e extracts of cercariae or adult schistosomes are helpful
• :n screening cas es since they are genus- specific but not
s-= ·es-specific.
Examine for 'parasites directly under' the microscope, or . _-':'~ough reliable complement fixation, precipitin, and
study sediment after centrifuging (if sputum is sufficiently - -- _:ination tests have been developed for the diagnosis of
fluid). Larvae of Strongyloides stercoralis, scolices of : :-a.:.of the parasitic infections of man, they have had only
Echinococcus granulosus, or eggs of Paragonimus westermani ~;eC. application. Comparatively few laboratories are
may be present in the sputum. e' ._?;>ed to perform these tests. Satisfactory antigens are
often difficult to prepare, and control sera are often not ob- C centration of Microfilariae (Knott Technic):
tainable. Thoroughly shake 2 ml. blood with 10 ml. of a 2% solu-
of formaldehyde. Centrifuge for five minutes at 2000
~ ::>. m. Decant supernatant and examine sediment by pre-
;>'L:.:ng dried thick films stained with Giemsa's stain or hema-
. xylin.
Small pieces of deltoid, biceps, or gastrocnemius
muscle are removed from the vicinity of their tendinous :e..-.;m Tests for Leishmania donovani:
attachment under local anesthesia. (1) Examine small pieces The Napier aldehyde test and the Chopra antimony test
of muscle compressed between two glass slides microscopic- a..-e based on an increase in the euglobulin fraction of the
ally for encysting or encysted larvae. (2) Digest muscle in ::U)(x! serum. Sometimes, but not always, they aid in diag-
artificial gastric juice (pepsin and hydrochloric acid) and :::osis. (See references for further details. )
examine sediment for motile larvae.
::::tt3"es for Blood Flagellates:
.:... Leishmania donovani: Culture sedimented cells from
citrated blood, bone marrow, liver or spleen pulp (ob-
tained by puncture) in N. N. N. (Novy, MacNeal, Nicolle)
Laboratory-bred reduviid bugs (obtainable from Gorgas medium at 20° to 24° C. for one to four weeks.
Memorial Laboratory, Panama City, Panama) are fed on :So Leishmania tropica and L. brasiliensis: Culture scrap-
patients suspected of having Chagas' disease. Two weeks ings or aspirated material from lesions as for L. dono-
later, they are examined for the presence of the parasite. vani. (Not found in blood. )
C Trypanosoma gambiense and T. rhodesiense: Culture
centrifuged citrated blood, lymph node aspiration fluid,
or spinal fluid in special media developed for these
organisms.
Combined Thin and Thick Films: D. Trypanosoma cruzi: Culture blood as for Leishmania
A. Making Films: Cleanse finger or ear lobe thoroughly donovani.
with acetone and allow to dry. Prick skin deeply to cause
a few drops of blood to flow freely. On one end of a
meticulously clean slide make a thin smear as for a blood
count. For the preparation of the thick film deposit a
large drop of blood at the other end of the slide and spread
it out evenly with the corner of another slide to a diameter
of about 20 mm. The film should not be too thick since it
may crack and peal when dry. Dry slide in a flat position
so that distribution of blood will be even. Protect from
dust and insects; avoid excessive heat. Allow to dry in
air for at least eight to 12 hours or for two hours in in-
cubator at 37° C.
B. Staining Films: Fix thin-filmed end of slide in methyl
alcohol for two to three minutes. THE TIUCK FILM
MUST NOT BE FIXED. Immerse slide for 30 minutes in
a mixture of one drop of concentrated Giemsa's stain to
each ml. of neutral distilled water. Wash off and dry in
air. Examine with oil-immersion objective. (For
further details, see references.) Hematoxylin stain is
preferred for microfilariae since their sheaths (if present)
stain more distinctly.
 Trophozoite ll,u Cyst lO.u Trophozoite (no cyst)
9p
Iodamoeba biitschlii Dientamoeba fragilis

...~;
Trophozoite 18 J.l ~
Chilomastix ~esnili
Trophozoite 14JJ Trophozoite (no cyst)
Giardia lamblia 12p
Trichomonas hominis
 Diphyllobothrium

,
latum Hymenolepis
nana

{~1:
!4Scolex
~~ 1 mm. ~:; ;.1;.~)
~.? Scolex o. :3 mm.

Gravid
Proglottid
6 X 12 mm.
Gravid
Proglottid
6 X 20 mm.

Adult fluke 60 X 30
mm.
C:cmorchis sinensis \\. )

Egg 31X 161' ~

~ ~~
'a'';'~ ~~~

Leptomonas Crithidia
15-251' 15-251'

- .::?3D0soma "\
cruzi i~
15-2"::7
~
~lk ~~
"~~
~;.
Trypanosoma
gambiense
 Diphyllobothrium

,
latum Hymenolepis
nana

{~1:
!4Scolex
~~ 1 mm. ~:; ;.1;.~)
~.? Scolex o. :3 mm.

Gravid
Proglottid
6 X 12 mm.
Gravid
Proglottid
6 X 20 mm.

Adult fluke 60 X 30
mm.
C:cmorchis sinensis \\. )

Egg 31X 161' ~

~ ~~
'a'';'~ ~~~

Leptomonas Crithidia
15-251' 15-251'

- .::?3D0soma "\
cruzi i~
15-2"::7
~
~lk ~~
"~~
~;.
Trypanosoma
gambiense