Module 6 July 2016

6.4 Parasites
Lecturer: Nico Fabian
Pharmaceutical Microbiology - Entamoeba dispar: less pathogenic, x hematophage
VI. PARASITES 2. Giardia lamblia
- “old man with eyeglasses” , teardrop
- Acquires nutrients via intimate contact - F
- Obligate vs facultative (free-living or commensal)
- Endo- vs ectoparasite
- Hosts where parasite lives
o Definitive host
 Needed for sexual maturaton
o Intermediate
 Development stage only
o Paratenic - Giardiasis: foul-smelling greasy diarrhea, gassy abdominal
distension
 Transport, eg. cockroaches
- Dx: enterotest/ string test
- Zoonosis: animal is the normal host but may also infect humans - Transmission: fecal-oral
- Infective (transmit from 1 organism to another) vs diagnostic (manifest in 3. Cyclospora cayetanensi
specimen) stage - Watery diarrhea assoc. w/ ingestion of occysts from contaminated
- Generalization fruits & vegetables
o No effective vaccine - Trans: fecal-oral
o No practical chemoprophylaxis 4. Trichomonas vaginalis
o Affects young & underprivileged - Trans: sexual
o Most are vecor-borne - Male manifestation: trichomoniasis w/c may be asymptomatic
- Classfication - Female manifestations: trichomoniasis
o Protozoa  Vaginal itching
o Helminthes  Burning itching
- Immunity  Frothy, yellow green discharge
o Less specific response (↑eosinophils) 5. Toxoplasma gondii
- Trans: sporulated oocyst from cat feces; undercooked meat;
o Premunition / nonsterilizing
congenital
o Antigen masking & switching related to antigenic phase variation
- *sidenote: congenital disease (TORCHES)
(exhibited in bacteria by E. coli)
 Toxoplasma
 Rubella
A. Protozoa  Cytomegalovirus
1. Entamoeba hystolitica
 HIV, Hepa B
- Cyst (infective) ↔ trophozoites (feeding form)
 Syphilis
- Capable of ingesting RBC (hematophage)
- S/Sx
- Clinical manifestations
 Blindness
 Intestinal amoebiasis: bloody diarrhea/ dysentery
 Lymphadenopathy
 Extraintestinal: amoebic liver abscess
 Encephalitis
- Dx: fecalysis
 Seizures
- Pathogenesis: flask-shaped ulceration
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Module 6.4 Parasites
6. Leishmaniasis c. P. vivax
- Trans: sandfly (sim. to Phlebovirus) - Infects Young RBC (reticulocyte) (Vata)
- Clinical manifestation - Most widespread
- Leishmania tropica - Cause enlargement of RBC
 Oriental sore/ Old World Cutaneous - Capable of producing HYPNOZOITES
 Lymphoid tissue of skin (cutaneous)  Dormant stage that stays in the liver
 a) simple, confined to bite, or b) diffused/spread  Capable of causing RELAPSE malaria
- L. braziliensis
 Espundia/ New World Cutaneous d. P. ovale
 Skin & mucus membrane (mucocutaneous) - Infects Young RBC (reticulocyte) (vata)
- L. donovani - Most recently identified
 Kala-azar/ Visceral Leishmaniasis - 48 hr Tertian malaria
 Reticuloendothelial system - Produce HYPNOZOITES
7. Malaria  Dormant stage that stays in the liver
- Vectore: female anopheles mosquito (night biter)  Relapse malaria
- Zooprophylaxis: mag-offer ng other animal para di ikaw kagatin - Dx: thin (ID species) & thick blood smear
- Clinical features - Protective factors:
 Relapsing fever (sim. to Borrelia recurrentis) o Damaged RBC  disrupts reproduction of Plasmodium
 Fever paroxysms (fever ↔ x fever) o Eg. G6PD, sickle cell anemia, thalassemia
 Fever (due to release of merozoites), chills, 8. Babesia spp
sweating) - Tick-borne (sim. to Lyme disease)
- Lifecycle - Babesiosis (w/o fever paroxysms)
1. Infected mosquito bites a person - Babesia microti: USA
2. Release sporozoites (Infective stage to humans) - Babesia divergens: Europe
3. Travel to the liver & becomes - Dx: Maltese cross formations 
4. Merozoites (exoerythrocytic stage) 9. Trypanosomiasis
5. Released from the liver tissue to infect RBC as a. Trypanosoma cruzi
6. Trophozoites - Chaga’s disease
7. RBC ruptures & release merozoites w/c matures into - Vector: kissing/ reduviid/ triatomine bugs
8. Gametocytes (infective stage to mosquito) - Chagoma (inflammation at the site of inoculation)
- Plasmodium spp - (+) Romaña’s sign (unilateral edema w/ conjunctivitis
a. Plasmodium falciparum characteristic of Chaga’s disease)
- Infects Young & Old RBC (fareho) b. T. brucei
- Found in the Philippines - African sleeping sickness
- Crescent shape gametocyte  T. brucei rhodesiense: acute form
- Most severe form of malaria  Rhodesian or East African Sleeping
- 24 hr Quotidian malaria Sickness
b. P. malariae  T. brucei gambiense: chronic form
- Infects Old RBC (Matanda)  Gambian or West African Sleeping
- Patchy distribution Sickness
- 72 hr Quartian malaria - Vector: tse tse fly

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Module 6.4 Parasites
- (+) Winterbottom syndrome: affects posterior cervical - Myalgia due to encystment of larvae in muscle tissues
lymph node - Reservoir: pig
8. Filarial parasites
- “disease of the poor”
B. Helminths a. Wucheria bancrofti, Brugia malayi
1. Ascaris lumbricoides  Vector: Culex, anopheles mosquitoes
- Giant roundworm/ nematode  Acute manifestations: a) tropical pulmonary eosinophilia,
- Most common human helminthic infection b) granuloma
- Coincidental w/ hookworm & trichuris (HAT)  Manifestations
- Trans: soil-oral  Lymphedema
 Embryonated egg: infectious stage to humans  Hydocoele: genital elephantiasis
- Dx: Kato-Katz technique (egg-counting)  Dx: thick blood smear prep.
2. Enterobius vermicularis/ human pinworm b. Onchocerca volvulus
- Most prevalent nematode in temperate climate  Onchocerciasis/ River blindness/ Robles’ disease
- Trans: hand-to-mouth, retroinfection (anus  GIT), autoinfection  Vector: black fly
- Dx: scotch tape test (while enterotest for G. lamblia)  S/Sx: excoriation of skin, loss of pigmentation, blindness
3. Trichuris trichiuria/ whipworm c. Loa loa (African eyeworm)
- Most prevalent in developing countries  Calabar swelling: episode of angioedema
- Require embryonation in soil 9. Flukes/ trematode
- Rectal prolapse: hallmark symptom of heavy T. trichiuria infection; - Flatworms/ platyhelminths  Cestodes & Trematodes
lower portion of colon inside anal canal becomes turned inside 1. Intestinal fluke
out & protrude out of the body a. Fasciolopsis buski
4. Hookworm - “Giant intestinal fluke”
- Trans: percutaneous, fecal, transpulmonary migration - S/Sx: GI
- Chronic: blood loss 0.2-0.5 mL/ day/ hookworm - Trans: kinilaw na kuhol
- Complication: Iron-deficiency anemia 2. Liver fluke
a. Ancyclostoma duodenale/ Old world hookworm: has teeth a. Fasciola hepatica
b. Necator americanus/ New world hookworm: cutting plates - “Giant liver fluke
5. Strongyloides stercoralis - Western liver fluke infection
- Trans: percutaneous, fecal, autoinfection - Trans: water crest
- Diarrhea b. Clonorchis sinensis, Opistorchis spp
- Risk factors - Small liver fluke
 Immunocompromised - Clonrchis: Chinese/ oriental liver fluke
 ↑steroid use - Trans: uncooked fish
 Autoimmunity 3. Lung fluke
 CA a. Paragonimus westermani
6. Capillaria philippinensis - Trans: nilasing na talangka
- Ilocos  Pleuropulmonary
- Intestinal capillariasis  Cerebral
- Trans: infected fish 4. Blood fluke
7. Trichinella spiralis a. Schistosoma japonicum (__________)

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Module 6.4 Parasites
- Release many eggs Enterobius Schistosoma
b. Schistosoma haematobium Ascaris (co-infection HAT)
- Urinary bladder Trichiuris
- Persistence of lifecycle thru Brugia
 Disposal of human excreta Strongyloides
 Snail
 Cercaria infested H2O WHEAT BRuSh PaCOFFS
- At risk: farmers
- Trans: percutaneous
- Immediate/ early: swimmer’s itch
- Delayed/ systemic: Katayama fever;
manifestation of Acute condition
- Chronic: immunopathological changes
- Complication: liver fibrosis  cirrhosis VII. Anti-protozoal
(irreversible) A. Malaria
10. Cestodes - Tissu schizonticide (exoerythrocytic)
- Foodborne except Hymenolepsis nana (ingestion of insects) o Primaquine
- Presence of Scolex - Blood schizonticide (erythrocytic)
a. Taenia saginata/ Beef tapeworm o Quinine
- Has suckers o Chloroquine
- x larval stage in humans (vs. Taenia solium w/c has) o Mefloquine
b. Taenia solium/ Pork tapeworm o Pyrimethamine
- Has suckers o Sulfadoxine
- Larval stage in humans o Artemisinin
- neurocystercosis o pyroguanil
c. Hymenolepsis nana/ dwarf tapeworm - Gametocide
- Has suckers o Primaquine
- Trans: ingestion of infected insects o Chloroquine
- Vector: flour beetle o Quinine
d. Diphyllobothrium latum/ fish tapeworm - Causal (prevents transmission; tissue schizonticide)
- Has 2 leaf-shaped grooves vs clinical prophylaxis (going to endemic places; blood schizont.)
- Assoc. w/ Vit B12 deficiency (cyanocobalamin) -
Clinical cure Suppressive cure Radical cure
Nematode (roundworm) Cestode (flat – tapeworm) Trematode (flat – flukes) Terminate S/Sx Radical cure for P. Prevent relapse of
Wucheria Taenia Paragonimus falciparum & vivax & ovale
Hookworm: Hymenolepsis Clonorchis malariae (non- (hypnozoite-
Cutaneous larva migrans Diphyllobothrium Opistorchis Blood schizonticide hypnozoite forming) forming)
- Most dangerous form Fasciolopsis
- Aimless wanderer Fasciola 1. Artemisinin
- Qinghaosu ~ antipyretic in China
- “qinghao” ~ sweet wormwood/ animal wormwood

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Module 6.4 Parasites
-MOA: rearrangement to form toxic heme prod.  Terminal prophylaxis for vivax & ovale
-Artemether (artemisinin deriv) +lumefantrine: Co-artem®  Chemoprophylaxis for falciparum & malariae
 Only drug vs. Quinine-resistant malaria 5. Sulfonamides (MOA: inh dihydropteroate synthase)
 Not for chemoprophylaxis due to short t1/2 6. Antibiotics
2. Atovaquone - Tetracycline: acute malarial attacks
-
- MOA: inh. e transport & collapses mitochondrial - Doxycycline: x active vs. liver stages
membrane potential B. Amoebiasis
- (+) Proguanil  Malarone®: prophylaxis & tx - Entamoeba hystolytica: ingests RBCs
3. Diaminopyridine - Amoebiasis
- Pyrimethamine o Asymptomatic
 MOA: inh dihydrofolate synthase  Intestinal amoebiasis
 (+) Sulfadoxine  Fansidar®:  Non-endemic areas
 Chloroquine-resistant  Lumimal amoebicide
 A/E: SJS (sulfa drugs) o Amoebic colitis
 Metronidazole (flagyl®)+ luminal amoebicides
- Proguanil (?)
 MOA: inh dihydrofolate reductase & o Extraintestinal
thymidylate synthetase 1. Metronidazole
 Safe for pregnant women - MOA: Nitro group reduction products  anti-amoebic
4. Quinolones - Penetrate body fluids except placenta
- Chloroquine & hydroxychloroquine - A/E:
 MOA: inh conversion of heme to hemozoin  metallic aftertaste
 DOC: tx, prophylaxis  disulfiram-like rxn
 A/E  (+) Mebendazole  toxic epidermal necrolysis
 Peripheral neuropathy 2. Chloroquine
 Retinopathy - Amoebic liver abscess
 Ototoxicity 3. Luminal amoebicide
 Myopathy - DOC: Diloxanide furoate
- Quinine & quinidine - Others: iodoquinol, paromomycin sulfate
 Alkaloid from Cinchona bark 4. Emetine & dihydrometine
 x for prophylaxis or DOC due to long t1/2 - Systemic amoebicide
 highly protein-bound
 Tox: VIII. Anti-helminthics
 Cinchonism A. Benzimidazole
 Tinnitus - Broadest spectrum
 Blackwater fever (hypersensitivity rxn) - Excellent toxicity profile except THIABENDAZOLE (only toxic)
 Hemolysis, 1. Thiabendazole
Methemogobinemia - Assoc. w/ irreversible liver failure
- Mefloquine - Alt. drug for Strongyloidiasis & cutaneous larva migrans
- Primaquine (hookworm)
 Radical cure for P. vivax & ovale 2. Mebendazole

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Module 6.4 Parasites
-Erractic absorption
 (+) fatty meal: act vs. tissue parasite REVIEW
 Empty stomach: act vs. intraluminl parasite - Autoinfection & retroinfection: Enterobius
(nematodes) - Protective factor for Malaria: sickle cell, G6PD, Thalassemia
3. Albendazole - Most common human helminth: ascaris
- DOC: neurocysticercosis - Disease of the poor: filariasis
- MOA: bind β-tubulin to inh. microtubule polymerization - Parasite-induced IDA: hookworm
B. Bithionol - Ecystment & myalgia: Trichinella
- DOC: fascioliasis - Capillaria: ilocos
- Alt drug for Paragonimiasis - Haematobium: urinary bladder
C. Diethyl carbamazine - Water crest: Fasciola
- DOC: filariasis - Kinilaw na kuhol: Fasciolopsis
- MOA: immobilize microfilariae & alter surface structure - Talangka/ crab: Paragonimus
- A/E: lymphangitis - Clonorchis: small liver fluke
D. Ivermectin - Donovan bodies: Calymmatobacterium granulomatis
- DOC: Onchocerciasis, strongyloidiasis - ↑steroids use, autoimmunity, CA: Strongyloides
- MOA: stim. GABA signals  paralyze nematode - Bactrim: Pneumocystic carinii pneumonia
 Whereas tetanospasmin inh GABA & glycine
- A/E: Mazzotti rxn
E. Metrifonate (organophosphate)
- MOA: inh AchE ↑Ach (indirect-acting cholinergic agonists)
- Alt for Schistosoma haematobium (in the urinary bladder;
prophylaxis in highly endemic areas)
F. Niclosamide
- MOA: inh oxidative phosphorylation & stim. ATPase
- 2nd line for cestodes
- A/E: disulfiram-like effect (sim. to 2nd, 3rd ceph & metronidazole)
G. Oxamniquine
- vs. Schistosoma mansoni
- MOA: contraction-paralysis of worm
- Alt to praziquantel
- A/E: orange urine (sim. to Rifampicin)
H. Piperazine
- MOA: Ach blocker
- Alt for ascariasis
I. Praziquantel
- MOA: ↑Ca2+ permeability  paralysis
- CI: ocular cysticercosis
J. Pyrantel pamoate
- vs. luminal parasite
- MOA: neuromuscular blocker

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