1. A 34-year-old woman living on Martha’s Vineyard,
a small island off the New England coast, develops the sudden onset of chills and fever. Microscopic examination of a peripheral blood smear reveal inclusions within the red blood cells, some of which form distinctive Maltese cross forms. What is the best diagnosis? a. Babesiosis b. Leishmaniasis c. Lyme disease d. Atypical malaria e. Toxoplasmosis 2. Soon after returning from a trip to Costa Rica, a 41-year-old woman develops recurrent chills and high fever that recur every 48 h. Examination of her peripheral blood reveals red granules (Schüffner’s dots) in enlarged, young erythrocytes. Which of the following organisms is most likely to have produced her signs and symptoms? a. Afipia felis b. Ancyclostoma duodenale c. B. microti d. P. ovale e. Toxoplasma gondii Plasmodia Four species, all cause different types of malaria Life cycle split between man and mosquito. When infected into skin by bite of a carrier female mosquito, sporozoites travel to liver, enter hepatocytes, grow and transform to merozoites which reenter the blood and RBC’s, and grow to become trophozoites. Some undergo sexual division into gametes which can then again be picked up by mosquitoes and transform into sporozoites Infected individuals show relapsing high fever with chills, rigor, headache, body ache, delirium; then sweating, break in fever, and lassitude Parasites can be found in the blood, and brown-black malarial pigment (hemozoin) can be found in histiocytes in the spleen and in Kupffer cells in the liver HbS carriers limit parasitemia by forcing parasite to leave the red cell as its heme starts sickling P. vivax, P. ovale Benign tertian malaria: fever spikes 48 hrs apart; rarely fatal Vivax can only infect RBCs with the Duffy blood group factor P. malariae Benign quartan malaria: fever spikes 72 hrs apart – long latency periods P. falciparum Malignant tertian malaria: fever spikes at 48 hr intervals, progressive damage to RBC’s, high parasitemias, can spread to CNS, accounts for most of the fatalities Leishmania Tiny <3μm intracellular parasite - on smears, two basophilic dots (nucleus and kinetoplast) Limited cutaneous infection or generalized visceral infection Babesia microti Babesiosis: acute, sometimes prolonged illness with headache, fever, chills, myalgia, fatigue Commonly seen on Eastern seaboard, especially Nantucket and Martha’s Vineyard Transmitted by tick T. rhodesiense, T gambiense Acute febrile attack with purpura and DIC, then chronic episodic fever with lymphadenopathy and splenomegaly, then progressive brain dysfunction, “sleeping sickness”, cachexia and death Transmitted by insect (Tsetse flies) - live in bloodstream Genetically programmed antigenic variation Strongyloides stercoralis Very small (1mm long) intestinal luminal dweller Burrow into mucosal crypts; can damage absorptive surface of gut leading to chronic enteritis Only intestinal nematode which can reproduce within host Larvae can invade and migrate to lung, liver, CNS Taenia Ingestion of undercooked meat - larvae excyst and mature into adults - attach to bowel wall by scolex - can grow to great lengths Can obstruct GI tract or lead to B12 deficiency Diagnose by finding proglotids or eggs in stool To cure, must remove scolex; a vermifuge can be used Cysticercosis Usually Taenia solium Acquired by consumption of eggs; invade through gut and disseminate to brain, muscles, skin, heart Can block spinal fluid reabsorption Ovoid, white to opalescent Often calcify or degenerate Minimal inflammation when alive, extensive when die Echinococcus granulosus Main host is dog Human ingestion of eggs leads to hatching in duodenum and invasive embryos which go usually to liver (66%) but also to lung (5- 15%) or bones, brain, etc. In target site, lodge within capillaries, incite an inflammatory reaction, and if survive encyst; this “hydatid cyst” grows in size over years and can reach 10cm or more Cysts unilocular (E. multilocularis causes multilocular cysts) Trichinella spiralis Trichinosis acquired by eating improperly cooked contaminated meat (pork, bear, wild game) – larvae released into stomach by digestion of cyst wall - attach to duodenal mucosa - mature to adult worms – produce numerous new larvae which invade bloodstream and spread to skeletal muscles where convert muscle cell to a nurse cell - encyst - in time, may die and calcify Most common muscles: diaphragm, eye muscles, laryngeal muscles, deltoid, gastrocnemius, intercostals Schistosoma 6 species, including S. mansoni, S. japonicum, S. haematobium Infective form burrows through skin of feet into blood-stream; pause in lung at 4-14 days until reach liver; mature in intrahepatic portal radicals; eventually descend to mesenteric or pelvic venules where mate and lay eggs Hypersensitivity granulomas in liver can lead to fibrosis Generally minimal host tissue reactions to adults until die Eggs produce significant inflammation; often calcify Predisposes to squamous cell carcinoma of the bladder Filaria Long string-like nematodes whose fertilized females release tiny microfilariae into the lymph, blood, and skin Can survive for many years, producing microfilariae Mosquito borne Wuchereria bancrofti 10 cm long; invade lymphatics producing lymphedema of scrotum, penis, vulva, leg, breast, or arm Onchocerca volvulus Largest of human filaria (50 cm) Transmitted by black flies Lives in skin - discharges microfilariae into subcutaneous tissue In addition to skin lesions, can get blindness from millions of microfilariae accumulating in eye chambers Entamoeba histolytica 15-40μm trophozoite with small nucleus, foamy cytoplasm Often ingests red cells; very motile on wet preps Infects cecum and ascending colon;sometimes whole colon Can cause mild to very bloody diarrhea Invade lamina propria from deep in crypts; do not go past muscularis mucosa; spread out, undermining site of invasion (flask shaped lesion); as spread, cut into blood supply of overlying mucosa, causing liquefactive necrosis with minimal inflammatory response In ~40% cases, enter blood vessels and travel to liver where can form a unilocular cyst, often large, often hemorrhagic (chocolate colored anchovy paste; NOT malodorous) Lung and brain abscesses can also be formed Naegleria fowleri Free-living ameboflagellate; large nucleus Enters arachnoid space through the cribriform plate while swimming in infected waters: causes meningoencephalitis Organism has large nucleus - easily mistaken for human cell Pneumocystis carinii 4-6μm cysts Ubiquitous opportunistic parasite - essentially all children have acquired antibodies to it by age 2 In protein malnourished children and immunosuppressed adults, can cause an interstitial pneumonia Foamy alveolar exudate with proliferating parasites Trichomonas vaginalis Most frequent venereal parasitic infection 15-18μm long turnip shaped flagellate Lives in postpubertal vaginas and male urethra (prepubertal vagina has wrong bacterial flora) Only small fraction of patients are symptomatic (itching, burning, especially during micturition) May be asymptomatic, even when present in large numbers