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Chapter 36 : Medical Parasitology: Case Histories

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Abstract:

The case histories in this chapter are taken from actual practice and provide an excellent method of review for the reader. The cases illustrate many kinds of potential diagnostic problems encountered within the parasitology section of the laboratory and emphasize clinical relevance and recommended approaches for specimen ordering, collection, processing, testing, and reporting. Although not every parasite known to be a human pathogen is included, a wide spectrum of organisms and diseases is presented to illustrate particular points. On examination of the permanent stained smears of a 30-year-old patient who had complained of diarrhea for about a week, protozoan trophozoites were found which measured approximately 17 μm long. The permanent stained smears have been stained using Wheatley’s trichrome stain modification. A key point for laboratory diagnosis is that ocular examinations may reveal retinal lesions, larval tracks, or migrating larvae; these findings may provide the tentative diagnosis involving a helminth infection. There are usually few symptoms associated with the presence of the adult worm in the intestine. Although rare symptoms (obstruction, diarrhea, hunger pains, weight loss, and appendicitis) have been reported, the most common complaint is the discomfort and embarrassment caused by the proglottids crawling from the anus. Physical signs of central nervous system (CNS) involvement are quite variable, and there is no real correlation between the severity of the symptoms and the peripheral-blood parasitemia. A sensitive microcapillary culture method (MCM) was developed for the rapid diagnosis of cutaneous leishmaniasis.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36

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Figures

Image of Figure 36.1
Figure 36.1

Case 1. Microscopic images (oil immersion 100× objective); permanent stained smear.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.2
Figure 36.2

Case 1. trophozoites containing ingested RBCs.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.3
Figure 36.3

Case 2. Protozoan. (Left) Trophozoite with “spiky” acanthapodia; (right) cyst with hexagonal double wall.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.4
Figure 36.4

Case 3. Protozoan. (Left) Trophozoites growing on a nonnutrient agar plate seeded with bacteria; (right) stained trophozoite (note the more globular pseudo-pods compared with the organism in case 2).

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.5
Figure 36.5

Case 4. (Left) Stool fecal concentration sediment examined as a wet mount (appears to be negative); (right) protozoan trophozoite containing two nuclei, which are fragmented into several nuclear granules.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.6
Figure 36.6

Case 5. (Left) Protozoan trophozoite seen in a wet mount; (right) protozoan cyst seen in a wet mount (note how round, distorted, and three-dimensional the cyst appears.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.7
Figure 36.7

Case 5. (Left) trophozoite seen in a permanent stained smear; (right) cyst seen in a permanent stained smear (note how much more detail is seen compared to the wet mounts in Figure 36.6 ).

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.8
Figure 36.8

Case 6. Helminth eggs (wet mounts of concentration sediment). Note the polar filaments that lie between the oncosphere and the egg shell.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.9
Figure 36.9

Case 6. eggs or artifacts (permanent stained smear). The image on the left is probably just an artifact that resembles a helminth egg. The image on the right may or may not be an actual egg. On permanent stained smears, helminth egg morphology often appears distorted with very dark staining.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.10
Figure 36.10

Case 7. Image from autopsy (colon). (Armed Forces Institute of Pathology photograph.)

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.11
Figure 36.11

Case 7. (Top) Larvae in sputum; (second from top) slit in the tail of filariform (infective) larva obtained using the Baermann concentration apparatus; (third from top) short buccal capsule and genital primordium packet of cells in a rhabditiform (noninfective) larva; (bottom) clear image of the genital primordium packet of cells in a rhabditiform larva.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.12
Figure 36.12

Case 8. (Upper) Structure obtained from stool specimen; (lower) objects seen in the concentration sediment wet mount (using high dry 40× objective).

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.13
Figure 36.13

Case 8. gravid proglottid; note the large number of lateral uterine branches when counted on one side.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.14
Figure 36.14

Case 9. Objects seen in the wet mount microscopic examination of concentration sediment. These objects measured about 140 by 70 µm and were easily seen in the saline wet preparation examination.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.15
Figure 36.15

Case 10. Image from autopsy (brain tissue).

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.16
Figure 36.16

Case 10. (Left) Typical eggs isolated from raccoons; (right) adult worms isolated from raccoons.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.17
Figure 36.17

Case 11. Blood films stained with Giemsa stain. (Upper left) Thick blood film; (upper right) thin blood film; (lower left) thick blood film; (lower right) thin blood film.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.18
Figure 36.18

Case 12. (Upper) Lesion on patient’s arm; (lower) skin biopsy specimen from margin of lesion.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.19
Figure 36.19

Case 12. Cutaneous leishmaniasis. (Left) Skin macrophage containing Leishman-Donovan bodies (note the nucleus and bar-shaped kinetoplast); (right) sand fly vector of leishmaniasis.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.20
Figure 36.20

Case 12. (Left) Wet mount of organisms from culture; (right) Giemsa-stained smear of culture sediment.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.21
Figure 36.21

Case 13. Objects seen in Giemsa-stained thin blood films. (Left) Patient smear.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.22
Figure 36.22

Case 14. Blood films stained with Giemsa stain. (Left) Thick blood film; (right) thin blood film.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.23
Figure 36.23

Case 14. Thin blood films stained with Giemsa stain. “band” forms are evident where the developing trophozoites spread across the RBC. Note that the infected RBCs are normal to smaller than normal size compared with the uninfected RBCs.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.24
Figure 36.24

Case 15. Objects seen in a wet mount (left) and a permanent stained smear (right). The structure on the right measures approximately 16 µm, and the structures on the left measure approximately 65 µm.

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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Image of Figure 36.25
Figure 36.25

Case 15. (Left) Objects in a concentrated fecal sediment stained with modified acid-fast stain. (Right) Objects in a concentrated fecal sediment stained with modified tri-chrome stain (note the diagonal or horizontal lines in some of the objects).

Citation: Garcia L. 2007. Medical Parasitology: Case Histories, p 998-1026. In Diagnostic Medical Parasitology, Fifth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555816018.ch36
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References

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1. Allahverdiyev, A. M.,, S. Uzun,, M. Bagirova,, M. Durdu, and, H. R. Memisoglu. 2004. A sensitive new microculture method for diagnosis of cutaneous leishmaniasis. Am. J. Trop. Med. Hyg. 70:294297.
2. Blum, J.,, P. Desjeux,, E. Schwartz,, B. Beck, and, C. Hatz. 2004. Treatment of cutaneous leishmaniasis among travellers. J. Antimicrob. Chemother. 53:15866.
3. Clinical Laboratory Standards Institute. 2005. Procedures for the Recovery and Identification of Parasites from the Intestinal Tract. Approved guideline M28-A2. Clinical Laboratory Standards Institute, Villanova, Pa.
4. Garcia, L. S. 1999. Practical Guide to Diagnostic Medical Parasitology. ASM Press, Washington, D.C.
5. Garcia, L. S.,, R. Y. Shimizu, and, D. A. Bruckner. 1986. Blood parasites: problems in diagnosis using automated differential instrumentation. Diagn. Microbiol. Infect. Dis. 4:173176.
6. Gavin, P. J.,, K. R. Kazacos, and, S. T. Shulman. 2005. Baylisascariasis. Clin. Microbiol. Rev. 18:703718.
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8. Isenberg, H. D. (ed.). 1995. Essential Procedures for Clinical Microbiology. ASM Press, Washington, D.C.
9. National Committee for Clinical Laboratory Standards. 2000. Laboratory Diagnosis of Blood-Borne Parasitic Diseases. Approved guideline M15-A. National Committee for Clinical Laboratory Standards, Wayne, Pa.
10. Ryan, N. J.,, G. Sutherland,, K. Coughlan,, M. Globan,, J. Doultree,, J. Marshall,, R. W. Baird,, J. Pedersen, and, B. Dwyer. 1993. A new trichrome-blue stain for detection of microsporidial species in urine, stool, and nasopharyngeal specimens. J. Clin. Microbiol. 31:32643269.
11. Visvesvara, G. S.,, H. Moura,, E. Kovacs-Nace,, S. Wallace, and, M. L. Eberhard. 1997. Uniform staining of Cyclospora oocysts in fecal smears by a modified safranin technique with microwave heating. J. Clin. Microbiol. 35:730733.
12. Warren, K. S.,, and A. A. F. Mahmoud. 1990. Tropical and Geographical Medicine, 2nd ed. McGraw-Hill Inc., New York, N.Y.
13. Weber, R.,, R. T. Bryan,, R. L. Owen,, C. M. Wilcox,, L. Gorelkin,, G. S. Visvesvara, and The Enteric Opportunistic Infections Working Group. 1992. Improved light-microscopical detection of microsporidia spores in stool and duodenal aspirates. N. Engl. J. Med. 326:161166.
14. Wilcox, A. 1960. Manual for the Microscopical Diagnosis of Malaria in Man. U.S. Department of Health, Education, and Welfare, Washington, D.C.

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