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Chapter 9.10 : Appendixes

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Appendixes, Page 1 of 2

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Abstract:

Laboratorians must differentiate extraneous materials present in a specimen from actual parasites.

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Figures

Image of Figure 9.10.3–A1
Figure 9.10.3–A1

(a) trophozoite. Note the evenly arranged nuclear chromatin, central compact karyosome, and relatively “clean” cytoplasm. (b) trophozoite. Note the unevenly arranged nuclear chromatin, eccentric karyosome, and “messy” cytoplasm. These characteristics are very representative of the two organisms. (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.3–A2
Figure 9.10.3–A2

(a) trophozoite. Note the evenly arranged nuclear chromatin, central compact karyosome and “clean” cytoplasm. (b) trophozoite. Note that the nuclear chromatin appears to be evenly arranged, the karyosome is central (but more diffuse), and the cytoplasm is “messy”, with numerous vacuoles and ingested debris. The nuclei of these two organisms tend to resemble one another (very common finding in routine clinical specimens). (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.3–A3
Figure 9.10.3–A3

(a) trophozoite. Again, note the typical morphology (evenly arranged nuclear chromatin, central compact karyosome, and relatively “clean” cytoplasm). (b) trophozoite. Although the nuclear chromatin is eccentric, note that the karyosome seems to be compact and central. However, note the various vacuoles containing ingested debris. These organisms show some characteristics that are very similar (very typical in clinical specimens). (Illustration by Sharon Belkin).

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.3–A4
Figure 9.10.3–A4

(a) trophozoite. Note the evenly arranged nuclear chromatin, central compact karyosome, and RBCs in the cytoplasm. (b) Human macrophage. The key difference between the macrophage nucleus and that of is the size. Usually, the ratio of nucleus to cytoplasm in a macrophage is approximately 1:6 or 1:8, while the true organism has a nucleus/cytoplasm ratio of approximately 1:10 or 1:12. The macrophage also contains ingested RBCs. In cases of diarrhea or dysentery, trophozoites of and macrophages can often be confused, occasionally leading to a false-positive diagnosis of amebiasis when no parasites are present. Both the actual trophozoite and the macrophage may also be seen without ingested RBCs, and they can mimic one another. (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.3–A5
Figure 9.10.3–A5

(a) precyst. Note the enlarged nucleus (prior to division) with evenly arranged nuclear chromatin and central compact karyosome. Chromatoidal bars (rounded ends, with smooth edges) are also present in the cytoplasm. (b) PMN. The nucleus is somewhat lobed (normal morphology) and represents a PMN that has not been in the gut very long. Occasionally, the positioning of the chromatoidal bars and that of the lobed nucleus of the PMN can mimic one another. The chromatoidal bars will stain more intensely, but shapes can overlap, as seen here. (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.3–A6
Figure 9.10.3–A6

(a) cyst. Note that the four nuclei are very consistent in size and shape. (b) PMN. Note that the normal lobed nucleus has now broken into four fragments, which mimic four nuclei with peripheral chromatin and central karyosomes. When PMNs have been in the gut for some time and have begun to disintegrate, the nuclear morphology can mimic that seen in an cyst. However, human cells are often seen in the stool in cases of diarrhea; with rapid passage of the gastrointestinal tract contents, there will not be time for amebic cysts to form. Therefore, in cases of diarrhea and/or dysentery, if “organisms” are seen that resemble the cell in panel b, think first of PMNs, not cysts. (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.3–A7
Figure 9.10.3–A7

(a) trophozoite. This organism is characterized by a large karyosome with no peripheral chromatin, although there are normally many nuclear variations seen in any positive specimen. (b) trophozoite. Normally, the nuclear chromatin is fragmented into several dots (often a “tetrad” arrangement). The cytoplasm is normally more “junky” than that seen in . If the morphology is typical, as in these two illustrations, then differentiating between these two organisms is not that difficult. However, the morphologies of the two will often be very similar. (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.3–A8
Figure 9.10.3–A8

(a) trophozoite. Notice that the karyosome is large and surrounded by a “halo”, with very little, if any, chromatin on the nuclear membrane. (b) trophozoite. In this organism, the karyosome is beginning to fragment, and there is a slight clearing in the center of the nuclear chromatin. If the nuclear chromatin has not become fragmented, trophozoites can very easily mimic trophozoites. This could lead to a report indicating that no pathogens were present, when, in fact, is considered a definite cause of symptoms. (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.3–A9
Figure 9.10.3–A9

(a) trophozoite. Note the large karyosome surrounded by a clear space. The cytoplasm is relatively “clean.” (b) . Although the karyosome is similar to that of , note that the cytoplasm in is much more heavily vacuolated and contains ingested debris. Often, these two trophozoites cannot be differentiated. However, the differences in the cytoplasm are often helpful. There will be a definite size overlap between the two genera. (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.3–A10
Figure 9.10.3–A10

(a) RBCs on a stained fecal smear. Note that the cells are very pleomorphic but tend to be positioned in the direction the stool was spread onto the slide. (b) Yeast cells on a stained fecal smear. These cells tend to remain oval and are not aligned in any particular way on the smear. These differences are important when the differential identification is between containing RBCs and containing ingested yeast cells. If RBCs or yeast cells are identified in the cytoplasm of an organism, they must also be visible in the background of the stained fecal smear. (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.3–A11
Figure 9.10.3–A11

(a) cyst. Note the shrinkage due to dehydrating agents in the staining process. (b) cyst. In this case, the cyst exhibits no shrinkage. Only three of the four nuclei are in focus. Normally, this type of shrinkage is seen with protozoan cysts and is particularly important when a species is measured and identified as either or . The whole area, including the halo, must be measured prior to species identification. If just the cyst is measured, the organism would be identified as (nonpathogenic) rather than (possibly pathogenic). (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.3–A12
Figure 9.10.3–A12

(a) rings. Note the two rings in the RBC. Multiple rings per cell are more typical of than of the other species of human malaria. (b) rings. In one of the RBCs are four small rings. This particular arrangement is called the Maltese cross and is diagnostic for spp. However, the Maltese cross configuration is not always present. infections can be confused with cases of malaria, primarily because multiple rings can be seen in the RBCs. Another difference involves ring morphology. rings are often of various sizes and tend to be very pleomorphic, while those of tend to be more consistent in size and shape. (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.3–A13
Figure 9.10.3–A13

(a) rhabditiform larva. Note the short buccal capsule (mouth opening) and the internal structure, including the genital primordial packet of cells. (b) Root hair (plant material). Note that there is no specific internal structure and the end is ragged (where it was broken off from the main plant). Often plant material mimics some of the human parasites. This comparison is one of the best examples. These artifacts are occasionally submitted as proficiency testing specimens. (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.3–A14
Figure 9.10.3–A14

(a) egg. This egg has been described as having a thick, radially striated shell containing a six-hooked embryo (oncosphere). (b) Pollen grain. Note that this trilobed pollen grain has a similar type of “shell” and, if turned the right way, could resemble a egg. This represents another confusion between a helminth egg and a plant material artifact. When examining fecal specimens in a wet preparation, tap on the coverslip to get objects to move around. As they move, you can see more morphological detail. (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.3–A15
Figure 9.10.3–A15

(a) egg. This egg is typical and is characterized by the barrel shape with a thick shell and two polar plugs. (b) Bee pollen. This artifact certainly mimics the actual egg. However, note that the actual shape is somewhat distorted. This is an excellent example of a parasite “look-alike” and could be confusing. (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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DIAGNOSTIC PARASITOLOGY QC (REAGENTS)—EXAMPLE

DIAGNOSTIC PARASITOLOGY QC (REAGENTS)—EXAMPLE

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of DIAGNOSTIC PARASITOLOGY QC (REAGENTS) EXAMPLE FOR MULTIPLE REAGENTS
DIAGNOSTIC PARASITOLOGY QC (REAGENTS) EXAMPLE FOR MULTIPLE REAGENTS

DIAGNOSTIC PARASITOLOGY QC (REAGENTS) EXAMPLE FOR MULTIPLE REAGENTS

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of DIAGNOSTIC PARASITOLOGY QC (REAGENTS) EXAMPLE FOR MULTIPLE REAGENTS
DIAGNOSTIC PARASITOLOGY QC (REAGENTS) EXAMPLE FOR MULTIPLE REAGENTS

DIAGNOSTIC PARASITOLOGY QC (REAGENTS) EXAMPLE FOR MULTIPLE REAGENTS

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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EQUIPMENT MAINTENANCE

EQUIPMENT MAINTENANCE

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.5–A1
Figure 9.10.5–A1

Procedure for processing fresh stool for the ova and parasite examination. Special stains will be necessary for and (modified acid-fast) and the microsporidia (modified trichrome, calcofluor). Immunoassay kits are now available for some of these organisms. If the permanent staining method (iron hematoxylin) contains a carbol fuchsin step, the coccidia will stain pink. Symbols: †, some protozoa may not be identified using the wet examination only; ‡, protozoa (primarily trophozoites) can be identified and cysts can be confirmed.

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.5–A2
Figure 9.10.5–A2

Procedure for processing liquid specimens for the ova and parasite examination. Polyvinyl alcohol (PVA) and specimen will be mixed together on the slide, allowed to air dry, and then stained (fixation is sufficient for liquid specimen but not for formed stool). Symbols: †, some protozoa may not be identified from the concentration procedure; ‡, protozoa (trophozoites can be identified).

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.5–A3
Figure 9.10.5–A3

Procedure for processing preserved stool for the ova and parasite examination. Fixatives and effects: mercuric chloride, best polyvinyl alcohol (PVA) (trichrome, iron hematoxylin); zinc, current best substitute (trichrome, hematoxylin probably okay); copper sulfate, fair substitute (trichrome, iron hematoxylin: both fair to poor); sodium acetate-acetic acid-formalin, good substitute for PVA fixative (iron hematoxylin is best, and trichrome is okay).

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.5–A4
Figure 9.10.5–A4

Procedure for processing sodium acetate-acetic acid-formalin (SAF)-preserved stool for the ova and parasite examination. SAF can also be used with EIA, fluorescent-antibody, and cartridge immunoassay kits and the modified trichrome stain for microsporidia.

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.5–A5
Figure 9.10.5–A5

Procedure for processing stool specimens preserved in the Universal Fixative (TOTAL-FIX). Approaches are provided for immunoassays, stool sedimentation concentration, permanent stained smears (modified acid-fast, trichrome, modified trichrome, etc.), and molecular testing. This fixation contains no mercury, no formalin, and no PVA.

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.10–A1
Figure 9.10.10–A1

The traditional method for preparing a thin blood film; the blood can be either “pushed” or “pulled” by the spreader slide Note that “D” illustrates a thin film with a good feather edge. (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.10–A2
Figure 9.10.10–A2

Poorly prepared thin and thick blood films (dirty slides, oil on slides, too-thick preparations, poor spreading of the blood); organism morphology will be very poor on the stained films.

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.10–A3
Figure 9.10.10–A3

Method of thick-thin combination blood film preparation. (a) Position of drop of EDTA-containing blood. (b) Position of the applicator stick in contact with blood and glass slide. (c) Rotation of the applicator stick. (d) Completed thick-thin combination blood film prior to staining. (Illustration by Sharon Belkin.)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Image of Figure 9.10.10–A4
Figure 9.10.10–A4

General diagram of a rapid malaria test; top, the negative test shows the control line only; middle, control line plus the line indicates the presence of a panspecific antigen (common to all spp., but most sensitive for rather than and ); bottom, control line, panspecific antigen line, and line specific for antigen presence. Note that most cartridge rapid malaria tests have not been developed to detect (under development). CI, confidence interval.

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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References

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1. Ash LR, Orihel TC. 1984. Atlas of Human Parasitology, 2nd ed. ASCP Press, Chicago, IL.
2. Ashfag-Drewett R, Allen C, Harrison RL. 1990. Detached ciliary tufts: comparison with intestinal protozoa and a review of the literature. Am J Clin Pathol 93:541545.
3. Garcia LS. 2016. Diagnostic Medical Parasitology, 6th ed. ASM Press, Washington, DC.
4. Garcia LS. 2009. Practical Guide to Diagnostic Parasitology, 2nd ed. ASM Press, Washington, DC.
5. Garcia LS, Shimizu RY. 1997. Evaluation of nine immunoassay kits (enzyme immunoassay and direct fluorescence) for detection of Giardia lamblia and Cryptosporidium parvum in human fecal specimens. J Clin Microbiol 35:15261529.
6. Garcia LS, Shimizu RY. 2000. Detection of Giardia lamblia and Cryptosporidium parvum antigens in human fecal specimens using the ColorPAC combination rapid solid-phase qualitative immunochromatographic assay. J Clin Microbiol 38:12671268.
7. Hanson KL, Cartwright CP. 2001. Use of an enzyme immunoassay does not eliminate the need to analyze multiple stool specimens for sensitive detection of Giardia lamblia. J Clin Microbiol 39:474477.
8. Isenberg HD (ed). 2004. Clinical Microbiology Procedures Handbook, 2nd ed, vol 2, p 9.0.19.10.8.3. ASM Press, Washington, DC.
9. Wilson M, Schantz PM. 2000. Parasitic immunodiagnosis, p 11171122. In Strickland GT (ed), Hunter’s Tropical Medicine and Emerging Infectious Diseases, 8th ed. WB Saunders Co, Philadelphia, PA.
1. Radonjic IV, Dzamic AM, Mitrovic SM, Arsic Arsenijevic VS, Popadic DM, Kranjcic Zec IF. 2006. Diagnosis of Trichomonas vaginalis infection: the sensitivities and specificities of microscopy, culture and PCR assay. Eur J Obstet Gynecol Reprod Biol 126:116120.
2. Hegazya MM, El-Tantawya NL, Solimana MM, El-Sadeekb ES, El-Nagar HS. 2012. Performance of rapid immunochromatographic assay in the diagnosis of Trichomoniasis vaginalis. Diagn Microbiol Infect Dis 74:4953.
3. Weinstock H, Berman S, Cates WJr. 2004. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health 36:610.
4. Soper D. 2004. Trichomoniasis: under control or undercontrolled? Am J Obstet Gynecol 190:281290.
5. Cotch MF, Pastorek JGII, Nugent RP, Hillier SL, Gibbs RS, Martin DH, Eschenbach DA, Edelman R, Carey JC, Regan JA, Krohn MA, Klebanoff MA, Rao AV, Rhoads GG. 1997. Trichomonas vaginalis associated with low birth weight and preterm delivery. The Vaginal Infections and Prematurity Study Group. Sex Transm Dis 24:353360.
6. Nye MB, Schwebke JR, Body BA. 2009. Comparison of APTIMA Trichomonas vaginalis transcription-mediated amplification to wet mount microscopy, culture, and polymerase chain reaction for diagnosis of trichomoniasis in men and women. Am J Obstet Gynecol 200:188.e1188.e7.
7. Gen-Probe Inc. August 2012. APTIMA Trichomonas vaginalis assay package insert. Gen-Probe Inc, San Diego, CA.
8. Becton, Dickinson and Co. 2011. Affirm™ VPIII microbial identification test package insert. Becton, Dickinson and Co, Franklin Lakes, NJ.
9. Brown HL, Fuller DD, Jasper LT, Davis TE, Wright JD. 2004. Clinical evaluation of Affirm VPIII in the detection and identification of Trichomonas vaginalis, Gardnerella vaginalis, and Candida species in vaginitis/vaginosis. Infect Dis Obstet Gynecol 12:1721.
10. Luminex. 2012. Luminex xTAG gastrointestinal pathogen panel package insert. Luminex, Austin, TX.
20. The following regulations appeared in the Federal Register on Friday, 4 December 1987 (vol. 52, no. 233: Occupational Exposure to Formaldehyde).
1. Code of Federal Regulations (29CFR1910. 1200 and 29CFR1910.1926)
2. Code of Federal Regulations (29CFR1910. 1048) Update 27 May 1992.
3. Garcia LS. 2016. Diagnostic Medical Parasitology, 6th ed. ASM Press, Washington, DC.
4. Code of Federal Regulations (29CFR1910. 1450)
1. American Medical Association. 2009. Current Procedural Terminology (CPT) 2009. AMA Press, Chicago, IL.
1. Garcia LS (ed). 2010. Clinical Microbiology Procedures Handbook, 3rd ed, vol 2, p 9.0.19.10.8.3. ASM Press, Washington, DC.
2. Garcia LS. 2016. Diagnostic Medical Parasitology, 6th ed. ASM Press, Washington, DC.
3. Garcia LS. 2009. Practical Guide to Diagnostic Parasitology, 2nd ed. ASM Press, Washington, DC.
4. Garcia LS. (coordinating ed). 2003. Cumitech 30A, Selection and Use of Laboratory Procedures for Diagnosis of Parasitic Infections of the Gastrointestinal Tract. ASM Press, Washington, DC.
5. National Committee for Clinical Laboratory Standards. 1997. Procedures for the recovery and identification of parasites from the intestinal tract, 2nd ed. Approved guideline M28-A. National Committee for Clinical Laboratory Standards, Wayne, PA.
6. Hiatt RA, Markell EK, Ng E. 1995. How many stool examinations are necessary to detect pathogenic intestinal protozoa? Am J Trop Med Hyg 53:3639.
7. Paustenbach D, Alarie Y, Kulle T, Schachter N, Smith R, Swenberg J, Witschi H, Horowitz SB. 1997. A recommended occupational exposure limit for formaldehyde based on irritation. J Toxicol Environ Health 50:217263.
8. Code of Federal Regulations. 1987. Update 27 May 1992. Title 29, CFR 1910.1200 and 29 CFR 1910.1296. US Government Printing Office, Washington, DC.
9. Code of Federal Regulations. 1989. Title 29, CFR 1910.106. US Government Printing Office, Washington, DC.
10. Code of Federal Regulations. 2015. Title 29, CFR 1910.1048. US Government Printing Office, Washington, DC.
11. Federal Register. 1992. Occupational exposure to formaldehyde—OSHA. Response to court remand; final rule. Fed Regist 57:2229022328.
12. Hanson KL, Cartwright CP. 2001. Use of an enzyme immunoassay does not eliminate the need to analyze multiple stool specimens for sensitive detection of Giardia lamblia. J Clin Microbiol 39:474477.
13. Isenberg HD (ed). 2004. Clinical Microbiology Procedures Handbook, 2nd ed, p 9.0.19.10.8.3. ASM Press, Washington, DC.
14. National Committee for Clinical Laboratory Standards. 2000. Use of blood film examination for parasites. Approved guideline M15-A. National Committee for Clinical Laboratory Standards, Wayne, PA.
15. Garcia LS (coordinating ed). 2008. Cumitech 46, Laboratory Procedures for the Diagnosis of Blood Parasites. ASM Press, Washington, DC.
16. World Health Organization. 2012. Malaria Rapid Diagnostic Test Performance (Summary Results of WHO Product Testing of Malaria RDTs: Round 4 (2012). World Health Organization, Geneva, Switzerland. http://apps.who.int/iris/bitstream/10665/77748/1/9789241504720_eng.pdf?ua=1.
17. Imwong M, Nakeesathit S, Day NP, White NJ. 2011. A review of mixed malaria species infections in anopheline mosquitoes. Malar J 10:253.

Tables

Generic image for table
Table 9.10.1–A1

Clinical specimens: summary of artifacts resembling parasites

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
Generic image for table
Table 9.10.2–A1

Body sites and specimen collection

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
Generic image for table
Table 9.10.2–A2

Body sites and possible parasites recovered (trophozoites, cysts, oocysts, spores, adults, larvae, eggs, amastigotes, and trypomastigotes)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Table 9.10.2–A3

Body site, specimen, and recommended stain(s)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Table 9.10.2–A4

Examination of tissues and body fluids

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Table 9.10.2–A5

Protozoa of the intestinal tract and urogenital system: key characteristics

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Table 9.10.2–A6

Tissue protozoa: characteristics

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Table 9.10.2–A7

Helminths: key characteristics

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Table 9.10.2–A8

Parasites found in blood: characteristics

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Table 9.10.2–A9

Parasitic infections: clinical findings in healthy and compromised hosts

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Table 9.10.2–A10

Fecal antigen detection method options

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Table 9.10.6–A1

Sources of commercial reagents and supplies

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Table 9.10.6–A2

Addresses of suppliers listed in Table 9.10.6-A1

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Table 9.10.6–A3

Sources of available reagents for immunodetection of parasitic organisms or antigens

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Table 9.10.6–A4

Addresses of suppliers listed in Table 9.10.6–A3

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Table 9.10.6–A5

Commercial suppliers of diagnostic parasitology products

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Table 9.10.6–A6

Sources of parasitologic specimens (catalogs of available materials and price lists available from the -companies listed)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Table 9.10.6–A7

Sources of additional teaching materials, including case histories

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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CPT codes for diagnostic parasitology

CPT codes for diagnostic parasitology

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Submission of stool specimens

Submission of stool specimens

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Examination of fecal specimens

Examination of fecal specimens

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Examination of blood specimensa

Examination of blood specimens

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Stool testing order recommendations (for physicians)

Stool testing order recommendations (for physicians)

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Untitled

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Untitled

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Untitled

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10
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Untitled

Citation: Leber A. 2016. Appendixes, p 9.10.1.1-9.10.10.32. In Clinical Microbiology Procedures Handbook, Fourth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818814.ch9.10

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