LEC.4 Blood and tissue flagellates Dr. Maysoon A.

Merdaw
Trypanosoma spp.

Trypanosomes are extracellular protozoa, the name is derived from the Greek
trypano- (borer) and soma (body) because of their corkscrew-like motion.
Trypanosomiasis is a vector-born disease and is lethal without treatment.
Taxonomy
1- The American and African trypanosomes: Trypanosoma brucei has 3
subspecies – Trypanosoma brucei brucei, T. b. gambiense and T. b.
rhodesiense. The first one is an animal pathogen and the other two cause
African trypanosomiasis or sleeping sickness in man. T. cruzi causes South
American trypanosomiasis or Chagas’ disease.
2- Salivarian trypanosomes (Trypanosoma brucei and T. rhodesiense) are
passed to the recipient in the saliva of the tsetse fly (Glossina spp.) and
Stercorians trypanosomes (T. cruzi) are passed to the recipient in the feces of
insects from the subfamily Triatominae bug.

African Trypanosomiasis (sleeping sickness)

Life Cycle
T. brucei completes its life cycle between tsetse fly (of the genus Glossina) and
mammalian hosts, including humans, cattle, horses, and wild animals.
In mammalian host:
Infection occurs when a vector tsetse fly bites a mammalian host. The fly injects
the metacyclic trypomastigotes into the skin tissue. The trypomastigotes enter
the lymphatic system and into the bloodstream. The initial trypomastigotes are
short and stumpy. Once inside the bloodstream, they grow into long and slender
forms. Then, they multiply by binary fission. The daughter cells then become
short and stumpy again. The long slender forms are able to penetrate the blood
vessel endothelium and invade extravascular tissues, including the central
nervous system (CNS).

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Sometimes, wild animals can be infected by the tsetse fly and they act as
reservoirs. In these animals, they do not produce the disease, but the live
parasite can be transmitted back to the normal hosts.
In tsetse fly:
The short and stumpy trypomastigotes are taken up by tsetse fly during blood
meal. The trypomastigotes enter the midgut of the fly where they become
procyclic trypomastigotes. These rapidly divide to become epimastigotes. The
epimastigotes migrate from the gut to the salivary glands and transform into
short, stumpy trypomastigotes. These become the infective metacyclic
trypomastigotes. They are injected into the mammalian host along with the
saliva on biting. Complete development in the fly takes about 20 days.

Only two subspecies, Trypanosoma brucei rhodesiense and Trypanosoma

brucei gambiense, have the additional feature of resistance to normal human
serum. Although both subspecies are pathogenic to human, they differ
significantly in virulence and geographical occurrence, T. b. gambiense causes
chronic infections in West and Central Africa which can persist up to 10 years
while T. b. rhodesiense is more prevalent in Eastern Africa and mostly results in
acute human infections that can be lethal within a few months.
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The development of protective vaccines has been unsuccessful until now,
mainly due to the ability of African trypanosomes to escape adaptive immune
responses by antigenic variation of the most abundant surface glycoprotein VSG
(variant-specific surface glycoprotein).
Pathogenesis:
In human infections, mortality results from neurological complications after
penetration of the parasite into the central nervous system. Human African
trypanosomiasis is characterized by two disease stages. During the first
(haemolymphatic) stage of the infection, parasites will proliferate in the blood
and the lymphatic circulation. Symptoms at this stage are nonspecific and
include fever, lymphadenopathies, spleenomegaly and endrocrine disorders.
Systemic inflammation finally if untreated, leads to increased blood-brain
barrier (BBB) permeability allowing parasites to penetrate the central nervous
system and cerebrospinal fluid, leading to the second (encephalitic) stage. The
symptoms of this stage include sensory, motoric and psychic disturbances,
neuroendocrine abnormalities and disturbed circadian rhythms, eventually
resulting in coma and death. The disturbed day-night cycles in the late stage of
infection are characteristic for “sleeping sickness”.
Diagnosis
The main points in diagnosis are the identification of the infecting trypanosome
subspecies as well as the determination of the disease stage. To date, diagnosis
of first stage mainly relies on microscopic detection of trypanosomes in blood
smears and lymph node aspirates. Second stage diagnosis is based on parasite
detection or lymphocyte counting in the CSF taken by lumbar puncture.
Molecular and serological tools can be used for diagnosis.
Treatment
Treatment relies on suramine, pentamidine and melarsoprol. Severe side effects
have often been reported, including anaphylactic shock, severe cutaneous
reactions, neurotoxic signs and renal failure. However they does not cross the

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BBB, their application is limited to the treatment of the haemolymphatic stage.
The generated nanobody (immunotherapeutic approach) was shown to be a
promising tool for targeting effector molecules to the trypanosome membrane as
it is able to penetrate into the VSG coat and bind to conserved trypanosome
surface epitopes that are inaccessible to lager conventional antibodies.
American Trypanosomiasis (Chagas Disease)
Life Cycle
The Trypanosoma cruzi lives as trypomastigote in the blood and as an
amastigote in reticuloendothelial cells and other tissue cells of man and many
mammals.
Life cycle starts in an animal reservoir, usually mammals, wild or domestic,
including humans. A triatomine bug serves as the vector. While taking a blood
meal, it ingests T. cruzi. In the triatomine bug the parasite goes into the
epimastigote stage, making it possible to reproduce. After reproducing through
binary fission, the epimastigotes move onto the rectal cell wall (hindgut), where
they become infectious. Infectious T. cruzi are called metacyclic
trypomastigotes. When the triatomine bug subsequently takes a blood meal
from a human, it defecates. The trypomastigotes enter the human host through
the wound or by crossing mucous membranes or conjunctiva.
Once in the vertebrate host, the metacyclic trypomastigotes, which is unable to
replicate, must invade host cell within which it can differentiate into the
replicating amastigote, which divides in the cytoplasm. After a number of
rounds of replication by binary fission and after passing through promastigote
and epimastigote forms, are again transformed into trypomastigote forms which
are liberated in the blood, which lyse the infected cell and escape to infect
adjacent cells or disseminate throughout the body via the bloodstream and
lymphatics. Trypomastigotes invade host cells and differentiate into
amastigotes. Alternatively, they may be taken up by a triatomine insect during a

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blood meal and differentiate into epimastigotes in the insect midgut, thereby
completing the life cycle.

Life Cycle of T. cruzi

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Within the vertebrate host, parasites can infect any nucleated cell, but have a
predilection for muscle, particularly of the heart and gastrointestinal tract. This
tissue tropism ultimately leads to the two predominant clinical forms of chronic
T. cruzi infection: cardiomyopathy and megacolon/megaesophagus.

Pathogenesis of Chagas Disease

Acute T. cruzi infection results from the contamination of wounds or mucous
membranes with insect feces containing expelled infective parasites. Acute
infection is marked by the development of localized swelling and erythema at
the site of the insect bite, which is termed a chagoma. This is a result of the
local replication of parasites and the influx of fluid and inflammatory cells into
the infected area. Infection through the conjunctiva can result in periorbital
swelling, termed Romana’s sign. Lymphatic drainage of the infected area into
regional lymph nodes results in activation and proliferation of cells, resulting in
regional lymphadenopathy. As the process continues, the amastigotes transform
into trypomastigotes, escape host cells and disseminate throughout the body.
In chronic infection, tissue parasites are difficult to detect but significant
interstitial fibrosis occurs, Cardiac involvement is signaled by the development
of fibrosis within the heart muscle damaging the affected tissue. In the
gastrointestinal tract, chronic infection leads to parasympathetic denervation,
resulting in massive dilatation of the esophagus and/or colon.
Diagnosis
History of potential exposure to T. cruzi is important to document.
1-Microscopic examination for a blood film.
2-Culture the blood on NNN (Novy-MCNeal-Nicolle) media.
3-PCR.
4-Immunoassay.
5-Xenodiagnosis:

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Is a technique that uses the arthropod host as an indicator of infection.
Uninfected reduviid bugs are allowed to feed on the blood of a patient who is
suspected of having Chagas’ disease (T. cruzi infection).
After 20–25 days, feces from the bugs are examined over a 3-month time frame
for the presence of developmental stages of the parasite, which are found in the
hindgut of the vector. This type of procedure is used primarily in South America
for field work, and the appropriate bugs are raised in various laboratories
specifically for this purpose.
The term “xenodiagnosis” has also been applied to the diagnosis of trichinosis
(Trichinella spiralis). Muscle tissue from a patient suspected of having the
disease is fed to uninfected rats; the rats are then checked after the appropriate
time for the presence of T. spiralis larvae, particularly in the diaphragm.

Treatment
Nifurtimox and benznidazole. Both these agents suppress parasitemia and can
cure acute phase of Chagas’ disease in 60–80% of cases.