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Contents
Preface xv
Acknowledgments XIX
PART I
Clinically Important Human ParasitesI Philosophy and Approach to Diagnostic
Parasitology 3
2 Intestinal Protozoa: Amebae 6
Entamoeba histolytica 6Entamoeba dispar 19Entamoeba mosh kovskii 21Entamoeba hartmanni 21Entamoeba coli 22
Entamoeba polecki 23Entamoeba gingivalis 24Endolimax nana 25Iodamoeba bütschlii 27
Blastocystishominis 27
3 Intestinal Protozoa: Flagellates and Ciliates 33Giardialamblia 33
Dientamoeba fragilis 47Pentatrichomonas hominis (Trichomonashominis) 49Trichomonas tenax 50Chilomastix mesnili 50Enteromonas hominis 51Retortamonas intestinalis 51Balantidium coli 51
4 Intestinal Protozoa (Coccidia and Microsporidia)andAlgae 57Coccidia 57
Cryptosporidiumspp. 57
Cyclospora cayetanensis 73Isospora (Cystoisospora) belli 80Sarcocystis spp. 83
Microsporidia 87
Algae (Prototheca) 98
5 Free-LivingAmebae 102
Naegleria fowleri 104Acanthamoeba spp. 109Balamuthia mandrillaris 118
Sappinia diploidea 121
6 Protozoa from Other Body Sites
Trichomonas vaginalis 123Toxoplasma gondii 130
123
7 Malaria and Babesiosis 142
Malaria 142Babesiosis 180
8 leishmaniasis 190
Old World leishmaniasis: cutaneousleishmaniasis 191Old World leishmaniasis: visceralleishmaniasis 198New World leishmaniasis: cutaneousleishmaniasis 205New World leishmaniasis: visceralleishmaniasis 212
9 Trypanosomiasis 218
African trypanosomiasis 218Trypanosomabruceigambiense 218Trypanosomabrucei rhodesiense 228
American trypanosomiasis 232Trypanosomacruzi 232Trypanosomarangeli 243
vii
viii Contents
10 Intestinal Nematodes 249
Ascaris lumbricoides 250Enterobius vermicularis 258Trichuris trichiura 261
Capillaria philippinensis 264Hookworms (Ancylostoma duodenale and Necatoramericanus) 266Trichostrongylus spp. 270Strongyloides spp. 271
11 Tissue Nematodes 283
Trichinella spp. 283Baylisascaris procyonis 294Lagochilascaris minar 298Toxocara canis and T. cati (visceral larva migransand ocular larva migrans) 298Ancylostoma braziliense and A. caninum (cutaneouslarva migrans) 302Human eosinophilic enteritis 303Dracunculus medinensis 304
Angiostrongylus (Parastrongylus) cantonensis(cerebral angiostrongyliasis) 307Angiostrongylus (Parastrongylus) costaricensis(abdominal angiostrongyliasis) 309Gnathostoma spinigerum 310Gnathostoma doloresi, G. nipponicum,G. hispidum, and G. binucleatum 312Anisakis simplex, A. physeteris, Pseudoterranovadecipiens, Contracaecum osculatum,Hysterothylacium aduncum, and Porrocaecumreticulatum (larval nematodes acquired fromsaltwater fish) 312Capillaria hepatica 315Thelazia spp. 315
12 Filarial Nematodes 3 19
Wuchereria bancrofti 321Brugia malayi 332Brugia timori 333Zoonotic Brugia infections (American brugianfilariasis) 334Tropical pulmonary eosinophilia 335Loa loa 335Mansonella ozzardi 338
Mansonella perstans 339Mansonella streptocerca 340Onchocerca volvulus 341
Dirofilaria Dirofilaria and DirofilariaNochtiella spp. 348
13 Intestinal Cestodes 357
Diphyllobothrium latum 357Taenia solium 362
Taenia saginata 371Taenia saginata asiatica (Asian Taenia or Taeniaasiatica) 373Hymenolepis nana 374Hymenolepis diminuta 376Dipylidium caninum 377
14 Tissue Cestodes: larval Forms 381
Echinococcus granulosus (cystic disease, hydatiddisease) 381Echinococcus multilocularis (alveolar disease,hydatid disease) 393Echinococcus oligarthrus and Echinococcus vogeli(polycystic hydatid disease) 399Taenia (Multiceps) spp. (Taenia multiceps, Taeniaserialis) (coenurosis) 402Spirometra mansonoides and Diphyllobothrium spp.(sparganosis) 402NOTE: Taenia solium (cysticercosis) is discussed inchapter 13.
15 Intestinal Trematodes 411
Fasciolopsis buski 411Echinostoma ilocanum 416
Heterophyes heterophyes 417Metagonimus yokogawai 419Gastrodiscoides hominis 420
16 Liver and lung Trematodes 423
Liver flukes 423Clonorchis sinensis 423
Opisthorchis viverrini 429Opisthorchis felineus 431Fasciola hepatica 432Fasciola gigantica 435
Less common liver flukes 436
Dicrocoelium dendriticum, Dicrocoelium hospes, andEurytrema pancreaticum 436
Lung flukes 438Paragonimus spp. 438
17 Blood Trematodes: Schistosomes --445
Schistosoma mansoni 446Schistosoma japonicum 458Schistosoma mekongi 463Schistosoma haematobium 466Schistosoma intercalatum 472
,..
18 Unusual Parasitic Infections 478
Aquatic Protist 478Rhinosporidium seeberi 478
Protozoa 482
Myxozoan parasites 482Nematodes 483
Oesophagostomum spp. 483Eustrongylides spp. 485Mermis nigrescens 486Micronema deletrix 487
Dioctophyma renale 487Ternidens deminutus 488
Mammomonogamus laryngeus (Syngamuslaryngeus) 488Ascaris suum 489
Gongylonema pulchrum 489Haycocknema perplexum 490
Cestodes 490
Diplogonoporus spp. 490Bertiella studeri 491
Inermicapsifer madagascariensis 491Raillietina celebensis 491
Mesocestoides spp. 492Taenia crassiceps 492
Trematodes 493Alaria americana 493
Plagiorchis spp. 493Neodiplostomum seoulense 494Spelotrema brevicaeca 494Brachylaima sr. 494Troglotrema salmincola 494Stellantchasmus falca tus 494Phaneropsolus bonnei and Prosthodendriummolenkempi 495Phaneropsolus spinicirrus 495Haplorchis taichui 496Gymnophalloides seoi 496Metorchis conjunctus (North American liverfluke) 497Schistosoma mattheei 498
Philophthalmus lacrimosus 498Achillurbainia spp. 499
Pentastomids 499
Armillifer spp., Linguatula serrata, and Sebekiaspp. 499
Acanthocephalans 500Macracanthorhynchus hirudinaceus and Moniliformismoniliformis 500
19 Parasitic Infections in the CompromisedHost 506
Entamoeba histolytica 508Free-living amebae 518
Giardia lamblia 522
Toxoplasma gondii 523Cryptosporidium spp. 524Cyclospora cayetanensis 528Isospora (Cystoisospora) belli 530Sarcocystis spp. 531Microsporidia 532Leishmania spp. 537Strongyloides stercoralis 540Crusted (Norwegian) scabies 540
Contents ix
20 Nosocomial and Laboratory-AcquiredInfections 549
Nosocomial infections 549
Nosocomial gastrointestinal infections 550Cryptosporidium spp. 550Giardia lamblia 553
Entamoeba histolytica 554
Microsporidia 555Isospora (Cystoisospora) belli 555Hymenolepis nana 555Taenia solium 555
Nosocomial blood and tissue infections 556
Plasmodium spp. 556Babesia spp. 556Trypanosoma brucei gambiense and T. bruceirhodesiense 556
Trypanosoma cruzi 556Leishmania donovani 557
Toxoplasma gondii 557
Nosocomial infections with ectoparasites 557Pediculus spp. and Phthirus pubis 557Sarcoptes scabiei 557Myiasis 557
Nosocomial infections in the pediatric patient 558Cryptosporidium spp. 558Giardia lamblia 558
Pediculus humanus capitis 558Sarcoptes scabiei 558
Nosocomial infections in the compromisedpatient 558Laboratory infections 560
Intestinal protozoa 560Free-living amebae 560Plasmodium spp. 560Trypanosoma brucei gambiense and T. bruceirhodesiense 560
Trypanosoma cruzi 562Leishmania spp. 562Toxoplasma gondii 562Specimen handling 563
Summary 563
x Contents
21 Immunology of Parasitic Infections 567Amebiasis 570Giardiasis 575
Toxoplasmosis 577African trypanosomiasis 579American trypanosomiasis 580Malaria 582
Summary 586
22 Antibody and Antigen Detection in ParasiticInfections 592
Protozoal infections 594Amebiasis 594Babesiosis 597
Chagas' distase 597Cryptosporidiosis 598Cyclosporiasis 598Giardiasis 598Leishmaniasis 598Malaria 600
Toxoplasmosis 601Trichomoniasis 603
Helminth infections 604
Cysticercosis 604Hydatid distase 605Fascioliasis 605Filariasis 606
Paragonimiasis 607Schistosomiasis 608
Strongyloidiasis 609Toxocariasis 610Trichinellosis 610
Intradermal tests 611Casoni test 611
Montenegro test 611
23 Histologic Identification of Parasites 616
24 Medically Important Arthropods 670
Arthropods and their relationship to disease 670Biological vectors of microorganisms 670Bites and envenomation 671Tissue invasion 676
Entomophobia and delusory parasitosis 676
Class Insecta (insects) 678arder Diptera (flies, mosquitoes, and midges) 679Myiasis 683arder Hemiptera (true bugs) 690arder Coleoptera (beetles) 692arder Siphonaptera (fleas) (Ctenocephalides spp.,Xenopsylla cheopis, Pulex irritans [human flea],Tunga penetrans, Nosopsyllus fasciatus, Echidnophagagallinacea, and "salid fleas") 693
arder Anoplura (sucking lice) 694arder Mallophaga (biting and chewing lice) 696arder Hymenoptera (bees, wasps, and ants) 696arder Blattaria (cockroaches) 698
Class Arachnida (ticks, mires, spiders, andscorpions) 699
Subclass Acari (ticks, mires, and chiggers) 699Subclass Araneae (spiders) 708Subclass Scorpiones (scorpions) 710
Other arthropods 711Class Chilopoda (centipedes) 711Class Diplopoda (millipedes) 712Class Crustacea (copepods, crabs, crayfish, ete.) 712
Control of arthropods of medical importance 712Physical control 712Biological control 712Chemical control 715
25 Treatment of Parasitic Infections 718
PART 11
Diagnostic Procedures 759
26 Collection, Preservation, and Shipment of FecalSpecimens 761
Safety 761
Fresh-specimen collection 762Collection of the specimen 762Number of specimens to be collected (standardrecommendation) 762Number of specimens to be collected (pros and cons ofvarious options) 763Collection times 764
Specimen type, specimen stability, and need forpreservarían 764
Preservarían of specimens 768Preservatives 768
Formalin 768MIF 769SAF 771Schaudinn's fluid 772PVA 772Modified PVA 773
Single-vial collection systems (other than SAF) 773Use of fixatives 774
Quality control for stool fixatives 774Procedure notes for use of preservatives 775Procedure limitations for use Ff preservatives 775
Shipment of diagnostic specimens, biological products,etiologic agents, or infectious substances 775
27 Macroscopic and Microscopic Examination ofFecal Specimens 782Macroscopic examinarían 782
Microscopic examination (ova and parasiteexamination) 783
Direct wet smear 783
Concentration (sedimentation and flotation) 788
Formalin-ethyl acetate sedimentationconcentration 789Iodine-trichrome stain for sediment 792Zinc sulfate flotation concentration 794Commercial fecal concentration devices 796
Automated workstation for the microscopic analysisof fecal concentra tes 797
Permanent stained smear 797
Preparation of material for staining 798Trichrome stain 802
Iron hematoxylin stain 807Modified iron hematoxylin stain (incorporating thecarbol fuchsin step) 811Polychrome IV stain 812Chlorazol black E stain 813
Specialized stains for coccidia (Cryptosporidium,Isospora, and Cyclospora species) and themicrosporidia 813
Modified Kinyoun's acid-fast stain (cold method) 813Modified Ziehl-Neelsen acid-fast stain (hotmethod) 816Carbol fuchsin negative stain for Cryptosporidium (fromW. lo Current) 819
Rapid safranin method for Cryptosporidium 819Rapid safranin method for Cyclospora, using amicrowave oyen 819
Auramine O stain for coccidia (from ThomasHanscheid) 819Modified trichrome stain for the microsporidia(Weber-green) 821Modified trichrome stain for the microsporidia (Ryan-bluf) 823Modified trichrome stain for the microsporidia(Kokoskin-hot method) 825Acid-fast trichrome stain for Cryptosporidium and themicrosporidia 826
28 AdditionalTechniques for Stool Examination 83 I
Culture of larval-stage nematodes 831Harada-Morifi!terpapel strip culture 832Filterpaper/slantculture technique (petri dish) 833Charcoalculture 834Baermanntechnique 835Agarplaceculturefor Strongyloidesstercoralis 837
Eggstudies 840Estimationof worm burdens 840Hatchingof schistosomeeggs 842
Searchfor tapeworm scolex 844Qualitative test for fecal fat 845Quantitation of reducing substances (Clinitest) 847
Contents xi
29 Examination of Other Specimens from theIntestinal Tract and the Urogenital System 850
Examination for pinworm 850Cellulose tape preparations 851Anal swabs 851
Sigmoidoscopy material 852Direct saline mount 853Permanent stained slide 853
Duodenal contents 854
Duodenal drainage 854Duodenal capsule technique (Entero-Test) 854
Urogenital specimens 855Trichomoniasis 855Filariasis 856Schistosomiasis 856
30 Sputum, Aspirates, and Biopsy Material 859
Expectorated sputum 859
Induced sputum 861
Aspirates 868Lungs and liver 868Lymph nades, spleen, liver, baile marrow, spinal fluid,eres, and nasopharynx 869Cutaneous ulcer 871
Biopsy material 871Skin 876
Lymph nades 876Muscle 876Rectum and bladder 877
31 Procedures for Detecting Blood Parasites 881
Preparation of thick and thin blood films 881Thick blood films 882Thin blood films 884
Combination thick and thin blood films (on the sameslide) 884Combination thick and thin blood films (can be stainedas either) 884Buffy coat blood films 886
Staining blood films 887Giemsa sta in 888
Wright's stain 889General notes on staining procedures 891
Proper examination of thin and thick bloodfilms 891
Thin blood films 891Thick blood films 893
Determination of parasitemia 893
Diagnosis of malaria: review of alternatives toconventional microscopy 894
QBC microhematocrit centrifugation method 895ParaSight F test 896NOW malaria test 900
,
xii Contents
11
Flow anti-pLDH Plasmodium monoclonalantibodies 901PCR 902
Automated blood cell analyzers 903
Diagnosis of leishmaniasis: review of alterna ti ves toconventional microscopy 903
ICT for detection of anti-rK-39 antibodies 903
Concentration procedures 903Cytocentrifugation technique 903Knott concentration procedure 904Membrane filtration technique 904Gradient centrifugation technique 905Triple-centrifugation method for trypanosomes 905
Special stain for microfilarial sheath 905Delafield's hematoxylin 905
32 Parasite Recovery: Culture Methods,AnimalInoculation, and Xenodiagnosis 910
Culture methods 910
Intestinal protozoa 911Pathogenic free-living amebae 917Pathogenic fIagellates 922Flagellates of blood and tissue 926Toxoplasma gondii 931Plasmodium and Babesia spp. 931Cryptosporidium spp. 932Microsporidia 932
Animal inoculation 932
Leishmania spp. 932Trypanosoma spp. 933Toxoplasma gondii 933
Xenodiagnosis 933
33 Fixation and Special Preparation of FecalParasite Specimens and Arthropods 936
Fixation of parasite specimens and arthropods 936Protozoa 937Solutions to induce relaxation in adult helminths 938Nematodes 939Trematodes 940Cestodes 940
Helminth eggs and larvae 940Arthropods 940
Mounting and staining of parasite specimens forexamination 941
Nematodes 941Trematodes 942Cesto des 943
Mounting of arthropods for examination 944Mites 944Fleas and lice 944Ticks 945
Miscellaneous arthropods 945
34 ArtifactsThat Can Be Confused with ParasiticOrganisms 947Protozoa 947
Amebae 947
Flagellates 949Ciliates 949
Coccidia and microsporidia 949Cryptosporidium spp. and Cyclosporacayetanensis 949Isospora belli 950Microsporidia 951
Blood and body fluids 951Malaria parasites and Babesia spp. 951Leishmaniae and trypanosomes 951Microfilariae 951
Body fIuids: ciliated epithelial cells 953Helminths 953
Adult worms and larvae 953
Eggs 954Human cells 954
Polymorphonuclear leukocytes 956Eosinophils 956Macrophages 956Lymphocytes 957Red blood cells 957
Charcot-Leyden crystals 957
Nonhuman elements seen in feces (yeast cells) 957Insect larvae 958
Spurious infections 958
Delusory parasitosis 959
35 Equipment, Supplies, Safety, and Quality SystemRecommendations for a Diagnostic ParasitologyLaboratory: Factors Influencing FutureLaboratory Practice 96 I
Equipment 961Microscope 961Centrifuge 965Fume hood 965
Biological safety cabinet 965Refrigerator-freezer 966
Supplies 966Glassware 966
Miscellaneous supplies 967ATCC qua lity control organisms 967
Safety: personnel and physical facilities 967General precautions 967Handwashing 968Personal protective equipment (OSHA 2001 bloodborne) 969Handling specimens 970Processing specimens 970Spills 972
T
Disposal of contaminated materials 973Standard precautions 974Hepatitis exposure protocol 976Dangerous properties of industrial materials 976Currellt OSHA regulations for the use offormaldehyde 977Latex allergy 978
Quality systems 979Extent of services 979
Proficiencytesting 979In-house quality control 982Patient outcome measures 986
Continuous quality improvement, total qualitymanagement, or lO-step and FOCUS-PDCA forperformance improvement activities 987CLlA '88 inspection process 989
New qua lity quidelines 989ISO guidelines 989CLSI (NCCLS) model 990
Faetors influeneing future laboratory praetiee 990Managed care 992Financial considerations 993
Decentralized testing 993Laboratory services 993Technological trends 994Clinical decision support 994Personnel issues 995
Changing demographics 995Emerging diseases 995
36 MedicalParasitology: Case Histories 998Protozoal infeetions 998Helminth infeetions 1007
Bloodparasite infeetions 1016Diagnostic methods 1024
APPENDIXES 1027
APPENDIX 1InformationTables 1028
A1.1 Classification of bullan parasites 1028A1.2 Distribution of selected parasitie infeetions in the
Amerieas 1031
AI.3 Distribution of selected parasitie infections inEurope 1031
A1.4 Distribution of selected parasitic infections inAfrica 1032
AI.5 Distribution of selected para sitie infeetions inAsia 1033
A1.6 Distribution of seleeted parasitie infeetions inOeeania 1033
AI.7 Cosmopolitan distribution of eommon parasitieinfeetions (North Ameriea, Mexieo, Central
Contents xiii
Ameriea, South America, Europe, Afriea, Asia,and Oeeania) 1034
A 1.8 Body sites and specimen collection 1035A 1.9 Body sites and possible parasites recovered
(trophozoites, eysts, ooeysts, spores, adults,larvae, eggs, amastigotes, andtrypomastigotes) 1036
A 1.1OBody site, specimen and procedures,reeommended methods, relevant parasites, andeomments 1037
A 1.11 Examination of tissue and body fluids 1042Al .12 Key eharacteristics of protozoa of the intestinal
traet and urogenital system 1044A 1.13 Key characteristics of tissue protozoa 1047Al. 14 Key characteristics of helminths 1049A 1.15 Key characteristies of parasites found in
blood 1052
A 1.16 Diagnostic laboratory report information thatshould be relayed to the physician 1054
A 1.17 Pros and eons of stool speeimen eollection andtesting options 1055
A 1.18 Approaches to stool parasitology: testordering 1057
A 1.19 Pros and eons of ova and parasite examinationoptions 1058
A 1.20 Laboratory test reports: optionalcomments 1060
A 1.21 Estimated prevalenee of parasitic distasesworldwide 1061
APPENDIX 2Flowcharts and Staining Tables for DiagnosticProcedures 1062
Flowcharts
A2.1 Proeedure for processing fresh stool for the ovaand parasite examination 1062
A2.2 Procedure for processing liquid speeimens for theova and parasite examination 1063
A2.3 Procedure for processing preserved stool forthe ova and parasite examination by using thetraditional two-vial colleetion kit 1064
A2.4 Procedure for processing sodium acetate-aceticacid-formalin (SAF)-preserved stool for the ovaand parasite examination 1065
A2.5 Use of various fixatives and their recommendedstains 1066
Tables
A2.1 Steps in the trichrome staining procedure(mereurie ehloride-based PVA-preserved stoolspecimens) 1067
A2.2 Steps in the trichrome staining proeedure(non-mercurie ehloride-based PVA-preserved stoolspecimens) 1068
xiv Contents
A2.J Steps in the iron hematoxylin staining procedure(mercuric chloride-based PVA-preserved stoolspecimens) (Spencer-Monroe method) 1069
A2.4 Steps in the iron hematoxylin staining procedure(mercuric chloride-based PVA-preserved stoolspecimens) (Tompkins-Miller method) 1070
A2.S Steps in the iron hematoxylin staining procedure(incorporating the carbol fuchsin step) 1071
A2.6 Oil-mounted permanent stained smears (noPermount is used) 1072
A2.7 Tips on stool processing and staining 1073
APPENDIX3Common Problems in Parasite Identification
FiguresAJ.I-AJ.2S Paired drawings of "look alikes"AJ.26 Relative sizes of helminth eggs 1080TableAJ.I
1074
1074
Adult nematodes and/or larva e found inÚool
specimens: size comparisons 1081
APPENDIX4Quality Control Recording Sheets 1082A4.1 Diagnostic parasitology quality control (QC)
(reagents) 1083A4.2 Diagnostic parasitology quality control (QC)
(reagents)-example for multiple reagents 1084A4.J Diagnostic parasitology quality control (QC)
(culture)-example of a worksheet 1085A4.4 Equipment maintenance 1086
APPENDIX5Commercial Supplies and Suppliers 1089Tables
AS.I Sources of commercial reagents andsupplies 1090
AS.2 Addresses of suppliers listed in Table A5.1 1092AS.J Sources of available reagents for immunodetection
of parasitic organisms or antigens 1094AS.4 Addresses of suppliers listed in Table A5.3 1095AS.S Commercial suppliers of diagnostic parasitology
products 1096AS.6 Sources of parasitologic specimens 1099AS.7 Sources of Kodachrome study slides (35 mili,
2 x 2) for rental 1100AS.8 Sources of additional teaching materials, including
case histories 1100
~
~.
I
APPENDIX 6Reference Sources 1101
APPENDIX 7Color Plates of Diagnostic Stages of HumanParasites I I04
APPENDIX 8
"late-Breaking" Published Information 1120
GLOSSARY 1151
INDEX 1165
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