Case Study For Unit 1

CDC
Case #440 - March, 2017
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Stool specimens were collected from an asymptomatic 10-year-old boy from Panama as
part of a refugee screening program. The stool was collected in 10% formalin and zinc PVA
(Zn-PVA) and sent to the county health department for routine ova-and-parasite (O&P)
examination. Figures A - I show what was observed at 1000x magnification with oil on a
trichrome-stained slide made from stool preserved in Zn-PVA. Objects in Figures A and G
measured approximately 10 micrometers; all other objects of interest ranged from 17-25
micrometers. Figures C - E show different focal planes of the same object of interest to
highlight internal structures. What is your diagnosis? Based on what criteria?
Figure A
Figure B
Figure C (Focal Plane 1)

Figure C (Focal Plane 2)
Figure D (Focal Plane 1)

Figure D (Focal Plane 2)
Figure E (Focal Plane 1)

Figure E (Focal Plane 2)
Figure F
Figure G
Figure H
Figure I
Figure J
Case Answer collapsed
This case demonstrated Blastocystis hominis and Entamoeba polecki, the latter is a
commensal amoebae and the pathogenicity of B. hominis continues to be open for debate
but gaining acceptance as a cause of symptoms in some patients. Morphologic features
shown included:
Blastocystis hominis:
 a cyst-like form within the size range (5-40 micrometers) for the species.
 a large green-stained central body, surrounded by a thin ring of cytoplasm
containing several red-stained inclusion bodies.
Entamoeba polecki:
 uninucleate trophozoites within the size range (10-25 micrometers) for the species
with a large, irregular nucleus with a pleomorphic karyosome, which may be central
or eccentric within the nucleus.
 vacuolated cytoplasm presented in some trophozoites (Fig F) as well as blunt
pseudopodia (Fig. B)
 uninucleate, rarely binucleate, cysts within the size range (9-25 micrometers) for
the species containing numerous irregular, red-staining chromatoid bodies.
 Some cysts may contain an ovoid or spherical inclusion body of unknown nature,
but not a glycogen mass as it will not stain with iodine (visible in figure D)
Case #419 - May 2016
A 23-year-old female presented to her primary care provider with abdominal pain, cramps,
flatulence, and diarrhea five days after returning from a white water rafting trip in the
Grand Canyon, Arizona. Stool specimens were collected in 10% formalin and zinc polyvinyl
alcohol (Zn-PVA) and sent to a reference lab for routine ova-and-parasite (O&P) testing.
Figures A-D show what was observed on a trichrome-stain slide of stool preserved in the
Zn-PVA. Images were captured at 1000x magnification with oil. What is your diagnosis?
Based on what criteria?
Figure A
Figure B
Figure C
Figure D
This case demonstrated a mixed infection of Giardia duodenalis and Blastocystis hominis.
Diagnostic morphologic features included:
 ellipsoidal cysts of within the size-range (8-19 μm) for G. duodenalis (Figures A, C,
D) that contained multiple nuclei, fibrils, and axonemes.
 pyriform trophozoite within the size range (10-20 μm) for G. duodenalis (Figure B)
that contained fibrils,median bodies, two nuclei, and sucking disks.
 cyst-like forms of B. hominis (Figures A-D) containing a large central body
surrounded by a narrow rim of cytoplasm containing nuclei and inclusion bodies.
More on: Giardiasis, Blastocystis hominis infection

Case #404 - September 2015
A 31-year-old male presented with recurrent anal warts first noticed the summer of 2014.
The warts were biopsied and diagnosed as low grade anal intraepithelial neoplasia (AIN1)
in March 2015. Other symptoms included mild discomfort with defecation. In September
2015, an anal Pap smear was performed and stained with Papanicolau. Figures A-E show
what was observed by the attending pathologist. The objects of interest ranged in size from
7-15 micrometers. What is your diagnosis? Based on what criteria?
Figure A
Figure B
Figure C
Figure D
Figure E
The images in this case showed trophozoites and cysts of the nonpathogenic intestinal
amoeba, Entamoeba coli. Diagnostic morphologic features included:
 trophozoites (Figures A-D) within the size range for E. coli with vacuolated
cytoplasm and a single nucleus that contains irregular peripheral chromatin and an
eccentric karyosome.
 mature cysts (Figure E) with more than four nuclei.
It is important to report nonpathogenic protozoa in all stool O&P examinations as their

presence may be indicative of fecal contamination of a food or water source.
More on: Intestinal Amoebae

Case #405 - October 2015
A 31-year-old male presented with recurrent anal warts first noticed the summer of 2014.
The warts were biopsied and diagnosed as low grade anal intraepithelial neoplasia (AIN1)
in March 2015. Other symptoms included mild discomfort with defecation. In September
2015, an anal Pap smear was performed and stained with Papanicolau. Figures A-E show
what was observed by the attending pathologist. The objects of interest ranged in size from
7-15 micrometers. What is your diagnosis? Based on what criteria?
Figure A
Figure B
Figure C
Figure D
Figure E
The images in this case demonstrated the nonpathogenic intestinal amoeba, Iodamoeba
buetschlii. Diagnostic morphologic features included the presence of cysts within the size
range (5-20 micrometers) for the species. Several of the cysts demonstrated the
characteristic glycogen vacuole (Figures A-D), in addition to a single nucleus with a large
karyosome.
Case #406 - October2015
Stool specimens were collected from a 27-year-old girl from Chad as part of a refugee
screening program. The stool was collected in 10% formalin and zinc PVA (Zn-PVA) and
sent to the county health department for routine ova-and-parasite (O&P) examination.
Figures A-D show what was observed at 1000x magnification with oil on a trichrome-
stained slide made from stool preserved in Zn-PVA. The objects shown measured 10-12 µm
in length, on average. What is your diagnosis? Based on what criteria?
Figure A
Figure B
Figure C
Figure D
The objects seen in the images are leukocytes (white blood cells). Large numbers of white
blood cells (WBCs) are often found in patients with bacterial infections and therefore other
tests should be considered. Some types of leukocytes can resemble trophozoites of
Entamoeba species, but lack the characteric nuclei containing a single, defined karyosome
and peripheral chromatin.
Case #369 - April 2014
A 24-year-old male with a history of granulomatous immunodeficiency had biopsy

specimens taken of skin lesions on his right forearm (Figure A). Specimens were submitted
to Pathology for routine histological work-up. Slides were examined by the attending
pathologist and images were captured and sent to the DPDx Team for diagnostic
assistance. Figures B-E show what was observed by the attending pathologist from the
superficial and mid-dermis. Figure B is from a biopsy specimen stained with Gomori
methenamine silver (GMS). Figures C and D are from hematoxylin-and-eosin (H&E) stained
sections. Figure E is from a section stained with periodic acid-Schiff (PAS). What is your
diagnosis? Based on what criteria?
Figure A
Figure B
Figure C
Figure D
Figure E
This was a case of free-living amebic infection caused by Acanthamoeba sp. Morphologic
features shown included:
 the presence cysts that will stain positive for PAS (Figure E) and GMS (Figure B). As
such, cysts of Acanthamoeba (and Balamuthia) but be distinguished from fungal
elements.
 the presence of cysts (Figures B-E) with a wrinkled outer cyst wall (exocyst) and a
spherical inner cyst wall (endocyst).
 the presence of trophozoites (Figure D) with large, centrally-located karyosomes
and no peripheral chromatin.
Case #371 - May 2014
Stool specimens were collected from a 14-year-old refugee from Myanmar as part of a
routine screening program. The stool was collected in 10% formalin and zinc PVA (Zn-PVA)
and sent to the state health laboratory for ova-and-parasite (O&P) examination. Images of
suspect parasites were captured and sent via email to the DPDx Team for diagnostic
assistance. Figures A and B show two objects of interest that were observed by the
attending microbiologist on a trichrome-stained slide prepared from Zn-PVA preserved
stool. The measurements shown were included in the original telediagnosis submission.
What is your diagnosis? Based on what criteria?
Figure A
Figure B
This case showed trophozoites of the nonpathogenic intestinal amoeba, Entamoeba

hartmanni. Diagnostic morphologic features included:
 trophozoites within the size range (5.0-15.0 μm, with an average range of 8.0-10.0
μm) of E. hartmanni.
 nuclei with a discrete central karyosome and evenly-distributed peripheral
chromatin.
While not considered pathogenic, E. hartmanni and other nonpathogenic amoebae should
be reported in all O&P examinations, as their presence may be indicative of fecal
contamination of a food or water source and does not preclude the presence of other
intestinal pathogens.
Case #341 - February, 2013
A 58-year-old man sought medical attention for numerous nodules on the right upper arm
and forearm. He had recently relapsed with lymphocytic leukemia. Two weeks prior to the
presentation of the nodules he was diagnosed with pneumonia and was also being treated
for Clostridium difficile colitis. Skin biopsies of the nodules were collected and sent to
Pathology for routine sectioning and staining. Numerous cells resembling histiocytes were
observed and were noted on Periodic acid-Schif stain (PAS) as positive and on Gomori-
Grocott methenamine silver stain (GMS) as negative. However, the GMS-stained sections
revealed possible cysts. Images were captured by the attending pathologist and sent to
DPDx for diagnostic assistance. Figure A shows one of the cysts observed on a GMS-stained
section. Figures B and C show organisms observed on hematoxylin-and-eosin (H&E)
stained sections. Figure D shows an organism on a PAS-stained section. All images
presented were captured at 1000x magnification. Embedded measurements were provided
by the submitter. What is your diagnosis? Based on what criteria?
Figure A
Figure B
Figure C
Figure D
This was a case of free-living amebic infection caused by Acanthamoeba sp. Morphologic
features shown included:
 the presence of cysts (Figure A) with a wrinkled outer cyst wall (exocyst) and a
spherical inner cyst wall (endocyst).
 the presence of trophozoites (Figures B, C, and D) with large, centrally-located
karyosomes and no peripheral chromatin.
Follow-up specimens (tissue blocks) were received for additional testing and confirmed
positive for Acanthamoeba by real-time PCR.
Case #320 - March, 2012
Stool specimens were collected from Haitian refugees as part of a screening program for
intestinal parasites. Stool was collected in polyvinyl alcohol (PVA) and 10% formalin and
sent to the county public health lab for routine ova-and-parasite (O&P) examination.
Figures A-D show what was observed in moderate numbers from one of the patients on a
trichrome-stained slide from the PVA-preserved stool. All images were captured at 1000x
magnification. What is your diagnosis? Based on what criteria?
Figure A
Figure B
Figure C
Figure D
This case showed a mix of two intestinal protozoa, Endolimax nana and Blastocystis
hominis. Both species were shown in all four images. Diagnostic features included:
 ovoid cysts of E. nana presenting with 2-4 nuclei, each with a discrete karyosome
(Figures A-C; there was also a cyst out-of-focus in the upper edge of Figure D).
 trophozoite of E. nana presenting with a single nucleus containing a large, central
karyosome and no peripheral chromatin (Figure D).
 cyst-like bodies of B. hominis presenting with a large, central body surrounded by a
narrow rim of cytoplasm containing nuclei and inclusion bodies (Figures A-D).
Case #331 - September, 2012
A 35-year-old woman, who had emigrated from Azerbaijan five years previous, presented
to her health care provider with abdominal pain. A CT scan revealed multiple pancreatic
cysts. The patient noted that she was diagnosed with pancreatic cysts while still living in
Azerbaijan. The cysts were aspirated and the fluid was sent to Pathology for histological
work-up. Figures A-D show what was observed on a slide made from the aspirate, stained
with trichrome. The objects of interest measured 12-15 micrometers on average. What is
your diagnosis? Based on what criteria??
Figure A
Figure B
Figure C
Figure D
This was a case of amebiasis caused by Entamoeba histolytica. Figures A, B, and D showed
trophozoites containing a single nucleus with fine, evenly-distributed peripheral chromatin
and a discrete central karyosome. The nucleus was not visible in the focal plane shown in
Figure C. Although there were no morphologic criteria separating the trophozoites from
the similar E. dispar, the location in the pancreas indicates an invasive infection and
justifies the species-level identification.
Case #334 - October, 2012
During the laboratory component of the DPDx Diagnostic Parasitology Workshop on

Intestinal Parasites, a participant made an observation on a trichrome-stained fecal smear
and wanted to share with the class. The images in Figures A and B were captured at 1000x
oil magnification. The two images show the same object in different focal planes. What is
your diagnosis? Based on what criteria?
Figure A
Figure B
The figures showed a trophozoite of Entamoeba coli with an ingested cyst of Giardia
duodenalis. Diagnostic features included:
 an amoeba trophozoite with coarse cytoplasm and within the size range for E. coli.
 a single nucleus with an eccentric karyosome.
 a large vacuole that contained a cyst within the size range for G. duodenalis
demonstrating intracytoplasmic fibrils, two nuclei.
Case #291 - January, 2011
A state health laboratory sent a formalin-ethyl acetate (FEA) stool concentrate to the DPDx
Team for Entamoeba confirmation/identification. Because formalin was used in the
preservation and processing of the specimen, PCR could not be employed to rule-out E.
histolytica. A wet mount was made and examined microscopically. Figure A shows an
object observed in moderate numbers on the wet mount at 1000x magnification. The object
measured 12 micrometers in diameter. Figures B-D show the same object but in different
focal planes. What is your diagnosis? Based on what criteria?
Figure A
Figure B
Figure C
Figure D
This case showed a mature cyst of Entamoeba coli. Showing the same cyst in four different
focal planes clearly demonstrated the presence of more than four nuclei, which is
diagnostic for this species. The cyst was also within the size range for E. coli.
Case #296 - March, 2011
A 30-year-old man presented to his primary care provider with abdominal pain, fatigue,
and diarrhea (sometimes tinged with blood). The patient had recently returned after two
weeks in Armenia. A stool specimen was collected in both 10% formalin and poly-vinyl
alcohol (PVA) for routine ova-and-parasite (O&P) examination. A smear was prepared from
the PVA-preserved specimen and stained with trichrome. Figures A-D show what was
observed in moderate numbers on the smear at 1000x magnification. The objects of
interest measured on average 25 micrometers in length. What is your diagnosis? Based on
what criteria?
Figure A
Figure B
Figure C
Figure D
This was a case of amebiasis caused by Entamoeba histolytica. Morphologic features shown
included:
 trophozoites showing ingested red blood cells.

 nuclei showing evenly distributed peripheral chromatin and a centrally-located
karyosome.
 some trophozoites showing progressive pseudopods.
If ingested red blood cells are observed, a species-level identification of E. histolytica may
be given. Specimens presenting with these morphologic features, but without ingested
RBCs, should be reported as E. histolytica/dispar and further testing such as PCR should be
performed.
A 42-year-old photographer, who is known to travel to remote locations in tropical regions,

presented to her health care provider with mild, intermittent abdominal cramping and low
grade fever. A fecal specimen in polyvinyl-alcohol (PVA) was submitted for ova-and-
parasite (O&P) examination. A smear was prepared and stained with trichrome. Figures A-
F show what was observed at 1000x magnification. Objects of interest measured 6-8
micrometers on average. What is your diagnosis? Based on what criteria?
Figure A
Figure B
Figure C
Figure D
Figure E
Figure F
This case presented two intestinal protozoa, Enteromonas hominis and Entamoeba
hartmanni. Both of these organisms are considered nonpathogenic, although their presence
in stool can be an indicator of fecal contamination of food or water. Morphologic diagnostic
features shown include:
 small, ovoid or pyriform trophozoites with nuclei that a have large, central
karyosome (Figures A, B, and D) and are within the size range for E. hominis (6-8
micrometers.
 oval cysts with 2-4 nuclei that have large, central karyosome and are within the size
range for E. hominis (Figures C, E, and F). Notice that the nuclei or pairs of nuclei are
located at polar opposite ends of the cysts.
 small trophozoites of E. hartmanni whose nuclei show even peripheral chromatin
and a small, central karyosome (Figures C and D). The trophozoites are also within
the size range of E. hartmanni (5-15 micrometers).
Case #276 - May, 2010

The DPDx Team received stained stool smears from the Vermont Department of Health
Laboratory for Entamoeba identification. The patient was a 12-year-old refugee from
Myanmar who had also traveled to Malaysia. The patient's stool had been collected in
sodium acetate-acetic acid-formalin (SAF) and sent to the state laboratory for processing.
Figures A-F show what was observed at 1000x magnification on a smear stained with iron
hematoxylin. What is your diagnosis? Based on what criteria?
Figure A
Figure B
Figure C
Figure D
Figure E
Figure F
This case presented a mix of three species of protozoa generally considered nonpathogenic:
Entamoeba hartmanni (Figures B, C, and E), Endolimax nana (Figures D and F), and
Pentatrichomonas hominis (Figure A). Diagnostic morphologic features included:
 a trophozoite of P. hominis containing a single nucleus with a small karyosome and a

posteriorly-directed axostyle (Figure A). The trophozoite was also within the size
range for P. hominis (6-20 micrometers long).
 a trophozoite of E. hartmanni containing a single nucleus with a small, central
karyosome and evenly-distributed peripheral chromatin (Figure B). The
trophozoite was also within the size range for E. hartmanni (5-15 micrometers).
 cysts of E. hartmanni containing a nucleus (within the focal plane) with a small,
central karyosome and evenly-distributed peripheral chromatin (Figures C and E).
The cysts were also in the size range for E. hartmanni (5-10 micrometers in
diameter).
 trophozoites of E. nana containing a nucleus with a large karyosome and no
peripheral chromatin (Figures D and F). The trophozoites were also within the size
range for E. nana (6-12 micrometers).
Although these three species are generally considered nonpathogenic, they should be
reported in all routine ova-and-parasite (O&P) examinations. Their presence in stool could
indicate fecal contamination of a food or water source and does not rule-out the presence
of a true pathogen.
Case #280 - July, 2010
A 35-year-old woman went to her health care provider with complaints of abdominal pain,
cramps and diarrhea. She told her doctor that she had recently returned from a business
trip to Mexico. Stool was collected in 10% formalin and polyvinyl alcohol (PVA) for routine
ova-and-parasite (O&P) examination. Figures A–D show what was observed at 1000x
magnification on a trichrome-stained slide made from the PVA-preserved stool. The objects
of interest measured on average 15-17 micrometers in diameter. What is your diagnosis?
Figure A
Figure B
Figure C
Figure D
This case showed cysts of Entamoeba coli, an intestinal amoeba generally considered
nonpathogenic. Diagnostic morphologic features included:
 cysts within the size range for E. coli (10-35 micrometers in diameter).
 more than four nuclei per cyst (Figures B, C, and D).
 nuclei containing coarse, clumped peripheral chromatin.
A 21-year-old man attending a local music festival developed intermittent diarrhea and
abdominal cramps on the second day. He went to his health care provider who requested a
stool specimen for routine testing. Figures A-E show what was observed on a wet mount
prepared from a formalin-ethyl acetate (FEA) concentration at 1000x oil magnification. The
objects in Figures A and B measured 30 micrometers on average in length; the objects in
Figures C-E measured 20 micrometers on average in length. What is your diagnosis? Based
on what criteria?
Figure A
Figure B
Figure C
Figure D
Figure E
The correct diagnosis for this case was No Parasites Found (NPF). Figures A and B showed
Charcot-Leyden crystals. Figures C-E showed pollen grains. Note that the cell walls
appeared striated, as in the eggs of Taenia spp., but the size and internal morphology were
not consistent with that genus.
Case #243 - January, 2009
A ten-year-old child returned from summer camp with abdominal discomfort, nausea and
diarrhea. He was taken to his pediatrician and a stool specimen was collected for routine
work-up, including ova and parasite (O&P) examination. Figures A-D show what was
observed on a trichrome-stained slide prepared from a PVA-preserved aliquot of the stool.
The objects in Figures A and B measured approximately 11 micrometers; the objects in
Figures C and D measured approximately seven micrometers. What is your diagnosis?
Figure A
Figure B
Figure C
Figure D
These images showed the trophozoites and cysts of the nonpathogenic ameba, Iodamoeba
buetschlii. Diagnostic features included:
 trophozoites (Figures A and B) within the size range (8-20 micrometers) for the
species, containing a single nucleus with a large karyosome and no peripheral
chromatin.
 cysts (Figures C and D) within the size range (5-20 micrometers) for the species,
containing a single nucleus with a large, eccentric karyosome and a large glycogen
vacuole.
Although I. buetschlii is considered non-pathogenic, it should be reported in all stool

parasite work-ups, as its presence may indicate fecal contamination of a food or water
source.
Case #258 - August, 2009
A biopsy was performed on a 23-year-old woman with no known travel history, presenting
with a perianal ulcer. The specimen was preserved in formalin and sent to a pathology lab
for work-up. Figures A and B show what was observed at 500x magnification from a
section of the tissue, stained with hematoxylin and eosin (H&E). What is your diagnosis?
Figure A
Figure B
This was a case of invasive amebiasis caused by Entamoeba histolytica. Morphologic

features seen in the images included:
 the presence of trophozoites in tissue with a single nucleus that contained

peripheral chromatin and a central karyosome.
 trophozoites with ingested red blood cells.
Case #234 - August, 2008
A 29 year-old man with travel history to Costa Rica, Belize, and Nicaragua developed an
ulcerative lesion on his right foot. The lesion did not respond to over-the-counter
medications so the patient went to his health care provider. He was referred to an
infectious disease specialist due to his travel history. A biopsy was performed near the
edge of the lesion and the tissue specimen was sent to a reference laboratory for testing.
The tissue specimen was divided into two parts, one of which was used to inoculate a NNN
slant for culture. The other part was used to prepare a touch-prep smear, which in turn was
fixed with methanol and then stained with Giemsa. Figures A and B show what was
observed on that smear. What is your diagnosis? Based on what criteria?
Figure A
Figure B
The oval objects shown in this case resembled some type of fungal element and may have
represented contamination of the biopsy specimen. The absence of nuclei and kinetoplasts
in the oval structures confirmed they were not amastigotes of Leishmania spp. Even though
travel history of the patient was to countries that have areas endemic for leishmaniasis, a
diagnosis could not be confirmed based on the images presented. The inoculated culture
was also contaminated with the fungus and had to be discarded. It was recommended that
a new biopsy be obtained and tested.
A 28-year-old man had loss of appetite, weight loss, and intermittent diarrhea
approximately one week after attending a family reunion located on a farm in the mid-
western U.S. He sought medical attention with his primary care provider who collected a
stool specimen for ova and parasite (O&P) examination using a single-vial fixative system.
A stool smear was prepared, stained with trichrome, and examined at 1000x magnification.
The objects shown in Figures A–D were observed in moderate numbers. Objects in
Figures C and D were 12 and 15 micrometers in diameter respectively. The object in
Figure E was 4 micrometers in diameter. What is your diagnosis? Based on what criteria?
Figure A
Figure B
Figure C
Figure D
Figure E
The objects shown in this case were artifacts, and the correct diagnosis for this case was no
parasites found (NPF). The structures shown in Figures A, B, and E appeared to be plant or
fungal elements. The small, round objects somewhat resembled the oocysts of
Cryptosporidium sp. However, oocysts would not stain red in a trichrome-stained smear as
they would in an acid-fast stained smear. Also, they appeared to mostly be found within
thin-walled sacs. The objects shown in Figures C and D were pollen grains. The outer layer
resembled the striated shell of the eggs of Taenia sp., however they lacked an oncosphere
(including presence of hooklets) and were too small (eggs of Taenia spp. are 30-35
micrometers in diameter).
Case #178 - April, 2006
A 29-year-old man went to a local health clinic with complaints of intermittent diarrhea for
a few months. He did not report any other symptoms but said he had difficulty sleeping
sometimes. A stool specimen was collected and preserved in both 10% formalin and
polyvinyl-alcohol (PVA). An ova and parasite (O & P) examination was performed. Figure A
shows what was seen on a concentrated wet mount preparation, and Figure B shows what
was seen on a wet mount stained with iodine. Figures C and D show what was seen on a
trichrome stained smear made from the PVA preserved specimen. Objects measured 7 to
10 µm in diameter. What is your diagnosis? Based on what criteria?
Figure A
Figure B
Figure C
Figure D
The organisms shown in the images are cyst-like forms of Blastocystis hominis. Diagnostic
features were:
 the size of the organisms, which was within the range for B. hominis (normally 8 to
10 micrometers in diameter, but can be 5 to 30 micrometers).
 the presence of small nuclei within the peripheral ring of cytoplasm. In trichrome
stained preparations, these nuclei often appear red.
 the presence of a large, centrally located vacuole or central body. In trichrome
stained preparations, these bodies appear green to dark purple in color.
Case #181 - June, 2006
A patient was admitted to a hospital with a one-day history of fever and persistent
headache on the right side. Approximately 10 days prior to the onset of symptoms, the
individual swam in a small swimming hole, associated with a river. Two days after
admission the patient developed a stiff neck, becoming progressively sleepy. The patient
became lethargic and unresponsive to pain stimulation, and treatment with acyclovir and
manitol was started. A computed tomography (CT) was performed and showed a lesion in
the right frontal lobe and diffuse cerebral edema. The patient was pronounced dead 6 days
after the onset of symptoms. Figures A and B are from hematoxylin and eosin (H & E)
stained brain tissue specimens sent to CDC for confirmatory diagnosis. Objects shown
Figure B ranged from 10 to 12 µm in diameter. What is your diagnosis? Based on what
criteria? Which additional diagnostic test would you recommend to achieve a final
diagnosis?
Figure A
Figure B
This was a case of primary amebic meningoencephalitis (PAM) caused by Naegleria fowleri.
Diagnostic features were:
 the presence of trophozoites, with large nuclei, conspicuous karyosomes, and

vacuolated cytoplasm.
 trophozoites that measured 10 to 12 µm in diameter.
Indirect immunofluorescence analysis demonstrated a positive reaction with anti-N. fowleri

serum (Figure C below). Along with morphology and immunological testing, clinical
features were compatible with PAM.
Figure A
Case #192 - November, 2006
A request for confirmation of an identification was submitted to DPDx Telediagnosis

Assistance. Figures A and B were captured from a hematoxylin and eosin (H & E) stained
histological section of a liver abscess found during an autopsy. The patient had a travel
history to Sri Lanka. What is your diagnosis? Based on what criteria?
Figure A
Figure B
This was a case of invasive extraintestinal amebiasis caused Entamoeba histolytica.

Diagnostic features were:
 the size of the nuclei in the trophozoites, which is smaller than those seen in
macrophages. The ratio for macrophages is generally 1:4 to 1:6, whereas the E.
histolytica/dispar ratio is 1:10 to 1:12.
 nuclei with even peripheral chromatin. In Figure B a distinct central karyosome was
present (black arrow). In pathological preparations all morphologic features may
not be visualized due angle of the cuts.
 location of these organisms in liver tissue, which is consistent with invasive
extraintestinal amebiasis and rules-out the morphologically-similar, E. dispar.
In addition to finding organisms in tissue, antigen detection or molecular testing should be

considered for a confirmatory diagnosis.
Case #194 - December, 2006
Images from a trichrome stained fecal smear were submitted to DPDx telediagnosis
assistance from a public health laboratory. Parasites were suspected and further
confirmation was needed. The patient was a 32-year-old male who had diarrhea; no travel
history was known. The objects in Figures A-D were present in moderately high numbers;
images were taken at 1000× magnification. What is your diagnosis? Based on what criteria?
Figure A
Figure B
Figure C
Figure D
The objects seen on the smear were white blood cells (WBCs) and red blood cells (RBCs). A
report of No Parasites Found (NPF) was given. However, the presence of these cells in a
fecal sample may be indicative of another type of infection or condition and further
evaluation should be performed by the health care provider. The RBCs stained red
(Figures A and C, red arrows) and one displayed the typical “doughnut” or ring shape
(Figure C, dark red arrow with black outline). The appearance of the nucleus is a key
feature of the WBCs and can be used to distinguish them from amoebae (Figures A and B,
black arrows). Sometimes WBCs can be confused with some amoebae as there is size
overlap; the WBCs in this case ranged from about 12 to 14 micrometers. Although the size
was not given in the case scenario, the RBCs in the specimen could have been used for size
comparison.
Figure A
Figure B
Figure C
Case #158 - June, 2005
A 42-year-old man complained of diarrhea for 2 weeks following an international

assignment that included travel to countries in Southeast Asia and the Indian subcontinent.
He explained to his physician that his symptoms began shortly before he returned to the
United States. An ova and parasites (O & P) examination was ordered, and Figures A-D
show what was observed. Figures A and B are from a wet mount stained with Lugol’s
iodine, and Figures C and D are from a trichrome stained fecal smear. The objects ranged
in size from 20-25 micrometers. What is your diagnosis? Based on what criteria?
Figure A
Figure B
Figure C
Figure D
This was a case of amebiasis caused by Entamoeba histolytica. Blastocystis hominis was also
observed in Figures C and D. Diagnostic features were:
 the size of the organisms, which was within the range trophozoites of E.
histolytica/E. dispar (10 to 60 micrometers).
 peripheral chromatin in the nuclei which was evenly distributed
 the karyosome seen in the nuclei, which was centrally located and small. This helps
to distinguish from E. coli.
 the cytoplasm, which appeared fine and granular in Figures A and B; Figures C and
D appear less so but this may be an effect of less than optimal preservation. The
cytoplasm in the trophozoites in Figure C and D does appear fine and granular,
especially in the pseudopodia.
 the presence of a pseudopod (Figures A, C and D), a feature more common with, but
not exclusive to, E. histolytica/E. dispar.
 a trophozoite with an ingested red blood cell (erythrophagocytosis; red arrow,
Figure D), which is a way to distinguish E. histolytica from E. dispar (see image
below, with red arrow pointing to the ingested red blood cell).
In addition to seeing ingested red blood cells in trophozoites, molecular tools such as PCR
can also be used to make a confirmatory diagnosis of amebiasis. Also shown in the images
is Blastocystis hominis (black arrows, Figure D). Diagnostic features of B. hominis included
the appearance of a central body, surrounded by a thin rim of cytoplasm containing up to
six nuclei. The size of the objects was also within range for B. hominis (5-30 micrometers).
Figure A
A 45-year-old woman went to her physician with complaints of recurring abdominal

cramping, bloating, and infrequent diarrhea. Her travel history included a 10-day camping
trip in Alaska, and her symptoms had started approximately 2 weeks after her return. Her
physician ordered an ova and parasites (O & P) examination. Figures A-D show objects
observed on a trichrome stained fecal smear; A-C were found in moderate numbers on the
smear, while D was found in very few numbers. The objects shown ranged in size from 5 to
7 micrometers. What is your diagnosis? Based on what criteria?
Figure A
Figure B
Figure C
Figure D
The organisms identified in this case were Entamoeba hartmanni and Endolimax nana.
These amoebae are generally considered to be nonpathogenic. Diagnostic features
included:
 trophozoites of E. hartmanni (Figures A and B). The morphology of E. hartmanni is

very similar to that of Entamoeba histolytica; both have a compact, centrally located
nuclear karyosome, uniform distribution of peripheral chromatin, and fine, granular
cytoplasm. Size of the trophozoites is consistent with the range for E. hartmanni (5
to 12 micrometers, averaging 8 to 10).
 a cyst of E. hartmanni (Figure C) with only two nuclei; mature cysts have four
nuclei. The number of nuclei is also similar to E. histolytica cysts, but size of the cyst
is consistent with E. hartmanni (5 to 10 micrometers) and distinguishes it from E.
histolytica.
 a trophozoite of Endolimax nana (Figure D). The size range for E. nana trophozoites
is 6 to 12 micrometers. The karyosome is generally large and red (when stained
with trichrome). The cytoplasm is coarsely granular and can be very vacuolated.
A 45-year-old woman went to her physician with complaints of recurring abdominal

cramping, bloating, and infrequent diarrhea. Her travel history included a 10-day camping
trip in Alaska, and her symptoms had started approximately 2 weeks after her return. Her
physician ordered an ova and parasites (O & P) examination. Figures A-D show objects
observed on a trichrome stained fecal smear; A-C were found in moderate numbers on the
smear, while D was found in very few numbers. The objects shown ranged in size from 5 to
7 micrometers. What is your diagnosis? Based on what criteria?
Figure A
Figure B
Figure C
Figure D
The organisms identified in this case were Entamoeba hartmanni and Endolimax nana.
These amoebae are generally considered to be nonpathogenic. Diagnostic features
included:
 trophozoites of E. hartmanni (Figures A and B). The morphology of E. hartmanni is

very similar to that of Entamoeba histolytica; both have a compact, centrally located
nuclear karyosome, uniform distribution of peripheral chromatin, and fine, granular
cytoplasm. Size of the trophozoites is consistent with the range for E. hartmanni (5
to 12 micrometers, averaging 8 to 10).
 a cyst of E. hartmanni (Figure C) with only two nuclei; mature cysts have four
nuclei. The number of nuclei is also similar to E. histolytica cysts, but size of the cyst
is consistent with E. hartmanni (5 to 10 micrometers) and distinguishes it from E.
histolytica.
 a trophozoite of Endolimax nana (Figure D). The size range for E. nana trophozoites
is 6 to 12 micrometers. The karyosome is generally large and red (when stained
with trichrome). The cytoplasm is coarsely granular and can be very vacuolated.

Case Study For Unit 1

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CDC

Case #440 - March, 2017

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Figure C (Focal Plane 1)

Figure D (Focal Plane 1)

Figure E (Focal Plane 1)

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