PARASITOLOGY

CASE PRESENTATION
GROUP 3
AYSON | CASTRO | CUARESMA | LEGASPI | SUTHAR
“Bilateral Conjunctivitis Due to
Trichomonas vaginalis without
Genital Infection: An Unusual
Presentation in an Adult Man”
INTRODUCTION
Conjunctivitis
● Inflammation or swelling of the conjunctiva.

● The conjunctiva is the thin transparent layer

of tissue that lines the inner surface of the
eyelid and covers the white part of the eye.

● Most common cause of a red, irritated eye.

 Conjunctivitis

● Most common viral etiology: adenovirus

○ watery discharge, mild foreign-body
sensation, and photophobia

● Bacterial infection tends to produce a more

mucopurulent exudate

● Can also develop due to an allergic reaction to

air irritants
○ pollen and smoke, chlorine in swimming
pools, ingredients in cosmetics, or other
products that contact the eyes, such as
contact lenses
 Trichomonas vaginalis

● Exists only in the trophozoite stage.

● Pyriform shape, measuring 7 to 23 μm

with four free anterior flagella that
appear to arise from a simple stalk, and
a fifth flagellum embedded in the
undulating membrane

● Has a median axostyle and a single

nucleus
Trichomonas vaginalis

● Found in the urogenital tract.

○ In women, it is found in the vagina but may ascend as far as the renal pelvis.
○ The parasite can be isolated from the urethra, prostate, and less
frequently, in the epididymis in men.

● Transferred passively from person to person

● Usual mode of transmission: sexual intercourse

CASE REPORT
Case Report
Patient Profile: 32/M

Chief Complaint: 2-week history of inflamed conjunctivae and a yellowish, purulent

discharge emanating from both eyes.

Multiple conjunctival swabs were collected from the lower conjunctiva for
microbiological investigation, including bacterial and viral cultures and microscopy.
Case Report
● Viral cultures:
○ Adenoviruses (-)
○ Herpes Simplex Viruses 1 and 2 (-)
○ Enteroviruses (-)

● Culture for Chlamydia trachomatis (-)

Case Report
● Gram Stain:
○ Moderate numbers of nondescript cell-like structures that were
indistinguishable mixed with numerous white blood cells, predominantly
polymorphonuclear leukocytes

● Morphological features of the cells:

○ Amoeboid shape, presence of one or two elliptically shaped nuclei, poorly
defined cytoplasm,
■ a provisional identification of trichomonad parasites was made.
Case Report
● In order to identify the trichomonad species isolated in the culture medium, a
PCR strategy was used, cultures from both the left and right eyes containing a
300-bp fragment were considered positive for T. vaginalis.

● Direct contact between patient’s eyes and female partner’s genital secretions
facilitated the transmission of parasites led to his conjunctivitis.
CASE DISCUSSION
Why is it unique?
● T. vaginalis is a protozoan parasite that infects the urogenital tracts of men and
women, causing trichomoniasis with a worldwide presence and significant
implications for global public health.

● This case was presented in 2013, and according to the extent of the author’s
knowledge, this was only the second case of T. vaginalis infection of the
conjunctiva reported and the first in an adult patient in the English language
literature.

● 1st report = case of bilateral conjunctivitis in a 17-day-old male yellowish and

purulent discharge. Source = the genital tract of the mother

● According to further reports in literature, chlamydia and gonorrhea are the

Why is it unique?
● In another study by Norm, Lundvall, and Paerregaard in 1976, conjunctival
trichomonads could not be demonstrated in 272 newborns despite evidence of
trichomonads in 3.7% of the pregnant mothers.

● UPDATE: An article that was published in 2012 by Chinyere, Romanus, Collins,

et al. reports that out of 688 pregnant women included in the study, 89 (12.9%)
were infected with T. vaginalis in Ebonyi State, South Eastern Nigeria, and 31
(18.8%) newborns developed conjunctivitis.
○ However, no mentioned confirmatory tests for T. vaginalis was done on the
infected infants
○ ASSOCIATION was suggested but NOT direct CAUSE/EFFECT
relationship
CONCLUSION
Conclusion

● Conjunctivitis caused by Trichomonas vaginalis is a rare occurrence.

According to supporting literature that we have read, although
trichomoniasis is the most common curable sexually transmitted
infection, extragenital trichomoniasis is a very uncommon event.
Conclusion

● This case may be helpful for physicians in treating patients (w/

pertinent sexual history) presenting with persistent conjunctivitis that
is unresponsive to standard antibiotic treatment
○ T. vaginalis must be ruled out as a possible cause
● Occurrence may be rare, but it can happen
References
● Belizario, V. Y., & U., D. L. (2015). Medical parasitology in the Philippines. Diliman, Quezon City: The University of the
Philippines Press.
● Chinyere, O., Romanus, I., Collins, O., Okoro, N., & Anthonia, O. (2012). Trichomonas vaginalis Associated with
Adverse Pregnancy Outcomes: Implications for Maternal Health Care Delivery System in South Eastern Nigeria.
British Journal Of Medicine And Medical Research, 2(4), 568-574. doi: 10.9734/bjmmr/2012/1345
● D’Auria A. (1984). Trichomonas conjunctivitis. Clin. Microbiol. Newsl.
6:96 –97.
● Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L. 1., Jameson, J. L., & Loscalzo, J. (2015). Harrison's principles of
internal medicine (19th edition.). New York: McGraw Hill Education.
● Norm MS, Lundvall F, Paerregaard P. (1976). May Trichomonas vaginalis provoke conjunctivitis? Acta Ophthalmol.
Copenh. 54:574 – 578.
● The Eye and STIs. Retrieved from https://opto.ca/health-library/the-eye-and-stis
● Trichomoniasis. (2017). Retrieved from https://www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm.
● Workowski, K., Bolan, G. Sexually transmitted diseases treatment guidelines. (2015). MMWR Recomm Rep 2015,
64(3), 74.
 “Sickle Cell Anemia with
Malaria: A Rare Case Report”
INTRODUCTION
Sickle Cell Anemia
● Autosomal recessive disorder
● Prototype of hereditary hemoglobinopathies
● Results from a point mutation that leads to
substitution of valine for glutamic acid at the
sixth position of the beta globin chain
● Promotes the polymerization of deoxygenated
hemoglobin, leading to red cell distortion,
hemolytic anemia, microvascular obstruction,
and ischemic tissue damage
Malaria
● Malaria remains the leading
parasitic disease that causes
mortality worldwide.
● Caused by the the genus
Plasmodium
● Transmitted by the bite of an
infected female mosquito
belonging to the genus Anopheles
Malaria
● 4 kinds of malaria parasites that can
infect humans:
○ Plasmodium vivax, P. ovale, P.
malariae, P. falciparum
■ P. falciparum causes a more
severe form of the disease
and those who contract
this form of malaria have a
higher risk of death.
CASE REPORT
Case Report
Patient Profile: 25/M
Physical Examination
Chief Complaint: fever and weakness for 3 days ● General Condition
○ Fair
Past Medical History ○ HR: 110/min
● (-) Tuberculosis ○ BP: 110/78
● (-) Syphilis ○ RR: 20/min
● (-) Diabetes ○ T: 103.2 F (febrile)
● (-) Hypertension
● (+) Sickle cell disease ● Systemic Examination
○ Medications taken: herbal and ayurvedic ○ (-) Hepatosplenomegaly
treatment ○ (-) Splenomegaly
Case Report
Blood Investigation ● ESR (Wintrobe): 10 mm

● CBC + Platelet count ● Reticulocyte count: 3%

○ RBC count: 3.0x106/mm3 ● Peripheral Blood Smear
○ Hgb: 9.0 g ○ (+) Anisocytosis
○ Hct: 28% ○ (+) Poikilocytosis
○ WBC count 8,600/mm3, ○ (+) Hypochromasia
■ N - 67 % ○ (+) Target cells
■ L - 30 % ○ (+) Normoblasts
■ M-1% ○ (+) Howell Jolly bodies
■ E-2% ○ (+) Sickle cells
■ B-0% ○ (+) Malaria parasite (Plasmodium
○ Platelet count: 1.0 lac/mm3 falciparum)
Case Report Blood Chemistry
● Malarial Antigen Test: (+) ● FBS: 72 mg%
● Creatinine: 0.99 mg %
● Quantitative Buffy Coat: (+) ● Total bilirubin: 2.10 mg %
● Sickling Test: (+) (conjugated 0.29 mg %, uncon. 1.81 mg %),
● SGPT: 110 IU
● Hemoglobin Electrophoresis: ● SGOT: 65 IU
○ HbS: 78.5 %, ● Alkaline phosphatase: 80 IU/dl
○ HbF: 15.5 % ● G6PD: normal
○ HbA: 3.5 % Serology
○ HbA2: 2.5 % ● Australia antigen: (-)
● HIV 1 and HIV 2: non-reactive
Case Report
Course in the Ward:
● Patient was treated with oral artesunate 200 mg, pyrimethamine 75 mg, and
sulfadoxine 1,500 mg on day 1, then oral artesunate 200 mg on day 2 and 3.
● On day 1, patient became afebrile.
● On day 3, his peripheral smear was negative for malaria parasite.
● Patient was cured from malaria and was discharged.
CASE DISCUSSION
Why is this case unique?
● The protection against falciparum malaria by HbS is well known.
● Sickle cell trait confers a high degree of resistance to severe and
complicated malaria and to some extent it almost certainly related to
the peculiar physical or biochemical properties of HbS red blood cells:
invasion, growth, and development of Plasmodium falciparum parasite
are all reduced in such cells.
● Also, parasite infected HbS red cells also tend to sickle and process that
may result their premature destruction by the spleen.
Why is this case unique?
● Red cells from people with sickle cell
disease do not sickle to any significant
degree at normal venous oxygen tension.
● Red cells in person of sickle cell disease
infected with P. falciparum deforms,
because parasite causes low oxygen
tension in red cells.
“These abnormal cells become vulnerable for
phagocytosis”.
Why is this case unique?
● Metabolically active intracellular parasites consume O2 and decrease
intracellular pH, both of which promote hemoglobin sickling in AS red cells.
○ These distorted and stiffened cells may be cleared more rapidly by
phagocytes in the spleen and liver, helping to keep parasite loads down.
● Another effect of sickling is that it impairs the formation of membrane knobs
containing a protein made by the parasite called PfEMP-1.
○ These membrane knobs are implicated in adhesion of infected red cells to
endothelium, which is believed to have an important pathogenic role in the
most severe form of the disease, cerebral malaria.
 Update
● According to CDC, sickle cell disease occurs
more often among people from parts of the
world where malaria is or was common.
● It is believed that people who carry the
sickle cell trait are less likely to have severe
forms of malaria.

Population studies have shown that the sickle hemoglobin

mutation has arisen independently at least six times in
areas in which falciparum malaria is endemic, providing
clear evidence of strong Darwinian selection for this trait.
Update
Protective Effect of Sickle Cell Trait Against Malaria
● The sickle cell gene is caused by a single amino acid mutation
(valine instead of glutamate at the 6th position) in the beta
chain of the hemoglobin gene.
● Inheritance of this mutated gene from both parents leads to
sickle cell disease and people with this disease have shorter life
expectancy.
 Update
● CDC’s birth cohort studies
(Asembo Bay Cohort Project in
western Kenya) conducted in
collaboration with the Kenya
Medical Research Institute
allowed an investigation into this
issue.
● It was found that that the sickle
cell trait provides 60% protection
against overall mortality.
CONCLUSION
Conclusion
● Sickle cell anemia with malarial infection presented in our case is a rare
occurrence. Despite the protective mechanism of sickle cells against P.
falciparum, still the patient in the case manifested a full-blown malarial
infection.
● According to our supporting literature, concomitant presentation of
sickle cell disease with malaria is very rare, but sickle cell disease is not
always immune to malaria.
● Although the trait does not completely protect a person from infection,
it makes death from malaria less likely.
Conclusion
● This case may help the physician in properly diagnosing malarial
infection in patients with sickle cell anemia.
○ Even if patients with sickle cell anemia have a protective mechanism
against malaria, they may still be infected with this parasite, especially
those that carry a homozygous gene mutation for sickle cell anemia.

● This case may also help the physicians in properly managing patients
with sickle cell anemia presenting with malarial infection.
○ Patients that have sickle cell anemia presenting with malarial infection
are easier to treat because of the natural mechanism of the sickle cells
with intracellular parasites being eliminated rapidly due to
consumption of oxygen.
References
● Belizario, V. Y., & U., D. L. (2015). Medical Parasitology in the Philippines. Diliman,
Quezon City: The University of the Philippines Press.
● Gupta, N. K., & Gupta, M. (2012). Sickle cell anemia with malaria: a rare case report.
Indian journal of hematology & blood transfusion : an official journal of Indian Society of
Hematology and Blood Transfusion, 30(1), 38-40.
● Kumar, V., Abbas, A.K., & Aster, J.C. (2015). Robbins and Cotran Pathologic Basis of
Disease, 9th Ed. Elsevier Saunders. Philadelphia, PA.
● Sickle Cell Disease, (2017). Retrieved from
https://www.cdc.gov/ncbddd/sicklecell/data.html
● Malaria. (2018). Retrieved from https://www.cdc.gov/malaria/about/biology/index.html