Medical Microbiology - Parasitology

Microbiology
(Parasitology)
By Alyazeed Hussein,
BSc, SUST
Alyazeed Hussein, BSc, SUST

Outline:
A. Protozoology.
1. Amoeba.
2. Flagellates.
3. Sporozoa.
4. Ciliates.
B. Helminthology.
1. Cestodes.
2. Trematodes.
3. Nematodes.

Entamoeba histolytica
Habitat:
large intestine.
Disease:
Amoebic dysentery, Amebic colitis, ulcers (flask shape), amoebic liver abscess (ALA)> Extraintestinal
amebiasis. Abdominal cramping, anorexia, fatigue, and diarrhea. Additional conditions include infections
of the spleen, brain, and lungs.
Host:
Human is the definitive host.
Infective stage:
Mature cyst: 8 to 22 μm, spherical, One to four nuclei. Chromatoid body.
Diagnostic stage:
1. Cyst.
2. Trophozoite: 5 to 70 μm, Pseudopods, directional motility, One nucleus. Cytoplasm may contain red
blood cell (diagnostic).
Mode of transmission:
Cysts are ingested via contaminated food or water.

Complications:
• Amoebic cerebral abscess
• Amoebic peritonitis
• Genitourinary amoebiasis
• Perianal ulceration
• Pulmonary amoebiasis
• Splenic abscess
• Toxic megacolon
Note:
The only ameba pathogenic for the gastrointestinal tract
Entamoeba coli contain no RBCs in cytoplasm!

Life cycle

Lab diagnosis of amoebiasis
A. Intestinal amoebiasis:
1. Stool: Cysts in formed stool usually or trophozoites in loose stool (Wet mount, Lugol's Iodine prep,
Trichrome stain).
2. Colonic scraping from ulcerated areas.
3. Stool culture.
4. Biopsy (H & E).
5. DNA probe (PCR), stool sample.
6. Blood examination: leukocytosis.
7. Serology: IHA, IFA, ELISA.
B. Hepatic amoebiasis:
1. Diagnostic aspiration.
2. liver biopsy.
3. Leukocytosis.
4. Serology: IHA, IFA, ELISA.
5. PCR.

Giardia lamblia (G. duodenalis and G. intestinalis)
Habitat:
Small intestine (duodenum & upper part of jejunum.
Disease:
Giardiasis (traveler's diarrhea) characterized by acute diarrhea, abdominal pain, and weight loss,
malabsorption (steatorrhea).
Host:
Infective stage:
Cyst: oval shaped, 12 μm long to 8 μm wide. four nuclei Cytoplasm contain two to four comma-shaped,
median bodies.
Diagnostic stage:
Cyst.
Trophozoite: 15 μm long to 10 μm wide, pear shaped, two large nuclei, central axostyle, four pair of
flagella, two median bodies, two axonemes, and a sucking disk are present, falling leaf motility.
Cysts are ingested via contaminated food or water.

Lab diagnosis of giardiasis
1. Presence of cysts and trophozoites in stool sample, wet mount and iodine prep.
2. Duodenal aspiration (for trophozoite).
3. Duodenal capsule or Enterotest:
Nylon string weighted and coiled inside a gelatin capsule. End of the string trapped to the side of patient
face. The patient is then asked to swallow the capsule with water. The string is recovered after 4 hours and
examined by wet mount for motile trophozoites.
4. Duodenal and jejunal biopsy.
5. Serology: ELISA.

Balantidium coli
Habitat:
Large intestine of human, monkeys and pigs. Largest intestinal protozoa.
Disease:
Balantidiasis, diarrhea & dysentery.
Host:
Pig is the natural host; human is accidental host.
Infective stage:
Cyst: 43 to 65 μm, round, two nuclei; one, the macronucleus, is kidney-shaped and very large. The
micronucleus is round and much smaller; it is rarely seen. double cyst cell wall with numerous cilia
between the two cell walls.
Diagnostic stage:
Cyst.
Trophozoite: up to 100 μm in length and 70 μm in width. two nuclei. one or two contractile vacuoles with
cilia around the cell, funnel shaped cytostome. Rotatory boring motility.
Cyst ingestion through contaminated (feces) water or food.

Lab diagnosis of Balantidiasis
1. Cysts and trophozoites in stool sample.
2. Biopsy or ulcer scrapings (sigmoidoscope).

Cryptosporidium parvum
Habitat:
Small intestine. Less frequently in stomach, large intestine and lungs.
Disease:
Cryptosporidiosis, which is characterized by moderate to severe diarrhea. In patients with acquired
immunodeficiency syndrome (AIDS),Cryptosporidium infections are an important cause of death due to
dehydration. In the immunosuppressed patient, the parasite causes malabsorption and stomach, liver, and
respiratory disorders.
Host:
Human, cattle, cat or dog.
Infective stage:
Oocysts: oval oocyst, 4 to 6 μm, contain four crescent-shaped sporozoites enclosed within a thick cell wall.
Diagnostic stage:
Oocysts.
Ingestion of oocyst through contaminated food, water or direct contact with infected animal (rodent, cow,
pig, or chicken feces). Human-to-human transmission has been documented in daycare centers.
Autoinfection.

Lab diagnosis of cryptosporidiosis
1. Presence of oocyst in stool sample (wet mount-mucus).
2. Concentration method: flotation by Sheather's sugar solution, zinc sulphate or in saturated sodium chloride
solution. FECT also can be used. Centrifugation: 500 g for at least 10 minutes.
3. Modified acid-fast staining (Kinyoun acid fast): red oocyst, in stool, sputum, bronchial washings and
duodenal or jejunal aspiration.
4. Fluorescence microscopy: auramine-rhodamine and acridine orange. IFA.
5. Sputum (10% formalin) in respiratory cryptosporidiosis (AIDS).
6. Intestinal biopsy.
7. Serology: IFA, IgG or IgM or both, ELISA.
8. PCR.

Cystoisospora belli (Formerly Known as Isospora belli)
Habitat:
Small intestine.
Disease:
Isosporiasis, which is characterized by mild diarrhea to severe dysentery.
Host:
Humans are the definitive host.
Infective stage:
Oocyst: oval, 25 to 40 μm in length. The cytoplasm contains two sporoblasts that contain four crescent-
shaped sporozoites each.
Diagnostic stage:
Oocyst.
Ingestion of the infective oocyst in contaminated food and water.

Lab diagnosis of Isosporiasis
1. Presence of oocyst in stool sample (wet mount or iodine).
2. Concentration method: flotation by Sheather's sugar solution, zinc sulphate or in saturated sodium chloride
solution. FECT also can be used.
3. Modified acid-fast staining (Kinyoun acid fast): red oocyst, in stool, duodenal aspirates.
4. Fluorescence microscopy: auramine-rhodamine.
5. Intestinal biopsy.
6. PCR.

Plasmodium spp
Habitat:
Hepatocytes and erythrocytes.
Disease:
Malaria by P. vivax, P. falciparium, P. malariae, P. ovale & P. knowlesi.
Febrile paroxysm: cold stage, hot stage and sweating stage.
Anemia: microcytic or normocytic hypochromic anemia.
Splenomegaly.
Host:
Definitive host: female Anopheles mosquito.
Intermediate host: human.
Infective stage:
Sporozoite.
By the bite of infected female Anopheles mosquito (sporozoite in salivary gland) during blood meal.
Other forms of transmission include contaminated blood products, contaminated needles (mainline), and
congenital malaria.

Plasmodium morphology
Trophozoites or ring forms
1) Erythrocytic intracellular ringlike appearance
2) Giemsa or Wright's stain will show a blue cytoplasmic ring connected to a red chromatin dot.
3) Mature trophozoites will lose the ring appearance but will contain remnants of the cytoplasmic ring and
chromatin dot.
Schizonts
1) Active chromatin activity causes the parasite to increase in size.
2) Pigmented granules are numerous and reddish-brown in color.
3) Schizonts contain merozoites; the number and arrangement depend on the species.
Gametocytes
1) Characterized by a chromatin mass staining pink to purple.
2) The gametocytes of most species are round. P falciparum gametocytes are "banana shaped."
3) Pigmentation varies by species.

• Plasmodium spp. have two life cycle phases.
• a. Sporogony: Sexual phase that occurs
within the intestinal tract of the mosquito
• b. Schizogony: Asexual phase that occurs in
the human host
• Sporozoite (anopheles)> exoerythrocytic
cycle> schizogony (Asexual)> merozoites
invade RBCs (erythrocytic)> ring forms &
schizogony> microgametocytes (male) or
macrogametocytes (female)
(mosquito/sexual).
Note: P. vivax & P. ovale form a dormant form
in liver (hypnozoites/relapse).

Plasmodium vivax
a. Infected erythrocytes appear enlarged and pale with prominent Schiiffner's dots.
Only reticulocytes are infected, thus limiting the parasitemia to 2-5%.
Trophozoite: Ring stage is one-third the size of an RBC; mature trophozoites fill the entire RBC.
c. Schizont contains 12 to 24 merozoites.
d. Gametocyte: Round to oval with a large chromatin mass that almost fills the RBC
e. Fever cycle lasts 48 hours.
f. P. vivax causes benign tertian malaria following a 10- to 17-day incubation period. It is the most common
cause of malaria.

Plasmodium falciparum
• Pernicious anemia: cerebral malaria, algid malaria, septicemic malaria.
• G6PD deficiency confers some protection against P. falciparum.
• Duffy factors increases the susceptibility to malaria.
• a. Infected erythrocytes appear normal in size, and all ages of RBCs can be infected, which can result in a
large number of infected cells.
• b. Trophozoite: Ring stage is one-fifth the size of the RBC, and multiple rings are found in a single RBC.
Some trophozoites will have two chromatin dots in one ring form.
• c. Schizonts are rarely seen in peripheral blood smears.
• d. Crescent- or banana-shaped gametocytes are diagnostic of P. falciparum.
• e. Miscellaneous characteristics: The interval between paroxysms (intense fever and chills) is 24 hours.
Patients have a high ratio of infected RBCs to uninfected RBCs compared to other Plasmodium spp.
• f. P. falciparum causes malignant tertian malaria (blackwater fever) following a 7- to l0-day incubation
period.

Plasmodium malariae
• a. Infected erythrocytes appear normal in size without dots; P. malariae prefers to infect older RBCs.
• b. Trophozoites appear similar to P. vivax but stain a more intense blue. Mature trophozoites can produce
band forms, which spread across the diameter of the RBC.
• c. Schizonts average 8 to 12 merozoites arranged in rosettes.
• d. Gametocytes resemble P. vivax.
• e. Fever cycle is 72 hours.
• f. P. malariae causes quartan or malarial malaria following an 18- to 40-day incubation period.

Plasmodium ovale
• a. Infected RBCs appear enlarged with thicker ring forms and contain Schliffner's dots. Infected RBCs
resemble those infected with P. vivax; however, P. ovate-infected RBCs are often oval shaped and have
irregularly shaped membranes with projections. Like P. vivax, only reticulocytes are infected.
• b. Trophozoites maintain their ring appearance as they develop.
• c. Schizont: Averages 4 to 8 merozoites arranged in rosettes
• d. Gametocyte resembles P. vivax but slightly smaller.
• e. P. ovale causes benign tertian or ovale malaria following a 10- to 20-day incubation period.

P. knowlesi
• Infect the monkeys.
• Ring stage resembles P. falciparum.
• Mature schizont has an average of 10 merozoites with a maximum of 16.
• Can resemble P. malariae or P. falciparum. Differentiate by PCR.
• Short life cycle 24hours (quotidian).

Lab diagnosis of malaria
• Diagnosis is made by clinical symptoms and microscopic examination of blood smears. Diagnosis is primarily
made by microscopic examination of Giemsa (stain of choice) or Wright's-stained smears.
• a. Because of the rapid progression of P. falciparum infections, examination of blood smears for malaria
should be considered a STAT procedure.
• b. Ideally, blood should be collected by finger stick and blood smears made immediately. Alternatively, EDTA
(ethylenediaminetetraacetic acid) can be used as an anticoagulant in a venipuncture. Heparin can cause
distortion of the parasites.
• c. Thick smears: A large drop of blood is placed on a slide and allowed to air dry. The RBCs are lysed in
distilled water, and the material. is stained with Giemsa stain (degaemoglobinization).
• d. Thin smears: A drop of blood is placed on a glass microscope slide, and the blood is spread out on the slide
using another slide. The smear is fixed in methanol to prevent RBC lysis and then stained.
• e. Both thick and thin smears are thoroughly examined microscopically. The thick smear allows examination
of about 20 times more blood volume than the thin smear, so it is much more sensitive. However, because the
RBCs are intact, it is easier to identify the parasites in thin smears, which makes them more specific.
• All asexual stages seen in all plasmodium spp, except p. falciparum only ring and gametocytes are seen
(cytoadherence phenomenon and confined to internal organ).
• Malarial pigment in WBCs.
• Culture: RPMI 1640.

• Rapid diagnostic tests (RDTs): AgxAb reaction in about
15 min,
• Antigen detection:
• Histidine-rich protein II (HRP-II) for p. falciparum.
• pLDH.
• Pan-malarial Ag for all spp.
• Quantitative buffy coat (QBC):
• PCR.
• IFA, ELISA,.

Babesia microti
Habitat:
Erythrocyte.
Disease:
Babesiosis, which can affect the spleen, liver, and kidneys. hemolytic anemia, Texas cattle fever.
Host:
Definitive host: lxodes scapularis (deer ticks).
Intermediate host: human, deer, cattle, rodents and birds.
Infective stage:
Sporozoite
Sporozoite is transmitted to humans by a tick bite (lxodes scapularis).

Lab diagnosis
1. Blood smear examination:
It is difficult to differentiate Babesia spp. from Plasmodium spp.
No malarial pigments.
Ring form: Size ranges from 3 to 5 μm.
Cytoplasm: Minimal with two or more chromatin dots.
Two to four rings per RBC are often seen, sometimes appearing tetrad like a "Maltese cross.“
2. serologic testing: IFA,
3. PCR.
4. Animal inoculation: in hamster (amplifying parasitemia).

Toxoplasma gondii
Habitat:
Reticuloendothelial cells and many nucleated cell, tissue, musculoskeletal, brain and eye.
Disease:
Toxoplasmosis is characterized by a broad spectrum of symptoms depending on the individual's state of
health. T gondii has a predilection for central nervous system (CNS) infections.
Fatigue, swollen lymph glands, fever, and myalgia. The disease can become chronic and affect the heart
and liver.
In patients with immunosuppression, such as AIDS, the parasite becomes localized in the CNS with
symptoms of encephalitis and brain lesions, often resulting in death.
Host:
Definitive host: cat.
Intermediate host: Rodents, mice, rats, birds, cattle, sheep, pigs human,
Infective stage:
Oocyst, Tachyzoite, Tissue cyst.

1. Ingestion of food and drinks contaminated with cat feces containing sporulated oocyst.
2. Ingestion of undercooked meat (mutton, pork and rarely beef), lamb, containing tissue cysts, in the
duodenum the oocyst release sporozoites, and tissue cysts release bradyzoites.
3. Congenital toxoplasmosis occurs in premature or antibody-deficient infants, where symptoms include
splenomegaly, jaundice, and fever. CNS infections can lead to developmental complications, including
vision and hearing problems, hydrocephalus, and mental retardation (birth defects).
4. Organ transplantation or blood transfusion.
5. Accidental inoculation of tachyzoites.

Lab diagnosis of toxoplasmosis
1. blood: buffy coat of heparinized blood, sputum, bone marrow, cerebrospinal fluid and biopsy from lymph
node, spleen and brain. Smear and sections stained with Giemsa stain or periodic acid-Schiff. Tachyzoites are
crescent-shaped and in sections round to oval. Tissue cysts are spherical stained with silver stain. Bradyzoites
stained with PSA.
Tachyzoites may be found in CSF in AIDS patients with toxoplasma encephalitis.
2. Tissue culture, CT scan (brain).
3. Toxoplasma Ags by ELISA in blood or CSF.
4. PCR.
5. Tissue culture.
6. Animal inoculation (intraperitoneal> mice).
7. Serology:
Sabin-Feldman dye test.
Latex agglutination test.
+ve IgG and –ve IgM> woman infected before pregnancy, no risk to the fetus.
Both IgG, IgM are +ve> with out raise in titer> infection occurred before pregnancy.
Both –ve> repeat tests, if infected during pregnancy, the fetus is at high risk.
8. Congenital infection: PCR, serology (IgG after 6-10 months).
Tachyzoites (trophozoites) range in size from 1 to 3 μm and are crescent to round in shape. Cysts contain many

A) Tachyzoites (arrowhead) in smear. Giemsa stain. Note nucleus dividing into two nuclei (arrow).
B) A small tissue cyst in smear stained with Giemsa and a silver stain. Note the silver-positive tissue cyst wall (arrowhead) enclosing
bradyzoites that have a terminal nucleus (arrow).
C) Tissue cyst in section, PAS. Note PAS-positive bradyzoites (arrow) enclosed in a thin PAS-negative cyst wall (arrowhead).
D) Unsporulated oocysts in cat faeces. Unstained.

Naegleria fowleri (free-living amoeba, FLA)
Habitat:
Central nervous system.
Disease:
Causes primary amebic meningoencephalitis (PAM), which is often fatal within 3-6 days. Found in lakes,
ponds, and swimming pools where the water is warm. Kernig's sign.
Host:
Trophozoite does not need a host to survive and can be free living, spending its entire life cycle in the
external environment.
Human.
Infective stage:
Trophozoite: amoeboid (motile by rounded-blunt pseudopodia> lobopodia), and flagellate (cigar or pear-
shaped with 2 flagella) forms. In tissue trophozoite ingest RBCs, WBCs.
Diagnostic stage:
Trophozoite
cyst: round cyst, single nucleus.
During swimming in freshwater lakes, ponds, or swimming pools.
Inhalation of dust containing infective from.

Lab diagnosis
1. Living or stained (Wright or Giemsa) amoeba in CSF. Don’t refrigerate the CSF! Fluorescent Ab can be
used for amoeba.
2. Brain biopsy: H & E.
3. PCR.
Note: cyst and flagellate forms not found in tissue or CSF.

Acanthamoeba (FLA)
Habitat:
CNS, eye.
Disease:
Causes amebic encephalitis and amebic keratitis (cornea infection), the eye is directly invaded by
trophozoites, producing keratitis. Causes granulomatous amebic encephalitis (GAE), brain abscesses
(AIDS) & ulcerative acanthamoeba keratitis in contact lens wearers. Skin, respiratory tract, and CNS
infections are caused by the cyst or trophozoite stage.
Host:
Human.
Infective stage:
Trophozoites: motility is by spinelike pseudopods (acanthopodia), move slowly. however, both cysts and
trophozoites can gain entry into the body through a variety of means.
Diagnostic stage:
Cyst: round, double-walled, resistant to the environment.
trophozoite:.
Inhalation of aerosol or dust containing trophozoites and cysts. The infection may also be acquired through
broken or ulcerated skin or eye.

Lab diagnosis
1. Presence of trophozoites in CSF or trophozoites and cysts in brain tissue (GAE).
2. Presence of trophozoites and cysts in corneal scrapings or corneal tissue (amoebic keratitis).
3. PCR.

Trichomonas vaginalis
Habitat:
Women: vagina & urethra. Men: urethra, seminal vesicles & prostate.
Disease:
Trichomoniasis, vaginitis, vulvovaginitis with discharges (greenish or yellow) in women, whereas men are
generally asymptomatic carriers (zinc).
Infect the epithelial or mucosal Lining of the vagina, urethra, and prostate gland.
Can infect neonates (aspiration pneumonia) during delivery.
Host:
Infective stage:
Trophozoite: with an undulating membrane, pear shaped, single prominent nucleus, actively motile (jerky
motility). Three to five anterior and one posterior flagella.
Diagnostic stage:
Trophozoite.
T. vaginalis is a sexually transmitted disease.
Note: T. vaginalis does not have a cyst stage. Alyazeed Hussein, BSc, SUST

Lab diagnosis
1. Presence of trophozoites in urine, vaginal discharges or vaginal scrapings. In male may be found in urine
or prostatic secretions.
2. ELISA.
3. PCR.

Trypanosoma
Habitat:
T. brucei: connective tissue spaces of various organs, reticular tissue, lymph nodes, lymph channels, spleen,
intracellular spaces in the brain, blood & CSF.
T. cruzi: blood, heart, colon, reticuloendothelial cells of spleen, liver, LN, BM, muscle, nervous system.
Disease:
T. Brucei (T. b. gambiense & T. b. rhodesiense ): African trypanosomiasis or sleeping sickness. Infection
affects the lymphatic system and CNS. Swollen lymph nodes at the posterior base of the neck
(Winterbottom' s sign) are sometimes present.
T. cruzi: South American trypanosomiasis or chagas disease. lesion formation (chagoma), conjunctivitis,
edema of the face (Romana's sign) and legs, and heart muscle involvement leading to myocarditis.
Host:
T. brucei: definitive host: human, game & domestic animals, intermediate host: tsetse fly.
T. cruzi: definitive host: human, intermediate host: reduviid or triatomine bug (kissing bug).
Infective stage:
Metacyclic trypomastigote.
T. brucei: bite of male and female tsetse fly (Glossina) & congenital transmission.
T. cruzi: bite of reduviid or triatomine bug, winged bug (kissing bug). Contaminated conjunctiva, blood
transfusion, organ transplantation and vertical (congenital) transmission, ingestion of bugs.

Lab diagnosis
A/ T. brucei:
1. Presence of trypomastigote in blood, lymph nodes, CSF.
2. Quantitative buffy coat.
3. IFA, ELISA, Card agglutination trypanosomiasis test (CATT).
B/ T. cruzi:
1. Trypomastigote (C-shaped) in blood; amastigote (round or oval) in RE cells (spleen, LN, liver, BM),
myocardium, CNS (neurological cells).
2. Aspirate from chagoma & enlarged LN (amastigotes & trypomastigotes).
3. QBC.
4. PCR.
5. Serology: confirmed by western blot.
6. Intradermal test (cruzin).
7. Biopsy (LN, muscle> amastigotes).
8. Xenodiagnosis.

T. brucei

T. cruzi

chagas
disease

T. cruzi vs T. brucei

Leishmania.
Old world leishmaniasis: L. donovani, L. tropica, L. major.
New world leishmaniasis: Leishmania braziliensis Complex and L. mexicana Complex
Habitat:
1. L. donovani: obligate intracellular parasite of reticuloendothelial cells (liver, spleen, BM & LN)>
amastigote form inside (macrophage, monocytes, PMN, endothelial cells).
2. L. Tropica & L. major: reticuloendothelial cells (clasmatocytes) of the skin.
Disease:
Leishmaniasis,
1. L. donovani: Viscral leishmaniasis(kala-azar): Liver, spleen, Dum Dum fever or kala-azar, post kala-azar
dermal leishmaniasis (PKDL) cutaneous & mucocutaneous leishmaniasis.
• PKDL: 2-10 years, after treatment, macules & papules around the mouth, then spread to the face and
to extensor surfaces of arms, trunk and legs.
2. L.tropica, L.major: Cutaneous leishmaniasis (leishmanioma) or oriental sore or Delhi boil is
characterized by skin and mucous membrane ulcers.
• L. tropica causes dry lesions (swollen and less necrotic).
• L. major causes wet lesions (necrotic and exudative), & lymphatic spread may occur with
subcutaneous nodules.

Host:
Sandfly is the vector, and intermediate host.
Reservoir host: mammals, dogs and rats, except L. donovani & L. tropica (anthroponotic, human only).
Infective stage:
Promastigote: in the digestive tract of vector sandfly and in the culture media (NNN, Hockmeyer medium).
Elongate, motile, E/C, central nucleus and kinetoplast, flagellated, no undulating membrane.
By inoculation of promastigotes through the bite of sandfly, or by crushing of the infected sandfly into the
punctured wound caused by the bite.

Lab diagnosis of visceral leishmaniasis
1. Pancytopenia, anemia, high serum protein (IgG). PBS: amastigotes form inside circulating monocytes,
neutrophils (thick film). Amastigote: round, non motile, nucleus and kinetoblast.
2. Needle biopsy/aspiration: deeper tissues: LN, BM, liver, spleen, touch preparation (amastigotes), spleen
best in kala-azar.
3. Culture (NNN).
4. DNA probes and PCR, promastigotes.
5. Animal inoculation.
6. IFA, IHA, ELISA, DAT (kala-azar).
7. Leishmanin or Montenegro test: intradermal crude leishmania antigen (killed suspension of
promastigotes)> erythema (>5mm) after cure from kala-azar.
8. PKDL: biopsy from the nodular lesions (Amastigotes).

Lab diagnosis of cutaneous leishmaniasis
1. Material obtained by puncture of the indurated edge of sore and stained with Giemsa or Wright stains
(Amastigotes inside macrophages). If negative, biopsy from the margin of ulcer, specific proof of
infection.
2. Culture NNN.
3. Leishmanin skin test.
Neal, Novy, Nicolle medium

L. donovani: phlebotomus
orientalis.
L. tropica: phlebotomus
sergenti.
L. major: phlebotomus
papatasi.

This has been a presentation of Alyazeed Hussein
Thanks for your attention and kind patience
@elyazeed7
@Alyazeed7ussein

Medical Microbiology - Parasitology

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