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NewInfections
Ova&Parasite(O&P)Exams ***Reminder: Slides and examination questions are copyrighted and
CPTCodes2016 cannotbecopiedforpublication.
Quizzes

ReviewTests
FAQ 1. The correct match between the organism and one method of
InformationTables acquiringtheinfectionis:
OrganismIndex(AZ)
a.Trypanosomabruceirhodesiensebiteofinfectedsandfleas
b.Plasmodiumfalciparumbiteofinfectedtriatomidbug
c.Leishmaniaspp.skinpenetrationofinfectiveformfromsoil
d. Plasmodium vivax bite of infected female Anopheline
mosquito

ANSWER(d):AllfourspeciesofPlasmodiumcanbetransmittedbythe
biteofAnophelinemosquitoes.
East and West African trypanosomiasis (Trypanosoma brucei
rhodesienseandT.b.gambiense)areacquiredwheninfectiveformsare
introducedinto the human body through the bite of the Tsetse fly, not
sand fleas. Leishmania spp. are generally transmitted by the bite of
variousgeneraofsandflies.

2.Babesiaisanorganismwhichhasbeenimplicatedindisease
from both splenectomized and nonsplenectomized patients.
Morphologically,theparasitesresemble:

a.Plasmodiumfalciparumrings
b.Leishmaniadonovaniamastigotes
c.Trypanosomacruzitrypomastigotes
d.Plasmodiumvivaxschizonts

ANSWER(a):Babesiaisanintracellularparasitethatcloselyresembles
theringforms(earlytrophozoites)ofPlasmodiumfalciparum.Oftenin
babesiosis there are more rings per cell and the ring form is the only
stageseen.AlthoughtheMalteseCrossringformationisseeninsome
Babesiaspp.,itisnotevidentinall.

3. Which microfilariae are usually not found circulating in the

peripheralblood?

a.Brugiamalayi
b.Wuchereriabancrofti
c.Onchocercavolvulus
d.Loaloa

ANSWER (c): The microfilariae of Onchocerca volvulus are normally

foundinthefluidrightundertheouterlayerofskin.Therefore,theskin
snipistheproperspecimentoexamine.Theothermicrofilariae listed
canbefoundinthecirculatingblood.
4. Massive hemolysis, Blackwater fever and central nervous
systeminvolvementaremostcommonwith:

a.Plasmodiumvivax
b.Plasmodiumfalciparum
c.Plasmodiumovale
d.Plasmodiummalariae

ANSWER (b): The pathogenic sequelae of malarial infections with

Plasmodiumfalciparumarethemostsevereofthefourspeciesandcan
include massive hemolysis, Blackwater fever and multiple organ
involvement,includingthecentralnervoussystem(cerebralmalaria).

5.TherearefewproceduresconsideredSTATinparasitology.The
mostobvioussituationwouldbe:

a.ovaandparasiteexaminationforgiardiasis
b.Baermannconcentrationforstrongyloidiasis
c.bloodfilmsformalaria
d.cultureforamebickeratitis

ANSWER(c):Therequestforbloodfilmsformalariashouldalwaysbe
considered a STAT request. Any laboratory providing these services
shouldhavetestingavailable24hoursperday,7daysaweek.Incases
of Plasmodium falciparum malaria, any delay in diagnosing the
infectioncouldbefatalforthepatient.

6.A60yearoldBrazilianwithcardiacirregularitiesandcongestive
heart failure suddenly dies. Examination of the myocardium revealed
numerous amastigotes, an indication that the cause of death was
probably:

a.leishmaniasiscausedbyLeishmaniadonovani.
b. leishmaniasis caused by Leishmania
braziliensis.
c. trypanosomiasis caused by Trypanosoma
gambiense.
d.trypanosomiasiscausedbyTrypanosomacruzi.

ANSWER (d): Trypanosoma cruzi, the cause of Chagas disease, has

two forms within the human, the trypomastigote in the blood and the
amastigote in the striated muscle (cardiac muscle and intestinal tract
muscle).

7.Whenmalariasmearsarerequested,whatpatientinformation
shouldbeobtained?

a.diet,age,sex
b.age,antimalarialmedication,sex
c.travelhistory,antimalarialmedication,dateofreturntoU.S.
d.feverpatterns,travelhistory,diet

ANSWER (c): Travel history (areas of drug resistance), the date of

return to the United States (primary vs. relapse case), and history of
antimalarial medication (severe illness, few organisms on smear) are
very important questions to ask. Without this information, a malaria
diagnosiscanbemissedordelayedwithseverepatientconsequences.
8.Whichofthefollowingistrueaboutonchocerciasis?

a.Theadultwormispresentintheblood.
b.Themicrofilariaeareinthebloodduringthelateeveninghours.
c.Thediagnostictestofchoiceistheskinsnip.
d.Theparasiteresidesinthedeeplymphatics.

ANSWER (c): The adult Onchocerca volvulus reside in subcutaneous

nodules and the microfilariae are found in the fluids right under the
outer layers of skin thus the appropriate diagnostic test is the
microscopicexaminationofskinsnipsforthepresenceofmicrofilariae
ratherthanbloodcollection.

9.PlasmodiumvivaxandPlasmodium ovale are similar because

they:

a.exhibitSchffnersdotsandhaveatruerelapseinthelifecycle.
b.havenomalarialpigmentbutdohavemultipleringsperRBC.
c.commonlyhaveappliquformsintheredcells.
d.havetruestippling,donothavearelapsestage,andinfectold
redcells.
ANSWER (a): Both Plasmodium vivax and Plasmodium ovale infect
youngredcells,havetruestippling(Schffnersdots),containmalarial
pigment,haveatruerelapsestageinthelifecycleandtendnottohave
multipleringspercell.

10. The main differences between finger stick and venipuncture

bloodare:

a.oxygencontentandnumberofRBCs
b. volume of blood and Plasmodium spp. parasites do not continue
developinginfingerstickblood
c.parasitemiavisibleandnumberofringforms
d.presenceofgametocytesandmatureschizonts

ANSWER(b):Usuallytheamountofbloodtakenduringafingerstickis
quitesmall,whilevenipuncturebloodisoftenapproximately7ml.Also,
whenfingerstickbloodisspreadontotheglassslide,thePlasmodium
spp.lifecycleisstoppedatthatpoint,whilethelifecyclecontinuesin
venipuncture blood that remains in the tube prior to blood film
preparation.

11.Themainbenefitofthethinbloodfilmis:

a.RBCmorphologyispreserved
b.morebloodisvisiblethanonthethickbloodfilm
c.thesensitivityisgreaterthanonthethickbloodfilm
d.thespecificityislessthanonthethickbloodfilm

ANSWER (a): One of the main benefits of the thin blood film is the
preservationoftheRBCthusparasiteswithintheRBCsarevisibleand
can be identified. Less blood is seen on the thin blood film thus
sensitivity is less than the thick blood film (less blood). However,
specificityisgreateronthethinbloodfilmanditiseasiertoidentifythe
parasitestothegenus/specieslevels.

12.AtravelerwhohasacquiredaPlasmodiumspp.infection,but
whohasneverbeenexposedtomalariabeforeisclassifiedasbeing:
a.immunologicallydeficient
b.immunologicallyimmunosuppressed
c.immunologicallymature
d.immunologicallynave

ANSWER (d): Travelers who have never been exposed to malaria

before,butwhoacquiretheinfectionarereferredtoasimmunologically
nave.Theyhavenopreexistingantibodyandareunprotected.Thus,
theycanbecomequiteillearlyonintheinfection,unlikeapatientliving
in the endemic area who has residual antibody and who may become
symptomaticlaterinthecourseoftheinfection.

13.Themainbenefitofthethickbloodfilmis:

a.thevolumeofbloodislargerthanthethinbloodfilm
b.thethickbloodfilmislesssensitiveintermsoforganismdetection
c.parasitemorphologyissuperiortothatonthethinbloodfilm
d.WBCsarenolongervisible

ANSWER(a):Thevolumeofbloodislargerthanthatseenonthethin
blood film. Actually, the thick film is more sensitive in terms of
organism detection, although parasite morphology is not as good as
thatseenonthethinbloodfilm.Also,onthethickbloodfilm,parasites,
platelets,andWBCsarevisible.

14.Whatisthebestanticoagulanttouseforbloodspecimensfor
parasitology(venipuncture)?

a.heparin
b.EDTA
c.noanticoagulantisrequired
d.doesntmatter

ANSWER(b):Althoughheparin(greentop)orEDTA(lavendertop)can
be used, EDTA is recommended as providing better organism
morphology,particularlyforPlasmodiumspp.Whenbloodiscollected
in EDTA, specimens should be processed immediately after blood
collection.

15.WhattypeofQCslidesshouldbeusedforbloodparasitework?

a.positiveslidescontainingmalarialparasites
b.positiveslidescontaininganybloodparasite
c.slidesstainedwithGiemsastainonly
d.patientslidethatyouarecurrentlystaining

ANSWER (d): Regardless of the stain you are using (Giemsa, Wright,
Wright/Giemsa, rapid stains), your QC slide is the actual slide you are
staining. This approach to QC is acceptable to CAP, as well. Any
parasites present will stain like WBCs, so your QC is built into the
system.

16.Theinfectivestagefromwhichthepatientacquiresmalariafrom
themosquitovectoris:
a.thesporozoite
b.theookinete
c.thegametocyte
d.theexflagellatingmalegametocyte

ANSWER (a): When the infected Anopheline mosquito takes a blood

meal,itinjectsinfectivesporozoitesintothewoundsite,thusinitiating
themalarialinfectioninthehuman.

17. Which of the following parasites has been linked to

splenectomized patients and transfusion transmission in the
easternUnitedStates?

a.Plasmodiumvivax
b.Trypanosomacruzi
c.Babesiaspp.
d.Leishmaniaspp.

ANSWER (c): Babesia infections have been seen in splenectomized

patients (Long Island) and have been documented in transfusion
transmission in the eastern United States. However, these cases are
notlimitedtotheeasternstates.

18.Amatureschizontisdescribedashaving8merozoitesarranged
aroundtheexcessmalarialpigmentandisseeninaninfectedRBCthat
is relatively small in size. The Plasmodium species is most probably
whichofthefollowing:

a.Plasmodiumfalciparum
b.Plasmodiumvivax
c.Plasmodiumovale
d.Plasmodiummalariae

ANSWER (d): The description above refers to the mature schizont of

Plasmodiummalariae,typicallywith8merozoitesarrangedlikeadaisy
headwithinsmallRBCs(oldercells).

19.Whenisthemostappropriatetimetodrawbloodforthickand
thinbloodfilmpreparationforthediagnosisofmalaria?

a.whenthefeverpeaks
b.afterthefeverpeaks
c.every2hours
d.immediatelyonrequest

ANSWER (d): The majority of patients we see in the US with malaria

have never been exposed to the organism before therefore they have
no antibody and when they present they do NOT have a synchronized
fever cycle. These immunologically nave patients may present with
nonspecificsymptomsthatcanmimicmanyotherdiseases.Theruleof
thumb is to draw immediately do not wait for some "magic" periodic
cyclethatmayneverappear.Patientswithaverylowparasitemiawith
P. falciparum can become quite ill before they have any type of fever
cycleorgametocytes.Withanypatientwheremalariaissuspectorthe
patienthasaFUO(feverofunknownorigin),bloodshouldbedrawnand
both thick and thin blood films prepared and examined immediately.
ThisrequestisalwaysconsideredaSTATrequest.

20.WhyisitimportantthattheEDTAbloodbeprocessedasquickly
as possible, particularly if the cap has been removed and the blood
beginstocooldown?

a.theWBCsdisappear
b.parasitemorphologychangesoccuronstanding
c.RBCcellsizechangesonstanding
d.plateletsbegintolooklikemalarialringforms

ANSWER (b): If a tube of blood containing EDTA cools to room

temperature and the cap has been removed, several parasite
morphologic changes can occur. The parasites within the RBCs will
respondasiftheywerenowinthemosquitoafterbeingtakeninwitha
blood meal. The morphology of these changes in the life cycle and
within the RBCs can cause confusion when examining blood films
prepared from this blood. Also after 46 hours, parasites begin to
disappearfromthebloodspecimen.
A.Stippling(Schffnersdots)maynotbevisible.
B.Themalegametocyte(ifpresent)mayexflagellate.
C.TheookinetesofPlasmodiumspeciesotherthanP.falciparum
maydevelopasiftheywereinthemosquitoandmaymimicthe
crescentshapedgametocytesofP.falciparum.

21. New glass slides need to be precleaned prior to blood film

preparationbecause:

a.thebloodwillfalloffboththickandthinbloodfilms
b.nofeatheredgewillbevisible
c.holeswillbevisibleintheblood
d.thebloodfilmswillnotstain

ANSWER(c):Evennewslideswillbecoatedwithaveryfinelayerofoil
(to allow the slides to be pulled apart one from the other) by
removingthecoating,thebloodwillflowmoresmoothlyovertheglass
duringbloodfilmpreparation.Holesinthebloodfilmareevidenceof
oilorgreaseontheslide.

22.Acceptablestainoptionsforbloodparasiteworkincludewhich
ofthefollowing:

a.Giemsastain
b.Giemsa,Wright,WrightGiemsa,Fieldsstains
c.Delafieldshematoxylinstain,rapidbloodstains
d.Alloftheabove

ANSWER (d): Although for many years, Giemsa stain has been the
stain of choice, the parasites can also be seen on blood films stained
with Wright's stain, a Wright/Giemsa combination stain or one of the
more rapid stains such as DiffQuik (American Scientific Products,
McGraw Park, IL), Wrights Dip Stat Stain (Medical Chemical Corp.,
Torrance,CA),orFieldsstain.Itismoreappropriatetouseastainwith
which you are familiar, rather than Giemsa which is somewhat more
complicatedtouse.PMNswillserveastheQCorganismforanyofthe
bloodstains.AnyparasitespresentwillstainlikethePMNs,regardless
ofthestainused.Also,theCAPchecklistdoesnotmandatetheuseof
Giemsastain.Delafieldshematoxylinisoftenusedtostainthesheath
ofWuchereriabancrofti(willnotstainusingGiemsastain).

23.Howshouldmalariabloodfilms(boththick and thin films) be

examined?

a.10mineachusing100xoilimmersionobjective
b.300oilimmersionfields(using100xoilobjective)
c.10minthin,20minthickfilmsusing60xoilimmersionobjective
d. screen using 60x oil immersion objective, 5 min using 100x oil
immersionobjective

ANSWER (b): A minimum of 300 oil immersion fields using the 100X
objective should be examined (for each of the blood films, thick and
thin).Thebloodfilmcanbescannedusinga50Xor60Xoilimmersion
lens,butfinalreportingoftheresultsshouldbebasedontheuseofthe
100X oil immersion lens for a total magnification of X1,000. Minutes
screened is normally not used since different individuals screen at
differentrates.Rememberthattheentirebloodfilmshouldbescreened
usingthe10Xlowpowerobjectivetodetectmicrofilariaebeforemoving
tooilimmersion.

24. It is important to rule out infections with Plasmodium

falciparumbecause:

a.thisspeciescausesthemostseriousmalarialillness
b.thisspeciesisthemostcommonseenintheUnitedStates
c.thisspeciesinfectsonlytheyoungRBCs
d.thisspeciesalwayscausesblackwaterfever

ANSWER(a):P.falciparumcausesmoreseriousdiseasethantheother
threespecies(P.vivax,P.ovale,andP.malariae).P.falciparumtendsto
invade all ages of RBCs, and the proportion of infected cells may
exceed 50%. Schizogony occurs in the internal organs (spleen, liver,
bonemarrow,etc.)ratherthaninthecirculatingblood.Ischemiacaused
bythepluggingofvesselswithintheseorgansbymassesofparasitized
RBCs will produce various symptoms, depending on the organ
involved. However, blackwater fever does not always occur in cases
withP.falciparum.
OnsetofaP.falciparummalariaattackoccursfrom8to
12 days after infection and is preceded by 3 to 4 days of vague
symptoms such as aches, pains, headache, fatigue, anorexia, or
nausea. The onset is characterized by fever, a more severe headache,
andnauseaandvomiting,withoccasionalsevereepigastricpain.There
may be only a feeling of chilliness at the onset of fever. Periodicity of
the cycle will not be established during the early stages, and the
presumptive diagnosis may be totally unrelated to a possible malaria
infection.Ifthefeverdoesdevelopasynchronouscycle,itisusuallya
cycle of somewhat less than 48 h. An untreated primary attack of P.
falciparummalariausuallyendswithin2to3weeks.Truerelapsesfrom
theliverdonotoccur,andafterayear,recrudescencesarerare.Severe
or fatal complications of P. falciparum malaria can occur at any time
during the infection and are related to the plugging of vessels in the
internal organs, the symptoms depending on the organ(s) involved.
NOTE:Theprimaryobjectivewhenperformingbloodfilm examination
for parasites is to rule out P. falciparum. Although rare, it is now
importanttoexaminethebloodfilmsforthepossibilityofinfectionwith
thefifthhumanmalaria,P.knowlesi(cancauseseveredisease).

25. RBCs containing multiple rings/cell are usually seen in

infectionswith:

a.Plasmodiumvivax
b.Plasmodiumovale
c.Plasmodiummalariae
d.Plasmodiumfalciparum

ANSWER (d): Although multiple rings/cell are occasionally seen in

infectionswithP.vivax,examplesaremuchmorecommonininfections
withP.falciparum.

26. A mature schizont containing 1618 merozoites within an

enlargedRBCismostlikely:

a.Plasmodiumfalciparum
b.Plasmodiumvivax
c.Plasmodiumovale
d.Plasmodiummalariae

ANSWER(b):BothP.vivaxandP.ovaletendtoinfectyoungRBCsthat
appear to be enlarged. However, the mature schizont of P. vivax
containsapproximately1618merozoites.

27.Itisimportanttoidentifymalariaparasitestothespecieslevel
because:

a.differenttherapymayberequired
b.itisimportanttoanticipateperiodicity
c.mixedinfectionsareverycommon
d.noneoftheabove

ANSWER(a):SinceP.falciparumcancauseseverediseaseanddeath,
itisveryimportantforthephysiciantoknowwhetherthisinfectioncan
be ruled out. It is also important to know if any of the other three
species are present, particularly P. vivax or P. ovale, which would
require therapy for both the liver and RBC stages due to potential
relapsefromtheliverstages.Itisalsoimportantbecauseofpotential
drug resistance [chloroquine, P. falciparum, P. vivax primaquine
tolerance/resistance,P.vivax(rare,butdocumented)].

28:Findingonlyringformsontwosetsofbloodfilmsdrawn6h
apartmaysuggest:
a.thepossibilityofamixedinfection
b.thepossibilityofaninfectionwithP.vivax
c.theprobabilityofaninfectionwithP.falciparum
d.theprobabilityofaninfectionwithP.ovale

ANSWER (c): Remember that all of the life cycle stages (rings,
developing trophozoites, early schizonts, late schizonts, mature
schizonts, and gametocytes) can be seen on the blood films in
infections with P. vivax, P. ovale, and P. malariae. Due to unique
characteristics of the life cycle, only rings and gametocytes (and
occasionalmatureschizonts)areseenintheperipheralbloodwithaP.
falciparum infection. Therefore, if you see two sets of blood films
(collected 6 h apart) that contain ring forms only, there is an excellent
chancethepatientisinfectedwithP.falciparum,themostseriousofthe
fourPlasmodiumspp.infections.

29.InfectionswithP.ovaleorP.vivaxrarelygoabove:

a.20%
b.10%
c.7%
d.2%

ANSWER (d): Because they infect young RBCs only, the parasitemia
rarelygoesabove2%.

30.WhyarentgametocytesofP.falciparumseeninmanypatients
presentingtotheEmergencyRoom(ER)?

a.nogametocytesareformedinmostinfections
b.itistooearlyinthecycletoseegametocytes
c.treatmenthasdestroyedthegametocytes
d.theparasitemiaistoolow

ANSWER (b): Many patients present to the ER early in the infection

prior to the formation of the gametocytes thus the diagnosis must be
made based on seeing the ring forms only. As you can imagine,
identification of Plasmodium to the species level can be very difficult
when rings only are present. These patients tend to be travelers who
have had no prior exposure to P. falciparum (immunologically nave)
and who become symptomatic very early after being infected. It
normally takes approximately 10 days for the crescentshaped P.
falciparumgametocytestoform.

31. A developing trophozoite has been described as follows:

enlargedRBC,veryameboidtroph,presenceofSchffnersdots.The
speciesismostlikely:

a.Plasmodiumvivax
b.Plasmodiumovale
c.Plasmodiummalariae
d.Plasmodiumfalciparum

ANSWER(a):AlthoughbothP.vivaxandP.ovaleareseeninenlarged
RBCs and both have Schffners dots, P. vivax has very ameboid
trophs,whilethoseofP.ovalearenot.


P.vivaxP.ovale

32.Atrypomastigoteseeninathinbloodfilmisdescribedasbeing
somewhat C shaped, has an undulating membrane and a very large
kinetoplast.Itismostlikely:

a.Trypanosomabruceirhodesiense
b.Trypanosomarangeli
c.Trypanosomacruzi
d.Trypanosomabruceigambiense

ANSWER (c): Typically, T. cruzi can be seen in a C shape, has an

undulating membrane like the other trypomastigotes, but has a very
largekinetoplast.

T.cruziT.b.gambienseorrhodesiense

33. The possibility of finding amastigotes in buffy coat cells is

limitedto:

a.Leishmaniatropica
b.Leishmaniabraziliensis
c.Leishmaniadonovani
d.Alloftheabove

ANSWER (c): While the amastigotes of L. tropica (cutaneous) and L.

braziliensis(mucocutaneous)arefoundinthemacrophagesoftheskin
and mucous membranes, the amastigotes of L. donovani are found in
the macrophages of the spleen, liver, bone marrow, and occasionally
buffycoatcells(monocytes).Thus,ifthelesionisconfinedtotheskin
and/ormucousmembranes,amastigotes will not be found in the buffy
coatcells.

34.Whichofthefollowingareimportanttoincludeinareportfrom
bloodfilmexaminationformalaria?

a.Genus,species
b.Parasitemia,possiblemixedinfection
c.AbilitytoruleoutP.falciparum
d.Alloftheabove
 ANSWER(d):Alloftheaboveisthecorrectresponse.
Using the thin blood film method, report the percentage of parasite
infectedRBCsper100RBCscounted.
Example:Plasmodiumfalciparum,parasitemia=0.01%
Usingthethick/thinbloodfilmmethod,reportthenumberofparasitesper
lofblood.
Example:Plasmodiumfalciparum,parasitemia=10,000perlofblood
It is important to convey to the physicianthatP. falciparum cannot be ruled
out therapy may be initiated on the assumption that this species might be
present.Thereportshouldread:
Example:Plasmodium spp. present unable to rule out Plasmodium
falciparum.
It is important to remember that mixed infections are much more common
than suspected and/or reported. When rings are present, along with other
developing stages (P. vivax, P. ovale, P. malariae) always look for the
presence of two populations of ring forms, one of which might be P.
falciparum!Thereportshouldread:
Example:Plasmodiumspp.present,possible mixedinfectionunable
to rule out P. falciparum. Another report example might be:
Plasmodium vivax rings, developing schizonts, and gametocytes
possiblemixedinfection:unabletoruleoutP.falciparum.

35.ProficiencyTestingbloodfilmscanbeexaminedasfollows:

a. Screenwith 10x, screen with 60x oil, and 300 fields with 100 x oil
objective
b.Screenwith60xoil,300fieldswith100xoilobjective
c.300fieldswith100xoilobjective
d.100fieldswith100xoilobjective

ANSWER (a): Since you have no idea what organisms might be

present, always review the blood films using the 10X objective (entire
slide). This examination is likely to reveal any microfilariae that are
presenthowever,smallparasiteslikePlasmodiumandBabesiamaybe
missed. It is also acceptable to screen the films using a 50 or 60x oil
immersion objective however, remember than very young ring forms
can be missed. Therefore, before reporting the smear as negative,
examineatleast300oilimmersionfieldsusingthe100Xoilimmersion
lens.

REFERENCES
Garcia,L.S.2016.DiagnosticMedicalParasitology, 6th Ed., ASM Press,
Washington,D.C.

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