Infections by Intestinal Coccidia and Giardia duodenalis

Identification of End-Binding 1 Protein as Novel α-4 Giardin-Binding Partners in Giardia lamblia Trophozoites

BACKGROUND

Giardia lamblia (syn. G. intestinalis, G. duodenalis) is a primitive opportunistic protozoon, and one of the earliest differentiated eukaryotes. Despite its primitive nature, G. lamblia has a sophisticated cytoskeleton system, which is closely related to its proliferation and pathogenicity. Meanwhile, α giardin is a G. lamblia-specific cytoskeleton protein, which belongs to the annexin superfamily. Interestingly, G. lamblia has 21 annexin-like α giardins, i.e., more than higher eukaryotes. The functional differences among α giardin members are not fully understood.

METHODS

We took α-4 giardin, a member of α giardin family, as a research object. A morpholino-mediated knockdown experiment was performed to identify the effect of α-4 giardin on G. lamblia trophozoites biological traits. A yeast two-hybrid cDNA library of G. lamblia strain C2 trophozoites was screened for interaction partners of α-4 giardin. Co-immunoprecipitation and fluorescent colocalization confirmed the relationship between G. lamblia EB1 (gEB1) and α-4 giardin.

RESULTS

α-4 Giardin could inhibit the proliferation and adhesion of G. lamblia trophozoites. In addition, it interacted with G. lamblia EB1 (gEB1).

CONCLUSIONS

α-4 Giardin was involved in proliferation and adhesion in G. lamblia trophozoites, and EB1, a crucial roles in mitosis, was an interacting partner of α-4 giardin.

Prevalence of intestinal parasites and comparison of detection techniques for soil-transmitted helminths among newly arrived expatriate labors in Jeddah, Saudi Arabia

Background

Diversity in clinical signs and symptoms are associated with soil transmitted diseases (STD), which are spread to humans by intestinal worms and transmitted in a variety of ways. There is a need for the present study, which aimed to investigate the prevalence of intestinal parasites and to compare between the common detection techniques for soil-transmitted helminths (STHs) among newly arrived expatriate labors in Jeddah, Saudi Arabia.

Methods

A total of 188 stool samples were analyzed by macroscopic examination, and microscopic examination using direct iodine smear and the formal ether sedimentation technique. Trichrome and modified Kinyoun's stains were used to confirm the morphology of any detected protozoa stages and oocyst of Cryptosporidium, respectively. A chromatographic immunoassay kit was used for Entamoeba histolytica, Giardia lamblia and Cryptosporidium. In addition, real-time PCR was employed only to identify various STHs.

Results

Out of 188, several types of parasites were detected in 35 samples (18.62%), of which some with multiple infections. Nine samples (4.79%) were positive for Entamoeba coli, seven samples (3.72%) for Trichuris trichiura, six samples (3.19%) for Necator americanus, four samples (2.13%) for Strongyloides stercoralis, four samples (2.13%) for Ascaris lumbricoides, four samples (2.13%) for E. histolytica, three samples (1.60%) for Blastocystis hominis and two samples (1.06%) for Ancylostoma duodenale. In comparison between laboratory techniques for STHs, real-time PCR was able to detect the DNA of 19 samples (10.1%) followed by Ritchie sedimentation technique (18, 9.6%), and direct smear (7, 3.7%) (p > 0.05).

Conclusion

The high rate of newly arrived foreign workers infected with intestinal parasites could lead to a risk to society. Continuous and regular surveys are needed to deal with the occurrence of intestinal parasitic infections including STHs. To improve the identification of these infections, we recommend a supporting infrastructure for the application of concentration methods and molecular assays.

Study of the economic impact of cryptosporidiosis in calves after implementing good practices to manage the disease on dairy farms in Belgium, France, and the Netherlands

Cryptosporidium spp. are widespread parasitic protozoans causing enteric infections in humans and animals. The parasites cause neonatal diarrhoea in calves, leading to a high mortality rate in the first three weeks. Losses are significant for farmers, but the cost of cryptosporidiosis remains poorly documented. In the absence of a vaccine, only preventive measures are available to farmers to combat the infection. This study, conducted between 2018 and 2021, aimed to evaluate the economic impact of Cryptosporidium spp. on European dairy farms and monitor changes in costs after implementing disease management measures. First, a field survey was carried out and questionnaires administered to 57 farmers in Belgium, France, and the Netherlands. The aim of the survey was to assess the losses associated with the occurrence of diarrhoea in calves aged between 3 days and 3 weeks. The economic impact of diarrhoea was calculated based on mortality losses, health expenditures, and additional labour costs. To refine the cost estimation specifically for Cryptosporidium spp., stool samples were collected from 10 calves per farm. The prevalence of Cryptosporidium spp. was determined, and the economic impact of diarrhoea was adjusted accordingly. The assumption was made that a certain percentage of costs was attributed to cryptosporidiosis based on the prevalence. These protocols were repeated at the end of the study to observe changes in costs. In the three years, the cost of diarrhoea for the 28 farms that stayed in the panel all along the study improved from €140 in 2018 to €106 on average per diarrhoeic calf in 2021. With a stable prevalence at 40%, the cost of cryptosporidiosis per infected calf decreased from €60.62 to €45.91 in Belgium, from €43.83 to €32.14 in France, and from €58.24 to €39.48 in the Netherlands. This represented an average of €15 saved per infected calf. The methodology employed in this study did not allow us to conclude that the improvement is strictly due to the implementation of preventive measures. However, with 11 million calves raised in the Interreg 2 Seas area covered by the study, it provided valuable insights into the economic burden of Cryptosporidium spp.

The Landscape of Parasitic Infections in the United States

The landscape of parasitic infections in the United States has shifted dramatically over the past century. Although infections such as malaria have been successfully eliminated, others remain endemic and pose a significant public health risk. Numerous parasitic infections are also imported each year. This article focuses on endemic parasitic infections that may be commonly seen in anatomical pathology preparations and discusses their biology, diagnostic histopathological features, and epidemiology.

British Association of Sexual Health and HIV (BASHH) United Kingdom national guideline for the management of sexually transmitted enteric infections 2023

This is the first British Association of Sexual Health and HIV (BASHH) national guideline for the management of sexually transmitted enteric infections (STEI). This guideline is primarily aimed for level 3 sexual health clinics; however, it may also be applicable to other settings such as primary care or other hospital departments where individuals with STEI may present. This guideline makes recommendations on testing, management, partner notification and public health control of STEI.

Development of a new multiplex PCR to detect fecal coccidian parasite

BACKGROUND

Cryptosporidium spp., Cystoisospora belli and Cyclospora cayetanensis are common intestinal coccidian parasites causing gastroenteritis. The clinical presentation caused by each parasite is indistinguishable from each other. Uniplex polymerase chain reaction (PCR) for these three groups of intestinal coccidian parasites was developed by us in our laboratory. Thereafter, we planned to develop a single-run multiplex polymerase chain reaction (mPCR) assay to detect Cryptosporidium spp., C. belli and C. cayetanensis simultaneously from a stool sample and described it here as coccidian mPCR.

METHODS

New primers for C. belli and C. cayetanensis were designed and uniplex PCRs were standardized. The coccidian mPCR was standardized with known positive DNA control isolates. It was validated with 58 known positive and 58 known negative stool samples, which were previously identified by uniplex PCR.

RESULTS

The coccidian mPCR was standardized with earlier primers designed by us for Cryptosporidium spp. and C. cayetanensis, and a newly designed primer for the internal transcribed spacer-1 (ITS-1) gene for C. belli. The coccidian mPCR was 92.1% sensitive for Cryptosporidium spp., and 100% sensitive for C. belli and C. cayetanensis each, when tested on 116 known samples. It was 100% specific for all intestinal coccidian parasites. Two representative PCR products of the newly designed ITS-1 primer for C. belli were sequenced and submitted to the GenBank, which best match with the sequences of C. belli.

CONCLUSION

A highly sensitive, specific, cost-effective, indigenous, single-run coccidian mPCR has been developed, which can simultaneously detect Cryptosporidium spp., C. belli and C. cayetanensis.

Mass Spectrometry-Based Metabolomics Revealed Effects of Metronidazole on Giardia duodenalis

Giardia duodenalis is a significant protozoan that affects humans and animals. An estimated 280 million G. duodenalis diarrheal cases are recorded annually. Pharmacological therapy is crucial for controlling giardiasis. Metronidazole is the first-line therapy for treating giardiasis. Several metronidazole targets have been proposed. However, the downstream signaling pathways of these targets with respect to their antigiardial action are unclear. In addition, several giardiasis cases have demonstrated treatment failures and drug resistance. Therefore, the development of novel drugs is an urgent need. In this study, we performed a mass spectrometry-based metabolomics study to understand the systemic effects of metronidazole in G. duodenalis. A thorough analysis of metronidazole processes helps identify potential molecular pathways essential for parasite survival. The results demonstrated 350 altered metabolites after exposure to metronidazole. Squamosinin A and N-(2-hydroxyethyl)hexacosanamide were the most up-regulated and down-regulated metabolites, respectively. Proteasome and glycerophospholipid metabolisms demonstrated significant differential pathways. Comparing glycerophospholipid metabolisms of G. duodenalis and humans, the parasite glycerophosphodiester phosphodiesterase was distinct from humans. This protein is considered a potential drug target for treating giardiasis. This study improved our understanding of the effects of metronidazole and identified new potential therapeutic targets for future drug development.

Enteric protozoal infections in camels: Etiology, epidemiology, and future perspectives

Camels have great potential as a safety valve for current and future food security for pastoralists, agropastoralists, and urban populations. Enteric protozoal diseases are important causes of economic losses in camels; however, they are poorly concerned globally. The most common members of enteric protozoa are Balantidium, Eimeria, Giardia, and Cryptosporidium. Some of them threaten human health as humans can be infected by consuming food or water contaminated with camel feces, particularly in poor communities with inadequate sanitation and low-quality healthcare facilities. For these reasons, a comprehensive and careful investigation was conducted on some enteric protozoal diseases of camels to present an updated insight into the etiology, epidemiology, and future trends in diagnosing and controlling camel enteric protozoa. Future studies on the camel enteric protozoa should be carried out to develop advanced diagnostic approaches in diverse farm animal species. Moreover, the protozoan zoonotic potential should be considered to secure human health.

Intestinal pseudo-obstruction caused byGiardia lambliainfection

A woman in her 40s presented with malaise, nausea, reduced appetite, abdominal distention, loose stools and weight loss. Symptoms had started 6 months earlier and worsened in the last 2 weeks. CT enterography showed hypotonic dilated small bowel loops in absence of any mechanical obstruction. Endoscopic examinations including capsule endoscopy did not reveal any obstructing lesion, but a delayed small bowel transit time of the capsule. Duodenal histology revealed Marsh 3a villous atrophy. Secondary causes of intestinal pseudo-obstruction and villous atrophy were investigated.Giardia lambliatrophozoites were found in the stools and in the duodenal biopsies. The patient’s symptoms quickly resolved after metronidazole treatment with complete normalisation of duodenal histology.

Investigating the Potential Effects of COVID-19 Pandemic on Intestinal Coccidian Infections

New infectious agents pose a global threat to the healthcare system, and studies are conducted to estimate their health and epidemiological outcomes in the long run. The SARS-CoV-2 virus, which has caused the COVID-19 disease, was formerly assumed to be a respiratory virus; however, it can have serious systemic effects, affecting organs such as the gastrointestinal tract (GIT). Viral RNA was reported in the stool in a subset of patients, indicating another mode of transmission and diagnosis. In COVID-19, prolonged GIT symptoms, especially diarrhea, were associated with reduced diversity and richness of gut microbiota, immunological dysregulation, and delayed viral clearance. Intestinal coccidian parasites are intracellular protozoa that are most typically transmitted to humans by oocysts found in fecally contaminated food and water. Their epidemiological relevance is coupled to opportunistic infections, which cause high morbidity and mortality among immunocompromised individuals. Among immunocompetent people, intestinal coccidia is also involved in acute diarrhea, which is usually self-limiting. Evaluating the available evidence provided an opportunity to carefully consider that; the COVID-19 virus and coccidian protozoan parasites: namely, Cryptosporidium spp., Cyclospora cayetanensis, and Isospora belli, could mutually influence each other from the microbiological, clinical, diagnostic, and elimination aspects. We further systemically highlighted the possible shared pathogenesis mechanisms, transmission routes, clinical manifestations, parasite-driven immune regulation, and intestinal microbiota alteration. Finally, we showed how this might impact developing and developed countries prevention and vaccination strategies. To the best of our knowledge, there is no review that has discussed the reciprocal effect between coccidian parasites and COVID-19 coinfection.

Detection of Giardia duodenalis Zoonotic Assemblages AI and BIV in Pet Prairie Dogs (Cynomys ludovicanus) in Bangkok, Thailand

Giardia is a flagellate protozoa that can be transmitted via direct contact and by consuming contaminated water. It is pathogenic in humans and various other animals, including exotic pets. Pet prairie dogs are popular in Thailand, but they have not been investigated regarding giardiasis. Giardia infection was measured, and genetic characterization was performed to investigate the zoonotic potential of Giardia carried by pet prairie dogs. In total, 79 fecal samples were examined from prairie dogs visiting the Kasetsart University Veterinary Teaching Hospital during 2017–2021. Simple floatation was conducted. Two Giardia-positive samples were submitted for DNA extraction, PCR targeting the Giardiassu rRNA, tpi and gdh genes was performed, and genetic characterization using sequencing analysis was conducted. Risk factors associated with Giardia infection were analyzed. Giardia infection was found in 11 out of the 79 pet prairie dogs (13.9%). Giardia infection was significantly higher in male prairie dogs (p = 0.0345). Coccidia cysts (12.7%), the eggs of nematodes (6.3%), and amoeba cysts (2.5%) were also detected. Genetic characterization of the two Giardia-positive samples revealed that they were G. duodenalis assemblage A, sub-genotypes AI and assemblage B, and sub-genotype BIV, the zoonotic assemblages. This was the first report of Giardia infection in pet prairie dogs in Bangkok, Thailand. The results revealed that these pet prairie dogs in Thailand were infected with zoonotic assemblages of G. duodenalis sub-genotype AI, which might have been derived from animal contaminants, whereas sub-genotype BIV might have been derived from human contaminants. Owners of prairie dogs might be at risk of giardiasis or be the source of infection to their exotic pets.

Wastewater treatment performance in microbiological removal and (oo)cyst viability assessed comparatively to fluorescence decay

Municipal wastewater is a source of pathogenic protozoan (oo)cysts and may play a significant role in spreading waterborne diseases. This scenario becomes more critical as treated sewage from municipal wastewater treatment plants (WWTP) is discharged into springs, which are often used for water supply, irrigation, recreation and, further downstream, indirect potable reuse, quite common in Brazil. This study aimed to elucidate, regarding microbiological quality, the performance of a full-scale WWTP, consisting of preliminary treatment, upflow anaerobic sludge blanket (UASB) reactor, activated sludge system and ultraviolet (UV) radiation disinfection. Pathogenic protozoa (Giardia spp. cysts and Cryptosporidium spp. oocysts), as well as microbiological indicators (Escherichia coli and Clostridium perfringens), were evaluated in terms of their removal. In addition, (oo)cyst viability and fluorescence reduction were assessed. By using the data obtained from this research, the prevalence of infection estimated for the population served by the WWTP was between 7.4% and 14.8% for giardiasis, and between 0.055% and 0.11% for cryptosporidiosis.

Comparison of Three Real-Time PCR Assays for the Detection of Cyclospora cayetanensis in Stool Samples Targeting the 18S rRNA Gene and the hsp70 Gene

Diagnostic real-time PCR for the detection of Cyclospora cayetanensis in human stool samples has been applied for two decades. However, recent comparative assessments between in-house and commercial assays suggested room for improvement regarding the agreement of positive signals of the applied real-time PCRs. In order to assess the effect of the choice of the target sequence, 3 inhouse real time PCR assays targeting the 18S rRNA gene (n = 2, one of them later referred to as SSU rRNA gene assay to avoid confusion) and the hsp70 gene of C. cayetanensis were compared in a head-to-head comparison with 905 samples with high pretest probability for C. cayetanensis infections from Ghanaian HIV patients in a test comparison without a reference standard. Only slight agreement kappa of 0.095 was observed. In the assays targeting the SSU rRNA gene, the 18S rRNA gene, and hsp70, positive signals were recorded in 63, 45, and 0 instances, respectively, with latent class analysis-based estimation of sensitivity of 32.2%, 23.3%, 0% as well as of specificity of 99.7%, 99.9% and 100%, respectively. High cycle threshold values with an average of about 35 indicated low quantities of target DNA in the samples with similar Ct values in concordantly and discordantly positive samples. In conclusion, the study suggested target-gene-specific differences in the diagnostic accuracy of real-time PCR-based diagnosis of C. cayetanensis as well as an ongoing need for further standardization of this diagnostic approach.

Literature Review: Coinfection in Young Ruminant Livestock-Cryptosporidium spp. and Its Companions

The protozoan Cryptosporidium parvum is one of the major causative pathogens of diarrhoea in young ruminants; therefore, it causes economic losses and impairs animal welfare. Besides C. parvum, there are many other non-infectious and infectious factors, such as rotavirus, Escherichia coli, and Giardia duodenalis, which may lead to diarrhoeic disease in young livestock. Often, more than one infectious agent is detected in affected animals. Little is known about the interactions bet-ween simultaneously occurring pathogens and their potential effects on the course of disease. In this review, a brief overview about pathogens associated with diarrhoea in young ruminants is presented. Furthermore, information about coinfections involving Cryptosporidium is provided.

Giardia duodenalis and Its Secreted PPIB Trigger Inflammasome Activation and Pyroptosis in Macrophages through TLR4-Induced ROS Signaling and A20-Mediated NLRP3 Deubiquitination

The extracellular protozoan parasite Giardia duodenalis is a well-known and important causative agent of diarrhea on a global scale. Macrophage pyroptosis has been recognized as an important innate immune effector mechanism against intracellular pathogens. Yet, the effects of noninvasive Giardia infection on macrophage pyroptosis and the associated molecular triggers and regulators remain poorly defined. Here we initially observed that NLRP3 inflammasome-mediated pyroptosis was activated in Giardia-treated macrophages, and inhibition of ROS, NLRP3, or caspase-1 could block GSDMD cleavage, IL-1β, IL-18 and LDH release, and the cell viability reduction. We also confirmed that Giardia-induced NLRP3 inflammasome activation was involved in its K63 deubiquitination. Thus, six candidate deubiquitinases were screened, among which A20 was identified as an effective regulator. We then screened TLRs on macrophage membranes and found that upon stimulation TLR4 was tightly correlated to ROS enhancement, A20-mediated NLRP3 deubiquitination, and pyroptotic signaling. In addition, several Giardia-secreted proteins were predicted as trigger factors via secretome analysis, of which peptidyl-prolyl cis-trans isomerase B (PPIB) independently induced macrophage pyroptosis. This was similar to the findings from the trophozoite treatment, and also led to the TLR4-mediated activation of NLRP3 through K63 deubiquitination by A20. Collectively, the results of this study have significant implications for expanding our understanding of host defense mechanisms after infection with G. duodenalis.

Pre-and post-treatment evaluation of intestinal inflammation in Giardia and Blastocystis infected children: a community-based study

Giardia intestinalis and Blastocystis hominis cause frequent infections in children in developing countries. However, the role of intestinal inflammation in their pathogenesis is still poorly understood. Faecal calprotectin (FC) level is used as an indicator of intestinal inflammation and neutrophil migration in the intestinal tract. The present study aimed to evaluate intestinal inflammation by measuring FC level among children infected with either G. intestinalis or B. hominis before and after treatment. Stool samples were collected from 282 children inhabiting a rural area in Egypt and examined microscopically for intestinal parasites. FC level was estimated in a group of children infected with G. intestinalis (n = 12) or B. hominis (n = 12) before and 3 weeks after receiving nitazoxanide (200 mg twice daily for 3 days) and compared to a control group (n = 18) of parasite-free children. Cases of mixed infection were excluded. Nitazoxanide cure rate was 83% in both infections with a remarkable reduction of infection intensity in uncured children. The difference in FC levels between infected children and controls was not statistically significant. Also, the difference between the pre- and post-treatment estimations was not statistically significant. Elevated levels were observed before treatment in three children (two infected with G. intestinalis and one with B. hominis) who displayed normal post-treatment levels. Although G. intestinalis and B. hominis infections appear to cause no remarkable intestinal inflammation, they may induce abnormally elevated FC levels in a subset of children.

An annotated checklist of the eukaryotic parasites of humans, exclusive of fungi and algae

The classification of "parasites" in the medical field is a challenging notion, a group which historically has included all eukaryotes exclusive of fungi that invade and derive resources from the human host. Since antiquity, humans have been identifying and documenting parasitic infections, and this collective catalog of parasitic agents has expanded considerably with technology. As our understanding of species boundaries and the use of molecular tools has evolved, so has our concept of the taxonomy of human parasites. Consequently, new species have been recognized while others have been relegated to synonyms. On the other hand, the decline of expertise in classical parasitology and limited curricula have led to a loss of awareness of many rarely encountered species. Here, we provide a comprehensive checklist of all reported eukaryotic organisms (excluding fungi and allied taxa) parasitizing humans resulting in 274 genus-group taxa and 848 species-group taxa. For each species, or genus where indicated, a concise summary of geographic distribution, natural hosts, route of transmission and site within human host, and vectored pathogens are presented. Ubiquitous, human-adapted species as well as very rare, incidental zoonotic organisms are discussed in this annotated checklist. We also provide a list of 79 excluded genera and species that have been previously reported as human parasites but are not believed to be true human parasites or represent misidentifications or taxonomic changes.

From celiac disease to coccidia infection and vice-versa: The polyQ peptide CXCR3-interaction axis

Zonulin is a physiological modulator of intercellular tight junctions, which upregulation is involved in several diseases like celiac disease (CeD). The polyQ gliadin fragment binds to the CXCR3 chemokine receptor that activates zonulin upregulation, leading to increased intestinal permeability in humans. Here, we report a general hypothesis based on the structural connection between the polyQ sequence of the immunogenic CeD protein, gliadin, and enteric coccidian parasites proteins. Firstly, a novel interaction pathway between the parasites and the host is described based on the structural similarities between polyQ gliadin fragments and the parasite proteins. Secondly, a potential connection between coccidial infections as a novel environmental trigger of CeD is hypothesized. Therefore, this report represents a promising breakthrough for coccidian research and points out the potential role of coccidian parasites as a novel trigger of CeD that might define a preventive strategy for gluten-related disorders in general. Also see the video abstract here: https://youtu.be/oMaQasStcFI.

Cyclosporiasis-Updates on Clinical Presentation, Pathology, Clinical Diagnosis, and Treatment

Cyclospora cayetanensis is an intestinal coccidian parasite transmitted to humans through the consumption of oocysts in fecally contaminated food and water. Infection is found worldwide and is highly endemic in tropical and subtropical regions with poor sanitation. Disease in developed countries is usually observed in travelers and in seasonal outbreaks associated with imported produce from endemic areas. Recently, summertime outbreaks in the United States have also been linked to locally grown produce. Cyclosporiasis causes a diarrheal illness which may be severe in infants, the elderly, and immunocompromised individuals. The increased adoption of highly sensitive molecular diagnostic tests, including commercially available multiplex panels for gastrointestinal pathogens, has facilitated the detection of infection and likely contributed to the increased reports of cases in developed countries. This manuscript reviews important aspects of the biology, epidemiology, and clinical manifestations of C. cayetanensis and provides an in-depth discussion of current laboratory diagnostic methods.

Comparison of Two Real-Time PCR Assays Targeting Ribosomal Sequences for the Identification of Cystoisospora belli in Human Stool Samples

Cystoisospora (C.) belli is a coccidian parasite associated with acute or chronic gastroenteritis in immunocompromised patients. Dissatisfactory sensitivity of microscopy as the diagnostic standard approach has been described. Here, we comparatively evaluated two real-time PCRs targeting ribosomal RNA gene sequences of C. belli in stool in a test comparison without a reference standard applying latent class analysis. Therefore, 1000 stool samples from Ghanaian HIV (human immunodeficiency virus) patients (n = 905) as well as military returnees from the tropics (n = 95) were assessed by both assays in parallel. After the exclusion of 33 samples showing PCR inhibition, 29 and 33 positive results were recorded with the 5.8S rRNA gene/ITS-2 sequence PCR and the ITS-2 sequence PCR, respectively, resulting in an accuracy-adjusted prevalence of 3.2%. Nearly perfect agreement between both assays was indicated by Fleiss’ kappa of 0.933 with sensitivity and specificity of 92.8% and 100% as well as 100% and 99.8% for the 5.8S rRNA gene/ITS-2 sequence PCR and the ITS-2 sequence PCR, respectively. Both assays proved to be suitable for the diagnosis of C. belli in human stool samples with slightly better sensitivity of the ITS-2 sequence assay, while the 5.8S rRNA gene/ITS-2 sequence PCR may be considered for confirmatory testing.

Giardia duodenalis: Biology and Pathogenesis

Giardia duodenalis captured the attention of Leeuwenhoek in 1681 while he was examining his own diarrheal stool, but, ironically, it did not really gain attention as a human pathogen until the 1960s, when outbreaks were reported. Key technological advances, including in vitro cultivation, genomic and proteomic databases, and advances in microscopic and molecular approaches, have led to an understanding that this is a eukaryotic organism with a reduced genome rather than a truly premitochondriate eukaryote. This has included the discovery of mitosomes (vestiges of mitochondria), a transport system with many of the features of the Golgi apparatus, and even evidence for a sexual or parasexual cycle. Cell biology approaches have led to a better understanding of how Giardia survives with two nuclei and how it goes through its life cycle as a noninvasive organism in the hostile environment of the lumen of the host intestine. Studies of its immunology and pathogenesis have moved past the general understanding of the importance of the antibody response in controlling infection to determining the key role of the Th17 response. This work has led to understanding of the requirement for a balanced host immune response that avoids the extremes of an excessive response with collateral damage or one that is unable to clear the organism. This understanding is especially important in view of the remarkable ranges of early manifestations, which range from asymptomatic to persistent diarrhea and weight loss, and longer-term sequelae that include growth stunting in children who had no obvious symptoms and a high frequency of postinfectious irritable bowel syndrome (IBS).

Cryptosporidium and waterborne outbreaks - A mini review

Cryptosporidium spp. is one of the prime agents of infectious diarrhea. Cryptosporidium spp. has been gaining awareness as a pathogen of public health importance in India and other developing countries. Owing to the nature of multiple transmission routes such as person-to-person, animal-to-person, waterborne and foodborne, the epidemiology of cryptosporidiosis in humans is not well known. A deeper understanding of the pathogenesis may lead to better diagnosis and better treatment of the condition. Asymptomatic human and animal transmission illustrates that the spread of infection through the environment is a more plausible explanation, waterborne transmission in particular. The disease burden is underestimated and its global impact is yet to be quantified due to the lack of country-specific estimates. Assessment of the disease itself has been crucial since the morphological indistinguishability, differences in distribution and transmission, and variations in the genotypes.

Seasonal Differences in Cyclospora cayetanensis Prevalence in Colombian Indigenous People

Fecal-orally transmitted cyclosporiasis is frequent in remote resource-limited settings in Central and South America with poor hygiene conditions. In this study, we aimed at assessing seasonal effects on the epidemiology of colonization or infection with C. cayetanensis in Colombian indigenous people living under very restricted conditions. In the rainy season between July and November and in the dry season between January and April, stool samples from indigenous people with and without gastrointestinal symptoms were collected and screened for C. cayetanensis applying in-house real-time polymerase chain reaction (PCR). In the rainy season and in the dry season, positive PCR results were observed for 11.8% (16/136) and 5.1% (15/292), respectively, with cycle threshold (Ct) values of 30.6 (±3.4) and 34.4 (±1.6), respectively. Despite higher parasite loads in the rainy season, fewer individuals (2/16, 12.5%) reported gastrointestinal symptoms compared to the dry season (6/15, 40%). In conclusion, considerable prevalence of C. cayetanensis in Colombian indigenous people persists in the dry season. Low proportions of gastrointestinal symptoms along with higher parasite loads make colonization likely rather than infection.

Cryptosporidium spp. and Giardia spp. (oo)cysts as target-organisms in sanitation and environmental monitoring: A review in microscopy-based viability assays

Cysts and (oo)cysts are the infective forms of parasitic protozoa, as Giardia and Cryptosporidium, which are widespread and associated to worldwide waterborne diseases outbreaks. These microorganisms pose a challenge to public health, as they are resistant to conventional disinfection methods, which make them important parameters when evaluating inactivation efficiency. However, when (oo)cysts are targets, it is challenging to infer inactivation efficacy, as it may require infectivity tests that are not often an option for laboratory routine analysis. In this scene, (oo)cyst viability based on induced excystation, membrane integrity and enzyme activity evaluated by dye inclusion and/or exclusion, as well as fluorescence reduction consist on microscopy-based techniques that may be options to estimate inactivation in the environmental context. This scoping review presents applications, advantages and limitations of these methodologies for viability assessment, in order to shed light on the (oo)cyst viability topic and provide insight strategies for choosing protocols in the environmental and sanitation field, in laboratory applications and novel research.

Infectious diseases of the upper gastrointestinal tract

A broad spectrum of pathogens produce gastrointestinal disease. The ongoing spread of human immunodeficiency virus/acquired immune deficiency syndrome, the increased use of immunosuppressive therapy and the persistence of overcrowding and suboptimal sanitation in underdeveloped areas facilitate both disease transmission from environmental and foodborne sources and person-to-person transmission. Clinicians increasingly rely on endoscopic biopsy sample interpretation to diagnose gastrointestinal infections. Thus, pathologists must be aware of diagnostic features of a variety of microbial pathogens. Detection with molecular techniques also allows for correlation between infectious agents and their histopathological features, which has expanded our knowledge of the inflammatory changes produced by infectious agents. This review covers infectious disorders of the upper gastrointestinal tract encountered in surgical pathology. Clinical, endoscopic and pathological features are presented. The review emphasises morphological features of viruses, bacteria, fungi and parasites that may be found in tissue samples, and the inflammatory patterns that they produce. Differential diagnoses and useful ancillary techniques are discussed.

Gastrointestinal parasite infections in fighting bulls in South Thailand

Background and Aim:

Bullfighting is booming in South Thailand, attracting tourists, and stimulating local economies. The bulls are well raised and practiced, but in many cases, the owners lack knowledge and understanding of the prevention of animal diseases, including parasitic infections. This study aimed to determine the occurrence of gastrointestinal (GI) parasite infection in fighting bulls.

Materials and Methods:

A total of 1501 fecal samples were collected from bulls aged 2-5 years visiting the animal hospital of Prince of Songkla University during 2016-2019. The formalin ethylether concentration method was used to detect GI parasites in feces.

Results:

The overall rate of GI parasite infection was 94.27%. Rumen fluke eggs were detected in 97.17% of all infected animals, followed in prevalence by strongyles (26.29%), Eurytrema spp. (2.83%), Fasciola spp. (2.47%), Trichuris spp. (0.35%), and Moniezia spp. (0.14%). Two protozoan genera were identified, Balantidium coli (6.64%) and Eimeria spp. (3.53%). Coinfection was observed in 33.99%. The five most common coinfections were rumen fluke with strongyles (20.85%), B. coli (4.66%), Eimeria spp. (1.55%), Eurytrema spp. (1.34%), and Fasciola spp. (1.06%).

Conclusion:

In addition to high GI parasite infection rates, zoonotic parasites were observed. Therefore, it is recommended that farmers should follow good sanitation and prevention practices to control parasitic infections in bulls, and proper hygienic precautions should be taken by the owners. Implementation of deworming programs using appropriateanthelmintic drugs as well as rotation of anthelmintic drug that have different chemical agent to prevent further drug resistance should be considered. The promotion of bull health management is highly recommended to protect humans from zoonotic diseases.

Cryptosporidium and Giardia in Ruminants

Cryptosporidium and Giardia are ubiquitous protozoan parasites that infect a broad range of vertebrate hosts, including domestic and wild animals as well as humans. Both parasites are of medical and veterinary importance. Infections with Cryptosporidium and Giardia in ruminants are associated with diarrhea outbreaks, mainly in young animals. Ruminants are potential sources of infection for humans because some species of Cryptosporidium and assemblages of Giardia duodenalis have been isolated from both ruminants and humans. Knowledge of these parasites has greatly expanded in the last 2 decades from simple microscopic observations of organisms to the knowledge acquired from molecular tools.

Cystoisospora belli infections in humans: the past 100 years

Cystoisospora belli is a coccidian parasite of humans, with a direct fecal-oral transmission cycle. It is globally distributed, but mainly found in tropical and subtropical areas. Many cases of C. belli infections have been reported in patients with HIV, and in patients undergoing immunosuppressive therapy for organ transplants or those treated for tumours worldwide. Unsporulated or partially sporulated oocysts of C. belli are excreted in feces. When sporulated oocysts in contaminated water or food are ingested, asexual and sexual stages of C. belli are confined to the epithelium of intestines, bile ducts and gallbladder. Monozoic tissue cysts are present in extra-intestinal organs (lamina propria of the small and large intestine, lymph nodes, spleen, and liver) of immunosuppressed humans. However, a paratenic host has not been demonstrated. Cystoisospora belli infections can be persistent, lasting for months, and relapses are common; the mechanism of relapse is unknown. Recently, the endogenous stages of C. belli were re-examined and attention was drawn to cases of misidentification of non-protozoal structures in the gallbladder of patients as C. belli. Here, we review all aspects of the biology of C. belli, including morphology, endogenous stages, prevalence, epidemiology, symptoms, diagnosis and control.

Host-directed therapies for parasitic diseases

Parasitic infections are responsible for significant morbidity and mortality throughout the world. Management strategies rely primarily on antiparasitic drugs that have side effects and risk of drug resistance. Therefore, novel strategies are needed for treatment of parasitic infections. Host-directed therapy (HDT) is a viable alternative, which targets host pathways responsible for parasite invasion/survival/pathogenicity. Recent innovative combinations of genomics, proteomics and computational biology approaches have led to discovery of several host pathways that could be promising targets for HDT for treating parasitic infections. Herein, we review major advances in HDT for parasitic disease with regard to core regulatory pathways and their interactions.

Efficiency of chlorine and UV in the inactivation of Cryptosporidium and Giardia in wastewater

Wastewater from different sources is contaminated by protozoan parasites including Cryptosporidium and Giardia. Many protozoan parasites are becoming resistant to chemical treatment. The challenge of finding alternatives is presented to researchers by exploring other methods of eliminating protozoan parasites from wastewater. The aim of this study was to assess the speciation and the viability of Cryptosporidium and Giardia in environmental samples with the specific objective of evaluating if effluent chlorination and UV affect the viability. Different doses of chlorine with different exposure times were experimented with both distilled water and waste water spiked with (oo)cysts derived from environmental samples. UV irradiation at different doses was also experimented using the same spiked samples. Two methods of quantification and detection, namely, microscopy and flow cytometry, were used in the experiment. Two vital dyes, Syto-9+PI and DAPI+PI, were the used for staining the collected wastewater samples. It was found that the (oo)cysts responded to chlorination and UV treatments with Giardia responding better than Cryptosporidium. Giardia responded very well to UV irradiations with almost 0 percent remaining viable after a low dose of UV. Cryptosporidium was found to be resistant to chlorination even at high doses but responded well to high UV doses. DAPI+PI dye gave a lower mean percentage viability values than Syto-9+PI. Flow cytometry gave higher mean percentage than microscopy from the results. It is concluded that UV is a promising alternative to Chlorine in removing Cryptosporidium and Giardia from waste water. Appropriate treatment method for wastewater is necessary to minimize water resources pollution when wastewater is released into water systems.

Immune response markers in sera of children infected with Giardia duodenalis AI and AII subassemblages

In this study, we evaluated serum markers of immune responses in children infected with G. duodenalis and compared them with the characterized parasite isolates. The reactivity indexes (RI) of IgG (1.503 ± 0.819) and IgA (2.308 ± 1.935) antibodies were significantly higher (P < 0.001) in infected children than in non-infected children. There were also statistically significantly higher serum levels (P < 0.05) of IFN-γ (393.10 ± 983.90 pg/mL) as well as serum (30.03 ± 10.92 μmol/L) and saliva nitric oxid derivatives (NO_x) (192.4 ± 151.2 μmol/L) in children infected with G. duodenalis compared to the group of non-parasitized children (127.4 ± 274.30 pg/mL; 25.82 ± 7.74 μmol/L and 122.5 ± 105.90 μmol/L, respectively). Regarding the characterized genetic variants of G. duodenalis and the immune response profiles, no differences were observed in terms of antibody reactivity or levels of serum cytokine and NO_x among children infected with AI or AII subassemblages. The elevated levels of IFN-γ and NO_x indicate that G. duodenalis intestinal infection in humans induces a cellular immune response detectable at the systemic level. Moreover, no significant differences in the antibody reactivity profile or the cytokine and NO_x production in the sera of children infected with AI or AII G. duodenalis variants were observed, suggesting that subtypes of the parasite do not influence the immune response profile.

Improving basic skills in celiac-like disease diagnosis: a case report

BACKGROUND

The diagnosis of Coeliac disease (CD) requires a combination of sign/symptoms, positivity of specific antibodies and duodenal histological evidence of villous atrophy. Duodenal villous atrophy, despite representing the CD landmark, is not specific since it is found in many gastrointestinal disorders. Giardiasis is one of the most common human intestinal protozoan infestations in industrialized countries whose histological duodenal mucosa damage could mimic that of CD. The present report shows how a wise clinical and laboratory assessment led us shortly to a correct diagnosis.

CASE PRESENTATION

A 42-year-old outpatient woman without previous significant gastrointestinal diseases, was referred with dyspeptic symptoms, fatigue and mild diarrhea from 4 months. Her first investigations including immunoglobulin A (IgA) anti-tissue transglutaminase antibodies (anti-tTG) and stool parasitological and cultural analysis were negative. An esophagogastroduodenoscopy (EGDS) showed no mucosal alteration. But histology demonstrated a Helicobacter Pylori (HP) pan-gastritis while duodenal mucosa showed villous atrophy consistent with a diagnosis of CD Marsh type 3b. While on gluten-free diet (GFD) the patient didn't experience any improvement of symptoms. Duodenal biopsies were then reviewed showing the presence of trophozoites of Giardia on the luminal surface of the duodenal wall and at the same time, a second stool examination revealed the presence of trophozoites and cysts of Giardia. Treated with metronidazole, 500 mg twice daily for 6 days the patient reduced diarrhea after few days. After about 2 months of GFD she was invited to discontinue it. At the same time stool examination was repeated with negative results. She subsequently performed eradication for Hp with triple therapy (Pylera®). Around 6 months later, the patient did not complain any gastrointestinal symptoms. Serological tests were normal and at a follow-up EGDS, duodenal mucosa had normal histology with normal finger-like villi and absence of Giardia trophozoites.

CONCLUSION

This case report shows how CD diagnosis can sometimes be manifold. Intestinal villous atrophy alone may not automatically establish a diagnosis of CD. In the present case the clinical scenario could be fully explained by giardiasis. Indeed, different diagnostic tools and a multi-step approaches have been used to determine the final correct diagnosis.

Ocular Parasitosis Caused by Protozoan Infection during Travel: Focus on Prevention and Treatment

International travel is rising quickly worldwide. Many people travel to tropical and subtropical areas, where there has been increasing exposure of travelers to infectious pathogens. Ocular parasitic infections are more prevalent in these geographical areas and they can lead to morbidity and mortality, often due to late or misdiagnosis due to the unfamiliarity of health staff with these diseases. This is an up-to-date comprehensive review article that familiarizes physicians with ocular signs and symptoms, treatment, prevention, and geographic distribution of some parasites associated with travel.

Common Gastrointestinal Infections

Gastrointestinal infections account for a large burden of acute and chronic disease, with diarrhea being the most common manifestation. Most cases are due to viruses, with norovirus being the most common, whereas bacteria and parasites are also important contributors to acute and chronic gastrointestinal infections and their sequelae. Nontyphoidal Salmonella species cause the most hospitalizations and deaths in the United States. This article reviews an evidence-based approach to diarrhea evaluation with a focus on pathogen-specific testing and management for the most common viral, bacterial, and parasitic causes in the United States.

Giardiasis: a diagnosis that should be considered regardless of the setting

Although Giardia, the aetiological agent of giardiasis, is one of the most prevalent intestinal parasitic infections world-wide, for industrialised countries, it is mainly appreciated as an imported disease with the minimal local transmission. However, the current evidence challenges this perception; Giardia has relevance beyond the high prevalence areas. This infection may be asymptomatic or cause gastrointestinal complains and long-term sequelae, including irritable bowel syndrome, chronic fatigue and impaired child growth and cognitive development. Its detection and diagnosis present a challenge to physicians who may not be familiar with this infection. To improve interventions to control this parasitosis, it is necessary to maintain a high index of suspicion and remain vigilant in finding cases at risk for infection. A better understanding of the characteristics of populations importing infections alongside improved methods to reliably classify infections as imported or acquired locally will help to ensure early and accurate diagnosis. The evidence shows that public health problems like giardiasis are global issues that need to be addressed collectively by both high and low prevalence countries.

Inflammatory and infectious manifestations of immunodeficiency in the gastrointestinal tract

Immune compromise may result from genetic abnormalities, HIV/AIDS, or consequences of therapy for neoplastic and autoimmune diseases. Many immunocompromised patients develop severe gastrointestinal symptoms, particularly diarrhea, accompanied by non-specific or mild endoscopic abnormalities; mucosal biopsy with pathologic interpretation has a major role in the diagnosis and management of these patients. Immunocompromised individuals are at risk for all the diseases that affect those with a healthy immune system, but they are also prone to other illnesses that rarely affect immunocompetent patients. This review discusses the gastrointestinal manifestations of primary and acquired immunodeficiency, chemotherapy-related injury, and infections that show a predilection for immunocompromised patients. Key histologic features and relevant differential diagnoses are emphasized.

Estimated Cost to a Restaurant of a Foodborne Illness Outbreak

OBJECTIVES

Although outbreaks of restaurant-associated foodborne illness occur periodically and make the news, a restaurant may not be aware of the cost of an outbreak. We estimated this cost under varying circumstances.

METHODS

We developed a computational simulation model; scenarios varied outbreak size (5 to 250 people affected), pathogen (n = 15), type of dining establishment (fast food, fast casual, casual dining, and fine dining), lost revenue (ie, meals lost per illness), cost of lawsuits and legal fees, fines, and insurance premium increases.

RESULTS

We estimated that the cost of a single foodborne illness outbreak ranged from $3968 to $1.9 million for a fast-food restaurant, $6330 to $2.1 million for a fast-casual restaurant, $8030 to $2.2 million for a casual-dining restaurant, and $8273 to $2.6 million for a fine-dining restaurant, varying from a 5-person outbreak, with no lost revenue, lawsuits, legal fees, or fines, to a 250-person outbreak, with high lost revenue (100 meals lost per illness), and a high amount of lawsuits and legal fees ($1 656 569) and fines ($100 000). This cost amounts to 10% to 5790% of a restaurant's annual marketing costs and 0.3% to 101% of annual profits and revenue. The biggest cost drivers were lawsuits and legal fees, outbreak size, and lost revenue. Pathogen type affected the cost by a maximum of $337 000, the difference between a Bacillus cereus outbreak (least costly) and a listeria outbreak (most costly).

CONCLUSIONS

The cost of a single foodborne illness outbreak to a restaurant can be substantial and outweigh the typical costs of prevention and control measures. Our study can help decision makers determine investment and motivate research for infection-control measures in restaurant settings.

Foodborne intestinal protozoan infection and associated factors among patients with watery diarrhea in Northern Ethiopia; a cross-sectional study

BACKGROUND

Intestinal protozoa are parasites transmitted by consumption of contaminated water and food and mainly affect children and elder people and cause considerable health problems. They are the leading causes of outpatient morbidity due to diarrhea in the developing countries. So, assessing water and food source of diarrheal patients and identifying the main associated factors for transmission of protozoan parasitic infections help for effective control measures of protozoan infections. Hence, the current study was aimed at determining the prevalence of foodborne intestinal protozoa infections and associated factors among diarrheic patients in North Ethiopia.

METHODS

A health facility based cross-sectional study was conducted among 223 patients with watery diarrhea in four selected government health facilities in North Ethiopia from November 2016-June 2017. A structured questionnaire was used to collect data on socio-demography of study participants and factors associated with foodborne protozoa infections. The diarrheic stool samples were collected, transported, and processed using direct wet mount, formal-ether concentration and modified ZiehlNeelson staining methods. The data were analyzed using SPSS version 21 and descriptive statistics, bi-variate, and multivariate logistic regressions were computed. P-value < 0.05 at 95% confidence interval was considered statistically significant.

RESULTS

The overall prevalence of foodborne protozoa infection was 101 (45.3%). The predominant protozoa species identified was Entamoeba histolytica/dispar 55 (24.7%), followed by Giardia intestinalis 25 (11.2%) and Cryptosporidium species 5 (2.2%). The highest proportion of protozoa infection was observed among males (23.3%) and the age group 15-24 years (13.5%). Statistically significant associations were observed between foodborne protozoan infection and not using any type of recipe to decontaminate salads and fruits (AOR = 2.64, 95 CI: 1.34-5.19, P = 0.005) and using vinegar as a decontaminant (AOR = 2.83, 95 CI: 1.24-6.48, P = 0.014). Eating out (meals at a restaurant) on the other hand was found to be protective for foodborne protozoan infection (AOR = 0.43, 95 CI: 0.23-0.78, P = 0.006).

CONCLUSION

Our study revealed that foodborne protozoa infections are of public health significance in the study area. Vinegar, which is frequently used as a recipe for decontaminating salads and fruits, is inversely related to foodborne protozoa parasite infection .

Giardiasis Diagnosis and Treatment Practices Among Commercially Insured Persons in the United States

Background

Giardiasis, the most common enteric parasitic infection in the United States, causes an estimated 1.2 million episodes of illness annually. Published clinical recommendations include readily available Giardia-specific diagnostic testing and antiparasitic drugs. We investigated sequences of giardiasis diagnostic and treatment events using MarketScan, a large health insurance claims database.

Methods

We created a longitudinal cohort of 2995 persons diagnosed with giardiasis (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 007.1) from 2006 to 2010, and analyzed claims occurring 90 days before to 90 days after initial diagnosis. We evaluated differences in number and sequence of visits, diagnostic tests, and prescriptions by age group (children 1-17 years, adults 18-64 years) using χ2 tests and data visualization software.

Results

Among 2995 patients (212433 claims), 18% had a Giardia-specific test followed by or concurrent with an effective antiparasitic drug, without ineffective antibiotics. Almost two-thirds of patients had an antiparasitic and 27% had an antibiotic during the study window. Compared with children, adults more often had ≥3 visits before diagnosis (19% vs 15%; P = .02). Adults were also less likely to have a Giardia-specific diagnostic test (48% vs 58%; P < .001) and more likely to have an antibiotic prescription (28% vs 25%; P = .04). When Giardia-specific tests and antiparasitic and antibiotic prescriptions were examined, pediatric clinical event sequences most frequently began with a Giardia-specific test, whereas adult sequences most frequently began with an antiparasitic prescription.

Conclusions

Giardiasis care infrequently follows all aspects of clinical recommendations. Multiple differences between pediatric and adult care, despite age-agnostic recommendations, suggest opportunities for provider education or tailored guidance.

The influence of serial fecal sampling on the diagnosis of giardiasis in humans, dogs, and cats

Giardia infection is a common clinical problem in humans and pets. The diagnosis of giardiasis is challenging as hosts intermittently excrete protozoan cysts in their feces. In the present study, we comparatively evaluated two methods of serial fecal sampling in humans, dogs, and cats from Rio de Janeiro, Brazil. The Faust et al. technique was used to examine fecal specimens collected in triplicate from 133 patients (52 humans, 60 dogs, and 21 cats). Specimens from 74 patients were received from the group assigned to carry out sampling on consecutive days - 34 humans, 35 dogs, and 5 cats, and specimens from 59 patients were received from the group assigned to carry out sampling on non-consecutive, separate days - 18 human beings, 25 dogs, and 16 cats. G. duodenalis cysts were found in stools of 30 individuals. Multiple stool sampling resulted in an increase in the number of samples that were positive for Giardia in both groups. The authors therefore conclude that multiple stool sampling increases the sensitivity of the Faust et al . technique to detect G. duodenalis cysts in samples from humans, cats and dogs.

Cytology Preparations of Formalin Fixative Aid Detection of Giardia in Duodenal Biopsy Samples

Giardiasis is the most common intestinal parasitic infection in the United States. The organism elicits no, or minimal, inflammatory changes in duodenal biopsy samples, so it can be easily overlooked. We performed this study to determine whether Giardia could be isolated from the formalin fixative of biopsy samples, and to evaluate the value of fluid analysis in the assessment for potential infection. We prospectively evaluated duodenal biopsy samples from 92 patients with a clinical suspicion of giardiasis or symptoms compatible with that diagnosis (ie, diarrhea, bloating, or abdominal pain) Biopsy samples were routinely processed and stained with hematoxylin and eosin. Histologic diagnoses included giardiasis (5 cases, 4%), normal findings (64 cases, 70%), peptic injury/active duodenitis (12 cases, 13%), and intraepithelial lymphocytosis with villous blunting (10 cases, 12%). Fifteen cases (13%) showed detached degenerated epithelial cells or mucus droplets in the intervillous space that resembled Giardia. Cytology slides were prepared from formalin in the biopsy container using the standard Cytospin protocol and reviewed by a cytopathologist blinded to the biopsy findings. Cytologic evaluation revealed Giardia spp. in all 5 biopsy-proven cases, and identified an additional case that was not detected by biopsy analysis. Organisms were significantly more numerous (mean: 400 trophozoites; range, 120 to 810) and showed better morphologic features in cytology preparations compared with tissue sections (mean: 129 trophozoites; range, 37 to 253 organisms; P=0.05). Our findings suggest that cytology preparations from formalin fixative can resolve diagnostically challenging cases and even enhance Giardia detection in some cases.

Lymphocytic duodenitis or microscopic enteritis and gluten-related conditions: what needs to be explored?

Microscopic enteritis (ME) is characterized by abnormal infiltration of intraepithelial lymphocytes in intestinal mucosa. It was described as duodenal lymphocytosis or lymphocytic duodenitis until the dedicated Consensus Conference of 2015. ME represents a common feature of several gluten-mediated and non-gluten related diseases; therefore, it is an umbrella term embracing several conditions. The most frequent causes of ME are gluten-related disorders (celiac disease, non-celiac gluten sensitivity, wheat allergy), Helicobacter pylori infection and drug-related damages. Less frequently, ME may be secondary to inflammatory bowel disease, some autoimmune conditions, immunoglobulin deficiencies, blood malignancies, infections and irritable bowel syndrome. Therefore, the differential diagnosis of ME may be challenging. The diagnosis of ME needs to be driven by predominant symptoms and patient history. However, it is often difficult to achieve an immediate identification of the underlying condition, and a broad variety of diagnostic tests may be required. Ultimately, long-term surveillance is needed for a final diagnosis in many cases, since a hidden or quiescent condition may be disclosed after a period of latency. In any case, strict collaboration between the clinician and the pathologist is pivotal. The treatment of ME should be personalized, depending on the underlying disease. For gluten-related conditions (celiac disease, gluten sensitivity, wheat allergy, dermatitis herpetiformis), a gluten-free diet may be proposed. For other conditions, a targeted etiologic treatment is necessary. In conclusion, ME represents a novel entity that is attracting increasing interest. The growing epidemiologic trend confirms that it will become a common condition in clinical practice.

Prevalence of Intestinal Protozoa among Saudi Patients with Chronic Renal Failure: A Case-Control Study

It has been hypothesized that chronic renal failure (CRF) predisposes patients to infection with intestinal protozoa. We tested this hypothesis with a matched case-control study to determine the prevalence of these protozoa and their diarrhea associated symptoms among 50 patients with CRF (cases) from Taif, western Saudi Arabia. Fifty diarrheal patients without CRF were recruited in the study as controls. Participants were interviewed by a structured questionnaire and stool samples were collected. Samples were thoroughly examined with microscopy and three coproantigens detection kits. Enteric protozoa were detected in 21 cases and 14 controls. Blastocystis spp. were the most predominant parasite (16% in cases versus 8% in controls), followed by Giardia duodenalis (10% in cases versus 12% in controls) and Cryptosporidium spp. (10% in cases versus 6% in controls). Cyclospora cayetanensis was identified in two cases, while Entamoeba histolytica was described in one case and one control. Intestinal parasitism was positively associated with the male gender, urban residence, and travel history. Clinical symptoms of nausea/vomiting and abdominal pain were significantly varied between the parasitized cases and controls (P value ≤ 0.05). Given the results, we recommend screening all diarrheal feces for intestinal protozoa in the study's population, particularly those with CRF.