Giardiasis
Encyclopedia
Giardiasis icon or beaver fever in humans is a diarrhea
l infection of the small intestine
by a single-celled organism Giardia lamblia
. Giardiasis occurs worldwide with a prevalence of 20–30% in developing countries. In the U.S., 20,000 cases are reported to the CDC annually, but the true annual incidence
is estimated at 2 million people. Giardia has a wide range of mammalian hosts besides humans, thus making it very difficult to eradicate. For people with compromised immune systems, such as elderly or AIDS
patients, giardiasis can be deadly.
The disease causing agent of giardiasis is the enteric protozoan parasite Giardia lamblia.
The phylogeny of Giardia is unclear. Because the organisms have simple intracellular structures, they might represent an early branching of eukaryotic lineage that diverges before the acquisition of mitochondria. Elucidating the taxonomy of Giardia would significantly aid the understanding of eukaryotic evolution In addition to G. lamblia, which is the only species found in humans, other species of Giardia have been identified. Distinction of Giardia on the species level is controversial and difficult because of limited knowledge. Based on morphological difference, six species are named: G. lamblia (affects a wide range of mammals such as humans and livestock), G. agilis (affects amphibians), G. muris (affects rodents), G. ardeae and G. psittaci (affect birds), and G. microti (affects muskrats and voles). However, forty-one species can be named if species classification is based on host origins. Recently, advances in molecular biology tools such as PCR have helped elucidate the genetic relationships among morphological identical "strains" of Giardia.
in the stool: "I have sometimes also seen tiny creatures moving very prettily; some of them a bit bigger, others a bit less, than a blood-globule but all of one and the same make. Their bodies were somewhat longer than broad, and their belly, which was flattish, furnished with sundry little paws, wherewith they made such a stir in the clear medium and among the globules, that you might even fancy you saw a woodlouse running up against a wall; and albeit they made a quick motion with their paws, yet for all that they made but slow progress."
Although Leeuwenhoek was the first person to discover G. lamblia, he was not able to provide an informative illustration of the parasite. Further studies and better illustrations of the morphology of the organism in their intestinal environments were made in 1859 by Vilem Lambl, a Czech physician He also named the organism as Cercomonas intestinalais. Despite his significant contribution, Lambl did not link the diarrheal disease with the Giardia parasite, but rather erroneously assumed that the organism is part of the normal, harmless flora
of the intestines.
In 1888, Raphael Anatole Emile Blanchard named the parasite Lamblia intestinalis. In 1915, Charles Wardell Stiles, an American Parasitologist, gave the parasite its current name, Giardia lamblia, to commemorate the work on Giardia by Professor A. Giard in Paris and Dr. Lambl in Prague. Charles Wardell Stiles also suspected a link between Giardia and diarrhea for the first time. The pathogenicity of Giardia was further studied during the First World War, when a large number of soldiers developed diarrhea. Giardia cysts were isolated from their feces and found to cause diarrheal symptoms in laboratory animals. In 1926, a physician in London named Justin Achoo found that Giardia causes malabsorption in some children but not in others. The causal link between Giardia and the disease was finally and conclusively established in 1954 by Dr. Robert Rendroff of the United States. To elucidate the natural history of Giardia, such as the incubation period and the minimal number of cysts needed for infection, Rendroff fed capsules containing known numbers of Giardia cysts to prisoner volunteers. The incubation period was shown to be 6 to 15 days, and that as few as 10 to 25 cysts were competent to produce infection. Furthermore, Rendroff observed that some patients were cured of Giardia spontaneously without treatment intervention.
Today, Giardia continues to affect large populations of people world wide. In developed nations, Giardia infects 2–5% of the population acutely, people who carry cysts may not know they are infected, as currently there is no treatment for Giardia cysts in the large intestine
. In developing countries with poor sanitation and contaminated food or water sources, Giardia may affect up to 20–30% of the population acutely. It is also the most commonly diagnosed enteric parasite in the United States and Canada.
Giardiasis is spread during periods of heavy rains, such as monsoon runoff.
Furthermore, a variety of birds may also serve as reservoirs of Giardia. Contaminated water supplies, such as water in rivers and lakes and improperly treated water in developing countries, are also reservoirs of the waterborne cysts. Often, contamination of surface water is caused by rain and wind carrying cysts from fields containing or fertilized by manures of infected humans, livestock, or wild animals to nearby rivers and streams. Giardia cysts can remain viable in surface water for approximately two months. As a result, it is more dangerous for hikers to consume water from rivers and lakes during and immediately after raining seasons as contamination tend to be most severe during these periods. Finally, the organism can often be found in soil, food, and surfaces contaminated with feces containing infectious cysts.
State health departments in the U.S. generally do not find Giardia in backcountry settings. "Outbreaks have been linked to contaminated drinking water in small towns, food handlers, and child-care workers who are infected when they change diapers — the researchers didn't find any evidence that wilderness water is a cause."
In both the acute and insidious onsets of symptoms, stools become greasy and malodorous but do not contain blood or pus because giardiasis does not involve dysenteric symptoms. Watery diarrhea may cycle with soft stools and constipation. Upper GI symptoms including nausea, early satiety, bloating, substernal burning, egg-smelling halitosis
, and acid indigestion may be exacerbated by eating and are generally present in the absence of soft stools.
are loss of appetite
, malaise
, and fatigue. Weight loss affects more than 50% of patients. Adults with long lasting malabsorption syndrome and children with failure to thrive may experience chronic illness.
Additional syndromes may include lactose intolerance
, biliary tract disease, and allergic manifestations such as erythema multiforme
, bronchospasm
, and urticaria
.
, failure to thrive
, lactose intolerance
, as well as chronic inflammation of intestinal lining leading to various forms of cancer. For immunocompromised individuals, these effects can be and often are deadly.
The most sensitive test for diagnosing giardiasis is ELISA
and should be done prior to performing stool ova and parasites (commonly called O&P) and string testing.
It may be found on duodenal biopsies and is in the differential diagnosis
of celiac disease.
Metronidazole
Tinidazole
Nitazoxanide
Furazolidone
Quinacrine
Albendazole
Mebendazole
"Diagnostic Tests" section source
s has not been thoroughly investigated, however, according to the American Medical Association
, about two-thirds of infected people have no symptoms.
Giardiasis is common in tourists and business travelers to developing countries, especially Mexico, Southeast Asia, western South America and Russia and the CIS. An increased prevalence of giardiasis among homosexual men has been reported by a number of studies. Lastly, because infection may be caused by poor hygiene, giardiasis has high infection rates in daycare centers and nursing homes, though the groups most at risk for infection are overseas travelers and hikers.
In the United States, many of the reported cases of Giardia occur in the summer because of the ideal climate, and related use of community swimming areas by young diaper-aged children during the summer. Reported Giardia levels have ranged
from 10,000 to 100,000 cysts/L in untreated sewage, 10 to 100 cysts/L in treated sewage, and 10 or few cysts/L in surface water sources and tap water.
State health departments in the U.S. generally do not find Giardia in backcountry settings. "Outbreaks have been linked to contaminated drinking water in small towns, food handlers, and child-care workers who are infected when they change diapers — the researchers didn't find any evidence that wilderness water is a cause."
For people who must drink water found "in the field", effective water treatment options include boiling, chemical treatment (iodine tablets), and filtering.
Diarrhea
Diarrhea , also spelled diarrhoea, is the condition of having three or more loose or liquid bowel movements per day. It is a common cause of death in developing countries and the second most common cause of infant deaths worldwide. The loss of fluids through diarrhea can cause dehydration and...
l infection of the small intestine
Small intestine
The small intestine is the part of the gastrointestinal tract following the stomach and followed by the large intestine, and is where much of the digestion and absorption of food takes place. In invertebrates such as worms, the terms "gastrointestinal tract" and "large intestine" are often used to...
by a single-celled organism Giardia lamblia
Giardia lamblia
Giardia lamblia is a flagellated protozoan parasite that colonizes and reproduces in the small intestine, causing giardiasis. The giardia parasite attaches to the epithelium by a ventral adhesive disc, and reproduces via binary fission...
. Giardiasis occurs worldwide with a prevalence of 20–30% in developing countries. In the U.S., 20,000 cases are reported to the CDC annually, but the true annual incidence
Incidence
Incidence may refer to:* Incidence , a measure of the risk of developing some new condition within a specified period of time* Incidence , the binary relations describing how subsets meet...
is estimated at 2 million people. Giardia has a wide range of mammalian hosts besides humans, thus making it very difficult to eradicate. For people with compromised immune systems, such as elderly or AIDS
AIDS
Acquired immune deficiency syndrome or acquired immunodeficiency syndrome is a disease of the human immune system caused by the human immunodeficiency virus...
patients, giardiasis can be deadly.
Agent and taxonomy
Cross referencing and synonyms
G. intestinalis, G. duodenalis, Giardiasis, Giardia enteritis, Lambliasis, Lamblia intestinalis, "beaver fever"Taxonomy and classification of G. lamblia
- Kingdom: Protista
- Subkingdom: Protozoa
- Phylum: Sarcomastia
- Subphylum: Mastigophora
- Class: Zommastigophora
- Order: Diplomonadida
- Family: Hexamitidae
- Genus: Giardia
- Species: lamblia
The phylogeny of Giardia is unclear. Because the organisms have simple intracellular structures, they might represent an early branching of eukaryotic lineage that diverges before the acquisition of mitochondria. Elucidating the taxonomy of Giardia would significantly aid the understanding of eukaryotic evolution In addition to G. lamblia, which is the only species found in humans, other species of Giardia have been identified. Distinction of Giardia on the species level is controversial and difficult because of limited knowledge. Based on morphological difference, six species are named: G. lamblia (affects a wide range of mammals such as humans and livestock), G. agilis (affects amphibians), G. muris (affects rodents), G. ardeae and G. psittaci (affect birds), and G. microti (affects muskrats and voles). However, forty-one species can be named if species classification is based on host origins. Recently, advances in molecular biology tools such as PCR have helped elucidate the genetic relationships among morphological identical "strains" of Giardia.
History of discovery
Antonie van Leeuwenhoek of Delft, Netherlands, described such microorganisms he observedin the stool: "I have sometimes also seen tiny creatures moving very prettily; some of them a bit bigger, others a bit less, than a blood-globule but all of one and the same make. Their bodies were somewhat longer than broad, and their belly, which was flattish, furnished with sundry little paws, wherewith they made such a stir in the clear medium and among the globules, that you might even fancy you saw a woodlouse running up against a wall; and albeit they made a quick motion with their paws, yet for all that they made but slow progress."
Although Leeuwenhoek was the first person to discover G. lamblia, he was not able to provide an informative illustration of the parasite. Further studies and better illustrations of the morphology of the organism in their intestinal environments were made in 1859 by Vilem Lambl, a Czech physician He also named the organism as Cercomonas intestinalais. Despite his significant contribution, Lambl did not link the diarrheal disease with the Giardia parasite, but rather erroneously assumed that the organism is part of the normal, harmless flora
Gut flora
Gut flora consists of microorganisms that live in the digestive tracts of animals and is the largest reservoir of human flora. In this context, gut is synonymous with intestinal, and flora with microbiota and microflora....
of the intestines.
In 1888, Raphael Anatole Emile Blanchard named the parasite Lamblia intestinalis. In 1915, Charles Wardell Stiles, an American Parasitologist, gave the parasite its current name, Giardia lamblia, to commemorate the work on Giardia by Professor A. Giard in Paris and Dr. Lambl in Prague. Charles Wardell Stiles also suspected a link between Giardia and diarrhea for the first time. The pathogenicity of Giardia was further studied during the First World War, when a large number of soldiers developed diarrhea. Giardia cysts were isolated from their feces and found to cause diarrheal symptoms in laboratory animals. In 1926, a physician in London named Justin Achoo found that Giardia causes malabsorption in some children but not in others. The causal link between Giardia and the disease was finally and conclusively established in 1954 by Dr. Robert Rendroff of the United States. To elucidate the natural history of Giardia, such as the incubation period and the minimal number of cysts needed for infection, Rendroff fed capsules containing known numbers of Giardia cysts to prisoner volunteers. The incubation period was shown to be 6 to 15 days, and that as few as 10 to 25 cysts were competent to produce infection. Furthermore, Rendroff observed that some patients were cured of Giardia spontaneously without treatment intervention.
Today, Giardia continues to affect large populations of people world wide. In developed nations, Giardia infects 2–5% of the population acutely, people who carry cysts may not know they are infected, as currently there is no treatment for Giardia cysts in the large intestine
Large intestine
The large intestine is the third-to-last part of the digestive system — — in vertebrate animals. Its function is to absorb water from the remaining indigestible food matter, and then to pass useless waste material from the body...
. In developing countries with poor sanitation and contaminated food or water sources, Giardia may affect up to 20–30% of the population acutely. It is also the most commonly diagnosed enteric parasite in the United States and Canada.
Transmission
Giardiasis is caused by the ingestion of infective cysts. There are multiple modes of transmission, including person-to-person, water-borne, and venereal. Person-to-person transmission accounts for a majority of Giardia infections and is usually associated with poor hygiene and sanitation. Water-borne transmission is associated with the ingestion of contaminated water. In the U.S. outbreaks typically occur in small water systems using inadequately treated surface water. Venereal transmission happens through fecal-oral contamination. Additionally, diaper changing and inadequate hand washing are risk factors for transmission from infected children. Lastly, food-borne epidemics of Giardia have developed through the contamination of food by infected food-handlers.Giardiasis is spread during periods of heavy rains, such as monsoon runoff.
Reservoir and vector
Giardia has no vector. It affects a wide range of human and mammalian reservoir hosts. Small aquatic or semi-aquatic wild mammals, such as beavers, muskrats, and small rodents harbor water-born cysts of Giardia and serve as important reservoir hosts.Furthermore, a variety of birds may also serve as reservoirs of Giardia. Contaminated water supplies, such as water in rivers and lakes and improperly treated water in developing countries, are also reservoirs of the waterborne cysts. Often, contamination of surface water is caused by rain and wind carrying cysts from fields containing or fertilized by manures of infected humans, livestock, or wild animals to nearby rivers and streams. Giardia cysts can remain viable in surface water for approximately two months. As a result, it is more dangerous for hikers to consume water from rivers and lakes during and immediately after raining seasons as contamination tend to be most severe during these periods. Finally, the organism can often be found in soil, food, and surfaces contaminated with feces containing infectious cysts.
State health departments in the U.S. generally do not find Giardia in backcountry settings. "Outbreaks have been linked to contaminated drinking water in small towns, food handlers, and child-care workers who are infected when they change diapers — the researchers didn't find any evidence that wilderness water is a cause."
Incubation period
Symptoms usually begin 1 to 2 weeks (average 7 days) after an individual becomes infected. In otherwise healthy individuals, symptoms may last 2 to 6 weeks. Though symptoms may last longer, medications can help decrease the duration of symptoms.Cysts
The cysts are non-motile and egg-shaped. They measure 8–14 μm by 7–10 μm. The cysts are encased by a smooth and colorless, thick and refractile wall. Immediately after encystations, newly formed cysts contain two genetically identical nuclei. However, each organelle duplicates so that in permanently stained mature cysts, four prominent nuclei and four median bodies are observed. Compared to trophozoites, cysts also have twice the number of intracytoplasmic flagellar structures. The cysts are the infective form of the parasite and each cyst gives rise to two trophozoites.Trophozoites
Trophozoites are motile and non-infectious because they cannot survive long outside the host body. The trophozoites are pear shaped with a broad anterior end and a narrow posterior end. It is 9–21 μm long and 5–15 μm wide. The parasite is bilaterally symmetrical and dorsoventrally flattened. A large sucking disk, which allows the parasite to attach to the surface of the intestinal mucosa of the host, takes up most of the ventral surface of the parasite. Behind the sucking disks, two rods known as median bodies are seen. Four pairs of flagella are located anterior, lateral, ventral, and posterior on the body of the organism. The pair of anterior flagella, known as axome, is straight, closely approximated and parallel to each other, dividing the body of the organism into two halves longitudinally. Motility brought by the four pairs of flagella is essential for virulence of the parasite. The two spherical or ovoid nuclei, containing a large, central karyosome, can be found on each side of the axonemes. The parasite does not have peripheral chromatin.Step 1
The life cycle of Giardia alternates between the cyst and the trophozoite forms, and both forms are found in feces. Cysts are more often found in non-diarrheal feces, and they are the infectious stage of the parasite. The cysts are hardy and resistant to standard concentrations of chlorine used in water treatment and they can persist for several months in cold, moist environment.Step 2
Infection begins when a new host ingests cysts in contaminated food, water, fomites or fecal-orally. Mature cysts are able to survive the acidic environment of the stomach and migrate to the small intestine of the host.Step 3
Exposure to stomach acid triggers a process called excystation, during which trophozoites are released from cysts. Each quadrinuclear cyst gives rise to two binuclear trophozoites.Step 4
The trophozoites multiply asexually by binary fission in the small intestine, either as free floating bodies or attached to the intestinal epithelium. Trophozoites are the disease causing stage of the parasite and they colonize the small intestine by attaching to the intestinal mucosa using the ventral sucking disks. Trophozoites are largely noninvasive and do not invade other organs; however, at times they might penetrate down into the secretary tubules of the mucosa and be found in gallbladder and the biliary drainage.Step 5
As trophozoites migrate toward the large intestine, they retreat into the cyst form in a process called encystation. Bile salts and intestinal mucous were found to enhance trophozoite multiplication and encystations. Trophozoites, if excreted in feces, cannot survive long in the environment and are therefore noninfectious. The cysts in excrements will quickly become infectious and will begin a new cycle of infection if ingested by a naïve host.Symptoms
A range of clinical syndromes may occur, with gastrointestinal syndromes being the most prevalent.Gastrointestinal
A small number of infected individuals experience an abrupt onset of abdominal cramps, watery diarrhea, vomiting, foul flatus, and fever which may last for 3–4 days before proceeding into a more sub-acute phase. The majority of infected persons develop gradual symptoms that become recurrent or resistant.In both the acute and insidious onsets of symptoms, stools become greasy and malodorous but do not contain blood or pus because giardiasis does not involve dysenteric symptoms. Watery diarrhea may cycle with soft stools and constipation. Upper GI symptoms including nausea, early satiety, bloating, substernal burning, egg-smelling halitosis
Halitosis
Halitosis is a term used to describe noticeably unpleasant odors exhaled in breathing. Halitosis is estimated to be the third most frequent reason for seeking dental aid, following tooth decay and periodontal disease.- General :...
, and acid indigestion may be exacerbated by eating and are generally present in the absence of soft stools.
Constitutional
The most common constitutional symptomsConstitutional symptoms
Constitutional symptoms refers to a group of symptoms that can affect many different systems of the body.Examples include Weight loss, fevers, fatigue, and malaise.Other examples include chills, night sweats, and decreased appetite....
are loss of appetite
Anorexia (symptom)
Anorexia is the decreased sensation of appetite...
, malaise
Malaise
Malaise is a feeling of general discomfort or uneasiness, of being "out of sorts", often the first indication of an infection or other disease. Malaise is often defined in medicinal research as a "general feeling of being unwell"...
, and fatigue. Weight loss affects more than 50% of patients. Adults with long lasting malabsorption syndrome and children with failure to thrive may experience chronic illness.
Additional syndromes may include lactose intolerance
Lactose intolerance
Lactose intolerance, also called lactase deficiency or hypolactasia, is the inability to digest and metabolize lactose, a sugar found in milk...
, biliary tract disease, and allergic manifestations such as erythema multiforme
Erythema multiforme
Erythema multiforme is a skin condition of unknown cause, possibly mediated by deposition of immune complex in the superficial microvasculature of the skin and oral mucous membrane that usually follows an infection or drug exposure...
, bronchospasm
Bronchospasm
Bronchospasm or a bronchial spasm is a sudden constriction of the muscles in the walls of the bronchioles. It is caused by the release of substances from mast cells or basophils under the influence of anaphylatoxins...
, and urticaria
Urticaria
Urticaria is a kind of skin rash notable for pale red, raised, itchy bumps. Hives is frequently caused by allergic reactions; however, there are many non-allergic causes...
.
Physical
Abdominal examination may expose nonspecific tenderness even if there is no sign of peritoneal irritation. Rectal examination should expose heme-negative stools and in severe cases, there may be evidence of dehydration.Long term effects
Studies into the long term effects of giardiasis have not been thoroughly conducted, however, due to inflammation and scarring occurring commonly with giardiasis, possible effects include long term weight loss, malnutritionMalnutrition
Malnutrition is the condition that results from taking an unbalanced diet in which certain nutrients are lacking, in excess , or in the wrong proportions....
, failure to thrive
Failure to thrive
Failure to thrive is a medical term which is used in both pediatric and adult human medicine, as well as veterinary medicine ....
, lactose intolerance
Lactose intolerance
Lactose intolerance, also called lactase deficiency or hypolactasia, is the inability to digest and metabolize lactose, a sugar found in milk...
, as well as chronic inflammation of intestinal lining leading to various forms of cancer. For immunocompromised individuals, these effects can be and often are deadly.
Diagnosis
ELISA
Enzyme-linked immunosorbent assay , is a popular format of a "wet-lab" type analytic biochemistry assay that uses one sub-type of heterogeneous, solid-phase enzyme immunoassay to detect the presence of a substance in a liquid sample."Wet lab" analytic biochemistry assays involves detection of an...
and should be done prior to performing stool ova and parasites (commonly called O&P) and string testing.
It may be found on duodenal biopsies and is in the differential diagnosis
Differential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
of celiac disease.
MetronidazoleMetronidazoleMetronidazole is a nitroimidazole antibiotic medication used particularly for anaerobic bacteria and protozoa. Metronidazole is an antibiotic, amebicide, and antiprotozoal....
(Flagyl)
- Adult dosage: 250 mg three times a day for 5 days
- Pediatric dosage: 5 mg per kilogram of body weight per dose, 3 times per day, for 5 days
- Side effects: Found in 7.1% of cases. Include unpleasant metallic taste which might cause noncompliance in patients, GI discomfort such as vomiting, nausea, diarrhea, abdominal cramps, pancreatitisPancreatitisPancreatitis is inflammation of the pancreas. It occurs when pancreatic enzymes that digest food are activated in the pancreas instead of the small intestine. It may be acute – beginning suddenly and lasting a few days, or chronic – occurring over many years...
, vertigo, headache, CNS toxicity, transient leukemia, dizziness, drowsiness, lassitude, paraethesias, urticariaUrticariaUrticaria is a kind of skin rash notable for pale red, raised, itchy bumps. Hives is frequently caused by allergic reactions; however, there are many non-allergic causes...
, and pruritis. It causes mutation in Salmonella and induces tumor in rodents, but mutagenicity has never been observed in humans. - Contraindication: Avoid alcohol while taking metronidazole. Metronidazole causes severe vomiting, headache, and GI discomfort by inhibiting acetaldehyde dehydrogenase, which is involved in alcohol breakdown.
- Additional drug facts: Metronidazole is a member of the family of nitroimidazoles, commercially known as Flagyl. The tablets are quickly and completely absorbed by the small intestine and found to have antigiardial effects on the trophozoites both in vivo and in vitro. However, it is ineffective against cysts. The drug is able to penetrate body tissues and could be found in saliva, breast milk, semen, and vaginal fluid. It is metabolized in liver and secreted in urine. Metronidazole targets trophozoites by forming active metabolites, which selectively inhibit DNA segregation in anaerobic protozoa such as Giardia by DNA breakage and cross-linking. It has minimal effects on host cells lining the intestinal lumen. Resistance is induced in laboratory and is correlated with decreased activity of parasite pyruvate.
TinidazoleTinidazoleTinidazole is an anti-parasitic drug used against protozoan infections. It is widely known throughout Europe and the developing world as treatment for a variety of amoebic and parasitic infections...
(Fasigyn)
- Adult dosage: 2 g once
- Pediatric dosage: 50 mg per kilogram of body weight once (max. 2 g)
- Side effects: Side effects similar to metronidazole but appears to be better tolerated and just as effective. Common side effects include bitter taste, vertigo, and GI discomfort. The drug should be taken with food to minimize side effects.
- Additional drug facts: Tinidazole was FDA approved. It is another member of the nitro-imidazole family. Health care providers recommend travelers (especially those traveling to Asian countries) buy the drug at the country of their destination and take it in an event of giardia infection. The drug tablets can also be crushed and mixed with cherry syrup (Humco and others) for children. The syrup suspension can be kept at room temperature for 7 days and should be shaken before use.
NitazoxanideNitazoxanideNitazoxanide, also known by the brand names Alinia and Annita is a synthetic nitrothiazolyl-salicylamide derivative and an antiprotozoal agent.Nitazoxanide is a light yellow...
- Adult dosage: 500 mg two times a day for 3 days
- Pediatric dosage: 1–3 yrs: 100 mg every 12 hours for 3 days; 4–11 yrs: 200 mg every 12 hours for 3 days
- Side effects: A variety of side effects were reported but they occurred infrequently in all studies. Studies failed to provide sufficiently similar results for a comprehensive analysis of the side effects of nitazoxanide. Some probable adverse effects include abdominal pain, dyspepsia, constipation, yellow discoloration of urine, dysuria and dry mouth, and dizziness. The drug should be taken with food to minimize adverse effects.
- Additional drug facts: nitazoxanide is FDA-approved as an oral suspension for treatment of giardiasis. It can be purchased in 500 mg tablets and in oral suspension.
Paramomycin (Humatin)
- Adult dosage: 25–35 mg per kilogram of body weight per dose, 3 doses per day for 7 days
- Pediatric dosage: 25–35 mg per kilogram of body weight per dose, 3 doses per day for 7 days
- Side effects: ototoxicity and nephrotoxicity with systemic administration
- Contraindication: Patients with impaired kidney function should use paramomycin with caution
- Additional drug facts: Paramomycin is a member of the aminoglycoside family. It inhibits Giardia protein synthesis by targeting the 50S and 30S ribosomal subunits. Its activity in vitro is lower than nitroimidazoles; however, because it is poorly absorbed by small intestine, a higher concentration of the drug remains in the lumen to combat giadia organisms. It is also the choice of drug to treat G. lamblia in resistant infection and during pregnancy.
FurazolidoneFurazolidoneFurazolidone is a nitrofuran antibacterial. It is marketed by Roberts Laboratories under the brand name Furoxone and by GlaxoSmithKline as Dependal-M.-Uses:It is used to treat diarrhoea and enteritis caused by bacteria or protozoan infections....
(Furoxone)
- Adult dosage: 100 mg four times a day for 7–10 days
- Pediatric dosage: 6 mg per kilogram of body weight per dose, 4 doses per day for 7–10 days
- Side effects: Gastrointestinal symptoms (nausea, vomiting, diarrhea) are observed in 10% of patients. Other side effects include brown discoloration of urine, and hemolysis in G6PDH-deficient patients.
- Additional drug facts: it is a member of the nitrofuran family penetrate body tissues and could be found in saliva, breast milk, semen and vaginal fluid. Not recommended to treating pregnant patients because it has been shown to cause mammary tumor in rats and mutations in bacteria.
QuinacrineQuinacrineQuinacrine is a drug with a number of different medical applications. It is related to mefloquine.-Uses:Its main effects are as an antiprotozoal, antirheumatic and an intrapleural sclerosing agent....
- Adult dosage: 100 mg three times a day for 5 days
- Pediatric dosage: 2 mg per kilogram of body weight, three times per day for 5 days (max. 300 mg/d)
- Side effects: bitter taste and vomiting observed in 28% of study participants; yellow/orange discoloration of the skin, sclerae, and urine. Other common side effects include nausea, vomiting, headache, dizziness and fever. Drug induced psychosis has been observed but is very rare. Dermatitis and drug-induced retinopathy are also uncommon. The drug also acts with lower efficacy in children because the drug has bitter taste and children are less compliant.
- Contraindication: Pregnant patients should avoid taking the drug because quinacrine can cross placenta and it might cause spina bifida and renal agenesis in the infant.
- The drug, unlike metronidazole, also target cysts.
- This drug cannot be obtained commercially.
AlbendazoleAlbendazoleAlbendazole, marketed as Albenza, Eskazole, Zentel and Andazol, is a member of the benzimidazole compounds used as a drug indicated for the treatment of a variety of worm infestations. Although this use is widespread in the United States, the U.S. Food and Drug Administration has not approved...
(Albenza)
- Adult dosage: 400 mg once a day for 5 days
- Pediatric dosage: 15 mg per kilogram of body weight per day for 5 to 7 days (max. 400 mg)
MebendazoleMebendazoleMebendazole or MBZ is a benzimidazole drug developed by Janssen Pharmaceutica and marketed as Vermox, Ovex, Antiox, and Pripsen...
(Vermox)
- Adult dosage: 200–400 mg per day for 5 to 10 days
- Side effects for albendazole and mebendazole: common side effects include anorexia and constipation. Rare side effects include reversible neutropenia and elevated liver function tests. Whether they are teratogenic is unclear
- Contraindication of albendazole and mebendazole: albendazole should be taken with caution for pregnant patients because there is a possibility that it might induce tumors. However, animal studies did not reveal increased incidences of cancer.
- Additional drug facts: albendazole and mebendazole are members of the benzimidazole family. They target G. lamblia by binding to β-tubulin and stopping cytoskeletal formation. It also interferes with glucose uptake of the organism.
Drug use during pregnancy and lactation
Pregnant patients who are infected but asymptomatic are advised not to receive treatment for Giardia because there are underlying risks in current therapies. For instance, metronidazole is rapidly absorbed and easily enters fetal circulation. Studies have shown mixed results regarding the adverse effects of metronidazole on the development of the fetus. One retrospective study involving 1469 women who took Metronidazole during the first trimester of pregnancy showed no adverse effects on the fetus. However, in the Collaborative Perinatal Project with over 50,000 mother-child pairs, the infants of 31 mothers who took metronidazole during the first trimester of pregnancy were found to developed drug-associated malformation. These older studies are nowadays under attack and considered flawed. More recent studies conclude that "the current data do not support a significant increased risk for birth defects or other adverse effects on the fetus." Paromomycin is the choice of drug for treating pregnant women infected with Giardia because it is poorly absorbed by the mother and excreted almost 100% in feces; hardly any of the drugs would reach the fetus.Treating asymptomatic infections
Management of asymptomatic infections is at the center of debate. In endemic areas, treating asymptomatic patients might not be efficient because they are likely to become quickly re-infected. However, treatment might be desirable for children who experienced growth retardation to allow for catch-up growth. However, asymptomatic infections in people with small chances of being re-infected (such as returning travelers) and who have high chances of transmitting the disease to naïve hosts (such as food handlers) should be treated to stop spread of disease in the population.Treating drug-resistant patients
Giardia parasites have developed resistance to all of the common anti-giardial drugs, such as metronidazole, quinacrine, and albendazole. Additionally, according to Dr. Upi Singh, a physician and Giardia specialist at Stanford Medical Center, drug resistance in lab isolates have been developed and used for studies. Fortunately, clinical drug resistance is minimal. Oftentimes, diarrhea due to post-giardial lactose intolerance can be confused with treatment failure due to drug resistance. In such cases, physicians must examine the stool of the patients to rule out the presence of Giardia organisms. Treatment for truly resistant strains consists of three options:- treating with the original drug for a longer period of time or at higher doses;
- using a drug from a different class to treat the resistant infection—the most efficacious approach, avoiding potential cross-resistance; and
- using a combination of different classes of drugs, such as metronidazole-albendazole and metronidazole-quinacrine.
Stool examination
- 3 stools taken at 2-day intervals are examined for ova and parasites. The cysts are detected 50–70% of the time in the first stool specimen examined, and 90% of the time the cysts are detected after 3 stool specimen examinations.
- Trophozoites disintegrate rapidly outside of the body but may be found in fresh, watery stools.
- Cysts are found in soft and (semi)formed stools. Cyst passage is variable and not related to clinical symptoms. If not fresh, stool should be preserved in polyvinyl alcohol or formalin. Cyst passage may fall behind the onset of symptoms by a week+
- Trichrome stain is useful for finding the cysts and trophozoites.
- Cysts are smooth walled and oval, measuring 8–12 μm long and 7–10 μm wide. Iodine stains the cysts brown and accentuates their intracystic structures, especially their curved median bodies, axonemes, and nuclei. (4 nuclei representing 2 daughter trophozoites).
- Trophozoites are leaf-shaped, measuring 9–21 μm long and 5–15 μm wide. Stained organisms have a characteristic facelike image with 2 nuclei.
Stool antigen detection
- Commercially available tests use either an immunofluorescent antibody (IFA) assay or a capture enzyme-linked immunosorbent assay (ELISA) against cyst or trophozoite antigens. These have a sensitivity of 85–98% and a specificity of 90–100%.
- While more sensitive than stool examination, these examinations are limited to the detection of Giardia.
Stool culture
- Not useful for diagnosing giardiasis because the organism cannot be grown from patient samples.
Serum antibody detection
- ELISA assays for serum antibodies against Giardia are not readily available.
- It is difficult to make a diagnosis of acute giardiasis because immunoglobulin G (IgG) levels remain elevated for long periods.
- However, serum anti-Giardia immunoglobulin M (IgM) can be helpful in distinguishing between acute and past infections.
String test
- String test (entero-test) involves a gelatin capsule connected to a weighted nylon string.
- The patient tapes one end of the string to his cheek and then swallows the capsule.
- After the gelatin is dissolved in the stomach, the weight carries the string into the duodenum.
- The string is left there for 4–6 hours or overnight while the patient fasts.
- After removal, the string is examined for bilious staining, which identifies successful passage into the duodenum.
- The mucus from the string is examined for trophozoites in iodine or saline.
"Diagnostic Tests" section source
Epidemiology
Acute prevalence rates for giardiasis range from 20 to 30% in most developing countries and 2–7% in developed countries. The CDC estimates that in the United States there are more than 2.5 million cases of giardiasis annually. Giardiasis occurs worldwide with increased prevalence in areas with poor water treatment facilities and unsanitary conditions. The area of highest prevalence is the tropics and subtropics. Despite this, giardiasis does affect a large number of individuals living in highly developed nations with strong infrastructure and water systems. In the United States, giardiasis is the most commonly reported pathogenic protozoan disease. Epidemiological rates for asymptomatic infection with cysts in the large intestineLarge intestine
The large intestine is the third-to-last part of the digestive system — — in vertebrate animals. Its function is to absorb water from the remaining indigestible food matter, and then to pass useless waste material from the body...
s has not been thoroughly investigated, however, according to the American Medical Association
American Medical Association
The American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...
, about two-thirds of infected people have no symptoms.
Giardiasis is common in tourists and business travelers to developing countries, especially Mexico, Southeast Asia, western South America and Russia and the CIS. An increased prevalence of giardiasis among homosexual men has been reported by a number of studies. Lastly, because infection may be caused by poor hygiene, giardiasis has high infection rates in daycare centers and nursing homes, though the groups most at risk for infection are overseas travelers and hikers.
In the United States, many of the reported cases of Giardia occur in the summer because of the ideal climate, and related use of community swimming areas by young diaper-aged children during the summer. Reported Giardia levels have ranged
from 10,000 to 100,000 cysts/L in untreated sewage, 10 to 100 cysts/L in treated sewage, and 10 or few cysts/L in surface water sources and tap water.
State health departments in the U.S. generally do not find Giardia in backcountry settings. "Outbreaks have been linked to contaminated drinking water in small towns, food handlers, and child-care workers who are infected when they change diapers — the researchers didn't find any evidence that wilderness water is a cause."
Public health and prevention strategies/vaccines
Currently, there is no vaccine to protect humans from acquiring giardiasis, nor does chlorinating municipal water protect against Giardia. Thus, various public health and prevention strategies should be taken to decrease risk of infection.- Avoid contaminated water. Hikers and overseas travelers to developing countries should consider all water sources contaminated and thus boil, filter, or treat all water with specially designed tablets or solutions. Freeze food as cysts cannot withstand the freeze cycle.
- Avoid foods washed in contaminated water or that cannot be cooked or peeled, which is especially important for travelers to developing countries. Using only bottled water and avoiding raw fruits and vegetables decreases risk of infection dramatically.
- Wash hands frequently, especially before eating and after using the bathroom, with soap and water for at least 20 seconds. Similarly, wash children with soap and water after diaper changes and before getting back into water (pool, lake, etc.)
- Avoid swallowing water in swimming pools and spas. Since public pools are not always adequately treated, they act as a potential source of Giardia contamination. Ultimately, practice good hygiene including avoiding contact with the feces of an infected person. Being aware of this helps to prevent spread of the infection.
For people who must drink water found "in the field", effective water treatment options include boiling, chemical treatment (iodine tablets), and filtering.
External links
- Giardiasis — Centers for Disease Control and PreventionCenters for Disease Control and PreventionThe Centers for Disease Control and Prevention are a United States federal agency under the Department of Health and Human Services headquartered in Druid Hills, unincorporated DeKalb County, Georgia, in Greater Atlanta...
- giardiasis.org A common protozoal infection of the small intestine, spread via contaminated food and water and direct person-to-person contact.
- bbc.co.uk Giardiasis
- Giardia: The Cosmopolitan Parasite
- canada.gc.ca Giardia And Cryptosporidium In Drinking Water