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Giardiasis

Giardiases


Presentation

It is established that more than half of the patients may harbor the Giardia trophozoites and pass out the cysts without any symptoms at all.

In cases of symptomatic giardiasis that occurs after a mean 9 day average of incubation, the following system-wise presentation may be seen in most patients:

  • General appearance: Patients may appear anorexic and nauseated due to electrolyte imbalance and impending dehydration. Some may appear undernourished or malnourished due to malabsorption problems of the gut.
  • Head and neck: Infants may present with sunken fontanels during massive diarrhea. Tongue may appear dry and eyes will appear sunken with dehydration. 
  • Chest and heart: Tachycardia and shallow breathing may be observable in dehydrated patients.
  • Abdomen: Abdominal cramps may present due to the uncontrolled presynaptic release of cyclic AMP in the abdominal muscles due to the enterotoxins effect. The passage of malodorous flatus and stools are due to intestinal malabsorption. Watery diarrhea is a product of the increased endothelial permeability of the intestines. 
  • Extremities: Thread-like pulses may be appreciated in dehydrated patients. 
  • Neurologic: Decreased mental development may be evident in severely malnourished infants. 
Weight Loss
  • Clinical states range from the asymptomatic cyst-passing stage, to the chronic or subacute stage mimicking gallbladder or ulcer disease, to the transient or, rarer, persistent acute stage with steatorrhea and substantial weight loss.[ncbi.nlm.nih.gov]
  • We report the case of a young man with diabetes mellitus and a family history of CD referred to our hospital because of diarrhoea and weight loss.[ncbi.nlm.nih.gov]
  • Abstract A 13-year-old Hispanic female presented with symptoms of abdominal pain, amenorrhea, and unintentional weight loss of 11 kg.[ncbi.nlm.nih.gov]
  • Usual symptoms of the acute infection are diarrhea, abdominal pain, nausea, and weight loss. Children are more frequently affected than adults. Various extra-intestinal manifestations have been reported, among which are arthritis and arthralgia.[ncbi.nlm.nih.gov]
  • Presentation is of chronic persistent, or recurrent diarrhoea with very offensive stools, abdominal distension and weight loss. Children may show failure to thrive from lack of fat soluble vitamins.[gpnotebook.co.uk]
Camping
  • Water supply varied between camps: in some camps water was provided by the municipal water ducts, in others there were individual tanks for each house. Municipal water (piped water) was the major source of drinking water and was used in 15 camps.[bmcpublichealth.biomedcentral.com]
  • Travel-related cases (both international and domestic) were more likely to go camping or kayaking, and consume untreated water compared to endemic cases.[ncbi.nlm.nih.gov]
  • […] identified: 1) and increased incidence of giardiasis in persons between the ages of 16 and 45, p less than .001, with males and females equally affected; and 2) a higher proportion of cases than controls who visited Colorado mountains (69% vs. 47%), camped[ncbi.nlm.nih.gov]
  • When camping: Bring bottled water for drinking, cooking, and brushing teeth. Purify untreated water before using—boil, filter, or sterilize. Thoroughly wash or peel raw fruits and vegetables before eating.[cancercarewny.com]
Malaise
  • Malaise (general feeling of being unwell) and fatigue (extreme tiredness). Weight loss due to the loss of water as well as impaired absorption of nutrients.[healthhype.com]
  • Other symptoms include: abdominal cramps low energy (malaise) lots of intestinal gas an enlarged belly from the gas loss of appetite nausea and vomiting sometimes a low-grade fever These symptoms may last for 5 to 7 days or longer.[kidshealth.org]
Recurrent Respiratory Infections
  • Medical history should be evaluated carefully regarding recurrent respiratory infections. In such cases with chronic diarrhea, common variable immunodeficiency should be kept in mind as a possible cause.[ncbi.nlm.nih.gov]
Recurrent Bacterial Infection
  • Recurrent bacterial infections, such as otitis media, chronic sinusitis and recurrent pneumonia due to diminished immunoglobulin (Ig) levels and impaired antibody production are frequently observed in common variable immunodeficiency.[ncbi.nlm.nih.gov]
Diarrhea
  • A 39-year-old woman was referred to our department with the complaint of chronic diarrhea. She had experienced diarrhea without mucus or blood in the last year and had lost 30 kg.[ncbi.nlm.nih.gov]
  • In our model to examine predictors of diarrhea only exclusive breastfeeding was significantly associated with decreased diarrhea (P value CONCLUSIONS: Early life Giardia was a risk factor for stunting at age 2 but not poor weight gain.[ncbi.nlm.nih.gov]
  • Failure to thrive in children with diarrhea may lead to malnutrition and result in permanent mental and physical retardation.[symptoma.com]
  • In addition to diarrhea, it can also lead to malnutrition and cognitive deficits in children from developing countries.[ncbi.nlm.nih.gov]
Nausea
  • Usual symptoms of the acute infection are diarrhea, abdominal pain, nausea, and weight loss. Children are more frequently affected than adults. Various extra-intestinal manifestations have been reported, among which are arthritis and arthralgia.[ncbi.nlm.nih.gov]
  • Symptoms include diarrhea, abdominal pain, bloating, nausea, and vomiting. In chronic giardiasis the symptoms are recurrent and malabsorption and debilitation may occur.[web.archive.org]
  • Gas, stomach cramps or pain, upset stomach, greasy stool, and nausea are also symptoms of Giardia infection.[alinia.com]
  • There are many prescription medications available for treating this infection including antibiotics and medications to relieve nausea and vomiting.[news-medical.net]
Abdominal Cramps
  • This can cause symptoms similar to Giardiasis: abdominal cramps, flatulence and diarrhea. For some reason, Giardiasis damages the body’s ability to produce the enzyme that digests lactose.[livestrong.com]
  • The main symptoms are abdominal cramping and diarrhea. People may have abdominal cramping, gas, belching, diarrhea, and nausea and feel tired.[merckmanuals.com]
  • Human infection may range from asymptomatic shedding of giardial cysts to symptomatic giardiasis, being responsible for abdominal cramps, nausea, acute or chronic diarrhoea, with malabsorption and failure of children to thrive.[ncbi.nlm.nih.gov]
  • Acute symptoms include[2,4,6]: Diarrhea Gas Greasy stools that tend to float Stomach or abdominal cramps Upset stomach or nausea/vomiting Dehydration (loss of fluids) Other, less common symptoms include itchy skin, hives, and swelling of the eye and joints[tripadvisor.com]
Vomiting
  • Side-effects including bitter taste, headache, vomiting and dizziness were significantly higher in the MTZ group. Abdominal pain was significantly higher in ABZ group.[ncbi.nlm.nih.gov]
  • Symptoms include diarrhea, abdominal pain, bloating, nausea, and vomiting. In chronic giardiasis the symptoms are recurrent and malabsorption and debilitation may occur.[web.archive.org]
  • Sameerna syrup acts to (i) wards off vomiting and sensation of tendency to vomit. (ii) create anti cholera atmosphere in intestines and digestive parts. (iii) control abdominal and renal colic boosts mental and physical health of children.[medium.com]
  • Acute symptoms include[2,4,6]: Diarrhea Gas Greasy stools that tend to float Stomach or abdominal cramps Upset stomach or nausea/vomiting Dehydration (loss of fluids) Other, less common symptoms include itchy skin, hives, and swelling of the eye and joints[tripadvisor.com]
Abdominal Pain
  • Other associated symptoms were abdominal pain (100%), abdominal distension (70%), flatulence (50%), less consistent stools (50%), anemia (30%), and increased erythrocyte sedimentation rate (60%).[ncbi.nlm.nih.gov]
  • Harmful outcomes were uncommon, and 5-NIs were associated with lower risk of abdominal pain, and higher risk of both bitter or metallic taste and headache.[ncbi.nlm.nih.gov]
  • Abstract A 13-year-old Hispanic female presented with symptoms of abdominal pain, amenorrhea, and unintentional weight loss of 11 kg.[ncbi.nlm.nih.gov]
  • Our study found the prevalence of abdominal pain, dyspeptic syndrome and the symptoms of intoxication in patients with giardiasis. The increase the level of sIgA was detected, especially in females (88 mg/l).[ncbi.nlm.nih.gov]
  • Abdominal pain was significantly higher in ABZ group.[ncbi.nlm.nih.gov]
Urticaria
  • Review of the world literature shows an association between giardiasis and urticaria. Other allergic phenomena, such as angioedema and possibly arthropathy, also might be associated with this infection.[ncbi.nlm.nih.gov]
  • .], and extra-intestinal manifestations (such as food allergy, urticaria, reactive arthritis, and inflammatory ocular manifestations), can develop and possibly persist beyond detectable parasite shedding". Quoted from: Bartelt LA, Sartor RB (2015).[en.wikipedia.org]
  • Anthelmin syrup neutralizes the toxicity and side effects caused by external and internal toxins of worms present in the body such as : (i) Low continuous fever (ii) Flatulence (iii) Diarrhea (iv) Urticaria (v) Difficult breathing (vi) Nervine convulsions[medium.com]
  • Giardiasis causing urticaria in a child. Am. J. Dis. Child. 137 :761–763. PubMed Google Scholar Harter, L., F. Frost, G. Grunenfelder, K. Perkins-Jones, and J. Libby. 1984. Giardiasis in an infant and toddler swim class. Am. J.[link.springer.com]
Skin Lesion
  • Patients with giardiasis are usually asymptomatic but the presence of the parasite may lead to a variety of clinical manifestations, including skin lesions.[ncbi.nlm.nih.gov]
Headache
  • Harmful outcomes were uncommon, and 5-NIs were associated with lower risk of abdominal pain, and higher risk of both bitter or metallic taste and headache.[ncbi.nlm.nih.gov]
  • Side-effects including bitter taste, headache, vomiting and dizziness were significantly higher in the MTZ group. Abdominal pain was significantly higher in ABZ group.[ncbi.nlm.nih.gov]
  • However, systemic symptoms particularly fatigue, lack of energy, muscle weakness, headache, sore throats, enlarged lymph glands, night sweats and occasional fever can be caused as well.[wddty.com]
  • The primary symptoms include: diarrhea, abdominal cramps, headaches, nausea, vomiting, and low-grade fever, which can lead to weight loss and dehydration.[water-research.net]
  • Drinking alcohol within a few days of taking tinidazole or metronidazole may cause nausea, vomiting, flushing, and headaches. Nitazoxanide is available in liquid form, which is useful for children, and as tablets. It is taken twice a day for 3 days.[merckmanuals.com]
Cognitive Deficit
  • In addition to diarrhea, it can also lead to malnutrition and cognitive deficits in children from developing countries.[ncbi.nlm.nih.gov]

Workup

The most common diagnostic modality is the direct identification of the Giardia cysts and trophozoites from stools and upper gastrointestinal tract washings under the light microscopy methodology. Direct light microscopy yield is operator dependent and may not be as specific as the immune assays in Giardia intestinalis identification [7].

The more sensitive antigenic test may involve enzyme immune-assays to identify the antigens. Studies have demonstrated that only 10% of the positive yield in Giradia intestinalis antigenic tests can be spotted in direct microscopy [8]. CDC makes use of specific DNA probes in the identification of Giardia intesinalis.

Giardia Lamblia
  • From Wikidata Jump to navigation Jump to search parasitic disease caused by Giardia lamblia Infection by Giardia lamblia beaver feaver Giardia infection Lambliases Giardia Giardiases infections, Giardia Lambliasis edit English giardiasis parasitic disease[wikidata.org]
  • PURPOSE: The intestinal flagellate Giardia lamblia includes many genetically distinct assemblages, of which assemblage A and B, predominantly infect humans.[ncbi.nlm.nih.gov]
  • Abstract Malabsorption is a well-known complication of infection with Giardia lamblia. However, selective protein-losing enteropathy is rare. We report a child with anasarca due to hypoalbuminemia as a result of gastrointestinal protein loss.[ncbi.nlm.nih.gov]
  • Infection with Giardia lamblia was proved histologically by jejunal biopsy. Treatment with metronidazole resulted in complete elimination of parasites and recovery of regular intestinal thyroid hormone absorption.[ncbi.nlm.nih.gov]
Colitis
  • (acute) (catarrhal) (chronic) (noninfective) (hemorrhagic) K52.9 - see also Enteritis ICD-10-CM Diagnosis Code K52.9 Noninfective gastroenteritis and colitis, unspecified 2016 2017 2018 2019 Billable/Specific Code Applicable To Colitis NOS Enteritis[icd10data.com]
  • Samranwetaya P et al . (1972) Fatal balantidial colitis. Report of a case . J Med Assoc Thai 55 : 259–262 71. Garcia-Laverde A and De Bonilla L (1975) Clinical trials with metronidazole in human balantidiasis . Am J Trop Med Hyg 24 : 781–783 72.[doi.org]
  • PubMed CrossRef 104 Cotton JA, Motta JP, Schenck LP, Hirota SA, Beck PL, Buret AG: Giardia duodenalis infection reduces granulocyte infiltration in an in vivo model of bacterial toxin-Induced colitis and attenuates inflammation in human intestinal tissue[doi.org]

Treatment

Dehydrated patients may benefit from intravenous fluids and plasma expanders. Antibiotic therapy is still the gold standard in the treatment [9].

Giardiasis is treated with oral metronidazole and tinidazole in adults while nitazoxanides are usually given to pediatric patients. Furazolidone and quinacrine have been also used for but have become less popular due to relative toxicity. Metronidazole and tinidazole are contraindicated with pregnancy.

Prognosis

The prognosis of patients with giardiasis is particularly good. Majority of the cases remains silent and asymptomatic while symptomatic cases are usually self-limiting. Mortality do rarely occur among immunocompromised hosts like premature infants, malnourished children and adults suffering severe dehydration

Complications

A number of cases are asymptomatic while symptomatic cases may resolve spontaneously and may cause persistent dysfunctions and complications. The following are the most common complications found in Giardia intestinalis infection:

  • Dehydration results from excessive watery diarrhea that damages the cell’s normal functionality.
  • Failure to thrive in children with diarrhea may lead to malnutrition and result in permanent mental and physical retardation.
  • Milk intolerance occurs due to the progressive flattening of the intestinal villi and malabsorption may predispose patients to lactose intolerance.

Etiology

The clinical infection in giardiasis is caused by the ingestion of the Giardia intestinalis cysts [2]. Humans are easily affected because of its relatively low infective doses which only range from 10 to 25 cysts to cause a clinically significant disease process.

World epidemics especially in the United States are usually due to waterborne transmission of the Giardia cysts. Food transmission of this intestinal protozoan via food contamination has also been observed among infected food handlers [3].

Epidemiology

In the United States, Giardia lamblia has been responsible for at least 90 diarrheal outbreaks between the periods of 1964 to 1984 afflicting more than 23,000 of the population. These were all associated to inadequately treated surface water system in the Western mountain regions of the country where G. lamblia remains endemic up to this date.

Giardiasis has an endemic occurrence in the months of July to October due to increased outdoor activities like recreational camping and mountain climbing [4]. Giardiasis predominantly affects children below the age of five and young adults between the ages 25 and 39 years old. The average prevalence of giardiasis in the United States climbs to as high as 23.5 cases per 100,000 population especially during the endemic months.

The worldwide prevalence of this enteropathogen ranges from 4 to 42% in both temperate and tropical countries. Giardia intestinalis has been implicated in epidemic childhood diarrhea with an infection rating of 15-20% among those below 10 years old [5]. Giardia has also been dubbed as the most common intestinal parasite in United Kingdom and Eastern Europe.

The highest prevalence rating of G. intestinalis reaching 73.4% is found in Nepal. Giardiasis may occur more common among males than females. It affects all ages but age-specific incidence is described to rise from infancy and wanes down during adolescence [6]. The Centers for Disease Control (CDC) identifies children between the age 1 to 9 years old and adults with ages 35 to 44 are most prone to the infection.

Sex distribution
Age distribution

Pathophysiology

The Giardia cysts entry to human gut is notably more common via oral-fecal route or waterborne transmission. Although a great majority of the human population in endemic areas pose as a Giardia carrier, a great majority of the cases remains asymptomatic.

Symptomatic patients generally present the infection within a mean average of 9 days of incubation and convey the whole natural clinical course from 3 to 10 weeks.

There are a number of postulated mechanisms that explain the pathophysiology of Giardia intestinalis in humans.

The most common of which is the adhesion of the Giardia trophozoite to the intestinal villi which flattens the intestinal brush borders causing increased endothelial permeability to cause watery diarrhea. The flattening of the villi has been closely associated with malabsorption syndromes among patients.

Giardia has also been identified to release an enterotoxin that damages the villi and contributes to the symptomatology.

Prevention

Giardiasis is effectively prevented by water treatment of public water sources with iodine and chlorine containing purifying compounds. Food handlers are encouraged to hygienically prepare food products to avoid fecal-oral route of transmission.

Water may be chlorinated and boiled at home for safety. Some fine filtration systems has been proven to remove Giardia intestinalis cysts from water sources. The proper pasteurization of milk products from dairy farm may prevent infections through zooanthroponotic transmissions [10].

Summary

Giardiasis is a clinical disease caused by a flagellated parasitic protozoan Giardia intestinalis (new name of Giardia lamblia) which is revered to be the most common intestinal protozoan parasite in the world [1].

Giardiasis is an ubiquitous intestinal infestation with predilection to poor sanitation and dirty water supply worldwide. Patients will usually complain of abdominal bloating, cramps, nausea and multiple bouts of diarrhea.

Giardiasis may be transmitted through oral-fecal route or from host person to another. The disorder is often times self-limiting but intestinal complication may persist with time. Although antiprotozoal medications provide adequate coverage for giardiasis, good sanitary awareness and clean hygienic practices are paramount to its prevention.

Patient Information

Definition

Giardiasis is a very common intestinal infestation that occurs anywhere in the world which is more endemic in regions with poor health sanitation and dirty water supply.

Cause

Giardiasis is caused by a flagellated protozoan called Giardia intestinalis (G. lamblia as its old name).

Symptoms

Abdominal cramping, pain, malodorous flatus and stools, and watery diarrhea occurs. 

Diagnosis

Giardiasis is diagnosed by direct light microscopy and immune fluorescence assay.

Treatment and follow-up

Patients diagnosed with Giardiasis will benefit from antiprotozoal agents like metronidazole and tinidazole. Patients suffering from dehydration may be given fluid and plasma expanders. Patients must practice proper hygiene and sanitation to prevent its recurrence.

References

Article

  1. Daly ER, Roy SJ, Blaney DD, et al. Outbreak of giardiasis associated with a community drinking-water source. Epidemiol Infect. Apr 2010; 138(4):491-500.
  2. Minvielle MC, Molina NB, Polverino D, Basualdo JA. First genotyping of Giardia lamblia from human and animal feces in Argentina, South America. Mem Inst Oswaldo Cruz. Feb 2008; 103(1):98-103.
  3. Robertson LJ, Forberg T, Hermansen L, Gjerde BK, Langeland N. Molecular characterisation of Giardia isolates from clinical infections following a waterborne outbreak. J Infect. Jul 2007; 55(1):79-88.
  4. Fort GG, Mikolich DJ, Policar M. Giardiasis. In: Ferri FF. Clinical Advisor. 3rd ed. Philadelphia, PA: Mosby, An Imprint of Elsevier; 2009:358.
  5. Yoder JS, Beach MJ. Giardiasis surveillance--United States, 2003-2005. MMWR Surveill Summ. Sep 7 2007; 56(7):11-8
  6. John CC. Giardiasis and Balantidiasis. In: Kliegman RM, Behrman BE, Jenson HB, Stanton BF. Nelson Textbook of Pediatrics. 18th ed. 279. Philadelphia, PA: Saunders, An imprint of Elsevier Inc; 2007:1462-1464.
  7. El-Nahas HA, Salem DA, El-Henawy AA, El-Nimr HI, Abdel-Ghaffar HA, El-Meadawy AM. Giardia diagnostic methods in human fecal samples: a comparative study. Cytometry B Clin Cytom. 2013; 84(1):44-9 
  8. Akyar I, Gültekin M. Five year surveillance of Entamoeba histolytica and Giardia antigen of stool samples by ELISA method.Turkiye Parazitol Derg. 2012; 36(1):12-6 
  9. Escobedo AA, Cimerman S. Giardiasis: a pharmacotherapy review. Expert Opin Pharmacother. Aug 2007; 8(12):1885-902
  10. Dixon B, Parrington L, Cook A, Pintar K, Pollari F, Kelton D, Farber J. The potential for zoonotic transmission of Giardia duodenalis and Cryptosporidium spp. from beef and dairy cattle in Ontario, Canada. Vet Parasitol. 2011; 175(1-2):20-6 

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Last updated: 2017-08-09 17:54