Detection of Dientamoeba fragilis in fresh stool specimens using PCR

Prevalence of Blastocystis sp. and other gastrointestinal pathogens among diarrheic COVID-19 patients in Italy

Background

Gastrointestinal pathogens (GPs) contribute significantly to the burden of illness worldwide with diarrhoea being the most common among gastrointestinal symptoms (GSs). In the COVID-19 disease, diarrhoea, could be one of the initial presenting symptoms. However, no data on the potential correlation between diarrhoea-causing pathogens and SARS-CoV-2 infection are available. Therefore, we carried out a 2-years retrospective study aimed to evaluate the prevalence of "classic" GPs among SARS-CoV-2 infected and non-infected patients with diarrhoea in Italy.

Methods

Results of SARS-CoV-2 research from nasopharyngeal and detection of GPs from stool swab samples by Allplex™ SARS-CoV-2 and GI Virus, Bacteria and Parasite Assay were analysed for all patients with diarrhoea referring to Policlinico Ospedaliero Universitario, Foggia, (Italy) from February 2022 to October 2023.

Results

Out of the 833 involved patients, 81 (3.9%) were COVID-19 positive, while 752 (90.3%) were COVID-19 negative. Among COVID-19-positive patients, 37% (n = 30/81) were found positive for one or more GPs with a higher prevalence of protozoan parasites (18.5%) (Blastocystis ST1-ST4 subtypes, Dientamoeba fragilis genotype I), followed by bacteria (7.4%) (Campylobacter sp., Salmonella sp.). Viral pathogens were more frequent among COVID-19 negative patients (Adenovirus, Norovirus). Among GPs, Blastocystis ST3 subtype was the most prevalent registered in the 16% of patients (p = 0.0001).

Conclusions

Based on obtained results, a likely interaction between the classic GPs and SARS-CoV-2 infection can be speculated, driven by protozoan parasites. Moreover, these results also provide baseline data to understand more deeply Blastocystis sp. role in this scenario of dysbiosis, particularly in those cases of SARS-CoV-2 co-infection.

Evaluation of the Use of Singleplex and Duplex CerTest VIASURE Real-Time PCR Assays to Detect Common Intestinal Protist Parasites

Cryptosporidium spp., Giardia duodenalis and Entamoeba histolytica are species of protozoa- causing diarrhoea that are common worldwide, while Entamoeba dispar, Dientamoeba fragilis and Blastocystis sp. appear to be commensal parasites whose role in pathogenicity remains controversial. We conducted the clinical evaluation of five singleplex and one duplex CerTest VIASURE Real-Time PCR Assays against a large panel of positive DNA samples (n = 358), and specifically to Cryptosporidium spp. (n = 96), G. duodenalis (n = 115), E. histolytica (n = 25) E. dispar (n = 11), Blastocystis sp. (n = 42), D. fragilis (n = 37), and related parasitic phylum species such as Apicomplexa, Euglenozoa, Microsporidia and Nematoda. DNA samples were obtained from clinical stool specimens or cultured isolates in a national reference centre. Estimated diagnostic sensitivity and specificity values were 0.94-1 for Cryptosporidium spp., 0.96-0.99 for G. duodenalis, 0.96-1 for E. histolytica, 1-1 for E. dispar, and 1-0.99 for D. fragilis in the evaluated singleplex assays. In the duplex assay for the simultaneous detection of Blastocystis sp. and D. fragilis these values were 1-0.98 and 1-0.99, respectively. Measures of diagnostic precision for repeatability and reproducibility were found to be under acceptable ranges. The assays identified six Cryptosporidium species (C. hominis, C. parvum, C. canis, C. felis, C. scrofarum, and C. ryanae), four G. duodenalis assemblages (A, B, C, and F), and six Blastocystis subtypes (ST1-ST5, and ST8). The evaluated singleplex and duplex VIASURE Real-Time PCR assays provide sensitive, practical, and cost-effective choices to the molecular diagnosis of the main diarrhoea-causing intestinal protists in clinical microbiology and research laboratories.

Detection and genotyping of Dientamoeba fragilis from symptomatic patients: New insights from Italy into a little-known gastrointestinal protozoan

Dientamoeba fragilis (D. fragilis) represents a common protozoan in both high and low income countries. Despite this, epidemiological data on dientamoebiasis are still limited, and it is possible that the actual prevalence rates of D. fragilis have been underestimated due to the challenges in its detection and identification. In the present study, symptomatic patients from Rome (Central Italy) were surveyed for two years to determine D. fragilis percentage of infection and genotypes. Stool samples collection was performed over 864 patients, DNA extracted, and RT-PCR performed by the SeeGene Allplex™ Gastrointestinal Parasite Panel Assays. Seventy-nine resulted positive for D. fragilis (9.1%). Co-infections were detected in 22 isolates: 21 displayed Blastocystis sp. + D. fragilis (27.8%). Based on the sequence of a central fragment of the SSU rRNA gene, only genotype 1 was identified. These findings are among the few available data regarding genetic diversity of D. fragilis in Italy. Large-scale human and animal research are required to enhance our knowledge of prevalence, host range, genetic variability and zoonotic transmission of this little-known intestinal protozoan.

Molecular diagnosis of intestinal protozoa in young adults and their pets in Colombia, South America

Intestinal parasitic infections have been considered a relevant public health problem due to the increased incidence worldwide. In developing countries, diarrhea and gastrointestinal symptoms cause impaired work capacity in adults and delayed rate growth in children. Enteric infections of unknown etiology can often lead to misdiagnosis, increased transmission, and morbidity. The aim of this study was to determine the prevalence of intestinal parasites in a young adult population and their pets. Stool samples from 139 university students and 44 companion animals were subjected to microscopy diagnosis using wet mounts, concentration by zinc sulphate flotation and staining techniques (Kinyoun and trichrome stain). Molecular diagnosis of protozoa was also performed by conventional PCR. The mean age was 24 years, 54% individuals were female, 46% were men, and 66% had at least one pet. The overall prevalence for at least one parasite was 74.8% and the rate of polyparasitism was 37.5%. Eighty-three patients (59.7%) were positive for Blastocystis spp., followed by Cryptosporidium spp. 24.5%, Endolimax nana 13.6%, Entamoeba dispar/E. moshkovskii 7.8% and Giardia intestinalis 1.4%. Molecular diagnosis substantially improved Cryptosporidium spp. and Blastocystis spp. detection and allowed to distinguish E. histolytica from commensals in the Entamoeba complex. Student's pets were also examined for parasitism. Samples from 27 dogs, 15 cats, one rabbit and one hen were analyzed, and parasites were detected in 30 (68.2%) as follows: Cryptosporidium spp. (24) Giardia spp. (4), hookworm (3), Endolimax nana (2) and Toxoplasma gondii (1). Overall, university students showed high prevalence of parasitism and polyparasitism suggesting exposure to parasite infected animals and contaminated environments. Cryptosporidium spp. was the predominant pathogen in human and domestic animals, and it was only detected by PCR, pointing out the need for sensitive tests in diagnosis and surveillance. Control strategies to prevent the effects of parasitic infections in young population should consider pets as reservoirs and transmission source.

Evaluation of microscopy and PCR for detection of Dientamoeba fragilis

Introduction

Dientamoeba fragilis (D. fragilis) diagnosis is an intestinal protozoan parasite globally found in rural and urban areas and is attracting a growing interest. Its prevalence in stool varies from 0.2% to more than 19% depending upon the population studied.

Materials and Methods

This study was based on the examination of 100 stool samples of randomly referred cases in a rural area in Motobus district, Kafr El-Sheikh governorate, Egypt. Our aim was to investigate the presence of D. fragilis in stool of the examined individuals using conventional polymerase chain reaction (PCR) compared to wet mount and trichrome stain with confirmation of infection by transmission electron microscopy.

Results

D. fragilis was detected in 13/100 of the stool samples examined using wet mount smears, while trichrome stain detected 17/100. Conventional PCR diagnosed 41 cases of D. fragilis in the studied group. A very good agreement was found between wet mount and trichrome stain for diagnosing D. fragilis, while there was fair agreement between conventional PCR and both microscopy methods. Transmission electron microscope was performed on pooled positive samples that revealed the internal structures of D. fragilis trophozoite with its characteristic nucleus.

Conclusions

PCR technique was superior to microscopy for the detection of D. fragilis. Trichrome stain remains vital for microscopic diagnosis.

First report and genotyping of Dientamoeba fragilis in pet budgerigars (Melopsittacus undulatus), with zoonotic importance

The protozoan Dientamoeba fragilis is one of the most common parasites in the digestive system of humans worldwide. The host range and transmission routes of D. fragilis, including the role of animals, are still ambiguous with few reports from non-human primates, sheep, rodents, pigs, a cat and a dog. In this study, we used microscopic and TaqMan qPCR analyses to investigate D. fragilisin 150 faecal samples from pet budgerigars (Melopsittacus undulatus) in the Central Anatolia Region of Turkey. Dientamoeba fragilis DNA was detected in 32 samples, resulting in a mean prevalence of 21.3%. In microscopic examination, trophozoites/cysts of D. fragilis were detected in 13 of 32 qPCR-positive samples. SSU rRNA sequence analyses of the qPCR-positive isolates identified genotype 1 of D. fragilis as predominant in budgerigars. Phylogenetic analyses of the SSU rRNA gene region clustered D. fragilis genotypes, as well as other trichomonads, in separate monophyletic clusters with bootstrap values ≥79.0. Our study provides the first evidence for the natural host status of pet budgerigars for D. fragilisand contributes to the knowledge of the epidemiology of this parasite. The high prevalence of genotype 1 of D. fragilis suggests that pet budgerigars are suitable reservoirs for zoonotic transmission. Our findings contribute to an increased awareness and knowledge of D. fragilis infections in the context of a one-health approach.

Dientamoeba fragilis - the most common intestinal protozoan in the Helsinki Metropolitan Area, Finland, 2007 to 2017

BackgroundDespite the global distribution of the intestinal protozoan Dientamoeba fragilis, its clinical picture remains unclear. This results from underdiagnosis: microscopic screening methods either lack sensitivity (wet preparation) or fail to reveal Dientamoeba (formalin-fixed sample).AimIn a retrospective study setting, we characterised the clinical picture of dientamoebiasis and compared it with giardiasis. In addition, we evaluated an improved approach to formalin-fixed samples for suitability in Dientamoeba diagnostics.MethodsThis study comprised four parts: (i) a descriptive part scrutinising rates of Dientamoeba findings; (ii) a methodological part analysing an approach to detect Dientamoeba-like structures in formalin samples; (iii) a clinical part comparing demographics and symptoms between patients with dientamoebiasis (n = 352) and giardiasis (n = 272), and (iv) a therapeutic part (n = 89 patients) investigating correlation between faecal eradication and clinical improvement.ResultsThe rate of Dientamoeba findings increased 20-fold after introducing criteria for Dientamoeba-like structures in formalin-fixed samples (88.9% sensitivity and 83.3% specificity). A further increase was seen after implementing faecal PCR. Compared with patients with giardiasis, the symptoms in the Dientamoeba group lasted longer and more often included abdominal pain, cramping, faecal urgency and loose rather than watery stools. Resolved symptoms correlated with successful faecal eradication (p < 0.001).ConclusionsPreviously underdiagnosed, Dientamoeba has become the most frequently recorded pathogenic enteroparasite in Finland. This presumably results from improved diagnostics with either PCR or detection of Dientamoeba-like structures in formalin-fixed samples, an approach applicable also in resource-poor settings. Symptoms of dientamoebiasis differ slightly from those of giardiasis; patients with distressing symptoms require treatment.

Irritable bowel syndrome in Egyptian patients: plausible risk factors and association with intestinal protozoa

The pathogenesis of irritable bowel syndrome (IBS) is not yet clear. Our study suggested parasitic infection and other plausible risk factors among Egyptian IBS patients. We studied 40 IBS patients diagnosed according to Rome III criteria (Group I), 40 with other gastrointestinal symptoms (Group II) and 40 healthy controls (Group III). Stool samples were examined using direct wet smear, sedimentation technique, trichrome stain and immune-chromatographic tests for Cryptosporidium parvum. IBS patients displayed a significantly greater percentage of Blastocystis hominis infection (45%) than non-IBS patients (20%) and healthy controls (10%). Dientamoeba fragilis was identified in two IBS patients. Detection of B. hominis was independent of demographic characters, IBS subtype, Helicobacter pylori infection or medications, but with a positive association with a history of antibiotic intake with IBS.

Pinning down the role of common luminal intestinal parasitic protists in human health and disease - status and challenges

While some single-celled intestinal parasites are direct causes of diarrhoea and other types of intestinal pathology, the impact of other gut micro-eukaryotes on human health remains elusive. The fact that some common luminal intestinal parasitic protists (CLIPPs) have lately been found more often in healthy than in diseased individuals has fuelled the hypothesis that some parasites might in fact be protective against disease. To this end, the use of new DNA technologies has helped us investigate trans-kingdom relationships in the gut. However, research into these relationships is currently hampered by the limited data available on the genetic diversity within the CLIPPs genera, which results in limited efficacy of publicly available DNA sequence databases for taxonomic annotation of sequences belonging to the eukaryotic component of the gut microbiota. In this paper, I give a brief overview of the status on CLIPPs in human health and disease and challenges related to the mapping of intestinal eukaryotic diversity of the human gut.

Use of shotgun metagenomics for the identification of protozoa in the gut microbiota of healthy individuals from worldwide populations with various industrialization levels

Protozoa have long been considered undesirable residents of the human gut, but recent findings suggest that some of them may positively affect the gut ecosystem. To better understand the role and ecological dynamics of these commensal and potentially beneficial protozoan symbionts, we need efficient methods to detect them, as well as accurate estimates of their prevalence across human populations. Metagenomics provides such an opportunity, allowing simultaneous detection of multiple symbionts in a single analytical procedure. In this study, we collected fecal samples of 68 individuals from three Cameroonian populations with different subsistence modes and compared metagenomics-based and targeted methods of detection for two common protozoan genera: Blastocystis and Entamoeba. In addition, we analyzed our data along with publicly available fecal metagenomes from various worldwide populations to explore the prevalence and association patterns of ten protozoan genera. Regarding the detection method, microscopy was much less sensitive than metagenomics for Entamoeba, whereas qPCR was at least as sensitive as metagenomics for Blastocystis sp. However, metagenomics was more likely to detect co-colonizations by multiple subtypes. Out of the ten examined genera in 127 individuals from Cameroon, Tanzania, Peru, Italy or USA, only three (Blastocystis, Entamoeba and Enteromonas) had an overall prevalence exceeding 10%. All three genera were more common in less industrialized populations and their prevalence differed between continents and subsistence modes, albeit not in a straightforward manner. The majority (72.5%) of colonized individuals carried at least two protozoan species, indicating that mixed-species colonizations are common. In addition, we detected only positive and no negative association patterns between different protozoa. Despite the pitfalls of the metagenomic approach, ranging from the availability of good-quality sequencing data to the lack of standard analytical procedures, we demonstrated its utility in simultaneous detection of multiple protozoan genera, and especially its ability to efficiently detect mixed-species colonizations. Our study corroborates and expands prevalence results previously obtained for Blastocystis sp. and provides novel data for Entamoeba spp. and several other protozoan genera. Furthermore, it indicates that multiple protozoa are common residents of the healthy human gut worldwide.

Molecular epidemiology of Dientamoeba fragilis

The flagellated protozoan Dientamoeba fragilis is one of the most commonly diagnosed parasite of the human gut, with a global distribution. Nevertheless, essential aspects of its biology remain incompletely understood or controversial, most notably life cycle, host range, transmission routes and the ability to cause disease. Molecular epidemiologic studies are also scarce, and limited by the lack of informative genotyping tools. To date, two D. fragilis genotypes (1 and 2) are recognized, with a strong predominance of genotype 1 in both humans and few animal hosts. Recent studies have shown that a very low level of genetic variability characterizes parasite isolates collected in various geographic areas and from both symptomatic and asymptomatic cases. This has raised the hypothesis D. fragilis may be a clonal organism. The recent availability of transcriptome data should greatly assist the development of markers useful to understand genetic diversity of D. fragilis at the population level.

MALDI-TOF MS as a new tool for the identification of Dientamoeba fragilis

BACKGROUND

In this study for the first time, a Dientamoeba fragilis protein profile by MALDI-TOF MS was created in order to identify specific markers for the application of this technology in the laboratory diagnosis of dientamoebiasis. In particular, one D. fragilis reference strain was used to create a reference spectrum and 14 clinical isolates to verify the reliability of the obtained results.

RESULTS

While 15 peaks were found to be discriminating between the reference strain and the culture medium used, six peaks, observed in all the 14 strains tested, were considered as markers able to identify D. fragilis.

CONCLUSIONS

In our hands, MALDI-TOF MS technology was demonstrated as a useful tool to be used in association with or in replacement of the real-time PCR assay for the identification of D. fragilis used in our laboratory on xenic cultures, due to its accuracy, rapidity and low cost.

Dientamoeba fragilis, the Neglected Trichomonad of the Human Bowel

Dientamoeba fragilis is a protozoan parasite of the human bowel, commonly reported throughout the world in association with gastrointestinal symptoms. Despite its initial discovery over 100 years ago, arguably, we know less about this peculiar organism than any other pathogenic or potentially pathogenic protozoan that infects humans. The details of its life cycle and mode of transmission are not completely known, and its potential as a human pathogen is debated within the scientific community. Recently, several major advances have been made with respect to this organism's life cycle and molecular biology. While many questions remain unanswered, these and other recent advances have given rise to some intriguing new leads, which will pave the way for future research. This review encompasses a large body of knowledge generated on various aspects of D. fragilis over the last century, together with an update on the most recent developments. This includes an update on the latest diagnostic techniques and treatments, the clinical aspects of dientamoebiasis, the development of an animal model, the description of a D. fragilis cyst stage, and the sequencing of the first D. fragilis transcriptome.

Is the treatment of Enterobius vermicularis co-infection necessary to eradicate Dientamoeba fragilis infection?

OBJECTIVES

Dientamoeba fragilis is a pathogenic protozoan of the human gastrointestinal tract with a worldwide distribution, which has emerged as an important and misdiagnosed cause of chronic gastrointestinal illnesses such as diarrhea and 'irritable-bowel-like' gastrointestinal disease. Very little research has been conducted on the use of suitable antimicrobial compounds. Furthermore, higher rates of co-infection with Enterobius vermicularis have been described, suggesting that E. vermicularis could influence the treatment of D. fragilis-infected patients. To study this, the treatment of E. vermicularis and D. fragilis co-infected patients was evaluated.

METHODS

Forty-nine patients with a D. fragilis infection, including 25 (51.0%) patients co-infected with E. vermicularis, were studied. All of them were treated with metronidazole. Patients with E. vermicularis co-infection and/or an E. vermicularis-positive case in the family were treated with mebendazole.

RESULTS

Metronidazole treatment failure was significantly more frequent in patients with E. vermicularis co-infection and in patients with children in the family.

CONCLUSIONS

Co-infection with E. vermicularis may act as a factor favoring D. fragilis infection by preventing eradication measures. This suggests that both parasites should be treated simultaneously.

Molecular testing for clinical diagnosis and epidemiological investigations of intestinal parasitic infections

Over the past few decades, nucleic acid-based methods have been developed for the diagnosis of intestinal parasitic infections. Advantages of nucleic acid-based methods are numerous; typically, these include increased sensitivity and specificity and simpler standardization of diagnostic procedures. DNA samples can also be stored and used for genetic characterization and molecular typing, providing a valuable tool for surveys and surveillance studies. A variety of technologies have been applied, and some specific and general pitfalls and limitations have been identified. This review provides an overview of the multitude of methods that have been reported for the detection of intestinal parasites and offers some guidance in applying these methods in the clinical laboratory and in epidemiological studies.

Dientamoeba fragilis, One of the Neglected Intestinal Protozoa

Dientamoeba fragilis is a single-celled protozoan, closely related to the trichomonads. Reported worldwide as causing human gastrointestinal symptoms, D. fragilis is very common and is second only to Blastocystis spp. Dientamoebiasis equals or exceeds the incidence of giardiasis. This minireview includes diagnostic options, clinical relevance, therapy, an animal model, the confirmed cyst stage, and sequencing data. The development of a rodent model, fulfilling Koch's postulates, and the confirmation of a cyst stage have clarified transmission routes, including fecal-oral transmission. The prevalence of D. fragilis varies between 0% to over 82%; results depend on the geographic location, group studied, and diagnostic methods used.

Blastocystosis in post-traumatic splenectomized patients

BACKGROUND/AIMS

The aim of this study was to determine the prevalence and significance of intestinal protozoa, specially Blastocystis spp., and to perform PCR-based subtype classification for understanding the importance of Blastocystis spp. in the pathogenesis of gastrointestinal disorders in post-traumatic splenectomized patients.

MATERIALS AND METHODS

A total of 60 stool samples were obtained from 30 post-traumatic splenectomized patients and 30 healthy controls. Wet mounts, trichrome and Kinyoun acid-fast stained slides were prepared from the stool specimens. PCR was used for detecting the presence of Giardia spp., Entamoeba spp., Dientamoeba fragilis, Cryptosporidium spp., Blastocystis spp. Genotyping was realized by using Blastocystis hominis STS primers.

RESULTS

In both study groups, any helminth eggs and other protozoa except Blastocystis spp. were not detected by microscopy and PCR, and also bacterial cultures were negative. Only stool microscopy was positive for Blastocystis spp. in 30% (9 of 30) of splenectomized patients and in 13% (4/30) of healthy controls. PCR for Blastocystis spp. was positive in 40% (12 of 30), B. hominis genotypes were 20% (6/30): STS1 in 10% (3/30) and STS3 in 10% (3/30) of splenectomized patients. In healthy controls Blastocystis spp. was 13% (4/30) by PCR and genotypes of B. hominis was not detected. The difference between the prevalence of Blastocystis spp. infection in splenectomized patients and control groups was statistically significant (p=0.020). Abdominal pain was the most frequent gastrointestinal symptom (p=0.019) among splenectomized patients positive for Blastocystis spp.

CONCLUSION

In post-traumatic healthy splenectomized patients, Blastocystis spp. were found to be the most prevalent protozoa and may be responsible for the gastrointestinal disorders.

Multi-locus typing of Histomonas meleagridis isolates demonstrates the existence of two different genotypes

Histomonas meleagridis is the aetiological agent of histomonosis or “blackhead disease”. Histomonosis is of special importance today, because there is no effective treatment to prevent its occurrence with considerable losses for the poultry industry. Despite its importance only a few molecular studies have yet been performed to investigate the degree of genetic diversity between different isolates of this parasite. In the present study a collection of well defined samples, previously shown positive for the DNA of H. meleagridis, was used to investigate genetic relatedness of the parasite. Samples originated from 25 turkey flocks collected in France between 2007 and 2010. Additionally, diagnostic samples, collected at our Clinic in Vienna, from different European countries and Azerbaijan, during 2010 to 2013 were included in the analyses. For the analysis three different genetic loci were analyzed: 18S rRNA, α-actinin1 and rpb1 genes. To amplify partial sequences of α-actinin1 and rpb1 genes, primers specifically targeting H. meleagridis were designed. Following PCR, the sequences of 18S rRNA, α-actinin1 and rpb1 loci were analyzed. Phylogenetic analyses demonstrated separation of H. meleagridis isolates in two different clusters. The majority of isolates grouped within the cluster 1 and originated from different European countries. The cluster 2 was rare and predominantly found in samples originating from France. Considering that the genetic variability of clusters can be seen as two distinct genetic types we propose the term genotype instead of cluster.

Evaluation of the EasyScreen™ enteric parasite detection kit for the detection of Blastocystis spp., Cryptosporidium spp., Dientamoeba fragilis, Entamoeba complex, and Giardia intestinalis from clinical stool samples

The aim of this study was to evaluate the EasyScreen™ Enteric Parasite Detection Kit (Genetic Signatures, Sydney, Australia) for the detection and identification of 5 common enteric parasites: Blastocystis spp., Cryptosporidium spp., Dientamoeba fragilis, Entamoeba complex, and Giardia intestinalis in human clinical samples. A total of 358 faecal samples were included in the study. When compared to real-time PCR and microscopy, the EasyScreen™ Enteric Parasite Detection Kit exhibited 92-100% sensitivity and 100% specificity and detected all commonly found genotypes and subtypes of clinically important human parasites. No cross reactivity was detected in stool samples containing various other bacterial, viral, and/or protozoan species. The EasyScreen™ PCR assay was able to provide rapid, sensitive, and specific simultaneous detection and identification of the 5 most important diarrhoea-causing enteric parasites that infect humans. It should be noted, however, that the EasyScreen™ Kit does not substitute for microscopy or for additional PCRs as it does not detect the pathogenic Coccidia spp. Cystoisospora belli or Cyclospora cayetanensis and it does not differentiate between pathogenic and nonpathogenic Entamoeba spp. This study also highlights the lack of sensitivity demonstrated by microscopy; as such, molecular methods should be considered the diagnostic method of choice for enteric parasites.

Detection of intestinal protozoa in paediatric patients with gastrointestinal symptoms by multiplex real-time PCR

The performance of a multiplex real-time PCR for the detection of Blastocystis, Dientamoeba fragilis, Giardia lamblia, Cryptosporidium species and Entamoeba species in faecal samples was evaluated in an observational prospective study. Paediatric patients (0-18 years) presenting with gastrointestinal symptoms and suspected of having enteroparasitic disease were included. A questionnaire on gastrointestinal symptoms and the chosen treatment was completed at the start of the study and after 6 weeks. Of 163 paediatric patients (mean age, 7.8 years), 114 (70%) had a PCR-positive faecal sample. D. fragilis was detected most frequently, in 101 patients, followed by Blastocystis in 49. In faecal samples of 47 patients, more than one protozoan was detected, mainly the combination of D. fragilis and Blastocystis. Reported gastrointestinal symptoms were abdominal pain (78%), nausea (30%), and altered bowel habits (28%). Eighty-nine of the PCR-positive patients were treated with antibiotics. A significant reduction in abdominal pain was observed both in treated and in untreated patients. This study demonstrated that multiplex real-time PCR detects a high percentage of intestinal protozoa in paediatric patients with gastrointestinal symptoms. However, interpretation and determination of the clinical relevance of a positive PCR result in this population are still difficult.

Cyst formation and faecal-oral transmission of Dientamoeba fragilis--the missing link in the life cycle of an emerging pathogen

Dientamoeba fragilis is a protozoan parasite emerging as a cause of diarrhoea and "irritable-bowel-like" gastrointestinal disease in humans with a propensity for establishing long-term, chronic infections in humans. Although Dientamoeba was discovered over a century ago its life cycle and mode of transmission is not known. No cyst stage has been described and no animal models are presently available for the study of this parasite. Here we describe the establishment of an animal model using laboratory rodents, the fulfilling of Koch's postulates, and the discovery of a new cyst stage in the life cycle of D. fragilis. Our demonstration of long-term parasite carriage by rodents and prolonged shedding of cysts, together with elevated levels of calprotectin in the stool, confirms the capacity of this organism to cause disease and indicates dientamoebiasis should be considered in the differential diagnosis of gastrointestinal diseases such as Inflammatory Bowel Syndrome (IBS). Finally, we suggest that the cyst stage described here is the vehicle that mediates faecal-oral transmission of D. fragilis between hosts.

Dientamoeba fragilis: a family cluster of disease associated with marked peripheral eosinophilia

Dientamoeba fragilis has emerged as an important and underrecognized cause of gastrointestinal illness. We report a familial cluster of D. fragilis associated with marked peripheral eosinophilia and gastrointestinal symptoms. Dientamoeba fragilis infection should be considered in the setting of unexplained eosinophilia. If confirmed, screening of household members should be considered.

Limited intra-genetic diversity in Dientamoeba fragilis housekeeping genes

Dientamoeba fragilis is a common intestinal parasite of unsettled clinical significance. Differences in clinical outcome of parasitic infections may reflect parasite genetic diversity, and so tools to study intra-genetic diversity that could potentially reflect differences in clinical phenotypes are warranted. Here, we show that genetic analysis of three D. fragilis housekeeping genes enables clear distinction between the two known genotypes, but that integration of housekeeping genes in multi-locus sequencing tools for D. fragilis may have limited epidemiological and clinical value due to no further added genetic resolution.

Childhood parasitic infections endemic to the United States

Endemic parasitic infections in the United States are more frequent than is commonly perceived. Intestinal parasitic infection with Cryptosporidium, Dientamoeba, and Giardia occurs most often in children in northern states during the summer months. Zoonotic Toxocara and Toxoplasma parasitic infections are more frequent in southern states, in African Americans, and in populations with lower socioeconomic status. Approximately 300, 000 people in the United States have Trypanosoma cruzi infection. Local, vector-borne transmission of T cruzi and Leishmania infections has been documented in southern states. Parasitic diseases endemic to the United States are not uncommon but are understudied.

Enteric protozoa in the developed world: a public health perspective

Several enteric protozoa cause severe morbidity and mortality in both humans and animals worldwide. In developed settings, enteric protozoa are often ignored as a cause of diarrheal illness due to better hygiene conditions, and as such, very little effort is used toward laboratory diagnosis. Although these protozoa contribute to the high burden of infectious diseases, estimates of their true prevalence are sometimes affected by the lack of sensitive diagnostic techniques to detect them in clinical and environmental specimens. Despite recent advances in the epidemiology, molecular biology, and treatment of protozoan illnesses, gaps in knowledge still exist, requiring further research. There is evidence that climate-related changes will contribute to their burden due to displacement of ecosystems and human and animal populations, increases in atmospheric temperature, flooding and other environmental conditions suitable for transmission, and the need for the reuse of alternative water sources to meet growing population needs. This review discusses the common enteric protozoa from a public health perspective, highlighting their epidemiology, modes of transmission, prevention, and control. It also discusses the potential impact of climate changes on their epidemiology and the issues surrounding waterborne transmission and suggests a multidisciplinary approach to their prevention and control.

In vitro susceptibility testing of Dientamoeba fragilis

Dientamoeba fragilis is a commonly encountered trichomonad which has been implicated as a cause of gastrointestinal disease in humans. Despite the frequency of reports recording infections with this parasite, little research has been undertaken in terms of antimicrobial susceptibility. The aim of this study was to evaluate the susceptibility of D. fragilis to several commonly used antiparasitic agents: diloxanide furoate, furazolidone, iodoquinol, metronidazole, nitazoxanide, ornidazole, paromomycin, secnidazole, ronidazole, tetracycline, and tinidazole. Antibiotic susceptibility testing was performed on four clinical strains of D. fragilis, designated A, E, M, and V, respectively. Molecular testing followed, and all strains were determined to be genotype 1. The activities of antiprotozoal compounds at concentrations ranging from 2 μg/ml to 500 μg/ml were determined via cell counts of D. fragilis trophozoites grown in dixenic culture. Minimum lethal concentrations (MLCs) were as follows: ornidazole, 8 to 16 μg/ml; ronidazole, 8 to 16 μg/ml; tinidazole, 31 μg/ml; metronidazole, 31 μg/ml; secnidazole, 31 to 63 μg/ml; nitazoxanide, 63 μg/ml; tetracycline, 250 μg/ml; furazolidone, 250 to 500 μg/ml; iodoquinol, 500 μg/ml; paromomycin, 500 μg/ml; and diloxanide furoate, >500 μg/ml. This is the first study to report the profiles of susceptibility to a wide range of commonly used treatments for clinical isolates of D. fragilis. Our study indicated 5-nitroimidazole derivatives to be the most active compounds in vitro against D. fragilis.

Blastocystis infection is associated with irritable bowel syndrome in a Mexican patient population

In recent times, some common "non-pathogenic" parasites, such as Blastocystis and Dientamoeba fragilis, have been associated to the aetiology of irritable bowel syndrome (IBS), while host pro-inflammatory cytokine gene polymorphisms might have a role in the pathophysiology of the disease. Therefore, Blastocystis subtypes (ST), D. fragilis and gene promoter single nucleotide polymorphisms of interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNF-α) in IBS patients and controls were studied. After giving written consent, 45 patients with symptoms of IBS according to the Rome III criteria and 45 controls were enrolled. DNA was extracted from peripheral blood for SNP analysis at position -174 for IL-6 as well as -238 and -308 for TNF-α. Blastocystis was more common in the IBS group (p = 0.043). Interestingly, D. fragilis was found more frequently in the control group (p = 0.002); Blastocystis ST1 and 3 were most frequent in both groups. Haploview analysis revealed linkage disequilibrium in TNF-α (p < 0.0001); however, none of the SNPs for IL-6 and TNF-α were found to be significantly related with IBS. The clinical and molecular approaches undertaken for the first time in Latin American IBS patients demonstrated an association with Blastocystis that supports a pathogenic role of this parasite in IBS Furthermore, co-infections with ST1 and ST3 were frequent; thus, the genetic diversity proposed within ST polymorphisms does not rule out that particular strains might be associated with disease. In addition, our results do not support a major contribution of IL-6 and TNF-α gene polymorphisms in the susceptibility to IBS.

Evaluation of multiplex tandem real-time PCR for detection of Cryptosporidium spp., Dientamoeba fragilis, Entamoeba histolytica, and Giardia intestinalis in clinical stool samples

The aim of this study was to describe the first development and evaluation of a multiplex tandem PCR (MT-PCR) assay for the detection and identification of 4 common pathogenic protozoan parasites, Cryptosporidium spp., Dientamoeba fragilis, Entamoeba histolytica, and Giardia intestinalis, from human clinical samples. A total of 472 fecal samples submitted to the Department of Microbiology at St. Vincent's Hospital were included in the study. The MT-PCR assay was compared to four real-time PCR (RT-PCR) assays and microscopy by a traditional modified iron hematoxylin stain. The MT-PCR detected 28 G. intestinalis, 26 D. fragilis, 11 E. histolytica, and 9 Cryptosporidium sp. isolates. Detection and identification of the fecal protozoa by MT-PCR demonstrated 100% correlation with the RT-PCR results, and compared to RT-PCR, MT-PCR exhibited 100% sensitivity and specificity, while traditional microscopy of stained fixed fecal smears exhibited sensitivities and specificities of 56% and 100% for Cryptosporidium spp., 38% and 99% for D. fragilis, 47% and 97% for E. histolytica, and 50% and 100% for G. intestinalis. No cross-reactivity was detected in 100 stool samples containing various other bacterial, viral, and protozoan species. The MT-PCR assay was able to provide rapid, sensitive, and specific simultaneous detection and identification of the four most important diarrhea-causing protozoan parasites that infect humans. This study also highlights the lack of sensitivity demonstrated by microscopy, and thus, molecular methods such as MT-PCR must be considered the diagnostic methods of choice for enteric protozoan parasites.

Newly defined conditions for the in vitro cultivation and cryopreservation of Dientamoeba fragilis: new techniques set to fast track molecular studies on this organism

Dientamoeba fragilis is a pathogen of the human gastrointestinal tract that is a common cause of diarrhoea. A paucity of knowledge on the in vitro cultivation and cryopreservation of Dientamoeba has meant that few studies have been conducted to investigate its biology. The objective of this study was to define, for the first time, in vitro culture conditions able to support the long-term in vitro growth of Dientamoeba. Also, we aimed to define a suitable method for cryopreserving viable Dientamoeba trophozoites. A modified BD medium, TYGM-9, Loeffler's slope medium, Robinson's medium, Medium 199, Trichosel and a Tritrichomonas fetus medium were compared, using cell counts, for their ability to support the growth of D. fragilis at various temperatures and atmospheric conditions. Loeffler's slope medium supported significantly better growth compared to other media. A temperature of 42°C and a microaerophilic atmosphere were also optimum for Dientamoeba growth. To our knowledge, this is the first study to describe and compare different culture media and conditions for the growth of clinical isolates of D. fragilis. This new technology will aid the development of diagnostics for dientamoebiasis as well as facilitate large-scale sequencing projects that will fast track molecular studies on D. fragilis.

Evaluation of a real-time polymerase chain reaction assay for the detection of Dientamoeba fragilis

The diagnostic value of a real-time polymerase chain reaction (PCR) assay targeting the 5.8S rDNA of Dientamoeba fragilis was investigated as compared with conventional parasitologic methods including cultivation testing 959 fecal samples from 491 patients attending a tertiary-care hospital and suspected of having an intestinal parasitosis. The real-time PCR assay revealed 117 additional D. fragilis-positive samples as compared with conventional methods, showing 100% sensitivity and specificity in our experience. On the whole, D. fragilis infection was detected in 186 samples from 105 patients (21.4%, third in frequency among the diagnosed intestinal parasitoses). The evaluated real-time PCR assay represents an effective tool to obtain both an accurate diagnosis and a reliable epidemiologic picture of dientamoebiasis.

A review of the clinical presentation of dientamoebiasis

Among 750 symptomatic and asymptomatic patients, Dientamoeba fragilis was detected at a prevalence of 5.2% and more common than Giardia intestinalis. Most infected patients presented with diarrhea and abdominal pain with symptoms greater than 2 weeks duration being common. Bacterial and viral causes of infection were excluded by routine microbiological techniques. Treatment of D. fragilis infection with either iodoquinol, paromomycin, or combination therapy resulted in the eradication of the parasite and complete resolution of symptoms. Treatment failure/relapses were associated only with the use of metronidazole. Nineteen patients were examined for pin worm, no Enterobius vermicularis, a proposed vector of transmission, were detected. Intermittent shedding of D. fragilis was found to be highly variable. These studies confirm the pathogenic nature of D. fragilis and we recommend laboratories routinely test for the organism.

Comparison of microscopy, two xenic culture techniques, conventional and real-time PCR for the detection of Dientamoeba fragilis in clinical stool samples

Dientamoeba fragilis is a pathogenic protozoan parasite that is notoriously difficult to diagnose. The aim of this study was to determine the gold standard for laboratory detection of D. fragilis. A total of 650 human faecal samples were included in the study. All specimens underwent the following: microscopy using a permanent stain (modified iron-haematoxylin), culture using a modified Boeck and Drbohlav's medium (MBD) and TYGM-9, a conventional polymerase chain reaction (PCR) and a real-time PCR (RT-PCR). The overall prevalence of D. fragilis in the study population was 5.4% (35/650). RT-PCR detected 35 isolates, conventional PCR detected 15 isolates, MBD culture detected 14 isolates, TYGM-9 detected ten isolates, while microscopy detected 12 isolates. RT-PCR detected an additional 15 positive samples compared to the other diagnostic methods, all of which were confirmed by sequencing. When all methods were compared to each other, RT-PCR showed a sensitivity and specificity of 100 and 100%, conventional PCR 42.9 and 100%, MBD culture 40 and 100%, TYGM-9 culture 28.6 and 100%, and microscopy 34.3 and 99%, respectively. These results show that RT-PCR is the diagnostic method of choice for the detection of D. fragilis in clinical samples and, as such, should be considered as the gold standard for diagnosis.

Clinical significance of enteric protozoa in the immunosuppressed human population

Globally, the number of immunosuppressed people increases each year, with the human immunodeficiency virus (HIV) pandemic continuing to spread unabated in many parts of the world. Immunosuppression may also occur in malnourished persons, patients undergoing chemotherapy for malignancy, and those receiving immunosuppressive therapy. Components of the immune system can be functionally or genetically abnormal as a result of acquired (e.g., caused by HIV infection, lymphoma, or high-dose steroids or other immunosuppressive medications) or congenital illnesses, with more than 120 congenital immunodeficiencies described to date that either affect humoral immunity or compromise T-cell function. All individuals affected by immunosuppression are at risk of infection by opportunistic parasites (such as the microsporidia) as well as those more commonly associated with gastrointestinal disease (such as Giardia). The outcome of infection by enteric protozoan parasites is dependent on absolute CD4(+) cell counts, with lower counts being associated with more severe disease, more atypical disease, and a greater risk of disseminated disease. This review summarizes our current state of knowledge on the significance of enteric parasitic protozoa as a cause of disease in immunosuppressed persons and also provides guidance on recent advances in diagnosis and therapy for the control of these important parasites.

Repeated Dientamoeba fragilis infections: a case report of two families from Sydney, Australia

We report cases of two unrelated families who both presented with recurrent Dientamoeba fragilis infections. Subsequent antimicrobial therapy resulted in the clearance of D. fragilis and total resolution of gastrointestinal symptoms in both families. This report highlights the potentially recurrent nature of D. fragilis infections and the need for laboratories to routinely test for this organism.

Genetic diversity of Dientamoeba fragilis isolates of irritable bowel syndrome patients by high-resolution melting-curve (HRM) analysis

Dientamoeba fragilis is a parasite that has been recognized as a causative agent of gastrointestinal symptoms. The search for genetic variation in D. fragilis based on the small-subunit (SSU) rRNA gene using restriction fragment length polymorphism was found not useful for molecular epidemiology. In this study, genetic variability of different clinical isolates of D. fragilis was explored by high-resolution melting curve (HRM) following polymerase chain reaction (PCR) in a one-step closed-tube method. Thirty fecal samples from irritable bowel syndrome (IBS) patients having D. fragilis trophozoites and negative for other organisms were involved in this study. According to the type of diarrhea, eight patients had acute, 14 patients had chronic intermittent, and eight patients had diarrhea alternating with constipation. HRM proved that four profiles (subtypes) were present as detecting by scanning mutation. One of these profiles (profile 1) was predominant (50%). Profile 2 was present on 20%. Profiles 3 and 4 were present on 16.7% and 13.4%, respectively. No mixed profiles were detected among the samples. The melting curves characterized by T(m)1=77.17+/-0.29 degrees C in profile 1, T(m)1=77.37+/-1.45 degrees C in profile 2, T(m)1=74.24+/-0.08 degrees C and T(m)2=79.64+/-0.09 degrees C in profile 3, and T(m)1=75.51 +/- 0.09 degrees C and T(m)=79.42 +/- 0.09 degrees C in profile 4. The relation between these profiles and types of diarrhea proved that the majority of patients having profile 1 (73.4%) and profile 4 (75%) had chronic intermittent diarrhea. All of the patients having profile 2 had acute diarrhea while all of the patients having profile 3 had diarrhea alternating with constipation. Although profile 1 was detected among all types of diarrhea, it was corresponding to 11/14 of patients with chronic intermittent diarrhea. All the differences were clinically and statistically significant. In conclusion, HRM following PCR was proved as a wide variation on D. fragilis genotypes that could be related to the characters of diarrhea among IBS patients. As the differences in HRM reflect different sequences of SSU RNA gene, thus, another study for identifying the sequences of these isolates (profiles) will be done and published later.

Partial sequence of the beta-tubulin of Histomonas meleagridis and the activity of benzimidazoles against H. meleagridis in vitro

The protozoan parasite Histomonas meleagridis is a member of the family Monocercomonadidae in the class Trichomonada. Due to food safety concerns, currently no prophylactic or therapeutic drug against the parasite is licensed in the European Union. Benzimidazoles are antiparasitic drugs, and some of them are licensed for use in food-producing animals. Benzimidazoles act on beta-tubulin, and the beta-tubulin sequence allows predictions about the efficacy of benzimidazoles. In this study, we sequenced and analyzed a part of the beta-tubulin gene of five H. meleagridis strains and of Dientamoeba fragilis. In each Histomonas strain, three to five different sequences were found. No clustering of sequences from the same strain was recognizable. A phylogenetic tree based on the amino acid sequences of trichomonal beta-tubulin genes placed the histomonal sequences on a branch with D. fragilis, separate from Monocercomonas sp. and Tritrichomonas foetus. All histomonal amino acid sequences predicted a susceptibility to benzimidazoles. However, when we tested the efficacy of five benzimidazoles, namely, albendazole, fenbendazole, flubendazole, mebendazole, and nocodazole, on H. meleagridis in vitro, all tested drugs showed no efficacy, even though the concentrations tested were higher than the concentrations found to be effective against Trichomonas vaginalis and T. foetus by other investigators.

Intragenomic variation in the internal transcribed spacer 1 region of Dientamoeba fragilis as a molecular epidemiological marker

Dientamoeba fragilis is a parasite that has been recognized to be a causative agent of gastrointestinal symptoms. Because in most studies only some infected persons experience symptoms, it is possible that D. fragilis is a heterogeneous species with variants that display similar morphologies but different pathogenicities. The search for genetic variation in D. fragilis was based on the small-subunit rRNA gene, which was not found to be useful for molecular epidemiology. In this report, we describe the isolation and characterization of additional rRNA gene cluster sequences, the internal transcribed spacer 1 (ITS-1)-5.8S rRNA gene-ITS-2 region. For comparative purposes, we also isolated the ITS-1-5.8S rRNA gene-ITS-2 region of Histomonas meleagridis, a protozoan parasite of birds and a close relative of D. fragilis. This region was found to be highly variable, and 11 different alleles of the ITS-1 sequence could be identified. Variation in the ITS-1 region was found to be intragenomic, with up to four different alleles in a single isolate. So-called C profiles were produced from the ITS-1 repertoire of single isolates. Analysis of the C profiles of isolates from nonrelated patients identified several clearly distinguishable strains of D. fragilis. Within families, it was shown that members can be infected with the same or different strains of D. fragilis. In conclusion, the ITS-1 region can serve as a molecular epidemiological tool for the subtyping of D. fragilis directly from feces. This may serve as a means of studying the transmission, geographical distribution, and relationships between strains and the pathogenicity of this parasite.

Gorillas are a host for Dientamoeba fragilis: an update on the life cycle and host distribution

Dientamoeba fragilis is a gastrointestinal protozoan that has a worldwide distribution and is emergeing as a common cause of diarrhea. As D. fragilis has a propensity to cause chronic illness with symptoms similar to irritable bowel syndrome (IBS) it is not surprising that some patients with D. fragilis are misdiagnosed as having IBS. In contrast to most other pathogenic protozoa very little is known about its life cycle, epidemiology and mode of transmission. What role animal reservoirs play in the transmission of this parasite is unknown. Consequently we undertook a prospective study to determine the host distribution of D. fragilis. Over a 2-year-period, 608 faecal samples from a wide range of animal and bird species, including pigs and other food species, were screened using permanent stained smears for the presence of D. fragilis. Trophozoites of D. fragilis were only detected in Western lowland gorillas (3/10) (Gorilla g. gorilla) and confirmed by PCR targeting the SSU rRNA gene. The limited host range detected suggests human infection may not involve transmission from other animal species. In addition, we provide an update on the limited knowledge about the life cycle of this parasite and its host distribution.

Transmission of Dientamoeba fragilis: evaluation of the role of Enterobius vermicularis

The role of Enterobius vermicularis in the transmission of Dientamoeba fragilis has been evaluated in two groups of patients admitted to the Parasitology Laboratory of Celal Bayar University: one group with E. vermicularis infection (n=187, Pinworm Group), and the other with D. fragilis infection (n=126, Dientamoeba Group). The presence of the other parasite, pinworm or Dientamoeba, was investigated with the microscopic examination of cellophane tape and stool samples for three consecutive days. In the Pinworm Group, 9.6% of the patients were found to be coinfected with D. fragilis, while 25.4% of the patients in the Dientamoeba Group were found to be coinfected with pinworms. The coincidence rates of D. fragilis and E. vermicularis, higher than the prevalence of each parasite in similar populations, suggest a common relation between these two parasites, possibly in entering the human body. E. vermicularis infection was found to be significantly more common in younger children (p<0.001), indicating that younger children may also be at higher risk for D. fragilis infection. These findings also raise the question of whether the unrelated symptoms of the pinworm infected patients such as abdominal pain and diarrhea may actually be due to overlooked Dientamoeba infections.

Real-time PCR for the detection of Dientamoeba fragilis in fecal samples

A real-time polymerase chain reaction (PCR) method targeting the 5.8S ribosomal RNA gene was developed for the detection of Dientamoeba fragilis in stool samples. The PCR also included an internal control to detect inhibition of the amplification by fecal constituents in the sample. The assay was performed on species-specific DNA controls (n=29) and a range of stool samples (n=85), and achieved high specificity and sensitivity. D. fragilis DNA could be detected in unpreserved fecal samples up to 8 weeks after storage at 4 degrees C. The use of this assay in a diagnostic laboratory offers the possibility of introducing DNA detection as a feasible technique for the routine diagnosis of intestinal D. fragilis infections.

Dientamoeba fragilis in swine population: A preliminary investigation

Dientamoeba fragilis, a protozoan with worldwide distribution is considered to be responsible for enteric disease in humans. A wide spectrum of clinical symptoms including; diarrhoea (acute or prolonged), flatulence, abdominal pains and other unspecific bowel symptoms have been ascribed to this parasite. Asymptomatic infection has also been reported. Dientamoeba fragilis is as its name indicates an extremely delicate protozoon and only the trophozoite has ever been demonstrated in stool samples. The definitive diagnosis of this infection is based on demonstration in permanently stained stool samples. In Italy examination of ova and parasite (O&P) samples are not currently performed. This protozoan is extremely difficult to cultivate but molecular techniques such as the Polymerase Chain Reaction offer promise as a means of diagnosing infection. The epidemiology of Dientamoebiasis is not clear. This paper will present preliminary results from a study looking for the parasite's presence in swine faeces. The possible role of pigs as a reservoir of infection was studied; 121 faecal samples from breeding and fattening pigs were examined using a Giemsa permanent stain. Dientamoeba fragilis was found in 53 (43.8%) of the stool samples examined.

Dientamoeba fragilis as a cause of travelers' diarrhea: report of seven cases

Dientamoeba fragilis is a pathogenic trichomonad parasite that causes gastrointestinal disease in humans. We report seven cases of travelers' diarrhea caused by D fragilis in patients who had traveled to overseas destinations within Asia or the Pacific which occurred over an 8-month period. Patients presented with diarrhea lasting from 5 days to over 4 weeks. Dientamoeba fragilis should be considered as a cause of diarrhea in returning travelers.

Irritable bowel syndrome: a review on the role of intestinal protozoa and the importance of their detection and diagnosis

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder in which abdominal pain is associated with a defect or a change in bowel habits. Gut inflammation is one of the proposed mechanisms of pathogenesis. Recent studies have described a possible role for protozoan parasites, such as Blastocystis hominis and Dientamoeba fragilis, in the etiology of IBS. Dientamoeba fragilis is known to cause IBS-like symptoms and has a propensity to cause chronic infections but its diagnosis relies on microscopy of stained smears, which many laboratories do not perform, thereby leading to the misdiagnosis of dientamoebiasis as IBS. The role of B. hominis as an etiological agent of IBS is inconclusive, due to contradictory reports and the controversial nature of B. hominis as a human pathogen. Although Entamoeba histolytica infections occur predominately in developing regions of the world, clinical diagnosis of amebiasis is often difficult because symptoms of patients with IBS may closely mimic those patients with non-dysenteric amoebic colitis. Clinical manifestations of Giardia intestinalis infection also vary from asymptomatic carriage to acute and chronic diarrhoea with abdominal pain. These IBS-like symptoms can be continuous, intermittent, sporadic or recurrent, sometimes lasting years without correct diagnosis. It is essential that all patients with IBS undergo routine parasitological investigations in order to rule out the presence of protozoan parasites as the causative agents of the clinical signs.

DETECTION OF BLASTOCYSTIS HOMINIS IN UNPRESERVED STOOL SPECIMENS BY USING POLYMERASE CHAIN REACTION

Blastocystis hominis is a common enteric parasite of worldwide distribution. Its pathogenetic potential has not yet been established, although numerous case reports suggest that B. hominis may cause the development of various gastrointestinal symptoms and disorders. The detection of the parasite in stool specimens is conventionally done by microscopy of direct smears, fecal concentrates, or permanently stained smears; however, morphology-based diagnosis is problematic. The aim of this study was to develop and evaluate a polymerase chain reaction (PCR) technique for the direct detection of B. hominis in human stool samples. Primers were based on small subunit ribosomal DNA and able to detect > or =32 parasites/200 mg stool artificially spiked with cultured B. hominis. In the evaluation of 43 clinical specimens, the PCR was tested against the formol ethyl acetate concentration technique (FECT) and a culture technique, proving 100% test specificity and a significantly higher sensitivity than the FECT. The PCR method is recommended for screening clinical specimens for B. hominis infection and for use in prevalence studies.