Immune response to Giardia duodenalis

Antigen-Based Diagnosis of Human Giardiasis: A Systematic Review and Meta-Analysis

BACKGROUND

We aimed to present a systematic review and meta-analysis of studies that used antigen-based assays for the diagnosis of human giardiasis.

METHODS

All the related published literature cited within PubMed, ISI web of science, Google Scholar, Embase, and Scopus, were searched up to December 2021. The search terms, both as MeSH terms and text words, were "Giardia", "Giardia lamblia", "Giardia intestinalis", "giardiasis", combined with "diagnosis", "antigen detection", serodiagnosis, or serological diagnosis. The required data was extracted from the papers. Pooled estimates of sensitivity and specificity were obtained and forest plots and summary receiver operating characteristics (SROC) plots were used to calculate sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

The search of databases found 1683 papers, of which 46 articles fulfilled our eligibility criteria. The sensitivity of antigen-based methods for the diagnosis of human giardiasis ranged from 45% (95% CI: 31-59%) to 100% (95% CI: 100-100%) and the pooled estimate of sensitivity was 92% (95% CI: 90-93%). The pooled estimated specificity was 97% (95% CI: 96-98%), ranged from 81% (95% CI: 68-89%) to 100% (95% CI: 98-100%). The summary estimate of PPV and NPV were 92 % (95% CI: 90-93%) and 97% (95% CI: 96-98%) respectively. Comparing the performance of the antigen detection assays by region revealed a significant difference in the assay's performances in different regions of the world.

CONCLUSION

The antigen-based detection methods have acceptable and satisfactory performance in the diagnosis of human giardiasis. The task ahead is to identify more specific target antigens and design simpler, cheaper, and more sensitive methods for the diagnosis of this common worldwide-distributed parasitic infection.

Conjugated linoleic acid modifies transcriptional cytokine profile and induces early specific secretory IgA response in Giardia lamblia infected mice

Objectives

Adaptive immunity is crucial in controlling Giardia lamblia infection in the intestinal mucosa, and some dietary lipids may improve mucosal immune function. The aim of this study was to evaluate conjugated linoleic acid (CLA) on the Th17/Treg response and secretory IgA production in a model of giardiasis infection.

Materials and Methods

C3H/HeN male mice were infected with 5×10⁶ G. lamblia trophozoites (GS/M-83-H7, ATCC collection). Mice were assigned randomly to experimental and control groups. CLA was administered to the experimental group and phosphate-buffered saline (PBS) was given to the control group. Parasite load kinetics was determined. Enzyme-linked immunosorbent assay (ELISA) was performed to evaluate IgA and cytokines. Nuclear transcription factors and cytokines were measured by RT-qPCR, and histology of small bowel cells was evaluated.

Results

CLA administration reduced the parasite load (P<0.05) and increased early Giardia-specific secretory IgA production. CLA also increased the expression of interleukin-10, transforming growth factor (TGF)-β, and inducible nitric oxide synthase (iNOS) (P<0.05), while infection elevated the expression of Foxp3, with a peak at 40 days post-infection (P<0.05). There were no pathological changes in the colonic mucosa due to infection or treatment. Thus, CLA stimulated mucosal immunity and enhanced the humoral response against G. lamblia, not only for early infection control but also to promote regulatory cytokine production at 40 dpi, restoring the intestinal balance after parasite elimination.

Conclusion

Our findings reveal novel anti-parasitic effects through the immune-modulatory activity of CLA against the intestinal parasite G. lamblia.

Role of anti-Giardia recombinant cyst wall protein IgG polyclonal antibodies in diagnosis and protection

Giardia duodenalis (G. duodenalis) is an infectious protozoan that has a global distribution especially in the hot climate. Around 200 million people are infected worldwide annually by Giardia, but infection is not always accompanied by symptoms, especially in endemic countries. Using traditional microscopy techniques in diagnosis, both in stool and water samples were less sensitive when compared to immunological methods; and the need for new diagnostic methods was necessary. Also, protection from infection is required in endemic areas. Therefore, the study aimed to produce anti- G. duodenalis IgG polyclonal antibodies (pAbs) by immunizing rabbit by G. duodenalis cyst recombinant protein. The produced antibodies were evaluated in the detection of G. duodenalis antigens in patients' stool and water samples from endemic areas across River Nile; where pAbs were used as a coating and a peroxidase conjugate antibody in sandwich ELISA. Moreover, pAbs were tested for the protection of mice from giardiasis. Sandwich ELISA using pAb has succeeded in the detection of G. duodenalis coproantigens in stool samples by a sensitivity of 97% and a specificity of 92.72%. Moreover, G. duodenalis cyst was detected in only seven water samples by ordinary microscopy; while sandwich ELISA revealed nineteen positive results. IgG pAb (1/200 µg/ml) protected mice from giardiasis; which was evident from the reduction in cysts and trophozoites numbers. We recommended the use of sandwich ELISA to monitor water quality, investigate environmental contamination and diagnosis in patients' stools. The pAbs can be prepared in large amount and used in field diagnosis and protection. This will help in the early diagnosis of G. duodenalis in water, which in turn can control outbreaks in rural areas.

Giardia lamblia infection: review of current diagnostic strategies

Giardiasis has a global distribution and it is a common cause of diarrhea in both children and adults and is transmitted via the fecal-oral route through direct or indirect ingestion of cysts. The laboratory diagnosis of Giardia spp. is mainly based on demonstration of microscopic cyst or trophozoite in stool samples but several immunological-based assays and molecular methods are also available for giardiasis diagnosis. The aim of this study was to conduct a review of the applied methods in medical laboratory and to highlight pitfalls and challenges of them for diagnosis of giardiasis. In this article we have evaluated the Giardia diagnostic methods with a broad review of literature, electronic databases and books. The search has covered the articles and some textbooks that have published up to 2018. It has been concluded that traditional microscopy combination with stool concentration method should still be held in the routine medical laboratory due to economical and high sensitivity and immunological-based assay and molecular methods which are recommended to use as a complementary test to the traditional technique.

Cytokines, Antibodies, and Histopathological Profiles during Giardia Infection and Variant-Specific Surface Protein-Based Vaccination

Giardiasis is one of the most common human intestinal diseases worldwide. Several experimental animal models have been used to evaluate Giardia infections, with gerbils (Meriones unguiculatus) being the most valuable model due to their high susceptibility to Giardia infection, abundant shedding of cysts, and pathophysiological alterations and signs of disease similar to those observed in humans. Here, we report cytokine and antibody profiles both during the course of Giardia infection in gerbils and after immunization with a novel oral vaccine comprising a mixture of purified variant-specific surface proteins (VSPs). Transcript levels of representative cytokines of different immune profiles as well as macro- and microtissue alterations were assessed in Peyer's patches, mesenteric lymph nodes, and spleens. During infection, cytokine responses showed a biphasic profile: an early induction of Th1 (gamma interferon [IFN-γ], interleukin-1β [IL-1β], IL-6, and tumor necrosis factor [TNF]), Th17 (IL-17), and Th2 (IL-4) cytokines, together with intestinal alterations typical of inflammation, followed by a shift toward a predominant Th2 (IL-5) response, likely associated with a counterregulatory mechanism. Conversely, immunization with an oral vaccine comprising the entire repertoire of VSPs specifically showed high levels of IL-17, IL-6, IL-4, and IL-5, without obvious signs of inflammation. Both immunized and infected animals developed local (intestinal secretory IgA [S-IgA]) and systemic (serum IgG) humoral immune responses against VSPs; however, only infected animals showed evident signs of giardiasis. This is the first comprehensive report of cytokine expression and anti-Giardia antibody production during infection and VSP vaccination in gerbils, a reliable model of the human disease.

Giardiasis: Serum antibodies and coproantigens in brown rats (Rattus norvegicus) from Grenada, West Indies

Aim:

Giardia is a serious zoonotic parasite, which causes diarrheal disease in humans and animals including rodents. The purpose of this study was to estimate the prevalence of Giardia spp. in brown rats (Rattus norvegicus) in Grenada.

Materials and Methods:

Intestinal contents from 99 and serum samples from 169 brown rats (R. norvegicus) from Grenada were collected. These samples were examined for the Giardia coproantigens using Cryptosporidium/Giardia Quik Chek assay (Tech lab^® Inc., USA), and the serum was screened through an enzyme-linked immunosorbent assay (ELISA) test kit for Giardia antibody (anti-GD) ELISA kit (MyBioSource, San Diego, CA, USA).

Result:

Giardia coproantigens were positive in 17.17% (95% confidence interval [CI]; 10.33-26.06%) rats, whereas 55% (95% CI: 47.20-62.68) were positive with serum antibodies (anti-GD) to Giardia.

Conclusion:

The prevalence of Giardia spp. in brown rats in Grenada was moderate based on the presence of coproantigens in the intestinal contents and antibody in serum. The findings of Giardia infections and prevalence in brown rats will help veterinarians and physicians to better plan diagnostic and preventative strategies. This is the first report of prevalence of Giardia in brown rats in Grenada.

Genetic variation in potential Giardia vaccine candidates cyst wall protein 2 and α1-giardin

Giardia is a prevalent intestinal parasitic infection. The trophozoite structural protein a1-giardin (a1-g) and the cyst protein cyst wall protein 2 (CWP2) have shown promise as Giardia vaccine antigen candidates in murine models. The present study assesses the genetic diversity of a1-g and CWP2 between and within assemblages A and B in human clinical isolates. a1-g and CWP2 sequences were acquired from 15 Norwegian isolates by PCR amplification and 20 sequences from German cultured isolates by whole genome sequencing. Sequences were aligned to reference genomes from assemblage A2 and B to identify genetic variance. Genetic diversity was found between assemblage A and B reference sequences for both a1-g (90.8% nucleotide identity) and CWP2 (82.5% nucleotide identity). However, for a1-g, this translated into only 3 amino acid (aa) substitutions, while for CWP2 there were 41 aa substitutions, and also one aa deletion. Genetic diversity within assemblage B was larger; nucleotide identity 92.0% for a1-g and 94.3% for CWP2, than within assemblage A (nucleotide identity 99.0% for a1-g and 99.7% for CWP2). For CWP2, the diversity on both nucleotide and protein level was higher in the C-terminal end. Predicted antigenic epitopes were not affected for a1-g, but partially for CWP2. Despite genetic diversity in a1-g, we found aa sequence, characteristics, and antigenicity to be well preserved. CWP2 showed more aa variance and potential antigenic differences. Several CWP2 antigens might be necessary in a future Giardia vaccine to provide cross protection against both Giardia assemblages infecting humans.

PCR-RFLP method to detect zoonotic and host-specific Giardia duodenalis assemblages in dog fecal samples

Giardia duodenalis is a zoonotic protozoan that parasitizes the upper small intestine of human and many mammals including dogs. To develop a restriction fragment length polymorphism (RFLP) method for typing zoonotic (A, B) and host-specific (C, D) assemblages of G. duodenalis from dog, β-giardin gene was amplified with design primer pairs B3 and B4. The PCR products were digested with restriction enzyme Afa I and Msp I; then, PCR-RFLP method was compared with HRM genotyping and sequencing method for G. duodenalis from dog. The results showed that each of assemblages A-D had unique restriction pattern, which was consistent with the predictive results. Among 21 samples tested by PCR-RFLP, 1 human-derived and 8 dog-derived G. duodenalis were identified as assemblage A; 5 dog-derived G. duodenalis as assemblage C; 7 dog-derived G. duodenalis as assemblage D, which were coincided with the HRM genotyping and sequencing results. It is concluded that the PCR-RFLP is quick, easy, and accurate method for the sequence typing of G. duodenalis zoonotic and specific assemblages from dogs.

Giardia duodenalis in Damascus, Syria: Identification of Giardia genotypes in a sample of human fecal isolates using polymerase chain reaction and restriction fragment length polymorphism analyzing method

Giardia duodenalis is a common gastrointestinal parasite that infects humans and many other mammals. It is most prevalent in many developing and industrialized countries. G. duodenalis is considered to be a complex species. While no morphological distinction among different assemblages exist, it can be genetically differentiated into eight major assemblages: A to H. The aim of this study was to determine the genetic heterogeneity of G. duodenalis in human isolates (a study conducted for the first time in Syria). 40 fecal samples were collected from three different hospitals during the hot summer season of 2014. Extraction of genomic DNA from all Giardia positive samples (based on a microscopic examination) was performed using QIAamp DNA Stool Mini Kit. β-giardin gene was used to differentiate between different Giardia assemblages. The 514 bp fragment was amplified using the Polymerase Chain Reaction method, followed by digestion in HaeIII restriction enzyme. Our result showed that genotype A was more frequent than genotype B, 27/40 (67.5%); 4/40 (10%) respectively. A mixed genotype of A+B was only detected in 9 isolates (22.5%). This is the first molecular study performed on G. duodenalis isolates in Syria in order to discriminate among the different genotypes. Further expanded studies using more genes are needed to detect and identify the Giardia parasite at the level of assemblage and sub-assemblage.

Drug Development Against the Major Diarrhea-Causing Parasites of the Small Intestine, Cryptosporidium and Giardia

Diarrheal diseases are among the leading causes of morbidity and mortality in the world, particularly among young children. A limited number of infectious agents account for most of these illnesses, raising the hope that advances in the treatment and prevention of these infections can have global health impact. The two most important parasitic causes of diarrheal disease are Cryptosporidium and Giardia. Both parasites infect predominantly the small intestine and colonize the lumen and epithelial surface, but do not invade deeper mucosal layers. This review discusses the therapeutic challenges, current treatment options, and drug development efforts against cryptosporidiosis and giardiasis. The goals of drug development against Cryptosporidium and Giardia are different. For Cryptosporidium, only one moderately effective drug (nitazoxanide) is available, so novel classes of more effective drugs are a high priority. Furthermore, new genetic technology to identify potential drug targets and better assays for functional evaluation of these targets throughout the parasite life cycle are needed for advancing anticryptosporidial drug design. By comparison, for Giardia, several classes of drugs with good efficacy exist, but dosing regimens are suboptimal and emerging resistance begins to threaten clinical utility. Consequently, improvements in potency and dosing, and the ability to overcome existing and prevent new forms of drug resistance are priorities in antigiardial drug development. Current work on new drugs against both infections has revealed promising strategies and new drug leads. However, the primary challenge for further drug development is the underlying economics, as both parasitic infections are considered Neglected Diseases with low funding priority and limited commercial interest. If a new urgency in medical progress against these infections can be raised at national funding agencies or philanthropic organizations, meaningful and timely progress is possible in treating and possibly preventing cryptosporidiosis and giardiasis.

Malaria endemicity and co-infection with tissue-dwelling parasites in Sub-Saharan Africa: a review

Mechanisms and outcomes of host-parasite interactions during malaria co-infections with gastrointestinal helminths are reasonably understood. In contrast, very little is known about such mechanisms in cases of malaria co-infections with tissue-dwelling parasites. This is lack of knowledge is exacerbated by misdiagnosis, lack of pathognomonic clinical signs and the chronic nature of tissue-dwelling helminthic infections. A good understanding of the implications of tissue-dwelling parasitic co-infections with malaria will contribute towards the improvement of the control and management of such co-infections in endemic areas. This review summarises and discusses current information available and gaps in research on malaria co-infection with gastro-intestinal helminths and tissue-dwelling parasites with emphasis on helminthic infections, in terms of the effects of migrating larval stages and intra and extracellular localisations of protozoan parasites and helminths in organs, tissues, and vascular and lymphatic circulations.

A perspective on Cryptosporidium and Giardia, with an emphasis on bovines and recent epidemiological findings

Cryptosporidium and Giardia are two common aetiological agents of infectious enteritis in humans and animals worldwide. These parasitic protists are usually transmitted by the faecal-oral route, following the ingestion of infective stages (oocysts or cysts). An essential component of the control of these parasitic infections, from a public health perspective, is an understanding of the sources and routes of transmission in different geographical regions. Bovines are considered potential sources of infection for humans, because species and genotypes of Cryptosporidium and Giardia infecting humans have also been isolated from cattle in molecular parasitological studies. However, species and genotypes of Cryptosporidium and Giardia of bovids, and the extent of zoonotic transmission in different geographical regions in the world, are still relatively poorly understood. The purpose of this article is to (1) provide a brief background on Cryptosporidium and Giardia, (2) review some key aspects of the molecular epidemiology of cryptosporidiosis and giardiasis in animals, with an emphasis on bovines, (3) summarize research of Cryptosporidium and Giardia from cattle and water buffaloes in parts of Australasia and Sri Lanka, considering public health aspects and (4) provide a perspective on future avenues of study. Recent studies reinforce that bovines harbour Cryptosporidium and Giardia that likely pose a human health risk and highlight the need for future investigations of the biology, population genetics and transmission dynamics of Cryptosporidium and Giardia in cattle, water buffaloes and other ruminants in different geographical regions, the fate and transport of infective stages following their release into the environment, as well as for improved strategies for the control and prevention of cryptosporidiosis and giardiasis, guided by molecular epidemiological studies.

Identification of an immunogenic protein of Giardia lamblia using monoclonal antibodies generated from infected mice

The humoral immune response plays an important role in the clearance of Giardia lamblia. However, our knowledge about the specific antigens of G. lamblia that induce a protective immune response is limited. The purpose of this study was to identify and characterise the immunogenic proteins of G. lamblia in a mouse model. We generated monoclonal antibodies (moAbs) specific to G. lamblia (1B10, 2C9.D11, 3C10.E5, 3D10, 5G8.B5, 5F4, 4C7, 3C5 and 3C6) by fusing splenocytes derived from infected mice. Most of these moAbs recognised a band of ± 71 kDa (5G8 protein) and this protein was also recognised by serum from the infected mice. We found that the moAbs recognised conformational epitopes of the 5G8 protein and that this antigen is expressed on the cell surface and inside trophozoites. Additionally, antibodies specific to the 5G8 protein induced strong agglutination (> 70-90%) of trophozoites. We have thus identified a highly immunogenic antigen of G. lamblia that is recognised by the immune system of infected mice. In summary, this study describes the identification and partial characterisation of an immunogenic protein of G. lamblia. Additionally, we generated a panel of moAbs specific for this protein that will be useful for the biochemical and immunological characterisation of this immunologically interesting Giardia molecule.

Antibody and cytokine responses to Giardia excretory/secretory proteins in Giardia intestinalis-infected BALB/c mice

The humoral and cellular responses against excretory/secretory proteins and soluble extracts of Giardia intestinalis were evaluated in the course of experimental G. intestinalis infection in BALB/c mice. Production of IgG1, IgG2a, IgA, and IgE antibodies against excreted/secreted proteins and soluble extract was detected after infection by G. intestinalis. Specific IgA antibody against E/S proteins and soluble extract form intestinal fluids in infected mice was detected by ELISA. The Western blotting identified proteins of 30, 58, 63, and 83 kDa for IgA and IgG, respectively. High proliferation rate in vitro of spleen cell and secretion of interleukin-4 (IL-4) at 21 days p.i. after stimulation with excreted/secreted proteins and low proliferative response in the presence of soluble extract in infected BALB/c mice was observed. High production of interferon gamma (IFN-γ) and interleukin-5 (IL-5) at the time of decreasing cyst output (14-21 days p.i.) in infected mice was recorded, suggesting the important role of these cytokines in the control of the infection. Interestingly, progressive and gradual increase of the interleukin-10 after stimulation with both preparations was recorded from 7 days until 28 days after infection, indicating the possible regulatory effect of these antigens on the immune response during Giardia infection. Therefore, the infection by Giardia duodenalis stimulates a mixed response Th1 and Th2, mainly stimulated by excretory/secretory antigens. The immunogenicity of these antigens may be a suitable for identification of the proteins related with the effective immune response in the course of infection by G. duodenalsis.

Resistance to reinfection in mice as a vaccine model for giardiasis

Infection with Giardia is the most commonly diagnosed parasitic cause of diarrhea in the developed world, yet no vaccine exists for human use and a commercially available veterinary vaccine is of limited utility. We have used the adult C57BL/6 mouse model of infection with Giardia duodenalis to better understand immunity to secondary infections with this parasite. Mice were primed by infection with either the GS or WB strains of Giardia and treated with metronidazole on day 7-12 to eliminate the primary infections. Challenge infections on day 21 or day 60 after the primary infections resulted in ~50-fold fewer parasites at day 5 than were found in unprimed mice that only received the challenge infection. Resistance to challenge infections was also observed in B cell deficient µMT mice and when primed mice were challenged with parasites of a different strain. While primed mice developed IgA, mast cell, and T cell responses against the parasite, no specific responses correlated with protection against challenge infections. Together these data suggest that development of an effective vaccine for giardiasis should be feasible since strong immunity can be developed against reinfection in the adult mouse model. Moreover we show that antibody responses are not essential for a protective vaccine and that protection is not parasite strain-specific.

The anti-giardial effectiveness of fungal and commercial chitosan against Giardia intestinalis cysts in vitro

Chitosan with poly-N-acetylglucosamine sequences is a deacetylated derivative of chitin that can be found in the exoskeletons of crabs, shrimp and lobsters, the cuticles of insects and the cell walls of fungi. The aim of the present study was to compare the effects of fungal chitosan (FC) prepared from the cell walls of Penicillium viridicatum and Penicillium aurantiogriseum with commercially available chitosan (CC) against Giardia intestinalis cysts in vitro. The giardia cysts were isolated using a sucrose method. Four concentrations (50, 100, 200 and 400 μg/ml) of each type of prepared chitosan were applied for 10, 30, 60 and 180 min. The viability of the cysts was checked via 0.1 % eosin staining. Our results indicate that P. viridicatum (with a 47.5 % DD) and P. aurantiogriseum (with a 47.3 % DD) at different concentrations after 180 min precipitated, respectively, 56, 69, 81 and 100 %, and 63, 75, 86 and 100 % mortality rates. CC (with a 54 % DD) showed 79, 84, 93 and 100 % mortality rates. In conclusion, both FC and CC at 400 μg/ml concentrations after 180 min of exposure showed the most potent effect against G. intestinalis cysts. Accordingly, chitosan could be suggested as a new natural nanoform agent for future research in the safe and effective treatment of Giardia infections.

Simplified protocol for DNA extraction and amplification of 2 molecular markers to detect and type Giardia duodenalis

We evaluated the ability of 3 kits: QIAmp® DNA stool mini kit (Qiagen, Hilden, Germany), PureLink PCR Purification®, and PureLink™ Genomic DNA® (Invitrogen, Carlsbad, CA, USA) for DNA extraction, and of 2 molecular markers (heat shock protein [HSP] and β-giardin genes) for detection and genotyping of Giardia duodenalis stool samples. The detection and typing limits of the markers were determined by the DNA concentration of trophozoites and cysts and were tested in 26 clinical samples. Of the 3 kits tested, the PureLink PCR Purification gave the best results when tested with clinical samples with low, intermediate, and high numbers of cysts. The DNA extracted from trophozoites and cysts was diluted successively in 1:2 ratios until it was no longer possible to observe the amplified product in polyacrylamide gel. Similarly, a suspension of cysts was diluted until no cysts were observed, and then the DNA was extracted. The amount of DNA of trophozoites and cysts for the typing of the parasite was smaller for the HSP marker than for β-giardin. Combined use of both markers allowed us to detect DNA of Giardia in parasitologically positive samples in a higher percentage (75%) than the results obtained for each marker and in 1 parasitologically negative sample, indicating that this combination increased the potential to accurately detect and genotype this parasite. We also concluded that the HSP marker has a higher limit of detection and typing than the β-giardin marker and that the DNA extraction method tested for G. duodenalis is simpler and more efficient than those that are currently in use and can be applied on a large scale.

Administration of kefir-fermented milk protects mice against Giardia intestinalis infection

Giardiasis, caused by the protozoan Giardia intestinalis, is one of the most common intestinal diseases worldwide and constitutes an important problem for the public health systems of various countries. Kefir is a probiotic drink obtained by fermenting milk with 'kefir grains', which consist mainly of bacteria and yeasts that coexist in a complex symbiotic association. In this work, we studied the ability of kefir to protect mice from G. intestinalis infection, and characterized the host immune response to this probiotic in the context of the intestinal infection. Six- to 8-week-old C75BL/6 mice were separated into four groups: controls, kefir mice (receiving 1 : 100 dilution of kefir in drinking water for 14 days), Giardia mice (infected orally with 4×10(7) trophozoites of G. intestinalis at day 7) and Giardia-kefir mice (kefir-treated G. intestinalis-infected mice), and killed at 2 or 7 days post-infection. Kefir administration was able to significantly reduce the intensity of Giardia infection at 7 days post-infection. An increase in the percentage of CD4(+) T cells at 2 days post-infection was observed in the Peyer's patches (PP) of mice belonging to the Giardia group compared with the control and kefir groups, while the percentage of CD4(+) T cells in PP in the Giardia-kefir group was similar to that of controls. At 2 days post-infection, a reduction in the percentage of B220-positive major histocompatibility complex class II medium cells in PP was observed in infected mice compared with the other groups. At 7 days post-infection, Giardia-infected mice showed a reduction in RcFcε-positive cells compared with the control group, suggesting a downregulation of the inflammatory response. However, the percentages of RcFcε-positive cells did not differ from controls in the kefir and Giardia-kefir groups. An increase in IgA-positive cells was observed in the lamina propria of the kefir group compared with controls at 2 days post-infection. Interestingly, the diminished number of IgA-positive cells registered in the Giardia group at 7 days post-infection was restored by kefir feeding, although the increase in IgA-positive cells was no longer observed in the kefir group at that time. No significant differences in CXCL10 expression were registered between groups, in concordance with the absence of inflammation in small-intestinal tissue. Interestingly, a slight reduction in CCL20 expression was observed in the Giardia group, suggesting that G. intestinalis might downregulate its expression as a way of evading the inflammatory immune response. On the other hand, a trend towards an increase in TNF-α expression was observed in the kefir group, while the Giardia-kefir group showed a significant increase in TNF-α expression. Moreover, kefir-receiving mice (kefir and Giardia-kefir groups) showed an increase in the expression of IFN-γ, the most relevant Th1 cytokine, at 2 days post-infection. Our results demonstrate that feeding mice with kefir reduces G. intestinalis infection and promotes the activation of different mechanisms of humoral and cellular immunity that are downregulated by parasitic infection, thus contributing to protection.

Effects of dietary zinc manipulation on growth performance, zinc status and immune response during Giardia lamblia infection: a study in CD-1 mice

Associations between Giardia lamblia infection and low serum concentrations of zinc have been reported in young children. Interestingly, relatively few studies have examined the effects of different dietary zinc levels on the parasite-infected host. The aims of this study were to compare the growth performance and zinc status in response to varying levels of dietary zinc and to measure the antibody-mediated response of mice during G. lamblia infection. Male CD-1 mice were fed using 1 of 4 experimental diets: adequate-zinc (ZnA), low-zinc (ZnL), high-zinc (ZnH) and supplemented-zinc (ZnS) diet containing 30, 10, 223 and 1383 mg Zn/kg respectively. After a 10 days feeding period, mice were inoculated orally with 5 × 10⁶G. lamblia trophozoites and were maintained on the assigned diet during the course of infection (30 days). Giardia-free mice fed ZnL diets were able to attain normal growth and antibody-mediated response. Giardia-infected mice fed ZnL and ZnA diets presented a significant growth retardation compared to non-infected controls. Zinc supplementation avoided this weight loss during G. lamblia infection and up-regulated the host’s humoral immune response by improving the production of specific antibodies. Clinical outcomes of zinc supplementation during giardiasis included significant weight gain, higher anti-G. lamblia IgG antibodies and improved serum zinc levels despite the ongoing infection. A maximum growth rate and antibody-mediated response were attained in mice fed ZnH diet. No further increases in body weight, zinc status and humoral immune capacity were noted by feeding higher zinc levels (ZnS) than the ZnH diet. These findings probably reflect biological effect of zinc that could be of public health importance in endemic areas of infection.

Giardia: both a harmless commensal and a devastating pathogen

The highly prevalent protozoan Giardia lamblia is an enteropathogen that can be asymptomatic in some individuals, while leading to persistent diarrhea and substantial morbidity in others. In this issue of the JCI, Bartelt et al. describe a mouse model of the disease and investigate the contribution of coincident malnutrition with the development of symptomatic infection. This work in part explains how Giardia infection can lead to growth retardation, and may offer insights that guide future therapeutic strategies.

Barcoding of Giardia duodenalis isolates and derived lines from an established cryobank by a mutation scanning-based approach

We barcoded 25 in vitro isolates (representing 92 samples) of Giardia duodenalis from humans and other animals, which have been assembled by the Upcroft team at the Queensland Institute of Medical Research over a period of almost three decades. We used mutation scanning-coupled sequencing of loci in the triosephosphate isomerase, glutamate dehydrogenase and β-giardin genes, combined with phylogenetic analysis, to genetically characterise them. Specifically, the isolates (n514) of G. duodenalis from humans from Australia (AD113; BRIS/83/HEPU/106; BRIS/87/HEPU/713; BRIS/89/HEPU/1003; BRIS/92/HEPU/1541; BRIS/92/HEPU/1590; BRIS/92/HEPU/2443; BRIS/93/HEPU/1706), Malaysia (KL/92/IMR/1106) and Afghanistan (WB), a cat from Australia (BAC2), a sheep from Canada (OAS1) and a sulphur-crested cockatoo from Australia (BRIS/95/HEPU/2041) represented assemblage A (sub-assemblage AI-1, AI-2 or AII-2); isolates (n510) from humans from Australia (BRIS/91/HEPU/1279; BRIS/92/HEPU/2342; BRIS/92/HEPU/2348; BRIS/93/HEPU/1638; BRIS/93/HEPU/1653; BRIS/93/HEPU/1705; BRIS/93/HEPU/1718; BRIS/93/HEPU/1727), Papua New Guinea (BRIS/92/HEPU/1487) and Canada (H7) represented assemblage B (sub-assemblage BIV) and an isolate from cattle from Australia (BRIS/92/HEPU/1709) had a match to assemblage E. Isolate BRIS/90/HEPU/1229 from a human from Australia was shown to represent a mixed population of assemblages A and B. These barcoded isolates (including stocks and derived lines) now allow direct comparisons of experimental data among laboratories and represent a massive resource for transcriptomic, proteomic, metabolic and functional genomic studies using advanced molecular technologies.

Stool sample storage conditions for the preservation of Giardia intestinalis DNA

Stool is chemically complex and the extraction of DNA from stool samples is extremely difficult. Haemoglobin breakdown products, such as bilirubin, bile acids and mineral ions, that are present in the stool samples, can inhibit DNA amplification and cause molecular assays to produce false-negative results. Therefore, stool storage conditions are highly important for the diagnosis of intestinal parasites and other microorganisms through molecular approaches. In the current study, stool samples that were positive for Giardia intestinalis were collected from five different patients. Each sample was stored using one out of six different storage conditions [room temperature (RT), +4ºC, -20ºC, 70% alcohol, 10% formaldehyde or 2.5% potassium dichromate] for DNA extraction procedures at one, two, three and four weeks. A modified QIAamp Stool Mini Kit procedure was used to isolate the DNA from stored samples. After DNA isolation, polymerase chain reaction (PCR) amplification was performed using primers that target the β-giardin gene. A G. intestinalis-specific 384 bp band was obtained from all of the cyst-containing stool samples that were stored at RT, +4ºC and -20ºC and in 70% alcohol and 2.5% potassium dichromate; however, this band was not produced by samples that had been stored in 10% formaldehyde. Moreover, for the stool samples containing trophozoites, the same G. intestinalis-specific band was only obtained from the samples that were stored in 2.5% potassium dichromate for up to one month. As a result, it appears evident that the most suitable storage condition for stool samples to permit the isolation of G. intestinalis DNA is in 2.5% potassium dichromate; under these conditions, stool samples may be stored for one month.

Probiotic Lactobacillus rhamnosus GG modulates the mucosal immune response in Giardia intestinalis-infected BALB/c mice

BACKGROUND

Gut homeostasis can be altered by the oral administration of health-promoting microorganisms, namely probiotics that are known to reinforce the host immune response.

AIM

The aim of this study was to elucidate the immunomodulatory effect of orally administered probiotic Lactobacillus rhamnosus GG (LGG) in Giardia-infected mice.

METHODS

BALB/c mice were fed orally with probiotic LGG either 7 days prior to or simultaneously with the challenge dose of Giardia trophozoites. The administration of the probiotic was continued for 25 days, and immunomodulatory potentials in terms of secretory immunoglobulin A (IgA) levels, CD8+ and CD4+ T lymphocytes, and expression of pro-inflammatory [tumor necrosis factor-alpha, interferon-gamma (INF-γ)] and anti-inflammatory cytokines [interleukin (IL)-4, IL-6, IL-10] were studied.

RESULTS

Oral feeding of LGG prior to or simultaneously with the test dose of Giardia seems to have modulated both arms (humoral and cellular) of the mucosal immune system since a significant increase in the levels of specific secretory IgA antibody, IgA+ cells, and CD4+ T lymphocytes were observed in contrast with the decreased percentage of cytotoxic CD8+ T lymphocytes. The stimulated mucosal immune response in probiotic fed Giardia-infected mice was further correlated with the enhanced levels of anti-inflammatory cytokines IL-6 and IL-10 and reduced levels of pro-inflammatory cytokine INF-γ.

CONCLUSIONS

This is the first study to show that oral administration of the effective probiotic LGG to Giardia infected mice could be used as a bacterio-therapy that restores the normal gut microflora and modulates the mucosal immune response.

Immunophenotyping in post-giardiasis functional gastrointestinal disease and chronic fatigue syndrome

Background

A Giardia outbreak was associated with development of post-infectious functional gastrointestinal disorders (PI-FGID) and chronic fatigue syndrome (PI-CFS). Markers of immune dysfunction have given conflicting results in CFS and FGID patient populations. The aim of this study was to evaluate a wide selection of markers of immune dysfunction in these two co-occurring post-infectious syndromes.

Methods

48 patients, reporting chronic fatigue in a questionnaire study, were clinically evaluated five years after the outbreak and grouped according to Fukuda criteria for CFS (n=19) and idiopathic chronic fatigue (n=5) and Rome II criteria for FGIDs (n=54). 22 Giardia exposed non-fatigued individuals and 10 healthy unexposed individuals were recruited as controls. Peripheral blood lymphocyte subsets were analyzed by flow cytometry.

Results

In peripheral blood we found significantly higher CD8 T-cell levels in PI-FGID, and significantly lower NK-cell levels in PI-CFS patients. Severity of abdominal and fatigue symptoms correlated negatively with NK-cell levels. A tendency towards lower T-cell CD26 expression in FGID was seen.

Conclusion

Patients with PI-CFS and/or PI-FGID 5 years after Giardia lamblia infection showed alterations in NK-cell and CD8-cell populations suggesting a possible immunological abnormality in these conditions. We found no significant changes in other markers examined in this well-defined group of PI-CFS and PI-FGID elicited by a gastrointestinal infection. Controlling for co-morbid conditions is important in evaluation of CFS-biomarkers.

Giardia duodenalis: dendritic cell defects in IL-6 deficient mice contribute to susceptibility to intestinal infection

Interleukin (IL)-6 is important in numerous infections. IL-6 can promote T cell survival and differentiation toward Th17 cells, as well as B cell proliferation and differentiation to plasma cells. Giardia duodenalis is a protozoan parasite that replicates in the lumen of the small intestine in humans and many other mammals resulting in diarrhea, cramps and developmental delays in children. IL-6 is required for control of this infection, but it is unclear what its role is or which cells are required to produce this cytokine to generate efficient immunity. We have analyzed infections in a series of chimeric mice in which specific cell types lacked the ability to produce IL-6 in order to determine which sources of IL-6 played an important role in controlling this infection. Analysis of bone marrow chimeras indicate that radiation-sensitive, bone-marrow derived cells must produce IL-6. T cell chimeras show that T cell production of IL-6 is not required. Finally, by transferring dendritic cells from wild-type mice into IL-6 deficient recipients, we show that dendritic cell defects are responsible for the inability of IL-6 deficient mice to respond to Giardia challenge.

Α1-giardin based live heterologous vaccine protects against Giardia lamblia infection in a murine model

Giardia lamblia is a leading protozoan cause of diarrheal disease worldwide, yet preventive medical strategies are not available. A crude veterinary vaccine has been licensed for cats and dogs, but no defined human vaccine is available. We tested the vaccine potential of three conserved antigens previously identified in human and murine giardiasis, α1-giardin, α-enolase, and ornithine carbamoyl transferase, in a murine model of G. lamblia infection. Live recombinant attenuated Salmonella enterica Serovar Typhimurium vaccine strains were constructed that stably expressed each antigen, maintained colonization capacity, and sustained total attenuation in the host. Oral administration of the vaccine strains induced antigen-specific serum IgG, particularly IgG(2A), and mucosal IgA for α1-giardin and α-enolase, but not for ornithine carbamoyl transferase. Immunization with the α1-giardin vaccine induced significant protection against subsequent G. lamblia challenge, which was further enhanced by boosting with cholera toxin or sublingual α1-giardin administration. The α-enolase vaccine afforded no protection. Analysis of α1-giardin from divergent assemblage A and B isolates of G. lamblia revealed >97% amino acid sequence conservation and immunological cross-reactivity, further supporting the potential utility of this antigen in vaccine development. Together. These results indicate that α1-giardin is a suitable candidate antigen for a vaccine against giardiasis.

Identification of a novel Assemblage B subgenotype and a zoonotic Assemblage C in human isolates of Giardia intestinalis in Egypt

Giardia intestinalis (G. intestinalis) is a flagellate parasite which has been considered the most common protozoan infecting human. Molecular techniques are of great value in studying the taxonomy, the zoonotic potential of animal isolates and the correlation between the genetic variability of the parasite and the range of clinical symptoms observed in humans. The present work aims at genotyping G. intestinalis isolates from Egypt using molecular techniques. PCR targeting the β-giardin locus, RFLP and sequencing were applied to 12 microscopically positive and 3 microscopically negative samples (which were positive by real time PCR targeting SSUr DNA). Two other loci, triose phosphate isomerase (TPI) gene and glutamate dehydrogenase (GDH) gene PCR and RFLP were also applied to all study isolates. The most frequent genotype was Assemblage B (13 out of 15), while Assemblage A and C were present in one sample each. This is the first report on zoonotic transmission of Assemblage C (dog genotype) to human in Egypt. Sequencing of the Assemblage B isolates revealed new subgenotypes with consistent mutations at specific positions, some of which were not characterized previously. The results shed light on the possibility that G. intestinalis can infect humans through a zoonotic route and open the door to wider investigations using different genetic loci to genotype Giardia isolates.

Co-infection with Ascaris lumbricoides modulates protective immune responses against Giardia duodenalis in school Venezuelan rural children

We evaluated the effect of Ascaris lumbricoides on Giardia duodenalis infection and TH1/TH2 type immune mechanisms toward this parasite in 251 rural parasitized and 70 urban non-parasitized school children. The children were classified according to light (0-5000 eggs/g faeces) or moderate (>5001-50,000 eggs/g faeces) A. lumbricoides infection. Anti G. duodenalis skin hyper-reactivity, IgE, IgG, IL-13, IFN γ, IL6 and IL-10 levels were compared among G. duodenalis infected and non-infected children according to light or moderate A. lumbricoides infection. It was found that 62% of the A. lumbricoides moderately infected children were co-infected by G. duodenalis compared to 45% of the lightly infected group. After treatment, 42% of the A. lumbricoides moderately group were infected with G. duodenalis compared to 11% of their lightly counterparts, being A. lumbricoides IL-10 levels higher (p<0.0001) in the moderately infected group. In the A. lumbricoides lightly parasitized children, G. duodenalis infection was associated to a significant increase (p<0.005) of the levels of G. duodenalis IL-13, IFN-γ, IL-6, IgE, IgG and skin test hyper reactivity. In contrast, there was no effect of G. duodenalis infection in the elevation of these parameters among the A. lumbricoides moderately parasitized group, being those levels similarly lower as those observed in the control group. Inverse correlations were found between the levels of anti G duodenalis antibodies, skin test hyper-reactivity and cytokines with the intensity of A. lumbricoides infection (p>0.0001) and A. lumbricoides IL-10 levels (p>0.0001), suggesting that co-infection with A. lumbricoides may affect both TH1 and TH2 type immunity against G. duodenalis that may play an important role in the susceptibility to the infection after chemotherapy in children from endemic areas.

Lipid metabolism in Giardia: a post-genomic perspective

Giardia lamblia, a protozoan parasite, infects a wide variety of vertebrates, including humans. Studies indicate that this anaerobic protist possesses a limited ability to synthesize lipid molecules de novo and depends on supplies from its environment for growth and differentiation. It has been suggested that most lipids and fatty acids are taken up by endocytic and non-endocytic pathways and are used by Giardia for energy production and membrane/organelle biosynthesis. The purpose of this article is to provide an update on recent progress in the field of lipid research of this parasite and the validation of lipid metabolic pathways through recent genomic information. Based on current cellular, biochemical and genomic data, a comprehensive pathway has been proposed to facilitate our understanding of lipid and fatty acid metabolism/syntheses in this waterborne pathogen. We envision that the current review will be helpful in identifying targets from the pathways that could be used to design novel therapies to control giardiasis and related diseases.

Giardia lamblia: interleukin 6 and tumor necrosis factor-alpha release from mast cells induced through an Ig-independent pathway

Giardia lamblia is a common cause of both acute and chronic diarrheal disease in humans worldwide. It has been shown that mast cells, IL-6 and TNF-alpha are substantially involved in the early control of G. lamblia infection in mice. However, no studies have yet been reported concerning the interaction between mast cell and Giardia, as well as the mast cells mediators generated in response to Giardia infection. In this study we demonstrated the direct activation of mast cells by G. lamblia live trophozoites or trophozoite-derived antigens followed by an increase in tryptase expression and a significant release of the preformed mediator histamine. In addition, parasite derived antigens increased TNF-alpha and de novo synthesized cytokine IL-6, at the mRNA and protein level. These results strongly suggest that mast cells might be an important source not only of IL-6 but also of TNF-alpha during Giardia infection, playing an important role in the outcome of the infection.

Antibody and cytokine responses in BALB/c mice immunized with the excreted/secreted proteins of Giardia intestinalis: the role of cysteine proteases

The mechanisms involved in the induction of the immune response in humans or experimental hosts infected with Giardia intestinalis are not well understood. The results of previous studies indicate that the parasite induces a mixed Th1/Th2 response and that, in experimentally infected mice, the parasite's excreted/secreted (E/S) proteins contain cysteine proteases that are recognised by the murine immune system. In the present study, the possible effects of the E/S proteases of G. intestinalis on the host's humoral and cellular immune responses were investigated in BALB/c mice immunized with the parasite's E/S proteins. High titres of specific IgG(1), IgG(2a) and IgE antibodies were detected after immunization with native E/S proteins. Spleen cells stimulated with such proteins in vitro showed a significant antigen-specific proliferative response accompanied by the production of high concentrations of interleukin-4 (IL-4), interleukin-5 (IL-5) and interleukin-10 (IL-10) but little secretion of interferon-gamma (IFN-gamma). When, before use, the proteases in the E/S proteins were inhibited, by heat treatment or the addition of E-64, they elicited much lower titres of specific IgG(1) and IgE in mice while, in splenocytes in vitro, they triggered much lower production of IL-4, IL-5 and IL-10 and reduced antigen-specific proliferation. Since E-64 only inhibits cysteine proteases, these results indicate that the excreted/secreted cysteine proteases of G. intestinalis may be involved in the induction and regulation of a specific immune response in the infected host.

Characteristics and risk factors for symptomatic Giardia lamblia infections in Germany

BACKGROUND

In developed countries, giardiasis is considered a travel related disease. However, routine surveillance data from Germany indicate that >50% of infections were acquired indigenously. We studied the epidemiological characteristics of symptomatic Giardia infections acquired in Germany and abroad, and verified the proportion of cases acquired in Germany in order to investigate risk factors for sporadic autochthonous Giardia infections.

METHODS

We identified Giardia cases notified by 41 local health authorities between February 2007 and January 2008 and interviewed them on their clinical symptoms, underlying morbidities, travel abroad and potential risk factors for the disease. We conducted a case-control-study including laboratory-confirmed (microscopy or antigen-test) autochthonous Giardia cases with clinical manifestations (diarrhoea, cramps, bloating) and randomly selected controls from the local population registry matched by county of residence and age-group (0-5, 6-19, > or =20 years). Secondary cases, controls with diarrhoea and persons who had travelled outside Germany in the three weeks prior to disease onset (exposure period) were excluded. We calculated adjusted odds ratios (aOR) with 95% confidence intervals (CI) using conditional logistic regression.

RESULTS

Of 273 interviewed cases, 131 (48%) had not travelled abroad during the defined exposure period. Of these 131, 85 (65%) were male, 68 (54%) were living in communities with >100,000 inhabitants and 107 (83%) were aged 20 years or older. We included 120 cases and 240 controls in the case-control study. Cases were more likely to be male (aOR 2.5 CI 1.4-4.4), immunocompromised (aOR 15.3 CI 1.8-127) and daily consumers of green salad (aOR 2.9 CI 1.2-7.2). Contact with animals (pets/farm animals) and exposure to surface water (swimming/water sports) were not associated with symptomatic disease.

CONCLUSIONS

A substantial proportion of Giardia lamblia cases in Germany are indigenously acquired. Symptomatic cases are significantly more likely to be immunocompromised than control persons from the general population. Physicians should consider Giardia infections among patients with no recent history of travel abroad, particularly if they have immune deficiencies. Green salads may be an important vehicle of infection. Information campaigns highlighting this food-borne risk should emphasise the risk to persons with immune deficiencies.

Evaluation of a real-time polymerase chain reaction assay for the laboratory diagnosis of giardiasis

A real-time polymerase chain reaction (PCR) assay was evaluated in comparison with the combination of conventional methods (microscopic examination and antigen detection assay) during the period 2006 to 2008 on 771 fecal samples belonging to 386 patients to assess its usefulness for an accurate laboratory diagnosis of giardiasis. The real-time PCR assay detected Giardia intestinalis DNA in 195 samples (106 patients), including 26 samples (21 patients) negative by the conventional assays. Among the 21 patients, in 8 cases, giardiasis was previously diagnosed also by conventional methods in additional samples of the same patients, whereas in 13, it would have been undiagnosed if real-time PCR assay was not used. The real-time PCR assay demonstrated a detection limit of 2 cysts per reaction and 100% specificity and sensitivity compared to conventional methods. A genotype analysis targeting the beta-giardin gene allowed to identify 53 samples (23 patients) containing genotype A and 59 samples (45 patients) containing genotype B.

Occurrence and genotype characterization of Giardia duodenalis in goat kids from the Canary Islands, Spain

Giardia duodenalis (syn. Giardia lamblia, Giardia intestinalis) is a wide-spread intestinal protozoa of both humans and animals. Although giardiosis in goat is commonly asymptomatic, young kids may bear an enteric disease associated with persistent diarrhoea and delayed weight gain. In the present study we have analysed the occurrence of Giardia in 315 young goat kids (2-6 months old) from Gran Canaria Island (Spain) through visualization of faecal cysts. The identification of genotypes of G. duodenalis among the farms was attained by nested PCR of the triophosphate isomerase (TPI) and single PCR of beta-giardin genes and subsequent sequencing. Positive samples were found in 42.2% of the animals and 95.5% of the farms. Goat faecal specimens were positive for only livestock-associated G. duodenalis assemblage E genotype for both TPI and beta-giardin genes. The genetic analysis of these two loci revealed the presence of different haplotypes among the farms included in the survey and high homology with homologous genes from cattle and sheep. Altogether, the data presented here provide additional information to the prevalence and genetic characterization of Giardia isolates. The absence of assemblages A and B in this study suggests that zoonotic transmission of Giardia from goats could be of low epidemiological significance, although these findings should be validated in studies including other geographical areas, age groups and larger number of samples.

The effect of blueberry extracts on Giardia duodenalis viability and spontaneous excystation of Cryptosporidium parvum oocysts, in vitro

The protozoan parasites Giardia duodenalis and Cryptosporidium parvum are common causes of diarrhoea, worldwide. Effective drug treatment is available for G. duodenalis, but with anecdotal evidence of resistance or reduced compliance. There is no effective specific chemotherapeutic intervention for Cryptosporidium. Recently, there has been renewed interest in the antimicrobial properties of berries and their phenolic compounds but little work has been done on their antiparasitic actions. The effect of various preparations of blueberry (Vaccinium myrtillus) extract on G. duodenalis trophozoites and C. parvum oocysts were investigated. Pressed blueberry extract, a polyphenolic-rich blueberry extract, and a commercially produced blueberry drink (Bouvrage) all demonstrated antigiardial activity. The polyphenol-rich blueberry extract reduced trophozoite viability in a dose dependent manner. At 167 microgml(-1), this extract performed as well as all dilutions of pressed blueberry extract and the Bouvrage beverage (9.6+/-2.8% live trophozoites remaining after 24h incubation). The lowest dilution of blueberry extract tested (12.5% v/v) contained >167 microgml(-1) of polyphenolic compounds suggesting that polyphenols are responsible for the reduced survival of G. duodenalis trophozoites. The pressed blueberry extract, Bouvrage beverage and the polyphenolic-rich blueberry extract increased the spontaneous excystation of C. parvum oocysts at 37 degrees C, compared to controls, but only at a dilution of 50% Bouvrage beverage, equivalent to 213 microgml(-1) gallic acid equivalents in the polyphenolic-rich blueberry extract. Above this level, spontaneous excystation is decreased. We conclude that water soluble extracts of blueberries can kill G. duodenalis trophozoites and modify the morphology of G. duodenalis and C. parvum.