Giardia duodenalis: Role of secreted molecules as virulent factors in the cytotoxic effect on epithelial cells

During the course of giardiasis in humans and experimental models, G. duodenalis trophozoites express and secrete several proteins (ESPs) affecting structural, cellular and soluble components of the host intestinal milieu. These include the toxin-like molecules CRP136 and ESP58 that induce intestinal hyper-peristalsis. After the completion of the Giardia genome database and using up-to date transcriptomic and proteomic approaches, secreted 'virulence factors' have also been identified and experimentally characterized. This repertoire includes arginine deiminase (ADI) that competes for arginine, an important energy source for trophozoites, some high-cysteine membrane proteins (HCMPs) and VSP88, a versatile variant surface protein (VSP) that functions as an extracellular protease. Another giardial protein, enolase, moonlights as a metabolic enzyme that interacts with the fibrinolytic system and damages host epithelial cells. Other putative Giardia virulence factors are cysteine proteases that degrade multiple host components including mucin, villin, tight junction proteins, immunoglobulins, defensins and cytokines. One of these proteases, named giardipain-1, decreases transepithelial electrical resistance and induces apoptosis in epithelial cells. A putative role for tenascins, present in the Giardia's secretome, is interfering with the host epidermal growth factor. Based on the roles that these molecules play, drugs may be designed to interfere with their functions. This review presents a comprehensive description of secreted Giardia virulence factors. It further describes their cytotoxic mechanisms and roles in the pathophysiology of giardiasis, and then assesses their potential as targets for drug development.

Giardia Alters Commensal Microbial Diversity throughout the Murine Gut

Giardia lamblia is the most frequently identified protozoan cause of intestinal infection. Over 200 million people are estimated to have acute or chronic giardiasis, with infection rates approaching 90% in areas where Giardia is endemic. Despite its significance in global health, the mechanisms of pathogenesis associated with giardiasis remain unclear, as the parasite neither produces a known toxin nor induces a robust inflammatory response. Giardia colonization and proliferation in the small intestine of the host may, however, disrupt the ecological homeostasis of gastrointestinal commensal microbes and contribute to diarrheal disease associated with giardiasis. To evaluate the impact of Giardia infection on the host microbiota, we used culture-independent methods to quantify shifts in the diversity of commensal microbes throughout the gastrointestinal tract in mice infected with Giardia We discovered that Giardia's colonization of the small intestine causes a systemic dysbiosis of aerobic and anaerobic commensal bacteria. Specifically, Giardia colonization is typified by both expansions in aerobic Proteobacteria and decreases in anaerobic Firmicutes and Melainabacteria in the murine foregut and hindgut. Based on these shifts, we created a quantitative index of murine Giardia-induced microbial dysbiosis. This index increased at all gut regions during the duration of infection, including both the proximal small intestine and the colon. Giardiasis could be an ecological disease, and the observed dysbiosis may be mediated directly via the parasite's unique anaerobic fermentative metabolism or indirectly via parasite induction of gut inflammation. This systemic alteration of murine gut commensal diversity may be the cause or the consequence of inflammatory and metabolic changes throughout the gut. Shifts in the commensal microbiota may explain observed variations in giardiasis between hosts with respect to host pathology, degree of parasite colonization, infection initiation, and eventual clearance.

Intestinal and urogenital flagellates

Although the human alimentary and urogenital tracts are parasitized by seven species of flagellate protozoa [115], only two, Giardia lamblia and Trichomonas vaginalis, are generally considered to be pathogens. This review, therefore, concentrates on these organisms and in particular on the experimental and clinical chemotherapy of trichomoniasis and giardiasis. Due to the limited space and the availability of excellent recently published reviews, topics such as life cycles, epidemiology, prevalence and pathology are only briefly discussed in the sections entitled 'Biological Aspects'. The reader seeking comprehensive reference lists and more information on Trichomonas and Giardia and the diseases they cause is referred to these reviews.

Clinical and diagnostic features and treatment of giardiasis

Giardia is the most common causes of protozoan diarrhea that lead to significant morbidity and mortality worldwide. Giardiasis can be cause of disturbance of host immune response. The treatment of Giardiasis is unsuccessful in some cases. The purpose of this study was to determine the clinical features and the content of secretory immunoglobulin A (sIgA) among adults and to evaluate efficiency of new plant preparation "Sausalin". The clinical studies were conducted in Karaganda Regional Infection Hospital (Kazakhstan). 250 patients with giardiasis were randomly assigned to receive sausalin at a dose 720 mg/day or ornidazole at 1500 mg/day. Clinical symptoms of giardisis and efficiency of treatment were evaluated. Protozoal clearance rate and clinical symptoms were assessed. Stool samples were collected from 40 patients and examined the content of sIgA. Our study found the prevalence of abdominal pain, dyspeptic syndrome and the symptoms of intoxication in patients with giardiasis. The increase the level of sIgA was detected, especially in females (88 mg/l). Sausalin was more effectiveness than ornidazole. After the treatment, the clearance rate of giardia (85.71% vs. 42.19%; P<0.05) and the clinical efficacy were significantly higher in the sausalin-treated group than in the ornidazole-treated group. The features of clinic manifestations of giardiasis were identified in population of Kazakhstan. Our data suggest the higher level of sIgA was significantly associated with features of clinic manifestations that the participant had. Treatment with sausalin was more effective than treatment with ornidazole. Further research is needed to explain the existence relationship between Giardia infection and host immune response.

[Comparative evaluation of clinical effectiveness of treatment of giardiasis]

Giardia is the most common causes of protozoan diarrhea that leads to significant morbidity and mortality worldwide. The purpose of this study was to determine the clinical efficiency of different scheme of therapy giardiasis with new original plant preparation "Sausalin" (Kazakhstan). We conducted open clinical trial with participation of 93 patients with giardiasis. According the method of treatment the patients were divided into three groups.  Group I - Sausalin at the dose 300 mg/day; group II - Metronidazole at 750 mg/ day; group III - combination of Sausalin 300 mg/day and Metronidazole 750 mg/ day. The treatment was conducted during 10 days. The protozoal clearance rate and clinical symptoms were assessed. There were no significant differences in the efficiency of treatments in group I and group II. The protozoal clearance rate was 68% in group I (Sausalin); in group II -  42,1% (metronidazole). In group III - 83,2% (combination therapy) (р=0.001; 95% CI 54,6-89,7). There was no negative effect on clinical and biochemical blood analysis. We detected statistically significant differences in the dynamics of clinical symptoms (defecation disorders, dyspepsia, abdominal pain, asthenia) of giardiasis in a group of patients receiving Sausalin.The scheme with new drug Sausalin can be used as alternative treatment of Giardiasis. Moreover, the use of the Sausalin is improved the clinical symptoms and safety of therapy.

Extra-intestinal and long term consequences of Giardia duodenalis infections

Giardiasis is the most common waterborne parasitic infection of the human intestine worldwide. The etiological agent, Giardia duodenalis (syn. G. intestinalis, G. lamblia), is a flagellated, binucleated protozoan parasite which infects a wide array of mammalian hosts. Human giardiasis is a true cosmopolitan pathogen, with highest prevalence in developing countries. Giardiasis can present with a broad range of clinical manifestations from asymptomatic, to acute or chronic diarrheal disease associated with abdominal pain and nausea. Most infections are self-limiting, although re-infection and chronic infection can occur. Recent evidence indicating that Giardia may cause chronic post-infectious gastrointestinal complications have made it a topic of intense research. The causes of the post-infectious clinical manifestations due to Giardia, even after complete elimination of the parasite, remain obscure. This review offers a state-of-the-art discussion on the long-term consequences of Giardia infections, from extra-intestinal manifestations, growth and cognitive deficiencies, to post-infectious irritable bowel syndrome. The discussion also sheds light on some of the novel mechanisms recently implicated in the production of these post-infectious manifestations.

Effect of Giardia infection on nutritional status in primary schoolchildren, in northwest Iran

In order to determine the association between Giardia infection and nutritional status, a cross-sectional study was performed on twenty randomly selected primary schools from two regions of Ardabil province in 2005. Anthropometric factors including height, weight and midarm muscle circumference (MAC) were measured for 813 children (413 males, 400 females). The food intake was estimated for energy and other nutrients by 24 h recall method for three days in week. Determination of Giardia infection was done by using direct wet mount and formalin-ether sedimentation concentration. 10.9% of boys and 17.2% of girls were infected with Giardia infection. Weight and MAC in none infected girls and boys (only 7 and 11 years old) were higher than in infected groups. The average values for weight, height and MAC for both genders were lower than those of NCHS values. Vitamin E and phosphorous intake in non infected boys (in 7-10 years old) were less than infected boys. Calorie, protein, vitamins (B3, B5, B6, E and folacin) and minerals (copper, magnesium, phosphorous, potassium and selenium) intake of infected girls were less than non infected girls in 11-12 years old category. Based on the results found in this study, we conclude that Giardia infection may affect on some of anthropometric factors as well as the calorie and other nutrients intake in some of age groups.

Outbreak of giardiasis and cryptosporidiosis associated with a neighborhood interactive water fountain--Florida, 2006

An outbreak of giardiasis and cryptosporidiosis was identified in central Florida in September 2006. Environmental and epidemiological investigations indicated the likely source was a neighborhood interactive water fountain in a large upscale urban neighborhood. Forty-nine cases meeting the case definition were identified, of which 38 were giardiasis, nine were cryptosporidiosis, and two were co-infections. The median age of those affected was four years old, and 32 (65.3%) cases were male. This outbreak and other similar occurrences highlight the need to design and implement more stringent disinfection practices and filtration requirements for treated interactive water venues. Giardia cysts and Cryptosporidium oocysts are small and chlorine-resistant, and they may require supplemental disinfection methods, such as ultraviolet light irradiation, ozonation, or chlorine dioxide. Individuals who use these types of venues also need to change their behavior to prevent disease transmission. This is the first documentation of a giardiasis outbreak associated with exposure to an interactive water fountain in the United States.

Persisting symptoms and duodenal inflammation related to Giardia duodenalis infection

OBJECTIVES

After a large waterborne outbreak of Giardia infection in Bergen, some patients experienced persisting abdominal symptoms despite metronidazole treatment. This study aimed at investigating possible causes for their symptoms.

METHODS

Over a 15 month period, 124 referred patients were evaluated in a prospective cohort analysis with a standardised investigation including duodenal biopsies and aspirate, blood tests and faecal parasite and calprotectin tests. Recovered subjects were recruited for symptom analysis.

RESULTS

Persisting Giardia duodenalis infection was found in 40 patients (32.3%). Duodenal biopsies showed signs of inflammation in 57 patients (47.1%). Microscopic duodenal inflammation was present in 34 (87.2%) of the Giardia positive and 23 (28.0%) of the Giardia negative patients. There were significant associations between persistent Giardia positivity, microscopic duodenal inflammation and a positive calprotectin test. Duodenal aspirate and duodenal biopsies performed poorly in diagnosis of persistent giardiasis.

CONCLUSIONS

In patients with persisting symptoms after metronidazole treated Giardia infection we commonly found chronic Giardia infection and microscopic duodenal inflammation, especially in illness duration less than 7 months. Both these findings subsided over time. Increasingly, investigations could not determine a definite cause for the persistent symptoms. The very long-term post-giardiasis diarrhoea, bloating, nausea and abdominal pain documented here need further study.

Giardiasis: a pharmacotherapy review

Giardia lamblia, the cause of human giardiasis, is among the most common intestinal protozoa worldwide. Human infection may range from asymptomatic shedding of giardial cysts to symptomatic giardiasis, being responsible for abdominal cramps, nausea, acute or chronic diarrhoea, with malabsorption and failure of children to thrive. At present, treatment options include the nitroimidazoles derivatives; especially metronidazole, which has been the mainstay of treatment for decades and is still widely used. The increasing number of reports of refractory cases with this group of drugs and other antigiardial agents, has raised concern and led to a search for other compounds, some of which have arisen due to the introduction of drugs initially addressed to other diseases. The present article examines some of the most important points of antigiardial pharmacotherapy available at present and the future prospects of development of new agents.

Mast cell-mediated changes in smooth muscle contractility during mouse giardiasis

Giardia intestinalis is a significant cause of diarrheal disease worldwide. Infections in animal models have been shown to cause changes in gastrointestinal transit that depend on adaptive immune responses and are mediated, in part, through neuronal nitric oxide synthase. Nitric oxide is an inhibitory neurotransmitter, and we therefore investigated potential excitatory pathways that might be involved in the response to Giardia infection. Infected mice exhibited increased spontaneous and cholecystokinin (CCK)-induced contractions of longitudinal smooth muscle. In contrast, enhanced contractile responses were not observed in response to acetylcholine, 5-hydroxytryptamine, or the protease-activated receptor-1 agonist peptide TFFLR. Giardia-induced changes in smooth muscle function appear to be mediated primarily by mast cells, as both spontaneous and CCK-induced contractions were blocked by pretreatment with either ketotifen or compound 48/80. Together, these data support a model in which CCK release triggers mast cell degranulation, leading to increases in smooth muscle contractility. These contractions, coupled with nitric oxide-mediated muscle relaxation, promote intestinal transit and parasite elimination.

[Experimental model of activated Lamblia (Giardia) muris infection in albino mice]

Experimental L. muris infection was reproduced in 100% of the intact albino mice intragastrically given levomycin in an average total dose of 15.88-34.84 or 0.88-1.02 g/kg for 18-34 days. With levomycin administration, the intensity of giardiasis was 1121.6-8540.1 (mean 4830.9) thousand L. muris trophozoites per animal. The total number of trophozoites per animal decreased to 302.2-3481.4 (mean 1546.4) thousand and 28.1-324.0 (mean 109.4) thousand specimens 5-8 and 11-13 days after discontinuation of the antibiotic, respectively. The maximum number of L. muris trophozoites was observed in the proximal and middle portions of the murine small intestine during and after the administration oflevomycin. The highest isolation of cysts was seen 12-14 days after the initiation of administration of the antibiotic. Following 8-10 days of terminations of a course of levomycin therapy the native smear of animal feces showed no Lamblia cysts. In mice with activated infection, the isolation rate of Lamblia cysts was directly related to the intensity of intestinal infection with trophozoites of the parasite.

Effect of chronic Giardia lamblia infection on epithelial transport and barrier function in human duodenum

BACKGROUND

Giardia lamblia causes infection of the small intestine, which leads to malabsorption and chronic diarrhoea.

AIM

To characterise the inherent pathomechanisms of G lamblia infection.

METHODS

Duodenal biopsy specimens from 13 patients with chronic giardiasis and from controls were obtained endoscopically. Short-circuit current (I(SC)) and mannitol fluxes were measured in miniaturised Ussing chambers. Epithelial and subepithelial resistances were determined by impedance spectroscopy. Mucosal morphometry was performed and tight junction proteins were characterised by immunoblotting. Apoptotic ratio was determined by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labelling staining.

RESULTS

In giardiasis, mucosal surface area per unit serosa area was decreased to 75% (3%) of control, as a result of which epithelial resistance should increase. Instead, epithelial resistance of giardiasis biopsy specimens was decreased (19 (2) vs 25 (2) Omega cm(2); p<0.05) whereas mannitol flux was not significantly altered (140 (27) vs 105 (16) nmol/h/cm(2)). As structural correlate, reduced claudin 1 expression and increased epithelial apoptosis were detected. Furthermore, basal I(SC) increased from 191 (20) in control to 261 (12) microA/h/cm(2) in giardiasis. The bumetanide-sensitive portion of I(SC) in giardiasis was also increased (51 (5) vs 20 (9) microA/h/cm(2) in control; p<0.05). Finally, phlorizin-sensitive Na(+)-glucose symport was reduced in patients with giardiasis (121 (9) vs 83 (14) microA/h/cm(2)).

CONCLUSIONS

G lamblia infection causes epithelial barrier dysfunction owing to down regulation of the tight junction protein claudin 1 and increased epithelial apoptoses. Na(+)-dependent d-glucose absorption is impaired and active electrogenic anion secretion is activated. Thus, the mechanisms of diarrhoea in human chronic giardiasis comprise leak flux, malabsorptive and secretory components.

Mechanisms of epithelial dysfunction in giardiasis

A better understanding of the pathophysiological processes of Giardia may lead to understanding the diseases it causes and to identifying new therapeutic agents

Infection of dogs by experimental inoculation with human isolates of Giardia duodenalis: clinical and laboratory manifestations

The susceptibility of dogs to experimental inoculation with trophozoites and cysts of human isolates of Giardia duodenalis and the clinical and laboratory profiles of infection of these animals were studied. Two groups (A and B), each comprising three dogs, were inoculated with G. duodenalis trophozoites and cysts, respectively. A third group of two dogs was not inoculated and remained as control. After inoculation feces were collected daily to determine the pre-patent period, by flotation in 33% zinc sulfate solution. Blood samples (5 mL) were collected from animals at 15-day intervals during the 165 days of the experimental period and were used to carry out the hemogram and biochemical evaluation of the levels of total protein, albumin, alanine aminotransferase, gamma glutamyltransferase, urea and creatinine. A prepatent period was observed at 5–6 days post-inoculation (p.i.) in the inoculated dogs, with cysts eliminated for approximately 3 months. No alterations were seen in the clinical parameters evaluated. Anemia was observed at 15 p.i. in the inoculated dogs. The mean eosinophil count of inoculated groups was higher than that of the control (p ≤ 0.05) but none of the biochemical parameters analyzed presented significant differences. The results of this study show that G. duodenalis from human isolates is able to infect dogs with minimal systemic manifestations without producing clinical signs of giardiasis.

Asymptomatic giardiasis and growth in young children; a longitudinal study in Salvador, Brazil

This study sought to assess the effect of giardiasis on growth of young children. In Salvador, northeast Brazil, 597 children initially aged 6 to 45 months were followed for a year in 1998/9, measured anthropometrically thrice, every 6 months, and monitored for diarrhoea prevalence twice weekly. Stool samples were collected and examined during the second round of anthropometry, and infected children were treated 39 days later, on average (S.D. 20 days). For each 6-month interval, the gains in z-scores of infected and uninfected children were compared, after adjustment for potential confounding factors, including longitudinal prevalence of diarrhoea. No significant difference was found for the first interval but in the second, the gain in adjusted height-for-age z-score was 0.09 less in infected than uninfected children, equivalent to a difference in height gain of 0.5 cm. The shortfall in growth was greater in children who remained free of diarrhoea, and was significantly correlated with the proportion of the second interval during which the child had remained untreated. We conclude that Giardia can impede child growth even when asymptomatic, presumably through malabsorption. This finding challenges the view that young children found to have asymptomatic giardiasis in developing countries should not be treated.

[Experimental infection of the gerbil (Meriones unguiculatus) by Colombian isolates of Giardia duodenalis]

INTRODUCTION

Natural and experimental Giardia infections have been reported from bovines, equines, goats, canines, felines and rodents such as mice, rats and gerbils. The latter have provided successful animal models for Giardia duodenalis and Giardia muris experimental infections.

OBJECTIVE

The gerbil model was used to establish the pattern of infection of Colombian Giardia human isolates.

MATERIALS AND METHODS

Giardia cysts were obtained from stool specimens of symptomatic giardiasis patients by means of sucrose-percoll gradients. Animal inoculation was performed by gastric intubation and injection with 5 x 10(3) Giardia cysts. The course of infection was established by counting cysts every day and trophozoites weekly throughout a period of 30 days.

RESULTS

The pattern of cyst excretion was found to be intermittent. Cysts were released during the second and third weeks of infection but not during the first or fourth weeks. The mean minimal number of cysts released per 2-hr collection period was 79 and the mean maximum number was 17,943. Colonization of the small intestine by trophozoites was observed with a mean number ranging from 15,000 to 6,577,778 trophozoites/ml.

DISCUSSION AND CONCLUSIONS

Gerbils inoculated with G. duodenalis isolates obtained from geographical areas outside Colombia resolved the infection between 86 and 114 days after infection, whereas gerbils infected with Colombian G. duodenalis isolates resolved the infection at 30 days. The gerbil proved to be a good animal model for experimental infection with Colombian isolates of G. duodenalis. Experimental Giardia infection of gerbils permit a sufficient yield of cysts and trophozoites to be used as antigens for the immunization of other animals and to obtain Giardia antibodies that could be used for Giardia antigen detection assays in stool specimens.

Experimental infections of neonatal mice with cysts of Giardia lamblia clone GS/M-83-H7 are associated with an antigenic reset of the parasite

Transmission of the protozoan parasite Giardia lamblia from one to another host individuum occurs through peroral ingestion of cysts which, following excystation in the small intestine, release two trophozoites each. Many studies have focused on the major surface antigen, VSP (for variant surface protein), which is responsible for the antigenic variability of the parasite. By using trophozoites of G. lamblia clone GS/M-83-H7 (expressing VSP H7) and the neonatal mouse model for experimental infections, we quantitatively assessed the process of antigenic variation of the parasite on the transcriptional level. In the present study, variant-specific regions identified on different GS/M-83-H7 vsp sequences served as targets for quantitative reverse transcription-PCR to monitor alterations in vsp mRNA levels during infection. Respective results demonstrated that antigenic switching of both the duodenal trophozoite and the cecal cyst populations was associated with a massive reduction in vsp H7 mRNA levels but not with a simultaneous increase in transcripts of any of the subvariant vsp genes analyzed. Most importantly, we also explored giardial variant-type formation and vsp mRNA levels after infection of mice with cysts. This infection mode led to an antigenic reset of the parasite in that a VSP H7-negative inoculum "converted" into a population of intestinal trophozoites that essentially consisted of the original VSP H7 type. This antigenic reset appears to be associated with excystation rather than with a selective process which favors expansion of a residual population of VSP H7 types within the antigenically diversified cyst inoculum. Based on these findings, the VSP H7 type has to be regarded as a predominant variant of G. lamblia clone GS/M-83-H7 which (re-)emerges during early-stage infection and may contribute to an optimal establishment of the parasite within the intestine of the experimental murine host.

Role of CD8+ and CD4+ T lymphocytes in jejunal mucosal injury during murine giardiasis

T-cell-mediated pathogenesis has been documented in various idiopathic and microbially induced intestinal disorders. Diffuse microvillous shortening seen in giardiasis is responsible for disaccharidase insufficiencies and malabsorption of electrolytes, nutrients, and water. Other mucosal changes include crypt hyperplasia and increased numbers of intraepithelial lymphocytes (IEL). A recent report using an athymic mouse model of infection showed that these epithelial injuries were dependent on T cells. The aim of the present study was to identify which subset of superior mesenteric lymph node (SMLN) T cells were responsible for mucosal alterations in giardiasis. CD4+ and CD8+ T cells, as well as whole lymphocyte populations, were isolated from SMLN of Giardia muris-infected mice for adoptive transfer. Jejunal segments of recipient mice were assessed for brush border ultrastructure, sucrase activity, crypt/villus ratio, and IEL numbers. Mice that received enriched CD8+ and whole SMLN lymphocytes, but not CD4+ T cells, from infected donors showed diffuse shortening of microvilli, loss of brush border surface area, impaired sucrase activity, and increased crypt/villus ratios compared to respective controls. Transfer of whole SMLN lymphocytes, as well as enriched CD4+ or CD8+ T cells, from infected donors led to increased IEL numbers in the recipient jejunum. The findings indicate that loss of intestinal brush border surface area, reduced disaccharidase activities, and increased crypt/villus ratios in giardiasis are mediated by CD8+ T cells, whereas both CD8+ and CD4+ SMLN T cells regulate the influx of IEL.

Mucosal defences against Giardia

Giardia lamblia (syn. G. duodenalis or G. intestinalis), the causative agent of giardiasis, is one of the most common causes worldwide of intestinal infections in humans. Symptomatic infection is characterized by diarrhoea, epigastric pain, nausea, vomiting, and weight loss, yet many infections are asymptomatic. The protozoan, unicellular parasite resides in the lumen and attaches to the epithelium and overlying mucus layers but does not invade the mucosa and causes little or no mucosal inflammation. Giardiasis is normally transient, indicating the existence of effective host defences, although re-infections can occur, which may be related to differences in infecting parasites and/or incomplete immune protection. Mucosal defences against Giardia must act in the small intestinal lumen in the absence of induction by classical inflammatory mediators. Secretory IgA antibodies have a central role in anti-giardial defence. B cell-independent mechanisms also exist and can contribute to eradication of the parasite, although their identity and physiological importance are poorly understood currently. Possible candidates are nitric oxide, antimicrobial peptides such as Paneth cell alpha-defensins, and lactoferrin. Elucidation of the key anti-giardial effector mechanisms will be important for selecting the best adjuvants in the rational development of vaccination strategies against Giardia.

Serum iron, zinc and copper levels and lipid peroxidation in children with chronic giardiasis

This study investigated the levels of iron, zinc, and copper and their demolishing effects against lipid peroxidation in chronic giardiasis. Serum iron, zinc and copper levels, erythrocyte cytosolic superoxide dismutase activity, and malondialdehyde levels were measured in 34 children with chronic giardiasis and were compared with controls. The serum iron and zinc levels and erythrocyte superoxide dismutase activity were significantly lower, and malondialdehyde levels were significantly higher among the children with chronic giardiasis compared to the control group (p < 0.001). There was no significant difference in copper levels between the two groups (p > 0.05). Consequently, the oxidant-antioxidant balance may tilt towards the oxidative side due to weakness of the antioxidant system in giardiasis. If early and proper treatment is not performed, free radical-mediated damage might occur in children with chronic giardiasis.

Effects of asymptomatic Giardia intestinalis infection on carbohydrate absorption in well-nourished Mexican children

The aim of this study was to evaluate carbohydrate absorption in well-nourished children with asymptomatic giardiasis. Two groups were selected based on results of stool examination of 211 children attending pre-school centers in Hermosillo, Sonora, Mexico: a control group of six non-infected children, and an infected group of seven children harboring Giardia intestinalis, without gastrointestinal symptoms of disease. Carbohydrate absorption was determined in the control group, before and after drug therapy in the infected group by the hydrogen breath test. Hydrogen production after lactose ingestion was higher in children with giardiasis compared with control group and after anti-parasite treatment; however, hydrogen production was not high enough to classify children as lactose malabsorbers by the cut-off criteria. Similar results were obtained for xylose absorption. None of the children had hydrogen increments high enough to be considered xylose malabsorbers. In conclusion, children asymptomatically infected with G. intestinalis showed significantly higher hydrogen production. However, the biological relevance is questionable since they did not exceed cut-off criteria to classify them as carbohydrate malabsorbers.

Protozoon infections and intestinal permeability

Intestinal permeability (IP) studies using some macromolecules have been assumed to demonstrate the intactness of intestinal mucosa. The aim of the present study is to determine the changes in IP among patients with protozoan infections. Thirty nine patients with protozoan infections and ten healthy controls were enrolled in the study. Protozoa were diagnosed by Native-lugol, Richie and Trichrome staining of faeces. IP was evaluated by diethyl triamine penta acetic acid labeled with 99m Technetium (99mTc labeled DTPA) assay. The IP was found to have increased in patients with protozoan infections compared with control patients (7.20+/-5.52 vs. 4.47+/-0.65%, P=0.0017). The IP values were 9.91+/-10.05% in Giardia intestinalis group, 6.81+/-2.25% in Blastocystis hominis group, 5.78+/-2.84% in Entamoeba coli group. In comparison with the control group, the IP was significantly higher in G. intestinalis and B. hominis patients (P=0.0025, P=0.00037, respectively), but not in E. coli patients. In conclusion, the IP increases in patients with G. intestinalis and B. hominis but not with E. coli infection. This finding supports the view that IP increases during the course of protozoan infections which cause damage to the intestinal wall while non-pathogenic protozoan infections have no effect on IP. The increase in IP in patients with B. hominis brings forth the idea that B. hominis can be a pathogenic protozoan.

Studies on the resistance/reactivation of Giardia muris cysts and Cryptosporidium parvum oocysts exposed to medium-pressure ultraviolet radiation

The ex vivo and in vivo reactivation of Giardia muris cysts and Cryptosporidium parvum oocysts after exposure to different doses of ultraviolet (UV) radiation was determined using animal infectivity. The infectivity of UV-treated parasites stored for 1-4 days (G. muris) or 1-17 days (C. parvum) at room temperature in the dark was similar to that of organisms administered immediately after UV treatment, indicating that the parasites did not reactivate ex vivo. In contrast, we observed in vivo reactivation of G. muris in three of seven independent animal infectivity experiments, when parasites were treated with relatively low doses of medium-pressure UV (<25 mJ/cm(2)). Our observations indicate that G. muris cysts and C. parvum oocysts exposed to medium-pressure UV doses of 60 mJ/cm(2) or higher did not exhibit resistance to and/or reactivation following treatment. This suggests that when appropriate doses of UV are used, significant and permanent inactivation of these parasites may be achieved.

Giardia in older people

CASE REPORTS

We report two cases of giardiasis in elderly women. Neither patient had been abroad recently and neither had diarrhoea at the time of diagnosis. In the first case, an extensive gastrointestinal cancer work-up was carried out before the diagnosis was made.

CONCLUSION

It is important to consider possible infective causes in older patients who have anaemia and weight loss.

Giardiasis--clinical and diagnostic perspective

Fifty patients of chronic diarrhoea in the pediatric age group admitted in Kalawati Saran Children's Hospital were studied. Thirty cases were diagnosed to be suffering from giardiasis based on microscopy of fecal and/or duodenal fluid specimens. Fecal specimen microscopy missed two cases which were diagnosed by duodenal aspirate microscopy and vice-versa. All fecal specimens were negative on culture, while duodenal aspirate culture gave large number of false negative results. Serum immunoglobulin levels did not show significant changes. Thus, routine microscopic testing is presently the best means for early diagnosis of giardiasis.

Human giardiasis: genotype linked differences in clinical symptomatology

Giardia duodenalis infection in humans can cause a variety of clinical symptoms. The relation between clinical symptomatology and the Giardia isolate genotype was studied in 18 Dutch patients infected with G. duodenalis who visited their general practitioner. Contrary to earlier studies, a 100% correlation between severity of diarrhoeal complaints and genotype was found: assemblage A isolates were solely detected in patients with intermittent diarrhoeal complaints, while assemblage B isolates were present in patients with persistent diarrhoeal complaints. These results are significant because they show for the first time that genetically linked features of G. duodenalis are major determinants in the severity of infection in human giardiasis.

Giardiasis-associated arthralgia in children

BACKGROUND

Giardiasis is the most common intestinal parasitosis in Mexico. Usual symptoms of the acute infection are diarrhea, abdominal pain, nausea, and weight loss. Children are more frequently affected than adults. Various extra-intestinal manifestations have been reported, among which are arthritis and arthralgia.

METHODS

A series of 10 children with arthralgia and cysts of Giardia lamblia in feces seen during 13 years of private practice were presented. Ages ranged between 5 and 11 years, and 70% of the children are males.

RESULTS

The joints involved in all cases were the knee and the ankle. No joint flogosis or changes in local temperature were observed. Other associated symptoms were abdominal pain (100%), abdominal distension (70%), flatulence (50%), less consistent stools (50%), anemia (30%), and increased erythrocyte sedimentation rate (60%). C-reactive protein and rheumatoid factor were negative in all cases. Arthralgia disappeared after treatment with metronidazole when coproparasitoscopic analyses were negative.

CONCLUSIONS

Arthralgia associated with giardiasis in children is a rare entity, relatively benign, and leaves no sequelae.

Anthelmintic treatment of rural Bangladeshi children: effect on host physiology, growth, and biochemical status

BACKGROUND

The effect of helminth infestation on the nutrition, growth, and physiology of the host is still poorly understood. Anthelmintic treatment of children in developing countries has had varying success in terms of growth improvements.

OBJECTIVE

The objective of this study was to assess the effect of regular deworming on child growth, physiology, and biochemical status.

DESIGN

The study was a 12-mo longitudinal intervention in 123 Bangladeshi children aged 2-5 y. Treatment (mebendazole) or placebo tablets were administered every 2 mo for 8 mo and again at 12 mo. Weight, height, midupper arm circumference, intestinal permeability, plasma albumin, alpha(1)-antichymotrypsin, and total protein concentration were assessed every 2 mo.

RESULTS

Treatment with mebendazole reduced the prevalence of Ascaris lumbricoides from 78% to 8%, of Trichuris trichiura from 65% to 9%, and of hookworm from 4% to 0%. There was no significant difference in the growth of treated children compared with those given placebo tablets. No changes in intestinal permeability or plasma albumin were observed after deworming. Significant decreases in total protein (P<0.001) and alpha(1)-antichymotrypsin (P<0.001) were observed in the treatment group, indicating possible reductions in inflammation and immunoglobulin concentration after deworming. A significant increase in the prevalence of Giardia intestinalis (from 4% to 49%) in the treatment group was associated with a short-term reduction in weight (P = 0.02) and higher intestinal permeability (P <0.001) in infected subjects. No long-term effects of G. intestinalis on growth were observed.

CONCLUSION

Low-intensity helminth infections, predominantly of A. lumbricoides and T. trichiura, do not contribute significantly to the poor growth and biochemical status of rural Bangladeshi children.

Giardia lamblia: effect of infection with symptomatic and asymptomatic isolates on the growth of gerbils (Meriones unguiculatus)

Gerbils (Meriones unguiculatus) were intragastrically inoculated with axenic Giardia lamblia cultures from symptomatic and asymptomatic children. All isolates were able to colonize the duodenum. However, the colonization capacity of the symptomatic isolates was significantly higher compared to that of the asymptomatic ones. Despite the different colonization capacity of the isolates, the growth curves of infected animals were significantly lower than those of controls. The study demonstrates that acute giardia infections are capable of altering the corporal development of the host. These results may suggest that not only symptomatic, but also asymptomatic giardiasis in children, often unnoticed by parents and clinicians, could be causing a silent detriment in their nutritional status.

Immune and pathophysiological responses to different strains of Giardia duodenalis in neonatal mice

Numerous studies have demonstrated various strain differences between Giardia isolates, but little is known about the immunology and pathogenesis of infections. This study aimed to compare host responses to strains of Giardi duodenalis differing in levels of virulence and pathogenicity and, by doing so, elucidate the mechanisms via which pathogenic strains establish infections. Marked differences were found in the infection dynamics, histopathological responses and serum antibody responses of neonatal mice infected with either G. duodenalis strain BRIS/83/HEPU/106 (isolated from a human) or BRIS/95/HEPU/2041 (isolated from a sulphur-crested cockatoo, Cacatua galerita). Infections with the bird strain were more intense (6.7-times greater) and persisted longer (by 14days) than infections with the human strain. The bird strain was more pathogenic and caused greater pathophysiological alteration to the gut mucosa, including increased villous atrophy, hyperplasia of goblet cells and vacuolated epithelial cells. Mice infected with the bird strain produced less serum anti-Giardia IgA and IgM, but more total (non-specific) serum IgA than those infected with the human strain of Giardia. This suggests that avian G. duodenalis strains are infective for mammalian hosts and may contribute to zoonotic infections. Furthermore, infection of mice with BRIS/95/HEPU/2041 serves as a good experimental model to provide further insight into the mechanisms via which G. duodenalis causes disease.

Comparison of serum antibody responses to Giardia lamblia of symptomatic and asymptomatic patients

The circulating anti-parasite antibody response against Giardia lamblia in symptomatic and asymptomatic Egyptian children with confirmed giardiasis was examined. Symptomatic patients were identified using the following criteria: presence of only G. lamblia cysts in the feces, and one or more of the following symptoms, diarrhea, abdominal pain, loss of weight, vomiting and/or nausea, and abdominal distention. The anti-parasite humoral response was measured using indirect immunofluorescence (IFA), ELISA, and immunoblotting. There was a significant difference in the anti-parasite antibody response measured by IFA of asymptomatic and symptomatic patients, in which more than 34% of the asymptomatic patients had a titer equal to or less than 1:500, and more that 29% of the symptomatic patients had a titer of 1:8,000 or higher. The circulating anti-parasite total IgM and IgA but not IgG, measured by ELISA, was significantly higher in symptomatic than in asymptomatic patients, and were related to higher cyst output observed in symptomatic individuals. Although total anti-parasite IgG response was similar in symptomatic and asymptomatic patients, the analysis of the IgG isotype responses revealed that both IgG1 and IgG3 were significantly higher in symptomatic patients. The antigen recognition by anti-parasite IgM, IgA, IgG1, and IgG3 of symptomatic and asymptomatic individuals, determined by immunoblotting, was heterogeneous and revealed only minor differences in the response of the two groups.

Experimental giardiasis in goat kids

The clinical, pathological and parasitological features of giardiasis resulting from experimental inoculation with 3 x 10(6) Giardia cysts were studied in goat kids. All experimentally inoculated goat kids given Giardia cysts became infected. Three of the eight inoculated kids had decreased appetite, formless feces and become slightly depressed beginning 7 or 8 days post inoculation. The mean duration of the appearance of abnormal feces was 6 days. Irregular and intermitted cysts shedding started after prepatent periods of 6-10 days and lasted throughout this study (10 weeks). The evidence of high infectivity and fast transmission of Giardia were observed under standard zoohygienic conditions. The characteristics of intestinal lesions were similar to those found in other hosts infected with Giardia. The most severe lesions were seen in the duodenum and proximal jejunum, and consisted of moderate villus atrophy, villus blunting, crypt hyperplasia and inflammatory infiltration in the lamina propria. Scanning electron microscopy revealed ultrastructural alterations in the microvillus border of enterocytes. Mucosal smears and histological sections of the gall bladder displayed Giardia trophozoites and gall bladder epithelium hyperplasia together with bile ductular proliferation in the liver tissue in two kids.

Preliminary data on the efficacy of a Giardia vaccine in puppies

Twenty puppies were vaccinated with a trophozoite-derived Giardia vaccine on day 0 and boosted on day 21 (Group 1); 10 control puppies received only saline (Group 2). Both groups were experimentally infected on day 35 with 1 x 10(6) Giardia duodenalis trophozoites by intraduodenal injection. Immunization provided protection to experimental Giardia infection.

Effects of Giardia lamblia infection on gastrointestinal transit and contractility in Mongolian gerbils

To determine if Giardia lamblia infection is associated with altered gastrointestinal transit and smooth muscle contractile function, Mongolian gerbils were infected orogastrically with 2 x 10(5) trophozoites (infected) or vehicle (uninfected controls). At the time of peak colonization, control and infected animals were infused either orogastrically or intraduodenally with 51Cr. Gastric emptying of isotope and intestinal transit (measured by the geometric center of distribution of intestinal 51Cr transit) were significantly (P < 0.05) greater in the infected compared to control animals in both the fasted and the fed states. Then, to determine whether Giardia lamblia has an effect on the contractility of longitudinal and circular smooth muscle, isometric tension of jejunal segments was recorded. The development of active tension with stretch and the dose-response curve to bethanechol were significantly increased in the longitudinal muscle of infected animals compared to controls. However, the circular smooth muscle did not show a similar increase in contractility. These findings suggest that an altered gastrointestinal transit and smooth muscle contractility may be involved in the pathophysiology of giardiasis.

Symptoms in patients with giardiasis undergoing upper gastrointestinal endoscopy

BACKGROUND AND STUDY AIMS

The aim of the study was to compare symptoms of Giardia-positive and -negative patients undergoing upper gastrointestinal endoscopy.

PATIENTS AND METHODS

Multi-center questionnaire-based case-control study of 120 Giardia-positive and -negative patients who underwent upper endoscopy. Cases were identified through histological detection of trophozoites of Giardia lamblia in duodenal biopsy specimens. Giardia-negative patients with inconspicuous duodenal histology served as controls.

RESULTS

There was a clear male predominance in the Giardia-positive groups, with 75 cases (62.5 %) being male and 45 (37.5 %) female (P < 0.0001). Giardia-positive cases tended to be older than controls (median 60 years vs. 45.2 years, P < 0.009). The main symptom of positive cases were tenderness to palpation (52.1%), abdominal discomfort (43.3 %), sensation of fullness (40.8%), distension (37.5%), epigastralgia (37.5%), nausea and/or vomiting (35.8%), heartburn (26.7%), and diarrhea (25.8%). Only sensation of fullness (P < 0.02), nausea/vomiting (P < 0.02) and heartburn (P < 0.03) were observed significantly more often in positive cases. Foul-smelling stools, considered typical for giardiasis, were observed in 5.8% of cases. Symptoms lasted for less than 1 month in 28.2 % of cases, for 1-6 months in 35.9%, and for more than 12 months in 35.9% (ns to controls). Treatment resulted in symptomatic cure in 60.5 % and in improvement of symptoms in 21.1 % of cases (P < 0.0001 vs controls).

CONCLUSION

There are no symptoms that reliably allow the recognition of giardiasis in patients undergoing upper endoscopy.

The efficacy of a Giardia lamblia vaccine in kittens

Twenty kittens were vaccinated with a Giardia lamblia vaccine prepared on a commercial scale on day 0 and boosted on day 21 (group 1); while 10 kittens received only saline (group 2). These kittens were challenged on day 35 with 10(6) Giardia lamblia trophozoites by a surgical intraduodenal injection. Three control kittens were not vaccinated and not challenged (group 3). Following challenge, Giardia vaccinated kittens had significantly fewer days in which abnormal stools were observed and reduced food intake occurred compared to saline injected animals. The rate of weight gain between group 1 and group 2 animals was not different in the prechallenge period (day 0 to day 35), but vaccinated animals had a significantly higher weight gain in the postchallenge period (P < 0.05). On day 56, all vaccinated animals were not passing cysts in their feces, while 40% of saline injected kittens had Giardia cysts in their feces. In vaccinated kittens, cysts were never demonstrated in 45% of the animals, while cysts were detected in 90% of the saline injected kittens. Viability of the cysts in vaccinated kittens was 38% while the cysts viability in saline injected kittens was 99%. On postmortem examination, trophozoites could be detected in 5% of vaccinated kittens and 60% of saline injected kittens. Vaccination produced an elevated Giardia specific serum IgG and IgA response prior to challenge and throughout the postinfection period. The Giardia infection in the saline injected group did not induce an elevated specific serum response. Giardia vaccination of kittens provides protection in kittens from an experimental challenge by reducing or eliminating intestinal trophozoites and fecal cyst excretion.

[Parasitic invasions and bronchial obstruction]

The course and outcomes of bronchial obstruction were reviewed for clonorchiasis, metagonimosis, lambliasis. Bronchial obstruction is shown to run more aggressive course in Trematoda infestation with further transformation into bronchial asthma despite dehelminthization. In lambliasis current antiparasitic therapy is able to abolish the obstruction. In combination of lambliasis with bronchial asthma it is feasible to achieve a persistent remission of bronchial asthma.

Effects of giardiasis on production in a domestic ruminant (lamb) model

OBJECTIVE

To examine the effects of giardiasis on production and carcass quality, using growing lambs as a domestic ruminant model.

DESIGN

Randomized block.

ANIMALS

Giardia-free lambs: 23 in infected group, 24 in control group.

PROCEDURE

Six-week-old, specific-pathogen-free lambs were infected with Giardia trophozoites; control lambs received saline solution. Clinical signs of infection, body weight, and feed intake were determined for 10 weeks. Carcass weight and quality were determined at slaughter weight of 45 kg.

RESULTS

Giardia infection persisted from weeks 7 to 16. For 5 weeks after challenge exposure, abnormal feces were more frequently observed in infected lambs. Giardia infection was associated with a decrease in rate of weight gain and impairment in feed efficiency. Time to reach slaughter weight was extended in infected lambs, and the carcass weight of Giardia-infected lambs was lower than that of control lambs.

CONCLUSION

Giardiasis has a negative effect on domestic ruminant production.

CLINICAL RELEVANCE

Giardiasis in domestic ruminants is an economically important disease, thus necessitating control or elimination of the infection.

Specialized surface adaptations of Giardia lamblia

Although Giardia lamblia trophozoites were first described by Von Leeuwenhoek in his own diarrheic stool, relatively little is known of the basic biology of this common parasite or the pathophysiology of giardiasis. In particular, there is little specific information about trophozoite properties that cause diarrhea, as neither toxins nor conventional virulence factors have been identified. Therefore, parasite adaptations that promote cyst survival in the external environment and infection and trophozoite persistence in the small intestine, may be viewed as key virulence properties. This review focuses on unusual surface structures of the trophozoite and cyst forms that enable Giardia to be such a successful parasite.