Intestinal Protozoal Diseases Differential Diagnoses

  • Author: Enrique Chacon-Cruz, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Mar 12, 2012
 
 

Differential Diagnoses

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Contributor Information and Disclosures
Author

Enrique Chacon-Cruz, MD  Chief, Pediatric Infectious Diseases Department, Head Professor of Pediatrics, General Hospital, Tijuana, Mexico

Enrique Chacon-Cruz, MD is a member of the following medical societies: Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Coauthor(s)

Douglas K Mitchell, MD  Associate Professor, Department of Pediatrics, Eastern Virginia Medical School; Chair, Bronchiolitis Clinical Pathway Committee, Children's Hospital of the King's Daughters

Douglas K Mitchell, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Virology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Healthcare Epidemiology of America, Society for Pediatric Research, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Ashir Kumar, MD, MBBS, FAAP  Professor Emeritus, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine

Ashir Kumar, MD, MBBS, FAAP is a member of the following medical societies: American Association of Physicians of Indian Origin and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Martin Weisse, MD  Program Director, Associate Professor, Department of Pediatrics, West Virginia University

Martin Weisse, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

References

  1. Matthys B, Bobieva M, Karimova G, Mengliboeva Z, Jean-Richard V, Hoimnazarova M, et al. Prevalence and risk factors of helminths and intestinal protozoa infections among children from primary schools in western Tajikistan. Parasit Vectors. Oct 7 2011;4:195. [Medline]. [Full Text].

  2. Alyousefi NA, Mahdy MA, Mahmud R, Lim YA. Factors associated with high prevalence of intestinal protozoan infections among patients in Sana'a City, Yemen. PLoS One. 2011;6(7):e22044. [Medline]. [Full Text].

  3. Sargeaunt PG, Jackson TFGH, Simjee AE. Biochemical homogeneity of Entamoeba histolytica isolates, especially those from liver abscess. Lancet. 1982;1:1386-8. [Medline].

  4. Carranza PG, Lujan HD. New insights regarding the biology of Giardia lamblia. Microbes Infect. Sep 20 2009;[Medline].

  5. Muller N, von Allmen N. Recent insights into the mucosal reactions associated with Giardia lamblia infections. Int J Parasitol. Nov 2005;35:1339-47. [Medline].

  6. Karanis P, Kourenti C, Smith H. Waterborne transmission of protozoan parasites: a worldwide review of outbreaks and lessons learnt. J Water Health. Mar 2007;5:1-38. [Medline].

  7. Hunter PR, Thompson RC. The zoonotic transmission of Giardia and Cryptosporidium. Int j Parasitol. Oct 2005;35:1181-90. [Medline].

  8. Fleming CA, Caron D, Gunn JE, Barry MA. A foodborne outbreak of Cyclospora cayetanensis at a wedding: clinical features and risk factors for illness. Arch Intern Med. May 25 1998;158(10):1121-5. [Medline].

  9. Huang P, Weber JT, Sosin DM, et al. The first reported outbreak of diarrheal illness associated with Cyclospora in the United States. Ann Intern Med. Sep 15 1995;123(6):409-14. [Medline].

  10. Kashyap B, Sinha S, Das S, Rustagi N, Jhamb R. Efficiency of diagnostic methods for correlation between prevalence of enteric protozoan parasites and HIV/AIDS status--an experience of a tertiary care hospital in East Delhi. J Parasit Dis. Oct 2010;34(2):63-7. [Medline]. [Full Text].

  11. Vandenberg O, Peek R, Souayah H, et al. Clinical and microbiological features of dientamoebiasis in patients suspected of suffering from a parasitic gastrointestinal illness: a comparison of Dientamoeba fragilis and Giardia lamblia infections. Int J Infect Dis. May 2006;10(3):255-61. [Medline].

  12. Graczyk TK, Shiff CK, Tamang L, et al. The association of Blastocystis hominis and Endolimax nana with diarrheal stools in Zambian school-age children. Parasitol Res. Dec 2005;98(1):38-43. [Medline].

  13. Ertug S, Karakas S, Okyay P, Ergin F, Oncu S. The effect of Blastocystis hominis on the growth status of children. Med Sci Monit. Jan 2007;13:CR40-3. [Medline].

  14. Lawrence DN, Neel JV, Abadie SH, et al. Epidemiologic studies among Amerindian populations of Amazonia. III. Intestinal parasitoses in newly contacted and acculturating villages. Am J Trop Med Hyg. Jul 1980;29(4):530-7. [Medline].

  15. Arellano J, Perez-Rodriguez M, Lopez-Osuna M, et al. Increased frequency of HLA-DR3 and complotype SCO1 in Mexican mestizo children with amoebic abscess of the liver. Parasite Immunol. Oct 1996;18(10):491-8. [Medline].

  16. Sarabia-Arce S, Salazar-Lindo E, Gilman RH, et al. Case-control study of Cryptosporidium parvum infection in Peruvian children hospitalized for diarrhea: possible association with malnutrition and nosocomial infection. Pediatr Infect Dis J. Sep 1990;9(9):627-31. [Medline].

  17. Wichro E, Hoelzl D, Krause R, et al. Microsporidiosis in travel-associated chronic diarrhea in immune-competent patients. Am J Trop Med Hyg. Aug 2005;73(2):285-7. [Medline].

  18. Osewe P, Addiss DG, Blair KA, et al. Cryptosporidiosis in Wisconsin: a case-control study of post-outbreak transmission. Epidemiol Infect. Oct 1996;117(2):297-304. [Medline].

  19. Hunter PR, Hughes S, Woodhouse S, et al. Health sequelae of human cryptosporidiosis in immunocompetent patients. Clin Infect Dis. Aug 15 2004;39(4):504-10. [Medline].

  20. Blanshard C, Jackson AM, Shanson DC, Francis N, Gazzard BG. Cryptosporidiosis in HIV-seropositive patients. Q J Med. Nov-Dec 1992;85(307-308):813-23. [Medline].

  21. El-Shazly AM, Abdel-Magied AA, El-Beshbishi SN, et al. Blastocystis hominis among symptomatic and asymptomatic individuals in Talkha Center, Dakahlia Governorate, Egypt. J Egypt Soc Parasitol. Aug 2005;35(2):653-66. [Medline].

  22. Duggan C, Santosham M, Glass RI. The management of acute diarrhea in children: oral rehydration, maintenance, and nutritional therapy. Centers for Disease Control and Prevention. MMWR Recomm Rep. Oct 16 1992;41(RR-16):1-20. [Medline].

  23. Rossignol JF, Kabil SM, Said M, Samir H, Younis AM. Effect of nitazoxanide in persistent diarrhea and enteritis associated with Blastocystis hominis. Clin Gastroenterol Hepatol. Oct 2005;3:987-91. [Medline].

  24. [Guideline] US Public Health Service and Infectious Diseases Society of America. 1999 USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus. MMWR Recomm Rep. Aug 20 1999;48(RR-10):1-59, 61-6. [Medline].

  25. Abubakar I, Aliyu SH, Arumugam C, Hunter PR, Usman NK. Prevention and treatment of cryptosporidiosis in immunocompromised patients. Cochrane Database Syst Rev. Jan 2007;24:CD004932. [Medline].

  26. Cirioni O, Giacometti A, Drenaggi D, et al. Prevalence and clinical relevance of Blastocystis hominis in diverse patient cohorts. Eur J Epidemiol. Apr 1999;15(4):389-93. [Medline].

  27. Collins PA, Wright MS. Emerging intestinal protozoa: a diagnostic dilemma. Clin Lab Sci. Sep-Oct 1997;10(5):273-8. [Medline].

  28. Croft SL, Williams J, McGowan I. Intestinal microsporidiosis. Semin Gastrointest Dis. Jan 1997;8(1):45-55. [Medline].

  29. Erickson MC, Ortega YR. Inactivation of protozoan parasites in food, water, and environmental systems. J Food Prot. Nov 2006;69:2786-808. [Medline].

  30. Farthing MJ. Treatment options for the erradication of intestinal protozoa. Nat Clin Pract Gastroenterol Hepatol. Aug 2006;3:436-45. [Medline].

  31. Fung HB, Doan TL. Tinidazole: a nitroimidazole antiprotozoal agent. Clin Ther. Dec 2005;27:1859-84. [Medline].

  32. Goodgame RW. Understanding intestinal spore-forming protozoa: cryptosporidia, microsporidia, isospora, and cyclospora. Ann Intern Med. Feb 15 1996;124(4):429-41. [Medline].

  33. Grazioso CF, Mitchell DK. Parasitic causes of diarrhea in children. Semin Pediatr Infect Dis. 1994;5:191-201.

  34. Hashmey R, Genta RM, White Jr AC. Parasites and Diarrhea. I: Protozoans and Diarrhea. J Travel Med. Mar 1 1997;4(1):17-31. [Medline].

  35. Hill DR. Giardiasis. Issues in diagnosis and management. Infect Dis Clin North Am. Sep 1993;7(3):503-25. [Medline].

  36. Hoffner RJ, Kilaghbian T, Esekogwu VI, Henderson SO. Common presentations of amebic liver abscess. Ann Emerg Med. Sep 1999;34(3):351-5. [Medline].

  37. Hussein EM, El-Moamly AA, Dawoud HA, et al. Real-time PCR and flow cytometry in detection of Cyclospora oocysts in fecal samples of symptomatic and asymptomatic pediatrics patients. J Egypt Soc Parasitol. Apr 2007;37(1):151-70. [Medline].

  38. Lebbad M, Svard SG. PCR differentiation of Entamoeba histolytica and Entamoeba dispar from patients with amoeba infection initially diagnosed by microscopy. Scand J Infect Dis. 2005;37(9):680-5. [Medline].

  39. Lengerich EJ, Addiss DG, Juranek DD. Severe giardiasis in the United States. Clin Infect Dis. May 1994;18(5):760-3. [Medline].

  40. Lindsay DS, Dubey JP, Blagburn BL. Biology of Isospora spp. from humans, nonhuman primates, and domestic animals. Clin Microbiol Rev. Jan 1997;10(1):19-34. [Medline].

  41. Martinez-Garcia MC, Munoz O, Garduno-Rodriguez G, et al. Pathogenic and non-pathogenic zymodemes of Entamoeba histolytica in a rural area of Mexico. Concordance with serology. Arch Invest Med (Mex). 1990;21 Suppl 1:147-52. [Medline].

  42. Moghaddam DD, Ghadirian E, Azami M. Blastocystis hominis and the evaluation of efficacy of metronidazole and trimethoprim/sulfamethoxazole. Parasitol Res. Jun 2005;96(4):273-5. [Medline].

  43. Molbak K, Aaby P, Hojlyng N, da Silva AP. Risk factors for Cryptosporidium diarrhea in early childhood: a case- control study from Guinea-Bissau, West Africa. Am J Epidemiol. Apr 1 1994;139(7):734-40. [Medline].

  44. Mungthin M, Subrungruang I, Naaglor T, et al. Spore shedding pattern of Enterocytozoon bieneusi in asymptomatic children. J Med Microbiol. May 2005;54(Pt 5):473-6. [Medline].

  45. Nesbitt RA, Mosha FW, Katki HA, et al. Amebiasis and comparison of microscopy to ELISA technique in detection of Entamoeba histolytica and Entamoeba dispar. J Natl Med Assoc. May 2004;96(5):671-7. [Medline].

  46. Ortega YR, Sterling CR, Gilman RH. Cyclospora cayetanensis. Adv Parasitol. 1998;40:399-418. [Medline].

  47. Pickering LK, Engelkirk PG. Giardia lamblia. Pediatr Clin North Am. Jun 1988;35(3):565-77. [Medline].

  48. Ramratnam B, Flanigan TP. Cryptosporidiosis in persons with HIV infection. Postgrad Med J. Nov 1997;73(865):713-6. [Medline].

  49. Sheehan DJ, Raucher BG, McKitrick JC. Association of Blastocystis hominis with signs and symptoms of human disease. J Clin Microbiol. Oct 1986;24(4):548-50. [Medline].

  50. Shlim DR, Hoge CW, Rajah R, et al. Is Blastocystis hominis a cause of diarrhea in travelers? A prospective controlled study in Nepal. Clin Infect Dis. Jul 1995;21(1):97-101. [Medline].

  51. Smith HV, Corcoran GD. New drugs and treatment for cryptosporidiosis. Curr Opin Infect Dis. Dec 2004;17(6):557-64. [Medline].

  52. Smith LA. Still around and still dangerous: Giardia lamblia and Entamoeba histolytica. Clin Lab Sci. Sep-Oct 1997;10(5):279-86. [Medline].

  53. Turgay N, Yolasigmaz A, Erdogan DD, Zeyrek FY, Uner A. Incidence of cyclosporiasis in patients with gastrointestinal symptoms in western Turkey. Med Sci Monit. Jan 2007;13:CR34-9. [Medline].

  54. Turner JA. Giardiasis and infections with Dientamoeba fragilis. Pediatr Clin North Am. Aug 1985;32(4):865-80. [Medline].

  55. Walzer PD, Judson FN, Murphy KB, et al. Balantidiasis outbreak in Truk. Am J Trop Med Hyg. Jan 1973;22(1):33-41. [Medline].

  56. Wolfe MS. Giardiasis. Clin Microbiol Rev. Jan 1992;5(1):93-100. [Medline].

 
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This micrograph stained with chlorazol black, revealed an Entamoeba histolytica cyst.
This is a scanning electron micrograph (SEM) of an in vitro Giardia lamblia culture. This photograph contains both trophozoites and a cluster of maturing cysts (bottom right). At far left, the 2 trophozoite-staged organisms are positionally situated opposite to one another, with the farthest left G lamblia displaying its dorsal, or upper surface, and the protozoan to its immediate right, its ventral, or bottom surface.
This photomicrograph revealed the morphologic details of Cryptosporidium parvum oocysts.
This is an illustration of the life cycle of Isospora belli, the causal agent of isosporiasis.
This photomicrograph of a fresh stool sample, which had been prepared using a 10% formalin solution, and stained with safranin, revealed the presence of 3 uniformly stained Cyclospora cayetanensis oocysts in the field of view.
Table 1. Protozoa Associated with Intestinal Illness in Humans
Name Mode of Transmission Symptoms
Flagellates
G lambliaContaminated water, fecal-oralNausea, bloating, gas, diarrhea, anorexia
Dientamoeba fragilisFecal-oral, associated with EnterobiusPreviously thought commensal; may cause diarrhea, abdominal, pain, nausea
Amebas
Entamoeba histolyticaContaminated water, fecal-oral, contaminated foodColitis, dysentery, diarrhea, liver abscess, other extraintestinal disease
Spore-forming (Coccidia)
Cryptosporidium parvumContaminated water, swimming pools, fecal-oralImmunocompetent patients: Self-limited diarrhea Immunosuppressed patients: Severe and interminable diarrhea
Isospora belliFecal-oralSame as in Cryptosporidium
Cyclospora cayetanensisFecal-oral, contaminated water and foodSame as in Cryptosporidium
Microsporidia (Septata intestinalis, Enterocytozoon bieneusi)Fecal-oral, contaminated waterSame as in Cryptosporidium
Ciliates
Balantidium coliFecal-oral (frequently associated with pigs)Colitis, diarrhea
Other
Blastocystis hominisFecal-oralMay cause mild diarrhea
Table 2
Organism Size (mm) Stain Used Other Tests
E histolyticaTrophozoite: 10-60



Cyst: 10-20



Wet mount,* trichrome, periodic SchiffEnzyme-linked immunosorbent assay (ELISA)
G lambliaTrophozoite: 9-21



Cyst: 7-12



Wet mount,* trichrome, hematoxylin, LugolELISA*
C parvum2-5Modified acid-fast,* auramine-rhodamine, Sheafer methodELISA*
I belli30x12Wet mount,* modified acid-fast*None
C cayetanensis8-10Modified acid-fast,* wet mountElectron microscopy
Microsporidia1-2Modified trichrome*Electron microscopy, fluorescence methods, small intestine biopsy
D fragilis7-12Iron hematoxylin,* trichrome*None
B. coli50-200Wet mount,* concentration techniquesNone
B hominis5-30Trichrome,* iron hematoxylin*None
*Preferred screening test in clinical settings.
Table 3. Specific Therapy for Intestinal Protozoal Infections
OrganismDrugs, Pediatric Dose, and Treatment Duration
E histolytica (Luminal disease or colonization)Iodoquinol: 40 mg/kg/d PO divided tid for 20 d; not to exceed 2 g/d
Paromomycin: 25-30 mg/kg/d PO divided tid for 7 d
E histolytica (Moderate colitis)Metronidazole: 50 mg/kg/d PO divided tid for 10 d
Tinidazole: 50 mg/kg/d PO for 3 d; not to exceed 2 g/d
E histolytica (Severe colitis or liver abscess)Metronidazole: 50 mg/kg/d PO divided tid for 10 d
Dehydroemetine*: 1-1.5 mg/kg/d divided bid PO for 5 d
Tinidazole†: 50 mg/kg/d PO for 3-5 d; not to exceed 2 g/d
G lambliaMetronidazole: 15-20 mg/kg/d PO divided tid for 5
Tinidazole: 50 mg/kg/d PO once; not to exceed 2 g/dose
Quinacrine‡: 6 mg/kg/d PO divided tid for 5 d; not to exceed 300 mg/d
Furazolidone: 6 mg/kg/d PO divided qid for 7-10 d
Paromomycin: 40 mg/kg/d PO divided tid for 7 d
Nitazoxanide: 200-400 mg/d PO divided bid for 3 d
D fragilisIodoquinol: 50 mg/kg/d PO divided tid for 20 d; not to exceed 2 g/d
Paromomycin: 30 mg/kg/d PO divided tid for 7 d
Tetracycline: 40 mg/kg/d PO divided qid for 10 d; not to exceed 2 g/d
C parvum§Paromomycin*: 30 mg/kg/d PO divided tid (duration unknown)
Nitazoxanide: 200-400 mg/d PO divided bid for 3 d
I belliTrimethoprim/sulfamethoxazole (TMP/SMZ): 20/100 mg/kg/d PO divided bid for 10 d, followed by 10/50 mg/kg/d PO divided bid for 21 d
C cayetanensisTMP/SMZ: 10/50 mg/kg/d PO divided bid for 3 d
Microsporidia S intestinalisAlbendazole* (adult dose): 800 mg/d PO divided bid
Microsporidia E bieneusiNo treatment recommended; albendazole may decrease the number of organisms
B coliTetracycline: 40 mg/kg/d PO divided qid for 10 d; not to exceed 2 g/d
Metronidazole: 35-50 mg/kg/d PO divided tid for 5 d
Iodoquinol: 40 mg/kg/d PO divided tid for 20 d
B hominisMetronidazole: 35-50 mg/kg/d PO divided tid for 10 d
Iodoquinol: 40 mg/kg/d PO divided tid for 20 d
Nitazoxanide||: 500 mg/d PO divided bid for 3 d
*Efficacy is unknown.



†Drug is available from the CDC Drug Service (phone: 404-639-3670; evenings, weekends, and holidays: 404-639-2888).



‡ Drug is not available in the United States.



§Recommended regimens are indicated only in patients who are immunosuppressed. A recent meta-analysis has not shown evidence for a reduction in the duration or frequency of diarrhea by nitazoxanide or paromomycin when compared with placebo in immunosuppressed patients, nevertheless, oocyst clearance was significantly reduced.[23]



||Recent studies have shown effective outcomes when compared to placebo, but no clinical trials have compared with other antiparasitic drugs.



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