eMedicine Specialties > Pediatrics: General Medicine > Parasitology

Intestinal Protozoal Diseases: Follow-up

Author: Enrique Chacon-Cruz, MD, Chief, Pediatric Infectious Diseases Department, Head Professor of Pediatrics, General Hospital, Tijuana, Mexico
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
Contributor Information and Disclosures

Updated: Nov 13, 2009

Follow-up

Further Inpatient Care

  • Patients with either necrotizing colitis or liver abscess caused by E histolytica may require further inpatient care only if surgical procedures were performed.
  • Patients with AIDS or other immunodeficiencies who have spore-forming protozoal infections may require prolonged hospitalization to correct electrolyte imbalance or accompanying conditions.

Further Outpatient Care

  • Symptoms usually resolve within 3-4 days after initiation of antiprotozoal therapy in immunocompetent patients with protozoal gastroenteritis. Nevertheless, especially in cases of giardiasis, patients should be monitored with a repeat stool examination if symptoms reappear.
  • In amebic liver abscess, ultrasonographic abnormalities can persist for months, and another ultrasound is usually not recommended after successful completion of therapy.

Inpatient & Outpatient Medications

  • Inpatient medications
    • Intravenous medications are indicated only in cases of severe amebic or balantidic colitis or in patients with amebic liver abscess.
    • Intravenous metronidazole with or without intramuscular dehydroemetine can be used until the patient can start oral therapy.
    • In some patients with AIDS and in unusual cases in immunocompetent hosts, hospitalization is required, and intravenous solutions are indicated to correct electrolyte imbalance.
  • Outpatient medications: Oral antiprotozoal therapy is usually administered at home.

Deterrence/Prevention

  • Standard hospital precautions are used for all hospitalized patients.
  • Additional control precautions are implemented for children with gastroenteritis, especially for patients using diapers or who have incontinence. This includes use of gowns and gloves for patient care, and hands must be washed after contact. A single room is indicated, if possible.
  • Prevention of exposure in persons infected with HIV consists in the following:21
    • Avoid contact with human and animal feces.
    • Request a veterinarian to examine the stools for Cryptosporidium in puppies or kittens younger than 6 months.
    • Avoid exposure to calves and lambs.
    • Avoid drinking water from lakes or rivers.
  • No chemoprophylactic agents are available for any of these diseases.
  • Protozoan parasites can survive under ambient and refrigerated storage conditions when associated with a range of substrates. Consequently, various treatments have been used to inactivate protozoan parasites in food, water, and environmental systems. Ozone is a more effective chemical disinfectant than chlorine or chlorine dioxide for inactivation of protozoan parasites in water systems. However, sequential inactivation treatments can optimize existing methods through synergistic effects.

Complications

  • Amebiasis
    • Amebic colitis - Electrolyte imbalance and dehydration
    • Necrotizing colitis - Intestinal perforation leading to peritonitis, septicemia leading to shock
    • Ameboma - Intestinal obstruction
  • Extraintestinal amebiasis
    • Liver abscess (most common complication, associated with high morbidity rates) - Rupture to pleura, pericardium (leading to tamponade), bronchia, or peritoneal cavity (leading to peritonitis); amebic hepatitis
    • Perianal perirectal abscess
    • Abscesses in other organs (eg, brain, kidney)
  • Giardiasis
    • Acute giardiasis - Dehydration and electrolyte imbalance, mainly in young infants
    • Chronic giardiasis - Transitory disaccharidase deficiency; malnutrition; malabsorption of fats, carbohydrates, vitamin B-12, folic acid, and vitamin A; malabsorption of antibiotics leading to failure in treatment for otitis media; chronic urticaria; arthritis (resolves after successful antiprotozoal therapy)
    • Complications in giardiasis are much more common in patients with predisposing conditions such as IgA deficiency and hypogammaglobulinemia.
  • Spore-forming protozoa
    • In the immunocompetent host - Dehydration and electrolyte imbalance, transitory malabsorption, and transitory disaccharidase deficiency
    • In the immunodeficient host - Severe dehydration and electrolyte imbalance during acute episodes; malabsorption of fats, carbohydrates, and vitamins, leading to severe malnutrition; disaccharidase deficiency; biliary disease (with cryptosporidia, microsporidia, and Isospora) leading to sclerosing cholangitis, acalculous cholecystitis, or pancreatic duct involvement (very rare); extraintestinal invasion (very rare, observed only with microsporidia in patients with AIDS), eg, to the liver or lung
  • Dientamoebiasis - Dehydration and electrolyte imbalance (rare)
  • Balantidiasis
    • Severe colitis (can lead to necrotizing colitis) - Same complications as in amebic colitis
    • Disseminated disease - Liver, lung
  • Blastocystosis - Complications are very rare and usually are associated with electrolyte imbalance and, when present, are only in patients who are malnourished or immunocompromised.

Prognosis

  • Following adequate therapy, acute protozoal gastroenteritis in the immunocompetent host has an excellent outcome.
  • Exceptions are complicated cases of amebiasis and inadequately treated chronic giardiasis.
  • Symptomatic spore-forming protozoal infection in immunocompromised hosts, especially in patients with AIDS, is associated with progression of the disease, particularly when low CD4 counts (<100/mL) are present. The mortality rate in this group of patients is high, although these individuals may improve significantly because of recovery of immune status with HAART.

Patient Education

  • Prevention of all intestinal protozoal infection requires disruption of the fecal-oral spread (hand washing), as well as decontamination of water (by heating at 55°C for 5 min or with saturated crystalline iodine, 12.5 mL/L/30 min) and food and adequate sanitation.
  • Amebiasis: Advise individuals traveling to endemic areas to avoid uncooked foods that might have been grown, washed, or prepared with potentially contaminated water.
  • Giardiasis
    • Children with acute symptomatic giardiasis should not attend childcare centers.
    • Infected persons and persons at risk should adhere to strict handwashing techniques after any contact with feces. This is especially important for caregivers of diapered infants in childcare centers, in which diarrhea is common and the carrier rates are high.
    • To date, antigiardial therapy for asymptomatic carriers has not been proven to reduce outbreaks in childcare centers.
    • Methods to adequately purify public water supplies include chlorination, sedimentation, and filtration.
    • Advise travelers to endemic areas to avoid uncooked foods that might have been grown, washed, or prepared with potentially contaminated water.
  • Spore-forming protozoa
    • These organisms are most commonly spread by person-to-person transmission; therefore, hand washing helps prevent infection.
    • Enteric precautions should be used for hospitalized patients, and children with diarrhea should not attend childcare centers.
    • Immunocompromised patients should take special precautions around animals and use only appropriately filtered water. This is important because regular chlorination does not kill C parvum.
  • Dientamoebiasis: Adequate sanitation, handwashing, and decontamination of water should be performed, as in giardiasis.
  • Balantidiasis: Useful methods of control include reducing human contact with infected pigs and with contaminated food and water, as well as improving conditions of personal hygiene and nutrition.
  • Blastocystosis: Adequate sanitation, handwashing, and enteric precautions interrupt person-to-person transmission.

Miscellaneous

Medicolegal Pitfalls

  • Failure to make the correct diagnosis

Special Concerns

  • Other intestinal protozoa very rarely have been associated with human disease. T hominis infection has been reported in infants, especially in developing countries, and symptomatic infection with E polecki associated with pigs has also been reported. Whether these 2 parasites contribute to diarrhea in patients who are immunosuppressed is not known.
 


More on Intestinal Protozoal Diseases

Overview: Intestinal Protozoal Diseases
Differential Diagnoses & Workup: Intestinal Protozoal Diseases
Treatment & Medication: Intestinal Protozoal Diseases
Follow-up: Intestinal Protozoal Diseases
Multimedia: Intestinal Protozoal Diseases
References
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Further Reading

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Keywords

intestinal protozoal diseases, protozoal gastroenteritis, spore-forming protozoa, amebiasis, giardiasis, dientamoebiasis, balantidiasis, blastocystosis, treatment, diagnosis

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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.

Medical Editor

Ashir Kumar, MBBS, MD, FAAP, Professor, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University; Consulting Staff, Department of Pediatrics, EW Sparrow Hospital
Ashir Kumar, MBBS, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association of Physicians of Indian Origin, American Federation for Clinical Research, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

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.

CME Editor

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: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare 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: None None None

 
 
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