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Intestinal Protozoal Diseases Treatment & Management

  • Author: Enrique Chacon-Cruz, MD; Chief Editor: Russell W Steele, MD  more...
 
Updated: May 02, 2014
 

Medical Care

See the list below:

  • The most important aspect of providing care for children with diarrhea caused by intestinal protozoa includes standard pediatric assessments.
  • Evaluate the child for signs of dehydration, including tachycardia, delayed capillary refill, decreased tears, decreased activity, decreased urine output, and altered mental status.
  • Hypovolemic shock rarely occurs with these infections but must be recognized.
  • The child must be evaluated for the adequacy of the nutritional status. This is particularly important in cases of chronic diarrhea and possible immunodeficiency.
  • Weight must be measured and compared on the growth curve. Appropriate interventions occur following this immediate assessment.
  • Oral rehydration therapy (ORT) is the preferred approach for children with mild-to-moderate dehydration. Intravenous rehydration should rarely be necessary. Current recommendations for pediatric rehydration are outlined best in The Management of Acute Diarrhea in Children: Oral Rehydration, Maintenance, and Nutritional Therapy.[22]
  • Following immediate fluid resuscitation for dehydration, the clinician must address potential nutritional issues and provide adequate nutrition to the child with acute or chronic diarrhea.
  • Protozoal GI infections in immunocompetent patients are usually mild-to-moderate self-limited diseases, and special precautions are not needed.
  • The hallmark for treatment of these diseases is specific antiprotozoal therapy.
  • Patients with severe amebic or balantidic colitis should not receive oral nutrition and should be monitored for potential surgical complications.
  • Consider parenteral nutrition in some patients.
  • Patients with amebic liver abscess should be treated in the hospital until potential complications have been ruled out.
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Surgical Care

Only 2 well-recognized conditions in which surgical therapy is necessary for intestinal protozoal diseases are known: necrotizing colitis, caused by E histolytica or B coli, and complicated amebic liver abscess.

  • Indications for surgery in fulminant amebic colitis include the following:
    • Failure to respond to antiamebic drugs following perforation and localized abscess formation
    • Persistence of abdominal distension and tenderness despite effective antiamebic therapy
    • Toxic megacolon
  • Partial colectomy with colostomy is recommended over primary anastomosis for localized colonic disease because an anastomosis may be incompetent because of the friable condition of the affected intestinal wall.
  • For extensive disease, better surgical results have been obtained with total colectomy with exteriorization of the proximal and distal ends.
  • Indications for needle aspiration in amebic liver abscess include the following:
    • Rupture to pleura, pericardium, or both
    • Left lobe abscesses and proximity to the pericardium
    • As a diagnostic procedure when a pyogenic abscess is highly suspected
    • When surgical drainage is indicated because of imminent rupture of the abscess to the peritoneal cavity or presence of necrotizing colitis
    • When, in some cases, perianal fistulization of intestinal amebic foci is present and necessitates surgical drainage
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Consultations

See the list below:

  • The primary care physician can manage the vast majority of cases of gastroenteritis associated with protozoal infections. These infections rarely result in complications requiring hospitalization.
  • In patients with chronic diarrhea or amebic liver abscess, consultation with a gastroenterologist along with an infectious-disease specialist may be useful.
  • Surgeons should be consulted when the patient is suspected to have necrotizing colitis, complicated amebic liver abscess, or both.
  • Nutritional support may also be beneficial in severe cases.
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Diet

See the list below:

  • In immunocompetent patients, effective antiprotozoal therapy results in full recovery.
  • Some patients with severe giardiasis may experience disaccharidase deficiency and may require lactose-free diets, but this is a temporary condition that usually does not last more than 2 weeks.
  • Patients with AIDS and severe spore-forming protozoal infections (chronic diarrhea with wasting syndrome) require hypercaloric diets. This is indicated for the protozoal illness in addition to the wasting syndrome associated with the underlying disease.
  • For amebic liver abscess, some experts recommend a low-fat diet during antiamebic treatment, but no clinical trials have examined the effects of this diet on the patient's outcome.
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Activity

See the list below:

  • The only limitations for physical activity are in patients with amebic liver abscess who may require hospitalization and patients who require surgery for necrotizing colitis.
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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.

Specialty Editor Board

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: Academic Pediatric Association, American Academy of Pediatrics, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

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, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

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

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

Disclosure: Nothing to disclose.

Acknowledgements

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.

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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.
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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