Giardiasis

The histopathology of the upper small bowel varies from normal to subtotal
villous atrophy in giardiasis. Giardia spp. seem unable to penetrate the mucosal
wall in humans but are able to attach to the mucosa of the small bowel. In
symptomatic cases there is increased mucus secretion and dehydration.[11]
Giardia lamblia may undergo antigenic variation, thereby evading the human
immune response.[12] Giardiasis is more common in the immunodeficiency
syndromes, particularly in common variable hypogammaglobulinemia, although
there is no particular increase in incidence among the HIV-infected population.

Giardiasis (Giardia lamblia)

The clinical spectrum of giardiasis ranges from asymptomatic infection, through

acute gastrointestinal infection to severe chronic diarrhea[33] with intestinal
malabsorption.[34] The average incubation period is 9 days and the acute
infection is self-limiting.[35] Common symptoms include nausea, diarrhea,
flatulence and upper abdominal cramps with distention and nausea. Weight loss
is common and there can be signs of malabsorption (steatorrhea, disaccharidase
deficiency and vitamin B12 deficiency).

DIAGNOSIS

Microscopic examination of the stool is fundamental to the diagnosis of all the

gastrointestinal infections (see Chapter 165 ). A minimum of three stool
specimens, examined by trained personnel using a concentration and a
permanent stain technique, should be used.

Amebiasis is often suspected on clinical grounds but confirmation is always

required by demonstrating cysts and trophozoites in the stools or trophozoites
from the bowel mucosa. Fresh stools examined within 20 minutes for the
presence of trophozoites containing ingested red blood cells enables E.
histolytica to be distinguished from the nonpathogenic E. dispar. Entamoeba
hartmanni, Entamoeba coli, Iodamoeba butschlii and Endolimax nana are
nonpathogenic amebae, the cysts of which can be distinguished by their size and
morphology (see Chapter 164 ). Material aspirated or scraped from mucosal
surfaces at sigmoidoscopy needs microscopic examination. Culture of amebae is
possible and allows zymodeme pattern analysis (a reference standard to
diagnose and distinguish between E. histolytica and E. dispar). The polymerase
chain reaction (PCR) can also distinguish E. histolytica from E. dispar. Monoclonal
antibodies and DNA probes for this purpose are available in research centers. A
recent rapid stool antigen enzyme-linked immunosorbent assay (ELISA) kit,
based on antilectin antibodies, is 80% sensitive and 99% specific in diagnosing
Entamoeba infection; another commercial test is 95% sensitive and 93% specific
in distinguishing between E. histolytica and E. dispar when compared with
culture and zymodeme analysis.[51] If this becomes widely accepted it may be
useful in the management of asymptomatic carriers, because it would allow
discrimination between pathogenic and nonpathogenic strains and avoid
unnecessary treatment. Serologic diagnosis of invasive amebiasis is discussed
below.

Giardial cysts and sometimes trophozoites are seen in fecal specimens. Multiple
fecal specimens are required. A duodenal aspirate, biopsy or string test may
sometimes be positive in the presence of negative stool microscopy. Giardial
antigens can be detected in feces by a commercially available ELISA with
reported sensitivity and specificity of 87100% compared with microscopy;
research laboratories can offer DNA probes or PCR diagnosis. An indirect
immunofluorescence test using a cyst-specific anti-Giardia lamblia monoclonal
antibody has been reported to detect twice the number of positive stool
specimens than light microscopy.[52] This may allow more accurate diagnosis
from fewer stool samples and obviate the need for biopsy or endoscopy.

Giardia Stephanie Boade Silas, MD, & DeVon Hale, MD

Essentials of Diagnosis

Key symptoms include initially profuse and watery diarrhea progressing to foul-
smelling and often greasy stools that float.

It is the most common pathogen in waterborne diarrheal illness.

Patients at highest risk include infants, young children, travelers, and

immunocompromised patients.

In North America, the Rocky Mountains and mountainous regions of the

northwest, northeast, and British Columbia are notorious Giardia reservoirs.

Giardiasis is diagnosed either by identification of cysts or trophozoites on wet

mounts of fresh stool or duodenal specimens or by antigen detection using
enzyme-linked immunosorbent assay or immunofluorescence techniques.

B. Laboratory Findings. Laboratory studies are notable for a normal peripheral

leukocyte count without eosinophilia. Stool studies are negative for the presence
of mucus, leukocytes, and blood.

Diagnosis
The key to diagnosis of G lamblia infection is the identification of trophozoites or
cysts, both of which can be seen in stools by standard ova and parasite exam
(Table 84-1). Trophozoites have a short survival time outside the small bowel
when not contained within cysts and are more likely to be seen in fresh wet
mounts of liquid stool. Semiformed stool may be preserved in formalin or
polyvinyl alcohol. Staining with trichrome or iron hematoxylin reveals cysts.
Formalin or zinc flotation concentration techniques may increase the yield of
diagnosis. Generally, one stool exam has a 50-70% diagnostic yield, which
improves to 85-90% after 3 stools collected over 2-3 days because of cyclic
shedding. Purged samples have no effect on diagnostic yield.

Enzyme immunoassay and direct fluorescent-antibody assay kits are

commercially available for testing for G lamblia infection. Both methods have
reported sensitivities of 87-100% and specificities of 99- 100% when compared
with microscopic stool examination. Advantages of these techniques include a
decrease in both examination time and required technician training. Both direct
fluorescent-antibody assay and enzyme immunoassay are particularly valuable
when the sole diagnosis or exclusion of G lamblia is needed, as may occur during
an epidemic or for screening purposes. Although cost of antigen detection
techniques is similar to ova and parasite microscopic exams, microscopy allows
for diagnosis of other possible pathogens. One commercially available direct
fluorescent antibody assay kit does detect both G lamblia and C parvum,
however.

Other, more invasive techniques are rarely used but may contribute to diagnosis.
The string test involves swallowing a capsule attached to a nylon string. The
capsule sits in the jejunum for 4-6 h while the patient is fasting. The string is
subsequently removed and examined for trophozoites by microscopy. A duodenal
aspirate can be similarly examined. Also, a duodenal biopsy or endoscopic
brushing can be examined for trophozoites, by using Giemsa stain.

Upper gastrointestinal aspirates can be cultured, but this test is generally not
available clinically. Serology, too, has little clinical utility but may be helpful
epidemiologically. Serum immunoglobulin M or IgA titers are indicative of recent
infection as compared with IgG titers. Polymerase chain reaction and gene probe
studies are still in experimental stages, with their most practical limitation being
extraction of DNA from the stool sample.

Diagnosis
(Table 208-1) Giardiasis is diagnosed by detection of parasite antigens in the feces or by
identification of cysts in the feces or of trophozoites in the feces or small intestines. Cysts are
oval, measure 812 m x 710 m, and characteristically contain four nuclei.

Trophozoites are pear-shaped, dorsally convex, flattened parasites with two nuclei and four
pairs of flagella (Fig. 208-2). The diagnosis is sometimes difficult to establish. Direct
examination of fresh or properly preserved stools as well as concentration methods should be
used. Because cyst excretion is variable and may be undetectable at times, repeated
examination of stool, sampling of duodenal fluid, and biopsy of the small intestine may be
required to detect the parasite. Tests for parasitic antigens in stool are at least as sensitive and
specific as good microscopic examinations and are easier to perform. All of these methods
occasionally yield false-negative results.

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