• Clinical science

Giardiasis

Abstract

Giardiasis is a common parasitic infection caused by the protozoan Giardia lamblia. Transmission usually occurs via the fecal-oral route (e.g., from contaminated drinking water) when traveling or living in an endemic region. Giardia live in two states: as active trophozoites in the human body and as infectious cysts surviving in various environments. Following ingestion of the cyst, individuals may experience abdominal cramps and frothy, greasy diarrhea. Diagnosis of giardiasis involves analyzing stool for microscopic confirmation of cysts or trophozoites, and possibly immunoassays to detect antigens. Treatment consists of antibiotic administration with metronidazole.

Epidemiology

  • Giardia lamblia is widespread throughout the world and affects ∼ 200 million people per year worldwide.
  • Incidence: estimated 5–8/100,000 per year in the US
  • In the US, Giardiasis is the most common intestinal disease caused by parasites.
  • Rates of infection are higher during the summer and early fall (June–October).

References:[1][2][3]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • Pathogen: Giardia lamblia; (also known as Giardia intestinalis or duodenalis), a protozoan
  • Transmission
    • Waterborne: from drinking of recreational water (e.g., lakes, rivers, ponds, swimming pools)
    • Fecal-oral (e.g., through food handlers, people in daycare and nurseries): Giardia cysts are passed into the environment from the feces of infected people and animals.
    • Swallowing of cysts in contaminated water → entry of Giardia into the gastrointestinal tract
    • Infection is more likely to occur after traveling to endemic regions such as the tropics, subtropics, and North-American mountain regions.

References:[2]

Pathophysiology

  • Life cycle: 2 stages
    1. Trophozoite: active form of the pathogen that multiplies, lives within the host's body
      • Morphology: long oval shape with two nuclei and four pairs of flagella that resemble a kite
    2. Cysts: excreted, infectious form of the pathogen, able to survive in moist environments
      • Morphology: oval, four nuclei
    • Ingestion of cysts → excystation and conversion to trophozoite form → rapid multiplication, adhesion to intestinal walls → encystation in large bowel → excretion of cysts → possible reinfection
  • Mechanism of injury: Although several theories exist, it is commonly suspected that infection with Giardia leads to impaired function and structure of intestinal tissue , resulting in malabsorption and diarrhea.

References:[4][5][6]

Clinical features

Infection with Giardia lamblia must be considered as a differential diagnosis for persistent diarrhea.

  • 3–25 days after ingestion of cysts → diarrhea consisting of soft, voluminous, frothy, and greasy stools (stools tend to float; no blood!)
  • Excessive gas, abdominal pain, and cramps
  • Fatigue, nausea/vomiting, anorexia
  • May be asymptomatic

References:[7]

Diagnostics

  • Stool analysis: microscopic confirmation of cysts or trophozoites
  • Immunoassay: detection of Giardia lamblia antigens in stool
  • Gastroduodenoscopy: confirms trophozoites in duodenal fluids, but generally not indicated

References:[8][9]

Treatment

  • Metronidazole: first-line agent in US
  • Tinidazole: first-line agent in many countries outside the US
  • Pregnant patients
    • Supportive therapy (nutrition, hydration) until after delivery
    • Paromomycin: in severe, symptomatic cases

References:[8]