ARTICLE

Giardiasis
James

Seidel

FOCUS

MD, PhD*
water with iodine preparations
will
kill most cysts; however,
they are
relatively
resistant
to chlorination.
Direct transmission
of giardiasis
from
animals to humans may occur, and
outbreaks
have been reported
from
water supplies
contaminated
with animal feces.

QUESTiONS

1. How is Giardia
lamblia,
a protozoan parasite
of man, spread?
2. What are the methods of diagnosing Giardia
lamblia?
3. What are the clinical signs of
symptoms
of giardiasis?
4. What Is the treatment
of choice
for glardlasis?

Pathogenesis
Giardiasis
is caused by infection
the protozoan
parasite Giardia
lamblia,
also called Giardia
intestinalis
in Europe.

with

Epidemiology
Giardia infections
are ubiquitous,
and
outbreaks
occur in developed
and
underdeveloped
nations throughout
the world. Infection
results from
ingestion
of cysts, usually contained
in water on food, on hands, or on
fomites contaminated
with feces. The
parasite is found in about 4% of stool
specimens
submitted
to laboratories
in the United States and is the most
common
parasite isolated.
The exact
prevalence
of the infection
in the
United States is not known because
it
is not reportable
in all states and may
be difficult to isolate in the laboratory. Epidemic
giandiasis
in day care
centers was first reported
in 1977,
with infection
rates varying
from 0 to
25%. Most children
have symptoms.
Chronic
passage of cysts by some
preschool
children
in day care facilities is found 5 to 6 months after the
initial diagnosis,
either because
of
continued
transmission
or chronic infection.
Prevalence
rates decline
when children are toilet-trained.
Sexual transmission
may occur in heterosexual or homosexual
contacts.
Campers
and hikers are at risk because of vertical transmission
from
animals,
and waterbonne
outbreaks
in
national parks have been reported.
In
addition,
many outbreaks
have been
attributed
to municipal
water supplies
that have not been treated with flocculation
or filtration.
Treatment
of
Chsef,

General

and Emergency

Pediatrics,

Harbor-UCLA
Medical
Center;
Professor
of
Pediatrics,
UCLA
School
of Medicine,
Los
Angeles,
CA.

284

The parasite has a direct life cycle.

The estimated
infective
dose is 50 to
100 cysts, and after ingestion,
two
trophozoites
are produced
from each
organism.
The donsoventrally
flattened, pear-shaped
trophozoite
measures 9 to 21 microns
in length and 5
to 15 microns
in width. A sucking
disc is found on the ventral surface,
which is used to attach to the intestinal mucosa (Fig. 1). The parasites
reproduce
by binary fission, colonizing the upper small intestine.
The cxact mechanism
of intestinal
damage
is not known,
but several factors
probably
contribute
to the pathogenesis. These include:
1) lange numbers
of parasites
attach to the brush bonder
of the intestine
and produce mechanical damage;
2) enzymes
produced
by
the organism
damage the mucosa;
3) children
who have poor host defenses, globulin
deficiencies
in particular, allow for rapid colonization
and an increase
in the number of parasites in the intestine;
and 4) altered
cellular immunity
may play a role in
the failure to eradicate
infection.
While differences
in strains can be
detected
by isoenzyme
analysis,
it is
not known whether
different
strains
vary in their ability to produce
disease.
Evidence
suggests
direct damage
to the microvillous
brush border by
the adherence
of the protozoa
to the
intestinal
surface.
Metabolites
and
enzymes
produced
by the parasite
also may play a role in damaging
the
mucosal
surface.
The resulting
disaccharide deficiencies
and disruption
of
digestion
by bile and pnoteases
may
lead to malabsonption
and malnutrition.
The host response
to infection
is
an important
factor in the pathogenesis of disease.
Infection
is more

prevalent
in young children,
and
some immunity
seems to develop in
long-term
residents
of endemic
areas.
The immune
response
is both cellular
and humonal.
Sensory
IgA seems to
play a role in the modulation
of infection in the intestine
as does the
migration
of infiltrating
lymphocytes
in the intestinal
mucosa.
Immunosuppressed patients may have more sevene symptoms
as well as difficulty
in eradicating
infection.
The inability
of some persons
to clear infection
may be due to the low concentrations
of a specific antiplasma
membrane
antibody.

Clinical

Manifestations

Many infections
are asymptomatic,
even in children
in day care centers.
When symptoms
do occur, they vary
from mild abdominal
discomfort
and
diarrhea
to cramping,
bloating,
severe diarrhea,
and abdominal
discomfort.
Many patients
describe
a
constellation
of signs and symptoms,
including
abdominal
bloating,
flatulence, and frequent
foul-smelling
stools. Young infants may have
anorexia,
weight loss, or a malabsorption
syndrome
that resembles
sprue. Lactose intolerance
may develop and persist for some time after
elimination
of the parasite.
A variety
of other signs and symptoms
have
been attributed
to giardiasis,
including arthralgia,
arthritis,
fever, and
eosinophilia;
the reports,
however,
are primarily
anecdotal,
and there are
few supporting
data to implicate
Giardia
lamblia
as the cause of these
symptoms.
Some children who have
giardiasis
fail to respond to treatment
with oral antibiotics
because
of mal-

oJringtoL.
intestinal

Pediatrics

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in Review

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July

1993

INFECTIOUS DISEASE
Giardiasis
absorption
due to the infection.
Parasitic
infection,
including
giardiasis, should be considered
in the
evaluation
of the child who fails to
thrive and in immunocompromised
infants and children who have dianrhea and gastrointestinal
complaints.
Giandiasis
should be considered
in
the differential
diagnosis
of any child
in day care who has gastrointestinal
symptoms.

Diagnosis
Examination
of preserved
fecal specimens will reveal the cysts and/or
trophozoites
of Giardia
lamblia
in
most infections.
Because
examination
of only a single stool specimen
may
miss 10% to 50% of infections,
multiple specimens
from different
days
are required.
Invasive
techniques,
such as endoscopy
with small bowel
biopsy on duodenal
aspiration,
also
can be used, as can the string test
(Entenotest)
(Fig. 2). In this latter
technique,
a nylon string is introduced into the duodenum
via a gelatin capsule.
The capsule is swallowed
and the free end of the string is taped
to the cheek, is removed
after 4
hours, and the liquid milked from the
distal end is examined
for organisms.
Recently,
monocbonal
antibodies
have been used to detect fecal organisms by immunofluorescence.
Commercially
available
enzyme linked
immunosonbent
assay (ELISA)
tests
also have been shown to be highly
specific and sensitive,
perhaps more
sensitive
than microscopic
examination of stool samples.
The ELISA is
an important
diagnostic
tool in epidemiobogic studies of large outbreaks
of
disease,
but it does not replace microscopic
examination
because of the
detection
of multiple
organisms
in
some children.
Because
organisms
are shed intermittently,
multiple
specimens
are necessary,
as with routine ova and parasite examinations,
to avoid false-negative
findings.

Treatment
Three drugs available in the United
States may be used to treat giardiasis. Quinacrine
HC1 is available
in
100-mg tablets. It is given at 7 mg/
kg pen day in three divided doses for
7 days. The medication
is extremely

Pediatrics

in Review

VoL

14

No.

Pregnant
women cannot be treated
with the standard
drugs, and a trial
of paromomycin,
a nonadsorbed
aminoglycoside,
has been recommended
for these cases.

Prognosis

FIGURE 2. Enterotest
string pinned
to
the clothing
of a pediatric patient.
The
string is removed after 4 hours in the
duodenum
and the liquid on the distal
end

examined

for parasites.

bitter and, thus, should be given in

applesauce,
jam, or cherry syrup. It
is unstable
in liquid preparations
and
has many side effects-most
commonly, nausea, vomiting,
and abdominal
upset. A temporary
yelloworange discoloration
of the skin and
sclera may occur with therapy,
particularly
when inappropriately
high
doses are given. It may cause hemolysis in children
who have glucose-6phosphate
dehydrogenase
(G-6-PD)
deficiency.
Metronidazole
also is effective in eradicating
the organism,
but is not approved
by the Food and
Drug Administration
for use in giandiasis. It is available
in 250-mg tablets and, like quinacrine,
is 90% to
95% effective.
The therapy of 15
mg/kg per day divided into three
doses lasts for 5 days. Side effects
include abdominal
upset, nausea,
vomiting,
headache,
and a lasting
metallic
taste. Peripheral
neuropathy
has been reported,
and it has a disulfinam effect when there is concomitant alcohol ingestion.
Furazolidone
is dispensed
as a liquid, containing
50 mg/iS mL, and as a 100-mg
tablet. It is less effective
in eradicating
the parasite than quinacnine
or metronidazole
and has frequent
side effects, including
rash, nausea, and
vomiting.
It also may cause hemolysis in G-6-PD-deficient
children.
Based on costs per treatment
of giardiasis in an average adult, quinacnine
costs about 84 cents, metronidazole
about $8.00, and furazolidone
about
$11.00.
All patients found to be infected,
whether with cysts or trophozoite
passers, whether asymptomatic or
symptomatic,
should be treated.

July 1993

Most Giardia
infections
can be
treated successfully
and have few Sequelae. It may take time for infants
who fail to thrive or who have malabsorption
to recover intestinal
enzymatic function,
but they usually do
well after treatment
and restoration
of
an anabolic
state. Chronic infections
can be problematic
in immunosuppressed individuals,
and multiple
courses of therapy with different
agents may be necessary.
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285

Giardiasis
James Seidel
Pediatrics in Review 1993;14;284
DOI: 10.1542/pir.14-7-284

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Giardiasis
James Seidel
Pediatrics in Review 1993;14;284
DOI: 10.1542/pir.14-7-284

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pedsinreview.aappublications.org/content/14/7/284

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and
trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove
Village, Illinois, 60007. Copyright 1993 by the American Academy of Pediatrics. All rights reserved.
Print ISSN: 0191-9601.

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