REVIEW

J Trop Med Parasitol 2001;24:16-22.

Is Blastocystis hominis a Human Pathogenic Protozoan?

Yaowalark Sukthana
Department of Protozoology, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok 10400, Thailand

Abstract
lastocystis hominis is an intestinal protozoan with mysterious pleomorphism. Its role as a human pathogen is somewhat controversial. Though many experts demonstrated no correlation between the persistent presence of B. hominis and patients symptoms, diarrhea occurring in particular groups such as immunocompromised hosts, travelers, homosexuals and day-care children are now increasingly reported. B. hominis is often found along with other organisms that are more likely to be the cause of diarrhea. Physicians, as well as diagnostic parasitologists, should be aware of the potential clinical significance of B. hominis, especially when more than five organisms per high power field are found. Positive findings otherwise should be considered as carriers and followed up for any ill effect. To enhance the detection of B. hominis, examination of multiple stool specimens is recommended. Permanently stained smear is the procedure of choice for light microscopic diagnosis. There is as yet no specific antibody test available for diagnosis. A culture method to demonstrate the more easily recognized vacuolated form is available, but probably not feasible for most diagnostic laboratories. Electron microscopy may assist in confirming the diagnosis of atypical morphological forms. There is molecular evidence of possible man-to-man and zoonotic transmission of B. hominis. A recent study showed the difference between protein patterns of B. hominis isolates in acute and chronic diarrhea. Whether B. hominis is a pathogen still remains uncertain. Recognition will allow public health authorities and clinicians to request appropriate laboratory investigations and properly manage this controversial parasite.

Introduction
Blastocystis hominis is an intestinal protozoon discovered in 1870 by the Russian physician, Fedor Aleksandrovich Lesh [1], the same year as Giardia lamblia and Balantidium coli, but it remains somewhat mysterious due to its pleomorphism, its uncertain taxonomic position and pathogenesis. Its role as a human pathogen

is controversial. Although previously classified as a non-pathogenic organism, B. hominis is now the agent implicated in causing diarrhea in immunocompromised patients [2-6]. It has become a major subject of study, particularly for evidence of disease causation.

Morphology and biology

B. hominis was classified in the subkingdom Protozoa, subphylum Sarcodina, in a separate suborder Blastocystina, but the exact taxonomic position of this parasite remains undetermined. It is transmitted by the fecal-oral route. Adults

Correspondence: Assist. Prof. Yaowalark Sukthana, Tel: 0-2246-9000-12 ext. 1830 E-mail: tmymv@mahidol.ac.th

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Is Blastocystis hominis a Human Pathogenic Protozoan?

are more likely to be infected than children. Travel history, familial transmission and spread within institutes for the mentally retarded have been reported [2,6-8], all being consistent with fecal-oral transmission. Three common morphological forms of B. hominis, vacuolar, granular, and ameboid have been recognized, but recent studies have revealed several additional forms such as cystic, avacuolar, and multivacuolar [9,10]. Light microscopy of several fecal samples has suggested that the vacuolar form seen before inoculation into culture was generally smaller than that recorded for cultured B. hominis. A very thick surface coat, often up to 0.5 mm, surrounded the cells, and as a gelatinous capsule it is considered as a contributing factor to the survival of the organism in laboratory culture. It probably acts as a mechanical and chemical protective barrier against host responses [9]. The vacuolated form is the most common. B. hominis appear as spherical or oval cyst-like structures. They can vary widely in size (5-30 m, the usual range being 8-10 m), and typically each consists of a central body or vacuole surrounded by a thin rim of cytoplasm containing up to six nuclei. Fig 1 shows B. hominis stained in trichrome. The sizes vary from 4 m (Fig 1C) to 10 m (Fig 1A). The vacuoles stain variably from red to blue. The nuclei in the peripheral cytoplasmic rim are clearly visible, stained purple, and numbering four and five nuclei in Figs 1A and 1B, respectively.

The ameboid form is found only in patients with acute diarrhea. It contains pseudopodia with varying sizes as is seen in amebae. Pseudopodia may be demonstrated in the ameboid form in heated microscope stage culture chambers. The granular form is mostly found in culture media. A life cycle for B. hominis was first proposed in 1911, involving binary fission of a binucleate stage and autogamy, a sexual phenomenon, to form primary cysts. The existence of both thinand thick-walled cysts in B. hominis suggests that the thin-walled cysts are autoinfectious, leading to multiplication of the organism in the intestinal tract. The thick-walled cysts are thought to be resistant forms and are responsible for external existence. They are smaller than the primary cysts, are uninucleate and are surrounded by a thick membrane [11]. Binary fission of B. hominis seems to have been generally accepted [9-12]. Commonly, two distinct cell types have been described, a large cell with a large central vacuole and a smaller cell type, usually described without a vacuole and thought to be a resistant form. The proposed life-cycle is shown in Fig 2: a small avacuolar cell without a surface coat in the colon of humans passes through the colon, the small vesicles probably coalesce to form the multivacuolar stage with a thick surface coat, the stage seen in the feces. Then, a cyst wall is formed; it is resistant to external environmental conditions and it is the infective form. Gastric

Fig 1 The morphology of Blastocystis hominis stained in trichrome.

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Is Blastocystis hominis a Human Pathogenic Protozoan?

acid and intestinal enzymes are possibly responsible for excystation. Differentiation to the ameboid form occurs. It is also possible that the ameboid form arises in vivo from the avacuolar form, which further develops into a vacuolar form. Adverse conditions have been demonstrated to initiate the transformation of the vacuolar form to the granular cell. The cystic

form was noted to be more common in stored fecal material than in fresh stools, suggesting that it may develop in response to passage from the host or to external environmental factors [9,10,12].

Clinical aspects
Is B. hominis the cause of intestinal

Culture

Cyst

External environment

Ameboid

Host intestine

Multivacuolar

Vacuolar

Fig 2

Proposed life cycle of B. hominis. Source: Luliasno W: Emillo Ribas Institute of Infectious Disease, Brazil.

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Avacuolar

Culture Granular
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Is Blastocystis hominis a Human Pathogenic Protozoan?

symptoms? It is hard to be sure, and experts disagree on this point [13-17]. Finding Blastocystis in stool samples should be followed by a careful search for other possible causes of disease. Symptoms may be caused by infection with other parasitic organisms, bacteria, or viruses. Often, B. hominis is found along with other such organisms that are more likely to be the cause of symptoms. In the absence of other identified causes, patients presenting with diarrhea or other gastrointestinal symptoms should be assessed for the presence of B. hominis. In general, reports from developing countries found a higher prevalence of B. hominis (30%50%) than those from developed countries (1%10%) [7,13]. Symptoms commonly attributed to infection with B. hominis are non-specific and include diarrhea, abdominal pain, cramps or discomfort and nausea. Profuse, watery diarrhea has been reported in acute cases, although this may be less pronounced in chronic cases. Fatigue, anorexia, flatulence and other nonspecific gastrointestinal effects may also be associated with blastocistosis. Fever has been recorded, particularly in acute cases. Large numbers of B. hominis cells may be present in fecal samples from patients who have no symptoms. The numbers of symptomless infection probably have been grossly underestimated, because not all forms of B. hominis have been used in diagnosis and many studies indicate the presence of B. hominis in fecal samples only if five or more organisms per oil immersion field are detected [18,19].

Laboratory diagnosis
Diagnosis is made microscopically by the presence of the vacuolar form, which is easily recognized by its large size and characteristic appearance. The organism must be distinguished from leukocytes, Cryptosporidium spp and the cysts of other protozoa, particularly those of Entamoeba histolytica, E. hartmani, and Endolimax nana. Concentration methods, as used for other protozoa and fecal parasites, generally appear unsuitable for this organism because these methods cause disruption of the

vacuolar, multivacuolar and granular forms. The addition of distilled water to the fecal material results in lysis of this organism and saline has been recommended if dilutions are performed during the preparation of samples for diagnosis. The vacuolar form can be observed in the examination of fresh fecal material in wet mount with iodine stain or with saline solution. To enhance the detection of B. hominis and other intestinal protozoa, examination of multiple stool specimens is recommended. Permanent smears appear to be the procedure of choice for light microscopic diagnosis. Localization of the lipid of B. hominis is histochemically demonstrated, when stained with Sudan Black, the central vacuole showing many black droplets with great variation in staining intensity. In Nile Blue stain, the central vacuole shows many pinkish granules or homogeneous blue reactions. These results indicate the presence of neutral lipids and/or acidic lipids in the central vacuole [20]. As yet, no specific antibody test is available for the diagnosis of B. hominis. A culture method to demonstrate the more easily recognized vacuolated form is available, but probably not feasible for most diagnostic laboratories [21-23]. Electron microscopy may assist in confirming the diagnosis of atypical morphological forms. Scanning electron microscopy of B. hominis has shown that its outer coat has a fibrillar structure and individual fibrils may extend up to 5 m from the periphery of the parasite. The surface coat remains intact during cell division. Bacteria are often seen adhering to it and it is postulated that the breakdown of attached organisms may provide nutrients for Blastocystis. At the ultrastructural level, the central vacuole and some cytoplasmic vesicles show enhanced electron density after post-fixation with imidazole-buffered osmium tetroxide solution. Great variation in the density and distribution of the electron-dense materials is observed in the central vacuole. Since the electron-dense vesicles are frequently observed in the cytoplasm, B. hominis may accumulate the lipid in the central vacuole, the function of which is not well known [20,24-26].

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Molecular implications
Due to its highly genotypic polymorphism, a genetic marker for B. hominis would be a powerful tool for the identification of its subtypes and could be used as a means to resolve its transmission route or origin. Bohm-Gloning, et al [30] demonstrated five B. hominis subgroups, none of which was found to be significantly correlated with clinical symptoms. Conversely, another report [31] showed two isolates from patients with chronic diarrhea belonging to protein patterns I and II and associated with antigenic group 1, whereas four isolates from patients with acute diarrhea were clustered in protein pattern III and antigenic group 2. A study from Japan suggested the first molecular evidence of possible man-to-man transmission among two small communities [32], whilst other researchers showed zoonotic transmission from isolates from chicken [33], pig and horse [Thathaisong, et al, personal communication].

physicians [13,14,17,27-29]. Metronidazole is commonly recommended for treatment with a dosage of 250 to 750 mg three times per day for seven days, or 2 g per day for five days. Some studies have reported the results of chemotherapy for B. hominis in immunocompromised patients [6,15,16,29]. The fecal-oral route is the most likely route for blastocistosis transmission. Control measures include good personal hygiene, as shown in Table 1, improvement in community sanitary conditions and education to prevent fecal contamination of the environment and ingestion of contaminated material. Animals may be a risk factor for human infection.

Conclusions
B. hominis may indeed be more than a harmless commensal protozoan. However, the role of B. hominis as a causative agent of human disease remains unsettled. It should, however, be recalled that protozoa such as Cryptosporidium spp and the microsporidia, which were previously considered to be non-pathogenic or to have low pathogenicity, are now recognized to cause disease, especially in immunocompromised patients. At present, it is prudent to consider B. hominis a potential pathogen. It may be a pathogen in day-care centers, travelers, and immunocompromised

Treatment and control

The requirement for treatment remains controversial. The infection may be self-limiting and intervention may not be required. In the absence of conclusive evidence of another organism, treatment with potentially dangerous drugs and the failure to investigate the true cause of symptoms in patients are of concern to many

Table 1 Recommendations for prevention of B. hominis transmission. How can I prevent infection with Blastocystis? Wash hands with soap and water after using the toilet and before handling food. Avoid water or food that may be contaminated. Wash and peel all raw vegetables and fruits before eating. When traveling in countries where the water supply may be unsafe, avoid drinking unboiled tap water and avoid uncooked food washed with unboiled tap water. Bottled or canned carbonated beverages, seltzers, pasteurized fruit drinks, and steaming hot coffee and tea are safe to drink. If you work in a child-care center where you change diapers, be sure to wash your hands thoroughly with plenty of soap and warm water after every diaper change, even if you wear gloves.

Source: Center for Disease Control, Department of Health and Human Service, 1998.

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hosts and may be more common in individuals with gastrointestinal symptoms of long duration. In outbreak situations, parasitology laboratories should routinely search for and report this parasite in stool samples, if found. B. hominis should be considered significant if more than five organisms per high power field are counted. Significant infection is higher among symptomatic than asymptomatic persons with detectable fecal leukocytes, especially eosinophils. Physicians, as well as diagnostic parasitologists, should be aware of the potential clinical significance of B. hominis, especially when present alone in significant numbers. Otherwise, positive cases must be considered as carriers and followed up for any ill effects. Recognition will allow public health authorities and clinicians to request appropriate laboratory investigations and properly manage this controversial parasite. Whether B. hominis is a pathogenic protozoan still remains uncertain. It is, therefore, clear that further research is in order.

7. 8.

9.

10.

11.

12.

References
1. Lesh FA. Massive development of amebas in the large intestine. Am J Trop Med Hyg 1975;24:383-92. 2. Carbajal JA, Villar J, Lanuza MD, Esteban JG, Munoz C, Borras R. Clinical significance of Blastocystis hominis infection: epidemiologic study. Med Clin 1997;108:608-12. 3. Junod C. Blastocystis hominis: a common commensal in the colon. Study of prevalence in different populations of Paris. Presse Med 1995;24:1683-8. 4. Cotte L, Rabodonirina M, Piens MA, Perreard M, Mojon M, Trepo C. Prevalence of intestinal protozoans in French patients infected with HIV. J Acquir Immune Defic Syndr 1993;6:1024-9. 5. Mendez OC, Szmulewicz G, Menghi C, Torres S, Gonzalez G, Gatta C. Comparison of intestinal parasite infestation indexes among HIV positive and negative populations. Medicina 1994;54:307-10. 6. Narkewicz MR, Janoff EN, Sokol RJ, Levin 13.

14.

15.

16.

17.

18.

MJ. Blastocystis hominis gastroenteritis in a hemophiliac with acquired immune deficiency syndrome. J Pediatr Gastroenterol Nutr 1989;8:125-8. Stenzel DJ, Boreham PF. Blastocystis hominis revisited. Clin Microbiol Rev 1996;9:563-84. Cirioni O, Giacometti A, Drenaggi D, Ancarani F, Scalise G. Prevalence and clinical relevance of Blastocystis hominis in diverse patient cohorts. Eur J Epidemiol 1999;15:38993. Singh M, Suresh K, Ho LC, Ng GC, Yap EH. Elucidation of the life cycle of the intestinal protozoan Blastocystis hominis. Parasitol Res 1995;81:446-50. Vdovenko AA. Blastocystis hominis: origin and significance of vacuolar and granular forms. Parasitol Res 2000;86:8-10. Stenzel DJ, Boreham PF, McDougall R. Ultrastructure of Blastocystis hominis in human stool samples. Int J Parasitol 1991;21:807-12. Moe KT, Singh M, Howe J, Ho LC, Tan SW, Chen XQ, et al. Development of Blastocystis hominis cysts into vacuolar forms in vitro. Parasitol Res 1999;85:103-8. Sun T, Katz S, Tanenbaum B, Schenone C. Questionable clinical significance of Blastocystis hominis infection. Am J Gastroenterol 1989;84:1543-7. Senay H, MacPherson D. Blastocystis hominis: epidemiology and natural history. J Infect Dis 1990;162:987-90. Garavelli PL, Scaglione L, Bicocchi R, Libanore M . Blastocystosis: a new disease in the acquired immunodeficiency syndrome? Int J STD AIDS 1990;1:134-5. Cegielsk JP, Msengi AE, Dukes CS, Mbise R, Redding-Lallinger R, Minjas JN, et al. Intestinal parasites and HIV infection in Tanzanian children with chronic diarrhea. AIDS 1993;7:213-21. Jelinek T, Peyerl G, Loscher T, von Sonnenburg F, Nothdurft HD. The role of Blastocystis hominis as a possible intestinal pathogen in travellers. J Infect Dis 1997;35:63-6. Sadek Y, el-Fakahany AF, Lashin AH, el-Salam

Vol 24 (No. 1) June 2001

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Is Blastocystis hominis a Human Pathogenic Protozoan?

19.

20.

21. 22.

23.

24.

25.

26.

27.

FA. Intestinal parasites among food-handlers in Qualyobia Governorate, with reference to the pathogenic parasite Blastocystis hominis. J Egypt Soc Parasitol 1997;27:471-8. Kain KC, Noble MA, Freeman HJ, Barteluk RL. Epidemiology and clinical features associated with Blastocystis hominis infection. Diagn Microbiol Infect Dis 1987;8:235-44. Yoshikawa H, Satoh J, Enose Y. Light and electron microscopic localization of lipids in Blastocystis hominis. J Electron Microsc 1995;44:100-3. Zierdt CH. Blastocystis hominispast and future. Clin Microbiol Rev 1991;4:61-79. Lanuza MD, Carbajal JA, Villar J, Borras R . Description of an improved method for Blastocystis hominis culture and axenization. Parasitol Res 1997;83:60-3. Tan SW, Singh M, Yap EH, Ho LC, Moe KT, Howe J, et al . Colony formation of Blastocystis hominis in soft agar. Parasitol Res 1996;82:375-7. Zaman V, Howe J, Ng M, Goh TK. Scanning electron microscopy of the surface coat of Blastocystis hominis . Parasitol Res 1999;85:974-6. Moe KT, Singh M, Howe J, Ho LC, Tan SW, Ng GC, et al . Observations on the ultrastructure and viability of the cystic stage of Blastocystis hominis from human feces. Parasitol Res 1996;82:439-44. Zaman V, Howe J, Ng M. Ultrastructure of Blastocystis hominis cysts. Parasitol Res 1995;81:465-9. Amenta M, Dalle Nogare ER, Colomba C,

28.

29.

30.

31.

32.

33.

Prestileo TS, Di Lorenzo F, Fundaro S, et al. Intestinal protozoa in HIV-infected patients: effect of rifaximin in Cryptosporidium parvum and Blastocystis hominis infections. J Chemother 1999;11:391-5 Ok UZ, Girginkardesler N, Balcioglu C, Ertan P, Pirildar T, Kilimcioglu AA. Effect of trimethoprim-sulfamethaxazole in Blastocystis hominis infection. Am J Gastroenterol 1999;94:3245-7. Albrecht H, Stellbrink HJ, Greten H. Blastocystis hominis in human immunodeficiency virus-related diarrhea. Scand J Gastroenterol 1995;30:909-14. Bohm-Gloning B, Knobloch J, Walderich B. Five subgroups of Blastocystis hominis from symptomatic and asymptomatic patients revealed by restriction site analysis of PCRamplified 16S-like rDNA. Trop Med Int Health 1997;2:771-8. Lanuza MD, Carbajal JA, Villar J, Mir A, Borras R. Soluble-protein and antigenic heterogeneity in axenic Blastocystis hominis isolates: pathogenic implications. Parasitol Res 1999;85:93-7. Yoshikawa H, Abe N, Iwasawa M, Kitano S, Nagano I, Wu Z, et al. Genomic analysis of Blastocystis hominis strains isolated from two long-term health care facilities. Clin Microbiol 2000;38:1324-30. Yoshikawa H, Nagono I, Yap EH, Singh M, Takahashi Y. DNA polymorphism revealed by arbitrary primers polymerase chain reaction among Blastocystis hominis strains isolated from humans, a chicken, and a reptile. J Eukaryot Microbiol 1996;43:127-30.

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