ParasitologyToday, voL 4, no.
I, 1988
Focus Blastocystis hominis, a Long-
misunderstood Intestinal Parasite
For over 50 years, Blastocystis hominis has been held to be a harmless intestinal yeast -
probably frequent in stool samples from man and other primates, but usually ignored
except as a possible source of confusion with Entamoeba histolytica. More recently, its
status as a protozoan parasite has been accepted, and it is now increasingly recognized
as an agent of intestinal disease - usually self-limiting but occasionally fatal in monkeys.
Here, Charles Zierdt reviews the status of this intriguing protozoan, drawing attention to
its unusual biochemistry.
In recent years, evidence that Blastocystis
hominis is a protozoan and not a yeast I
has been persuasive for most
parasitologists. The organism may have
been described by Loesch as early as
1849, but in manuscripts at hand, I have
not yet been able to confirm this. There
is reference by one author to Perron-
cito's 1899 manuscript 2 as the first
adequate description, but examination
of his manuscript does not confirm this.
At present, priority for the first adequate
description must go to Alexieff 3 who in
1911 named it Blastocystis enterocola.
This was followed in 1912 by Brumpt 4
who retained Alexieffls B/astocystis but
changed the specific epithet to Blastocys-
tis hominis, and also classified it as a yeast.
Brumpt's publication is the one that
has been cited ever since. His classifica-
tion, and a brief description of B. hominis
as a harmless intestinal yeast-important
only because it might be confused with
Entamoeba histolytica- became the stan-
dardized paragraph in succeeding edi-
tions of parasitology and medical texts.
Two recent texts present adequate
descriptions of B. hominis and some
others now refer to its classification as a
protozoan. The Centers for Disease
Control has also, in publication and edu-
cation, treated it as a pathogenic proto-
zoan. The College of American
Pathologists requires reporting of B.
hominis in stool specimens and includes it
in proficiency test samples. Foreign liter-
ature from Italy, German),, France, and
Argentina, through the first: four decades
of this century documented over a
dozen papers reporting hundreds of
cases of intestinal disease caused by B.
hominisS-~ ~.
Yeast or Protozoan ?
There were good reasons for classify-
ing B. hominis as a yeast. It has a very
yeast-like, glistening appearance in fresh
wet mounts. There are no pseudopodia
in the usual unheated wet preparations
~)198B, ElsevqerPubl,cat~ons,Cambridge 0169~.758/88/$02 00
C,H. Zierdt
and no evidence of locomotion. The size
range is more extreme than is expected
in a protozoan (Fig. I a), as is the diversity
of forms in a single specimen (Figs I, 2).
Division is commonly via binary fission
(Fig. 3) which is easily construed as bud-
ding. There is no cyst form and the
amoeba forms of the organism were not
recognized as Blastocystis in origin. The
nuclei are not recognizable in unstained
cells. Blastocystis may not invade the mu-
cosa and has no evident life cycle in man.
It has no known secondary or alternate
hosts, and its mode of transmission is un-
known.
Conversely, there seems to be no
single major attribute of B. hominis that
suggests a yeast, whereas any one of sev-
eral attributes could be selected to pro-
claim its protozan nature. Physiological
evidence that B. hominis is a protozoan
includes (I) strict anaerobe; (2) no
growth on fungal or bacteriological
media; (3) no growth on the surface of
solid media; (4) optimal growth at 37°C;
(5) no growth at 30°C or lower; (6) opti-
mal growth at neutral pH; (7) no growth
at pH 5.5; (8) requires the presence of
bacteria for growth; (9) axenic growth
achieved slowly under carefully control-
led conditions; (I 0) resistant to 400 Ilg/
y
! J
/
/
?
\
Fig. I. o - Blastocyscis hominis in culture (Nomarski inte~erence optics) shows a wide range of
size. Top cell showspods of organelles at poles of cell, compressed between membrane of central
body (CB) and cell membrane, b - Thin section electron micrograph showing nuclei With nucleoli,
which tend to be crescentic, and surrounding mitochondria.
15
ml amphotericin B; (I I) capable of
ingesting bacteria and other particulate
matter; (12) nutritional requirements
similar to other intestinal protozoa, and
(I 3) cultures die in three days at room
temperature or overnight at 4°C.
Structural and ultrastructural evi-
dence that B. hominis is a protozoan
includes (I) absence of a cell wall; (2) a
limiting membrane with micropinocyto-
tic and other vesicles or pores; (3)
mitochondria (hundreds in giant cells) of
a general protozoan type (Figs I, 2); (4)
Golgi apparatus; (5) multiple nuclei (Fig.
I); (6) feeding pseudopods (Fig. 2); (7)
locomotion pseudopods (rare); (8)
endodyogeny (Fig. 3a); (9) schizogeny
(merogony), (Fig. 3b); (10) binary fission
(Fig. 3c); ( I I ) no budding; (12) support of
a stable bacterial endosymbiont (an obli-
gate mutualism) 12;(13) well-demarcated
smooth and rough endoplasmic
reticulum; (14) membrane-bounded
central body formerly called a vacuole
(Fig. I) functional in endodyogeny and
schizogeny; (15) other complex struc-
tures of unknown function.
Culture of B. hominis is best in a
biphasic medium with a slant of coagu-
lated whole egg-a Locke's solution mix-
ture,with an overlay of Locke's with 30-
40% horse or human serum. Scant but
passaged growth is obtainable in a liquid
medium composed of Locke's or Hank's
solution plus 40% horse or human
serum. Foetal bovine serum does not
support growth, and media containing
liver or liver-extract (Diamond's or
Balamuth's) do not support continuous
16 Parasitology Today, vol. 4, no. I, 1988

and schizogeny, feeding pseudopodia,

rarely larger, rapidly formed locomotion
pseudopodia, pinocytotic feeding,
mesomitotic, no flagella, intestinal para-
site of higher primates).

S y m p t o m s and T r e a t m e n t

Several clinical studies of B. horninis

Fig, 2. "Giant' Blastocystis hominis cell
(Nomarski interference optics), showing
mitochondria and feeding pseudopods. This
type of pseudopod is extended and retracted
over a period of 5-10 rain.
have recently been initiated in hospitals
but few reports have ensued, because of
insufficient cases. Most infected indi-
viduals are not admitted to hospitals.
Recorded symptoms include cramps,
vomiting, dehydration, abdominal pain,
sleeplessness, nausea, weight loss, inabil-
ity to work, lassitude, dizziness, flatus, Fig. 4. Section of caecum from gnotobiotic
anorexia, pruritis, and tenesmus. Blood guinea pig infected w/th B. hominis. Organism
in the stool has also been reported. is in glandular epithelium here, but more often
Many cases are self-limited. Symptoms occurs in interglandular mucosa. (H & E stain.)
may develop and then disappear in I-3 Clinical reports of human infection with
days. In one study, eosinophilia was re- B. hominis are now accumulating Is-2t
ported in 8 of 19 patients Is. and fatal infections have been encoun-

passage of B. hominis. Stock transfers ( I/3

of cell volume) may be done at 3 and 4
day intervals. Cultures may not be viable
after I0 days at 36°C, and do not grow
at 30°C or lower - cultures die within a
few days at room temperature or over-
night at 4°C.
Generation time in biphasic egg
medium is 8.5 to 19.4 hrs 13.Binary fission
of individually observed cells required
40-60 min and cell counts rose from
5 x I OS/mlto I x 108/ml in 5 days.

N e w Suborder

B. hominis was tentatively classified

with the Sporozoa i2, but further know-
ledge of the organism now suggests that
it be transferred to the Sarcodina. A new
suborder is required. Therefore I now
place it, according to the classification
schemes of Levine et al. 14, in the King-
dom Protista, Subkingdom Protozoa,
Phylum Sarcomastigophora, Subphylum
Sarcodina, Superclass Rhizopoda, Class
Lobosea, Subclass Gymnamoeba, Order
Amoebida, new Suborder Blastocystina
(cells spherical and widely variable in size,
can be amoebiform in disease, limiting
membrane only, no cyst form, may have
glycocalyx, large membrane-bound cen- Fig. 3a - Blastocystis
tral body occupying large volume of cell hominis undergoing
endodyogeny; b - B.
which delineates a peripheral band of
hominis undergoing
cytoplasm including most of the cell's or- schizogeny, c - diagrammatic
ganelles, multinucleate, cytochrome-free representation 0fB. hominis in cultureshowing
mitochondria always present, division binary fission, schizogeny, and plasmotomy.
usually binary fission, also endodyogeny
Parasitology Today, vol. 4, no. I, 1988
Fig. 5a - Old B. hominis cell:; with accumulated lipid globules, b - Aggregation of thousands of B. hominis mitochondria in heated-stage culture
chamber. Lipid is expressed continuously and collects as large globules. (Both pictures using Nomarski interference optics.)
tered in monkey colonies. Apes housed
in a zoo (and a secretary in the same
zoo) have been infected by B. hominis
and cured with trime~.hoprim-sulfa -
methoxazole (Lee Monroe, pers.
comm.). An infection in a pig-tailed
Macaque was cured with diiodohy-
droxyquin 22. Experimental infections
were induced in gnotobiotic guinea pigs23
and invasion of the mucosa was ob-
served (Fig. 4). T w o bacterial species
were essential to infection of
gnotobiotes by B. hominis.
Drug susceptibility tests 24 show the
following descending order of in vitro
effectiveness: emetine, metronidazole,
furazolidone, trimethoprim sulfa-
methoxazole, 5-chloro-8-hydroxy-7-
iodo-quinoline (Entero-Vioform) and
pentamidine. T w o othe.r quinolines,
chloroquin and diiodo quinoline (Flora-
quin), were moderately inhibitory.
Ketoconazole, paromomycin and di-
Ioxanide furoate were not effective.
Metronidazole is most widely used, at
250 mg three times daily, but numerous
recurrences at this dosage have resulted
in physicians using 750 mg three times
daily- a dose that is not always tolerated.
Trimethoprim sulfamethoxazole has re-
cently been reported to cure infections
resistant to metronidazole.
In our experience treatment with
Entero-Vioform is very successful and it
is easily tolerated. Japanese physicians
liberally prescribed the drug for continu-
ous yearly use in thousands of patients
with a variety of complaints. However, a
self-resolving non-fatal neuropathy
occurred among hundreds of these
patients, leading to a massive govern-
ment ordained investigation and lengthy
report. The US Government in turn
banned its use.
J
]
"2 J
Cell of General Interest
Aside from its role as an agent of in-
testinal disease in man, B. hominis has
turned outto be a cell of general interest,
and it may become a research subject for
ceil physiologists because of its unusual
biochemistry. Although it is a strict
anaerobe, B. hominis has numerous
mitochondria, particularly in old large
cells in culture which may have hun-
dreds 2s, These mitochondria are of par-
ticular interest for their complete lack of
cytochrome protein. They also lack lac-
tate dehydrogenase, cytochrome C
oxidase, pyruvate dehydrogenase com-
plex, e-ketoglutarate dehydrogenase
complex, isocitrate dehydrogenase
N A D P + , glutamate dehydrogenase,
diaphorase, aspartate aminotransferase
and alanine aminotransferase. Thus, the
mitochondria probably qualify as
anaerobic, and their real function is un-
known. B. hominis stores lipid as the cell
ages, until some cells are over 75% filled
with triglycerides (Fig. 5a). Possibly the
mitochondria function in lipid
metabolism. Also, large aggregations of
these mitochondria in heated-stage cul-
ture chambers steadily express lipid
globules, which coalesce to form larger
globules (Fig. 5b).
In conclusion, a protozoan that was
largely forgotten and even misclassifled is
now being recognized as an agent of in-
testinal disease in primates. There is
much to be learned from this complex,
intriguing parasite - particularly for cell
physiologists. But for parasitologists, the
transmission, pathogenesis, and treat-
ment of B. hominis requires much to be
done.
17
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Charles Zierdt is at the Department of Clinical
Pathology, Clinical Center, National Institutes of
Health, Bethesda, M D 20892, USA.