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Giardiasis
• Giardiasis (beaver fever)

• parasitic infection

• caused by a single celled organism called Giardia lamblia

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 Epidemiology
• Six species of Giardia  G. lamblia (mammals), G. agilis (amphibians), G. muris
(rodents), G. ardeae and G. psittaci (Birds) and G. microti (Muskrats)

• Only G. lamblia is responsible for clinical disease in humans

• Worldwide, more common in tropics

• Mode of infection : unclean/unfiltered water directly from taps, ponds, rivers, etc.,

• Children, tourists and immunosuppressed individuals

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 Life Cycle
• Giardia has no vector
• Reservoirs :Humans, aquatic and semi-aquatic mammals, rodents
• Two forms : Trophozoite and cyst
• cystic form  viable in water for up to 3 months

• Upon ingestion, they survive the acidic environment of the stomach, reach the small
intestine and upon excystation give rise to two binuclear trophozoites

• They attach themselves to the intestinal mucosa and divide by binary fission.

4 • They do not cause invasive disease

 Life Cycle

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 Clinical features
• Majority asymptomatic

• Acute symptoms  crampy abdominal pain, watery diarrhoea, vomiting and fever
which may last for few days.

• chronic stage  bloating, nausea, abdominal fullness, epigastric or substernal

burning, malaise, fatigue, etc.

• Few patients  malabsorption syndrome

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 Diagnosis
• Stool examination  cysts and trophozoites

• Trophozoites are visible only in fresh watery stools

• Usually three stool samples are taken and the trichrome stain is used

• Trophozoites in duodenal aspirate more specific and sensitive than stool examination

• The ‘string test’ may be used, in which one end of a piece of string is passed into the
duodenum by swallowing and retrieved after an overnight fast; expressed fluid is then
examined for the presence of G. lamblia trophozoites

• Immunofluorescent antibody (IFA) assay or a capture ELISA against cyst or trophozoite

antigens  sensitivity of 85% to 98% and specificity of 90% to 100%
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 Differential Diagnosis

• Other causes of acute diarrhoea should be considered like amoebiasis, viral

infection, helminths, salmonellosis

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 Treatment
Single dose of tinidazole 2 g

Metronidazole 400 mg 3 times daily for 10 days

Nitazoxanide 500 mg orally twice daily for 3 days

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 Amoebiasis

• Two separate species—E. histolytica and E. dispar, morphologically indistinguishable

from one another

• Entamoeba histolytica is one of the most prevalent intestinal protozoa in developing

countries

• E. dispar also colonises the human gut but has no pathogenic potential
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 Life Cycle

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 Life Cycle

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 Epidemiology
• Reservoirs of E. histolytica are humans

• E. dispar infection is approximately 10-fold more common than E. histolytica

infection

• Symptomatic invasive amoebiasis  10% of individuals with E. histolytica infection

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 Pathology and Pathogenesis

Amoebiasis

Intestinal Extra intestinal

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 Spectrum of Disease

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 Intestinal Amoebiasis - Pathogenesis

• Amoebic dysentery

• Most amoebic infections are asymptomatic

• The typical amoebic intestinal ulcers (flask shaped ulcers) are found in the caecum,
sigmoid colon, and rectum

• These ulcers are characteristically shallow with broad elevated margins

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 Clinical Features
• Patients with acute amoebic dysentery present with a 1 to 2 week history of
abdominal pain, tenesmus, and frequent loose, watery stools containing blood and
mucous

• Colonoscopy may show the characteristic appearance of the punctate, hemorrhagic

ulcers dispersed throughout a normal appearing mucosa

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 Complications

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 Diagnosis

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 Amoebic Ulcers

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 Treatment

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 Extraintestinal Amoebiasis
• Amoebic liver abscess, and abscess
involving the pleura, lung, pericardium
or peritoneum, brain, skin, and, rarely,
genitourinary disease.

• Amoebic liver abscess (ALA) is the

most common form of extra intestinal
amoebiasis

• It is an inflammatory space occupying

lesion of the liver caused by E.
22 histolytica
 Amoebic Liver Abscess
• The incidence of ALA varies between 3% and 9% of all cases of amoebiasis

• About 75% of all liver abscesses amoebic

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 Clinical features
• Age group  20 to 45 years

• Seven to nine times more common in males

• It is classified by the duration of illness and severity into:

• Acute
Acute benign
Acute aggressive

• Chronic
Chronic benign

24 Chronic accelerated
 Clinical features
• Acute symptoms of less than two weeks

• Abdominal pain, fever and anorexia

• Abdominal pain  moderate and localised to the right upper quadrant or

epigastrium (left lobe abscess)

• Fever is of moderate degree, high fever with chills is suggestive of secondary

bacterial infection.

• Cough, with or without expectoration and pleuritic chest pain

• One-third of the patients  clinical jaundice

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 Clinical Features
• Tender hepatomegaly  up to 80% of patients

• Ascites developing in patients with ALA  inferior vena caval obstruction

• cough with copious expectoration  rupture and communication with the right
lower lobe bronchus

• ALA usually occurs in the right lobe of the liver and is solitary (30% to 70%)

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 Diagnosis

Ultrasound

• Non-homogeneous hypoechoic round or oval mass with well defined borders

• Complete sonologic resolution of an amoebic liver abscess may take up to two years
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 Imaging

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 Imaging

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 Treatment
• Nitroimidazoles including metronidazole are effective in over 90% of cases. Therapy
should continue for at least 14 days

• Metronidazole 800 mg PO tid × 14 days abscess (500 mg qid IV)

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 Abscess Aspiration

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 Surgical Management
• Surgical drainage  infrequently required

• Relative indications

Large abscess with a poor yield on needle aspiration

Clinical deterioration despite aspiration

Repeated symptomatic recurrences after aspiration

• Absolute indication

Rupture into the peritoneal cavity

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 Long-term follow-up
• The mean time for disappearance of the sonographic abnormality is 6-9 months

• Clinical resolution does not correlate with ultrasonographic resolution, and clinical
criteria rather than ultrasonography should monitor the result of therapy

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 Bacillary Dysentery
• Bacillary dysentery is an acute bacterial disease involving the large and small
intestine manifested by the presence of loose stool mixed with blood and mucous,
accompanied by fever, abdominal cramps and tenesmus (a symptom characterised
by incomplete sense of evacuation with rectal pain)

• It is caused by bacteria of the genus Shigella (Gram negative rods)

S. dysenteriae type 1 causes the most severe disease and the largest outbreaks
(other species include S. flexneri, S. sonnei and S. boydii).

34 It is the most important cause of acute bloody diarrhea

 Epidemiology
• Worldwide

• Humans are the principal reservoir of infection.

• The organism is acid resistant and can easily pass the gastric acid barrier.

• The infective dose is as low as 10 to 100 organisms.

• The disease is transmitted faeco-orally, the commonest modes being person-to-

person contact and contaminated food and water

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 clinical features
• After an incubation period of 1 to 7 days (average 3 days), Shigella organisms invade
the intestinal mucosa and cause inflammation

• Acute rectocolitis manifesting as fever and bloody diarrhoea, with tenesmus

• Abdominal cramping, high-grade fever, emesis, anorexia

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 Complications
• Electrolyte imbalance (especially, hypokalaemia), metabolic acidosis and shock,
seizures

• Less common complications include conjunctivitis, iritis, arthritis, rectal prolapse,

secondary bacterial infection, acute blood loss from mucosal ulcers, and toxic
neuritis

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 Diagnosis
1. Acute diarrhoea often with blood and mucous

2. Crampy abdominal pain and systemic toxicity

3. White blood cells in stool; organism isolated on stool culture

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 Differential Diagnosis

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 Treatment
• General principles of treatment include:

1. Fluid therapy

2. Correction of electrolyte imbalance

3. Supportive treatment for fever

4. Antibiotic therapy

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 Treatment
• generally is a self-limited diarrhoeal
illness  lasts 5 to 7 days and may
not require antibiotics in individuals
who are otherwise healthy.

• Antibiotic treatment 
recommended for infants or older
patients, malnourished children,
patients infected with HIV, food
handlers, health care workers and
children in day care centres
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