Quantitative histology as a diagnostic tool for celiac disease in children and adolescents.

OBJECTIVE: To measure the villous height, the crypt depth, and the number of intraepithelial lymphocytes/100 enterocytes of the small intestinal mucosa of children and adolescents with celiac disease; and to classify these findings according to Q- Marsh and Q-histology scales. METHODS: Retrospective study of a database from the Department of Pathology of biopsies from the second portion of the duodenum of pediatric patients. According to the histological report, three groups were established: celiac disease at diagnosis (n = 50), controls (n = 26), giardiasis (n = 10). In each biopsy, software (cellSens and Image J) evaluated 5 villous heights, 5 crypt depth and the number of intraepithelial lymphocytes/100 enterocytes. RESULTS: The celiac group had the lowest mean villous height (197.83 µm) of all three groups (control = 477.70 µm; giardiasis = 397.04 µm. The celiac group's villous:crypt ratio (0.78) was significantly lower than the control group (1.89). The number of intraepithelial lymphocytes ≥25 was exclusive to the celiac group, with a sensitivity and specificity of 100 %. Only celiac patients were included in types 2 and 3 of the Q-histology classification. CONCLUSION: Celiac disease patients showed shorter villous height than other groups, and the number of intraepithelial lymphocytes ≥25 was the best parameter to differentiate celiac from controls and giardiasis groups. Intraepithelial lymphocytes ≥25/100 enterocytes associated with any degree of villous atrophy, the classic Marsh 3 type, set the histological parameters of celiac disease. Quantitative histology is a valuable tool for diagnosing celiac disease, enabling histological changes in a short time, and the Q-histology scale appears to be more suitable than the Q-Marsh scale.

Giardia lamblia and Helicobacter pylori coinfection in gastrointestinal biopsies: A retrospective single-center analysis from Switzerland.

BACKGROUND: The protozoan Giardia lamblia (GL) and the bacterium Helicobacter pylori (HP) are common causes of gastrointestinal disease. Coinfection is common and has been reported in studies from Africa, Europe, North America and Asia, but data for Switzerland are scarce. AIM: To investigate GL and HP prevalence and coinfection rate in gastrointestinal biopsies from the Zurich area of Switzerland. METHODS: Cases were retrieved from the laboratory information system (Medica Institute of Clinical Pathology, Zurich, Switzerland). Histological slides of cases with GL were reviewed, as were the concurrent gastric biopsies, where available. RESULTS: Between January 1, 2013 and December 31, 2020, GL was found in 88 (0.14%) of 62,402 patients with a small intestine biopsy and HP in 10,668 (15.5%) of 68,961 patients with a gastric biopsy. 74/88 (84.1%) of patients with GL had unremarkable small intestine biopsies, 13/88 (14.8%) had increased intraepithelial lymphocytes, 5/88 (5.7%) showed villous atrophy and 2/88 (2.3%) acute inflammation. 71/88 patients (80.7%) with GL had an available gastric biopsy, of which 12/71 (16.9%) were unremarkable, 28/71 (39.4%) had HP-associated gastritis, 11/71 (15.5%) showed reactive gastropathy and 1/71 (1.4%) had autoimmune gastritis. CONCLUSION: Coinfection with HP is common in patients with GL in gastrointestinal biopsies from the Zurich area of Switzerland. Therefore, gastroenterologists should consider sampling the stomach when GL is suspected for evaluation of possible concurrent HP-associated gastritis. Likewise, pathologists should scrutinize any small intestine biopsy for the presence of GL when HP-associated gastritis is seen, and vice versa.

Giardia Is Often Overlooked on Histopathologic Examination: A High-Volume, Single-Institution Experience.

AIMS. GIARDIA: is sometimes missed by the pathologist, and we sought to determine how often this occurs at our institution-a large tertiary care center with a subspecialty gastrointestinal pathology service and what certain clinical and histologic clues can be used to flag cases with a higher likelihood of infection, targeting them for greater scrutiny. METHODS AND RESULTS: We identified a set of patients who tested positive for Giardia with a stool-based test, and who also received a small bowel biopsy at a similar time-point. These biopsies were retrospectively reviewed for Giardia, finding 8 positive cases. The organism was prospectively detected in 4 cases (50%) but overlooked in the remaining 4 cases (50%). Three of the 4 cases missed cases showed only rare organisms. The detected cases tended to more frequently have prominent lymphoid aggregates (3 detected cases, 0 overlooked cases) and intraepithelial lymphocytosis (3 detected cases, 0 overlooked cases). Certain clinical and histologic clues can be used to flag cases with a higher likelihood of infection. Specifically, we found abnormalities of the mucosa (active inflammation, intraepithelial lymphocytosis, villous expansion, prominent lymphoid aggregates) in each case, and 4 of 8 cases were from immunocompromised patients. Finally, 2 of 8 cases were terminal ileum biopsies. CONCLUSIONS: Biopsies with a histologic abnormality or those from immunocompromised patients should receive greater attention. Routinely looking for Giardia at that terminal ileum is necessary.

Pathogenesis and post-infectious complications in giardiasis.

Giardia is an important cause of diarrhoea, and results in post-infectious and extra-intestinal complications. This chapter presents a state-of-the art of our understanding of how this parasite may cause such abnormalities, which appear to develop at least in part in Assemblage-dependent manner. Findings from prospective longitudinal cohort studies indicate that Giardia is one of the four most prevalent enteropathogens in early life, and represents a risk factor for stunting at 2 years of age. This may occur independently of diarrheal disease, in strong support of the pathophysiological significance of the intestinal abnormalities induced by this parasite. These include epithelial malabsorption and maldigestion, increased transit, mucus depletion, and disruptions of the commensal microbiota. Giardia increases epithelial permeability and facilitates the invasion of gut bacteria. Loss of intestinal barrier function is at the core of the acute and post-infectious complications associated with this infection. Recent findings demonstrate that the majority of the pathophysiological responses triggered by this parasite can be recapitulated by the effects of its membrane-bound and secreted cysteine proteases.

Report of Giardia assemblages and giardiasis in residents of Guilan province-Iran.

Giardia duodenalis is considered a highly diverse organism that infects a variety of mammalian hosts. Giardiasis is a significant public health problem in Iran. The purpose of this study was to investigate the occurrence of Giardia duodenalis (G. lamblia, G. intestinalis) infections in humans residing in the Guilan province of Iran. Stool samples were collected during 12 months from 8356 individuals that had been referred to certain hospitals in the capital city of Rasht in the Guilan province, of which 4126 were males and 4230 were females. The samples were separated into three groups according to patient age: group A 1-9 years old (n = 483); group B 10-19 years old (n = 491); and group C greater than 20 years old (n = 7382). The wet mount technique was performed directly on 8356 fecal samples for microscopy. Samples were examined using a saline and iodine direct smear technique in order to confirm the presence of G. duodenalis. The results indicated that 2.5% (206/8356) of the samples were identified as positive for G. duodenalis. A total of 30% of the infected patients (n = 62) had no symptoms. In symptomatic cases, the most common symptoms (46%, n = 95) were abdominal cramps and bloating. Twenty-four percent of patients (n = 50) had cramps, bloating, nausea, and diarrhea. Sixty positive samples were sent for G. duodenalis genotyping based on the amplification of the gdh gene. Forty-one PCR products were successfully selected and sequenced, where 38 (92.6%) samples were identified as genotype A/subgenotype II and in three samples (7.4%) genotype B/subgenotype IV. Genotype A-II had a dominant prevalence as compared to the genotype B-IV samples that were identified in the study. Based on the samples provided by the regional teaching hospitals and subsequent sample analysis, the authors concluded that assemblage A-II is most likely the most common Giardia subgroup infection in the Guilan region. Assemblages have been reported in both humans and animals; however, further studies need to investigate the role of domestic animals and water reservoirs as potential sources of Giardia infection in the Guilan region.

Epidemiological distribution of genotypes of Giardia duodenalis in humans in Spain.

BACKGROUND: Although the distribution of Giardia duodenalis genotypes in humans has been increasingly reported in recent years, data on possible differences in pathogen transmission between age groups and virulence between genotypes are scarce. The purpose of this study is to investigate the genetic diversity of G. duodenalis in humans in Spain and compare the distribution of G. duodenalis assemblages A and B between children and adults and clinical presentations between the two genotypes. METHODS: In the present study, 125 microscopy-positive fecal samples were collected from humans in Spain over a 7-year period. PCR and sequence analyses of the triosephosphate isomerase, ß-giardin and glutamate dehydrogenase genes were used to identify the multilocus genotypes of G. duodenalis. RESULTS: Sequence analysis of three genetic loci identified both G. duodenalis assemblages A (29) and B (66), with co-infections of the two in two patients. Among the sequences obtained in this study, four multilocus genotypes (MLGs) of the sub-assemblage AII were observed within assemblage A. In contrast, 19 MLGs were detected within assemblage B due to the high sequence diversity at each locus. One MLG, however, was found in 51.9% (27/52) of assemblage B samples. Children were more commonly infected by assemblage B (44/53 or 83%) than adults (22/42 or 52.4%; χ2 = 10.371, df = 1, P = 0.001). Asymptomatic infection was more common in patients with assemblage A (4/29 or 13.8%) than in those with assemblage B (1/66 or 1.5%; χ2 = 6.091, df = 1, P = 0.029), and the frequency of abdominal pain occurrence was higher in assemblage B patients (65/66 or 98.5%) than assemblage A patients (25/29 or 86.2%; χ2 = 6.091, df = 1, P = 0.029). CONCLUSIONS: These results illustrate the existence of differences in genotype distribution between children and adults and clinical presentations between G. duodenalis genotypes. They are useful in understanding the transmission of G. duodenalis in humans in Spain.

Gastrointestinal disorders in Down syndrome.

Down syndrome is the most common human chromosomal disorder. Among clinical findings, one constant concern is the high prevalence of gastrointestinal system alterations. The aim of this study was to determine the prevalence of gastrointestinal disorders at a Down syndrome outpatient clinic during a 10-year follow-up period. Data from medical files were retrospectively reviewed from 1,207 patients. Gastrointestinal changes occurred in 612 (50.7%). The most prevalent disorder was chronic intestinal constipation. Intestinal parasite occurred in 22% (mainly giardiasis), gastroesophageal reflux disease in 14%, digestive tract malformations occurred in 5%: 13 cases of duodenal atresia, 8 of imperforate anus, 4 annular pancreases, 2 congenital megacolon, 2 esophageal atresias, 2 esophageal compression by anomalous subclavian and 1 case of duodenal membrane. We had 38/1,207 (3.1%) patients with difficulty in sucking and only three with dysphagia that resolved before the second year of life. Peptic ulcer disease, celiac disease, and biliary lithiasis were less prevalent with 3% each. Awareness of the high prevalence of gastrointestinal disorders promotes outstanding clinical follow-up as well as adequate development and greater quality of life for patients with Down syndrome and their families.

Etiology and severity of diarrheal diseases in infants at the semiarid region of Brazil: A case-control study.

BACKGROUND: Diarrheal diseases are an important cause of morbidity and mortality among children in developing countries. We aimed to study the etiology and severity of diarrhea in children living in the low-income semiarid region of Brazil. METHODOLOGY: This is a cross-sectional, age-matched case-control study of diarrhea in children aged 2-36 months from six cities in Brazil's semiarid region. Clinical, epidemiological, and anthropometric data were matched with fecal samples collected for the identification of enteropathogens. RESULTS: We enrolled 1,200 children, 596 cases and 604 controls. By univariate analysis, eight enteropathogens were associated with diarrhea: Norovirus GII (OR 5.08, 95% CI 2.10, 12.30), Adenovirus (OR 3.79, 95% CI 1.41, 10.23), typical enteropathogenic Escherichia coli (tEPEC), (OR 3.28, 95% CI 1.39, 7.73), enterotoxigenic E. coli (ETEC LT and ST producing toxins), (OR 2.58, 95% CI 0.99, 6.69), rotavirus (OR 1.91, 95% CI 1.20, 3.02), shiga toxin-producing E. coli (STEC; OR 1.77, 95% CI 1.16, 2.69), enteroaggregative E. coli (EAEC), (OR 1.45, 95% CI 1.16, 1.83) and Giardia spp. (OR 1.39, 95% CI 1.05, 1.84). By logistic regression of all enteropathogens, the best predictors of diarrhea were norovirus, adenovirus, rotavirus, STEC, Giardia spp. and EAEC. A high diarrhea severity score was associated with EAEC. CONCLUSIONS: Six enteropathogens: Norovirus, Adenovirus, Rotavirus, STEC, Giardia spp., and EAEC were associated with diarrhea in children from Brazil's semiarid region. EAEC was associated with increased diarrhea severity.

Prophylactic Potential of Synbiotic (Lactobacillus casei and Inulin) in Malnourished Murine Giardiasis: an Immunological and Ultrastructural Study.

Giardiasis is a re-emerging infectious disease with outbreaks reported globally specially in children and malnourished individuals leading to malabsorption, growth retardation, and severe diarrhea. Thus, in the present study, prophylactic administration of synbiotic as the functional food was used to assess its antigiardial potential in malnourished murine giardiasis. Interestingly, prior administration of synbiotic (Lactobacillus casei + inulin) even to malnourished-Giardia-infected mice led to increased body mass, small intestine mass, lactobacilli counts, and reduced severity of giardiasis as evident by decreased cyst and trophozoite counts. Synbiotic therapy further boosted the innate and acquired immune response resulting into increase in nitric oxide, antigiardial secretory IgA and IgG antibody levels along with IL-6 and IL-10 cytokines, and decreased levels of inflammatory TNF-α cytokine in both serum and intestinal fluid in malnourished-synbiotic-Giardia-infected mice compared with malnourished-Giardia-infected mice. More specifically, histopathological and scanning electron microscopy analysis of the small intestine also confirmed the modulatory potentials of synbiotic in malnourished-synbiotic-Giardia mice which had less cellular and mucosal damage compared with severely damaged, mummified, and blunted villi in malnourished-Giardia-infected mice. Taken together, this is the first experimental study to report that prior supplementation of synbiotic restored the gut morphology and improved the immune status of the malnourished-Giardia-infected mice, and could be considered as the prophylactic adjunct therapy for malnourished individuals.

Lactoferrin and lactoferricin endocytosis halt Giardia cell growth and prevent infective cyst production.

Lactoferrin (LF) is an 80 KDa iron-binding glycoprotein that plays a significant role in the innate immune system and is considered to be an important microbicide molecule. It has been suggested to be effective in the treatment of giardiasis, an intestinal disease caused by the protozoan parasite G. lamblia. However, the molecular mechanisms by which LF exerts its effect on this parasite are unknown. Most of the microbicidal activity of human or bovine LF (hLF or bLF) has been associated with the N-terminal region of the mature LF - lactoferricin (LFcin). LFcin is produced by pepsin cleavage of the native protein in vitro and likely in vivo. In this work, we analyse the participation of the endocytic machinery of G. lamblia in the internalization of bLF and bLFcin and their effects on cell homeostasis. Our results show that, when bLF or bLFcin are internalized by receptor-mediated endocytosis, cell growth stops, and morphological changes are produced in the trophozoites, which ultimately will produce immature cysts. Our findings contribute to disclose the fine mechanism by which bLF and bLFcin may function as an antigiardial molecule and why they have therapeutic potential to eradicate giardiasis.

The course of experimental giardiasis in Mongolian gerbil.

Fifteen Mongolian gerbils were inoculated with 10 × 106 viable trophozoites of Giardia intestinalis. Their faeces were examined daily by flotation method and the number of shed cysts was counted. Two animals (male and female) were euthanised at 4- to 5-day intervals (9, 14, 18 days post-infection (DPI)). The remaining nine gerbils were sacrificed and dissected at the end of the experiment (23 DPI). Their small intestinal tissues were processed for examination using histological sectioning and scanning electron microscopy and their complete blood count (CBC) was examined. The highest number of trophozoites at the total was observed in the duodenum in gerbils sacrificed on 14 DPI. Number of shed cysts was positively correlated with number of trophozoites rinsed from the intestine. Infected gerbils had lower body weight gain in comparison with control group and in three male gerbils; diarrhoea occurred during infection. Cyst shedding was negatively correlated with values of mean corpuscular haemoglobin concentration. Females showed another pattern in cyst shedding than males. This information needs to be taken into account while planning the experiments.

Assemblages A and B of Giardia duodenalis reduce enteric glial cells in the small intestine in mice.

Infection of Giardia duodenalis is one of the most common human parasitic disease worldwide. This infection may be related to important changes in the enteric nervous system. The objective of this study was to evaluate the myenteric and submucosal plexuses, the intestinal muscle layer, and gastrointestinal transit in mice infected with assemblages A and B of G. duodenalis. Swiss albino mice (Mus musculus) were infected with assemblages A and B of G. duodenalis for 15 days. Gastrointestinal transit time was evaluated before euthanasia. Duodenum and jejunum were removed for histological and immunohistochemical analyses. It was observed a reduction in the enteric glial cell count and a decrease in the ratio of enteric glial cells to neurons. The number of neurons did not change, but morphological changes were observed in the duodenum and jejunum in both plexuses, including an increase in the nuclear area and a reduction of cell bodies in the myenteric plexus and a decrease in the nuclear area in the submucosal plexus. A reduction of the thickness of the muscle layer was observed in the duodenum, with no significant differences in the gastrointestinal transit times. Assemblages A and B of G. duodenalis decrease the number of enteric glial cells in the myenteric and submucosal plexuses, decrease the thickness of the muscle layer, and change the morphology of neurons. Graphical abstract ᅟ.

Modulation of human dendritic cell activity by Giardia and helminth antigens.

Giardia duodenalis is a common intestinal protozoan parasite known to modulate host immune responses, including dendritic cell (DC) function. Coinfections of intestinal pathogens are common, and thus, DCs may be concurrently exposed to antigens from multiple parasites. Here, we investigated the effects of G. duodenalis products on human monocyte-derived DC function independently and in combination with helminth antigens (Ascaris suum and Trichuris suis). All antigens individually induced an anti-inflammatory phenotype in DCs, reducing lipopolysaccharide (LPS)-induced interleukin (IL)-6, IL-12p70 and tumour necrosis factor (TNF)-α secretion. G. duodenalis and T. suis products also consistently upregulated IL-10 production. Despite a similar modulation of cytokine secretion, additive effects between Giardia and helminth products were not observed, indicating a dominant effect of a single parasite stimulus and limited interactive effects on DC function. G. duodenalis trophozoites induced rapid apoptosis in DCs, which was not observed with the helminth antigens suggesting that the modulatory effects of G. duodenalis may override that of A. suum and T. suis. Thus, G. duodenalis modulates DC activity by modulating cytokine secretion and/or inducing apoptosis, which may be a parasite-driven mechanism to dampen host immunity and establish chronic infections. The differential mechanisms of DC modulation by intestinal parasites warrant further attention.

Comparative study of effects of assemblages AII and BIV of Giardia duodenalis on mucosa and microbiota of the small intestine in mice.

AIMS: Giardiasis is one of the major causes of diarrhea worldwide and its symptoms vary in intensity, which can be attributed to different parasite assemblages. The goal of the present study was to compare the effects of infection caused by assemblages AII and BIV ofGiardia duodenalis on the response of the small intestine, microbiota, and behavioral parameters in mice. MAIN METHODS: Swiss mice were infected with assemblages AII and BIV of G. duodenalis for 15 days. Leucometry, pain, intestinal microbiota and histological parameters of the duodenum and jejunum were evaluated in the experimental groups. KEY FINDINGS: Both assemblages modified the composition of the intestinal microbiota. Infection with assemblage AII promoted leukocytosis, reflected by increasing number of polymorphonuclear cells, intraepithelial lymphocytes and pain-related behavior, indicating that this was the more aggressive assemblage with regard to its effects on the intestinal mucosa and duodenum. SIGNIFICANCE: The specific assemblage of the parasite is an important parameter that affects symptomatology in the host.

The Intersection of Immune Responses, Microbiota, and Pathogenesis in Giardiasis.

Giardia lamblia is one of the most common infectious protozoans in the world. Giardia rarely causes severe life-threatening diarrhea, and may even have a slight protective effect in this regard, but it is a major contributor to malnutrition and growth faltering in children in the developing world. Giardia infection also appears to be a significant risk factor for postinfectious irritable bowel and chronic fatigue syndromes. In this review we highlight recent work focused on the impact of giardiasis and the mechanisms that contribute to the various outcomes of this infection, including changes in the composition of the microbiota, activation of immune responses, and immunopathology.

Interleukin-17 receptor A (IL-17RA) as a central regulator of the protective immune response against Giardia.

The protozoan parasite Giardia is a highly prevalent intestinal pathogen with a wide host range. Data obtained in mice, cattle and humans revealed the importance of IL-17A in the development of a protective immune response against Giardia. The aim of this study was to further unravel the protective effector mechanisms triggered by IL-17A following G. muris infection in mice, by an RNA-sequencing approach. C57BL/6 WT and C57BL/6 IL-17RA KO mice were orally infected with G. muris cysts. Three weeks post infection, intestinal tissue samples were collected for RNA-sequencing, with samples from uninfected C57BL/6 WT and C57BL/6 IL-17RA KO animals serving as negative controls. Differential expression analysis showed that G. muris infection evoked the transcriptional upregulation of a wide array of genes, mainly in animals with competent IL-17RA signaling. IL-17RA signaling induced the production of various antimicrobial peptides, such as angiogenin 4 and α- and ß-defensins and regulated complement activation through mannose-binding lectin 2. The expression of the receptor that regulates the secretion of IgA into the intestinal lumen, the polymeric immunoglobulin receptor, was also dependent on IL-17RA signaling. Interestingly, the transcriptome data showed for the first time the involvement of the circadian clock in the host response following Giardia infection.

Prevalence and Predictors of Giardia in the United States.

BACKGROUND: Infection with Giardia lamblia is a common cause of diarrheal disease in the developing and industrialized world. AIMS: We aimed to assess the prevalence of giardiasis in the United States (US) among patients with duodenal biopsies, investigating demographic and clinical factors associated with this condition. METHODS: We conducted a cross-sectional study of patients with duodenal biopsies submitted to a national pathology laboratory between January 2, 2008, and December 31, 2015. The prevalence of giardiasis was calculated and categorized by the following patient sociodemographic and clinical data: age, sex, ethnicity, endoscopy indication, season, year, urban-rural setting, region, and presence of H. pylori and atrophic gastritis. RESULTS: Among all patients (n = 432,813), the mean age was 52.2 years. The prevalence of giardiasis was 0.11%. Patients with giardiasis were more likely to be male (57.8 vs. 34.1%, p < 0.0001). Among patients who had a gastric biopsy (n = 363,788), those with giardiasis were more likely to be colonized with H. pylori (25.7 vs. 9.4%, p < 0.0001). There was no statistically significant association with age, endoscopy indication, urban-rural setting, ethnicity, season, or the presence of atrophic gastritis. On multivariate analysis, male sex, Southern region, and the presence of H. pylori were independently associated with giardiasis. CONCLUSIONS: To our knowledge, this is the largest study to date to assess predictors of giardiasis in the US. We found that male sex, being colonized with H. pylori, and residing in the Southern US are independently associated with giardiasis infection.

IMPACT OF IMMUNE SUPPRESSION ON HISTOPATHOLOGICAL AND IMMUNOLOGICAL PARAMETERS OF MICE EXPERIMENTALLY INFECTED WITH GIARDIA LAMBLIA.

Giardiasis is one of the most frequent entero-parasites worldwide; its prevalence is more common in developing countries. Giardia lamblia is considered one of the opportunistic parasites and aits clinical manifestations represent the expression of host resistance and parasite viri lence. As of chronic giardiasis cases were expected to worsen in immunosuppressed patients with development of various complications. This work assessed the histolopathological and the possible immunological effects of infection with G. lamblia in an immunosuppressed experimental animal model in comparison to immunocompetent one. Mice were divided into 4 groups;. group I: simmunocompetent (IC) mice infected with G. lamblia cysts, group II: immunosup pressed (S) mice infected with cysts, group III: uninfected immunocompetent mice and group. IV: uninfected immunosuppressed mice. From each group, small intestine was. removed for histopathological and molecular studies. Also, cyst counting in the stool of infected mice was estimated. We found that the number of G. lamblia cysts in the stool of IS mice was significantly higher than that from IC ones. Shortening of the villi was more pronounced in the IS than in IC group. Furthermore, intraepithelial lymphocytic count, goblet cell count and mast cell count were significantly decreased in the IS infected group as compared to IC ones. Expression of interleukin.6 mRNA showed high expression in IC infected mice while it was weak in IS mice. In conclusicn, the present study revealed the importance of the innate immunity presented by goblet cells, mast cells and other adaptive immunity responses; in the clearance of Giardia.