Giardia lamblia (synonymous with Lamblia intestinalis and Giardia duodenalis) is a flagellated protozoan parasite that colonises and reproduces in the small intestine, causing giardiasis. The giardia parasite attaches to the epithelium by a ventral adhesive disc, and reproduces via binary fission. Giardiasis does not spread via the bloodstream, nor does it spread to other parts of the gastro-intestinal tract, but remains confined to the lumen of the small intestine. Giardia trophozoites absorb their nutrients from the lumen of the small intestine, and are anaerobes. If the organism is split and stained, it has a very characteristic pattern that resembles a smiley face.
As well as waterborne sources, fecal-oral transmission can also occur, for example in day care centres, where children may have poor hygiene practices. Those who work with children are also at risk of being infected, as are family members of infected individuals. Not all Giardia infections are symptomatic, and many people can unknowingly serve as carriers of the parasite.
The life cycle begins with a noninfective cyst being excreted with the faeces of an infected individual. The cyst is hardy, providing protection from various degrees of heat and cold, desiccation, and infection from other organisms. A distinguishing characteristic of the cyst is four nuclei and a retracted cytoplasm. Once ingested by a host, the trophozoite emerges to an active state of feeding and motility. After the feeding stage, the trophozoite undergoes asexual replication through longitudinal binary fission. The resulting trophozoites and cysts then pass through the digestive system in the faeces. While the trophozoites may be found in the faeces, only the cysts are capable of surviving outside of the host.
Distinguishing features of the trophozoites are large karyosomes and lack of peripheral chromatin, giving the two nuclei a halo appearance. Cysts are distinguished by a retracted cytoplasm. This protozoan lacks mitochondria, although the discovery of the presence of mitochodrial remnants organelles in one recent study "indicate that Giardia is not primitively amitochondrial and that it has retained a functional organelle derived from the original mitochondrial endosymbiont
Colonization of the gut results in inflammation and villous atrophy, reducing the gut's absorptive capability. In humans, infection is symptomatic only about 50% of the time, and protocol for treating asymptomatic individuals is controversial. Symptoms of infection include (in order of frequency) diarrhea, malaise, excessive gas (often flatulence or a foul or sulphuric-tasting belch, which has been known to be so nauseating in taste that it can cause the infected person to vomit), steatorrhoea (pale, foul smelling, greasy stools), epigastric pain, bloating, nausea, diminished interest in food, possible (but rare) vomiting which is often violent, and weight loss. Pus, mucus and blood are not commonly present in the stool. It usually causes "explosive diarrhea" and while unpleasant, is not fatal. In healthy individuals, the condition is usually self-limiting, although the infection can be prolonged in patients who are immunocompromised, or who have decreased gastric acid secretion.
People with recurring Giardia infections, particularly those with a lack of IgA, may develop chronic disease.
Lactase deficiency may develop in an infection with Giardia, however this usually does not persist for more than a few weeks, and a full recovery is the norm.
Some studies have shown that giardiasis should be considered as a cause of Vitamin B12 deficiency, this a result of the problems caused within the intestinal absorption system.
Treatment of drinking water for Giardia is ordinarily indicated in wilderness regions in North America, , although at least four researchers disagree with this statement, including Robert W. Derlet, a professor at the University of California-Davis School of Medicine, Timothy P. Welch and Thomas R. Welsh of Tulane Medical School and the Children's Hospital of Cincinnati respectively, and Robert Rockwell, a widely quoted writer who is an engineer by training.
In other areas frequented by hikers and campers, as well as places where many residents rely on untreated surface water, reliable prevention typically involves filtration with a filter that has a nominal 1-micrometer pore size. Most chemical treatment methods, including common point-of-use treatments such as iodine and chlorine dioxide, are considered unreliable in inactivating Giardia cysts. Water parameters such as temperature, turbidity, and dissolved solids may also affect the effectiveness of such treatments.
Giardia lamblia infection in humans is frequently misdiagnosed. Accurate diagnosis requires an antigen test or, if that is unavailable, an ova and parasite examination of stool. Multiple stool examinations are recommended, since the cysts and trophozoites are not shed consistently. Given the difficult nature of testing to find the infection, including many false negatives, some patients should be treated on the basis of empirical evidence; treating based on symptoms.
Human infection is conventionally treated with metronidazole, tinidazole or nitazoxanide. Although Metronidazole is the current first-line therapy, it is mutagenic in bacteria and carcinogenic in mice, so should be avoided during pregnancy. One of the most common alternative treatments is berberine sulfate (found in Oregon grape root, goldenseal, yellowroot, and various other plants). Berberine has been shown to have an antimicrobial and an antipyretic effect. Berberine compounds cause uterine stimulation, and so should be avoided in pregnancy. High doses of berberine can cause bradycardia and hypotension.
|Drug||Treatment duration||Possible Side Effects|
|Metronidazole||5-7 days||Metallic taste; nausea; vomiting; dizziness; headache; disulfiram-like effect; neutropenia|
|Tinidazole||Single dose||Metallic taste; nausea; vomiting; belching; dizziness; headache; disulfiram-like effect|
|Nitazoxanide||3 days||Abdominal pain; diarrhea; vomiting; headache; yellow-green discolouration of urine|
Table adapted from Huang, White..
Under a normal compound light microscope, Giardia often looks like a "clown face," with two nuclei outlined by adhesive discs above dark median bodies that form the "mouth." Cysts are oval, have four nuclei, and have clearly visible axostyles. In spite of the common belief that all Eukaryotes have mitochondria, Giardia is one of the few that lack these organelles.
In 1998, a highly publicised Giardia and Cryptosporidium outbreak was reported in Sydney, Australia, but it was found to be due to mis-measurement of the concentrations of microbes in the water supply. A 2004 outbreak in Bergen (Norway) hastened work on adding UV treatment to the water facilities. In October 2007, Giardia was found in the water supply for parts of Oslo, prompting authorities to advise the public to boil drinking water; but subsequent test showed levels of contamination too low to pose a threat, so this advice has since been cancelled In 2008, Giardia was identified as one of the causes of the dysentery afflicting Crusaders in Palestine in the 12th and 13th centuries.