Showing posts with label diarrhoea. Show all posts
Showing posts with label diarrhoea. Show all posts

Friday, November 22, 2013

Do IBS Patients Lack Blastocystis and Dientamoeba??

I feel like sharing data from a poster created by one of my colleagues, Dr Laura Rindom Krogsgaard who works at Køge Sygehus, Denmark. She presented the poster last month at the United European Gastrointestinal (UEG) Week in Berlin.

Laura is currently doing a very interesting survey on IBS and IBS-like symptoms in Danish individuals. Her first publication was on the epidemiology of IBS in Denmark (see literature list below). She performed a web-based survey, using YouGov Zapera, and questionnaires were emailed to a web panel (n = 19,567) representative of the general Danish population aged 18-50 years containing info on gender, age, geography and type of intestinal symptoms (if any). IBS and subtypes were estimated by the Rome III criteria. Of 6,112 responders, 979 (16%) fulfilled the Rome III criteria for IBS and had no organic diagnosis likely to explain their symptoms. IBS subtypes detected included  mixed IBS (36%), IBS with diarrhea (33%), IBS with constipation (18%), and unsubtyped IBS (11%).

At the Laboratory of Parasitology, we helped Laura analyse stool samples from survey participants for parasites. Not surprisingly, Blastocystis and Dientamoeba were by far the most common parasites detected; however, it appeared that individuals with IBS symptoms were less likely to be colonised by these parasites than their controls! Which means that we have a situation reminiscent of that seen in IBD patients, only less pronounced. 

Laura was able to survey symptom developement over 1 year and compare this to the incidence of Blastocystis and Dientamoeba, and none of the parasites (indvidually or in co-infection) were linked to symptom development.

Indeed, Laura's data are in line with the general tendency that we see for Blastocystis (see figure below). Blastocystis appears to be rare in individuals with perturbation of the intestinal microbiota (due to antibiotic treatment, inflammation, infection, diet, etc.), while common in healthy individuals, most of whom are probably characterised by high gut microbial diversity and thereby - apparently - the right substrate/growth conditions for Blastocystis.


Krogsgaard LR, Engsbro AL, & Bytzer P (2013). The epidemiology of irritable bowel syndrome in Denmark. A population-based survey in adults ≤50 years of age. Scandinavian Journal of Gastroenterology, 48 (5), 523-9 PMID: 23506174

The entire poster "Dientamoeba fragilis and Blastocystis: Two parasites the irritable bowel might be missing" presented at the UEGweek can be viewed here via SlideShare.

Friday, August 30, 2013

This Month In Blastocystis Research (AUG 2013)

Quite a few papers relevant to Blastocystis research have made it to PubMed over the past month! Therefore, the August version of 'This Month in Blastocystis Research' is more like a list of papers + short descriptions/comments, rather than one or two actual paper reviews.

Dr Aldert Bart and his Dutch colleagues have published a study that confirms data emerging from other parts of Europe. Using microscopy (fixed faecal smears) and PCR, they found an almost 40% prevalence of Blastocystis in returning travelers with symptoms, and a prevalence of 18% in patients referred for other reasons. The distribution of subtypes found in the study population was quite similar to what has been found elsewhere in Europe with ST3 predominating (42%) and the rest of the subtypes attributable to ST1 (22%), ST2 (22%), ST4 (12%), ST6 (1%) and ST7 (1%).

The Tropical Parasitology theme issue on Blastocystis has now gone live. You’ll find a link to the editorial and the three papers included in the symposium here.

In my previous post I referred to a new study from Colombia which includes subtyping of Blastocystis isolates from humans, and a variety of animals, including birds. The paper is interesting for a number of reasons, but first and foremost it confirms the virtual absence of ST4 in humans in S America. Moreover, the study included 70 Blastocystis positive samples from asymptomatic carriers, 40 positive samples from patients with diarrhoea, and 15 positive samples form patients with IBS. Remarkably, all samples from healthy carriers were typed as ST1, those from patients with diarrhoea belonged to ST2, and those from IBS patients to ST3. Such a clear-cut distribution of subtypes across cohorts is unprecedented and of course warrants confirmation and further investigation. In Europe, ST4 is very common in humans, while it appears rare in humans in many other parts of the world. ST4 also appears rare among non-human primates (NHPs), our closest living relatives, and while NPHs and humans otherwise tend to share the same major subtypes (ST1, ST2, and ST3), this suggests that while subtypes 1, 2 and 3 have probably co-evolved with primates, ST4 has only recently entered the primate population with a preference for humans! I have hinted at this many times by now, but I find it extremely interesting which is why I keep repeating it.

There is a paper out by Santos and Rivera from the Philippines comparing microscopy of direct faecal smear with culture and PCR for detection of Blastocystis. They ended up concluding that culture was the best diagnostic modality, but it should be noted that the PCR used in the study targets a 1.8 kbp product (complete SSU rRNA gene!), and much smaller products are usually targeted in diagnostic PCR assays. The Blastocystis real-time PCR developed by me and my colleagues targets a sequence stretch of ~120 bp, securing optimum test sensitivity. The results of the Philippine study should be interpreted with this in mind.

Li et al., have published data on experimental infection of ST1 in Sprague-Dawley rats. Animals belonging to this species appeared susceptible to a ST1 strain isolated from a diarrhoeic patient that had been kept in culture and for which induction of cysts had been performed with a view to infecting the rats. The study confirms that Blastocystis is mainly a parasite of the coecum and colon. The authors found evidence of Blastocystis invasion into the lamina propria in one of the animals, and signs of inflammation in all animals challenged. While it is great to see that experimental models can be sustained and that encystation can be induced in vitro, at least two important factors must be kept in mind to fully comprehend the study: Although cysts were isolated by gradient centrifugation prior to inoculation, it is unlikely that all bacteria have been removed from cyst suspensions; in other words, the cyst preparation is not likely to be 'sterile', and any effect of the potentially accompanying bacterial flora is difficult to determine. Moreover, rats may not be natural hosts of ST1 (very few data available on the topic!), and so, the pathology caused in the rats may be an unlikely finding in humans, who are indeed natural hosts of ST1 and may have developed a high degree of tolerance to this subtype.

Are dogs, wolves, and other canids natural hosts of Blastocystis?

When visiting Australia earlier this month, I had the pleasure of meeting Wenqi Wang and Tawin Inpankaew, both PhD students working at School of Veterinary Science, The University of Queensland Gatton Campus and supervised by Dr Rebecca Traub. One of the foci of this group is to study Blastocystis in animals, for instance in households where animals are kept as pets. Recently, a paper emerged from this group on diversity of Blastocystis subtypes in dogs in different geographical settings, hence domestic/pound dogs from Brisbane, Australia, semi-domesticated dogs from a village in Cambodia, and stray dogs from Mumbai and other Indian cities. Using sensitive PCR methods they observed that almost one fourth of the Indian dogs were infected, while dogs in the Cambodian village and in Queensland remained largely uninfected. Coprophagy and access to Blastocystis-positive stool from different hosts may account for the relatively high prevalence in stray dogs in India, although one might assume that the prevalence would then be even much higher? The team used nested PCR in their study and found four different subtypes in the Indian dogs, including ST1, ST4, ST5 and ST6. Whether all of their data collectively indicate that dogs are not natural hosts of Blastocystis is a matter of debate and remains to be more thoroughly investigated. Indeed, prevalence and subtype data from studies of samples from wild life canids (dingos, jackals, wolves, coyotes, but also foxes and raccoon dogs) would shed further light on this topic.

Finally, for those interested in how Blastocystis deals with oxidative stress and related metabolic issues, there is a paper out on iron-sulphur cluster biogenesis in protozoan parasites by Ali and Nozaki citing works by Tsaousis (2012), Denoeud (2011), Long (2011), and Stechmann (2008).


Ali V, & Nozaki T (2013). Iron-sulphur clusters, their biosynthesis, and biological functions in protozoan parasites. Advances in Parasitology, 83, 1-92 PMID: 23876871

Bart A, Wentink-Bonnema EM, Gilis H, Verhaar N, Wassenaar CJ, van Vugt M, Goorhuis A, van Gool T. Diagnosis and subtype analysis of Blastocystis sp. in patients in a hospital setting in the Netherlands. BMC Infectious Diseases, 13:289.

Li J, Deng T, Li X, Cao G, Li X, & Yan Y (2013). A rat model to study Blastocytis subtype 1 infections. Parasitology Research PMID: 23892480 DOI: 10.1007/s00436-013-3536-7

Parija SC (2013). Blastocystis: Status of its pathogenicity. Tropical Parasitology, 3 (1) PMID: 23961433

Parija SC, & Jeremiah S (2013). Blastocystis: Taxonomy, biology and virulence. Tropical Parasitology, 3 (1), 17-25 PMID: 23961437 

Ramírez JD, Sánchez LV, Bautista DC, Corredor AF, Flórez AC, & Stensvold CR (2013). Blastocystis subtypes detected in humans and animals from Colombia. Infection, Genetics and Evolution : Journal of Molecular Epidemiology and Evolutionary Genetics in Infectious Diseases PMID: 23886615

Sekar U, & Shanthi M (2013). Blastocystis: Consensus of treatment and controversies. Tropical Parasitology, 3 (1), 35-9 PMID: 23961439

Stensvold CR (2013). Blastocystis: Genetic diversity and molecular methods for diagnosis and epidemiology. Tropical Parasitology, 3 (1), 26-34 PMID: 23961438  

Wang W, Cuttell L, Bielefeldt-Ohmann H, Inpankaew T, Owen H, & Traub RJ (2013). Diversity of Blastocystis subtypes in dogs in different geographical settings. Parasites & Vectors, 6 PMID: 23883734

Saturday, November 17, 2012

Amelioration of Colitis by Parasites - or "An Elliott & Weinstock Special"

Common parasites such as Blastocystis and Dientamoeba fragilis are often incriminated of causing chronic or intermittent diarrhoea or other intestinal symptoms despite the absence of compelling evidence. What most of us probably fail to realise is that parasites may actually prevent and ameliorate intestinal illness, including inflammatory bowel disease, other types of colitis, and other types of autoimmune diseases.

Inflammatory bowel disease (IBD) includes the two most common manifestations ulcerative colitis and Crohn’s Disease and affects more than 2 million people in North America and Europe. They are chronic inflammatory conditions of the gut that usually begin when people are in the second to third decade of life. Although the causes of these inflammatory diseases remain unknown, they are assumed to result from inappropriately aggressive mucosal (i.e. related to our intestinal lining) immune responses to elements or substances in our intestine. IBD is treated with immuno-suppresive drugs.

IBD has emerged primarily in the Western world along with a significant reduction in cases of intestinal helminthiasis due to clean food and water, improved hygiene and sanitation, and the development and use of antibiotics. In Denmark, helminthic infections due to previously common parasitic worms such as Ascaris (roundworm) are now at the point of being almost extinct in the indigenous population.

The hygiene hypothesis proposes that a causal link exists between the adoption of modern hygiene and the increase in the prevalence of immune dysfunctions. The extent of perinatal maturation of the immune system may play a crucial role in terms of our likelihood of developing allergic and autoimmune diseases later in life. The maturation process includes establishment of tolerance to food and harmless microorganisms, but also defence mechanisms against pathogens. If our environment is "too clean", we may fail to give our immune system the best possible opportunity to mature and differentiate appropriately. A robust immune response will protect us from recurrent infections, but if misdirected, it can cause disease.

Part of our immune system is the "adaptive immune system" -  or our "immunologic memory" - made up by cells such as lymphocytes (T- and B-cells), macrophages, dendritic cells, etc. plus antibodies and hormone-like substances (eg. cytokines) that are secreted to activate/inactivate or up- and down-regulate these cells. Our immune systems has to be able to recognise a plethora of foreign material such as bacteria, viruses and parasites, and to distinguish "self" from "non-self". IBD may be caused by mal-functions in our own immune system, and so may a lot of other diseases, diseases that we call "autoimmune diseases", and which include coeliac disease, multiple sclerosis, type 1 diabetes, and rheumatoid arthritis.

10,000 years ago, humans were infected by a variety of species of worms that are common in some parts of the world even today and hence humans and parasites have co-evolved over thousands of years. Importantly, most wild animals in their natural habitat are carriers of many types of parasites. A "clever" parasite does little harm to its host. Parasites have developed mechanisms that enable them to survive in their hosts, and also, the human immune system has developed a way to adapt to these common intruders.

Egg of Trichuris trichiura. Courtesy of Dr Marianne Lebbad.
How can one explain the amelioration of symptoms due to colitis by the presence of intestinal nematodes? Helminths appear to induce immune host regulatory cells that suppress inflammation, and helminth infections are strong inducers of immune regulatory circuits. The immune system changes in response to helminth colonisation and factors secreted by helminths that can influence immune cell function. It is likely that several immune-regulatory mechanisms are exploited by individual helminths. Otherwise, a helminth could not reliably evade our immune system to reproduce.

A new study has produced data that suggest that treatment of macaques suffering from chronic diarrhoea with eggs of the whipworm Trichuris suis can alleviate symptoms and modulate both the intestinal microbiota and immunoregulatory pathways. Trichuris suis is the whipworm of the pig, and contrary to Trichuris trichiura (image), T. suis appears not to be able to produce disease in primate hosts (including humans). When T. suis ova (TSO) are administered to humans, transient shedding of ova in faeces may be seen after a few weeks, but the individual remains asymptomatic.
Gene expression profiling of colonic biopsies from the macaques treated with TSO revealed up-regulation of genes typically involved in the so-called Th1-type immuno-response prior to TSO challenge, while induction of the Th2-type response followed after the TSO challenge; the Th2-type response resulted in mucosal repair, probably by increasing mucus production and turnover of epithelial cells, which again led to a reduction of bacterial attachment to the gut lining and a restoration of microbial diversity.

Briefly, a Th1-type response is generally a pro-inflammatory response that, among many other things, is responsible for microbicidal actions and perpetuating autoimmune responses. Excessive pro-inflammatory responses can lead to uncontrolled tissue damage, so there needs to be a mechanism to counteract this. The Th2­-type response includes the secretion of the anti-inflammatory cytokines, co-responsible for a general anti­-inflammatory response. In excess, Th2-type responses will counteract the Th1-mediated microbicidal action. The optimal scenario would therefore seem to be that humans should produce a well balanced Th1- and Th2-type response, suited to the immune challenge.
On top of the immunoregulatory impact, there is emerging evidence that helminths promote the growth and expansion of groups of bacteria that are beneficial or "probiotic" to the host. In the study of the macaques, the TSO induced a change in the intestinal microbiota.

While variation in160 genes in the human genome or more have been associated with increased risk of developing IBD, no specific gene variant that is sufficient or required for dysregulated mucosal inflammation as occurs in Crohn's disease or ulcerative colitis has been identified so far. There is a field of thought now saying that - over thousands of years - the human gut flora, including helminths, drove the development of variations in genes orchestrating various immune response pathways, and such genetic variations selected to operate under the influence of helminth infection could cause disease when operating without that influence.

So, the take home message here is that infestation by intestinal parasites may be a double-edged sword: While on one hand they may cause symptoms, they may on the other hand prevent us from developing inflammatory bowel disease and other autoimmune or allergic manifestations. Hence, helminths, although parasites, may contribute something in return to their hosts, and the loss of helminths removes a natural governor that helped to prevent disease due to immune regulation. Of course, more trials are needed before "helminth therapy" can actually be standardised, commercialised and used in the prophylaxis and treatment of IBD and gut allergic conditions. Once a good mechanistic understanding of how helminths alter immunity is available, it may even be possible to apply identified factors individually or in combination to treat disease.

As always, things are much more complex than presented here, but this post gives an impression of some of the fields of thought. Not all autoimmune diseases are driven by excessive Th1-type responses; some types of asthma may be driven by Th2-type response, but even here, helminths may favourably modulate immunoregulatory pathways.

Obviously, it would be interesting to explore how other parasitic infections impact on our immune system and gut flora. Interestingly, one helminth species appears to have "survived" in our "sterile" environment, - the pinworm (Enterobius)... and as pointed out in one of my recent blog posts (go here), many of us are definitely exposed to parasites that persist in our intestines for months, maybe years. What's their role in all of this?

Further reading:

Dirtying Up Our Diets - go here

Parasitic Worm Eggs Ease Intestinal Ills By Changing Gut Microbiota - go here.

Jostins L, et al. Host-microbe interactions have shaped the genetic architecture of inflammatory bowel disease. Nature, 491 (7422), 119-24 PMID: 23128233

Berger, A. (2000). Science commentary: Th1 and Th2 responses: what are they? BMJ, 321 (7258), 424-424 DOI: 10.1136/bmj.321.7258.424
Elliott, D., & Weinstock, J. (2012). Where are we on worms? Current Opinion in Gastroenterology, 28 (6), 551-556 DOI: 10.1097/MOG.0b013e3283572f73
Elliott, D., & Weinstock, J. (2012). Helminth-host immunological interactions: prevention and control of immune-mediated diseases Annals of the New York Academy of Sciences, 1247 (1), 83-96 DOI: 10.1111/j.1749-6632.2011.06292.x
Weinstock, J. (2012). Autoimmunity: The worm returns Nature, 491 (7423), 183-185 DOI: 10.1038/491183a

Elliott DE, Summers RW, & Weinstock JV (2007). Helminths as governors of immune-mediated inflammation. International journal for parasitology, 37 (5), 457-64 PMID: 17313951

Broadhurst, MJ., et al.Therapeutic helminth infection of macaques with idiopathic chronic diarrhoea alters the inflammatory signature and mucosal microbiota of the colon PLoS Pathogens (PLoS Pathog 8(11): e1003000. doi:10.1371/journal.ppat.1003000).

Friday, October 26, 2012

The "Flagyl" Poll

For some reason the "Flagyl" poll in the right side bar of this blog was reset; the number of votes was approaching 100. The question was

"For those who have received metronidazole (Flagyl or Protostat) treatment for Blastocystis, please indicate whether you experienced no, transient or permanent improvement (or none of the above)"

The interesting thing is that there was a tie between "no improvement" and "transient improvement", and although this poll could have been heavily biased in numerous ways, it is still completely in line with our experience: Many patients report transient alleviation of symptoms, while others have no clinical benefit from Flagyl. Flagyl is an antibiotic targeting a wide range of bacteria and single-celled parasites. It is sometimes successful in terms of eradicating Dientamoeba fragilis, one of the most common parasites in the human intestine, and a parasite which may cause symptoms especially in children (we are currently conducting a randomised control clinical trial at Statens Serum Institut to explore clinical and microbiological effect of metronidazole treatment of children with D. fragilis).

Many people will get diagnosed with Blastocystis without knowing whether they might also be positive for D. fragilis (and vice versa). It is a complex situation, since both parasites are common, they are difficult to detect unless you use PCR or other specialised analyses, and in most labs they are not tested for on a routine basis. And if they happen to be part of the panel of organisms that is tested for, it may be so that insensitive methods are used for their detection, which means that only a fraction of the cases will be detected. So, this is a bit of a conundrum in itself!

So, it's not easy to know what causes the temporary alleviation in some patients. Is it due to parasite recrudescence? Is it due to parasite eradication with subsequent re-infection? And which parasite? Blastocystis? Dientamoeba? Any others? Or, is it due to perturbation of the intestinal flora in a "positive" direction, which is then gradually going back to normal? Placebo effect? There are possibly many more explanations...

However, deep sequencing of faecal samples pre- and post treatment of parasite-positive patients will probably answer many of our questions...

Engsbro AL, Stensvold CR, Nielsen HV, & Bytzer P (2012). Treatment of Dientamoeba fragilis in Patients with Irritable Bowel Syndrome. The American journal of tropical medicine and hygiene PMID: 23091195

Engsbro AL, & Stensvold CR (2012). Blastocystis: to treat or not to treat ... But how? Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 55 (10), 1431-2 PMID: 22893582

Saturday, March 31, 2012

Blastocystis Treatment

In my opinion, in many cases we should "leave Blastocystis alone". In some cases, however, treatment may be warranted. However, currently there are no convincing drug regimens. RCTs needed.
For more information, please consult this review. 

Some updates on Blastocystis

Blastocystis is a micro-eukaryote, a so-called protist, parasitising the intestine of humans and a variety of animals.

We estimate that at least 1 billion people worldwide are colonised by this parasite, and we believe that the majority experience no more episodes of intestinal upset, e.g. diarrhoea, than the average individual.

Blastocystis colonises the intestine for a long time (probably months or years).

Many species of Blastocystis are known, of which at least 9 have been found in humans. Such species are currently termed "subtypes" (STs). ST1, ST2, ST3 and ST4 are common in Europe. While ST1, ST2, and ST3 appear to have equal prevalences in patients with diarrhoea and healthy individuals, ST4 appears to be linked to diarrhoea and/or chronic conditions such as irritable bowel syndrome (IBS).

There is no known efficient treatment of Blastocystis. Although metronidazole is often prescribed for Blastocystis infections, there is conflicting reports on its efficacy. Even in combination with a luminal agent, such as paromomycin, Blastocystis eradication cannot be guaranteed.

Whether Blastocystis causes symptoms in humans may depend on factors such as co-evolution. ST3 is the most common subtype in humans and ST3 may account for 30-50% of Blastocystis in humans. ST3 shows substantial intra-subtype genetic variation, and we believe that Blastocystis ST3 has co-evolved with humans, and therefore we may have adapted to ST3 colonisation. ST4 on the other hand is almost clonal and may have entered the human population relatively recently. This could partly explain why ST4 colonisation has been linked to intestinal symptoms.

Further reading:
1. Stensvold CR, Alfellani M, Clark CG. Levels of genetic diversity vary dramatically between Blastocystis subtypes.
2. Stensvold CR, Christiansen DB, Olsen KE, Nielsen HV. Blastocystis sp. ST4 is common in Danish Blastocystis-positive patients presenting with acute diarrhea.