This Month In Blastocystis Research (SEP 2016) - 500,000 PW edition

The Blastocystis Parasite Blog has been going on for about 4 years and 3 months or so. Just now,  the number of pageviews passed 500,000!

I want to thank everyone who has browsed my page. I hope that I have been able to contribute to bringing on a couple of topics for debate and stimulate research into Blastocystis - maybe other parasites too. The FB community is quite active in terms of referring to my website, and so I extend a big Thank You to this community also.

I won't be doing a regular post this time - just hope that some of you will take to (re)visiting one or more of the 174 posts I've developed so far.

I know that I am not replying to all the emails I get; please try again... there are times when I don't really get to check my blog email... but every now and then I do, and I might stumble upon your query... I tend not to reply to those that deal exclusively with questions on how to eradicate Blastocystis. If you are curious about this and my personal opinion on it, please look up posts on "treatment" (you can see the labels in the right side bar).

Please also note that this blog has a FB page.

Thank you for stopping by and for contributing to the debate on Blastocystis.

This Month in Blastocystis Research - AUG 2016

Last month, I asked about your thoughts on Blastocystis and age... is age a limiting factor with regard to the susceptibility to infection/colonisation? One of the reasons why I asked is that we and others have noted that Blastocystis becomes more and more common with age... at least until a certain stage in life (adulthood) and at least in certain countries.

Among the answers I got, I'd like to highlight one from Dr Graham Clark, London School of Hygiene and Tropical Medicine, with whom I've had the tremendous privilege of working for more than 10 years. Dr Clark writes:

In my opinion, prevalence is a mixture of three things: exposure, immunity and ‘loss’.

To illustrate the latter, infection with Entamoeba histolytica (and probably other Entamoeba species) can be lost spontaneously with a half-life of 13 months (in one study at least, Blessmann et al. 2003 J Clin Micro). There is no evidence that immunity is involved, just chance. Extrapolating to Blastocystis, I suspect the same is true – loss can occur spontaneously but what the half-life of colonisation is we have no idea and it would be difficult to evaluate without high resolution genotyping (which is what we used in E. histolytica). If you had a population of infected individuals that were followed over time and a high res[olution] typing method you could calculate rates of loss and of new infections, as we did for E. histolytica.

I do not think there is any evidence for immunity to Blastocystis infection, which leaves exposure. If the rate of exposure is greater than the rate of spontaneous loss then you would get an increase in prevalence with age. I suspect (hope!) exposure is higher in children for behavioural reasons than in adults so you will get a levelling out of prevalence with age to a point where the rate of new infection balances the rate of spontaneous loss. If exposure stays high then this plateau may not be reached.

So why are other parasites different? Probably there is immunity leading to clearance of the infection in children.

Certainly, we have quite good data from Ireland indicating that once established, Blastocystis will keep colonising the GI tract for ages (i.e., many years). Regarding loss, I hope that I'll soon be able to refer to some data that we have obtained in a study on experimental animals.

Exposure is obvisouly something to think about - Blastocystis is transmitted by ingesting food/drink contaminated with Blastocystis and/or improper hygiene. The fact remains that studies using molecular methods for detection have identified most children in Sub-Saharan African study populations as being colonised, while in more developed countries, parasites such as Dientamoeba fragilis are more common in toddlers and smaller children; Blastocystis emerges and gains in prevalence only in teenagers and older individuals... roughly speaking.

One aspect of colonisation that I've been very interested in myself, is whether it's each individual's gut microbiota that "decides" whether Blastocystis colonisation/infection establishes upon exposure. We are seeing some data emerging from a couple of labs on this, and maybe next month I'll be able to bring you up to speed in this matter. To my knowledge, there is not a lot of precedence–if any–for such a situation, but the fact that we have seen quite clear differences in gut microbiota patterns between those who have Blastocystis and those who have not, has left me thinking...

If you want to contribute to the discussion, please drop a line. 

References:

Blessmann, J., Ali, I., Ton Nu, P., Dinh, B., Ngo Viet, T., Le Van, A., Clark, C., & Tannich, E. (2003). Longitudinal Study of Intestinal Entamoeba histolytica Infections in Asymptomatic Adult Carriers Journal of Clinical Microbiology, 41 (10), 4745-4750 DOI: 10.1128/JCM.41.10.4745-4750.2003

Scanlan PD, Stensvold CR, Rajilić-Stojanović M, Heilig HG, De Vos WM, O'Toole PW, & Cotter PD (2014). The microbial eukaryote Blastocystis is a prevalent and diverse member of the healthy human gut microbiota. FEMS microbiology ecology, 90 (1), 326-30 PMID: 25077936

This Month in Blastocystis Research - Interactive Edition

What are your thoughts on Blastocystis carriage and age?

More and more data suggest that the prevalence of Blastocystis carriage increases by age - at least to a certain point.

Some intestinal parasites, such as Cryptosporidium, may not be that uncommon in infants/very young toddlers, while they are much less common in older children and adolescents. Other parasites appear to peak in prevalence around the age of 7, e.g., Dientamoeba fragilis.

Meanwhile, Blastocystis appear to increase in prevalence by age until mature adulthood... why is that? And what does it tell us? Please comment! I'm not having all the answers to these questions myself, and if some interesting suggestions pop up, I'll post them! You only need a Google account to be able to comment. If you don't have one, please send your comment using

crs[at]blastocystis.net 

For those interested in Blastocystis carriage in association with age, I have listed a couple of relevant recent studies below.

References:

Forsell J, Granlund M, Samuelsson L, Koskiniemi S, Edebro H, & Evengård B (2016). High occurrence of Blastocystis sp. subtypes 1-3 and Giardia intestinalis assemblage B among patients in Zanzibar, Tanzania. Parasites & Vectors, 9 (1) PMID: 27356981  

Poulsen CS, Efunshile AM, Nelson JA, & Stensvold CR (2016). Epidemiological Aspects of Blastocystis Colonization in Children in Ilero, Nigeria. The American Journal of Tropical Medicine and Hygiene, 95 (1), 175-9 PMID: 27139454

This Month in Blastocystis Research (JUN 2016) - FMT Edition

From time to time, I've been touching upon the concept of faecal microbiota transplantion (FMT) in my blog posts. Now, there is a chance to familiarize yourself a lot more with this therapeutic approach to treating recurrent Clostridium difficile infection and other types of gastrointestinal diseases.

In my opinion, one of the more interesting aspects of FMT is to obtain knowledge about what microbes are actually being transferred (what microbes are allowed in stool selected for FMT?), and what are in fact the components in faecal transplants resulting in the high treatment success rates generally observed?

I dedicate this month's post to the launching of an online course in Faecal Microbiota Transplantation (FMT) supported and developed by United European Gastroenterology (UEG) in collaboration with leading Italian gastroenterologists, including Dr Gianluca Ianiro, who was recently appointed as a new member of the UEG Young Talent Group. I was lucky to involved in the editing of the course.

Targeted learners include not only gastroenterologists, but also endoscopists, internists, paediatricians, endocrinologists, surgeons, infectious disease specialists and clinical microbiologists who are interested in gut microbiota and who deal with diseases associated with gut microbiota perturbation (recurrent CDI, IBD, IBS, obesity, diabetes and other metabolic disorders).

If you wish to take the course, it can be accessed through your myUEG account.

For general information about UEG, please go here. And for more information on UEG Education, please go here.

This Month in Blastocystis Research (MAY 2016)

Very much belated, I'm back to give you the MAY entry of the 2016 "This Month in Blastocystis Research" blog series.

I'm basically just going to highlight a few papers and some other interesting things.

Ever since our metagenomics paper came out, it's as if the interest in Blastocystis in a gut microbiota context is exploding. If you put "Blastocystis microbiota" into the search box in PubMed, today you will get 20 hits, most of which papers are extremely interesting and of course very central to this type of research. Given the number of times I've addressed the relevance of studying Blastocystis in relation to gut microbiota diversity on this blog, I'll try not to flog it to death this time!

Over at Gut Microbiota For Health, a blog was posted a week ago summarising the recent findings of Audebert and colleagues and comparing them to data coming out from our lab. You can read the blog here. Using the Ion Torrent PGM sequencing platform, 16S rDNA gene sequencing was performed on genomic DNAs extracted from Blastocystis-positive and - negative stool samples. What Audebert hypothesised was that if Blastocystis is associated to intestinal disease such as for instance diarrhoea, one would expect to find a higher degree of microbiota perturbation (dysbiosis) in Blastocystis carriers than in non-carriers. Meanwhile, and similar to what we have have published, they reported that gut microbiota diversity is higher in Blastocystis carriers than in non-carriers, indicating that Blastocystis is generally a marker of a healthy gut microbiota rather than a perturbed one. Again similar to what we found in the metagenomics paper, Audebert et al. saw that the bacterial families Ruminococcaceae and Prevotellaceae were also more abundant in carriers than in Blastocystis-negative patients, while Enterobacteriaceae were enriched in Blastocystis-negative patients. What is also really interesting is the fact that the genera Faecalibacterium and Roseburia had a significantly higher abundance in Blastocystis-positive patients. These genera contain bacteria that produce butyrate which has a lot of important and beneficial functions. Loss of butyrate producers is seen for instance in patients with inflammatory bowel disease. The group used some of the same methods as we used in our study presented recently at ECCMID, including rarefaction analysis and calculation of Chao1 indices.

Together with colleagues at the Technical University of Denmark, we were lucky to have The European Journal of Clinical Microbiology and Infection publish our novel data on associations between common single-celled intestinal parasites--Blastocystis and Dientamoeba--and groups of intestinal bacteria, as evidenced by qPCR assays. We confirmed the findings from our metagenomics study, by finding a relatively lower abundance of Bacteroides in the parasite-positive samples than in the -negative ones.

By the way, on the Gut Microbiota For Health site you will find an e-learning course on Microbiota provided by the Gut Microbiota and Health Section of the European Society of Neurogastroenterology and Motility (ESNM) and developed for gastroenterologists.

Speaking of e-learning and gastroenterology: For a couple of years, I've had the immense pleasure of being part of the United European Gastroenterology e-learning task force. We host a resource - UEG Education - developed mainly for gastroenterologists, boasting e-learning courses, "Decide-on-the-Spot" series, "Mistakes in..." series, blogs, and other features. I have included a UEG widget in the right side bar of my blog - please click it!

Back to Blastocystis! Graham Clark and I published a personal view on the current status of Blastocystis in Parasitology International, in which we summarise the development and recent advances in Blastocystis research. The article is expected to form part of a special section/issue dedicated to Blastocystis to commemorate last year's 1st International Blastocystis Symposium in Ankara.

My colleague Juan-David Ramirez and his colleauges published data from a subtyping study from South America including 346 samples. More than 85% of the subtypes found belonged to either ST1, ST2, and ST3 as expected, while the rest belonged to ST4, ST5, ST6, ST7, ST8, ST12 and what they call a new subtype. I think this is the first time ST12 has been reported in humans. Despite the fact that the authors accounted for the databases that they used for subtype and allele calling, there is no mention on the criteria by which the subtypes were called in the NCBI database (i.e., in those cases where no hits could be found at the online Blastocystis database). For instance, what level of similarity was used to identify three samples as ST12? On the same note, which level of similarity was used to identify nine samples as belonging to a "novel subtype" (also, - was it the same sequence across the nine samples?). When dealing with a potentially novel subtype, usually the entire SSU rRNA gene is seqeunced and subjected to phylogenetic analysis, and sequences have not yet been made public in GenBank, so there is no possibility to work with the data so as to validate the findings (which are highly accurate, I'm sure). I think this information is critical to interpreting the data. Nontheless, the work that went into the sampling and the lab work should be highly accredited.

References:

Andersen LO, Bonde I, Nielsen HB, & Stensvold CR (2015). A retrospective metagenomics approach to studying Blastocystis. FEMS microbiology ecology, 91 (7) PMID: 26130823

Audebert C, Even G, Cian A, Blastocystis Investigation Group, Loywick A, Merlin S, Viscogliosi E, & Chabé M (2016). Colonization with the enteric protozoa Blastocystis is associated with increased diversity of human gut bacterial microbiota. Scientific reports, 6 PMID: 27147260  

O'Brien Andersen L, Karim AB, Roager HM, Vigsnæs LK, Krogfelt KA, Licht TR, & Stensvold CR (2016). Associations between common intestinal parasites and bacteria in humans as revealed by qPCR. European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology PMID: 27230509 

Ramírez JD, Sánchez A, Hernández C, Flórez C, Bernal MC, Giraldo JC, Reyes P, López MC, García L, Cooper PJ, Vicuña Y, Mongi F, & Casero RD (2016). Geographic distribution of human Blastocystis subtypes in South America. Infection, genetics and evolution : journal of molecular epidemiology and evolutionary genetics in infectious diseases, 41, 32-5 PMID: 27034056

Stensvold CR, & Clark CG (2016). Current status of Blastocystis: A personal view. Parasitology international PMID: 27247124   

This Month in Blastocystis Research (APR 2016)

I thought I’d give examples of some of the Blastocystis-related activities in which I was involved in April.

I was lucky to be invited as part of the faculty for this year’s ECCMID conference in Amsterdam. I had an opportunity to give a talk on Detection of protozoans using molecular techniques in routine clinical practice (click link to watch it). I also co-authored a poster with the title Blastocystis colonization correlates with gut bacterial diversity which is one of several studies recently performed by our group that suggest that Blastocystis is a biomarker – or an indicator if you wish – of a healthy gut microbial environment and high gut microbiota diversity. 

This very topic was one of the two major topics of my colleague Lee O’Brien Andersen’s PhD work; Lee just defended his thesis this Friday and being involved in his work is some of the most interesting, rewarding, and challenging professional activities I’ve experienced so far. I will soon provide a link to an electronic version of his thesis here on this site. I hope that we will be able to fund his post doc aiming to expand his work on comparative Blastocystis genomics, since he only just started this work. Also, I hope that we will be able to do much more research on Blastocystis’ impact on host immunity and gut microbiota using in vitro and in vivo models. We need to know much more about to which extent Blastocystis can actually induce changes in bacterial communities and what these changes are. We also need to know whether manipulation of gut bacteria in a Blastocystis carrier can lead to eradication of the organism. 

Last week, I was so fortunate to oversee the production of an e-learning course in faecal microbiota transplantation (FMT) for Unite European Gastroenterology (UEG), which will probably appear online already in June. FMT is currently used primarily for treating recurrent Clostridium difficile infections, but the application range may extend far beyond this. The presentations included both theoretical and live sessions, and it was a lot of fun to do, not only because of the topic, but also because my colleagues at the Agostino Gemelli University Hospital in Rome were extremely professional, enthusiastic and well-organised. The reason why FMT is interesting in a Blastocystis context includes the fact that while there are quite standardized guidelines as to what is not allowed in donor stool, there is no consensus on what is actually allowed in the stool. Obviously, Blastocystis will often be present in donor stool, and when conventional microbiological methods are used to screen donor stool for pathogens, Blastocystis will only rarely be picked up. Hence recipients may receive stool containing Blastocystis. And so of course we would like to know whether to recommend using or excluding stool positive for Blastocystis (and other common parasites such as Dientamoeba) for FMT.

This Month in Blastocystis Research (MAR 2016)

I'm going to dedicate this post entirely to a recent case presented by my wonderful colleague Bobbi Pritt (Mayo Clinic) in collaboration with Blaine Mathison (CDC), whom I have also been so fortunate to meet.

Please go here to see the case.

Creepy Dreadful Wonderful Parasites: Case of the Week 390.

Let me use the opportunity to congratulate Bobbi Pritt on her fantastic work, admirable skills, and dedication to parasitology!

And by the way; why not treat yourself to Bobbi's 2016 parasite calendar available for purchase here.

This Month in Blastocystis Research (FEB 2016) - Rash Edition

A couple of years ago, I contributed to writing up a Case Report on what appeared to be Blastocystis-associated urticaria (hives). Receiving various courses of ineffective antibiotic treatment with a view to eradicating Blastocystis, a woman continued to suffer from gastrointestinal symptoms and generalized urticaria. Only when the infection was eventually successfully eradicated using a combination of metronidazole and paromomycin, the women experienced symptom resolution.

There is a systematic review out just now in the well-esteemed journal "Allergy" on chronic spontaneous urticaria in patients with intestinal parasites. The approach is useful, interesting, and relevant. One of the main results, which was also highlighted in the abstract, is that patients with chronic urticaria more frequently have "Blastocystis hominis allele 34 (ST3)". This observation, however, pertains to one single study, and should be interpreted in this context. The original study was carried out by Rudolfo Daniel Casero and last-authored by a close colleague of mine, Juan David Ramirez, who currently does a lot to promote and improve molecular parasitology research in Latin America; among other things, he's a very successful and avid arranger of workshops. Anyway, the study included observations on Blastocystis in a group of Argentinean patients, who were stratified by the presence or absence of symptoms. Hence, there were four groups, reflecting 1) asymptomatic patients, 2) patients with chronic urticaria, 3) patients with non-specific gastrointestinal symptoms (NSGI), and 4) patients with both chronic urticaria and NSGI. No specific subtype was linked to any of the four groups; however, a very striking observation related to the distribution of ST3 strains across the groups: out of a total of 21 patients positive for ST3 allele 34 (the allele number is used to provide "genotype" information of the subtype), 18 had urticaria. On the other hand, out of 28 patients positive for ST3 allele 134, only 3 had urticaria.

ST3 allele 34 is probably the most common Blastocystis strain overall in many European countries; also in Asia (e.g. India), this genotype particularly common. Although common in South America too, it might not be the most common strain, given the data by Casero et al. These authors are the first to provide a clear association between a Blastocystis strain (i.e., on genotype level) and development of symptoms. Although the data warrant confirmation by prospective studies, the data should be food for thought.

About 20 papers are listed in PubMed on "Blastocystis AND urticaria". Last year, I was so fortunate to host Małgorzata Lepczynska in our lab for a couple of weeks. Incidentally, a review of the role of Blastocystis in the development of urticaria and first-authored by Lepczynska just emerged in PubMed. The authors try to explain the potential mecanisms underlying the development of Blastocystis-induced urticaria. For some reason, the authors did not include a study by Armentia et al. from 1993 (maybe due to the possibility that they had no access the paper?). Armentia presented a case series (n = 10) of Blastocystis patients who all had chronic urticaria; both the parasite and the symptom disappeared upon treatment with paromomycin sulfate.

I am not sure that the data available at this point are sufficient to generate inferences on the contributing role of Blastocystis in the development of urticaria; however, I would not hesitate to encourage dermatologists to look into the issues of "idiopathic chronic urticaria", with a view to clarifying the rate of Blastocystis colonisation among these patients and whether parasite eradication leads to symptom resolution. Such studies should also involve total analysis of the intestinal microbiota, both before and after treatment.

References:

Armentia A, Méndez J, Gómez A, Sanchís E, Fernández A, de la Fuente R, & Sánchez P (1993). Urticaria by Blastocystis hominis. Successful treatment with paromomycin. Allergologia et Immunopathologia, 21 (4), 149-51 PMID: 8237719   

Casero, R., Mongi, F., Sánchez, A., & Ramírez, J. (2015). Blastocystis and urticaria: Examination of subtypes and morphotypes in an unusual clinical manifestation Acta Tropica, 148, 156-161 DOI: 10.1016/j.actatropica.2015.05.004

Kolkhir P, Balakirski G, Merk HF, Olisova O, & Maurer M (2016). Chronic spontaneous urticaria and internal parasites - a systematic review. Allergy, 71 (3), 308-22 PMID: 26648083

Lepczyńska M, Chen WC, & Dzika E (2016). Mysterious chronic urticaria caused by Blastocystis spp.? International Journal of Dermatology, 55 (3), 259-66 PMID: 26469206 


Vogelberg C, Stensvold CR, Monecke S, Ditzen A, Stopsack K, Heinrich-Gräfe U, & Pöhlmann C (2010). Blastocystis sp. subtype 2 detection during recurrence of gastrointestinal and urticarial symptoms. Parasitology International, 59 (3), 469-71 PMID: 20363362 

This Month in Blastocystis Research (JAN 2016)

Three publications have caught my attention over the past month.

The first one is by my Turkish colleagues Kurt, Dogruman-Al, and Tanyüksel. They just published the paper "Eradication of Blastocystis in humans: Really necessary for all?" This title implies that treatment of Blastocystis is recommendable in some cases. The authors appear to acknowledge the view that treatment should be given to symptomatic carriers when all other causes of gastrointestinal symptoms have been rule out, - the popular 'last-resort' approach.

What I think is really useful and admirable is that the authors leave so many questions open/unanswered, despite the fact that they have been "in business" for so many years, representing some of the most avid Blastocystis researchers. It becomes clear from reading the paper that even in 2016, we still do not know how to eradicate Blastocystis from the intestine in those cases where we'd really like to try and do so. Importantly, the authors give examples of data supporting the fact that treatment failure may be due to failure of the drug to reach the parasite as well as treatment resistance. They also highlight the possibility that eradication of Blastocystis by antibiotic/anti-protozoal agents may be due to microbiota perturbation rather than a direct action on Blastocystis. I also very much appreciate the fact that the authors are embracing the necessity of studying Blastocystis in a parasite-microbiota-host context in order to be able to draw useful conclusions on its role in human health and disease.

Das and colleagues just published data on Blastocystis and subtypes of Blastocystis in IBS patients and controls in New Delhi, India. Using multiple traditional and DNA-based methods, they found that in their study material, the prevalence of Blastocystis was higher among patients with IBS than among healthy controls. It is not exactly clear how the controls were picked and what type of study population they represented. What I found really useful is the fact that they not only carried out subtyping of Blastocystis, but also identified subtype alleles. The subtypes and alleles found in the study were very similar to those found recently by Pandey et al. (2015) in Maharashtra, India.  Interestingly, it appears that only two subtypes are found in humans in India, namely ST1 and ST3. However, only two studies from India are available on subtypes in humans, to my knowledge, and so we need much more data to draw conclusions.

The last paper that I'm going to address is one by Zanzani and colleagues. When I read the abstract I almost dislocated my lower jaw from stupefaction: Studying the gastrointestinal parasitic fauna of captive non-human primates (Macaca fascicularis), they found a variety of protozoa and helminths, which is not surprising at all. Neither is it surprising that most macaques were positive for Blastocystis. Now, what really made my jaw drop was the fact their data on the subtypes found in the macaques challenged the host specificity of Blastocystis identified so far: They reported finding ST1, ST2, ST3, ST5, and ST7. And so, I had a closer look at the methods used to obtain data on subtypes. I take the liberty of questioning the data, since the authors report using a set of primers for amplification of Blastocystis DNA targeting the SSU rRNA gene, while using the STS primers developed by Yoshikawa et al. as sequencing primers! I guess that it is possible that the description of the methods was flawed (should have been picked up by the reviewer though), in which case I hope that an erratum will be developed and published.

References:

Das R, Khalil S, Mirdha BR, Makharia GK, Dattagupta S, & Chaudhry R (2016). Molecular Characterization and Subtyping of Blastocystis Species in Irritable Bowel Syndrome Patients from North India. PloS One, 11 (1) PMID: 26784888  

Kurt Ö, Doğruman Al F, & Tanyüksel M (2016). Eradication of Blastocystis in humans: Really necessary for all? Parasitology International PMID: 26780545

Pandey PK, Verma P, Marathe N, Shetty S, Bavdekar A, Patole MS, Stensvold CR, & Shouche YS (2015). Prevalence and subtype analysis of Blastocystis in healthy Indian individuals. Infection, Genetics and Evolution: Journal of Molecular Epidemiology and Evolutionary Genetics in Infectious Diseases, 31, 296-9 PMID: 25701123  

Zanzani SA, Gazzonis AL, Epis S, & Manfredi MT (2016). Study of the gastrointestinal parasitic fauna of captive non-human primates (Macaca fascicularis). Parasitology Research, 115 (1), 307-12 PMID: 26374536  

Yoshikawa H, Wu Z, Kimata I, Iseki M, Ali IK, Hossain MB, Zaman V, Haque R, & Takahashi Y (2004). Polymerase chain reaction-based genotype classification among human Blastocystis hominis populations isolated from different countries. Parasitology Research, 92 (1), 22-9 PMID: 14598169