Chapter 215

### Giardiasis

Giardia intestinalis (also known as G. lamblia or G. duodenalis) is a cosmopolitan protozoal parasite that inhabits the small intestines of humans and other mammals. Giardiasis is one of the most common parasitic diseases in both developed and developing countries worldwide, causing both endemic and epidemic intestinal disease and diarrhea.

#### Life Cycle and Epidemiology

(Fig. 215-1) Infection follows the ingestion of environmentally hardy cysts, which excyst in the small intestine, releasing flagellated trophozoites (Fig. 215-2) that multiply by binary fission. Giardia remains a pathogen of the proximal small bowel and does not disseminate hematogenously. Trophozoites remain free in the lumen or attach to the mucosal epithelium by means of a ventral sucking disk. As a trophozoite encounters altered conditions, it forms a morphologically distinct cyst, which is the stage of the parasite usually found in the feces. Trophozoites may be present and even predominate in loose or watery stools, but it is the resistant cyst that survives outside the body and is responsible for transmission. Cysts do not tolerate heating, desiccation, or continued exposure to feces but do remain viable for months in cold fresh water. The number of cysts excreted varies widely but can approach 107 per gram of stool.

###### Figure 215-1

Life cycle of Giardia. (Reprinted from RL Guerrant et al: Tropical Infectious Disease: Principles, Pathogens and Practice, 2nd ed, 2006, p 987, with permission from Elsevier Science.)

Ingestion of as few as 10 cysts is sufficient to cause infection in humans. Because cysts are infectious when excreted, person-to-person transmission occurs where fecal hygiene is poor. Giardiasis (symptomatic or asymptomatic) is especially prevalent in day-care centers; person-to-person spread also takes place in other institutional settings with poor fecal hygiene and during anal-oral contact. If food is contaminated with Giardia cysts after cooking or preparation, food-borne transmission can occur. Waterborne transmission accounts for episodic infections (e.g., in campers and travelers) and for major epidemics in metropolitan areas. Surface water, ranging from mountain streams to large municipal reservoirs, can become contaminated with fecally derived Giardia cysts; outmoded water systems are subject to cross-contamination from leaking sewer lines. The efficacy of water as a means of transmission is enhanced by the small infectious inoculum of Giardia, the prolonged survival of cysts in cold water, and the resistance of cysts to killing by routine chlorination methods that are adequate for controlling bacteria. Viable cysts can be eradicated from water by either boiling or filtration. In the United States, Giardia (like Cryptosporidium; see below) is a common cause of waterborne epidemics of gastroenteritis. Giardia is common in developing countries, and infections may be acquired by travelers.

Giardia parasites genotypically similar to those in humans are found in many mammals, including beavers from reservoirs implicated in epidemics. The importance ...

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