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1Urinary infection due to Balantioides coli: a rare

2accidental zoonotic disease in an addicted and diabetic
3young female in Iran

4Saman Soleimanpour1*, Ali Babaei2*, Abdolghayyoum Movahhedi Roudi3,
5Seyedeh Sara Raeisalsadati1

61Microbiology and Virology Research Centre, Bu-Ali Research Institute, Mashhad
7University of Medical Sciences, Mashhad, Iran.
82Laboratory of 22nd Bahman hospital, Khaf, Mashhad University of Medical
9Sciences, Mashhad, Iran.
103Department of Parasitology, 22nd Bahman hospital, Khaf, Mashhad University of
11Medical Sciences, Mashhad, Iran.

12*Corresponding author:
13Saman Soleimanpour
14Microbiology and Virology Research Centre, Bu-Ali Research Institute, Mashhad
15University of Medical Sciences, Mashhad, Iran.
16Tel: +98-9126590092
17E-mail: soleimanpour.saman@yahoo.com

18*Corresponding author:
19Ali Babaei
20Laboratory of 22nd Bahman hospital, Khaf, Mashhad University of Medical
21Sciences, Mashhad, Iran. Tel: +98-9139054564
22E-mail: alibabaei206@yahoo.com

* Saman Soleimanpour and Ali Babaei contributed equally to this work and should both be
considered as first authors.

Supplementary material is available with the online version of this paper.

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Trichomonas 39vaginalis 3 2 4 . coli). an 29interesting case of urinary balantiosis in a 35-year-old addicted woman 30with multiple health problems including spontaneous abortion and diabetes 31is reported. Her midstream urine sample collected while all sterile 32precautions were taken demonstrated B. coli was detected in urine 37sediment. coli along with Trichomonas 33vaginalis and bacteria. B. 38Key words: Balantioides coli. 26Humans acquire it via the fecal-oral route. Conclusion: This is only the 36eighth case described in literature in which B. Very rarely. There are very few case 28reports of urinary balantiosis in humans. which is an 35abnormal site for invasion by this parasite.23Abstract 24Background: Balantiosis. it is reported for its rarity and for future reference. coli was identified by its characteristic 34morphology and rapid rotary motility in the urinary tract. extra-intestinal 27infections can occur in the urinary tract system. a rare zoonotic infection resulting in dysentery. 25is caused by the large ciliated protozoan parasite Balantioides coli (B. Urinary balantiosis. Case presentation: Here.

It has a worldwide distribution.40Introduction 41Balantioides coli (formerly Balantidium coli. coli is found most frequently 63in Iranian wild boars. 62Additionally. Therefore. which suggests that maybe a different animal is a 60reservoir host. 2008). albeit rarely. were closed after the 1979 Islamic revolution. 48especially in settings where water sources may be contaminated with 49porcine or human feces and hygiene is poor (Schuster & Ramirez-Avila. and pig 57breeding and the consumption of pork was prohibited. 2008).. Balantiosis is 45a zoonotic disease acquired by humans via the fecal-oral route from its 46normal hosts. Because of the Islamic prohibition on eating pork. but the prevalence of 44its human infection is very low (Schuster & Ramirez-Avila. Thus. a 56Muslim country. synonym Neobalantidium coli) is 42a large ciliated protozoan parasite of low virulence which causes balantidial 43dysentery in humans. Although B. 50Human-to-human transmission may also occur.. Therefore. However. 5 3 6 . the pig 58can be excluded as a source of infection in Iran. this infection has an increased 54prevalence in countries and communities that live in close contact with 55pigs. piggeries in Iran. some reports have shown that B. although it is an uncommon infection. they are probably the source of human 64infection in Iran. The wild boar is found in rural areas of different parts of Iran 61and has close contact with farmlands and natural water sources. 51coli infects a wide range of mammals. especially in rural areas where they roam and their feces 65could contaminate food and water (Solaymani-Mohammadi et al. 1999). domestic pigs and wild boars are 52generally considered to be the most important natural reservoir for human 53balantiosis (Nakauchi et al. 2005). there are still 59reports of this infection. Infection in humans is 47mostly found in tropical and subtropical regions and developing countries.

Koopowitz et al. 89This paper reports a rare and interesting case of urinary balantiosis in an 90addicted. especially in 70immunocompromised subjects. 2004). A complete 98haemogram and other laboratory tests (shown in the Table 1) revealed a 7 4 8 . In rare cases. 2010). genitourinary tract has also been reported 73(Rivasi and Giannotti. 2003). coli (Umesh. (ii) acute or fulminating forms presenting with stool 81containing mucus and blood resembling Entamoeba histolytica dysentery. 82severe dehydration and weight loss. Abdominal 97examination of this patient revealed generalized tenderness. 2010). Urinary balantiosis is thought to occur via direct spread 88from the anal area or a rectovaginal fistula created from infection with B. 2007). (iii) chronic 84symptomatic infection which is characterized by non-bloody diarrhea alternating 85with constipation and nonspecific abdominal pains (Bellanger et al... 67After ingestion. 2008).. and cystitis.. vaginitis.. 1991). 2007). are thought to 75occur via direct spread from the anal area (usually in females) or as 76secondary to a rectovaginal fistula created from infection with this 77organism (Umesh. Genitourinary 74infections. diabetic woman showing ciliated parasite along with 91Trichomonas vaginalis and bacteria in a MSU sample collected while all 92sterile precautions were taken. 93Case report 94A 35-year-old addicted woman suffering from diabetes and hypothyroidism 95referred to the hospital emergency department with the chief complaint of 96spontaneous abortion and a temporary loss of consciousness. peritoneal (Ferry et al. B. 86Extraintestinal spread to the genitourinary tract has rarely been reported 87(Koopowitz et al. 78Clinical manifestation of balantiosis can take one of three forms: (i) 79asymptomatic or mild infection that presents with intermittent diarrhea 80alternating with constipation. lung 72(Sharma and Harding. including uterine infection. 2013). coli can penetrate the mucosa layer of the large 68intestine and cause ulcers and balantidial dysentery in humans and other 69vertebrates (Schuster & Ramirez-Avila. 2014).66In humans. liver (Kapur et al. 1983. the cecum and colon are the natural habitats of this organism. In rare cases. fulminant ulceration with 83perforation of the colon may cause hemorrhage and even death. extraintestinal spread to the appendix 71(Dodd.

and a few 121ingested red blood cells were present within the cytoplasm. 1). bacteria. Microscopic 108examination of the sediment revealed a tubular cast. coli trophozoites or cysts. 130Discussion 9 5 10 .. 106Samples were examined using Merthiolate-Iodine-Formaldehyde 107Concentration (MIFC) method (Pomajbikova et al. a few epithelial cells. micronucleus (next to macronucleus). available in the online Supplementary Material). hypokalaemia. and an initial functional 101renal deficiency. In the urine sediment. The urine sample showed few 111large ovoid-shaped ciliated parasites measuring approximately 61μm × 11251μm. and pus cells 20-25/HPF. 103The patient’s fresh midstream urine (MSU) sample was sent for 104macroscopic and microscopic examination. diabetes. The cilia which 117lined the mouth part appeared to be longer than the others (adoral cilia). and she gradually improved. which maintained a constant synchronized motion. Repeated MSU samples from the 125patient were also positive for similar organisms. This 122morphology. hypernatremia. 1. The trophozoites’ 115bodies were completely covered with short delicate cilia. but mucosal clamps with 127lots of pus cells were seen. Several food 120vacuoles. 109amorphous urates. 2). boring motion and were moving very rapidly 113across the slide (Video. The stool samples collected 126were negative for B. 99severe anaemia. 2010). They had a rotary. all of uniform 116length. and its rotary motion were typical of 123Balantioides coli. 114suggesting trophozoites of Balantioides coli (Fig. the ciliary covering. and the urine test strip revealed sugar and proteinuria. a few motile trophozoites of 124Trichomonas vaginalis were also seen (Fig. macronucleus. Examination of the arterial blood gas revealed a metabolic 102acidosis (Table 1). biological inflammatory syndrome (C-reactive protein 100positive). hematuria with 50-60 red blood cells/high 110power field (HPF). Its physical appearance was 105smoky and turbid. 118The organism had a mouth that was located at the pointed anterior end 119(cytostome) and a rounded posterior end (cytopyge). The patient was given tetracycline (500 mg 128four times a day) and metronidazole (750 mg three times a day) for a total 129of 7 days.

coli can become an opportunistic parasite in immunosuppressed. 161immunosuppressed patients appear to be less resistant to balantiosis. addictive drugs 159and opioids suppress the immune system. one from 133Italy (Maino et al. 136In the case presented here. a 35-year-old female patient presented with 137diabetes and addiction. 1452013). the 149trophozoites may have invaded the colonic mucosa to enter the blood 150stream and finally metastasized to the urinary bladder or spread directly 151through the anal area. It 143seems that more studies like analyze using molecular-phylogenetic methods are required to 144determine the existence of balantioides-like ciliates in rabbits (Pomajbikova et al. 148coli cysts. 2012). and five cases in India (Umesh.. Bandyopadhyay 134et al. 2007... 154In conclusion. after ingestion and excystation in the large intestine. there were only 132seven cases reported in literature [one from Iran (Maleky. 2003). She denied direct contact with swine or wild boar. 162Thus. living in rural 164environments where wild boars roam and their feces could contaminate 11 6 12 . both of which can become dreadful conditions 138making her vulnerable to invasion by any opportunistic microbe at any 139site. the patient lives in a village and is in contact 146with wild animals. patients with uncontrolled diabetes are considered 155immunosuppressed due to the negative effect of elevated blood sugars on 156the immune system. she might have been infected 141from contaminated rabbit meat. Then. Moreover. but had a history 140of eating the meat of hunted rabbit. 163diabetic. even though there has so far been no 142report of human infection via consumption of rabbit meat in the world. Khanduri et al. On the other hand. which limits the activity of the 158immune system (Casqueiro and Alves. On the other hand. 1352014)]. the body's innate defense 160against infections (Friedman et al. Basavraj et al. and addicted patients like the present case. The patient also mentioned that she had diarrhea 152before.131Human urinary balantiosis is a rare disease. B. so it is not farfetched to surmise that she may have 147consumed water or food contaminated with wild boar feces containing B. but at the time of admission she had severe constipation that 153implied the common phase of a parasite. 2010). 2012. 1998). Hyperglycemia destroys overall immunity by various 157mechanisms and can lead to acidosis. thus. Karuna & Khadanga... 2013. 2014. Before 2015..

M. 182References 183Anargyrou. this 171case emphasizes the fact that B. Cermeno et al. 188Basavraj. 180-3. A. Balantidium coli in urine 187sediment: report of a rare case presenting with hematuria. 2003. J Med Educ Res 2. 179Financial support: No grants or funding were received for this 180publication.P. M. 2003). 181Conflict of interest statement: there is no conflict of interest. 174Yazar et al.T..L... 167Nevertheless. Ciliated Protozoan 189Parasite In Urine Of Diabetic Female – What Could Be Its Significance. Majumder. (2012). coli to the lung (Anargyrou et al. Using 176microscopic examination of fresh urine sediment.... Pulmonary 185Balantidium coli infection in a leukemic patient. K.. G. to determine 166the prevalence of balantidia in Immunocompromised individuals. Sarita. K. R. J Parasit Dis 37. Skiada. Siakantaris. Vishwas.. Suller.. 283–85. a microbiologist can easily 177diagnose this large parasite by its characteristic morphology and rapid 178rotary motility. Petrikkos. Goswami. K. Thus... 13 7 14 . Am J Hematol 73. N. 1983). 184M. K. coli should also be considered as a 172possible pathogen in immunocompromised patients with or without 173diarrhea even if they have no contact with pigs (Anargyrou et al. (2003). A.. There have been no more studies. B. Osuntoyinbo. 1692003). It should come in the differential 175diagnosis of these patients presenting with dysuria and hematuria. 186Bandyopadhyay. especially in immunocompromised subjects. Pangalis.... Vaiopoulos.. M. K. Pradeep. G. some extraintestinal infections have previously been 168reported in association with spread of B. 19049-51. Shegar. 2004..165food and water. peritoneal (Ferry et al.. G. however. (2013).T. 2004) and genitourinary tract (Rivasi and 170Giannotti.

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19 10 20 . arrow 246C: cytostome and arrow D: The cilia which lined the mouth part appeared 247to be longer than the others (adoral cilia). macronucleus and food 245vacuoles in urine sample. Trophozoite of Balantioides coli with micronucleus. arrow B: micronucleus. Arrow A: macronucleus.244Fig 1.

Table 1.8 mg/dl deficiency Examination of the arterial blood gas pH 6.9 mmol/L hypokalaemia Blood sugar (BS) 520 mg/dl diabetes Fasting blood sugar (FBS) 210 mg/dl Kidney function tests Serum urea 17mg/dl initial functional renal Serum creatinine 1.9 g/dl anaemia Biochemistry tests Serum Na+ 147 mmol/L hypernatremia Serum K+ 2. Lab test results of patient Laboratory Tests Results Clinical Implications Haemogram tests Total leukocyte count 17.9 mm Hg bicarbonate 2.4 mm Hg metabolic acidosis PaO2 78.7 mmol/L 248 21 11 22 .985 PaCO2 11.5×103/μL leukocytos Total platelet count 374×103/ μL Hb level 8.