Symposium on Blastocystis

Blastocystis: Consensus of treatment and controversies

Uma Sekar, M Shanthi
Department of Microbiology, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra University, Porur, Chennai, Tamil Nadu, India

KEY WORDS ABSTRACT

Blastocystis hominis, Blastocystis is a highly controversial protozoan parasite. It has been variably regarded as
a commensal and pathogen. Scientists have for decades wondered whether it is truly an
enteropathogen and if it is observed in symptomatic patients whether treatment is required
because patient recovery and improvement has been noted even without any treatment.
Though associated with self-limiting infection, treatment is warranted in many patients
due to persistence of symptoms. This particularly holds true for children and adults who
are immuno compromised. Several drugs have been used to treat Blastocystis but each one
of them has produced widely variable rates of clinical cure and eradication of the parasite
from the feces. Based on the studies carried out in vitro and clinical responses obtained in
patients, metronidazole appears to be the most effective drug for Blastocystis infection.
However, the therapy is complicated due to different dosages and regimens adopted
and the unresponsiveness to treatment observed in several sections of the population
studied. Recently, the finding of different subsets of Blastocystis exhibiting resistance
to metronidazole and associated with variable degrees of symptoms has underscored the
importance of typing the subsets of the parasite in order to foretell the clinical response
and the need to treat. Till date, the mode of action of the drugs used and the mechanism
of resistance is not entirely known and is a topic of speculation. Other drugs with anti
Blastocystis activity and used in therapy includes trimethoprim sulfamethoxazole and
nitazoxanide. Several other compounds have also been evaluated for the treatment
either alone or in combination with the first or second line drugs. A lot of interest has
also been generated on the role of probiotics particularly Saccharomyces boularrdii and
other natural food compounds on eradication of the parasite. This review provides a
comprehensive overview of antimicrobials used to target Blastocystis and discusses the
issues pertaining to drug resistance, treatment failure, reinfection, and the current views
on treatment modalities.

INTRODUCTION
Address for correspondence
Dr. Uma Sekar, Blastocystis
Department of Microbiology, Sri Ramachandra Medical College and
Research Institute, Sri Ramachandra University,
Porur, Chennai - 600 116, Tamil Nadu, India.
E-mail: umasekarsrmc@gmail.com

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DOI: In
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Tropical Parasitology 35 Jan 2013 | Volume 3 | Issue 1 |

 Sekar and Shanthi: Blastocystis hominis: Treatment and controversies

Table 1: Drugs and dosage schedules for treatment of

Blastocystis B. hominis
Drug Dose

Blastocystis
Blastocystis in the feces,

Blastocystis

Blastocystis

S. boulardii
S. boulardii: Saccharomyces boulardii

Blastocystis

Blastocystis

THERAPEUTIC OPTIONS

to treat Blastocystis

Saccharomyces boulardii

There are

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 Sekar and Shanthi: Blastocystis hominis: Treatment and controversies

Blastocystis

in vitro in vivo

et al Blastocystis
Blastocystis

Blastocystis
is not clear. et al.,

Blastocystis

Blastocyst

Blastocystis

Blastocystis

In contrast
et al.,
In

of Blastocystis Blastocystis.

et al against Blastocystis.
Blastocystis

Blastocystis acts as a repository Blastocystis

In vitro, Blastocystis

Blastocystis Blastocystis

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 Sekar and Shanthi: Blastocystis hominis: Treatment and controversies

in vitro Blastocystis (Brucea

javanica Coptis chinensis

in vitro
Blastocystis
infection. Blastocystis
for Blastocystis s et al.,

Blastocystis.

assays.
on Blastocystis

The Blastocystis
Blastocystis
in vitro for Blastocystis
et al

Blastocystis

Blastocystis

Blastocystis

Blastocystis isolates resistant

REFERENCES
1. Farthing MJ. Treatment options for the eradication of
S. boulardii intestinal protozoa. Nat Clin Pract Gastroenterol Hepatol
2006;3:436-45.
2. van Hellemond JJ, Molhoek N, Koelewijn R, Wismans PJ,
van Genderen PJ. Is paromomycin the drug of choice for
eradication of Blastocystis in adults? J Infect Chemother
October 2012; PMID: 23053509
3. Boorom KF, Smith H, Nimri L, Viscogliosi E, Spanakos G,
Parkar U, et al. Oh my aching gut: Irritable bowel
syndrome, Blastocystis, and asymptomatic infection.
Parasit Vectors 2008;1:40.
In 4. Low G. Two chronic amoebic dysentery carriers treated
by emetine, with some remarks on the treatment of
Lamblia, Blastocystis and E. coli infections. J Trop Med
Blastocystis Hyg 1916;19:29-34.
5. Stensvold CR, Smith HV, Nagel R, Olsen KE, Traub RJ.
Eradication of Blastocystis carriage with antimicrobials:
Reality or delusion? J Clin Gastroenterol 2010;44:85-90.
6. Kuo HY, Chiang DH, Wang CC, Chen TL, Fung CP, Lin CP,

Jan 2013 | Volume 3 | Issue 1 | 38 Tropical Parasitology

 Sekar and Shanthi: Blastocystis hominis: Treatment and controversies
et al. Clinical significance of Blastocystis hominis:
Experience from a medical center in northern Taiwan.
J Microbiol Immunol Infect 2008;41:222-6.
7. Nigro L, Larocca L, Massarelli L, Patamia I, Minniti S,
Palermo F, et al. A placebo-controlled treatment trial
of Blastocystis hominis infection with metronidazole.
J Travel Med 2003;10:128-30.
8. Dinleyici EC, Eren M, Dogan N, Reyhanioglu S, Yargic ZA,
Vandenplas Y. Clinical efficacy of Saccharomyces
boulardii or metronidazole in symptomatic children
with Blastocystis hominis infection. Parasitol Res
2011;108:541-5.
9. Tan KS. New insights on classification, identification, and
clinical relevance of Blastocystis spp. Clin Microbiol Rev
2008;21:639-65.
10. Coyle CM, Varughese J, Weiss LM, Tanowitz HB.
Blastocystis: To treat or not to treat. Clin Infect Dis
2012;54:105-10.
11. Aguilar C, Lucia JF. An overview of Blastocystis hominis
infection and published experience in hemophilic
population. J Coagul Disord 2010;2:1-4.
12. Mirza H, Teo JD, Upcroft J, Tan KS. A rapid, high-throughput
viability assay for Blastocystis spp. reveals metronidazole
resistance and extensive subtype-dependent variations
in drug susceptibilities. Antimicrob Agents Chemother
2011;55:637-48.
13. Haresh K, Suresh K, Khairul Anus A, Saminathan S.
Isolate resistance of Blastocystis hominis to metronidazole.
Trop Med Int Health 1999;4:274-7.
14. Zaman V, Zaki M. Resistance of Blastocystis hominis cysts
to metronidazole. Trop Med Int Health 1996;1:677-8.
15. Vassalos CM, Spanakos G, Vassalou E, Papadopoulou C,
Vakalis N. Differences in clinical significance and
morphologic features of Blastocystis sp subtype 3. Am J
Clin Pathol 2010;133:251-8.
16. Dunn LA, Boreham PF. The in-vitro activity of drugs
against Blastocystis hominis. J Antimicrob Chemother
1991;27:507-16.
17. Boorom K. Commensal and Pathogenic Blastocystis with
Case Studies from Oregon’s Willamette Valley. Corvallis:
FBH Press; 2006.
18. Nasirudeen AM, Hian YE, Singh M, Tan KS. Metronidazole
induces programmed cell death in the protozoan parasite
Blastocystis hominis. Microbiology 2004;150:33-4.
19. Lantsman Y, Tan KS, Morada M, Yarlett N. Biochemical
characterization of a mitochondrial-like organelle from
Blastocystis sp. subtype 7. Microbiology 2008;154:2757-66.
20. Upcroft P, Upcroft JA. Drug targets and mechanisms of
resistance in the anaerobic protozoa. Clin Microbiol Rev
2001;14:150-64.
21. Yakoob J, Jafri W, Jafri N, Islam M, Asim Beg M. In vitro
susceptibility of Blastocystis hominis isolated from
patients with irritable bowel syndrome. Br J Biomed Sci
2004;61:75-7.
22. Tungtrongchitr A, Manatsathit S, Kositchaiwat C,
Ongrotchanakun J, Munkong N, Chinabutr P, et al.
Blastocystis hominis infection in irritable bowel syndrome
patients. Southeast Asian J Trop Med Public Health
2004;35:705-10.
Tropical Parasitology
23. Mahdi NK, Strak SK. The effectiveness of metronidazole,
praziquantel and cotrimoxazole on Blastocystis hominis.
Int J Glob Educ 2005;1 (5).
24. Stenzel DJ, Boreham RE. Blastocystis. In: Gillespie S and
Pearson RD, editors. Principles and Practice of Clinical
parasitology. Hoboken, New Jersey: John Wiley and Sons;
2001. p. 355-67.
in Blastocystis hominis infection. Am J Gastroenterol
1999;94:3245-7.
trimethoprim-sulfamethoxazole in Blastocystis hominis
infection. Turkiye Parazitol Derg 2009;33:270-2.
27. Heyland K, Friedt M, Buehr P, Braegger CP. No advantage
for antibiotic treatment over placebo in Blastocystis
hominis-positive children with recurrent abdominal pain.
J Pediatr Gastroenterol Nutr 2012;54:677-9.
28. Moghaddam DD, Ghadirian E, Azami M. Blastocystis
hominis and the evaluation of efficacy of metronidazole
and trimethoprim/sulfamethoxazole. Parasitol Res
2005;96:273-5.
29. Idris NS, Dwipoerwantoro PG, Kurniawan A, Said M.
Intestinal parasitic infection of immunocompromised
children with diarrhoea: Clinical profile and therapeutic
response. J Infect Dev Ctries 2010;4:309-17.
30. Diaz E, Mondragon J, Ramirez E, Bernal R. Epidemiology
and control of intestinal parasites with nitazoxanide in
children in Mexico. Am J Trop Med Hyg 2003;68:384-5.
31. Rossignol JF, Kabil SM, Said M, Samir H, Younis AM.
Effect of nitazoxanide in persistent diarrhea and enteritis
associated with Blastocystis hominis. Clin Gastroenterol
Hepatol 2005;3:987-91.
32. Kick G, Rueff F, Przybilla B. Palmoplantar pruritus
subsiding after Blastocystis hominis eradication. Acta
Derm Venereol 2002;82:60.
33. Valsecchi R, Leghissa P, Greco V. Cutaneous lesions
in Blastocystis hominis infection. Acta Derm Venereol
2004;84:322-3.
34. Zierdt CH, Swan JC, Hosseini J. In vitro response of
Blastocystis hominis to antiprotozoal drugs. J Protozool
1983;30:332-4.
35. Tan KS, Mirza H, Joshua DW, Wu B, MacAry Pa. Current
views on the clinical relevance of Blastocystis spp. Curr
Infect Dis Rep 2010;12:28-35.
36. Kelesidis T, Pothoulakis C. Efficacy and safety of the
probiotic Saccharomyces boulardii for the prevention
and therapy of gastrointestinal disorders. Therap Adv
Gastroenterol 2012;5:111-25.
37. Yakoob J, Abbas Z, Beg MA, Naz S, Awan S, Hamid S,
et al. In vitro sensitivity of Blastocystis hominis to garlic,
ginger, white cumin, and black pepper used in diet.
Parasitol Res 2011;109:379-85.
How to cite this article: Sekar U, Shanthi M. Blastocystis: Consensus
of treatment and controversies. Trop Parasitol 2013;3:35-9.
Source of Support: Nil. None declared.
DOA: 12-03-2013, DOP: 24-06-2013
39 Jan 2013 | Volume 3 | Issue 1 |
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