e-ISSN 1941-5923

© Am J Case Rep, 2023; 24: e939583

DOI: 10.12659/AJCR.939583

Received:
Accepted:
2023.01.25
2023.06.26 A Case of Urbanorum spp. in a Woman
Available online:
Published:
2023.07.06
2023.08.09 from an Urban-Marginal Sector of Ecuador
Authors’ Contribution: ABCDEFG 1 Roberto Darwin Coello Peralta 1 Department of Microbiology, Faculty of Veterinary Medicine and Zootechnics,
Study Design A E 1 Sandra Gabriela Parra-Guayasamin Universidad de Guayaquil, Guayaquil, Ecuador
Data Collection B 2 Faculty of Health and Social Services, Universidad Estatal de Milagro
Statistical Analysis C DFG 2 Carmen A. Yancha Moreta (UNEMI), Milagro, Ecuador
Data Interpretation D DFG 2 Gilma Esperanza Guerrero Lapo 3 Department of Biological Sciences, Universidad Central del Ecuador, Quito,
Manuscript Preparation E BCF 1 Diego Martín Cushicóndor Collaguazo Ecuador
Literature Search F 4 Faculty of Medical Sciences, Universidad Católica de Santiago de Guayaquil,
Funds Collection G BCF 3 Natali Estefanía Ortega Tinajero Guayaquil, Ecuador
E 2 Betty Judith Pazmiño Gómez 5 Instituto de Invertebrados, Fundación Miguel Lillo, San Miguel de Tucumán,
AE 4 Eduardo Alfredo Gómez Landires Argentina

ABCDEF 5 Geraldine Ramallo

Corresponding Author: Roberto Darwin Coello Peralta, e-mail: roberto.coellope@ug.edu.ec

Financial support: Universidad de Guayaquil
Conflict of interest: None declared

Patient: Female, 40-year-old

Final Diagnosis: Presence of Urbanorum in a woman from Ecuador
Symptoms: Diarrhea • low body weight • abdominal discomfort • fever
Clinical Procedure: Clinical finding • microscopic parasite identification.
Specialty: Laboratory Diagnostics • Infectious Diseases • General and Internal Medicine •
Microbiology and Virology • Public Health • Tropical Medicine

Objective: Rare disease

Background: Worldwide, there are few cases of Urbanorum spp. in humans; however, it is associated with gastrointestinal
pathologies, where humans probably acquire the disease by fecal-oral transmission, by ingesting food or water
with infective cysts. The main symptoms of the patients who have this presumed parasite are fever, vomiting,
colic, dyspepsia, and watery diarrhea. Since the first case of Urbanorum spp. was reported in 1994 in Colombia,
cases have subsequently been reported in Peru, Ecuador, Colombia, Brazil, and Mexico. In Ecuador, a prevalence
of 1.16% has been reported, and the objective of this study was to record another case of Urbanorum spp. in-
fection in Ecuador.
Case Report: A female patient (mixed race; 40 years old; and thin, weighing 57 to 62 kg) requested help from the FCI Project
approved and financed by the University of Guayaquil (Ecuador). She underwent routine tests, such as direct
parasitology and sedimentation with centrifugation using saline solution. Samples were observed under an
optical microscope with 10x and 40x objectives and stained with and without Lugol’s solution. We detected a
rounded structure with several filaments similar to light yellow pseudopods.
Conclusions: Herein, a case of Urbanorum spp. infection in Ecuador, where current environmental and sanitary conditions
have contributed to new cases, is reported, indicating that the community was exposed to this probable para-
site with importance in public health. Further studies are recommended to confirm its etiology, life cycle, and
epidemiology, in order to create a national registry, in case it is defined as a protozoan.

Keywords: Ecuador • Environment and Public Health • Clinical Laboratory Techniques • Parasitology

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Background
Protozoa and helminths (enteroparasites) are very prevalent
and persistent worldwide. It is estimated that 3.5 billion peo-
ple around the world are affected, constituting a serious pub-
lic health problem due to the epidemiological triangle of par-
asitic diseases, that is, the relationship between the condition
of the host, the parasite, and the environment [1,2]. Helminths
are highly prevalent in developing countries, and their frequen-
cy is an indicator of socioeconomic and health deficiency in a
region. Parasite occurrence is prevalent among hosts exposed
to poor basic sanitary conditions and with low levels of edu-
cation (schooling) and inadequate hygiene habits, which al-
lows the appearance of parasites, affecting the health of local
populations [3]. Parasites can cause various gastrointestinal
pathologies, malnutrition, cognitive and physiological delays,
and even death, independent of age [2].
In 1991, Dr. Francisco Tirado Santamaría reported the first cas-
es of Urbanorum spp. in fecal samples of patients treated in
Barrancabermeja Health Center (Colombia) and described it
as a risk of public health [4]. Urbanorum spp. are observed as
rounded structures between 80 and 100 µm in diameter; when
stained with Lugol’s solution, this helminth exhibits light yel-
low content with a double outer membrane that presents pores
through which hyaline structures emerge from its interior, simi-
lar to pseudopods, constituting their mode of locomotion [4,5].
Reproduction occurs by binary division, and thus, Urbanorum spp.,
apparently does belong to the phylum Sarcomastigophora, are
considered an amoeboid protozoan, with reproduction by endo-
diogenesis, and so far, the life cycle in humans is not known [6,7].
Similar to other intestinal parasites, the transmission of
Urbanorum spp. is associated with lack of personal hygiene
and water, soil, and food contaminated by the protozoan and
is the cause of acute diarrheal syndrome, which is character-
ized by fever, vomiting, diarrheal stools, colic, dyspepsia, and
liquid stool samples without blood, mucus, or leukocytes, and
with acidic pH. These symptoms are due to the attack of this
presumed parasite in the large intestine of the host. [2,6]. For
the treatment of infected patients, metronidazole and secni-
dazole are recommended [7,8].
Ecuador has high rates of intestinal parasites [9,10], and this
report presents a case of natural infection by Urbanorum spp.
Therefore, health professionals and officials must provide in-
formation to the population to guide them in prevention.
This case report was part of the FCI-029 Project (Fund
Competitive of Research) approved and was financed by the
University of Guayaquil (Ecuador), called: “Ecoepidemiology of
neglected intestinal helminthiasis in urban-marginal and rural
areas of the Guayas province”.
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NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)
Coello Peralta R.D. et al:
Urbanorum spp. in a woman from Ecuador
© Am J Case Rep, 2023; 24: e939583
Case Report
A thin, 40-year-old woman who weighed between 57 and 60
kg was a resident of the urban-marginal sector of the “Balerio
Estacio” Cooperative of the city of Guayaquil, Ecuador; she had
a history of diarrhea, low body weight, abdominal discom-
fort, and fever of 2 days of evolution. She consulted research-
ers from the FCI-029 Project of the University of Guayaquil
(“Ecoepidemiology of Neglected Intestinal Helminthiases in
Urban-Marginal and Rural Areas of the Province of Guayas,”
on November 24, 2022. That same day the patient was seen
in the Private Ecomedical Center, the symptoms were consid-
ered, and the infection was confirmed with the results ob-
tained from the laboratory.
The physical evaluation carried out showed that the ocular and
oral mucosa, cardiac and pulmonary auscultation, and abdom-
inal palpation and percussion were normal.
The place where the patient resides did not have adequate
sanitation, which had a large epidemiological impact, and was
a research site of the aforementioned project. Informed con-
sent was requested from the patient before a sample was ob-
tained. The method for obtaining the sample was explained to
the patient, who was provided a sterile container. Fecal sam-
ples were transported on the day of collection in refrigerated
boxes (4-8°C) to the “Pazmiño” Clinical and Microbiological
Laboratory in the city of Milagro.
The samples obtained were semi-liquid, common to diarrhea.
Later, they were analyzed using coproparasitic methods: di-
rect parasitological and sedimentation with centrifugation us-
ing saline solution. The sample was stained with Lugol’s solu-
tion and examined the same day using 10× and 40× objectives.
The analyzed sample lacked red blood cells, leukocytes, and
mucus, but contained a round structure and several filaments,
similar to those described by Rodrigues and Gonçalves (2022)
and Sousa and Alves (2018) [2,6] (Figure 1). In addition, the
microscopic analysis of the presumed parasite was indica-
tive of Urbanorum spp., later confirmed by an expert from the
University of the Americas (UDLA) of Ecuador, causing con-
cern because it was another case report of this presumed par-
asite in Ecuador.
The patient was treated with metronidazole administered in
doses of 500-750 mg PO every 8 hours for 10 days. Fourteen
days after treatment, the team from Project FCI-029 of the
University of Guayaquil reported that the patient’s health
had improved.
The blood tests performed presented normal values. In addi-
tion, a differential diagnosis was made in a private laboratory
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Coello Peralta R.D. et al:
Urbanorum spp. in a woman from Ecuador
© Am J Case Rep, 2023; 24: e939583
through fecal parasitology and stool cultures of Amebiasis,
Giardiasis, Cystoisosporiasis, Colibacillosis, and Salmonellosis,
but none were registered.
A limitation of the present report is that the patient could not
be followed up after treatment since she did not repeat the
parasitological tests after she felt better. However, the identi-
fication of Urbanorum spp. was very important.
Discussion
The environmental conditions in Ecuador are favorable for the
appearance of cases of intestinal parasites. In Latin America,
Urbanorum spp. infection has also been reported in Colombia,
Peru, Ecuador, Brazil, and Mexico [5,6,11,12]. The structure of
Urbanorum spp. in this report had the same morphological
characteristics as those reported by other authors [2,13,14],
which suggests the presence of natural infection of this pre-
sumed protozoan in Ecuador.
In South America, Urbanorum spp., like other human intesti-
nal parasites, are acquired through fecal-oral infection by in-
gesting food or water containing parasite cysts [4].
Tirado Santamaría carried out several studies that serve as an
epidemiological record of this infectious agent in Colombia. In
1991, he observed Urbanorum spp. in samples of symptomat-
ic patients treated at the Barrancabermeja Health Center [5].
Three years later, Urbanorum spp. was found in 16.6% of 283
samples analyzed, and in 13.98% of 143 samples in 1996.
Between 1997 and 1998, of 14 000 fecal samples, 1400 con-
tained the presumed parasite. In Barrancabermeja, in 2006,
of 500 fecal samples of from school children, a prevalence of
10% was determined. One year later, in Piedecuesta-Santander,
200 samples from school-age children were analyzed, of which
5% contained the presumed parasite [4,5].
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Figure 1. Microscopic identification of
Urbanorum spp., determined in
feces of an investigated woman,
highlighting their shape, light yellow
color, and morphology, using the direct
coproparasitic method, as viewed
under a light microscope using 40×
objective and stained with Lugol’s
solution.
In Peru, during 2006, of a total of 96 children 3-14 years of
age, 20.8% were infected with Urbanorum spp. [15]. That same
year, a 67-year-old woman with abdominal pain and dyspep-
sia for 9 months from San Juan de Lurigancho (Lima) consult-
ed at the Aurelio Díaz Hospital, and was diagnosed with infec-
tion with Urbanorum spp. and other protozoa [5].
In Ecuador in 2016, in a study on the prevalence of protozoa
and helminths in 3 different regions of Ecuador, out of a total
of 295 fecal samples, various types of parasites were identified.
Furthermore, the presence of Urbanorum spp. was reported in
the Costa region for the first time, with a prevalence rate of
1.16% [12]. Two years later, this infectious agent was identi-
fied in the city of Milagro. Of a total of 225 people studied, be-
tween 2 and 86 years old, 4 were infected by Urbanorum spp.
(1.77%), but they were asymptomatic; this was presented at
the 14th International Congress of Parasitology 2018 in Daegu-
Korea [16]. Ayol (2022) identified the protozoan in a child from
the rural parish of Mariscal Sucre in the city of Milagro [17].
In Brazil, the first report of Urbanorum spp. occurred in 2017
in a 41-year-old woman who weighed 55-60 kg and resid-
ed in the city of Buriti in Maranhão. This rural area does not
have basic sanitation or access to drinking water. She had ab-
dominal cramps and fever and was diagnosed with acute di-
arrhea [6]. A year later, the second case was reported, in the
city of Livramento, Rio Grande do Sul, in a 72-year-old patient
with Sjögren’s syndrome, but he did not have symptoms. In the
same year, 2 other patients were diagnosed with Urbanorum
spp. [18]. In that same year, in the city of Imperatriz – Ma, of
5428 parasitological examinations of samples from individu-
als 28-77 years old, 25 (0.46%) were positive. In 2018, Leão et
al analyzed a total of 5786 stool samples, and 84 (1.45%) had
morphological characteristics compatible with Urbanorum spp.
[19,20]. In 2019, in São José dos Pinhais-Paraná, infection oc-
curred in a 56-year-old male diabetic patient who used metfor-
min and consulted the doctor mainly for abdominal colic [18].
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In a study carried out in 2020 in cities of the Vale do Paraíba
metropolitan region, of a total of 2777 samples analyzed us-
ing the Hoffman, Pons, and Janner technique, 252 samples
(9.07%) were positive for Urbanorum spp. [2].
In 2019 in Veracruz (Mexico), Bonilla et al found the first
case of Urbanorum spp, using the direct coproparasitic meth-
od. The patient was a 49-year-old woman with nausea, head-
ache, flatulence, substantial abdominal distention, and colicky
pain, without fever or vomiting. Her stools were brown, soft,
and bloodless, with mucus. Three days after onset, she devel-
oped hyporexia, a poor general condition, nausea, abdominal
distention, slight dehydration of the oral mucosa, an increase
in the number of evacuations from 4 to 5 per 24 hours, and
prostration [13].
Although previous studies have performed several different
parasitological techniques, the techniques used in the pres-
ent study (direct method and sedimentation method) effec-
tively identified Urbanorum spp. The environmental, sanitary,
sociocultural, and economic conditions of an area influence
the epidemiology of this presumed parasite [15]; therefore, it
can persist in different environments, for example, rural ar-
eas [6], urban areas [4,5] and urban-marginal areas, as in the
present study, creating a high public health risk.
The reports of Urbanorum spp. have sparked debates in the sci-
entific community. According to Rivero, the hyaline structures
identified by Professor Tirado are related to connective tissue
adipose cells, which, when broken, release a series of filaments
that can temporarily exhibit ineffective movement, similar to
the emission of pseudopods from macrophages [21]. In addition,
Silva-Diaz stated that studies are needed to verify the biological
status of Urbanorum spp. and contribute to taxonomy, and it is
necessary to perform parasitological cultures, molecular analy-
sis, and electron microscopy. Further scientific evidence and ran-
domized controlled trials are needed to determine the cause-ef-
fect relationship between the infectious agent and the host [8].
This study was based on the identification of morphological
characteristics of Urbanorum spp; however, more studies are
needed to confirm the parasitic etiology. Likewise, in light of
this other case of this presumed parasite in Ecuador and an-
other case in South America, and because of the favorable
conditions for development, it is likely that cases will occur in
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Coello Peralta R.D. et al:
Urbanorum spp. in a woman from Ecuador
© Am J Case Rep, 2023; 24: e939583
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