Case report

報告人: I2 顏銘漢 指導人: 盧章智 主任

History
 A 25-year-old woman had recently returned from a trip to the Rocky Mountains. She had been traveling with a group of campers, who had obtained their drinking water from a lake. A few days after returning home, she presented to her internist suffering from profuse(過多 的) watery diarrhea, crampy epigastric pain, and foul(惡臭)-smelling flatulence (屁). She discovered that most of the other campers had reported symptoms similar to her own.

no wet mounts (載片) were made to detect motility. A permanent trichrome stain revealed rare. . oval protozoan trophozoites.History  Three stool specimens were submitted for laboratory analysis. All specimens were negative for enteric bacterial pathogens. and two were also negative for parasites. Since the specimens for ova and parasites were received in vials containing the preservatives polyvinyl alcohol and 10% formalin. measuring 9 to 20 jjum in length and 5 to 15 jjim in width.

having four nuclei. . and characteristic median bodies and longitudinal fibers were also seen. Typical cysts are demonstrated. The structure of this parasite gave the overall appearance of a "smiling face" .History  The broad anterior end of each trophozoite(滋養期原蟲 ) contained a concave area which covered half the ventral surface. Rare cysts.

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Which protozoan parasite is causing the camper's infection? Which form of this parasite is infectious? A: Giardia lamblia. (giardiasis)梨形蟲病 cyst .Questions       1.

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are passed in the feces of an infected host. How is this parasite transmitted? A: Cysts. and the next host is infected when it ingests cysts in food or water contaminated with feces . which are resistant to adverse environmental conditions.    2.

fountains. or streams that can be contaminated with sewage or feces from humans or animals. changing tables. jacuzzis.  Swallowing recreational water contaminated with Giardia.  Accidentally swallowing Giardia picked up from surfaces (such as bathroom fixtures. rivers. . hot tubs. springs.  Eating uncooked food contaminated with Giardia. ponds. Recreational water includes water in swimming pools. or toys) contaminated with feces from an infected person. Accidentally putting something into your mouth or swallowing something that has come into contact with feces of a person or animal infected with Giardia. lakes. diaper pails.

     .  3. Avoid food that might be contaminated. Avoid fecal exposure during sexual activity. Avoid water that might be contaminated. How can this infection be controlled and prevented? A: Practice good hygiene.

    4. . in the trophozoite (active) form. There. it feeds and reproduces. attaches itself with an adhesive disk (ventral side) to the lining of the upper intestinal tract of the host animal. How does this parasite attach itself to the intestinal wall? A: Giardia is a flagellated (having whip-like appendages for locomotion) protozoan that.

fatty. Which condition might result as a consequence of this attachment?  1.milk allergy or lactose intolerance (<1 Y/O) . four-smelling stools after eating  3.malabsorptive diarrhea  2.

How is this infection treated? The most common treatment for giardiasis is metronidazole (Flagyl) for 5-10 days. It eradicates the Giardia more than 85% of the time. It is approximately as effective as metronidazole. The only drug approved for treating giardiasis in the U.   5. but it often causes gastrointestinal side effects such as nausea and a metallic taste as well as dizziness and headache.S.  . is furazolidone (Furoxone) for 710 days.

 Occasionally. though effective. . the drug may be changed or a longer duration or higher dose may be used. are less effective than other treatments. It also can be given as a single dose and is well tolerated.S. and is highly effective at treating giardiasis(>90%).. Combination therapy also may be effective (e.g.  Quinacrine is very effective for treating giardiasis but is no longer available in the U. quinacrine and metronidazole).S. Tinidazole is available outside the U. treatment fails to eradicate Giardia.  Paromomycin and albendazole. In such cases.

Then. it transforms into an egg-like structure called a cyst. Duration of cyst excretion. Describe the life cycle of this parasite. As it makes its journey. and the cycle repeats. At some time in its active life. may persist for months. the trophozoite releases its hold on the bowel wall and floats in the fecal stream. which is eventually passed in the stool. called shedding. Once outside the body. . they “hatch” into trophozoites due to stomach acid action and digestive enzymes.   6. the cysts can be ingested by another animal.

. They may not appear at all. The symptoms typically appear one to two weeks after ingestion. with an average of nine days. Symptoms can vanish suddenly and then reappear. A significant infestation can leave millions of trophozoites stuck tight to the intestinal lining. but four weeks is not uncommon.   7. especially fats. Describe the pathogenesis of this infection. There. They may hide for months. they cripple the gut’s ability to secrete enzymes and absorb food. thereby producing the disease’s symptoms.

these procedures reduce the number of recognizable organisms in the sample. A commercial fluorescent antibody kit is available to stain the organism. either the trophozoite or the cyst in stained preparations or unstained wet mounts with the aid of a microscope.    . Organisms may be concentrated by sedimentation or flotation.    8. An enzyme linked immunosorbant assay (ELISA) that detects excretory secretory products of the organism is also available. however. How is the laboratory diagnosis of this infection made? A: Giardia lamblia is frequently diagnosed by visualizing the organism.

 9. This is presumed to be due to sexual transmission. both HIV-positive and HIVnegative individuals. This organism is implicated in 25% of the cases of gastrointestinal disease and may be present asymptomatically. . especially those in which diapering is done. The overall incidence of infection in the United States is estimated at 2% of the population. possibly because many individuals seem to have a lasting immunity after infection.  A:  Giardiasis is more prevalent in children than in adults.  Discuss the epidemiology of this infection. This disease afflicts many homosexual men. The disease is also common in child day care centers.

 How does the structure of these trophozoites account for the "smilingface" appearance?  A: . 10.

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