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Balantidium coli is a large ciliated intestinal protozoan found worldwide, but particularly in the tropics Pigs are the main reservoir The infection is rare in humans, and results from ingestion of cysts passed in stools of humans or swine In the new host, the cyst wall dissolves and the trophozoite may invade intestinal mucosa, causing abscesses and ulcerations Many infections are asymptomatic Chronic infections may cause recurrent diarrhea or dysentery Deaths have occurred from intestinal perforation and hemorrhage

Dientamoeba fragilis is a protozoan that commonly causes infection without symptoms, so its role in human disease remains somewhat controversial Symptoms attributed to the pathogen include diarrhea, abdominal pain, and anorexia Other flagellates may infect humans, are generally considered nonpathogens, but may be markers for fecal-oral contamination Diagnosis of balantidiasis is established by finding trophozoites or cysts in stool, or ulcer scrapings of the large bowel D fragilis infection can be hard to diagnose because it only exists in the trophozoite form; the sensitivity of evaluation of three stools is 70 90% The treatment of choice for balantidiasis is tetracycline, 500 mg orally four times daily for 10 days The alternative is iodoquinol (diiodohydroxyquin), 650 mg orally three times daily for 21 days, and metronidazole, paromomycin, and nitazoxanide have also been used successfully D fragilis infections have been successfully treated with metronidazole, iodoquinol, and tetracycline; all the doses are the same as for balantidiasis

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Ferry T et al Severe peritonitis due to Balantidium coli acquired In France Eur J Clin Microbiol Infect Dis 2004 May;23(5): 393 5 [PMID: 15112068] Stark DJ et al Dientamoebiasis: clinical importance and recent advances Trends Parasitol 2006 Feb;22(2):92 6 [PMID: 16380293] Vandenberg O et al Clinical and microbiological features of dientamoebiasis in patients suspected of suffering from a parasitic gastrointestinal illness: a comparison of Dientamoeba fragilis and Giardia lamblia infections Int J Infect Dis 2006 May;10(3):255 61 [PMID: 16469517]

yellow or green in color Inflammation of the vaginal walls and cervix with punctate hemorrhages are common Most men infected with T vaginalis are asymptomatic, but it can be isolated from about 10% of men with nongonococcal urethritis In men with trichomonal urethritis, the urethral discharge is generally more scanty than with other causes of this syndrome

Diagnosis is made by identifying the organism in vaginal or urethral secretions Examination of wet mounts will show motile organisms Tests for bacterial vaginosis (pH > 45, fishy odor after addition of potassium hydroxide) are often positive with trichomoniasis Other diagnostic techniques include culture of trichomonads, immunologic assays, and molecular probes, but these are not used routinely

The treatment of choice is metronidazole (2 g single oral dose) Tinidazole is now also approved for this indication at the same dose, and it may be better tolerated and active against some resistant parasites Toxicities of these drugs are discussed in the section on amebiasis If the large single dose cannot be tolerated, an alternative metronidazole dosage is 500 mg orally twice daily for 1 week All infected persons should be treated, even if asymptomatic, to prevent subsequent symptomatic disease and limit spread Treatment failure suggests reinfection, but metronidazoleresistant organisms have been reported These may be treated with tinidazole, longer courses of metronidazole, or some experimental therapies

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Nanda N et al Trichomoniasis and its treatment Expert Rev Anti Infect Ther 2006 Feb;4(1):125 35 [PMID: 16441214] Swygard H et al Trichomoniasis: clinical manifestations, diagnosis and management Sex Transm Infect 2004 Apr;80(2): 91 5 [PMID: 15054166] Wendel KA et al Trichomoniasis: challenges to appropriate management Clin Infect Dis 2007 Apr 1;44 Suppl 3:S123 9 [PMID: 17342665]

Copious vaginal discharge in women Nongonococcal urethritis in men Motile trichomonads on wet mounts

Trichomoniasis is caused by the protozoan Trichomonas vaginalis and is among the most common sexually transmitted diseases, causing vaginitis in women and nongonococcal urethritis in men It can also occasionally be acquired by other means, since it can survive in moist environments for several hours

HELMINTHIC INFECTIONS TREMATODE (FLUKE) INFECTIONS SCHISTOSOMIASIS (BILHARZIASIS)

T vaginalis is often harbored asymptomatically For women with symptomatic disease, after an incubation period of 5 days to 4 weeks, a vaginal discharge develops, often with vulvovaginal discomfort, pruritus, dysuria, dyspareunia, or abdominal pain Examination shows a copious discharge, which is usually not foul smelling but is often frothy and

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