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Difficulties in Diagnosis

Parasitic infections have long been considered diseases of the tropics, so physicians often don’t consider them when diagnosing common illnesses. Parasitology is seldom discussed in the mainstream medical journals, and traditionally there has been little reporting of parasite incidence. For example, Giardia has been widely tracked by the Centers for Disease Control (CDC) only since 1987. When physicians receive their training, very little Informa­tion is provided on parasitology in medical school and in professional jour­nals. Given the lack of information and minimal clinical exposure, doctors don’t usually consider parasites as a possible cause of illness, especially when the symptoms aren’t confined to the digestive tract. It is those medical professionals who fail to prescribe the proper diagnostic tests for parasites because their presence is even not suspected. And when that is not done, a proper treatment is not even considered. For the sake of detection of parasitic infections, doctors need to be able to recognize parasitic symptoms so that their patients’ well-being is not compromised. We provide below a summary of intestinal and extra-intestinal parasitic symptoms that are needed to ascertain for parasite testing and detection so that proper corrective measures are employed:

GI symptoms	Systemic/other symptoms
Diarrhea/constipation	Fatigue
Irritable bowel	Skin rash
Cramps	Dry cough
Gas & bloating	Brain fog/memory loss
Bleeding.	Lymph blockage
Appetite changes	Allergies
Malabsorption	Nausea
Mucus	Muscle or joint pain
Rectal itching	Dermatitis
Poor digestion	Headaches

Difficulties in Detection

Parasites have complex life cycles and are often not shed at regular intervals. In fact, three of the major parasites in the United States and worldwide (amoebas, giardia, and cyclospora) tend to be shed at irregular intervals. This means that the parasite may be present in the stool for two, three, or four days a week, but not the rest of the week. Entamoeba histolytica is active for one or two days and then is not typically active or detectable the next day or two. When E. histolytica migrates to the liver, it disappears from the gut and becomes undetectable in fecal specimens. If the stool sample is collected from a patient with one of these cyclical parasites on a day when the pathogen is not active, it won’t be in the stool and obviously won’t be detected by testing. However, this doesn’t mean that there’s no infection present. At the current time this is a limitation for which no modem technology can compensate. Consequently repeated samples are very important. Generally, to make testing practicable, we recommend at least two or three samples be taken on different days.

Emerging Pathogens

Another problem we encounter in detection is the fact that there are so many emerging pathogens. These are new parasites, which remain insufficiently studied. For example, cyclospora was formally classified as a human parasite for the first time just a few years ago. Before that the labs were probably seeing it, but didn’t know what it was because it hadn’t been described as such and its diagnostic characteristics were not reported. Other pathogens are reclassified as they become better understood or as their virulence is observed to change. Only in the 1990s has Dientamoeba fragilis come to be considered capable of causing disease (pathogenic). Similarly, Chelomastix mesnili, Endolimax nana, Iodoamoeba butschlii, and until recently Entamoeba coli and Entamoeba hartmanni, are often not treated because they are not considered full-fledged parasites by some. We cannot help but note that doctors are not parasitologists. We often note that the body will not be indifferent to a foreign organism feeding upon its tissues and fluids. In addition there are some life forms in nature that make detection extremely difficult. Bacteria have been identified that can exist without a cell wall and therefore can take on many shapes. These elusive pathogens make diagnosis extremely difficult.

Optimal Detection

The most effective method of detecting intestinal parasites continues to be stool sampling following our PCI protocol. The optimal approach involves taking samples every other day, a min­imum of 48 hours apart, collecting at least two or three samples. Specimens are collected and transported to the testing facility in Proto-fix™ in plastic vials provided in mailable kits. Specimens are collected throughout the United States following physician’s orders. Tests are ordered either as part of routine medical examinations or when patients experience changes in bowel habits, energy level, or normalcy after a foreign trip, bad meals, or other exposures. Specimens are processed and stained in CONSED™ according to manufacturer’s (AlphaTec Systems, Inc., Vancouver, WA) directions. This procedure was used in 10,358 specimens by 1998, and was described, fully evaluated, and compared with other methods. The number of specimens found positive (number of individuals and of species of parasites) was significantly higher than in other methods compared, e.g., formalin-ethyl acetate or trichrome stain. These observations were supported by findings of other observers.

The Proto-fix™-CONSED™ system involves filtering of fixed specimens, mixing with CONSED™ and ethyl acetate, vortexing, centrifugation, decanting all but the fecal plug, and mixing with CONSED™ diluting reagent. The plug is then transferred to and mounted on a slide for examination. All microscopic evaluations and identification are made by the same observer(s) blinded to patient information, e.g., symptoms, travel, etc. Positive results were quantified (number of organisms per high-power field on a scale of 1 to 4) from duplicate samples from the same patient.

      Although some microbes such as E. histolytica reside in the large intes­tine, many are harbored in the small intestine. Pathogens such as Giardia reside primarily in the small intestine, where they strongly adhere to the intestinal lining and therefore cannot usually be detected in samples from stool further down the digestive tract. For this reason the test must include matter from the small intestine in order to test as accurately as possible. The best specimen is a sample of soft stool taken during the occurrence of a diarrheal episode because it usually contains material from the small intestine. In the patient who has constipation, the purge test is most optimal.

Other Methods of Testing

Elevated white blood count (eosinophil level) may be used as a screening tool to indicate the need for further testing.

Antibody testing is also available. Antibody levels for immunoglobulin G (IgG) can indicate infection, but not whether the infection is current or previous. If repeated testing for IgM levels (base then a 2-week sample) shows an increasing titer, it will indicate that the infection is currently active.

Samples of blood serum can be evaluated to detect parasites found in the blood. However, this method is useful only for parasites of the circulatory system such as malaria, Babesia, Chagas disease and other trypanosome infections, but not those most typically found in the GI tract.

Blood parasites aside, thin blood films demonstrating blood cells’ abnormalities will indicate many metabolic dysfunctions and thus become a very important diagnostic tool for managing systemic pathologies. Some of the metabolic dysfunctions marked by blood cell abnormalities include alcoholic cirrhosis, hemolytic anemia, renal disease, cold agglutination disease, macroglobulinemia, heavy metal poisoning, oxidant stress, thalassemia, iron deficiency anemia, megaloblastic anemia, hemolytic anemia, tuberculosis, uremia, renal failure, and many more, depending on if the RBS are abnormal. Abnormal RBC may be acanthocytic (spur cell), degmacytic (with multiple arculate defects), codocytic (thin hypochromatic cell), dacrocytic (tear-drop-shaped), drepanocytic (sickle-cell-shaped), elliptocytic (elliptical in shape), macrocytic (thin large cells), or echinocytic (crenated).

Tissue samples from biopsies of the colon or duodenum can be tested for parasitic infection, as well as tumors or pathology. Similarly, puncture biopsies of skin lesions become indispensable to test for leishmaniasis and oriental sore disease, providing that the epidemiology of the case is supportive.

Other tests for gut microbiome do not actually attempt to detect parasites but they provide parameters for biofilms, inflammatory activities, digestive efficiency, gut lining health, gas production, protein fermentation, and active microbial diversity.

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