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Le Infezioni in Medicina, n. 2, 171-175, 2018 CASE REPORTS 171

Potential sexual of in an endemic region: a case series

Angel A. Escobedo1,2, Gustavo Acosta-Ballester3, Pedro Almirall4, Alfonso J. Rodríguez-Morales2,5, Cecilia Ortíz6, Alfredo Laffita7, Elaine Chirino8 1Academic Hospital “Pedro Borrás”, La Habana, Cuba; 2Working Group on Zoonoses, International Society for Chemotherapy, Aberdeen, United Kingdom; 3Primary Health Care clinic “Lawton”, La Habana, Cuba; 4Municipal Centre of , Epidemiology and Microbiology “Plaza”, La Habana, Cuba; 5Research group Public Health and infection, Faculty of Health Sciences, Universidad Tecnológica de Pereira (UTP), Pereira, Risaralda, Colombia; 6Gyneco-obstetric Hospital “Ramón González Coro”, La Habana, Cuba; 7Gyneco-obstetric Hospital “América Árias”, La Habana, Cuba; 8Primary Health Care clinic “Héroes del Moncada”, La Habana, Cuba

SUMMARY

We present four cases in which probable sexual trans- when other more frequent modes of transmission mission of Giardia lamblia was suspected. could be playing the main role, the possibility of (re) Diagnosing this mode of transmission in endemic ar- infection due to sexual transmission should not be eas is often difficult and should be considered only forgotten. as possible, because exposure to poor and Talking openly with patients, strengthening pa- a potentially contaminated environment are always tient-specific preventive measures and counselling latent. However, as patients reported, there was no appear to be needed to reduce risks of Giardia infec- history of drinking tap water, exposure to recreation- tion transmission due to this often neglected route. al water, eating contaminated , or other potential sources of infection but anilingus with an infected Keywords: Giardia, giardiasis, sexual transmission, HIV, partner. We consider that in endemic countries, even diarrhoea, combination therapy.

n INTRODUCTION In the same way, faecal-oral transmission can occur within households, daycare centres and custodial iardia lamblia, the aetiological agent of hu- institutions, and in those people who include and Gman giardiasis, is a protozoan widespread practice anilingus in their sexual repertoire, espe- throughout the world and it is estimated that in- cially in men who have sex with men (MSM) [3-6]. fects approximately 5-10% of the world´s popula- Giardia is often an asymptomatic -or self-limited- tion, especially in low- and middle-income coun- infection of the upper . When symp- tries where the prevalence rates may range from tomatic, this infection presents with non-specific 4-43% [1, 2]. Giardia transmission mainly occurs manifestations like diarrhoea, , when faecal excretion of cysts by ill persons or anorexia, nausea, vomiting, , and in- healthy carriers is followed by oral ingestion of creased [7]. Were these reasons not contaminated water or food by a susceptible host. enough, the value of the recent Giardia research is increased by the recognition that this protozoan has been linked to and Corresponding author chronic [8]. Angel A. Escobedo Relatively non-specific clinical features of this dis- E-mail: [email protected] ease lead to diagnostic difficulties. High indexes of 172 A.A. Escobedo, G. Acosta-Ballester, P. Almirall, et al.

suspicion by clinicians, as well as thorough eval- tological cure. She had completely recovered, with uation using sensitive techniques, are essential to resolution of her symptoms and both, she and her diagnose this infection. Treatment of giardiasis is husband remained well. based on 5- compounds (mainly and ), and Case 2. A 24-year-old healthy MSM noticed a (ABZ). When treatment fails to cure, change in bowel habits, with increased frequen- a number of factors must be considered, includ- cy and decreased consistency of faeces. Yellowish ing re-infections, non-compliance, re- foul watery diarrhoea, 3-4 times a day, abdomi- sistance, etc. [7]. nal pain and a decreased appetite were the main While in endemic areas the main sources of Gi- clinical manifestations. These started around 10 ardia infection seem to be water- or food-borne, days after a sexual encounter with an adult male other modes of infection including sexual trans- with whom he sporadically had sexual encoun- mission could have a role in transmission. Herein ters. He was very concerned about the possibility we report our experience with 4 cases, living in an of Giardia infection because his occasional partner endemic region in which the sexual transmission had had giardiasis no less than 4 times before. was considered as possible. He denied both receptive and insertive anal in- tercourse; however, they practiced fellatio and anilingus without protection, considering these n CASE REPORTS less risky practices in relation with HIV infection. Exposure to contaminated food and water were Case 1: A 35-year-old healthy woman started ruled out. The findings of a physical examina- with diarrhoea, , abdominal pain of several tion revealed moderated periumbilicar tender- days’duration; mild nausea and a decreased ap- ness. Faecal specimens for ova and parasites, and petite. On physical exam her abdomen was dif- modified acid-fast staining were requested. HIV fusely tender to palpation. There was no obvious testing was also offered. HIV tests were negative rash seen. Up to three faecal specimens were re- and modified acid-fast staining was negative for quested and Giardia cysts were observed. She was intestinal coccidia. After microscopic detection of treated with (SCZ) with resolution of Giardia cysts in faecal specimens, metronidazole symptoms and three negatives faecal specimens (MTZ) was prescribed for 5 days to the patient in follow up consultation. Four weeks later, she and he received the recommendation of abstain- started with similar symptoms and Giardia cysts ing anilingus without protection. In the follow up, were found in faecal specimens again. On repeated his faecal examination were negative for ova and questioning, exposure to persons with diarrhoeal parasites. He improved clinically with resolution illness or to contaminated food and water were of diarrhoea, and weight gain. Despite history of ruled out. However, she stated that had heard that recurrent giardiasis, his sporadic sexual partner Giardia could be transmitted sexually -by receptive had been asymptomatic throughout the patient’s vaginal intercourse-, and someone told her that if evaluation and management. He was invited to she had giardiasis, maybe her husband should re- attend to the doctor office and to be examined ceive treatment at the same time. We denied this for intestinal parasites. He was also confirmed to route of transmission, but on continued question- be infected with Giardia and successfully treated ing, she stated that she enjoyed actively perform- with a 7-day course of MTZ. ing anilingus during the sexual intercourse with her husband. Her husband was invited to attend to Case 3: A 56-year-old, HIV-infected MSM (11 the consultation. He was asymptomatic but when years diagnosed, receiving treatment with he was parasitologically examined, Giardia infec- HAART the last 5 years with apparent adher- tion was confirmed, too. Other family members, ence) with a past medical history of hyperten- who lived in the same house, were parasitologi- sion and asthma, started complaining with ab- cally examined and were negative for Giardia cysts dominal pain, diarrhoea, flatulence and weight in faecal specimens. The patient and her husband loss. The findings of a physical examination were given giardiasis treatment at the same time were unremarkable, only diffuse abdominal ten- with a single dose of SCZ, which resulted in parasi- derness. At the faecal examination it was found Potential sexual transmission of Giardia in an endemic region: a case series 173

Giardia and Entamoeba coli cysts. Modified ac- mal. HIV testing was offered to both, and was id-fast staining of faecal specimens was negative negative. Up to three faecal specimens were re- for intestinal coccidia. A thorough history re- quested and Giardia cysts were observed. Once vealed no potential source of infection other than etiological diagnosis was established, they were sexual. He protected himself avoiding drinking counseled about Giardia and its mode of transmis- unboiled water or eating food out of his house sion. Also, it was prescribed MTZ for 7 days for in order to prevent enteric parasitic infections the patient and his partner, and the recommen- that may complicate his HIV seropositive status. dation of drinking boiled water and abstaining He practiced protected anal intercourse (both re- anilingus until three negative faecal specimens ceptive and insertive). He participated in group after completion of a 7 day course of MTZ were sex, used sex toys and also practiced anilingus obtained. Only the 21-year-old patient attend- without protection. He had been previously di- ed to follow up and the three faecal specimens agnosed with intestinal amoebiasis, enterobiasis requested revealed the complete parasitological and . He was asked about the health cure. However, three weeks later, he re-attended of his most recent partner and he stated he used with symptoms again. The findings of his faecal to have recurrent Giardia infection. The patient examination revealed Giardia cysts again. On re- was initially and successfully treated with MTZ peated questioning, it appeared that the 28-year- for 5 days, parasitologically confirmed by faecal old male partner had only taken MTZ for three tests for ova and parasites, three weeks later, on days, time in which resolution of abdominal pain the day of their follow-up visit. A month later, and diarrhoea occurred and he stopped taking the symptoms reappeared, he reported being with 3 drug. So, they recommenced their sexual activi- nights history of severe pruritus ani; enterobiasis ties including mutual anilingus without protec- was suspected; however, it was not confirmed. tion. A repeat course of the same therapy led to a The patient reported a sexual encounter with complete parasitological cure in both men. They the same last partner and having had active an- improved clinically with resolution of diarrhoea, ilingus with him, again. Three additional faecal and weight gain. The complete parasitological specimens were requested. Once again exposure cure was achieved. to contaminated food and water were ruled out. Giardia cysts were found again and he was suc- cessfully treated with MTZ and ABZ, both for 5 n DISCUSSION days and repeating 200 milligrams of ABZ after 15 days, according to the guidelines for the treat- Giardia is a common and globally distributed ment of Enterobius vermicularis infections. Addi- intestinal protozoan, although this infection is tionally, he was recommended abstaining anilin- mainly observed in developing countries. It is the gus without protection. Apart from mild nausea commonest intestinal parasitic protozoan infec- and bitter taste he tolerated the treatment well. tion in Cuba, where the highest prevalence has Within several days after therapy, he improved been found in children [9]. According to Cuban clinically with resolution of diarrhoea, and studies, despite the high proportion of the pop- weight gain. He achieved a complete parasito- ulation who lives with improved water supplies, logical cure. His occasional partner was invited water seems to play a major role in the transmis- to attend to the consultation but he never came. sion of this protozoan [10]. In the present case series, the mode of transmission in each instance Case 4: A 21-year-old healthy MSM attended with was thought to be probably via faecal oral contact his 28-year-old male partner to the doctor´s office. during anilingus, a common risk factor found in Both were complaining with recurrent abdomi- the cases reported. nal pain with moderate intensity, increased flatu- Direct transmission from person to person is an lence, diarrhoea and weight loss. They had visited established mode of transmission for some enteric a camping in the countryside and drank unboiled including Shigella, Entamoeba, Enterobi- water a month before. They stated anilingus with- us, and Giardia when there is an oral contact with out protection as a common sexual practice. The the perianal area, previously contaminated with findings of their physical examination were nor- faeces [6, 11-13]. As our cases live in endemic areas, 174 A.A. Escobedo, G. Acosta-Ballester, P. Almirall, et al.

diagnosing this mode of infection is often difficult required to minimize the ongoing transmission and should be considered only as possible; howev- of Giardia in the general population. For giardi- er, the sexual route appears to have provided the asis, primary prevention is difficult, because a necessary link for transmission in each one of our 4 human vaccine is not available nor is one likely cases, according to the each case history. to be available in the near future. It seems neces- In endemic areas, sexual transmission of Giardia sary that providers have open and non-judgmen- infection may be underappreciated, due to the tal conversations with patients about the varying continuous exposure to a potentially contam- levels of risk for Giardia infection also based on inated environment because of poor hygienic sexual activity. Providers can intervene with ed- conditions. That is why in these regions, the sex- ucation about harm reduction techniques; for ual transmission of Giardia infection is hard to instance, messages that include information that be distinguished from other routes of transmis- individuals with giardiasis are infectious during sion. However, it might be more common than the cyst shedding. These patients should be coun- is currently recognized, especially if the sexual selled to avoid oral-anal contact during this time, repertoire of couples is taken into consideration. and it should be explained that being asympto- In addition, although this route has been mainly matic, improvement of abdominal pain or the reported in homosexual males, anilingus may be achievement of diarrhoea resolution do not une- a practice carried out independent of sexual ori- quivocally mean parasite clearance neither cessa- entation, as in our first case. tion of infectivity. It is important to highlight that our 4 cases were The present case series highlights some important highly motivated and we were able to form a close points; firstly, the importance of considering the doctor-patient relationship throughout their period possibility of sexual transmission of Giardia infec- of diagnosis, treatment and follow up to talk in an tion in endemic countries, at least in those with open manner. We were therefore almost confident recurrent Giardia infection or when other causes of excluding other potential sources of reinfection of treatment failures were ruled out, even among but anilingus. They denied history of exposure to heterosexual couples: in this way the patient can drinking tap water, eating contaminated food or be appropriately investigated and promptly - and contact with diaper-age children, neither exposure properly - treated. Secondly, it is an important to recreational contact with fresh water. reminder that the human factor of compliance to HIV/AIDS awareness may have a side-effect therapy and preventive measures are at least as on the transmission of Giardia and other enteric relevant, if not more so, than the drugs we choose parasitic infections, due to the HIV transmission for a regimen after failure of first-line therapy. through the oral route is considered uncommon Thirdly, the importance of tailoring messages ac- [14]. In this way, because of the perceived “rel- cording to the route and mode of transmission; ative safety” of oral sex, in comparison to other patients could be receiving counselling messages types of sexual behaviour, oral sexual practic- sufficiently tailored to the epidemiological reality es have been prevalent among many high-risk of the local endemicity regarding Giardia trans- groups and this could increase the possibility of mission that emphasize drinking unboiled water, sexual transmission of this protozoan, mainly if it eating contaminated food or swimming in con- is considered the high number of asymptomatic taminated pools, etc., forgetting other important cysts passers, the high cyst excretion rate and the modes of transmission that could be implicated. long-term faecal shedding from infected human While the importance of sexual transmission of host, the immediate infectivity of cysts released in Giardia infection in an endemic region need not the faeces, and the low infectious dose necessary to be overemphasized, its inadequate assessment to initiate an infection (10 organisms) [7, 15]. makes re-infections possible. So, it is necessary to From a public health perspective, the major chal- find an easy route into discussion about sexual lenge is how best to avoid acute infections in at- transmission of this protozoan, avoiding moral risk populations, and for those already infected, judgments. Additionally, patients and their cou- how to prevent consequent morbidity and trans- ples should be warned to use protection during mission to other members in the community. A this kind of sexual practice or abstain from it until combination of both prevention and treatment is a negative ova and parasites control after comple- Potential sexual transmission of Giardia in an endemic region: a case series 175

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