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Dermatologic Manifestations Of Giardiasis J Am Board Fam Pract: first published as 10.3122/jabfm.5.4.425 on 1 July 1992. Downloaded from

jerry T. McKnight, M.D., and Paul E. Tietze, M.D.

Giardia lamblia is the most common intestinal The physical examination was remarkable only parasite in the United States and is worldwide in for an eczematous-type dermatitis with erythema, distribution.l Approximately 4 percent of stool xerosis, and several fine papular and vesicular specimens submitted to public health laboratories lesions on the extremities. The rash was con­ in this country contain cysts.2 The usual fined primarily to the trunk and extremities symptoms of acute giardiasis include , and was located predominately on the flexor sur­ abdominal cramps, nausea, and . faces. This pattern was consistent with the previ­ Many, if not most, individuals with Giardia infec­ ous diagnosis of atopic dermatitis. The involved tion are asymptomatic. Giardiasis can be an acute skin was excoriated, and lichenification was self-limiting diarrheal illness, or it can lead to present. chronic diarrhea and .3 Children The patient's complete blood count, chemical are affected more often than adults, and person­ analysis of serum, urinalysis, and thyroid profile to-person has been documented.4,s were normal. The serum immunoglobin E(IgE) There have been reports of allergic symptoms was 48 ,....glL (20 U/mL), normal 24-240 ,....glL associated with giardiasis. This article describes a (10-100 U/mL). case of dermatitis associated with Giardia infec­ The were changed to fluocinonide tion and reviews dermatologic manifestations of ointment 0.05 percent twice daily and terfenadine Giardia lamblia infection. 60 mg twice daily. This regimen de­ creased symptoms somewhat; however, the der­ Case Report matitis persisted with the pruritus being especially A 48-year-old woman complained of an 8-month bothersome. history of atopic dermatitis. The patient had Several weeks after changing medications, the been cared for by a dermatologist, who pre­ patient developed the new complaint of abdomi­ scribed triamcinolone ointment 0.1 percent topi­ nal cramping without nausea, diarrhea, or weight cally twice daily, hydroxyzine hydrochloride 25 loss. Further questioning revealed that cramp­ mg four times daily, and doxepin hydrochloride ing had been an intermittent problem start­ http://www.jabfm.org/ 50 mg at bedtime. This treatment provided some ing soon after coming to live with her daughter. symptomatic relief but had not cleared the mark­ A stool culture was negative for enteric patho­ edly pruritic chronic dermatitis. There was no gens; however, a microscopic examination history of atopy, nor was there any history of showed numerous Giardia cysts. Treatment with dermatologic conditions. The patient requested , 250 mg three times a day for

her medications be changed because of worsen­ 7 days, relieved the abdominal complaints. Addi­ on 25 September 2021 by guest. Protected copyright. ing of the rash. tionally, the dermatitis completely resolved The patient's medical history was unremark­ within 2 weeks. All medications were discon­ able except one previous hospitalization for an tinued, and the rash had not recurred after 18 uncomplicated childbirth. The social history was months of follow-up care. pertinent for a move to east Tennessee 10 months The suspected source of infection was an earlier from her native country of Germany to underground well, which was the only water live with her daughter. The dermatitis developed source for the family. The local health de­ approximately 2 months after moving. partment believed it was impractical to filter mass quantities of water for detection of Giardia. The other family members were asked to have Submitted, revised, 2 October 1991. stool specimens for parasites. No members of From the Department of Family Medicine, University of the household were symptomatic, and they de­ . Alabama, Tuscaloosa. Address reprint requests to Jerry T. McKnight, M.D., Department of Family Medicine, University clined. The family was asked to boil water used of Alabama, 107 Educational Tower, Tuscaloosa, AL 35401. for consumption.

Dermatologic Manifestations of Giardiasis 425 i!

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Discussion ritus, and anal itching. Urticaria or dermatitis was J Am Board Fam Pract: first published as 10.3122/jabfm.5.4.425 on 1 July 1992. Downloaded from This case illustrates a possible complication of not specifically reported. The report indicated giardiasis. An extensive review of the medical lit­ that after treatment with either metronidawle or erature, including foreign sources, revealed sev­ quinacrine, 90 percent of the articular and extra­ eral references to dermatologic manifestations, articular disappeared.II specifically urticaria, associated with giardiasis.6-s Another specific report of note is that by Infection with Giardia has been associated with Chirila, et al.,IO who in 1981 studied 434 patients urticaria, pruritus, and possibly angioedema.9,10 who came to the Department of Allergy at the Other allergic manifestations, such as reactive ar­ Institute of Internal Medicine in Bucharest. Of thritis, have also been reported.ll Giardia is not these patients, 186 had chronic urticaria, 120 had usually associated with elevated IgE levels or angioedema, and 50 had both urticaria and an­ eosinophilia.S,12 Appropriate treatment of this gioedema. Giardia was found in 74 (40 percent) of parasite resulted in complete resolution of patients with chronic urticaria, in 42 (35 percent) .,1 skin manifestations in all cases described. The of patients with angioedema, and in 48 (96 per­ cases described in the literature are presented cent) of patients who had both chronic urticaria . I in Table 1. and angioedema. The authors indicated clinical Additional studies not tabulated include a study symptoms were rarely suggestive of giardiasis. in 1977 of 66 Argentinian children, aged 2 to 15 Giardia was found in these allergic patients three years, who came to a rheumatology clinic with times more frequently than the normal popula­ joint symptoms. Goobarll reported that these tion of Rumania. The authors did not report der­ , ! children had joint symptoms of pain accompanied matologic response to treatment in these patients. by synovitis. Sixty-four of these children had There have been many cases of urticaria associ­ I, I giardiasis. The 66 patients were selected because ated with Giardia lamblia infection. Previous ap­ of gastrointestinal symptoms, including diarrhea, proximations of nine total cases by Hamrick and nausea or vomiting, abdominal cramps, or bloody Moorel9 in 1983 and 20 cases by Clyne and stools. Sixty percent had what were described as Eliopoulos20 in 1989 were underestimations. The allergic symptoms: nasal itching, generalized pru- total number of cases reported is 33, not counting

Table 1. Literature Rmew of GianUasis AII80dated wi1Il U1tlcarla or Prurltis. , ,

; http://www.jabfm.org/ ~ Year Cases Ages (yr) Other Symptoms Treaonent Outcome 1949 1 16 Diarrhea, Quinacrine All symptoms resolved6 , 1, 1957 2 34,42 Diarrhea, weight loss Quinacrine All symptoms resolved7 1958 6* NR Gastrointestinal symptoms Quinacrine Urticaria resolved8 1969 St NR NR NR NR13 1976 1 28 Diarrhea, weight loss Metronidazole All symptoms resolved 14 on 25 September 2021 by guest. Protected copyright. 1978 4 NR Diarrhea Metronidazole All symptoms resolved 15 1979 30s None Metronidazole Urticaria resolved16 1980 3 1,13.35 Anorexia. diarrhea. weight loss Metronidazole All symptoms resolved17 1983 6* 5-33 50% had gastrointestinal symptoms Metronidazole All symptoms resolved 18 1983 4 None Metronidazole All S}'D}ptoms resolved 19 1983 6 Diarrhea, arthritis Metronidazole All symptoms resolved9 1989 28 Diarrhea, fever Metronidazole All symptoms resolved2o 1989 1 53 Diarrhea. fever Metronidazole Uticaria resolved21 1990 IS NR Mild gastrointestinal symptoms Metronidazole All symptoms resolved22 NR • not reported. *6 of 32 patients with giardiasis. tS of 500 patients with giardiasis. *6 of 50 patients with chronic urticaria. §Self-report, allergist, pruritis only.

426 JABFP July-August 1992 Vol. 5 No.4 additional cases unreported by Kennou, et alP the association with Giardia is immunologically J Am Board Fam Pract: first published as 10.3122/jabfm.5.4.425 on 1 July 1992. Downloaded from and the Rumanian study,IO which did not re­ based. This reaction, however, might not be a port response to treatment. Goobarll also did classical IgE-mediated phenomenon.33 Although not quantitate the exact number with pruritus urticaria is not a usual manifestation of Giardia, it or the specific response to treatment in each should be recognized, especially in view of the incident. ubiquitous nature of the organism. Because Some of these patients had few if any gastroin­ chronic urticaria is a relatively common dermato­ testinal symptoms. This finding is not surprising logic disorder and results in a frequently frustrat­ in view of the known history of giardiasis.3 The ing and unfruitful evaluation, it would be reason­ types of gastrointestinal presentations of giardia­ able to include Giardia in the differential sis range from minimal or no symptoms to diar­ diagnosis and to search for Giardia by either mi­ rhea and weight loss. 3 Fever is also occasionally croscopic stool analysis or by the newer and per­ seen.20,23,24 The number of reports and the differ­ haps more sensitive stool antigen detection ences in clinical presentations, coupled with the method. geographic diversity, make clear that this problem Detection of Giardia Iomblia can be difficult. is not unusual worldwide. The rather consistent Microscopic identification is dependent on the response to treatment leaves little doubt there is skill of the examiner and appropriate sample an association between Giardia and urticaria, pru­ collection and preparation. The sensitivity of ritus, and possibly other allergic symptoms, such microscopic stool analysis varies but is approxi­ as other skin rashes and synovitis. mately 50 to 60 percent.34,35 The sensitivity of Our patient had what appeared to be atopic stool antigen detection methods has been re­ dermatitis, but it occurred in an adult who had no ported as 88 to 96 percent and the specificity as 95 personal or family history of atopy and who had a to 100 percent.36-38 normal IgE level. Atopic dermatitis in association with giardiasis has not previously been described. Summary It is, however, not unreasonable to postulate a We have presented a case of atopic dermatitis similar pathogenesis, as this condition is clearly associated with Giardia lambJia infection, which allergy related. has not been previously described. Review of the The appearance of the dermatitis after exp0- world literature shows an association between sure to untreated well water was significant. The giardiasis and urticaria. Other allergic phenom­ http://www.jabfm.org/ dermatologic response to treatment for giardiasis ena, such as angioedema and possibly arthropa­ was dramatic and, although anecdotal, is highly thy, also might be associated with this infection. suggestive of a relation between the two. It is When confronted with these clinical problems, possible this rash was secondary to another cause; giardiasis should be included in the differential however, complete resolution of this dermatitis diagnosis. As these complications respond to spe­ after a single course of metronidazole and the lack cific therapy, identification of this organism as its of recurrence make other causes unlikely. cause can be particularly rewarding. on 25 September 2021 by guest. Protected copyright. The immune response to Giardia Iomblia is not completely understood. The immune system generates both a humoral and cellular response to References Giardia. 25,26 Serum antibodies to Giardia of IgG 1. CraftJc. GiardUI and giardiasis in childhood. Pediatr and IgM classes have been foundP-29 Secretory Infect Dis 1982; 1:196-211. 2. Center for Disease Control. Intestinal parasite sur­ IgA antibodies to Giardia antigens have been veillance-United States, 1976. MMWR 1978; found in breast milk. 30 Giardiasis has been associ­ 27(20):167-8. ated with reduced intestinal secretory IgA, and 3. Dupont HL, Sullivan PS. Giardiasis: the clinical patients with immunodeficiency syndromes have spectrum, diagnosis and therapy. Pediatr Infect Dis more severe gastrointestinal syndromes.31,32 1986; 5(Suppl):S131-8. The mechanism of urticaria associated with 4. Black RE, Dykes AC, Sinclair SP, WellsJG. Giardia­ sis in day-care centers: evidence of person-to-person giardiasis has not been elucidated. Although transmission. Pediatrics 1977; 60:486-91. urticaria can be cauSed by immunologic and 5. Burke JA. Giardiasis in childhood. Am J Dis Child . nonimmunologic mechanisms, it is most likely 1975; 129:1304-10.

Dennatologic Manifestations of Giardiasis 427

d 6. Harris RH, Mitchell JH. Chronic urticaria due to neous killing by mononuclear leukocytes in vitro. J Am Board Fam Pract: first published as 10.3122/jabfm.5.4.425 on 1 July 1992. Downloaded from Giardia lamblia. Arch Dennatol Syphilology 1949; J Immuno11982; 128:1372-6. 59:587-9. 26. Vtsvesvara GS, Smith PD, Healy GR, Brown WR. 7. WIlhelm RE. Urticaria associated with Giardia An immunoflourescence test to detect serum anti­ Iamblia.J Allergy 1957; 28:351-3. bodies to Giardia lamblia. Ann Intern Med 1980; 8. Webster BH. Human infection with Giardia lamblia: 93:802-5. an analysis of thirty-two cases. Am J Dig Dis 1958; 27. Ridley MJ, Ridley DS. Serum antibodies and jejunal 3:64-71. histology in giardiasis associated with malabsorp­ 9. Farthing MJ, Chong SK, Walker-SmithJA. Acute al­ tion. J Clin Path 1976; 29:30-4. lergic phenomena in giardiasis petter]. Lancet 1983; 28. Smith PD, Gillin FD, Brown WR, Nash TE. IgG 2:1428. antibody to Giardia lamblia detected by enzyme­ 10. Chirila M, Panaitescu D, Capraro T. Frequency of linked immunosorbent assay. Giardia lamblia in certain allergic syndromes. Med 1981; 80:1476-80. Interne 1981; 19:367-72. 29. Gob AI(, Rolston DD, Mathan VI, Farthing MJ. 11. Goobar JP.Joint symptoms in giardiasis petter]. Lan­ Diagnosis of giardiasis by specific IgM antibody en­ cet 1977; 1:1010-1. zyme-linked immunosorbent assay. Lancet 1986; 12. Geller M, Geller M, Flaherty DK, Black P, Madruga 2:184-6. M. Serum IgE levels in giardiasis. Clin Allergy 1978; 30. Miotti PG, Gilman RH, Pickering LK, Ruiz­ 8:69-71. Palacios G, Park HS, Yolken RH. Prevalence of 13. Felix H, FreyriaJ, Maillard A, Legendre M, Douchet serum and milk antibodies to Giardia lamblia in dif­ C, Le Vagueresse R [Apropos of 500 cases of ferent populations of lactating women. J Infect Dis lambliasis in adults].J Med Lyon 1969; 50:163-73. 1985; 152:1025-31. 14. Dellamonica P, Le Fichoux Y, Monnier B, Duplay H. 31. Ament ME. Immunodeficiency syndromes and gas­ , [Dysenteric syndrome and urticaria in giardiasis (let­ trointestinal disease. Pediatr Clin North Am 1975; ! ter)]. Nouv Presse Med 1976; 5:1913. 22:807-25. 15. La Rosa F, Caruso R, Bertuccio O. [Urticarial mani­ Ij 32. Zinneman HH, Kaplan AP. The association of festations during lambliasis]. Policlinico Sez Med giardiasis with reduced intestinal secretory im­ 1978; 85:77-81. mhnoglobulinA. AmJ Dig Dis 1972; 17:793-7. · I · ; 16. Weisman BL. Urticaria and Giardia Jamblia infec­ 33. Monroe Ew, Jones HE. Urticaria. An updated re­ · ~ ; f tion. Ann Allergy 1979; 42(2):91. view. Arch DennatoI1977; 113:80-90. i ~ i 17. Kennou MF,Jenayah S, Rekhis M, Bayar N, Necibi 34. Kamath KR, Murugasu R A comparative study of ; ! S. [Skin manifestations of giardiasis. Some clinical four methods for detecting Giardia lamblia in chil­ cases]. Arch Inst Pasteur Tunis 1980; 57:257-60. dren with diarrheal disease and malabsorption. Gas­ 18. Veronesi S, Palmerio B, Negosanti M, Tosti A. Urti­ troenterology 1974; 66:16-21. caria and giardiasis. Dennatologica 1983; 166:42-3. 35. Danciger M, Lopez M. Numbers of Giardia in the ,'1 http://www.jabfm.org/ ! I 19. Hamrick HJ, Moore Gw, Giardiasis causing urti­ of infected children. Am J Trop Med Hyg caria in a child. AmJ Dis Child 1983; 137:761-3. 1975; 24:237-42. 20. Clyne CA, Eliopoulos GM. Fever and urticaria in 36. Janoff EN, Craft JC, Pickering LK, Novotny T, acute giardiasis. Arch Intern Med 1989; 149:939-40. Blaser MJ, Knisley cv. et al. Diagnosis of Giardia 21. Juergens UR, Predel HG, Vetter H. [Urticaria, pru­ lamblia infections by detection of parasite-specific ritus (clinical conference)]. Schweiz Rundsch Med antigens.J Clin Microbiol1989; 27:431-5. Prax 1989; 78:403-5. 37. Rosoff JD, Sanders CA, Sonnad SS, DeLay PR,

22. Spaulding HS Jr. Pruritis without urticaria in acute Hadley WI<, Vmcenzi FF, et al. Stool diagnosis of on 25 September 2021 by guest. Protected copyright. giardiasis petter]. Ann Allergy 1990; 65:161. giardiasis using a commercially available enzyme im­ 23. Pickering LK, Engelkirk PG. Giardia IambJia. Pedi­ munoassay to detect Giardia-specific antigen 65 atr Clin North Am 1988; 35:565-77. (GSA 65).J Clin Microbiol1989; 27:1997-2002. 24. Meyer EA, Jarroll EL. Giardiasis. Am J Epidemiol 38. Knisley cv, Engelkirk PG, Pickering LK, West MS, 1980; 111:1-12. Janoff EN. Rapid detection of Giardia antigen in the 25. Smith PD, Elson CO, Keister DB, Nash TE. stool with the use of enzyme immunoassays. Am J Human host response to Giardia IambJia. 1. Sponta- Clin Path 1989; 91:704-8.

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