Blastocystis sp., an emerging parasite with controversial pathogenicity. Should all human cases be treated?

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Alexieff (1911) and Brumpt (1912) described the parasite as a yeast-like fungus, while Zierdt et al. (1967) reclassified it among the protozoa.<a class="elsevierStyleCrossRef" href="#bib0075">1</a> The parasite is currently included in the Chromista kingdom.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The study of the host–parasite relationship and the determinants of pathogenicity expressed by Blastocystis sp. constitute one of the most exciting fields of research on understanding its biology and clarifying its potential pathogenic power.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Various genetic subtypes (ST) were defined by international consensus in 2007, with the species of the genus Blastocystis being named Blastocystis sp.,<a class="elsevierStyleCrossRef" href="#bib0020">4</a> followed by the abbreviation ST and the number corresponding to the gene subtype, when this is known (e.g., B. hominis ST4), thereby losing any relationship with the animal reservoir in which they were first observed (e.g., B. hominis in humans and Blastocystis ratti in rats).<a class="elsevierStyleCrossRefs" href="#bib0075">1,4</a> To date, 17 subtypes (ST1–ST17) have been described, 9 of which (ST1–ST9) have been detected as producing infections in humans. Eight of the 17 subtypes (ST1–ST8) recognize a zoonotic origin, while ST9 recognizes an anthroponotic origin.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> These microorganisms are intestinal nonprotozoan parasites that produce blastocystosis, a symptomatic or asymptomatic parasite infection, also known as colonization, which in most cases has a zoonotic origin.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a> Various studies have shown that Blastocystis sp. are the most common parasite observed in coproparasitological studies and that blastocystosis is a parasitosis of cosmopolitan distribution, with a greater prevalence in depressed areas and in poor countries.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a>The conventional diagnosis of blastocystosis is morphometric and is based on the direct microscopic examination of recently excreted feces or on the microscopic examination of preserved concentrated stools and subsequent differential staining, if necessary.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> In both cases, the presence of >5 forms in the field of view at 40× magnification is considered to show infection.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>In this issue of Revista Clínica Española, Losada-Ocaña et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> present the results of a retrospective clinical-epidemiological study on parasite infection by Blastocystis sp. The study was conducted between October 2004 and March 2016 in a tropical medicine unit in El Ejido (Almeria, Spain) on a population of 3070 patients. The study diagnosed 570 cases of blastocystosis, which represents a prevalence of 18.6% (570/3070), in a population whose mean age was 31 years (age range, 6–77 years), most of whom were men (83.7%; 477/570) of foreign nationality (96.8%; 449/570), with a mean stay in Spain of 52 months (range, 0–348 months), most from sub-Saharan countries (351/570; 61.6%) and from the Maghreb (98/570; 17.2%).The observed prevalence (18.6%) is a priori high for what would be expected for Spain (7%)<a class="elsevierStyleCrossRef" href="#bib0045">9</a> and neighboring countries (United Kingdom, 3.9%<a class="elsevierStyleCrossRef" href="#bib0050">10</a>; France, 6.1%<a class="elsevierStyleCrossRef" href="#bib0055">11</a>; Italy, 7.1%<a class="elsevierStyleCrossRef" href="#bib0060">12</a>), according to studies that used microscopy as the diagnostic procedure. Evidently, this difference could be due to the patients from abroad included in the study; however, in this series, the authors do not describe the study population, which precludes calculating the precise rates for each age group, sex, asymptomatic patients and nationalities. The actual prevalence of blastocystosis in the various cohorts is not estimated, nor is the influence of other factors. Nevertheless, the results do agree with those of other publications<a class="elsevierStyleCrossRef" href="#bib0015">3</a> in that parasitic co-infections are a common phenomenon (single parasitic infection, 245; parasitic co-infections: 325; ratio 1:1.33). However, Losada-Ocaña et al.,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> without considering the sensitivity-specificity of the diagnostic procedures, indicate that their results are similar to those obtained in France by El Safadi et al.,<a class="elsevierStyleCrossRef" href="#bib0015">3</a> who indicated a prevalence of 18.1% using a quantitative polymerase chain reaction, a more sensitive and specific procedure than microscopy.The most common blastocystosis-related clinical manifestations are gastrointestinal, such as abdominal pain, diarrhea, flatulence and nausea. Less common manifestations include skin reactions, such as pruritus and urticaria.<a class="elsevierStyleCrossRefs" href="#bib0025">5,13</a> These signs and symptoms were presented by the patients in this series with symptomatic blastocystosis. There are studies that suggest the relationship between certain STs and clinical manifestations,<a class="elsevierStyleCrossRefs" href="#bib0025">5,14</a> an issue that has not been elucidated.A diagnostic–therapeutic problem obviously results from a patient with a coproparasitological study positive for Blastocystis sp., in the absence of other enteropathogens. It is commonly thought that this organism is part of the intestinal microbiota (standard/conventional flora) and that humans can be colonized (asymptomatic carrier or asymptomatic blastocystosis), but this thinking does not consider that this condition is common among other protozoan pathogens (e.g., Entamoeba histolytica and Giardia duodenal).<a class="elsevierStyleCrossRef" href="#bib0085">15</a> We therefore believe that if there are questions regarding its significance, we should (1) review the reasons for the parasitological study; (2) request quantification (the presence of >5 forms in the field of view at 40× magnification signifies infection) or, in lieu thereof, repeat the study and (3) rule out other causes.In terms of treatment, there is consensus in not treating asymptomatic patients and in the need to rule out other causes before starting anti-Blastocystis treatment.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> The available drugs include paromomycin, cotrimoxazole, metronidazole and nitazoxanide.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> The results of this series for the 23 patients with symptomatic single parasitic infection who completed the treatment can generally be considered adequate, because parasitological cure and clinical improvement was observed in 82.6% and 78.2% of the cases, respectively." 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