Abstract
It remains controversial whether Dientamoeba fragilis is a commensal parasite or a pathogen. The objective of this systematic review was to establish the strength of the evidence that Dientamoeba fragilis would cause diarrhea. A search was performed for studies that reported either the association between D. fragilis detection in stools and diarrhea or diarrhea outcomes with D. fragilis therapy or challenge. Data from seven studies of specific populations reported that 22% had D. fragilis in stools of which only 23% had diarrhea. Eleven studies of stool samples submitted to laboratories reported that 4.3% of individuals had D. fragilis of which 54% had diarrhea. Twelve studies reported that D. fragilis was detected from 1.6% of individuals with diarrhea and 9.6% of diarrheal stools. Five studies analyzed the prevalence of D. fragilis in individuals with and without diarrhea; the two with a statistically significant difference between groups had discordant results. The only cohort study with an appropriate control group reported diarrhea in a higher proportion of children with D. fragilis than in controls. No D. fragilis treatment studies included diarrhea as an outcome. There were only two challenge studies involving one person each. In conclusion, the evidence that D. fragilis would cause diarrhea or that treatment would hasten diarrhea resolution is inconclusive.
Similar content being viewed by others
References
Al-Hindi AI, Shammala BMA (2013) Dientamoeba fragilis in Gaza Strip: a neglected protozoan parasite. Iran J Parasitol 8:249
Anuar TS, Hasim L, Moktar N, Salleh FM, Al-Mekhlafi HM (2015) Prevalence of Dientamoeba fragilis among an Orang Asli population in rural Malaysia. Southeast Asian J Trop Med Public Health 46:844
Ayadi A, Bahri I (1999) Dientamoeba fragilis: a pathogenic flagellate? Bull Soc Pathol Exot 92(5):299–301
Banik G, Barratt J, Marriott D, Harkness J, Ellis J, Stark D (2011) A case-controlled study of Dientamoeba fragilis infections in children. Parasitology 138(07):819–823. https://doi.org/10.1017/S0031182011000448
Barratt JL, Banik GR, Harkness J, Marriott D, Ellis JT, Stark D (2010) Newly defined conditions for the in vitro cultivation and cryopreservation of Dientamoeba fragilis: new techniques set to fast track molecular studies on this organism. Parasitology 137(13):1867–1878. https://doi.org/10.1017/s0031182010000764
Bartolini A, Zorzi G, Besutti V (2017) Prevalence of intestinal parasitoses detected in Padua teaching hospital, Italy, March 2011-February 2013. Infez Med 25:133–141
Boga JA, Rojo S, Fernández J, Rodríguez M, Iglesias C, Martínez-Camblor P, Vázquez F, Rodríguez-Guardado A (2016) Is the treatment of Enterobius vermicularis co-infection necessary to eradicate Dientamoeba fragilis infection? Int J Infect Dis 49:59–61. https://doi.org/10.1016/j.ijid.2016.05.027
Bruijnesteijn van Coppenraet LE, Dullaert-de Boer M, Ruijs GJ, van der Reijden WA, van der Zanden AG, Weel JF, Schuurs TA (2015) Case-control comparison of bacterial and protozoan microorganisms associated with gastroenteritis: application of molecular detection. Clin Microbiol Infect 21:592.e599–592.e519. https://doi.org/10.1016/j.cmi.2015.02.007
Burrows RB, Swerdlow MA (1956) Enterobius vermicularis as a probable vector of Dientamoeba fragilis. Am J Trop Med Hyg 5(2):258–265. https://doi.org/10.4269/ajtmh.1956.5.258
Calderaro A, Gorrini C, Montecchini S, Gargiulo F, Manca N, Dettori G, Chezzi C (2010) Detection of Dientamoeba fragilis: a comparison between real-time polymerase chain reaction and conventional diagnostic assays. Clin Microbiol Infect 16:S631–S632. https://doi.org/10.1111/j.1469-0691.2010.03239.x
Chan D, Barratt J, Roberts T, Phillips O, Slapetea J, Ryan U, Marriott D, Harkness J, Ellis J, Stark D (2016) Detection of Dientamoeba fragilis in animal faeces using species-specific real-time PCR assay. Vet Parasitol 227:42–47. https://doi.org/10.1016/j.vetpar.2016.07.025
Chehboub SM, Achir I, Hamrioui B (2016) Prévalence de Dientamoeba fragilis (Trichomonadida, Monocercomonadidae) au Centre hospitalier universitaire Mustapha d’Alger: aspects diagnostiques et épidémiologiques. Rev Fr Lab 2016(486):71–77. https://doi.org/10.1016/S1773-035X(16)30331-8
Crotti D, D’Annibale ML (2007a) Human intestinal parasitosis: role of Dientamoeba fragilis in human infections. Ann Ig 19:27–34
Crotti D, D’Annibale ML (2007b) Intestinal infections caused by Dientamoeba fragilis and Giardia duodenalis in our experience. Recenti Prog Med 98:361–366
Crotti D, D’Annibale ML (2007c) Role of Dientamoeba fragilis in human bowel infections. Infez Med 15:30–39
Crotti D, D’Annibale M, Fonzo G, Lalle M, Caccio S, Pozio E (2005) Dientamoeba fragilis is more prevalent than Giardia duodenalis in children and adults attending a day care centre in Central Italy. Parasite 12(2):165–170. https://doi.org/10.1051/parasite/2005122165
Dobell C (1940) Researches on the intestinal protozoa of monkeys and man. X. The life-history of Dientamoeba fragilis: observations, experiments, and speculations. Parasitology 32(04):417–161. https://doi.org/10.1017/S0031182000015924
ElBakri A, Al-Qahtani A, Samie A (2015) Advances on Dientamoeba fragilis infections. In: An overview of tropical diseases. InTech, DOI: https://doi.org/10.5772/61809
Fletcher S, Caprarelli G, Merif J, Andresen D, Hal SV, Stark D, Ellis J (2014) Epidemiology and geographical distribution of enteric protozoan infections in Sydney, Australia. J Public Health Reear 3(2):298. https://doi.org/10.4081/jphr.2014.298
Garcia LS (2016) Dientamoeba fragilis, one of the neglected intestinal protozoa. J Clin Microbiol 54(9):2243–2250. https://doi.org/10.1128/jcm.00400-16
Garcia JA, Cimerman S (2012) Detection of Dientamoeba fragilis in patients with HIV/AIDS by using a simplified iron hematoxylin technique. Rev Soc Bras Med Trop 45(2):156–158. https://doi.org/10.1590/S0037-86822012000200003
Girginkardeşler N, Coşkun Ş, Cüneyt Balcıoğlu İ, Ertan P, Ok Ü (2003) Dientamoeba fragilis, a neglected cause of diarrhea, successfully treated with secnidazole. Clin Microbiol Infect 9(2):110–113. https://doi.org/10.1046/j.1469-0691.2003.00504.x
Gonzalez-Moreno O, Domingo L, Teixidor J, Gracenea M (2011) Prevalence and associated factors of intestinal parasitisation: a cross-sectional study among outpatients with gastrointestinal symptoms in Catalonia, Spain. Parasitol Res 108(1):87–93. https://doi.org/10.1007/s00436-010-2044-2
Grendon J, DiGiacomo R, Frost F (1995) Descriptive features of Dientamoeba fragilis infections. J Trop Med Hyg 98:309–315
Hakansson EG (1936) Dientamoeba fragilis, a cause of illness. Report of case. Am J Trop Med 16:175–185
Heusinkveld M, Mughini-Gras L, Pijnacker R, Vennema H, Scholts R, van Huisstede-Vlaanderen KW, Kortbeek T, Kooistra-Smid M, van Pelt W (2016) Potential causative agents of acute gastroenteritis in households with preschool children: prevalence, risk factors, clinical relevance and household transmission. Eur J Clin Microbiol Infect Dis 35(10):1691–1700. https://doi.org/10.1007/s10096-016-2714-9
Holtman GA, Kranenberg JJ, Blanker MH, Ott A, Lisman-van Leeuwen Y, Berger MY (2017) Dientamoeba fragilis colonization is not associated with gastrointestinal symptoms in children at primary care level. Fam Pract 34(1):25–29. https://doi.org/10.1093/fampra/cmw111
Hood M (1940) Diarrhea caused by Dientamoeba fragilis. J Lab Clin Med 25:914–918
Janakiram K, Shetty SK, Readdy K, Lalithamma B (2001) Prevalence of intestinal parasitic infections among patients attending Adichunchanagiri Hospital and Research Centre, BG Nagar, Mandya (Karnataka). J Commun Disord 33(4):297–299
Jepps MW, Dobell C (1918) Dientamoeba fragilis ng, n. sp., a new intestinal amoeba from man. Parasitology 10(03):352–367. https://doi.org/10.1017/S0031182000003929
Jokelainen P, Hebbelstrup Jensen B, Andreassen BU, Petersen AM, Röser D, Krogfelt KA, Nielsen HV, Stensvold CR (2017) Dientamoeba fragilis, a commensal in children in Danish day care centers. J Clin Microbiol 55(6):1707–1713. https://doi.org/10.1128/jcm.00037-17
Julio C, Furtado C, Rocha R, Escobar C, Brito M, Oleastro M (2015) Detection of Dientamoeba fragilis in Portuguese children with acute gastroenteritis between 2011 and 2013. Parasitology 142(11):1398–1403. https://doi.org/10.1017/S0031182015000906
Kaminsky RG (1991) Parasitism and diarrhoea in children from two rural communities and marginal barrio in Honduras. Trans R Soc Trop Med Hyg 85(1):70–73. https://doi.org/10.1016/0035-9203(91)90162-R
Kean B, Malloch C (1966) The neglected ameba: Dientamoeba fragilis. Dig Dis Sci 11(9):735–746. https://doi.org/10.1007/BF02239427
Keystone J, Yang J, Grisdale D, Harrington M, Pillon L, Andreychuk R (1984) Intestinal parasites in metropolitan Toronto day-care centres. Can Med Assoc J 131:733
Kurt Ö, Girginkardeşler N, Balcioğlu I, Özbilgin A, Ok Ü (2008) A comparison of metronidazole and single-dose ornidazole for the treatment of dientamoebiasis. Clin Microbiol Infect 14:601–604
Leiva B, Lebbad M, Winiecka-Krusnell J, Altamirano I, Tellez A, Linder E (2006) Overdiagnosis of Entamoeba histolytica and Entamoeba dispar in Nicaragua: a microscopic, triage parasite panel and PCR study. Arch Med Res 37(4):529–534. https://doi.org/10.1016/j.arcmed.2005.10.009
Lindo JF, Dubon JM, Ager AL, de Gourville EM, Solo-Gabriele H, Klaskala WI, Baum MK, Palmer CJ (1998) Intestinal parasitic infections in human immunodeficiency virus (HIV)-positive and HIV-negative individuals in San Pedro Sula, Honduras. Am J Trop Med Hyg 58(4):431–435. https://doi.org/10.4269/ajtmh.1998.58.431
Millet V, Spencer MJ, Chapin M, Stewart M, Yatabe JA, Brewer T, Garcia LS (1983) Dientamoeba fragilis, a protozoan parasite in adult members of a semicommunal group. Dig Dis Sci 28(4):335–339. https://doi.org/10.1007/BF01324950
Naiman HL, Sekla L, Albritton WL (1980) Giardiasis and other intestinal parasitic infections in a Manitoba residential school for the mentally retarded. Can Med Assoc J 122:185–188
Norberg A, Nord C, Evengård B (2003) Dientamoeba fragilis—a protozoal infection which may cause severe bowel distress. Clin Microbiol Infect 9:65–68
Ockert G (1972) The epidemiology of Dientamoeba fragilis Jepps et Dobell, 1918. 2. Attempts to transmit the species with ova of Enterobius. J Hyg Epidemiol Microbiol Immunol 16:222–225
Ockert G (1975) Epidemiology of Dientamoeba fragilis Jepps and Dobell, 1918. 3. Further studies on Enterobius transmission through eggs. J Hyg Epidemiol Microbiol Immunol 19:17–21
Ögren J, Dienus O, Löfgren S, Einemo IM, Iveroth P, Matussek A (2015) Dientamoeba fragilis prevalence coincides with gastrointestinal symptoms in children less than 11 years old in Sweden. Eur J Clin Microbiol Infect Dis 34(10):1995–1998. https://doi.org/10.1007/s10096-015-2442-6
Ögren J, Van Nguyen S, Nguyen MK, Dimberg J, Matussek A (2016) Prevalence of Dientamoeba fragilis, Giardia duodenalis, Entamoeba histolytica/dispar, and Cryptosporidium spp in Da Nang, Vietnam, detected by a multiplex real-time PCR. APMIS 124:529–533. https://doi.org/10.1111/apm.12535
Osman M, El Safadi D, Cian A, Benamrouz S, Nourrisson C, Poirier P, Pereira B, Razakandrainibe R, Pinon A, Lambert C, Wawrzyniak I, Dabboussi F, Delbac F, Favennec L, Hamze M, Viscogliosi E, Certad G (2016) Prevalence and risk factors for intestinal protozoan infections with Cryptosporidium, Giardia, Blastocystis and Dientamoeba among schoolchildren in Tripoli, Lebanon. PLoS Negl Trop Dis 10:e0004496
Oyofo BA, Peruski LF, Ismail TF, El-Etr SH, Churilla AM, Wasfy MO, Petruccelli BP, Gabriel ME (1997) Enteropathogens associated with diarrhea among military personnel during Operation Bright Star 96, in Alexandria, Egypt. Mil Med 162(6):396–400
Peters C, Sable R, Janda W, Chittom A, Kocka F (1986) Prevalence of enteric parasites in homosexual patients attending an outpatient clinic. J Clin Microbiol 24:684–685
Preiss U, Ockert G, Bromme S, Otto A (1990) Dientamoeba fragilis infection, a cause of gastrointestinal symptoms in childhood. Klin Padiatr 202(02):120–123. https://doi.org/10.1055/s-2007-1025503
Preiss U, Ockert G, Broemme S, Otto A (1991) On the clinical importance of Dientamoeba fragilis infections in childhood. J Hyg Epidemiol Microbiol Immunol 35:27–34
Rayan H, Ismail O, El Gayar E (2007) Prevalence and clinical features of Dientamoeba fragilis infections in patients suspected to have intestinal parasitic infection. J Egypt Soc Parasitol 37:599–608
Ribes JA, Seabolt JP, Overman SB (2004) Point prevalence of Cryptosporidium, Cyclospora, and Isospora infections in patients being evaluated for diarrhea. Am J Clin Pathol 122(1):28–32. https://doi.org/10.1309/AUJ5WKE0497XKRUU
Röser D, Simonsen J, Nielsen HV, Stensvold CR, Molbak K (2013) Dientamoeba fragilis in Denmark: epidemiological experience derived from four years of routine real-time PCR. Eur J Clin Microbiol Infect Dis 32(10):1303–1310. https://doi.org/10.1007/s10096-013-1880-2
Röser D, Simonsen J, Stensvold CR, Olsen KE, Bytzer P, Nielsen HV, Mølbak K (2014) Metronidazole therapy for treating dientamoebiasis in children is not associated with better clinical outcomes: a randomized, double-blinded and placebo-controlled clinical trial. Clin Infect Dis 58(12):1692–1699. https://doi.org/10.1093/cid/ciu188
Sarafraz S, Farajnia S, Jamali J, Khodabakhsh F, Khanipour F (2013) Detection of Dientamoeba fragilis among diarrheal patients referred to Tabriz health care centers by nested PCR. Trop Biomed 30:113–118
Sawangjaroen N, Luke R, Prociv P (1993) Diagnosis by faecal culture of Dientamoeba fragilis infections in Australian patients with diarrhoea. Trans R Soc Trop Med Hyg 87(2):163–165. https://doi.org/10.1016/0035-9203(93)90472-3
Schure JM, de Vries M, Weel JF, van Roon EN, Faber TE (2013) Symptoms and treatment of Dientamoeba fragilis infection in children, a retrospective study. Pediatr Infect Dis J 32(4):e148–e150. https://doi.org/10.1097/INF.0b013e31827f4c20
Schuster H, Jackson R (2009) Prevalence of Dientamoeba fragilis among patients consulting complementary medicine practitioners in the British Isles. J Clin Pathol 62(2):182–184. https://doi.org/10.1136/jcp.2008.059659
Spencer MJ, Garcia LS, Chapin MR (1979) Dientamoeba fragilis: an intestinal pathogen in children? Am J Dis Child 133(4):390–393. https://doi.org/10.1001/archpedi.1979.02130040044010
Spencer MJ, Chapin MR, Garcia LS (1982) Dientamoeba fragilis: a gastrointestinal protozoan infection in adults. Am J Gastroenterol 77(8):565–569
Spencer MJ, Millet VE, Garcia LS, Rhee L, Masterson L (1983) Parasitic infections in a pediatric population. Pediatr Infect Dis 2(2):110–113. https://doi.org/10.1097/00006454-198303000-00008
Staat MA, Rice M, Donauer S, Mukkada S, Holloway M, Cassedy A, Kelley J, Salisbury S (2011) Intestinal parasite screening in internationally adopted children: importance of multiple stool specimens. Pediatrics 128(3):e613–e622. https://doi.org/10.1542/peds.2010-3032
Stark D, Beebe N, Marriott D, Ellis J, Harkness J (2005) Prospective study of the prevalence, genotyping, and clinical relevance of Dientamoeba fragilis infections in an Australian population. J Clin Microbiol 43(6):2718–2723. https://doi.org/10.1128/JCM.43.6.2718-2723.2005
Stark D, Beebe N, Marriott D, Ellis J, Harkness J (2006) Evaluation of three diagnostic methods, including real-time PCR, for detection of Dientamoeba fragilis in stool specimens. J Clin Microbiol 44(1):232–235. https://doi.org/10.1128/jcm.44.1.232-235.2006
Stark D, Fotedar R, Van Hal S, Beebe N, Marriott D, Ellis JT, Harkness J (2007) Prevalence of enteric protozoa in human immunodeficiency virus (HIV)-positive and HIV-negative men who have sex with men from Sydney, Australia. Am J Trop Med Hyg 76:549–552
Stark D, Barratt J, Roberts T, Marriott D, Harkness J, Ellis J (2010) Comparison of microscopy, two xenic culture techniques, conventional and real-time PCR for the detection of Dientamoeba fragilis in clinical stool samples. Eur J Clin Microbiol Infect Dis 29(4):411–416. https://doi.org/10.1007/s10096-010-0876-4
Stark D, Barratt J, Chan D, Ellis JT (2016) Dientamoeba fragilis, the neglected trichomonad of the human bowel. Clin Microbiol Rev 29(3):553–580. https://doi.org/10.1128/cmr.00076-15
Steinitz H, Talis B, Stein B (1970) Entamoeba histolytica and Dientamoeba fragilis and the syndrome of chronic recurrent intestinal amoebiasis in Israel. Digestion 3:146–153
Stensvold C, Arendrup M, Mølbak K, Nielsen H (2007) The prevalence of Dientamoeba fragilis in patients with suspected enteroparasitic disease in a metropolitan area in Denmark. Clin Microbiol Infect 13(8):839–842. https://doi.org/10.1111/j.1469-0691.2007.01760.x
Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB (2000) Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 283(15):2008–2012. https://doi.org/10.1001/jama.283.15.2008
Tavarez LA, Pena F, Placencia F, Mendoza HR, Polanco D (1991) Prevalence of protozoans in children with acute diarrheal disease. Arch Dominicanos Pediatr 27:43–47
van Hellemond JJ, Molhoek N, Koelewijn R, Wismans PJ, van Genderen PJ (2012) Is paromomycin the drug of choice for eradication of Dientamoeba fragilis in adults? Int J Parasitol Drugs Drug Resist 2:162–165. https://doi.org/10.1016/j.ijpddr.2012.03.002
Vandenberg O, Peek R, Souayah H, Dediste A, Buset M, Scheen R, Retore P, Zissis G, van Gool T (2006) 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 10(3):255–261. https://doi.org/10.1016/j.ijid.2005.05.011
Wenrich DH (1944) Studies on Dientamoeba fragilis (Protozoa). IV. Further observations, with an outline of present-day knowledge of this species. J Parasitol 30(5):322–338. https://doi.org/10.2307/3272582
Windsor J, Rafay A, Shenoy A, Johnson E (1998) Incidence of Dientaboeba fragilis in faecal samples submitted for routine microbiological analysis. Br J Biomed Sci 55:172
Yakoob J, Jafri W, Beg MA, Abbas Z, Naz S, Islam M, Khan R (2010) Blastocystis hominis and Dientamoeba fragilis in patients fulfilling irritable bowel syndrome criteria. Parasitol Res 107:679–684
Yang J, Scholten T (1977) Dientamoeba fragilis: a review with notes on its epidemiology, pathogenicity, mode of transmission, and diagnosis. Am J Trop Med Hyg 26:16–22
Author information
Authors and Affiliations
Ethics declarations
Conflict of interest
The authors declare that they have no conflicts of interest.
Rights and permissions
About this article
Cite this article
Wong, ZW., Faulder, K. & Robinson, J.L. Does Dientamoeba fragilis cause diarrhea? A systematic review. Parasitol Res 117, 971–980 (2018). https://doi.org/10.1007/s00436-018-5771-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00436-018-5771-4