Inflammatory bowel disease (IBD) is attributed to complex conditions of gastrointestinal tract that is frequently reported all over the world. Fecal calprotectin evaluation is described as a primary tool to screen IBD patients. There are reports showing the confounding role of some microbial agents in diagnostic levels of calprotectin. A 32-yr-old woman with symptoms like IBD/IBS (irritable bowel syndrome); admitted to IBD Clinic of Behbood Research Center for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran, Jan 2017 for evaluation of the level of fecal calprotectin. In spite of high level of calprotectin, trophozoite of Giardia intestinalis was observed in direct examination of stool sample. Microbial pathogens can lead to false elevation of fecal calprotectin and misdiagnosis of gastrointestinal patients suspected to IBD

Hamed MIRJALALI

Hamid ASADZADEH  AGHDAEI

Mohammad Reza ZALI

Sara MOHAMMAD ALI GOL

Iranian Journal of Parasitology

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Iran J Parasitol: Vol. 13, No. 3, Jul-Sep 2018, pp.505-509 505                                                                                                Available at: http://ijpa.tums.ac.ir         Case Report Can Giardia Infection Impair the Diagnostic Level of Fecal  Calprotectin in Patients with Inflammatory Bowel Disease? A Case Report  Sara MOHAMMAD ALI GOL 1, *Hamed MIRJALALI 2, Hamid ASADZADEH  AGHDAEI 3, Mohammad Reza ZALI 4  1. Behbood Research Center for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2. Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran 3. Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenter-ology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran 4. Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran   Received         11  Sep 2017  Accepted       19  Nov 2017  Abstract Inflammatory bowel disease (IBD) is attributed to complex conditions of gastroin-testinal tract that is frequently reported all over the world. Fecal calprotectin evalua-tion is described as a primary tool to screen IBD patients. There are reports show-ing the confounding role of some microbial agents in diagnostic levels of calprotec-tin. A 32-yr-old woman with symptoms like IBD/IBS (irritable bowel syndrome); admitted to IBD Clinic of Behbood Research Center for Gastroenterology and Liv-er Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran, Jan 2017 for evaluation of the level of fecal calprotectin. In spite of high level of calprotectin, trophozoite of Giardia intestinalis was observed in direct examination of stool sam-ple. Microbial pathogens can lead to false elevation of fecal calprotectin and misdi-agnosis of gastrointestinal patients suspected to IBD.  Keywords: Inflammatory bowel dis-eases,  Giardia intestinalis,  Fecal calprotectin test  *Correspondence Email:  hamedmirjalali@sbmu.ac.ir   Introduction  iardia spp., is a flagellated protozoan causing chronic diarrhea over the world. G. intestinalis (Syn. G. duodenalis, or G. lamblia) is known as one of the most prevalent causative agents of traveler’s diarrhea and waterborne/foodborne out-breaks. Currently, Giardiasis considered as neglected disease, but about 280 million peo-G      Iranian Society of Parasitology                                                                                                                                                         http://isp.tums.ac.ir  Iran J Parasitol  Open access Journal at http://ijpa.tums.ac.ir  Tehran University of Medical Sciences Publication http://tums.ac.ir    Mohammad Ali Gol et al.: Can Giardia Infection Impair the Diagnostic Level … Available at: http://ijpa.tums.ac.ir                                                                                                506 ple are annually infected with this parasite. Although infected patients with G. intestinalis are often asymptomatic, severe complications such as diarrhea, steatorrhea, nonspecific gas-trointestinal symptoms, flatulence, excessive fatigue, nausea, foul-smelling stools, and weight loss are sporadically reported (1, 2). There are studies on prevalence of Giardia in-fection and molecular distribution of this par-asitic protozoan in Iran that suggest a poten-tial linkage between certain genotypes and di-arrhea (3, 4). IBD is a gastrointestinal disorder frequently reported in Iran (5, 6). Many biomarkers are in-troduced to screen patients suspected to IBD. Calprotectin is a protein that mainly released from leukocytes and epithelial cells during in-flammation. This protein is suggested as a mark-er for primary screening and follows up of IBD patients. However, fecal calprotectin has 95% sensitivity and 91% specificity to monitor IBD patients (7-10).  Elevated level of fecal calprotectin proposed to be attributed to some other disor-ders/diseases such as acute or chronic gastro-intestinal microbial infections (viral, bacterial or parasite), allergic colitis, celiac disease, Nonsteroidal anti-inflammatory drugs (NSAIDs)- induced enteropathy and colorec-tal cancer (11-16). Until now, some intestinal parasitic diseases have been reported that ele-vated concentration level of fecal calprotectin (17, 18). Therefore, elevated level of fecal cal-protectin resulting from gastrointestinal path-ogens should be considered as a confounding factor of primary screening of IBD patients. The current study reports a young female with sudden and acute abdominal complaints with heavy giardiasis who had high level of calprotectin and was referred to the gastroin-testinal clinic as IBD-suspected patient.  Case report  A 32-yr-old female patient who had severe bloating, nausea, fatigue and abdominal pain for a week admitted to IBD Clinic of Beh-bood Research Center for Gastroenterology and Liver Diseases, Jan 2017. She traveled to abroad approximately 1 month before clinical symptoms and took prolonged antibiotic ther-apy for acute sinusitis. She had no previous history of any abdominal complaints. The blood tests revealed normal Complete Blood Count (CBC) consisted of White Blood Cell (W.B.C): 6600 /micL, Red Blood Cell (R.B.C): 4.7 mil/micL, Hemoglobin (Hb): 13.8 g/dl. Differential count of WBC was Neutrophils: 70%, Lymphocytes: 26%, Monocytes: 3% and eosinophils: 1%. Liver function tests such as SGPT, SGOT and Alkaline phosphatase were 44 U/L, 28 U/L, and 170 U/L, respectively. Celiac disease tests including IgA, EMA, tTg (IgA) were 180 mg/dL, Negative and 1.0 U/ml, respectively. IgA, EMA, and tTg (IgA) were analyzed by turbidimetry, Immunofluo-rescence (EUROIMMUN, Germany) and ELISA (ORIENTEC, Germany), respectively. Antigen of Helicobacter pylori was not detected in stool using rapid chromatographic immu-noassay test. A fresh stool sample was taken and examined for intestinal parasites. Stool sample was loose, few greasy and yellow col-ored in the appearance. Trophozoite of G. intestinalis was detected in direct examination (Fig. 1). RBC and PMNs were not seen in microscopical examination of stool sample. It was not seen cyst of G. intestinalis, and other eukaryotic parasites and also ova of helminths in formalin-ethyl acetate concentration. Primary fecal calprotectin was determined using an ELISA-based kit (EUROIMMUN, Germany) and revealed a high elevation level of calprotectin (2047 mg/kg). The patient was treated with metronidazole (250 mg/kg), omeprazole (20 mg) and bis-muth (120 mg), three times a day for 10 days. After treatment period, stool sample was tak-en and secondary fecal calprotectin determina-tion was performed that showed a significantly decreased level. The second stool examination showed that there were no trophozoite and cyst of G. intestinalis.  Iran J Parasitol: Vol. 13, No. 3, Jul-Sep 2018, pp.505-509 507                                                                                                Available at: http://ijpa.tums.ac.ir   Fig.1: Trophozoites of Giardia sp., in fresh stool sample of an IBD patient characterized with arrows (400X magnification)  After treatment, the general condition was well and there were no clinical complaints.   Discussion  G. intestinalis is an intestinal protozoan that infects human subjects, particularly children. Fecal-oral transmission is known as primary route of infection, but food and drinking wa-ter are suggested as important sources of in-fection. G. intestinalis is one of the most im-portant causes of traveler’s diseases frequently reported in Iran (4, 19, 20).  IBD is called to a complex of gastrointesti-nal disorders reported from Iran (21, 22). However, although some gastrointestinal dis-eases can lead to false elevation of fecal cal-protectin level, fecal calprotectin is a serologi-cal test introduced for screening and differen-tiation between IBD and IBS patients (23). There are evidences showing the important role of microbial pathogens in elevation of the level calprotectin. It was seen correlation be-tween severity of viral and bacterial infections and increased level of fecal calprotectin (13). The role of some parasitic diseases has also been discussed in false-increasing the diagnos-tic levels of fecal calprotectin in IBD patients. G. duodenalis can increase the level of fecal cal-protectin (24). Furthermore, Schistosoma mansoni (intestinal schistosomiasis) was able to increase the level of fecal calprotectin (17). Heavy infection with some parasitic protozo-an such as Dientamoeba fragilis leads to infiltrate neutrophiles in intestine (25) that can elevate the level of fecal calprotectin associated with inflammatory process (18).  Conclusion  The current case supports the interesting role of some parasitic diseases in elevation the diag-nostic levels of fecal calprotectin. Therefore, it is important to consider the probability of mi-crobial infection in patients suspected to IBD who referred to gastrointestinal clinic.   Acknowledgements  The authors would like to appreciate all col-leagues of Foodborne and Waterborne Dis-eases Research Center and Behbood Research Center for Gastroenterology and Liver Dis-eases for their laboratory cooperation. Mohammad Ali Gol et al.: Can Giardia Infection Impair the Diagnostic Level … Available at: http://ijpa.tums.ac.ir                                                                                                508 Conflict of interest  The authors declare that they have no con-flict of interest.  References  1. Feng Y, Xiao L. Zoonotic potential and molecular epidemiology of Giardia species and giardiasis. Clin Microbiol Rev. 2011; 24(1):110-40. 2. Esch KJ, Petersen CA. Transmission and epidemiology of zoonotic protozoal diseases of companion animals. Clin Microbiol Rev. 2013; 26(1):58-85. 3. Rayani M, Zasmy Unyah N, Hatam G. Molecular Identification of Giardia duodenalis Isolates from Fars Province, Iran. Iran J Parasitol. 2014;9(1):70-8. 4. Sarkari B, Hosseini G, Motazedian MH, Fararouei M, Moshfe A. Prevalence and risk factors of intestinal protozoan infections: a population-based study in rural areas of Boyer-Ahmad district, Southwestern Iran. BMC Infect Dis. 2016; 16(1):703. 5. 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Can Giardia Infection Impair the Diagnostic Level of Fecal  Calprotectin in Patients with Inflammatory Bowel Disease? A Case Report

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Can Giardia Infection Impair the Diagnostic Level of Fecal Calprotectin in Patients with Inflammatory Bowel Disease? A Case Report

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