Protozoa is a loose term for certain nucleated, unicellular organisms (eukaryotes) that lack a cell wall and are neither animals, plants, nor fungi. The most important intestinal protozoan pathogens that cause enteric infections in humans include
Cryptosporidium species (see Cryptosporidiosis)
Cyclospora cayetanensis (see Cyclosporiasis)
Cystoisospora belli (previously known as Isospora belli—see Cystoisosporiasis)
Entamoeba histolytica (see Amebiasis)
Giardia duodenalis (previously known as G lamblia, G intestinalis—see Giardiasis)
Members of the phylum Microsporidia used to be classified as protozoa but are now, based on DNA studies, thought to be fungi or closely related to them.
Multiple pathogenic parasites and nonpathogenic commensal organisms may be present in the intestine at the same time.
Intestinal protozoa are spread by the fecal-oral route, so infections are widespread in areas with inadequate sanitation and water treatment. They are common in settings where fecal incontinence and poor hygiene prevail, as may occur in mental institutions and day care centers. Some gastrointestinal protozoa are spread sexually, especially with practices involving oral-anal contact. Several protozoan species cause severe opportunistic infections in immunocompromised patients, including those with human immunodeficiency virus (HIV).
Occasionally, large foodborne and waterborne outbreaks of intestinal protozoan infection have occurred in the United States (eg, the multi-state outbreak of Cyclospora cayetanensis infection attributed to contaminated fresh vegetable trays in 2018 and the massive waterborne Cryptosporidium outbreak in Milwaukee in 1993).
Systemic protozoal diseases are discussed elsewhere and include malaria, babesiosis, toxoplasmosis, leishmaniasis, Chagas disease, and African trypanosomiasis.
Diagnosis of Intestinal Protozoan and Microsporidia Infections
Making a diagnosis of intestinal protozoan and microsporidia infections based on symptoms and physical findings is difficult; stool testing for parasite antigens or DNA and microscopic examination of stool for cysts or organisms are necessary.
Fecal antigen tests that are sensitive and specific are available for
Cryptosporidium species
E. histolytica
G. duodenalis
Microscopic diagnosis may require several samples, concentration methods, and special stains; thus, the laboratory should be notified which pathogen or pathogens are suspected. Some patients require semi-invasive diagnostic techniques such as endoscopic biopsy (see table Collecting and Handling Specimens for Microscopic Diagnosis of Parasitic Infections).
Molecular diagnosis using polymerase chain reaction (PCR) assays is available for many enteric protozoa.
