Distribution and relevance of Dientamoeba fragilis and Blastocystis species in gastroenteritis: results from a case-control study

  • Maria Dullaert- de BoerEmail author
  • Theo A. Schuurs
  • Marloes Vermeer
  • Gijs J.H.M. Ruijs
  • Adri G. M. van der Zanden
  • Jan F. Weel
  • Lesla E.S. Bruijnesteijn van Coppenraet
Original Article


The actual role of Dientamoeba fragilis and Blastocystis in patients with gastrointestinal symptoms is still under debate. A multicenter case-control study was performed in The Netherlands to elucidate the clinical relevance of molecular diagnostics results in gastroenteritis (GE). Samples from this case-control study were used to perform a detailed analysis on the presence of D. fragilis and Blastocystis in relation to gastrointestinal symptoms. In the present study, a real-time PCR for Blastocystis was performed on 1374 case samples and 1026 control samples from the multicenter gastroenteritis case-control study previously tested for D. fragilis. Prevalence of both micro-organisms was highest in children under 20 years of age and lowest in the oldest age group. A significantly lower overall detection of D. fragilis and Blastocystis was found in cases (both 25.8%) as compared to controls (37.6% and 40.0%, respectively). The difference for D. fragilis was statistically significant for subjects above 20 years of age. For Blastocystis, the difference was statistically significant in all age groups, except in children less than 5 years of age. A negative relation between D. fragilis-positive cases and diarrhea was found in this study population. More GE symptoms were reported in cases without D. fragilis or Blastocystis. In the present study, prevalence of both D. fragilis and Blastocystis is lower in cases with gastroenteritic symptoms than in controls. Besides, in cases with D. fragilis or Blastocystis, no association is shown between any of the GE symptoms. Interestingly, this suggests that the presence of these protozoans may be considered characteristic of a healthy intestinal microbiome.


Dientamoeba fragilis Blastocystis Gastroenteritis Diarrhea Case-control Multiplexed real-time PCR 



The authors acknowledge Rune Stensvold for the technical information and technical support of the Blastocystis PCR and suggestions for the manuscript, Jaco J Verweij for PCR technical advice and fruitful discussions and suggestions for the manuscript, Roche Diagnostics for financial support of nucleic acid extraction, and Life Technologies for financial support of the PCR reactions. Special thanks to V. Tuchter, A. Stellingwerf, O. Lindenboom, M. Janssen, and J. Wallinga for technical support.


  1. 1.
    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 43:2718–2723CrossRefGoogle Scholar
  2. 2.
    Barratt JL, Harkness J, Marriott D, Ellis JT, Stark D (2011) A review of Dientamoeba fragilis carriage in humans: several reasons why this organism should be considered in the diagnosis of gastrointestinal illness. Gut Microbes 2:3–12CrossRefGoogle Scholar
  3. 3.
    Garcia LS (2016) Dientamoeba fragilis, One of the Neglected Intestinal Protozoa. J Clin Microbiol 54:2243–2250CrossRefGoogle Scholar
  4. 4.
    Krogsgaard LR, Engsbro AL, Stensvold CR, Nielsen HV, Bytzer P (2015) The prevalence of intestinal parasites is not greater among individuals with irritable bowel syndrome: a population-based case-control study. Clin gastroent hepat 13:507–513.e2CrossRefGoogle Scholar
  5. 5.
    Millet V, Spencer MJ, Chapin M, Stewart M, Yatabe JA, Brewer T (1983) Dientamoeba fragilis, a protozoan parasite in adult members of a semicommunal group. Dig Dis Sci 28:335–339CrossRefGoogle Scholar
  6. 6.
    De Wit MA, Koopman MP, Kortbeek LM, van Leeuwen NJ, Vinje J, van Duynhoven YT (2001) Etiology of gastroenteritis in Sentinel general practices in the Netherlands. Clin Infect Dis 33:280–288CrossRefGoogle Scholar
  7. 7.
    Bruijnesteijn van Coppenraet LE, Dullaert-de Boer M, Ruijs GJ, van der Reijden WA, van der Zanden AG, Weel JF et al (2015) Case-control comparison of bacterial and protozoan microorganisms associated with gastroenteritis: application of molecular detection. Clin Microbiol Infect 21:592.e9–592.e19CrossRefGoogle Scholar
  8. 8.
    De Jong MJ, Korterink JJ, Benninga MA, Hilbrink M, Widdershoven J, Deckers-Kocken JM (2014) Dientamoeba fragilis and chronical abdominal pain in children: a case-control. Arch Dis Child 99:1109–1113CrossRefGoogle Scholar
  9. 9.
    Röser D, Simonsen J, Stensvold CR, Olsen KE, Bytzer P, Nielsen HV et al (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 58:1692–1699CrossRefGoogle Scholar
  10. 10.
    Engsbro AL, Stensvold CR, Nielsen HV, Bytzer P (2012) Treatment of Dientamoeba fragilis in patients with irritable bowel syndrome. AM J trop Med Hyg 87(6):1046–1052CrossRefGoogle Scholar
  11. 11.
    Verweij JJ, Stensvold CR (2014) Molecular testing for clinical Diagnosis and Epidemiological investigations of intestinal parasitic infections. J Clin Microbiol rev:371–418CrossRefGoogle Scholar
  12. 12.
    de Wit MA, Koopmans MP, Kortbeek LM, Wannet WJ, Vinjé J, van Leusden F et al (2001) Sensor, a population-based cohort study on gastroenteritis in The Netherlands: incidence and etiology. Am J Epidemiol 154:666–674CrossRefGoogle Scholar
  13. 13.
    Stark D, Barratt J, Chan D, Ellis JT (2016) Dientamoeba fragilis, the neglected Trichomonad of the human Bowel. J Clin Microbiol rev 29(3):553–580CrossRefGoogle Scholar
  14. 14.
    Van Gool T, Weijts R, Lommerse E, Mank TG (2003) Triple feces test: an effective tool for detection of intestinal parasites in routine clinical practice. Eur J Clin Microb. Infect Dis 22(5):284–290CrossRefGoogle Scholar
  15. 15.
    Stensvold CR, Ahmed UN (2012) O’brien Andersen L, Nielsen HV. Development and Evaluation of a genus-Specific, probe based, internal-process-controlled real-time PCR assay for sensitive and specific detection of Blastocystis. J Clin Microbiol 50(6):1847–1851CrossRefGoogle Scholar
  16. 16.
    Stensvold CR (2015) Laboratory diagnosis of Blastocystis. Trop Parasitol. 5(1):3–5CrossRefGoogle Scholar
  17. 17.
    Bruijnesteijn van Coppenraet LE, Wallinga JA, Ruijs GJ, Bruins MJ, Verweij JJ (2009) Parasitological diagnosis combining an internally controlled real-time PCR assay for the detection of four protozoa in stool samples with a testing algorithm for microscopy. Clin Microbiol Infect. 15(9):869–874CrossRefGoogle Scholar
  18. 18.
    Stark D, Barrett 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. EurJ Clin microbial Infect Dis 29:411–416CrossRefGoogle Scholar
  19. 19.
    El Safadi D, Gaayeb L, Meloni D, Cian A, Poirier P, Wawrzyniak I et al (2014) Children of Senegal River basin show the highest prevalence of Blastocystis Evre observed worldwide. BMC Infect Dis. 14:164CrossRefGoogle Scholar
  20. 20.
    Scanlan PD, Stensvold CR, Rajilic-Stojanovic M, Heilig HGHJ, de Vos WM, O’toole PW et al (2014) The microbial eukaryote Blastocystis is a prevalent and diverse member of the healthy human gut microbiota. FEMS Microbiol Ecol. 90(1):326–330CrossRefGoogle Scholar
  21. 21.
    Wawrzyniak I (2013) Blastocystis, an unrecognized parasite: an overview of pathogenesis and diagnosis. Ther Adv Infect Dis. 1(5):167–178PubMedPubMedCentralGoogle Scholar
  22. 22.
    Morton ER, Lynch J, Froment A, Lafrosse S, Heyer E, Przeworski M et al (2015) Variation in rural African gut microbiota is strongly correlated with colonization by Entamoeba and subsistence. PLoS Genet. 11(11):e1005658CrossRefGoogle Scholar
  23. 23.
    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):25–29CrossRefGoogle Scholar
  24. 24.
    Poulsen CS, Efunshile AM, Nelson JA, Stensvold CR (2016) Epidemiological Aspects of Blastocystis colonization in children in Ilero, Nigeria. Am J Trop Med Hyg. 95(1):175–179CrossRefGoogle Scholar
  25. 25.
    Robins-Browne RM, Levine MM (2012) Laboratory diagnostic challenges in case/control studies of diarrhea in developing countries. Clin Infect Dis 55(Suppl. 4):S312–S316CrossRefGoogle Scholar
  26. 26.
    van Hattem JM, Arcilla MS, Schultsz C, Bootsma MC, van Gool T, Bart A, COMBAT consortium (2019) Carriage of Blastocystis spp. in travellers - A prospective longitudinal study. Travel Med Infect Dis 27:87–91. CrossRefGoogle Scholar
  27. 27.
    Jokelainen P, Hebbelstrup Jensen B, Andreassen BU, Petersen AM, Röser D, Stensvold CR (2017) Dientamoeba fragilis, a Commensal in Children in Danish Day Care Centers. J Clin Microbiol. 55(6):1707–1713. CrossRefGoogle Scholar
  28. 28.
    Bart A, van der Heijden HM, Greve S, Speijer D, Landman WJ, van Gool T (2008) Intragenomic Variation in the internal transcribed spacer 1 region of Dientamoeba fragilis as a molecular epidemiological marker. J Clin Microbiol. 46(10):3270–3275CrossRefGoogle Scholar
  29. 29.
    Stensvold CR, Clark CG, Roser D (2013) Limited intra-genetic diversity in Dientamoeba fragilis housekeeping genes. Infection, Infect Genet Evol. 18:284–286CrossRefGoogle Scholar
  30. 30.
    Andersen LO, Stensvold CR (2016) Blastocystis in health and disease: are we moving from a clinical to a public health perspective? J Clin Microbiol 54:524–528CrossRefGoogle Scholar
  31. 31.
    Fernandez-Suarez J, Boga J, Rodriguez-Guardado A, Sabater C, Fernández-Blazquez A, Leal A et al. Blastocystis hominis and PCR: contributions and doubts. 27ste ECCMID Vienna, AustriaGoogle Scholar
  32. 32.
    Taylor-Robinson D (1983) The role of mycoplasmas in non-gonococcal urethritis: a review. Yale J Biol Med. 56(5-6):537–543PubMedPubMedCentralGoogle Scholar
  33. 33.
    Stensvold CR, van der Giezen M. Associations between Gut Microbiota and Common Luminal Intestinal Parasites. Trends Parasitol. 2018;34(5):369–377. CrossRefGoogle Scholar
  34. 34.
    Bowen AC, Sheorey H, Bryant PA, Robson J, Burgner DP (2016) Polymerase chain reaction testing for faecal parasites: risks and alternatives. The Medical journal of Australia 204(7):262–262CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Maria Dullaert- de Boer
    • 1
    Email author
  • Theo A. Schuurs
    • 2
  • Marloes Vermeer
    • 3
  • Gijs J.H.M. Ruijs
    • 4
  • Adri G. M. van der Zanden
    • 1
  • Jan F. Weel
    • 2
  • Lesla E.S. Bruijnesteijn van Coppenraet
    • 4
  1. 1.Laboratory for Medical Microbiology and Public HealthHengeloThe Netherlands
  2. 2.Centre for Infectious Diseases FrieslandIzoreLeeuwardenThe Netherlands
  3. 3.ZGT AcademyZGTAlmeloThe Netherlands
  4. 4.Laboratory for Medical Microbiology and Infectious DiseasesIsalaZwolleThe Netherlands

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