Giardiasis Diagnosed onEsophageal Brush Smearsin a Case of Chronic AlcoholicLiver Disease With EsophagealCandidiasis

Dear Dr. Bedrossian:

A 42-year-old male patient presented to us with abdom-

inal distension and jaundice since 4 months. Patient was a

known alcoholic. Physical examination showed icterus,

ascitis, pedal edema, and hepatomegaly. Laboratory tests

showed total bilirubin—17.1 mg%, SGOT—37 IU/ml,

SGPT—23 IU/ml, serum alkaline phosphatase—92 IU/ml.

Viral serology for hepatitis B and C was negative. Ultra-

sonography showed nodular liver with coarse ecotexture.

A clinical diagnosis of chronic alcoholic liver disease

with portal hypertension was made. An esophageal endos-

copy confirmed the presence of esophageal varices and

also showed small, multiple, white patches in the lower

esophagus. Esophageal brush smears were made from the

white patches. The smears showed low cellularity. Clus-

ters and singly scattered benign squamous epithelial cells

with some neutrophils were seen (Fig. 1) along with

spores and pseudohyphae of Candida (Fig. 1, inset A). On

further examination of the smears we were surprised to

find some pear-shaped structures in three clusters lying

adjacent to the squamous cells. These structures on higher

magnification were identified as trophozoites of Giardialamblia (Fig. 1, inset B). A diagnosis of esophageal can-

didiasis with Giardiasis was made. The diagnosis of Giar-

diasis was confirmed by stool examination, which showed

cysts of Giardia. Immediately after diagnosis, the patient

was started on antifungal and antiprotozoal therapy along

with treatment of alcoholic liver disease. A second stool

examination after completion of antiprotozoal therapy was

negative for Giardia infection. The patient is still on fol-

low-up in our gastroenterology OPD.

Giardia is a flagellated protozoan parasite causing gas-

trointestinal tract infection. Giardia most commonly

infects children. Majority of cases present with symptoms

like diarrhea, abdominal cramps, bloating, nausea, vomit-

ing, and weight loss.1 Repeated infections lead to resist-

ance which results in a large number of asymptomatic cyst

carriers. The most common site of colonization by troph-

ozoites of Giardia is proximal duodenum. Giardia has

also been isolated from sites such as stomach, jejunum,

ileum, colon, biliary tree, gallbladder, bronchoalveolar

lavage fluid, and even peritoneal fluid.2–4 To this long

list we add one more site—‘‘esophagus.’’ In all these

cases the diagnosis of Giardiasis was made by morpho-

logic identification of trophozoites either on endoscopic/

colonoscopic biopsy or on brush smears taken during

endoscopy. Studies have shown that brush smears have a

much higher diagnostic yield compared to biopsies in

cases of Giardiasis.5

In our case it is difficult to say with certainty whether

the trophozoites were colonizing the esophagus along

with candida or gained access to the esophagus by gastro-

esophageal reflux. In the latter case, the trophozoites

might have been entering the stomach passively from the

duodenum or may have been colonizing the stomach.

Gastric involvement by Giardia is usually associated with

small intestinal involvement. During the life cycle of

Giardia, the excystation occurs in the stomach at an acidic

pH, the optimum pH being 1.3–2.7.6 The optimum pH for

the trophozoites to grow and multiply is reported to be

6.38–7.02.6 If the trophozoites were colonizing the stom-

ach then gastroduodenal reflux may provide the optimum

environment for their survival by raising the gastric pH

and by ensuring the supply of bile salts, which are an im-

portant growth factor for Giardia trophozoites. Hypochlo-

rhydria may also be responsible for raising the gastric pH

*Correspondence to: Deepak Kumar Singh, M.D., 597, Z-Type Flats,Lucknow Road, Timarpur, Delhi 10054, India.E-mail: dr_kumar2004@ yahoo.com

Received 19 May 2008; Accepted 20 June 2008DOI 10.1002/dc.20930Published online in Wiley InterScience (www.interscience.wiley.com).

846 Diagnostic Cytopathology, Vol 36, No 11 ' 2008 WILEY-LISS, INC.

and facilitating growth of trophozoites in these cases.

Unfortunately, biopsies were not available to assess gas-

tric and duodenal colonization as endoscopy was done

only to look for esophageal varices, and gastric and duo-

denal biopsies were not taken. Although duodenum is the

most common site of colonization by Giardia, a duodenal

biopsy done only for diagnosing/confirming Giardiasis is

not indicated. Stool examination is the preferred method

for diagnosis as it is easy, fast, and inexpensive.5

To the best of our knowledge this is the first reported

case where a diagnosis of Giardiasis was made on esopha-

geal brush smears. We want to highlight the facts that

many patients of Giardiasis are asymptomatic and that

Giardia can colonize any part of the gastrointestinal tract

from the esophagus to colon including hepatobiliary

tree. It is important to be familiar with the morphology of

the protozoan parasite and to carefully search for the

trophozoites of Giardia when examining brush smear/

biopsy from any part of gastrointestinal tract including

the esophagus.

Deepak Kumar Singh, M.D.*

Archana Rastogi, M.D.

Puja Sakhuja, M.D.

Ranjana Gondal, M.D.

Department of Pathology

Govind Ballabh Pant Hospital

New Delhi 110002, India

References1. Oberhuber G, Stolte M. Symptoms in patients with Giardiasis

undergoing upper gastrointestinal endoscopy. Endoscopy 1997;29:716–720.

2. Oberhuber G, Kastner N, Stolte M. Giardiasis: A histologic analysisof 567 cases. Scand J Gastroenterol 1997;32:48–51.

3. Stevens WJ, Vermeire PA. Giardia lamblia in bronchoalveolar la-vage fluid. Thorax 1981;36:875.

4. Block T, Davis TE, Jr, Schwenk GR. Giardia lamblia in peritonealfluid. Acta Cytol 1987;31:783–784.

5. Sun T. The diagnosis of Giardiasis. Am J Surg Pathol 1981;4:265–271.

6. Bingham AK, Meyer EA. Giardia excystation can be induced in vitroin acidic solutions. Nature 1979;277:301–302.

Fig. 1. Trophozoites of Giardia(arrow) are seen in endoscopic esoph-ageal brush smear. Epithelial squa-mous cells are seen in the upper leftcorner. (Gimesa, 3200). Inset Ashows spores and pseudohyphae ofcandida. (Gimesa, 3400). Inset Bshows trophozoites of Giardia athigher magnification. The morphologyof the trophozoites was well preservedin the smears. (Gimesa, 31,000).

ESOPHAGEAL GIARDIASIS

Diagnostic Cytopathology, Vol 36, No 11 847

Diagnostic Cytopathology DOI 10.1002/dc