1Urinary infection due to Balantioides coli: a rare

2accidental zoonotic disease in an addicted and diabetic

3young female in Iran

4Saman Soleimanpour1*, Ali Babaei2*, Abdolghayyoum Movahhedi Roudi3,

5Seyedeh Sara Raeisalsadati1

61Microbiology and Virology Research Centre, Bu-Ali Research Institute, Mashhad

7University of Medical Sciences, Mashhad, Iran.
82Laboratory of 22nd Bahman hospital, Khaf, Mashhad University of Medical
9Sciences, Mashhad, Iran.
103Department of Parasitology, 22nd Bahman hospital, Khaf, Mashhad University of
11Medical Sciences, Mashhad, Iran.

12*Corresponding author:
13Saman Soleimanpour
14Microbiology and Virology Research Centre, Bu-Ali Research Institute, Mashhad
15University of Medical Sciences, Mashhad, Iran.
16Tel: +98-9126590092
17E-mail: soleimanpour.saman@yahoo.com

18*Corresponding author:
19Ali Babaei
20Laboratory of 22nd Bahman hospital, Khaf, Mashhad University of Medical
21Sciences, Mashhad, Iran. Tel: +98-9139054564
22E-mail: alibabaei206@yahoo.com

* Saman Soleimanpour and Ali Babaei contributed equally to this work and should both be
considered as first authors.

Supplementary material is available with the online version of this paper.

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23Abstract

24Background: Balantiosis, a rare zoonotic infection resulting in dysentery,

25is caused by the large ciliated protozoan parasite Balantioides coli (B. coli).
26Humans acquire it via the fecal-oral route. Very rarely, extra-intestinal
27infections can occur in the urinary tract system. There are very few case
28reports of urinary balantiosis in humans. Case presentation: Here, an
29interesting case of urinary balantiosis in a 35-year-old addicted woman
30with multiple health problems including spontaneous abortion and diabetes
31is reported. Her midstream urine sample collected while all sterile
32precautions were taken demonstrated B. coli along with Trichomonas
33vaginalis and bacteria. B. coli was identified by its characteristic
34morphology and rapid rotary motility in the urinary tract, which is an
35abnormal site for invasion by this parasite. Conclusion: This is only the
36eighth case described in literature in which B. coli was detected in urine
37sediment; it is reported for its rarity and for future reference.

38Key words: Balantioides coli, Urinary balantiosis, Trichomonas

39vaginalis

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40Introduction

41Balantioides coli (formerly Balantidium coli, synonym Neobalantidium coli) is

42a large ciliated protozoan parasite of low virulence which causes balantidial
43dysentery in humans. It has a worldwide distribution, but the prevalence of
44its human infection is very low (Schuster & Ramirez-Avila, 2008). Balantiosis is
45a zoonotic disease acquired by humans via the fecal-oral route from its
46normal hosts, although it is an uncommon infection. Infection in humans is
47mostly found in tropical and subtropical regions and developing countries,
48especially in settings where water sources may be contaminated with
49porcine or human feces and hygiene is poor (Schuster & Ramirez-Avila, 2008).
50Human-to-human transmission may also occur, albeit rarely. Although B.
51coli infects a wide range of mammals, domestic pigs and wild boars are
52generally considered to be the most important natural reservoir for human
53balantiosis (Nakauchi et al., 1999). Thus, this infection has an increased
54prevalence in countries and communities that live in close contact with
55pigs. Because of the Islamic prohibition on eating pork, piggeries in Iran, a
56Muslim country, were closed after the 1979 Islamic revolution, and pig
57breeding and the consumption of pork was prohibited. Therefore, the pig
58can be excluded as a source of infection in Iran. However, there are still
59reports of this infection, which suggests that maybe a different animal is a
60reservoir host. The wild boar is found in rural areas of different parts of Iran
61and has close contact with farmlands and natural water sources.
62Additionally, some reports have shown that B. coli is found most frequently
63in Iranian wild boars. Therefore, they are probably the source of human
64infection in Iran, especially in rural areas where they roam and their feces
65could contaminate food and water (Solaymani-Mohammadi et al., 2005).

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66In humans, the cecum and colon are the natural habitats of this organism.
67After ingestion, B. coli can penetrate the mucosa layer of the large
68intestine and cause ulcers and balantidial dysentery in humans and other
69vertebrates (Schuster & Ramirez-Avila, 2008). In rare cases, especially in
70immunocompromised subjects, extraintestinal spread to the appendix
71(Dodd, 1991), liver (Kapur et al., 2014), peritoneal (Ferry et al., 2004), lung
72(Sharma and Harding, 2003), genitourinary tract has also been reported
73(Rivasi and Giannotti, 1983; Koopowitz et al., 2010). Genitourinary
74infections, including uterine infection, vaginitis, and cystitis, are thought to
75occur via direct spread from the anal area (usually in females) or as
76secondary to a rectovaginal fistula created from infection with this
77organism (Umesh, 2007).
78Clinical manifestation of balantiosis can take one of three forms: (i)
79asymptomatic or mild infection that presents with intermittent diarrhea
80alternating with constipation; (ii) acute or fulminating forms presenting with stool
81containing mucus and blood resembling Entamoeba histolytica dysentery,
82severe dehydration and weight loss. In rare cases, fulminant ulceration with
83perforation of the colon may cause hemorrhage and even death; (iii) chronic
84symptomatic infection which is characterized by non-bloody diarrhea alternating
85with constipation and nonspecific abdominal pains (Bellanger et al., 2013).
86Extraintestinal spread to the genitourinary tract has rarely been reported
87(Koopowitz et al., 2010). Urinary balantiosis is thought to occur via direct spread
88from the anal area or a rectovaginal fistula created from infection with B. coli (Umesh, 2007).
89This paper reports a rare and interesting case of urinary balantiosis in an
90addicted, diabetic woman showing ciliated parasite along with
91Trichomonas vaginalis and bacteria in a MSU sample collected while all
92sterile precautions were taken.

93Case report

94A 35-year-old addicted woman suffering from diabetes and hypothyroidism

95referred to the hospital emergency department with the chief complaint of
96spontaneous abortion and a temporary loss of consciousness. Abdominal
97examination of this patient revealed generalized tenderness. A complete
98haemogram and other laboratory tests (shown in the Table 1) revealed a

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 99severe anaemia, biological inflammatory syndrome (C-reactive protein
100positive), hypernatremia, hypokalaemia, diabetes, and an initial functional
101renal deficiency. Examination of the arterial blood gas revealed a metabolic
102acidosis (Table 1).
103The patients fresh midstream urine (MSU) sample was sent for
104macroscopic and microscopic examination. Its physical appearance was
105smoky and turbid, and the urine test strip revealed sugar and proteinuria.
106Samples were examined using Merthiolate-Iodine-Formaldehyde
107Concentration (MIFC) method (Pomajbikova et al., 2010). Microscopic
108examination of the sediment revealed a tubular cast, a few epithelial cells,
109amorphous urates, bacteria, hematuria with 50-60 red blood cells/high
110power field (HPF), and pus cells 20-25/HPF. The urine sample showed few
111large ovoid-shaped ciliated parasites measuring approximately 61m
11251m. They had a rotary, boring motion and were moving very rapidly
113across the slide (Video. 1, available in the online Supplementary Material),
114suggesting trophozoites of Balantioides coli (Fig. 1). The trophozoites
115bodies were completely covered with short delicate cilia, all of uniform
116length, which maintained a constant synchronized motion. The cilia which
117lined the mouth part appeared to be longer than the others (adoral cilia).
118The organism had a mouth that was located at the pointed anterior end
119(cytostome) and a rounded posterior end (cytopyge). Several food
120vacuoles, macronucleus, micronucleus (next to macronucleus), and a few
121ingested red blood cells were present within the cytoplasm. This
122morphology, the ciliary covering, and its rotary motion were typical of
123Balantioides coli. In the urine sediment, a few motile trophozoites of
124Trichomonas vaginalis were also seen (Fig. 2). Repeated MSU samples from the
125patient were also positive for similar organisms. The stool samples collected
126were negative for B. coli trophozoites or cysts, but mucosal clamps with
127lots of pus cells were seen. The patient was given tetracycline (500 mg
128four times a day) and metronidazole (750 mg three times a day) for a total
129of 7 days, and she gradually improved.

130Discussion

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131Human urinary balantiosis is a rare disease. Before 2015, there were only
132seven cases reported in literature [one from Iran (Maleky, 1998), one from
133Italy (Maino et al., 2010), and five cases in India (Umesh, 2007; Bandyopadhyay
134et al., 2013; Khanduri et al., 2014; Basavraj et al., 2012; Karuna & Khadanga,
1352014)].
136In the case presented here, a 35-year-old female patient presented with
137diabetes and addiction, both of which can become dreadful conditions
138making her vulnerable to invasion by any opportunistic microbe at any
139site. She denied direct contact with swine or wild boar, but had a history
140of eating the meat of hunted rabbit; thus, she might have been infected
141from contaminated rabbit meat, even though there has so far been no
142report of human infection via consumption of rabbit meat in the world. It
143seems that more studies like analyze using molecular-phylogenetic methods are required to
144determine the existence of balantioides-like ciliates in rabbits (Pomajbikova et al.,
1452013). On the other hand, the patient lives in a village and is in contact
146with wild animals, so it is not farfetched to surmise that she may have
147consumed water or food contaminated with wild boar feces containing B.
148coli cysts. Then, after ingestion and excystation in the large intestine, the
149trophozoites may have invaded the colonic mucosa to enter the blood
150stream and finally metastasized to the urinary bladder or spread directly
151through the anal area. The patient also mentioned that she had diarrhea
152before, but at the time of admission she had severe constipation that
153implied the common phase of a parasite.
154In conclusion, patients with uncontrolled diabetes are considered
155immunosuppressed due to the negative effect of elevated blood sugars on
156the immune system. Hyperglycemia destroys overall immunity by various
157mechanisms and can lead to acidosis, which limits the activity of the
158immune system (Casqueiro and Alves, 2012). Moreover, addictive drugs
159and opioids suppress the immune system, the body's innate defense
160against infections (Friedman et al., 2003). On the other hand,
161immunosuppressed patients appear to be less resistant to balantiosis.
162Thus, B. coli can become an opportunistic parasite in immunosuppressed,
163diabetic, and addicted patients like the present case, living in rural
164environments where wild boars roam and their feces could contaminate

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165food and water. There have been no more studies, however, to determine
166the prevalence of balantidia in Immunocompromised individuals.
167Nevertheless, some extraintestinal infections have previously been
168reported in association with spread of B. coli to the lung (Anargyrou et al.,
1692003), peritoneal (Ferry et al., 2004) and genitourinary tract (Rivasi and
170Giannotti, 1983), especially in immunocompromised subjects. Thus, this
171case emphasizes the fact that B. coli should also be considered as a
172possible pathogen in immunocompromised patients with or without
173diarrhea even if they have no contact with pigs (Anargyrou et al., 2003;
174Yazar et al., 2004; Cermeno et al., 2003). It should come in the differential
175diagnosis of these patients presenting with dysuria and hematuria. Using
176microscopic examination of fresh urine sediment, a microbiologist can easily
177diagnose this large parasite by its characteristic morphology and rapid
178rotary motility.

179Financial support: No grants or funding were received for this

180publication.

181Conflict of interest statement: there is no conflict of interest.

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244Fig 1. Trophozoite of Balantioides coli with micronucleus, macronucleus and food
245vacuoles in urine sample. Arrow A: macronucleus; arrow B: micronucleus; arrow
246C: cytostome and arrow D: The cilia which lined the mouth part appeared
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 Table 1. Lab test results of patient

Laboratory Tests Results Clinical Implications

Haemogram tests
Total leukocyte count 17.5103/L leukocytos
Total platelet count 374103/ L
Hb level 8.9 g/dl anaemia
Biochemistry tests
Serum Na+ 147 mmol/L hypernatremia
Serum K+ 2.9 mmol/L hypokalaemia
Blood sugar (BS) 520 mg/dl
diabetes
Fasting blood sugar (FBS) 210 mg/dl
Kidney function tests
Serum urea 17mg/dl initial functional renal
Serum creatinine 1.8 mg/dl deficiency
Examination of the arterial blood gas
pH 6.985
PaCO2 11.4 mm Hg
metabolic acidosis
PaO2 78.9 mm Hg
bicarbonate 2.7 mmol/L
248

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