Nutritional status of children infected with Giardia lamblia and Entamoeba histolytica infections in Kalar town, Iraq

Giardia lamblia is a flagellate protozoon which causes giardiasis. The infection is limited to the small intestine and/ or the biliary tract. It may produce a wide range of gastrointestinal symptoms especially in children; which include vomiting, flatulence, diarrhea and malabsorption syndrome. Entamoeba histolytica causes amoebiasis in human beings which is an infection of the large intestine; it may invade the host tissues. It may produce acute amoebic dysentery which is accompanied with blood, mucus and tenesmus; chronic and asymptomatic amoebiasis or extra-intestinal amoebiasis. This study was carried out from second of May to thirties of November 2008 to show the relationship between Giardia lamblia and Entamoeba histolytica infections with some biochemical parameters and anthropometric measurements among 348 children aged 2-13 years old in Kalar General Hospital. Stool examination was done by direct method using normal saline and lugols iodine solution. Biochemical parameters (total protein, albumin, globulin, zinc, copper, and iron were estimated by spectrometry. The nutritional status were determined by measuring weight for age (WFA), weight for height (WFH) and height for age (HFA) according to National Center for Health Statistics (NCHS). The overall prevalence of infections was 48%. The infection rate of E. histolytica 31.6% was higher than G. lamblia 16.37%. Total serum protein and albumin concentrations were decreased significanly in G. lamblia (7.15 mg/dl, 4.91 mg/dl) and E. histolytica (6.48mg/dl,


Introduction
Parasitic infections can affect the nutritional status of infected people, by modifying the key stages of food intake, digestion and absorption.Indirect morbidity is particularly important in children with parasitic infections, ranging from malnutrition, anemia, growth retardation, irritability and cognitive impairment to increase susceptibility to other infections and acute complications (1), protein energy malnutrition is another complication of parasitic infection which is common problem in populations with low socioeconomic status and low level of public health sanitation (2).Attachment of a large number of G. lamblia to intestinal mucosa may exert an irritative, mechanical, or possibly a toxic action on the intestinal mucosa may lead to shortening and blunting of the villi, thus interfering with intestinal absorption of nutrients and producing malabsorption syndrome (3).E. histolytica have numerous virulence factors such as proteinases, lectin and amoebapore for digestion and penetration of intestinal mucosa leading to diarrhea as well as malabsorption of nutrients and minerals (4).It has been reported that blood levels of iron, zinc, and copper might decrease in children infected with amoebiasis (5).Epidemiological studies indicate an association between relatively low zinc concentration and increased diarrheal morbidity.Moreover, zinc supplementation reduces duration and treatment failure of diarrhea.It is suggested that zinc alters the function of E. histolytica in vitro reflected by decreasing in replication and adhesion, and in vivo as manifested by inhibition of amoebic pathogenicity (2), serological level of zinc is also decreased during giardiasis due to malabsorption (6).Although a relation of copper deficiency and diarrheal morbidity has not been shown, E. histolytica acid phosphatase activity is significantly inhibited by copper suggesting a possible role in amoebic intestinal disease (5), while studies revealed that giardiasis increased serological level of copper like other infections (6 &7).

Materials and Methods
This study was carried out from second of May to thirties of November 2008 to investigate the relation of E. histolytica and G infection with some biochemical parameters and anthropometric measurements among 348 children aged 2-13 years old visited Kalar General Hospital.General stool examination was carried out for each child using direct wet mount technique.

Biochemical parameters
Total protein determination was performed by spectrophotometer wave length 540 nm, following the procedure of Tietz (8).Albumin determination was performed using spectrophotometer at 630 nm following the procedure of Daumas et al., (9).Globulin calculation was calculated by subtracting the value of albumin from total protein.Determination of Zinc (Zn) was carried out following the procedure of Makino (10) using Spectrophotometer at 580 nm.Determination of Copper (Cu) was carried out according to Pasquinelli, (11) using spectrophotometer at 578 nm.Determination of iron (Fe) was performed according to procedure of Hennesy et.al., (12), using spectrophotometer at 600 nm.

Nutritional status
Nutritional status was determined as weight for age (WFA), weight for height (WFH), and height for age (HFA) according to National Center for Health Statistics (13).

Statistical analysis
Statistical analysis was carried out using statistically available software (SPSS version 17).Comparisons between control and patient groups were made using t-test at (0.05 and 0.01) levels ( 14).

Nutritional status
As shown in lamblia and E. histolytica infected males (42.85% and 52.17%) than in females (37.5% and 21.42%) repectively, and the rates of stunting were higher in infected males with E. histolytica (31.81%) than in females (7.14%), while the rate of stunting were lower in infected males with G. lamblia (28.57%) than in females (42.85%).

Biochemical parameters
Protein-energy malnutrition and intestinal parasitic infections are common problem in those populations characterized by low socioeconomic status and low level of public health sanitation.G. lamblia and E. histolytica infections were related to deleterious consequences to proteinenergy nutritional status.Two major consequences may result from proteinenergy malnutrition: deficient growth and intellectual performance (2).The total serum protein and albumin were significantly lower in both infections.In Kirkuk (15) recorded significantly lower level of total serum protein in G. lamblia infected patients 5.83±0.65 gm/dl in comparison to control ones 6.73±0.45gm/dl.
In Erbil (16), recorded no significant differences in the level of total serum protein and albumin between G. lamblia infected and non-infected group (6.82±0.59gm/dl, 3.8±0.3gm/dl), (7.27±0.4gm/dl, 3.82±0.27gm/dl), respectively.This may be due to her study was on the general population which includes a large proportion of asymptomatic patients which can not be affected as heavy as symptomatic children who visit hospitals.Higher concentration of serum globulin among G. lamblia infected patients than non-infected ones is identical to study obtained by Baqai (17) who recorded significantly higher concentration of total globulin in serum of G. lamblia infected 2.57 gm/dl compared to control 1.83 gm/dl.In this study the concentration of serum globulin in Entamoeba did not vary significantly between infected and non infected ones.

Serum concentration of minerals in relation to G. lamblia and E. histolytica infections:
In agreement with other studies, serum zinc concentration decreased in both giardiasis and amoebiasis.23) in Iran, observed significantly higher degree of malnutrition, underweight (WFA) and stunted (HFA) among G. lamblia infected than non-infected children.Hama (24) in Erbil, found that the intestinal parasitic infections were more prevalent in underweight (low WFA), whereas wasted children (low HFA) was slightly associated with parasitic infections but there is no relation between stunted children (low HFA) and intestinal parasitic infections.Some studies have not found a relation between intestinal parasitic infection and nutritional status such as Al-Agha and Teodorscu (25) in Palestine, Abd-El-Aal et al. (26) in Egypt, recorded no significant difference between weight and height of G. lamblia and non-infected children, these may be due to the high standard of socio-economic level and better quality meals of the studied areas or intestinal parasites intensity and the type of infection have a notable role to reveal the symptoms as well as the signs of malnutrition.It is not worthy to compare studies conducted among acute infections, because it can not correlate the effect of parasites on nutritional status clearly because the period of infection is not efficient to assess the nutritional parameters change, but chronic and asymptomatic intestinal parasitic infections cause nutritional deficiency.Our data support the hypothesis that early treatment of G. lamblia and E. histolytica infections will improve the growth of children and decrease the morbidity and mortality of the related illnesses.It is concluded that both G. lamblia and E. histolytica infections were more prevalent in underweight children (low WFA), and stunted children (low HFA), whereas in wasted children (WFH) had no relation with both infections.

Table ( 3):-The rate of malnutrition among children infected with G. lamblia and E. histolytica and non-infected children.
table (3) G. lamblia and E. histolytica infections were prevalent in malnourished children and the rate