Persistent Giardia

I was in Africa (Ghana, Tanzania, Kenya) for 2 months (9/15/08 – 11/10/08). A few days after returning to the US I developed diarrhea, nausea, bloating, abdominal discomfort, weakness and tiredness.  After a week of that I went to my GP and he prescribed me Azithromycin as he suspected traveler’s diarrhea.  5 days later after treatment my diarrhea had disappeared but the other symptoms remained along with terrible smelling gas.

After 3 weeks of symptoms I went to a GI doctor.  He performed many tests (blood and stool) that came back normal except for the giardia antigen stool test.  He said that I did in fact have giardia and put me on Flagyl (250 mg, 3 times a day, for 5 days).  After completing treatment as outlined I felt fantastic; back to my old self.  However, 4 days after feeling better nausea, bloating, abdominal discomfort, weakness, and tiredness returned.

I went back to my GI doctor and he scheduled me for an upper endoscopy and another giardia antigen stool test.  The stool test came back negative.  However during the upper endo, my doctor took a biopsy of my stomach and duodenum.  He also saw a lot of inflammation of the duodenum.  The biopsy of the tissue from my duodenum did show giardia under the microscope.  I found this out today (01/05/09).

My doctor said he will call me tomorrow with a course of treatment after doing some investigation.

My question is what should the proper course of treatment be given the fact that the original course of treatment with Flagyl didn’t wipe out the giardia completely.  At every step I have had to press for investigating giardia as a possible cause for my symptoms, so I am not sure if this is something that GIs commonly deal with. Because of this, I want to make sure that the next course of treatment I get is going to do the trick, or if nothing else is the next best scientifically and medically based treatment option.  Can you please provide thoughts on what the next course of treatment should or could be?

[Kevin Pho, MD]

I agree with the workup thus far, and under normal circumstances Flagyl is the appropriate antibiotic for Giardia.

Other options can include tinidazole, albendazole, furazolidone, nitazoxanide, bacitracin.

These are all alternative regimens for cases that are resistant to the Flagyl.

A referral to an infectious disease specialist can also be considered, in addition to the GI consultation.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin Pho, M.D.
www.kevinmd.com
www.twitter.com/kevinmd

[Ihhg]

Dr. Pho,

Thank you.  I do understand that all the drugs you have listed are alternatives and can be used with flagyl resistant Giardia.  What I am asking is if I were your patient could you provide me with some examples of the exact course of treatment you'd prescribe at this point.

Which drug (or drugs if a combination is in order), for how long and what doseage?

Thanks,
Mark