Genotyping of Giardia duodenalis Cysts by New Real-Time PCR Assays for Detection of Mixed Infections in Human Samples

Of the seven genetic groups, or assemblages, currently recognized in the Giardia duodenalis species complex, only assemblages A and B are associated with human infection, but they also infect other mammals. Recent investigations have suggested the occurrence of genetic exchanges among isolates of G. duodenalis, and the application of assemblage-specific PCR has shown both assemblages A and B in a significant number of human infections. In this work, three real-time quantitative (qPCR) assays were developed to target the G. duodenalis triose phosphate isomerase, glutamate dehydrogenase, and open reading frame C4 sequences. Primers were designed to allow the specific amplification of the DNA of assemblage A or B and to generate products distinguishable by their melting curves or, after qPCR, by their sequences, sizes, or restriction patterns. The assays showed full specificity and detected DNA from a single trophozoite (4 to 8 target copies). We applied these assays, as well as a TaqMan assay that targets the β-giardin gene, to genomic DNA extracted from 30 human stools and to Giardia cysts purified by immunomagnetic capture from the same samples. Simultaneous detection of both assemblages was observed in a large number of DNAs extracted from stools, and experiments on the cysts purified from the same samples showed that this was essentially attributable to mixed infections, as only one assemblage was detected when dilutions of cysts were tested. In a few cases, detection of both assemblages was observed even when single cysts were tested. This result, which suggests the presence of recombinants, needs to be confirmed using more accurate methods for cyst separation and enumeration. The assays described in this study can be used to detect Giardia cysts infectious to humans in samples from animals and in water and food.Giardia duodenalis (syn. Giardia intestinalis and Giardia lamblia) is the only species within the genus Giardia that infects humans, although it is also found in other mammals, including pets and livestock (1). The infection has a global distribution and, with an estimated 2.8 × 10⁸ cases per year, represents the most common gastrointestinal parasitic infection of humans in developed countries (20). In Asia, Africa, and Latin America, about 200 million people have symptomatic giardiasis, with some 500,000 new cases reported each year (35). Several characteristics of G. duodenalis influence the epidemiology of infection: (i) in humans, the infective dose is about 10 to 100 cysts; (ii) cysts are immediately infectious when excreted in feces and can be transmitted by person-to-person or animal-to-animal contact; (iii) cysts are remarkably stable and can survive for weeks to months in the environment; and (iv) environmental contamination can lead to the contamination of drinking water and food (6, 32).A considerable amount of data has shown that G. duodenalis should be considered a species complex whose members show little variation in their morphology yet can be assigned to at least seven distinct assemblages (A to G) based on genetic analyses (7, 34). The analysis of more than a thousand human isolates from different geographical locations, examined by PCR amplification of DNA extracted directly from feces, has demonstrated that in almost all cases, only G. duodenalis assemblages A and B are associated with human infections (6). The prevalence of each assemblage varies considerably from country to country; assemblage B seems more common overall, but no strong conclusions can be drawn from current data. The remaining assemblages (C to G) are likely to be host specific, as assemblages C and D have been identified in dogs, cats, coyotes, and wolves; assemblage E in cattle, sheep, goats, pigs, water buffaloes, and muflons; assemblage F in cats; and assemblage G in rats.The epidemiology of human giardiasis is further complicated by the occurrence of mixed infections and the possibility of genetic exchanges between isolates of assemblage A (10) or even between isolates of assemblages A and B (21, 33). Ideally, genotyping should be performed on single cysts, as this allows a distinction between mixed infections and recombinants. To reach this technically demanding high level of sensitivity and specificity, real-time quantitative PCR (qPCR) appears to be a promising technique.This work describes the development of new qPCR assays that, through the use of assemblage-specific primers, allow the specific and simultaneous detection of DNAs of assemblages A and B. The application of these assays to DNA extracted from human stools and to cysts purified from the same samples is described.