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Debunking Myths in the Parasite Cleanse Trend – A Clinician’s Refresher on Parasites and Testing

Part 1:

How confident are you in your parasite knowledge? Most clinicians receive minimal training on parasitology, leading to misdiagnosis or underdiagnosis.1-5 With the current parasite cleanse trend over the last few years, you may have received patient questions or even pondered whether you should consider parasites more often in your differential diagnosis. This article aims to explore parasite identification methodologies and strengthen clinicians’ confidence in deciding whether to pursue testing and treatment. We’ll also dispel some popular parasitology myths… let’s dig in!

Note: Part 2 of this article focuses on parasite prevention and evidence-based natural parasite treatments.

Brief disclosure: I work for a functional medicine laboratory. The views and opinions presented in this article are mine alone and should not be interpreted as representing the official views or policies of Genova Diagnostics or any associated institutions.

The Parasite Cleanse Trend

As a medical education specialist in a stool-parasite testing lab, I’ve watched interest in parasites surge, largely mirroring the rise of social media “parasite cleanse” trends. Many patients who feel poorly and feel dismissed by conventional medicine turn to online explanations for their fatigue, gut issues, and other symptoms. Influencers offer compelling stories that parasites are the hidden cause, followed by subscriptions for recurring “cleanses” that promise restored energy.

What does the medical community think? Some clinicians are unfortunately reinforcing the hype, including respected physician influencers who promote the idea that “everyone has parasites” and requires regular treatment. This puts those of us who work in diagnostics in a difficult position: we support appropriate testing, and we see how fear-based messaging unnecessarily amplifies the topic, driving unnecessary treatment and delaying the real diagnosis.

To be clear, I’m not referring to regions where malaria and intestinal parasites are genuinely endemic. In those settings, clinicians are well-versed in recognizing symptoms, diagnosing infections, and treating appropriately—often including prophylactic or empiric treatment. I’m focusing on people living in developed countries, with no international travel history or major risk factors, who nonetheless believe they’re infested with intestinal worms and/or other parasites. Are parasites absent in these regions? By no means. An article entitled “The Landscape of Parasitic Infections in the United States” can help readers from the U.S. better understand the scope of parasitic infections.

The notion of hidden parasites triggers understandable anxiety, fueling the popularity of cleanses. Convincing arguments appeal to pet owners, sushi lovers, travelers, adventurers, produce eaters, and others that, because they participate in these things, they undeniably have parasites. We live in a globalized society, so wouldn’t we be susceptible? The real question is whether parasitic infections are truly on the rise and/or underreported, or if social media is causing unnecessary concern.

Influencers also claim that testing is unreliable, so treatment should proceed without confirmation. But this bypasses essential questions: Which parasite is present, if any? What treatment is actually indicated, since different parasites require different treatments? For example, they argue that if you’ve ever eaten sushi, you should be treated; no testing is necessary. But this is flawed thinking, because not everybody who is exposed to parasites becomes infected.

For example, a documented outbreak of Diphyllobothrium latum (fish tapeworm) occurred after a wedding in Switzerland in 2006, where 26 wedding guests consumed raw, marinated perch that had been caught fresh that day. However, there were only 7 confirmed cases and 1 probable case, illustrating the importance of testing as the primary means of determining the extent of the outbreak.6

A 2022 Norwegian study on the surveillance of berries for parasite contamination detected DNA via qPCR. They found an occurrence of 2.9% Toxoplasma gondii, 6.6% Cyclospora cayetanensis, and 8.3% Cryptosporidium spp. on raspberries, strawberries, and blueberries. It’s important to note that finding parasite DNA on food does not automatically translate to infection. There is no certainty that the intact, infective stages of viable parasites are present.7,8

Though true delusional parasitosis is uncommon, social media amplification may be contributing to milder, fear-driven cases. Delusional parasitosis is a psychiatric illness where patients report being infested by parasites despite negative testing. Incidence is 1.9 to 3.7 cases per 100,000 people, but may be higher depending on the population, with middle-aged women most at risk.9-11 Even without meeting DSM criteria, people swept up in the parasite-cleanse trend can still find themselves genuinely distressed by the experience.

Parasites have become the latest target—much like past trends around Candida—because they’re poorly understood and easy to fear. It’s a hyped-up silent epidemic on the coattails of the COVID pandemic. (I’ve even wondered whether this entire trend is, in part, a backdoor attempt to justify over-the-counter ivermectin use for COVID.) If parasites are going to be the new object of collective anxiety, let’s at least understand them accurately.

Defining Parasites: Are They All Bad?

Parasitology is a vast field, with humans hosting around 300 species of parasitic worms and over 70 species of protozoa.12 There are three main parasite classes: protozoa (microscopic, one-celled organisms), helminths (large, multicellular organisms, i.e., worms), and ectoparasites (live on the exterior of the host, i.e., lice, ticks). Intestinal parasites are the most common and the main target of the parasite cleanse trend and will thus be the focus of this article.

Merriam-Webster dictionary provides two definitions of the word “parasite”:

  1. An organism living in, on, or with another organism in order to obtain nutrients, grow, or multiply often in a state that directly or indirectly harms the host
  2. Someone or something that resembles a biological parasite in living off of, being dependent on, or exploiting another while giving little or nothing in return

We’ll mainly focus on the first definition, but the second one is also essential when it comes to holistic health.

Pathogenic parasites are a major global burden, mostly in developing countries, causing significant illness and death.13Intestinal worms and protozoan parasites are prevalent in developing countries, whereas protozoan parasites more commonly cause GI infections compared to worms in developed countries.14

Believe it or not, there are non-pathogenic parasites. Many mistakenly believe that all parasites are pathogenic—it would make sense, though, because of the mere definition of a parasite, right? The CDC lists several non-pathogenic amebae, including Endolimax nana, Entamoeba coli, Entamoeba hartmanni, Entamoeba polecki, and Iodamoeba buetschlii.15Although they may not cause symptoms, it’s important to note that their presence indicates that the person had fecal exposure, which puts them at risk of acquiring a pathogenic parasite or other organism.

Another concept challenging parasite pathogenicity is helminth therapy, or the purposeful infection of the host with certain helminth species. Helminth infections play a role in shaping immune responses that may benefit the host and are being studied in inflammatory bowel disease (IBD), multiple sclerosis, asthma, and atopy.16 Studies show that helminth infections can be associated with increased intestinal bacterial diversity or richness, a sign of intestinal health.17-19 So… are they always bad?

Patients often receive a diagnosis of irritable bowel syndrome (IBS) without any clear etiology. The lab where I work published a study on the frequency of abnormal stool biomarkers in IBS patients, which revealed that 82.8% had at least one abnormal marker on comprehensive stool testing.20 Comprehensive stool testing is not typically performed in conventional medical settings, and IBS patients often learn to live with their condition rather than finding and treating its root cause. Comprehensive stool testing includes a parasite exam, and parasites were detected in 7.5% of IBS patients, with the most common being Blastocystis spp.20 Its prevalence is 5%-23% in developed countries, and up to 60% in developing countries.21 The carriage of Blastocystis is reported to be three times higher in patients with IBS-D.22

Blastocystis spp. (previously Blastocystis hominis) pathogenicity is controversial. The prevailing thought is to treat only if the patient is symptomatic—many are asymptomatic. Symptoms include bloating, nausea, vomiting, diarrhea, constipation, anorexia, weight loss, and abdominal pain. Additionally, reports of rash, pruritus, weakness, and joint pain are also associated.21,23

This all brings me to a very important point: Always correlate lab results with the clinical presentation. This may sound like a no-brainer, but many clinicians want to treat test results versus patients. More on this later.

Beyond gut symptoms, intestinal parasites may be involved in the pathogenesis of other conditions, including Hashimoto’s thyroiditis, neurological conditions, arthritis, impaired cognition, cancer, urticaria, chronic fatigue, and others.23-27 So how would you even know to test for parasites when a patient has any of these conditions? When the presentation doesn’t fit neatly within one diagnosis, or when a patient isn’t improving as expected, evaluating for parasites (or other hidden infectious triggers) can become a reasonable part of a broader differential diagnosis.

Parasite Testing

For clarity, we’re not covering bacterial, fungal, or viral pathogens here, though these can be equally problematic and are best evaluated through comprehensive testing. There are hundreds of parasites, each with its own symptom profile, and each with varying sensitivities and specificities with different detection methods and sample type requirements. So how do you know where to begin?

The American Society for Microbiology (ASM) discourages “checking all the boxes” or ordering every test, and instead encourages selective ordering based on pretest probability. However, clinicians are busy and may not have the in-depth knowledge needed to choose the appropriate parasitology test. If the clinician selects the wrong test, the diagnosis may be missed.5 Parasite test selection algorithms would be helpful, but are not offered by laboratories or even the CDC. For this reason, certain functional medicine laboratories offer comprehensive stool parasitology testing for convenience and to give the clinician peace of mind that nothing is missed.

Much of the epidemiologic data is based on testing through conventional labs, which may underestimate the actual number of parasite infections if all testing is not performed. However, in working at a functional medicine laboratory that does comprehensive parasitology testing on all stool samples, they’re still not that common in samples received from developed countries. As discussed above, 7.5% of samples from IBS patients had parasites. In light of the parasite cleanse trend, this figure does not seem high enough to warrant eradication for the masses or regular cleansing.

The majority of parasites infect the gastrointestinal tract; therefore, stool testing is the main tool for diagnosing parasites. However, many parasites are not detected in stool, and blood testing and/or imaging may be more appropriate. So how would you know when to order specific testing? The resources listed at the end of the article can help, specifically the CDC’s DPDx website: https://www.cdc.gov/dpdx/az.html.

Which Laboratory is Best for Diagnosing Parasites?

The ASM states that, “It should be recognized that not all laboratories offer the same types of services. Small hospital laboratories may offer limited parasitology, the degree of which should be determined by test volume and technologist competency… Large hospital laboratories and reference laboratories should offer full parasitology services. These include EIAs, full O&P examination, modified acid-fast staining for Cryptosporidium, Cyclospora, and Cystoisospora, modified trichrome staining for microsporidian species, and the ability to identify adult helminths that may be passed in the stool. These laboratories will often also offer advanced molecular diagnostics for parasites.”5

 The ASM recommends that clinicians understand what procedures are performed with the O&P, such as certain staining techniques, and that the test may not recover all parasites. Additional staining techniques may need to be ordered separately.5 Most ordering clinicians are not aware of these methodology distinctions and may unknowingly order an incomplete test.

In the functional medicine laboratory industry, parasite testing services vary widely, and it’s very important to understand the methodologies offered and find out which parasites are actually being tested. At the lab where I work, we are often asked if we can identify certain parasites. As long as it’s a GI parasite that can be assessed with stool testing, then the answer is yes. The lab does not offer serology testing for bloodborne parasites, for example. There is a notion that labs can miss diagnoses for various reasons. But a main reason is that we’re not going to find a blood or brain parasite in a stool sample.

Asking a lab about their sensitivity and specificity for parasites in general is not helpful question—sensitivity and specificity varies for each parasite and diagnostic method used. The lab also receives questions about parasite detection rates. This does not help qualify whether the lab is proficient or not—it depends on the patient population submitting the samples and prevalence within that population. For example, a lab in sub-Saharan Africa will likely detect a higher rate of parasite infections than a lab in the United States. The positivity rate is unique to the institution that generates them, due to the patient sampling population and pretest probability of a parasite infection.

A better question to ask is whether the lab participates in proficiency testing where they receive unknown “spiked” samples from inspection agencies such as the College of American Pathologists (CAP) and Wisconsin State Laboratory of Hygiene (WSLH). Are they using gold-standard and FDA-cleared assays? Ask about their laboratory-developed tests, like PCR, and whether they have been validated against gold standard methods. Are they running FDA-cleared tests according to the kit recommendations, or did they adapt their methodology?

I’ve spoken with dozens of clinicians who do split-sample testing with our lab and other labs. I may sound biased, but our lab results tend to correlate most of the time compared to the other labs’ findings. The clinician may express concern that the other lab found 3 major pathogens, but we did not, and may challenge the validity of our lab. Come to find out, the patient is not exhibiting any symptoms expected with those major pathogens. Always correlate lab results with the clinical presentation.

Parasite Testing Methodologies: Which One is Best?

Currently, there is not one methodology that provides a complete and sensitive examination for all parasites.Each methodology has its benefits and limitations. The best approach is to order a combination of methodologies that account for varying parasite sensitivities and specificities.23 A detailed description of diagnostic methods for parasites can be found on the CDC website.

Stool Parasite Testing Methodologies

Methodology Benefits Limitations
Microscopic Ova & Parasite Exam (O&P) · Gold standard

· Can detect all stool parasites

· Can visualize other findings under the microscope (i.e., WBCs, etc.)

·       Cost-effective

 · Not standard across laboratories

· Technician training varies

·  Requires more than one stool collection for increased sensitivity
Polymerase Chain Reaction (qPCR) · Highly sensitive

· One sample usually sufficient

 · Limited number of targets limits comprehensiveness of the test

· 15% of samples demonstrate inhibition

· Lab-developed tests lack standardization and may result in higher false positives or negatives

·       Costly
Enzyme Immunoassay (EIA) · One sample usually sufficient · Commercially available FDA-cleared kits limited to a few organisms

· Costly
Macroscopic Exam (for worms) · Trained technician can identify worms versus mucus or food · Not for microscopic organisms
Parasite Culture · Simpler technique used in resource-poor countries · Not a routine exam for most labs

Stool Microscopic Exam – Gold Standard

A microscopic ova and parasite exam performed on three different stool samples (O&P x3) is the gold standard for parasite diagnosis. There are many tests performed with different staining techniques. Technician experience is key, as it is important to recognize artifacts in the sample versus parasites. A microscopic exam looks for any parasites in the stool sample. The ASM states that, “Physicians should be aware that the probability of detecting clinically relevant parasites in a single specimen may be as low as 50% to 60% but is >95% if three samples are examined by O&P.”5 A total of 3 specimens, one collected every other day, over a period of up to 10 days, is ideal to account for irregular protozoal shedding.28

Stool qPCR – Highly Sensitive

Polymerase Chain Reaction, or PCR, is a method that utilizes probes that target specific DNA segments, which allows identification of specific organisms. The cycle of denaturing and synthesizing new DNA is repeated as many as 30 or 40 times.29 It’s important that labs don’t overcycle as this can lead to false positives by picking up artifact.

For certain organisms, PCR is emerging as a more sensitive detection method compared to microscopic O&P or EIA testing.5,30 However, until all potential human parasitic pathogens are included in molecular panels, PCR will remain highly sensitive but will fail to detect the scope of possible pathogens that can be found via an O&P microscopic exam.31

Also, up to 15% of samples demonstrate inhibition, leading to potential false negative results. This can occur due to medications, excessive unrelated DNA, and other constituent stool factors.

It’s important to note that DNA detection does not differentiate between viable or dead parasites.7,30,32-34 Always correlate lab results clinically.

Enzyme Immunoassay (EIA)

Enzyme Immunoassay, or EIA, is a methodology that detects specific parasite antigens. EIAs are known to have a higher rate of false positives.5 EIA is increasingly being replaced with PCR.

Stool Macroscopic Exam/ Gross Examination

This technique uses a combination of visual inspection and some microscopic techniques to identify larger parasites such as adult helminths or helminth parts. This is a good option for patients claim to “see worms” in their stool. Many worm-like samples are sent to the lab where I work and end up being mucus threads or undigested stringy food particles.

“Rope worm” is promoted on the internet; however, there is no evidence that this worm exists. The group that first promoted this theory in a non-peer-reviewed article identified 99% human DNA in the sample—it’s not a worm.35 It’s likely intestinal mucus. They also promote laxative regimens to expel the “worms” which can be damaging to the gut lining.36 Colon hydrotherapists may further propagate the problem by showing their clients all the “worms” passing. Worms must be diagnosed by a trained professional.

The parasite cleanse treatments may be harsh on the intestinal lining, causing sloughing, which can look like a worm. These treatments may result in altered gut barrier integrity and intestinal hyperpermeability. 36 If your patient is passing mucus, you might want to look deeper at what could be going on, as it could indicate inflammation from serious causes. Or unnecessary overuse of harsh cathartic herbs.

Stool Culture

Parasite culture is another method used for detection, similar to culturing bacteria or yeast. This method is not employed in routine diagnostic laboratories and is mainly used in resource-poor countries.31,37-40

What If the Methodologies Conflict?

We see this in the lab sometimes. It may be positive on the microscopic exam and negative with PCR, or vice versa. This is why it’s important to have more than one methodology due to the limitations of each. At a minimum, at least do a microscopic exam, then add another. Again, always correlate test findings clinically.

Eosinophil Count

Elevated eosinophils on a complete blood count might be a sign of a parasite generating an immune response. It’s a nonspecific marker and can signal an allergic or other etiology.11,41,42 In general, eosinophilia is present with worms versus protozoan parasites.42

Is Purge Testing Necessary?

Purge testing refers to taking a substance, like a laxative or herbal cleanse, before testing. The idea behind it is that it helps “loosen up” the parasites so there is a higher chance for detection. This is not an evidence-based recommendation. In the lab where I work, there was no difference in parasite detection between purged and non-purged samples.

The Parasite Test is Negative, Now What?

You have a few options. If the testing sensitivity and specificity for a particular parasite are low, yet you still suspect the parasite, you could just treat empirically. If you strongly suspect a parasite, there’s no harm in repeating the exam due to irregular parasite shedding. Or you can continue your workup for why the patient is experiencing their symptoms. One article mentioned that secondary delusions of parasitosis can be linked to factors such as B12 and folate deficiencies, hyperthyroidism, diabetes, and neuropathy.11

If your patient doesn’t have parasites upon testing, help your patients identify the other “parasites” in their life (the Merriam-Webster parasite definition #2 above). What is draining their joy, energy, and quality of life? A toxic relationship, workplace burnout, standard American diet, etc.? The parasite cleanse supplement companies are preying on the public and appealing to non-specific symptoms like fatigue and gut issues. As clinicians, we know these symptoms can be attributed to several other diagnoses, and while it might be a parasite, you need to do your due diligence and be thorough in your workup.

Post-Infectious IBS

I discuss acute gastroenteritis cases regularly with clinicians. They explain that their patient travelled, or they had food poisoning, and their gut has not been the same since. They may be testing to assess for the original pathogen, but that was likely already performed at a local lab at the time of the episode. Most clinicians ordering comprehensive stool testing are testing weeks to months later due to chronic symptoms, and although chronic parasite infections can occur, the original infectious agent is probably long gone. Yet the patient continues to suffer.

This classic scenario is post-infectious IBS, where the gut pathogen is typically self-limiting and has been cleared by the immune system, but the damage to the gut lining, disrupted microbiome, and ongoing immune response leave the patient feeling symptomatic.43,44 In this case, focusing on microbiome balancing and gut lining repair with substances like glutamine can help heal post-infectious IBS.44 (See the article “The Missing Piece In SIBO Treatment: Beyond Eradication” to learn about how post-infectious IBS may actually be a case of underlying small intestinal bacterial overgrowth.)

A Final Burning Question: Are Parasites More Active Around the Full Moon?

A quick Google search reveals that people believe parasites are more active during full moons because of folk theories about melatonin shifts, sleep disruption, and borrowed ideas from lunar-synchronized marine biology. However, there is no scientific evidence supporting the claim. In the lab where I work, we have not seen monthly trends around the full moon. We do see more parasites seasonally, in the summertime, mainly because people have more opportunities for exposure (drinking contaminated water while hiking, swimming in contaminated water, etc.).

Final Thoughts

  • Although the parasite cleanse trend promotes it, routine, universal parasite cleansing is not best practice unless the patient lives in or regularly travels to an endemic area. We don’t routinely mass prescribe antibiotics and antifungals, just for good measure. So why would we do so with antiparasitics in non-endemic areas?
  • Always take a thorough history if parasites are suspected.
  • Test, don’t guess.
  • If it still feels outside your scope, when in doubt, call the CDC (below) for guidance, or refer out to an infectious disease specialist or travel clinic.
  • Check out part 2 of this article series to learn about parasite risk factors, prevention, and evidence-based natural parasite treatments.

 

Helpful Resources

References:

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  38. Popruk S, Pintong A-r, Radomyos P. Diversity of Blastocystis subtypes in humans. J Trop Med Parasitol. 2013;36:88-97.
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