Co-infection of balantidium coli and emerging enteric pathogens: a public health perspective

Balantidium coli is a large ciliated protozoan that causes Balantidiasis, a forgotten intestinal infection transmitted by the fecal-oral route in tropical and low-resource settings. Even though it is usually asymptomatic, it may cause severe dysenteric diarrhea, particularly in patients with compromised immunity. Other enteric pathogens that co-infect, such as Entamoeba histolytica, Giardia lamblia, Shigella, and Salmonella, compound disease severity, making it difficult to diagnose and treat. Recent advances in molecular diagnostics, including PCR and environmental sampling, have revealed the surprising prevalence and genomic diversity of B. coli, suggesting that the bacteria may differ in virulence by region. Its persistence can be attributed to environmental factors such as intensive pig farming, inadequate water and sanitation, and global warming. It examines this in the context of the changing epidemiology of B. coli, co-infection processes, new testing methodologies, and the imperative to strengthen surveillance and control methods, particularly in poorly reported areas worldwide, such as Pakistan.