Case Report: Molecular Diagnosis of Cystoisospora belli in a Severely Immunocompromised Patient with HIV and Kaposi Sarcoma.

Diarrhea in an immunocompromised patient has a broad infectious differential. Diagnosis is difficult despite advances in diagnostic modalities. We report a case of a 45-year-old Nigerian woman who immigrated to the United States 2 years ago. She presented to the hospital with gastrointestinal bleeding, newly diagnosed HIV, and disseminated Kaposi sarcoma. During hospitalization, the patient had an onset of watery diarrhea and high eosinophilia. Subsequent stool analysis using multi-parallel real-time quantitative polymerase chain reaction for 13 parasites was positive for Cystoisospora belli. The patient was treated with trimethoprim-sulfamethoxazole, but had relapsed disease when her antibiotics were stopped prematurely. After restarting trimethoprim-sulfamethoxazole, her diarrhea and eosinophilia improved, and she had undetectable Cystoisospora belli DNA on repeat stool quantitative polymerase chain reaction. This case highlights the importance of a thorough workup for diarrhea, including parasites, especially for immunocompromised patients. Antibiotic prophylaxis is recommended in patients with Cystoisospora belli and HIV/AIDS.

Antibiotic treatment increases yellowness of carotenoid feather coloration in male greenfinches (Chloris chloris).

Carotenoid plumage coloration is an important sexually selected trait in many bird species. However, the mechanisms ensuring the honesty of signals based on carotenoid pigments remain unclear. It has recently been suggested that intestinal integrity, which is affected by gut parasites and microbiota and influences nutrient absorption and acquisition, mediates the relationship between carotenoid ornamentation and individual quality. Here, we test whether carotenoid plumage coloration in greenfinches (Chloris chloris) is affected by the treatment of an antibiotic or an antiparasitic drug. We captured wild greenfinches (N = 71) and administered anticoccidial medication toltrazuril (TOLTRA) to one group, antibiotic metronidazole (METRO) to the second group to target trichomonosis, and the third group received no medication. In the METRO group, feathers grown during the experiment had significantly higher chroma of yellow parts, but there was no effect of TOLTRA on feather chroma. The results suggest that METRO increased the efficiency of carotenoid modification or deposition to the feathers rather than nutrient acquisition and/or freed energy resources that could be invested in coloration. Alternatively, though not measured, METRO might have affected microbial community and host physiology as microbial metabolites can modulate mitochondrial and immune function.

Chronic Cystoisospora belli infection in a Colombian patient living with HIV and poor adherence to highly active antiretroviral therapy. / Infección crónica por Cystoisospora belli en un paciente colombiano con HIV y cumplimiento deficiente de la terapia antirretroviral de gran actividad

Cystoisospora belli is an intestinal Apicomplexan parasite associated with diarrheal illness and disseminated infections in humans, mainly immunocompromised individuals such as those living with the human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS). An irregular administration of highly active antiretroviral therapy (HAART) in HIV patients may increase the risk of opportunistic infections like cystoisosporiasis. We describe here a case of C. belli infection in a Colombian HIV patient with chronic gastrointestinal syndrome and poor adherence to HAART. His clinical and parasitological cure was achieved with trimethoprim-sulfamethoxazole treatment. Although a reduction in the number of C. belli cases has been observed since the use of HAART, this parasite still has to be considered as a differential diagnosis of diarrheal disease in HIV/AIDS patients. Effective interventions enhancing adherence to HAART should be included in HIV patient care programs.

Cystoisospora belli es un parásito intestinal del filo Apicomplexa asociado con enfermedades diarreicas e infecciones diseminadas en humanos, principalmente en individuos inmunocomprometidos, como aquellos infectados con el virus de la inmunodeficiencia humana (HIV) o el síndrome de inmunodeficiencia adquirida (sida). El cumplimiento inadecuado de la terapia antirretroviral de gran actividad (TARGA) puede aumentar el riego de infecciones oportunistas, incluida la cistoisosporiasis. Se describe el caso de infección por C. belli en un paciente colombiano con HIV, que presentó un síndrome gastrointestinal crónico e incumplía el tratamiento con la TARGA. Después del diagnóstico parasitológico, el paciente fue tratado con trimetoprimsulfametoxazol, lográndose la recuperación clínica y la cura parasitológica. Aunque se ha observado una reducción en el número de casos de C. belli desde la implementación de la TARGA, este parásito aún debe considerarse en el diagnóstico diferencial de las enfermedades diarreicas en pacientes con HIV/sida. Los programas de atención deben incluir intervenciones efectivas que potencien el cumplimiento de la TARGA en estos pacientes.

Chronic cystoisosporiasis in an immunocompetent adult: A case report.

RATIONALE: Cystoisosporiasis is an intestinal infectious disease caused by a coccidian protozoa, Cystoisospora belli (C. belli). It can cause prolonged and refractory diarrhea most commonly in immunocompromised patients, while immunocompetent individuals usually exhibit no symptoms or self-limited diarrhea. PATIENT CONCERNS: We herein report a case of chronic cystoisosporiasis in an immunocompetent patient. A 62-year-old man, who had been first diagnosed with cystoisosporiasis 15 years ago and had been treated with oral administration of trimethoprim-sulfamethoxazole (TMP-SMX), complained of persistent watery diarrhea. He was negative for anti-human immunodeficiency virus antibody and anti-human T-cell leukemia virus type 1 (HTLV-1) antibody. DIAGNOSIS: Biopsy specimens from the duodenum revealed oocysts in the atrophic absorptive epithelium and protozoa were detected through stool examination, indicating the recurrence of cystoisosporiasis. Capsule endoscopy showed diffuse atrophic mucosa with white villi in the entire small intestine. We diagnosed him with chronic cystoisosporiasis that occurred in an immunocompetent adult. INTERVENTIONS: Since oral administration of TMP-SMX and ciprofloxacin were ineffective, the intravenous administration of TMP-SMX was initiated. OUTCOMES: Intravenous TMP-SMX exhibited a significant improvement. LESSONS: This case indicates that even immunocompetent individuals may develop recurrent and refractory cystoisosporiasis. Furthermore, intravenous treatment of antibiotic agents should be considered when the impaired absorptive ability from the small intestine is suspected.

Cystoisospora belli associated persistent diarrhea in an AIDS patient.

Cystoisospora belli infection is regarded as an indicator disease of AIDS in Japan; however, only a few case reports showing this association are present. Our case study involved a 49-year-old Thai woman living in Japan since her marriage to a Japanese man. She was repeatedly hospitalized owing to persistent diarrhea. Considering her native country, she was suggested of having AIDS. Serological examination for HIV-1 tested positive, and C. belli infection was diagnosed on detection of oocysts in her stool samples. She was treated successfully for the parasitic infection with oral trimethoprim-sulphamethoxazole therapy for 10 days. No AIDS-associated opportunistic infections other than cystoisosporiasis were detected. Thus, this study suggests that an immunocompromised individual with persistent and recurrent diarrhea should be examined to confirm for C. belli infection. Moreover, it is possible that a person in a high-latitude region will develop a parasitic infection common in tropical areas because of globalization.

A review of Cystoisospora felis and C. rivolta-induced coccidiosis in cats.

Until the discovery of Toxoplasma gondii oocysts in cat feces in 1970, little was known of coccidiosis in cats. Until 1970, three coccidian parasites based on different sized oocysts were recognized, the parasite with large oocysts (∼40 µm long and called Isospora felis), medium sized oocysts (∼25 µm long, called Isospora rivolta), and small sized oocysts (14 µm or less, called Isospora bigemina) were known and they were considered not host-specific. Later, it was demonstrated that these parasites were host-specific and had also extra-intestinal stages. The Isospora bigemina turned out to be more than 25 organisms belonging to T. gondii, Hammondia spp., Sarcocystis spp., Besnoitia spp., and Neospora spp.; these subjects have been reviewed previously in detail. The present paper summarizes biology of Isospora felis, and I. rivolta (now transferred to genus Cystoisospora), including taxonomy, life cycle, diagnosis, and treatment. Re-excretion of T. gondii oocysts from chronically infected cats after superinfection with Cystoisospora felis oocysts is discussed. There are only two species of Cystoisospora species in cats, C. felis and C. rivolta; Isospora novocati and Cystoisospora frenkeli named for I. rivolta-like parasites of cats are considered synonym of C. rivolta. Clinical coccidiosis occurs more commonly in recently weaned kittens and C. felis infections are more prevalent than C. rivolta.

Molecular and morphological description of Isospora sp. from the common mynah (Acridotheres tristis) and a preliminary survey of two anticoccidial drugs in natural infection.

Coccidian parasites, especially Isospora, are prevalent parasites in Passeriformes. Isosporan oocysts from common mynahs (Acridotheres tristis) are incompletely described. Detailed knowledge on biology, prevalence, pathogenesis and treatment of avian isosporiasis is scant. In this study, isosporan oocysts isolated from common mynahs were morphologically and molecularly characterized. The medication efficiencies of diclazuril and sulfadiazine-trimethoprim in isosporiasis in naturally infected mynahs were evaluated. Isosporan oocysts from common mynahs were described morphologically by microscopic imaging. The 18S rRNA and COI genes were amplified using PCR and the resultant products were sequenced and analysed phylogenetically. To evaluate the efficiencies of diclazuril and sulfadiazine-trimethoprim, two experimental treatment groups and a null control were assigned. General health status, weight and oocysts per gram of faeces were evaluated. Oocysts from all birds contained isosporan oocysts that were morphologically and dimensionally similar (P < 0.05). The oocysts were spherical; with no oocyst residuum, micropyle or polar granules. At both loci, phylogenetic analyses placed the Isospora isolate in the same clade with Isospora spp. from other Passeriformes. Both of the anticoccidials were well tolerated by the birds, a rapid reduction in oocyst excretion was noted at the commencement of treatment and 72 h after drug administration, oocyst excretion zeroed in all treated birds. Based on morphological and molecular data, this isolate does not resemble any previously described isosporas, hence Isospora tristum n. sp. is proposed for the current species. Both evaluated anticoccidials seemed to be efficient in reduction of oocyst production and can be recommended for the treatment of mynah isosporiasis.

Uncommon and fatal case of cystoisosporiasis in a non HIV-immunosuppressed patient from a non-endemic country.

Cystoisospora belli (previously known as Isospora belli) is a tropical coccidian parasite sometimes leading to severe diarrhea in immunocompromised patients. Here we describe a fatal case of cystoisosporiasis in a non HIV-immunocompromised 71-year-old female with no recent travel history. Infection was either latent or potentially caused by the consumption of contaminated imported food from Asia. Diagnosis was made by microscopical detection of numerous C. belli oocysts in stools without specific staining. Treatment with TMP-SMZ slightly improved diarrhea within 3days, but dehydration subsequently led to acute decompensated heart failure and a fatal evolution. This report illustrates the possibility of severe cystoisosporiasis in non HIV-immunocompromised patients in a non-endemic country and highlights the risk of transmission through imported contaminated food consumption.

Cystoisospora sp. Infection Determined in Immunosuppressed and Immunocompetent Children: Three Cases Report.

The aim of this study was to present three cystoisosporiasis cases diagnosed in pediatric patients of the Yuzuncu Yil University Medical Faculty. In the study, stool samples of the patients were evaluated by native-Lugol and modified acid-fast staining methods in the Parasitology Laboratory. The first case was a 4-year-old male child diagnosed with acute lymphoblastic leukemia (ALL). It was reported that the patient had abdominal pain, and permanent bloody and mucous diarrhea (8-10 times a day) was present for almost 1 week after the beginning of ALL treatment. The second case was a 10-year-old boy diagnosed with depression. The patient was brought to our hospital by his parents with complaints of abdominal pain, diarrhea, lack of appetite, weight loss, and fatigue persisting since 1 month in addition to headache, fear, sleeplessness, and waking up with cry. The third case was a 13-year-old boy who complained of abdominal pain, diarrhea (rare occasions), lack of appetite, and headache for 2 months. These patients had not traveled abroad. The cases were treated successfully with co-trimoxazole. Our results suggest that all patient groups with diarrhea and abdominal pain should also be considered in cystoisosporiasis.

Treatment of atoxoplasmosis in the Blue-crowned Laughing Thrush (Dryonastes courtoisi).

Passerines are frequently parasitized by coccidia, especially species of the genus Isospora, with extra-intestinal stages that can be highly pathogenic causing serious clinical damage in young birds. Whilst there is still no effective treatment to completely clear isosporoid coccidia with extra-intestinal stages from a host species, our results showed that prolonged treatment with toltrazuril (BAYER AG, Leverkusen, Germany) can decrease the oocysts in faeces and thus reduce the extra-intestinal phase of the infection. The toltrazuril treatment is therefore probably indirectly effective against the systemic form of atoxoplasmosis.

An unusual complication in ulcerative colitis during treatment with azathioprine and infliximab: Isospora belli as 'Casus belli'.

The treatment of ulcerative colitis is based on systemic corticosteroids, immunomodulators such as cyclosporine and azathioprine and TNF-α antagonists. Patients undergoing such immunosuppressive treatment are more susceptible for infectious pathogens. Here, we report the case of a patient with a 13-year history of ulcerative colitis, treated initially with systemic corticosteroids in combination with immunomodulators, and subsequently with infliximab. The patient presented with severe watery diarrhoea, abdominal cramps, weight loss and low-grade fever. Stool examinations for cytomegalovirus, bacteria and parasites were negative. Following detection of numerous oocytes of Isospora belli (IB) in direct smear preparations of the diarrhoeic stool samples, the patient was successfully treated with trimethoprim-sulfamethoxazole (co-trimoxazole).

Isospora belli Infection with Chronic Diarrhea in an Alcoholic Patient.

Chronic diarrhea with a 35 kg weight loss (75 kg to 40 kg) occurred during 2 years in an alcoholic patient was diagnosed with Isospora belli infection in the Republic of Korea. The patient, a 70-year old Korean male, had been a heavy drinker for more than 30 years. He was admitted to the Seoul National University Hospital because of long-standing diarrhea and severe weight loss. He had an increased white blood cell (WBC) count with high peripheral blood eosinophilia (36.8-39.9%) and lowered protein and albumin levels but without any evidence of immunosuppression. A parasitic infection was suspected and fecal examination was repeated 3 times with negative results. Peroral endoscopy with mural biopsy was performed in the upper jejunum. The biopsy specimens revealed villous atrophy with loss of villi together with various life cycle stages of I. belli, including trophozoites, schizonts, merozoites, macrogamonts, and microgamonts. The patient was treated successfully with oral doses of trimethoprim 160-320 mg and sulfamethoxazole 800-1,600 mg daily for 4 weeks. A follow-up evaluation at 2.5 years later revealed marked improvement of body weight (68 kg), increased protein and albumin levels, and normal WBC count with low eosinophils (3.1%). This is the first clinical case of isoporiasis with demonstration of various parasitic stages in the Republic of Korea.

Isospora belli superinfection in a patient with eosinophilic gastroenteritis--a diagnostic challenge.

Isospora belli infection, characterized by peripheral blood eosinophilia, is often seen as an opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS). It is also reported in patients with underlying lymphoproliferative disorders including lymphoma and leukemia. Eosinophil-associated gastrointestinal disorders (EGID), including eosinophilic gastroenteritis (EGE), is characterized by eosinophilic infiltration of the gastrointestinal (GI) tract with various GI symptoms. We report a case of a 50-year-old male who developed Isospora superinfection of the small bowel while receiving systemic corticosteroids for EGE. He presented with worsening diarrhea, abdominal pain, nausea and vomiting with worsening peripheral eosinophilia. I. belli infection was diagnosed by the detection of oocysts in stool samples and by the presence of the parasite on duodenal biopsy in the background of tissue eosinophilia. I. belli can cause severe chronic diarrhea in immunocompromised patients on corticosteroids. Trimethoprim-sulfamethoxazole often provided rapid cure. Even though peripheral blood eosinophilia was seen in both EGE and Isospora infection, the identification of subnuclear protozoal inclusions as a new histologic finding, as well as the absence of this finding in previous duodenal biopsies coupled with the continued presence of tissue eosinophilia, favored a parasitic superinfection in the setting of underlying EGE.

Isospora belli in a patient with liver transplantation.

Isospora belli is an opportunistic protozoon which should be monitored in patients with gastrointestinal complaints such as abdominal pain, nausea and diarrhoea, in both immune-compromised and immune-competent patients. Our case was a 35 year-old male patient who had received a liver transplant because of cirrhosis and hepatic fibrosis. A diarrhoeic stool sample of the patient was sent to the laboratory for microbiological and parasitological analyses. Faecal occult blood was positive and bacteriological analysis was negative. Isospora belli infection was diagnosed by detection of the oocysts in stool samples. Per oral trimethoprim-sulphamethoxazole treatment was given in 500 mg bid dose for 10 days. At the end of the treatment, no oocyst of Isospora belli was seen but non-pathogenic cysts of Entamoeba coli and vacuolar forms of Blastocystis hominis were observed. Two months later the patient had abdominal pain, fatigue and diarrhoea again and parasitological re-evaluation showed oocysts of Isospora belli.

Influence of toltrazuril treatment on parasitological parameters and health performance of piglets in the field--an Austrian experience.

Porcine coccidiosis caused by Isospora suis is one of the leading causes of neonatal diarrhea in suckling piglets. Currently the only registered drug for metaphylaxis is toltrazuril. To evaluate the effect of treatment on piglets from 7 Austrian farms without and 8 Austrian farms with toltrazuril application we examined oocyst excretion (including determination of oocysts per gram of feces; OPG), diarrhea (fecal score FS 1-4 with 3 and 4 being diarrhea), and general health (health score HS 1-4 with 3 and 4 describing poor health). Both groups included farms with different levels of hygiene. Samples from 265 litters without treatment, comprising 1588 individual samples, and 1548 samples from 258 treated litters were taken twice (around the 14th and the 21st day of life, respectively), examined by autofluorescence and, if positive, by McMaster counting. In both groups animals had less diarrhea and lower health scores during the second sampling but the treated piglets were always significantly healthier and had less diarrhea. The percentage of weaned piglets was higher in treated animals although this was not significant (p=0.052). In the first round of sampling 17.8% of the individual samples from untreated piglets were positive for oocysts (with a maximum prevalence on the 12-15th day of life) while in the treated piglets only 0.4% shed oocysts p<0.001). At the second sampling only 2.1% of the untreated animals and none of treated piglets excreted I. suis (p=0.083). Positive animals shed up to 8 × 10(3)OPG. There was an increased risk for infected piglets to develop diarrhea (odds ratio, OR 4.73) and poor health (OR 5.05) in untreated piglets, and poor hygiene without disinfection was identified as a risk factor for poor health (OR 1.90), diarrhea (OR 1.42) and oocyst excretion (OR 1.73). The risk of poor health (OR 2.89) and diarrhea (OR 1.44) was also increased for piglets under poor hygienic conditions receiving toltrazuril, so both metaphylaxis of coccidiosis and good hygiene are necessary to effectively control neonatal diarrhea. The costs of treatment are considerably lower than the estimated financial production losses. Therefore, treatment is recommended for farms where clinical coccidiosis is diagnosed.

Efficacy of emodepside plus toltrazuril suspension (Procox(®) oral suspension for dogs) against prepatent and patent infection with Isospora canis and Isospora ohioensis-complex in dogs.

Three randomised, blinded and placebo-controlled laboratory studies were conducted to evaluate the efficacy of emodepside plus toltrazuril suspension (Procox(®) suspension for dogs) against Isospora canis and Isospora ohioensis-complex. Unweaned puppies were experimentally infected with sporulated oocysts of I. canis and/or I. ohioensis-complex. In each study, one group was treated during prepatency (2 or 4 days post infection) while dogs in the second group were treated individually after the onset of oocyst excretion of the respective coccidia species. The dogs were treated with the minimum therapeutic dose of 0.45 mg emodepside and 9 mg toltrazuril per kg body weight. Daily faecal oocyst counts from both groups were compared to placebotreated control groups to determine efficacy.Dogs treated during prepatent I. canis or I. ohioensis-complex infection showed significantly lower oocyst counts for up to 12 days compared to the control group. Oocyst counts were reduced by 90.2 - 100 % while the control groups continued to exhibit an adequate infection, except for one study where efficacy against prepatent I. canis infection faded 13 days after treatment. Following treatment of patent I. canis or I. ohioensis-complex infections, significantly lowered oocyst counts were observed for up to 9 days compared to the control group. Faecal oocyst counts were reduced by 91.5 - 100 %. In all three studies the number of days with diarrhoea was significantly lower when dogs were treated during prepatent Isospora spp. infection compared to the control groups. No adverse drug reactions were observed during the studies. In conclusion, the studies demonstrated that emodepside plus toltrazuril suspension is an efficient coccidiocide for dogs.

Field evaluations of the efficacy and safety of Emodepside plus toltrazuril (Procox® oral suspension for dogs) against naturally acquired nematode and Isospora spp. infections in dogs.

Three controlled, blinded and randomised multicentre field studies evaluated the efficacy and safety of a new formulation containing emodepside plus toltrazuril (Procox® suspension for dogs) against naturally acquired parasite infections in dogs. In two studies dogs positive for gastrointestinal nematodes and/or Isospora spp. were treated with emodepside/toltrazuril suspension (at least 0.45 mg emodepside plus 9 mg toltrazuril per kg body weight) or a reference product containing either milbemycin oxime plus praziquantel (Milbemax®) or sulfadimethoxine (Kokzidiol SD®) at recommended dose rates. The third study investigated efficacy against prepatent natural Isospora spp. infections in comparison to an untreated control group by enrolling Isospora- negative dogs that were at risk to develop a patent infection during the study.No suspected adverse drug reactions were observed in any of the 403 dogs enrolled in the three studies including 234 dogs treated with emodepside/toltrazuril suspension. In dogs treated with emodepside/toltrazuril suspension against nematode infection faecal egg counts were reduced by 100 % (reference product: 99.7 %). Similarly, in the dogs that had been treated against patent Isospora spp. infection, faecal oocyst counts were reduced by 100 % (reference product: 99.0 %). In both studies, statistical analysis demonstrated non-inferiority and even superiority to the reference products (p ≤ 0.009). Dogs treated with emodepside/toltrazuril suspension during suspected prepatent Isospora spp. infection had 98.7 % lower faecal oocyst counts after treatment compared to untreated dogs (p < 0.0001).The studies demonstrated that emodepside/toltrazuril suspension is safe and highly efficacious against nematodes and Isospora spp. under field conditions.