Cryptosporidium infection in infancy as a cause of malnutrition: a community study from Guinea-Bissau, west Africa.

Cryptosporidium parvum causes persistent diarrhea in young children in developing countries. To determine the interaction between nutritional status and cryptosporidiosis, an open cohort of 1064 children younger than 3 y of age was followed for 1441 child-years by weekly diarrhea recall visits. A total of 5072 weight and 4264 height measurements was made. There were no tendencies of low weight (P = 0.38) or height (P = 0.16) in children who acquired cryptosporidiosis. Cryptosporidiosis in infancy was accompanied by an estimated weight loss of 392 g (95% CI: 247, 538 g) in boys and 294 g (95% CI: 109, 479 g) in girls, corresponding to 3.7% and 2.9% of mean weight, respectively, at 2 y of age. No significant catch-up growth covered for this loss in weight. A similar effect in linear growth was shown (P = 0.02). Although it has been suggested that the effect of infections on nutrition is usually transient because of catch-up growth, the present study suggests that cryptosporidiosis in infancy has a permanent effect on growth.

Aerosolized pentamidine for primary prophylaxis of Pneumocystis carinii pneumonia: a controlled, randomized trial.

The objective was to assess the efficacy of a biweekly dose of 60 mg aerosolized pentamidine (AP) for primary prophylaxis (PP) of Pneumocystis carinii pneumonia (PCP) and the impact of prophylaxis on survival in HIV-infected patients. Participants were AIDS patients with no history of PCP, patients with a CD4 count < or = 0.200 x 10(9)/L, or patients belonging to the CDC group IVC2, irrespective of CD4 count. It was an open, randomized, controlled trial. Patients were assigned to receive AP, 60 mg biweekly via a System 22 nebulizer, or to a control group not receiving any prophylaxis. Incidence curves for PCP and survival were generated using the Kaplan-Meier method, stratified by treatment group, and compared using the log-rank test. Data were analyzed according to intention to treat. There were 15 cases of PCP among 105 patients in the AP group and 32 cases among 104 patients in the control group. The cumulative incidence of PCP by 18 months was 13% (95% CI 5-21%) in the AP group and 30% (95% CI 18-41%) in the control group, (p = 0.002). During the study period 19 patients (18%) in the AP group died and 24 patients (23%) in the control group (NS; p = 0.28). We conclude that a biweekly dose of 60 mg AP is efficient as primary PCP prophylaxis when a System 22 nebulizer is used. There was, however, no difference in survival between the groups, suggesting that AP has an impact on morbidity only.

An epidemic outbreak of cryptosporidiosis: a prospective community study from Guinea Bissau.

In the first year of a prospective community study of childhood diarrhea conducted in a semiurban area in the capital of Guinea Bissau, Cryptosporidium sp. was found in 73 (6.0%) of 1216 episodes of diarrhea. The parasite was the second most prevalent intestinal parasite, and the only one significantly associated with diarrhea (OR = 2.79, P = 0.0006). The seasonal distribution was striking, with a peak prevalence in the beginning of the rainy season (May 17.6%) when an epidemic outbreak of diarrhea started. The prevalence was highest in children younger than 18 months, an age at which prevalences of other intestinal parasites were low. This reverse age pattern may possibly be explained by the small infective dose needed to create severe infections, by air-borne transmission and by the development of protective immunity.

Persistent and acute diarrhoea as the leading causes of child mortality in urban Guinea Bissau.

An investigation of child mortality in a semi-urban community, Bandim II, in the capital of Guinea Bissau was carried out from April 1987 to March 1990. 153 deaths were recorded among 1426 live-born children who were followed for 2753 child-years. The under-five mortality risk was 215 per 1000 children (95% confidence interval [CI] 176-264), infant mortality 94 per 1000 (95% CI 73-115), and perinatal mortality 52 per 1000 (95% CI 41-63). By prospective registration of morbidity, post-mortem interviews, and examination of available hospital records, a presumptive cause of death was established in 86% of the deaths. Persistent and acute diarrhoea were the most frequent causes of death, accounting for 43 and 31 deaths per 1000 children, respectively. Fever deaths (possibly malaria), neonatal deaths, acute respiratory infections, and measles were other frequent causes. The access to health services was relatively easy: 75% of the children who died had attended for treatment at a hospital or a health centre. It is important to find ways of preventing and managing persistent diarrhoea, the major cause of death, and to improve the control of acute diarrhoea by a targeted approach.

Prolonged breast feeding, diarrhoeal disease, and survival of children in Guinea-Bissau.

OBJECTIVE: To analyse the impact of breast feeding on diarrhoeal disease and survival in children above 1 year of age in Guinea-Bissau, west Africa. DESIGN: A community study of an open cohort followed up weekly by interviews over 15 months. Data on feeding practices, anthropometry, and survival were recorded for three years. SETTING: 301 randomly selected houses in a semiurban area in the capital, Bissau. SUBJECTS: 849 children aged less than 3 years. MAIN OUTCOME MEASURES: Incidence and duration of diarrhoea, weight for age, and death of a child. RESULTS: The incidence of diarrhoea was higher in weaned children than in partially breast fed children, both in 1 year olds (relative risk 1.41; 95% confidence interval 1.23 to 1.62) and in 2 year olds (1.67; 1.29 to 2.15). The mean duration of an episode of diarrhoea was 5.3 days in breast fed children compared with 6.3 days in weaned children (P = 0.001). Independent of the age of weaning, a similar increase was found in an analysis comparing, for each child, the rate and duration of diarrhoea one month before and one month after weaning. Children with low weight for age were breast fed longer than the better nourished children (P = 0.02). Children aged 12-35 months who were not breast fed had a 3.5 times higher mortality (1.4 to 8.3) than breast fed children. CONCLUSIONS: The beneficial effects of breast feeding are not restricted to infancy. Though children who are partially breast fed after infancy may have a lower state of nutrition than the weaned ones, the benefit in terms of lower morbidity may be more important for child survival in places with a high morbidity from diarrhoea and with high mortality.

Nosocomial outbreak of cryptosporidiosis in AIDS patients.

OBJECTIVE: To describe a nosocomial outbreak of cryptosporidiosis during four months after June 1989. SETTING: A department of infectious diseases in Copenhagen, seeing about half the patients with AIDS in Denmark. SUBJECTS: 73 HIV antibody negative subjects and 60 antibody positive subjects admitted as inpatients during the transmission period of the outbreak (20 June-14 August), of whom 18 (17 with AIDS, one with AIDS related complex), developed cryptosporidiosis. Two further HIV negative subjects (one departmental secretary, one visiting relative) developed cryptosporidiosis. MAIN OUTCOME MEASURES: Cryptosporidia in stool samples, clinical symptoms, CD4 cell count, HIV antigen concentration, chemotherapeutic treatment. RESULTS: The source of the outbreak was identified as ice from an ice machine in the ward, contaminated by an incontinent, psychotic patient with cryptosporidiosis picking out ice for cold drinks. The mean incubation time was at least 13 days-that is, twice that in HIV-negative patients. Of the 18 patients with AIDS who developed cryptosporidiosis, five recovered, two were symptomless carriers, three died of unrelated causes, and eight died after prolonged diarrhoea. Among the 57 exposed HIV antibody positive inpatients (excluding two patients and the index case with cryptosporidiosis diagnosed elsewhere), significantly more of those who developed symptomatic cryptosporidiosis received oral sulphonamides than those who did not (91%, 10/11 v 48%, 21/44, p less than 0.05). CONCLUSIONS: The clinical and epidemiological findings indicate that infection was the consequence of very small inocula. Increased sensitivity to cryptosporidiosis may be an unrecognised side effect of oral sulphonamide treatment in patients with AIDS.

Cryptosporidiosis in infancy and childhood mortality in Guinea Bissau, west Africa.

OBJECTIVE: To investigate the epidemiology of and mortality from cryptosporidiosis in young children in Guinea Bissau, West Africa. DESIGN: Three year community study of an open cohort followed up weekly. SETTING: 301 randomly selected houses in a semi-urban area in the capital, Bissau. SUBJECTS: 1315 children aged less than 4 years. MAIN OUTCOME MEASURES: Cryptosporidium infection detected by examination of stools during episode of diarrhoea and death of a child. RESULTS: Cryptosporidium spp were found in 239 (7.4%) out of 3215 episodes of diarrhoea. The parasite was most common in younger children (median age 12 months) and at the beginning of the rainy seasons. The prevalence of cryptosporidiosis was 15% (77/513) in cases of persistent diarrhoea compared with 6.1% (148/2428) in diarrhoea lasting less than two weeks (p < 0.0001). Cryptosporidiosis was associated with excess mortality in children who had the infection in infancy, and this excess mortality persisted into the second year of life (relative mortality 2.9 (95% confidence interval 1.7 to 4.9)). The excess mortality could not be explained by malnutrition, or by socioeconomic factors, hygienic conditions, or breast feeding. CONCLUSIONS: Cryptosporidiosis is an important cause of death in otherwise healthy children in developing countries.

[Multimicrobial pulmonary infection in an AIDS patient]. / Multimikrobiel lungeinfektion hos en AIDS-patient.

A case of a 44 year old male AIDS patient with multimicrobial lung infection is presented. Six possible pathogens were found and the relative importance of these is discussed. An active diagnostic and therapeutic approach is recommended when treating AIDS patients with pneumonia.

[Cutaneous myiasis--an imported case caused by the South American fly larvae Dermatobia hominis]. / Kutan myiasis--et importeret tilfoelde forårsaget af den sydamerikanske fluelarve Dermatobia hominis.

Cutaneous myiasis is the infestation of skin or mucous membranes with larvae of flies. We describe a case caused by Dermatobia hominis, acquired in South America. Cutaneous myiasis should be suspected in a patient with a secreting, non-healing furuncular skin-lesion and relevant travel history. The patient may remember being bitten by insects. Sensation of movement in the lesion, which may be observed, supports the diagnosis. Correct diagnosis will prevent unnecessary treatment with antibiotics, and surgery will almost always prove unnecessary.

[Parasitic diseases in patients with impaired immune response. Clinical picture and diagnosis]. / Parasitaere sygdomme hos patienter med nedsat immunforsvar. Klinisk billede og diagnose.

Patients with impaired immune system are frequently infected with various parasitic diseases. The clinical picture is characterized by unusual manifestations and frequently severe recurrences of infections which are not normally serious. Some almost parasitic microorganisms produce symptoms exclusively in patients with impaired immune system. Parasitic infections have become increasingly common with the increasing number of patients who live for prolonged periods with impaired immune systems, often as a result of infection with HIV. Among the numerous parasitic infections which are observed in man, there are a few which occur particularly frequently in patients with impaired immune systems. This is a brief review of the clinical pictures and diagnostic options in parasitic disease in individuals with impaired immune system with particular emphasis on infections caused by: Pneumocystis carinii, Toxoplasma gondii, Cryptosporidium ssp., Microspora, Entamoeba histolytica, Leishmania ssp., and Strongyloides stercoralis. In patients with impaired immunity, parasitic infections frequently cause nonspecific symptoms and, on account of the impaired immunity, antibodies to the parasite are not always produced. The diagnosis of these infections is, therefore, based on morphological demonstration of the microorganism concerned, culture, specific antigen or DNA defections.

High prevalence of campylobacter excretors among Liberian children related to environmental conditions.

Campylobacter was the bacterial pathogen most prevalent in 859 children, aged 6-59 months, examined in a house-to-house diarrhoea survey in two Liberian communities. 44.9% of the children from an urban slum and 28.4% from a rural area were excretors. Since the prevalence of diarrhoea was very high and consequently many convalescent carriers were found, it was not possible to evaluate the pathogenic role of campylobacter. The excretor rate increased with age and was significantly correlated to the use of supplementary feeding, inversely correlated to the quality of the water supply, and also associated with helminthic infestation. Results from re-examination of 172 children suggested a high intensity of transmission. The findings all indicate the existence of a heavy environmental contamination with campylobacter, probably of both human and animal faecal origin.

Cryptosporidium spp., a frequent cause of diarrhea in Liberian children.

This report presents results from a sample survey designed to investigate the possible role of Cryptosporidium spp. in childhood diarrhea in a developing country, Liberia, West Africa. During the four months of January to April 1983, a house-to-house study was carried out in two geographically and socially different communities--an urban slum and three rural villages. Stool samples from 374 children, aged 6 to 59 months, were tested for Cryptosporidium spp. Among the children with diarrhea 8.4% were Cryptosporidium spp. positive compared with a prevalence rate of 5.9% in asymptomatic children. Of the children living in a household with a Cryptosporidium spp.-positive index child, 8.6% had a positive stool sample. Of all children attending a clinic because of diarrhea, 14.6% were Cryptosporidium spp. positive. Cryptosporidiosis was more frequent in younger children; 24 of the total of 29 positive cases (83%) were below 2.5 years old. Actual or previous bottle feeding (formula) was a risk factor, particularly in children below 18 months old. Of the bottle-fed children, 28% were Cryptosporidium spp. positive versus 9.1% of children never bottle fed. Crowding is another possible risk factor. The prevalence of cryptosporidiosis was 13.5% in big urban households with more than 10 children, whereas the prevalence in the small urban households was 6.1%. Ethnic and religious differences were particularly evident in the rural area. No Muslim households had cryptosporidiosis, whereas the prevalence in non-Muslim tribes was 9%. The general belief that cryptosporidiosis is primarily a zoonosis is questioned in this study, partly because many carriers and asymptomatic household contacts were found.

Bacterial contamination of stored water and stored food: a potential source of diarrhoeal disease in West Africa.

The food and water hygiene in two Liberian communities was studied in a house-to-house diarrhoea survey. The level of contamination with enterobacteria of drinking water stored in the households was significantly higher than at the water sources. Food hygiene standards were low, particularly in the urban slum where storage of cooked food for long periods led to bacterial multiplication at high levels. Infant foods were particularly heavily contaminated. It is concluded that when water supply programmes are planned, the presence of other risk factors for water-related diseases should be investigated. To ensure maximum health benefits, water projects should as a rule be accompanied by other interventions.

Severe cryptosporidiosis in children with normal T-cell subsets.

Though Cryptosporidium spp. is considered to cause only a self-limiting illness in immunocompetent children, data from Guinea Bissau suggest that cryptosporidiosis may be a significant cause of deaths in developing countries. An impaired cellular immune function could explain the severe course of cryptosporidiosis in these children. We therefore investigated in a community study whether pre-infectious CD4/CD8 status had an impact on incidence and severity of cryptosporidiosis. Of 168 children below two years of age 21 experienced Cryptosporidium-infection within 156 days after blood sampling, but no tendencies of pre-infectious impaired cellular immune function was found in the cases compared with controls, nor did nine children who acquired persistent diarrhoea or three who died have impaired CD4/CD8 status.

First cases of microsporidiosis in Scandinavian patients with AIDS.

The first 2 cases of infection with Enterocytozoon bieneusi in Denmark and Scandinavia are reported. Both patients were women and to the best of our knowledge this is the first report of E. bieneusi in female AIDS patients. Both had late stage AIDS, and both had complained of intermittent diarrhoea for more than 1 year. At the time microsporidiosis was diagnosed, no other pathogens causing diarrhoea were found. Immunodeficient patients with chronic unexplained diarrhoea should be investigated for intestinal microsporidiosis, especially as treatment is now available.

Immunofluorescence assay for detection of antibodies to human immunodeficiency virus type 2.

A total of 215 serum samples were tested for antibodies against human immunodeficiency virus type 2 (HIV-2) with an immunofluorescence assay (IFA). Some samples originated from Denmark and some originated from Guinea-Bissau. The IFA results were compared with enzyme-linked immunosorbent assay (ELISA) and Western (immuno-) blot (WB) results. Twenty-nine serum samples were found to be true positive for HIV-2 antibodies as judged from WB and radioimmunoprecipitation results; all of these were also found to be positive in the HIV-2 IFA. Of 80 serum samples originating from HIV-1-infected persons, 60% showed reactivity in the HIV-2 ELISA, and 51% cross-reacted with at least one band in the HIV-2 WB. None of the sera cross-reacted in the HIV-2 IFA. A total of five serum samples (three African and two Danish) gave unspecific results in the HIV-2 IFA. It is concluded that the HIV-2 IFA is more specific and at least as sensitive as a first-generation ELISA and that IFA is superior to WB in discriminating between HIV-1 and HIV-2 infections.