Intestinal parasitic infections in relation to CD4(+) T cell counts and diarrhea in HIV/AIDS patients with or without antiretroviral therapy in Cameroon.

BACKGROUND: Intestinal parasitic infections (IPI) are a major public health concern in HIV/AIDS patients particularly in resource-limited settings of Sub-Saharan Africa. Studies investigating the relationship between intestinal parasitic infections and CD4(+) T cell counts and diarrhea in HIV/AIDS patients with or without antiretroviral therapy in the region are not readily available hence the need to perform this study. METHODS: In a comparative cross-sectional study involving 52 pre-ART and 248 on-ART HIV patients. Stool samples were collected and analysed for intestinal parasites by wet and iodine mounts, Kato-Katz, formol ether, modified field staining, and modified Ziehl-Neelsen staining techniques. Blood samples were collected and analysed for CD4(+) T cell counts by flow cytometry. A pre-tested semi-structured questionnaire was used to collect data on socio-demographic and clinical presentation. Data were analysed using STATA version 12.1. Statistical tests performed included the Pearson Chi-square, logistic regression and student's t-test. P < 0.05 was considered to be statistically significant. RESULTS: The prevalence of intestinal parasitic infections in pre-ART and on-ART was 84.6% and 82.3% respectively with no significant difference observed with respect to age (p = 0.06), and gender (p = 0.736). All the opportunistic parasites including Cryptosporidium parvum, Cyclospora cayetanensis, Isospora belli and Microsporidium spp. were isolated from both groups, with only Microsporidium spp. significantly associated with CD4(+) T cell counts below 200 cells/µl in pre-ART (p = 0.006) while Cryptosporidium parvum, Microsporidium spp. and Isospora belli were associated with counts below 200 cells/µl in on-ART. Cryptosporidium parvum was significantly associated with diarrhea in pre-ART (p = 0.025) meanwhile it was significantly associated with diarrhea in on-ART (p = 0.057). The risk of diarrhea was highest in patients with CD4(+) T cell counts below 200 cells/µl (COR = 10.21, p = 0.000) for both pre- and on-ART treatment. CONCLUSION: A very high prevalence of intestinal parasitic infections was observed, which did not differ with respect to ART status. All known opportunistic parasites were isolated in both pre-ART and on-ART patients. Low CD4(+) T cell count may appear to be a factor for intestinal parasitic infections and development of diarrhea. Regular screening and treatment of intestinal parasitic infections is very vital in improving the overall quality of care of HIV/AIDS patients.

Cryptosporidiosis and Isosporiasis among HIV-positive individuals in south Ethiopia: a cross sectional study.

BACKGROUND: Cryptosporidium spp and I. belli are intestinal opportunistic infections associated with HIV/AIDS. A decline in the incidence of these opportunistic infections due to HAART was reported. We aim to investigate these parasites among HAART naïve and experienced HIV patients in south Ethiopia. METHODS: A cross sectional study was carried out among 268 HIV- positive patients between January and September, 2007. Interview with questionnaires and document reviews were used to collect data. Stool samples were obtained from each patient and parasites were examined by direct, formol-ether and modified Ziehl-Neelsen stain for Cryptosporidium spp and I. belli. Univariate and multivariate analysis were carried out. Level of significance was set at p-value of 0.05. RESULTS: A total of 268 patients participated in the study. The mean age was 34.0 (±1 SD of 8.34) years. Females constituted 53.4% (143) of the study participants. Half of the study participants were on HAART; majorities (85.8%) of such patients were within the first year of treatment. The prevalence of Cryptosporidium spp was 34.3% (92/268) and I. belli was 1.5% (4/268). Dual infection was detected in two patients (0.75%). The crude analysis revealed significant reduction in the odds of Cryptosporidium spp infection among patients who have started HAART (crude OR = 0.59, 95% CI 0.35, 0.98). The adjusted analysis remained in the same direction but has lost significance (Adj OR 0.65, 95%CI 0.35, 1.24). No differences in the risk of developing infection with Cryptosporidium spp were observed between groups based on most recent CD4 counts, sex, duration on HAART and age (p > 0.05 for all variables). Patients with Cryptosporidium spp were more likely to report vomiting [Adj OR 2.34 (95% CI 1.22, 5.41)], weight loss [Adj OR 2.10 (95% CI 1.15, 3.81)] and chronic diarrhea [Adj OR 3.35 (95%CI 1.05, 10.63)]. CONCLUSION: There is high burden of infection with Cryptosporidium spp among HIV infected individuals in southern Ethiopia but that of I. belli is low. We recommend considering infection with Cryptosporidium spp in HIV infected people with chronic diarrhea, weight loss and vomiting for HAART naïve patients and/or for patients who are within the first year of starting HAART.

Cystoisospora belli infection in an AIDS patient in China: Need for cautious interpretation of mNGS.

Cystoisospora belli (C. belli) is an opportunistic coccidian parasite. This case is the first reported C. belli infection associated with AIDS in China. C. belli infection of this case was diagnosed with the presence of oocysts using direct wet mount and Ziehl-Neelsen acid-fast stain method, and confirmed by polymerase chain reaction (PCR) and Sanger sequencing, ruling out the result of metagenomic next-generation sequencing (mNGS). This case demonstrates that C. belli infection in AIDS could be a potential risk factor for persistent diarrhea, and should not be neglected in non-endemic area and emphaise the necessity of accurate mNGS databases.

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.

Intestinal parasitic infections in relation to HIV/AIDS status, diarrhea and CD4 T-cell count.

BACKGROUND: HIV infection has been modifying both the epidemiology and outcome of parasitic infections. Hence, this study was undertaken to determine the prevalence of intestinal parasitic infection among people with and without HIV infection and its association with diarrhea and CD4 T-cell count. METHODS: A cross-sectional study was conducted at Hawassa Teaching and Referral Hospital focusing on HIV positive individuals, who gave blood for CD4 T-cell count at their first enrollment and clients tested HIV negative from November, 2008 to March, 2009. Data on socio-demographic factors and diarrhea status were obtained by interviewing 378 consecutive participants (214 HIV positive and 164 HIV negative). Stool samples were collected from all study subjects and examined for parasites using direct, formol-ether and modified acid fast stain techniques. RESULTS: The prevalence of any intestinal parasitic infection was significantly higher among HIV positive participants. Specifically, rate of infection with Cryptosporidium, I. belli, and S. stercoralis were higher, particularly in those with CD4 count less than 200 cells/microL. Diarrhea was more frequent also at the same lower CD4 T-cell counts. CONCLUSION: Immunodeficiency increased the risk of having opportunistic parasites and diarrhea. Therefore; raising patient immune status and screening at least for those treatable parasites is important.

Isosporosis and unizoite tissue cysts in patients with acquired immunodeficiency syndrome.

Isospora belli, a coccidian parasite in humans, has been described as causing chronic diarrhea and acalculous cholecystitis in patients with the acquired immunodeficiency syndrome (AIDS). Diagnosis can be made at the tissue level in the epithelium of the small bowel and by fecal examination. Disseminated extraintestinal forms are uncommon. We studied 118 adult patients with AIDS and chronic diarrhea using stool analysis and endoscopy with duodenal biopsy specimen collection. These samples were processed by routine histology and transmission electron microscopy. Isosporosis was diagnosed in 8 cases. In 2 of them, unizoite tissue cysts were present in the lamina propria, with negative results in stool materials. The cysts were located within a large parasitophorous vacuole. There were no structural means of differentiating the species level of Isospora based on morphology using light or electron microscopy. We believe further work should be done to determine if unizoite tissue cysts are part of the cycle of I belli or of other species of Isospora that could be pathogenic in immunocompromised hosts.

Point prevalence of Cryptosporidium, Cyclospora, and Isospora infections in patients being evaluated for diarrhea.

From March to September 2001, 315 specimens from "nonrepeat" patients that were submitted for ova and parasite examination were stained using the Kinyoun modified acid-fast stain to detect the intestinal coccidians. Four patients (1.3%) were infected with coccidians, 2 with Cryptosporidium parvum and 2 with Cyclospora cayetanensis. No infections with Isospora belli were detected. In comparison, 15 patients (4.8%) had infections with one or more intestinal parasites detected by routine trichrome staining: 5 had Giardia lamblia; 2, Dientamoeba fragilis; 3, Strongyloides stercoralis; 1, Iodamoeba bütschlii; 3, Endolimax nana; 6, Blastocystis hominis; and 1, Entamoeba coli. Four patients were multiply infected. Coccidians made up 29% of the clinically significant parasitic infections. The coccidians were missed in all 4 cases because no special staining was ordered. Clinicians need to be reminded that additional tests should be ordered to fully evaluate patients with chronic diarrhea in which no diagnosis is found by routine testing.

Isospora belli infection in a patient with non-Hodgkin's lymphoma.

Isospora belli infection is frequent in patients with acquired immunodeficiency syndrome in tropical areas. It has also been reported in other immunodepressive diseases, such as lymphoblastic leukemia, adult T-cell leukemia, and Hodgkin's disease. To date, no case of non-Hodgkin's lymphoma-related isosporiasis has been reported in a non-HIV-infected patient. We describe a case of non-Hodgkin's lymphoma with chronic diarrhea due to I. belli. In Europe, I. belli can cause severe chronic diarrhea in patients with malignancies whose country of origin is in an endemic area. Trimethoprim-sulfamethoxazole can provide rapid and prolonged clinical and parasitologic cure.

Intestinal parasites in HIV-2 associated AIDS cases with chronic diarrhoea in Guinea-Bissau.

Previous studies from African countries where HIV-1 infection is prevalent have shown that infections with Cryptosporidium parvum, Isospora belli and microsporidia are frequently associated with chronic diarrhoea in AIDS patients. The information about the occurrence of these parasites in HIV-2 associated AIDS cases with chronic diarrhoea is limited. We have performed a study of stool parasites in patients from Guinea-Bissau, the country with the highest prevalence of HIV-2 in the world. Stool specimens from 52 adult patients with chronic diarrhoea of which 37 were HIV-positive and fulfilling the clinical criteria of AIDS (five HIV-1, 28 HIV-2 and four dually infected with HIV-1 and HIV-2) were screened for parasitic infections. Twenty five percent of the HIV-2 positive patients were infected with C. parvum, 11% with I. belli and 11% with microsporidia, all three parasites were seen only in HIV-positive patients. The three patients with microsporidiosis, all HIV-2 infected, are to our knowledge the first cases reported from Guinea-Bissau. Other stool parasites such as Blastocystis hominis, hookworm and Strongyloides stercoralis were observed both among HIV-positive and HIV-negative patients.

Uvitex 2B stain for the diagnosis of Isospora belli infections in patients with the acquired immunodeficiency syndrome.

OBJECTIVE: Fluorescent stains with Uvitex 2B or other fluorochromes are widely used today, especially for the diagnosis of microsporidian infections in human immunodeficiency virus (HIV)-infected patients. Our objective was to ascertain whether the fluorescent stain with Uvitex 2B is also able to detect Isospora belli in stool samples and duodenal/bile juice of HIV-infected patients. DESIGN: Case study. SETTING: University hospital of the University of Cologne, Germany. PATIENTS: Two HIV-infected patients with chronic diarrhea who had intestinal infections with I. belli. METHODS: Stool was concentrated by a modified water-ether sedimentation method, and duodenal/bile juice was concentrated by centrifugation. Wet-mount preparations were examined by phase-contrast and bright-field microscopy, and smears were stained with a modified acid-fast stain and a fluorescent stain with Uvitex 2B. RESULTS: Using the fluorescent stain with Uvitex 2B, the oocysts of I. belli stained bright white/blue fluorescent and showed a structure similar to that of the oocysts in acidfast stains. CONCLUSIONS: Staining with Uvitex 2B is a suitable method for the diagnosis of I. belli infections. This technique can be used for the diagnosis of three important gastrointestinal parasites (viz, microsporidia, cryptosporidia, and I. belli) responsible for diarrhea in HIV-infected patients.

Isosporiasis in children.

The clinical, laboratory and therapeutic data of patients with diarrhea in Human immunodeficiency virus (HIV) antibody positive, immunocompromised and immunocompetent individuals were studied especially to look for prevalence of intestinal coccidiosis. During a study period of one decade, Isospora belli were identified in the stool samples of seven children with diarrhea. Diarrhea persisted for a little longer period in HIV-seropositive children compared to sero-negatives but the clinical picture did not differ significantly in either HIV infected or HIV uninfected individuals.

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).

Common variable immunodeficiency and isosporiasis: first report case.

We report a severe case of diarrhea in a 62-year-old female HIV-negative patient from whom Giardia lamblia and Isospora belli were isolated. Because unusual and opportunistic infections should be considered as criteria for further analysis of immunological status, laboratory investigations led to a diagnosis of common variable immunodeficiency (CVID). This is the first reported case of isosporiasis in a patient with CVID and illustrates the importance of being aware of a possible link, particularly in relation to primary immunodeficiency.

Failure to eradicate Isospora belli diarrhoea despite immune reconstitution in adults with HIV--a case series.

Isospora belli causes diarrhoea in patients with AIDS. Most respond to targeted therapy and recommendations are that secondary prophylaxis can be stopped following immune reconstitution with ART. We report eight cases of chronic isosporiasis that persisted despite standard antimicrobial therapy, secondary prophylaxis, and good immunological and virological response to ART. Median CD4 nadir was 175.5 cells/mm(3) and median highest CD4 while symptomatic was 373 cells/mm(3). Overall 34% of stool samples and 63% of duodenal biopsy specimens were positive for oocytes. Four patients died, two remain symptomatic and two recovered. Possible explanations for persistence of symptoms include host factors such as antigen specific immune deficiency or generalised reduction in gut immunity. Parasite factors may include accumulating resistance to co-trimoxazole. Research is required to determine the optimum dose and duration of co-trimoxazole therapy and whether dual therapy may be necessary. Mortality was high and pending more data we recommend extended treatment with high-dose co-trimoxazole in similar cases.

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.

Prevalence of coccidian infection in suckling piglets in China.

To determine the prevalence of coccidian infection in suckling piglets in China, fecal samples from 779 litters of suckling piglets were collected on 80 different farms in 17 provinces from September 2009 to December 2010. These samples were examined through saturated saline flotation technique. The prevalences of coccidian infection ranged from 0 to 32.5% among different provinces and the average was 16.7% (130/779). The highest prevalence of 19.9% (69/346) was found in 8-14 day-old litters of suckling piglets. Seven coccidian species were detected in the positive litters of suckling piglets, including Isospora suis (63.9%), Eimeria debliecki (46.9%), Eimeria polita (19.2%), Eimeria suis (20.8%), Eimeria perminuta (13.9%), Eimeria scabra (4.6%), and Eimeria yanglingensis (1.5%). 55.4% of the positive litters of suckling piglet infected more than one coccidian species. The results of this investigation will provide the relevant basic data for control strategies against porcine coccidiosis on pig farms in China.

Molecular diagnosis of cystoisosporiasis using extended-range PCR screening.

The differential diagnosis of diarrhea in immunocompromised patients encompasses many intestinal parasites including the coccidian Cystoisospora belli. Gastrointestinal infection with C. belli leads to cystoisosporiasis with diarrhea and, depending on host immune status, can cause extraintestinal disease. C. belli is usually diagnosed by examination of stool or intestinal biopsy specimens; however, the organism may be undetected using these test methods. Thus, more sensitive molecular tools for detection of pathogenic parasites are desirable. Herein is described a patient with AIDS who had persistent diarrhea of unknown cause. Microscopic examinations of stool and ileal biopsy specimens were initially unremarkable for any specific pathogen. Screening of DNA extracted from biopsy material using extended-range PCR primers recognizing conserved DNA sequences found in many fungi and parasites revealed infection with C. belli, which was confirmed at repeat histologic analysis. Extended-range PCR screening was used because the differential diagnosis was broad and other tools were not applied, yet this molecular approach led to the appropriate diagnosis and treatment of the condition. Thus, this approach offers a promising test for diagnosis of parasitic diseases that elude diagnosis using conventional methods.