Intestinal protozoa in returning travellers: a GeoSentinel analysis from 2007 to 2019.

BACKGROUND: Prolonged diarrhoea is common amongst returning travellers and is often caused by intestinal protozoa. However, the epidemiology of travel-associated illness caused by protozoal pathogens is not well described. METHODS: We analysed records of returning international travellers with illness caused by Giardia duodenalis, Cryptosporidium spp., Cyclospora cayetanensis or Cystoisospora belli, reported to the GeoSentinel Network during January 2007-December 2019. We excluded records of travellers migrating, with an unascertainable exposure country, or from GeoSentinel sites that were not located in high-income countries. RESULTS: There were 2517 cases, 82.3% giardiasis (n = 2072), 11.4% cryptosporidiosis (n = 287), 6.0% cyclosporiasis (n = 150) and 0.3% cystoisosporiasis (n = 8). Overall, most travellers were tourists (64.4%) on long trips (median durations: 18-30 days). Cryptosporidiosis more frequently affected people < 18 years (13.9%) and cyclosporiasis affected people ≥ 40 years (59.4%). Giardiasis was most frequently acquired in South Central Asia (45.8%) and sub-Saharan Africa (22.6%), cryptosporidiosis in sub-Saharan Africa (24.7%) and South-Central Asia (19.5%), cyclosporiasis in South East Asia (31.3%) and Central America (27.3%), and cystoisosporiasis in sub-Saharan Africa (62.5%). Cyclosporiasis cases were reported from countries of uncertain endemicity (e.g. Cambodia) or in countries with no previous evidence of this parasite (e.g. French Guiana). The time from symptom onset to presentation at a GeoSentinel site was the longest amongst travellers with giardiasis (median: 30 days). Over 14% of travellers with cryptosporidiosis were hospitalized. CONCLUSIONS: This analysis provides new insights into the epidemiology and clinical significance of four intestinal protozoa that can cause morbidity in international travellers. These data might help optimize pretravel advice and post-travel management of patients with travel-associated prolonged gastrointestinal illnesses. This analysis reinforces the importance of international travel-related surveillance to identify sentinel cases and areas where protozoal infections might be undetected or underreported.

Contamination of fresh produce sold on the Italian market with Cyclospora cayetanensis and Echinococcus multilocularis.

To investigate the presence of Cyclospora cayetanensis, Toxoplasma gondii and Echinococcus spp. in fresh produce sold in Italy, 324 locally produced 'ready-to-eat' (RTE) mixed-salad packages belonging to three brands and 324 berries packages (blueberries and blackberries imported from Peru and Mexico, respectively, and raspberries grown in Italy) were purchased at retail. Nine individual packages from each of the six types of fresh produce were collected monthly for one year, and with the same produce pooled, this resulted in a total of 72 pools for the whole year. Using microscopy (FLOTAC), a Cyclospora-like oocyst was detected in a blueberry sample and a taeniid egg was detected in a RTE-salad sample. Molecular tools confirmed these to be C. cayetanensis and Echinococcus multilocularis, respectively. Toxoplasma gondii was not detected in any of the samples. This study shows for the first time in Europe that imported berries on the Italian market may be contaminated with C. cayetanensis and RTE salads grown in Italy with E. multilocularis. The results indicate a new epidemiological scenario and highlight that current management of fresh produce, locally produced or imported, does not ensure products are free from parasite contamination.

Modifications of the U.S. food and drug administration validated method for detection of Cyclospora cayetanensis oocysts in prepared dishes: Mexican-style salsas and guacamole.

Although multiple outbreak clusters of Cyclospora cayetanensis have been traced back to consumption of dishes in Mexican-style restaurants, the FDA Bacteriological Analytical Manual (BAM) does not currently provide methods to detect C. cayetanensis in dishes that contain multiple produce ingredients, such as salsas and guacamole. These complex food matrices also may contain high levels of fats, which can interfere with the detection. Several modifications to the BAM Chapter 19b method (washing produce, DNA extraction, and a TaqMan real-time PCR assay targeting the 18S rRNA gene of C. cayetanensis) were assessed with the goal to detect as few as 5 oocysts of C. cayetanensis in 25 g samples of commercial salsa/pico de gallo, guacamole, and salsa verde. Both freshly prepared and frozen versions of these foods were seeded with 5, 10 and 200 oocysts. For salsa samples, using a gentler washing step than recommended by BAM, we achieved detection of 5 oocysts in the samples (81.8%, n = 11). Increasing the amount of Alconox® in the wash solution to 1%, rather than the 0.1% used in BAM, and adjusting the DNA extraction protocol to process large wash pellets, enabled detection of 5 oocysts in guacamole. To reach the desired level of detection in salsa verde, two types of modifications were necessary: gentler washing and DNA extraction modifications. The use of these same method modifications on previously frozen food samples, provided levels of detection similar to those achieved with fresh dishes. Our modifications enabled robust and reproducible detection of C. cayetanensis in multi-ingredient Mexican dishes, detecting as few as 5 oocysts in 25 g samples. Validating and deploying effective methods to detect C. cayetanensis in high risk fresh produce and prepared dishes are critically important for prevalence studies and outbreak investigations of this parasite.

Acute kidney injury associated with intestinal infection by Cyclospora cayetanensis in a kidney transplant patient. A case report.

This study shows a clinical case report of a kidney transplant patient who traveled from Mexico to The Netherlands and ate green vegetables in an international food restaurant. After 5 days, he started having diarrhea, nausea, colic, and a physical feeling of malaise. The patient only received symptomatic treatment after showing the characteristic symptoms of traveler's diarrhea. When he returned to Mexico, the clinical picture worsened, and he was hospitalized. Clinical analyses indicated dehydration and acute kidney injury stage II. Coproparasitoscopic study showed the presence of Cyclospora cayetanensis. Parenteral solutions, gastric mucosal protector, ciprofloxacin, and a soft diet were administrated as treatment. The patient was discharged 72 h later with an improvement of the kidney function.

Sporadic cyclosporiasis in symptomatic Cuban patients: Confirmation of positive results from conventional diagnostic methods by molecular assay.

In Cuba, there are few studies on cyclosporiasis. Here, we report results from 1247 stool samples from symptomatic patients that were examined by microscopy methods and positive cases confirmed by nested PCR targeting the 18S rRNA gene, followed by sequencing. Seven positive samples, all diagnosed during May-June, were confirmed by the molecular method, indicating an occurrence in this patient cohort of 0.56%.

Human intestinal protozoa in fresh asparagus from different types of markets in northwest Mexico.

Caborca is one of the most productive asparagus-growing regions in the state of Sonora in northwest Mexico, an area where some fresh fruits and vegetables are sold at unregulated open-air street markets. This is a cross-sectional study in which fifty bundles of asparagus for exportation, 50 bundles of sub-standard asparagus, and 50 bundles of asparagus from open-air markets were selected randomly and then subjected to Faust, Kinyoun and ELISA testing to detect intestinal parasites. Pearson's chi-square (χ2) and Student-NewmanKeuls tests were used to estimate differences among the sampling site groups (P < 0.05). The pathogens Cryptosporidium spp. (29%) G. intestinalis (5%) and Cyclospora spp. (3%) were found in the asparagus sold in the region. The prevalence of Cryptosporidium spp. was higher in both the sub-standard asparagus and the product sampled from the open-air markets than in the samples for exportation (P < 0.05). This is the first study to demonstrate contamination by intestinal parasites in asparagus sold in different markets in northwest Mexico.

Molecular detection and genotyping of pathogenic protozoan parasites in raw and treated water samples from southwest Colombia.

BACKGROUND: Protozoan parasites such as Giardia duodenalis, Cryptosporidium spp., Cyclospora cayetanensis, Toxoplasma gondii and Entamoeba histolytica represent a great challenge to the systems producing water for human consumption because their cystic forms are persistent in the environment and resist to the disinfection methods conventionally used for their control. In this study, we investigated the presence of these protozoan pathogens in both raw and treated water samples used for the production of drinking water in Nariño Department, southwest Colombia. We collected 110 water samples (10 lof each sample) and analyzed them with real-time PCR (qPCR). qPCR-positive samples were genotyped with PCR and DNA sequencing. RESULTS: Giardia duodenalis was detected in 35/110 (31.8%) of the samples and Cryptosporidium spp. in 9/110 (8.2%) of the samples; no sample was positive for T. gondii, E. histolytica or C. cayetanensis. Giardia duodenalis was detected in samples of both raw water (Drinking Water Treatment Plants (DWTP): 47.83%;Drinking Water Rural Plants (DWRP): 18.42%) and water collected either after conventional physicochemical treatment (26.09%) or after disinfection by chlorine (50%), whereas Cryptosporidium spp. were only detected in raw waters (DWTP: 17.39%; DWRP: 13.16%). The two pathogens were detected in both types of treatment plants supplying water to urban areas and to rural zones. Analysis of gdh and tpi markers identified assemblages AI, AII and H of G. duodenalis, while analysis of the small subunit rRNA and gp60 markers of Cryptosporidium-positive samples identified C. parvum (Subtype IIcA5G3c), C. galli, C. molnari, Cryptosporidium sp. genotype II of bats and Cryptosporidium sp. genotype VIII of birds. CONCLUSIONS: The results obtained demonstrate the presence of protozoan parasites in the water of the study region, and the need to improve the surveillance systems for these pathogens and identify the corresponding sources of contamination.

Cyclosporiasis in travellers returning to the United Kingdom from Mexico in 2017: lessons from the recent past to inform the future.

During the summers of 2015 and 2016, the United Kingdom experienced large outbreaks of cyclosporiasis in travellers returning from Mexico. As the source of the outbreaks was not identified, there is the potential for a similar outbreak to occur in 2017; indeed 78 cases had already been reported as at 27 July 2017. Early communication and international collaboration is essential to provide a better understanding of the source and extent of this recurring situation.

Marked seasonality of Cyclospora cayetanensis infections: ten-year observation of hospital cases, Honduras.

BACKGROUND: Document seasonality occurrence and epidemiologic characteristics of Cyclospora cayetanensis infections during a 10-year period from patients consulting at the University Hospital, Honduras. METHODS: Retrospective non interventional hospital-based study analyzed laboratory results from the period 2002 to 2011 of fresh and Ziehl-Nielsen carbolfuchsin stained routine stool samples received for parasitologic examination. Sporadically a sample with numerous oocysts was allowed to sporulate in 2.5 % potassium dichromate confirming the presence of bi-cystic bi-zoic oocysts. RESULTS: A total of 35,157 fecal samples were examined during a ten-year span, of which a third (28.4 %) was stained by the Ziehl-Neelsen carbolfuchsin method diagnosing a total of 125 (1.3 %) C.cayetanensis infections. A statistically significant apparent seasonality was observed most years during May to August (range p < 0.036-0.001), with 83.3 % of 125 cases occurring in those rainy months. All C. cayetanensis cases came from urban poor neighborhoods; male/female relation was 1:1 except in 2006, when all patients were females (p = 0.05; r(2) = 22,448). Forty four point eight percent of the stool samples were diarrheic or liquid and 65.6 % infections were identified in children 10 years old or less. Enteric helminths and protozoa co-infected Cyclospora positive patients in 52 instances.: 8 % Ascaris lumbricoides, 8 % Giardia duodenalis, 23.2 % Blastocystis spp. and less frequently Entamoeba histolytica/E. dispar, Strongyloides stercoralis, and Trichuris trichiura. CONCLUSIONS: Results suggest a seasonal pattern for Cyclospora infections diagnosed in a clinical setting during the rainy months in Tegucigalpa and surrounding areas. Community studies should be conducted to support or dispute these observations.

Multistate product traceforward investigation to link imported romaine lettuce to a US cyclosporiasis outbreak - Nebraska, Texas, and Florida, June-August 2013.

During June-August 2013, 25 US states reported 631 cyclosporiasis cases including Nebraska and Iowa where a regional investigation implicated common-source imported salad mix served in two chain restaurants. At least two common-origin growing fields were likely sources of contaminated romaine lettuce. Using producer- and distributor-provided data, we conducted a grower-specific traceforward investigation to reveal exposures of ill US residents elsewhere who reported symptom onset during 11 June-1 July 2013, the time period established in the Nebraska and Iowa investigation. Romaine lettuce shipped on 2-6 June from one of these Mexico-origin growing fields likely caused cyclosporiasis in 78 persons reporting illness onsets from 11 June to 1 July in Nebraska, Texas, and Florida. Nationwide, 97% (314/324) of persons confirmed with cyclosporiasis with symptom onset from 11 June to 1 July 2013 resided in 11 central and eastern US states receiving approximately two-thirds of romaine lettuce from this field. This grower's production practices should be investigated to determine potential sources of contamination and to develop recommendations to prevent future illnesses.

Cyclospora infection linked to travel to Mexico, June to September 2015.

Cyclospora cayetanensis was identified in 176 returned travellers from the Riviera Maya region of Mexico between 1 June and 22 September 2015; 79 in the United Kingdom (UK) and 97 in Canada. UK cases completed a food exposure questionnaire. This increase in reported Cyclospora cases highlights risks of gastrointestinal infections through travelling, limitations in Cyclospora surveillance and the need for improved hygiene in the production of food consumed in holiday resorts.

Cyclospora cayetanensis in a pediatric hospital in Morelia, México.

Cyclospora cayetanensis, a coccidian parasite, can cause gastrointestinal illness in humans and is characterized by watery and persistent diarrhea and abdominal pain. Cyclosporiasis has been associated with traveler's diarrhea. The infection is acquired through food and waterborne transmission, particularly by consumption of contaminated fresh fruits and vegetables. In the present study, stool samples from 8,877 children were examined for ova and parasites at the Pediatric Hospital of Morelia in Michoacán, Mexico, during 2000-2009. Sixty children (0.67%) had Cyclospora in their stools. Diarrhea (45.8%), abdominal pain (39.6%), and vomiting (18.8%) were the most frequent symptoms of cases with cyclosporiasis. Most of the cases (93.3%) were observed during June-August, the rainy season. In 45 children, Cyclospora was the only parasitic pathogen detected (75%); 15 children were co-infected with commensal, pathogenic, or both groups of parasites. Our findings suggest that C. cayetanensis is endemic to Michoacán and shows characteristically temporal patterns.

Cyclospora cayetanensis: this emerging protozoan pathogen in Mexico.

A Mexican airline pilot had clinical manifestations of illness after a five-day stay in Lima, Peru. Six months later in Mexico, he was given a diagnosis of infection with Cyclospora cayetanensis by using coproparasitoscopic serial tests. He was treated twice with nitazoxadine successfully.

Application of a qPCR assay with melting curve analysis for detection and differentiation of protozoan oocysts in human fecal samples from Dominican Republic.

A quantitative polymerase chain reaction assay with melt curve analysis (qPCR-MCA) was applied for the detection of protozoan oocysts in 501 human fecal samples collected in Dominican Republic. Samples were subjected to qPCR using universal coccidia primers targeting 18S rDNA to detect oocysts followed by MCA to identify oocyst species based on amplicon melting temperature. Putative positive samples were also tested by conventional PCR and microscopy. Cystoisospora belli (×3), Cryptosporidium parvum (×3), Cryptosporidium hominis (×5), Cryptosporidium meleagridis (×1), Cryptosporidium canis (×1), and Cyclospora cayetanensis (×9) were detected by qPCR-MCA and confirmed by sequencing. This assay consistently detected 10 copies of the cloned target fragment and can be considered more efficient and sensitive than microscopy flotation methods for detecting multiple species of oocysts in human feces. The qPCR-MCA is a reliable protozoan oocyst screening assay for use on clinical and environmental samples in public health, food safety and veterinary programs.

Cystoisospora and cyclospora.

PURPOSE OF REVIEW: The present review focuses on recent epidemiological and diagnostic advances in cystoisosporiasis and cyclosporiasis. RECENT FINDINGS: Continuous outbreaks of these parasites occur worldwide. Sporadic cases in the United States are travel acquired, but also domestically acquired. New molecular diagnostic methods allow for accurate early diagnosis in humans, and might potentially decrease the burden of disease by detecting these parasites in vehicles of transmission. SUMMARY: Better understanding of the epidemiology of Cyclospora cayetanensis and to a less extent to Cystoisospora belli has been gained recently. However, several gaps still remain in knowledge on the transmission and on mechanisms of persistent infection in immunosuppressed patients and prevention. New molecular methods might help in filling these gaps and in controlling transmission.

[Microsporidia in pediatric patients with leukemia or limphoma]. / Microsporidiosis en pacientes pediátricos con leucemia o linfoma.

INTRODUCTION: Microsporidia are intracellular micro-organisms, characterized by mature spores with chitin walls and by one extrusive polar tube through which they pour their sporoplasm to the host cells. In immunocompromised patients, Enterocytozoon bieneusi and Encephalitozoon intestinalis produce diarrhea and systemic dissemination. In Mexico there is not information about microsporidia in children with cancer. OBJECTIVE: The aim of this pilot study was to investigate the presence of microsporidia species in pediatric patients with leukemia or lymphoma. MATERIAL AND METHODS: We obtained fecal samples from thirteen patients. The samples were processed to detect microsporidia by both modified Ziehl-Neelsen and clacofluor white stains, DNA was isolated to amplify rRNA specific sequences, to identify E. bieneusi, E. intestinalis, E. cuniculi and E. hellem by DNA polymerase chain reaction (PCR). Other parasites and pathogenic bacteria were also tested. RESULTS: Based on morphologic traits 7/13 samples were found positives to microsporidia and 6/10 by PCR. Was identified E. bieneusi in three patients with leukemia and one with lymphoma, another two children with leukemia were infected with E. intestinalis. Almost all children were high-risk patients and in phase of re-induction, consolidation or with many chemotherapy treatments. All the patients with microspiridia did not present diarrhea at the moment of the sampling; however, in two children with diarrhea it was found Cyclospora cayetanensis. Also we obtained feces from five patients' mothers and microsporidia spores were identified by stain in all of them and by PCR it was diagnosed the species in three of them. CONCLUSION: It was demonstrated that the feces of patients with leukemia or lymphoma had microsporidia, therefore is necessary to know the prevalence of these microorganisms and to analyze their impact in evolution of cancer patients.

Infección por Cyclospora cayetanensis: Revisión a propósito de tres casos de diarrea del viajero / Cyclospora cayetanensis infection: Updated review a propos of three cases of traveler's diarrhea

Human infection by Cyclospora cayetanensis, namely cyclosporiasis, can cause a wide range of symptoms in immunocompetent patients, from mild to severe diarrhea. Immunocompromised patients can present with chronic diarrhea and it has been recognized as a cause of traveler's diarrhea. We report three patients who traveled from Chile to Peru, who presented upon returning with prolonged traveler's diarrhea. A literature review about cyclosporiasis is presented, with emphasis on the clinical, epidemiological, diagnostic and therapeutic aspects of this disease.

Challenges of investigating community outbreaks of cyclosporiasis, British Columbia, Canada.

Investigations of community outbreaks of cyclosporiasis are challenged by case-patients' poor recall of exposure resulting from lags in detection and the stealthy nature of food vehicles. We combined multiple techniques, including early consultation with food regulators, traceback of suspected items, and grocery store loyalty card records, to identify a single vehicle for a cyclosporiasis outbreak in British Columbia, Canada, in 2007.