Consultant Microbiologist AFIP Rawalpindi

Cryptosporidiosis in a young immunocompromised patient

Dr Shams AfridiTrainee in Microbiology

SupervisorDr Nasrullah Malik

Case Presentation

Name XYZ

Age 12 years

Gender Male

Residence Peshawar

Date of admission 28 Aug 2009

Hospital AFBMTC

PATIENT’S PROFILE

● Watery diarrhoea 3 days

● Low grade fever

● Non productive cough 2 days

PRESENTING COMPLAINTS

● Known case of Fanconi’s anemia

● Allogenic bone marrow transplant at AFBMTC Rwp on 10th Aug 2009

● Discharged after two weeks

● Re-admitted on Aug 28, with symptoms of acuteGvHD

● HISTORY OF PRESENT ILLNESS

● Non-bloody, watery diarrhoea with 15-20 stools per day

● Low grade fever

● Developed non productive cough with

breathlessness

● HISTORY OF PRESENT ILLNESS

● Cyclosporine , steroids , immunoglobulins

● Antibiotic therapy including antifungal agents

● Fluid and electrolyte replacement

● Condition remained the same

● HISTORY OF PRESENT ILLNESS

● PAST HISTORY

● Frequent admissions in AFBMTC

● Fanconi's anemia diagnosed in May, 2009

at AFBMTC

● Bone marrow transplantation at AFBMTC

● Was on oral immunosuppressive therapy

● SOCIOECONOMIC HISTORY

Socioeconomic status satisfactory

● PERSONAL HISTORY

Not contributory

● FAMILY HISTORY

Not contributory

A boy of lean built lying in bed conscious and oriented

Vital signs

GENERAL PHYSICAL EXAMINATION

● Pallor +

● Jaundice +

● Dehydration + +

● Cyanosis

● Clubbing

● Edema Absent

● Lymphadenopathy

● Ascites

GENERAL PHYSICAL EXAMINATION

GIT - Hepatosplenomegaly

RESP - NAD

CNS - NAD

CVS - NAD

SYSTEMIC EXAMINATION

● Acute graft versus host disease

● Bacterial, viral and protozoal causes of watery diarrhoea

● Atypical pneumonia

● Bacteraemia/Septicaemia

PROVISIONAL DIAGNOSIS

● Blood C/P

Hb 9.5 g /dl

WBC 2.1 x 109/l

Platelets 51 x 109/l

● Urine R/E WNL

● Fasting plasma Glucose 4.8 mmol/l

LAB EVALUATION

● Renal function tests

Serum urea 2.9mmol/l

Serum creatinine 68 μmol/l

Serum Na 136mmol/l

Serum K 3.8mmol/l

Serum HCO3 23mmol/l

● Liver Function Tests

Bilirubin 70 μ mol/l

ALT 75 U/l

ALP 708 U/l

Albumin 19 g/l (reduced)

LAB EVALUATION (Cont’d)

● CXR

Normal

● USG abdomen

Mild hepatosplenomegaly

● Repeated blood cultures

No growth

LAB EVALUATION (Cont’d)

● Stool routine examination

Loose watery stools

Numerous pus cells

No ova or cysts

● Stool for culture and sensitivity

No Salmonella, Shigella or Vibrio cholerae

● Sputum for C/S and AFB

AFB not seen

Culture Non significant ( normal throat flora )

LAB EVALUATION (Cont’d)

● Stool for Clostridium difficile toxin

Negative

● Stool for Cryptosporidium

Cysts of Cryptosporidium parvum

• Sputum for Cryptosporidium

Cysts of Cryptosporidium parvum

LAB EVALUATION (Cont’d)

Cysts of Cryptosporidium parvum in stool

Cysts of Cryptosporidium parvum in sputum

Intestinal and pulmonary cryptosporidiosis

FINAL DIAGNOSIS

• Supportive therapyo I/V Fluidso Antiemeticso Antipyretics

● Syp Azithromycin (200mg/ 5ml) 1 TSF BD

● Tab Cotrimoxazole 480mg 8 hourly

● Frequency of diarrhea reduced to 5-6 stools per day● Pulmonary symptoms improved

TREATMENT

Repeat stool sample No cyst Repeat sputum sample ● Condition started to deteriorate

CMV PCR ---- Positive

o Put on Gancyclovir and I/V Immunoglobulins Oct 7, Epileptic fit with tongue bite

Bilateral bronchopneumonia

Respiratory failure and death

TREATMENT

Case Discussion

● Cryptosporidium — “hidden spores”

● Phylum Apicomplexa (the sporozoa)o Coccidian protozoan parasite

● Important Specieso C. parvumo C. hominiso C. muriso C. wrairi

● Oocyst 4-6μm in dm

● 240,000 times resistant to chlorination than Giardia

INTRODUCTION

● 1907 Tyzzer, gastric mucosa of mice

● 1976 First human case — 3-year old girl rural

Tennessee, USA

● 1980s Strong association with AIDS

Most common cause of

HIV related gastroenteritis

HISTORICAL BACKGROUND

● Infection reported in six continents

● 3 days to 95 years old

● The frequency of cryptosporidiosis not well-defined o 30% of adult US population seropositive

● A local prospective study conducted at AFIP (May to September 2005)

(n=300) 8%

92%

present absent

EPIDEMIOLOGY

* Hunter PR, Nichols G. Epidemiology and clinical features ofCryptosporidium infection in immunocompromised patients.Clin Microbiol Rev 2002; 15: 145–54.

● Population at risk

o Immunocompromised individuals

o Infants and young children (day-care centres)

o Drinking unfiltered and untreated water

o Hospitalized patients & Health-care employees

o Livestock workers and farmers

o Travelers to endemic areas

EPIDEMIOLOGY (Cont’d)

Year Location Population exposed

Population infected

1984 Braun station, Texas 50900 2006

1992 Jackson county, Oregon 15000 15000

1993 Milwaukee, Wisconsin 403,000 403,000

1996 British Columbia, Canada 90,000 15000

2001 Belfast , Ireland 252,000 257

2007 Galway, Ireland 90,000 5000

2008 Northampton, UK 108,000 252

MAJOR OUTBREAKS

MacKenzie WR, Hoxie NJ, Proctor ME, Gradus MS, Blair KA, Peterson DE, Kazmierczak JJ, Addiss DG, Fox KR, Rose JB. Amassive outbreak in Milwaukee of cryptosporidium infection transmitted through the public water supply. N Engl J Med 1994; 331: 161–7.

Life cycle of Cryptosporidium

● Fecal-oral

o Contaminated food and water

o Untreated groundwater, well water

o Swimming pools, water park wave pools

TRANSMISSION

● Food borne transmission

o Beverages, salads, or other foods not heated or cooked after handling.

● Day-care and Nursing centres

● Nosocomial transmission

o Patients to health care staff, patient-to-patient transmission

TRANSMISSION (Cont’d)

Guerrant R.L. Cryptosporidiosis: An emerging highly infectious threat. Emerg Infect Dis 1997;3:51-7.  

● Low infectious dose

● Sporozoites adhere to the intestinal mucosa

● Cells release cytokines-activate phagocytes

● Soluble factors are released

● Increase intestinal secretion of water and chloride and inhibit absorption

PATHOGENESIS

● Epithelial cells damaged by:

o Direct parasite invasion and multiplication or

o T cell-mediated-villus atrophy

PATHOGENESIS (Cont’d)

● Incubation periodo 2 – 10 days

● Immunocompetent patients

● Acute self-limitingo Frequent, watery diarrhea o Nausea o Vomiting o Abdominal cramps o Low-grade fever

Henry MC, Alary M, Desmet P, et al. Community survey of diarrhoea in children under 5 years in Kinshasa, Zaire. Ann SocBelg Med Trop 1995;75:105–14. [PubMed: 7487197]

●

CLINICAL MANIFESTATIONS

● Immunocompromised patients- more severe illness

o Cholera-like diarrhea (up to 20 liters/day) o Severe abdominal cramps o Malaise o Low grade fever o Weight loss o Anorexia

CLINICAL MANIFESTATIONS(Cont’d)

Kumar S.S., Ananthan S., Saravanan P. Role of coccidian parasites in causation of diarrhea in HIV infected patients in Chennai. Indian J Med Res 2002;116:85-9. 

● Pulmonary involvement

● Rare complication of intestinal cryptosporidiosis

o Chronic cougho Fever o Dyspnoea

Moore, J., and J. Frenkel. 2005. Respiratory and enteric cryptosporidiosis in humans. Arch. Pathol. Lab. Med. 115:1160–1162.

CLINICAL MANIFESTATIONS(Cont’d)

● Microscopic examination

● Serological investigations

o Enzyme immunoassays

o Immunofluorescence assays

● Molecular techniques

LABORATORY DIAGNOSIS

Mehta P. Laboratory diagnosis of cryptosporidiosis. J Postgrad Med 2002;48:217

● MICROSCOPIC EXAMINATION

o Most reliable and specifico Gold standard-Modified ZN (Kinyoun) stainingo Cysts: Bright red, round to oval (4-6 µm)

LABORATORY DIAGNOSIS (Cont’d)

● MICROSCOPIC EXAMINATION

o Auramine-phenol (fluorescent stain)o Cysts appear small, round and bright yellowo False positive results

LABORATORY DIAGNOSIS (Cont’d)

● SEROLOGICAL METHODS

● ELISA o Cryptosporidium specific IgM, IgG, IgAo Sensitivity: 80-100 %o Active infection / previous exposure

LABORATORY DIAGNOSIS (Cont’d)

Marques FR, Cardoso LV, et al. Performance of an immunoenzymatic assay for Cryptosporidium diagnosis of fecal samples; Braz J Infect Dis. 2005 Feb;9(1):3-5. Epub 2005 Jun 6.

● SEROLOGICAL METHODS

● IMMUNOFLUORESCENCE ASSAYS o Sensitiveo Specifico High cost

LABORATORY DIAGNOSIS (Cont’d)

Mehta P. Laboratory diagnosis of cryptosporidiosis. J Postgrad Med 2002;48:217

● Rapid Immunochromatographic detection

o 97% sensitivityo 100% specificity

o High cost

LABORATORY DIAGNOSIS (Cont’d)

LYNNE S. GARCIA* AND ROBYN Y. SHIMIZU. Detection of Giardia lamblia and Cryptosporidium parvumAntigens in Human Fecal Specimens Using the ColorPAC Combination Rapid Solid-Phase Qualitative Immunochromatographic Assay ; JOURNAL OF CLINICAL MICROBIOLOGY, Mar. 2000, p. 1267–1268

● MOLECULAR METHODS

● Polymerase chain reaction(PCR)

o Speciation of cryptosporidiumo Epidemiological studieso Expensiveo Not used as routine

● INTESTINAL BIOPSY SECTIONSo False negative results

LABORATORY DIAGNOSIS (Cont’d)

● No reliable effective therapy

● In immunocompetent patients

o Self limiting

o General supportive care

o Rehydration, replacement of electrolytes and antimotility agents

o Nitazoxanide, Paromomycin and Azithromycin

decrease the intensity of infection*

* De la Tribonnière X, Valette M, Alfandari S. Oral nitazoxanide and paromomycin inhalation for systemic cryptosporidiosis in a patient with AIDS. Infection 1999 May-Jun; 27(3): 232.

TREATMENT

● In immunocompromised patients

o Resolves slowly or not at all

● Spiramycin in the early stages

● Paromomycin and Azithromycin help clear the infection*

● Immunoglobulins

* Palmieri F, Cicalini S, Froio N, Rizzi EB, Goletti D, Festa A, et al. Pulmonary cryptosporidiosis in an AIDS patient: successful treatment with paromomycin plus azithromycin. Int J STD AIDS. 2005 Jul; 16(7): 515-7.

TREATMENT(Cont’d)

● Personal hygieneo Hand washing

● Avoid water that might be contaminatedo Do not swallow recreational watero Avoid swimming when having diarrhoeao Boil water for 1 min or use 1 micron filter

● Avoid food that might be contaminated

● Take extra care when travelling

PREVENTION

Havelaar A, Boonyakarnkul T, Cunliffe D, Grabow W, Sobsey M, Giddings M, Magara Y, Ohanian E, Toft P, Chorus I, Cotruvo J, Howard G, Jackson P. Guidelines for Drinking Water Quality Water Borne Pathogens, 3rd edn. Geneva: WHO 2003.

● Stool sample for Cryptosporidium oocysts should always be sent to laboratory in cases of persistent diarrhoea

● Pulmonary cryptosporidiosis is an important but rare cause of pneumonia/mortality in immunocompromised patients

CONCLUSION

THANK YOU !