Cryptosporidium as cause of laryngotracheitis in an infant

Cryptosporidium infection in solid organ transplantation

Diarrhea is a common complication in solid organ transplant (SOT) recipients and may be attributed to immunosuppressive drugs or infectious organisms such as bacteria, viruses or parasites. Cryptosporidium usually causes self-limited diarrhea in immunocompetent hosts. Although it is estimated that cryptosporidium is involved in about 12% of cases of infectious diarrhea in developing countries and causes approximately 748000 cases each year in the United States, it is still an under recognized and important cause of infectious diarrhea in SOT recipients. It may run a protracted course with severe diarrhea, fluid and electrolyte depletion and potential for organ failure. Although diagnostic methodologies have improved significantly, allowing for fast and accurate identification of the parasite, treatment of the disease is difficult because antiparasitic drugs have modest activity at best. Current management includes fluid and electrolyte replacement, reduction of immunosuppression and single therapy with Nitazoxanide or combination therapy with Nitazoxanide and other drugs. Future drug and vaccine development may add to the currently poor armamentarium to manage the disease. The current review highlights key epidemiological, diagnostic and management issues in the SOT population.

The evolution of respiratory Cryptosporidiosis: evidence for transmission by inhalation

The protozoan parasite Cryptosporidium infects all major vertebrate groups and causes significant diarrhea in humans, with a spectrum of diseases ranging from asymptomatic to life-threatening. Children and immunodeficient individuals are disproportionately affected, especially in developing countries, where cryptosporidiosis contributes substantially to morbidity and mortality in preschool-age children. Despite the enormous disease burden from cryptosporidiosis, no antiprotozoal agent or vaccine exists for effective treatment or prevention. Cryptosporidiosis involving the respiratory tract has been described for avian species and mammals, including immunocompromised humans. Recent evidence indicates that respiratory cryptosporidiosis may occur commonly in immunocompetent children with cryptosporidial diarrhea and unexplained cough. Findings from animal models, human case reports, and a few epidemiological studies suggest that Cryptosporidium may be transmitted via respiratory secretions, in addition to the more recognized fecal-oral route. It is postulated that transmission of Cryptosporidium oocysts may occur by inhalation of aerosolized droplets or by contact with fomites contaminated by coughing. Delineating the role of the respiratory tract in disease transmission may provide necessary evidence to establish further guidelines for prevention of cryptosporidiosis.

Cryptosporidium pathogenicity and virulence

Cryptosporidium is a protozoan parasite of medical and veterinary importance that causes gastroenteritis in a variety of vertebrate hosts. Several studies have reported different degrees of pathogenicity and virulence among Cryptosporidium species and isolates of the same species as well as evidence of variation in host susceptibility to infection. The identification and validation of Cryptosporidium virulence factors have been hindered by the renowned difficulties pertaining to the in vitro culture and genetic manipulation of this parasite. Nevertheless, substantial progress has been made in identifying putative virulence factors for Cryptosporidium. This progress has been accelerated since the publication of the Cryptosporidium parvum and C. hominis genomes, with the characterization of over 25 putative virulence factors identified by using a variety of immunological and molecular techniques and which are proposed to be involved in aspects of host-pathogen interactions from adhesion and locomotion to invasion and proliferation. Progress has also been made in the contribution of host factors that are associated with variations in both the severity and risk of infection. Here we provide a review comprised of the current state of knowledge on Cryptosporidium infectivity, pathogenesis, and transmissibility in light of our contemporary understanding of microbial virulence.

Respiratory cryptosporidiosis in HIV-seronegative children in Uganda: potential for respiratory transmission

BACKGROUND

Respiratory cryptosporidiosis is recognized as a late-stage complication in persons with human immunodeficiency virus (HIV) infection and AIDS. However, respiratory signs and symptoms are common in otherwise healthy children with intestinal cryptosporidiosis, which suggests that respiratory infection may occur in immunocompetent hosts.

METHODS

We recruited children 9-36 months of age who presented with diarrhea to Mulago Hospital in Kampala, Uganda, from November 2007 through January 2009. Children with stool samples positive or negative for Cryptosporidium species were selected for further evaluation, including sputum induction in those with cough or unexplained respiratory signs and collection of saliva and blood specimens. Sputum samples were subjected to comprehensive bacteriologic testing, and both sputum and saliva specimens were tested for Cryptosporidium species by nested polymerase chain reaction.

RESULTS

Of 926 fecal samples screened, 116 (12.5%) were positive for Cryptosporidium. Seventeen (35.4%) of 48 sputum samples tested from children with positive stool samples were positive for Cryptosporidium. Sixteen (94.1%) of the 17 children with confirmed respiratory cryptosporidiosis were HIV seronegative, and 10 (58.8%) of 17 children were not malnourished. None of the 12 sputum specimens from children with negative stool samples tested positive for Cryptosporidium (P = .013, compared with children who tested positive for Cryptosporidium in the stool). Parasite DNA was detected in only 2 (1.9%) of 103 saliva samples (P < .001, compared with sputum samples).

CONCLUSIONS

Respiratory cryptosporidiosis was documented in one-third of HIV-seronegative children who were tested. These novel findings suggest the potential for respiratory transmission of cryptosporidiosis. Trial registration. ClinicalTrials.gov identifier: NCT00507871.

Cryptosporidiosis: biology, pathogenesis and disease

Ninety-five years after discovery and after more than two decades of intense investigations, cryptosporidiosis, in many ways, remains enigmatic. Cryptosporidium infects all four classes of vertebrates and most likely all mammalian species. The speciation of the genus continues to be a challenge to taxonomists, compounded by many factors, including current technical difficulties and the apparent lack of host specificity by most, but not all, isolates and species.

A review of the importance of cryptosporidiosis in farm animals

Cryptosporidium species are coccidian parasites with a large capacity to reproduce and to disseminate. Several species are known to infect farm animals, although the economic importance of cryptosporidiosis is highly host species dependent. This paper reviews the impact of cryptosporidial infections in livestock and poultry. For different farm animals, the Cryptosporidium spp. that occur, as well as their clinical and pathological features, and their interactions with other pathogens, are described. In addition, data concerning the prevalence, the transmission and the epidemiology of the disease are mentioned and a description of the economic losses associated with cryptosporidiosis in each of the hosts is given. Cryptosporidiosis seems to be mainly a problem in neonatal ruminants. Cryptosporidium parvum is considered to be an important agent in the aetiology of the neonatal diarrhoea syndrome of calves, lambs and goat kids, causing considerable direct and indirect economic losses. Avian cryptosporidiosis is an emerging health problem in poultry, associated with respiratory disease in chickens and other Galliformes, and with intestinal disease in turkeys and quails. Because of limited availability of effective drugs, the control of cryptosporidiosis relies mainly on hygienic measures and good management.

Respiratory cryptosporidiosis: case series and review of the literature

Five case of intestinal cryptosporidiosis with pulmonary involvement in patients with AIDS are reported. The diagnosis was based on the recognition of acid-fast oocysts in sputum or aspirated bronchial material and stool specimens. Coughing and excess secretions were present in all cases. Four patients had other associated pulmonary pathogens: two Mycobacterium tuberculosis, one Mycobacterium fortuitum and one Cytomegalovirus + Pneumocystis carinii; all of them had a previous (three cases) or simultaneous (one case) diagnosis of intestinal cryptosporidiosis, presenting with diarrhoea and vomiting. In the fifth patient Cryptosporidium was the only pulmonary pathogen found in a bronchial aspirate, and the onset of diarrhoea was 1 month after respiratory detection. Fifty-seven cases of respiratory cryptosporidiosis have been reported since 1980. In 17 of them, no other pathogen was found. Diarrhoea was present in 77% of the patients, cough in 77%, dyspnea in 58%, expectoration in 54%, fever in 45%, thoracic pain in 33%.

Intestinal and extraintestinal cryptosporidiosis in AIDS patients

In a prospective study in AIDS patients with chronic diarrhea, the overall prevalence of intestinal cryptosporidiosis was 15.6% (43/275). The prevalence was higher in homosexual patients (33.3%) than in intravenous drug abusers (10.6%) (p < 0.001). Extraintestinal infection was present in 30% (13/43) of the patients with known intestinal cryptosporidiosis. Eight of the 13 (61.5%) patients with extraintestinal cryptosporidiosis had Cryptosporidium in the bile and 7 of 13 (16.28%) had it in the sputum. Of the seven patients with Cryptosporidium in the sputum, four had respiratory symptoms and an abnormal chest radiograph, although another pulmonary pathogen was isolated simultaneously. Two other patients from whom Cryptosporidium was the sole respiratory pathogen isolated had no respiratory symptoms and normal chest radiographs. The seventh patient had pulmonary symptoms, interstitial infiltrate on chest radiograph and excessive activity on a pulmonary Gallium scan; Cryptosporidium was the only organism detected in induced sputum and bronchoalveolar lavage specimens. The mean CD4+ lymphocyte count in patients with extraintestinal cryptosporidiosis was 55 cells/mm3.

Cryptosporidiosis

Before 1982, only eight case reports of human cryptosporidiosis and fewer than 30 papers on Cryptosporidium spp. appeared in the biomedical literature. At that time, cryptosporidiosis was thought to be an infrequent infection in animals and rarely an opportunistic infection in humans. The concept of Cryptosporidium spp. as pathogens has changed dramatically within the past 8 years because of improved diagnostic techniques, increased awareness within the biomedical community, and the development of basic research programs in numerous laboratories. Presently, greater than 1,000 publications including over 400 case reports in the biomedical literature address Cryptosporidium spp. and cryptosporidiosis. Cryptosporidium parvum is now thought to be one of the three most common enteropathogens causing diarrheal illness in humans worldwide, especially in developing countries. It is likely that cryptosporidiosis was previously included in the 25 to 35% of diarrheal illness with unknown etiology. Because of the severity and length of diarrheal illness and because no effective therapy has been identified, cryptosporidiosis is one of the most ominous infections associated with AIDS. The role of C. parvum as an enteropathogen is well established; documentation of its role as a cause of hepatobiliary and respiratory diseases is now appearing in the literature. Our present understanding of the natural history, epidemiology, biology, and immunology of Cryptosporidium spp. as well as the clinical features, pathogenicity, and treatment of cryptosporidiosis are reviewed here.

Cryptosporidiosis in children in Gaza

A prospective survey of children admitted with gastro-enteritis to the Nasser Children's Hospital, Gaza revealed that 19% were excreting cryptosporidium, a significantly (p less than 0.001) greater percentage than that (7%) observed in children admitted for other reasons. Detection of cryptosporidium decreased when the change from hot dry to colder wetter weather occurred. Although Salmonella spp were isolated more frequently than cryptosporidium in children with diarrhoea (20% of cases), there was no statistically significant association between excretion of Salmonella spp and gastro-enteritis. A follow-up study of a cohort of the children with cryptosporidiosis indicated that over three-quarters were dehydrated and all were below their expected weight-for-age. There was a statistically significant association between cryptosporidium gastro-enteritis and evidence of respiratory tract infection.

The first finding of Cryptosporidium baileyi in man

Oocysts of cryptosporidia whose morphology and measurements corresponded with those of the species Cryptosporidium baileyi were found in the stool of an immunodeficient patient. In autopsy material, cryptosporidia were found in the esophagus, whole intestine, trachea, larynx, lungs, and gall and urinary bladders. None of the 69 suckling mice inoculated with this isolate developed cryptosporidial infection. Infection was successful in 26 chickens inoculated perorally and 6 others subjected to intratracheal inoculation; it was localized in the duodenum, jejunum, bursa Fabricii, and respiratory tract. From day 12 after infection, oocysts of cryptosporidia were found in the excrement. Human infection with C. baileyi may have occurred due to disruption of the immune system by human immunodeficiency virus (HIV) and to immunosuppressive therapy undertaken after allogeneic kidney transplantation.

Intestinal cryptosporidiosis acquired from a cat

A case of intestinal cryptosporidiosis in an eight-year-old boy is presented. The patient became ill during a visit to a farm where diarrhoea in newborn calves is a recurrent problem. Furthermore, on that farm kittens periodically suffer from diarrhoea and failure to thrive. Oocysts of Cryptosporidium sp. were identified in the stool of the patient, and in the stool of the cat he had contact with. At that time the calves were not infected. The patient's gastrointestinal symptomatology consisted of severe diarrhoea, vomiting, colics and moderate dehydration, and was preceded by coughing.

Symptoms and transmission of intestinal cryptosporidiosis

Cryptosporidium spp are a cause of diarrhoea in toddlers. Symptoms and routes of transmission were investigated in a prospective case-control study in the city and surroundings of Basel, Switzerland. Twenty one (4.6%) out of 455 children with diarrhoea who attended paediatric and general practices from June to September 1988 were positive for cryptosporidium. The mothers of each case, of two controls with diarrhoea of another origin, and of two healthy controls were interviewed with a standardised questionnaire. In comparison with controls with diarrhoea of another origin, respiratory symptoms were significantly more frequent in children with cryptosporidiosis: eight of 19 (42%) compared with five of 38 (13%). In comparison with healthy controls, preceding contact with a person suffering from diarrhoea was associated with the greatest relative risk for cryptosporidiosis, followed by travel in a Mediterranean country. Transient cryptosporidial infection of the respiratory tract may be common in immunocompetent children. In the area investigated person to person transmission may account for most cases.

Contemporary issues: diseases with a food vector

Foodborne disease has become a contemporary issue. Several large, well-publicized outbreaks of foodborne disease have heightened public awareness that harmful microorganisms may be present in food and that chronic as well as acute disease may be caused by foodborne microbes. The field of food microbiology has likewise experienced a resurgence of interest. New tools, such as recombinant deoxyribonucleic acid technology and monoclonal antibody production, used to elucidate microbial virulence factors have facilitated identification of disease-causing microbes once thought to be harmless and demonstrated the complexity of individual virulence mechanisms previously considered to be well understood. Foodborne pathogens are also causing disease via some surprising food vectors, such as chopped, bottled garlic and sauteed onions. In addition to acute gastrointestinal disturbances, certain microorganisms may, through complex interactions with the human immune response, cause chronic diseases that affect several major organ systems. These microbes are serving as models in studies of molecular mimicry and genetic interrelatedness of procaryotes and eucaryotes. Other recently recognized attributes of foodborne microorganisms, such as the heat shock phenomenon and the possible nonculturability of some bacteria, may affect their ability to cause disease in humans. Because foodborne disease is a major cause of morbidity and mortality, the study of these diseases and their causative microorganisms presents a unique challenge to many professionals in the subdisciplines of microbiology, epidemiology, and clinical medicine.

Cryptosporidiosis in perspective

In this review I have examined the vast literature which has accumulated on Cryptosporidium, particularly in the past 3 years, in an attempt to highlight areas in which progress has been made in relation to the organism and the disease, and to indicate areas in which knowledge is still lacking. Since 1982, a global effort by scientists and clinicians has been directed towards determining the nature of the disease in humans and the relative contribution of cryptosporidiosis to gastroenteritis. From published data, the incidence of diarrhoea is 1-5% in most developed countries, and 4-7% in less developed countries, when measured throughout the year and in all age groups. The frequency of cryptosporidiosis is highest in children aged between 6 months and 3 years, and in particular locations (e.g., day-care centres) and at particular times of the year. Although susceptibility to infection is life-long, one suspects that the lower prevalence among older children and adults is due to immunity acquired from frequent exposure. Other important factors contributing to higher prevalence are the season--it is more frequent in a wet, warm climate--association with travel to particular destinations, poor hygiene, intimate contact with certain animals, and congregation of large numbers of young previously unexposed children in day-care centres. The association between cryptosporidiosis and giardiasis presumably results from the existence of a common source of infection. The immune status of the host appears to be a major determinant of whether the infection is self-limiting or persistent. It is clear that both branches of the immune system are required for complete recovery, since T-lymphocyte dysfunction or hypogammaglobulinaemia can both lead to persistent illness. Chronic diarrhoea and malabsorption attributed to cryptosporidiosis also occur in the absence of evidence of immune defect. The importance of respiratory tract infection in humans, other than in the terminal stages of chronic illness, requires investigation. The infection has now been identified in all classes of vertebrates; it has been observed in all domestic animals including pets, and a wide range of wildlife including birds. Cryptosporidiosis seems to cause diarrhoea in young ruminants, less frequently in pets. In birds the parasite has been observed in the gastrointestinal tract, without ill effect, and in the respiratory tract, in which clinical symptoms of variable severity have been described. The mucosal response of the gastrointestinal tract to infection appears to vary among mammals and may be the key to the variable clinical manifestations observed.(ABSTRACT TRUNCATED AT 400 WORDS)

Human cryptosporidiosis

Cryptosporidium is an enteric coccidial protozoan recognized in humans in 1976. Since its manifestation as an acquired immunodeficiency syndrome (AIDS)-related infection, new diagnostic techniques have improved recognition of Cryptosporidium oocysts, making apparent its true prevalence in human populations. Cryptosporidium represents 5 to 15% of all enteric pathogens in children in warm climate countries. It is responsible for both endemic and epidemic disease. Day-care center spread is well known, and evidence is strong for person-to-person transmission. The spectrum of illness caused by Cryptosporidium is broad, and while self-limited in immunocompetent individuals, gastrointestinal symptoms can be severe. Asymptomatic infection has been described in population surveys and outbreak investigations. Severe dehydration with malabsorption and failure-to-thrive in children from developing countries has been attributed to this organism. Intractable, incurable diarrhea can be fetal in immunosuppressed adults. Cryptosporidiosis in human immunodeficiency virus-infected individuals is declining in frequency in New York City, possibly reflecting changing sexual behaviors and comparatively low infectivity. No effective treatment for Cryptosporidium has been documented, but clinical trials are in progress.

Cryptosporidial diarrhoea in children

By auramine and modified Ziehl-Neelsen staining, cryptosporidial oocysts were found in the stools of 31 (1.36%) out of 2,367 patients with diarrhoea. All specimens were also tested for Salmonella, Shigella, Campylobacter, Yersinia, and Rotavirus. Among these patients, 432 were children and 24 (5.5%) of them were positive for cryptosporidia. All children infected with cryptosporidia were immunocompetent. Watery diarrhoea, vomiting and abdominal pain were the most frequent symptoms. The survey showed that in patients with gastroenteritis, cryptosporidial oocysts were found more commonly in the stools of children than in those of adults, and the prevalence of infection was the highest in August and September (16 cases). The epidemiological aspects and clinical significance are discussed.

Two year study of cryptosporidium infection

During a two year period 48 children admitted to hospitals in the Blackburn district were found to have cryptosporidium in stool samples. Cryptosporidium accounted for 6% of the 742 cases of childhood gastroenteritis, being as common as campylobacter. Altogether, 89% of children with cryptosporidiosis had diarrhoea, which was usually offensive and watery, and 80% vomited, the mean duration of both symptoms being six days. A substantial proportion were moderately ill with dehydration and persistent vomiting. Over half of all cases were aged 2 years or more and 37% were over 5 years. Most of the ill children were over 2 years, in contrast with other cases of gastroenteritis. Eight children were less than the 3rd centile for weight and three of these were investigated for failure to thrive. Only 6% of cases occurred in Asian children, but Asians accounted for 32% of all admissions with gastroenteritis and 59% of admissions with shigella. This unexpected ethnic difference may be due to limited contact with animals among Asians or to differences in diet.

Cryptosporidium spp. and cryptosporidiosis

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