Isosporosis and unizoite tissue cysts in patients with acquired immunodeficiency syndrome

Cystoisospora belli, liver disease and hypothesis on the life cycle

Cystoisospora belli causes chronic diarrhoea, acalculous cholecystitis, cholangiopathy and disseminated cystoisosporosis in patients with AIDS. Clinical manifestations and histological stages during C. belli infection in a patient with AIDS and liver disease were described. It was possible to identify sporozoite-like structures in the villus epithelium of the duodenum, close to the vascularization that underlies the basal membrane and unizoite tissue cysts near to the vascularization in the lamina propria. Unizoite tissue cysts were found inside of sinusoids in the liver communicating with the central vein and with a bile canaliculus and portal spaces. Based on these findings a hypothesis on C. belli life cycle could consider that the route of migration of unizoite tissue cysts up the liver is via the portal blood. The unizoite tissue cysts located in hepatic portal vein could migrated via sinusoid to central vein and general circulation through the venous system. The unizoite tissue cysts could also return via bile canaliculus to bile duct to portal triad. This hypothesis allows to understand the presence of unizoite stages in blood, the pathway by which the bile ducts become infected and unizoites in the liver being able to behave like hypnozoites that favour relapses and treatment failures.

Cystoisospora belli infections in humans: the past 100 years

Cystoisospora belli is a coccidian parasite of humans, with a direct fecal-oral transmission cycle. It is globally distributed, but mainly found in tropical and subtropical areas. Many cases of C. belli infections have been reported in patients with HIV, and in patients undergoing immunosuppressive therapy for organ transplants or those treated for tumours worldwide. Unsporulated or partially sporulated oocysts of C. belli are excreted in feces. When sporulated oocysts in contaminated water or food are ingested, asexual and sexual stages of C. belli are confined to the epithelium of intestines, bile ducts and gallbladder. Monozoic tissue cysts are present in extra-intestinal organs (lamina propria of the small and large intestine, lymph nodes, spleen, and liver) of immunosuppressed humans. However, a paratenic host has not been demonstrated. Cystoisospora belli infections can be persistent, lasting for months, and relapses are common; the mechanism of relapse is unknown. Recently, the endogenous stages of C. belli were re-examined and attention was drawn to cases of misidentification of non-protozoal structures in the gallbladder of patients as C. belli. Here, we review all aspects of the biology of C. belli, including morphology, endogenous stages, prevalence, epidemiology, symptoms, diagnosis and control.

Endogenous development of Cystoisospora belli in intestinal and biliary epithelium of humans

Cystoisospora(Isospora)belliis a coccidian parasite of humans. It can cause serious digestive disorders involving infection of intestines, biliary tract and gallbladder, especially in those with depressed immunity. It has a direct fecal–oral transmission cycle. After ingestion of sporulated oocysts, the parasite multiplies asexually and sexually within host epithelial cells, resulting in unsporulated oocysts that are excreted in feces. The details of asexual and sexual stages are not known and certain inclusions in epithelial cells in biopsy samples have been erroneously identified recently asC. belli. Here, we provide details of developmental stages ofC. belliin two patients, in duodenal biopsy of one and biliary epithelium of the other. Immature and mature asexual stages (schizonts/meronts) were seen in epithelial cells. The merozoites were seen singly, in pairs and in groups in single parasitophorous vacuole (pv) in host cytoplasm. Immature and mature meronts were seen together in the same pv; up to eight nuclei were seen in meronts that retained elongated crescent shape; round multinucleated schizonts, seen in other coccidians, were not found. Meronts were up to 25µm long and contained up to ten merozoites that were 8–11µm long. The merozoites and meronts contained PAS-positive granules. Microgamonts (male) contained up to 30 nuclei that were arranged at the periphery and had condensed chromatin; 1–3 PAS-positive, eosinophilic, residual bodies were left when microgametes were formed. The microgametes were 4µm long and PAS-negative. All stages of macrogamonts, including oocysts were PAS-positive. The detailed description of the life cycle stages ofC. bellireported here should facilitate in histopathologic diagnosis of this parasite.

Cystoisospora belli Gallbladder Infection in a Liver Transplant Donor

Introduction

Cystoisospora belli (previously Isospora belli) is a parasitic protozoan of the human gastrointestinal system. It rarely causes symptoms in immunocompetent hosts but can cause severe diarrhea in immunocompromised patients, with a rate of recurrence and risk of dissemination. Gallbladder infections are however rare. The treatment of choice for symptomatic patients is a 7–10-day course of trimethoprim-sulfamethoxazole.

Case

In this case, we report on an incidental finding of Cystoisospora belli organisms in the donor gallbladder following a transplant cholecystectomy. There was no report of symptoms in the donor. The recipient was treated with a course of trimethoprim-sulfamethoxazole, without evidence of cystoisosporiasis. Given the risk of recurrence in immunocompromised hosts, the patient will continue to be monitored for reactivation in the future.

Conclusion

Despite advances in transplant protocols and screening, disease transmission from the donor to recipient still occurs in about 0.2% of all organ transplants. With the increased use of organs from drug overdose victims and other high-risk donors, practitioners (including pathologists, hepatologists, and surgeons) must maintain a high index of suspicion for such potentially harmful organisms.

First detection of Cryptosporidium DNA in blood and cerebrospinal fluid of HIV-infected patients

Human cryptosporidiosis is an intestinal infection caused by different species belonging to the genus Cryptosporidium in both immunocompetent and immunocompromised individuals. The life cycle of Cryptosporidium sp. when affecting the digestive system is well known but the infection of other organs is less studied. Molecular methods are necessary for species and subtypes identification. The goal of this work is to propose a new approach that contributes to the diagnosis of the extra-intestinal dissemination process of Cryptosporidium infection. Cryptosporidium sp. was detected in stool and biopsy samples of two HIV-infected patients. DNA was extracted from feces, biopsy specimens, blood, and cerebrospinal fluid (CSF). All samples were analyzed by nested PCR-RFLP of the 18S rDNA, real-time PCR, and gp60 subtyping. Cryptosporidium DNA was detected in stool and tissue samples and it was also present in blood and CSF samples. Both cases were characterized as Cryptosporidium hominis subtype IeA11G3T3. This is the first report that demonstrates the presence of Cryptosporidium DNA in blood and CSF of HIV-infected patients.

Molecular testing for clinical diagnosis and epidemiological investigations of intestinal parasitic infections

Over the past few decades, nucleic acid-based methods have been developed for the diagnosis of intestinal parasitic infections. Advantages of nucleic acid-based methods are numerous; typically, these include increased sensitivity and specificity and simpler standardization of diagnostic procedures. DNA samples can also be stored and used for genetic characterization and molecular typing, providing a valuable tool for surveys and surveillance studies. A variety of technologies have been applied, and some specific and general pitfalls and limitations have been identified. This review provides an overview of the multitude of methods that have been reported for the detection of intestinal parasites and offers some guidance in applying these methods in the clinical laboratory and in epidemiological studies.

Ultrastructural aspects of Cystoisospora belli (syn. Isospora belli) in continuous cell lines

Cystoisospora belli is an opportunistic protozoan that causes human cystoisosporiasis, an infection characterized by diarrhea, steatorrhea, abdominal pain, fever, and weight loss. The lack of animal models susceptible to C. belli, and the difficulty in obtaining clinical samples with fair amounts of oocysts have limited the research pertaining to the basic biology of this parasite. This study aimed to describe the ultrastructure of endogenous stages of C. belli in Monkey Rhesus Kidney Cells (MK2) and Human Ileocecal Adenocarcinoma cells (HCT-8). Zoites of C. belli exhibited typical morphological features of coccidia, which included a trilaminar pellicle, an apical complex formed by a conoid, polar rings, rhoptries, and micronemes, in addition to dense granules and the endoplasmic reticulum. No crystalloid body was observed but various lipid and amylopectin granules were usually present in the cytoplasm of zoites. We observed a tendency of the endoplasmic reticulum of the host cell to be located near the parasitophorous vacuole membrane. Merozoites were formed by endodyogeny and during replication, the apical complex of the mother cell remained intact. The formation of gametes or oocysts was not observed. The ultrastructural findings of C. belli are further evidence of its proximity to Sarcocystidae family members and corroborate their reclassification as Cystoisospora spp.

Cystoisospora canis (Apicomplexa: Sarcocystidae): development of monozoic tissue cysts in human cells, demonstration of egress of zoites from tissue cysts, and demonstration of repeat monozoic tissue cyst formation by zoites

Sporozoites of Cystoisospora canis penetrated and developed to monozoic tissue cysts in 4 human, 1 monkey, 1 bovine and 2 canine cell lines. No asexual division was documented although multiple infection of a single cell was observed. Examination of cultures using transmission electron microscopy demonstrated that they were monozoic tissue cysts and contained a single sporozoite. The appearance of monozoic tissue cysts in all cell lines was similar but the parasitophorous vacuole surrounding some sporozoites in DH82 dog macrophages was swollen. Monozoic tissue cysts were observed for up to 127 days in human pigmented retinal epithelial cells. Treatment of cell cultures containing monozoic tissue cysts with 0.75 sodium taurocholic acid and 0.25% trypsin stimulated egress of zoites (former sporozoites) from tissue cysts. Zoites collected from monozoic tissue cysts were able to penetrate and develop to monozoic tissue cysts in new host cells. Monozoic tissue cysts survived exposure to acid pepsin solution indicating that they would be orally infectious. The tissue cyst wall surrounding zoites did not autofluoresce as did oocyst and sporocyst walls exposed to UV light. We believe that C. canis can be used as a model system to study extra-intestinal monozoic tissue cysts stages of Cystoisospora belli of humans.

Molecular characterization of Cystoisospora belli and unizoite tissue cyst in patients with Acquired Immunodeficiency Syndrome

Cystoisospora belli is a coccidian protozoan that can cause chronic diarrhoea, acalculous cholecystitis and cholangiopathy in AIDS patients. We applied molecular methods to identify Cystoisospora at species level in AIDS patients presenting with and without the presence of unizoites in lamina propria. Coprological and histological analyses were performed in stool and/or biopsy samples from 8 Cystoisospora-infected patients. DNA from the same samples was used to amplify 2 fragments of the SSU-rRNA gene and the ITS-1 region. Sequencing of the resulting amplicons identified C. belli infections in all cases, independent of the presence or absence of unizoite tissue cysts. Further work should be considered in order to find molecular targets related to strain variations in C. belli.

Development and ultrastructure of Cystoisospora canis Nemeséri, 1959 (syn, Isospora canis) monozoic cysts in two noncanine cell lines

Cystoisospora canis is a coccidial parasite of the intestinal tract that can cause severe disease in dogs. Clinical signs include watery diarrhea, vomiting, fever, and weight loss. Extraintestinal stages of Cystoisospora spp. have been demonstrated in the mesenteric lymph nodes of paratenic hosts. Information on the biology of extraintestinal stages of canine Cystoisospora species is limited. The current study examined the development of C. canis in 2 noncanine cell lines and the ultrastructure of the monozoic cysts that formed. Monolayers of bovine turbinate cells and African green monkey kidney cells were grown on coverslips and inoculated with excysted C. canis sporozoites. Coverslips were collected on various days and fixed and stained for light microscopy (LM) or transmission electron microscopy (TEM). A single, centrally located, slightly crescent-shaped sporozoite surrounded by a thick cyst wall within a parasitophorous vacuole was observed with the use of LM and TEM. No division and no multinucleated stages were observed with either LM or TEM. With TEM, typical organelles of sporozoites were observed, such as rhoptries, dense granules, a crystalloid body, polysaccharide granules, and a conoid. The structure and ultrastructure of C. canis monozoic cysts produced in vitro are similar to extraintestinal cysts of other Cystoisospora species in experimentally infected animals and those of Cystoisospora belli observed in immunocompromised humans. This is the first study that fully demonstrates in vitro the development of what structurally resemble extraintestinal cysts of a Cystoisospora spp.

Isospora belli Infection: Observation of Unicellular Cysts in Mesenteric Lymphoid Tissues of a Brazilian Patient with AIDS and Animal Inoculation

We describe the finding of unizoic cysts of Isospora belli in lymphoid tissues of a Brazilian patient with AIDS, and discuss the possibilities of their drug resistance, they being the cause of relapses, and of being an indication for the existence of intermediary or paratenic animal hosts.

[Extraintestinal finding of Isospora belli unizoic cysts in a patient with AIDS: case report]

This report describes the presence of Isospora belli unizoic cysts in mesenteric lymph nodes and of gametocytes in the gallbladder epitelium of a 26 year-old Brazilian male patient with Acquired Immune Deficiency Syndrome. This patient had received treatment for several times with sulfamethoxazole-trimethoprim. It is discussed the significance of I. belli tissue cysts as possible foci of resistance of the parasite and their association with the infection relapse even post-treatment with anticoccidian medication.