Cryptosporidiosis: multiattribute evaluation of six diagnostic methods

Comparison of current methods used to detect Cryptosporidium oocysts in stools

In this review all of the methods that are currently in use for the investigation of Cryptosporidium in stool material are highlighted and critically discussed. It appears that more qualifications and background knowledge in this field regarding the diagnosis of the Cryptosporidium parasite is required. Furthermore, there is no standardization for the protocols that are commonly used to either detect oocysts in faeces or to diagnose the Cryptosporidium infection. It is therefore necessary to initiate further education and research that will assist in improving the accuracy of the diagnosis of Cryptosporidium oocysts in the faecal micro-cosmos. Where ambient concentrations of oocysts are low in stool material, detection becomes a formidable task. Procedures for ring tests and the standardization of multi-laboratory testing are recommended. It is also necessary to enhance the routine surveillance capacity of cryptosporidiosis and to improve the safety against it, considering the fact that this disease is under diagnosed and under reported. This review is intended to stimulate research that could lead to future improvements and further developments in monitoring the diagnostic methodologies that will assist in harmonizing Cryptosporidium oocysts in stool diagnosis.

Risk factors and infection due to Cryptosporidium spp. in dogs and cats in southern Rio Grande do Sul

Abstract This study investigated the frequency of oocysts of Cryptosporidium spp. in feces from dogs and cats in five municipalities in the southern region of the state of Rio Grande do Sul. The risk factors associated with infection were also investigated. Feces samples from 110 dogs and 18 cats were stained using the auramine method. At the time of feces sampling, a questionnaire with semi-open-ended questions was applied to the animal guardians and all data obtained underwent statistical analysis. The real frequency of oocysts of Cryptosporidium spp. was 24.63% (27 dogs and two cats). Only four samples of dog feces were diarrheic and no presence of oocysts was observed in any of them. Variables that represented risk factors for infection were: homemade food, untreated water, circulation of animals on grassy terrain and living in the same environment as other animals (cattle). The results made it possible to inferring that within the population studied, the frequency of parasitism due to Cryptosporidium spp. in dogs was relevant and emphasize the asymptomatic nature of this infection. The adopting control measures are highlighted, particularly in relation to variables that represent risk factors for this infection.

Laboratory diagnosis of cryptosporidiosis

Cryptosporidiosis is a major etiology of persistent and chronic diarrhea in children and immunocompromised patients. In addition, it is also one of the important pathogens causing zoonotic or waterborne outbreaks. A number of conventional and molecular tests are available, but each test is riddled with few limitations. Further, there is a need to develop point of care tests and multiplexed tests for simultaneous detection of multiple pathogens.

Liver fluke (Fasciola hepatica) naturally infecting introduced European brown hare (Lepus europaeus) in northern Patagonia: phenotype, prevalence and potential risk

Fascioliasis has recently been included in the WHO list of Neglected Zoonotic Diseases. Besides being a major veterinary health problem, fascioliasis has large underdeveloping effects on the human communities affected. Though scarcely considered in fascioliasis epidemiology, it is well recognized that both native and introduced wildlife species may play a significant role as reservoirs of the disease. The objectives are to study the morphological characteristics of Fasciola hepatica adults and eggs in a population of Lepus europaeus, to assess liver fluke prevalence, and to analyze the potential reservoir role of the European brown hare in northern Patagonia, Argentina, where fascioliasis is endemic. Measures of F. hepatica found in L. europaeus from northern Patagonia demonstrate that the liver fluke is able to fully develop in wild hares and to shed normal eggs through their faeces. Egg shedding to the environment is close to the lower limit obtained for pigs, a domestic animal whose epidemiological importance in endemic areas has already been highlighted. The former, combined with the high prevalence found (14.28%), suggest an even more important role in the transmission cycle than previously considered. The results obtained do not only remark the extraordinary plasticity and adaptability of this trematode species to different host species, but also highlight the role of the European brown hare, and other NIS, as reservoirs capable for parasite spillback to domestic and native cycle, representing a potentially important, but hitherto neglected, cause of disease emergence.

Evaluation of ImmunoCard STAT test and ELISA versus light microscopy in diagnosis of giardiasis and cryptosporidiosis

This study was designed to evaluate ImmunoCard STAT Cryptosporidium/Giardia rapid assay and ELISA copro-antigen assays in detecting Giardia lamblia and Cryptosporidium species in fecal samples in comparison to microscopy. Both ImmunoCard STAT and ELISA assays were evaluated with 90 stool specimens that were tested by the standard ova and parasite examination including staining with both iron hematoxylin stain and modified Ziehl Neelson stains. Counting the number of Giardia cysts and Cryptosporidia oocysts in the positive stool samples was done in order to quantify the lower limit of parasite number that was able to be detected by all included assays. Both ImmunoCard STAT and ELISA assays were compared on the basis of the attributes which are number of detected cases, sensitivity, specificity, time required for the procedure and screening, ease of performance and interpretation, and cost. Microscopic examination revealed that 13.3% of the samples were positive for Giardia and 2.2% for Cryptosporidium. By ELISA, 16.7% of the samples were infected with Giardia and 3.3% with Cryptosporidium, while by ImmunoCard STAT, 17.8 and 4.45% of the samples were positive for Giardia and Cryptosporidium, respectively. There is no statistically significant difference between the results of ELISA and ImmunoCard STAT assays. The lowest concentration detected in the stool samples was 10.50 ± 1.05 Giardia cysts and 2.83 ± 1.72 Cryptosporidium oocysts. The ImmunoCard STAT was extremely easy to read, thus requiring much less time, but its cost was much higher than ELISA. We concluded that although the overall ranking of both assays was high, the ImmunoCard STAT rapid assay was a more desirable test despite its higher cost.

Molecular copro-prevalence of Cryptosporidium in Egyptian children and evaluation of three diagnostic methods

OBJECTIVE

To determine molecular prevalence of Cryptosporidium in a cohort of Egyptian children and compare three diagnostic tests.

METHODS

Stool samples from children with diarrhea (n=150) and from apparently healthy children (n=100) were examined for Cryptosporidium using microscopy, enzyme linked immuosorbant assay (ELISA) and nested polymerase chain reaction (nPCR).

RESULTS

nPCR detected Cryptosporidium in 22.4% of children. Acid-fast stain and ELISA showed false negativity but 100% specificity with nPCR as gold standard.

CONCLUSION

Cryptosporidium is a common cause of diarrhea in children in Egypt.

Microscopic identification of possible Clonorchis/Opisthorchis infection in two Ghanaian women with undiagnosed abdominal discomfort: two case reports

INTRODUCTION

The impact of foodborne trematode infections is gaining recognition worldwide. Clonorchiasis and opisthorchiasis are some of the most neglected tropical foodborne diseases that pose a significant threat to human health. Persistent or chronic infection of Clonorchis/Opisthorchis often leads to hepatobiliary diseases including cholangitis, cholelithiasis, cholecystitis, pancreatitis, hepatic fibrosis, cholangiocarcinoma and liver cancer. Two cases of Clonorchis/Opisthorchis infection in humans in the Central Region of Ghana are reported.

CASE PRESENTATION

Eggs suspected to be from Clonorchis sinensis or Opisthorchis species were detected in the stools of a 29-year-old Ghanaian woman and an 18-year-old Ghanaian woman in two clinics in the Central Region of Ghana. The diagnosis was based on clinical symptoms as well as detection of the eggs of the trematode in the faeces of the patients using light microscopy after staining with Giemsa or Ziehl-Neelsen stains.

CONCLUSIONS

To the best of our knowledge these are the first documented cases of Clonorchis sinensis or Opisthorchis species infection in Ghana. The detection of this infection in these patients in Ghana should be of concern to clinicians because the infection can be easily misdiagnosed since the accompanying clinical symptoms are malaria-like. Consideration should therefore be given to Clonorchis sinensis and Opisthorchis species when diagnosing patients presenting with malaria-like symptoms.

Laboratory utility of coproscopy, copro immunoassays and copro nPCR assay targeting Hsp90 gene for detection of Cryptosporidium in children, Cairo, Egypt

Cryptosporidium is a significant cause of diarrhea worldwide especially in children. Infection may end fatally in immunocompromised patients. Multi-attribute analysis was used to determine the lab utility of 4 diagnostics; coproscopy of AF stained fecal smear, fecal immunoassays by ICT and ELISA and copro-nPCR assay targeting Hsp90 gene, for detection of Cryptosporidium in stool of 250 Egyptian children (150 diarrheic and 100 non-diarrhaeic children). Also, to determine Cryptosporidium molecular prevalence. Cryptosporidium was an important enteric pathogen among both diarrheic and non-diarrheic study children with a clearly high prevalence of 16.4 % (n = 41). Conventional methods had perfect specificity (100 %) but couldn`t be used as a consistent single detection method due to their lowered sensitivities. Multi-attribute analysis ranked nPCR the highest test for lab use. Being the test with the best diagnostic yield, nPCR is a reliable diagnostic test and is going to replace conventional methods for reliable detection of Cryptosporidium.

Several staining techniques to enhance the visibility of Acanthamoeba cysts

Acanthamoeba is one of the most common free-living amoebae. It is widespread in the environment and can infect humans causing keratitis. Delayed diagnosis or misdiagnosis leads to extensive corneal inflammation and profound visual loss. Therefore, accurate and rapid diagnosis of Acanthamoeba keratitis is essential for successful treatment and good prognosis. This study was designed to use different staining techniques to facilitate the identification of Acanthamoeba cysts. Acanthamoeba cysts were isolated by cultivation of either corneal scraping specimens or tap water samples onto non-nutrient agar plates seeded with Escherichia coli. Subcultures were done from positive cultures until unique cysts were isolated. Acanthamoeba cysts were stained temporarily using iodine, eosin, methylene blue, and calcofluor white (CFW) stains and as permanent slides after processing for mounting using modified trichrome, Gimenez and Giemsa staining. These stains were compared on the basis of staining quality including clarity of morphological details, differentiation between cytoplasm and nuclei, color and contrast, and also other characteristics of the staining techniques, including ease of handling, time taken for the procedure, and cost effectiveness. The cysts of Acanthamoeba were recognized in the form of double-walled cysts: the outer wall (ectocyst) that was being differentiated from the variably stained surrounding background and the inner wall (endocyst) that was sometimes stellated, polygonal, round, or oval and visualized as separate from the spherical, sometimes irregular, outline of the ectocyst. Regarding the temporary stains, it was found that they were efficient for visualizing the morphological details of Acanthamoeba cysts. In CFW staining, Acanthamoeba cysts appeared as bluish-white or turquoise oval halos although the internal detail was not evident. On the other hand, the results of permanent-stained slides showed the most consistent stain for identification of Acanthamoeba cysts was modified trichrome followed by Gimenez stain and lastly Giemsa stain that gave poor visibility of Acanthamoeba cysts due to the intense staining background and monochrome staining of parasite. In the present study, multi-attribute ranking of the used staining techniques showed the highest rank for iodine stain (92 %) followed by eosin stain (84 %), Gimenez stain (76 %), methylene blue (72 %), CFW (64 %), modified trichrome (56 %), and the least was Giemsa stain (44 %). In conclusion, the staining techniques enhance the overall visibility of Acanthamoeba cysts.

R. Intestinal Cryptosporidiosis and the Profile of the CD4 Counts in a Cohort of HIV Infected Patients

BACKGROUND

Cryptosporidium is an infectious enteric pathogen which is capable of causing life-threatening illnesses in immunocompromised patients.

AIMS

This prospective study was planned to know the frequency of intestinal cryptosporidiosis in HIV infected patients and its correlation with their immune status. Also, the conventional diagnostic methods were compared with the copro-antigen detection test by using Enzyme Linked Immuno Sorbent Assay (ELISA).

SETTINGS AND DESIGN

This was a prospective cohort study.

METHODS AND MATERIAL

Three consecutive stool samples which were collected from 90 HIV seropositive patients and 50 seronegative controls were screened for cryptosporidiosis by wet mount, direct modified ZN (Ziehl Neelsen) staining, modified ZN staining with formol ether concentration and copro-antigen detection by ELISA. Their immune statuses were measured by CD4 + cell counting. Statistical Analytical Tests which were Used: Odds ratio, Chi square test, Fisher extract test.

RESULTS

Cryptosporidiosis was detected in 15 HIV seropositive cases. 13 cases had CD4 cell counts of < 100 cells/ μL. The formol ether concentration technique resulted in an increased number of oocysts/oil immersion field in 8 cases. ELISA was positive in 2 cases which were shown to be negative by modified ZN staining. All the controls were negative for cryptosporidium.

CONCLUSIONS

Cryptosporidiosis is an opportunistic infection in HIV infected people who present with diarrhoea. The wet mount technique, though it is simple and inexpensive, is insensitive for the detection of cryptosporidium. The conventional modified ZN staining and the modified ZN staining with concentration have a sensitivity and a specificity of 85.71% and 98.84% respectively. The copro antigen detection by ELISA which has a greater sensitivity and specificity, is a useful tool in epidemiological studies.

Comparison of nested PCR and microscopy for the detection of cryptosporidiosis in bovine calves

The comparative efficacies of different conventional parasitological methods and nested PCR for diagnosis of bovine cryptosporidiosis in faecal samples were evaluated. Among the 100 samples collected from calves in and around Ludhiana Direct faecal smear staining technique revealed 25.0 % positivity for the oocysts of Cryptosporidium spp. with sensitivity and specificity of 68.12 and 92.98 %, respectively. Zinc sulphate solution floatation and saturated sugar solution floatation staining techniques showed sensitivity and specificity of 83.92 and 96.36; 81.03 and 98.14 %, respectively. Products of the primary PCR of Cryptosporidium spp. directed against small subunit (18S) ribosomal RNA when employed as template in nested PCR produced the amplicons of desired size (834 bp) in 47.0 % of the samples. Amplification of 834 bp fragment was also observed in positive control, while no amplification was observed in negative control. Results indicated PCR assays as highly sensitive and specific techniques for the screening of the samples for Cryptosporidium spp. but in developing countries and under field conditions where limited resources do not allow the application of PCR assays, concentration staining methods are recommended.

Enteric protozoa in the developed world: a public health perspective

Several enteric protozoa cause severe morbidity and mortality in both humans and animals worldwide. In developed settings, enteric protozoa are often ignored as a cause of diarrheal illness due to better hygiene conditions, and as such, very little effort is used toward laboratory diagnosis. Although these protozoa contribute to the high burden of infectious diseases, estimates of their true prevalence are sometimes affected by the lack of sensitive diagnostic techniques to detect them in clinical and environmental specimens. Despite recent advances in the epidemiology, molecular biology, and treatment of protozoan illnesses, gaps in knowledge still exist, requiring further research. There is evidence that climate-related changes will contribute to their burden due to displacement of ecosystems and human and animal populations, increases in atmospheric temperature, flooding and other environmental conditions suitable for transmission, and the need for the reuse of alternative water sources to meet growing population needs. This review discusses the common enteric protozoa from a public health perspective, highlighting their epidemiology, modes of transmission, prevention, and control. It also discusses the potential impact of climate changes on their epidemiology and the issues surrounding waterborne transmission and suggests a multidisciplinary approach to their prevention and control.

Comparison of three DNA extraction methods for feed products and four amplification methods for the 5'-junction fragment of Roundup Ready soybean

Three methods of DNA extraction from feed products and four detection methods for the 5'-junction fragment of genetically modified (GM) Roundup Ready soybean (RRS) were compared and evaluated. The DNA extraction methods, including cetyltrimethylammonium bromide (CTAB), sodium dodecyl sulfate (SDS), and guanidine hydrochloride (Kit), were assessed for their yields and purity of DNA, extraction time, and reagent cost. The DNA yields of CTAB, SDS, and Kit were 52-694, 164-1750 and 23-105 ng/mg sample, and their extraction time was 2.5-3, 2-2.5, and 1.5-2 h with reagent cost about US dollar 0.24, 0.13, and 1.9 per extraction, respectively. The SDS method was generally well suited to all kinds of feed matrices tested. The limits of detection for the four amplification protocols, including loop-mediated isothermal amplification (LAMP), hyperbranched rolling circle amplification (HRCA), conventional polymerase chain reaction (PCR), and real-time PCR, were 48.5, 4.85, 485, and 9 copies of the pTLH10 plasmid, respectively. The ranked results of the four detection methods were based on multiattribute utility theory as follows (from best to worse): HRCA, LAMP, PCR, and real-time PCR. This comparative evaluation was specifically useful for selection of a highly efficient DNA extraction or amplification method for detecting different GM ingredients.

Environmental and physiological factors contributing to outbreaks of cryptosporidium in Coquerel's sifaka (Propithecus coquereli) at the Duke Lemur Center: 1999-2007

This population-based, retrospective study examined the susceptibility of a prosimian primate, Coquerel's sifaka (Propithecus coquereli), to Cryptosporidium spp. over a 9-yr period from 1999 to 2007 at the Duke Lemur Center (DLC) located in Durham, North Carolina. The investigation examined potential epidemiologic risk factors that could be correlated to infectious outbreaks at the center, such as prevalence, signalment (species, age, and sex), seasonality of occurrence, recurrence rate, family lineage, parturition, clinical signs, and concurrent diseases or health conditions. Findings included Propithecus spp. being the only lemur species at the DLC showing clinical signs of infection, with age being an important factor in susceptibility, and showing a strong correlation between temperature and seasonality with shedding of Cryptosporidium oocysts. These findings present new information regarding cryptosporidiosis in captive prosimians.

Use of multiattribute utility theory for formulary management in a health system

PURPOSE

The application, utility, and flexibility of the multiattribute utility theory (MAUT) when used as a formulary decision methodology in a Korean medical center were evaluated.

METHODS

A drug analysis model using MAUT consisting of 10 steps was designed for two drug classes of dihydropyridine calcium channel blockers (CCBs) and angiotensin II receptor blockers (ARBs). These two drug classes contain the most diverse agents among cardiovascular drugs on Samsung Medical Center's drug formulary. The attributes identified for inclusion in the drug analysis model were effectiveness, safety, patient convenience, and cost, with relative weights of 50%, 30%, 10%, and 10%, respectively. The factors were incorporated into the model to quantify the contribution of each attribute. For each factor, a utility scale of 0-100 was established, and the total utility score for each alternative was calculated. An attempt was made to make the model adaptable to changing health care and regulatory circumstances.

RESULTS

The analysis revealed amlodipine besylate to be an alternative agent, with the highest total utility score among the dihydropyridine CCBs, while barnidipine hydrochloride had the lowest score. For ARBs, losartan potassium had the greatest total utility score, while olmesartan medoxomil had the lowest.

CONCLUSION

A drug analysis model based on the MAUT was successfully developed and used in making formulary decisions for dihydropyridine CCBs and ARBs for a Korean health system. The model incorporates sufficient utility and flexibility of a drug's attributes and can be used as an alternative decision-making tool for formulary management in health systems.

A multiattribute utility evaluation of different methods for the detection of enteric protozoa causing diarrhea in AIDS patients

Background

Enteric protozoa and sporozoa have emerged as important opportunistic parasites and can cause fatal infections in AIDS patients. The line of treatment being different for them necessitates an accurate and prompt identification of these to avoid empirical treatment. In this study which is the first of its kind from India we did a comprehensive evaluation of different techniques, comparing them on the basis of the attributes like yield, cost, time taken, expertise and infrastructure. For the first time combination of Calcoflour White and DAPI, a nuclear stain, were used to identify Microsporidia spp. Thus, a diagnostic protocol was devised for rapid, sensitive and cost effective identification of the opportunistic enteric protozoa.

Results

The organisms isolated from the stool samples of the cases (450 HIV patients) were predominantly Cryptosporidium spp., Microsporidia spp. and Cyclospora spp. Interestingly, the control group (200 relatives of the patients who were HIV negative) showed a high incidence (21%) of Cryptosporidium spp. We found a significant increase in the sensitivity of microscopy in detecting Cryptosporidium spp. and Cyclospora spp. after formol ether concentration. Kinyoun's staining was better compared to Modified safranin staining for Cryptosporidium spp. identification. Although ELISA had a sensitivity of 93.25% and specificity of 97% for Cryptosporidium spp. detection, we ranked Kinyoun's staining better than ELISA because it is not affordable to most of our patients. For detecting Cyclospora cayetanensis, autoflourescence was the easiest and most cost effective method followed by Safranin technique. Combination of Calcoflour White stain and DAPI gave good results for the identification of Microsporidia spp. We assessed the above techniques and graded the attributes in the following descending order: cost effectiveness, sensitivity, ease of use and interpretation, time taken for the procedure and batch testing.

Conclusion

Thus, we conclude that a combination of minimum three procedures should be carried out for the screening of stool specimens of HIV positive patients. Kinyoun's staining should be made mandatory for every diarrheal stool sample from HIV patients. Also every laboratory should assign its own value to the attributes and apply Multiattribute utility theory or the Analytical hierarchy process to decide the most appropriate methodology.

Detection of Cryptosporidium oocysts in fresh and frozen cattle faeces: comparison of three methods

AIMS

The aim of this study was to compare the performance of three commonly used screening tests for Cryptosporidium oocysts in fresh and frozen cattle faeces.

METHODS AND RESULTS

Twenty-nine freshly voided faecal samples were collected from calves from three farms in the northwest of England. Three diagnostic tests for Cryptosporidium were carried out on each sample both before and after freezing - the modified Ziehl-Neelsen (MZN) and auramine phenol (APh) stains and a commercial enzyme immunoassay (EIA) kit, the ProSpecT Cryptosporidium Microplate assay (Remel, Lenexa, KS). Twelve samples were deemed positive by the reference standard (polymerase chain reaction, PCR). There were some discrepancies between the results of the screening tests and the levels of agreement were quantified. The sensitivity and specificity of each method was determined, with PCR as the gold standard. Sensitivity and specificity of the MZN stain was optimized when samples with fewer than two oocyst-like bodies were classified as negative.

CONCLUSIONS

All three screening methods used were effective in detecting Cryptosporidium infection in both fresh and frozen calf faeces.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study has highlighted the value of determining characteristics of tests used for diagnosis and epidemiological studies.

Screening of auramine-stained smears of all fecal samples is a rapid and inexpensive way to increase the detection of coccidial infections

INTRODUCTION

Coccidia are important causes of diarrhea that is often indistinguishable from other forms of community-acquired diarrhea. However, the detection of oocysts is often only performed when explicitly requested, as part of the ova and parasite (O&P) examination. Reappraisal and understanding of the accurate staining characteristics of auramine O (AuO), which stains nucleic acids, may permit the inexpensive and reliable identification of coccidian oocysts at routine workup of all fecal samples.

METHODS

AuO-stained smears were prepared from all stool samples received for stool culture in transport medium (SC) and from concentrated stools received for the ova and parasite (O&P) examination.

RESULTS

A total of 3732 samples for stool cultures and 3132 samples for O&P examinations were included. Ninety-one samples (1.3%) from 52 patients yielded Coccidia (45 Cryptosporidium spp and 7 Isospora belli). In seven cases oocysts were only detected in samples sent for stool culture in transport medium. The oocysts showed a typical staining pattern and were easy to recognize. The observation of one smear took only around 30seconds, and the reagents and glass slide for one smear did not exceed US$ 0.03.

CONCLUSIONS

The screening of all fecal samples with AuO-stained smears is a rapid and inexpensive way to increase the detection of coccidial infections, which in most laboratories can be incorporated into the microscopic workup for mycobacteria.

Understanding Medical Decision Making in Hand Surgery

The practice of medicine takes place in an environment of uncertainty. Expected value decision making, prospect theory, and regret theory are three theories of decision making under uncertainty that may be used to help us learn how patients and physicians make decisions. These theories form the underpinnings of decision analysis and provide the opportunity to introduce the broad discipline of decision science. Because decision analysis and economic analysis are underrepresented in upper extremity surgery, the authors believe these are important areas for future research.

Diarréia por parasitas

A diarréia é uma causa importante de morbimortalidade nos países em desenvolvimento. Os agentes etiológicos mais comuns são os vírus e as bactérias. Este artigo tem o objetivo de analisar a ocorrência de diarréia como manifestação clínica de parasitose. Discute-se quais os protozoários e os helmintos que podem causar diarréia, as bases científicas atuais que explicam os mecanismos fisiopatológicos que desencadeiam a diarréia, bem como os exames complementares e o tratamento adequado para cada parasita implicado.

Fecal shedding of Giardia duodenalis, Cryptosporidium parvum, Salmonella organisms, and Escherichia coli O157:H7 from llamas in California

OBJECTIVE

To evaluate fecal shedding of Giardia duodenalis, Cryptosporidium parvum, Salmonella organisms, and Escherichia coli O157:H7 from llamas in California with respect to host factors and management practices.

ANIMALS

354 llamas from 33 facilities.

PROCEDURE

Fecal specimens were collected and examined for G. duodenalis and C. parvum by means of immunofluorescent microscopy. Salmonella organisms were cultured by placing feces into selenite enrichment broth followed by selective media. Escherichia coli O157:H7 was cultured by use of modified tryptocase soy broth followed by sorbitol MacConkey agar, with suspect colonies confirmed by means of immunofluorescent microscopy.

RESULTS

12 of 354 fecal specimens (3.4%) had G. duodenalis cysts. Younger llamas (crias) were more likely to be shedding cysts, compared with older llamas. Farm-level factors that increased the risk of shedding were large numbers of yearlings on the property (> 10), smaller pen sizes, large numbers of crias born during the previous year (> 10), and large pen or pasture populations (> 20). None of the 354 fecal specimens had C. parvum oocysts. Seventy-six (from 7 facilities) and 192 (from 22 facilities) llamas were tested for Salmonella organisms and E. coli O157:H7, respectively. All fecal specimens had negative results for these bacteria.

CONCLUSIONS AND CLINICAL RELEVANCE

Shedding of G. duodenalis was primarily limited to crias 1 to 4 months old. Llamas from properties with large numbers of crias born in the previous year, resulting in large numbers of yearlings in the current year, were at greater risk of infection. In addition, housing llamas in smaller pens or pastures and managing llamas and crias in large groups also increased the risk of G. duodenalis shedding.

Cross-sectional study of faecal shedding of Giardia duodenalis and Cryptosporidium parvum among packstock in the Sierra Nevada Range

Faecal specimens from 305 horses and mules used as packstock at one of 17 commercial or governmental (National Park Service, US Forest Service) operations were examined for Giardia duodenalis and Cryptosporidium parvum using immunofluorescent microscopy. Fourteen packstock (4.6%) were shedding G. duodenalis cysts, with herd-level prevalences ranging 0-22%. Number of packstock in the corral, size of corral and density of packstock in the corral were associated with the odds of shedding G. duodenalis cysts. None of the horses had detectable C. parvum oocysts. Assuming a sensitivity of at least 43% and a specificity of 100% for our assay, the estimated maximum true prevalence of shedding of C. parvum for packstock would be < or = 2.3% of the population. These data suggest that faecal dispersal of C. parvum on back country watersheds is unlikely with packstock.

New insights into human cryptosporidiosis

Cryptosporidium parvum is an important cause of diarrhea worldwide. Cryptosporidium causes a potentially life-threatening disease in people with AIDS and contributes significantly to morbidity among children in developing countries. In immunocompetent adults, Cryptosporidium is often associated with waterborne outbreaks of acute diarrheal illness. Recent studies with human volunteers have indicated that Cryptosporidium is highly infectious. Diagnosis of infection with this parasite has relied on identification of acid-fast oocysts in stool; however, new immunoassays or PCR-based assays may increase the sensitivity of detection. Although the mechanism by which Cryptosporidium causes diarrhea is still poorly understood, the parasite and the immune response to it probably combine to impair absorption and enhance secretion within the intestinal tract. Important genetic studies suggest that humans can be infected by at least two genetically distinct types of Cryptosporidium, which may vary in virulence. This may, in part, explain the clinical variability seen in patients with cryptosporidiosis.

Cryptosporidiosis in immunocompromised patients in a Turkish university hospital

The prevalence of Cryptosporidiosis in 18 immunosuppressed diarrheic patients was evaluated by examination of fecal samples by direct staining (Modified Kinyoun and Giemsa), direct and indirect immunofluorescence methods. Forty patients (10 nondiarrheic immunosuppressed, 10 nondiarrheic immunocompetent, and 20 diarrheic immunocompetent) were included in the study as the control group. 11 of 18 samples were positive for cryptosporidial oocysts by at least one of the methods. Oocysts were detected in all (n = 7) of the AIDS patients. This high frequency was attributed to a probable nosocomial infection. None of the samples from control subjects were found positive for Cryptosporidium. Our results indicate that Cryptosporidial oocysts should be detected particularly in immunosuppressed patients with diarrhea. Modified Kinyoun staining method is practical and reliable for this purpose. Immunofluorescence staining methods can be applied for confirmation of the results.

Efficacy of different methods for detection of low Cryptosporidium parvum oocyst numbers or antigen concentrations in stool specimens

The detection of Cryptosporidium parvum oocysts in stool specimens by acid-fast (AF) stains or immunofluorescence assays (IFA) requires the presence of large numbers of oocysts. To determine whether new commercially available enzyme immunoassays (EIAs) are more sensitive alternatives, three EIAs, a direct IFA, and the modified cold Kinyoun AF stain were compared, particularly with respect to detection of low oocyst numbers or antigen concentrations. Thirty-one negative and 31 calf stool-enriched human stool specimens were tested. One EIA method detected only nine positive specimens, demonstrating a sensitivity significantly less (p < 0.0001) than that of the IFA, the AF stain, and the other two EIAs. No differences could be found with respect to specificity. In addition, serial dilutions of 28 patients' stool samples containing cryptosporidian oocysts were prepared and examined using two EIAs, IFA, and the AF stain. One EIA yielded significantly inferior results (p < 0.0001), whereas the other one and the two microscopic methods did not differ significantly in either part of the study. The results indicate that the new EIAs do not exhibit higher sensitivities for detection of Cryptosporidium parvum than the two routinely used microscopic methods. Thus, for most laboratories, the IFA or AF stain may still represent the preferred method for the diagnosis of cryptosporidiosis.

Flow cytometric detection of Cryptosporidium oocysts in human stool samples

Cryptosporidium parvum is an important pathogen that causes diarrhea in virtually all human populations. Improved diagnostic methods are needed to understand the risk factors, modes of transmission, and impact of cryptosporidiosis. In the present study, we fluorescently labeled and counted C. parvum oocysts by flow cytometry (FC) and developed a simple and efficient method of processing human stool samples for FC analysis. Formed stool (suspended in phosphate-buffered saline) from an asymptomatic, healthy individual was seeded with known concentrations of oocysts, and oocysts were labeled with a cell wall-specific monoclonal antibody and detected by FC. The method described herein resulted in a mean oocyst recovery rate of 45% +/- 16% (median, 42%), which consistently yielded a fourfold increase in sensitivity compared to direct fluorescent-antibody assay of seeded stool samples. However, in many instances, FC detected as few as 10(3) oocysts per ml. Thus, FC provides a reproducible and sensitive method for C. parvum oocyst detection.

Cyclosporiasis: a new cause of diarrhea

Cyclospora cayetanensis, a coccidian parasite, is a new cause of prolonged diarrhea. It has been most recently associated with ingestion of contaminated fruit. Although infection with C. cayetanensis is considered rare, the exact prevalence in Canada is unknown. Transmission is thought to occur through contaminated food and water. The incubation period varies from days to weeks. Patients present with nausea, vomiting, anorexia, bloating, abdominal cramping, increased gas and watery diarrhea. The illness may last up to 6 weeks and may respond to treatment with trimethoprim-sulfamethoxazole. C. cayetanensis is differentiated from other coccidians by its sporulation characteristics and its autofluorescence. To obtain a positive result of a laboratory test for the organism, a modified Ziehl-Neelsen acid-fast stain is recommended. Proper laboratory handling of specimens is facilitated by inclusion of clinical information on requisition forms.

[Oocysts of Cryptosporidium sp in feces: comparison of the modified Kinyoun and Heine methods]

The diagnosis of intestinal infection by Cryptosporidium sp is crucial today; with the progression of the AIDS epidemic, many cases of cryptosporidiosis have appeared in this setting and in other immunodeficiency diseases. We compared the advantages and disadvantages of Heine's method and modified Kinyoun's method in the following parameters: morphology of the parasite, quantitation of cysts, stability of the staining characteristics timewise on the slides and time spend at staining. All positive fecal smears were obtained from patients with AIDS. The sensitivity of these two techniques was the same. The choice should be made by the best aspects of each method. Heine's was better for quantitation of the cysts and was faster. Kinyoun's was better for conserving the stained smear.

Factors influencing Cryptosporidium testing in Connecticut

To describe patterns of testing for Cryptosporidium oocysts in stool samples, Connecticut laboratories were surveyed. Different detection methods were used. Most laboratories examined stools specifically for Cryptosporidium only on physician request. The rate of positive tests varted widely (0 to 28%). Higher rates of positivity were associated with the use of monoclonal antibody methods, the use of two or more staining procedures, and testing of stool specimens in addition to those requested by physicians.

Detection of Cryptosporidium parvum in raw milk by PCR and oligonucleotide probe hybridization

Cryptosporidium spp. are potential contaminants of food. Suspected cases of food-borne cryptosporidiosis are rarely confirmed because of the limited numbers of oocysts in the samples and the lack of sensitive detection methods adaptable to food. PCR was investigated as a means of overcoming this problem. A PCR assay was designed for the specific amplification of a previously sequenced portion of an oocyst protein gene fragment of Cryptosporidium parvum (N. C. Lally, G. D. Baird, S. J. McQuay, F. Wright, and J. J. Oliver, Mol. Biochem. Parasitol. 56:69-78, 1992) and compared with the primer set of Laxer et al. (M. A. Laxer, B. K. Timblin, and R. J. Patel, Am. J. Trop. Med. Hyg. 45:688-694, 1991). The PCR products were hybridized with digoxigenin-labeled internal probes and detected by chemiluminescence to enhance sensitivity. The two sets of primers were compared with regard to their sensitivity and specificity by using a variety of human and animal isolates of C. parvum and related parasites. Both assays enabled the detection of 1 to 10 oocysts in 20 ml of artificially contaminated raw milk. The assay based on the PCR set and probe of Laxer et al. detected DNAs from Eimeria acervulina and Giardia intestinalis. The new assay has good specificity for C. parvum bovine isolates and hence has a better potential for monitoring the prevalence of C. parvum in raw milk and other environmental samples.

Prevalence, detection and control of Cryptosporidium parvum in food

The role of Cryptosporidium parvum as a foodborne pathogen has not been well documented. Epidemiological features of this parasitic protozoon lead to the assumption that the incidence of cryptosporidiosis due to contaminated food is under-estimated. The high prevalence of C. parvum among dairy herds has increased the spread of oocysts in the farm environment, and their potential presence in raw milk and other raw foods. In October 1993, the first well-documented foodborne outbreak was reported in Maine, USA, and was caused by contaminated hand-pressed apple cider. Although various cases of cryptosporidiosis among humans have pointed to raw milk and other raw foods as possible sources of infection, a conclusive demonstration of foodborne cryptosporidiosis has rarely been established. The limited numbers of oocysts in the suspected samples and the lack of sensitive detection methods adapted for oocyst detection in food contribute to this under-reporting. This review paper discusses various aspects of Cryptosporidium spp. and cryptosporidiosis, including the routes of transmission, the control of oocysts in food, and the available detection methods. The polymerase chain reaction (PCR) combined with DNA probe hybridization is a promising detection method. Recent knowledge on the molecular biology of the parasite for the development of new PCR assays and their potential use in the detection of C. parvum in food are described.

Parasitic diseases in immunocompromised hosts. Cryptosporidiosis, isosporiasis, and strongyloidiasis

Cryptosporidiosis and isosporiasis are intestinal infections caused by the protozoan parasites Cryptosporidium parvum and Isospora belli, respectively. HIV infection and other immunodeficiency diseases predispose human subjects to severe and prolonged cryptosporidiosis. There is also evidence that HIV infection predisposes to chronic isosporiasis. Strongyloidiasis is caused by a nematode worm, Strongyloides stercoralis. Administration of corticosteroids to patients with chronic low-grade S. stercoralis infection can trigger a fulminant, life-threatening form of strongyloidiasis.

Detection of infection or infectious agents by use of cytologic and histologic stains

A wide variety of stains are useful for detection of different organisms or, for viruses, the cytopathologic changes they induce, in smears prepared directly from clinical specimens and in tissue sections. Other types of stains, such as hematoxylin and eosin, are used routinely to stain tissue sections and are most valuable for assessing the immunologic response of the host to the invading pathogen. In many cases, the pattern of inflammation provides important clues to diagnosis and helps to guide the selection of additional "special" stains used predominantly for diagnosis of infectious diseases. A stain may be nonspecific, allowing detection of a spectrum of organisms, as do the Papanicolaou stain and silver impregnation methods, or detection of only a limited group of organisms, as do the different acid-fast techniques. Some nonspecific stains, such as the Gram stain, are differential and provide valuable preliminary information concerning identification. Immunohistochemical stains, on the other hand, are specific for a particular organism, although in some cases cross-reactions with other organisms occur. Despite the wealth of information that can be gleaned from a stained smear or section of tissue, however, the specific etiology of an infection often cannot be determined on the basis of only the morphology of the organisms seen; culture data are essential and must be considered in the final diagnosis.

Evaluation for detection of Cryptosporidium oocysts in diarrheal feces of calves

For the detection of Cryptosporidium oocysts, fecal samples were collected from 201 calves which showed diarrhea. Among the 201 samples, 29 samples (14.4%) were positive for Cryptosporidium spp. by the DMSO-modified acid-fast stain (MAFS), 23 samples (11.4%) were positive by commercial kit (Meridian Diagnostics, Cincinnati, Ohio) and 23 by the indirect immunofluorescence antibody (IFA) assay employing the monoclonal antibody (mAb C6). When tested by both IFA and MAFS, 20 fecal samples were positive for Cryptosporidium oocysts whereas 169 fecal samples were negative. If the MAFS is considered a standard method for oocyst detection, the IFA showed 69% of sensitivity and 98% of specificity. When tested by both IFA and commercial kit, 22 fecal samples were positive for Cryptosporidium oocysts while 177 samples were negative. One sample tested by IFA was found to be false negative, when compared with the results by commercial kit. The sensitivity of IFA was calculated as high as 96%; the specificity as 99% and the predictive value was also 99%. In the present study, IFA employing the mAb C6 revealed that 23 samples (11.4%) were positive among the 201 calves showing diarrhea. Of 23 IFA positive samples, 4 samples (5%) showed cryptosporidial oocysts more than 10(5) OPG. Therefore, it is concluded that the calves showing cryptosporidial oocysts more than 10(5) OPG in the feces were highly associated with clinical cryptosporidiosis.

Human cryptosporidiosis

Cryptosporidium parvum is a protozoan which can cause severe debilitating disease in immunocompromised individuals. Animal models have shown that cellular immunity is the most important factor against the development of the disease. Individuals with a humoral immune deficiency are also at risk. In HIV-infected patients there is a clear relationship between disease severity and CD4 cell counts. Insight into the pathogenesis and development of new agents is hampered by the lack of an in vitro culture system. Prevention is of the utmost importance due to the difficulties of therapy and the severity of clinical disease which can develop. Oocysts are highly resistant to commonly used disinfectants. In HIV-infected patients with cryptosporidiosis, antiretroviral therapy should be instituted or modified. Moreover, non-specific therapy with antidiarrhoeal agents should also be instituted. If no effect is seen, therapy with paromomycin 500 mg 4 times daily for 2-3 weeks should be initiated, followed by maintenance therapy with 500 mg twice daily to prevent relapse.

Patterns of Cryptosporidium antigen and oocyst excretion in calves studied by reverse passive haemagglutination and light microscopy

A reverse passive haemagglutination (RPH) assay incorporating a monoclonal antibody against Cryptosporidium parvum oocysts was used to follow Cryptosporidium coproantigen excretion by calves. RPH detected soluble antigen that passed 0.22 micron filters. Non-specific reactions that occurred in some samples were markedly reduced by heat treatment of the faecal specimens and were abolished by filtration after heat treatment. Results were compared with oocyst counts performed by microscopy of modified Ziehl-Neelsen (MZN) stained faecal smears. Five hundred and thirty-two daily specimens were examined from 30 calves. The mean age at which positive results for both oocysts and antigen was detected was 9 days (range 5-15 days), and excretion lasted for 5-11 days with some cycling of positive reactions in some calves. The occasional cycling to a negative reaction demonstrates a need to take samples from consecutive days to ensure diagnosis. Two hundred and ninety-one (54.7%) specimens were negative in both tests, 178 (33.5%) were positive in both, 14 (2.6%) were positive only by microscopy, and 49 (9.2%) were positive only by RPH. By these criteria the kappa coefficient of agreement between the tests was good (0.753). Compared with MZN, the sensitivity of RPH is 92.7%, specificity 85.6%, positive predictive value 78.4% and negative predictive value 95.4%. The method is simple, objective, has ease of quality control, and either single samples or batches can be processed.

Cryptosporidium and cryptosporidiosis

The tiny, iodine- and chlorine-resistant protozoan oocysts of Cryptosporidium parvum, long recognized by veterinarians, have become increasingly noted as a cause of watery diarrhea in developed and developing countries throughout the world. For immunocompromised patients, particularly those with AIDS, this diarrhea can be severe and life-threatening. Clovis Martins and Richard Guerrant here discuss the increasing recognition of this important pathogen in immunocompetent patients as well, and outline new challenges to improved water treatment, immunologic and antiparasite chemotherapy.

Evaluation of new rapid commercial enzyme immunoassay for detection of Cryptosporidium oocysts in untreated stool specimens

Sixty-six stool specimens were evaluated by the ProSpecTR Cryptosporidium rapid enzyme immunoassay (EIA) (Alexon, Sunnyvale, Calif.). Approximately 2 g of untreated stool suspended in buffer was filtered through membranes labelled with anti-Cryptosporidium-specific antigen antibody. Anti-Cryptosporidium-specific antigen antibody was labelled with biotin, horseradish peroxidase conjugated to streptavidin, and tetramethylbenzidine, and each labelled antibody was added in sequence to the membranes. Each membrane had a positive control and test area. EIA results were compared with those of the modified acid-fast procedure. Twenty-three specimens were positive by the initial acid-fast procedure and the EIA. Forty-two specimens were negative by the initial acid-fast test and the EIA. One specimen was negative by the initial acid-fast test and positive by the EIA (sensitivity, 100%; specificity, 98.5%). This technique is easy to use by comparison with the cumbersome, labor-intensive, and more subjective microscopic methods currently available, and its sensitivity equals that of current microscopic methods.

Comparison of four different methods for detection of Cryptosporidium species

Newly available assays offer alternatives to conventional microscopic examination for Cryptosporidium spp. We compared two enzyme immunoassays, ProSpect Cryptosporidium microtiter assay (Alexon, Inc., Mountain View, Calif.) and Color Vue Cryptosporidium assay (Serady, Indianapolis, Ind.), and a direct immunofluorescent assay, Merifluor Cryptosporidium kit (Meridian Diagnostics, Cincinnati, Ohio), with acid-fast Kinyoun-staining for the detection of Cryptosporidium spp. Examinations were performed on 129 stool specimens received from patients during a recent waterborne outbreak. A specimen was considered positive when organisms could be identified visually by acid-fast and immunofluorescent stains or if organisms could be visualized by either acid-fast or immunofluorescent stain and detected by both enzyme immunoassays. The final number of positive specimens was 55. No single procedure detected all 55 positive specimens. Of these, ProSpect and Color Vue detected 52 (sensitivity, 94.5%), and the Kinyoun stain and Merifluor detected 53 (sensitivity, 96.4%). The final number of negative specimens was 74. One false-positive result was seen with both the Kinyoun stain and the ProSpect assay. The Color Vue and ProSpect assays required the most hands-on technologist time. The ProSpect assay and Merifluor kit were easiest to perform. The acid-fast stain was difficult to interpret. The Merifluor kit was easiest to read and was adaptable to both batch and single testing. Overall, the Kinyoun stain and the Merifluor test were preferable to both of the enzyme immunoassays because of the high reagent cost and hands-on time required for the enzyme immunoassays. The difficult interpretation of the Kinyoun stain smears made the Merifluor a more desirable test despite its higher cost. We conclude that all methods tested were equally sensitive and specific for the detection of Cryptosporidium spp. Ease of use, adaptability to batch testing, and cost are important criteria in determining the method of choice.

Evaluation of the optimal number of faecal specimens in the diagnosis of cryptosporidiosis in AIDS and immunocompetent patients

This study determines the optimal number of faecal samples that should be examined in order to minimize the occurrence of false-negative results in the diagnosis of cryptosporidiosis using routine techniques. A total of 23,023 faecal samples from 10,870 patients submitted for parasitological examination were processed by the formalin-ethyl acetate concentration technique and stained using a modified Ziehl-Neelsen method. Cryptosporidiosis was diagnosed in 232 patients (2.13%), 44 of whom were infected by HIV, the prevalence rate in this population group being 15.54%. The increase in the number of diagnoses obtained by the examination of n and (n-1) specimens was evaluated statistically. This study found that three is the optimal number of faecal samples that should be examined when cryptosporidiosis is suspected in immunocompetent patients; whereas, only two samples are required for diagnosing this protozoosis in AIDS patients.

Cryptosporidium antigen detection in human feces by reverse passive hemagglutination assay

A reverse passive hemagglutination (RPH) assay was developed for Cryptosporidium oocyst antigen with an antioocyst monoclonal antibody (MAb; MAb-C1) coupled to stabilized sheep erythrocytes. RPH was compared with microscopy of auramine-phenol-stained smears of 56 oocyst-positive fecal samples, each of which was tested blindly by RPH with two oocyst-negative samples received on the same day (a total of 112 controls). Thirty-nine additional fecal samples from human immunodeficiency virus type 1 antibody-positive patients with diarrhea (10 of which were positive in auramine-phenol-stained smears) were stored at -20 degrees C before testing. Thirty specimens with a variety of other fecal pathogens (all negative for oocysts) were also tested. Of the 237 samples tested, 69 were positive by one or both methods: 65 by RPH and 66 by microscopy. The kappa coefficient of agreement between the methods was very high at 0.926. The sensitivity of RPH was 93.9%, the specificity was 98.2%, the positive predictive value was 95.4%, and the negative predictive value was 97.7%. Visible oocyst numbers and RPH titers were measured after storage of fecal samples and oocyst concentrates for 8 days at 4 degrees C. Oocyst morphology was generally poor in specimens from the human immunodeficiency virus type 1 antibody-positive group, and it degenerated during the 8-day storage experiments. MAb-C1-reactive antigen eluted from oocysts to give progressively higher reciprocal titers during storage, and it was partially removed from the oocysts by concentration. RPH is a promising technique for the detection of Cryptosporidium antigen in human feces and may be useful when specimens are stored before testing. Studies of the sensitivity of Cryptosporidium immunoassays should take into account the possible release of antigen from oocysts.

Parasitic gastroenteritis

Parasitic causes of diarrhea are common in pediatric patients and have important public health implications. Therefore, diagnosis should be pursued vigorously in the appropriate clinical setting. Giardia and Cryptosporidium infections are the most common causes of disease in the United States, and stool examination for ova and parasites is the best way to make the diagnosis. This should be performed three times, on alternate days, in order to rule out parasitic disease with confidence. In treatment of Giardia, it is important to interrupt transmission, particularly in the day-care setting. Because of the potential for major outbreaks, patients with cryptosporidiosis should be kept out of day care until their symptoms resolve. Although amebiasis is not a common problem in the United States, all patients with bloody diarrhea who have traveled to, or are from, endemic areas should be tested for amebiasis by serology and stool examination. If patients with suspected inflammatory bowel disease are being considered for therapy with corticosteroids, mucosal scrapings of colonic lesions should be examined for amoebae, because corticosteroid therapy can lead to more invasive amoebic disease. Acquired immunodeficiency syndrome patients with diarrhea can be infected with a number of pathogens and a specific diagnosis should be pursued aggressively. These patients are often infected with one or more of the parasites described in this article. The approach to diarrhea in these children is described in a separate article of this issue (Deveikis A. 'Gastrointestinal Disease in Immunocompromised Children," pages 562-569).

Comparison of the ProSpecT and Color Vue enzyme-linked immunoassays for the detection of Cryptosporidium in stool specimens

Two enzyme-linked immunosorbent assays, the ProSpecT (Al-exon, Sunnyvale, CA, USA) and the Color Vue (Seradyn, Indianapolis, IN, USA) were compared for their ability to detect Cryptosporidium in 236 formalin-fixed stool specimens using the Merifluor C/G (Meridian, Cincinnati, OH, USA) stain as the reference method. The initial sensitivities of the ProSpecT and the Color Vue were 96.0% and 76.0%, which upon repeat testing of all discrepancies remained at 96.0% for the ProSpecT and decreased to 72.0% for the Color Vue. There were 25 (11%) specimens positive by the reference method. Initially, there were five false positive specimens by the ProSpecT, only one of which remained positive on retesting. The specificity of the Color Vue was 100% for the initial and repeated results, whereas the ProspecT had an initial specificity of 97.6% that increased to 99.5% upon repeat testing. The enzyme-linked immunosorbent assays offered the advantages of objectivity, batch testing, and, in the case of the ProSpecT, an acceptable sensitivity.

Evaluation of an antigen capture enzyme-linked immunosorbent assay for detection of Cryptosporidium oocysts

The diagnosis of the small (4- to 6-microns) Cryptosporidium oocysts is labor intensive and relies on stool concentration, with subsequent staining and microscopy. The primary purpose of this study was to evaluate the clinical utility of an antigen capture enzyme-linked immunosorbent assay (ELISA) (LMD Laboratories, Carlsbad, Calif.) in detecting Cryptosporidium oocysts in human stools. A total of 591 specimens (76 diarrheal, 515 control) obtained from 213 inhabitants of an urban slum in northeastern Brazil were examined by both ELISA and conventional microscopic examination (CME) of formalin-ethyl acetate-concentrated stool samples stained with modified acid-fast and auramine stains. Forty-eight diarrheal stools (63.2%) were positive for Cryptosporidium oocysts by CME, with 40 of these positive by ELISA. Thirty-five control stools (6.8%) had Cryptosporidium oocysts detected by CME, with 15 of these also positive by ELISA. All of the 480 nondiarrheal stools and all but one of the diarrheal stools negative by CME were negative by ELISA. The test had an overall sensitivity of 66.3% and a specificity of 99.8% (positive predictive value, 98.2%; negative predictive value, 94.8%). In the evaluation of human diarrheal stool samples, the test sensitivity increased to 83.3%, with a specificity of 96.4%, and, in analysis of samples from individual patients with diarrhea, the sensitivity was 87.9%, with a specificity of 100%. These results indicate that this stool ELISA is sensitive and specific for the detection of Cryptosporidium oocysts in human diarrheal stool specimens but has limited use in epidemiologic studies for the diagnosis of asymptomatic Cryptosporidium infection.