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Abstract
Intestinal parasites include intestinal protozoa and intestinal helminths. Intestinal parasitic infections (IPIs) pose a global health problem affecting over one billion people worldwide. Although these infections are predominantly seen in the developing world, they are frequently seen in the developed countries, particularly in immunocompromised patients. Patients' clinical presentations generally include diarrhea, dysentery, abdominal pain, nausea, vomiting, nutritional deficiency, iron deficiency anemia, anal and perianal itching, and rarely intestinal obstruction. The intestinal parasites have similarities in their mode of transmission and life cycle. The stool test is the primary way of diagnosing IPIs. Treatment is given with various anti-parasitic agents. However, appropriate preventive measures are essential for successfully controlling the IPIs.
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Affiliation(s)
- Monjur Ahmed
- Division of Gastroenterology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Gopinath A, Alkhasawneh A, Mubeen A, Makary R, Mohammed I, Baskovich B. Pitfalls in Morphologic Diagnosis of Pathogens: Lessons Learned From the Pseudo- Cystoisospora Epidemic. Int J Surg Pathol 2020; 29:169-173. [PMID: 33016162 DOI: 10.1177/1066896920960813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Multiple groups have recently reported involvement of the gallbladder mucosa of immunocompetent patients by cystoisospora organisms. However, this has recently been disproved with the support of molecular and ultrastructural studies. Here we present a summary of these events, recounting how this pseudo-Cystoisospora epidemic began and ended. This review also highlights the important role played by ancillary techniques in supplementing the morphologic diagnosis of pathogens.
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Affiliation(s)
| | | | - Aysha Mubeen
- 21370University of Florida Jacksonville, FL, USA
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Gopinath A, Mubeen A, Baskovich B, Ginn A, Shukri A, Menes M, Kenneth K, Makary R, Herrera GA, Masood S, Alkhasawneh A. Ultrastructural Characteristics of Gallbladder Epithelial Inclusions Mimicking Cystoisospora. Am J Clin Pathol 2020; 153:88-93. [PMID: 31600399 DOI: 10.1093/ajcp/aqz137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES There is recently reported increased prevalence of Isospora organisms in cholecystectomy specimens from immunocompetent patients, especially in acalculous cholecystectomies. We performed an ultrastructural and molecular evaluation of these specimens. METHODS From 28 gallbladders with intraepithelial inclusions, two specimens with diffuse involvement of the gallbladder epithelium were analyzed by electron microscopy. Polymerase chain reaction was performed on five samples for the ITS2 region of C belli and eukaryotic 18S region. The 18S products were sequenced by next-generation sequencing. RESULTS Electron microscopic analysis showed cytoplasmic condensations leading to vacuole formation. In contrast with true C belli, there were no identifiable organelles or organization. None of these cases showed amplified products other than human on molecular analysis. CONCLUSIONS Electron microscopic analysis demonstrates that the inclusions are condensed cytoplasmic material and not true organisms.
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Affiliation(s)
- Arun Gopinath
- Department of Pathology, University of Florida Health, College of Medicine, Jacksonville
| | - Aysha Mubeen
- Department of Pathology, University of Florida Health, College of Medicine, Jacksonville
| | - Brett Baskovich
- Department of Pathology, University of Florida Health, College of Medicine, Jacksonville
| | - Amber Ginn
- Department of Pathology, University of Florida Health, College of Medicine, Jacksonville
| | - Amal Shukri
- Department of Pathology, University of Florida Health, College of Medicine, Jacksonville
| | - Manual Menes
- Department of Pathology, Baptist Hospital Miami, Miami, FL
| | - Keyler Kenneth
- Department of Pathology, University of Florida Health, College of Medicine, Jacksonville
| | - Raafat Makary
- Department of Pathology, University of Florida Health, College of Medicine, Jacksonville
| | - Guillermo A Herrera
- Department of Pathology and Translational Pathobiology, Louisiana State University Health Sciences Center, Shreveport
| | - Shahla Masood
- Department of Pathology, University of Florida Health, College of Medicine, Jacksonville
| | - Ahmad Alkhasawneh
- Department of Pathology, University of Florida Health, College of Medicine, Jacksonville
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4
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Abstract
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.
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Affiliation(s)
- J P Dubey
- United States Department of Agriculture, Agricultural Research Service, Beltsville Agricultural Research Service, Animal Parasitic Disease Laboratory, Building 1001, BARC-East, Beltsville, MD 20705-2350, USA
| | - S Almeria
- Departmentof Health and Human Services, Food and Drug Administration, Center for Food Safety and Nutrition, Office of Applied Research and Safety Assessment, Division of Virulence Assessment, Laurel, MD 20708, USA
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Rose GS, Arnold CA, Badizadegan K, Carter CM, Conces MR, Kahwash SB, Nicol KK, Arnold MA. Cytoplasmic Fibrillar Aggregates in Gallbladder Epithelium Are a Frequent Mimic of Cystoisospora in Pediatric Cholecystectomy Specimens. Arch Pathol Lab Med 2019; 143:1259-1264. [DOI: 10.5858/arpa.2018-0335-oa] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Context.—Cystoisospora belli is an intracellular parasite associated with gastrointestinal disease in immunocompromised hosts. Although infection has been classically associated with intestinal disease, studies have identified Cystoisospora in the gallbladder of immunocompetent patients based on hematoxylin-eosin morphology. Recently, the identity of this histologic finding as Cystoisospora has been questioned based on negative results of nucleic acid studies.Objective.—To determine the prevalence of this histologic feature in pediatric patients, we retrospectively reviewed all cholecystectomy specimens from a pediatric hospital during a 24-month period.Design.—In 180 cholecystectomy specimens, we identified 11 cases (6.1%) with classical histologic features previously described to represent Cystoisospora organisms. To further investigate these structures, we retrieved tissue from paraffin-embedded blocks and performed electron microscopy.Results.—Ultrastructural examination identified ovoid perinuclear cytoplasmic structures composed of dense fibrillar aggregates rather than organisms. Patients with positive cases were similar in age to controls (positive cases: mean patient age 13.4 years [range, 2–23 years]; negative cases: mean patient age 14.7 years [range, 12 weeks–31 years]; P = .35). There was no significant association of this finding with cholelithiasis (54.5% versus 65.1%, P = .52), cholesterolosis (0% versus 22.5%, P = .12), acute cholecystitis (9.1% versus 10.1%, P > .99), or chronic cholecystitis (45.5% versus 66.3%, P = .20).Conclusions.—To our knowledge, this is the first positive identification of these structures as cytoplasmic fibrillar aggregates rather than parasitic inclusions by ultrastructural examination, and the first study of this histologic finding in pediatric cholecystectomies.
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Affiliation(s)
- Gary S. Rose
- From the Department of Pathology, University of Maryland Medical Center, Baltimore (Dr Rose); the Department of Pathology, The Ohio State University Wexner Medical Center, Columbus (Drs C. A. Arnold, Badizadegan, Carter, Conces, Kahwash, Nicol, and M. A. Arnold); and the Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio (Drs Badizadegan, Carter, Conce
| | - Christina A. Arnold
- From the Department of Pathology, University of Maryland Medical Center, Baltimore (Dr Rose); the Department of Pathology, The Ohio State University Wexner Medical Center, Columbus (Drs C. A. Arnold, Badizadegan, Carter, Conces, Kahwash, Nicol, and M. A. Arnold); and the Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio (Drs Badizadegan, Carter, Conce
| | - Kamran Badizadegan
- From the Department of Pathology, University of Maryland Medical Center, Baltimore (Dr Rose); the Department of Pathology, The Ohio State University Wexner Medical Center, Columbus (Drs C. A. Arnold, Badizadegan, Carter, Conces, Kahwash, Nicol, and M. A. Arnold); and the Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio (Drs Badizadegan, Carter, Conce
| | - Christopher M. Carter
- From the Department of Pathology, University of Maryland Medical Center, Baltimore (Dr Rose); the Department of Pathology, The Ohio State University Wexner Medical Center, Columbus (Drs C. A. Arnold, Badizadegan, Carter, Conces, Kahwash, Nicol, and M. A. Arnold); and the Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio (Drs Badizadegan, Carter, Conce
| | - Miriam R. Conces
- From the Department of Pathology, University of Maryland Medical Center, Baltimore (Dr Rose); the Department of Pathology, The Ohio State University Wexner Medical Center, Columbus (Drs C. A. Arnold, Badizadegan, Carter, Conces, Kahwash, Nicol, and M. A. Arnold); and the Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio (Drs Badizadegan, Carter, Conce
| | - Samir B. Kahwash
- From the Department of Pathology, University of Maryland Medical Center, Baltimore (Dr Rose); the Department of Pathology, The Ohio State University Wexner Medical Center, Columbus (Drs C. A. Arnold, Badizadegan, Carter, Conces, Kahwash, Nicol, and M. A. Arnold); and the Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio (Drs Badizadegan, Carter, Conce
| | - Kathleen K. Nicol
- From the Department of Pathology, University of Maryland Medical Center, Baltimore (Dr Rose); the Department of Pathology, The Ohio State University Wexner Medical Center, Columbus (Drs C. A. Arnold, Badizadegan, Carter, Conces, Kahwash, Nicol, and M. A. Arnold); and the Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio (Drs Badizadegan, Carter, Conce
| | - Michael A. Arnold
- From the Department of Pathology, University of Maryland Medical Center, Baltimore (Dr Rose); the Department of Pathology, The Ohio State University Wexner Medical Center, Columbus (Drs C. A. Arnold, Badizadegan, Carter, Conces, Kahwash, Nicol, and M. A. Arnold); and the Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio (Drs Badizadegan, Carter, Conce
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Noor M, Katzman PJ, Huber AR, Findeis-Hosey JJ, Whitney-Miller C, Gonzalez RS, Zhou Z, N’kodia HD, Skonick K, Abell RL, Saubermann LJ, Lamps LW, Drage MG. Unexpectedly High Prevalence of Cystoisospora belli Infection in Acalculous Gallbladders of Immunocompetent Patients. Am J Clin Pathol 2019; 151:100-107. [PMID: 30285068 PMCID: PMC6287653 DOI: 10.1093/ajcp/aqy122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Objectives Indications for cholecystectomy have changed dramatically over the past three decades. Cystoisospora belli has been reported in cholecystectomy specimens of immunocompetent patients. The present study was designed to determine the prevalence and clinical association of C belli in the gallbladder. Methods The study included retrospective review of cholecystectomy specimens (n = 401) removed for various indications, and a prospective cohort of cholecystectomy specimens (n = 22) entirely submitted for histologic evaluation. Correlations of presence of C belli with age, sex, clinical indication, and abnormalities of preoperative laboratory values were assessed by Fisher exact test. Results C belli was identified in 39/401 (9.7%) of the retrospective cohort, and 6/22 (27.3%) of the entirely submitted specimens. The presence of C belli showed no correlation with age, sex, clinical indication, or laboratory abnormalities. Conclusions C belli resides in a latent state in the gallbladder and may be best considered a commensal organism.
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Affiliation(s)
- Mushal Noor
- Department of Pathology, University of Rochester Medical Center, Rochester, NY
| | - Philip J Katzman
- Department of Pathology, University of Rochester Medical Center, Rochester, NY
| | - Aaron R Huber
- Department of Pathology, University of Rochester Medical Center, Rochester, NY
| | | | | | - Raul S Gonzalez
- Department of Pathology, University of Rochester Medical Center, Rochester, NY
| | - Zhongren Zhou
- Department of Pathology, University of Rochester Medical Center, Rochester, NY
| | - Henriette D N’kodia
- Department of Pathology, University of Rochester Medical Center, Rochester, NY
| | - Kathryn Skonick
- Department of Pathology, University of Rochester Medical Center, Rochester, NY
| | - Rebecca L Abell
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY
| | - Lawrence J Saubermann
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY
- Department of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY
| | - Laura W Lamps
- Department of Pathology, University of Michigan, Ann Arbor
| | - Michael G Drage
- Department of Pathology, University of Rochester Medical Center, Rochester, NY
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Swanson EA, March JK, Clayton F, Couturier MR, Arcega R, Smith R, Evason KJ. Epithelial Inclusions in Gallbladder Specimens Mimic Parasite Infection: Histologic and Molecular Examination of Reported Cystoisospora belli Infection in Gallbladders of Immunocompetent Patients. Am J Surg Pathol 2018; 42:1346-1352. [PMID: 30020094 PMCID: PMC6133732 DOI: 10.1097/pas.0000000000001094] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recent publications have described epithelial cytoplasmic vacuoles and inclusions incidentally noted within gallbladder epithelium and concluded that they represent coccidian parasite infection, in particular, Cystoisospora belli. We identified 8 gallbladder specimens from our institution in the past 3 years in which this diagnosis was suggested or in which similar epithelial alterations were prominent. Molecular analysis was performed on the 8 gallbladder specimens and on 3 positive control specimens: small bowel biopsies from acquired immunodeficiency syndrome patients with diarrhea. Polymerase chain reaction using primers designed to amplify an internal transcribed spacer (ITS2) in the C. belli ribosomal gene cluster was performed on the DNA samples. All 8 gallbladder specimens were negative for amplification, while a product consistent with C. belli was amplified from all 3 positive controls. Histologically, the gallbladder cytoplasmic inclusions stained diffusely positive for Grocott-Gomori's methenamine silver and Periodic acid-Schiff with diastase. In contrast, sections from a positive control small bowel biopsy demonstrated organisms that were negative for Grocott-Gomori's methenamine silver and showed a distinct capsular and punctate internal staining on Periodic acid-Schiff with diastase in various parasite forms. Together, the lack of molecular evidence of C. belli and the distinct morphologic and special staining patterns in these gallbladders compared with positive control small bowel suggest that these epithelial changes do not represent true C. belli infection. Our results suggest that gallbladders of immunocompetent patients may occasionally show epithelial changes that can morphologically mimic C. belli infection. Pathologists should be aware of this histologic variant to minimize unnecessary treatment, testing, and patient anxiety.
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Affiliation(s)
| | | | | | | | - Ramir Arcega
- Department of Pathology, Cedar-Sinai Medical Center, Los Angeles, CA
| | | | - Kimberley J Evason
- Department of Pathology
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
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Cystoisospora belli Gallbladder Infection in a Liver Transplant Donor. Case Rep Infect Dis 2018; 2018:3170238. [PMID: 30057834 PMCID: PMC6051245 DOI: 10.1155/2018/3170238] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/14/2018] [Accepted: 06/13/2018] [Indexed: 11/17/2022] Open
Abstract
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.
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