Cyclospora cayetanensis among expatriate and indigenous populations of West Java, Indonesia

A Molecular Tool for Rapid Detection and Traceability of Cyclospora cayetanensis in Fresh Berries and Berry Farm Soils

Due to recent outbreaks of cyclosporiasis associated with consumption of fresh berries, producers are demanding modern microbiological tools for the rapid and accurate identification of the human pathogen Cyclospora cayetanensis in berries and environmental samples. The aim of the present work was to develop a molecular tool based on a PCR approach for the rapid and accurate detection of C. cayetanensis. A nested PCR assay was validated for the amplification of a 294 bp size region of the 18S rRNA gene from C. cayetanensis. The limit of detection for the nested PCR assay was validated using 48 berry samples spiked with ~0, 10, 100, and 1000 oocyst per gram of sample. With this assay, it was possible to detect as few as 1 oocyst per gram of berry, in a 50 g sample. Sanger DNA sequencing and phylogenetic analysis were carried out to confirm the presence of C. cayetanensis in berry (n = 17) and soil (n = 5) samples. The phylogenetic analysis revealed that the C. cayetanensis sequences obtained from Mexico clustered within a group recovered from China, Peru, Guatemala-Haiti, and Japan. The PCR protocol designed in the present study could be an important tool for the rapid and accurate detection of this human pathogen in environmental and food samples.

Advances in Cyclosporiasis Diagnosis and Therapeutic Intervention

Cyclosporiasis is caused by the coccidian parasite Cyclospora cayetanensis and is associated with large and complex food-borne outbreaks worldwide. Associated symptoms include severe watery diarrhea, particularly in infants, and immune dysfunction. With the globalization of human food supply, the occurrence of cyclosporiasis has been increasing in both food growing and importing countries. As well as being a burden on the health of individual humans, cyclosporiasis is a global public health concern. Currently, no vaccine is available but early detection and treatment could result in a favorable clinical outcome. Clinical diagnosis is based on cardinal clinical symptoms and conventional laboratory methods, which usually involve microscopic examination of wet smears, staining tests, fluorescence microscopy, serological testing, or DNA testing for oocysts in the stool. Detection in the vehicle of infection, which can be fresh produce, water, or soil is helpful for case-linkage and source-tracking during cyclosporiasis outbreaks. Treatment with trimethoprim-sulfamethoxazole (TMP-SMX) can evidently cure C. cayetanensis infection. However, TMP-SMX is not suitable for patients having sulfonamide intolerance. In such case ciprofloxacin, although less effective than TMP-SMX, is a good option. Another drug of choice is nitazoxanide that can be used in the cases of sulfonamide intolerance and ciprofloxacin resistance. More epidemiological research investigating cyclosporiasis in humans should be conducted worldwide, to achieve a better understanding of its characteristics in this regard. It is also necessary to establish in vitro and/or in vivo protocols for cultivating C. cayetanensis, to facilitate the development of rapid, convenient, precise, and economical detection methods for diagnosis, as well as more effective tracing methods. This review focuses on the advances in clinical features, diagnosis, and therapeutic intervention of cyclosporiasis.

Cyclospora cayetanensis infection in humans: biological characteristics, clinical features, epidemiology, detection method and treatment

Cyclospora cayetanensis, a coccidian parasite that causes protracted and relapsing gastroenteritis, has a short recorded history. At least 54 countries have documented C. cayetanensis infections and 13 of them have recorded cyclosporiasis outbreaks. Cyclospora cayetanensis infections are commonly reported in developing countries with low-socioeconomic levels or in endemic areas, although large outbreaks have also been documented in developed countries. The overall C. cayetanensis prevalence in humans worldwide is 3.55%. Among susceptible populations, the highest prevalence has been documented in immunocompetent individuals with diarrhea. Infections are markedly seasonal, occurring in the rainy season or summer. Cyclospora cayetanensis or Cyclospora-like organisms have also been detected in food, water, soil and some other animals. Detection methods based on oocyst morphology, staining and molecular testing have been developed. Treatment with trimethoprim-sulfamethoxazole (TMP-SMX) effectively cures C. cayetanensis infection, whereas ciprofloxacin is less effective than TMP-SMX, but is suitable for patients who cannot tolerate co-trimoxazole. Here, we review the biological characteristics, clinical features, epidemiology, detection methods and treatment of C. cayetanensis in humans, and assess some risk factors for infection with this pathogen.

Cyclospora cayetanensis and Cyclosporiasis: An Update

Cyclospora cayetanensis is a coccidian parasite of humans, with a direct fecal-oral transmission cycle. It is globally distributed and an important cause of foodborne outbreaks of enteric disease in many developed countries, mostly associated with the consumption of contaminated fresh produce. Because oocysts are excreted unsporulated and need to sporulate in the environment, direct person-to-person transmission is unlikely. Infection by C. cayetanensis is remarkably seasonal worldwide, although it varies by geographical regions. Most susceptible populations are children, foreigners, and immunocompromised patients in endemic countries, while in industrialized countries, C. cayetanensis affects people of any age. The risk of infection in developed countries is associated with travel to endemic areas and the domestic consumption of contaminated food, mainly fresh produce imported from endemic regions. Water and soil contaminated with fecal matter may act as a vehicle of transmission for C. cayetanensis infection. The disease is self-limiting in most immunocompetent patients, but it may present as a severe, protracted or chronic diarrhea in some cases, and may colonize extra-intestinal organs in immunocompromised patients. Trimetoprim-sulfamethoxazole is the antibiotic of choice for the treatment of cyclosporiasis, but relapses may occur. Further research is needed to understand many unknown epidemiological aspects of this parasitic disease. Here, we summarize the biology, epidemiology, outbreaks, clinical symptoms, diagnosis, treatment, control and prevention of C. cayetanensis; additionally, we outline future research needs for this parasite.

Marked seasonality of Cyclospora cayetanensis infections: ten-year observation of hospital cases, Honduras

Background

Document seasonality occurrence and epidemiologic characteristics of Cyclospora cayetanensis infections during a 10-year period from patients consulting at the University Hospital, Honduras.

Methods

Retrospective non interventional hospital-based study analyzed laboratory results from the period 2002 to 2011 of fresh and Ziehl-Nielsen carbolfuchsin stained routine stool samples received for parasitologic examination. Sporadically a sample with numerous oocysts was allowed to sporulate in 2.5 % potassium dichromate confirming the presence of bi-cystic bi-zoic oocysts.

Results

A total of 35,157 fecal samples were examined during a ten-year span, of which a third (28.4 %) was stained by the Ziehl-Neelsen carbolfuchsin method diagnosing a total of 125 (1.3 %) C.cayetanensis infections. A statistically significant apparent seasonality was observed most years during May to August (range p < 0.036–0.001), with 83.3 % of 125 cases occurring in those rainy months. All C. cayetanensis cases came from urban poor neighborhoods; male/female relation was 1:1 except in 2006, when all patients were females (p = 0.05; r² = 22,448). Forty four point eight percent of the stool samples were diarrheic or liquid and 65.6 % infections were identified in children 10 years old or less. Enteric helminths and protozoa co-infected Cyclospora positive patients in 52 instances.: 8 % Ascaris lumbricoides, 8 % Giardia duodenalis, 23.2 % Blastocystis spp. and less frequently Entamoeba histolytica/E. dispar, Strongyloides stercoralis, and Trichuris trichiura.

Conclusions

Results suggest a seasonal pattern for Cyclospora infections diagnosed in a clinical setting during the rainy months in Tegucigalpa and surrounding areas. Community studies should be conducted to support or dispute these observations.

"Freezing" parasites in pre-Himalayan region, Himachal Pradesh: Experience with mini-FLOTAC

BACKGROUND

Helminths and protozoa infections pose a great burden especially in developing, countries, due to morbidity caused both by acute and chronic infections. Data on distribution of intestinal parasitic infections among the native and expatriates populations in Himachal Pradesh are scarce. The aim of our survey was to analyze the intestinal parasitic burden in communities from Dharamsala, Kangra district, in clinical and public health settings. We also field-tested the mini- FLOTAC, an innovative diagnostic device.

METHODS

Subjects referring to the Tibetan Delek Hospital for abdominal discomfort and all children of the Tibetan Primary School in Dharamsala were screened for intestinal parasitic infections with direct smear, formol-ether concentration (FEC) method and mini-FLOTAC, their clinical history was recorded, and correlations between clinical symptoms and infections analyzed.

RESULTS

152 subjects were screened for intestinal parasites, of which 72 subjects in the outpatients department (OPD) (36 expatriates and 36 natives) and 80 in the school. 60% of schoolchildren and 57% of OPD patients were found positive for any infection, the most represented were protozoa infections (50%), whereas helminthic infections accounted only for 13% and 20% in OPD patients and schoolchildren, respectively. The most prevalent among helminths was Ascaris lumbricoides (11%). Giardia intestinalis was more present among schoolchildren than the OPD patients (20% vs 6%) and E. histolytica/dispar was more prevalent among the OPD patients (42%) than the school children (23%). Correlations were found between nausea and loose or watery stools and parasitic infections, particularly in expatriates, whereas schoolchildren, despite being as infected as adults, were completely asymptomatic. Mini-FLOTAC detected higher number of helminth infections whereas FEC method was more accurate for the diagnosis of protozoa.

CONCLUSIONS

This study presents an accurate snapshot of intestinal parasitic infections in Dharamsala, and their high prevalence calls for more awareness and control measures. Mini-FLOTAC is a promising and simple technique for the diagnosis of helminth infections.

Molecular characterization of human-pathogenic microsporidia and Cyclospora cayetanensis isolated from various water sources in Spain: a year-long longitudinal study

Recent studies suggest the involvement of water in the epidemiology of Cyclospora cayetanensis and some microsporidia. A total of 223 samples from four drinking water treatment plants (DWTPs), seven wastewater treatment plants (WWTPs), and six locations of influence (LI) on four river basins from Madrid, Spain, were analyzed from spring 2008 to winter 2009. Microsporidia were detected in 49% of samples (109/223), Cyclospora spp. were detected in 9% (20/223), and both parasites were found in 5.4% (12/223) of samples. Human-pathogenic microsporidia were detected, including Enterocytozoon bieneusi (C, D, and D-like genotypes), Encephalitozoon intestinalis, Encephalitozoon cuniculi (genotypes I and III), and Anncaliia algerae. C. cayetanensis was identified in 17 of 20 samples. To our knowledge, this is the first study that shows a year-long longitudinal study of C. cayetanensis in drinking water treatment plants. Additionally, data about the presence and molecular characterization of the human-pathogenic microsporidia in drinking water, wastewater, and locations of influence during 1 year in Spain are shown. It is noteworthy that although the DWTPs and WWTPs studied meet European and national regulations on water sanitary quality, both parasites were found in water samples from these plants, supporting the idea that new and appropriate controls and regulations for drinking water, wastewater, and recreational waters should be proposed to avoid health risks from these pathogens.

Epidemiology of Cyclospora cayetanensis: A review focusing in endemic areas

Cyclospora cayetanensis is an intestinal coccidian protozoon that has emerged as an important cause of endemic or epidemic diarrhoeal illness in children and adults worldwide. Humans appear to be the only natural hosts. However, the role of animals as natural reservoirs is uncertain but of increasing concern. Human-to-human spread of the parasite occurs indirectly via the environment through oocysts in contaminated water, food or soil. In endemic areas, risk factors associated with the infection include contaminated water or food, contact with soil or animals, type of sanitation and low socioeconomic status. Infections linked to soil contact provide reasons to believe that this route of spread may be more common than realised in disadvantaged community settings. C. cayetanensis is an important cause of traveller's diarrhoea and numerous large foodborne outbreaks associated with the globalisation of the food supply and importation of fruits and vegetables from developing countries have occurred. Waterborne outbreaks have also been reported. Implementation of measures to prevent or control the spread of Cyclospora oocysts in the environment is critical. In endemic areas, the most important steps to prevent infection are improving environmental sanitation and health education. Significant gaps remain in our understanding of the epidemiology of human cyclosporiasis that highlight the need for continued research in several aspects of C. cayetanensis.

Update on Cyclospora cayetanensis, a food-borne and waterborne parasite

The coccidian parasite Cyclospora cayetanensis is recognized as an emerging pathogen that causes protracted diarrhea in humans. The first cases of Cyclospora infection were reported in the late 1970s and were observed among expatriates and travelers in regions where infections are endemic. Since then, Cyclospora has been considered a cause of traveler's diarrhea. Epidemiological investigations were reported and examined in areas of endemicity even before the true identity of Cyclospora was elucidated. Cyclospora was fully characterized in the early 1990s, but it was not until the 1995 Cyclospora outbreak in the United States and Canada that it caught the attention of the public and physicians. The biology, clinical presentation, epidemiology, diagnosis, treatment, and control of cyclosporiasis are reviewed, with a focus on diagnostic assays currently being used for clinical and environmental samples. Challenges and limitations in working with Cyclospora are also discussed.

Clinical significance of enteric protozoa in the immunosuppressed human population

Globally, the number of immunosuppressed people increases each year, with the human immunodeficiency virus (HIV) pandemic continuing to spread unabated in many parts of the world. Immunosuppression may also occur in malnourished persons, patients undergoing chemotherapy for malignancy, and those receiving immunosuppressive therapy. Components of the immune system can be functionally or genetically abnormal as a result of acquired (e.g., caused by HIV infection, lymphoma, or high-dose steroids or other immunosuppressive medications) or congenital illnesses, with more than 120 congenital immunodeficiencies described to date that either affect humoral immunity or compromise T-cell function. All individuals affected by immunosuppression are at risk of infection by opportunistic parasites (such as the microsporidia) as well as those more commonly associated with gastrointestinal disease (such as Giardia). The outcome of infection by enteric protozoan parasites is dependent on absolute CD4(+) cell counts, with lower counts being associated with more severe disease, more atypical disease, and a greater risk of disseminated disease. This review summarizes our current state of knowledge on the significance of enteric parasitic protozoa as a cause of disease in immunosuppressed persons and also provides guidance on recent advances in diagnosis and therapy for the control of these important parasites.

Intestinal parasitic infections in HIV/AIDS patients presenting with diarrhoea in Jakarta, Indonesia

We investigated the occurrence of intestinal parasites in Indonesian HIV/AIDS patients with chronic diarrhoea prior to administering antiretroviral therapy. The influence of age, CD4(+) cell count and season on parasite occurrence was also studied. In total, 318 unconcentrated stool samples were analysed using Lugol's iodine and modified acid fast staining to detect intestinal coccidia. Most samples (94.5%) were from males aged 21-40 years with CD4(+) counts < or = 50 cells/mm(3). Parasites were found in 84.3% of samples (single species infections, 71.4%; polyparasitism, 12.9%), with protozoan pathogens occurring most commonly. Cryptosporidium (4.9%), Cyclospora cayetanensis (4.5%) and Giardia duodenalis (1.9%) were the most frequent single infections, but Blastocystis hominis (72.4%) was the most commonly occurring protist. Cryptosporidium and C. cayetanensis occurred in 11.9% and 7.8% of all (single and mixed) infections. The most common co-infection was with B. hominis and Cryptosporidium (6.3%). Intestinal protozoan pathogens were detected more frequently in cases with CD4(+) counts < or = 200/mm(3). No seasonal influence was determined for Cryptosporidium, C. cayetanensis or B. hominis, but gross seasonal disturbances may have influenced our findings. Intestinal parasites should be looked for routinely in this group of individuals and should be treated to reduce complications and the likelihood of transmission.

Special infectious disease risks of expatriates and long-term travelers in tropical countries. Part II: infections other than malaria

A wide range of viral, bacterial, and protozoal diseases pose risk to long-term tropical travelers. Risk varies geographically and with lifestyle. For some infections, risk increases with duration of stay, coming to resemble that of the local population. Risk management strategies include vaccination, chemoprophylaxis, avoidance measures, and screening, where appropriate. Vaccination against hepatitis A and B, typhoid, and rabies is recommended for all long-term travelers to (sub-)tropical areas. Lowering of the vaccination threshold for Japanese encephalitis is suggested. Meningococcal disease is rare in travelers, but vaccination is safe and acceptable. The efficacy of Bacillus Calmette-Guérin (BCG) is uncertain; immunological testing avoids BCG's confounding of tuberculin testing. Diarrhea is common, and self-treatment may be recommended. Sexually transmitted infections including human immunodeficiency virus (HIV) are serious risks; education, screening, and HIV postexposure prophylaxis following involuntary exposure are recommended. Many infections are chronic or asymptomatic, and appropriate screening is recommended on return or after prolonged exposure.

The immunology of parasite infections in immunocompromised hosts

Immune compromise can modify the severity and manifestation of some parasitic infections. More widespread use of newer immnosuppressive therapies, the growing population of individuals with immunocompromised states as well as the prolonged survival of these patients have altered the pattern of parasitic infection. This review article discusses the burden and immunology of parasitic infections in patients who are immunocompromised secondary to congenital immunodeficiency, malnutrition, malignancy, and immunosuppressive medications. This review does not address the literature on parasitic infections in the setting of HIV-1 infection.

Cyclosporiasis outbreak, Indonesia

We describe an outbreak of Cyclospora cayetanensis infection among Dutch participants at a scientific meeting in September 2001 in Bogor, Indonesia. Fifty percent of the investigated participants were positive for C. cayetanensis. To our knowledge, this outbreak is the first caused by C. cayetanensis among susceptible persons in a disease-endemic area.

Cyclospora cayetanensis, a food- and waterborne coccidian parasite

Food- and waterborne coccidia including Cryptosporidium parvum, Cyclospora cayetanensis, Sarcocystis hominis and Sarcocystis suihominis, and Isospora belli are cyst-forming apicomplexan protozoa that cause intracellular infections, predominantly in the epithelial cells of the intestine. They are transmitted by oocysts from person-to-person by the fecal-oral route or via contaminated water or food. The most common symptom of infection is diarrhea, however, asymptomatic infections occur. Infections are associated with intestinal inflammation, with pathological lesions such as villus blunting, and abnormal function such as malabsorption. Mild-to-moderate, self-limiting diarrhea is common in healthy individuals ingesting infective stages of these organisms. However, patients with immune dysfunction can have severe intestinal injury and prolonged diarrhea. Diagnosis in many cases is made by a microscopic examination of the stool, and the use of appropriate staining techniques, but more recently molecular methods for detection are used increasingly. Effective antimicrobial treatment for prolonged infection in immunocompromised patients is available for most of these infections. These gastrointestinal coccidial pathogens have important similarities in epidemiology, disease pathogenesis, clinical manifestations, diagnosis, and treatment. Although there are many other cyst-forming coccidia of public health, veterinary and/or economic importance, discussion in this chapter will be limited to C. cayetanensis, as an important example of the group. Aspects of the biology, epidemiology, diagnosis, disease, treatment and control are considered. This parasite is considered to be an emerging pathogen. From 1990 to 2000, there were 11 foodborne outbreaks of cyclosporosis in North America that affected at least 3600 people. There are many outstanding questions regarding this parasite and under-reporting is common because general diagnostic methods for intestinal parasites are inadequate for detection of Cyclospora.

Intestinal coccidia in Cuban pediatric patients with diarrhea

From May to August 1999, we evaluated 401 patients from a pediatric hospital of Havana City. One group was composed of 113 patients with diarrhea admitted to the Gastroenterology ward and a second consisted of 288 patients without diarrhea, admitted for other reasons, and hospitalized within the same time period. Three stool samples were collected from each child and were examined using three parasitological techniques. When we compared the frequency of parasite species between both groups, we found Cryptosporidium spp. and Cyclospora cayetanensis, only in the group of children with diarrhea (P < 0.01). However, no significant differences were found in the occurrence of the other intestinal parasites (P > 0.05). In addition, in those children infected with Cryptosporidium, the diarrhea had a more prolonged duration (P < 0.01), while those infected with Cyclospora, the abdominal cramps or pain, and acute diarrhea were more frequently detected (P < 0.01). Our results showed that emerging intestinal coccidia are pathogens strongly associated in this group of children with diarrhea.

Detection of Cyclospora cayetanensis in travellers returning from the tropics and subtropics using microscopy and real-time PCR

We examined 100 stool specimens of returning travellers with diarrhoea for the presence of Cyclospora cayetanensis using fluorescence microscopy and real-time PCR. C. cayetanensis was found in four cases with microscopy and PCR. One additional sample was positive only by PCR, and could be confirmed by microscopic examination of several additional slides. C. cayetanensis was the most frequent parasitic cause of diarrhoea after Giardia duodenalis.

Cyclospora cayetanensis: a review of an emerging parasitic coccidian

Cyclospora cayetanensis is a sporulating parasitic protozoan that infects the upper small intestinal tract. It has been identified as both a food and waterborne pathogen endemic in many developing countries. It is an important agent of Traveller's Diarrohea in developed countries and was responsible for numerous foodborne outbreaks in the United States and Canada in the late 1990s. Like Cryptosporidium, infection has been associated with a variety of sequelae such as Guillain-Barré syndrome, reactive arthritis syndrome (formally Reiter syndrome) and acalculous cholecystitis. There has been much debate as to where to place C. cayetanensis taxonomically due to its homology with Eimeria species. To date, the only genomic DNA sequences available are the ribosomal DNA of C. cayetanensis and three other species; within these a high degree of homology has been observed. This homology and the lack of sequence data from other Cyclospora species have hindered identification methods.

Cyclospore cayetanensis in Anhui, China

AIM: To investigate the infection of Cyclospore cayetanensis in Anhui Province.

METHODS: Identification of Cyclospore cayetanensis was made microscopically by finding the oocysts of Cyclospore cayetanensis in fecal smears taken from the infants, pupils and adults with obstinate diarrhea, and immunocompromised individuals by using a auramine-phenol stain and modified acid-fast stain. Cellular immune function was detected with biotin-streptavidin (BSA), and the specific antibody against Cyclospore cayetanensis was detected with method of ELISA.

RESULTS: (1) The positive rates of Cyclospore cayetanensis infection in infants, pupils, infants and adults with obstinate diarrhea and with immunocompromised individuals were significantly different (P < 0.01), with the rates of 0%, 0.50% (1/200), 5.62% (10/178), and 9.38% (3/32) respectively. (2) The infection rates of males and females were 2.61% (10/383) and 1.44% (4/227) respectively, with no significant difference (P < 0.05). (3) The positive rates of population with oocysts in urban and rural areas were 0.92% (3/325) and 3.86% (11/285) respectively. (4) The positive rates of CD₃⁺, CD₄⁺, CD₈⁺ and the ratio of CD₄⁺/CD₈⁺ of individuals with and without oocysts were significantly different (P < 0.05, P < 0.01), and their values were (64.28% ± 6.55%), (43.55% ± 5.80%), (28.23% ± 4.32%), 1.52 ± 0.32 and (58.97% ± 5.23%), (39.26% ± 4.93%), (30.54% ± 5.17%), 1.26 ± 0.21, respectively. (5) Specific IgG, IgM and IgG+IgM in serum of the patients with oocyst were significantly different (P < 0.01) with the positive rates of 63.41% (9/14), 17.07% (1/14) and 19.51% (4/14) respectively.

CONCLUSION: Cyclospore cayetanensis infection is present in Anhui, China and it was confirmed to be a new pathogen associated with children diarrhea, adults obstinate diarrhea and diarrhea in immunocompromised individuals. Among all the infected individuals, adult obstinate diarrhea patients and immunocompromised individuals are common. Feces examination of oocysts and serological examination of the specific antibody will be of much help in the diagnosis of Cyclospore cayetanensis infection.

Cyclospora cayetanensis in stools submitted to hospitals in Lagos, Nigeria

BACKGROUND

Cyclospora cayetanensis is an emerging human pathogen associated with gastrointestinal disease. The epidemiology and biology of the parasite are poorly understood, and numerous outbreaks of cyclosporiasis have been recorded from around the world since 1990, but the incidence of the parasite in Nigeria has not been described.

DESIGN AND METHODS

A cross-sectional, laboratory-based study was conducted in Lagos-metropolis state in southwestern Nigeria. All stool samples submitted to the Microbiology and Parasitology Department between March 1999 and April 2000 were processed for the presence of Cyclospora cayetanensis. Data from each patient were obtained from health records and via questionnaires, including age, sex and reason for hospital visit.

RESULTS

In total, 1109 stool samples were collected during the period of study. Eleven (0.99%) were confirmed to be positive for Cyclospora cayetanensis oocysts. Other parasites were also detected, including Cryptosporidium sp., Entamoeba sp., Ascaris, Trichuris, Strongyloides sp., and hookworm.

CONCLUSIONS

Cyclospora cayetanensis is an infrequent but important cause of gastrointestinal disease in Lagos, Nigeria. This is the first report of Cyclospora infection in Nigeria and suggests that medical practitioners and laboratory scientists should be made more aware of the infection.

[Cyclosporiasis: a clinical and epidemiological study in travellers with imported Cyclospora cayetanensis infection]

BACKGROUND

To assess the clinical and epidemiological characteristics of the enteritis produced by Cyclospora cayetanensis.

PATIENTS AND METHOD

A microbiological, epidemiological and clinical protocol in travelers to tropical and temperate areas affected by travelers diarrhea (TD).

RESULTS

C. cayetanenesis was isolated from 55 patients. 96% of them suffered TD. Persistent diarrhea (> 2 weeks) was present in 69% and weight loss > or = 3 kg in 38%. In 36% of cases, TD began after returning from the trip. Although C. cayetanensis has a cosmopolitan distribution, it was mostly isolated from travellers to Latin America, the Indian subcontinent and South East Asia. In only five cases a potential risk factor was detected: strawberries (3), buffalo's milk (1) and marinated fish "ceviche" (1).

CONCLUSIONS

C. cayetanensis is an emerging enteropathogen, isolated in 2-4% of Spanish travellers suffering from TD, and should be considered in the diferential diagnosis of this clinical entity.

Cyclospora cayetanensis: a review, focusing on the outbreaks of cyclosporiasis in the 1990s

Cyclospora cayetanensis, a coccidian parasite that causes protracted, relapsing gastroenteritis, has a short recorded history. In retrospect, the first 3 documented human cases of Cyclospora infection were diagnosed in 1977 and 1978. However, not much was published about the organism until the 1990s. One of the surprises has been the fact that a parasite that likely requires days to weeks outside the host to become infectious has repeatedly caused foodborne outbreaks, including large multistate outbreaks in the United States and Canada. In this review, I discuss what has been learned about this enigmatic parasite since its discovery and what some of the remaining questions are. My focus is the foodborne and waterborne outbreaks of cyclosporiasis that were documented from 1990 through 1999. The occurrence of the outbreaks highlights the need for health care personnel to consider that seemingly isolated cases of infection could be part of widespread outbreaks and should be reported to public health officials. Health care personnel should also be aware that stool specimens examined for ova and parasites usually are not examined for Cyclospora unless such testing is specifically requested and that Cyclospora infection is treatable with trimethoprim-sulfamethoxazole.