Enteric pathogens in HIV-positive patients with diarrhoea and their correlation with CD4+ T-lymphocyte counts

Epidemiology and aetiology of moderate to severe diarrhoea in hospitalised patients ≥5 years old living with HIV in South Africa, 2018-2021: A case-control analysis

Diarrhoea is a recognised complication of HIV-infection, yet there are limited local aetiological data in this high-risk group. These data are important for informing public health interventions and updating diagnostic and treatment guidelines. This study aimed to determine the pathogenic causes of diarrhoeal admissions in people living with HIV (PLHIV) compared to hospital controls between July 2018 and November 2021. Admitted diarrhoeal cases (n = 243) and non-diarrhoeal hospital controls (n = 101) ≥5 years of age were enrolled at Kalafong, Mapulaneng and Matikwana hospitals. Stool specimens/rectal swabs were collected and pathogen screening was performed on multiple platforms. Differences in pathogen detections between cases and controls, stratified by HIV status, were investigated. The majority (n = 164, 67.5%) of enrolled diarrhoeal cases with known HIV status were HIV-infected. Pathogens could be detected in 66.3% (n = 228) of specimens, with significantly higher detection in cases compared to controls (72.8% versus 50.5%, p<0.001). Amongst PLHIV, prevalence of Cystoisospora spp. was significantly higher in cases than controls (17.7% versus 0.0%, p = 0.028), while Schistosoma was detected more often in controls than cases (17.4% versus 2.4%, p = 0.009). Amongst the HIV-uninfected participants, prevalence of Shigella spp., Salmonella spp. and Helicobacter pylori was significantly higher in cases compared to controls (36.7% versus 12.0%, p = 0.002; 11.4% versus 0.0%, p = 0.012; 10.1% versus 0.0%, p = 0.023). Diarrhoeal aetiology differed by HIV status, with Shigella spp. (36.7%) and Salmonella spp. (11.4%) having the highest prevalence amongst HIV-uninfected cases and Shigella spp. (18.3%), Cystoisospora (17.7%), and Cryptosporidium spp. (15.9%) having the highest prevalence in cases amongst PLHIV. These differences should be considered for the development of diagnostic and treatment guidelines.

Prevalence, Antibiotic Susceptibility Pattern, and Associated Factors of Enteric Bacterial Pathogens Among HIV Infected Patients with Diarrhea Attending the ART Clinic of Dilla University Referral Hospital, Southern Ethiopia

Background

In people with human immunodeficiency virus infection, diarrhea is reportedly associated with significant morbidity and mortality. Therefore, the aim of this study was to determine the prevalence, antibiotic susceptibility pattern, and associated factors of enteric bacterial pathogens among HIV infected patients with diarrhea attending the antiretroviral treatment (ART) clinic of Dilla University Referral Hospital, southern Ethiopia.

Methods

This institutional-based cross-sectional study was conducted on 422 study participants attending at ART clinic of Dilla University Referral Hospital from March to August 2022. Demographic and clinical data were collected by using a semi-structured questionnaire. Stool specimens were inoculated on selective media like Butzller's medium and Xylose Lysine Deoxycholate (XLD) agar. Antimicrobial resistance pattern was assessed by using Kirby-Bauer disk diffusion techniques. Adjusted odds ratio (AOR) and 95% Confidence Interval (CI) was used to determine the presence of association.

Results

A total of 422 adult patients were enrolled in this study, 51.7% were females. The mean age of the study participants was 27.4 (±15.6 SD) years. The overall prevalence of enteric pathogens was 14.7% (95% CI=11.4-18.2). Shigella spp was the most prevalent organism. Being a farmer (AOR=5.1; 95% CI=1.4-19.1; p<0.015), the habit of hand washing after toilet (AOR=1.9; 95% CI=1.02-3.47; p<0.04), low CD₄ cell count of <200 cells (AOR=2.22; 95% CI=1.15-4.27; p<0.02), and longer duration of diarrhea (AOR=2.68; 95% CI=1.23-5.85; p<0.01) were statistically associated. In total, 98.4% of enteric bacterial isolates were sensitive for Meropenem, whereas 82.5% were resistant against Ampicillin. Multidrug resistance was detected in 49.2% of enteric bacteria.

Conclusion

We found that enteric bacteria are common causative agents of diarrhea in immune-compromised patients. The high rate of drug resistance calls for escalating antimicrobial susceptibility testing before prescribing antimicrobial agent.

Investigation of the relationship between lymphocyte subsets and intestinal parasites

We analyzed the peripheral blood lymphocyte subsets of cancer patients infected with intestinal parasites, with an aim to find out the relationship between the levels of different types of lymphocytes with the prognosis of patients. 201 cancer patients aged 18 and over were included. Stool samples of the patients were examined using native-lugol, trichrome, modified trichrome (Weber's Trichrome stain), and modified Ziehl-Neelsen staining methods. Microsporidia and Cryptosporidium parvum were investigated at the genus and species levels using PCR. Lymphocyte subsets were determined by flow cytometry in blood samples. One or more parasite species were detected in 115 (56.7%) patients. The most common parasite species were Microsporidia, Blastocystis and Entamoeba coli, respectively. The frequency of parasites was high in patients with low lymphocyte percentage, CD3⁺ T cell and CD3⁺ CD4⁺ T (Th) cell levels in blood samples studied by flow cytometry. Microsporidia infection was significantly higher in patients with low lymphocyte percentage and Th cell levels. Similarly, C. parvum infection was found to be significantly higher in patients with low T lymphocyte percentage and Th cell level. Finally, Blastocystis infection was significantly higher in patients with low lymphocyte percentage and CD4/CD8 ratio higher than 1. The decrease in lymphocyte percentage, CD3⁺ T cell and Th cell count, and low CD4/CD8 ratio in cancer patients increase the frequency of intestinal parasitic infections. Based on these results, lymphocyte subsets may help identify cancer patients at high risk of opportunistic parasites. We suggest that opportunistic parasitic infections affecting the clinical course of the disease should be considered by clinicians during the follow-up and treatment of patients.

Prevalence of enteric bacteria and enteroparasites in human immunodeficiency virus-infected individuals with diarrhoea attending antiretroviral treatment clinic, Arba Minch General Hospital, southern Ethiopia

In Ethiopia, only limited data are available regarding the prevalence of enteric bacterial pathogens and enteroparasites in human immunodeficiency virus (HIV) -infected individuals with diarrhoea. Hence, this study aims to assess the prevalence of enteric bacteria and enteroparasites, and also the antibiotic susceptibility patterns of bacteria in them. An institution-based cross-sectional study was performed in HIV patients with diarrhoea, who visited the Anti-Retroviral Therapy Clinic of the Arba Minch General Hospital between 1 March and 31 August 2019. Data pertaining to sociodemographic characteristics and other factors were collected using a structured questionnaire. Stool culture is of utmost importance in the case of HIV-infected individuals with diarrhoea. Stool samples were collected and examined for bacterial and parasitic pathogens following standard procedures. The antibiotic susceptibility test was performed as per the Kirby-Bauer disc diffusion technique. Data were analysed using SPSS software. A total of 180 individuals were included in the stool collection process. The prevalence rates of enteric bacteria and enteroparasites were 8.3% and 36.1%, respectively. Parasitic infections were more frequent than bacterial infections in these HIV-infected individuals; commonly identified enteroparasites were Giardia lamblia (8.9%) and Cryptosporidium parvum (8.3%). Campylobacter sp. was the most predominant enteric bacterial isolate (4.4%), followed by Salmonella (2.1%) and Shigella (1.1%) species. CD4 counts <200 cells/μL was significantly associated with both bacterial infections (adjusted OR 9.55, 95% CI 1.54-59.3, p 0.015) and parasitic infections (adjusted OR 3.53, 95% CI 1.3-17.9, p 0.03). Multidrug resistance was also detected in 100%, 75% and 60% of Shigella, Campylobacter and Salmonella sp., respectively. We found that enteroparasitic infections were more frequent than bacterial infections. Statistical analysis revealed that CD4 T-cell counts <200 cells/μL, quality of drinking water sources, hand washing habits after toilet and the presence of domestic animals were significantly associated with the prevalence of enteric pathogens.

Cryptosporidiosis in HIV-positive patients and related risk factors: A systematic review and meta-analysis

Cryptosporidium is one of the major causes of diarrhea in HIV-positive patients. The aim of this study is to systematically review and meta-analyze the prevalence of Cryptosporidium in these patients. PubMed, Science Direct, Google Scholar, Web of Science, Cochrane and Ovid databases were searched for relevant studies dating from the period of 1 January 2000 to 31 December 2017. Data extraction for the included studies was performed independently by two authors. The overall pooled prevalence was calculated and subgroup analysis was performed on diagnostic methods, geographical distribution and study population. Meta-regression was performed on the year of publication, proportion of patients with diarrhea, and proportion of patients with CD4 < 200 cells/mL. One hundred and sixty-one studies and 51,123 HIV-positive participants were included. The overall pooled prevalence of Cryptosporidium infection in HIV-positive patients was 11.2% (CI95%: 9.4%–13.0%). The pooled prevalence was estimated to be 10.0% (CI95%: 8.4%–11.8%) using staining methods, 13.5% (CI95%: 8.9%–19.8%) using molecular methods, and 26.3% (CI95%: 15.0%–42.0%) using antigen detection methods. The prevalence of Cryptosporidium in HIV patients was significantly associated with the country of study. Also, there were statistical differences between the diarrhea, CD4 < 200 cells/mL, and antiretroviral therapy risk factors with Cryptosporidiosis. Thus, Cryptosporidium is a common infection in HIV-positive patients, and safe water and hand-hygiene should be implemented to prevent cryptosporidiosis occurrence in these patients.

Cystoisospora belli infections in humans: the past 100 years

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

Spectrum of Parasitic Infections in Patients with Diarrhoea Attending a Tertiary Care Hospital in Western Rajasthan, India

INTRODUCTION

Owing to the poor socioeconomic conditions and lack of sanitary hygiene, a large number of population in developing countries remain under constant threat of different parasitic infections causing severe morbidity and mortality. Enough measures to prevent and reduce the disease burden are still to be undertaken.

AIM

Aim of the study was to determine the spectrum of parasitic infections in patients with complaints of diarrhoea and other gastrointestinal symptoms attending a tertiary care hospital in Western Rajasthan, India.

MATERIALS AND METHODS

It is a retrospective study conducted in the Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, India, between the period of September 2014 and April 2016. The records of routine stool examination carried out during the study period, were analyzed. A total of 968 stool samples from the same number of patients complaining of diarrhoea and other gastrointestinal symptoms such as nausea, vomiting, flatulence, and pain abdomen were received from different outdoor and indoor wards of the hospital. Microscopic examination was performed after the concentration of stool samples by formol-ether concentration technique and their wet mount preparations. Modified Ziehl-Neelsen (ZN) staining was performed on 17 samples for the detection of coccidian parasites.

RESULTS

Out of 968 cases, 158 (16.3%) were found to be infected with either a parasite or a commensal or both. A maximum number of isolates (21.1%) were from the age group of 31-40 years. Overall, protozoans (95.38%) were detected in excess of helminths (4.62%). The most common protozoa isolated was Entamoeba histolytica (37.57%) followed by Giardia lamblia (23.12%), and the most common helminth isolated was Hymenolepis nana (2.9%) followed by Ascaris lumbricoides (1.15%). Out of 17 stool samples, where modified ZN staining was performed, Cryptosporidium spp., Isospora belli, and Cyclospora spp. were detected in one sample each.

CONCLUSION

Intestinal protozoal infections are more prevalent as compared to helminthic infections in this study group.

Prevalence of intestinal parasites among HIV/AIDS patients attending Infectious Disease Hospital Kano, Nigeria

Introduction

Intestinal parasitic infection has been a major source of morbidity in tropical countries especially among HIV patients. The aim of this study was to determine prevalence of intestinal parasites and its association with immunological status and risk factors among HIV infected patients in Kano, Nigeria.

Methods

105 HIV+ subjects and 50 HIV- controls were recruited into the studies from June to December 2010. Clinical information was collected using a questionnaire. Single stool and venous blood samples were collected from each subject. Stool examination and CD4+ count were performed.

Results

Prevalence of intestinal parasites was 11.4% and 6% among the HIV+ and control subjects respectively with no statistically significant difference (p = 0.389). Specifically, the following intestinal parasites were isolated from HIV+ subjects: Entamoebahistolytica (5.7%), hookworm (3.8%), Entamoeba coli (1%), Blastocystishominis (1%). Only Entamoebahistolytica was isolated among the control subjects. The mean CD4+ count of HIV+ and control subjects was 287 cells/ul and 691 cells/µlrespectively while the median was 279(Q1-120, Q3-384) cell/µl and 691(Q1-466, Q3-852) cell/µlrespectively with statistically significant difference (P= 0.021). Diarrhea and the absence of anti-parasitic therapy seem to be important risk factors associated with the occurrence of intestinal parasites among HIV+ subjects. A higher prevalence (14.5%) of intestinal parasites was observed in subject with CD4+ count 350cell/µl.

Conclusion

Routine examination for intestinal parasites should be carried out for better management of HIV/AIDS patients.

Intestinal protozoans in adults with diarrhea

Background:

Diarrhea is one of the most common presenting complaints in human immunodeficiency virus-infected individuals.

Aims:

The study was designed to determine the magnitude of opportunistic and nonopportunistic intestinal parasitic infections among diarrheal patients and association between CD4⁺ T-cell counts and human immunodeficiency virus (HIV)-infected intestinal parasites.

Materials and Methods:

A cross-sectional study was conducted among 207 enrolled diarrheal patients attending HIV integrated counseling and testing center from January 2012 to December 2012. Stool samples were subjected to special modified Ziehl-Neelsen and chromotrope staining method for detection of opportunistic protozoans. Blood samples were also collected from all study subjects for HIV testing and CD4⁺ T-cell counts were estimated by only in HIV-infected patients.

Results:

Intestinal parasitic pathogens were detected in 46.1% HIV-infected patients and the major pathogens were opportunistic protozoans 32.2% (37/115), most common being Isospora belli 16.5% (19/115) followed by Cryptosporidium parvum 12.2% (14/115). In HIV noninfected diarrheal patients, major pathogens detected were Entamoeba histolytica/Entamoeba dispar 8.7% (8/92) and Ascaris lumbricoides 3.3% (3/92).

Conclusions:

The opportunistic intestinal protozoans especially I. belli and C. parvum were most commonly isolated in HIV-infected patients with diarrhea. Majority of the infections occurred in patients when a CD4⁺ T-cell counts were less than 200 cells/μl.

Enteric Parasitic Infections in Relation to Diarrhoea in HIV Infected Individuals with CD4 T Cell Counts <1000 Cells/μl in Chennai, India

AIM

This study was conducted to estimate the prevalence of enteric parasites in HIV patients in Chennai and to correlate with CD4 counts and diarrhoeal status.

MATERIAL AND METHODS

Faecal specimens from 100 HIV infected individuals with CD4 < 1000/μl were screened for enteric parasites with wet mounts, modified acid-fast stain for coccidian parasites, modified trichrome stain for Microsporidia, before and after the stool concentration. Agar plate culture for Strongyloides was put up. Chi-square and ANOVA tests were used for statistical analysis.

RESULTS

Study group comprised of 38 subjects with acute diarrhoea, 30 with chronic diarrhoea (> 2 weeks) and remaining 32 without diarrhoea. Enteric parasites were detected in 33% of subjects; Isoapora belli (21) being the commonest followed by E.histolyt/Entamoeba dispar (5), Entamoeba coli (2), Cryptosporidium spp (2), Hookworms (2), Strongyloides stercoralis (2), Giardia lamblia (1) and Microsporidium spp (1). There was a significant inverse relation between CD4 counts and duration of diarrhoea. Opportunistic parasites were isolated from the subjects with wide range of CD4 counts and different diarrhoeal status but most commonly from chronic diarrhoea patients.

CONCLUSION

The prevalence of intestinal parasitic infections in HIV patients is high in Chennai, India, especially at CD4 <1000/μl, I.belli infection being the commonest. Routine screening of all HIV patients with low CD4 counts for coccidian parasitic infections by using simple stool microscopic techniques can help in early diagnosis and treatment.

Prevalence of isosporiasis in relation to CD4 cell counts among HIV-infected patients with diarrhea in Odisha, India

BACKGROUND

To determine the prevalence of Isospora belli and its correlation with CD4+ cell counts in HIV-positive patients with diarrhea in this region.

MATERIALS AND METHODS

Stool samples from 250 HIV-positive patients, including 200 with diarrhea and 50 without diarrhea included in the study were examined for the presence of enteric parasites under microscopy. Prevalence of the enteric parasites with special reference to I. belli in HIV-positive patients with and without diarrhea were calculated and correlated with their CD4+ cell counts.

RESULTS

Enteric parasites were detected in 39% of the HIV patients with diarrhea compared to 30% without diarrhea. I. belli was detected in 22% of the patients with diarrhea and in 4% without diarrhea (P = 0.0019). I. belli was the most common parasite, followed by Entamoeba histolytica/dispar (8%) and Cryptosporidium parvum (5%) in HIV-positive patients with diarrhea. In HIV-positive patients without diarrhea, the most common parasite detected was E. histolytica/dispar (12%) followed by C. parvum (6%) and I. belli (4%). The mean CD4 cell count of HIV-positive patients with diarrhea suffering from isosporiasis was 138.35 ± 70.71. In patients with CD4 cell counts <200/μl, I. belli was seen in 36/123 stool samples and 2/27 stool samples which was statistically significant (P = 0.0157).

CONCLUSION

I. belli was the predominant parasite with a prevalence of 22% among HIV-positive patients with diarrhea, majority having CD4 cell count <200/μl. This study highlights the importance of routine screening for coccidian parasites in HIV-positive patients with and without diarrhea especially in those with low CD4 cell counts.

To Study the Prevalence of Various Enteric Parasitic Infections Among HIV Infected Individuals in the P.D.U. Medical College and Hospital, Rajkot, Gujarat, India

BACKGROUND AND OBJECTIVES

Enteric parasites are a major cause of diarrhoea in HIV infected individuals. The present study was undertaken to detect the enteric parasites in HIV infected patients with diarrhoea, who were at different levels of immunity.

METHODS

This study was carried out in the P.D.U Medical College and Civil Hospital, Rajkot, India. during the period from June 2009 to June 2010. A total of 100 stool samples from HIV seropositive patients were examined for opportunistic, gastrointestinal parasitic infections. The samples were classified according to the age groups, sex, and occupation, a history of diarrhoea and different categories of the CD4 cell count. The stool samples were collected and examined for enteric parasites by microscopy and by special staining methods. The CD4 cell counts were estimated by using the FACS count system.

RESULTS

The intestinal parasitic pathogens were detected in 28% patients. Among all, Isospora appeared to have the highest prevalence (18%), followed by Giardia lamblia (5%), Strongyloides stercoralies (3%) and Cryptosporidium parvum (2%). In the HIV infected patients with a CD4 count of < 200 cells/μl, Isospora was the most commonly observed (56%) pathogen. The proportion of the opportunistic pathogens in the patients with CD4 counts of <200 cells/μl was significantly higher as compared to those in the other two groups of patients with CD4 counts of >200 respectively.

INTERPRETATION AND CONCLUSIONS

Parasitic infections were detected in 28% of the HIV infected patients and a low CD4 count was significantly associated with an opportunistic infection. The detection of the aetiologic pathogens might help the clinicians in deciding the appropriate management strategies.