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 ~  Abstract
 ~  Materials and Me...
 ~  Results
 ~  Discussion
 ~  Acknowledgement
 ~  References

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ORIGINAL ARTICLE
Year : 2002  |  Volume : 20  |  Issue : 2  |  Page : 88-91
 

Intestinal parasitic infection in HIV infected patients with diarrhoea in Chennai


Dept. of Microbiology, Dr. ALM PGIBMS, University of Madras, Taramani, Chennai - 600 113, India

Correspondence Address:
Dept. of Microbiology, Dr. ALM PGIBMS, University of Madras, Taramani, Chennai - 600 113, India

 ~ Abstract 

PURPOSE: To determine the prevalence of intestinal parasites in HIV patients with and without diarrhoea in Chennai. METHODS: A total of 150 stool samples, 41 - acute diarrhoea, 59 - chronic diarrhoea and 50 control samples without diarrhoea were collected and examined for enteric parasites by microscopy. RESULTS: Enteric parasites were detected in 39% patients with diarrhoea compared to 14% in patients without diarrhoea. Isospora belli was found in 18.6% (11/59) of chronic diarrhoea and 7.3% (3/41) in acute diarrhoea (P > 0.2). Cryptosporidium was detected in 7 cases each in acute and chronic diarrhoea, which was statistically insignificant as compared to the control group (P >0.05). Microsporidia and Cyclospora cayetanensis associated diarrhoea were detected in only one chronic case each 1/59 (1.69 %). CONCLUSIONS: Isospora belli appeared to be a predominant parasite associated with diarrhoea among HIV patients. Detection rate of Microsporidia and Cyclospora was found to be very low.

How to cite this article:
Kumar S S, Ananthan S, Lakshmi P. Intestinal parasitic infection in HIV infected patients with diarrhoea in Chennai. Indian J Med Microbiol 2002;20:88-91


How to cite this URL:
Kumar S S, Ananthan S, Lakshmi P. Intestinal parasitic infection in HIV infected patients with diarrhoea in Chennai. Indian J Med Microbiol [serial online] 2002 [cited 2018 Sep 22];20:88-91. Available from: http://www.ijmm.org/text.asp?2002/20/2/88/8354


Diarrhoea is a common complication of HIV positive patients inducing weight loss and cachexia. It occurs in almost 90% of AIDS patients in developing countries.[1] In HIV infected patients, progressive decline in their immunological responses makes them extremely susceptible to a variety of common and opportunistic infections. In recent years, numerous studies have outlined the emergence of important gastrointestinal protozoa like Microsporidia species, Cryptosporidium species, Isospora belli, and Cyclospora cayetanensis.[1],[2] Microsporidia are obligate intracellular parasites. Approximately 100 genera and 1000 species are currently recognized worldwide, and seven genera have been reported to cause disease in man. Studies on intestinal Microsporidiosis from developed countries have revealed 6-60% prevalence among AIDS patients.[2] The disease associated with Cryptosporidium and Isospora belli are usually associated with diarrhoea in immunocompromised patients and has been reported in Tanzania and Zambia with high incidence rate.[2],[3]
Cyclosporiasis has been reported with increasing frequency in the United states, Latin America, Nepal, Peru and New Guinea. The disease associated with C.cayetanensis usually presents with watery diarrhoea in immunocompromised patients with a duration of four months.[4] Since the diarrhoeal illness due to parasitic etiology among HIV patients is on the rise during recent times, the present study was undertaken to examine the prevalence of enteric parasites among HIV patients with diarrhoea in Chennai.

 ~ Materials and Methods Top

The study was carried out on patients admitted to the HIV wards at Government Hospital of Thoracic Medicine and Y.R.Gaitonde Health Centre, Chennai. A total of 150 HIV positive patients were included in the study, these comprised of 100 HIV patients (age 14 to 66 years) who presented with diarrhoea and 50 HIV patients (age 20 to 62 years) without diarrhoea.
HIV infection in patients was confirmed by ELISA and TRIDOT (J.Mitra and Co. Ltd., New Delhi) method adopted by the hospital authorities applying the diagnosis and definition of AIDS established by the Centers for Disease Control and Prevention. All the patients enrolled in the study were interviewed using a questionnaire to collect clinical data. The HIV symptomatic patients were categorized into two groups acute (<14 days) or chronic (14days-4 months) diarrhoea. In each HIV patient, two consecutive faecal specimens were collected and transported to the laboratory within one hour for coproparasitological study. Stool samples were subjected to examination for helminths and protozoa by direct wet mount and concentrated by formol-ether sedimentation method.5 One stool specimen was cultured for enteric bacterial pathogens except for Campylobacter and Clostridium spp. Direct smears of stool samples and smears made from deposits of sedimentation were stained with modified trichrome stain for detection of microsporidial spores.[6] For the detection of coccidian parasites, modified Kinyoun acid-fast stain[7] was used for staining. Stool smears of Isospora belli, Cyclospora cayetanensis and Microsporidia positive cases were sent to Division of Parasitic Diseases, CDC, Atlanta, to confirm the diagnosis.
Statistical analysis of the data was done using the Chi square test with Yates correction to determine the significance of differences.

 ~ Results Top

In a total of 100 symptomatic HIV seropositive patients studied, 59 had chronic diarrhoea and 41 had acute diarrhoea. The mean age of group of patients in acute diarrhoea was 33.0 8.48 (median 31) and those with chronic diarrhoea was 34.6 7.49 (median 34) presenting with symptoms like vomiting, nausea, weight loss and abdominal pain in either forms of diarrhoea.
One or more enteric parasites were detected in 36 patients (34.5 7.55 median 33) and protozoan infection was more frequent than helminths. In patients with acute diarrhoea, Cryptosporidium parvum oocyst appeared as pinkish or orange spherical bodies measuring 4-6mm and was found in higher proportion (7 / 41, 17%) of cases than those of chronic cases (11.8%) and controls (8%) [Table]. Isospora belli oocyst appear as oval bodies with immature or mature sporocyst measuring 20 - 40 mm [Figure:1] and was found to be predominant with 18.6% in patients with chronic diarrhoea than those with acute diarrhoea (c2 = 1.72 P>0.2).
*HIV infected individuals without diarrhoea
f Include 1 Mixed infection with Isospora belli
ff Include 2 cases of Mixed infection, one with Isospora and one with Ancylostoma
Isospora belli: c2 = 1.72 P>0.2
Cryptosporidium parvum: c2 = 1.135 P>0.05
In 59 patients with chronic diarrhoea, Microsporidial spores (Enterocytozoon bieneusi) was detected in one case and appeared ovoid and refractile and the spore wall stained bright pinkish red and cellular content of spores distinctly did not stain and appeared transparent pinkish-red stained belt like stripe that girded the spores diagonally or equatorially. The size of each spore was approximately 1.5 by 0.9mm.[6]
Cyclospora cayetanensis was detected in only one case and appeared as pinkish spherical bodies measuring 8 - 10mm in diameter [Figure:2]. Mixed infection was observed in 3 cases of chronic diarrhoea with Cryptosporidium found along with 3 enteric parasites as mentioned in the table.
Among the 50 control patients analysed, enteric parasite was detected in 7 cases, the predominant parasite being Cryptosporidium, which was found in 4 cases (8%) and other coccidian parasites were not detected among the controls studied. There was no significant difference observed in the incidence rate of Cryptosporidiosis among study and control group (c2 = 1.135; p>0.05).
Other enteric parasites detected among HIV patients were Ancylostoma duodenale in 4%, Entamoeba histolytica in 2%, Strongyloides stercoralis in 2% and Hymenolepis nana in 0.6% cases. In stool culture the enteric bacterial organisms identified in both forms of diarrhoea and control group includes E.coli 53/150 (35.3%), Klebsiella spp. 34/150 (22.6%), Enterococci 11/150 (7.3%), Proteus spp. 4/150 (2.6%), and Pseudomonas 2/150 (1.3%). Enteric pathogen like Shigella spp. was identified in 2/59 (3.3%) cases of chronic diarrhoea and  Salmonella More Details spp. was identified in 3/100 (3%) cases comprising one in acute and two in chronic diarrhoea. As far as fungal pathogens are concerned Candida spp. was identified in 4/150 (2.6%) cases consisting of one each in acute diarrhoea and control group and two cases in chronic diarrhoea.

 ~ Discussion Top

The present study documents the prevalence of enteric parasites in HIV patients with diarrhoea in Chennai. The most predominant parasite was Isospora belli (18%), which was associated with chronic diarrhoeal cases than with acute diarrhoea and control cases studied. The frequency of Isosporiasis in AIDS is likely to be underestimated due to asymptomatic shedding of oocyst and treatment with trimethoprim sulphamethaxazole for other infections in AIDS cases which may confer some protection against this protozoan.[8] The isolation rate of Isospora belli was high in our study (14%) compared to other studies (0-3%) [9] and correlates with a recent report from another part of south India.[1]
Apparently, Cryptosporidium was the next common parasite encountered with 14% diarrhoeal cases. No significant difference in the prevalence among the cases and control indicated an existing high risk of infection by this parasite in Chennai. Some other studies have highlighted Cryptosporidium as the predominant pathogen with significant association to diarrhoeal cases.[10]
Microsporidium has been described as an important emerging opportunistic enteric pathogen in HIV patients causing chronic diarrhoea.[11] There are several studies documenting the prevalence of Microsporidium in HIV positive patients[11],[12],[13],[14] and only a few studies in immunocompetent individuals.[2],[15] However, in the present study Microsporidium and Cyclospora were detected only in one case each.
The present study, to the best of our knowledge, is the first report of the detection of Microsporidia and Cyclospora cayetanensis from HIV patients in Chennai. The most predominant parasitic pathogen was found to be Isospora belli in our study. A high prevalence of Cryptosporidium among both control and test population indicates high prevalence of asymptomatic carrier status among HIV seropositive individuals in Chennai which warrants further examination of its role as a potential pathogen..

 ~ Acknowledgement Top

The authors gratefully acknowledge the help of Stephanie P Johnston, Microbiologist, Division of parasitic Diseases, Centre for Disease Control and Prevention, Atlanta for providing the positive stool specimens (Cyclospora, Isospora and Microsporidia) and confirming our diagnosis. We are thankful to Prof. CN Deivanayagam, Govt. Hospital of Thoracic Medicine and YRG Health care authorities for providing stool specimens from HIV patients. 

 ~ References Top

1.Mukhopadya A, Ramakrishna BS, Gagandeep Kang, et al. Enteric pathogens in Southern Indian HIV infected patients with and without diarrhoea. Indian J Med Res 1999; 109:85-89.  Back to cited text no. 1    
2.Cegieslki JP, Ortega YR, Mc Kee S, et al. Cryptosporidium, Enterocytozoon and Cyclospora infection to pediatric and adult patients with diarrhoea in Tanzania. Clin Infect Dis 1994; 28:314-21.  Back to cited text no. 2    
3.Kelly P, Lungu F, Keane E, Baggaley R, Kazembu F, Pobee J, et al. Albendazole chemotherapy for treatment of diarrhoea in patients with AIDS in Zambia ; a randomized double blind controlled trial. Br med J 1996; 312:1187-91.  Back to cited text no. 3    
4.Soave R. Cyclospora: An overview. Clin Infect Dis 1996; 23:429-37.  Back to cited text no. 4    
5.Ash LR, Orihel TC: Parasites: A guide to laboratory procedures and identification - Ist Edition: (American society of Clinical pathologist, Chicago) 1987:5-53.  Back to cited text no. 5    
6.Weber R, Bryan RT, Owen RL, et al. Improved light microscopical detection of Microsporidia spores in stool and duodenal aspirates. The New Eng J Med 1992; 326:161-166.  Back to cited text no. 6    
7.Ma P, Soave R. Three step stool examination for Cryptosporidiosis in 10 homosexual men with protracted watery diarrhoea. J Infect Dis. 1983; 147: 824-28.  Back to cited text no. 7    
8.Escoledo AA, Nunez FA. Prevalence of intestinal parasites in Human Acquired Immunodeficiency Syndrome (AIDS) patients. Acta Tropica 1999; 72:125-30.  Back to cited text no. 8    
9.Ullrich R, Heise W, Berg C, L' age M, Riecken EO, Zectz M. Gastrointestinal symptom in patients infected with Human Immunodeficiency Virus:relevance of infective agents isolated from gastrointestinal tract. Gut 1992; 33:1080-4.  Back to cited text no. 9    
10.Tarimo DS, Killewo JZJ, Minijas JN, Msamanga GI. Prevalence of intestinal parasites in adult patients with enteropathic AIDS in north eastern Tanzania. East Afr Med J 1996; 73:397-9.  Back to cited text no. 10    
11.Molina JM, Sarfati C, Beanvas B, et al. Intestinal Microsporidiosis in Human Immunodeficiency Virus infected patients with chronic unexplained diarrhoea; Prevalence and Clinical and Biological features. J Infect Dis1993; 167:217-21.  Back to cited text no. 11    
12.Asmuth DM, De Girolami PC, Micheline F, et al. Clinical features of Microsporidiosis in patients with AIDS Clin Infect Dis1994; 18:819-825.  Back to cited text no. 12    
13.Shadduck JA. Human Microsporidiosis and AIDS. Rev infect Dis 1989; 11:203-07.  Back to cited text no. 13    
14.Van Gool T, Luder hoff E, Nathoo KJ, Kiire CF, Dankert J, Mason PR. High prevalence of Enterocytozoon bieneusi infections among HIV-positive individuals with persistent diarrhoea in Harare, Zimbabwe. Trans Royal Soc Trop Med Hyg 1995; 89:478-80.  Back to cited text no. 14    
15.Sandfort J, Hannemann A, Gelderblon H, Stark K, Owen RL, Nand Ruf B. Enterocytozoon bieneusi in immunocompetent patient who had acute diarrhoea and who was not infected with the Human Immunodeficiency Virus Clin Infect Dis 1994; 19: 514-6.  Back to cited text no. 15    
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