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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~ Conclusion
 ~  References
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  Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 35  |  Issue : 3  |  Page : 432-435
 

Multiple parasitic and viral infections in a patient living with HIV/AIDS on antiretroviral therapy


1 Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Web Publication12-Oct-2017

Correspondence Address:
Nonika Rajkumari
Department of Microbiology, 2nd Floor, Institute Block, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmm.IJMM_16_304

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 ~ Abstract 

Patients with human immunodeficiency virus (HIV) infection are more prone for gastrointestinal infections causing diarrhoea, particularly with parasites. Parasitic infections have been regularly reported in such patients. A female patient confirmed positive for HIV 1 on antiretroviral therapy came with complaints of chronic diarrhoea for the past 7 months. Her initial CD4 count was 89 cells/μl of blood, and antibodies to cytomegalovirus and herpes simplex virus 1 and 2 virus were found to be positive in the patient's serum, but there was no HIV-associated retinopathy. Her stool examination showed decorticated fertilised eggs of Ascaris lumbricoides, cysts of Blastocystis sp. and Entamoeba species in the unconcentrated sample and oocysts of Cystoisospora species, egg of Schistosoma haematobium and eggs of Trichuris trichiura in the concentrated. The patient responded well to cotrimoxazole and albendazole, and repeat samples were negative for all these parasites.


Keywords: Cystoisospora belli, cytomegalovirus, human immunodeficiency virus, intestinal parasites, Schistosoma haematobium


How to cite this article:
Deepika K, Rajkumari N, Liji A S, Parija SC, Hamide A. Multiple parasitic and viral infections in a patient living with HIV/AIDS on antiretroviral therapy. Indian J Med Microbiol 2017;35:432-5

How to cite this URL:
Deepika K, Rajkumari N, Liji A S, Parija SC, Hamide A. Multiple parasitic and viral infections in a patient living with HIV/AIDS on antiretroviral therapy. Indian J Med Microbiol [serial online] 2017 [cited 2018 Oct 22];35:432-5. Available from: http://www.ijmm.org/text.asp?2017/35/3/432/216617



 ~ Introduction Top


Enteroparasites are the parasites that reside in the intestine of humans and animals. Their distribution is worldwide and they are most commonly associated with the immunocompromised patients such as those on glucocorticoid therapy, malignancy, and diabetes mellitus.[1] Patients with the human immunodeficiency virus (HIV) infection are more prone for gastrointestinal infections causing diarrhoea, particularly with parasites. This occurrence is more among the AIDS patients, where opportunistic parasitic infections cause severe diarrhoea, absorptive dysfunction and significant mortality. Multiple parasitic infections are frequently found in people with HIV infection in developing countries. However, the occurrence of simultaneous multiple parasitic infections or co-infections with other non-parasitic pathogens in a person who is on antiretroviral therapy (ART) have been rarely reported.[2] We report an interesting case of a patient living with HIV/AIDS on treatment presenting with multiple parasitic and viral infections.


 ~ Case Report Top


A 20-year-old unmarried female patient came to our hospital with complaints of chronic diarrhoea for the past 7 months. The stool was semisolid in consistency and frequency ranged from 4 to 6 episodes per day and was not associated with foul smell or blood. There were no complaints of vomiting or fever. The patient was apparently normal, except for diarrhoea and mild abdominal pain.

The patient has had complaints of abdominal pain, distension and progressive weight loss for the past 11 months, for which she was evaluated in our hospital. Ultrasonography of the whole abdomen showed multiple mesenteric lymphadenitis. The serum sample of the patient was identified to be reactive for antibodies to HIV 1 by the Pondicherry AIDS Control Society performed according to the NACO guidelines. The initial CD4 count of the patient was 89 cells/μl of the blood, and antibodies to cytomegalovirus (CMV) and herpes simplex viruses (HSV) 1 and 2 were found to be positive in the patient's serum. This suggests an infection in the past or recently or just a mere exposure to these agents. The patient could not give definite history or any symptoms of these two viral infections, nor were there any records in her treatment sheet. There was no evidence of any diseases in the oesophagus, intestine or liver, but some macular changes can be seen in her right eye which can be related to it. Results for this test are awaited. Further, on examination, infra-scapular creps can be elicited. The patient is on further evaluation. In addition, the treatment history showed that the patient did not have any changes related to HIV retinopathy too. The result of her HIV viral load is also awaited.

The patient was also worked up for tubercular adenitis as she complains of pain abdomen and had mesenteric lymphadenitis. She was afebrile and gives no history of evening rise of temperature. There was no ascites on per abdominal examination. Her sputum cultures were negative for Mycobacterium tuberculosis. An ultrasound-guided fine needle aspiration sample of the enlarged mesenteric lymph nodes showed negative for M. tuberculosis by both culture and histopathological examination. A repeat sample was taken and its result is awaited. Furthermore, the sputum samples were negative for fungal infections and coccidian parasites by microscopy.

The patient gave a history of having the basic diet of her financial status as she belongs to a lower middle-class family. All basic workup investigations were done on this patient. Her complete haemogram showed haemoglobin as 10.5 g/dL, red blood cells count as 4.1 × 106/μl, mean corpuscular volume as 82 fL, mean corpuscular haemoglobin (MCH) as 26 pg, MCH content as 32 g/dL, white blood cell count as 9.5 × 103/μl. Mild anaemia was seen in the patient. Moreover, hepatic function tests, renal function tests and lipid profile were done on the patient. Her first test report showed serum urea level as 24 mg/dL, creatinine as 0.8 mg/dL whereas total serum bilirubin level as 0.6 mg/dL, total protein as 7.3 g/dL, albumin as 4.0 g/dL, aspartate transaminase (AST) as 81 IU/L, alanine transaminase (ALT) as 43 IU/L and alkaline phosphatase as 248 IU/L. A repeat test of her serum sample showed urea level as 15 mg/dL, creatinine as 0.7 mg/dL whereas total serum bilirubin level as 0.6 mg/dL, total protein as 7.4 g/dL, albumin as 4.0 g/dL, AST as 86 IU/L, ALT as 67 IU/L, gamma-glutamyl-transpeptidase as 15 IU/L and alkaline phosphatase as 184 IU/L. Her lipid profile was within normal limits.

The patient was then categorised as Stage IV Clinical Staging according to WHO and was started on ART. She was started on tenofovir, lamivudine and efavirenz from November 2015. She was also on prophylaxis with cotrimoxazole. The CD4 count of the patient gradually increased to 292 cells/μl by May 2016. On going through her records, we found that there was a variation in the adherence rate to ART drugs. There was neither clinical manifestation nor any history of treatment for sexually transmitted infections.

The patient's parents had died when she was <1 year of age. She has two elder sisters who are apparently normal till now. The patient has completed tenth grade of education and is at her home currently. She is not employed. The likely source of HIV infection is suspected to be from her mother. The HIV status of her father was unknown, but her mother had died from complications due to this infection.

The patient was examined and her vitals were noted to be stable. Stool sample collected in a sterile leakproof screw-capped container was sent to Microbiology Department to check for the presence of parasitic infections. Saline, lactophenol cotton blue and iodine wet mounts of the unconcentrated stool sample were made, and we identified decorticated fertilised eggs of Ascaris lumbricoides [Figure 1], cysts of Blastocystis sp. [Figure 2] and Entamoeba species were noted. As the patient was immunocompromised, we performed a Sheather's sugar floatation technique thinking about the possibility of infection with intestinal coccidian parasites. Wet mount and modified acid-fast staining were performed from the sediment. We noted that a plenty of acid-fast oocysts of Cystoisospora species [Figure 3] along with eggs of Schistosoma haematobium [Figure 4] and eggs of Trichuris trichiura [Figure 5] were seen.
Figure 1: Saline wet mount of the unconcentrated stool sample showing decorticated fertilised eggs of Ascaris lumbricoides

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Figure 2: Lactophenol cotton blue wet mount of the stool sample showing the cyst of Blastocystis species

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Figure 3: Modified acid-fast stain showing the acid-fast oocyst of Cystoisospora spp

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Figure 4: Modified acid-fast staining showing the non-acid-fast egg of Schistosoma haematobium

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Figure 5: Trichrome-stained smear showing egg of Trichuris trichiura

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Following microscopy report, the patient was immediately treated with cotrimoxazole at the dose of 800/160 mg once daily and albendazole 400 mg QID for 10 days. The patient responded well to the treatment, and a repeat stool sample was taken on the 12th day, in which there was no evidence of active parasitic infection. The condition of the patient improved and diarrhoea was reduced.


 ~ Discussion Top


The emergence and widespread distribution of AIDS is a major challenge to public health in recent years. HIV infection is a serious problem in the present day. A high rate of infection is found in many regions of the world, mainly the developing countries such as the Southeast Asia. Progression of AIDS and its association with intestinal parasitic infections is now a major hurdle to improvement.[1],[2] The prevalence of intestinal infections among HIV positive patients has been increasing in the recent years. Although atypical infections and multiple infections have been reported in HIV/AIDS patients before, to the best of our knowledge, this must be the first time where six multiple parasitic infections of different types were reported with possible infections by other etiological agents such as CMV, HSV1 and M. tuberculosis. A case report described an HIV-positive patient with infections by three different intestinal parasitic infections. However, the type of infecting parasites are different from what was seen in our case as it reported simultaneous infections by Giardia lamblia, Strongyloides stercoralis and Cryptosporidium species in a 35-year-old male.[3] The study done by Mathur et al. in 2013 demonstrated a prevalence rate of 50.36% intestinal parasite among the seropositive HIV patients. The most common parasites identified were Cryptosporidium parvum, followed by Entamoeba histolytica, Cystoisospora belli, hookworm, Cyclospora and Microsporidia.[4]Cystoisospora belli was seen associated with diarrhoea in AIDS patients mainly in the USA and Europe. A study done in Gujarat showed an increasing incidence of Cystoisospora infection in AIDS patients.[4] In our case also, we found C. belli as the predominant parasite in high numbers compared to the other parasites. Cystoisospora has also been found to the most common cause of diarrhoea in HIV patients in a study done in Chennai, South India,[5] whereas another study done by Mohandas et al. showed Cryptosporidium species as the most common parasite.[6] In the developed nations, there is an increased use of highly active antiretroviral therapy (HAART) therapy in AIDS patients, and as a result, there has been a reduction in the prevalence of infection with intestinal parasites.[7] Reports showed that S. stercoralis infection is very common in immunocompromised patients;[8] though we did not find the infection by this parasite in this patient.

Another interesting finding in our case was that the patient has concomitant HSV and CMV exposures that were demonstrated by the presence of antibodies in the patients serum. Co-infections with viruses are common among the opportunistic infections seen in HIV patients. Among the viral infections, HSV2 was found to be common in a study done in Kolkata.[9] Progressive loss of immune system in the patient along with low CD4 count makes the patient more prone to CMV infections.[8] When the patient has higher CD4+ T-cell levels, there occurs a spontaneous clearing of the parasite. In developing countries and resource-poor settings, patients are undiagnosed for long periods and usually present late in the course of the disease. As a result, the patients present with persisting and multiple intestinal infections along with low CD4+ T-cell counts.[7]

Most of the people living in this region has a habit of walking barefooted due to the hot climate and that must be one of the factors of her getting infections such as A. lumbricoides. In addition, most of her family members are farmers and manual labours which necessitate her working in unhygienic environment, which might be the possible source of her getting multiple infections. Her compromised immune status due to the HIV infection and lack of strict adherence to the HAART must have rendered her vulnerable to multiple parasitic infections. The patient has been counselled about the various risks and its sources and also the various precautions to be taken by her.


 ~ Conclusion Top


Intestinal coccidian parasites are the predominant cause of chronic diarrhoea in people living with HIV/AIDS. This study emphasises that though Cystoisospora is one of the most common coccidian parasites to cause diarrhoea among such persons, other intestinal parasitic infections along with co-infections by pathogens other than parasites can occur. Hence, effective screening and proper prophylaxis should be provided to the immunocompromised patients to prevent the subsequent consequences and complications in such patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ~ References Top

1.
Framm SR, Soave R. Agents of diarrhea. Med Clin North Am 1997;81:427-47.  Back to cited text no. 1
[PUBMED]    
2.
Manual on Laboratory Diagnosis of Common Opportunistic Infections Associated with HIV/AIDS. In Baveja UK, Sokhey J, editors. National Institute of Communicable Diseases and National AIDS Control Organization, Govt of India;2001. p.51-2. Available from: http://nicd.nic.in/writereaddata/linkimages/195.doc. [Last accessed on 2017 Oct 04].  Back to cited text no. 2
    
3.
Del Pilar-Morales EA, Cardona-Rodríguez Z, Bertrán-Pasarell J, Soto-Malave R, De León-Borras R. Multiple simultaneous gastrointestinal parasitic infections in a patient with human immunodeficiency virus.PR Health Sci J 2016;35:97-9.  Back to cited text no. 3
    
4.
Mathur MK, Verma AK, Makwana GE, Sinha M. Study of opportunistic intestinal parasitic infections in human immunodeficiency virus/acquired immunodeficiency syndrome patients. J Glob Infect Dis 2013;5:164-7.  Back to cited text no. 4
    
5.
Kumar SS, Ananthan S, Lakshmi P. Intestinal parasitic infection in HIV infected patients with diarrhoea in Chennai. Indian J Med Microbiol 2002;20:88-91.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Mohandas K, Sehgal R, Sud A, Malla N. Prevalence of intestinal parasitic pathogens in HIV-seropositive individuals in Northern India. Jpn J Infect Dis 2002;55:83-4.  Back to cited text no. 6
    
7.
Gupta S, Narang S, Nunavath V, Singh S. Chronic diarrhoea in HIV patients: Prevalence of coccidian parasites. Indian J Med Microbiol 2008;26:172-5.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Vazquez Guillamet LJ, Saul Z, Miljkovich G, Vilchez GA, Mendonca N, Gourineni V, et al. Strongyloides stercoralis infection among human immunodeficiency virus (HIV)-infected patients in the United States of America: A Case report and review of literature. Am J Case Rep 2017;18:339-46.  Back to cited text no. 8
    
9.
Saha K, Firdaus R, Santra P, Pal J, Roy A, Bhattacharya MK, et al. Recent pattern of co-infection amongst HIV seropositive individuals in tertiary care hospital, Kolkata. Virol J 2011;8:116.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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