72
THE NATIONAL MEDICAL JOURNAL OF INDIA
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2 National AIDS Control Organization. Needle stick: First documented case. AIDS in
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3 Rose D, SudarsanamA, Padankatti T, Babu PG,John TJ. IncreasingprevalenceofHIV
antibody among blood donors monitoredover9
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4 Makroo RN, Salil P, Vashist RP, Shivlal. Trends of HI V infection in the blood donors
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5 Bhushan N, Pulimood BR, Babu PG, John TJ. Rising trend in the prevalence of HI V
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6 Richard VS, Kenneth J, Cheri an T, Chandy GM. Preventing transmission of bloodborne pathogens to health care workers. Natl Med J India 2000;13:82-5.
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9 National AJDS Control Organization. Management of occupational exposure and
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IO Beltrami EM, Williams IT, ShapiroCN, Chamberland ME. Riskand management of
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II Menon V, Bharucha K. Acquired immunodeficiency
syndrome and health care
professionals.v
Assoc Physicians India 1994;42:22-3.
Parasitic diarrhoea in patients with AIDS
A. S. CHOWDHARY,
P. J. DALAL,
ABSTRACT
Background. Diarrhoea is a common clinical manifestation
of HIV infection regardless of whether or not patients have
AIDS. Two newly recognized opportunistic coccidial protozoa
are parasitic pathogens in AIDS patients. We attempted to
determine the common parasites in Indian patients with AIDS.
Hethods. Between October 1994 and December 1996, a
total of 110 stool specimens from 94 AIDS patients with acute
or chronic diarrhoea were examined by microscopy of wet
mounts and smears stained by a modified Ziehl-Neelsen's (cold)
staining method.
Results. Isospora belli was the most frequently encountered
parasite in 17% of patients, followed by Entamoeba histolytica in
14.9% and Cryptosporidium in 8.5%. Strongyloides stercoralis
and Giardia lamblia were detected in 5.3% and 4.3% of patients,
respectively.
Conclusion. The presence of different parasites in 56.4%
of stool specimens of patients with AIDS indicates that their
specific diagnosis is essential. This will help initiate therapy to
Grant Medical College, Mumbai 400008, Maharashtra, India
MANOJ JOSHI, A. S. CHOWDHARY,
P. J. DALAL
Department of Microbiology
J. K. MANTAR
Department of Skin and Venereal Diseases
Correspondence
to MAN OJ JOSHI; [email protected]
© The National Medical Journal of India 2002
2, 2002
12 Siwach V, Dahiya D, Maheshwar Rao Ch V, Dhanda R, Sharma A, MinzM. Resident
doctors. blood borne pathogens and universal precautions: Are we sitting on a volcano?
Natl Med} India 2001 ;14: 179.
13 Bell DM. Occupational risk of human immunodeficiency virus infection in health care
workers: An overview. Am} Med 1997;102 (suppI5B):9-15.
14 Ippolito G. Puro V, De Carli G. The risk of occupational human immunodeficiency
virus infection in health care workers. The Italian Study Groupon Occupational Risk
of HIV infection. Arch Intern Med 1993;153: 1451-8.
15 Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R, Abiteboul D, et al.
A case-control study of HI V seroconversion in health care workers after percutaneous
exposure. Centers for Disease Control and Prevention Needlestick Surveillance group.
N Engl J Med 1997;337: 1485-90.
16 McClureHM, Anderson DC, Ansari AA, Fultz PN, Klumpp SA, Schinazi RF. Nonhuman primate models forevaluation of AIDS therapy. AnnN Y Acad Sci 1990;616:
287-98.
17 Jochimsen EM. Failures of zidovudine postexposure
prophylaxis.
Am J Med
1997;102(suppI5B):52-7.
18 Tokars 11, Marcus R, Culver DH, Schab Ie CA, McKibben PS, Bandea CI, et al.
Surveillance of HI V infection and zidovudine use among health care workers after
occupational exposure to HIV -infected blood. Ann Intern Med 1993;118:913-19.
19 Duff SE, Wong CKM, May RE. Surgeon's and occupational health departments'
awareness of guidelines on post-exposure prophylaxis for staff exposed to HIV: A
telephone survey. BM} 1999;319: 162-3.
20 Diprose P, Deakin CD, Smedley J.lgnoranceofpost-exposure
prophylaxis guidelines
following HIV needle-stick injury may increase the risk of seroconversion. Br J
Anaesth 2000;84:767-70.
reduce the morbidity and mortality among such patients due to
these pathogens.
Natl Med
MANOJ JOSHI,
J. K. MANIAR
VOL. JS,NO.
J
India 2002;15:72-4
INTRODUCTION
Although
gastrointestinal
diseases
occur in all groups of
immunocompromised
patients, they occur with the greatest frequency (up to 90% of patients in developing countries) in patients
with AIDS.' Diarrhoea is a common clinical manifestation
of
patients with HIV infection regardless of whether or not they have
AIDS.2 In the immunocompetent
host, Cryptosporidium and
Isospora cause acute enteritis which resolves spontaneously within
10-14 days. As an exception, cyclosporal diarrhoea can be prolonged (often 4 weeks) but self-limiting. However, in immunocompromised patients, diarrhoea due to coccidial species may be
severe, prolonged, debilitating and can become life-threatening. 3,4
Small bowel infection generally produces bloating, nausea, abdominal cramps, weight loss and profuse diarrhoea, which may
be watery and voluminous.'
Infection with the nematode Strongyloides is potentially lethal
because of its ability to cause an overwhelming
auto-infection,
particularly
in immunocompromised
patients." Disseminated
strongyloidiasis occurs in a variety of clinical settings of immunosuppression."
PATIENTS
AND METHODS
A total of94 AIDS patients with diarrhoea who were attending the
outpatient department or were admitted to the Sir lJ. Group of
Hospitals, Mumbai were studied between October 1994 and
December 1996. HIV seropositivity of the patients was confirmed
by testing for HIV antibodies
by DETECT-HIV
(Biochem
Immunosystems Inc., Montreal) and HIV -SPOT (Genelabs Diagnostics, Singapore).
AIDS patients with a history of3-4loose motions a day or more
73
JOSHI et al. : PARASITIC DIARRHOEA IN PATIENTS WITH AIDS
TABLE1. Clinical profile of AIDS indicator diseases
Disease
Pulmonary tuberculosis
Extensive oro mucosal candidiasis
Pulmonary tuberculosis and oromucosal candidiasis
Extrapulmonary tuberculosis (meningitis and abdominal)
and cryptococcal meningitis
Herpes simplex and tuberculosis
Herpes simplex and oromucosal candidiasis
Extensive molluscum contagiosum
Pyrexia of unknown origin and diarrhoea for> 1 month
n(%)
38 (40.4)
11 (11.7)
8 (8.5)
7 (7.4)
2 (2.1)
2 (2.1)
3 (3.2)
23 (24.5)
were included in the study. Symptoms such as passage of mucus
and blood in the stools, vomiting, abdominal pain and weight loss
were also noted.
A detailed clinical history was recorded for the presence of
AIDS indicator diseases such as tuberculosis (abdominal tuberculosis and tubercular meningitis), extensive oromucosal candidiasis, cryptococcal meningitis, extensive molluscum contagiosum
and chronic recurrent herpes simplex infections (Table I).
A total of 110 stool specimens were examined from the 94
AIDS patients. They were instructed to collect the faecal specimen, preferably in the morning, and to include the mucus and
watery or blood-tinged portions of the faeces in the specimen
submitted to the laboratory. Patients were instructed to avoid
contact of the specimen with urine or water. The specimens were
brought to the laboratory within one hour of submission and
processing was started immediately. Two wet mounts each (saline
and Lugol' s iodine) were prepared from the formed or semiformed
part of the stool by emulsifying a small portion of the specimen, as
well as the mucus. The wet mounts were carefully examined, first
under low power (10x) and then under high power (40x) with
reduced light. Micrometry was done to ascertain the size of various
ova, cysts and oocysts.
Isospora belli oocysts were identified as being 25-40 u in size,
colourless, transparent-shelled structures with a central granular
mass. Occasional oocysts with two sporocysts were also observed.
Rhabditiform larvae of Strongyloides stercoralis were identified
by their short mouth, double-bulb oesophagus and large genital
primordium. The non-motile larvae were carefully studied to
exclude plant fibres, root hair or body hair.
The presence of Isospora and Cryptosporidium oocysts was
confirmed by examining faecal smears stained by the modified
Ziehl-Neelsen's cold staining method.!? The faecal smears (fixed
in methanol for 5 minutes) were flooded with 4% carbol fuchsin
for 15 minutes without heating. Decolorization was done by 1%
acid alcohol (1 ml concentrated HCI in 99 ml ethanol) for 5-15
seconds depending upon the thickness of the smears. Counterstaining was done with 0.4% malachite green for 1 minute.
Microscopic examination was carried out under low power (lOx),
high power (40x) and under oil-immersion (100x) lenses. Intense
red, pink or faint pink, round and oval structures were especially
searched for and brought to focus under higher magnification for
confirmation and detailed study of their morphology and internal
contents and structures. The size of the suspected structures was
estimated by micrometry. The large number of artefacts, yeast
cells, fungal spores, pollen grains and vegetable cells, which
retained the red stain after decolorization were compared with
standard negative control slides.
RESULTS
Parasitological studies revealed a high positivity of 56.4% (Table
TABLEII. Presence of enteric parasites in stool specimens and
their correlation with duration of diarrhoea (n=94)
Parasites detected
n
Isospora belli
Cryptosporidium
Giardia lamblia
Entamoeba histolytica
Strongyloides stercoralis
Ascaris lumbricoides
Trichuris trichiura
Total
Values in parentheses
16
8
4
14
5
3
3
53
(17)
(8.5)
(4.3)
(14.9)
(5.3)
(3.2)
(3.2)
(56.4)
Acute diarrhoea
«4 weeks)
Chronic diarrhoea
(>4 weeks)
4 (4.2)
1 (1.1)
12 (12.8)
7 (7.5)
4 (4.3)
5 (5.3)
4 (4.2)
I (1.1)
9 (9.6)
I (1.1)
2 (2.1)
2 (2.1)
19 (20.2)
1 (1.1)
34 (36.2)
are percentages
TABLE
III. Correlation of gross and microscopic findings with
parasites detected in diarrhoeal stool specimens (n=llO)
Parasites
Stool
specimens
Consistency
Watery
Isospora
21 (19.1)
Cryptosporidium 10 (9.1)
Giardia
5 (4.5)
Entamoeba
15 (13.6)
7 (6.4)
Strongyloides
Ascaris
3 (2.7)
Trichuris
3 (2.7)
64 (58.2)
Total
Formed
Mucus
Present
Puscellsl
hpf
Absent
18
10
5
9
4
3
18
3 0-2 (8-10*)
0-2 (6-8*)
0
10
0
0
5
0
10-20
15
6
0
10-20
3
1
0-2
6
0
3
2
1
0-2
0
3
2
1
0-2
46 (41.8) 18 (16.4) 58 (52.7) 6 (5.5)
• In specimen with mixed infections
parentheses are percentages
due to Giardia or E. histolytica
Values in
II). The most frequently detected protozoan was Isospora belli in
16 patients (17%) followed by E. histolytica in 14 (14.9%). The
most common helminthic parasite detected was Strongyloides
stercoralis in 5 patients (5.3%).
Protozoan parasites were predominantly observed in the stool
specimens of patients presenting with diarrhoea of >4 weeks'
duration (chronic diarrhoea). Coccidial parasites and chronic
diarrhoea were significantly associated (p=0.005), as compared to
the other enteric parasites.
Enteric parasites were detected in 41.8% of watery specimens
and in 16.4% of formed specimens (Table III). The presence of
mucus in the faecal specimen and examination of wet mounts and
smears prepared from it revealed parasites in 52.7% of specimens.
Only 5.5% of specimens without mucus revealed enteric parasites. Infection with extracellular protozoa was associated with
10-20 pus cells per high power field or more. There was a
significant association between the presence of protozoan parasites and watery diarrhoea (p=0.007). Also, the number of pus
cells were higher in stool samples from patients with E. histolytica
and G. lamblia, indicating the possibility of their invasive nature
in these immunocompromised patients (Table III).
DISCUSSION
Since the onset of the AIDS pandemic, the number of parasitic
pathogens recognized and the frequency with which they are
encountered in clinical practice have increased. 10 Gastrointestinal
symptoms, particularly diarrhoea, occur in 30%-50% of North
American and European patients and in nearly 90% of AIDS
patients in developing countries. II Isospora belli, a coccidial
protozoan has recently been recognized as an opportunistic enteric
pathogen in patients with AIDS. Isospora belli is more common
in tropical and subtropical than in temperate climates, and has
been encountered in 15% of patients with AIDS in Haiti. 12.13 It is
74
THE NATIONAL MEDICAL JOURNAL OF INDIA
the cause of gastrointestinal infections in about 1%-3% of patients
with AIDS and diarrhoea in the USA, but in 15%-19% of AIDS
patients in developing countries. In an earlier study, 131 patients
with AIDS were treated for opportunistic
infection. Chronic
diarrhoea of >2 months' duration was a presenting symptom in
110 (S4%) of these patients. Eighty patients (61 %) had Isospora
belli, Cryptosporidium or both in their stool specimens.
Wefound Isospora belli to be the most common parasite (17%)
in AIDS patients with diarrhoea. In two other Indian studies,
Isospora was reported in 4.5% and 10.3% of patients.v'-" Hence,
the correct diagnosis of Isospora is of utmost importance to reduce
morbidity, especially since effective therapy as well as a prophylactic regimen for immunocompromised
patients are available. In
immunocompromised
patients, Isospora belli responds well to
treatment with trimethoprim (160 mg) and sulphamethoxazole
(SOOmg) given orally four times a day for 10 days. The prophylactic regimen/comprises
administration of 160 mg of trimethoprim
and SOOmg of sulphamethoxazo1e
three times a week."
Cryptosporidium spp. is increasingly being encountered as an
important
cause of diarrhoea
and enterocolitis
in immunocompromised
patients. In recent studies, the parasite was detected in 16% of patients with AIDS and diarrhoea in the USA.2,16
In Haiti, up to 50% of patients with AIDS have cryptosporidiosis."
Indian studies have reported higher prevalence rates (21 %-53%)
of cryptosporidiosis
in HIV -related diarrhoea.'4,'5,'7,'9We detected
Cryptosporidium in S.5% of AIDS patients. One reason for the
difference could be that intestinal parasitism differs markedly in
various conditions and factors such as humidity of the soil,
presence of organic matter, disposal of excreta, drinking water
supply and personal hygiene. Another reason could be that during
microscopic examination of the specially stained faecal smears,
many structures (pollen grains, vegetable cells, fungal spores and
yeast cells in particular) may resist decolorization and mimick an
acid-fast
body, and thus get misdiagnosed
as oocysts of
Cryptosporidium or Cyclospora.
Microscopic examination of multiple specimens and the use of
sensitive methods such as fluorescent techniques and antigen
detection is likely to reveal even larger numbers of coccidial and
other parasites. Also, in the concentration method, the filtration
step leads to loss of mucus and thereby considerably reduces the
number of cysts and oocysts.
Strongyloides stercoralis was observed in 5.3% of patients,
which correlates well with other Indian studies.'4,'5,'7 For strongy-
VOL. 15,NO.
2, 2002
loidiasis, thiabendazole (2.5 mg/kg twice daily for 5 days) is the
current treatment, although the maintenance regimen!has yet to be
established.v"
This study has shown the common pathogens involved in
causing morbidity in AIDS patients. Treatment ofthese may help
to decrease the morbidity and improve the quality of life of these
patients.
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