Intestinal Coccidian Parasites

Intestinal coccidian parasites
Introduction
• Coccidian parasites belong to the phylum Apicomplexa
• Contain specialized structures(polar rings, micronemes and rhoptries)
which help them to invade host cells
• Includes Plasmodium, Babesia and Toxoplasma (in blood and tissues)
• Intestinal coccidian parasites
• Cryptosporidium
• Cyclospora
• Cystoisospora
Cryptosporidium
• So called because they were first identified in gastric crypts of mice in

1907
• First human case reported in 1976
• Two species infect man- C.hominis (only man) and C.parvum (man
and other mammals)
Morphology
• Oocyst- both infective and diagnostic form
found in faeces
• Round, small, 4-6µm in size, surrounded by a
cyst wall
• Contains 4 sporozoites
• Uniformly acid fast in nature
• Two types of oocysyts- thick walled (2 layers)
and thin walled(single layer)
• Extremely resistant to routine chlorination and
other disinfectants
Completes life cycle
in single host
Mode of transmission-
through contaminated
food and water (thick
Infective stage- walled oocyst) and
sporulated autoinfection (thin
oocyst walled oocyst)
Habitat
• Found attached to surface epithelial cells of villi of small intestine
• Also found less frequently in stomach, appendix, colon,rectum
• Intracellular but extracytoplasmic inside a parasitophorous vacuole
Pathogenesis
• Excystation- release of sporozoites in small intestine due to enzymatic action
• Attachment- to brush border with the help of CP47
• Penetration – with the help of apical complex
• Exists inside parasitophorous vacuole
• Activation of host cell kinase signaling pathway with release of
proinflammatory cytokines leading to -
Blunting and loss of villi
Lengthening of crypts
Infiltration of lamina propria by lymphocytes,plasma cells
Finally leads to increased secretion of water and chloride and reduced
absorption of sodium
Clinical features
• Immunocompetent hosts-
• Mild to moderate diarrhea (2 to 10 times per day) lasting 1-2 weeks
• Malaise, nausea, fever, abdominal cramps
• Recovery is complete, rarely fatal
• Immunocompromised hosts (AIDS)-
• Severe watery or mucus diarrhea for more than 20 weeks, 70 episodes of stool per
day, loss of body fluids upto 17 litres per day noted
• Weight loss of more than 50%, may end fatally in 50% of patients
• Extra intestinal manifestations- cholangitis, pancreatitis and respiratory infections
Epidemiology
• MAN is the key reservoir of infection
• Human faeces containing thick walled oocysts –human to human
faeco oral transmission (large water borne outbreaks reported)
• Cattle, livestock,pet animals –animal to human transmission
• Auto infection – by thin walled oocysts
• Rarely sexual contact or laboratory acquired infections have been
reported
Laboratory diagnosis
PARASITIC DIAGNOSIS
Diagnostic forms: OOCYSTS
SPECIMENS: faeces (3 samples)
Less frequently used specimens include sputum, bronchial washings,

duodenal aspirations (mainly in AIDS patients)
Stool- direct microscopy as well as concentration techniques (Sheather’s

sucrose floatation)
Saline/iodine preparation, acid fast staining, safranin-methylene blue stain

and DFA(gold standard)
50,000-500,000 oocysts/ml of liquid or formed stool required for smear

positivity
Laboratory diagnosis, cont’d
• Antigen detection in stool
ELISA- 66-100% sensitivity
ICT- Triage panel- detects E.histolytica, Giardia and
Cryptosporidium- 83-96% sensitivity and 99-100%
specificity
• PCR- 18srRNA, ß-tubulin genes- used for both stool
and water samples
• Commercial GE panel- multiplex PCR assay
Treatment
• Infection self limiting in immunocompetent hosts
• Supportive therapy to prevent dehydration include replacement of

fluid, electrolytes,nutrients
• Anti diarrhoeal agents of no value
• Nitazoxanide in HIV negative patients, paramomycin, spiramycin,

clarithromycin and azithromycin- some activity against Cryptosporidium
Cyclospora cayatanensis
• Humans are the only source
• Cause of traveler’s diarrhea
• Disease is prevalent in south America and south Asia including India and
Nepal
• Life cycle similar to Cryptosporidium except that the oocyst is double the
size, unsporulated when excreted, later develops 2 sporocysts with 2
sporozoites each
• Oocysts are partially acid fast and autofluorescent
• Similar pathogenesis as Cryptosporidium
• Amenable to treatment with cotrimoxazole, alternate- ciprofloxacin or
nitazoxanide
Life cycle of Cyclospora
Cystoisospora belli
• 200 species
• Only C.belli infects man
• Largest coccidian parasite
• Oocyst is oval, 20-33x 10-19 µm in size
• Unsporulated when excreted- develops 2 sporocysts each containing 4
sporozoites
• Acid fast and occasionally demonstrate autofluorescence
• Similar pathogenesis as the other two
• Responds to treatment with cotrimoxazole or ciprofloxacin or
pyrimethamine
Life cycle of Cystoisospora belli
Comparison of intestinal coccidian parasites
Cryptosporidium Cyclospora Cystoisospora

Microsporidia
• Historically considered protozoa but recently classified as fungus
• 200 genera and 1400 species- infect both vertebrate and invertebrate
hosts
• important human pathogens- Enterocytozoon bieneusi,
Encephalitozoon spp, Nosema and Microsporidium
• Small intracellular spore forming acid fast organisms – 1-4 µm in size
• They possess a unique organelle, the polar tubule
• Infective form- resistant spore (survives for months in the environment)
• Exposure to water and soil- major modes of transmission
Life cycle
Clinical presentation
• Highly varied
• Traditionally associated with severe diarrhea in AIDS patients,
sometimes affects immunocompetent hosts (E.bieneusi, E.intestinalis)
• Corneal ulcers- (Microsporidium)
Laboratory diagnosis
• Stool examination or corneal scrapings

• Trichrome stain method of choiuce
• Acid fast staining can be done
• Calcofluor white stain or DFA
• PCR
Treatment
• No specific treatment available
• ART and supportive therapy
• Fumagillin and nitazoxanide- some effect

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Intestinal coccidian parasites

• So called because they were first identified in gastric crypts of mice in

• First human case reported in 1976

Diagnostic forms: OOCYSTS

SPECIMENS: faeces (3 samples)

Less frequently used specimens include sputum, bronchial washings,

Stool- direct microscopy as well as concentration techniques (Sheather’s

Saline/iodine preparation, acid fast staining, safranin-methylene blue stain

50,000-500,000 oocysts/ml of liquid or formed stool required for smear

• Supportive therapy to prevent dehydration include replacement of

• Anti diarrhoeal agents of no value

• Nitazoxanide in HIV negative patients, paramomycin, spiramycin,

Cryptosporidium Cyclospora Cystoisospora

• Stool examination or corneal scrapings

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