Opportunistic Coccidia_PARA 10N_12 Aug 2023_ksn.pdf

upcph Opportunistic Coccidians: Cryptosporidium, Cyclospora, Cystoisospora, Toxoplasma Kathyleen S. Nogrado, MSPH, PhD Associate Professor Department of Parasitology/College of Public Health COL...

upcph Opportunistic Coccidians: Cryptosporidium, Cyclospora, Cystoisospora, Toxoplasma Kathyleen S. Nogrado, MSPH, PhD Associate Professor Department of Parasitology/College of Public Health COLLEGE OF PUBLIC HEALTH UNIVERSITY OF THE PHILIPPINES MANILA SEAMEO TROPMED Philippines Regional Centre for Public Health, Hospital Administration, Environmental and Occupational Health At the end of the class, the students are expected to: Describe the biology of opportunistic coccidian parasites Differentiate the different opportunistic coccidian parasites in relation to their biology Determine the appropriate diagnostic tool in detecting the opportunistic coccidian parasites Identify the prevention and control of these opportunistic coccidian parasites COLLEGE OF PUBLIC HEALTH SEAMEO TROPMED Regional Centre for Public Health, UNIVERSITY OF THE PHILIPPINES MANILA Hospital Administration, Environmental and Occupational Health  TAXONOMY KINGDOM : Protista PHYLUM: Apicomplexa CLASS: Conoidasida ORDER: Eucoccidiorida FAMILY: Eimeriidae SUBFAMILY: Cryptosporidinae SUBFAMILY: CYCLOSPORINAE Adapted from : The conceptual basis for a new classification of the coccidia. 2002. Astrid M. Tentera,*, John R. Bartab, Ian Beveridgec, Donald W. Duszynskid, Heinz Mehlhorne, David A. Morrisonf, R.C. Andrew Thompsong, Patricia A. Conradh  Picture of apicomplexan structure taken using an electron Diagrammatic representation of an apicomplexan structure microscope Image taken from The Apicoplast: An organelle with a Green Past Image taken from Roberts, Foundation of Parasitology COLLEGE OF PUBLIC HEALTH SEAMEO TROPMED Regional Centre for Public Health, UNIVERSITY OF THE PHILIPPINES MANILA Hospital Administration, Environmental and Occupational Health I. Cryptosporidium - Cryptosporidium parvum typically infects both cattle and humans. Ø C. hominis highly similar to C. parvum - Occupies the brush borders of intestinal epithelia - Causes CRYPTOSPORIDIOSIS -Opportunistic parasite of humans Ø immunodeficient Ø young children Ø Patient under immune-suppressive regimes Cryptosporidium sp. oocysts stained with modified Ø Persons infected with HIV acid-fast. Image taken from CDC website  Cryptosporidiosis as global disease Ø Globally, considered as a leading cause of diarrheal disease and child mortality. (Gerin and Striepen, 2020) Ø Among immunocompromised patients worldwide, diarrhea is a significant problem. Acute DALYs per 1000 child-years associated with Cryptosporidium infection in children younger than 5 years in 2016. (DALYs=disability-adjusted life-years ) Image taken from Lancet Glob Health 2018; 6: e758–68  Mode of Infection : INGESTION of the oocyst THICK-WALLED oocyst = excreted out with the feces/stool THIN-WALLED oocyst= AUTOINFECTION Mode of transmission : Fecal-oral route Life cycle of Cryptosporidium spp. COLLEGE OF PUBLIC HEALTH SEAMEO TROPMED Regional Centre for Public Health, UNIVERSITY OF THE PHILIPPINES MANILA Hospital Administration, Environmental and Occupational Health  DIAGNOSTIC METHODS Microscopy Sample is concentrated using formalin-ether sedimentation method Microscopic examination Acid-Fast (modified Ziehl-Neelsen method) or phenol- auramine staining Oocyst stain red Enzyme-linked immunosorbent assay (ELISA) Immunochromotographic test (ICT) – antigen- antibody based detection methods Polymerase Chain Reaction – GOLD STANDARD for detection of the parasite in stool Image taken from DOI: 10.1556/1886.2019.00019  Treatment Approved treatment : Nitazoxanide – For humans halofuginone – for animals Macrolides antibiotics Spiramycin Azithromycin – rat model (Georgiev V. Opportunistic infections: Treatment and developmental therapeutics of cryptosporidiosis and isosporiasis)  PREVENTION AND CONTROL Elimination and/or reduction of contamination of the environment with infectious oocysts Disinfection of contaminated areas – if feasible chlorine dioxide, hydrogen peroxide, or ammonia Use of physical stresses: irradiation, heat, cold, pressure, and desiccation Filtration of water sources CONVENTIONAL FILTRATION: coagulation, flocculation, and sedimentation DIFFERENT FILTRATION METHOD: direct filtration, conventional filtration, slow-sand filtration, diatomaceous earth filtration, bag filtration cartridge filtration, and membrane filtration  II. Cyclospora - Cyclospora cayetanensis - Causes Cyclosporiasis - Infect the epithelial cells of duodenum and jejunum (small intestines) Cyclospora oocysts from fresh stool stained using a modified acid-fast stain. Image taken from https://www.cdc.gov/parasites/cyclosporiasis/disease.html  Mode of Infection : INGESTION of the sporulated oocyst OOCYST has 2 sporocyst, each sporocyst contains 2 sporozoites *fluoresce under UV LIFE CYCLE OF Cyclospora Photo taken from https://www.cdc.gov/dpdx/cyclosporiasis/modules/Cyclosporiasis_LifeCycle_lg.jpg COLLEGE OF PUBLIC HEALTH SEAMEO TROPMED Regional Centre for Public Health, UNIVERSITY OF THE PHILIPPINES MANILA Hospital Administration, Environmental and Occupational Health Number of documented cases of human infection of C. cayetanensis worldwide. Image taken from https://doi.org/10.1017/S0031182019001471 COLLEGE OF PUBLIC HEALTH SEAMEO TROPMED Regional Centre for Public Health, UNIVERSITY OF THE PHILIPPINES MANILA Hospital Administration, Environmental and Occupational Health  DIAGNOSTIC METHODS MICROSCOPY - LIGHT OR EPIFLUORESENCE MOLECULAR DETECTION TECHNIQUES – NESTED PCR targeting the 18S rRNA gene  TREATMENT trimethoprim-sulfamethoxazole (TMP- SMX) Ciprofloxacin – given to patients intolerant of sulfonamide drugs Nitazoxanide  PREVENTION AND CONTROL Proper hygiene habits Food washing and sanitation Good agricultural practices Abstaining from eating raw produce (fruits and vegetables) in endemic areas  III. ISOSPORA - Cystoisospora proposed new member of phylum Apicomplexa to contain the genus Isospora - Cycloisospora belli - Cystoisosporiasis Image of C. belli oocyst viewed under ultraviolet - Endogenous stages are located the enterocytes lining (UV) microscopy showing the two sporoblasts pointed by the arrow. the villi of the the small intestines Image taken from https://www.cdc.gov/dpdx/cystoisosporiasis/index.html  Mode of infection: Ingestion of the oocyst Infective stage: Sporulated oocyst Diagnostic stage: Oocyst ( in feces) Image taken from https://www.cdc.gov/dpdx/cystoisosporiasis/index.html COLLEGE OF PUBLIC HEALTH SEAMEO TROPMED Regional Centre for Public Health, UNIVERSITY OF THE PHILIPPINES MANILA Hospital Administration, Environmental and Occupational Health  Cystoisosporiasis v Cystoisospora belli (formerly known as Isospora belli) v Infection with C. belli is found in tropical, subtropical and warm temperate regions. v Infection causes diarrheal disease in immunocompetent and immunocompromised individuals. *Could cause chronic and recurrent infection in AIDS patients. v Tissue cysts of C. belli can also occur among patients Image of a monozoic tissue cyst (arow) of C. belli in the mesenteric with AIDS found in mesenteric and other lymph nodes. lymph node of an AIDS patient. Image taken from DOI 10.1007/978-3-642-27769- 6_798-2  DIAGNOSTIC METHOD Ø MICROSCOPY o Sheather sugar flotation method o Stained fecal smears § Modified acid-fast staining : Oocysts – stained pink § Auramine-rhodamine – oocyst fluoresce bright yellow § Giemsa stain – oocysts and sporocyst stain pale blue § Heated safranin-methylene blue – oocysts are orange-red Ø PCR methods  Treatment v Trimethroprim sulfamethoxazole (TMP) or pyrimethamine + sulfonamides (sulfamethoxazole-Trimethoprim, sulfadiazine or sulfadioxine) v Macrolide antibiotics – roxithromycin v Veterinary anticoccidial drugs  Prevention and Control Improvement of personal hygiene and sanitary conditions To prevent fecal-oral transmission Washing fruits and vegetables thoroughly before consumption. Improvement of water quality in endemic areas by filtration or boiling. Water used for drinking and food preparation  Prevention and Control Controlling sources of contamination in the field can be done by: Thorough hand washing Access to toilet facilities Proper disposal and treatment of human sewage Workers having gastrointestinal symptoms should not be allowed to come in contact with vegetables or food.  IV. Toxoplasma - Toxoplasma gondii - Toxoplasmosis - Important in humans because it is a complicating Sporulated oocyst of factor among immunosuppressed patients Toxoplasma gondii in an unstained wet mount. Image taken from https://www.cdc.gov/dpdx/toxoplasmosis/ - Definitive host/s: cats and other felines intermediate host: other vertebrate animals  Humans can acquire infection via: - ingestion of contaminated meat - Consuming food or water contaminated with the sporulated oocysts -blood transfusion or organ transplant - transplacental Image was taken from Schmidt, GD and Robert, LS. Foundations of Parasitology. 8th edition LIFE CYCLE OF Toxoplasma gondii COLLEGE OF PUBLIC HEALTH SEAMEO TROPMED Regional Centre for Public Health, UNIVERSITY OF THE PHILIPPINES MANILA Hospital Administration, Environmental and Occupational Health  Toxoplasmosis Antibody to T. gondii is prevalent in humans worldwide Clinical toxoplasmosis is less common – ASYMPTOMATIC OR MILD INFECTIONS Infection with toxoplasmosis during pregnancy could result to abortion. This has been document for example in the outbreak that occurred in Atlanta Georgia, USA Mother to fetus transmission This has been documented in an outbreak that occurred in Canada, mothers who were found infected with T. gondii gave birth to infected children. Comorbidity factor in organ or hematopoietic stem cell transplant as well as in immunocompromised patients. COLLEGE OF PUBLIC HEALTH SEAMEO TROPMED Regional Centre for Public Health, UNIVERSITY OF THE PHILIPPINES MANILA Hospital Administration, Environmental and Occupational Health  DIAGNOSTIC METHOD Definitive diagnosis could be done if the parasite is identified by necropsy or biopsy. Enzyme-Linked Immunosorbent Assay (ELISA) Indirect Fluorescence Antibody Test (IFAT) Molecular method by Polymerase Chain Reaction (PCR) Detection of DNA parasite Especially important among immunocompromised patients Samples : cerebrospinal fluid (CSF, broncho-alveolar lavage fluid (BALF), or peripheral blood  TREATMENT - The widely used chemotherapeutic for toxoplasmosis is pyrimethamine + sulfonamide. OTHER drug combination: - Trimethoprim+ sulfamethoxazole  PREVENTION AND CONTROL Food for consumption like meat should be cooked thoroughly. Wash the fruits or vegetables thoroughly Avoid drinking untreated water Proper handwashing  PREVENTION AND CONTROL Sandbox outside home should be covered. Cat litter box should be changed regularly. For pregnant women and immunocompromised patients: Refrain from cleaning the litter box if they own cat as pet. References: Schmidt, GD and Robert, LS. Foundations of Parasitology. 8th edition.MrGraw-Hill Higher Education. 2009. Gerace E. et al.2019.Cryptosporidium Infection: Epidemiology, pathogenesis, and differential diagnosis.European Journal of Microbiology and Immunology. 9:4. pp.119-123 Guerin A and Striepen B. 2020. The biology of the intestinal intracellular parasite Cryptosporidium. Cell and Host & Microbe. Cell Press. https://doi.org/10.1016/j.chom.2020.09.007 Lindsay DS and Weiss LM. Chapter 141. Cystoisospora, Cyclospora, and Sarcosystis. Manual of Clinical Microbiology, 11th ed. Wiley Online Library. Li J, Wang R, Chen Y et al..2020. Cyclospora cayetanensis infection in humans: biological characteristics, clinical features, epidemiology, detection method and treatment. Parasitology. 147. pp 160-170. https://doi.org/10.1017/ S0031182019001471 Ortega YR and Sanchez R. 2010. Update on Cyclospora cayetanensis, a food-borne and waterborne parasite. Clinical Microbiology Reviews. 23:pp. 218-234.  References: Roberts LS and Janovy, Jr. J. 2009. Foundations of Parasitology. 8th ed. McGraw-Hill Companies. Li J, Wang R, Chen Y, Xiao L. 2020. Cyclospora cayetanensis infection in humans: biological characteristics, clinical features, epidemiology, detection method and treatment. Parasitology.147. pp.160-170. https://doi.org/10.1017/ S0031182019001471 Ortega YR and Sanchez R. 2010. Update on Cyclospora cayetanensis,a Food-borne and Waterborne Parasite. Clinical Microbiology Reviews.23:1. pp. 218-234. Lindsay D, Dubey JP and Blagburn BL. 1997. Biology of Isospora spp. from humans, nonhuman primates, and domestic animals. Clinical Microbiology Reviews. 10:1.pp19-34. Dubey, JP and Almeria S. 2019.Cystoisospora belli infections in humans: the past 100 years. Parasitology. 146. pp.1490-1527. Lindsay, DS.2015. Cystoisospora. Encyclopedia of Parasitology. DOI 10.1007/978-3-642-27769-6_798-2 Dubey, JP. 2021. Outbreaks of clinical toxoplasmosis in humans: five decades of personal experience, perspectives and lessons learned. Parasites Vectors. 14:63. https://doi.org/10.1186/s13071-021-04769-4 Dupon, D, Fricker-Hidalgo, H, Brenier-Pinchart M-P et al. 2021. Serology for Toxoplasma in immunocompromised patients: Still Useful?. Trends in Parasitology. 37:3. https://doi.org/10.1016/j.pt.2020.09.006 COLLEGE OF PUBLIC HEALTH SEAMEO TROPMED Regional Centre for Public Health, UNIVERSITY OF THE PHILIPPINES MANILA Hospital Administration, Environmental and Occupational Health