144Indian Journal of Medical Microbiology, (2006) 24 (2):144-5 Case Report
CYCLOSPORIASIS IN AN INFANT
RN Iyer Abstract
This report describes cyclosporiasis in a seven month old infant who presented with incessant crying and refusal of feeds. The routine modified ZN stained smears showed the oocysts of Cyclospora when all other tests failed to reveal enteric pathogens. The need for the clinical laboratory to screen faeces samples for all possible pathogens in a given clinical situation needs to be emphasized.
Key words: Cyclospora, infant, faeces.
Acute diarrhoeal illness represents a significant health subcultured on MacConkey’s agar after six hours of incubation problem in children, particularly in infants where infective at 37oC. Rotavirus antigen was tested using a sandwich ELISA diarrhoeal disease can lead to suboptimal development. Whilst technique. Parasitology studies were carried out on both the Cyclospora has been described in the literature as a cause of samples employing saline and Lugol’s iodine mounts, formalin childhood diarrhea.1,2 there are no reports of an infant suffering ether concentration technique with wet mounts for from cyclosporiasis. The following case report is an attempt examination and smears from the deposit for modified Ziehl in this direction. Neelsen. Four smears were also made directly from both the faecal samples for a modified ZN stain(cold carbol fuchsin and Case Report with 3% acid alcohol) for the oocysts of coccidian parasites. A Sheather’s sucrose floatation technique3 was carried out on A seven-month-old male infant, was brought to the out both the samples to detect oocysts of Cryptosporidium patient department with a history of low grade fever with species. Serotyping was done on E. coli isolates identified incessant crying. The infant was feeding poorly over the past by biochemical reactions from the growth on MacConkey’s week. It was weaned off breast milk at the fifth month of life agar plates in an attempt to identify one of the strains of and was on artificial feeds including milk and infant solid feeds. diarrhoegenic E. coli using standard antisera (BioRad). The mother added that her child had an episode of diarrhoea with three loose stools, a day before the onset of symptoms. The haematological parameters were within normal limits. However, the baby did not have any previous episodes of The HIV test was non reactive and the serum vomiting or diarrhoea. On examination, the infant appeared ill immunoglobulins were within normal limits. The faeces at ease, was pale but not icteric. The infant was mildly febrile samples appeared mushy and ill formed with no obvious o with a temperature of 99 F. A detailed examination of the mucoid, purulent or bloody areas. Cultures did not reveal any cardiovascular and respiratory systems was unremarkable. An pathogens. The Rotavirus antigen assay was negative in both abdominal examination did not reveal any abnormality. the faeces samples. Saline and iodine mounts from both the faeces samples did not reveal any cysts or trophozoites of Laboratory investigations included a complete blood count parasites. and ESR. The infant was also investigated for HIV infection and serum immunoglobulin levels were determined using rate Sheather’s sucrose floatation technique did not reveal any nephelometry. Two faeces samples were collected for oocysts of Cryptosporidium species. Modified ZN stained microbiological analysis and were processed in the laboratory smears showed the oocysts of Cyclospora species (10-12 within half hour of collection. The gross appearance of both oocycts were seen in the entire smear). They measured 10-12 samples was noted. Both samples were plated on blood agar, µ in size with variable staining characteristics that are typical MacConkey’s agar, Sorbitol- MacConkey agar, Salmonella- of Cyclospora (Figure). A diagnosis of Cyclospora infection Shigella agar, Hekton- Enteric agar, Wilson and Blair bismuth was made. The patient was treated with cotrimaxozole for sulphite medium and selenite F broth medium which was seven days. Repeat faeces examination on follow up after two weeks and four weeks of initiating therapy did not reveal any oocysts of Cyclospora species. (email:
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prasitology examination as it is readily amenable to therapy with cotrimaxozole and a follow-up through faecal parasitology examination is possible. This also obviates unnecessary antibiotic therapy in children which only serves to augment antibiotic resistance. Hence, it is mandatory for all clinical microbiology laboratories to attempt to screen for all possible pathogens in faeces, irrespective of the age or the clinical presentation or the request made by a clinician as this enhances chances of detecting a treatable pathogen.
Acknowledgement
The author wishes to thank Dr. A. Venkatalakshmi, consultant paediatrician and neonatologist from Rainbow Children’s Hospital, Hyderabad, for her help in providing the Figure: Modified ZN stained smear of faeces shows the oocyst of clinical details of the patient. Cyclopsora (x1000). References increasingly being identified in modified ZN stained smears of faeces samples from immunocompetent children, even in 1. Bern C, Hernandez B, Lopez MB, Arrowood MJ, deMejia MA, those with no history of travel.5 Whilst cyclosporiasis has been deMerida AM, et al. Epidemiological studies of Cyclospora reported in children, the exact prevalence of the infection in cyatanensis in Guatemala. Emerg Infect Dis 1999;5:766-84. immunocompetent children in developing nations is not 2. Madico G, Mc Donald J, Glman RA, Cabrera R, Sterling CR. determined. Studies from Nepa and Peru have placed the Epidemiology abd treatment of Cyclopora cayetanensis highest incidence of infection in children aged 18 months to infection in Peruvian children. Clin Infect Dis 1997;24:977-81. five years and the incidence is found to decrease with age.6,7 Infants who have been weaned off breast milk and given 3. Garcia LS, Bruckner DA, Brewen TC, Shimizu RY. Techniques artificial feeds are at a risk for water borne cyclosporiasis. The for the recovery and identification of Cryptosporidium oocysts present case is an example which also shows that not all cases from stool specimens. J Clin Microbiol 1983;18:185. of cyclosoriasis in infants will present with a watery diarrhoea. 4. Keystone JS, Kiyersky P, Belli I. Sarcocystis species, We believe that a single episode of loose stools with a low Blastocystis hominis and Cyclospora; Chapter 273. In: Mandell grade fever and incessant crying with refusal to feed may well Douglas and Bennett’s Principles and Practice of Infectious be the presenting symptoms of cyclosporiasis. Diseases, 5th ed. Mandell GL, Bennett JE, Dolin R, Editors Churchill Livingstone: London; 2000. p. 2915-20. The diagnosis rests on the demonstration of the oocysts of cyclospora with their variable staining characteristics. It is 5. Hale D, Aldea W, Caroll K. Diarrhoea associated with also important to examine a modified ZN stained smear from cyanobacteria like bodies in immunocompetent host. JAMA 271 the concentrated deposit of the faecal sample for these 1994; :144-5. coccidian parasites as they would be missed if this exercise is 6. Hooge W, Echeverrial P, Rajah R, Jacobs J, Malthouse S, not undertaken as in the present case. Special stains for Chapman E, et al. Prevalence of Cyclospora speices and other coccidian parasites may be required to be performed on all enteric pathogens among children less than five years of age in faecal samples submitted for a diarrhoeal work up in the Nepal. J Clin Microbiol 1995;33:3058-60. laboratory. Sole reliance on wet mount examination can lead 7. Madico G, Mc Donald J, Gilman RH, Cabrera L, Sterling CR. to errors in identification of these parasites, particularly by Epidemiology and treatment of Cyclopsora cyatenensis 8 inexperienced personnel. Sporulation assays and molecular infection in Peruvian children. Clin Infect Dis 1997;24:977-81. identification methods, though superior, are tedious, cumbersome and not available in al clinical laboratories. 8. Eberhard ML, Pieniayek NJ, Arrowood MJ. Laboratory diagnosis of Cyclospora infections (Review). Arch Pathol Lab Cyclosporiasis should not be missed on a faecal Med 1997;121:792-7.
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