Case report
Year : 2022 Month : July Volume : 11 Issue : 3 Page : MC01 - MC02 Full Version

Severe Cystoisospora belli Diarrhoea in Post Renal Transplant Patient
Swati Tewari, Sandeep Garg, Shweta Garg
1. Associate Professor, Department of Microbiology, NCR Institute of Medical Science, Meerut, Uttar Pradesh, India. 2. Consultant Nephrologist, Department of Nephrology, Nutema Hospital, Meerut, Uttar Pradesh, India. 3. Consultant Pathologist, Department of Pathology, Nutema Hospital, Meerut, Uttar Pradesh, India.
 
Correspondence Address :
Dr. Swati Tewari,
Address- L-8, Medical Campus LLRM Medical Campus, Meerut-250004,
Uttar Pradesh, India.
E-mail: tiwari.kaval.swati@gmail.com
 
ABSTRACT
: Cystoisospora belli (C. belli) is an opportunistic protozoal parasite. It is prevalent in tropical and subtropical areas of the world. It is frequently encountered in immunocompromised patients with Acquired Immunodeficiency Syndrome (AIDS) and other immunodeficiency illnesses. Infection usually occurs due to faecal contamination of food and water. Chronic severe watery diarrhoea occurs in C. belli infected patients. C. belli is diagnosed by demonstration of characteristic oocyst in the stool sample. The common methods used for stool examination are wet saline mount, iodine mount, and modified acid fast staining. Although C. belli is distributed worldwide and more prevalent in developing countries, it is hardly reported from India. Most of the cases reported from India are in Human Immunodeficiency Virus (HIV)-positive patients and not many are reported in renal transplant patients. Here, a case of a 27-year-old male post renal transplant patient having severe diarrhoea has been presented. The patient complained of watery diarrhoea off and on for last one month for which he had taken some medicine from his local level but was not relieved. The patient was negative for HIV and was on immunosuppressive drugs. The stool sample of the patient was examined by direct wet mount, iodine mount and acid fast staining. On microscopy, characteristic oocysts of C. belli were detected. The patient was given combination treatment to which he responded well.
Keywords : Chronic diarrhoea, Immunocompromised patients, Oocyst, Protozoal parasite
DOI and Others : DOI: 10.7860/NJLM/2022/53583.2655 Date of Submission: Dec 13, 2021 Date of Peer Review: Jan 09, 2022 Date of Acceptance: May 13, 2022 Date of Publishing: Jul 01, 2022 Author declaration: • Financial or Other Competing Interests: None • Was informed consent obtained from the subjects involved in the study? No • For any images presented appropriate consent has been obtained from the subjects. No PLAGIARISM CHECKING METHODS: • Plagiarism X-checker: Dec 15, 2021 • Manual Goog
 
Case Report
A 27-year-old male presented with diarrhoea and fever to the Nephrology Outpatient Department. The diarrhoea was described as pale yellow without frank blood. He had a frequency of 6-8 episodes per day for more than one month off and on. The past history revealed that the patient was a renal transplant recipient and his cousin was the donor. The patient was on Sirolimus (2 mg OD) for immunosuppression. Haematological investigations showed slightly increased total leucocyte count (13100/mm3). Biochemical laboratory tests indicated blood urea 36 mg/dL, serum creatinine 1.3 mg/dL, serum Alanine Transaminase (ALT) 108 IU/L, Aspartate Aminotransferase (AST) 52 IU/L, serum sodium 139 mEq/L, and potassium 3.6 mEq/L. He was also tested for Human Immunodeficiency Virus (HIV), and results were negative for Enzyme Linked Immunosorbent Assay (ELISA). The patient had no travel history to foreign countries.

The stool was pale yellow in colour and semisolid in consistency with presence of mucus. The pH was 7.0 and occult blood was strongly positive. C. belli was diagnosed by demonstration of characterstic oocyst in the stool sample. The methods used for stool examination were wet saline mount, iodine mount and modified acid fast staining. On microscopy many Cystoisospora oocysts were present in stool, elliptical in shape, with one or both ends slightly tapered. (Table/Fig 1)a,b Characteristically, most of the parasitic stages were with one or two sporoblasts and rarely immature forms.

The patient was treated symptomatically and with Bactrim-double-strength Trimethoprim-Sulfamethoxazole (TMP-SMZ) BD for 10 days and nitazoxanide (500 mg BD for three days). Repeat stool examination after two weeks on follow-up did not show C. belli oocysts even after concentration.
 
 
Discussion
C. belli is a coccidian, unicellular protozoan parasite that exists in the gastrointestinal region. It frequently causes diarrhoea, nausea, vomiting, abdominal pain, dehydration, weight loss, and headache in tropical and subtropical environments. Infection occurs by ingestion of sporocysts, containing oocysts (1),(2). The infection can cause disease in both adults and children, although it frequently occurs in immunocompromised patients. It is commonly spread through consumption of contaminated food or water. The diagnosis is based on examination of stool or duodenum biopsy. Acid fast staining is employed to detect C. belli oocysts. The routine analysis of infection with C. belli is challenging. The oocysts are hard to differentiate from some components in faeces, which makes it difficult to make a definitive diagnosis (3). Mostly recipients with any transplant suffer from some type of gastrointestinal difficulties. The detection of human intestinal coccidian parasites depends on the comprehensive examination of stool specimens, but apart from ova and parasites (O and P) examination, an acid fast stain is recommended for detection of Cystoisospora oocysts (3),(4).

Advances in the diagnosis of infectious diseases occur regularly, although the first form of diagnosis of parasitic infections is still by light microscopy of stool by an experienced microbiologist. Cystoisosporiasis is one of the indicators of immunocompromised status of patients. The patient responded well to treatment. A 7-10 day course of TMP-SMZ is impactful and provides quick clinical and parasitological cure (5). Other treatment regimens are also available (pyrimethamine-sulfadoxine), but there is limited data to support this (6). Fluoroquinolones can be used; however they have been found to be less effective as compared to TMP-SMZ (7).

In India, among most of the patients the disease is reported from HIV positive patients, such as studies by Haider M et al., Ghadage DP et al., Shah UV et al., Mudholkar VG and Namey RD, and Kumar SS et al., (8),(9),(10),(11),12]. To the best of the authors’ knowledge, the first case of cystoisosporiasis in a renal transplant patient was reported by Marathe A and Parikh K from Gujarat (13), and the present study reports the second case in a renal transplant patient in India. Moreover, this is the first reported case of C. belli infection in a renal transplant recipient in Western Uttar Pradesh.
 
 
Conclusion
Cystoisosporiasis occurs in immunocompromised patients and transplant patients along with those infected with HIV. Although, it is prevalent in immunocompromised patients, it can be prevented through personal hygiene and sanitation practices. Thorough washing of vegetables and fruits and sterilisation of water generally prevents fecal-oral transmission from contaminated food, water, and possibly, environmental surfaces. Moreover, a thorough history of patients regarding travel to endemic areas is important.
 
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TABLES AND FIGURES