See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/224973462

Cryptosporidiosis

Thesis · April 2012

DOI: 10.13140/2.1.3546.7840

CITATIONS READS
0 198

1 author:

Paromit Chatterjee
WWF India
27 PUBLICATIONS   24 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Biodiversity Assessment through Long-term monitoring plots in the Indian Himalayan Landscape View project

Biodiversity Assessment through Long-term monitoring plots in the Indian Himalayan Landscape View project

All content following this page was uploaded by Paromit Chatterjee on 20 May 2014.

The user has requested enhancement of the downloaded file.

 April 27

Cryptosporidiosis 2012
Cryptosporidiosis, also known as crypto, is a parasitic disease caused by
Cryptosporidium, a protozoan parasite in the phylum Apicomplexa.
By Paromit
It affects the intestines of mammals and is typically an acute short-term infection. Chatterjee
 Cryptosporidiosis
Introduction
Cryptosporidiosis, also known as crypto, [1] is
a parasitic disease caused by Cryptosporidium, a
protozoan parasite in the phylum Apicomplexa. It
affects the intestines of mammals and is typically
an acute short-term infection. It is spread through
the fecal-oral route, often through contaminated
water; the main symptom is self-limiting diarrhea in people with intact immune systems. In
immunocompromised individuals, such as AIDS patients, the symptoms are particularly
severe and often fatal. Cryptosporidium is the organism most commonly isolated in HIV
positive patients presenting with diarrhea. Treatment is symptomatic, with fluid rehydration,
electrolyte correction and management of any pain. Despite not being identified until 1976, it
is one of the most common waterborne diseases and is found worldwide. The parasite is
transmitted by environmentally hardy microbial cysts (oocysts) that, once ingested, excyst in
the small intestine and result in an infection of intestinal epithelial tissue.
In India, there have been reports from the mid 1990s on the prevalence of cryptosporidiosis
from different parts of the country ranging from 8.53 to 81 per cent 4 with a high prevalence
being reported from the north eastern States4,5. A few studies from developed countries have
identified social and behavioural risk factors involved in transmission of cryptosporidiosis in
HIV infected patients6

Causal organism of cryptosporidiosis:

Cryptosporidiosis is caused by Cryptosporidium parvum, a microscopic one-celled parasite

that can live in the intestines of humans, farm animals, wild animals, and pets.
C. hominis (previously C. parvum). C. canis, C. felis, C. meleagridis, and C. muris can also
cause disease in humans.

By Paromit chatterjee Page 2

SCIENTIFIC CLASSIFICATION

Kingdom : Protista

Subkingdom : Protozoa

Phylum : Apicomplexa

Class : Conoidasida

Subclass : Coccidiasina

Order : Eucoccidiorida

Family : Cryptosporidiidea

Genus: Cryptosporidium

Life cycle

Cryptosporidium has a complex life cycle, which takes place within the intestinal epithelial
cell. Humans are infected after ingestion of the oocyst form. The infectious dose is low (less
than 10 oocysts for some strains) (70). In the intestinal lumen, the oocyst releases sporozoites,
which attach to host enterocytes and are enveloped. The parasites then enlarge and divide
within the parasitophorous vacuole within the microvillus layer of the epithelial cell (21).
After 48 to 72 h the host cell ruptures and releases the motile merozoites, which bind to the
epithelial surface and reinvade. Some of the merozoites differentiate into sexual forms, which
fuse to form the oocysts that are then shed into the intestinal lumen and the environment,
where they can survive for many months before infecting a new host.

By Paromit chatterjee Page 3

 Fig. 4 Diagrammatic
representation of lifecycle of
Cryptosporidium.
Infection starts with ingestion of
an oocyst(A) containing
sporozoites(B).Each of the
oocyst contains four sporozoites.
Digestive enzymes probably
release sporozoites (B) from
oocyst. Sporozoites enters an
epithelial cell, takes up a pseudo
external position, and matures
into a trophozoite (C).
Trophozoites feeds and
undergoes asexual multiple
budding process (schizogony) to
produce a type I Meront (D-E),
which releases Merozoites.
Merozoites invade other
epithelial cells and develop into
trophozoites (C). Once again
these undergo schizogony and
release Merozoites. Merozoites
of this second cycle of asexual
reproduction infect further
epithelial cells but mature into either microgamonts (G) or microgamonts (H) of the sexual
cycle. Microgamonts produces microgamete’s which, on release, fertilize the microgamonts
and produce a zygote (I). Zygote may follow several sporogenous developmental routes: it
may transform into an oocyst (J) by secretion of a thick wall and development of sporozoites,
while attached to the host cell, before becoming detached, and passing out of the gut; zygote
may secrete a thick wall and oocyst produced may become detached (DTO) before
development of sporozoites occurs; or zygote may develop into a thin walled oocyst (K)
containing sporozoites. Thin walled oocyst may liberate sporozoites, thus spreading infection
within the host. Microvilli have been omitted from infected cells for clarity.

Transmission

Infection is transmitted through contaminated material such as earth, water, uncooked or

cross-contaminated food that has been in contact with the feces of an infected individual or
animal. Contact must then be transferred to the mouth and swallowed. It is especially

By Paromit chatterjee Page 4

prevalent amongst those in regular contact with bodies of fresh water including recreational
water such as swimming pools. Other potential sources include insufficiently treated water
supplies, contaminated food, or exposure to feces. The high resistance of Cryptosporidium
oocysts to disinfectants such as chlorine bleach enables them to survive for long periods and
still remain infective. Some outbreaks have happened in day care related to diaper changes

People get cryptosporidiosis by swallowing Cryptosporidium oocysts. Even a few can cause
infection. Some sources of cryptosporidiosis are:

Human and animal waste

 Diapers, clothing, bedding, or other items can be soiled with stool from an infected
person or animal.
 Infected persons might have small amounts of Cryptosporidium-containing stool on
their skin in the genital area. Sexual activities that might involve contact with stool can
lead to infection with Cryptosporidium.
 The feces of animals, especially young animals and animals with diarrhea can contain
Cryptosporidium. People can be exposed to the parasite when touching animals,
cleaning up their droppings, cleaning cages or stalls, or visiting barns and other places
where animals live.

Food

 Food can be grown in or can fall on soil contaminated with human or animal waste.
 Unpasteurized milk and dairy products can be contaminated after contact with stool
from an infected animal.
 Food can be contaminated when it is handled by someone who is infected or when it is
washed with Cryptosporidium-contaminated water.

Water

Water in lakes, rivers, streams, ocean bays, swimming pools, hot tubs, and recreational water
parks can be contaminated with Cryptosporidium. People can get cryptosporidiosis if they

By Paromit chatterjee Page 5

drink this water or accidentally swallow it when swimming. Neither the chlorine used to
disinfect swimming pools nor the types of filters used in most pools can be depended on to
kill or remove Cryptosporidium.

 Contaminated drinking water or ice can be a source of Cryptosporidium infection.

Unlike most disease-causing organisms, Cryptosporidium is not completely removed or
killed by the treatment methods most commonly used for drinking water.

PATHOLOGY
The organism was first described in 1907 by Tyzzer, who recognized it was a coccidian. The first
recorded case of human cryptosporidiosis was reported in 1976 in a 3 year old girl from
Nashville who had symptoms of vomiting, watery diarrhea, and abdominal pains. At rectal
biopsy she was found to be infected with Cryptosporidium, and she recovered uneventfully
with supportive treatment. A review of three cases between 1976 and 1979 focused attention
on opportunistic cryptosporidial infections in immunocompromised patients. Each patient had

By Paromit chatterjee Page 6

presented with fever and chronic watery diarrhea, ranging from 10 days' to 3 years' duration.
In one patient the symptom of dehydration was so severe that during 10 days 60 liters of
parenteral fluid were administered, in addition to substantial oral intake.

Moderate to severe abnormalities of villous architecture were reported with mild chronic
inflammation of the lamina propria and slightly increased numbers of plasma cells,
polymorphonuclear leucocytes, and lymphocytes.
Between 1980 and 1983 more than 80 cases of cryptosporidial gastroenteritis in man
were reported either as a self limiting gastroenteritis in normal patients or as the severe
symptoms produced in immunocompromised patients, especially those with the acquired
immunodeficiency syndrome (AIDS).

 THE DISEASE IN IMMUNOCOMPETENT SUBJECTS

A total of 159 cases have been reported as separate case studies and surveys.
The outstanding clinical features of cryptosporidiosis are: flu like illness with watery
diarrhea; cramps; fever; malaise; and nausea (Table 4). Diarrhea is often characterized by two
to 10 watery stools a day, often beginning on the first or second day of illness

By Paromit chatterjee Page 7

 Alt
hough
anorexia
and
vomiting
were
noticed
more often
and, in a
few cases,
vomiting
was the
predominant or initial symptom. The diarrhoea, which was usually foul smelling, was
accompanied by considerable weight loss (10% of body weight) and prostration in some cases.
The abdominal pain tended to occur in the upper right quadrant. The incubation period usually
lasted between five days and two weeks after initial contact with the organism,293032 36
inducing symptoms that could last for five to 14 days.

 THE DISEASE IN IMMUNODEFICIENT SUBJECTS

In contrast to the short term flu like gastrointestinal illness in immunocompetent

patients, Cryptosporidium may cause severe protracted diarrhea in immunodeficient patients.
Most of the patients in the published records of immunocompromised patients had AIDS but
others had hypogammaglobulinaemia or were receiving immunosuppressive treatment. In
contrast to healthy subjects who had cryptosporidial infections, immunodeficient patients
inhabited urban rather than rural environments. Consequently, person to person transmission
may be an important factor in the spread of cryptosporidiosis, particularly in homosexuals.
Among these subjects it may form part of the so called "gay bowel syndrome" of
gastrointestinal infection acquired through homosexual practices.

By Paromit chatterjee Page 8

The mean duration of diarrhea for patients with AIDS was 20-6 weeks (range one to 78
weeks), with a fluid loss of between 1 and 12 liters a day. Patients who did not have AIDS
complained of diarrhea for between three and seven weeks, and three patients suffered
episodes of diarrhea lasting for three to six years. Fever, substantial weight loss (up to 50% of
initial weight), and abdominal pain were often reported.

DIAGNOSIS IN IMMUNOCOMPROMISED PATIENTS

Cryptosporidium infection in immunocompromised patients was usually diagnosed

by histological examination of biopsy material. Small bowel biopsy specimens were used
most often, although in seven of 30 cases biopsy together with faecal examination was
preferred. Necropsy studies showed that the proximal jejunum was the most heavily infected
region of the gastrointestinal tract, but infection may extend from the pharynx to the rectum.
In addition, cryptosporidia were also observed in lung biopsy specimens; they may have
spread to the respiratory tract either haematogenously or more probably as a result of
aspiration.13Histological changes are described as generally mild, consisting of slight
blunting and distortion of the villi, lengthening of the crypts, and a modest mononuclear cell
infiltration of the lamina propria.
Patients with AIDS have been co infected with a bewildering array of micro-
organisms in stark contrast to those without AIDS and immunocompetent patients.
Correlation between Cryptosporidium and AIDS has led to the proposal that it should be
included as an important factor in the differential diagnosis.
Immunosuppressant occurs naturally as a direct result of measles infection.
Cryptosporidiosis may occur in patients with measles, and local experience with more than
one such case suggests that the severity of symptoms is increased, more akin to the illness
seen in patients with AIDS, although with spontaneous resolution.

By Paromit chatterjee Page 9

Diagnosis of cryptosporidiosis
Cryptosporidiosis is diagnosed in a laboratory by examining a stool sample for oocysts. A
health-care worker who suspects cryptosporidiosis must specifically order testing for
Cryptosporidium, since routine tests do not test for this parasite.

Diagnostic tests

There are many diagnostic tests for Cryptosporidium. They include microscopy, staining, and
detection of antibodies. Microscopy can help identify oocyst in fecal matter.] to increase the
chance of finding the oocyst, the diagnostician should inspect at least 3 stool samples. There
are several techniques to concentrate either
the stool sample or the oocyst. The
modified formalin- ethyl acetate (FEA)
concentration method concentrates the stool.
Both the modified zinc sulfate
centrifugal flotation technique and the
Sheather’s sugar flotation procedure
can concentrate the oocyst by causing them to float. Another form of microscopy is
fluorescent microscopy done by staining with auramine.

Other staining techniques include acid-fast staining, which will stain the oocyst red. One type
of acid-fast stain is the Kinyoun technique. Giemsa staining can also be performed. Part of the
small intestine can be stained with hematoxylin and eosin (H & E), which will show oocyst
attached to the epithelial cells.

Detecting antigens is yet another way to diagnose the disease. This can be done with direct
fluorescent antibody (DFA) techniques. It can also be achieved through indirect
immunofluorescence assay. Enzyme-Linked ImmunoSorbent Assay (ELISA) also detects
antigens.

By Paromit chatterjee Page 10

Polymerase chain reaction (PCR) is another way to diagnose cryptosporidiosis. It can even
identify the specific species of Cryptosporidium. If the patient is thought to have biliary
cryptosporidiosis, then an appropriate diagnostic technique is ultrasonography. If that returns
normal results, the next step would be to perform endoscopic retrograde
cholangiopancreatography. TaqMan-based real-time PCR assay for detection and speciation
of Cryptosporidium parvum (bovine genotype) and Cryptosporidium hominis (human
genotype) has been developed and validated at CDC. The assay combines the detection of
two genomic targets: the 18S rRNA gene to achieve a sensitive detection
of Cryptosporidium spp. and a gene with unknown function to provide species differentiation.

Spreading of cryptosporidiosis

 Direct from livestock (common). Beware of risk from:

o Farms or petting zoos (especially in young ruminants).
o Contact with animal dung (for example during outdoor recreation).
 From personal contact with infected individuals (who may or may not have
symptoms). Beware particularly of the risk within playgroups, nurseries and day
centres.
 Waterborne. Note that new standards relating to monitoring of water supply were
introduced in 2000 in the UK.7 Beware of risk from:
o Contaminated water supply.
o Contamination of swimming pools and other water-based recreation sites.
o Through travel to less developed countries.

By Paromit chatterjee Page 11

  Food borne (salads, meat products, unpasteurized dairy products and milk).
 From infected patients in hospital.
 By exposure to human feces through sexual contact.

TREATMENT

Prevention & Control of Cryptosporidiosis

The following recommendations are intended to help prevent and control cryptosporidiosis.

Immunocompetent patients:
In healthy individuals, the disease is self-limiting and requires no treatment other than routine
rehydration measures.

Immunocompromised patients:
In malnourished or immunocompromised patients, drug management can be more
complicated and should be referred for specialist advice. The aim of treatment is symptomatic
improvement and clearance of the infection. Complete clearance of the parasite is unlikely
without correction of the immunodeficiency.

 Treatment of the immunodeficiency:

By Paromit chatterjee Page 12

 o In patients with HIV, highly active antiretroviral therapy (HAART) is the
treatment of choice. These are given in combination after the antiparasitic
drugs, to assist absorption of subsequent antiretroviral drugs.
o Protease inhibitors can produce dramatic improvements in clinical response.
As well as improving the CD4 cell level and restoring a degree of immunity,
protease inhibitors have reduced cryptosporidial host cell invasion and parasite
development in vitro.
o In other patients, improving immunity can also lead to improvement. For
example, reduction of immunosuppression in transplant patients has been
associated with parasite clearance and resolution of complications.
 Specific treatment:
o Nitazoxanide is not licensed in the UK but is available on a named patient
basis. It shortens duration and reduces mortality in malnourished children.
o Nitazoxanide is well tolerated with a good safety profile.
o Nitazoxanide, paromomycin and azithromycin are only partially effective and
results with cryptosporidiosis in AIDS patients remain disappointing.
o All the drugs currently available in the UK are of unproven benefit and
unlicensed for treatment of cryptosporidiosis. Trials are small and evidence is
conflicting. Drugs include the amino glycoside paromomycin, and macrolides
such as spiramycin, azithromycin, and clarithromycin.

Some Notable Cases:

1. In 1987, 13,000 people in Carrollton, Georgia, became ill with cryptosporidiosis. This
was the first report of its spread through a municipal water system that met all state
and federal drinking water standards.

2. In 1993, a waterborne cryptosporidiosis outbreak occurred in Milwaukee, Wisconsin,

USA. An estimated 403,000 people became ill, including 4,400 people hospitalized.
An estimated 69 people died during the outbreak, according to the CDC.

3. As of April 2011, there has been an ongoing outbreak in Skellefteå, Sweden. Although
many people have been diagnosed with cryptosporidiosis, the source of the parasite
has not yet been found. Several tests have been taken around the water treatment unit
"Abborren", but so far no results have turned up positive. Residents are being advised
to boil the tap water as they continue to search for the contaminating source.

By Paromit chatterjee Page 13

Surveillance and Outbreaks
Cryptosporidiosis is a nationally notifiable disease. This means that health care providers and
laboratories that diagnose cases of laboratory-confirmed cryptosporidiosis are required to
report those cases to their local or state health departments, which in turn report the cases to
CDC.

Outbreaks of cryptosporidiosis affecting multiple people that are related to water and food
should be reported to CDC by state health departments. It is important to inform local, state,
and federal health authorities about cases of cryptosporidiosis so that appropriate public health
responses can be taken to help control the spread of this disease.

Foodborne Outbreaks

 Outbreak Surveillance Data

 FoodNet Reports
 Foodborne Disease Surveillance and Outbreak Investigation Toolkit
 Diagnosis and Management of Foodborne Illness

Waterborne Outbreaks

 Recreational Water
 Recreational Water Illness Outbreak Response Toolkit
 Drinking Water
 Drinking Water Outbreak Response Toolkit
 CDC Waterborne Disease and Outbreak Report Form - CDC 52.12 (Rev. 03/2008)

Cryptosporidiosis

 Cryptosporidiosis Surveillance
 Cryptosporidiosis Case Definition
 Emergency Survey Methods in Acute Cryptosporidiosis Outbreak

By Paromit chatterjee Page 14

  Cryptosporidium Outbreak Response and Evaluation (CORE) Guidelines
Cryptosporidium and Water: A Public Health

CONCLUSION

Cryptosporidium has now emerged as a significant cause of diarrheal disease in humans,

lifestock and other animals throughout the world, and a major economic burden to the water
industry. Effects of infection vary with different species of Crystosporidium. Some species
effect many host species, whereas others appear restricted to groups such as rodents or
ruminants. Some species primarily infect the intestine, whereas some primarily infect the
stomach. Some species are pathogenic, whereas some are not realted to any disease
manifestation. Some infections are acute and self limiting, whereas some others are chronic.

The severity and duration of infection with pathogenic species are also affected by the
immune status of the infected person or animal. Immunocompetent individuals might suffer
mild, moderate or severe acute illness, whereas immunocompromised individuals can suffer
severe chronic illnesss or even death. Recent increased awareness of the threat of
cryptosporidiosis should improve detection in patients with diarrhea.New methods such as
those using polymerase chain reaction may help with detection of Cryptosporidium in water
supplies or in asymptomatic carriers. Although treatment is very limited, new approaches that
may reduce secretion or enhance repair of the damaged intestinal mucosa are under study.

References

1. "Cryptosporidiosis". Centers for Disease Control and Prevention. 2009-02-05.

By Paromit chatterjee Page 15

 2. Abrahamsen, M. S.; Templeton, TJ; Enomoto, S; Abrahante, JE; Zhu, G; Lancto, CA;
Deng, M; Liu, C et al. (2004). "Complete Genome Sequence of the
Apicomplexan, Cryptosporidium parvum". Science(Science/AAAS) 304 (5669): 441
3. Xu, Ping; Widmer, G; Wang, Y; Ozaki, LS; Alves, JM; Serrano, MG; Puiu, D;
Manque, P et al. (2004). "The genome of Cryptosporidium
hominis". Nature 431 (7012): 1107.
4. Carpenter C, Fayer R, Trout J, Beach M (1999). "Chlorine disinfection of recreational
water for Cryptosporidium parvum". Emerg Infect Dis 5 (4): 579–84.
5. Chen XM, Keithly JS, Paya CV, LaRusso NF (May 2002). "Cryptosporidiosis". N.
Engl. J. Med. 346 (22): 1723–31.
6. Harvey, Richard A., Pamela C. Champe, and Bruce D. Fisher. Lippincott’s Illustrated
Reviews: Microbiology. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007:
367, 388.
7. Winn Jr., Washington, Stephen Allen, William Janda, Elmer Koneman, Gary Procop,
Paul Schreckenberger, and Gail Woods. Koneman’s Color Atlas and Textbook of
Diagnostic Microbiology. 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006:
1267-1270.
8. "Cryptosporidiosis". Medline Plus. 2009-01-16. "A service of the U.S. National
Library of Medicine (NLM) and the National Institutes of Health (NIH)"
9. Ryan, Kenneth J. and C. George Ray. Sherris Medical Microbiology: An Introduction
to Infectious Disease. 4th ed. New York: McGraw-Hill, 2004: 727-730.
10. Brooks, Geo. F., Janet S. Butel, and Stephen A. Morse. Jawetz, Melnick, & Adelberg’s
Medical Microbiology. 23rd ed. New York: Lange Medical Books/McGraw Hill,
2004: 684-685.
11. Chen W, Harp JA, Harmsen AG (April 2003). "Cryptosporidium parvum infection in
gene-targeted B cell-deficient mice". J. Parasitol. 89 (2): 391–3.
12. Smith HV, Corcoran; New drugs and treatment for cryptosporidiosis. Curr Opin Infect
Dis. 2004 Dec; 17(6):557-64. [abstract]

By Paromit chatterjee Page 16

View publication stats