Isospora belli associated recurrent diarrhea in a child with AIDS

Abstract

Persistent diarrhea is a major manifestation of Acquired Immunodeficiency Syndrome (AIDS) which might be more complicated in Human Immunodeficiency Virus (HIV) infected children especially those from developing countries. There are numerous reports showing the emergence of intestinal opportunistic coccidian parasites, mostly Cryptosporidium parvum and Isospora belli in HIV-infected individuals. The prevalence of isosporiasis is probably underestimated in developing countries because routinely not all HIV-infected patients are examined for the presence of this protozoan infection. Here we report a case of HIV-infected isosporiasis presenting with failure to thrive and persistent diarrhea. Since I. belli infection in children responds well to therapy with trimethoprim-sulfamethoxazole, isosporiasis should be considered as a treatable infection in AIDS, if it is detected at proper time.

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SHORT COMMUNICATION
Isospora belli associated recurrent diarrhea in a child with AIDS
M. Nateghi Rostami •B. Nikmanesh •
M. T. Haghi-Ashtiani •M. Monajemzadeh •
M. Douraghi •Z. Ghalavand •L. Kashi
Received: 14 January 2013 / Accepted: 23 February 2013 / Published online: 7 March 2013
ÓIndian Society for Parasitology 2013
Abstract Persistent diarrhea is a major manifestation of
Acquired Immunodeficiency Syndrome (AIDS) which
might be more complicated in Human Immunodeficiency
Virus (HIV) infected children especially those from
developing countries. There are numerous reports showing
the emergence of intestinal opportunistic coccidian para-
sites, mostly Cryptosporidium parvum and Isospora belli in
HIV-infected individuals. The prevalence of isosporiasis is
probably underestimated in developing countries because
routinely not all HIV-infected patients are examined for the
presence of this protozoan infection. Here we report a case
of HIV-infected isosporiasis presenting with failure to
thrive and persistent diarrhea. Since I. belli infection in
children responds well to therapy with trimethoprim-
sulfamethoxazole, isosporiasis should be considered as a
treatable infection in AIDS, if it is detected at proper time.
Keywords Isospora belli Failure to thrive AIDS 
Diarrhea
Introduction
Opportunistic infections account for cases of severe and
persistent diarrhea in immunocompromised individuals.
Isospora belli, one of the human coccidian parasites, is
among the most commonly identified causes of chronic
diarrhea in patients with Acquired Immunodeficiency
Syndrome (AIDS). Isosporiasis is primarily considered a
waterborne and/or a foodborne disease. I. belli infection in
immuocompetent hosts is often associated with a self-
limited watery diarrhea accompanied with abdominal pain,
steatorrhea, and peripheral eosinophilia. In children, espe-
cially those with AIDS or other immunodeficiencies,
clinical outcome may be more severe, characterized by
dehydration, malabsorption, weight loss, nausea, vomiting,
fever and malaise (Arora and Arora 2009; Mirdha et al.
2002). Since coccidian parasites are important opportu-
nistic infections in AIDS, it is crucial to have as much
information as possible regarding the manifestations and
management of these infections especially in children.
Here a case of HIV-infected isosporiasis presenting with
failure to thrive (FTT) is reported.
Case report
In February 2009, a 3 year-old girl was admitted with FTT
with a 4 kg weight loss during 2–3 months, low-grade fever,
and severe diarrhea. She experienced episodes of recurrent
diarrhea from 5 months ago with 1 week relief intervals.
Physical examination was normal except for white patches
M. Nateghi Rostami
Department of Public Health, Faculty of Health, Qom University
of Medical Sciences, Qom, Iran
e-mail: rostami52@yahoo.com
B. Nikmanesh (&)M. T. Haghi-Ashtiani 
M. Monajemzadeh L. Kashi
Department of Pathology, Children’s Medical Center, Tehran
University of Medical Sciences, No. 62, Dr. Gharib St.,
Keshavarz Blvd., Tehran, Iran
e-mail: bahram_nikmanesh@yahoo.com
M. Douraghi
Division of Bacteriology, Department of Pathobiology,
School of Public Health, Tehran University of Medical
Sciences, Tehran, Iran
Z. Ghalavand
Department of Microbiology, Shaheed Beheshti University
of Medical Sciences, Tehran, Iran
123
J Parasit Dis (Oct-Dec 2014) 38(4):444–446
DOI 10.1007/s12639-013-0272-y

on the mouth palate. Biopsy of esophageal and duodenum
showed moderate esophagitis and dilated lymphatic chan-
nels in lamina propria of duodenum suggestive of lym-
phangiectasis. Cystic fibrosis and celiac disease were ruled
out in the patient by laboratory methods. Leukocyte count,
Hb and platelet count were in normal range. Erythrocyte
sedimentation rate (ESR) was varied between 37 and
45 mm/hr. Liver function tests (LFT) were slightly
increased, with ALT of 68 mg/dl (normal up to 40) and AST
of 97 mg/dl (normal up to 40), but ALP was 318 mg/dl
which existed in normal range (180–1200 mg/dl). Routine
stool examination for ova and parasites and stool culture for
pathogenic coliforms were negative. Sudan black staining of
stool smear showed significant fat droplets and moderate
number of yeast bodies. Treatment was started with cefexim,
gentamycin, metronidazole and fluconazole, and then fol-
lowed by amikacin and penicillin. After 2 weeks, the patient
ameliorated and discharged with orally administered tri-
methoprim-sulfamethoxazole (TMP-SMX) and medium
chain triglycerides (mct oil) regimen.
After 13 months, the patient again was admitted with
malabsorption and abdominal discomfort. She suffered
from fever, productive cough, wheezing, violent mucoid
diarrhea, steatorrhea, repeated foul smelling feces and
emaciation. Endoscopy showed esophageal ulceration,
exodative otitis was noticed at physical examination, and
chest X-ray showed paratracheal bilateral consolidation.
Human Immunodeficiency Virus (HIV) Ab was positive
using ELISA method which was confirmed by western
blotting technique. HBs Ag and Ab, HBc Ab, and HCV Ab
all were negative. CD4/CD8 T cell ratio was reduced to as
much as 0.2 % down to 0.09 %. The relative count of
CD4 ?cells ranged from 6.9 to 9 % of total lymphocytes.
Also, CD19 and CD20 positive cells were reduced to 1.8
and 1.9 % of total lymphocyte, respectively. Laboratory
examinations showed that leukocyte count was 5.3 910
9
/l
and platelet count dropped to 38 910
9
/l. Also, laboratory
findings showed hyper c-globulinemia and increased liver
enzymes as AST 127 mg/dl, ALT 59 mg/dl, c-GT 184 IU/l
(normal range: 7–60) and bilirubin in normal range. There
was history of sibling death as a result of pulmonary
infection and dysentery at 8 month old age. The patient’s
mother, a 55 years old white woman was infected with
HIV through heterosexual transmission from her husband
who was working as a truck driver and had been diagnosed
with AIDS. The stool specimen was macroscopically
watery and permanent stained smear with modified Ziehl-
Neelsen acid fast method showed many I. belli oocysts,
measuring on average 27 913 lm in diameter (Fig. 1)
Careful search failed to reveal other coccidian parasites
such as Cryptosporidium spp. infection. Small bowel fol-
low-through showed severe hypertrophy of duodenal and
jejunal mucosa and normal ileum.
She was put under the treatment of vancomycin, cefo-
taxime, ceftazidim, and TMP-SMX. The acid-fast staining
of stool specimens turned negative for I. belli oocyst after
TMP-SMX treatment completion. She discharged after
9 days by her parents request and consent, and unfortu-
nately died after 1 month.
Discussion
Isospora is worldwide distributed particularly in the trop-
ical and subtropical regions (Arora and Arora 2009; Gupta
et al. 2008). Very limited information is available on
isosporiasis infection from Iran, few cases were reported in
a recent study of 356 HIV-positive patients (Agholi et al.
2013) and as a case report (Hazrati Tappeh et al. 2001).
Different studies have shown I. belli is the most common
parasite in HIV-positive patients which was strongly
associated with diarrhea. In a study of 245 diarrheal stool
specimens from HIV-infected individuals from India, who
received prophylactic treatment with TMP-SMX, parasitic
infections were observed in 37 % of cases, while I. belli
(26.1 %) was the most common parasite followed by Ent-
amoeba spp. (3.3 %), Cryptosporidium parvum (2.9 %),
and Giardia lamblia (1.6 %) (Vignesh et al. 2007). The
same results were found by others who reported I. belli in
17 % (16/94) (Joshi et al. 2002) and in 41.1 % (14/34) HIV
seropositive patients with chronic diarrhea (Gupta et al.
2008). In the latter study I. belli was also seen in 6.3 % (5/
79) of non-diarrheal cases. In another study of HIV-posi-
tive patients (n=397) diarrhea was reported in 98 % of
the cases, of whom 14 % (n=56) was infected with
I. belli (Certad et al. 2003). The presence of persistent
diarrhea is a common feature of AIDS. In Zaire, results of a
cohort study of 429 infants born to mothers with HIV?
Fig. 1 Isospora belli oocysts on stool smear stained using Ziehl-
Neelsen method
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123

showed HIV?infants comparing HIV-infants had greater
risk of development of recurrent and/or persistent diarrhea
and 11-fold increased risk of mortality due to diarrhea (Thea
et al. 1993). In our patient, abdominal discomfort was con-
comitant with steatorrhea which is a common complication
of isosporiasis, as in the report of Brandborg e al. (1970)of
six I. belli infections that all presented with steatorrhea. Our
patient was admitted with malabsorption and weight loss and
eosinophil count not exceeded 4 % on average. Study of
HIV-infected patients showed that eosinophilia was strongly
associated with isosporiasis; however higher eosinophil
counts were described in I. belli infected patients without
weight loss (Certad et al. 2003). This finding could be
described that in patients with considerable weight loss the
HIV disease is more severe and defect of the immune system
may involve the production of eosinophils (Arora and Arora
2009). Celiac was not confirmed in our patient, however
celiac disease is one of the most frequent causes of malab-
sorption as reported previously (Behera et al. 2008). Isos-
poriasis might manifest itself as a systemic disseminated
infection in patients with AIDS, I. belli was detected within
the cells of mediastinal, periaortic and mesenteric lymph
nodes at autopsy (Restrepo et al. 1987), and in gallbladder
biopsy samples of a patient presenting with cholecystitis
(Benator et al. 1994). A number of studies have reported I.
belli as an etiologic agent of diarrhea in other groups of
immunodeficient patients (Koru et al. 2007; Meamar et al.
2009; Resiere et al. 2003).
Because chronic diarrhea in patients infected with HIV
results in a significant morbidity and mortality, the reliable
diagnosis and management of diarrhea associated oppor-
tunistic infections in patients with AIDS is very important
in preventing sever complications. Isosporiasis should be
regarded in children presenting with FTT and in HIV-
infected children with chronic watery diarrhea and weight
loss.
Conflict of interest The authors declare that they have no conflicts
of interest.
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