The pathogenesis of cryptosporidiosis

A multiplex PCR test to identify four common cattle-adapted Cryptosporidium species

Cryptosporidiumis a well-known cause of neonatal enteritis in cattle worldwide. Cattle are commonly infected with four different species ofCryptosporidiumbut only one of these,Cryptosporidium parvum, is associated with clinical disease. Identification of species in cases of calf scour can give an indication ifCryptosporidiumis the causative agent or not. In addition,C. parvumis a zoonotic species and so has implications for human health, for this reason it is important to identify the species ofCryptosporidiuminfecting cattle particularly where a farm is implicated in an outbreak of cryptosporidiosis in humans. Here a multiplex PCR test, which can identify the four common cattle-adaptedCryptosporidiumspecies, includingC. parvum, has been developed. This test allows quick and accurate detection ofCryptosporidiumspecies in cattle fecal samples including mixed infections, which could be missed by the more common method of sequencing the same gene.

Cryptosporidium enteritis in solid organ transplant recipients: multicenter retrospective evaluation of 10 cases reveals an association with elevated tacrolimus concentrations

BACKGROUND

Cryptosporidial enteritis, a diarrheal infection of the small intestine caused by the apicomplexan protozoa Cryptosporidium, is infrequently recognized in transplant recipients from developed countries.

METHODS

A retrospective review of all cases of cryptosporidiosis in solid organ transplant (SOT) recipients at 2 centers from January 2001 to October 2010 was performed and compared with transplant recipients with community-onset Clostridium difficile infection (CDI). A literature search was performed with regard to reported cases of cryptosporidiosis in SOT recipients.

RESULTS

Eight renal, 1 liver, and 1 lung transplant recipient were diagnosed with cryptosporidiosis at median 46.0 months (interquartile range [IQR] 25.2-62.8) following SOT. Symptoms existed for a median 14 days (IQR 10.5-14.8) before diagnosis. For the 9 patients receiving tacrolimus (TAC), mean TAC levels increased from 6.3 ± 1.1 to 21.3 ± 9.2 ng/mL (P = 0.0007) and median serum creatinine increased temporarily from 1.3 (IQR 1.1-1.7) to 2.4 (IQR 2.0-4.6) mg/dL (P = 0.008). By comparison, 8 SOT recipients (6 kidney, 2 liver) hospitalized with community-onset CDI had a mean TAC level of 10.8 ± 2.8 ng/dL during disease compared with 9.2 ± 2.3 ng/mL at baseline (P = 0.07) and had no change in median creatinine. All patients recovered from Cryptosporidium enteritis after receiving various chemotherapeutic regimens.

CONCLUSIONS

Cryptosporidiosis should be recognized as an important cause of diarrhea after SOT and is associated with elevated TAC levels and acute kidney injury. Increased TAC levels may reflect altered drug metabolism in the small intestine.

ImmunoCard STAT! cartridge antigen detection assay compared to microplate enzyme immunoassay and modified Kinyoun's acid-fast staining technique for detection of Cryptosporidium in fecal specimens

Cryptosporidium species infect humans and a wide range of animals worldwide; outbreaks of cryptosporidiosis have been reported in several countries. Routine diagnostic methods may be insufficient to demonstrate the presence of these organisms. The study assessed the diagnostic accuracy of the antigen detection immuno-cartridge test, ImmunoCard STAT! (Meridian Bioscience Inc., Cincinnati, OH, USA), compared to the combined gold standard: modified Kinyoun's acid-fast technique confirmed with the microplate enzyme immunoassay (EIA) for the detection of Cryptosporidium in fecal specimens. Three hundred fifteen formalin-fixed stool specimens were submitted for testing. The Kinyoun's acid-fast-stained smear revealed 24 positive samples for Cryptosporidium (of which 23 specimens were confirmed by the EIA) and 291 negative samples (of which 289 were negative by EIA). Agreement between the three used tests was shown in 22 positive and 288 negative samples for Cryptosporidium. Kappa score of agreement between the immuno-cartridge test and EIA was 0.957, p = 0.000. The sensitivity of the immuno-cartridge test was 96% (95% confidence interval (CI), 87% to 104%) and the total accuracy of the test was 97% (95% CI, 93-103). The ImmunoCard STAT! Cryptosporidium cartridge assay is easy to use and does not require specialized training or equipment and is useful in routine diagnosis and screening for Cryptosporidium especially where rapid, point of care testing is needed or where other reliable tests are unfeasible with a performance comparable to the EIA and acid-fast technique.

Some Opportunistic Parasitic Infections in AIDS: Candidiasis, Pneumocystosis, Cryptosporidiosis, Toxoplasmosis

Almost 80% of patients with AIDS die from infections other than human immunodeficiency virus (HIV). These infections usually occur late in the course of disease when CD4(+) T-cell count has fallen below 200 permm(3) cells per milliliter. Most of these infections are caused by organisms that do not normally afflict healthy individuals and are thus considered to be opportunistic. In this article, Lloyd Kasper and Dominique Buzoni-Gatel review the host-parasite interaction for four important pathogens: Candida albicans and Pneumocystis carinii (usually non-invasive pathogens), Cryptosporidium parvum (invades the cells but remains localized in the gut) and Toxoplasma gondii (penetrates through the gut to cause systemic infection). These organisms, which generally cause limited or even insignificant clinical evidence of infection in the normal host, were chosen because of their high prevalence in AIDS patients and because they exhibit different invasive abilities. The reason why individuals with AIDS are susceptible to this particular group of pathogens is uncertain.

Investigation of Cryptosporidium spp. antigen by ELISA method in stool specimens obtained from patients with diarrhea

Cryptosporidium spp. is an important parasitic protozoan causing diarrhea in developing and developed countries. The agent causes severe life-threatening diarrhea especially in immunocompromised hosts. Diagnosis of the Cryptosporidium oocyst in stool samples by conventional microscopy is labor-intensive and time-consuming. Thus, we aimed to evaluate the usefulness of a copro-antigen enzyme-linked immunosorbent assay (ELISA) test in detecting Cryptosporidium spp. from fecal specimens. For this aim, microscopy and specific antigen detection methods were compared to determine Cryptosporidium spp. In addition, specific antigen by ELISA method in stool was investigated in order to find out whether or not it contributes to the diagnosis of Cryptosporidium spp. One hundred and fifty-four stool specimens taken from patients whose ages ranged from 0 to 86 with diarrhea applied to Department of Parasitology, Balcali Hospital of Cukurova University in Adana, Turkey were used. All samples were examined for Cryptosporidium spp. antigen by ELISA and oocysts via gold standard modified acid-fast staining, between October 2008 and July 2009. Eight (5.19%) specimens were found to be positive by modified acid-fast staining method and 37 (24.03%) specimens by copro-antigen ELISA method were found to be positive. The sensitivity and specificity for copro-antigen ELISA were 100% and 80.1%, respectively. The results of copro-antigen ELISA indicate that the simple, rapid, reliable, and standardized immunoassay test is sensitive and specific for routine diagnosis and may be useful for large-scale epidemiological studies of cryptosporidiosis.

Gliding motility leads to active cellular invasion by Cryptosporidium parvum sporozoites

We examined gliding motility and cell invasion by an early-branching apicomplexan, Cryptosporidium parvum, which causes diarrheal disease in humans and animals. Real-time video microscopy demonstrated that C. parvum sporozoites undergo circular and helical gliding, two of the three stereotypical movements exhibited by Toxoplasma gondii tachyzoites. C. parvum sporozoites moved more rapidly than T. gondii sporozoites, which showed the same rates of motility as tachyzoites. Motility by C. parvum sporozoites was prevented by latrunculin B and cytochalasin D, drugs that depolymerize the parasite actin cytoskeleton, and by the myosin inhibitor 2,3-butanedione monoxime. Imaging of the initial events in cell entry by Cryptosporidium revealed that invasion occurs rapidly; however, the parasite does not enter deep into the cytosol but rather remains at the cell surface in a membrane-bound compartment. Invasion did not stimulate rearrangement of the host cell cytoskeleton and was inhibited by cytochalasin D, even in host cells that were resistant to the drug. Our studies demonstrate that C. parvum relies on a conserved actin-myosin motor for motility and active penetration of its host cell, thus establishing that this is a widely conserved feature of the Apicomplexa.

Zoonotic transmission of Cryptosporidium parvum: Implications for water-borne cryptosporidiosis

The emergence of Cryptosporidium parvum-associated cryptosporidiosis as a worldwide zoonosis has stimulated interest in the modes of pathogen transmission. Here, Thaddeus Graczyk, Ronald Fayer and Michael Cranfield discuss the complex epidemiology of C. parvum, emphasizing the crosstransmission potential of the pathogen, mechanical vectors involved in water-borne transmission of the oocysts, and factors contributing to contamination of pristine waters with Cryptosporidium. They also outline the public health importance of proper interpretation of positive detection of Cryptosporidium oocysts at water-treatment facilities and identify means by which watersheds can be protected from Cryptosporidium contamination.

Host cell fate on Cryptosporidium parvum egress from MDCK cells

Cryptosporidium parvum is an intracellular protozoan parasite that causes a severe diarrheal illness of unclear etiology. Also unclear is the fate of the host cell upon parasite egress. We show in an MDCK cell model that the host cell is killed upon parasite egress; this death is necrotic, rather than apoptotic, in nature.

The role of cytokines in the pathogenesis of Cryptosporidium infection

First described in 1912, the importance of the coccidian parasite Cryptosporidium parvum as an enteropathogen in humans was not recognized until the early 1980s, when it was found to be a common opportunistic infection in AIDS. Infection with this organism triggers a complex array of innate and cell-mediated immune responses within the intestinal mucosa. How cytokines and chemokines interact to regulate these responses in order to achieve clearance of the parasite yet preserve the integrity of the intestinal mucosa is still being unravelled. T helper type 1 cytokines, and particularly interferon-gamma, have long been considered to be the main orchestrators of the immune response to this infection, but recent studies suggest that T helper type 2 cytokines may also be involved. In addition, transforming growth factor-beta 1, although having little effect on parasite development, is an important modulator of the immune response and plays a role in protecting the epithelial integrity from the effects of the inflammatory process.

Cryptosporidium parvum infection requires host cell actin polymerization

The intracellular protozoan parasite Cryptosporidium parvum accumulates host cell actin at the interface between the parasite and the host cell cytoplasm. Here we show that the actin polymerizing proteins Arp2/3, vasodilator-stimulated phosphoprotein (VASP), and neural Wiskott Aldrich syndrome protein (N-WASP) are present at this interface and that host cell actin polymerization is necessary for parasite infection.

Cryptosporidium parvum induces host cell actin accumulation at the host-parasite interface

Cryptosporidium parvum is an intracellular protozoan parasite that causes a severe diarrheal illness in humans and animals. Previous ultrastructural studies have shown that Cryptosporidium resides in a unique intracellular compartment in the apical region of the host cell. The mechanisms by which Cryptosporidium invades host intestinal epithelial cells and establishes this compartment are poorly understood. The parasite is separated from the host cell by a unique electron-dense structure of unknown composition. We have used indirect immunofluorescence microscopy and confocal laser scanning microscopy to characterize this structure. These studies indicate that host filamentous actin is assembled into a plaque-like structure at the host-parasite interface during parasite invasion and persists during parasite development. The actin-binding protein alpha-actinin is also present in this plaque early in parasite development but is lost as the parasite matures. Other actin-associated proteins, including vinculin, talin, and ezrin, are not present. We have found no evidence of tyrosine phosphorylation within this structure. Molecules known to link actin filaments to membrane were also examined, including alpha-catenin, beta-catenin, plakoglobin, and zyxin, but none was identified at the host-parasite junction. Thus, Cryptosporidium induces rearrangement of the host cell cytoskeleton and incorporates host cell actin and alpha-actinin into a host-parasite junctional complex.

New insights into human cryptosporidiosis

Cryptosporidium parvum is an important cause of diarrhea worldwide. Cryptosporidium causes a potentially life-threatening disease in people with AIDS and contributes significantly to morbidity among children in developing countries. In immunocompetent adults, Cryptosporidium is often associated with waterborne outbreaks of acute diarrheal illness. Recent studies with human volunteers have indicated that Cryptosporidium is highly infectious. Diagnosis of infection with this parasite has relied on identification of acid-fast oocysts in stool; however, new immunoassays or PCR-based assays may increase the sensitivity of detection. Although the mechanism by which Cryptosporidium causes diarrhea is still poorly understood, the parasite and the immune response to it probably combine to impair absorption and enhance secretion within the intestinal tract. Important genetic studies suggest that humans can be infected by at least two genetically distinct types of Cryptosporidium, which may vary in virulence. This may, in part, explain the clinical variability seen in patients with cryptosporidiosis.

A clinicopathologic analysis of AIDS-related cryptosporidiosis

OBJECTIVE

To characterize the histology of AIDS-associated cryptosporidiosis and identify features that explain the clinical variability.

DESIGN

A retrospective analysis of HIV-positive individuals with cryptosporidiosis who underwent endoscopy at the Johns Hopkins Hospital between 1985 and 1996.

METHODS

The histologic features (intensity of Cryptosporidium infection, inflammation, mucosal damage, copathogens) of gastrointestinal biopsies from 37 HIV-positive individuals with cryptosporidiosis were systematically graded. These histologic features were correlated with the severity of the diarrheal illness obtained from a patient chart review.

RESULTS

Histologic features associated with Cryptosporidium infection include a neutrophilic infiltrate in the stomach, villus blunting in the duodenum, cryptitis and epithelial apoptosis in the colon, and reactive epithelial changes in the stomach and duodenum. The nature and intensity of the inflammatory response varied widely; however, duodenal biopsies from a subset of patients (37%) revealed marked acute inflammation that was associated with concomitant cytomegalovirus infection. Although duodenal infection was common (93% of individuals), infection of other sites was variable (gastric cryptosporidiosis in 40% and colonic cryptosporidiosis in 74%). Widespread infection of the intestinal tract, which included both the large and small intestine, was associated with the most severe diarrheal illness.

CONCLUSIONS

Cryptosporidium infection produces histologic evidence of gastrointestinal mucosal injury. The inflammatory response to the infection is variable, and may be modified by copathogens such as cytomegalovirus. The clinical manifestations are influenced, in part, by the anatomic distribution of the infection, with extensive infections involving both small and large intestines producing the most severe illness.

High-temperature inducible cell-free transcription and replication of double-stranded RNAs within the parasitic protozoan Cryptosporidium parvum

Sporozoites of the protozoan parasite, Cryptosporidium parvum, were found to contain free, full-size plus strands transcribed from two extrachromosomal, cytoplasmic, virus-like double-stranded RNAs (dsRNAs). Cell-free transcription and replication of both dsRNAs were observed in crude sporozoite lysates. RNA polymerase activity was found to be dependent upon addition of Mg2+ or Mn2+, as well as the four ribonucleoside triphosphates, and was insensitive to inhibitors of cellular DNA-dependent RNA polymerase. Semiconservative transcription of the dsRNAs (plus strand synthesis) was observed at a wide range of temperatures, with an optimum of 50 degrees C. In contrast, replication (minus strand synthesis) was detected only at 50 and 60 degrees C.

Sexual and asexual development of Cryptosporidium parvum in five oocyst- or sporozoite-infected human enterocytic cell lines

The human enterocytic cell lines Caco-2, HT29, HCT8 and the Caco-2 clones TC7 and PF11 were studied for their ability to support Cryptosporidium parvum development. Following the addition in cultures of either oocysts or excysted sporozoites, immunofluorescent and transmission electron microscopy revealed the presence of all stages of the parasite life cycle by both procedures, and no difference in the ratio of infected cells was found among cell lines. More oocysts were seen in cell monolayers infected with oocysts than with sporozoites (p < 0.0001). The number of meronts observed was the same after either oocysts or sporozoites inoculation. Data suggest that the two methods yield a same cell infection rate.

Cryptosporidiosis in Houston, Texas. A report of 95 cases

Cryptosporidiosis is an important cause of diarrhea. We identified 95 patients with cryptosporidiosis over a 6-year period in our county hospital system, including 9 children and 86 adults infected with the human immunodeficiency virus (HIV). Risk factors included male-to-male sexual practices and Hispanic race. Diarrhea, weight loss, and gastrointestinal complaints were the most common symptoms at presentation. Among the HIV-infected adults, 20 (23%) developed biliary tract disease. Biliary involvement was associated with low CD4 counts. Treatment with paromomycin and antimotility agents was effective in reducing diarrheal symptoms in 54 of 70 (77%) patients with the acquired immunodeficiency syndrome (AIDS), although there was a high rate of relapse. Paromomycin did not prevent the development of biliary disease. Biliary disease responded to cholecystectomy or sphincterotomy with stent placement. Though often a cause of morbidity, cryptosporidiosis was only rarely the cause of death, even among patients with HIV. Cryptosporidiosis continues to be an important medical problem even in developed-countries. Current methods of prevention and treatment are suboptimal.