Human microsporidial infection and possible animal sources

Microsporidial keratopathy in two dogs

A microsporidial keratopathy is described in two dogs. Both dogs presented with a unilateral stromal keratopathy characterized by multifocal coalescing opacities, and the diagnosis was made on histopathologic examination of keratectomy specimens. Transmission electron microscopy (TEM) on formalin-fixed, paraffin-embedded corneal tissue was performed in one dog, and the morphologic features were consistent with Nosema species infection. Both dogs were initially diagnosed and treated by superficial keratectomy. One dog received additional antifungal medication and underwent a penetrating keratoplasty following local recurrence two years later. No other systemic lesions attributable to the microsporidial infection were identified clinically. The clinical and diagnostic pathology findings, treatment, and follow-up are discussed.

Outbreak of microsporidial keratoconjunctivitis with rugby sport due to soil exposure

AIMS

To investigate a cluster of microsporidial keratoconjunctivitis in 33 eyes of 25 previously healthy paediatric and teenage individuals after a rugby match.

METHODS

An observational case series was reported. Analysis of medical record of patients with microsporidial keratoconjunctivitis, who presented within May 2012, was performed. All patients were treated by a single ophthalmologist with a standardized topical regime, including a fluoroquinolone (moxifloxacin) and an antiseptic (Brolene or Desomedine). Five eyes received corneal scrapings.

RESULTS

The mean age was 13.36 years (range 5-16). All patients have participated in a rugby match on 21-22 April 2012. The onset of symptoms ranged from 10 to 30 days post exposure. All eyes had multiple superficial coarse punctate keratitis. Four (12%) eyes presented with keratic precipitates. One (3%) eye had intraocular pressure of 27 mm Hg. Microscopic examination of corneal scrapings with modified trichrome or calcofluor white (CFW) fluorescent staining was unremarkable but subsequent PCR test was positive for the small subunit rRNA gene of Vittaforma corneae in three out of five eyes. Sequencing of the PCR product of 1150 bp showed 96-100% identity with the Indian or Singaporean strains of V. corneae. After treatment, all eyes healed without sequel.

CONCLUSIONS

The first outbreak of microsporidial keratoconjunctivitis in paediatric and teenage individuals with a rugby match is reported. A standardized topical regime, including a fluoroquinolone (moxifloxacin) and an antiseptic (Brolene or Desomedine), seems to be safe and effective, and requires validation in future treatment trials.

Molecular diagnostic tests for microsporidia

The Microsporidia are a ubiquitous group of eukaryotic obligate intracellular parasites which were recognized over 100 years ago with the description of Nosema bombycis, a parasite of silkworms. It is now appreciated that these organisms are related to the Fungi. Microsporidia infect all major animal groups most often as gastrointestinal pathogens; however they have been reported from every tissue and organ, and their spores are common in environmental sources such as ditch water. Several different genera of these organisms infect humans, but the majority of infections are due to either Enterocytozoon bieneusi or Encephalitozoon species. These pathogens can be difficult to diagnose, but significant progress has been made in the last decade in the development of molecular diagnostic reagents for these organisms. This report reviews the molecular diagnostic tests that have been described for the identification of the microsporidia that infect humans.

A case of bilateral microsporidial keratitis from Bangladesh – infection by an insect parasite from the genus Nosema

An HIV-negative patient from Bangladesh with bilateral keratitis was found to be infected with a microsporidian parasite belonging to the genus Nosema. Significantly, the patient had bathed in a rural pond 7 days prior to the development of ocular symptoms. Nosema parasites are common insect parasites and the source of this microsporidial infection was possibly from mosquito larvae developing in the pond in which the patient bathed. The reduced temperature of the human eye and its immune status may have allowed a poikilothermic insect parasite to establish infection in the cornea of a homeothermic human host. This case highlights the opportunistic potential of insect microsporidial parasites to infect immunocompetent humans as well as those who are immunodeficient.

Identification of potentially human-pathogenic Enterocytozoon bieneusi genotypes in various birds

Enterocytozoon bieneusi was detected in 24 of 83 samples from birds of the orders Columbiformes, Passeriformes, and Psittaciformes. It was identical to or closely related to the Peru6 genotype, which was previously found in humans in Peru. Thus, various birds can be a significant source of environmental contamination by potentially human-pathogenic E. bieneusi.

Chlorine and ozone disinfection of Encephalitozoon intestinalis spores

Microsporidia are intracellular eukaryotic parasites which have the potential for zoonotic and environmental, including waterborne, transmission. Encephalitozoon intestinalis is a microsporidian pathogen of humans and animals and has been detected in surface water. It is also on the Contaminant Candidate List of potential emerging waterborne pathogens for the US EPA. We performed disinfection studies using chlorine and ozone on E. intestinalis spores with a cell-culture most-probable-number assay to determine infectivity. Chlorine experiments were performed at 5 degrees C at pH of 6, 7, and 8 with 1mg/L initial chlorine concentrations, while ozone experiments were performed at 5 degrees C and pH 7 with initial ozone doses of 1 and 0.5mg/L, both in buffered water. A derivation of Hom's model for disinfection kinetics under dynamic disinfectant concentrations was used to fit observed data and calculate concentration-time product (C*t) values. Chlorine C*t values varied with pH such that 99% (2-log(10)) C*t ranged from 12.8 at pH 6 to 68.8 at pH 8 (mg min/L). Ozone C*t values were approximately an order of magnitude less at 0.59--0.84 mg min/L, depending on initial concentration.

Ultrastructural examination of two cases of stromal microsporidial keratitis

Two cases with chronic stromal keratitis are described in immunocompetent hosts where the diagnosis was originally thought to be herpetic or adenoviral disease. Light microscopy and ultrastructural examination of corneal tissue by electron microscopy were performed following penetrating keratoplasty (case 1) and corneal biopsy (case 2). Specimens from both cases were analysed for viral identification by PCR. Two different species of Microsporidia were identified. Case 1 represents the fourth reported case of corneal stromal Vittaforma corneae where the spores measured 3.3 x 1.4 microm, arranged in characteristic linear groups of about four to eight. Each spore contained a diplokaryotic nucleus and a single row of ten polar tube coils. By contrast, case 2 is the first reported case of stromal keratitis caused by Trachipleistophora hominis. In this case, spores measured 4 x 2.4 microm, located typically within packets. In this species, the polar tube was arranged as a single row of about 10-13 profiles. Viral DNA could not be amplified by PCR. In conclusion, microsporidial stromal keratitis should be considered in culture-negative cases refractory to medical therapy. As microbiological culture techniques are unsuccessful, diagnosis may only be established following histopathological and ultrastructural examination of corneal tissue.

Detection of protozoan parasites and microsporidia in irrigation waters used for crop production

The occurrence of human pathogenic parasites in irrigation waters used for food crops traditionally eaten raw was investigated. The polymerase chain reaction was used to detect human pathogenic microsporidia in irrigation waters from the United States and several Central American countries. In addition, the occurrence of both Cryptosporidium oocysts and Giardia cysts was determined by immunofluorescent techniques. Twenty-eight percent of the irrigation water samples tested positive for microsporidia, 60% tested positive for Giardia cysts, and 36% tested positive for Cryptosporidium oocysts. The average concentrations in samples from Central America containing Giardia cysts and Cryptosporidium oocysts were 559 cysts and 227 oocysts per 100 liters. In samples from the United States, averages of 25 Giardia cysts per 100 liters and <19 (average detection limit) Cryptosporidium oocysts per 100 liters were detected. Two of the samples that were positive for microsporidia were sequenced, and subsequent database homology comparisons allowed the presumptive identification of two human pathogenic species, Encephalitozoon intestinalis (94% homology) and Pleistophora spp. (89% homology). The presence of human pathogenic parasites in irrigation waters used in the production of crops traditionally consumed raw suggests that there may be a risk of infection to consumers who come in contact with or eat these products.

Genotyping of Enterocytozoon bieneusi in AIDS patients from the north west of England

OBJECTIVES

In this study Enterocytozoon bieneusi -positive faeces samples from AIDS patients in the north west of England were investigated by polymerase chain reaction (PCR) and DNA sequencing for potential zoonotic origins.

METHODS

The ITS and flanking regions of the rDNA was amplified by PCR and product sequenced. Sequences were compared with those held on GenBank to ascribe known genotypes.

RESULTS

Of 13 E. bieneusi -positive samples tested, all gave a 508 bp amplification product by PCR. The samples yielded the following: genotypes B (n=11; so far only been found in humans), D (n=1; has been reported from humans and a laboratory macaque) and K (n=1; previously identified only from a cat).

CONCLUSIONS

A possible zoonotic link with cats has been demonstrated for one human case. The origin of the majority of cases in the north west of England is unknown and may indicate that genotype B is solely a human pathogen.

Electron microscopy as a tool for identifying new pathogens

Electron microscopy (EM) is still an important tool for the investigation of infectious diseases, despite the introduction of powerful new methods, mainly involving the polymerase chain reaction. Particularly in the field of parasitic protozoology associated with AIDS, where many new species of human pathogens have been recognized in tissue biopsies, EM remains an essential 'catch-all' diagnostic method. The resolved ultrastructural details of these newly recognized parasites allows a unique insight into the biology of these organisms. The information produced by EM is different, but complementary, to that provided by alternative methods.