Evaluation of an immunofluorescent-antibody test using monoclonal antibodies directed against Enterocytozoon bieneusi and Encephalitozoon intestinalis for diagnosis of intestinal microsporidiosis in Bamako (Mali)

Global prevalence and risk factors of Enterocytozoon bieneusi infection in humans: a systematic review and meta-analysis

Enterocytozoon bieneusi is one of the most important zoonotic pathogens. In this study, we present a systematic review and meta-analysis of the prevalence of human E. bieneusi infection in endemic regions and analyze the various potential risk factors. A total of 75 studies were included. Among 31,644 individuals tested, 2,291 (6.59%) were E. bieneusi-positive. The highest prevalence of E. bieneusi in the male population was 5.50%. The prevalence of E. bieneusi in different age groups was varied, with 10.97% in teenagers. The prevalence of E. bieneusi in asymptomatic patients (6.49%) is significantly lower than that in HIV-infected patients (11.49%), and in patients with diarrheal symptoms (16.45%). Rural areas had a higher rate (7.58%) than urban ones. The prevalence of E. bieneusi in humans was the highest (6.42%) at altitudes <10 m. Moreover, the temperate zone marine climate (13.55%) had the highest prevalence. A total of 69 genotypes of E. bieneusi have been found in humans. This is the first global study regarding E. bieneusi prevalence in humans. Not only people with low immunity (such as the elderly, children, people with HIV, etc.), but also people in Europe in temperate marine climates should exercise caution to prevent infection with E. bieneusi during contact process with animals.

Investigation of the presence of Enterocytozoon bieneusi and Encephalitozoon intestinalis in immunosuppressed patients with diarrhea by IFA and real time PCR methods

PURPOSE

This study aimed to investigate the frequency of Enterocytozoon bieneusi and Encephalitozoon intestinalis in patients with diarrhea in the immunosuppressed.

METHODS

Patients between the ages of 18-85 who applied to different clinics of Muş Bulanık and Bitlis State Hospitals and were referred to the microbiology or parasitology laboratory were selected for this study. A total of 200 individuals, including 88 immunosuppressed with diarrhea patients, 38 immunocompetent with diarrhea patients, 38 immunosuppressed without diarrhea patients, and 36 immunocompetent without diarrhea individuals, were included. Collected stool samples were evaluated using IFA-MAbs and real-time PCR methods to determine the frequency of E.intestinalis and E.bieneusi.

RESULTS

E. intestinalis was detected in 59 (29.5%) of 200 samples and E. bieneusi was detected in 46 (23.0%) of them. Mixed infection was detected in 16 (8%) of the positive samples. While there was no statistically significant difference between E. intestinalis positivity and gender, age, diarrhea status and immune system status, a statistically significant relationship was determined between E. bieneusi positivity and diarrhea. When the real-time PCR method was accepted as the gold standard, the sensitivity of the IFA-MAbs method in the diagnosis of E. intestinalis was 94.54%, the specificity was 97.24, the sensitivity in the diagnosis of E. bieneusi was 95.45%, and the specificity was 98.72%. The overall accuracy of the IFA-MAbs method was 96.5% for the diagnosis of E. intestinalis and 98% for the diagnosis of E. bieneusi.

CONCLUSIONS

The findings suggest that E. intestinalis and E. bieneusi should be considered in both immunosuppressed and healthy individuals with diarrhea. IFA-MAbs method can be used in addition to the real-time PCR method to diagnose E. intestinalis and E. bieneusi.

The estimated burden of fungal diseases in Mali

Mali is a developing country facing several health challenges with a high rate of tuberculosis (TB) and a moderate HIV infection burden. Little is known or done about fungal diseases, yet they represent a significant public health problem in certain populations. The aim of this study was to estimate the national burden of fungal disease, and summarize data, diagnostic and treatment gaps. We used national demographics and PubMed searches to retrieve articles on published data on these infections and at-risk populations (pulmonary TB, HIV/AIDS patients, patients receiving critical care etc.) in Mali. The estimated Malian population was 21,251,000 in 2020 (UN), of which 45% were children <14 years. Among HIV patients, we estimate an annual incidence of 611 cryptococcosis, 1393 Pneumocystis pneumonia, 180 histoplasmosis and >5,700 esophageal candidiasis and some microsporidiosis cases. Our prevalence estimates for tinea capitis are 2.3 million, for recurrent vulvovaginal candidiasis 272,460, ∼60,000 fungal asthma and 7,290 cases of chronic pulmonary aspergillosis (often mistaken for TB). Less common acute fungal infections are probably invasive aspergillosis (n=1230), fungal keratitis (n=2820), candidaemia (>1,060) and mucormycosis (n=43). Histoplasmin was found in 6% in general population. A few cases of mycetoma are described in Mali. Many WHO Essential medicines and Diagnostics are not available in Mali. This shows a marked disparity in documented and estimated cases of fungal diseases in Mali. These infections are underestimated due to the lack of accurate diagnosis tools and lack of support for fungal diseases diagnosis and management.

Identification and Characterization of Three Spore Wall Proteins of Enterocytozoon Bieneusi

Enterocytozoon bieneusi is the most common microsporidian pathogen in farm animals and humans. Although several spore wall proteins (SWPs) of other human-pathogenic microsporidia have been identified, SWPs of E. bieneusi remain poorly characterized. In the present study, we identified the sequences of three E. bieneusi SWPs from whole genome sequence data, expressed them in Escherichia coli, generated a monoclonal antibody (mAb) against one of them (EbSWP1), and used the mAb in direct immunofluorescence detection of E. bieneusi spores in fecal samples. The amino acid sequence of EbSWP1 shares some identity to EbSWP2 with a BAR2 domain, while the sequence of EbSWP3 contains a MICSWaP domain. No cross-reactivity among the EbSWPs was demonstrated using the polyclonal antibodies generated against them. The mAb against EbSWP1 was shown to react with E. bieneusi spores in fecal samples. Using chromotrope 2R staining-based microscopy as the gold standard, the sensitivity and specificity of the direct immunofluorescence for the detection of E. bieneusi were 91.4 and 73.7%. Data generated from the study could be useful in the characterization of E. bieneusi and immunological detection of the pathogen.

Encephalitozoon spp. as a potential human pathogen

Encephalitzoon spp. are microsporidia, and intracellular opportunistic pathogens. The hosts of these pathogens include vertebrates, invertebrates, and certain protozoa. In people microsporidia may be opportunistic pathogens for immunocompromised patients (with AIDS or after organ transplantation). Infection with these microorganisms was also described in persons with diarrhea and corneal diseases.

The species causing rare infections in humans, Encephalitozooncuniculi, had previously been described from animal hosts. However, several new microsporidial species, including E. intestinalis and E. hellem, have been discovered in humans, raising the question of their natural origin. Vertebrate animals are now identified as hosts for all three microsporidial species infecting humans, implying a zoonotic nature of these microorganisms. Molecular studies have identified phenotypic and/or genetic variability within these species, indicating that they are not uniform, and have allowed the question of their zoonotic potential to be addressed. The focus of this review is to present the zoonotic potential of E. intestinalis, E. cuniculi, and E. hellem.

Intestinal microsporidiosis among HIV/AIDS patients receiving antiretroviral therapy in Sana'a city, Yemen: first report on prevalence and predictors

Background

Intestinal microsporidiosis is an opportunistic infection associated with persistent diarrhea among HIV/AIDS patients. In Yemen, however, its epidemiology is unknown. Therefore, this study determined its prevalence and predictors among HIV/AIDS patients receiving antiretroviral therapy (ART) in Sana’a city, the capital of Yemen.

Methods

This cross-sectional study included 402 patients receiving ART at Al-Jomhori Educational Hospital in Sana’a from November 2019 to December 2020. Data about demographics, clinical characteristics and risk factors were collected using a pre-designed questionnaire. Stool samples were collected and examined for microsporidian spores using the Gram-chromotrope Kinyoun staining. Blood samples were also collected and used for CD4 cell counting by flow cytometry. Univariate analysis was used to test the association of patients’ characteristics and risk factors with intestinal microsporidiosis. Multivariable logistic regression was then used to identify the independent predictors of infection. Statistical significance was considered at P-values < 0.05.

Results

Intestinal microsporidiosis was prevalent among 14.2% (57/402) of HIV/AIDS patients and was significantly associated with diarrhea (OR 3.4, 95% CI 1.7–6.6; P = 0.001). The significant independent predictors of infection were < 200 CD4 cells/µl (AOR 3.2, 95% CI 1.5–6.9; P = 0.003), not washing hands after contacting soil (AOR 2.5, 95% CI 1.1–5.4; P = 0.026) and before eating (AOR 3.1, 95% CI 1.5–6.4; P = 0.003), eating unwashed raw produce (AOR 2.5, 95% CI 1.2–5.3; P = 0.017) and absence of indoor latrines (AOR 6.2, 95% CI 1.5–25.9; P = 0.012).

Conclusions

The prevalence of intestinal microsporidiosis among HIV/AIDS patients in Sana'a is high and comparable to that reported from several other countries, being prevalent among approximately 14.0% of patients and significantly associated with diarrhea. It could be predicted among patients who have < 200 CD4 cells/µl, have poor hand hygiene after contacting soil and before eating, usually eat unwashed raw produce, or do not possess indoor latrines. Large-scale studies on its epidemiology and predictors among HIV/AIDS patients across the country are warranted.

First Identification and Genotyping of Enterocytozoon bieneusi and Prevalence of Encephalitozoon intestinalis in Patients with Acute Diarrhea in the Republic of Korea

Encephalitozoon intestinalis and Enterocytozoon bieneusi can cause diarrhea in humans, especially severe diarrhea in immunocompromised patients. However, there have been few studies on Enc. intestinalis and Ent. bieneusi in patients with acute diarrhea in the Republic of Korea (ROK). In this study, fecal samples were collected from 1241 patients with acute diarrhea in 2020. Among these, 24 cases of Enc. intestinalis and one case of Ent. bieneusi were detected via PCR amplification of small subunit ribosomal RNA. Genotyping of the internal transcribed spacer region sequence revealed that the detected Ent. bieneusi genotype was in Group 1. This study provides the first evidence that Ent. bieneusi exists in humans in addition to animals in the ROK. To identify the causative agent, continuous monitoring of Enc. intestinalis and Ent. bieneusi is necessary for patients with acute diarrhea in the ROK.

Enterocytozoon bieneusi of animals-With an 'Australian twist'

Enterocytozoon bieneusi is a microsporidian microorganism that causes intestinal disease in animals including humans. E. bieneusi is an obligate intracellular pathogen, typically causing severe or chronic diarrhoea, malabsorption and/or wasting. Currently, E. bieneusi is recognised as a fungus, although its exact classification remains contentious. The transmission of E. bieneusi can occur from person to person and/or animals to people. Transmission is usually via the faecal-oral route through E. bieneusi spore-contaminated water, environment or food, or direct contact with infected individuals. Enterocytozoon bieneusi genotypes are usually identified and classified by PCR-based sequencing of the internal transcribed spacer region (ITS) of nuclear ribosomal DNA. To date, ~600 distinct genotypes of E. bieneusi have been recorded in ~170 species of animals, including various orders of mammals and reptiles as well as insects in >40 countries. Moreover, E. bieneusi has also been found in recreational water, irrigation water, and treated raw- and waste-waters. Although many studies have been conducted on the epidemiology of E. bieneusi, prevalence surveys of animals and humans are scant in some countries, such as Australia, and transmission routes of individual genotypes and related risk factors are poorly understood. This article/chapter reviews aspects of the taxonomy, biology and epidemiology of E. bieneusi; the diagnosis, treatment and prevention of microsporidiosis; critically appraises the naming system for E. bieneusi genotypes as well as the phylogenetic relationships of these genotypes; provides new insights into the prevalence and genetic composition of E. bieneusi populations in animals in parts of Australia using molecular epidemiological tools; and proposes some areas for future research in the E. bieneusi/microsporidiosis field.

Diagnosis and molecular typing of Enterocytozoon bieneusi: the significant role of domestic animals in transmission of human microsporidiosis

Enterocytozoon bieneusi is an obligate intracellular fungus-like parasite with high genetic diversity among mammalian and avian hosts. Based on polymorphism analysis of the ribosomal internal transcribed spacer (ITS), nearly 500 genotypes were identified within E. bieneusi. Those genotypes form several genetic groups that exhibit phenotypic differences in host specificity and zoonotic potential and probably have varying public health implications. Some of the genotypes in Group 1 (e.g., D, EbpC, and Type IV) and Group 2 (e.g., BEB4, BEB6, I, and J) are the most common ones that infect a variety of hosts including humans and thus are of public health importance. By contrast, those genotypes in other genetic groups (Groups 3-11) are mostly restricted to the hosts from which they were originally isolated, which would have unknown or limited impacts on public health. Advances on diagnosis and molecular typing of E. bieneusi are introduced in this review. Genotype distribution pattern of E. bieneusi in major domestic animal groups (pigs, cattle, sheep, goats, cats, and dogs), the role of those animals in zoonotic transmission of microsporidiosis, and food and water as potential vehicles for transmission are interpreted here as well. This review highlights the importance of including more genetic or epidemiological data obtained in the same geographical areas and using more reliable genetic markers to analyze the actual extent of host specificity in E. bieneusi, for the purpose of fully appreciating zoonotic risks of those domestic animals in close contacts with men and enhancing our understanding of the modes of transmission.

First identification of genotypes of Enterocytozoon bieneusi (Microsporidia) among symptomatic and asymptomatic children in Mozambique

Enterocytozoon bieneusi is a human pathogen with a broad range of animal hosts. Initially, E. bieneusi was considered an emerging opportunistic pathogen in immunocompromised, mainly HIV-infected patients, but it has been increasingly reported in apparently healthy individuals globally. As in other African countries, the molecular epidemiology of E. bieneusi in Mozambique remains completely unknown. Therefore, we undertook a study to investigate the occurrence and genetic diversity of E. bieneusi infections in children with gastrointestinal symptoms as well as in asymptomatic children in Mozambique. Individual stool specimens were collected from 1,247 children aged between 0 and 14 years-old living in urban and rural settings in Zambézia (n = 1,097) and Maputo (n = 150) provinces between 2016 and 2019. Samples were analysed for E. bieneusi by nested-PCR targeting the internal transcribed spacer (ITS) region of the rRNA gene. All positive amplicons were confirmed and genotyped. Penalised logistic regression (Firth) was used to evaluate risk associations. The overall prevalence of E. bieneusi in this children population was 0.7% (9/1,247). A 10-fold higher prevalence was found in Maputo (4.0%; 6/150) than in Zambézia (0.3%; 3/1,097). All E. bieneusi-positive samples were from children older than 1-year of age, and most (8/9) from asymptomatic children. Nucleotide sequence analysis of the ITS region revealed the presence of four genotypes, three previously reported (Peru11, n = 1; Type IV, n = 2, and S2, n = 2) and a novel genotype (named HhMzEb1, n = 4). Novel genotype HhMzEb1 was identified in both asymptomatic (75%, 3/4) and symptomatic (25%, 1/4) children from a rural area in Maputo province in southern Mozambique. Genotypes HhMzEb1, Peru11, S2, and Type IV belonged to the Group 1 that includes genotypes with low host specificity and the potential for zoonotic and cross-species transmission. Being infected by enteric protozoan parasites and no handwashing were identified as risk associations for E. bieneusi infection. This study reports the first investigation of E. bieneusi genotypes in Mozambique with the identification of three previously reported genotypes in humans as well as a novel genotype (HhMzEb1). Findings highlight the need to conduct additional research to elucidate the epidemiology of E. bieneusi in the country, especially in rural areas where poor hygiene conditions still prevail. Special attention should be paid to the identification of suitable animal and environmental reservoirs of this parasite and to the characterization of transmission pathways.

An optimized assay for detecting Encephalitozoon intestinalis and Enterocytozoon bieneusi in dairy calf feces using polymerase chain reaction technology

The purpose of this study was to optimize primary and nested polymerase chain reaction (PCR) assays for detecting the microsporidia Encephalitozoon intestinalis and Enterocytozoon bieneusi in fecal samples from dairy calves. PCR for these microsporidia were compared to immunofluorescence assays (IFA) based on commercially available monoclonal antibodies specific for outer wall proteins of Enc. intestinalis or Ent. bieneusi. Fecal samples were collected from 15 dairy calves and processed by molecular sieving followed by salt floatation to recover Enc. intestinalis and Ent. bieneusi spores. An aliquot of the final supernatant was applied to glass slides for IFA testing; another aliquot was extracted for total DNA using a QIAamp Stool Mini-Kit for primary and nested Enc. intestinalis- and Ent. bieneusi-specific PCR analysis. Internal standards were generated for both Enc. intestinalis and Ent. bieneusi PCR assays to control for false negative reactions due to the presence of inhibitors commonly found in fecal samples. Using the commercial MicrosporIFA (Waterborne, Inc.) as the gold standard, the optimized Enc. intestinalis PCR method provided 85.7% sensitivity and 100% specificity with a kappa value = 0.865. Likewise, using the commercial BienusiGlo IFA (Waterborne, Inc.) as the gold standard, the optimized Ent. bieneusi PCR method provided 83.3% sensitivity and 100% specificity with a kappa value = 0.857. Sequencing of amplicons from both PCR assays confirmed the presence of Enc. intestinalis or Ent. bieneusi. In conclusion, our optimized assays for recovering and detecting Enc. intestinalis or Ent. bieneusi in feces from dairy calves provides a valuable alternative to traditional IFA methods that require expertise to identify extremely small microsporidia spores (~ 2.0 µm). Our assays also improve upon existing molecular detection techniques for these microsporidia by incorporating an internal standard to control for false negative reactions.

Production and characterization of monoclonal antibodies against Encephalitozoon intestinalis and Encephalitozoon sp. spores and their developmental stages

Background

Microsporidia are intracellular obligate parasites traditionally associated with immunosuppressed patients; their detection in immunocompetent patients has increased, highlighting their possible importance as emerging pathogens. Detection of spores in stools, urine, body fluids and tissues is difficult and immunological techniques such as immunofluorescence have proved to be a useful and reliable tool in the diagnosis of human microsporidiosis. For this reason, we have produced and characterized monoclonal antibodies (MAbs) specific for Encephalitozoon intestinalis (the second most frequent microsporidian infecting humans), and other Encephalitozoon species, that can be used in different diagnostic techniques.

Results

Seven MAbs were selected in accordance with their optical density (OD). Four (4C4, 2C2, 2E5 and 2H2) were isotype IgG2a; two (3A5 and 3C9) isotype IgG3, and one Mab, 1D7, IgM isotype. The selected monoclonal antibody-secreting hybridomas were characterized by indirect immunofluorescence antibody test (IFAT), enzyme-linked immunosorbent assay (ELISA), Western blot, immunoelectron microscopy (Immunogold) and in vitro cultures. The study by IFAT showed different behavior depending on the MAbs studied. The MAbs 4C4, 2C2, 2E5 and 2H2 showed reactivity against epitopes in the wall of the spore (exospore and endospore) epitopes located in Encephalitozoon sp. spores, whereas the MAbs 3A5, 1D7 and 3C9 showed reactivity against internal epitopes (cytoplasmic contents or sporoplasm) of E. intestinalis spores. All MAbs recognized the developing parasites in the in vitro cultures of E. intestinalis. Additionally, 59 formalin-fixed stool samples that had been previously analyzed were screened, with 26 (44%) presenting microsporidian spores (18 samples with E. intestinalis and 8 samples with Enterocytozoon bieneusi). Detection of microsporidian spores by microscopy was performed using Calcofluor stain, Modified Trichrome, Quick-Hot Gram Chromotrope, as well as IFAT using MAbs 4C4, 2C2, 2E5 and 2H2. The 4 MAbs tested clearly recognized the larger spores corresponding to E. intestinalis, but showed no reactivity with Enterocytozoon bieneusi spores. The mass spectrometry and proteomic study revealed that the Mabs 4C4, 2C2, 2E5 and 2H2 recognized the Spore Wall Protein 1 (SWP1) as the antigenic target.

Conclusions

The IFAT-positive MAbs exhibited excellent reactivity against spores and developmental stages, permitting their use in human and animal diagnosis. The epitopes recognized (exospore, endospore and cytoplasmic contents) by the different MAbs developed need further study, and may reveal potential targets for vaccine development, immunotherapy and chemotherapy.

A Novel Spore Wall Protein from Antonospora locustae (Microsporidia: Nosematidae) Contributes to Sporulation

Microsporidia are obligate intracellular parasites, existing in a wide variety of animal hosts. Here, we reported AlocSWP2, a novel protein identified from the spore wall of Antonospora locustae (formerly, Nosema locustae, and synonym, Paranosema locustae), containing four cysteines that are conserved among the homologues of several Microspodian pathogens in insects and mammals. AlocSWP2 was detected in the wall of mature spores via indirect immunofluorescence assay. In addition, immunocytochemistry localization experiments showed that the protein was observed in the wall of sporoblasts, sporonts, and meronts during sporulation within the host body, also in the wall of mature spores. AlocSWP2 was not detected in the fat body of infected locust until the 9th day after inoculating spores via RT‐PCR experiments. Furthermore, the survival percentage of infected locusts injected with dsRNA of AlocSWP2 on the 15th, 16th, and 17th days after inoculation with microsporidian were significantly higher than those of infected locusts without dsRNA treatment. Conversely, the amount of spores in locusts infected with A. locustae after treated with RNAi AlocSWP2 was significantly lower than those of infected locusts without RNAi of this gene. This novel spore wall protein from A. locustae may be involved in sporulation, thus contributing to host mortality.

Encephalitozoon intestinalis: A Rare Cause of Diarrhea in an Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) Recipient Complicated by Albendazole-Related Hepatotoxicity

A 50-year-old male patient previously diagnosed with acute myelomonocytic (M4) leukemia in July 2009 underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT). During the pre-transplant period complete blood count (CBC), liver and renal function tests, coagulation tests, and other parameters were normal. On the first day of transplantation teicoplanin (400 mg d-1 for the first 3 d, and then 400 mg d-1) and caspofungin (first dose was 1×70 mg d-1, followed by 1×50 mg d-1) were started intravenously due to white plaques and oropharyngeal candidiasis in the patient's mouth and perianal erythema. On the 14th d of transplantation watery diarrhea occurred, along with abdominal discomfort, nausea, and fatigue. Stool examination was negative for findings of bleeding. Investigation of Microsporidia confirmed a rare pathogen Encephalitozoon intestinalis in the patient's stool sample via species-specific immunofluorescence antibody (IFA) assay and albendazole treatment was started at a dose of 2×400 mg d-1. On the 5th d of albendazole treatment (d 18 of treatment) liver function test (LFT) results began to deteriorate. As LFT results continued to deteriorate, albendazole was withdrawn on the 7th d of treatment. Biopsy was performed on the 22nd d of transplantation and histopathological analysis confirmed the diagnosis of toxic hepatitis. LFT results began to decrease after withdrawal of albendazole treatment. On the 13th d of albendazole treatment all LFT values returned to normal. The presented allo-HSCT case had a rare pathogenic agent (E. intestinalis) that caused diarrhea, as well as hepatotoxicity due to albendazole treatment. This is the first reported case of E. intestinalis diagnosed via IFA in Turkey.

CONFLICT OF INTEREST

None declared.

Epidemiology of Enterocytozoon bieneusi Infection in Humans

A review was conducted to examine published works that focus on the complex epidemiology of Enterocytozoon bieneusi infection in humans. Studies on the prevalence of these emerging microsporidian pathogens in humans, in developed and developing countries, the different clinical spectra of E. bieneusi intestinal infection in children, in different settings, and the risk factors associated with E. bieneusi infection have been reviewed. This paper also analyses the impact of the recent application of PCR-based molecular methods for species-specific identification and genotype differentiation has had in increasing the knowledge of the molecular epidemiology of E. bieneusi in humans. The advances in the epidemiology of E. bieneusi, in the last two decades, emphasize the importance of epidemiological control and prevention of E. bieneusi infections, from both the veterinary and human medical perspectives.

Enterocytozoon bieneusi Identification Using Real-Time Polymerase Chain Reaction and Restriction Fragment Length Polymorphism in HIV-Infected Humans from Kinshasa Province of the Democratic Republic of Congo

Objective. To determine the prevalence and the genotypes of Enterocytozoon bieneusi in stool specimens from HIV patients. Methods. This cross-sectional study was carried out in Kinshasa hospitals between 2009 and 2012. Detection of microsporidia including E. bieneusi and E. intestinalis was performed in 242 HIV-infected patients. Typing was based on DNA polymorphism of the ribosomal DNA ITS region of E. bieneusi. PCRRFLP generated with two restriction enzymes (Nla III and Fnu 4HI) in PCR-amplified ITS products for classifying strains into different lineages. The diagnosis performance of the indirect immune-fluorescence-monoclonal antibody (IFI-AcM) was defined in comparison with real-time PCR as the gold standard. Results. Out of 242 HIV-infected patients, using the real-time PCR, the prevalence of E. bieneusi was 7.9% (n = 19) among the 19 E. bieneusi, one was coinfected with E. intestinalis. In 19 E. bieneusi persons using PCR-RFLP method, 5 type I strains of E. bieneusi (26.3%) and 5 type IV strains of E. bieneusi (26.3%) were identified. The sensitivity of IFI-AcM was poor as estimated 42.1%. Conclusion. Despite different PCR methods, there is possible association between HIVinfection, geographic location (France, Cameroun, Democratic Republic of Congo), and the concurrence of type I and type IV strains.

Identification and characterization of microsporidia from fecal samples of HIV-positive patients from Lagos, Nigeria

Background

Microsporidia are obligate intracellular parasites that infect a broad range of vertebrates and invertebrates. They have been increasingly recognized as human pathogens in AIDS patients, mainly associated with a life-threatening chronic diarrhea and systemic disease. However, to date the global epidemiology of human microsporidiosis is poorly understood, and recent data suggest that the incidence of these pathogens is much higher than previously reported and may represent a neglected etiological agent of more common diseases indeed in immunocompetent individuals. To contribute to the knowledge of microsporidia molecular epidemiology in HIV-positive patients in Nigeria, the authors tested stool samples proceeding from patients with and without diarrhea.

Methodology/Principal Findings

Stool samples from 193 HIV-positive patients with and without diarrhea (67 and 126 respectively) from Lagos (Nigeria) were investigated for the presence of microsporidia and Cryptosporidium using Weber’s Chromotrope-based stain, Kinyoun stain, IFAT and PCR. The Weber stain showed 45 fecal samples (23.3%) with characteristic microsporidia spores, and a significant association of microsporidia with diarrhea was observed (O.R.  = 18.2; CI: 95%). A similar result was obtained using Kinyoun stain, showing 44 (31,8%) positive samples with structures morphologically compatible with Cryptosporidium sp, 14 (31.8%) of them with infection mixed with microsporidia. The characterization of microsporidia species by IFAT and PCR allowed identification of Enterocytozoon bieneusi, Encephalitozoon intestinalis and E. cuniculi in 5, 2 and 1 samples respectively. The partial sequencing of the ITS region of the rRNA genes showed that the three isolates of E.bieneusi studied are included in Group I, one of which bears the genotype B.

Conclusions/Significance

To our knowledge, this is the first report of microsporidia characterization in fecal samples from HIV-positive patients from Lagos, Nigeria. These results focus attention on the need to include microsporidial diagnosis in the management of HIV/AIDS infection in Nigeria, at the very least when other more common pathogens have not been detected.

Clinical significance of enteric protozoa in the immunosuppressed human population

Globally, the number of immunosuppressed people increases each year, with the human immunodeficiency virus (HIV) pandemic continuing to spread unabated in many parts of the world. Immunosuppression may also occur in malnourished persons, patients undergoing chemotherapy for malignancy, and those receiving immunosuppressive therapy. Components of the immune system can be functionally or genetically abnormal as a result of acquired (e.g., caused by HIV infection, lymphoma, or high-dose steroids or other immunosuppressive medications) or congenital illnesses, with more than 120 congenital immunodeficiencies described to date that either affect humoral immunity or compromise T-cell function. All individuals affected by immunosuppression are at risk of infection by opportunistic parasites (such as the microsporidia) as well as those more commonly associated with gastrointestinal disease (such as Giardia). The outcome of infection by enteric protozoan parasites is dependent on absolute CD4(+) cell counts, with lower counts being associated with more severe disease, more atypical disease, and a greater risk of disseminated disease. This review summarizes our current state of knowledge on the significance of enteric parasitic protozoa as a cause of disease in immunosuppressed persons and also provides guidance on recent advances in diagnosis and therapy for the control of these important parasites.

Cytometric approach for detection of Encephalitozoon intestinalis, an emergent agent

Encephalitozoon intestinalis is responsible for intestinal disease in patients with AIDS and immunocompetent patients. The infectious form is a small spore that is resistant to water treatment procedures. Its detection is very important, but detection is very cumbersome and time-consuming. Our main objective was to develop and optimize a specific flow cytometric (FC) protocol for the detection of E. intestinalis in hospital tap water and human feces. To determine the optimal specific antibody (Microspor-FA) concentration, a known concentration of E. intestinalis spores (Waterborne, Inc.) was suspended in hospital tap water and stool specimens with different concentrations of Microspor-FA, and the tap water and stool specimens were incubated under different conditions. The sensitivity limit and specificity were also evaluated. To study spore infectivity, double staining with propidium iodide (PI) and Microspor-FA was undertaken. Distinct approaches for filtration and centrifugation of the stool specimens were used. E. intestinalis spores stained with 10 microg/ml of Microspor-FA at 25 degrees C overnight provided the best results. The detection limit was 5 x 10(4) spores/ml, and good specificity was demonstrated. Simultaneous staining with Microspor-FA and PI ensured that the E. intestinalis spores were dead and therefore noninfectious. With the stool specimens, better spore recovery was observed with a saturated solution of NaCl and centrifugation at 1,500 x g for 15 min. A new approach for the detection of E. intestinalis from tap water or human feces that ensures that the spores are not viable is now available and represents an important step for the prevention of this threat to public health.

Molecular study of microsporidiosis due to Enterocytozoon bieneusi and Encephalitozoon intestinalis among human immunodeficiency virus-infected patients from two geographical areas: Niamey, Niger, and Hanoi, Vietnam

Microsporidiosis cases due to Enterocytozoon bieneusi and Encephalitozoon intestinalis are emerging opportunistic infections associated with a wide range of clinical syndromes in humans. The aim of this study was to specify microsporidial epidemiology in two different geographical areas. From November 2004 to August 2005, 228 and 42 stool samples were collected in Niamey, Niger, and Hanoi, Vietnam, respectively. Screening for microsporidia was performed using UV-light microscopy. Detection was confirmed by molecular biology using two methods specific for E. bieneusi and E. intestinalis. All samples positive for E. bieneusi were subjected to genotyping. In this study, we found high prevalences of microsporidiosis among human immunodeficiency virus-infected patients, 10.5% and 9.5%, respectively, in Niamey and Hanoi. These levels of prevalence are similar to those recorded in European countries before highly active antiretroviral therapy was introduced. In the samples positive for E. bieneusi, we found seven distinct genotypes, including two genotypes not previously described. The E. bieneusi genotype distributions in the two geographical areas suggest different routes of infection transmission, person-to-person in Niger and zoonotic in Vietnam.

Microsporidian infection is prevalent in healthy people in Cameroon

Most studies of opportunistic infections focus on those with weak immune systems, such as human immunodeficiency virus (HIV)/AIDS patients and children. However, there is a lack of information on these infectious agents in healthy people worldwide. In the present study, stool samples from both HIV patients and healthy people were examined to begin filling in this serious gap in the understanding of human microsporidiosis, particularly the enteric parasite Enterocytozoon bieneusi. Specimens were obtained from 191 individuals living in Yaoundé, the capital city of Cameroon, in sub-Sahara Africa, including 28 HIV-positive patients who also had tuberculosis (TB). E. bieneusi prevalence was 35.7% among the HIV(+) TB patients, whereas it was only 24.0% among 25 HIV(-) TB patients in the same hospital. Unexpectedly, the prevalence (67.5%) of microsporidiosis was found to be even higher for 126 immunocompetent individuals than for those with TB (healthy people compared to HIV(+) TB and HIV(-) TB patients; P < 0.001). The immunocompetent group included people ranging from 2 to 70 years of age living in four different neighborhoods in Yaoundé. The highest prevalence (81.5%) was among teenagers, and the highest mean infection score (+2.5) was among children. Additional studies of immunocompetent people in other parts of Cameroon, as well as in other countries, are needed to better understand microsporidiosis epidemiology. There is still much more to be learned about the natural history of microsporidia, the pathogenicity of different strains, and the role of enteric microsporidia as opportunistic infections in immunodeficient people.

New highly divergent rRNA sequence among biodiverse genotypes of Enterocytozoon bieneusi strains isolated from humans in Gabon and Cameroon

Intestinal microsporidiosis due to Enterocytozoon bieneusi is a leading cause of chronic diarrhea in severely immunocompromised human immunodeficiency virus (HIV)-positive patients. It may be a public health problem in Africa due to the magnitude of the HIV pandemic and to poor sanitary conditions. We designed two prevalence studies of E. bieneusi in Central Africa, the first with HIV-positive patients from an urban setting in Gabon and the second with a nonselected rural population in Cameroon. Stool samples were analyzed by an immunofluorescence antibody test and PCR. Twenty-five out of 822 HIV-positive patients from Gabon and 22 out of 758 villagers from Cameroon were found to be positive for E. bieneusi. The prevalence rates of the two studies were surprisingly similar (3.0% and 2.9%). Genotypic analysis of the internal transcribed spacer region of the rRNA gene showed a high degree of diversity in samples from both countries. In Gabon, 15 isolates showed seven different genotypes: the previously reported genotypes A, D, and K along with four new genotypes, referred to as CAF1, CAF2, CAF3, and CAF4. In Cameroon, five genotypes were found in 20 isolates: the known genotypes A, B, D, and K and the new genotype CAF4. Genotypes A and CAF4 predominated in Cameroon, whereas K, CAF4, and CAF1 were more frequent in Gabon, suggesting that different genotypes present differing risks of infection associated with immune status and living conditions. Phylogenetic analysis of the new genotype CAF4, identified in both HIV-negative and HIV-positive subjects, indicates that it represents a highly divergent strain.

Zoonotic potential of the microsporidia

Microsporidia are long-known parasitic organisms of almost every animal group, including invertebrates and vertebrates. Microsporidia emerged as important opportunistic pathogens in humans when AIDS became pandemic and, more recently, have also increasingly been detected in otherwise immunocompromised patients, including organ transplant recipients, and in immunocompetent persons with corneal infection or diarrhea. Two species causing rare infections in humans, Encephalitozoon cuniculi and Brachiola vesicularum, had previously been described from animal hosts (vertebrates and insects, respectively). However, several new microsporidial species, including Enterocytozoon bieneusi, the most prevalent human microsporidian causing human immunodeficiency virus-associated diarrhea, have been discovered in humans, raising the question of their natural origin. Vertebrate hosts are now identified for all four major microsporidial species infecting humans (E. bieneusi and the three Encephalitozoon spp.), implying a zoonotic nature of these parasites. Molecular studies have identified phenotypic and/or genetic variability within these species, indicating that they are not uniform, and have allowed the question of their zoonotic potential to be addressed. The focus of this review is the zoonotic potential of the various microsporidia and a brief update on other microsporidia which have no known host or an invertebrate host and which cause rare infections in humans.

Purification of Enterocytozoon bieneusi from stools and production of specific antibodies

Enterocytozoon bieneusi is clinically the most significant of the microsporidia in humans, causing chronic diarrhea wasting and cholangitis in individuals with human immunodeficiency virus infection and AIDS. Little progress on this infection has been made because of the inability to propagate E. bieneusi in vitro and in vivo, which limits the source of parasite spores to the stools of infected human patients. Given the size and shape of the E. bieneusi spores (1.1 to 1.6 by 0.7 to 1.0 microm) and the lack of specific immune reagents, the identification and purification of large quantities of spores from feces are technically challenging. Consequently, diagnosis relies entirely on PCR, a labor-intensive approach that requires highly skilled personnel. We describe a method for the purification of E. bieneusi spores from human stools and the production of rabbit-specific antisera. Spores were purified by a combination of isopycnic Percoll gradient centrifugation and continuous sucrose gradient centrifugation. Specific polyclonal antibodies raised in mice and rabbits reacted by indirect immunofluorescence with E. bieneusi but not with Encephalitozoon spp., Candida albicans, Staphylococcus aureus, Escherichia coli, or other forms present in human stools.

Concentrating, purifying and detecting waterborne parasites

There has been recent emphasis on developing better methods for detecting diseases of zoonotic and veterinary importance. This has been prompted by an increase in human disease agents detectable in environmental samples, the potential for bioterrorism, and the lowering of international trade barriers and expansion of personal travel, which are bringing previously considered exotic diseases to new geographical localities. To appreciate the complexities of developing detection methods and working with environmental samples, it is appropriate to review technologies currently in use, as well as those in development and presently limited to research laboratories. Discussion of parasite detection would not be possible without including methods for parasite sampling, concentration, and purification because it is often necessary to process large sample volumes prior to analysis, and no reliable methods are available for significantly amplifying parasites in vitro. Reviewing proven methods currently in use will provide a baseline for generating, accepting and implementing the more sensitive and specific methods under development today.

Emerging Causes of Traveler's Diarrhea: Cryptosporidium, Cyclospora, Isospora, and Microsporidia

Travel is a risk factor for acquiring infection with a spore-forming protozoa: Cryptosopridium, Cyclospora, Microsporidia, and Isospora. Certain travel destinations have a high disease burden and intense exposure. Patients present with persistent diarrhea and a history of recent travel to a developing country in the tropics. Very mild infections may be underdiagnosed and may cause typical traveler's diarrhea. In a patient with a history of travel and persistent diarrhea unresponsive to the usual antibiotic and antidiarrhea treatment, stool studies for all four of these protozoa infections should be performed. If immune status is normal and the disease is mild, symptomatic therapy may suffice. Effective treatment is available for Cyclospora, Microsporidia, and Isospora.

Parasitic infections of the gastrointestinal tract

Intestinal parasites continue to be a significant health problem in both developed and developing countries. In developed countries, protozoans are more commonly the cause of gastrointestinal infections than are helminths. Some protozoan parasites have stages in which, in addition to being resistant to chemicals used for water treatment, they are small enough to pass through commonly used filtration processes. The relatively large size of helminth eggs increases the likelihood of their removal during water filtration. The direct impact of protozoan parasites on both human and animal health is considerable, and there is some evidence that infection may contribute to the development of various forms of intestinal dysregulation as well as disseminated infection, especially in AIDS patients. Protozoans of special interest, due to either their frequency of isolation or their role as emerging pathogens, include Giardia duodenalis, Cryptosporidium parvum, Cyclospora cayetanensis, and the microsporidians, Enterocytozoon bieneusi and Encephalitozoon intestinalis.

Intestinal parasites

Although safe and efficacious broad-spectrum antiparasitic drugs have been developed, their availability for use in mass-treatment programs and for individual treatment worldwide can be limited by economic resources, existing manufacturing and distribution networks, and national regulations. Increasing population density, environmental pollution with human waste products, and global migration patterns will continue to promote transmission of human intestinal parasites in the foreseeable future because untreated or incompletely treated infected individuals can serve as roving reservoirs of infection for long-lived parasites. Asking primary care patients about possible geographic exposures and activities associated with an increased likelihood of intestinal parasite infection is an important part of the medical history. Many intestinal parasites can be treated effectively with oral medications, and treatment relatively early in the course of infection may prevent development of disease associated with chronic infections.