The successful treatment of Enterocytozoon bieneusi Microsporidiosis with nitazoxanide in a patient with B-ALL: A Case Report

Molecular detection and phylogenetic analysis of microsporidia in stool specimens isolated from multiple sclerosis patients in the west of Iran

BACKGROUND

Intestinal microsporidiosis is an emerging opportunistic infection that primarily affects individuals with compromised immune systems. This study investigated intestinal microsporidia infections in individuals diagnosed with multiple sclerosis (MS) and elucidated the genetic diversity and evolutionary relationships of microsporidia.

METHODS

A total of 116 stool samples were collected from individuals diagnosed with MS, including 54 men and 63 women, during 2022-2023 in Kurdistan Province, western Iran. The mean age of the participants was 38.28 ± 7.8 years. RNA extraction was performed, followed by amplification of the small subunit ribosomal RNA (SSU rRNA) to identify and characterize microsporidia and their associated genetic markers. A phylogenetic tree was constructed using MEGA X software to explore the evolutionary relationships among the isolates.

RESULTS

PCR revealed Enterocytozoon bieneusi in 5 of 116 samples (4.3 %), whereas no positive cases of Encephalitozoon species were detected. Additionally, no statistically significant associations were observed between the presence of microsporidia and variables such as age, sex, or geographic region.

CONCLUSION

This study highlights the clinical significance of Enterocytozoon bieneusi in immunocompromised populations, particularly in patients with multiple sclerosis (MS). The findings underscore the potential role of zoonotic transmission and highlight the urgent need for enhanced diagnostic capabilities and preventive strategies to combat intestinal microsporidiosis in vulnerable groups, particularly in regions such as western Iran.

Therapeutic Potential of Propolis and Royal Jelly in Encephalitozoon Intestinalis Infection: An in Vitro Study

PURPOSE

Encephalitozoon intestinalis is an obligate intracellular microsporidian fungus that causes severe gastrointestinal infections, particularly in immunocompromised individuals. Propolis (PROP), a resinous substance derived from bees, has antimicrobial, anti-inflammatory and antioxidant properties, while royal jelly (RJ) has immunomodulatory, antioxidant and antimicrobial activities. The aim of this study was to investigate the therapeutic potential of PROP and RJ against E. intestinalis.

METHODS

The phenolic composition of PROP was analysed by high-performance liquid chromatography with diode array detection, and the chemical components of RJ were evaluated according to ISO12824 standards. The cytotoxicity of PROP and RJ on HEK-293 cells was evaluated using the XTT assay. The three highest non-cytotoxic concentrations of each sample were tested for their effects on E. intestinalis spores by qRT-PCR. Trichrome-stained photomicrographs were used to assess spore density in HEK-293 cells treated with PROP and RJ.

RESULTS

PROP analysis revealed flavonoids such as quercetin, kaempferol, pinocembrin and galangin, as well as phenolic acids such as caffeic and cinnamic acids, known for their bioactive properties. RJ contained mainly proteins, lipids, carbohydrates and sugars, reflecting its role as a nutritionally and biologically active substance. According to the results of this first study evaluating the effect of PROP and RJ on E. intestinalis, all concentrations evaluated in the study showed a significant inhibitory effect on the growth of E. intestinalis spores compared to the control group.

CONCLUSION

In conclusion, we believe that PROP and RJ should be considered as an alternative option in the development of antimicrosporidial drugs due to their potential medicinal and pharmaceutical properties.

Fumagillin Shortage: How to Treat Enterocytozoon bieneusi Microsporidiosis in Solid Organ Transplant Recipients in 2024?

Intestinal microsporidiosis caused by Enterocytozoon bieneusi is an opportunistic infection that especially affects solid organ transplant (SOT) recipients. Management revolves around tapering the immunosuppressive regimen and/or using a specific anti-microsporidia treatment, but only fumagillin has demonstrated efficacy for treatment of this infection. Since fumagillin has been commercially discontinued, nitazoxanide is increasingly being used in this indication. We aimed to describe therapeutic management of E. bieneusi infections in this context. We conducted a French nationwide observational retrospective study on reported cases of E. bieneusi infections in SOT recipients. We identified 154 cases: 64 (41.6%) were managed by simply modifying the immunosuppressive regimen, 54 (35.1%) were given fumagillin, and 36 (23.4%) were given nitazoxanide. Clinical remission rate ranged from 77.8% to 90.7% and was not significantly different between therapeutic strategies but tended to be lower with nitazoxanide. Stool negativization rate was highest with fumagillin (91.7%) and lowest with nitazoxanide (28.6%). Relapses occurred in 6.9% of cases and were more frequent with nitazoxanide (14.3%). This study shows that tapering immunosuppression can result in a satisfactory remission rate but is sometimes accompanied by relapses. Nitazoxanide had limited effectiveness, whereas fumagillin had good results that provide a solid rationale for bringing fumagillin back to market.

Trial Registration Number

ClinicalTrials.gov ID: NCT05417815.

Enterocytozoon bieneusi, a human pathogen

Although brought to the forefront in the 1980s with the AIDS pandemic, microsporidia infecting humans are still little known. Enterocytozoon bieneusi, by far the most frequent microsporidia species causing diseases in humans, is responsible for intestinal illness in both non- and immunocompromised patients. This species presents an astonishing genetic diversity with more than 500 genotypes described, some of which have a strong zoonotic potential. Indeed, E. bieneusi infects a broad array of hosts, from wild to domestic animals. This emerging eukaryotic pathogen has thus been associated with foodborne/waterborne outbreaks. Several molecular assays have been developed to enhance its diagnosis or for epidemiological purposes, providing valuable new data. Here, we propose an overview of the current knowledge on this major species among the microsporidia, so far rather neglected in human medicine.

Application of metagenomic next-generation sequencing in the diagnosis of infectious diseases

Metagenomic next-generation sequencing (mNGS) is a transformative approach in the diagnosis of infectious diseases, utilizing unbiased high-throughput sequencing to directly detect and characterize microbial genomes from clinical samples. This review comprehensively outlines the fundamental principles, sequencing workflow, and platforms utilized in mNGS technology. The methodological backbone involves shotgun sequencing of total nucleic acids extracted from diverse sample types, enabling simultaneous detection of bacteria, viruses, fungi, and parasites without prior knowledge of the infectious agent. Key advantages of mNGS include its capability to identify rare, novel, or unculturable pathogens, providing a more comprehensive view of microbial communities compared to traditional culture-based methods. Despite these strengths, challenges such as data analysis complexity, high cost, and the need for optimized sample preparation protocols remain significant hurdles. The application of mNGS across various systemic infections highlights its clinical utility. Case studies discussed in this review illustrate its efficacy in diagnosing respiratory tract infections, bloodstream infections, central nervous system infections, gastrointestinal infections, and others. By rapidly identifying pathogens and their genomic characteristics, mNGS facilitates timely and targeted therapeutic interventions, thereby improving patient outcomes and infection control measures. Looking ahead, the future of mNGS in infectious disease diagnostics appears promising. Advances in bioinformatics tools and sequencing technologies are anticipated to streamline data analysis, enhance sensitivity and specificity, and reduce turnaround times. Integration with clinical decision support systems promises to further optimize mNGS utilization in routine clinical practice. In conclusion, mNGS represents a paradigm shift in the field of infectious disease diagnostics, offering unparalleled insights into microbial diversity and pathogenesis. While challenges persist, ongoing technological advancements hold immense potential to consolidate mNGS as a pivotal tool in the armamentarium of modern medicine, empowering clinicians with precise, rapid, and comprehensive pathogen detection capabilities.

First molecular detection and characterization of Enterocytozoon bieneusi different genotypes in human patients from Italy

Enterocytozoon bieneusi is one of the 17 microsporidian species pathogenic to humans in low and high-income countries, inducing both symptomatic and asymptomatic intestinal infections, independently of the immunological condition of the infected individual. Faecal-oral transmission occurs in a broad hosts range, including several animal species, but the parasite's zoonotic potential remains still unclear. Few studies are available in Italy regarding E. bieneusi presence in humans and no data on its genetic variability are so far reported. In this investigation, through the ITSr RNA sequences analysis, we provided the first E. bieneusi molecular characterization from symptomatic patients in Italy. Faecal samples from 410 patients sent for routine analyses to the Unit of Parasitology, Policlinico Tor Vergata, Rome, and resulted positive for E. bieneusi to a cartridge-based molecular test for qualitative detection (Novodiag® Stool Parasites assay), were collected. DNA was extracted, endpoint PCR performed and then sequences obtained for 3/410 patients (0.7 %). Genotype A (N = 1), genotype C (N = 1) and genotype K (N = 1) were identified, all belonging to phylogenetic Group 1. One patient (identified as genotype A) showed positivity to the same genotype previously characterized after a two-month period. Additional investigations are required, within a One Health framework, to review the importance of a zoonotic potential linked to E. bieneusi in human populations, animals and environmental reservoirs worldwide.

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.