Detecting Cryptosporidium in Stool Samples Submitted to a Reference Laboratory

Rapid detection of Cryptosporidium spp. in diarrheic cattle feces by isothermal recombinase polymerase amplification assays

As a zoonotic parasite, Cryptosporidium spp. could cause severe diarrhea mainly in calves and children globally. Monitoring and prevention of Cryptosporidium spp.'s prevalence is of great significance in both economy and public health aspects. In this study, specific primers and probes were designed within the conserved region of 18S rRNA gene for Cryptosporidium spp. and recombinase polymerase amplification assays based on the fluorescence monitoring (real-time RPA) as well as combined with a lateral flow strip (LFS RPA) were developed. Both of the two RPA assays allowed the exponential amplification of the target fragment within 20 min. After incubation on a metal bath at 42 °C, the LFS RPA results were displayed on the lateral flow strip within 5 min while real-time RPA allowed the real-time observation of the results in Genie III at 39 °C. The RPA assays showed high specificity for Cryptosporidium spp. without any cross-reaction with other tested pathogens causing diarrhea in cattle. With the recombinant plasmid DNA containing the 18S rRNA gene of Cryptosporidium spp. serving as a template, the limit of detection for real-time RPA and LFS RPA assays were 14.6 and 12.7 copies/reaction, respectively. Moreover, the RPA assays were validated by testing diarrheic cattle fecal samples and compared with a real-time PCR. The positive ratio of Cryptosporidium spp. was 24.04 % (44/183) and 26.23 % (48/183) in both RPA assays and real-time PCR assay, respectively, and the kappa coefficient value was 0.942. The diagnostic specificity and diagnostic sensitivity of both RPA assays were 100 % and 91.67 %, respectively. Forty-one of 48 positive samples were successfully sequenced and four Cryptosporidium species were detected, including C. parvum (n = 20), C. andersoni (n = 17), C. bovis (n = 3) and C. ryanae (n = 1). The developed RPA assays are easy to operate and faster to obtain the detection results, and they are suiting for the point-of-care detection and facilitating the prevention and control of Cryptosporidium spp. infections.

Identification and Evaluation of Cryptosporidium Species from New York City Cases of Cryptosporidiosis (2015 to 2018): a Watershed Perspective

Watersheds that supply residents with drinking water have the potential for contamination with Cryptosporidium oocysts. To evaluate any potential similarities between Cryptosporidium species previously found in the New York City (NYC) watershed and those causing disease in NYC, the species were identified in stool specimens from residents with cryptosporidiosis. Genetic analysis was performed on 628 positive stool samples collected from NYC residents between 2015 and 2018 to determine the species present. A total of 547 samples yielded positive results by real-time PCR. Of these samples, 512 (93.6%) were identified to the species level, with 94.7% positive for either Cryptosporidium hominis or Cryptosporidium parvum (56.4% and 38.5%, respectively), including one coinfection. Less common Cryptosporidium species identified included C. felis, C. canis, C. ubiquitum, C. meleagridis, and a Cryptosporidium sp. chipmunk genotype. Results were evaluated and compared to species and genotypes of Cryptosporidium previously identified from stormwater collected within the NYC watershed. While there was overlap with some of the rare species found in case specimens, the prevalence and distribution of species did not suggest a connection between sources previously identified in the watershed and the species causing human cases of cryptosporidiosis in NYC residents. IMPORTANCE It is important to identify the species causing human cryptosporidiosis in a population in order to investigate possible sources or routes of contamination. Many species of Cryptosporidium are host-adapted and therefore have the potential to be tracked back to specific sources that can subsequently be managed. There has been no evidence to suggest that the water supply has ever been a source of cryptosporidiosis cases in NYC, and since 2013, the New York City Department of Environmental Protection has further reduced the risk of disease through the use of ultraviolet treatment to inactivate any Cryptosporidium present in the source water. However, as one of the largest unfiltered water supplies in the country, it is important to evaluate watershed sources for potential impacts to public health. In this unique study, species of Cryptosporidium causing disease in NYC residents were identified and compared with previously identified species from the watershed.

Treatment of cryptosporidiosis: nitazoxanide yes, but we can do better

INTRODUCTION

Cryptosporidiosis was initially recognized as an important cause of diarrhea in AIDS patients. It has been underdiagnosed in other populations. Recent studies have highlighted the importance of Cryptosporidium as a cause of diarrhea and malnutrition in young children in resource-poor countries and an emerging pathogen in organ-transplant recipients.

AREAS COVERED

Nitazoxanide is FDA approved for treatment of cryptosporidiosis in immunocompetent people. However, it is less effective in HIV and transplant patients and malnourished children. In transplant recipients, there is emerging data on antiparasitic combinations for cryptosporidiosis, including combinations of nitazoxanide, azithromycin, and in one case rifaximin. High-throughput phenotypic screens have identified some potential treatments. Among them, clofazimine was no better than placebo in a trial in AIDS patients. There have also been efforts to develop drug versus specific parasite targets. However, in part due to safety issues, none of these compounds have advanced into clinical trials.

EXPERT OPINION

Development of new and more efficacious therapies for cryptosporidium is imperative. Current approve therapy is far from optimal and lacks efficacy in high-risk populations, such as, patients living with HIV. Additionally, there is limited data on patients with other types of immunosuppression (Transplanted, autoimmune conditions, etc).

Point of care diagnostics for Cryptosporidium: new and emerging technologies

PURPOSE OF REVIEW

Although Cryptosporidium detection and typing techniques have improved dramatically in recent years, relatively little research has been conducted on point of care (POC) detection and typing tools. Therefore, the main purpose of the present review is to summarize and evaluate recent and emerging POC diagnostic methods for Cryptosporidium spp.

RECENT FINDINGS

Microscopy techniques such as light-emitting diode fluorescence microscopy with auramine-phenol staining (LED-AP), still have utility for (POC) diagnostics but require fluorescent microscopes and along with immunological-based techniques, suffer from lack of specificity and sensitivity. Molecular detection and typing tools offer higher sensitivity, specificity and speciation, but are currently too expensive for routine POC diagnostics. Isothermal amplification methods such as loop-mediated isothermal amplification (LAMP) or recombinase polymerase amplification (RPA) including a commercially available LAMP kit have been developed for Cryptosporidium but are prone to false positives. Clustered regularly interspaced short palindromic repeats (CRISPR)-Cas diagnostic technologies (CRISPRDx) have recently been combined with isothermal amplification to increase its specificity and sensitivity for detection and typing. Other emerging technologies including amplification-free CRISPR detection methods are currently being developed for Cryptosporidium using a smartphone to read the results.

SUMMARY

Many challenges are still exist in the development of POC diagnostics for Cryptosporidium. The ideal POC tool would be able to concentrate the pathogen prior to detection and typing, which is complicated and research in this area is still very limited. In the short-term, CRISPR-powered isothermal amplification lateral flow tools offer the best opportunity for POC Cryptosporidium species and subtype detection, with a fully integrated autonomous biosensor for the long-term goal.

Development of duplex real-time PCR for quick detection of cryptosporidiosis in goats

Cryptosporidium spp. is the most important foodborne and waterborne pathogens and a leading cause of mortality from foodborne and waterborne gastrointestinal diseases. In neonates of domestic animals, it is associated with consistent diarrhea and dehydration. Cryptosporidium infection begins with the ingestion of sporulated oocytes disseminated by carrier animals that consistently contaminate the environment. Many diagnostic tests are available including microscopy and antigen trap-ELISA, but none of the diagnostic tests available currently cannot differentiate between active and passive infection in the host. In the current study, to address this challenge an mRNA-based duplex TaqMan® probe PCR was developed to target the Cryptosporidium oocyst wall protein gene and 18SSU rRNA gene in a single tube that can detect metabolically active cryptosporidial oocysts. The mRNA transcripts are the direct indicator of any actively replicating cell and they will help decipher the active stages of its lifecycle in a host. This diagnostic assay was standardized by computing transcript copy number-based limit of detection (LOD). For COWP and 18SSU rRNA genes, the LOD was 7.08 × 10⁰⁴ and 5.95 × 10⁰⁵ , respectively. During active infections, the oocyst wall protein will be active and so its COWP gene transcripts will act as a marker for active infection. While transcripts for 18SSU rRNA are constitutively expressed in cryptosporidial life cycle. This current diagnostic assay will be a quantitative marker that will help assess the active stages of Cryptosporidium infection in neonates. The disease dynamics will help better understand to formulate the control strategies and contain infection among healthy animals.

Review of generic screening level assumptions for quantitative microbial risk assessment (QMRA) for estimating public health risks from Australian drinking water sources contaminated with Cryptosporidium by recreational activities

As urban communities continue to grow, demand for recreational access (including swimming) in drinking water sources have increased, yet relatively little is understood about the public health implications this poses for drinking water consumers. Preventative risk-based approaches to catchment management, informed by quantitative microbial risk assessment (QMRA), requires accurate input data to effectively model risks. A sound understanding of the knowledge gaps is also important to comprehend levels of uncertainty and help prioritise research needs. Cryptosporidium is one of the most important causes of waterborne outbreaks of gastroenteritis globally due to its resistance to chlorine. This review was undertaken by Water Research Australia to provide the most up-to-date information on current Cryptosporidium epidemiological data and underlying assumptions for exposure assessment, dose response and risk assessment for generic components of QMRA for Cryptosporidium and highlights priorities for common research. Key interim recommendations and guidelines for numerical values for relatively simple screening level QMRA modelling are provided to help support prospective studies of risks to drinking water consumers from Cryptosporidium due to body-contact recreation in source water. The review does not cover site-specific considerations, such as the levels of activity in the source water, the influence of dilution and inactivation in reservoirs, or water treatment. Although the focus is Australia, the recommendations and numerical values developed in this review, and the highlighted research priorities, are broadly applicable across all drinking source water sources that allow recreational activities.

Comparison of Three Real-Time PCR Assays Targeting the SSU rRNA Gene, the COWP Gene and the DnaJ-Like Protein Gene for the Diagnosis of Cryptosporidium spp. in Stool Samples

As qualified microscopy of enteric parasitoses as defined by high diagnostic accuracy is difficult to maintain in non-endemic areas due to scarce opportunities for practicing with positive sample materials, molecular diagnostic options provide less investigator-dependent alternatives. Here, we compared three molecular targets for the real-time PCR-based detection of Cryptosporidium spp. From a population of 1000 individuals comprising both Ghanaian HIV (human immunodeficiency virus) patients and military returnees after deployment in the tropics, stool samples were assessed for Cryptosporidium spp. by real-time PCR targeting the small subunit ribosomal RNA (SSU rRNA) gene, the Cryptosporidium oocyst wall (COWP) gene, and the DnaJ-like protein gene (DnaJ), respectively. In declining order, sensitivity of 100% for the SSU rRNA gene PCR, 90.0% for the COWP PCR and 88.8% for the DnaJ PCR, respectively, as well as specificity of 99.6% for the COWP PCR and 96.9% for both the SSU rRNA gene PCR and the DnaJ PCR, respectively, were recorded. Substantial agreement (kappa value 0.663) between the three assays was observed. Further, an accuracy-adjusted Cryptosporidium spp. prevalence of 6.0% was calculated for the study population. In conclusion, none of the assessed real-time PCR assays were associated with perfect test accuracy. However, a combination of highly sensitive SSU rRNA gene PCR for screening purposes and more specific COWP PCR for confirmatory testing should allow reliable diagnosis of Cryptosporidium spp. in stool samples even in low prevalence settings.