Biliary Cyclospora Infection in Compromised Hosts
Biliary Cyclospora Infection in Compromised Hosts
Abstract & Commentary
Synopsis: Immunocompromised individuals are at increased risk for severe complications from infectious causes of traveler’s diarrhea. For example, greater risk of dehydration and sepsis has been reported in immunocompromised hosts who acquire Campylobacter jejuni. Several opportunistic pathogens have been implicated as the cause of biliary disease in patients with HIV infection and immunosuppression, such as cytomegalovirus, Cryptosporidium, and Microsporidium. A recent report indicates that biliary complications due to cyclosporiasis can also occur in this group.
Source: Zar FA, El-Bayoumi E, Yungbluth MM. Histologic proof of acalculous cholecystitis due to Cyclospora cayetanensis. Clin Infect Dis. 2001;33:E140-141.
This report is the first histologically documented case of Cyclospora cayetanensis associated with acalculous cholecystitis. The most common clinical manifestation of the coccidian parasite C cayetanensis is profuse watery diarrhea, which can occur in either immunocompetent or immunosuppressed persons. In this case, Zar and associates report a 35-year-old man with AIDS, whose CD4 count was 11 cells/mm3 2 months prior to this admission. He presented with a 10-day history of sudden onset watery diarrhea. There was no evidence of fecal blood or white cells and no documented travel history. In addition to having 6 stools per day, he developed fever on day 5 of his illness associated with right upper quadrant pain, which worsened while eating and radiated to the right subscapular region. He was not receiving antiretroviral therapy or trimethoprim-sulfamethoxazole, and had a history of Stevens-Johnson syndrome associated with taking this combination agent 3 years earlier. His examination was significant for pain on deep palpation of the right upper quadrant, but without evidence of guarding or rebound tenderness.
His WBC was 4100 cells/mm3; hemoglobin 10.3 g/dL; hematocrit 31.4%, and platelets 129,000/mm3. Serum electrolytes, creatinine, and liver function tests were all within normal limits. A right upper quadrant ultrasound showed thickening of the anterior portion of the gallbladder wall with no stones, pericholecystic fluid, or dilation of the bile ducts. Acid-fast oocysts measuring 8-10 µm in diameter, typical of C cayetanensis, were seen on Kinyoun stain performed on a concentrated stool specimen.
Despite treatment with oral levofloxacin, 500 mg once daily, his pain worsened over the next 2 days and a repeat ultrasound showed thickening of the entire gallbladder wall, but no stones or dilatation of the common bile duct. Adequate filling of the gallbladder and duodenum was demonstrated by hepatic iminodiacetic acid (HIDA) scan. Laparoscopic cholecystectomy was performed on day 3 when the severe pain persisted. The gallbladder was not distended and the mucosal surface was intact. There were no calculi. Routine histologic sections demonstrated acute and chronic cholecystitis. There were numerous intracytoplasmic vacuoles in the gallbladder epithelium that contained Cyclospora trophozoites, merozoites, and schizonts (see Figure 1). These were also observed in intestinal epithelium, and oocysts were demonstrated on auramine-rhodamine fluorochrome staining. Symptoms resolved and treatment was continued with a 3-week course of oral levoquine followed by indefinite prophylaxis with 500 mg, taken 3 times per week. Stool examination for ova and parasites, obtained 2 weeks after surgery, were negative.
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Comment by Maria D. Mileno, MD
Although earlier reports had implicated cyclosporiasis as a cause of acalculous cholecystitis, histologic proof had been lacking. Based upon the findings reported for this case, Cyclospora cayetanensis might be considered as a potential cause for acalculous cholecystitis in HIV-infected immunosuppressed persons. Travelers with HIV disease may develop biliary complications as well as diarrhea from this agent. Due to a history of severe sulfa allergy this particular patient had not been using trimethoprim-sulfamethoxazole for prophylaxis against Pneumocystis carinii pneumonia (PCP), a standard preventive measure for HIV-infected persons whose CD4 counts remain below 200 cell/mm3. Trimethoprim-sulfamethoxazole is also an effective therapy for Cyclospora-associated diarrhea. This case report demonstrates yet another reason to advise HIV-infected individuals to remain consistent with taking both their antiretroviral and prophylactic regimens while traveling abroad.
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