• 1

    Weber R, Bryan RT, 1994. Microsporidial infections in immunodeficient and immunocompetent patients. Clin Infect Dis 19 :517–521.

  • 2

    Desportes I, Le Charpentier Y, Galian A, Bernard F, Cochand-Priollet B, Lavergne A, Ravisse P, Modigliani R, 1985. Occurrence of a new microsporidian: Enterocytozoon bieneusi n. g., n. sp., in the enterocytes of a human patient with AIDS. J Protozool 32 :250–254.

    • Search Google Scholar
    • Export Citation
  • 3

    Xiao L, Escalante L, Yang C, Sulaiman I, Escalante AA, Montali RJ, Fayer R, Lal AA, 1999. Phylogenetic analysis of Cryptosporidium parasites based on the small-subunit rRNA gene locus. Appl Environ Microbiol 65 :1578–1583.

    • Search Google Scholar
    • Export Citation
  • 4

    Liguory O, David F, Sarfati C, Derouin F, Molina JM, 1998. Determination of types of Enterocytozoon bieneusi strains isolated from patients with intestinal microsporidiosis. J Clin Microbiol 36 :1882–1885.

    • Search Google Scholar
    • Export Citation
  • 5

    Edouard A, Edouard S, Desbois N, Plumelle Y, Rat C, Cales-Quist D, Jouannelle J, Lombard F, François H, 2004. Evolution de la prévalence des parasitoses digestives au CHU de Fort-de-France (Martinique). Presse Med 33 :707–709.

    • Search Google Scholar
    • Export Citation
  • 6

    Cegielski JP, Ortega YR, McKee S, Madden JF, Gaido L, Schwartz DA, Manji K, Jorgensen AF, Miller SE, Pulipaka UP, Msengi AE, Mwakyusa DH, Sterling CR, Reller LB, 1999. Cryptosporidium, Enterocytozoon, and Cyclospora infections in pediatric and adult patients with diarrhea in Tanzania. Clin Infect Dis 28 :314–321.

    • Search Google Scholar
    • Export Citation
  • 7

    Lebbad M, Norrgren H, Nauclér A, Dias F, Andersson S, Linder E, 2001. Intestinal parasites in HIV-2 associated AIDS cases with chronic diarrhoea in Guinea-Bissau. Acta Trop 80 :45–49.

    • Search Google Scholar
    • Export Citation
  • 8

    Tumwine JK, Kekitiinwa A, Bakeera-Kitaka S, Ndeezi G, Downing R, Feng W, Akiyoshi DE, Tzipori S, 2005. Cryptosporidiosis and microsporidiosis in Ugandan children with persistent diarrhea with and without concurrent infection with human immunodeficiency virus. Am J Trop Med Hyg 73 :921–925.

    • Search Google Scholar
    • Export Citation
  • 9

    Endeshaw T, Kebede A, Verweij JJ, Zewide A, Tsige K, Abraham Y, Wolday D, Woldemichael T, Messele T, Polderman AM, Petros B, 2006. Instestinal microsporidiosis in diarrheal patients infected with human immunodeficiency virus-1 in Addis Ababa, Ethiopia. Jpn J Infect Dis 59 :306–310.

    • Search Google Scholar
    • Export Citation
  • 10

    Samie A, Obi CL, Tzipori S, Weiss LM, Guerrant RL, 2007. Microsporidiosis in South Africa: PCR detection in stool samples of HIV-positive and HIV-negative individuals in school children in Vhembe district, Limpopo Province. Trans R Soc Trop Med Hyg 101 :547–554.

    • Search Google Scholar
    • Export Citation
 
 
 

 

 
 
 

 

 

 

 

 

 

Presence of Enterocytozoon bieneusi Associated with Intestinal Coccidia in Patients with Chronic Diarrhea Visiting an HIV Center in Haiti

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  • 1 Service de Parasitologie et Mycologie Médicales, Centre Hospitalier Universitaire d’Amiens, Université de Picardie Jules Verne, Amiens, France; Groupe Haïtien d’Étude du Syndrome de Kaposi et des Infections Opportunistes (GHESKIO), Port-au-Prince, Haïti; Laboratoire de Parasitologie, Hôpital Saint-Louis, Université de Paris 6, Paris, France; Weill Medical College, Cornell University, New York

This study investigated the presence of Enterocytozoon bieneusi as a possible cause of chronic diarrhea in Haitian patients attending the GHESKIO AIDS clinic in Port-au-Prince, Haiti. Coccidian oocysts were found by polymerase chain reaction (PCR) in the stools of 58/74 patients with chronic diarrhea and included the following agents: 45 (60%) Cryptosporidium spp., 27 (34%) Cyclospora cayetanensis, and 11 (15%) Isospora belli. Four patients (5.5%) were co-infected with E. bieneusi and one (1.4%) had E. bieneusi alone. The PCR-restriction fragment length polymorphism (RFLP) method made it possible to document the presence in human feces of E. bieneusi in Haiti. As in sub-Saharan Africa, the association of E. bieneusi with coccidian parasites found in Haitian patients with diarrhea is probably caused by the high level of fecal contamination of soils and surface waters usually associated with countries with low hygienic standards.

Chronic diarrhea accompanied by weight loss is a common and often debilitating manifestation of the human immunodeficiency virus (HIV) infection. Enterocytozoon bieneusi has been reported to be associated with chronic diarrhea and wasting in acquired immunodeficiency syndrome (AIDS) patients in Europe, the United States, South America, and Africa. However, intestinal microsporidiosis has also been incriminated as a cause of travelers’ diarrhea in immunocompetent patients1 and has been detected in immunocompetent inhabitants of sub-Saharan Africa. Despite the first description of E. bieneusi from a Haitian patient with AIDS living in France,2 the presence of this intestinal parasite has only recently been established in Haiti. On three occasions in 2007, the first fresh stool specimens (up to 25 per month for a total of 74) of a total of 810 patients with chronic diarrhea attending an AIDS clinic in Port-au-Prince obtained during the months of March (N = 25), May (N = 25), and September 2007 (N = 24) were preserved with potassium dichromate and shipped to France. These specimens were evaluated by polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP) for the presence of E. bieneusi as a possible cause of chronic diarrhea in Haiti. All patients had a history of intermittent liquid or semi-liquid stools for > 3 weeks.

Weber modified trichrome, fluorochrome staining (Uvi-bio), and indirect immunofluorescent antibody assays using anti-E. bieneusi and Encephalitozoon intestinalis monoclonal antibodies (Bordier Affinity Products, Crissier, Switzerland) were used for microscopic detection of microsporidium spores. The PCR-RFLP technique was used to identify Cryptosporidium spp.3 Genotyping of E. bieneusi strains isolated from stool specimens was performed by digestion of amplification products with NlaIII and Fnu4HI endonucleases (New England Biolabs, Beverly, MA).4

The 74 patients consisted of 30 males and 44 females (sex ratio = 0.59). Their distribution by age and HIV serologic status was as follows: 13 children < 14 years of age (17.6%), of whom 6 were HIV positive; 60 adults 16–52 years of age (81.1%), all HIV positive; and 1 HIV-infected female of unknown age.

Of 58 patients with coccidian oocysts documented in their stools by PCR-RLFP, 45 (60%) were infected with Cryptosporidium spp., 27 (34%) with Cyclospora cayetanensis, and 11 (15%) with Isospora belli; 4 (5.5%) were co-infected with E. bieneusi, and 1 (1.4%) was infected with E. bieneusi alone (Table 1). Molecular genotyping of 50 strains of Cryptosporidium showed the following distribution in these patients: 31 C. parvum (42%), 17 C. hominis (23%), and 2 C. felis (2.7%); 5 adults and 1 12-month-old child (8%) had a co-infection with C. parvum and C. homini.

Enterocytozoon bieneusi has recently been found in Port-au-Prince in HIV-positive patients at GHESKIO by reverse transcriptase (RT)-PCR (R. Dillingham and J. Pape, personal communication). To our knowledge, Haiti is the second Caribbean country where this parasite has been detected in humans. In this study, this microsporidial fungus was found in patients living in both urban and rural areas. Among these patients, it was found twice in HIV-negative children and three times in HIV-positive adults, two of whom were strongly immunocompromised with low CD4 counts (< 50/100 μL). All patients presented with chronic debilitating diarrhea. In Martinique, only four cases of microsporidiosis have been found in HIV-positive patients between January 1, 1997 and December 31, 1999, from 4,684 parasitologic stool examinations performed on 2,407 patients.5 In our small study, we detected five cases (6.6%) from 74 stool samples obtained during a 3-month period. However, Edouard and others5 did not state whether their four cases in Martinique were autochthonous or imported. Indeed, the high level of sanitation and good living conditions in Martinique exclude significant human fecal contamination of the environment.

The delay in report of E. bieneusi in humans in Haiti is because of the fact that the PCR-RLFP method was used in this study and that this technique has only been recently introduced at the GHESKIO center. It is important in Haiti to train laboratory technicians in biomolecular methods to identify such pathogens, and it is essential to have reference laboratories with the capacity to conduct such techniques.

This small survey indicates that E. bieneusi is frequently associated with coccidian parasites in patients with diarrhea in Haiti. These findings are similar to those reported from sub-Saharan Africa.610 It is the consequence of high fecal contamination of soils and surface waters in these tropical countries where poverty and promiscuousness are usual and hygienic standards are low.

Table 1

Demographic characteristics of the five Haitian patients infected with E. bieneusi, with or without concomitant intestinal coccidial infection

Stool examination
AgeSexResidenceHIVCD4C. hominisC. parvumCy. cayetanensisE. bieneusi
10 monthsMaleVillage de Dieu, Bicentenaire (Port-au-Prince)++
20 monthsFemaleThiote (eastern-south province)++
23 yearsFemaleRoute de Frères (Port-au-Prince)+281+++
27 yearsMaleGalette Dumay (western province)+42++
38 yearsMaleThor Lamentin (Port-au-Prince)+19+

*

Address correspondence to Christian P. Raccurt, Service de Parasitologie et Mycologie Médicales, Hôpital Sud, CHU d’Amiens, 80054 Amiens, France. E-mails: raccurt.christian@chuamiens.fr or raccurt@yahoo.fr

Authors’ addresses: Christian Raccurt, Patrice Agnamey, Taieb Chouaki, and Anne Totet, Service de parasitologie et mycologie médicales, CHU d’Amiens, Hôpital Sud, avenue Laënnec, Salouel, 80054 Amiens, France. Bernadette Fouché and Jean W. Pape, Les Centres GHESKIO, 33, Boulevard Harry Truman, Cité de l’Exposition, Port-au-Prince, Haiti. Jean Menotti, Laboratoire de parasitologiemycologie, Hôpital Saint-Louis, 1, rue Claude Velle-faux, 75475 Paris Cedex 10, France.

REFERENCES

  • 1

    Weber R, Bryan RT, 1994. Microsporidial infections in immunodeficient and immunocompetent patients. Clin Infect Dis 19 :517–521.

  • 2

    Desportes I, Le Charpentier Y, Galian A, Bernard F, Cochand-Priollet B, Lavergne A, Ravisse P, Modigliani R, 1985. Occurrence of a new microsporidian: Enterocytozoon bieneusi n. g., n. sp., in the enterocytes of a human patient with AIDS. J Protozool 32 :250–254.

    • Search Google Scholar
    • Export Citation
  • 3

    Xiao L, Escalante L, Yang C, Sulaiman I, Escalante AA, Montali RJ, Fayer R, Lal AA, 1999. Phylogenetic analysis of Cryptosporidium parasites based on the small-subunit rRNA gene locus. Appl Environ Microbiol 65 :1578–1583.

    • Search Google Scholar
    • Export Citation
  • 4

    Liguory O, David F, Sarfati C, Derouin F, Molina JM, 1998. Determination of types of Enterocytozoon bieneusi strains isolated from patients with intestinal microsporidiosis. J Clin Microbiol 36 :1882–1885.

    • Search Google Scholar
    • Export Citation
  • 5

    Edouard A, Edouard S, Desbois N, Plumelle Y, Rat C, Cales-Quist D, Jouannelle J, Lombard F, François H, 2004. Evolution de la prévalence des parasitoses digestives au CHU de Fort-de-France (Martinique). Presse Med 33 :707–709.

    • Search Google Scholar
    • Export Citation
  • 6

    Cegielski JP, Ortega YR, McKee S, Madden JF, Gaido L, Schwartz DA, Manji K, Jorgensen AF, Miller SE, Pulipaka UP, Msengi AE, Mwakyusa DH, Sterling CR, Reller LB, 1999. Cryptosporidium, Enterocytozoon, and Cyclospora infections in pediatric and adult patients with diarrhea in Tanzania. Clin Infect Dis 28 :314–321.

    • Search Google Scholar
    • Export Citation
  • 7

    Lebbad M, Norrgren H, Nauclér A, Dias F, Andersson S, Linder E, 2001. Intestinal parasites in HIV-2 associated AIDS cases with chronic diarrhoea in Guinea-Bissau. Acta Trop 80 :45–49.

    • Search Google Scholar
    • Export Citation
  • 8

    Tumwine JK, Kekitiinwa A, Bakeera-Kitaka S, Ndeezi G, Downing R, Feng W, Akiyoshi DE, Tzipori S, 2005. Cryptosporidiosis and microsporidiosis in Ugandan children with persistent diarrhea with and without concurrent infection with human immunodeficiency virus. Am J Trop Med Hyg 73 :921–925.

    • Search Google Scholar
    • Export Citation
  • 9

    Endeshaw T, Kebede A, Verweij JJ, Zewide A, Tsige K, Abraham Y, Wolday D, Woldemichael T, Messele T, Polderman AM, Petros B, 2006. Instestinal microsporidiosis in diarrheal patients infected with human immunodeficiency virus-1 in Addis Ababa, Ethiopia. Jpn J Infect Dis 59 :306–310.

    • Search Google Scholar
    • Export Citation
  • 10

    Samie A, Obi CL, Tzipori S, Weiss LM, Guerrant RL, 2007. Microsporidiosis in South Africa: PCR detection in stool samples of HIV-positive and HIV-negative individuals in school children in Vhembe district, Limpopo Province. Trans R Soc Trop Med Hyg 101 :547–554.

    • Search Google Scholar
    • Export Citation
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