• View in gallery

    Agarose gel electrophoresis of polymerase chain reaction (PCR) products with V1/PMP2 primers stained with ethidium bromide. Lane 1, 100-basepair DNA ladder (Amersham, UK); lane 2, positive sample of E. bieneusi; lane 3, positive control of E. bieneusi; lane 4, positive control of E. intestinalis; lane 5, 6, positive sample of E. intestinalis; lane 7, positive sample of E. hellem; lane 8, negative control.

  • View in gallery

    Agarose gel electrophoresis of polymerase chain reaction (PCR) products obtained using species–specific primers V1/EB450 and V1/SI500. Lane 1, negative samples of E. bieneusi; lane 2, positive sample of E. bieneusi; lane 3, positive control of E. bieneusi; lane M, molecular size marker of 100 pb (Amersham, UK); lane 5, positive control of E. intestinalis; lane 6, positive samples of E. intestinalis; lane 7, negative samples of E. intestinalis; lane 8, negative control.

  • 1

    Molina JM, Sarfati C, Beauvais B, Lemann M, Lesourd F, Ferchal F, Casin I, Lagrange P, Modigliani R, Derouin F, Modai J, 1993. Intestinal microsporidiosis in human immunodeficiency virus-infected patients with chronic unexplained diarrhea: prevalence and clinical and biologic features. J Infect Dis 167 :217–221.

    • Search Google Scholar
    • Export Citation
  • 2

    Guerard A, Rabodonirina M, Cotte L, Liguory O, Piens MA, Daoud S, Picot S, Touraine JL, 1999. Intestinal microsporidiosis occurring in two renal transplant recipients treated with mycophenolate mofetil. Transplantation 5 :699–707.

    • Search Google Scholar
    • Export Citation
  • 3

    Weber R, Bryan RT, 1992. Improved light-microspridial detection of microsporidia spores in stool and duodenal aspirates. N Engl J Med 326 :161–166.

    • Search Google Scholar
    • Export Citation
  • 4

    Katzwinkel-Wladarsch S, Lieb M, Helse W, Loscher T, Rindier H, 1996. Direct amplification and species determination of microsporidian DNA from stool specimens. Top Med Int Health 1 :373–378.

    • Search Google Scholar
    • Export Citation
  • 5

    Didier ES, 1997. Effects of Albendazole, Fumagillin, and TMP-470 on microsporidial replication in vitro. Antimicrob Agents Chemother 41 :1541–1546.

    • Search Google Scholar
    • Export Citation
  • 6

    Weber R, Bryan RT, Schwartz DA, Owen RL, 1994. Human microsporidial infections. Clin Microbiol Rev 7 :426–461.

  • 7

    Franzen C, Schwartz DA, Visvesvara GS, Muller A, Schwenk A, Salzberger B, Fatkenheur G, Hartmann P, Diehl V, Schrappe M, 1995. Immunologically confirmed disseminated asymptomatic Encephalitozoon cuniculi infection of gastrointestinal tract in patient with AIDS. Clin Infect Dis 21 :1480–1484.

    • Search Google Scholar
    • Export Citation
  • 8

    Belhadj S, Kallel K, Boussen N, Ghobatini A, Bejoui M, Ben salem N, Ziribi A, BenChaabane T, Chaker E, 1999. Places des cryptosporidies et des microsporidies dans les diarrhées des immunodéprimés. Tunis Med 77 :638–643.

    • Search Google Scholar
    • Export Citation
  • 9

    Aoun K, Bouratbine A, Darty A, Biligui S, Ben Ismail R, 1997. Présence de microsporidies intestinales en Tunisie: à propos d’un cas. Bull Soc Path Ex 90 :176.

    • Search Google Scholar
    • Export Citation
  • 10

    Kokoskin E, Gyorkos TW, Camus A, Cedilotte L, Purtill T, Ward B, 1994. Modified technique for efficient detection of microsporidia. J Clin Microbiol 36 :1974–1975.

    • Search Google Scholar
    • Export Citation
  • 11

    Fedorko DP, Nelson NA, Cartwright CP, 1995. Identification of microsporidiabin stool specimens by using PCR and restriction endonucleases. J Clin Microbiol 33 :1739–1741.

    • Search Google Scholar
    • Export Citation
  • 12

    Coyle CM, Wittner M, Kotler DP, Noyer C, Orenstein JM, Tanowitz HB, Weiss LM, 1996. Prevalence of microsporidiosis due to Enterocytozoon bieneusi and Encephalitozoon (Septata) intestinalis among patients with AIDS-related diarrhea: determination by chain polymerase reaction to the microsporidian small-subunit rRNA gene. Clin Infect Dis 23 :1002–1006.

    • Search Google Scholar
    • Export Citation
  • 13

    Müller A, Stellerman K, Hartmann P, Scharppa M, Fathenheuer G, Salzberger B, Diehl V, Franzen C, 1999. A powerful DNA extraction method and PCR for detection of mocrosporidia in clinical stool specimens. Clin Diagn Lab Immunol 2 :243–246.

    • Search Google Scholar
    • Export Citation
  • 14

    Didier ES, Orenstein JM, Aldras A, Bertucci D, Rogers LB, Janney FA, 1995. Comparaison of three methods for detecting microsporidia in fluids. J Clin Microbiol 33 :3138–3145.

    • Search Google Scholar
    • Export Citation
  • 15

    Dowd SE, Gerba CP, Pepper IL, 1998. Confirmation of human-pathogenic microsporidia Enterocytozoon bieneusi, Encephalitozoon intestinalis and Vittaforma corneae in water. Appl Environ Microbiol 64 :3332–3335.

    • Search Google Scholar
    • Export Citation
  • 16

    Cali A, Kotler P, Orenstein JM, 1993. Septata intestinalis N. G., N. sp., an intestinal microsporidian associated with chronic diarrhea and dissemination in AIDS patients. J Eukaryot Microbiol 40 :101–112.

    • Search Google Scholar
    • Export Citation
  • 17

    Didier ES, Didier PJ, Friedberg DN, Stenson SM, Orenstein JM, Yee RW, Tio FO, Davis MR, Vossbrinck C, Millichamp N, Shadduck JA, 1991. Isolation and characterization of a new human microsporidia, Encephalitozoon hellem (n. sp), from three AIDS patients with keratoconjunctivitis. J Infect Dis 163 :617–621.

    • Search Google Scholar
    • Export Citation
  • 18

    Schwartz DA, Visvesvara GS, Leitch GJ, Tashjian L, Pollack M, Holden J, Bryan RT, 1993. Pathology of symptomatic microsporidial (Encephalitozoon hellem) bronchiolitis in AIDS: a new respiratory pathogen diagnosed from lung biopsy, bronchoalveolar lavage, sputum, and tissue culture. Hum Pathol 24 :937–943.

    • Search Google Scholar
    • Export Citation

 

 

 

 

 

Genetic Identification of Intestinal Microsporidia Species in Immunocompromised Patients in Tunisia

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  • 1 Laboratoire de Recherche 05-SP-03, Laboratoire de Parasitologie, Institut Pasteur de Tunis, Tunis, Tunisia; Service des Maladies Infectieuses, Hôpital de la Rabta, Tunis, Tunisia; Service d’Immunohématologie Pédiatrique, Centre de Greffe de Moelle Osseuse, Tunis, Tunisia; Laboratoire de Parasitologie-Mycologie, Hôpital de la Pitié-Salpétrière, Unité INSERM 511, Université Paris VI Pierre et Marie Curie, Paris, France

Stool samples from 86 immunocompromised patients (51 human immunodeficiency virus (HIV)–infected patients and 35 patients with haematologic malignancies) were systematically screened for intestinal microspordiosis by microscopic examination and polymerase chain reaction (PCR) using universal primer V1/PMP2. Nine samples (10.5%) showed amplification with the predictive size of fragment (6 from HIV–infected patients and 3 from patients with myeloma). Only 5 out of them (all HIV–infected patients) were revealed positive by microscopy. By means of amplicons fragment size, species–specific primers (V1/EB450, V1/IS500) and sequencing, 3 microsporidia species were for the first time identified in Tunisia: Enterocytozoon bieneusi (3 isolates), Encephelitozoon intestinalis (2 isolates), and Encephalitozoon hellem (1 isolate). Systematic use of such sensitive and discriminative molecular tools will contribute to determining the true prevalence of microsporidiosis in Tunisia and to better management of infected immunocompromised subjects.

INTRODUCTION

Intestinal microsporidiosis ranks among the most common causes of diarrhea among immunocompromised individuals.1 Most cases have been documented in patients infected with the human immunodeficiency virus (HIV) and only a few of them have been related to other immunosupressive etiologies.2 Diagnostic procedures of intestinal microsporidiosis have been markedly improved by the use of Weber’s chromotrope-based stain.3 Molecular-based techniques, such as polymerase chain reaction (PCR), are mainly used for positive case confirmation and/or species differentiation.4 Despite the important implications of microsporidia species identification on the clinical and therapeutic management of patients, the corresponding data are still rare.5 Enterocytozoon (E.) bieneusi and Encephalitozoon (E.) intestinalis are the two species responsible for the majority of infections in man.6 Published human cases caused by Encephalitozoon hellem and Encephalitozoon cuniculi are rare. 6,7

In Tunisia, microsporidia parasites have been found in both immunocompetent and immunocompromised diarrheal subjects. 8,9 However, no species identification has been performed yet. The purpose of this study was to detect and to identify microsporidia species in stools from immunocompromised Tunisian patients.

MATERIALS AND METHODS

Stool samples.

Stool samples were collected from 86 immunocompromised Tunisian patients; 51 HIV–infected patients, and 35 suffering from haematologic malignancies (HM) (8 chronic myeloid leukaemia, 8 myeloma, 7 acute lymphoid leukaemia, 6 chronic lymphoid leukaemia, and 6 Hodgkin disease). Fifty-four patients were diarrheic. Collections were done, after individual consent, within the framework of routine screening for opportunistic pathogens. All specimens were systematically investigated for microsporidia infection by light microscopy and PCR.

Weber’s modified trichrome stain.

Each stool specimen was mixed with 10% formalin (1:3 ratio) then filtered through sieves with pore diameters of 400 μ m; 3 mL of ether were added to the filtrate. The mixture was shaken for a minute and centrifuged at 2,000 g for 2 minutes. From pellet a thin smear was prepared on a glass slide, dried, fixed with methanol for 5 minutes, and stained with Weber’s modified trichrome stain (MTS), as adapted by Kokoskin and others. 10 Each stained smear was examined using Leitz Laborlux binocular microscopes (Wetzlar, Germany) with built-in illumination and a total magnification of 1000× (10× widefield eyepieces and a 100× oil immersion lens). Negative results were reported after at least 10 minutes of examination.

DNA extraction.

The DNA was extracted from frozen samples using the QIAamp DNA Tissue Kit (Qiagen Inc, Germany). Briefly, 200 μ L of stool suspension was washed three times in phosphate-buffered-saline (PBS) solution by centrifugation at 12,000 g for 5 minutes. The final pellet was suspended in 180 μ L of tissue lysis buffer and incubated with proteinase K for 2 hours at 55°C. The manufacturer’s recommendations were followed for purification and elution of DNA, which was then stored at −20°C until analyzed.

PCR amplifications.

Two sets of PCR primers were used in this study as described in previous reports. The forward primer V1: 5′-CACCAGGTTGATTCTGCCTGAC-3′ and the reverse primer PMP2: 5′-CCTCTCCGGAACCAAACCCTG-3′) amplify the small-subunit ribosomal DNA (SSU-rDNA) of four human microsporidia, E. bieneusi, E. intestinalis, E. cuniculi, and E. hellem.11 Samples proved positive by V1/PMP2 primers with predictive size fragment about 250 to 279 bp, have been subject to two other PCR, using species–specific primers, V1/EB450 (5′-ACTCAGGTGTTATACTCACGTC-3′) and V1/SI500 (5′-CTCGCTCCTTTACACTCG-3′) to differentiate E. bieneusi infection from E. intestinalis infection, respectively. 12

Amplification for all PCR was done in 50 μ L reaction mixtures under the following conditions: 1 × PCR buffer, 2.5 mM of MgCl2, 20 pmol of each primer, 200 μ M concentrations of each dNTP, 1.25 U of Goldstar Taq DNA polymerase (Applied biosystem, Roche, Switzerland), and 10 μ L of the DNA. Amplification consisted of 5 minutes at 94°C followed by 35 cycles of 45 seconds at 94°C, 30 seconds at 55°C, and 45 seconds at 72°C; a final phase of extension at 72°C for 10 minutes. The amplified products were separated by electrophoresis on a 2% agarose gel and visualized after staining with ethidium bromide.

Each set of experiments included a negative (distilled water) and two positive PCR controls. The positive controls were DNA template extracted from positive stool specimens infected with E. bieneusi and E. intestinalis kindly provided by Marc Thellier from Pitié-Salpetrière Hospital, Paris-France.

DNA sequencing analysis.

All DNA fragments obtained by universal primers V1/PMP2 were sequenced. The PCR products were purified using GenElute PCR Clean-Up kit (Sigma, St. Louis, MO). Sequencing reactions were performed directly on the amplification products using ABI Prism 377 DNA Sequencer (Applied Bio System, Foster City, CA). The sequences were compared with those available in the GenBank Database with the BlastN program located at (http://www.ncbi.nlm.nih.gov).

RESULTS

Examination of the 86 stool samples by microscopy showed microsporidian spores in 5 samples (5.8%), all 5 out of 51 (9.8%) HIV–infected patients. Using universal primers V1/PMP2, 9 out of 86 (10.5%) stool samples showed a positive amplification. Considering that technique, the prevalence rate of microsporidia infection were 11.8% (6 out of 51) and 8.6% (3, all with myeloma, out of 35) for, respectively, HIV and HM groups (Table 1). Of the nine 7 were diarrheic.

Among the 9 samples that proved positive by PCR, microsporidia species identification was successfully achieved in 6 isolates. A 250 bp DNA fragment, suggesting infection with E. bieneusi, was obtained from stools of 3 HIV–infected patients (Figure 1). In those samples, amplification of 353 bp DNA fragment was achieved with E. bieneusi–specific primers and no amplification was obtained with E. intestinalis–specific primers. The 3 sequences had 98–99% sequence identity with E. bieneusi (Genbank accession no. AY257180). A 270 bp DNA fragment, suggesting infection with E. intestinalis, was amplified from stool specimens from 2 patients (1 HIV patient, 1 patient with myeloma) ( Figure 1 ). A 375 bp DNA fragment was obtained from these samples after PCR with E. intestinalis–specific primers ( Figure 2 ). The 2 amplicons had 96% and 99% sequence identity with E. intestinalis (Genbank accession no. EU436735). A 279 bp DNA fragment was amplified in one sample from a myeloma patient, suggesting infection with E. hellem. This sample, negative by both E. intestinalis and E. bieneusi–specific primers, had 98% sequence identity with E. hellem (Genbank accession no. L19070). In the remaining 3 positive samples (2 HIV and 1 myeloma patients), the length of the obtained fragment was too weak for further analysis. These 3 samples revealed negative by both species–specific primers (Table 1).

DISCUSSION

As previously reported, PCR using universal primers V1/PMP2 detected more intestinal microsporidia infections (9 cases) than did light microscopy (5 cases). 13 The difference is probably a result of the limited sensitivity of light microscopy estimated to be between 104 and 106 spores per g of stool, whereas PCR can detect parasitic loads of 102 spores per g of stool. 14 This better sensitivity of PCR allows us to establish a higher prevalence rate (10.5%) of intestinal microsporidiosis in Tunisia in comparison to those reported in previous studies.8

The distinction between Encephalitozoon and Enterocytozoon in light microscopy is often impossible because of the very small size of the microsporidia spores 10; In fact, spores of E. bieneusi average 1.5 × 1.0 μ m and those of E. intestinalis 2.2 × 1.2 μ m. 1,6 The PCR and sequencing, which represent the reference tools for species identification, 13,15 are here used for the first time in North Africa to identify the Microsporidia species found in stool samples from a group of 86 immunocompromised Tunisian patients. Such parasites characterization is now necessary for an appropriate therapeutic management of patients. In fact, if albendazole is effective against Encephalitozoon spp., only fumagillin have shown to be effective against E. bieneusi.5

The species identification was successfully performed in 6 isolates, 3 corresponded to E. bieneusi, 2 to E. intestinalis, and the last to E. hellem (Table 1, Figures 1 and 2). As largely described, E. bieneusi was predominant in HIV–infected patients (3 out of 4 identifications). 6,12 Encephalitozzon hellem and E. intestinalis were identified in 2 patients with HM, it is to our knowledge among the rare reports of Encephalitozoon spp. in stools from non-HIV infected patients.6 In fact, E. intestinalis has been mainly documented in HIV–infected patients, 16 whereas E. hellem has been more described as infecting the epithelial surfaces of ocular and respiratory tissues. 17,18

Table 1

Light microscopy and PCR results for nine patients with intestinal microspridiosis

Table 1
Figure 1.
Figure 1.

Agarose gel electrophoresis of polymerase chain reaction (PCR) products with V1/PMP2 primers stained with ethidium bromide. Lane 1, 100-basepair DNA ladder (Amersham, UK); lane 2, positive sample of E. bieneusi; lane 3, positive control of E. bieneusi; lane 4, positive control of E. intestinalis; lane 5, 6, positive sample of E. intestinalis; lane 7, positive sample of E. hellem; lane 8, negative control.

Citation: The American Journal of Tropical Medicine and Hygiene Am J Trop Med Hyg 80, 1; 10.4269/ajtmh.2009.80.24

Figure 2.
Figure 2.

Agarose gel electrophoresis of polymerase chain reaction (PCR) products obtained using species–specific primers V1/EB450 and V1/SI500. Lane 1, negative samples of E. bieneusi; lane 2, positive sample of E. bieneusi; lane 3, positive control of E. bieneusi; lane M, molecular size marker of 100 pb (Amersham, UK); lane 5, positive control of E. intestinalis; lane 6, positive samples of E. intestinalis; lane 7, negative samples of E. intestinalis; lane 8, negative control.

Citation: The American Journal of Tropical Medicine and Hygiene Am J Trop Med Hyg 80, 1; 10.4269/ajtmh.2009.80.24

*

Address correspondence to Karim Aoun, LR “Parasitoses Émergentes”, Laboratoire de Parasitologie, Institut Pasteur de Tunis, 13 Place Pasteur, BP 74, 1002 Tunis Belvedère, Tunisia. E-mail: karim.aoun@fmt.rnu.tn

Authors’ addresses: Najla Chabchoub, Aïda Bouratbine, and Karim Aoun, LR “Parasitoses Émergentes”, Laboratoire de Parasitologie, Institut Pasteur de Tunis, 13 Place Pasteur, BP 74, 1002 Tunis Belvedère, Tunisia, Tel: 216-71-890-827, Fax: 216-71-791-833. Rim Abdelmalek and Fakher Kanoun, Service des Maladies Infectieuses, la Rabta, 1007 Jebbari Tunis, Tunisia, Tel/Fax: 216-71-578-833. Fethi Mellouli, Service d’Immuno-Hématologie Pédiatrique, Centre de Greffe de Moelle Osseuse, 2 rue Djebel Lakhdhar, Tunis, Tunisia. Marc Thellier, Laboratoire de Parasitologie-Mycologie, Hôpital de la Pitié Salpétrière, 47-83 Boulevard de l’Hôpital, 75 651 Paris, France, Tel: 33-01-42-16-01-84, Fax: 33-1-42-16-01-65.

Acknowledgments: The authors thank Saloua Laddab, Essia Ben Hassen, Mohamed Bejaoui, and Tarak Ben Othmane from the Bone Marrow Transplant Center of Tunis; Samah Aissa and Taoufik Ben Chaabene from the Department of Infectious Diseases, and Neyla Ben Romdhane from the Department of Haematology of La Rabta Hospital-Tunis, and all the physicians in charge of the patients for their help in the collection of stools and clinical data. The authors are grateful to Mrs. Rim Essid, Olfa Souissi, Najet Zallagua, and Mr. Adel Rhim from Pasteur Institute of Tunis, and Mr. Sylvestre Billigui from Pitié-Salpétrière hospital, Paris-France, for their technical collaboration.

Financial support: This study was supported by the Ministry of Higher Education, Research and Technology, Tunisia, in the setting of the Research Lab “Parasitoses emergentes” LR 05-SP-03.

REFERENCES

  • 1

    Molina JM, Sarfati C, Beauvais B, Lemann M, Lesourd F, Ferchal F, Casin I, Lagrange P, Modigliani R, Derouin F, Modai J, 1993. Intestinal microsporidiosis in human immunodeficiency virus-infected patients with chronic unexplained diarrhea: prevalence and clinical and biologic features. J Infect Dis 167 :217–221.

    • Search Google Scholar
    • Export Citation
  • 2

    Guerard A, Rabodonirina M, Cotte L, Liguory O, Piens MA, Daoud S, Picot S, Touraine JL, 1999. Intestinal microsporidiosis occurring in two renal transplant recipients treated with mycophenolate mofetil. Transplantation 5 :699–707.

    • Search Google Scholar
    • Export Citation
  • 3

    Weber R, Bryan RT, 1992. Improved light-microspridial detection of microsporidia spores in stool and duodenal aspirates. N Engl J Med 326 :161–166.

    • Search Google Scholar
    • Export Citation
  • 4

    Katzwinkel-Wladarsch S, Lieb M, Helse W, Loscher T, Rindier H, 1996. Direct amplification and species determination of microsporidian DNA from stool specimens. Top Med Int Health 1 :373–378.

    • Search Google Scholar
    • Export Citation
  • 5

    Didier ES, 1997. Effects of Albendazole, Fumagillin, and TMP-470 on microsporidial replication in vitro. Antimicrob Agents Chemother 41 :1541–1546.

    • Search Google Scholar
    • Export Citation
  • 6

    Weber R, Bryan RT, Schwartz DA, Owen RL, 1994. Human microsporidial infections. Clin Microbiol Rev 7 :426–461.

  • 7

    Franzen C, Schwartz DA, Visvesvara GS, Muller A, Schwenk A, Salzberger B, Fatkenheur G, Hartmann P, Diehl V, Schrappe M, 1995. Immunologically confirmed disseminated asymptomatic Encephalitozoon cuniculi infection of gastrointestinal tract in patient with AIDS. Clin Infect Dis 21 :1480–1484.

    • Search Google Scholar
    • Export Citation
  • 8

    Belhadj S, Kallel K, Boussen N, Ghobatini A, Bejoui M, Ben salem N, Ziribi A, BenChaabane T, Chaker E, 1999. Places des cryptosporidies et des microsporidies dans les diarrhées des immunodéprimés. Tunis Med 77 :638–643.

    • Search Google Scholar
    • Export Citation
  • 9

    Aoun K, Bouratbine A, Darty A, Biligui S, Ben Ismail R, 1997. Présence de microsporidies intestinales en Tunisie: à propos d’un cas. Bull Soc Path Ex 90 :176.

    • Search Google Scholar
    • Export Citation
  • 10

    Kokoskin E, Gyorkos TW, Camus A, Cedilotte L, Purtill T, Ward B, 1994. Modified technique for efficient detection of microsporidia. J Clin Microbiol 36 :1974–1975.

    • Search Google Scholar
    • Export Citation
  • 11

    Fedorko DP, Nelson NA, Cartwright CP, 1995. Identification of microsporidiabin stool specimens by using PCR and restriction endonucleases. J Clin Microbiol 33 :1739–1741.

    • Search Google Scholar
    • Export Citation
  • 12

    Coyle CM, Wittner M, Kotler DP, Noyer C, Orenstein JM, Tanowitz HB, Weiss LM, 1996. Prevalence of microsporidiosis due to Enterocytozoon bieneusi and Encephalitozoon (Septata) intestinalis among patients with AIDS-related diarrhea: determination by chain polymerase reaction to the microsporidian small-subunit rRNA gene. Clin Infect Dis 23 :1002–1006.

    • Search Google Scholar
    • Export Citation
  • 13

    Müller A, Stellerman K, Hartmann P, Scharppa M, Fathenheuer G, Salzberger B, Diehl V, Franzen C, 1999. A powerful DNA extraction method and PCR for detection of mocrosporidia in clinical stool specimens. Clin Diagn Lab Immunol 2 :243–246.

    • Search Google Scholar
    • Export Citation
  • 14

    Didier ES, Orenstein JM, Aldras A, Bertucci D, Rogers LB, Janney FA, 1995. Comparaison of three methods for detecting microsporidia in fluids. J Clin Microbiol 33 :3138–3145.

    • Search Google Scholar
    • Export Citation
  • 15

    Dowd SE, Gerba CP, Pepper IL, 1998. Confirmation of human-pathogenic microsporidia Enterocytozoon bieneusi, Encephalitozoon intestinalis and Vittaforma corneae in water. Appl Environ Microbiol 64 :3332–3335.

    • Search Google Scholar
    • Export Citation
  • 16

    Cali A, Kotler P, Orenstein JM, 1993. Septata intestinalis N. G., N. sp., an intestinal microsporidian associated with chronic diarrhea and dissemination in AIDS patients. J Eukaryot Microbiol 40 :101–112.

    • Search Google Scholar
    • Export Citation
  • 17

    Didier ES, Didier PJ, Friedberg DN, Stenson SM, Orenstein JM, Yee RW, Tio FO, Davis MR, Vossbrinck C, Millichamp N, Shadduck JA, 1991. Isolation and characterization of a new human microsporidia, Encephalitozoon hellem (n. sp), from three AIDS patients with keratoconjunctivitis. J Infect Dis 163 :617–621.

    • Search Google Scholar
    • Export Citation
  • 18

    Schwartz DA, Visvesvara GS, Leitch GJ, Tashjian L, Pollack M, Holden J, Bryan RT, 1993. Pathology of symptomatic microsporidial (Encephalitozoon hellem) bronchiolitis in AIDS: a new respiratory pathogen diagnosed from lung biopsy, bronchoalveolar lavage, sputum, and tissue culture. Hum Pathol 24 :937–943.

    • Search Google Scholar
    • Export Citation

Author Notes

Reprint requests: Karim Aoun, LR “Parasitoses Émergentes”, Laboratoire de Parasitologie, Institut Pasteur de Tunis, 13 Place Pasteur, BP 74, 1002 Tunis Belvedère, Tunisia, Tel: 216-98-699-512, Fax: 216-71-791-833, E-mail: karim.aoun@fmt.rnu.tn.
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