Cryptosporidiosis differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S [2]

Overview

Cryptosporidiosis primarily presents with diarrheasandhould bethus differentiated from other causes of diarrhea which can be viral, bacterial or parasitic.

Differential Diagnosis

Organism			Age predilection	Travel History	Incubation Size (cell)	Incubation Time	History and Symptoms			Diarrhea type∞				Food source	Specific consideration
Organism			Age predilection	Travel History	Incubation Size (cell)	Incubation Time	Fever	N/V	Cramping Abd Pain	Small Bowel	Large Bowel	Inflammatory	Non-inflammatory	Food source	Specific consideration
Viral	Rotavirus		<2 y	–	<10²	<48 h	+	+	–	+			+	–	Mostly in day cares, most common in winter.
	Norovirus		Any age	–	10 -10³	24-48 h	+	+	+	+			+	–	Most common cause of gastroenteritis, abdominal tenderness,
	Adenovirus		<2 y	–	10⁵ -10⁶	8-10 d	+	+	+	+			+	–	No seasonality
	Astrovirus		<5 y	–		72-96 h	+	+	+	+			+	Seafood	Mostly during winter
Bacterial	Escherichia coli	ETEC	Any age	+	10⁸ -10¹⁰	24 h	–	+	+	+			+	–	Causes travelers diarrhea, contains heat-labile toxins (LT) and heat-stable toxins (ST)
		EPEC	<1 y	–	10^†	6-12 h	–	+	+	+			+	Raw beef and chicken	–
		EIEC	Any ages	–	10^†	24 h	+	+	+		+		+	Hamburger meat and unpasteurized milk	Similar to shigellosis, can cause bloody diarrhea
		EHEC	Any ages	–	10	3-4 d	–	+	+		+	+		Undercooked or raw hamburger (ground beef)	Known as E. coli O157:H7, can cause HUS/TTP.
		EAEC	Any ages	+	10¹⁰	8-18 h	–	–	+		+		+	–	May cause prolonged or persistent diarrhea in children
	Salmonella sp.		Any ages	+	1	6 to 72 h	+	+	+		+	+		Meats, poultry, eggs, milk and dairy products, fish, shrimp, spices, yeast, coconut, sauces, freshly prepared salad.	Can cause salmonellosis or typhoid fever.
	Shigella sp.		Any ages	–	10 – 200	8-48 h	+	+	+		+	+		Raw foods, for example, lettuce, salads (potato, tuna, shrimp, macaroni, and chicken)	Some strains produce enterotoxin and Shiga toxin similar to those produced by E. coli O157:H7
	Campylobacter sp.		<5 y, 15-29 y	–	10⁴	2-5 d	+	+	+		+	+		Undercooked poultry products, unpasteurized milk and cheeses made from unpasteurized milk, vegetables, seafood and contaminated water.	May cause bacteremia, Guillain-Barré syndrome (GBS), hemolytic uremic syndrome (HUS) and recurrent colitis
	Yersinia enterocolitica		<10 y	–	10⁴ -10⁶	1-11 d	+	+	+		+	+		Meats (pork, beef, lamb, etc.), oysters, fish, crabs, and raw milk.	May cause reactive arthritis; glomerulonephritis; endocarditis; erythema nodosum. can mimic appendicitis and mesenteric lymphadenitis.
	Clostridium perfringens		Any ages		> 10⁶	16 h	–	–	+		+		+	Meats (especially beef and poultry), meat-containing products (e.g., gravies and stews), and Mexican foods.	Can survive high heat,
	Vibrio cholerae		Any ages	–	10⁶-10¹⁰	24-48 h	–	+	+	+			+	Seafoods, including molluscan shellfish (oysters, mussels, and clams), crab, lobster, shrimp, squid, and finfish.	Hypotension, tachycardia, decreased skin turgor. Rice-water stools
Parasites	Protozoa	Giardia lamblia	2-5 y	+	1 cyst	1-2 we	–	–	+	+			+	Contaminated water	May cause malabsorption syndrome and severe weight loss
		Entamoeba histolytica	4-11 y	+	<10 cysts	2-4 we	–	+	+		+	+		Contaminated water and raw foods	May cause intestinal amebiasis and amebic liver abscess
		Cryptosporidium parvum	Any ages	–	10-100 oocysts	7-10 d	+	+	+	+			+	Juices and milk	May cause copious diarrhea and dehydration in patients with AIDS especially with 180 > CD₄
		Cyclospora cayetanensis	Any ages	+	10-100 oocysts	7-10 d	–	+	+	+			+	Fresh produce, such as raspberries, basil, and several varieties of lettuce.	More common in rainy areas
	Helminths	Trichinella spp	Any ages	–	Two viable larvae (male and female)	1-4 we	–	+	+		+		+	Undercooked meats	More common in hunters or people who eat traditionally uncooked meats
		Taenia spp	Any ages	–	1 larva or egg	2-4 m	–	+	+	+			+	Undercooked beef and pork	Neurocysticercosis: Cysts located in the brain may be asymptomatic or seizures, increased intracranial pressure, headache.
		Diphyllobothrium latum	Any ages	–	1 larva	15 d	–	–	–	+			+	Raw or undercooked fish.	May cause vitamin B₁₂ deficiency

Cryptosporidiosis must be differentiated from other diseases that may cause chronic diarrhea, weight loss, and abdominal pain especially in immunocompromised patients.


Disease	Prominent clinical findings	Laboratory or radiological findings
Chronic giardiasis^[1]	Chronic giardiasis may develop after acute episode of giardiasis or without any acute events. Loose foul smelling stools Flatulence Fatigue Weight loss Steatorrhea Some patients develop acquired lactose intolerance (manifested by exacerbation of symptoms following ingestion of dairy products)	Microscopic identification of the organism in the stool Hypoalbuminaemia Vitamin B12 and folate deficiencies (as the organism inhabits the duodenum)
Cryptosporidiosis^[2]	Incubation period is 7-10 days. In immunocompetent patients: Disease might be asymptomatic or cause gastroenteritis (but without any biliary involvement) Gastroenteritis usually resolves spontaneously within 14 days. In immunocompromised patients: Disease is usually more severe and prolonged (especially in severly immunocomprmised patients with CD4 count < 100 cells/microL). Cryptosporidiosis may involve the biliary tract and the liver. Weight loss Abdominal RUQ tenderness might be present if biliary or hepatic involvement is present.	Microscopic identification of the organism in the stool: The oocysts appear red on staining with modified acid fast staining PCR: Most specific and sensitive diagnostic tool. PCR is expensive and used in limited cases.
Cystoisosporiasis (isosporiasis)^[3]	Cystoisosporiasis is usually seen in immunocompromised patients. Incubation period can last up to 2 weeks Watery diarrhea that is profuse and foul smelling Constitutional symptoms (headache, low grade fever, myalgia and malaise)	Isospora ova or parasites can be visualized on stool microscopic examination. Upper GI endoscopy may used for excluding other esophageal or gastric disease and obtaining specimens for histopathology.
Tropical sprue^[4]	History of travel to a tropical region (for a period more than a month) Chronic diarrhea Steatorrhea Examination may show signs of vitamin deficiencies (eg glossitis)	Megaloblastic anemia that might progress into pancytopenia Hypoalbuminaemia Vitamin D defeciency and hypocalcemia

References

↑ Thompson RC (2000). “Giardiasis as a re-emerging infectious disease and its zoonotic potential”. Int. J. Parasitol. 30 (12–13): 1259–67. PMID 11113253.
↑ Sánchez-Vega JT, Tay-Zavala J, Aguilar-Chiu A, Ruiz-Sánchez D, Malagón F, Rodríguez-Covarrubias JA, Ordóñez-Martínez J, Calderón-Romero L (2006). “Cryptosporidiosis and other intestinal protozoan infections in children less than one year of age in Mexico City”. Am. J. Trop. Med. Hyg. 75 (6): 1095–8. PMID 17172373.
↑ Current WL, Garcia LS (1991). “Cryptosporidiosis”. Clin. Microbiol. Rev. 4 (3): 325–58. PMC 358202. PMID 1889046.
↑ Klipstein FA, Schenk EA (1975). “Enterotoxigenic intestinal bacteria in tropical sprue. II. Effect of the bacteria and their enterotoxins on intestinal structure”. Gastroenterology. 68 (4 Pt 1): 642–55. PMID 1091526.

[pmid11113253-1] Thompson RC (2000). “Giardiasis as a re-emerging infectious disease and its zoonotic potential”. Int. J. Parasitol. 30 (12–13): 1259–67. PMID 11113253.

[pmid17172373-2] Sánchez-Vega JT, Tay-Zavala J, Aguilar-Chiu A, Ruiz-Sánchez D, Malagón F, Rodríguez-Covarrubias JA, Ordóñez-Martínez J, Calderón-Romero L (2006). “Cryptosporidiosis and other intestinal protozoan infections in children less than one year of age in Mexico City”. Am. J. Trop. Med. Hyg. 75 (6): 1095–8. PMID 17172373.

[pmid1889046-3] Current WL, Garcia LS (1991). “Cryptosporidiosis”. Clin. Microbiol. Rev. 4 (3): 325–58. PMC 358202. PMID 1889046.

[pmid1091526-4] Klipstein FA, Schenk EA (1975). “Enterotoxigenic intestinal bacteria in tropical sprue. II. Effect of the bacteria and their enterotoxins on intestinal structure”. Gastroenterology. 68 (4 Pt 1): 642–55. PMID 1091526.

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