Cryptosporidiosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Cryptosporidiosis is a parasitic disease affecting the intestines of mammals that is caused by Cryptosporidium, a protozoan parasite in the phylum Apicomplexa. It is a disease spread through the fecal-oral route; the main symptom is self-limiting diarrhea in people with intact immune system. In immunocompromised individuals, such as AIDS patients, infection can cause permanent & life-threatening diarrhea. Despite not being identified until 1976 it is one of the most common waterborne diseases and is found worldwide.

Cryptosporidium was first described by Tyzzer in 1910. In the 1970s, it was determined to be a significant cause of gastrointestinal disease in humans. In 1995, the UK had the largest outbreak of cryptosporidia with 575 people falling ill. Recently, outbreaks of cryptosporidiosis have been reported in 2005 and 2007 in the UK and the US and have been linked with contaminated water supplies and water recreation parks.^[1]In 2017, there was a rise in the cases of cryptosporidiosis in the United States following swimming pool exposure.

Cryptosporidiosis may be classified according to the affected organ system. In immunocompetent individuals, cryptospyoridiosis primarily affects the gastrointestinal system. Immunocompromised patients infected with cryptosporidiosis often have extragastrointestinal manifestions such as meningitis, encephalitis, pneumonia, or cholecystitis.

Cryptosporidiosis is a zoonotic disease, humans could be infected by contact with contaminated water and through inhalation of the spores. Following transmission, white blood cells phagocyte the pathogen and transports it via hematologic or lymphatic route to different organs.^[2][1]

A number of species of Cryptosporidium infect mammals. In humans the main causes of disease are C. parvum and C. hominis (previously C. parvum genotype 1). C. canis, C. felis, C. meleagridis, and C. muris can also cause disease in humans.

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

Cryptosporidium parasites are found in every region of the United States and throughout the world. Travelers to developing countries may be at greater risk for infection because of poorer water treatment and food sanitation, but cryptosporidiosis occurs worldwide. In the United States, an estimated 748,000 cases of cryptosporidiosis occur each year.

The risk factors of cryptosporidiosis include malnutrition, HIV infection and unhygienic environments. Cryptosporidiosis can also affect cancer and transplant patients and those at risk of exposure to contaminated materials.^[3][1]

Theere are no guidelines for screening for cryptosporidiosis according to United States Preventive Services Task Force (USPSTF).

Cryptosporidiosis causes short term illness in healthy individuals. While in immunocompromized individuals it can cause prolonged diarrhea. Cholangitis, malabsorption, pancreatitis and weight loss are some common complications of cryptosporidiosis.^[3]

The symptoms of cryptosporidiosis are seen 2-10 days after infection. The common manifestations include watery diarrhea, abdominal pain, nausea, vomiting and fever.

Physical examination findings in cryptosporidiosis include fever, fatigue, weakness, dehydration, hypotension and tachycardia.^[3]

Diagnosis of cryptosporidiosis is made by microscopic identification of the oocysts in stool or tissue with acid-fast staining or direct immunofluorescence.

There are no CT scan findings associated with Cryptosporidiosis.

There are no MRI findings associated with Cryptosporidiosis.

Diagnosis of cryptosporidiosis is made by microscopic identification of the oocysts in stool or tissue with acid-fast staining or direct immunofluorescence. Other diagnostic tests useful for the diagnosis of cryptosporidiosis include the ELISA and PCR.

Medical management of Cryptosporidium infection includes supportive care, symptomatic management and prompt initiation of antiretroviral therapy.

The role of surgical intervention for cryptosporidiosis is reserved for cases of biliary cryptosporidiosis causing acalculous cholecystitis.^[4][5][6]

Cryptosporidiosis is primarily transmitted via fecal oral route and dwells in water resevoirs. Primary prevention of cryptosporidiosis lies in appropriate hygiene after contact with sources or environments that may be contaminated with fecal material such as: after using the toilet, after contact with animals, after contact with children, after gardening or outdoor activities, after engaging in anal sex. Other primary preventive measures include avoidance public swimming areas or water recreation parks for two weeks after resolution of an episode of diarrhea, avoidance of contact with someone who has diagnosed cryptospiroidosis, and caution when traveling in countries where the safety of the food or water supply is unknown or in question. People who are immunocompromised should be particularly cautious to follow these prevention strategies. A cryptosporidiosis infection may have serious and possibly life-threatening sequelae in immune compromised patients.

Secondary prevention strategies for cryptosporidiosis are the same as primary prevention strategies.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Tarek Nafee, M.D. [2]

Cryptosporidium was first described by Tyzzer in 1910. In the 1970s, it was determined to be a significant cause of gastrointestinal disease in humans. In 1995, the UK had the largest outbreak of cryptosporidia with 575 people falling ill. Recently, outbreaks of cryptosporidiosis have been reported in 2005 and 2007 in the UK and the US and have been linked with contaminated water supplies and water recreation parks.^[1]

In 2017, there was a rise in the cases of cryptosporidiosis in the United States following swimming pool exposure.

• In 1910 cryptosporidium was first described by Tyzzer.^[1]
• In 1912 cryptosporidiosis was discovered to be a major cause of gastrointestinal disease.^[1]
• In October 2005 Gwynedd and Anglesey areas of North Wales (UK) suffered an outbreak of Cryptosporidiosis. The outbreak may be linked to the drinking water supply from Llyn Cwellyn but this is yet to be confirmed. This has resulted in over 200 people falling ill and the company Welsh Water (Dwr Cymru) advising 61000 people to boil their water before use.

• The UK’s biggest outbreak occurred in Torbay in Devon in 1995 when 575 people fell ill.

• In March 2007, a suspected outbreak occurred in Galway, Ireland, after the source of water for much of the county, Lough Corrib, was suspected to be contaminated with the parasite. A large population (90,000 people) including areas of both Galway City and County were advised to boil water for drinking, food preparation and for brushing teeth. On 21 March 2007, it was confirmed that the city and county’s water supply was contaminated with the parasite. The area’s water supply was finally given the all-clear on 20 August, 2007; five months after it was first detected. Around 240 people contracted the disease, however experts say the true figure could be anything up to 5,000. ^[2]

• As of June 20, 2007, Anglian Water Services prepared an alert confirming the possibility that cryptosporidium might have entered the drinking water supply in North Walsham, Anglia, England.^[3]. Customers in North Walsham and in the North Walsham Road area of Felmingham are being advised to boil their tap water before drinking it or using it in cooking.

• As of August 9 2007, there is an outbreak of Crypto in Montgomery County, PA. There are 20 confirmed cases, and the Health Department is keeping close watch on local swimming pools. The Spring Valley YMCA has been under closest watch as all 20 of the cases have been to it. They have been closing the pools for extra disinfection after accidents. Other local pools have been affected and most are taking the same steps to assure safety, whether they have crypto or not.

• Hundreds of public pools in 20 Utah counties were closed to young children in 2007, as children under 5 are most likely to spread the disease, especially children wearing diapers. As of September 10, 2007 the Utah State health department had reported ^[4] of cryptosporidiosis in the year; a more usual number would be 30. On September 25, the pools were re-opened to those not requiring diapers, but hyperchlorination requirements were not lifted.

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

Cryptosporidiosis is a zoonotic disease, humans could be infected by contact with contaminated water and through inhalation of the spores. Following transmission, white blood cells phagocyte the pathogen and transports it via hematologic or lymphatic route to different organs.^[1][2]

The pathophysiology of cryptosporidiosis can be described in the following steps

• Transmission of Cryptosporidium parvum and C. hominis occurs mainly through contact with contaminated water (e.g., drinking or recreational water).
• Occasionally food sources, such as chicken salad, may serve as vehicles for transmission.
• Many outbreaks in the United States have occurred in waterparks, community swimming pools, and day care centers.
• Zoonotic and anthroponotic transmission of C. parvum and anthroponotic transmission of C. hominis occur through exposure to infected animals or exposure to water contaminated by feces of infected animals.

• Incubation period for cryptosporidiosis is of 7 days (but can vary from 2 to 10 days).

• Following ingestion (and possibly inhalation) by a suitable host, excystation occurs.
• The sporozoites are released and parasitize epithelial cells of the gastrointestinal tract or other tissues such as the respiratory tract.

• In these cells, the parasites undergo asexual multiplication (schizogony or merogony) and then sexual multiplication (gametogony) producing microgamonts (male) and macrogamonts (female).
• Upon fertilization of the macrogamonts by the microgametes, oocysts develop that sporulate in the infected host.
• Two different types of oocysts are produced, the thick-walled, which is commonly excreted from the host, and the thin-walled oocyst, which is primarily involved in autoinfection.
• Oocysts are infective upon excretion, thus permitting direct and immediate fecal-oral transmission.
• Oocysts of Cyclospora cayetanensis, another important coccidian parasite, are unsporulated at the time of excretion and do not become infective until sporulation is completed.

• 
  Life cycle of different species of Cryptosporidium, the causal agents of Cryptosporidiosis. From Public Health Image Library (PHIL). ^[3]

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

Cryptosporidium parasites are found in every region of the United States and throughout the world. Travelers to developing countries may be at greater risk for infection because of poorer water treatment and food sanitation, but cryptosporidiosis occurs worldwide. In the United States, an estimated 748,000 cases of cryptosporidiosis occur each year.^[1]

• The annual incidence rates of cryptosporidiosis between 2006-2010 is estimated to be 2.3 and 3.9 cases per 100,000 population.
• Yearly incidence of cryptosporidiosis in the United States:
  • In 2003 3505 cases of cryptosporidiosis were reported
  • In 2004 3911 cases of cryptosporidiosis were reported
  • In 2005 8269 cases of cryptosporidiosis were reported
  • In 2009 7656 cases of cryptosporidiosis were reported
  • In 2010 8951 cases of cryptosporidiosis were reported
  • In 2012 8008 cases of cryptosporidiosis were reported
• Worldwide incidence rate of cryptosporidiosis is similar to that in the United States.

• Children under the age of 5 years are more prone to infection than others.

• Women are more commonly affected with cryptosporidiosis than men.

• There is no racial predilection for cryptosporidiosis.

• Cryptosporidiosis is distrubuted worldwide.
• Outbreaks of cryptosporidiosis have been reported in several countries

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

The risk factors of cryptosporidiosis include malnutrition, HIV infection and unhygienic environments. Cryptosporidiosis can also affect cancer and transplant patients and those at risk of exposure to contaminated materials.^[1][2]

The risk factors for Cyptosporidiosis include:^[1][3][4]

• Malutrition
• HIV
• Immunocompromiszed individuals (can also occur in immunocompetent)
• Unhygienic environments
• Certain areas like
  • Sub-saharan Africa
• Patients with inherited diseases of immune system
• Cancer patients
• Transplant patients
• People with greater exposure to contaminated materials are more at risk for infection, such as:
  • Children who attend day care centers, including diaper-aged children
  • Child care workers
  • Parents of infected children
  • People who take care of other people with cryptosporidiosis
  • International travelers
  • Backpackers, hikers, and campers who drink unfiltered, untreated water
  • People who drink from untreated shallow, unprotected wells
  • People, including swimmers, who swallow water from contaminated sources
  • People who handle infected cattle
  • People exposed to human feces through sexual contact
  • Contaminated water may include water that has not been boiled or filtered, as well as contaminated recreational water sources. Several community-wide outbreaks of cryptosporidiosis have been linked to drinking municipal water or recreational water contaminated with Cryptosporidium.
• Persons who are immunocompromised are at increased risks of having the diseases. Once infected, people with decreased immunity are most at risk for severe disease. The risk of developing severe disease may differ depending on each person’s degree of immune suppression.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

A number of species of Cryptosporidium cause diseases in mammals. In humans, out of the 11 species of Cryptosporidium, C. parvum and C. hominis (previously C. parvum genotype 1) are mainly associated with disease. C. canis, C. felis, C. meleagridis, and C. muris are also sometimes associated cause disease in humans.^[1]

Following are the causes of Cryptosporidiosis:^[1]

• Cryptosporidium parvum (known previously as C. parvum genotype II)
• Cryptosporidium hominis
• Cryptosporidium felis, from cats
• Cryptosporidium canis, from dogs
• Cryptosporidium meleagridis, from birds
• Cryptosporidium suis, from pigs
• Cryptosporidium muris, from rodents
• Cryptosporidium cervine genotype from various animals

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

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

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

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Cryptosporidiosis causes short term illness in healthy individuals. While in immunocompromized individuals it can cause prolonged diarrhea. Cholangitis, malabsorption, pancreatitis and weight loss are some common complications of cryptosporidiosis.^[1]

If left untreated cryptsporidiosis cures by itself in healthy people.

• Cryptosporidiosis causes short term illness in healthy individuals.
• While in immunocompromized individuals it can cause prolonged diarrhea.

• Cholangitis
• Cholecystitis
• Hepatitis
• Malabsorption
• Pancreatitis
• Wasting syndrome

• In healthy individuals, the infection settles down but can last up to a month.
• In immunosuppressed individuals, long-term diarrhea may occur leading to:^[1]
  • Weight loss
  • Malnutrition

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