Colitis by Cryptosporidium as initial manifestation of acquired immunodeficiency syndrome

Colitis por Cryptosporidium como forma de presentación en un paciente con síndrome de inmunodeficiencia adquirida

L. Pita-Fernández, J. Vargas-Castrillón¹, 
C. Pazos², I. Gallego¹ and C. García-Monzón

Service of Internal Medicine. Sections of 
¹Pathology and ²Microbiology. 
Hospital Universitario Santa Cristina. Madrid, Spain

A previously healthy 39-year-old man was attended in our hospital because of asthenia, weight loss, watery diarrhea, and relapsing fever for the past 2 months. Physical examination was normal. Hematology and coagulation tests, as well as serum biochemical parameters, were all normal. Blood cultures were negative, but the examination of a stool sample smear using the Ziehl-Neelsen method revealed Cryptosporidium oocysts (Fig. 1), which was confirmed by a direct immunofluorescence technique using a monoclonal antibody against specific Cryptosporidium antigens (Fig. 2). A serological examination detected antibodies to human immunodeficiency virus (HIV). Peripheral blood lymphocyte subset counts was: CD4⁺: 126/mm³, CD8+: 576/mm³, and CD4⁺/CD8⁺: 0.2. Colonoscopy showed a diffusely hyperemic mucosa mostly in the ascending and transverse colon. A colonic biopsy demonstrated a marked congestion of the lamina propria along with a lymphoplasmocytic inflammatory infiltrate (Fig. 3). Interestingly, Cryptosporidium oocysts were reported on the surface of colonic mucosal cells (Fig. 4).

Cryptosporidium spp. is an intestinal protozoan parasite belonging to the Sporozoea (Phylum Apiomplexa) class and the Coccidia subclass. Cryptosporidium is transmitted via the fecal-oral route, and is passed in the feces in the form of 4-6-mm oocysts containing four sporozoites. In recent years Cryptosporidium has been recognized as a significant cause of diarrhea in both immunocompetent and immunocompromised humans, particularly in patients infected by HIV (1). In HIV+ patients with diarrhea Cryptosporidium infection rates of about 4-6% have been reported, these being higher in patients with a CD4⁺ count lower than 200/mm³ (2,3). Although considered a complication associated with advanced stages of immunosuppression, colitis by Cryptosporidium may also be the initial manifestation in patients infected by HIV (4,5).

References

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4. Fujikawa H, Miyakawa H, Iguchi K, Nishizawa M, Moro K, Nagai K, et al. Intestinal cryptosporidiosis as an initial manifestation in a previously healthy Japanese patient with AIDS. J Gastroenterol 2002; 37: 840-3.

5. Schoofs MW, Maartense E, Eulderink F, Vreede RW. Cryptosporidiosis leading to an unsuspected diagnosis of AIDS. Neth J Med 2004; 62: 198-200.