Prevalence of Cryptosporidium in Children with Diarrhea in North Indian Tertiary Care Hospital

¹Department of Microbiology, J.N. Medical College, Aligarh Muslim University, Aligarh, UP, India

²Department of Pediatrics, J.N. Medical College, Aligarh Muslim University, Aligarh, UP, India

Corresponding Author:

Fatima Shujatullah
Department of Microbiology
J.N. Medical College, Aligarh Muslim University
Aligarh, UP, India
Tel: +919837568948
E-mail: sfatima777@gmail.com, farhat_thr@yahoo.co.in

Received Date: March 15, 2012; Accepted Date: March 29, 2012; Published Date: March 31, 2012

Citation: Tahira F, Khan HM, Shukla I, Shujatullah F, Malik MA, et al. (2012) Prevalence of Cryptosporidium in Children with Diarrhoea in North Indian Tertiary Care Hospital. J Community Med Health Edu 2:136. doi:10.4172/jcmhe.1000136

Copyright: © 2012 Tahira F, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: Enteric parasitic protozoan of genus cryptosporidium has become an important cause of diarrhoea in developing countries. It is a cause of acute and persistent diarrhoea in immunocompromised and immunocompetent subjects.

Methodology: This study was conducted to determine the prevalence of Cryptosporidium spp. as an enteric pathogen causing diarrhoea in children. 250 stool specimens of children with diarrhoea were examined using staining procedures like modified Ziehl-Neelsen (Z.N.) staining, safranine-methylene blue staining after concentration of stool specimens by formol-ether concentration technique and antigen detection ELISA was performed for diagnosis.

Results: Modified Z. N. staining and safranine-methylene blue staining were positive in 21 cases while 29 cases were positive by ELISA. Prevalence of Cryptosporidium in children with diarrhoea was found to be 11.6%.

Conclusion: High prevalence as noted in this study advocates need to screen for this parasite as a routine diagnostic measure in patients of diarrhoea.

Keywords

Cryptosporidium; Diarrhoea; Prevalence; Children

Introduction

Cryptosporidium species were recognized and named over 80 years ago, these small (2-6 μm) obligate intracellular protozoans remained until, recently nothing more than a biomedical curiosity. Beginning in 1982, our concept of these protozoan parasites changed, now it is regarded as an important cause of diarrhoea in immunocompetent and immunocompromised subjects. Cryptosporidium spp. are apicomplexan parasites that infect the micro villous border of the gastrointestinal epithelium of a wide range of hosts, including humans. Cryptosporidia have been found most frequently in stools of children aged less than 3 years [1].

Cryptosporidiosis is reported worldwide but its prevalence varies widely in different parts of the world. In the more industrialized countries of North America and Europe, the prevalence rate is 1-3%, while prevalence rates are higher in underdeveloped continents, ranging from approximately 5% in Asia to approximately 10% in Africa [2]. In India, prevalence has been reported to be between 1.3% - 18.9% [3-6]. Their oocysts are highly infectious, which are transmitted by contaminated water, faecal transmission from infected animals, person-to-person spread or by contaminated food.

Materials and Methods

This study was carried out in the Department of Microbiology for the detection of Cryptosporidium in 250 stool samples from children attending the out-patient clinics and those admitted in Pediatric wards of J. N. Medical College Hospital suffering from acute, persistent and chronic diarrhoea over a period of 15 months. The demographic information of the patients in the study group is mentioned in Table 1. Detailed histories regarding clinical features (Table 2) were taken from patient’s parents or guardian after informed consent. Fifty age and sex matched children attending the outpatient clinic of pediatric department with no symptoms suggestive of gastrointestinal disorder for a period of at least one month were selected as controls.

Table 1: Demographic information of study group.

Table 2: Presenting complaints of patients in study group.

The specimens were collected in sterile containers with tightfitting, leak-proof lid. Specimens were taken to the laboratory soon after collection. One part of each specimen was immediately frozen at -20^°C until further processing for Cryptosporidium antigen detection by ELISA. The other part was processed for detection of cellular exudates, helminthic eggs and different protozoan parasites mainly Cryptosporidium by macroscopic and microscopic examination. Stool was concentrated by formol-ether concentration technique [7]. Smears were made and stained by the Modified Z.N. technique [8] and Safranine-methylene blue staining technique [9]. In vitro immunoassay for detection of Cryptosporidium antigen in stool specimens were performed by Cryptosporidium Microwell ELISA manufactured by IVD Research Inc. Carlsbad, CA, USA.

Results

The highest prevalence of Cryptosporidium was found in the age group 2– 4 years (18.36%) followed by the age group 6-8 years (14.28%), 0–2 years (11.03%) and 4- 6 years (9.52%), no patients with diarrhoea in age group of 8- 10 years and 10-12 years had Cryptosporidium in their stool specimens. The overall prevalence was found to be 11.6%. No child with diarrhoea above the age of 8 years, and those in control group showed Cryptosporidium spp. in stool specimen. Out of 250 children included in the study, Cryptosporidium was detected in 16 patients by wet mount preparation, 21 cases were positive by Modified Ziehl-Neelsen and Safranine-methylene blue staining whereas ELISA was found to be positive in 29 patients. Most of the patients (41.37%) had diarrhoea of more than 14 days, watery stools were present in 62.06% cases, abdominal pain, vomiting, fever, nausea, anorexia, was present in 37.93, 27.58, 24.13, 31.03, 34.48 percent of cases respectively. Thirty one percent patients were in PEM grade III and 18.7% of patients belonged to socioeconomic class V.

Discussion

Prevalence of Cryptosporidium were found to be 11.6% in this area, while in other parts of India slightly higher prevalence of 13% and 14% have been reported [6,10]. Studies from other part of the world have shown prevalence of up to 15% in children presenting with diarrhoea. Till date, there is no approved ‘gold standard’ for the detection of Cryptosporidium in human stool specimens, but different authors have used different gold standards in their respective studies [11-13]. We considered Cryptosporidiosis to be a definite diagnosis if the organisms were found in any two of the three techniques as employed by Ungar [14]. There were 29 samples for which confirmed identification was made by any two of the tests. Most of the patients were in age group of 0-2 years; this is in agreement with findings of other authors from India [15,16], higher prevalence is reported in first two years of life in other countries also [17,18]. The explanation for it remains hypothetical though it has been suggested that their immune functions are low so that a low dose of infection may result in Cryptosporidiosis and that repeated low dose infections may induce immunity against Cryptosporidium spp. which protects older children [19]. Maximum number of children infected with Cryptosporidium were from low socio-economic group and were having protein energy malnutrition, Nagamani et al. [20] reported higher prevalence of infection in low socio-economic group, Jaggi et al. [10] observed in their study malnutrition as important factor that predisposes to Cryptosporodial infection. Presentation of Cryptosporidium infection with persistent diarrhoea, abdominal pain, vomiting, fever, nausea, anorexia as observed in our study is also been reported by sallon et al. [21] and sethi et al. [15].

Detection rates of Cryptosporidium by wet mount examination, modified Ziehl Nelson and safranine - methylene blue staining and ELISA were found to be 55.17%, 72.41% and 100% respectively [14,22,23],similar results are reported by other workers also [15,23,24].

Conclusion

Cryptosporidium is an important cause of diarrhoea in younger children and should always be screened in cases of diarrhoea mainly in immunocompromised host prolong diarrhoea, malnutrition and in low socioeconomic class.

References

1. Reinthaler FF, Mascher F, Sixl W, Enayat U, Marth E (1989) Cryptosporidiosis in children in Idukki District in Southern India. J Diarrhoeal Dis Res 7: 89-91.
2. Current WL, Garcia LS (1991) Cryptosporidiosis. Clin Microbiol Rev 4: 325-358.
3. Mathan MM, Venkatesan S, George R, Mathew M, Mathai VI (1985) Cryptosporidium and diarrhea in southern Indian children. Lancet 2: 1172-1175.
4. Das P, Sengupta K, Dutta P, Bhattacharya MK, Pal SC, et al. (1993) Significance of Cryptosporidium as an aetiologic agent of acute diarrhoea in Calcutta. A hospital based study. J Trop Med Hyg 96: 124-127.
5. Nath G, Singh TB, Singh SP (1999) Prevalence of Cryptosporidium Associated Diarrhea in a Community. Indian Pediatr 36: 180-183.
6. Kaur R, Rawat D, Kakkar M, Uppal B, Sharma VK (2002) Intestinal parasites in children with diarrhea in Delhi, India. Southeast Asian J Trop Med Public Health 33: 725-729.
7. Basic Laboratory Methods in Medical Parasitology. WHO, Geneva 1991, 9-33.
8. Henriksen SA, Pohlenz JF (1981) Staining of cryptosporidia by a modified Ziehl-Neelsen technique. Acta Vet Scand 22: 594-596
9. Baxby D, Blundell N (1983) Sensitive, rapid, simple methods for detecting Cryptosporidium in faeces. The Lancet 322: 1149.
10. Jaggi N, Rajeshwari S, Mittal SK, Mathur MD, Baveja UK (1994) Assessment of the immune and nutritional status of the host in childhood diarrhoea due to Cryptosporidium. J Commun Dis 26: 181-185.
11. Vastert D, Brinkman M, Wilke H, Mulder B (2006) Diagnosis of Cryptosporidium parvum with microscopy, striptest, ELISA and real-time PCR. Clin Microbiol Infect 12: P857.
12. Magi B, Canocchi V, Tordini G, Cellesi C, Barberi A (2006) Cryptosporidium infection: diagnostic techniques. Parasitol Res 98: 150-152.
13. Mehta P (2002) Laboratory diagnosis of cryptosporidiosis. J Postgrad Med 48: 217.
14. Ungar BL (1990) Enzyme-linked immunoassay for detection of Cryptosporidium antigens in fecal specimens. J Clin Microbiol 28: 2491-2495.
15. Sethi S, Sehgal R, Malla N, Mahajan RC (1999) Cryptosporidiosis in a tertiary care hospital. Natl Med J India 12: 207-209.
16. Palit A, Sur D, MitraDhar K, Saha MR (2005) Asymptomatic Cryptosporidiosis in a Periurban Slum setting in Kolkata, India – a Pilot Study. Jpn J Infect Dis 58: 110-111.
17. Abdel-Messih IA, Wierzba TF, Abu-Elyazeed R, Ibrahim AF, Ahmed SF, et al. (2005) Diarrhoea associated with Cryptosporidium parvum among young children of the Nile River Delta in Egypt. J Trop Pediatr 51: 154-159.
18. Saredi N, Bava J (1998) Cryptosporidiosis in pediatric patients. Rev Inst Med Trop S Paulo 40: 197-200.
19. Mølbak K, Højlyng N, Ingholt L, Da Silva AP, Jepsen S, et al. (1990) An epidemic outbreak of cryptosporidiosis: a prospective community study from Guinea Bissau. Pediatr Infect Dis J 9: 566-570.
20. Nagamani K, Rajkumari A, Gyaneshwari (2001) Cryptosporidiosis in a tertiary care hospital in Andhra Pradesh. Indian J Med Microbiol 19: 215-216.
21. Sallon S, Deckelbaum RJ, Schmid II, Harlap S, Baras M, et al. (1988) Cryptosporidium, malnutrition, and chronic diarrhea in children. Am J Dis Child 142: 312–315.
22. Mahgoub ES, Almahbashi A, Abdulatif B (2004) Cryptosporidiosis in children in a north Jordanian paediatric hospital. East Mediterr Health J 10: 494-501.
23. IAP (1972) Report of Convenor, Nutritional sub-committee of the Indian Academy of Paediatrics. Ind Ped 9: 360.
24. Bhaskara Rao T (2002) Sociology of Medicine: 76.
25. Crawford FG, Vermund SH (1988) Human cryptosporiosis. Crit Rev Microbiol 16: 113-159