Assessing The Prevalence Of Microsporidia In HIV / AIDS Patients

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Assessing The Prevalence Of Microsporidia In HIV / AIDS Patients


Abstract


This study assessed the prevalence of microsporidia in HIV/Aids patients. To contribute to the knowledge of microsporidia molecular epidemiology in HIV-positive patients in Nigeria, the study tested stool samples proceeding from patients with and without diarrhea.Stool samples from 193 HIV-positive patients with and without diarrhea (67 and 126 respectively) from Lagos (Nigeria) were investigated for the presence of microsporidia and Cryptosporidium using Weber’s Chromotrope-based stain, Kinyoun stain, IFAT and PCR. The Weber stain showed 45 fecal samples (23.3%) with characteristic microsporidia spores, and a significant association of microsporidia with diarrhea was observed (O.R. = 18.2; CI: 95%). A similar result was obtained using Kinyoun stain, showing 44 (31,8%) positive samples with structures morphologically compatible with Cryptosporidium sp, 14 (31.8%) of them with infection mixed with microsporidia. The characterization of microsporidia species by IFAT and PCR allowed identification of Enterocytozoonbieneusi, Encephalitozoon intestinalis and E. cuniculi in 5, 2 and 1 samples respectively. The partial sequencing of the ITS region of the rRNA genes showed that the three isolates of E.bieneusi studied are included in Group I, one of which bears the genotype B.To our knowledge, this is the first report of microsporidia characterization in fecal samples from HIV-positive patients from Lagos, Nigeria. These results focus attention on the need to include microsporidial diagnosis in the management of HIV/AIDS infection in Nigeria, at the very least when other more common pathogens have not been detected.


Chapter One


Introduction

1.1 Background Of The Study

Microsporidia are single-celled, obligate intracellular parasites that were recently reclassified from protozoa to fungi. Microsporidia are a group of intracellular parasites which have attracted the interest of parasitologists for over 100 years. The first species, Nosemabombycis, was discovered in the middle of the 19th century as the cause of silkworm disease (i.e., pepper disease, pebrine disease), which nearly destroyed the silkworm industry in Southern Europe (Didier,2005; Franzen,2008).More than 1,400 microsporidian species have been described in both invertebrate and vertebrate hosts. Only eight genera and 15 species of microsporidia have been associated with human infections.

The first report on human microsporidia infection was in 1959 and described the case of a 9-year-old Japanese boy who presented with disseminated microsporidiosis associated with fever, headache, vomiting, and spastic convulsions, (Matsubayashet al.,1959). Interest in this group of parasites started with the development of the AIDS pandemic around the world in 1980’s. In 1985, a new species Enterocytozoonbieneusi was found in an HIV-infected patient. Since then,species of microsporidia have been recognized world wideas etiologic agents of opportunistic infections. The clinical course of microsporidiosis depends on the immune statusof the patient and the site of infection. The groups at riskconstitute people with HIV/AIDS, organ transplant recipients being treated with immunosuppressive drugs, travellers, children and the elderly, (Didier, 2000; Garcia, 2002;Rabodonirina, 2003; Wichro, 2005; Dworkin, 2007; Galvan, 2011).

Two microsporidia Enterocytozoonbieneusi and Encephalitozoonintestinalis have been identified as possible causes of diarrhoeal illness in HIV-infected patients, (Mouraet al.,1993; Kotler, 1995).Over 40 million people are living with HIV/AIDS, the majority (more than 25 million) of whom live in sub-Saharan Africa. Up to 2.4 million deaths were recorded worldwide in 2005, (Akinboet al.,2009).

People in the advanced stages of HIV infection are vulnerable to secondary infections and malignancies that are generally termed as opportunistic infections as they take the advantage of the opportunity offered by a weakened immune system, (Saidu, et al.,2009). In HIV/AIDS positive patients, the most clinical manifestation is chronic diarrhoea and wasting due to enteric infection, (UNIADS 1998).This parasite is commonly observed in HIV-infected patients with CD4 Lymphocytes count of less than 50cells/mm3 who complain of chronic diarrhoea, nausea, malabsorption and severe weight loss but asymptomatic infection have also been reported in immuno competent persons, (Sak et al.,2011).

Diarrhea is a common clinical manifestation in human immunodeficiency virus (HIV) infection. The prevalence ranges from33% (Pape et al, 1994) to 45% (Tarimo et al, 1996). Important protozoan pathogens causing diarrhea include cryptosporidium, microsporidium, Isospora belli and cyclosporabesides Giardia intestinalis and Entamoeba histolytica (Deodhar et al, 2000). The diarrhea, often associated with weight loss, may affect the nutritional state and quality of life in AIDS patients. It has been shown that patients with AIDS who presented with diarrhea have a greater degree of immunosuppression than those without diarrhea, predisposing the gastrointestinal tract to the action of protozoa, bacteria, viruses, and fungal pathogens which may cause morbidity and death (Manatsathit et al, 1996). Enteric protozoan parasites have become increasingly recognized as important and rapidly emerging human pathogens in immunocompromised individuals. They tend to aid disease progression and may be lethal. Manatsathitet al (1996) reported that cryptosporidium (20%) was the most common cause of chronic diarrhea in Thai HIV-infected patients. Other leading causes of morbidity include Mycobacterium tuberculosis, Salmonella, Cytomegalovirus and Mycobacteriumaviumintracellulare (Manatsathit et al, 1996). Microsporidium is also an important protozoan infecting HIV/AIDS patient. In general, the prevalence of microsporidium in HIV-infected patients ranges from 1-40% (Kotler and Orenstein, 1994). In Thailand, several studies have reported the prevalence to be from 1.67% to 33.3% (Punpoowong et al, 1998; Wanachiwanaw in et al, 1998; Wiwanitkit, 2001). The prevalence of microsporidium infection varies greatly, and identification of the organism is often associated with diagnostic difficulties. Diagnosis of microsporidium is still dependent on morphological demonstration of the organisms. We studied the enteric pathogens in HIV-infected patients with a special emphasis on microsporidium, and we sought to determine possible clinical correlations.


1.2 Statement Of The Problem

Microsporidia, have been known for over a decade to cause opportunistic infections in patients with human immunodeficiency virus (HIV) infection. Enterocytozoonbieneusi is the most commonly identified microsporidia in patients with HIV/AIDS. Microsporidiosis usually produces diarrheal illness but can produce disseminated illness in some persons depending upon the species involved. Few reports in the medical literature describe the prevalence of intestinal microsporidiosis; those that do are not considered reliable and generalizable. According to a study by Abel (2013), conducted before the widespread use of highly active antiretroviral therapy (HAART), reported that microsporidia accounted for 14.1% and 34.8% of cases of acute and chronic diarrhea, respectively, in HIV-infected patients12. However, since use of HAART has become widespread, very few data are available on the prevalence of microsporidiosis in HIV-infected persons.

Fisher (2016) suggests that the prevalence of infectious diarrhea (along with AIDS opportunistic illnesses) has declined in recent years. It is not known whether the prevalence of microsporidiosis has declined as well. Because clinical laboratory testing for microsporidia is not part of the routine testing for ova and parasites, infection with microsporidia is likely underrecognized. Therefore, active surveillance for infection with microsporidia is necessary to estimate the true burden of this infectious disease in patients with HIV and AIDS. In addition, the sensitivity of testing for this infection could vary according to type of test used.


1.3 Aim

This study is aimed at assessing the prevalence of Microsporidia in HIV/AIDSpatients in Lagos State.


1.4 Objectives

The specific objectives of this study are to determine:

  1. The prevalence of Intestinal Microsporidia among HIV/AIDS patients of General Hospital Lagos state.
  2. The species of Microsporidiainvolved in relation to sex and age among HIV/AIDs patients of General Hospital Lagos State
  3. The association of CD4 Cell count and Microsporidia infection in HIV / AIDS patients.

1.5 Justification

Microsporidiosisis a neglected tropical disease that is associated with chronic diarrhoea especially in persons living with HIV/AIDS, and in other immune-compromised individuals (elderly, organ transplant individuals, travellers). In developing countries like Nigeria, there has not been any serious efforts toward the eradication of Microsporidiosis. Infection rate of Microsporodiosis is on the increase in tropical and subtropical countries due to lack of health hygiene, access to public health centres, and knowledge of the disease. In Nigeria detection of microsporidia is not routinely performed in clinical practice, there is therefore dearth of information concerning Microsporidia in respect to prevalence, diagnosis, treatment and control.

Few cases of the disease has been reported in HIV/AIDS, and other immune-compromised individuals in Nigeria. However, epidemiology and prevalence of the disease has not been well documented for sustainable control. There is therefore a need for further study and understanding of the epidemiology of the parasite. Documenting the prevalence of the Infection will aid in management and control of the disease.


Chapter Five


Conclusion

In conclusion, our results provide new data on microsporidia epidemiology on the African continent, where the control of HIV/ AIDS is already due to limited access to HAART. Because of this, the presence of chronic intestinal microsporidiosis and cryptosporidiosis should be suspected in HIV/AIDS infected patients with persistent diarrhea, malabsorption and progressive weight loss. More importantly, there is further need to investigate other clinical and environmental samples in order to identify the major sources of these pathogens in human, in the environment.


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