Attention to the nutritional aspects of patient care, to avoid potentially fatal malnutrition, is crucial. Mature epithelial cells at the tips of the villi are preferentially lost; hence, enzymes expressed on these cells (including lactase) are also lost. This leads to secondary lactose intolerance. Therefore, supportive care should include a lactose-free diet. Enteral nutrition is usually sufficient; studies have not supported the use of parenteral nutrition. Infection may improve with nutritional supplementation, particularly with regimens including zinc or glutamine.
Patients with acalculous cholecystitis should generally be treated with cholecystectomy.
The following specialists should be consulted:
Infectious disease specialist - For consideration of antiparasitic and antiretroviral therapy
Gastroenterologist - For ERCP and sphincterotomy; endoscopy is sometimes required for diagnosis
General surgeon - For suspected acalculous cholecystitis
Trials of antiparasitic drugs in patients with AIDS and cryptosporidiosis have been disappointing. Nitazoxanide, paromomycin, and azithromycin are partially active. Combination antiretroviral therapy that includes an HIV protease inhibitor is associated with dramatic improvement in many cases. [1, 2] Improvement is likely to result from immune reconstitution but may, in part, reflect the antiparasitic activity of protease inhibitors. Use of partially active antiparasitic drugs (eg, nitazoxanide or paromomycin combined with azithromycin) should be considered along with initiating antiretroviral therapy. [28, 29, 30, 31, 32]
However, in patients with AIDS, cryptosporidiosis usually cannot be eradicated prior to restoration of the CD4 cell count in response to combination antiretroviral therapy. During early immune reconstitution, patients should generally continue antiparasitic therapy (eg, nitazoxanide or paromomycin) and antimotility agents, as needed. [28, 31]
Symptomatic therapy includes replacement of fluids, provision of appropriate nutrition, and treatment with antimotility agents. Loperamide or diphenoxylate-atropine may help in some cases. More potent opiates, including anhydrous morphine (Paregoric), may work in some cases that fail to respond to milder agents.
Octreotide, a somatostatin analogue and substance P antagonist, suppresses diarrhea in chronic cryptosporidiosis.
Fluid and electrolyte loss
Replacement of fluids and electrolytes is the critically important first step in the management of cryptosporidiosis, particularly in patients with large diarrheal losses. Fluids should include sodium, potassium, bicarbonate, and glucose. Oral rehydration is the preferred mode, but severely ill patients may require parenteral fluids.
Biliary involvement in cryptosporidiosis requires specific interventions. Acalculous cholecystitis should be treated with cholecystectomy.
Patients with sclerosing cholangitis can usually be treated with endoscopic retrograde cholangiopancreatography (ERCP), although sphincterotomy may result in temporary relief. In selected cases, recurrence may be prevented by placing a stent.
Prevention of Cryptosporidiosis
Water purification is the most important public health measure in the prevention of cryptosporidiosis. [31, 33] Because chlorination has little effect on the oocysts, water purification should involve flocculation and filtration (using filters with a pore size of 1-4 μm). Ultraviolet radiation and ozonization are other means of disinfecting contaminated water. Decontamination can also be achieved by bringing water to a boil.
Prompt, aggressive measures, including temporary closure of pools, must be carried out in cases of suspected fecal contamination of recreational water. People with diarrhea should not use recreational water, and those with cryptosporidiosis should not use recreational waters for 2 weeks after symptoms resolve.
Wearing gloves and handwashing after handling diapers can prevent person-to-person spread in daycare centers and hospitals. Endoscopes and similar instruments should be disinfected between uses. Prompt antiparasitic treatment of infected children decreases oocyst shedding.
Individuals with AIDS or another immunosuppressive condition should avoid swimming in communal pools or recreational water.
In hospitalized patients, contact precautions are strictly recommended in addition to standard precautions for patients who are incontinent or who use diapers.
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