Cyclospora Workup

  • Author: William H Shoff, MD, DTM&H; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Feb 26, 2010
 

Laboratory Studies

  • Stool examination for oocysts is the standard procedure for diagnosing C cayetanensis. Other specimens that may contain oocysts include intestinal aspirates and duodenal or jejunal biopsy samples. Unusual specimens include bile and pulmonary samples (eg, induced sputum, bronchial washings, biopsy) based on the growing reports of complicated cyclosporiasis.
    • Three specimens should be submitted for analysis, preferably on alternate days. The number of oocysts in the stool can vary considerably, but infected individuals with symptoms continuously excrete oocysts.
    • Standard laboratory procedures for ova and parasites do not identify Cyclospora; therefore, the laboratory must be notified that Cyclospora is a specific consideration.
    • Stool specimens are submitted to the laboratory as a fresh specimen or in some type of preservative. (Many laboratories require that specimens be submitted in a preservative.)
    • The stool specimen is recommended to be concentrated using the formalin–ethyl acetate technique, which leads to greater recovery of oocysts.
    • An important detail is that the specimen be centrifuged at 500 g for 10 minutes; if the speed is reduced, recovery of Cyclospora will be compromised.
    • Ethyl acetate has been substituted for ether because ethyl acetate is an excellent debris extractor and a much safer agent (ie, less explosive).
  • Cyclospora oocysts are difficult to identify with microscopic examination (high dry, 400X) without special techniques: acid-fast staining (fresh or preserved specimen), safranin staining (fresh or preserved specimen), direct wet smear (no preservative, no stain) using fluorescent microscope, direct wet smear with a differential interference contrast microscope (bright field), or lacto-phenol cotton blue staining (fresh specimen). Each of these techniques is discussed below.
    • If an unconcentrated wet mount is prepared, the entire cover-slipped area should be scanned. Concentration of the organism on the wet mount can be effected by adding a few drops of Sheather's sucrose solution to the wet mount; the oocysts float to the surface and, reportedly, appear faint pink.
    • If the stool specimen has been concentrated (not wet mount concentration), the recommendation is to scan 300 fields. A single negative specimen does not rule out the diagnosis.
    • When viewing coccidia microscopically, calibration of the microscope's ocular micrometer for measuring is important, because size matters when differentiating Cyclospora (8-10 µm) and cryptosporidium (4-5 µm).
    • In circumstances in which a confirmatory step is required to verify that the oocysts are indeed those of Cyclospora, a sporulation assay can be conducted using freshly passed oocysts. See the CDC for details.
  • In 2005, monoclonal antibodies were not yet commercially available.
  • Acid-fast and safranin staining: C cayetanensis is an acid-fast organism, but the oocyst stains very unevenly with acid-fast stains (no staining, to mixed or variable staining, to full staining), complicating identification.
    • A modified acid-fast stain (less intense decolorizing) may be attempted using Kinyoun acid-fast stain (cold method) or Ziehl-Neelsen acid-fast stain (hot method). With the hot method, the stained material on the slide is heated to steaming (not boiling) and allowed to stand for 5 minutes before proceeding. With the cold method, heat is not applied.
    • The cold method is preferred because the hot method is not thought to have a significant advantage of improved staining.
    • Safranin staining has demonstrated superior results, producing reddish orange staining of more than 98% of oocysts on a slide, when heating the safranin application was performed using a microwave (650 W) at full power for 30 or 60 seconds. The CDC recommends heating the slide to boiling for 1 minute. The heating produces a more uniform staining.
  • Combining fluorescence and differential interference contrast (DIC) microscopy: The CDC states that, used together, these two techniques provide an efficient and reliable approach to the diagnosis.
    • Wet preparations of Cyclospora, independent of specimen age or type, exhibit an intense color when viewed with a fluorescence microscope. With a UV excitation filter set at 330-365 nanometers, the color is an intense blue. With a filter set at 450-490 nanometers, the color is a less intense green.
    • Wet preparations of Cyclospora viewed with a DIC microscope (bright field) appear as refractile spheres (8-10 µm in size) with a distinct oocyst wall.
  • Other procedures for the diagnosis of cyclosporiasis include demonstration of oocyst sporulation and polymerase chain reaction (PCR) of Cyclospora stages isolated from stool or duodenal or jejunal aspirates or biopsies. For further discussion of PCR, see below.
  • No reliable immunological techniques are available to detect Cyclospora.
  • Lactol-phenol cotton blue (LPCB) staining: In laboratories where acid-fast stains are not routinely used, such as in rural areas and in developing countries, the LPCB wet mount is a suitable and practicable substitute with many advantages. It is a single stain that can be used to detect both coccidian and noncoccidian parasites, and it is simpler and less expensive than the acid-fast stain.[5, 6]
  • Polymerase chain reaction: PCR of Cyclospora stages isolated from stool or other specimens has been used for diagnosis. The protocol originally developed by Relman in 1996 was unable to differentiate Cyclospora species and Eimeria species.
    • This protocol was modified using a restriction enzyme Mn/I to distinguish the two species, designated a nested-PCR restriction length fragment polymorphism (RLFP).
    • The PCR-RLFP protocol has been reliable for clinical purposes in detecting C cayetanensis in stool specimens but has been found to be unreliable when applied to environmental specimens because of the presence of genetically similar microorganisms. This has led to the development of PCR protocols that can reliably detect C cayetanensis in large numbers of environmental and clinical specimens (see below).
  • Environmental and outbreak sampling: C cayetanensis produces an environmentally resistant oocyst that is infective in humans (see Pathophysiology). The US Environmental Protection Agency's Interim Enhanced Surface Water Treatment Rule (EPA-IESWTR) sets zero as the maximum contaminant level goal for Cryptosporidium and other pathogens in water.
  • In the late 1990s, several outbreaks of cyclosporiasis were attributed to food imported into the United States. These outbreaks generated the need to have techniques for sampling large numbers of environmental specimens, as well as large numbers of clinical specimens in order to prevent outbreaks before they occur and to better and more rapidly manage them when they do occur.
  • Three techniques that meet these criteria and are evolving include the new PCR protocols, flow cytometry, and electrorotation.
    • PCR: Newer PCR assays have been reported that can be used to reliably screen large numbers of clinical and environmental specimens for C cayetanensis. New primers have been identified for C cayetanensis and used to modify existing protocols (an alternative nested-primer PCR-RFLP) or to develop new protocols. Such new protocols include single-nucleotide polymorphisms (SNP-PCR), which amplifies allelic sequences that differ by at least a single base pair; and real-time PCR, which uses the 5 prime-exonuclease activity of AmpliTaq Gold DNA polymerase to cleave C cayetanensis.
    • A modified Relman-PCR protocol was used to determine the sensitivity of PCR in detecting C cayetanensis in experimentally spiked raspberries, basil, and mesclun lettuce. The protocol detected 40 or fewer oocysts per 100 g of raspberries or basil and 1,000 per 100 g of mesclun lettuce. This experiment demonstrated the importance of testing different the various PCR protocols on food to determine the detection sensitivity.
    • Flow cytometry: Flow cytometry has been used to accurately detect and enumerate of various organisms in a prepared suspension (0.5 mL), including Cyclospora, by recording characteristic forward (size) and side (complexity) scattering of incident light emitted by an argon-ion laser operating at 488 nm. Scatter patterns are specific to the organism.
    • Electrorotation: This technique (which is not commercially available) takes advantage of the unique patterns of rotation around their axis of biological organisms, including Cyclospora, secondary to the application of uniform rotating alternating current fields. These real-time and noninvasive measurements are performed on a microscale (ie, one cell at a time). It allows the identification of the organism and the determination of its viability. It could potentially be used for rapid assessment of food and water.
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Histologic Findings

Duodenal and jejunal overall microscopic architecture is altered with mild to moderately severe villous atrophy (villous-to-crypt ratio reported 0.6-1.5:1 versus normal 3-4:1).

  • Total length of the villi is reduced. Villi are widened secondary to infiltration of both the surface epithelium and villous mucosa.
  • The surface epithelium is less organized with loss of normal polarity and infiltrated extensively with lymphocytes, which displace the nuclei.
  • Neutrophils are often present.
  • Vessel congestion and dilatation are increased.
  • Focal vacuolization is present.
  • Loss of the brush border and altered cell shape from columnar to cuboidal is observed (more at tips of villi).
  • The villous mucosa is diffusely edematous and infiltrated with a mixed inflammatory cell infiltrate of plasma cells, lymphocytes, and, in some cases, eosinophils.
  • Mitotic activity in the crypts is increased.
  • The lamina propria is mildly to intensely inflamed.
  • All stages of the known life cycle of C cayetanensis have been observed in the enterocytes.
  • Electron microscopy (EM) demonstrates pronounced enterocyte vacuolization and abundant intraepithelial reactive cells. Predominantly in the apical areas, numerous intraenterocytic coccidial organisms are within parasitophorous vacuoles. The concentration of cells with organisms decreased progressively to zero in the crypts.
  • Follow-up studies of a few patients indicate that mild inflammation may persist (duration not known), manifested on light microscopy as focal vacuolization and gapping of enterocytes and mild increase in intraepithelial lymphocytes or other reactive cells. On EM, myelinlike material was uncommon. Its significance is unknown. Scarce and moderate amounts have been noted in protozoal infections of the upper gastrointestinal tract. It may be a marker of cell injury, but that is not substantiated.

The above discussion of histology is adapted from Connor (1993[7] , 1999[8] ) and Ortega (1997[9] ).

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Contributor Information and Disclosures
Author

William H Shoff, MD, DTM&H  Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania

William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Glaxo Smith Kline None None; Glaxo Smith Kline Honoraria Speaking and teaching

Coauthor(s)

Amy J Behrman, MD  Associate Professor, Department of Emergency Medicine, Director, Division of Occupational Medicine, University of Pennsylvania School of Medicine

Amy J Behrman, MD is a member of the following medical societies: American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM  Associate Professor, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Jeffrey D Band, MD  Clinical Professor of Medicine, Wayne State University School of Medicine; Director, Division of Infectious Diseases and International Medicine, Corporate Epidemiologist, William Beaumont Hospital

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

John W King, MD  Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center

John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, and Sigma Xi

Disclosure: emedicine $50.00 author of chapter; MERCK None Other

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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Table 1. Epidemiology of C cayetanensis *
Pattern of Spread Countries Comments
EndemicBangladesh, Brazil, Chile, China, Cuba, Dominican Republic, Egypt, Guatemala, Haiti, India, Indonesia, Jordan, Mexico, Morocco, Nepal, Nigeria, Pakistan, Peru, Puerto Rico, Romania, Saudi Arabia, Tanzania, Thailand, Turkey, Venezuela, Viet Nam, Zimbabwe Prevalence (1-15%†) varies significantly with the season and from year to year; children (≤ 9 y, most studies) account for 70-80% cases, which are typically asymptomatic (72-94%); asymptomatic disease is higher in older children (10-18 y) and adults (>18 y); infection rate in those with HIV is significantly higher than overall prevalence
International travel-relatedAustralia, Belgium, Czech Republic, Germany, Greece, Ireland, Italy, Japan, The Netherlands, Spain, Switzerland, United Kingdom, United States ≤4% returning travelers with diarrhea
Foodborne outbreaksCanada, United States, Germany, MexicoCanada/United States: raspberries, blackberries, mesclun, basil‡; Germany: lettuce imported from Southern France/Southern Italy; Mexico: watercress
Waterborne outbreaksUnited States (Chicago), Nepal14 cases of cyclosporiasis; tap water in medical dormitory, suspected source was contaminated water storage tank; 12 of 14 developed cyclosporiasis
* Community-based studies



† Highest in spring and early summer



‡ Fresh produce. Raspberries from Guatemala; blackberries from Guatemala or undetermined source; mesclun (young salad greens, eg, spring mix, field greens, baby greens, gourmet salad mix) from Peru or United States; basin from Mexico or United States



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