Pediatric Cryptosporidiosis Clinical Presentation

  • Author: Jaya Sureshbabu, MBBS, DCh, MRCPCH(UK), MRCPI(Paeds), MRCPS(Glasg), DCH(Glasg); Chief Editor: Russell W Steele, MD   more...
 
Updated: Jun 15, 2011
 

History

The incubation period for cryptosporidiosis is 2-14 days, and symptoms begin 2-10 days after being infected by the parasite.

The main symptoms are related to the GI tract, but respiratory symptoms, such as shortness of breath, may also develop.

Diarrhea, with or without crampy abdominal pain, may be intermittent and scant or continuous, watery, and copious; sometimes, the diarrhea is mucoid. Diarrhea rarely contains blood or leukocytes.

In individuals who are immunocompetent, the median duration of diarrhea ranges from 5-10 days (mean of 10 d). Diarrhea can persist longer in individuals who are immunosuppressed. (Oocyst shedding can continue for as long as 2 weeks after clinical improvement.) The volume of fluid losses through diarrhea may be as high as 15 liters per day, particularly in individuals with AIDS. Relapses may follow a diarrhea-free period of several days to weeks.

In sporadic cases, fever may be low grade or nonexistent; however, during outbreaks, fever may occur in 30-60% of patients.

Nausea and vomiting are present in 50% of cases.

Malaise may be reported.

Approximately 15% of patients with AIDS may present with fever, right upper-quadrant pain, jaundice, nausea, and vomiting but not necessarily with concomitant diarrhea.

Nonspecific respiratory symptoms, including shortness of breath, wheezing, cough, hoarseness, and croup, may be a manifestation of infection in the respiratory system. Rarely, conjunctival irritation can also be present.

In waterborne outbreaks, immunocompetent patients present with subclinical or milder illness that lasts for less than 5 days.

The clinical manifestations of cryptosporidiosis in patients with HIV vary.[2, 4, 12, 13] In patients with CD4 cell counts of more than 200, most infections are self-limited, similar to those in normal hosts. Other patients develop chronic diarrheal illness with frequent, foul-smelling, bulky stools associated with significant weight loss. A minority of patients develop a cholera like illness. Respiratory tract involvement is often asymptomatic but may manifest as bilateral pulmonary infiltrates with dyspnea. Biliary involvement is correlated with significantly low CD4 counts, and patients present with acalculous cholecystitis, sclerosing cholangitis, or pancreatitis.[12, 13, 14]

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Physical Examination

Watery diarrhea, which may also contain mucus, and dehydration are the most common signs related to GI cryptosporidiosis. (Secondary malabsorption of fat, D-xylose, and vitamin B-12 has been noted in some cases.)

Other signs related to GI illness include right upper-quadrant or epigastric tenderness, icterus, and, rarely, ascites related to pancreatic involvement.

Reactive arthritis that affects the hands, knees, ankles, and feet has been described.

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Contributor Information and Disclosures
Author

Jaya Sureshbabu, MBBS, DCh, MRCPCH(UK), MRCPI(Paeds), MRCPS(Glasg), DCH(Glasg),  Consultant, Department of Pediatrics and Neonatology, Credence Institute for Womens Health and Fertility Research, Thiruvananthapuram

Jaya Sureshbabu, MBBS, DCh, MRCPCH(UK), MRCPI(Paeds), MRCPS(Glasg), DCH(Glasg), is a member of the following medical societies: Indian Academy of Pediatrics, Indian Medical Association, Royal College of Paediatrics and Child Health, Royal College of Physicians and Surgeons of Glasgow, and Royal College of Physicians of Ireland

Disclosure: Nothing to disclose.

Coauthor(s)

Poothirikovil Venugopalan, MBBS, MD, FRCP(Glasg), FRCPCH,  Consulting Staff, Department of Child Health, University Hospital of North Tees and Hartlepool, UK

Poothirikovil Venugopalan, MBBS, MD, FRCP(Glasg), FRCPCH, is a member of the following medical societies: British Cardiac Society, Paediatrician with Cardiology Expertise Special Interest Group, Royal College of Paediatrics and Child Health, and Royal College of Physicians and Surgeons of Glasgow

Disclosure: Nothing to disclose.

Athena P Kourtis, MD, PhD  Associate Professor, Department of Pediatrics, Divisions of Infectious Diseases and Epidemiology, Emory University School of Medicine; Senior Fellow, Centers for Disease Control and Prevention

Athena P Kourtis, MD, PhD is a member of the following medical societies: American Academy of Pediatrics and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

References

  1. Flynn PM. Cryptosporidium parvum. In: Long SS, Pickering LK, Prober CG, eds. Principles and Practice of Pediatrics. New York, NY: Churchill Livingstone; 1997.

  2. White C Jr. Cryptosporidiosis. In: Mandell GL, Bennett JE, Doilin R. Principles and practice of Infectious Diseases. Vol 2. 6th. Philadelphia, Pennsylvania: Elsivier Churchill Livingstone; 2005:280.

  3. Huang DB, Chappell C, Okhuysen PC. Cryptosporidiosis in children. Semin Pediatr Infect Dis. Oct 2004;15(4):253-9. [Medline].

  4. Committee on Infectious Diseases, American Academy of Pediatrics. Cryptosporidiosis. In: Pickering LK, Baker CJ, Long S, McMillan JA. Red book. 27th. Elk Grove Village, IL: AAP; 2006:270-272.

  5. Meinhardt PL, Casemore DP, Miller KB. Epidemiologic aspects of human cryptosporidiosis and the role of waterborne transmission. Epidemiol Rev. 1996;18(2):118-36. [Medline].

  6. Fayer R, Morgan U, Upton SJ. Epidemiology of Cryptosporidium: Transmission,detection and identification. Int J Parasitol. 2000;30:1305-1322.

  7. Cryptosporidiosis surveillance--United States, 2003-2005.Division of Parasitic Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases, CDC [database online]. Atlanta, GA 30333: Centers for Disease Control and Prevention (CDC); Updated 2007 Sep 7.

  8. MacKenzie WR, Schell WL, Blair KA, Addiss DG, Peterson DE, Hoxie NJ, et al. Massive outbreak of waterborne cryptosporidium infection in Milwaukee, Wisconsin: recurrence of illness and risk of secondary transmission. Clin Infect Dis. Jul 1995;21(1):57-62. [Medline].

  9. Semenza JC, Nichols G. Cryptosporidiosis surveillance and water-borne outbreaks in Europe. Euro Surveill. May 1 2007;12(5):E13-4. [Medline].

  10. Cooper DL, Verlander NQ, Smith GE, Charlett A, Gerard E, Willocks L, et al. Can syndromic surveillance data detect local outbreaks of communicable disease? A model using a historical cryptosporidiosis outbreak. Epidemiol Infect. Feb 2006;134(1):13-20. [Medline]. [Full Text].

  11. Navin TR, Hardy AM. Cryptosporidiosis in patients with AIDS. J Infect Dis. Jan 1987;155(1):150. [Medline].

  12. Abubakar I, Aliyu SH, Arumugam C, Usman NK, Hunter PR. Treatment of cryptosporidiosis in immunocompromised individuals: systematic review and meta-analysis. Br J Clin Pharmacol. Apr 2007;63(4):387-93. [Medline]. [Full Text].

  13. Wolska-Kusnierz B, Bajer A, Caccio S, Heropolitanska-Pliszka E, Bernatowska E, Socha P, et al. Cryptosporidium infection in patients with primary immunodeficiencies. J Pediatr Gastroenterol Nutr. Oct 2007;45(4):458-64. [Medline].

  14. Cello JP. Acquired immunodeficiency syndrome cholangiopathy: spectrum of disease. Am J Med. May 1989;86(5):539-46. [Medline].

  15. Weintraub JM. Improving cryptosporidium testing methods: a public health perspective. J Water Health. 2006;4 Suppl 1:23-6. [Medline].

  16. Soave R. Treatment strategies for cryptosporidiosis. Ann N Y Acad Sci. 1990;616:442-51. [Medline].

  17. Ayuo PO. Human cryptosporidiosis: a review. East Afr Med J. Feb 2009;86(2):89-93. [Medline].

  18. Juranek DD. Cryptosporidiosis: sources of infection and guidelines for prevention. Clin Infect Dis. Aug 1995;21 Suppl 1:S57-61. [Medline].

  19. Fox LM, Saravolatz LD. Nitazoxanide: a new thiazolide antiparasitic agent. Clin Infect Dis. Apr 15 2005;40(8):1173-80. [Medline].

  20. Smith NH, Cron S, Valdez LM, Chappell CL, White AC Jr. Combination drug therapy for cryptosporidiosis in AIDS. J Infect Dis. Sep 1998;178(3):900-3. [Medline].

  21. Mofenson LM, Brady MT, Danner SP, Dominguez KL, Hazra R, Handelsman E, et al. Guidelines for the Prevention and Treatment of Opportunistic Infections among HIV-exposed and HIV-infected children: recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics. MMWR Recomm Rep. Sep 4 2009;58:1-166. [Medline]. [Full Text].

  22. Hicks P, Zwiener RJ, Squires J, Savell V. Azithromycin therapy for Cryptosporidium parvum infection in four children infected with human immunodeficiency virus. J Pediatr. Aug 1996;129(2):297-300. [Medline].

  23. Abubakar I, Aliyu SH, Arumugam C, Hunter PR, Usman NK. Prevention and treatment of cryptosporidiosis in immunocompromised patients. Cochrane Database Syst Rev. Jan 24 2007;CD004932. [Medline].

 
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Hematoxylin and eosin stain of intestinal epithelium. The blue dots (arrows) represent Cryptosporidium on the surface of the epithelial cells. Image courtesy of Carlos Abramowsky, MD, Professor of Pediatrics and Pathology, Emory University School of Medicine.
Cryptosporidium species oocysts are rounded and measure 4.2-5.4 µm in diameter. Sporozoites are sometimes visible inside the oocysts, indicating that sporulation has occurred on wet mount.
Cryptosporidium parvum oocysts stained with modified acid-fast. Against a blue-green background, the oocysts stand out in a bright red stain. Image courtesy of CDC DPDx parasite image library.
Cryptosporidium species oocysts stained with modified acid-fast.
 
 
 
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