eMedicine Specialties > Pediatrics: General Medicine > Parasitology

Cryptosporidiosis: Differential Diagnoses & Workup

Author: Jaya Sureshbabu, MBBS, DCh, MRCPCH (UK), MRCPI (Paeds), DCH (GLAS), Registrar, Department of Pediatrics/Neonatology, Mid-western Regional Hospital, Limerick, Ireland
Coauthor(s): Poothirikovil Venugopalan, MBBS, MD, FRCP (Glasg), FRCPCH, Consulting Staff, Department of Child Health, University Hospital of Hartlepool, UK; Athena P Kourtis, MD, PhD, Assistant Professor, Department of Pediatrics, Divisions of Infectious Diseases and Epidemiology, Emory University School of Medicine
Contributor Information and Disclosures

Updated: Apr 29, 2008

Differential Diagnoses

Campylobacter Infections
Salmonella Infection
Cytomegalovirus Infection
Shigella Infection
Giardiasis
Isosporiasis
Rotavirus enteritis

Other Problems to Be Considered

Clostridium difficile
Giardia lamblia
Entamoeba histolytica
Microsporidia
Mycobacterium avium

Workup

Laboratory Studies

  • Stool examination
    • The detection of oocysts upon microscopic examination of stool specimens is diagnostic.
    • The sucrose flotation method or formalin ethyl acetate method is used to concentrate stool before staining with a modified Kinyoun acid-fast satin because routine laboratory examination of stool for ova and parasites does not detect Cryptosporidium.7,4 This technique stains oocysts pink or red, whereas fecal debris or yeast assumes the color of blue or green counterstain.
    • A monoclonal antibody-based fluorescein conjugated stain for oocysts in stool is commercially available. An enzyme immunoassay (EIA) to detect antigen in stool is also commercially available and is the most specific, reliable test that is widely available.16
    • Because shedding may be intermittent, examine at least 3 stool specimens collected on separate days before considering the test results negative. Fecal leukocytes are not found in stool specimens because it does not invade below the epithelial layer of the mucosa.
    • Oocysts are small (4-6 μ m in diameter) and can be missed without a very careful examination of the slide.
    • GI biopsy specimens can be used instead of stool specimens. A high concentration of oocysts are seen in the jejunum.
    • Electron microscopy of stool or biopsy specimens can also be performed for direct visualization of oocysts.
    • For research purposes and for species identification, polymerase chain reaction (PCR) assays are used.
  • Serologic detection: Serologic detection of specific anti-Cryptosporidium antibodies is primarily used as a research or epidemiological tool.

Imaging Studies

Imaging studies are not indicated as a first-line diagnostic approach.

  • Abdominal radiography and CT scanning are nonspecific and may reveal distended loops of bowel, air-fluid levels, and disrupted bowel motility.
  • When indicated, as guided by symptoms, ultrasonography or CT scanning may reveal an enlarged gallbladder with a thickened wall, dilated or irregular intrahepatic and extrahepatic biliary ducts, and a normal or stenotic distal common bile duct.
  • Cholangiography may reveal beading of the common bile duct or papillary stenosis.
  • In cases of respiratory involvement, chest radiography is unremarkable, with modest infiltrates or increased bronchial markings.

Procedures

  • GI or liver biopsy may be indicated in cases of diagnostic uncertainty. Different parts of the intestinal tract may be affected. Liver biopsy findings may reveal the organism attached to bile duct epithelial cells. Concurrent infection with cytomegalovirus (CMV), Enterobacter cloacae, and microsporidia is common.
  • In patients with related symptoms, bronchoalveolar lavage or lung biopsy findings may reveal the parasite in lavage fluid, in brush biopsy specimens, attached to the surface of bronchial mucosal cells, or in macrophages. In most instances, another pulmonary pathogen, such as CMV or Pneumocystis carinii, is concurrently detected; however, in a series of 4 patients infected with HIV, Cryptosporidium was the only pathogen identified in the respiratory tract. Clear association with intestinal cryptosporidiosis or diarrhea has not been shown in these cases.

Histologic Findings

Villous atrophy with blunting, epithelial flattening, and an increase in lamina propria lymphocytes are seen in patients with persistent cryptosporidiosis. In patients with heavier infection, crypt hyperplasia and marked infiltration with lymphocytes, plasma cells, and neutrophils is also noted. Biopsy samples of the biliary ducts may reveal the parasites.

More on Cryptosporidiosis

Overview: Cryptosporidiosis
Differential Diagnoses & Workup: Cryptosporidiosis
Treatment & Medication: Cryptosporidiosis
Follow-up: Cryptosporidiosis
Multimedia: Cryptosporidiosis
References
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References

  1. 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].

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

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

  4. 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.

  5. Huang DB, Chappell C, Okhuysen PC. Cryptosporidiosis in children. Semin pediatr Infect Dis. Oct, 2004;15 (4):253-259. [Medline].

  6. CDC. Classification system for human T-lymphotropic virus type III/lymphadenopathy-associated virus infections. MMWR Morb Mortal Wkly Rep. May 23 1986;35(20):334-9. [Medline].

  7. 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.

  8. MacKenzie WR, Schell WL, Blair KA. Massive outbreak of waterborne Cryptosporidium infection in Milwaukee, Wisconsin. Clin Infect Dis. Jul, 1995;21 (1):57-62. [Medline].

  9. Cryptosporidiosis surveillance--United States, 2003-2005 [database online]. Division of Parasitic Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases, CDC, Atlanta, GA 30333, USA. jey9@cdc.gov: Yoder JS, Beach MJ; Centers for Disease Control and Prevention (CDC).; 2007 Sep 7.

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

  11. Cooper DL, Verlander NQ, Smith GE, 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].

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

  13. 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].

  14. 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].

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

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

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

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

  19. Smith NH, Cron S, Valdez LM, et al. Combination drug therapy for cryptosporidiosis in AIDS. J Infect Dis. Sep 1998;178(3):900-3. [Medline].

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

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Further Reading

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Keywords

cryptosporidiosis, Cryptosporidium, Cryptosporidium parvum, C parvum, Cryptosporidium hominis, C hominis, diarrhea, oocysts, acquired immunodeficiency syndrome, AIDS, Plasmodium, Cryptosporidium canis, waterborne infection, traveler's diarrhea, diarrhea, villous atrophy, malabsorption, steatorrhea, foodborne diarrhea, hepatobiliary disease, respiratory disease, jaundice, nausea, vomiting, croup, respiratory infection, human immunodeficiency virus, HIV, acalculous cholecystitis, sclerosing cholangitis, pancreatitis, ascites, icterus, reactive arthritis, diabetes mellitus, cytomegalovirus, CMV, Enterobacter cloacae, microsporidia, Pneumocystis carinii

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Contributor Information and Disclosures

Author

Jaya Sureshbabu, MBBS, DCh, MRCPCH (UK), MRCPI (Paeds), DCH (GLAS), Registrar, Department of Pediatrics/Neonatology, Mid-western Regional Hospital, Limerick, Ireland
Jaya Sureshbabu, MBBS, DCh, MRCPCH (UK), MRCPI (Paeds), DCH (GLAS) is a member of the following medical societies: 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 Hartlepool, UK
Poothirikovil Venugopalan, MBBS, MD, FRCP (Glasg), FRCPCH is a member of the following medical societies: British Cardiac Society, 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, Assistant Professor, Department of Pediatrics, Divisions of Infectious Diseases and Epidemiology, Emory University School of Medicine
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.

Medical Editor

Michael D Nissen, MBBS, BMedSc, FRACP, FRCPA, Associate Professor in Biomolecular, Biomedical Science & Health, Griffith University; Director of Infectious Diseases and Unit Head of Queensland Paediatric Infectious Laboratory, Sir Albert Sakzewski Viral Research Centre, Royal Children's Hospital
Michael D Nissen, MBBS, BMedSc, FRACP, FRCPA is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Pediatric Infectious Diseases Society, Royal Australasian College of Physicians, and Royal College of Pathologists of Australasia
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Martin Weisse, MD, Program Director, Associate Professor, Department of Pediatrics, West Virginia University
Martin Weisse, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching

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: None None None

 
 
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