eMedicine Specialties > Pediatrics: General Medicine > Parasitology

Cyclosporiasis

Author: 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
Coauthor(s): Cathy Jo Schroeder, RN, MSN, APN-C, Family Nurse Practitioner for James A Boozan MD, Otolaryngologist
Contributor Information and Disclosures

Updated: Jan 21, 2009

Introduction

Background

Cyclospora cayetanensis is a coccidian parasite that infects the GI tract of both immunocompetent and immunocompromised hosts. This organism was first described in human feces in 1979. Since the advent of the acquired immunodeficiency syndrome (AIDS) epidemic, C cayetanensis has been increasingly recognized as an enteric pathogen.1

Cyclospora species are ubiquitous and infect various animals, including vipers, moles, rodents, and myriapods. Humans are the only known hosts of C cayetanensis. The first known outbreak of cyclosporiasis in the United States occurred in 1990 in a Chicago hospital's physicians' dormitory and was attributed to an infected water source. In 1996-97, US epidemics of cyclosporiasis were attributed to infected Guatemalan raspberries,2,3 basil, and mesclun lettuce.4,5,6,7 An outbreak resulted from exposure to contaminated berries at a social function in Ontario, Canada in 1999. More recent outbreaks have been associated with imported Thai basil8 and snow peas in a cluster of infections in Pennsylvania in 2004.9,10 Otherwise, only sporadic cases, primarily involving travelers, have been documented.

Pathophysiology

Cyclospora species are variably acid-fast, round-to-ovoid organisms that measure 8-10 µm in diameter. Cyclospora species exogenously sporulate and have 2 sporocysts per oocyst. Transmission follows ingestion of oocysts in fecally contaminated water or produce. Direct person-to-person transmission is considered unlikely because the oocysts are not infectious when excreted; the oocysts undergo sporulation outside the human host before becoming infective. The median incubation period is 1 week, during which time the organism invades enterocytes of the small intestine.

Disease manifests as protracted and relapsing gastroenteritis. Cyclospora species are characterized by an anterior polar complex that allows penetration into host cells, but the life cycle of the parasite and the mechanisms by which it interacts with human host target cells to cause disease are poorly understood.

Frequency

United States

The frequency of cyclosporiasis is unknown.

International

Most fecal isolates have been obtained from residents of developing countries or from travelers returning from these regions. Cyclosporiasis is endemic in Haiti, Nepal, and Peru, with a strong seasonal predominance during rainy spring and summer months. Cyclosporiasis has also been reported in travelers returning from Mexico, Southeast Asia, Puerto Rico, Indonesia,11 Morocco, Pakistan, and India.

Mortality/Morbidity

Death is exceptionally rare. Very little morbidity results from this infection, except in persons with underlying immunosuppression, in whom chronic diarrhea can develop.

Race

No racial predilection has been reported.

Sex

Cyclosporiasis equally affects both sexes.

Age

Persons of all ages can be affected, although cyclosporiasis primarily affects children in developing countries where the disease is endemic.

Clinical

History

Diarrhea is the hallmark of cyclosporiasis. Onset is abrupt, 1-14 days after exposure to a contaminated source. The diarrhea is described as profuse, malodorous, and watery and can cause dehydration and weight loss. Diarrhea may be associated with 1 or more nonspecific symptoms, including intermittent crampy abdominal pain, nausea, vomiting, low-grade fever, malaise, myalgias, anorexia, bloating, flatulence, and/or profound fatigue. These symptoms are indistinguishable from those of Isospora and Cryptosporidium infections.

In an immunocompromised host, onset is more insidious, and the condition becomes chronic; symptoms and shedding of oocysts continue indefinitely. Biliary disease with right upper quadrant pain, increased alkaline phosphatase, and thickened gallbladder on ultrasound findings has been reported in an immunocompromised host infected with Cyclospora.

In an immunocompetent host, diarrhea can persist for 7 days to several weeks, with a waxing and waning course.

Physical

Physical examination findings are unremarkable, other than signs of dehydration or, in an immunocompromised host, biliary disease.

Causes

Causes of cyclosporiasis include consumption of infected water or produce or exposure to the organism during travel to countries where it is endemic. Immunosuppression is a risk factor for chronic cyclosporiasis in endemic areas or among travelers to these areas.

More on Cyclosporiasis

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

  1. Mannheimer SB, Soave R. Protozoal infections in patients with AIDS. Cryptosporidiosis, isosporiasis, cyclosporiasis, and microsporidiosis. Infect Dis Clin North Am. Jun 1994;8(2):483-98. [Medline].

  2. Herwaldt BL, Ackers ML. An outbreak in 1996 of cyclosporiasis associated with imported raspberries. The Cyclospora Working Group. N Engl J Med. May 29 1997;336(22):1548-56. [Medline].

  3. Ho AY, Lopez AS, Eberhart MG, et al. Outbreak of cyclosporiasis associated with imported raspberries, Philadelphia, pennsylvania, 2000. Emerg Infect Dis. Aug 2002;8(8):783-8. [Medline].

  4. CDC. From the Centers for Disease Control and Prevention. Outbreaks of cyclosporiasis--United States, 1997. JAMA. Jun 11 1997;277(22):1754. [Medline].

  5. CDC. From the Centers for Disease Control and Prevention. Update: outbreaks of cyclosporiasis--1997. JAMA. Jul 9 1997;278(2):108. [Medline].

  6. CDC. From the Centers for Disease Control and Prevention. Update: outbreaks of cyclosporiasis--United States, 1997. JAMA. Jun 18 1997;277(23):1838. [Medline].

  7. CDC. From the Centers for Disease Control. Outbreak of cyclosporiasis-- Northern Virginia-Washington, DC-Baltimore, Maryland, metropolitan area, 1997. JAMA. Aug 20 1997;278(7):538-9. [Medline].

  8. Hoang LM, Fyfe M, Ong C, et al. Outbreak of cyclosporiasis in British Columbia associated with imported Thai basil. Epidemiol Infect. Feb 2005;133(1):23-7. [Medline].

  9. CDC. Outbreak of cyclosporiasis associated with snow peas--Pennsylvania, 2004. MMWR Morb Mortal Wkly Rep. Sep 24 2004;53(37):876-8. [Medline]. [Full Text].

  10. Heilpern KL, Wald M. Update on emerging infections: news from the Centers for Disease Control and Prevention. Outbreak of cyclosporiasis associated with snow peas--Pennsylvania, 2004. Ann Emerg Med. May 2005;45(5):529-31. [Medline].

  11. Blans MC, Ridwan BU, Verweij JJ, et al. Cyclosporiasis outbreak, Indonesia. Emerg Infect Dis. Sep 2005;11(9):1453-5. [Medline].

  12. Bouree P, Lancon A, Bisaro F, Bonnot G. Six human cyclosporiasis: with general review. J Egypt Soc Parasitol. Aug 2007;37(2):349-60. [Medline].

  13. Aksoy U, Akisu C, Sahin S, et al. First reported waterborne outbreak of cryptosporidiosis with Cyclospora co-infection in Turkey. Euro Surveill. 2007;12(2):E070215.4. [Medline].

  14. Atkins JT, Cleary TG. Cryptosporidiosis, Cyclospora infection, isosporiasis, and microsporidiosis. In: Textbook of Pediatric Infectious Diseases. 2004:2687-707.

  15. Cegielski JP, Ortega YR, McKee S, et al. Cryptosporidium, enterocytozoon, and cyclospora infections in pediatric and adult patients with diarrhea in Tanzania. Clin Infect Dis. Feb 1999;28(2):314-21. [Medline].

  16. Chacin-Bonilla L. Transmission of Cyclospora cayetanensis infection: a review focusing on soil-borne cyclosporiasis. Trans R Soc Trop Med Hyg. Mar 2008;102(3):215-6. [Medline].

  17. Chiodini PL. New diagnostics in parasitology. Infect Dis Clin North Am. Mar 2005;19(1):267-70. [Medline].

  18. Connor BA, Johnson EJ, Soave R. Reiter syndrome following protracted symptoms of Cyclospora infection. Emerg Infect Dis. May-Jun 2001;7(3):453-4. [Medline].

  19. Connor BA, Reidy J, Soave R. Cyclosporiasis: clinical and histopathologic correlates. Clin Infect Dis. Jun 1999;28(6):1216-22. [Medline].

  20. Diaz E, Mondragon J, Ramirez E, Bernal R. Epidemiology and control of intestinal parasites with nitazoxanide in children in Mexico. Am J Trop Med Hyg. Apr 2003;68(4):384-5. [Medline]. [Full Text].

  21. Dixon BR, Bussey JM, Parrington LJ, Parenteau M. Detection of Cyclospora cayetanensis oocysts in human fecal specimens by flow cytometry. J Clin Microbiol. May 2005;43(5):2375-9. [Medline]. [Full Text].

  22. Doller PC, Dietrich K, Filipp N, et al. Cyclosporiasis outbreak in Germany associated with the consumption of salad. Emerg Infect Dis. Sep 2002;8(9):992-4. [Medline].

  23. Eberhard ML, Arrowood MJ. Cyclospora spp. Curr Opin Infect Dis. Oct 2002;15(5):519-22. [Medline].

  24. Erickson MC, Ortega YR. Inactivation of protozoan parasites in food, water, and environmental systems. J Food Prot. Nov 2006;69(11):2786-808. [Medline].

  25. Farthing MJ. Treatment options for the eradication of intestinal protozoa. Nat Clin Pract Gastroenterol Hepatol. Aug 2006;3(8):436-45. [Medline].

  26. Fitzgerald DW, Pape JW. Cyclosporiasis. Curr Treatment Options Infect Dis. 2001;3:345-9.

  27. Flynn PM. Isospora and Cyclospora species. In: Principles and Practice of Pediatric Infectious Diseases. 2003:1280-1.

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

  29. Gilles HM, Hoffman PS. Treatment of intestinal parasitic infections: a review of nitazoxanide. Trends Parasitol. Mar 2002;18(3):95-7. [Medline].

  30. Harp JA. Parasitic infections of the gastrointestinal tract. Curr Opin Gastroenterol. Jan 2003;19(1):31-6. [Medline].

  31. Herwaldt BL. Cyclospora cayetanensis: a review, focusing on the outbreaks of cyclosporiasis in the 1990s. Clin Infect Dis. Oct 2000;31(4):1040-57. [Medline].

  32. Hussein EM. Molecular identification of Cycospora spp. using multiplex PCR from diarrheic children compared to others conventional methods. J Egypt Soc Parasitol. Aug 2007;37(2):585-98. [Medline].

  33. Hussein EM, El-Moamly AA, Dawoud HA, Fahmy H, El-Shal HE, Sabek NA. Real-time PCR and flow cytometry in detection of Cyclospora oocysts in fecal samples of symptomatic and asymptomatic pediatrics patients. J Egypt Soc Parasitol. Apr 2007;37(1):151-70. [Medline].

  34. Karanis P, Kourenti C, Smith H. Waterborne transmission of protozoan parasites: a worldwide review of outbreaks and lessons learnt. J Water Health. Mar 2007;5(1):1-38. [Medline].

  35. Lalonde LF, Gajadhar AA. Highly sensitive and specific PCR assay for reliable detection of Cyclospora cayetanensis oocysts. Appl Environ Microbiol. Jul 2008;74(14):4354-8. [Medline].

  36. Lee MB. Everyday and exotic foodborne parasites. Can J Infect Dis. May 2000;11(3):155-8. [Medline].

  37. Lewthwaite P, Gill GV, Hart CA, Beeching NJ. Gastrointestinal parasites in the immunocompromised. Curr Opin Infect Dis. Oct 2005;18(5):427-35. [Medline].

  38. Lopez AS, Dodson DR, Arrowood MJ, et al. Outbreak of cyclosporiasis associated with basil in Missouri in 1999. Clin Infect Dis. Apr 1 2001;32(7):1010-7. [Medline].

  39. Nimri LF. Cyclospora cayetanensis and other intestinal parasites associated with diarrhea in a rural area of Jordan. Int Microbiol. Jun 2003;6(2):131-5. [Medline].

  40. Ochoa TJ, Salazar-Lindo E, Cleary TG. Management of children with infection-associated persistent diarrhea. Semin Pediatr Infect Dis. Oct 2004;15(4):229-36. [Medline].

  41. Ortega YR, Nagle R, Gilman RH, et al. Pathologic and clinical findings in patients with cyclosporiasis and a description of intracellular parasite life-cycle stages. J Infect Dis. Dec 1997;176(6):1584-9. [Medline].

  42. Pape JW, Verdier RI, Boncy M, et al. Cyclospora infection in adults infected with HIV. Clinical manifestations, treatment, and prophylaxis. Ann Intern Med. Nov 1 1994;121(9):654-7. [Medline]. [Full Text].

  43. Pearson RD. Nitazoxanide As Treatment of Intestinal Parasites in Children. Curr Infect Dis Rep. Feb 2004;6(1):25-26. [Medline].

  44. Puente S, Morente A, Garcia-Benayas T, et al. Cyclosporiasis: a point source outbreak acquired in Guatemala. J Travel Med. Nov-Dec 2006;13(6):334-7. [Medline].

  45. Soave R, Herwaldt BL, Relman DA. Cyclospora. Infect Dis Clin North Am. Mar 1998;12(1):1-12. [Medline].

  46. Steiner T, Pape J, Guerrant R. Intestinal coccidial infections. In: Guerrant RL, Walker DH, Weller PF, eds. Tropical Infectious Diseases: Principles, Pathogens, and Practice. Churchill Livingstone; 1999:721-35.

  47. Suh KN, Keystone JS. Antibiotics for Travelers: What's Good and What's Not. Curr Infect Dis Rep. Feb 2004;6(1):13-21. [Medline].

  48. Sun T. Current topics in protozoal diseases [published erratum appears in Am J Clin Pathol 1994 Nov;102(5):708]. Am J Clin Pathol. Jul 1994;102(1):16-29. [Medline].

  49. Torres-Slimming PA, Mundaca CC, Moran M, et al. Outbreak of cyclosporiasis at a naval base in Lima, Peru. Am J Trop Med Hyg. Sep 2006;75(3):546-8. [Medline].

  50. Valdez LM, Gotuzzo E, DuPont HL. Gastrointestinal symptoms. In: Guerrant RL, Walker DH, Weller PF, eds. Tropical Infectious Diseases: Principles, Pathogens, and Practice. Churchill Livingstone; 1999:1367-79.

  51. Verweij JJ, Blange RA, Templeton K, et al. Simultaneous detection of Entamoeba histolytica, Giardia lamblia, and Cryptosporidium parvum in fecal samples by using multiplex real-time PCR. J Clin Microbiol. Mar 2004;42(3):1220-3. [Medline]. [Full Text].

  52. Wiesner J, Reichenberg A, Heinrich S, Schlitzer M, Jomaa H. The plastid-like organelle of apicomplexan parasites as drug target. Curr Pharm Des. 2008;14(9):855-71. [Medline].

  53. Wilson ME. Diarrhea in nontravelers: risk and etiology. Clin Infect Dis. Dec 1 2005;41 Suppl 8:S541-6. [Medline].

  54. Wittner M, Tanowitz HB, Weiss LM. Parasitic infections in AIDS patients. Cryptosporidiosis, isosporiasis, microsporidiosis, cyclosporiasis. Infect Dis Clin North Am. Sep 1993;7(3):569-86. [Medline].

  55. Zar FA, El-Bayoumi E, Yungbluth MM. Histologic Proof of Acalculous Cholecystitis Due to Cyclospora cayetanensis. Clin Infect Dis. Dec 15 2001;33(12):E140-1. [Medline].

  56. Zimmer SM, Schuetz AN, Franco-Paredes C. Efficacy of nitazoxanide for cyclosporiasis in patients with sulfa allergy. Clin Infect Dis. Feb 1 2007;44(3):466-7. [Medline].

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Further Reading

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Keywords

cyclosporiasis, acquired immunodeficiency syndrome, AIDS, biliary disease, blue-green algae, chronic diarrhea, coccidian-like body, Cyanobacterium infection, Cyclospora cayetanensis, C cayetanensis, diarrhea, gastroenteritis, GI infection, large Cryptosporidium infection, parasite, parasitic infection

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Contributor Information and Disclosures

Author

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; Baxter Healthcare Honoraria Speaking and teaching

Coauthor(s)

Cathy Jo Schroeder, RN, MSN, APN-C, Family Nurse Practitioner for James A Boozan MD, Otolaryngologist
Cathy Jo Schroeder, RN, MSN, APN-C is a member of the following medical societies: American Academy of Nurse Practitioners and Sigma Theta Tau International
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
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

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

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

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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