Opportunistic infections of the gastrointestinal tract have played a critical role in determining symptomatic illness in immuno compromised individuals. In recent years intestinal infections such as Cryptosporidium, Cyclospora and Isospora are becoming more prevalent in acquired immuno deficiency syndrome. Strongyloides stercoralis infections can lead to hyper infection syndrome and found to be lethal in immuno compromised patients the present study was under taken to determine the prevalence of intestinal parasites in HIV sero positive patients. Stool samples from 166 HIV infected patients with diarrhoea and 123 HIV infected patients without diarrhoea were examined for intestinal parasites by microscopy. Intestinal parasites were seen in 69.2% HIV patients with diarrhoea as compare to their presence in 30.08% HIV patients without diarrhoea.
Human Immuno Deficiency virus, Intestinal parasites Ahmedabad.
Parasitic infections of gastrointestinal tract are a major cause of morbidity in developing countries and are increasingly important in certain populations from developed countries, particularly in patients with the acquired immunodeficiency syndrome.1 Despite the wide spread HIV awareness programmes which are going on at present, a large number of patients either go undiagnosed or present late with multiple infections.2 Diarrhoea is a common complication of infection with HIV, leading to weight loss and cachexia. it occurs in almost 90% of the HIV patients.3 Chronic diarrhoea significantly reduces the quality of life in patients with HIV infection and is an independent predictor of mortality in AIDS.4 The most commonly reported parasites include Giarrdia Lamblia, Entamoeba, Histolytica, Cryptosporidium parvum, Isosporabelly and Cyclospora species, besides these the nematode, strongyloides stercoralis can cause an over whelming infestation in patients with such immunosuppressive disorder.2,5 The detection of these parasites will help in the proper management of these patients as drugs are available for the treatment of most of the infections.6
Material and Methods
A retrospective study was carried out in department of microbiology Kesar Sal Medical College and Research centre, Ahmedabad for a period of three years (December 2008 to November 2011)
A total of 289 HIV sero positive patients were included in the study. The HIV sero positive patients were defined as those who had been tested positive for HIV antibodies by any of two tests i.e. ELISA /Rapid/simples as per the recommendations given by WHO.
A total of 3 freshly voided stool samples were obtained in sterile plastic container from all the subjects who were enrolled in the study. The stool samples were macro scopically examined for consistency, colour and presence of blood and mucus, adult intestinal helminths and segments of tapeworm. Saline and Iodine preparation were examined microscopically for the ova of helminths as well as for the cysts and the trophozoites of protozoa. Formalin ether concentration was done when the stool did not reveal any parasites by direct microscopy. The modified Ziehl Neelsen staining method was used for the detection of coccidian parasite.8
Highest Incidence of diarrhoea which was associated with HIV infection was seen in the age group of 31- 40 years followed by the age group of 21 – 30 years (Table I). The percentage of HIV infected females presenting with diarrhoea (70.1%) was more than that of males (51.9%) (Table II). Out of 289 stool samples which were screened 152 revealed intestinal parasites, 115 in HIV positive patients with diarrhoea 37 in HIV positive patients without diarrhoea (table IV). Initially 133 parasites were seen by direct microscopy and an additional 19 parasites were seen after the formalin ether concentration technique (Table III) out of 166 HIV sero positive patients with diarrhoea 73 (43.97%) patients had episodes of acute diarrhoea (<2 weeks) while 93 (56.03%) had chronic diarrhoea (>4 weeks) in 73 patients who presented with acute diarrhoea 59 (80.8%) stool samples revealed intestinal parasites, while in stool samples from 93 patients with chronic diarrhoea 55(59.13%) showed the presence of intestinal parasites.
Giardia Lamblia (27.1%) was the commonest parasite in patients with diarrhoea followed by Cryptospodium parvum (9.6%). The prevalence of Entamoeba Histolytica (12.19%) was more in patients without diarrhoea as compared to the prevalence of Gardia Lamblia. Among the intestinal helminthes, Ankylostoma duodenale (9.3%) was the commonest helminth which was detected followed by Ascaris Lumbricoides (3.6%), Hymenolepis nana (3.01%), Taenia species (1.8%) and Storngyloides stercoralis (0.6%) (Table IV). The incidence of isospora belli was (5.42%). In case of Taenia species, Hymenolepis nana, Ankylostoma duodenale and Ascaris Lumbricoides there was no significant difference in the diarrhoea and non diarrhoea groups. It indicates that in these parasitic infections diarrhoea was not a common symptom or they are a symptomatic infections (Table IV).
Among the opportunistic infections, intestinal parasitic disease is the commonest and is the major cause of morbidity and mortality in HIV positive individuals worldwide.9 These organisms usually cause a self limiting illness in immuno competent individuals, but in the case of immuno compromise patients they can cause life threatening profuse watery diarrhoea.10 Giardia Lamblia was the most common parasites which was detected in patients with diarrhoea (27.1%) which is comparable to the study of Sethi etal.11 Where as Mukhopadhya etal reported Giardia Lamblia predominantly in non diarrhoeal patients.12 In our study cryptosporidium parvum was the most common coccidian parasites which was associated with HIV patients both with diarrhoea and without diarrhoea, this was correlated with the study of Tulli etal,13 Sadrai etal,14 Mohandas etal.15 While Gupta etal2 and Mukhopadhya etal12 reported low prevalence of cryptosporidium parvum as compared to isospora belli. Among intestinal helminths Ankylostoma duodenale was reported to be the commonest parasite which was comparable to that which was reported by Sethi etal.11 The major parasite which was detected in HIV positive patients without diarrhoea was Entamoeba histolytica. The tropozoities of Entamoeba histolytica were identified, but cysts of Entamoeba histolytica and E. dispar are morphologically identical and therefore they can not be differentiated microscopically. The cysts were presumed to be that of Entamoeba histolytica as E. dispar in non invasive and non pathogenic species.2 The cysts of E. histolytica were considered in asymptomatic patients because asymptomatic non invasive intestinal infections by E. histolytica are the most common events and excretion of Entamoeba cysts characterise them. The facility for the iso enzyme electrophoresis technique was not available in our setup.
Screening of the coccidian parasite is still not done as routine test in HIV positive patients in most of microbiology laboratories but a good number of HIV patients suffer from diarrhoea due to coccidian intestinal parasites. A high prevalence of intestinal parasite infections in HIV positive individuals may be due to poor water supply and lack of personal hygiene. Authors suggest that along with the diagnosis and treatment steps should be taken to improve the water supply and sanitation to prevent morbidity and mortality which are associated with HIV infections.
- Centers for disease control 1993. Revised classification for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR Morb Mortal Wkly report 1993;41:1-19.
- Gupta S, Narang S, Nunavath V, Singh S. Chronic diarrhoea in HIV patients. Prevalence of coccidian parasites. Ind J Med Micro2008; 26(2): 172-175.
- Kumar SS, Ananthan S, Lakshmi P. Intestinal Parasitic Infections in HIV infected Patients with diarrhoea in Chennai. Ind J Med Microbiology 2002;20(2):88 – 91.
- Lubeck DP, Bennett CL, Mazonsen PD, Fifer SK, Fries JF. Quality of life and health service use among HIV infected patients with chronic diarrhoea. J Acquired immune Defic Syndr 1993; 6:478-484.
- Harrison’s principles of internal medicines. In: Micheal camilleri, Joseph A Murray, editors. Diarrhoea and constipation. New York Mc Grawhill 2008: 245-255.
- Arora DR, Arora B. AIDS associated parasitic diarrhoea. Ind J Med Microbiology 2009; 27(3):185 – 190.
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- Sharpston D, Gazzard B. Gastroinstestinal manifestation on HIV infection, Lancet 1996;348:379-83.
- Chaission RE, Gallant JE, Keruly JC, Moor RD. Impact of opportunistic disease on survival in patients with HIV infection. AIDS 1998; 12:29-33.
- Meisel JF, Perera DR, Meligrilo C, Rubin CB, overwhelming watery diarrhoea associated with cryptospodium and immuno suppressed patient gastroenterology 1976;70:1156-66.
- Sethi S, Sehgal R, Mallan N, Dubey ML, Mahajan RC. Changing Trends of intestinal parasitic infections in Chandigarh. Hospital Based study Indian Journal of Medical Microbiology 2000;18(3):106-109
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- . Tuli L, Gulati AK, Sundar S, Moha Patra TM, correlation between CD4 count of HIV patients and enteric protozone in different seasons. An experience of tertiary care hospital in Varanasi. BMCV Gastroentrology 2008;8:36.
- Sodraei J, Rizvi MA, Baveja UK, Diarrhoea, CD4 cell counts and opportunistic protozoa in Indian HIV infected patients. Parasito Research 2005;97:270-273
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