Key words

Human Immuno Deficiency virus, Intestinal parasites Ahmedabad.

Introduction

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.

Stool Examination

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

Results

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).

Table I : Age and diarrhoea wise distribution of HIV positive Patients

Table II : Sex and diarrhoea wise distribution of HIV positive patients.

Table III : comparison between direct microscopy and concentration method.

Table IV: Diarrhoea wise distribution of parasites detected.

Discussion

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.

Conclusion

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.