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 Zambia HIV National Guidelines
 


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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Diagnosis>Opportunistic Infections>
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Cryptosporidiosis

Khalil G. Ghanem, M.D.
07-10-2008

  • Cryptosporidiosis endemic in Zambia and is common cause of persistent diarrhea in HIV+ Zambians.
  • Diagnostic testing is limited in Zambia; diarrhea typically treated empirically per routine guidelines (see diarrhea).
  • If cryptosporidiosis specifically diagnosed, treatment recommendations are same as in developed world.
  • Nitazoxanide is novel treatment for cryptosporidiosis that has been studied specifically in Zambian patients with AIDS and persistent diarrhea. In one small study, it was demonstrated to have modest benefit.
  • Prevention techniques listed below apply to Zambia.

REFERENCES

Zambia Information Author: Larry William Chang, MD, MPH

PATHOGENS

  • Cryptosporidium parvum: intracellular protozoan parasite related to parasite that causes malaria (Plasmodium)
  • Ingestion of sporulated oocysts (4-6 m in diameter) containing 4 sporozoites, which excyst and attach to colonic epithelium; these mature to meronts, which release merozoites leading to zygote formation; oocyst then released through feces into environment.
  • Environmental oocysts can survive for many months.
  • Person-to-person transmission among family members and close contacts tends to occur because infectious dose relatively small (<1000 oocysts); zoonotic transmission also possible; most outbreak cases due to contaminated water (BMJ 1991).
  • In-hospital person-to-person transmission among patients w/ AIDS thought to be rare (Clin Infect Dis 2000).

CLINICAL

  • Most common cause of chronic diarrhea in severely immunosuppressed (CD4 <100).
  • Med. time from exposure to Sx ~13d in pts. w/ AIDS
  • Sx: large volume (scant in some cases), nonbloody, non-inflammatory diarrhea; occasional crampy abdominal pain; occasional low-grade fever; N&V may accompany diarrhea.
  • DDx: Microsporidium, Cyclospora, Isospora, MAC, Giardia, Entamoeba, & Clostridium difficile.
  • Other manifestations: acalculous cholecystitis (chronic carriage in gallbladder may make eradication of intestinal disease difficult), cholangiopathy; pancreatitis; sinusitis & tracheitis described; reactive arthritis.

DIAGNOSIS

  • Stool/duodenal aspirate/bile smears; concentration techniques (e.g. FEA concentration) should be routinely performed to increase sensitivity.
  • Modified Kinyoun's acid-fast stain is mainstay of Dx; oocysts stain red. DFA used occasionally to confirm Dx of suitable oocysts.
  • Giemsa stain (purple oocysts), methenamine-silver (clear oocysts, dark background) have also been used.
  • Multiple smears may be necessary as shedding can be intermittent. Duodenal Bx rarely needed.
  • Commercial serology (EIA), stool IFAuncommonly used (mostly in outbreak settings where large volumes of studies are performed and results needed promptly); PCR mostly of research interest.

TREATMENT

HAART

  • Immune reconstitution w/ HAART is the only proven cure (Lancet 1998)
Antiparasitics

  • Effectiveness of antiparasitics in patients w/ AIDS without immune reconstitution has been disappointing.
  • Paromomycin 500mg PO tid (w/ meals) x14-28d OR 1g PO bid x14-28d followed by 0.5-1g PO bid is commonly used agent.
  • Azithromycin in combination w/ paromomycin has also been used. (J Infect Dis 1998)
  • Nitazoxanide approved for immune-competent children; recent study in HIV-infected pts suggests reasonable response rate (ref #10) at dose of 500-1500 mg mg PO bid
Symptomatic Rx

  • Diet: high-fiber & low fat; frequent small meals; avoid caffeine and lactose.
  • Antiperistaltics: loperamide (Imodium) 4 mg PO x1, then 2 mg PO prn, up to 16 mg/d
  • Antiperistaltics: atropine/diphenoxylate (Lomotil): 1-2 tabs PO tid-qid prn
  • Antiperistaltics: deodorized tincture of opium (DTO) 0.3-1 ml PO qid prn.
  • Other: bismuth sub-salicylate and NSAIDs
  • Octreotide: 100 mcg SQ tid up to 250 mcg SQ tid; limited efficacy data.
Prevention

  • Use bottled water (filtered through 1 m filter), or boil water for 1 min.
  • Avoid raw shellfish
  • Can be transmitted from person to person through ingestion of contaminated water (drinking water & water used for recreational purposes) or food, from animal to person, or by contact with fecally contaminated environmental surfaces.

Drug Comments

DrugRecommendations/Comments
Paromomycin Commonly used antiparasitic agent, though results in clinical trials have been inconsistent.
Nitazoxanide Limited but positive data in HIV-infected adults (see ref #10); approved in immunocompetent children.
Atovaquone No in vivo data
Azithromycin Typically used in combination with paromomycin; limited data

FOLLOW UP

  • Paromomycin 0.5-1.0 g PO bid may be used chronically in those who respond while awaiting immune reconstitution.

REFERENCES

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