David writes:
Greetings Team TWiP,
I will make this a quick guess for the case of the HIV positive patient from Georgia who visits NYC for HIV care.
Based on the short description of the case, the emphasis on drinking the NYC water while visiting, and the sudden onset of watery diarrhea, two possibilities come to mind: cryptosporidiosis and giardia.
I seem to recall a recent TWiP covering cryptosporidium – TWiP 233 – as well as discussion of much of the NYC water supply from the Catskills being unfiltered and potentially containing low levels of crypto. My guess for the new case in TWiP 237 is cryptosporidium, although testing might be wise to definitively differentiate the cause.
Thanks as always for an entertaining and informative episode.
David from Maryland
Justin writes:
Hello hosts,
With an immunocompromised patient and New York city tap water my first thought is cryptosporidiosis or a C. diff bacterial infection. Giardiasis could also be possible but without fatty diarrhea this seems less likely. There are likely many other differentials for this case, but I think the most likely is a Cryptosporidium species infection. C. hominis or parvum being most likely.
All the best,
Justin
University of Central Lancashire Parasitology CLub writes:
Dear TWIP Professors,
Greetings from the University of Central Lancashire Parasitology Club in the wonderful
North West of Britain. Today it was a chilly 13 Celsius, however the week before was an amazing 30 degrees. We ran our Parasitology Club Summer School last week supported by BioConnections (UK) with parasite suspensions and this provided an opportunity for the team students to practice microscopy skills and parasite identification. Our signed copies of Parasitic Diseases were highly useful.
The clinical case presented looks like a classic case of cryptosporidiosis in a patient with HIV and declining into AIDS.
As we learned in summer school, the oocysts can be found abundantly in faecal samples but are too small and indistinct for identification by microscopy without Ziehl Neelsen or auramine staining. Current methods usually rely on immunoassays such as ELISA or tests are included in gastrointestinal pathogens panels by nucleic acid amplification methods. (Amar et al, 2004)
Thank you for another wonderful podcast and interesting case.
Neal Vickers
On behalf of the University of Central Lancashire Parasitology Club
References
Despommier, D., Griffin, D., Gwadz, R., Hotez, P. and Knirsch, C. (2019) Parasitic Diseases. 7th Edition. New York: Springer-Verlag.
Nissapatorn V, Sawangjaroen N. (2011) Parasitic infections in HIV infected individuals: diagnostic and therapeutic challenges. Indian J Med Res.134(6):878-97. doi: 10.4103/0971-5916.92633
Amar CF, East C, Maclure E, McLauchlin J, Jenkins C, Duncanson P, Wareing DR. (2004) Blinded application of microscopy, bacteriological culture, immunoassays and PCR to detect gastrointestinal pathogens from faecal samples of patients with community-acquired diarrhoea. Eur J Clin Microbiol Infect Dis. 23(7):529-34. doi: 10.1007/s10096-004-1149-x.
Frithjof (pronounced Freed-yoff) writes:
Hello from the top of the Alps,
Here in South Tyrol (northern Italy) we have nice 21°C / 70°F and amazing views! For the gentleman from Georgia, presenting with watery diarrhea in New York, I think the causative agent is Microsporidiosis. The parasite can spread through chlorinated tap water. Other differential diagnoses would be Cryptosporidium or Cystoisosporiasis. Stool microscopy should lead to a definite diagnosis.
Yours Frithjof
John writes:
Still hoping to win a book and hope not too tardy.
Hello esteemed hosts. Two parasites that came to mind are giardia and cryptosporidiosis. However, a few things steered me from giardia to crypto.
Fever is rarely present in giardia but common with crypto. The gentleman has compliance with therapy issues and his weakened immune system is susceptible to cryptosporidiosis ubiquitous in the unfiltered NYC surface water tap. It also sounds like this is a common enough occurrence that Dr. Griffin recognized it for hiv/aids patients coming to NYC for treatment.
Foul odor and floating stool are common for giardia but also absent here. Cryptosporidiosis does match signs of voluminous watery diarrhea. In both cases, a stool can be tested with pcr or even a less sensitive microscopic examination.
As for crypto treatment, there is an fda approved drug but usually skipped, and getting the client to comply with hiv/aids therapy would shore up the immune system to clear the infection.
John
Ed writes:
Sunny and cool in Minnesota today, 74 F 23 C, good weather for a bicycle ride. I am a long time TWIP listener. I sent you a diagnosis for the first time in May when guests got sick with myalgias after a banquet with game meat. Immediately I thought it was a trichinosis outbreak, and of course I was wrong! I was fooled by “the most successful parasite on earth”.
One can never be too sure about anything in human health. But I am going to double down on my losing strategy and again go with my first guess. It seems likely that our HIV patient with “very watery diarrhea” who is immunocompromised by not taking his antiviral therapy has cryptosporidiosis. NYC water is unfiltered and heavily chlorinated. Cryptosporidium laughs at chlorine.
For the patient’s sake, I hope I am wrong. While other people get over cryptosporidiosis without treatment, I remember how bad it was in the AIDS era before HAART. Maybe this miserable illness can persuade Daniel’s patient to resume HIV meds and extend his life.
Ed in Minnesota
PS
I attach another photomicrograph, not of Cryptosporidium but of related Eimeria, an avian coccidian. The slide of infected chicken ceacum was made at Johns Hopkins School of Hygiene in 1948 and shows multiple protist life stages. EE Tyzzer at Harvard University elucidated the complex life cycle of Eimeria in birds in 1929. Tyzzer was also the first to discover Cryptosporidium, in 1910.
Felix writes:
Dear Hosts,
I am amazed by the diversity of countries that people writing in are from. You should get a scratch map to keep track of them!
As for my guess, there are two parasites I considered when thinking about drinking water: Cryptosporidium parvum and Giardia lamblia. The one I mostly associate with HIV is Crypto, so that’s my final guess, but it could also be the other one. If I am right, I anticipate a malaria or babesiosis case next week to keep the apicomplexa streak going!
Greetings from south Germany
Felix
Tuomas writes:
Hello,
It is 29°C in Southern Finland.
The unfiltered tap water of New York City is a recurring theme on TWIP. Unfortunately I don’t know what our patient is suffering from.
My differential is three parasites used as examples of “pathogens with environmentally resistant stages”:
1. Giardia lamblia
2. Entamoeba histolytica
3. Cryptosporidium parvum
and Cyclospora cayetanensis as a fourth alternative.
The relevant parts for the diagnosis are:
1. Patient has HIV/AIDS
2. Watery diarrhea
3. Fever
Giardia:
– No steatorrhea mentioned.
– Consistent with fever
E. histolytica:
– Consistent with watery diarrhea and fever
– It is unclear to me if New York City tap water has E. histolytica
Crypto:
– Consistent with watery diarrhea
– Inconsistent with fever
– Crypto was the solution three cases ago
C. cayetanensis:
– Consistent with watery diarrhea
– Not endemic in North America
In conclusion, I don’t know. But it may or may not be one of these.
Hot regards,
Tuomas
Agnese writes:
Dear Twippers!!
Thank you again for interesting cases and scientific evidence discussions.
My guessing for this new case is Microsporidia, these parasites are worldwide distributed and reports have found double prevalence among immunocompromised individuals, especially among people living with HIV. Despite being mostly asymptomatic, the severity of the clinic worsen with lower CD4 cells count, which is the case of our patient. The species is likely to be either Enterocytozoon bieneusi or Encephalitozoon intestinalis.
I would put Cryptosporidium spp and Isospora belli in the differentials as well, also typical of people living with HIV.
Giardia and Entamoeba could also be considered in the differential.
A microscopic examination of stools should help with the diagnosis, together with serological and molecular analyses.
The treatment should be Albendazole, if Microsporidia is confirmed, and disseminate diseases should be ruled out to establish the duration of treatment. Antiretroviral treatment should be assured for immunological recovery.
Can’t wait for the next case,
Agnese
PS I won a book last year, but I haven’t received it yet.
Michelle and Alexander from the First Vienna Parasitology Passion Club write:
Dear TWIP hosts,
It seems that lately you’ve had a lot of “cryptic” cases on “tap” and since we recently submitted a case guess about a patient who presented with a cryptosporidium infection after swimming in a public pool in Florida, we decided to keep it short this time. Also, we are running out of cryptosporidium puns. Cryptosporidium is a common cause of diarrhea in HIV positive patients with uncontrolled disease and is usually treated with nitazoxanide or paromomycin. More importantly the patient should be connected to HIV care and ART.
As always, thank you for this great case. All the best,
Michelle and Alexander from the First Vienna Parasitology Passion Club
Håkon writes:
Greetings from sunny, muggy Athens!
Thank you for another fun case, and another chance to win a book. For this week’s case, there were a few protists that come to mind- cyclospora cayetanensis, cryptosporidium bovis/parvum, isospora spp., Entamoeba spp. or a microsporidial infection given our patients HIV+ status. Without doing an acid-fast staining or PCR analysis, I feel more inclined to lean on the tentative diagnosis being cryptosporidium due to the hint about NY drinking water. Hope all is well with the team and thanks again!
Håkon