Microsporidiosis

Microsporidiosis is an important cause of diarrhea in HIV infected patients. Micro-sporidia are obligate intracellular protozoa. At least four genera that are pathogenic in humans have been described. Of these, Enterocytozoon bieneusi is the most important. Microsporidia were previously among the most frequent diarrhea-causing microbes, and in the pre-HAART era, could be found in approximately one third of all patients and in some studies in up to two thirds of all HIV infected patients with chronic diarrhea (Sobottka 1998). The incidence of microsporidiosis has reduced significantly due to HAART, and is now only diagnosed occasionally. Microspo-ridiosis is not AIDS defining, although chronic microsporidiosis almost always occurs in severely immunocompromised patients with CD4-cell counts of less than 50 cells/^l.

Diarrhea may be very severe and is usually watery, though not bloody. It is accompanied by abdominal pain, nausea and vomiting. Fever is almost always absent. Rarely, myositis, keratoconjunctivitis and sinusitis have been described. Infections of the biliary ducts are more frequent.

Even more than in the case of cryptosporidia, it is essential that the laboratory is experienced. Microsporidia are very small, and those who are not explicitly asked to detect them will not find them! Culture has not generally been established. Detection is most successful with specialized staining methods. Special transport or preparation is not necessary.

Albendazole (1-2 tbl. a 400 mg bid for 4 weeks) is quite effective, but certainly not in every case. In particular, E. bieneusi is frequently resistant to albendazole. Positive reports from France of treatment with fumagillin have been published (watch for thrombocytopenia!), but the case numbers remain low (Molina 2002). Case reports (Bicart-See 2000) are also available for niazoxanide (see cryptosporidiosis). Thalidomide can be considered for symptomatic treatment. HAART-induced immune reconstitution, however, seems to have the greatest effect (Carr 1998+2002, Maggi 2000).

References

1. Bicart-See A, Massip P, Linas MD, Datry A. Successful treatment with nitazoxanide of Enterocyto-zoon bieneusi microsporidiosis in a patient with AIDS. Antimicrob Agents Chemother 2000, 44:167-8.

2. Carr A, Cooper DA. Fumagillin for intestinal microsporidiosis. N Engl J Med 2002, 347:1381.

3. Carr A, Marriott D, Field A, Vasak E, Cooper DA. Treatment of HIV-1 associated microsporidiosis and cryptosporidiosis with combination antiretroviral therapy. Lancet 1998, 351:256-61. http://amedeo.com/lit.php?id=9457096

4. Leder K, Ryan N, Spelman D, Crowe SM. Microsporidial disease in HIV-infected patients: a report of 42 patients and review of the literature. Scand J Infect Dis 1998, 30:331-8. http://amedeo.com/lit.php?id=9817510

5. Maggi P, Larocca AM, Quarto M, et al. Effect of antiretroviral therapy on cryptosporidiosis and micro-sporidiosis in patients infected with HIV virus type 1. Eur J Clin Microbiol Infect Dis 2000, 19:213-7. http://amedeo.com/lit.php?id=10795595

6. Molina JM, Tourneur M, Sarfati C, et al. Fumagillin treatment of intestinal microsporidiosis. N Engl J Med 2002, 346:1963-9. http://amedeo.com/lit.php?id=12075057

7. Sobottka I, Schwartz DA, Schottelius J, et al. Prevalence and clinical significance of intestinal microsporidiosis in HIV-infected patients with and without diarrhea in Germany: a prospective coprodiag-nostic study. Clin Infect Dis 1998, 26:475-80. http://amedeo.com/lit.php?id=9502473

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