CYSTOISOSPORIASIS AND ASSOCIATED RISK FACTORS IN HIV-INFECTED PATIENTS WITH MALARIA IN GENERAL HOSPITAL MINNA. NIGER STATE NIGERIA
ABSTRACT
Cystoisospora belli infection often occurs in immunocompriomised individuals, notably in patients suffering from HIV/AIDS. Concentration techniques was used for diagnosis of Cystoisospora belli. A total of 375 samples from HIV-positive patients and 50 samples from HIV-negative patients were processed using the modified kiyoun staining methods. In addition patients blood samples were analysed and examined for malaria and CD4 cells by Giemsa staining technique and Flow cytometry. The overall prevalence of the coccidian was 14.93% and there was a significant association between the HIV infected patients and Non HIV subjects (P<0.05). There was no significant diference among the sex and age group (P>0.05). There was a significant relationship between Cystoisosporiasis and CD4 cell counts in HIV-positive patients (P<0.05). Risk factors such as level of education, swimming and occupation among HIV patients did not significantly (P>0.05) affect the prevalence of C. belli infection while source of water and contact with animals significantly affected the prevalence of C. belli infection. Other risks factors such as washing of hands and washing of vegetables showed significant differences. This study has demonstrated that C. belli infection is prevalent in General Hospital Minna, Niger State, Nigeria and, as a result, may increase the burden on HIV-infected patient
TABLE OF CONTENTS
TITLE PAGE
Title page i
Declaration ii
Certification iii
Dedication iv
Acknowledgment v
Abstract vii
Table of contents viii
List of Tables xii
List of Figures xiii
List of Plate xiv
CHAPTER ONE
1.0 INTRODUCTION 1
1.1 Background of study 1
1.2 Justification 4
1.3 Aim of Study 5
1.4 Objectives of Study 5
CHAPTER TWO
2.0 LITERATURE REVIEW 6
2.1 Classification of Cystoisospora 10
2.2 Structure of Cystoisospora 10
2.3 Geographical Distribution of Cystoisospora 12
2.4 Risk factors for transmission of Cystoisospora 12
2.5 Site of Infection and Public Health Implication of Cystoisospora 12
2.6 Life Cycle of Cystoisospora 15
2.7 Mode of Transmission of Cystoisospora 16
2.7.1 Food Borne C. Belli infection 17
2.8 Diagnosis of Cystoisospora 17
2.9 Symptoms of Cystoisospora 18
2.10 Prevention and Control of Cystoisospora 19
2.11.0 Treatment of Cystoisospora 19
2.11.1 Antiparasitic Therapy 19
2.11.2 Immunosuppressed Hosts 20
2.11.3.0 Alternative Treatment 20
2.11.3.1 Pyrimethamine 20
2.11.3.2 Ciprofloxamin 21
2.11.3.3 Nitazoxanide 22
2.11.3.4 Amprolium 22
2.11.4 Other Agent 22
CHAPTER THREE
3.0 MATERIALS AND METHODS 24
3.1 Study Area and Population 24
3.2 Sample Collection 24
3.3 Blood Analysis 24
3.3.1 HIV Screening 24
3.3.2 Malaria Screening 25
3.3.3 CD4 Count Test 25
3.4 Stool Analysis 25
3.5 Data Analysis 26
3.6 Ethical Clearance 26
CHAPTER FOUR
4.0 RESULTS AND DISCUSSION 27
4.1 Results 27
4.1.1 Prevalence of Cystoisospora Belli in HIV-infected patients
with Malaria in General Hospital Minna 27
4.1.2 Prevalence of Cystoisospora Belli among Sex group in
HIV-infected patients with Malaria 30
4.1.3 Prevalence of Cystoisospora Belli among Age group in
HIV-infected patients with Malaria 32
4.1.4 Prevalence of Cystoisospora Belli in HIV-infected patients
With Malaria in Relation to CD4 Cell Count 34
4.1.5 Risk Factors associated with Cystoisospora Belli in
HIV-infected Patients in Minna. 36
4.2 Discussions 38
CHAPTER FIVE
5.0 CONCLUSION AND RECOMMENDATIONS 41
5.1 Conclusion 41
5.2 Recommendations 41
REFERENCES 42
CHAPTER ONE1.0 INTRODUCTION1.1 Background to the StudyCystoisosporiasis which was previously known as Isosporiasis, is an uncommon diarrheal illness caused by the protozoan Cystoisospora belli (formerly known as Isospora belli). Cystoisospora belli was first described by Virchow in 1980. The genus Cystoisospora is related closely to the genera Cryptosporidium, Cyclospora, and Toxoplasma. However, Cystoisospora belli infection is not as common as infections with Cryptosporidium, and Toxoplasma. The first of human infection with C. belli was described in 1915 (Woodcock, 1915). Human are the only known host of C. belli, which has no known reservoir.This protozoan parasite is opportunistic in immune suppressed human hosts (Gutierrez, 1990). It primarily exists in the epithelial cells of the small intestine, and develops in the cell cytoplasm (Gutierrez, 1990). The distribution of this coccidian parasite is cosmopolitan, but is mainly found in tropical and subtropical areas of the world such as the Caribbean, Central and South. America, India, Africa, & South East Asia. In the United States, it is usually associated with HIV infection (Auwarter et al., 2015).Cystoisosporiasis is found worldwide, especially in tropical and subtropical areas. Infection often occurs in immunocompromised individuals, notably in patients suffering fromHuman Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS), and outbreaks have been reported in institutionalized groups in the USA. The first documented case was in 1915. Until 2005 the etiological agent belonged to the genus Isospora. In 2005 it was included in the genus Cystoisospora. These genuses belong to different families. Isospora belongs to family Eimeriidae and Cystoisospora to Sarcocystidae. Both families belong to the suborder Eimeriorina (order Eucoccidiorida of the phylum Apicomplexa).The causative pathogen of cystoisosporiasis is C. belli, a protozoan that belongs to the subclass Coccidia in the phylum Apicomplexa. The mode of transmission of Cytoisosporiasis is faecal-oral, i.e. through food or water contaminated with human faeces. In immunocompetent individuals, C. belli infection causes a self-limited diarrheal illness. In individuals with immunocomprise, it may cause chronic life-threatening diarrhoea and dehydration.International statisticsof Endemic areas of cystoisosporiasis include Africa,Australia, the Caribbean islands, Latin America, and Southeast Asia(Rowe et al., 2010). One study found positive examination findings in up to 15% of Haitians infected with AIDS. In developing countries, 8-40% of patients with AIDS are infected. Cystoisosporiasis is the initial AIDS-defining illness in approximately 2-3% of patients with AIDS who are from Africa. Among patients with AIDS who are from South America, 10% with chronic diarrhoea have Cystoisosporiasis.In patients with AIDS who are from Haiti and Africa, 7-20% with chronic diarrhoea have cystoisosporiasis. People of all age are susceptible to C belli infection, although it tends to be more serious in infants and young children, possibly as a result of the risk of dehydration in the population. C. belli can cause severe diarrhoea in infants. No gender predilection for infection has been noted, aside from the gender distribution of people with AIDS and the risk factor most commonly associated with this disease. No racial predilection for Cystoisosporiasis has been reported, other than racial distribution of people with AIDS in the United States.In Immunocompetent patients, cystoisosporiasis is usually a transient, self-limited illness but can sometimes result in a protracted diarrheal illness. Cystoisosporiasis has also been reported as a contributor to malabsorption syndrome in immunocompetent patients(Sasakiet al., 2004). Infection with the intestinal protozoaCystoisospora belli is associated with chronic and severe diarrhoea, in particular, for persons living with AIDS and other immune-compromised individuals (Atambay et al., 2007 ). Infections are also seen in children and travellers to tropical regions (Goodgame, 2003; Jongwutiwes et al., 2007; Okhuysen, 2001).Although symptomsare self-limiting in immune-competent individuals, early diagnosis and treatment can shorten the period of intestinal symptoms substantially.Malaria is a deadly infectious disease and one of the main health problems facing developing countries in Sub-Saharan Africa (SSA) and Asia. Globally, 3.4 billion people are at risk of new malaria infections, and there are around one million deaths annually (WHO). Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae, Plasmodium ovale and Plasmodium knowlesi parasites infect humans under normal conditions (Hayakawa et al., 2008) with P. falciparum and P. vivax being the major species that cause morbidity and mortality in children under five years of age, pregnant women and travellers from non malarious areas (Warimwe et al., 2013).In Sub-Saharan African, morbidity and mortality due to malaria is decreasing despite a lack of a malaria vaccine, emergence of parasite resistance to available anti-malarial drugs, the Anopheles mosquito being resistant to insecticide residual spraying and a poor socio-economic situation that hinders malaria control and management. Efforts in drug discovery and vaccine development are hindered by limited knowledge of the underlying cellular and molecular mechanisms of host-parasite interactions during co-infection and poly-parasitism (Good et al., 2010).Epidemiological studies have shown that the largest burden of malaria infections is felt by communities living in poor regions of developing countries (Brooker et al., 2007). This results in co-infections, multi-parasitism or poly-parasitism (Hamid et al., 2010). In the past three decades, several studies have been undertaken to establish the nature of interaction that occurs between intestinal parasite and malaria during co-infection scenarios.Over 40 million people are living with HIV/AIDS, the majority (more than 25 million) of whom live in sub-Saharan Africa. Up to 2.4 million deaths were recorded worldwide in 2005 (Akinbo et al., 2009). People in the advanced stages of HIV infection are vulnerable to secondary infections and malignancies that are generally termed as opportunistic infections as they take the advantage of the opportunity offered by a weakened immune system (Saidu et al., 2009). In HIV-positive patients, the most clinical manifestation is chronic diarrhoea and wasting due to enteric infection (UNIADS, 1998).
1.2 JustificationCystoisospora belli disease “Cystoisosporiasis” is a neglected tropical disease that is associated with the chronic diarrhoea, malabsorption, wasting and weight loss especially in persons living with HIV/AIDS, and in other immune-compromised individuals. Developed countries are now battling/combating terminal illnesses like cancer, hypertension, leukaemia but not Cystoisosporiasis because it has been brought to a level that it has little or no public health concern. Infection rate of Cystoisosporiasis is on the increase in tropical and subtropical countries due to lack of health hygiene, access to public health centres, and knowledge of the disease within the regions. However, study has not been made over the years on this disease to cover a wide range of regions in Nigeria, less Niger state despite its morbidity and mortality rate, for sustainable control of this disease, there is need for further study and understanding of the epidemiology of the parasite because of paucity of information on the epidemiology of this parasite disease in Niger State. This research will be useful as a reference point for those who may wish to venture into different aspect of the study while discovering the risk factors for transmission of parasitemia in Minna will help the people in devising ways of curbing the spread of the infection.
1.3 Aims of the study.This study is aimed at determining Cystoisosporiasis and associated risk factors in HIV-infected patients with malaria in Minna, Niger state.
1.4 Objectives of the studySpecific objectives of the study are to determine: i. the prevalence of Cystoisosporiasis in HIV-infected patients with malaria in Minna, Niger state.ii. Cystoisospora belliinfection in relation to sex and age.iii. the effect of CD4 cell count on Cystoisospora belli infection in Minna, Niger state.iv. the risk factors associated with Cystoisospora Belli infection in Minna, Niger state.
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