Occurrence of intestinal parasitic infections in HIV-positive patients

 

Vasundhara^1*, Hare Krishna², Umar Farooq³, Mohd Nadeem⁴

 

Abstract               Background: Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) are among the leading causes of infectious disease morbidity and mortality worldwide. Diarrhea is one of the most common AIDS-related illnesses causing a significant morbidity and mortality in HIV infected patients. The opportunistic enteric parasites most commonly implicated in HIV-positive patients are Cryptosporidium parvum, Isospora belli, Cyclospora, Microsporidium spp, Giardia intestinalis, Entamoeba histolytica and Strongyloides stercoralis. Despite the spread of HIV infection in India, and the high prevalence of diarrheal disease, there is little information available on the epidemiology of diarrheal disease among people with HIV infection. Methods: The present study was aimed to determine the prevalence of intestinal parasites in HIV infected patients. The study was conducted in patients attending the ICTC centre in TMMC &RC Hospital, during the period from March 2017 to March 2018. The study group comprised of 50 HIV sero-positive patients and 10 healthy individuals (as negative control), of similar age group. This study group was further divided into 2 categories-Patients with gastrointestinal symptoms and Patients without gastrointestinal symptoms. Stool samples were collected in clean wide mouth container. Macroscopic examination of stool samples was performed for consistency, colour, odour, presence of mucus and/or blood, adult intestinal helminthes and segment of tapeworm. Results: HIV infection was prevalent in the age group 36 -40 years, followed by age group of 31-35 years, with males outnumbering females. Cryptosporidium parvum followed by Isospora belli and Giardia intestinalis were the most common intestinal parasites isolated. Conclusion: Our study highlights the importance of early diagnosis and treatment of intestinal parasites, so as to reduce morbidity and mortality in HIV/AIDS patients due to diarrhea.

Keywords: Cryptosporidium Parvum, Giardia Intestinalis, Isospora Belli, Human Immunodeficiency Virus, Intestinal Parasites, Diarrhea.

 

 

INTRODUCTION

The human immunodeficiency virus (HIV) has changed the social, moral, economic and health fabric of the world in a short space. In the coming years there is likely to be an increase in the number of HIV/AIDS deaths, with worrying projections of 6.5 million deaths in 2030 and HIV/AIDS being the main burden of disease in some developing countries by 2018. It has been recently estimated that 2.5 million individuals are living with HIV infection in India. Opportunistic infections leading to significant morbidity and mortality grossly effect the health and quality of life of person infected with HIV. Since the beginning of the AIDS pandemic, opportunistic infections (OIs) have been recognized as common complications of HIV infection. Diarrhea is one of the most common AIDS-related illnesses causing a significant morbidity and mortality in HIV infected patients.¹ Reports indicate that diarrhea occurs in 30-60% of AIDS patients in developed countries and in about 90% of Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) are among the leading causes of infectious disease morbidity and mortality worldwide. The opportunistic enteric parasites most commonly implicated in HIV-positive patients are Cryptosporidium parvum, Isospora belli, Cyclospora, Microsporidium spp, Giardia intestinalis, Entamoeba histolytica and Strongyloides stercoralis. Despite the spread of HIV infection in India, and the high prevalence of diarrheal disease, there is little information available on the epidemiology of diarrheal disease among people with HIV infection. The present study was aimed to determine the prevalence of intestinal parasites in HIV infected patients. HIV infection was prevalent in the age group 36 -40 years, followed by age group of 31-35 years, with males outnumbering females. Cryptosporidium parvum followed by Isospora belli and Giardia intestinalis were the most common intestinal parasites isolated. Our study highlights the importance of early diagnosis and treatment of intestinal parasites, so as to reduce morbidity and mortality in HIV/AIDS patients due to diarrhea. Reports indicate that diarrhea occurs in 30 -60% of AIDS patients in developed countries and in about 90% of AIDS patients in developing countries.² The etiologic spectrum of enteric pathogens causing diarrhea includes bacteria, parasites, fungi and viruses³, though that of parasitic origin is prominent in patients with AIDS in developing countries.⁴ Of these, protozoan parasitic infections are the most serious ones causing severe morbidity and mortality. In India, the prevalence of enteric parasites varies from 7.5% to 73.3%. The opportunistic enteric parasites are Cryptosporidium, Isospora, Cyclospora, Microsporidia, Giardia, Entamoeba and Strongyloides. The outcome of infection by intestinal parasites is dependent on absolute CD4+ cell counts, with lower counts being associated with more severe disease, more atypical disease, and a greater risk of disseminated disease. However, with the progressive introduction of HAART starting in 1996, modifications have been observed in the morbi-mortality profile among HIV/AIDS patients, reflecting the reduced occurrence of opportunistic infections, including those caused by enteroparasites.⁵ The present study is, therefore, aimed to determine the prevalence of intestinal parasites in HIV-positive patients.

MATERIALS AND METHODS

The study was conducted in patients attending the ICTC centre in TMMC &RC Hospital, during the period from March 2017 to March 2018. The study group comprised of 50 HIV sero-positive patients and 10 healthy individuals (as negative control), of similar age group. This study group was further divided into 2 categories-Patients with gastrointestinal symptoms and Patients without gastrointestinal symptoms. Stool samples were collected in clean wide mouth container. The samples were processed as per WHO standard procedure (WHO, Basic laboratory methods in Medical Parasitology, 1991).⁶ Macroscopic examination of stool samples was performed for consistency, colour, odour, presence of mucus and/or blood, adult intestinal helminthes and segment of tapeworm.⁷Microscopic examination was done with the help of wet mounts (saline wet mount and iodine wet mount) for detection of cysts and trophozoites, and various staining techniques like Modified acid-fast staining, Chromotrope staining, Quick-Hot Gram staining and Modified Safranin (Hot Method) Staining, for demonstration of coccidian parasites.

 RESULTS AND DISCUSSION

Table 1 shows the age and sex distribution of HIV infected individuals into 7 groups. Maximum numbers of patients (34%) were in the age group 36-40 years, followed by age group of 31-35 years. Mean age of study group was 36.44+7.66 years. Males were more than females and comprised 60% of study group, whereas females were 20 in number (40%). Mean age of males was 38.23+7.31 years. Mean age of females was 33.75+7.55 years. In our study, maximum numbers of patients (34%) were in the age group 36-40 years, followed by age group of 31-35 years. Males were more than females and comprised 60% of study group. In a similar study done by Uppal et al. (2009)⁸, New Delhi, in HIV positive patients with diarrhea, the age range of 31-40 years old was the most predominant with overall size (46%), and males outnumbered females in the study group. Another study done by Mehta et al. (2013)⁹, showed majority of the patients (76%) are in 25-44 years age group with a male preponderance (76%).

Table 1: Age and sex distribution of study group

        Figure 1                                                                                                        Figure 2

Figure 1: Distribution of patients according to their clinical presentations.

Figure 2: Pie-chart showing distribution of positive clinical isolates in stool samples of study group.

 

Figure 1 shows distribution of patients according to their clinical presentations. Most of the patients (50%) were not having any complaints at the time of presentation. 30% patients presented with gastrointestinal complaints like pain abdomen, diarrhea and abdominal tuberculosis. 8 (16%) patients were having oral candidiasis, 5 (10%) patients complained of pulmonary problems like cough, bronchitis and TB, while 2 (4%) patients presented with complain of herpes zoster.

Figure 2 shows distribution of patients in relation to positive findings. 13(26%) of the HIV positive patients were found to be infected with intestinal parasites. Cryptosporidium sp. was the most common protozoa detected in the study group (13%). Giardia (5%) and Isospora belli (5%) & strongyloides (3%) were seen in rest of the patients respectively. This observation was comparable with the study done by Kashyap et al. (2010)¹⁰, in which protozoal etiology was seen in 30% patients, and most common pathogen isolated was Cryptosporidium in 42% cases, followed by Giardia in 16% and Isospora belli in 5% patients respectively. A study done by Tuli et al. (2010)¹¹, showed Cryptosporidium spp (36.22%) to be the most common isolated protozoan, followed by Microsporidia spp. (23.11%). In a study done by Uppal et al. (2009)⁸, enteric parasitosis was seen in 20% of HIV positive patients with diarrhea. In HIV-positive patients with diarrhea, out of 10 cases of enteric parasitosis, they isolated helminthes in 3 cases (Ascaris lumbricoids in 2 and Strongyloides stercoralis in 1) and protozoa in 7 cases (Entamoeba histolytica, Giardia lamblia, and Cryptosporidium parvum in 2 each and Isospora belli in 1).

 

 

 

CONCLUSION

Intestinal parasites are important cause of diarrhea in HIV/AIDS patients, and may cause symptomatic or asymptomatic infections. Our study emphasizes the importance of screening of HIV infected patients for presence of intestinal parasites that will help reducing morbidity and mortality in HIV patients.

 

REFERENCES