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Isospora belli enteric infection in patients with human T-cell leukemia virus type I-associated adult T-cell leukemia
1sospora beKEnteric Infection in Patients with Human T-Cell Leukemia Virus Type I-Associated Adult T-Cell Leukemia STEVENJ.GREENBERG,M.D., Bethesda,
MICHAELP. DAVEY,M.D.,P~.D., WILLADENES.ZIERDT,M.T.,THOMASA.
WALDMANN,M.D.
Maryland
R
etroviruses of animal and human origin may be immunosuppressive as well as oncogenic in their hosts [1,2]. Human T-cell leukemia virus type I (HTLV-I), a member of the family of human T-lymphotrophic retroviruses, is associated with an aggressive T-cell malignancy, adult T-cell leukemia (ATL) [3,4] and is linked to a neurologic progressive spastic paralytic condition [5,6]. HTLV-I, II, and human immunodeficiency virus (HIV), the causative agent of the acquired immunodeficiency syndrome (AIDS), exert cytopathic and suppressive effects on lymphocytes with consequent development of immune dysfunction in the host. Such immunosuppression leads to opportunistic infection frequently [7,8] and is commonly manifest by enteric parasitic infestation. The protozoan Cryptosporidium species is associated with a chronic, wasting diarrhea in a significant number of patients with AIDS [9,10]. Isospora beHi, a coccidian parasite, is a recently recognized opportunistic pathogen [11,12] implicated in an enteritis in as many as 20 percent of Haitian patients with AIDS [13]. In contrast, opportunistic parasitic infection with I. belli has not been reported among the HTLV-I retroviral-associated ATL patient population. Recently, .we evaluated two patients among our ATL population presenting with debilitating, profuse, watery diarrhea. The patients were immunocompromised, and one was deficient solely by virtue of his HTLV-I associated ATL. I. belli was the causative agent isolated in both instances and a search for other enteropathic organisms was negative. No other predisposing factors could be identified, including AIDS. In both cases, effective treatment of the I. belli enteritis led to a remission of gastrointestinal symptoms. I. belli is a previously unrecognized opportunistic pathogen that must be considered in the clinical setting of chronic diarrhea in patients with ATL.
CASE REPORTS Patients with ATL were admitted to the Metabolism Branch Clinical Ward, Clinical Center, National Institute for Health, for evaluation as candidates for immunotherapy. Infection wi.th human T-cell leukemia.virus was affirmed by the presence of circulating antibodies specific for HTLV-I antigens demonstrated via an enzyme-linked immunoassay assay that employs a preparation of disrupted viral particles, and From the Metabolism Branch, Division of Cancer Biology and Diagnosis, National Cancer Institute. and Microbiology Service, Clinical Pathology Department, Clinical Center, National Institutes of Health, Bethesda, Maryland. Requests for reprints should be addressed to Dr. Steven J. Greenberg, Metabolism Branch, Division of Cancer Biology and Diagnosis, National Cancer Institute, Building 10, Room 4N109, Bethesda, Maryland 20892. Manuscript submitted January 22, 1988, and accepted in revised form July 8, 1988.
by demonstration of HTLV-I proviral DNA integrated into host genome on Southern hybridization. Diagnosis of ATL was confirmed by: (1) a lymphocytosis accompanied by circulating abnormal mature lymphocytes, frequently characterized by multilobulated nuclei, dense clumped nuclear chromatin, and inconspicuous nucleoli; (2) a CD2+ CD3+ CD4+ CD8- T-cell phenotype and interleukin-2 receptor expression (CD25+); (3) elevated soluble interleukin-2 receptor serum levels [14]; and (4) T-cell clonal expansion on the basis of beta-chain gene rearrangement by Southern hybridization. Associated findings of hypercalcemia, elevated serum liver enzyme levels, and the presence of polyadenopathy, hepatosplenomegaly, and infiltrating skin lesions, although frequently associated with ATL, was not required for diagnosis. Fresh stool specimens were obtained from two ATL patients because of the complicating feature of diarrhea and processed within two hours. A direct salinestool preparation in a 1:l mixture and a concentrate prepared from 0.5 g of stool were scanned under low (100X) and high (400X) power light microscopy. Isospora oocysts were identified by their characteristic size, shape, and presence of sporoblasts. All stool specimens were also examined for other ova and parasites, including Cryptosporidium species, and serology for Entamoeba histolytica was performed. Specimens from each patient were cultured for Shigella, Salmonella, and Campylobacter. Specimens were also concentrated and stained according to the method of Zierdt [15]. Briefly, the concentrated and filtered specimen was centrifuged at 300 g for five minutes, the supernatant was discarded, and the pellet was resuspended in Sheather’s sugar solution and examined by light microscopy as described earlier. I. belli was identified as pink-staining oocysts. The remaining sediment was fixed with methanol on,a glass slide and stained with Kinyoun carbolfuchsin. Slides were then decolorized with 1 percent sulfuric acid and counterstained with light green stain. Staining confirmed the presence of coccidia in all positive wet mounts and corroborated the clearance of coccidia from the stool upon treatment.
Patient1 A 40-year-old black Haitian man lived in the United States for seven years, enjoying excellent health until the development of recurrent bouts of watery diarrhea associated with occasional nausea and vomiting, decreased appetite, and a progressive lo-kg weight loss. He was hospitalized for severe dehydration and subsequently found to have a lymphocytosis. There were no complaints of skin rash, swollen lymph nodes, or skeletal pain, and the patient denied parenteral drug abuse, transfusion, homosexuality, or sexual promiscuity. September
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hours of initial treatment and appetite returned. Serial stool specimens were negative for oocysts after three days of treatment. Subsequent to this therapeutic response, Trichuris trichiura was identified and was effectively treated with a three-day course of mebendazole 100 mg twice daily. The patient gained weight and remained asymptomatic until 10 days following completion of his trimethoprim/sulfamethoxazole regimen when diarrhea, nausea, bloating, and loss of appetite recurred. I. belli oocysts were again present and were the sole pathogenic organisms recovered from stool. Trimethoprim 160 mg and sulfamethoxazole 800 mg were reinstituted four times daily for 10 days, and then once daily and continued indefinitely. The clinical response was equally dramatic with rapid clearance of oocysts from the stool. At a six-month followup, with once daily trimethoprim/sulfamethoxazole, there has been no recurrence of diarrhea, and stool specimens are negative for oocysts.
Mucous membranes were dry with poor skin turgor, but examination failed to reveal evidence of orthostatic hypotension, hepatosplenomegaly, lymphadenopathy, or palpable skeletal tenderness. The white blood cell count was 22,200/mm3 with 10 percent granulocytes, 6 percent monocytes, 6 percent lymphocytes, 18 percent eosinophils, and 60 percent abnormal lymphocytes. Serum calcium levels were normal, and findings on abdominal computed tomography and ultrasound were unremarkable. Serum lactate dehydrogenase, transaminases, and alkaline phosphatase levels were elevated; however, the patient also had positive results for cytomegaloviral infection (high serum antibody titers and virus isolated from urine) and acute hepatitis B virus infection (serum hepatitis B surface antigen positive). On two separate occasions, the patient had sero-negative results for HIV. In addition, HIV gene sequences could not be identified in host DNA by signal amplification using the technique of polymerase chain reaction. The patient was anergic on skin testing against tetanus and diphtheria toxoids and Streptococcus group C, tuberculin, Candida, Trichophyton, and Proteus antigens. Thirty-four percent of the peripheral blood lymphocyte population was CD4+ and 4 percent was CD8+. Serum protein electrophoresis, immunoglobulin levels, and complement were normal. Examination of fresh stool specimens revealed 1. belli oocysts (Figure 1). An extensive search for other enteropathic organisms was negative. Initial treatment for I. belli consisted of oral trimethoprim 160 mg and sulfamethoxazole 800 mg given four times daily for one week, and then once daily for one month. Diarrhea and nausea ceased within 48
Patient 2 A 47-year-old black female from Trinidad resided in the United States for 10 years. One month prior to admission, she began having episodes of watery diarrhea. One year previously, the patient had undergone right mastectomy for adenocarcinoma, and she had completed 12 cycles of cyclophosphamide, methotrexate, and 5-fluorouracil alternating with doxorubicin, vinblastine, and thiotepa. Five months prior to admission, she presented with dyspnea. Chest radiography revealed bilateral infiltrates. The white blood cell count was 68,000/mm3 with 84 percent abnormal lymphocytes. Phenotypic analysis of the peripheral mononuclear cells revealed a mature T-cell leukemia. The serum was positive for antibodies to HTLV-I. In contradistinction, the serum was HIV antibody negative. She underwent induction chemotherapy with daunorubicin, cytarabine, thioguanine, vincristine, and prednisone, followed by methotrexate with leucovorin. Candida albicans and herpes simplex virus pharyngitis developed for which she received ketoconazole and acyclovir. Four months later, the patient was treated with cytarabine and L-asparaginase for a recurring elevated white blood cell count. On admission, the patient was noted to have diffuse vesicular skin eruptions over the trunk and limbs. A splenic tip was palpable, but a generalized lymphadenopathy was not present. The white blood cell count was 54,000/mm3 with 25 percent granulocytes, 18 percent monocytes, 10 percent normal lymphocytes, 0 percent eosinophils, and 47 percent abnormal lymphocytes. Liver enzymes were markedly elevated; however, the serum calcium level was normal. Delayedtype hypersensitivity by skin testing against a battery of seven antigens, as in Patient 1, was totally unreactive. The results of serum protein electrophoresis were normal; however, serum levels of IgG, IgA, and IgM were minimally depressed. Smear preparations and cultures of the skin lesions disclosed a varicella zoster infection that was treated with intravenous acyclovir. In addition, the hospital course was complicated by recurrent bouts of watery diarrhea, occurring several times per shift, occasionally associated with fecal incontinence. Nausea and vomiting developed, and the patient tolerated fluids poorly. The stool contained large numbers of I. belli oocysts. There was no evi-
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Figure 1. High magnification
of 1. be//i oocysts. Mostly immature, large, oval oocysts (25 to 30 pm X 12 to 16 pm) containing a single granular zygote are evacuated in feces in 1. be//i infection (A), although fully mature oocysts containing two sporocysts with four sporozoites each may be present in some cases (B). (Original magnification X400, reduced by 20 percent.)
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dence of a co-infection with other parasitic or pathogenic bacterial organisms. Intravenous trimethoprim 160 mg and sulfamethoxazole 800 mg every six hours resulted in complete resolution of diarrhea over the ensuing 24 hours. Treatment was discontinued after four days due to the development of thrombocytopenia, and diarrhea recurred nine days later. The patient’s leukemia was refractory to all modalities of therapy, the white blood cell count continued to rise, hypercalcemia developed, and the patient died.
COMMENTS Human infections with I. belli were considered rare and sporadic in the Western Hemisphere [16,17]. However, the explosive increase in the prevalence of HIV infection and AIDS cases within the last decade has been associated with a parallel rise in the number of patients with parasitic infections, including I. belli [ll-131. As exemplified by both patients cited herein, the clinical presentation consists of recurrent bouts of profuse watery diarrhea associated with weakness, anorexia, weight loss, and malaise. Volume depletion may be significant, resulting in dehydration and orthostatic hypotension. Abdominal pain when present is usually not severe. Blood is conspicuously absent from the stool. Occasionally, as in the first case, a prominent eosinophilia may herald the clini,cal presentation of a parasitic infecti.on [1.1,16]. In the chronic state, the parasitic enteritis may lead to malabsorption, and steatorrhea and hepatic complications have been reported [18]. Therapeutic regimens for 1. belIi.enteritis have varied. Trials with quinacrine hydrochloride or nitrofurantoin were not effective [16]. Responses to tetracycline, metronidazole, or primaquine phosphate and chloroquine phosphate in combination were variable and transient [16,19]. Administration of pyrimethamine and sulfadiazine in combination has proven effective [E]. More recently, treatment with trimethoprim and sulfamethoxazole bas been associated with prompt clinical improvement and disappearance of intestinal coccidia [11,13,,19]. Recurrent infection, as demonstrated in both patient,cases, occurs frequently and early on after cessation of drug therapy [13]. Relapse in both patients most likely represented recrudescence rather than reinfection. However, if Zsospora proves to be as ubiquitous as Giardia and Cryptosporidium [20], the possibility of reinfection should be borne in mind. Subsequent .recurrent infection would seem to suggest the necessity for long-term medication. Coccidial infection in the immunocompetent host is usually an acute self-limited d.isease. However, severe, chronic diarrhea has been associated with Isospora infection in a number of immunosuppressed settings, including AIDS [ll-131, alpha-chain disease [21], and acute lymphoblastic leukemia either prior to [22] or following [19] chemotherapy. The second case history was confounded by prior treatment with chemotherapy, and the I. belli enteritis, therefore, cannot be attributed solely to ATL. The other patient received no prior therapy and indeed, his presenting medical complaint was related to I. belli enteritis and profuse diarrhea and not to other manifestations of ATL. Cellular and humoral immune responses are markedly impaired in patients with ATL. Abnormalities
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reported include disordered helper and suppressor Tcell function, mitogen responsiveness, killer cell induction and B-cell immunoglobulin synthesis [23-251, and the presence of immunosuppressive factors [26] that suggest a fundamental disruption in immune regulation with multifactorial consequences. Indeed, humoral factors in ATL sera and ATL culture supernatants suppress production of interleukin-2 [27]. The HTLV-I virus encodes a 42-Kd protein termed tat that is a trans-activator of virus genes. In addition, the tat protein activates the expression of host genes in the infected T cells associated with T-cell proliferation, including the genes encoding the interleukin-2 receptor and interleukin-2 [28]. Further, HTLV-I may induce the leukemic cells to function as immune suppressors. HTLV-I-infected ATL cells and supernatants of ATL lines suppress the lectin-induced immunoglobulin synthesis of co-cultured mononuclear cells [27,29]. Such altered regulation of genes controlling the immune response may ultimately manifest in the clinical scenario of susceptibility to opportunistic infection in which I. belli enteritis may figure prominently.
REFERENCES 1. Wong-Staal F, Gallo RC: Human T lymphotropic retroviruses. Nature 1985; 317: 395-403. 2. Dent PB: lmmunodepression by oncogenic viruses. Prog Med Virol1972; 14: l35. 3. Poiesz BJ, Ruscetti FW. Gazdar AF, Bunn PA, Minna JD, Gallo RC: Detection and isolation of type C retrovirus particles from fresh and cultured lymphocytes of a patient with cutaneous T cell Ivmphoma. Proc Nat1 Acad Sci USA 1980; 77: 7415j419. 4. Uchiyama T, Yodoi J. Sagawa K, Takatsuki K, Uchino H: Adult T cell leukemia: clinical and hematological features of 16 cases. Blood 1977; 50: 481-491. 5. Osame M, Matsumoto M, Usuku K, eta/:Chronic progressive myelopathyassociated’with elevated antibodies to human T-lymphotropic virus type I and adult Tcell leukemic cells. Ann Neural 1987; 21: 117-122. 6. Roman GC, Schoenberg BS, Madden DL, eta/:Human T-lymphotropic virus type I antibodies in serum of patients with tropical spastic paraparesis in the Seychelles. Arch Neural 1987; 44: 605-607. 7. Yamaguchi K, Matules E, Catovsky D. Galton DAG: Strongyloides stercoralis as candidate co-factor for HTLV-l-induced leukemonenesis. Lancet 1987: II: 94-95. 8. Gallo RC: HTLV: the family of human T-lymphoiropic retroviruses and their role in leukemia and AIDS. Med Oncol Tumor Pharmacother 1986; 3: 265-267. 9. Current WL, Reese NC, Ernst JV, Bailey WS, Heyman MD, Weinstein WM: Human crvotosooridiosis in immunocomoetent and immunodeficient oersons: studies of an&break and experimental transmission. N Engl J Med 1983; 308: 1252-1257. 10. Soave R, Danner RL, Honig CL, et al: Cryptosporidiosis in homosexual men. Ann Intern Med 1984; 100: 504-511. 11. Whiteside ME, Barkin JS, May RG. Weiss SD, Fischl MA, MacLeod CL: Enteric coccidiosis among patients with the acquired immunodeficiency syndrome. Am J Trop Med Hyg 1984; 33: 1065-1072. 12. Pitchenik AE, Fischl MA, Dikinson GM, et a/:Opportunistic infections and Kaposi’s sarcoma among Haitians: evidence of a new acquired immunodeficiency state. Ann Intern Med 1983; 98: 277-284. 13. DeHovitz JA, Pape JW, Boncy M, Johnson WD Jr: Clinical manifestations and therapy of lsospora b&infection in patients with the acqurred immunodeficiency syndrome. N Engl J Med 1986; 315: 87-90. 14. Rubin LA, Kurman CC, Fritz ME, Yarchoan R, Nelson DL: Identification and characterization of a released form of the interleukin-2 receptor. In: Oppenheim JJ, Jacobs DM, eds. Progress in leukocyte biology, voi 5. New York: Alan R. Liss, 1986; 95-102. 15. Zierdt W: Concentration and identification of Cryptosporidium sp. by use of a parasite concentrator. J Clin Microbial 1984; 20: 860-861. 16. Trier JS, Moxey PC, Shimmel EM, Robles E: Chronic intestinal coccidiosis in man: intestinal morphology and response to treatment. Gastroenterology 1974; 66: 923-935. 17. Faust EC, Giraldo LE. Caicedo G, Bonfante R: Human isosporosis in the Western Hemisphere. Am J Trop Med Hygiene 1961; 10: 343-349. 18. Brandborg LL, Goldberg SB. Bridenbach WF: Human coccidiosis-a possible cause of malabsorption. N Engl J Med 1970: 283: 1306-1313. 19. Westermann EL, Christensen RP: Chronic lsospora belliinfection treated with co-trimoxazole. Ann Intern Med 1979: 91: 413-414. 20. Issac-Renton JL, Fogel D. Stibbs HH, Ongerth JE: Giardiaand Cryptospordium
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in drinking water. Lancet 1987; I: 973-974. 21. Henry K, Bird RG, Doe WF: Intestinal coccidiosis in a patient with alpha-chain disease. Br Med J 1974; 1: 542-543. 22. Hallak A, Yost I, Ratan Y, Adar U: Malabsorption syndrome, coccidiosis, combined immune deficiency, and fulminant lymphoproliferative disease. Arch Intern Med 1982; 142: 196-197. 23. Morimoto C, Matsuyama T, Oshige C, et al: FunctIonal and phenotypic studies of Japanese adult T-cell leukemia cells. J Clin Invest 1985; 75: 836-843. 24.Shaw GM, Broder S, Essex M, Gallo RC: Human T-cell leukemia virus: its discovery and role in leukemogenesis and immunosuppression. Adv Intern Med 1984; 30: l-27. 25. Uchiyama T, Sagawa K. Takatsuki K, Uchino H: Effect of adult T-cell leukemia cells on pokeweed mitogen-induced normal B-cell differentiation. Clin lmmunol
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lmmunopathol 1978; 10: 23-34. 26. Tagawa S, Sawada M, Tokumine Y, et al: Serum immunosuppressive acidic protein in adult T-cell leukemia (ATL). Stand J Haematol 1985; 34: 360-369. 27. Shirakawa F, Tanaka Y, Oda S, et al: Immunosuppressive factors from adult Tcell leukemia cells. Cancer Res 1986; 46: 4458-4462. 28. Maruyama M, Shibuya H, Harada H, et al: Evidence for aberrant activation of the interleukin-2 autocrine loop by HTLV-l- encoded p40X and T3/Ti complex triggering. Cell 1987; 48: 343-350. 29. Waldmann TA, Greene WC, Sarin PS. eta/: Functional and phenotypic comparison of human T cell leukemia/lymphoma virus positive adult T cell leukemia with human T cell leukemia/lymphoma virus negative Sezary leukemia, and their distinction using anti-Tat: monoclonal antibody identifying the human receptor for T cell growth factor. J Clin Invest 1984; 73: 1711-1718.
85
MICHAELP. DAVEY,M.D.,P~.D., WILLADENES.ZIERDT,M.T.,THOMASA.
WALDMANN,M.D.
Maryland
R
etroviruses of animal and human origin may be immunosuppressive as well as oncogenic in their hosts [1,2]. Human T-cell leukemia virus type I (HTLV-I), a member of the family of human T-lymphotrophic retroviruses, is associated with an aggressive T-cell malignancy, adult T-cell leukemia (ATL) [3,4] and is linked to a neurologic progressive spastic paralytic condition [5,6]. HTLV-I, II, and human immunodeficiency virus (HIV), the causative agent of the acquired immunodeficiency syndrome (AIDS), exert cytopathic and suppressive effects on lymphocytes with consequent development of immune dysfunction in the host. Such immunosuppression leads to opportunistic infection frequently [7,8] and is commonly manifest by enteric parasitic infestation. The protozoan Cryptosporidium species is associated with a chronic, wasting diarrhea in a significant number of patients with AIDS [9,10]. Isospora beHi, a coccidian parasite, is a recently recognized opportunistic pathogen [11,12] implicated in an enteritis in as many as 20 percent of Haitian patients with AIDS [13]. In contrast, opportunistic parasitic infection with I. belli has not been reported among the HTLV-I retroviral-associated ATL patient population. Recently, .we evaluated two patients among our ATL population presenting with debilitating, profuse, watery diarrhea. The patients were immunocompromised, and one was deficient solely by virtue of his HTLV-I associated ATL. I. belli was the causative agent isolated in both instances and a search for other enteropathic organisms was negative. No other predisposing factors could be identified, including AIDS. In both cases, effective treatment of the I. belli enteritis led to a remission of gastrointestinal symptoms. I. belli is a previously unrecognized opportunistic pathogen that must be considered in the clinical setting of chronic diarrhea in patients with ATL.
CASE REPORTS Patients with ATL were admitted to the Metabolism Branch Clinical Ward, Clinical Center, National Institute for Health, for evaluation as candidates for immunotherapy. Infection wi.th human T-cell leukemia.virus was affirmed by the presence of circulating antibodies specific for HTLV-I antigens demonstrated via an enzyme-linked immunoassay assay that employs a preparation of disrupted viral particles, and From the Metabolism Branch, Division of Cancer Biology and Diagnosis, National Cancer Institute. and Microbiology Service, Clinical Pathology Department, Clinical Center, National Institutes of Health, Bethesda, Maryland. Requests for reprints should be addressed to Dr. Steven J. Greenberg, Metabolism Branch, Division of Cancer Biology and Diagnosis, National Cancer Institute, Building 10, Room 4N109, Bethesda, Maryland 20892. Manuscript submitted January 22, 1988, and accepted in revised form July 8, 1988.
by demonstration of HTLV-I proviral DNA integrated into host genome on Southern hybridization. Diagnosis of ATL was confirmed by: (1) a lymphocytosis accompanied by circulating abnormal mature lymphocytes, frequently characterized by multilobulated nuclei, dense clumped nuclear chromatin, and inconspicuous nucleoli; (2) a CD2+ CD3+ CD4+ CD8- T-cell phenotype and interleukin-2 receptor expression (CD25+); (3) elevated soluble interleukin-2 receptor serum levels [14]; and (4) T-cell clonal expansion on the basis of beta-chain gene rearrangement by Southern hybridization. Associated findings of hypercalcemia, elevated serum liver enzyme levels, and the presence of polyadenopathy, hepatosplenomegaly, and infiltrating skin lesions, although frequently associated with ATL, was not required for diagnosis. Fresh stool specimens were obtained from two ATL patients because of the complicating feature of diarrhea and processed within two hours. A direct salinestool preparation in a 1:l mixture and a concentrate prepared from 0.5 g of stool were scanned under low (100X) and high (400X) power light microscopy. Isospora oocysts were identified by their characteristic size, shape, and presence of sporoblasts. All stool specimens were also examined for other ova and parasites, including Cryptosporidium species, and serology for Entamoeba histolytica was performed. Specimens from each patient were cultured for Shigella, Salmonella, and Campylobacter. Specimens were also concentrated and stained according to the method of Zierdt [15]. Briefly, the concentrated and filtered specimen was centrifuged at 300 g for five minutes, the supernatant was discarded, and the pellet was resuspended in Sheather’s sugar solution and examined by light microscopy as described earlier. I. belli was identified as pink-staining oocysts. The remaining sediment was fixed with methanol on,a glass slide and stained with Kinyoun carbolfuchsin. Slides were then decolorized with 1 percent sulfuric acid and counterstained with light green stain. Staining confirmed the presence of coccidia in all positive wet mounts and corroborated the clearance of coccidia from the stool upon treatment.
Patient1 A 40-year-old black Haitian man lived in the United States for seven years, enjoying excellent health until the development of recurrent bouts of watery diarrhea associated with occasional nausea and vomiting, decreased appetite, and a progressive lo-kg weight loss. He was hospitalized for severe dehydration and subsequently found to have a lymphocytosis. There were no complaints of skin rash, swollen lymph nodes, or skeletal pain, and the patient denied parenteral drug abuse, transfusion, homosexuality, or sexual promiscuity. September
1988
The American
Journal
of Medicine
Volume
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1. BELL/INFECTION
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ET AL
hours of initial treatment and appetite returned. Serial stool specimens were negative for oocysts after three days of treatment. Subsequent to this therapeutic response, Trichuris trichiura was identified and was effectively treated with a three-day course of mebendazole 100 mg twice daily. The patient gained weight and remained asymptomatic until 10 days following completion of his trimethoprim/sulfamethoxazole regimen when diarrhea, nausea, bloating, and loss of appetite recurred. I. belli oocysts were again present and were the sole pathogenic organisms recovered from stool. Trimethoprim 160 mg and sulfamethoxazole 800 mg were reinstituted four times daily for 10 days, and then once daily and continued indefinitely. The clinical response was equally dramatic with rapid clearance of oocysts from the stool. At a six-month followup, with once daily trimethoprim/sulfamethoxazole, there has been no recurrence of diarrhea, and stool specimens are negative for oocysts.
Mucous membranes were dry with poor skin turgor, but examination failed to reveal evidence of orthostatic hypotension, hepatosplenomegaly, lymphadenopathy, or palpable skeletal tenderness. The white blood cell count was 22,200/mm3 with 10 percent granulocytes, 6 percent monocytes, 6 percent lymphocytes, 18 percent eosinophils, and 60 percent abnormal lymphocytes. Serum calcium levels were normal, and findings on abdominal computed tomography and ultrasound were unremarkable. Serum lactate dehydrogenase, transaminases, and alkaline phosphatase levels were elevated; however, the patient also had positive results for cytomegaloviral infection (high serum antibody titers and virus isolated from urine) and acute hepatitis B virus infection (serum hepatitis B surface antigen positive). On two separate occasions, the patient had sero-negative results for HIV. In addition, HIV gene sequences could not be identified in host DNA by signal amplification using the technique of polymerase chain reaction. The patient was anergic on skin testing against tetanus and diphtheria toxoids and Streptococcus group C, tuberculin, Candida, Trichophyton, and Proteus antigens. Thirty-four percent of the peripheral blood lymphocyte population was CD4+ and 4 percent was CD8+. Serum protein electrophoresis, immunoglobulin levels, and complement were normal. Examination of fresh stool specimens revealed 1. belli oocysts (Figure 1). An extensive search for other enteropathic organisms was negative. Initial treatment for I. belli consisted of oral trimethoprim 160 mg and sulfamethoxazole 800 mg given four times daily for one week, and then once daily for one month. Diarrhea and nausea ceased within 48
Patient 2 A 47-year-old black female from Trinidad resided in the United States for 10 years. One month prior to admission, she began having episodes of watery diarrhea. One year previously, the patient had undergone right mastectomy for adenocarcinoma, and she had completed 12 cycles of cyclophosphamide, methotrexate, and 5-fluorouracil alternating with doxorubicin, vinblastine, and thiotepa. Five months prior to admission, she presented with dyspnea. Chest radiography revealed bilateral infiltrates. The white blood cell count was 68,000/mm3 with 84 percent abnormal lymphocytes. Phenotypic analysis of the peripheral mononuclear cells revealed a mature T-cell leukemia. The serum was positive for antibodies to HTLV-I. In contradistinction, the serum was HIV antibody negative. She underwent induction chemotherapy with daunorubicin, cytarabine, thioguanine, vincristine, and prednisone, followed by methotrexate with leucovorin. Candida albicans and herpes simplex virus pharyngitis developed for which she received ketoconazole and acyclovir. Four months later, the patient was treated with cytarabine and L-asparaginase for a recurring elevated white blood cell count. On admission, the patient was noted to have diffuse vesicular skin eruptions over the trunk and limbs. A splenic tip was palpable, but a generalized lymphadenopathy was not present. The white blood cell count was 54,000/mm3 with 25 percent granulocytes, 18 percent monocytes, 10 percent normal lymphocytes, 0 percent eosinophils, and 47 percent abnormal lymphocytes. Liver enzymes were markedly elevated; however, the serum calcium level was normal. Delayedtype hypersensitivity by skin testing against a battery of seven antigens, as in Patient 1, was totally unreactive. The results of serum protein electrophoresis were normal; however, serum levels of IgG, IgA, and IgM were minimally depressed. Smear preparations and cultures of the skin lesions disclosed a varicella zoster infection that was treated with intravenous acyclovir. In addition, the hospital course was complicated by recurrent bouts of watery diarrhea, occurring several times per shift, occasionally associated with fecal incontinence. Nausea and vomiting developed, and the patient tolerated fluids poorly. The stool contained large numbers of I. belli oocysts. There was no evi-
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Figure 1. High magnification
of 1. be//i oocysts. Mostly immature, large, oval oocysts (25 to 30 pm X 12 to 16 pm) containing a single granular zygote are evacuated in feces in 1. be//i infection (A), although fully mature oocysts containing two sporocysts with four sporozoites each may be present in some cases (B). (Original magnification X400, reduced by 20 percent.)
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1988
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dence of a co-infection with other parasitic or pathogenic bacterial organisms. Intravenous trimethoprim 160 mg and sulfamethoxazole 800 mg every six hours resulted in complete resolution of diarrhea over the ensuing 24 hours. Treatment was discontinued after four days due to the development of thrombocytopenia, and diarrhea recurred nine days later. The patient’s leukemia was refractory to all modalities of therapy, the white blood cell count continued to rise, hypercalcemia developed, and the patient died.
COMMENTS Human infections with I. belli were considered rare and sporadic in the Western Hemisphere [16,17]. However, the explosive increase in the prevalence of HIV infection and AIDS cases within the last decade has been associated with a parallel rise in the number of patients with parasitic infections, including I. belli [ll-131. As exemplified by both patients cited herein, the clinical presentation consists of recurrent bouts of profuse watery diarrhea associated with weakness, anorexia, weight loss, and malaise. Volume depletion may be significant, resulting in dehydration and orthostatic hypotension. Abdominal pain when present is usually not severe. Blood is conspicuously absent from the stool. Occasionally, as in the first case, a prominent eosinophilia may herald the clini,cal presentation of a parasitic infecti.on [1.1,16]. In the chronic state, the parasitic enteritis may lead to malabsorption, and steatorrhea and hepatic complications have been reported [18]. Therapeutic regimens for 1. belIi.enteritis have varied. Trials with quinacrine hydrochloride or nitrofurantoin were not effective [16]. Responses to tetracycline, metronidazole, or primaquine phosphate and chloroquine phosphate in combination were variable and transient [16,19]. Administration of pyrimethamine and sulfadiazine in combination has proven effective [E]. More recently, treatment with trimethoprim and sulfamethoxazole bas been associated with prompt clinical improvement and disappearance of intestinal coccidia [11,13,,19]. Recurrent infection, as demonstrated in both patient,cases, occurs frequently and early on after cessation of drug therapy [13]. Relapse in both patients most likely represented recrudescence rather than reinfection. However, if Zsospora proves to be as ubiquitous as Giardia and Cryptosporidium [20], the possibility of reinfection should be borne in mind. Subsequent .recurrent infection would seem to suggest the necessity for long-term medication. Coccidial infection in the immunocompetent host is usually an acute self-limited d.isease. However, severe, chronic diarrhea has been associated with Isospora infection in a number of immunosuppressed settings, including AIDS [ll-131, alpha-chain disease [21], and acute lymphoblastic leukemia either prior to [22] or following [19] chemotherapy. The second case history was confounded by prior treatment with chemotherapy, and the I. belli enteritis, therefore, cannot be attributed solely to ATL. The other patient received no prior therapy and indeed, his presenting medical complaint was related to I. belli enteritis and profuse diarrhea and not to other manifestations of ATL. Cellular and humoral immune responses are markedly impaired in patients with ATL. Abnormalities
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reported include disordered helper and suppressor Tcell function, mitogen responsiveness, killer cell induction and B-cell immunoglobulin synthesis [23-251, and the presence of immunosuppressive factors [26] that suggest a fundamental disruption in immune regulation with multifactorial consequences. Indeed, humoral factors in ATL sera and ATL culture supernatants suppress production of interleukin-2 [27]. The HTLV-I virus encodes a 42-Kd protein termed tat that is a trans-activator of virus genes. In addition, the tat protein activates the expression of host genes in the infected T cells associated with T-cell proliferation, including the genes encoding the interleukin-2 receptor and interleukin-2 [28]. Further, HTLV-I may induce the leukemic cells to function as immune suppressors. HTLV-I-infected ATL cells and supernatants of ATL lines suppress the lectin-induced immunoglobulin synthesis of co-cultured mononuclear cells [27,29]. Such altered regulation of genes controlling the immune response may ultimately manifest in the clinical scenario of susceptibility to opportunistic infection in which I. belli enteritis may figure prominently.
REFERENCES 1. Wong-Staal F, Gallo RC: Human T lymphotropic retroviruses. Nature 1985; 317: 395-403. 2. Dent PB: lmmunodepression by oncogenic viruses. Prog Med Virol1972; 14: l35. 3. Poiesz BJ, Ruscetti FW. Gazdar AF, Bunn PA, Minna JD, Gallo RC: Detection and isolation of type C retrovirus particles from fresh and cultured lymphocytes of a patient with cutaneous T cell Ivmphoma. Proc Nat1 Acad Sci USA 1980; 77: 7415j419. 4. Uchiyama T, Yodoi J. Sagawa K, Takatsuki K, Uchino H: Adult T cell leukemia: clinical and hematological features of 16 cases. Blood 1977; 50: 481-491. 5. Osame M, Matsumoto M, Usuku K, eta/:Chronic progressive myelopathyassociated’with elevated antibodies to human T-lymphotropic virus type I and adult Tcell leukemic cells. Ann Neural 1987; 21: 117-122. 6. Roman GC, Schoenberg BS, Madden DL, eta/:Human T-lymphotropic virus type I antibodies in serum of patients with tropical spastic paraparesis in the Seychelles. Arch Neural 1987; 44: 605-607. 7. Yamaguchi K, Matules E, Catovsky D. Galton DAG: Strongyloides stercoralis as candidate co-factor for HTLV-l-induced leukemonenesis. Lancet 1987: II: 94-95. 8. Gallo RC: HTLV: the family of human T-lymphoiropic retroviruses and their role in leukemia and AIDS. Med Oncol Tumor Pharmacother 1986; 3: 265-267. 9. Current WL, Reese NC, Ernst JV, Bailey WS, Heyman MD, Weinstein WM: Human crvotosooridiosis in immunocomoetent and immunodeficient oersons: studies of an&break and experimental transmission. N Engl J Med 1983; 308: 1252-1257. 10. Soave R, Danner RL, Honig CL, et al: Cryptosporidiosis in homosexual men. Ann Intern Med 1984; 100: 504-511. 11. Whiteside ME, Barkin JS, May RG. Weiss SD, Fischl MA, MacLeod CL: Enteric coccidiosis among patients with the acquired immunodeficiency syndrome. Am J Trop Med Hyg 1984; 33: 1065-1072. 12. Pitchenik AE, Fischl MA, Dikinson GM, et a/:Opportunistic infections and Kaposi’s sarcoma among Haitians: evidence of a new acquired immunodeficiency state. Ann Intern Med 1983; 98: 277-284. 13. DeHovitz JA, Pape JW, Boncy M, Johnson WD Jr: Clinical manifestations and therapy of lsospora b&infection in patients with the acqurred immunodeficiency syndrome. N Engl J Med 1986; 315: 87-90. 14. Rubin LA, Kurman CC, Fritz ME, Yarchoan R, Nelson DL: Identification and characterization of a released form of the interleukin-2 receptor. In: Oppenheim JJ, Jacobs DM, eds. Progress in leukocyte biology, voi 5. New York: Alan R. Liss, 1986; 95-102. 15. Zierdt W: Concentration and identification of Cryptosporidium sp. by use of a parasite concentrator. J Clin Microbial 1984; 20: 860-861. 16. Trier JS, Moxey PC, Shimmel EM, Robles E: Chronic intestinal coccidiosis in man: intestinal morphology and response to treatment. Gastroenterology 1974; 66: 923-935. 17. Faust EC, Giraldo LE. Caicedo G, Bonfante R: Human isosporosis in the Western Hemisphere. Am J Trop Med Hygiene 1961; 10: 343-349. 18. Brandborg LL, Goldberg SB. Bridenbach WF: Human coccidiosis-a possible cause of malabsorption. N Engl J Med 1970: 283: 1306-1313. 19. Westermann EL, Christensen RP: Chronic lsospora belliinfection treated with co-trimoxazole. Ann Intern Med 1979: 91: 413-414. 20. Issac-Renton JL, Fogel D. Stibbs HH, Ongerth JE: Giardiaand Cryptospordium
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in drinking water. Lancet 1987; I: 973-974. 21. Henry K, Bird RG, Doe WF: Intestinal coccidiosis in a patient with alpha-chain disease. Br Med J 1974; 1: 542-543. 22. Hallak A, Yost I, Ratan Y, Adar U: Malabsorption syndrome, coccidiosis, combined immune deficiency, and fulminant lymphoproliferative disease. Arch Intern Med 1982; 142: 196-197. 23. Morimoto C, Matsuyama T, Oshige C, et al: FunctIonal and phenotypic studies of Japanese adult T-cell leukemia cells. J Clin Invest 1985; 75: 836-843. 24.Shaw GM, Broder S, Essex M, Gallo RC: Human T-cell leukemia virus: its discovery and role in leukemogenesis and immunosuppression. Adv Intern Med 1984; 30: l-27. 25. Uchiyama T, Sagawa K. Takatsuki K, Uchino H: Effect of adult T-cell leukemia cells on pokeweed mitogen-induced normal B-cell differentiation. Clin lmmunol
438
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1988
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Journal
of Medicine
Volume
lmmunopathol 1978; 10: 23-34. 26. Tagawa S, Sawada M, Tokumine Y, et al: Serum immunosuppressive acidic protein in adult T-cell leukemia (ATL). Stand J Haematol 1985; 34: 360-369. 27. Shirakawa F, Tanaka Y, Oda S, et al: Immunosuppressive factors from adult Tcell leukemia cells. Cancer Res 1986; 46: 4458-4462. 28. Maruyama M, Shibuya H, Harada H, et al: Evidence for aberrant activation of the interleukin-2 autocrine loop by HTLV-l- encoded p40X and T3/Ti complex triggering. Cell 1987; 48: 343-350. 29. Waldmann TA, Greene WC, Sarin PS. eta/: Functional and phenotypic comparison of human T cell leukemia/lymphoma virus positive adult T cell leukemia with human T cell leukemia/lymphoma virus negative Sezary leukemia, and their distinction using anti-Tat: monoclonal antibody identifying the human receptor for T cell growth factor. J Clin Invest 1984; 73: 1711-1718.
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