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Important Notice

Original article / research
Year : 2012 | Month : September | Volume : 6 | Issue : 7 | Page : 1207 - 1209 Full Version

The Intestinal Parasitic Infections and the CD4 Counts in HIV Seropositive Individuals in the Dhule District in Maharashra, India


Published: September 1, 2012 | DOI: https://doi.org/10.7860/JCDR/2012/.2491
Madhuri Suryawanshi, Varsha Kalshetti, Khooshaboo Telele, Rahul Wadile, Neha Haswani, Karuna Ahire

Dr. Madhuri M. Suryawanshi Lecturer Department of Microbiology ACPM Medical college, Dhule Maharashtra. E-mail: dr.madhurijk@gmail.com

Correspondence Address :
Financial OR OTHER COMPETING INTERESTS:
None.
Date of Submission: Jun 25, 2012
Date of Peer Review: Jul 25, 2012
Date of Acceptance: Aug 16, 2012
Date of Publishing: ???, 2012

Abstract

Context:
Acquired Immunodeficiency Syndrome (AIDS) is fast becoming a major threat in the Indian subcontinent. Numerous opportunistic infections occur in such infected patients due to the downregulation of the immune system. Gastrointestinal parasitic infections are a universally recognized problem in these patients, reaching a rate of upto 50% in the developed and upto 95% in the developing countries. These infections largely present with diarrhoea, leading to life threatening complications.
Aims:
The present study was undertaken to determine the opportunistic parasitic infections in HIV AIDS patients and their correlation with the TCD4 count.
Settings and Design:
The present study was conducted in the Department of Microbiology, ACPM Medical College, Dhule, Maharashtra, India, a tertiary care hospital, between Dec 2010 to August 2011. The HIV infected patients who presented with diarrhoea were selected.
Materials and Methods:
The stool samples which were collected by taking universal precautions were examined by saline and iodine preparations and by the modified acid fast staining. The CD4 cell counts were estimated by using a FACS count system.
Results:
A total of 100 samples were received. Intestinal parasitic pathogens were detected in 55% of the patients. Among these 55 patients, coccidians were detected in 28 (50.9%) patients, protozoa in 15 (27.27%) patients, helminths in 12 (21.8%) patients, Cryptosporidium parvum in 15 (27.27%) patients, Isospora belli in 13 (23.63%) patients, Entamoeba histolytica in 9 (16.36%) patients, Giardia lamblia in 6 (10.9%) patients, Ascaris lumbricoides in 5 (9%) patients, Ancyclostoma duodenale in 3 (5.45%) patients, Hymenolepsis nana in 2 (3.6%) patients and Strongyloides stercoralis in 2 (3.6%) patients.
Conclusion:
Low CD4 counts were significantly associated with opportunistic infections. The detection of the aetiological pathogens might help the clinicians in deciding the appropriate management strategies, as an early diagnosis and a prompt treatment definitely contribute to an increased life expectancy by delaying the progression of AIDS.

Keywords

HIV, Opportunistic parasites, Diarrhoea, CD4 count

Introduction
Parasitic infections are among the most widespread of all the chronic human infections worldwide. The individuals with HIV/ AIDS are threatened by a great number of diseases which include those which are caused by different kinds of biological agents. The progressive decline and the ultimate collapse of the immune system functions which are characteristic for AIDS, usually result in morbidity and ultimately death, due to the opportunistic bacterial, viral, and parasitic infections. Though India is a country with a low Human Immunodeficiency Virus prevalence, it has the third largest number of people living with HIV/AIDS. As per the HIV estimates of 2008-09, there are an estimated 2.39 million people living with HIV/AIDS in India (1). Most of the morbidity and the mortality which are seen in the AIDS patients, result from opportunistic infections which take advantage of the deficient cell mediated and the humoral defense mechanisms (2). Gastrointestinal infections are very common in such patients and they play a major role in causing chronic diarrhoea, which is accompanied by weight loss (3),(4). Reports have indicated that diarrhoea occurs in 30-60% of the AIDS patients in the developed countries and in about 90% AIDS patients in the developing countries (5). The incidence and the prevalence of the infection which is caused by an enteric parasite depend upon the endemicity of that particular parasite in the community (6). AIDS is rapidly becoming a major threat in the Indian subcontinent. The present study aimed at finding out the intestinal parasitic infections and their simultaneous correlation with the CD4 counts, as an early diagnosis and a prompt treatment help in a better management of these patients.

Material and Methods

This study was carried out in the Department of Microbiology, ACPM Medical College, Dhule, Maharashtra, India, from December 2010 to August 2011, on the 100 HIV infected patients who presented with diarrhoea. Written informed consents were obtained from the subjects, while for minors, the informed consents were taken from their parents. The study patients were interviewed by using a structured questionnaire and information was obtained regarding the present and the past history of the diarrhoea and the antibiotic treatment which was taken. The patients who were already on an antibiotic treatment were excluded from the study. Their HIV status was confirmed by three different types of commercially available Enzyme Linked Immunosorbent Assay (cassette ELISA) kits, as was recommended by the National AIDS Control Organization (NACO).The stool samples of the subjects were collected in a wide mouthed, clean container by taking the universal precautions. The gross examination of the stool was carried out to note the consistency of the stool, as well as the presence of the body segments of any parasites. The stool specimens were examined microscopically for ova, cysts, or parasites by using saline and iodine mounts on grease-free slides. Following this, each fresh stool sample was preserved in 10% formol saline. The faecal samples which were preserved in 10% formol saline were concentrated by the formalether sedimentation method. This was simultaneously done for all the stool samples and they were screened for the presence of parasites. The smears of all the direct and the concentrated specimens were examined by modified acid-fast staining by using 1% H2SO4 for Cryptosporidium parvum and Isospora belli. 3ml of blood in EDTA was collected for assessing the CD4 cell counts and they were measured by using the FACS count system.

Results

Among the 100 patients, 70 were males and 30 were females. The mean ages of the male and female patients were 34.6 ± 7.51 and 33.2 ± 9.95 year respectively. Enteric parasites were detected in 55(55%) stool samples after the formal ether sedimentation. Among these 55 samples, coccidians were detected in 28(50.9%) samples, protozoa in 15(27.27%) samples and helminths in 12(21.8%) samples. Cryptosporidium parvum cysts were present in 15(27.27%) samples, Isospora belli in13 (23.63%) samples, Entamoeba histolytica in 9(16.36%) samples, Giardia lamblia in 6(10.9%) samples, Ascaris lumbricoides in 5(9%) samples, Ancyclostoma duodenale in 3(5.45%) samples, Hymenolepsis nana in 2(3.6%) samples and Strongyloides stercoralis in 2(3.6%) samples.Hence, there was no significant association between the parasite type and the sex of the patient. The study population consisted of 47 patients with CD4 counts which were >500 cells/μl, 18 patients with CD4 counts which were 200-499 cells/μl and 35 patients with CD4 counts which were less than 200 cells/μl. (Table/Fig 2) Effect of CD4 count on the prevalence of intestinal parasites among HIV infected patients. The P value was highly significant between the CD4 count and the parasite type association.

Discussion

The progressive decline in the immunological and the mucosal defensive mechanisms predisposes the HIV positive individuals to gastrointestinal infections. Most of the morbidity and the mortality in such patients is due to opportunistic infections. A wide variety of infections are encountered in the HIV positive patients at different stages, which include bacterial, fungal, viral, protozoal and helminthic infections (7). The present study was focused on finding the various intestinal parasitic infections in HIV seropositive individuals. The absolute CD4 counts were evaluated in these cases because there were reports which emphasized the importance of the CD4 counts in relation to the species of the intestinal parasites, where the patients with higher CD4 counts took less time to respond well to the treatment, as compared to those who had comparatively low CD4 counts, who responded poorly to the treatment (8),(9).In the present study, enteric parasites were detected in 55% of the HIV infected patients with diarrhoea in the study population. Various studies from India and other countries have reported a high prevalence of the intestinal parasites, which was found to range from 30%-60% (10),(11),(12),(13),(14). Among the opportunistic parasites, Cryptosporidium parvum (27.27%) was found to be the predominant pathogen. Several studies from India and other parts of the world also reported the same (15),(16),17],(18). The prevalence of opportunistic parasites in the patients with CD4 counts of 200-499 cells/μl, was found to be 18%. In our study, non-opportunistic parasites were detected in 49.09% patients. The reported prevalence of the non-opportunistic parasites varied from 5-30% in the HIV infected patients (19),(20). Our findings highlighted the importance of screening the HIV seropositive individuals and evaluating their absolute CD4 counts regularly. As the intestinal parasitic infections vary with the geographical areas, the studies must be aimed out in different regions, to evaluate the frequent causes of the intestinal parasitic infections in the HIV seropositive individuals. This highlights the need for an early detection and treatment of such infections among the HIV infected patients, to reduce the morbidity and the mortality.

References

1.
The National AIDS Control Organization Ministry of Health and Family Welfare, Government of India, Annual Report 2010-2011 http:\nacoonline.org.
2.
Smith PD, Lane HC, Gill VJ, Manischewitz JF, Quinnan GV, Fauci AS, et al. Intestinal infections in patients with the acquired immunodeficiency syndrome (AIDS). Ann Intern Med 1988;108:328-33
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Janoff EN, Smith PD. Prospectives on the gastrointestinal infections in AIDS. Gastroenterol Clin North Am 1988; 17:451-63.
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Hammouda NA, Sadaka HA, EI-Gebaly WM, EI-Nassery SM. Opportunistic intestinal protozoa in chronic diarrheic immunosuppressed patients. J Egypt Soc Parasitol 1996; 26 : 143-53.
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Framm SR, Soave R. The agents of diarrhea. Med Clin North Am 1997; 81:427-47.
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Mannheimer SB, Soave R. Protozoal infections in patients with AIDS. Cryptosporidiasis, cyclosporiasis and microsporidiasis. Infect Dis Clin North Am 1994;8:483-98.
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Escoledo AA, Nunez FA. The prevalence of intestinal parasites in Human Acquired Immunodeficie syndrome (AIDS) patients. Acta Tropica 1999;72:125-30.
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Flanigan T, Whalen C, Turner J, Soave R, Toerner J, Havlir D, et al. The Cryptosporidium infection and the CD4 counts. Ann Intern Med 1992;116:840-2.
9.
Guk SM Yong TS, Chai JY. The role of the murine intestinal intra epethelial lymphocytes and the lamina propria lymphocytes against the primary and the challenge infections which are caused by Cryptosporidium parvum. J Parasitol 2003;89:270-5.
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Prasad KN, Nag VL, Dhole TN, Ayyagari A. Identification of the enteric pathogens in HIV-positive patients with diarrhea in northern India. J Health Popul Nutr 2000; 18:23-6.
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Ramakrishnan K, Shenbagarathai R, Uma A, Kavitha K, Rajemdran R, Thirumalai P. The prevalence of intestinal parasite infestations in HIV/ AIDS patients with diarrhea in Madurai, south India. Jpn J Infect Dis 2007; 60:209-10.
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Brink AK, Mahe C, Watera C, Lugada E, Gilks C, Whitworth J, et al. Diarrhea, the CD4 counts and the enteric infections in a communitybased cohort of HIV-infected adults in Uganda. J Infect 2000; 45: 99-106.
13.
Weber R, Ledergerber B, Zbindin R, Altwegg M, Pfyffer GE, Spycher MA, et al. Enteric infections and diarrhea in human immunodeficiency virus- infected persons: a prospective, community-based cohort study. Swiss HIV cohort study. Arch Intern Med 1999; 159:1473-80.
14.
Gomez Morales MA, Atzori C, Ludovisi A, Rossi P, Seaglia M, Pozio E. Opportunistic and non-opportunistic parasites in HIV positive and negative patients with diarrhea in Tanzania. Trop Med Parasitol 1995: 46:109-14.
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Dwivedi KK, Prasad G, Saini S, Mahajan S, Lal S, Baveja UK. Enteric opportunistic parasites among HIV- infected individuals: the associated risk factors and the immune status. Jpn J Infect Dis 2007;60: 76-81.
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Sadraei J, Rizvi MA, Baveja UK. Diarrhea, the CD4+ cell counts and the opportunistic protozoa in Indian HIV-infected patients. Parasitol Res 2005; 97:270-3.
17.
Attili SV, Gulati AK, Singh VP, Varma DV, Raj M, Sunder S. Diarrhea, the CD4 counts and the enteric parasites in a hospital based cohort of HIV-infected patients around Varanasi, India. BMC Infect Dis 2006; 1:39.
18.
Wiwanitkit V. Intestinal parasitic infections in Thai HIV infected patients with different immunity statuses. BMC Gastroenterol 2001;1:3-5.

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ID: JCDR/2012/4905:2491

Date of Submission: Jun 25, 2012
Date of Peer Review: Jul 25, 2012
Date of Acceptance: Aug 16, 2012
Date of Publishing: Sep 30, 2012

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