Grand Rounds

A 3 year old girl with chronic diarrhea

Consultant Pediatric Infectious Diseases, Nanavati Hospital, Mumbai

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056

Clinical Problem :
A 3 year old girl born of non-consanguineous marriage presented with watery diarrhea since 1 month. The diarrhea initially was blood stained and then foul smelling, greasy with a frequency of 12-15 times, day. There was a weight loss of 2 kg in last one month. She had history of right-sided otorhoea 1½ year back. There was no history of similar complaints in the past, no contact with tuberculosis and similar history in the family. She was treated for same with oral antibiotics but there was no response. On examination, she was malnourished {Weight = 8 kg, Less than 5th centile, Height = 87 cm { Less than 5th centile}} with no significant examination finding. Her investigations showed:
_? Stool examination – fat globules
_? Urine examination – Normal
_? Mantoux test – Negative
_? HIV ELISA – Normal
_? S. electrolytes, blood gases – Normal
_? Hemoglobin = 8.2 gm, dl
_? WBC count = 21,600, cumm {59 percent neutrophils, 40 percent lymphocytes}
_? ESR = 6 mm at end of 1 hour
_? Stool for cryptosporidia – multiple oocysts seen

She was treated with Nitazoxanide to which she responded.

How should she be investigated further_?

Discussion :
Cryptosporidiosis is usually a protozoal organism that causes disease in an immunocompromised person. It can also occur in immunocompetent children. It can lead to persistent unremitting diarrhea which may be difficult to treat. Whenever cryptosporidium are found in a patient, the patient should be investigated for an underlying immunodeficiency. This child’s HIV ELISA is negative. Cryptosporidium is usually seen with T-cell defects. Hence this child should undergo a CD lymphocyte analysis and serum immunoglobulins. The immunoglobulins were normal in this child. CD lymphocyte subset showed normal T-cell counts.
Cryptosporidium is a parasite that is acquired by drinking contaminated water. Chlorination does not eradicate the organism and thus it is commonly seen in lakes, rivers, recreational pools and swimming pools. Drinking this contaminated water leads to ingestion of the oocyst that will invade the jejunum and release sporozoites that act on the intestinal mucosa leading to watery diarrhea. Cryptosporidium is usually eradicated by boiling and filtering the water.
Treatment is Nitazoxanide. However it may not be very useful in immunocompromised individuals. In such patients, the treatment of choice is immune reconstitution. Other drugs that have been tried are Pararomycin and azithromycin.

E-published: January 2013 Vol 10 Issue 1 Art No. 5

Correct Answers :  yes 54%
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