Microsporidium: Difference between revisions

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==Background==
==Background==
Microsporidia are unicellular spore-forming parasitic protozoa that are found pervasively throughout the environment.<ref>Leder K, Weller PF. Microsporidiosis. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on September 4, 2017.)</ref> Microsporidiosis most commonly affects immunosuppressed individuals and seldom has implications for the immunocompetent patient.  
*Unicellular spore-forming parasitic [[protozoa]] that are found pervasively throughout the environment.<ref>Leder K, Weller PF. Microsporidiosis. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on September 4, 2017.)</ref> Microsporidiosis most commonly affects immunosuppressed individuals and seldom has implications for the immunocompetent patient.  


==Clinical Features==
==Clinical Features==
Clinical manifestations are wide ranging and typically affect immunosuppressed hosts (e.g. HIV/AIDS, long-term steroid use, transplant and chemotherapy patients), travelers, children, and the elderly<ref>Kotler DP, Orenstein JM. Prevalence of intestinal microsporidiosis in HIV-infected individuals referred for gastroenterological evaluation. Am J Gastroenterol 1994; 89:1998.</ref>. The most common manifestation is copious diarrhea with volume depletion leading to electrolyte derangements.<ref>Centers for Disease Control and Prevention. (2016). DPDx - Laboratory Identification of Parasitic Diseases of Public Health Concern - Microsporidiosis. Retrieved from https://www.cdc.gov/dpdx/microsporidiosis/index.html</ref>  
''Clinical manifestations are wide ranging and typically affect immunosuppressed hosts (e.g. HIV/AIDS, long-term steroid use, transplant and chemotherapy patients), travelers, children, and the elderly<ref>Kotler DP, Orenstein JM. Prevalence of intestinal microsporidiosis in HIV-infected individuals referred for gastroenterological evaluation. Am J Gastroenterol 1994; 89:1998.</ref>. The most common manifestation is copious [[diarrhea]] with volume depletion leading to [[electrolyte derangements]].<ref>Centers for Disease Control and Prevention. (2016). DPDx - Laboratory Identification of Parasitic Diseases of Public Health Concern - Microsporidiosis. Retrieved from https://www.cdc.gov/dpdx/microsporidiosis/index.html</ref> ''


Immunosuppressed patients:<ref>Pol S, Romana CA, Richard S, et al. Microsporidia infection in patients with the human immunodeficiency virus and unexplained cholangitis. N Engl J Med 1993; 328:95.</ref>
===Immunosuppressed patients:<ref>Pol S, Romana CA, Richard S, et al. Microsporidia infection in patients with the human immunodeficiency virus and unexplained cholangitis. N Engl J Med 1993; 328:95.</ref>===
* Profuse watery diarrhea with massive fluid loss  
*Profuse watery [[diarrhea]] with massive fluid loss  
* Cholangitis and acalculous cholecystitis
*[[Cholangitis]] and [[acalculous cholecystitis]]
* Disseminated infection
*Disseminated infection
* Myositis
*[[Myositis]]


Immunocompetent patients:<ref>Centers for Disease Control and Prevention. (2016). DPDx - Laboratory Identification of Parasitic Diseases of Public Health Concern - Microsporidiosis. Retrieved from https://www.cdc.gov/dpdx/microsporidiosis/index.html</ref>  
===Immunocompetent patients:<ref>Centers for Disease Control and Prevention. (2016). DPDx - Laboratory Identification of Parasitic Diseases of Public Health Concern - Microsporidiosis. Retrieved from https://www.cdc.gov/dpdx/microsporidiosis/index.html</ref> ===


* Self-limited diarrhea
*Self-limited [[diarrhea]]


==Differential Diagnosis==
==Differential Diagnosis==
* Microsporidiosis
*Microsporidiosis
* Cryptosporidiosis
*[[Cryptosporidiosis]]
* CMV (CD4 < 100)
*[[CMV]] (CD4 < 100)
* MAC (CD4 < 100)
*[[mycobacterium avium|MAC]] (CD4 < 100)
* Adenovirus
*[[Adenovirus]]
* Isospora
*Isospora
* Giardia
*[[Giardia]]
* E. coli
*[[E. coli]]
* C. difficile
*[[C. difficile]]
 
{{Diarrhea DDX}}


==Evaluation==
==Evaluation==
 
===Work-up===
Work-up
*  CBC
*  CBC
*  Metabolic panel
*  Metabolic panel
*  C. difficile toxin EIA
*  [[C. difficile]] toxin EIA
*  Fecal WBC and RBC
*  Fecal WBC and RBC
*  Lactoferrin  
*  Lactoferrin  
*  Wet mount microscopy
*  Wet mount microscopy
*  Stool culture  
*  Stool culture  
Evaluation
*  It is important to differentiate bloody vs non-bloody and acute vs chronic diarrhea. Additionally helpful information includes recent antibiotic use, history of C. difficile, presence of nausea, vomiting, fevers, altered mental status, severe abdominal pain, and whether their diarrhea is distracting them from an additional problem.


==Management<ref>Leder K, Weller PF. Microsporidiosis. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on September 4, 2017.)</ref>==  
==Management<ref>Leder K, Weller PF. Microsporidiosis. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on September 4, 2017.)</ref>==  
 
*Initial treatment consists of the ABCs
* Initial treatment consists of the ABCs
**[[IV fluid resuscitation]] with LR or NS  
** IV fluid resuscitation with LR or NS (bolus 500 mL adults, 20/30 mL/kg in children)
**[[Oral rehydrating solution]] for mild dehydration and tolerating PO intake  
** Oral rehydrating solution for mild dehydration and tolerating PO intake (WHO advocates 250 mL orange juice, 4 tsp sugar, 1 tsp baking powder, 3.75 mL salt in 1 L of boiled water. Goal is 50-100 mL/kg over the first 4 hours)
**Address [[electrolyte derangements]]
** Address electrolyte derangements  
*[[Albendazole]] 400 mg PO bid for 14-28 days in adults (15mg/kg PO bid for 7 days in children)
* Albendazole 400 mg PO bid for 14-28 days in adults (15mg/kg PO bid for 7 days in children)
*[[Ondansetron]] or [[promethazine]] for [[nausea]] (avoid [[metoclopramide]] due to pro-motility effects)
* Ondansetron or promethazine for nausea (avoid metoclopramide due to pro-motility effects)
*[[Loperamide]] for symptom reduction (contraindicated with bloody stool)
* Loperamide for symptom reduction (contraindicated with bloody stool)


==Disposition<ref>Leder K, Weller PF. Microsporidiosis. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on September 4, 2017.)</ref>==  
==Disposition<ref>Leder K, Weller PF. Microsporidiosis. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on September 4, 2017.)</ref>==  
 
*Discharge: immunocompetent or low risk patients with unclear etiology but normal examination findings after rehydration  
* Discharge: immunocompetent or low risk patients with unclear etiology but normal examination findings after rehydration  
*Admission: patients with life-threatening volume loss, failure to improve after resuscitation, electrolyte abnormalities requiring gradual and/or significant correction, toxic or ill-appearing, intolerant of PO intake or significant risk factors (CD4 < 100, chemotherapy, transplant, etc.)
* Admission: patients with life-threatening volume loss, failure to improve after resuscitation, electrolyte abnormalities requiring gradual and/or significant correction, toxic or ill-appearing, intolerant of PO intake or significant risk factors (CD4 < 100, chemotherapy, transplant, etc.)
*Pearl: Obtain contact information for patients PCP and specialist providers (oncology, infectious disease, rheumatology, etc). Consultation and coordination of care is especially important for patients with significant and relevant co-morbidities
* Pearl: Obtain contact information for patients PCP and specialist providers (oncology, infectious disease, rheumatology, etc). Consultation and coordination of care is especially important for patients with significant and relevant co-morbidities
   
   
==External Links==
==External Links==
[https://www.cdc.gov/dpdx/microsporidiosis/index.html] CDC-Microsporidiosis
*[https://www.cdc.gov/dpdx/microsporidiosis/index.html CDC-Microsporidiosis]
 
==References==
==References==
<references/>
<references/>


Erich KDHCD Burton
[[Category:GI]]
[[Category:ID]]

Latest revision as of 23:06, 29 September 2019

Background

  • Unicellular spore-forming parasitic protozoa that are found pervasively throughout the environment.[1] Microsporidiosis most commonly affects immunosuppressed individuals and seldom has implications for the immunocompetent patient.

Clinical Features

Clinical manifestations are wide ranging and typically affect immunosuppressed hosts (e.g. HIV/AIDS, long-term steroid use, transplant and chemotherapy patients), travelers, children, and the elderly[2]. The most common manifestation is copious diarrhea with volume depletion leading to electrolyte derangements.[3]

Immunosuppressed patients:[4]

Immunocompetent patients:[5]

Differential Diagnosis

Acute diarrhea

Infectious

Noninfectious

Watery Diarrhea

Traveler's Diarrhea

Evaluation

Work-up

  • CBC
  • Metabolic panel
  • C. difficile toxin EIA
  • Fecal WBC and RBC
  • Lactoferrin
  • Wet mount microscopy
  • Stool culture

Management[7]

Disposition[8]

  • Discharge: immunocompetent or low risk patients with unclear etiology but normal examination findings after rehydration
  • Admission: patients with life-threatening volume loss, failure to improve after resuscitation, electrolyte abnormalities requiring gradual and/or significant correction, toxic or ill-appearing, intolerant of PO intake or significant risk factors (CD4 < 100, chemotherapy, transplant, etc.)
  • Pearl: Obtain contact information for patients PCP and specialist providers (oncology, infectious disease, rheumatology, etc). Consultation and coordination of care is especially important for patients with significant and relevant co-morbidities

External Links

References

  1. ↑ Leder K, Weller PF. Microsporidiosis. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on September 4, 2017.)
  2. ↑ Kotler DP, Orenstein JM. Prevalence of intestinal microsporidiosis in HIV-infected individuals referred for gastroenterological evaluation. Am J Gastroenterol 1994; 89:1998.
  3. ↑ Centers for Disease Control and Prevention. (2016). DPDx - Laboratory Identification of Parasitic Diseases of Public Health Concern - Microsporidiosis. Retrieved from https://www.cdc.gov/dpdx/microsporidiosis/index.html
  4. ↑ Pol S, Romana CA, Richard S, et al. Microsporidia infection in patients with the human immunodeficiency virus and unexplained cholangitis. N Engl J Med 1993; 328:95.
  5. ↑ Centers for Disease Control and Prevention. (2016). DPDx - Laboratory Identification of Parasitic Diseases of Public Health Concern - Microsporidiosis. Retrieved from https://www.cdc.gov/dpdx/microsporidiosis/index.html
  6. ↑ Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
  7. ↑ Leder K, Weller PF. Microsporidiosis. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on September 4, 2017.)
  8. ↑ Leder K, Weller PF. Microsporidiosis. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on September 4, 2017.)
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