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. | *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. | ||
==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 | ||
* | *Cholangitis and acalculous cholecystitis | ||
* | *Disseminated infection | ||
* | *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 | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
* | *Microsporidiosis | ||
* | *Cryptosporidiosis | ||
* | *CMV (CD4 < 100) | ||
* | *MAC (CD4 < 100) | ||
* | *Adenovirus | ||
* | *Isospora | ||
* | *Giardia | ||
* | *E. coli | ||
* | *C. difficile | ||
==Evaluation== | ==Evaluation== | ||
Work-up | Work-up | ||
* CBC | * CBC | ||
| Line 38: | Line 37: | ||
Evaluation | 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 | |||
* | **IV fluid resuscitation with LR or NS (bolus 500 mL adults, 20/30 mL/kg in children) | ||
** 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 (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) | ||
** 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) | ||
* | *Ondansetron or promethazine for nausea (avoid metoclopramide due to pro-motility effects) | ||
* | *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 | |||
* | *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== | ==External Links== | ||
[https://www.cdc.gov/dpdx/microsporidiosis/index.html | *[https://www.cdc.gov/dpdx/microsporidiosis/index.html CDC-Microsporidiosis] | ||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:GI]] | |||
Revision as of 05:52, 7 September 2017
Background
- Microsporidia are 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]
- Profuse watery diarrhea with massive fluid loss
- Cholangitis and acalculous cholecystitis
- Disseminated infection
- Myositis
Immunocompetent patients:[5]
- Self-limited diarrhea
Differential Diagnosis
- Microsporidiosis
- Cryptosporidiosis
- CMV (CD4 < 100)
- MAC (CD4 < 100)
- Adenovirus
- Isospora
- Giardia
- E. coli
- C. difficile
Evaluation
Work-up
- CBC
- Metabolic panel
- C. difficile toxin EIA
- Fecal WBC and RBC
- Lactoferrin
- Wet mount microscopy
- 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[6]
- Initial treatment consists of the ABCs
- 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 (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
- 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)
- Loperamide for symptom reduction (contraindicated with bloody stool)
Disposition[7]
- 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
- ↑ Leder K, Weller PF. Microsporidiosis. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on September 4, 2017.)
- ↑ Kotler DP, Orenstein JM. Prevalence of intestinal microsporidiosis in HIV-infected individuals referred for gastroenterological evaluation. Am J Gastroenterol 1994; 89:1998.
- ↑ 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
- ↑ 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.
- ↑ 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
- ↑ Leder K, Weller PF. Microsporidiosis. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on September 4, 2017.)
- ↑ Leder K, Weller PF. Microsporidiosis. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on September 4, 2017.)