Mendonça et al., J Clin Case Rep 2012, 2:8 DOI: 10.4172/2165-7920.1000135 Volume 2 • Issue 8 • 1000135 J Clin Case Rep ISSN: 2165-7920 JCCR, an open access journal Open Access Case Report Local Acquired Cyclosporiasis in an Immunocompromised Portuguese Boy Vanessa Mendonça 1 *, Teresa Carvalho 2 , Angélica Ramos 2 , Margarida Tavares 3 and A Bonito Vitor 4 1 Serviço de Pediatria – Unidade Autónoma de Gestão da Mulher e da Criança do Hospital S. João do Porto, E.P.E, Portugal 2 Laboratório de Microbiologia do Serviço de Patologia Clínica – Unidade Autónoma de Gestão dos Meios Diagnósticos e Terapêutica do Hospital S. João do Porto, E.P.E, Portugal 3 Unidade de Infecciologia Pediátrica do Serviço de Pediatria – Unidade Autónoma de Gestão da Mulher e da Criança do Hospital S. João do Porto, E.P.E, Portugal 4 Unidade de Imunoalergologia Pediátrica do Serviço de Pediatria – Unidade Autónoma de Gestão da Mulher e da Criança do Hospital S. João do Porto, E.P.E, Portugal Abstract Cyclospora cayetanensis is an emergent parasite traditionally associated with diarrhoea in travellers to endemic countries. Several cases of cyclosporiasis were also reported in non travellers associated with imported food and water- borne outbreaks. Recently, only sporadic cases were described in Europe, probably because it’s underdiagnosed. Cyclospora is a protozoan very diffcult to identify. It’s not detected in specimen routinely tested for ova and parasite, if not explicitly requested. Other reasons include morphologic similarities of Cyclospora cayetanensis oocysts with those of Cryptosporidium; necessity of profciency in parasitology and probably because its notifcation is not obligatory in all countries. We report one case of acquired cyclosporiasis in Portugal in an immunocompromised boy, that is, to the best of our knowledge, the frst reported in our country. Cyclosporosiasis should be considered in all persons with persistent or remitting-relapsing diarrheal illness, regardless of immunological status and explicitly requesting testing for this parasite. *Corresponding author: Vanessa Mendonça, Rua de Moçambique nº 467 A, HAB 2N, 4100-349 Porto, Portugal, Tel: +351 96 26 530 76; E-mail: mendonca.vanessa@gmail.com Received February 03, 2012; Accepted April 20, 2012; Published April 28, 2012 Citation: Mendonça V, Carvalho T, Ramos A, Tavares M, Vitor AB (2012) Local Acquired Cyclosporiasis in an Immunocompromised Portuguese Boy. J Clin Case Rep 2:135. doi:10.4172/2165-7920.1000135 Copyright: © 2012 Mendonça V, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Keywords: Cyclospora cayetanensis; Cryptosporidium; Protozoan; Oocysts Introduction Coccidian are protozoan obligate intracellular parasites [1,2,3], which include species that complete their life cycles in single hosts like Cyclospora, Eimeria, Isospora and Cryptosporidium and others that need intermediate hosts, like Toxoplasma, Neospora and Frenkelia [2,4]. C. cayetanensis is an important and emerging cause of traveler’s diarrhea and water and food-borne outbreaks associated with facilitated international travel and food importation from endemic areas [2,5]. In Europe, only a few cases have been described, and almost all of them were reported in patients returning from endemic countries [2,6,7]. In 2000, Peter C. Döller et al. [8] documented the frst cyclosporiasis foodborne outbreak in Germany, with 34 persons related ingestion of a mixture of various types of baby lettuce leaves [8]. Luca Masucci et al. [9] reported the frst documented case of acquired cyclosporiasis in Italy. Tere is evidence that Cyclospora is transmitted by fecal-oral route [1,4,5], but person-to-person transmission is unlikely because oocytes require days to weeks, depending on favorable climatic factors, to become infectious (sporulated oocysts) afer leaving an infected host [4,5,10]. Cyclospora is also highly resistant to desiccation, common water and food disinfectants [5]. Indirect transmission is possible with sufciently aged stools or stool contaminated products [4]. Humans appear to be the only host [2,11], but the role of animals as natural reservoirs is of increasing concern [6]. Recently, Cyclospora was identifed in one chicken, two dogs and one monkey by microscopy and polymerase chain reaction [12]. Whether these fndings represent a natural infection or either the shedding of ingested oocysts remains to be proven [2]. Mark Eberhard Nadeem Sajjad Raja and S. Schelenz reported a case of Cyclospora infection in a farm worker with close association with pigs’ dysentery, although animal feces weren’t tested [13]. In endemic areas, risk factors include contaminated water or food, contact with soil and domestic animals and poor sanitation [11]. AIDS epidemics in the 1980s enhanced the use of acid-fast stains to search opportunistic Cryptosporidium infections which in turn allowed observation of Cyclospora oocysts [5]. Tese were initially misdiagnosed as Cryptosporidium or assumed as an artefact and only in 1993 were classifed as coccidian by Ortega and colleagues [14]. Cyclospora infection is diagnosed by examination of stool specimens using microscopy, sporulation studies or molecular diagnostic methods [5]. Diagnosis is challenging and difcult for several reasons: intermittent and low level of oocyst shedding [15]; morphological similarities between Cyclospora and Cryptosporidium oocysts, (Cyclospora oocysts are larger round organisms, with 8 to 10 μm of diameter) which manifestations are clinically indistinguishable; routine parasitology stains do not reliably demonstrate Cyclospora oocysts. Centers for Disease Control and Prevention recommend testing at least 3 samples that should be concentrated prior to microscopic examination to maximize recovery of oocysts [16]. Also, examination of wet mounts can be enhanced by: ultraviolet light fuorescence microscopy (Cyclospora oocyst wall auto-fuoresces, but not those of Cryptosporidium) and two special stains. With modifed acid-fast stain (or Modifed Kinyoun stain) - Cyclospora oocysts stain variably, ranging from no staining to deep purple and have a wrinkled appearance. Safranin stains oocysts uniformly, red to reddish-orange. Tis uniform staining decreases the risk of misdiagnosis that can result from modifed acid-fast stain. Journal of Clinical Case Reports J o u r n a l o f C li n i c a l C a s e R e p o r t s ISSN: 2165-7920