|Year : 2015 | Volume
| Issue : 2 | Page : 74-78
Intestinal protozoal and helminthic infections in immunocompromised patients attending RIMS Hospital, Imphal
Yompe Kamki, Rebachandra H Singh, Nabakumar Th Singh, Phangreichon Lungram, Brajachand Ng Singh
Department of Microbiology, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||20-Aug-2015|
Department of Microbiology, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
Source of Support: None, Conflict of Interest: None
Background: Intestinal parasites continue to be a significant health problem among immunocompromised patients in both developed and developing countries. With the increasing numbers of immunocompromised individuals throughout the world, closer examination and detection of intestinal protozoal and helminthic infections in these individuals is highly needed. Objectives: To find out the prevalence of various intestinal protozoal and helminthic infections in immunocompromised individuals and to compare the pattern of their infection depending on sociodemographic characteristics. Materials and Methods: One hundred seventy stool samples of immunocompromised patients were examined by direct wet mount, formol-ether concentration, Modified Kinyoun's acid-fast stain, and Kato-Katz technique. Data analysis was performed by using SPSS version 17 software. Results: Thirty-two intestinal parasites were detected, of which Ascaris lumbricoides was the most frequently detected parasite (5.90%) and the least frequent was Trichuris trichiura (1.18%). Twenty-one parasites were detected in the immunocompromised patients from rural areas. Conclusion: Immunocompromised patients, especially human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients from rural areas, were found to have more intestinal protozoal and helminthic infections compared to urban patients due to low socioeconomic status and poor hygiene conditions.
Keywords: Acquired immunodeficiency syndrome (AIDS), Human immunodeficiency virus (HIV), Immunocompromised, Intestinal parasites, Kato-Katz
|How to cite this article:|
Kamki Y, Singh RH, Singh NT, Lungram P, Singh BN. Intestinal protozoal and helminthic infections in immunocompromised patients attending RIMS Hospital, Imphal. J Med Soc 2015;29:74-8
|How to cite this URL:|
Kamki Y, Singh RH, Singh NT, Lungram P, Singh BN. Intestinal protozoal and helminthic infections in immunocompromised patients attending RIMS Hospital, Imphal. J Med Soc [serial online] 2015 [cited 2020 May 27];29:74-8. Available from: http://www.jmedsoc.org/text.asp?2015/29/2/74/163192
| Introduction|| |
Parasitic diseases are one of the major causes of morbidity and mortality, with more than 3 billion people infected worldwide. Many of these infections occur in the developing world, where improved measures to prevent infection require considerable investments in the public health infrastructure. The segment of the population with significant defects in the immune system continues to grow. This population includes malnourished persons, those with acquired or congenital immunodeficiencies, and patients receiving a wide array of immunosuppressive regimens including corticosteroids and aggressive immunosuppressive agents used in hematopoietic and solid transplant patients as well as agents to combat collagen-vascular diseases. 
The intracellular intestinal protozoa Cryptosporidium parvum, Cyclospora cayetanensis, Isospora belli, and Blastocystis hominis are the major causes of uncontrollable debilitating diarrhea in developing countries.  The infection is self-limiting in immunocompetent hosts who readily clear the parasites, but it may cause persistent diarrhea and severe malabsorption in immunodeficient hosts.  Other kinds of parasites, such as Entamoeba histolytica, Giardia lamblia, Trichuris trichiura, Ascaris lumbricoides, Strongyloides stercoralis, and Ancylostoma duodenale/Necator americanus are also frequently encountered in developing countries. 
As per World Health Organization (WHO) estimates, Ascaris lumbricoides infects over 1 billion people, Trichuris trichiura 795 million, and hookworms 740 million. 
The most important immunodeficiency in humans is AIDS. In addition to the AIDS pandemic there are other cases of immunodeficiencies, such as malignancies, the cytotoxic effects of radiation, prolonged corticosteroid therapy, and the drugs used to prevent organ transplant rejection. Patients whose immune systems are weakened for any of these reasons may more readily become infected with certain parasites. 
In developing countries, gastrointestinal parasite infections are mostly due to poverty characterized by poor hygienic habits, absence of potable and clean water, absence of good fecal disposal systems, and poor nutrition. The pathogens responsible for causing diarrhea differ according to geographical location. Therefore, laboratory diagnostic evaluations are required to determine their prevalence in each population to provide guidelines for therapy and necessary data for the planning and evaluation of these patients' care and management. 
With the increasing numbers of immunocompromised individuals throughout the world, closer examination and detection of intestinal protozoal and helminthic infections in those individuals is highly needed.
Therefore, the present study was carried out at the Regional Institute of Medical Sciences (RIMS), Imphal, Manipur to find out the prevalence of various intestinal protozoal and helminthic infections in immunocompromised individuals and to compare the pattern of their infection depending on sociodemographic characteristics among immunocompromised patients attending various outpatient and inpatient departments of RIMS Hospital, Imphal, Manipur.
| Materials and methods|| |
This cross-sectional study was conducted at the Department of Microbiology, RIMS, Imphal from November 2011 to July 2013. The protocol of the present research work has been approved by the institutional Ethical Committee, RIMS Hospital, Imphal, Manipur. A total of 170 stool samples from immunocompromised patients attending the Medicine Department, Radiotherapy Department, the antiretroviral therapy (ART) center, Diabetic Clinic, and the fluorescence-activated cell sorting (FACS) Count center of RIMS Hospital, Imphal were examined. The patients below 18 months of age and the patients who had taken antiprotozoal and/or antihelminthic treatment in the past 4 weeks were excluded from the study.
A detailed clinical history detailing the age, sex, residence, marital and socioeconomic status, education, and other medications of each patient was recorded in a predesigned pro forma.
Samples were collected in a sterile widemouthed container and processed as soon as possible. If a delay of longer than 2 h was anticipated, stool collection was done with 10% formalin as preservative.
Macroscopic examination  of the fecal sample was done for color, consistency, and presence or absence of blood or exudate. Direct microscopic examination  using normal saline and Lugol's iodine was carried out to detect motile trophozoites, ova, cysts, erythrocytes, cellular debris, or excess fat. Formol-ether concentration technique  was used for concentrating the eggs, trophozoites, oocysts, etc. Modified Kinyoun's acid-fast stain  was used to detect oocysts of coccidian parasites such as Isosopora belli, Cryptosporidium parvum, and Cyclospora cayetanensis, and the Kato-Katz technique  (kits procured from Department of Helminthology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand) was used for the detection of helminthic eggs.
Data analysis was performed by using SPSS version 17 software (Incorporate IBM corporation, New York). Different characteristics of the study of the participants were described using percentage, range, and mean, as appropriate. A P value <0.05 was considered significant.
| Results|| |
In this study, a total of 170 confirmed immunocompromised patients were included, of whom 118 (69.41%) were male and 52 (30.59%) were female. A majority of the patients of both sexes were in the age group of 31-40 years, of whom 43 (36.44%) were male and 13 (25%) were female, although the maximum number of female patients 17 (32.7%) was in the age group of 41-50 years [Table 1]. The youngest patient was 2.5 years old, while the oldest patient was 80 years old. Male preponderance was observed in all the age groups except the 21-30-years group. Among the 170 patients, 124 (72.94%) were Hindus, 8 (4.7%) were Muslims, 29 (27.05%) were Christians, and 9 (5.29%) belonged to other faiths [Figure 1]. Of the total, most of the patients 153 (90%) were married, 87 (51.18%) were from rural areas, and 83 (48.82%) were from urban areas.
|Table 1: Age and gender distribution (n = 170) of immunocompromised patients|
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In our study, the maximum number of immunocompromised patients had HIV/AIDS [142(83.53%)], followed by cancer [12 (7.06%)] and diabetes [10 (5.88%)]. Malnourished patients and patients on long-term steroid therapy included in the study consisted of 6 (3.53%) patients [Figure 2]. The majority of the immunocompromised patients belonged to the lower-class socioeconomic group [76 (44.70%)], followed by lower middle class [33 (19.41%)] and upper lower class [31 (18.23%)] [Figure 3].
|Figure 3 : Distribution of immunocompromised patients according to socioeconomic status|
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The macroscopic examination of the stool samples revealed that in a majority of the cases, the consistency of the stool was formed [in 80 (47.06%)], followed by semiformed [41 (24.12%)], loose [28 (16.47%)], and watery [21 (12.35%)]. In the present study, out of 32 intestinal parasites detected, Ascaris lumbricoides was the most frequently detected parasite [10 (5.90%)], followed by Cryptosporidium parvum [8 (4.70%)]. Cyclospora cayetanensis, Isospora belli, Ancylostoma duodenale, and Giardia lamblia were detected in 3 (1.76%) each, and the least frequently detected was Trichuris trichiura (1.18%) [Table 2]. It was observed that half of the patients having loose stool in the study showed evidence of parasites, and hence the most parasites were detected in loose stool (43.75%) compared to other forms of stool. This association was statistically significant (P = 0.001) [Table 3].
|Table 3: Association between stool consistency and parasite isolation (n = 170)|
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In our study, 11 (34.38%) and 21 (65.62%) parasites were detected in the immunocompromised patients from urban and rural areas, respectively. It was observed that the maximum number of parasites was detected from the HIV/AIDS patients (22), followed by diabetes (4), cancer (3), and other (3) patients [Table 4]. The association of parasite detection and type of disease was found to be statistically significant (P = 0.001) in HIV/AIDS patients. Out of the 32 parasites detected, 15 (46.88%) parasites were detected from the patients of lower socioeconomic status. Eight (25%), 5 (25.62%), and 4 (12.50%) parasites were detected in patients of upper lower-, lower middle-, and upper middle-class status, respectively [Table 5].
|Table 4: Association between parasite detection and type of disease among immunocompromised patients|
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|Table 5: Association between socioeconomic status and parasite detection among immunocompromised patients|
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| Discussion|| |
Immunocompromised patients are increasing and commonly encountered in daily clinical practice. This is likely due to the increased prevalence of HIV infection, improved survival rates of individuals with malignancy, and an increased number of patients receiving immunosuppressive agents for various reasons. Immunocompromised patients are prone to various infections, and among different pathogens causing gastrointestinal infection, intestinal protozoal and helminthic parasites are likely to play a significant role in morbidity and mortality in these patients. Therefore, laboratory diagnostic evaluation is required to determine the prevalence of intestinal parasites to provide guidelines for the therapy and management of these patients.
In our study, we observed a preponderance of male patients (69.41%) in comparison to female ones (30.59%) [Table 1]. This finding is consistent with other published reports of intestinal parasitic infections in immunocompromised patients, where male subject are more often infected than their female counterparts, probably due to high-risk behavior. , The age of the patients ranged 2.6-80 years. However, the majority of the patients belonged to the sexually active age group of 31-40 years. Our finding is consistent with the findings of other studies. ,, The mean age of patients was 39 ± 13.84 years, with male and female mean ages being 39.41 ± 13.63 years and 39.39 ± 14.44 years, respectively.
Of the immunocompromised patients in our study, 87 (51.18%) were from rural areas and 83 (48.82%) from urban areas. Similar findings have been previously reported.  Among 170 patients, most were Hindus (124), followed by Christians (29), Muslims (8), and those of other faiths (9). The reason for the higher number of subjects of Hindu faith in the present study may be because the study was undertaken at RIMS Hospital, located in a Hindu-dominated area.
Earlier, different workers had observed that patients from rural areas had more intestinal protozoal and helminthic infections than those from urban areas. , Likewise, in this study, 11 (34.38%) and 21 (65.62%) parasites were detected in the immunocompromised patients from urban and rural areas, respectively.
In the present study, intestinal parasites were detected in 32 (18.82%) immunocompromised patients, of which intestinal protozoa accounted for 17 (10.00%) and intestinal helminths 15 (8.82%). It was noted that Ascaris lumbricoides was the most frequently detected parasite (5.90%), followed by Cryptosporidium parvum (4.70%), Cyclospora cayetanensis (1.76%), Isospora belli (1.76), Ancylostoma duodenale (1.76%), and Giardia lamblia (1.76%), and the least frequently detected parasite was Trichuris trichiura (1.18%) [Table 2]. Our finding is consistent with the findings of other workers. , The contributing factors for Ascaris lumbricoides being the most frequently detected parasite in our study may be because of the fact that more patients were from rural areas with poor sanitation and the food habit of eating singju, a saladlike preparation of raw green leafy vegetables.
The higher percentage of HIV/AIDS in this study may be due to the high prevalence rate of HIV in Manipur.  We observed that the maximum number of parasites (22) was detected from the HIV/AIDS patients, followed by diabetic (4), cancer (3), and other (3) patients. The association of parasite detection and type of disease was found to be statistically significant (P = 0.001).
We observed that a majority of the immunocompromised patients belonged to the lower-class socioeconomic group (44.70%), followed by lower middle-class (19.41%), upper middle-class (18.23%), upper middle-class (17.06%), and upper-class (0.60%) groups. We noted that out of 32 parasites detected, 15 (46.88%) were detected from the patients of lower socioeconomic status.
In this study, most of the intestinal protozoa and helminths were detected in the loose stool (43.75%), followed by watery (28.12%), semiformed (18.75%), and formed (9.37%), and this association was found to be statistically significant (P = 0.001) in loose stool samples [Table 3]. Our finding is consistent with the findings of other studies. , Parasites are found commonly in loose and watery stool, compared to formed/semiformed stool.  Trophozoites of intestinal protozoa are usually found in liquid or soft stool and occasionally in semiformed stool, whereas cysts are found in formed and semiformed stools. Though coccidian oocysts and microsporidian spores could be detected in any type of fecal specimen, the more liquid the stool specimen, the more coccidian oocysts could be detected.  We detected one each of Ascaris lumbricoides, Ancylostoma duodenale, and Cryptosporidium parvum parasites from the formed stool of patients. Hence, this study shows that immunocompromised patients, especially HIV/AIDS patients, whether or not they are suffering from diarrhea, can still harbor intestinal parasites. Similar findings were also reported by another worker.  The present study provides the information about the prevalence of intestinal protozoal and helminthic infections among immunocompromised patients and their pattern of infection among various sociodemographic groups. In this study, we detected intestinal protozoal and helminthic parasites in the stool of immunocompromised patients. The prevalence of intestinal protozoa was higher than that of intestinal helminths. Ascaris lumbricoides was the most predominant parasite among the detected parasites.
Immunocompromised patients from rural areas were found to have more intestinal protozoal and helminthic infections compared to urban patients, which may be due to poor hygiene habits, absence of potable and clean water, absence of good fecal disposal systems, and poor nutrition.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]