Journal of Infection (199o) 2I, 139-I41

P r e v a l e n c e o f c r y p t o s p o r i d i o s i s in I srae l i c h i l d r e n w i t h d i a r r h o e a

Michael Dan* and Ruth GutmanT

* The Infectious Diseases Unit and tMicrobiology Laboratory, The Edith Wolfson Hospital, Holon, Israel

Accepted for publication 7 March 199o

Summary In a prospective study, Cryptosporidium oocysts were detected in seven (3.25 %) immunocompetent children with diarrhoea. The predominant clinical features were watery diarrhoea and vomiting. The patients' mean age was 1. 9 years and infection was more common in late summer-autumn than in the rest of the year. This first survey on cryptosporidiosis in Israeli children has shown a prevalence similar to that observed in other developed countries.

Introduction

Initially considered mainly as a cause of severe, prot racted diarrhoea in i m m u n o c o m p r o m i s e d patients, 1 Cryptosporidium is now increasingly recog- nised as a relatively c o m m o n agent in self-l imited enteritis in otherwise healthy personsf1-4 Sporadic and epidemic cryptosporidiosis has been most often recorded in young children and with a prevalence that varies greatly be tween developed and developing countries. 5 T h e purpose of the present com- municat ion is to repor t o n the presence of Cryptosporidium oocysts in the faeces of immunological ly normal Israeli children with diarrhoea. We have also compared the clinical presentat ion of cryptosporidiosis with that of shigellosis.

Patients and methods

T h e survey was conduc ted at the Edi th Wolfson Medical Center which is an urban hospital serving the suburbs of Te l Aviv, Israel.

Dur ing a per iod of I2 months , faecal specimens from 215 children in hospital and some at tending as outpat ients with diarrhoea were examined for the presence of enteropathogenic bacteria and Cryptosporidium oocysts. We also examined faecal samples f rom 131 persons with normal stools. In order to detect Cryptosporidium oocysts, a smear was prepared f rom each specimen, and stained by means of a modif ied K i n y o u n acid-fast stain. 3 For the isolation of enteropathogenic bacteria, rout ine bacteriological methods were used. 6 N o a t tempt was made to detect viral pathogens. T h e symptoms, medical history and epidemiological data of children with cryptosporidiosis were recorded and compared with those of children with shigellosis diagnosed over the same period.

Address correspondence to: Dr M. Dan, The Edith Wolfson Hospital, P.O. Box 5, Holon 58 IO0, Israel.

o163-4453/9o/o5o139 + o3 $o2.oo/o © 199o The British Society for the Study of Infection

I40 M. DAN AND R. GUTMAN

Table I Clinical features of cryptosporidiosis compared with those of shigellosis

Cryptosporidiosis Shigellosis

Mean age in years 1"9 5"6 Duration of diarrhoea in days 5"6 3"6 Blood in faeces o/6 9/lO Mucus in faeces 0/6 8/lO Vomiting 4/6 I3/13 Abdominal pain * 6/13 Fever ( > 37"5 °C) 3/6 12/15 Dehydration 2/6 3/13

* Data unreliable because of the patients' young age.

Results

During the period of the study, Cryptosporidia were detected in faecal specimens from seven (3"25 %) children with diarrhoea. One of them was also infected with Shigella sp. Cryptosporidium was the third most common enteric pathogen after Salmonella spp. (22 %) arid Shigella spp. (I7 %). Campylobacter jejuni was isolated in 2. 7 ~o cases. Oocysts were not observed in the faeces of persons with normal stools. The mean age of children with cryptosporidiosis was r" 9 years (range, 8 months-3"o years). All children were from urban households; none had close contact with animals. Most episodes (5/7) occurred in October-November. None of the patients showed evidence of irnmunodeficiency or had received immunosuppressive therapy before the infection. One patient's sibling had had diarrhoea shortly before the reported case but a faecal sample was not examined. Parents of two patients reported concomitant diarrhoea affecting several children in related day-care centres.

The predominant clinical features were watery diarrhoea (7/7 patients) and vomiting (5/7). The duration of diarrhoea ranged from 2 to 7 days (mean, 5"6 days). Four patients developed fever (oral temperature > 37"5 °C) which reached or exceeded 39'0 °C in two of them. Because the children were so young, reliable information about abdominal pain could not be obtained. Mean duration of stay in hospital was 3 days. All patients recovered completely after non-specific supportive therapy.

In order to better characterise cryptosporidiosis in children, we have compared its various features with those of shigellosis diagnosed in I5 children during the survey, none of whom had received antimicrobial therapy. The comparative data are shown in Table I. (Only cases with cryptosporidiosis or shigellosis alone were included although concomitant viral infection was not excluded.) Patients with cryptosporidiosis were younger and their diarrhoea lasted longer than it did in those with shigellosis. Most patients with shigellosis but none with cryptosporidiosis had mucus and blood in their faeces.

Discuss ion

Epidemiological surveys of cryptosporidiosis have indicated that Crypto- sporidium is a common cause of diarrhoea worldwide, being more prevalent in

Cryptosporidiosis in Israeli children z4z

developing countries. In most industr ial ised societies, prevalence ranges f rom 0"5-4"o % while, in less advanced populat ions , be tween 7"7 and I6"7 % persons with diarrhoea are infected by the parasite. 5 T h e prevalence of c rypto- sporidiosis in Israeli chi ldren with acute diarrhoea (3"25 %) a t tending our hospital is similar to that observed in o ther developed countries. A recent survey among Arabic chi ldren, 7 however , repor ted a high prevalence of infect ion reflecting the si tuation in a developing area.

Before its descr ipt ion in h u m a n beings, Cryptosporidium had been exclusively regarded as an animal pathogen, s'9 H u m a n cryptosporidiosis is of ten considered to be acquired f rom animals, 9 thereby joining the long list of zoonoses. Other studies, however , have indicated that Cryptosporidium is t ransmissible f rom person to person, 2 part icular ly among children. Th i s p robab ly was the main mode of t ransmiss ion in our young urban popula t ion since none of the infected chi ldren had close contact with animals.

All our patients had symptoms typical of cryptosporidiosis in immuno- compe ten t persons. 1 T h e p redominance of the disease in younger chi ldren ( < 2 years of age) has also been observed in American and Brit ish surveys 1°' 11 while the late s u m m e r - a u t u m n peak of prevalence was noted in studies f rom the U.S.A. 2 and Australia. 1"

T h e absence of Cryptosporidium in persons with normal stools in our survey is in keeping with previous findings according to which asymptomat ic carriers of the parasite are rare in developed countries. 5

In conclusion, Cryptosporidium seems not to be a negligible cause of infectious diarrhoea in young Israeli children. T h e infect ion was more c o m m o n in late s u m m e r - a u t u m n . In accordance with previous repor ts on i m m u n o c o m p e t e n t persons, the disease was benign and self-limited.

(We thank Mr A. Markovics from the Kimron Veterinary Institute for his advice.)

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