Parsotam R. Hira

Unique Endemicity of Cryptosporidiosis in Children in Kuwait

ABSTRACT To understand the transmission of Cryptosporidium infection in children, fecal specimens from 62 Kuwaiti children with gastrointestinal symptoms found to be positive by microscopy were genotyped and subtyped with a small subunit rRNA-based PCR-restriction fragment length polymorphism analysis and a 60-kDa glycoprotein-based DNA sequencing tool. The median age of infected children was 4.5 years, and 77% of infections occurred during the cool season of November to April. Fifty-eight of the children (94%) had Cryptosporidium parvum, three (5%) had Cryptosporidium hominis, and one (1%) had both C. parvum and C. hominis. Altogether, 13 subtypes of C. parvum (belonging to four subtype allele families) and C. hominis (belonging to three subtype allele families) were observed, with 92% of specimens belonging to the common allele family IIa and the unusual allele family IId. Thus, the transmission of cryptosporidiosis in Kuwaiti children differed significantly from other tropical countries.

Comparison of Two Commercial Assays with Expert Microscopy for Confirmation of Symptomatically Diagnosed Malaria

ABSTRACT Conventional light microscopy has been the established method for malaria diagnosis. However, recently several nonmicroscopic rapid diagnostic tests have been developed for situations in which reliable microscopy may not be available. This study was conducted to evaluate the diagnostic performance of a recently introduced ICT Malaria Pf/Pv test. This assay detects Plasmodium falciparum histidine-rich protein 2 antigen (PfHRP-2) for P. falciparum diagnosis and pan-malarial antigen for P. vivax diagnosis. In this study we compared the performance of ICT Malaria Pf/Pv with microscopy of Giemsa-stained blood films and with an OptiMAL test that detects Plasmodium lactate dehydrogenase (pLDH) antigen. A total of 750 clinically suspected malaria patients were examined at local health centers in Kuwait. Both the antigen tests had a high degree of specificity (>98%) for detection of malaria infection. However, they were less sensitive than microscopy. Compared with microscopy the ICT Malaria PF/pf test failed to detect malaria infection in 93 (34%) of 271 malaria patients (11% of patients with P. falciparum and 37% of patients with P. vivax) and the OptiMAL test failed to detect malaria infection in 41 (15%) of 271 malaria patients (7% of patients with P. falciparum and 13% of patients with P. vivax). The sensitivities of the ICT Malaria Pf/Pv and OptiMAL tests for detection of P. falciparum infection were 81 and 87%, and those for detecting P. vivax were 58 to 79%, respectively. The sensitivity of the ICT Malaria Pf/Pv and OptiMAL tests decreased significantly to 23 and 44%, respectively, at parasite densities of <500/μl. Both of the tests also produced a number of false-positive results. Overall, the performance of the OptiMAL test was better than that of the ICT Malaria Pf/Pv test. However, our results raise particular concern over the sensitivity of the ICT Malaria Pf/Pv test for detection of P. vivax infection. Further developments appear necessary to improve the performance of the ICT Malaria Pf/Pv test.

DIAGNOSIS OF CYSTIC HYDATID DISEASE: ROLE OF ASPIRATION CYTOLOGY

Fine needle aspiration of mass lesions is reported in eleven patients in whom cystic hydatid disease (CHD) was not a differential diagnosis or whose serological results were negative. Aspiration was continued until no more fluid could be obtained. In five patients aspiration was done under ultrasound guidance. No sequelae were observed that could be attributed to aspiration per se. Aspirated fluid was stained with haematoxylin and eosin and giemsa or was passed through 5 micron polycarbonate filters which were then stained in the same way. The aspirated material and polycarbonate filters were also stained with trichrome which proved the best stain to demonstrate the acid-fast hooklets. Such filtration of the total volume of the aspirated material or that evacuated at operation is simple, quick, and accurate.

Cysticercosis: imported and autochthonous infections in Kuwait

Intracerebral and non-central nervous system (non-CNS) cysticercosis caused by the larval pork tapeworm Taenia solium was diagnosed in patients in an Islamic state. The mode of transmission and challenges in diagnosis are highlighted. Sixteen patients with neurocysticercosis and six with non-CNS lesions were diagnosed by imaging studies (computerized tomography [CT]/magnetic resonance imaging [MRI]) and serology (ELISA and/or enzyme-linked immunoelectrotransfer blot assay [EITB]). Four of 55 family members, including servants, tested for antibodies were positive by the EITB and ELISA. Only one of these sera tested for antibodies to adult T. solium was positive: that of the cook, the probable source of the infection. We postulate a similar mode of transmission in the other Kuwaitis. Evaluation of several commercially available ELISA kits showed they were of poor specificity. Even in countries where pork consumption is proscribed by religious laws, physicians should include cysticercosis in their differential diagnosis in patients with neurological symptoms or non-CNS lesions, especially in non-endemic countries with a large expatriate population such as Kuwait. In children particularly, and in this region, suspected tuberculous lesions on CT must be investigated to rule out cysticerci by a more diligent use of the sensitive and specific EITB assay. Failure to understand the local epidemiology leads to empirical, inappropriate and prolonged therapy for chronic disease.

Cryptosporidiosis in Kuwaiti children: association of clinical characteristics with Cryptosporidium species and subtypes

To determine the association of clinical characteristics with Cryptosporidium types and subtypes, faecal specimens from 2548 children with diarrhoea were screened by microscopy for Cryptosporidium spp., and positive specimens were genotyped and subtyped by PCR-RFLP. A total of 87 of the 2548 children (3.4 %) had cryptosporidial diarrhoea by microscopy and the majority (41.4 %) of the infected children were in the 4-8-year-old age group. Molecular characterization of the 83 children studied further (4 had mixed infections and were not subtyped) showed that Cryptosporidium parvum was the most commonly identified species (73.5 %) and consisted of three subtypes: IIa and IId were the most common (80.3 %), followed by IIc. Twenty-two (26.5 %) of the children had Cryptosporidium hominis and showed three subtypes: Id was the most common (54.5 %), followed by Ia (36.4 %) and Ie. Associated clinical manifestations varied between C. parvum and C. hominis. Diarrhoea associated with subtype Id, the most commonly identified C. hominis subtype, was more severe than that associated with other subtypes. In conclusion, this study confirmed a very different Cryptosporidium genotype and subtype distribution compared with other tropical countries among Kuwaiti children with diarrhoea, with a predominance of C. parvum IIa and IId. In addition, subtype Id of C. hominis was associated with more diverse and severe clinical manifestations in infected children, suggesting that parasite genetics may play an important role in the clinical manifestations of human cryptosporidiosis.

An enzyme-linked immunosorbent assay using an arc 5 antigen for the diagnosis of cystic hydatid disease

We report on an easily standardized enzyme-linked immunosorbent assay (ELISA) for the diagnosis of cystic hydatid disease. The antigen used is commercially available, and purified to elicit an arc 5 precipitation line by immunoelectrophoresis (IEP) with sera of patients harbouring hydatid cysts. The IgG-ELISA was highly sensitive and specific, and of diagnostic value compared to total Ig-ELISA, IgM-ELISA or IgA-ELISA. When compared to the indirect hemagglutination test and to counterimmunoelectrophoresis using an arc 5 antigen, minimal cross-reactions were observed in sera of patients with a presumptive diagnosis of hydatidosis but none were observed in those harbouring intestinal helminths, schistosomes or filarial parasites. The assay is of low cost, simple to perform, and highly reproducible. The IgG-ELISA provides an unequivocal laboratory diagnosis of hydatidosis. It is eminently suited for accurate and early identification of hydatid disease patients, for instance in mass surveys, who may benefit immediately from currently available anthelmintics, thereby obviating the need for surgery later.

Performance of Rapid Malaria PF Antigen Test for the Diagnosis of Malaria and False-Reactivity with Autoantibodies

Recently introduced rapid nonmicroscopic immunocapture assays for the diagnosis of malaria infection are being evaluated for their sensitivity and specificity in various epidemiological settings. A Plasmodium falciparum histidine-rich protein-2 (PfHRP-2)-based assay (ICT malaria Pf assay) was evaluated for its performance and compared to that of Giemsa-stained thick blood film microscopy. Of the 515 patients tested, 163 were positive for malaria parasites on thick blood film microscopy: 87 were infected with P. vivax; 63 with P. falciparum; 1 with P. malariae; and 12 with both P. falciparum and P. vivax. The ICT assay detected 53 P. falciparum infections and, as expected, failed to detect all but one case of P. vivax. Three cases of mixed infections were also not detected by this assay. The performance of the ICT assay in diagnosing P. falciparum infection was comparable to that of microscopy. The sensitivity of the ICT assay was 82% and the specificity 99.0%. The ICT assay also detected 4 false-positive cases. These patients reported treatment with chloroquine in the previous 2-5 weeks. The specificity of the assay was evaluated in different groups of patients, who had tested negative for malaria infection by microscopy. These patients were selected from different disease groups: rheumatoid arthritis; hepatitis C; toxoplasmosis; schistosomiasis; and hydatid disease. Of the 225 patients studied, 133 were positive for rheumatoid factor. Thirty-five (26%) of the 133 patients had false positive-reactions with the ICT assay, while only four had false positive-reactions with the OptiMAL test. After the rheumatoid factor was absorbed 33 of the 35 false-positive specimens were negative when retested with the ICT assay. Our study shows that the PfHRP-2-based ICT assay gave a false positive-reaction in 26% of the patients who had rheumatoid factors, but were negative for malaria by microscopy. We conclude that new rapid nonmicroscopic methods for the diagnosis of malaria that complement or support blood film microscopy would be of great use in the diagnosis and treatment of patients with malaria and also in epidemiological studies.

Fatal Strongyloidiasis in Three Kidney Recipients in Kuwait

Objective: It was the aim of this study to report 3 rare fatal cases of strongyloidiasis in Kuwaiti renal transplant patients. Clinical Presentation and Intervention: All 3 cases received allografts from cadaveric donors of Asian origin, the first 2 from an Indian (transplanted on the same day) and the third from a Bangladeshi. In all 3 cases, Strongyloides stercoralis larvae were first isolated from bronchoalveolar lavage. All 3 patients were on immunosuppressive therapy which included prednisolone, thereby leading to the hyperinfection syndrome. All patients presented with gastrointestinal symptoms (abdominal pain, vomiting, diarrhea, constipation and paralytic ileus), as well as pulmonary symptoms (cough, dyspnea and blood-stained sputum). Albendazole 800 mg twice daily orally was started. Cyclosporine A was started after discontinuing prograf. The patients continued to deteriorate with a fall in blood pressure and platelets. All 3 patients died from adult respiratory distress syndrome following hyperinfection with S. stercoralis.Conclusion: Hyperinfection with S. stercoralis is a rare but preventable complication of immunosuppressive therapy. A high index of suspicion is required for the diagnosis of this infection. Persistent examination of sputum, bronchial washings and upper intestinal aspirates should be done as part of surveillance following cadaveric renal transplantation. Adult respiratory distress syndrome is indeed a red flag in patients who are on steroids, not on cyclosporine and receiving a kidney from donors in endemic countries of S. stercoralis.

Parasites of urological importance.

With the world increasingly becoming a global village, transnational and transcontinental migration has become the order of the day. It is expected that migrants will take with them some diseases (including parasites) which are normally endemic in their countries of origin, to their host countries. Similarly, environmental changes that result from development of water resources, global warming, growth and migration of population can facilitate the spread of parasites. In this review we describe the epidemiology, presentation, diagnosis and treatment options of parasites that urologists may encounter. Notably among these parasites are Schistosoma haematobium, Echinococcus granulosus, Wuchereria bancrofti and Onchocerca volvulus.

Imported Malaria in Kuwait (1985–2000)

BACKGROUND The objective of this study was to document the status of malaria infection and effect of preventive measures on the epidemiologic profile of imported malaria cases in Kuwait during 1985-2000. METHODS The study included screening of two groups of individuals for malaria infection by microscopy; (1) all migrant workers from malaria-endemic countries on their first entry to Kuwait; and (2) all suspected malaria cases already residing in the country. The study period was divided into pre-war (1985-1990), postwar (1992-1997) and proactive preventive (1998-2000) periods. During the proactive preventive period, the home countries were also involved in screening for malaria infection in all prospective immigrants to Kuwait. RESULTS The annual incidence of malaria cases detected during the pre-war, postwar and proactive preventive periods ranged between 465 and 1,229, 654 and 1,379, and 248 and 393, respectively. Plasmodium vivax infection was detected in 71% of the cases and P. falciparum in 27%. The number of malaria cases detected increased to >1,300 after the war during 1992-1993. However, the number of malaria cases dropped significantly to less than 400 during 1998-2000 (p80%) of malaria patients were young male adults between 21 and 40 years of age. The data on drug resistance were not well defined, due to limited testing. CONCLUSION This study suggests that the proactive preventive program to screen all prospective immigrants for malaria infection in their home countries significantly reduced the numbers of imported infections to <400 cases/year, a drop of 52.6%. In addition, it also identified a group of settled immigrants, the majority of whom were at high risk for acquisition of malaria infection during their visit to home countries. There is an urgent need to target this group for prevention strategies such as education/information and other preventive measures against malaria infection.