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Travel and Mountain Medicine Center, Nepal International Clinic, Kathmandu, NepalOxford University Clinical Research Unit-Nepal, Center for Tropical Medicine and Global Health, University of Oxford, UK
A 27-year-old woman presented to a travel medicine clinic with 4 weeks of diarrhea. Her stool was watery with no mucus or blood, and she had more than 5 bowel movements per day. She also complained of severe fatigue, nausea, anorexia, occasional mid-belly cramps, and bloating sensation. She denied any history of fever, headache, vomiting, lightheadedness, recent weight changes, or urinary symptoms. She had never experienced prolonged diarrhea in the past. She had been travelling around Nepal for the past 4 months. She was initially treated at a primary care center with antibiotics for bacterial diarrhea, followed by antiprotozoal suspecting giardiasis, but her diarrhea persisted. On examination, her vital signs were stable. On examination, bowel sound was hyperactive and belly nontender without hepatosplenomegaly. Microscopic examination of the fresh stool sample revealed Cyclospora oocysts (Figure). Cyclosporiasis was diagnosed, and the patient was treated with oral trimethoprim-sulfamethoxazole. On follow-up visit after 2 weeks the patient's diarrhea had resolved, and her follow-up microscopic stool examination was normal.
FigureUnsporulated Cyclospora oocyst seen under microscopic examination (arrow). Unsporulated oocysts are uniformly spheroidal with a bilayer cell lining and granular cytoplasm.
An acute, nonbloody, watery diarrhea associated with profound fatigue is the most striking feature. It can also be accompanied by abdominal cramps, nausea, vomiting, bloating sensation, anorexia, weight loss, and malabsorption.
Ultraviolet fluorescence microscopy is a useful technique for screening wet mounts of stool sample and to distinguish it from Cryptosporidium oocysts. Cyclospora oocysts are autofluorescent, in contrast to Cryptosporidium oocysts, which are not autofluorescent.
Alternative therapies for those allergic to trimethoprim-sulfamethoxazole are lacking. Nitazoxanide and ciprofloxacin may be an alternative regimen for patients with sulfa allergy.
Trimethoprim-sulfamethoxazole compared with ciprofloxacin for treatment and prophylaxis of Isospora belli and Cyclospora cayetanensis infection in HIV-infected patients: a randomized, controlled trial.
Cyclospora infection can cause protracted diarrhea for weeks if left untreated and responds best to treatment with trimethoprim-sulfamethoxazole only, which makes the diagnosis of cyclosporiasis more crucial.
Trimethoprim-sulfamethoxazole compared with ciprofloxacin for treatment and prophylaxis of Isospora belli and Cyclospora cayetanensis infection in HIV-infected patients: a randomized, controlled trial.
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