CRYPTOSPORIDIOSIS IN HUMAN IMMUNODEFICIENCY VIRUS (HIV) RELATED DIARRHEA IN ADULT PATIENTS IN PLATEAU STATE SPECIALIST HOSPITAL (PSSH), JOS.

SUMMARY (ABSTRACT)

 

Cryptosporidium parvum is the organism most frequently implicated in

Human Immunodeficiency Virus (HIV) – related diarrhoea worldwide. Cryptosporidiosis is prevalent in areas with poor sanitary environments, poor water supply and poor personal hygiene. Chronic diarrhoea is one of the common presentations of HIV in Nigeria.

 

HIV infection has permeated every social strata in Nigeria. With the advent of Highly Active Antiretroviral therapy, the number of people living with the HIV virus is on the increase. This means that the number of patients presenting with chronic diarrhoea is also on the increase. It is therefore necessary to determine the prevalence of this organism in HIVinfected patients in Plateau State Specialist Hospital, Jos, North Central

Nigeria.

 

Three hundred adult HIV patients with diarrhoea, seen in Plateau State Specialist Hospital, Jos, were investigated. Their stool samples were examined under the microscope after staining with a modified ZiehlNeelson (Z-N) method. Out of the 300 patients, (172 females and 128 males), 45 patients (25 females and 20 males) had cryptosporidium oocysts in their stool (15%). Ova of Ascaris, Hookworm and Schistosoma mansoni were seen in 13(4.3%), 15(5.0%), 1(0.3%) of stool samples respectively. Cyst of Entamoeba histolytica was seen in 52(17.3%) of samples.

Of the 45 stool samples positive for oocyst of cryptosporidium, ova of Ascaris and Hookworm were seen in 4(8.9%) and 5(11.1%) of samples respectively. Cyst of Entamoeba histolytica was seen in 11(24.4%) of the sample.

Cryptosporidium parvum is pathogenic in HIV-related diarrhoea in

Plateau State Specialist Hospital, Jos.

TABLE OF CONTENTS

Contents			Pages
Title Page  -           -        -        -        -        -	-	-	I
Declaration  -        -        -        -        -        -	-	-	II
Certification          -        -        -        -        -	-	-	III
Dedication  -         -        -        -        -        -	-	-	IV
Acknowledgment -          -        -        -        -	-	-	V
Table of Contents  -         -        -        -        -	-	-	VI
List of Figures       -        -        -        -        -	-	-	VII
List of Tables        -        -        -        -        -	-	-	VIII
List of Abbreviations       -        -        -        -	-	-	IX
Summary     -        -        -        -        -        -	-	-	1
Chapter One:         INTRODUCTION -        -	-	-	3
Chapter Two:        LITERATURE REVIEW	-	-	17
Chapter Three: METHODOLOGY     -        -	-	-	47
Chapter Four:        RESULT               -        -	-	-	57
Chapter Five:         Discussion  -         -        -	-	-	67
Conclusions:         -        -        -        -        -	-	-	78
Recommendations:          -        -        -        -	-	-	79
References: -         -        -        -        -        -	-	-	81

 

CHAPTER ONE

INTRODUCTION

1.1    BACKGROUND TO THE STUDY

In 1978, a Portuguese taxi driver presented in Paris with a rare form of pneumonia caused by a lung parasite, pneumocystis carinii.⁽¹⁾ This was an unusual finding to the medical practitioners who attended to the patient. This was followed by a publication in 1981 by the United States Center for Disease control and prevention in Atlanta, of similar cases of pneumocystis carinii pneumonia in gay men in United States.^(1,2) Subsequently, there

were reports of the isolation of the virus, Human Immunodeficiency Virus (HIV) by Gallo RC and group in America.⁽³⁾ Later, the trio of Rozenbaum, Leibowitch and Mayaud isolated the HIV virus at the Pasteur Institute in Paris.⁽¹⁾ This was the birth of HIV infection, the viral infection that causes Acquired

Immunedeficiency Syndrome (AIDS).

 

The first few cases of pneumocystis carinii pneumonia treated in

Paris, had African connections.⁽¹⁾ They all had worked in Africa, Angola in particular. The infection was spreading fast all over Europe and America.

The HIV pandemic became such a challenge to the world that in the late 1980’s and early 1990’s there was an unprecedented media campaign on HIV/AIDS.⁽⁴⁾ Despite the media campaign, the

epidemic has continued to spread to all countries of the world.⁽⁵⁾

 

By the end of the year 2003, the estimated number of people living with HIV globally was put at 40 million.⁽⁶⁾ Sub-Saharan Africa is the most traumatized by the HIV scourge.^(5,6) Africa’s grim AIDS data include over 25 million people living with HIV and 2.2 million dead in 2003 alone.^(7,8,9) The world AIDS epidemic status as at the end of 2006 shows that the total number of people living with HIV/AIDS was 39.5 million and adults and children under the age of 15 years account for 37.2 millions and 2.3 million respectively.⁽⁹⁾ The situation in Sub-Saharan Africa, by the end of 2006, showed that 21.8 – 22.7 million live with HIV, 2.4 – 3.2 million were newly infected, and    1.8 – 2.4 million died due to AIDS. The Adult prevalence rate was 5.2 – 6.7% by the end of 2006.⁽⁹⁾ Despite this, some African governments or leaders refused to consent to provision of antiretrovirals for the treatment of the disease in their countries. This refusal might have been due to doubts of the causal relation between HIV and AIDS, as was the case of South Africa, or due to the financial consequences of drug treatment.⁽¹⁰⁾

Though the scourge of HIV/AIDS is more in Africa, there was a global resolve to fight the pandemic. This culminated in a special session of the General Assembly of the United Nations, in June 2001, agreeing on a comprehensive and co-ordinated global response to the AIDS crisis.⁽⁵⁾ At this special session, the members adopted a powerful declaration of commitment to halt and begin to reverse the spread of AIDS by 2015.⁽⁵⁾ There is a ray of hope in achieving this goal in Sub-Saharan Africa with governments, Nongovernment organizations and faith-based organizations coming to the rescue of Nigeria, Zimbabwe, and South Africa for

example.^(6,10,11,12) In these countries, there are proofs on ground, that in collaboration with Donor Agencies, they are working hard to fight HIV/AIDS through programmes like prevention of

maternal to child transmission (PMTCT), provision of antiretroviral drugs, and intense campaigns for voluntary confidential counseling and testing (VCCT).^(6,11,12)

 

In Africa, there are identifiable factors that militate against the control of HIV/AIDS. These factors include, gender issues with males dominating decision taking functions, lack of commitment of government, lack of structures that support people living with HIV positively, ignorance, legislature and policies , poverty and poor community involvement or mobilization.⁽¹³⁾ The earlier these key factors are addressed, Africa will make considerable progress in the control of HIV infection. Africa and the developed world need to address the issues in very constructive manner and avoid blaming African governments of nonchalant attitude towards the health of their citizens.⁽¹⁴⁾ America has achieved substantial decline in AIDS incidence and mortality,⁽¹⁵⁾ and this can be replicated in Africa with adequate support from the developed world. Because of poverty of resources and lack of equipment, technology and trained manpower it was difficult to make diagnosis in resource poor countries and developing nations.

 

The Centers for Disease Control (CDC) therefore developed a two tier clinical classification for adults and adolescents (> 13 years old.)⁽⁶⁾ The first tier involves the use of CD4 + lymphocyte count which was not readily available. The second tier uses clinical staging based on clinical symptoms. This CDC classification system can also be used for surveillance and case definition of

Aids.

 

The Nigerian AIDS case definition for adults is two major signs plus one minor sign plus an HIV positive test result.⁽⁶⁾

The major signs include:

 Weight loss of 10% of body weight or more.

 Chronic diarrhoea lasting more than a month.

 Prolonged fever lasting more than a month.

The minor signs include:

 Persistent cough longer than one month

 Persistent generalized lymphadenopathy

 Recurrent Herpes zoster

 Generalized pruritic dermatitis

 Oropharyngeal candidiasis

 Chronic progressive and disseminated herpes simplex infection.

 

The Abidjan definition (WHO) is still a pilot programme in Nigeria.⁽⁶⁾ It is used as a case reporting system in 12 sites and is based on the presence of one or more of the underlisted conditions plus an HIV positive test to define AIDS. These include the following:

 Pulmonary or extrapulmonary tuberculosis

 Cryptococcal meningitis

 Kaposi’s sarcoma

 Neurological impairment sufficient to prevent independent daily

activities.

 

Candidiasis of the aesophagus (may be presumptive based on the presence of oral candidiasis accompanied by dysphagia).

 Clinically diagnosed life-threatening pneumonia or recurrent episodes of pneumonia.

 Invasive cervical cancer.

 

The staging system for HIV infection and disease in Nigeria is the same as the World Health Organisation (WHO) staging system.⁽⁶⁾

 

Clinical stage 1

 Asymptomatic

 Persistent generalized lymphadenopathy

 Performance scale 1: asymptomatic, normal activity.

 

Clinical stage 2

 Weight loss < 10% body weight.

 Minor mucocutaneous manifestations.

 Herpes zoster within the last 5 years

 Recurrent upper respiratory infections.

 Performance scale 2: symptomatic, normal activity.

Clinical stage 3

 Weight loss > 10% body weight

Unexplained chronic diarrhoea > 1 month

 Oral candidiasis

 Severe bacterial infections

 Performance scale 3: bed-ridden < 50% of the day during the last month.

 

Clinical stage 4

 HIV wasting syndrome

 Pneumocystis carinii pneumonia

 Toxoplasmosis of the brain

 Cryptosporidiosis with diarrhoea > 1 month

 Cryptococcosis, extrapulmonary

 Cytomegalovirus infection

 Herpes simplex virus infection > 1 month

 Progressive multifocal leukoencephalopathy

 Any disseminated endemic mycosis

 Candidiasis of the oesophagus

 Atypical mycobacteriosis/disseminated

 Non-typhoid salmonella septicaemia

 Extrapulmonary tuberculosis

 Lymphoma

 Kaposi’s sarcoma

HIV encephalopathy

 Performance scale: bed-ridden > 50% of the day during the last month.

 

The World Health Organization staging system for HIV infection and disease also takes cognisance of laboratory classification based on CD4 + cell count. This laboratory classification is class A for

CD4 cell count above 500/ul; class B for CD4 cell counts of 200 to

500/uL and class C for CD4 cell counts below 200/ul. (6)

 

The first case of AIDS in Nigeria was diagnosed in 1986.⁽⁶⁾ Since then, the HIV scourge has permeated the entire Nigerian community and social strata, affecting men, women and children alike.^(6,24,25) The prevalence of HIV rose from 1.8% in 1991 to 5.8% in 2001 and then 5.0% in 2003.^(6,16,17) World Health Organization reported an adult prevalence of 5.2 – 6.7% by the end of 2006 in sub-Saharan Africa.⁽⁹⁾ This downward trend of adult HIV prevalence might be deceptive. The Cameroon experience showed a steep rise from an urban prevalence of 2% in 1988 to 4.7% in 1996 and in 2000 the national prevalence rate in Cameroon was 11% among pregnant women.^(5,18) These data sound a loud warning to Nigeria, the most populous country in Sub-Saharan Africa. The adult HIV prevalence rate of 5% in Nigeria is not significant

 

statistically, but translates to over 7 million Nigerians infected with the HIV virus.⁽¹⁹⁾ It was, therefore, not surprising that the Federal Government of Nigeria, in late 2001, launched the National Antiretroviral Programme.⁽⁶⁾ It was estimated that by the year 2005, 300,000 Nigerian HIV patients should be on antiretroviral drugs,⁽⁶⁾ but only 20,000 out of this number are on antiretrovirals.⁽¹⁹⁾ A number of international bodies such as the Global AIDS funds,

World Bank and the Presidential Emergency Plan for AIDS relief (PEPFAR) have indeed assisted in considerably making these drugs more accessible and available.⁽²⁰⁾ The AIDS prevention initiative in Nigeria (APIN) programme of prevention of mother-to-child transmission (PMTCT), funded by the Bill and Melinda Gates Foundation was an initiative geared towards providing drugs for pregnant women in Nigeria.⁽⁶⁾ PMTCT activities are well

established in most health care centres in Plateau State.⁽²¹⁾  Prevention of the transmission of HIV infection will go a long way to reduce the population of those living with HIV and reduce the morbidity and mortality associated with HIV.^{(6,20,22,23,24)} This can be achieved through lifestyle modifications,⁽²⁵⁾ prevention of maternal to child transmission, universal precautions for those at risk, blood safety, prevention services for injection drug users, prevention and prompt treatment of sexually transmitted infection (STI) and

education of the populace on HIV.^{(5,6,13,20,24)}

Managing people living with HIV is an arduous task in developing countries, Nigeria inclusive. The cited problems are weak health systems, poor infrastructure, inadequate numbers of health professionals and finally high cost of antiretroviral drugs.^(7,26) The challenges of treatment of HIV/AIDS in Nigeria include cost of antiretroviral drugs, accessibility of voluntary counseling and HIV testing, laboratory capacity for CD₄ and viral load testing, stigmatization attached to HIV/AIDS and adherence to

treatment.^(20,27)

 

The common life threatening complications of HIV infection seen in Nigerian patients include chronic diarrhoeal disease causing severe weight loss,^(6,24,28) anaemia,^(17,29) HIV nephropathy,⁽³⁰⁾ and opportunistic infections like Tuberculosis.^{(31,32,33,34,35)}

Chronic diarrhoea is one of the major symptoms of AIDS in developing countries and is a more prominent symptom than in developed or wealthier nations.⁽³⁶⁾ Chronic diarrhoea is one of the problems medical practitioners and those caring for people living with HIV must cope with.

 

Diarrhoea in people living with HIV is caused by HIV itself and many other intestinal protozoal parasites that become opportunistic

infections due to immune deficiency secondary to HIV infection.^(22,23,37) These include Amoebiasis, Giardiasis,

Cryptosporidiosis,        Microsporidiosis,        Balantidiasis       and

Isosporiasis.^{(6,22,23,36,37,38)} These parasitic intestinal infections are preventable through personal hygiene, portable water supply, good environmental sanitation and waste disposal and public

education.^(36,37,38)

 

Cryptosporidium parvum has been incriminated as the common protozoan enteropathogen causing chronic diarrhoea in people

living with HIV. (22,23,36,37,38,39)

 

Studies in some parts of Africa implicate cryptosporidium parvum as a causative parasite in HIV-related diarrhoea in their study subjects. Mengesha B and Khumalo et al reported cryptosporidiosis in HIV-related diarrhoea in Ethiopia and Zambia respectively.^(40,41) These studies in Ethiopia and Zambia were carried out on adult HIV subjects with significant prevalence rates of 12% - 19%. Two separate studies in Nigeria reported the presence of

cryptosporidium parvum in stools of diarrhoeal patients. Chira FU et al reported cryptosporidium oocysts in the stool of undernourished, under five children with diarrhoea at the

University of Port Harcourt Teaching Hospital, Port Harcourt, South-south of Nigeria. ⁽⁴²⁾  Nwabuisi C in a study in Ilorin, North Central Nigeria, also reported the presence of oocysts of cryptosporidium parvum in stools of children having diarrhoea.⁽⁴³⁾ These studies were carried out in children and tended to suggest that cryptosporidiosis was primarily a disease of children. The studies also did not indicate the immune status of the subjects studied. Nwokediuko et al in Enugu, South-Eastern Nigeria, carried out a study in adult HIV patients with diarrhoea and reported an apparent rarity of cryptosporidiosis in the study subjects. ⁽⁴⁴⁾

 

Ikeh E I et al in a recent study in Jos, North Central Nigeria, reported a prevalence of 19.4% in healthy urban population of Jos and 17.4% in HIV patients for cryptosporidiosis.⁽⁴⁵⁾ This study by Ikeh et al in Jos is suggestive of the fact that cryptosporidiosis occurs in Jos and this is consistent with its prevalence in areas with poor sanitary conditions. Cryptosporidium parvum may therefore contribute to diarrhoea in HIV patients in Jos.

 

Since the prevalence of cryptosporidium varies from region to region and even in the same locality, this prompted the desire to carry out this study in Plateau State Specialist Hospital,  Jos.

 

Immunosuppressed individuals are prone to opportunistic infections especially in environments with poor environmental hygiene, poor water supply system and poor waste disposal

systems^(36,37,38) as obtains in most parts of Nigeria. These conditions are also prevalent in Jos and therefore makes the water supply prone to contamination.

 

1.2     STATEMENT OF THE PROBLEM

Unpublished records of admissions in the medical ward of Plateau State Specialist Hospital (PSSH) Jos, over a period of seven months, January to July 2004, revealed that 127 cases of HIV infected adult patients with diarrhoea were admitted into the ward. Fifty three of these patients died while on admission due to diarrhoea and its complications. This is 41.7% mortality and is quite significant. This gave impetus to the decision to carry out this study, to find a possible association of cryptosporidiosis with HIVrelated diarrhoea in PSSH. Jos.

 

1.3     AIMS AND OBJECTIVES OF THE STUDY

The    study    is    aimed    at    establishing    the    implication    of

cryptosporidiosis   in HIV-related diarrhoea in Plateau State Specialist Hospital, Jos.

 

SPECIFIC OBJECTIVES

1. To determine the prevalence of cryptosporidium parvum in

HIV-related diarrhoeal disease in Plateau State Specialist Hospital, Jos.

2. To determine if other opportunistic parasitic infections, probably contribute to HIV-related diarrhoea in Plateau State

Specialist hospital, Jos.

 

 

 

 

1.4     RATIONALE FOR THE STUDY

The study is carried out to create awareness of the prevalence of cryptosporidium parvum infection among HIV infected adults in

Plateau State Specialist Hospital, Jos.

 

This research will be limited to history taking, physical examination, obtaining stool and blood specimens from adult HIV infected patients  having diarrhoea, seen at the medical out-patient department or admitted into the medical ward of Plateau State Specialist Hospital,

Jos.

 

 

 

CRYPTOSPORIDIOSIS IN HUMAN IMMUNODEFICIENCY VIRUS (HIV) RELATED DIARRHEA IN ADULT PATIENTS IN PLATEAU STATE SPECIALIST HOSPITAL (PSSH), JOS.

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