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Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 53-55  

Pulmonary cryptosporidiosis in a case of adenocarcinoma of stomach: A rare case report


1 Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission12-Apr-2020
Date of Decision24-Dec-2020
Date of Acceptance07-Jan-2021
Date of Web Publication13-May-2021

Correspondence Address:
Vikram Kate
Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
India
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DOI: 10.4103/tp.TP_41_20

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   Abstract 


Cryptosporidium species are commonly known to cause chronic intractable diarrhea in patients suffering from human immunodeficiency virus (HIV)-acquired immunodeficiency syndrome, however extra-intestinal presentations have been rarely reported. Hereby, we report a rare case of isolated pulmonary cryptosporidiosis in a 75-year-old HIV-negative patient with metastatic carcinoma of the stomach who was managed conservatively with hemostatic radiotherapy for palliative care. The patient had presented with cough with expectoration for 2 months. Sputum microscopic examination was suggestive of pulmonary cryptosporidiosis. There was no evidence of intestinal cryptosporidiosis. Therapy for pulmonary cryptosporidiosis was started with tablet nitazoxanide. The patient succumbed to the disease few days later following discharge. Although rare, patients with disseminated gastrointestinal malignancy can potentially have isolated pulmonary cryptosporidiosis.

Keywords: Adenocarcinoma stomach, Cryptosporidium, pulmonary cryptosporidiosis


How to cite this article:
Chaudhari K, Gurushankari B, Rajkumari N, Joseph NM, Amaranathan A, Sathasivam S, Barathi D, Kate V. Pulmonary cryptosporidiosis in a case of adenocarcinoma of stomach: A rare case report. Trop Parasitol 2021;11:53-5

How to cite this URL:
Chaudhari K, Gurushankari B, Rajkumari N, Joseph NM, Amaranathan A, Sathasivam S, Barathi D, Kate V. Pulmonary cryptosporidiosis in a case of adenocarcinoma of stomach: A rare case report. Trop Parasitol [serial online] 2021 [cited 2021 Jun 25];11:53-5. Available from: https://www.tropicalparasitology.org/text.asp?2021/11/1/53/315932




   Introduction Top


Cryptosporidium species are intracellular protozoan affecting the intestinal epithelium and are an important cause of diarrhea worldwide.[1] They cause severe diarrhea in immunocompromised individuals, especially in human immunodeficiency virus (HIV)-affected group.[2] The most common mode of transmission is feco–oral, through contaminated water or food. A few case reports have detected this pathogen from the respiratory tract, with most of these cases being HIV patients.[3] Detection of this pathogen extra-intestinally from other groups of immunocompromised patients is even rare. We describe a rare case report of Cryptosporidium species from sputum of a HIV-negative patient with adenocarcinoma of stomach.


   Case Report Top


A 75-year-old male patient, a known case of Type II diabetes mellitus and hypertension for the last 2 years, presented with the complaints of intolerance to oral feeds for 2 months, initially intolerant to solids and gradually developing intolerance to liquid diet for the past 2 weeks associated with altered blood in vomitus and drooling of saliva. The patient complained of cough with expectoration for the past 2 months. The patient also complained of having upper abdominal pain for the past 2 months, which was burning, intermittent, and nonradiating, and there was no history of diarrhea. He also had a history of melena for the past 2 months. On examination, the patient was conscious, oriented, and afebrile. Vitals were within normal limits. The patient was poorly built. His general physical examination revealed pallor. Systemic examination revealed coarse crepitus in the bilateral lung fields. Per abdomen, there was mild diffuse tenderness with sluggish bowel sounds on auscultation. On direct rectal examination, presence of melena was noted. Chest radiograph revealed bilateral mild pleural effusion with irregular opacity in the right upper zone [Figure 1]a. Nebulization with salbutamol for 6 h and parenteral ceftriaxone 1 g twice daily was started. Contrast-enhanced computed tomography (CECT) abdomen revealed a large polypoidal lesion in the anterior wall of the antero-pyloric region, causing complete luminal obstruction [Figure 1]b. It also revealed multiple, enlarged perigastric, periportal, celiac, pre-aortic, para-aortic, and aortocaval nodes. Omental nodes were present with mild ascites [Figure 1]c. CECT thorax showed extensive bilateral centrilobular emphysematous changes. Irregular opacities with adjacent bands were seen in the right upper lobe, suggestive of fibrotic changes. Bilateral moderate pleural effusion was seen [Figure 1]d. Routine biochemical and hematological investigations revealed blood glucose of 240 mg/dL with a normal HbA1c of 4.5%, low hemoglobin (6.7 g%), and normal renal and liver function test. Serum samples were negative for HIV, hepatitis B virus, and hepatitis C virus. Histopathology of the gastric biopsy specimen showed moderately differentiated adenocarcinoma. Sputum sample of the patient was sent for culture of Mycobacterium tuberculosis. The sample was decontaminated by N-acetyl-l-cysteine-sodium hydroxide method and stained with auramine phenol stain. In auramine phenol stain, fluorescent circular structures measuring 4–7 μm were observed [Figure 2]a. The bacterial culture was negative and there was no growth of M. tuberculosis in the culture. Modified Ziehl–Neelsen staining showed circular acid-fast structures measuring 4–7 μm [Figure 2]b, which were identified as Cryptosporidium species based on morphological characteristics.[4],[5] The patient was started on tablet nitazoxanide 500 mg twice daily for 3 days. Stool examination was negative for oocysts of Cryptosporidium spp.
Figure 1: Chest X-ray and contrast-enhanced computed tomography of the abdomen and thorax. (a) Bilateral mild pleural effusion with irregular opacity in the right upper zone in postero-anterior view of chest X-ray. (b) Antro-pyloric growth in the stomach (solid red arrow) on contrast-enhanced computed tomography abdomen. (c) (empty red arrow) Enlarged para-aortic lymph nodes on contrast-enhanced computed tomography abdomen. (d) (solid yellow arrow) Emphysematous changes in the lung fields on contrast-enhanced computed tomography thorax and (empty arrow) pleural effusion

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Figure 2: Microscopic examination of sputum sample . (a) Auramine-stained smear with numerous Cryptosporidium oocysts (×200). (b) Modified Ziehl–Neelsen stain with unevenly stained acid-fast structures (arrow) (×1000)

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The patient was diagnosed as a case of metastatic carcinoma of the stomach. As the patient presented with hematemesis, he was managed conservatively with tranexamic acid and pantoprazole. Hemostatic radiotherapy was given following which bleeding from the tumor was controlled. There were no symptoms of melena or hematemesis at discharge. Feeding jejunostomy could not be carried out in view of the patient's poor condition. The patient was taking restricted oral fluids. The patient was discharged with advice for follow-up. However, on telephonic follow-up, it was found that the patient expired few days after the discharge.


   Discussion Top


Cryptosporidium species is one of the leading causes of diarrhea in acquired immunodeficiency syndrome (AIDS) patients and also became one of the entities defining AIDS.[1] In immunocompetent individuals, Cryptosporidium species cause self-limiting infection, whereas infection in immunocompromised individuals can be life threatening. Diarrhea is the most common clinical manifestation of cryptosporidiosis in both the groups, though pulmonary cryptosporidiosis and disseminated cryptosporidiosis have also been described.[2] The usual mode of transmission is ingestion of water or food contaminated with the oocyst of Cryptosporidium. Autoinfection is more commonly seen in immunocompromised individuals.[2]

Pulmonary cryptosporidiosis has been described more commonly in immunocompromised individuals suffering from AIDS. Apart from AIDS, the other reported conditions where immunodeficiency is associated with pulmonary cryptosporidiosis are hypogammaglobulinemia, severe combined immunodeficiency, leukemia,[6] and bone marrow transplantation.[3],[7] In the present case, the patient had metastatic adenocarcinoma of the stomach. Although the present case was HIV negative, Cryptosporidium infection may be attributed to some degree of immunosuppression due to the underlying gastric malignancy.

Pulmonary cryptosporidiosis presents typically with productive cough, dyspnea, and fever. Chest radiograph may show opacities.[3],[4] This case presented with respiratory symptoms, along with pleural effusion. Pulmonary infection caused by Cryptosporidium can be solitary as described by Goodstein et al.,[8] but in many cases, other concurrent respiratory tract pathogens have also been isolated.[3] In the present case, bacterial cultures were negative. The patient was also evaluated for tuberculosis considering the local epidemiology, and sputum cultures were negative. Absence of concurrent infection may s uggest the role of Cryptosporidium as a respiratory pathogen.

Although in majority of cases of pulmonary cryptosporidiosis diarrhea was present and oocyst was isolated from the stool specimen, Kibbler et al.[6] described a case of bone marrow transplant in which there was no diarrhea and stool examination was negative. Similar findings were observed by others.[3],[5] In the present case, symptoms of intestinal cryptosporidiosis were absent. It was difficult to postulate the mode of transmission in the present case. As there were no complaints of diarrhea, primary intestinal cryptosporidiosis was very unlikely. There is a possibility that hematological spread may not have led to the infection. However, inhalational mode of transmission suggested by several studies could not be ruled out in this case.[3],[7]

There is no definitive treatment for pulmonary cryptosporidiosis. However, nitazoxanide therapy has been found beneficial.[4] Most cases of pulmonary cryptosporidiosis are of immunocompromised patients and have a bad prognosis. Antiretroviral therapy has shown some beneficial effects in AIDS patients in a few studies.[3]

One of the limitations of this case report is although molecular-level identification of Cryptosporidium species is considered the gold standard for the confirmation of diagnosis, it could not be done as facilities were not available. Microscopic examination is also an accepted method for the diagnosis of cryptosporidiosis.[1],[4]

This case study emphasizes the fact that pulmonary cryptosporidiosis can be seen in nonretroviral immunodeficiency cases and diarrhea may not be present in such cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


   Conclusion Top


Our experience reveals that although pulmonary cryptosporidiosis is an infrequent presentation and is most commonly seen in AIDS patients, it can also be seen in HIV-negative patients who are immunocompromised. It may not always be associated with the symptoms of intestinal cryptosporidiosis and hence, the clinician should have an index of suspicion in patients with isolated pulmonary cryptosporidiosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
McDonald V, Kelly M. Intestinal Coccidia: Cryptosporidiosis, Isosporiasis, Cyclosporiasis. In :Topley & Wilson's Microbiology and Microbial Infections : Parasitology. 10th ed. London: Hodder Arnold ASM Press; 2010.  Back to cited text no. 1
    
2.
Hunter PR, Nichols G. Epidemiology and clinical features of Cryptosporidium infection in immunocompromised patients. Clin Microbiol Rev 2002;15:145-54.  Back to cited text no. 2
    
3.
Sponseller JK, Griffiths JK, Tzipori S. The evolution of respiratory cryptosporidiosis: Evidence for transmission by inhalation. Clin Microbiol Rev 2014;27:575-86.  Back to cited text no. 3
    
4.
Kumar H, Singh VB, Meena BL, Agrawal J, Beniwal S, Swami T. Pulmonary cryptosporidiosis in an immunocompetent host treated successfully with nitazoxanide. Lung India 2016;33:69-71.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Shrikhande SN, Chande CA, Shegokar VR, Powar RM. Pulmonary cryptosporidiosis in HIV negative, immunocompromised host. Indian J Pathol Microbiol 2009;52:267-8.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Kibbler CC, Smith A, Hamilton-Dutoit SJ, Milburn H, Pattinson JK, Prentice HG. Pulmonary cryptosporidiosis occurring in a bone marrow transplant patient. Scand J Infect Dis 1987;19:581-4.  Back to cited text no. 6
    
7.
Mor SM, Tumwine JK, Ndeezi G, Srinivasan MG, Kaddu-Mulindwa DH, Tzipori S, et al. Respiratory cryptosporidiosis in HIV-seronegative children in Uganda: Potential for respiratory transmission. Clin Infect Dis 2010;50:1366-72.  Back to cited text no. 7
    
8.
Goodstein RS, Colombo CS, Illfelder MA, Skaggs RE. Bronchial and gastrointestinal cryptosporid iosis in AIDS. J Am Osteopath Assoc 1989;89:195-7.  Back to cited text no. 8
    


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