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Isosporiasis in Patients With HIV Infection in The Highly Active Antiretroviral Therapy Era in France
Isosporiasis in Patients With HIV Infection in The Highly Active Antiretroviral Therapy Era in France
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HIV Medicine (2008), 9, 126–130 r 2008 British HIV Association
ORIGINAL RESEARCH
Background
Isosporiasis, a rare cause of diarrhoea among HIV-infected patients in the pre-highly active
antiretroviral therapy (HAART) era, seems to be re-emerging.
Methods
A retrospective study was carried out for the period 1995–2003 in two hospitals in Paris to describe
the prevalence, clinical characteristics and therapeutic outcome of isosporiasis in HIV-infected
patients, and to compare the findings with those for cryptosporidiosis and microsporidiosis.
Results
The prevalence of isosporiasis increased from 0.4 per 1000 patients in the pre-HAART era
(1995–1996) to 4.4 per 1000 patients in the HAART era (2001–2003), whereas the prevalence
of cryptosporidiosis and microsporidiosis decreased. Compared with patients with either
cryptosporidiosis (n 5 91) or microsporidiosis (n 5 58), patients with isosporiasis (n 5 28) more
frequently originated from sub-Saharan Africa (72%), were more frequently female and
heterosexual, and had a higher median CD4 count at diagnosis (142 cells/mL). All patients
with isosporiasis presented with diarrhoea, which was severe enough to lead to hospital admission
for 60% of them. Fever was uncommon (7%). All patients were treated for isosporiasis, 27 of them
with cotrimoxazole. Relapse of isosporiasis occurred in six of 16 patients (38%) despite maintenance
cotrimoxazole therapy and HAART.
Conclusion
Isosporiasis in France occurs mostly in patients emigrating from sub-Saharan Africa and can induce
severe diarrhoea. Relapse is common despite cotrimoxazole maintenance therapy.
Keywords: cotrimoxazole, diarrhoea, HIV, isosporiasis, relapse, sub-Saharan Africa
Received: 7 September 2007, accepted 2 November 2007
126
Isosporiasis in the HAART era 127
Methods 2.5
of HIV infection, previous opportunistic infections, CD4 cell Fig. 1 Annual prevalence of isosporiasis, cryptosporidiosis and
count, plasma HIV RNA level, Centers for Disease Control microsporidiosis at Lariboisière and Saint Louis Hospitals from
and Prevention clinical classification and the use of 1995 to 2003.
HAART. These characteristics were also recorded for HIV-
infected patients diagnosed during the same period in the
Parasitology Laboratory with either microsporidiosis or
test, using Hochberg’s correction for multiple testing [14].
cryptosporidiosis, two other intestinal opportunistic infec-
Similarly, we compared the characteristics of patients, with
tions [12]. Furthermore, for each patient for whom a
a minimum of 12 months of follow-up, with or without a
diagnosis of isosporiasis was made, the following data were
relapse of isosporiasis, using Fisher’s exact test or the
recorded from clinical charts: presence and duration of
Wilcoxon rank-sum test. The cumulated incidence rate of
diarrhoea (defined as more than three loose or liquid stools
the first relapse of isosporiasis was estimated by the
per day for more than 48 h), presence of fever (temperature
Kaplan–Meier method. All tests were two-sided at the
higher than 37.5 1C), weight loss (in kg), presence of
0.05 level.
alithiasic cholecystitis (defined as right hypochondrium
pain and thickening of the gall bladder wall on ultrasono-
graphy) and/or cholangitis (elevated alkaline phosphatase Results
and dilatation of intra- and extra-hepatic bile ducts on
ultrasonography), initial therapy for isosporiasis, use of Prevalence and baseline characteristics
maintenance therapy and relapses (defined as the reap-
Between January 1995 and September 2003, 28 patients
pearance of oocysts in stools after at least 7 days of
were diagnosed with isosporiasis and included in our study.
appropriate therapy, with recurrence of diarrhoea).
Isosporiasis was diagnosed on parasitological stool exam-
ination in 28 patients, and duodenal biopsy in three
patients. I. belli oocysts were detected in the first stool
Statistical analysis
sample in 26 of 28 patients. In one patient, only the fourth
In order to compare the prevalences of the three stool sample yielded the parasite. The annual prevalences
opportunistic intestinal infections (microsporidiosis, cryp- of isosporiasis, cryptosporidiosis and microsporidiosis
tosporidiosis and isosporiasis) in the pre- and post-HAART during the study period are shown in Fig. 1. Compared
eras, we defined two periods: 1995–1996 and 2001–2003. with the pre-HAART era (prevalence of 0.4 per 1000
The numbers of patients followed in each period in the two patients in 1995–1996), the prevalence of isosporiasis
hospitals were obtained from our computerized database increased in the post-HAART era (prevalence of 4.4 per
(French Hospital Database) [13]. 1000 patients in 2001–2003; P 5 0.001). The opposite was
The baseline characteristics of patients with each of these true for both cryptosporidiosis and microsporidiosis, the
protozoal intestinal infections were first compared using prevalences of which decreased from 19 and 12 per 1000
Fisher’s exact test for qualitative variables and the Kruskal– patients in the pre-HAART era to 2.6 and 1.3 per 1000
Wallis rank-sum test for quantitative variables. In the case patients in the post-HAART era, respectively (both
of a significant difference in the three-group comparison, Po0.0001).
post-hoc two-by-two group comparisons were performed Comparing the baseline characteristics of patients
using either Fisher’s exact test or the Wilcoxon rank-sum with isosporiasis to those with cryptosporidiosis or
Table 1 Baseline characteristics of patients with isosporiasis, cryptosporidiosis and microsporidiosis in Lariboisière and Saint Louis Hospitals
(1 January 1995 to 31 December 2003) and P-values for comparison of isosporiasis vs. cryptosporidiosis and microsporidiosis
Percentages may differ from 100% because of rounding. * There were 725 patients with unknown geographical provenance.