CYSTOISOSPORIOSIS (isosporiosis)

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Cystoisospora belli (syn. Isospora belli)

Causal Agent:
The coccidian parasite, Cystoisospora belli, infects the epithelial cells of the
small intestine, and is the least common of the three intestinal coccidia that
infect humans.

Life Cycle:
At time of excretion, the immature oocyst contains usually one sporoblast (more
rarely two) .  In further maturation after excretion, the sporoblast divides in two
(the oocyst now contains two sporoblasts); the sporoblasts secrete a cyst wall,
thus becoming sporocysts; and the sporocysts divide twice to produce four
sporozoites each .  Infection occurs by ingestion of sporocysts-containing
oocysts: the sporocysts excyst in the small intestine and release their
sporozoites, which invade the epithelial cells and initiate schizogony .  Upon
rupture of the schizonts, the merozoites are released, invade new epithelial
cells, and continue the cycle of asexual multiplication .  Trophozoites develop
into schizonts which contain multiple merozoites.  After a minimum of one week,
the sexual stage begins with the development of male and female gametocytes
.  Fertilization results in the development of oocysts that are excreted in the
stool .  Cystoisospora belli infects both humans and animals.

Geographic Distribution:
Worldwide, especially in tropical and subtropical areas. Infection occurs in
immunodepressed individuals, and outbreaks have been reported in
institutionalized groups in the United States.

Clinical Features:
Infection causes acute, nonbloody diarrhea with crampy abdominal pain, which
can last for weeks and result in malabsorption and weight loss. In
immunodepressed patients, and in infants and children, the diarrhea can be
severe. Eosinophilia may be present (differently from other protozoan
infections).

Laboratory Diagnosis:
Microscopic demonstration of the large, typically shaped oocysts, is the basis
for diagnosis. Because the oocysts may be passed in small amounts and
intermittently, repeated stool examinations and concentration procedures are
recommended.
If stool examinations are negative, examination of duodenal specimens by
biopsy or string test (Enterotest®) may be needed.
The oocysts can be visualized on wet mounts by microscopy with bright-field,
differential interference contrast (DIC), and epifluorescence. They can also be
stained by modified acid-fast stain.

Diagnostic findings
Microscopy

Treatment:
Trimethoprim-sulfamethoxazole is the drug of choice.
Microscopy
The oocysts of C. belli are large (25 to 30 µm) and have a typical ellipsoidal
shape. When excreted, they are immature and contain one sporoblast. The
oocyst matures after excretion: the single sporoblast divides in two sporoblasts,
which develop cyst walls, becoming sporocysts, which eventually contain four
sporozoites each. Cystoisospora will autofluoresce under ultraviolet (UV)
microscopy.

A B

A: Immature oocyst of C. belli in an unstained wet mount, showing a single

sporoblast.
B: Immature oocyst of C. belli stained with safranin, showing a single
sporoblast.

C D

C: Immature oocyst of C. belli stained with acid-fast, showing a single

sporoblast.
D: Immature oocyst of C. belli viewed under differential interference contrast (DIC),
showing two sporoblasts.
 Immature oocyst of C. belli
viewed under ultraviolet (UV)
microscopy.

F G

F, G: Oocysts of C. belli in the epithelial cells of a mammalian host, stained

with H&E (yellow arrows).