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Cyclosporiasis

Cyclosporiasis describes the condition of being infected with the coccidian protozoan parasite Cyclospora cayetanensis. The main symptom of infection in an immunocompetent host is a self-limiting diarrhea. An infected immunocompromised patient will have chronic diarrhea and rarely acalculous cholecystitis. Children in underdeveloped countries and travelers are especially susceptible to recurrent diarrhea illness. It is an emerging infectious disease with increased incidence rates over the last 20 years. Diagnosis is made by analyzing stool samples for oocysts. Trimethoprim/sulfamethoxazole is an effective treatment. Ciprofloxacin or nitazoxanide are alternative treatments.


Presentation

Incubation lasts between 7 and 14 days after consuming sporulated oocysts. The primary symptom is profuse, malodorous, watery, and non-bloody diarrhea. This type of diarrhea is seen in many other types of GI infection and is indistinguishable from Cryptosporidium or Isospora infections. Additionally, the patient may suffer from the associated symptoms of abdominal cramps, nausea, loss of appetite, malaise, fatigue, dehydration, and weight loss [13]. Malabsorption and low grade fever are also possible. These symptoms are self-limiting in a patient with a healthy immune system, but remission is common. The condition may last several weeks. These symptoms are more aggressive in children. The symptoms of cyclosporiasis in patients with a depressed immune system are more aggressive and should be treated with antibiotics. Additionally, these patients may develop acalculous cholecystitis with right upper quadrant pain and tenderness [10] [11] [12].

Weight Loss
  • Reported here is the case of a 30-year-old Turkish woman, a lawyer, who was admitted to hospital in July 2002 with complaints of watery diarrhoea, anorexia, nausea, vomiting, abdominal pain and weight loss over a period of 1 week.[ncbi.nlm.nih.gov]
  • Patients presented with gastrointestinal symptoms, including diarrhea, flatulence, weight loss, abdominal discomfort, and nausea.[ncbi.nlm.nih.gov]
  • An epidemiological, clinical and biological retrospective study was carried out on 6 patients, 24 to 67 years old, who complained of diarrhea and weight loss, after a travel abroad.[ncbi.nlm.nih.gov]
  • Weight loss in 71.4%. Abdominal pain, rectal tenesmus, and nausea in 42.8%. Vomiting and eructation in 14.2%. Heart burn was a frequent symptom, a finding not often previously described. The infection was probably acquired from raspberry juice.[ncbi.nlm.nih.gov]
  • Additionally, the patient may suffer from the associated symptoms of abdominal cramps, nausea, loss of appetite, malaise, fatigue, dehydration, and weight loss. Malabsorption and low grade fever are also possible.[symptoma.com]
Fever
  • Fever and heart burn in 85.7%. Weight loss in 71.4%. Abdominal pain, rectal tenesmus, and nausea in 42.8%. Vomiting and eructation in 14.2%. Heart burn was a frequent symptom, a finding not often previously described.[ncbi.nlm.nih.gov]
  • Vomiting, body aches, headache, fever, and other flu-like symptoms may be noted. Some people who are infected do not have any symptoms. The disease is usually treated with certain antibiotics.[epi.publichealth.nc.gov]
  • Symptoms of cyclosporiasis may include the following: Watery diarrhea (most common) Loss of appetite Weight loss Cramping Bloating Increased gas Nausea Fatigue Other symptoms that may occur but are less common include the following: Vomiting Low-grade fever[cdc.gov]
  • Most sickened individuals experience diarrhea, cramping, abdominal pain and fever within two to five days after bacterial exposure. The diarrhea may be bloody. The illness typically lasts about a week.[beckershospitalreview.com]
  • Symptoms of cyclosporiasis include watery diarrhea, nausea, vomiting, fever, loss of appetite, abdominal cramps, fatigue, muscle ache and weight loss.[publichealthontario.ca]
Fatigue
  • Additionally, the patient may suffer from the associated symptoms of abdominal cramps, nausea, loss of appetite, malaise, fatigue, dehydration, and weight loss. Malabsorption and low grade fever are also possible.[symptoma.com]
  • Some symptoms, such as diarrhea, can return; and some symptoms, such as fatigue, may continue after the gastrointestinal symptoms have gone away. The infection usually is not life threatening.[cdc.gov]
  • Other common symptoms include loss of appetite, weight loss, stomach cramps/pain, bloating, increased gas, nausea and fatigue. Vomiting, body aches, headache, fever, and other flu-like symptoms may be noted.[epi.publichealth.nc.gov]
  • Most people who become ill with cyclosporiasis get watery diarrhea, loss of appetite, weight loss, stomach cramps/pain, bloating, gas, nausea and fatigue within one week after exposure to the organism.[www11.maine.gov]
  • Symptoms of cyclosporiasis include watery diarrhea, nausea, vomiting, fever, loss of appetite, abdominal cramps, fatigue, muscle ache and weight loss.[publichealthontario.ca]
Malaise
  • Symptoms and Signs The primary symptom of cyclosporiasis is sudden, nonbloody, watery diarrhea, with fever, abdominal cramps, nausea, anorexia, malaise, and weight loss.[merckmanuals.com]
  • […] of constipation Loss of appetite and weight loss Bloating, flatulence and burping Stomach cramps Nausea and vomiting Muscle aches Fever Fatigue – this symptom may last long after the active infection has gotten better General feeling of unwellness (malaise[assignmentpoint.com]
  • Additionally, the patient may suffer from the associated symptoms of abdominal cramps, nausea, loss of appetite, malaise, fatigue, dehydration, and weight loss. Malabsorption and low grade fever are also possible.[symptoma.com]
  • […] fruits & vegetables Clinical Protracted diarrhea described as profuse, malodorous, watery, and can cause dehydration and weight loss; the diarrhea may be associated with nonspecific complaints–eg, intermittent abdominal colic, N&V, low-grade fever, malaise[medical-dictionary.thefreedictionary.com]
Vietnamese
  • Eleven (92%) of the patients had consumed Thai basil, an essential ingredient in Vietnamese cuisine, compared to 3 out of 16 (19%) of the control patients (P 0.003).[ncbi.nlm.nih.gov]
  • Oocysts were isolated from all varieties of farm-grown herbs examined (basil, coriander, lettuce, marjoram, and Vietnamese mint).[cmr.asm.org]
Diarrhea
  • We detected the oocyst of Cyclospora cayetanensis from a 14-yr old girl who complained of persistent diarrhea after traveling to Indonesia.[ncbi.nlm.nih.gov]
  • Cyclospora cayetanensis has been mainly described as a cause of travelers' diarrhea. This pathogen has given rise to a number of epidemic outbreaks attributable to ingestion of imported foods, particularly from tropical areas.[ncbi.nlm.nih.gov]
  • The main symptom of infection in an immunocompetent host is a self-limiting diarrhea. An infected immunocompromised patient will have chronic diarrhea and rarely acalculous cholecystitis.[symptoma.com]
  • Patients presented with gastrointestinal symptoms, including diarrhea, flatulence, weight loss, abdominal discomfort, and nausea.[ncbi.nlm.nih.gov]
  • Because of the apparent increasing incidence of cyclosporiasis in the United States, family physicians should consider testing for Cyclospora in any patient with prolonged, unexplained diarrhea.[ncbi.nlm.nih.gov]
Nausea
  • Reported here is the case of a 30-year-old Turkish woman, a lawyer, who was admitted to hospital in July 2002 with complaints of watery diarrhoea, anorexia, nausea, vomiting, abdominal pain and weight loss over a period of 1 week.[ncbi.nlm.nih.gov]
  • Patients presented with gastrointestinal symptoms, including diarrhea, flatulence, weight loss, abdominal discomfort, and nausea.[ncbi.nlm.nih.gov]
  • Abdominal pain, rectal tenesmus, and nausea in 42.8%. Vomiting and eructation in 14.2%. Heart burn was a frequent symptom, a finding not often previously described. The infection was probably acquired from raspberry juice.[ncbi.nlm.nih.gov]
  • Additionally, the patient may suffer from the associated symptoms of abdominal cramps, nausea, loss of appetite, malaise, fatigue, dehydration, and weight loss. Malabsorption and low grade fever are also possible.[symptoma.com]
  • A brief period of flu-like illness characterized by weakness and low-grade fever is followed by watery diarrhea, nausea, loss of appetite, and muscle aches.[medical-dictionary.thefreedictionary.com]
Vomiting
  • Reported here is the case of a 30-year-old Turkish woman, a lawyer, who was admitted to hospital in July 2002 with complaints of watery diarrhoea, anorexia, nausea, vomiting, abdominal pain and weight loss over a period of 1 week.[ncbi.nlm.nih.gov]
  • Vomiting and eructation in 14.2%. Heart burn was a frequent symptom, a finding not often previously described. The infection was probably acquired from raspberry juice. All cases improved with trimethoprim/sulphametoxazol.[ncbi.nlm.nih.gov]
  • Cases are subject to restriction on school and day-care attendance, food handling, and patient care for the duration of any diarrhea and/or vomiting.[oregon.gov]
  • There are many other causes of nausea, vomiting, diarrhea that can range anything from food poisoning to other infectious agents," he said.[nbcdfw.com]
  • Vomiting, body aches, headache, fever, and other flu-like symptoms may be noted. Some people who are infected do not have any symptoms. The disease is usually treated with certain antibiotics.[epi.publichealth.nc.gov]
Loss of Appetite
  • Additionally, the patient may suffer from the associated symptoms of abdominal cramps, nausea, loss of appetite, malaise, fatigue, dehydration, and weight loss. Malabsorption and low grade fever are also possible.[symptoma.com]
  • Other common symptoms include loss of appetite, weight loss, stomach cramps/pain, bloating, increased gas, nausea and fatigue. Vomiting, body aches, headache, fever, and other flu-like symptoms may be noted.[epi.publichealth.nc.gov]
  • Most people who become ill with cyclosporiasis get watery diarrhea, loss of appetite, weight loss, stomach cramps/pain, bloating, gas, nausea and fatigue within one week after exposure to the organism.[www11.maine.gov]
  • Symptoms of cyclosporiasis may include the following: Watery diarrhea (most common) Loss of appetite Weight loss Cramping Bloating Increased gas Nausea Fatigue Other symptoms that may occur but are less common include the following: Vomiting Low-grade[cdc.gov]
  • Symptoms of cyclosporiasis include watery diarrhea, nausea, vomiting, fever, loss of appetite, abdominal cramps, fatigue, muscle ache and weight loss.[publichealthontario.ca]
Abdominal Cramps
  • Additionally, the patient may suffer from the associated symptoms of abdominal cramps, nausea, loss of appetite, malaise, fatigue, dehydration, and weight loss. Malabsorption and low grade fever are also possible.[symptoma.com]
  • Symptoms of cyclosporiasis include watery diarrhea, nausea, vomiting, fever, loss of appetite, abdominal cramps, fatigue, muscle ache and weight loss.[publichealthontario.ca]
  • Watery diarrhea is the most common symptom, but patients may also experience anorexia, fatigue, weight loss, nausea, flatulence, abdominal cramping, myalgia, vomiting and low-grade fever, typically an average of 7 days after infection, according to the[healio.com]
  • The Cyclospora cayetanensis organism in responsible for watery diarrhea, nausea, abdominal cramping, anorexia and weight loss.[ehagroup.com]
  • Symptoms include watery diarrhea, nausea, loss of appetite, fatigue, abdominal cramps and weight loss. Cyclosporiasis is spread by consuming contaminated food or water or swimming in contaminated water.[simcoemuskokahealthstats.org]
Myalgia
  • Watery diarrhea is the most common symptom, but patients may also experience anorexia, fatigue, weight loss, nausea, flatulence, abdominal cramping, myalgia, vomiting and low-grade fever, typically an average of 7 days after infection, according to the[healio.com]
  • Other symptoms include anorexia, fatigue, weight loss, nausea, flatulence, abdominal cramping, and myalgia. Symptoms may begin an average of 7 days after infection, and if untreated, the illness can last from a few days to a month or longer.[pharmacytimes.com]
  • Anorexia, fatigue, weight loss, nausea, flatulence, abdominal cramping, myalgia, vomiting, low-grade fever are other common symptoms. After ingestion of the parasite, symptoms may develop in about seven days.[empr.com]
  • Other common symptoms include loss of appetite, nausea, abdominal cramps, weight loss, fatigue, and myalgia (muscle pain); vomiting and low-grade fever also may occur. Cyclospora infection is diagnosed by examining stool.[foodsafety.gov]
  • Other common symptoms include anorexia, fatigue, weight loss, nausea, flatulence, abdominal cramping and myalgia; vomiting and low-grade fever may also be seen.[aafp.org]

Workup

Laboratory studies

Stool 

  • The most common method of diagnosis is by detecting oocysts in a stool sample. Analysis for Cyclospora oocysts is typically not a part of the normal ova and parasite order set. It may require a special request. At least three stool samples should be evaluated because oocyst excretion is not consistent. Samples are stained with safranin stain or modified acid-fast stain. Under microscopy, the oocysts are 8-10 micrometers in diameter, are round to ovoid in shape [14]. Charcot-Leyden crystals may be observed in the stool sample as well. Additionally, under ultraviolet light between wavelengths of 340–380 nm the oocysts autofluoresce to produce a pale blue glow [15].
  • Cyclospora PCR assays are available for investigating large outbreaks, but they are not FDA approved at this time.

Blood

Histology

Procedures

  • D-xylose absorption test is used to diagnose malabsorption, a symptom of severe cyclosporiasis. Normally, when D-xylose is taken orally it will be absorbed by the small intestine and excreted, unchanged, in the urine. GI infections that inflame the small intestine mucosa, such as Whipple disease and cyclosporiasis, cause malabsorption and will show decreased D-xylose excretion in the urine because most of the sugar is not absorbed, but passed with stool. Normal excretion levels are restored after a treatment with the appropriate antibiotics.

Imaging studies

  • Immunocompromised patients suffering from acalculous cholecystitis will show a thickened gallbladder on ultrasound.
Giardia Lamblia
  • Three protozoan parasites are shown schematically: a Giardia lamblia cyst (length ranges from 8 to 19 µm and averages 11–12 µm), a Cyclospora cayetanensis oocyst (8–10 µm), and a Cryptosporidium parvum oocyst (average dimensions, 4.5 µm 5 µm).[academic.oup.com]
  • Simultaneous detection of Entamoeba histolytica, Giardia lamblia, and Cryptosporidium parvum in fecal samples by using multiplex real-time PCR. J Clin Microbiol. 2004 Mar. 42(3):1220-3. [Medline]. [Full Text].[emedicine.com]
  • Simultaneous detection of Entamoeba histolytica, Giardia lamblia, and Cryptosporidium parvum in fecal samples by using multiplex real-time PCR. J Clin Microbiol . 2004 Mar. 42(3):1220-3. [Medline] . [Full Text] .[emedicine.medscape.com]
Entamoeba Histolytica
  • Parasites such as Cryptosporidium, Giardia intestinalis, Entamoeba histolytica/dispar, Blastocystis hominis and others were also observed.[ncbi.nlm.nih.gov]
  • For comparison, it is thought that the first documented human cases of infection with other protozoan parasites date back as follows: for Giardia lamblia , to the late 17th century [ 28 ]; for Entamoeba histolytica , to the late 19th century [ 29 ]; for[academic.oup.com]
  • For comparison, it is thought that the first documented human cases of infection with other protozoan parasites date back as follows: for Giardia lamblia, to the late 17th century [ 28 ]; for Entamoeba histolytica, to the late 19th century [ 29 ]; for[doi.org]
  • Simultaneous detection of Entamoeba histolytica, Giardia lamblia, and Cryptosporidium parvum in fecal samples by using multiplex real-time PCR. J Clin Microbiol. 2004 Mar. 42(3):1220-3. [Medline]. [Full Text].[emedicine.com]
Cyclospora Cayetanesis
  • Contact Us Enteric, Zoonotic and Vector-Borne Diseases Cyclosporiasis is an infection of the small bowel caused by the parasite Cyclospora cayetanesis .[publichealthontario.ca]
  • cayetanesis, cyclospora cayetanensis, Cyclospora cayetanensis, Cyclospora cayetanesis, Cyclospora cayetanensis (organism), Cyclospora cayetanesis (organism) Spanish Cyclospora cayetanensis, Cyclospora cayetanensis (organismo), Cyclospora cayetanesis,[fpnotebook.com]
Colitis

Treatment

Cyclosporiasis is a self-limiting condition in an immunocompetent patient. Treatment with antibiotics is not required, though it will shorten the symptomatic period and the time excreting oocytes.

  • First line treatment for cyclosporiasis is trimethoprim/sulfamethoxazole [16]: TMP 160 mg /SMX 800 mg by mouth twice a day for 1-2 weeks.
  • The pediatric dose is: TMP 5 mg/kg /SMX 25 mg/kg by mouth twice a day for 1-2 weeks.
  • In patients with a depressed immune system a higher dose may be required for a longer period of time [16] [17] [18]. Suppressive therapy after treatment is complete is also recommended to prevent reinfection. 
  • For patients that with sulfa allergies or other conditions that preclude trimethoprim/sulfamethoxazole use [19] [20]: Ciprofloxacin 500mg by mouth twice a day for 1 week or Nitazoxanide 500 mg twice daily with food for 3 days.

Prognosis

The mortality rate from cyclosporiasis is very low. Infection in an immunocompetent patient is usually self-limiting. The severe, though short lived, diarrhea associated with this infection can lead to severe dehydration and malnutrition, especially in children. Full recovery in this population is expected but reinfection is possible. Treatment with antibiotics can speed recovery and reduce oocyte shedding, but is usually not necessary. In an immunosuppressed patient, infection is chronic. Dehydration and malnutrition can lead to weight loss. Additionally, this population can develop acalculous cholecystitis. Antibiotics are usually required to treat the infection and prophylactic antibiotics may be necessary to prevent reinfection.

Etiology

Cyclosporiasis is caused by ingestion of sporulated Cyclospora cayetanensis oocysts. They are often found in fecal contaminated water or sewage, especially in the underdeveloped world. Travelers to these areas are very susceptible [2]. However, cyclosporiasis is becoming more common in the developed world as well. The immunocompromised population is at risk of developing chronic cyclosporiasis.

Epidemiology

C. cayetanesis oocysts are frequently isolated in individuals from developing countries or travelers returning from these countries [3] [4]. Infection prevalence in endemic areas is between 2-18%. Endemic areas include Guatemala, Haiti, Nepal, and Peru. In developed countries the prevalence is between 0.1% - 0.5% [5]. The incidence rate in the developed world is increasing. Cases of infection are often associated with contaminated food or water and travelers returning from endemic areas. 

Sex distribution
Age distribution

Pathophysiology

Cyclospora measure 8-10 micrometers in diameter, are round to ovoid in shape, and variably acid-fast. As part of their life cycle, they require about 7 days outside the human GI tract to sporulate. Two infectious sporocysts are produced for every one immature, noninfectious oocyst. Transmission occurs after the sporocysts are ingested, usually in feces infected water or contaminated food. Incubation takes 7-14 days after consumption. Two sporozoites emerge from each sporocytsts and invade the enterocyte lining of the GI tract in the small intestine. The sporozoites have an anterior polar complex that is required to enter the host’s enterocytes. The precise mechanism is not known.

In the enterocytes of the jejunum and ileum of the small intestine the parasite replicates asexually to form type I and type II meronts. Type II meronts mature into male mircogametocytes and female macrogametocytes. The microgametocyte fertilizes the microgametocyte, still while inside the intestinal epithelial cell. Unsporulated oocysts are formed and escape the intracellular space into the lumen of the GI tract, where they are excreted with the stool to continue the cycle. Cyclospora unsporulated oocysts may be confused with cryptosporidium oocysts because they are both acid fast, but cryptosporidium (4-5 um) are about half the size of Cyclospora oocysts (8-10 um) [7]. Cryptosporidium oocysts are also instantly infectious where Cyclospora oocysts are not [8] [9]. Experiments to infect various animals species with Cyclospora cayetanensis were unsuccessful, suggesting the need for a specific, unknown trigger to initiate infection [6].

Prevention

While traveling abroad in underdeveloped countries do not consume untreated water or ice and do not eat unpeeled fruits and vegetables which can be contaminated. Thoroughly heating foods and boiling water effectively neutralizes the parasite and will prevent infection. Hand hygiene is also essential.

Summary

Cyclospora are single celled coccidian protozoa. They are found throughout the world and infect many different types of animals including mammals and reptiles. Humans are the only recognized hosts for C. cayetanesis. Cyclosporiasis is classified as an emerging infectious disease. The parasite is infectious to both immunocompetent and immunocompromised hosts. In the immunocompromised, it produces a chronic disease. Infection is limited to the gastrointestinal (GI) tract and is characterized by a profuse, malodorous, and watery diarrhea with nausea, abdominal cramping, bloating, and fatigue. Symptoms can last up to 2 months. Explosive diarrhea is also possible. Similar GI symptoms are found in other parasite infections from Cryptosporidium or Isospora. The route of transmission is person to person as oocysts are released in the stool. A fresh stool sample is not communicable, they require about 1 week outside the GI tract to sporulate before they are infectious [1]. A person with an active C. cayetanesis infection may be asymptomatic but still excrete oocysts.

Patient Information

Cyclosporiasis describes an intestinal infection caused by Cyclospora cayetanensis. It is more commonly found in the developing world, especially in children, and in travelers to these parts of the world; however, it is an emerging infectious disease in the developed world.

Causes

Transmission is caused by ingestion of water or food contaminated with fecal material that contains Cyclospora oocysts. Incubation is 1-2 weeks after ingestion of infectious oocytes.

Signs and symptoms

The main symptoms is a watery, malodorous, and profuse diarrhea. This may be worse in children and immunosuppressed adults. Other symptoms include:

Bloating
Cramping
Fatigue
• Increased flatulence
Loss of appetite
Nausea
Weight loss

Diagnosis

Cyclosporiasis is diagnosed by stool examination. Multiple stool samples may need to be analyzed to find an oocyte.

Treatment

Most patients with a healthy immune systems (immunocompetent) will recover without treatment, though antibiotics will ameliorate symptoms (especially the diarrhea). Patients with a compromised immune system (HIV/AIDS, chemotherapy for cancer, anti-rejection medication after an organ transplant) may develop a chronic disease and will require antibiotic treatment and prophylaxis to prevent future disease. Treatment consists of the combination of trimethoprim and sulfamethoxazole. Ciprofloxacin and nitazoxanide are equivalent alternative treatments.

References

Article

  1. Herwaldt BL. Cyclospora cayetanensis: a review, focusing on the outbreaks of cyclosporiasis in the 1990s. Clin Infect Dis. 2000 Oct;31(4):1040-57. Epub 2000 Oct 10.
  2. Stark D, Barratt JL, van Hal S, Marriott D, Harkness J, Ellis JT. Clinical significance of enteric protozoa in the immunosuppressed human population. Clin Microbiol Rev. 2009 Oct. 22(4):634-50.
  3. Chacin-Bonilla L. Epidemiology of Cyclospora cayetanensis: A review focusing in endemic areas. Acta Trop. 2010 Sep. 115(3):181-93.
  4. Samie A, Guerrant RL, Barrett L, Bessong PO, Igumbor EO, Obi CL. Prevalence of intestinal parasitic and bacterial pathogens in diarrhoeal and non-diarroeal human stools from Vhembe district, South Africa. J Health Popul Nutr. 2009 Dec. 27(6):739-45.
  5. Murray P, Rosenthal K, Pfaller M. Intestinal and Urogenital protozoa. Medical Microbiology. 7th edition. 2013. 745-758.
  6. Eberhard ML, Ortega YR, Hanes DE, Nace EK, Do RQ, Robl MG, Won KY, Gavidia C, Sass NL, Mansfield K, Gozalo A, Griffiths J, Gilman R, Sterling CR, Arrowood MJ.  Attempts to establish experimental Cyclospora cayetanensis infection in laboratory animals. J Parasitol. 2000 Jun;86(3):577-82.
  7. Sterling CR, Ortega YR. Cyclospora: an enigma worth unraveling. Emerg Infect Dis. 1999 Jan-Feb;5(1):48-53.
  8. Ortega YR, Gilman RH, Sterling CR. A new coccidian parasite (Apicomplexa: Eimeriidae) from humans. J Parasitol. 1994 Aug;80(4):625-9.
  9. Ortega YR, Sterling CR, Gilman RH, Cama VA, Díaz F. Cyclospora species--a new  protozoan pathogen of humans. N Engl J Med. 1993 May 6;328(18):1308-12.
  10. Sifuentes-Osornio J, Porras-Cortés G, Bendall RP, Morales-Villarreal F, Reyes-Terán G, Ruiz-Palacios GM. Cyclospora cayetanensis infection in patients with and without AIDS: biliary disease as another clinical manifestation. Clin Infect Dis. 1995 Nov. 21(5):1092-7.
  11. Zar FA, El-Bayoumi E, Yungbluth MM. Histologic proof of acalculous cholecystitis due to Cyclospora cayetanensis. Clin Infect Dis. 2001 Dec 15. 33(12):E140-1.
  12. de Górgolas M, Fortés J, Fernández Guerrero ML. Cyclospora cayetanensis Cholecystitis in a patient with AIDS. Ann Intern Med. 2001 Jan 16. 134(2):166.
  13. Centers for Disease Control and Prevention (CDC). Outbreak of cyclosporiasis associated with snow peas--Pennsylvania, 2004. MMWR Morb Mortal Wkly Rep. 2004 Sep 24;53(37):876-8.
  14. McHardy IH, Wu M, Shimizu-Cohen R, Couturier MR, Humphries RM. Detection of intestinal protozoa in the clinical laboratory. J Clin Microbiol. 2014 Mar. 52(3):712-20.
  15. Eberhard ML, Pieniazek NJ, Arrowood MJ. Laboratory diagnosis of Cyclospora infections. Arch Pathol Lab Med. 1997 Aug;121(8):792-7.
  16. Ortega YR, Sterling CR, Gilman RH, Cama VA, Díaz F. Cyclospora species--a new protozoan pathogen of humans. N Engl J Med. 1993 May 6;328(18):1308-12.
  17. Bourée P, Lancon A, Bisaro F, Bonnot G. Six human cyclosporiasis: with general review. J Egypt Soc Parasitol. 2007 Aug. 37(2):349-60.
  18. Hoge CW, Shlim DR, Ghimire M, Rabold JG, Pandey P, Walch A, Rajah R, Gaudio P, Echeverria P. Placebo-controlled trial of co-trimoxazole for Cyclospora infections among travellers and foreign residents in Nepal. Lancet. 1995 Mar 18;345(8951):691-3. Erratum in: Lancet 1995 Apr 22;345(8956):1060.
  19. Madico G, Gilman RH, Miranda E, Cabrera L, Sterling CR. Treatment of Cyclospora infections with co-trimoxazole. Lancet. 1993 Jul 10;342(8863):122-3. 
  20. Verdier RI, Fitzgerald DW, Johnson WD Jr, Pape JW. Trimethoprim-sulfamethoxazole compared with ciprofloxacin for treatment and prophylaxis of Isospora belli and Cyclospora cayetanensis infection in HIV-infected patients. A randomized, controlled trial. Ann Intern Med. 2000 Jun 6. 132(11):885-8.

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Last updated: 2019-07-11 22:03