Chronic Cryptosporidiosis in an Immunocompetent Patient with Non-insulin Dependent Diabetes Mellitus

Abstract

Background:Cryptosporidium parvum, a protozoan pathogen, is a well-documented cause of multiple gastrointestinal symptoms in immuncompromised patients, particularly in patients with AIDS. A limited number of cases have described immunocompetent patients who suffered from cryptosporidiosis. However, the relationship between chronic cryptosporidiosis and immunocompetent patient with diabetes has been poorly defined. Case: An 85-year-old Caucasian man with history of type II diabetes diagnosed 7 years prior to presentation, hypertension, and gouty arthritis presented with chronic diarrhea. The patient recalled that after having a meal at a local restaurant two years ago, he abruptly developed watery diarrhea. Within a day, patient developed loose urgent stool each morning after breakfast and also presented with borborygemi each evening after supper. Frequently, the patient experienced stool incontinence and did not have suffi cient time to reach the restroom. The patient endorsed a 25-pound, unintentional weight loss since the onset of his diarrhea 2 years ago. Patient was only taking glyburide for his diabetes without using insulin in the past. Patient's initial abdominal exam was benign and his rectal exam revealed liquid brown stool that was stool guaiac test negative. Patient's initial laboratory results showed hemoglobin 12.5, hematocrit 37.2, white count 8.99, platelet 209, glucose 141, and hemoglobin A1c of 7.0; the rest of the complete metabolic panel was within normal limits. Stool studies were negative for ova and parasites, Clostridium difficile toxin, and giardia antigen. However, the stool study was positive for Cryptosporidium antigen. Immediately after the incidental finding of the positive result for Cryptosporidium antigen, an immune deficiency profile panel was placed. Patient was found to have non-reactive human immunodeficiency virus (HIV) antibody, no HIV viral load, normal absolute CD4 helper count at 863, and no eosinophilia. Patient was evaluated by an infectious disease specialist and was placed on Paromomycin. After 2 weeks of therapy, patient's explosive diarrhea subsided. Patient has been symptom free for the past 6 months. Discussion: There is decreased polymorphonuclear leukocytes (PMN) chemotaxis in both type 1 and 2 diabetes patients compared to that of people without this disease. There is also phagocytic deficiency of neutrophils and T cell deficiency in patients with diabetes. A prior condition of non-insulin dependent diabetes mellitus may have predisposed our patient to severe Cryptosporidium infection. In addition, elderly patients may also be at increased risk of infection due to normal immunosenescence.