S2919 Atypical Presentation odslrf Cryptosporidiosis in an Immunocompetent Female

Abstract

INTRODUCTION: Cryptosporidiosis is an opportunistic diarrheal infection caused by Cryptosporidium, an intracellular protozoan, prevalent mostly in immunocompromised individuals. We report a rare case of extensive cryptosporidiosis of the upper gastrointestinal (UGI) tract in an immunocompetent individual. CASE DESCRIPTION/METHODS: A 77 year-old female with history of cholecystectomy presented to the clinic with 2-months history of nausea and chronic epigastric pain. Her symptoms were aggravated by spicy foods and not relieved with omeprazole and sucralfate. She did not have any diarrhea, fever or chills. She was a retired nurse and denied any sick contacts, contact with farm animals or a travel history. She denied any animal bites. She consumed only bottled water for drinking. Her workup was unremarkable for anemia or leukocytosis and normal liver enzymes. She had mild delayed gastric emptying and a positive glucose breath test for small bowel bacterial overgrowth (SIBO). She received Reglan and Doxycycline with no significant improvement. Her esophagogastroduodenoscopy (EGD) showed esophagitis and antral erosions. Biopsy report by local pathologist showed esophagitis, chronic inactive gastritis and duodenitis. A secondary review by our GI pathologist confirmed prior findings but also reported cryptosporidium in the esophageal, gastric and duodenal biospies. Giemsa stain was negative for helicobacter pylori. Her HIV antibody was negative and IgA levels were normal. She was treated with a 3-day course of Nitazoxanide 500 mg twice daily with improvement in her symptoms. A repeat EGD after 4 months showed no inflammation and absence of cryptosporidium suggesting successful eradication. DISCUSSION: Cryptosporidiosis presents commonly as secretory diarrhea, malaise and cramping abdominal pain with or without biliary involvement (10–30%). Asymptomatic cases have been reported in immunocompetent hosts especially in children. Fecal leukocytes are rare unless co-infected with another enteric pathogen. We report an atypical presentation of non-diarrheal cryptosporidiosis associated with biopsy-proven inflammation in UGI tract that responded to Nitazoxanide. The patient likely contracted the parasite from an untraceable contaminated water source. Clinically, a high level of suspicion should be exercised in patients with refractory UGI symptoms to look for infectious causes. It is also important to consider an expert GI pathologist’s review of the histopathology in cases with an unclear diagnosis.Figure 1.: A. Low power photomicrograph of the stomach demonstrates only mild reactive change.Figure 2.: B. At high power, numerous organisms similar to those seen in B are noted in adherent mucus.Figure 3.: C. High power image of duodenum highlights numerous small (1-2 micron) basophilic “beads” seemingly adherent to the brush border.