Introduction:Cryptosporodium parvum is an intracellular protozoa typically associated with immunosuppression, farm animal exposure, and waterborne outbreaks. In a previous literature review, there have only been 7 cases of cryptosporidium enteritis in adult patients after orthotopic liver transplantation (OLT). Typically, the disease is self-limited in immunocompetent patients, but can be severe and debilitating in the immunosuppressed. We present a case of cryptosporidium enteritis in a liver transplant patient associated with farm animal exposure. Case Report: A 31-year-old male patient with a history of cryptogenic cirrhosis status post OLT 15 months prior to admission presented with acute, severe, non-bloody diarrhea, emesis, and crampy abdominal pain after petting a calf approximately one week prior. The patient’s immunosuppressant regimen consisted of tacrolimus 7 mg twice daily and mycophenolate mofetil 1,000 mg twice daily. His tacrolimus levels were therapeutic on admission. Given his gastrointestinal complaints, his mycophenolate mofetil was initially held. Stool studies, including an ELISA ova and parasite antigen screen, returned positive for Cryptosporidium parvum. Infectious disease was consulted, and the patient was started on the thiazolide antiprotozoal agent nitazoxanide 500 mg twice daily. After the patient developed a rash, his treatment was changed to azithromycin and paromomycin. The patient’s hospital course was complicated by mild acute rejection confirmed on liver biopsy, most likely secondary to his immunosuppression changes on admission. Further into his hospital course, the patient did develop elevated tacrolimus levels that were first noted after the initiation of paromomycin and azithromycin. The patient completed a 6-week course of anti-parasitic therapy with subsequent resolution of his diarrhea. Discussion:Cryptosporidium parvum typically infects the upper small bowel villi. Noted complications of cryptosporidiosis cases in solid organ transplant patients have included acute kidney injury, biliary stricturing, sclerosing cholangitis, and persistently elevated tacrolimus levels with a mechanism that is poorly understood. Currently, first-line therapy is nitazoxanide, and a longer antiparasitic course of several weeks is favored over a shorter one to prevent relapse. In immunosuppressed patients with diarrhea, we would recommend adding ova and parasite testing to the standard bacterial and viral work-up. In addition, patients’ tacrolimus levels need to be monitored closely, as elevated tacrolimus levels have been associated with cryptosporidial enteritis.
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Dec 1, 2015
Simon Mbarushimana + 3
Open Access
