Intestinal Microsporidiosis from Duodenal Aspirate in a HIV-1 Positive Child with Polymicrobial Infections

Excerpt

To the Editor: We report a case of intestinal microsporidiosis in a 9-y-old HIV-1 positive girl child who was receiving both anti-retroviral and anti-tubercular treatment (ATT) for last 4 mo. She presented with non-productive cough for two months and had complains of high-grade fever, progressive yellowish discoloration of eyes, and persistent loose stools for a period of two weeks. On admission, she was febrile, anemic, icteric, had tachycardia, tachypnea, generalised lymphadenopathy, and oral thrush. Other systemic examination revealed no significant abnormalities and baseline Contrast Enhanced Computed tomography (CECT) of brain could detect multiple abscesses with peri-lesional edema. Upon respiratory system examination bilateral chest in-drawing, bronchial breath sounds and coarse crackles were noted. Computed tomography (CT) of chest showed widening of mediastinum with bilateral multifocal consolidations. Examination of aspirated pus from lingular lobe consolidation region revealed thin, branching, filamentous beaded bacteria, confirmed as Nocardia species by culture. GeneXpert of broncho-alveolar lavage fluid (BALF) was positive for Mycobacterium tuberculosis. In view of persistent diarrhea, upper gastro-intestinal endoscopy (UGIE) was performed and examination of duodenal aspirate could demonstrate 0.5-1 μm, pink colored characteristic acid-fast spores on Ziehl-Neelsen stained slide (Supplementary Fig. S1) which was more conclusive compared to available images in published literature and was re-confirmed by polymerase chain reaction (PCR) assay and gene sequencing as Enterocytozoon bieneusi. The child was treated with combination of meropenem and amikacin for nocardiosis, trimethoprim-sulphamethoxazole for microsporidiosis and fluconazole for thrush. The child improved significantly clinically, however after four months she complained of intractable diarrhea, fever and breathlessness and succumbed to the illness. Albeit various reports of Enterocytozoon bieneusi in duodenal aspirates, stool, and intestinal biopsy specimens in HIV infected patients [1‐4] using stainings, PCR assay and transmission electron microscopy (TEM), pediatric microsporidiosis, is rare and present case is probably the first as per available English literature detected in duodenal aspirate. …