Triple protozoal enteropathy of the small intestine in an immunocompromised male: A rare histopathology report
A 43-year-old male was diagnosed in November 2008 as HIV-positive and was on regular ART. He was admitted to hospital with complaint of passing loose stools 8-10 times per day since 1 month without associated pain abdomen, passage of blood or mucus in stool. He had an episode of diarrhea about 6 months back. It was diagnosed as cryptosporidial diarrhea on stool examination and he was treated with nitrazoxamide successfully.\nThe patient had several associated comorbidities. He was a documented case of disseminated tuberculosis since August 2010 and was on ATT. Presently, he is also a patient of Herpes Zoster (T6-T10 dermatome) and is on acyclovir therapy. On general physical examination, he was found to be a thinly built, well oriented, afebrile with a supine blood pressure of 90/66 mmHg and a regular pulse rate of 88/min. He had a significant left cervical and axillary lymphadenopathy with matted nodes. No organomegaly on abdominal examination was seen. Upper GI endoscopy revealed essentially normal esophagus and stomach and first part of duodenum. The second part of duodenum showed nodular folds. Ultrasonography of abdomen and pelvis showed calcified areas in segment VII of liver and multiple hypoechoic focal lesions (? granulomas).\nThe laboratory investigations revealed hemoglobin-10.9 g/dl, total leucocytic count -4,200/μl, differential leucocytic count was lymphocytic predominant (54%), and a platelet count of 1.5 lakh/μl. His absolute CD4+ T lymphocyte count was 219 cells/μl and viral load was less than 400 copies/ml. His liver and renal function tests and urine examination were essentially normal. Upon stool examination no ova, cyst, acid-fast bacilli, or any other organism was discerned. Culture of stool showed no growth. Stool was also negative for fat globules.\nHistopathological examination of biopsy from second part of duodenum revealed mild atrophy in the form of blunting, shortening, and fusion of villi with crypt elongation at places. A focal disorganization of the epithelium, loss of nuclear polarity, cell crowding, and cell vacuolation was seen []. Lamina propria showed an intense lymphoplasmacytic infiltrate along with few eosinophils and occasional macrophages. Numerous enterocytes showed intracytoplasmic loose parasitophorous vacuoles containing isosporidia schizonts and merozoites. These organisms were seen in the basal part of cytoplasm below and around the nucleus. The single organisms were the schizonts. Focally on luminal surface of occasional enterocytes, small bluish intracellular but extracytoplasmic round to oval amphophilic structures resembling cryptosporidia were seen. Also noted were foci of occasional enterocytes containing intracytoplasmic vacuoles with small, round to oval, bluish supranuclear refractile spores resembling microsporidia []. No crypt destruction, dysplasia, or granulomas were seen. Lamina propria showed dilated vascular channels at places. Special histochemical stains to identify the parasites done were – Brown – Bren modification of Gram stain, PAS, Masson's trichrome, toluidine blue [], Giemsa, modified acid fast, and Gomori's methanamine silver (GMS) stains. A histopathology opinion of enteritis due to triple infection by isosporidia, cryptosporidia, and microsporidia was offered.\nBased on histopathology report, patient was put on tablets niazoxanide, Septran, Cifran, and Fluconazole. He has since improved and is under regular follow-up in the outpatient department and ART center of the hospital.