Stressing a Tired Host: Cryptosporidium Species and Helicobacter Pylori Infections in Diabetes Mellitus Patients with Gastrointestinal Manifestations

Background: Cryptosporidium spp. and Helicobacter pylori are widespread gastrointestinal infections that appear to resist treatment in many cases. Cryptosporidiosis results in increased intestinal permeability while H. pylori causes atrophic changes in stomach, and both are opportunistic pathogens. The outcome of infection depends largely on the degree of the host immune status. Diabetes mellitus (DM) is a growing health problem in Egypt, with detrimental consequences that can affect the immune system, the gastrointestinal tract, and virtually all body systems, exposing diabetic patients to higher susceptibility to infections and intensified morbidity. Objective: The present study was designed to determine the burden of Cryptosporidium spp. and H. pylori among diabetic patients compared to non-diabetic patients attending Kasr Al Ainy hospitals. Subjects and Methods: Stool samples, demographic and clinical data were collected from 80 patients, 40 diabetics and 40 non-diabetics, with gastrointestinal manifestations. Microscopic stool examination and coproimmunoassays for the detection of Cryptosporidium spp. and H. pylori were performed for all samples. Results: Cryptosporidium spp. infection was detected in 15% of diabetics; with a frequency of 7.4% and 30.8% in patients with controlled DM and uncontrolled DM, respectively, and in 5% of non-diabetics. While H. pylori was equally detected at a rate of 60% in non-diabetic and diabetic patients (51.9% and 76.9% in patients with controlled DM and uncontrolled DM, respectively). Microscopic examination of stools revealed Blastocystis in 25% of diabetics (22.2% in controlled DM versus 30.7% in uncontrolled DM) and in 5% of non-diabetic patients. Co-infection with Cryptosporidium and H. pylori occurred in 10% of diabetic cases (3.7% in controlled DM versus 23.1% in uncontrolled DM), and in 5% of non-diabetic patients. Conclusion: Diabetic patients had a higher infection rate of Cryptosporidium as well as Blastocystis in comparison to non-diabetics. Screening for intestinal parasites is needed to control the infection and reduce morbidity in diabetics. PARASITOLOGISTS UNITED JOURNAL 262 cryptosporidiosis is increasing, and the frequency of infection is likely to be one hundred-fold higher than the number of reported cases[14]. Parasite oocysts are transmitted primarily through the fecal oral route[15], and hence Cryptosporidium is responsible for several waterborne outbreaks of gastrointestinal disease[16-18]. The oocysts are highly infectious and are resistant to hard environmental conditions[19,20]. The severity, persistence, and outcome of infection depend largely on the host immune status[21]. A self-limited disease usually occurs in the immunocompetent individuals, the most common symptom being a watery diarrhoea, while in immunocompromised patients, prolonged diarrhoea can be life threatening[22]. Cryptosporidiosis pathogenesis may include increased intestinal permeability, chloride loss, altered glucose transport mechanisms in infected enterocytes, malabsorption, and host immune response to infection[22-24]. In patients with immunodeficiencies, the biliary and respiratory tracts may also be involved[25,26]. A link between cryptosporidiosis and colorectal carcinoma was suggested[18]. Cholangiocarcinoma, complicating chronic cryptosporidiosis and cholangitis, was also postulated[27]. Additionally, H. pylori is a gram-negative spiral bacterium, found in the stomach of about 50% of the global population. Chronic infection may induce atrophic changes and metaplasia in the stomach[28,29]. Infection by H. pylori can spread directly from one person to the other, or indirectly through environmental exposure routes[30]. Concomitant infection of H. pylori and intestinal parasites may correlate with fecal exposure. The co-colonization of the gut may be attributed to intestinal parasites affection in millions of individuals globally, thus increasing the odds of coinfection with H. pylori[31]. Besides, mutual symbiosis was postulated since H. pylori could provide favorable conditions for intestinal parasitosis or vice versa[32]. Results of different studies revealed that H. pylori infection is a risk factor for type 2-DM[33-35]. The mechanisms involved in the bacterium-type 2-DM interaction may be related to infection induced inflammation, production of inflammatory cytokines, and hormonal imbalance[33]. The co-existence of Cryptosporidium spp. and H. pylori presents a challenge in diabetics. In addition to the aforementioned possible complications, both pathogens are difficult to treat with increasing reports of H. pylori antibiotic resistance[29] and the lack of fully effective medication against Cryptosporidium[36]. In this context, it must be noted that detrimental consequences of DM can virtually involve all the body systems[37], rendering diabetic patients compromised hosts. The present study was conducted to determine the burden of Cryptosporidium spp. and H. pylori among diabetic patients versus non-diabetic patients attending Kasr Al Ainy hospitals. SUBJECTS AND METHODS This case-control study was performed in the period from September 2018 to June 2019 on patients attending the Diagnostic and Research Unit of Parasitology (DRUP) and the Diabetes Unit, Kasr AlAiny, Faculty of Medicine, Cairo University. Study population and sample collection: A total of 80 patients presenting with gastrointestinal symptoms and not under immunosuppressive therapy were included in the study; 40 were diabetics and 40 were non-diabetics. Patients in both groups were matched for age and sex. Relevant data were obtained from all participants comprising demographic data, gastrointestinal manifestations, and clinical history of diabetes including a significant HbA1c level. Fecal samples were collected from each patient in labeled, leak-proof, dry, and clean plastic stool containers. From each stool sample, a small part was stored at -20°C for subsequent use in the coproimmunoassays, and the remaining of the sample was preserved in formalin saline fixative for parasitological examination. Stool examination: The stool samples were examined microscopically using direct wet smear and formalinethyl acetate sedimentation methods for routine screening of ova and other parasitic stages[38]. Coproimmunoassays: The frozen fecal specimens were thawed at room temperature before testing. For each sample, two tests were performed using RIDA QUICK Cryptosporidium ICT (R-Biopharm AG, Germany Cat. # N1203) for detection of Cryptosporidium coproantigens[39]; and OnSite H. pylori Ag Rapid testCassette (CTK Biotech, Inc., San Diego, CA, USA Cat. # R0192C) for detection of H. pylori coproantigens[40]. Both tests were done according to the manufacturer’s instructions. Statistical methods: Data were coded and tabulated using the statistical package for the Social Sciences (SPSS) version 26 (IBM Corp., Armonk, NY, USA). Quantitative variables were summarized using mean, standard deviation (±SD), minimum and maximum, while categorical variables were presented as frequencies (number of cases) and relative frequencies (percentages). Comparisons between groups were by unpaired t-test and chi square (X2) test. Exact Fisher test was used when the expected frequency was <5. P-values <0.05 were considered as statistically significant. Ethical consideration: All procedures in the present work fulfilled the ethical standards recognized by Helsinki Declaration 1964. An informed consent was obtained from all participants. Infected patients were notified and prescribed the appropriate treatment. Cryptosporidium and H. pylori in diabetics Fadl et al.,