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Cyclospora Infection or Cyclosporiasis (sigh-clo-spore-EYE-uh-sis)

Cyclospora cayetanensis (SIGH-clo-SPORE-uh KYE-uh-tuh-NEN-sis) is a parasite composed of one cell, too small to be seen without a microscope. The first known human cases of illness caused by Cyclospora infection (that is, cyclosporiasis) were reported in 1979. Cases began being reported more often in the mid-1980s. In the last several years, outbreaks of cyclosporiasis have been reported in the United States and Canada.

Cyclospora is spread by people ingesting something, for example, water or food that was contaminated with infected stool. For example, outbreaks of cyclosporiasis have been linked to various types of fresh produce. Cyclospora needs time (days or weeks) after being passed in a bowel movement to become infectious. Therefore, it is unlikely that Cyclospora is passed directly from one person to another. It is not known whether or not animals can be infected and pass infection to people.

People of all ages are at risk for infection. In the past, Cyclospora infection was usually found in people who lived or traveled in developing countries. However, nowadays the infection is found worldwide.

Cyclospora infects the small intestine (bowel) and usually causes watery diarrhea, with frequent, sometimes explosive, bowel movements. Other symptoms can include loss of appetite, substantial loss of weight, bloating, increased gas, stomach cramps, nausea, vomiting, muscle aches, low-grade fever, and fatigue. Some people who are infected with Cyclospora do not have any symptoms.

The time between becoming infected and becoming sick is usually about 1 week.

If not treated, the illness may last from a few days to a month or longer. Symptoms may seem to go away and then return one or more times (relapse).

If you think you might be infected with Cyclospora, see your health care provider.

Your health care provider will ask you to submit stool specimens to see if you are infected. Because testing for Cyclospora infection can be difficult, you may be asked to submit several stool specimens over several days. Identification of this parasite in stool requires special laboratory tests that are not routinely done. Therefore, your health care provider should specifically request testing for Cyclospora. Your health care provider might have your stool checked for other organisms that can cause similar symptoms.

The recommended treatment for infection with Cyclospora is a combination of two antibiotics, trimethoprim-sulfamethoxazole, also known as Bactrim*, Septra*, or Cotrim*. People who have diarrhea should rest and drink plenty of fluids.

No alternative drugs have been identified yet for people with Cyclospora infection who are unable to take sulfa drugs. See your health care provider to discuss other possible treatment options.

Avoiding water or food that may be contaminated with stool may help prevent Cyclospora infection. People who have previously been infected with Cyclospora can become infected again.

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Frequently Asked Questions

Q. What is infectious diarrhea?

A. Infectious diarrhea is an alteration of normal bowel habits, usually characterized by increased stool frequency and liquid consistency, which is caused by infectious bacteria, viruses or protozoa that infect the intestinal tracts of humans and animals. The infectious organisms are normally contracted by ingestion of contaminated water or food. Some of the more well-known organisms causing infectious diarrhea include Campylobacter, enterotoxigenic or Shiga toxin-producing E. coli, Salmonella, Shigella, Clostridium, Cryptosporidium, Giardia, Cyclospora and rotavirus.

Q. How common are infectious diarrheal diseases?

A. Infectious diarrheal diseases are the second leading cause of morbidity and mortality worldwide. There are 3.1 million deaths worldwide due to diarrhea per year (more than 8,400 per day), mostly among children in developing areas. In the United States, an estimated 211-- 357 million episodes of diarrheal illness occur each year resulting in 73 million physician consultations, 1.8 million hospitalizations and 3,100 deaths. The CDC issued a new study November 22, 2002 reporting that outbreaks of waterborne illnesses roughly doubled in the U.S. in a three-year period ending in 2000. Studies have shown that approximately 20 percent of children in the United States are exposed to Cryptosporidium by age 5-7 years. Approximately 9% of all hospitalizations of children younger than 5 years are due to diarrhea

Q. How do diarrheal illnesses affect those suffering from the infection?

A. Most cases of infectious diarrhea are self-limiting in nature resolving spontaneously after a few days. Acute cases of infectious diarrhea can, however, lead to dehydration and even death. Persistent or chronic diarrhea often associated with intestinal protozoan infections can also cause serious long-term consequences, including malnutrition and impairment of physical or cognitive development.

Q. Who is most at-risk of contracting infectious diarrhea?

A. Anyone who is exposed to the causative organism is susceptible to contracting infectious diarrhea. Young children, the elderly and people with weakened immune systems however, are particularly susceptible to infection with a variety of different pathogens and often are more likely to develop illness of greater severity.

Q. Is there a way to prevent or control exposure to these infections?

A. The risk of contracting infectious diarrheal diseases can be reduced by improved sanitary conditions, but they are very difficult to prevent. Efforts to guarantee clean water supplies and food have been successful in reducing the prevalence of infectious diarrhea in developed countries. Still, these organisms cause millions of cases of infectious diarrhea in the United States each year.

Q. What can be done to treat infectious diarrhea?

A. The first step in treating diarrhea of any origin is to initiate rehydration therapy, orally or intravenously if necessary. Then, a diagnosis of the causative organism should be made, and where appropriate, antimicrobial therapy should be administered to reduce the duration of diarrhea and prevent potential long-term consequences of the infection. The lack of a specific diagnosis is the most significant obstacle hindering appropriate management and treatment of many infections. For diarrhea lasting more than 7 days, standards of care call for consideration of Cryptosporidium or Giardia infection, especially if the patient is immunocompromised.

Q. Why is it difficult to determine the specific cause of infectious diarrhea?

A. Specific diagnosis of the cause of infectious diarrhea requires the collection of fecal samples (often 2 or 3 samples collected on consecutive days) for microscopic examination or cultures to grow bacteria. The time required to conduct these fecal tests can delay treatment of the patient for several days, and the accuracy of the tests is less than optimal. As a result, many physicians view fecal tests as an unnecessary expense and inconvenience, particularly if the physician believes the infection will ultimately resolve spontaneously. In such cases, the physician either treats empirically with an antimicrobial agent or recommends rehydration therapy until the infection resolves spontaneously.

By questioning a patient about his symptoms and epidemiological risks, a physician can obtain clues that might lead him to suspect a particular infection. Factors suggestive of a particular infection might include recent consumption of unsafe foods, daycare center attendance or employment, swimming in lakes or streams, contact with animals with diarrhea, recent use of certain medications, recent hospitalization, travel to a developing country, blood in the stool, fever, the duration of diarrhea and associated symptoms.

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What is Cyclosporiasis?

Cyclospora is a parasite composed of one cell, too small to be seen without a microscope. The organism was previously thought to be a blue-green alga or a large form of Cryptosporidium. Cyclospora cayetanensis is the only species of this organism found in humans. The first known human cases of illness caused by Cyclospora infection (that is, cyclosporiasis) were first discovered in 1977. An increase in the number of cases being reported began in the mid-1980s, in part due to the availability of better diagnostic techniques. Over 15,000 cases are estimated to occur each year in the United States. The first outbreak in North America occurred in 1990 from contaminated water. Since then, several outbreaks of cyclosporiasis have been reported in the U.S. and Canada, many associated with eating fresh fruits or vegetables. In some developing countries, cyclosporiasis is common among the population and travelers to those areas have become infected as well.

Where does Cyclospora come from?

Cyclospora is spread by people ingesting water or food contaminated with infected stool. For example, exposure to contaminated water among farm workers may have been the original source in raspberry-associated outbreaks in North America.

Cyclospora needs time (one to several weeks) after being passed in a bowel movement to become infectious. Therefore, it is unlikely that Cyclospora is passed directly from one person to another. It is not known whether or not animals can be infected and pass infection to people.

What are the typical symptoms of Cyclospora infection?

Cyclospora infects the small intestine (bowel) and usually causes watery diarrhea, bloating, increased gas, stomach cramps, loss of appetite, nausea, low-grade fever, and fatigue. In some cases, vomiting, explosive diarrhea, muscle aches, and substantial weight loss can occur. Some people who are infected with Cyclospora do not have any symptoms. The time between becoming infected and becoming ill is usually about one week. If not treated, the illness may last from a few days up to six weeks. Symptoms also may recur one or more times (relapse). In addition, people who have previously been infected with Cyclospora can become infected again.

What are the serious and long-term risks of Cyclospora infection?

Cyclospora has been associated with a variety of chronic complications such as Guillain-BarrÈ syndrome, reactive arthritis or Reiterís syndrome, biliary disease, and acalculous cholecystitis. Since Cyclospora infections tend to respond to the appropriate treatment, complications are more likely to occur in individuals who are not treated or not treated promptly. Extraintestinal infection also appears to occur more commonly in individuals with a compromised immune system.

How is Cyclospora infection detected?

Your health care provider will ask you to submit stool specimens to see if you are infected. Because testing for Cyclospora infection can be difficult, you may be asked to submit several stool specimens over several days. Identification of this parasite in stool requires special laboratory tests that are not routinely done. Therefore, your health care provider should specifically request testing for Cyclospora if it is suspected. Your health care provider might have your stool checked for other organisms that can cause similar symptoms.

How is Cyclospora infection treated?

The recommended treatment for infection with Cyclospora is a combination of two antibiotics, trimethoprim-sulfamethoxazole, also known as Bactrim, Septra, or Cotrim. People who have diarrhea should rest and drink plenty of fluids. No alternative drugs have been identified yet for people with Cyclospora infection who are unable to take sulfa drugs. Some experimental studies, however, have suggested that ciprofloxacin or nitazoxanide may be effective, although to a lesser degree than trimethoprim-sulfamethoxazole. See your health care provider to discuss alternative treatment options.

How can Cyclospora infection be prevented?

Avoiding water or food that may be contaminated is advisable when traveling. Drinking bottled or boiled water and avoiding fresh ready-to-eat produce should help to reduce the risk of infection in regions with high rates of infection. Improving sanitary conditions in developing regions with poor environmental and economic conditions is likely to help to reduce exposure.

Washing fresh fruits and vegetables at home may help to remove some of the organisms, but Cyclospora may remain on produce even after washing.

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