Prevalence of Cryptosporidium in immunocompetent Indian children with recurrent abdominal pain

Cryptosporidium spp. is an important cause of gastroenterological problems in children in developing countries.[1] A number of studies from India have reported Cryptosporidium in diarrheal stool samples from children, with positivity rates of up to nearly 20%.[2] Asymptomatic infection rates of up to 10% have also been reported.[3] In addition to causing symptoms associated with acute and chronic diarrhea, childhood cryptosporidiosis has been associated with abdominal pain.[4] However, there are no reports on prevalence of cryptosporidiosis in children with recurrent abdominal pain.

A retrospective study was carried out at our centre examining children aged 2 to 15 years presenting with recurrent abdominal pain over one year. All children underwent a thorough history and physical examination and at least three stool investigations. The definition of recurrent abdominal pain was taken as that defined by Apley.[5] Fecal smears were prepared by smearing fecal material on glass slides, mixing with polyvinyl alcohol and drying at room temperature. Cryptosporidium oocysts were identified using Kinyoun’s modified acid-fast stain.[6] Forty children presented with recurrent abdominal pain over a period of 12 months. Out of these seven were infected with Cryptosporidium spp. Abdominal pain due to Cryptosporidium infection was most prevalent in the 6 to 9 year-old age group (27.3%). None of the patients were suffering from any immunodeficiency disorder or were on any immunosuppressants or corticosteroids.

All the children with documented Cryptosporidium infection were put on nitazoxanide therapy in age appropriate doses for 3 days and were followed up as outpatients or telephonically. Two children were lost to follow-up. Of the remaining 5 children, 4 (71.4%) reported an improvement in their symptoms.

Our analysis showed that children infected with Cryptosporidium consistently develop abdominal pain unrelated to their age. This could be a hitherto unrecognized presentation of cryptosporidiosis. Our study has a few limitations. Being a tertiary center there is a possibility of selection bias. Secondly, we did not check for eradication of the organism after administering nitazoxanide, so in some of the cases there could be a placebo effect. However, since recurrent abdominal pain is a frequent symptom in pediatric practice, more studies are required to validate our observations.

References

Dillingham RA, Lima AA, Guerrant RL. Cryptosporidiosis: epidemiology and impact. Microbes Infect. 2002;4:1059–66.
Kaur R, Rawat D, Kakkar M, Uppal B, Sharma VK. Intestinal parasites in children with diarrhea in Delhi, India. Southeast Asian J Trop Med Public Health. 2002;33:725–9.
Mathan MM, Venkatesan S, George R, Mathew M, Mathan VI. Cryptosporidium and diarrhoea in southern Indian children. Lancet. 1985;2:1172–5.
Bentley C, Laubach H, Spalter J, Ginter E, Jensen L. Relationship of cryptosporidiosis to abdominal pain and diarrhea in Mayan Indians. Rev Inst Med Trop Sao Paulo. 2004;46:235–7.
Apley J, Naish N. Recurrent abdominal pains: a field survey of 1,000 school children. Arch Dis Child. 1958;33:165–70.
Henriksen SA, Pohlenz JF. Staining of cryptosporidia by a modified Ziehl-Neelsen technique. Acta Vet Scand. 1981;22:594–6.

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