Volume 4, Number 1—March 1998
Autofluorescence and the Detection of Cyclospora Oocysts
To the Editor: From May through July 1997, we searched for the seasonally occurring Cyclospora cayetanensis, along with other coccidia and microsporidia, in fecal samples from 385 patients. The samples, in 10% formalin for evaluation of coccidia and microsporidia, were initially processed by a routine formalin-ethyl acetate concentration method; the parasite was detected in 18 patients (1,2). The resulting sediment was examined as follows. A drop of sediment was placed on a slide, cover-slipped, and examined microscopically as a wet mount at 200x and 400x magnification and subsequently at 200x magnification by epifluorescence with a 330 to 380 nm UV filter. Four smears were also prepared and stained by routine trichrome (2), modified trichrome (3), auramine-rhodamine (4), and Kinyoun acid-fast (5) procedures. All wet mount and stained preparations were evaluated by at least two trained persons.
Of the 385 fecal samples examined, 18 were positive for C. cayetanensis. The positive samples were from eight states, which encompassed northeastern (Rhode Island, New York, Massachusetts, Pennsylvania), midwestern (Wisconsin), western (Oregon, California), and southern (Florida) sections of the United States.
In 12 of 18 patients, the organisms were detected without much difficulty in wet mounts as round or partially collapsed nonrefractile bodies; however, in the other six, repeated wet preparations were needed to detect the organisms. When the same wet mounts were examined with epifluorescence microscopy, oocysts were easily discerned in all samples, even the six in which repeated wet preparations and stains were needed. While the trichrome procedures were ineffective, the auramine-rhodamine and Kinyoun stains gave varied results. The autofluorescence technique, however, was distinctly superior to the wet mount and staining procedures.
Extensive outbreaks of diarrhea caused by C. cayetanensis were reported in 1997 from different parts of the United States (6-8), and several procedures have been used to confirm the diagnosis in clinical samples. While the organisms are large enough to be seen in direct wet mounts, they are frequently caught up in mucus or covered by debris, so they are difficult to detect. Autofluorescence in C. cayetanensis oocysts makes them easily visible in clinical samples (1,9) with the use of a 330 to 380 nm UV filter; this feature enhanced their detection at least twofold over the direct wet mount, especially when the wet mount and stained slides contained few oocysts. (The same wet mount preparation can be used for the epifluorescence procedure.)
The 18 patients with cyclosporiasis were ages 2 to 71 years, which indicates that the infection was not specific to any age group. Twelve of the 18 cases were in women. Massachusetts had 11, the largest number of C. cayetanenis-positive patients. Of the 18, 16 were adults; the other two were children with a coexisting parasite (Dientamoeba fragilis). In one instance, three members of the same family were infected, the parents with only C. cayetanensis, the son with D. fragilis and Blastocystis hominis.
Because C. cayetanensis is a seasonal diarrheal agent, fecal samples from persons with persistent unexplained explosive diarrhea during the summer should be carefully evaluated for this infection. Stool specimens should be fixed in 10% formalin and examined with autofluorescence microscopy for enhanced detection.
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