Concurrent Parasitic Infections in a Renal Transplant Patient

and microsporidia such as Enterocytozoon bieneusi, are well-known agents of diarrhea and a major public health problem in developing countries. Infection with Cy-clospora cayetanensis and E. bieneusi can occur in immunocompromised and immunocompetent persons. Severe diarrhea and weight loss along with anorexia, nausea, and low-grade fever occur in immunocompromised persons, particularly those with HIV/ AIDS and transplant recipients who are taking immunosuppressive drugs (1,2). However, transient diarrhea occurs in immunocompetent persons, notably in travelers returning from countries with poor hygienic standards (1–3). We report on a kidney transplant recipient who had uncontrollable diarrhea and weight loss in whom C. cay-etanensis and E. bieneusi were detected in biopsy specimens; the diarrhea resolved after treatment with drugs that act specifically on these 2 parasites. The patient was a 55-year-old man from the Dominican Republic living in New York, NY, USA; he had a history of long-term diabetes, coronary disease, and alcoholism. He had undergone a cadaveric renal transplant 14 months earlier and had an uneventful posttrans-plant course. After returning from visiting family in the Dominican Republic, he sought treatment for acute, profuse watery diarrhea in early November, 2009. He had >10 watery bowel movements daily that were associated with a 20-lb weight loss. His symptoms persisted for 2 months, and he required 2 hospitalizations for the diarrhea. Results of 4 repeat fecal specimen tests (routine diagnostic micros-copy and culture) were negative for parasites. Colonoscopy findings were normal; because of evidence of leuko-cytes in the feces and elevated fecal fat level, however, he received empirically prescribed metronidazole. Because his diarrhea and weight loss persisted, an upper endoscopy was performed, which revealed the presence of micro-sporidia. He then received albendazole for 3 weeks without substantial benefit. The biopsy specimens were sent to the Centers for Disease Control and Prevention (Atlanta, GA, USA) for further analysis. Biopsy slides were stained with hematoxylin and eosin and with Gram chromotrope (4) and examined by microscopy. The Gram chromotrope–stained slide revealed oval spores, pinkish-red in color, measuring ≈1 µm (5). These spores were supra nuclear in position and were consistent with E. bieneusi (Figure, panel A). The tissue sections were scraped from the slides, DNA was extracted, and conventional PCR was performed by using E. bieneu-si–specific primers as described (5); the sizes of the amplified product in the tissue DNA specimen and in the E. bieneusi control specimen were identical (Figure, panel B), confirming the presence of E. …