MAJOR ARTICLE

Differences in Clinical Manifestations

among Cryptosporidium Species
and Subtypes in HIV-Infected Persons
Vitaliano A. Cama,1,3 Jennifer M. Ross,1 Sara Crawford,1 Vivian Kawai,4 Raul Chavez-Valdez,4 Daniel Vargas,4
Aldo Vivar,4,5 Eduardo Ticona,6 Marco Ñavincopa,6 John Williamson,1 Ynes Ortega,2 Robert H. Gilman,3,4 Caryn Bern,1
and Lihua Xiao1
1
Division of Parasitic Diseases, National Center for Zoonotic, Vector-Borne and Enteric Diseases, US Centers for Disease Control and Prevention,
Atlanta, and 2University of Georgia, Griffin; 3Johns Hopkins University, Baltimore, Maryland; 4Asociacion Benéfica PRISMA, 5Hospital Arzobispo
Loayza, and 6Hospital Dos de Mayo, Lima, Peru

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We performed a cross-sectional study to determine the epidemiology of Cryptosporidium in human immu-
nodeficiency virus (HIV)–infected persons at 3 diagnostic levels: microscopy, genotypes of Cryptosporidium,
and subtype families of C. hominis and C. parvum. The study enrolled 2490 HIV-infected persons in Lima,
Peru, and 230 were microscopy positive for Cryptosporidium infection. Specimens from 193 participants were
available for genotyping. They had C. hominis (141 persons), C. parvum (22 persons), C. meleagridis (17
persons), C. canis (6 persons), C. felis (6 persons), and C. suis (1 person) infection. Although microscopy
results showed that Cryptosporidium infections were associated with diarrhea, only infections with C. canis,
C. felis, and subtype family Id of C. hominis were associated with diarrhea, and infection with C. parvum was
associated with chronic diarrhea and vomiting. These results demonstrate that different Cryptosporidium
genotypes and subtype families are linked to different clinical manifestations.

Cryptosporidium is an important opportunistic path-
ogen affecting HIV-infected persons, and it has been
associated with chronic diarrhea [1, 2], decreased qual-
ity of life, and shortened survival in HIV-positive pa-
tients [3, 4]. Because no antiparasitic agent is effective
against cryptosporidiosis in patients with AIDS who
Received 10 October 2006; accepted 15 March 2007; electronically published
13 July 2007.
Potential conflicts of interest: none reported.
Financial support: Opportunistic Infections Working Group of the Centers for
Disease Control and Prevention (CDC); RG-ER Fund; National Institute for Allergy
and Infectious Disease, National Institutes of Health (projects 5P01AI051976-04
and 5R21AI059661-02 to R.H.G. and V.A.C.); Division of Parasitic Diseases, CDC
(Research Participation Program appointment to S.C. administered by the Oak
Ridge Institute for Science and Education through an interagency agreement
between the US Department of Energy and the CDC).
The findings and conclusions in this article are those of the authors and do
not necessarily represent the views of the Centers for Disease Control and
Prevention.
Reprints or correspondence: Lihua Xiao, Div. of Parasitic Diseases, Centers for
Disease Control and Prevention, 4770 Buford Hwy. NE, MS-F12, Atlanta, GA 30341
(lxiao@cdc.gov).
The Journal of Infectious Diseases 2007; 196:684–91
 2007 by the Infectious Diseases Society of America. All rights reserved.
0022-1899/2007/19605-0006$15.00
DOI: 10.1086/519842
have low CD4+ cell counts, preventing infections de-
pends on avoiding exposure to the parasite and main-
taining immune competence. In developed countries,
access to highly active antiretroviral therapy (HAART)
has reduced the morbidity from cryptosporidiosis [3–
5]. Nonetheless, infections with Cryptosporidium spe-
cies are still a major threat to patients with AIDS who
do not have access to HAART, especially in developing
countries [6, 7].
As with other opportunistic protozoa, there is limited
knowledge about the transmission dynamics and path-
ogenicity of the different species and subtypes of Cryp-
tosporidium species. One study in the United Kingdom
reported that infections with C. hominis in immuno-
competent persons were associated with extraintestinal
sequelae [8]. A small study of cryptosporidiosis in HIV-
infected patients in Tanzania demonstrated potential
clinical differences between 15 persons infected with C.
hominis and 6 infected with C. parvum [9]. Recently,
a study in Brazil showed that children infected with C.
hominis or C. parvum had reductions in their anthro-
pometric measurements, but long-term effects were

684 • JID 2007:196 (1 September) • Cama et al.

only observed in children who infected with C. hominis [10].
These studies indicate that there may be differences in the
clinical manifestations of the different Cryptosporidium species
in humans.
We have previously reported 6 different species of Crypto-
sporidium in Peruvian HIV-infected persons [11]. In the present
study, we analyzed the associations between the different species
and clinical manifestations and infection risk factors. C. hominis
and C. parvum, the species most frequently recognized in hu-
man infections, were further categorized into subtype families
using a molecular tool based on sequence analysis of the 60-
kDa glycoprotein gene (GP60) [12–14].
SUBJECTS AND METHODS
Study population and enrollment. This study was designed
to be cross-sectional with optional follow-up. It was a com-
ponent of a project conducted between September 2000 and
December 2002 to characterize opportunistic enteric parasites
in Peruvian HIV-positive persons [15]. The objective of the
study was to determine the genetic diversity of Cryptosporidium
species in the study population and the associations between
infections with different genotypes or subtype families and clin-
ical manifestations or infection risk factors. The criteria for
inclusion in the study were documented HIV infection, age
⭓17 years, and the ability to provide informed consent and at
least 1 stool specimen, irrespective of symptoms [15].
Participants were recruited from 3 different sources: patients
(hospitalized or ambulatory) attending the Arzobispo Loayza
and Dos de Mayo hospitals in Lima and patients referred to
the study by their attending physicians. The research protocol
was approved by the institutional review boards of the Centers
for Disease Control and Prevention; Johns Hopkins University
Bloomberg School of Public Health; Asociacion Benéfica Pro-
yectos de Informática, Salud, Medicina, Agricultura; and the 2
study hospitals. All participants had given written informed
consent before enrollment into the study.
Laboratory methods. Each participant was asked to pro-
vide 3 stool specimens from 3 separate days for detection of
ova and parasites, including Giardia intestinalis; Cryptospori-
dium, Cyclospora, and Isospora species; and microsporidia. The
stool specimens were concentrated with the modified Ritchie
formalin-ether method, followed by microscopic examination.
Cryptosporidium, Cyclospora, and Isospora species were detected
using a modified acid-fast stain; Cyclospora-positive specimens
were confirmed using epifluorescent microscopy [16]. Micro-
sporidia were detected using a modified trichrome stain [17].
The study protocol did not include screening for bacterial or
viral enteropathogens. The intensity of Cryptosporidium oocyst
shedding in stools was determined by counting the number of
oocysts in 50 mL of sample. We used a 0–3+ scoring system: 0
for negative, 1+ for 1–50 oocysts, 2+ for 51–150 oocysts, and
Different Symptoms in Cryptosporidiosis • JID 2007:196 (1 September) • 685
3+ for 1150 oocysts. All participants were asked to provide a
blood sample for CD4+ cell quantification, which was deter-
mined using the Coulter Manual CD4 Count Kit (Beckman
Coulter).
Genotyping. The available Cryptosporidium microscopy-
positive specimens were processed for DNA extraction as de-
scribed elsewhere [11, 18]. Briefly, specimens were subjected to
alkaline treatment and phenol-chloroform extraction followed
by DNA purification using the QIAmp DNA Stool MiniKit
(Qiagen). These Cryptosporidium-positive specimens were ge-
notyped using a small subunit–rRNA–based polymerase chain
reaction–restriction fragment length polymorphism tool that
differentiates Cryptosporidium species and genotypes [18].
Subtyping. C. hominis and C. parvum were categorized into
subtype families (Ia, Ib, Id, Ie, and If for C. hominis and IIa,
IIb, IIc, IId, IIe, and IIf for C. parvum) by sequence analysis
of the GP60 gene [13, 14, 19]. Clinical and risk-factor data
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were also analyzed at the subtype family level because of ex-
tensive sequence differences among subtype families in the gene
coding for GP60, an immunodominant antigen recognized by
almost all infected persons.
Each GP60 subtype family had multiple subtypes, which dif-
fered from each other mostly in the number serine-coding tri-
nucleotide repeats (TCA, TCG, or TCT) located in the 5
region
of the gene. A previously proposed subtype nomenclature system
was used to differentiate subtypes within each subtype family
[13]. The subtype name usually starts with the subtype family
designation, followed by the number of TCA (represented by the
letter A), TCG (represented by the letter G), and TCT (repre-
sented by the letter T) repeats found in the serine-coding re-
petitive region. However, subtypes in the C. hominis subtype
family Ia differed further in the number of a 15-bp repetitive
sequence 5
-AAA/G ACG GTG GTA AGG-3
(the last copy is 13
bp) (represented by the letter R) shortly downstream the tri-
nucleotide repeats. Thus, the name “IaA13R8” indicates that par-
asite belongs to C. hominis subtype family Ia and has 13 copies
of the TCA repeat in the trinucleotide-repeat region and 8 copies
of the 13–15-bp repeat. In addition, subtypes in the C. parvum
subtype family IIc had identical sequences (5 copies of TCA and
3 copies of TCG) in the trinucleotide-repeat region but differed
from each other in the sequence of the 3
region of the GP60
gene and, thus, were arbitrarily assigned the extension letters a,
b, or c, with the original GP60 sequence for subtype family IIc
(GenBank accession number AF164491) assigned as IIcA5G3a.
Using this sequence as the reference, IIcA5G3b had a trinucle-
otide deletion (ACA) shortly after the serine-coding repeat and
31 nucleotide substitutions, whereas subtype IIcA5G3c had 33
nucleotide substitutions.
Study definitions. We performed a cross-sectional analysis
using data collected from evaluable patients. A patient was
considered evaluable if he or she had at least 1 microscopy test
result for a specimen collected during his or her first week in
the study, data concerning clinical manifestations and risk fac-
tors within 35 days of the first stool specimen, and CD4+ cell
count within 90 days of the date of enrollment. Evaluable pa-
tients with at least 1 fecal specimen positive for Cryptosporidium
during their first week in the study were considered to be
infected for the cross-sectional analysis. A person was consid-
ered to have diarrhea if there were ⭓3 loose or liquid stools
in a 24-h period. Diarrhea was acute when it lasted !28 days
and chronic when the episode lasted ⭓28 days [15]. A diarrheal
episode was considered to end when the participant had ⭓7
consecutive days without diarrhea [15].
Survey questions. Each study participant provided their
history of diagnosis and treatment of HIV/AIDS. A structured
questionnaire captured data on clinical symptoms (duration of
diarrhea, vomiting, fever, acid reflux, weight loss, abdominal
cramps, and joint/muscle aches). It also gathered information
on potential exposures within the past month or the past year,
including person-to-person (42 variables for sexual practices
and contacts with infants, children, other persons with diarrhea,
soiled diapers, and human stools), waterborne (12 variables,
including source, storage, and treatment of drinking water;
street-sold beverages; and swimming and contact with recre-
ational water), zoonotic (15 variables, including the presence
of animals or contact with their excreta, both at the global
animal category and by species of domestic animals), and food-
borne (33 variables covering the consumption of food usually
eaten raw in the area, such as vegetables, leafy greens, and fruits)
exposure.
Statistical analysis. Data were double-entered into elec-
tronic databases, validated for accuracy, and analyzed at 3 levels
of parasite categorization: microscopic (cryptosporidiosis), spe-
cies/genotypes of Cryptosporidium, and subtype families of C.
hominis and C. parvum. Data from persons infected with low-
frequency species were pooled on the basis of genetic similar-
ities. Whenever a species showed the presence of a single sub-
type family, findings were presented at the species level, the
foregoing category of differentiation.
Statistical models were used to perform clinical symptoms
and risk-factor analyses, exploring the association with Cryp-
tosporidium for each variable. Because multiple associations
were explored, a separate Bonferroni adjustment was used for
both the symptoms and risk factors analysis.
The statistical models for symptoms used the species or sub-
type families identified in participants as the predictor of the
clinical outcomes. These analyses were controlled for CD4+ cell
counts, source of participants, and the presence of enteric par-
asites that were independently associated with diarrhea: Entero-
cytozoon bieneusi, Cyclospora cayetanensis, and Isospora belli.
The statistical models did not control for infections with Giar-
dia, because this parasite was not significantly associated with
686 • JID 2007:196 (1 September) • Cama et al.
diarrhea, chronic diarrhea, or vomiting (P p .21 , P p .48, and
P p .94, respectively; x2 analysis). Logistic regression modeling
was performed to estimate odds ratios (ORs). Because 7 clinical
symptoms were studied, the statistical significance of clinical
manifestations was assessed at a Bonferroni-adjusted a level of
.05/7 p .0071.
All potential exposure risk factors were evaluated using lo-
gistic regression models and controlling for only CD4+ cell
counts and source of patient participants. Because 102 risk
factors were assessed, a significant relationship between each
risk factor and Cryptosporidium infections was determined by
an a level of .05/102 p .0005. Models evaluating consumption
of fresh produce were additionally controlled for seasonality,
and the intensity of parasite shedding was modeled using or-
dinal logistic regression analysis. All analyses were performed
using SAS software (version 9.0; SAS Institute).
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RESULTS
Study patients. Among the 2490 participants, 66% were male.
The median age was 31 years, the mean CD4+ cell count was
131 cells/mL, and 6% reported taking any antiretroviral drug.
Two hundred thirty (9.2%) of the 2490 participants had cryp-
tosporidiosis detected by microscopy in the first week.
Cryptosporidium genotypes and subtype families of C.
hominis and C. parvum. Specimens from 193 of 230 Cryp-
tosporidium-infected participants were available for genetic char-
acterization. Cryptosporidium hominis (n p 141 ) and C. parvum
(n p 22) were the species most frequently detected, followed by
C. meleagridis (n p 17), C. canis or C. felis (n p 12), and C. suis
(n p 1).
Subtype family data were obtained from 127 (90%) of 141
of the participants with C. hominis and showed the presence
of subtype families Ia, Ib, Id, and Ie in 35, 39, 40, and 13
persons, respectively. By contrast, all 22 C. parvum infections
belonged to subtype family IIc (table 1).
Genetic diversity within subtype families of C. hominis and
C. parvum. Subtype family Ia of C. hominis was the most
genetically diverse and had 9 subtypes, followed by subtype
families Id and Ib, with 4 and 2 subtypes, respectively. By con-
trast, subtype family Ie was monophyletic: all were subtype
IeA11G3T3. Overall, participants in the study were infected
with 16 different subtypes of C. hominis. The subtypes most
frequently detected were IbA10G2 and IdA10, in 35 and 25
patients, respectively. Three subtypes were identified in C. par-
vum, including IIcA5G3a, IIcA5G3b, and IIcA5G3c in 16, 4,
and 2 patients, respectively (table 1).
Molecular epidemiology. For the statistical analyses, data
from persons infected with the species C. canis (n p 6) and C.
felis (n p 6) were pooled because of their distant genetic re-
latedness to C. hominis and C. parvum. Data from the person
infected with C. suis was incomplete and excluded from the
 Table 1. Distribution of geno- or subtype families identified in the study were associated with
types and subtypes of Cryptospo- acute diarrhea, fever, acid reflux, weight loss, and muscle or
ridium species in HIV-positive joint pain.
persons in Lima, Peru.
Intensity of Cryptosporidium shedding. The intensity of
No. of
Cryptosporidium oocyst shedding in stools was analyzed at the
Genotype, subtype persons species and subtype family levels of detection. The mean shed-
family, subtype infected ding intensity scores for C. parvum, C. hominis, C. meleagridis,
C. hominis 141 and C. canis or C. felis were 1.77, 1.62, 1.23, and 1.40, respec-
Ia 35 tively. No significant differences were observed in models that
IaA12R3 1 compared shedding intensity among all genotypes or subtype
IaA12R4 5 families. However, persons infected with C. parvum or C. hom-
IaA12R5 3 inis were more likely to excrete more parasites in their stools
IaA13R2 1
than were persons with C. meleagridis (OR, 5.4 [P p .033] and
IaA13R6 1
OR, 3.9 [P p .039], respectively).
IaA13R7 9
Infection risk factors. After the Bonferroni correction, al-
IaA13R8 12
IaA14R7 2
most all person-to-person contact, all animal contact, and food-
IaA17R6 1 borne variables were not associated with infections. Only con-

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Ib 39 tacts with children !5 years of age during the previous month
IbA10G2 35 or year were a significant risk factor for infections with C.
IbA13G3 4 hominis subtype family Ie (OR, 2.1 [95% confidence interval
Id 40 {CI}, 1.4–3.0]; P p .0003). No significant differences were de-
IdA10 25 tected between other human contacts, sexual practices, the pres-
IdA12 2 ence of animals (any animal or specific species), and any water-
IdA15G1 1 related variables. Among foodborne variables, although not
IdA20 12
significant using the Bonferroni-adjusted a level, eating raw
Ie 13
celery was associated with a decreased number of infections
IeA11G3T3 13
with Cryptosporidium species in general (OR, 0.4 [95% CI, 0.2–
C. parvum 22
IIc 22
0.9]; P p .008), and with infections with subtype family Ib of
IIcA5G3a 16 C. hominis (OR, 0.2 [95% CI, 0.1–0.9]; P p .007).
IIcA5G3b 4
IIcA5G3c 2 DISCUSSION
C. meleagridis 17
C. canis or C. felis 12 Our findings show that Peruvian HIV-positive persons were
C. suis 1 infected with a diverse population of Cryptosporidium species
and that the infections with different genotypes or subtype
families were associated with different clinical manifestations.
analysis. Because all C. parvum subtypes belonged to subtype C. hominis was the genotype most frequently detected, which
family IIc, the statistical analyses for C. parvum were conducted is in agreement with several reports of human cryptosporidiosis
only at the species level. in developing countries [20–23]. However, the distribution of
Clinical manifestations. The Bonferroni-corrected statis- subtype families of C. hominis and C. parvum in this study was
tical analysis (a p .0071) showed that infections with Cryp- quite different, with subtype families Ia, Ib, Id, and IIc present
tosporidium species (determined by microscopy) were associ- in similar proportions and very few persons infected with sub-
ated with chronic diarrhea (table 2). However, the associated type family Ie. By contrast, subtype family Ib was predominant
clinical manifestations varied when analyzed by Cryptospori- in Portugal [12], and subtype family Id was the most frequently
dium species or subtype families of C. hominis. The infections detected in Malawi [24], whereas C. hominis subtype family Ie
with C. canis or C. felis and subtype family Id of C. hominis was not detected among HIV-infected patients in India [21].
were significant predictors of diarrhea; most of these diarrhea We also identified that the C. parvum in this study population
occurrences were chronic in nature (table 2). The infections belonged to subtype family IIc, an anthroponotic parasite. This
with C. parvum were associated with chronic diarrhea (table pattern seems unique to Peru, given that patients in Portugal
2) and vomiting (table 3). By contrast, infections with C. me- with AIDS also had infections with the zoonotic subtype fam-
leagridis or subtype families Ia, Ib, and Ie of C. hominis were ilies IIa and IId [12, 25], whereas infections with C. parvum
not associated with any type of diarrhea. None of the species subtype families IIa and IId were the most prevalent in Kuwaiti

Different Symptoms in Cryptosporidiosis • JID 2007:196 (1 September) • 687

 Table 2. Association with diarrhea or chronic diarrhea by Cryptosporidium genotypes and subtype
families of C. hominis.

Subjects, Episodes of
Parameter no. diarrhea, no. (%) OR (95% CI) P
Model 1: risk of diarrhea by microscopy
Cryptosporidium speciesa 230 87 (38) 1.5 (1.1–2.0) .019
b

No Cryptosporidium 2260 572 (25) Referent

Model 2: risk of diarrhea by genotype
C. hominis 139 52 (37) 1.3 (0.9–1.9) .132
C. parvum 20 10 (50) 2.1 (0.8–5.1) .112
C. meleagridis 17 4 (24) 0.7 (0.2–2.4) .613
c
C. canis or C. felis 12 9 (75) 6.4 (1.7–24.6) .0069
No Cryptosporidium 2260 572 (25) Referent
Model 3: risk of diarrhea by subtype families
of C. hominis
Ia 35 10 (29) 1.0 (0.5–2.0) .915
Ib 39 19 (49) 1.9 (1.0–3.7) .055
Id 40 21 (53) 2.5 (1.3–4.8) .005c

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Ie 13 3 (23) 0.6 (0.1–2.1) .384
No Cryptosporidium 2260 572 (25) Referent
Model 4: risk of chronic diarrhea by microscopya
a c
Cryptosporidium species 230 43 (19) 1.8 (1.2–2.8) .004
No Cryptosporidium 2258 190 (8) Referent
Model 5: risk of chronic diarrhea by genotypesa
C. hominis 139 23 (17) 1.4 (0.9–2.4) .164
c
C. parvum 20 8 (40) 4.1 (1.6–10.9) .005
C. meleagridis 17 3 (18) 1.7 (0.5–6.2) .435
b
C. felis or C. canis 12 4 (33) 5.3 (1.1–24.9) .033
No Cryptosporidium 2258 190 (8) Referent
Model 6: risk of chronic diarrhea by subtype
families of C. hominisa
Ia 35 2 (6) 0.5 (0.1–2.2) .380
Ib 39 7 (18) 1.8 (0.7–4.4) .201
Id 40 11 (28) 2.8 (1.3–6.3) .012b
Ie 13 3 (23) 1.3 (0.3–5.4) .719
No Cryptosporidium 2258 181 (8) Referent

NOTE. All models were controlled for source of patients, CD4+ cell counts, and infections with Isospora belli, Cyclospora
cayetanensis, or Enterocytozoon bieneusi.
a
The model excluded participants with acute diarrhea.
b
Statistically significant at a p .05.
c
Statistically significant at a p .0071 (Bonferroni’s correction).

children [13]. Altogether, these findings are in agreement with
the suggestion that socioeconomic and geographic differences
affect the distribution of Cryptosporidium genotypes and sub-
type families of C. hominis and C. parvum [23].
It has been frequently reported that not all HIV-infected
persons with cryptosporidiosis have diarrhea [26–30]. These
differences in clinical manifestations were previously attributed
to the immune status of the person, and persons with CD4+
cell counts !180 cells/mm3 were most likely to have chronic
cryptosporidiosis [31], as well as other opportunistic infections
[32]. However, our results suggested that genetic differences in
the parasite, such as genotypes or subtype families, also play a
role in the presentation of clinical symptoms. Our data showed
that, among genotypes, C. parvum was probably the most path-
ogenic because of its significant association with chronic di-
arrhea and vomiting, followed by C. canis and C. felis, which
had significant associations with diarrhea. Contrarily, C. me-
leagridis appeared to be the less pathogenic, given that it was
not associated with the symptoms evaluated in this study.
We also observed differences in clinical manifestations among
subtype families of C. hominis: persons infected with subtype
family Id were more likely to have an increased risk for diarrhea,
whereas infections with subtype family Ib were marginally as-
sociated with diarrhea. By contrast, subtype family Ia was not

688 • JID 2007:196 (1 September) • Cama et al.

 Table 3. Association with vomiting by Cryptosporidium genotypes and C. hominis
subtype families.

Subjects,
Parameter no. (%) OR (95% CI) P
Model 7: risk of vomiting based on microscopy
Cryptosporidiumspecies 188 (44) 1.5 (1.1–2.1) .009a
No Cryptosporidium 1718 (29) Referent
Model 8: risk of vomiting by genotypes
C. hominis 117 (40) 1.3 (0.9–1.9) .214
b
C. parvum 15 (80) 7.2 (2.0–25.8) .003
C. meleagridis 15 (33) 1.0 (0.3–3.1) .941
C. felis or C. canis 12 (42) 1.3 (0.4–4.4) .622
No Cryptosporidium 1718 (29) Referent
Model 9: risk of vomiting by subtype families
of C. hominis
Subtype families
Ia 30 (27) 0.7 (0.3–1.7) .468
Ib 37 (49) 1.8 (0.9–3.6) .077

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Id 34 (32) 0.8 (0.4–1.8) .669
Ie 9 (67) 4.0 (1.0–16.5) .057
No Cryptosporidium 1718 (29) Referent

NOTE. All models were controlled for source of patients, CD4+ cell counts, and infections with
Isospora belli, Cyclospora cayetanensis, or Enterocytozoon bieneusi. Not all patients provided data
about vomiting. Data from variables not having significant associations were not presented.
a
Statistically significant at a p .05.
b
Statistically significant at a p .0071 (Bonferroni’s correction).

associated with diarrhea. These findings are in disagreement
with those of a previous small-scale study of hospitalized HIV-
infected South African children with diarrhea and cryptospo-
ridiosis, in which infections with all subtype families had similar
symptoms [33].
Our study also found that infections with C. meleagridis were
not associated with any of clinical manifestations, which is in
contrast to the results of a previous Portuguese study in which
a few HIV-infected persons with C. meleagridis had diarrhea,
despite having been prescribed antiretroviral therapies. We have
corroborated their finding that persons infected with C. me-
leagridis excreted fewer parasites than those infected with other
Cryptosporidium species [37]. This apparent contradiction may
be due to the endemicity of C. meleagridis in Peru [11, 18],
where it seems to be more prevalent than in most other geo-
graphical locations [37–39], and to the small number of cases
in the Portuguese study. Because of the cross-sectional nature
of our study, we can only hypothesize that the lack of associated
clinical manifestations could be a consequence of prior infec-
tions and subsequent amelioration of symptoms [40, 41] or of
the genetic uniqueness of C. meleagridis in Peru.
It is also conceivable that persons in the study might have
been infected with other bacterial or viral pathogens. Neverthe-
less, there is no evidence suggesting that Cryptosporidium-in-
fected persons were more likely to have other enteropathogens
that might have caused diarrhea or vomiting. Furthermore, other
symptoms previously associated with cryptosporidiosis, such as
fever, acid reflux, and muscle and joint pain [36] or extraintestinal
sequelae [8], and frequently reported in infections with other
pathogens were not corroborated by our findings.
Overall, our findings suggest that infections with C. hominis
subtype family Id, C. parvum, C. canis, or C. felis can severely
affect HIV-infected persons, because chronic diarrhea can lead
to wasting syndrome and eventually death [2, 34, 35]. Because
infections with C. parvum subtype family IIc were also asso-
ciated with vomiting, HIV-infected patients also infected with
this subtype may be at higher risk for severe complications and
can be considered for receiving more aggressive antiretroviral
therapies.
The analyses of risk factors identified that persons who had
contacts with children !5 years of age were more likely to be
infected with C. hominis subtype family Ie. This finding is in
concordance with the anthroponotic nature of C. hominis. Our
study did not categorically identify other infection risk factors,
and this was probably due to a multitude of reasons, including
the cross-sectional nature of our study design to evaluate
chronic infections, the use of a very stringent significance level
in our analyses (Bonferroni-adjusted a levels), and the fact that
our study was conducted in an area of endemicity, where ex-
posure to Cryptosporidium may occur frequently and through
multiple routes.
Although not statistically significant after the Bonferroni cor-

Different Symptoms in Cryptosporidiosis • JID 2007:196 (1 September) • 689

rection, eating fresh produce showed a significant trend for
protection against cryptosporidiosis. Because our study was
conducted in a city where Cryptosporidium contamination in
vegetables has already been demonstrated [42], it is possible
that consumption of raw vegetables served as a vehicle for low-
dose exposure to Cryptosporidium that resulted in some degree
of protection [43].
This study clearly demonstrates differences in the prevalence
patterns among different Cryptosporidium species and subtype
families, which suggests that different species or subtype fam-
ilies of Cryptosporidium are associated with different clinical
manifestations and reaffirms the value of genotyping and sub-
typing tools for enhancing our knowledge of cryptosporidiosis.
The identification of the large number of subtypes among the
study population, most previously identified elsewhere, con-
firmed the high resolution of the GP60-based molecular sub-
typing tool and its value to detect subtle sequence differences,
especially in outbreak investigations or transmission-dynamics
studies.
Our results also confirm the need for further longitudinal
molecular epidemiologic studies that use thorough microscopy-
based screening of parasites and comprehensive bacteriologic
and virologic screening. Such studies will allow researchers to
address more accurately the incidence of cryptosporidiosis, the
occurrence of subclinical infections, the role of latent infections
in transmission, and differences in pathogenicity, clinical syn-
dromes, and transmission risk factors among Cryptosporidium
species.
Acknowledgments
We thank our study personnel, Yrma Chuquiruna, Eleana Sanchez,
Fanny Garcia, Sonia Lopez, and Nurys Cabanillas, for their excellent work
at the hospitals; Carmen Taquiri and Jacqueline Balqui, for their invaluable
efforts in the parasitology laboratory; Marco Varela, for data management;
Paula Maguiña, Ana Rosa Contreras, and Paola Maurtua, for administrative
support; Lilia Cabrera, for project support; and J. B. Phu and D. Sara, for
technical assistance.
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