Etiology and Epidemiology of Diarrhea in Hospitalized Children from Low Income Country: A Matched Case-Control Study in Central African Republic

Background

In Sub-Saharan Africa, infectious diarrhea is a major cause of morbidity and mortality. A case-control study was conducted to identify the etiology of diarrhea and to describe its main epidemiologic risk factors among hospitalized children under five years old in Bangui, Central African Republic.

Methods

All consecutive children under five years old hospitalized for diarrhea in the Pediatric Complex of Bangui for whom a parent’s written consent was provided were included. Controls matched by age, sex and neighborhood of residence of each case were included. For both cases and controls, demographic, socio-economic and anthropometric data were recorded. Stool samples were collected to identify enteropathogens at enrollment. Clinical examination data and blood samples were collected only for cases.

Results

A total of 333 cases and 333 controls was recruited between December 2011 and November 2013. The mean age of cases was 12.9 months, and 56% were male. The mean delay between the onset of first symptoms and hospital admission was 3.7 days. Blood was detected in 5% of stool samples from cases. Cases were significantly more severely or moderately malnourished than controls. One of the sought-for pathogens was identified in 78% and 40% of cases and controls, respectively. Most attributable cases of hospitalized diarrhea were due to rotavirus, with an attributable fraction of 39%. Four other pathogens were associated with hospitalized diarrhea: Shigella/EIEC, Cryptosporidium parvum/hominis, astrovirus and norovirus with attributable fraction of 9%, 10%, 7% and 7% respectively. Giardia intestinalis was found in more controls than cases, with a protective fraction of 6%.

Conclusions

Rotavirus, norovirus, astrovirus, Shigella/EIEC, Cryptosporidium parvum/hominis were found to be positively associated with severe diarrhea: while Giardia intestinalis was found negatively associated. Most attributable episodes of severe diarrhea were associated with rotavirus, highlighting the urgent need to introduce the rotavirus vaccine within the CAR’s Expanded Program on Immunization. The development of new medicines, vaccines and rapid diagnostic tests that can be conducted at the bedside should be high priority for low-resource countries.     

Multiplex PCR detection of waterborne intestinal protozoa: microsporidia, Cyclospora, and Cryptosporidium

Recently, emerging waterborne protozoa, such as microsporidia, Cyclospora, and Cryptosporidium, have become a challenge to human health worldwide. Rapid, simple, and economical detection methods for these major waterborne protozoa in environmental and clinical samples are necessary to control infection and improve public health. In the present study, we developed a multiplex PCR test that is able to detect all these 3 major waterborne protozoa at the same time. Detection limits of the multiplex PCR method ranged from 10(1) to 10(2) oocysts or spores. The primers for microsporidia or Cryptosporidium used in this study can detect both Enterocytozoon bieneusi and Encephalitozoon intestinalis, or both Cryptosporidium hominis and Cryptosporidium parvum, respectively. Restriction enzyme digestion of PCR products with BsaBI or BsiEI makes it possible to distinguish the 2 species of microsporidia or Cryptosporidium, respectively. This simple, rapid, and cost-effective multiplex PCR method will be useful for detecting outbreaks or sporadic cases of waterborne protozoa infections.     

Prevalence of microsporidia and other intestinal parasites in patients with HIV infection, Bogota, 2001

Opportunistic intestinal parasites are a common cause of diarrhea in HIV-infected patients. To determine the prevalence of microsporidia and other opportunistic parasites infecting HIV patients in Bogotá, Colombia, 115 patients were examined for these infections during the year 2001. The institution and the sample percent from each are as follows: Santa Clara Hospital, 33.0%; San Pedro Claver, 20.0%; Simón Bolívar Hospital, 14.8%; San José Hospital, 13.9%; Central de la Policía Hospital, 6.1%; Compensar, 5.2%; Colombian League against AIDS, 2.6%; San Ignacio Hospital, 2.6%, and the Military Hospital, 1.7%. The average patient age was 36 years, with a range from 18 to 71 years. Patients with complaint of gastrointestinal symptoms were asked to provide two consecutive stool samples. The samples were concentrated in formalin-ether and examined microscopically for intestinal coccidian parasites by direct wet slide mounts. The prevalence of intestinal opportunistic parasites was 10.4% for Cryptosporidium sp. Initially, 29% of the samples were found to be positive for microsporidian spores using a modified Ziehl Neelsen chromotrope stain, but only 3.5% of them were confirmed as positive when a calcofluor/Gram chromotrope stain was used. The general prevalence of intestinal parasites was 59.1%. The most frequently found pathogens were Blastocystis hominis, 25.2%, and Entamoeba histolytica, 13%. In other studies with HIV patients in Colombia, lower prevalences of Cryptosporidium sp. infection were observed.     

Bacterial, viral and parasitic enteric pathogens associated with acute diarrhea in hospitalized children from northern Jordan

To determine the etiology of acute diarrhea in Jordanian children under 5 years of age, we examined stool samples from 265 children admitted to the pediatric ward at Princess Rahma Hospital for Children, Irbid, Jordan, for parasites, rotavirus and enteric bacteria. Using both traditional and molecular diagnostic techniques, we detected enteropathogens in 66.4% of patients with diarrhea. A single enteric pathogen was detected in 50.9% of the children, and multiple pathogens were detected in 15.5%. The prevalence of enteropathogens identified was as follows: rotavirus (32.5%), enteropathogenic Escherichia coli (12.8%), enteroaggregative E. coli (10.2), enterotoxigenic E. coli (5.7%), Shigella spp. (4.9%), Entamoeba histolytica (4.9%), Salmonella spp. (4.5%), Campylobacter jejuni/coli (1.5%), Cryptosporidium spp. (1.5%), enteroinvasive E. coli (1.5%), eae-, Ehly-positive E. coli (0.8%), Giardia lamblia (0. 8%) and Yersinia enterocolitica (0.4%). No Vibrio cholerae, Shiga toxin-producing E. coli, microsporidia, adenovirus or small round virus were detected. Findings from this study demonstrate that rotavirus and several types of diarrheagenic E. coli, which are not screened for during routine examinations of stool samples in public health laboratories, were the most frequently detected enteropathogens in these children. Our findings highlight the value of using a combination of traditional and molecular techniques in the diagnosis of diarrheal disease in this population.     

On the use of FTA technology for collection, archieving, and molecular analysis of microsporidia dna from clinical stool samples

The FTA technology was applied for sampling, archiving, and molecular analysis of the DNA isolated from stool samples to diagnose and identify microsporidia, the intracellular opportunistic parasites which induce malabsortion syndrome in immunosuppressed humans, particularly in patients with AIDS. Microsporidia DNA was successfully amplified in 6 of 50 stool samples of HIV-positive patients of the S. P. Botkin Memorial Infectious Disease Hospital (St. Petersburg) applied to FTA cards (FTA-Cars, Whatman Inc. Florham Park, NJ, USA). Amplicons (the fragments of rDNA) were directly sequenced, and microsporidia species--Encephalitozoon intestinalis, E. cuniculi, E. hellem, and Enterocytozoon bieneusi--were identified in Genbank by NCBI BLAST program. The FTA method of DNA immobilization is especially promising for epidemiological and field population studies which involve genotyping of microsporidia species and isolates.     

Intestinal parasites in the Camiri, Gutierrez and Boyuibe areas, Santa Cruz Department, Bolivia

A parasitological study was carried out on 381 apparently healthy subjects from Camiri, Boyuibe, Gutierrez. Intestinal parasites and non-pathogenic protozoa were present in 78.7% of the population sampled; multiple infections were observed in 67.7% of the parasitized individuals. The protozoon most commonly found was Entamoeba coli (in 40.7% of specimens), followed by Giardia intestinalis (30.7%), Iodamoeba bütschlii (10%), Chilomastix mesnili (8.7%). Other protozoon parasites also present were Enteromonas hominis (3.4%), Retortamonas intestinalis (2.4%), Cryptosporidium (2.1%), Endolimax nana (2.1%), Balantidium coli (1.8%) and Pentatrichomonas hominis (0.8%). The helminths observed were hookworms (28.6%), Trichuris trichiura (19.7%), Ascaris lumbricoides (9.7%), Hymenolepis nana (8.7%), Trichostrongylus (5.5%), Strongyloides stercoralis (1.8%), Taenia (5 cases) and Enterobius (6 cases). Prevalence for nematodes is probably underestimated in the 3-9 years age group because of a mebendazole treatment given 5 weeks before the survey, under a Program of P D C of the Ministry of Health. The sample from Camiri was found to be the most parasitized (84.1%). An extraordinarily high infection rate was found in two urban institutions, as well as in Itanambicua, a rural community close to Camiri. No significant differences were observed in parasitic prevalence between rural and urban environments. Exposure to contamination with human and animal faeces, overcrowding and poor sanitation habits are some of the factors responsible for the parasitic situation evidenced.     

Septata Intestinalis N. G., N. Sp., an Intestinal Microsporidian Associated With Chronic Diarrhea and Dissemination In Aids Patients

ABSTRACT. Intestinal microsporidiosis in patients diagnosed with acquired immunodeficiency syndrome (AIDS) and having chronic diarrhea was first reported in 1985 and the associated microsporidian was named Enterocytozoon bieneusi. the intracellular developmental cycle of E. bieneusi in enterocytes has been demonstrated and many cases have been reported worldwide. This report presents the life cycle of a second intestinal microsporidian, associated with the same symptoms, in five AIDS patients. This new microsporidian also infects enterocytes but its pathology and morphology differ from that of E. bieneusi. It involves lamina propria macrophages, fibroblasts, and endothelial cells and can disseminate to infect other parts of the body, e.g. the kidney and gall bladder. the parasite cycle includes development of rounded uninucleate and elongated bi- or tetranucleate cells without the formation of plasmodial stages. Sporogony is similar to the more typical development of microsporidia with sporoblast morphogenesis occurring after the last cell division. the development of cells within chambers of a septate, honeycomb-like, parasite-secreted fibrillar network and surrounded by a parasitophorous vacuole, however, is unique to this microsporidian, justifying the establishment of a new genus and species, Septata intestinalis n. g., n. sp.     

Intestinal microsporidiosis: a current infection in HIV-seropositive patients in Portugal

Intestinal microsporidiosis is recognised as an important cause of opportunistic infections in immunocompromised patients, especially those with AIDS. Two species are implicated in diarrhoea and other gastrointestinal disease in HIV-infected patients: Enterocytozoon bieneusi and Encephalitozoon intestinalis. Diagnosis of gastrointestinal microsporidiosis was made by detecting spores of the parasite in stool specimens with Weber's modified trichrome stain and with some optical brightening agents such as UVITEX 2B or calcofluor white M2R. The identification of microsporidiosis at the species level was made using appropriate primers with PCR. The diagnosis of intestinal microsporidiosis is currently performed in the parasitology laboratory. In a study of 215 HIV-infected patients, conducted from 1996 to 1999 (approximately n = 60/year), we found a prevalence of spores of microsporidia of 51.5% (n = 31) in 1996, 14.0% (n = 5) in 1997 and 12.5% (n = 8) in 1998 and 42.8% (n = 25) in 1999. Using PCR we found that E. intestinalis was the only species responsible for the gastrointestinal symptoms in 49 patients with microsporidian spores (71%) and E. bieneusi in 29% (n = 20).     

First detection and genotyping of human-associated microsporidia in pigeons from urban parks

Microsporidia are ubiquitous opportunistic parasites in nature infecting all animal phyla, and the zoonotic potential of this parasitosis is under discussion. Fecal samples from 124 pigeons from seven parks of Murcia (Spain) were analyzed. Thirty-six of them (29.0%) showed structures compatible with microsporidia spores by staining methods. The DNA isolated from 26 fecal samples (20.9%) of microsporidia-positive pigeons was amplified with specific primers for the four most frequent human microsporidia. Twelve pigeons were positive for only Enterocytozoon bieneusi (9.7%), 5 for Encephalitozoon intestinalis (4%), and one for Encephalitozoon hellem (0.8%). Coinfections were detected in eight additional pigeons: E. bieneusi and E. hellem were detected in six animals (4.8%); E. bieneusi was associated with E. intestinalis in one case (0.8%); and E. hellem and E. intestinalis coexisted in one pigeon. No positive samples for Encephalitozoon cuniculi were detected. The internally transcribed spacer genotype could be completed for one E. hellem-positive pigeon; the result was identical to the genotype A1 previously characterized in an E. hellem Spanish strain of human origin. To our knowledge, this is the first time that human-related microsporidia have been identified in urban park pigeons. Moreover, we can conclude that there is no barrier to microsporidia transmission between park pigeons and humans for E. intestinalis and E. hellem. This study is of environmental and sanitary interest, because children and elderly people constitute the main visitors of parks and they are populations at risk for microsporidiosis. It should also contribute to the better design of appropriate prophylactic measures for populations at risk for opportunistic infections.     

Cryptosporidiosis in patients with colorectal cancer

Parasitological examination of feces was carried out for 55 patients with diagnosed colorectal cancer before chemotherapy. Except for Cryptosporidium sp., no other intestinal parasites were found in the specimens; moreover, only the patients with watery diarrhea were Cryptosporidium sp.-positive by enzyme immunoassay. Prevalence of infection in the group of patients with diarrhea (23 persons) was 43.5%, whereas it was 18% for the entire group of patients under study. Coproantigens of this parasite were detected primarily in the patients with tumors located on the left side (in the sigmoid and descending colon).     

Seasonal variation of intestinal protozoa infections in outpatients of the north section of Santiago, Chile. 1995-1996]

Formalin preserved fecal samples from 6,058 and 5,863 outpatients were examined for intestinal parasites during 1995 and 1996 respectively. Prevalence rates of infections by intestinal protozoa in both years were similar. By age group (0-9, 10-19 and > 20 years old) Blastocystis hominis was observed in 18.6-19.3, 37.0-31.1 and 25.3-25.4% in 1995-1996 respectively. Prevalence of Giardia intestinalis infections decreased from 16.6-17.4% in the 0-9 year-old children group to 4.1-4.5% in patients over 20 years. Overall percentages of infection by Entamoeba histolytica varied between 4.2 and 10.9. Rates of infections by G. intestinalis, E. histolytica, and Entamoeba coli observed during rainy-cold months (april-september) of the year versus drywarmy period (october-march) were the same. On the contrary, more cases of B. hominis infection 25.8% versus 18.2% (this difference being statistically significant, p > 0.001) were observed during rainy-cold months of the year.     

Gastrointestinal and urinary tract pathogenic infections among HIV seropositive patients at the Komfo Anokye Teaching Hospital in Ghana

ABSTRACT: BACKGROUND: Gastrointestinal and urinary tract pathogenic infections are aggravating the incidence and progression of the Human Immunodeficiency Virus (HIV) infection into Acquired Immune Deficiency Syndrome (AIDS) more especially in the developing countries. This study was conducted to assess the common gastrointestinal and urinary infections among HIV/AIDS patients at the Komfo Anokye Teaching Hospital (KATH) in Ghana between April and December 2008. FINDINGS: This work reports on gastrointestinal and urinary tract pathogenic infections among 500 HIV seropositive and 300 HIV seronegative patients. There was a 35% (175/500) prevalence of intestinal parasites among HIV seropositive patients compared to 4.3% (13/300) in HIV seronegative patients. Giardia lamblia and Cryptosporidium accounted for 19% (95/500) and 14% (70/500) respectively, while Schistosoma mansoni, Strongyloides stercoralis and hookworm together accounted for 2% (10/500) of intestinal parasitic infections among the HIV seropositive patients. There was no significant difference (p > 0.05) in urinary parasitic infection between HIV seropositive 1% (2/500) and seronegative patients 0.7% (2/300). Most, 60 (86%) out of 70, of the urinary tract infection among the HIV seropositive patients was due to bacteria with E. coli being the most predominant isolate, 28 (47%) out of 60. There was no significant difference in infections based on age and gender. CONCLUSION: G. lamblia and Cryptosporidium were the most common gastrointestinal parasites detected while bacteria accounted for majority of the urinary tract infections among the HIV seropositive patients at the hospital.     

A new monoclonal antibody enzyme-linked immunosorbent assay to measure in vitro multiplication of the microsporidium Encephalitozoon intestinalis

Microsporidia are obligate intracellular eukaryotic parasites that infect a wide range of hosts, including invertebrates and vertebrates. Microsporidia have emerged as important opportunistic pathogens of humans with the onset of the AIDS pandemic. The potential impact of these infections in human pathology has required the development of antiparasitic strategies, based on the search for molecules having an effect on the development and/or the multiplication of microsporidia. This creates a demand for a simple and reliable in vitro technique for measuring the multiplication of microsporidia. We developed a new monoclonal antibody (MAb) enzyme-linked immunosorbent assay (ELISA) technique and measured the growth of Encephalitozoon intestinalis in an in vitro culturing system using this method. The monoclonal antibody is specific for a coat protein of E. intestinalis sporogonic stages produced in parasitophorous vacuole. An anti-mouse antibody labeled with peroxidase was used as conjugate. This ELISA is a suitable, specific and semiquantitative technique for measuring the spread of E. intestinalis. It is easy to perform and required 5 h from start to end. A good correlation was observed when the ELISA data were compared with the manual microscopic counts of parasitophorous vacuoles obtained after immunofluorescent assay (IFA). Moreover, the ELISA method proved more accurate than the immunofluorescent assay. In summary, the ELISA system described in this study provides a simple reliable assay for measuring the spread of microsporidia in vitro and may prove valuable for the screening of putative interesting antimicrosporidial compounds.     

Identification and characterization of microsporidia from fecal samples of HIV-positive patients from Lagos, Nigeria

Background

Microsporidia are obligate intracellular parasites that infect a broad range of vertebrates and invertebrates. They have been increasingly recognized as human pathogens in AIDS patients, mainly associated with a life-threatening chronic diarrhea and systemic disease. However, to date the global epidemiology of human microsporidiosis is poorly understood, and recent data suggest that the incidence of these pathogens is much higher than previously reported and may represent a neglected etiological agent of more common diseases indeed in immunocompetent individuals. To contribute to the knowledge of microsporidia molecular epidemiology in HIV-positive patients in Nigeria, the authors tested stool samples proceeding from patients with and without diarrhea.

Methodology/Principal Findings

Stool samples from 193 HIV-positive patients with and without diarrhea (67 and 126 respectively) from Lagos (Nigeria) were investigated for the presence of microsporidia and Cryptosporidium using Weber’s Chromotrope-based stain, Kinyoun stain, IFAT and PCR. The Weber stain showed 45 fecal samples (23.3%) with characteristic microsporidia spores, and a significant association of microsporidia with diarrhea was observed (O.R.  = 18.2; CI: 95%). A similar result was obtained using Kinyoun stain, showing 44 (31,8%) positive samples with structures morphologically compatible with Cryptosporidium sp, 14 (31.8%) of them with infection mixed with microsporidia. The characterization of microsporidia species by IFAT and PCR allowed identification of Enterocytozoon bieneusi, Encephalitozoon intestinalis and E. cuniculi in 5, 2 and 1 samples respectively. The partial sequencing of the ITS region of the rRNA genes showed that the three isolates of E.bieneusi studied are included in Group I, one of which bears the genotype B.

Conclusions/Significance

To our knowledge, this is the first report of microsporidia characterization in fecal samples from HIV-positive patients from Lagos, Nigeria. These results focus attention on the need to include microsporidial diagnosis in the management of HIV/AIDS infection in Nigeria, at the very least when other more common pathogens have not been detected.     

Infection Status of Hospitalized Diarrheal Patients with Gastrointestinal Protozoa, Bacteria, and Viruses in the Republic of Korea

To understand protozoan, viral, and bacterial infections in diarrheal patients, we analyzed positivity and mixed-infection status with 3 protozoans, 4 viruses, and 10 bacteria in hospitalized diarrheal patients during 2004-2006 in the Republic of Korea. A total of 76,652 stool samples were collected from 96 hospitals across the nation. The positivity for protozoa, viruses, and bacteria was 129, 1,759, and 1,797 per 10,000 persons, respectively. Especially, Cryptosporidium parvum was highly mixed-infected with rotavirus among pediatric diarrheal patients (29.5 per 100 C. parvum positive cases), and Entamoeba histolytica was mixed-infected with Clostridium perfringens (10.3 per 100 E. histolytica positive cases) in protozoan-diarrheal patients. Those infected with rotavirus and C. perfringens constituted relatively high proportions among mixed infection cases from January to April. The positivity for rotavirus among viral infection for those aged ≤ 5 years was significantly higher, while C. perfringens among bacterial infection was higher for ≥ 50 years. The information for association of viral and bacterial infections with enteropathogenic protozoa in diarrheal patients may contribute to improvement of care for diarrhea as well as development of control strategies for diarrheal diseases in Korea.     

Characterization of anti-Cryptosporidium IgA antibodies in sera from immunocompetent individuals and HIV-infected patients.

Human antibody response to Cryptosporidium parvum has been previously shown as involving immunoglobulin (Ig)M and IgG isotypes. The interest in anti-cryptosporidial IgA antibody response has been recently stimulated by studies on the therapeutic effects of secretory IgA antibodies to Cryptosporidium in animal models and in patients. In the present study, isotypes of serum anti-Cryptosporidium antibodies have been characterized in donors of the following categories: (a) healthy adults, (b) healthy children, (c) immunocompetent children with transient cryptosporidial diarrhea, (d) HIV-infected patients without clinical and parasitological evidence of Cryptosporidium infection and (e) AIDS patients with cryptosporidial diarrhea. Antibodies were detected using C. parvum oocysts purified by density gradient centrifugation from bovine faeces. The IgA antibodies were revealed using alpha-chain specific antibodies. Indirect immunofluorescence analysis with oocysts was used as control. Although high levels of serum antibodies of the IgA class were detected in some donors in the group of healthy adults, elevated values were consistently found in HIV-infected patients. Higher values were found in HIV patients with clinical cryptosporidiosis. The presence of a secretory component in serum IgA antibodies in these patients has been documented. Data indicate that IgA serum antibodies are produced as well as IgM and IgG antibodies upon contact with the parasite, and suggest that elevated IgA serum antibodies to Cryptosporidium are not associated with protection in HIV patients.     

In vitro effect of nitazoxanide against Entamoeba histolytica,Giardia intestinalis and Trichomonas vaginalis trophozoites

Nitazoxanide, a 5-nitrothiazolyl derivative, is effective in the treatment of a broad range of parasitic infections. In vitro, it is active against several protozoa, including Cryptosporidium parvum, Blastocystis hominis, and Giardia intestinalis. The objective of this study was to determine the in vitro effect of nitazoxanide on the growth and morphology of three anaerobic protozoa (Entamoeba histolytica, Giardia intestinalis, and Trichomonas vaginalis) and to compare these effects with those of metronidazole and albendazole. A subculture method was used to determine the concentrations required to inhibit growth by 50% or 90% (IC50 and IC90,). Nitazoxanide exhibited IC50, and IC90 values of 0.017 and 0.776 microg/ml respectively, against E. histolytica, 0.004 and 0.067 microg/ml against G. intestinalis, and 0.034 and 2.04 6 microg/ml against T. vaginalis. Based on the IC90 values, nitazoxanide was more toxic than metronidazole and albendazole against E. histolytica; albendazole and nitazoxanide were more toxic than metronidazole against G. intestinalis; and metronidazole was the most toxic drug against T. vaginalis. The effects of nitazoxanide on trophozoite ultrastructure of all three parasites included cell swelling and distorted cell shape, a redistribution of vacuoles, plasma membrane damage, and the formation of extensive empty areas in the cytoplasm of the protozoa.     

Genital microsporidiosis in women with AIDS: A post-mortem study

BackgroundMicrosporidiosis is a life threatening opportunistic infection of AIDS patients. The infection is usually restricted to specific anatomical areas, but could become systemic depending on the involved species. Genital microsporidiosis in female patients is rare.ObjectiveTo report genital microsporidiosis in female AIDS patients.MethodsTissues samples from the genital tract (ovary, fallopian tubes and uterus) of eight deceased women who died of wasting syndrome associated to AIDS and disseminated microsporidiosis at the Institute of Tropical Medicine Pedro Kourí were collected between 1997 and 2005. Using an indirect immunohistochemistry assay the microsporidia species involved in those cases were identified.ResultsWe report several cases of microsporidial infection of the female genital tract. Six out of eight women with the disseminated form of the disease showed the presence of microsporidia in the genital tract. Encephalitozoon cuniculi and Encephalitozoon hellem were identified in the internal lining epithelium of the fallopian tubes and endometrium.ConclusionsMicrosporidia species could disseminate to other organs and become systemic in severe immunocompromised cases. To our knowledge this is the greatest number of female genital tract microsporidiosis cases so far reported in humans.     

Opportunistic parasites among immunosuppressed children in Minia District, Egypt

A total of 450 stool samples were collected from inpatient and outpatient clinics of Pediatric Department, Minia University Hospital, Minia District, Egypt. Two groups of patients were studied, including 200 immunosuppressed and 250 immunocompetent children. Stool samples were subjected to wet saline and iodine mounts. A concentration technique (formol-ether sedimentation method) was carried out for stool samples diagnosed negative by wet saline and iodine mounts. Samples were stained by 2 different methods; acid fast stain (modified Ziehl-Neelsen stain) and Giemsa stain. Total 188 cases (94%) were diagnosed positive for parasitic infections among immunosuppressed children, whereas 150 cases (60%) were positive in immunocompetent children (P<0.0001). The most common protozoan infection in immunosuppressed group was Cryptosporidium parvum (60.2%), followed by Blastocystis hominis (12.1%), Isospora belli (9.7%), and Cyclospora caytenensis (7.8%). On the other hand, Entamoeba histolytica (24.6%) and Giardia lamblia (17.6%) were more common than other protozoans in immunocompetent children.