الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
The numbers of immunosuppresed individuals continue to increase in developing countries as a result of medical interventions with more aggressive immunosuppressive therapies for immune-mediated disorders and hematopoietic and solid organ transplants, with approximately one million transplants performed annually. Enteric protozoan parasites like coccidia remain the most commonly encountered parasitic diseases and continue to cause significant morbidity and mortality. The most common complaint after liver transplantation is diarrhea. Liver transplantation requires the use of immunosuppressive agents in the immediate postoperative period. Consequently, the most common causes for diarrhea are infection and medication-associated side effects. Enteric coccidian parasites are increasingly recognized as causes of enterocolitis in those immunocompromised patients. Toxoplasmosis after solid organ transplantation cause severe or life-threatening disease and may result from primary infection or reactivation of latent infection. The aim of the present study was to assess coccidial parasitic infection among 50 liver transplant recipients by microscopic stool examination including direct smear method and different staining methods (trichrome and modified Ziehl Neelsen). Mostly coccidia found was Cryptosporidium parvam, stool samples were subjected to ELISA testing for detection of Cryptosporidium oocysts antigen. All cases were subjected to serological examination to detect anti Toxoplasma gondii antibodies including ELISA IgM and IgG. The current study was undertaken from March 2011 to June 2013. The study included 75 participants aging (15-55 years) were divided into two groups: Group-1: They were 50 selected patients (38 males and 12 females) during the first six months after liver transplantation in liver transplant unit, National Liver Institute, Menoufia University. Group-2: Included 25 apparently healthy subjects of matching age and gender to an extent as control group. In both groups, 20 and 7 residened in rural areas respectively and 30 and 18 in urban areas respectively, where 37 and 19 used tap water and 13 and 6 used filtered water respectively. All patients were presenting with signs and symptoms suggestive for coccidial infection, such as abdominal pain, diarrhea, nausea, flatulence, vomiting and lymphadenopathy were also included. All the examined individuals were subjected to full history and laboratory investigation in the form of, fresh stool and serum samples were collected from each individual. All studied individuals were subjected to microscopic stool examination including direct smear method, formal ether concentration technique and staining with iodine, trichrome and mZN. The stool samples subjected to ELISA testing for detection of Cryptosporidium oocysts antigen, also all cases were subjected to serum examination to detect anti Toxoplasma gondii antibodies including ELISA IgM and IgG. The study results reveled that: Cryptosporidium species was the most predominant enteric coccidian parasites in 12% of six cases followed by Cyclospora in 6% of three cases positive by modified ZN-stained wet mounts preparations among group I. Flatulence was the most frequent symptoms among group I (74%), followed by diarrhea (56%), nausea (48%), loose diarrhea (40%), lymphadenopathy (34%), abdominal pain (28%), vomiting (16%), watery diarrhea (12%) and mixed diarrhea (4%). Iodine-stained wet mount stool examination detected two cases (4%) with Entamoeba complex cysts in group I and two positive cases (8%) in group II. Also, six positive cases (12%) with Giardia lamblia cysts in group I were detected with no other parasites detected in group II. There was no significant difference (P>0.05) between group I and group II regarding iodine-stained wet mount stool examination. Trichrome stain detected one patient (2%) with Entamoeba complex cyst, five patients (10 %) with Giardia lamblia cysts, six patients (12%) with Blastocystis hominis. Mixed infection of Entamoeba complex cyst and Blastocystis hominis in one patient (2%) while mixed infection of Giardia cyst and Blastocystis hominis in one patient (2%) in group I while two cases (8%) with Entamoeba complex cysts in group II and the difference between two groups was statistically non significant (P>0.05). Regarding parasitic infection detected by modified Ziehl Neelsen stain stool examination, this stain detected Cryptosporidium oocysts in four patients (8%) and Cyclospora oocysts in two patients (4%) in group I. Mixed infection of Cryptosporidium oocyst and Giardia cyst was in one patient (2%) while mixed infection of Cryptosporidium and Cyclospora oocysts in one patient (2%) in group I while no parasitic infections detected in group II. The difference between two groups was statistically non significant (P>0.05). Regarding socidemographic, it was noticed that prevalence rate of coccidia by stool examination using mZN stain in relation to age, gender, residence and water supply in group I, eight positive cases (16%) were distributed among age group 33-55 years old, while 42 negative cases (84%) were distributed among age group 15-55 years old and this variation was statistically non significant (P>0.05). Between infection rates, there were six males (75%) out of eight positive cases and two females (25%) positive cases and this variation was statistically non-significant (P>0.05). Regarding residence, from urban areas, the number of positive cases was more than from rural areas (62.5% & 37.5% respectively) and this variation was statistically non significant (P>0.05), while regarding water supply there is no significant difference between usage of tap and filter water (P>0.05). The most frequent symptoms that recorded in group I who were positive to coccidian positive by mZN were diarrhea and flatulence (62.5%) with non-significant relation (P>0.05). This followed by abdominal pain (37.5%), nausea (37.5%), lymphadenopathy (25%) and vomiting (12.5%) which were also non-significant (P>0.05). Regarding results of ridascreen Cryptosporidium oocysts antigen in stool, ten positive cases (20%) were detected in group I without any positive cases in group II. This relation was significant difference (P<0.05). Regarding comparison between the results of mZN stain and ridascreen Cryptosporidium oocysts antigen in stool in group I, out of ten positive patients by ridascreen Cryptosporidium oocysts antigen in stool, four cases (40%) were negative for parasitic detection by mZN, four cases (40%) showed Cryptosporidium oocyst, one case (10%) with mixed Cryptosporidium & Giardia oocyst and one case (10%) with mixed Cryptosporidium & Cyclospora oocyst by mZN stain in group I. Out of 40 patients negative by ridascreen test, two cases (5%) showed Cyclospora oocyst by mZN stain in group I. This variation was statistically significant (P<0.05). Regarding sensitivity, specificity and accuracy of mZN in relation to ridascreen Cryptosporidium oocysts antigen in stool in groupI, sensitivity of mZN was 60%, specificity was 100% and accuracy was 92%. Regarding serological examination, it was noticed that Toxoplasma antibodies detected by ELISA – IgM and IgG among studied groups, the nine patients (18%) in group I were seropositives for Toxoplasma IgM, without any positive case was recorded in group II for the same test. This difference was statistically significant (P<0.05). While, the seropositive patients for Toxoplasma IgG were 14 patients (28%) in group I, without any positive case was recorded in group II and this difference was statistically significant (P<0.05). Out of nine Toxoplasma IgM-positive patients, five cases (55.6%) had enlarged lymph nodes by clinical examination. Also, out of 41 seronegative patients for Toxoplasma IgM, 12 cases (29.3%) had enlarged lymph nodes. These differences were statistically non significant (P>0.05). Out of 14 seropositive patients for Toxoplasma IgG, 12 cases (85.7%) had enlarged lymph nodes, while out of 36 seronegative patients for Toxoplasma IgG, five cases (13.9%) had enlarged lymph nodes. These differences were statistically significant (P<0.05). from the previous results, it was concluded that enteric coccidian parasites should always be taken into account when investigating the aetiologies of diarrhea which appears in cases where the immune system has been suppressed among liver transplant recepients. Cryptosopridium oocysts antigen in stool by ELISA is an important confirmatory test in diagnosis of Cryptosporidium. Toxoplasma gondii was common opportunistic parasite and caused enlarged lymph nodes among liver transplant recipients, ELISA IgM and IgG are important screening tests commonly used as they are sensitive, rapid and easy to perform.