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DISCOVERY OF THE PARASITIC PROTOZOA

Because of their small size, it was not possible to recognize any protozoa until the invention of the microscope and its use by Antonie van Leeuwenhoek toward the end of the 17th century. The study of parasitic protozoa only really began two centuries later, following the discovery of bacteria and the promulgation of the germ theory by Pasteur and his colleagues at the end of the 19th century.

Amoebae and AmoebiasisHumans harbor nine species of intestinal amoebae, of which only one, Entamoeba histolytica, is a pathogen. The life cycle is simple. The amoebae live and multiply in the gut and form cysts that are passed out in the feces and infect new individuals when they are consumed in contaminated water or food. Most infections are asymptomatic, but some strains of E. histolytica can invade the gut wall, causing severe ulceration and amoebic dysentery characterized by bloody stools. If the parasites gain access to damaged blood vessels, they may be carried to extraintestinal sites anywhere in the body, the most important of which is the liver, where the amoebae cause hepatic amoebiasis. Supposed evidence that both the intestinal and liver forms of the disease were recognized from the earliest times is circumstantial because there are so many causes of both the bloody dysentery characteristic of amoebiasis and the symptoms of hepatic amoebiasis that many of these records are open to other interpretations (24). With these reservations in mind, the earliest record is possibly that from the Sanskrit document Brigu-samhita, written about 1000 BC, which refers to bloody, mucose diarrhea (260). Assyrian and Babylonian texts from the Library of King Ashurbanipal refer to blood in the feces, suggesting the presence of amoebiasis in the Tigris-Euphrates basin before the sixth century BC (24, 148), and it is possible that the hepatic and perianal abscesses described in both Epidemics and Aphorisms in the Corpus Hippocratorum refer to amoebiasis (131). Since epidemics of dysentery by itself are likely to result from bacterial infections and dysentery associated with disease of the liver is likely to be amoebic, later records are easier to interpret. In the second century AD, Galen and Celsus both described liver abscesses that were probably amoebic, and the works of Aretaeus, Archigenes, Aurelanus, and Avicenna toward the end of the first millennium give good accounts of both dysentery and hepatic involvement (238). As amoebiasis became widespread in the developed world, there were numerous records of “bloody flux” in Europe, Asia, Persia, and Greece in the Middle Ages (137). The disease appears to have been introduced into the New World by Europeans sometime in the 16th century (51), and with the later development of European colonies and increased world trade, there are numerous clear descriptions of both the intestinal and hepatic forms of amoebiasis. In the 19th century, several books mainly concerned with diseases in India, including Researches into the Causes, Nature and Treatment of the More Prevalent Diseases of India and of Warm Climates Generally by James Annersley, clearly refer to both intestinal and hepatic amoebiasis (6), and it is now generally agreed that this book contains the first accurate descriptions of both forms of the disease. The connection between amoebic dysentery and liver abscesses was described by William Budd, the English physician who discovered the method of transmission of typhoid (30). The amoeba itself, E. histolytica, was discovered by Friedrich Lösch (also known as Fedor Lesh) in 1873 in Russia (163), and Lösch also established the relationship between the parasite and the disease in dogs experimentally infected with amoebae from humans. Stephanos Kartulis, a Greek physician, also found amoebae in intestinal ulcers in patients suffering from dysentery in Egypt in 1885 and 1896 and noted that he never found amoebae from nondysenteric cases (132). Kartulis also showed that cats could be infected with amoebae per rectum and developed dysentery (133) a finding discussed below. The authoritative report by William Thomas Councilman and Henri Lafleur, working at the Johns Hopkins Hospital in 1891, represents a definitive statement of what was known about the pathology of amoebiasis at the end of the 19th century, and much of it is still valid today (47).

It was pointed out above that humans harbor several species of amoebae. The most common are E. histolytica, which has just been considered, and a larger and superficially similar harmless species, E. coli; the presence of these two parasites confused early workers in this field. The first clues that there was more than one species in humans came from the work of Heinrich Iranaus Quincke and Ernst Roos working in Kiel in 1894, who observed that cats could only be infected per rectum or orally with cysts of amoebae that contained ingested red blood cells and not with those that did not, i.e., E. coli (220, 227). Thereafter, the most contentious arguments relate to the various morphologically identical species and strains of E. histoloytica, and their relationship to disease has only recently been resolved by using biochemical techniques that clearly show that the presence of two common species, E. histolytica, which can cause disease, and E. dispar, which cannot (237).

The history of amoebiasis is well documented. The most comprehensive account of the early history is that by Dobell (60), and there are also good accounts of the early history by Bray (24), Foster (89), Kean (135), Scott, (238), and Wenyon (272) and reviews containing more recent information by Craig (50), Guirola (110), Imperato (127), Martínez-Báez, (184), Stilwell (248), and Svanidtse (249).

Giardia and Giardiasis Giardia holds a special place in the science of parasitic protozoology because the parasite Giardia duodenalis, also known as G. lamblia or G. intestinalis, was the first parasitic protozoan of humans seen by Antonie van Leeuwenhoek in 1681 (62, 136). The life cycle of Giardia is very simple: the parasites multiply in the duodenum and form cysts that are passed out in the feces and infect new individuals when they are swallowed in food or water. Most infected individuals show few or no signs of infection, but in some, particularly children, there may be malabsorbtion, diarrhea, and abdominal pain. G. duodenalis was first seen by Leeuwenhoek and, interestingly, associated by him with his own loose stools. Leeuwenhoek's illustrations are not very informative, and the first good illustrations of Giardia are those of Vilém Lambl in 1859 (136, 150). The parasite received little attention until 1902, when the American parasitologist Charles Wardell Stiles began to suspect that there was a causal relationship with diarrhea (247). This was not followed up until the 1914 to 1918 World War, when soldiers with diarrhea were found to pass Giardia cysts that caused similar symptoms when administered to laboratory animals (75). In 1921, Clifford Dobell suggested that Giardia was a pathogen (61), and in 1926, Reginald Miller, a physician working in London, conclusively showed that some children infected with Giardia did suffer from malabsorption whereas others acted as unaffected carriers (188). It was not until 1954, however, that the detailed studies by the American physician Robert Rendtorff produced unambiguous evidence linking the parasite with the disease (224). In the 300 years since Giardia was first discovered, it has become recognized as a common parasite and potential pathogen worldwide; however, it is still not known how many species infect humans and what role, if any, reservoir hosts play in the epidemiology of the infection. Fuller accounts of the history of giardiasis are given by Wenyon (272) and Farthing (78).

African Trypanosomes and Sleeping SicknessAfrican trypanosomiasis is caused by infection with two subspecies of trypanosomes, Trypanosoma brucei gambiense, which causes Gambian or chronic sleeping sickness, and T. b. rhodesiense, which causes Rhodesian or acute sleeping sickness. The trypanosomes multiply in the blood and are taken up by tsetse flies when they feed. Within the tsetse fly, there is a phase of multiplication and development resulting in the formation of infective trypanosomes in the salivary glands of the fly, which are injected into a new host when the fly feeds. The infection itself causes a number of symptoms including anemia, wasting and lethargy, and, in some cases, if the parasites pass into the brain and cerebrospinal fluid, coma and death. There are similar parasites in wild and domesticated animals. The first definitive accounts of sleeping sickness are by an English naval surgeon, John Atkins, in 1721 (10) and Thomas Winterbottom, who coined the term “negro lethargy” in 1803 (276). An appreciation of the real cause of the disease was not possible until Pasteur had established the germ theory toward the end of the 19th century. Trypanosomes had been seen in the blood of fishes, frogs, and mammals from 1843 onward, but it was not until 1881 that Griffith Evans found trypanosomes in the blood of horses and camels with a wasting disease called surra and suggested that the parasites might be the cause of this disease (74). These observations led to the most important discoveries about human and animal trypanosomiasis shortly afterwards. In 1894, David Bruce, a British army surgeon investigating an outbreak of nagana, a disease similar to surra, in cattle in Zululand, was looking for a bacterial cause and found trypanosomes in the blood of diseased cattle; he demonstrated experimentally that these caused nagana in cattle and horses and also infected dogs. He also observed that infected cattle had spent some time in the fly-infested “tsetse belt” and that the disease was similar to that in humans with negro lethargy and fly disease of hunters (26). Trypanosomes were seen in human blood by Gustave Nepveu in 1891 (200). In 1902, Everett Dutton identified the trypanosome that causes Gambian or chronic sleeping sickness (T. b. gambiense) in humans (68), and in 1910 J. W. W. Stephens and Harold Fantham described T. b. rhodesiense, the cause of Rhodesian or acute sleeping sickness (136, 246). Although Bruce had shown that trypanosome infections in cattle were acquired from tsetse flies, he thought that transmission was purely mechanical, and the role of the tsetse fly in the transmission of sleeping sickness remained controversial until Friedrich Kleine, a colleague of Robert Koch, demonstrated in 1909 the essential role of the tsetse fly in the life cycle of trypanosomes (138).

The persistence of trypanosomes in the blood and the existence of successive waves of parasitemia were described in detail by Ronald Ross and David Thompson in 1911 (232), but the actual mechanism of what happens and how the parasite evades the immune response, now called antigenic variation, was not elaborated until the work of Keith Vickerman in 1969 (265). The story of African sleeping sickness is told briefly by Hoare (119) and in more detail by Foster (89), Nash (196), Lyons (166), Wenyon (272), and Williams (274).

South American Trypanosomiasis: Chagas' DiseaseChagas' disease is caused by infection with another trypanosome, Trypanosoma cruzi, transmitted by insects belonging to the order Hemiptera or true bugs, commonly known as kissing bugs because of their tendency to bite the lips and face. The transient trypanosome forms circulate in the blood and are taken up by a blood-sucking bug when it feeds. The parasites multiply in the gut of the bug, and infective forms are passed out in the feces while the bug is feeding on a new host and are rubbed into the bite. In the human host, parasites enter and multiply in a variety of different cells and eventually induce what are thought to be autoimmune responses that results in the destruction of both infected and uninfected tissues. The nature of the disease depends on the tissues and organs involved, and the most conspicuous forms are massive distension of the intestinal tract, especially the esophagus and colon, and destruction of cardiac muscle, which can result in death many years after the initial infection. T. cruzi infections are common in many mammals on the American continent, but the human disease now occurs only in South and Central America. The earliest indication that Chagas' disease is an ancient infection in South America comes from the examination of spontaneously mummified human remains from Chile between 470 BC and AD 600 that show clear signs of the characteristic destructive nature of the disease (233). The use of immunological and molecular techniques has made it possible to detect the presence of T. cruzi without necessarily visualizing the parasites themselves. T. cruzi DNA has been detected in the heart and esophagus of mummified bodies from Peru and northern Chile dating from 2000 BC to AD 1400 (109) and in samples from bodies in museums from northern Chile from about AD 1000 to 1400 (85). The parasites themselves have also been identified by light and electron microscopy in a Peruvian mummy from the 15 to 16th century AD (88).

The history of T. cruzi and Chagas' disease really begins with a series of discoveries by the Brazilian scientist Carlos Chagas, between 1907 and 1912. Chagas not only discovered the trypanosome T. cruzi and demonstrated its transmission by bugs but also described the disease that affects some 18 million people and now commemorates his name. Chagas' first observation was that the blood-sucking bugs that infested the poorly constructed houses harbored flagellated protozoa and that when these flagellates were injected into monkeys and guinea pigs, trypanosomes appeared in the blood (39, 136). Chagas later found the same trypanosomes in the blood of children with an acute febrile condition and suspected that blood-sucking bugs might also transmit the parasite to humans, but he thought that the trypanosomes were transmitted via the bite of the insect (40, 41). It was the French parasitologist Emile Brumpt who demonstrated transmission via the fecal route (28, 136). The links between infection with T. cruzi and the various signs of Chagas' disease, such as distended colon and esophagus and cardiac failure, were not determined until the work of Fritz Koberle in the 1960s (140). Exactly how the damage to heart and nerves is caused and what role the autoimmune component plays are still controversial. The history of Chagas' disease has been well documented by Scott (238), Lewinsohn (158), Leonard (156), Miles (187), and Wenyon (272).

Leishmania and LeishmaniasisLeishmaniasis, caused by several species of Leishmania, is transmitted by sandflies and occurs in various forms in the Old and New World. The parasites infect and multiply in macrophages and are taken up by sandflies when they feed. In the gut of the sandfly, the parasites multiply and reach the mouthparts, from where they are injected into a new host when the sandfly feeds again. The disease, leishmaniasis, takes a number of forms ranging from simple cutaneous ulcers to massive destruction of cutaneous and subcutaneous tissues in the mucocutaneous forms and the involvement of the liver and other organs in the visceral form.

From a historical viewpoint, it is easiest to consider the Old World forms first. Old World cutaneous leishmaniasis, known as oriental sore, is an ancient disease, and there are descriptions of the conspicuous lesions on tablets in the library of King Ashurbanipal from the 7th century BC, some of which are thought to have been derived from earlier texts from 1500 to 2500 BC (183). There are detailed descriptions of oriental sore by Arab physicians including Avicenna in the 10th century, who described what was (and is) called Balkh sore from northern Afghanistan, and there are later records from various places in the Middle East including Baghdad and Jericho; many of the conditions were given local names by which they are still known (183). Old World visceral leishmaniasis, or kala azar, characterized by discolored skin, fever, and enlarged spleen, is easily confused with other diseases, especially malaria. Kala azar was first noticed in Jessore in India in 1824, when patients suffering from fevers that were thought to be due to malaria failed to respond to quinine; by 1862 the disease had spread to Burdwan, where it reached epidemic proportions (71). The cause remained unknown, and several eminent clinicians, including Ronald Ross, were convinced that kala azar was a virulent form of malaria (230). It was not until the parasite, L. donovani, was discovered in 1900 by Leishman and Donovan (see below) that the true nature of the disease became apparent (118).

The discovery of the parasites responsible for the Old World cutaneous disease is controversial, and a number of observers described structures that might or might not have been leishmanial parasites from oriental sores (272). Credit for their discovery is usually given to an American, James Homer Wright (136, 279), although there is no doubt that they were actually seen in 1885 by David Cunningham (52, 136), who did not realize what they were, and in 1898 by a Russian military surgeon, P. F. Borovsky (118, 136). The discovery of the parasite that causes visceral leishmaniasis, L. donovani, is less controversial, and it is universally accepted that a Scottish army doctor, William Leishman (136, 155), and the Professor of Physiology at Madras University, Charles Donovan (64, 136), independently discovered the parasite in the spleens of patients with kala azar. It is fair to point out that Borovsky's discoveries were unknown to Wright and to Leishman and Donovan.

The search for a vector was a long one, and it was not until 1921 that the experimental proof of transmission to humans by sandflies belonging to the genus Phlebotomus was demonstrated by the Sergent brothers, Edouard and Etienne (239). The actual mode of infection, through the bite of the sandfly, was not finally demonstrated until 1941 (4, 136). The history of Old World leishmaniasis is described by Garnham (96), Manson-Bahr (183), and Wenyon (272).

In the New World, cutaneous and mucocutaneous leishmaniasis cause disfiguring conditions that have been recognized in sculptures since the 5th century and in the writings of the Spanish missionaries in the 16th century (149). It was originally thought that New World Leishmaniasis and Old World leishmaniasis were the same, but in 1911 Gaspar Vianna found that the parasites in South America differed from those in Africa and India and created a new species, Leishmania braziliensis (264). Since then, a number of other species unique to the New World have been described. Following the discovery of the sandfly transmission of Old World leishmaniasis, the vectors in the New World were also assumed to belong to the genus Phlebotomus, but in 1922 it was discovered that the genus involved was actually Lutzomyia. Over the last two decades, the complex pattern of species of parasite, vector, reservoir host, and disease has been painstakingly elaborated by Ralph Lainson and his colleagues (149).

MalariaMalaria is one of the most important infectious diseases in the world, and its history extends into antiquity. The disease is caused by four species of the genus Plasmodium, P. falciparum, P. vivax, P. ovale, and P. malariae. Similar parasites are common in monkeys and apes. It is now generally held that malaria arose in our primate ancestors in Africa and evolved with humans, spreading with human migrations first throughout the tropics, subtropics, and temperate regions of the Old World and then to the New World with explorers, missionaries, and slaves. The characteristic periodic fevers of malaria are recorded from every civilized society from China in 2700 BC through the writings of Greek, Roman, Assyrian, Indian, Arabic, and European physicians up to the 19th century. The earliest detailed accounts are those of Hippocrates in the 5th century BC, and thereafter there are increasing numbers of references to the disease in Greece and Italy and throughout the Roman Empire as its occurrence became commonplace in Europe and elsewhere. Over this period, it became clear that malaria was associated with marshes, and there were many ingenious explanations to explain the disease in terms of the miasmas rising from the swamps (112).

Our scientific understanding of malaria did not begin until the end of the 19th century following the establishment of the germ theory and the birth of microbiology, when it became necessary to discover the cause of the disease that was then threatening many parts of the European empires. The discovery of the malaria parasite and its mode of transmission are among the most exciting events in the history of infectious diseases, and this topic has been reviewed many times, particularly by Bruce-Chwatt (27), Garnham (94), Harrison (112), McGregor (170), Poser and Bruyn (218), and Wenyon (273).

The life cycle is a very complex one that begins when an infected anopheline mosquito injects sporozoites, the infectious stages, into the blood of its host. Sporozoites enter and multiply in liver cells, and thousands of daughter forms, merozoites, are released into the blood. These merozoites invade red blood cells, in which another phase of multiplication occurs; this process is repeated indefinitely, causing the symptoms of the disease we call malaria. Some merozoites do not divide but develop into sexual stages, the male and female gametocytes, that are taken up by another mosquito when it feeds; fertilization and zygote formation occur in the gut of the mosquito. The zygote develops into an oocyst on the outside of the mosquito gut, and within the oocyst there is another phase of multiplication that results in the production of sporozoites that reach the salivary glands to be injected into a new host. The parasites in the blood were first seen in 1880 by a French army surgeon, Alphonse Laveran, who was looking for a bacterial cause of malaria and who immediately realized that the parasites were responsible for the disease (152).

The discovery that the mosquito acted as a vector was due to the intuition of Patrick Manson. Manson had already demonstrated that filarial worms, also blood parasites, were transmitted by mosquitoes and postulated that the vector of the malaria parasite might also be a mosquito, partly because of his knowledge of the life cycle of filarial worms and partly because of the known association between the disease and marshy places in which mosquitoes breed (178). Manson was unable to undertake this investigation himself and persuaded Ronald Ross, an army surgeon, to carry out the work in India. The story of Ross' discoveries has been told many times and is not repeated in detail here, since there are excellent accounts by Ross himself (231) and in the Ross-Manson collected letters (34) and also by Bruce-Chwatt (27), Garnham (94), Harrison (112), Manson-Bahr (182), Nye and Gibson (206), Poser and Bruyn (218), and Russell (236). In 1897, Ross saw what we now know to be the oocysts of P. falciparum in an anopheline mosquito that had fed on a patient with crescentic malaria parasites (gametocytes) in his blood, but he was unable to follow this up at the time (228). Turning his attention to a bird malaria, P. relictum, he found all the stages of the parasite in culicine mosquitoes that had fed on infected sparrows (136, 229). In making this discovery, Ross acknowledged the work of a young Canadian, William George MacCullum, whose studies on the development of the sexual stages of a related avian parasite Halteridium (=Haemoproteus) columbae had led him to the conclusion that these parasites were similar to those in the blood of humans with malaria (168, 136). In the same year that Ross made his discovery, the Italian malariologists Giovanni Battista Grassi, Amico Bignami, and Giuseppe Bastianelli described the developmental stages of malaria parasites in anopheline mosquitoes; the life cycles of P. falciparum, P. vivax, and P. malariae were described a year later (103). For nearly 50 years, the life cycle in humans remained incompletely understood and nobody knew where the parasites, which could not be seen in the blood, developed during the first 10 days after infection. In 1947, Henry Shortt and Cyril Garnham, working in London, showed that a phase of division in the liver preceded the development of parasites in the blood (242). The final brick was put in place when an American clinician, Wojciech Krotoski, in collaboration with Garnham's team, showed that in some strains of P. vivax the stages in the liver could remain dormant for several months (142). Sadly, the discovery of the life cycle of the malaria parasite eventually led to acrimony between Ross and Manson and between the British and the Italians, something that still rumbles on a century later (56, 63, 76).

Toxoplasma, Toxoplasmosis, and Infections Caused by Related OrganismsToxoplasmosis is one of the most common and widespread parasitic infections but is relatively little known because in the majority of cases, infections are asymptomatic; however, it can be a serious cause of mortality and morbidity in fetuses and immunodeficient individuals. The parasite that causes the infection, Toxoplasma gondii, was discovered independently by the French parasitologists Charles Nicolle and Louis Herbert Manceaux while looking for a reservoir host of Leishmania in a North African rodent, the gundi Ctenodactylus gondi (136, 201) and by Alfonso Splendore in Sao Paulo in rabbits (136, 245). At about the same time, Samuel Taylor Darling saw what were probably similar organisms in a human (53), and the first definitive observation of T. gondii from a child in connection with an infection was made by a Czech physician, Josef Janku, in 1923 (130). Even then, T. gondii was largely regarded as an interesting curiosity until an association with human congenital disease was recognized in 1937 by Arne Wolf and David Cowen (277). This association was followed by the realization that T. gondii rarely causes disease even though it is a very common parasite of adults but that in pregnant women the parasite can cross the placenta and can damage the fetus. The early history of the discovery of T. gondii and toxoplasmosis is discussed by Wenyon (273) and Dubey and Beattie (65).

While these developments were taking place, there were increasing numbers of records from virtually all species of mammals and many birds, but the nature of the parasite remained obscure until the life cycle had been worked out. The life cycle of T. gondii is a very complicated one and remained elusive until 1970, when scientists in Britain, Germany, The Netherlands, and the United States independently demonstrated that this parasite was a stage in the life cycle of a common intestinal coccidian of cats. In the most simple form of the life cycle, cats become infected when they swallow oocysts, the resistant infective stages containing sporozoites, which invade and multiply in intestinal cells, where sexual stages are produced, fertilization occurs, and oocysts are produced. However, there is an alternative life cycle. If the oocysts are swallowed by a mouse (or any other nonfeline host), multiplication occurs in the intestinal cells, but instead of sexual stages being produced there follows a disseminated infection during which resistant stages form in the brain and muscle. There is no further development in the mouse, but when the mouse is eaten by a cat, the life cycle reverts to its basic sexual pattern. Humans are infected in the same way as mice if they consume oocysts, but they can also become infected by eating any kind of meat containing the resistant forms. It is therefore not surprising that the life cycle remained elusive until William McPhee Hutchison, working in Glasgow in 1965, showed that the infectious agent was passed in the feces of cats. At the time he thought that it was transmitted with a nematode worm, as happens with the flagellate Histomonas meleagridis and the nematode Heterakis gallinarum in fowl. Hutchison subsequently identified protozoan cysts in the feces as those of a coccidian related to Isospora, a common parasite of cats (125, 126). In the meantime, other groups were following up Hutchison's 1965 observation of the presence of infectious agents in the feces of cats, and Hutchison's incrimination of the isosporan parasite of cats as T. gondii was independently confirmed by Jack Frenkel (90) and Harley Sheffield (241) in the United States, Gerhard Piekarski in Germany (216), and J. P. Overdulve in The Netherlands (210). The discovery of the T. gondii life cycle initiated a massive search for similar phases in the life cycles of other coccidian parasites, with the result that a number of protozoa that had not been properly identified were classified as stages in the life cycle of other poorly understood coccidians and that in many cases transmission depended on a predator-prey relationship (250). Humans are infected with two related parasites, Sarcocystis hominis and S. suihominis, acquired from beef and pork, respectively, and S. lindemanni, whose source is unknown. The early history of our knowledge of Sarcocystis is covered by Wenyon (273), and subsequent discoveries are described by Tadros and Laarman (250).

Humans are also hosts to three other species of coccidia, Isospora belli, Cryptosporidium parvum, and Cyclospora cayetanensis, that have in the past been regarded as rare and accidental curiosities but have recently been identified as pathogens in AIDS patients and other immunocompromised individuals. All have simple life cycles initiated by the ingestion of oocysts followed by multiplication and spread within the intestinal cells of the host and the eventual production of sexual stages, as for T. gondii infection in cats. C. parvum was discovered in 1912 by the American parasitologist Edward Ernest Tyzzer in the gastric glands of laboratory mice in which he had previously found another species, C. muris (259). C. parvum is not very host specific, and the first cases in humans were recorded in 1976 independently by Nime (203) and Meisel (186). From 1981 onward, numerous new cases began to be recognized in AIDS patients. The oocysts Cryptosporidium are very resistant to chlorination, and the source of these infections is probably drinking water contaminated with cattle feces. Cryptosporidium infections are now known to be very common and have caused a number of epidemics in which the victims have experienced abdominal pain and diarrhea. In immunodepressed individuals, especially those infected with HIV, the infection can become disseminated to the liver, pancreas, and respiratory tract and can be fatal. There is an excellent history of human cryptosporidiosis by McDonald (169) and a short but useful review by Dubey et al. (66).

C. cayetanensis is another coccidian that is associated mainly with AIDS. In 1979, the English parasitologist Richard Ashford found an unidentified coccidian in patients in Papua New Guinea (8), but it received little attention until it was found again in the stools of patients with HIV by Soave et al. in 1986 (243). In 1992, this parasite was named Cyclospora cayetanensis (209), and since then it has been identified as the cause of a number of outbreaks of diarrhea and fatigue in both immunocompetent and immunosuppressed individuals (108). Cyclospora infections are known to be transmitted in water and on fruit, but the original source is not known.

The last of this group of parasites, Isospora belli, discovered by Woodcock in 1915 (278), is another coccidian frequently found in asymptomatic immunocompetent individuals but associated with diarrhea in AIDS patients. The whole subject of parasitic infections in immunocompromised hosts is discussed by Ambroise-Thomas (5).

MicrosporidiansMicrosporidians are extemely common spore-forming parasites of vertebrates and invertebrates that were until relatively recently grouped with myxosporidians as cnidosporidians and classified with or close to the Sporozoa. We now know that the myxosporidians are more closely related to the Metazoa than the Protozoa and that the microsporidians are more closely related to the Fungi (38). Nevertheless, microsporidians are still regarded as the province of parasitologists and have become important as concomitant infections in AIDS patients. The life cycle of microsporidians is quite complex. The most conspicuous stage is the resistant gram-positive spore containing a coiled filament and an infective body, the sporoplasm. The host becomes infected when the spore is ingested or inhaled. The sporoplasm is extruded through the filament and penetrates a host cell, within which the organism multiplies and spreads to other cells; eventually, another generation of spores is produced. There are, however, many variations on this basic pattern. What are now thought to have been the spores of Nosma bombycis were described by Nägeli investigating an outbreak of a disease called pébrine in the silkworm Bombyx mori in 1857 (195) and studied in much more detail by Louis Pasteur in 1865 to 1870 (261). During the 19th century, microsporidians attracted considerable attention mainly as parasites of invertebrates. Our knowledge of human microsporidiosis in the past is limited because of difficulties in interpreting various structures that might or might not have been spores, but from the second decade of the 20th century onward, there have been a number of sporadic reports of what might have been human microsporidial infections. The first case was probably that of Encephalitozoon chagasi in a newborn baby recorded in 1927 (255), but the first authenticated record was not until 1959, when Hisakichi Matsubayashi and his colleagues in Japan found an Encephalitozoon sp. in boy with convulsions (185). Thereafter, there were reports of a number of sporadic cases of microsporidian infections in humans (38), but interest in this group really took off in 1988, when E. bieneusi was found in an AIDS patient (58). Since then, about 7 genera and 14 species associated with fulminating infections in immunodepressed patients and less serious infections in immunocompetent individuals have been described (36, 37) and the number of cases, particularly in AIDS patients, continues to rise (5). Despite their importance, very little is known about the transmission and epidemiology of the microsporidians.

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