Molecular detection of Tropheryma whipplei, Cryptosporidium spp., and Giardia lamblia among celiac disease samples
Mostafa Sayyadi1, Saeid Hosseinzadeh1, Masoud Hosseinzadeh2, Zahra Pourmontaseri3
1 Department of Food Hygiene and Public Health, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
2 Department of Pathology, Shiraz University of Medical Science, Shiraz, Iran
3 Department of Infectious Diseases, School of Medicine, Fasa University of Medical Science, Fasa, Iran
|Date of Submission||07-Aug-2019|
|Date of Decision||16-Feb-2020|
|Date of Acceptance||07-Aug-2020|
|Date of Web Publication||30-Dec-2020|
Prof. Saeid Hosseinzadeh
Department of Food Hygiene and Public Health, School of Veterinary Medicine, Shiraz University, Shiraz
Source of Support: None, Conflict of Interest: None
Background: Celiac disease (CD) is one of the most common disorders, resulting from both environmental (gluten) and genetic factors. The clinical features of the Iranian CD are still unknown and there is insufficient information about the atypical presentation of CD from Iran. As, many previous reports revealed an association between controlled protozoal infections and the CD according to cytokines production, the aim of this study was to determine the prevalence of CD and possible co-infection with the most prevalent protozoal infections including Tropheryma whipplei, Cryptosporidium, and Giardia duodenalis among CD samples. Materials and Methods: In this study, from April 2014 to November 2016, 524 samples were obtained from small intestine of patients with gastrointestinal diseases referring to the Pathology Department of Namazi Hospital, Shiraz, Iran. Multiplex polymerase chain reaction assay was then performed on the histological positive CD samples for the prevalence of the microorganisms. Results: Sixty-four (12.21%) patients were diagnosed as having CD by histopathological examination. The prevalence of T. whipplei and Cryptosporidium spp. was 19 (29.69%) and 8 (12.5%) respectively, among CD positive samples there was no positive sample for Giardia lamblia. Conclusion: The prevalence of CD among the southwestern Iranian population was high and comparable with other areas of Iran as well as many other countries. Furthermore, no significant association between the presence of T. whipplei, Cryptosporidium spp., and level of the histopathological changes of villi in the CD was observed (P > 0.05).
Keywords: Celiac disease, Cryptosporidium, Giardia lamblia, Tropheryma
|How to cite this article:|
Sayyadi M, Hosseinzadeh S, Hosseinzadeh M, Pourmontaseri Z. Molecular detection of Tropheryma whipplei, Cryptosporidium spp., and Giardia lamblia among celiac disease samples. J Res Med Sci 2020;25:113
|How to cite this URL:|
Sayyadi M, Hosseinzadeh S, Hosseinzadeh M, Pourmontaseri Z. Molecular detection of Tropheryma whipplei, Cryptosporidium spp., and Giardia lamblia among celiac disease samples. J Res Med Sci [serial online] 2020 [cited 2021 Dec 1];25:113. Available from: https://www.jmsjournal.net/text.asp?2020/25/1/113/305355
| Introduction|| |
The typical autoimmune disorder of the small intestine is referred to as celiac disease (CD) which affects many organs and also causes malabsorption. The CD occurring in all age groups of the working population. Both intestinal and extra-intestinal symptoms of the CD are probably induced by the consumption of wheat, rye, and barley proteins. Classical CD and severe malabsorption, diarrhea, abdominal discomfort, and general malaise have been observed in some patients., The active form of CD is closely associated with mild gastrointestinal (GI) symptoms, iron deficiency, and autoimmune diseases. The similarity of the GI symptoms of CD with Giardia have been formerly addressed in the literature. Cryptosporidium species are also causative agents of self-limiting diarrhea which may last for a few months, with children under 5 years old enduring the highest burden. These pathogenic parasites were detected simultaneously with the CD. However, the laboratory diagnosis of the infection is mainly based on staining techniques, ELISA, and various Polymerase chain reaction (PCR) assays., PCR assay showed high sensitivity and specificity and was successfully employed for the Giardia identification in stool specimens.
Whipple's disease (WD) has been cultivated as a chronic infectious disease caused by the bacterium Tropheryma whipplei. A carefully developed diagnostic procedure to differentiate the WD is critical since the untreated cases are potentially lethal in humans. None of the previous works were simultaneously employed the possible role of the three micro-pathogens (T. whipplei, Cryptosporidium, and Giardia lamblia) using multiplex-PCR assay. Finally, the iliac disease is considered as a complicated and multifactorial metabolic disorder with many GI complications. As such, this study aimed to include the samples with a broad spectrum of different levels of CD and to investigate co-infection with the most prevalent protozoal and bacterial infections among the pathologically confirmed cases of celiac in Southern, Iran. Furthermore, the possible association between such infections among the confirmed celiac cases was probed.
| Subjects and Methods|| |
From April 2014 to November 2016, a total of 525 samples taken from the small intestine of the patients referred to the Pathology Department of Nemazi Hospital, Shiraz University of Medical School, Iran; which were then chosen for the presence of CD. The mean age of patients was 14.46 ± 1.82 years ranged from 0.5 to 78 years. The specimens were pathologically investigated for any evidence of CD. Patients were divided into male (n = 24) and female (n = 40) groups. Tissue sections (5 mm thickness) were prepared in the paraffin blocks at − 20°C. The first section was discarded and the other sections were displaced in a clean 1.5 ml tube using a sterile toothpick or tweezers. Alternatively, the tissues could have been previously laser capture micro-dissected directly from the sections.
One milliliter of xylene was added to the vortex for 10s; then, the tube was maintained at room temperature for approximately 5 min. The tubes were spun for 5 min at maximum speed (14,000 rpm) and the supernatants were discarded. Then, the wash with a fresh aliquot of xylene was performed and repeated. The pellet was washed by adding 1 ml of absolute ethanol. The tubes were flicked to dislodge the pellet; then, the tubes were spun for 10s. Next, they were left at RT for approximately 5 min. The tubes were spun for 5 min at maximum speed (14,000 rpm) and then carefully removed. Then, the supernatants were discarded. The washes were repeated using once 90% and then 70% ethanol. Finally, the tissue allowed the pellet to air dry in a thermoblock at 37°C for about 30 min.
DNA extraction and polymerase chain reaction amplification
The histopathologic celiac positive samples were subjected to a multiplex PCR assay for three intestinal bacterium and protozoa including T. whipplei, Cryptosporidium spp., and G. lamblia. Total DNA was extracted from the samples (100–500 ml of the packed pellet) by lysis in 50 mM Tris-HCl, 20 mM EDTA, containing 2 mg of proteinase K per ml and 0.5% Sarkosyl, incubated at 37°C for 1 h. Then, 5 M NaCl was added to give a final concentration of 1 M, and CTAB was added to a concentration of 1%. Following the incubation at 65°C for 30 min, one freeze-thaw cycle, and phenol-chloroform extraction, the DNA was precipitated by the addition of 0.6 volumes of isopropanol, and the DNA pellet was washed with 70% ethanol. After desiccation, the DNA pellet was resuspended in 100 ml of sterile distilled water. The PCR assays were performed with the specific primers to amplify Cryptosporidium spp. (F: GAGGTAGTGACAAGAAATAACAATACAGG, R: CTGCTTTAAGCACTCTAATTTTCTCAAAG), G. lamblia (F: CGAGACAAGTGTTGAGATGC, R: GGTCAAGAGCTTACAACACG), T. whipplei (F: AGAGAGATGGGGTGCAGGAC, R: AGCCTTTGCCAGACAGACAC).,,
Multiple mucosal biopsies were obtained from the second part of the duodenum or proximal jejunum. Duodenal biopsy specimens were paraffin-processed, formalin-fixed, serially sectioned and stained by hematoxylin and eosin staining. The presence of parasitic elements (trophozoites of Giardia, coccidian oocysts, and spores of microsporidia) was carefully investigated. Modified Marsh classification was used for the grading of the mucosal changes: Grade 0, normal histology; Grade 1, mild increase in the intraepithelial lymphocytes (IEL), crypt-villous (CV) ratio 1:1; Grade 2, moderate villous atrophy with CV ratio more than 1; Grade 3, flat mucosa with no recognizable villi [Table 1].
|Table 1: Marsh modified histologic classification used for diagnosis of celiac disease|
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The results were analyzed using the SPSS software Version 10.1 (IBM, New York, USA). The Chi-square test was used to determine the relationship between the occurrence of CD and the pathogen microorganisms. The differences were considered statistically significant when the P < 0.05.
| Results|| |
Histological findings and polymerase chain reaction assay
Of a total of 524 samples examined by microscopy in the Department of Pathology of Nemazi Hospital in Shiraz, Iran, 64 samples (12.21%) were confirmed the occurrence of CD. Mucosal histological findings were studied in the celiac patients including increased intraepithelial T lymphocyte (IEL) in 53 samples of, villous atrophy in 40 samples, flattening of villi in 10 samples, shortening of villi in 4 samples, and increased lymphoplasmacytic cells in 4 samples [Figure 1] and [Table 1].
|Figure 1: (a) Marsh 0: Normal duodenal mucosa with unremarkable villus and loos connective tissue in lamina propria. (b) Marsh 1: increased intraepithelial lymphocytes > 30/100 enterocytes (×400). (c) Marsh 2: normal villus morphology with crypt hyperplasia and increased, and intraepithelial lymphocytes. (d) Marsh 3b. Moderate villus atrophy with increased intraepithelial lymphocytes >30/100 enterocytes|
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The positive celiac samples (40% males and 60% females) were subjected to the multiplex PCR assay to amplify T. whipplei, Cryptosporidium spp., and G. lamblia. The result of PCR (for T. whipplei, Cryptosporidium spp., and G. lamblia) are shown in [Figure 2]. Of a total of celiac cases (64 samples), 25 samples (39.06%) were PCR positive [Table 2]. Of the 25 positive samples, Marsh type of 3b, demonstrating marked atrophy of villi, revealed the highest rate (15 samples (60%) (P < 0.05). The frequency of 3a and 3c the Marsh types was also 2 (8%) and 8 (32%) samples, respectively.
|Figure 2: Detection of Tropheryma whipplei DNA (a) and Cryptosporidium spp. DNA (b) from CD samples on polyacrylamide gel electrophoresis. Lane 1: DNA ladder (100 bp), 2, 3 and 4: Positive samples, 5: Negative control, 6: Positive control|
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|Table 2: Frequency of the bacterial and protozoal diseases in the celiac positive cases|
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Among all the celiac positive specimens (64 samples), 19 samples (29.69%) were positive for T. whipplei, and 8 samples (12.5%) were positive for Cryptosporidium spp. G. lamblia was not detected in the samples.
The morphological aspects of the small intestinal in 19 T. whipplei PCR positive with light microscopy showed that 18 of them had IEL, 12 had villous atrophy, 4 had flattening of villi, 2 had shortening of villi, and 1 had increasing lymphoplasmacytic cells. There was no significant association between the PCR positive and the histological changes of patients with T. whipplei. Moreover, the morphological changes in 8 Cryptosporidium spp. PCR positive included 7 IEL, 6 villous atrophy, 1 flattening of villi, and 1 increasing lymphoplasmacytic cells. There was no significant association between the PCR positive and histological changes of patients with Cryptosporidium spp. [Table 2].
Numerical differences in the frequency of the diseases (T. whipplei, Cryptosporidium spp., and celiac) were observed within the ages of 1–9 years old which was not significant. Besides, no significance association was found between the sex and occurrence of the diseases [Table 3]. Surprisingly, of a total of 25 PCR positive patients, two cases were simultaneously infected with T. whipplei and Cryptosporidium spp.
|Table 3: The frequency of polymerase chain reaction positive samples and the celiac patients (25 samples) according to the age and sex classification|
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| Discussion|| |
CD is a life-long gluten-sensitive autoimmune disease of the small intestine affecting genetically susceptible individuals, worldwide. The prevalence of CD varies based on diagnostic methods and geographical locations. Biopsy method is remarked as a gold standard for the CD diagnosis. The occurrence of the CD in Asia 0.6%, South America 0.4%, and Europe 0.8% was reported using the biopsy method. In the present study, according to the Modified Marsh Criteria, 12.21% of cases (including 64 samples out of 524 samples) were found to be positive for CD. Nikpour and Mohammad Hosseini reported the histopathological features of CD in 8 (6.3%) of the patients (6 Marsh IIIA; 2Marsh IIIC). A distinct association was also reported between helminthic or protozoal infections and the immune-mediated intestinal disorder such as CD. Parasites infections are common in the developing country. They mainly affect host immune response and take part in the progress of autoimmune diseases. Alongside, parasites may colonize as opportunistic pathogens in the intestinal tissues of celiac patients revealing remarkable GI disorders. Severe villous atrophy, malabsorption, dyspepsia, and secretory diarrhea were reported following the infection of small intestine epithelial tissues by Cryptosporidium spp. and Giardia spp. in the celiac and nonceliac cases., Cryptosporidiosis is a zoonotic protozoal disease usually causing self-limited diarrhea in the immunocompetent patients; chronic lethal forms of the infection were also reported in the immunocompromised hosts. Coincidence of Cryptosporidium spp. infection (in stool) with the CD (in the duodenal biopsy) was also diagnosed in children., According to the study conducted by Stuppy and Garcia, 10.6% of patients with GI complaints showed cryptosporidium spp. oocytes in stools; meanwhile, 23.2% indicated the serologically confirmed cases of CD. In addition, the parasitic treatment led to mitigating the occurrence of CD. In a recent study performed by Khalaf Ali, et al., no evidence of G. lamblia infection was also shown in the CD patients. 12.5% Cryptosporidium spp. and 0% G. lamblia in the celiac patients were also identified in our study.
T. whipplei is the causative agent of a rare chronic infectious disease responsible for GI disorders such as malabsorption, diarrhea, weight loss, and villous atrophy which may be misdiagnosed with CD. In some cases, this enteropathy caused by T. whipplei may be severe and lethal.,, Furthermore, a considerable association between WD and the immunomodulatory condition was indicated in the literature. In the study conducted by Amsler et al., 4.2% of saliva and stool samples were positive for T. whipplei in GI patients. In our study, a high rate (29.69%) of celiac specimens were found positive for WD.
Various causative agents play roles in the villi atrophy as well as the CD. They comprise autoimmune disorders including Crohn's disease, neoplasia, drug associated enteropathy, infiltrative amyloidosis, collagenous sprue, and parasitic infectious including Whipple's disease, giardiasis. As the villi atrophy is a multifactorial disorder, it is difficult to differentiate CD with other causative agents. As such, it is necessary to employ both serological and hematological tests coincident with taking a proper biopsy to confirm the disease. The confirmation of the disease is also crucial to apply accurate strategy for treatment. In addition, the high prevalence of WD in the celiac patients was remarkable which need more investigations in this area.
Based on previous published data, possible association between the lymphocytic reduction and triggering the immune response to activate this inflammatory reaction was reported. In this cases, the occurrence of GI pathogens was suggested. Furthermore, a considerable atrophy of GI villi was observed in this study. These changes were not directly taken part in the occurrence of CD, but may explain the presence of the inflammatory diseases which resulted from the GI pathogens.
| Conclusion|| |
The coincident occurrence of CD with other infectious agents was observed in the present study. Therefore, the application of other confirmatory laboratory tests is essential to differentiate the causative agents and finally to choose a better strategy of treatment. Since no association between the occurrences of histopathological level of destruction of villi and those parasitic and bacterial infections was found, more investigations are suggested to find the association between the intensity of villi atrophy and the infectious agents.
Authors are grateful of the School of Veterinary Medicine, Shiraz University and Dr Maryam Pourmontaseri for her invaluable technical support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hosseini SM, Soltanizadeh N, Mirmoghtadaee P, Banavand P, Mirmoghtadaie L, Shojaee-Aliabadi S. Gluten-free products in celiac disease: Nutritional and technological challenges and solutions. J Res Med Sci 2018;23:109.
] [Full text]
Habibi F, Mahdavi SB, Khaniabadi BM, Habibi ME, Gharavinia A, Baghaei A, et al
. Sleep quality and associated factors in Iranian inflammatory bowel disease patients. J Res Med Sci 2019;24:59.
] [Full text]
Mohammadi R, Hosseini-Safa A, Ehsani Ardakani MJ, Rostami-Nejad M. The relationship between intestinal parasites and some immune-mediated intestinal conditions. Gastroenterol Hepatol Bed Bench 2015;8:123-31.
Abubakar I, Aliyu SH, Arumugam C, Hunter PR, Usman NK. Prevention and treatment of cryptosporidiosis in immunocompromised patients. Cochrane Database Syst Rev 2007;(1):CD004932.
Behera B, Mirdha BR, Makharia GK, Bhatnagar S, Dattagupta S, Samantaray JC. Parasites in patients with malabsorption syndrome: A clinical study in children and adults. Dig Dis Sci 2008;53:672-9.
Gile M, Warhurst DC, Webster KA, West DM, Marshall JA. A multiplex allele specific polymerase chain reaction (MAS-PCR) on the dihydrofolate reductase gene for the detection of Cryptosporidium parvum
genotypes 1 and 2. Parasitology 2002;125:35-44.
Kaushik K, Khurana S, Wanchu A, Malla N. Evaluation of staining techniques, antigen detection and nested PCR for the diagnosis of cryptosporidiosis in HIV seropositive and seronegative patients. Acta Trop 2008;107:1-7.
Guy RA, Xiao C, Horgen PA. Real-time PCR assay for detection and genotype differentiation of Giardia lamblia
in stool specimens. J Clin Microbiol 2004;42:3317-20.
Dutly F, Altwegg M. Whipple's disease and “Tropheryma whippelii
”. Clin Microbiol Rev 2001;14:561-83.
Müller SA, Vogt P, Altwegg M, Seebach JD. Deadly carousel or difficult interpretation of new diagnostic tools for Whipple's disease: case report and review of the literature. Infection 2005;33:39-42.
Amar CFL, Dear PH, McLauchlin J. Detection and genotyping by real-time PCR/RFLP analyses of Giardia duodenalis from human faeces. J Med Microbiol 2003;52:681-3.
Fenollar F, Laouira S, Lepidi H, Rolain JM, Raoult D. Value of Tropheryma whipplei
quantitative polymerase chain reaction assay for the diagnosis of Whipple disease: Usefulness of saliva and stool specimens for first-line screening. Clin Infect Dis 2008;47:659-67.
Hadfield SJ, Robinson G, Elwin K, Chalmers RM. Detection and different. J Clin Microbiol 2011;49:918-24.
Marsh MN, Crowe PT. Morphology of the mucosal lesion in gluten sensitivity. Baillieres Clin Gastroenterol 1995;9:273-93.
Singh P, Arora A, Strand TA, Leffler DA, Catassi C, Green PH, et al
. Global prevalence of celiac disease: Systematic review and meta-analysis. Clin Gastroenterol Hepatol 2018;16:823-36.
Catassi C, Fasano A. Celiac disease diagnosis: Simple rules are better than complicated algorithms. Am J Med 2010;123:691-3.
Nikpour S, Mohammad Hosseini E. Prevalence of celiac disease in patients with idiopathic iron deficiency of referred to gastroenterology clinic. IUMS 2007;25:10-5.
Abdel-Messih IA, Wierzba TF, Abu-Elyazeed R, Ibrahim AF, Ahmed SF, Kamal K, et al.
Diarrhea associated with Cryptosporidium parvum
among young children of the Nile River Delta in Egypt. J Trop Pediatr 2005;51:154-9.
Hunter PR, Thompson RC. The zoonotic transmission of Giardia and Cryptosporidium. Int J Parasitol 2005;35:1181-90.
Pal N, Sharma R, Sharma B, Suman R. A case of Cryptosporidium
infection in a child of celiac disease. J Postgrad Med 2012;58:160. [Full text]
Butt T, Ahmad RN, Kazmi SY, Afzal RK, Leghari MJ. Cryptosporidiosis in a case of celiac disease. Pak Armed Forces Med J 2005;55:84-5.
Stuppy W, Garcia T. Nitazoxanide, Cryptosporidium, and celiac disease: A case of cure, cause, and effect: 351. Am J Gastroenterol 2013;108:S104.
Khalaf Ali J, AL-Haboobi ZA, Khesbak AA, Hadi SS. Protozoa infections and celiac disease: Relationship and hematological study among children under 5 years. J Phys Conf Ser 2019;1294:1-8.
de Roulet J, Hassan MO, Cummings LC. Capsule endoscopy in Whipple's disease. Clin Gastroenterol Hepatol 2013;11:A26.
Kutlu O, Erhan SŞ, Gökden Y, Kandemir Ö, Tükek T. Whipple's disease: A case report. Med Prin Pract 2020;29:90-3.
Petruzziello C, Sinatti D, Petroselli V, Riccioni ME, Giustiniani MC, Franceschi F, et al.
Severe malnutrition with Whipple's disease. Trop Gastroenterol 2019;38:186-8.
Marth T. Tropheryma whipplei
, Immunosuppression and Whipple's disease: From a low-pathogenic, environmental infectious organism to a rare, multifaceted inflammatory complex. Dig Dis 2015;33:190-9.
Amsler L, Bauernfeind P, Nigg C, Maibach RC, Steffen R, Altwegg M. Prevalence of Tropheryma whipplei DNA in patients with various gastrointestinal diseases and in healthy controls. Infection 2003;31:81-5.
Jansson-Knodell CL, Hujoel IA, Rubio-Tapia A, Murray JA. Not all that flattens villi is celiac disease: A review of enteropathies. Mayo Clin Proc 2018;93:509-17.
Desnues B, Ihrig M, Raoult D, Mege JL. Whipple's disease: A macrophage disease. Clin Vaccine Immunol 2006;13:170-8.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]