الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Acute leukemia patients commonly present with bone marrow failure resulting in symptoms of anemia, neutropenic infections, and bleeding from thrombocytopenia. Infections could be bacterial, viral, fungal or parasitic. Parasitic diseases contribute significantly to the burden of infectious diseases worldwide. While most infections and death from parasitic diseases affect people in developing countries, they also cause significant illness in developed countries. In 2004, the WHO reported that diarrheal disease affected far more individuals than any other illness, even in regions that include high income countries. Several species of enteric protozoa are associated with diarrheal illnesses in humans, with some causing severe debilitating illness, especially in immunosuppressed (IS) populations and neutropenic patients as in acute leukemias.
The aim of the present work was to detect the frequency of intestinal protozoan infections in Egyptian neutropenic patients with acute leukemia and to correlate this with the clinical status of the patients.
The study was conducted on two study groups, cases and controls. The cases included forty newly diagnosed neutropenic acute leukemia patients (25 had acute myeloid leukemia and 15 had acute lymphoblastic leukemia) admitted to the Hematology Unit, Internal Medicine Department, Alexandria Main University Hospital and Hematology Department, Medical Research Institute, Alexandria University during the period from May 2018 to April 2019. Control group was composed of 30 healthy non neutropenic individuals with diarrheal illness.
Thorough history taking was done with emphasis on relevant symptoms like fever, abdominal pain, diarrhea, constipation, dyspepsia etc. Thorough clinical examination stressing on detection of organomegaly, lymphadenopathy and abdominal tenderness was executed as well .Additionally, routine work up including complete blood count (CBC) with total and differential counts, renal and liver function tests, bone marrow aspirate and immunophenotyping by flow cytometry were done.
Stool examination was done to cases and control groups. All cases were tested post chemotherapy during the nadir of neutropenia when the absolute neutrophilic count (ANC) was ≤ 0.5x109/L and whenever possible, cases were also tested initially prior to chemotherapy.
Fresh stool specimens free from water and urine were collected in clean, dry disposable plastic containers labeled with the patient’s name and code number. Stool samples were transferred to the laboratory of Parasitology Department, Medical Research Institute and divided into 2 parts: First portion for microscopic examination by direct wet saline smear, Lugol’s iodine smear, and Modified Trichrome stain for detection of Microsporidia and Modified Ziehl-Neelsen stain for detection of coccidia. The second portion of stool was subjected to Copro-antigen detection for E. histolytica/dispar, G. lamblia and C. parvum using RIDA®QUICK Entamoeba/ Giardia/ Cryptosporidium Combi Test (R-Biopharm AG, Germany) according to the manufactures’ directions.
Our results showed that acute leukemia patients included 23 males and 17 females. Control subjects were 11 males and 19 females. The median age was 40 and 34.5 years for cases and controls respectively. 25 of the cases had acute myeloid leukemia (62.5%) and 15 had acute lymphoblastic leukemia (37.5%). The median ANC for the cases post chemotherapy during the nadir of neutropenia was 0.2x109/L.
Out of the 40 neutropenic acute leukemia cases post chemotherapy 15 (37%) were positive for Blastocystis by wet mount, 10 (25%) were positive for Microsporidium using Modified Trichrome stain and 2 cases (5%) were positive by Ziehl Neelsen stain for Cryptosporidium.
When compared with the control group, in which 20% of subjects were positive for Blastocystis by wet mount, 20% positive to Microsporidium by modified Trichrome and none was positive to Cryptosporidium by Ziehl Neelsen, results were not statistically significant. However there was a statistically significant difference between cases and controlsregarding intestinal protozoa detected by rapid diagnostic test (RIDA®QUICK Entamoeba/ Giardia/ Cryptosporidium Combi Test). 20% of acute leumekia cases were positive compared to the entirely negative control group with (p= 0.009). The 8 positive cases included 4 cases with Giardia (10%) and 2 cases for each Entamoeba and Cryptosporidium (5%).
In our study, 19 cases were tested pre and post chemotherapy for Blastocystis by wet mount, Cryptosporidium by Ziehl Neelsen stain and Microsporidium by modified Trichrome. Only Microsporidium diagnosed by modified Trichrome stain was statistically significant (p= 0.03) on comparing the pre- and post-chemotherapy results.
When comparing between our two studied subgroups (AML and ALL) post chemotherapy regarding the intestinal protozoa detected, Blastocystis by wet mount were 60% positive in ALL patients compared to 24% positivity in AML patients and the difference was of statistical significance (P= 0.023). The remaining protozoa detected in both AML and ALL patients by different stains and by the rapid diagnostic test did not show a statistically significant difference (p>0.05).
By thorough history taking and clinical examination fatigability was the most dominant complaint in 80% of the cases. Fever was noticed in 45% of the patients however no statistically significant correlation between fever and intestinal protozoa was found. As for gastrointestinal symptoms, the predominant symptom was abdominal pain in 45% of the patients followed by diarrhea in 42.5% and constipation in 25%. Of all patients with Blastocystis infection, 58% had diarrhea and 50% had abdominal pain, and presence of diarrhea was significantly associated with positive Blastocystis in stool (p=0.017). On the contrary, there was no other statistically significant correlation between the different gastrointestinal symptoms and any of the other studied protozoa detected by the different methods.