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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Dear Editor&#44; </span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Cryptosporidium parvum </span>is an intracellular protozoan that can produce gastroenteritis in humans&#46; In immunodepressed patients the infection can be severe and lead to persistent diarrhoea and endanger life&#46; There is limited experience with the treatment of this infection in solid organ recipients&#46; We describe the importance of diagnosis and early treatment in a case of severe cryptosporidiosis in a kidney transplant recipient&#46; To optimise the patient&#8217;s immunological status and resolve the infection it is necessary to apply antibiotic treatment&#44; together with the reduction of immunosuppression&#46;</p><p class="elsevierStylePara">We present the case of a 78 year old woman with chronic kidney disease&#44; secondary to chronic interstitial nephropathy on haemodialysis since February 2003&#46; She received a kidney transplant from a deceased donor in December 2003 with a basal CRP of 2 mg&#47;dl&#46; The patient was being treated with steroids&#44; m<span class="elsevierStyleItalic">ofetil mycophenolate</span><span class="elsevierStyleItalic"> </span><span class="elsevierStyleItalic">and tacrolimus</span><span class="elsevierStyleItalic">&#46;</span> Steroids were discontinued 3 months post-transplant&#46; In June 2008 the patient was admitted with watery diarrhoea without any pathological substance that had a 7 day evolution&#44; without fever&#44; vomiting or abdominal pain&#46; The patient also had haemodynamic instability and a blood pressure of 80&#47;50 mmHg&#44; her diuresis rhythm decreased and renal failure deteriorated to CRP and plasma urea levels of 4&#46;3 and 177 mg&#47;dl&#44; respectively&#46; As diarrhoea persisted in spite of absolute diet and saline therapy&#44; treatment with metronidazol and ciprofloxacin was initiated&#46; The detection of adenovirus and rotavirus antigens in faeces&#44; and the culture and cytotoxicity in direct faeces samples to <span class="elsevierStyleItalic">Clostridium difficile</span> were negative&#46; In the analysis of fresh faeces no parasites were observed&#46; Antigen tests and quantitative PCR for cytomegalovirus &#40;CMV&#41; were negative&#46; Finally&#44; and in view of the poor evolution of the patient&#44; modified Kinyoun stain &#40;Figure 1&#41; was used and <span class="elsevierStyleItalic">Cryptosporidium </span>oocysts were seen in the faeces&#46; Treatment&#44; therefore&#44; began with paramomycin and azithromycinuntil for a period of 14 days&#46; Subsequently nitazoxanide was administered for 6 days and the doses of m<span class="elsevierStyleItalic">ofetil mycophenolate</span><span class="elsevierStyleItalic"> </span><span class="elsevierStyleItalic">and tacrolimus were reduced&#46;</span> After these measures were taken&#44; diarrhoea disappeared and kidney function recovered to basaline levels and 17 months later the patient was still asymptomatic&#46;</p><p class="elsevierStylePara">Acute diarrhoea is a significant complication in solid organ transplant recipients &#40;SOTR&#41;&#46; The differential diagnosis of acute diarrhoea in these cases is difficult&#44; since both microorganisms and immunosuppressive medication can be involved&#44; especially mofetil mycofenolate&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">Our patient maintained a stable kidney function for 5 years after transplant with double immunosuppressive therapy&#46; Drug levels remained stable&#44; therefore it was ruled out that the diarrhoea could be secondary to immunosuppressive therapy&#46; Suspected diagnosis was microorganisms&#59; the usual ones were quickly ruled out&#44; including <span class="elsevierStyleItalic">Clostridium difficile</span><span class="elsevierStyleSup">2 </span>and CMV&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Cryptosporidium parvum </span>is an intracellular protozoan that causes gastrointestinal disease worldwide&#44; since it is an intestinal parasite of domestic and wild animals&#46; This infection is more common in developing countries&#46; The parasite is initially transmitted by the faecal-oral route&#44; and in epidemics it has been associated with contaminated municipal water&#44; person-to-person transmission and even animal-to-person transmission&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Clinical symptoms of cryptosporidiosis depend on the host&#8217;s immunological status&#46; In immunocompetent subjects it causes self-limited diarrhoea&#44; but in immunodepressed patients the infection can be prolonged and life-threatening&#44; since there is no specific antiparasite drug&#46;<span class="elsevierStyleSup">4&#44;5</span>&#160;In addition to intestinal involvement&#44; in immunosuppressed patients&#44; cases have been described with respiratory system&#44; gallbladder and sclerosing cholangitis involvement&#46;<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">Microbiological diagnosis depends on the observation of the parasite in the faeces using a microscope and a modified Ziehl-Neelsen stain or modified Kinyoun stain that reveal the presence of 4-6 micron red oocysts&#46; Several samples of faeces collected on subsequent days must be examined since oocyst shedding is intermittent&#46;<span class="elsevierStyleSup">7</span></p><p class="elsevierStylePara">The cornerstone of treatment in immunodepressed patients is correction of electrolyte and acid base balance disorders&#46;<span class="elsevierStyleSup">4</span> This infection can be treated with nitazoxanide&#44; <span class="elsevierStyleItalic">paromomycin</span><span class="elsevierStyleItalic"> </span>and <span class="elsevierStyleItalic">azithromycin</span>&#46; However&#44; clinical response is variable and the intestinal protozoan can be difficult to eradicate&#46; It would seem that in a SOTR reduction of immunosuppression&#44; together with antimicrobial treatment&#44; can improve immunological status and achieve infection resolution&#46;<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara">This case is interesting due to the importance of suspecting this infection in any immunodepressed patient who develops diarrhoea when no other cause is found&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10366&#95;108&#95;7822&#95;en&#95;10366&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10366_108_7822_en_10366_f1.jpg" alt="Modified Kinyoun stain"></img></a></p><p class="elsevierStylePara">Figure 1&#46; 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