J Biomed Clin Res Volume 15 Number 1, 2022

DOI:10.2478/jbcr-2022-0003 Review

CRYPTOSPORIDIOSIS: HISTORY, ETIOLOGY, BIOLOGY,

PATHOGENESIS AND PATHOANATOMY - A REVIEW

Petya V. Dragomirova Summary

Department of Anatomy, Histology, Cryptosporidiosis is a protozoan disease, usually

Cytology and Biology, asymptomatic. However, in some cases, the
Section of Biology, infection can progress to gastroenteritis and, more
Medical University – Pleven rarely, to colitis. Intensive studies on the biology of
Cryptosporidium started in the 20th century after the
outbreak of a major waterborne epidemic. The interest
in this parasitosis increased after the WHO identified it
as an opportunistic parasitosis - an indicator of AIDS.
In this regard, the purpose of this article is to provide
a scientific overview of this parasitosis, analyzing the
state and development of modern research in a global
and national aspect.
Keywords: Cryptosporidium parvum,
cryptosporidiosis, parasitosis, infection, pathogenesis

Introduction

The species of Cryptosporidium were first

isolated in 1907 by E. E. Tyzzer from the
gastrointestinal tract (gastric glands) of
laboratory mice. E. Tyzzer described this
causative agent as Cryptosporidium muris
[1]. He also reported a second species -
Cryptosporidium parvum, again isolated from
lab mice. The two species differed in their site of
Corresponding Author: infection and morphological development [2, 3].
Petya V. Dragomirova Slavin reported cases of infection caused by C.
Department of Anatomy, Histology, Cytology meleagridis - a new pathogenic species isolated
and Biology,
from the intestines of turkeys. This newly isolated
Section of Biology,
Medical University – Pleven species was associated with an acute clinical
1, St. Kliment Ohridski Str. disease, manifested with severe diarrhoea and
Pleven, 5800, a low death rate [4]. Cryptosporidium was
Bulgaria isolated from domesticated birds suffering from
e-mail: [email protected] gastroenteritis with a lethal outcome [4]. Since
the 1970s, Cryptosporidium has been detected
Received: October 05, 2021 in/or the gastrointestinal or respiratory tract of
Revision received: December 02, 2021 many mammals, birds, fishes, and reptiles
Accepted: February 10, 2022 Cryptosporidiosis in a calf was reported
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 Dragomirova P. Cryptosporidiosis: Hystory, etiology, pathogenesis and pathoanatomy ...

in 1971 [5] and a pig in 1977 [6, 7]. The first in humans are Cryptosporidium parvum
disease cases in humans were reported in 1976: (previously known as C. parvum Type 1,
a 3-year-old girl from the USA living in a rural invading only humans) and Cryptosporidium
area [8] and an immunosuppressed patient [9]. hominis (previously known as C. parvum
Since the 1980s, representatives of the genus Type 2 – zoonotic, invading humans and other
Cryptosporidium have been found to cause mammalians). However, reports of infections
infections in humans quite often. The study with C. felis, C. meleagridis, C. canis, C. muris,
of these infections is related to improving the and C. cuniculus have also been published.
diagnostic process and increasing the number of Livestock, especially cattle, are recognized as
immunocompromised subjects, especially those one of the main sources of zoonotic infections.
with acquired immune deficiency syndrome It was demonstrated that domestic and wild
(AIDS). After 1982, the medical community’s animals could be infected with several species
interest in Cryptosporidium significantly and genotypes of Cryptosporidium, which have
increased when the Center for Disease Control a narrow spectrum of hosts, and therefore may
and Prevention in Atlanta-USA (CDC) [10] not play an essential role in public health (Ryan
published information about cases of protracted U. et al., 2014) [26].
acute diarrhoea caused by Cryptosporidium The oocysts of Cryptosporidium are highly
in 21 male patients diagnosed with AIDS. In infectious: as few as 101 - 103 oocysts are
14 of them, the outcome was lethal [11, 12]. sufficient to establish an infection in humans
Later, in 1993, an outbreak of waterborne (50% infectious dose, 102). They can cause
cryptosporidiosis in Milwaukee-Wisconsin infection immediately after being excreted, and
affected 403 000 people. The epidemic prompted the life cycle of the parasite creates forms that are
the commencement of intensive research of the renewed in the intestine. The location of parasites
biological characteristics of the parasite [13, 14]. in the gut is intracellular but extracytoplasmic,
Cox and McDonald were the first to describe which can contribute to a pronounced resistance
the course of human cryptosporidiosis [15, 16]. of Cryptosporidium species to treatment. The
Dubey J.P. et al. had earlier published a short excreted large numbers of oocysts are resistant to
and helpful review [17]. disinfectants (such as chlorine) at levels routinely
The condition was first diagnosed in Bulgaria used in water processing. Cryptosporidiosis is
by M. Halacheva and Belchev in calves with usually manifested by watery diarrhoea. The
chronic diarrhoea [18]. R. Kurdova diagnosed mechanism by which Cryptosporidium causes
the first cases in humans [3, 19]. Among the diarrhoea involves a combination of increased
population in the country, cryptosporidiosis is intestinal permeability, chloride secretion, and
also known as diarrhoea of newborn animals malabsorption. It is considered that the host
(calves, lambs, pigs). The importance of this response to the infection causes these symptoms.
parasitosis has increased after WHO defined it In immunocompetent individuals, the infection
as an AIDS indicator of parasitoses [20-24]. is usually restricted to the small intestine.
In 2002, Cryptosporidium parvum was Cryptosporidium infection has also been
included in agents for bioterrorism Category B, observed in immunocompromised individuals
water safety threats [25]. such as HIV-infected persons [27].

Etiology and pathophysiology Taxonomy

The genus Cryptosporidium belongs to the
Cryptosporidiosis is caused by intestinal phylum Apicomplexa, class - Sporozoasida,
coccidian parasites (apicomplexan protozoa). subclass - Coccidiasina, order Eucoccidiorida,
These parasites belong to class Sporozoasida, suborder Eimeriorina, family Cryptosporidiidae
subclass Coccidiasina, order Eucoccidiorida, [28]. Cryptosporidium has been classified
suborder Eimeriarina, family Cryptosporiidae, together with other intestinal coccidian parasites
genus Cryptosporidium (from Greek –occult in the order Eucoccidiorida based on their similar
spore). morphology and life cycle [29].
The major aetiological agents of the disease

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Morphology and species diversity following stages of development: a) sporozoites

Currently, 29 species and more than 60 (merozoites) (Figure 1) - motile elongated coma-
genotypes of Cryptosporidium are recognized - shaped (banana) cells, coated with a three-layer
valid based on morphological, biological, and membrane.
molecular data, including recently described They contain a single nucleus in one pole; b)
C. rubeyi in ground squirrels from the genus trophozoites (wrapped in 5-layer shells, two of
Spermophilus [30]. More than 17 species have them forming a parasitophorous vacuole) have a
been identified in humans [31, 32, 33]. In large nucleus with a vacuole; c) schizonts - two
addition, Cryptosporidium viatorum has been types with 8 or 4 banana-shaped merozoites are
recently identified among travellers returning distinguished. Merozoites have a large nucleus
to the UK from the Indian subcontinent with a nucleolus in its posterior pole and a
[34]. The occurrence of mixed infection of 3 microneme and rhoptries - in the anterior pole;
species of Cryptosporidium – C. meleagridis, d) microgametocytes and macrogametocytes -
the Cryptosporidium mink genotype, and the mature forms contain 12 to16 wedge-shaped
an unknown Cryptosporidium species in an (cuneiform) non-flagellated microgametes
immunocompetent individual was reported [35]. located on the periphery, and residual bodies
Recently, ultrastructural and DNA analyses in the centre. Macrogametocytes possess large
have shown a high degree of morphological polysaccharide and phospholipid granules; e)
similarity of Cryptosporidium spp. with oocysts (C. parvum 6-8μm) have a circular or
gregarine - as a trophozoite [36, 37]. The oval shape (Figure 2).
identification of stages similar to gregarines and Sporulated oocysts contain four banana-
the ability of Cryptosporidium to complete its shaped sporozoites aligned in parallel to each
life cycle in the absence of host cells has further other and a residual body. A sporocyst is
confirmed its connection to gregarines. This absent. Oocysts were detected free in the lumen
offers new opportunities to study pathogenesis, of the infected organ or attached within the
epidemiology, treatment, and control of parasitophorous vacuole [19, 24, 38, 39].
Cryptosporidium infection [32].
C. parvum exists in two biological forms: Biology and life cycle
trophozoite and an oocyst. The parasite has the The parasite is monoxenic (one-host). The

Figure 1. Electron microscopy of Cryptosporidium sp. from a lamb. First-generation of a cryptosporidium meront
with 8 merozoites (x 1970) [24]
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 Dragomirova P. Cryptosporidiosis: Hystory, etiology, pathogenesis and pathoanatomy ...

Figure 2. Oocysts of Cryptosporidium sp. (on light microscope under immersion, scale bar -5 μm) in a fecal
sample from a homosexual male with AIDS and persistent watery diarrhoea [24]

oocyst-to-oocyst development occurs in the host and attack the cell wall of the epithelium of the
organism without an intermediate host. It passes gastrointestinal or respiratory tract of various
three stages of development - schizogony, animals and humans. Sporozoites are sucked
merogony (of asexual reproduction), into the microcrypts of the epithelial cells.
gametogony (of sexual reproduction), and The endogenous stage of development of the
sporogony (sporulation) (Figures 3, 4) [40, 41]. cryptosporidia occurs in the parasitophorous
A sporulated oocyst is excreted through the vacuole, which is composed of two cells of
faeces of an infected person or animal in the the host and two parasitic membranes. Thus,
external environment (exogenous development). the location of cryptosporidia in the intestine
After its ingestion or inhalation, it undergoes is intracellular but extracytoplasmic. The
excystation within the host and releases the duration of excretion of oocysts in the faeces
sporozoites, sized up to 5.5 μm. They are motile lasts 7-30, possibly more days, depending on the

Figure 3. Biological cycle of C. parvum and C. hominis [40]

*Developmental stages: a - oocyst; b - sporozoite; c - trophozoite; d, e - Type I meront = asexual reproduction;
f - Type II meront = sexual reproduction; g - microgamont (male germ cell); h - macrogamont (female germ cell);
I - zygote; k - thin-walled oocyst (sporulated) - re-invasion; j - thick-walled oocyst
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Figure 4. The life cycle of Cryptosporidium in the enterocyte) [41]

immunological status of the host. Thick-walled heavily on extracting nutrients from the host
oocysts shed in faeces represent the parasite’s rather than biosynthesis on substrate level for
infective stage for humans and animals. Thin- energy production [27].
walled oocysts undergo excystation within the
small intestine lumen to re-invade the intestinal Pathogenesis and pathological
epithelium, thus facilitating the endogenous anatomy
reinvasion, which explains the chronic course of
cryptosporidiosis [22, 42, 43, 44, 45]. The pathogenesis of Cryptosporidium has not
The genome of Cryptosporidium consists of been studied sufficiently. It is similar to the
eight chromosomes containing nearly 9.2 million pathogenesis of enteric and rotaviruses, intestinal
base pairs. Comparison of the genomes of C. protozooses like amebiasis, giardiasis, etc. The
parvum Type1 and C. parvum Type 2 showed that major damage inflicted in cryptosporidiosis is
both genomes have 3-5% sequence variations in the gut, but cryptosporidia can be found in
without significant removal or rearrangement other organs such as the lungs, conjunctiva, and
of genes. The phenotypic differences between the digestive tract. In rare cases, enlargement
the two types are assumed to be due to selective of mesenteric lymph nodes is present. In the
pressures occurring in the interaction between pathogenesis of the disease, the toxic and
host cells and parasites [46]. sensitising effects of the parasite through its
Several metabolic pathways, numerous metabolic products and toxins in endogenous
organelles, and genes common to eukaryotes or development probably play a role. The intestinal
limited to Apicomplexa are reduced or absent damages include atrophy of the villi, epithelium
in Cryptosporidium. Cryptosporidium lacks hyperplasia in the crypts of the villi, and
enzymes for synthesizing key biochemical degenerative changes in the lamina propria, the
building blocks, such as sugars, amino latter being rich in macrophages and neutrophils,
acids, and nucleotides. Genomic analysis of eosinophils, and lymphocytes. Thus, the small
Cryptosporidium indicates that it encodes more intestine’s enzyme activity and absorptive
than 80 genes with strong similarities with surface decrease. Malabsorption syndrome
known transporters and several hundred genes develops with profuse diarrhoea, lactose, and
with transporter-like properties. enzyme deficiency, and the protein metabolism
Therefore, Cryptosporidium spp. relies and water and electrolyte balance are severely
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