Cyclospora cayetanensis

Updated: 31 October 2001
E-mail: Steve J. Upton Division of Biology, Kansas State University, Manhattan, KS 66506
Main menu: Cryptosporidium homepage

History: The first published report of Cyclospora cayetanensis in humans appears to be by Ashford (1979), who found unidentified Isospora-like coccidia in the feces of 3 individuals in Papua, New Guinea. At least the photomicrographs in the paper reveal an organism morphologically identical to that we see now. Later, Narango et al. (1989) reported what may be the same organism from several Peruvians with chronic diarrhea and termed the organism Cryptosporidium muris-like. Other investigators thought the unsporulated oocysts appeared more similar to cyanobacteria, and the name "cyanobacterium-like body" or CLB became prevalent in the literature (occasionally, authors also used the term "coccidian-like body" for CLB). Eventually, Ortega et al. (1992) published an abstract reporting that they had sporulated and excysted the oocysts, resulting in placement of the parasite in the genus Cyclospora. They also created the name Cyclospora cayetanensis at this time. However, since no morphologic information was presented in the abstract, C. cayetanensis technically became a nomen nudum (a named species without a description). Although Ortega et al. (1993) later published additional details about this coccidian, it wasn't until 1994 that a complete morphologic description was published to validate the name (Ortega et al., 1994). Thus, the correct name for this parasite is Cyclospora cayetanensis Ortega, Gilman, & Sterling, 1994, and the etymology of the nomen triviale is derived from Cayetano Heredia University in Lima, Peru. During this 2-year period when C. cayetanensis was a nomen nudum, anyone wishing to publish a complete morphologic description and change the name would have been free to do so. But, we are now doomed forever in our struggle to spell and pronounce "cayetanensis."

Life-cycle and basic biology: The life-cycle of Cyclospora cayetanensis begins, like all enteric coccidia, with ingestion of a sporulated "oocyst" (the environmentally resistent cyst stage). This sporulated oocyst contains 2 "sporocysts" (smaller cysts within the oocyst), each enclosing 2 "sporozoites" (the infective stages; each oocyst contains a total of 4 sporozoites). Once inside the gut, these sporozoites exit from the sporocysts and oocyst, eventually penetrating epithelial cells along the small intestine. The preferred site is the jejunum. Sporozoites undergo multiple fission inside cells to form "meronts," which contain numerous "merozoites." Ortega et al. (1997a) has described two asexual generations: the first having 8-12 merozoites and the second as having 4 merozoites. The final generation of merozoites penetrate new cells to form gametes, which can also be found in the jejunum. Most gametes simply enlarge to form the female gamete, or "macrogamete." Some become "microgametocytes," which undergo multiple fission to form numerous flagellated sperm-like "microgametes." Mature microgametes exit the microgametocyte, fertilize the macrogametes, and a resistent oocyst wall is layed down around the zygote. In time, the unsporulated oocyst is sloughed from the intestinal wall along with the host cell and passes into the external environment with the feces. Further development of sporocysts and sporozoites is termed "sporogony" or "sporulation" and occurs only in the presence of the higher atmospheric oxygen concentrations. Sporulation is complete in 7-12 days at a "warm" room temperature, for instance at 30 C.

Hosts: Humans may be the only true hosts for this coccidian. Although the parasite has been reported from chimpanzees, Pan troglodytes from Uganda (Ashford et al., 1993), and baboons and chimpanzees from Tanzania (Smith et al., 1996), these may actually represent one or more morphologically similar species. Eberhard et al. (1999, Emerg. Inf. Dis. 5: 651-658) described 3 new species from primates although both the morphologic and molecular data suggested little difference between the three and with that found in humans. Nonetheless, a more recent follow up study suggests that oocysts derived from humans may not be infectious to non-human primates (although no positive controls, humans, could be used in the study) (Eberhard et al. 2000). There are also reports of the parasite in dogs (Yai et al. 1997) and poultry (Garcia-Lopez et al. 1996; Sherchand et al. 1999), but it is likely that the former is either Hammondia heydorni or Neospora caninum and the latter either Eimeria mitis or a pseudoparasite.

Diagnosis: Oocysts of Cyclospora are spherical, measure 9.0 micrometers in diameter, and are passed in the feces unsporulated. They are passed in low to moderate numbers, and are easily recognized using conventional microscopy (try here). Fluorescent microscopy employing a filter with a wavelength in the range of 340-380 nm reveals the oocysts to glow a bright, pale blue.

Clinical signs and pathogenesis: Individuals infected with Cyclospora may experience prolonged watery diarrhea, abdominal cramping, weight loss, anorexia, myalgia, and occasionally vomiting and/or fever. Symptoms generally begin approximately 1 week (5-8 days) after ingestion of oocysts and these may persist for a month or more. The small intestine becomes inflammed, and the parasite causes mucosal changes that include villous atropy and crypt hyperplasia. Mild infections may produce few or no clinical signs.

Epidemiology: With the exception of some outbreaks, the overall prevalence of Cyclospora in North America appears to be far less than 1%. Outbreaks seem to occur most frequently in late spring and summer, and these warmer temperatures are clearly needed to get oocysts to sporulate with any rapidity. In addition, this time of year correlates with increased import of fruits and vegetables into the US from our more southern neighbors. Individuals become infected when they ingest contaminated food or water containing viable, sporulated oocysts. Because so many of the foods we consume are shipped over long distances and involve contact by many individuals, transportation of pathogens such as Cyclospora between states and countries has become unavoidable. However, the odds of becoming infected with Cyclospora, and many other foodborne pathogens, can be greatly diminished by simply washing fruits and vegetables well prior to consumption. However, it should be noted that simply washing foods does not removed 100% of the oocysts (see Ortega et al., 1997b).

Treatment: Some success has been achieved treating patients with co-trimoxazole (160 mg trimethoprim, 800 mg sulfamethoxazole) twice daily for 7 days. Children should receive trimethoprim at 5 mg/kg body weight plus sulfamethoxazole at 25 mg/kg body weight twice a day for 7 days. For more specific information on treatment, see the papers below marked with an asterisk (*).

Other: An informal survey by the American Society of Parasitologists a few years ago found that the average physician in medical school now receives only about 6 total hours of parasitologic training during medical school. Considering that over 400 different species of parasites are known to infect humans (see Ashford and Crewe, 1998, The parasites of Homo sapiens. Liverpool School of Tropical Medicine, 128 pp. ISBN 0-9508756-9-4), excluding most arthropods such as mosquitos, flies, and ticks, this training is nothing less than dismal. Few physicians will initially suspect cyclosporiasis, and few have even heard of it, which collectively results in lack of specific testing for this organism (see 2000, Emerg. Inf. Dis. 6: 200-203). It appears likely that most infections go undiagnosed.

CDC information for health care providers
Differentiation of Cyclospora from Eimeria by PCR
FDA public announcement
Outbreaks in 1996 (MMWR 45: 549-551, June 1996)
Protocol for preparation of oocysts for PCR following extraction from produce

2001 papers

Barta, J.R. et al. 2001. Molecular phylogeny of the other tissue coccidia: Lankesterella and Caryospora. J. Parasitol. 87: 121-127.

Chokephaibulkit, K. et al. 2001. A report case of Cyclospora and Cryptosporidium mixed infection in a HIV-negative child in Thailand. J. Med. Assoc. Thailand. 84: 589-592.

Clark, S.C. and McIntyre, M. 2001. Acid-fast bodies in faecal smears stained by the modified Ziehl-Neelsen technique. Br. J. Biomed. Sci. 58: 7-10.

Connor, B.A. et al. 2001. Reiter syndrome following protracted symptoms of Cyclospora infection. Emerg. Inf. Dis. 7: 453-454.

Dalton, C. et al. 2001. Viability of Giardia intestinalis cysts and viability and sporulation state of Cyclospora cayetanensis oocysts determined by electrorotation. Appl. Environment. Microbiol. 67: 586-590.

Egloff, N. et al. 2001. Chronic watery diarrhea due to co-infection with Cryptosporidium spp. and Cyclospora cayetanensis in Swiss AIDS patient traveling in Thailand. J. Travel Med. 8: 143-145.

Gascon, J. et al. 2001. Cyclosporiasis: a clinical and epidemiological study in travellers with imported Cyclospora cayetanensis infection. Med. Clin. (Barcelona) 116: 461-464.

de Gorgolas, M. et al. 2001. Cyclospora cayetanensis cholecystitis in a patient with AIDS. Ann. Intern. Med. 134: 166.

Katz, D.E. and Taylor, D.N. 2001. Parasitic infections of the gastrointestinal tract. Gastroent. Clin. North Amer. 30: 797-815.

Khalifa, A.M. et al. 2001. Effect of ozone on the viability of some protozoa in drinking water. J. Egypt. Soc. Parasitol. 31: 603-616.

Klein, N.C. and Cunha, B.A. 2001. New uses of older antibiotics. Med. Clin. North Amer. 85: 125-132.

Lopez, A.S. et al. 2001. Outbreak of cyclosporiasis associated with basil in Missouri in 1999. Clin. Inf. Dis. 32: 1010-1017.

Nunez, F.A. and Finlay, C.M. 2001. Training for diagnosis of intestinal parasitic diseases in the national laboratory system of Cuba. Cad. Saude Publica 17: 719-724.

Pinel C. et al. 2001. Cyclosporiasis: an emerging intestinal protozoan infection. Presse Med. 30: 23.

Pratdesaba, R.A. et al. 2001. Cyclospora cayetanensis in three populations at risk in Guatemala. J. Clin. Microbiol. 39: 2951-2953.

Okhuysen, P.C. 2001. Traveler's diarrhea due to intestinal protozoa. Clin. Inf. Dis. 33: 110-114.

Oliver, C. et al. 2001. Sequence variability in the first internal transcribed spacer region within and among Cyclospora species is consistent with polyparasitism. Int. J. Parasitol. 31: 1475-1487.

Sanders, J.W. and Tribble, D.R. 2001. Diarrhea in the returned traveler. Curr. Gastroenterol. Rep. 3: 304-314.

2000 papers

Alakpa, G.E. et al. 2000. Cyclospora cayetanensis infection in Lagos, Nigeria: a preliminary report. Proceedings of the annual meeting of the American Society for Microbiology, 21-25 May 2000, Washington, D.C. American Society for Microbiology. p. 603. (abstract).

Alakpa, G.E. et al. 2000. Cyclospora cayetanensis in watery-diarrhoeal stools in Lagos, Nigeria. Specialist Doctor 7: 5-9.

Ali, M.S. et al. 2000. Intestinal spore-forming protozoa among patients suffering from chronic renal failure. J. Egypt. Soc. Parasitol. 30: 93-100.

Arcay, L. 2000. Elagua como ruto para infecciones de protozoarios especialmente de enteropatogeos emergentes: Cryptosporidium parvum, Cyclospora cayetanensis y microspora. Arch Hosp. Vargas 42: 107-116.

Arcay, L. et al. 2000. Structures of the life cycle of Cyclospora cayetanensis (Protozoa, Coccidia) in the feces of patients with diarreic syndrome. Acta Biol. Venez. 20: 35-42.

Bern, C. et al. 2000. The contrasting epidemiology of Cyclospora and Cryptosporidium among outpatients in Guatemala. Am. J. Trop. Med. Hyg. 63: 231-235.

Cann, K.J. et al. 2000. Cyclospora infections in England and Wales: 1993 to 1998. Commun. Dis. Publ. Health 3: 46-49.

Chalmers, R.M. et al. 2000. Foodborne outbreaks of cyclosporiasis have arisen in North America. Is the United Kingdom at risk? Commun. Dis. Publ. Health 3: 50-55.

De Carli, G.A. 2000. Infeccoes oportunistas por protozoarios parasitos: uma revisao sobre Cryptosporidium parvum, Cyclospora cayetanensis, Isospora belli e microsporidios. Rev. Bras. Anal. Clin. 32: 205-214.

De Carli, G.A. 2000. Parasitologia Clinica. Diagnostico de Laboratorio dos coccidiios e microsporidios intestinais. Cadernos EPIPUCRS 14, Serie Farmacia 1, Analises Clinicas-Parasitologia, Porto Alegre. 73 pp.

Deodhar, L. et al. 2000. Cyclospora infection in acquired immunodeficiency syndrome. J. Assoc. Phys. India 48: 404-406.

Di Giullo, A.B. et al. 2000. Cyclospora cayetanensis in sputum and stool samples. Rev Inst. Med. Trop. Sao Paulo 42: 115-117.

Eberhard, M.L. et al. 2000. Attempts to establish experimental Cyclospora cayetanensis infection in laboratory animals. J. Parasitol. 86: 577-582.

Ferreira, M.S. 2000. Infections by protozoa in immunocompromised hosts. Mem. Inst. Oswaldo Cruz 95: 159-162.

Franzen, C. et al. 2000. Taxonomic position of the human intestinal protozoan parasite Isospora belli as based on ribosomal RNA sequences. Parasitol. Res. 86: 669-676.

Green, S.T. et al. 2000. Two simultaneous cases of Cyclospora cayetanensis enteritis returning from the Dominican Republic. J. Travel Med. 7: 41-42.

Hermandez-Mora, M.G. et al. 2000. Cyclosporiasis. Med. Clin. (Barcelona) 115: 431-444.

Herwaldt, B.L. 2000. Cyclospora cayetanensis: a review, focusing on the outbreaks of cyclosporiasis in the 1990s. Clin. Inf. Dis. 31: 1040-1057.

Mohle-Boetani, J.C. et al. 2000. The impact of health communication and enhanced laboratory-based surveillance on detection of cyclosporiasis outbreaks in California. Emerg. Inf. Dis. 6: 200-203.

Mota, P. et al. 2000. Microsporidia and Cyclospora: epidemiology and assessment of risk from the environment. Crit. Rev. Microbiol. 26: 69-90.

Nichols, G.L. 2000. Food-borne protozoa. Br. Med. Bull. 56: 209-235.

Orlandi, P.A. and Lampel, K.A. 2000. Extraction-free, filter-based template preparation for rapid and sensitive PCR detection of pathogenic parasitic protozoa. J. Clin. Microbiol. 38: 2271-2277.

Parija, S.C. and Bhattacharya, S. 2000. Pictorial CME. Isospora belli and Cyclospoa cayetanensis in a case of chronic diarrhea in an immunocompromosed host. J. Assoc. Phys. India 48: 1192.

Robertson, L.J. and Gjerde, B. 2000. Isolation of Cyclospora oocysts from fruits and vegetables using lectin-coated paramagnetic beads. J. Food Prot. 63: 1410-1414.

Santana, A.M. et al. 2000. Emergence of a new pathogen: Cyclospora cayetanensis in patients infected with human immunodeficiency virus. Rev. Cubana Med. Trop. 52: 66-69.

Thomas, R.E. 2000. Preparing patients to travel abroad safely. Part 4: Reducing risk of accidents, diarrhea, and sexually transmitted diseases. Can. Fam. Physician 46: 1634-1638.

Vasquez Tsuji, O. et al. 2000. Cyclospora cayetanensis infection. Laboratory diagnosis. Rev. Latinoam. Microbiol. 42: 45-52.

*Verdier, R.I. et al. 2000. Trimethoprim-sulfamethoxazole compared with ciprofloxacin for treatment and prophylaxis of Isospora belli and Cyclospora cayetanensis infection in HIV-infected patients. A randomized, controlled trial. Ann. Int. Med. 132: 885-888.

Wallace, D.J. et al. 2000. Incidence of foodborne illnesses reported by the foodborne diseases active surveillance network (FoodNet)-1997. FoodNet working group. J. Food Prot. 63: 807-809.

1999 papers

Abou el Naga, I.F. 1999. Studies on a newly emerged protozoal pathogen: Cyclospora cayetanensis. J. Egypt. Soc. Parasitol. 29: 575-586.

Ajisawa, A. 1999. Cryptosporidium, Cyclopsora, Microsporidia. Ryoikibetsu Shokogun Shirizy 1999: 97-99.

Alakpa, G.E. et al. 1999. Preliminary studies on Cyclospora cayetanensis, an emerging diarrhoeal pathogen: are physicians in Nigeria aware? Specialist Doctor 6: 9-12.

Albert, M.J. et al. 1999. Case-control study of enteropathogens associated with childhood diarrhea in Dhaka, Bangladesh. J. Clin. Microbiol. 37: 3458-3464.

Bern, C. et al. 1999. Epidemiologic studies of Cyclospora cayetanensis in Guatemala. Emerg. Inf. Dis. 5: 766-774.

Brown, G.H., & Rotschafer, J.C. 1999. Cyclopospora: a review of an emerging parasite. Pharmacotherapy 19: 70-75.

Casemore, D.P. 1999. Cyclospora species as a cause of diarrhoea in humans. Br. J. Biomed. Sci. 56: 78-79.

Cegielski, J.P. et al. 1999. Cryptosporidium, Enterocytozoon, and Cyclospora infections in pediatric and adult patients with diarrhea in Tanzania. Clin. Inf. Dis. 28: 314-321.

Connor, B.A. et al. 1999. Cyclosporiasis: clinical and histopathologic correlates. Clin. Inf. Dis. 28: 1216-1222.

De Carli, G.A. 1999. Diagnostico laboratorial da Cyclospora cayetanensis. Revista Brasileira de Analises Clinicas 31(3): 143-150.

Duszynski, D.W. et al. 1999. Coccidia (Apicomplexa: Eimeriidae) in the primates and the scandentia. Int. J. Primatol. 20: 761-797.

Eberhard, M.L. et al. 1999. Morphologic and molecular characterization of new Cyclospora species from Ethiopian monkeys: C. cercopitheci sp. n., C. colobi sp. n., and C. papionis sp. n. Emrg. Inf. Dis. 5: 651-658.

Eberhard, M.L. et al. 1999. Survey for Cyclospora cayetanensis in domestic animals in endemic area of Haiti. J. Parasitol. 85: 562-563.

Eberhard, M.L. et al. 1999. Cyclospora cayetanensis infections in Haiti: a common occurrence in the absence of watery diarrhea. Am. J. Trop. Med. Hyg. 60: 584-586.

Escobedo, A.A., & Nunez, F.A. 1999. Prevalence of intestinal parasites in Cuban acquired immunodeficiency syndrome (AIDS) patients. Acta Trop. 72: 125-130.

Fryauff, D.J. et al. 1999. Cyclospora cayetanensis among expatriate and indigenous populations of west Java, Indonesia. Emerg. Inf. Dis. 5: 585-588.

Gumbo, T. et al. 1999. Intestinal parasites in patients with diarrhea and human immunodeficiency virus infection in Zimbabwe. AIDS 13: 819-821.

Herwaldt, B.L. et al. 1999. The return of Cyclospora in 1997: another outbreak of cyclosporiasis in North America associated with imported raspberries. Ann. Int. Med. 130: 210-220.

Jinneman, K.C. et al. 1999. An oligonucleotide-ligation assay for the differentiation between Cyclospora and Eimeria spp. polymerase chain reaction amplification products. J. Food Protect. 62: 682-685.

Katz, D. et al. 1999. Cyclosporiasis associated with imported rapberries, Florida, 1996. Publ. Health Rep. 114: 427-438.

Lopez, F.A. et al. 1999. Molecular characterization of Cyclospora-like organisms from baboons. J. Inf. Dis. 179: 670-676.

Mezzari, A. et al. 1999. Cyclospora cayetanensis, um novo protozoario a ser pesquisado. Rev. Assoc. Med. Brasil. 45: 347-348.

Mosimann, M. et al. 1999. Excessive watery diarrhea and pronounced fatigue due to Cyclospora cayetanensis infection in an HIV infected traveler returning from the tropics. Schweiz. Med. Wochenschr. 129: 1158-1161.

Nace, E.K. et al. 1999. Evaluation of Streck tissue fixative, a nonformalin fixative for preservation of stool samples and subsequent parasitologic examinations. J. Clin. Microbiol. 37: 4113-4119.

Ponce de Leon et al. 1999. A new trichromic safranin stain for the detection of Cryptosporidium parvum, Cyclospora cayetanensis, species of Microsporidia and Isospora belli in fecal material. Rev. Latinoam. Microbiol. 41: 211-214.

Ramakrishna, B.S. 1999. Prevalence of intestinal pathogens in HIV patients with diarrhea: implications for treatment. Ind. J. Pediatr. 66: 85-91.

Ranhitham, M. et al. 1999. Cyclospora cayetanensis - an emerging coccidian parasite. J. Assoc. Physicians India 47: 1198-1199.

Ranjitham, M. et al. 1999. Cyclospora cayetanensis, a new emerging coccidian parasite. J. Commun. Dis. 31: 137-139.

Reverand, S. et al. 1999. Cyclospora cayetanensis en ninos asintomaticos del area Metropolitana de Caracas. Rev. Fed. Med. Venez. 7: 26-31.

Rose, J.B. and Slifko, T.R. 1999. Giardia, Cryptosporidium, and Cyclospora and their impact on foods: a review. J. Food Prot. 62: 1059-1070.

Serpentini, A. et al. 1999. Cyclospora cayetanensis: review of an emerging intestinal pathogen. Ann. Biol. Clin. (Paris) 57: 677-683.

Shellabear, C.K. & Shah, A.J. 1999. Cyclospora cayetanensis: an emerging food pathogen. Food Australia 51: 30-32.

Sherchand, J.B. et al. 1999. Study of Cyclospora cayetanensis in health care facilities, sewage water and green leafy vegetables in Nepal. S. E. Asian J. Trop. Med. Publ. Health 30: 58-63.

Shlim, D.R. et al. 1999. Persistent high risk diarrhea among foreigners in Nepal during the first 2 years of residence. Clin. Inf. Dis. 29: 613-616.

Sterling, C.R. & Ortega, Y.R. 1999. Cyclospora: an enigma worth unraveling. Emerg. Inf. Dis. 5: 48-53.

1998 papers

Abou el Naga, I.F. et al. 1998. Preliminary identification of an intestinal coccidian parasite in man. J. Egypt. Soc. Parasitol. 28: 807-814.

Abreu de Borges, E.B. et al. 1998. Cyclospora cayetanensis y microsporidia en heces de pacientes con sida y sindrome diarreico. Rev. Fed. Med. Venez. 6: 89-96.

Arcay, L. et al. 1998. Incidencia de Cyclospora cayetanensis y microspora en pacientes de la poblacion circunvecina del Rio Anare (Venezuela) y su presencia en el agua del Rio. Arch. Hosp. Vargas 40: 157-162.

Bellagra, N. et al. 1998. Co-infection with Cryptosporidium sp. and Cyclospora sp. in a AIDS stage HIV patient. Ann. Biol. Clin. (Paris) 56: 476-478.

Berlin, O.G. et al. 1998. Autoflourescence and the detection of Cyclospora oocysts. Emerg. Inf. Dis. 4: 127-128.

Caceres, V.M. et al. 1998. A foodborne outbreak of cyclosporiasis caused by imported raspberries. J. Fam. Pract. 47: 231-234.

Curry, A. and H.V. Smith. 1998. Emerging pathogens: Isospora, Cyclospora and microsporida. Parasitology 117: s143-s159.

Drenaggi, D. et al. 1998. Cyclosporiasis in a traveler returning from South America. J. Travel Med. 5: 153-155.

Fernandes, A.O. et al. 1998. Human cyclosporiasis diagnosis: report of a case in Sao Paulo, SP, Brazil. Rev. Inst. Med. Trop. Sao Paulo 40: 391-394.

Fleming, C.A. et al. 1998. A foodborne outbreak of Cyclospora cayetanensis at a wedding: clinical features and risk factors for illness. Arch. Int. Med. 158: 1121-1125.

Graczyk, T.K. et al. 1998. Recovery of Waterborne oocysts of Cyclospora cayetanensis by asian freshwater clams (Corbicula fluminea). Am. J. Trop. Med. Hyg. 59: 928-932.

Jayshree, R.S. et al. 1998. Cyclospora cayetanensis-associated diarrhoea in a patient with acute myeloid lukaemia. J. Diarrh. Dis. 16: 254-255.

Jinneman, K.C. et al. 1998. Template preparation for PCR and RFLP of amplification products for the detection and identification of Cyclospora sp. and Eimeria spp. Oocysts directly from raspberries. J. Food Prot. 61: 1497-1503.

Kimata, I. 1998. Laboratory diagnosis of protozoan and parasitic infections. 1. Protozoan infections. e. Isospora and Cyclopsora infections. Rinsho Byori 108: 198-203.

Koumans, E.H. et al. 1998. An outbreak of cyclosporiasis in Florida in 1995: a harbinger of multistate outbreaks in 1996 and 1997. Am. J. Trop. Med. Hyg. 59: 235-242.

Lepes, T. 1998. Newly established causes of diarrhea: the protozoan Cyclospora cayetanensis. Med. Pregl. 51: 242-244.

Lindhorst, E., and E.G. Long. 1998. Cyclospora cayetanensis--an intestinal protozoan pathogenic for humans which is of increasing clinical significance. Dtsch. Med. Wochenschr. 123: 504-509.

Looney, W.J. 1998. Cyclospora species as a cause of diarrhoea in humans. Br. J. Biomed. Sci. 55: 157-161.

Madrid, V.V. et al. 1998. Cyclosporiosis. Case report. Rev. Med. Chil. 126: 559-562.

Miller, M.A. et al. 1998. Other food borne infections. Vet. Clin. North Amer. Food Anim. Pract. 14: 71-89.

Moreno-Camacho, A. et al. 1998. Infecciones parasitarias intestinales y leishmaniosis en pacientes con infeccion por el VIH. Enferm. Microbiol. Clin. 16: 52-60.

el Naga, I.F. et al. 1998. Preliminary identification of an intestinal coccidian parasite in man. J. Egypt. Soc. Parasitol. 28: 807-814.

Nasseff, N.E. et al. 1998. Cyclospora: a newly identified protozoan pathogen of man. J. Egypt. Soc. Parasitol. 28: 213-219.

Negm, A.Y. 1998. Identification of Cyclospora cayetanensis in stool using different stains. J. Egypt. Soc. Parasitol. 28: 429-436.

O'Mahony, C. et al. 1998. Cyclospora cayetanensis and HIV-related diarrhea. Int. J. STD AIDS 9: 59.

*Ortega, Y.R. et al. 1998. Cyclospora cayetanensis. Adv. Parasitol. 40: 399-418.

Richardson, R.F. et al. 1998. Guillain-Barre syndrome after Cyclospora infection. Muscle Nerve 21: 669-671.

Soave, R. 1998. Cyclospsora. Inf. Dis. Clin. North Amer. 12: 1-12.

Sturbaum, G.D. et al. 1998. Detection of Cyclospora cayetanensis in wastewater. Appl. Environment. Microbiol. 64: 2284-2286.

Terra, L. et al. 1998. Laboratory diagnosis of intestinal micro-parasitosis in AIDS patients: state of the art. Minerva Med. 89: 23-27.

Varea, M. et al. 1998. Fuchsin fluorescence and autofluorescence in Cryptosporidium, Isospora and Cyclospora oocysts. Int. J. Parasitol. 28: 1881-1883.

Ackers, J.P. 1997. Gut coccidia-Isospora, Cryptosporidium, Cyclospora, and Sarcocystis. Semin. Gastrointest. Dis. 8: 33-44.

Anonymous. 1997. Diagnosis of Cyclospora cayetanensis infections. Commun. Dis. Rep. CDR Wkly 7(37) Sept. 12: 329.

Anonymous. 1997. Outbreaks of cyclosporiasis--United States, 1997. MMWR 46(20) May 23: 451-452.

Anonymous. 1997. Outbreaks of pseudo-infection with Cyclospora and Cryptosporidium--Florida and New York City, 1995. MMWR 46(16) Apr 25: 354-358.

Clarke, S.C. and McIntyre, M. 1997. An attempt to demonstrate a serological immune response in patients infected with Cyclospora cayetanensis. Br. J. Biomed. Sci. 54: 73-74.

Collins, R. 1997. Protozoan parasites of the intestinal tract: a review of coccidia and microsporidia. J. Am. Osteopath. Assoc. 97: 593-598.

Colomina Rodriguez, J. et al. 1997. Morphological, clinical and therapeutic characteristics of Cyclospora cayetanensis. Bol. Chil. Parasitol. 52: 26-32.

Connor, B.A. 1997. Cyclospora infection: a review. Ann. Acad. Med. Singapore 26: 632-636.

Diaz Carbonell, J.V. and Villar Amigo, V.M. 1997. Cyclospora cayetanensis: a new enteropathogenic parasite. Gastroenterol. Hepatol. 20: 160-162.

Eberhard, M.L. et al. 1997. Laboratory diagnosis of Cyclospora infections. Arch. Pathol. Lab. Med. 121: 792-797.

Gumbo, T. et al. 1997. Cyclospora: update on an emerging pathogen. Clev. Clin. J. Med. 64: 299-301.

Herwaldt, B.L. and Ackers, M.L. 1997. An outbreak in 1996 of cyclosporiasis associated with imported raspberries. The Cyclospora working group. N. Engl. J. Med. 336: 1548-1556.

Jackson, G.J. et al. 1997. Cyclospora-still another new foodborne pathogen. Food Tech. 51: 120.

Jelinek, T. et al. 1997. Prevalence of infection with Cryptosporidium and Cyclospora cayetanensis among international travelers. Gut 41: 801-804.

Logar, J. et al. 1997. Cyclospora cayetanensis, potential cause of diarrhoea. J. Inf. 34: 284-285.

Madico, G. et al. 1997. Epidemiology and treatment of Cyclospora cayetanensis infection in Peruvian children. Clin. Inf. Dis. 24: 977-981.

Marquardt, W.C. 1997. The taxonomy of Cyclospora. Emerg. Inf. Dis. 3: 579-580.

Marshall, M.M. et al. 1997. Waterborne protozoan pathogens. Clin. Microbiol. Rev. 10: 67-85.

Medina de la Garza, C.E. et al. 1997. Use of discontinuous percoll gradients to isolate Cyclospora oocysts. Ann. Trop. Med. Parasitol. 91: 319-321.

Ockelford, A. et al. 1997. Cyclospora cayetanensis diarrhoea in a traveller. N. Z. Med. J. 110: 404.

Ortega, Y.R. et al. 1997a. Pathologic and clinical findings in patients with cyclosporiasis and a description of intracellular parasite life-cycle stages. J. Inf. Dis. 176: 1584-1589.

Ortega, Y.R. et al. 1997b. Isolation of Cryptosporidium parvum and Cyclospora cayetanensis from vegetables collected in markets in an endemic region of Peru. Am. J. Trop. Med. Hyg. 57: 683-686.

Petry, F. et al. 1997. Cyclospora cayetanensis: first imported infections in Germany. Infection 25: 167-170.

Pieniazek, N.J. and B.L. Herwaldt. 1997. Reevaluating the molecular taxonomy: is human-associated Cyclospora a mammalian Eimeria species? Emerg. Inf. Dis. 3: 381-383.

Roberts, R.B. 1997. Emerging pathogens associated with infectious diarrhea. Braz. J. Inf. Dis. 1: 153-176.

Rodriguez, J.C., and J.V. Serrano. 1997. Morphological, clinical and therapeutic characteristics of Cyclospora cayetanensis. Bol. Chil. Parasitol. 52: 26-32.

Schubach, T.M. et al. 1997. Cyclospora cayetanensis in an asymptomatic patient infected with HIV and HTLV-1. Trans. R. Soc. Trop. Med. Hyg. 91: 175.

*Shlim, D.R. et al. 1997. An open trial of trimethoprim alone against Cyclospora infections. J. Travel Med. 4: 44-45.

Smith, H.V. et al. 1997. Sporulation of Cyclospora sp. oocysts. Appl. Environment. Microbiol. 63: 1631-1632.

Steiner, T.S. et al. 1997. Protozoal agents: what are the dangers for the public water supply? Ann. Rev. Med. 48: 329-340.

Sterling, C.R. et al. 1997. Outbreaks of pseudo-infection with Cyclospora and Cryptosporidium - Florida and New York City, 1995. J. Am. Med. Assoc. 18: 1428-1429 (reprinted from MMWR 46: 354-358, 1997).

Taylor, A.P. et al. 1997. Cyclospora. Curr. Clin. Top. Infect. Dis. 17: 256-268.

Visvesvara, G.S. et al. 1997. Uniform staining of Cyclospora oocysts in fecal smears by a modified safranin technique with microwave heating. J. Clin. Microbiol. 35: 730-733.

Yai, L.E. et al. 1997. The first two cases of Cyclospora in dogs, Sao Paulo, Brazil. Rev. Inst. Med. Trop. Sao Paulo 39: 177-179. [note: I would guess the oocysts to actually be Hammondia heydorni or Neospora caninum].

Anonymous. 1996. Cyclospora infections on the increase. J. Ark. Med. Soc. 93: 143.

Anonymous. 1996. Outbreak of Cyclospora infection in North America. Commun. Dis. Rept. 6(26): 223-226.

Booy, R. 1996. Are Cyclospora an important cause of diarrhoea in Bangladesh? Arch. Dis. Childhood 74: 90.

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Chambers, J. et al. 1996. Outbreaks of Cyclospora cayetanensis infection-United States, 1996. J. Am. Med. Assoc. 276: 183.

Chambers, J. et al. 1996. Outbreaks of Cyclospora cayetanensis infection - United States. MMWR 45: 549-551.

Charatan, F.B. 1996. Cyclospora outbreaks in the US. Br. Med. J. 313: 71.

Clarke, S.C. 1996. Laboratory diagnosis and autofluorescence of Cyclospora. Br. J.Biomed. Sci. 52: 231.

Clarke, S.C. and McTintyre, M. 1996. Incidental laboratory diagnosis of Cyclospora cayetanensis. Br. J. Biomed. Sci. 53: 243.

Clarke, S.C., McIntyre, M. 1996. The incidence of Cyclospora cayetanensis in stool samples submitted to a district general hospital. Epidemiol. Infect. 117: 189-193.

Clarke, S.C., McIntyre, M. 1996. Modified detergent Ziehl-Neelsen technique for the staining of Cyclospora cayetanensis. J. Clin. Pathol. 49: 511-512.

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Deluol, A.-M. et al. 1996. Cyclospora sp.: Life cycle studies in patient by electron-microscopy. J. Euk. Microbiol. 43: 128s-129s.

Fernandes, F.F. et al. 1996. Deianostico morfologico da Cyclospora cayetanensis: um parasito emergente. J. Bras. Patol. 32: 118-120.

Flynn, P.M. 1996. Emerging diarrheal pathogens: Cryptosporidium parvum, Isospora belli, Cyclospora species, and microsporidia. Pediatr. Ann. 25: 480-481.

Fryauff, D.J. et al. 1996. Short report: case report of Cyclospora infection acquired in Indonesia and treated with cotrimoxazole. Am. J. Trop. Med. Hyg. 55: 584-585.

Garcia-Lopez, H.L. et al. 1996. Identification of Cyclospora in poultry. Emerg. Inf. Dis. 2: 356-357. [note: I would guess oocysts to actually represent either a pseudoparasite or Eimeria mitis].

Goodgame, R.W. 1996. Understanding intestinal spore-forming protozoa: Cryptosporidia, Microsporidia, Isospora, and Cyclospora. Ann. Int. Med. 124: 429-441.

Jinneman, K.C. et al. 1996. Differentiation of Cyclospora sp. and Eimeria spp. by using the polymerase chain reaction amplification products and restriction fragment length polymorphisms. FDA Laboratory Information Bulletin, No. 4044, 9 pp.

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Manatsathit, S. et al. 1996. Causes of chronic diarrhea in patients with AIDS in Thailand: a prospective clinical and microbiological study. J. Gastroenterol. 31: 533-537.

Nhieu, J.T. et al. 1996. Identification of intracellular stages of Cyclospora species by light microscopy of thick sections using hematoxylin. Hum. Pathol. 27: 1107-1109.

Pieniazek, N.J. et al. 1996. PCR confirmation of infection with Cyclospora cayetanensis. Emerg. Inf. Dis. 2: 357-359.

Ponce-Macotela, M. et al. 1996. Cyclospora in 2 Mexican children. Rev. Invest. Clin. 48: 461-463.

Relman, D.A. et al. 1996. Molecular phylogenetic analysis of Cyclospora, the human intestinal pathogen, suggests that it is closely related to Eimeria species. J. Inf. Dis. 173:440-445.

Roxas, C. et al. 1996. Vegetables as a potential transmission route for Cyclospora and Cryptosporidium. Abstract, Proc. Ann. Meet., Am. Soc. Microbiol., 1996, C-102, p. 19.

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Sun, T. et al. 1996. Light and electron microscopy identification of Cyclospora species in the small intestine. Evidence of the presence of asexual life cycle in human host. Am. J. Clin. Pathol. 105: 216-220.

Tran Van Nhieu, J. et al. 1996. Identification of intracellular stages of Cyclospora species by light microscopy of thick sections using hematoxylin. Human Pathol. 27: 1107-1109.

van Gool, T. and Dankert, J. 1996. 3 emerging protozoal infections in The Netherlands: Cyclospora, Dientamoeba, and Microspora. Ned. Tijdschr. Geneeskd. 140: 155-160.

Yoder, K.E. et al. 1996. PCR-based detection of the intestinal pathogen Cyclospora. In, PCR protocols for emerging infectious diseases, a supplement to Diagnostic Molecular Biology: Principles and Applications. D.H. Persing, ed. ASM Press, Washington, DC. pp. 169-176.

Arcay, L. 1995. Immunosupresion, sida y parasitosis. Abstract. XII Congreso LatinoAmericano de Parasitologia, Oct. 1995. p. 17.

*Booy, R., Tudor-Williams, G. 1995. Co-trimoxazole for Cyclospora infection. Lancet 345: 1303-1304.

Caramello, P. et al. 1995. Clinical and diagnostic aspects of Travelers' diarrhea due to Cyclospora organisms. J. Travel Med. 2: 232-234.

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Clarke, S.C. 1995. Laboratory diagnosis and autofluorescence of Cyclospora. Br. J. Biomed. Sci. 52: 231-232.

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Deluol, A.M. et al. 1995. Cyclospora sp. Nouvelle coccidie intetinale agent de diarrhee des voyageurs. Feuillets de Biologie 36: 17-23.

Dytrych, J.K., Cooke, R.P.D. 1995. Autofluorescence of Cyclospora. Br. J. Biomed. Sci. 52: 76.

Gascon, J. et al. 1995. Cyclospora in patients with traveller's diarrhea. Scand. J. Infect. Dis. 27: 511-514.

*Hoge, C.W. et al. 1995. Placebo-controlled trial of co-trimoxazole for Cyclospora infections among travellers and foreign residents in Nepal. Lancet 345: 691-693.

Hoge, C.W. et al. 1995. Prevalence of Cyclospora species and other pathogens among children less than 5 years of age in Nepal. J. Clin. Microbiol. 33: 3058-3060.

Huang, P. et al. 1995. The first reported outbreak of diarrheal illness associated with Cyclospora in the United States. Ann. Int. Med. 123: 409-414.

Knight, P. 1995. Once misidentified parasite is a cyclosporan. ASM News 61: 520-522.

Lontie, M. et al. 1995. Cyclospora sp.: a coccidian that causes diarrhoea in travellers. Acta Clin. Belg. 50: 288-290

Luca, M. et al. 1995. Cyclospora--a new genus of enteropathogen in man. Rev. Med. Chir. Soc. Med. Nat. Iasi 99: 279-280.

Maggi, P. et al. 1995. Cyclospora in AIDS patients: not always an agent of diarrhoic syndrome. Microbiologica 18: 73-76.

Marakote, N. et al. 1995. Microsporidium and Cyclospora in human stools in Chiang Mai, Thailand. SE Asian J. Trop. Med. Publ. Health 26: 799-800.

Nunez Fernandez, F.A. et al. 1995. The first report in Cuba of human intestinal infection by Cyclospora cayetanensis, Ortega, 1993. Rev. Cubana Med. Trop. 47: 211-214.

Ooi, W.W. et al. 1995. Cyclospora species as a gastrointestinal pathogen in immunocompetent hosts. J. Clin. Microbiol. 33: 1267-1269.

Purych, D.B. et al. 1995. A case of Cyclospora infection in an Albertan traveller. Can. Commun. Dis. Rep. 21: 88-91.

Raguin, G. et al. 1995. Cyclospora infection in a HIV infected patient. Presse Med. 24: 1134.

Robinson, R.D. 1995. Parasitic infections associated with HIV/AIDS in the Caribbean. Bull. Pan Am. Health Org. 29: 129-137.

Sifuentes-Osornio, J. et al. 1995. Cyclospora cayetanensis infection in patients with and without AIDS: biliary disease as another clinical manifestation. Clin. Inf. Dis. 21: 1092-1097.

*Soave, R., Johnson, W.D. 1995. Cyclospora: conquest of an emerging pathogen. Lancet 345: 667-668.

Wanachiwanawin, D. et al. 1995. Cyclospora infection in an HIV infected patient with ultrastructural study. SE Asian J. Trop. Med. Publ. Health 26: 375-377.

Weber, R., Deplazes, P. 1995. Neue parasitare Erkrankungen beim Menschen: Infektionen durch Mikrosporidien und Cyclospora species. Schweiz. Med. Wochenschr. 125: 909-923.

Zerpa, R. et al. 1995. Cyclospora cayetanensis associated with watery diarrhea in Peruvian patients. J. Trop. Med. Hyg. 98: 325-329.

Adal, K.A. 1994. From Wisconsin to Nepal: Cryptosporidium, Cyclospora, and microsporidia. Curr. Opin. Inf. Dis. 7: 609-615.

Albert, M.J. et al. 1994. Diarrhea associated with Cyclospora sp. in Bangladesh. Diag. Microbiol. Inf. Dis. 19: 47-49.

Atias, A. 1994. La ciclosporosis: una nueva entidad clinica. Parasitol. al Dia (Chile) 18: 62-65.

Berlin, O.G.W. et al. 1994. Recovery of Cyclospora organisms from patients with prolonged diarrhea. Clin. Inf. Dis. 18: 606-609.

Butcher, A.R. et al. 1994. Coccidian/cyanobacterium-like body associated diarrhea in an Australian traveller returning from overseas. Pathology 26: 59-61.

Casemore, D.P. 1994. Cyclospora: another "new" pathogen. J. Med. Microbiol. 41: 217-219.

Chiodini, P.L. 1994. A new' parasite: human infection with Cyclospora cayetanensis. Trans. R. Soc. Trop. Med. Hyg. 88: 369-371.

Clarke, S.C., McIntyre, M. 1994. Human infection with Cyclospora. J. Inf. 29: 112-113.

Deluol, A.-M. et al. 1994. Travellers diarrhea associated with Cyclopsora sp. J. Euk. Microbiol. 41: 32s.

Garavelli, P.I. 1994. Pathogenicity of Cyclospora sp. Parasite 1: 94.

Herwaldt, B.L. et al. 1994. Infections with intestinal parasites in Peace Corps volunteers in Guatemala. J. Clin. Microbiol. 32: 1376-1378.

Junod, C. et al. 1994. Cyclospora, nouvelle coccidie agent de diarrhees des voyageurs 11 observations. La Presse Med. 23: 1312.

Ortega, Y.R. et al. 1994. A new coccidian parasite (Apicomplexa: Eimeriidae) from humans. J. Parasitol. 80: 625-629.

*Pape, J.W. et al. 1994. Cyclospora infection in adults infected with HIV. Clinical manifestations, treatment, and prophylaxis. Ann. Int. Med. 121: 654-657.

Piales, I. et al. 1994. Search for cyanobacterium-like bodies in the stools of travellers with diarrhoeal illness. J. Euk. Microbiol. 41: 58s.

Rabold, J.G. et al. 1994. Cyclospora outbreak associated with chlorinated drinking water. Lancet 344: 1360-1361.

Scaglia, M. et al. 1994. Intestinal co-infection by Cyclospora sp. and Cryptosporidium parvum: first report in an AIDS patient. Parasite 1: 387-390.

Sinniah, B. et al. 1994. Cyclospora sp. causing diarrhea in man. SE Asian J. Trop. Med. Publ. Health 25: 221-223.

Topazian, M. and Bia, F.J. 1994. New parasites on the block: emerging intestinal protozoa. Gastroenterologist 2: 147-159.

Wurtz, R. 1994. Cyclospora: a newly identified intestinal pathogen of humans. Clin. Inf. Dis. 18: 620-623.

*Anonymous. 1993. Diarrhoea associated with Cyclospora species. Commun. Dis. Rep. CDC Wkly 3: 103.

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Bendall, R.P. et al. 1993. Diarrhoea associated with cyanobacterium-like bodies: a new coccidian enteritis of man. Lancet 341: 590-592.

Berlin, G.W., Porschen, R.K. 1993. Coccidian-like bodies (CLB)-a novel parasite associated with diarrhea. Investigator 8: 1-2.

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Gascon, J. et al. 1993. Cyanobacteria-like body (CLB) in travellers with diarrhea. Scand. J. Infect. Dis. 25: 253-257.

Heyworth, M.F. 1993. Cyanobacterium-like Cyclospora species. N. Engl. J. Med. 329: 1505.

Hoge, C.W. et al. 1993. Epidemiology of diarrhoeal illness associated with coccidian-like organism among travellers and foreign residents in Nepal. Lancet 341: 1175-1179.

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McDougall, R.J., Tandy, M.W. 1993. Coccidian/cyanobacterium-like bodies as a cause of diarrhea in Australia. Pathol. 25: 375-378.

Ortega, Y.R. et al. 1993. Cyclospora species-a new protozoan pathogen of humans. N. Engl. J. Med. 328: 1308-1312.

Rijpstra, A.C., Laarman, J.J. 1993. Repeated findings of unidentified small Isospora-like coccidia in faecal specimens from travellers returning to The Netherlands. Trop. Geograph. Med. 45: 280-282.

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