With Special Guest Dr. Scott Curry
In this Inpatient Update News Flash, Dr. Mason Turner is joined by infectious disease physician and hospital epidemiologist Dr. Scott Curry to examine the sharp rise in cyclosporiasis cases across the United States—and what it should change in clinical practice.
Thousands of confirmed cases have been reported across more than 40 states, with hundreds of hospitalizations and additional clusters still under investigation.
So what should hospitalists do differently?
What Is Cyclospora?
Cyclospora is a foodborne parasite that infects the small intestine and commonly causes:
- Prolonged watery diarrhea
- Frequent or urgent bowel movements
- Bloating and gas
- Poor oral intake
- Hypovolemia, AKI, and electrolyte abnormalities
Unlike many other gastrointestinal infections, illness may relapse and persist for a month or longer without treatment.
Person-to-person transmission is not expected because the organism must mature in the environment before becoming infectious.
When Should Hospitalists Suspect It?
Think about cyclosporiasis when a patient has:
- Prolonged or relapsing diarrhea
- Recent consumption of uncooked produce
- Restaurant or grocery-store exposures
- Symptoms lasting longer than expected for viral gastroenteritis
- Hypovolemia, AKI, or hyponatremia associated with ongoing diarrhea
The incubation period may be 7–14 days, so the food history needs to extend well beyond the last meal.
Ask about:
- Fresh produce and salads
- Restaurants and shared meals
- Grocery stores and product brands
- Travel
- Well water
- Whether anyone else who shared the meal became ill
Document those details. They may become important during a public-health investigation.
How Should We Test?
For patients admitted with acute or prolonged gastrointestinal symptoms:
- Order and collect a GI multiplex PCR early, ideally at admission.
- Do not wait until the patient has been hospitalized for several days.
- Interpret results in the context of the clinical syndrome because false positives can occur.
Avoid reflexively ordering a traditional stool ova and parasite examination. It is labor-intensive, low yield, and may miss Cyclospora unless special testing is performed.
A positive result that does not fit the clinical picture should prompt discussion with microbiology or infectious disease rather than automatic treatment.
How Is It Treated?
For an immunocompetent adult with clinically convincing cyclosporiasis:
Trimethoprim-sulfamethoxazole double strength twice daily for 7–10 days
Treatment usually shortens what can otherwise become a prolonged and miserable illness.
Consult infectious disease when the patient:
- Has a serious sulfa allergy
- Is significantly immunocompromised
- Has severe, relapsing, or complicated illness
- Has testing that conflicts with the clinical picture
There is currently no clearly proven, equally effective alternative for patients with a serious sulfa allergy.
Isolation and Reporting
Cyclospora does not require special isolation beyond standard precautions once the diagnosis is known.
However, patients presenting with undifferentiated vomiting or diarrhea should initially be approached with appropriate gown and glove precautions because norovirus and other highly contagious infections remain much more common.
Laboratories generally report confirmed cases to public-health authorities. Clinicians should also consider contacting their health department when a detailed food history suggests a specific restaurant, product, or shared exposure.
Practice-Changing Takeaways
- Take a real food history—and go back up to two weeks.
- Order GI PCR early in the hospitalization when clinically appropriate.
- Stop reflexively ordering stool ova and parasite examinations.
- Treat convincing cyclosporiasis with TMP-SMX.
- Recognize that a positive multiplex PCR does not override a clinical picture that does not fit.
- Call microbiology or ID when the diagnosis or treatment is uncertain.
Bottom Line
The Cyclospora outbreak does not require a completely new approach.
It should sharpen the approach hospitalists already use for gastrointestinal illness:
Ask earlier. Test earlier. Interpret thoughtfully. Treat the patient in front of you.
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