Joey Wahler, MD (Host): You want to prevent an outbreak affecting your children. So, we're discussing cyclosporiasis. Our guest is Dr. Carla Garcia Carreno. She's Medical Director for Infection Prevention and Control at Children's Medical Center Plano. This is Children's Health Checkup, where we answer parents' most common questions about raising healthy and happy kids. Thanks so much for joining us. I'm Joey Wahler. Hi there, Doctor. Welcome.

Carla Garcia Carreno, MD: Thank you, Joey. Thank you for having me. Good afternoon.

Host: Good afternoon. Great to have you aboard. So first, what exactly in a nutshell is cyclosporiasis? And why should parents be aware of this infection?

Carla Garcia Carreno, MD: Yeah. Thank you for the question. Cyclosporiasis is the disease caused by a parasite called Cyclospora cayetanensis. This is a microscopic parasite of the type of a protozoa, like an amoeba. So, it's really microscopic. You couldn't see it with your naked eye. It can contaminate water and food products, particularly fresh produce like fruits and vegetables.

In recent years, we have seen in the US a presentation of cases from May to August. And in general, parents should be aware of any GI bugs, right? That they can make their children sick and their families sick. But particularly this year, we are seeing higher than normal number of cases of cyclosporiasis compared to prior years. So, that's why parents need to be aware of this infection at this moment.

Host: So, let me ask you about this. You mentioned how children are typically infected, this getting into produce, fruits, vegetables, et cetera. So, what's going on since you mentioned that it's higher than usual that's causing that increase?

Carla Garcia Carreno, MD: Well, the investigation is ongoing, right? So, children can get cyclospora by, as you say, eating contaminated food or drinking contaminated water. In previous years, cyclospora has been associated with food items like cilantro and basil, raspberries, lettuce, and sugar snap peas. For the current outbreak, again, as we said, the investigation is ongoing, but there is a potential link with iceberg lettuce, particularly the shredded iceberg lettuce, which a recall has been given by the FDA in nine states already. Possibly some prepackaged salads as well, but there is still investigation ongoing. And these different outbreaks in the different parts of the United States may not be related completely. There are certain states where we are seeing higher than the number of cases that we're seeing in other states, like particularly Ohio and Michigan. Here in Texas, we're part of the states that have been reporting cases.

But the limitation for this investigation is that after eating contaminated products, symptoms may take from two days to two weeks to appear. So, this is challenging when you are trying for somebody that is sick to recall what they ate two weeks ago.

Host: And speaking of symptoms, which one should parents look for if their child possibly has cyclosporiasis, and how can that differ from other common stomach illnesses? How do you know it's not something else?

Carla Garcia Carreno, MD: Yeah. So as there are an overlap of these symptoms, right? Like, all the GI illnesses are going to present with vomiting, diarrhea, abdominal pain or cramps. However, there are certain aspects that can point towards cyclospora. if your child has a diarrhea that is persistent in time, that may be cyclosporiasis.

It's usually a watery diarrhea, so you're not going to see blood or mucus in the stools. Also, cyclospora can give you severe abdominal bloating, a lot of gas, cramps, nausea, vomiting. You can have low-grade fever, decreased appetite, weight loss and fatigue spells because you're not absorbing all your nutrients well. So, it's prolonged in time. So, you can have these weight gain issues.

A particularly distinguishing factor is that albeit the illness can be self-limited, some people with cyclosporiasis will have recurring bouts of intermittent diarrhea lasting for weeks to months, specifically if they don't get treatment. So, that's another important difference with other GI bugs, that it can prolong and persist in time.

Host: Well, you led me beautifully at the end there, Doctor, into my next question, namely, when should parents contact their child's pediatrician and seek medical care for possible symptoms? Where do you know that line to be?

Carla Garcia Carreno, MD: Excellent question. And this is what parents really need to be careful with. If you or your family or your child has persistent diarrhea lasting more than, let's say two, three days, talk to your primary care provider because you may discuss testing and these patients may qualify for treatment.

Additionally, if your child has severe symptoms, for example, diarrhea that is profuse in a small infant or toddler overflowing the diaper. If your child is unable to tolerate oral intake, hence they cannot keep themself hydrated and they may become dehydrated, those are signs to seek immediate medical care. Also, seek immediate care if there is any signs of dehydration, and these include decreased urine output, which in the infants and young childrens may have decreased number of wet diapers, a sunken spot, the soft spot in the infants, if they're crying without tears, if they have dry or pasty oral secretions, or in severe cases, altered mental status. So, these signs of dehydration, you need to seek medical care immediately.

People at risk for severe disease will include those people with a compromised immune system, older adults older than 65 years of age, and pregnant women. So if you are in any of these high-risk conditions, you need special attention and evaluation as early as possible.

Host: So once a professional is seen, how is cylcosporiasis diagnosed and what can parents expect during that evaluation process?

Carla Garcia Carreno, MD: Yeah. Cyclospora is diagnosed via stool testing. It's really important to know that a regular or a routine stool evaluation for cyclospora may miss the parasite. So, there needs to be a request to identify cyclospora, provided by the ordering physician to the laboratory because there are special stainings that need to be performed.

So, ruling out cyclospora with a negative test requires careful interpretation because it may be a false negative. There are also molecular testing available, DNA testing, and these are usually more sensitive to identify cyclospora.

Host: How about treatment? What treatments are available for children, and how quickly do they typically work and enable kids to recover?

Carla Garcia Carreno, MD: Yeah. Some individuals with cyclospora may qualify for antibiotic therapy. And it's a prescription antibiotic. And usually, the treatment is given for seven to 10 days. However, the treatment may be longer in immunocompromised individuals. But ideally, by the end of the treatment course, the symptoms should be better, and especially what we want to prevent is that intermittent bouts of diarrhea that may happen afterwards.

Host: How about the most important steps parents can take to prevent cyclosporiasis and protect their children? You mentioned some of the things to look for, some of the things that can happen. How about just trying to avoid it altogether? I would imagine you can't do it totally, but you can try to increase your odds, so to speak here, right?

Carla Garcia Carreno, MD: Yeah. So at this time, Joey, the most important thing is to listen to the local news and the notifications from the health department and the Center for Disease Control and Prevention, the CDC, regarding the updates in the ongoing investigation. So as we mentioned, a potential link with iceberg lettuce, particularly shredded iceberg lettuce may have been identified.

So, it's really important to see what products need to be avoided in the meantime. Until further notice, it may be prudent to avoid them. So, make sure that if you live in a state where there has been a recall, especially if you or your family are high-risk conditions for a severe disease, stay away from those items.

But there are a few other things that you may also practice in order to prevent. So, wash your hands with soap and water, particularly before and after preparing meals and after diaper change. It's really important to know that there is no documented person-to-person transmission of this parasite because this parasite is secreted in the stool and needs to have some time in the environment to sporulate and become infectious. That's why it takes that long to become sick. But still, washing hands is really important to prevent other GI bugs and decrease the risk for cyclospora.

Second thing to do for parents is cook fruits and vegetables thoroughly, ideally to reach an internal temperature of 158 degrees Fahrenheit. High heat inactivates the parasite. Next, wash fruits and vegetables with running water, and solid fruits and vegetables with soap as well. Even though this technique may not eliminate the parasite completely, it's still helpful to reduce the risk. If you decide to provide uncooked vegetables or fruits, stick with fruits that can be washed, and can be peeled.

Stay away from berries that can have crevices because the parasite can hide on these crevices. So, taking the outer part of the fruits and the vegetables is another measure that you can take to prevent this. And lastly, eating at home would be preferable because you know how you're preparing your products.

Host: I should point out, by the way, Doc, that while I'm not a child, obviously, I do love my iceberg lettuce. I think I'm one of the relatively few that still prefers it over romaine. So, just my luck, right?

Carla Garcia Carreno, MD: Yeah. For the meantime, maybe stick with romaine. Wash it very well until this outbreak is over.

Host: Indeed, I think if anything were going to get me to finally change, this would be it, right?

Carla Garcia Carreno, MD: That's correct. But again, I think you brought a very important point, Joey. And this will not be an excuse for the kids to stop eating fruits and vegetables. It's still very important to eat the fiber, the vitamins and all the advantages that we have for a healthy and balanced nutrition. What we need to do is modify our habits right now, but still stick with cooked fruits and vegetables, washed and peeled.

Host: Great point indeed, Doctor. Don't let your kid try and tell you, "Bu mom, dad, there's that outbreak. I can't eat this." Don't fall for that, right?

Carla Garcia Carreno, MD: Correct.

Host: Well, folks, we trust you are now more familiar with cyclosporiasis. Doctor, valuable information indeed. Thanks so much again.

Carla Garcia Carreno, MD: Thank you for having me.

Host: And a reminder, if you're in North Texas and have questions about your child's health, Children's Health Pediatric Primary Care offers trusted care close to home, from routine checkups and preventative care to evaluation and treatment for illnesses like cylcosporiasis and a whole lot more. Find a location near you at childrens.com/primarycare. Now, if you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks so much again for being part of Children's Health Checkup.