Microsporidial Infection and Associated Risk Factors Among Pediatric Renal Patients

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Al-azazi, Mostafa A. El hoda, Mahmoud M. El-kersh, Mona M. Tolba, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7789598/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Microsporidia are intracellular parasites with a worldwide distribution, known to opportunistically infect immunocompromised individuals. This study aimed to investigate microsporidial infection and associated risk factors among pediatric renal patients. Methods : A total of 90 children were included in the study: 30 with chronic kidney disease (CKD), 30 undergoing hemodialysis (HD), and 30 apparently healthy children. Enzyme-linked immunosorbent assay was used for serologic detection of anti-microsporidia antibodies. Modified trichrome staining (MTS) was applied for the detection of microsporidia spores in urine and stool samples. PCR was used to detect microsporidia DNA in blood samples. The Association of infection with different variables was evaluated using univariate and multivariate statistical analysis. Results : Anti-microsporidia antibodies were detected in 46.7% of participants, with a significantly higher seropositivity among HD (83.3%) compared to CKD patients (36.7%) and the control group (36.7%) (p < 0.0001). The duration of dialysis was significantly longer in seropositive patients (p < 0.001). Fecal spores were detected in 42.2% of children with no statistically significant difference between groups. A fair agreement was observed between serological and stool-based diagnostic methods. Examination of urine samples and PCR on blood samples yielded negative results. The child’s gender, place of residence, source of drinking water, and animal contact were identified as independent risk factors for microsporidial infection. Conclusion : Microsporidial infection is highly prevalent in the study population. HD and several demographic and environmental factors favor its spread. These findings highlight the need for further epidemiological studies to support preventive strategies. Given the diagnostic complexity, a combination of complementary methods is recommended to ensure accurate detection. Health sciences/Diseases Health sciences/Medical research Biological sciences/Microbiology Health sciences/Nephrology microsporidia hemodialysis kidney antibodies PCR modified trichrome Figures Figure 1 Figure 2 Introduction Microsporidia are intracellular organisms that produce spores and are found in multiple species of both vertebrates and invertebrates. There are at least 1,700 species of microsporidia, organized into about 220 genera[ 1 ]. Spores represent the infectious stage of the microsporidia life cycle and are released in large quantities into the environment, mainly via feces[ 2 ]. Consequently, spores that spread widely might be transmitted through contaminated food/water or via airborne inhalation[ 3 , 4 ]. In humans, clinical manifestations associated with microsporidial infection vary considerably depending on the host's immune status[ 5 ]. In immunocompetent individuals, infections are typically mild, self-limiting[ 6 ]. However, in immunosuppressed patients, as well as in the elderly, children, and malnourished individuals, these infections can lead to severe illness i.e: systemic disease affecting the gastrointestinal tract, eyes, lungs, kidneys, and muscles[ 7 ]. Recognition of microsporidia as emerging opportunistic pathogens linked to life-threatening infections has grown significantly with the rising number of AIDS and other immunosuppressive conditions [ 8 ]. Although many microsporidia species exist, only a few have been identified as human pathogens. The most frequently identified species are Enterocytozoon bieneusi and Encephalitozoon species such as E. intestinalis, E. cuniculi , and E. hellem. E. bieneusi is predominantly localized in the upper digestive tract and often causes persistent diarrhea and weight loss, although it has also been detected in respiratory samples[ 9 ]. E. intestinalis is the second most common species known to infect humans and primarily affects the gastrointestinal system[ 10 ]. E. hellem and E. cuniculi cause widespread infections involving the ocular, urogenital, and respiratory systems, with occasional detection in stool samples, indicating enteric involvement[ 9 , 11 ]. In immunocompromised hosts, disseminated microsporidiosis may lead to serious complications such as pneumonia, fever, hepatitis, and cholangitis, with documented spread to ocular, respiratory, urinary tracts, and the central nervous system. Disseminated microsporidiosis is potentially fatal and presents with nonspecific symptoms[ 12 , 13 ]. Diagnosis of microsporidial infection typically involves identifying the organism in stool samples, body fluids, or biopsies, depending on the organ involved. Numerous stains, such as MTS and Calcofluor white stain, are traditionally used for light microscopic detection of the spores. Transmission electron microscopy is mainly used for confirmation and species identification, but it is time-consuming, expensive, and impractical for routine diagnosis[ 5 ]. Polymerase chain reaction (PCR) has become a widely used and preferred method for initial diagnosis and species determination. Serologic testing for specific anti-microsporidia antibodies can provide information about the prevalence of infection in humans. However, it is not a definitive diagnostic tool due to potential cross-reactivity and persistence of antibodies after infection [ 6 ]. Chronic kidney disease (CKD) denotes functional or structural kidney damage lasting more than three months and leading to adverse health consequences[ 7 ]. Treatment of CKD aims to slow disease progression, but once end-stage renal disease develops, replacement therapy by hemodialysis (HD) or kidney transplantation becomes necessary [ 14 ]. In patients with renal disease, immune dysfunction associated with declining kidney function increases susceptibility to recurrent infections, which increase disease burden and mortality in this population[ 15 ]. The present study aimed to investigate the prevalence of microsporidial infection and its associated risk factors in pediatric renal patients in Egypt. Materials and Methods Study subjects A total of 90 children admitted to Alexandria University Children’s Hospital, Egypt, participated in the present study, including 30 children undergoing HD, 30 with CKD but not on dialysis, and 30 apparently healthy children as a control group. The age of the participating children ranged from five to 14 years, and both males and females were included. HD patients received three dialysis sessions per week and had been on maintenance dialysis for durations ranging from three to twelve months. Subjects with a history of anti-parasitic drug intake within the two weeks preceding the study were excluded. The parents or legal guardians of all participating children provided written informed consent before enrollment in the study. Ethical approval was obtained from the Research Ethics Committee at the Medical Research Institute, Alexandria University, Egypt. Demographic data and clinical history, as well as information on exposure to potential risk factors for microsporidial infection, were recorded for all participants. Since the eligible pediatric hemodialysis and CKD populations are generally small, we enrolled 30 children per group. Assuming an expected prevalence of 50%, a group size of 30 gives a 95% confidence interval of approximately 18% for each group and an overall estimate from all 90 participants gives about 10% precision. Parasitological examination: Fresh urine and stool samples were collected from all participants and examined microscopically for the presence of microsporidia spores using MTS (Kokoskin hot method). Smears prepared from fecal samples and the sediment of centrifuged urine samples were stained in duplicate, followed by microscopic examination under oil immersion lenses at high magnification (×1000). The stained fecal smears were examined by two experts in a blinded manner. Microsporidia spores were identified based on the presence of specific morphological features, including pink-red ovoid refractile structures measuring 1–2 µm with a belt-like stripe near one end and a vacuole at the opposite end, observed in a relatively pale pink background[ 16 ]. Serological examination: Blood samples were collected from all participants, sera were separated and examined for the presence of anti-microsporidia antibodies using a commercially available ELISA kit, Chongqing Biospes Co., Ltd., China (catalog #: BZEK1341). Molecular detection Anti-coagulated blood samples collected on ethylene-diamine tetra-acetic acid (EDTA) were stored at -20 ̊C for molecular analysis. DNA extraction was performed using the QIAamp DNA Mini kit (Qiagen, Canada; catalogue no. 51104), according to the manufacturer’s instructions. DNA amplification was carried out using a pan-specific primer pair targeting a conserved region of the SSU rRNA gene shared by E. bieneusi, E. intestinalis , E. hellem , and E. cuniculi; C1:5′CACCAGGTTGATTCTGCC3′ as the forward primer and C2: 5′GTGACGGGCGGTGTGTAC3′ as the reverse primer [17] . The PCR was performed using denaturation of the DNA at 94°C for 5 min, 35 cycles consisting of 94°C for 1min, 55°C for 40 s, and 72°C for 1.5 min, and finally, a 5-min 72°C extension. PCR products were subjected to agarose gel electrophoresis. The resulting bands were visualized using UV light. Both a positive control and a negative control reaction (without template DNA) were included. PCR product sizes were estimated based on comparison with a 3000-bp DNA ladder." Statistical analysis Data were analyzed using RStudio (version 2022.02.0 + 443). Categorical variables were tested using the Chi-square test. The degree of agreement between diagnostic tests was evaluated based on Cohen’s Kappa agreement test. The degree of agreement was interpreted based on kappa statistics, according to the following criteria: < 0.2, slight agreement; 0.2 - < 0.4, fair agreement; 0.4 - < 0.6, moderate agreement; 0.6 - < 0.8, substantial agreement; ≥0.8, almost perfect agreement. The normality of numerical variables was tested by the Shapiro-Wilk test. For non-normally distributed continuous data, the Wilcoxon rank sum test was used to compare two groups. Univariate analysis was used to identify variables associated with microsporidial infection among the participating children. Odds ratio (OR) and 95% confidence interval (CI) were presented to show the odds of an event in one group compared to the odds in another group. Multivariate logistic regression analysis was used to adjust for confounders by calculating the adjusted ORs. The multivariate model included all variables that were significant in the univariate analysis. Factors that remained significant were identified as independent risk factors or predictors of infection[ 18 ]. RESULTS Microsporidial infection in the studied groups Among the 90 participants, the spores of microsporidia (Fig. 1 ) were detected in stool samples using MTS in 17 of 30 HD patients (56.7%), 12 of 30 CKD patients (40%), and 9 of 30 children in the control group (30%). However, the differences between groups were not statistically significant. In contrast, the seropositivity rate was significantly higher in HD patients (25 of 30; 83.3%) compared to both CKD patients (11 of 30; 36.7%) and controls (6 of 30; 20%) (p values < 0.0001). Microscopic examination of urine samples and PCR analysis of blood samples (Fig. 2) were negative for all participants (Table 1 ). Analysis of agreement between spore detection in stool samples and serologic detection of antibodies by ELISA revealed that 25 out of the 90 examined cases had concordant positive results, while 35 cases were concordantly negative. Statistically, there was fair agreement between the two tests (Kappa index = 0.32) (Table 2 ). Table 1 Microsporidial infection in the studied groups as diagnosed by MTS for stool spores and ELISA for specific serum antibodies Detection methods Controls (n = 30) HD (n = 30) CKD (n = 30) Total (n = 90) P MTS for stool spores 9 (30.0) 17 (56.7) 12 (40.0) 38 (42.2) 0.1073 ELISA for serum IgG antibodies 6 (20.0) 25 (83.3) 11 (36.7) 42 (46.7) < 0.00001* P1 < 0.0001* 0.2518 P2 < 0.0001* The data shown are the number (and percentage) of positive cases, P for the Chi-square test P1: pairwise comparison of HD and CKD compared to controls, P2: pairwise comparison between HD and CKD MTS: modified trichrome stain, ELISA: enzyme-linked immunosorbent assay. PCR: polymerase chain reaction. HD: hemodialysis patients, CKD: chronic kidney disease patients, IgG: immunoglobulin G Table 2 Agreement between MTS and ELISA for the detection of microsporidial infection Microscopic detection in stool Antibody detection in serum Positive Negative Total Positive 25 17 42 Negative 13 35 48 Total 38 52 90 Kappa 0.3263 Degree of agreement Fair agreement ELISA: enzyme-linked immunosorbent assay Factors associated with microsporidial infection Regarding the time since initiation of dialysis in the HD group, microsporidia-seropositive children had been on dialysis for a significantly longer period (median: 12 months; IQR: 8–12) compared to seronegative children (median: 4 months; IQR: 3–4.0; p < 0.001). In contrast, there was no significant association between the duration of dialysis and detection of the microsporidia spores by MTS in stool samples (Table 3 ). Table 3 Relation between the duration of dialysis and microsporidial infection among renal dialysis patients (n = 30) as diagnosed by MTS and ELISA. Diagnostic method No. of Patients Dialysis duration in months median (IQR) W p-value MTS for spore detection Negative 13 9.0 (5.0 to 9.0) 69.5 0.0812 Positive 17 12.0 (8.0 to 12.0) ELISA for antibodies Negative 5 4.0 (3.0 to 4.0) 0 < 0.001* Positive 25 12.0 (8.0 to 12.0) Data are presented as median (IQR: interquartile range), W, and p-values obtained by the Wilcoxon rank sum test with continuity correction. * Statistically significant. The association between microscopic detection of microsporidia spores in stool samples and different clinical and environmental variables among the study participants (n = 90) is shown in Table 4. Univariate analysis showed that the risk of microsporidial infection was significantly higher in the HD compared to the control group (OR = 3.05; 95% 1.08–9.15; p = 0.040) and among males compared to females (OR = 2.84; 95% CI: 1.21–6.92; p = 0.019). Also, tap water consumption increased the risk of microsporidial infection compared to filtered water (OR = 3.34; 95% CI:1.21–9.94; p = 0.023). Subjects reporting animal contact had a higher risk (OR = 5.48;95% 95% CI:1.86–8.66; p = 0.003. Urban residents had lower risk of infection compared to rural residents (OR = 0.22; 95% CI: 0.09–0.54; p = 0.001) Symptoms that were significantly associated with microsporidial infection in the studied groups were diarrhea (OR = 8.93, 95% CI: 2.16–0.82; p = 0.007) and colic (OR = 10.19; 95% CI: 2.51-.99; P = 0.004). Among these factors, multivariate analysis confirmed that gender (adjusted OR 3.74; 95% CI: 1.24–12.70, P = 0.024), area of residence (adjusted OR 0.32; 95% CI: 0.11–0.93; p = 0.039) and the source of drinking water ( adjusted OR 3.79; 95% CI: 1.10-13.88; p = 0.037) were independently associated with spore detection. The association between serologic detection of anti-microsporidia antibodies and different clinical and environmental variables among the study participants is shown in Table 5. In the univariate analysis, HD (OR = 20.00; 95% CI: 5.83–82.70; p < 0.001) and animal contact (OR = 4.30; 95% 1.47–14.54; p = 0.011) had a significant association with microsporidia seropositivity rates. In the multivariate analysis, both variables were independently associated with detection of anti-microsporidia antibodies among the study participants: HD (adjusted OR = 51.89; 95% CI:10.30-384.78; P < 0.001); and animal contact (adjusted OR = 25.68; 95% CI = 3.93-283.59; P = 0.002). Table (4): Univariate and multivariate analysis of factors associated with the presence of microsporidia spores in stool samples of the study participants (n = 90) Variables Negative MTS Positive MTS Univariate Multivariate NO. (%) NO. (%) OR (95% CI) p Adjusted OR (95% CI) p Group Control 21 (70.0) 9 (30.0) - - HD 13 (43.3) 17 (56.7) 3.05 (1.08–9.15) 0.040 3.34 (0.87–14.30) 0.088 CKD 18 (60.0) 12 (40.0) 1.56 (0.54–4.63) 0.418 0.59 (0.12–2.63) 0.489 Age in years < 6 28 (60.9) 18 (39.1) - 0.544 - 0.829 ≥ 6 24 (54.5) 20 (45.5) 1.30 (0.56–3.02) 1.12 (0.39–3.23) Gender Female 31 (70.5) 13 (29.5) - 0.019 - 0.024 Male 21 (45.7) 25 (54.3) 2.84 (1.21–6.92) 3.74 (1.24–12.70) Area of residence Rural 20 (41.7) 28 (58.3) - 0.001 - 0.039 Urban 32 (76.2) 10 (23.8) 0.22(0.09–0.54) 0.32 (0.11–0.93) Source of Water Filter 45 (64.3) 25 (35.7) - 0.023 - 0.037 Tap 7 (35.0) 13 (65.0) 3.34 (1.21–9.94) 3.79 (1.10-13.88) Animal contact No 47 (66.2) 24 (33.8) - 0.003 - 0.644 Yes 5 (26.3) 14 (73.7) 5.48 (1.86–8.66) 1.43 (0.30–6.76) Diarrhea No 50 (64.1) 28 (35.9) - 0.007 - 0.095 Yes 2 (16.7) 10 (83.3) 8.93 (2.16–60.82) 5.58 (0.87–56.01) Colic No 50 (64.9) 27 (35.1) - 0.004 - 0.105 Yes 2 (15.4) 11 (84.6) 10.19 (2.51–68.99) 5.27 (0.78–50.34) Fever No 48 (59.3) 33 (40.7) - 0.398 - 0.916 Yes 4 (44.4) 5(55.6) 1.82 (0.45–7.83) 0.91 (0.14–5.77) OR: odds ratio, CI: confidence interval. Bold p-values are statistically significant at p < 0.05 Table (5): Univariate and multivariate analysis of factors associated with the presence of anti-microsporidia antibodies in serum samples of the study subjects (n = 90) Variable ELISA negative Negative ELISA positive Univariate Multivariate No. (%) No. (%) OR (95% CI) p Adjusted OR (95% CI) p Study Group Control 24 (80.0) 6 (20.0) - - HD 5 (16.7) 25 (83.3) 20.0 (5.83–82.70) < 0.001 51.89 (10.30- 384.78) 0.001 CKD 19 (63.3) 11(36.7) 2.32 (0.74–7.81) 0.157 4.09 (0.86–25.68) 0.094 Age in years < 6 26 (56.5) 20 (43.5) - 0.536 - 0.440 ≥ 6 22 (50.0) 22 (50.0) 1.30 (0.57-3.00) 1.60 (0.49–5.55) Gender Female 26 (59.1) 18 (40.9) - 0.285 - 0.467 Male 22 (47.8) 24 (52.2) 1.58 (0.69–3.67) 1.60 (0.46–6.06) Area of residence Rural 21 (43.8) 27 (56.2) - 0.053 - 0.786 Urban 27 (64.3) 15 (35.7) 0.43 (0.18-1.00) 0.85 (0.25–2.90) Source of Water Filter 40 (57.1) 30 (42.9) - 0.180 - 0.661 Tap 8 (40.0) 12 (60.0) 2.00 (0.74–5.69) 1.38 (0.33–6.13 Animal contact No 4 (60.6) 28 (39.4) - 0.011 - 0.002 Yes 5 (26.3) 14 (73.7) 4.30 (1.47–14.54) 25.68 (3.93-283.59) Diarrhea No 42 (53.8) 36 (46.2) - 0.804 - 0.236 Yes 6 (50.0) 6 (50.0) 1.17 (0.34–4.04) 0.28 (0.03–2.11) Colic No 42 (54.5) 35 (45.5) - 0.576 - 0.629 Yes 6 (46.2) 7 (53.8) 1.40 (0.43–4.72) 0.59 (0.06–5.13) Fever No 45 (55.6) 36 (44.4) - 0.217 - 0.165 Yes 3 (33.3) 6 (66.7) 2.50 (0.61–12.50) .34 (0.60–41.40) OR: odds ratio, CI: confidence interval. Bold p-values are statistically significant at p < 0.05 Discussion Microsporidiosis represents a global opportunistic infection affecting mainly HIV-positive and other immunosuppressed patients. Although they were previously considered nonpathogenic, microsporidia have now gained great importance as causative agents of emerging infections[ 19 ]. The present study revealed that HD patients had a significantly higher seropositive rate for anti-microsporidia IgG antibodies compared to CKD patients and the control group Moreover, the duration of dialysis was significantly longer in seropositive than in seronegative patients These results are in line with research conducted in the Czech Republic as anti-microsporidia antibodies were significantly elevated in patients with chronic pyelonephritis which is considered an end stage renal disease requiring hemodialysis [ 20 ]. A previous research carried out in China and the Netherlands among healthy individuals revealed that 9.76% and 8% respectively, were seropositive for anti-microsporidia antibodies using the ELISA technique [ 21 , 22 ]. Seropositivity is indicative of latent or chronic microsporidial infections that may persist after infection. Parasitological examination of fecal samples of participants revealed the presence of microsporidia spores at relatively high rates across all study groups (30–56%) with non-significant differences between them as confirmed by the multivariate analysis. Similarly, high prevalence rates were reported by Elsayad et al. (2020), who identified microsporidia spores in 48% of HD patients and 62% of CKD patients. However, they found no spores in the healthy controls [ 23 ]. Also, Abd-Elbaki et al.(2020) found microsporidiosis in 55.6% of immunocompromised Egyptian patients compared to 44.4% in immunocompetent patients [ 24 ]. A study conducted in South Africa documented that 52.6% of HIV positive patients under 10 years of age had microsporidia spores in their stool samples, detected using the MTS technique [ 25 ]. However, a higher infection rate was reported by Nkinin et al. (2007) [ 26 ]. PCR technique failed to detect any positive cases, even among seropositive individuals and those with detectable fecal spores. This explanation is supported by the negative microscopic examination of urine samples using MTS smears. A study on molecular detection of microsporidiosis in whole blood and stool samples of immunocompromised Iranian patients found that among 70 blood samples, only four (5.7%) were positive for Encephalitozoon sp., while among 70 stool samples, only one (1.43%) was positive for Enterocytozoon sp. [ 27 ]. Molecular methods for detecting microsporidiosis face certain limitations, particularly in DNA extraction from spores, which is technically challenging due to the rigid double-layered spore wall that is difficult to lyse. Thus, the PCR results are significantly influenced by the efficiency of the DNA extraction method. It is worth mentioning that false negative results may occur when the number of spores is below the PCR detection threshold [ 28 ]. The absence of microsporidia spores in urine samples using the MTS technique. is consistent with previous reports from Spain[ 29 , 30 ], Portugal[ 31 ], and Egypt [ 32 , 33 ]. Comparing the results of MTS and ELISA techniques demonstrated a fair level of agreement in diagnosing microsporidiosis. Although concordant positive and negative cases were observed, each method also detected cases missed by the other. This can be attributed to several factors. The small size of microsporidia spores and their remarkable similarity to some bacteria and other fungal spores could be a possible explanation for the cases not detected by microscopy. The discrepancy might also be the result of the poor sensitivity of light microscopy, estimated at approximately 10 5 spores per gram of stool, which necessitates examining several stool samples before excluding microsporidial infection [ 9 , 34 ]. Another explanation is that in early or localized intestinal infections, spores may be present in stool before a systemic antibody response is elicited. Conversely, in cases of past or cleared infections, antibodies may persist even in the absence of detectable spores in stool samples. Additionally, in immunosuppressed individuals, the antibody response may be weak or absent, leading to false-negative serological results despite active infection[ 35 ]. Concerning risk factors for infection, a statistically significant association between gender and microsporidia spore detection in stool samples was observed after adjusting for potential confounders. Specifically, males had a significantly higher spore detection rate in stool samples than females (54.3% versus 29.5%). Several previous studies have also declared a significant association between gender and microsporidiosis [ 27 , 36 – 39 ]. This could be due to varying exposure to different risk factors and environmental conditions. On the other hand, age was not a significant risk factor for microsporidial infection in our study population, which is consistent with findings in Iranian, South African, Yemeni, Chinese, and Indian published research [ 40 ],[ 25 ],[ 39 , 41 , 42 ]. Regarding residence, the rates of microsporidia spore detection in stool samples were lower among children residing in urban communities compared to rural residents (23.8% vs 58.3%), and this was confirmed in the multivariate analysis. Parallel to the present study, a significant correlation between residing in slums or rural areas and intestinal microsporidiosis was identified in HIV-positive individuals from Zimbabwe and India [ 43 , 44 ]. In contrast to the present finding, a study conducted in a rural village and an urban town in north-central Nigeria reported prevalence rates of microsporidial infection of 39.6% and 47.3% among rural and urban dwellers, respectively, with a non-significant difference [ 45 ]. Another study carried out in Southeastern Iran reported the detection of microsporidia spores in 41 out of 418 individuals (9.8%), of whom 39% were from rural areas and 61% from urban areas [ 40 ]. Most of the study participants (77.8%) used filtered water as their source of drinking water. Nevertheless, drinking unfiltered water was identified as an independent risk factor for intestinal microsporidiosis in the study participants. The findings of Khanduja et al. (2017 are in line with the present results[ 38 ]. Factors that may enhance transmission of microsporidiosis through potable tap water include the small size of the microsporidia spores and their resistance to physical agents and disinfectants used in water purification. Other potential factors contributing to water contamination at home include the method of collecting water in containers and the frequency of cleaning these containers[ 46 ]. Animal contact was independently associated with a significantly high seroprevalence of anti-microsporidia antibodies among the study participants. In agreement with this finding, Abu-Akkada et al. (2015) reported that 76.9% of seropositive immunocompromised Egyptian individuals had a history of animal contact [ 33 ]. Consistent with our results, several studies have highlighted the zoonotic potential of specific microsporidia genotypes, such as E. bieneusi and E. cuniculi , which are known to infect domestic animals and can be transmitted to humans [ 24 , 25 , 47 – 49 ]. On the other hand, although the history of animal contact was associated with a five times higher risk of microsporidial infection diagnosed by the MTS technique, this association was not confirmed after adjusting for other variables. Several studies found that among immunocompromised individuals, the presence of household animals was not substantially related to intestinal microsporidiosis [ 38 , 39 , 50 , 51 ]. The pathogenicity of microsporidial infection has been one of the main controversial issues concerning this parasite. It is thought to cause gastrointestinal symptoms, including chronic diarrhea, particularly in immunocompromised patients [ 52 ]. In the present study, more than 10% of patients reported diarrhea and/or abdominal colic, with fever being a less common symptom. Although there was a statistically significant association between colic and diarrhea and the detection of spores in fecal samples, this association did not persist in the multivariate model after adjusting for other variables. In contrast, some studies reported the identification of microsporidia spores in the stool of patients who presented with gastrointestinal discomfort, diarrhea, and other symptoms such as colic and anorexia [ 53 – 56 ]. A positive correlation between the presence of microsporidia in fecal specimens and diarrhea was previously reported among immunocompromised patients in Egypt and South Africa [ 24 , 25 ]. However, other studies suggested that microsporidial infections may be asymptomatic even in immunocompromised patients[ 57 , 58 ]. A transient association between microsporidia detection in stool and gastrointestinal symptoms suggests that microsporidial infection may lead to clinical symptoms during the early stage of infection, which may resolve even though the microsporidia persist [ 55 ]. Shehata et al. (2019) found no association between parasitic infection and diarrhea among Egyptian HD patients[ 59 ]. It is noteworthy that gastrointestinal symptoms, including diarrhea, among chronic renal failure patients may be largely attributed to other factors such as elevated levels of uremic toxins, intake of medications, and psychosocial factors [ 60 ]. In conclusion, the results of this study revealed a higher frequency of microsporidial infection among children undergoing HD compared to a healthy control group. Considering that HD patients are immunocompromised, such a parasitic infection may further complicate their clinical condition. The duration of dialysis was found to increase susceptibility to microsporidial infection. Factors such as gender, place of residence, source of drinking water, and animal contact are identified as independent risk factors for microsporidial infection in children. These findings highlight the need for further epidemiological and experimental studies to collect more data that can help in developing effective preventive strategies against this infection. Owing to the complexity of diagnosing microsporidial infection, the use of complementary diagnostic techniques is essential to ensure accurate and reliable results. Abbreviations AIDS : Acquired Immune Deficiency Syndrome CKD : Chronic kidney disease CI : Confidence interval C : Control DNA : Deoxyribonucleic Acid E. bieneusi : Enterocytozoon bieneusi E. hellem : Encephalitozoon hellem E. intest ina lis : Encephalitozoon intestinalis E. cuniculi : Encephalitozoon cuniculi ELISA : enzyme-linked immunosorbent assay EDTA : ethylene-diamine tetra-acetic acid HD : Hemodialysis HIV : Human Immunodeficiency Virus IgG : Immunoglobulin G IQR : Interquartile range MTS : Modified trichrome staining NC : Negative control OR : Odds ratio PCR : Polymerase chain reaction PC : Positive control W : Wilcox test Declarations Ethical approval and consent to participate : The study protocol was reviewed and approved by the Ethics Committee of Medical Research institute (MRI), Alexandria University, Egypt ( IORG0008812 ). All procedures performed in studies involving human participants were under the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments. In addition, written informed consent was signed or thumb-printed by the parents of HD patients and apparently healthy individuals after explaining them the purpose of the study. Consent for publication Not applicable. Competing interests: The authors have no relevant financial or non-financial interests to disclose. Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Author Contribution MAE , [HAE](https:/www.tandfonline.com/author/El-Taweel%2C+Hend+A) , MME, MMT and AAA designed and put the conception of the article. AAA collected the data. [HAE](https:/www.tandfonline.com/author/El-Taweel%2C+Hend+A) and AAA wrote the original draft. MMT and AAA implemented the laboratory investigations and analyzed the results. All authors revised and approved the final version of the manuscript submitted to the journal. Acknowledgement The authors thank the staff members and patients for their cooperation and participation while conducting the study. Data Availability All data generated or analyzed during this study are included in this article. Data of this study are available from the corresponding author upon reasonable request. References Weiss, L. M. Microsporidiosis. Hunter's tropical medicine and emerging infectious diseases, : pp. 825–831. (2020). Karimi, K. et al. Molecular epidemiology of Enterocytozoon bieneusi and Encephalitozoon sp., among immunocompromised and immunocompetent subjects in Iran. Microb. Pathog. 141 , 103988 (2020). Didier, E. et al. Epidemiology of microsporidiosis: sources and modes of transmission. Vet. Parasitol. 126 (1–2), 145–166 (2004). Askari, Z. et al. 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K. et al. Enteric opportunistic parasites among HIV infected individuals: associated risk factors and immune status. Jpn. J. Infect. Dis. 60 (2/3), 76 (2007). Gumbo, T. et al. Intestinal parasites in patients with diarrhea and human immunodeficiency virus infection in Zimbabwe. Aids 13 (7), 819–821 (1999). Ikeh, E. et al. Intestinal parasitism in Magama Gumau rural village and Jos township in north central Nigeria. Niger. Postgrd. Med. J. 14 (4), 290–295 (2007). Izquierdo, F. et al. Detection of microsporidia in drinking water, wastewater and recreational rivers. Water Res. 45 (16), 4837–4843 (2011). Yu, F. et al. Molecular characterization of three intestinal protozoans in hospitalized children with different disease backgrounds in Zhengzhou, central China Vol. 12, p. 1–10 (Parasites & vectors, 2019). 1. Al-Sadi, H. I. & Al-Mahmood, S. S. Pathology of experimental Encephalitozoon cuniculi infection in immunocompetent and immunosuppressed mice in Iraq. Pathology Research International, 2014. (2014). Sharaf, M. A. et al. Prevalence of Parasitic Infections and Related Morbidity in Pediatric Patients on Regular Hemodialysis in Ain‎ Shams University Pediatric Hospital, Cairo, Egypt‎. Afro-Egyptian J. Infect. Endemic Dis. 11 (2), 134–145 (2021). Ubanwa, D. E. et al. Epidemiology of microsporidia infection among apparently healthy subject and immunocompromised patients in Minna. (2019). Rodríguez-Pérez, E. G. et al. Opportunistic intestinal parasites in immunocompromised patients from a tertiary hospital in Monterrey, Mexico. Infez Med. 27 (2), 168–174 (2019). Lono, A. R., Kumar, S. & Chye, T. T. Incidence of microsporidia in cancer patients. J. Gastrointest. cancer . 39 , 124–129 (2008). Tumwine, J. K. et al. Cryptosporidiosis and microsporidiosis in Ugandan children with persistent diarrhea with and without concurrent infection with the human immunodeficiency virus. Am. J. Trop. Med. Hyg. 73 (5), 921–925 (2005). Endeshaw, T. et al. Intestinal microsporidiosis in diarrheal patients infected with human immunodeficiency virus-1 in Addis Ababa, Ethiopia. Jpn. J. Infect. Dis. 59 (5), 306 (2006). Wichro, E. et al. Microsporidiosis in travel-associated chronic diarrhea in immune-competent patients. Am. J. Trop. Med. Hyg. 73 (2), 285–287 (2005). Ojuromi, O. T. et al. Identification and characterization of microsporidia from fecal samples of HIV-positive patients from Lagos, Nigeria. PLoS One . 7 (4), e35239 (2012). Rabeneck, L. et al. The role of microsporidia in the pathogenesis of HIV-related chronic diarrhea. Ann. Intern. Med. 119 (9), 895–899 (1993). Angela, R. & Suresh, K. Microsporidia in stool from cancer patients. J. Med. Sci. 1 (2), 88–90 (2007). Shehata, A. I., Hassanein, F. & Abdul-Ghani, R. Opportunistic parasitoses among Egyptian hemodialysis patients in relation to CD4 + T-cell counts: a comparative study. BMC Infect. Dis. 19 (1), 480 (2019). Dong, R. & Guo, Z. Y. Gastrointestinal symptoms in patients undergoing peritoneal dialysis: multivariate analysis of correlated factors. World J. Gastroenterology: WJG . 16 (22), 2812 (2010). Additional Declarations No competing interests reported. Supplementary Files STROBEchecklistcrosssectional.docx originalblotandimage.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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(1000×).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7789598/v1/245c47cdac2777aa03ad8eb6.png"},{"id":95226807,"identity":"9a543c10-98d0-42ea-b5dc-aea13064d5af","added_by":"auto","created_at":"2025-11-05 16:31:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":267441,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAnalysis of PCR products of human blood samples by 1.5% agarose gel electrophoresis. \u003c/strong\u003eA\u003cstrong\u003e \u003c/strong\u003e1200 bp DNA fragment of the microsporidia DNA gene was amplified using primers C1 and C2. Lane L (DNA marker ladder). Lane NC negative control, PC positive control. Lane 1, 2, 3, 4, 5, 6, and 7 negatives for microsporidia.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7789598/v1/112e4b7f58aab0606876b001.png"},{"id":102194316,"identity":"f69928a1-be1d-4286-b6c4-8f39d03e9380","added_by":"auto","created_at":"2026-02-09 09:43:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3396681,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7789598/v1/f336cc12-e490-4fd8-93de-e4101a166caf.pdf"},{"id":95227333,"identity":"5691f228-9704-4ca3-a2ff-a5c2d7213afe","added_by":"auto","created_at":"2025-11-05 16:32:24","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":32394,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEchecklistcrosssectional.docx","url":"https://assets-eu.researchsquare.com/files/rs-7789598/v1/41050b6aae7d4ec99e067f76.docx"},{"id":95171336,"identity":"debe903a-d37c-4c4e-a9b6-83bffd6d009a","added_by":"auto","created_at":"2025-11-05 06:32:03","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":134470,"visible":true,"origin":"","legend":"","description":"","filename":"originalblotandimage.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7789598/v1/59d4cf07e27bdba849c5db9b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Microsporidial Infection and Associated Risk Factors Among Pediatric Renal Patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMicrosporidia are intracellular organisms that produce spores and are found in multiple species of both vertebrates and invertebrates. There are at least 1,700 species of microsporidia, organized into about 220 genera[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Spores represent the infectious stage of the microsporidia life cycle and are released in large quantities into the environment, mainly via feces[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Consequently, spores that spread widely might be transmitted through contaminated food/water or via airborne inhalation[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn humans, clinical manifestations associated with microsporidial infection vary considerably depending on the host's immune status[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In immunocompetent individuals, infections are typically mild, self-limiting[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, in immunosuppressed patients, as well as in the elderly, children, and malnourished individuals, these infections can lead to severe illness i.e: systemic disease affecting the gastrointestinal tract, eyes, lungs, kidneys, and muscles[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Recognition of microsporidia as emerging opportunistic pathogens linked to life-threatening infections has grown significantly with the rising number of AIDS and other immunosuppressive conditions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough many microsporidia species exist, only a few have been identified as human pathogens. The most frequently identified species are \u003cem\u003eEnterocytozoon bieneusi\u003c/em\u003e and \u003cem\u003eEncephalitozoon\u003c/em\u003e species such as \u003cem\u003eE. intestinalis, E. cuniculi\u003c/em\u003e, and \u003cem\u003eE. hellem. E. bieneusi\u003c/em\u003e is predominantly localized in the upper digestive tract and often causes persistent diarrhea and weight loss, although it has also been detected in respiratory samples[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. \u003cem\u003eE. intestinalis\u003c/em\u003e is the second most common species known to infect humans and primarily affects the gastrointestinal system[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. \u003cem\u003eE. hellem\u003c/em\u003e and \u003cem\u003eE. cuniculi\u003c/em\u003e cause widespread infections involving the ocular, urogenital, and respiratory systems, with occasional detection in stool samples, indicating enteric involvement[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In immunocompromised hosts, disseminated microsporidiosis may lead to serious complications such as pneumonia, fever, hepatitis, and cholangitis, with documented spread to ocular, respiratory, urinary tracts, and the central nervous system. Disseminated microsporidiosis is potentially fatal and presents with nonspecific symptoms[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDiagnosis of microsporidial infection typically involves identifying the organism in stool samples, body fluids, or biopsies, depending on the organ involved. Numerous stains, such as MTS and Calcofluor white stain, are traditionally used for light microscopic detection of the spores. Transmission electron microscopy is mainly used for confirmation and species identification, but it is time-consuming, expensive, and impractical for routine diagnosis[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Polymerase chain reaction (PCR) has become a widely used and preferred method for initial diagnosis and species determination. Serologic testing for specific anti-microsporidia antibodies can provide information about the prevalence of infection in humans. However, it is not a definitive diagnostic tool due to potential cross-reactivity and persistence of antibodies after infection [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eChronic kidney disease (CKD) denotes functional or structural kidney damage lasting more than three months and leading to adverse health consequences[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Treatment of CKD aims to slow disease progression, but once end-stage renal disease develops, replacement therapy by hemodialysis (HD) or kidney transplantation becomes necessary [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In patients with renal disease, immune dysfunction associated with declining kidney function increases susceptibility to recurrent infections, which increase disease burden and mortality in this population[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe present study aimed to investigate the prevalence of microsporidial infection and its associated risk factors in pediatric renal patients in Egypt.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy subjects\u003c/h2\u003e\u003cp\u003e A total of 90 children admitted to Alexandria University Children\u0026rsquo;s Hospital, Egypt, participated in the present study, including 30 children undergoing HD, 30 with CKD but not on dialysis, and 30 apparently healthy children as a control group. The age of the participating children ranged from five to 14 years, and both males and females were included. HD patients received three dialysis sessions per week and had been on maintenance dialysis for durations ranging from three to twelve months. Subjects with a history of anti-parasitic drug intake within the two weeks preceding the study were excluded.\u003c/p\u003e\u003cp\u003e The parents or legal guardians of all participating children provided written informed consent before enrollment in the study. Ethical approval was obtained from the Research Ethics Committee at the Medical Research Institute, Alexandria University, Egypt. Demographic data and clinical history, as well as information on exposure to potential risk factors for microsporidial infection, were recorded for all participants.\u003c/p\u003e\u003cp\u003eSince the eligible pediatric hemodialysis and CKD populations are generally small, we enrolled 30 children per group. Assuming an expected prevalence of 50%, a group size of 30 gives a 95% confidence interval of approximately 18% for each group and an overall estimate from all 90 participants gives about 10% precision.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParasitological examination:\u003c/h3\u003e\n\u003cp\u003eFresh urine and stool samples were collected from all participants and examined microscopically for the presence of microsporidia spores using MTS (Kokoskin hot method). Smears prepared from fecal samples and the sediment of centrifuged urine samples were stained in duplicate, followed by microscopic examination under oil immersion lenses at high magnification (\u0026times;1000). The stained fecal smears were examined by two experts in a blinded manner. Microsporidia spores were identified based on the presence of specific morphological features, including pink-red ovoid refractile structures measuring 1\u0026ndash;2 \u0026micro;m with a belt-like stripe near one end and a vacuole at the opposite end, observed in a relatively pale pink background[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eSerological examination:\u003c/h3\u003e\n\u003cp\u003eBlood samples were collected from all participants, sera were separated and examined for the presence of anti-microsporidia antibodies using a commercially available ELISA kit, Chongqing Biospes Co., Ltd., China (catalog #: BZEK1341).\u003c/p\u003e\n\u003ch3\u003eMolecular detection\u003c/h3\u003e\n\u003cp\u003eAnti-coagulated blood samples collected on ethylene-diamine tetra-acetic acid (EDTA) were stored at -20 ̊C for molecular analysis. DNA extraction was performed using the QIAamp DNA Mini kit (Qiagen, Canada; catalogue no. 51104), according to the manufacturer\u0026rsquo;s instructions. DNA amplification was carried out using a pan-specific primer pair targeting a conserved region of the SSU rRNA gene shared by \u003cem\u003eE. bieneusi, E. intestinalis\u003c/em\u003e, \u003cem\u003eE. hellem\u003c/em\u003e, and \u003cem\u003eE. cuniculi;\u003c/em\u003e C1:5\u0026prime;CACCAGGTTGATTCTGCC3\u0026prime; as the forward primer and C2: 5\u0026prime;GTGACGGGCGGTGTGTAC3\u0026prime; as the reverse primer\u003cb\u003e[17]\u003c/b\u003e.\u003c/p\u003e\u003cp\u003eThe PCR was performed using denaturation of the DNA at 94\u0026deg;C for 5 min, 35 cycles consisting of 94\u0026deg;C for 1min, 55\u0026deg;C for 40 s, and 72\u0026deg;C for 1.5 min, and finally, a 5-min 72\u0026deg;C extension. PCR products were subjected to agarose gel electrophoresis. The resulting bands were visualized using UV light. Both a positive control and a negative control reaction (without template DNA) were included. PCR product sizes were estimated based on comparison with a 3000-bp DNA ladder.\"\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using RStudio (version 2022.02.0\u0026thinsp;+\u0026thinsp;443). Categorical variables were tested using the Chi-square test. The degree of agreement between diagnostic tests was evaluated based on Cohen\u0026rsquo;s Kappa agreement test. The degree of agreement was interpreted based on kappa statistics, according to the following criteria: \u0026lt; 0.2, slight agreement; 0.2 - \u0026lt; 0.4, fair agreement; 0.4 - \u0026lt; 0.6, moderate agreement; 0.6 - \u0026lt; 0.8, substantial agreement; \u0026ge;0.8, almost perfect agreement. The normality of numerical variables was tested by the Shapiro-Wilk test. For non-normally distributed continuous data, the Wilcoxon rank sum test was used to compare two groups.\u003c/p\u003e\u003cp\u003eUnivariate analysis was used to identify variables associated with microsporidial infection among the participating children. Odds ratio (OR) and 95% confidence interval (CI) were presented to show the odds of an event in one group compared to the odds in another group. Multivariate logistic regression analysis was used to adjust for confounders by calculating the adjusted ORs. The multivariate model included all variables that were significant in the univariate analysis. Factors that remained significant were identified as independent risk factors or predictors of infection[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eMicrosporidial infection in the studied groups\u003c/h2\u003e\u003cp\u003eAmong the 90 participants, the spores of microsporidia (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) were detected in stool samples using MTS in 17 of 30 HD patients (56.7%), 12 of 30 CKD patients (40%), and 9 of 30 children in the control group (30%). However, the differences between groups were not statistically significant. In contrast, the seropositivity rate was significantly higher in HD patients (25 of 30; 83.3%) compared to both CKD patients (11 of 30; 36.7%) and controls (6 of 30; 20%) (p values\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Microscopic examination of urine samples and PCR analysis of blood samples (Fig.\u0026nbsp;2) were negative for all participants (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAnalysis of agreement between spore detection in stool samples and serologic detection of antibodies by ELISA revealed that 25 out of the 90 examined cases had concordant positive results, while 35 cases were concordantly negative. Statistically, there was fair agreement between the two tests (Kappa index\u0026thinsp;=\u0026thinsp;0.32) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMicrosporidial infection in the studied groups as diagnosed by MTS for stool spores and ELISA for specific serum antibodies\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDetection methods\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControls (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHD\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCKD\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMTS for stool spores\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (30.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (56.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (40.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e38 (42.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.1073\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eELISA for serum IgG antibodies\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (20.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (83.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (36.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e42 (46.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.00001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.2518\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe data shown are the number (and percentage) of positive cases, P for the Chi-square test\u003c/p\u003e\u003cp\u003eP1: pairwise comparison of HD and CKD compared to controls, P2: pairwise comparison between HD and CKD\u003c/p\u003e\u003cp\u003eMTS: modified trichrome stain, ELISA: enzyme-linked immunosorbent assay. PCR: polymerase chain reaction. HD: hemodialysis patients, CKD: chronic kidney disease patients, IgG: immunoglobulin G\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAgreement between MTS and ELISA for the detection of microsporidial infection\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eMicroscopic detection in stool\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAntibody detection in serum\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePositive\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePositive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e90\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eKappa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e0.3263\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDegree of agreement\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003eFair agreement\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eELISA: enzyme-linked immunosorbent assay\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eFactors associated with microsporidial infection\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eRegarding the time since initiation of dialysis in the HD group, microsporidia-seropositive children had been on dialysis for a significantly longer period (median: 12 months; IQR: 8\u0026ndash;12) compared to seronegative children (median: 4 months; IQR: 3\u0026ndash;4.0; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In contrast, there was no significant association between the duration of dialysis and detection of the microsporidia spores by MTS in stool samples (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eRelation between the duration of dialysis and microsporidial infection among renal dialysis patients (n\u0026thinsp;=\u0026thinsp;30) as diagnosed by MTS and ELISA.\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eDiagnostic method\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo. of Patients\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDialysis duration\u003c/p\u003e\u003cp\u003ein months\u003c/p\u003e\u003cp\u003emedian (IQR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eW\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eMTS for spore detection\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.0 (5.0 to 9.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e69.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.0812\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.0 (8.0 to 12.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eELISA for antibodies\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.0 (3.0 to 4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.0 (8.0 to 12.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData are presented as median (IQR: interquartile range), W, and p-values obtained by the Wilcoxon rank sum test with continuity correction. \u003cb\u003e*\u003c/b\u003eStatistically significant.\u003c/p\u003e\u003cp\u003eThe association between microscopic detection of microsporidia spores in stool samples and different clinical and environmental variables among the study participants (n\u0026thinsp;=\u0026thinsp;90) is shown in Table\u0026nbsp;4. Univariate analysis showed that the risk of microsporidial infection was significantly higher in the HD compared to the control group (OR\u0026thinsp;=\u0026thinsp;3.05; 95% 1.08\u0026ndash;9.15; p\u0026thinsp;=\u0026thinsp;0.040) and among males compared to females (OR\u0026thinsp;=\u0026thinsp;2.84; 95% CI: 1.21\u0026ndash;6.92; p\u0026thinsp;=\u0026thinsp;0.019). Also, tap water consumption increased the risk of microsporidial infection compared to filtered water (OR\u0026thinsp;=\u0026thinsp;3.34; 95% CI:1.21\u0026ndash;9.94; p\u0026thinsp;=\u0026thinsp;0.023). Subjects reporting animal contact had a higher risk (OR\u0026thinsp;=\u0026thinsp;5.48;95% 95% CI:1.86\u0026ndash;8.66; p\u0026thinsp;=\u0026thinsp;0.003. Urban residents had lower risk of infection compared to rural residents (OR\u0026thinsp;=\u0026thinsp;0.22; 95% CI: 0.09\u0026ndash;0.54; p\u0026thinsp;=\u0026thinsp;0.001) Symptoms that were significantly associated with microsporidial infection in the studied groups were diarrhea (OR\u0026thinsp;=\u0026thinsp;8.93, 95% CI: 2.16\u0026ndash;0.82; p\u0026thinsp;=\u0026thinsp;0.007) and colic (OR\u0026thinsp;=\u0026thinsp;10.19; 95% CI: 2.51-.99; P\u0026thinsp;=\u0026thinsp;0.004). Among these factors, multivariate analysis confirmed that gender (adjusted OR 3.74; 95% CI: 1.24\u0026ndash;12.70, P\u0026thinsp;=\u0026thinsp;0.024), area of residence (adjusted OR 0.32; 95% CI: 0.11\u0026ndash;0.93; p\u0026thinsp;=\u0026thinsp;0.039) and the source of drinking water ( adjusted OR 3.79; 95% CI: 1.10-13.88; p\u0026thinsp;=\u0026thinsp;0.037) were independently associated with spore detection.\u003c/p\u003e\u003cp\u003eThe association between serologic detection of anti-microsporidia antibodies and different clinical and environmental variables among the study participants is shown in Table\u0026nbsp;5. In the univariate analysis, HD (OR\u0026thinsp;=\u0026thinsp;20.00; 95% CI: 5.83\u0026ndash;82.70; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and animal contact (OR\u0026thinsp;=\u0026thinsp;4.30; 95% 1.47\u0026ndash;14.54; p\u0026thinsp;=\u0026thinsp;0.011) had a significant association with microsporidia seropositivity rates. In the multivariate analysis, both variables were independently associated with detection of anti-microsporidia antibodies among the study participants: HD (adjusted OR\u0026thinsp;=\u0026thinsp;51.89; 95% CI:10.30-384.78; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001); and animal contact (adjusted OR\u0026thinsp;=\u0026thinsp;25.68; 95% CI\u0026thinsp;=\u0026thinsp;3.93-283.59; P\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;(4): Univariate and multivariate analysis of factors associated with the presence of microsporidia spores in stool samples of the study participants (n\u0026thinsp;=\u0026thinsp;90)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNegative MTS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePositive MTS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eUnivariate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003eMultivariate\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNO. (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNO. (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eGroup\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (70.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (30.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (43.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 (56.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.05 (1.08\u0026ndash;9.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.040\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.34 (0.87\u0026ndash;14.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.088\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCKD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (60.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (40.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.56 (0.54\u0026ndash;4.63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.418\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.59 (0.12\u0026ndash;2.63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.489\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eAge in years\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (60.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18 (39.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.544\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.829\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (54.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20 (45.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.30 (0.56\u0026ndash;3.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.12 (0.39\u0026ndash;3.23)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31 (70.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13 (29.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.019\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.024\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (45.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (54.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.84 (1.21\u0026ndash;6.92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.74 (1.24\u0026ndash;12.70)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eArea of residence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (41.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28 (58.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.039\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (76.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (23.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.22(0.09\u0026ndash;0.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.32 (0.11\u0026ndash;0.93)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eSource of\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eWater\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFilter\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45 (64.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (35.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.023\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTap\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (35.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13 (65.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.34 (1.21\u0026ndash;9.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.79 (1.10-13.88)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eAnimal contact\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47 (66.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24 (33.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.644\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (26.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (73.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.48 (1.86\u0026ndash;8.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.43 (0.30\u0026ndash;6.76)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eDiarrhea\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50 (64.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28 (35.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.095\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (16.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (83.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.93 (2.16\u0026ndash;60.82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5.58 (0.87\u0026ndash;56.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eColic\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50 (64.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27 (35.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.105\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (15.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (84.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.19 (2.51\u0026ndash;68.99)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5.27 (0.78\u0026ndash;50.34)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eFever\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48 (59.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33 (40.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.398\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.916\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (44.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5(55.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.82 (0.45\u0026ndash;7.83)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.91 (0.14\u0026ndash;5.77)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eOR: odds ratio, CI: confidence interval. Bold p-values are statistically significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;(5): Univariate and multivariate analysis of factors associated with the presence of anti-microsporidia antibodies in serum samples of the study subjects (n\u0026thinsp;=\u0026thinsp;90)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eELISA negative\u003c/p\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eELISA positive\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eUnivariate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003eMultivariate\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eOR (95% CI)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003eAdjusted OR (95% CI)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eStudy Group\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (80.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (20.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (16.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (83.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20.0 (5.83\u0026ndash;82.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e51.89 (10.30- 384.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCKD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (63.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11(36.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.32 (0.74\u0026ndash;7.81)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.157\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.09 (0.86\u0026ndash;25.68)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.094\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eAge in years\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (56.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20 (43.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.536\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.440\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.30 (0.57-3.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.60 (0.49\u0026ndash;5.55)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (59.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18 (40.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.285\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.467\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (47.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24 (52.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.58 (0.69\u0026ndash;3.67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.60 (0.46\u0026ndash;6.06)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eArea of residence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (43.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27 (56.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.053\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.786\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (64.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15 (35.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.43 (0.18-1.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.85 (0.25\u0026ndash;2.90)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eSource of\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eWater\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFilter\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40 (57.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30 (42.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.180\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.661\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTap\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (40.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (60.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.00 (0.74\u0026ndash;5.69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.38 (0.33\u0026ndash;6.13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eAnimal contact\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (60.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28 (39.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (26.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (73.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.30 (1.47\u0026ndash;14.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e25.68 (3.93-283.59)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eDiarrhea\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (53.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36 (46.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.804\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.236\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.17 (0.34\u0026ndash;4.04)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.28 (0.03\u0026ndash;2.11)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eColic\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (54.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35 (45.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.576\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.629\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (46.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (53.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.40 (0.43\u0026ndash;4.72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.59 (0.06\u0026ndash;5.13)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eFever\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45 (55.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36 (44.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.217\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.165\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.50 (0.61\u0026ndash;12.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.34 (0.60\u0026ndash;41.40)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eOR: odds ratio, CI: confidence interval. Bold p-values are statistically significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMicrosporidiosis represents a global opportunistic infection affecting mainly HIV-positive and other immunosuppressed patients. Although they were previously considered nonpathogenic, microsporidia have now gained great importance as causative agents of emerging infections[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe present study revealed that HD patients had a significantly higher seropositive rate for anti-microsporidia IgG antibodies compared to CKD patients and the control group Moreover, the duration of dialysis was significantly longer in seropositive than in seronegative patients These results are in line with research conducted in the Czech Republic as anti-microsporidia antibodies were significantly elevated in patients with chronic pyelonephritis which is considered an end stage renal disease requiring hemodialysis [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A previous research carried out in China and the Netherlands among healthy individuals revealed that 9.76% and 8% respectively, were seropositive for anti-microsporidia antibodies using the ELISA technique [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Seropositivity is indicative of latent or chronic microsporidial infections that may persist after infection.\u003c/p\u003e\u003cp\u003eParasitological examination of fecal samples of participants revealed the presence of microsporidia spores at relatively high rates across all study groups (30\u0026ndash;56%) with non-significant differences between them as confirmed by the multivariate analysis. Similarly, high prevalence rates were reported by Elsayad et al. (2020), who identified microsporidia spores in 48% of HD patients and 62% of CKD patients. However, they found no spores in the healthy controls [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Also, Abd-Elbaki et al.(2020) found microsporidiosis in 55.6% of immunocompromised Egyptian patients compared to 44.4% in immunocompetent patients [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A study conducted in South Africa documented that 52.6% of HIV positive patients under 10 years of age had microsporidia spores in their stool samples, detected using the MTS technique [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, a higher infection rate was reported by Nkinin et al. (2007) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePCR technique failed to detect any positive cases, even among seropositive individuals and those with detectable fecal spores. This explanation is supported by the negative microscopic examination of urine samples using MTS smears. A study on molecular detection of microsporidiosis in whole blood and stool samples of immunocompromised Iranian patients found that among 70 blood samples, only four (5.7%) were positive for \u003cem\u003eEncephalitozoon\u003c/em\u003e sp., while among 70 stool samples, only one (1.43%) was positive for \u003cem\u003eEnterocytozoon\u003c/em\u003e sp. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Molecular methods for detecting microsporidiosis face certain limitations, particularly in DNA extraction from spores, which is technically challenging due to the rigid double-layered spore wall that is difficult to lyse. Thus, the PCR results are significantly influenced by the efficiency of the DNA extraction method. It is worth mentioning that false negative results may occur when the number of spores is below the PCR detection threshold [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The absence of microsporidia spores in urine samples using the MTS technique. is consistent with previous reports from Spain[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], Portugal[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], and Egypt [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eComparing the results of MTS and ELISA techniques demonstrated a fair level of agreement in diagnosing microsporidiosis. Although concordant positive and negative cases were observed, each method also detected cases missed by the other. This can be attributed to several factors. The small size of microsporidia spores and their remarkable similarity to some bacteria and other fungal spores could be a possible explanation for the cases not detected by microscopy. The discrepancy might also be the result of the poor sensitivity of light microscopy, estimated at approximately 10\u003csup\u003e5\u003c/sup\u003e spores per gram of stool, which necessitates examining several stool samples before excluding microsporidial infection [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Another explanation is that in early or localized intestinal infections, spores may be present in stool before a systemic antibody response is elicited. Conversely, in cases of past or cleared infections, antibodies may persist even in the absence of detectable spores in stool samples. Additionally, in immunosuppressed individuals, the antibody response may be weak or absent, leading to false-negative serological results despite active infection[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eConcerning risk factors for infection, a statistically significant association between gender and microsporidia spore detection in stool samples was observed after adjusting for potential confounders. Specifically, males had a significantly higher spore detection rate in stool samples than females (54.3% versus 29.5%). Several previous studies have also declared a significant association between gender and microsporidiosis [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan additionalcitationids=\"CR37 CR38\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This could be due to varying exposure to different risk factors and environmental conditions. On the other hand, age was not a significant risk factor for microsporidial infection in our study population, which is consistent with findings in Iranian, South African, Yemeni, Chinese, and Indian published research [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e],[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e],[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRegarding residence, the rates of microsporidia spore detection in stool samples were lower among children residing in urban communities compared to rural residents (23.8% vs 58.3%), and this was confirmed in the multivariate analysis. Parallel to the present study, a significant correlation between residing in slums or rural areas and intestinal microsporidiosis was identified in HIV-positive individuals from Zimbabwe and India [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In contrast to the present finding, a study conducted in a rural village and an urban town in north-central Nigeria reported prevalence rates of microsporidial infection of 39.6% and 47.3% among rural and urban dwellers, respectively, with a non-significant difference [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Another study carried out in Southeastern Iran reported the detection of microsporidia spores in 41 out of 418 individuals (9.8%), of whom 39% were from rural areas and 61% from urban areas [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e Most of the study participants (77.8%) used filtered water as their source of drinking water. Nevertheless, drinking unfiltered water was identified as an independent risk factor for intestinal microsporidiosis in the study participants. The findings of Khanduja et al. (2017 are in line with the present results[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Factors that may enhance transmission of microsporidiosis through potable tap water include the small size of the microsporidia spores and their resistance to physical agents and disinfectants used in water purification. Other potential factors contributing to water contamination at home include the method of collecting water in containers and the frequency of cleaning these containers[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAnimal contact was independently associated with a significantly high seroprevalence of anti-microsporidia antibodies among the study participants. In agreement with this finding, Abu-Akkada et al. (2015) reported that 76.9% of seropositive immunocompromised Egyptian individuals had a history of animal contact [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Consistent with our results, several studies have highlighted the zoonotic potential of specific microsporidia genotypes, such as \u003cem\u003eE. bieneusi\u003c/em\u003e and \u003cem\u003eE. cuniculi\u003c/em\u003e, which are known to infect domestic animals and can be transmitted to humans [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. On the other hand, although the history of animal contact was associated with a five times higher risk of microsporidial infection diagnosed by the MTS technique, this association was not confirmed after adjusting for other variables. Several studies found that among immunocompromised individuals, the presence of household animals was not substantially related to intestinal microsporidiosis [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe pathogenicity of microsporidial infection has been one of the main controversial issues concerning this parasite. It is thought to cause gastrointestinal symptoms, including chronic diarrhea, particularly in immunocompromised patients [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. In the present study, more than 10% of patients reported diarrhea and/or abdominal colic, with fever being a less common symptom. Although there was a statistically significant association between colic and diarrhea and the detection of spores in fecal samples, this association did not persist in the multivariate model after adjusting for other variables. In contrast, some studies reported the identification of microsporidia spores in the stool of patients who presented with gastrointestinal discomfort, diarrhea, and other symptoms such as colic and anorexia [\u003cspan additionalcitationids=\"CR54 CR55\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. A positive correlation between the presence of microsporidia in fecal specimens and diarrhea was previously reported among immunocompromised patients in Egypt and South Africa [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, other studies suggested that microsporidial infections may be asymptomatic even in immunocompromised patients[\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. A transient association between microsporidia detection in stool and gastrointestinal symptoms suggests that microsporidial infection may lead to clinical symptoms during the early stage of infection, which may resolve even though the microsporidia persist [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Shehata et al. (2019) found no association between parasitic infection and diarrhea among Egyptian HD patients[\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. It is noteworthy that gastrointestinal symptoms, including diarrhea, among chronic renal failure patients may be largely attributed to other factors such as elevated levels of uremic toxins, intake of medications, and psychosocial factors [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn conclusion, the results of this study revealed a higher frequency of microsporidial infection among children undergoing HD compared to a healthy control group. Considering that HD patients are immunocompromised, such a parasitic infection may further complicate their clinical condition. The duration of dialysis was found to increase susceptibility to microsporidial infection. Factors such as gender, place of residence, source of drinking water, and animal contact are identified as independent risk factors for microsporidial infection in children. These findings highlight the need for further epidemiological and experimental studies to collect more data that can help in developing effective preventive strategies against this infection. Owing to the complexity of diagnosing microsporidial infection, the use of complementary diagnostic techniques is essential to ensure accurate and reliable results.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eAIDS\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAcquired Immune Deficiency Syndrome\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCKD\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChronic kidney disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCI\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConfidence interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eC\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eDNA\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDeoxyribonucleic Acid\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eE. bieneusi\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEnterocytozoon bieneusi\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eE.\u003c/b\u003e \u003cb\u003ehellem\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEncephalitozoon hellem\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eE. intest\u003c/b\u003e\u003cb\u003eina\u003c/b\u003e\u003cb\u003elis\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEncephalitozoon intestinalis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eE. cuniculi\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEncephalitozoon cuniculi\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eELISA\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eenzyme-linked immunosorbent assay\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eEDTA\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eethylene-diamine tetra-acetic acid\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eHD\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHemodialysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eHIV\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHuman Immunodeficiency Virus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eIgG\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eImmunoglobulin G\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eIQR\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInterquartile range\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMTS\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eModified trichrome staining\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eNC\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNegative control\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eOR\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOdds ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePCR\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePolymerase chain reaction\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePC\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePositive control\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eW\u003c/b\u003e:\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWilcox test\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cb\u003eEthical approval and consent to participate\u003c/b\u003e:\u003c/strong\u003e\u003cp\u003eThe study protocol was reviewed and approved by the Ethics Committee of Medical Research institute (MRI), Alexandria University, Egypt (\u003cb\u003eIORG0008812\u003c/b\u003e). All procedures performed in studies involving human participants were under the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments. In addition, written informed consent was signed or thumb-printed by the parents of HD patients and apparently healthy individuals after explaining them the purpose of the study.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests:\u003c/h2\u003e\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMAE , [HAE](https:/www.tandfonline.com/author/El-Taweel%2C+Hend+A) , MME, MMT and AAA designed and put the conception of the article. AAA collected the data. [HAE](https:/www.tandfonline.com/author/El-Taweel%2C+Hend+A) and AAA wrote the original draft. MMT and AAA implemented the laboratory investigations and analyzed the results. All authors revised and approved the final version of the manuscript submitted to the journal.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank the staff members and patients for their cooperation and participation while conducting the study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data generated or analyzed during this study are included in this article. Data of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWeiss, L. M. \u003cem\u003eMicrosporidiosis.\u003c/em\u003e Hunter's tropical medicine and emerging infectious diseases, : pp. 825\u0026ndash;831. 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Gastroenterology: WJG\u003c/em\u003e. \u003cb\u003e16\u003c/b\u003e (22), 2812 (2010).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"microsporidia, hemodialysis, kidney, antibodies, PCR, modified trichrome","lastPublishedDoi":"10.21203/rs.3.rs-7789598/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7789598/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMicrosporidia are intracellular parasites with a worldwide distribution, known to opportunistically infect immunocompromised individuals. This study aimed to investigate microsporidial infection and associated risk factors among pediatric renal patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eA total of 90 children were included in the study: 30 with chronic kidney disease (CKD), 30 undergoing hemodialysis (HD), and 30 apparently healthy children. Enzyme-linked immunosorbent assay was used for serologic detection of anti-microsporidia antibodies. Modified trichrome staining (MTS) was applied for the detection of microsporidia spores in urine and stool samples. PCR was used to detect microsporidia DNA in blood samples. The Association of infection with different variables was evaluated using univariate and multivariate statistical analysis.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e: Anti-microsporidia antibodies were detected in 46.7% of participants, with a significantly higher seropositivity among HD (83.3%) compared to CKD patients (36.7%) and the control group (36.7%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). The duration of dialysis was significantly longer in seropositive patients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Fecal spores were detected in 42.2% of children with no statistically significant difference between groups. A fair agreement was observed between serological and stool-based diagnostic methods. Examination of urine samples and PCR on blood samples yielded negative results. The child\u0026rsquo;s gender, place of residence, source of drinking water, and animal contact were identified as independent risk factors for microsporidial infection.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e: Microsporidial infection is highly prevalent in the study population. HD and several demographic and environmental factors favor its spread. These findings highlight the need for further epidemiological studies to support preventive strategies. Given the diagnostic complexity, a combination of complementary methods is recommended to ensure accurate detection.\u003c/p\u003e","manuscriptTitle":"Microsporidial Infection and Associated Risk Factors Among Pediatric Renal Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-05 06:31:58","doi":"10.21203/rs.3.rs-7789598/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f5c2b2a0-e97e-415b-b933-480815b7a36c","owner":[],"postedDate":"November 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":57333398,"name":"Health sciences/Diseases"},{"id":57333399,"name":"Health sciences/Medical research"},{"id":57333400,"name":"Biological sciences/Microbiology"},{"id":57333401,"name":"Health sciences/Nephrology"}],"tags":[],"updatedAt":"2026-02-09T09:41:28+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-05 06:31:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7789598","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7789598","identity":"rs-7789598","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}