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Cryptosporidium Infections in Cats and Dogs


David S. Lindsay, PhDa Anne M. Zajac, DVM, PhD
Virginia-Maryland Regional College of Veterinary Medicine

ABSTRACT:

Cryptosporidiosis was recognized as an important zoonosis in the early 1980s. Early studies assumed that all infections in mammals, including humans, were caused by the parasite Cryptosporidium parvum. Recent studies using molecular biologic tools and hostspecificity studies indicate that cats and dogs have their own unique species of Cryptosporidium (C. felis and C. canis, respectively). Surveys indicate that up to 38.5% of cats and up to 44.8% of dogs are infected with Cryptosporidium spp. Initial studies indicate that owning a cat or dog does not increase the risk of humans acquiring cryptosporidiosis, although human infections with C. felis and C. canis have been found in patients with AIDS, immunosuppressed patients, and children from impoverished areas. Clinical signs of cryptosporidiosis in cats and dogs vary from none to chronic or intermittent diarrhea. Fluids and other supportive measures should be used in animals with diarrhea, but there is no proven safe and effective treatment of cryptosporidiosis.

embers of the genus Cryptosporidium are in the protozoan phylum Apicomplexa. They are coccidia-like parasites that develop in the microvillous border of epithelial cells in the digestive, respiratory, and urinary tracts of vertebrates.1 Recent molecular phylogenetic studies indicate that cryptosporidia are more closely related to the gregarine parasites of invertebrates than to the true coccidial parasites of vertebrates.2 This may explain why cryptosporidia are not sensitive to chemotherapeutic agents normally used to treat coccidial infections. 1 In the early 1980s, Cryptosporidium parvum was identified as a major cause of intestinal disease in patients with
Lindsay receives funding from Bayer Animal Health and Merck & Company. Neither company has been involved in the preparation of this article.
a Dr.

Email comments/questions to compendium@medimedia.com, fax 800-556-3288, or log on to www.VetLearn.com

AIDS, and it was later found in immunocompetent humans who had been exposed to infected dair y calves. 3 Several groups of researchers conducted studies in which C. parvum was successfully transmitted from calves to young animals, including cats and dogs.1,3 Successful cross-species transmission studies with C. parvum led to the proposal that the organism was responsible for all infections in mammals.4 Most parasitologists embraced this concept, which has been taught in most veterinary schools since the 1980s. Recent studies of Cr yptosporidium spp from cats, 510 dogs, 1113 and humans 14 indicate that these organisms are biologically and genetically different from C. parvum; thus they are now considered separate species. Cryptosporidium felis is primarily found in cats5 and Cryptosporidium canis in dogs11; Cryptosporidium hominis is the newly recognized parasite in humans.14
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Sporozoite Trophozoite Excystation

Ingestion Thick-walled oocyst Exits body

Host Excystation epithelial cell Autoinfection

Type I meront

Merozoite Thin-walled oocyst

Merozoite

Microgamont

Mature oocyst

Immature oocyst

Type II meront

Macrogamont

Figure 1. Life cycle of Cryptosporidium spp. (Adapted from Dubey JP, Speer CA, Fayer R: Cryptosporidiosis of Man and Animals. Boca Raton, FL, CRC Press, 1990)

LIFE CYCLE Sporulated oocysts are ingested via direct contact with the feces of an infected host or contaminated food or water (Figure 1). The oocysts excyst in the digestive tract, and the sporozoites penetrate the microvilli of a variety of epithelial cells. The location of the infected host cells depends on the species of Cryptosporidium. The elongated sporozoite rounds up and becomes a trophozoite. The trophozoite becomes a multinucleated type I schizont and produces eight type I merozoites, which penetrate other microvilli and become type II schizonts. Type II schizonts repeat this developmental cycle, resulting in four type II merozoites. Recycling of asexual stages may occur. Type II merozoites penetrate microvilli and become sexual stages. The male stage (i.e., microgaNovember 2004

mont) produces nonflagellated microgametes. In the female stage (i.e., macrogamont), fertilization occurs and oocysts are produced. Two types of oocysts are produced, both of which sporulate endogenously and contain four sporozoites, an oocyst residuum, and no sporocysts. Thin-walled oocysts are autoinfective. Thick-walled oocysts are excreted in the feces.5,11,14 Cryptosporidium spp contain approximately 5,000 members, including Plasmodium (malaria), Toxoplasma, Babesia, Neospora, Sarcocystis, and Eimeria spp. Most are obligate intracellular parasites. Apicomplexans lack appendages for locomotion and instead move by a gliding motion. Cell entry by this group is mechanically distinct from uptake of viruses, bacteria, and other parasites. Cryptosporidium , Eimeria , and Toxoplasma spp
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form oocysts that are shed in the feces of infected hosts. Cryptosporidia oocysts are very resistant to environmental damage, chlorination, and standard cleansers. This makes Cryptosporidium spp an important foodand waterborne pathogen. Extreme temperatures and prolonged contact with ammonia destroy the oocysts.

PATHOGENESIS The mechanisms by which Cryptosporidium spp induce diarrhea, malabsorption, and wasting in humans and animals are not well understood.15 Cryptosporidial parasites can develop in a variety of epithelial cells in the body, not just in enterocytes in the intestines. This can lead to respiratory, ocular, pancreatic, and hepatic infections in humans; fortunately, these extraintestinal loci of cryptosporidial infection have not been reported in dogs or cats. Cryptosporidia develop in the microvillous border and displace it, eventually leading to loss of mature

Dogs Most reported cases of cryptosporidiosis in dogs involve young animals.13,2833 Cases in adult dogs are rare.34 Clinical signs can vary from none to chronic or intermittent diarrhea and wasting. Immunosuppression due to canine distemper may exacerbate infections in dogs.29,31 Concurrent canine parvovirus infection and intestinal Isospora spp infection may also enhance cryptosporidiosis in immunosuppressed dogs.13,32 Two recent reports used molecular methods to determine the Cryptosporidium spp in a fatal case involving an 8-week-old Yorkshire terrier from Georgia33 and a nonfatal case involving a 9-week-old bullmastiff from Australia,13 and both reports found that C. canis organisms were present. DIAGNOSIS The small size of Cryptosporidium oocysts makes them difficult to detect. Oocysts are often overlooked unless

Oocysts of C. felis and C. canis are structurally similar to the well-known and zoonotic C. parvum.
surface epithelium.15 This causes shortening and fusion of villi and lengthening of the crypts due to acceleration of cell division to compensate for loss of cells.15 This causes reduced uptake of fluids, electrolytes, and nutrients from the gut lumen.15 The minimum infective dose of Cryptosporidium oocysts for cats and dogs is unknown. Experimental studies in humans using C. parvum oocysts collected from calves indicate that 10 or fewer oocysts can cause infection.16 Differences in infectivity among different C. parvum isolates in human volunteers have been documented.15 an examiner is specifically looking for them, and this is especially true if few oocysts are present in the sample. Fecal flotation techniques used routinely in veterinary laboratories are adequate to demonstrate Cryptosporidium oocysts if large numbers are present. The slide should be examined using the high-power objective. Sheathers sugar solution is the best flotation medium.3 Because oocysts are small, they float in a plane higher than that of helminth ova and other protozoal cysts. They are light pink, and a central residual body is usually visible in Cryptosporidium oocysts in fecal flotations. C. felis oocysts are smaller9,17,35 than those of C. parvum, but morphology alone cannot be used to determine the species of Cryptosporidium in a sample.36 Many small animal technicians are not taught to recognize Cryptosporidium oocysts and may have difficulty identifying them when the tests are run only infrequently. In these cases, it is probably better for samples to be sent to diagnostic reference laboratories for testing. Fecal samples sent to diagnostic laboratories can be tested using a number of procedures.37 More than 10 different types of staining methods have been developed for use with fecal smears to aid in detecting Cryptosporidium oocysts via standard light microscopy.37 The Ziehl-Neelsen
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CLINICAL SIGNS Cats Most cats that are excreting Cryptosporidium oocysts do not have clinical signs.5,7,1720 Young17,18 or immunocompromised18,21 animals are more likely to be infected. Chronic or intermittent diarrhea, anorexia, and wasting are common clinical signs in symptomatic cats. 2125 Coinfection with Giardia spp or Tritrichomonas foetus may exacerbate clinical signs of cryptosporidiosis in cats.26,27 Administering prednisolone (10 mg/kg/day SC for 4 to 9 days7 or 2.8 to 3.8 mg/kg/day PO for 26 days27) may cause oocysts to reappear in feline feces.
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Table 1. Transmission Studies with C. felis and C. canis Oocysts


Source Recipient Results Study

Cat Cat Cat Cat Cat Cat Cat Dog Dog Dog

Guinea pigs Mice Newborn mice Lambs Immunosuppressed mice Rats Dogs Newborn mice Immunosuppressed mice Calves

Negative Negative Negative Positive Negative Negative Negative Negative Negative Positive

Iseki , Arai et al17 Iseki5, Arai et al17 Mtambo et al8, Arai et al17 Mtambo et al8 Mtambo et al8 Arai et al17 Arai et al17 Fayer et al11 Fayer et al11 Fayer et al11

Table 2. Prevalence of Cryptosporidium spp in Cats


Number Examined Location Test Prevalence (%) Study

600 418 40 102 10 300 13 507 608 57 235 205 263

United States Australia Australia Australia France Germany Japan Japan Japan Scotland Scotland Colorado New York

Serology Fecal PCR Fecal Fecal Fecal Fecal Fecal Fecal Fecal Fecal Fecal Fecal

8.3 0 10 1.2 0 1.3 38.5 20 3.8 12.3 8.1 5.4 3.8

McReynolds et al50 McGlade et al52 McGlade et al52 Sargent et al9 Chermette and Blondel53 Augustin-Bichl55 Iseki5 Uga et al54 Arai et al17 Nash et al19 Mtambo et al18 Hill et al51 Spain et al20

acid-fast staining technique is most often used and produces red-stained oocysts against a bluegreen background of fecal material. Fluorescently labeled monoclonal antibodies to the oocyst stage of C. parvum have been made and are used in a commercial direct immunofluorescent antibody (IFA) test.38 Most Cryptosporidium spp, including C. felis and C. canis, cross-react in commercial IFAbased diagnostic tests developed to detect C. parvum.39,40 Cross-reactivity also occurs in many ELISAs for C. parvum.38 Polymerase chain reaction (PCR) can detect Cryptosporidium spp in fecal samples, and PCR is more sensitive than IFA testing.41 Most PCR-based tests indicate only the presence of Cryptosporidium spp, but a recently developed set of PCR tests can differentiate between C. felis, C. canis, C. parvum, and C. hominis.42
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TREATMENT Table 3. Prevalence of Cryptosporidium spp in Dogs Chemotherapy for Cryptosporidium Prevalence Number infections in animals and humans has Examined Location Test (%) Study been actively investigated over the past 421 Australia Fecal/PCR 0 Bugg et al62 two decades (see box on page 871). 493 Australia Fecal 11 Johnston and Gasser65 Over 100 compounds have been tested 195 Australia Fecal 7.1 Milstein and in laboratory animal models, but none 66 43 Goldsmith is highly effective clinically. Paro25 Egypt Fecal 12 El-Hohary and momycin44 and nitazoxanide (NTZ)27 67 Abdel-Latif are compounds that have shown some 57 Finland Fecal 0 Pohjola68 efficacy in animal models and have 29 France Fecal 44.8 Chermette and also been used to treat intestinal cryp53 Blondel tosporidiosis in cats. Treatment with 200 Germany Fecal 0 Augustin-Bichl et al55 paromomycin (165 mg/kg PO bid for 213 Japan Fecal 1.4 Uga et al54 5 days) resulted in resolution of diar140 Japan PCR 9.3 Abe et al63 rhea and disappearance of oocysts 257 Korea Fecal 9.7 Kim et al40 from the feces of a 6-month-old cat 44 with persistent diarrhea. Paro81 Spain Fecal 7.4 Causape et al61 momycin is potentially nephrotoxic, 101 Scotland Fecal 0 Simpson et al59 and acute renal failure was reported in 100 Scotland Fecal 1 Grimason et al69 four cats that received paromomycin 200 California Fecal 2 el-Ahraf et al60 for cryptosporidiosis or trichomonia130 Colorado Fecal 3.8 Hackett and Lappin64 sis.45 Treatment using NTZ (25 mg/kg 49 Georgia Fecal 10.2 Jafri et al70 PO bid for 28 days) eliminated Cryp100 Kentucky Fecal 17 Juett et al71 tosporidium oocysts from the feces of naturally infected laboratory cats. Use of NTZ was associated with vomiting and the presence of dark brownblack, foul-smelling However, additional well-controlled PCR-based and diarrhea while treating these cats.27 Chlorpromazine (0.5 PCR speciesvalidated transmission studies need to be to 1.5 mg SC once daily) was given to alleviate vomiting conducted before these earlier observations can be comin NTZ-treated cats.27 Fenbendazole administered at 50 pletely accepted. C. felis was not infectious in dogs or labmg/kg PO for 5 days did not affect Cryptosporidium oratory rodents in a limited number of studies. It is infecoocyst excretion in cats.26 tious in lambs8 and has been found in a naturally infected Treatment of an 18-month-old cat with inflammatory cow.35 C. canis is not infectious in laboratory rodents but bowel disease and Cryptosporidium infection was sucis mildly infectious in calves.11 The infectivity of C. canis cessful using a course of clindamycin (25 mg/kg/day oocysts in cats has not been examined. C. parvum oocysts [three-fourths of the total dose was administered in the are moderately infectious in cats and dogs.3,11 Molecularly morning and one-fourth of the total dose at night] PO confirmed natural cases of C. parvum or C. hominis have for 60 days) and then tylosin (11 mg/kg PO bid with not been reported in cats or dogs. 15 food for 28 days). Interpretation of these results was Several studies have suggested that humans have been hampered because of the presence of Clostridium perinfected with Cryptosporidium spp from kittens or fringens in the cats intestinal tract. Clindamycin admincats.4648 None of these studies conducted genotyping or istered at 15 mg/kg PO q8h for 6 days did not eliminate other studies, and they should be viewed as only circum34 Cryptosporidium oocysts from a 5-year-old pointer. stantially incriminating cats in the transmission of Cryptosporidium spp to humans. STUDIES ON HOST SPECIFICITY OF One study indicated that a veterinary student caring C. FELIS AND C. CANIS for an adult dog with cryptosporidiosis developed crypTransmission studies with C. felis and C. canis indicate tosporidiosis.34 The parasite in the dog or the veterinary that these species are relatively host-specific (Table 1). student was not genotyped or further characterized.
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Table 4. Reports of C. felis, C. canis, C. parvum, and C. hominis in Humans Who Tested Positive for Oocystsa
Number and Type of Patients Percentage with C. felis C. canis C. parvum C. hominis Study

30 with HIV 22 with HIV 1 with HIV 34 with HIV 25 with HIV 80 childrenb 1,680 (mixed) 57 (mixed) 1,075 (mixed) 39 (mixed) 102 (mixed) 63 (mixed) 22 (mixed) 11 (mixed) 26 (mixed) 12 (mixed)
aPercentages may not bFrom Lima, Peru.

30% 27% 100% 9% 4% 1% <1% 11% 0% 0% 0% 0% 0% 0% 0% 0%

10% 0% NA 6% 0% 3% <1% 0% 0% 0% 0% 0% 0% 0% 0% 0%

10% 32% NA 15% 56% 10% NR 51% 62% 87% 14% 22% 14% 0% 35% 100%

50% 9% NA 50% 32% 84% NR 32% 38% 13% 86% 75% 73% 36% 58% 0%

Pieniazek et al72 Morgan et al73 Caccio et al74 Gatei et al75 Alves et al76 Xiao et al77 Pedraza-Diaz et al78 Guyot et al79 McLauchlin et al80 Lowery et al81 Gasser et al82 Gatei et al83 Yagita et al84 Ong et al85 Sinclair et al86 Fretz et al87

equal 100% because of the presence of other Cryptosporidium spp not listed.

NA = not applicable; NR = not reported.

One study in patients with AIDS addressed the issue of pet-to-human transmission of Cryptosporidium infection.49 The study found that patients with AIDS who owned cats or dogs were not at significantly higher risk of acquiring cryptosporidiosis than were patients with AIDS who did not own pets. Further critically controlled studies are needed to determine the importance of cats and dogs as sources of Cryptosporidium infection in humans.

erally considered nonspecific for coccidial parasites.58 Prevalence studies conducted to date with cats have not used molecular methods to determine the actual species of Cryptosporidium found in cats. Therefore, the real prevalence of C. felis versus C. parvum or other Cryptosporidium spp in cats is unknown. This information is important because C. felis has a more narrow host range than C. parvum.

PREVALENCE IN CATS Fecal-, PCR-, and serologic-based surveys indicate that up to 38.5% of cats examined have been exposed to or are excreting Cryptosporidium oocysts (Table 2).5,9,1720,5055 One hundred litters of kittens from Germany were examined for Cryptosporidium infection, which was found in 4.3% of 70 litters that were kept outdoors and 3.3% of 30 litters kept indoors.56 One serologic study not listed in Table 1 indicated that 192 (74%) of 258 cats tested positive for IgG antibody via IFA testing.57 The results are questionable: Interpretation of the IFA tests may have been flawed because positive apical fluorescence was considered an indicator of a true positive reaction. Apical fluorescence is genCOMPENDIUM

PREVALENCE IN DOGS Fecal-, PCR-, and serologic-based surveys indicate that up to 44.8% of dogs examined have been exposed to or are excreting Cryptosporidium oocysts (Table 3).40,5355,5971 One PCR-based study from Japan indicated that all 13 positive samples of 140 tested were C. canis.63 Two clinical cases in puppies have been attributed to C. canis.13,33 The prevalence of C. parvum or other Cryptosporidium spp in dogs is unknown. PREVALENCE OF C. FELIS AND C. CANIS IN HUMANS Most studies on the prevalence of C. felis and C. canis in humans have been conducted in HIV-infected huNovember 2004

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On the Horizona
The genome sequence for C. parvum has recently been generated. C. parvum lacks many typical metabolic pathways, including Krebs cycle and de novo synthesis of amino acids and nucleotides. In addition, Cryptosporidium spp contain many plant-like enzymes that are absent or very different from those usually found in mammals. Further analysis of this genome could provide important clues in developing an effective drug against this parasite.
aAbrahamsen

Resources
avma.org/noah/resources/zoonosis/crypto.asp (password protected) The AVMA Network of Animal Health provides zoonosis updates. vin.com (password protected) Search cryptosporidiosis photographs: Kirsten Vances Arthropod and Protozoa slide show Lindsay D: Proc West Vet Conf: Giardia and Cryptosporidia: Really Zoonotic

et al: Science 304:441, 2004.

mans,7276 children,77 or humans with cryptosporidiosis and some underlying immunosuppressive conditions7887 (Table 4). The prevalence of C. felis and C. canis in humans is less than that of C. hominis and C. parvum. Some studies have not found C. felis or C. canis in humans.

PREVALENCE OF CRYPTOSPORIDIUM SPECIES IN THE ENVIRONMENT Cryptosporidium oocysts are common in the environment and have been found in surveys of nondrinking surface and waste waters. 8891 However, genotyping Cryptosporidium isolates from nondrinking water sources indicates little contamination by C. felis or C. canis.90

zoonotic potential. The contribution of canine and feline Cryptosporidium spp to clinical disease in pets does not seem to be great at this time but may be underestimated because so few cats and dogs are tested for infection. In contrast, the risk of zoonotic infection has received considerably more attention. Many practicing veterinarians are unaware that, to minimize exposure to Cryptosporidium spp, current guidelines from the US Public Health Service and Infectious Diseases Society of America recommend that HIV-infected humans should not take into their homes stray dogs or cats, animals with diarrhea, or dogs and cats younger than 6 months of age.99 They further recommend that if a dog

Clinical signs of Cryptosporidium infection in cats and dogs vary from none to chronic or intermittent diarrhea.
One study documented C. felis or C. canis oocysts in raw waste water but found none in raw surface water. 90 Although major outbreaks of human cryptosporidiosis have been linked to contaminated drinking water,9295 molecular studies indicate that C. hominis 9698 and C. parvum96,98 have been responsible for drinking water associated outbreaks of human cryptosporidiosis. No reports indicate that C. felis or C. canis has been associated with waterborne outbreaks of human disease. or cat younger than 6 months of age is acquired by an HIV-infected person, the animal should be tested for Cryptosporidium spp. These recommendations, dating from 1999, may be more stringent than necessary, but further molecular analysis of human and animal infections is needed to realistically assess potential transmission from pets to humans. Until more is known, practitioners should recognize that Cryptosporidium infection in dogs and cats is not uncommon in North America and that zoonotic transmission from pets could cause serious disease in immunocompromised humans.

CONCLUSION Despite extensive experimental and epidemiologic literature on Cryptosporidium spp , the primary species infecting dogs and cats, C. canis and C. felis, respectively, have been identified only recently, and there is little experimental work documenting their pathogenicity or
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93. Hayes EB, Matte TD, OBrien TR, et al: Large community outbreak of cryptosporidiosis due to contamination of a filtered public water supply. N Engl J Med 320:13721376, 1989. 94. Atherton F, Newman CP, Casemore DP: An outbreak of waterborne cryptosporidiosis associated with a public water supply in the UK. Epidemiol Infect 115:123131, 1995. 95. Goldstein ST, Juranek DD, Ravenholt O, et al: Cryptosporidiosis: An outbreak associated with drinking water despite state-of-the-art water treatment. Ann Intern Med 124:459468, 1996. 96. Patel S, Pedraza-Diaz S, McLauchlin J, Casemore DP: Molecular characterization of Cryptosporidium parvum from two large suspected waterborne outbreaks. Commun Dis Public Health 1:231233, 1998. 97. Dalle F, Roz P, Dautin G, et al: Molecular characterization of isolates of waterborne Cryptosporidium spp. collected during an outbreak of gastroenteritis in South Burgundy, France. J Clin Microbiol 41:26902693, 2003. 98. Glaberman S, Moore JE, Lowery CJ, et al: Three drinking-water-associated cryptosporidiosis outbreaks, Northern Ireland. Emerg Infect Dis 8:631633, 2002. 99. 1999 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infection in Persons Infected with Human Immunodeficiency Virus. MMWR 48(RR-10), 1999. (www.cdc.gov/mmwr/preview/mmwrhtml/rr4810a1.htm)

4. NTZ therapy for cryptosporidiosis in cats has been associated with a. vomiting. b. pneumonia. c. kidney failure. d. liver failure. 5. What is the best fecal flotation medium for finding Cryptosporidium oocysts? a. zinc sulfate solution b. Sheathers sugar solution c. saturated salt solution d. sugarsalt solution 6. Because Cryptosporidium oocysts are small, they a. float in a plane higher than that of helminth ova and other protozoal cysts. b. can be seen only by using oil immersion. c. look like Isospora spp. d. look like Giardia cysts. 7. Administering ________ may cause oocysts to reappear in cat feces. a. NTZ b. paromomycin c. clindamycin d. prednisolone 8. Developmental stages of Cryptosporidium spp can be found in a host cells a. nucleus. b. microvilli. c. cytoplasm. d. neurons. 9. Immunofluorescent detection tests for Cryptosporidium oocysts a. are not reliable. b. cross-react with most Cryptosporidium spp. c. are highly specific for C. canis but not C. felis. d. are highly specific for C. hominis but not C. felis. 10. Lesions and subsequent clinical signs of cryptosporidiosis are associated with a. reduced uptake of fluids, electrolytes, and nutrients from the gut lumen. b. hemorrhagic diarrhea due to invasive stages. c. excretory diarrhea due to parasite toxins. d. fatty diarrhea due to infection of the upper small intestine.

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CE

1. Which Cryptosporidium spp was, until recently, believed to be responsible for all cases of cryptosporidiosis in humans and other mammals? a. C. hominis c. C. felis b. C. canis d. C. parvum 2. Waterborne outbreaks of cryptosporidiosis have been associated with a. C. parvum and C. hominis. b. C. felis and C. parvum. c. C. felis and C. canis. d. C. felis and C. hominis. 3. Paromomycin therapy for cryptosporidiosis in cats has been associated with a. vomiting. b. diarrhea. c. kidney failure. d. liver failure.

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