A parasite that can keep people chained to the bathroom for weeks has reached Wyoming.
State health officials have now confirmed six cases of cyclosporiasis this year — double the number reported just days ago — including one domestically acquired infection that remains under investigation while federal officials search for the source of one of the nation's largest Cyclospora outbreaks in recent years.
The illness is often dismissed as just another stomach bug — until it refuses to go away, said Cheyenne Regional Medical Center emergency physician Dr. Matthew Loptien.
"Ultimately I understand those words can provoke that (laughter)," Loptien told Cowboy State Daily, referring to the phrase "explosive diarrhea."
"But it is not funny, that's for sure."
His warning comes as Wyoming health officials continue tracking the parasite's spread within the state.
Five of Wyoming's six confirmed infections were likely acquired while patients traveled to countries where the microscopic parasite Cyclospora cayetanensis is endemic, according to the Wyoming Department of Health.
That leaves just one case believed to have been contracted inside the United States.
"We have not linked our one non-travel-related case to any other cluster at this time," Wyoming Department of Health Surveillance Epidemiologist Matt Peterson said Monday.
Weeks, Not Days
Unlike the stomach viruses that typically disappear after a day or two, the parasite can linger for weeks — sometimes even months — before finally loosening its grip.
The Centers for Disease Control and Prevention says symptoms usually begin two days to two weeks after someone consumes contaminated food or water, often making it difficult for patients to remember exactly what they ate before becoming sick.
"The hallmark of this is a prolonged diarrheal illness," Loptien said. "The biggest risk is for developing dehydration as a result."
Young children, older adults and people with weakened immune systems are especially vulnerable because dehydration can develop much more quickly in those groups.
"Individuals who are experiencing profuse watery diarrhea and cramps for extended periods, especially if the symptoms subside and then return, or are accompanied by loss of appetite and significant weight loss, should see their physician about testing," he added.
Three Weeks
For Grover resident Eve Sutter Buehler, the illness struck so suddenly she initially assumed it was food poisoning.
"Feeling fine one minute and not able to function the next," she said.
Buehler said several members of her extended family became ill after gathering for wedding festivities over Memorial Day weekend. Most were sick for nearly three weeks, while younger family members recovered after about 10 days.
"The first onset of sickness was on May 31st late in the day … by June 2nd in the evening, we were almost all miserable," Buehler said. "We eat a lot of raw fruit and raw veggies. Those who don’t, didn’t get sick. That’s how we started putting it all together. We did have a bridal shower meal where most of us ate a strawberry/spinich salad. We’ve considered that."
One relative became so ill she was repeatedly evaluated for appendicitis and gallbladder problems before a physician assistant suggested Cyclospora as a possible explanation.
"At first, we all thought we had food poisoning or a flu," she said.
Easy To Miss
One reason Cyclospora is so difficult to track is that doctors first have to think of it.
Loptien said patients usually provide a stool sample, but many commonly used laboratory panels don't automatically test for parasites like Cyclospora.
Instead, providers often must order specialized ova-and-parasite testing when they suspect the illness.
That means some infections could easily be mistaken for a routine stomach virus.
Asked whether additional Wyoming cases may have gone undiagnosed, Loptien said, "I think that is always a possibility."
"There certainly is overlap in regard to the symptoms with Cyclospora and more common viral intestinal illnesses," he said. "However, the symptoms tend to be a bit more persistent and tend to last a little bit longer."
Unlike norovirus, Cyclospora generally does not spread directly from person to person. The CDC notes the parasite must first mature in the environment before becoming infectious, meaning most U.S. infections are linked to contaminated food or water rather than casual contact.
Loptien said patients should focus on hydration and electrolyte replacement while seeking medical care. Once diagnosed, Cyclospora is typically treated with the antibiotic Bactrim, and most patients begin improving within a couple of days. Without treatment, however, symptoms can continue coming and going for weeks.
Cause Unknown
Although Wyoming's case count has doubled, Peterson said the state's investigation still points overwhelmingly toward travel-related infections rather than a local outbreak.
"All but one of them likely acquired the infection while traveling to regions endemic for Cyclospora outside the USA," Peterson said.
That leaves investigators with just one domestically acquired case to study.
"With only one domestically acquired Cyclospora infection, determining a food vehicle is nearly impossible," Peterson said.
The CDC, Food and Drug Administration and health departments across the country are interviewing patients, tracing grocery purchases and studying food distribution networks in hopes of identifying the contaminated food responsible for what has become one of the country's largest Cyclospora outbreaks in years. The FDA has opened an active outbreak investigation, but because investigators have not identified the contaminated product, no recall has been issued.
Past U.S. outbreaks have been linked to imported fresh produce including cilantro, basil, lettuce, raspberries, mesclun greens and snow peas.
Peterson said imported produce remains Wyoming's most likely source whenever infections are acquired domestically because the parasite isn't naturally found here.
"Because Cyclospora is not endemic here, imported fresh produce is always the most likely vehicle," he previously told Cowboy State Daily.
Washing produce helps reduce risk but doesn't always remove the parasite, according to the FDA. Cooking food to an internal temperature of 158 degrees Fahrenheit will kill or inactivate it.
Watching Closely
Although Wyoming's lone domestically acquired case hasn't been connected to the national outbreak, Peterson said investigators around the country are beginning to make progress.
"The national picture remains unclear," he said, "investigators in other jurisdictions are making progress on their respective outbreaks, which may inform our own if we see more domestically acquired cases moving forward."
"We typically don't release much information on isolated cases," Peterson said. "But if we find something new that is actionable for the public, we will issue a press release."
Loptien echoed that message, saying there's no reason for Wyoming residents to panic.
"Maintain good hydration, maintain good hand hygiene, wash your foods, and I think that is going to go a long way for a lot of people," he said.
Kolby Fedore can be reached at kolby@cowboystatedaily.com.
