Strongyloides hyperinfection syndrome after heart transplantation: case report and review of the literature.
Schaeffer Michael W,Buell Joseph F,Gupta Manish,Conway Ginger D,Akhter Shahab A,Wagoner Lynne E
The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation
Stronglyoides hyperinfection syndrome (SHS) is an augmentation of the infective life cycle of S stercoralis. Immunosuppressed patients, especially those taking corticosteroid therapy, are at risk. We present a case of fatal SHS with disseminated infection following orthotopic heart transplantation. The patient was treated with increased doses of immunosuppressive medications for graft rejection, including corticosteroids. A review of the literature describing the pathophysiology, host defenses and treatment of SHS is also presented. Diagnostic tests for S stercoralis are reviewed. SHS should be part of the differential diagnosis in immunosuppressed patients presenting with sepsis or gastrointestinal or pulmonary complaints. Pretransplant evaluation for parasitic infections, including strongyloidiasis, should occur in endemic areas or in patients at risk for occult infestation.
Strongyloidiasis hyperinfection after renal transplant presenting as diffuse alveolar hemorrhage with respiratory failure.
Hakeem Imtiyaz,Moritz Charles,Khan Faiza,Garrett Erin,Narayanan Mohanram
Proceedings (Baylor University. Medical Center)
is a helminthic enteric parasite estimated to infect at least 30 to 100 million people globally. It is transmitted via contaminated soil with a unique ability to complete its entire life cycle in the human host. It is common in humid, tropical, and subtropical regions of the world and is endemic in the Southeastern United States. Strongyloidiasis hyperinfection has been described in a variety of conditions that impair host immunity, including immunosuppression after transplantation. The syndrome has a high mortality rate but may initially present with nonspecific symptoms. A high degree of clinical suspicion coupled with early detection and aggressive therapeutic measures is paramount to a successful outcome.
Strongyloidiasis in the immunocompetent: an overlooked infection.
Tachamo Niranjan,Nazir Salik,Lohani Saroj,Karmacharya Paras
Journal of community hospital internal medicine perspectives
Strongyloidiasis is a parasitic infestation caused by Strongyloides stercoralis. Most cases are asymptomatic; however, symptomatic patients may present with a wide range of non-specific cutaneous, pulmonary, or gastrointestinal symptoms posing a diagnostic dilemma and delay in diagnosis. We report a case of a 58-year-old female who presented with months of generalized pruritus and abdominal discomfort along with persistent eosinophilia due to strongyloidiasis, which completely resolved with treatment.
Disseminated Strongyloidiasis in an Immunodeficient Patient (Pemphigus Vulgaris) Due to Corticosteroid Therapy: A Case Report.
Najjari Mohsen,Ebrahimipour Mohammad,Kaheh Amir,Karimazar Mohammadreza
Iranian journal of parasitology
Strongyloidiasis is a frequent misdiagnosed parasitic infection in the world that caused by . In Iran, the disease is predominantly reported from warm and humid climate provinces. The patient was a 54-yr-old man, originated from Khuzestan Province with a history of pemphigus and diabetes that was treated with high-dose of corticosteroid drugs before admission in a non-private hospital in Shiraz, Iran in 2014. After different primary diagnosis and administrating of several drugs, endoscopy and histopatholgical biopsy revealed a massive infection in the duodenal mucosa and gastric wall. In spite treating with anti-helminthic drugs in the last days, due to using different steroid drugs, clinical manifestations of the patient were exacerbated and he was expired on the seventeenth day due to severe dyspnea. Physicians' awareness and using various diagnosis methods like serology, endoscopy, and biopsy should be considered in the endemic areas. In suspicious cases, anthelmintic drugs should be started before the initiation of immunosuppressive therapy.
A Case of Strongyloidiasis: An Immigrant Healthcare Worker Presenting with Fatigue and Weight Loss.
Grewal Tarundeep,Azizi Heela,Kahn Alexa,Shakir Zaid,Takkouche Sahar,Aung Khin N,Lois William,Hasan Muhammad
Case reports in infectious diseases
BACKGROUND: is an intestinal nematode parasite classified as a soil-transmitted helminth, endemic in tropical and subtropical regions. can remain dormant for decades after the initial infection. CASE:We describe a patient who was diagnosed with infection three weeks after a left inguinal hernia repair and discuss approaches to prevention, diagnosis, and treatment. CONCLUSIONS:Physicians in the United States often miss opportunities to identify patients with chronic strongyloidiasis. Symptoms may be vague and screening tests have limitations. We review current strategies for diagnosis and treatment of chronic intestinal strongyloidiasis in immigrant patients who have significant travel history to tropical regions and discuss the clinical features and management of the infection.
Disseminated Strongyloidiasis in an Iranian Immunocompromised Patient: A Case Report.
Najafi Narges,Soleymani Eissa,Sarvi Shahabeddin,Marofi Amirkeivan,Nosrati Anahita,Davoodi Alireza
Iranian journal of parasitology
is a soil-transmitted helminth (STH) widespread in various part of the world. A 78-yr-old peasant diabetic female from Mazandaran Province northern Iran, was admitted to Infection Department of the Razi Hospital in city of Qaemshahr, north of Iran complaining about abdominal skin rash, pruritus, itching, anorexia, nausea, vomiting, dysuria and cough. This patient had cutaneous migration effects of larvae in her abdominal skin (larva currents and urticaria). Lung CT without contrast demonstrate s bilateral diffuse ground glass opacity draws attention. Upper gastrointestinal endoscopy revealed gastro esophageal reflux with antral gastritis. Duodenal endoscopy showed unusual mucosa and a biopsy from it sent to the pathology laboratory. Histopathology of duodenal bulb and duodenum biopsy showed mild villous atrophy and infection. The patient was treated with albendazole and clinical sings improved completely after treatment. Strongyloidiasis should be carefully considered by clinicians who practice in endemic areas. Clinicians must keep a high level of skepticism for patients from endemic area.
Strongyloides stercoralis associated with a bleeding gastric ulcer.
Dees A,Batenburg P L,Umar H M,Menon R S,Verweij J
Infection with the helminthic parasite, Strongyloides stercoralis, is usually acquired by skin invasion (or occasionally via ingestion of larvae). After transformation to the adult form, the parasite preferentially localises in the small intestine, especially in the duodenal and jejunal part. A remarkable feature of Strongyloides is its property of endogenous reinfection. In the case of an immunocompromised host a massive infection, called hyperinfections Strongyloides, may occur. Numerous gastrointestinal complications of strongyloides infections, sometimes with a lethal outcome, have been reported. The intestinal manifestations are usually limited to the small bowel, and rarely involve the stomach. We report a patient with complicated strongyloides infection of the stomach.
Severe Strongyloidiasis in Solid Organ Transplant Recipients: Should We Preventively Treat the Recipient, the Donor, or Both?
Eperon Gilles,Tourret Jerome,Ailioaie Oana,Paris Luc,Mercadal Lucile,Mayaux Julien,Caumes Eric,Barrou Benoit
The American journal of tropical medicine and hygiene
Strongyloidiasis is caused by a soil-transmitted helminth that is endemic in tropical and subtropical countries. The parasite can complete its life cycle without leaving the host, allowing autoinfection and persistence. The risk of infection in travelers is low, but the disease may become lethal following immunosuppression. In case of solid organ transplantation, the risk of donor transmission has been suspected for several years. However, the management of live donors in this context has only recently been considered, and no guidelines exist for the management of deceased donors. To highlight the complexity of diagnosing, treating, and preventing strongyloidiasis donor transmission, we describe a case of possible transmission of severe strongyloidiasis to a kidney transplant recipient with limited travel history. Taking into account the difficulty of diagnosing chronic strongyloidiasis infection and the increase in travel and immunosuppressive treatments, we recommend pragmatic management guidelines to limit the risks of infection.
[Intestinal strongyloidiasis in a psoriasis patient with diabetes].
Iraz Meryem,Karaman Ulkü,Topukçu Buğçe,Doymaz Mehmet Ziya
Turkiye parazitolojii dergisi
This case study underlined the importance of parasitological examination before starting immunosuppressive treatment since a heavy burden of strongyloidiasis could lead to fatal infections. It represents the first strongyloidiasis from a patient with psoriasis and diabetes mellitus in this country. In the case, 59 years old female subject had psoriasis for six years and during the treatment with topical corticosteroid and anti-psorial medication, psoriatic lesions flared up. The patient had constipation and foul smelling stool complaints. Blood tests showed an increase in eosinophil and a decrease of vitamin B12 level. Stool examination indicated the presence of abundant amount of S. stercoralis larvae. The patient was given albendazole for two weeks. After treatment, the symptoms decreased and S. stercoralis larvae were not detected in stool. In this case, it was emphasized that the clinicians planning immunosuppressive regimens should bear in mind that parasitic examination could be present in the subjects.
The autochthonous cases of acute strongyloidiasis in the Moscow region.
Bronstein Alexandr M,Lukashev Alexandr N,Maximova Maria S,Sacharova Tatiana V
Introduction:At present, strongyloidiasis is considered by the World Health Organizaiton (WHO) as one of the most neglected diseases. Case report:A husband and a wife, both born in the Moscow region and never having traveled, initially presented with fever and unexplained peripheral eosinophilia. Parasitological examination revealed in feces samples. Helminth infection was strongly associated with poor sanitary conditions. While albendazole was ineffective, after the treatment with ivermectin, both patients were asymptomatic, their ELISA tests were negative, and no larvae of were found in the feces. Conclusions:We concluded that patients with unexplained eosinophilia must be checked for the presence of parasites before steroid or immunosuppressive therapy. These patients, if infected, may develop the highly fatal hyperinfective syndrome. The cases reported here raise concern about possible hidden strongyloidiasis in the Moscow region and re-emergence of this infection in this and other temperate regions in Russia.
Gastric Strongyloidiasis: Report of 2 Cases and Brief Review of the Literature.
Mohamed Rawia,Hamodat Mowafak M,Al-Abbadi Mousa A
Strongyloides stercoralis is an intestinal nematode with a complicated lifecycle and auto-infection. In healthy individuals, this parasite usually does not cause any symptoms. But in immunocompromised patients, the symptoms vary from abdominal pain and discomfort to sepsis and death.Gastric infection and involvement by this nematode are rare and uncommon. Here we report 2 cases of Strongyloides stercoralis hyperinfection that were discovered in gastric biopsies in 2 immunocompromised patients. A gastric biopsy was taken for each patient and both showed cross sections of adult worms, eggs, and rhabditiform larvae of S. stercoralis embedded within gastric crypts. This short report describes these 2 immunocompromised patients with disseminated infection by S. strecoralis with gastric involvement with emphasis on recognition of the histological findings in gastric biopsies.
Strongyloides hyper-infection: a case for awareness.
Potter A,Stephens D,De Keulenaer B
Annals of tropical medicine and parasitology
In patients receiving immunosuppressive therapies, Strongyloides stercoralis can cause a life-threatening septic shock, with multi-organ failure and infestation. Strongyloides hyper-infection should be considered in any immunosuppressed patient who has been exposed to the parasite, even if it is many years since that exposure occurred. Delayed eosinophilia may be a feature and treatment with high doses of anthelmintics may be required. An interesting case of S. stercoralis hyper-infection was recently observed at the Royal Darwin Hospital in tropical, northern Australia. The patient was an 18-year-old female with lupus glomerulonephritis, who was receiving immunosuppression in the form of corticosteroids and pulse cyclophosphamide. The characteristics and intensive-care management of this case, including the use of granulocyte-colony stimulating factor and high-dose ivermectin, are described. The patient, who survived, appears to represent the first reported case of S. stercoralis hyper-infection with suspected myocarditis.
Case report: failure of subcutaneous ivermectin in treating Strongyloides hyperinfection.
Leung Victor,Al-Rawahi Ghada N,Grant Jennifer,Fleckenstein Lawrence,Bowie William
The American journal of tropical medicine and hygiene
A man with Escherichia coli meningitis and bacteremia, while on dexamethasone, developed Strongyloides hyperinfection syndrome and died despite salvage therapy with subcutaneous ivermectin. We report the first documented total and free levels of subcutaneous ivermectin used for therapy.
Hyperinfection strongyloidiasis in renal transplant recipients.
Khuroo Mehnaaz S
BMJ case reports
Strongyloidiasis is infection caused by the nematode Strongyloides stercoralis. Chronic uncomplicated strongyloidiasis is known to occur in immunocompetent individuals while hyperinfection and dissemination occurs in selective immunosuppressed hosts particularly those on corticosteroid therapy. We report two cases of hyperinfection strongyloidiasis in renal transplant recipients and document endoscopic and pathological changes in the involved small bowel. One patient presented with features of dehydration and malnutrition while another developed ileal obstruction and strangulation, requiring bowel resection. Oesophagogastroduodenoscopy showed erythematous and thickened duodenal mucosal folds. Histopathological examination of duodenal biopsies revealed S. stercoralis worms, larvae and eggs embedded in mucosa and submucosa. Wet mount stool preparation showed filariform larvae of S. stercoralis in both cases. Patients were managed with anthelmintic therapy (ivermectin/albendazole) and concurrent reduction of immunosuppression. Both patients had uneventful recovery. Complicated strongyloidiasis should be suspected in immunocompromised hosts who present with abdominal pain, vomiting and diarrhoea, particularly in endemic areas.
Gastrointestinal strongyloidiasis in immunocompromised patients: a case report.
Moghadam Katayoun G,Khashayar Patricia,Hashemi Mahmoodreza
Acta medica Indonesiana
Strongyloides stercoralis is an intestinal nematode, endemic in tropical countries. The parasite has a complex life cycle, causing a long-lived auto infection in hosts. It may remain asymptomatic or with minor symptoms; the dormant carrier state of the illness may persist for a long period of time. Inflammatory bowel disease (IBD) including Crohn's disease (CD) and ulcerative colitis (UC), commonly treated with immunosuppressive drugs is a well-known condition predisposing individuals to various infections. The condition is more prevalent among immunocompromised patients; the diagnosis of which, however, is troublesome in such individuals. The present article reports a 45- year-old female with gastric strongyloides stercoralis infection while receiving the treatment for her underlying UC. Strongyloides stercoralis can easily be missed especially in IBD patients in the absence of accompanying diarrhea or any symptom of lower GI discomfort because it presents with various manifestations including multiple GI symptoms, multiple stool exams and special attention to peripheral eosinophilia are specially important but not so sensitive or specific.
Strongyloides hyperinfection syndrome and VRE pneumonia.
Abu Omar Mohannad,Abu Ghanimeh Mouhanna,Kim Sola,Howell Gregory
BMJ case reports
Immunocompromised patients have high risk of infections from bacteria, viruses, fungi and parasites. One of these infections is those caused by Strongyloides stercoralis Immunocompromised patients are at risk of hyperinfection syndrome which is characterised with more systemic manifestation and a higher risk of morbidity and mortality. This can be complicated by coinfection with enteric organisms, specifically Gram-negative. Enterococci are Gram-positive cocci which are inhabitants of the human gastrointestinal tract. Even though enterococci can cause serious infections in multiple sites, they are a rare cause of pneumonia. We present a case of disseminated strongyloides with vancomycin-resistant enterococcus causing pneumonia. The patient had a complicated course with respiratory failure and septic shock. He died eventually due to his severe infections. After a literature review, we could not find a similar case of coinfection of disseminated strongyloides with vancomycin-resistant enterococcus pneumonia in immune-compromised patients.
Strongyloides Hyperinfection Syndrome causing fatal meningitis and septicemia by Citrobacter koseri.
Reyes Felix,Singh Navneet,Anjuman-Khurram Nigar,Lee Jihae,Chow Lillian
is a gram-negative bacillius that belongs to the Enterobacteriaceae family. It is an uncommon pathogen that typically causes meningitis and brain abscesses in children, however central nervous system (CNS) infections are rarely found in adults. We present a case of C. koseri meningitis in an immunocompetent adult secondary to intestinal micro-perforation caused by A 76-year-old man admitted for asthma exacerbation developed septic shock. A lumbar puncture revealed bacterial meningitis. Blood and CSF cultures grew with identical susceptibilities, suggesting infection by one strain. Despite broad-spectrum antibiotics, the patient expired of multi-organ failure. Autopsy identified diffuse alveolar hemorrhage as the immedi ate cause of death with a heavy burden of in his gastrointestinal system, lungs, and meninges. is a gram-negative bacillus of the family. It is an uncommon pathogen that typically causes meningitis and brain abscesses in children. Infections in adults occur in immunocompromised hosts or instances where an insult creates a port of entry. This is the first documented case of sepsis in an immunocompetent host associated with Strongyloides Hyperinfection Syndrome (SHS), where massive parasitic intestinal invasion reaches pulmonary circulation and perforates the alveolar membrane. This case highlights that presence of rare enterobacterial infections should prompt consideration of differentials including SHS.
Mileo Bacelar Guerreiro Flávio,Tavares Sodré Celso,Brandão Pavan Lorena,Feijó Barroso Paulo,Carvalho Quintella Daniele,Cuzzi Tullia,Ramos-E-Silva Marcia
Acta dermatovenerologica Croatica : ADC
Strongyloidiasis is a parasitic infestation caused by the helminth Strongyloides stercoralis. It is essentially gastrointestinal and in general asymptomatic but can sometimes present with skin signs. Immunocompromised patients can develop the disseminated form of the disease due to the parasite's opportunistic behavior, as in cases of coinfection by the human T-lymphotropic type 1 virus (HTLV-1). This article presents a case of a patient infected with HTLV-I and Strongyloides stercoralis who developed the disseminated form. There were purpuric reticulated periumbilical lesions as well as vibices on the patient's flanks. Histopathologic exam of a skin lesion revealed the presence of larvae in the deep reticular dermis. We emphasize the relevance of awareness regarding interaction between HTLV-1 and strongyloidiasis, besides identification of the cutaneous manifestations of the disease to reach an appropriate therapeutic diagnosis.
Strongyloidiasis in a healthy 8-year-old girl in north-eastern USA.
Kratimenos Panagiotis,Koutroulis Ioannis,Vasireddy Deepa,Degroote Richard,Fisher Margaret C
Paediatrics and international child health
A previously healthy, white 8-year-old girl presented with a 1-week history of abdominal pain and vomiting after a trip to a lake in Pennsylvania, north-eastern USA. There was marked dehydration. A raised blood eosinophilic count prompted microscopy for ova and parasites which demonstrated a heavy load of larvae of Strongyloides stercoralis. Charcot-Leyden crystals were also detected. The child received oral ivermectin and made a complete recovery.
A COMPLICATED CASE OF STRONGYLOIDIASIS PRESENTING WITH INTESTINAL LYMPHADENOPATHY OBSTRUCTION: MOLECULAR IDENTIFICATION.
Chunlertrith Kitti,Noiprasit Athiwat,Kularbkaew Churairat,Sanpool Oranuch,Maleewong Wanchai,Intapan Pewpan M
The Southeast Asian journal of tropical medicine and public health
Strongyloides stercoralis is an intestinal nematode, which can cause complications in immune-compromised hosts. We present a rare case of intestinal obstruction due to mesenteric lymphadenopathy, a complication due to strongyloidiasis, developing in a male subject chronically receiving corticosteroid for pemphigus vulgaris. DNA was extracted from biopsied lymph nodes containing nematode larvae and PCR amplified using primers specific for S. stercoralis 18S rDNA. Nucleotide sequence of the amplicon showed identity with that of S. stercoralis deposited in GenBank. To the best of our knowledge, this is the first report of a diagnosis of strongyloidiasis from biopsied samples using molecular techniques.
Strongyloides Infection Presenting as Proximal Small Intestinal Obstruction.
Patra Ananya Apurba,Nath Preetam,Pati Girish Kumar,Panigrahi Sarat Chandra,Mallick Bipadabhanjan,Acharya Jyotiprakash C K,Adhya Amit
ACG case reports journal
Duodenal obstruction is an infrequent but potentially fatal complication of strongyloidiasis infection. can clinically manifest in a broad variety of ways and lacks a classic clinical syndrome, which makes the diagnosis of strongyloidiasis difficult. The diagnosis is usually delayed and made by duodenal aspirate, duodenal biopsy, and/or postoperative biopsy specimen of the resection stricture segment. We present a case of partial duodenal obstruction caused by . A 46-year-old man had presented with repeated bilious vomiting for 12 days. Upper gastrointestinal endoscopy showed ulceronodular mucosa with luminal compromise at the second part of the duodenum. Abdominal computed tomography scan also showed a wall thickening with luminal narrowing of the second and third part of the duodenum. Duodenal mucosal biopsy revealed larval forms of .
A case report suggestive of strongyloidiasis infection occurring in temperate Australia.
Rural and remote health
Strongyloides stercoralis is a nematode that can cause fatal systemic or disseminated infections in immunocompromised persons. It is known to be endemic in tropical Australia. Sporadic cases arising from temperate regions are reported in Russia and North America. An Aboriginal woman aged 71 years with ovarian carcinoma developed worsening lethargy and tiredness. She was diagnosed with strongyloidiasis based on serology in 2015. She had resided in the state of New South Wales all her life. This case report provides further evidence that strongyloides transmission is possible in temperate areas of Australia and has occurred in the past when sanitation was not as advanced as it is today.
Notes from the Field: Strongyloidiasis at a Long-Term-Care Facility for the Developmentally Disabled - Arizona, 2015.
Jones Jefferson M,Hill Clancey,Briggs Graham,Gray Elizabeth,Handali Sukwan,McAuliffe Isabel,Montgomery Susan,Komatsu Kenneth,Adams Laura
MMWR. Morbidity and mortality weekly report
Strongyloides stercoralis is an intestinal nematode endemic in the tropics and subtropics. Infection is usually acquired through skin contact with contaminated soil, or less commonly, from person to person through fecal contamination of the immediate environment. Infections are often asymptomatic, but can result in a pruritic rash, respiratory symptoms (e.g., cough or wheeze), and gastrointestinal symptoms (e.g., diarrhea and vomiting). Immunosuppressed persons can develop strongyloides hyperinfection syndrome, which can be fatal (1). In June 2015, the Pinal County Public Health Services District in Arizona was notified of a suspected strongyloidiasis infection in a resident of a long-term-care facility for developmentally disabled persons. The patient had anemia and chronic eosinophilia. The patient's serum tested positive for S. stercoralis-specific immunoglobulin G (IgG) by a commercial enzyme-linked immunosorbent assay (ELISA) and at CDC by a crude antigen ELISA, a quantitative assay for detection of IgG against S. stercoralis. An investigation was conducted to determine the infection source and identify additional cases.
Strongyloides as a cause of fever of unknown origin.
Neumann Iliana,Ritter Rhianna,Mounsey Anne
Journal of the American Board of Family Medicine : JABFM
Strongyloides is endemic in parts of the United States. Most often it is asymptomatic but it has a wide range of clinical presentations. Because of the unusual capacity of strongyloides for autoinfection, it can cause hyperinfection, when it effects the pulmonary and gastrointestinal systems, or disseminated infection, when other organs are involved. Both hyperinfection and disseminated strongyloides usually occur in immunosuppressed patients. We report a case of hyperinfection with strongyloides in a man presenting with fever of unknown origin who was not immunosuppressed.
[Histological diagnosis of strongyloidiasis in the Medical Unit of High Specialty of Puebla].
Pérez-Corro Miguel Ángel,Baltazar-Ramos Javier Iván,Montano-Hernández Alejandra,Cabrales-Santiago Héctor Enrique,Cadena-Reyes Jacinto
Revista medica del Instituto Mexicano del Seguro Social
Background:Strongyloides stercolaris is one of the most important intestinal nematodes due to its worldwide distribution. It’s estimated that it affects 50 to 100 million people in 70 countries of the world. In a large percentage of cases it is asymptomatic, however, patients with immunosuppression may present more serious symptoms. The life cycle of this parasite comprises two phases: one as a free-living organism and the other as a parasite. The objective of this case report is to describe the histological findings compatible with this parasitosis and the importance of recognizing them in order to provide adequate and timely treatment. Case report:This is a 37-year-old male patient who began his condition in December 2018, with an acute respiratory condition that occurs after a diarrheal event. Due to the initial evolution, the presumptive diagnosis of Crohn’s disease was made, treated with prednisone without showing improvement. During follow-up, stomach and duodenal biopsies were performed, among others, which allowed the detection of S. stercolaris, which was managed with ivermectin. Conclusions:The case presented agrees with what is referred to in the consulted literature, as it demonstrates the wide spectrum of clinical manifestations, the relationship with immunosuppression states and how frequent it is to make a first-instance erroneous diagnosis. Likewise, it exemplifies the difficulty involved in making the diagnosis of a parasitosis through histological study, due to the particularities of the parasite itself, as well as the little familiarity that the surgical pathologist may have due to how unusual this pathology is outside of tropical environments.
Severe strongyloidiasis and systemic vasculitis: comorbidity, association or both? Case-based review.
Miskovic Rada,Plavsic Aleksandra,Bolpacic Jasna,Raskovic Sanvila,Ranin Jovan,Bogic Mirjana
A possible association between strongyloidiasis and systemic vasculitis is rarely reported in the literature. We report the case of a patient with severe strongyloidiasis and an angiographic finding consistent with polyarteritis nodosa. Diagnosis of strongyloidiasis was made by finding of larvae and adult parasites in samples of the upper gastrointestinal tract mucosa and stool. The patient was treated with albendazole, ivermectin and corticosteroid withdrawal. This therapy led to the resolution of symptoms, with repeated stool samples negative for S. stercoralis. However, the clinical course was complicated with pulmonary tuberculosis. Despite tuberculostatic therapy and supportive measures, a lethal outcome occurred. The report is followed by a focused review of the available literature on the association of strongyloidiasis and systemic vasculitis.
Strongyloides hyperinfection syndrome complications: a case report and review of the literature.
Najmuddin Asif,Hadique Sarah,Parker John
The West Virginia medical journal
Strongyloidiasis is a major global health challenge that is often underestimated in many countries. In immuno-compromised hosts, an autoinfection can go unchecked with large numbers of invasive Strongyloides larvae disseminating widely and causing hyperinfection, with fatal consequences. This review will highlight a case of gram negative bacteremia complicated by meningitis and Adult Respiratory Distress Syndrome (ARDS) as a fatal outcome of Strongyloides hyperinfection, commonly known to occur in the setting of immunosuppression. A middle aged female with chronic lymphocytic leukemia and hypogammaglobulinemia presented with severe respiratory distress requiring intubation. She had been on intermittent corticosteroids and multiple courses of antibiotics for the past six months for COPD exacerbations. Bronchoalveolar lavage showed Strongyloides stercoralis. Blood cultures grew Vancomycin Resistant Enterococci and a few days later Vancomycin Sensitive Enterococcus was found in the CSF. Afterwards, she grew Vancomycin Sensitive Enterococcus in the blood. She was treated with Ivermectin and Albendazole for Strongyloides and Linezolid and Vancomycin for these two different strains of E. faecium. After initial resolution of bacteremia and meningitis, she relapsed three weeks later with the same organism growing in the CSF. The clinical course continued to deteriorate with the development of significant neurological dysfunction. Poor nutritional state and ventilator associated pneumonia contributed to this downward trend. After a detailed discussion with the family, life support was discontinued and the patient succumbed to her illness.
Donor-derived strongyloidiasis in a Saudi pediatric kidney transplant recipient: A case report and mini-review.
Alsager Khaled,Waqar Saadia,Furrukh Hina,Alattas Nadia
S. stercoralis infection has been identified as a donor-derived infection in cases of solid organ transplant among recipients with no prior risk factor for parasitic exposure. Worldwide and regional reports from the adult kidney transplant population highlight this indirect method of infection and caution about delayed diagnosis, severe complications, and death related to donor-derived S. stercoralis infection. We report a deceased-donor-derived S. stercoralis infection in a 12-year-old Saudi girl who underwent kidney transplantation. This is the first pediatric case reported outside the United States of America. Although she presented with mild bouts of gastrointestinal symptoms, the need for additional immune suppression put her at risk of serious complications. A literature review highlights the importance of awareness about S. stercoralis infections and complications in kidney transplant recipients, pretransplant screening of donors based on risk assessment, and the challenges with treatment availability and duration in this vulnerable population.
Strongyloidiasis in a diabetic patient accompanied by gastrointestinal stromal tumor: cause of eosinophilia unresponsive to steroid therapy.
Won Eun Jeong,Jeon Jin,Koh Young-Il,Ryang Dong Wook
The Korean journal of parasitology
We report here a case of strongyloidiasis in a 72-year-old diabetic patient (woman) accompanied by gastrointestinal stromal tumor receiving imatinib therapy, first diagnosed as hypereosinophilic syndrome and treated with steroids for uncontrolled eosinophilia. She suffered from lower back pain and intermittent abdominal discomfort with nausea and diagnosed with gastrointestinal stromal tumor. After post-operative imatinib treatment eosinophilia persisted, so that steroid therapy was started under an impression of hypereosinophilic syndrome. In spite of 6 months steroid therapy, eosinophilia persisted. Stool examination was performed to rule out intestinal helminth infections. Rhabditoid larvae of Strongyloides stercoralis were detected and the patient was diagnosed as strongyloidiasis. This diagnosis was confirmed again by PCR. The patient was treated with albendazole for 14 days and her abdominal pain and diarrhea improved. This case highlights the need for thorough investigation, including molecular approaches, to test for strongyloidiasis before and during steroid therapies.
[Strongyloides stercoralis in the south of Galicia].
Martínez-Vázquez C,González Mediero G,Núñez M,Pérez S,García-Fernaández J M,Gimena B
Anales de medicina interna (Madrid, Spain : 1984)
Strongyloides stercoralis is the only parasite which can produce a chronic illness in humans, being through autoinfection. This nematode can also provoke death when patient's immunologic state deteriorates producing a massive hyper infection. The first patient with strongyloidiasis who has always lived in the Galician South area is described. The clinical picture consisted of unspecific cutaneous lesions and abdominal pain with severe peripheral eosinophilia (> 20,000/ml. The diagnosis was carried out observing the larvae in the fecal examination and was confirmed with a culture. Treatment with albendazole failed and the healing was reached with ivermectin. We must consider the possibility of strongyloidiasis because misdiagnosing these patients as eosinophilic gastroenteritis there would be a higher risk of hyperinfection if they are treated with corticosteroids.
Strongyloides stercoralis infestation associated with septicemia due to intestinal transmural migration of bacteria.
Ghoshal Uday C,Ghoshal Ujjala,Jain Manoj,Kumar Arvind,Aggarwal Rakesh,Misra Asha,Ayyagari Archana,Naik Subhash R
Journal of gastroenterology and hepatology
Strongyloides stercoralis infestation is common in the tropics and is usually asymptomatic. Patients with immunocompromised states may develop hyperinfection and fulminant disease. It has been suggested that bacteria accompany S. stercoralis during its passage across the bowel wall, resulting in systemic sepsis. Herein is a report on a 30-year-old man with S. stercoralis infestation and small bowel bacterial overgrowth presenting as malabsorption syndrome. He developed extensive duodenojejunal ulceration, septicemia and fatal hypokalemia. Blood and jejunal fluid grew Escherichia coli with the same antibiotic sensitivity patterns. This supports the hypothesis of migration of bacteria from the intestinal lumen as a cause of septicemia in patients with fulminant S. stercoralis infestation.
Strongyloides Hyperinfection Causing Gastrointestinal Bleeding and Bacteremia in an Immunocompromised Patient.
De la Cruz Mayhua Juan Carlos,Rizvi Bisharah
Strongyloidiasis is a parasitic infestation caused by ( Most cases are asymptomatic or mildly symptomatic with respiratory, gastrointestinal, or non-specific cutaneous symptoms. However, in immunocompromised patients, such as patients on chronic corticosteroids, malignancy, or human immunodeficiency virus (HIV) infection, hyperinfection syndrome can occur. The following is a case of hyperinfection in an individual taking prednisone for uveitis who developed upper gastrointestinal (GI) bleed and gram-negative bacteremia.
Strongyloides disseminated infection successfully treated with parenteral ivermectin: case report with drug concentration measurements and review of the literature.
Donadello Katia,Cristallini Stefano,Taccone Fabio Silvio,Lorent Sophie,Vincent Jean-Louis,de Backer Daniel,Jacobs Frédérique
International journal of antimicrobial agents
We report the case of an immunosuppressed patient with Strongyloides disseminated infection who was successfully treated with the veterinary parenteral form of ivermectin. A kidney transplant recipient developed disseminated infection with Strongyloides stercoralis. Because oral treatment with ivermectin was not possible, subcutaneous ivermectin (75 µg/kg/day, then 200 µg/kg/day) was given for 9 days, with clinical improvement and disappearance of all larvae. Serum ivermectin concentrations were between 15.6 ng/mL and 19.7 ng/mL during the 9 days of therapy; however, drug accumulation (plasma levels >40 ng/mL) 48 h after discontinuation of therapy was associated with the development with encephalopathy. We also review all cases of human disseminated Strongyloides infection treated with parenteral ivermectin.
Diagnosis of Strongyloides stercoralis in a peritoneal effusion from an HIV-seropositive man. A case report.
Hong In S,Zaidi Syed Y,McEvoy Peter,Neafie Ronald C
BACKGROUND:Strongyloides stercoralis, a nematode parasite in humans with free-living and autoinfective cycles, is often an asymptomatic infection of the upper small intestine. If the host becomes immunocompromised, autoinfection may increase the intestinal worm burden and lead to disseminated strongyloidiasis. The parthenogenetic adult female larvae can remain embedded in the mucosa of the small intestine for years, producing eggs that develop into either rhabditiform, noninfective larvae or filariform, infective larvae. Manifestations of dissemination occur when the filariform larvae penetrate the intestinal wall and migrate into the blood. Pulmonary involvement is common, and the central nervous system may be affected. Blood eosinophilia is typical, and gram-negative sepsis from enteric bacteria may occur. Much less commonly described is invasion of the peritoneal cavity with peritoneal effusion. CASE:A 49-year-old man who came to the United States from Liberia 4 years earlier presented with sudden onset of severe abdominal distention, generalized weakness and marked pedal edema. Diagnostic paracentesis showed numerous filariform larvae of S stercoralis. Stool examination confirmed the presence of both rhabditiform and filariform larvae. Subsequently the patient was found to be HIV seropositive, with a CD4 lymphocyte count of 59. CONCLUSION:Early detection of S stercoralis may alter the often-fatal course of infection. The present case is the second reported one in the English-language literature of the diagnosis of S stercoralis in ascitic fluid.
Strongyloidiasis duodenum: A histopathological study.
Pandey Rimi,Agarwal Padam Kumari,Katiyar Prashant
Indian journal of pathology & microbiology
Strongyloides stercoralis is an intestinal nematode that infects humans, percutaneously and has a complex life cycle. We report a case of a thirty year old male presenting with chief complaints of profuse watery diarrhoea, abdominal fullness, loss of appetite, creepy abdominal pain and low-grade fever for the last one month. He was on corticosteroids for systemic sclerosis. Endoscopy showed thickened and oedematous duodenal folds with pinpoint areas of bleeding and multiple ulcerations on the duodenal mucosa. Histopathologial examination of duodenal biopsy revealed infestation by Strongyloides stercoralis in the duodenum, the duodenal mucosal glands were occupied by various parts of parasite. The patient was successfully treated and had uneventful recovery.
Fatal Strongyloides stercoralis infection in a young woman with lupus glomerulonephritis.
Arsić-Arsenijević Valentina,Dzamić Aleksandar,Dzamić Zoran,Milobratović Danica,Tomić Dragan
Journal of nephrology
We report a case of fatal Strongyloides stercoralis (S. stercoralis) infection in a 35-year-old female with lupus glomerulonephritis after prolonged steroid therapy. An epidemiological evaluation revealed that our patient originated from a rural area in Bosnia and Herzegovina, which was an endemic region of S. stercoralis infection in the former Yugoslavia. She had severe gastrointestinal and pulmonary symptoms and history of a 13 kg weight loss in 3 months. Histopathological examination of large bowel mucosa showed nematode larvae. Microscopy of stool, sputum and urine samples confirmed S. stercoralis. The diagnosis was delayed because of the low suspicion index, the absence of eosinophilia and non-specific signs of infection, which could be a result of the underlying disease or the effects of corticosteroids. This case highlights the importance of screening for S. stercoralis in patients starting immunosuppressive therapy, especially if they are from endemic areas. Timely diagnosis and therapy could save the patient's life.
The Worm that Clogs the Lungs: Strongyloides Hyper-Infection Leading to Fatal Acute Respiratory Distress Syndrome (ARDS).
Nnaoma Christopher,Chika-Nwosuh Ogechukwu,Engell Christian
The American journal of case reports
BACKGROUND Strongyloides stercoralis is an intestinal helminth. Parasitism is caused by penetration of the larvae through the skin. It is endemic in tropical and subtropical regions of the world and in the United States occurs in the southeastern region. It has a tendency to remain dormant or progress to a state of hyper-infection during immunosuppression. CASE REPORT We present the case of a 70-year-old Nigerian who developed fatal ARDS secondary to Strongyloides infection after been treated with steroids for treatment of autoimmune necrotizing myopathy. Despite adequate management with mechanical ventilation and appropriate antifungal therapy, the patient died on day 19 of hospitalization. CONCLUSIONS S. stercoralis is known to affect every organ in the body. ARDS is often an overlooked complication of Strongyloides hyper-infection, which is often deadly. Immediate diagnosis and treatment are important for patient survival.
[Strongyloides stercoralis infestation in an immunocompetent 82-year-old woman].
López Gaona Virginia,Miñana Climent Juan Carlos,Delgado Parada Eduardo,Gutiérrez Vara Solange,Vázquez Valdés Fernando,Solano Jaurrieta Juan José
Revista espanola de geriatria y gerontologia
A laboratory finding of eosinophilia in patients with gastrointestinal symptoms should prompt the differential diagnosis of a parasitosis. The diagnosis is based on identification of larvae in three different stool samples. We report the case of an 82-year-old woman who was independent for instrumental and advanced activities of daily living and showed no risk factors for strongyloidiasis who was admitted to our service with diarrhoea and abdominal pain. Blood examination showed peripheral eosinophilia of 38%. Stool sample revealed Strongyloides stercoralis. In the patient's case history, we found similar clinical features with fluctuating eosinophilia over the previous 8 years. The patient was treated with albendazole, resulting in clinical improvement and elimination of eosinophilia.
Strongyloides stercoralis: a cause of morbidity and mortality for indigenous people in Central Australia.
Einsiedel L,Fernandes L
Internal medicine journal
BACKGROUND:Strongyloides stercoralis may cause a complicated infection in immunocompromised patients, which has a high case fatality rate. Death generally results from sepsis with enteric pathogens. Globally, infection with the human T-cell lymphotropic virus type 1 (HTLV-1) is a major risk factor for this syndrome. Both S. stercoralis and HTLV-1 are endemic to Central Australia. AIMS:The aim of the study was to determine whether complicated strongyloidiasis occurs in association with HTLV-1 infection in Central Australia. METHODS:A retrospective audit of all cases of complicated strongyloidiasis presenting to Alice Springs Hospital between January 2000 and December 2006 was carried out. Diagnosis was defined as definite or probable according to whether diagnosis was made by faecal studies or serology respectively. The medical records, investigations and outcomes of patients who met predetermined criteria for a diagnosis of complicated strongyloidiasis were reviewed. RESULTS:Eighteen indigenous patients met the criteria for complicated strongyloidiasis (definite 9, probable 9). Seven of 11 patients tested were HTLV-1 seropositive. At diagnosis, no treatment was documented for nine patients (definite 4, probable 5), three received a single dose of ivermectin and one a single dose of albendazole. Fifteen patients (83%) died because of sepsis (definite 7, probable 8). Pathogens isolated and their foci of infection included Klebsiella pneumoniae pneumonia (4), bloodstream infection with Enterococcus spp. (2), K. pneumoniae peritonitis (1) and streptococcal meningitis (1). CONCLUSION:Complicated strongyloidiasis occurs in association with HTLV-1 infection in central Australia. This finding has significant implications for the management of S. stercoralis in the region.
Pancreatitis associated with Strongyloides stercoralis infection in a patient chronically treated with corticosteroids.
Jones Nathan,Cocchiarella Andrew,Faris Khaldoun,Heard Stephen O
Journal of intensive care medicine
Strongyloides stercoralis is a nematode that is a ubiquitous parasite in man. Life-threatening infections can occur in immunocompromised patients. We report a case of a 64-year-old Puerto Rican gentleman treated chronically with corticosteroids for reactive airway disease, who presented to our institution with pancreatitis complicated by sepsis and acute lung injury requiring mechanical ventilation. The initial working diagnosis was gallstone pancreatitis; however, several days into his hospital course, he was found to have a history of strongyloidiasis. Subsequent examination of his stool revealed the parasite, and the patient was treated with ivermectin. This case highlights the occasional association between pancreatitis and strongyloidiasis and the importance of proper treatment and consideration of infection in patients from endemic regions, which include Central America, Africa, and Asia.
Strongyloides stercoralis hyperinfection syndrome after liver transplantation: case report and literature review.
Vilela E G,Clemente W T,Mira R R L,Torres H O G,Veloso L F,Fonseca L P,de Carvalho E Fonseca L R,Franca M d C,Lima A S
Transplant infectious disease : an official journal of the Transplantation Society
Strongyloides stercoralis is an intestinal nematode that causes human infections and whose life cycle has special features, including autoinfection. Strongyloides infection may be asymptomatic for years, owing to a low parasite load. During immunosuppressive therapy, however, if cellular immunity is depressed, autoinfection can occur at a higher rate, resulting in hyperinfection syndrome. In this specific circumstance, it can become a fatal illness. We describe a case of hyperinfection syndrome in a liver transplant recipient and also review the literature.
[Chronic Strongyloides stercoralis infection. Larva currens as skin manifestation].
Der Hautarzt; Zeitschrift fur Dermatologie, Venerologie, und verwandte Gebiete
Strongyloidiasis is a nematode infection that can persist asymptomatically for years. Pathognomonic skin manifestation is the larva currens. A human immunodeficiency virus-infected patient native from an endemic area presented with pruritus, an urticarial serpiginous rash and eosinophilia. The histology was not helpful. Strongyloidiasis was confirmed on the basis of stool and serum examination. He was treated successfully with Ivermectin.
Gastric infection by Strongyloides stercoralis: a case report.
Yaldiz Mehmet,Hakverdi Sibel,Aslan Ahmet,Temiz Muhittin,Culha Gülnaz
The Turkish journal of gastroenterology : the official journal of Turkish Society of Gastroenterology
Strongyloides stercoralis is an intestinal nematode with a complex life cycle that involves colonizing and reproducing in the upper small intestinal mucosa. In a healthy host, the parasite usually does not cause any symptoms. We report a gastric infection case of S. stercoralis. A 72-year-old Turkish man was admitted to the Department of General Surgery with complaints of epigastric pain, nausea and vomiting for five days. Upper gastrointestinal endoscopy evidenced a diffuse infiltrate in the stomach, causing decreased distensibility. Microscopically, superficial chronic inflammation with hyperplastic reactive changes and damaged surface was observed. Histopathological examination of the gastric mucosa showed numerous cross-sections of adult worms, eggs and rhabditiform larvae of S. stercoralis developing in the gastric crypts.
Hyperinfection of Strongyloides stercoralis in an immunocompetent patient.
Tiwari Shreekant,Rautaraya Bibhudutta,Tripathy Krishna Padarabinda
Strongyloides stercoralis is an intestinal nematode causing endemic infection, mostly in immunocompromised individuals, in tropical and subtropical regions. Herewith, we are reporting a rare case of this kind in immunocompetent patient. A 31-year-old male patient presented with chief complaints of chronic diarrhea and loss of weight since last 4 months. He reported passing watery and foul smelling stool. He also had loss of appetite since last 2 months and was diagnosed as diabetic since last 4 months but he was not given any treatment for this and his fasting blood sugar was 110 mg/dl. His HIV status was negative. Stool examination done on three occasions showed plenty of S. stercoralis larvae. Patient responded well to albendazole therapy. Strongyloidiasis is not always associated with compromise in immune status. It should be suspected in immunocompetent individuals with history of long-term diarrhea and weight loss.
disseminated infection and schistosomiasis in an AIDS patient.
Brandão Rodrigo Martins,Brandão Renata Paula Martins,Gonçalves Amanda Cristina Maria Aparecida,Laborda Lorena Silva,de Lima Patricia Picciarelli,de Campos Fernando Peixoto Ferraz
Autopsy & case reports
hyperinfection syndrome is classically associated with impaired host response and implies in an overburden of larvae in its usual cycle. It has been recognized as a severe and potentially fatal condition in immunocompromised individuals, especially those using oral corticosteroids. Infection with not only increases the susceptibility to HIV infection, but also promotes progression to disease. The association of the most severe forms of strongyloidiasis and AIDS is scarcely described, even more when is also associated. The authors describe a case of a 34-year-old previously healthy male, admitted to the emergency department with a history of hematemesis associated with dyspnea, hemoptysis, and fever. He referred homosexual relations for 6 years. Physical examination showed an ill-looking patient, and was remarkable for tachycardia, tachypnea, diaphoresis, and pulse oximetry of 70% in room air. Lungs examination revealed the presence of rales in the left base. Chest radiography showed a diffuse and bilateral reticulo-nodular pattern. HIV serology was positive. Empirical antimicrobial therapy and corticosteroids were initiated. On the third day of hospitalization, petechiae appeared over the periumbilical area, but no further investigation was undertaken because the patient died soon after. The autopsy findings were compatible with disseminated infection, a hepatic intestinal chronic form of schistosomiasis, and septic shock as the primary cause of death. The authors call attention to this infrequent association.
Strongyloides Stercoralis infection associated with repititive bacterial meningitis and SIADH: a case report.
Vandebosch S,Mana F,Goossens A,Urbain D
Acta gastro-enterologica Belgica
Strongyloidiasis is an infection by the intestinal parasite Strongyloides Stercoralis, which usually stays asymptomatic. In some situations a hyperinfection or disseminated disease can occur. We report a case of a 49-year-old Congolese man with a medical history of 5 episodes of bacterial meningitis, who presents himself with a paralytic ileus and a low serum sodium. A Strongyloides hyperinfection with a syndrome of inappropriate secretion of the antidiuretic hormone (SIADH) was diagnosed. After treatment with ivermectine the abdominal symptoms subsided and the serum sodium returned to normal values. In comparison to other case reports our patient had no respiratory or gastrointestinal symptoms during the episodes of bacterial meningitis. Screening for Strongyloides stercoralis is indicated in patients with unexplained SIADH, bacterial meningitis or bacterial septicaemia, who originally come from endemic countries.
Strongyloides Hyperinfection Syndrome: A Curious Case of Asthma Worsened by Systemic Corticosteroids.
Salam Reshad,Sharaan Ahmed,Jackson Stephanie M,Solis Roberto A,Zuberi Jamshed
The American journal of case reports
BACKGROUND Strongyloidiasis, caused by infection with Strongyloides stercoralis parasitic nematodes, is most prevalent in tropical regions of the world, such as South America, Southeast Asia, and sub-Saharan Africa, but its incidence has increased in nonendemic areas of the United States due to immigration. The majority of patients remain asymptomatic or have only mild gastrointestinal, respiratory, or dermatologic symptoms. Unrecognized strongyloidiasis can progress to Strongyloides hyperinfection syndrome, a highly fatal complication that can occur in response to immunosuppressive therapy. This rare complication is easily misdiagnosed because of its similar presentation to asthma or exacerbation of chronic obstructive pulmonary disease. CASE REPORT We report a case of worsening therapeutic response to systemic corticosteroids in an elderly Colombian man who presented with symptoms of acute exacerbation of asthma. His history was positive for residence in a region endemic to S. stercoralis, and he had undergone multiple hospitalizations over the past few years for pulmonary, gastrointestinal, and dermatologic complaints. Laboratory results were significant for increased eosinophilia, and chest radiography showed blunting of the left costophrenic angle. The patient was found to have S. stercoralis hyperinfection after parasitic larvae were detected in a bronchoalveolar lavage sample. Symptoms improved after a course of ivermectin, and the patient was subsequently discharged. CONCLUSIONS This unusual presentation of Strongyloides hyperinfection syndrome showcases the dangers of corticosteroid therapy in individuals with undiagnosed Strongyloides infection who present with a presumed diagnosis of asthma exacerbation. Clinicians should maintain a high level of suspicion when treating patients from S. stercoralis endemic regions presenting with pulmonary, gastrointestinal, and/or dermatologic symptoms. Ivermectin is the current standard of care for both asymptomatic and complicated strongyloidiasis.
Disseminated infection with Strongyloides stercoralis in a diabetic patient.
Murali A,Rajendiran G,Ranganathan K,Shanthakumari S
Indian journal of medical microbiology
A 58-year-old male diabetic who was operated for carcinoma larynx 4 years back was admitted with exertional dyspnoea and bilateral leg swelling for the past 2 years. Over the last 2 months, there was a progressive worsening of symptoms. Echocardiography done 2 years back showed pericardial effusion. Echo done during the current admission also showed pericardial effusion with preserved left ventricular function; cytological examination of the pericardial fluid showed larvae of Strongyloides stercoralis. He was treated with antinematodal drugs. A follow-up echo done at discharge showed no pericardial effusion and the patient was completely asymptomatic. To our knowledge, this is the first reported case of Strongyloides pericardial effusion in a diabetic patient.
Disseminated Strongyloides stercoralis infection in HTLV-1-associated adult T-cell leukemia/lymphoma.
Stewart Donn M,Ramanathan Roshan,Mahanty Siddhartha,Fedorko Daniel P,Janik John E,Morris John C
A 55-year-old woman with human T-cell lymphotropic virus type-1 (HTLV-1)-associated adult T-cell leukemia (ATL) and a history of previously treated Strongyloides stercoralis infection received anti-CD52 monoclonal antibody therapy with alemtuzumab on a clinical trial. After an initial response, she developed ocular involvement by ATL. Alemtuzumab was stopped and high-dose corticosteroid therapy was started to palliate her ocular symptoms. Ten days later, the patient developed diarrhea, vomiting, fever, cough, skin rash, and a deteriorating mental status. She was diagnosed with disseminated S. stercoralis. Corticosteroids were discontinued and the patient received anthelmintic therapy with ivermectin and albendazole with complete clinical recovery.
Strongyloides stercoralis hyperinfection presenting with symptoms mimicking acute exacerbation of chronic obstructive pulmonary disease.
Liu Hsu-Chung,Hsu Jeng-Yuan,Chang Ki-Ming
Journal of the Chinese Medical Association : JCMA
Hyperinfection syndrome with Strongyloides stercoralis is not uncommon in immunocompromised patients. We present 2 fatal cases of Strongyloides hyperinfection with initial presentation mimicking acute exacerbation of chronic obstructive pulmonary disease (COPD). Both cases had a history of COPD and had received systemic steroid treatment before or during admission. The initial chest radiograph in both of these cases showed diffuse axial interstitial pattern. The sputum examinations of Gram stain both yielded larvae of Strongyloides stercoralis precipitously. Case 1 developed acute respiratory distress syndrome and bacteremia of Escherichia coli and Klebsiella pneumoniae soon after admission, and died even after receiving albendazole and antibiotic treatment. Case 2 received albendazole and antibiotic treatment for over 2 weeks, but developed refractory aseptic meningitis and died of septic shock. Neither case had high eosinophil count in peripheral blood during admission. Clinical manifestations of unexplained wheezing and respiratory failure, increased infiltration on chest radiograph, Gram-negative bacteremia, and aseptic meningitis may all be clues of Strongyloides hyperinfection. Due to the high mortality rate and severe complications in these patients, clinicians should always keep this diagnosis in mind, especially when dealing with immunocompromised patients. We suggest that a screening test be done for patients who live in endemic areas and those who are going to receive steroids for chronic disease.
Strongyloides stercoralis in bronchoalveolar lavage specimen processed as Prussian Blue Stain.
Zhao Po,Maleki Zahra
Strongyloidiasis is an infectious disease caused by the nematode helminth, Strogyloides stercoralis. Subjects immunosuppressed, immunocomprised, or on steroids are susceptible to hyperinfection and dissemination. Early detection of parasitic infection in such individuals is extremely important as disseminated Strongyloidiasis is potentially fatal. Here, we present a case of Strongyloidiasis initially detected by Prussian blue stain of bronchoalveolar lavage (BAL) specimen from an immunosuppressed patient who was treated with prednisone for acute interstitial nephritis and developed hemoptysis.
Strongyloides stercoralis in a bronchial washing specimen processed as conventional and Thin-Prep smears: report of a case and a review of the literature.
Grapsa Dimitra,Petrakakou Efthalia,Botsoli-Stergiou Efi,Mikou Panagiota,Athanassiadou Pauline,Karkampasi Athina,Ioakim-Liossi Anna
Strongyloidiasis is an opportunistic infection which may result in a fatal hyperinfection syndrome in immunocompromised patients. We report the case of a pulmonary infection with Strongyloides stercoralis in a 61-year-old male with a history of a long-term administration of corticosteroids. Cytologic examination of a bronchial washing specimen, processed both as conventional and as Thin-Prep smears, revealed an abundance of the typical larvae of Strongyloides stercoralis, amidst a cellular population comprising several acute inflammatory cells as well as bronchial epithelial cells with features of basal cell hyperplasia or regenerative atypia. To the best of our knowledge there is only one previous report describing Strongyloides stercoralis in thin-layer smears, and there are no previous studies comparing its morphology in conventional and thin-layer preparations.
A case of triple infection including strongyloides stercoralis in a microscopic polyangiitis patient.
Cai De-Han,Wang Jun,Fang Xiao-Lin
Respiratory medicine case reports
We present the case of a microscopic polyangiitis (MPA) patient who developed strongyloidiasis, (CF) infection after corticosteroides and immunosuppressant therapy. When digestive, respiratory or other system symptoms consecutively occur in a immunocompromised host who lives in tropical or temperate zone and have close contact with soil, we should take strongyloidiasis into consideration despite absence of eosinophilia. Mixed infection with cannot be easily excluded. It is essential to search for the etiology proof with multiple approaches positively and repeatedly.
Importance of a Rapid and Accurate Diagnosis in and Human T-Lymphotropic Virus 1 Co-infection: A Case Report and Review of the Literature.
Quintero Olga,Berini Carolina A,Waldbaum Carlos,Avagnina Alejandra,Juarez María,Repetto Silvia,Sorda Juan,Biglione Mirna
Frontiers in microbiology
and Human T-Lymphotropic Virus 1 (HTLV-1) share some endemic regions such as Japan, Jamaica, and South America and are mostly diagnosed elsewhere in immigrants from endemic areas. This co-infection has not been documented in Argentina although both pathogens are endemic in the Northwest. We present a case of and HTLV-1 co-infection with an initial presentation due to gastrointestinal symptoms which presented neither eosinophilia nor the presence of larvae in stool samples in a non-endemic area for these infections. A young Peruvian woman living in Buenos Aires attended several emergency rooms and finally ended up admitted in a gastroenterology ward due to incoercible vomiting, diarrhea, abdominal pain, fever, and weight loss. Gastrointestinal symptoms started 3 months before she returned to Argentina from a trip to Peru. She presented malnutrition and abdominal distension parameters. HIV-1 and other immunodeficiencies were discarded. The serial coproparasitological test was negative. Computed tomography showed diffuse thickening of duodenal and jejunal walls. At the beginning, vasculitis was suspected and corticosteroid therapy was initiated. The patient worsened rapidly. Skin, new enteral biopsies, and a new set of coproparasitological samples revealed . Then, HTLV-1 was suspected and infection was confirmed. Ivermectin and albendazole were administrated, until the stool sample remained negative for 2 weeks. Larvae were not observed in fresh stool, Ritchie method, and agar culture 1 week post-treatment. Although she required initial support with parenteral nutrition due to oral intolerance she slowly progressed favorably. It has been highly recommended to include a rapid and sensitive PCR strategy in the algorithm to confirm infection, which has demonstrated to improve early diagnosis in patients at-risk of disseminated strongyloidiasis.
Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) in Strongyloides stercoralis Hyperinfection.
Chowdhury Deepshikha Nag,Dhadham Gautamy Chitiki,Shah Anish,Baddoura Walid
Journal of global infectious diseases
Strongyloides stercoralis (S. stercoralis) is a soil transmitted intestinal roundworm that has a unique ability to multiply within the human host and reinfect the human carrier by a process of autoinfection. By this property, S. stercoralis can persist as an occult infection for many decades. In situations of immunosuppression or other permissive gastrointestinal conditions, there occurs a massive increase in parasite multiplication. The parasites penetrate through the intestinal mucosa and are carried in circulation and can cause multisystem involvement. We report a case of a 76-year-old Columbian male who presented with intractable vomiting and hyponatremia who was then diagnosed to have syndrome of inappropriate antidiuretic hormone (SIADH). The patient's symptoms improved after treatment with two doses of ivermectin and his serum sodium levels returned to normal. S. stercoralis infection should be suspected in patients from endemic regions who present with gastrointestinal symptoms and unexplained hyponatremia.
Late diagnosis of central nervous system involvement associated with lethal dissemination of Strongyloides stercoralis in an advanced HIV patient from Nigeria.
Ursini Tamara,Polilli Ennio,Fazii Paolo,Ieraci Alfio,Sindici Giulia,Parruti Giustino
International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases
Strongyloides stercoralis is a ubiquitous intestinal nematode, endemic in tropical and subtropical areas, with an unusual life cycle in which autoinfection can take place. In the immunosuppressed host, autoinfection is accelerated and larvae can spread in all organs, leading to hyperinfection syndrome or to disseminated disease. Strongyloidiasis is presently rare in Western Countries, often with delayed diagnosis due to a lack of clinical suspicion, nonspecific presentation, and low parasite intestinal output. Foreign HIV-infected patients from endemic areas are at increased risk of severe disease caused by this parasite. Here we report the case of a patient with disseminated lethal disease, whose disseminated state was missed 2 years prior to the current presentation. This emblematic case shows that intestinal parasitic infections, highly prevalent in Sub-Saharan Africa, Southeast Asia, and Latin America, are difficult to recognize but should be thoroughly investigated and excluded in high-risk patients, to prevent severe long-term lethal sequelae.
Strongyloides stercoralis hyperinfection associated with impaired intestinal motility disorder.
Figueira Cláudia Frangioia,Gaspar Márcio Teodoro da Costa,Cos Lynda Dorene,Ussami Edson Yassushi,Otoch José Pinhata,Felipe-Silva Aloisio
Autopsy & case reports
Infection by Strongyloides stercoralis is a highly prevalent helminthiasis, which is mostly distributed in the tropical and subtropical regions of the world. Although a substantial number of cases are asymptomatic or paucisymtomatic, severe and life-threatening forms of this infection still occur and not infrequently is lately diagnosed. Gram-negative bacteria septicemia, which frequently accompanies the severe helminthiasis, contributes to the high mortality rate. Severe infection is invariably triggered by any imbalance in the host's immunity, favoring the auto-infective cycle, which increases the intraluminal parasite burden enormously. Clinical presentation of severe cases is varied, and diagnosis requires a high suspicion index. Acute abdomen has been reported in association with S. stercoralis infection, but intestinal necrosis is rarely found during the surgical approach. The authors report the case of a man who sought the emergency unit with recent onset abdominal pain. Clinical and imaging features were consistent with obstructive acute abdomen. Scattered adhesions and a necrotic ileal segment with a tiny perforation represented the surgical findings. The patient outcome was unfavorable and respiratory distress required an open lung biopsy. Both surgical specimens showed S. stercoralis infection. Unfortunately the patient underwent multiple organ failure and septicemia, and subsequently died. The authors call attention to the finding of intestinal necrosis and impaired intestinal motility disorder as possibilities for the diagnosis and risk factor, respectively, for a severe infection of S. stercoralis.
Fatal Strongyloides stercoralis infection in a patient with chronic inflammatory demyelinating polyneuropathy.
Kalita Jayantee,Bhoi Sanjeev K,Misra Usha Kant
Pathogens and global health
A 50-year-old villager with chronic inflammatory demyelinating polyradiculoneuropathy developed pain abdomen, diarrhea, and vomiting after 8 weeks of prednisolone (40 mg/day) therapy. After 10 weeks, he developed abdominal distension, leucocytosis, thrombocytopenia, liver dysfunction, coagulopathy, and respiratory failure. Stool examination showed larvae of Strongyloides stercoralis. He died in spite of antibiotics, metronidazole, ivermectin, vasopressor, and artificial ventilation. The patients on corticosteroid therapy are at risk of fatal septicemia due to Strongyloides stercoralis hyperinfection.
Hyperinfection with Strongyloides stercoralis.
Romero-Cabello Raúl,Villagroy Gómez Javier,Hernández González Mercedes,Romero Feregrino Raúl
BMJ case reports
Strongyloidiasis is caused by Strongyloides stercoralis, which commonly produces gastrointestinal problems. If immune systems are compromised, the nematode larvae may spread and produce Strongyloides hyperinfection. Diagnosis of strongyloidiasis is based on the observation of larvae in coproparasitological studies. We present a case of a 49-year-oldman, VIH, who developed Strongyloides hyperinfection, diagnosed postmortem. Our patient reached the dissemination stage, which resulted in severe damage to the stomach and intestine, perforation of the intestinal wall, as well as sepsis due to the dissemination of bacteria. The diagnosis is difficult because of the low larvae excretion in stools. It is usually performed by the microscopic examination of fresh and fixed enriched stool samples. Serology was reported to be useful for screening and follow-up after treatment. This case reaffirms that HIV immunosuppression favours the dissemination of S stercoralis larvae. Thus, a search for intestinal parasites should be considered in similar cases.
Transmission of Strongyloides stercoralis through transplantation of solid organs--Pennsylvania, 2012.
MMWR. Morbidity and mortality weekly report
Strongyloides stercoralis is an intestinal nematode endemic in the tropics and subtropics. Immunocompetent hosts typically are asymptomatic, despite chronic Strongyloides infection. In contrast, immunocompromised patients are at risk for hyperinfection syndrome and disseminated disease, with a fatality rate >50%. The infection source for immunocompromised patients, such as solid organ transplant recipients, is not always apparent and might result from reactivation of chronic infection after initiation of immunosuppressive therapy or transmission from the donor. In October 2012, the United Network for Organ Sharing (UNOS) notified CDC of a left kidney and pancreas recipient in Pennsylvania diagnosed with strongyloidiasis. This report summarizes the results of the investigation of the source of Strongyloides infection in three of four organ recipients. Testing of pretransplant donor and recipient sera confirmed that infection in the recipients was donor derived. This investigation underscores the importance of prompt communication between organ procurement organizations, transplant centers, and public health authorities to prevent adverse events in recipients when transmission is suspected. Additionally, it emphasizes the utility of stored pretransplant samples for investigation of suspected transplant-transmitted infections and the need to consider the risk for Strongyloides infection in organ donors.
Fatal septicemic shock associated with Strongyloides stercoralis infection in a patient with angioimmunoblastic T-cell lymphoma: a case report and literature review.
Abdelrahman M Z,Zeehaida M,Rahmah N,Norsyahida A,Madihah B,Azlan H,Nazlee W Z
INTRODUCTION:Strongyloides stercoralis infection can persist in the host for several decades, and patients with cancer and other clinical conditions who are exposed to immunosuppressive therapy are at risk of developing hyperinfection. CASE REPORT:This is a case of angioimmunoblastic T-cell lymphoma (AITL) in a patient with lymphadenopathy and bulky neck mass. Severe sepsis and episodes of diarrhea were observed upon the first cycle of cyclophosphamide, doxorubicin, oncovin (vincristine) and prednisone (CHOP) regime chemotherapy preceded by high dose of dexamethasone. There was Klebsiella pneumoniae bacteremia and moderate eosinophilia. Rhabditiform S. stercoralis larvae were observed in the stool, and this was confirmed by real-time PCR. Strongyloides-specific IgG and IgG4 were also positive. The patient was treated with oral albendazole (400mg/day) for 3 days and intravenous tazocin (4.5gm/6 hours) for 5 days; however he succumbed following multi-organ failure. CONCLUSION:This is likely a case of Strongyloides hyperinfection with secondary bacteremia.
" infestation in a severely malnourished (SAM) celiac disease child:" A rare case report from Western Rajasthan.
Verma Usha,Ashopa Vishakha,Nareda Pooja,Gupta Eshank,Gupta Ekta,Prakash Prabhu
A case of Strongyloides stercoralis infection in severe protein energy malnutrition child with associated celiac disease (CD) is herein reported. The case was a 4-year-old, severely malnourished female admitted to the tertiary level hospital of Western Rajasthan, due to watery diarrhea, pain abdomen, and vomiting, not responding to treatment. The patient was HIV negative, nondiabetic, had no evidence of tuberculosis, Liver Function Test, Renal Function Test were normal was within normal limits. She had microcytic hypochromic anemia, hypoalbuminemia, and serum Antitissue transglutaminase (anti tTG IgA)was 301.35 U/ML which confirmed the diagnosis of CD. Stool parasitological examination revealed numerous rhabditiform larvae of threadworm "S. stercoralis." After treatment with gluten free diet and Albendazole and Ivermectin, the patient recovered without evidence of S. stercoralis in follow-up stool samples.
Strongyloides stercoralis Hyperinfection Syndrome: A Neglected Cause of Abdominal Pain.
Piranavan Paramarajan,Kalantri Pooja,Pandey Deepali,Bharadwaj Hariharan Sivakumar,Verma Ashish
infection is usually acquired from tropics or subtropics, often causes asymptomatic chronic infection, but in immunosuppressed, it can lead to hyperinfection syndrome. We report a case of chronic abdominal pain resulting from infection in a 55-year-old male with a history of partial small bowel resection for small intestinal lymphoma and a recent diagnosis of chronic kidney disease with proteinuria on steroid therapy. He presented with chronic abdominal pain, nausea, loss of appetite, and weight loss. Initial laboratory workup and imaging including retroperitoneal ultrasound and CT of the abdomen/pelvis were within normal limits, and he was discharged on acid suppression therapy. He was readmitted with worsening symptoms and underwent esophagogastroduodenoscopy (EGD) and duodenal biopsy, which revealed infection. We later discovered a travel history to Cambodia. His symptoms resolved with ivermectin therapy. This case highlights the importance of travel history, which can prevent unnecessary investigations and delay in the diagnosis.
Subcutaneous ivermectin use in the treatment of severe Strongyloides stercoralis infection: two case reports and a discussion of the literature.
Barrett Jessica,Broderick Claire,Soulsby Hannah,Wade Paul,Newsholme William
The Journal of antimicrobial chemotherapy
BACKGROUND:Strongyloides stercoralis infection presents with varying degrees of severity, but it often primarily involves the small bowel. In severe infection and cases of hyperinfection, ileus and small-bowel obstruction may prevent enteral absorption of anthelminthics such as ivermectin. At present there are no parenteral anthelminthics licensed for use in humans. METHODS:Here, we describe two cases of severe S. stercoralis infection treated with an unlicensed veterinary preparation of subcutaneous ivermectin, and we discuss the published reports of the use of this treatment elsewhere. RESULTS:Both patients were successfully treated with subcutaneous ivermectin, and both recovered completely. CONCLUSIONS:Despite the limited published experience of parenteral ivermectin use, there is evidence that it may be a safe and effective treatment for severe strongyloidiasis. However, more data are needed to guide dosing schedules and monitoring for toxicity.
Severe Anemia and Lung Nodule in an Immunocompetent Adopted Girl with Strongyloides stercoralis Infection.
Buonfrate Dora,Gobbi Federico,Beltrame Anna,Bisoffi Zeno
The American journal of tropical medicine and hygiene
Strongyloides stercoralis is a soil-transmitted helminth widely diffused in tropical areas. Chronic infection is usually characterized by absent or mild symptoms, but immunocompromised subjects are at risk of developing a severe syndrome that can be fatal if not promptly treated. We report a case of S. stercoralis infection causing severe anemia (hemoglobin 4.9 g/dL) and a lung nodule in a 14-year-old girl of Ethiopian origin adopted by an Italian couple. Severe anemia due to strongyloidiasis has been rarely reported, and mostly in severely ill patients, whereas our patient was immunocompetent and in good general conditions. Also, lung nodules have been only occasionally described in absence of respiratory symptoms. We discuss the management of patients with these findings, and we suggest to update the screening of immigrants from countries endemic for strongyloidiasis, including serology.
Multiorgan Dysfunction Syndrome from Strongyloides stercoralis Hyperinfection in a Patient with Human T-Cell Lymphotropic Virus-1 Coinfection After Initiation of Ivermectin Treatment.
Choksi Tatvam T,Madison Gul,Dar Tawseef,Asif Mohammed,Fleming Kevin,Clarke Leon,Danilewitz Mervyn,Hennawy Randa
The American journal of tropical medicine and hygiene
Strongyloides stercoralis is well known to cause hyperinfection syndrome during the period of immunosuppression; but dissemination, worsening hyperinfection, and development of multiorgan dysfunction syndrome after initiation of ivermectin has not been reported in the past. Herein, we describe the case of a 62-year-old man with chronic strongyloidiasis and human T-cell lymphotropic virus-1 coinfection, who developed significant clinical worsening after 24-48 hours of initiation of treatment with ivermectin (200 μg/kg daily). Oral albendazole (600 mg every 12 hours) was added to the regimen due to clinical deterioration. Notably, after a protracted clinical course with multiple complications, which included respiratory failure from gram-negative pneumonia and pulmonary alveolar hemorrhage, Klebsiella meningitis, Clostridium difficile colitis, and herpes labialis, the patient eventually recovered. Health-care providers should be aware that during the early days of antihelminthic treatment initiation, significant dissemination of S. stercoralis and worsening of the clinical scenario can occur.
Strongyloides Stercoralis Infection: A Rare Cause of Acute Abdomen.
Gao Ashley R,Matta Abhishek
A 30-year-old female presented to the emergency department with severe recurrent abdominal pain, nausea, vomiting and a 50-pound unintentional weight loss within the past few years. After emigrating from Liberia to the United States in 2005, the patient was evaluated for similar complaints in the past and underwent exploratory laparotomies and partial small bowel resection with no significant improvement in symptoms. Computerized tomography (CT) of the abdomen showed intestinal inflammation and mesenteric edema. Small intestinal enteroscopy was unremarkable. Small intestinal biopsy showed larval round worms in intestinal crypts. Stool ova and parasite exam revealed larval forms of Strongyloides stercoralis. She was treated with ivermectin 200 mcg/kg daily for two days and recommended to return in four weeks to repeat stool exam to ensure complete parasite clearance.
[Strongyloides stercoralis hyperinfection syndrome in a patient with Behçet's Disease].
Yılmaz Insu,Cağlar Banu,Akay Bengü Nisa,Alkız Gamze,Boyvat Ayşe,Akyol Aynur
Turkiye parazitolojii dergisi
Strongyloides stercoralis is endemic in the tropical and subtropical areas of the world. It is a soil-transmitted intestinal nematode affecting anywhere from 30 to 100 million people worldwide. Strongyloides stercoralis is capable of causing autoinfection, which increases larval migration and proliferation in the host. This condition may lead to hyperinfection syndrome which has the potential to cause serious life threatening complications, especially in immunosuppressed patients. Thus, Strongyloides stercoralis hyperinfection syndrome should be suspected if there are clinical clues including gastrointestinal tract symptoms (abdominal pain, nausea, vomiting, diarrhoea), respiratory tract symptoms (cough, dyspnoea, wheezing, haemoptysis), skin symptoms (pruritus, erythema) and peripheral eosinophilia in a patient with underlying risk factors. Herein, we report a case of Strongyloides stercoralis hyperinfection syndrome in a patient with Behçet's Disease on immunosuppressive treatment.
Henoch-Schönlein purpura associated with Strongyloides stercoralis infection.
Janković Sveta,Nikolić Marijana,Simović Aleksandra,Vujić Ana
INTRODUCTION:Henoch-Schönlein purpura (HSP) is a small blood vessel vasculitis, which usually manifests during childhood. The exact cause of the disease is unknown. CASE REPORT:We reported a 14-year-old girl who had been admitted to our clinic due to the appearance of red macules on her extremities and face, vomiting, and pain in the abdomen and joints. The patient was initially diagnosed with Henoch-Schönlein purpura. At the end of the fourth week of illness, larvae of Strongyloides stercoralis were detected in stool samples. The patient was therefore treated with mebendazole, after which all symptoms permanently withdrew. About a month later laboratory examinations were repeated demonstrating increasing signs of renal damage. Kidney biopsy was performed, showing mesangioproliferative glomerulonephritis with crescents and IgA and C3 positive staining in the mesangium. Upon reviewing the clinical presentation, biochemically demonstrated progressive renal damage and biopsy results, the patient was diagnosed with HSP nephritis. CONCLUSION:The time course of the disease and present knowledge concerning the pathogenic mechanisms of HSP suggest that Strongyloides stercoralis infection could have caused HSP in the presented patient, which was complicated by nephritis.
Recurrence of strongyloides stercoralis infection in a patient with Hansen's disease: a case report.
De Souza Joelma Nascimento,Machado Paulo Roberto Lima,Teixeira Márcia Cristina Aquino,Soares Neci Matos
In patients with immunosuppressive disorders, S. stercoralis infection may develop into a hyperinfection syndrome which, on rare occasions, may be a life-threatening condition. Therapy of S. stercoralis infection with thiabendazole has been limited, due to its numerous side effects, and has been replaced by albendazole and ivermectin. The present case report describes a case of Strongyloides Hyperinfection Syndrome (SHS) in a patient with Hansen's disease and lack of response to first-line anthelmintic treatment. A 38 year-old man was diagnosed as having borderline lepromatous leprosy. He developed Erythema Nodosum Leprosum and was treated with thalidomide and prednisone. In May 2010 he was diagnosed with S. stercoralis infection and was treated with albendazole. One year later, the stool examination showed continued presence of S. stercoralis larvae. He was treated with ivermectin (6 mg) in a double dose (given 1 month apart) which resulted in larvae excretion clearance. The absence of infection was confirmed three times during a 1 year followup period by stool examination and non-detection of anti-S. stercoralis IgG levels.
Terminal ileum resection as a trigger for Strongyloides stercoralis hyperinfection and ensuing serial sepsis in a 37-year-old patient with complicated Crohn's disease: a case report.
Topić Mirjana Balen,Čuković-Čavka Silvija,Brinar Marko,Kalauz Mirjana,Škrlec Ivica,Majerović Matea
Zeitschrift fur Gastroenterologie
The nematode Strongyloides stercoralis, outside the tropics and subtropics present in small endemic foci, can cause an infection after direct skin contact with contaminated soil containing infective filariform larvae and, rarely, after intimate interhuman contact or after transplantation of an infected solid organ. Following skin penetration, migration, and maturation through several stages, a small number of invasive filariform larvae can develop anew in the gut lumen, perpetuating new cycles of penetration, tissue migration, and reproduction, without leaving the host.In a state of immunosuppression, autoinfection can progress to life-threatening hyperinfection and/or infection disseminated through virtually any organ. In developed countries, the most frequently recognized risk for severe hyperinfection is corticosteroid therapy, but this has been also described in malnourished, alcoholic, cancer, and transplant patients. Due to the frequent need for immunosuppressive therapy, patients suffering from inflammatory bowel disease (IBD) are susceptible to develop overwhelming strongyloidiasis. Strongyloidiasis can be easily overlooked in clinical settings, and in many European regions there is poor insight into the epidemiological burden of this disease.We present a case of S. stercoralis hyperinfection that triggered 3 successive episodes of sepsis caused by pathogens of the gut flora in a young patient suffering from stenotic form of Crohn's disease. S. stercoralis hyperinfection occurred in the corticosteroid-free period, shortly after resection of the terminal ileum, which was probably the trigger for the overwhelming course. The patient was successfully treated with 10-day albendazole therapy.
Comorbid gastric adenocarcinoma and gastric and duodenal Strongyloides stercoralis infection: a case report.
Seo An Na,Goo Youn-Kyoung,Chung Dong-Il,Hong Yeonchul,Kwon Ohkyoung,Bae Han-Ik
The Korean journal of parasitology
Strongyloides stercoralis can cause systemic infection, termed strongyloidiasis, and gastrointestinal ulcer disease in immunocompromised patients. However, to our knowledge, there are no reported cases of comorbid gastric adenocarcinoma and S. stercoralis infection. Here, we report a case of an 81-year-old Korean man who presented with S. stercoralis infection coexisting with early gastric adenocarcinoma (T1aN0M0). S. stercoralis eggs, rhabditiform larvae, and adult females were observed in normal gastric and duodenal crypts. They were also observed in atypical glands representative of adenocarcinoma and adenoma. Preliminary laboratory tests revealed mild neutrophilic and eosinophilic leukocytosis. A routine stool test failed to detect rhabditiform larvae in the patient's fecal sample; however, S. stercoralis was identified by PCR amplification and 18S rRNA sequencing using genomic DNA extracted from formalin-fixed paraffin-embedded tissues. Postoperatively, the patient had a persistent fever and was treated with albendazole for 7 days, which alleviated the fever. The patient was followed-up by monitoring and laboratory testing for 4 months postoperatively, and no abnormalities were observed thus far. The fact that S. stercoralis infection may be fatal in immunocompromised patients should be kept in mind when assessing high-risk patients.
Co-infection with Strongyloides stercoralis hyperinfection syndrome and Klebsiella in a nephrotic syndrome patient: A case report.
RATIONALE:Patients with chronic Strongyloides stercoralis infection are usually asymptomatic; therefore, their condition is easily overlooked. In immunosuppressed patients, mortality is high because of disseminated infection and hyperinfection. This report describes a fatal S stercoralis hyperinfection in a patient with nephrotic syndrome after treatment with steroids. PATIENT CONCERNS:A 70-year-old male presented with a history of progressive edema, skin infection, persistent fever, cough, intermittent abdominal pain, and progressive respiratory failure after steroid treatment. DIAGNOSIS:Nephrotic syndrome; cellulitis; S stercoralis hyperinfection; Klebsiella pneumonia. INTERVENTIONS:During the first hospital admission, the patient was administered full-dose glucocorticoid and antibiotic therapy after suffering from cellulitis. During the second admission, he was diagnosed and treated for normal digestive discomfort and a bacterial infection. The patient had progressive respiratory failure and was placed on a ventilator. He was immediately treated with albendazole when S stercoralis was found in samples of his sputum and feces. OUTCOMES:The patient died despite treatment with albendazole and antibiotic therapy. LESSONS:It is essential to consider the possibility of S stercoralis infection in immunosuppressed patients with nephrotic syndrome. Given the lack of classic manifestations and high mortality rate of advanced disease, continuous monitoring, early diagnosis, and proper treatment are imperative.
Fatal Strongyloides stercoralis hyperinfection syndrome in an alcoholic diabetic patient from México
Rodríguez-Pérez Elba G,Arce-Mendoza Alma Y,Saldívar-Palacios Roberto,Escandón-Vargas Kevin
Biomedica : revista del Instituto Nacional de Salud
Strongyloides stercoralis hyperinfection syndrome is a medical emergency that requires a high level of suspicion. Immunocompromised patients are at high risk of hyperinfection syndrome; however, malnutrition, alcoholism, and diabetes mellitus also need to be considered as predisposing factors. The diagnosis and treatment of Strongyloides hyperinfection are challenging and patients often have severe complications. Consequently, mortality is overwhelmingly high, with proportions above 60%. Herein, we report a case of Strongyloides hyperinfection in a 40-year-old alcoholic diabetic patient living in México. Unfortunately, the late diagnosis resulted in his death despite the treatment and supportive measures. Increased awareness is needed to prevent the dire consequences of strongyloidiasis.
Unsuspected Strongyloides stercoralis infection in hospital patients with comorbidity in need of proper management.
Kaminsky Rina Lisette Girard,Reyes-García Selvin Zacarías,Zambrano Lysien Ivania
BMC infectious diseases
BACKGROUND:Investigate the role of latent strongyloidiasis infection in patients at the University Hospital, Honduras. METHODS:Prospective observational cohort study during 20 non consecutive months from March 2009 to February 2011. Epidemiological and clinical data obtained from patients excreting Strongyloides stercoralis larvae in stool who consulted at the hospital were recorded and analyzed. RESULTS:Thirty five (5 %) of 712 patients had S. stercoralis larvae in one stool sample; 62.8 % came from rural areas and 91.7 % were poor; 68.5 % (24/35) were 21 years old or older. Eight patients (22.8 %) had no predisposing illness; 3 (8.6 %) received steroid treatment, 29/35 (82.8 %) presented with persistent diarrhea and 24/35 (68.5 %) presented following comorbidities: HIV/AIDS (31.4 %), alcoholism alone (11.4 %) or with other associated illness (8.6 %), malignancy (8.6 %), renal failure (5.7 %) and hyperthyroidism (2.8 %). A combination of symptoms suggestive of strongyloidiasis but indistinguishable from those potentially associated to their comorbid condition included severe epigastric pain, diarrhea of weeks duration, peripheral eosinophilia, astenia, adynamia, fever, anemia and weight loss in 85.7 % of the cases, 3 of whom described skin lesions compatible with larva currens. None of the diagnostic clinical impressions mentioned Strongyloides infection. Ten strongyloidiasis patients received partial treatment with albendazole or ivermectin. Incomplete data, underestimation of the parasitic infection and no laboratory follow-up of the patients limited our observations. CONCLUSIONS:Strongyloides stercoralis is an unsuspected and neglected parasitic infection by health personnel in Honduras. Lack of awareness of its importance represents a strong barrier to proper treatment and follow-up, posing a threat of possible fatal complications in patients with comorbid conditions.
Diffuse alveolar haemorrhage and severe hypoxemia from Strongyloides stercoralis hyperinfection syndrome.
El-Sameed Yaser Abu,Beejay Nigel,Al Maashari Rehab
The clinical respiratory journal
Strongyloides stercoralis hyperinfection syndrome is a rare, yet highly fatal disorder. It occurs most commonly in immunocompromised patients. We report a case of a 36-year-old Ethiopian female who presented with abdominal pain and hypotension. Shortly thereafter, she developed acute respiratory failure and progressed to acute respiratory distress syndrome and septic shock. She was found to have diffuse alveolar hemorrhage due to disseminated strongyloidiasis. We discuss the clinical condition of Strongyloides hyperinfection syndrome presenting with severe hypoxemia and complicated by severe diffuse alveolar hemorrhage leading to death. Similar cases in the literature are also describe.
Strongyloides stercoralis infection after the use of emergency corticosteroids: a case report on hyperinfection syndrome.
Vasquez-Rios George,Pineda-Reyes Roberto,Ruiz Eloy F,Terashima Angelica,Mejia Fernando
Journal of medical case reports
BACKGROUND:In clinical practice, identification of a case of severe asthma exacerbation prompts initiation of corticosteroids. However, not all that wheezes is asthma. CASE PRESENTATION:A 61-year-old man from the Peruvian Amazon presented with progressive dyspnea, abdominal pain, and cough for the past week. His medical history was remarkable for asthma since childhood; he was treated with beta-agonists, ipratropium, and orally administered corticosteroids. On evaluation, he was febrile and ill-appearing. His chest examination revealed diffuse wheezing and bilateral crackles. He was diagnosed as having community-acquired pneumonia and asthma exacerbation and was started on empiric antibiotics, nebulized beta-agonists, and orally administered corticosteroids. His clinical status continued deteriorating and he became critically ill despite broad-spectrum antibiotics and antifungals. Considering the epidemiological background of our patient, bronchoalveolar and fecal samples were obtained to investigate soil-transmitted helminths. Larvae of Strongyloides stercoralis were found in both specimens. Ivermectin was initiated and corticosteroids were discontinued. He experienced remarkable improvement of clinical condition over the next weeks. The literature on this topic was reviewed. CONCLUSION:Cases of severe asthma exacerbation warrant careful evaluation before the initiation of corticosteroids, especially in patients at risk for parasitic infections. A high index of suspicion is critical. Alternative etiologies of respiratory decompensation should be considered in patients who fail to improve with broad-spectrum antibiotics and antifungals.
Is Gastric Involvement by Strongyloides stercoralis in an Immunocompetent Patient a Common Finding? A Case Report and Review of the Literature.
Pecorella Irene,Okello Tom Richard,Ciardi Gaia,Ogwang David Martin
PURPOSE:Gastric infection with Strongyloides stercoralis (SS) usually occurs in immunocompromised patients. The unexpected observation of this parasite in an otherwise healthy young lady who had undergone upper endoscopy and biopsy sampling of the gastro-duodenal mucosa, prompted us to review the literature to ascertain the conditions favouring gastric colonization by SS. METHODS:Pathology files of gastroduodenal biopsies received at St. Mary's hospital, Northern Uganda, between 2007 and 2017 were reviewed. Pubmed search was performed under the headings "Strongyloides stercoralis", "Gastric parasitosis". RESULTS:Histology of the only gastroduodenal biopsy with SS infection showed parasite eggs, immature rhabditiform larvae, and numerous adult worms in gastric pits and rhabditiform larvae in interepithelial parasitic tunnels, causing reactive changes of the glandular epithelium. There was no significant acute inflammatory cell infiltrate surrounding the parasites. Literature review showed that gastric SS infection appears to be very uncommon and was, as expected, largely prevalent in immunodeficient individuals (84.2% of published cases). The rare gastric SS infection is a complication of systemic strongyloidiasis, either hyperinfective, or disseminated form. It is also commonly associated with duodenal infection at microscopical examination. CONCLUSION:Involvement of gastric mucosa in the absence of duodenal strongyloidiasis appears to be quite rare and false-negative histopathological exams are reported if only the stomach is biopsied.
[Duodenal obstruction by Strongyloides stercoralis, an unusual complication].
Soto-Febres Fernando,Pérez-Lazo Giancarlo,Anicama William,Maquera-Afaray Julio
Revista chilena de infectologia : organo oficial de la Sociedad Chilena de Infectologia
Strongyloidiasis is a neglected disease in Latin America. Gastrointestinal manifestations are nonspecific and duodenal obstruction is a rare complication. Here we present the case of a 31-year-old male from the central jungle of Peru, admitted due to a high intestinal obstruction, with duodenal ulcers and stenosis evidenced in the upper endoscopy. The histopathological report revealed presence of larvae of Strongyloides stercoralis. Clinical and endoscopic follow up were favorable with ivermectin treatment. There are near 20 reported cases of duodenal obstruction due to S. stercoralis. Additionally, infection by HTLV-1 was confirmed, being this a frequent association.
Gastric Ulcer: A Rare Cause of Upper Gastrointestinal Bleeding.
Costa Silva Ryan,Carvalho Joana Rita,Crespo Ricardo,Martins Joana Rosa,Zózimo Nídia,Tato Marinho Rui
GE Portuguese journal of gastroenterology
Strongyloidiasis is an infection caused by Gastrointestinal manifestations typically include duodenitis, chronic enterocolitis, and malabsorption, while gastric involvement is very rare. In this case report, the -authors present a case of upper gastrointestinal bleeding caused by a gastric ulcer with a challenging etiological diagnosis. In Portugal, there have been reports in the past century of autochthonous cases of infection suggesting endemic zones, but with the current sanitation infrastructure strongyloidiasis is thought to be rare. A 56-year-old Caucasian male smoker with a history of significant weight loss presented to the emergency department with hema-temesis and abdominal pain. Upper endoscopy revealed a giant gastric ulcer with a macroscopic appearance suggestive of malignancy. Further investigation with CT scan highlighted gastric wall thickness and a spiculated lung lesion in the upper right lobe without lymph node involvement or metastatic disease. Bronchoscopy with bronchial brushing was performed. Histological examination identified squamous cell carcinoma of the lung and the patient was referred to Oncological Pneumology. Gastric ulcer biopsies ruled out malignancy and identified fragments of nematodes with inflammatory infiltrates and fibrinogranulocytic exudate, suggestive of . Accordingly, the diagnosis of strongyloidiasis was made and further confirmed with molecular methods and serology. The giant gastric ulcer was affirmed to be caused by infection and the patient was treated with ivermectin with improvement of epigastric pain. On reevaluation 6 weeks later the patient was asymptomatic, had gained weight, parasitological stool examinations were negative, and upper endoscopy showed complete ulcer healing. Further tests were done targeting risk factors for strongyloidiasis, and in addition to the presence of malignancy, other underlying causes for immunosuppression were ruled out. In this case report strongyloidiasis was manifested by gastric involvement with upper gastrointestinal bleeding in a patient who was subsequently diagnosed with squamous cell carcinoma of the lung.
Human infection with Strongyloides stercoralis and other related Strongyloides species.
Nutman Thomas B
The majority of the 30-100 million people infected with Strongyloides stercoralis, a soil transmitted intestinal nematode, have subclinical (or asymptomatic) infections. These infections are commonly chronic and longstanding because of the autoinfective process associated with its unique life cycle. A change in immune status can increase parasite numbers, leading to hyperinfection syndrome, dissemination, and death if unrecognized. Corticosteroid use and HTLV-1 infection are most commonly associated with the hyperinfection syndrome. Strongyloides adult parasites reside in the small intestine and induce immune responses both local and systemic that remain poorly characterized. Definitive diagnosis of S. stercoralis infection is based on stool examinations for larvae, but newer diagnostics - including new immunoassays and molecular tests - will assume primacy in the next few years. Although good treatment options exist for infection and control of this infection might be possible, S. stercoralis remains largely neglected.
Does Strongyloides stercoralis infection protect against type 2 diabetes in humans? Evidence from Australian Aboriginal adults.
Hays Russell,Esterman Adrian,Giacomin Paul,Loukas Alex,McDermott Robyn
Diabetes research and clinical practice
OBJECTIVE:To explore the relationship between infection with Strongyloides stercoralis and the likelihood of having type 2 diabetes mellitus (T2DM). METHODS:Cross-sectional survey of 259 Aboriginal adults living in a remote community in northern Australia during 2013. Prior infection with S. stercoralis was determined by ELISA testing on serum. Main outcomes were eosinophil count, T2DM diagnosis, HbA1c, BMI, fasting lipids, Hb, blood pressure. FINDINGS:Ninety two participants (36%) had prior infection with S. stercoralis and 131 (51%) had T2DM. Those with previous S. stercoralis infection (ELISA titre ≥0.3) were 61% less likely to have a diagnosis of T2DM than those uninfected, adjusted for age, triglycerides, blood pressure and BMI using propensity score (adjusted OR=0.39, 0.23-0.67, P=0.001). INTERPRETATION:In this remote community where prevalence of both S. stercoralis and T2DM is very high, infection with S. stercoralis appears to be associated with a significantly reduced risk of T2DM in adults. A plausible immunological mechanism has been identified in animal models. If confirmed, this result may have practical implications for the prevention of T2DM and associated metabolic disorders in humans. This finding should be explored further with larger longitudinal studies in transitional populations where the risk of both conditions is high. FUNDING:No external funding was required for this study.
Strongyloides stercoralis seroprevalence in Vietnam.
Diep Nguyen Thi Ngoc,Thai Pham Quang,Trang Nghiem Nguyen Minh,Jäger Julia,Fox Annette,Horby Peter,Phuong Hoang Vu Mai,Anh Dang Duc,Mai LE Thi Quynh,VAN Doorn H Rogier,Nadjm Behzad
Epidemiology and infection
Strongyloidiasis is a neglected tropical disease caused by the roundworm Strongyloides stercoralis affecting 30-100 million people worldwide. Many Southeast-Asian countries report a high prevalence of S. stercoralis infection, but there are little data from Vietnam. Here, we evaluated the seroprevalence of S. stercoralis related to geography, sex and age in Vietnam through serological testing of anonymized sera. Sera (n = 1710, 1340 adults and 270 children) from an anonymized age-stratified serum bank from four regions in Vietnam between 2012 and 2013 were tested using a commercial Strongyloides ratti immunoglobulin G ELISA. Seroreactivity was found in 29·1% (390/1340) of adults and 5·5% (15/270) of children. Male adults were more frequently seroreactive than females (33·3% vs. 24·9%, P = 0·001). The rural central highlands had the highest seroprevalence (42·4% of adults). Seroreactivity in the other regions was 29·9% (Hue) and 26·0% and 18·2% in the large urban centres of Hanoi and Ho Chi Minh City, respectively. We conclude that seroprevalence of S. stercoralis was high in the Vietnamese adult population, especially in rural areas.
Investigating the prevalence of intestinal parasites with an emphasis on Strongyloides stercoralis infection in hospitalized patients: a regional report from Iran.
Norouzi Pirasteh,Mohaghegh Mohammad-Ali,Ghorbani Mohammad,Mirzaii Mehdi,Abolhassani Moussa,Mirbadie Seyed-Reza
Annals of parasitology
Intestinal parasitic infections such as strongyloidosis are more common among individuals with immune deficiency and sometimes accompanied by severe symptoms. The purpose of this cross-sectional study was to evaluate the prevalence of intestinal parasites with focus on strongyloidosis in hospitalized patients. A total number of 566 faecal samples were obtained from different wards and assessed by the use of direct smear, formalin-ether concentration, and agar plate culture procedures in order to find parasitic protozoa and helminthes. The findings revealed that 10.1% (n=57) of the examined samples were positive for intestinal parasites. The highest prevalence rate was related to Entamoeba coli (4.6%, n=26) and the lowest one was related to Strongyloides stercoralis (0.5%, n=3). In addition, Giardia lamblia prevalence rate was 3.2% (n=18) and the prevalence rate of Blastocystis hominis was 1.8% (n=10). The sensitivity of S. stercoralis diagnosis was equal for agar plate culture and formalin-ether concentration methods. This study demonstrated the significance of focus on intestinal parasites in hospitalized patients and highlighted the necessity of improving the insight in health care providers about the occurrence of parasitic infections especially strongyloidiasis in these patients.
Disseminated Strongyloides stercoralis infection in a dog following long-term treatment with budesonide.
Journal of the American Veterinary Medical Association
CASE DESCRIPTION:A 1.5-year-old 1.5-kg (3.3-lb) castrated male Pomeranian was examined because of a 10-month history of diarrhea characterized by hematochezia and weight loss and an acute onset of respiratory distress (ie, tachypnea and dyspnea). A presumptive diagnosis of inflammatory bowel disease had been made previously, and the dog had been treated with budesonide and tylosin but continued to have diarrhea and weight loss. CLINICAL FINDINGS:On initial examination, the dog was weak and slightly obtunded. Thoracic radiography revealed a moderate to severe, diffuse, unstructured interstitial pattern. Serum biochemical abnormalities consisted of mild hypoalbuminemia, hypoglycemia, hypocalcemia, hypomagnesemia, and hypocholesterolemia that were likely secondary to chronic gastrointestinal disease and malnutrition. Pyuria and moderate bacteriuria with a single live larva were found on microscopic evaluation of the urine sediment. Fecal examination revealed numerous nematode larvae; the morphology was consistent with first-stage, rhabditiform larvae of Strongyloides stercoralis. TREATMENT AND OUTCOME:A diagnosis of disseminated S stercoralis infection was made. The dog was treated with fenbendazole and ivermectin but developed respiratory collapse approximately 12 hours later and was euthanized because of the poor prognosis. Postmortem examination revealed S stercoralis in the lungs, small intestine, and kidney. CLINICAL RELEVANCE:Findings illustrated the importance of performing diagnostic testing, including routine fecal examination, to rule out infectious causes of diarrhea before beginning empirical treatment with glucocorticoids such as budesonide. Further, repeated fecal examinations, including Baermann tests, should be considered if a positive response to glucocorticoids is not observed.
Accuracy of molecular biology techniques for the diagnosis of Strongyloides stercoralis infection-A systematic review and meta-analysis.
Buonfrate Dora,Requena-Mendez Ana,Angheben Andrea,Cinquini Michela,Cruciani Mario,Fittipaldo Andrea,Giorli Giovanni,Gobbi Federico,Piubelli Chiara,Bisoffi Zeno
PLoS neglected tropical diseases
BACKGROUND:Strongyloides stercoralis infection is a neglected tropical disease which can lead to severe symptoms and even death in immunosuppressed people. Unfortunately, its diagnosis is hampered by the lack of a gold standard, as the sensitivity of traditional parasitological tests (including microscopic examination of stool samples and coproculture) is low. Hence, alternative diagnostic methods, such as molecular biology techniques (mostly polymerase chain reaction, PCR) have been implemented. However, there are discrepancies in the reported accuracy of PCR. METHODOLOGY:A systematic review with meta-analysis was conducted in order to evaluate the accuracy of PCR for the diagnosis of S. stercoralis infection. The protocol was registered with PROSPERO International Prospective Register of Systematic Reviews (record: CRD42016054298). Fourteen studies, 12 of which evaluating real-time PCR, were included in the analysis. The specificity of the techniques resulted high (ranging from 93 to 95%, according to the reference test(s) used). When all molecular techniques were compared to parasitological methods, the sensitivity of PCR was assessed at 71.8% (95% CI 52.2-85.5), that decreased to 61.8% (95% CI 42.0-78.4) when serology was added among the reference tests. Similarly, sensitivity of real-time PCR resulted 64.4% (95% CI 46.2-77.7) when compared to parasitological methods only, 56.5% (95% CI 39.2-72.4) including serology. CONCLUSIONS:PCR might not be suitable for screening purpose, whereas it might have a role as a confirmatory test.
Strongyloides stercoralis, the hidden worm. Epidemiological and clinical characteristics of 70 cases diagnosed in the North Metropolitan Area of Barcelona, Spain, 2003-2012.
Valerio Lluís,Roure Sílvia,Fernández-Rivas Gema,Basile Luca,Martínez-Cuevas Octavio,Ballesteros Ángel-Luis,Ramos Xavier,Sabrià Miquel,
Transactions of the Royal Society of Tropical Medicine and Hygiene
BACKGROUND:The nematode Strongyloides stercoralis has a very particular autoinfection life-cycle which leads to chronic infections remaining undetected for decades. However, hyperinfection can occur in patients receiving immunotherapy resulting in high mortality rates. The main objective of this study was to assess the results of a 10-year multicenter surveillance program performed in an area with dense immigration in Barcelona, Spain. METHODS:From January 2003 to December 2012, all individuals with Strongyloides stercoralis infection attending the four centers with diagnostic capability in the North Metropolitan area of Barcelona were recorded. RESULTS:The annual detection rate was 0.2 new diagnosed cases x10 000 inhabitants/year and 1 case x10 000 immigrants/year. Many patients were immigrants (63; 90.0%), asymptomatic (45; 64.3%) and with a high eosinophil count (63; 90.0%). Immunosuppression was present in 11 (15.7%) patients, among whom two (2.8%) cases of disseminated hyperinfection were recorded. Ivermectin was prescribed in 45 (76.3%) and albendazole in 14 (23.7%). Following treatment seven patients (11.9%) receiving albendazole presented relapse, that is, albendazole failed to clear the parasite in 50% of these drug-treated patients (p < 0.001). CONCLUSIONS:During the study period, 90% of the cases of Strongyloides stercoralis diagnosed could be considered as imported by immigrants, most being asymptomatic and with eosinophilia. The infection is probably largely underestimated and population-based studies are needed to determine its true prevalence. Meanwhile, diagnosis must be based on active investigation of the helminth (serology and feces culture), especially in immunocompromised patients. The implementation of pre-immunosuppression protocols with the aim of identifying Strongyloides stercoralis is encouraged with empirical treatment with ivermectin being recommended in sites without diagnostic facilities.
Strongyloides stercoralis infection: A systematic review of endemic cases in Spain.
Barroso Maria,Salvador Fernando,Sánchez-Montalvá Adrián,Bosch-Nicolau Pau,Molina Israel
PLoS neglected tropical diseases
BACKGROUND:Strongyloides stercoralis infection, a neglected tropical disease, is widely distributed. Autochthonous cases have been described in Spain, probably infected long time ago. In recent years the number of diagnosed cases has increased due to the growing number of immigrants, travelers and refugees, but endemically acquired cases in Spain remains undetermined. METHODOLOGY:We systematically searched the literature for references on endemic strongyloidiasis cases in Spain. The articles were required to describe Strongyloides stercoralis infection in at least one Spanish-born person without a history of travel to endemic areas and be published before 31st May 2018. Epidemiological data from patients was collected and described individually as well as risk factors to acquisition of the infection, diagnostic technique that lead to the diagnosis, presence of eosinophilia and clinical symptoms at diagnosis. FINDINGS:Thirty-six studies were included, describing a total of 1083 patients with an average age of 68.3 years diagnosed with endemic strongyloidiasis in Spain. The vast majority of the cases were described in the province of Valencia (n = 1049). Two hundred and eight of the 251 (82.9%) patients in whom gender was reported were male, and most of them had current or past dedication to agriculture. Seventy percent had some kind of comorbidity. A decreasing trend in the diagnosed cases per year is observed from the end of last decade. However, there are still nefigw diagnoses of autochthonous cases of strongyloidiasis in Spain every year. CONCLUSIONS:With the data provided by this review it is likely that in Spain strongyloidiasis might have been underestimated. It is highly probable that the infection remains undiagnosed in many cases due to low clinical suspicion among Spanish population without recent travel history in which the contagion probably took place decades ago.
Infection in Ethiopia: Systematic Review and Meta-analysis on Prevalence and Diagnostic Methods.
Hailu T,Nibret E,Amor A,Munshea A
is a helminthic intestinal parasite that causes the disease strongyloidiasis. Its prevalence is high in tropics and sub-tropics due to poor sanitation and hygiene. However, its true prevalence is not well known in Ethiopia as most health institutions use low sensitive diagnostic methods. This review aimed to determine the pooled prevalence of at country, and regional state levels. Papers published on in Ethiopia from 2010 to 2020 were collected from PubMed, Google Scholar and Science direct databases and Addis Ababa repository. Identification, screening, checking the eligibility, and inclusion of the relevant literatures were done. Articles with positive results from Ethiopian populations were included. Articles which focused on infection in foreigners, and other than stool samples were excluded. The pooled prevalence of and heterogeneity between studies and across regions were computed. From the 43 articles, the overall prevalence of in Ethiopia was 1.82 %. Across regions, relatively high prevalence of (8.78 %) was recorded in Addis Ababa city. High prevalence of was found to be 44.02 % with a combination of formol ether concentration, Baermann concentration, and molecular methods. Low prevalence of 0.26 %, 0.31 %, and 1.20 % was evidenced respectively with Kato-Katz, direct saline microscopy, and formol ether concentration methods. Using random effect analysis, the pooled prevalence of in Ethiopia, across regions and across diagnostic methods was 2.1 % (95 %CI: 1.20 - 3.60), 2.6 % (95 %CI: 0.80 - 8.20) and 3.7 % (95 %CI: 1.10 - 11.70), respectively. The heterogeneity was high (). This review revealed that infection is probably underreported and its prevalence could be higher than the reported in Ethiopia. Therefore, a revision of the best combination of diagnostic methods could be advisable as it gives better diagnostic results in routine diagnosis of infection in Ethiopia.
Identification of antigenic proteins in Strongyloides stercoralis by proteomic analysis.
Rodpai Rutchanee,Intapan Pewpan M,Thanchomnang Tongjit,Sanpool Oranuch,Janwan Penchom,Laummaunwai Porntip,Wongkham Chaisiri,Insawang Tonkla,Maleewong Wanchai
Strongyloides stercoralis is an intestinal helminth that infects people worldwide. Hyperinfection or disseminated human strongyloidiasis can involve vital organs, leading to lethal outcomes. We analyzed immunoproteomics of antigenic spots, derived from S. stercoralis third-stage larvae and reacted with human strongyloidiasis sera, by two-dimensional gel electrophoresis and immunoblotting. Of 26 excised antigenic spots analyzed by liquid chromatography-electrospray ionization-tandem mass spectrometry, 20 proteins were identified. Most proteins were associated with enzymes involved in the metabolic process, energy generation, and oxidation-reduction. The proteins relate to promotion of worm development, cell division, cell signaling and transportation, and regulation of muscular contraction. Identification of antigenic proteins shows promise in helping to discover potential diagnostic protein markers or vaccine candidates for S. stercoralis infection.
Strongyloides stercoralis and hookworm co-infection: spatial distribution and determinants in Preah Vihear Province, Cambodia.
Forrer Armelle,Khieu Virak,Schär Fabian,Vounatsou Penelope,Chammartin Frédérique,Marti Hanspeter,Muth Sinuon,Odermatt Peter
Parasites & vectors
BACKGROUND:Strongyloides stercoralis and hookworm are two soil-transmitted helminths (STH) that are highly prevalent in Cambodia. Strongyloides stercoralis causes long-lasting infections and significant morbidity but is largely neglected, while hookworm causes the highest public health burden among STH. The two parasites have the same infection route, i.e. skin penetration. The extent of co-distribution, which could result in potential high co-morbidities, is unknown in highly endemic settings like Cambodia. The aim of this study was to predict the spatial distribution of S. stercoralis-hookworm co-infection risk and to investigate determinants of co-infection in Preah Vihear Province, North Cambodia. METHODS:A cross-sectional survey was conducted in 2010 in 60 villages of Preah Vihear Province. Diagnosis was performed on two stool samples, using combined Baermann technique and Koga agar culture plate for S. stercoralis and Kato-Katz technique for hookworm. Bayesian multinomial geostatistical models were used to assess demographic, socioeconomic, and behavioural determinants of S. stercoralis-hookworm co-infection and to predict co-infection risk at non-surveyed locations. RESULTS:Of the 2576 participants included in the study, 48.6% and 49.0% were infected with S. stercoralis and hookworm, respectively; 43.8% of the cases were co-infections. Females, preschool aged children, adults aged 19-49 years, and participants who reported regularly defecating in toilets, systematically boiling drinking water and having been treated with anthelmintic drugs had lower odds of co-infection. While S. stercoralis infection risk did not appear to be spatially structured, hookworm mono-infection and co-infection exhibited spatial correlation at about 20 km. Co-infection risk was positively associated with longer walking distances to a health centre and exhibited a small clustering tendency. The association was only partly explained by climatic variables, suggesting a role for underlying factors, such as living conditions and remoteness. CONCLUSIONS:Both parasites were ubiquitous in the province, with co-infections accounting for almost half of all cases. The high prevalence of S. stercoralis calls for control measures. Despite several years of school-based de-worming programmes, hookworm infection levels remain high. Mebendazole efficacy, as well as coverage of and compliance to STH control programmes should be investigated.
Central Nervous System Strongyloides Stercoralis. A Case Report.
Oktar Nezih,Ozer Haluk M,Demirtas Eren
Strongyloidiasis is an infestation caused by the intestinal nematode Strongyloides stercoralis. It is potentially fatal in immunocompromised hosts due to its capacity to cause an overwhelming hyperinfestation however infested healthy individuals are usually asymptomatic. Hyperinfestation is extremely rare in the Central Nervous System (CNS) and usually limited to the gastrointestinal tract or lungs. CNS involvement in strongyloidiasis has only been seen in patients with hyperinfestation syndrome and may be fatal when misdiagnosed. In this report, we describe an unusual case of a 13-year-old girl presented with epileptic fits, multiple brain lesions and diagnosed as Strongyloides stercoralis infestation. Suitable frontal lesion biopsied and diagnosed as Strongyloides infestation and vasculitis. MRI features were totally regressed after the treatment with oral Albendazole for 3 months.
Strongyloides stercoralis infection in patients with systemic lupus erythematosus: diagnosis and prevention of severe strongyloidiasis.
de Souza Joelma Nascimento,Inês Elizabete De Jesus,Santiago Mittermayer,Teixeira Márcia Cristina Aquino,Soares Neci Matos
International journal of rheumatic diseases
AIM:Strongyloides stercoralis infection is usually chronic and asymptomatic and may persist undiagnosed for decades. However, in immunocompromised individuals, the infection can cause hyperinfection and dissemination. Therefore, early diagnosis is essential to prevent severe forms of strongyloidiasis. The aims of this study were: (i) to evaluate the frequency of S. stercoralis infection in patients with systemic lupus erythematous (SLE) and (ii) to estimate specific immunoglobulins G (IgG) and E (IgE) production using an enzyme-linked immunosorbent assay (ELISA) method. METHODS:Seventy-five SLE patients treated with prophylactic anthelmintic therapy were evaluated using the spontaneous sedimentation (SS), Baermann-Moraes (BM) and agar plate culture (APC) methods. Serum anti-S. stercoralis IgG and IgE antibodies were measured by ELISA. RESULTS:Using parasitological methods, the frequency of intestinal parasites was 10.7%, whereas the frequency of S. stercoralis infection was 1.3%. The sensitivity of the ELISA to detect anti-S. stercoralis IgG and IgE was 80% and 76.9%, respectively. Both assays presented the same specificity of 96.7%. The frequency of anti-S. stercoralis IgG and IgE was 16% and 28%, respectively. Six patients were positive for both antibodies. CONCLUSIONS:Diagnostic approaches using high-sensitivity parasitological methods and the detection of specific antibodies are essential for the diagnosis of strongyloidiasis in immunocompromised patients. Early detection of infection can alter the course of the disease via appropriate treatment, preventing the occurrence of severe strongyloidiasis.
Strongyloides stercoralis in Patients on Corticosteroids Therapy Using Enzyme-Linked Immunosorbent Assay and Gelatin Particles Indirect Agglutination Tests: A Diagnostic Approach.
Ahmed Shahira A,El-Moselhy Amany,El-Moammaly Amal,El-Shewy Khalid
INTRODUCTION:Patients on corticosteroids therapy (POCT) are more likely to flare up concealed Strongyloides infection and develop Strongyloides hyperinfection syndrome and/or dissemination. Such critical complications can lead to high mortality rates. Rapid detection methods are, therefore, necessary to detect Strongyloides infection in POCT with the advantage of being applicable in a developing country. METHODS:Two hundred POCT have been enrolled in this study to determine the rate of infection with Strongyloides. Three different groups of POCT (Strongyloides infected, non-infected, infected with other parasites) were used to evaluate the antibodies detection capability of two serological techniques (enzyme-linked immunosorbent assay (ELISA) and gelatin particles indirect agglutination (GPIAT) against the results of the gold standard agar plate culture (APC). RESULTS:With APC, the infection rate of Strongyloides stercoralis in POCT was 9.5% (19/200). POCT with Strongyloides infection displayed related risk factors (job, rural settlements, and soil contact) for infection combined with the subtropical nature of Ismailia Governorate. With regard to serology, ELISA detection results were poor compared to APC with sensitivity and specificity of 42.1% and 82.6%, respectively, and positive and negative predictive values of 72% and 30%. GPIAT appeared to be closely related to APC with sensitivity and specificity of 89.4% and 81.8%, respectively, and positive and negative predictive values of 80.9% and 96.7%. Statistical moderate correlation was detected between GPIAT and ELISA. CONCLUSION:The GPIAT technique is more convenient, easier, cheaper and faster to rule out the infection of Strongyloides in POCT. It might be the test of choice for routine immunodiagnosis of human strongyloidiasis.
Strongyloides stercoralis infection in San Marino Republic: first epidemiological data from an observational study.
Cappella E D,Piscaglia A C,Cadioli A,Manoni S,Silva R,Buonfrate D
Epidemiology and infection
Strongyloides stercoralis is a neglected parasite that can cause death in immunocompromised individuals. There were no data on the epidemiology of S. stercoralis infection in San Marino Republic until two patients (one of whom died) were diagnosed with severe strongyloidiasis (hyperinfection) between September 2016 and March 2017. A serology test for Strongyloides spp. was introduced in routine practice in the laboratory of the State Hospital to test patients considered to be at risk for strongyloidiasis. Between August 2017 and August 2018, of 42 patients tested with serology, two (4.8%) were positive. An additional case was found by gastric biopsy. Two of the positive cases were presumably autochthonous infections (elderly people with no significant travel history), while the other was a probable imported case (young man born in Nigeria and settled in Europe since 2003). Epidemiology of strongyloidiasis in San Marino might be similar to Northern Italy, where a relevant proportion of cases was diagnosed in immigrants (mainly from sub-Saharan Africa) and in elderly Italians with eosinophilia. Screening for strongyloidiasis might be worthwhile in inhabitants of San Marino in the same categories of individuals, particularly those at risk of immune suppression.
Strongyloides stercoralis infection in human immunodeficiency virus-infected patients and related risk factors: A systematic review and meta-analysis.
Ahmadpour Ehsan,Ghanizadegan Mohammad Ali,Razavi Atefeh,Kangari Mahsa,Seyfi Rouhollah,Shahdust Maryam,Yazdanian Ali,Safarpour Hanie,Bannazadeh Baghi Hossein,Zarean Mehdi,Hosseini Seyed Abdollah,Norouzi Roghayeh,Ebrahimi Mina,Bangoura Berit
Transboundary and emerging diseases
Strongyloidiasis is caused by nematode infections of the genus Strongyloides, mainly Strongyloides stercoralis, and affects tens of millions of people around the world. S. stercoralis hyperinfection and disseminated strongyloidiasis are unusual but potentially fatal conditions mostly due to Gram-negative bacteremia and sepsis, primarily affecting immunocompromised patients. Infections with immunosuppressive viruses such as human immunodeficiency virus (HIV) and Human T-cell leucemia virus type 1 (HTLV-1) have been reported as risk factors for strongyloidiasis. Hyperinfection syndrome has been described in HIV-positive patients following the use of corticosteroids or during immune reconstitution inflammatory syndrome (IRIS). In this research, we conducted a global systematic review and meta-analysis to assess the seroprevalence and odds ratios (ORs) of S. stercoralis infections in HIV-infected patients. A total of 3,649 records were screened, 164 studies were selected and evaluated in more detail, and 94 studies were included in the meta-analysis. The overall pooled prevalence of S. stercoralis infection in HIV positive patients was 5.1% (CI95%: 4%-6.3%), and a meta-analysis on six studies showed that with a pooled OR of 1.79 (CI95%: 1.18%-2.69%) HIV-positive men are at a higher risk of S. stercoralis infections (p < .0052) compared to HIV positive women.
Case Report: Incidentally Discovered Infection after Urinary Diversion.
Bhasin Ajay,Yura Emily,Boyd Darren,Kuksuk Linda,Flaherty John P
The American journal of tropical medicine and hygiene
Strongyloidiasis is a disease caused by the parasite in humans. We present a case of incidentally discovered urinary tract infection in a patient in whom there was a urologic surgery consisting of urinary diversion created by self-bowel transplantation and conduit creation. Historical review demonstrated eosinophilia before surgery and detection of the parasite. Social review demonstrated endemic exposure. Our patient's case was differentiated from hyperinfection by the presence of rhabditiform larvae, and not filariform larvae, in the urine, suggesting localized small bowel infection was transferred to the urinary tract secondary to the creation of the ileal loop conduit. This patient's clinical course improved with antibiotic treatment of the bacterial infectious complications of surgery and resolution of infection with ivermectin. To our knowledge, this is the first case of infection of the urinary tract secondary to ileal loop conduit creation and not as a result of hyperinfection.
High prevalence of Strongyloides stercoralis in school-aged children in a rural highland of north-western Ethiopia: the role of intensive diagnostic work-up.
Amor Aranzazu,Rodriguez Esperanza,Saugar José M,Arroyo Ana,López-Quintana Beatriz,Abera Bayeh,Yimer Mulat,Yizengaw Endalew,Zewdie Derejew,Ayehubizu Zimman,Hailu Tadesse,Mulu Wondemagegn,Echazú Adriana,Krolewieki Alejandro J,Aparicio Pilar,Herrador Zaida,Anegagrie Melaku,Benito Agustín
Parasites & vectors
BACKGROUND:Soil-transmitted helminthiases (hookworms, Ascaris lumbricoides and Trichuris trichiura) are extremely prevalent in school-aged children living in poor sanitary conditions. Recent epidemiological data suggest that Strongyloides stercoralis is highly unreported. However, accurate data are essential for conducting interventions aimed at introducing control and elimination programmes. METHODS:We conducted a cross-sectional survey of 396 randomly selected school-aged children in Amhara region in rural area in north-western Ethiopia, to assess the prevalence of S. stercoralis and other intestinal helminths. We examined stools using three techniques: conventional stool concentration; and two S. stercoralis-specific methods, i.e. the Baermann technique and polymerase chain reaction. The diagnostic accuracy of these three methods was then compared. RESULTS:There was an overall prevalence of helminths of 77.5%, with distribution differing according to school setting. Soil-transmitted helminths were recorded in 69.2%. Prevalence of S. stercoralis and hookworm infection was 20.7 and 54.5%, respectively, and co-infection was detected in 16.3% of cases. Schistosoma mansoni had a prevalence of 15.7%. Prevalence of S. stercoralis was shown 3.5% by the conventional method, 12.1% by the Baermann method, and 13.4% by PCR, which thus proved to be the most sensitive. CONCLUSIONS:Our results suggest that S. stercoralis could be overlooked and neglected in Ethiopia, if studies of soil-transmitted helminths rely on conventional diagnostic techniques alone. A combination of molecular and stool microscopy techniques yields a significantly higher prevalence. In view of the fact that current control policies for triggering drug administration are based on parasite prevalence levels, a comprehensive diagnostic approach should instead be applied to ensure comprehensive control of helminth infections.
Strongyloides stercoralis and other intestinal parasites in patients receiving immunosuppressive drugs in northern Iran: a closer look at risk factors.
Mirzaei Leila,Ashrafi Keyhan,Atrkar Roushan Zahra,Mahmoudi Mohammad Reza,Shenavar Masooleh Irandokht,Rahmati Behnaz,Saadat Farshid,Mirjalali Hamed,Sharifdini Meysam
Epidemiology and health
OBJECTIVES:The objective of this study was to evaluate the prevalence of Strongyloides stercoralis and other intestinal parasites in patients receiving immunosuppressive drugs in northern Iran and to investigate related risk factors. METHODS:This cross-sectional study was conducted among 494 patients receiving immunosuppressive drugs, including cancer patients undergoing chemotherapy (n=188) and those treated with prolonged corticosteroid administration (n=306). All fresh fecal samples were examined using the direct wet-mount, formalin ethyl acetate concentration, and agar plate culture techniques. RESULTS:In total, 16.8% of patients were positive for at least 1 intestinal parasite; the helminthic and protozoan infection rates were 5.1% and 12.3%, respectively. The infection rate was significantly higher in corticosteroid-treated individuals (19.6%) than cancer patients (12.2%) (p<0.05). The prevalence rate of S. stercoralis among patients receiving chemotherapy and those treated with corticosteroids were 4.3% and 5.2%, respectively. The prevalence rate of S. stercoralis infection was significantly higher in older patients (p<0.05). CONCLUSIONS:Strongyloidiasis is one of the most common parasites among patients receiving immunosuppressive drugs in northern Iran. Early diagnosis and proper treatment of these patients are necessary to minimize the complications of severe strongyloidiasis.
Normal serum IgE levels and eosinophil counts exhibited during Strongyloides stercoralis infection.
Higashiarakawa Miwa,Hirata Tetsuo,Tanaka Teruhisa,Parrott Gretchen,Kinjo Tetsu,Naka Hidekatsu,Hokama Akira,Fujita Jiro
Infections with parasites, such as Strongyloides stercoralis, typically cause elevated levels of serum immunoglobulin E (IgE) and eosinophils; however, co-infection with human T cell lymphotropic virus type 1 (HTLV-1) can cause lower levels of serum IgE during S. stercoralis infection. We conducted this study to determine whether serum IgE levels and eosinophil counts could also be related to other patient characteristics or symptoms. Between 1991 and 2014, we measured and compared the symptoms of 237 patients and evaluated serum IgE levels and eosinophil counts of 199 patients who were infected with S. stercoralis at the Ryukyu University Hospital and the Nishizaki Hospital. Medical records were reviewed and blood samples were taken before treatment with the anthelminthic, ivermectin, 2weeks following the first dosage, and 2weeks following the second dosage. Commonly reported symptoms included abdominal pain, diarrhea, and general fatigue. Serum IgE levels were found to be normal in patients co-infected with HTLV-1. Additionally, females and patients younger than 70years old exhibited normal serum IgE levels when infected with S. stercoralis. No factor included in our analysis was found to affect eosinophil counts. Serum IgE levels can remain within the normal range for some patients infected with S. stercoralis. Therefore, physicians should not eliminate S. stercoralis infection from the differential diagnosis solely according to findings of normal or low IgE levels.
Strongyloides stercoralis disseminated infection in an HIV-infected adult.
Le Pogam Ambroise,Lopinto Julien,Pecriaux Adrien,Fartoukh Muriel,Guitard Juliette,Voiriot Guillaume
PLoS neglected tropical diseases
In this visual case of Strongyloides stercoralis disseminated infection with Enterobacteriaceae-related invasive infection, we demonstrated the in-host S. stercoralis circulation with DNA found in different fluids and specimens, but also in cerebrospinal fluid (CSF), supporting the role of migrant larvae in the Enterobacteriaceae-related invasive and central nervous system infection.
Strongyloides stercoralis: detection of parasite-derived DNA in serum samples obtained from immunosuppressed patients.
Gorgani-Firouzjaee Tahmineh,Kalantari Narges,Javanian Mostafa,Ghaffari Salman
Strongyloidiasis is an important neglected disease, which is life threatening in immunocompromised patients. This study aimed to evaluate the frequency of Strongyloides stercoralis infection among immunosuppressed subjects living in endemic communities by conventional PCR of the 18S rRNA and Cox1 genes to detect cell-free DNA in the patients' serum samples. Fresh stool and serum samples were obtained from participants. The stool samples were examined using parasitological methods. Total DNA was extracted from the serum samples and S. stercoralis larvae isolated from patient fecal samples. Conventional PCR to amplify a 101 bp fragment of the 18S rRNA gene was carried out for all extracted DNA, and then positive samples were further evaluated for a 121 bp fragment of the Cox1 gene. The PCR products of selected samples were sequenced and BLAST analysis was performed. Out of 120 patients, 57 and 63 cases had autoimmune disorders and cancer, respectively. The 101 bp fragments of the 18S rRNA were successfully amplified in 36 out of 120 (30%) serum samples. The PCR products of five samples were sequenced and compared with reference sequences in GenBank, which showed 97% identity and 90% coverage. In conclusion, to the best of our knowledge, this is the first molecular study for the detection of S. stercoralis cell-free DNA in human serum samples. These results provide useful insights for future studies and show that serum is an alternative specimen and may be useful in molecular diagnosis of diseases, particularly in immunosuppressive patients.
Limitations to the adoption of a standardized Strongyloides stercoralis diagnostic method: Case study in the Caribbean.
Ketzis Jennifer K
BACKGROUND:Strongyloides stercoralis is frequently under-diagnosed due to the low sensitivity of common faecal diagnostic methods used in clinical laboratories. This leads to a belief that prevalence is low and that S. stercoralis is not an important soil-transmitted helminth (STH). S. stercoralis diagnostic methods with higher sensitivity are available but often not used. Reasons for their lack of use need to be identified and addressed in order to increase awareness of this neglected parasite. METHODOLOGY/PRINCIPAL FINDINGS:A survey was conducted with public health (14) and private laboratories (15) within the Caribbean region to determine current diagnostic methods used and technological capabilities within the laboratories. Formal-ether concentration and direct smears were the primary methods used. Five of the laboratories used a specific method for S. stercoralis (Baermann and/or agar plate culture). A Standard Operating Procedure (SOP) for a modified Baermann tailored to be compatible with the technological capabilities of the laboratories was developed and demonstrated at ten laboratories to determine limitations to adopting a S. stercoralis specific method. The primary limitations were: cost of using two diagnostic methods for one submitted sample; lack of communication with the physician regarding the reason for the faecal analysis; general lack of awareness of S. stercoralis; and lack of awareness of differences in sensitivity of diagnostic methods. CONCLUSIONS/SIGNIFICANCE:Changing diagnostic methods involves more than ensuring the method fits within the technological capabilities of the laboratories. Several factors that influence the method used are external to the laboratory. To improve diagnosis of any of the STHs, these external factors must be addressed. Within the laboratory, more education on the sensitivity of diagnostic methods, differences in excretion levels of diagnostic stages with low infection, and increased awareness of S. stercoralis is required.
Fatal outcome in a patient under immunosuppressant therapy infected with human T-lymphotropic virus type 1 (HTLV-1), cytomegalovirus (CMV) and Strongyloides stercoralis: a case report.
Ashida Chisato,Kinoshita Koji,Nozaki Yuji,Funauchi Masanori
BMC infectious diseases
BACKGROUND:Strongyloidiasis is a gastrointestinal parasitic infection caused by percutaneous infection with Strongyloides stercoralis. Digestive symptoms such as diarrhea and abdominal pain are the main manifestation, but serious infections such as septicemia, purulent meningitis, and bacterial pneumonia may occur in individuals harboring human T-lymphotropic virus type 1 (HTLV-1) or who are immunocompromised. Although coinfection with Strongyloides stercoralis and HTLV-1 can lead to chronic strongyloidiasis and a disseminated form of the disease, there is a high rate of response to the anthelmintic ivermectin. CASE PRESENTATION:We report a case of strongyloidiasis infection syndrome that was difficult to differentiate from immune reconstitution inflammatory syndrome (IRIS) for various reasons. The patient had been treated with the corticosteroids tacrolimus (Tac) and mycophenolate mofetil (MMF) for systemic lupus erythematosus (SLE) with lupus nephritis and pancytopenia. When the steroid was reduced, she developed cytomegalovirus (CMV) enteritis, and her respiratory status rapidly deteriorated immediately after the withdrawal of Tac and MMF. It was difficult to distinguish immune reconstitution inflammatory syndrome from strongyloidiasis infection syndrome because stool cultures were negative and eosinophils were not increased. Bronchoscopy revealed viable Strongyloides, leading to a diagnosis of strongyloidiasis infection syndrome, but the patient died despite treatment. CONCLUSIONS:Both corticosteroid therapy and HTLV-1 infection can be associated with a decrease of eosinophils, despite the presence of parasitic infection. In conclusion, even if multiple culture tests are negative, the risk of parasitic infection should be assessed in patients receiving immunosuppressants and steroids even in non-endemic areas.
The investigation of Strongyloides stercoralis seroprevalence in immunosupressed patients in Turkey
Kaya Filiz,İnkaya Ahmet Çağkan,Ertenli Ali İhsan,Abbasoğlu Osman,Aksoy Sercan,Akyön Yılmaz Yakut,Ergüven Sibel
Turkish journal of medical sciences
Background/aim:In immunosuppressed patients, strongyloidiasis can be lifethreatening because of hyperinfection or dissemination. Therefore, diagnosis of S. stercoralis is important in immunosuppressed patients with chronic strongyloidiasis. In this study, our objective was to investigate the presence of S. stercoralis antibodies by an ELISA method in immunosuppressed patients. Materials and methods:A total of 100 immunosuppressed patients’ sera were included in the study. Forty-two of the patients were receiving immunosuppressive therapies for cancer or being treated for hematopoietic malignancies, 38 of the patients were receiving immunosuppressive drugs for rheumatic diseases, 14 were receiving immunosuppressive therapies for liver transplantation. Two of the patients were being treated for HIV infection and 4 were being treated for hypogammaglobulinemia. As control group, 50 individuals without a known disease were included in the study. The presence of IgG antibodies against S. stercoralis was investigated with a commercial ELISA kit. Results:S. stercoralis antibody test was positive in 4 of 100 (4%) sera from immunosuppressed patients. All control patients were negative for S. stercoralis. Conclusions:Strongyloidiasis can be a lifelong chronic infection if not treated. In patients who are going to receive immunosuppressive therapy, it should be tested before treatment, as it can become a disseminated and life-threatening infectious disease.
Seroprevalence of Strongyloides stercoralis infection among HTLV-I infected blood donors in Barcelona, Spain: A cross-sectional study.
Salvador Fernando,Sulleiro Elena,Piron Maria,Sánchez-Montalvá Adrián,Sauleda Silvia,Molina Israel
Strongyloides stercoralis infection in patients with HTLV-I infection may lead to severe clinical manifestations. The aim of the present study is to determine the seroprevalence of S. stercoralis infection among blood donors who tested positive for HTLV-I infection. A cross-sectional study was performed at the Vall d'Hebron University Hospital (Barcelona, Spain) in 2016. Serum samples from HTLV-I positive patients diagnosed from 2008 to 2015 were retrieved from the Blood Bank, and S. stercoralis serology was performed. Thirty six serum samples from HTLV-I positive patients were retrieved from the Blood Bank. The blood samples came from 36 blood donors, and most of them were born in Latin America (75%), being Peru the most frequent country (11 participants). S. stercoralis serology was positive in one patient, corresponding to a prevalence of 2.8% (3.4% if we exclude donors coming from European countries, where the risk of S. stercoralis infection is highly unlikely).
Morbidity Associated with Chronic Infection: A Systematic Review and Meta-Analysis.
Tamarozzi Francesca,Martello Elisa,Giorli Giovanni,Fittipaldo Andrea,Staffolani Silvia,Montresor Antonio,Bisoffi Zeno,Buonfrate Dora
The American journal of tropical medicine and hygiene
, a worldwide-distributed soil-transmitted helminth, causes chronic infection which may be life threatening. Limitations of diagnostic tests and nonspecificity of symptoms have hampered the estimation of the global morbidity due to strongyloidiasis. This work aimed at assessing -associated morbidity through a systematic review and meta-analysis of the available literature. MEDLINE, Embase, CENTRAL, LILACS, and trial registries (WHO portal) were searched. The study quality was assessed using the Newcastle-Ottawa scale. Odds ratios (ORs) of the association between symptoms and infection status and frequency of infection-associated symptoms were calculated. Six articles from five countries, including 6,014 individuals, were included in the meta-analysis-three were of low quality, one of high quality, and two of very high quality. Abdominal pain (OR 1.74 [CI 1.07-2.94]), diarrhea (OR 1.66 [CI 1.09-2.55]), and urticaria (OR 1.73 [CI 1.22-2.44]) were associated with infection. In 17 eligible studies, these symptoms were reported by a large proportion of the individuals with strongyloidiasis-abdominal pain by 53.1% individuals, diarrhea by 41.6%, and urticaria by 27.8%. After removing the low-quality studies, urticaria remained the only symptom significantly associated with infection (OR 1.42 [CI 1.24-1.61]). Limitations of evidence included the low number and quality of studies. Our findings especially highlight the appalling knowledge gap about clinical manifestations of this common yet neglected soil-transmitted helminthiasis. Further studies focusing on morbidity and risk factors for dissemination and mortality due to strongyloidiasis are absolutely needed to quantify the burden of infection and inform public health policies.
Microbial Translocation Associated with an Acute-Phase Response and Elevations in MMP-1, HO-1, and Proinflammatory Cytokines in Strongyloides stercoralis Infection.
Rajamanickam Anuradha,Munisankar Saravanan,Bhootra Yukthi,Dolla Chandrakumar,Nutman Thomas B,Babu Subash
Infection and immunity
Microbial translocation, characterized by elevated levels of lipopolysaccharide (LPS) and related markers, is a common occurrence in HIV and some parasitic infections. This is usually associated with extensive inflammation and immune activation. To examine the occurrence of microbial translocation and the associated inflammatory response in asymptomatic Strongyloides stercoralis infection, we measured the plasma levels of LPS and other microbial translocation markers, acute-phase proteins, inflammatory markers, and proinflammatory cytokines in individuals with (infected [INF]) or without (uninfected [UN]) S. stercoralis infections. Finally, we also measured the levels of all of these markers in INF individuals following treatment of S. stercoralis infection. We show that INF individuals exhibit significantly higher plasma levels of microbial translocation markers (LPS, soluble CD14 [sCD14], intestinal fatty acid-binding protein [iFABP], and endotoxin core IgG antibody [EndoCAb]), acute-phase proteins (α-2 macroglobulin [α-2M], C-reactive protein [CRP], haptoglobin, and serum amyloid protein A [SAA]), inflammatory markers (matrix metalloproteinase 1 [MMP-1] and heme oxygenase 1 [HO-1]), and proinflammatory cytokines (interleukin-6 [IL-6], IL-8, monocyte chemoattractant protein 1 [MCP-1], and IL-1β) than do UN individuals. INF individuals exhibit significantly decreased levels of tissue inhibitor of metalloproteinases 4 (TIMP-4). Following treatment of S. stercoralis infection, the elevated levels of microbial translocation markers, acute-phase proteins, and inflammatory markers were all diminished. Our data thus show that S. stercoralis infection is characterized by microbial translocation and accompanying increases in levels of acute-phase proteins and markers of inflammation and provide data to suggest that microbial translocation is a feature of asymptomatic S. stercoralis infection and is associated with an inflammatory response.
Strongyloides stercoralis hyperinfection syndrome presenting as mechanical ileus after short-course oral steroids for chronic obstructive pulmonary disease (COPD) exacerbation.
Rothe Kathrin,Katchanov Juri,Schneider Jochen,Spinner Christoph D,Phillip Veit,Busch Dirk H,Tappe Dennis,Braren Rickmer,Schmid Roland M,Slotta-Huspenina Julia
We report a case of a fatal Strongyloides stercoralis hyperinfection syndrome (SHS) in a migrant from Kenya, who had been living in Germany for three decades. A short-course oral steroid treatment for Chronic Obstructive Pulmonary Disease (COPD) exacerbation had been administered four weeks prior to the presentation. The initial clinical and radiological findings suggested a mechanical small bowel obstruction as a cause of ileus. Our case highlights the importance of maintaining a high index of suspicion for strongyloidiasis in patients from endemic areas even years after they left the country of origin. It demonstrates that even a five-day course of prednisolone is able to trigger SHS in patients with underlying strongyloidiasis. History of frequent previous administration of oral prednisolone for COPD exacerbations in our case raises the question why and how the last steroid regimen provoked SHS. SHS can present with multiple gastrointestinal symptoms including ileus and the absence of eosinophilia during the whole course of the disease should not lower the level of suspicion in the appropriate clinical setting.
Development and validation of an LC-MS/MS method for the quantification of the anthelmintic drug moxidectin in a volumetric absorptive microsample, blood, and plasma: Application to a pharmacokinetic study of adults infected with Strongyloides stercoralis in Laos.
Hofmann Daniela,Sayasone Somphou,Keiser Jennifer
Journal of chromatography. B, Analytical technologies in the biomedical and life sciences
Moxidectin is a promising candidate for addition to the lean repertoire of drugs against neglected tropical diseases (NTD) including strongyloidiasis. Pharmacokinetic (PK) and -dynamic studies are required to support its clinical development. Microsampling approaches enable PK studies in the challenging environments where NTDs are most prevalent, due to simplified collection and processing. We developed a liquid chromatography tandem mass spectrometry method for the sensitive quantification of moxidectin in human blood obtained by capillary sampling with the microsampling device Mitra® compared to blood and plasma obtained by venous sampling. Sample preparation consisted of protein precipitation, evaporation and reconstitution and also included phospholipid filtration for blood and plasma. Moxidectin was detected by multiple reaction monitoring (640.4 → 528.5 m/z) using a Luna C8(2) (30 × 2.0 mm, 3 µm particle size, 100 Å) analytical column with a gradient program of 6 min duration. Validation was performed with respect to accuracy, precision, sensitivity, selectivity, linearity, stability, recovery, and haematocrit influence with a limit of quantification of 0.5 and 2.5 ng/mL, for venous and capillary blood respectively. Moxidectin was stable up to 2 months at storage condition (blood and plasma: -20 °C, microsamples: room temperature), 3 cycles of temperature shift, for at least 4 h on the bench-top and 24 h in the autosampler (4 °C). Deviations of inter- and intra-assay accuracy and precision were smaller than 12.6% and recoveries were in the range of 80.7-111.2%. The method was applied to samples obtained from nine Strongyloides stercoralis-infected adults from northern Laos. A good agreement in the time-concentration profiles of moxidectin and a high consistency in PK parameters was found between the different matrixes and sampling strategies: e.g. identical time to reach maximal concentration of 4.0 h and a similar maximal concentration of 83.9-88.5 ng/mL of moxidectin. The simple and practical capillary procedure using Mitra® microsampling has been demonstrated to be suitable for PK studies of moxidectin and will pave the way for future PK studies.
The roundworm Strongyloides stercoralis in children, dogs, and soil inside and outside a segregated settlement in Eastern Slovakia: frequent but hardly detectable parasite.
Štrkolcová G,Goldová M,Bocková E,Mojžišová J
A comparative study was carried out to evaluate the Strongyloides stercoralis infections in children and dogs inside and outside the segregated settlement in Medzev, Eastern Slovakia, and a survey of the soil within the settlement was included. Applying the Koga agar plate (KAP) culture method and microscopy examination of stool samples collected from 60 Roma and 21 nonRoma children, no larvae of S. stercoralis were detected but eggs of three nematodes (Ascaris lumbricoides, Trichuris trichiura, and Enterobius vermicularis) and cysts of two protozoan endoparasites (Giardia duodenalis and Cryptosporidium spp.) were often found. However, immunoenzymatic assay (ELISA) for the evidence of IgG antibodies against S. stercoralis showed 33.3% seroprevalence in Roma children and 23.8% prevalence in children from the majority population, attending the same school. Eosinophilia was regularly present in children with exclusive infection of S. stercoralis (eight cases) as well as in individuals suffering from mixed infections of S. stercoralis and some of the above listed parasites (16 cases); high eosinophil counts sometimes, but not always, occurred in parasitized children lacking S. stercoralis antibodies. A comparison of S. stercoralis in dogs from the settlement (40 dogs) and from a distant dog shelter (20 dogs) did not reveal remarkable differences: the direct microscopy of faecal samples revealed rhabditiform larvae in 13.3% of the dogs from the settlement (4/30) and in 10.0% of the dogs from the shelter (2/20). Out of blood samples collected from the second dog group, 55% of the dogs contained antibodies against S. stercoralis. In the soil collected from 14 various locations within the settlement, S. stercoralis larvae were observed in two samples (14.3%); however, 13 samples (92.9%) were positive for human or dog endoparasites of the genera Ancylostoma, Ascaris, Toxocara, Toxascaris, Trichuris, and Hymenolepis.
Diagnosis of Strongyloides stercoralis by morphological characteristics combine with molecular biological methods.
Wang Li-Fu,Xu Lian,Luo Shi-Qi,Xie Hui,Chen Wei,Wu Zhong-Dao,Sun Xi
Strongyloidiasis is one of the neglected tropical diseases caused by infection with the nematode Strongyloides genus and distributed worldwide. Strongyloidiasis can be fatal in immunosuppressed patients induced hyperinfection or disseminated strongyloidiasis. Unfortunately, until now, due to the unspecific clinical symptom in infected individuals and the low sensitivity diagnosis of strongyloidiasis, many patients were misdiagnosed every year. Furthermore, the larvae of the Strongyloides stercoralis (S. stercoralis) is similar to other nematodes such as hookworm, Trichostrongylus increased the difficulty of diagnosis. In this case, the patient is a 63-year-old male person, who had a nearly 30 years medical history of asthma and emphysema, and 4-5-year medical history of diabetes. The sputum examination found some parasite larvae, then we identify the larvae using clinical observation and morphological characteristics combine with examined cytochrome oxidase subunit 1 (COX1) and 18S rRNA genes by PCR, sequence analysis and finally classified by phylogenetic analysis, the larvae were diagnosed as S. stercoralis. Our results showed that diagnosis with strongyloidiasis by morphological characteristics combine with molecular biological methods can improve the sensitive of diagnosis and provide a final diagnosis for the disease in the clinics.
Seropositivity and geographical distribution of Strongyloides stercoralis in Australia: A study of pathology laboratory data from 2012-2016.
Shield Jennifer,Braat Sabine,Watts Matthew,Robertson Gemma,Beaman Miles,McLeod James,Baird Robert W,Hart Julie,Robson Jennifer,Lee Rogan,McKessar Stuart,Nicholson Suellen,Mayer-Coverdale Johanna,Biggs Beverley-Ann
PLoS neglected tropical diseases
BACKGROUND:There are no national prevalence studies of Strongyloides stercoralis infection in Australia, although it is known to be endemic in northern Australia and is reported in high risk groups such as immigrants and returned travellers. We aimed to determine the seropositivity (number positive per 100,000 of population and percent positive of those tested) and geographical distribution of S. stercoralis by using data from pathology laboratories. METHODOLOGY:We contacted all seven Australian laboratories that undertake Strongyloides serological (ELISA antibody) testing to request de-identified data from 2012-2016 inclusive. Six responded. One provided positive data only. The number of people positive, number negative and number tested per 100,000 of population (Australian Bureau of Statistics data) were calculated including for each state/territory, each Australian Bureau of Statistics Statistical Area Level 3 (region), and each suburb/town/community/locality. The data was summarized and expressed as maps of Australia and Greater Capital Cities. PRINCIPAL FINDINGS:We obtained data for 81,777 people who underwent serological testing for Strongyloides infection, 631 of whom were from a laboratory that provided positive data only. Overall, 32 (95% CI: 31, 33) people per 100,000 of population were seropositive, ranging between 23/100,000 (95% CI: 19, 29) (Tasmania) and 489/100,000 population (95%CI: 462, 517) (Northern Territory). Positive cases were detected across all states and territories, with the highest (260-996/100,000 and 17-40% of those tested) in regions across northern Australia, north-east New South Wales and north-west South Australia. Some regions in Greater Capital Cities also had a high seropositivity (112-188/100,000 and 17-20% of those tested). Relatively more males than females tested positive. Relatively more adults than children tested positive. Children were under-represented in the data. CONCLUSIONS/SIGNIFICANCE:The study confirms that substantial numbers of S. stercoralis infections occur in Australia and provides data to inform public health planning.
A possible origin population of pathogenic intestinal nematodes, Strongyloides stercoralis, unveiled by molecular phylogeny.
Nagayasu Eiji,Aung Myo Pa Pa Thet Hnin Htwe,Hortiwakul Thanaporn,Hino Akina,Tanaka Teruhisa,Higashiarakawa Miwa,Olia Alex,Taniguchi Tomoyo,Win Soe Moe Thu,Ohashi Isao,Odongo-Aginya Emmanuel Igwaro,Aye Khin Myo,Mon Mon,Win Kyu Kyu,Ota Kei,Torisu Yukari,Panthuwong Siripen,Kimura Eisaku,Palacpac Nirianne M Q,Kikuchi Taisei,Hirata Tetsuo,Torisu Shidow,Hisaeda Hajime,Horii Toshihiro,Fujita Jiro,Htike Wah Win,Maruyama Haruhiko
Humans and dogs are the two major hosts of Strongyloides stercoralis, an intestinal parasitic nematode. To better understand the phylogenetic relationships among S. stercoralis isolates infecting humans and dogs and to assess the zoonotic potential of this parasite, we analyzed mitochondrial Cox1, nuclear 18S rDNA, 28S rDNA, and a major sperm protein domain-containing protein genes. Overall, our analyses indicated the presence of two distinct lineages of S. stercoralis (referred to as type A and type B). While type A parasites were isolated both from humans and dogs in different countries, type B parasites were found exclusively in dogs, indicating that the type B has not adapted to infect humans. These epidemiological data, together with the close phylogenetic relationship of S. stercoralis with S. procyonis, a Strongyloides parasite of raccoons, possibly indicates that S. stercoralis originally evolved as a canid parasite, and later spread into humans. The inability to infect humans might be an ancestral character of this species and the type B might be surmised to be an origin population from which human-infecting strains are derived.
Multiple-dose versus single-dose ivermectin for Strongyloides stercoralis infection (Strong Treat 1 to 4): a multicentre, open-label, phase 3, randomised controlled superiority trial.
Buonfrate Dora,Salas-Coronas Joaquin,Muñoz José,Maruri Begoña Trevino,Rodari Paola,Castelli Francesco,Zammarchi Lorenzo,Bianchi Leila,Gobbi Federico,Cabezas-Fernández Teresa,Requena-Mendez Ana,Godbole Gauri,Silva Ronaldo,Romero Marilena,Chiodini Peter L,Bisoffi Zeno
The Lancet. Infectious diseases
BACKGROUND:Strongyloides stercoralis infection is a neglected condition that places people who are immunocompromised at risk of hyperinfection and death. Ivermectin is the drug of choice for the treatment of S stercoralis infection, but there is no definitive evidence on the optimal dose. This trial aimed to assess whether multiple doses of ivermectin were superior to a single dose for the treatment of non-disseminated strongyloidiasis. METHODS:Our study was designed as a multicentre, open-label, phase 3, randomised controlled superiority trial. Participants were enrolled in four centres in Italy, three in Spain, and two in the UK, and recruiting sites were predominantly hospitals. Eligible patients were older than 5 years, weighed more than 15 kg, were residents in an area not endemic for S stercoralis, and either were positive for S stercoralis in faecal tests and on serology (any titre) or had a positive serological test with high titres, irrespective of the result of faecal tests. Patients were randomly assigned (1:1) using a computer-generated, blinded allocation sequence (with randomly mixed block sizes of six, eight, and ten participants) to receive either one dose of ivermectin 200 μg/kg or four doses of ivermectin 200 μg/kg (given on days 1, 2, 15, and 16). The primary endpoint was the proportion of participants with clearance of S stercoralis infection at 12 months, which was assessed in all randomly assigned participants who were not lost to follow-up (modified full-analysis set) and in participants in the modified full-analysis set who did not deviate from the assigned treatment regimen (per-protocol set). All participants were included in the safety analysis. The trial was registered with ClinicalTrials.gov, NCT01570504, and is now closed for recruitment. FINDINGS:Of the 351 patients assessed for eligibility, 309 recruited between March 26, 2013, and May 3, 2017, were randomly assigned to one dose (n=155) or four doses (n=154) of ivermectin. At 12 months in the modified full-analysis set, 86% (95% CI 79 to 91; 102 of 118 participants) had responded to treatment in the single-dose group compared with 85% (77 to 90; 96 of 113 participants) in the four-dose group (risk difference 1·48%, 95% CI -7·55 to 10·52; p=0·75); similar results were observed in the per-protocol set. Adverse events were generally of mild intensity and more frequent in the multiple-dose than in the single-dose group. The trial was terminated early due to futility. INTERPRETATION:Multiple doses of ivermectin did not show higher efficacy and was tolerated less than a single dose. A single dose should therefore be preferred for the treatment of non-disseminated strongyloidiasis. FUNDING:There was no funding source for this study.
Image of the month: Target the bugs: hyperinfection.
Hokama Akira,Kishimoto Kazuto
Clinical medicine (London, England)
A 74-year-old woman carrying the human T-lymphotropic virus type-1 (HTLV-1) presented with abdominal pain and vomiting. Computed tomography and microscopic analysis of the gastroduodenal drainage fluid made a diagnosis of paralytic ileus due to hyperinfection with underlying HTLV-1 infection. Strongyloidiasis should be included in the differential diagnosis for paralytic ileus in patients who have lived in or migrated from the endemic regions.
Innovative approaches to improve serodiagnosis of Strongyloides stercoralis infection.
The Brazilian journal of infectious diseases : an official publication of the Brazilian Society of Infectious Diseases
Strongyloidiasis is a helminthiasis of neglected condition that has no gold standard parasitological diagnosis due to the intermittent release of larvae in feces. This study aimed to use an scFv (single chain variable fragment) obtained by Phage Display, previously validated to detect immune complexes in serum samples from individuals infected with Strongyloides stercoralis by enzyme-linked immunosorbent assay (ELISA). Now the ability of scFv to detect the immune complexes was verified by immunofluorescence, flow cytometry using magnetic beads and surface plasmon resonance (SPR). As ELISA, the SPR, immunofluorescence and flow cytometry demonstrated the ability of scFv to detect immune complexes in sera from individuals with strongyloidiasis and discriminate them from sera of individuals with other parasitic diseases and healthy individuals. Besides de conventional ELISA, the novel approaches can also be promptly applied as auxiliary diagnostic tools to the existing parasitological method for accurate diagnosis of human strongyloidiasis.
Different but overlapping populations of Strongyloides stercoralis in dogs and humans-Dogs as a possible source for zoonotic strongyloidiasis.
Jaleta Tegegn G,Zhou Siyu,Bemm Felix M,Schär Fabian,Khieu Virak,Muth Sinuon,Odermatt Peter,Lok James B,Streit Adrian
PLoS neglected tropical diseases
Strongyloidiasis is a much-neglected soil born helminthiasis caused by the nematode Strongyloides stercoralis. Human derived S. stercoralis can be maintained in dogs in the laboratory and this parasite has been reported to also occur in dogs in the wild. Some authors have considered strongyloidiasis a zoonotic disease while others have argued that the two hosts carry host specialized populations of S. stercoralis and that dogs play a minor role, if any, as a reservoir for zoonotic S. stercoralis infections of humans. We isolated S. stercoralis from humans and their dogs in rural villages in northern Cambodia, a region with a high incidence of strongyloidiasis, and compared the worms derived from these two host species using nuclear and mitochondrial DNA sequence polymorphisms. We found that in dogs there exist two populations of S. stercoralis, which are clearly separated from each other genetically based on the nuclear 18S rDNA, the mitochondrial cox1 locus and whole genome sequence. One population, to which the majority of the worms belong, appears to be restricted to dogs. The other population is indistinguishable from the population of S. stercoralis isolated from humans. Consistent with earlier studies, we found multiple sequence variants of the hypervariable region I of the 18 S rDNA in S. stercoralis from humans. However, comparison of mitochondrial sequences and whole genome analysis suggest that these different 18S variants do not represent multiple genetically isolated subpopulations among the worms isolated from humans. We also investigated the mode of reproduction of the free-living generations of laboratory and wild isolates of S. stercoralis. Contrary to earlier literature on S. stercoralis but similar to other species of Strongyloides, we found clear evidence of sexual reproduction. Overall, our results show that dogs carry two populations, possibly different species of Strongyloides. One population appears to be dog specific but the other one is shared with humans. This argues for the strong potential of dogs as reservoirs for zoonotic transmission of S. stercoralis to humans and suggests that in order to reduce the exposure of humans to infective S. stercoralis larvae, dogs should be treated for the infection along with their owners.
hyperinfection in an unconscious diabetic patient with dermatomyositis.
Sharifdini Meysam,Hesari Aniseh,Mahdavi Seif Ali,Alipour Akram,Kia Eshrat Beigom
Indian journal of pathology & microbiology
A case of Strongyloides stercoralis hyperinfection in a patient with dermatomyositis and diabetes mellitus is herein reported. The case was a 60-year-old female admitted due to watery diarrhea and unconsciousness. She had a 10-year history of chronic immunosuppressive therapy including methotrexate and prednisolone for dermatomyositis. Stool parasitological examination revealed numerous rhabditiform larvae of threadworm "S. stercoralis." Larva in stool sample was characterized by sequencing of mitochondrial DNA. After treatment with ivermectin, the patient recovered without evidence of S. stercoralis in follow-up stool samples. In endemic areas, stool examination for detection of S. stercoralis should be performed on a regular basis for all patients receiving immunosuppressive therapy, as early detection and treatment are necessary to minimize complications of severe strongyloidiasis.
Metabolic Consequences of Concomitant Strongyloides stercoralis Infection in Patients With Type 2 Diabetes Mellitus.
Rajamanickam Anuradha,Munisankar Saravanan,Bhootra Yukthi,Dolla Chandrakumar,Thiruvengadam Kannan,Nutman Thomas B,Babu Subash
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
BACKGROUND:Human and animal studies have demonstrated that helminth infections are associated with a decreased prevalence of type 2 diabetes mellitus (T2DM). However, very little is known about their biochemical and immunological interactions. METHODS:To assess the relationship between a soil-transmitted helminth, Strongyloides stercoralis (Ss), and T2DM, we examined analytes associated with glycemic control, metabolic processes, and T-cell-driven inflammation at the time of Ss diagnosis and 6 months after definitive anthelmintic treatment. We measured plasma levels of hemoglobin A1c, glucose, insulin, glucagon, adipocytokines, and T-helper (TH) 1-, 2-, and 17- associated cytokines in patients with T2DM with (INF group) or without (UN group) Ss infection. In INF individuals, we again assessed the levels of these analytes 6 months following anthelmintic treatment. RESULTS:Compared to UN individuals, INF individuals exhibited significantly diminished levels of insulin and glucagon that increased significantly following therapy. Similarly, INF individuals exhibited significantly diminished levels of adiponectin and adipsin that reversed following therapy. INF individuals also exhibited significantly decreased levels of the TH1- and TH17- associated cytokines in comparison to UN individuals; again, anthelmintic therapy augmented these levels. As expected, INF individuals had elevated levels of TH2-associated and regulatory cytokines that normalized following definitive therapy. Multivariate analysis revealed that these changes were independent of age, sex, body mass index, and liver and renal function. CONCLUSIONS:Strongyloides stercoralis infection is associated with a significant modulation of glycemic, hormonal, and cytokine parameters in T2DM and its reversal following anthelmintic therapy. Hence, Ss infection has a protective effect on diabetes-related parameters.
Strongyloides stercoralis infection in a patient with rheumatoid arthritis and type 2 diabetes mellitus: a case-based review.
Ashiri Alireza,Beiromvand Molouk,Khanzadeh Abdollah
Strongyloides stercoralis (S. stercoralis), a human intestinal nematode, can lead to hyper/disseminated (HD) infection in patients treated with corticosteroids. Here, we report a case of strongyloidiasis in a 58-year-old female with a history of rheumatoid arthritis (RA) and type 2 diabetes mellitus (T2DM). The patient presented with abdominal pain and gastrointestinal (GI) bleeding. Stool was negative for parasitic agents in the first direct smear examination, and the patient with the probable diagnosis of Helicobacter pylori (H. pylori) infection or Crohn's disease received antibiotics and corticosteroids. Parasitic agents were not detected in further direct stool examinations, and the patient with the diagnosis of pneumonia, chronic kidney disease (CKD), ulcerative colitis, sepsis, and candidiasis received fungal, antibiotic, and corticosteroids medications. Low sensitivity of direct smear and the lack of using two methods in diagnosing intestinal parasitic infections led to delayed detection. In the fourth direct stool examination, rhabditiform larva of S. stercoralis was reported. The treatment of corticosteroids was discontinued and albendazole was started. A literature review was conducted by searching Medline, Embase, Scopus, and Web of Science with the keywords S. stercoralis, strongyloidiasis, RA, and T2DM. Our case indicates that screening S. stercoralis infection in high-risk groups, especially those who are candidates for corticosteroids medications, must be implemented using at least two diagnostic techniques.
A retrospective study comparing agar plate culture, indirect immunofluorescence and real-time PCR for the diagnosis of Strongyloides stercoralis infection.
Buonfrate Dora,Perandin Francesca,Formenti Fabio,Bisoffi Zeno
Strongyloides stercoralis is a parasite that can cause death in immunocompromised people. A proper diagnosis is hence essential. The real-time polymerase-chain reaction (RT-PCR) is a novel, promising diagnostic method, that detects the DNA of the parasite in stool samples. In this retrospective study, we compared the sensitivity of agar plate coproculture (APC), an in-house immunofluorescence test (IFAT) and an in-house RT-PCR for the diagnosis of S. stercoralis infection. The study sample was composed by 223 samples. Samples resulting positive to APC, IFAT and RT-PCR were 20, 140 and 25, respectively. When sensitivity was calculated against a composite reference standard, serology confirmed the best performance (sensitivity 95%), followed by RT-PCR (57%) and APC (45%). In conclusion, in a non-endemic setting, serology is the best screening method, while the combination of APC and RT-PCR does not seem a reasonable approach to increase sensitivity. Both methods can have a role as confirmatory tests for selected cases.
Efficacy and safety of ascending doses of moxidectin against Strongyloides stercoralis infections in adults: a randomised, parallel-group, single-blinded, placebo-controlled, dose-ranging, phase 2a trial.
Hofmann Daniela,Sayasone Somphou,Sengngam Khanpaseuth,Chongvilay Bounthunh,Hattendorf Jan,Keiser Jennifer
The Lancet. Infectious diseases
BACKGROUND:Strongyloidiasis represents a major public health issue, particularly in resource-limited countries. Preliminary studies suggest that moxidectin might serve as an alternative to the only available treatment option, ivermectin. We aimed to evaluate the efficacy and safety of ascending doses of moxidectin in Strongyloides stercoralis-infected patients. METHODS:We did a randomised, parallel-group, single-blinded, placebo-controlled, dose-ranging, phase 2a trial in four villages in northern Laos. Eligible adults (aged 18-65 years) with S stercoralis infection intensities of at least 0·4 larvae per g of stool in at least two stool samples were randomly assigned (1:1:1:1:1:1:1) by use of computerised, stratified, block randomisation into seven treatment groups: 2 mg of moxidectin, 4 mg of moxidectin, 6 mg of moxidectin, 8 mg of moxidectin, 10 mg of moxidectin, 12 mg of moxidectin, or placebo. Participants and primary outcome assessors were masked to treatment allocation, but study site investigators were not. Participants received a single oral dose of their allocated dose of moxidectin in 2 mg tablets, or four placebo tablets. Three stool samples were collected at baseline and two stool samples were collected 28 days after treatment from each participant. A Baermann assay was used to quantify S stercoralis infection and Kato-Katz thick smears were used to qualitatively identify coinfections with additional helminths species. The primary endpoint was cure rate against S stercoralis and was analysed in an available case analysis set, defined as all randomly assigned participants with primary endpoint data. Predicted cure rates and associated CIs were estimated with hyperbolic E models. Safety was evaluated in the intention-to-treat population. This trial is registered at ClinicalTrials.gov, NCT04056325, and is complete. FINDINGS:Between Nov 27, 2019, and March 15, 2020, 785 adults were screened for trial eligibility. Of these, 223 participants were randomly assigned to treatment groups and 209 completed the study and were analysed for the primary outcome. 2 mg of moxidectin had a predicted cure rate of 75% (95% CI 59-87; 22 [73%] of 30 cured) against S stercoralis compared with a predicted cure rate of 14% (5-31; four [14%] of 29 cured) for placebo. With escalating doses, the probability of cure increased from 83% (95% CI 76-88; 26 [90%] of 29 cured) at 4 mg to 86% (79-90; 27 [84%] of 32 cured) at 6 mg, and to 87% (80-92; 24 [83%] of 29 cured) at 8 mg, levelling off at 88% (80-93; 29 [97%] of 30 cured) at 10 mg and 88% (80-93; 26 [87%] of 30 cured) at 12 mg. Moxidectin was well tolerated across all treatment groups, with no serious adverse events being recorded and all reported symptoms being classified as mild. INTERPRETATION:4-12 mg of moxidectin showed promising tolerability and efficacy profiles in the treatment of S stercoralis infections in adults. Because 8 mg of moxidectin is used for the treatment of onchocerciasis and has been evaluated for other helminth infections, we recommend this dose for phase 2b and phase 3 trials of strongyloidiasis therapy. FUNDING:Fondazione Adiuvare.
Screening of Strongyloides stercoralis infection in high-risk patients in Khuzestan Province, Southwestern Iran.
Ashiri Alireza,Rafiei Abdollah,Beiromvand Molouk,Khanzadeh Abdollah,Alghasi Arash
Parasites & vectors
BACKGROUND:Strongyloidiasis, one of the neglected tropical diseases (NTDs), can be fatal in immunocompromised patients. Available data on Strongyloides stercoralis infection in high-risk patients in Iran are limited. The aim of the present study was to determine the prevalence of S. stercoralis infection and associated risk factors among high-risk patients as well as to evaluate the sensitivity of the diagnostic tests used in the diagnose of S. stercoralis infection. METHODS:This cross-sectional study was performed from 2019 to 2020 among 300 high-risk patients in Khuzestan Province, southwestern Iran. Patients with autoimmune diseases, uncontrolled diabetes, HIV/AIDS, cancer, organ transplant, hematological malignancy, asthma and chronic obstructive pulmonary disease (COPD) were examined using direct smear examination, formalin-ether concentration, Baermann funnel technique, agar plate culture, and ELISA test. Since agar plate culture was considered the reference diagnostic test, culture-positive samples were confirmed by PCR amplification and the sequencing of the nuclear 18S rDNA (SSU) hypervariable region (HVRIV) of the parasite. RESULTS:The prevalence of S. stercoralis infection was 1%, 1.3%, 2%, 2.7%, and 8.7% using direct smear examination, formalin-ether concentration, Baermann funnel technique, agar plate culture, and ELISA test, respectively. All culture-positive samples were confirmed by SSU-PCR. According to the results, the most sensitive test was ELISA, with 100% sensitivity, followed by the Baermann funnel technique with the sensitivity of 75%. Direct smear examination, formalin-ether concentration technique, and Baermann funnel technique had the highest PPV (100%) while the ELISA test had the highest NPV (100%). Significant eosinophilia was observed in the patients whose culture test was positive (7/8; P < 0.05). In the present study, the majority of the positive cases by the agar plate culture had a history of prolonged exposure to soil and of asthma and COPD and were > 60 years old. CONCLUSIONS:Given that the ELISA test had the highest NPV, the screening of all high-risk patients for S. stercoralis infection in endemic areas is recommended prior to starting corticosteroid therapy with the ELISA test. The results indicate the importance of paying attention to patients with unknown eosinophilia in endemic areas. Ivermectin should be available to strongyloidiasis patients in the endemic areas.
Epidemiology and risk factors of Strongyloides stercoralis infection in Papua, Indonesia: a molecular diagnostic study.
Kridaningsih Tri N,Sukmana Dhika J,Mufidah Hartalina,Diptyanusa Ajib,Kusumasari Rizqiani A,Burdam Faustina H,Kenangalem Enny,Poespoprodjo Jeanne R,Fuad Anis,Mahendradhata Yodi,Supargiyono Supargiyono,Utzinger Jürg,Becker Sören L,Murhandarwati E Elsa Herdiana
Strongyloides stercoralis is a parasitic worm that is of considerable clinical relevance. Indeed, it may persist asymptomatically for many years, but can lead to potentially fatal dissemination when the host's immune status is impaired. As commonly employed stool microscopy techniques (e.g. Kato-Katz thick smear) fail to detect S. stercoralis, the epidemiology is poorly understood. In 2013, we conducted a cross-sectional household survey in the district of Mimika in Papua, Indonesia. A total of 331 individuals, aged 1 month to 44 years, had a single stool sample subjected to real-time polymerase chain reaction (PCR) for S. stercoralis diagnosis. The prevalence of S. stercoralis infection was 32.0% (106/331 individuals); higher than any of the three main soil-transmitted helminths (Ascaris lumbricoides, 23.9%; Trichuris trichiura, 18.4%; and hookworm, 17.2%). Amongst the S. stercoralis-infected individuals, 73.6% were concurrently infected with another helminth, with hookworm being the most frequent co-infection (27.4%). Fourteen percent of the S. stercoralis infections had low cycle threshold values on real-time PCR, which may indicate a higher infection intensity. Multivariate logistic regression analysis revealed that age ≥5 years (adjusted odds ratio (OR) 5.8, 95% confidence interval (CI): 3.1-10.8) was significantly associated with S. stercoralis infection. There is a need for in-depth clinical and diagnostic studies to elucidate the public health impact of S. stercoralis infection in Indonesia.
Molecular characterization of human isolates of Strongyloides stercoralis and Rhabditis spp. based on mitochondrial cytochrome c oxidase subunit 1 (cox1).
Fadaei Tehrani Mandana,Sharifdini Meysam,Zahabiun Farzaneh,Latifi Robabeh,Kia Eshrat Beigom
BMC infectious diseases
BACKGROUND:Due to the similarity of Strongyloides stercoralis with free-living nematodes of Rhabditis species they might be miss-diagnosed with each other in microscopical examination of stool samples. The aim of this study was molecular characterization and differentiation of human derived isolates of S. stercoralis and Rhabditis species based on the mitochondrial gene of cytochrome c oxidase subunit 1 (cox1) amplification. METHODS:Using parasitological methods, ten isolates of S. stercoralis and three isolates of Rhabditis spp. were obtained from fresh stool samples of patients and the genomic DNA of the samples were extracted. PCR amplification of cox1 gene was carried out for all the isolates and the products were sequenced. RESULTS:The phylogenetic analysis illustrated that S. stercoralis and Rhabditis spp. isolates were placed in two distinguishable separate clades. Inter-species genetic variation between isolates of S. stercoralis and Rhabditis spp. were ranged from 13.5 to 14.5%. CONCLUSIONS:Cox1 gene was a suitable marker for discrimination of S. stercoralis from Rhabditis spp. retrieved from human in the current study. The availability of gene sequence information will be helpful in the future development and validation of discriminatory PCR-based assays of these nematodes.
Strongyloides stercoralis Infection in a Patient with Chronic Renal Failure from North China.
Yu Peixia,Wang Xufei,Wen Xiaoting,Ji Yongjin
INTRODUCTION:Human strongyloidiasis is a generally neglected parasitic disease of major global distribution, spreading commonly in tropical and subtropical areas. As for China, strongyloidiasis occur mainly in South of China and no relevant information about the parasite infection in North China was available. CASE PRESENTATION:An 84-year-old man from Shanxi province, North China, was admitted to Department of Nephrology with complaints of a 7-month history of intermittent edema of both lower extremity with foam urine and 3-day history of fever, chill and diarrhea. Large numbers of rhabditiform larva of Strongyloides stercoralis (S. stercoralis) were observed in a stool sample. Diagnosis of S. stercoralis infection was established by morphological observations of larvae under the microscope in both wet mount and Wright-Giemsa staining smear and further confirmed by molecular biology identification. CONCLUSIONS:We report a rare case of S. stercoralis infection in a patient with chronic renal failure from North China, which implies the possibility of developing human strongyloidiasis in cooler climates. In addition, our case suggests that clinicians should consider the complication of S. stercoralis infection in immunosuppressed patient populations with chronic renal failure. Morphological details of S. stercoralis in Wright-Giemsa staining was first described in the present case. Our results also support the use of molecular techniques targeting COX1 gene sequence for the diagnosis of S. stercoralis infection, which was prove to be necessary in laboratory practice, especially for those inexperienced morphologists in temperature zone.
Phylogenetic Positioning of a Strongyloides stercoralis Isolate Recovered from a Korean Patient and Comparison with Other Asian Isolates.
Bae Jaeho,Jeong Mi Jin,Shin Dong Hoon,Kim Hyun Woo,Ahn Sung Ho,Choi Jun Ho,Yu Hak Sun
The Korean journal of parasitology
Strongyloidiasis is caused by Strongyloides stercoralis and is one of the most neglected tropical diseases in tropical and subtropical regions. Although several strongyloidiasis cases have been reported in Korea, genetic analysis of Korean isolates is still incomplete. In this study, a parasite was isolated from a 61-year-old man diagnosed with strongyloidiasis during the treatment of lymphoma on his retroperitoneal lymph node. Diffuse symmetric wall thickening from the ascending to descending colon and a nematode-infected intestine was observed following microscopic examination. Genomic DNA was isolated from a patient tissue block, and S. stercoralis was identified by PCR and sequencing (18S rDNA). In order to determine phylogenetic location of a Korean isolate (named KS1), we analyzed cox1 gene (500-bp) and compared it with that from 47 previous S. stercoralis isolates (28 human isolates and 19 canid isolates) from Asian countries. Our results showed that phylogenetic tree could clearly be divided into 5 different groups according to hosts and regions. KS1 was most closely related with the Chinese isolates in terms of genetic distance.
From the feces to the genome: a guideline for the isolation and preservation of Strongyloides stercoralis in the field for genetic and genomic analysis of individual worms.
Zhou Siyu,Harbecke Dorothee,Streit Adrian
Parasites & vectors
Strongyloidiasis is a soil-borne helminthiasis, which, in spite of the up to 370 million people currently estimated to be infected with its causing agent, the nematode Strongyloides stercoralis, is frequently overlooked. Recent molecular taxonomic studies conducted in Southeast Asia and Australia, showed that dogs can carry the same genotypes of S. stercoralis that also infect humans, in addition to a presumably dog-specific Strongyloides species. This suggests a potential for zoonotic transmission of S. stercoralis from dogs to humans. Although natural S. stercoralis infections have not been reported in any host other than humans, non-human primates and dogs, other as yet unidentified animal reservoirs cannot be excluded. Molecular studies also showed that humans carry rather different genotypes of S. stercoralis. As a result, their taxonomic status and the question of whether they differ in their pathogenic potential remains open. It would therefore be very important to obtain molecular genetic/genomic information about S. stercoralis populations from around the world. One way of achieving this (with little additional sampling effort) would be that people encountering S. stercoralis in the process of their diagnostic work preserve some specimens for molecular analysis. Here we provide a guideline for the isolation, preservation, genotyping at the nuclear 18S rDNA and the mitochondrial cox1 loci, and for whole genome sequencing of single S. stercoralis worms. Since in many cases the full analysis is not possible or desired at the place and time where S. stercoralis are found, we emphasize when and how samples can be preserved, stored and shipped for later analysis. We hope this will benefit and encourage researchers conducting field studies or diagnostics to collect and preserve S. stercoralis for molecular genetic/genomic analyses and either analyze them themselves or make them available to others for further analysis.
Genomic studies on Strongyloides stercoralis in northern and western Thailand.
Aupalee Kittipat,Wijit Adulsak,Singphai Kittikhun,Rödelsperger Christian,Zhou Siyu,Saeung Atiporn,Streit Adrian
Parasites & vectors
BACKGROUND:Strongyloidiasis is a soil borne helminthiasis, which in most cases is caused by Strongyloides stercoralis. Human infections with S. fuelleborni fuelleborni and S. fuelleborni kellyi also occur. Although up to 370 million people are currently estimated to be infected with S. stercoralis, this parasite is frequently overlooked. Strongyloides stercoralis is prevalent among humans in Thailand; however, S. fuelleborni fuelleborni has also been reported. Three recent genomic studies of individual S. stercoralis worms found genetically diverse populations of S. stercoralis, with comparably low heterozygosity in Cambodia and Myanmar, and less diverse populations with high heterozygosity in Japan and southern China that presumably reproduce asexually. METHODS:We isolated individual Strongyloides spp. from different localities in northern and western Thailand and determined their nuclear small ribosomal subunit rDNA (18S rDNA, SSU), in particular the hypervariable regions I and IV (HVR-I and HVR-IV), mitochondrial cytochrome c oxidase subunit 1 (cox1) and for a subset whole genome sequences. These sequences were then compared with each other and with published sequences from different geographical locations. RESULTS:All 237 worms isolated from 16 different human hosts were S. stercoralis, no S. fuelleborni was found. All worms had the common S. stercoralis SSU HVR IV haplotype A. Two different SSU HVR I haplotypes (I and II), both previously described in S. stercoralis, were found. No animal heterozygous for the two haplotypes was identified. Among the twelve cox1 haplotypes found, five had not been previously described. Based upon the mitochondrial cox1 and the nuclear whole genome sequences, S. stercoralis in Thailand was phylogenetically intermixed with the samples from other Southeast Asian countries and did not form its own branch. The genomic heterozygosity was even slightly lower than in the samples from the neighboring countries. CONCLUSIONS:In our sample from humans, all Strongyloides spp. were S. stercoralis. The S. stercoralis from northern and western Thailand appear to be part of a diverse, intermixing continental Southeast Asian population. No obvious indication for genetic sub-structuring of S. stercoralis within Thailand or within the Southeast Asian peninsula was detected.
Streptococcus pyogenes bacteremia and toxic shock syndrome related to Strongyloides stercoralis hyperinfection: a case report.
Cohen Regev,Finn Talya,Babushkin Frida,Shapiro Maurice,Uda Martina,Grossman Tamar
Journal of medical case reports
BACKGROUND:We describe a patient with Strongyloides stercoralis hyperinfection associated with Streptococcus pyogenes and with streptococcal toxic shock syndrome. To the best of our knowledge this association has not been previously described. CASE PRESENTATION:A 78 year-old Israeli man, who was born in Iraq but lived in Israel for 66 years, presented with multi-organ failure including acute kidney and hepatic injury, coagulopathy, and lactic acidosis. He had a medical history including aortic valve replacement, diabetes mellitus, spinal stenosis, and low back pain treated with repeated local steroid injections. Blood cultures were positive for Streptococcus pyogenes and antibiotic treatment was switched to penicillin G, clindamycin, and intravenous immunoglobulins. Repeated physical examinations failed to identify the source of the bacteremia. On day 12 of hospitalization the serology results for Strongyloides stercoralis sent on admission, because of chronic eosinophilia, came back positive. A microscopic stool examination and stool polymerase chain reaction were positive for Strongyloides stercoralis. Ivermectin therapy was commenced and continued for a total of 4 weeks. He was discharged for rehabilitation after 25 days. He had no exposure to endemic countries or to immigrants. During many years he had multiple gastrointestinal symptoms, respiratory symptoms, cutaneous symptoms, chronic eosinophilia, and high immunoglobulin E levels. He underwent several operative procedures and numerous hospitalizations and medical encounters with different experts but a parasitic infection was not considered. His asymptomatic daughter was also found to be serologically positive. CONCLUSIONS:Strongyloides stercoralis hyperinfection associated with Streptococcus pyogenes bacteremia and toxic shock is described for the first time. The case also highlights the importance of history taking and reviewing past laboratory results, the utility of serological tests for Strongyloides stercoralis, and the importance of screening asymptomatic family members of an infected patient. Strongyloides stercoralis hyperinfection must be considered in the differential diagnosis of any patient with Streptococcus pyogenes bacteremia or toxic shock of no clear source as well as in symptomatic patients with chronic or intermittent eosinophilia, even without any epidemiological risk factors.