Strongyloidiasis

Epidemiology

Geography

  • Endemic in Subtropical/Tropical Regions: prevalence may be >25%
    • Highest Rates Occur in Military Personnel/Travelers Returning from Endemic Areas and Immigrants/Refugees from Endemic Areas
  • Sporadic in Southeastern US, Appalachia, and Southern Europe
  • Cases May Also Occur Due to Transmission in Long-Term Care Settings

Microbiology

  • Strongyloides Stercoralis
    • Nematode Roundworm
  • Transmission/Lifecycle
    • Transmission Occurs Via the Skin Through Contact with Soil on Beaches or Mud
    • Larvae Travel to the Lungs, Where They Break into the Alveoli
    • Larvae Ascend the trachea, are Coughed Up, and are Subsequenrty Swallowed
    • Larvae Reside in the Small Intestine, Where They Mature: larvae are first detected in the stool approximately 3-4 wks after initial dermal penetration
      • Females Lay Eggs, Which are Passed in the Feces

Diagnosis

Stool Ova and Parasite Exam (see Stool Ova and Parasite Exam, [[Stool Ova and Parasite Exam]])

  • Larvae are First Detected in the Stool Approximately 3-4 wks After Initial Dermal Penetration

Clinical Manifestations

General Comments

  • Most Patients with Strongyloidiasis Do Not Experience Significant Symptoms

Typical Strongyloidiasis

Allergic/Immunologic Manifestations

Dermatologic Manifestations

  • General Comments
    • Symptoms May Wax and Wane Over Years
  • “Ground Itch”
    • Physiology: due to larvae penetrating the skin
    • Clinical (Acute Infection): most commonly on the feet
      • Edema
      • Local Inflammation
      • Petechiae (see Petechiae, [[Petechiae]])
      • Serpiginous/Urticarial Tracts (see Urticaria, [[Urticaria]])
      • Severe Pruritus (see Pruritus, [[Pruritus]])
    • Clinical (Chronic Infection)
      • Angioedema (see Angioedema, [[Angioedema]])
      • Eruption on Buttocks
      • Erythroderma (see Erythroderma, [[Erythroderma]]) (J Am Acad Dermatol, 2003) [MEDLINE]
      • Larva Currens (“Running Larva”): pathognomonic of Strongyloidiasis
      • Non-Palpable Purpura (see Purpura, [[Purpura]])
      • Periumbilical Purpura (see Purpura, [[Purpura]]): occurs in disseminated infection
      • Pruritus (see Pruritus, [[Pruritus]])
      • Urticaria (see Urticaria, [[Urticaria]])

Gastrointestinal Manifestations

  • General Comments
    • Symptoms May Wax and Wane Over Years

Hematologic Manifestations

  • Peripheral Eosinophilia (see Peripheral Eosinophilia, [[Peripheral Eosinophilia]])
    • Clinical: peripheral eosinophilia may be absent in cases with concomitant pyogenic infection or corticosteroid administration

Pulmonary Manifestations

  • General Comments
    • Symptoms May Wax and Wane Over Years
  • Asthma-Like Illness (Br Med J, 1973) MEDLINE and [MEDLINE]
    • Epidemiology
      • May Occur with Chronic Strongyloidiasis
    • Clinical
      • Asthma Paradoxically Worsens with Corticosteroid Administration
  • Restrictive Lung Disease
    • Epidemiology
      • Occurs with Chronic Strongyloidiasis
    • Epidemiology
      • Case Reports (Am J Respir Crit Care Med, 1995) [MEDLINE]
  • Simple Pulmonary Eosinophilia (Loffler Syndrome) (see Simple Pulmonary Eosinophilia, [[Simple Pulmonary Eosinophilia]])
    • Physiology: occurs when larvae migrate through the lungs
    • Diagnosis
      • Sputum Culture: may recover Strongyloides
      • Bronchoscopy with Bronchial Wash/Bronchoalveolar Lavage (BAL): may recover Strongyloides
    • Clinical

Strongyloides Hyperinfection Syndrome

General Comments

  • Repeated Autoinfection within the Gastrointestinal Tract Increases the Parasite Burden, Resulting in the Hyperinfection Syndrome
    • Rhabditiform Larvae Transform into Filariform Larvae, Which Then Penetrate the Intestinal Wall to Enter the Bloodstream
    • Massive Dissemination of Filariform Larvae Occurs to the Lungs, Liver, Heart, Central Nervous System, and Endocrine Glands
  • Risk Factors
    • General Comments
      • Retrospective Case Review of Strongyloides Hyperinfection Syndrome Cases (Infection, 2015) [MEDLINE]
        • Immunosuppression was Present in Most Cases of Hyperinfection Syndrome (with Chronic Long-Term Corticosteroids Being the Most Common Immunosuppressive)
    • Anti-Tumor Necrosis Factor-α Therapy (see Anti-Tumor Necrosis Factor-α Therapy, [[Anti-Tumor Necrosis Factor-α Therapy]])
      • Case Report in Filipino RA Patient Treated with Anti-TNFα Therapy in Addition to Prednisone and Methotrexate ( J Clin Rheumatol, 2007) [MEDLINE]
    • Hypogammaglobulinemia (see Hypogammaglobulinemia, [[Hypogammaglobulinemia]])
    • Impaired Cell-Mediated Immunity (with TH-2 Helper Cell Dysfunction)
      • Alcoholism (see Ethanol, [[Ethanol]])
      • Congenital Immunodeficiency
      • Corticosteroids (see Corticosteroids, [[Corticosteroids]])
        • Even Short Corticosteroid Courses Can Lead to Severe (and Potentially Fatal) Hyperinfection Syndrome (Trans R Soc Trop Med Hyg, 2007) [MEDLINE]
      • Cytotoxic Agents
        • However, in Contrast to Other Immunosuppressives, Cyclosporine A Has Activity Against Strongyloides (see Cyclosporine A, [[Cyclosporine A]]): it is unclear if this activity is sufficient to inhibit the development of the hyperinfection syndrome
      • Hematopoietic Stem Cell Transplantation (HSCT) (see Hematopoietic Stem Cell Transplantation, [[Hematopoietic Stem Cell Transplantation]])
      • Human Immunodeficiency Virus (HIV) (see Human Immunodeficiency Virus, [[Human Immunodeficiency Virus]])
        • Risk of Hyperinfection Syndrome is Less with HIV than with HTLV-1
        • However, Immune Reconstitution Syndrome (IRIS) May Be a Risk Factor for Disseminated Strongyloidiasis
      • Human T-Lymphotropic Virus Type I (HTLV-I) Infection (see Human T-Lymphotropic Virus-1, [[Human T-Lymphotropic Virus-1]])
        • HTLV-1 Decreases the Production of IL-4, IL-5, IL-13, and IgE: these are all required for host defense against Strongyloides
      • Malignancy
      • Malnutrition (see Malnutrition, [[Malnutrition]])
    • Organ Transplant (Donor-Derived Strongyloidiasis)

Gastrointestinal Manifestations

  • General Comments
    • Retrospective Case Review of Strongyloides Hyperinfection Syndrome Cases (Infection, 2015) [MEDLINE]
      • Gastrointestinal Symptoms were Present in 71.2% of Cases
  • Abdominal Pain (see Abdominal Pain, [[Abdominal Pain]])
  • Anorexia (see Anorexia, [[Anorexia]])
  • Diarrhea (see Diarrhea, [[Diarrhea]])
  • Nausea/Vomiting (see Nausea and Vomiting, [[Nausea and Vomiting]])

Hematologic Manifestations

  • Peripheral Eosinophilia (see Peripheral Eosinophilia, [[Peripheral Eosinophilia]])
    • Epidemiology
      • Retrospective Case Review of Strongyloides Hyperinfection Syndrome Cases (Infection, 2015) [MEDLINE]
        • Peripheral Eosinophilia Occurred in Only 34.3% of Cases

Neurologic Manifestations

  • Meningitis
    • Microbiology
      • Gastrointestinal Flora: Klebsiella, etc
      • Streptococcus Gallolyticus (Formerly Streptococcus Bovis) (Clin Microbiol Infect, 2015)[MEDLINE]

Pulmonary Manifestations

  • General Comments
    • Retrospective Case Review of Strongyloides Hyperinfection Syndrome Cases (Infection, 2015) [MEDLINE]
      • Respiratory Symptoms were Present in 88.6% of Cases
  • Cough (see Cough, [[Cough]])
  • Dyspnea (see Dyspnea, [[Dyspnea]])
  • Hemoptysis (see Hemoptysis, [[Hemoptysis]])
  • Pulmonary Infiltrates/Pneumonia
  • Respiratory Failure (see Respiratory Failure, [[Respiratory Failure]])
    • Epidemiology
      • May Occur (Chest, 2005) [MEDLINE]
      • Retrospective Case Review of Strongyloides Hyperinfection Syndrome Cases (Infection, 2015) [MEDLINE]
        • Respiratory Failure Requiring Mechanical Ventilation Occurred in 67.9% of Cases
  • Wheezing/Bronchospasm (see Wheezing, [[Wheezing]])
    • Physiology
      • Adult Parasites Localize within the Bronchial Tree and Lay Eggs Which Develop into Larvae in the Airway

Other Manifestations

  • Bacteremia (see Bacteremia, [[Bacteremia]])
    • Epidemiology
      • Retrospective Case Review of Strongyloides Hyperinfection Syndrome Cases (Infection, 2015) [MEDLINE]
        • Concomitant Bacterial Infection Occurred in 38.4% of Cases
    • Physiology: bacteria originate from either the lung or gastrointestinal tract (J Gastroenterol Hepatol, 2002) [MEDLINE]
    • Microbiology
      • Gastrointestinal Flora: Klebsiella, etc
      • Streptococcus Gallolyticus (Formerly Streptococcus Bovis) (Clin Microbiol Infect, 2015)[MEDLINE]
    • Clinical
  • Fever (see Fever, [[Fever]])
  • Sepsis (see Sepsis, [[Sepsis]])
    • Epidemiology
      • Retrospective Case Review of Strongyloides Hyperinfection Syndrome Cases (Infection, 2015) [MEDLINE]
        • Shock Occurred in 57.3% of Cases
        • Predictors of Shock
        • Concomitant Bacterial Infection
        • Peripheral Eosinophilia (see Peripheral Eosinophilia, [[Peripheral Eosinophilia]])

Treatment

Ivermectin (see Ivermectin, [[Ivermectin]])

  • xxx

Prognosis

  • Mortality Rate with the Strongyloides Hyperinfection Syndrome: 10-80%
  • ICU Mortality Rate
    • Retrospective Case Review of Strongyloides Hyperinfection Syndrome Cases (Infection, 2015) [MEDLINE]: ICU mortality rate was 60.3%
      • Poor Prognostic Factors
        • Need for Mechanical Ventilation
        • Presence of Shock

References

  • Strongyloidiasis of respiratory tract presenting as “asthma”. Br Med J. 1973;2(5859):153 [MEDLINE]
  • Immunoepidemiologic studies of Strongyloides stercoralis and human T lymphotropic virus type I infections in Jamaica. J Infect Dis. 1994;169(3):692 [MEDLINE]
  • Pulmonary strongyloidiasis: clinical and imaging features. AJR Am J Roentgenol. 1994;162(3):537 [MEDLINE]
  • The prevalence and response to therapy of Strongyloides stercoralis in patients with asthma from endemic areas. Chest. 1994;106(3):762 [MEDLINE]
  • Corticosteroid-induced asthma: a manifestation of limited hyperinfection syndrome due to Strongyloides stercoralis. South Med J. 1995;88(9):923 [MEDLINE]
  • Restrictive pulmonary disease due to interlobular septal fibrosis associated with disseminated infection by Strongyloides stercoralis. Am J Respir Crit Care Med. 1995;151(1):205 [MEDLINE]
  • Strongyloides stercoralis infestation associated with septicemia due to intestinal transmural migration of bacteria. J Gastroenterol Hepatol. 2002;17(12):1331 [MEDLINE]
  • Community-acquired pneumonia in immunocompromised patients. Opportunistic infections to consider in differential diagnosis. Postgrad Med. 2003;113(1):65 [MEDLINE]
  • Cutaneous Strongyloides stercoralis infection: an unusual presentation. J Am Acad Dermatol. 2003;49(2 Suppl Case Reports):S157 [MEDLINE]
  • Parasitic central nervous system infections in immunocompromised hosts. Clin Infect Dis. 2005;40(7):1005. Epub 2005 Mar 2 [MEDLINE]
  • Strongyloides stercoralis hyperinfection in a patient with rheumatoid arthritis after anti-TNF-alpha therapy. J Clin Rheumatol. 2007 Jun;13(3):150-2 [MEDLINE]
  • Strongyloides stercoralis in the Immunocompromised Population. Clin Microbiol Rev. 2004;17(1):208 [MEDLINE]
  • Strongyloides hyperinfection presenting as acute respiratory failure and gram-negative sepsis. Chest. 2005;128(5):3681 [MEDLINE]
  • Strongyloides stercoralis septicaemia following steroid therapy for eosinophilia: report of three cases. Trans R Soc Trop Med Hyg. 2007;101(11):1163. Epub 2007 Jul 26 [MEDLINE]
  • Strongyloides stercoralis hyperinfection in a patient with rheumatoid arthritis after anti-TNF-alpha therapy. J Clin Rheumatol 2007; 13:150-152 [MEDLINE]
  • Case records of the Massachusetts General Hospital. Case 28-2014. A 39-year-old man with a rash, headache, fever, nausea, and photophobia. N Engl J Med. 2014 Sep 11;371(11):1051-60. doi: 10.1056/NEJMcpc1405886 [MEDLINE]
  • Streptococcus gallolyticus meningitis in adults: report of five cases and review of the literature. Clin Microbiol Infect. 2015 Dec;21(12):1077-83. doi: 10.1016/j.cmi.2015.08.003. Epub 2015 Aug 24 [MEDLINE]
  • Strongyloides stercoralis hyperinfection syndrome: a case series and a review of the literature. Infection. 2015 Dec;43(6):691-8. doi: 10.1007/s15010-015-0799-1. Epub 2015 May 26 [MEDLINE]