Strongyloides

Morning Report
Dec 14
th
, 2009
Nicole Cullen

What is Strongyloides?
Parasitic infection
with a predilection for the
intestines
2 most common and clinically
relevant species are:
Strongyloides stercoralis
Strongyloides fuelleborni
Limited to Africa and Papua New
Guinea


Epidemiology
Relatively uncommon in the US
BUT, endemic areas in the rural parts of the
Southeastern states and the Appalachian
mountain area
Certain pockets with prevalence 4%
Usually found in tropical and subtropical
countries
Prevalence up to 40% in areas of West Africa, the
Caribbean, Southeast Asia
Affects >100 million worldwide
No sexual or racial disparities. All age groups.
How Do You Get It?
Penetration of intact skin by filiariform
larvae in the soil, or ingestion through
contaminated food or water
Larvae enter the circulation
Lungs alveoli ascension up
tracheobronchial tree swallowed molt
in the small bowel and mature into adult
female
Females enter the intestinal mucosa
and produce several eggs daily through
parthenogenesis (hatch during transit
through the gut)


Clinical Presentation
Acute infection:
Lower extremity itching (mild
erythematous maculopapular rash at
the site of skin penetration)
Cough, dyspnea, wheezing
Low-grade fevers
Epigastric discomfort, n/v/d

Clinical Presentation
Chronic Infection
Can be completely asymptomatic
Abdominal pain that can be very vague, crampy,
burning
Often worse after eating
Intermittent diarrhea
Can alternate with constipation
Occasional n/v
Weight loss (if heavy infestation)
Larva currens (racing larva a recurrent
maculopapular or serpiginous rash)
Usually begins perianally and extends up the buttocks,
upper thighs, abdomen
Chronic urticaria
Larva Currens
Clinical Presentation
Severe infection
Can be abrupt or insidious in onset
N/v/d, severe abdominal pain, distention
Cough, hemoptysis, dyspnea, wheezing, crackles
Stiff neck, headache, MS changes
If CNS involved
Fever/chills
Hematemesis, hematochezia
Rash (petechiae, purpura) over the trunk and proximal extremities
Caused by dermal blood vessel disruption brought on by massive
migration of larvae within the skin
Risk factors for severe infection
Immunosuppressant meds (steroids, chemo, TNF modulators,
tacro, etc all BUT cyclosporine)
Malignancy
Malabsorptive state
ESRD
DM
Advanced age
HIV
HTLV1
Etoh
Clinical Presentation
Can replicate in the host for
decades with minimal or no sx
High morbidity and mortality when
progresses to hyperinfection
syndrome or disseminated
strongyloidiasis
Usually in immunocompromised
hosts (pregnancy?)
Dangerous Complications
Hyperinfection Syndrome
Acceleration of the normal life cycle, causing
excessive worm burden
Autoinfection (turn into infective filariform larva within
the lumen
Spread of larvae outside the usual migration pattern
of GI tract and lungs
Disseminated strongyloidiasis
Widespread dissemination of larvae to extraintestinal
organs
CNS (meningitis), heart, urinary tract, bacteremia, etc
Can be complicated by translocation of enteric
bacteria
Travel on the larvae themselves or via intestinal ulcers
Mortality rate close to 80%
Due to delayed diagnosis, immunocompromised state
of the host at this point

Laboratory Findings
CBC
WBC usually wnl for acute and
chronic cases, can be elevated in
severe cases
Eosinophilia common during acute
infection, +/- in chronic infection
(75%), usually absent in severe
infection
Diagnostic Testing
Stool O&P
Microscopic ID of S. sterocoralis larvae is
the definitive diagnosis
Ova usually not seen (only helminth to
secrete larva in the feces)
Stool wet mount (direct exam)
In chronic infection, sensitivity only 30%,
can increase to 75% if 3 consecutive stool
exams
Can enhance larvae recovery with more
obscure methods (Baermann funnel, agar
plate, Harada-Mori filter paper)
Wet Mount

Larva seen via direct examination of stool
Serology
ELISA
Most sensitive method (88-95%)
May be lower in immunocompromised
patients
Cannot distinguish between past and
present infections
Can cross-react with other nematode
infections
If results are positive, can move on to
try and establish a microscopic dx
Imaging
CXR patchy alveolar infiltrates, diffuse
interstitial infiltrates, pleural effusions
AXR Loops of dilated small bowel,
ileus
Barium swallow stenosis, ulceration,
bowel dilitation
Small bowel follow-through worms in
the instestine
CT abdomen/pelvis nonspecific
thickening of the bowel wall
Procedures
EGD duodenitis, edematous mucosa, white
villi, erythema
Colonoscopy colitis
Duodenal aspiration examine for larvae
Sputum sample, bronchial washings, BAL
show larvae
Sputum cx
Nl respiratory flora organisms pushed to the outside
in groups as a result of migrating larvae
Characteristic pattern can be diagnostic of
S.Stercoralis infection
If CNS involved, LP gram stain, cell count/diff
( protein, glu, poly predominance), wet
mount prep
Histology
Larvae typically found in proximal
portion of small intestine
Embedded in lamina propria
Cause edema, cellular infiltration,
villous atrophy, ulcerations
In-long standing infections, may
see fibrosis
Treatment
Antihelminitic therapy
Ivermectin
Albendazole
Thiabendazole
Abx directed toward enteric pathogens if
bacteremia or meningitis (2-4wks)
Minimize immunosuppression as possible
Directed supportive tx
Transfusions if GI bleed, antihistamines for itching,
surgery if bowel perf, etc
Repeat course of antihelminitic therapy if
immunocompromised, as relapse common
Follow-Up
Repeat stool exams or duodenal
aspirations in 2-3 mos to document cure
Repeat serologies 4-8 mos after therapy
Ab titer should be low or undetectable 6-18
mos after successful tx
If titer not falling, additional
antihelminitic tx
Precautions for travelers to endemic
areas, but no prophylaxis or vaccine
available
References
Arch EL, Schaefer JT and Dahiya A. Cutaneous
manifestation of disseminated strongyloidiasis in a
patient coinfected with HTLV-1. Dermatology Online
Journal. 2008;14(12):6.
Chadrasekar PH, Bharadwaj RA, Polenakovik H,
Polenakovik S. Emedicine: Strongyloidiasis. April 3,
2009.
Concha R, Harrington W and Rogers A. Intestinal
Strongyloidiasis. Recognition, Management and
Determinants of Outcome. Journal of Clinical
Gastroengerology. 2005;39(3):203-211.
Greiner K, Bettencourt J, and Semolic C.
Strongyloidiasis: A Review and Update by Case
Example. Clinical Laboratory Science. 2008;21(2):82-8.
Siddiqui AA, Berk SL. Diagnosis of Strongyloides
stercoralis infection. Clin Infect Dis. October 1,
2001;33:1040-7.
Zeph, Bill. Strongyloides stercoralis Infection Can Be
Fatal. American Family Physician. March 15, 2002.