Parasite Cases: Strongyloides - Part 5

Strongyloides is hard to get a diagnosis for, particularly, in the States. It is apparent that the tropics has problems with diagnosing these parasites too.

http://www.ncbi.nlm.nih.gov/pubmed/18804829?dopt=Abstract
Trans R Soc Trop Med Hyg. 2008 Sep 18

Intestinal strongyloidiasis: a diagnosis frequently missed in the tropics.

Agrawal V, Agarwal T, Ghoshal UC.

Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow 226014, Uttar Pradesh, India.

Strongyloides stercoralis, a nematode parasite, is endemic in tropical and subtropical regions. Infection usually remains asymptomatic, but in immunocompromised hosts hyperinfection and dissemination can occur, which has a high mortality. Early detection of S. stercoralis may alter the fatal course of infection. We present our experience of five patients with S. stercoralis hyperinfection diagnosed by endoscopic duodenal and jejunal biopsy in northern India. A predisposing factor was present in all patients in the form of corticosteroid intake, chronic liver disease and panhypogammaglobulinaemia. Common gastrointestinal symptoms were abdominal pain, diarrhoea, gastrointestinal bleeding, nausea, vomiting and weight loss with evidence of malabsorption. The initial stool examination and peripheral blood eosinophil count were normal in all patients. Strongyloidiasis was not suspected clinically in any patient and the diagnosis was achieved on endoscopic biopsy. Three of the patients with disseminated disease developed fatal Gram-negative systemic infection. This study highlights the importance of considering strongyloidiasis in all patients on immunosuppressive drug therapy who present with gastrointestinal symptoms so that the patient can be appropriately investigated and promptly treated. In endemic regions, patients with systemic Gram-negative bacterial infections without an obvious cause should be tested for strongyloidiasis.

PMID: 18804829 [PubMed - as supplied by publisher]

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When I had been looking into a cause for unusual red/purplish rashes, I came across the below publication. I had approached several physicians to see if I could get an opinion (this included one who was very familiar with parasites and symptoms) - ALL of them had shrugged their shoulders not knowing what to think. I never had the rash until I had disturbed the parasites with migration. A few years ago someone had suggested that I may have Strongyloides because of other symptoms with lungs, etc. I'm not saying that all reddish/purplish rashes are parasite related, but the connection seemed to obvious to ignore.

http://www.amjmedsci.com/pt/re/ajms/abstract.00000441-200305000-00007.htm;jsessionid=
JJLSTGzwL21wKBbqyvmbsJTh9dX2g1XpWjShGVCgZzztVY0JSnJS!1600976923!181195628!8091!-1

Abstract:
Strongyloidiasis stercoralis hyperinfection presenting as vasculitic-like skin lesions is rare. An autoinfection cycle allows intestinal strongyloidiasis, usually a benign infection, to persist for many decades. We report a woman with disseminated S stercoralis infection presenting as nonpalpable purpuric skin rash and syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Upon admission, she was treated with corticosteroids for her vasculitic skin lesions, which then worsened her status. When the diagnosis was recognized, steroids were stopped, thiabendazole treatment was instituted, and she gradually recovered. Serious or fatal infection can occur in patients with strongyloidiasis who were treated with immunosuppressive drugs. Stool specimen screening and/or serological tests for S stercoralis infection in patients who require immunosuppressive therapy helps to prevent complications before embarking on such treatment. Unexplained hyponatremia, severe hypoalbuminemia without proteinuria, and unusual skin rashes, especially over the lower aspect of the abdomen and upper aspects of the thighs, in persons living in areas endemic to S stercoralis should raise suspicion of S stercoralis infection.

(C) Copyright 2003 Southern Society for Clinical Investigation

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Note this below: "...Strongyloides stercoralis hyperinfection syndrome (SHS) may develop in individuals.....".

I'd like to add that SHS "may develop" is an interesting choice of words - if Strongyloides was recognized as part of a diagnosis a hyperinfection may not have occurred.

http://linkinghub.elsevier.com/retrieve/pii/S0049017206000837

Strongyloides Stercoralis Hyperinfection in Systemic Lupus Erythematosus and the Antiphospholipid Syndrome . Seminars in Arthritis and Rheumatism , Volume 36 , Issue 3 , Pages 135 - 143 - C . Mora , M . Segami , J . Hidalgo

Abstract
Objective

The Strongyloides stercoralis hyperinfection syndrome (SHS) may develop in individuals with asymptomatic infection receiving immunosuppressive treatment. This report summarizes current knowledge regarding SHS in patients with systemic lupus erythematosus (SLE) and associated antiphospholipid syndrome (APS).

Methods

Two patients with active SLE and associated APS presenting with SHS are reported. Additional cases of strongyloidiasis in SLE were identified and reviewed.

Results

Patient 1: A 34-year-old woman with SLE and APS characterized by active glomerulonephritis, stroke, and several hospital-acquired infections presented with vomiting and diffuse abdominal pain. Intestinal vasculitis was suspected, and treatment with methylprednisolone and cyclophosphamide was given. Response was partial. A gastric biopsy revealed S. stercoralis larvae. She received ivermectin and eventually recovered. Patient 2: A 37-year-old man with active glomerulonephritis and APS with recurrent thrombosis presented with digital necrosis. Necrotizing vasculitis was suspected and treated with immunosupressants. He suddenly developed respiratory failure secondary to alveolar hemorrhage and bronchoalveolar lavage was performed. The patient developed Gram-negative septic shock and died. The postmortem result of bronchoalveolar lavage yielded Strongyloides larvae. Nine cases of strongyloidiasis and the SHS in SLE patients reported in the literature were identified and reviewed. Five of these patients died; none had associated APS.

Conclusions

These cases suggest that the SHS can exacerbate SLE and APS, predisposing to Gram-negative sepsis and death. Immunocompromised patients need an early diagnosis and specific treatment of parasitic diseases and their complications. The SHS should be considered in the differential diagnosis of lupus complications in patients from endemic areas.

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