Chronic Strongyloidiasis Research Articles

First field study using Strong-LAMP for diagnosis of strongyloidiasis in Cubal, Angola

BackgroundStrongyloides stercoralis infection is a common neglected tropical disease distributed worldwide, mainly in tropical and subtropical climates. The impact of S. stercoralis infections on human health ranges from mild asymptomatic infections to chronic strongyloidiasis unnoticeable until the host is immunosuppressed. In severe strongyloidiasis, a syndrome of hyperinfection and larval dissemination to various organs can occur with high mortality rates. The diagnosis of strongyloidiasis is challenging because of the absence of a single standard reference test with high sensitivity and specificity, which also makes it difficult to estimate the accuracy of other diagnostic tests. This study aimed to evaluate, for the first time, the use of an easy-to-perform loop-mediated isothermal amplification (LAMP) colorimetric assay (named Strong-LAMP) for the molecular screening of strongyloidiasis in stool samples from patients in a low-resource endemic area in Cubal, Angola. To compare different LAMP application scenarios, the performance of the Strong-LAMP under field conditions in Angola was reassessed in a well-equipped reference laboratory in Spain and compared with a quantitative polymerase chain reaction (qPCR) method.MethodsA total of 192 stool samples were collected from adult population in Cubal, Angola, and examined by parasitological methods (direct saline microscopy and Baermann’s technique). DNA was extracted from each stool sample using a commercial kit and tested by the colorimetric Strong-LAMP assay for the detection of Strongyloides spp. under field conditions. Furthermore, all samples were shipped to a well-equipped laboratory in Spain, reanalysed by the same procedure and compared with a qPCR method. The overall results after testing were compared.ResultsStrongyloides stercoralis larvae were identified by direct saline microscopy and Baermann in a total of 10/192 (5.2%) and 18/192 (9.4%) stool samples, respectively. Other helminth and protozoan species were also identified. The Strong-LAMP-positive results were visually detected in 69/192 (35.9%) stool samples. The comparison of Strong-LAMP results in field conditions and at a reference laboratory matched in a total of 146/192 (76.0%) samples. A total of 24/192 (12.5%) stool samples tested positive by qPCR.ConclusionsThis is the first study in which colorimetric Strong-LAMP has been clinically evaluated in a resource-poor strongyloidiasis endemic area. Strong-LAMP has been shown to be more effective in screening for strongyloidiasis than parasitological methods under field conditions and qPCR in the laboratory. Our Strong-LAMP has proven to be a field-friendly and highly accurate molecular test for the diagnosis of strongyloidiasis.Graphical

Prevalence of asymptomatic strongyloidiasis co-infection in COVID-19 patients residing in endemic areas

BackgroundFatal forms of strongyloidiasis, hyperinfection syndrome (HS) and disseminated strongyloidiasis (DS), are caused by exaggerated autoinfection of the intestinal nematode, Strongyloides stercoralis (S. stercoralis). Corticosteroids, frequently administered to patients with severe COVID-19, can transform chronic asymptomatic strongyloidiasis into the above-mentioned fatal diseases. This study aimed to investigate the prevalence of strongyloidiasis in COVID-19 patients receiving corticosteroids in a hypoendemic region.MethodsThe present cross-sectional study enrolled 308 COVID-19 patients admitted to two hospitals in Ahvaz and Abadan in the southwest of Iran between 2020 and 2022. A real-time reverse transcription polymerase chain reaction (RT-PCR) test and chest computed tomography (CT) scan were employed to detect and monitor the disease’s severity in the patients, respectively. All patients were evaluated for IgG/IgM against S. stercoralis using Enzyme-linked immunosorbent assay (ELISA) test. Subsequently, individuals with a positive ELISA test were confirmed using parasitological methods, including direct smear and agar plate culture (APC).ResultsThe patients were between 15 and 94 years old, with a mean age of 57.99 ± 17.4 years. Of the 308 patients, 12 (3.9%) had a positive ELISA test, while 296 (96.1%) had negative results. Three of the 12 patients with a positive ELISA result died, and three failed to provide a stool sample. To this end, only six cases were examined parasitologically, in which S. stercoralis larvae were observed in five patients. Significant differences were found between S. stercoralis infection with sex (p = 0.037) and age (p = 0.027). Binary regression analysis revealed that strongyloidiasis was positively associated with sex (odds ratio [OR]: 5.137; 95% confidence interval [CI]: 1.107–23.847), age (OR: 5.647; 95% CI 1.216–26.218), and location (OR: 3.254; 95% CI: 0.864–12.257).ConclusionsOur findings suggest that screening for latent strongyloidiasis in COVID-19 patients in endemic areas using high-sensitivity diagnostic methods, particularly ELISA, before receiving suppressive drugs should be given more consideration.

Strongyloides stercoralis infection: an underlying cause of invasive bacterial infections of enteric origin. Results from a prospective cross-sectional study of a northern Italian tertiary hospital.

We assessed the prevalence of S. stercoralis in a cohort of inpatients with invasive bacterial infections of enteric origin to investigate whether the parasite may facilitate these bacterial infections even in the absence of larval hyperproliferation. We performed a prospective cross-sectional study in a hospital in northern Italy. Subjects admitted due to invasive bacterial infection of enteric origin and potential previous exposure to S. stercoralis were systematically enrolled over a period of 10months. S. stercoralis infection was investigated with an in-house PCR on a single stool sample and with at least one serological method (in-house IFAT and/or ELISA Bordier). Univariate, bi-variate and logistic regression analyses were performed. Strongyloidiasis was diagnosed in 14/57 patients (24.6%; 95% confidence interval 14.1-37.8%) of which 10 were Italians (10/49, 20.4%) and 4 were migrants (4/8, 50.0%). Stool PCR was performed in 43/57 patients (75.4%) and no positive results were obtained. Strongyloidiasis was found to be significantly associated (p ≤ 0.05) with male gender, long international travels to areas at higher endemicity, deep extra-intestinal infectious localization and solid tumors. In the logistic regression model, increased risk remained for the variables deep extra-intestinal infectious localization and oncologic malignancy. Our findings suggest a new role of chronic strongyloidiasis in favoring invasive bacterial infections of enteric origin even in the absence of evident larval dissemination outside the intestinal lumen. Further well-designed studies should be conducted to confirm our results, and possibly establish the underlying mechanisms.

Cost-effectiveness of treatment strategies for populations from strongyloidiasis high-risk areas globally who will initiate corticosteroid treatment in the USA.

The risk of developing strongyloidiasis hyperinfection syndrome appears to be elevated among individuals who initiate corticosteroid treatment. Presumptive treatment or treatment after screening for populations from Strongyloides stercoralis-endemic areas has been suggested before initiating corticosteroids. However, potential clinical and economic impacts of preventative strategies have not been evaluated. Using a decision tree model for a hypothetical cohort of 1000 individuals from S. stercoralis-endemic areas globally initiating corticosteroid treatment, we evaluated the clinical and economic impacts of two interventions, 'Screen and Treat' (i.e. screening and ivermectin treatment after a positive test), and 'Presumptively Treat', compared to current practice (i.e. 'No Intervention'). We evaluated the cost-effectiveness (net cost per death averted) of each strategy using broad ranges of pre-intervention prevalence and hospitalization rates for chronic strongyloidiasis patients initiating corticosteroid treatment. For the baseline parameter estimates, 'Presumptively Treat' was cost-effective (i.e. clinically superior with cost per death averted less than a threshold of $10.6 million per life) compared to 'No Intervention' ($532 000 per death averted) or 'Screen and Treat' ($39 000 per death averted). The two parameters contributing the most uncertainty to the analysis were the hospitalization rate for individuals with chronic strongyloidiasis who initiate corticosteroids (baseline 0.166%) and prevalence of chronic strongyloidiasis (baseline 17.3%) according to a series of one-way sensitivity analyses. For hospitalization rates ≥0.022%, 'Presumptively Treat' would remain cost-effective. Similarly, 'Presumptively Treat' remained preferred at prevalence rates of ≥4%; 'Screen and Treat' was preferred for prevalence between 2 and 4% and 'No Intervention' was preferred for prevalence <2%. The findings support decision-making for interventions for populations from S. stercoralis-endemic areas before initiating corticosteroid treatment. Although some input parameters are highly uncertain and prevalence varies across endemic countries, 'Presumptively Treat' would likely be preferred across a range for many populations, given plausible parameters.

Chronic Strongyloides stercoralis infection increases presence of the Ruminococcus torques group in the gut and alters the microbial proteome

We explored the impact of chronic Strongyloides stercoralis infection on the gut microbiome and microbial activity in a longitudinal study. At baseline (time-point T0), 42 fecal samples from matched individuals (21 positive for strongyloidiasis and 21 negative) were subjected to microbiome 16S-rRNA sequencing. Those positive at T0 (untreated then because of COVID19 lockdowns) were retested one year later (T1). Persistent infection in these individuals indicated chronic strongyloidiasis: they were treated with ivermectin and retested four months later (T2). Fecal samples at T1 and T2 were subjected to 16S-rRNA sequencing and LC–MS/MS to determine microbial diversity and proteomes. No significant alteration of indices of gut microbial diversity was found in chronic strongyloidiasis. However, the Ruminococcus torques group was highly over-represented in chronic infection. Metaproteome data revealed enrichment of Ruminococcus torques mucin-degrader enzymes in infection, possibly influencing the ability of the host to expel parasites. Metaproteomics indicated an increase in carbohydrate metabolism and Bacteroidaceae accounted for this change in chronic infection. STITCH interaction networks explored highly expressed microbial proteins before treatment and short-chain fatty acids involved in the synthesis of acetate. In conclusion, our data indicate that chronic S. stercoralis infection increases Ruminococcus torques group and alters the microbial proteome.

446: DISSEMINATED STRONGYLOIODES INFECTION AFTER CORTICOSTEROID USE

Introduction: While there are endemic foci of Strongyloides in the southeastern United States, strongyloidiasis in the US is most commonly found in immigrants and military veterans who have lived in endemic regions. We report a case of reactivated disseminated strongyloidiasis in a critically ill COVID-19 patient. Description: A 46 year old undomiciled man with a medical history of hypertension was found down by a friend and brought to the hospital for evaluation of altered mental status. The patient immigrated from Mexico in 1991 and lived in Florida for several years working as a gardener. On presentation he complained of headaches, with tremors and tongue fasciculations noted on physical exam. He underwent treatment for alcohol withdrawal. His hospital course was complicated by COVID-19 pneumonia requiring intubation, and a subarachnoid hemorrhage that did not require acute neurosurgical intervention. Several days after completion of remdesivir and dexamethasone treatment for COVID-19, the patient’s absolute eosinophil count increased from 20/uL on admission to 340/uL with a peak at 1500/uL. The patient was found to have Strongyloides and ESBL Klebsiella in a bronchoalveolar lavage after a bedside bronchoscopy. Ivermectin 200ug/kg/day and meropenem 2g every 8 hours were started. The patient remained persistently comatose despite being off sedation and a relatively benign brain MRI that demonstrated resolving subarachnoid hemorrhages. Strongyloides were confirmed in the CSF nine days after initial discovery in the BAL. Albendazole 400mg BID was added to the regimen and meropenem was continued for possible culture negative bacterial meningitis in the setting of disseminated strongyloidiasis. HIV and HTLV-1 serology was negative. The patient remained in the ICU with poor neurological status and ongoing goals of care discussions with the family. Discussion: Strongyloides hyperinfection is an uncommon complication with a high mortality rate, with meningeal involvement often described post-mortem. Prophylactic anti-parasitic agents can be considered for patients identified as high risk for chronic strongyloidiasis who are about to undergo corticosteroid treatments, including COVID-19 associated regimens.

Chronic Strongyloidiasis in the Primary Care Setting

Abstract Strongyloides stercoralis can persist for decades in the human host through autoinfection. It can lead to hyperinfection syndrome, which has a high mortality rate and is associated with corticosteroid use. Twelve patients presented to our primary care clinic in New York with eosinophilia and were found to have chronic strongyloidiasis. The patients' characteristics are summarized and the current literature on screening of strongyloidiasis is reviewed. We aim to increase awareness for this condition among primary care providers that care for immigrant populations, especially with widespread use of corticosteroids for the treatment of coronavirus disease 2019.

1383. Universal Strongyloides Screening in a Heart Transplant Program in South Carolina: Just How Endemic Is It?

Abstract Background Strongyloides stercoralis is endemic in sub-Saharan Africa, Southeast Asia, Latin America, and the southeastern United States, particularly Appalachia, where Strongyloides seroprevalence approaches 2%. SC is considered a state in which Strongyloides is endemic, however the degree of endemnicity is not known. Here we define the epidemiology of chronic strongyloidiasis in our state, through data obtained via universal screening of heart transplant candidates at our center. Methods This single center retrospective study was performed at a 700 bed academic medical center that is the only comprehensive transplant center in SC. All adult patients who underwent heart transplant evaluation 1/1/2019 - 12/31/2020 were included. Routine pre-transplant evaluation by Transplant Infectious Diseases (TxID) was implemented in the heart transplant program in 2015 and universal screening with Strongyloides IgG began in late 2018. We assessed demographics, risk factors for exposure to Strongyloides, treatment, and outcomes for seropositive subjects. Results During the study period, 218 patients underwent heart transplant evaluation. Adherence to universal screening was 96.8% (211/218). 187 subjects (88.6%) had negative screening results (≤ 0.9 IV) and 24 subjects (11.4%) had equivocal or positive screening results (≥ 1.0 IV). Demographics and risk factors for the 24 equivocal/positive subjects are presented in Table 1. 15 equivocal/positive subjects (66.7%) received ivermectin and 9 (33.3%) did not. The majority of untreated patients were declined for transplant (8/9) and did not have a TxID evaluation (6/9). One untreated patient was waitlisted for transplant and has received ivermectin since being identified in this study. There were no episodes of hyperinfection or disseminated infection in the cohort. Table 1. Demographics and risk factors for subjects with equivocal or positive Strongyloides IgG Conclusion Universal screening of adult heart transplant candidates at SC’s only transplant center detected a Strongyloides seroprevalence rate of 11.4%. The majority of subjects with equivocal/positive Strongyloides IgG were born in the US and did not have other known risk factors (residence in the Appalachian region of SC, military service, overseas travel). These data suggest a high level of endemnicity of strongyloidiasis in SC. Disclosures All Authors: No reported disclosures

Systemic profile of immune factors in an elderly Italian population affected by chronic strongyloidiasis

BackgroundStrongyloidiasis caused by Strongyloides stercoralis is a soil-transmitted helminthiasis affecting an estimated 370 million people and considered one of the most neglected tropical diseases. Although mostly distributed in tropical and subtropical areas, autochthonous infections have also been documented in north-eastern Italy, even though the transmission presumably stopped decades ago. Because of its peculiar auto-infective cycle, strongyloidiasis can persist lifelong, but the pathophysiological mechanisms associated with the maintenance of such a chronic infection are yet to be fully deciphered.MethodsSerum levels of 23 immune factors were retrospectively assessed in a subgroup of participants in a randomised clinical trial for the treatment of strongyloidiasis (Strong Treat). Here we included Italian subjects born between 1931 and 1964 and diagnosed with strongyloidiasis between 2013 and 2017 (Ss+, n = 32). Serum samples obtained before (BT) and 6 months (6M AT) after ivermectin treatment, as well as from age- and gender-matched uninfected controls (CTRL, n = 34) were analysed.ResultsThe assessed immune factors showed a general reduced concertation in Ss+ patients and a lack of association with eosinophilia. In our cohort, we did not observe the classical shift towards a type 2 immune response, since Th1 and Th2 cytokines were mostly unaltered. Instead, we observed chemokines as particularly affected by the presence of the parasite, since IL-8, CCL3, CCL4 and CCL5 were significantly reduced in concentration in Ss+ subjects compared to CTRL, suggesting that immune cell recruitment to the infection site might be dampened in these patients. This observation was further sustained by a significant increase of CCL4, CCL5 and CCL11 concentrations 6M AT. A significant raised systemic concentration of three growth factors, bFGF, PDGF-BB and IL-7 (haematopoietic growth factor) was also observed post-treatment, indicating a potential involvement in restoring tissue integrity and homeostasis following parasite elimination.ConclusionsThese preliminary data suggest that, in order to survive for such a long period, S. stercoralis might suppress host responses that could otherwise result in its ejection. Our results offer novel insights in the potential mechanisms of disease tolerance that might take place during this chronic infection, including a potential T-cell hypo-responsiveness and a role for chemokines.

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

BackgroundStrongyloidiasis 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 presentationWe 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.ConclusionsBoth 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.

Integrating testing for chronic strongyloidiasis within the Indigenous adult preventive health assessment system in endemic communities in the Northern Territory, Australia: An intervention study.

BackgroundThe life-threatening clinical manifestations of strongyloidiasis are preventable with early detection and effective treatment. The aim of this study was to assess if there was an increase to the number and proportion of persons tested for chronic strongyloidiasis, as a result of integrating Strongyloides stercoralis serology into the existing preventive health assessment system in four Aboriginal health services in endemic communities.MethodologyA prospective, longitudinal, before-and-after intervention study was conducted in four Aboriginal health services in remote endemically infected communities in the Northern Territory, Australia, from July 2012 to December 2016. The electronic patient information and recall systems enabled the integration of Strongyloides stercoralis serology into the adult preventive health assessment. Strongyloides reports for each health service were extracted half-yearly to examine the number and proportion of persons tested for chronic strongyloidiasis during the study and to measure the effect of the intervention.Principal findingsThe number and proportion of persons tested increased significantly during the study. From a total resident population of 3650 Indigenous adults over 15 years of age, 1686 persons (47.4%) were tested. The percentage of adults who had at least one serology test increased in all four health services to between 41% (446/1086) and 81.9% (172/210). Of the 1686 persons tested, 680 positive cases of chronic strongyloidiasis (40.3%) were identified.Conclusions/SignificanceThis population health systems intervention increased the number and proportion of persons tested for chronic strongyloidiasis in four health services in endemically infected communities. This intervention is relevant to other health services with high-risk populations.

Efficacy of Single Dose Ivermectin Against Strongyloides stercoralis Infection Among Primary School Children in Amhara National Regional State.

Background:Ivermectin has been proven to be highly effective against Strongyloides stercoralis in some countries. However, its single dose (200 μg/kg) efficacy has not been proven up until now in Ethiopia.Objective:This study aimed to evaluate the efficacy of single dose ivermectin against S. stercoralis infection among school children.Methods:Stool sample was collected from April 2019 to December 2019 among 844 school children and screened by formol ether concentration, spontaneous tube sedimentation, Baermann concentration, and agar plate techniques. Single oral dose (200 μg/kg) ivermectin was given to 101 S. stercoralis–infected student and posttreatment diagnosis was done for 92 students after 2 weeks.Results:Of the total 92 S. stercoralis–infected students who took ivermectin treatment, 87 were negative with cure rate of 94.6%. No side effect of ivermectin was observed.Conclusion:Single dose ivermectin is an effective dose in uncomplicated chronic strongyloidiasis.

2477 Strongyloidiasis Presenting as Isolated Hepatic Mass in an Immunocompetent Host: A Case Report

INTRODUCTION: Strongyloidiasis is caused by an infection with Strongyloides stercoralis. Manifestations range from absent to minimal symptoms in immunocompetent persons to a hyperinfection syndrome in immunocompromised persons. Hepatobiliary complications have been described as granulomatous hepatitis and biliary obstruction. We report a case of strongyloidiasis presenting as a solitary hepatic mass in an immunocompetent patient. CASE DESCRIPTION/METHODS: A 27-year-old woman with no past medical history or medications and recent travel to Costa Rica presented with intermittent right upper quadrant pain after trauma while skiing. She had no hepatomegaly, tenderness, or signs of chronic liver disease on exam. Laboratory analysis showed WBC 24.7 103/mL, absolute eosinophils 15,314 cells/mL, AST 21 U/L, ALT 35 U/L, ALP 106 IU/L, albumin 3.9 g/dL, and total bilirubin 0.3 mg/dL. Strongyloides IgG was positive. Stool was unremarkable. CEA, AFP, and CA 19-9 levels were normal. Abdominal US revealed a hepatic mass. MRI confirmed a 5 × 6 cm lesion in the inferior and anterior right lobe (Figure 1). The patient received ivermectin for strongyloidiasis. Repeat MRI at 4 weeks showed no change in lesion size. To prepare for lesion excision, the patient underwent CT imaging at 7 weeks. This showed a significant decrease in mass size to 3 × 2.5 cm (Figure 2). Surgery was deferred. MRI at 15 weeks showed continued resolution of the mass to a long axis of 2.5 cm. Marked lesion improvement with ivermectin alone was felt consistent with strongyloidiasis. DISCUSSION: Chronic strongyloidiasis affects 30 million people worldwide, with clinical significance mediated by equilibrium between human host and helminthic parasite. Most people are asymptomatic or have nonspecific gastrointestinal symptoms. Hepatic presentation is exceedingly rare and has been associated with immunocompromise and dissemination. To our knowledge, only one case of immunocompetent hepatic presentation has been reported. 1 In the presently described case, a large hepatic lesion in a healthy woman with marked eosinophilia was initially evaluated for a neoplastic process. Strongyloides consideration and testing was key to obtaining the diagnosis. Imaging also expanded our understanding of the range of possible radiographic findings in this disease. Physicians should be aware of chronic strongyloidiasis as they consider the differential for hepatic masses in immunocompetent patients.

The investigation of Strongyloides stercoralis seroprevalence in immunosupressed patients in Turkey

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.Conclusion 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.

A Case of Chronic Strongyloidiasis with Recurrent Hyperinfection

A Case of Chronic Strongyloidiasis with Recurrent Hyperinfection

436. A survey of Schistosomiasis and Strongyloidiasis Among Eritrean Immigrants to Israel

BackgroundImmigration from east Africa (mainly Eritrea) to Israel peaked during 2011–2013. Little is known about the prevalence of chronic parasitic diseases in this population. We performed a survey of Schistosomiasis and Strongyloidiasis among immigrants, both are pararsites that can cause chronic infections, and can lead to significant morbidity and complications.MethodsA prospective survey of adults (>18 years) from Eritrea was performed at a primary care clinic for immigrants in Tel Aviv, Israel. Participants provided written informed consent. Stool and blood samples were collected, and participants filled epidemiological and clinical questionnaires. Stool was tested by real time PCR for Strongyloides stercoralis and Schistosoma species, serum was tested for IgG antibodies against these pathogens using comercial kits (WB, LDBio Diagnostic for schistosoma, ELISA, SciMedx for Strongyloides).ResultsA total of 106 patients were included in the survey; 85% were males and 15% females, median age was 34 (IQR30-39) years, and median duration living in Israel was 7 years (IQR 6–9). Serology was positive in 55/106 (52%) for Schistosoma spp. and in 1/106 (1%) for Strongyloides. Stool PCR for Schistosoma was positive in 34 of 106 (32%), and uniformly negative for Strongyloides. Risk factors for positive schistosoma serology and PCR were male gender and younger age. Other factors such as duration of residence in Israel, staying in other countries along the way to Israel, self-reported swimming in fresh water reservoirs and symptoms such as diarrhea, abdominal pain, and blood in stool were not significantly associated with Schistosoma infection.ConclusionWe found high rate of Schistosomiasis (both by serology and PCR in stool) among Eritrean immigrants in Israel. While serology can remain positive for many years after there are no longer living parasites, high rates of positive stool PCR suggest current active infection. In contrary, chronic Strongyloidiasis was rarely detected. Empirical treatment of schistosomiasis with praziquantel should be considered for immigrants from Eritrea.Disclosures All authors: No reported disclosures.

STRINGS OF FURY: A CASE OF STRONGYLOIDES HYPERINFECTION SYNDROME IN A CHEMOTHERAPY-NAIVE PATIENT WITH EXTENSIVE SCLC

SESSION TITLE: Chest Infections 2 SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/09/2018 05:00 PM - 06:00 PM INTRODUCTION: Strongyloidiasis is one of the most neglected tropical diseases. Diagnosis is difficult because of non-specific clinical features, irregular larval output and lack of specific test. This infection can be chronic and asymptomatic but a change in immune status can lead to increased parasite burden, hyperinfection syndrome, dissemination, and death if unrecognized. CASE PRESENTATION: An 80-year old Filipino male diagnosed with Small Cell Lung Cancer - extensive disease (brain and liver metastases) was admitted due to a 5-day history of watery blood-streaked stools, dry cough and decreased sensorium. Dexamethasone was started for raised intracranial pressure. The patient was started on empiric antibiotics for pneumonia (Fig2) and acute gastroenteritis. Fecalysis showed Strongyloides larvae (Fig1) and Albendazole was started. Neurologic and respiratory status worsened and necessitated ventilatory support. Endotracheal aspirate smear revealed Strongyloides rhabditiform larvae (FIg3). Blood culture revealed Klebsiella pneumoniae. Despite adequate antibiotic coverage and discontinuation of steroids, the patient continued to deteriorate and was brought home. DISCUSSION: Hyperinfection is a syndrome of accelerated autoinfection which may or may not result from alteration in immune status. Development of gastrointestinal and pulmonary symptoms is seen. The hallmark is detection of increased numbers of larvae in stool and/or sputum. Regardless of dose or route of administration, even short courses (6-17 days) of steroids in immunocompetent patients have been associated with hyperinfection syndrome and death.Hyperinfections are often complicated and, rarely, preceded by infections caused by gut flora that gain access to extraintestinal sites, presumably through ulcers induced by the filariform larvae or by virtue of being carried on the surface or in the intestinal tract of the larvae themselves. Blood cultures from patients with hyperinfection have grown Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas, Enterococcus faecalis, coagulase-negative staphylococci, Streptococcus bovis, and Streptococcus pneumoniae.Centers for Disease Control and Prevention recommend that immunosuppressive therapy should be stopped or reduced if possible. Only Ivermectin is recommended for hyperinfection however it is not available in the Philippines. Albendazole is recommended as alternative regimen for acute and chronic forms strongyloidiasis. CONCLUSIONS: As the number of immunosuppressed individuals increase, a more thorough investigation is warranted to detect situations under which S. stercoralis infection can potentially worsen. Early diagnosis is a challenge as it may mimic other diseases. Primary prevention as well as better approaches to identifying, screening, and treating those at risk will likely decrease the morbidity and mortality associated with this hyperinfection syndrome. Reference #1: Olsen A, van Lieshout L, Marti H, et al. Strongyloidiasis - the most neglected of the neglected tropical diseases? Trans R Soc Trop Med Hyg. 2009; 103:967-972. Reference #2: Mejia R, Nutman TB, Screening, prevention, and treatment for hyperinfection syndrome and disseminated infections caused by Strongyloides stercoralis. Opin Infect Dis. 2012 August ; 25(4): 458-463. Reference #3: Keiser PB, Nutman TB. Strongyloides Stercoralis In The Immunocompromised Population. Clinical Microbiology Reviews, Jan. 2004, P. 208-217 DISCLOSURES: no disclosure on file for Raquel Victoria Ecarma; No relevant relationships by Myrna Mendoza, source=Web Response No relevant relationships by Irene Rosellen Tan, source=Web Response

A case of chronic strongyloidiasis diagnosed by histopathological study

A case of chronic strongyloidiasis diagnosed by histopathological study

Strongyloides Stercoralis Hyperinfection in A Steroid-Dependent Leukemic Patient

Strongyloides stercoralis is one of the most common human pathogenic parasitic nematodes that is able to complete a life cycle and proliferate within its host. The majority of patients with strongyloidiasis have an asymptomatic infection or mild disease. Nowadays, with increasing the incidence of autoimmune diseases and as well as corticosteroids therapy and increase in diseases such as Human Immunodeficiency Virus (HIV), cancer has been a source of concern for secondary disorders. These individuals are more likely to develop microbial diseases including bacteria, parasites, fungi, and viral infections, and if they are affected may be endanger the patient's life. Amongst the parasitic infections of Strongyloides stercoralis is very important in the life cycle of the parasite due to the specificity of the infection (Hyperinfection). Our case represents chronic strongyloidiasis with acute lymphoblastic leukemia.

Clinical Characteristics of Patients Diagnosed with Strongyloidiasis in a United States Urban Outpatient Dermatology Department: A Case Series

Background: Although considered a tropical disease, strongyloidiasis may be encountered in non-endemic regions, primarily amongst immigrants and travelers from endemic areas. Chronic strongyloides infection may be under-detected owing to its non-specific cutaneous presentation and the low sensitivity of commonly used screening tools. Methods: 18 consecutive patients with serologic evidence of strongyloides infestation who presented to a single urban, academic dermatology clinic between September 2013 and October 2016 were retrospectively included. Patient age, sex, country of origin, strongyloides serology titer, absolute eosinophil count, presenting cutaneous manifestations, and patient reported subjective outcome of pruritus after treatment were obtained via chart review. Results: Of the 18 patients, all had non-specific pruritic dermatoses, 36% had documented eosinophila and none were originally from the United States. A majority reported subjective improvement in their symptoms after treatment. Conclusion: Strongyloides infection and serologic testing should be considered in patients living in non-endemic regions presenting with pruritic dermatoses and with a history of exposure to an endemic area.Key Points:Chronic strongyloidiasis can be encountered in non-endemic areas and clinical manifestations are variableEosinophilia was not a reliable indicator of chronic infection in this case series Dermatologists should consider serologic testing for strongyloidiasis in patients with a history of exposure and unexplained pruritus