Hyperinfection Syndrome Research Articles

Epidemiological and clinical profile of immunosuppressed patients with imported strongyloidiasis: a substudy from a larger cohort of the +REDIVI Spanish Collaborative Network.

ABSTRACT The aim of this study was to describe the clinical and epidemiological profile of immunosuppressed patients with imported strongyloidiasis in a non-endemic setting, and to compare these results with non-immunosuppressed patients. This is a case-control substudy from a larger observational retrospective study that included all patients with strongyloidiasis registered in the +REDIVI Spanish Collaborative Network. Overall, 1245 patients with imported strongyloidiasis were included. From these, 80 (6.4%) patients had some kind of immunosuppression. Three (3.8%) patients had a hyperinfection syndrome, and 34 (52.3%) patients had eosinophilia. The percentages of positive results of the formalin-ether technique, the fecal culture and serology were 12.3%, 21.1% and 95.4%, respectively. When comparing the main characteristics, immunosuppressed patients had higher proportion of severe clinical manifestations and lower proportion of eosinophilia. No differences were found regarding yield of microbiological techniques and treatment response. These results stress the importance of strongyloidiasis screening among immunosuppressed patients coming from endemic areas. Serological tests have an acceptable sensitivity to be used as a screening tool.

A Case of Gastroduodenal Strongyloidiasis Causing Protein Losing Enteropathy

Strongylodiasis is an intestinal parasitic infection which can cause cataclysmic hyper infection syndrome in immunocompromised. Here we report an interesting and rare case of gastroduodenal strongyloidiasis presenting as protein losing enteropathy which was promptly diagnosed and dramatically reversed with antihelminthic therapy. J Microbiol Infect Dis 2020; 10(4): 237-239.

Donor Derived Strongyloidiasis in a Lung Transplant Recipient: From Life Cycle to Hyperinfection Syndrome

Strongyloides stercoralis infection derived from the donor in solid organ transplant (SOT) places recipients at risk for hyperinfection syndrome and death. We describe the case of a lung transplant recipient who developed strongyloidiasis presenting with GI symptoms and progressing to diffuse alveolar hemorrhage, bacteremia and multi-organ failure. The patient’s clinical course illustrates the life cycle of Strongyloides. For treatment, the patient received ivermectin and albendazole. We advocate that early diagnosis and treatment, prior to hyperinfection, are essential in management in SOT. These rarer donor-derived infections need to remain in the differential, especially given the expanding landscape of the donor population.

A CONFUSING CASE OF PNEUMONIA IN A PATIENT WITH HUMAN IMMUNODEFICIENCY VIRUS

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The incidence of acquired immunodeficiency syndrome (AIDS) related opportunistic infections has declined dramatically following the introduction of potent antiretroviral therapy. However, pulmonary infections remain a significant cause of morbidity and mortality (1). The spectrum of pulmonary disease that can affect patients with human immunodeficiency virus (HIV) is wide and includes opportunistic infection with many bacterial, fungal, viral, and parasitic organisms (2). Herein, we present a rare case of pneumonia caused by four different pathogens: Strongyloides Stercoralis, Pneumocystis Jirovecii (PCP), Cytomegalovirus (CMV) and Pseudomonas Aeruginosa. CASE PRESENTATION: A 65-year-old female from Mexico with a past medical history of HIV presents to the emergency department with subacute dyspnea, mild hemoptysis, melena, and fatigue. She was non-compliant with her anti-retroviral therapy. Her CD4 count was <20 cells/uL with a HIV PCR of 1,690,000 copies/mL. CBC demonstrated normocytic anemia (hemoglobin: 6.0 g/dl); hemolysis was excluded. Her Pa02 was 60 mmHg on room air. A computed tomography (CT) scan of the chest with contrast (image) revealed diffuse bilateral ground-glass opacities with diffuse interlobular septal thickening. Severe enteritis and colitis were seen on the CT abdomen/pelvis with contrast. The patient was empirically started on levofloxacin, metronidazole, intravenous (IV) trimethoprim-sulfamethoxazole and prednisone. Sputum cultures were positive for pan sensitive Pseudomonas Aeruginosa. Bronchoalveolar lavage (BAL), upper and lower endoscopy were performed. Blood and BAL CMV PCR were positive. She was subsequently started on IV ganciclovir. BAL PCP PCR was high. Several days later, numerous Strongyloides Stercoralis larvae were seen in the BAL and on the duodenal biopsy. Daily ivermectin was initiated. The patient progressed to septic shock requiring IV norepinephrine and her oxygenation worsened. The patient refused escalation of care and decided to proceed with comfort measures. The patient passed away within a few hours. DISCUSSION: Prior to the era of potent antiretroviral therapy, parasitic pulmonary infections were more commonly seen than they are today (2). Immunocompromised patients are at high risk for systemic strongyloidiasis which presents as either disseminated strongyloidiasis or hyper infection syndrome (3). Aside from HIV, our patient was empirically started on prednisone for PCP treatment which might have contributed to worsening systemic strongyloidiasis and therefore worsening clinical status. For severe disease, patients should be started on daily ivermectin along with empiric antibiotic therapy with activity against gram-negative bacteria. CONCLUSIONS: We describe a rare case of HIV related pneumonia caused by four different pathogens. Reference #1: Boyton RJ. Infectious lung complications in patients with HIV/AIDS. Curr Opin Pulm Med. 2005 May;11(3):203-7. Reference #2: Skalski JH, Limper AH. Fungal, Viral, and Parasitic Pneumonias Associated with Human Immunodeficiency Virus. Semin Respir Crit Care Med. 2016;37(2):257. Reference #3: Celedon JC, Mathur-Wagh U, Fox J, Garcia R, Wiest PM. Systemic strongyloidiasis in patients infected with the human immunodeficiency virus. A report of 3 cases and review of the literature. Medicine (Baltimore). 1994;73(5):256 DISCLOSURES: No relevant relationships by Ahmad Al-Shyoukh, source=Web Response No relevant relationships by Laith Derbas, source=Web Response No relevant relationships by Ashraf Gohar, source=Web Response No relevant relationships by Raed Qarajeh, source=Web Response No relevant relationships by Moustafa Younis, source=Web Response

Two Deaths of Acute Transplant Patients from Strongyloides Hyperinfection Syndrome (SHS): Can We Prevent Harm with Screening and Prophylaxis at the Time of Transplantation?

Two Deaths of Acute Transplant Patients from Strongyloides Hyperinfection Syndrome (SHS): Can We Prevent Harm with Screening and Prophylaxis at the Time of Transplantation?

Descriptive Investigation of Strongyloidiasis Infection and Characterization of Strongyloides stercoralis Using Morphological and Molecular-Based Methods.

Strongyloidiasis is caused by the nematode Strongyloides stercoralis which has the unique ability to reproduce and complete its entire life cycle within the human host through its autoinfection cycle. Diagnosis of this infection is important because of its potential to cause fatal hyperinfection syndrome or disseminated infections in those with defective cellular immunity. Parasitological methods based on faecal microscopy and culture often fail to detect low-intensity infections. A multiplex polymerase chain reaction (PCR) assay was developed for the detection of S. stercoralis, Ascaris lumbricoides, and Enterobius vermicularis by designing primers specific for the ITS1 region of ribosomal DNA of S. stercoralis and A. lumbricoides and 18S region of rRNA of E. vermicularis. A 61-year-old patient presented with chronic gastrointestinal and respiratory symptoms and weight loss with a stool microscopy positive for helminth larvae. Stool cultures with the Harada–Mori technique yielded L3 larvae which were identified as S. stercoralis based on morphology. The multiplex PCR performed on DNA extracted from stool elicited the expected band at 129 bp on gel electrophoresis of the PCR yield providing molecular evidence of intestinal strongyloidiasis. The patient's gastrointestinal symptoms improved with a six-day course of albendazole (400 mg twice daily). Negative posttreatment stool microscopy, culture, and PCR confirmed successful clearance of infection. Molecular-based PCR assay is a promising tool to diagnose and assess the therapeutic efficacy of anthelmintics in intestinal helminthiases such as strongyloidiasis.

Strongyloidiasis in Southern Alicante (Spain): Comparative Retrospective Study of Autochthonous and Imported Cases.

Background: Strongyloidiasis is a parasitic disease with global prevalence. In Spain, autochthonous cases are concentrated in the Mediterranean basin. We aimed to analyze clinical and epidemiological characteristics of Strongyloides stercoralis infection in Vega Baja del Segura (Spain), comparing autochthonous versus imported cases. Methods: Observational retrospective study of all strongyloidiasis cases from January 2009 to January 2019. Cases were diagnosed by stool larvae visualization, positive culture, PCR, Strongyloides serology, and/or compatible histology. Results: We included 36 patients (21 men) with a mean age of 60.8 years ±17.6; 15 cases were autochthonous and 21 imported 80.9% from Latin America. Autochthonous cases were associated with older age (mean 71.3 vs. 53.3 years; p = 0.002), male sex (odds ratio (OR) 5.33; 95% confidence interval (CI) 1.15–24.68; p = 0.041), and agricultural activity (OR 13.5; 95% CI 2.4–73.7; p = 0.002). Fourteen were asymptomatic, three autochthonous cases presented with hyperinfection syndrome, and two patients died. There was no difference between autochthonous versus imported origin in eosinophilia at diagnosis (93.3% vs. 75%; p = 0.207), treatment received, or clinical response (85.7% vs. 88.9% cured; p = 1). Conclusion: In our region, imported strongyloidiasis coexists with autochthonous cases, which are mainly in older male farmers who are diagnosed at more advanced stages. Systematic screening programs are needed.

Strong-LAMP Assay Based on a Strongyloides spp.-Derived Partial Sequence in the 18S rRNA as Potential Biomarker for Strongyloidiasis Diagnosis in Human Urine Samples.

Human strongyloidiasis a soil-transmitted infection caused by Strongyloides stercoralis is one of the most neglected amongst the so-called Neglected Tropical Diseases (NTDs). S. stercoralis is a nematode, which is distributed worldwide; it has been estimated that it could affect millions of people, mainly in tropical and subtropical endemic regions. The difficulties of diagnosis lead to infection rates being underreported. Asymptomatic patients have chronic infections that can lead to severe hyperinfection syndrome or disseminated strongyloidiasis in immunocompromised patients. Strongyloidiasis can easily be misdiagnosed because conventional faecal-based techniques lack of sensitivity for the morphological identification of infective larvae in faeces. None of the currently used molecular methods have used urine samples as an alternative to faecal samples for diagnosing strongyloidiasis. This study was thus aimed at comparing, for the first time, the use of a new loop-mediated isothermal amplification (LAMP) molecular assay (Strong-LAMP) to traditional methods on patients' urine samples. Twenty-four urine samples were taken from patients included in a study involving two Spanish hospitals for strongyloidiasis screening using parasitological and serological tests. Strongyloides larvae were found in 11 patients' faecal samples, thereby ascertaining that they had the disease. Other patients had high antibody titres but no larvae were found in their faeces. All urine samples were analysed by PCR and Strong-LAMP assay. No amplification occurred when using PCR. Strong-LAMP led to detecting S. stercoralis DNA in urine samples from patients having previously confirmed strongyloidiasis by parasitological tests and/or a suspicion of being infected by serological ones. The Strong-LAMP assay is a useful molecular tool for research regarding strongyloidiasis in human urine samples. After further validation, the Strong-LAMP assay could also be used for complementary and effective diagnosis of strongyloidiasis in a clinical setting.

Should We Screen HIV-Positive Migrants for Strongyloidiasis?

Background: Strongyloides stercoralis, a nematode endemic in all (sub)tropical regions, can cause life-threatening disease, especially in immunosuppressed patients. Many countries with high HIV-prevalence rates are also highly S. stercoralis endemic, and co-infection may occur. Methods: Retrospective study based on serological testing for S. stercoralis in all HIV-infected migrants followed at the Institute of Tropical Medicine, Antwerp, Belgium. If untested, serologic testing was performed on stored samples, dating from the first HIV viral load determination. The epidemiological, clinical and laboratory features of patients with and without strongyloidiasis were retrieved from the electronic medical files. Results: Of the 2846 HIV patients in active follow-up, 723 (25.4%) had a migration background. Thirty-six patients (5.1%) were diagnosed with Strongyloides co-infection, including 29 during their medical evaluation and seven retrospectively. Patients had a median age of 35.3 years (IQR 30.3–44.4), 28 patients (78%) originated from Sub-Saharan Africa and median time in Belgium was 3.5 years (IQR 0.8–5.7). Symptoms compatible with strongyloidiasis were present in 17 (47%) patients, of whom two were diagnosed retrospectively. Eosinophilia (eosinophil cell count > 450/µL) was observed in 19 (53%) participants. Median CD4 level was 386 /µL (IQR 299–518) at diagnosis of co-infection. Of note, 8 (22%) patients with strongyloidiasis had no reported symptoms nor eosinophilia. None of the patients developed hyperinfection syndrome. There were no differences in age, gender, geographic origin, clinical presentation, CD4 level or viral load between patients with and without strongyloidiasis. Only eosinophilia was strongly correlated with the presence of Strongyloides in multivariate analysis (OR 10.74 (95% CI 5.19–22.25), p < 0.001); the positive likelihood ratio (LR+) of eosinophilia for strongyloidiasis was 5.38 (95% CI 3.66–7.91). Conclusion: Strongyloidiasis was diagnosed in 5.1% of HIV-infected migrants. Eosinophilia had good confirming power for the presence of the disease. However, a sizeable proportion (22%) of co-infected individuals were asymptomatic and had normal eosinophil count, supporting universal screening of all HIV-positive patients native to tropical countries.

EP44 Taking eosinophilia more seriously

Abstract Background Asymptomatic eosinophilia is common in migrants and travellers returning from the tropics, and helminth infection is the most common identifiable cause. Most helminth infections have a benign course, but some carry a risk of serious disease which is relevant to the rheumatologist as administration of immunosuppression can trigger severe reactions such as the potentially fatal hyper infection syndrome in strongyloidiasis. Helminth infections are of increasing relevance in an era of growing migration from endemic regions. A recent audit performed at a central London hospital in HIV outpatients found that of those patients with asymptomatic eosinophilia that were investigated, 28.6% had serological evidence of strongyloidiasis. Unexplained eosinophilia should be evaluated prior to starting immunosuppressive medications, especially in those who have lived in regions endemic for helminth infections. In 2010 the British Infection Society (BIS) published guidelines on the investigation of migrants and returning travellers with asymptomatic eosinophilia. We set out to establish how often our unit investigated unexplained eosinophilia prior to initiating immunosuppressive medication. Methods All patients attending rheumatology outpatients at our centre were screened and included if they had a recorded eosinophilia of ≥ 0.8 X109/L between December 2016 to December 2018. Patients were excluded if they did not have a sustained eosinophilia ≥0.8 X109/L &amp;gt; 1 year or if another documented diagnosis was recognised as the cause of eosinophilia. Investigation of asymptomatic eosinophilia was compared to the best practice set out in British Infection Society guideline. Results 109 patients fulfilled the inclusion criteria. 64 patients did not have a sustained eosinophilia &amp;gt; 1 year and 16 had an alternate diagnosis to explain eosinophilia and so were excluded. The remaining 29 patients were included. 13 patients were male and 16 female. 16 (55%) had a diagnosis of rheumatoid arthritis. 19 (66%) had an eosinophil count &amp;gt; 1 X109/L and 7 (24%) &amp;gt; 2 X109/L. Despite this, eosinophilia was only noted in documentation for 4 (14%) patients. Five (17%) patients had a travel history documented and 4 of them had travelled to the tropics. 3 (10%) patients were investigated for eosinophilia and only 1 (3%) was investigated fully according to the BIS guideline. 14 (48%) patients were on bDMARDs and a further 6 (21%) were on cDMARDs. Of the 14 (48%) on bDMARDS, 7 had ethnic origin in the tropics. Median eosinophil count was 1.2 x109/L. One had travel history taken. All had a negative HIV test. None of the patients on biological therapy had investigations for eosinophilia. Conclusion This study confirms the local lack of awareness of eosinophilia. Most patients with unexplained eosinophilia were not identified or investigated, even prior to administration of immunosuppressive medication. With a growing migrant population, the likelihood of serious consequences of ignoring eosinophilia are rising. Disclosures: Z. Rutter-Locher: None. J. Galloway: None. B. Menon: None. A. Goodman: None.

Strongyloides Screening in Heart Transplant Candidates

The ability of Strongyloides to establish auto-infection in the human host allows it to sustain subclinical infection that can go on for a lifetime. In solid-organ transplant recipients, Strongyloides can cause hyper-infection syndrome which has very high morbidity and mortality. Clinical suspicion for chronic infection should be considered for any persons with birth or travel to endemic regions, history of incarceration, homelessness and group home residence. Targeted screening based on epidemiologic risk is recommended by AST and ISHLT however, testing remains challenging due to variability in the diagnostic yield of currently available serologic assays. We performed a retrospective chart review of heart transplant (HT) recipients from 2010-2019, who had Strongyloides serologic screening performed pre-transplant, with the aim to correlate results with epidemiological risk factors for infection. Two-hundred and fifty HT recipients were reviewed. Of these, 197 had pre-transplant Strongyloides serology performed, in accordance with institutional policy of universal pre-transplant screening. Based on serologic testing, prevalence of strongyloidiasis was 2.5%. Of the 5 patients with positive serology, all but 1 had epidemiologic risk for infection; 3 due to birth in an endemic region and 1 due to history of incarceration. Eosinophilia was noted in 3/5, all of whom were from endemic regions by birth. All with positive serologic screening were treated pre-transplant with ivermectin. One-hundred and ninety two patients tested negative for Strongyloides, and 58% (111/192) of those had epidemiological risk factors, due to birth (90) or travel to endemic regions (21). There were no cases of clinical strongyloidiasis in the study cohort. In this population with high epidemiologic risk, we found a lower than expected rate of Strongyloides infection. Given the variability in diagnostic yield across commercially available serologic assays, these findings raise the possibility of false negative results and thus, bring into question the utility and reliability of using serologic testing alone, for screening of Strongyloides infection among HT candidates. Accordingly, a thoughtful assessment of epidemiologic risk is essential for appropriate risk stratification and management of Strongyloides in HT candidates and recipients.

Chronicle of migrant hyperinfective Strongyloides stercolaris larvae and associated bacteremia in a patient suffering from Idiopathic Thrombocytopenic Purpura

Background: Strongyloidiasis is a neglected nematode infestation and can lead to hyperinfection syndrome. The onset of strongyloides hyper-infection syndrome is associated with a myriad of seemingly unrelated symptoms including diarrhoea, abdominal pain, urticaria, anaemia, sepsis and acute respiratory distress syndrome. Case report: A 65-year-old female patient presenting with chief complaints of nausea, vomiting, abdominal cramps, diarrhea, fever and cough and was admitted to a teaching hospital on 2nd May 2019. The patient was a diagnosed case of idiopathic thrombocytopenic purpura on Azathioprine (50mg, BD) and oral corticosteroid therapy (Prednisolone 60mg, OD) and was on treatment from the same hospital. The patient developed these symptoms after 23 days of immunosuppressive therapy. Patient was continued with previous medication along with supportive management after admission. Blood and urine sample was received in the department of Microbiology on 3rd May 2019 for culture and sensitivity testing. Urine sample was sterile after 24 hours of aerobic incubation. Escherichia coli grew in blood culture and the isolate was susceptible to gentamicin, amikacin and colistin. Stool sample was received on 6th of May 2019 for routine microscopy. With wet mount preparation of stool specimen, numerous larvae of Strongyloides stercoralis were seen. Modified Ziehl-Neelsen staining was performed and oocysts of Cryptosporidium species were also seen. Wet mount preparation of sputum sample was also performed in which few larvae of S. stercoralis were seen. Conclusion: As corticosteroid is the mainstay of treatment in idiopathic thrombocytopenic purpura an early diagnosis and prompt specific anti-parasitic therapy is required to eradicate these infections

Donor-derived Strongyloides stercoralis infection in a simultaneous kidney-pancreas transplant recipient diagnosed on a bronchoalveolar lavage specimen

Donor-derived Strongyloides stercoralis infection occurs rarely after transplantation and can lead to potentially fatal hyperinfection syndrome.1,2 We present a case of a 29-year-old man who was in a critical state due to Strongyloides stercoralis hyperinfection after receiving simultaneous kidney-pancreas transplant. The diagnosis was established following cytologic examination of a bronchoalveolar lavage (BAL) specimen showing numerous typical larvae of Strongyloides stercoralis. This illustrates the importance of a thorough examination of BAL and careful search for Strongyloides stercoralis in immunocompromised patients, particularly when the donor has lived in an endemic area.

STRONGYLOIDES STERCORALIS AND CANCER

Strongyloidiasis is caused by infection with Strongyloides stercoralis. Manifestations of infection can range from asymptomatic eosinophilia in immunocompetent host to disseminated disease with septic shock in the immunocompromised host. Strongyloidiasis is endemic in tropical and subtropical regions and occurs sporadically in temperate areas. Burden of adult worms in infected humans can increase substantially via autoinfection. Among immunocompromised hosts, autoinfection can lead to hyperinfection syndrome where there is massive dissemination of filariform larvae to the lungs, liver, heart, central nervous system, and endocrine glands. Most infected patients do not experience prominent symptoms. The most common manifestations are mild waxing and waning gastro-intestinal, cutaneous, or pulmonary symptoms that persist for years; others simply have eosinophilia in the absence of symptoms.

Development of immunochromatographic device as a point-of-care tool for serodiagnosis of human strongyloidiasis cases

Human strongyloidiasis is an important gastrointestinal disease with an estimated 30 to 100 million people infected. Prevalence is generally underestimated since many infections are asymptomatic, and traditional diagnostic tests based on parasitological examination of stool samples are not adequately sensitive. Serological tests are useful and supportive but are still only available in a reference research setting. We made an immunochromatographic test (ICT) kit for rapid serodiagnosis of human strongyloidiasis. The antigen used in the ICT kit was extracted from larvae of Strongyloides stercoralis. Diagnostic efficacy of the kit was evaluated using human serum samples from strongyloidiasis patients, healthy persons, and those with other parasitoses. When using a cutoff level of 0.5 or above, the diagnostic sensitivity, specificity, and positive and negative predictive values at the prevalence of infection of 34.4%, were 93.3%, 83.7%, 76.7%, and 95.6%, respectively. This ICT kit is easy to use at the point-of-care and a result can be obtained in 15 min. Sophisticated instruments and highly trained staff are not required. It can be used in several diagnostic and public-health settings, e.g., prevalence surveys in endemic areas, confirmation and monitoring of cure post-treatment, diagnosis and screening of infected but asymptomatic individuals, and populations “at risk” for hyperinfection syndrome or disseminated strongyloidiasis if they are given immunosuppressive treatment for other conditions.

Association between HTLV-1 infection and adverse health outcomes: a systematic review and meta-analysis of epidemiological studies

Human T-cell lymphotropic virus type 1 (HTLV-1) is a human retrovirus that causes a lifelong infection. Several diseases, including an aggressive form of leukaemia, have been designated as associated with HTLV-1, whereby having HTLV-1 is a necessary condition for diagnosis. Beyond these diseases, there is uncertainty about other health effects of HTLV-1. We aimed to synthesise evidence from epidemiological studies on associations between health outcomes and HTLV-1. For this systematic review and meta-analysis, we searched Embase, MEDLINE, MEDLINE In-Process, and Global Health for publications from their inception to July, 2018. We included cohort, case-control, and controlled cross-sectional studies that compared mortality or morbidity between people with and without HTLV-1. We excluded studies of psychiatric conditions, of symptoms or clinical findings only, of people who had undergone blood transfusion or organ transplant, and of population groups defined by a behavioural characteristic putting them at increased risk of co-infection with another virus. We extracted the risk estimates (relative risks [RRs] or odds ratios [ORs]) that reflected the greatest degree of control for potential confounders. We did a random-effects meta-analysis for groups of effect estimates where case ascertainment methods, age groups, and confounders were similar, presenting pooled estimates with 95% CIs and prediction intervals. Of the 3318 identified studies, 39 met the inclusion criteria, examining 42 clinical conditions between them. The adjusted risk of death due to any cause was higher in people with HTLV-1 when compared with HTLV-1-negative counterparts (RR 1·57, 95% CI 1·37-1·80). From meta-analysis, HTLV-1 was associated with increased odds of seborrheic dermatitis (OR 3·95, 95% CI 1·99-7·81), Sjogren's syndrome (3·25, 1·85-5·70), and, inversely, with lower relative risk of gastric cancer (RR 0·45, 0·28-0·71). There were a further 14 diseases with significant associations or substantially elevated risk with HTLV-1 from single studies (eczema [children]; bronchiectasis, bronchitis and bronchiolitis [analysed together]; asthma [males]; fibromyalgia; rheumatoid arthritis; arthritis; tuberculosis; kidney and bladder infections; dermatophytosis; community acquired pneumonia; strongyloides hyperinfection syndrome; liver cancer; lymphoma other than adult T-cell leukaemia-lymphoma; and cervical cancer). There is a broad range of diseases studied in association with HTLV-1. However, the elevated risk for death among people with HTLV-1 is not explained by available studies of morbidity. Many of the diseases shown to be associated with HTLV-1 are not fatal, and those that are (eg, leukaemia) occur too rarely to account for the observed mortality effect. There are substantial research gaps in relation to HTLV-1 and cardiovascular, cerebrovascular, and metabolic disease. The burden of disease associated with the virus might be broader than generally recognised. Commonwealth Department of Health, Australia.

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.

3204 Abdominal Pain From the Sahara: An Atypical Source for a Common Complaint

INTRODUCTION: Chest and abdominal pain are staple symptoms that plague the emergency room and the differential that it poses is vast and can sometimes be misleading. The more common cardiac and gastrointestinal causes are well known and can easily be discerned but every once in a while, an unlikely source emerges and urges clinicians to think outside the box. CASE DESCRIPTION/METHODS: This case looks at the story of a 61-year-old recently immigrated Ethiopian male with a history of diabetes mellitus and hypertension who presented with a twenty one day history of intermittent chest and abdominal pain. His initial troponins were negative and his electrocardiography showed no ischemia. Due to his historical risk factors, he was admitted and an echocardiogram and stress test were done but no ischemic changes were noted. Although troponins and images were negative, labs showed eosinophilia and due to recent travel to Ethiopia, additional stool workup was initiated after he started to complain with concurrent symptoms of nausea. Gastroenterology weighed in by performing an endoscopy that showed mild erosive gastropathy but benign biopsies. Lab results came back positive for the strongyloides antibody and the ova and parasite culture showed some strongyloides larvae. Infectious disease advised two doses of ivermectin and patient reported improvement through his hospital course and was eventually discharged. DISCUSSION: Strongyloides is a helminthic parasite that is usually shed in human feces and the larvae in the stool find their way through the skin of another host and eventually deposit themselves in the small bowel until they are ready to shed their new larvae into the feces; thereby restarting the cycle. Though the disease may be more common in third world areas, it only affects a fraction of patients in the United States. Per the Center for Disease Control, small studies showed that it affected 0 to 6.1% of people tested in the United States. Most patients present with cutaneous, gastrointestinal, or pulmonary findings but cardiac complaints are rare. His eosinophilia helped prompt further investigation and eventually brought forth a formal diagnosis. However common or mundane a symptom may be, every clinical picture is unique and should be evaluated thoroughly with a wide differential. Had his disease been misdiagnosed, it could have lead to a hyperinfection syndrome and may have caused sepsis and even death. Thus, whether a patient is in suburbia or the Sahara, it is vital to keep a broad differential.

Strongyloides stercoralis infection in human immunodeficiency virus-infected patients and related risk factors: A systematic review and meta-analysis.

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.

Methotrexate exposure and risk of strongyloidiasis.

Rheumatologic disease patients receiving immunomodulating drugs such as methotrexate (MTX) have increased infection rates. Strongyloides, a global endemic intestinal parasite, can cause significant or fatal disease in immunocompromised patients. The risk of serious Strongyloides infection with MTX dosed for rheumatologic disease is unknown. We performed a systematic literature review searching EMBASE, Medline and Web of Science databases. All studies reporting humans exposed to MTX and tested for Strongyloides were reviewed. Exclusion criteria were bone marrow transplantation, intrathecal route and MTX exposure completed >1year prior to clinically apparent Strongyloides disease. After excluding duplicates, 294 articles were reviewed. Of these, 29 cases were described in 27 papers. Twenty cases (69%) had an underlying rheumatologic or dermatologic disease, the rest had a haematologic disease. Hyperinfection or dissemination was found in 59% of cases (52% low-dose MTX; 75% high-dose MTX). Death occurred in 34% of cases (19% low-dose MTX; 75% high-dose MTX, P<0.01). All eight patients on high-dose MTX received other immunosuppressants. Corticosteroids were taken in 18/21 patients on low-dose MTX. One of the three patients on MTX monotherapy had hyperinfection syndrome. None had disseminated Strongyloides. Serious Strongyloides infection can occur with low-dose MTX particularly when given with other immunosuppression. Global travel and greater awareness of rheumatologic conditions in low- to middle-income countries will increase the exposure of individuals prescribed MTX (with or without corticosteroids) to Strongyloides. Strongyloides screening and treatment should be considered for individuals receiving low-dose MTX therapy, particularly if combined with additional immunosuppression.