Strongyloides Stercoralis Hyperinfection Research Articles

Strongyloides stercoralis hyperinfection presenting pneumatosis intestinalis and acute respiratory distress syndrome after treatment for COVID-19.

A 91-year-old man was admitted with vomiting and abdominal pain. He had had COVID-19 pneumonia a month before and the treatment had consisted of remdesivir, dexamethasone and baricitinib. CT scans showed pneumatosis intestinalis. His respiratory condition rapidly deteriorated and chest CT scans showed ground-glass opacity and Strongyloides stercoralis was identified in the sputum, making a diagnosis of hyperinfection syndrome associated acute respiratory distress syndrome. Treatment of ivermectin was not achieved in time and he died of multiple organ failure. S. stercoralis is a soil-transmitted helminth endemic to tropical and subtropical areas. Immunosuppressive conditions can cause hyperinfection syndrome and life-threatening conditions. Our case highlights the importance of assessing for untreated chronic strongyloidiasis in COVID-19 patients requiring steroid treatment in endemic areas.

Enhancing screening adherence for strongyloides infection in latinx inpatients with COVID-19: a local protocol implementation study

ABSTRACT Strongyloides stercoralis hyperinfection syndrome has been observed in immunosuppressed coronavirus disease 2019 (COVID-19) patients. Detecting and treating asymptomatic Strongyloides infection in individuals from endemic areas can effectively prevent hyperinfection. Unfortunately, many clinicians are unaware of this neglected infection. Therefore, we aimed to evaluate whether including Strongyloides screening in COVID-19 management protocols would encourage this practice. To accomplish this, we conducted a retrospective single-center study at ‘Hospital Universitario 12 de Octubre’ in Madrid, Spain, comparing two consecutive cohorts. The first cohort comprised all Latinx patients over 18 years old who were admitted for COVID-19 between March 1st and April 30th, 2020. The second cohort consisted of Latinx patients admitted between July 1st and December 31st, 2020, following an amendment to the COVID-19 management protocol that recommended screening for strongyloidiasis in at-risk patients. We identified 559 and 795 patients in the first and second periods, respectively. The percentage of individuals screened increased significantly from 8.8% to 51.6% after the screening recommendation was included in the protocol (odds ratio [OR] 11.08, 95% confidence interval [CI] 8.01–15.33). In both periods, the screening rate was significantly higher among those receiving immunosuppression than those who did not receive steroids and/or tocilizumab. No other factors influenced the screening rate. In conclusion, including strongyloidiasis screening recommendations in COVID-19 management protocols led to its increased implementation. However, the overall screening rate remained low, emphasizing the need for further efforts to enhance screening practices.

Strongyloides stercoralis hyperinfection syndrome mimicking pseudomembranous enteritis, complicated by Escherichia coli bacteremia and Pneumocystis jirovecii pneumonia in a patient after immunosuppressive therapy: a case report

BackgroundStrongyloidiasis, caused by Strongyloides stercoralis (S. stercoralis), is endemic worldwide, especially in countries with warm and humid climates. Strongyloides stercoralis hyperinfection syndrome (SHS) is an extremely serious manifestation of strongyloidiasis, which results from an acute exacerbation of auto-infection and is often fatal.Case presentationWe present a case of SHS mimicking pseudomembranous enteritis with a final definitive diagnosis of a triple infection including S. stercoralis, Escherchia coli (E. coli) and Pneumocytis jirovecii (P. jirovecii) that occurred in a microscopic polyangiitis (MPA) patient after immunosuppressive therapy. SHS, together with E. coli bacteremia and Pneumocytis jirovecii pneumonia (PJP) in the same patient, is rare in clinical practice, which is first reported worldwide, to our knowledge. After the diagnosis was confirmed, the treatment protocol was quickly adjusted; however, the patient’s life could not be saved.ConclusionThis case reminds us of the necessity to consider strongyloidiasis as a differential diagnosis in immunocompromised populations who live in or have visited to S. stercoralis endemic areas, especially patients with suspected pseudomembranous enteritis, even if stool examination, serological tests, and eosinophilia are negative. For this group, it is advisable to complete the relevant endoscopy and/or PCR as soon as possible. The fundamental solution to prevent this catastrophic outcome is to implement effective preventive measures at multiple levels, including physicians, patients, and relevant authorities.

Is Strongyloides stercoralis hyperinfection induced by glucocorticoids a result of both suppressed host immunity and altered parasite genetics?

The gastrointestinal (GI) nematode Strongyloides stercoralis (S.s.) causes human strongyloidiasis, a potentially life-threatening disease that currently affects over 600 million people globally. The uniquely pernicious aspect of S.s. infection, as compared to all other GI nematodes, is its autoinfective larval stage (L3a) that maintains a low-grade chronic infection, allowing undetectable persistence for decades. Infected individuals who are administered glucocorticoid therapy can develop a rapid and often lethal hyperinfection syndrome within days. Hyperinfection patients often present with dramatic increases in first- and second-stage larvae and L3a in their GI tract, with L3a widely disseminating throughout host organs leading to sepsis. How glucocorticoid administration drives hyperinfection remains a critical unanswered question; specifically, it is unknown whether these steroids promote hyperinfection through eliminating essential host protective mechanisms and/or through dysregulating parasite development. This current deficiency in understanding is largely due to the previous absence of a genetically defined mouse model that would support all S.s. life-cycle stages and the lack of successful approaches for S.s. genetic manipulation. However, there are currently new possibilities through the recent demonstration that immunodeficient NOD.Cg-PrkdcscidIl2rgtm1Wjl/SzJ (NSG) mice support sub-clinical infections that can be transformed to lethal hyperinfection syndrome following glucocorticoid administration. This is coupled with advances in transcriptomics, transgenesis, and gene inactivation strategies that now allow rigorous scientific inquiry into S.s. biology. We propose that combining in vivo manipulation of host immunity and deep immunoprofiling strategies with the latest advances in S.s. transcriptomics, piggyBac transposon-mediated transgene insertion, and CRISPR/Cas-9-mediated gene inactivation will facilitate new insights into the mechanisms that could be targeted to block lethality in humans with S.s. hyperinfection.

Thrombotic micro-angiopathy due to Strongyloides stercoralis hyperinfection

• Strongyloides stercoralis infection is a common disease in endemic (sub)tropical areas. • Strongyloides stercoralis hyperinfection syndrome might develop in immunocompromised patients. • Strongyloides stercoralis infection might trigger a thrombotic micro-angiopathy. • Two weeks of treatment with ivermectin can lead to full recovery. A parasitic Strongyloides stercoralis infection is a common disease in endemic (sub)tropical areas. It may persist for years due to auto-infection. Most patients have no or mild respiratory, cutaneous, and gastrointestinal symptoms. A 61-year-old female was hospitalized at the Intensive Care Unit with acute respiratory distress requiring mechanical ventilation and eosinophilia. Feces Baermann test and bronchoalveolar lavage showed S. stercoralis larvae, confirming the diagnosis of S. stercoralis hyperinfection syndrome. Remarkably, she suffered from Coombs negative hemolysis, thrombocytopenia and acute renal insufficiency. Following thorough examinations, we arrived at the diagnosis thrombotic micro-angiopathy caused by S. stercoralis hyperinfection syndrome. Full recovery was achieved following two weeks of oral treatment with ivermectin. Severe S. stercoralis hyperinfection syndrome can trigger thrombotic micro-angiopathy and is easily treated with ivermectin. A small proportion of S. stercoralis infections may develop into severe systemic disease with high mortality and morbidity rate, including thrombotic micro-angiopathy.

Strongyloides stercoralis hyperinfection and disseminated tuberculosis

Strongyloides stercoralis hyperinfection and disseminated tuberculosis

Strongyloides hyperinfection in a patient from Venezuela with lower gastrointestinal bleeding

We herein present a case of unsuspected Strongyloides stercoralis (Ss) hyperinfection diagnosis. No screening due to origin or immunosuppressed condition had been done and treatment was presumably prescribed lately, with subsequent vital risk for the patient.

Strongyloides stercoralis hyperinfection and disseminated tuberculosis

Strongyloides stercoralis hyperinfection and disseminated tuberculosis

Immune thrombocytopenia, Strongyloides stercoralis hyperinfection syndrome with coinfection of Cryptosporidium: A rare case

Immune thrombocytopenia, Strongyloides stercoralis hyperinfection syndrome with coinfection of Cryptosporidium: A rare case

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 larvae or egg: Which came first?

Strongyloides stercoralis (SS) hyperinfection is a well-documented condition. However, SS eggs in stool samples are not commonly observed during routine analysis. Here, we report a case on SS hyperinfection where both larvae and eggs were observed in the stool sample of an immunossupressed liver allograft transplanted patient.

Delayed Strongyloides stercoralis hyperinfection syndrome in a renal transplant patient with Pneumocystis jirovecii pneumonia receiving high-dose corticosteroids

Delayed Strongyloides stercoralis hyperinfection syndrome in a renal transplant patient with Pneumocystis jirovecii pneumonia receiving high-dose corticosteroids

Strongyloides stercoralis Hyperinfection Syndrome as a Cause of Fatal Gastrointestinal Hemorrhage.

ABSTRACTStrongyloides stercoralis is a small intestinal nematode that is widespread in regions with poor sanitation. We present a 57-year-old man from Colombia who was undergoing corticosteroid therapy for a meningioma who presented after neurosurgery with abdominal pain and a profound gastrointestinal (GI) bleed. The patient underwent an esophagogastroduodenoscopy (EGD), an attempted embolization, and an exploratory laparotomy to remove the necrosed duodenum. His pathology examination revealed Strongyloides infection of the duodenum, and he died of profound blood loss. This rare diagnosis displays the importance of screening patients at a high risk of Strongyloides infection before starting glucocorticoid therapy.

Strongyloides stercoralis hyperinfectionsyndrome: a deeper understanding of a neglected disease.

Strongyloides stercoralis hyperinfection syndrome (SHS) is a life-threatening condition that warrants early detection and management. We describe the pathogenesis, organ-specific clinical manifestations, and risk factors associated to this condition. A comprehensive review of the literature was conducted in PubMed, LILACS, EBSCO and SciELO by using the keywords: "hyperinfection syndrome"; "Strongyloides stercoralis"; "disseminated strongyloidiasis"; "systemic strongyloidiasis", "pathogenesis" and "pathophysiology". Relevant articles on this topic were evaluated and included by consensus. Also, a secondary search of the literature was performed. Articles in English and Spanish language were included. SHS has been described in tropical and sub-tropical regions. However, there is growing evidence of cases detected in developed countries favored by increasing migration and the advance in immunosuppressive therapies for oncologic and inflammatory diseases. SHS is characterized by massive multiplication of larvae, typically in immunocompromised hosts. Clinical manifestations vary according to the organ involved and include diarrhea, intestinal bleeding, alveolar hemorrhages, heart failure, jaundice, bacteremia among others. Despite advances in the understanding of this condition, fatality rates are near 90%. Clinicians should consider SHS in the differential diagnosis of acutely ill patients with multiple organ damage and epidemiological risk factors. Adverse outcomes are common, especially with delayed anti-parasitic treatment.

Strongyloides stercoralis hyperinfection masquerading as chronic obstructive pulmonary disease: A case report

Strongyloides stercoralis is a soil-transmitted helminth. Infection in human beings may be asymptomatic in immunocompetent individuals or cause life-threatening symptoms in immunocompromised individuals. We present a case of S. stercoralis in an immunocompetent individual who was misdiagnosed as obstructive airway disease.

Strongyloides stercoralis hyperinfection complicated by secondary infections in a case of transformed diffuse large B-cell lymphoma

AbstractWe report Strongyloides stercoralis hyperinfection complicated by secondary infections in a case of transformed diffuse large B-cell lymphoma. The hyperinfection was followed by a sequela of candidemia and infection of the peritoneal fluid that was associated with the leakage of gut flora from the bowel damaged by the migration of larvae. This phenomenon has seldom been reported in a case of hematolymphoid cancer such as transformed diffuse large B-cell lymphoma. The complications arising due to S. stercoralis hyperinfection are associated with a high fatality rate in immunocompromised patients, and this should be taken into account in the diagnosis and management of this condition.

Streptococcus pyogenes bacteremia and toxic shock syndrome related to Strongyloides stercoralis hyperinfection: a case report

BackgroundWe describe a patient with Strongyloides stercoralis hyperinfection associated with Streptococcus pyogenes and with streptococcal toxic shock syndrome. To the best of our knowledge this association has not been previously described.Case presentationA 78 year-old Israeli man, who was born in Iraq but lived in Israel for 66 years, presented with multi-organ failure including acute kidney and hepatic injury, coagulopathy, and lactic acidosis. He had a medical history including aortic valve replacement, diabetes mellitus, spinal stenosis, and low back pain treated with repeated local steroid injections. Blood cultures were positive for Streptococcus pyogenes and antibiotic treatment was switched to penicillin G, clindamycin, and intravenous immunoglobulins. Repeated physical examinations failed to identify the source of the bacteremia. On day 12 of hospitalization the serology results for Strongyloides stercoralis sent on admission, because of chronic eosinophilia, came back positive. A microscopic stool examination and stool polymerase chain reaction were positive for Strongyloides stercoralis. Ivermectin therapy was commenced and continued for a total of 4 weeks. He was discharged for rehabilitation after 25 days.He had no exposure to endemic countries or to immigrants. During many years he had multiple gastrointestinal symptoms, respiratory symptoms, cutaneous symptoms, chronic eosinophilia, and high immunoglobulin E levels. He underwent several operative procedures and numerous hospitalizations and medical encounters with different experts but a parasitic infection was not considered. His asymptomatic daughter was also found to be serologically positive.ConclusionsStrongyloides stercoralis hyperinfection associated with Streptococcus pyogenes bacteremia and toxic shock is described for the first time. The case also highlights the importance of history taking and reviewing past laboratory results, the utility of serological tests for Strongyloides stercoralis, and the importance of screening asymptomatic family members of an infected patient. Strongyloides stercoralis hyperinfection must be considered in the differential diagnosis of any patient with Streptococcus pyogenes bacteremia or toxic shock of no clear source as well as in symptomatic patients with chronic or intermittent eosinophilia, even without any epidemiological risk factors.

Prevalence of Strongyloides stercoralis infection and hyperinfection syndrome among renal allograft recipients in Central Europe

Strongyloides stercoralis is not hyperendemic in European countries but has been increasing in prevalence due to migration and travel. The infection is characterized by a mostly asymptomatic course or nonspecific symptoms in healthy subjects. However, immunosuppression or chemotherapy have been described as leading triggers for Strongyloides stercoralis hyperinfection syndrome and may have a fatal course. A post hoc analysis was performed among renal transplant patients during a 5-year period. Plasma samples of two hundred kidney allograft recipients were retrospectively analyzed for Strongyloides stercoralis seropositivity by established ELISA testing. Positive Strongyloides stercoralis serology was found in 3% of allograft recipients. One patient developed a life-threatening hyperinfection syndrome. His Strongyloides IgG signal had been elevated for years before the outbreak of the disease. Stronglyoides infections in transplant recipients are an important issue that physicians also in Central Europe should be aware of, given the risk of hyperinfection syndrome and the challenges in clinical diagnosis. Our study suggests that recipient and donor screening should be recommended in kidney transplantation programs in Central Europe as Strongyloides infection rates increase and its prevalence may be underestimated. Further research is needed to understand why some Strongyloides stercoralis seropositive individuals develop hyperinfection syndrome and others do not.

Methylprednisolone acetate induces, and Δ7-dafachronic acid suppresses, Strongyloides stercoralis hyperinfection in NSG mice

Strongyloides stercoralis hyperinfection causes high mortality rates in humans, and, while hyperinfection can be induced by immunosuppressive glucocorticoids, the pathogenesis remains unknown. Since immunocompetent mice are resistant to infection with S. stercoralis, we hypothesized that NSG mice, which have a reduced innate immune response and lack adaptive immunity, would be susceptible to the infection and develop hyperinfection. Interestingly, despite the presence of large numbers of adult and first-stage larvae in S. stercoralis-infected NSG mice, no hyperinfection was observed even when the mice were treated with a monoclonal antibody to eliminate residual granulocyte activity. NSG mice were then infected with third-stage larvae and treated for 6 wk with methylprednisolone acetate (MPA), a synthetic glucocorticoid. MPA treatment of infected mice resulted in 50% mortality and caused a significant >10-fold increase in the number of parasitic female worms compared with infected untreated mice. In addition, autoinfective third-stage larvae, which initiate hyperinfection, were found in high numbers in MPA-treated, but not untreated, mice. Remarkably, treatment with Δ7-dafachronic acid, an agonist of the parasite nuclear receptor Ss-DAF-12, significantly reduced the worm burden in MPA-treated mice undergoing hyperinfection with S. stercoralis Overall, this study provides a useful mouse model for S. stercoralis autoinfection and suggests a therapeutic strategy for treating lethal hyperinfection.

Strongyloides stercoralis hyperinfection syndrome in patient with non- proliferative glomerulopathy

Strongyloides stercoralis hyperinfection syndrome in patient with non- proliferative glomerulopathy