Strongyloidiasis Presenting Research Articles

S2843 Concealed Culprit: Disseminated Strongyloidiasis Presenting as Gastrointestinal and Respiratory Symptoms in an Immunocompromised Host

S2843 Concealed Culprit: Disseminated Strongyloidiasis Presenting as Gastrointestinal and Respiratory Symptoms in an Immunocompromised Host

Jejunal strongyloidiasis mimicking crohn's colitis: A diagnostic dilemma!

We report an unusual case of jejunal strongyloidiasis presenting as chronic malabsorption and intractable small bowel diarrhea in an immunocompetent adolescent boy who posed a diagnostic challenge for pathologists, radiologists, and gastroenterologists. Histopathology revealed chronic active colitis and was consistent with the clinicoradiological diagnosis of Crohn's colitis but nonresponse to immunomodulators warranted full-thickness jejunal biopsy through laparotomy which showed numerous larvae and eggs of Strongyloides. There is a need to increase the awareness of Strongyloides colitis given its high rate of misdiagnosis and mortality as the correct diagnosis can avoid a fatal outcome of this curable disease.

Masquerading Lethal Strongyloidiasis in A Patient with Chronic Kidney Disease: A Case Report

Strongyloides stercoralis is a nematode typified by a complex replication cycle exhibiting autoinfection, parthenogenesis and a long tenacity of survival in the human host. This infection remains endemic in the humid tropical countries of the world. There exists no gold standard test for the diagnosis of this parasitic infection. However, Inability to clinch the diagnosis can prove fatal among immunosuppressed individuals. We report one such rare case of strongyloidiasis presenting as thrombocytopenic acute gastroenteritis in a patient with chronic kidney disease.

Strongyloidiasis in a newly diagnosed patient living with HIV – A case report

Strongyloides stercoralis has a unique free-living stage in addition to the parasitic life cycle causing dissemination and hyperinfection syndrome. Clinical manifestations ranges from asymptomatic presentation in the immunocompetent host to disseminated disease and even septic shock in immunocompromised host. The non-specific presentation, risk factors, and complications of strongyloidiasis often require multiple tests for screening and diagnosis to increase the sensitivity of the tests. Here, we present a case report of a newly diagnosed patient of HIV with overlapping symptoms of respiratory and gastrointestinal tract involvement who was treated successfully. This emphasizes the need for strong clinical suspicion and screening of patients with the risk factors of strongyloidiasis.

Strongyloides stercoralis Presenting as diffuse alveolar hemorrhage in a lupus nephritis patient

Strongyloidiasis is a parasitic disease caused by Strongyloides stercoralis (SS), a nematode predominately endemic to the tropical and subtropical regions. Autoinfection enables the organism to infect the host for extended periods. Symptoms, when present, are nonspecific and may initially lead to misdiagnosis, particularly if the patient has additional comorbid conditions. Immunosuppressive states place patients at risk for strongyloides hyperinfection syndrome, whereby the organism rapidly proliferates. Unfortunately, the nonspecific presentation of strongyloidiasis often leads to delays in diagnosis and treatment. We describe an unusual case of SS hyperinfection in a 34-year-old female with a long-standing history of lupus nephritis Class V on treatment, who presented to us with diffuse alveolar hemorrhage. The diagnosis was rendered on the identification of numerous organisms during histologic examination of the bronchoalveolar lavage specimen. Despite specific anti-infective treatment, the patient succumbed to her illness.

Strongyloidiasis presenting during treatment of low-dose glucocorticoid plus rituximab for anti-signal recognition particle antibody-positive polymyositis: A case report.

Strongyloidiasis, an intestinal parasitic infection caused by Strongyloides stercoralis, rarely occurs in Japan. When treated with immunosuppressive drugs, two potentially lethal conditions, hyperinfection and dissemination, may develop in asymptomatic carriers of this parasite. We report the development of strongyloidiasis during treatment of polymyositis with glucocorticoids plus rituximab (RTX). A 44-year-old woman had been diagnosed with anti-signal recognition particle antibody-positive polymyositis with interstitial pneumonia 6 years previously, for which she had recently been receiving prednisolone at 5 mg/day and RTX at 375 mg/m2 twice every 3 months. Her condition appeared to be well controlled. She was admitted to our hospital with a 1-month history of chronic diarrhoea and epigastric pain. Standard microscopic examination of a sample of faeces revealed the presence of S. stercoralis; however, serologic testing for parasites was negative. Treatment with ivermectin alleviated her inflammatory diarrhoea and eradicated the faecal parasites. We believe that our patient had an exacerbation of S. stercoralis infection (hyperinfection syndrome) that was exacerbated by low-dose glucocorticoids plus RTX. Strongyloidiasis should be considered in immunocompromised individuals with unexplained diarrhoea, even in non-endemic areas.

S3450 Atypical Endoscopic and Clinical Presentation of Strongyloidiasis

Introduction: Strongyloidiasis is a helminthic parasitic infection caused by the nematode Strongyloides stercoralis. Due to its replication cycle within the human host, acute infection classically presents sequentially with skin irritation, dry cough, and then non-specific gastrointestinal (GI) symptoms. Mild GI and dermatologic symptoms appear to be more prevalent in chronic infections. Here we present a case of strongyloidiasis manifesting in atypical symptoms with normal endoscopic findings. Case Description/Methods: An 81-year-old female with a medical history of diverticulosis, hypertension, type 2 diabetes mellitus, hypercholesterolemia, and chronic kidney disease was admitted to the hospital for anorexia, abdominal pain, and unintentional 26-pound weight loss over 6 months. Computed tomography of chest, abdomen, and pelvis revealed a moderate left-sided pleural effusion and uncomplicated sigmoid diverticulitis. Pleural fluid studies showed exudative features, with negative cultures and cytology. She was started on ciprofloxacin and metronidazole for diverticulitis. The patient also had a chronic iron deficiency anemia with an average hemoglobin of 7.4 g/dL. Absolute eosinophil count, total IgE, sedimentation rate, and c-reactive protein were elevated. Enteroscopy up to the mid jejunum appeared normal except for a 4 cm hiatal hernia. Random duodenal biopsies showed chronic active duodenitis with several eosinophils and parasitic organisms (Figure). Colonoscopy was deferred due to acute diverticulitis. Strongyloides serum antibodies were positive. Stool studies were not analyzed due to lab errors. The patient was treated with oral ivermectin 200 mcg/kg/day for 14 days due to concern for disseminated infection and scheduled for an outpatient endoscopy and colonoscopy. Discussion: This case highlights the need to keep parasitic infections on the differential when patients present with symptoms concerning for malignancy, such as weight loss, anemia, abnormal laboratory markers, and new pleural effusions. While S. stercoralis has been found to mimic inflammatory bowel disease, it has not been associated with diverticulitis thus far. In addition, typical endoscopic findings include edematous and erythematous mucosa with white villi, however, this patient had normal endoscopic findings despite the extent of her infection. The duodenal biopsies aided in making the diagnosis for this case and should be considered in patients with similar presentations.Figure 1.: Duodenal biopsies showing chronic active duodenitis with several eosinophils and parasitic organisms.

DISSEMINATED STRONGYLOIDES PRESENTING WITH DIFFUSE ALVEOLAR HEMORRHAGE

DISSEMINATED STRONGYLOIDES PRESENTING WITH DIFFUSE ALVEOLAR HEMORRHAGE

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 Case of Ulcerated Gastric Mass and Anemia due to Strongyloidiasis

Strongyloidiasis is an intestinal infection caused by the nematode Strongyloides, and it is rarely seen in our clinical practice in the United States. Although it remains localized to the gastrointestinal tract most of the time, it can disseminate to other organs when it causes autoinfection in the setting of immunosuppression. The clinical manifestations vary depending on the involved organ. A case of disseminated strongyloidiasis presenting as a case of ulcerated gastric mass and anemia is described here along with a review of the literature on this condition.

2602 Strongyloidiasis Presenting as Gastric Outlet Obstruction

INTRODUCTION: Strongyloides Stercoralis is an intestinal parasite mostly seen in tropical areas. Commonly patients are asymptomatic with non-specific gastrointestinal manifestations. We present a case of strongyloidiasis presenting as gastric outlet obstruction. CASE DESCRIPTION/METHODS: Our patient is a 67-year- old woman, originally from Jamaica, recently diagnosed with Diabetes Mellitus who presented with 50 pounds weight loss, anorexia postprandial epigastric pain and recurrent episodes of vomiting. Her symptoms have been progressively getting worse and let her to doctor visits over the past several months. On physical exam she was afebrile but appeared cachectic. She did have minimal tenderness to palpation of the epigastric area and had minimal bilateral pedal edema. Laboratory testing revealed normocytic normochromic anemia, thrombocytosis, Hyponatremia and hypoalbuminemia. An Abdominal CT scan revealed dilatation of the second portion of duodenum and tapering of third portion of duodenum plus mild intrahepatic and extrahepatic bile ducts dilatation as well as dilation of the proximal pancreatic duct (Figures 1 and 2). The patient was admitted to the hospital for hydration and subsequently had an upper endoscopy. The procedure revealed marked retention of bilious fluid as well as evidence of severe duodenitis. Narrowing of the lumen of the duodenum was also seen (Figure 3). Biopsies from the duodenum were obtained and confirmed the presence of Strongyloides Stercoralis. Pt was given two days of Ivermectin with dramatic improvement of her symptoms and subsequent discharge. DISCUSSION: 1. Stercoralis is a nematode with a complex life cycle. The parasite infects humans and replicates within its host for years or even decades (autoinfection). Patients would have positive serologies for S. Stercoralis but usually are asymptomatic. Immunosuppressive medications, HIV, HTLV1, Chronic diseases and in our case the new onset diabetes cause the parasite to replicate and leads to life-threatening dissemination of larvae to multiple internal organs called hyperinfection.

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.

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.

Strongyloidiasis Presenting as Yellowish Nodules in Colonoscopy of an Immunocompetent Patient.

Strongyloides stercoralis is endemic to tropical and subtropical regions, and infections are usually asymptomatic. However, immunocompromised patients, such as those receiving immunosuppressive therapy, high-dose steroids, or chemotherapy, can develop fatal hyperinfections. An 84-year-old man without any symptoms was diagnosed with strongyloidiasis during a regular screening colonoscopy. His medical history only involved a gastric endoscopic submucosal dissection for early gastric cancer 6 months previously. Few cases have been published about asymptomatic strongyloidiasis diagnosed in an immunocompetent host via endoscopic mucosal resection with characteristic colonoscopic findings. We report a case of colon-involved asymptomatic strongyloidiasis with specific colonic findings of yellowish-white nodules. This finding may be an important marker of S. stercoralis infection, which could prevent hyperinfections.

Hepatobiliary strongyloidiasis presenting as an ampullary lesion on esophagogastroduodenoscopy/endoscopic ultrasound

Strongyloidiasis is an intestinal infection caused by the parasitic nematodes of the Strongyloides species, most commonly Strongyloides stercoralis. We report a case of a 66-year-old immigrant male from Haiti who presented with complaints of diarrhea and an unintentional 80-lb weight loss over the past 5 years. Stool examination was positive for strongyloidiasis. Following albendazole therapy, esophagogastroduodenoscopy (EGD) showed a unique ampullary lesion. Histopathology of the ampullary lesion showed reactive epithelium with Strongyloides larva. In addition, endoscopic ultrasound (EUS) detected a large pancreatic cyst. Both these findings were absent on EGD 5 years previously, prior to the onset of his symptoms. This paper documents a rare case of an ampullary lesion and pancreatic cyst secondary to hepatobiliary strongyloidiasis in a non-Human Immunodeficiency Virus (HIV) patient. We review the epidemiology, life cycle, clinical presentation and treatment of strongyloidiasis.

Hepatobiliary Strongyloidiasis Presenting as an Ampullary Lesion on EGD/EUS

Hepatobiliary Strongyloidiasis Presenting as an Ampullary Lesion on EGD/EUS

Answer to March 2017 Photo Quiz

Answer: Disseminated strongyloidiasis presenting with larva migrans or cutaneous strongyloidiasis. A repeated stool examination for ova and parasites revealed a few typical rhabditiform larvae (not shown); examination of a fresh sputum smear revealed no larvae. On hospital day 6, the patient

Determinants of reactivation of inapparent Strongyloides stercoralis infection in patients hospitalized for unrelated admitting diagnosis

Clinical presentation of strongyloidiasis in humans is highly variable, ranging from clinically inapparent infection to life-threatening multisystem disease. The course of infection is dependent on the immune status of the patient. Our objective was to ascertain the clinical characteristics of patients who developed reactivated strongyloidiasis from a primary infection acquired in the past, and to evaluate risk factors that contributed to its exacerbation. We identified 31 patients diagnosed with strongyloidiasis by stool examination at our institution from January 2007 to June 2012. We reviewed their clinical records and selected eight patients whose admitting diagnosis was not suggestive of strongyloidiasis-associated gastrointestinal disease. However, they developed symptoms consistent with strongyloidiasis during their hospitalization, and stool examinations revealed diagnostic larvae. We have identified immunosuppressive therapy, viral infection-associated immunodeficiency, alcoholism, and diabetes mellitus as risk factors for reactivation of chronic inapparent strongyloidiasis. Analysis of hemogram data suggests the low sensitivity of hypereosinophilia to be a marker for this helminthiasis.

High risk of strongyloïdes hyperinfection in a patient with sarcoidosis

Strongyloïdes stercoralis infection is a polymorphic and non specific clinical presentation. Often asymptomatic, it can be not seen. However, in patients with immunodeficiency, high parasite load can be observed, consequence of self-infestation cycle, and can spread throughout the body. This presentation of malignant strongyloidiasis presents a mortality rate of 70%. The case report presents a 45 years old patient of Caribbean origin, long time treated with corticosteroids for sarcoidosis, and hospitalized for Strongyloïdes stercoralis colitis with high parasite load, raising fears an evolution to hyperinfection. His last visit to endemic area was in 2002. In conclusion, the potential severity of strongyloidiasis is strongly increased by immunosuppression, including corticosteroids. This risk should be notified prior to initiation of any treatment with corticosteroids, firstly by looking at a stay in endemic areas. The case of our patient illustrates the fact that a long time between risk of contamination and clinical manifestations is not a sufficient criterion for excluding an asymptomatic chronic infection with Strongyloïdes stercoralis. It is therefore recommended for patients who have lived in endemic areas to search the parasite in stool by a sensitive method.