Fatal strongyloides stercoralis hyperinfection in acute leukaemia

Severe strongyloidiasis in corticosteroid-treated patients: case series and literature review

OBJECTIVE

To describe the main features of severe strongyloidiasis in corticosteroid-treated patients

METHODS

We report on 3 cases of corticosteroid-treated patients with severe strongyloidiasis and review cases of severe strongyloidiasis in corticosteroid-treated patients reported in the literature.

RESULTS

One hundred and fifty-one cases of severe strongyloidiasis complicated a therapy with corticosteroids were evaluated. The mean age of the patients was 48+/-17 years and 71% were men. Corticosteroids were given for hematological malignancies in 34 (23%), systemic lupus erythematosus or vasculitis in 27 (18%), and nephropathy or renal transplantation in 32 (21%). At time of infection, the mean daily dosage of prednisone-equivalent was 52+/-42 mg (median: 40 mg) and 84% of patients had received a cumulative dosage of prednisone-equivalent higher than 1000 mg. The total duration of treatment ranged from 4 days to 20 years (6 months or less: 69%). Non-specific gastro-intestinal symptoms were reported in 91% of these patients associated or not with pulmonary complaints. Low-grade fever was present in 54% of patients. Fifty-nine patients (39%) experienced severe bacterial or yeast infection during the course of severe strongyloidiasis. Peripheral eosinophilia was detected at presentation in 32% of patients. Strongyloidiasis was usually confirmed by repeated stool examinations. Thiabendazole was the treatment the more widely used. Eighty-nine patients (59%) deceased during the course of the disease.

CONCLUSIONS

Severe strongyloidiasis is a risk in every corticosteroid-treated patient who has traveled to a soil-infested country, even if the contact was 30 years prior. This diagnosis should be suspected in patients who either experience unusual gastro-intestinal or pulmonary symptoms or suffer from unexplained Gram-negative bacilli sepsis.

Disseminated strongyloidiasis presenting as purpura

We report a patient with disseminated strongyloidiasis who was being treated with steroids for cerebral edema caused by brain metastases from urinary bladder carcinoma. He had extensive purpura involving the abdomen, arms, and thighs. A skin biopsy specimen showed numerous larvae of Strongyloides stercoralis. Subsequently, rhabdoid larvae of S. stercoralis were isolated in the stool and the sputum. The patient died 2 days later despite thiabendazole therapy.

The clinical significance of gastrointestinal helminths--a review

Gastrointestinal helminths (nematodes, trematodes and cestodes) constitute some of the most common and important infective agents of mankind and are responsible for much morbidity and some mortality. Whereas many symptoms and signs are confined to the intestine and less often the associated digestive organs, systemic manifestations are also numerous; this applies especially to indigenous populations of developing 'Third World' countries. Using a clinical classification these organisms can be broadly separated into those involving the small-intestine and those which have a colo-rectal distribution; of the former, a minority has been causally related to intestinal malabsorption. Clearly, however, not all gastrointestinal helminths are associated with disease and it is important to be able to separate these two groups; when present at high concentration and especially in infants and children some of the least pathogenic are not, however, entirely asymptomatic. Maintenance of a high 'index of suspicion' is necessary and this applied especially to 'western' populations in whom rapid and extensive travel to areas of the world with substandard sanitation and contaminated food and water supplies is now common; first evidence of infection in them may result from serious clinical complications. Recent advances have focussed on treatment, and especially the introduction of the benzimidazole compounds (especially albendazole) for nematode, and praziquantel for cestode, infections. Treatment of strongyloidiasis remains, however, unsatisfactory. Mass elimination of gastrointestinal helminths in developing 'Third World' countries remains a major challenge.