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Morel R, Maddumabandara K, Amarasinghe N, Amarangani S, Amarasinghe A, Gunathilaka M, Wathsala G, Bandara L, Wijesundara S, Gunaratne N, Waduge R, Medagama A. Strongyloidiasis infection in a borderline lepromatous leprosy patient with adrenocorticoid insufficiency undergoing corticosteroid treatment: a case report. J Med Case Rep 2022; 16:458. [PMID: 36482424 PMCID: PMC9733215 DOI: 10.1186/s13256-022-03673-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 11/07/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Strongyloidiasis is a soil-transmitted helminthiasis mainly caused by Strongyloides stercoralis. It is endemic to the tropics and subtropics. Sri Lanka has a 0-1.6% prevalence rate. S. stercoralis infection was identified in a 33-year-old Sri Lankan male patient treated with corticosteroids for borderline lepromatous leprosy with adrenocortical dysfunction. CASE PRESENTATION In March 2020, a 33-year-old Sri Lankan (Sinhalese) male patient presented with watery diarrhea, lower abdominal pain, and post-prandial abdominal fullness. Previously, he was diagnosed with borderline lepromatous leprosy and was treated with rifampicin, clofazimine, and prednisolone 60 mg daily since July 2019. After developing gastrointestinal symptoms, he had defaulted leprosy treatment including the prednisolone for 3 months. Duodenal biopsy revealed numerous intraepithelial nematodes within the lumina of glands in the duodenum whose appearance favored Strongyloides. Fecal wet smear revealed numerous Strongyloidis stercoralis L1 rhabditiform larvae. Larval tracks were seen in the agar plate culture. L3 filariform larvae of Strongyloidis stercoralis were seen in the Harada-Mori culture. In addition, the short synacthen test revealed adrenocortical insufficiency, and oral hydrocortisone and fludrocortisone were started with albendazole treatment against strongyloidiasis. Fecal wet smear and culture repeated after treatment with albendazole were negative for Strongyloidis stercoralis. The patient was discharged in July 2020 on oral hydrocortisone. One month later his condition was reviewed and the repeated fecal wet smear and agar plate culture was normal. He is being followed up every 3 months. CONCLUSION This is the first case of strongyloidiasis diagnosed in a patient with borderline lepromatous leprosy from Sri Lanka. The patient manifested symptoms of strongyloidiasis while on high-dose steroid therapy for his lepromatous reaction. Subsequently, the patient not only discontinued his steroid therapy, but also developed adrenocortical insufficiency as a complication of leprosy. Therefore, although diagnosis of strongyloidiasis was delayed, his subsequent low steroid levels probably protected him from disseminated disease. This is an interesting case where symptomatic strongyloidiasis was diagnosed in a patient who was initially treated with high-dose steroids but subsequently developed adrenocortical insufficiency. We emphasize the need to screen all patients prior to the commencement of immunosuppressive therapy.
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Affiliation(s)
- Rumala Morel
- grid.11139.3b0000 0000 9816 8637Department of Parasitology, Faculty of Medicine, University of Peradeniya, Peradeniya, Kandy, Sri Lanka
| | - Kusala Maddumabandara
- grid.11139.3b0000 0000 9816 8637Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Kandy, Sri Lanka
| | - Nisansala Amarasinghe
- grid.11139.3b0000 0000 9816 8637Department of Pathology, Faculty of Medicine, University of Peradeniya, Peradeniya, Kandy, Sri Lanka
| | - Sujeewa Amarangani
- grid.11139.3b0000 0000 9816 8637Department of Pathology, Faculty of Medicine, University of Peradeniya, Peradeniya, Kandy, Sri Lanka
| | - Anjalie Amarasinghe
- grid.11139.3b0000 0000 9816 8637Department of Parasitology, Faculty of Medicine, University of Peradeniya, Peradeniya, Kandy, Sri Lanka
| | - Mihiri Gunathilaka
- grid.11139.3b0000 0000 9816 8637Department of Parasitology, Faculty of Medicine, University of Peradeniya, Peradeniya, Kandy, Sri Lanka
| | - Gayani Wathsala
- grid.11139.3b0000 0000 9816 8637Department of Parasitology, Faculty of Medicine, University of Peradeniya, Peradeniya, Kandy, Sri Lanka
| | - Lakmalee Bandara
- grid.11139.3b0000 0000 9816 8637Department of Parasitology, Faculty of Medicine, University of Peradeniya, Peradeniya, Kandy, Sri Lanka
| | - Sunil Wijesundara
- grid.11139.3b0000 0000 9816 8637Department of Parasitology, Faculty of Medicine, University of Peradeniya, Peradeniya, Kandy, Sri Lanka
| | - Nilupuli Gunaratne
- grid.11139.3b0000 0000 9816 8637Department of Pathology, Faculty of Medicine, University of Peradeniya, Peradeniya, Kandy, Sri Lanka
| | - Roshitha Waduge
- grid.11139.3b0000 0000 9816 8637Department of Pathology, Faculty of Medicine, University of Peradeniya, Peradeniya, Kandy, Sri Lanka
| | - Arjuna Medagama
- grid.11139.3b0000 0000 9816 8637Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Kandy, Sri Lanka
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Mati VLT, Raso P, de Melo AL. Strongyloides stercoralis infection in marmosets: replication of complicated and uncomplicated human disease and parasite biology. Parasit Vectors 2014; 7:579. [PMID: 25499310 PMCID: PMC4287166 DOI: 10.1186/s13071-014-0579-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 11/28/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Strongyloides stercoralis can undergo an alternative autoinfective life cycle in the host, which, in some individuals can lead to a lethal infection. However, due to a number of factors, such as, the majority of those infected are from low-income backgrounds and the limitation in experimental models for studying human S. stercoralis, strongyloidiasis remains neglected. Improved knowledge of animal models that are susceptible to this parasite is needed in order to investigate the immunological mechanisms involved during infection and in particular to further understand the natural history of the autoinfective cycle. METHODS Callithrix penicillata were inoculated subcutaneously with 100 (n = 2), 300 (n = 4) or 500 (n = 9) third-stage infective larvae (L3i) of S. stercoralis of human origin. Three marmosets received smaller inocula (i.e., one received 100 and two received 300 L3i) to ensure a greater capacity to withstand the infection after immunosuppression, which was triggered by administration of dexamethasone during early patency. Qualitative faecal analyses began at 7 days post-infection (DPI), and semi-quantitative tests were also performed for the dexamethasone-treated primates and the three matched controls. During the necropsies, specimens of S. stercoralis were recovered and tissue fragments were processed for histopathology. RESULTS The mean prepatency and patency periods were 16.1 ± 3.0 and 161.1 ± 72.2 DPI, respectively. The marmosets typically tolerated the infection well, but immunosuppressed individuals exhibited higher numbers of larvae in the faeces and progressive clinical deterioration with late disseminated infection. In these cases, the number of females recovered was significantly higher than the number of inoculated L3i. Large quantities of larvae were observed migrating through the host tissues, and histopathology revealed pulmonary and intestinal injuries consistent with those observed in human strongyloidiasis. CONCLUSIONS Both complicated and uncomplicated strongyloidiasis occur in C. penicillata that is described as a susceptible small non-human primate model for S. stercoralis. This host permits the maintenance of a human strain of the parasite in the laboratory and can be useful for experimental investigations of strongyloidiasis. In parallel, we discuss data related to the autoinfective cycle that provides new insights into the biology of S. stercoralis.
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Affiliation(s)
| | - Pedro Raso
- Department of Pathological Anatomy and Legal Medicine, FM, UFMG, Belo Horizonte, Brazil.
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Incani RN, Hernández M, González ME. Hyperinfection by Strongyloides stercoralis probably associated with Rituximab in a patient with mantle cell lymphoma and hyper eosinophilia. Rev Inst Med Trop Sao Paulo 2010; 52:221-4. [DOI: 10.1590/s0036-46652010000400011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Accepted: 04/22/2010] [Indexed: 01/21/2023] Open
Abstract
The first report to our knowledge, of hyperinfection by Strongyloides stercoralis (HS) and hypereosinophilia, associated to immune suppression by Rituximab (the only drug received for the last one year and 10 months), in a patient with mantle-cell lymphoma (MCL), is presented. The patient has a 3-year history of MCL, and developed two accesses of HS during 2008, including meningitis, pneumonia and presence of larvae of S. stercoralis in the lungs. We had a unique chance to look at cytotoxicity of filariform larvae in the expectoration after Ivermectin treatment, showing immobilization and death of larvae, associated with eosinophils attached to the cuticle of the parasite.
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Marcos LA, Terashima A, Dupont HL, Gotuzzo E. Strongyloides hyperinfection syndrome: an emerging global infectious disease. Trans R Soc Trop Med Hyg 2008; 102:314-8. [PMID: 18321548 DOI: 10.1016/j.trstmh.2008.01.020] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Revised: 01/24/2008] [Accepted: 01/25/2008] [Indexed: 11/26/2022] Open
Abstract
The hyperinfection syndrome (HS) caused by Strongyloides stercoralis has a high mortality rate (15% to 87%). A variety of risk factors and predisposing conditions have been described, including new immunosuppressive therapies; HTLV-1 infection; cadaveric transplantation; immune reconstitution syndrome; haematological malignancies (especially lymphoma); tuberculosis; malnutrition secondary to chronic Strongyloides diarrhoea; international travel and immigration. Inhibition of Th2 cell-mediated, humoral or mucosal immunity is associated with HS. HS is more frequently seen in HTLV-1 than HIV patients. In AIDS, there is an increase in Th2 cytokines, while in HTLV-1 infection there is a decrease in the Th2 response, leading to an increased risk of autoinfection. Corticosteroid use remains the most frequent risk factor for HS. A number of ELISAs are useful for diagnosis and post-treatment evaluation. Once diagnosed, the disease may be managed effectively with anthelminthic drugs, including ivermectin. HS causes diverse symptoms and signs, with unusual manifestations leading to misdiagnosis and medical errors related to healthcare providers' lack of familiarity with the condition. HS is an example of an emerging tropical infection migrating to developed countries and requiring greater clinician awareness.
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Affiliation(s)
- Luis A Marcos
- Internal Medicine Department, University of Texas Health Science, 6431 Fannin Street, Suite 1.150, Houston, TX 77030, USA.
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Concha R, Harrington W, Rogers AI. Intestinal strongyloidiasis: recognition, management, and determinants of outcome. J Clin Gastroenterol 2005; 39:203-11. [PMID: 15718861 DOI: 10.1097/01.mcg.0000152779.68900.33] [Citation(s) in RCA: 158] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Significant advances have occurred in our understanding of the biology, immunology, and immunopathology of the usually asymptomatic human infection by the intestinal parasite, Strongyloides stercoralis. Factors that increase the risk for the occurrence of symptomatic intestinal hyperinfection and/or often-fatal disseminated strongyloidiasis have been better defined. The pathophysiology underlying these risk factors, whether disease-related or iatrogenically induced, is a compromised immune system leading to dysfunction of TH-2 helper cells. These specialized lymphocytes are central to maintaining the delicate balance that exists between the infected human host and the stabilized parasite. Recognition of risk factors that impair the function of TH-2 lymphocytes is essential to heightening the index of clinical suspicion enhancing earlier, accurate diagnosis, and the introduction of appropriate therapy. This review summarizes what is understood about infection by S. stercoralis; its focus will be on the epidemiology, diagnosis, clinical presentation patterns in the immunocompetent and immunocompromised human hosts, and recommended treatment regimens.
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Affiliation(s)
- Ronald Concha
- Division of Internal Medicine, University of Miami, 8501 SW 87th Court, Miami, FL 33173-4552, USA.
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