1
|
Yeung S, Bharwada Y, Bhasker S, Boggild A. Strongyloidiasis: what every gastroenterologist needs to know. Ther Adv Chronic Dis 2022; 13:20406223221137499. [PMID: 36407019 PMCID: PMC9666874 DOI: 10.1177/20406223221137499] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/20/2022] [Indexed: 04/28/2024] Open
Abstract
Strongyloidiasis is caused by the intestinal roundworm, Strongyloides stercoralis, which has the potential for fatal outcome. It may present with vague gastrointestinal symptoms and mimic gastrointestinal diseases such as inflammatory bowel disease, and as such, it should be in the purview of the gastroenterologist. While strongyloidiasis is generally asymptomatic or produces mild symptoms in patients with an intact immune system, individuals who are immunocompromised may develop life-threatening disease through hyperinfection syndrome and disseminated disease. The worm has a complex lifecycle and is able to autoinfect its host, thereby allowing indefinite persistence even decades after initial infection. This leads to cases where travelers, and those who lived in endemic countries, may present years after travel. With its features of prolonged infection, relatively high global prevalence, and potential for fatal outcomes, it is imperative for all clinicians to be aware of this disease. Owing to its involvement with the gastrointestinal system, however, we will outline salient points about strongyloidiasis for the gastroenterologist.
Collapse
Affiliation(s)
- Sabrina Yeung
- Department of Internal Medicine, McMaster
University, Hamilton, ON, Canada
| | - Yashvi Bharwada
- Department of Internal Medicine, University of
Manitoba, Winnipeg, MB, Canada
| | - Shveta Bhasker
- Institute of Health Policy, Management and
Evaluation, Dalla Lana School of Public Health, University of Toronto,
Toronto, ON, Canada
| | - Andrea Boggild
- Tropical Disease Unit, Division of Infectious
Diseases, Toronto General Hospital, 200 Elizabeth Street, 13EN-218, Toronto,
ON M5G 2C4, Canada
- Department of Medicine, University of Toronto,
Toronto, ON, Canada
- Institute of Medical Science, University of
Toronto, Toronto, ON, Canada
| |
Collapse
|
2
|
Buonfrate D, Rodari P, Barda B, Page W, Einsiedel L, Watts M. Current pharmacotherapeutic strategies for Strongyloidiasis and the complications in its treatment. Expert Opin Pharmacother 2022; 23:1617-1628. [PMID: 35983698 DOI: 10.1080/14656566.2022.2114829] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Strongyloidiasis, an infection caused by the soil-transmitted helminth Strongyloides stercoralis, can lead immunocompromised people to a life-threatening syndrome. We highlight here current and emerging pharmacotherapeutic strategies for strongyloidiasis and discuss treatment protocols according to patient cohort. We searched PubMed and Embase for papers published on this topic between 1990 and May 2022. AREAS COVERED Ivermectin is the first-line drug, with an estimated efficacy of about 86% and excellent tolerability. Albendazole has a lower efficacy, with usage advised when ivermectin is not available or not recommended. Moxidectin might be a valid alternative to ivermectin, with the advantage of being a dose-independent formulation. EXPERT OPINION The standard dose of ivermectin is 200 µg/kg single dose orally, but multiple doses might be needed in immunosuppressed patients. In the case of hyperinfection, repeated doses are recommended up to 2 weeks after clearance of larvae from biological fluids, with close monitoring and further dosing based on review. Subcutaneous ivermectin is used where there is impaired intestinal absorption/paralytic ileus. In pregnant or lactating women, studies have not identified increased risk with ivermectin use. However, with limited available data, a risk-benefit assessment should be considered for each case.
Collapse
Affiliation(s)
- Dora Buonfrate
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria hospital, via Sempreboni 5, 37024 Negrar, Verona, Italy
| | - Paola Rodari
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria hospital, via Sempreboni 5, 37024 Negrar, Verona, Italy
| | - Beatrice Barda
- Ospedale La Carità, Ospedale regionale di Locarno, Locarno 6600, Switzerland
| | - Wendy Page
- Miwatj Health Aboriginal Corporation, 1424 Arnhem Rd, Nhulunbuy NT 0880, Australia
| | - Lloyd Einsiedel
- Peter Doherty Institute, University of Melbourne, 792 Elizabeth St, Melbourne VIC 3000, Australia
| | - Matthew Watts
- Centre for Infectious Diseases and Microbiology, Institute of Clinical Pathology and Medical Research - New South Wales Health Pathology and Sydney Institute for Infectious Diseases, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
3
|
Talukder MR, Pham H, Woodman R, Wilson K, Taylor K, Kaldor J, Einsiedel L. The Association between Diabetes and Human T-Cell Leukaemia Virus Type-1 (HTLV-1) with Strongyloides stercoralis: Results of a Community-Based, Cross-Sectional Survey in Central Australia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042084. [PMID: 35206272 PMCID: PMC8872355 DOI: 10.3390/ijerph19042084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 11/16/2022]
Abstract
In central Australia, an area that is endemic for the human T-cell leukaemia virus type-1 (HTLV-1), the prevalence of Strongyloides stercoralis and its association with other health conditions are unknown. A cross-sectional community-based survey was conducted in seven remote Aboriginal communities in central Australia, from 2014 to 2018. All residents aged ≥10 years were invited to complete a health survey and to provide blood for Strongyloides serology, HTLV-1 serology and HTLV-1 proviral load (PVL). Risk factors for Strongyloides seropositivity and associations with specific health conditions including diabetes and HTLV-1 were determined using logistic regression. Overall Strongyloides seroprevalence was 27% (156/576) (children, 22% (9/40); adults (≥15 years), 27% (147/536), varied widely between communities (5–42%) and was not associated with an increased risk of gastrointestinal, respiratory or dermatological symptoms. Increasing age, lower HTLV-1 PVL (<1000 copies per 105 peripheral blood leucocytes) compared to the HTLV-1 uninfected group and community of residence were significant risk factors for Strongyloides seropositivity in an adjusted model. A modest reduction in the odds of diabetes among Strongyloides seropositive participants was found (aOR 0.58, 95% CI 0.35, 1.00; p = 0.049); however, this was lost when body mass index was included in the adjusted model (aOR 0.48, 95% CI 0.48, 1.47; p = 0.542). Strongyloides seropositivity had no relationship with anaemia. Exploring social and environmental practices in communities with low Strongyloides seroprevalence may provide useful lessons for similar settings.
Collapse
Affiliation(s)
- Mohammad Radwanur Talukder
- Baker Heart and Diabetes Institute, Alice Springs Hospital, Alice Springs, NT 0870, Australia; (M.R.T.); (H.P.)
| | - Hai Pham
- Baker Heart and Diabetes Institute, Alice Springs Hospital, Alice Springs, NT 0870, Australia; (M.R.T.); (H.P.)
| | - Richard Woodman
- Flinders Centre for Epidemiology and Biostatistics, Flinders University, Adelaide, SA 5001, Australia;
| | - Kim Wilson
- National Serology Reference Laboratory, Melbourne, VIC 3065, Australia;
| | - Kerry Taylor
- Poche Centre for Indigenous Health and Wellbeing, Alice Springs, NT 0870, Australia;
| | - John Kaldor
- Kirby Institute, University of New South Wales, Sydney, NSW 2052, Australia;
| | - Lloyd Einsiedel
- Baker Heart and Diabetes Institute, Alice Springs Hospital, Alice Springs, NT 0870, Australia; (M.R.T.); (H.P.)
- Alice Springs Hospital, Alice Springs, NT 0870, Australia
- Correspondence:
| |
Collapse
|
4
|
Rosadas C, Brites C, Arakaki-Sanchez D, Casseb J, Ishak R. Brazilian Protocol for Sexually Transmitted Infections 2020: human T-cell lymphotropic virus (HTLV) infection. Rev Soc Bras Med Trop 2021; 54:e2020605. [PMID: 34008723 PMCID: PMC8210483 DOI: 10.1590/0037-8682-605-2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/10/2021] [Indexed: 12/26/2022] Open
Abstract
This article addresses the Human T-lymphotropic virus (HTLV). This subject comprises the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health. HTLV-1/2 infection is a public health problem globally, and Brazil has the largest number of individuals living with the virus. HTLV-1 causes several clinical manifestations of neoplasm (adult T-cell leukemia/lymphoma) and inflammatory nature, such as HTLV-1-associated myelopathy and other manifestations such as uveitis, arthritis, and infective dermatitis. These pathologies have high morbidity and mortality and negatively impact the quality of life of infected individuals. This review includes relevant information for health authorities professionals regarding viral transmission, diagnosis, treatment, and monitoring of individuals living with HTLV-1 and 2 in Brazil. HTLV-1/2 transmission can occur through blood transfusion and derivatives, injectable drug use, organ transplantation, unprotected sexual intercourse, and vertical transmission.
Collapse
Affiliation(s)
- Carolina Rosadas
- Imperial College London, Department of Infectious Disease, London, United Kingdom
| | - Carlos Brites
- Universidade Federal da Bahia, Faculdade de Medicina, Salvador, BA, Brasil
| | | | - Jorge Casseb
- Universidade de São Paulo, Faculdade de Medicina, São Paulo, SP, Brasil
| | - Ricardo Ishak
- Universidade Federal do Pará, Instituto de Ciências Biológicas, Belém, PA, Brasil
| |
Collapse
|
5
|
Rosadas C, Brites C, Arakaki-Sánchez D, Casseb J, Ishak R. [Brazilian Protocol for Sexually Transmitted Infections 2020: human T cell lymphotropic virus (HTLV) infection]. ACTA ACUST UNITED AC 2021; 30:e2020605. [PMID: 33729406 DOI: 10.1590/s1679-497420200006000015.esp1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/07/2020] [Indexed: 11/22/2022]
Abstract
This manuscript is related to the chapter about human T-cell lymphotropic virus (HTLV) that is part of the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Health Ministry. HTLV-1/2 infection is a worldwide public health problem and Brazil has the largest number of individuals living with the virus. HTLV-1 causes a variety of clinical manifestations of a neoplastic nature, such as adult leukemia/T-cell lymphoma, and also of an inflammatory nature, such as HTLV-1-associated myelopathy, as well as other manifestations such as uveitis, arthritis and infective dermatitis. These pathologies have high morbidity and mortality and negatively impact the quality of life of infected individuals. This review includes relevant information for health service managers and workers regarding virus transmission modes, diagnosis, treatment and monitoring of individuals living with HTLV-1 and 2 in Brazil.
Collapse
Affiliation(s)
- Carolina Rosadas
- Imperial College London, Department of Infectious Disease, Londres, Reino Unido
| | - Carlos Brites
- Universidade Federal da Bahia, Faculdade de Medicina, Salvador, BA, Brasil
| | | | - Jorge Casseb
- Universidade de São Paulo, Faculdade de Medicina, São Paulo, SP, Brasil
| | - Ricardo Ishak
- Universidade Federal do Pará, Instituto de Ciências Biológicas, Belém, PA, Brasil
| |
Collapse
|
6
|
Gordon CA, Shield JM, Bradbury RS, Muhi S, Page W, Judd JA, Lee R, Biggs BA, Ross K, Kurscheid J, Gray DJ, McManus DP. HTLV-I and Strongyloides in Australia: The worm lurking beneath. ADVANCES IN PARASITOLOGY 2021; 111:119-201. [PMID: 33482974 DOI: 10.1016/bs.apar.2020.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Strongyloidiasis and HTLV-I (human T-lymphotropic virus-1) are important infections that are endemic in many countries around the world with an estimated 370 million infected with Strongyloides stercoralis alone, and 5-10 million with HTVL-I. Co-infections with these pathogens are associated with significant morbidity and can be fatal. HTLV-I infects T-cells thus causing dysregulation of the immune system which has been linked to dissemination and hyperinfection of S. stercoralis leading to bacterial sepsis which can result in death. Both of these pathogens are endemic in Australia primarily in remote communities in Queensland, the Northern Territory, and Western Australia. Other cases in Australia have occurred in immigrants and refugees, returned travellers, and Australian Defence Force personnel. HTLV-I infection is lifelong with no known cure. Strongyloidiasis is a long-term chronic disease that can remain latent for decades, as shown by infections diagnosed in prisoners of war from World War II and the Vietnam War testing positive decades after they returned from these conflicts. This review aims to shed light on concomitant infections of HTLV-I with S. stercoralis primarily in Australia but in the global context as well.
Collapse
Affiliation(s)
- Catherine A Gordon
- Infectious Diseases Program, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia.
| | - Jennifer M Shield
- Department of Pharmacy and Biomedical Sciences, La Trobe University, Bendigo, VIC, Australia; Department of Medicine, The Peter Doherty Institute for Infection and Immunity, University of Melbourne and the Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Richard S Bradbury
- School of Health and Life Sciences, Federation University, Berwick, VIC, Australia
| | - Stephen Muhi
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Wendy Page
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
| | - Jenni A Judd
- School of Health Medical and Applied Sciences, Central Queensland University, Bundaberg, QLD, Australia; Centre for Indigenous Health Equity Research, Central Queensland University, Bundaberg, QLD, Australia
| | - Rogan Lee
- Westmead Clinical School, The University of Sydney, Westmead, NSW, Australia
| | - Beverley-Ann Biggs
- Department of Medicine, The Peter Doherty Institute for Infection and Immunity, University of Melbourne and the Royal Melbourne Hospital, Melbourne, VIC, Australia; Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Kirstin Ross
- College of Science and Engineering, Flinders University, Adelaide, South Australia, Australia
| | - Johanna Kurscheid
- Department of Global Health, Research School of Population Health, Australian National University, Acton, ACT, Australia
| | - Darren J Gray
- Department of Global Health, Research School of Population Health, Australian National University, Acton, ACT, Australia
| | - Donald P McManus
- Infectious Diseases Program, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| |
Collapse
|
7
|
Strongyloides stercoralis, Human T-cell Lymphotropic Virus Type-1 and Cytomegalovirus Coinfection in an Allogeneic Hematopoietic Stem-Cell Transplant Recipient. Transplant Direct 2020; 6:e573. [PMID: 32766428 PMCID: PMC7339139 DOI: 10.1097/txd.0000000000001021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/04/2020] [Accepted: 05/14/2020] [Indexed: 11/26/2022] Open
|
8
|
Bhasin A, Yura E, Boyd D, Kuksuk L, Flaherty JP. Case Report: Incidentally Discovered Strongyloides stercoralis Infection after Urinary Diversion. Am J Trop Med Hyg 2020; 102:1396-1398. [PMID: 32228779 PMCID: PMC7253084 DOI: 10.4269/ajtmh.19-0956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/20/2020] [Indexed: 11/07/2022] Open
Abstract
Strongyloidiasis is a disease caused by the parasite Strongyloides stercoralis in humans. We present a case of incidentally discovered Strongyloides urinary tract infection in a patient in whom there was a urologic surgery consisting of urinary diversion created by self-bowel transplantation and conduit creation. Historical review demonstrated eosinophilia before surgery and detection of the parasite. Social review demonstrated endemic exposure. Our patient's case was differentiated from hyperinfection by the presence of rhabditiform larvae, and not filariform larvae, in the urine, suggesting localized small bowel infection was transferred to the urinary tract secondary to the creation of the ileal loop conduit. This patient's clinical course improved with antibiotic treatment of the bacterial infectious complications of surgery and resolution of Strongyloides infection with ivermectin. To our knowledge, this is the first case of Strongyloides infection of the urinary tract secondary to ileal loop conduit creation and not as a result of hyperinfection.
Collapse
Affiliation(s)
- Ajay Bhasin
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Emily Yura
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Darren Boyd
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Linda Kuksuk
- Department of Microbiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - John P. Flaherty
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
9
|
Lowe RC, Chu JN, Pierce TT, Weil AA, Branda JA. Case 3-2020: A 44-Year-Old Man with Weight Loss, Diarrhea, and Abdominal Pain. N Engl J Med 2020; 382:365-374. [PMID: 31971683 DOI: 10.1056/nejmcpc1913473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Robert C Lowe
- From the Department of Medicine, Boston Medical Center (R.C.L.), the Department of Medicine, Boston University School of Medicine (R.C.L.), the Departments of Medicine (J.N.C., A.A.W.), Radiology (T.T.P.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Medicine (J.N.C., A.A.W.), Radiology (T.T.P.), and Pathology (J.A.B.), Harvard Medical School - all in Boston
| | - Jacqueline N Chu
- From the Department of Medicine, Boston Medical Center (R.C.L.), the Department of Medicine, Boston University School of Medicine (R.C.L.), the Departments of Medicine (J.N.C., A.A.W.), Radiology (T.T.P.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Medicine (J.N.C., A.A.W.), Radiology (T.T.P.), and Pathology (J.A.B.), Harvard Medical School - all in Boston
| | - Theodore T Pierce
- From the Department of Medicine, Boston Medical Center (R.C.L.), the Department of Medicine, Boston University School of Medicine (R.C.L.), the Departments of Medicine (J.N.C., A.A.W.), Radiology (T.T.P.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Medicine (J.N.C., A.A.W.), Radiology (T.T.P.), and Pathology (J.A.B.), Harvard Medical School - all in Boston
| | - Ana A Weil
- From the Department of Medicine, Boston Medical Center (R.C.L.), the Department of Medicine, Boston University School of Medicine (R.C.L.), the Departments of Medicine (J.N.C., A.A.W.), Radiology (T.T.P.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Medicine (J.N.C., A.A.W.), Radiology (T.T.P.), and Pathology (J.A.B.), Harvard Medical School - all in Boston
| | - John A Branda
- From the Department of Medicine, Boston Medical Center (R.C.L.), the Department of Medicine, Boston University School of Medicine (R.C.L.), the Departments of Medicine (J.N.C., A.A.W.), Radiology (T.T.P.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Medicine (J.N.C., A.A.W.), Radiology (T.T.P.), and Pathology (J.A.B.), Harvard Medical School - all in Boston
| |
Collapse
|
10
|
La Hoz RM, Morris MI. Intestinal parasites including Cryptosporidium, Cyclospora, Giardia, and Microsporidia, Entamoeba histolytica, Strongyloides, Schistosomiasis, and Echinococcus: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13618. [PMID: 31145496 DOI: 10.1111/ctr.13618] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 05/20/2019] [Indexed: 01/08/2023]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of intestinal parasites in the pre- and post-transplant period. Intestinal parasites are prevalent in the developing regions of the world. With increasing travel to and from endemic regions, changing immigration patterns, and the expansion of transplant medicine in developing countries, they are increasingly recognized as a source of morbidity and mortality in solid-organ transplant recipients. Parasitic infections may be acquired from the donor allograft, from reactivation, or from de novo acquisition post-transplantation. Gastrointestinal multiplex assays have been developed; some of the panels include testing for Cryptosporidium, Cyclospora, Entamoeba histolytica, and Giardia, and the performance is comparable to conventional methods. A polymerase chain reaction test, not yet widely available, has also been developed to detect Strongyloides in stool samples. New recommendations have been developed to minimize the risk of Strongyloides donor-derived events. Deceased donors with epidemiological risk factors should be screened for Strongyloides and recipients treated if positive as soon as the results are available. New therapeutic agents and studies addressing the optimal treatment regimen for solid-organ transplant recipients are unmet needs.
Collapse
Affiliation(s)
- Ricardo M La Hoz
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michele I Morris
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | | |
Collapse
|
11
|
Malpica L, White AC, Leguia C, Freundt N, Barros N, Chian C, Antunez EA, Montes M. Regulatory T cells and IgE expression in duodenal mucosa of Strongyloides stercoralis and human T lymphotropic virus type 1 co-infected patients. PLoS Negl Trop Dis 2019; 13:e0007415. [PMID: 31170141 PMCID: PMC6581271 DOI: 10.1371/journal.pntd.0007415] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 06/18/2019] [Accepted: 04/28/2019] [Indexed: 12/20/2022] Open
Abstract
Background Strongyloides stercoralis is an intestinal nematode unique in its ability to replicate in the human host, allowing ongoing cycles of autoinfection, persisting for decades within the same host. Although usually asymptomatic, overwhelming infections can occur in Strongyloides and HTLV-1 co-infected individuals (SS/HTLV-1). Regulatory T cells (Tregs) are able to blunt specific Th2 responses necessary to control the parasite. We previously reported that peripheral blood Tregs are increased in SS/HTLV-1 and correlate with low Th2 responses. We hypothesized that Tregs are also increased at the site of infection in duodenal mucosa. Methods Paraffin embedded duodenal biopsies were obtained from 10 SS/HTLV-1 patients, 3 controls with non-parasitic chronic duodenitis, and 2 healthy controls. Immunohistochemistry was performed using monoclonal antibodies against human CD3, CD8, IgE and FoxP3. The number of cells were counted using a conventional light microscope. The number of CD3+, CD8+, FoxP3+ and IgE positive cells per 0.35 mm2 was measured using ImagePro Plus software comparing areas adjacent or distant from parasite material. Results In patients with SS/HTLV-1, T lymphocyte counts and CD8+ cells were lower in areas adjacent to the parasite compared to non-adjacent areas (CD3+: adjacent: 6.5 [Interquartile range (IQR: 2.8–12.3)]; non-adjacent: 24.5 [IQR: 20.9–34.4]; Mann-Whitney p = 0.0003; CD8+: adjacent: 4.5 [IQR: 2.3–11.8]; non-adjacent: 21 [IQR: 15.3–42.9]; Mann-Whitney p = 0.0011). Tregs cells in the intestines (FoxP3+ expressing cells) were increased in patients with SS/HTLV-1 compared with patients with chronic duodenitis (SS/HTLV-1: 1.5 [IQR: 0.7–2.3]; duodenitis controls: 0 [range 0–0.7]; healthy controls: 0; Mann-Whitney p = 0.034). There was also a trend towards fewer eosinophils adjacent to the parasites. Among SS/HTLV-1 patients the number of IgE expressing cells was increased for in areas not adjacent to the parasite compared to non-adjacent areas (ANOVA, p = 0.001). Conclusions Our data shows increased Treg cell numbers localized adjacent to the parasites in the duodenum SS/HTLV-1 patients. In addition, other T lymphocytes and IgE expressing cells were decreased adjacent to the parasites, suggesting an important role for Tregs in down-regulating local parasite effector responses. Strongyloidiasis is a parasitic infection found worldwide in warm, moist climates. In most people, Strongyloides causes a mild and chronic infection with few symptoms. However, some patients, including those infected with the Human T Lymphotrophic Virus 1 (HTLV-1), can get uncontrolled disease called hyperinfection, which can be fatal. To help determine why this infection is so serious in co-infected patients, we studied biopsies obtained from the small intestine from patients with both infections and compared them to control biopsies. The biopsies from patients with both Strongyloides and HTLV-1 had increased numbers of white blood cells in their biopsies. In particular they displayed a type of lymphocyte that downregulates immune responses. Some of them had increased numbers of cells called eosinophils in the intestines. These cells can help eliminate Strongyloides. However, they were not found near the parasite, suggesting that something near the parasite was suppressing the host response that would control infection. These studies provide more evidence that HTLV-1 suppresses the host response that controls Strongyloides and that the suppression occurs at the site of infection in the small intestines.
Collapse
Affiliation(s)
- Luis Malpica
- Instituto de Medicina Tropical ‘Alexander von Humboldt’, Facultad de Medicina “Alberto Hurtado”, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - A. Clinton White
- Instituto de Medicina Tropical ‘Alexander von Humboldt’, Facultad de Medicina “Alberto Hurtado”, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Internal Medicine, Division of Infectious Diseases, University of Texas Medical Branch at Galveston, Texas, United States of America
| | - Cristina Leguia
- Instituto de Medicina Tropical ‘Alexander von Humboldt’, Facultad de Medicina “Alberto Hurtado”, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Natalia Freundt
- Instituto de Medicina Tropical ‘Alexander von Humboldt’, Facultad de Medicina “Alberto Hurtado”, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Nicolas Barros
- Instituto de Medicina Tropical ‘Alexander von Humboldt’, Facultad de Medicina “Alberto Hurtado”, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Cesar Chian
- Instituto de Medicina Tropical ‘Alexander von Humboldt’, Facultad de Medicina “Alberto Hurtado”, Universidad Peruana Cayetano Heredia, Lima, Peru
- Departamento de Patología, Hospital Nacional Arzobispo Loayza in Lima, Peru
| | - E. Antonio Antunez
- Instituto de Medicina Tropical ‘Alexander von Humboldt’, Facultad de Medicina “Alberto Hurtado”, Universidad Peruana Cayetano Heredia, Lima, Peru
- Departamento de Patología, Hospital Nacional Arzobispo Loayza in Lima, Peru
| | - Martin Montes
- Instituto de Medicina Tropical ‘Alexander von Humboldt’, Facultad de Medicina “Alberto Hurtado”, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Internal Medicine, Division of Infectious Diseases, University of Texas Medical Branch at Galveston, Texas, United States of America
- * E-mail:
| |
Collapse
|
12
|
Yeung SHM, Mourad O, Klowak M, Showler AJ, Klowak S, Boggild AK. Implementation and evaluation of a quality and safety tool for ambulatory strongyloidiasis patients at high risk of adverse outcome. TROPICAL DISEASES TRAVEL MEDICINE AND VACCINES 2019; 5:3. [PMID: 30988956 PMCID: PMC6448213 DOI: 10.1186/s40794-019-0080-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/26/2019] [Indexed: 01/20/2023]
Abstract
Background Strongyloidiasis is a common infection in Canadian migrants that can cause life-threatening hyperinfection in immunosuppressed hosts. We designed and implemented a safety tool to guide management of patients with Strongyloides in order to prevent adverse outcomes. Methods: Patients treated at our centre for strongyloidiasis from January 1, 2013 to December 31, 2015 were identified through our ivermectin access log. Patients were categorized into pre-implementation and post-implementation groups. A retrospective chart review for predefined variables was conducted. Results Of 37 patients with strongyloidiasis, 26 were in the pre-implementation group and 11 were in the post-implementation group. Documented seroreversion (positive to negative) occurred in 42.1% of patients pre-implementation and 62.5% of patients post-implementation (p = 0.420). Documented stool clearance occurred in 80.0% of patients pre-implementation and 100.0% of patients post-implementation (p = 1.000). More patients were screened for HTLV-1 coinfection post-implementation (80.0%) versus pre-implementation (30.8%) (p = 0.011). Loss to follow-up after treatment occurred in 23.1% of patients pre-implementation and 20.0% of patients post-implementation (p = 1.000). Conclusions The safety tool may be useful in the treatment of patients with strongyloidiasis to improve documentation of patient outcomes and standardize care. Future research should include a powered prospective study. Electronic supplementary material The online version of this article (10.1186/s40794-019-0080-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Sabrina H M Yeung
- 1University of Toronto, 27 King's College Circle, Toronto, Ontario M5S1A1 Canada
| | - Omar Mourad
- 2Western University, 1151 Richmond Street, London, Ontario N6A 3K7 Canada
| | - Michael Klowak
- 3McMaster University, 1280 Main Street West, Hamilton, Ontario L8S4L8 Canada
| | - Adrienne J Showler
- 4Georgetown University, 3800 Reservoir Rd NW, Washington, DC 20007 USA.,5Tropical Disease Unit, Toronto General Hospital, 200 Elizabeth Street 13EN-218, Toronto, Ontario M5G2C4 Canada
| | - Stefanie Klowak
- 5Tropical Disease Unit, Toronto General Hospital, 200 Elizabeth Street 13EN-218, Toronto, Ontario M5G2C4 Canada
| | - Andrea K Boggild
- 1University of Toronto, 27 King's College Circle, Toronto, Ontario M5S1A1 Canada.,5Tropical Disease Unit, Toronto General Hospital, 200 Elizabeth Street 13EN-218, Toronto, Ontario M5G2C4 Canada.,6Public Health Ontario Laboratory, 661 University Avenue, Toronto, Ontario M5G1M1 Canada.,7Department of Medicine, University of Toronto, Toronto, Canada
| |
Collapse
|
13
|
Vasquez-Rios G, Pineda-Reyes R, Pineda-Reyes J, Marin R, Ruiz EF, Terashima A. Strongyloides stercoralis hyperinfection syndrome: a deeper understanding of a neglected disease. J Parasit Dis 2019; 43:167-175. [PMID: 31263320 DOI: 10.1007/s12639-019-01090-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 01/23/2019] [Indexed: 12/22/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- George Vasquez-Rios
- 1Laboratory of Parasitology, Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Roberto Pineda-Reyes
- 1Laboratory of Parasitology, Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Juan Pineda-Reyes
- 2Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Ricardo Marin
- 2Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Eloy F Ruiz
- 1Laboratory of Parasitology, Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Angélica Terashima
- 1Laboratory of Parasitology, Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru.,2Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
| |
Collapse
|
14
|
Reddy PR, Thomas SM, Rajalakshmi A, Vijayan D, Raman M. A Rare Case of Strongyloides Hyperinfection from Hypogammaglobulinemia. Indian J Crit Care Med 2017; 21:466-468. [PMID: 28808370 PMCID: PMC5538098 DOI: 10.4103/ijccm.ijccm_139_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Strongyloides infection can range from asymptomatic eosinophilia to disseminated disease. Common in tropical and subtropical nations, it can lead to hyperinfection, an autoinfection increasing parasitic burden in immunocompromised. Cell-mediated immunity is important in combating parasite infection. We present a case of Strongyloides hyperinfection in hypogammaglobulinemia which was refractory to conventional treatment but responded to immunoglobulin administration with complete resolution indicating role of humoral immunity also.
Collapse
Affiliation(s)
- Paidi Ramakrishna Reddy
- Department of Critical Care, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Sujith M Thomas
- Department of Critical Care, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - A Rajalakshmi
- Department of Internal Medicine, Division of Infectious Disease, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Deepak Vijayan
- Department of Critical Care, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Muraleedharan Raman
- Department of Critical Care, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| |
Collapse
|
15
|
Luvira V, Watthanakulpanich D, Pittisuttithum P. Management of Strongyloides stercoralis: a puzzling parasite. Int Health 2014; 6:273-81. [DOI: 10.1093/inthealth/ihu058] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
|
16
|
Salles F, Bacellar A, Amorim M, Orge G, Sundberg M, Lima M, Santos S, Porto A, Carvalho E. Treatment of strongyloidiasis in HTLV-1 and Strongyloides stercoralis coinfected patients is associated with increased TNFα and decreased soluble IL2 receptor levels. Trans R Soc Trop Med Hyg 2014; 107:526-9. [PMID: 23843560 DOI: 10.1093/trstmh/trt052] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Human T cell lymphotropic virus type 1 (HTLV-1) infection has been associated with recurrent and disseminated strongyloidiasis and adult T cell leukemia/lymphoma (ATLL). METHODS We compared immunological aspects and markers for ATLL in HTLV-1 patients with or without strongyloidiasis, and evaluated the influence of Strongyloides stercoralis treatment on the immune response and clinical outcomes of HTLV-1 infection. RESULTS Levels of TNFα and IFNγ were lower in patients coinfected with HTLV-1 and S. stercoralis than in patients with HTLV-1 only (p < 0.05), and there was an increase in TNFα levels after anthelmintic treatment. Levels of sIL-2R were higher in patients with HTLV-1 coinfected with S. stercoralis and anthelmintic treatment decreased sIL-2R levels (p < 0.05). The one patient who developed ATLL was coinfected with S. stercoralis. CONCLUSION These data show that helminthic infection has a modulatory role in HTLV-1 infection and that S. stercoralis may be a cofactor in the development of ATLL.
Collapse
Affiliation(s)
- Fernanda Salles
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, Brazil
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Naves MM, Costa-Cruz JM. High prevalence of Strongyloides stercoralis infection among the elderly in Brazil. Rev Inst Med Trop Sao Paulo 2014; 55:309-13. [PMID: 24037284 PMCID: PMC4105067 DOI: 10.1590/s0036-46652013000500003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 02/20/2013] [Indexed: 11/22/2022] Open
Abstract
Little is known about the frequency of intestinal parasites in the elderly due to a lack of attention given to the occurrence of these infections among older adults. This study compares the frequency of Strongyloides stercoralis and other enteroparasites between elderly living in nursing homes (n = 100) and those noninstitutionalized (n = 100) from Uberlândia, state of Minas Gerais, southeastern Brazil, associated with data of epidemiological and socio-demographic conditions. Through coproparasitological examination of both groups, enteroparasites were detected in 15 of 200 individuals examined (7.5%; CI: 5.1- 9.9). S. stercoralis was the most frequent parasite 10/200 (5%; CI: 4.2-5.8), being significantly higher in males and in individuals with autonomy for daily living activities. There were no statistical differences in the prevalence of parasites between the two groups compared. In conclusion, S. stercoralis infection was highly prevalent in elderly patients and it does not depend on whether the individual was institutionalized or not.
Collapse
Affiliation(s)
- Maria Margarida Naves
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brasil
| | | |
Collapse
|
18
|
Einsiedel L, Spelman T, Goeman E, Cassar O, Arundell M, Gessain A. Clinical associations of Human T-Lymphotropic Virus type 1 infection in an indigenous Australian population. PLoS Negl Trop Dis 2014; 8:e2643. [PMID: 24454973 PMCID: PMC3894183 DOI: 10.1371/journal.pntd.0002643] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 12/01/2013] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION In resource-poor areas, infectious diseases may be important causes of morbidity among individuals infected with the Human T-Lymphotropic Virus type 1 (HTLV-1). We report the clinical associations of HTLV-1 infection among socially disadvantaged Indigenous adults in central Australia. METHODOLOGY AND PRINCIPAL FINDINGS HTLV-1 serological results for Indigenous adults admitted 1(st) January 2000 to 31(st) December 2010 were obtained from the Alice Springs Hospital pathology database. Infections, comorbid conditions and HTLV-1 related diseases were identified using ICD-10 AM discharge morbidity codes. Relevant pathology and imaging results were reviewed. Disease associations, admission rates and risk factors for death were compared according to HTLV-1 serostatus. HTLV-1 western blots were positive for 531 (33.3%) of 1595 Indigenous adults tested. Clinical associations of HTLV-1 infection included bronchiectasis (adjusted Risk Ratio, 1.35; 95% CI, 1.14-1.60), blood stream infections (BSI) with enteric organisms (aRR, 1.36; 95% CI, 1.05-1.77) and admission with strongyloidiasis (aRR 1.38; 95% CI, 1.16-1.64). After adjusting for covariates, HTLV-1 infection remained associated with increased numbers of BSI episodes (adjusted negative binomial regression, coefficient, 0.21; 95% CI, 0.02-0.41) and increased admission numbers with strongyloidiasis (coefficient, 0.563; 95% CI, 0.17-0.95) and respiratory conditions including asthma (coefficient, 0.99; 95% CI, 0.27-1.7), lower respiratory tract infections (coefficient, 0.19; 95% CI, 0.04-0.34) and bronchiectasis (coefficient, 0.60; 95% CI, 0.02-1.18). Two patients were admitted with adult T-cell Leukemia/Lymphoma, four with probable HTLV-1 associated myelopathy and another with infective dermatitis. Independent predictors of mortality included BSI with enteric organisms (aRR 1.78; 95% CI, 1.15-2.74) and bronchiectasis (aRR 2.07; 95% CI, 1.45-2.98). CONCLUSION HTLV-1 infection contributes to morbidity among socially disadvantaged Indigenous adults in central Australia. This is largely due to an increased risk of other infections and respiratory disease. The spectrum of HTLV-1 related diseases may vary according to the social circumstances of the affected population.
Collapse
Affiliation(s)
- Lloyd Einsiedel
- Flinders University/Northern Territory Rural Clinical School, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
- SAPathology, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia
- * E-mail:
| | - Tim Spelman
- Flinders University/Northern Territory Rural Clinical School, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Emma Goeman
- Remote Health, Alice Springs, Northern Territory, Australia
| | - Olivier Cassar
- Institut Pasteur, Unité d'Epidémiologie et Physiopathologie des Virus Oncogènes, Département de Virologie, Paris, France
- CNRS, UMR 3569, Paris, France
| | - Mick Arundell
- Clinical Information Analyst, Central Australian Health Network, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Antoine Gessain
- Institut Pasteur, Unité d'Epidémiologie et Physiopathologie des Virus Oncogènes, Département de Virologie, Paris, France
- CNRS, UMR 3569, Paris, France
| |
Collapse
|
19
|
Gillet NA, Cook L, Laydon DJ, Hlela C, Verdonck K, Alvarez C, Gotuzzo E, Clark D, Farré L, Bittencourt A, Asquith B, Taylor GP, Bangham CRM. Strongyloidiasis and infective dermatitis alter human T lymphotropic virus-1 clonality in vivo. PLoS Pathog 2013; 9:e1003263. [PMID: 23592987 PMCID: PMC3617147 DOI: 10.1371/journal.ppat.1003263] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 02/05/2013] [Indexed: 01/03/2023] Open
Abstract
Human T-lymphotropic Virus-1 (HTLV-1) is a retrovirus that persists lifelong by driving clonal proliferation of infected T-cells. HTLV-1 causes a neuroinflammatory disease and adult T-cell leukemia/lymphoma. Strongyloidiasis, a gastrointestinal infection by the helminth Strongyloides stercoralis, and Infective Dermatitis associated with HTLV-1 (IDH), appear to be risk factors for the development of HTLV-1 related diseases. We used high-throughput sequencing to map and quantify the insertion sites of the provirus in order to monitor the clonality of the HTLV-1-infected T-cell population (i.e. the number of distinct clones and abundance of each clone). A newly developed biodiversity estimator called “DivE” was used to estimate the total number of clones in the blood. We found that the major determinant of proviral load in all subjects without leukemia/lymphoma was the total number of HTLV-1-infected clones. Nevertheless, the significantly higher proviral load in patients with strongyloidiasis or IDH was due to an increase in the mean clone abundance, not to an increase in the number of infected clones. These patients appear to be less capable of restricting clone abundance than those with HTLV-1 alone. In patients co-infected with Strongyloides there was an increased degree of oligoclonal expansion and a higher rate of turnover (i.e. appearance and disappearance) of HTLV-1-infected clones. In Strongyloides co-infected patients and those with IDH, proliferation of the most abundant HTLV-1+ T-cell clones is independent of the genomic environment of the provirus, in sharp contrast to patients with HTLV-1 infection alone. This implies that new selection forces are driving oligoclonal proliferation in Strongyloides co-infection and IDH. We conclude that strongyloidiasis and IDH increase the risk of development of HTLV-1-associated diseases by increasing the rate of infection of new clones and the abundance of existing HTLV-1+ clones. HTLV-1 is a human retrovirus estimated to infect 20 million people world-wide and is causing in a small proportion of the infected individuals an inflammatory disease or a leukemia/lymphoma. HTLV-1 persists lifelong by driving clonal proliferation of infected T-cells. Strongyloidiasis, a gastrointestinal infection by an helminth (Strongyloides stercoralis) and Infective Dermatitis associated with HTLV-1 (IDH), a skin inflammation with bacterial infection, appear to increase the risk of developing HTLV-1-related diseases. It is well known that the chance of developing HTLV-1-related diseases increases with the number of cells infected by the virus (also called proviral load). It is also known that HTLV-1-infected individuals co-infected by Strongyloides or affected by IDH have a higher proviral load, but the mechanism is still unclear. Consequently, the aim of this study was to test if co-infection increases the total number and/or the abundance (or size) of HTLV-1-infected T-cell clones. We have shown that the significantly increased proviral load in HTLV-1-infected individuals with IDH or strongyloidiasis is due to an increase in the mean clone abundance (bigger clones), not to an increase in the number of infected clones. These patients appear to be less capable of restricting clone abundance than those with HTLV-1 alone.
Collapse
Affiliation(s)
- Nicolas A. Gillet
- Section of Immunology, Wright-Fleming Institute, Imperial College London, London, United Kingdom
- Molecular and Cellular Epigenetics, Interdisciplinary Cluster for Applied Genoproteomics (GIGA) of University of Liège (ULg), Liège, Belgium
- * E-mail: (NAG); (CRMB)
| | - Lucy Cook
- Section of Immunology, Wright-Fleming Institute, Imperial College London, London, United Kingdom
| | - Daniel J. Laydon
- Section of Immunology, Wright-Fleming Institute, Imperial College London, London, United Kingdom
| | - Carol Hlela
- Section of Immunology, Wright-Fleming Institute, Imperial College London, London, United Kingdom
| | - Kristien Verdonck
- Instituto de Medicina Tropical Alexander von Humboldt and Hospital Nacional Cayetano Heredia, Universidad Peruana Cayetano Heredia, Lima, Peru
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Carolina Alvarez
- Instituto de Medicina Tropical Alexander von Humboldt and Hospital Nacional Cayetano Heredia, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Eduardo Gotuzzo
- Instituto de Medicina Tropical Alexander von Humboldt and Hospital Nacional Cayetano Heredia, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Daniel Clark
- Instituto de Medicina Tropical Alexander von Humboldt and Hospital Nacional Cayetano Heredia, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Lourdes Farré
- Laboratory of Experimental Pathology, Oswaldo Cruz Foundation, Salvador, Bahia, Brazil
| | - Achiléa Bittencourt
- Complexo Hospitalar Universitário Prof. Edgard Santos, Department of Pathology, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Becca Asquith
- Section of Immunology, Wright-Fleming Institute, Imperial College London, London, United Kingdom
| | - Graham P. Taylor
- Section of Infectious Diseases, Wright-Fleming Institute, Imperial College London, London, United Kingdom
| | - Charles R. M. Bangham
- Section of Immunology, Wright-Fleming Institute, Imperial College London, London, United Kingdom
- * E-mail: (NAG); (CRMB)
| |
Collapse
|
20
|
Báez-Vallecillo L, Stewart BD, Kott MM, Bhattacharjee M. Strongyloides hyperinfection as a mimic of inflammatory bowel disease. Am J Gastroenterol 2013; 108:622-3. [PMID: 23552316 DOI: 10.1038/ajg.2012.456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
21
|
Sultana Y, Gilbert GL, Ahmed BN, Lee R. Strongyloidiasis in a high risk community of Dhaka, Bangladesh. Trans R Soc Trop Med Hyg 2012; 106:756-62. [PMID: 23084030 DOI: 10.1016/j.trstmh.2012.08.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 08/29/2012] [Accepted: 08/29/2012] [Indexed: 11/28/2022] Open
Abstract
Residents of a slum community of Dhaka city, Bangladesh were tested by serological and faecal examination for evidence of Strongyloides stercoralis infection. In stool specimens from a total of 147 participants Strongyloides larvae were found in 34 (23.1%) by Harada-Mori culture, 15 (10.2%) by agar plate culture (APC) and one (0.7%) by microscopy. Strongyloides IgG, IgG1 and IgG4 antibodies were found in 90 (61.2%), 46 (31.3%) and 53 (36.1%) of participants, respectively. A positive correlation was observed between total IgG levels and the presence of isotypes IgG1 and IgG4 (p<0.001). Six sera (4.0%) reacted to the recombinant filaria antigen Bm 14, three of which were Strongyloides IgG positive. This indicates either there is cross reactivity or some participants are co-infected with lymphatic filariasis. No correlations were found between positive serology and Strongyloides infection in stool, socio- demographic factors or domestic hygienic practices. However, positive stool cultures showed significant associations with irregular nail trimming, walking bare-foot and irregular hand washing after defecation (p<0.05). Other enteric parasites were detected in stools of some participants but their presence showed no correlation with S. stercoralis infection or socio demographic factors. This study confirms that squatters in this slum community in Dhaka have a high prevalence of S. stercoralis infection identified both by serological and coprological methods.
Collapse
Affiliation(s)
- Yasmin Sultana
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, Westmead Hospital, Westmead, NSW, Australia.
| | | | | | | |
Collapse
|
22
|
Abstract
SUMMARYHuman strongyloidiasis is a neglected tropical disease with global distribution and this infection is caused by the parasitic nematodeStrongyloides stercoralis. The aim of this study was to determine the prevalence of strongyloidiasis in Dhaka, Bangladesh. Sera from 1004 residents from a slum (group A) and 299 from city dwellers (group B) were tested for total IgG and IgG subclasses toStrongyloidesantigen. There was a significant difference (P < 0·001) in IgG seroprevalence between group A (22%) and group B (5%). Reactive IgG subclasses (IgG1 and IgG4) were also higher in group A (P < 0·05). The seroprevalence of strongyloidiasis in group A increased with age but was unrelated to sex. The presence of reactive IgG toStrongyloidesantigen had no correlation with either socio-economic or personal hygiene factors. However, a history of diarrhoea in a family member, in the past 6 months, but not in the respondents was associated with detection of antibodies toS. stercoralis(P < 0·01). None of the sera from either group had an HTLV-I reaction. This study demonstrates that strongyloidiasis is prevalent in Dhaka, especially among slum dwellers, but concurrent infection with HTLV-I was not found. Future epidemiological studies should identify individual risk factors and other communities at risk so that appropriate interventions can be planned.
Collapse
|
23
|
Pays JF. [Combined infection with HTLV-1 and Strongyloides stercoralis]. BULLETIN DE LA SOCIETE DE PATHOLOGIE EXOTIQUE (1990) 2011; 104:188-99. [PMID: 21800110 DOI: 10.1007/s13149-011-0175-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 05/31/2011] [Indexed: 10/17/2022]
Abstract
Infection of carriers of strongyloides by the human oncogenic retrovirus HTLV-1 significantly augments the number of larval parasites in the stools and impairs the action of anti-helminthic agents, resulting in an increase in immediate and longer term failure of therapy. The proliferation of cytokine type 1 secreting lymphocytes, the preferred target for viral infection, shifts the Th1/Th2 balance in favour of a Th1 response with a consequent increase in the production of gamma interferon (INF-γ). In addition to other effects, this causes a decrease in the secretion of cytokines IL-4, IL-5 and IL-13, which results in substantial reduction in total and specific IgE; failure of activation of eosinophils or stagnation in or reduction of their numbers; and an increased risk of development of a severe form of strongyloidiasis. This risk is clearly correlated with the level of anti-HTLV-1 antibodies and the amplitude of the proviral load of peripheral lymphocytes. The polyclonal expansion of infected CD4 cells might be partly due to the activation of the IL-2/IL-2R system by parasite antigens together with the action of the virus type 1 Tax protein. The fact that adult T cell leukaemia arises significantly earlier and more often in individuals with combined infection is an argument in favour of the parasite's role as a leukaemogenic co-factor. In practice it is, therefore, appropriate to initiate all available measures to eliminate parasites from co-infected hosts although this does present difficulties, and one should not reject the possibility of a diagnosis of strongyloidiasis in the absence of hypereosinophilia. In all cases of chronic strongyloidiasis without hypereosinophilia, co-infection with HTLV-1 should be looked for routinely. The same applies to carriers of strongyloides with repeated treatment failures. Finally, corticosteroids and immunosuppressants should be used only with care in HTLV-1-positive patients who seem not to be co-infected, even if they have received precautionary therapy.
Collapse
Affiliation(s)
- J-F Pays
- Faculté de médecine Descartes-Necker, Université Paris-V-René-Descartes, Paris, France.
| |
Collapse
|
24
|
Domínguez-Castellano A, Molina Gil-Bermejo J. [34-year old sub-saharan male with epigastralgia and vomits for five months evolution]. Med Clin (Barc) 2011; 136:447-53. [PMID: 21145079 DOI: 10.1016/j.medcli.2010.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 10/01/2010] [Accepted: 10/05/2010] [Indexed: 11/30/2022]
|
25
|
Marcos LA, Terashima A, Canales M, Gotuzzo E. Update on strongyloidiasis in the immunocompromised host. Curr Infect Dis Rep 2011; 13:35-46. [PMID: 21308453 DOI: 10.1007/s11908-010-0150-z] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Immunocompromised persons are the most vulnerable population at risk for developing life-threatening clinical syndromes associated with strongyloidiasis, such as hyperinfection syndrome (HS) or dissemination. This review focuses on describing Strongyloides infection in the immunocompromised host, including immune response against this infection, analyzing the cases with HS published during the past 4 years in the United States, and describing the most sensitive diagnostic tools and the most effective treatment for each clinical syndrome. Strongyloidiasis is becoming an important parasitic disease in the United States, especially in the immunocompromised immigrant population. Because the transplant population is particularly at risk for developing HS, both recipients and donors should be screened for Strongyloides. Clinicians should also be aware that the development of HS can follow unexpectedly a few days after appropriate anthelminthic therapy. Highly sensitive screening tests are still not available in the major tertiary medical centers. Parenteral ivermectin has been used in some severe cases. Further therapy developments and improving diagnostic tools are warranted.
Collapse
Affiliation(s)
- Luis A Marcos
- Infectious Diseases Division, Internal Medicine Department, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO, 63110, USA,
| | | | | | | |
Collapse
|
26
|
Fusco DN, Downs JA, Satlin MJ, Pahuja M, Ramos L, Barie PS, Fleckenstein L, Murray HW. Non-oral treatment with ivermectin for disseminated strongyloidiasis. Am J Trop Med Hyg 2010; 83:879-83. [PMID: 20889884 DOI: 10.4269/ajtmh.2010.10-0258] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Critically ill patients with disseminated strongyloidiasis may not be candidates for oral treatment. We report four patients with disseminated strongyloidiasis, believed to be unable to absorb oral therapy, who were treated with ivermectin by rectal and/or subcutaneous administration. Obtaining subcutaneous ivermectin and dosing it appropriately is a challenge. These cases underscore the need for improved access to subcutaneous ivermectin and more pharmacological data to guide use of this treatment approach.
Collapse
Affiliation(s)
- Dahlene N Fusco
- Division of Infectious Diseases, and Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, USA.
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Santiago M, Leitão B. Prevention of strongyloides hyperinfection syndrome: a rheumatological point of view. Eur J Intern Med 2009; 20:744-8. [PMID: 19892301 DOI: 10.1016/j.ejim.2009.09.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 08/30/2009] [Accepted: 09/04/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND Strongyloides stercoralis (S.stercoralis) is a parasite that infects humans and in conditions of immunodeficiency may disseminate, causing the potentially fatal strongyloides hyperinfection syndrome (SHS). The aim of this review was to investigate the literature evidence on the prophylaxis of SHS in immunosuppressed patients with rheumatological disorders. MATERIAL AND METHODS The MEDLINE database (from 1966 to 2008) was searched using the following terms: "strongyloidiasis", "disseminated strongyloidiasis", "Strongyloides stercoralis", "Strongyloides stercoralis dissemination", "strongyloides hyperinfection syndrome", "treatment", "prophylaxis", "prevention", "immunocompromised", "immunodepression", "immunosuppressed", "immunosuppression", "corticosteroids", "glucocorticoids", "lupus erythematosus", "rheumatoid arthritis", "rheumatic diseases". A search of the therapeutic studies using the same set of terms was carried out. RESULTS No study on the prophylaxis of SHS restricted to rheumatic immunosuppressed patients was identified. However, two articles have been published on the prophylaxis of strongyloidiasis in other immunosuppressed patients. Additionally, 13 studies dealing with different therapeutical options for strongyloidiasis were identified and presented. CONCLUSIONS Since there is no evidence on the prophylaxis of SHS in immunosuppressed rheumatic patients, the suggested regimen for that prophylaxis may rely on the results obtained from therapeutical studies. Ivermectin has the best safety profile, lower cost and best efficacy and should be the drug of choice for the prophylaxis of SHS in such patients. Although a definitive prophylactic regimen has not been defined, the option for 200 microg/kg/day for 2 days, repeated within 2 weeks, seems to be a reasonable approach. Such regimen should be repeated every 6 months in case of persisting immunosuppression in permanent residents of endemic areas.
Collapse
|
28
|
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.
Collapse
Affiliation(s)
- Luis A Marcos
- Internal Medicine Department, University of Texas Health Science, 6431 Fannin Street, Suite 1.150, Houston, TX 77030, USA.
| | | | | | | |
Collapse
|
29
|
Cooper PJ, Ayre G, Martin C, Rizzo JA, Ponte EV, Cruz AA. Geohelminth infections: a review of the role of IgE and assessment of potential risks of anti-IgE treatment. Allergy 2008; 63:409-17. [PMID: 18315729 DOI: 10.1111/j.1398-9995.2007.01601.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Geohelminth infections are major parasitic infections with a worldwide distribution. Immunoglobulin E (IgE) is considered to play a central role in protective immunity against these parasites although the evidence from experimental animal models infected with helminth parasites and treated with anti-IgE antibodies and from observational studies in human populations of the immunologic correlates of protective immunity against helminths do not support a critical role for IgE in mediating protection against helminths. Anti-IgE treatment of human allergic disorders using a humanized monoclonal IgE antibody (omalizumab, Xolair) has been approved for clinical use in the USA and Europe and there is concern that this treatment may be associated with increased morbidity in populations exposed to helminth infections. A recently published randomized controlled trial investigating the risk of geohelminth infections in allergic patients receiving omalizumab in Brazil has provided some evidence that omalizumab may not be associated with increased morbidity attributable to these parasites. This review examines the evidence for a role of IgE in protective immunity against helminth parasites, discusses the findings of the randomized controlled trial, assesses the potential risks and provides recommendations for anti-IgE treatment in groups of allergic patients with different exposure risks for helminth infections.
Collapse
Affiliation(s)
- P J Cooper
- Laboratorio de Investigaciones extensión Quinindé, Hospital Pedro Vicente Maldonado, Pichincha Province, Ecuador
| | | | | | | | | | | |
Collapse
|
30
|
Chan JFW, Choy BY, Lai KN. Nephrotic Syndrome Secondary to Strongyloidiasis: A Common Infection with an Uncommon Presentation. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s1561-5413(08)60017-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
31
|
Verdonck K, González E, Van Dooren S, Vandamme AM, Vanham G, Gotuzzo E. Human T-lymphotropic virus 1: recent knowledge about an ancient infection. THE LANCET. INFECTIOUS DISEASES 2007; 7:266-81. [PMID: 17376384 DOI: 10.1016/s1473-3099(07)70081-6] [Citation(s) in RCA: 433] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Human T-lymphotropic virus 1 (HTLV-1) has infected human beings for thousands of years, but knowledge about the infection and its pathogenesis is only recently emerging. The virus can be transmitted from mother to child, through sexual contact, and through contaminated blood products. There are areas in Japan, sub-Saharan Africa, the Caribbean, and South America where more than 1% of the general population is infected. Although the majority of HTLV-1 carriers remain asymptomatic, the virus is associated with severe diseases that can be subdivided into three categories: neoplastic diseases (adult T-cell leukaemia/lymphoma), inflammatory syndromes (HTLV-1-associated myelopathy/tropical spastic paraparesis and uveitis among others), and opportunistic infections (including Strongyloides stercoralis hyperinfection and others). The understanding of the interaction between virus and host response has improved markedly, but there are still no clear surrogate markers for prognosis and there are few treatment options.
Collapse
Affiliation(s)
- Kristien Verdonck
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | | | | | | | | | | |
Collapse
|
32
|
Walker M, Zunt JR. Parasitic central nervous system infections in immunocompromised hosts. Clin Infect Dis 2005; 40:1005-15. [PMID: 15824993 PMCID: PMC2692946 DOI: 10.1086/428621] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2004] [Accepted: 11/28/2004] [Indexed: 11/03/2022] Open
Abstract
Immunosuppression due to therapy after transplantation or associated with HIV infection increases susceptibility to various central nervous system (CNS) infections. This article discusses how immunosuppression modifies the presentation, diagnosis, and treatment of selected parasitic CNS infections, with a focus on toxoplasmosis, Chagas disease, neurocysticercosis, schistosomiasis, and strongyloidiasis.
Collapse
Affiliation(s)
- Melanie Walker
- Department of Neurology, University of Washington School of Medicine, Seattle, USA
| | | |
Collapse
|
33
|
Safdar A, Malathum K, Rodriguez SJ, Husni R, Rolston KVI. Strongyloidiasis in patients at a comprehensive cancer center in the United States. Cancer 2004; 100:1531-6. [PMID: 15042689 DOI: 10.1002/cncr.20120] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The frequency of Strongyloides stercoralis infestation and complication in patients with cancer in the United States is unknown. METHODS The authors performed a retrospective analysis of S. stercoralis infection in patients who were undergoing cancer treatment at The University of Texas M. D. Anderson Cancer Center (Houston, TX). RESULTS The overall S. stercoralis infection frequency was approximately 1.0 per 10,000 new cancer cases between 1971 and 2003. Twenty-two of 25 patients (88%) were U.S. residents (19 from Texas; 1 each from Mississippi, Tennessee, and Puerto Rico), and the remaining 3 (13%) were from Latin America. Thirteen (52%) had solid-organ malignancies, whereas 12 (48%) had hematologic malignancies (lymphoma or multiple myeloma, n=8; leukemia, n=3; aplastic anemia, n=1). Twelve patients (48%) received systemic corticosteroids, 9 (36%) received antineoplastic therapy, and 2 underwent hematopoietic stem cell transplantation (HSCT). Diarrhea was reported in 13 patients (57%), and eosinophilia was observed in 11 patients (48%); 4 patients (16%) had probable hyperinfection syndrome (in 3 cases of polymicrobial gram-negative bacteremia, 1 patient had Klebsiella pneumoniae pneumonia, whereas 1 patient presented with K. pneumoniae lung infection alone). Evidence of definite pulmonary hyperinfection syndrome was observed in 2 HSCT recipients (8%). Fourteen (74%) of 19 patients responded to thiabendazole therapy. Two patients with definite pulmonary hyperinfection syndrome developed fatal S. stercoralis hemorrhagic alveolitis despite receiving high-dose thiabendazole plus ivermectin therapy. CONCLUSIONS In the current study, strongyloidiasis was uncommon in patients with cancer and remained localized in individuals with solid-organ malignancies. Definite pulmonary accelerated autoinfections were observed only in HSCT recipients. Therefore, pre-HSCT S. stercoralis screening in individuals from endemic regions of the United States warrants further study.
Collapse
Affiliation(s)
- Amar Safdar
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas M D Anderson Cancer Center, Houston, Texas 77030, USA.
| | | | | | | | | |
Collapse
|
34
|
|