Hyperinfection syndrome with Strongyloides stercoralis in malignant lymphoma

Strongyloides spp. and Cytomegalovirus Co-Infection in Patient Affected by Non-Hodgkin Lymphoma

To our knowledge, we have described the first case of Strongyloides/Cytomegalovirus (CMV) concomitant infection that occurred in a European country. The patient was a 76-year-old woman affected by relapsed non-Hodgkin lymphoma who presented interstitial pneumonia with a rapidly progressive worsening of respiratory insufficiency, leading to cardiac dysfunction and consequent death. CMV reactivation is a common complication in immunocompromised patients, while hyperinfection/disseminated strongyloidiasis (HS/DS) is rare in low endemic regions, but has been widely described in Southeast Asia and American countries. HS and DS are two consequences of the failure of infection control by the immune system: HS is the uncontrolled replication of the parasite within the host and DS the spreading of the L3 larvae in organs other than the usual replication sites. Only a few cases of HS/CMV infection have been reported in the literature, and only in one patient with lymphoma as an underlying disease. The clinical manifestations of these two infections overlap, usually leading to a delayed diagnosis and a consequent poor outcome.

Histopathological diagnosis of strongyloidiasis hyperinfection in Tunisian patient with hodgkin lymphoma: Case report

Introduction

Strongyloides stercoralis, an intestinal nematode, is commonly dispersed throughout the tropical and subtropical regions. Strongyloides stercoralis infection typically contributes to an asymptomatic chronic disease which can remain hidden for decades. However, in immunocompromised patients, the hyperinfection can take place, causing high mortality rates.

Case presentation

A 45 year-old Tunisian women, with heavy medical history, suffering of stage 3 classic Hodgkin lymphoma under treatment; presented with complaints of epigastric pain, nausea, vomiting. Gastroduodenoscopy showed duodenal and gastric erythematous and ulcerated mucosa. Histological assessment showed chronic infiltration with a large amount of eosinophils around numerous helminth forms identified as larvae of Strongyloides stercoralis.

Conclusion

Early detection of Strongyloides stercoralis infection in immunocompromised patients is life saving and avoids fatality caused by hyperinfection or systemic dissemination. Routine stool examination may be negative, so histopathological identification of the parasite in tissue sections provides the definite diagnosis.

Fatal septicemic shock associated with Strongyloides stercoralis infection in a patient with angioimmunoblastic T-cell lymphoma: a case report and literature review

INTRODUCTION

Strongyloides stercoralis infection can persist in the host for several decades, and patients with cancer and other clinical conditions who are exposed to immunosuppressive therapy are at risk of developing hyperinfection.

CASE REPORT

This is a case of angioimmunoblastic T-cell lymphoma (AITL) in a patient with lymphadenopathy and bulky neck mass. Severe sepsis and episodes of diarrhea were observed upon the first cycle of cyclophosphamide, doxorubicin, oncovin (vincristine) and prednisone (CHOP) regime chemotherapy preceded by high dose of dexamethasone. There was Klebsiella pneumoniae bacteremia and moderate eosinophilia. Rhabditiform S. stercoralis larvae were observed in the stool, and this was confirmed by real-time PCR. Strongyloides-specific IgG and IgG4 were also positive. The patient was treated with oral albendazole (400mg/day) for 3 days and intravenous tazocin (4.5gm/6 hours) for 5 days; however he succumbed following multi-organ failure.

CONCLUSION

This is likely a case of Strongyloides hyperinfection with secondary bacteremia.

Strongyloides stercoralis hyperinfection in a post-renal transplant patient

Strongyloides stercoralis is an intestinal nematode that is able to infect the host tissue and persist asymptomatic for many years through autoinfection. It causes life-threatening hyperinfection in immunocompromised hosts. This report describes a rare case of strongyloidiasis in a 40-year-old male following renal transplant, which was diagnosed by colonoscopic biopsy. The literature on the subject is also reviewed.

Strongyloides stercoralis infection and small intestinal lymphoma

A West Indian man who was infected with Strongyloides stercoralis developed small intestinal obstruction. Treatment with thiabendazole did not relieve the obstruction which was found at laparotomy to be due to a poorly differentiated small intestinal lymphoma. There was no blood eosinophilia or accumulation of eosinopohils in the sites of infection. There was no reaction in the skin to delayed hypersensitivity antigens and the blood T lymphocyte count and serum C3 levels were low. From these findings and a review of the literature it was concluded that the immune response in man to Strongyloides stercoralis may depend on T lymphocyte mediated reactions including granuloma formation, and mast cell and eosinophil responses in tissues. We suggest that the association of strongyloides hyperinfection and small bowel lymphoma in this patient may not have been fortuitous. The lymphoma may have led to a reduction in cellular immunity, with the subsequent development of strongyloides hyperinfection.

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.

Anguillulose sévère chez une hémodialysée chronique

INTRODUCTION

Strongyloidiasis can result in severe forms in immunodepressed patients or those treated with prolonged corticosteroids.

OBSERVATION

A 59 year-old woman suffering from chronic kidney failure, treated for the past year by haemodialysis, was hospitalized for alteration in her general status of health and severe digestive problems. Three parasitological examinations of the faeces revealed the presence of Strongyloides stercoralis larvae, although she had never spent time in the Tropics. The outcome was rapidly good following treatment with thiabendazole.

DISCUSSION

Some severe forms of strongyloidiasis occurring in immunodepressed or chronic dialysed patients can be fatal in the absence of early management.

Complicated and fatal Strongyloides infection in Canadians: risk factors, diagnosis and management

Strongyloidiasis, which is caused by the nematode Strongyloides stercoralis, is a common and persistent infection, particularly in developing countries. In the setting of compromised cellular immunity, it can result in fulminant dissemination with case-fatality rates of over 70%. The majority of new Canadian immigrants come from countries where Strongyloides is highly endemic; therefore, the burden of Strongyloides may be underappreciated in Canada. Because early diagnosis and therapy can have a marked impact on disease outcome, screening for this infection should be considered mandatory for patients who have a history of travel or residence in a disease-endemic area and risk factors for disseminated disease (e.g., corticosteroid use and human T-lymphotropic virus type I infection).

Strongyloides stercoralis in the Immunocompromised Population

Strongyloides stercoralis is an intestinal nematode of humans that infects tens of millions of people worldwide. S. stercoralis is unique among intestinal nematodes in its ability to complete its life cycle within the host through an asexual autoinfective cycle, allowing the infection to persist in the host indefinitely. Under some conditions associated with immunocompromise, this autoinfective cycle can become amplified into a potentially fatal hyperinfection syndrome, characterized by increased numbers of infective filariform larvae in stool and sputum and clinical manifestations of the increased parasite burden and migration, such as gastrointestinal bleeding and respiratory distress. S. stercoralis hyperinfection is often accompanied by sepsis or meningitis with enteric organisms. Glucocorticoid treatment and human T-lymphotropic virus type 1 infection are the two conditions most specifically associated with triggering hyperinfection, but cases have been reported in association with hematologic malignancy, malnutrition, and AIDS. Anthelmintic agents such as ivermectin have been used successfully in treating the hyperinfection syndrome as well as for primary and secondary prevention of hyperinfection in patients whose exposure history and underlying condition put them at increased risk.

Disseminated strongyloidiasis in a child with lymphoblastic lymphoma

PURPOSE

This report describes a case of disseminated strongyloidiasis in a child receiving chemotherapy for T-cell lymphoblastic lymphoma.

PATIENT AND METHODS

A 10-year-old boy became severely ill with disseminated strongyloidiasis 4 weeks after starting chemotherapy for T-cell lymphoblastic lymphoma. He responded to treatment with supportive care, antibiotics, and albendazole but required ivermectin to eradicate the strongyloides infection.

CONCLUSION

Disseminated strongyloidiasis is a severe, life-threatening complication of Strongyloides stercoralis infection that can occur in patients on immunosuppressive therapy, particularly when this therapy includes corticosteriods. In endemic areas, screening patients due to undergo immunosuppressive treatment and appropriate antistrongyloides treatment may be life saving. Ivermectin is the treatment of choice.

Disseminated strongyloidiasis with central nervous system involvement diagnosed antemortem in a patient with acquired immunodeficiency syndrome and Burkitts lymphoma

A 45-year-old man presented with central nervous system involvement as the initial manifestation of disseminated infection with Strongyloides stercoralis. Several concurrent clinical factors contributed to this event, all related to the patient's immunosuppression, including high-grade lymphoma, corticosteroid therapy, and acquired immunodeficiency syndrome. This is only the third case of CNS involvement in disseminated strongyloidiasis diagnosed antemortem.

Opportunistic Strongyloides stercoralis infection in lymphoma patients. Report of a case and review of the literature

Strongyloides stercoralis is an intestinal parasite that may cause fatal opportunistic infections in immunocompromised patients. Herein is reported a patient who developed fatal disseminated strongyloidiasis 6 weeks after the initiation of chemotherapy for a large cell lymphoma of the small intestine. After reviewing the clinical and epidemiologic features of 16 other cases of disseminated strongyloidiasis in patients with malignant lymphomas, the currently available laboratory methods for the diagnosis of this parasite are outlined. Because uncomplicated infections are treatable, candidates for chemotherapy or immunosuppression with a relevant geographic history should be screened for S. stercoralis prior to the initiation of the treatment.

[A case of strongloidiasis with hyperinfection syndrome]

A 73-year-old Korean male was admitted to Jeil hospital with clinical complaints of backache, cough, sputum, vomiting and diarrhea. He had a history of long term administration of prednisolone. At admission he was comatose and showed generalized pitting edema and anasarca. Laboratory data revealed leukocytosis, hyperproteinemia with hypoalbuminemia, sepsis, anemia and brown-colored urine. Stool examination revealed rhabditiform nematode larvae. By fecal cultivation, filariform larvae of Strogyloides were obtained and the patient was diagnosed as hyperinfection syndrome due to S. stercoralis infection. On the 3rd day of hospitalization, albendazole treatment was started and continued for 4 days. On the 7th dsy of hospitalization, sputum revealed filariform larvae. Total 619 parasitic adult females, expelled by chemotherapy, were collected from the diarrheal stool. However, the patient was discharged hopelessly and died at home.

[A case of hyperinfection syndrome with Strongyloides stercoralis]

A case of Strongyloides stercoralis infection wss experienced in a 73-year old Korean female patient, was hospitalized with relapse of cholecystitis. The patient developed cough and dyspnea 17 days after the admission. On the 27th hospitalized day, diarrhoea, nausea, vomiting and abdominal pain started. A number of parasitic larvae were incubated at 25 degrees C for 2 days. Typical fork tailed filariform larvae of S. stercoralis (Bavay, 1876) Stiles and Hassall, 1902, were identified after cultivation. There was no improvement of diarrhoea after the medication with mebendazole. After the administration of thiabendazole, however, diarrhoea was stopped. On the 6th day of medication, S. stercoralis larvae were no more detected, and thereafter no larva was observed by repeated stool examinations upto 2 months after chemotherapy. The patient had the history of administration of steroid for articular rheumatism. Therefore this case seems to be a hyperinfection of S. stercoralis due to an autoinfection and to be the first report on the hyperinfected strongyloidiasis in Korea. Related literature was briefly reviewed.

Subconjunctival corticosteroid therapy complicated by hyperinfective strongyloidiasis

A 57-year-old man was treated for a corneal ulcer with a penetrating keratoplasty, followed by six weeks of a regimen of 4 to 8 mg of dexamethasone injected subconjunctivally daily. Before therapy, he was clinically well and 10% eosinophils were noted on his differential white blood cell count. He developed a gastric peptic ulcer with hemorrhage and severe strongyloidiasis of the stomach and duodenum that worsened as the ulcer responded to medical therapy. The strongyloidiasis resulted in physiologic gastric outlet obstruction by decreasing gastrointestinal motility. There was evidence of hyperinvasive and disseminated strongyloidiasis, complicated by meningitis and Serratia marcescens bacteremia. He survived and received thiabendazole treatment for strongyloidiasis, which was successful. Subconjunctival corticosteroids caused a systemic effect that changed asymptomatic Strongyloides infection into hyperinvasive strongyloidiasis.

Reiter's syndrome, immunodepression and strongyloidiasis. Report of a fatal case

We present the case of a 52-year-old white male who showed arthritis, conjunctivitis and non-gonococcal urethritis. Besides those manifestations, the patient also showed mucocutaneous lesions that were both clinically and histologically indistinguishable from those of pustular psoriasis. Due to the severity of the disease it was necessary to treat this patient with corticosteroids and immunosuppressors. With this therapy the clinical manifestations of Reiter's Syndrome disappeared but sudden abdominal and bronchopulmonary symptoms complicated the picture and the patient died in a septical shock. The autopsy findings revealed massive Strongyloidiasis with the presence of larvae in several organs, particularly in the intestinal wall, the lungs and the liver.

A comparison of the effect of benzopyrones and other drugs with anti-inflammatory properties on acid and neutral protease activity levels in various tissues after thermal injury

Generally, the benzopyrones enhanced acid protease activity levels in the oedema fluid and the extracellular compartment of the skin. This is the region where thermal injury has its greatest impact. The proteolysis induced by the drugs in this region represents a means of rapidly reducing some of the derangements which the thermal injury has caused. Levamisole also enhanced acid protease activity levels in the serum and extracellular compartment of the skin 6 hours after thermal injury, while Reparil had the same effect at 24 hours. Generally the benzopyrones had little or no effect on neutral protease levels, while levamisole and Reparil caused their depression. The later effects could possibly be attributed to serum deactivation or to inhibition of their release. The enzyme enhancing activity of these drugs has been shown to correlate remarkably well with their oedema reducing ability. Generally, those which increased enzyme activity levels the most were the most effective in reducing the oedema. The cells upon which the drugs exert their effects in thermal oedema mainly seem to be the macrophages; the fibroblasts seem to be of secondary importance. This is to be contrasted with their action in the initial stages of lymphoedema where they are believed to stimulate the neutrophils. The net result of the proteolysis is many small fragments which can rapidly leave the injured tissue thus releasing the oedema fluid.

Opportunistic pulmonary strongyloidiasis complicating asthma treated with steroids

A man aged 57 years who had lived most of his life in London, suffered from asthma which had begun during army service in Burma 37 years previously. Latterly he was treated with increasing doses of corticosteroids but his symptoms continued to worsen and he died of asthma. Necropsy revealed a heavy opportunistic infection of the bronchi and lungs by the nematode Strongyloides stercoralis which he had presumably acquired while on service abroad. The case illustrates the need, even in non-endemic areas, to suspect opportunistic pulmonary strongyloidiasis when a patient's asthma worsens despite treatment with increasing doses of corticosteroids. Although it is a potentially lethal iatrogenic opportunistic infection, it is amenable to treatment with anthelminthic agents if recognized in time.

A comparison of the effectiveness of some anti-inflammatory drugs on thermal oedema

The efficacy of a group of anti-inflammatory drugs with similar modes of action was tested on thermal oedema. Of these, coumarin and sodiumrutin-sulphate were most effective. A combination of these, marketed as Venolot, although still beneficial, was not as effective as either given singly. The other drugs tested--levamisole, Reparil and Venoruton--although also of some benefit in treatment of this oedema, did not approach the overall effectiveness of coumarin of sodium-rutin-sulphate. Both drugs are characterized by a very wide safety margin between the therapeutic and the toxic dose. In addition, they are cheap, easy to obtain and can be taken orally. They work by stimulating phagocytosis, enzyme production and thus proteolysis and a subsequent removal of protein and oedema fluid from the injured tissues.

Disseminated strongyloidiasis. A complication of the immunosuppressed host

Images

Hyperinfection with Strongyloides stercoralis in Great Britain

A Jamaican who had been in England for 13 years was successfully treated for hyperinfection with the nematode Strongyloides stercoralis. She presented as an emergency with acute abdominal pain, developed paralytic ileus and responded well to a long course of thiabendazole. A review of the literature revealed reports of 3 other cases of hyperinfection in Great Britain, all of whom had died, 2 afrer laparotomy.