Enterococcal meningitis in association with Strongyloides hyperinfection syndrome

Severe strongyloidiasis: a systematic review and meta-analysis of 339 cases

Strongyloidiasis is a parasitosis representing a significant public health problem in tropical countries. It is often asymptomatic in immunocompetent individuals but its mortality rate increases to approximately 87% in severe forms of the disease. We conducted a systematic review, including case reports and case series, of Strongyloides hyperinfection and dissemination from 1998 to 2020 searching PubMed, EBSCO and SciELO. Cases that met the inclusion criteria of the Preferred Reported Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist were analysed. Statistical analysis was performed using Fisher's exact test and Student's t-test and a Bonferroni correction for all the significant values. A total of 339 cases were included in this review. The mortality rate was 44.83%. The presence of infectious complications, septic shock and a lack of treatment were risk factors for a fatal outcome. Eosinophilia and ivermectin treatment were associated with an improved outcome.

Strongyloides hyperinfection syndrome due to corticosteroid therapy after resection of meningioma: illustrative case

BACKGROUND

Strongyloidiasis is an underdiagnosed and preventable life-threatening disease caused by infection with the helminth Strongyloides stercoralis. Chronic asymptomatic infection can be sustained for decades, and immunosuppression can lead to disseminated infection, with a mortality rate of 70%–100%. In the neurosurgical population, corticosteroids are the most consistent cause of hyperinfection.

OBSERVATIONS

The authors present the case of a 33-year-old woman of Paraguayan origin who was diagnosed with sphenoid planum meningioma and treated with a high dose of corticosteroids on the basis of the diagnosis. She underwent surgery, and pathological anatomy reflected grade I meningioma. After the surgery, she started with a history of dyspnea, productive cough, fever, and urticarial rash. Later, she presented with intestinal pseudo-obstruction and bacterial meningitis with hydrocephalus. Serology was positive for Strongyloides (enzyme-linked immunosorbent assay), and she was diagnosed with hyperinfection syndrome. Ivermectin 200 µg/kg daily was established.

LESSONS

It may be of interest to rule out a chronic Strongyloides infection in patients from risk areas (immigrants or those returning from recent trips) before starting treatment with corticosteroids.

Combination therapy for disseminated strongyloidiasis with associated vancomycin-resistant, linezolid-intermediate Enterococcus faecium meningitis: A case report

WHAT IS KNOWN AND OBJECTIVE

The rhabditid nematode Strongyloides stercoralis is the major causative agent of disseminated strongyloidiasis (DS). In rare cases, DS has caused enterococcal meningitis. If DS-associated vancomycin-resistant Enterococcus faecium (VRE) meningitis is suspected, combination antibiotic therapy should be considered.

CASE SUMMARY

We present a case of a 61-year-old male who developed DS associated with vancomycin-resistant and linezolid-intermediate E. faecium meningitis after receiving corticosteroids. The VRE meningitis was treated with high-dose daptomycin 12 mg/kg, linezolid, tigecycline and quinupristin/dalfopristin. Despite negative cultures, the patient expired.

WHAT IS NEW AND CONCLUSION

In patients with DS-associated VRE meningitis, early use of combination therapy may be warranted to improve patient outcomes.

Clinico-epidemiological spectrum of strongyloidiasis in India: Review of 166 cases

Strongyloidiasis is frequently asymptomatic but can cause disseminated disease and variable presentations. Diagnosis is often delayed or misdirected either due to poor degree of clinical suspicion or clinical imitation of other gastrointestinal conditions. This infection is not infrequent and several cases from all over India have been reported barring few states from central India. We reviewed 166 cases published in English literature from India; from 2001 till 2018 including 2 recent cases from our institute. The mean age of presentation was 35 years with male female ratio of 2.8:1. The duration of disease at the time of presentation varied from 15 days to 10 years. Most important predisposing factor identified in the study was HIV (13.3%) and steroid therapy (6.6%). Most common modality of diagnosis was by stool microscopy (69.3%). Radiological investigations were ordered in 33.7% patients before stool microscopy. Ivermectin was the most common treatment regimen with cure rate of 97.6%. Better awareness and early clinical suspicion of the disease with stool microscopy and adequate therapy are necessary to improve the outcome. Strongyloidiasis is rather widely prevalent infection with variable symptomatology and calls for a close coordination from family physicians and microbiologists.

Strongyloides stercoralis hyperinfection complicated by secondary infections in a case of transformed diffuse large B-cell lymphoma

We report Strongyloides stercoralis hyperinfection complicated by secondary infections in a case of transformed diffuse large B-cell lymphoma. The hyperinfection was followed by a sequela of candidemia and infection of the peritoneal fluid that was associated with the leakage of gut flora from the bowel damaged by the migration of larvae. This phenomenon has seldom been reported in a case of hematolymphoid cancer such as transformed diffuse large B-cell lymphoma. The complications arising due to S. stercoralis hyperinfection are associated with a high fatality rate in immunocompromised patients, and this should be taken into account in the diagnosis and management of this condition.