Fatal Strongyloides stercoralis hyper-infection in a patient with multiple myeloma

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.

Investigation of the relationship between lymphocyte subsets and intestinal parasites

We analyzed the peripheral blood lymphocyte subsets of cancer patients infected with intestinal parasites, with an aim to find out the relationship between the levels of different types of lymphocytes with the prognosis of patients. 201 cancer patients aged 18 and over were included. Stool samples of the patients were examined using native-lugol, trichrome, modified trichrome (Weber's Trichrome stain), and modified Ziehl-Neelsen staining methods. Microsporidia and Cryptosporidium parvum were investigated at the genus and species levels using PCR. Lymphocyte subsets were determined by flow cytometry in blood samples. One or more parasite species were detected in 115 (56.7%) patients. The most common parasite species were Microsporidia, Blastocystis and Entamoeba coli, respectively. The frequency of parasites was high in patients with low lymphocyte percentage, CD3⁺ T cell and CD3⁺ CD4⁺ T (Th) cell levels in blood samples studied by flow cytometry. Microsporidia infection was significantly higher in patients with low lymphocyte percentage and Th cell levels. Similarly, C. parvum infection was found to be significantly higher in patients with low T lymphocyte percentage and Th cell level. Finally, Blastocystis infection was significantly higher in patients with low lymphocyte percentage and CD4/CD8 ratio higher than 1. The decrease in lymphocyte percentage, CD3⁺ T cell and Th cell count, and low CD4/CD8 ratio in cancer patients increase the frequency of intestinal parasitic infections. Based on these results, lymphocyte subsets may help identify cancer patients at high risk of opportunistic parasites. We suggest that opportunistic parasitic infections affecting the clinical course of the disease should be considered by clinicians during the follow-up and treatment of patients.

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.

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.

Fatal strongyloidiasis after corticosteroid therapy for presumed chronic obstructive pulmonary disease

INTRODUCTION

Strongyloidiasis is a neglected tropical disease with global prevalence. Under some cases of immune suppression (especially with corticosteroid administration), the nematode involved disseminates, leading to an amplified, possibly lethal hyper-infection syndrome.

CASE PRESENTATION

A 56-year-old Nepalese man presenting with chief complaints of nausea, vomiting, joint pain and abdominal cramps was admitted to Sumeru Hospital. His past history revealed: chronic obstructive pulmonary disease (COPD), systemic hypertension and previously treated pulmonary tuberculosis. The patient had been treated with oral prednisolone (60 mg gl-1) for 8 days due to a presumed exacerbation of his COPD. Sequentially, he developed haemoptysis, chest tightness, frequent wheezing and worsening cough. Bronchoscopy showed severe diffuse alveolar haemorrhage; microbiological examination of broncho-alveolar lavage (BAL) was recommended. Examination of an acid fast bacilli stain preparation of BAL revealed filariform larvae of Strongyloides. Stool specimen examination revealed larvae of Strongyloides. The physical condition of the patient began to deteriorate; a few days after admission, vancomycin-sensitive Enterococcus faecium was isolated from a blood sample. He was treated with ivermectin and albendazole for strongyloides and linezolid plus vancomycin for E. faecium. However, the patient failed to recover from the illness and died.

CONCLUSION

The findings of our study suggest that corticosteroid administration in strongyloidiasis can lead to the development of fatal strongyloides hyper-infection syndrome. Hence our experience suggests the need for early diagnosis of strongyloidiasis to avoid such an outcome. A deterioration of the patient's condition after the initiation of corticosteroid therapy in endemic areas should raise the possibility of strongyloidiasis.

Human infection with Strongyloides stercoralis and other related Strongyloides species

The majority of the 30-100 million people infected with Strongyloides stercoralis, a soil transmitted intestinal nematode, have subclinical (or asymptomatic) infections. These infections are commonly chronic and longstanding because of the autoinfective process associated with its unique life cycle. A change in immune status can increase parasite numbers, leading to hyperinfection syndrome, dissemination, and death if unrecognized. Corticosteroid use and HTLV-1 infection are most commonly associated with the hyperinfection syndrome. Strongyloides adult parasites reside in the small intestine and induce immune responses both local and systemic that remain poorly characterized. Definitive diagnosis of S. stercoralis infection is based on stool examinations for larvae, but newer diagnostics - including new immunoassays and molecular tests - will assume primacy in the next few years. Although good treatment options exist for infection and control of this infection might be possible, S. stercoralis remains largely neglected.

Fatal Strongyloides hyper-infection in a patient with myasthenia gravis

PURPOSE

We report a fatal case of Strongyloides hyper-infection as the result of corticosteroid therapy of a patient with myasthenia gravis.

CASE PRESENTATION

Our patient was a farmer with a past history of living in an endemic area for Strongyloides stercoralis in Iran. Hyper-infection was diagnosed during the advanced-stage disease by demonstration of enormous number of larvae in the direct smears prepared from both the stool and tracheal secretions. Unfortunately, despite appropriate anti-parasite therapy, the patient died due to respiratory failure.

CONCLUSION

We recommend the provision of more awareness in high-risk people prior to immunosuppressive therapy, through screening for S. stercoralis, even in non-endemic regions.