Screening, prevention, and treatment for hyperinfection syndrome and disseminated infections caused by Strongyloides stercoralis

Strongyloides stercoralis infection in a patient initiating corticosteroid therapy for hypereosinophilia: A case report

Strongyloides stercoralis (S. stercoralis) is a soil-transmitted nematode that is endemic to tropical and subtropical regions. S. stercoralis has the ability to cause autoinfection, potentially leading to a chronic disease that can last for decades or result in severe hyperinfection especially in individuals who are taking corticosteroids or other immunosuppressive medications. Here, we report the case of a patient presenting a two-week history of symptoms including cough, fatigue, weight loss, pruritus, and rash. Due to a significant increase in the percentage of eosinophils, the patient was referred to the hematology clinic. The patient underwent a comprehensive evaluation that included an autoimmune panel, genetic testing, and imaging methods. The results of these investigations were found to be normal. The upper gastrointestinal system endoscopy revealed eosinophilic duodenitis and corticosteroid treatment was initiated. The commencement of corticosteroid therapy resulted in a worsening of the patient's symptoms. In the repeated endoscopy of the upper gastrointestinal tract, the presence of S. stercoralis larvae was observed between the crypts. Subsequently, stool tests for S. stercoralis diagnosis were also found to be positive. The patient was at risk of developing a hyperinfection syndrome. Corticosteroids are commonly used to reduce inflammation and manage symptoms associated with eosinophilic disorders. The immunosuppressive effects of corticosteroids are known to precipitate S. stercoralis hyperinfection syndrome, which can result in significant morbidity and mortality. This case highlights the importance of maintaining a high index of suspicion for S. stercoralis in patients undergoing immunosuppressive therapy, particularly when presenting with unexplained eosinophilia.

Strongyloides Infection Presenting as E. coli Meningitis Post-Transplant

Strongyloidiasis is a common intestinal infection that may persist in humans for decades without symptoms or can present as a potentially fatal, broadly disseminated infection in an immunocompromised host. This report describes a rare case of concomitant strongyloidiasis and E. coli meningitis that was successfully recognized and treated in a patient 20 years post-renal transplantation.

Screening for strongyloidiasis among selected populations in Taiwan: Prevalence, associated factors, and outcomes

BACKGROUND

When and how to screen for strongyloidiasis in high-income countries remain to be elucidated. This study aimed to investigate the prevalence, associated factors, and outcome of strongyloidiasis in Taiwan and proposed clinical criteria for serological screening.

METHODS

Adults who were immunocompromised or about to undergo iatrogenic immunosuppression (proactive-screening cohort) and those with clinical presentations suggesting strongyloidiasis (diagnosis-driven cohort) were prospectively enrolled at five hospitals in Taiwan. Serum anti-Strongyloides IgG was determined by two enzyme-linked immunosorbent assays (ELISAs). Stool samples were obtained for microscopy and cultures. Prevalence of confirmed/probable strongyloidiasis, as defined by identification of characteristic larvae from stool or testing positive for both ELISAs, was calculated. Factors associated with strongyloidiasis were identified in multivariable analysis. Six-month mortality was compared between participants with and without strongyloidiasis using Cox proportional hazards model.

RESULTS

From January 2021 to June 2024, confirmed/probable cases of strongyloidiasis were identified in 1.9 % and 4.8 % of the participants in proactive-screening and diagnosis-driven cohorts, respectively. Multivariable analysis revealed that skin and skin structure infection (adjusted odds ratio [aOR] 3.180), gastrointestinal bleeding of unknown causes (aOR 3.229), and hemoglobin <10 g/dl (aOR 4.300) were independently associated with strongyloidiasis. Six-month mortality was 33.3 % in participants with confirmed/probable strongyloidiasis, higher than that in those without strongyloidiasis (11.4 %), but not statistically significant after adjusting for age, sex, and clinical severity (p = 0.09).

CONCLUSIONS

Strongyloidiasis continued to occur among at-risk populations in Taiwan. Screening strategies are needed to improve the detection of this neglected parasitic infection in Taiwan and other high-income countries.

Illustrative case series of eosinophilia in UK Armed Forces personnel and recommended management for non-specialists

Peripheral eosinophilia (>0.5×109/L) in the full blood count is caused by a variety of infectious and non-infectious aetiologies. Of particular importance to the UK military are parasitic infections, especially in individuals recruited from overseas and those who have deployed to areas that are highly endemic for schistosomiasis, strongyloidiasis and soil-transmitted helminths. These infections may persist for decades without causing symptoms. UK Armed Forces (UKAF) personnel have recently presented with more severe forms of strongyloidiasis, which can be fatal, especially following immunosuppression for chronic non-communicable diseases. Most uncomplicated infections respond to oral ivermectin or oral praziquantel, which are easy to take and generally well tolerated. We present the histories of three UKAF personnel to raise awareness of these infections, and we describe a framework for the initial investigation and management of people found to have eosinophilia in military primary care settings, together with indications for onward referral to infection or haematology specialists. Furthermore, given their relatively unknown prevalence in the UKAF Forces population, increased awareness and seroprevalence studies may be beneficial.

The Unwelcome Guest: Strongyloides stercoralis Hyperinfection in a Patient With Steroid-Dependent Asthma-COPD Overlap Syndrome (ACOS)-A Case Report and Review of Literature

Strongyloides stercoralis is a soil-transmitted roundworm nematode estimated to affect over 600 million people worldwide. Hyperinfection syndrome (HS) has been described in immunosuppressed patients. Our case highlights a rare manifestation of HS due to Strongyloides stercoralis causing acute respiratory failure in an asthma-COPD overlap syndrome (ACOS) patient on chronic corticosteroid therapy. A 63-year-old woman with diabetes, chronic obstructive pulmonary disorder due to chronic cigarette smoking, and severe asthma on chronic prednisone therapy presented with recurrent intractable abdominal pain and shortness of breath. The patient underwent esophagogastroduodenoscopy (EGD) showing friable mucosa returning positive for Strongyloides stercoralis infection. The patient deteriorated with progressive acute hypoxic respiratory failure and acute metabolic encephalopathy requiring invasive mechanical ventilation. Dual antiparasitic therapy with ivermectin and albendazole was initiated, and the patient was treated for septic shock. The patient was successfully extubated and was discharged from the hospital to a rehabilitation center without steroid therapy. Due to the classic transmission and life cycle of the filiform larvae, the lungs are target organs in HS. The mortality of Strongyloides HS ranges from 85% to 100% when untreated. HS due to Strongyloides stercoralis carries a high risk for disseminated infection in patients with chronic steroids. High index of suspicion, tissue sample, and prompt institution of target therapy institutions are key for a successful clinical outcome.

Strongyloides Hyperinfection Syndrome Following Immunosuppressant Therapy for COVID-19: A Case Report With Literature Review

Strongyloides hyperinfection and disseminated infections are usually associated with immunosuppression; these severe manifestations occur in a minority of cases. The use of immunosuppressants such as corticosteroids and Baricitinib for treating COVID-19 pneumonia can be responsible for patients' immunosuppression and cause Strongyloides hyperinfection syndrome. The chance increases when the patient belongs to countries or regions where chronic infection with Strongyloides is more prevalent. This case report describes the clinical scenario of a 78-year-old man from southeastern Bangladesh who was initially diagnosed with COVID-19 pneumonia. His condition improved after receiving corticosteroid therapy for approximately 1 month at various doses and Baricitinib therapy for more than a week due to moderate-to-severe COVID-19 pneumonia. Approximately 2 months later, he presented with low-grade fever, diarrhea, and itching throughout the body. Blood analysis revealed eosinophilia; stool examination revealed Rhabditiform larvae of Strongyloides stercoralis. The patient was diagnosed with Strongyloides hyperinfection syndrome and treated with Albendazole and Ivermectin. His clinical condition gradually improved, and he was discharged from the hospital. The stool sample was sent for a repeat microscopic examination after 14 days, which yielded a negative result. Clinicians should be more vigilant while prescribing corticosteroids and other immunosuppressants for a prolonged period. Proper screening to identify asymptomatic cases of strongyloidiasis, followed by empirical treatment of screening-positive cases, prompt detection, and management of severe manifestations, is crucial to reduce further morbidity and mortality related to Strongyloides stercoralis.

Coinfection of cytomegalovirus and strongyloidiasis presenting as massive gastrointestinal bleeding in an immunocompromised host: a case report

Cytomegalovirus (CMV) infection is an opportunistic disease in immunocompromised patients that may appear without symptoms, with constitutional symptoms, or as a tissue-invasive disease. Strongyloides stercoralis infection often manifests with non-specific symptoms; however, it can lead to severe malabsorption and extraintestinal dissemination by accelerated autoinfection. The coinfection of CMV and Strongyloides stercoralis has rarely been reported, particularly with solely severe gastrointestinal bleeding. A 29-year-old female patient with a history of nephrotic syndrome treated with long-term corticosteroid and poorly controlled type 2 diabetes presented with a 20-day history of persistent epigastric pain, diarrhea, and significant weight loss. At the hospitalization, the patient appeared to have persistent gastrointestinal bleeding, leading to hypovolemic shock and diabetic ketoacidosis. Strongyloides stercoralis was detected by the duodenal biopsy results, and the polymerase chain reaction of these samples was positive for CMV. The patient underwent upper endoscopy four times to control the bleeding and was treated with ivermectin and ganciclovir. The patient improved gradually and was discharged after 23 days of hospitalization. The coinfection of CMV and Strongyloides stercoralis causing massive gastrointestinal (GI) bleeding has been rarely reported. To the best of our knowledge, this is also the first case of coinfection of these pathogens in an immunocompromised patient complicated with hypovolemic shock caused by GI bleeding and diabetic ketoacidosis. Clinicians should have a high index of suspicion and test simultaneously CMV and Strongyloides stercoralis in patients with immunosuppression, other risk factors, or unexplained gastrointestinal symptoms.

Pneumonia in Transplant Recipients: A Comprehensive Review of Diagnosis and Management

Transplant recipients have an increased risk of complications, including graft dysfunction and infections, which can be life-threatening if not recognized early. Pneumonia ranks as one of the most frequent complications in both solid organ and hematopoietic stem cell transplants. Clinical symptoms manifest late during infections in immunocompromised patients. An aggressive approach centered on early confirmatory diagnosis and a low threshold for empiric therapy is often the most effective strategy. The isolation of a pathogen in an upper airway sample does not necessarily mean the same organism is responsible for pneumonia. Viruses such as CMV (cytomegalovirus virus) may function as co-pathogens for opportunistic infections in transplant recipients in addition to causing their own primary infectious syndrome. Furthermore, some viruses exhibit immunomodulatory effects that can affect the graft function. Given the exhaustive list of causative pathogens responsible for pneumonia, the best approach to the diagnosis is to have a conceptual framework that includes a detailed history, such as the type of transplant, degree of immunosuppression, antimicrobial prophylaxis, risk factors, time of presentation since transplantation and the radiographic pattern on the CT chest (computer tomography of the chest). Management depends predominantly on the degree of antimicrobial resistance, drug-to-drug interaction, and adjustments to the immunosuppression.

Multiple sclerosis in Colombia: A review of the literature

Background

The prevalence of multiple sclerosis (MS) in Latin America is generally considered low to moderate. However, accurate data regarding MS epidemiology in Colombia is lacking.

Objective

This study aims to discuss the situation of MS in Colombia.

Results

Analysis reveals a lack of accurate data regarding MS epidemiology in Colombia, however, there have been notable improvements in diagnosis and ultimately leading to better access to treatment for MS patients. While ethnic diversity may potentially influence MS prevalence, there is currently no strong data supporting this claim. MS treatment in Colombia, focuses on early disease-modifying therapy, nevertheless, MS is considered an orphan disease in Colombia, contributing to MS patients not receiving comprehensive evaluation in MS centers. Regional efforts are ongoing to improve diagnostic access and access to treatment for MS patients.

Conclusion

Despite the challenges in accurately defining MS epidemiology in Colombia, an increase in neurological training, diagnostic capabilities, and access to treatment has been observed. However, the status of MS as an orphan disease in Colombia poses challenges to comprehensive care for affected individuals. Further studies are needed to elucidate risk factors and improve care conditions for MS patients in the region.

Concomitant Serological and Molecular Methods for Strongyloides stercoralis Screening in an Endemic Area of Spain

Strongyloidiasis is a widespread parasitic disease that can be life-threatening in immunosuppressed people. In the Mediterranean basin, autochthonous cases coexist with imported ones. We aimed to assess the utility of different screening methods, along with the frequency of strongyloidiasis and its associated risk factors in migrants and the native population. This cross-sectional study took place from 2019 to 2022 in the area of the Vega Baja Hospital in Alicante, Spain. Screening was performed in people who were immunosuppressed, at risk of immunosuppression, with blood asymptomatic eosinophilia, and in asymptomatic people from highly endemic countries. Screening methods were serological techniques (ELISA), stool parasitological tests (fecal concentration methods and agar plate culture), and a stool molecular test (PCR). Of the 168 participants (62.5% males, 53.0% migrants, 36.3% immunosuppressed, median age 57 years), 14 (8.3%) had confirmed strongyloidiasis, where 6 were confirmed by serology, 4 by PCR, and 4 by both methods. Overall, 9% of the migrants and 7.6% of the native-born patients were infected. Elevated IgE and hemoglobin and Latin American origin were associated with strongyloidiasis diagnosis. Screening with serology alone would have missed 28.6% of cases. We conclude that strongyloidiasis prevalence is high in our population, both in native and migrant groups, and stool PCR is a useful tool to increase case detection.

Ten tips on immunosuppression in primary membranous nephropathy

Membranous nephropathy (MN) management poses challenges, particularly in selecting appropriate immunosuppressive treatments (IST) and monitoring disease progression and complications. This article highlights 10 key tips for the management of primary MN based on current evidence and clinical experience. First, we advise against prescribing IST to patients without nephrotic syndrome (NS), emphasizing the need for close monitoring of disease progression. Second, we recommend initiating IST in patients with persistent NS or declining kidney function. Third, we suggest prescribing rituximab (RTX) or RTX combined with calcineurin inhibitors in medium-risk patients. Fourth, we propose cyclophosphamide-based immunosuppression for high-risk patients. Fifth, we discourage the use of glucocorticoid monotherapy or mycophenolate mofetil as initial treatments. Sixth, we underscore the importance of preventing infectious complications in patients receiving IST. Seventh, we emphasize the need for personalized monitoring of IST by closely measuring kidney function, proteinuria, serum albumin and anti-M-type phospholipase A2 receptor levels. Eighth, we recommend a stepwise approach in the treatment of resistant disease. Ninth, we advise adjusting treatment for relapses based on individual risk profiles. Finally, we caution about the potential recurrence of MN after kidney transplantation and suggest appropriate monitoring and treatment strategies for post-transplantation MN. These tips provide comprehensive guidance for clinicians managing MN, aiming to optimize patient outcomes and minimize complications.

Astacin metalloproteases in human-parasitic nematodes

Parasitic nematodes infect over 2 billion individuals worldwide, primarily in low-resource areas, and are responsible for several chronic and potentially deadly diseases. Throughout their life cycle, these parasites are thought to use astacin metalloproteases, a subfamily of zinc-containing metalloendopeptidases, for processes such as skin penetration, molting, and tissue migration. Here, we review the known functions of astacins in human-infective, soil-transmitted parasitic nematodes - including the hookworms Necator americanus and Ancylostoma duodenale, the threadworm Strongyloides stercoralis, the giant roundworm Ascaris lumbricoides, and the whipworm Trichuris trichiura - as well as the human-infective, vector-borne filarial nematodes Wuchereria bancrofti, Onchocerca volvulus, and Brugia malayi. We also review astacin function in parasitic nematodes that infect other mammalian hosts and discuss the potential of astacins as anthelmintic drug targets. Finally, we highlight the molecular and genetic tools that are now available for further exploration of astacin function and discuss how a better understanding of astacin function in human-parasitic nematodes could lead to new avenues for nematode control and drug therapies.

Factors associated with the sexual transmission of Strongyloides stercoralis in men who have sex with men: A systematic review

Strongyloides stercoralis is a parasitic worm with a complex life cycle and can cause significant morbidity, including a proctocolitis and life-threatening hyperinfection syndrome. Limited reports from non-endemic areas, including in men who have sex with men (MSM), suggest sexual transmission of S. stercoralis. In this systematic review of the published literature, we aimed to explore the associated factors of S. stercoralis in MSM. We systematically searched three bibliographical databases (MEDLINE, CINAHL and EMBASE) up to November 2022. We used a two-stage process to assess eligibility: the primary author conducted an initial screen of abstracts, and then three authors conducted independent full manuscripts to determine the final eligible manuscripts. We only included manuscripts written in English that contained data on specific factors associated with sexual transmission in MSM. We used the STROBE checklist to assess the risk of bias and synthesized the narrative data using the SWiM method. Seven manuscripts were eligible for this review (four case reports, one case series, one cross-sectional study and one experimental study), which included 22 individuals from Europe and the Americas. From these studies, S. stercoralis in MSM was associated with living with HIV (including having a low CD4 count and not using antiretrovirals), having a concomitant sexually transmitted infection (Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum and hepatitis C) and a concomitant (sexually transmitted) protozoal infection (Entamoeba histolytica, Giardia lamblia), travel to the S. stercoralis endemic area, multiple sexual partners from endemic areas, oro-anal sexual contact and chemsex. Although limited by the number of cases in the literature, we have highlighted some possible biological and behavioural risk factors associated with the sexual transmission of S. stercoralis in MSM that could be used to both target future research and S. stercoralis public health control interventions.

Generation of IgG antibodies against Strongyloides stercoralis in mice via immunization with recombinant antigens A133 and Ss-IR

Strongyloidiasis, caused by the nematode Strongyloides stercoralis, remains a threat to global public health, and a vaccine would be useful to control the disease, especially in developing countries. This study aimed to evaluate the efficacy of recombinant proteins, A133 and Ss-IR, as potential vaccine candidates against strongyloidiasis by investigating the humoral and cellular immune responses in immunized mice. Respective antigens were adjuvanted with Complete Freund's Adjuvant (prime) and Incomplete Freund's Adjuvant (boost) and administered intraperitoneally (prime) and subcutaneously (boost) to female BALB/c mice. For antigen-only doses, only antigens were injected without adjuvants. Altogether, 1 prime dose, 4 booster doses, and 2 antigen-only doses were administered successively. ELISAs were conducted to assess the antibody responses, along with flow cytometry and cytokine ELISA to elucidate the cellular immune responses. Results showed that A133 and Ss-IR induced the production of IgG1 and IgG2a, with A133 generating more robust IgG2a responses than Ss-IR. Flow cytometry findings indicated that effector CD8+T-cells and memory B-cells activity were upregulated significantly for A133 only, whereas cytokine ELISA demonstrated that a Th1/Th2/Th17 mixed cell responses were triggered upon vaccination with either antigen. This preliminary study illustrated the good potential of recombinant A133 and Ss-IR as vaccine candidates against S. stercoralis. It provided information on the probable immune mechanism involved in host defence and the elicitation of protection against S. stercoralis.

Canadian Consensus Guidelines for the Diagnosis and Treatment of Autoimmune Encephalitis in Adults

Autoimmune encephalitis is increasingly recognized as a neurologic cause of acute mental status changes with similar prevalence to infectious encephalitis. Despite rising awareness, approaches to diagnosis remain inconsistent and evidence for optimal treatment is limited. The following Canadian guidelines represent a consensus and evidence (where available) based approach to both the diagnosis and treatment of adult patients with autoimmune encephalitis. The guidelines were developed using a modified RAND process and included input from specialists in autoimmune neurology, neuropsychiatry and infectious diseases. These guidelines are targeted at front line clinicians and were created to provide a pragmatic and practical approach to managing such patients in the acute setting.

Modifications to the parasitological technique of Rugai increase the diagnostic sensitivity for strongyloidiasis

Strongyloidiasis is a neglected tropical disease caused mainly by Strongyloides stercoralis, a nematode that can persist for decades in the human host with a very low parasitic burden and without specific symptoms. Hence, it is difficult to diagnose and control. Larval concentration and culture methods with fecal samples show higher sensitivity for the diagnosis of Strongyloides-infected individuals; however, these techniques are not routinely used, primarily due to the challenges associated with processing a substantial volume of fecal samples. In the current study, we comparatively evaluated the sensitivity and applicability of modifications made to the Rugai parasitological method for the diagnosis of strongyloidiasis in fecal samples of experimentally infected rats and in 68 individuals from an urban community close to Maceió, Brazil. The presence and quantity of parasite larvae in the feces were comparatively evaluated using different parasitological techniques. In the experimental model, we demonstrated that the modified Rugai technique (RMOD) allowed for significantly higher recovery of larvae than the original Rugai technique (RO). Moreover, the sediment was cleaner and easier to evaluate using optical microscopy. Compared to other parasitological techniques, such as agar-plate culture (A-PC) and spontaneous sedimentation (SS), the RMOD technique showed higher sensitivity in the detection of larvae in all infected groups and presented comparatively better performance, especially in rats with a low parasite burden. In the human population, among the 68 stool samples evaluated, Strongyloides larvae were detected in the feces of six individuals with an estimated prevalence of 8.82%. However, the performance of each parasitological method was remarkably different. SS identified Strongyloides larvae in only two individuals and A-PC in three, whereas RMOD was able to identify six infected individuals, resulting in sensitivities of 33.3%, 50%, and 100%, respectively. In conclusion, the modifications introduced to the Rugai technique resulted in improved sensitivity for the detection of Strongyloides spp. infections, especially in stool samples with a low parasite burden, in comparison with other routinely used parasitological techniques.

Pulmonary strongyloidiasis and hyperinfection in a Patient with idiopathic inflammatory myopathy：A case report

Pulmonary strongyloidiasis is a rare infection in patients with autoimmune diseases, and immunosuppression can lead to the development of hyperinfection syndrome with a high mortality rate. We present a case of a 78-year-old male with previous idiopathic inflammatory myopathy (IIM) with interstitial lung disease. He developed hyperinfection syndrome and respiratory failure, and diagnostic metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage fluid (BALF) confirmed the presence of Strongyloides stercoralis. After treatment with ivermectin, the patient's symptoms improved. Therefore, adequate screening and prophylactic treatment are needed for people at risk of immunosuppression, which can reduce the occurrence of the devastating S. stercoralis hyperinfection syndrome. It also highlights mNGS as a highly accurate test for the detection of difficult to atypical pathogens.

Human strongyloidiasis: complexities and pathways forward

Strongyloidiasis is a World Health Organization neglected tropical disease usually caused by Strongyloides stercoralis, a parasitic worm with a complex life cycle. Globally, 300-600 million people are infected through contact with fecally contaminated soil. An autoinfective component of the life cycle can lead to chronic infection that may be asymptomatic or cause long-term symptoms, including malnourishment in children. Low larval output can limit the sensitivity of detection in stool, with serology being effective but less sensitive in immunocompromise. Host immunosuppression can trigger catastrophic, fatal hyperinfection/dissemination, where large numbers of larvae pierce the bowel wall and disseminate throughout the organs. Stable disease is effectively treated by single-dose ivermectin, with disease in immunocompromised patients treated with multiple doses. Strategies for management include raising awareness, clarifying zoonotic potential, the development and use of effective diagnostic tests for epidemiological studies and individual diagnosis, and the implementation of treatment programs with research into therapeutic alternatives and medication safety.

An 85-Year-Old Man with Fever, Dyspnea, and Dry Cough Diagnosed with Idiopathic Hypereosinophilic Syndrome, Successfully Treated with High-Dose Corticosteroids

BACKGROUND Idiopathic hypereosinophilic syndrome (I-HES) is a rare disease diagnosed as absolute eosinophil count >1500 cells/µl and end-organ involvement attributable to tissue eosinophilia with no secondary cause of underlying eosinophilia. The mean age of presentation for I-HES is 44 years. The skin, lungs, and gastrointestinal (GI) system are most common sites of presenting manifestations, including fatigue, cough, dyspnea, myalgias, angioedema, rash, fever, nausea, and diarrhea. Although cardiac and neurologic symptoms are less common at presentation, they can be life-threatening. CASE REPORT We report the case of an 85-year-old man who presented with fever, malaise, and loss of appetite for 3 weeks, followed by dyspnea and dry cough for 2 weeks. His absolute eosinophil count was 9000 cells/µl, which was not responding to empirical antibiotic therapy, with worsening of symptoms, suggesting a non-infective origin. He was then extensively evaluated to establish underlying an etiology for specific treatment, which was negative for common causes like atypical infections, malignancy, and autoimmune disorders. He was then started on corticosteroid therapy to overcome an exaggerated immune response and reduce inflammation-related injury, to which he responded well. On follow-up, hypereosinophilia was fully cured, with reversal of end-organ involvement including myocarditis and pneumonitis. CONCLUSIONS This report shows that idiopathic HES can present with various clinical features and that accurate diagnosis, excluding known causes of eosinophilia, and early management are essential to prevent long-term organ damage. Our patient responded to prompt treatment with high-dose corticosteroids.

Strongyloides infection screening in transplant candidates: What is the best strategy?

BACKGROUND

The potential that Strongyloides stercoralis infection has to cause major morbidity and high mortality when the disseminated form occurs in transplant patients is of particular concern.

METHODS

In this study, the objective was to observe S. stercoralis infection in patients who are candidates for transplantation by using parasitological, serological, and molecular techniques and to propose an algorithm for the detection of that infection in transplant candidates.

RESULTS

By parasitological techniques, 10% of fecal samples were positive. Anti-Strongyloides antibodies immunoglobulin G were detected in 19.3% and 20.7% of patients by immunofluorescence assay and enzyme-linked immunosorbent assay, respectively. S. stercoralis DNA was observed in 17.3% of samples by conventional polymerase chain reaction and 32.7% of samples by quantitative polymerase chain reaction (qPCR).

CONCLUSION

The set of results allows us to reinforce that a positive result by parasitological techniques and/or qPCR indicates that the specific treatment should be applied. However, the improvement of diagnostic techniques may suggest changes in the screening for strongyloidiasis in these patients.

Strongyloides stercoralis Infection in Humans: A Narrative Review of the Most Neglected Parasitic Disease

Strongyloidiasis is a helminth infection affecting 613.9 million people annually, mainly in the tropics and subtropics. The reported seroprevalence in the United States is 4% with most of the cases reported in immigrants. Human T-lympho-tropic virus 1 (HTLV-1) infections, hypogammaglobulinemia, immunosuppressant use - particularly steroid use, alcoholism, and malnutrition have been associated with an increased risk of strongyloidiasis. Recently, cases of strongyloidiasis hyperinfection syndrome have been described in coronavirus disease 2019 (COVID-19) patients treated with steroids as well. This brief review discusses the epidemiology, clinical features, management, and prevention of strongyloidiasis including some facts about the infection in pregnancy, transplant recipients, and COVID-19 patients. We conducted an online search using the PubMed, Scopus, and Google Scholar databases. Strongyloidiasis can be asymptomatic or present with mild symptoms. Strongyloides stercoralis is known to cause autoinfection. In immunocompromised individuals, it can present with severe symptoms, hyperinfection, or disseminated disease. Reported mortality in cases of disseminated Strongyloidiasis is 87.1%. Serology and detection of larvae in stool by direct microscopy are the most commonly used methods to diagnose strongyloidiasis. The drug of choice for the treatment is ivermectin. However, the use of ivermectin in human pregnancy is not well studied, and its teratogenic risks are unknown. Proactive screening of strongyloidiasis is necessary in immunocompromised individuals to prevent severe disease.

Fatal Disseminated Strongyloidiasis in an Immunosuppressed Patient During COVID-19 Pandemic

INTRODUCTION

This report presents a fatal case of disseminated strongyloidiasis in a patient with myasthenia gravis and diabetes mellitus who had received corticosteroid therapy.

CASE REPORT

The patient was a 67-year-old woman living in a rural area endemic for Strongyloides stercoralis in northern Iran. Disseminated strongyloidiasis was diagnosed in the advanced stage of the disease, with enormous numbers of larvae demonstrated in direct smears prepared from stool samples and stomach biopsy. Despite treatment with ivermectin and antibiotics, the patient succumbed to the severity of the infection.

CONCLUSION

Clinicians working in endemic areas should be mindful of the possibility of gastric involvement in strongyloidiasis, even if symptoms are nonspecific. We recommend that high-risk individuals be screened for S. stercoralis prior to immunosuppressive therapy in endemic regions to raise awareness and prevent similar cases.

Disseminated Strongyloides stercoralis infection in the setting of Escherichia coli meningitis and bacteraemia in a patient living with HIV on high-dose corticosteroid therapy

Strongyloidiasis, a helminth infection caused by Strongyloides stercoralis, can be complicated by hyperinfection, especially in the setting of immunosuppression; however, many patients go undiagnosed. One clue to diagnosis is unexplained gram-negative bacteraemia or meningitis in patients who are immunosuppressed. Serology can be helpful but may be negative in these patients who are immunocompromised.We present the case of a white cisgender man from Central America in his 40s, living with HIV, with a CD4 count of 77 cells/µL. He was diagnosed with Strongyloides hyperinfection after an increase in his steroid dose. He also had Escherichia coli meningitis and bacteraemia. Strongyloidiasis was diagnosed by stool microscopy despite a negative serology test.This case highlights the challenges in diagnosing strongyloidiasis in the setting of immunosuppression. A high index of clinical suspicion is warranted for patients living with HIV on high-dose corticosteroids. Up to three stool microscopy studies for Strongyloides should be sent in addition to serology.

Diagnostic performance of Strongyloides-specific IgG4 detection in urine for diagnosis of human strongyloidiasis

BACKGROUND

Detection of parasite-specific IgG in urine is a sensitive method for diagnosis of strongyloidiasis and gives similar accuracy to serum IgG. However, there are no data concerning detection of IgG subclass in urine. To further explore the utility of diagnosis from urine samples, we evaluated the diagnostic performance of IgG4 in urine compared with parasitological and other immunological methods.

METHODS

The urine and sera included proven strongyloidiasis (group 1, n = 93), other parasitic infections (group 2, n = 40) and parasite negatives (group 3, n = 93). The performance of Strongyloides-specific IgG4 in urine for diagnosis of strongyloidiasis using fecal examinations as the reference standard was assessed.

RESULTS

With fecal examination as a gold standard, Strongyloides-specific IgG4 in urine had 91.4% sensitivity and 93.2% specificity while serum IgG4 had 93.6% sensitivity and 91.0% specificity. IgG4 in both urine and serum had almost perfect diagnostic agreements with fecal examination (Cohen's kappa coefficient was > 0.8). Cross-reactivity to Opisthorchis viverrini and Taenia spp. of IgG4 in urine were 7.5% and 12.5% in serum. Concurrent analyses of total IgG in urine and serum showed that the sensitivities (97.9-100%) and specificities (88.7-91.0%) were similar (P > 0.05). The sensitivity for parasitological examination by the formalin-ethyl acetate concentration technique (FECT) was 49.5% and that for agar plate culture technique (APC) it was 92.6%.

CONCLUSION

Our findings showed that specific IgG4 detection in urine yielded similar diagnostic performance to the same biomarkers in serum. This suggests that accurate diagnosis of strongyloidiasis can be performed using urine samples and IgG4 is a valid choice of diagnostic marker. Further assessment is required to assess the utility of urine IgG4 for measuring the response treatment in strongyloidiasis.

Prevalence of asymptomatic strongyloidiasis co-infection in COVID-19 patients residing in endemic areas

BACKGROUND

Fatal forms of strongyloidiasis, hyperinfection syndrome (HS) and disseminated strongyloidiasis (DS), are caused by exaggerated autoinfection of the intestinal nematode, Strongyloides stercoralis (S. stercoralis). Corticosteroids, frequently administered to patients with severe COVID-19, can transform chronic asymptomatic strongyloidiasis into the above-mentioned fatal diseases. This study aimed to investigate the prevalence of strongyloidiasis in COVID-19 patients receiving corticosteroids in a hypoendemic region.

METHODS

The present cross-sectional study enrolled 308 COVID-19 patients admitted to two hospitals in Ahvaz and Abadan in the southwest of Iran between 2020 and 2022. A real-time reverse transcription polymerase chain reaction (RT-PCR) test and chest computed tomography (CT) scan were employed to detect and monitor the disease's severity in the patients, respectively. All patients were evaluated for IgG/IgM against S. stercoralis using Enzyme-linked immunosorbent assay (ELISA) test. Subsequently, individuals with a positive ELISA test were confirmed using parasitological methods, including direct smear and agar plate culture (APC).

RESULTS

The patients were between 15 and 94 years old, with a mean age of 57.99 ± 17.4 years. Of the 308 patients, 12 (3.9%) had a positive ELISA test, while 296 (96.1%) had negative results. Three of the 12 patients with a positive ELISA result died, and three failed to provide a stool sample. To this end, only six cases were examined parasitologically, in which S. stercoralis larvae were observed in five patients. Significant differences were found between S. stercoralis infection with sex (p = 0.037) and age (p = 0.027). Binary regression analysis revealed that strongyloidiasis was positively associated with sex (odds ratio [OR]: 5.137; 95% confidence interval [CI]: 1.107-23.847), age (OR: 5.647; 95% CI 1.216-26.218), and location (OR: 3.254; 95% CI: 0.864-12.257).

CONCLUSIONS

Our findings suggest that screening for latent strongyloidiasis in COVID-19 patients in endemic areas using high-sensitivity diagnostic methods, particularly ELISA, before receiving suppressive drugs should be given more consideration.

Epidemiological, Clinical and Laboratory Features of Strongyloidiasis in 69 Attendees at a French Outpatient Clinic

The present retrospective study analyzed the characteristics of strongyloidiasis in patients who were diagnosed at the Outpatient Clinic of the Department of Parasitology-Mycology, Toulouse, France. Sixty-nine file records were included in the study on the basis of a positive stool examination that used Baermann's method. The prominent epidemiological findings were the presence of former immigrants from Italy or Portugal, veterans from the 1st Indochina war, and autochthonous cases. Almost 1/4 of the patients were asymptomatic. Manifestations of skin allergy were the main clinical feature. Blood eosinophilia was present in 76.8% of the patients, and serum total IgE was ≥150 kIU/L in 79.7%. Immunodiagnosis was achieved from 1990 to 2001 by indirect immunofluorescence (IFAT) that was then replaced with ELISA, both methods using Strongyloides ratti filariform larvae. ELISA was found to be similar to IFAT in terms of specificity but exhibited a greater sensitivity. Patients were primarily treated with albendazole or ivermectin beginning in 1993. Forty-eight patients attended the follow-up consultation. Kinetics of the clinical picture and blood eosinophilia were found to be the most convenient parameters to assess the efficacy of anthelmintic therapy. In conclusion, strongyloidiasis remains a neglected disease in Southwestern France. The resolution of clinical features along with the kinetics of eosinophilia appeared to be the most appropriate parameters to check during the posttreatment follow-up.

Gastroduodenal strongyloidiasis infection causing protein-losing enteropathy: A case report and review of the literature

Strongyloides stercoralis is an intestinal nematode in which adult worms in the host small intestine can cause strongyloidiasis. Symptoms in immunocompromised patients might range from diarrhea and bleeding to sepsis and even death. A 56-year-old patient presented with a 2-month history of weight loss, vomiting, and diarrhea. The patient had type 2 diabetes mellitus (T2DM) and was on long-term prednisone for chronic kidney disease. The results of the gastric emptying test and head magnetic resonance (MRI) were normal. A blood test revealed increased IgE levels, eosinophilia, and hypoalbuminemia. Parasitic larvae were not discovered during stool analysis. Gastroscopy revealed chronic nonatrophic gastritis with erosions and dilation of lymphatic vessels of the duodenum. Small-bowel capsule endoscopy suggested dilation of lymphatic vessels of the small intestine. Colonoscopy revealed no abnormalities. Finally, a histopathology examination identified S. stercoralis pervasion in the gastric antrum and duodenum. The patient was treated with albendazole and discharged successfully. In conclusion, we discovered S. stercoralis as a cause of protein-losing enteropathy in a patient with a long-term oral corticosteroid therapy and T2DM. The diagnosis was made through histopathology, once parasitological examination was negative. Therefore, health professionals should stay alert to S. stercoralis infection in immunocompromised patients with vague gastrointestinal symptoms. More sensitive methods should be applied in the diagnosis.

Efficacy of Oral Ivermectin as Empirical Prophylaxis for Strongyloidiasis in Patients Treated with High-Dose Corticosteroids: A Retrospective Cohort Study

People living in areas endemic for strongyloidiasis are at risk of latent Strongyloides stercoralis infection. Corticosteroid therapy is a well-established risk factor for life-threatening hyperinfection syndrome and disseminated disease owing to suppression of the immune system. There are limited data available on the efficacy and cost of providing oral ivermectin prophylaxis to all patients receiving high-dose corticosteroids for strongyloidiasis in endemic areas. We thus conducted this retrospective cohort study at Khon Kaen University's Srinagarind Hospital from 2015 to 2019. Inclusion criteria were as follows: age ≥ 18 years, having received ≥ 0.5 mg/kg/day of prednisolone or equivalent for at least 14 days, and hospitalization during the study period. A total of 250 patients were included in the study: 125 in the empirical prophylaxis group (prescribed ivermectin even if fecal examination results were negative or nonexistent) and the remaining patients in the definite therapy group (prescribed ivermectin only if S. stercoralis was detected by fecal examination). The prevalence of strongyloidiasis at enrollment estimated by fecal examination was 5.5%. Ivermectin was given to 125 patients (100%) in the prophylaxis group compared with 12 (9.6%) in the definite therapy group (P value < 0.001). During the 12-month follow-up period, S. stercoralis was detected in three patients, two in the prophylaxis group and one in the definite therapy group (P value = 1.000). No cases of hyperinfection syndrome or disseminated disease were found. The empirical prophylaxis strategy had a significantly higher cost than the definite therapy strategy (563 versus 254, P value < 0.001) and did not demonstrate superior efficacy in strongyloidiasis prevention.

Importance of Balanced Attention Toward Coronavirus Disease 2019 and Neglected Tropical Diseases

Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has been spreading since 2019, causing a worldwide pandemic. Amid the COVID-19 pandemic, tuberculosis, AIDS, and malaria have adversely affected the quality of life of patients and killed millions of people. In addition, COVID-19 continues to impede the delivery of health services, including those for the control of neglected tropical diseases (NTDs). Furthermore, NTDs have been reported as possible co-pathogens among patients infected with COVID-19. However, studies regarding parasitic co-infection among these patients have been limited. This review aimed to explore and describe the cases and reports of parasitic infections in the backdrop of COVID-19 to provide comprehensive knowledge regarding this aspect. We reviewed seven cases of patients who had parasitic co-infection and tested positive for COVID-19, and summarized the literature on the importance of controlling parasitic diseases. In addition, we identified recommendations for the control of parasitic diseases under possible difficulties, such as declining funding for parasitic diseases in 2020. This review highlights the growing burden of NTDs under COVID-19 that may be caused by the deficiency of healthcare infrastructure and human resources as the main reasons. Clinicians should remain vigilant for possible co-infections with parasites in COVID-19 patients, while policymakers are urged to reinforce a balanced and long-term health strategy that addresses both NTDs and COVID-19.

Bacterial, fungal and parasitic co-infections in leprosy: A scoping review

BACKGROUND

In leprosy patients, the most commonly reported non-viral co-infections are Tuberculosis, Leishmaniasis, Chromoblastomycosis and Helminths. The presence of a secondary infection is believed to increase the likelihood of leprosy reactions. The purpose of this review was to describe the clinical and epidemiological characteristics of the most reported bacterial, fungal, and parasitic co-infections in leprosy.

METHODOLOGY/PRINCIPAL FINDINGS

Following the PRISMA Extension for Scoping Reviews guidelines, a systematic literature search was conducted by two independent reviewers, resulting in the inclusion of 89 studies. For tuberculosis, a total of 211 cases were identified, with a median age of 36 years and male predominance (82%). Leprosy was the initial infection in 89% of cases, 82% of individuals had multibacillary disease, and 17% developed leprosy reactions. For leishmaniasis, 464 cases were identified, with a median age of 44 years and male predominance (83%). Leprosy was the initial infection in 44% of cases, 76% of individuals presented with multibacillary disease, and 18% developed leprosy reactions. Regarding chromoblastomycosis, we identified 19 cases with a median age of 54 years and male predominance (88%). Leprosy was the primary infection in 66% of cases, 70% of individuals had multibacillary disease, and 35% developed leprosy reactions. Additionally, we found 151 cases of co-infection with leprosy and helminths, with a median age of 43 years and male predominance (68%). Leprosy was the primary infection in 66% of cases, and 76% of individuals presented with multibacillary disease, while the occurrence of leprosy reactions varied from 37% to 81% across studies.

CONCLUSION

We observed a male-dominated pattern of co-infections among working-age individuals with multibacillary leprosy. Unlike prior studies reporting increased leprosy reactions in chronic viral co-infections, our findings did not indicate any increase among bacterial, fungal, or parasitic co-infections. Rather, co-infections with tuberculosis and leishmaniasis appeared to reduce leprosy reactions.

Coinfection with Strongyloides and SARS-CoV-2: A Systematic Review

BACKGROUND

Treatments for COVID-19, including steroids, might exacerbate Strongyloides disease in patients with coinfection. We aimed to systematically review clinical and laboratory features of SARS-CoV-2 and Strongyloides coinfection, investigate possible interventions, assess outcomes, and identify research gaps requiring further attention.

METHODS

We searched two electronic databases, LitCOVID and WHO, up to August 2022, including SARS-CoV-2 and Strongyloides coinfection studies. We adapted the World Health Organization-Uppsala Monitoring Centre (WHO-UMC) system for standardized case causality assessment to evaluate if using corticosteroids or other immunosuppressive drugs in COVID-19 patients determined acute manifestations of strongyloidiasis.

RESULTS

We included 16 studies reporting 25 cases of Strongyloides and SARS-CoV-2 coinfection: 4 with hyperinfection syndrome; 2 with disseminated strongyloidiasis; 3 with cutaneous reactivation of strongyloidiasis; 3 with isolated digestive symptoms; and 2 with solely eosinophilia, without clinical manifestations. Eleven patients were asymptomatic regarding strongyloidiasis. Eosinopenia or normal eosinophil count was reported in 58.3% of patients with Strongyloides reactivation. Steroids were given to 18/21 (85.7%) cases. A total of 4 patients (19.1%) received tocilizumab and/or Anakirna in addition to steroids. Moreover, 2 patients (9.5%) did not receive any COVID-19 treatment. The causal relationship between Strongyloides reactivation and COVID-19 treatments was considered certain (4% of cases), probable (20% of patients), and possible (20% of patients). For 8% of cases, it was considered unlikely that COVID-19 treatment was associated with strongyloidiasis reactivations; the relationship between the Strongyloides infection and administration of COVID-19 treatment was unassessable/unclassifiable in 48% of cases. Of 13 assessable cases, 11 (84.6%) were considered to be causally associated with Strongyloides, ranging from certain to possible.

CONCLUSIONS

Further research is needed to assess the frequency and risk of Strongyloides reactivation in SARS-CoV-2 infection. Our limited data using causality assessment supports recommendations that clinicians should screen and treat for Strongyloides infection in patients with coinfection who receive immunosuppressive COVID-19 therapies. In addition, the male gender and older age (over 50 years) may be predisposing factors for Strongyloides reactivation. Standardized guidelines should be developed for reporting future research.

A Rare Case of Strongyloides stercoralis Hyperinfection in a Diabetic Patient from Romania-Case Report and Review of the Literature

Severe cases of strongyloidiasis are most often associated with multiple causes of immune suppression, such as corticoid treatment and HTLV (human T-lymphotropic virus) coinfection. Diabetes is not traditionally considered a risk factor for the development of severe strongyloidiasis. We report a rare case of autochthonous severe strongyloidiasis in Romania, a European country with a temperate climate. A 71-year-old patient with no prior travel history was admitted with multiple gastrointestinal complaints and recent weight loss. CT (computed tomography) scans indicated duodenal wall thickening, and duodenal endoscopy evidenced mucosal inflammation, ulcerations and partial duodenal obstruction at D4. Microscopic examination of stool samples and biopsy specimens from the gastric and duodenal mucosa revealed an increased larval burden characteristic of Strongyloides stercoralis hyperinfection. Sequential treatment with albendazole and ivermectin achieved parasitological cure and complete recovery. The novelty of our case stems from the scarcity of severe strongyloidiasis cases reported in Europe and especially in Romania, the absence of other risk factors in our patient aside from diabetes, the involvement of the gastric mucosa and the rare presentation as partial duodenal obstruction. This case highlights the importance of considering strongyloidiasis as a differential diagnosis, even in temperate climates where cases are sporadic, in cases in which immune suppression is not evident and in the absence of eosinophilia. The case is presented in the context of the first literature review examining the relationship between severe strongyloidiasis and diabetes, emphasizing diabetes as a possible risk factor for severe strongyloidiasis.

Disseminated Strongyloidiasis in Renal Transplant Recipient Complicated with Neurological Manifestations

Introduction: Infections caused by Strongyloides stercoralis are quite difficult to detect. It can remain silent long before manifesting, which used to occur when patients were under immunosuppressed conditions. This scenario makes the patient’s treatment and recovery hard to deal with. Case Presentation: This paper reports the case of a renal transplant patient who presented disseminated strongyloidiasis infection complicated with neurological manifestations. In order to eliminate Strongyloides stercoralis, the patient initially received oral Ivermectin treatment, and as the infection persisted, parenteral treatment was provided. The patient developed flaccid tetraparesis and increased cerebrospinal fluid protein with albumin- cytological dissociation, initially suggesting the diagnosis of Guillain-Barré syndrome. Conclusions: This clinical report highlights the need for early diagnosis and treatment in cases of immunosuppressed patients with strongyloidiasis infection, as the diagnosis might be neglected.

Seroprevalence of Strongyloides stercolaris in Patients about to Receive Immunosuppressive Treatment in Gran Canaria (Spain)

Strongyloides stercoralis infection is generally asymptomatic or mildly symptomatic, but in the immunosuppressed host, it is associated with more severe and complicated forms with a worse prognosis. S. stercoralis seroprevalence was studied in 256 patients before receiving immunosuppressive treatment (before kidney transplantation or starting biological treatments). As a control group, serum bank data of 642 individuals representative of the population of the Canary Islands were retrospectively analyzed. To avoid false positives due to cross-reactivity with other similar helminth antigens present in the study area, IgG antibodies to Toxocara spp. and Echinococcus spp. were evaluated in cases positive for Strongyloides. The data show this is a prevalent infection: 1.1% of the Canarian population, 2.38% of Canarian individuals awaiting organ transplants and 4.8% of individuals about to start biological agents. On the other hand, strongyloidiasis can remain asymptomatic (as observed in our study population). There are no indirect data, such as country of origin or eosinophilia, to help raise suspicion of the disease. In summary, our study suggests that screening for S. stercoralis infection should be performed in patients who receive immunosuppressive treatment for solid organ transplantation or biological agents, in line with previous publications.

Strongyloides and COVID-19: Challenges and Opportunities for Future Research

Strongyloides stercoralis is a soil transmitted helminth endemic to tropical and subtropical areas that can persist for decades in immunocompetent human hosts as a chronic asymptomatic infection. The use of corticosteroids, a mainstay of treatment for patients hospitalized with severe coronavirus disease (COVID-19), can trigger a life-threatening Strongyloides hyperinfection syndrome and disseminated disease. We identified 22 previously published cases of strongyloidiasis occurring in individuals with COVID-19, with one death reported among the seven patients who had Strongyloides hyperinfection syndrome. A total of seventeen patients had previously received corticosteroids, and of the five with no prior corticosteroid use, one presented with hyperinfection syndrome. We identify the key challenges in the diagnosis and treatment of Strongyloides within the context of COVID-19, including our imprecise knowledge of the global distribution of Strongyloides, the overlapping symptoms and signs of COVID-19 and Strongyloides hyperinfection syndrome, the limited utility of eosinophilia as a clinical marker for strongyloidiasis in this setting, the lack of validated algorithms to screen for Strongyloides prior to corticosteroid use, and the paucity of treatment options for critically ill patients with COVID-19 who cannot take oral ivermectin. Future research should focus on improved diagnostic methods and population prevalence estimates, optimizing the approaches for Strongyloides screening in persons with COVID-19 (including clinical trial participants and strategies for resource-limited settings) and better defining the role of pre-emptive treatment.

Prevalence and risk factors of Strongyloides stercoralis in haemodialysis in Cochabamba, Bolivia: a cross-sectional study

BACKGROUND

Strongyloidiasis is an infectious disease that can be fatal in immunocompromised patients. Patients with end-stage renal failure who are on dialysis have a considerably weakened immune system, and organ transplantation is a major risk factor for severe strongyloidiasis. Knowledge of the local epidemiology in tropical and subtropical areas is an essential prerequisite for designing an appropriate strategy to prevent this potentially lethal complication. In this study, we aimed to estimate the prevalence and associated risk factors of S. stercoralis infection in patients on dialysis in Cochabamba, Bolivia.

METHODS

A cross-sectional study was carried out among patients undergoing haemodialysis in Cochabamba (elevation 2,500 m, temperate climate), collecting information on socio-demographic, lifestyle, and clinical variables, and using one coproparasitological technique (the modified Baermann technique) and one serological (ELISA) test for S.stercoralis diagnosis.

RESULTS

In total, 149 patients participated in the study (mean age = 51.4 years, 48.3% male). End-stage renal disease was predominantly (59%) of hypertensive and/or diabetic origin. The positive serological prevalence was 18.8% (95% CI: 13.3%-25.9%). Based on the sensitivity and specificity of the ELISA test, the estimate of the actual prevalence was 15.1% (95% CI: 9.4%-20.7%). Stool samples of 105 patients (70.5%) showed a coproparasitological prevalence of 1.9% (95% CI: 0.52%-6.68%). No potential risk factors were significantly associated with S. stercoralis infection.

CONCLUSIONS

We found a high seroprevalence of S. stercoralis in Bolivian patients undergoing haemodialysis in Cochabamba. We recommend presumptive antiparasitic treatment at regular intervals to avoid the potentially fatal complications of severe strongyloidiasis.

Strongyloidiasis presenting during treatment of low-dose glucocorticoid plus rituximab for anti-signal recognition particle antibody-positive polymyositis: A case report

Strongyloidiasis, an intestinal parasitic infection caused by Strongyloides stercoralis, rarely occurs in Japan. When treated with immunosuppressive drugs, two potentially lethal conditions, hyperinfection and dissemination, may develop in asymptomatic carriers of this parasite. We report the development of strongyloidiasis during treatment of polymyositis with glucocorticoids plus rituximab (RTX). A 44-year-old woman had been diagnosed with anti-signal recognition particle antibody-positive polymyositis with interstitial pneumonia 6 years previously, for which she had recently been receiving prednisolone at 5 mg/day and RTX at 375 mg/m2 twice every 3 months. Her condition appeared to be well controlled. She was admitted to our hospital with a 1-month history of chronic diarrhoea and epigastric pain. Standard microscopic examination of a sample of faeces revealed the presence of S. stercoralis; however, serologic testing for parasites was negative. Treatment with ivermectin alleviated her inflammatory diarrhoea and eradicated the faecal parasites. We believe that our patient had an exacerbation of S. stercoralis infection (hyperinfection syndrome) that was exacerbated by low-dose glucocorticoids plus RTX. Strongyloidiasis should be considered in immunocompromised individuals with unexplained diarrhoea, even in non-endemic areas.

Living without eosinophils: evidence from mouse and man

The enduring view of eosinophils, as immune effector cells whose primary function is host defence against infection by helminths and other microbial pathogens, sets the stage for a fundamental question regarding the safety of therapeutic eosinophil depletion. If eosinophils are significantly reduced or altogether depleted in an effort to alleviate the negative effects of tissue eosinophilia and eosinophilic inflammation in conditions such as asthma, COPD, chronic rhinosinusitis with nasal polyps, eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndrome, would these patients become susceptible to infection or another illness? Development of mouse models in which the eosinophil lineage has been ablated, observations in patients naturally lacking eosinophils and data from studies of eosinophil-depleting medical therapies indicate that the absence of eosinophils is not detrimental to health. The evidence available to date, as presented in this review, supports the conclusion that even if certain homeostatic roles for the eosinophil may be demonstrable in controlled animal models and human in vitro settings, the evolution of the human species appears to have provided sufficient immune redundancy such that one may be hale and hearty without eosinophils.

Prevalence of intestinal parasitic infections and genetic differentiation of Strongyloides stercoralis among migrant workers from Myanmar, Lao PDR and Cambodia in northeastern Thailand

Intestinal parasitic infections (IPIs) remain a public-health problem worldwide, including in countries of the Lower Mekong subregion. Increases in human migration from neighboring countries might cause reemerging parasitic infections, leading to spread of parasites in the landscape. Here, we conducted a cross-sectional study to identify the prevalence of IPIs in migrant workers from Myanmar, Lao PDR, and Cambodia who were dwelling in Nakhon Ratchasima Province, northeastern Thailand. The identification of Strongyloides species and genetic differentiation of worms from migrant workers with different countries of origin was also assessed. Fresh stool samples were collected from 338 migrant workers and examined for evidence of IPIs using agar plate culture (APC) and the formalin-ethyl acetate concentration technique (FECT). Among those nine samples positive for nematodes by APC, the Strongyloides or hookworm species present was confirmed using the polymerase chain reaction (PCR) followed by DNA sequencing. This revealed eight cases of Strongyloides stercoralis infection and one of Necator americanus. Fifty-one out of 338 individuals (15.09%) were positive for IPIs using FECT and APC. Eggs of Opisthorchis-like flukes were the most common parasite (11.83% of samples), followed by S. stercoralis (2.37%), Entamoeba coli (1.50%), hookworm (0.89%), Taenia sp. (0.60%) and Hymenolepis nana (0.30%). The genetic differentiation of S. stercoralis recovered from migrant workers with different countries of origin was analyzed. Specimens of S. stercoralis isolated from workers from Lao PDR, Cambodia and Myanmar were genetically similar to those sequenced from Thailand. However, there were population-genetic differences between S. stercoralis from these Southeast Asian countries and other regions of the world. This study demonstrated that IPIs were prevalent in migrant workers in the northeastern region of Thailand. Our findings provided molecular confirmation of the presence of S. stercoralis and explored the genetic differentiation of S. stercoralis from those infected migrant workers. An effective anti-parasitic drug should be provided for migrant workers and its administration enforced.

Opportunistic etiological agents causing lung infections: emerging need to transform lung-targeted delivery

Lung diseases continue to draw considerable attention from biomedical and public health care agencies. The lung with the largest epithelial surface area is continuously exposed to the external environment during exchanging gas. Therefore, the chances of respiratory disorders and lung infections are overgrowing. This review has covered promising and opportunistic etiologic agents responsible for lung infections. These pathogens infect the lungs either directly or indirectly. However, it is difficult to intervene in lung diseases using available oral or parenteral antimicrobial formulations. Many pieces of research have been done in the last two decades to improve inhalable antimicrobial formulations. However, very few have been approved for human use. This review article discusses the approved inhalable antimicrobial agents (AMAs) and identifies why pulmonary delivery is explored. Additionally, the basic anatomy of the respiratory system linked with barriers to AMA delivery has been discussed here. This review opens several new scopes for researchers to work on pulmonary medicines for specific diseases and bring more respiratory medication to market.

Strongyloidiasis infection in a borderline lepromatous leprosy patient with adrenocorticoid insufficiency undergoing corticosteroid treatment: a case report

BACKGROUND

Strongyloidiasis is a soil-transmitted helminthiasis mainly caused by Strongyloides stercoralis. It is endemic to the tropics and subtropics. Sri Lanka has a 0-1.6% prevalence rate. S. stercoralis infection was identified in a 33-year-old Sri Lankan male patient treated with corticosteroids for borderline lepromatous leprosy with adrenocortical dysfunction.

CASE PRESENTATION

In March 2020, a 33-year-old Sri Lankan (Sinhalese) male patient presented with watery diarrhea, lower abdominal pain, and post-prandial abdominal fullness. Previously, he was diagnosed with borderline lepromatous leprosy and was treated with rifampicin, clofazimine, and prednisolone 60 mg daily since July 2019. After developing gastrointestinal symptoms, he had defaulted leprosy treatment including the prednisolone for 3 months. Duodenal biopsy revealed numerous intraepithelial nematodes within the lumina of glands in the duodenum whose appearance favored Strongyloides. Fecal wet smear revealed numerous Strongyloidis stercoralis L1 rhabditiform larvae. Larval tracks were seen in the agar plate culture. L3 filariform larvae of Strongyloidis stercoralis were seen in the Harada-Mori culture. In addition, the short synacthen test revealed adrenocortical insufficiency, and oral hydrocortisone and fludrocortisone were started with albendazole treatment against strongyloidiasis. Fecal wet smear and culture repeated after treatment with albendazole were negative for Strongyloidis stercoralis. The patient was discharged in July 2020 on oral hydrocortisone. One month later his condition was reviewed and the repeated fecal wet smear and agar plate culture was normal. He is being followed up every 3 months.

CONCLUSION

This is the first case of strongyloidiasis diagnosed in a patient with borderline lepromatous leprosy from Sri Lanka. The patient manifested symptoms of strongyloidiasis while on high-dose steroid therapy for his lepromatous reaction. Subsequently, the patient not only discontinued his steroid therapy, but also developed adrenocortical insufficiency as a complication of leprosy. Therefore, although diagnosis of strongyloidiasis was delayed, his subsequent low steroid levels probably protected him from disseminated disease. This is an interesting case where symptomatic strongyloidiasis was diagnosed in a patient who was initially treated with high-dose steroids but subsequently developed adrenocortical insufficiency. We emphasize the need to screen all patients prior to the commencement of immunosuppressive therapy.

Controversies in neuroimmunology: multiple sclerosis, vaccination, SARS-CoV-2 and other dilemas

Neuroimmunology is a discipline that increasingly broadens its horizons in the understanding of neurological diseases. At the same time, and in front of the pathophysiological links of neurological diseases and immunology, specific diagnostic and therapeutic approaches have been proposed. Despite the important advances in this discipline, there are multiple dilemmas that concern and filter into clinical practice. This article presents 15 controversies and a discussion about them, which are built with the most up-to-date evidence available. The topics included in this review are: steroid decline in relapses of multiple sclerosis; therapeutic recommendations in MS in light of the SARS-CoV-2 pandemic; evidence of vaccination in multiple sclerosis and other demyelinating diseases; overview current situation of isolated clinical and radiological syndrome; therapeutic failure in multiple sclerosis, as well as criteria for suspension of disease-modifying therapies; evidence of the management of mild relapses in multiple sclerosis; recommendations for prophylaxis against Strongyloides stercolaris; usefulness of a second course of immunoglobulin in the Guillain-Barré syndrome; criteria to differentiate an acute-onset inflammatory demyelinating chronic polyneuropathy versus Guillain-Barré syndrome; and, the utility of angiotensin-converting enzyme in neurosarcoidosis. In each of the controversies, the general problem is presented, and specific recommendations are offered that can be adopted in daily clinical practice.

Strongyloides stercoralis: A Neglected but Fatal Parasite

Strongyloidiasis is a disease caused by Strongyloides stercoralis and remains a neglected tropical infection despite significant public health concerns. Challenges in the management of strongyloidiasis arise from wide ranging clinical presentations, lack of practical high sensitivity diagnostic tests, and a fatal outcome in immunocompromised hosts. Migration, globalization, and increased administration of immunomodulators, particularly during the COVID-19 era, have amplified the global impact of strongyloidiasis. Here, we comprehensively review the diagnostic tests, clinical manifestations, and treatment of strongyloidiasis. The review additionally focuses on complicated strongyloidiasis in immunocompromised patients and critical screening strategies. Diagnosis of strongyloidiasis is challenging because of non-specific presentations and low parasite load. In contrast, treatment is simple: administration of single dosage ivermectin or moxidectin, a recent anthelmintic drug. Undiagnosed infections result in hyperinfection syndrome and disseminated disease when patients become immunocompromised. Thus, disease manifestation awareness among clinicians is crucial. Furthermore, active surveillance and advanced diagnostic tests are essential for fundamental management.

A systematic review and meta-analysis of human and zoonotic dog soil-transmitted helminth infections in Australian Indigenous communities

Soil-transmitted helminths (STH) infect 1.5 billion people and countless animals worldwide. In Australian Indigenous communities, STH infections have largely remained endemic despite control efforts, suggesting reservoirs of infection may exist. Dogs fulfil various important cultural, social and occupational roles in Australian Indigenous communities and are populous in these settings. Dogs may also harbour zoonotic STHs capable of producing morbidity and mortality in dogs and humans. This review provides an overview of human and zoonotic STH infections, identifies the Australian Indigenous locations affected and the parasite species and hosts involved. The meta-analysis provides estimates of individual study and pooled true prevalence of STH infections in Australian Indigenous communities and identifies knowledge gaps for further research on zoonotic or anthroponotic potential. A systematic literature search identified 45 eligible studies documenting the presence of Strongyloides stercoralis, Trichuris trichiura, Ancylostoma caninum, Ancylostoma duodenale, Ancylostoma ceylanicum, undifferentiated hookworm, and Ascaris lumbricoides. Of these studies, 26 were also eligible for inclusion in meta-analysis to establish true prevalence in the light of imperfect diagnostic test sensitivity and specificity by Rogan-Gladen and Bayesian methods. These studies revealed pooled true prevalence estimates of 18.9% (95% CI 15.8–22.1) for human and canine S. stercoralis infections and 77.3% (95% CI 63.7–91.0) for canine A. caninum infections indicating continued endemicity, but considerably more heterogenous pooled estimates for canine A. ceylanicum infections, and A. duodenale, undifferentiated hookworm and T. trichiura in humans. This review suggests that the prevalence of STHs in Australian Indigenous communities has likely been underestimated, principally based on imperfect diagnostic tests. Potential misclassification of hookworm species in humans and dogs due to outdated methodology, also obscures this picture. High-quality contemporary studies are required to establish current true prevalence of parasite species in all relevant hosts to guide future policy development and control decisions under a culturally sound One Health framework.

Soil-transmitted helminths include hookworms, threadworms, whipworms and roundworms. These worms may infect different hosts including humans and dogs, and some species are zoonotic, meaning that they are able to transmit between animals and humans. In many Australian Indigenous communities, people remain infected with these worms at high rates compared to other parts of the country despite various control strategies. Resource and health literacy inequalities are primary drivers for these differences. However, the potential for dogs to act as reservoirs for zoonotic worm infections in humans must also be considered. For this reason, it’s important to create a clear picture of the level of infection by location and host. Given that tests used to establish prevalence can produce false positive or negative results, we performed a meta-analysis allowing comparison of true prevalence estimates by location and host, regardless of the test used. This review suggests that threadworm and dog hookworm remain endemic in Australian Indigenous communities, though a gap exists to accurately inform the prevalence of the other worms. It also highlights the need for One Health strategies in research, policy and control where humans, all animal hosts and the environment are considered in a culturally relevant way.

Strongyloides stercoralis hyperinfection syndrome with cerebral involvement

Strongyloidiasis is a disease caused by the intestinal helminth Strongyloides stercoralis. When the immune system of infected individuals is compromised, larvae may migrate from the gastrointestinal tract to other tissues, causing S. stercoralis hyperinfection syndrome, which has a reported mortality of 71%. In this case, we report a patient with S. stercoralis hyperinfection syndrome with central nervous system (CNS) involvement. An elderly South East Asian male tourist presented with pulmonary symptoms, fever and infiltrates on chest X-ray. He later developed symptoms of CNS infection. S. stercoralis larvae were found in a stool sample. Microbiological examination of cerebrospinal fluid revealed S. stercoralis-specific DNA. The patient was treated with oral and rectal ivermectin and albendazole. The condition was complicated by sepsis, bacteraemia and hypereosinophilia. Unfortunately, the patient eventually died from pulmonary oedema and insufficiency. This case highlights the global importance of Strongyloides CNS infection in endemic and non-endemic regions.

Strongyloidiasis Hyperinfection Syndrome in COVID-19 Positive Migrants Treated with Corticosteroids

The aim of this study is to highlight the potentially fatal risk of Strongyloidiasis Hyperinfection Syndrome for hospitalized immigrant patients with moderate to severe COVID-19 disease and undiagnosed Strongyloidiasis. We reviewed electronic medical records of immigrants from 2010 to 2022 and extracted the number of patients with eosinophilia, strongyloidiasis and COVID-19 infection, outpatient and hospitalized. While 885 outpatients were diagnosed with eosinophilia, only 356 (40.2%) were tested for strongyloidiasis and 160 (44.9%) yielded a reactive serology. COVID-19 infection was reported in 6,412 patients. 1135 (17.7%) of these patients sought hospital care. Patients with undiagnosed strongyloidiasis are at risk for a potentially fatal parasitosis if treated with systemic corticosteroids for COVID-19. This supports clinical guidelines in hospital settings for those with severe COVID-19. Strongyloidiasis should be considered by taking a thorough travel or migration history and testing before giving immunosuppressive drugs.

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.

Disseminated strongyloidiasis in a patient with rheumatoid arthritis: A case report

BACKGROUND

Strongyloidiasis is usually a chronic infection but it can develop into a fatal disease in immunosuppressed patients.

CASE SUMMARY

A 68-year-old male with rheumatoid arthritis was treated with a variety of immunosuppressants for the past 3 years. Recently, the patient presented with a partial small-bowel obstruction, petechia, coughing and peripheral neuropathy. The diagnosis was difficult to clarify in other hospitals. Our hospital found Strongyloides stercoralis larvae with active movement in the routine stool and sputum smears. The diagnosis of disseminated strongyloidiasis was established. Ivermectin combined with albendazole was used for treatment. The patient responded to therapy and was discharged.

CONCLUSION

This case underscores the importance of comprehensive differential diagnosis in immunocompromised patients.

Ineffectiveness of TF-Test® and Coproplus® Methods in Strongyloides stercoralis Infection Diagnosis

PURPOSE

S. stercoralis diagnosis is currently performed by parasitological methods, mainly by Baermann-Moraes (BM), although Agar Plate Culture (APC) presents a higher sensitivity. New techniques, such as TF-Test® and Coproplus® have been suggested as more practical alternatives. The aim of this study was to evaluate the sensitivity of TF-Test® and Coproplus®, compared with APC, BM and Spontaneous Sedimentation (SS) methods.

METHODS

One-hundred and forty male alcoholic patients, who provided three stools samples collected on alternate days, were included in this study. The most frequently found parasite was S. stercoralis, 20% (28/140), and the most sensitive method was APC, 96.4% (27/28), followed by BM, 89.3% (25/28) and SS, 57.1% (16/28). TF-Test® and Coproplus® presented a sensitivity of 46.4 (13/28) and 39.3% (11/28), respectively. In samples with a parasitic load of 1-10 larvae/g of feces, which occurred in 39.3% (11/28) of the infected patients, both the TF-Test® and Coproplus® methods demonstrated sensitivities of 18.2% (2/11), while APC and BM methods reached a sensitivity of 100% (11/11) (p < 0.05). For other intestinal helminth infections, TF-Test® and Coproplus® sensitivities were 22.2 (4/18) and 11.1% (2/18), respectively, this being lower than the SS, 66.7% (12/18) (p < 0.05). On the other hand, for protozoa infection diagnosis, TF-Test® and Coproplus® presented the highest sensitivities, 62.2 (46/74) and 43.2% (32/74), respectively.

CONCLUSION

TF-Test® and Coproplus® methods presented the lowest sensitivities for S. stercoralis and other helminth infection diagnosis; therefore, they can be indicated for use in parasitological diagnosis, only when associated with other more effective methods of helminth identification.