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Buonfrate D, Bradbury RS, Watts MR, Bisoffi Z. Human strongyloidiasis: complexities and pathways forward. Clin Microbiol Rev 2023; 36:e0003323. [PMID: 37937980 PMCID: PMC10732074 DOI: 10.1128/cmr.00033-23] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/11/2023] [Indexed: 11/09/2023] Open
Abstract
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.
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Affiliation(s)
- Dora Buonfrate
- Department of Infectious Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Richard S. Bradbury
- School of Health and Life Sciences, Federation University Australia, Berwick, Victoria, Australia
| | - Matthew R. Watts
- Centre for Infectious Diseases and Microbiology, Institute of Clinical Pathology and Medical Research – New South Wales Health Pathology and Sydney Institute for Infectious Diseases, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Zeno Bisoffi
- Department of Infectious Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
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Corrêa LQ, do Couto BP, de Carvalho EFG, de Sousa JEN, da Silva Ribeiro V, Gonzaga HT, Costa-Cruz JM. Route of dexamethasone administration influences parasite burden in Strongyloides hyperinfection model. J Parasit Dis 2023; 47:520-526. [PMID: 37520210 PMCID: PMC10382442 DOI: 10.1007/s12639-023-01595-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/06/2023] [Indexed: 08/01/2023] Open
Abstract
Rodents infected with Strongyloides venezuelensis are experimental models applied to strongyloidiasis research. This study evaluated oral and subcutaneous dexamethasone (DEX) treatments to establish immunosuppression in an experimental model of Strongyloides hyperinfection. Rattus norvegicus Wistar were divided: G I (-): untreated and uninfected animals, G II (+): untreated and infected, G III (o -) orally treated and uninfected, G IV (o +) orally treated and infected, G V (sc -) subcutaneously treated and uninfected, G VI (sc +) subcutaneously treated and infected. For oral administration, DEX was diluted in sterile water (5 µg/ml) and made available to the animals on intervals in experimental days - 5-0, 8-13 and 21-26. For subcutaneous administration, animals received daily injections of DEX disodium phosphate (2 mg/kg). Infection was established by the subcutaneous inoculation of 3000 S. venezuelensis filarioid larvae. Groups were evaluated by egg per gram of feces and parasite females counts and IgG, IgG1 and IgG2a detection. GIV (o +) had egg peaks count on days 13 and 26 and maintained egg elimination until the last experimental day. Parasitic females recovery at day 30 was significantly higher in G IV (o +) when compared to G VI (sc +). Levels of IgG, IgG1 and IgG2a of all groups, except the positive control GII (+), were below the detection threshold. Pharmacological immunosuppression induced by oral administration of DEX produced high parasitic burden, and is a noninvasive method, useful to establish immunosuppression in strongyloidiasis hyperinfection model in rats.
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Affiliation(s)
- Luisa Queiroz Corrêa
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais Brazil
| | - Bruna Patrícia do Couto
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais Brazil
| | - Edson Fernando Goulart de Carvalho
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais Brazil
| | - José Eduardo Neto de Sousa
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais Brazil
| | - Vanessa da Silva Ribeiro
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais Brazil
| | - Henrique Tomaz Gonzaga
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais Brazil
| | - Julia Maria Costa-Cruz
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais Brazil
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Vera Torres A, González LP, Mususú WC, Vásquez SV, Cortés Mejía NA, López Panqueva RDP. Case Report: Duodenal Papillary Stenosis Secondary to Strongyloides stercoralis Infection in a Non-Immunocompromised Host. Am J Trop Med Hyg 2023; 109:332-334. [PMID: 37364861 PMCID: PMC10397460 DOI: 10.4269/ajtmh.22-0631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 04/21/2023] [Indexed: 06/28/2023] Open
Abstract
Strongyloides stercoralis infection is a common infection in tropical and subtropical regions and is considered one of the "neglected tropical diseases." Owing to its life cycle, this infection can remain undetectable for years, preventing an early diagnosis and prompt treatment. We report the case of a 65-year-old woman who presented to us with a history of nausea, abdominal pain, bloating, and weight loss and, after initial radiologic and laboratory workup, was diagnosed with a periampullary mass with no secondary spread. She underwent an uneventful pylorus-preserving pancreatoduodenectomy, and on histopathological study of the lesion, a diagnosis of S. stercoralis infection was confirmed. This case stands out because of the importance of keeping S. stercoralis infections as a differential diagnosis of periampullary masses, particularly when the patient comes from regions where S. stercoralis is prevalent.
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Affiliation(s)
- Alonso Vera Torres
- Hepatobiliary Surgery and Liver Transplantation Services, University Hospital Fundación Santa Fe de Bogotá, Bogotá, Colombia
- Faculty of Medicine, Universidad de los Andes, Bogotá, Colombia
| | - Laura Peña González
- Hepatobiliary Surgery and Liver Transplantation Services, University Hospital Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - William Cruz Mususú
- Hepatobiliary Surgery and Liver Transplantation Services, University Hospital Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Sergio Valencia Vásquez
- Hepatobiliary Surgery and Liver Transplantation Services, University Hospital Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Nicolás Andrés Cortés Mejía
- Hepatobiliary Surgery and Liver Transplantation Services, University Hospital Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Rocío del Pilar López Panqueva
- Faculty of Medicine, Universidad de los Andes, Bogotá, Colombia
- Pathology and Clinical Laboratory Department, Fundación Santa Fe de Bogotá University Hospital, Bogotá, Colombia
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Magnaval JF, Fillaux J, Fabre R, Cassaing S, Valentin A, Iriart X, Berry A. Epidemiological, Clinical and Laboratory Features of Strongyloidiasis in 69 Attendees at a French Outpatient Clinic. Pathogens 2023; 12:983. [PMID: 37623943 PMCID: PMC10459160 DOI: 10.3390/pathogens12080983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/26/2023] Open
Abstract
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.
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Affiliation(s)
- Jean-François Magnaval
- Service de Parasitologie Médicale, Faculté de Médecine, Université de Toulouse, 31000 Toulouse, France
| | - Judith Fillaux
- Service de Parasitologie-Mycologie, Hôpital Purpan, Centre Hospitalier Universitaire de Toulouse, TSA 4003, 31059 Toulouse, France
| | - Richard Fabre
- DENDRIS, 335 Rue du Chêne Vert, 31670 Labège, France
| | - Sophie Cassaing
- Service de Parasitologie-Mycologie, Hôpital Purpan, Centre Hospitalier Universitaire de Toulouse, TSA 4003, 31059 Toulouse, France
- FLAMES/RESTORE (Inserm UMR 1301/CNRS UMR 5070/EFS), Université de Toulouse, 31100 Toulouse, France
| | - Alexis Valentin
- Service de Parasitologie-Mycologie, Hôpital Purpan, Centre Hospitalier Universitaire de Toulouse, TSA 4003, 31059 Toulouse, France
- PHARMA-DEV (UMR 152), Institut de Recherche Pour le Développement, Université de Toulouse, 31062 Toulouse, France
| | - Xavier Iriart
- Service de Parasitologie-Mycologie, Hôpital Purpan, Centre Hospitalier Universitaire de Toulouse, TSA 4003, 31059 Toulouse, France
- Institut Toulousain des Maladies Infectieuses et Inflammatoires (UMR “Infinity”, Inserm/CNRS/Université de Toulouse III), 31024 Toulouse, France
| | - Antoine Berry
- Service de Parasitologie-Mycologie, Hôpital Purpan, Centre Hospitalier Universitaire de Toulouse, TSA 4003, 31059 Toulouse, France
- Institut Toulousain des Maladies Infectieuses et Inflammatoires (UMR “Infinity”, Inserm/CNRS/Université de Toulouse III), 31024 Toulouse, France
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Rosca EC, Heneghan C, Spencer EA, Plüddemann A, Maltoni S, Gandini S, Onakpoya IJ, Evans D, Conly JM, Jefferson T. Coinfection with Strongyloides and SARS-CoV-2: A Systematic Review. Trop Med Infect Dis 2023; 8:tropicalmed8050248. [PMID: 37235296 DOI: 10.3390/tropicalmed8050248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/28/2023] Open
Abstract
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.
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Affiliation(s)
- Elena C Rosca
- Department of Neurology, Victor Babes University of Medicine and Pharmacy, Piata Eftimie Murgu 2, 300041 Timisoara, Romania
| | - Carl Heneghan
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Elizabeth A Spencer
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Annette Plüddemann
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Susanna Maltoni
- Division of Research and Innovation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Sara Gandini
- Department of Experimental Oncology, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Igho J Onakpoya
- Department of Continuing Education, University of Oxford, Rewley House, 1 Wellington Square, Oxford OX1 2JA, UK
| | - David Evans
- Li Ka Shing Institute of Virology and Department of Medical Microbiology & Immunology, University of Alberta, Edmonton, AB T6G 2E1, Canada
| | - John M Conly
- Departments of Medicine, Microbiology, Immunology & Infectious Diseases, and Pathology & Laboratory Medicine, Synder Institute for Chronic Diseases and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB T2N 1N4, Canada
| | - Tom Jefferson
- Department of Continuing Education, University of Oxford, Rewley House, 1 Wellington Square, Oxford OX1 2JA, UK
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Ramprasad A, Kodan P, Jonnalagadda K, Bir R, Verma N, Sahni K, Vikram NK, Soneja M, Mirdha BR, Wig N. Seroprevalence of Strongyloides infection among steroid recipients in a tertiary care centre in North India. Infez Med 2022; 30:593-601. [PMID: 36482946 PMCID: PMC9715000 DOI: 10.53854/liim-3004-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/10/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Strongyloides stercoralis (S. stercoralis), a unique parasite, can cause mortal disease even years after the exposure. Iatrogenic use of steroids can complicate asymptomatic infections to a life-threatening hyperinfection and/or disseminated infection. Data regarding seroprevalence of strongyloidiasis remains scarce and this knowledge gap needs due attention in many endemic countries including India. AIM The present study is aimed at assessing the seroprevalence of Strongyloides infection and the need for routine screening among individuals receiving steroid therapy. METHODOLOGY Eighty patients receiving steroid therapy and thirty healthy volunteers who had not received any immunosuppressive drugs and/or anthelminthic therapy in last six months were enrolled as cases and controls respectively and they were screened by Strongyloides IgG ELISA. RESULTS Among the 80 patients on steroids, the mean cumulative prednisolone equivalent dose received was 8.2 g (±11.2 g) for a mean duration of 184 days, 16 patients (20%, 95% CI 11.9-30) had a positive Strongyloides IgG serology. Only 4 controls (4/30, 13.3%, CI 3.8-30.7) tested positive (p=0.4). CONCLUSIONS Our study demonstrated a Strongyloides seroprevalence of 20% in the study population emphasizing the need for screening for Strongyloides infection prior to immunosuppressive therapy in order to prevent hyperinfection or possible dissemination.
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Affiliation(s)
- Aishwarya Ramprasad
- Department of Medicine, All India Institute of Medical Sciences, New Delhi,
India
| | - Parul Kodan
- Department of Medicine, All India Institute of Medical Sciences, New Delhi,
India
| | - Kirtana Jonnalagadda
- Department of Medicine, All India Institute of Medical Sciences, New Delhi,
India
| | - Raunak Bir
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi,
India
| | - Nishant Verma
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi,
India
| | - Kanika Sahni
- Department of Dermatology, All India Institute of Medical Sciences, New Delhi,
India
| | - Naval K Vikram
- Department of Medicine, All India Institute of Medical Sciences, New Delhi,
India
| | - Manish Soneja
- Department of Medicine, All India Institute of Medical Sciences, New Delhi,
India
| | - Bijay Ranjan Mirdha
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi,
India
| | - Naveet Wig
- Department of Medicine, All India Institute of Medical Sciences, New Delhi,
India
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Herbert DR, Stoltzfus JDC, Rossi HL, Abraham D. Is Strongyloides stercoralis hyperinfection induced by glucocorticoids a result of both suppressed host immunity and altered parasite genetics? Mol Biochem Parasitol 2022; 251:111511. [PMID: 36007683 DOI: 10.1016/j.molbiopara.2022.111511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/01/2022] [Accepted: 08/18/2022] [Indexed: 11/19/2022]
Abstract
The gastrointestinal (GI) nematode Strongyloides stercoralis (S.s.) causes human strongyloidiasis, a potentially life-threatening disease that currently affects over 600 million people globally. The uniquely pernicious aspect of S.s. infection, as compared to all other GI nematodes, is its autoinfective larval stage (L3a) that maintains a low-grade chronic infection, allowing undetectable persistence for decades. Infected individuals who are administered glucocorticoid therapy can develop a rapid and often lethal hyperinfection syndrome within days. Hyperinfection patients often present with dramatic increases in first- and second-stage larvae and L3a in their GI tract, with L3a widely disseminating throughout host organs leading to sepsis. How glucocorticoid administration drives hyperinfection remains a critical unanswered question; specifically, it is unknown whether these steroids promote hyperinfection through eliminating essential host protective mechanisms and/or through dysregulating parasite development. This current deficiency in understanding is largely due to the previous absence of a genetically defined mouse model that would support all S.s. life-cycle stages and the lack of successful approaches for S.s. genetic manipulation. However, there are currently new possibilities through the recent demonstration that immunodeficient NOD.Cg-PrkdcscidIl2rgtm1Wjl/SzJ (NSG) mice support sub-clinical infections that can be transformed to lethal hyperinfection syndrome following glucocorticoid administration. This is coupled with advances in transcriptomics, transgenesis, and gene inactivation strategies that now allow rigorous scientific inquiry into S.s. biology. We propose that combining in vivo manipulation of host immunity and deep immunoprofiling strategies with the latest advances in S.s. transcriptomics, piggyBac transposon-mediated transgene insertion, and CRISPR/Cas-9-mediated gene inactivation will facilitate new insights into the mechanisms that could be targeted to block lethality in humans with S.s. hyperinfection.
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Affiliation(s)
- De'Broski R Herbert
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, 3800 Spruce St., Philadelphia, PA 10104, USA.
| | - Jonathan D C Stoltzfus
- Department of Biology, Millersville University of Pennsylvania, 50 E. Frederick St., Millersville, PA 17551, USA.
| | - Heather L Rossi
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, 3800 Spruce St., Philadelphia, PA 10104, USA.
| | - David Abraham
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St., Philadelphia, PA 19107, USA.
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Rodríguez-Guardado A, Álvarez-Martínez MJ, Flores MD, Sulleiro E, Torrús-Tendero D, Velasco M, Membrillo FJ. Screening for strongyloidiasis in Spain in the context of the SARS-CoV-2 pandemic: Results of a survey on diagnosis and treatment. Enfermedades infecciosas y microbiologia clinica (English ed ) 2022:S2529-993X(22)00174-5. [PMID: 35970704 PMCID: PMC9372776 DOI: 10.1016/j.eimce.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/31/2021] [Accepted: 11/06/2021] [Indexed: 12/15/2022]
Abstract
Introduction The generalization of treatment with dexamethasone or other immunosuppressants in patients with SARS-CoV-2 infection may increase the risk of occurrence of severe forms of strongyloidiasis. A nationwide survey was conducted to better understand the diagnostic and therapeutic situation of strongyloidiasis in SARS-CoV-2 co-infected patients in Spain. Materials and methods A survey was designed and sent to all SEIMC members during February and March 2021. Responses were exported for computer processing to Microsoft Excel 2017 and statistically processed with the free software PSPP. Results 189 responses were received, of which 121 (64%) were selected for further processing. Eighty-four centers (69.5%) had no specific strongyloidiasis screening protocol. Forty-two centers (34.7%) had serological techniques available in their laboratories and the rest were sent to a reference laboratory. Only 22 centers (18%) screened for strongyloidiasis in SARS-CoV-2 infected patients. A total of 227 cases of strongyloidiasis were diagnosed in patients with SARS-CoV-2 infection. In four cases patients developed a massive hyperinfestation syndrome leading to the death of one patient. Conclusion COVID-19 has highlighted the need to unify screening and treatment protocols for imported pathologies such as strongyloidiosis. Efforts to disseminate knowledge are needed to ensure that this potentially fatal disease is adequately treated in patients with the highest risk of complications, such as those with COVID-19.
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Rodríguez-Guardado A, Álvarez-Martínez MJ, Flores MD, Sulleiro E, Torrús-Tendero D, Velasco M, Membrillo FJ; En Nombre Del Grupo De Estudio De Patología Importada De La Seimc. [Screening for strongyloidiasis in Spain in the context of the SARS-CoV-2 pandemic: results of a survey on diagnosis and treatment]. Enferm Infecc Microbiol Clin 2021. [PMID: 34931102 DOI: 10.1016/j.eimc.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/06/2021] [Indexed: 12/15/2022]
Abstract
Introducción La generalización del tratamiento con dexametasona u otros inmunosupresores en pacientes con infección por SARS-CoV-2 puede aumentar el riesgo de aparición de formas graves de estrongiloidiosis. Se realizó una encuesta a nivel nacional para conocer mejor de la situación diagnóstica y terapéutica de la estrongiloidiosis en España en pacientes coinfectados por SARS-CoV-2. Materiales y métodos Se diseñó una encuesta que fue enviada a todos los miembros de SEIMC durante los meses de febrero y marzo de 2021. Las respuestas se exportaron para su procesamiento informático al programa Microsoft Excel 2017 y se procesaron estadísticamente con el software libre PSPP. Resultados Se recibieron 189 respuestas, de las cuales se seleccionaron 121 (64%) para su procesamiento posterior. En 84 centros (69,5%) no existía ningún protocolo de cribado específico de estrongiloidiosis. Cuarenta y dos centros (34,7%) disponían de técnicas serológicas en sus laboratorios y en el resto se enviaban a un laboratorio de referencia. Solo 22 centros (18%) realizaron cribado de estrongiloidiosis en pacientes infectados por SARS-CoV-2. Se diagnosticaron 227 casos de estrongiloidiosis en pacientes con infección por el SARS-CoV-2. En cuatro casos los pacientes desarrollaron un síndrome de hiperinfestación masiva que condujo al fallecimiento de uno. Conclusión La COVID-19 ha puesto de manifiesto la necesidad de unificar protocolos de cribado y tratamiento de patologías importadas como la estrongiloidiosis. Es necesario realizar un esfuerzo de difusión del conocimiento para que esta patología potencialmente mortal sea tratada adecuadamente en los pacientes con mayor riesgo de complicaciones, como son aquellos con COVID-19.
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Ruge M, Surati M, Manesh R, Segreti J, Solarewicz J, Mba B. Buried Deep. J Hosp Med 2021; 16:757-762. [PMID: 34338628 DOI: 10.12788/jhm.3584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/15/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Max Ruge
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Mosmi Surati
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Reza Manesh
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John Segreti
- Department of Infectious Disease, Rush University Medical Center, Chicago, Illinois
| | - Joanna Solarewicz
- Department of Pathology, Rush University Medical Center, Chicago, Illinois
| | - Benjamin Mba
- Department of Medicine, John H Stroger, Jr Hospital of Cook County, Chicago, Illinois
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Rodpai R, Sanpool O, Thanchomnang T, Laoraksawong P, Sadaow L, Boonroumkaew P, Wangwiwatsin A, Wongkham C, Laummaunwai P, Ittiprasert W, Brindley PJ, Intapan PM, Maleewong W. Exposure to dexamethasone modifies transcriptomic responses of free-living stages of Strongyloides stercoralis. PLoS One 2021; 16:e0253701. [PMID: 34181669 PMCID: PMC8238218 DOI: 10.1371/journal.pone.0253701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/10/2021] [Indexed: 12/15/2022] Open
Abstract
Hyperinfection and disseminated infection by the parasitic nematode Strongyloides stercoralis can be induced by iatrogenic administration of steroids and immunosuppression and lead to an elevated risk of mortality. Responses of free-living stages of S. stercoralis to the therapeutic corticosteroid dexamethasone (DXM) were investigated using RNA-seq transcriptomes of DXM-treated female and male worms. A total of 17,950 genes representing the transcriptome of these free-living adult stages were obtained, among which 199 and 263 were differentially expressed between DXM-treated females and DXM-treated males, respectively, compared with controls. According to Gene Ontology analysis, differentially expressed genes from DXM-treated females participate in developmental process, multicellular organismal process, cell differentiation, carbohydrate metabolic process and embryonic morphogenesis. Others are involved in signaling and signal transduction, including cAMP, cGMP-dependent protein kinase pathway, endocrine system, and thyroid hormone pathway, as based on Kyoto Encyclopedia of Genes and Genomes analysis. The novel findings warrant deeper investigation of the influence of DXM on growth and other pathways in this neglected tropical disease pathogen, particularly in a setting of autoimmune and/or allergic disease, which may require the clinical use of steroid-like hormones during latent or covert strongyloidiasis.
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Affiliation(s)
- Rutchanee Rodpai
- Department of Parasitology, Faculty of Medicine, and Mekong Health Science Research Institute, Khon Kaen University, Khon Kaen, Thailand
| | - Oranuch Sanpool
- Department of Parasitology, Faculty of Medicine, and Mekong Health Science Research Institute, Khon Kaen University, Khon Kaen, Thailand
| | | | - Pokkamol Laoraksawong
- School of Health Science, Sukhothai Thammathirat Open University, Nonthaburi, Thailand
| | - Lakkhana Sadaow
- Department of Parasitology, Faculty of Medicine, and Mekong Health Science Research Institute, Khon Kaen University, Khon Kaen, Thailand
| | - Patcharaporn Boonroumkaew
- Department of Parasitology, Faculty of Medicine, and Mekong Health Science Research Institute, Khon Kaen University, Khon Kaen, Thailand
| | - Arporn Wangwiwatsin
- Department of Biochemistry, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Chaisiri Wongkham
- Department of Biochemistry, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Porntip Laummaunwai
- Department of Parasitology, Faculty of Medicine, and Mekong Health Science Research Institute, Khon Kaen University, Khon Kaen, Thailand
| | - Wannaporn Ittiprasert
- Department of Microbiology, Immunology and Tropical Medicine, and Research Center for Neglected Diseases of Poverty, School of Medicine and Health Sciences, George Washington University, Washington, DC, United States of America
| | - Paul J. Brindley
- Department of Microbiology, Immunology and Tropical Medicine, and Research Center for Neglected Diseases of Poverty, School of Medicine and Health Sciences, George Washington University, Washington, DC, United States of America
| | - Pewpan M. Intapan
- Department of Parasitology, Faculty of Medicine, and Mekong Health Science Research Institute, Khon Kaen University, Khon Kaen, Thailand
| | - Wanchai Maleewong
- Department of Parasitology, Faculty of Medicine, and Mekong Health Science Research Institute, Khon Kaen University, Khon Kaen, Thailand
- * E-mail:
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12
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Gordon CA, Shield JM, Bradbury RS, Muhi S, Page W, Judd JA, Lee R, Biggs BA, Ross K, Kurscheid J, Gray DJ, McManus DP. HTLV-I and Strongyloides in Australia: The worm lurking beneath. Adv Parasitol 2021; 111:119-201. [PMID: 33482974 DOI: 10.1016/bs.apar.2020.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Strongyloidiasis and HTLV-I (human T-lymphotropic virus-1) are important infections that are endemic in many countries around the world with an estimated 370 million infected with Strongyloides stercoralis alone, and 5-10 million with HTVL-I. Co-infections with these pathogens are associated with significant morbidity and can be fatal. HTLV-I infects T-cells thus causing dysregulation of the immune system which has been linked to dissemination and hyperinfection of S. stercoralis leading to bacterial sepsis which can result in death. Both of these pathogens are endemic in Australia primarily in remote communities in Queensland, the Northern Territory, and Western Australia. Other cases in Australia have occurred in immigrants and refugees, returned travellers, and Australian Defence Force personnel. HTLV-I infection is lifelong with no known cure. Strongyloidiasis is a long-term chronic disease that can remain latent for decades, as shown by infections diagnosed in prisoners of war from World War II and the Vietnam War testing positive decades after they returned from these conflicts. This review aims to shed light on concomitant infections of HTLV-I with S. stercoralis primarily in Australia but in the global context as well.
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Affiliation(s)
- Catherine A Gordon
- Infectious Diseases Program, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia.
| | - Jennifer M Shield
- Department of Pharmacy and Biomedical Sciences, La Trobe University, Bendigo, VIC, Australia; Department of Medicine, The Peter Doherty Institute for Infection and Immunity, University of Melbourne and the Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Richard S Bradbury
- School of Health and Life Sciences, Federation University, Berwick, VIC, Australia
| | - Stephen Muhi
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Wendy Page
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
| | - Jenni A Judd
- School of Health Medical and Applied Sciences, Central Queensland University, Bundaberg, QLD, Australia; Centre for Indigenous Health Equity Research, Central Queensland University, Bundaberg, QLD, Australia
| | - Rogan Lee
- Westmead Clinical School, The University of Sydney, Westmead, NSW, Australia
| | - Beverley-Ann Biggs
- Department of Medicine, The Peter Doherty Institute for Infection and Immunity, University of Melbourne and the Royal Melbourne Hospital, Melbourne, VIC, Australia; Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Kirstin Ross
- College of Science and Engineering, Flinders University, Adelaide, South Australia, Australia
| | - Johanna Kurscheid
- Department of Global Health, Research School of Population Health, Australian National University, Acton, ACT, Australia
| | - Darren J Gray
- Department of Global Health, Research School of Population Health, Australian National University, Acton, ACT, Australia
| | - Donald P McManus
- Infectious Diseases Program, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
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13
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Balachandra D, Ahmad H, Arifin N, Noordin R. Direct detection of Strongyloides infection via molecular and antigen detection methods. Eur J Clin Microbiol Infect Dis 2020; 40:27-37. [DOI: 10.1007/s10096-020-03949-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/09/2020] [Indexed: 12/16/2022]
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14
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Rothe K, Katchanov J, Schneider J, Spinner CD, Phillip V, Busch DH, Tappe D, Braren R, Schmid RM, Slotta-Huspenina J. Strongyloides stercoralis hyperinfection syndrome presenting as mechanical ileus after short-course oral steroids for chronic obstructive pulmonary disease (COPD) exacerbation. Parasitol Int 2020; 76:102087. [PMID: 32087332 DOI: 10.1016/j.parint.2020.102087] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/06/2020] [Accepted: 02/16/2020] [Indexed: 12/14/2022]
Abstract
We report a case of a fatal Strongyloides stercoralis hyperinfection syndrome (SHS) in a migrant from Kenya, who had been living in Germany for three decades. A short-course oral steroid treatment for Chronic Obstructive Pulmonary Disease (COPD) exacerbation had been administered four weeks prior to the presentation. The initial clinical and radiological findings suggested a mechanical small bowel obstruction as a cause of ileus. Our case highlights the importance of maintaining a high index of suspicion for strongyloidiasis in patients from endemic areas even years after they left the country of origin. It demonstrates that even a five-day course of prednisolone is able to trigger SHS in patients with underlying strongyloidiasis. History of frequent previous administration of oral prednisolone for COPD exacerbations in our case raises the question why and how the last steroid regimen provoked SHS. SHS can present with multiple gastrointestinal symptoms including ileus and the absence of eosinophilia during the whole course of the disease should not lower the level of suspicion in the appropriate clinical setting.
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Affiliation(s)
- Kathrin Rothe
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University Munich, Munich, Germany.
| | - Juri Katchanov
- Department of Internal Medicine II, University Hospital Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Jochen Schneider
- Department of Internal Medicine II, University Hospital Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Christoph D Spinner
- Department of Internal Medicine II, University Hospital Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Veit Phillip
- Department of Internal Medicine II, University Hospital Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Dirk H Busch
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University Munich, Munich, Germany; German Centre for Infection Research (DZIF), partner site Munich, Munich, Germany
| | - Dennis Tappe
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Rickmer Braren
- Department of Radiology, University Hospital Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Roland M Schmid
- Department of Internal Medicine II, University Hospital Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
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Couto BPD, Corrêa LQ, de Sousa JEN, Goulart de Carvalho EF, Gonzaga HT, Costa-Cruz JM. Parasitological and immunological aspects of oral and subcutaneous prednisolone treatment in rats experimentally infected with Strongyloides venezuelensis. Acta Trop 2020; 204:105349. [PMID: 31958413 DOI: 10.1016/j.actatropica.2020.105349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 01/15/2020] [Accepted: 01/16/2020] [Indexed: 10/25/2022]
Abstract
Strongyloides venezuelensis is a model to study human strongyloidiasis, which infects wild rodents and shares common antigenic epitopes with Strongyloides stercoralis. This study aimed to evaluate parasitological and immunological parameters of prednisolone immunosuppression protocols in rats (Rattus novergicus) infected with S. venezuelensis. Rats were divided into six groups (n = 36): untreated and uninfected (-) or infected (+); oral treatment and uninfected (o-) or infected (o+); subcutaneous treatment and uninfected (sc-) or infected (sc+). For oral immunosuppression, 5 mg/mL of water diluted prednisolone were given five days before infection, and in the days 8 and 21 (for 5 days). For subcutaneous immunosuppression, 10 mg/kg of prednisolone were given daily. The infection was established by the subcutaneous injection of approximately 3,000 S. venezuelensis filarioid larvae per animal. All animals from the (+) and (o+) groups survived, while four rats from the (sc+) died prior to necropsy date. Parasitological analysis showed higher egg elimination in (o+) in comparison to (+) and (sc+) on 7, 13 and 26 days post infection (d.p.i.).The recovery of parasitic females at day 30 was significantly higher in (o+), compared to (+). The (+) and (o+) groups showed a clear increase in anti-S. venezuelensis IgG, IgG1 and IgG2 from 13th d.p.i. Oral immunosuppression led to a higher number of adult females and increased egg output while maintaining IgG and subclasses antibody levels comparable to the positive control.
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Affiliation(s)
- Bruna Patricia do Couto
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Av. Amazonas s/n, bloco 4C, 38400-902 Uberlândia, Minas Gerais, Brasil
| | - Luísa Queiroz Corrêa
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Av. Amazonas s/n, bloco 4C, 38400-902 Uberlândia, Minas Gerais, Brasil
| | - José Eduardo Neto de Sousa
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Av. Amazonas s/n, bloco 4C, 38400-902 Uberlândia, Minas Gerais, Brasil
| | - Edson Fernando Goulart de Carvalho
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Av. Amazonas s/n, bloco 4C, 38400-902 Uberlândia, Minas Gerais, Brasil
| | - Henrique Tomaz Gonzaga
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Av. Amazonas s/n, bloco 4C, 38400-902 Uberlândia, Minas Gerais, Brasil
| | - Julia Maria Costa-Cruz
- Laboratório de Diagnóstico de Parasitoses, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Av. Amazonas s/n, bloco 4C, 38400-902 Uberlândia, Minas Gerais, Brasil.
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De Souza JN, Cruz ADV, Araújo WAC, Sampaio LM, Allegretti SM, Teixeira MCA, Handali S, Galvão-Castro B, Soares NM. Alcohol consumption alters anti-Strongyloides stercoralis antibodies production. Immunobiology 2020; 225:151898. [PMID: 31902530 DOI: 10.1016/j.imbio.2019.151898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 12/01/2019] [Accepted: 12/10/2019] [Indexed: 02/01/2023]
Abstract
Individuals infected with Strongyloides stercoralis have been reported to produce different immunoglobulins isotypes, yet few studies have evaluated their use in strongyloidiasis diagnosis. The aim of this work was to evaluate the immunoreactivity of different classes and subclasses of anti-S. stercoralis circulating antibodies in alcoholic patients by ELISA and to perform immunoblotting in samples with discordant results between parasitological and immunological methods. 345 male patients with a clinical diagnosis of alcoholism hospitalized at a reference center for alcoholics in Salvador, Bahia, Brazil, were included in this study. The fecal samples were examined by three different parasitological methods (spontaneous sedimentation, Baermann-Moraes and Agar Plate Culture methods). The ELISA was performed for the detection of IgG, IgG1, IgG4, IgE and IgA1 anti-S. stercoralis. Immunoblotting, for the detection of specific IgA1, was used to elucidate discordant results between parasitological and immunological methods. S. stercoralis infection frequency in alcoholic patients by parasitological methods was 21.4% (74/345). Although IgE-ELISA demonstrated a high sensitivity and specificity in non-alcoholic patients, about 30% (22/74) of alcoholics with larvae in feces were negative. IgG1-ELISA detected the lowest frequency of antibodies in alcoholic patients with larvae in feces, only 57% (42/74). IgG4-ELISA was the best assay for S. stercoralis infection immunodiagnosis. Immunoreactivity in the immunoblotting for IgA1 at 90, 75, 26 and/or 17 kDa bands was observed in 92% (33/36) of alcoholics with larvae excretion and negative ELISA for one or more antibody isotypes. In conclusion, IgG4-ELISA showed the highest sensitivity and specificity, thus demonstrating its superiority for strongyloidiasis immunodiagnosis in alcoholic and non-alcoholic individuals. Both, IgE and IgG1-ELISA presented high sensitivities and specificities for S. stercoralis infection diagnosis in non-alcoholics, however there was low reactivity in alcoholic individuals. This can be associated with an increased susceptibility to severe strongyloidiasis in these patients. IgA1-immunoblotting can be used to confirm S. stercoralis infection when there are discordant results between parasitological methods and ELISA.
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Affiliation(s)
- Joelma Nascimento De Souza
- Faculdade de Farmácia, Universidade Federal da Bahia (UFBA), Salvador, Brazil; Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil
| | | | | | | | | | | | - Sukwan Handali
- Centers for Disease Control and Prevention (CDC), Atlanta, USA
| | | | - Neci Matos Soares
- Faculdade de Farmácia, Universidade Federal da Bahia (UFBA), Salvador, Brazil.
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17
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Richards C, Penner J, Colmegna I, Loewen H, Melaku Z, Melkie A, Meltzer M, Scuccimarri R, Mengistu Y, Hitchon CA. Methotrexate exposure and risk of strongyloidiasis. Trop Med Int Health 2019; 24:1032-1041. [PMID: 31302948 DOI: 10.1111/tmi.13288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Rheumatologic disease patients receiving immunomodulating drugs such as methotrexate (MTX) have increased infection rates. Strongyloides, a global endemic intestinal parasite, can cause significant or fatal disease in immunocompromised patients. The risk of serious Strongyloides infection with MTX dosed for rheumatologic disease is unknown. METHODS We performed a systematic literature review searching EMBASE, Medline and Web of Science databases. All studies reporting humans exposed to MTX and tested for Strongyloides were reviewed. Exclusion criteria were bone marrow transplantation, intrathecal route and MTX exposure completed >1 year prior to clinically apparent Strongyloides disease. RESULTS After excluding duplicates, 294 articles were reviewed. Of these, 29 cases were described in 27 papers. Twenty cases (69%) had an underlying rheumatologic or dermatologic disease, the rest had a haematologic disease. Hyperinfection or dissemination was found in 59% of cases (52% low-dose MTX; 75% high-dose MTX). Death occurred in 34% of cases (19% low-dose MTX; 75% high-dose MTX, P < 0.01). All eight patients on high-dose MTX received other immunosuppressants. Corticosteroids were taken in 18/21 patients on low-dose MTX. One of the three patients on MTX monotherapy had hyperinfection syndrome. None had disseminated Strongyloides. CONCLUSIONS Serious Strongyloides infection can occur with low-dose MTX particularly when given with other immunosuppression. Global travel and greater awareness of rheumatologic conditions in low- to middle-income countries will increase the exposure of individuals prescribed MTX (with or without corticosteroids) to Strongyloides. Strongyloides screening and treatment should be considered for individuals receiving low-dose MTX therapy, particularly if combined with additional immunosuppression.
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Affiliation(s)
- Ceri Richards
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Justin Penner
- Department of Paediatrics, University of British Columbia, Trail, BC, Canada.,Department of Paediatric Infectious Diseases, Imperial College London, London, UK
| | - Ines Colmegna
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Hal Loewen
- Neil John Mclean Library, University of Manitoba, Winnipeg, MB, Canada
| | - Zenebe Melaku
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA.,Department of Internal Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Addisu Melkie
- Department of Internal Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | | | | | | | - Carol A Hitchon
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
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18
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Shrestha P, O'Neil SE, Taylor BS, Bode-Omoleye O, Anstead GM. Hemoptysis in the Immunocompromised Patient: Do Not Forget Strongyloidiasis. Trop Med Infect Dis 2019; 4:tropicalmed4010035. [PMID: 30759812 PMCID: PMC6473255 DOI: 10.3390/tropicalmed4010035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/26/2019] [Accepted: 01/29/2019] [Indexed: 11/16/2022] Open
Abstract
Strongyloidiasis, due to infection with the nematode Strongyloides stercoralis, affects millions of people in the tropics and subtropics. Strongyloides has a unique auto-infective lifecycle such that it can persist in the human host for decades. In immunosuppressed patients, especially those on corticosteroids, potentially fatal disseminated strongyloidiasis can occur, often with concurrent secondary infections. Herein, we present two immunocompromised patients with severe strongyloidiasis who presented with pneumonia, hemoptysis, and sepsis. Both patients were immigrants from developing countries and had received prolonged courses of corticosteroids prior to admission. Patient 1 also presented with a diffuse abdominal rash; a skin biopsy showed multiple intradermal Strongyloides larvae. Patient 1 had concurrent pneumonic nocardiosis and bacteremia with Klebsiella pneumoniae and Enterococcus faecalis. Patient 2 had concurrent Aspergillus and Candida pneumonia and developed an Aerococcus meningitis. Both patients had negative serologic tests for Strongyloides; patient 2 manifested intermittent eosinophilia. In both patients, the diagnosis was afforded by bronchoscopy with lavage. The patients were successfully treated with broad-spectrum antibiotics and ivermectin. Patient 1 also received albendazole. Strongyloidiasis should be considered in the differential diagnosis of hemoptysis in immunocompromised patients with possible prior exposure to S. stercoralis.
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Affiliation(s)
- Prakash Shrestha
- Covenant Medical Group, Infectious Diseases, Division of Internal Medicine, Lubbock, TX 79410, USA.
| | - Sean E O'Neil
- Texas Center for Infectious Diseases, San Antonio, TX 78223, USA.
| | - Barbara S Taylor
- Department of Medicine, Division of Infectious Diseases, University of Texas Health, San Antonio, TX 78229, USA.
| | | | - Gregory M Anstead
- Department of Medicine, Division of Infectious Diseases, University of Texas Health, San Antonio, TX 78229, USA.
- Medicine Service, Division of Infectious Diseases, South Texas Veterans Healthcare System, San Antonio, TX 78229, USA.
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19
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Barreto NMPV, de Souza JN, Araújo WAC, Khouri NA, de Oliveira EP, Teixeira MCA, Soares NM. Urinary Tract Infection by Strongyloides stercoralis: A Case Report. J Parasitol 2018; 104:433-437. [DOI: 10.1645/17-88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Nilo M. P. V. Barreto
- Faculdade de Farmácia, Universidade Federal da Bahia–R. Barão de Jeremoabo, 147 Ondina, Salvador BA, 40170-115, Brazil
| | - Joelma N. de Souza
- Faculdade de Farmácia, Universidade Federal da Bahia–R. Barão de Jeremoabo, 147 Ondina, Salvador BA, 40170-115, Brazil
| | - Weslei A. C. Araújo
- Faculdade de Farmácia, Universidade Federal da Bahia–R. Barão de Jeremoabo, 147 Ondina, Salvador BA, 40170-115, Brazil
| | - Nadia A. Khouri
- Faculdade de Farmácia, Universidade Federal da Bahia–R. Barão de Jeremoabo, 147 Ondina, Salvador BA, 40170-115, Brazil
| | - Ernesto P. de Oliveira
- Faculdade de Farmácia, Universidade Federal da Bahia–R. Barão de Jeremoabo, 147 Ondina, Salvador BA, 40170-115, Brazil
| | - Márcia C. A. Teixeira
- Faculdade de Farmácia, Universidade Federal da Bahia–R. Barão de Jeremoabo, 147 Ondina, Salvador BA, 40170-115, Brazil
| | - Neci M. Soares
- Faculdade de Farmácia, Universidade Federal da Bahia–R. Barão de Jeremoabo, 147 Ondina, Salvador BA, 40170-115, Brazil
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20
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Beknazarova M, Whiley H, Judd JA, Shield J, Page W, Miller A, Whittaker M, Ross K. Argument for Inclusion of Strongyloidiasis in the Australian National Notifiable Disease List. Trop Med Infect Dis 2018; 3:E61. [PMID: 30274457 PMCID: PMC6073110 DOI: 10.3390/tropicalmed3020061] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 05/23/2018] [Accepted: 05/31/2018] [Indexed: 11/25/2022] Open
Abstract
Strongyloidiasis is an infection caused by the helminth, Strongyloides stercoralis. Up to 370 million people are infected with the parasite globally, and it has remained endemic in the Indigenous Australian population for many decades. Strongyloidiasis has been also reported in other Australian populations. Ignorance of this disease has caused unnecessary costs to the government health system, and been detrimental to the Australian people's health. This manuscript addresses the 12 criteria required for a disease to be included in the Australian National Notifiable Disease List (NNDL) under the National Health Security Act 2007 (Commonwealth). There are six main arguments that provide compelling justification for strongyloidiasis to be made nationally notifiable and added to the Australian NNDL. These are: The disease is important to Indigenous health, and closing the health inequity gap between Indigenous and non-Indigenous Australians is a priority; a public health response is required to detect cases of strongyloidiasis and to establish the true incidence and prevalence of the disease; there is no alternative national surveillance system to gather data on the disease; there are preventive measures with high efficacy and low side effects; data collection is feasible as cases are definable by microscopy, PCR, or serological diagnostics; and achievement of the Sustainable Development Goal (SDG) # 6 on clean water and sanitation.
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Affiliation(s)
- Meruyert Beknazarova
- College of Science and Engineering, Flinders University, Bedford Park, SA 5042, Australia.
| | - Harriet Whiley
- College of Science and Engineering, Flinders University, Bedford Park, SA 5042, Australia.
| | - Jenni A Judd
- School of Health Medical and Applied Sciences, Centre of Indigenous Health Equity Research, Central Queensland University, Bundaberg, QLD 4670, Australia.
| | - Jennifer Shield
- Department of Pharmacy and Applied Science, La Trobe University, Bendigo, VIC 3552, Australia.
| | - Wendy Page
- Miwatj Health Aboriginal Corporation, Nhulunbuy, NT 0881, Australia.
- Public Health and Tropical Medicine, James Cook University, Cairns, QLD 4870, Australia.
| | - Adrian Miller
- Indigenous Research Unit, Griffith University, Nathan, QLD 4111, Australia.
| | - Maxine Whittaker
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4811, Australia.
| | - Kirstin Ross
- College of Science and Engineering, Flinders University, Bedford Park, SA 5042, Australia.
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Panarelli NC, Yantiss RK. Inflammatory and infectious manifestations of immunodeficiency in the gastrointestinal tract. Mod Pathol 2018; 31:844-861. [PMID: 29403083 DOI: 10.1038/s41379-018-0015-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 11/24/2017] [Accepted: 12/11/2017] [Indexed: 12/27/2022]
Abstract
Immune compromise may result from genetic abnormalities, HIV/AIDS, or consequences of therapy for neoplastic and autoimmune diseases. Many immunocompromised patients develop severe gastrointestinal symptoms, particularly diarrhea, accompanied by non-specific or mild endoscopic abnormalities; mucosal biopsy with pathologic interpretation has a major role in the diagnosis and management of these patients. Immunocompromised individuals are at risk for all the diseases that affect those with a healthy immune system, but they are also prone to other illnesses that rarely affect immunocompetent patients. This review discusses the gastrointestinal manifestations of primary and acquired immunodeficiency, chemotherapy-related injury, and infections that show a predilection for immunocompromised patients. Key histologic features and relevant differential diagnoses are emphasized.
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Page W, Judd JA, Bradbury RS. The Unique Life Cycle of Strongyloides stercoralis and Implications for Public Health Action. Trop Med Infect Dis 2018; 3:E53. [PMID: 30274449 DOI: 10.3390/tropicalmed3020053] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 05/21/2018] [Accepted: 05/21/2018] [Indexed: 02/07/2023] Open
Abstract
Strongyloides stercoralis has one of the most complex life cycles of the human-infecting nematodes. A common misconception in medical and public health professions is that S. stercoralis in its biology is akin to other intestinal nematodes, such as the hookworms. Despite original evidence provided by medical and veterinary research about this unique helminth, many assumptions have entered the scientific literature. This helminth is set apart from others that commonly affect humans by (a) the internal autoinfective cycle with autoinfective larvae randomly migrating through tissue, parthenogenesis, and the potential for lifelong infection in the host, the profound pathology occurring in hyperinfection and systemic manifestations of strongyloidiasis, and (b) a limited external cycle with a single generation of free-living adults. This paper aims to review and discuss original research on the unique life cycle of S. stercoralis that distinguishes it from other helminths and highlight areas where increased understanding of the parasite's biology might lead to improved public health prevention and control strategies.
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Repetto SA, Ruybal P, Batalla E, López C, Fridman V, Sierra M, Radisic M, Bravo PM, Risso MG, González Cappa SM, Alba Soto CD. Strongyloidiasis Outside Endemic Areas: Long-term Parasitological and Clinical Follow-up After Ivermectin Treatment. Clin Infect Dis 2018; 66:1558-1565. [PMID: 29360939 DOI: 10.1093/cid/cix1069] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 11/30/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Strongyloides stercoralis affects 30-100 million people worldwide. The first-line therapy is ivermectin. Cure is defined as the absence of larvae by parasitological methods 1 year after treatment. To date, no longitudinal parasitological studies for longer periods of time have been conducted to confirm its cure. Here, we evaluated treatment response in long-term follow-up patients with chronic infection using parasitological and molecular methods for larvae or DNA detection. METHODS A prospective, descriptive, observational study was conducted between January 2009 and September 2015 in Buenos Aires, Argentina. Twenty-one patients with S. stercoralis diagnosis were evaluated 30, 60, and 90 days as well as 1, 2, 3, and/or 4 years after treatment by conventional methods (fresh stool, Ritchie method, agar plate culture), S. stercoralis-specific polymerase chain reaction (PCR) in stool DNA, and eosinophil values. RESULTS During follow-up, larvae were detected by conventional methods in 14 of 21 patients. This parasitological reactivation was observed starting 30 days posttreatment (dpt) and then at different times since 90 dpt. Eosinophil values decreased (P = .001) 30 days after treatment, but their levels were neither associated with nor predicted these reactivations. However, S. stercoralis DNA was detected by PCR in all patients, both in their first and subsequent stool samples, thus reflecting the poor efficacy of ivermectin at eradicating parasite from host tissues. Asymptomatic eosinophilia was the most frequent clinical form among chronically infected patients. CONCLUSIONS These results suggest that the parasitological cure is unlikely. Strongyloidiasis must be considered a chronic infection and ivermectin administration schedules should be reevaluated.
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Affiliation(s)
- Silvia A Repetto
- Facultad de Medicina, Instituto de Investigaciones en Microbiología y Parasitología Médica, Consejo Nacional de Investigaciones Científicas y Técnicas
- División Infectología, Hospital de Clínicas "José de San Martín," Universidad de Buenos Aires
| | - Paula Ruybal
- Facultad de Medicina, Instituto de Investigaciones en Microbiología y Parasitología Médica, Consejo Nacional de Investigaciones Científicas y Técnicas
| | - Estela Batalla
- Facultad de Medicina, Instituto de Investigaciones en Microbiología y Parasitología Médica, Consejo Nacional de Investigaciones Científicas y Técnicas
| | - Carlota López
- Sección Infectología, Hospital General de Agudos "Carlos G. Durand"
| | - Vanesa Fridman
- División Infectología, Hospital de Clínicas "José de San Martín," Universidad de Buenos Aires
| | - Mariela Sierra
- División Infectología, Hospital de Clínicas "José de San Martín," Universidad de Buenos Aires
| | - Marcelo Radisic
- División de Enfermedades Infecciosas, Instituto de Nefrología/Nephrology, Buenos Aires, Argentina
| | - Pablo M Bravo
- División Infectología, Hospital de Clínicas "José de San Martín," Universidad de Buenos Aires
- División de Enfermedades Infecciosas, Instituto de Nefrología/Nephrology, Buenos Aires, Argentina
| | - Marikena G Risso
- Facultad de Medicina, Instituto de Investigaciones en Microbiología y Parasitología Médica, Consejo Nacional de Investigaciones Científicas y Técnicas
| | - Stella M González Cappa
- Facultad de Medicina, Instituto de Investigaciones en Microbiología y Parasitología Médica, Consejo Nacional de Investigaciones Científicas y Técnicas
| | - Catalina D Alba Soto
- Facultad de Medicina, Instituto de Investigaciones en Microbiología y Parasitología Médica, Consejo Nacional de Investigaciones Científicas y Técnicas
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Abstract
Infection is a major complication of patients with hematological malignancies. Prophylaxis is a key element in the management of these patients, and is composed by two main components: infection control measures and antimicrobial chemoprophylaxis. Infection control measures are safe, but not always effective. Antimicrobial prophylaxis is usually effective but may increase resistance rates, toxicity, and cost. Therefore, a careful evaluation of the actual risk for infection, the pathogens that predominate in a particular setting, and the periods at risk are important in order to define the most appropriate strategy. In this chapter we review the most important parameters to assess the risk on an individual basis, and the evidences and recommendations supporting infection control measures and antimicrobial prophylaxis against bacteria, fungi, viruses, and parasites.
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Patton JB, Bonne-Année S, Deckman J, Hess JA, Torigian A, Nolan TJ, Wang Z, Kliewer SA, Durham AC, Lee JJ, Eberhard ML, Mangelsdorf DJ, Lok JB, Abraham D. Methylprednisolone acetate induces, and Δ7-dafachronic acid suppresses, Strongyloides stercoralis hyperinfection in NSG mice. Proc Natl Acad Sci U S A 2018; 115:204-9. [PMID: 29203662 DOI: 10.1073/pnas.1712235114] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Strongyloides stercoralis hyperinfection causes high mortality rates in humans, and, while hyperinfection can be induced by immunosuppressive glucocorticoids, the pathogenesis remains unknown. Since immunocompetent mice are resistant to infection with S. stercoralis, we hypothesized that NSG mice, which have a reduced innate immune response and lack adaptive immunity, would be susceptible to the infection and develop hyperinfection. Interestingly, despite the presence of large numbers of adult and first-stage larvae in S. stercoralis-infected NSG mice, no hyperinfection was observed even when the mice were treated with a monoclonal antibody to eliminate residual granulocyte activity. NSG mice were then infected with third-stage larvae and treated for 6 wk with methylprednisolone acetate (MPA), a synthetic glucocorticoid. MPA treatment of infected mice resulted in 50% mortality and caused a significant >10-fold increase in the number of parasitic female worms compared with infected untreated mice. In addition, autoinfective third-stage larvae, which initiate hyperinfection, were found in high numbers in MPA-treated, but not untreated, mice. Remarkably, treatment with Δ7-dafachronic acid, an agonist of the parasite nuclear receptor Ss-DAF-12, significantly reduced the worm burden in MPA-treated mice undergoing hyperinfection with S. stercoralis Overall, this study provides a useful mouse model for S. stercoralis autoinfection and suggests a therapeutic strategy for treating lethal hyperinfection.
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Hassanudin NS, Wahab ZA, Ibrahim K, Nor FM. Disseminated strongyloidiasis in an immunocompromised host: A case report. Asian Pac J Trop Biomed 2017; 7:587-590. [DOI: 10.1016/j.apjtb.2017.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
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.
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Verweij JJ, Stensvold CR. Molecular testing for clinical diagnosis and epidemiological investigations of intestinal parasitic infections. Clin Microbiol Rev 2014; 27:371-418. [PMID: 24696439 DOI: 10.1128/CMR.00122-13] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Over the past few decades, nucleic acid-based methods have been developed for the diagnosis of intestinal parasitic infections. Advantages of nucleic acid-based methods are numerous; typically, these include increased sensitivity and specificity and simpler standardization of diagnostic procedures. DNA samples can also be stored and used for genetic characterization and molecular typing, providing a valuable tool for surveys and surveillance studies. A variety of technologies have been applied, and some specific and general pitfalls and limitations have been identified. This review provides an overview of the multitude of methods that have been reported for the detection of intestinal parasites and offers some guidance in applying these methods in the clinical laboratory and in epidemiological studies.
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Abstract
Strongyloidiasis (caused by Strongyloides stercoralis, and to a lesser extent by Strongyloides fuelleborni) is one of the most neglected tropical diseases with endemic areas and affecting more than 100 million people worldwide. Chronic infections in endemic areas can be maintained for decades through the autoinfective cycle with the L3 filariform larvae. In these endemic areas, misdiagnosis, inadequate treatment and the facilitation of the hyperinfection syndrome by immunosuppression are frequent and contribute to a high mortality rate. Despite the serious health impact of strongyloidiasis, it is a neglected disease and very little is known about this parasite and the disease when compared to other helminth infections. Control of the disease is difficult because of the many gaps in our knowledge of strongyloidiasis. We examine the recent literature on different aspects of strongyloidiasis with emphasis in those aspects that need further research.
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Affiliation(s)
- Rafael Toledo
- Departamento de Parasitología, Universidad de Valencia, Valencia, Spain
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Abstract
Patient: Male, 77 Final Diagnosis: Deere strongyloidiasis Symptoms: Abdominal pain • apetite loss • diarrhea Medication: Prednisolon Clinical Procedure: Upper endoscopy Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Eduardo A Rodriguez
- Departnment of Internal Medicine, University of Miami Palm Beach Regional Campus, Atlantis, FL, USA
| | - Thomas Abraham
- Departnment of Internal Medicine, University of Miami Palm Beach Regional Campus, Atlantis, FL, USA
| | - Frederick K Williams
- Departnment of Internal Medicine, University of Miami Palm Beach Regional Campus, Atlantis, FL, USA
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Malakoutian T, Mohammadi R, Asgari M, Amouzegar A. Disseminated strongyloidiasis in a patient with membranoproliferative glomerulonephritis-case report. Iran J Parasitol 2015; 10:141-5. [PMID: 25904959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Accepted: 10/21/2014] [Indexed: 11/04/2022]
Abstract
Strongyloides stercoralis (SS) is a unique nematode with an auto infective cycle, so that it completes its life cycle within the human host and can live there for many years. In immunocompromised patients, infection can cause Strongyloides hyperinfection syndrome (S.H.S) that is associated with serious morbidity and mortality. As various infections are one of the leading causes of membranoproliferative glomerulonephritis (MPGN), we should consider subclinical strongyloidiasis as a possible underlying disease, especially in endemic areas. Here we describe a case of strongyloidiasis following immunosuppressive therapy for MPGN, the diagnosis of which was made, only a few hours before death, by stomach biopsy.
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Mati VLT, Raso P, de Melo AL. Strongyloides stercoralis infection in marmosets: replication of complicated and uncomplicated human disease and parasite biology. Parasit Vectors 2014; 7:579. [PMID: 25499310 PMCID: PMC4287166 DOI: 10.1186/s13071-014-0579-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 11/28/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Strongyloides stercoralis can undergo an alternative autoinfective life cycle in the host, which, in some individuals can lead to a lethal infection. However, due to a number of factors, such as, the majority of those infected are from low-income backgrounds and the limitation in experimental models for studying human S. stercoralis, strongyloidiasis remains neglected. Improved knowledge of animal models that are susceptible to this parasite is needed in order to investigate the immunological mechanisms involved during infection and in particular to further understand the natural history of the autoinfective cycle. METHODS Callithrix penicillata were inoculated subcutaneously with 100 (n = 2), 300 (n = 4) or 500 (n = 9) third-stage infective larvae (L3i) of S. stercoralis of human origin. Three marmosets received smaller inocula (i.e., one received 100 and two received 300 L3i) to ensure a greater capacity to withstand the infection after immunosuppression, which was triggered by administration of dexamethasone during early patency. Qualitative faecal analyses began at 7 days post-infection (DPI), and semi-quantitative tests were also performed for the dexamethasone-treated primates and the three matched controls. During the necropsies, specimens of S. stercoralis were recovered and tissue fragments were processed for histopathology. RESULTS The mean prepatency and patency periods were 16.1 ± 3.0 and 161.1 ± 72.2 DPI, respectively. The marmosets typically tolerated the infection well, but immunosuppressed individuals exhibited higher numbers of larvae in the faeces and progressive clinical deterioration with late disseminated infection. In these cases, the number of females recovered was significantly higher than the number of inoculated L3i. Large quantities of larvae were observed migrating through the host tissues, and histopathology revealed pulmonary and intestinal injuries consistent with those observed in human strongyloidiasis. CONCLUSIONS Both complicated and uncomplicated strongyloidiasis occur in C. penicillata that is described as a susceptible small non-human primate model for S. stercoralis. This host permits the maintenance of a human strain of the parasite in the laboratory and can be useful for experimental investigations of strongyloidiasis. In parallel, we discuss data related to the autoinfective cycle that provides new insights into the biology of S. stercoralis.
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Affiliation(s)
| | - Pedro Raso
- Department of Pathological Anatomy and Legal Medicine, FM, UFMG, Belo Horizonte, Brazil.
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Sasaki Y, Taniguchi T, Kinjo M, McGill RL, McGill AT, Tsuha S, Shiiki S. Meningitis associated with strongyloidiasis in an area endemic for strongyloidiasis and human T-lymphotropic virus-1: a single-center experience in Japan between 1990 and 2010. Infection 2013; 41:1189-93. [PMID: 23761268 PMCID: PMC3832757 DOI: 10.1007/s15010-013-0483-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 05/22/2013] [Indexed: 11/30/2022]
Abstract
Meningitis caused by enteric flora is a known complication of strongyloidiasis, and human T-lymphotropic virus-1 (HTLV-1) predisposes individuals to severe strongyloidiasis. We reviewed the clinical features of bacterial meningitis associated with strongyloidiasis seen at a single center in subtropical Japan, in an area endemic for both strongyloidiasis and HTLV-1. We found 33 episodes in 21 patients between 1990 and 2010. The results were remarkable for the high incidence of meningitis due to Gram-positive cocci (27.3 %), especially Streptococcus bovis, and culture-negative cases (42.4 %). Given the high incidence of Gram-positive meningitis, a modified approach to corticosteroid use would be advisable in areas where strongyloidiasis is endemic, due to the potentially adverse consequences of glucocorticoid therapy.
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Affiliation(s)
- Y Sasaki
- Department of Medicine, Okinawa Chubu Hospital, Okinawa, Japan,
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Schär F, Trostdorf U, Giardina F, Khieu V, Muth S, Marti H, Vounatsou P, Odermatt P. Strongyloides stercoralis: Global Distribution and Risk Factors. PLoS Negl Trop Dis. 2013;7:e2288. [PMID: 23875033 PMCID: PMC3708837 DOI: 10.1371/journal.pntd.0002288] [Citation(s) in RCA: 449] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 05/14/2013] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The soil-transmitted threadworm, Strongyloides stercoralis, is one of the most neglected among the so-called neglected tropical diseases (NTDs). We reviewed studies of the last 20 years on S. stercoralis's global prevalence in general populations and risk groups. METHODS/PRINCIPAL FINDINGS A literature search was performed in PubMed for articles published between January 1989 and October 2011. Articles presenting information on infection prevalence were included. A Bayesian meta-analysis was carried out to obtain country-specific prevalence estimates and to compare disease odds ratios in different risk groups taking into account the sensitivities of the diagnostic methods applied. A total of 354 studies from 78 countries were included for the prevalence calculations, 194 (62.4%) were community-based studies, 121 (34.2%) were hospital-based studies and 39 (11.0%) were studies on refugees and immigrants. World maps with country data are provided. In numerous African, Asian and South-American resource-poor countries, information on S. stercoralis is lacking. The meta-analysis showed an association between HIV-infection/alcoholism and S. stercoralis infection (OR: 2.17 BCI: 1.18-4.01; OR: 6.69; BCI: 1.47-33.8), respectively. CONCLUSIONS Our findings show high infection prevalence rates in the general population in selected countries and geographical regions. S. stercoralis infection is prominent in several risk groups. Adequate information on the prevalence is still lacking from many countries. However, current information underscore that S. stercoralis must not be neglected. Further assessments in socio-economic and ecological settings are needed and integration into global helminth control is warranted.
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Abstract
PATIENT Male, 36. FINAL DIAGNOSIS Strongyloidiasis. SYMPTOMS Abdominal pain • anorexia • eosinophilia • fever • letargy • weight loss. MEDICATION - CLINICAL PROCEDURE - SPECIALTY Infectious diseases. OBJECTIVE Challenging differential diagnosis, rare disease. BACKGROUND Strongyloidiasis is a worldwide infection, infecting approximately 100 million people in more than 70 countries. It is common in Southeast Asia, Latin America, Papua New Guinea and some parts of the United States. Malnutrition, cancer, organ transplantation, hemodialysis and prolonged use of corticosteroids increase the risk of this opportunistic infection. Undiagnosed and untreated, its mortality rate can be high. CASE REPORT We present a 36 year old Black man with history of malignant hypertension and glomerulonephritis who had chronic eosinophilia and vague, poorly localized abdominal pain and tenderness. He received three deceased donor kidney transplants, two of them failed and the third one succeeded. However, after transplantation, his abdominal pain and discomfort increased, became anorexic, lost weight and developed fever and lethargy. Duodenal aspirate examination was positive for strongyloides stercoralis. Immunosuppressant medications were discontinued and he was treated with thiabendazole. In spite of treatment, his condition deteriorated and he expired. CONCLUSIONS Due to low sensitivity of stool and serological examinations, diagnosis of strongyloidiasis often is delayed. A high index of suspicion and prompt diagnosis and treatment are essential in decreasing the morbidity and mortality of this infection. Before organ transplantation, every attempt should be made to find the cause of peripheral blood eosinophilia and in endemic areas and among patients coming from countries where the infection is known to exist, organ recipients and donors should be screened for parasitic infections including strongyloidiasis.
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Abstract
Infection is a frequent complication and a leading cause of morbidity and mortality in patients with hematological malignancies. Problems associated with the management of infections in these patients include difficulties in early diagnosis because the clinical signs of infection are subtle, the low performance of diagnostic tests, and suboptimal response to treatment because recovery of host defenses is a key factor for resolution of infection. Preventing these infections relies on infection control measures and antimicrobial chemoprophylaxis. While infection control measures are safe (but not always effective), the use of antimicrobial agents for prophylaxis of infection is not devoid of problems. Its wide use may increase the possibility of the development of resistance, select for resistant organisms, and increase toxicity and cost. Therefore, any attempt to administer an antimicrobial agent should be accompanied by a reflection of the potential benefits and risks of prophylaxis.
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Affiliation(s)
- Peter H. Wiernik
- Beth Israel Hospital, Cancer Center, St. Lukes-Roosevelt Hospital Center, 10th Avenue 1000, New York, 10019 New York USA
| | - John M. Goldman
- , Department of Hematology, Imperial College of London, Du Cane Road 150, London, W12 0NN United Kingdom
| | - Janice P. Dutcher
- Continuum Cancer Centers, Department of Medicine, St. Luke's-Roosevelt Hospital Center, 10th Avenue 1000, New York, 10019 New York USA
| | - Robert A. Kyle
- , Division of Hematology, Mayo Clinic, First Street SW. 200, Rochester, 55905 Minnesota USA
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Gomez JB, Maque Y, Moquillaza MA, Anicama WE. E. coli Meningitis Presenting in a Patient with Disseminated Strongyloides stercoralis. Case Rep Infect Dis 2013; 2013:424362. [PMID: 24324900 PMCID: PMC3845250 DOI: 10.1155/2013/424362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 10/07/2013] [Indexed: 11/23/2022] Open
Abstract
Introduction. Spontaneous Escherichia coli meningitis is an infrequent condition in adults and is associated with some predisposing factors, including severe Strongyloides stercoralis (SS) infections. Case Presentation. A 43-year-old Hispanic man, with history of travelling to the jungle regions of Peru and Brazil two decades ago, and who received prednisone due to Bell's palsy for three weeks before admission, presented to the Emergency Department with diarrhea, fever, and hematochezia. A week after admission he developed drowsiness, meningeal signs, abdominal distension, and constipation. A cerebrospinal fluid culture showed extended spectrum β -lactamase producing E. coli. A colonoscopy was performed and showed pancolitis. Three days after the procedure the patient became unstable and developed peritoneal signs. He underwent a laparotomy, which ended up in a total colectomy and partial proctectomy due to toxic megacolon. Three days later the patient died in the intensive care unit due to septic shock. Autopsy was performed and microscopic examination revealed the presence of multiple Strongyloides larvae throughout the body. Conclusion. Strongyloides stercoralis infection should be excluded in adults with spontaneous E. coli meningitis, especially, if gastrointestinal symptoms and history of travelling to an endemic area are present. Even with a proper diagnosis and management, disseminated strongyloidiasis has a poor prognosis.
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Affiliation(s)
- Juliana B. Gomez
- 1Department of Internal Medicine, Guillermo Almenara Irigoyen National Hospital, Lima, Peru
- *Juliana B. Gomez:
| | - Yvan Maque
- 2Grupo de Investigacion en Inmunologia, Universidad Nacional de San Agustin, Arequipa, Peru
| | - Manuel A. Moquillaza
- 3Department of Neurology, Guillermo Almenara Irigoyen National Hospital, Lima, Peru
| | - William E. Anicama
- 4Department of Pathology, Guillermo Almenara Irigoyen National Hospital, Lima, Peru
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Tefé-Silva C, Beneli CT, Celes MR, Machado ER, Ueta MT, Sorgi CA, Floriano EM, Faccioli LH, Ramos SG. Dexamethasone reduces bronchial wall remodeling during pulmonary migration of Strongyloides venezuelensis larvae in rats. Parasitol Int 2012; 61:425-30. [PMID: 22808527 DOI: 10.1016/j.parint.2012.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Strongyloidiasis is an intestinal parasitosis with an obligatory pulmonary cycle. A Th2-type immune response is induced and amplifies the cellular response through the secretion of inflammatory mediators. Although this response has been described as being similar to asthma, airway remodeling during pulmonary migration of larvae has not yet been established. The aim of this study was to identify the occurrence of airway remodeling during Strongyloides venezuelensis (S. v.) infection and to determine the ability of dexamethasone treatment to interfere with the mechanisms involved in this process. Rats were inoculated with 9,000 S. v. larvae, treated with dexamethasone (2 mg/kg) and killed at 1, 3, 5, 7, 14 and 21 days. Morphological and morphometric analyzes with routine stains and immunohistochemistry were conducted, and some inflammatory mediators were evaluated using ELISA. Goblet cell hyperplasia and increased bronchiolar thickness, characterized by edema, neovascularization, inflammatory infiltrate, collagen deposition and enlargement of the smooth muscle cell layer were observed. VEGF, IL1-β and IL-4 levels were elevated throughout the course of the infection. The morphological findings and the immunomodulatory response to the infection were drastically reduced in dexamethasone-treated rats. The pulmonary migration of S. venezuelensis larvae produced a transitory, but significant amount of airway remodeling with a slight residual bronchiolar fibrosis. The exact mechanisms involved in this process require further study.
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Affiliation(s)
- Cristiane Tefé-Silva
- Department of Pathology, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil.
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Abstract
PURPOSE OF REVIEW To provide an updated perspective of the most common parasitic infections occurring in solid-organ transplant (SOT) recipients. RECENT FINDINGS Parasitic infections are an emerging problem in SOT programs and represent a diagnostic and therapeutic challenge. Transplantation in endemic areas - including medical tourism, international travel and migration - justify the necessity of considering parasitic infections in the differential diagnosis of posttransplant complications. Molecular techniques, such as PCR, may improve the diagnostic accuracy and help during the follow-up. SUMMARY Parasitic infections are an uncommon but potentially severe complication in SOT recipients. An increase of donors emigrated from tropical areas and more posttransplant patients traveling to endemic areas have led to a rise in parasitic infections reported among SOT recipients. Transplant physicians should get familiar with parasitic infections and promote adherence to preventive measures in SOT recipients.
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Machado ER, Carlos D, Sorgi CA, Ramos SG, Souza DI, Soares EG, Costa-Cruz JM, Ueta MT, Aronoff DM, Faccioli LH. Dexamethasone effects in the Strongyloides venezuelensis infection in a murine model. Am J Trop Med Hyg 2011; 84:957-66. [PMID: 21633034 DOI: 10.4269/ajtmh.2011.10-0490] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The aim of this study was to investigate the immunomodulatory effects of glucocorticoids on the immune response to Strongyloides venezuelensis in mice. Balb/c mice were infected with S. venezuelensis and treated with Dexamethasone (Dexa) or vehicle. Dexa treatment increased circulating blood neutrophil numbers and inhibited eosinophil and mononuclear cell accumulation in the blood, bronchoalveolar, and peritoneal fluid compared with control animals. Moreover, Dexa decreased tumor necrosis factor-α (TNF-α), interferon-γ (IFN-γ), interleukin-3 (IL-3), IL-4, IL-5, IL-10, and IL-12 production in the lungs and circulating immunoglobulin G1 (IgG1), IgG2a, and IgE antibody levels while increasing the overall parasite burden in the feces and intestine. Dexa treatment enhanced the fertility of female nematodes relative to untreated and infected mice. In summary, the alterations in the immune response induced by Dexa resulted in a blunted, aberrant immune response associated with increased parasite burden. This phenomenon is similar to that observed in S. stercoralis-infected humans who are taking immunosuppressive or antiinflammatory drugs, including corticosteroids.
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Affiliation(s)
- Eleuza R Machado
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Avenida do Café s/n, Ribeirão Preto, SP, Brazil.
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Abstract
The objective of this review was to outline an epidemiological profile of Strongyloides stercoralis by parasitological and serological diagnosis in inhabitants, and to associate this profile with different immunosupression situations, in Brazil, over 20 years (1990-2009). The occurrence of S. stercoralis using parasitological methods was 5·5%, being 4·8% in rural and 5·0% in urban areas, characterizing the country as hyperendemic. There was a diversity of techniques used as a diagnostic tool and only 39·1% of the studies presented results based on at least 1 specific method. The occurrence increased with age, being 12·1%, for those over 60 that suggests an epidemiological condition of concern for the elderly population. Of the seroepidemiological studies in the general population the mean positivity in serum samples was 21·7% and 29·2%, using an immunofluorescence antibody test and enzyme-linked immunosorbent assay (ELISA), respectively. The occurrence of strongyloidiasis in immunosuppressed individuals was 11·8% by parasitological methods and 19·5% using immunological methods. Considering that Brazil is a tropical country and that the character of chronicity and autoinfection of the parasite that can result in severe forms of hyperinfection or dissemination makes strongyloidiasis an important medically and socially neglected problem.
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Abstract
Infection of carriers of strongyloides by the human oncogenic retrovirus HTLV-1 significantly augments the number of larval parasites in the stools and impairs the action of anti-helminthic agents, resulting in an increase in immediate and longer term failure of therapy. The proliferation of cytokine type 1 secreting lymphocytes, the preferred target for viral infection, shifts the Th1/Th2 balance in favour of a Th1 response with a consequent increase in the production of gamma interferon (INF-γ). In addition to other effects, this causes a decrease in the secretion of cytokines IL-4, IL-5 and IL-13, which results in substantial reduction in total and specific IgE; failure of activation of eosinophils or stagnation in or reduction of their numbers; and an increased risk of development of a severe form of strongyloidiasis. This risk is clearly correlated with the level of anti-HTLV-1 antibodies and the amplitude of the proviral load of peripheral lymphocytes. The polyclonal expansion of infected CD4 cells might be partly due to the activation of the IL-2/IL-2R system by parasite antigens together with the action of the virus type 1 Tax protein. The fact that adult T cell leukaemia arises significantly earlier and more often in individuals with combined infection is an argument in favour of the parasite's role as a leukaemogenic co-factor. In practice it is, therefore, appropriate to initiate all available measures to eliminate parasites from co-infected hosts although this does present difficulties, and one should not reject the possibility of a diagnosis of strongyloidiasis in the absence of hypereosinophilia. In all cases of chronic strongyloidiasis without hypereosinophilia, co-infection with HTLV-1 should be looked for routinely. The same applies to carriers of strongyloides with repeated treatment failures. Finally, corticosteroids and immunosuppressants should be used only with care in HTLV-1-positive patients who seem not to be co-infected, even if they have received precautionary therapy.
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Affiliation(s)
- J-F Pays
- Faculté de médecine Descartes-Necker, Université Paris-V-René-Descartes, Paris, France.
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Affiliation(s)
- Anuradha Ramaswamy
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Stewart DM, Ramanathan R, Mahanty S, Fedorko DP, Janik JE, Morris JC. Disseminated Strongyloides stercoralis infection in HTLV-1-associated adult T-cell leukemia/lymphoma. Acta Haematol 2011; 126:63-7. [PMID: 21474923 DOI: 10.1159/000324799] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 01/26/2011] [Indexed: 11/19/2022]
Abstract
A 55-year-old woman with human T-cell lymphotropic virus type-1 (HTLV-1)-associated adult T-cell leukemia (ATL) and a history of previously treated Strongyloides stercoralis infection received anti-CD52 monoclonal antibody therapy with alemtuzumab on a clinical trial. After an initial response, she developed ocular involvement by ATL. Alemtuzumab was stopped and high-dose corticosteroid therapy was started to palliate her ocular symptoms. Ten days later, the patient developed diarrhea, vomiting, fever, cough, skin rash, and a deteriorating mental status. She was diagnosed with disseminated S. stercoralis. Corticosteroids were discontinued and the patient received anthelmintic therapy with ivermectin and albendazole with complete clinical recovery.
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Affiliation(s)
- Donn M Stewart
- Metabolism Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA.
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Argelich R, Pujol MT, Álvarez-martínez MJ. Varón de 69 años con meningitis recidivante. Med Clin (Barc) 2011; 136:167-74. [DOI: 10.1016/j.medcli.2010.09.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Accepted: 09/28/2010] [Indexed: 11/22/2022]
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Abstract
Immunocompromised persons are the most vulnerable population at risk for developing life-threatening clinical syndromes associated with strongyloidiasis, such as hyperinfection syndrome (HS) or dissemination. This review focuses on describing Strongyloides infection in the immunocompromised host, including immune response against this infection, analyzing the cases with HS published during the past 4 years in the United States, and describing the most sensitive diagnostic tools and the most effective treatment for each clinical syndrome. Strongyloidiasis is becoming an important parasitic disease in the United States, especially in the immunocompromised immigrant population. Because the transplant population is particularly at risk for developing HS, both recipients and donors should be screened for Strongyloides. Clinicians should also be aware that the development of HS can follow unexpectedly a few days after appropriate anthelminthic therapy. Highly sensitive screening tests are still not available in the major tertiary medical centers. Parenteral ivermectin has been used in some severe cases. Further therapy developments and improving diagnostic tools are warranted.
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Affiliation(s)
- Luis A Marcos
- Infectious Diseases Division, Internal Medicine Department, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO, 63110, USA,
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Fusco DN, Downs JA, Satlin MJ, Pahuja M, Ramos L, Barie PS, Fleckenstein L, Murray HW. Non-oral treatment with ivermectin for disseminated strongyloidiasis. Am J Trop Med Hyg 2010; 83:879-83. [PMID: 20889884 DOI: 10.4269/ajtmh.2010.10-0258] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Critically ill patients with disseminated strongyloidiasis may not be candidates for oral treatment. We report four patients with disseminated strongyloidiasis, believed to be unable to absorb oral therapy, who were treated with ivermectin by rectal and/or subcutaneous administration. Obtaining subcutaneous ivermectin and dosing it appropriately is a challenge. These cases underscore the need for improved access to subcutaneous ivermectin and more pharmacological data to guide use of this treatment approach.
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Affiliation(s)
- Dahlene N Fusco
- Division of Infectious Diseases, and Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, USA.
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Abstract
Parasitic infections are an uncommon but potentially severe complication in solid organ transplant (SOT) recipients. An increase in donors who have emigrated from tropical areas and more transplant recipients traveling to endemic areas have led to a rise in parasitic infections reported among SOT recipients. Clinicians should include these infections in their differential diagnosis and promote adherence to preventive measures in SOT recipients.
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