Severe Strongyloides stercoralis infection in kidney transplant recipients: A multicenter case-control study

BACKGROUND

Severe Strongyloides stercoralis infection in kidney transplant recipients is associated with considerable morbidity and mortality, although little is known about the risk factors for such infection.

METHODOLOGY/PRINCIPAL FINDINGS

This was a retrospective, multicenter, case-control study in which we assessed the risk factors for and clinical outcomes of severe S. stercoralis infections in kidney transplant recipients in Brazil. We included 138 kidney transplant recipients: 46 cases and 92 controls. Among the cases, the median number of days from transplantation to diagnosis was 117 (interquartile range [IQR], 73.5-965) and the most common clinical findings were gastrointestinal symptoms (in 78.3%) and respiratory symptoms (in 39.1%), whereas fever and eosinophilia were seen in only 32.6% and 43.5%, respectively. The 30-day all-cause mortality among the cases was 28.3% overall and was significantly higher among the cases of infection occurring within the first three months after transplantation (47% vs. 17.2%, P = 0.04). The independent risk factors were receiving a transplant from a deceased donor (odds ratio [OR] = 6.16, 95% confidence interval [CI] = 2.05-18.5), a history of bacterial infection (OR = 3.04, 95% CI = 1.2-7.5), and a cumulative corticosteroid dose (OR = 1.005, 95% CI = 1.001-1.009). The independent predictors of mortality were respiratory failure (OR = 98.33, 95% CI = 4.46-2169.77) and concomitant bacteremia (OR = 413.00, 95% CI = 4.83-35316.61).

CONCLUSIONS/SIGNIFICANCE

Severe S. stercoralis infections are associated with considerable morbidity and mortality after kidney transplantation. In endemic areas, such infection may occur late after transplantation, although it seems to be more severe when it occurs earlier after transplantation. Specific risk factors and clinical manifestations can identify patients at risk, who should receive prophylaxis or early treatment.

The investigation of Strongyloides stercoralis seroprevalence in immunosupressed patients in Turkey

Background/aim

In immunosuppressed patients, strongyloidiasis can be lifethreatening because of hyperinfection or dissemination. Therefore, diagnosis of S. stercoralis is important in immunosuppressed patients with chronic strongyloidiasis. In this study, our objective was to investigate the presence of S. stercoralis antibodies by an ELISA method in immunosuppressed patients.

Materials and methods

A total of 100 immunosuppressed patients’ sera were included in the study. Forty-two of the patients were receiving immunosuppressive therapies for cancer or being treated for hematopoietic malignancies, 38 of the patients were receiving immunosuppressive drugs for rheumatic diseases, 14 were receiving immunosuppressive therapies for liver transplantation. Two of the patients were being treated for HIV infection and 4 were being treated for hypogammaglobulinemia. As control group, 50 individuals without a known disease were included in the study. The presence of IgG antibodies against S. stercoralis was investigated with a commercial ELISA kit.

Results

S. stercoralis antibody test was positive in 4 of 100 (4%) sera from immunosuppressed patients. All control patients were negative for S. stercoralis.

Conclusions

Strongyloidiasis can be a lifelong chronic infection if not treated. In patients who are going to receive immunosuppressive therapy, it should be tested before treatment, as it can become a disseminated and life-threatening infectious disease.

Strongyloides stercoralis in solid organ transplantation: early diagnosis gets the worm

PURPOSE OF REVIEW

Strongyloidiasis is a parasitic infection affecting millions of people worldwide. Complications of infection are strongly associated with alcoholism, immunosuppression, and organ transplantation. Delayed diagnosis results in hyperinfection syndrome and disseminated strongyloidiasis leading to mortality rates approaching 80%. Early detection, and prevention of infection and transmission are key to diminish this illness.

RECENT FINDINGS

In this review, we cover the basic concepts in immunity, immunosuppression, and disorder necessary for understanding the infectious syndromes associated with Strongyloides stercoralis infection. Focused discussion on donor-derived transmission and recipient risk in solid organ transplantation is presented. Current methodology for diagnosis, screening algorithms, and treatment are also reviewed.

SUMMARY

Strongyloidiasis complicated by hyperinfection and dissemination remains associated with a poor outcome. The poor outcome pleads for a high level of suspicion and aggressive treatment in at-risk patients. As the population of transplant patients continues to increase, the risk of infection also increases, compelling us to address this highly fatal infectious complication in solid organ transplantation (SOT). Here we review the pathology, immunology, diagnosis, and treatment of strongyloides infection in the immunosuppressed SOT population.

Comparison of albendazole regimen for prophylaxis of strongyloides hyperinfection in nephrotic syndrome patients on long-term steroids in Cambodia

Nephrotic syndrome patients on long-term steroids face the risk of having heavy uncomplicated strongyloidiasis or death from its extreme form, the strongyloides hyperinfection. The risk can be minimized if we eradicate the parasite first. We compare a once daily and twice daily albendazole regimen in preventing this potentially fatal complication in 122 patients with nephrotic syndrome.

[Strongyloidiasis: who is at risk of severe infection and how to prevent it?]

Strongyloides stercoralis hyperinfection syndrome, which carries a high mortality (60%), occurs usually after immunosuppressive therapy. Cellular immunosuppression allows the parasite to reactivate and stimulate its cycle of auto-infection. It is therefore important to prevent this syndrome by screening at risk patients at risk for chronic strongyloidiasis before starting immunosuppressive treatment and especially before treatment with corticosteroids, even that of short duration. Ivermectine is the treatment of choice.

[Infection due to Strongyloides stercoralis: epidemiological, clinical, diagnosis findings and outcome in 30 patients]

BACKGROUND

Strongyloides stercoralis is a nematode parasite, which is endemic in tropical and subtropical regions. Infection usually remains asymptomatic, but in immunocompromised hosts severe and life-threatening manifestations such as hyperinfection syndrome and disseminated disease might occur.

METHODS

We retrospectively analyzed the epidemiological and clinical characteristics, including HIV co-infection, microbiological findings, and outcome in 30 patients with strongyloidiasis, who attended in the Infectious Diseases F. J. Muñiz Hospital in Buenos Aires from January 2004 to December 2008.

RESULTS

The study included 20 men and 10 women with an average age of 33 years. HIV co-infection was present in 21 patients (70%) with a median CD4 T cell count of 50 cells/mm³ (range 7-355) (average 56 cells/mm³). Among HIV negative patients the following comorbidities were detected: tuberculosis (n = 3) and chronic alcoholism, leprosy treated with corticosteroids, immunosuppressive treatment for psoriasis, and diabetes mellitus (each in one patient). Two patients did not have any predisposing diseases or immunosuppressive treatments. Seventeen patients presented with diarrhea and were classified as chronic intestinal strongyloidiasis (57%), asymptomatic infection with peripheral eosinophilia was diagnosed in 7 (23%), and 6 patients (20%) developed hyperinfection syndrome. Seventeen patients (57%) presented peripheral eosinophilia. Diagnosis was achieved by direct visualization of larvae in feces by Baermann technique (n = 20), by multiple stool smears examinations (n = 2), by combination of both (n = 1), by visualization of the filariform larvae in duodenal fluid and stool (n = 1), and in fecal and bronchoalveolar lavage specimens (n = 6). Overall mortality in this series was 20% (6/30). There was no significant correlation between age and mortality. A significant inverse correlation between the survival rate and CD4 T-cell count as well as eosinophilia was observed. There was also a significant correlation between HIV co-infection and mortality. Twenty-two patients responded favorably to treatment with ivermectin.

Strongyloidiasis in transplant patients

Strongyloides stercoralis is an intestinal nematode that can persist in the human host for decades after the initial infection and can progress to fulminant hyperinfection syndrome in immunocompromised hosts. We describe a patient who died of Strongyloides hyperinfection syndrome 2 months after orthotopic heart transplantation and discuss approaches to prevention, diagnosis, and treatment. Current practice guidelines recommend screening for and treatment of Strongyloides infection before transplantation, but physicians in the United States often miss opportunities to identify patients with chronic strongyloidiasis. Screening tests have limitations, and clinical suspicion remains an important component of the evaluation before transplantation. After immunocompromised patients develop hyperinfection syndrome, diagnosis is often delayed and mortality is high, so emphasis must be placed on screening and treatment before transplantation. We review current strategies for prevention, diagnosis, and treatment of chronic intestinal strongyloidiasis in patients who will undergo transplantation and discuss the clinical features and management of Strongyloides hyperinfection syndrome in transplant recipients.

[Infections in hospitalized patients with cirrhosis]

We evaluated the prevalence and the clinical relevance of bacterial and nonbacterial infections in predominantly alcoholic cirrhotic patients, admitted to an intermediate complexity hospital, and we also compared the clinical characteristics, laboratory and evolution of these patients with and without bacterial infection in a prospective study of cohort. A total of 211 consecutive admissions in 132 cirrhotic patients, between April 2004 and July 2007, were included. The mean age was 51.8 (+/-8) years, being 84.8% male. The alcoholic etiology of cirrhosis was present in 95.4%. One hundred and twenty nine episodes of bacterial infections were diagnosed in 99/211 (46.9%) admissions, community-acquired in 79 (61.2%) and hospital-acquired in 50 (38.8%): spontaneous bacterial peritonitis (23.3%); urinary tract infection (21.7%); pneumonia (17.8%); infection of the skin and soft parts (17.1%), sepsis by spontaneous bacteremia (7.7%); other bacterial infections (12.4%). Gram-positive organisms were responsible for 52.2% of total bacterial infections documented cases. There were eight serious cases of tuberculosis, fungal and parasitic infections; the prevalence of tuberculosis was 6% with an annual mortality of 62.5%; 28.1% (9/32) of the coproparasitological examination had Strongyloides stercolaris. The in-hospital mortality was significantly higher in patients with bacterial infection than in non-infected patients (32.4% vs. 13.2%; p=0.02). The independent factors associated with mortality were bacterial infections, the score of Child-Pügh and creatininemia > 1.5 mg/dl. By the multivariate analysis, leukocytosis and hepatic encephalopathy degree III/IV were independent factors associated to bacterial infection. This study confirms that bacterial and nonbacterial infections are a frequent and severe complication in hospitalized cirrhotic patients, with an increase of in-hospital mortality.

Invasive enteric infections in hospitalized patients with underlying strongyloidiasis

Disseminated strongyloidiasis is often associated with enteric bacterial infections. This study was undertaken to determine if enteric organisms caused extraintestinal infections in patients infected with Strongyloides stercoralis but without apparent dissemination. The medical records of hospitalized patients from central Kentucky with strongyloidiasis (1993-2003) were examined to determine the occurrence of extraintestinal infections with enteric organisms. Of 30 patients with S stercoralis, 16 had invasive infections, including sepsis, meningitis, pneumonia, peritonitis, and endocarditis caused by enteric bacteria and Candida organisms. Infections were seen in 8 (62%) of 13 patients with disseminated strongyloidiasis and 8 (47%) of 17 with disease apparently limited to the gastrointestinal tract. Fifteen patients were receiving corticosteroids or other immunosuppressive therapy. Peripheral eosinophilia was seen in only 23% (7/30). Infection with S stercoralis, even without obvious dissemination, may predispose to invasive infections caused by enteric organisms. In Strongyloides-endemic areas, patients with invasive infections caused by enteric organisms should be examined for coinfection with S stercoralis.

Hyperinfection Strongyloidiasis: An Anticipated Outbreak in Kidney Transplant Recipients in Kuwait

BACKGROUND

Hyperinfection strongyloidiasis is a potentially fatal syndrome associated with conditions of depressed host cellular immunity. A high degree of suspicion is required to detect cases early and thereby avoid a fatal outcome.

PATIENTS AND METHODS

Three consecutive cadaveric kidney transplant recipients died within 2 months from hyperinfections with strongyloides. All members of the transplant team were involved in a campaign to localize the source of infection, identify and treat affected patients, and provide adequate prophylaxis to other transplant recipients. We reviewed cadaveric donor files and screened 61 hospital personnel, 27 hospital inpatients, and the 87 hospital outpatients transplanted in a year's time before that event for a possible source. The screening test included analysis of fresh stool samples on 3 consecutive days for strongyloides larvae. The anti-helminthic drug albendazol was administered to all patients during screening. They were followed for possible development of the disease during the infectivity period.

RESULTS

The first 2 recipients received their kidneys from 1 cadaveric donor, while the third received it from a different donor. Both donors came from areas endemic for strongyloidiasis. The 3 recipients were on tacrolimus-based immunosuppression. The twin recipient of the second kidney was on cyclosporine and did not manifest a disease. All stool samples taken for screening were negative for the infective larvae. None of the other recipients developed the disease.

CONCLUSIONS

Cadaveric donors were the possible source for this outbreak. Cyclosporine probably has a protective effect against strongyloides. In our setting, screening of cadaveric donors for strongyloides is mandatory before accepting them for donation, and oral prophylaxis is required for all recipients.

Disseminated strongyloidiasis: a retrospective study of clinical course and outcome

A retrospective study was carried out to evaluate the clinical course and outcome of disseminated strongyloidiasis treated in a regional hospital in Hong Kong over a 10-year period. Seven cases were identified, and the case history of each patient was analysed. The most common presenting symptom was fever (100%). Five (71%) patients had gastrointestinal symptoms, the most common being abdominal pain and diarrhoea. Three (42%) patients had a significant drop in haemoglobin. Six (85%) patients had bronchoalveolar infiltrates on chest radiographs. Most patients were immunosuppressed by means of steroid treatment for their underlying primary disease. One patient was diabetic, and another had lymphoma and was receiving chemotherapy. Strongyloides larvae were identified in stool specimens in two patients, in sputum smears in two patients, and in gastric biopsies in three patients. Five (71%) of the patients with lung involvement progressed to respiratory failure and died. Two (29%) cases were complicated by gram-negative bacterial infection. No patient had eosinophilia on presentation. All patients received antihelminthic treatment of variable duration. The case fatality rate in the cohort was 71% despite aggressive supportive therapy. Pulmonary and bowel symptoms were prominent in our series. In conclusion, the diagnosis of disseminated strongyloidiasis is often delayed because of nonspecific presenting symptoms. Early diagnosis relies on a high index of clinical suspicion, especially in immunocompromised hosts. Screening for Strongyloides infection before the initiation of immunosuppressive therapy should be considered, especially in endemic areas.

Risk factors for strongyloidiasis hyperinfection and clinical outcomes

Strongyloidiasis, caused by Strongyloides stercoralis, consists of various clinical syndromes. Strongyloidiasis hyperinfection leads to morbidity and mortality particularly in immunocompromized patients. This study aimed to determine the risk factors for strongyloidiasis hyperinfection and clinical outcomes. The medical records for hospitalized patients infected with S. stercoralis at Ramathibodi Hospital during 1994-2005 were retrospectively reviewed. Risk factors for strongyloidiasis hyperinfection were determined. There were 123 episodes of strongyloidiasis in 111 patients. The mean age was 46.8 +/- 17.8 years; 61% were males. Of 123 episodes, 37 (30.1%) had strongyloidiasis hyperinfection; the others had chronic strongyloidiasis. All the patients with strongyloidiasis hyperinfection and 88.3% of those with chronic strongyloidiasis were immunocompromized (p = 0.032); 89.2% of the former and 55.8% of the latter had received corticosteroids (p < 0.001). There were no significant differences in the type of immunocompromized host and the corticosteroid dosage between the two groups (p > 0.05). The hyperinfection group had a lower mean serum protein (p = 0.026) and albumin (p = 0.027) but a higher frequency of sepsis (p = 0.029), asthma-like symptoms (p = 0.025), adult respiratory distress syndrome (p = 0.026), and a longer duration of treatment (p=0.004). By logistic regression, corticosteroids use was a risk factor for hyperinfection (OR = 6.5, 95% CI = 2.1-20.0, p = 0.001). Most of the patients were treated with albendazole or thiabendazole, with a cure rate of 76.9%, whereas other recent cases treated with ivermectin had an average cure rate of 83.3%. The overall mortality rate was 8.1%.

Identification and characterization of the threadworm, Strongyloides procyonis, from feral raccoons (Procyon lotor) in Japan

Strongyloides procyonis Little, 1966 was detected about 45 years ago in raccoons (Procyon lotor) of southern Louisiana, U.S.A., and was demonstrated experimentally to cause creeping eruption and a short-lived intestinal infection in a healthy human volunteer. After its description and demonstration of its pathogenicity in humans, S. procyonis has not been found in raccoons in North America despite repeated surveys. During a survey on feral raccoons in Japan, S. procyonis parasitic females were identified in 66 (28.3%) of 233 raccoons collected between May 2004 and January 2005. The number of parasitic females recovered from individual raccoons was 1-197 (geomean, 3.2). Both the morphological features and the nucleotide sequences of the small and large subunit ribosomal RNA genes (SSU/LSU rDNA) of S. procyonis closely resembled those of zoonotic Strongyloides stercoralis. The sequences of internal transcribed spacer (ITS)1 and 28S rDNA could differentiate clearly these 2 species. Awareness of S. procyonis in raccoons in North America and other places worldwide where raccoons are introduced and naturalized is important to assess the epidemiological significance of this potentially zoonotic helminth species.

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

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

Hyperinfective strongyloidiasis in the medical ward: review of 27 cases in 5 years

BACKGROUND

Hyperinfective strongyloidiasis is rare, but the mortality rate is very high. It occurs most commonly in immunocompromised patients. We reviewed the clinical presentation and mortality rate of cases managed in our facility.

METHOD

Twenty-seven patients with hyperinfective strongyloidiasis admitted to our medical ward over a 5-year period were prospectively studied.

RESULTS

In our study, there were 18 males and 9 females (mean age, 58 years). Weight loss, gastrointestinal symptoms, hypoproteinemia, and anemia were the main clinical presentations. Mortality rate was 26%; human T-lymphotropic virus (HTLV-1) infection, chronic alcoholism, eosinopenia, sepsis, and prerenal azotemia on admission were poor prognostic factors. HTLV-1 infection was the main underlying disease in 71% of patients, and 44% of patients had a history of chronic alcoholism.

CONCLUSION

Early diagnosis and treatment with thiabendazole may reduce mortality in hyperinfective strongyloidiasis. Hyperinfective strongyloidiasis may also be a clinical marker of HTLV-1 infection in areas where both entities are endemic or in immigrants from such areas.

Strongyloides stercoralis infection in AIDS

Strongyloides stercoralis infection in humans continues to be a subject that has frequently inspired reviews and papers. Within the AIDS epidemic, interest gathered momentum with the inclusion of this infection in the indicator diseases list, and its subsequent removal 5 years later by the CDC. These actions have prompted a debate as to whether this infection has special significance in patients with AIDS and whether its exclusion from the CDC criteria is justified. A detailed review of the world literature reveals an increased awareness and diagnosis of this infection in patients with AIDS which takes the form of dissemination, a rapid course, and a usually fatal outcome.

Effect of Strongyloides stercoralis infection and eosinophilia on age at onset and prognosis of adult T-cell leukemia

Onset of adult T-cell leukemia (ATL) usually follows a long period of viral latency. Strongyloides stercoralis infection has been considered a cofactor of leukemogenesis. Hypereosinophilia (HE) is also observed and could be associated with either the presence of parasites or the leukemic process. In non-Hodgkin's lymphoma, eosinophilia may or may not affect prognosis. To determine whether infection with S stercoralis and therefore eosinophilia has a significant effect on the development of ATL, we studied two variables in 38 patients: age at onset and median survival rate. Infected (Ss+) patients (n = 19) were younger (P = .0002) and survived longer (P = .0006) than uninfected (Ss-) patients (n = 19) (median age, 39 vs 70 years; median survival, 167 vs 30 days). Mean survival of patients with hypereosinophilia (HE+) was not significantly different from that of patients without hypereosinophilia (HE-) (P = .57). However, overall survival was longer for Ss + HE + patients than for Ss-HE-patients (P = .01; 180 vs 30 days) or Ss-HE + patients (P = .03; 180 vs 45 days). Among patients with mean survival more than 180 days, Ss + HE + patients survived longer (P = .028). Our data confirm that cofactors related to the environment, such as S stercoralis and hypereosinophilia associated with S stercoralis or human T-cell leukemia virus, type 1 (HTLV-1) might be important in HTLV-1-associated leukemogenesis and suggest that hypereosinophilia affects the prognosis of HTLV-1-associated leukemia.

Massive experimental infection with Strongyloides venezuelensis in rats and absence of sudden death

Ten rats were divided into five groups, A - E, to determine the larval dose-effect of infection with Strongyloides venezuelensis (SVZ). The rat groups were exposed to SVZ infective larvae as follow: (A) 100, (B) 1,000, (C) 10,000, (D) 100,000 and (E) 1,000,000. The eight rats in Groups A - D survived the infection. Rats exposed to the higher doses of larvae had the higher egg per gram counts (EPG), but more rapid reduction in EPG counts. The four rats in Groups C and D had EPG counts greater than 10,000 EPG during days 7 - 21 after infection. Maximum EPG values in Group C were 85,400 and 106,600; those in Group D were 134,000 and 346,000. The two rats in Group E showed severe itching and bleeding on their digital pads at the time of infection. They became listless thereafter and died with hemorrhagic pneumonia at 4 days after infection. The sudden death that has been demonstrated in calves infected with massive doses of S. papillosus was not observed in SVZ-infected rats.

Sudden cardiac death in calves with experimental heavy infection of Strongyloides papillosus

For obtaining the preliminary data on the pathogenesis of sudden death in calves naturally heavily infected with Strongyloides papillosus, we monitored 8 Holstein calves experimentally infected with the larvae on electrocardiographic and pneumographic changes. Six calves died suddenly on days 11 to 17 after infection. Sinus tachycardia had been recorded continuously since 1 to 6 days before death. Heart rates increased gradually until death. Since 1 or 2 days before death, various patterns of tachyarrhythmia and bradyarrhythmia had been observed among patterns of sinus tachycardia. Arrhythmias included serious ventricular premature beat, paroxysmal ventricular tachycardia, complete atrioventricular block and so on. The terminal pattern observed suddenly in all of the cases was ventricular arrhythmias consisting of serial ventricular tachycardia, flutter and fibrillation, which were followed by respiratory arrest. Abnormal pneumograms were not obtained before the terminal ventricular fibrillation. Two of 8 calves recovered from the infection, only one of which showed sinus arrest and the second degree of atrioventricular block transiently. We concluded that calves heavily infected with the larvae died due to sudden cardiac arrest.

Sudden death of calves by experimental infection with Strongyloides papillosus. I. Parasitological observations

Recently, an unknown disease, 'sudden death', in calves has been found in Japanese beef production farms. A previous study conducted by Taira and Ura indicated that sudden death can be effected in calves by hyperinfection of Strongyloides papillosus (SPL) and that the disease is possibly caused by SPL infection. In the present work, an experimental infection of SPL in calves was conducted to confirm the field occurrence. Fifteen Holstein Friesian calves, ranging from 45.5 to 85.6 kg in body weight, were divided into six groups. Calves of Groups A, B, C, D, E and F were infected once at the rate of 100,000, 320,000, 1,000,000, 3,200,000, 10,000,000 and 32,000,000 SPL larvae per 100 kg of body weight, respectively. Five calves were assigned to Group B, while two calves were assigned to the other groups. After showing no premonitory signs, sudden death of ten calves took place. The survival time of these calves was 27.4 and 16.8 days (Group B), 14.8 and 14.8 days (Group C), 13.3 and 14.2 days (Group D), 11.0 and 11.1 days (Group E) and 11.6 and 10.8 days (Group F). Three calves of Group B did not exhibit sudden death. The results of this study demonstrate that strongyloidiasis was the cause of sudden death.

Sudden death in calves associated with Strongyloides papillosus infection

In recent years, a total of 152 calves have died suddenly on three farms in the southern part of Japan which used sawdust as litter. Calves often died within a few minutes of a violent fall without showing previous clinical signs. On necropsy of these cases, only a slight lesion was observed, although all showed heavy infection with Strongyloides papillosus (SPL). They appeared to have not only a large number of SPL eggs in the faeces, together with many adult SPL worms in the intestine, but also many migratory SPL larvae in tissues such as the lung and muscle. These outbreaks ceased following medication with thiabendazole or ivermectin. It is concluded that 'sudden death' is associated with heavy infection with SPL.

Disseminated Strongyloides stercoralis: a fatal case eluding diagnosis

We have described a patient who died of disseminated strongyloidiasis as a result of steroid therapy, despite an extensive diagnostic evaluation in the face of eosinophilia, but before any immunosuppressive therapy. This death might have been prevented by presumptive treatment after work-up but before immunosuppressive therapy, and repeat diagnostic evaluation after antistrongyloides therapy and during immunosuppressive therapy.

Differential responses of Duroc, Hampshire, and crossbred pigs to a superimposed experimental infection with the intestinal threadworm, Strongyloides ransomi

In both spring and fall, 12 Duroc, 12 Hampshire, and 12 Duroc times Hampshire F1 weanling pigs all reared under the same management were fed in pens of 3 to slaughter weights. Three Duroc and 4 Hampshire boars, essentially unrelated within breed, were used in sampling the breeds. Swine herd management allowed pig infection with Strongyloides ransomi and Ascaris suum, but neither clinical nor subclinical parasitism was evident in the herd. Pigs were percutaneously exposed by pens within breed and season, half to none (control) and half to 3,000,000 (exposed) S. ransomi infective larvae, Breed, treatment, and seasons were prominent sources of variation in pig response. Breeds failed to respond alike to parasitism in respect to experimental periods and exposure levels. This interaction response (P smaller than 0.01) showed that S. ransomi egg production increased rapidly for all breed groups but decreased quicker and greater in Durocs, slowest and least in Hampshires, with cross breds intermediate in these respects. The 2.0830 for mean of log A. suum EPG from exposed Durocs was near double that of control Durocs but the mean for exposed Hampshires was less than half that for controls; crossbreds tended to be intermediate in this respect. Daily gains of 0.70 and 0.73 for Durocs and crossbreds were similar (P greater than 0.10) but averaged 11.7% more (P smaller than 0.05) than the 0.64 kg for Hampshires and gains by control pigs were 20.6% above (P greater than 0.01) that of exposed pigs. Exposed pigs required more feed per kg of gain (P greater than 0.05) than control pigs (3.60 vs. 3.33 kg). Comparison of relative gains and feed efficiences of control and exposed pigs among and within breed groups supported the position that a superimposed exposure of 3,000,000 S. ransomi larvae was more severe for Hampshires, intermediate for crossbreds, and least severe for Durocs.