Strongyloides stercoralis: Difference between revisions
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==Background==
==Background==
* Intestinal nematode; roundworm
 
*Intestinal nematode; roundworm
*Endemic in tropical/subtropical areas such as Africa, Southeast Asia, Central/South America<ref>Buonfrate D, Requena-Mendez A, Angheben A, Munoz J, Gobi F, Van Den Ende J, Bisoffi Z.  Severe strongyloidiasis: a systematic review of case reports. BMC Infectious Diseases 2013, 13: 78.  doi:10.1186/1471-2334-13-78</ref>
*Endemic in tropical/subtropical areas such as Africa, Southeast Asia, Central/South America<ref>Buonfrate D, Requena-Mendez A, Angheben A, Munoz J, Gobi F, Van Den Ende J, Bisoffi Z.  Severe strongyloidiasis: a systematic review of case reports. BMC Infectious Diseases 2013, 13: 78.  doi:10.1186/1471-2334-13-78</ref>


===Life Cycle===
===Life Cycle===
* Present in contaminated soil => larvae penetrate skin of hosts walking barefoot => enter venous circulation, migrate to lungs, then are expectorated to pharynx and swallowed => larvae develop into females that lay eggs asexually into GI tract, which hatch into larvae and are excreted into stool
 
* Larvae either become sexually reproducing males/females or filariform larvae that can reinfect host
*Present in contaminated soil → larvae penetrate skin of hosts walking barefoot → enter venous circulation, migrate to lungs, then are expectorated to pharynx and swallowed → larvae develop into females that lay eggs asexually into GI tract, which hatch into larvae and are excreted into stool
* Autoinfection: Unique to Strongyloides; GI larvae can migrate from GI tract to venous system, then to lungs and proceed with life cycle
*Larvae either become sexually reproducing males/females or filariform larvae that can reinfect host
** Can lead to dramatic increase in worm burden and hyperinfection in immunocompromised
*Autoinfection: Unique to Strongyloides; GI larvae can migrate from GI tract to venous system, then to lungs and proceed with life cycle
**Can lead to dramatic increase in worm burden and hyperinfection in immunocompromised
 


===Risk factors===
===Risk factors===
*Corticosteroid use, immunosuppression
 
*Transplantation
*[[Corticosteroid|Corticosteroid]] use, immunosuppression
*Hematologic neoplasm
*[[transplant complications|Transplantation]]
*Hematologic neoplasm (e.g. [[leukemia|leukemia]])
*Human T-lymphotropic virus-1 infection (HTLV-1)
*Human T-lymphotropic virus-1 infection (HTLV-1)
*Malnutrition
*[[Malnutrition|Malnutrition]]
*Diabetes
*[[Diabetes|Diabetes]]
*Chronic renal failure
*Chronic [[renal failure|renal failure]]
*Chronic alcohol use
*Chronic [[alcohol Abuse|alcohol use]]
 


===Clinical significance===
===Clinical significance===
* Chronic infection in immunosuppressed can lead to fulminant dissemination with case fatality rate as high as 70%; strong index of suspicion is needed in such cases


==Diagnosis==
*Chronic infection in immunosuppressed can lead to fulminant dissemination with case fatality rate as high as 70%; strong index of suspicion is needed in such cases
===Clinical Presentation===
 
 
==Clinical Features==
 
*Asymptomatic in up to 60% of those infected<ref>Greaves D, Coggle S, Pollar C, Aliyu SH, Moore EM. Strongyloides stercoralis infection. BMJ 2013;347:f4610 doi: 10.1136/bmj.f4610 (Published 30 July 2013).</ref>
*Asymptomatic in up to 60% of those infected<ref>Greaves D, Coggle S, Pollar C, Aliyu SH, Moore EM. Strongyloides stercoralis infection. BMJ 2013;347:f4610 doi: 10.1136/bmj.f4610 (Published 30 July 2013).</ref>
*Nonspecific GI complaints are most common presentation
*Nonspecific GI complaints are most common presentation
**Weight loss, [[diarrhea]], [[abdominal pain]], [[vomiting]]
**Weight loss, [[diarrhea|diarrhea]], [[abdominal pain|abdominal pain]], [[vomiting|vomiting]]
===Dermatologic===  
 
**Larva currens: rapidly progressive pruritic linear eruption due to migration of larvae
===Dermatologic===
**Perianal pruritis
 
**Foot pruritus (“ground itch”)
*Larva currens: rapidly progressive pruritic linear eruption due to migration of larvae
*Perianal [[pruritus|pruritus]]
*Foot [[pruritus|pruritus]] (“ground itch”)
 
 
===Respiratory===
===Respiratory===
**Dry cough
 
**Wheezing
*Dry [[cough|cough]]
**Loeffler’s-like syndrome: fever, SOB, wheezing, pulmonary infiltrates
*[[Wheezing|Wheezing]]
*Loeffler’s-like syndrome: [[fever|fever]], [[shortness of breath|shortness of breath]], [[wheezing|wheezing]], pulmonary infiltrates
 


====Immunocompromised patients====
====Immunocompromised patients====
*Respiratory and systemic symptoms such as fever will be more common<ref>Lim S, Katz K, Krajden S, Fuksa M, Keystone JS, Kain KC.  Complicated and fatal Strongyloides infection in Canadians: risk factors, diagnosis and management. CMAJ 2004; 171 (5): 479-484.</ref>
*Respiratory and systemic symptoms such as fever will be more common<ref>Lim S, Katz K, Krajden S, Fuksa M, Keystone JS, Kain KC.  Complicated and fatal Strongyloides infection in Canadians: risk factors, diagnosis and management. CMAJ 2004; 171 (5): 479-484.</ref>
*Disseminated disease will invade multiple organ systems, including liver and brain
*Disseminated disease will invade multiple organ systems, including liver and brain


==Differential Diagnosis==
==Differential Diagnosis==
*[[Inflammatory bowel disease]]
*[[Schistosomiasis]]
*[[Filariasis]]
*[[Hookworm]]
*[[Toxocara canis]]
*[[Atopic dermatitis]]
*[[Asthma]]
*Allergic bronchopulmonary aspergillosis
*[[Coccidioidomycosis]]
*[[HIV]]
*[[Churg-Strauss syndrome]]
*Eosinophilic leukemia]


==Work-Up==
*[[Inflammatory bowel disease|Inflammatory bowel disease]]
*''High index of suspicion, good travel history''
*[[Schistosomiasis|Schistosomiasis]]
===Labs===
*[[Filariasis|Filariasis]]
*Notable eosinophilia in up to 70% of cases, though can be absent in immunosuppressed
*[[Hookworm|Hookworm]]
*Gram negative bacteremia may be present in immunocompromised
*[[Toxocara canis|Toxocara canis]]
*[[Atopic dermatitis|Atopic dermatitis]]
*[[Asthma|Asthma]]
*Allergic bronchopulmonary [[aspergillosis|aspergillosis]]
*[[Coccidioidomycosis|Coccidioidomycosis]]
*[[HIV|HIV]]
*[[Churg-Strauss syndrome|Churg-Strauss syndrome]]
*Eosinophilic [[leukemia|leukemia]]
 
 
==Evaluation==
 
*Establish possibility of infection (travel to endemic areas, etc)
*Uncomplicated strongyloidiasis: 3 serial stool samples screened for ova and parasites, as well as ELISA for Strongyloides
*Uncomplicated strongyloidiasis: 3 serial stool samples screened for ova and parasites, as well as ELISA for Strongyloides
*Complicated strongyloidiasis: blood/sputum Cx, in addition to above
**Complicated strongyloidiasis: blood/sputum cultures, in addition to above
*Notable [[eosinophilia|eosinophilia]] in up to 70% of cases, though can be absent in immunosuppressed
*Gram negative bacteremia may be present in immunocompromised
 
 
==Management==
 


==Treatment==
===Uncomplicated strongyloidiasis, normal immune system===
===Uncomplicated strongyloidiasis, normal immune system===
*[[Albendazole]] 400 mg BID x 7d
 
:'''''OR'''''
*[[Ivermectin|Ivermectin]] 200 mcg/kg daily x 1-2d (drug of choice)
*[[Ivermectin]] 200 mcg/kg daily x 1-2d (drug of choice)
'''OR'''
*[[Albendazole|Albendazole]] 400mg BID x 7d
*Can consider albendazole prophylaxis in immigrants from endemic regions with consistent clinical presentation
*Can consider albendazole prophylaxis in immigrants from endemic regions with consistent clinical presentation


===Immunosuppressed===
===Immunosuppressed===
*Combo therapy: albendazole 400 mg BID x 7d AND ivermectin 200 mcg/kg daily x 1-2d<ref name="treat">Feely NM, Waghorn DJ, Dexter T, Gallen I, Chiodini.  Strongyloides stercoralis hyperinfection: difficulties in diagnosis and treatment.  Anaesthesia 2010; 65: 298-301.</ref>
 
*Antibiotics may need to be continued until there is evidence that parasite is cleared<ref name="treat"></ref>
*Combination therapy: [[albendazole|albendazole]] 400mg BID x 7d AND [[ivermectin|ivermectin]] 200 mcg/kg daily x 1-2d<ref name="treat">Feely NM, Waghorn DJ, Dexter T, Gallen I, Chiodini.  Strongyloides stercoralis hyperinfection: difficulties in diagnosis and treatment.  Anaesthesia 2010; 65: 298-301.</ref>
*Antibiotics may need to be continued until there is evidence that parasite is cleared<ref name="treat" />
 
 
 
===Antibiotic Dosing===
*{{AntibioticDose|drug=Ivermectin|dose=0.2mg/kg PO x1|context=Strongyloidiasis|disease=Strongyloides stercoralis|population=Adult}}


==Disposition==
==Disposition==
*Often diagnosed in outpatient setting, can discharge uncomplicated cases in those who are not immunosuppressed
 
*Immunocompromised patients or those with systemic symptoms will require admission
*Discharge uncomplicated cases in those who are not immunosuppressed
*Admit if immunocompromised or systemic symptoms
 


==References==
==References==
<references/>
<references/>


[[Category:Tropical Medicine]]
[[Category:ID]]
[[Category:ID]]
[[Category:GI]]
[[Category:GI]]

Latest revision as of 11:01, 20 March 2026


Background

  • Intestinal nematode; roundworm
  • Endemic in tropical/subtropical areas such as Africa, Southeast Asia, Central/South America[1]


Life Cycle

  • Present in contaminated soil → larvae penetrate skin of hosts walking barefoot → enter venous circulation, migrate to lungs, then are expectorated to pharynx and swallowed → larvae develop into females that lay eggs asexually into GI tract, which hatch into larvae and are excreted into stool
  • Larvae either become sexually reproducing males/females or filariform larvae that can reinfect host
  • Autoinfection: Unique to Strongyloides; GI larvae can migrate from GI tract to venous system, then to lungs and proceed with life cycle
    • Can lead to dramatic increase in worm burden and hyperinfection in immunocompromised


Risk factors


Clinical significance

  • Chronic infection in immunosuppressed can lead to fulminant dissemination with case fatality rate as high as 70%; strong index of suspicion is needed in such cases


Clinical Features

Dermatologic

  • Larva currens: rapidly progressive pruritic linear eruption due to migration of larvae
  • Perianal pruritus
  • Foot pruritus (“ground itch”)


Respiratory


Immunocompromised patients

  • Respiratory and systemic symptoms such as fever will be more common[3]
  • Disseminated disease will invade multiple organ systems, including liver and brain


Differential Diagnosis


Evaluation

  • Establish possibility of infection (travel to endemic areas, etc)
  • Uncomplicated strongyloidiasis: 3 serial stool samples screened for ova and parasites, as well as ELISA for Strongyloides
    • Complicated strongyloidiasis: blood/sputum cultures, in addition to above
  • Notable eosinophilia in up to 70% of cases, though can be absent in immunosuppressed
  • Gram negative bacteremia may be present in immunocompromised


Management

Uncomplicated strongyloidiasis, normal immune system

  • Ivermectin 200 mcg/kg daily x 1-2d (drug of choice)

OR

  • Albendazole 400mg BID x 7d
  • Can consider albendazole prophylaxis in immigrants from endemic regions with consistent clinical presentation


Immunosuppressed

  • Combination therapy: albendazole 400mg BID x 7d AND ivermectin 200 mcg/kg daily x 1-2d[4]
  • Antibiotics may need to be continued until there is evidence that parasite is cleared[4]


Antibiotic Dosing

Disposition

  • Discharge uncomplicated cases in those who are not immunosuppressed
  • Admit if immunocompromised or systemic symptoms


References

  1. ↑ Buonfrate D, Requena-Mendez A, Angheben A, Munoz J, Gobi F, Van Den Ende J, Bisoffi Z. Severe strongyloidiasis: a systematic review of case reports. BMC Infectious Diseases 2013, 13: 78. doi:10.1186/1471-2334-13-78
  2. ↑ Greaves D, Coggle S, Pollar C, Aliyu SH, Moore EM. Strongyloides stercoralis infection. BMJ 2013;347:f4610 doi: 10.1136/bmj.f4610 (Published 30 July 2013).
  3. ↑ Lim S, Katz K, Krajden S, Fuksa M, Keystone JS, Kain KC. Complicated and fatal Strongyloides infection in Canadians: risk factors, diagnosis and management. CMAJ 2004; 171 (5): 479-484.
  4. ↑ 4.0 4.1 Feely NM, Waghorn DJ, Dexter T, Gallen I, Chiodini. Strongyloides stercoralis hyperinfection: difficulties in diagnosis and treatment. Anaesthesia 2010; 65: 298-301.
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