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 | *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 | *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 | *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 | **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 | *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== | ==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=== | ===Dermatologic=== | ||
*Larva currens: rapidly progressive pruritic linear eruption due to migration of larvae | *Larva currens: rapidly progressive pruritic linear eruption due to migration of larvae | ||
*Perianal | *Perianal [[pruritus|pruritus]] | ||
*Foot pruritus (“ground itch”) | *Foot [[pruritus|pruritus]] (“ground itch”) | ||
===Respiratory=== | ===Respiratory=== | ||
*Dry cough | |||
*Wheezing | *Dry [[cough|cough]] | ||
*Loeffler’s-like syndrome: fever, | *[[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|Inflammatory bowel disease]] | ||
*[[Schistosomiasis|Schistosomiasis]] | |||
*[[Filariasis|Filariasis]] | |||
*[[Hookworm|Hookworm]] | |||
*[[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) | *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 | **Complicated strongyloidiasis: blood/sputum cultures, in addition to above | ||
*Notable eosinophilia in up to 70% of cases, though can be absent in immunosuppressed | *Notable [[eosinophilia|eosinophilia]] in up to 70% of cases, though can be absent in immunosuppressed | ||
*Gram negative bacteremia may be present in immunocompromised | *Gram negative bacteremia may be present in immunocompromised | ||
==Management== | ==Management== | ||
===Uncomplicated strongyloidiasis, normal immune system=== | ===Uncomplicated strongyloidiasis, normal immune system=== | ||
*[[Ivermectin]] 200 mcg/kg daily x 1-2d (drug of choice) | |||
*[[Ivermectin|Ivermectin]] 200 mcg/kg daily x 1-2d (drug of choice) | |||
'''OR''' | '''OR''' | ||
*[[Albendazole]] | *[[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=== | ||
*Combination therapy: albendazole | |||
*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" /> | *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== | ||
*Discharge uncomplicated cases in those who are not immunosuppressed | *Discharge uncomplicated cases in those who are not immunosuppressed | ||
*Admit if immunocompromised or systemic symptoms | *Admit if immunocompromised or systemic symptoms | ||
==References== | ==References== | ||
<references/> | <references/> | ||
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
- Corticosteroid use, immunosuppression
- Transplantation
- Hematologic neoplasm (e.g. leukemia)
- Human T-lymphotropic virus-1 infection (HTLV-1)
- Malnutrition
- Diabetes
- Chronic renal failure
- Chronic alcohol use
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
- Asymptomatic in up to 60% of those infected[2]
- Nonspecific GI complaints are most common presentation
- Weight loss, diarrhea, abdominal pain, vomiting
Dermatologic
- Larva currens: rapidly progressive pruritic linear eruption due to migration of larvae
- Perianal pruritus
- Foot pruritus (“ground itch”)
Respiratory
- Dry cough
- Wheezing
- Loeffler’s-like syndrome: fever, shortness of breath, wheezing, pulmonary infiltrates
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
- Inflammatory bowel disease
- Schistosomiasis
- Filariasis
- Hookworm
- Toxocara canis
- Atopic dermatitis
- Asthma
- Allergic bronchopulmonary aspergillosis
- Coccidioidomycosis
- HIV
- Churg-Strauss syndrome
- Eosinophilic 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
- 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
- Ivermectin 0.2mg/kg PO x1
Disposition
- Discharge uncomplicated cases in those who are not immunosuppressed
- Admit if immunocompromised or systemic symptoms
References
- ↑ 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
- ↑ 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).
- ↑ 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.
- ↑ 4.0 4.1 Feely NM, Waghorn DJ, Dexter T, Gallen I, Chiodini. Strongyloides stercoralis hyperinfection: difficulties in diagnosis and treatment. Anaesthesia 2010; 65: 298-301.