Despite the limited published experience of parenteral ivermectin use, there is evidence that it may be a safe and effective treatment for severe strongyloidiasis. However, more data are needed to guide dosing schedules and monitoring for toxicity.

Case series of four patients with strongyloides after occupational exposure TO THE EDITOR: Strongyloidosis in Australia has been reported in Indigenous Australians, war veterans who have served in SouthEast Asia and travellers and immigrants from regions in which strongyloidosis is endemic. 1,2 The condition is caused by Strongyloides stercoralis, and chronic infection with the nematode is maintained by an autoinfective life cycle. The consequences of infection range from asymptomatic minor infection to chronic symptomatic strongyloidosis. In immunocompromised people, lifethreatening dissemination can occur 3 with a mortality of nearly 90%. 2 In the past 8 years at Alice Springs Hospital, four people have presented with strongyloidosis, in whom the only identifiable exposure was their occupation. Work-related exposure resulting in S. stercoralis infection has been documented previously in healthy Australian medical professionals volunteering in the Solomon Islands. 4 In our series, Patient 1 was a middle-aged white man who had previously worked as a teacher in an Indigenous school. He had documented Still's disease treated with prednisolone, methotrexate and hydroxychloroquine, and presented with urticaria, diarrhoea and a cough. Patient 2 was a child care worker with rheumatoid arthritis, treated with methotrexate and hydroxychloroquine. She presented with a rash, cough, wheezing and eosinophilia. Patient 3 was a middle-aged ex-nurse treated with methotrexate for rheumatoid arthritis, who presented with recurrent epigastric pain. Patient 4 was a paediatrician with systemic lupus erythematosis, who developed abdominal pain, nausea, diarrhoea and eosinophilia after commencing prednisolone for worsening arthralgia and vasculitis. All four patients tested positive for S. stercoralis in serological tests.

This 81-year-old man with a history of type 2 diabetes presented with a cramping right arm, trismus, stiffness in the jaw, swallowing and breathing difficulties. He developed respiratory failure shortly after admission so was intubated on the intensive therapy unit where he received tetanus immunoglobulin and a course of metronidazole. Kilic et al. compared the level of tetanus antitoxin between patients with type 2 diabetes and healthy controls. They found a statistically significant difference between the groups, with people with diabetes having lower antitoxin levels. A further study shows that serum levels of tetanus antibody significantly decrease in diabetic patients older than 50 years of age. Among patients with diabetes only 55.9% had protective levels of antitoxin when aged 50-64 compared to 73.8% of controls. Copyright © 2010 John Wiley & Sons. Copyright © 2010 John Wiley & Sons, Ltd