Management of severe strongyloidiasis attended at reference centers in Spain

Abstract

IntroductionStrongyloides stercoralis is a globally distributed nematode that causes diverse clinical symptoms in humans. Spain, once considered an endemic country, has experienced a recent increase in imported cases. The introduction of serology helps diagnosis and is currently replacing microbiological techniques in some settings, but its sensitivity is variable and can be low in immunocompromised patients. Diagnosis can only be confirmed by identification of larvae. Often, this “gold standard” can only be achieved in severe cases, such as disseminated S.stercoralis infection, or S.stercoralis hyperinfection syndrome, where parasite load is high. In addition, these clinical presentations are not well-defined. Our aim is to describe severe cases of S.stercoralis, their epidemiological profile, and their clinical details.MethodsAn observational retrospective study of disseminated S.stercoralis infection, or hyperinfection syndrome. Inclusion criteria: aged over 18, with a diagnosis of disseminated S.stercoralis infection, or hyperinfection syndrome, confirmed by visualization of larvae. Patients were identified through revision of clinical records for the period 2000–2015, in collaboration with eight reference centers throughout Spain.ResultsFrom the period 2000–2015, eighteen cases were identified, 66.7% of which were male, with a median age of 40 (range 21–70). Most of them were foreigners (94.4%), mainly from Latin America (82.3%) or Western Africa (17.6%). Only one autochthonous case was identified, from 2006. Immunosuppressive conditions were present in fourteen (77%) patients, mainly due steroids use and to retroviral coinfections (four HIV, two HTLV). Transplant preceded the clinical presentation in four of them. Other comorbidities were coinfection with HBV, Trypanosoma cruzi, Mycobacterium leprae or Aspergillus spp. All presented with digestive disorders, with 55.6% also presenting malaise. 44.4% of cases had fever, 27.8% skin complaints, and 16.7% respiratory or neurological disorders. One patient presented anemia, and one other nephrotic syndrome. Diagnosis was confirmed by identification of larvae in fresh stool samples (n = 16; 88.9%), concentration techniques (n = 6; 33.3%), larval culture (n = 5; 29.4%), or digestive biopsies (n = 8; 44%). S.stercoralis forms were identified during necropsy in one case. In addition, ten (55%) had a positive serology. All the cases were treated with ivermectin, six (33%) also received albendazole and one case received thiabendazole followed by ivermectin. All needed inpatient management, involving a mean hospitalization stay of 25 days (range 1–164). Two cases received intensive care and eventually died.ConclusionsOnly eighteen cases of disseminated S.stercoralis infection/hyperinfection syndrome were identified from the 15-year period, most of which were considered to have been imported cases. Among those, immunosuppression was frequent, and mortality due to S.stercoralis was lower than previously described.

Prevalence of Strongyloides stercoralis infection and hyperinfection syndrome among renal allograft recipients in Central Europe

“…In this post hoc analysis we find a Strongyloides stercoralis seropositivity of 3% among renal allograft transplant patients originating, at least half of them, from Central Europe and the remainder from the former Yugoslavia, Turkey and East Asia and a 16% risk of developing hyperinfection syndrome in seropositive patients. In view of the current literature and supported by our results, screening for S. stercoralis infections in both transplant recipients and donors in Austria is justified based on (1) data revealing a not insignificant prevalence of latent infection amongst recipients in nonendemic areas, particularly amongst those of migrant background or travel history (2) there being cases of Strongyloides infections transmitted from donors 20 , 21 and (3) previous studies demonstrating increased risk of developing hyperinfection syndrome in transplant recipients 22 .…”

Correspondence

“…However, rapid replication with dissemination (so-called hyper-infection) to virtually all organs can occur if the host becomes immunosuppressed. Severe strongyloidiasis is frequently seen in organ transplant recipients and can also be triggered by corticosteroid treatment 8 . Patients may develop diarrhoea, pulmonary wheezing, Gram-negative meningitis and bacteraemia as well as high-grade fever and the mortality of severe strongyloidiasis may be up to 60% 9 .…”

Asymptomatic Strongyloidiasis among Latin American Migrants in Spain: A Community-Based Approach

“…This can result in severe systemic bacterial infections that may lead to multiorgan failure and death [ 4 , 5 , 6 ]. Hyperinfection and disseminated strongyloidiasis can be fatal, especially among immunocompromised individuals, with a reported mortality up to 62% [ 7 , 8 , 9 ].…”