Serum ivermectin levels after enteral and subcutaneous administration for Strongyloides hyperinfection: A case report

Grein, Jonathan; Mathisen, Glenn E.; Donovan, Suzanne; Fleckenstein, Lawrence

doi:10.3109/00365540903443165

Cited by 31 publications

(24 citation statements)

References 23 publications

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“…HS has been seen in AIDS patients because of the use of corticosteroids for immune reconstitution inflammatory syndrome (IRIS) or during IRIS [65,66]. Only 14 HIV cases with disseminated strongyloidiasis have been reported in the English-language literature until 1994 [67].…”

Section: Strongyloides Infection In Hiv Patientsmentioning

confidence: 99%

Update on Strongyloidiasis in the Immunocompromised Host

Marcos

Terashima

Canales

et al. 2010

Curr Infect Dis Rep

147

126

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Immunocompromised persons are the most vulnerable population at risk for developing life-threatening clinical syndromes associated with strongyloidiasis, such as hyperinfection syndrome (HS) or dissemination. This review focuses on describing Strongyloides infection in the immunocompromised host, including immune response against this infection, analyzing the cases with HS published during the past 4 years in the United States, and describing the most sensitive diagnostic tools and the most effective treatment for each clinical syndrome. Strongyloidiasis is becoming an important parasitic disease in the United States, especially in the immunocompromised immigrant population. Because the transplant population is particularly at risk for developing HS, both recipients and donors should be screened for Strongyloides. Clinicians should also be aware that the development of HS can follow unexpectedly a few days after appropriate anthelminthic therapy. Highly sensitive screening tests are still not available in the major tertiary medical centers. Parenteral ivermectin has been used in some severe cases. Further therapy developments and improving diagnostic tools are warranted.

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Section: Strongyloides Infection In Hiv Patientsmentioning

confidence: 99%

Update on Strongyloidiasis in the Immunocompromised Host

Marcos

Terashima

Canales

et al. 2010

Curr Infect Dis Rep

147

126

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“…[4][5][6][7][8][9][10][11][12] Although there are many cases of patient recovery, several clinical failures are reported as well. 9,11,12 Several studies that measured plasma concentrations of subcutaneously administered ivermectin 5,8,9,11,12 have usually demonstrated levels within a range well tolerated by healthy volunteers. 13 A major problem with SC ivermectin is that it is only available as a veterinary formulation that is not yet licensed in humans and is frequently associated with a significant delay in drug administration.…”

Section: Discussionmentioning

confidence: 99%

“…11,12,14 This mode of drug delivery has the benefit of rapid administration to patients because PO preparations of ivermectin can be compounded into suppositories or enemas rather quickly, thereby avoiding delays in obtaining SC ivermectin from veterinary sources. Tarr and others 14 successfully treated a case of disseminated Strongyloides following renal transplantation with PR ivermectin by crushing ivermectin tablets (200 μg/kg/day) and creating a 230 mOsm/kg suspension as a retention enema.…”

Section: Discussionmentioning

confidence: 99%

Failure of Ivermectin per Rectum to Achieve Clinically Meaningful Serum Levels in Two Cases of Strongyloides Hyperinfection

Bogoch¹,

Khan²,

Abrams³

et al. 2015

The American Society of Tropical Medicine and Hygiene

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Abstract. Two cases of Strongyloides hyperinfection are presented. Ivermectin was initially administered orally and per rectum pending the availability of subcutaneous (SC) preparations. In neither case did rectal suppositories of ivermectin achieve clinically meaningful serum values. Clinicians should use SC preparations of ivermectin as early as possible in Strongyloides hyperinfection and dissemination. CASE 1A 38-year-old Nigerian-born female with no prior medical history presented with worsening nausea and vomiting over a 6-week period. One year prior admission she had traveled to Nigeria for 1 month. Two months before admission she was referred to a gastroenterologist for dyspepsia and underwent upper endoscopy with a small bowel biopsy. At the time of her presentation to hospital, endoscopic biopsy results showed filariform larvae of Strongyloides stercoralis. On admission she was ill appearing, afebrile, with a blood pressure of 90/ 50 mmHg, heart rate of 115 beats/min, and normal oxygen saturations. Her examination was unremarkable apart from a tender epigastrium and diminished bowel sounds.Blood examination revealed a normal complete blood count, creatinine, and liver function tests. Computed tomography (CT) of her abdomen with contrast demonstrated a thickened proximal small bowel wall and evidence of ileus. Strongyloides hyperinfection syndrome was suspected, and she was empirically treated with crystalloid resuscitation and albendazole (400 mg PO BID) while an urgent request for ivermectin was made to Health Canada (ivermectin is a special access drug in Canada available only with the authorization of the Health Protection Branch). In addition, intravenous ceftriaxone and metronidazole were administered for presumed gram-negative sepsis. The patient was unable to tolerate oral albendazole because of intractable nausea and vomiting, so albendazole was administered via nasogastric (NG) tube although there was concern regarding poor absorption given her ileus and persistent vomiting. Pending the availability of subcutaneous (SC) ivermectin, we had a compounding pharmacy prepare oral ivermectin into rectal suppositories; we administered these in the evening on her first and second hospital day (200 μg/kg, totaling 15 mg per rectum (PR). Her persistent ileus prompted the General Surgery service to perform an urgent laparotomy on her second hospital day. She was found to have a dilated proximal small bowel, what appeared to be a fecal bezoar as a result of the ileus that was milked distally. She required norepinephrine for blood pressure control during the operation and for 6 hours immediately after. She was extubated shortly after her laparotomy and was able to tolerate oral medications the following day at which point she was given oral ivermectin. Table 1 shows her medication schedule and microbiology results during and after her hospital stay. Serum ivermectin levels were measured on hospital day 2, 3, and 8 as per the protocol described previously in a study. 1 PR ivermectin did not achieve clinicall...

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“…It is also worth noting that some patients have failed to respond to subcutaneous ivermectin, including patient 4 in this report. 11,13 Thus, the delivery and efficacy of parenteral ivermectin in extraintestinal Strongyloides infection merits further evaluation. Early studies of ivermectin for intestinal versus nonintestinal infection were performed in canines by using oral formulation ivermectin only.…”

Section: Discussionmentioning

confidence: 99%

“…Whereas no parenteral antihelminthic medications are licensed for human use, parenteral ivermectin (Stromectol ® ; Merck, Whitehouse Station, NJ) is approved for veterinary use and has been used as subcutaneous treatment in a limited number of patients with severe strongyloidiasis refractory to oral agents. [5][6][7][8][9][10][11][12][13][14] This report describes four patients with disseminated strongyloidiasis treated at New York Presbyterian Hospital/ Weill Cornell Medical Center in [2007][2008][2009]. None of the four patients were candidates for oral ivermectin because of ileus, diarrhea, or vomiting, which led to concern for poor drug absorption.…”

Section: Introductionmentioning

confidence: 99%

Non-Oral Treatment with Ivermectin for Disseminated Strongyloidiasis

Fusco¹,

Downs²,

Satlin³

et al. 2010

The American Society of Tropical Medicine and Hygiene

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Critically ill patients with disseminated strongyloidiasis may not be candidates for oral treatment. We report four patients with disseminated strongyloidiasis, believed to be unable to absorb oral therapy, who were treated with ivermectin by rectal and/or subcutaneous administration. Obtaining subcutaneous ivermectin and dosing it appropriately is a challenge. These cases underscore the need for improved access to subcutaneous ivermectin and more pharmacological data to guide use of this treatment approach.

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Serum ivermectin levels after enteral and subcutaneous administration for Strongyloides hyperinfection: A case report

Cited by 31 publications

References 23 publications

Update on Strongyloidiasis in the Immunocompromised Host

Update on Strongyloidiasis in the Immunocompromised Host

Failure of Ivermectin per Rectum to Achieve Clinically Meaningful Serum Levels in Two Cases of Strongyloides Hyperinfection

Non-Oral Treatment with Ivermectin for Disseminated Strongyloidiasis

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