Strongyloides hyper-infection causing life-threatening gastrointestinal bleeding

Abstract

A 55-year old male patient was diagnosed with strongy-loides hyper-infection with stool analysis and intestinal biopsy shortly after his chemotherapy for myeloma. He was commenced on albendazole anthelmintic therapy. After initiation of the treatment he suffered life-threatening gastrointestinal (GI) bleeding. Repeated endoscopies showed diffuse multi-focal intestinal bleeding. The patient required huge amounts of red blood cells and plasma transfusions and correction of haemostasis with recombinant activated factor VII. Abdominal aorto-angiography showed numerous micro-aneurysms ('berry aneurysms') in the superior and inferior mesenteric arteries' territories. While the biopsy taken prior to the treatment with albendazole did not show evidence of vasculitis, the biopsy taken after initiation of therapy revealed leukoclastic aggregations around the vessels. These findings suggest that, in addition to direct destruction of the mucosa, vasculitis could be an important additive factor causing the massive GI bleeding during the anthelmintic treatment. This might result from substances released by the worms that have been killed with anthelmintic therapy. Current guidelines advise steroids to be tapered and stopped in case of systematic parasitic infections as they might reduce immunity and precipitate parasitic hyper-infection. In our opinion, steroid therapy might be of value in the management of strongyloides hyper-infection related vasculitis, in addition to the anthelmintic treatment. Indeed, steroid therapy of vasculitis with other means of supportive care resulted in cessation of the bleeding and recovery of the patient.

Strongyloides stercoralis infection in the immunocompromised host

“…Mesenteric lymphadenopathy has been reported to cause intestinal pseudo-obstruction in HIV-infected patients with hyperinfection syndrome [22]. Mucosal ulceration can occur in the small intestine as a result of direct invasion of larvae and may be associated with occult blood, hematochezia, or life-threatening gastrointestinal bleeding [23].…”

Endoscopic and histopathological study on the duodenum of Strongyloides stercoralis hyperinfection

“…However, pathognomonic findings are apparently not evident [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] . Our present study confirmed the aforementioned frequent findings.…”

“…Brasitus et al [3] 1980 1 None Brisk bleeding, deformed bulb Milder et al [4] 1981 2 ND Enlarged folds Bone et al [5] 1982 1 ND Deformed cap, obliterated second part Bhatt et al [6] 1990 1 None Mild erythema Chen et al [7] 1994 1 Corticosteroids Flattened folds, swelling mucosa, tiny ulcer Choudhry et al [8] 1995 3 DM, none Multiple serpiginous lesions, duodenal nodule Hizawa et al [9] 1996 1 HTLV-1 and corticosteroids Edema, tiny white spots Friedenberg et al [10] 1999 1 HTLV-1 Severe stenosis Overstreet et al [11] 2003 1 HIV White punctate dotting mucosa Asano et al [12] 2004 1 HTLV-1 Fine granule, coarse mucosa, disappeared folds Thompson et al [13] 2004 6 Corticosteroids, DM, HIV, none Edema, brown discoloration, erythematous spots, subepithelial hemorrhage, megaduodenum Seet et al [14] 2005 1 Anti-myeloma drugs Erythematous and granular mucosa Karmo et al [15] 2006 1 Corticosteroids Normal Ghoshal et al [16] 2006 1 Corticosteroids Multiple nodules Werneck-Silva et al [17] 2006 4 ND Erythema, erosion Csermely et al [18] 2006 1 Anti-myeloma drugs Necrotic ulcerations Suarez and Sanchez [19] 2006 11 ND Swollen folds of nodular aspect ND: Not determined.…”

“…As S. stercoralis colonizes in the duodenum where the larvae mature, endoscopic evaluation has been recognized as an important tool for diagnosing strongyloidiasis. Although there have been several reports demonstrating endoscopic findings of strongyloidiasis, most of these are case reports or small case series [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] . This study aims at investigating the relationship of endoscopic markers to clinical and histopathological findings of the duodenum in patients with S. stercoralis hyperinfection in an endemic region.…”

Strongyloides stercoralis Hyperinfection Syndrome Presenting as Severe, Recurrent Gastrointestinal Bleeding, Leading to a Diagnosis of Cushing Disease

“…3,5,11 However, individuals with impaired host defense (particularly corticosteroid excess and HTLV-I infection) are at risk for accelerated larval proliferation 2,5,12 and high parasite burden leading to S. stercoralis hyperinfection. Severe GI bleeding may occur in hyperinfection due to massive larval invasion of the GI mucosa.…”