Strongyloides Stercoralis Infection Among Human Immunodeficiency Virus (HIV)-Infected Patients in the United States of America: A Case Report and Review of Literature

Abstract

Patient: Male, 61Final Diagnosis: Strongyloides stercolaris-associated diarrheaSymptoms: Diarrhea • epigastric pain • nausea • weight lossMedication: IvermectinClinical Procedure: Colonic biopsiesSpecialty: Infectious DiseasesObjective:Rare diseaseBackground:Strongyloides stercoralis infection is endemic in subtropical and tropical regions but is reported rather sporadically in temperate countries. In the USA, the highest rates of infection are from the southeastern states, predominantly among immigrants. There is paucity of case reports on S. stercoralis infection among HIV-infected patients who were born and raised in the USA.Case Report:A 61-year-old male with known HIV infection (CD4 count: 235 cells/uL, undetectable HIV RNA, on antiretroviral therapy) presented with a 3-month history of diarrhea. He was initially diagnosed to have diarrhea secondary to norovirus and later with Escherichia coli. He was treated with levofloxacin but the diarrhea persisted. Stool PCR, Clostridium difficile enzyme-linked immunoassay, cryptosporidium and giardia antigen, cyclospora and isospora smear, and fecal microscopy were all negative. Peripheral blood eosinophil count was 1,000 eosinophils/mcL. Colonic biopsies revealed fragments of S. stercoralis larvae within the crypts. The patient was treated with ivermectin with improvement of symptoms. Social history revealed that he was born and raised in the northeastern USA. He was a daily methamphetamine user and engaged in anal sex with men. He denied travel to endemic areas, except for a visit to Japan more than 30 years ago.Conclusions:Our case highlights that S. stercoralis may be an underdiagnosed/under-reported cause of chronic diarrhea among HIV-infected patients. What makes this case peculiar is that the patient was born and raised in the continental USA, absence of recent travel to endemic areas, and relatively high CD4 counts. Parasitic infections, such as S. stercoralis, should be considered among HIV-infected patients with persistent diarrhea and eosinophilia regardless of ethnicity or recent travel history.

Epidemiology of Strongyloides stercoralis infection in Bolivian patients at high risk of complications

“…Strongyloidiasis, which is endemic in tropical and subtropical regions, was believed to occur only sporadically in temperate areas [8, 24, 25]. This study finds however equally high prevalence in the tropical region of Santa Cruz and the temperate region of Cochabamba, at least in patients at high-risk of complications.…”

Soil-Transmitted Helminths in the USA: a Review of Five Common Parasites and Future Directions for Avenues of Enhanced Epidemiologic Inquiry

“…Demographics of strongyloidiasis mortality rates differ across region of the USA, though regional differences in race and ethnicity are not fully understood [ 30 , 31 ]. S. stercoralis is unique due to its autoinfective mechanism leading to decades-long infection, and it is particularly difficult to diagnose, as variation in ova shedding in stool leads to low sensitivity of stool microscopy for this helminth [ 10 , 11 , 17 ]. Furthermore, sexual contact is believed to be a significant route of transmission for S. stercoralis in the USA particularly with men who have sex with men (MSM) [ 11 ].…”

“…[ 37 ] 2016: 14-month-old canine with hookworm invasion of the brainstem, TX ( Ancylostoma spp. ) [ 38 ] Trichuris trichiura (whipworm) unavailable Highest: 55.2% in 366 Native born School children ages 6–12, KY Lowest:: 0.5% in 3729 Caucasian school children ages 5–15, GA unavailable Strongyloides stercoralis 68,000 – 100,000[ 26 ] Highest: 3.8% in 366 Native born School children ages 6–12, KY Lowest: 0% in 439 School children ages 10–14, KY 2020: 68-year -old man with COVID-19 infection immigrating 20 years prior from Ecuador, CT 2020: 16.5% positive serology in 97 individuals from a community with failing sanitation/poverty, central TX (75% with no travel history) [ 13 ••] 2017: 61-year old US-born man with HIV coinfection, no significant travel history, CT [ 11 ] 2017: 7.3% stool samples from 55 individuals in area of failing sanitation and poverty, Lowndes County, AL [ 24 ] 2013: 1.9% in 378 positive serology from persons presenting to Remote Area Medical Clinics, KY (only 1 positive participant had significant travel history) [ 28 ] Toxocara canis , T. cati 1.3–2.8 million [ 26 ] unavailable 2019: 3-year-old girl with OLM, previously healthy presenting with blurry vision and headache, AK [ 33 ] 2017: 5.2% positive serology from 11 individuals testing positive for any GI parasites in area of failing sanitation and poverty, Lowndes County, AL [ 24 ] 2015–2016: 66.7% contamination with eggs & larvae in 10/15 soil samples from the Bronx, 38.9% in 7/18 soil samples from Staten Island, 33.3% in 6/18 soil samples from Queens, 30.8% 4/13 soil samples from Brooklyn, 29.6% in 8/27 soil samples from Manhattan, NY [ 39 ] 2014: 4.6% egg positive fecal samples from 523,934 cats and 1.8% egg positive fecal samples from 2,750,718 dogs, national [ 40 ] 2014: 75-year-old female with pulmonary toxocariasis (only travel history 15 years prior to Caribbean), NJ [ 41 ] 2011–2014: 5.1% overall seroprevalence from 13,509 individuals from NHANES 2011–2014, national [ 42 ] 2009–2010: 68 case reports of OLM in individuals aged 1–60, national [ 43 ] …”

“…Though subclinical disease is common in children, complications particularly in the immunocompromised can lead to potentially fatal conditions including intestinal obstruction, visceral larva migrans, blindness, disseminated disease, respiratory failure and hemorrhage [ 6 – 10 ]. Pregnant women and adults with comorbidities such as HIV are additionally susceptible to severe outcomes and death in extreme cases [ 11 ].…”

The Experimental Infections of the Human Isolate of Strongyloides Stercoralis in a Rodent Model (The Mongolian Gerbil, Meriones Unguiculatus)

“…The autoinfective larvae (L3a) can penetrate through the intestinal wall into other organs and cause death due to organ failure and sepsis. Mortality rates of the hyperinfection and dissemination syndrome are 34.6–87% [8,9,10,11]. Moreover, fatal hyperinfection cases are also found, even in immunocompetent hosts [12,13].…”