Background Strongyloides stercoralis is an ubiquitous intestinal nematode, that commonly causes chronic, asymptomatic infection. Endemic areas include most tropical and subtropical weather zones. The capability for autoinfection accounts for the recurrence and chronicity of the disease. Impaired cell-mediated immunity as in corticosteroid therapy can ensue in an accelerated life cycle. The resulting hyperinfection syndrome and disseminated infection, the two most severe forms of strongyloidiasis, have high mortality rates if left untreated.
Methods We report four cases of strongyloidiasis in patients with rheumatic disease. Clinical manifestations, risk factors, diagnostic and therapeutic approaches are presented.
Results One patient with new-onset rheumatoid arthritis presented with mild isolated eosinophilia; a patient with long-standing rheumatoid arthritis and secondary Sjögren's syndrome presented with recurrent moderate eosinophilia and a previous episode of acute eosinophilic pneumonia, probable Löeffler's syndrome misdiagnosed as eosinophilic granulomatosis with polyangiitis; a patient with long-standing ankylosing spondylitis and renal transplant due to secondary amyloidosis presented with hyperinfection syndrome involving the respiratory and the gastrointestinal tract and past mild eosinophilia; and a patient with lupus nephritis presented with disseminated infection characterized by absence of eosinophilia, paralytic ileus, alveolar haemorrhage, meningitis and recurrent septicaemia due to enteric bacteria.
Patients 1 and 2 were of Portuguese origin and had no travels abroad; patients 3 and 4 were of Angolan and Brazilian origin residing in Portugal for thirty and fifteen years respectively. Patient 1 didn't receive any immunosuppressive therapy; patient 2 was treated after first manifestation with low-dose prednisolone, methotrexate, azathioprine and hydroxychloroquine, remaining asymptomatic until diagnosis; patient 3 was being treated with tacrolimus and mycophenolate mofetil; and patient 4 with high-dose prednisolone (1mg/kg daily).
Diagnosis was made by stool microscopy exam for parasitic ova and larvae in all four patients. A previous stool examination from the second patient was negative and the fourth had also larvae identified in sputum.
Patients 1 and 2 were treated with oral albendazole, 400mg, twice a day for seven days, patient 3 with subcutaneous ivermectin, 200μg/kg, daily for three alternating days, and patient 4 with a combination of subcutaneous ivermectin, 200μg/kg, daily in divided doses for nineteen days, and oral albendazole, 400mg, twice a day for thirty-eight days. No recurrence was seen.
Conclusions High degree of suspicion is needed in the diagnosis of strongyloidiasis. The potentially fatal manifestations in high risk patients can be prevented by adequate screening.
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Mejia R, Nutman TB (2012) Screening, prevention, and treatment for hyperinfection syndrome and disseminated infections caused by Strongyloides stercoralis. Curr Opin Infect Dis 25(4):458–463. doi:10.1097/QCO.0b013e3283551dbd.
Disclosure of Interest None declared