Disseminated strongyloidiasis in a patient with rheumatoid arthritis:A case report

BACKGROUND Strongyloidiasis is usually a chronic infection but it can develop into a fatal disease in immunosuppressed patients.CASE SUMMARY A 68-year-old male with rheumatoid arthritis was treated with a variety of immunosuppressants for the past 3 years.Recently,the patient presented with a partial small-bowel obstruction,petechia,coughing and peripheral neuropathy.The diagnosis was difficult to clarify in other hospitals.Our hospital found Strongyloides stercoralis larvae with active movement in the routine stool and sputum smears.The diagnosis of disseminated strongyloidiasis was established.Ivermectin combined with albendazole was used for treatment.The patient responded to therapy and was discharged.CONCLUSION This case underscores the importance of comprehensive differential diagnosis in immunocompromised patients.

Diagnostic value of metagenomics next-generation sequencing technology in disseminated strongyloidiasis

The symptoms of disseminated strongyloidiasis are not typical,and it is difficult for clinicians to identify strongyloidiasis in some non-endemic areas.We report a 70-year-old woman who was diagnosed with Guillain-Barrésyndrome due to autonomic disturbance,symmetrical bulbar palsy,and lower-motor-nerve damage in the extremities;her symptoms continued to worsen after hormone and immunoglobulin therapy.Later,parasitic larvae were found in the patient’s gastric fluid,and metagenomic next generation sequencing(mNGS)detection of bronchoalveolar-lavage fluid also found a large number of Strongyloides roundworms.The patient was diagnosed with disseminated strongyloidiasis.The patient was given albendazole for anthelmintic treatment,but died two days after being transferred to the intensive care unit due to the excessive strongyloidiasis burden.In recent years,mNGS has been increasingly used in clinical practice,and is becoming the main means of detecting strongyloides stercoralis in non-endemic areas.Especially during the corona virus disease 2019 pandemic,mNGS technology has irreplaceable value in identifying the source of infection.

Disseminated strongyloidiasis in an immunocompromised host:A case report

Infections caused by Strongyloides stercoralis(S.stercoralis) in human are generally asymptomatic,however in immunocompromised individual,hyperinfection may develop with dissemination of larvae to extra-intestinal organs.The diagnosis could be easily missed due to asymptomatic presentation and insufficient exposure towards the infection itself,which may lead to low index of suspicion as a consequence.In this report,a case of a Malaysian male with underlying diabetes mellitus,hypertension,cerebrovascular accident,bullous pemphigus and syndrome of inappropriate antidiuretic hormone secretion who initially complained of generalized body weakness and poor appetite without any history suggestive of sepsis is presented.However,he developed septicemic shock later,and S.stercoralis larvae was incidentally found in the tracheal aspirate that was sent to look for acid fast bacilli.Regardless of aggressive resuscitation,the patient succumbed due to pulmonary hemorrhage and acute respiratory distress syndrome.It was revealed that the current case has alarmed us via incidental finding of S.stercoralis larvae in the tracheal aspirate,indicating that the importance of the disease should be emphasized in certain parts of the world and population respectively.

Strongyloidiasis:a case report with its lessons and rare facts about the disease

Strongyloidiasis is endemic to the entire inter-tropical zone.Newly infected people are the most prone to experience the symptoms of this intestinal nematodosis.In this article,a 38-year old German citizen consulted for bowel movement disturbances and dyspepsia as well as diffuse and erratic pruritus,and was finally diagnosed with to have strongylodiasis is presented and discussed.

Control programs for strongyloidiasis in areas of high endemicity: an economic analysis of different approaches

Background:Implementation of control programmes for Strongyloides stercoralis infection is among the targets of the World Health Organization Roadmap to 2030.Aim ofthis work was to evaluate the possible impact in terms of economic resources and health status of two different strategies of preventive chemotherapy(PC)compared to the current situation(strategy A,no PC):administration of ivermectin to school-age children(SAC)and adults(strategy B)versus ivermectin to SAC only(strategy C).Methods:The study was conducted at the IRCCS Sacro Cuore Don Calabria hospital,Negrar di Valpolicella,Verona,Italy,at the University of Florence,Italy,and at the WHO,Geneva,Switzerland,from May 2020 to April 2021.Data for the model were extracted from literature.A mathematical model was developed in Microsoft Excel to assess the impact of strategies B and C in a standard population of 1 million subjects living in a strongyloidiasis endemic area.In a case base seenario,15%prevalence of strongyloidiasis was considered;the 3 strategies were then evaluated at different thresholds of prevalenee,ranging from 5 to 20%.The results were reported as number of infected subjects,deaths,costs,and Incremental-Effectiveness Ratio(ICER).A 1-year and a 10-year horizons were considered.Results:In the case base seenario,cases of infections would reduce dramatically in the first year of implementation of PC with both strategy B and C:from 172500 cases to 77040 following strategy B and 146700 following strategy C.The additional cost per recovered person was United States Dollar(USD)2.83 and USD 1.13 in strategy B and C,respectively,compared to no treatment in the first year.For both strategies,there was a downtrend in costs per recovered person with increasing prevalenee.The number of adverted deaths was larger for strategy B than C,but cost to advert one death was lower for strategy C than B.Conclusions:This analysis permits to estimate the impact of two PC strategies for the control of strongyloidiasis in terms of costs and adverted infections/deaths.This could represent a basis on which each endemic country can evaluate which strategy can be implemented,based on available funds and national health priorities.

Hepatobiliary strongyloidiasis presenting as an ampullary lesion on esophagogastroduodenoscopy/endoscopic ultrasound

Strongyloidiasis is an intestinal infection caused by the parasitic nematodes of the Strongyloides species,most commonly Strongyloides stercoralis.We report a case of a 66-year-old immigrant male from Haiti who presented with complaints of diarrhea and an unintentional 80-lb weight loss over the past 5 years.Stool examination was positive for strongyloidiasis.Following albendazole therapy,esophagogastroduodenoscopy(EGD)showed a unique ampullary lesion.Histopathology of the ampullary lesion showed reactive epithelium with Strongyloides larva.In addition,endoscopic ultrasound(EUS)detected a large pancreatic cyst.Both these findings were absent on EGD 5 years previously,prior to the onset of his symptoms.This paper documents a rare case of an ampullary lesion and pancreatic cyst secondary to hepatobiliary strongyloidiasis in a non-Human Immunodeficiency Virus(HIV)patient.We review the epidemiology,life cycle,clinical presentation and treatment of strongyloidiasis.

Strongyloidiasis: the most neglected tropical disease in Ethiopia

Background:Strongyloidiasis is the most neglected of the neglected tropical diseases(NTDs).The aim of this commentary is to describe the possible reasons why strongyloidiasis is so overlooked in Ethiopia,and shed light on better ways of control and elimination of the disease.

Endoscopic and histopathological study on the duodenum of Strongyloides stercoralis hyperinfection

AIM:To investigate endoscopic and histopathological findings in the duodenum of patients with Strongyloides stercoralis(S.stercoralis)hyperinfection. METHODS:Over a period of 23 years(1984-2006),we investigated 25 patients withS.stercoralis hyperinfection who had had an esophagogastroduodenoscopy before undergoing treatment for strongyloidiasis.The clinical and endoscopic findings were analyzed retrospectively. RESULTS:Twenty-four(96%)of the patients investigated were under immunocompromised condition which was mainly due to a human T lymphotropic virus type 1(HTLV-1)infection.The abnormal endoscopic findings,mainly edematous mucosa,white villi and erythematous mucosa,were observed in 23(92%) patients.The degree of duodenitis including villous atrophy/destruction and inflammatory cell infiltration corresponded to the severity of the endoscopic findings. The histopathologic yield for identifying larvae was 71.4% by duodenal biopsy.The endoscopic findings of duodenitis were more severe in patients whose biopsies were positive for larvae than those whose biopsies were negative(Endoscopic severity score:4.86±2.47vs 2.71 ±1.38,P<0.05). CONCLUSION:Our study clearly demonstrates that,in addition to stool analysis,endoscopic observation and biopsies are very important.We also emphasize that S.stercoralis and HTLV-1 infections should be ruled out before immunosuppressive therapy is administered in endemic regions.

Adult female of strongyloides stercoralis in respiratory secretions

Objective:To communicate the presence of adult females,rabditoid larvae and eggs of Strongyloides stercoralis(S.stercoralis)in the respiratory secretions obtained by tracheal aspirate from a HIV-negative patient who was suffering from polymyositis,and treated with corticoids and amethopterin and assisted by pneumonia.Methods:The respiratory secretions submitted to the Parasitology Laboratory of the Mu(?)iz Hospital were made more concentrated by centrifugation(1 500 r/min for 15 seconds).Wet mount microscopy was performed with the pellet.Results:It revealed adult females,rabditoid larvae and eggs of S.stercoralis.Further parasitological studies performed after the start of the treatment with ivermectin on fresh fecal samples,gastric lavages and tracheal aspirates showed scanty mobile filariform and rabditoid larvae of the same parasite.Conclusions:The presence of adult female S.stercoralis which has never been observed before in the clinical samples submitted to our Laboratory for investigation can be considered as an indirect marker of the severe immunosupression of the patient.

Prevalence of Strongyloides stercoralis and other intestinal parasitic infections among mentally retarded residents in central institution of southern Iran

Objective:To determine the prevalence of intestinal parasitic infections among mentally retarded residents of rehabilitation center of Bandar Abbas,Hormozgan province,southern Iran.Methods:A cross-sectional study was carried out in central rehabilitation institute of Hormozgan province in summer 2010.Fecal samples of all 133 residents(72 males,61 females)aged 3-52,were collected in triplicate.Specimens were examined by direct smear,formalin-ether concentration techniques and stained by permanent Trichrome,Ziehl-Neelsen stains.Statistical analysis was conducted by SPSS 13.5.Results:Intestinal parasitic infections were seen in 48.5%(64 out of 133 subjects:53.4%in males and 46.6%in females).Strongyloides stercoralis with17.3%showed the highest incidence followed by Entamoeba coli(9.8%),Blastocystis hominis(7.5%),Giardia lamblia(2.3%),Endolimax nana(2.3%),Hymenolepis nana(0.8%),Oxyuris vermicularis(0.8%),and Chilomasix mesnili(0.8%).Double infections were found to be as:Strongyloides stercoralis+Giardia lamblia(2.3%),Entamoeba coli+Giardia lamblia(1.5%),Entamoeba coli+Blastocystis hominis(1.5%),Oxyuris vermicularis+Entamoeba coli(0.8%),Strongyloides stercoralis+Entamoeba coli(0.8%),respectively.Conclusions:Our findings reveal that strongyloidiasis is a common disease among mentally retarded population in southern Iran.

Helminths as an alternative therapy for intestinal diseases

Animal models and clinical studies have shown that helminth infections exert immunomodulatory activity,altering intestinal permeability and providing a potential beneficial action on autoimmune and inflammatory disorders in human beings,such as inflammatory bowel disease(IBD) and celiac disease. This is consistent with the theory that intestinal microbiota is responsible for shaping human immunological responses. With the arrival of the immunobiologic era and the use of antibodies,we propose a distinctive pathway for treating patients with IBD and celiac disease. We have some evidence about the safety and tolerability of helminth use,but evidence about their impact on disease activity is lacking. Using worms to treat diseases could be a possible way to lower treatment costs,since the era of immunobiologic agents is responsible for a significant rise in expenses. Some questions remain to be investigated regarding the use of helminths in intestinal disease,such as the importance of the specific species of helminths used,appropriate dosing regimens,optimal timing of treatment,the role of host genetics,diet,environment,and the elucidation of the exact mechanisms of action. One promising approach is the use of helminth-derived anti-inflammatory molecules as drugs. Yet there are still many challenges with this method,especially with regard to safety. Studies on intestinal permeability point to Strongyloides stercoralis as a useful nematode for these purposes.

Prevalence of Strongyloides in Southeast Asia:a systematic review and meta-analysis with implications for public health and sustainable control strategies

Background Strongyloidiasis,caused by the nematodes Strongyloides stercoralis and Strongyloides fuelleborni,is estimated to afect over 600 million individuals worldwide.The disease is endemic in Southeast Asia,where a warmhumid climate and socio-economic conditions maintain the parasite’s life cycle and transmission.However,the current diagnostic methods may not be sufciently sensitive,suggesting that the true prevalence of strongyloidiasis could be seriously underestimated in this.This study aims to determine the prevalence of strongyloidiasis in Southeast Asia through a systematic review and meta-analysis and to discuss the implications of the estimated prevalence on diagnostic approaches and control strategies.Methods Following PRISMA guidelines,we conducted a systematic literature search in PubMed and Google Scholar databases to identify studies reporting Strongyloides prevalence data in the 11 Southeast Asian countries up to December 2022.A random efects model was employed to estimate the pooled prevalence of S.stercoralis at both regional and country levels.Results Out of 3722 articles identifed,224 met our inclusion criteria.For S.stercoralis specifcally,we found 187 articles,of which 52.4%were from Thailand.All Southeast Asian countries,except Brunei,had at least one study on Strongyloides prevalence.The estimated pooled prevalence of S.stercoralis regionally was 12.7%(95%CI 10.70-14.80%),ranging from 0.4 to 24.9%at the country level.Cambodia had the highest pooled prevalence(24.9%,95%CI 15.65-35.38%),followed by Lao PDR(16.5%,95%CI 9.50-24.95%).Moreover,we obtained a pooled prevalence of 10%(95%CI 7.06-13.52%)in a group comprising immigrants,workers,and veterans from Southeast Asian countries.S.stercoralis infects various host types,including nonhuman primates,domestic dogs and cats,rodents,and transport carriers such as cockroaches and vegetables.Conclusions A high prevalence of strongyloidiasis in Southeast Asia was revealed,highlighting the importance of the region’s ongoing research,surveillance,and control eforts.Factors contributing to the strongyloidiasis transmission include the role of animal hosts,the impact of global connectivity,and the signifcance of the co-endemicity of other Strongyloides species.Based on these fndings,a multi-pronged One-Health approach is essential for sustainable intervention and control.

A study implementing real-time PCR to identify Strongyloides species of third-stage larvae in human stool samples from Southern Vietnam

Background:Strongyloidiasis,a neglected disease caused by intestinal nematodes of the genus,is endemic to tropical and subtropical areas such as Vietnam.Morphological methods only identify the genus,while DNA-molecular techniques are susceptible in Strongyloides spp.detection.The study aims to determine the prevalence of dominant Strongyloides species among the population in Duc Hoa district,Long An,Vietnam.Methods:A cross-sectional study used 1190 stool specimens collected from July 2017 to November 2018.All samples were transported within 2 h,stored at 2-8℃,and processed within 48 h for microscopy smear and culture at the Laboratory of Medical Parasitology,Pham Ngoc Thach University of Medicine(PNT).Then all positive samples with the above 2 methods were verified by real-time PCR technique.Real-time PCR amplification was conducted at the Laboratory of Molecular Biology,PNT.Results:Direct microscopy and modified Harada-Mori culture detected Strongyloides spp.larvae in 79/1190 sam-ples(6.6%).About 94.2%of the DNA samples were Strongyloides stercoralis,2.9%were co-infections with Strongy-loides ratti and S.stercoralis,and 2.9%were patients with S.ratti.The identity of 12/14 sequences was confirmed as S.stercoralis with a high level of similarity(91.3%-100%)and over 98%for S.ratti.Conclusion:DNA-molecular techniques and sequence analysis are highly suitable for identifying Strongyloides species isolated from stool samples.It is remarkable evidence of the presence of zoonosis S.ratti disease in human,not just the known S.stercoralis.It is likely to result in a certain proportion of people being infected by this animal-borne infectious pathogen.

Strongyloides stercoralis prevalence and diagnostics in Vientiane, Lao People’s Democratic Republic

Background:Despite the high prevalence of strongyloidiasis in the Laotian population,Laotian hospitals still lack diagnostic capacity to appropriately diagnose Strongyloides stercoralis infections.This cross-sectional hospital-based study was conducted to assess the prevalence of Strongyloides stercoralis infection among hospitalized patients treated at Mahosot Hospital,the primary reference hospital of Lao People’s Democratic Republic(Lao PDR),and to validate feasible methods for diagnosing S.stercoralis infection at hospital’s laboratory.Methods:Between September and December 2018,stool samples of 104 inpatients were investigated for S.stercoralis infection by wet smear,Baermann technique,Koga Agar plate culture(KAPC),and real-time detection polymerase chain reaction(RTD-PCR)at the Infectious Diseases Ward of the Mahosot Hospital in Vientiane.The sensitivity,the specificity,the negative predictive value(NPV)of each diagnostic test,as well as their combination(s)was calculated using a composite reference standard(CRS).The correlation of the different test methods was assessed by chi-square or Fisher’s exact test.Cohen’s kappa coefficient was used to assess the diagnostic agreement of the different test methods.Results:The overall prevalence of S.stercoralis infections among the study population was 33.4%.The cumulative infection prevalence statistically significantly increased from the lowest age group of 40 years and below(22.4%),to the medium(40.0%)and to the oldest age group of 61 year and above(72.7%)(P=0.003).The cumulative infection prevalence of CRS was considerably higher in male(40.4%)compared to female patients(28.1%),but not statistically different(P=0.184).The diagnostic sensitivity of Baermann technique,KAPC,RTD-PCR,and the combination of Baermann technique and KAPC were 60.0,60.0,74.3,and 77.1%,respectively.Only 13 patients(37.1%)of the total 35 S.stercoralis patients diagnosed with any technique had a simultaneously positive diagnostic test with Baermann,KAPC and RTD-PCR.Conclusions:We identified Baermann technique and KAPC to be currently the most feasible and implementable standard methods for diagnosing S.stercoralis at a hospital setting such as Mahosot Hospital and provincial and district hospitals in Lao PDR and other low-and middle income countries in Southeast Asia.Trial registration:This study was approved by the National Ethics Committee for Health Research in Lao PDR(reference no.083/NECHR)and by the Ethics Committee Northwest and Central Switzerland(reference no.2018–00594).