Strongyloides stercoralis, a silent killer A case-report

Stefaan Kurvers

Dr. C. Linssen, Dr. E. de Brauwer, Dr. F. Stals

Department of Medical Microbiology

Zuyderland Medical Center, Heerlen

The Netherlands

International Conference on Parasitology Aug 24-26, 2015 Philadelphia, USA

•Male patient, 57 years of age origin from Liberia

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• Time-line

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Medical review

• Patient origin from Liberia

• Living for 9 years in the Netherlands

• Medical history: • Chronic hepatitis B

• Diabetes type II

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Medical review

• A year earlier (2011 – May):

Diagnosis of non-Hodgekin lymphoma (NHL) treated with chemotherapy

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• A month earlier (2012 – April):

Hospitalized due to abdominal and respiratory complaints • Symptoms: vomiting, nausea, fever

• Fever remained despite of broad spectrum antibiotics

• Infiltrate shown on the thoracic X-ray

• LAB results

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Hb: 7.4 mmol/L ↓ Hct: 0.35 L/L ↓ RBC: 4.09 x10E9/L ↓ WBC: 1.2 x10E9/L ↓

Neu: 0.8 ↓ Eos: 0.07 Monos: 0.1 ↓ Lymphs: 0.3 ↓

PLT: 124 x10E9/L ↓ CRP: 101 mg/L ↑

• Suspicion of PCP => TMP-SMX (Cotrim) therapy was started combined with prednisone

After the treatment the patient was discharged from the hospital in good clinical condition.

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• Recent (2012 – May):

Hospitalized due to general weakness and abdominal complaints • Symptoms: headache, diarrhea, vomiting, nausea, fever

After extensive diagnostic examinations however no cause was found.

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After 14 days, because of the persistent vomiting, a gastroscopy was performed

• The following was found:

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Image of an ulcerative lesion

• During the gastroscopy biopsies were taken.

After preparation and staining at the pathology department the following was seen.

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H&E staining 1000x oil magnification

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Enlarged

• Biopsies showed:

• Worm/larvae-like structures

Because of these findings the

Department of Medical

Microbiology was consulted.

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• Before the parasitological diagnosis was made the patient deteriorated and was admitted to ICU.

• Mechanical ventilation

• Broad spectrum antibiotics

• Collecting stool was difficult because the patient was suffering from ileus

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Stool samples were collected and examined for parasites.

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R h a b d i t i fo r m l a r va e o f S t r o n g y l o i d e s s te r co r a l i s

Genital primordium

Short buccal cavity

250 µm x 17 µm Wet mounts

• Ivermectin therapy was started

One day after the diagnosis was confirmed: Patient died of septicemia combined with massive bleeding from the stomach ulcers.

Conclusion:

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Disseminated Strongyloidiasis

• How could this have been prevented?

• No awareness for strongyloidiasis due to the lack of eosinophilia and the patient was living in the Netherlands for 9 years, no recent visits to endemic countries

• Role of serology before start immunosuppressive therapy (screening)

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Discussion:

• Collection of BAL was not done

• Are there guidelines on screening for Strongyloides concerning patients who will have immunosuppressive therapy?

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Discussion:

Facts on Strongyloidiasis

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Life cycle

• Infection is acquired through direct contact with contaminated soil.

Facts on Strongyloidiasis

• Transmission occurs mainly in tropical and subtropical regions

• 30-100 million people are infected worldwide; precise data on prevalence are unknown in endemic countries

• Strongyloidiasis is frequently underdiagnosed because many cases are asymptomatic; moreover, diagnostic methods lack sensitivity

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Facts on Strongyloidiasis

• Without appropriate therapy, the infection does not resolve and may persist for life

• Infection may be severe and even life-threatening in cases of immunodeficiency

• No public health strategies for controlling the disease are active at the global level

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Take home messages!

• Health-care providers should be made aware of this parasite, and particularly about the risk of disseminated infections

• Standardization of screening for Strongyloidiasis before starting immunosuppressive therapy using serology and/or PCR concerning high-risk patients

• More detailed epidemiological data on the global distribution of strongyloidiasis are needed

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Special thanks to:

Medical Microbiologists: Dr. C. Linssen

Dr. E. de Brauwer

Dr. F. Stals

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Internal Medicine: Dr. Schutten

Dr. de Conick

Dr. v.d. Berkmortel

Dr. Buys

Intensive Care Unit (ICU) Dr. Zandijk

Dr. v.d. Horst

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Thank you for your attention!