Estrongiloidiasis gastrointestinal en paciente inmunocompetente: a propósito de un caso / Gastrointestinal strongyloidosis in an immunocompetent patient: a case report

Intestinal parasitic infections cause a not insignificant number of chronic diarrhea in children, however, with the sociodemographic change that our country has experienced, the number of cases and new parasites (immigration from tropical endemic areas) could increase. We report the case of an immunocompetent patient who presents with chronic diarrhea associated with Strongyloides stercoralis infection. The patient migrated two years ago from an endemic area for this helminth. The diagnosis is challenging, and the chances of a successful outcome depend on the administration of the antiparasitic.

Las infecciones parasitarias intestinales provocan un número no despreciable de causas de diarrea crónica en niños, sin embargo, con el cambio sociodemográfico que ha vivido nuestro país se podría incrementar el número de casos y de nuevos parásitos (inmigración de áreas endémicas tropicales). Reportamos el caso de un paciente inmunocompetente, que presenta cuadro de diarrea crónica asociada a infección por Strongyloides stercoralis. El paciente habría migrado hace dos años desde zona endémica para este helminto. El diagnóstico es desafiante y las posibilidades de un resultado exitoso dependen de la administración del antiparasitario.

Screening of Strongyloides infection using an ELISA test in transplant candidates

OBJECTIVES: Hyperinfection or disseminated strongyloidiasis has been frequently reported after transplants and is related to high mortality. This study aimed to screen for strongyloidiasis using serological diagnoses in transplant candidates. METHODS: An ELISA test was performed with filariform larvae of Strongyloides venezuelensis as a source of antigen. RESULTS: In the serum from transplant candidates, anti-Strongyloides IgG antibodies were detected in 35/150 (23.3%) samples by soluble fractions in phosphate buffered saline (PBS), 31/150 (20.7%) samples by soluble fractions in Tris-HCl, 27/150 (18.0%) samples by membrane fractions in PBS and 22/150 (14.7%) samples by membrane fractions in Tris-HCl. CONCLUSIONS: The present results suggest the ELISA test, ideally using soluble fractions of filariform larvae S. venezuelensis in PBS, as an additional strategy for the diagnosis of strongyloidiasis in transplant candidates.

Infección severa por Strongyloides stercoralis en líquido ascítico / Severe infection by Strongyloides stercoralis in ascitic liquid

La estrongiloidiosis es una infección cuyos agentes responsables son Strongyloides stercoralis y S. fuelleborni. Estos nematodos son de localización intestinal, el factor de riesgo principal es el andar descalzo en lugares contaminados con las larvas filariformes. El estudio presenta a un paciente varón de 23 años de edad, residente de San Juan de Lurigancho, presentó 14 meses de enfermedad con signos de meteorismo, náuseas, vómitos y permaneció afebril, se indica también que 28 días antes presentó dolor del epigastrio irradiado a la espalda de duración constante. Al examen físico se encontró un abdomen distendido, blando timpánico doloroso a la palpación, el informe de ecografía abdominal evidenció dilatación de las asas intestinales, meteorismo, con presencia abundante de líquido libre en la cavidad abdominal (ascitis) y en los exámenes parasitológicos del líquido se observó larvas rabditoides L1, L2 y filariformes L3 de Strongyloides stercoralis; por lo que recibió tratamiento con Ivermectina, obteniéndose la recuperación del paciente.

The strongyloidiasis is an infection whose responsible agents are Strongyloides stercoralis and S. fuelleborni. These nematodes have an intestinal location; the main risk factor is to be barefoot in places contaminated with filariform larvae. The study presents a male 23-year-old resident of San Juan de Lurigancho, with 14 months of illness with signs of bloating, nausea, vomiting and wasafebrile,also indicates that 28 days before he had epigastric pain irradiated to the back. On physical examination a distended abdomen was found, soft painful tympanic tenderness, the abdominal ultrasonography showed dilated bowel loops, bloat, with abundant presence of free fluid in the abdominal cavity (ascites) and parasitological examinations observed, rabditoides larvae L1 and L2 and filariform L3 of Strongyloides stercoralis. He received Ivermectin, obtaining the patient's recovery.

Impacto da infecção por HTLV-1 nas manifestações clínicas e no tratamento de pacientes com estrongiloidíase / Impact of HTLV-1 infection on clinical presentations and treatment of strongyloidiasis patients

A estrongiloidíase é uma enfermidade que acomete cerca de 100 milhões de pessoas em todo mundo. Essa parasitose apresenta alta prevalência e tem maior gravidade clínica entre indivíduos imunossuprimidos, principalmente aqueles portadores do vírus linfotrópico de células T humana tipo 1 (HTLV). Este fato torna a coinfecção por esse vírus em pacientes parasitados por Strongyloides stercoralis um grave problema de saúde pública. O presente estudo teve por objetivo revisar os estudos sobre coinfecção por HTLV/S. stercoralis. Foi realizada busca eletrônica completa de dados disponíveis sobre a coinfecção entre o vírus e S. stercoralis. As publicações foram capturadas a partir das bases de dados PubMed e SciELO, sendo utilizados os seguintes descritores "vírus linfotrópico de células T humanas tipo 1", "HTLV-1", "S. stercoralis" e "estrongiloidiase". A infecção por HTLV em pacientes parasitados representa fator de risco para o desenvolvimento de estrongiloidíase grave e, nesses indivíduos, o tratamento recomendado deve ser realizado e monitorado para garantir o sucesso terapêutico.(AU)

Strongyloidiasis is a disease that affects approximately 100 million people worldwide. This parasitosis is highly prevalent and more clinically severe among immunosuppressed individuals, particularly those with Human T-lymphotropic virus 1 (HTLV-1). This fact makes the co-infection with this virus in patients parasitized by Strongyloides stercoralis a serious public health problem. The present study aimed at reviewing the studies of co-infection with HTLV/S. stercoralis. A complete electronic search for available data about the co-infection of the virusand S. stercoralis was performed. The publications were obtained from the databases PubMed and SciELO, with the following descriptors being used: "Human T-lymphotropic Virus type 1, "HTLV-1", S. stercoralis, and "strongyloidiasis". The infection with HTLV in infected patients is a risk factor for the development of severe strongyloidiasis, and for these individuals the recommended treatment should be performed and monitored to ensure therapeutic success.(AU)

Fatal disseminated strongyloidiasis after kidney transplantation / Estrongiloidíase disseminada fatal após transplante renal

Disseminated strongyloidiasis (DS) is a rare and severe parasitic disease that is difficult to recognize and affects immunocompromised individuals. We report the case of a kidney transplant recipient who presented with DS despite prophylaxis with albendazole. We have discussed the need for better prophylactic strategies and for a higher degree of suspicion in order to diagnose DS.

A estrongiloidíase disseminada (ED) é uma doença parasitária rara de difícil diagnóstico que acomete indivíduos imunocomprometidos. Relatamos um caso de um paciente transplantado renal que desenvolveu ED apesar do uso de profilaxia com albendazol. São discutidas estratégias profiláticas e de diagnóstico da estrongiloidíase disseminada.

Estrongiloidosis diseminada en un paciente con SIDA / Disseminated strongyloidiasis in an AIDS patient / Estrongiloidíase disseminada em um paciente com AIDS

Se comunica un caso de hiperinfección por Strongyloides stercoralis diagnosticado a partir de una secreción respiratoria obtenida por lavado broncoalveolar (LBA). El paciente, oriundo de una región endémica (Paraguay), VIH positivo (50 linfocitos T CD4+/µL en sangre venosa periférica) se internó por un cuadro pulmonar, presuntivamente identificado como neumocistosis pulmonar (PCP). La microscopia en fresco del concentrado de las secreciones respiratorias reveló larvas rabditoides y filariformes de Strongyloides stercoralis. En la microscopia con tinta china del LCR se observaron levaduras capsuladas (por cultivo Criptococcus neoformans) y la determinación del antígeno polisacárido capsular de C. neoformans fue de 1/1000 en sangre y 1/10 en LCR. El estudio virológico por PCR del LCR fue positivo para citomegalovirus, mientras que el estudio parasitológico del mismo fue negativo, al igual que el examen micológico de las secreciones respiratorias. Tras el diagnóstico parasitológico comenzó el tratamiento con ivermectina (200 µg/kg/día vía oral), el cual resultó ineficaz, tal como lo determinó la presencia de larvas móviles en la microscopia de una muestra de aspirado traqueal. El paciente falleció 3 días después.

A case of Strongyloides stercoralis hyperinfection diagnosed from respiratory secretions obtained by bronchoalveolar lavage (BAL) is communicated. The patient, born in an endemic region (Paraguay), HIV positive (50 T CD4+ lymphocytes/µL), was hospitalized with respiratory pathology, presumptively suspected as pulmonary pneumocystosis (PCP). Fresh microscopy of the respiratory secretions concentrate revealed filariform and rabditoide larvae of Strongyloides stercoralis. India ink microscopy of CSF showed capsulated yeasts (Criptococcus neoformans by culture). The titles bron of polysaccharide capsular antigen of C. neoformans were 1/1.000 in blood and 1/10 in CSF. Virological study of CSF by PCR was positive for citomegalovirus, and parasitological examination was negative, as well as the mycological study of respiratory secretions. After diagnosis, treatment with ivermectin (200 µg/kg/day) was started, which proved ineffective, as was determined by the presence of multiple motile larvae in the microscopy of a tracheal lavage. The patient died 3 days later.

Comunica-se um caso de hiperinfecção por Strongyloides stercoralis diagnosticado a partir de uma secreção respiratória obtida através de lavagem broncoalveolar (LBA). O paciente, originário de uma região endêmica (Paraguai), HIV positivo (50 linfócitos T CD4+/µL em sangue venoso periférico) foi hospitalizado devido a um quadro pulmonar, presuntivamente identificado como pneumocistose pulmonar (PCP). A microscopia em fresco da concentração das secreções respiratórias revelou larvas rabditoides e filariformes de Strongyloides stercoralis. Na microscopia com tinta nanquim do LCR foram observadas leveduras capsuladas (por cultura Criptococcus neoformans) e a determinação do antígeno polissacarídeo capsular de C. neoformans foi de 1/1000 em sangue e 1/10 em LCR. O estudo virológico por PCR do LCR foi positivo para Citomegalovirus, enquanto que o estudo parasitológico do mesmo foi negativo, do mesmo modo que o exame micológico das secreções respiratórias. Após o diagnóstico parasitológico começou o tratamento com ivermectina (200 µg/kg/día vo), o qual resultou ineficaz, tal como foi determinado pela presença de larvas móveis na microscopia de uma amostra de aspiração traqueal. O paciente faleceu 3 dias depois.

Molecular Identification of Oesophagostomum and Trichuris Eggs Isolated from Wild Japanese Macaques

Natural habitat fragmentation and reducing habitat quality have resulted in an increased appearance of Japanese macaques, Macaca fuscata (Gray, 1870), in suburban areas in Japan. To investigate the risk of zoonotic infections, a coprological survey of helminth eggs passed by wild Japanese macaques was carried out in 2009 and 2010 in Shiga Prefecture, Japan. Microscopic examination found helminth eggs in high prevalence, and nucleotide sequencing of DNA extracted from the eggs identified Oesophagostomum cf. aculeatum and Trichuris trichiura. A fecal culture also detected infective larvae of Strongyloides fuelleborni. These zoonotic nematodes pose a potential health issue to local people in areas frequented by Japanese macaques.

Host-finding behavior of Strongyloides stercoralis infective larvae to sodium cation, human serum, and sweat.

The host-finding behavior of Strongyloides stercoralis infective larvae was examined by in vitro agarose assay method. As human body fluid contains 0.85% (ca 0.15 molar) NaCl, various concentrations of sodium chloride, from 0.5M to 0.01M (7 steps), were examined. Many larvae were attracted at concentrations between 0.5 and 0.05M of sodium chloride. The concentration of 0.05M attracted the most larvae. The concentration of 0.02M of sodium chloride showed greatly reduced larval attraction compared with 0.05M. Therefore, the threshold concentration was determined as 0.05M. Then, 0.05M of chemicals were examined in a further experiment. Chloride compounds (NaCl, KCl, CaCl2, MgCl2) were investigated. These chemicals are components of human body fluids. Distilled water was used as the control in all experiments. Only sodium chloride attracted the larvae. Next, alkaline compounds were examined [NaOH, KOH, Ca(OH)2, and Mg(OH)2]. Larvae accumulated only at the NaOH site. The results suggested that the Na cation is important for larval attraction. A high pH value did not influence attraction at all. Next, human serum was tested. The human serum used was from normal serum to 1:32 diluted sera by distilled water (7 steps). Hierarchical attraction was seen according to serum concentration. Next, human sweat was collected from a limited zone of chest skin where only eccrine glands were distributed. Non-diluted sweat attracted the most larvae. Sweat might act as one of the most probable factors for infection by this skin-penetrating nematode.

Avaliação da eficiência dos métodos Direto, COPROTEST e Rugai no diagnóstico da estrongiloidíase / Evaluation of the efficiency of the Direct, COPROTEST and Rugai methods on the diagnosis of Strongyloidiasis

Estrongiloidíase, parasitose intestinal relativamente comum em áreas tropicais e subtropicais, resulta da infecção causada pelo nematódeo, Strongyloides stercoralis. O homem pode ser infectado pelo parasita, que possui em seu ciclo vital machos e fêmeas capazes de viver no solo, porém com outra parte do ciclo obrigatoriamente parasitária na parede intestinal. O diagnóstico da infecção é rotineiramente realizado pela observação microscópica da larva em amostras de fezes e a alta sensibilidade de um método sobre outro, nos leva a um diagnóstico mais confiável e eficiente. Foi avaliado a eficiência dos três métodos (Direto, COPROTEST e Rugai), empregados no setor de Parasitologia do NAC-LACAL (Núcleo de Atendimento à Comunidade - Laboratório de Análises Clínicas Prof. Dr. Antônio Longo) na cidade de Araraquara - SP, no diagnóstico da estrongiloidíase. Um total de 2346 amostras fecais provenientes de pacientes do NAC-LACAL (1597) e do Hospital Nestor Goulart Reis (749) foram analisadas no período entre agosto e dezembro de 2002. O método Rugai com 65% de positividade mostrou ser o mais eficiente entre os três

Estudo da apoptose e da proliferação do enterócitos na estrongiloidíase / Enterocyte apoptosis and proliferation in strongyloidiasis

A estrongiloidíase é uma parasitose de alta prevalência em nosso meio, que provoca alterações inflamatórias no intestino delgado. Foram estudados os índices de apoptose e de proliferação das células epitelias do duodeno e jejuno de 23 pacientes parasitados pelo Strongyloides stercoralis, comparados com um grupo controle de 17 indivíduos. A média do índice de apoptose, avaliada pelo método do TUNEL / Strongyloidiasis is a wide prevalent parasitosis in our enviroment that causes inflammatory alterations in the bowel. The aim of this study was to investigate the apoptotic and proliferative indices in a group of 23 patients, compared to 17 controls. The mean apoptotic indices when evaluated by TUNEL...

High prevalence of giardiasis and stronglyloidiasis among HIV-infected patients in Bahia, Brazil

Diarrhea due to intestinal microbial infections is a frequent manifestation among HIV-infected patients. It has been postulated that HIV-infected patients may have special types of intestinal infections, and that immune activation from such parasites may affect the progression of HIV disease. To evaluate these associations, the frequency of infections was examined in HIV-infected patients in Bahia, Brazil. To determine the potential impact of the presence of intestinal parasitic infections on HIV disease progression, a retrospective study approach was used. The medical charts of 365 HIV-infected patients who had been treated at the AIDS Clinic of the Federal University of Bahia Hospital were reviewed, and the prevalence of parasites was compared with 5,243 HIV-negative patients who had attended the hospital during the same period of time. Among HIV-infected subjects, CD(4) count, RNA plasma viral load (VL), and number of eosinophils were compared according to their stool examination results. The overall prevalence of each parasite was similar for HIV-positive and HIV-negative patients. However, the prevalence of S. stercoralis (p<10(-7)) and G. lamblia (p=0.005) was greater for HIV-infected subjects. The mean CD(4) count and viral load of HIV patients in our clinic who had stool examinations was 350 cells +/- 340 and 4.4 +/- 1.4 log RNA viral load, respectively. In this patient group there was no clear association between the level of the absolute CD(4) count or the viral load and a specific parasitic infection. The presence of an intestinal parasitic infection was not associated with faster progression of the HIV disease among HIV-infected patients. We conclude that strongyloidiasis and giardiasis are more frequent in HIV-infected patients in Bahia, Brazil. If this association is due to immune dysregulation, as has been proposed elsewhere, it must occur in patients after only minor shifts in CD(4) count from normal levels, or as a result of immune dysfunction not represented by CD(4) count. These infections do not appear to alter the progression of HIV disease.

Intestinal permeability in strongyloidiasis

The objective of the present study was to assess intestinal permeability in patients with infection caused by Strongyloides stercoralis. Twenty-six patients (16 women and 10 men), mean age 45.9, with a diagnosis of strongyloidiasis were evaluated. For comparison, 25 healthy volunteers (18 women and 7 men), mean age 44.9, without digestive disorders or intestinal parasites served as normal controls. Intestinal permeability was measured on the basis of urinary radioactivity levels during the 24 h following oral administration of chromium-labeled ethylenediaminetetraacetic acid (51Cr-EDTA) expressed as percentage of the ingested dose. The urinary excretion of 51Cr-EDTA was significantly reduced in patients with strongyloidiasis compared to controls (1.60 + or - 0.74 and 3.10 + or - 1.40, respectively, P = 0.0001). Intestinal permeability is diminished in strongyloidiasis. Abnormalities in mucus secretion and intestinal motility and loss of macromolecules could explain the impaired intestinal permeability

Tratamento de ratos, experimentalmente infectados pelo Strongyloides venezuelensis, através da ivermectina administrada por via oral / The treatment of rats experimentally infected with Strongyloides venezuelensis by orally administered ivermectin

Em modelo experimental, baseado na infecção de ratos pelo Strongyloides venezuelensis, foi avaliada a atividade terapêutica de duas preparações de ivermectina, para usos veterinário e humano. Houve interesse em verificar a efetividade em relação a vermes adultos e formas larvárias. A administração dos fármacos ocorreu sempre por via oral e a posologia correspondeu à dose única de 0,2mg/kg. Considerados os vermes adultos e as formas larvárias, o produto para emprego veterinário propiciou eliminações expressas pelas porcentagens de 98,0% e 84,2%; quanto à outra preparação, as taxas situaram-se em 59,3% e 73,0%, respectivamente. O estudo revelou, então, utilidade do anti-helmíntico quando usada a via oral e, também, mostrou significativa ação sobre as formas larvárias, certamente valiosa quando vigente a modalidade disseminada da estrongiloidíase.

Strongyloides venezuelensis experimental infection in rats was treated by two different oral preparations of ivermectin, 0.2 mg/kg. One was a human formula used by WHO in the treatment of onchocerciasis; the other was a veterinary preparation. Adult worms and larvae were evaluated. The human formulation cleared both forms in 59.3% (adult worms) and 73.0% (larvae), whereas the veterinary one cleared 98.0% and 84.2%, respectively. The antilarval action is very useful when treating systemic strongyloidiasis.

Prospective study of strongyloidosis in patients with hematologic malignancies

Immunocompromised individuals infected with Strongyloides stercoralis may develop severe hyperinfection or disseminated disease with high mortality. Patients with hematological malignancies are at risk because of immunodepression produced either by the disease or its treatment. A prospective study was undertaken at the Hospital de Clínicas de Porto Alegre, from July 1994 to July 1995. Seventy-two (HIV negative), had 3 stool samples collected at different days and had not received recent anthelmintic therapy. Larvae, isolated in a modified Baermann method, were found in 6 patients, with a resultant prevalence of 8.3%. No complicated strongyloidosis was documented. The positive result for S. stercoralis larvae was significantly associated (p < 0.001) with eosinophilia. Knowledge of prevalence figures and incidence of severe disease is important to adequate guidelines for empirical treatment besides the rigorous search for strongyloidosis in patients with hematological malignancies.

Indivíduos imunocomprometidos infectados com Strongyloides stercoralis podem desenvolver quadros severos de hiperinfecção ou doença disseminada com elevada mortalidade. Pacientes portadores de neoplasias hematológicas tem imunodepressão causada pela doença básica ou pelo seu tratamento. Um estudo prospectivo foi desenvolvido no Hospital de Clínicas de Porto Alegre, entre julho 1994 e julho de 1995. Setenta e dois pacientes (HIV negativos), tiveram 3 amostras de fezes coletadas em diferentes dias e não tinham recebido medicação antihelmíntica recentemente. Larvas, isoladas por método de Baermann modificado, foram encontradas em 6 pacientes, resultando em prevalência de 8,3%. Não foi documentado nenhum episódio de estrongiloidose complicada. O resultado positivo para pesquisa de S. stercoralis estava significativamente associado (p < 0,001) com eosinofilia. O conhecimento das taxas de prevalência e incidência de doença grave é importante para adequar as recomendações para tratamento empírico além da rigorosa pesquisa da estrongiloidose nos pacientes com neoplasias hematológicas.

Revendo a importancia do Strongyloides stercoralis / Reviewing the importance of Strongyloides stercoralis

A estrongiloidiase e uma doenca parasitaria de distribuicao mundial e de grande importancia no Brasil. Entre as diversas especies existentes do genero Strongyloides, apenas o S. stercoralis, o S. fulleborni e o S. fulleborni-like tem importancia para o homen. Embora o S. stercoralis seja um helminto intestinal, a estrongiloidiase e uma infeccao sistemica, podendo acometer alem do trato gastrointestinal, os pulmoes, SNC, figado e vias biliares, pancreas, trato genitourinario e pele. Na maioria dos casos, a estrongiloidiase e assintomatica, de curso cronico e benigno. Os sintomas gastrointestinais e pulmonares sao os mais importantes entre os casos assintomaticos. Por motivos ainda nao muito bem compreendidos, a infeccao pelo estrongiloides pode resultar em doenca severa e disseminada. O uso de terapia imunossupressora foi identificado como fator de risco importante para a forma disseminada nos paises industrializados. O diagnostico da estrongiloidiase pode ser dificil, e embora o exame parasitologico de fezes seja o mais utilizado nem sempre sao identificados larvas do parasito...

Estrongiloidíase em pacientes com pênfigo foliáceo / Strongyloidiasis in patients with pemphigus foliaceus

Em 30 pacientes com pênfigo foliáceo, a freqüência da estrongiloidíase foi de 40 por cento, através de três exames de Baermann-Moraes. No "Hospital do Pênfigo", em Uberaba, as freqüências da estrongiloidíase nos funcionários (n=14) e escolares (n=47) da Escola creche, anexa, também foram altas, respectivamente 35,7 por cento e 23,4 por cento. Em 7 (58,3 por cento) das 12 amostras do solo, do jardim/pátio do "Hospital", foram observadas formas de vida livre do Strongyloides stercoralis. O fator ambiental e a predisposiçäo dos pacientes foram associados à alta transmissäo da estrongiloidíase

Estudio clínico - parasitológico de pacientes con autoinfección por Strongyloides stercolaris en el Hospital Cayetano Heredia 1973 - 1991

Se presenta un estudio retrospectivo de 24 pacientes adultos con autoinfección por Strongyloides Stercoralis, que fueron atendidos en el Hospital Cayetano Heredia entre 1973 y febrero de 1991. la mayoría tuvo edades entre 20 y 39 años, el 75 por ciento fueron varones. No hubo antecedentes de viaje a la selva en el 37.5 por ciento. El 100 por ciento de pacientes tuvieron síntomas gastrointestinales diarrea, náuseas, vómitos, hiporexia, dolor abdominal, etc.) Otros síntomas fueron: disminución de peso, malestar general, fiebre y edema. Los signos importantes fueron palidez, edema y hepatomegalia. Hubo eosinofilia en 10/20 pacientes e hipoalbuminemia en 11/11 pacientes. El 70.8 por ciento de casos fue diagnósticado por el hallazgos de larvas en esputo, el 16.6 por ciento por falla terapéutica al Thiabendazol, el 8.3 por ciento por hallazgos de larvas filariformes en heces y el 4.1 por ciento por el hallazgo de larvas filariformes mediante cuerda encapsulada. El 87 por ciento de pacientes no tuvo inmunosupresión. El 62.5 por ciento negativizó heces y esputo por 2 o más meses con Thiabenzadol, Ivermectina o ambos