Strongyloides stercoralis como causa infrecuente de infección de líquido ascítico en cirrosis / Strongyloides stercoralis as uncommon cause of ascitic fluid infection in cirrhosis

Resumen Se comunica el caso clínico de un varón, con antecedentes de una cirrosis hepática alcohólica y gota, usuario crónico de antiinflamatorios, incluyendo corticoesteroides. Consultó por una melena secundaria a una úlcera bulbar. Durante su internación presentó fiebre, tratándose con ceftriaxona por un probable foco urinario. Por persistir febril, se realizó una paracentesis diagnóstica. En la muestra de líquido ascítico se observaron larvas de Strongyloides stercoralis. Recibió tratamiento antiparasitario con ivermectina, con buena respuesta clínica. Aunque la infección por S. stercoralis es relativamente frecuente en pacientes con cirrosis hepática alcohólica, la ascitis infectada por Strongyloides corresponde a una forma de presentación infrecuente. Este caso muestra la importancia de la paracentesis diagnóstica en todo paciente con ascitis secundaria a una cirrosis. Es importante considerar la presentación atípica de la infestación por Strongyloides en el contexto del paciente inmunocomprometido, ya que sin tratamiento puede tener una alta mortalidad.

Abstract Male patient, with a history of alcoholic cirrhosis frequent user of anti-inflammatory drugs including corticosteroids. He consulted for digestive bleeding secondary to a bulbar ulcer. During the admission, he had fever and antibiotic treatment with ceftriaxone is started, for a urinary infection. Fever persisted for 48 hours, so a diagnostic paracentesis was made: Strongyloides stercoralis larvae were seen in the direct microscopic exam. The patient started antiparasitic treatment with ivermectin. He was discharged and did not returned for follow up. Although infection with S. stercoralis is relatively common in patients with alcoholic liver cirrhosis, ascites infected with Strongyloides corresponds to an infrequent form of presentation. This case shows the importance of diagnostic paracentesis in every cirrhotic patient. It is important to consider atypical presentation of Strongyloides infection in the immunocompromised host, considering it could be fatal without treatment.

Obstrucción duodenal por Strongyloides stercoralis, una complicación inusual / Duodenal obstruction by Strongyloides stercoralis, an unusual complication

Resumen La estrongiloidiasis es una enfermedad desatendida en Latinoamérica. Las manifestaciones gastrointestinales son inespecíficas y la obstrucción duodenal es una complicación infrecuente. Presentamos el caso clínico de un varón de 31 años, procedente de la selva central de Perú, que ingresó por una obstrucción intestinal alta, con úlceras y una estenosis duodenal evidenciadas en la endoscopia digestiva alta. El informe histopatológico reveló la presencia de larvas de Strongyloides stercoralis. La evolución clínica y endoscópica fueron favorables con el tratamiento con ivermectina. Existen poco más de 20 casos publicados de obstrucción duodenal por S. stercoralis. Adicionalmente, se confirmó una infección por HTLV-1, asociación descrita frecuente.

Strongyloidiasis is a neglected disease in Latin America. Gastrointestinal manifestations are nonspecific and duodenal obstruction is a rare complication. Here we present the case of a 31-year-old male from the central jungle of Peru, admitted due to a high intestinal obstruction, with duodenal ulcers and stenosis evidenced in the upper endoscopy. The histopathological report revealed presence of larvae of Strongyloides stercoralis. Clinical and endoscopic follow up were favorable with ivermectin treatment. There are near 20 reported cases of duodenal obstruction due to S. stercoralis. Additionally, infection by HTLV-1 was confirmed, being this a frequent association.

Púrpura por Strongyloides stercoralis en un paciente inmunocompetente / Purpura due to Strongyloides stercoralis in an immunocompetent patient

Resumen La infección por Strongyloides stercoralis es una parasitosis frecuente en las regiones tropicales y subtropicales, incluyendo la Amazonía peruana. En pacientes con inmunocompromiso, las manifestaciones clínicas son variadas y es frecuente la diseminación sistémica de la enfermedad, con compromiso de diversos órganos. Las manifestaciones cutáneas son infrecuentes y se describen en pacientes con algún grado de inmunosupresión. Se presenta el caso de un paciente inmunocompetente que desarrolló una púrpura reactiva por una infección por Strongyloides stercoralis crónica. Ante ello, es posible el compromiso cutáneo en pacientes inmunocompetentes con reagudización sistémica por este parásito.

Infection with Strongyloides stercoralis is a common parasitic infection in tropical and subtropical regions, including the Peruvian Amazon. The clinical manifestations are varied in patients with immunocompromised disease, and the systemic spread of the disease is frequent, compromising different organs and systems. Cutaneous manifestations are infrequent, being described in patients with some degree of immunosuppression. We present the case of an immunocompetent patient who developed a reactive purpura due to chronic Strongyloides stercoralis infection. Thus, skin involvement is possible in immunocompetent patients with systemic exacerbation due to this parasite.

Estrongiloidiasis crónica y uso prolongado de corticoides / Chronic strongyloidiasis and extended use of corticoids

La infección causada por Strongyloides stercoralis puede permanecer asintomática o con síntomas ligeros en humanos por varios años. Sin embargo, algunos individuos inmunodeprimidos, entre ellos los pacientes tratados con esteroides por tiempo prolongado, pueden presentar hiperinfección con altas tasas de mortalidad. El objetivo es reportar por primera vez en Cuba el caso de una paciente con síntomas de estrongiloidiasis crónica asociada al uso de esteroides orales. Se trata de una paciente de 63 años, asmática con síntomas de estrongiloidiasis crónica y riesgo de hiperinfección por el uso de esteroides orales por tiempo prolongado. Se describen las manifestaciones clínicas y los análisis complementarios. Se discuten los factores predisponentes para la adquisición inicial y el desarrollo de la enfermedad. El laboratorio confirmó la presencia de larvas rabditoides de Strongyloides stercoralis en las heces de la paciente. Aunque existen evidencias de casos fatales de pacientes con strongiloidiasis asociada al uso prolongado de esteroides en la literatura internacional, hay escasez de esos reportes en Cuba. Adicionalmente, es probable que el diagnóstico y el tratamiento oportunos, hayan contribuido a evitar complicaciones fatales en esta paciente(AU)

The infection caused by Strongyloides stercoralis may remain asymptomatic or with slight symptoms in humans for decades. However, immunocompromised patients, particulary those receiving long-term steroid therapy, may face hyperinfection resulting in high mortality rates. The objective was to present the first report in Cuba about a patient with chronic strongyloidiasis associated to use of oral steroids. Here is a 63 years-old asthmatic woman, who showed chronic strongyloidiasis symptoms and hyperinfection risk due to the long-term use of oral steroids. The symptoms and physical examination were described as well as various diagnostic tests. Predisposing factors for the onset and development of the disease were discussed. Laboratory diagnosis confirmed the presence of Strongyloides stercoralis rabditoid larvae in the patient's feces. Although there has been evidence of fatal cases with chronic strongyloidiasis associated with long-term use of steroids in the international literature, such reports are rare in Cuba. Additionally, it is likely that timely diagnosis and treatment have contributed to avoid fatal complications in this patient(AU)

Strongyloides stercoralis hyperinfection: an unusual cause of gastrointestinal bleeding / Hiperinfecção por Strongyloides stercoralis: uma causa incomum de hemorragia digestiva

SummaryStrongyloidiasis is a parasitic disease that may progress to a disseminated form, called hyperinfection syndrome, in patients with immunosuppression. The hyperinfection syndrome is caused by the wide multiplication and migration of infective larvae, with characteristic gastrointestinal and/or pulmonary involvement. This disease may pose a diagnostic challenge, as it presents with nonspecific findings on endoscopy.

ResumoHiperinfecção por Strongyloides stercoralis: uma causa incomum de hemorragia digestiva A estrongiloidíase é uma parasitose que pode evoluir para uma forma disseminada, denominada síndrome de hiperinfecção, nos pacientes em estados de imunossupressão. A síndrome de hiperinfecção é ocasionada pela grande multiplicação e migração de larvas infectantes, com envolvimento gastrointestinal e/ou pulmonar característico. Essa doença pode representar um desafio diagnóstico, pois apresenta- se em achados inespecíficos à endoscopia.

Comorbid Gastric Adenocarcinoma and Gastric and Duodenal Strongyloides stercoralis Infection: A Case Report

Strongyloides stercoralis can cause systemic infection, termed strongyloidiasis, and gastrointestinal ulcer disease in immunocompromised patients. However, to our knowledge, there are no reported cases of comorbid gastric adenocarcinoma and S. stercoralis infection. Here, we report a case of an 81-year-old Korean man who presented with S. stercoralis infection coexisting with early gastric adenocarcinoma (T1aN0M0). S. stercoralis eggs, rhabditiform larvae, and adult females were observed in normal gastric and duodenal crypts. They were also observed in atypical glands representative of adenocarcinoma and adenoma. Preliminary laboratory tests revealed mild neutrophilic and eosinophilic leukocytosis. A routine stool test failed to detect rhabditiform larvae in the patient's fecal sample; however, S. stercoralis was identified by PCR amplification and 18S rRNA sequencing using genomic DNA extracted from formalin-fixed paraffin-embedded tissues. Postoperatively, the patient had a persistent fever and was treated with albendazole for 7 days, which alleviated the fever. The patient was followed-up by monitoring and laboratory testing for 4 months postoperatively, and no abnormalities were observed thus far. The fact that S. stercoralis infection may be fatal in immunocompromised patients should be kept in mind when assessing high-risk patients.

Comorbid Gastric Adenocarcinoma and Gastric and Duodenal Strongyloides stercoralis Infection: A Case Report

Strongyloides stercoralis can cause systemic infection, termed strongyloidiasis, and gastrointestinal ulcer disease in immunocompromised patients. However, to our knowledge, there are no reported cases of comorbid gastric adenocarcinoma and S. stercoralis infection. Here, we report a case of an 81-year-old Korean man who presented with S. stercoralis infection coexisting with early gastric adenocarcinoma (T1aN0M0). S. stercoralis eggs, rhabditiform larvae, and adult females were observed in normal gastric and duodenal crypts. They were also observed in atypical glands representative of adenocarcinoma and adenoma. Preliminary laboratory tests revealed mild neutrophilic and eosinophilic leukocytosis. A routine stool test failed to detect rhabditiform larvae in the patient's fecal sample; however, S. stercoralis was identified by PCR amplification and 18S rRNA sequencing using genomic DNA extracted from formalin-fixed paraffin-embedded tissues. Postoperatively, the patient had a persistent fever and was treated with albendazole for 7 days, which alleviated the fever. The patient was followed-up by monitoring and laboratory testing for 4 months postoperatively, and no abnormalities were observed thus far. The fact that S. stercoralis infection may be fatal in immunocompromised patients should be kept in mind when assessing high-risk patients.

Fulminant gastrointestinal hemorrhage due to Strongyloides stercoralis hyperinfection in an AIDS patient

Strongyloides stercoralis is an endemic nematode to tropical and subtropical regions of the globe. The parasite is capable of autoinfection, which is limited by an intact immune response. In immunocompromised hosts, hyperinfection and dissemination can occur and have a high index of mortality. A hyperinfection syndrome with dissemination is frequently associated with corticosteroid administration and other conditions (malignancies and organ transplantation). Interestingly, although strongyloidiasis is common among AIDS patients in endemic areas, the hyperinfection syndrome is rarely noted. We report here on a rare manifestation of fulminant gastrointestinal hemorrhage due to hyperinfection of strongyloidiasis in a female drug-abusing, alcoholic HIV/AIDS patient.

Spectrum of malabsorption syndrome among adults & factors differentiating celiac disease & tropical malabsorption.

Background & objectives: Aetiology of malabsorption syndrome (MAS) differs in tropical and temperate countries over time; clinical and laboratory parameters may differentiate between various causes. This study was undertaken to investigate the spectrum of MAS among Indian adults and to find out the features that may help to differentiate between TM and celiac disease. Methods: Causes of MAS, and factors differentiating tropical malabsorption (TM) from celiac disease (CD) were determined in 275 patients. Results: Using standard criteria, causes in 275 patients [age 37.5+13.2 yr, 170, (61.5%) male] were, TM 101 (37%), CD 53 (19%), small intestinal bacterial overgrowth 28 (10%), AIDS 15 (5.4%), giardiasis 13 (5%), hypogammaglobulinemia 12 (4%), intestinal tuberculosis 7 (2.5%), strongyloidiasis 6 (2%), immunoproliferative small intestinal disease 5 (2%), Crohn's disease 6 (2%), amyloidosis 4 (1.5%), intestinal lymphangiectasia 3 (1%) and unknown 22 (8%). On univariate analysis, patients with CD were younger than TM (30.6+12 vs. 39.3+12.6 yr, P<0.001), had lower body weight (41.3+11.8 vs. 49.9+11.2 kg, P<0.001), longer diarrhoea duration (median 36 inter-quartile range 17.8-120 vs. 24-months, 8-48, P<0.01), lower stool frequency (6/day, 5-8 vs. 8, 5-10, P<0.05), lower haemoglobin (9.4+3.2 vs. 10.4+2.7 g/dl, P<0.05), higher platelet count (2,58,000, range 1,35,500-3,23,500 vs. 1,60,000, 1,26,000-2,58,000/mm3, P<0.05), and more often had hepatomegaly (9/53, 17% vs. 4/101, 4%, P<0.01), and subtotal or partial villous atrophy (36/50, 72% vs. 28/87, 32%, P<0.001). Younger age (<35 yr), longer diarrhoea duration, higher platelet count and villous atrophy were significant on multivariate analysis. Interpretation & conclusions: TM and CD are common causes of MAS among Indian adults. Younger age (<35 yr), longer diarrhoea duration, higher platelet count and villous atrophy were found to be associated with CD.

Falla orgánica múltiple por estrongiloidiasis diseminada: Comunicación de un caso / Multiple-organ dysfunction caused by dissemination of Strongyloides stercoralis infection: A case report

We report here the case of a 50-year-old male patient, from a rural setting, with past history of alcoholism. He was admitted in the Intensive Care Unit due to a worsening health status after a febrile syndrome of 25 days. In addition, he had diarrhea, intense muscle ache predominantly on upper extremities and abdomen, weight loss, confusion, seizures, psychomotor agitation, tachycardia, tachipnea, anuria, septic shock, coma, and multiple-organ dysfunction syndrome. The hyperinfection syndrome caused by Strongyloides stercoralis was suspected because of severe eosinophilia (52 percent of peripheral blood leukocytes). This diagnosis was verified by the parasitological examination of stool samples by direct wet mount and Baermann techniques. Treatment with thiabendazole at 25 mg/kg per day was started, as well as cefepime, vasoactive drugs, artificial mechanic ventilation, and hemodialysis. The patient died 12 hours after admission, probably due to secondary infection with Escherichia coli.

Se presenta el caso de un paciente masculino, de 50 años, con antecedentes de alcoholismo, procedente de área rural, que ingresó en la Unidad de Cuidados Intensivos por agravamiento de su estado general después de un síndrome febril de 25 días de evolución, presentando shock séptico, coma y falla orgánica múltiple. Se sospechó un síndrome de hiperinfección por Strongyloides stercoralis ante la presencia de una eosinofilia importante (52%), diagnóstico que fue confirmado con el examen parasitológico de las heces. Se inició tratamiento con tiabendazol a 25 mg/ kg al día, cefepima, fármacos vasoactivos, ventilación mecánica y hemodiálisis. Falleció 12 horas después del ingreso, posiblemente a causa de una infección secundaria por Escherichia coli.

A Case of Steroid-induced Hyperinfective Strongyloidiasis with Bacterial Meningitis / 대한소화기학회지

Strongyloides stercoralis is a soil transmitted intestinal nematode that is endemic in the tropical and subtropical regions. In most individuals who are infected, chronic, usually asymptomatic, gastrointestinal infection persists. But, in immunocompromized hosts or in patients receiving immunosuppressive therapy, autoinfection of S. stercoralis may result in the dissemination of larvae, leading to fatal hyperinfection and increased rate of complications. We report a case of hyperinfective strongyloidiasis with bacterial meningitis in a patient receiving steroid therapy. Strongyloidiasis was diagnosed by the presence of filariform larvae of S. stercoralis in the bronchoalveolar lavage cytology and upper gastrointestinal endoscopic biopsy specimen. Her clinical symptoms had progressively aggravated and developed bacterial meningitis during treatment. She died despite aggressive antibiotic and antihelminthic therapy.

Staphylococcus warneri meningitis in a patient with Strongyloides stercoralis hyperinfection and lymphoma: first report of a case / Staphylococcus warneri meningite em paciente com hiperinfecção com Strongyloides stercoralis e linfoma: primeiro relato de caso

A case of meningitis due to Staphylococcus warneri in a patient with a hyperinfection with Strongyloides stercoralis possibly associated with rituximab treatment for mantel cell lymphoma is reported for the first time in the literature. The patient was a 59-year-old woman, with a 3-year history of an apparently well controlled lymphoma after treatment with chemotherapy-immunotherapy and then immunotherapy alone, and diagnosis of strongyloidiasis. Meningitis was diagnosed by cerebrospinal fluid culture and tested with an automated plate system. The patient was successfully treated with vancomycin; although fever and productive cough persisted. Severe gastrointestinal symptoms and pneumonia developed three weeks later. Hyperinfection syndrome by S. stercoralis was diagnosed, with abundant larvae in feces and expectoration.

Caso de meningite por Staphylococcus warneri em paciente com hiperinfecção com Strongyloides stercoralis, possivelmente associada com tratamento de rituximab para linfoma de células do manto é relatada pela primeira vez na literatura. A paciente, mulher de 59 anos com história de três anos de linfoma aparentemente bem controlado com tratamento com quimioterapia-imunoterapia e, em seguida, somente imunoterapia e diagnóstico de estrongiloidíase. Meningite foi diagnosticada por cultura do líquido cefalorraquidiano e testada com sistema automatizado de placa. A paciente foi tratada com sucesso com vancomicina, embora a febre e a tosse produtiva não tenham desaparecido. Após graves sintomas gastrointestinais a paciente desenvolveu pneumonia três semanas mais tarde. Síndrome de hiperinfecção por S. stercoralis foi diagnosticada, com larvas abundantes nas fezes e expectoração.

Efeito da infecção com Strongyloides venezuelensis no desenvolvimento da encefalite autoimune (EAE) / Effect of infection with Strongyloides venezuelensis in the development of experimental autoimmune encephalitis (EAE)

A esclerose múltipla (EM) é uma doença inflamatória, crônica e desmielinizante do sistema nervoso central (SNC). A caracterização de uma estratégia profilática e/ou terapêutica na EM é necessária, já que não há cura para essa doença. No contexto da hipótese da higiene, a exposição diminuída a certos agentes infecciosos como os helmintos, os lactobacilos e as micobactérias saprófitas estaria relacionada com o aumento na incidência de doenças alérgicas e autoimunes. Assim, o objetivo deste trabalho foi caracterizar a infecção por Strongyloides venezuelensis em ratos Lewis e avaliar se a mesma modula as características clínicas, imunológicas e histopatológicas da encefalite autoimune experimental (EAE) nestes animais. Na primeira etapa, caracterizamos as fases aguda e de recuperação da infecção e avaliamos os padrões de resposta imune nestas duas fases. Na segunda etapa, avaliamos o efeito de uma ou várias infecções com S. venezuelensis na evolução da EAE. Os animais foram avaliados diariamente quanto ao peso e escore clínico da doença e a eutanásia foi realizada na fase de recuperação da EAE para avaliação da resposta imune (produção de citocinas e anticorpos) e do processo inflamatório no SNC. A frequência de células T CD4+CD25+Foxp3+ no baço e nos linfonodos (inguinais e poplíteos) também foi determinada após infecção única (fase aguda e de recuperação) ou múltipla com este helminto. De acordo com os diversos parâmetros avaliados, os resultados demonstraram que a infecção com S. venezuelensis não modificou a progressão da EAE em ratos Lewis e também não alterou a frequência de células T CD4+CD25+Foxp3+ nos órgãos linfóides secundários...

Infecciones en pacientes hospitalizados por cirrosis / Infections in hospitalized patients with cirrhosis

Evaluamos la prevalecencia y relevancia clínica de las infecciones bacterianas y no bacterianas en pacientes cirróticos predominantemente alcohólicos internados en un hospital de mediana complejidad, y comparamos las características clínicas, de laboratorio y la evolución de pacientes con y sin infección bacteriana en un estudio prospectivo de cohorte. Se incluyeron 211 internaciones consecutivas de 132 pacientes con diagnóstico de cirrosis, de abril 2004 a julio 2007. El promedio de edad (±DS) fue 51.8 (±8) años, 112 fueron hombres (84.8%); etiología alcohólica 95.4%. Se diagnosticaron 129 episodios de infecciones bacterianas en 99/211 (46.9%) internaciones, adquiridos en la comunidad 79 (61.2%) y 50 (38.8%) intrahospitalarios: peritonitis bacteriana espontánea (23.3%); infección urinaria (21.7%); neumonías (17.8%); infecciones de piel y partes blandas (17.1%); sepsis por bacteriemia espontánea (7.7%); otras infecciones bacterianas (12.4%). El 52.2% fueron por gérmenes gram-positivos. Hubo ocho casos de tuberculosis e infecciones graves por hongos y parásitos. La prevalecencia de tuberculosis fue del 6% con una mortalidad anual de 62.5%. El 28.1% (9/32) de los exámenes coproparasitológicos tuvieron Strongyloides stercolaris. La mortalidad hospitalaria fue mayor en los pacientes con infección bacteriana (32.4% vs. 13.2%; p=0.02). Fueron identificados como predictores independientes de mortalidad: las infecciones bacterianas, el score de Child-Pügh y creatininemia > 1.5 mg/dl. En el análisis multivariado fueron factores independientes asociados a infección bacteriana la leucocitosis y la encefalopatía hepática grado III/IV. Este estudio confirma que las infecciones bacterianas y no bacterianas son una complicación frecuente y grave en pacientes cirróticos internados, con un aumento de la mortalidad hospitalaria.

We evaluated the prevalence and the clinical relevance of bacterial and nonbacterial infections in predominantly alcoholic cirrhotic patients, admitted to an intermediate complexity hospital, and we also compared the clinical characteristics, laboratory and evolution of these patients with and without bacterial infection in a prospective study of cohort. A total of 211 consecutive admissions in 132 cirrhotic patients, between April 2004 and July 2007, were included. The mean age was 51.8 (±8) years, being 84.8% male. The alcoholic etiology of cirrhosis was present in 95.4%. One hundred and twenty nine episodes of bacterial infections were diagnosed in 99/211 (46.9%) admissions, community- acquired in 79 (61.2%) and hospital-acquired in 50 (38.8%): spontaneous bacterial peritonitis (23.3%); urinary tract infection (21.7%); pneumonia (17.8%); infection of the skin and soft parts (17.1%), sepsis by spontaneous bacteremia (7.7%); other bacterial infections (12.4%). Gram-positive organisms were responsible for 52.2% of total bacterial infections documented cases. There were eight serious cases of tuberculosis, fungal and parasitic infections; the prevalence of tuberculosis was 6% with an annual mortality of 62.5%; 28.1% (9/32) of the coproparasitological examination had Strongyloides stercolaris. The in-hospital mortality was significantly higher in patients with bacterial infection than in non-infected patients (32.4% vs. 13.2%; p=0.02). The independent factors associated with mortality were bacterial infections, the score of Child-Pügh and creatininemia > 1.5 mg/dl. By the multivariate analysis, leukocytosis and hepatic encephalopathy degree III/IV were independent factors associated to bacterial infection. This study confirms that bacterial and nonbacterial infections are a frequent and severe complication in hospitalized cirrhotic patients, with an increase of in-hospital mortality.

A Case of Fatal Strongyloidiasis in a Patient with Chronic Lymphocytic Leukemia and Molecular Characterization of the Isolate

Strongyloides stercoralis is a human intestinal parasite which may lead to complicated strongyloidiasis in immunocompromised. Here, a case of complicated strongyloidiasis in a patient with chronic lymphocytic leukemia is reported. Presence of numerous S. stercoralis larvae in feces and sputum confirmed the diagnosis of hyperinfection syndrome in this patient. Following recovery of filariform larvae from agar plate culture of the stool, the isolate was characterized for the ITS1 region of ribosomal DNA gene by nested-PCR and sequencing. Albendazole therapy did not have cure effects; and just at the beginning of taking ivermectin, the patient died. The most important clue to prevent such fatal consequences is early diagnosis and proper treatment.

Severe and treatment resistant strongyloidiasis--indicator of HTLV-I infection.

The association between severe and persistent strongyloidiasis with human T cell lymphotropic virus type I (HTLV-1) infection is well documented in reports from HTLV-1 endemic regions like Japan and Jamaica. But there are no reports from non-endemic areas like India. We report a case of severe intestinal strongyloidiasis in a 45-year old Keralite man, living in Sikkim. Despite standard treatment with many courses of albendazole, his stool persistently showed Strongyloides stercoralis larvae. In the absence of other immunosuppressive conditions, human T cell lymphotropic virus type I infection was considered and determined positive. Subsequently, treatment with 2 courses of ivermectin achieved eradication of the infection. On follow-up, 3 years later, his stools again revealed Strongyloides stercoralis larvae.

Syndrome of inappropriate secretion of antidiuretic hormone associated with strongyloidiasis.

We report a case of syndrome of inappropriate secretion of antidiuretic hormone (SIADH) with accompanying severe strongyloidiasis in a 52-year-old male. On admission, he showed drowsiness and emaciation with severe hyponatremia. We gave sodium (saline or salts) in an i.v. drip infusion and orally without improvement. A urinalysis and plasma osmotic pressure test indicated SIADH, therefore, treatment was changed to restrict his sodium intake. The hyponatremia gradually improved initially, but the appetite loss, nausea, and hyponatremia continued. Endoscopy revealed white patches on the stomach wall and histopathological examination revealed infestation of the mucosal epithelium with numerous Strongyloides stercoralis larvae. Ivermectin treatment was then initiated and the abdominal symptoms and hyponatremia gradually resolved. We carefully investigated the underlying cause of the SIADH, such as disease of the central nervous system, lung cancer, and other malignancies, but no abnormality or clear cause could be found. We concluded that the patient developed SIADH secondary to severe S. stercoralis infection.

Strongyloidosis hyperinfection in a neutropenic host diagnosed by bronchoalveolar lavage.

Opportunistic disseminated strongyloidosis is an important cause of morbidity and mortality in immunocompromised patients. In addition to a high index of clinical suspicion, alerting the microbiologist will help in diagnosing this condition early and institute therapy. We report a 51-year-old male who developed pulmonary infiltrates during the period of chemotherapy-induced neutropenia. Strongyloidosis larvae were found on bronchoalveolar lavage fluid and stool specimens. The patient responded to treatment with albendazole.