Coinfection with Strongyloides and SARS-CoV-2: A Systematic Review.

BACKGROUND: Treatments for COVID-19, including steroids, might exacerbate Strongyloides disease in patients with coinfection. We aimed to systematically review clinical and laboratory features of SARS-CoV-2 and Strongyloides coinfection, investigate possible interventions, assess outcomes, and identify research gaps requiring further attention. METHODS: We searched two electronic databases, LitCOVID and WHO, up to August 2022, including SARS-CoV-2 and Strongyloides coinfection studies. We adapted the World Health Organization-Uppsala Monitoring Centre (WHO-UMC) system for standardized case causality assessment to evaluate if using corticosteroids or other immunosuppressive drugs in COVID-19 patients determined acute manifestations of strongyloidiasis. RESULTS: We included 16 studies reporting 25 cases of Strongyloides and SARS-CoV-2 coinfection: 4 with hyperinfection syndrome; 2 with disseminated strongyloidiasis; 3 with cutaneous reactivation of strongyloidiasis; 3 with isolated digestive symptoms; and 2 with solely eosinophilia, without clinical manifestations. Eleven patients were asymptomatic regarding strongyloidiasis. Eosinopenia or normal eosinophil count was reported in 58.3% of patients with Strongyloides reactivation. Steroids were given to 18/21 (85.7%) cases. A total of 4 patients (19.1%) received tocilizumab and/or Anakirna in addition to steroids. Moreover, 2 patients (9.5%) did not receive any COVID-19 treatment. The causal relationship between Strongyloides reactivation and COVID-19 treatments was considered certain (4% of cases), probable (20% of patients), and possible (20% of patients). For 8% of cases, it was considered unlikely that COVID-19 treatment was associated with strongyloidiasis reactivations; the relationship between the Strongyloides infection and administration of COVID-19 treatment was unassessable/unclassifiable in 48% of cases. Of 13 assessable cases, 11 (84.6%) were considered to be causally associated with Strongyloides, ranging from certain to possible. CONCLUSIONS: Further research is needed to assess the frequency and risk of Strongyloides reactivation in SARS-CoV-2 infection. Our limited data using causality assessment supports recommendations that clinicians should screen and treat for Strongyloides infection in patients with coinfection who receive immunosuppressive COVID-19 therapies. In addition, the male gender and older age (over 50 years) may be predisposing factors for Strongyloides reactivation. Standardized guidelines should be developed for reporting future research.

Ivermectin Effect on In-Hospital Mortality and Need for Respiratory Support in COVID-19 Pneumonia: Propensity Score-Matched Retrospective Study.

INTRODUCTION: There is negligible evidence on the efficacy of ivermectin for treating COVID-19 pneumonia. This study aimed to assess the efficacy of ivermectin for pre-emptively treating Strongyloides stercoralis hyperinfection syndrome in order to reduce mortality and the need for respiratory support in patients hospitalized for COVID-19. METHODS: This single-center, observational, retrospective study included patients admitted with COVID-19 pneumonia at Hospital Vega Baja from 23 February 2020 to 14 March 2021. Because strongyloidiasis is endemic to our area, medical criteria support empiric administration of a single, 200 µg/kg dose of ivermectin to prevent Strongyloides hyperinfection syndrome. The outcome was a composite of all-cause in-hospital mortality and the need for respiratory support. RESULTS: Of 1167 patients in the cohort, 96 received ivermectin. After propensity score matching, we included 192 patients. The composite outcome of in-hospital mortality or need for respiratory support occurred in 41.7% of the control group (40/96) and 34.4% (33/96) of the ivermectin group. Ivermectin was not associated with the outcome of interest (adjusted odds ratio [aOR] 0.77, 95% confidence interval [CI] 0.35, 1.69; p = 0.52). The factors independently associated with this endpoint were oxygen saturation (aOR 0.78, 95% CI 0.68, 0.89, p < 0.001) and C-reactive protein at admission (aOR: 1.09, 95% CI 1.03, 1.16, p < 0.001). CONCLUSIONS: In hospitalized patients with COVID-19 pneumonia, ivermectin at a single dose for pre-emptively treating Strongyloides stercoralis is not effective in reducing mortality or the need for respiratory support measures.

Investigating intestinal parasitic infections with emphasis on molecular identification of Strongyloides stercoralis and Trichostrongylus colubriformis in north of Iran.

Currently, parasitic infections are one of the important health problems in the world, especially in developing countries. This study aims to investigate intestinal parasites with an emphasis on molecular identification through the analysis of mitochondrial COX1 and ITS2 gene sequences of Strongyloides stercoralis (S. stercoralis) and Trichostrongylus spp. in north of Iran. Five hundred forty stool samples were collected from medical diagnostic laboratories affiliated with Mazandaran University of Medical Sciences in Sari city, north of Iran. First, all the samples were examined using direct smear, formalin-ether sedimentation, and trichrome staining technique. Suspected samples of Strongyloides larvae were cultured in agar plate. Then, DNA was extracted from samples containing Trichostrongylus spp. eggs and Strongyloides larvae. To amplify DNA, PCR was performed and the samples with a sharp band in electrophoresis were sequenced by Sanger method. Overall, the prevalence of parasitic infections in the study population was 5.4%. The highest and the lowest level of infection was observed with Trichostrongylus spp. and S. stercoralis at 3% and 0.2%, respectively. No traces of live Strongyloides larvae were seen in the culture medium of the agar plate. The six isolates obtained from the amplification of the ITS2 gene of Trichostrongylus spp. were sequenced, all of which were Trichostrongylus colubriformis. The sequencing results of COX1 gene indicated S. stercoralis. In the present study, the prevalence of intestinal parasitic infections in north of Iran has relatively decreased that its main reason can be due to the coronavirus epidemic and compliance with health principles. However, the prevalence of Trichostrongylus parasite was relatively high that it requires special attention to apply appropriate control and treatment strategies in this field.

Sars-CoV-2 and human strongyloidiasis

The Sars-CoV-2, the virus that causes Covid-19 (coronavirus disease 2019), is highly transmissible and of rapid dissemination, and transmitted by respiratory droplets and by direct contact, which can cause respiratory failure and reach multiple organs. Although there is still no effective treatment for the disease, the use of corticosteroids has shown positive results in patients with severe Covid-19, such as dexamethasone, which acts as an immunosuppressant to control cytokine storm syndrome (CSS). In this review, we will abroad the challenge of establishing a balance between risk and benefit in corticosteroid therapy in severe cases of the disease, since corticosteroids can activate the latent infection by Strongyloides stercoralis and develop the critical form of strongyloidiasis, the Strongyloides stercoralis hyperinflation syndrome (SHS). For these circumstances, screening and empirical treatment with ivermectin is recommended for those patients at moderate to high risk of hyperinfection. The keywords used were "Strongyloides" AND "Covid" and the searched databases were PubMed, Scopus, and Web of Science. The selected articles were published from 2020 to 2021 and without language restriction.Copyright © 2022 Sociedade Brasileira de Pneumologia e Tisiologia. All rights reserved.

Larva currens secondary to corticotherapy. Case report.

The infection by the new coronavirus (SARS-CoV-2) had in its beginnings a debated treatment, due to the unknown about its pathogenesis, which with the passage of time was clarified evidencing an inflammatory component. Corticosteroid therapy showed as a therapeutic option. In patients with corticosteroids it is essential to know the possible side reactions due to their immunosuppressive effect. We present the case of a 48-year-old male from Ecuador, who after infection by SARSCoV- 2 treated with corticosteroids, suffering as a complication the appearance of a serpiginous rash in the lumbar region. Due to its migratory history, serology for Strongyloides stercoralis, the diagnosis of currens larva was confirmed.Copyright © 2023 Sociedad Madrinela de Neumologia y Cirugia Toracica. All rights reserved.

Strongyloides stercoralis: A Neglected but Fatal Parasite.

Strongyloidiasis is a disease caused by Strongyloides stercoralis and remains a neglected tropical infection despite significant public health concerns. Challenges in the management of strongyloidiasis arise from wide ranging clinical presentations, lack of practical high sensitivity diagnostic tests, and a fatal outcome in immunocompromised hosts. Migration, globalization, and increased administration of immunomodulators, particularly during the COVID-19 era, have amplified the global impact of strongyloidiasis. Here, we comprehensively review the diagnostic tests, clinical manifestations, and treatment of strongyloidiasis. The review additionally focuses on complicated strongyloidiasis in immunocompromised patients and critical screening strategies. Diagnosis of strongyloidiasis is challenging because of non-specific presentations and low parasite load. In contrast, treatment is simple: administration of single dosage ivermectin or moxidectin, a recent anthelmintic drug. Undiagnosed infections result in hyperinfection syndrome and disseminated disease when patients become immunocompromised. Thus, disease manifestation awareness among clinicians is crucial. Furthermore, active surveillance and advanced diagnostic tests are essential for fundamental management.

Strongyloides and COVID-19: Challenges and Opportunities for Future Research.

Strongyloides stercoralis is a soil transmitted helminth endemic to tropical and subtropical areas that can persist for decades in immunocompetent human hosts as a chronic asymptomatic infection. The use of corticosteroids, a mainstay of treatment for patients hospitalized with severe coronavirus disease (COVID-19), can trigger a life-threatening Strongyloides hyperinfection syndrome and disseminated disease. We identified 22 previously published cases of strongyloidiasis occurring in individuals with COVID-19, with one death reported among the seven patients who had Strongyloides hyperinfection syndrome. A total of seventeen patients had previously received corticosteroids, and of the five with no prior corticosteroid use, one presented with hyperinfection syndrome. We identify the key challenges in the diagnosis and treatment of Strongyloides within the context of COVID-19, including our imprecise knowledge of the global distribution of Strongyloides, the overlapping symptoms and signs of COVID-19 and Strongyloides hyperinfection syndrome, the limited utility of eosinophilia as a clinical marker for strongyloidiasis in this setting, the lack of validated algorithms to screen for Strongyloides prior to corticosteroid use, and the paucity of treatment options for critically ill patients with COVID-19 who cannot take oral ivermectin. Future research should focus on improved diagnostic methods and population prevalence estimates, optimizing the approaches for Strongyloides screening in persons with COVID-19 (including clinical trial participants and strategies for resource-limited settings) and better defining the role of pre-emptive treatment.

Strongyloidiasis Hyperinfection Syndrome in COVID-19 Positive Migrants Treated with Corticosteroids.

The aim of this study is to highlight the potentially fatal risk of Strongyloidiasis Hyperinfection Syndrome for hospitalized immigrant patients with moderate to severe COVID-19 disease and undiagnosed Strongyloidiasis. We reviewed electronic medical records of immigrants from 2010 to 2022 and extracted the number of patients with eosinophilia, strongyloidiasis and COVID-19 infection, outpatient and hospitalized. While 885 outpatients were diagnosed with eosinophilia, only 356 (40.2%) were tested for strongyloidiasis and 160 (44.9%) yielded a reactive serology. COVID-19 infection was reported in 6,412 patients. 1135 (17.7%) of these patients sought hospital care. Patients with undiagnosed strongyloidiasis are at risk for a potentially fatal parasitosis if treated with systemic corticosteroids for COVID-19. This supports clinical guidelines in hospital settings for those with severe COVID-19. Strongyloidiasis should be considered by taking a thorough travel or migration history and testing before giving immunosuppressive drugs.

Strongyloides: a Minireview and Update

Strongyloidiasis, typically caused by Strongyloides stercoralis, is a neglected tropical disease that affects 30 to 100 million people worldwide. Despite the commonly asymptomatic nature of the infection, S. stercoralis infection of immunocompromised individuals can be lethal. Infected but asymptomatic immunocompetent individuals can develop hyperinfection or disseminated infection if they experience any significant change in their immune status, and recently, cases have been described following the use of corticosteroids to treat COVID-19-related pneumonia. Definitive diagnosis is established via stool examination for rhabditiform larvae;however, contemporary methods, including serologic and molecular testing, are increasingly used as adjunct tests. Importantly, exposed individuals and those expected to become immunosuppressed should be screened and pre-emptively treated before starting immunosuppressive agents to avoid cases of dissemination and hyperinfection. Copyright © 2022 Elsevier Inc.

DYSPNEIC AFTER EVERY COVID-19 SHOT: SUSPECTED BNT162B2 MRNA VACCINE-RELATED, DRUG-INDUCED PULMONARY EOSINOPHILIA

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Eosinophilia is the most commonly reported adverse event following administration of the Pfizer/BioNTech vaccine, accounting for 237 of 372 events (63.7%). Eosinophilic pneumonia has been described noted in 3 of all reported cases. CASE PRESENTATION: We present the case of a 73 year-old male presented to his PCP with a 3 week history of nonproductive cough and wheezing. He completed a 2-shot series of BNT162b2 mRNA (Pfizer/BioNTech) COVID vaccine 1 week prior to symptom onset. He had no history of respiratory symptoms, smoking, sick contacts, recent travel, chemical or biological exposures. On presentation, he was afebrile, tachycardic and required 3LPM supplemental oxygen to maintain peripheral oxygen saturation (SpO2) above 94%. Laboratory findings noted leukocytosis (13,200/mL) and eosinophilia at 5% (Absolute Eosinophil Count (AEC): 580 cells/L). Respiratory viral panel, procalcitonin, ESR and D-dimer were negative. Chest CT scan was unremarkable. He was treated with azithromycin, prednisone and inhaled bronchodilators with improvement in hypoxia. 2 weeks later, he reported intermittent dyspnea during a pulmonary clinic visit. Pulmonary function testing was normal (FEV1/FVC: 76%;FVC: 3.67L (90% predicted);FEV1: 2.80L (88% predicted). IgE level was normal and eosinophilia had resolved. 6 months after initial symptom onset, the patient received his third BNT162b2 mRNA vaccine dose. 2 weeks after vaccination, he presented to the ED with severe dyspnea, wheezing and cough with yellow sputum. He also noted a new itchy, erythematous bilateral forearm rash and painless oral ulcers. On exam, he was afebrile, tachypneic with SpO2 of 93% on 4LPM supplemental oxygen and audibly wheezing with a prolonged expiratory phase. Laboratory studies noted elevated creatinine and leukocytosis (23,100/mL) with marked eosinophilia (29.5 %, AEC: 6814 cells/L). Chest CT scan revealed a 2 cm rounded ground-glass opacity in the right upper lobe. (Figure 1.) Further workup revealed a weakly positive antihistone antibody (1:4 titer). IgE, ANA, ANCA, SS-A/B, anti-CCP, and complement levels were normal. Intravenous methylprednisolone treatment was initiated with rapid improvement in dyspnea, eosinophilia and renal function. A transbronchial biopsy (Figure 2.) of the RUL lung lesion revealed organizing pneumonia with mixed inflammatory infiltrate. Bronchoalveolar lavage analysis revealed elevated WBC (432 cells/L) with neutrophilic predominance (85%). Patient was discharged home on a prednisone taper with resolution of symptoms. DISCUSSION: Subsequent allergy work up did not indicate any apparent etiology of hypereosinophilia. Testing for strongyloides, coccidiosis and aspergillosis were also negative. A final diagnosis of BNT162b2 mRNA vaccine related pulmonary eosinophilia was made. CONCLUSIONS: Additional study is warranted into eosinophilic disease associated with the BNT162b2 mRNA vaccine. Reference #1: 1. United States Department of Health and Human Services (DHHS), Public Health Service (PHS), Centers for Disease Control (CDC) / Food and Drug Administration (FDA), Vaccine Adverse Event Reporting System (VAERS) 1990 - 03/11/2022, CDC WONDER On-line Database. Accessed at http://wonder.cdc.gov/vaers.html on Mar 11, 2022 1:18:37 PM DISCLOSURES: No relevant relationships by Matthew Haltom No relevant relationships by Nikky Keer No relevant relationships by Thekrayat Khader No relevant relationships by Muthiah Muthiah

A Rare Presentation of Strongyloides stercoralis Infection from an Immunocompetent Individual in a Tertiary Care Center in South India

Strongyloidiasis is a neglected parasitic disease caused by the intestinal parasite, Strongyloides stercoralis. Most patients with strongyloidiasis are asymptomatic, but few present with varied clinical manifestations such as cutaneous, gastrointestinal, pulmonary, and disseminated disease. It creates a diagnostic dilemma and undue delay in the diagnosis of patients. We report the case of a 79-yearold male who presented with fever and abdominal pain due to strongyloidiasis with no history of immunosuppression. The infection resolved entirely on treatment with ivermectin.

Improving the Care of Newly Arrived Immigrant Patients in Two Primary Care Clinics

Purpose/Objectives: 1) To design and implement a clinical pathway that delineates evidence-based recommendations of screening for newly arrived immigrant children in an academic primary care setting. 2) To improve adherence to recommended biomedical and infectious screening by providers caring for newly arrived immigrant children. 3) To evaluate the effectiveness of the clinical pathway and adjunct tools to support uptake and adherence to the pathway with a goal of achieving 90% adherence to key indicators in 18 months. Design/Methods: A clinical pathway for primary care of newly arrived immigrant children was developed and implemented based on existing evidence from immigrant and refugee populations, delineating recommended psychosocial, developmental, biomedical, and infectious screenings by region of origin. Adjuncts to support uptake were implemented, including an EMR order-set and note template. Faculty and resident education to the pathway was conducted in person and with pre-recorded educational presentations. Indicators of adherence were defined as the percentage of patients who obtained the recommended screening tests according to their world region of origin. Results: A total of 301 newly arrived immigrant patients were seen at the clinics during our observation period (from Dec 2018-May 2021);190 (63%) were seen after the rollout of our main interventions in August 2019, and 70 (23%) were seen after the onset of the COVID-19 pandemic in March 2020. We observed an improvement in the % of patients who obtained lead level, Complete Blood Count (CBC) with differential, Strongyloides, and Tuberculosis screening on their first visit in the U.S. following the introduction of the clinical pathway and order-set (Images 1 and 2). There have been six consecutive points above the mean in the case of lead level and Tuberculosis screening. In the case of Strongyloides screening, a mean shift was observed months after the implementation of the pathway. On average, 74% of the ordered screening tests for these patients were entered using the order-set. The COVID-19 pandemic impacted the number of new patients in both clinics from April 2020-Sep 2020. Periodical reminders and continuous education to providers also have proved beneficial to our goals. Conclusion/Discussion: Implementation of a clinical pathway for the care of newly arrived immigrant children resulted in improvements in adherence to region-specific recommendations for biomedical and infectious screenings;specifically for lead, CBC with differential, Strongyloides, and Tuberculosis screening. Implementation of an order-set embedded in the electronic medical records system was a successful strategy to facilitate adherence. Drastic reductions in the number of new immigrant children seeking care during the initial months of the COVID-19 pandemic raised concerns about access barriers for this vulnerable population and required strategies to remind clinicians about the use of the pathway as numbers of new immigrant patients return to baseline.

Controversies in neuroimmunology: multiple sclerosis, vaccination, SARSCoV-2 and other dilemas

Neuroimmunology is a discipline that increasingly broadens its horizons in the understanding of neurological diseases. At the same time and in front of the pathophysiological links of neurological diseases and immunology, specific diagnostic and therapeutic approaches have been proposed. Despite the important advances in this discipline, there are multiple dilemmas that concern and filter into clinical practice. This article presents 15 controversies and a discussion about them, which are built with the most up-to-date evidence available. The topics included in this review are: steroid decline in relapses of multiple sclerosis (MS), therapeutic recommendations in MS in light of the SARS-CoV2 pandemic, evidence of vaccination in MS and other demyelinating diseases, overview current situation of isolated clinical and radiological syndrome, therapeutic failure in MS as well as criteria for suspension of disease-modifying therapies, evidence of the management of mild relapses in MS, recommendations for prophylaxis against strongyloides stercolaris, usefulness of a second course of immunoglobulin in the syndrome Guillain-Barre (GBS), criteria to differentiate an acute-onset inflammatory demyelinating chronic polyneuropathy versus GBS and the utility of angiotensin-converting enzyme in neurosarcoidosis. In each of the controversies, the general problem is presented and specific recommendations are offered that can be adopted in daily clinical practice.

Diagnostic challenge of Strongyloides stercoralis hyperinfection syndrome: a case report

Strongyloides stercoralis causes chronic, mostly asymptomatic infections but hyperinfection syndrome may occur in immunosup-pressed patients, especially in those receiving corticosteroids. We report a case of S. stercoralis hyperinfection syndrome in a solid organ transplant recipient that occurred approximately 2.5 months after heart transplantation. The patient presented to the inten-sive care unit with acute respiratory distress, bacteremia, and petechial rash on abdomen and toe. Microbiology testing of respiratory samples excluded infection with Pneumocystis jirovecii, respiratory viruses, pathogenic bacteria and fungi. No eosinophilia was found. Histopathological examination of the skin biopsy of the petechial rash provided the first indication of the diagnosis, revealing the presence of isolated filariform S. stercoralis larvae in the dermis. Subsequent microbiology testing confirmed the diagnosis. This case highlights the role of histopathological examination of a skin rash in diagnosing patients with atypical clinical presentation of Strongyloides hyperinfection syndrome.

Screening for strongyloidiasis in Spain in the context of the SARS-CoV-2 pandemic: Results of a survey on diagnosis and treatment.

INTRODUCTION: The generalization of treatment with dexamethasone or other immunosuppressants in patients with SARS-CoV-2 infection may increase the risk of occurrence of severe forms of strongyloidiasis. A nationwide survey was conducted to better understand the diagnostic and therapeutic situation of strongyloidiasis in SARS-CoV-2 co-infected patients in Spain. MATERIALS AND METHODS: A survey was designed and sent to all SEIMC members during February and March 2021. Responses were exported for computer processing to Microsoft Excel 2017 and statistically processed with the free software PSPP. RESULTS: 189 responses were received, of which 121 (64%) were selected for further processing. Eighty-four centers (69.5%) had no specific strongyloidiasis screening protocol. Forty-two centers (34.7%) had serological techniques available in their laboratories and the rest were sent to a reference laboratory. Only 22 centers (18%) screened for strongyloidiasis in SARS-CoV-2 infected patients. A total of 227 cases of strongyloidiasis were diagnosed in patients with SARS-CoV-2 infection. In four cases patients developed a massive hyperinfestation syndrome leading to the death of one patient. CONCLUSION: COVID-19 has highlighted the need to unify screening and treatment protocols for imported pathologies such as strongyloidiosis. Efforts to disseminate knowledge are needed to ensure that this potentially fatal disease is adequately treated in patients with the highest risk of complications, such as those with COVID-19.

Atypical pulmonary presentation of Strongyloides stercoralis hyperinfection in a patient with philadelphia chromosome-positive acute lymphoblastic leukemia: Case report.

Strongyloides stercoralis is a soil-transmitted helminth endemic to tropical and subtropical regions and can be acquired due to parasite penetration through the skin. It can remain dormant in the gastrointestinal system for decades after the primary infection. In immunocompromised patients, this parasite can cause autoinfection with progression to hyperinfection syndrome. Here we report a unique case of pulmonary strongyloidiasis in a 32-year-old female, originally from Guatemala, with a significant clinical history of Philadelphia chromosome-positive B-cell acute lymphoblastic leukemia diagnosed in 2019. The patient is status post chemotherapy with tyrosine kinase inhibitor plus hyper-CVAD regimen (Cyclophosphamide, Vincristine sulfate, Doxorubicin hydrochloride (Adriamycin), and Dexamethasone). History of drug-induced hyperglycemia and obesity was also noted. Her current chief complaint included dyspnea, tachycardia, and chest pain. Chest computerized tomography (CT) scan showed diffuse interstitial pulmonary edema with septal thickening, scattered ground-glass opacities, and small pericardial effusion. Due to normal ejection fraction, the differential diagnosis included non-cardiogenic pulmonary edema, pneumonitis secondary to chemotoxicity, and infection. She rapidly progressed to acute hypoxic respiratory failure, and a bronchoalveolar lavage study revealed numerous larvae consistent with Strongyloides hyperinfection. Further workup revealed eosinophilia with negative Strongyloides IgG antibody. Given the rarity of this infection in the United States and the patient's place of birth, acquired latent Strongyloides infection is favored as the initial source of infection. The reactivation of the infection process was most likely secondary to her chemotherapy treatment. Strongyloides hyperinfection diagnosis can be challenging to establish and entails a high level of suspicion. Cytology evaluation is an essential factor for diagnosis.

Coinfection with Strongyloides and Ascaris in a COVID-19-positive male presenting with acute abdomen: a case report.

Ascaris lumbricoides and Strongyloides stercoralis are soil-transmitted helminthic infections usually seen in people with poor socioeconomic conditions, hygiene and fecal sanitation living in endemic countries. Here, we present a case of coinfection in a COVID-positive older adult male presenting to our facility with symptoms of acute abdomen. Investigative workup guided timely diagnosis of the case. Prompt initiation of antihelminthic drugs together with antibiotics/antivirals for COVID symptoms resulted in favorable outcome in the case. A high index of suspicion on the part of the treating and diagnosing doctor is required in the COVID era. This will help not only in diagnosis but will also give an understanding of the exact pathogenesis for better patient outcome.

Strongyloides Hyperinfection Syndrome among COVID-19 Patients Treated with Corticosteroids.

Widespread use of corticosteroids for COVID-19 treatment has led to Strongyloides reactivation and severe disease in patients from endemic areas. We describe a US patient with COVID-19 and Strongyloides hyperinfection syndrome and review other reported cases. Our findings highlight the need for Strongyloides screening and treatment in high-risk populations.

Practice Variations in Pre-Hematopoietic Stem Cell Transplantation Infectious Disease Evaluation

Background. Hematopoietic stem cell transplantation (HCT), and other forms of cellular therapies such as chimeric antigen receptor T cell therapy (CAR-T), while of critical therapeutic value, confers significant, long-term risk of infectious complications. Recipients would benefit from evaluation by infectious disease (ID) specialists. However, amidst many existing guidelines from ID and oncology societies, pre-transplant ID evaluation and management practices vary across US institutions. To better understand these variations and identify targets for standardization, we conducted a survey of ID and oncology providers at transplant centers in the US. Methods. A 38-question, anonymous, voluntary, online survey was distributed via Google Forms to a professional organization e-mail list of ID providers as well as to followers of relevant Twitter accounts. Responses were collected and analyzed. Results. A total of 51 responses were received, the majority of which (68.6%) came from ID providers. 60.8% of respondents worked at healthcare facilities with over 500 beds. 43 respondents (84.3%) reported that their center performed autologous and allogeneic HCT as well as CAR-T. 56.8% of CAR-T centers use a standardized template, compared to 70.8% of those providing HCT. For allogeneic HCT centers, 8% reported that no ID evaluation is offered;34% reported that it is offered "sometimes." Practices varied for treatment of latent tuberculosis infection prior to HCT: 26.5% treat "All the time;" 10.2% treat "Very rarely." In assessing risk factors, only 63% and 54% identified HIV infection and healthcare occupation, respectively, as epidemiologic risk factors for tuberculosis infection. 59.2% answered that < 10% of patients are screened for Strongyloides. Only 5 respondents reported universal Strongyloides screening prior to transplant. COVID-19 vaccination for family is recommended "Always" by 95.5% of respondents. 25% have offered influenza vaccination to family through the transplant clinic. Conclusion. Practices around pre-HCT infectious disease evaluation and management are heterogenous among the centers surveyed. The adoption of standardized screening for and management of infectious diseases in this patient population would likely be beneficial.

Time of incubation of agar-plate culture for the diagnosis of Strongyloides stercoralis infection.

PURPOSE: Agar-plate culture (APC) remains the most sensitive parasitological technique for S. stercoralis diagnosis. Although it was first described three decades ago, the time of incubation of the plates is neither a commonly described feature nor usually standardized. The aim of the study was to analyze the required time to detect S. stercoralis larvae in APC. METHODS: A prospective laboratory-based study including all patients with at least one positive APC was performed. The plates were incubated at room temperature for 7 days. Clinical, analytical and parasitological features including results of the direct visualization of the stool (DV) after formalin-ether concentration and time-to-detection (TTD) of the larvae in APC were recorded. RESULTS: A total of 141 samples from 75 patients had a positive APC. In 49 of them (65.3%) three or more stool samples were processed for direct visualization (DV) and APC. Of these 49 patients, 8 (16.3%) were also diagnosed with DV and 41 (83.7%) were diagnosed only with APC. In 38 samples from 23 (30.7%) patients, the TTD was below 2 days, while in 27 samples from 13 (17.3%) patients, the larvae were detected on the 6th and 7th day. CONCLUSION: Direct visualization failed to detect S. stercoralis in most of the patients that were diagnosed with APC. Incubation periods below 2 and 5 days would miss an important percentage of infections. At least 7 days of incubation of the APC are required to detect presumably low-burden chronic infections in non-endemic countries.