A severe case of hyperinfection by Strongyloides stercoralis in a pet dog from Romania.

Strongyloides stercoralis is a zoonotic soil-transmitted nematode affecting mainly humans and dogs but identified also in non-human primates, cats and wild carnivores. It has a cosmopolitan distribution being endemic in tropical and subtropical areas. In Romania, the infection was reported on several occasions in dogs with low prevalence (3.5% -3.8%), assessed by coproscopy and it was confirmed in human patients with no travel history. A 2-year-old male Boston Terrier dog presented to a private clinic due to severe digestive problems, in July 2022. The animal had a long history of health problems. The dog was in a very bad clinical condition with severe abdominal pain, bloody diarrhea, and weight loss. Coproparasitological examinations using the saline flotation method and the modified Baermann's technique were done, both being negative. In addition, an intestinal biopsy was performed during the second endoscopy. Nematodes were collected and identified morphologically and molecularly confirmed. Histology revealed severe inflammation of the duodenal mucosa with areas of edema, necrosis, and hemorrhage, and in the intestinal glands, there were numerous nematodes suggesting a parasitic infection by Strongyloides spp. PCR followed by sequencing confirmed the infection with S. stercoralis. The dog was treated with a combination of oral fenbendazole and milbemycin oxime for 5 months. No relapse was observed 3 months after negativity was attained. This case describes a severe clinical infection by Strongyloides stercoralis in a domestic dog from Romania and the recovery after long-term treatment.

Proliferative strongyloidiasis in a colony of colubrid snakes.

Strongyloides are small rhabditid nematodes primarily associated with enteric disease in a variety of animal species, including reptiles. Strongyloides spp life stages were associated with a disease outbreak in a large breeding colony of snakes. Multiple Pantherophis and Lampropeltis colubrids exhibited respiratory distress, anorexia, stomatitis, facial deformation, and waning body condition that resulted in death or necessitated euthanasia. Postmortem examinations of 13 snakes revealed epithelial hyperplasia and inflammation of the alimentary and respiratory tracts associated with varying numbers of adult and larval nematodes and embryonated or larvated ova. In a subset of snakes, aberrant nematode migration was also observed in the eye, genitourinary system, coelom, and vasculature. Histomorphology and gross examination of parasitic adult female nematodes from host tissues were consistent with a Strongyloides spp. Sedimented fecal material from 101/160 (63%) snakes housed in the affected facility was positive for nematodes and/or larvated ova. Polymerase chain reaction amplification and sequencing of portions of the 18S and 28S ribosomal ribonucleic acid (RNA) genes and the internal transcribed spacer region of adult female parasites and positive fecal samples supported the diagnosis of strongyloidiasis. Strongyloides spp possess a unique life cycle capable of alternating between parasitic (homogonic) and free-living (heterogonic) stages, resulting in the production of directly infective larvae. Commonly utilized husbandry practices in reptile collections can amplify the numbers of infective larvae generated in the captive environment, increasing the risk for rhabditid hyperinfections. This report documents morbidity, mortality, and non-enteric disease manifestations due to Strongyloides hyperinfections in a captive colubrid snake colony.

Pulmonary strongyloidiasis and hyperinfection in a Patient with idiopathic inflammatory myopathy：A case report.

Pulmonary strongyloidiasis is a rare infection in patients with autoimmune diseases, and immunosuppression can lead to the development of hyperinfection syndrome with a high mortality rate. We present a case of a 78-year-old male with previous idiopathic inflammatory myopathy (IIM) with interstitial lung disease. He developed hyperinfection syndrome and respiratory failure, and diagnostic metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage fluid (BALF) confirmed the presence of Strongyloides stercoralis. After treatment with ivermectin, the patient's symptoms improved. Therefore, adequate screening and prophylactic treatment are needed for people at risk of immunosuppression, which can reduce the occurrence of the devastating S. stercoralis hyperinfection syndrome. It also highlights mNGS as a highly accurate test for the detection of difficult to atypical pathogens.

A Unique Patient Presentation of Disseminated Strongyloidiasis: Unraveling the Clinical Complexity of an Immunocompromised Patient.

Strongyloidiasis is a rare parasitic disease that can remain dormant and asymptomatic in many individuals. However, in cases of immunosuppression, the motility rate of the Strongyloides parasite increases significantly. This case study presents a unique clinical scenario involving an 88-year-old Hispanic male with a disseminated Strongyloidesinfection. The patient's medical history includes coronary artery disease, a history of percutaneous coronary intervention, heart failure with reduced ejection fraction and subsequent recovery of left ventricular function, hypertension, dyslipidemia, mantle cell lymphoma being treated with rituximab every two months since 2019, and chronic anemia. This case emphasizes the importance for physicians to consider strongyloidiasis when faced with a diverse range of symptoms, including syndrome of inappropriate antidiuretic hormone secretion (SIADH), rash, gastrointestinal upset, urinary retention, chronic anemia, and chronic eosinophilia, as these manifestations may share a common origin.

Strongyloides stercoralis Infection in Humans: A Narrative Review of the Most Neglected Parasitic Disease.

Strongyloidiasis is a helminth infection affecting 613.9 million people annually, mainly in the tropics and subtropics. The reported seroprevalence in the United States is 4% with most of the cases reported in immigrants. Human T-lympho-tropic virus 1 (HTLV-1) infections, hypogammaglobulinemia, immunosuppressant use - particularly steroid use, alcoholism, and malnutrition have been associated with an increased risk of strongyloidiasis. Recently, cases of strongyloidiasis hyperinfection syndrome have been described in coronavirus disease 2019 (COVID-19) patients treated with steroids as well. This brief review discusses the epidemiology, clinical features, management, and prevention of strongyloidiasis including some facts about the infection in pregnancy, transplant recipients, and COVID-19 patients. We conducted an online search using the PubMed, Scopus, and Google Scholar databases. Strongyloidiasis can be asymptomatic or present with mild symptoms. Strongyloides stercoralis is known to cause autoinfection. In immunocompromised individuals, it can present with severe symptoms, hyperinfection, or disseminated disease. Reported mortality in cases of disseminated Strongyloidiasis is 87.1%. Serology and detection of larvae in stool by direct microscopy are the most commonly used methods to diagnose strongyloidiasis. The drug of choice for the treatment is ivermectin. However, the use of ivermectin in human pregnancy is not well studied, and its teratogenic risks are unknown. Proactive screening of strongyloidiasis is necessary in immunocompromised individuals to prevent severe disease.

Strongyloides Hyperinfection Syndrome Triggered by a Single Dose of Dexamethasone Administered for Fetal Lung Development.

Strongyloides hyperinfection syndrome is a rare manifestation caused by the Strongyloides stercoralis parasite and has mortality rates close to 90% if left untreated. Corticosteroids are commonly implicated as a trigger for hyperinfection syndrome in patients with Strongyloides autoinfection, and it has been suggested that even a single dose of corticosteroids can trigger hyperinfection syndrome. Here, we report a case of hyperinfection syndrome eight days after administering a single 8 mg dose of dexamethasone for fetal lung development before a late preterm, emergency cesarean section (C-section) delivery secondary to placental abruption. Prior to the C-section, the patient had been exhibiting signs of autoinfection syndrome, cough, and abdominal pain, for several months. Following corticosteroid administration, she had sequelae of Strongyloides hyperinfection syndrome, including gram-negative bacteremia, undulating fevers, protein wasting enteropathy, and hypersensitivity pneumonitis. Sputum cultures were positive for Strongyloides, and after treatment with ivermectin and albendazole, the patient fully recovered. Strongyloides hyperinfection syndrome is a documented consequence of short courses of corticosteroids. Still, this case is unique because the patient only received a single dose of corticosteroids before developing hyperinfection syndrome. Clinicians must recognize patients at risk for Strongyloides hyperinfection syndrome and understand the risks of administering corticosteroids to patients harboring the parasite.

Strongyloides hyperinfection syndrome precipitated by immunosuppressive therapy for rheumatoid arthritis and COVID-19 pneumonia.

The COVID-19 pandemic has posed clinical and public health challenges worldwide. The use of corticosteroids has become an evidence-based practice to reduce the hyperinflammatory process involved in severe COVID-19 disease. However, this can result in the reactivation of parasitic infestations, even with a short course. We report the case of a 64-year-old Cuban born patient who passed away from S. stercoralis hyperinfection syndrome following treatment with dexamethasone for severe COVID-19 disease on a background of prolonged immunosuppression for rheumatoid arthritis. Clinicians should be aware of the risk of strongyloidiasis as a complication of the treatment for severe COVID-19 and other immunosuppressive therapies. We recommend empiric Strongyloides treatment for those who are from, or who have accumulated risk by travelling to endemic areas, and are being treated with corticosteroids for severe COVID-19 disease.

Obstrucción intestinal por Strongyloides Stercolaris: A propósito de un caso / Intestinal obstruction due to strongyloides stercolaris: About a case

RESUMEN La estrongiloidiasis comúnmente produce problemas gastrointestinales. Presentamos el caso de un varón, cadete en la marina de guerra del Perú, de 30 años, procedente de lima; que desarrolló síndrome de hiperinfección por Strongyloides Stercoralis, teniendo como antecedente el diagnóstico presuntivo de polimiositis, por lo cual recibió un ciclo corto de corticoesteroides. No portador del virus htlv 1/2. Presentó al ingreso hiporexia, debilidad generalizada, caquexia, diarrea intermitente autolimitada, intolerancia oral y leve distensión abdominal. El paciente llegó a la etapa de diseminación, lo que resultó en un daño severo a nivel intestinal. La baja excreción de larvas en las heces dificultó el diagnóstico. Se brindó tratamiento con ivermectina parenteral a dosis de 1.2ml vía subcutánea cada 48 horas por tres dosis, con buena respuesta clínica y posteriormente con buena tolerancia oral. La importancia de presentar el caso es comentar sobre el abordaje diagnóstico y terapéutico de esta geohelmintiasis endémica del Perú.

Abstract Strongyloidiasis commonly causes gastrointestinal problems. We present the case of a male, a 30-year-old cadet in the peruvian navy from lima, who developed a hyperinfection syndrome due to strongyloides stercoralis, having a presumptive diagnosis of polymyositis for which he received a short cycle of corticosteroids. He was not a carrier of the htlv 1/2 virus. Upon admission, he presented with hyporexia, generalized weakness, cachexia, intermittent self-limited diarrhea, oral intolerance, and mild abdominal distension. The patient reached the dissemination stage, resulting in severe intestinal damage. The low excretion of larvae in the feces made the diagnosis difficult. Treatment was provided with parenteral ivermectin at a dose of 1.2ml subcutaneously every 48 hours for three doses, with a good clinical response and subsequently good oral tolerance. The importance of presenting the case is to comment on the diagnostic and therapeutic approach to this endemic geohelminthiasis of peru.

Strongyloides stercoralis Hyperinfection Syndrome in Pregnancy.

Strongyloidiasis is a parasitic infection with a high global burden of disease. Hyperinfection syndrome is a life-threatening complication that predominantly affects immunosuppressed individuals, such as those receiving corticosteroid treatment. Despite its worldwide prevalence, little is known about the clinical effects of this condition on the feto-maternal dyad during pregnancy. We present a case of placental abruption leading to preterm delivery in a pregnancy complicated by Strongyloides stercoralis hyperinfection syndrome following antenatal corticosteroid use. Although rare, this condition is associated with high mortality rates and adverse pregnancy outcomes. Therefore, screening at-risk individuals may be warranted in pregnancies where antenatal corticosteroid administration is considered.

Route of dexamethasone administration influences parasite burden in Strongyloides hyperinfection model.

Rodents infected with Strongyloides venezuelensis are experimental models applied to strongyloidiasis research. This study evaluated oral and subcutaneous dexamethasone (DEX) treatments to establish immunosuppression in an experimental model of Strongyloides hyperinfection. Rattus norvegicus Wistar were divided: G I (-): untreated and uninfected animals, G II (+): untreated and infected, G III (o -) orally treated and uninfected, G IV (o +) orally treated and infected, G V (sc -) subcutaneously treated and uninfected, G VI (sc +) subcutaneously treated and infected. For oral administration, DEX was diluted in sterile water (5 µg/ml) and made available to the animals on intervals in experimental days - 5-0, 8-13 and 21-26. For subcutaneous administration, animals received daily injections of DEX disodium phosphate (2 mg/kg). Infection was established by the subcutaneous inoculation of 3000 S. venezuelensis filarioid larvae. Groups were evaluated by egg per gram of feces and parasite females counts and IgG, IgG1 and IgG2a detection. GIV (o +) had egg peaks count on days 13 and 26 and maintained egg elimination until the last experimental day. Parasitic females recovery at day 30 was significantly higher in G IV (o +) when compared to G VI (sc +). Levels of IgG, IgG1 and IgG2a of all groups, except the positive control GII (+), were below the detection threshold. Pharmacological immunosuppression induced by oral administration of DEX produced high parasitic burden, and is a noninvasive method, useful to establish immunosuppression in strongyloidiasis hyperinfection model in rats.

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.

A Rare Case of Strongyloides stercoralis Hyperinfection in a Diabetic Patient from Romania-Case Report and Review of the Literature.

Severe cases of strongyloidiasis are most often associated with multiple causes of immune suppression, such as corticoid treatment and HTLV (human T-lymphotropic virus) coinfection. Diabetes is not traditionally considered a risk factor for the development of severe strongyloidiasis. We report a rare case of autochthonous severe strongyloidiasis in Romania, a European country with a temperate climate. A 71-year-old patient with no prior travel history was admitted with multiple gastrointestinal complaints and recent weight loss. CT (computed tomography) scans indicated duodenal wall thickening, and duodenal endoscopy evidenced mucosal inflammation, ulcerations and partial duodenal obstruction at D4. Microscopic examination of stool samples and biopsy specimens from the gastric and duodenal mucosa revealed an increased larval burden characteristic of Strongyloides stercoralis hyperinfection. Sequential treatment with albendazole and ivermectin achieved parasitological cure and complete recovery. The novelty of our case stems from the scarcity of severe strongyloidiasis cases reported in Europe and especially in Romania, the absence of other risk factors in our patient aside from diabetes, the involvement of the gastric mucosa and the rare presentation as partial duodenal obstruction. This case highlights the importance of considering strongyloidiasis as a differential diagnosis, even in temperate climates where cases are sporadic, in cases in which immune suppression is not evident and in the absence of eosinophilia. The case is presented in the context of the first literature review examining the relationship between severe strongyloidiasis and diabetes, emphasizing diabetes as a possible risk factor for severe strongyloidiasis.

Strongyloides hyperinfection syndrome and cytomegalovirus infection in a patient with type II diabetes mellitus.

Strongyloidiasis is a gastrointestinal parasitic infection caused by percutaneous infection with Strongyloides stercoralis, which is mainly distributed in the tropics and subtropics worldwide. Digestive symptoms like diarrhea and abdominal pain are the main manifestation, but serious infections such as bacterial pneumonia, purulent meningitis and sepsis also occur in immunocompromised individuals. Herein, we present a rare case of a type II diabetes mellitus (T2DM) patient presented with gastrointestinal hemorrhage and sepsis caused by concomitant Strongyloides stercoralis and cytomegalovirus (CMV) infection. This 51-year-old male patient presented to the hospital with vomiting, diarrhea, dyspnea, palpitation and weakness. Examination revealed skin soft-tissue infection with T2DM, and upper endoscopy revealed gastric mucosal erosion and hemorrhage. Radiology revealed bilateral diffuse interstitial infiltrates and thickened walls of the colon. Importantly, stool and vomitus examination showed numerous larvae of Strongyloides stercoralis. Then the diagnosis of Strongyloides hyperinfection syndrome was made. But antibiotics and albendazole treatment did not improve the patient's symptoms of gastrointestinal bleeding and sepsis. Subsequently, other pathogens were screened by sequence and a positive CMV gene was found in the peripheral blood. Thus, antibiotics, albendazole and ganciclovir were all used which ultimately resolved the infection in this patient. Therefore, this case indicated CMV could also by co-infected with Strongyloides stercoralis in the immunocompromised patient, which remind us that an CMV test should also be performed when encountered in severe strongyloidiasis infection, which could improve the prognosis of the patient.

Prevalence and risk factors of Strongyloides stercoralis in haemodialysis in Cochabamba, Bolivia: a cross-sectional study.

BACKGROUND: Strongyloidiasis is an infectious disease that can be fatal in immunocompromised patients. Patients with end-stage renal failure who are on dialysis have a considerably weakened immune system, and organ transplantation is a major risk factor for severe strongyloidiasis. Knowledge of the local epidemiology in tropical and subtropical areas is an essential prerequisite for designing an appropriate strategy to prevent this potentially lethal complication. In this study, we aimed to estimate the prevalence and associated risk factors of S. stercoralis infection in patients on dialysis in Cochabamba, Bolivia. METHODS: A cross-sectional study was carried out among patients undergoing haemodialysis in Cochabamba (elevation 2,500 m, temperate climate), collecting information on socio-demographic, lifestyle, and clinical variables, and using one coproparasitological technique (the modified Baermann technique) and one serological (ELISA) test for S.stercoralis diagnosis. RESULTS: In total, 149 patients participated in the study (mean age = 51.4 years, 48.3% male). End-stage renal disease was predominantly (59%) of hypertensive and/or diabetic origin. The positive serological prevalence was 18.8% (95% CI: 13.3%-25.9%). Based on the sensitivity and specificity of the ELISA test, the estimate of the actual prevalence was 15.1% (95% CI: 9.4%-20.7%). Stool samples of 105 patients (70.5%) showed a coproparasitological prevalence of 1.9% (95% CI: 0.52%-6.68%). No potential risk factors were significantly associated with S. stercoralis infection. CONCLUSIONS: We found a high seroprevalence of S. stercoralis in Bolivian patients undergoing haemodialysis in Cochabamba. We recommend presumptive antiparasitic treatment at regular intervals to avoid the potentially fatal complications of severe strongyloidiasis.

Strongyloidiasis presenting during treatment of low-dose glucocorticoid plus rituximab for anti-signal recognition particle antibody-positive polymyositis: A case report.

Strongyloidiasis, an intestinal parasitic infection caused by Strongyloides stercoralis, rarely occurs in Japan. When treated with immunosuppressive drugs, two potentially lethal conditions, hyperinfection and dissemination, may develop in asymptomatic carriers of this parasite. We report the development of strongyloidiasis during treatment of polymyositis with glucocorticoids plus rituximab (RTX). A 44-year-old woman had been diagnosed with anti-signal recognition particle antibody-positive polymyositis with interstitial pneumonia 6 years previously, for which she had recently been receiving prednisolone at 5 mg/day and RTX at 375 mg/m2 twice every 3 months. Her condition appeared to be well controlled. She was admitted to our hospital with a 1-month history of chronic diarrhoea and epigastric pain. Standard microscopic examination of a sample of faeces revealed the presence of S. stercoralis; however, serologic testing for parasites was negative. Treatment with ivermectin alleviated her inflammatory diarrhoea and eradicated the faecal parasites. We believe that our patient had an exacerbation of S. stercoralis infection (hyperinfection syndrome) that was exacerbated by low-dose glucocorticoids plus RTX. Strongyloidiasis should be considered in immunocompromised individuals with unexplained diarrhoea, even in non-endemic areas.

Epidemiology, clinical features, and outcomes of strongyloidiasis in Taiwan from 1988 to 2020: A case series and literature review.

OBJECTIVES: We described a case of Strongyloides hyperinfection syndrome, reported a case series, and reviewed published cases of strongyloidiasis in Taiwan. METHODS: Confirmed cases of strongyloidiasis at the National Taiwan University Hospital (NTUH) and NTUH Hsin-Chu Branch from 1988 to 2020 were identified in the medical record database. Literature search was carried out through Pubmed, Google Scholar, and Index to Taiwan Periodical Literature System to identify published cases of strongyloidiasis in Taiwan from 1979 to 2020. Data pertaining to the demographics, underlying medical conditions, clinical manifestations, laboratory findings, and outcomes were extracted. RESULTS: A total of 117 cases of strongyloidiasis were identified, including 20 previously unpublished cases from the two hospitals and 97 published cases in the literature. Overall, 85 (73%) were male and the mean age was 64 years (range, 6-95 years). Classical symptoms such as diarrhea, cough, and skin rash were only observed in 43%, 37%, and 18% of the patients, respectively, whereas eosinophilia at presentation was only found in 48%. Strongyloides hyperinfection syndrome and disseminated strongyloidiasis were identified in 41 (35%) and 4 (3%) patients, respectively. Four (3%) patients had concurrent meningitis. In univariable analysis, being older and having pre-existing chronic obstructive pulmonary disease or asthma were associated with hyperinfection or dissemination (p = 0.024 and 0.003, respectively). The mortality rate was 43% among those with hyperinfection or disseminated infection. CONCLUSIONS: Strongyloidiasis can cause serious complications and mortality. Efforts to diagnose strongyloidiasis early are urgently needed to improve the outcome of patients with strongyloidiasis in Taiwan.

Seroprevalence of Strongyloides infection among steroid recipients in a tertiary care centre in North India.

Background: Strongyloides stercoralis (S. stercoralis), a unique parasite, can cause mortal disease even years after the exposure. Iatrogenic use of steroids can complicate asymptomatic infections to a life-threatening hyperinfection and/or disseminated infection. Data regarding seroprevalence of strongyloidiasis remains scarce and this knowledge gap needs due attention in many endemic countries including India. Aim: The present study is aimed at assessing the seroprevalence of Strongyloides infection and the need for routine screening among individuals receiving steroid therapy. Methodology: Eighty patients receiving steroid therapy and thirty healthy volunteers who had not received any immunosuppressive drugs and/or anthelminthic therapy in last six months were enrolled as cases and controls respectively and they were screened by Strongyloides IgG ELISA. Results: Among the 80 patients on steroids, the mean cumulative prednisolone equivalent dose received was 8.2 g (±11.2 g) for a mean duration of 184 days, 16 patients (20%, 95% CI 11.9-30) had a positive Strongyloides IgG serology. Only 4 controls (4/30, 13.3%, CI 3.8-30.7) tested positive (p=0.4). Conclusions: Our study demonstrated a Strongyloides seroprevalence of 20% in the study population emphasizing the need for screening for Strongyloides infection prior to immunosuppressive therapy in order to prevent hyperinfection or possible dissemination.

Strongyloides colitis, a rare but important mimic of Crohn's disease, resulting in coma and multi-organ failure: a case report.

BACKGROUND: Strongyloides colitis is a severe form of strongyloidiasis that carries a high mortality rate if untreated. There is an overlapping clinical presentation between Strongyloides colitis and Crohn's disease. Here, we present a case of a patient who was diagnosed with Crohn's disease and was treated with immunosuppressant therapy which resulted in a poor outcome. CASE PRESENTATION: A middle-aged, native African male presented with diarrhea, abdominal pain, and weight loss. Colonoscopy showed some patchy inflammation in the caecum, which on biopsy was suggestive of Crohn's disease. He had a short course of steroids before being admitted to an emergency with abdominal pain, diarrhea, malnutrition, and severe weight loss. Initial conservative treatment failed, and he became acutely unwell and septic with peritonitis. Laparotomy was carried out, which showed mild inflammation in the terminal ileum, which was not resected. Postoperatively, the patient became comatose and went into multi-organ dysfunction. He failed to progress, and a further laparotomy and subtotal colectomy were performed on the 12th postoperative day. His multi-organ failure progressed, and he succumbed to death 4 days later. DISCUSSION: Strongyloides stercoralis is a parasite causing an enteric infection in animals and humans. Strongyloidiasis in immunocompetent individuals is usually an indolent disease. However, in immunocompromised individuals, it can cause hyperinfective syndrome. Patients with strongyloid colitis should undergo colonoscopy and biopsy where acute inflammation with eosinophilic infiltrates indicates parasitic infiltration of the colonic wall. Surgery is generally not indicated, and any surgical intervention with misdiagnosis of a flare-up of IBD can be very detrimental to the patient. CONCLUSION: Strongyloid colitis can very harmfully mimic Crohn's colitis, and the use of steroids and immunosuppressants can disseminate parasitic infection. Hyperinfection syndrome can lead to sepsis, organ dysfunction, and comma. Disseminated infection carries a high mortality.

Strongyloidiasis - diagnostic and therapeutic dilemmas in hyperinfection patients: a case series.

The helminth infection caused by Strongyloides stercoralis is widespread in tropical regions, but rare in European countries. Unfamiliarity with the disease and diagnostic obstacles could contribute to its lethal outcome. Frequent use of corticosteroids during the COVID-19 pandemic could increase its significance. The aim of this retrospective descriptive study was to explore disease patterns and discuss clinical dilemmas in patients with S. stercoralis hyperinfection treated at the University Hospital for Infectious Diseases 'Dr. Fran Mihaljevic' in Zagreb, Croatia, between 2010 and 2021. Five out of 22 (22.7%) immunosuppressed patients treated due to strongyloidiasis developed hyperinfection. All patients were male, median 64 years; four were immunosuppressed by corticosteroids (although ileum resection could have been the trigger in one) and one by rituximab. The diagnosis was established after a median of 1.5 months of symptom duration, accidentally in all patients, by visualizing the parasite in the gastric/duodenal mucosa in four cases, and bronchial aspirate in one. All patients were cachectic, four out of five had severe hypoalbuminemia and all suffered secondary bacterial/fungal infection. Despite combined antibiotic, antifungal and antihelmintic therapy, three out of five of the patients died, after failing to clear living parasites from stool samples. We can conclude that significant delays in diagnosis and lack of clinical suspicion were observed among our patients with the most severe clinical presentations of strongyloidiasis. Although being beyond diagnostic recommendations for strongyloidiasis, an early upper gastrointestinal endoscopy with mucosal sample analysis could expedite diagnosis in severe, immunosuppressed patients. The persistence of viable parasites in the stool despite antihelmintic therapy should be further investigated.

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.