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special report: Ashley M. Newberry, David N. Williams, William M. Stauffer, David R. Boulware, Brett R. Hendel-Paterson, and Patricia F. Walker Strongyloides Hyperinfection Presenting as Acute Respiratory Failure and Gram-Negative Sepsis Chest 2005; 128: 3681-3684 [Abstract] [Full text] [PDF]

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Screening and Prevention of S. Stercoralis Hyperinfection

H.Erhan Dincer   (28 December 2005)

Hyperinfective Strongyloidiasis

Olayinka A Adedayo   (5 March 2006)

Screening and Prevention of S. Stercoralis Hyperinfection 28 December 2005
H.Erhan Dincer, MD FCCP FAASM VA Southern Nevada Health Care System Send letter to journal: Re: Screening and Prevention of S. Stercoralis Hyperinfection erhan_dincer{at}yahoo.com H.Erhan Dincer	Newberry and colleagues have reported a case series of Strongyloides hyperinfection presenting as acute respiratory failure and gram-negative sepsis in the issue of Chest (November 2005) (1). Although the well-known clinical presentations and complications of S.Stercoralis infection have been reported in the manuscript (1), they did not mention the importance of screening and primary prophylaxis of the parasite infection in those with immunocompromised state. S. Stercoralis hyperinfection has been described in patients with hematologic malignancies, HIV, HTLV-1 infections, hypogammaglobulinemia, bone marrow, kidney transplantation and immunosuppressive drug therapy, such as glucocorticoids, vinca alkaloids, azathioprine and cyclophosphamide (2). Because glucocorticoids are the most widely used immunosuppressant, more cases of S. Stercoralis hyperinfection have been reported related to their use (3, 4). We have recently diagnosed S.Stercoralis hyperinfection complicated by adult respiratory distress syndrome and E.coli sepsis in a patient with rheumatoid arthritis who was recently started on a TNF-á inhibitor in addition to his regimen of a low dose prednisone (5mg/day for 4 years) and methotrexate (15mg/week for 4 years). Our patient had been living in the USA for the last 25 years and had a travel history to Phillipines 2 years ago. Although this is not a common infection seen in the United States, screening of S. Stercoralis by stool examination or blood serology should be considered in those who traveled to the endemic areas (tropical and subtropical regions) prior to initiation of immunosuppressive therapies or those are already on. Primary prophylaxis can be done with Ivermectin 200 mic/kg/day for a total of two days and a repeat dose in two weeks, if S. Stercoralis is detected on screening (5). However, it is controversial whether all patients should be screened since the parasite can present decades in human host without any symptoms. References: 1. Newberry AM, Williams DN, Stauffer WM, et al. Strongyloides hyperinfection presenting as acute respiratory failure and gram-negative sepsis. Chest 2005;128;3681-3684. 2. Keiser PB, Nutman TB. Strongyloides Stercoralis in the immunocompromised population. Clin Microbiol Rev 2004;17(1):208-217. 3. Debussche X, Toublanc M, Camillieri JP et al. Overwhelming Strongyloidasis in a diabetic patient following adrenocorticotropin treatement and keto-acidosis. Diabetes Metab 1988;14:294-298. 4. Wurtz R, Mirot M, Frunda G, et al. Short report: gastric infection by strongyloides stercoralis. Am J Trop Med Hyg 1994;51:339-340. 5. Drugs for parasitic infections. August 2004. Online available at: www.medletter.com/freedocs/parasitic.pdf.
Hyperinfective Strongyloidiasis 5 March 2006
Olayinka A Adedayo, MD Fletcher Allen Health Care,Burlington,Vermont Send letter to journal: Re: Hyperinfective Strongyloidiasis oadedayo{at}hotmail.com Olayinka A Adedayo	Hyperinfective Strongyloidiasis Dear Editor, The article by Newberry et. al. titled “strongyloides hyperinfection presenting as acute respiratory failure and Gram negative sepsis in Chest 2005;128:3681-3684 re-emphasized the high mortality in disseminated or hyperinfective strongyloidiasis. The clinical presentation may mimic other respiratory diseases as most patients in this series were initially diagnosed with asthma. Eosinophilia was not prominent, it may thus be an unreliable hematologic finding unlike eosinopenia which occurred in seven out of the nine patients . All the patients had prior corticosteroid therapy. It will be of interest to know the HTLV-1 serologic status of these patients. Hyperinfective strongyloidiasis is associated with HTLV-1 and may be a new disease marker for HTLV-1 patients from HTLV-1 and strongyloides endemic areas. Gotuzzo et.al. in Lima, Peru documented HTLV-1 seropositivity in 18 of 21 (85.7%) patients with hyperinfective strongyloides which was higher than 6 out of 62 (10%) in group with intestinal strongyloidiasis and 4.7% in asymptomatic controls.1 There are also case reports linking this association.2,3 The underlying mechanism is related to immunomodulation of normal immune response to strongyloides by HTLV-1 infected T-lymphocytes. The normal Th-2 immune response to strongyloides is suppressed by exaggerated Th-1 cytokine from HTLV-1 infected cells. Elevated IFN-ã released by HTLV -1 infected lymphocytes down regulates IL-4 and IL-5 and causes a low level of parasite specific IgE.4,5.This leads to overwhelming parasitemia through the auto infective cycle. HTLV-1 seropositive patients infected with strongyloides also do have a poorer response to therapy6. It is suggested that patients with hyperinfective strongyloides be tested for HTLV-1 and all HTLV-1 positive patients should be screened at intervals for strongyloides. When screening is positive, repeated courses of Thiabendazole or Ivermectin may be needed to avert this fatal complication. Olayinka Adedayo Fellow - Infectious Diseases Unit Fletcher Allen Health Care University of Vermont Burlington, VT 05401 E-mail: oadedayo@hotmail.com References 1.Gotuzzo E, Terashima A, Alvarez H et. al Strongyloides stercoralis hyperinfection associated with human T-cell lymphotropic virus Type-1 infection in Peru. Am. J Trop. Med. Hyg. 1999;60:146-149 2.Newton RC, Limpuangthip P, Greenberg S, Gam A, Neva FA Strogyloides stercoralis hyperinfection in a carrier of HTLV-1 virus with evidence of selective immunosupression. Am. J Med 1992;92:202-8 3.Adedayo AO, Grell GC, Bellot P, Fatal strongyloidiais associated with human T-cell lymphotropic virus type -1 infection. Am. J Trop. Med. Hyg 2001;65:650-651 4.Neva A, Filho JO, Gam AA et. al. Interferon-ã and Interleukim-4 responses in relation to serum IgE levels in persons infected with Human T-cell lymphotropic virus Type-1 and strongyloides stercoralis. JID 1998;178:1856-9 5.Porto AF, Neva FA, Bittencourt H et. al. HTLV-1 decreases Th2 type of immune response in patients with strogyloidiasis Parasite immunology 2001;23:503-507 6.Sato Y, Shiroma Y, Kiyuna S, Toma H, Kobayashi T Reduced efficacy of chemotherapy might accumulate concurrent HTLV-1 infection among strongyloidiasis patients in Okinawa, Japan Trans R Soc Trop Med Hyg 1994;88:59