Post on 09-Jun-2020
Strongyloides stercoralis, a silent killer A case-report
Stefaan Kurvers
Dr. C. Linssen, Dr. E. de Brauwer, Dr. F. Stals
Department of Medical Microbiology
Zuyderland Medical Center, Heerlen
The Netherlands
International Conference on Parasitology Aug 24-26, 2015 Philadelphia, USA
•Male patient, 57 years of age origin from Liberia
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• Time-line
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Medical review
• Patient origin from Liberia
• Living for 9 years in the Netherlands
• Medical history: • Chronic hepatitis B
• Diabetes type II
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Medical review
• A year earlier (2011 – May):
Diagnosis of non-Hodgekin lymphoma (NHL) treated with chemotherapy
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• A month earlier (2012 – April):
Hospitalized due to abdominal and respiratory complaints • Symptoms: vomiting, nausea, fever
• Fever remained despite of broad spectrum antibiotics
• Infiltrate shown on the thoracic X-ray
• LAB results
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Hb: 7.4 mmol/L ↓ Hct: 0.35 L/L ↓ RBC: 4.09 x10E9/L ↓ WBC: 1.2 x10E9/L ↓
Neu: 0.8 ↓ Eos: 0.07 Monos: 0.1 ↓ Lymphs: 0.3 ↓
PLT: 124 x10E9/L ↓ CRP: 101 mg/L ↑
• Suspicion of PCP => TMP-SMX (Cotrim) therapy was started combined with prednisone
After the treatment the patient was discharged from the hospital in good clinical condition.
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• Recent (2012 – May):
Hospitalized due to general weakness and abdominal complaints • Symptoms: headache, diarrhea, vomiting, nausea, fever
After extensive diagnostic examinations however no cause was found.
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After 14 days, because of the persistent vomiting, a gastroscopy was performed
• The following was found:
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Image of an ulcerative lesion
• During the gastroscopy biopsies were taken.
After preparation and staining at the pathology department the following was seen.
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H&E staining 1000x oil magnification
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Enlarged
• Biopsies showed:
• Worm/larvae-like structures
Because of these findings the
Department of Medical
Microbiology was consulted.
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• Before the parasitological diagnosis was made the patient deteriorated and was admitted to ICU.
• Mechanical ventilation
• Broad spectrum antibiotics
• Collecting stool was difficult because the patient was suffering from ileus
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Stool samples were collected and examined for parasites.
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R h a b d i t i fo r m l a r va e o f S t r o n g y l o i d e s s te r co r a l i s
Genital primordium
Short buccal cavity
250 µm x 17 µm Wet mounts
• Ivermectin therapy was started
One day after the diagnosis was confirmed: Patient died of septicemia combined with massive bleeding from the stomach ulcers.
Conclusion:
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Disseminated Strongyloidiasis
• How could this have been prevented?
• No awareness for strongyloidiasis due to the lack of eosinophilia and the patient was living in the Netherlands for 9 years, no recent visits to endemic countries
• Role of serology before start immunosuppressive therapy (screening)
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Discussion:
• Collection of BAL was not done
• Are there guidelines on screening for Strongyloides concerning patients who will have immunosuppressive therapy?
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Discussion:
Facts on Strongyloidiasis
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Life cycle
• Infection is acquired through direct contact with contaminated soil.
Facts on Strongyloidiasis
• Transmission occurs mainly in tropical and subtropical regions
• 30-100 million people are infected worldwide; precise data on prevalence are unknown in endemic countries
• Strongyloidiasis is frequently underdiagnosed because many cases are asymptomatic; moreover, diagnostic methods lack sensitivity
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Facts on Strongyloidiasis
• Without appropriate therapy, the infection does not resolve and may persist for life
• Infection may be severe and even life-threatening in cases of immunodeficiency
• No public health strategies for controlling the disease are active at the global level
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Take home messages!
• Health-care providers should be made aware of this parasite, and particularly about the risk of disseminated infections
• Standardization of screening for Strongyloidiasis before starting immunosuppressive therapy using serology and/or PCR concerning high-risk patients
• More detailed epidemiological data on the global distribution of strongyloidiasis are needed
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Special thanks to:
Medical Microbiologists: Dr. C. Linssen
Dr. E. de Brauwer
Dr. F. Stals
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Internal Medicine: Dr. Schutten
Dr. de Conick
Dr. v.d. Berkmortel
Dr. Buys
Intensive Care Unit (ICU) Dr. Zandijk
Dr. v.d. Horst
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Thank you for your attention!