Strongyloides stercoralisStrongyloides stercoralis in transplant patientsin transplant patients

Alisa AlkerAlisa Alker

Life cycle

Geographic distribution

❖ Over 50 million people are infected worldwide

❖ It endemic in Africa, parts of Asia, South America, Mexico, and the Southern US

❖ National survey of 216,275 stool samples in 1987 found the prevalence of S. stercoralis to be 0.4% (CDC, 1991)

Clinical manifestations❖ diarrhea, abdominal pain, nausea, and vomiting

❖ dry cough, dyspnea, transient pulmonary infiltrate, throat irritation, wheezing

❖ Loffler syndrome (eosinophilic pneumonia)

❖ fluctuating eosinophilia

❖ rash (larva currens)

❖ asymptomatic

Severe manifestations❖ Almost always found in immunocompromized hosts

(associated with steroid use, HTLV, lymphoma, not HIV)

❖ Hyperinfection and dissemination, leading to ileus, obstruction, GIB, pneumonitis, meningitis, peritonitis, UTI

❖ the larvae bring with them bowel flora, leading to bacteremia, bacterial pneumonia, bacterial meningitis, etc

❖ mortality is ~50% with treatment

Transplant patients

❖ S. stercoralis has been reported in kidney (n=54), liver (n=3), lung (n=1), heart (n=3) and stem cell (n=7) transplant patients

❖ More common for transplant patients to have hyperinfection, though more mild presentations have been reported

❖ 0.7% of the renal transplant recipients between 1971-1984 at Vanderbilt had strongloidiasis (Morgan 1986)

Transplant patients

❖ Strongloidiasis can be transmitted by solid organs and it has been documented in people who have not left the US

❖ presentation more likely after transplantation or after treatment of acute rejection

❖ associated with steroid use

❖ cyclosporine may be protective

❖ mortality rate in kidney transplant patients: 49% (Roxby 2009)

Diagnosis

Roxby 2009

Treatment

❖ ivermectin 200 ug/kg once daily for 2-3 days

❖ thiabendazole 25 mg/kg twice daily for 3 days

❖ more effective in killing the adult worms than the migrating larvae

Prevention

❖ wearing shoes

❖ improved sanitation

❖ screening prior to transplantation?

References1. Neva FA. Biology and immunology of human strongyloidiasis. J. Infect. Dis. 1986

Mar ;153(3):397-406.

2. Siddiqui AA, Berk SL. Diagnosis of Strongyloides stercoralis infection. Clin. Infect. Dis. 2001 Oct 1;33(7):1040-1047.

3. Segarra-Newnham M. Manifestations, diagnosis, and treatment of Strongyloides stercoralis infection. Ann Pharmacother. 2007 Dec ;41(12):1992-2001.

4. DeVault GA, King JW, Rohr MS, Landreneau MD, Brown ST, McDonald JC. Opportunistic infections with Strongyloides stercoralis in renal transplantation. Rev. Infect. Dis. 1990 Aug ;12(4):653-671.

5. Morgan JS, Schaffner W, Stone WJ. Opportunistic strongyloidiasis in renal transplant recipients. Transplantation. 1986 Nov ;42(5):518-524.

6. Marty FM. Strongyloides hyperinfection syndrome and transplantation: a preventable, frequently fatal infection. Transpl Infect Dis. 2009 Apr ;11(2):97-99.

7. Vilela EG, Clemente WT, Mira RRL, Torres HOG, Veloso LF, Fonseca LP, et al. Strongyloides stercoralis hyperinfection syndrome after liver transplantation: case report and literature review. Transpl Infect Dis. 2009 Apr ;11(2):132-136.

8. Roxby AC, Gottlieb GS, Limaye AP. Strongyloidiasis in transplant patients. Clin. Infect. Dis. 2009 Nov 1;49(9):1411-1423.

9. Mandell G, Bennett J, Dolin R. Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, PA: Elsevier;

10. Center for Disease Control and Prevention. CDC surveillance summaries. MMWR. 1991 ;40(SS):