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Infectious Diseases > MEDICAL TOPICS
Strongyloidiasis
Article Last Updated: Mar 24, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Hari Polenakovik, MD, Infectious Diseases and General Medicine Consultant Physician, Department of Medicine, Western Health, Footscray, Victoria, Australia
Hari Polenakovik is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and Infectious Diseases Society of America
Coauthor(s):
Sylvia Polenakovik, MD, Clinical Instructor, Internist, Wayne Hospital, Greenville, Ohio, Department of Internal Medicine, Wright State University
Editors: Wesley W Emmons, MD, FACP, Assistant Professor, Department of Medicine, Thomas Jefferson University; Consulting Staff, Infectious Diseases Section, Department of Internal Medicine, Christiana Care, Newark, DE; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Ronald A Greenfield, MD, Professor, Chief, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine; Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital; Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Author and Editor Disclosure
Synonyms and related keywords:
strongyloidiasis, hyperinfection syndrome, disseminated strongyloidiasis, Strongyloides, threadworm infection, Cochin China diarrhea, parasitic nematodes, Strongyloides stercoralis, S stercoralis, bacterial meningitis, rhabditiform larvae, parthenogenesis, filariform, bacteremia, Escherichia coli, E coli, Klebsiella species, helminth, strongyloidosis, acute strongyloidiasis, chronic strongyloidiasis
Background
Strongyloidiasis is an intestinal infection caused by the parasitic nematode Strongyloides stercoralis. Distinctive characteristics of this parasite are its ability to persist and replicate within a host for decades while producing minimal or no symptoms and its potential to cause life-threatening infection (hyperinfection syndrome, disseminated strongyloidiasis) in an immunocompromised host.
Pathophysiology
The life cycle of S stercoralis is complex and unique among the helminths because its complete cycle of development may take place both within the host (autoinfection) and in the external environment (free-living cycle).
Strongyloidiasis is typically acquired when the infective (filariform) larvae penetrate the skin during contact with contaminated soil, although ingestion of filariform larvae (fecal-oral route) may also result in infection. Larvae are carried by venous circulation to the lungs or directly to the small intestine. From the lungs, they enter the alveoli, go up the tracheobronchial tree and larynx, are subsequently swallowed, and reach the small intestine. Here, they molt twice and become parasitic adult female worms (2 X 0.05 mm in diameter). Parasitic male worms apparently do not exist.
The parasitic female worm produces eggs by means of parthenogenesis, yielding noninfective (rhabditiform) larvae. These larvae either can be passed out of the host's body in the feces or, under certain conditions, can cause autoinfection.
Autoinfection involves premature transformation of noninfective larvae (rhabditiform, 0.25 X 0.015 mm) into infective larvae (filariform, 0.5 X 0.015 mm), which can penetrate the intestinal mucosa (internal autoinfection) or the skin of the perineal area (external autoinfection), thus establishing a developmental (parasitic) cycle within the host. Infection can be maintained by repeated migratory cycles for the remainder of the person's life.
The 2 most severe forms of strongyloidiasis are hyperinfection syndrome and disseminated strongyloidiasis. Hyperinfection syndrome represents an acceleration of the normal life cycle of S stercoralis, leading to excessive worm burden without the spread of larvae outside the usual migration pattern (eg, gastrointestinal tract, lungs). Disseminated strongyloidiasis involves widespread dissemination of larvae to extraintestinal organs (eg, CNS, heart, urinary tract, endocrine organs), which are not ordinarily part of the parasite life cycle. In these severe forms of strongyloidiasis, the migration of the larvae from the gastrointestinal tract into the circulation and various organs may result in bacteremia and, occasionally, meningitis with enteric microorganisms. The enteric microorganisms either are carried by the filariform larvae or enter the circulation via the intestinal ulcers.
Rhabditiform larvae that are passed into the stool can become either filariform larvae or free-living adult males and females (1 X 0.06 mm) capable of producing rhabditiform larvae (ie, free-living cycle). The latter, in turn, can either develop into infective (filariform) larvae (ie, able to penetrate human skin and initiate the parasitic cycle) or repeat the free-living cycle.
Frequency
United States
Strongyloidiasis is uncommon, although endemic foci exist in rural areas of the southeastern states and the Appalachia region, with prevalence rates close to 4%. Populations with higher prevalence rates include patients in long-term institutionalized care, immigrants or refugees from tropical and subtropical countries, and persons stationed in Southeast Asia during World War II and the Vietnam War.
International
Strongyloidiasis is endemic in tropical and subtropical countries. Prevalence rates are as high as 40% in certain areas, especially West Africa, the Caribbean, and Southeast Asia. The disease is estimated to affect more than 70 million people worldwide.
Mortality/Morbidity
Severe strongyloidiasis has a high mortality rate (up to 80%) because diagnosis is often delayed. This relates to its nonspecific presentation and the host's immunocompromised status. Most immunocompetent patients have asymptomatic chronic infections causing negligible morbidity.
Race
Strongyloidiasis has no predilection for any racial or ethnic group.
Sex
Strongyloidiasis has no predilection for either sex.
Age
Infection occurs in all age groups, although acquisition is more common during childhood.
History
- Acute strongyloidiasis
- Lower-extremity itch (eg, mild rash at the site of larval skin penetration, usually on feet)
- Cough, dyspnea, wheezing, and low-grade fever (due to larval migration through lungs)
- Epigastric discomfort, diarrhea, occasional nausea, and vomiting
- Chronic strongyloidiasis
- Asymptomatic or vague abdominal discomfort (most patients)
- Abdominal pain, burning, and cramping (sometimes worse after eating)
- Intermittent diarrhea (eg, alternating with constipation)
- Occasional nausea and vomiting
- Weight loss (if heavier infestation)
- Recurrent rashes
- Severe strongyloidiasis
- Insidious and occasionally abrupt onset
- Nausea, vomiting, and severe abdominal pain
- Diarrhea, occasionally bloody
- Cough, hemoptysis, dyspnea, and wheezing
- Stiff neck, headache, and confusion (if CNS involvement)
- Rash
- Fever, chills
Physical
- Acute strongyloidiasis
- Pruritic erythematous maculopapules at the site of larval skin penetration, usually on the feet
- Wheezing
- Low-grade fever
- Epigastric tenderness
- Chronic strongyloidiasis
- Epigastric tenderness
- Chronic urticaria
- Larva currens ("racing larva") - Rapidly progressive serpiginous wheals beginning perianally and extending to the buttocks, upper thighs, and abdomen at a rate of 5-10 cm/h; pathognomonic lesion of strongyloidiasis possibly due to an external autoinfection (ie, filariform larvae in feces penetrate perianal skin, producing local allergic reaction)
- Severe strongyloidiasis
- Diffuse abdominal tenderness; abdominal distension; hyperactive, hypoactive, or absent bowel sounds; vomiting; hematemesis; and hematochezia
- Altered mental status and meningismus (if CNS involvement)
- Rash (petechiae, purpura) over the trunk and proximal extremities caused by small dermal blood vessel disruption from massive migration of filariform larvae within the skin
- Cough, respiratory distress, wheezing, hemoptysis, and crackles
- Fever, chills
Causes
- Risk factors for severe strongyloidiasis
- Corticosteroids - most important risk factor; other immunosuppressive agents (eg, chemotherapeutic agents, tacrolimus, tumor necrosis factor [TNF] modulators)
- Human T-cell leukemia virus type 1 infection
- Neoplasms, particularly hematologic malignancies (lymphoma, leukemia)
- Organ transplantation
- Malabsorption states
- End-stage renal disease
- Diabetes mellitus
- Advanced age
- HIV-1 infection
- No obvious precipitating factor
Acute Respiratory Distress Syndrome
Ascariasis
Diverticulitis
Eosinophilia
Eosinophilic Gastroenteritis
Gastroenteritis, Bacterial
Ileus
Inflammatory Bowel Disease
Intra-abdominal Sepsis
Lower Gastrointestinal Bleeding
Malabsorption
Meningitis
Peptic Ulcer Disease
Pneumonia, Bacterial
Sepsis, Bacterial
Septic Shock
Upper Gastrointestinal Bleeding
Urticaria
Lab Studies
- CBC count with differential
- WBC count is usually within the reference range in acute and chronic strongyloidiasis; it is often elevated in severe strongyloidiasis.
- Eosinophilia (>600/mL) is common during acute infection, intermittent during chronic infection, and frequently absent in severe strongyloidiasis.
- Evaluate and suspect strongyloidiasis in any patient who presents with persistent, mild, or moderate-to-high eosinophilia and who has lived in or traveled to an area endemic for S stercoralis.
- Stool for ova and parasites
- Microscopically identify S stercoralis larvae (definitive diagnostic test).
- Ova are almost never observed during a strongyloidiasis infection; results from this examination are typically negative during acute infection.
- Examine stool directly in wet mounts (very low yield) or after ethyl acetate-formalin concentration occurs.
- Single stool examination has a low sensitivity (approximately 30%) in chronic strongyloidiasis because larval output is low and intermittent. Perform at least 3 stool examinations on consecutive days because this may increase sensitivity to 70-80%.
- To establish a diagnosis, enhance larvae recovery by using special methods such as the Baermann funnel method, the Harada-Mori filter paper method, and the agar plate method when needed. The latter appears to be the most sensitive and efficient method.
- Obtain blood cultures in all patients presenting with possible severe strongyloidiasis. Blood cultures often yield growth of enteric pathogens, most commonly Escherichia coli and/or Klebsiella species.
- Strongyloides serology (eg, enzyme immunoassay, indirect fluorescent antibody)
- With 90-95% sensitivity, it is the most sensitive test for detecting strongyloidiasis in immunocompetent patients. Sensitivity may be lower in severely immunocompromised patients, however, and this test cannot be used to differentiate between past and present infection.
- If results are positive, continue efforts to establish a parasitologic (microscopic) diagnosis because of cross-reactivity with other nematode infections (8-16%).
- This test is also useful for monitoring a patient's response to therapy (antibody titers decrease markedly within 6-12 mo of successful therapy).
- Sputum cultures: These may occasionally suggest Strongyloides infection; when observing the agar plate, the microorganisms that are part of the normal respiratory flora may be found outside the area of streaking as groups of colonies arranged in a characteristic pattern. This laboratory phenomenon is a result of migrating larvae on the agar plates, and, in an appropriate clinical setting, is considered
diagnostic of S stercoralis infection.
Imaging Studies
- Obtain a chest radiograph to reveal possible patchy alveolar infiltrates in acute infection. In severe strongyloidiasis, findings are diverse; the chest radiograph may depict diffuse interstitial infiltrates, segmental or diffuse alveolar infiltrates, or pleural effusions.
- A plain abdominal radiograph may reveal loops of a dilated small bowel, or ileus, in severe strongyloidiasis.
- Barium swallow and barium enema findings may be within the reference range, may exhibit bowel dilatation, or may occasionally indicate stenosis with ulceration.
- Obtain a CT scan of the abdomen and pelvis to reveal any nonspecific thickening of the bowel wall.
Procedures
- Findings from upper and lower gastrointestinal endoscopy may range from normal-appearing mucosa to severe duodenitis and colitis. Duodenal and jejunal biopsies are not sensitive means to assist in diagnosing strongyloidiasis.
- Conduct an Enterotest (string test) or duodenal aspiration to examine duodenal fluid for Strongyloides species larvae. These tests produce more positive results than a stool examination does.
- Perform sputum examinations, bronchial washings and bronchoalveolar lavages in cases of severe strongyloidiasis. These procedures frequently reveal filariform and/or rhabditiform larvae.
- Perform a lumbar puncture if CNS involvement is suspected.
- Perform cerebrospinal fluid analysis (elevated protein, decreased glucose, pleocytosis with neutrophilic predominance) to evaluate for acute bacterial meningitis.
- A Gram stain may exhibit gram-negative rods or, rarely, gram-positive cocci in chains (Enterobacteriaceae, Streptococcus species).
- A wet mount preparation may reveal S stercoralis larvae.
Histologic Findings
S stercoralis larvae are typically found in the proximal part of the small intestine, embedded in the mucosal lamina propria, where they produce mild-to-moderate degrees of edema, cellular infiltration, partial villous atrophy, and, occasionally (in severe strongyloidiasis), ulcerations. In long-standing infections, fibrosis may develop.
Medical Care
- Administer anthelmintic therapy.
- Provide supportive treatment as indicated (eg, intravenous fluids if volume depletion, blood transfusion if gastrointestinal or alveolar hemorrhage, mechanical ventilation if respiratory failure).
- Provide antibiotic therapy directed toward enteric pathogens if bacteremia or meningitis is present or suggested.
Surgical Care
Perform surgery in patients with acute abdominal symptoms (peritonitis due to bowel perforation or infarction) in the context of severe strongyloidiasis.
Consultations
Notify the microbiology laboratory when strongyloidiasis is suspected to ensure that specific tests are performed for optimal larval detection in stool specimens. Other consultations include the following:
- Infectious disease specialist
- Pulmonary or critical care specialist
- General surgery specialist
Diet
No specific diet is required.
Activity
Limit activity as tolerated by the patient.
The goal of therapy is eradication of the parasite by using anthelmintic drugs.
Drug Category: Anthelmintics
Parasite biochemical pathways are sufficiently different from the human host to allow selective interference by chemotherapeutic agents in relatively small doses.
| Drug Name | Ivermectin (Stromectol, Mectizan) |
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| Description | DOC for acute and chronic strongyloidiasis. Binds selectively with glutamate-gated chloride ion channels in invertebrate nerve and muscle cells, causing cell death. Half-life is 16 h; metabolized in liver. |
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| Adult Dose | 200 mcg/kg/d PO for 2 d; may repeat course in 14 d |
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| Pediatric Dose | Administer as in adults |
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| Contraindications | Documented hypersensitivity; do not use in first trimester of pregnancy and avoid use until after delivery if possible |
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| Interactions | None reported |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Treat mothers who intend to breastfeed only when risk of delayed treatment outweighs possible risks to newborn caused by ivermectin excretion in milk; repeat courses may be required in immunocompromised patients; may cause nausea, vomiting, mild CNS depression, and drowsiness |
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| Drug Name | Albendazole (Albenza, Eskazole, Valbazen, Zentel) |
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| Description | Second line for treatment of acute and chronic strongyloidiasis. Decreases ATP production in worm, causing energy depletion, immobilization, then death. To avoid inflammatory response in CNS, administer with anticonvulsants and high-dose glucocorticoids. |
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| Adult Dose | 400 mg/d PO for 3 d; may repeat course in 14-21 d |
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| Pediatric Dose | <2 years: 200 mg/d PO for 3 d
>2 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity; do not use in first trimester of pregnancy and avoid use until after delivery if possible |
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| Interactions | Coadministration with carbamazepine may decrease efficacy; dexamethasone, cimetidine, and praziquantel may increase toxicity |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Discontinue use if LFTs increase significantly (resume when levels decrease to pretest values); caution in women who are breastfeeding |
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| Drug Name | Thiabendazole (Mintezol) |
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| Description | DOC for hyperinfection syndrome and disseminated strongyloidiasis. For mixed helminthic infections; inhibits helminth-specific mitochondrial fumarate reductase. |
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| Adult Dose | Acute or chronic strongyloidiasis: 1.5 g PO bid for 2 d
Severe strongyloidiasis: 1.5 g PO bid for 7-14 d |
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| Pediatric Dose | Acute or chronic strongyloidiasis: 25 mg/kg PO bid for 2 d; not to exceed 3 g/d
Severe strongyloidiasis: 25 mg/kg PO bid for 7-14 d; not to exceed 3 g/d |
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| Contraindications | Documented hypersensitivity; do not use in the first trimester of pregnancy and avoid use until after delivery if possible |
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| Interactions | May elevate theophylline serum levels, increasing toxicity (monitor serum levels and reduce dose prn) |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Closely monitor in hepatic or renal dysfunction; prior to initiating therapy, supportive therapy is necessary for anemia, dehydration, or malnutrition; use in confirmed worm infestation (not prophylactically); may cause nausea, vomiting, and mild CNS depression |
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Further Inpatient Care
- Consider contact isolation in patients with severe strongyloidiasis because sputum, stool, vomitus, and other bodily excreta may contain infective (filariform) larvae.
Further Outpatient Care
- Medication: Repeat courses of ivermectin in immunocompromised patients because relapse is common in this population.
- Follow-up examination
- To ensure a parasitologic cure, repeat stool examinations and/or duodenal aspirations every 2-3 months.
- Alternatively, schedule follow-up strongyloides serology studies (4-8 mo after therapy) to monitor the patient's response to therapy.
- Ensure that the Strongyloides antibody titer declines to low or undetectable levels within 6-18 months after successful treatment.
- A nondeclining titer may indicate a need for additional anthelmintic therapy.
In/Out Patient Meds
- Conduct definitive treatment with anthelmintic drugs (see Medication).
- Treat bacterial complications (eg, bacteremia, meningitis) for 2-4 weeks with antibiotics according to the results of in vitro testing against the bacterial isolate(s).
Deterrence/Prevention
- Instruct travelers to endemic areas to avoid walking barefoot in places or soil that potentially contain infective larvae. Shoes help protect against infection.
- No prophylactic regimens are accepted, and no vaccines are available.
Complications
- Gastrointestinal
- GI hemorrhage
- Malabsorption
- Intestinal obstruction
- Peritonitis
- Appendicitis
- Obstructive jaundice
- Ileus
- Pneumatosis intestinalis
- Intestinal perforation
- Intestinal infarction
- Respiratory
- Asthma or exacerbation of preexisting obstructive pulmonary disease
- Pneumonitis
- Respiratory failure
- Acute respiratory distress syndrome
- Alveolar hemorrhage
- Pleural effusion
- Granulomatous lung disease
- Dermatologic
- Larva currens
- Purpura of the trunk and proximal extremities
- Chronic urticaria
- Neurologic
- Meningitis due to enteric bacteria
- Brain abscess
- Vascular - Hyperinfection syndrome presenting as bacteremia (occasionally recurrent) due to enteric microorganisms (eg, E coli, Klebsiella pneumoniae, Enterococcus species including vancomycin-resistant Enterococcus faecium, Streptococcus bovis)
- Renal - Nephrotic syndrome (rare)
- Musculoskeletal - Reactive arthritis (rare)
- Death
Prognosis
- In cases of acute and chronic strongyloidiasis, prognosis is good.
- In severe cases of hyperinfection syndrome or disseminated strongyloidiasis, prognosis is poor.
Medical/Legal Pitfalls
- Diagnosis relies on a high index of suspicion because patients present with no distinctive clinical features and ancillary laboratory, imaging, and endoscopic findings are often nonspecific.
- Obtaining an appropriate travel and residence history is important. Furthermore, the possibility of strongyloidiasis should always be considered in any immunocompromised patient who suddenly deteriorates.
- Delay in diagnosing strongyloidiasis frequently results in death, despite vigorous treatment.
Special Concerns
- Pregnancy: Clinicians may prefer to defer treatment until after the first trimester. All of the medications listed are FDA category C agents.
- Immunocompromise: In patients with an appropriate geographic history, rule out strongyloidiasis by means of thorough evaluation, including several stool examinations for ova and parasites, special larvae detection techniques, and/or serology in all transplant candidates or others who are likely to receive a prolonged course of steroids or other immunosuppressive medications. Among the immunosuppressive agents, only cyclosporine A is known to possess anthelmintic activity. This was initially confirmed in animal models and subsequently observed in clinical practice. To date, no cases of severe strongyloidiasis developing in transplant recipients treated with cyclosporine have been reported.
| Media file 1:
First stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman. |
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| Media file 2:
Second stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman. |
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| Media file 3:
Third stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman. |
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| Media file 4:
Fourth stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman. |
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| Media file 5:
Fifth stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman. |
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| Media file 6:
Rhabditiform larva of Strongyloides stercoralis in stool specimen (wet mount stained with iodine). |
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Strongyloidiasis excerpt Article Last Updated: Mar 24, 2006
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