Tropical Infections in the Context of Kidney Transplantation in Latin America.

Reports on tropical infections among kidney transplant (KT) recipients have increased in recent years, mainly because of the growing number of KT programs located in tropical and subtropical areas, and greater mobility or migration between different areas of the world. Endemic in emerging and developing regions, like most countries in Latin America, tropical infections are an important cause of morbidity and mortality in this population. Tropical infections in KT recipients may exhibit different pathways for acquisition compared with those in nonrecipients, such as transmission through a graft and reactivation of a latent infection triggered by immunosuppression. Clinical presentation may differ compared with that in immunocompetent patients, and there are also particularities in diagnostic aspects, treatment, and prognosis. KT patients must be screened for latent infections and immunized properly. Last, drug-drug interactions between immunosuppressive agents and drugs used to treat tropical infections are an additional challenge in KT patients. In this review, we summarize the management of tropical infections in KT patients.

Impact of Helminth Infection on Metabolic and Immune Homeostasis in Non-diabetic Obesity.

Several epidemiological and immunological studies indicate a reciprocal association between obesity/metabolic syndrome and helminth infections. Numerous studies demonstrated that obesity is concomitant with chronic low-grade inflammation, which is marked by vital changes in cellular composition and function of adipose tissue. However, the effect of helminth infection on the homeostatic milieu in obesity is not well-understood. To determine the relationship between Strongyloides stercoralis (Ss) infection and obesity, we examined an array of parameters linked with obesity both before and at 6 months following anthelmintic treatment. To this end, we measured serum levels of pancreatic hormones, incretins, adipokines and Type-1, Type-2, Type-17, and other proinflammatory cytokines in those with non-diabetic obesity with (INF) or without Ss infection (UN). In INF individuals, we evaluated the levels of these parameters at 6 months following anthelmintic treatment. INF individuals revealed significantly lower levels of insulin, glucagon, C-peptide, and GLP-1 and significantly elevated levels of GIP compared to UN individuals. INF individuals also showed significantly lower levels of Type-1, Type-17 and other pro-inflammatory cytokines and significantly increased levels of Type-2 and regulatory cytokines in comparison to UN individuals. Most of these changes were significantly reversed following anthelmintic treatment. Ss infection is associated with a significant alteration of pancreatic hormones, incretins, adipokines, and cytokines in obese individuals and its partial reversal following anthelmintic treatment. Our data offer a possible biological mechanism for the protective effect of Ss infection on obesity.

Update on the major imported helminth infections in travelers and migrants.

Helminth infections cause considerable morbidity worldwide and may be frequently underdiagnosed especially in areas of lower endemicity. Patients may harbor latent infections that may become symptomatic years or decades after the initial exposure and timely diagnosis may be critical to prevent complications and improve outcomes. In this context, disease in special populations, such as immunosuppressed patients, may be of particular concern. Heightened awareness and recent diagnostic developments may contribute to the correct management of helminth infections in nonendemic regions. A review of the main helminth infections in travelers and migrants (strongyloidiasis, taeniasis-neurocysticercosis and schistosomiasis) is presented, focusing on epidemiology, developments in diagnosis, treatment and prevention.

Disseminated strongyloidiasis in an immunocompetent male: A Case Report.

Strongyloidiasis is a human parasitic disease caused by infection of Strongyloidesstercoralis. It can manifest from asymptomatic eosinophilia in an immunocompetent host and disseminate the disease in the immunocompromised ones. The inconsistency of eosinophilia and low sensitivity of a standard microscopic stool examination makes it difficult to diagnose the disease. We report a case of chronic strongyloidiasis who, despite being immunocompetent, developed dissemination. The patient was a 30-years-old male who presented with diarrhoea, vomiting, high-grade fever and dyspnoea. On examination, he was pale, oedematous and had ascites with systolic murmurs in tricuspid area. After a fullworkup for differentials, biopsy confirmed the diagnosis of strongyloidiasis. Echocardiogram revealed vegetations on mitral and tricuspid valves and regurgitation through the valves, which confirmed dissemination to endocardium. A course of Ivermectin 9 mg daily for two weeks eradicated the infection in time. In conclusion, awareness for physicians and the use of various diagnostic methods like serology, endoscopy and biopsy should be considered for high risk patients.

Prevalence and clinical outcomes of Plasmodium falciparum and intestinal parasitic infections among children in Kiryandongo refugee camp, mid-Western Uganda: a cross sectional study.

BACKGROUND: The prevalence of Plasmodium falciparum and Intestinal Parasitic Infections (IPIs) - with the corresponding pathogenesis among children remain uncertain. This study aimed at determining the prevalence and the outcomes (including anaemia) of the respective infections and co-infections. Anaemia is a condition in which the number of red blood cells transporting oxygen to the various body parts is not sufficient to meet the needs of the body. METHODS: This was a cross sectional study conducted among 476-refugee camp school children. Kato-Katz technique was used to screen stool samples for intestinal parasites. Microscopy was used for malaria testing while the portable Haemoglobin (Hb) calorimeter was used to measure haemoglobin concentration. RESULTS: The overall prevalence of the mixed infections was 63.03%. Plasmodium falciparum was most prevalent of the single infections 262(55.04%) followed by Taenia spp. 14 (2.9%), Schistosoma mansoni 12(2.5%), Giardia lamblia 7 (2.9%), Trichuris trichiura 2(0.4%), Hookworm 2(0.4%) and Strongyloides stercoralis 1(0.2%). The odds of developing simple or uncomplicated malaria infection or anaemia was 14 times higher in individuals with dual co-infection with Plasmodium falciparum + Taenia sp. compared to single parasitic infection (Odds = 14.13, P = 0.019). Co-infection with Plasmodium falciparum + Taenia spp, was a strong predictor of Malaria and anaemia. CONCLUSION: This study shows that Plasmodium falciparum and Taenia spp. co-infections is a stronger predictor of malaria and anaemia. The prevalence of malaria and anaemia remains higher than the other regions in Uganda outside restricted settlements. The findings of this study underline the need for pragmatic intervention programmes to reduce burden of the co-infections in the study area and similar settlements.

The Worm that Clogs the Lungs: Strongyloides Hyper-Infection Leading to Fatal Acute Respiratory Distress Syndrome (ARDS).

BACKGROUND Strongyloides stercoralis is an intestinal helminth. Parasitism is caused by penetration of the larvae through the skin. It is endemic in tropical and subtropical regions of the world and in the United States occurs in the southeastern region. It has a tendency to remain dormant or progress to a state of hyper-infection during immunosuppression. CASE REPORT We present the case of a 70-year-old Nigerian who developed fatal ARDS secondary to Strongyloides infection after been treated with steroids for treatment of autoimmune necrotizing myopathy. Despite adequate management with mechanical ventilation and appropriate antifungal therapy, the patient died on day 19 of hospitalization. CONCLUSIONS S. stercoralis is known to affect every organ in the body. ARDS is often an overlooked complication of Strongyloides hyper-infection, which is often deadly. Immediate diagnosis and treatment are important for patient survival.

Critical diagnosis of complicated strongyloidosis with nested-PCR and High Resolution Melting analysis (HRM)

Diagnosis of strongyloidosis is sometimes problematic and requires novel techniques. Here, critical diagnosis of a complicated case of strongyloidosis using molecular methods is reported. A young woman referred to the Diagnostic Laboratory of Strongyloidiasis in School of Public Health, Tehran University of Medical Sciences. She had taken albendazole before referring to the laboratory. She had cerebral edema, behavior disorders, hypereosinophilia and titer of IgE >2000 IU/mL. The patient had history of intestinal and skin disorders and steroid therapy. For detection of Strongyloides stercoralis infection, parasitological techniques and novel methods of nested-PCR and HRM analysis were applied on stool samples upon admission and during the following up. On the samples provided upon first admission, parasitology showed negative results, while both molecular methods revealed infection with S. stercoralis. After specific treatment, during the following up, the patient general health was much improved and the results of all parasitological and molecular tests were negative for strongyloidosis. Application of novel sensitive diagnostic methods for detection of S. stercoralis is necessary, especially once parasitological techniques have lack of sensitivity.

Treatment of disseminated Strongyloides spp. infection in an infant Sumatran orangutan (Pongo abelii).

Strongyloides nematodes have been reported in all species of great apes with orangutans ≤5 years old most susceptible to severe clinical disease. This brief communication describes the first published case of antemortem diagnosis and treatment of disseminated strongyloidiasis in a clinically affected 5-month-old Sumatran orangutan (Pongo abelii).

Management of severe strongyloidiasis attended at reference centers in Spain.

INTRODUCTION: Strongyloides stercoralis is a globally distributed nematode that causes diverse clinical symptoms in humans. Spain, once considered an endemic country, has experienced a recent increase in imported cases. The introduction of serology helps diagnosis and is currently replacing microbiological techniques in some settings, but its sensitivity is variable and can be low in immunocompromised patients. Diagnosis can only be confirmed by identification of larvae. Often, this "gold standard" can only be achieved in severe cases, such as disseminated S.stercoralis infection, or S.stercoralis hyperinfection syndrome, where parasite load is high. In addition, these clinical presentations are not well-defined. Our aim is to describe severe cases of S.stercoralis, their epidemiological profile, and their clinical details. METHODS: An observational retrospective study of disseminated S.stercoralis infection, or hyperinfection syndrome. Inclusion criteria: aged over 18, with a diagnosis of disseminated S.stercoralis infection, or hyperinfection syndrome, confirmed by visualization of larvae. Patients were identified through revision of clinical records for the period 2000-2015, in collaboration with eight reference centers throughout Spain. RESULTS: From the period 2000-2015, eighteen cases were identified, 66.7% of which were male, with a median age of 40 (range 21-70). Most of them were foreigners (94.4%), mainly from Latin America (82.3%) or Western Africa (17.6%). Only one autochthonous case was identified, from 2006. Immunosuppressive conditions were present in fourteen (77%) patients, mainly due steroids use and to retroviral coinfections (four HIV, two HTLV). Transplant preceded the clinical presentation in four of them. Other comorbidities were coinfection with HBV, Trypanosoma cruzi, Mycobacterium leprae or Aspergillus spp. All presented with digestive disorders, with 55.6% also presenting malaise. 44.4% of cases had fever, 27.8% skin complaints, and 16.7% respiratory or neurological disorders. One patient presented anemia, and one other nephrotic syndrome. Diagnosis was confirmed by identification of larvae in fresh stool samples (n = 16; 88.9%), concentration techniques (n = 6; 33.3%), larval culture (n = 5; 29.4%), or digestive biopsies (n = 8; 44%). S.stercoralis forms were identified during necropsy in one case. In addition, ten (55%) had a positive serology. All the cases were treated with ivermectin, six (33%) also received albendazole and one case received thiabendazole followed by ivermectin. All needed inpatient management, involving a mean hospitalization stay of 25 days (range 1-164). Two cases received intensive care and eventually died. CONCLUSIONS: Only eighteen cases of disseminated S.stercoralis infection/hyperinfection syndrome were identified from the 15-year period, most of which were considered to have been imported cases. Among those, immunosuppression was frequent, and mortality due to S.stercoralis was lower than previously described.

Electroacupuncture in rats infected with Strongyloides venezuelensis: effects on gastrointestinal transit and parasitological measurements.

OBJECTIVE: To investigate the effects of electroacupuncture (EA) at ST36 and CV12 on gastrointestinal transit and parasitological measurements during Strongyloides venezuelensis infection in rats. DESIGN: Rats were infected with S. venezuelensis and allocated to one of three groups that were infected and remained untreated (SV group, n=8), infected and treated with EA at CV12 (SV+CV12 group, n=8) or infected and treated with EA at ST36 (SV+ST36 group, n=8). EA was performed every 3 days over a 21-day period, at 4 mA intensity and 15 Hz frequency for 20 min. At 2 and 20 days post-infection (dpi), body weight, food and water intake, and faecal characteristics were monitored over a 24-hour period. Gastric emptying, caecal arrival time, small intestinal transit and eggs per gram (EPG) of faeces were calculated at 3, 9, 15 and 21 dpi. At 21 dpi, intestinal worm recovery was counted. RESULTS: EA at ST36 and CV12 slowed gastric emptying over the course of infection time. An accelerated intestinal transit was observed in the ST36 group, and after CV12 treatment the same effect was observed at 9 and 15 dpi. At 9 dpi, EPG was increased in the CV12 group. ST36 treatment decreased EPG at 9 and 15 dpi. At 21 dpi, both the ST36 and CV12 groups had increased EPG and worm numbers. No changes were observed in the other parameters analysed. CONCLUSIONS: EA at ST36 and CV12 provoked changes in gastrointestinal transit that may be beneficial to the host during S. venezuelensis infection; however, based on the number of worms and EPG at 21 dpi, the indication for EA in the treatment of strongyloidiasis needs to be carefully assessed.

Anemia, intractable vomiting, chronic diarrhea, and syndrome of inappropriate antidiuretic secretion: a diagnostic dilemma: Disseminated strongyloidosis in a patient with newly diagnosed HTLV infection-case report and review of literature.

RATIONALE: Strongyloidiasis hyperinfection and disseminated disease have high mortality rates due to several complications and early detection of Strongyloides infection is therefore prudent. PATIENT CONCERNS: A 37-year-old male patient came with chronic diarrhea, intractable vomiting and was found to have hyponatremia, and anemia on the initial laboratory tests. DIAGNOSES: Further work up revealed syndrome of inappropriate antidiuretic secretion to be the cause of the hyponatremia in addition to gastrointestinal loses. His hospital course was complicated by persistent hyponatremia and later development of partial small bowel obstruction. INTERVENTIONS: Considering his symptoms we had a suspicion of small bowel pathology for which he underwent an esophagogastroduodenoscopywith biopsies that revealed strongyloidosis as the cause of his symptoms. He was also found to have human T-cell lymphotropic virus infection, likely contributing to the disseminated disease. OUTCOMES: He was started on ivermectin with complete resolution of symptoms and improvement of hyponatremia. LESSONS: It is very important to suspect Strongyloides infection in a patient presenting with syndrome ofinappropriate antidiuretic secretion as hyperinfection and disseminated disease can be life threatening without antihelmintic therapy.

Cutaneous Strongyloides Infection Postchemotherapy.

BACKGROUND AND OBJECTIVE: While clinical symptoms of strongyloidiasis are often nonspecific, larva currens (with erythematous, serpiginous, and pruritic papules and plaques) should prompt investigation including stool microscopy, serology, and skin biopsy of the lesion. Appropriate diagnosis and treatment with ivermectin is necessary, especially in the immunocompromised patient who is at increased risk for hyperinfection syndrome and disseminated disease. CONCLUSION: We present a 61-year-old immunocompromised man with presentation of larva currens of cutaneous strongyloides infection without symptoms of hyperinfection or disseminated disease.

Wait!!! No Steroids for this Asthma .

BACKGROUND: Strongyloides stercoralis (SS) is a parasite seen in certain parts of the USA and in people from other endemic areas. In these patients steroids might precipitate or exacerbate asthma. Apart from worsening of asthma, serious complications like hyperinfection syndrome and even death can occur in these patients if treated with steroids. Treatment is either ivermectin or albendazole based on severity of the disease. Clinicians have to be very careful when prescribing steroids in patients presenting with an exacerbation of asthma from areas endemic for Strongyloides stercoralis. CASE REPORT: A young woman with history of asthma presented with complaints of nausea, vomiting, abdominal pain, wheezing, and dry cough. Physical examination revealed diffuse expiratory wheezing and mild diffuse abdominal pain without rebound or guarding. Laboratory results showed leukocytosis with eosinophilia. Stool studies showed Strongyloides stercoralis. Imaging revealed ground-glass opacities in the right upper and lower lobe along with an infiltrate in the lingular lobe on the left side. Bronchoscopy showed Strongyloides stercoralis. The patient was diagnosed with hyperinfection syndrome due to Strongyloides stercoralis most probably exacerbated by prednisone given for her asthma. Steroids were then discontinued and the patient was started on ivermectin. The patient improved with treatment. Repeat stool examination was negative for Strongyloides stercoralis. CONCLUSIONS: Clinicians have to be very careful when prescribing steroids in patients presenting with an exacerbation of asthma who are from areas endemic for Strongyloides stercoralis and should test for it (preferably with serology test) before starting treatment.

Severe strongyloidiasis with negative serology after corticosteroid treatment.

BACKGROUND: Strongyloidiasis usually presents as a chronic and limited disease, but in some immunocompromised patients it may become a life-threatening disease. CASE REPORT: A 77-year-old Haitian male, with history of temporal arteritis on 40 mg of oral prednisone presented complaining of decreased oral intake, epigastric pain, and non-bloody diarrhea. He had bi-temporal wasting and a distended abdomen but without guarding or tenderness. Laboratory examination included mild leukocytosis, anemia, negative HIV antibody, negative parasite stool exam, and negative serology for Giardia and Strongyloides. CT of the abdomen showed multiple distended loops, without obstruction. During the admission he had a 4 g hemoglobin drop and a positive occult blood test, requiring blood transfusions, IV pantoprazole, and upper endoscopy. Findings included severe duodenitis, blunted villi, and intramucosal and luminal helminthic worms and eggs. Pathology showed Strongyloides stercoralis infection, confirmed by subsequent PCR. He was given 1 day of 15 mg oral ivermectin, diarrhea resolved, and was discharged with a percutaneous endoscopic gastrostomy tube because of the persistent lack of appetite. ConCLUSIONS: Given the persistent nature of strongyloidiasis and its high susceptibility to ivermectin, it potentially would be worth consider treating high-risk patients in the appropriate clinical and epidemiological setting, irrespective of screening test results, in order to avoid false-negative result consequences.

Strongyloidiasis--an insight into its global prevalence and management.

BACKGROUND: Strongyloides stercoralis, an intestinal parasitic nematode, infects more than 100 million people worldwide. Strongyloides are unique in their ability to exist as a free-living and autoinfective cycle. Strongyloidiasis can occur without any symptoms or as a potentially fatal hyperinfection or disseminated infection. The most common risk factors for these complications are immunosuppression caused by corticosteroids and infection with human T-lymphotropic virus or human immunodeficiency virus. Even though the diagnosis of strongyloidiasis is improved by advanced instrumentation techniques in isolated and complicated cases of hyperinfection or dissemination, efficient guidelines for screening the population in epidemiological surveys are lacking. METHODOLOGY AND RESULTS: In this review, we have discussed various conventional methods for the diagnosis and management of this disease, with an emphasis on recently developed molecular and serological methods that could be implemented to establish guidelines for precise diagnosis of infection in patients and screening in epidemiological surveys. A comprehensive analysis of various cases reported worldwide from different endemic and nonendemic foci of the disease for the last 40 years was evaluated in an effort to delineate the global prevalence of this disease. We also updated the current knowledge of the various clinical spectrum of this parasitic disease, with an emphasis on newer molecular diagnostic methods, treatment, and management of cases in immunosuppressed patients. CONCLUSION: Strongyloidiasis is considered a neglected tropical disease and is probably an underdiagnosed parasitic disease due to its low parasitic load and uncertain clinical symptoms. Increased infectivity rates in many developed countries and nonendemic regions nearing those in the most prevalent endemic regions of this parasite and the increasing transmission potential to immigrants, travelers, and immunosuppressed populations are indications for initiating an integrated approach towards prompt diagnosis and control of this parasitic disease.

Strongyloides stercoralis infection complicating the central nervous system.

Strongyloides stercoralis is a nematode endemic in humid tropical regions. The life cycle of this parasite is complex and unique due to its capacity to cause autoinfection, resulting in chronic infections. Innate and adaptive immune responses are responsible for clearing the parasite. Many risk factors have been described, but the most important is living in or having visited an endemic area. The clinical presentation of strongyloidiasis is varied and ranges from asymptomatic chronic infection to hyperinfection syndrome. Hyperinfection syndrome is more common in patients with immunosuppresion due to therapy with corticosteroids, coinfection with human T-lymphotropic virus type I (HTLV-1), transplant patients, or patients receiving chemotherapy. Multiplication and migration of large parasite numbers cause worsening of the initial symptoms and leads to a high mortality rate. CNS involvement in strongyloidiasis has only been seen in patients with hyperinfection syndrome. Meningitis is the most common form of CNS involvement and gram-negative bacteria are the more frequent etiology. Repeated stool samples with concentration methods have a good sensitivity and specificity. In patients that are not from endemic areas serum antibody tests may be useful in the diagnosis. Treatment with a single dose of ivermectin is recommended for most patients. In severe or hyperinfection cases repeated doses may be needed.