Clinical Characteristics and Outcomes of Disseminated Strongyloidiasis in the United States-A Multicenter Network Analysis.

Human strongyloidiasis is a potentially life-threatening parasitic disease among immunocompromised hosts. We aim to determine the factors and mortality associated with disseminated strongyloidiasis. We conducted a U.S.-based multicenter retrospective cohort study to determine 90-day clinical outcomes for people diagnosed with Strongyloides infection in the TriNetX patient database. We identified adult patients with the International Classification of Diseases (10th revision, clinical modification) code for Strongyloides infection (B78) or a positive Strongyloides IgG antibody test and captured outcomes at 90 days. We identified 5,434 patients with strongyloidiasis, of whom 48 had disseminated strongyloidiasis for 0.9% prevalence of disseminated disease. Systemic connective tissue disorders, pulmonary eosinophilia, liver cirrhosis, blood disorders (monoclonal gammopathy, aplastic anemia, and lymphoid malignancy), malnutrition, alcohol use disorder, and transplantation status were frequent in patients with disseminated disease. Mortality was significantly higher in people with disseminated disease at 30 days (21%). The 90-day risk of hospitalization, bacteremia, and acute respiratory distress syndrome (ARDS) was higher in those with disseminated infection. People with disseminated strongyloidiasis had a heightened risk of hospitalization, bacteremia, acute respiratory distress syndrome, and mortality. The population at risk for severe strongyloidiasis infection is evolving, reflecting conditions in which glucocorticoids or additional immunosuppressive medications are commonly used for treatment.

Severe Strongyloides stercoralis infection in kidney transplant recipients: A multicenter case-control study.

BACKGROUND: Severe Strongyloides stercoralis infection in kidney transplant recipients is associated with considerable morbidity and mortality, although little is known about the risk factors for such infection. METHODOLOGY/PRINCIPAL FINDINGS: This was a retrospective, multicenter, case-control study in which we assessed the risk factors for and clinical outcomes of severe S. stercoralis infections in kidney transplant recipients in Brazil. We included 138 kidney transplant recipients: 46 cases and 92 controls. Among the cases, the median number of days from transplantation to diagnosis was 117 (interquartile range [IQR], 73.5-965) and the most common clinical findings were gastrointestinal symptoms (in 78.3%) and respiratory symptoms (in 39.1%), whereas fever and eosinophilia were seen in only 32.6% and 43.5%, respectively. The 30-day all-cause mortality among the cases was 28.3% overall and was significantly higher among the cases of infection occurring within the first three months after transplantation (47% vs. 17.2%, P = 0.04). The independent risk factors were receiving a transplant from a deceased donor (odds ratio [OR] = 6.16, 95% confidence interval [CI] = 2.05-18.5), a history of bacterial infection (OR = 3.04, 95% CI = 1.2-7.5), and a cumulative corticosteroid dose (OR = 1.005, 95% CI = 1.001-1.009). The independent predictors of mortality were respiratory failure (OR = 98.33, 95% CI = 4.46-2169.77) and concomitant bacteremia (OR = 413.00, 95% CI = 4.83-35316.61). CONCLUSIONS/SIGNIFICANCE: Severe S. stercoralis infections are associated with considerable morbidity and mortality after kidney transplantation. In endemic areas, such infection may occur late after transplantation, although it seems to be more severe when it occurs earlier after transplantation. Specific risk factors and clinical manifestations can identify patients at risk, who should receive prophylaxis or early treatment.

The investigation of Strongyloides stercoralis seroprevalence in immunosupressed patients in Turkey

Background/aim: In immunosuppressed patients, strongyloidiasis can be lifethreatening because of hyperinfection or dissemination. Therefore, diagnosis of S. stercoralis is important in immunosuppressed patients with chronic strongyloidiasis. In this study, our objective was to investigate the presence of S. stercoralis antibodies by an ELISA method in immunosuppressed patients. Materials and methods: A total of 100 immunosuppressed patients' sera were included in the study. Forty-two of the patients were receiving immunosuppressive therapies for cancer or being treated for hematopoietic malignancies, 38 of the patients were receiving immunosuppressive drugs for rheumatic diseases, 14 were receiving immunosuppressive therapies for liver transplantation. Two of the patients were being treated for HIV infection and 4 were being treated for hypogammaglobulinemia. As control group, 50 individuals without a known disease were included in the study. The presence of IgG antibodies against S. stercoralis was investigated with a commercial ELISA kit. Results: S. stercoralis antibody test was positive in 4 of 100 (4%) sera from immunosuppressed patients. All control patients were negative for S. stercoralis. Conclusions: Strongyloidiasis can be a lifelong chronic infection if not treated. In patients who are going to receive immunosuppressive therapy, it should be tested before treatment, as it can become a disseminated and life-threatening infectious disease.

Strongyloides stercoralis in solid organ transplantation: early diagnosis gets the worm.

PURPOSE OF REVIEW: Strongyloidiasis is a parasitic infection affecting millions of people worldwide. Complications of infection are strongly associated with alcoholism, immunosuppression, and organ transplantation. Delayed diagnosis results in hyperinfection syndrome and disseminated strongyloidiasis leading to mortality rates approaching 80%. Early detection, and prevention of infection and transmission are key to diminish this illness. RECENT FINDINGS: In this review, we cover the basic concepts in immunity, immunosuppression, and disorder necessary for understanding the infectious syndromes associated with Strongyloides stercoralis infection. Focused discussion on donor-derived transmission and recipient risk in solid organ transplantation is presented. Current methodology for diagnosis, screening algorithms, and treatment are also reviewed. SUMMARY: Strongyloidiasis complicated by hyperinfection and dissemination remains associated with a poor outcome. The poor outcome pleads for a high level of suspicion and aggressive treatment in at-risk patients. As the population of transplant patients continues to increase, the risk of infection also increases, compelling us to address this highly fatal infectious complication in solid organ transplantation (SOT). Here we review the pathology, immunology, diagnosis, and treatment of strongyloides infection in the immunosuppressed SOT population.

A case of Strongyloides hyperinfection syndrome in the setting of persistent eosinophilia but negative serology.

Strongyloides stercoralis is a unique intestinal nematode with the ability to replicate and complete its life cycle without leaving the host. We report a fatal case of Strongyloides hyperinfection syndrome in a patient who had persistent eosinophilia for several years but negative Strongyloides serology. Our case suggests that ELISA serologies cannot solely be relied upon to diagnose Strongyloides stercoralis infection; history and clinical judgment remain crucial to this diagnosis.

Diagnosis of Strongyloides stercoralis by morphological characteristics combine with molecular biological methods.

Strongyloidiasis is one of the neglected tropical diseases caused by infection with the nematode Strongyloides genus and distributed worldwide. Strongyloidiasis can be fatal in immunosuppressed patients induced hyperinfection or disseminated strongyloidiasis. Unfortunately, until now, due to the unspecific clinical symptom in infected individuals and the low sensitivity diagnosis of strongyloidiasis, many patients were misdiagnosed every year. Furthermore, the larvae of the Strongyloides stercoralis (S. stercoralis) is similar to other nematodes such as hookworm, Trichostrongylus increased the difficulty of diagnosis. In this case, the patient is a 63-year-old male person, who had a nearly 30 years medical history of asthma and emphysema, and 4-5-year medical history of diabetes. The sputum examination found some parasite larvae, then we identify the larvae using clinical observation and morphological characteristics combine with examined cytochrome oxidase subunit 1 (COX1) and 18S rRNA genes by PCR, sequence analysis and finally classified by phylogenetic analysis, the larvae were diagnosed as S. stercoralis. Our results showed that diagnosis with strongyloidiasis by morphological characteristics combine with molecular biological methods can improve the sensitive of diagnosis and provide a final diagnosis for the disease in the clinics.

[Strongyloidiasis: who is at risk of severe infection and how to prevent it?]. / Strongyloïdose: qui est à risque d'infection sévère et comment la prévenir?

Strongyloides stercoralis hyperinfection syndrome, which carries a high mortality (60%), occurs usually after immunosuppressive therapy. Cellular immunosuppression allows the parasite to reactivate and stimulate its cycle of auto-infection. It is therefore important to prevent this syndrome by screening at risk patients at risk for chronic strongyloidiasis before starting immunosuppressive treatment and especially before treatment with corticosteroids, even that of short duration. Ivermectine is the treatment of choice.

Strongyloides stercoralis hyperinfection syndrome: a case series and a review of the literature.

BACKGROUND: Strongyloides stercoralis may lead to overwhelming infestation [Strongyloides hyperinfection syndrome (SHS)]. We aimed at describing a case series of patients admitted in intensive care unit (ICU) with SHS and report a literature review of such cases. PATIENTS AND METHODS: Retrospective multicenter study of 11 patients admitted to the ICU of tertiary hospitals with SHS between 2000 and 2013. Literature review with Pubmed retrieved 122 cases. Logistic regression analysis was performed to identify predictive factors of ICU mortality and shock occurrence. RESULTS: 133 patients [median age 53 (39, 64), 72.2 % males] were included. Underlying immunosuppression was present in 127 patients, mostly long-term corticosteroid treatment in 111 (83.5 %) patients. Fever (80.8 %), respiratory (88.6 %), and gastrointestinal (71.2 %) symptoms were common clinical manifestations. Shock occurred in 75 (57.3 %) patients and mechanical ventilation was required in 89 (67.9 %) patients. Hypereosinophilia and a concomitant bacterial infection were observed in 34 (34.3 %) and 51 (38.4 %) patients, respectively. The in-ICU mortality rate was 60.3 %. Predictive factors of ICU mortality were shock occurrence [Odds ratio (OR) 18.1, 95 % confidence interval (95 % CI) 3.03-107.6, p < 0.01] and mechanical ventilation (OR 28.1, 95 % CI 3.6-217, p < 0.01). Hypereosinophilia (OR 0.21, 95 % CI 0.06-0.7, p = 0.01) and a concomitant bacterial infection (OR 4.68, 95 % CI 1.3-16.8, p = 0.02) were independent predictors of shock occurrence. CONCLUSION: SHS remains associated with a poor outcome, especially when associated with shock and mechanical ventilation. Deterioration to shock is often related to concomitant bacterial infection. The poor outcome of established SHS pleads for a large application of antiparasitic primary prophylaxis in at-risk patients.

Enterobiasis and strongyloidiasis and associated co-infections and morbidity markers in infants, preschool- and school-aged children from rural coastal Tanzania: a cross-sectional study.

BACKGROUND: There is a paucity of data pertaining to the epidemiology and public health impact of Enterobius vermicularis and Strongyloides stercoralis infections. We aimed to determine the extent of enterobiasis, strongyloidiasis, and other helminth infections and their association with asymptomatic Plasmodium parasitaemia, anaemia, nutritional status, and blood cell counts in infants, preschool-aged (PSAC), and school-aged children (SAC) from rural coastal Tanzania. METHODS: A total of 1,033 children were included in a cross-sectional study implemented in the Bagamoyo district in 2011/2012. Faecal samples were examined for intestinal helminth infections using a broad set of quality controlled methods. Finger-prick blood samples were subjected to filariasis and Plasmodium parasitaemia testing and full blood cell count examination. Weight, length/height, and/or mid-upper arm circumference were measured and the nutritional status determined in accordance with age. RESULTS: E. vermicularis infections were found in 4.2% of infants, 16.7%, of PSAC, and 26.3% of SAC. S. stercoralis infections were detected in 5.8%, 7.5%, and 7.1% of infants, PSAC, and SAC, respectively. Multivariable regression analyses revealed higher odds of enterobiasis in children of all age-groups with a reported anthelminthic treatment history over the past six months (odds ratio (OR): 2.15; 95% confidence interval (CI): 1.22 - 3.79) and in SAC with a higher temperature (OR: 2.21; CI: 1.13 - 4.33). Strongyloidiasis was associated with eosinophilia (OR: 2.04; CI: 1.20-3.48) and with Trichuris trichiura infections (OR: 4.13; CI: 1.04-16.52) in children of all age-groups, and with asymptomatic Plasmodium parasitaemia (OR: 13.03; CI: 1.34 - 127.23) in infants. None of the investigated helminthiases impacted significantly on the nutritional status and anaemia, but moderate asymptomatic Plasmodium parasitaemia was a strong predictor for anaemia in children aged older than two years (OR: 2.69; 95% CI: 1.23 - 5.86). CONCLUSIONS: E. vermicularis and S. stercoralis infections were moderately prevalent in children from rural coastal Tanzania. Our data can contribute to inform yet missing global burden of disease and prevalence estimates for strongyloidiasis and enterobiasis. The association between S stercoralis and asymptomatic Plasmodium parasitaemia found here warrants further comprehensive investigations.

[Infection due to Strongyloides stercoralis: epidemiological, clinical, diagnosis findings and outcome in 30 patients]. / Infección por Strongyloides stercoralis: estudio epidemiológico, clínico, diagnóstico y terapéutico en 30 pacientes.

BACKGROUND: Strongyloides stercoralis is a nematode parasite, which is endemic in tropical and subtropical regions. Infection usually remains asymptomatic, but in immunocompromised hosts severe and life-threatening manifestations such as hyperinfection syndrome and disseminated disease might occur. METHODS: We retrospectively analyzed the epidemiological and clinical characteristics, including HIV co-infection, microbiological findings, and outcome in 30 patients with strongyloidiasis, who attended in the Infectious Diseases F. J. Muñiz Hospital in Buenos Aires from January 2004 to December 2008. RESULTS: The study included 20 men and 10 women with an average age of 33 years. HIV co-infection was present in 21 patients (70%) with a median CD4 T cell count of 50 cells/mm³ (range 7-355) (average 56 cells/mm³). Among HIV negative patients the following comorbidities were detected: tuberculosis (n = 3) and chronic alcoholism, leprosy treated with corticosteroids, immunosuppressive treatment for psoriasis, and diabetes mellitus (each in one patient). Two patients did not have any predisposing diseases or immunosuppressive treatments. Seventeen patients presented with diarrhea and were classified as chronic intestinal strongyloidiasis (57%), asymptomatic infection with peripheral eosinophilia was diagnosed in 7 (23%), and 6 patients (20%) developed hyperinfection syndrome. Seventeen patients (57%) presented peripheral eosinophilia. Diagnosis was achieved by direct visualization of larvae in feces by Baermann technique (n = 20), by multiple stool smears examinations (n = 2), by combination of both (n = 1), by visualization of the filariform larvae in duodenal fluid and stool (n = 1), and in fecal and bronchoalveolar lavage specimens (n = 6). Overall mortality in this series was 20% (6/30). There was no significant correlation between age and mortality. A significant inverse correlation between the survival rate and CD4 T-cell count as well as eosinophilia was observed. There was also a significant correlation between HIV co-infection and mortality. Twenty-two patients responded favorably to treatment with ivermectin.

Immunization with the recombinant antigen Ss-IR induces protective immunity to infection with Strongyloides stercoralis in mice.

Human intestinal infections with the nematode Strongyloides stercoralis remain a significant problem worldwide and a vaccine would be a useful addition to the tools available to prevent and control this infection. The goal of this study was to test single antigens for their efficacy in a vaccine against S. stercoralis larvae in mice. Alum was used as the adjuvant in these studies and antigens selected for analysis were either recognized by protective human IgG (Ss-TMY-1, Ss-EAT-6, and Ss-LEC-5) or were known to be highly immunogenic in humans (Ss-NIE-1 and Ss-IR). Only mice immunized with the Ss-IR antigen demonstrated a significant decrease of approximately 80% in the survival of larval parasites in the challenge infection. Antibodies, recovered from mice with protective immunity to S. stercoralis after immunization with Ss-IR, were used to locate the antigen in the larvae. Confocal microscopy revealed that IgG from mice immunized with Ss-IR bound to the surface of the parasites and observations by electron microscopy indicated that IgG bound to granules in the glandular esophagus. Serum collected from mice immunized with Ss-IR passively transferred immunity to naïve mice. These studies demonstrate that Ss-IR, in combination with alum, induces high levels of protective immunity through an antibody dependent mechanism and may therefore be suitable for further development as a vaccine against human strongyloidiasis.

Infección por Strongyloides stercoralis: estudio epidemiológico, clínico, diagnóstico y terapéutico en 30 pacientes / Infection due to Strongyloides stercoralis: epidemiological, clinical, diagnosis findings and outcome in 30 patients

Background: Strongyloides stercoralis is a nematode parasite, which is endemic in tropical and subtropical regions. Infection usually remains asymptomatic, but in immunocompromised hosts severe and life-threatening manifestations such as hyperinfection syndrome and disseminated disease might occur. Methods: We retrospectively analyzed the epidemiological and clinical characteristics, including HIV co-infection, microbiological findings, and outcome in 30 patients with strongyloidiasis, who attended in the Infectious Diseases F. J. Muñiz Hospital in Buenos Aires from January 2004 to December 2008. Results: The study included 20 men and 10 women with an average age of 33 years. HIV co-infection was present in 21 patients (70 percent) with a median CD4 T cell count of 50 cells/mm³ (range 7-355) (average 56 cells/mm³). Among HIV negative patients the following comorbidities were detected: tuberculosis (n = 3) and chronic alcoholism, leprosy treated with corticosteroids, immunosuppressive treatment for psoriasis, and diabetes mellitus (each in one patient). Two patients did not have any predisposing diseases or immunosuppressive treatments. Seventeen patients presented with diarrhea and were classified as chronic intestinal strongyloidiasis (57 percent), asymptomatic infection with peripheral eosinophilia was diagnosed in 7 (23 percent), and 6 patients (20 percent) developed hyperinfection syndrome. Seventeen patients (57 percent) presented peripheral eosinophilia. Diagnosis was achieved by direct visualization of larvae in feces by Baermann technique (n = 20), by multiple stool smears examinations (n = 2), by combination of both (n = 1), by visualization of the filariform larvae in duodenal fluid and stool (n = 1), and in fecal and bronchoalveolar lavage specimens (n = 6). Overall mortality in this series was 20 percent (6/30). There was no significant correlation between age and mortality. A significant inverse correlation between the survival rate and CD4 T-cell count as well as eosinophilia was observed. There was also a significant correlation between HIV co-infection and mortality. Twenty-two patients responded favorably to treatment with ivermectin.

Antecedentes: Strongyloides stercoralis, parásito endémico de áreas tropicales y subtropicales del planeta, en sujetos inmunodeprimidos puede cursar con formas graves y aun mortales como el síndrome de hiperinfestación y la enfermedad diseminada. Métodos: Análisis retrospectivo de las características epidemiológicas, manifestaciones clínicas, co-infección por virus de inmunodeficiencia humana (VIH), hallazgos microbiológicos y evolución de 30 pacientes con estrongiloidiasis, atendidos en el Hospital de Enfermedades Infecciosas F. J. Muñiz de Buenos Aires, entre enero 2004 y diciembre 2008. Resultados: Se incluyeron en la evaluación 20 hombres y 10 mujeres con una mediana de edad de 33 años. Co-infección por VIH hubo en 21 pacientes (70 por ciento); la mediana de linfocitos T CD4+ en ellos al momento del diagnóstico de la parasitosis fue de 50 céls/mm³ (rango 7 a 355), (media de 56 céls/mm³). En los pacientes seronegativos para VIH, se comprobaron las siguientes co-morbilidades: tuberculosis (n: 3) y un caso de cada una de las siguientes afecciones: alcoholismo crónico, diabetes mellitus, reacción lepromatosa bajo corticotera-pia, y psoriasis en tratamiento inmunosupresor. Hubo dos pacientes sin aparentes enfermedades de base. Diecisiete pacientes presentaron enfermedad intestinal crónica con diarrea (57 por ciento), era asintomática y fue sospechada por la eosinofilia periférica (n: 7, 23 por ciento) y se clasificó como síndrome de hiperinfestación (n: 6, 20 por ciento) diagnosticado por la identificación de larvas en la materia fecal y secreciones broncopulmonares. Diecisiete pacientes (57 por ciento) presentaron eosinofilia periférica. El diagnóstico se efectuó por la visualización directa de las larvas en muestras de heces en fresco mediante la técnica de concentración de Baer-man (n: 20); por el examen copro-parasitológico seriado (n: 2) y por ambos métodos (n: 1); en líquido duodenal y materia fecal (n: 1) y por la identificación de larvas en materia fecal y secreciones respiratorias (n: 6). Letalidad global: 20 por ciento (6/30). Los pacientes con eosinofilia tuvieron una menor letalidad que aquellos sin esta respuesta (p < 0,001). No hubo correlación estadística entre la edad y la supervivencia. Sí fue significativa la correlación entre el recuento de CD4 y la letalidad, incluyendo 18 de los 21 pacientes seropositivos para VIH (p: 0,03). Finalmente, la correlación seropositividad para VIH y letalidad también fue significativa. Veintidós pacientes respondieron a la terapia antiparasitaria con ivermectina y evolucionaron favorablemente.

Strongyloidiasis-related deaths in the United States, 1991-2006.

The objective of this study was to 1) assess the incidence of strongyloidiasis in the United States, 2) evaluate demographic and regional associations, and 3) identify comorbid conditions as risk factors for death. A population-based case-control study was performed by using mortality data during 1991-2006. We identified 347 strongyloidiasis deaths (0.79 per 10 million deaths, 14-29 deaths per year), which decreased slightly over time. Deaths occurred primarily among older (median age = 66.0 years), white (57.6%) and Hispanic (22.2%) men (69.2%), residing in the Southeastern United States (49.3%). Associated health conditions included chronic obstructive pulmonary disease (28.7%, odds ratio [OR] = 4.0, 95% confidence interval [CI] = 3.0-5.4) and infection with human immunodeficiency virus (12.5%, OR = 4.6, 95% CI = 2.7-7.9). Strongyloidiasis deaths in the second half of the study period (1999-2006) were less likely to be associated with chronic obstructive pulmonary disease (19.4%, OR = 1.2, 95% CI = 0.7-1.9), but continued to be associated with human immunodeficiency virus infection (12.9%, OR = 2.8, 95% CI = 1.3-6.0). Early detection and treatment of at-risk patients with latent strongyloidiasis infections is needed to reduce strongyloidiasis mortality.

Strongyloidiasis in transplant patients.

Strongyloides stercoralis is an intestinal nematode that can persist in the human host for decades after the initial infection and can progress to fulminant hyperinfection syndrome in immunocompromised hosts. We describe a patient who died of Strongyloides hyperinfection syndrome 2 months after orthotopic heart transplantation and discuss approaches to prevention, diagnosis, and treatment. Current practice guidelines recommend screening for and treatment of Strongyloides infection before transplantation, but physicians in the United States often miss opportunities to identify patients with chronic strongyloidiasis. Screening tests have limitations, and clinical suspicion remains an important component of the evaluation before transplantation. After immunocompromised patients develop hyperinfection syndrome, diagnosis is often delayed and mortality is high, so emphasis must be placed on screening and treatment before transplantation. We review current strategies for prevention, diagnosis, and treatment of chronic intestinal strongyloidiasis in patients who will undergo transplantation and discuss the clinical features and management of Strongyloides hyperinfection syndrome in transplant recipients.

[Infections in hospitalized patients with cirrhosis]. / Infecciones en pacientes hospitalizados por cirrosis.

We evaluated the prevalence and the clinical relevance of bacterial and nonbacterial infections in predominantly alcoholic cirrhotic patients, admitted to an intermediate complexity hospital, and we also compared the clinical characteristics, laboratory and evolution of these patients with and without bacterial infection in a prospective study of cohort. A total of 211 consecutive admissions in 132 cirrhotic patients, between April 2004 and July 2007, were included. The mean age was 51.8 (+/-8) years, being 84.8% male. The alcoholic etiology of cirrhosis was present in 95.4%. One hundred and twenty nine episodes of bacterial infections were diagnosed in 99/211 (46.9%) admissions, community-acquired in 79 (61.2%) and hospital-acquired in 50 (38.8%): spontaneous bacterial peritonitis (23.3%); urinary tract infection (21.7%); pneumonia (17.8%); infection of the skin and soft parts (17.1%), sepsis by spontaneous bacteremia (7.7%); other bacterial infections (12.4%). Gram-positive organisms were responsible for 52.2% of total bacterial infections documented cases. There were eight serious cases of tuberculosis, fungal and parasitic infections; the prevalence of tuberculosis was 6% with an annual mortality of 62.5%; 28.1% (9/32) of the coproparasitological examination had Strongyloides stercolaris. The in-hospital mortality was significantly higher in patients with bacterial infection than in non-infected patients (32.4% vs. 13.2%; p=0.02). The independent factors associated with mortality were bacterial infections, the score of Child-Pügh and creatininemia > 1.5 mg/dl. By the multivariate analysis, leukocytosis and hepatic encephalopathy degree III/IV were independent factors associated to bacterial infection. This study confirms that bacterial and nonbacterial infections are a frequent and severe complication in hospitalized cirrhotic patients, with an increase of in-hospital mortality.

Infecciones en pacientes hospitalizados por cirrosis / Infections in hospitalized patients with cirrhosis

Evaluamos la prevalecencia y relevancia clínica de las infecciones bacterianas y no bacterianas en pacientes cirróticos predominantemente alcohólicos internados en un hospital de mediana complejidad, y comparamos las características clínicas, de laboratorio y la evolución de pacientes con y sin infección bacteriana en un estudio prospectivo de cohorte. Se incluyeron 211 internaciones consecutivas de 132 pacientes con diagnóstico de cirrosis, de abril 2004 a julio 2007. El promedio de edad (±DS) fue 51.8 (±8) años, 112 fueron hombres (84.8%); etiología alcohólica 95.4%. Se diagnosticaron 129 episodios de infecciones bacterianas en 99/211 (46.9%) internaciones, adquiridos en la comunidad 79 (61.2%) y 50 (38.8%) intrahospitalarios: peritonitis bacteriana espontánea (23.3%); infección urinaria (21.7%); neumonías (17.8%); infecciones de piel y partes blandas (17.1%); sepsis por bacteriemia espontánea (7.7%); otras infecciones bacterianas (12.4%). El 52.2% fueron por gérmenes gram-positivos. Hubo ocho casos de tuberculosis e infecciones graves por hongos y parásitos. La prevalecencia de tuberculosis fue del 6% con una mortalidad anual de 62.5%. El 28.1% (9/32) de los exámenes coproparasitológicos tuvieron Strongyloides stercolaris. La mortalidad hospitalaria fue mayor en los pacientes con infección bacteriana (32.4% vs. 13.2%; p=0.02). Fueron identificados como predictores independientes de mortalidad: las infecciones bacterianas, el score de Child-Pügh y creatininemia > 1.5 mg/dl. En el análisis multivariado fueron factores independientes asociados a infección bacteriana la leucocitosis y la encefalopatía hepática grado III/IV. Este estudio confirma que las infecciones bacterianas y no bacterianas son una complicación frecuente y grave en pacientes cirróticos internados, con un aumento de la mortalidad hospitalaria.

We evaluated the prevalence and the clinical relevance of bacterial and nonbacterial infections in predominantly alcoholic cirrhotic patients, admitted to an intermediate complexity hospital, and we also compared the clinical characteristics, laboratory and evolution of these patients with and without bacterial infection in a prospective study of cohort. A total of 211 consecutive admissions in 132 cirrhotic patients, between April 2004 and July 2007, were included. The mean age was 51.8 (±8) years, being 84.8% male. The alcoholic etiology of cirrhosis was present in 95.4%. One hundred and twenty nine episodes of bacterial infections were diagnosed in 99/211 (46.9%) admissions, community- acquired in 79 (61.2%) and hospital-acquired in 50 (38.8%): spontaneous bacterial peritonitis (23.3%); urinary tract infection (21.7%); pneumonia (17.8%); infection of the skin and soft parts (17.1%), sepsis by spontaneous bacteremia (7.7%); other bacterial infections (12.4%). Gram-positive organisms were responsible for 52.2% of total bacterial infections documented cases. There were eight serious cases of tuberculosis, fungal and parasitic infections; the prevalence of tuberculosis was 6% with an annual mortality of 62.5%; 28.1% (9/32) of the coproparasitological examination had Strongyloides stercolaris. The in-hospital mortality was significantly higher in patients with bacterial infection than in non-infected patients (32.4% vs. 13.2%; p=0.02). The independent factors associated with mortality were bacterial infections, the score of Child-Pügh and creatininemia > 1.5 mg/dl. By the multivariate analysis, leukocytosis and hepatic encephalopathy degree III/IV were independent factors associated to bacterial infection. This study confirms that bacterial and nonbacterial infections are a frequent and severe complication in hospitalized cirrhotic patients, with an increase of in-hospital mortality.

Paralytic ileus and subsequent death caused by enteric parasite, Strongyloides papillosus, in Mongolian gerbils.

Adult worms of Strongyloides papillosus were surgically implanted into the duodenum and successfully established in Mongolian gerbils (Meriones unguiculatus). These worms persisted in the small intestine for at least four days after implantation. Following decreased fecal output, however, increased death rate and decreased survival time were observed. The increase in death rate and the decrease in survival time correlated with the increase in the number of implanted adult worms. Animals were then intraperitoneally inoculated with extracts from adult S. papillosus, and the pathogenetic effects of gastrointestinal (GI) motility were assessed by contrast radiography after oral administration of barium sulfate. Paralytic ileus was observed in the GI tracts of Mongolian gerbils and these symptoms intensified with increasing inoculation of adult worm extract. The results suggest that paralytic ileus underlies the subsequent death observed in Mongolian gerbils after implantation of adult S. papillosus. Furthermore, experimental infection with S. papillosus in Mongolian gerbils will provide a good model for laboratory investigations into GI motor disturbances in animals and humans caused by parasites.

Strongyloides colitis is a lethal mimic of ulcerative colitis: the key morphologic differential diagnosis.

Strongyloides stercoralis colitis is a severe, but easily curable, form of strongyloidiasis that carries a high mortality rate if untreated. Autoinfection characteristic of Strongyloides stercoralis frequently makes the infection a life-long disease unless it is effectively treated. Our experience with 4 cases of Strongyloides colitis prompted us to assess the clinical outcome of the disease by literature review. In this case series, the misdiagnosis and resultant mortality rates of Strongyloides colitis are 52% and 39.1%, respectively. A low index of suspicion and morphologic resemblance to ulcerative colitis were the main sources of diagnostic error. Ulcerative colitis alone accounted for 38.5% of the erroneous diagnoses. Features of Strongyloides colitis that contrast with those of ulcerative colitis include (1) skip pattern of the inflammation, (2) distal attenuation of the disease, (3) eosinophil-rich infiltrates, (4) relative intact crypt architecture, and (5) frequent involvement of submucosa. We also found that history of steroid therapy, chronic colitis refractory to conventional immune-modifying management, and endoscopic finding of distal attenuation of the colitis are helpful clues. It is also our experience that if Strongyloides colitis is included in the differential diagnosis, the correct diagnosis can usually be made. Current therapy with ivermectin or albendazole is very effective at a cure rate greater than 98%. We believe that the misdiagnosis and mortality rates of this curable, but often, unnecessarily deadly, infectious disease are alarming and warrant efforts to increase the awareness of the disease.