Case Report: Disseminated Strongyloidiasis in a Patient with COVID-19.

The SARS-CoV-2 virus has emerged and rapidly evolved into a current global pandemic. Although bacterial and fungal coinfections have been associated with COVID-19, little is known about parasitic infection. We report a case of a COVID-19 patient who developed disseminated strongyloidiasis following treatment with high-dose corticosteroids and tocilizumab. Screening for Strongyloides infection should be pursued in individuals with COVID-19 who originate from endemic regions before initiating immunosuppressive therapy.

Strongyloides stercoralis: a rare and severe presentation in a pregnant woman.

Strongyloides stercoralis is a parasitic nematode with a worldwide distribution. It can go from an asymptomatic infection to a life-threatening hyperinfection syndrome. Here, we report a case of intestinal obstruction due to S. stercoralis in a pregnant woman. This condition, as well as severe strongyloidiasis in pregnant women, is seldomly reported. In this case, Human T-lymphotropic Virus 1 (HTLV-1) coinfection was confirmed, a well-known risk factor for a more severe presentation of strongyloidiasis. We suggest that HTLV status should be screened in every severe S. stercoralis infection, or when, despite a correct treatment, a relapse is observed.

[Strongyloides hyperinfection in patient from Patagonia with HTLV-1 co-infection]. / Hiperinfección por Strongyloides en paciente de la Patagonia con co-infección por HTLV-1.

Strongylodiasis is an unattended condition caused by the parasite Strongyloides stercoralis. The Strongyloides hyperinfection syndrome can develop in immunosuppressed hosts, mainly in those with depression of cellular immunity. Co-infection with human T-cell lymphotropic virus (HTLV) is a risk factor for the development of severe forms of strongyloidiasis. We present the case of a 50-year-old man with Strongyloides hyperinfection and coinfection with HTLV. The diagnosis was delayed owing to its unusual epidemiology and an initial suspicion of inflammatory bowel disease. Identification of the parasite in bronchioalveolar lavage and duodenal and colonic mucosa biopsies confirmed the diagnosis. Subcutaneous ivermectin was used as an anthelmintic treatment with an adequate therapeutic response.

La estrongiloidiasis es una afección desatendida causada por el parásito Strongyloides stercoralis. En los individuos inmunosuprimidos, fundamentalmente en los que tienen depresión de la inmunidad celular, puede desarrollarse el síndrome de hiperinfección por Strongyloides. La coinfección con virus linfotrópico de células T humanas (HTLV) es un factor de riesgo para el desarrollo de formas graves de estrongiloidiasis. Presentamos el caso de un hombre de 50 años con hiperinfección por Strongyloides y coinfección con HTLV. Se demoró el diagnóstico debido a su epidemiología inusual y a la sospecha inicial de enfermedad inflamatoria intestinal. El diagnóstico se confirmó mediante la identificación del parásito en muestras de lavado bronquio-alveolar y biopsias de mucosa duodenal y colónica. Se utilizó ivermectina subcutánea como tratamiento antihelmíntico con adecuada respuesta terapéutica.

Hiperinfección por Strongyloides en paciente de la Patagonia con co-infección por HTLV-1 / Strongyloides hyperinfection in patient from Patagonia with HTLV-1 co-infection

La estrongiloidiasis es una afección desatendida causada por el parásito Strongyloides stercoralis. En los individuos inmunosuprimidos, fundamentalmente en los que tienen depresión de la inmunidad celular, puede desarrollarse el síndrome de hiperinfección por Strongyloides. La coinfección con virus linfotrópico de células T humanas (HTLV) es un factor de riesgo para el desarrollo de formas graves de estrongiloidiasis. Presentamos el caso de un hombre de 50 años con hiperinfección por Strongyloides y coinfección con HTLV. Se demoró el diagnóstico debido a su epidemiología inusual y a la sospecha inicial de enfermedad inflamatoria intestinal. El diagnóstico se confirmó mediante la identificación del parásito en muestras de lavado bronquio-alveolar y biopsias de mucosa duodenal y colónica. Se utilizó ivermectina subcutánea como tratamiento antihelmíntico con adecuada respuesta terapéutica.

Strongylodiasis is an unattended condition caused by the parasite Strongyloides stercoralis. The Strongyloides hyperinfection syndrome can develop in immunosuppressed hosts, mainly in those with depression of cellular immunity. Co-infection with human T-cell lymphotropic virus (HTLV) is a risk factor for the development of severe forms of strongyloidiasis. We present the case of a 50-year-old man with Strongyloides hyperinfection and coinfection with HTLV. The diagnosis was delayed owing to its unusual epidemiology and an initial suspicion of inflammatory bowel disease. Identification of the parasite in bronchioalveolar lavage and duodenal and colonic mucosa biopsies confirmed the diagnosis. Subcutaneous ivermectin was used as an anthelmintic treatment with an adequate therapeutic response.

Persistent strongyloidiasis complicated by recurrent meningitis in an HTLV seropositive Peruvian migrant resettled in Italy.

We describe a case of persistent strongyloidiasis complicated by recurrent meningitis, in a human T cell lymphotropic virus type 1 (HTLV-1) seropositive Peruvian migrant adult resettled in Italy. He was admitted with signs and symptoms of acute bacterial meningitis, reporting four other meningitis episodes in the past 6 years, with an etiological diagnosis of Escherichia coli and Enterococcus faecium in two cases. He had been previously treated with several antihelmintic regimens not including ivermectin, without eradication of strongyloidiasis, and he had never been tested for HTLV before. During the described episode, the patient was treated for meningitis with broad-spectrum antibiotic therapy and 200 µg/kg/dose oral ivermectin once daily on day 1, 2, 15 and 16 with full recovery and no further episodes of meningitis. The presented case underlines several critical points concerning the management of poorly known neglected diseases such as strongyloidiasis and HTLV infection in low-endemic areas. Despite several admissions for meningitis and strongyloidiasis, the parasitic infection was not adequately treated and the patient was not previously tested for HTLV. The supply of ivermectin and the choice of treatment scheme was challenging since ivermectin is not approved in Italy and there are no standardized guidelines for the treatment of severe strongyloidiasis in HTLV seropositive subjects.

Meningitis associated with strongyloidiasis in an area endemic for strongyloidiasis and human T-lymphotropic virus-1: a single-center experience in Japan between 1990 and 2010.

Meningitis caused by enteric flora is a known complication of strongyloidiasis, and human T-lymphotropic virus-1 (HTLV-1) predisposes individuals to severe strongyloidiasis. We reviewed the clinical features of bacterial meningitis associated with strongyloidiasis seen at a single center in subtropical Japan, in an area endemic for both strongyloidiasis and HTLV-1. We found 33 episodes in 21 patients between 1990 and 2010. The results were remarkable for the high incidence of meningitis due to Gram-positive cocci (27.3 %), especially Streptococcus bovis, and culture-negative cases (42.4 %). Given the high incidence of Gram-positive meningitis, a modified approach to corticosteroid use would be advisable in areas where strongyloidiasis is endemic, due to the potentially adverse consequences of glucocorticoid therapy.

Eosinophilia: clinical significance in HIV-infected individuals.

This study was conducted to determine the relationship between eosinophilia and parasitic infection in HIV-infected individuals. HIV-positive patients attending an HIV clinic in Birmingham were recruited and classified as either eosinophilic (>400 eosinophils/mm(3)) or non-eosinophilic. A demographic and parasitic risk history was taken and clinical examination was performed. Urine and stool were examined for parasites, and blood samples taken for parasite serology. A total of 266 patients (96 eosinophilic and 170 non-eosinophilic) were recruited. Of 64 eosinophilic patients who had a stool examination, one (1.6%) was positive for both Strongyloides larvae and schistosomal eggs. Urine microscopy was negative in the 245 patients (88 eosinophilic, 157 non-eosinophilic) from whom a sample was available. Two hundred and sixty-three patients underwent serological investigation (96 eosinophilic and 167 non-eosinophilic): 13 (4.9%) were positive for schistosomiasis and three (1.1%) positive for Strongyloides. A significant association between eosinophilia and positive schistosomal serology was found (P = 0.003): 11 (10.5%) were eosinophilic patients, while only four (2.3%) were non-eosinophilic patients. Eosinophilia was associated with a low nadir CD4 count (P = 0.021) and prior AIDS-defining illness (P = 0.041). In all, 7.8% of patients from a developing country and 5.3% of patients from a developed country with a travel history had positive parasitic serology. Eosinophilia in HIV-infected patients was significantly associated with positive serology for schistosomiasis, low nadir CD4 count and prior AIDS-defining illness. Geographical exposure is also an important determinant of positive parasitic serology.

Seroepidemiology of Strongyloides stercoralis in Dhaka, Bangladesh.

Human strongyloidiasis is a neglected tropical disease with global distribution and this infection is caused by the parasitic nematode Strongyloides stercoralis. The aim of this study was to determine the prevalence of strongyloidiasis in Dhaka, Bangladesh. Sera from 1004 residents from a slum (group A) and 299 from city dwellers (group B) were tested for total IgG and IgG subclasses to Strongyloides antigen. There was a significant difference (P < 0·001) in IgG seroprevalence between group A (22%) and group B (5%). Reactive IgG subclasses (IgG1 and IgG4) were also higher in group A (P < 0·05). The seroprevalence of strongyloidiasis in group A increased with age but was unrelated to sex. The presence of reactive IgG to Strongyloides antigen had no correlation with either socio-economic or personal hygiene factors. However, a history of diarrhoea in a family member, in the past 6 months, but not in the respondents was associated with detection of antibodies to S. stercoralis (P < 0·01). None of the sera from either group had an HTLV-I reaction. This study demonstrates that strongyloidiasis is prevalent in Dhaka, especially among slum dwellers, but concurrent infection with HTLV-I was not found. Future epidemiological studies should identify individual risk factors and other communities at risk so that appropriate interventions can be planned.

Fatal relapse of disseminated strongyloidiasis in an HIV-positive patient, despite ivermectin treatment.

There are no established guidelines for the treatment of disseminated strongyloidiasis in immunosuppressed patients, and many different treatment regimens have been used. Here, the case of a 48-year-old, HIV-positive, Congolese man, who was hospitalized for disseminated tuberculosis but developed life-threatening disseminated strongyloidiasis, is described. This patient died, with relapsing disseminated strongyloidiasis, 3 months after being treated with ivermectin. The reasons for this poor outcome and the various treatment options for strongyloidiasis in HIV-infected patients are discussed.

[Human T-lymphotropic virus 1 (HTLV-1), strongyloidiasis and scabies. Infections and associations to considerate]. / Virus linfotrópico T humano 1 (HTLV-1), strongyloidiasis y escabiosis. Infecciones y asociaciones a considerar.

Human T-lymphotropic virus 1 (HTLV-1) is classified into the family of Retroviridae and preferentially causes a chronic infection of CD4+ T cells. Most people infected with HTLV-1 remain asymptomatic. However, less than 105 of infected individuals eventually develop any of the associated severe diseases such as inflammatory syndromes, neoplastic diseases and opportunistic infections including Strongyloides stercoralis and Sarcoptes scabiei hyperinfections. Recently, it has been described that a weak Th2 cell-mediated response is associated with HTLV-1 infection and Strongyloides hyperinfection. The evaluation for HTLV-1 in all Norwegian scabies and S. stercoralis hyperinfection cases is highly recommended, especially when no other risk factors are apparent, in order to start a specific therapy against these parasite-virus coinfections.

Dissemination of Strongyloides stercoralis as an immune restoration phenomenon in an HIV-1-infected man on antiretroviral therapy.

We present a case of Strongyloides stercoralis infection in an HIV-infected man, resulting in Escherichia coli meningitis after initiation of antiretroviral therapy. Recent evidence from studies of strongyloides development supports the concept that strongyloides dissemination in this case is an example of an immune reconstitution inflammatory syndrome.

Intestinal parasitoses.

BACKGROUND: Intestinal parasitoses is a clinical problem in the developing world and severe parasitaemia may be associated with retroviruses. OBJECTIVE: Studies on intestinal parasitoses were conducted in Dominica, and the health implications in an HTLV-1 endemic area were discussed. METHOD OF STUDY: A retrospective study of data of stool samples analysed at the parasitology unit of the medical laboratory services of Princess Margaret Hospital, Dominica, was conducted in January-December 1999. RESULTS: Parasites were found in 393 out of 3,752 stool samples (10.47%). The main parasites were Entamoeba coli, 1.4% (51/3,752); hookworm, 1.5% (56/3,752); Giardia lamblia, 1.4% (51/3,752); Strongyloides stercoralis, 1.0% (37/3,752); Ascaris lumbricoides, 0.8% (28/3,752); and Trichuris trichiura, 0.9% (34/3,752). CONCLUSION: Intestinal parasites are still endemic in Dominica, but significant reduction in prevalence has occurred over the last two decades.

Predictive markers for development of strongyloidiasis in patients infected with both Strongyloides stercoralis and HTLV-1.

Severe strongyloidiasis has often been reported to occur in some patients infected with both Strongyloides stercoralis (S. stercoralis) and human T-cell leukaemia virus type 1 (HTLV-1); however, there are few useful predictive markers for the risk of development of strongyloidiasis in these patients. To search for such predictive markers, we examined peripheral blood and stool samples of individuals infected with both S. stercoralis and HTLV-1 in Okinawa, Japan, an area in which both of these are endemic. The HTLV-1 proviral load and antibody titre were examined in relation to the S. stercoralis load as measured by the direct faecal smear method in patients infected with both S. stercoralis and HTLV-1. The Epstein-Barr virus (EBV)-associated nuclear antigen (EBNA) antibody titre was also measured in these patients in order to examine the relationship between host immunity and HTLV-1 proviral load or antibody titre. The direct faecal smear-positive group showed both a higher HTLV-1 proviral load and HTLV-1 antibody titre than the -negative group (P < 0.05). In contrast, inverse correlations of these parameters with the EBNA antibody titre were observed, especially for proviral load (rho = -0.387, P < 0.05). These results suggest that HTLV-1 proviral load and antibody titre influence the S. stercoralis load via disturbance of the host immunity, and that proviral load would be an especially useful predictive marker of the risk of development of strongyloidiasis in patients infected with both S. stercoralis and HTLV-1.

High circulating proviral load with oligoclonal expansion of HTLV-1 bearing T cells in HTLV-1 carriers with strongyloidiasis.

Adult T cell leukemia (ATLL) develops in 3 - 5% of HTLV-1 carriers after a long period of latency during which a persistent polyclonal expansion of HTLV-1 infected lymphocytes is observed in all individuals. This incubation period is significantly shortened in HTLV-1 carrier with Strongyloides stercoralis (Ss) infection, suggesting that Ss could be a cofactor of ATLL. As an increased T cell proliferation at the asymptomatic stage of HTLV-1 infection could increase the risk of malignant transformation, the effect of Ss infection on infected T lymphocytes was assessed in vivo in HTLV-1 asymptomatic carriers. After real-time quantitative PCR, the mean circulating HTLV-1 proviral load was more than five times higher in HTLV-1 carriers with strongyloidiasis than in HTLV-1+ individuals without Ss infection (P<0.009). This increased proviral load was found to result from the extensive proliferation of a restricted number of infected clones, i.e. from oligoclonal expansion, as evidenced by the semiquantitative amplification of HTLV-1 flanking sequences. The positive effect of Ss on clonal expansion was reversible under effective treatment of strongyloidiasis in one patient with parasitological cure whereas no significant modification of the HTLV-1 replication pattern was observed in an additional case with strongyloidiasis treatment failure. Therefore, Ss stimulates the oligoclonal proliferation of HTLV-1 infected cells in HTLV-1 asymptomatic carriers in vivo. This is thought to account for the shortened period of latency observed in ATLL patients with strongyloidiasis. Oncogene (2000) 19, 4954 - 4960