strongyloides stercoralis in transplant patients alisa alker
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Strongyloides stercoralisStrongyloides stercoralis in transplant patientsin transplant patients
Alisa AlkerAlisa Alker
Life cycle
Geographic distribution
❖ Over 50 million people are infected worldwide
❖ It endemic in Africa, parts of Asia, South America, Mexico, and the Southern US
❖ National survey of 216,275 stool samples in 1987 found the prevalence of S. stercoralis to be 0.4% (CDC, 1991)
Clinical manifestations❖ diarrhea, abdominal pain, nausea, and vomiting
❖ dry cough, dyspnea, transient pulmonary infiltrate, throat irritation, wheezing
❖ Loffler syndrome (eosinophilic pneumonia)
❖ fluctuating eosinophilia
❖ rash (larva currens)
❖ asymptomatic
Severe manifestations❖ Almost always found in immunocompromized hosts
(associated with steroid use, HTLV, lymphoma, not HIV)
❖ Hyperinfection and dissemination, leading to ileus, obstruction, GIB, pneumonitis, meningitis, peritonitis, UTI
❖ the larvae bring with them bowel flora, leading to bacteremia, bacterial pneumonia, bacterial meningitis, etc
❖ mortality is ~50% with treatment
Transplant patients
❖ S. stercoralis has been reported in kidney (n=54), liver (n=3), lung (n=1), heart (n=3) and stem cell (n=7) transplant patients
❖ More common for transplant patients to have hyperinfection, though more mild presentations have been reported
❖ 0.7% of the renal transplant recipients between 1971-1984 at Vanderbilt had strongloidiasis (Morgan 1986)
Transplant patients
❖ Strongloidiasis can be transmitted by solid organs and it has been documented in people who have not left the US
❖ presentation more likely after transplantation or after treatment of acute rejection
❖ associated with steroid use
❖ cyclosporine may be protective
❖ mortality rate in kidney transplant patients: 49% (Roxby 2009)
Diagnosis
Roxby 2009
Treatment
❖ ivermectin 200 ug/kg once daily for 2-3 days
❖ thiabendazole 25 mg/kg twice daily for 3 days
❖ more effective in killing the adult worms than the migrating larvae
Prevention
❖ wearing shoes
❖ improved sanitation
❖ screening prior to transplantation?
References1. Neva FA. Biology and immunology of human strongyloidiasis. J. Infect. Dis. 1986
Mar ;153(3):397-406.
2. Siddiqui AA, Berk SL. Diagnosis of Strongyloides stercoralis infection. Clin. Infect. Dis. 2001 Oct 1;33(7):1040-1047.
3. Segarra-Newnham M. Manifestations, diagnosis, and treatment of Strongyloides stercoralis infection. Ann Pharmacother. 2007 Dec ;41(12):1992-2001.
4. DeVault GA, King JW, Rohr MS, Landreneau MD, Brown ST, McDonald JC. Opportunistic infections with Strongyloides stercoralis in renal transplantation. Rev. Infect. Dis. 1990 Aug ;12(4):653-671.
5. Morgan JS, Schaffner W, Stone WJ. Opportunistic strongyloidiasis in renal transplant recipients. Transplantation. 1986 Nov ;42(5):518-524.
6. Marty FM. Strongyloides hyperinfection syndrome and transplantation: a preventable, frequently fatal infection. Transpl Infect Dis. 2009 Apr ;11(2):97-99.
7. Vilela EG, Clemente WT, Mira RRL, Torres HOG, Veloso LF, Fonseca LP, et al. Strongyloides stercoralis hyperinfection syndrome after liver transplantation: case report and literature review. Transpl Infect Dis. 2009 Apr ;11(2):132-136.
8. Roxby AC, Gottlieb GS, Limaye AP. Strongyloidiasis in transplant patients. Clin. Infect. Dis. 2009 Nov 1;49(9):1411-1423.
9. Mandell G, Bennett J, Dolin R. Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, PA: Elsevier;
10. Center for Disease Control and Prevention. CDC surveillance summaries. MMWR. 1991 ;40(SS):