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Strongyloides stercoralis in
transplant patients
Alisa Alker
Life cycle
Geographic distribution
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Over 50 million people are infected worldwide
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It endemic in Africa, parts of Asia, South America,
Mexico, and the Southern US
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National survey of 216,275 stool samples in 1987 found
the prevalence of S. stercoralis to be 0.4% (CDC, 1991)
Clinical manifestations
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diarrhea, abdominal pain, nausea, and vomiting
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dry cough, dyspnea, transient pulmonary infiltrate, throat
irritation, wheezing
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Loffler syndrome (eosinophilic pneumonia)
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fluctuating eosinophilia
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rash (larva currens)
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asymptomatic
Severe manifestations
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Almost always found in immunocompromized hosts
(associated with steroid use, HTLV, lymphoma, not HIV)
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Hyperinfection and dissemination, leading to ileus,
obstruction, GIB, pneumonitis, meningitis, peritonitis, UTI
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the larvae bring with them bowel flora, leading to
bacteremia, bacterial pneumonia, bacterial meningitis, etc
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mortality is ~50% with treatment
Transplant patients
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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
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More common for transplant patients to have
hyperinfection, though more mild presentations have
been reported
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0.7% of the renal transplant recipients between 19711984 at Vanderbilt had strongloidiasis (Morgan 1986)
Transplant patients
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Strongloidiasis can be transmitted by solid organs and it
has been documented in people who have not left the US
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presentation more likely after transplantation or after
treatment of acute rejection
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associated with steroid use
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cyclosporine may be protective
mortality rate in kidney transplant patients: 49% (Roxby 2009)
Diagnosis
Roxby 2009
Treatment
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ivermectin 200 ug/kg once daily for 2-3 days
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thiabendazole 25 mg/kg twice daily for 3 days
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more effective in killing the adult worms than the
migrating larvae
Prevention
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wearing shoes
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improved sanitation
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screening prior to transplantation?
References
1. Neva FA. Biology and immunology of human strongyloidiasis. J. Infect. Dis. 1986 Mar ;153(3):397406.
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):