Invasive enteritis by Strongyloides stercoralis presenting as acute abdominal distress under corticosteroid therapy

Abstract

Overwhelming helminthiasis is still a problem in endemic areas, especially in immunocompromised patients. We report a case of invasive intestinal strongyloidiasis that was clinically expressed as acute abdominal distress in a 73-year-old man from São Paulo who had been receiving methylprednisone, 20 mg/day, for one year for osteoarthritis. A surgical specimen from the ileum revealed invasive enteritis with severe infestation by Strongyloides stercoralis. The patient died of sepsis 6 days after surgery. The possibility of invasive strongyloidiasis should be considered in the differential diagnosis of acute abdominal distress in patients undergoing immunosuppressive therapy.

HIGH PREVALENCE OF Strongyloides stercoralis INFECTION AMONG THE ELDERLY IN BRAZIL

“…Some reports have described a significant association between human T cell lymphotropic virus type-1 (HTLV-1) and S. stercoralis hyperinfection20 40 41. Case reports of hyperinfection syndrome or disseminated infection in immunocompromised elderly showed high mortality indexes associated with the use of immunosuppressive therapy as well as protein-caloric malnutrition and the aging process32 42. Chronic alcoholism is another factor referred to as a predisposition to strongyloidiasis, and the frequency of infection by S. stercoralis in alcoholic patient varies from 33.3% to 44%1 42.…”

“…Among the parasitic nematodes, Strongyloides stercoralis is the most aggressive parasite, since it may cause hyperinfection and dissemination of strongyloidiasis through auto-infection20 23 27. Thus, chronic intestinal parasitism in elderly patients may result in a serious health problem27 29 32.…”

Dexamethasone Effects in the Strongyloides venezuelensis Infection in A Murine Model

“…9,[27][28][29] Immunosuppression with glucocorticoid treatment can reactivate latent diseases such as tuberculosis, 29 Chagas disease, 30 leishmaniasis, 31 toxoplasmosis, 32 cryptosporidiosis, 33 amebiasis, 34 and strongyloidiasis. 35,36 The antiinflammatory activity of glucocorticoids is caused by interactions between the drug and the glucocorticoid receptor within the cytoplasm, which then translocates into the nucleus where it promotes the transcription of several inflammatory genes encoding cytokines, enzymes, receptors, and adhesion molecules. The major consequence of glucocorticoids that affect the transcription factors, such as nuclear factor-κB (NF-κB) and AP-1, is the potent reduction in the synthesis of the cytokines IL-1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-9, IL-13, and GM-CSF, the chemokines IL-8, RANTES, MCP-1, MCP-3, MCP-4, and eotaxin, 9,13,37 and the antibodies IgG, IgM, and IgA.…”

Infections with biological therapy: strategies for risk minimization in tropical and developing countries

“…Amoebiasis prophylaxis should be given before the onset of therapy with secnidazole 2 grams orally single dose, and repeated every year if the patient's immunosuppression persists or if the patient lives in an endemic area [38]. Regarding strongylodiasis, some studies have shown an association between SLE patients with corticosteroids and hyperinfection due to Strongyloides stercoralis [38,40,41]. This nematode can even migrate in this clinical context to the central nervous system, which is a life-threating condition.…”