Case Report: Rectal Adminstration of Ivermectin to a Patient With Strongyloides Hyperinfection Syndrome

Abstract

Strongyloides hyperinfection syndrome may be complicated by paralytic ileus that interferes with the absorption of oral anti-helminthics. We report on the administration of ivermectin as a rectal enema preparation to a renal transplant recipient with Strongyloides hyperinfection syndrome and progressive ileus. Attempts at treatment using nasogastric albendazole and ivermectin were unsuccessful despite clamping the nasogastric tube after drug administration. Ivermectin tablets were ground to a powder, resuspended in a commercially available suspending agent, and administered per rectum. The suspending agent was chosen for its near-physiologic osmolality to allow longer retention, in contrast to many enema preparations that have a laxative effect. The patient improved markedly within 72 hours of initiation of the therapy per rectum and recovered fully. Ivermectin administered as an enema may be beneficial in patients with severe strongyloidiasis who are unable to absorb or tolerate oral therapy.

Recurrent Streptococcus bovis Meningitis in Strongyloides stercoralis Hyperinfection after Kidney Transplantation: The Dilemma in a Non-Endemic Area

“…7 Multisystem involvement is not rare, as in our case, with paralytic ileus, E. coli acute tracheobronchitis, meningitis, and weight loss. [12][13][14]16 Saudi Arabia is not considered endemic for Ss 17 and may be the reason it was not considered in the differential diagnosis. Early diagnosis is vital but is liable to get delayed in nonendemic areas because the disease is neither suspected, nor pursued if the stool samples are negative, as in our case.…”

Failure of Ivermectin per Rectum to Achieve Clinically Meaningful Serum Levels in Two Cases of Strongyloides Hyperinfection

“…16 The patients described here received PR ivermectin but had undetectable or clinically insignificant serum levels 12 hours after each dose (Table 1). We used a suppository preparation of ivermectin for rapidity of drug delivery rather than the retention enema described by Tarr and others; 14 however, our approach did not lead to clinical improvement or therapeutic serum levels. Serum levels rose dramatically after the initiation of SC ivermectin, or resolution of ileus and ability to tolerate PO preparations.…”

“…11,12,14 This mode of drug delivery has the benefit of rapid administration to patients because PO preparations of ivermectin can be compounded into suppositories or enemas rather quickly, thereby avoiding delays in obtaining SC ivermectin from veterinary sources. Tarr and others 14 successfully treated a case of disseminated Strongyloides following renal transplantation with PR ivermectin by crushing ivermectin tablets (200 μg/kg/day) and creating a 230 mOsm/kg suspension as a retention enema. This patient concurrently received NG ivermectin and albendazole therapy.…”

Non-Oral Treatment with Ivermectin for Disseminated Strongyloidiasis

“…Because of presumed poor absorption of oral ivermectin, rectal administration was initiated (6 mg, twice a day 15 ), and oral albendazole (400 mg/day) was added because of concern for ivermectin resistance. The patient improved slowly, and larvae were not present on repeat duodenal aspirate or stool examination by concentrated wet mount technique (hereafter referred to as routine stool examination).…”