Disseminated Strongyloidiasis

Abstract

A Salvadoran man in his 60s underwent resection of a meningioma that was complicated by a postoperative brain abscess requiring highdosedexamethasone.Inthehospital,hedevelopedEscherichiacolibacteremiapresumedtobefromurinarysourceandworseningpulmonary infiltrates treated as aspiration pneumonia. Shortly after initiation of antibiotic therapy, the patient developed a purpuric eruption on his abdomen (Figure 1) and thighs with concurrent eosinophilia peaking at 2.9 × 10 9 cells/L. The presence of visible tracks on the blood agar plates led to closer inspection of the respiratory specimen and detection of Strongyloides larvae (Figure 2).Skin biopsy findings were consistent with noninflammatory purpura, with no parasites seen. Follow-up analysis of stool samples and blood tests revealed the presence of Strongyloides stercoralis. The patient was treated with a combination of oral ivermectin and albendazole for a total of 16 days. He eventually made a slow recovery after requiring rehabilitation for 2 months.Strongyloidesstercoralisisanintestinalnematodeendemictotropicalandsubtropicalregions.Filariformlarvapresentinthesoilpenetrate human skin and then travel via the lungs to the small intestine. Acute infection can result in a pruritic eruption after the larvae penetrate the skin, also known as ground itch. Larva currens is a pathognomonic skin manifestation of chronic strongyloidiasis that is characterized by rapidly progressing evanescent serpiginous tracks. The parasite can persist indefinitely in a single host through an autoinfection cycle. 1 Risk factors for hyperinfection syndrome and disseminated strongyloidiasis include any form of impaired cell-mediated immunity, with corticosteroid use constituting the most common risk factor.Cutaneous purpura is a rare manifestation of hyperinfection syndrome and/or disseminated strongyloidiasis resulting from massive larval migration though intradermal vessels. 2 A case series of 6 patients with disseminated strongyloidiasis consistently found the distribution of purpura to be around the umbilicus and on the proximal lower extremities, 3 as in the present patient. This distribution is postulated to result from larval migration through mesenteric veins into the portal circulation. 4 Positive-pressure mechanical ventilation may contribute to this finding by increasing portal pressure and portosystemic shunting through umbilical and periumbilical veins. 4 Larval migration and ulceration in the intestinal mucosa may also lead to secondary bacteremia with enteric organisms. This case illustrates the importance of obtaining a travel and exposure history, particularly in the setting of a new eruption and eosinophilia. In disseminated strongyloidiasis, delayed diagnosis contributes to its high case-fatality rate. 1 In the appropriate clinical and epidemiological context, early recognition of periumbilical purpura may improve survival for patients with disseminated disease.

Dermatopatología de la oclusión intraluminal vascular: parte I (trombos)

“…La entrada en el ser humano se produce a través de la piel en contacto con la tierra donde residen las larvas filariformes. Estas viajan hasta los pulmones, para posteriormente situarse en el intestino delgado 31 .…”

Fatal Disseminated Strongyloidiasis with Periumbilical Purpura

“…During intensive care unit admission, a detailed examination of the skin revealed purplish macules and papules on the periumbilical area, abdomen, and flanks (Figure 1A), with linear and serpiginous configurations resembling thumbprints (Figure 1B). 1,2 Treatment with oral ivermectin for strongyloidiasis and meropenem as empirical therapy for enteric Gram-negative pathogens 3 was started; however, despite intensive care and hemodynamic support, the patient worsened progressively to multiple-organ dysfunction and died 6 days after admission.…”

“…E-mail: guilhermepivoto@hotmail.com respiratory tract is the hallmark of disseminated strongyloidiasis. [3][4][5] Disseminated strongyloidiasis is far more associated with human T-cell leukemia virus type 1 co-infection than with HIV infection alone, but unfortunately it could not be ruled out because of the lack of diagnostic testing availability. This clinical picture emphasizes that even in endemic areas for strongyloidiasis, clinical suspicion remains low, delaying treatment and increasing mortality.…”

“…Treatment with oral ivermectin for strongyloidiasis and meropenem as empirical therapy for enteric Gram-negative pathogens 3 was started; however, despite intensive care and hemodynamic support, the patient worsened progressively to multiple-organ dysfunction and died 6 days after admission.…”

“…The finding of S. stercoralis parasites outside the digestive and respiratory tract is the hallmark of disseminated strongyloidiasis. 3 – 5 …”