Complicated and fatal Strongyloides infection in Canadians: risk factors,diagnosis and management

STRONGYLOIDIASIS, WHICH IS CAUSED by the nematode Strongyloides stercoralis, is a common and persistent infection, particularly in developing countries. In the setting of compromised cellular immunity, it can result in fulminant dissemination with case-fatality rates of over 70%. The majority of new Canadian immigrants come from countries where Strongyloides is highly endemic; therefore, the burden of Strongyloides may be underappreciated in Canada. Because early diagnosis and therapy can have a marked impact on disease outcome, screening for this infection should be considered mandatory for patients who have a history of travel or residence in a disease-endemic area and risk factors for disseminated disease (e.g., corticosteroid use and human T-lymphotropic virus type I infection). The following case is typical of a Strongyloides infection presenting to an infectious diseases service at a tertiary care hospital: A 50-year-old man who was originally from Cambodia but who had lived in Canada for the past 15 years presented with nausea and vomiting. His history was notable for arthritis, which was treated with prednisone, and type 2 diabetes mellitus. After admission, the patient became febrile and hypotensive. Blood cultures were positive for a gram-negative bacillus, and he was given ciprofloxacin and ceftriaxone. His respiratory status deteriorated, and Strongyloides larvae were incidentally noted on Gram stain and culture after bronchoalveolar lavage (Fig. 1). The patient was given 400 mg of albendazole twice a day and 15 mg of ivermectin once daily, but progressive respiratory failure followed and he died 3 weeks later.Open in a separate windowFig. 1: Strongyloides stercoralis larva tracks on a blood agar plate from the bronchoalveolar lavage of a patient with disseminated strongyloidiasis.This case exemplifies 2 key points. Foremost is that delays in establishing the diagnosis of strongyloidiasis can result in disseminated and fatal infection. Although the gastrointestinal tract is the primary site of Strongyloides infection, associated symptoms such as abdominal pain and intermittent diarrhea may be vague; if ignored by the clinician, the diagnosis may be made only upon dissemination and clinical deterioration of the patient. Second, eliciting an appropriate travel and migration history from patients and recognizing risk factors for disseminated infection are the essential epidemiologic clues for establishing early diagnosis. The purpose of this article is to highlight the risk factors and clinical presentation of strongyloidiasis and to provide a strategy for diagnosis and management. The goal is to raise awareness of this relatively common infection and thereby to facilitate early diagnosis and treatment of this potentially fatal but eminently curable disease.