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CASE REPORT
Year : 2020  |  Volume : 64  |  Issue : 1  |  Page : 90-92  

Strongyloides hyperinfection in a patient with solid malignant tumor a case report


1 Assistant Professor, Department of Microbiology, Meenakshi Ammal Dental College, Chennai, Tamil Nadu, India
2 Clinical Microbiologist, Department of Laboratory Medicine, MIOT International, Chennai, Tamil Nadu, India

Date of Submission05-Mar-2019
Date of Decision03-May-2019
Date of Acceptance04-Feb-2020
Date of Web Publication16-Mar-2020

Correspondence Address:
Krishnarao Arthi
F9, Gblock, Divyavarshini No: 7, Govindasamy Street, Palavanthangal, Chennai - 600 114, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_111_19

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   Abstract 


Strongyloides stercoralis is unique among the nematodes, in which it completes its life cycle inside a single human host by causing autoinfection in the host, and it causes hyperinfection leading to persistent and fatal disseminated infections in immunocompromised hosts. The present case report is about strongyloidiasis fatal hyperinfection in a patient with malignant tumor of the tongue on radiotherapy treatment, to highlight the need for clinical suspicion of strongyloidiasis in an immunocompromised host. As per the Centers for Disease Control and Prevention, the mortality in strongyloides hyperinfection syndrome is alarmingly high, a case fatality rate that is almost 90%. Hence, the clinicians should be well equipped to diagnose, treat, and also prevent the fatal consequences of this lethal nematode. Detailed workup for this parasitic infection is crucial, and this case report emphasizes that a simple wet mount stool microscopic examination can clinch the diagnosis.

Keywords: Autoinfection, hyperinfection, stool wet mount, Strongyloides stercoralis, strongyloidiasis


How to cite this article:
GeethaBanu S, Arthi K. Strongyloides hyperinfection in a patient with solid malignant tumor a case report. Indian J Public Health 2020;64:90-2

How to cite this URL:
GeethaBanu S, Arthi K. Strongyloides hyperinfection in a patient with solid malignant tumor a case report. Indian J Public Health [serial online] 2020 [cited 2020 Apr 3];64:90-2. Available from: http://www.ijph.in/text.asp?2020/64/1/90/280760




   Introduction Top


Strongyloides stercoralis is a soil-transmitted, intestinal parasitic nematode, infecting 30–100 million people worldwide.[1] Among the soil-transmitted helminthic diseases, S. stercoralis is unique, in that it completes its life cycle inside a single human host by causing autoinfection in the host, and that it causes hyperinfection leading to persistent and fatal disseminated infections in immunocompromised hosts.

The present case report is about strongyloidiasis fatal hyperinfection in a patient with a malignant tumor of the tongue on radiotherapy treatment, to highlight the need for clinical suspicion of strongyloidiasis in an immunocompromised host.


   Case Report Top


A 39-year-old, chronic alcoholic, malnourished, anemic male patient was admitted in a tertiary care government general hospital, with complaints of fever, loss of appetite and weight, diarrhea, abdominal pain, cough, and breathlessness for 6 months. The evaluation of the soft mass lesion over the tongue was diagnosed as Stage III malignant growth of the tongue, and the patient was started on radiotherapy and chemotherapy for the same. His hemoglobin was 5.8 g/dl, and peripheral blood smear examination revealed hypochromic microcytic anemia. The cause of associated gastrointestinal and pulmonary symptoms was evaluated. Chest X-ray revealed bilateral hyperinflation with left upper zone fibrotic band. Microbiological investigations were done. Stool wet mount examination done at the department of microbiology on 2 successive days revealed motile larvae of S. stercoralis identified by characteristic morphology. Stool culture showed no growth of enteric bacterial pathogens [Figure 1] and [Figure 2]. Examination of sputum for strongyloides larva was not done. Antibodies to human immunodeficiency virus (HIV) 1 and 2 were negative. Human T-cell leukemia virus testing was not performed.
Figure 1: Saline wet mount examination of stool sample showing Strongyloides stercoralis larva under ×10 magnification.

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Figure 2: Saline wet mount examination of stool sample showing Strongyloides stercoralis larva under ×40 magnification.

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However, the patient's condition continued to deteriorate during his hospital stay, with persistent diarrhea and elevated renal parameters. The diagnosis of strongyloides hyperinfection syndrome was made, and the patient was started on ivermectin. The patient did not improve, and his general condition deteriorated and died a few days later with the diagnosis of strongyloides hyperinfection syndrome.


   Discussion Top


In 2016, it was estimated that 450.7 million cases of soil-transmitted helminths are found globally, of which 16% are from India.[2] Strongyloidiasis is considered to be one of the neglected tropical diseases, and it is probably an underdiagnosed parasitic disease due to its uncertain clinical symptoms.[3] Strongyloidiasis is a major cause of morbidity and mortality, particularly in developing countries like India.[4]

The characteristic feature of strongyloidiasis is that the clinical presentation varies with the immune status of the patient. The ability of S. stercoralis to establish a cycle of autoinfection within the host will lead to chronic infections that can persist in an individual for decades. Uncontrolled autoinfection of S. stercoralis is more likely to occur in immunosuppressed patients, leading to hyperinfection syndrome. Hyperinfection refers to a state of accelerated autoinfection, consisting of signs and symptoms attributable to increased larval migration. The syndrome is characterized by the development or exacerbation of gastrointestinal (GI) and pulmonary symptoms. This is usually restricted to organs of the autoinfective cycle. The clinical features of hyperinfection syndrome include GI manifestations such as abdominal pain, watery diarrhea, weight loss, vomiting, and occasionally bleeding. Pulmonary symptoms include cough, breathlessness, pneumonia, pulmonary hemorrhage, and pleural effusion.[5] Varied clinical findings appear with fatal outcomes after treatment with steroids, chemoradiation, or immunosuppression for a severe disease and are later confirmed as a case of hyperinfection or disseminated strongyloidiasis, as seen in our patient.

Dissemination occurs upon larval migration to organs beyond the range of the pulmonary phase, such as the liver, heart, lymph nodes, gallbladder, kidneys, pancreas, and brain, with a mortality rate above 80%. High-risk factors for hyperinfection and dissemination include corticosteroid therapy, malignancies, transplantation, malnutrition, hypogammaglobulinemia, and viral infections such as HIV and human T-cell lymphotropic Type 1 virus.[6] Patients with hematologic malignancies have a high prevalence of S. stercoralis infection, as the patients were treated with glucocorticoids. Solid malignant tumors are also associated with hyperinfection during the administration of immunosuppressive chemotherapy or radiotherapy.[7],[8]

The diagnosis of strongyloidiasis requires a high degree of suspicion, as there are no distinctive clinical features, and laboratory and imaging findings often are nonspecific. In this patient, stool wet mount examination revealed motile larvae of S. stercoralis, clinching the diagnosis. Moreover that the patient was an immunosuppressed individual due to malignant tumor of the tongue on radiotherapy with associated GI and pulmonary symptoms suggestive of strongyloidiasis hyperinfection syndrome. According to the Centers for Disease Control and Prevention, the mortality in strongyloides hyperinfection syndrome is alarmingly high, a case fatality rate that approaches 90%, as seen in this case.[9]

Infection with strongyloides represents one of the major challenges in the management of cancer patients, as only complete eradication of parasites is essential to remove the danger of hyperinfection or dissemination. Moreover, also, it is even harder to determine the efficacy of treatment because a true cure cannot be ascertained on the basis of negative findings of a follow-up stool examination alone.

However, ivermectin has been registered as the drug of choice in the World Health Organization's list of essential drugs for the treatment of strongyloidiasis. Daily ivermectin is the treatment of choice for treating disseminated strongyloidiasis, with the length of treatment being for a minimum of 2 weeks and often until there has been evidence of 2 full weeks of negative stool examination.[10] A brief reduction or termination of immunosuppressants is also considered vital to allow for the clearance of the parasites.

As said rightly by Cook, still the index of suspicion is far too low for parasitic diseases.[11] Hence, the screening and treatment of strongyloidiasis should be made an essential part of the routine protocol in all immunocompromised patients and before the start of chemotherapy, immunosuppression, or before initiating steroid therapy. Such a protocol would prevent the potentially fatal complications of hyperinfection, as prevention is always better than cure.


   Conclusion Top


It is evident from this case report that it is important to have a high degree of suspicion to diagnose strongyloidiasis when an immunocompromised patient presents with pulmonary and GI symptoms and rapid decline and that emphasizes that a simple wet mount stool microscopic examination can clinch the diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
World Health Organization. Available from: Strongyloidiasis.https://www.who.int/intestinal_worms/epidemiology/strongyloidiasis/en/. [Last accessed on 2019 Feb 21].  Back to cited text no. 1
    
2.
Hotez PJ, Damania A. India's neglected tropical diseases. PLoS Negl Trop Dis 2018;12:e0006038.  Back to cited text no. 2
    
3.
Puthiyakunnon S, Boddu S, Li Y, Zhou X, Wang C, Li J, et al. Strongyloidiasis – An insight into its global prevalence and management. PLoS Negl Trop Dis 2014;8:e3018.  Back to cited text no. 3
    
4.
Acharya AS, Kaur R, Goel AD. Neglected tropical diseases – Challenges and opportunities in India. Indian J Med Specialities 2017;8:102-8.  Back to cited text no. 4
    
5.
Tefé-Silva C, Machado ER, Faccioli LH, Ramos SG. Hyperinfection Syndrome in Strongyloidiasis. Available from: https://www.intechopen.com/books/current-topics-in-tropical-medicine/hyperinfection-syndrome-in-strongyloidiasis. [Last accessed on 2019 Feb 19].  Back to cited text no. 5
    
6.
Chordia P, Christopher S, Abraham OC, Muliyil J, Kang G, Ajjampur S. Risk factors for acquiring Strongyloides stercoralis infection among patients attending a tertiary hospital in south India. Indian J Med Microbiol 2011;29:147-51.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Reddy IS, Swarnalata G. Fatal disseminated strongyloidiasis in patients on immunosuppressive therapy: Report of two cases. Indian J Dermatol Venereol Leprol 2005;71:38-40.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Imperatore K, Basra P, Herring N, Omarzai Y, Vincentelli C, et al. Fatal disseminated strongyloidiasis secondary to corticosteroid use: A report of two cases. Med Microbiol Rep 2017;1:1.  Back to cited text no. 8
    
9.
Centers for Disease Control and Prevention. Available from: Strongyloides. https://www.cdc.gov/parasites/strongyloides/health_professionals/index.html. [Last accessed on 2019 Feb 21].  Back to cited text no. 9
    
10.
Mejia R, Nutman TB. Screening, prevention, and treatment for hyperinfection syndrome and disseminated infections caused by Strongyloides stercoralis. Curr Opin Infect Dis 2012;25:458-63.  Back to cited text no. 10
    
11.
Cook GC. Strongyloides stercoralis and its hyperinfection syndrome: The index of suspicion is still far too low. Parasitic Disease in Clinical Practice, The Bloomsbury Series in Clinical Science. London: Springer; 1990.  Back to cited text no. 11
    


    Figures

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