Strongyloidiasis history and symptoms: Difference between revisions
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{{CMG}}; {{AE}} {{ADG}} | {{CMG}}; {{AE}} {{ADG}} | ||
==Overview== | ==Overview== | ||
[[Strongyloides]] infection can present in various forms. On acquiring the infection, there may be respiratory symptoms ([[Löffler's syndrome]]). The infection may then become chronic with mainly digestive symptoms. | [[Strongyloides]] infection can present in various forms. On acquiring the infection, there may be respiratory symptoms ([[Löffler's syndrome]]). The infection may then become [[chronic]] with mainly digestive symptoms. Upon reinfection (when larvae migrate through the body), there may be [[respiratory]], [[skin]] and [[digestive]] symptoms. Finally, hyperinfection syndrome causes symptoms in many organ systems, including the [[central nervous system]].<ref name="pmid20733481">{{cite journal |vauthors=Montes M, Sawhney C, Barros N |title=Strongyloides stercoralis: there but not seen |journal=Curr. Opin. Infect. Dis. |volume=23 |issue=5 |pages=500–4 |year=2010 |pmid=20733481 |pmc=2948977 |doi=10.1097/QCO.0b013e32833df718 |url=}}</ref><ref name="pmid18321548">{{cite journal |vauthors=Marcos LA, Terashima A, Dupont HL, Gotuzzo E |title=Strongyloides hyperinfection syndrome: an emerging global infectious disease |journal=Trans. R. Soc. Trop. Med. Hyg. |volume=102 |issue=4 |pages=314–8 |year=2008 |pmid=18321548 |doi=10.1016/j.trstmh.2008.01.020 |url=}}</ref> | ||
==History== | ==History== | ||
The significant information that needs to focused in the history of the patient includes: | The significant information that needs to be focused on in the history of the patient includes: | ||
*Any history of travel to the endemic areas | *Any history of travel to the endemic areas | ||
*Any ill contact with similar complaints | *Any ill contact with similar complaints | ||
==Symptoms== | ==Symptoms== | ||
The majority of people infected with [[strongyloides]] are | The majority of people infected with [[strongyloides]] are [[asymptomatic]]. The symptomatic spectrum of [[strongyloides]] ranges from [[Subclinical infection|subclinical]] in [[acute]] and [[chronic]] infection to severe and [[fatal]] in hyperinfection syndrome and [[Strongyloidiasis|disseminated strongyloidiasis,]] which have case-fatality rates that approach 90%. In either case, patients’ symptoms are a result of the [[Parasites|parasite’s]] larval form migrating through various [[organs]] of the body. Those who do develop symptoms tend to have non-specific, or generalized complaints. Some people develop [[abdominal pain]], [[bloating]], [[heartburn]], intermittent episodes of [[diarrhea]] and [[constipation]], a dry [[cough]], and [[rashes]]. | ||
===Acute strongyloidiasis=== | ===Acute strongyloidiasis=== | ||
*The initial sign of acute [[strongyloidiasis]], if noticed at all, is a localized [[Pruritic Urticarial Papules and Plaques of Pregnancy|pruritic]], [[erythematous]] [[rash]] at the site of skin penetration. | *The initial sign of acute [[strongyloidiasis]], if noticed at all, is a localized [[Pruritic Urticarial Papules and Plaques of Pregnancy|pruritic]], [[erythematous]] [[rash]] at the site of skin penetration. | ||
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*After the larvae are swallowed into the [[gastrointestinal tract]], patients may experience [[diarrhea]], [[constipation]], [[abdominal pain]], and [[anorexia]]. | *After the larvae are swallowed into the [[gastrointestinal tract]], patients may experience [[diarrhea]], [[constipation]], [[abdominal pain]], and [[anorexia]]. | ||
===Chronic strongyloidiasis=== | ===Chronic strongyloidiasis=== | ||
*[[Chronic]] [[strongyloidiasis]] is generally asymptomatic, but in patients with clinical disease [[gastrointestinal]] and [[cutaneous]] manifestations are the most common. | *[[Chronic]] [[strongyloidiasis]] is generally [[asymptomatic]], but in patients with clinical disease, [[gastrointestinal]] and [[cutaneous]] manifestations are the most common. | ||
*The [[gastrointestinal]] symptoms include [[epigastric]] pain, [[postprandial]] fullness, [[heartburn]], and brief episodes of intermittent [[diarrhea]] and [[constipation]]. | *The [[gastrointestinal]] symptoms include [[epigastric]] pain, [[postprandial]] fullness, [[heartburn]], and brief episodes of intermittent [[diarrhea]] and [[constipation]]. | ||
*Less commonly, patients may present with [[fecal occult blood]], or massive [[Colon (anatomy)|colonic]] and [[Hemorrhage|gastric hemorrhage]]. | *Less commonly, patients may present with [[fecal occult blood]], or massive [[Colon (anatomy)|colonic]] and [[Hemorrhage|gastric hemorrhage]]. | ||
*Presentations resembling [[inflammatory bowel disease]], specifically [[ulcerative colitis]], are rare. Also rare, but documented, are endoscopic exams revealing pathology similar to pseudopolyposis. | *Presentations resembling [[inflammatory bowel disease]], specifically [[ulcerative colitis]], are rare. Also rare, but documented, are [[endoscopic]] exams revealing pathology similar to pseudopolyposis. | ||
*[[Cutaneous]] symptoms include [[Urticaria|chronic urticaria]] and the pathognomonic [[larva currens]] - a recurrent serpiginous [[maculopapular]] or [[Rash|urticarial rash]] along the buttocks, [[perineum]], and thighs due to repeated [[autoinfection]]. | *[[Cutaneous]] symptoms include [[Urticaria|chronic urticaria]] and the [[pathognomonic]] [[larva currens]] - a recurrent [[serpiginous]] [[maculopapular]] or [[Rash|urticarial rash]] along the buttocks, [[perineum]], and thighs due to repeated [[autoinfection]]. The rash has been described as advancing as rapidly as 10 cm/hr. | ||
*Rarely, patients with chronic [[strongyloidiasis]] have complained of [[arthritis]], [[Cardiac arrhythmia|cardiac arrhythmias]], and signs and symptoms consistent with chronic [[malabsorption]], [[Obstruction|duodenal obstruction,]] [[nephrotic syndrome]], and recurrent [[asthma]]. | *Rarely, patients with chronic [[strongyloidiasis]] have complained of [[arthritis]], [[Cardiac arrhythmia|cardiac arrhythmias]], and signs and symptoms consistent with chronic [[malabsorption]], [[Obstruction|duodenal obstruction,]] [[nephrotic syndrome]], and recurrent [[asthma]]. | ||
*Up to 75% of people with chronic [[strongyloidiasis]] have mild peripheral [[eosinophilia]] or elevated [[IgE]] levels. | *Up to 75% of people with chronic [[strongyloidiasis]] have mild peripheral [[eosinophilia]] or elevated [[IgE]] levels. | ||
===Hyperinfection syndrome and disseminated strongyloidiasis=== | ===Hyperinfection syndrome and disseminated strongyloidiasis=== | ||
*Hyperinfection syndrome and disseminated [[strongyloidiasis]] are most frequently associated with subclinical infection in patients receiving high-dose [[corticosteroids]] for the treatment of [[asthma]] or [[chronic obstructive pulmonary disease]] ([[COPD]]) exacerbations. | *Hyperinfection syndrome and disseminated [[strongyloidiasis]] are most frequently associated with [[subclinical infection]] in patients receiving high-dose [[corticosteroids]] for the treatment of [[asthma]] or [[chronic obstructive pulmonary disease]] ([[COPD]]) exacerbations. | ||
*Subsequent impaired host immunity leads to accelerated [[autoinfection]] and an overwhelming number of migrating larvae. | *Subsequent impaired host immunity leads to accelerated [[autoinfection]] and an overwhelming number of migrating larvae. | ||
* | *While in chronic [[strongyloidiasis]] and hyperinfection syndrome, the larvae are limited to the [[GI tract]] and the [[lungs]], in disseminated [[strongyloidiasis]], the larvae invade numerous organs. | ||
*Left untreated, the [[Mortality rate|mortality]] rates of hyperinfection syndrome and disseminated [[strongyloidiasis]] can approach 90%. | *Left untreated, the [[Mortality rate|mortality]] rates of hyperinfection syndrome and disseminated [[strongyloidiasis]] can approach 90%. | ||
The following are signs and symptoms that can be seen with hyperinfection syndrome and disseminated strongyloidiasis: | The following are signs and symptoms that can be seen with hyperinfection syndrome and disseminated strongyloidiasis: | ||
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*[[Diarrhea]] | *[[Diarrhea]] | ||
*[[Ileus]] | *[[Ileus]] | ||
*[[ | *Bowel [[edema]] | ||
*Intestinal [[obstruction]] | *Intestinal [[obstruction]] | ||
*[[Mucosal ulceration]] | *[[Mucosal]] [[ulceration]] | ||
*[[Massive hemorrhage]] | *[[Massive hemorrhage]] | ||
*[[Peritonitis]] | *[[Peritonitis]] | ||
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*[[Hemoptysis]] | *[[Hemoptysis]] | ||
*[[Respiratory failure]] | *[[Respiratory failure]] | ||
*Diffuse interstitial | *Diffuse interstitial infiltrates | ||
'''Neurologic findings''' | '''Neurologic findings''' | ||
*[[Aseptic]] or [[Meningitis|gram-negative meningitis]] | *[[Aseptic]] or [[Meningitis|gram-negative meningitis]] | ||
*Larvae have been reported in the [[CSF]], meningeal vessels, [[dura]], [[epidural]], [[Subdural empyema|subdural]], and [[Subarachnoid space|subarachnoid spaces]] | *Larvae have been reported in the [[CSF]], [[Meninges|meningeal]] vessels, [[dura]], [[epidural]], [[Subdural empyema|subdural]], and [[Subarachnoid space|subarachnoid spaces]] | ||
'''Systemic symptoms''' | '''Systemic symptoms''' | ||
*Peripheral [[edema]] and [[ascites]] secondary to [[hypoalbuminemia]] from [[protein losing enteropathy]] | *Peripheral [[edema]] and [[ascites]] secondary to [[hypoalbuminemia]] from [[protein losing enteropathy]] | ||
*Recurrent gram negative [[bacteremia]]/[[sepsis]] from larvae carrying bacteria that penetrate [[mucosal]] walls | *Recurrent [[gram negative]] [[bacteremia]]/[[sepsis]] from larvae carrying bacteria that penetrate [[mucosal]] walls | ||
*[[Syndrome of inappropriate antidiuretic hormone|Syndrome of inappropriate secretion of anti-diuretic hormone]] ([[SIADH]]) | *[[Syndrome of inappropriate antidiuretic hormone|Syndrome of inappropriate secretion of anti-diuretic hormone]] ([[SIADH]]) | ||
*Peripheral [[eosinophilia]] is frequently absent | *Peripheral [[eosinophilia]] is frequently absent | ||
'''Cutaneous manifestations''' | '''Cutaneous manifestations''' | ||
*Recurrent [[maculopapular]] or [[Urticaria|urticarial rash]] most commonly found along the [[buttocks]], [[perineum]], and thighs due to repeated [[autoinfection]], but can be found anywhere on the skin | *Recurrent [[maculopapular]] or [[Urticaria|urticarial rash]] most commonly found along the [[buttocks]], [[perineum]], and thighs due to repeated [[autoinfection]], but can be found anywhere on the [[skin]] | ||
*[[Larva currens|Larva curren<nowiki/>s]] - pathognomonic [[serpiginous]] or urticarial [[rash]] that advances as rapidly as 10 cm/hr | *[[Larva currens|Larva curren<nowiki/>s]] - [[pathognomonic]] [[serpiginous]] or urticarial [[rash]] that advances as rapidly as 10 cm/hr | ||
==References== | ==References== | ||
Revision as of 19:50, 1 August 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
Strongyloides infection can present in various forms. On acquiring the infection, there may be respiratory symptoms (Löffler's syndrome). The infection may then become chronic with mainly digestive symptoms. Upon reinfection (when larvae migrate through the body), there may be respiratory, skin and digestive symptoms. Finally, hyperinfection syndrome causes symptoms in many organ systems, including the central nervous system.[1][2]
History
The significant information that needs to be focused on in the history of the patient includes:
- Any history of travel to the endemic areas
- Any ill contact with similar complaints
Symptoms
The majority of people infected with strongyloides are asymptomatic. The symptomatic spectrum of strongyloides ranges from subclinical in acute and chronic infection to severe and fatal in hyperinfection syndrome and disseminated strongyloidiasis, which have case-fatality rates that approach 90%. In either case, patients’ symptoms are a result of the parasite’s larval form migrating through various organs of the body. Those who do develop symptoms tend to have non-specific, or generalized complaints. Some people develop abdominal pain, bloating, heartburn, intermittent episodes of diarrhea and constipation, a dry cough, and rashes.
Acute strongyloidiasis
- The initial sign of acute strongyloidiasis, if noticed at all, is a localized pruritic, erythematous rash at the site of skin penetration.
- Patients may then develop tracheal irritation and a dry cough as the larvae migrate from the lungs up through the trachea.
- After the larvae are swallowed into the gastrointestinal tract, patients may experience diarrhea, constipation, abdominal pain, and anorexia.
Chronic strongyloidiasis
- Chronic strongyloidiasis is generally asymptomatic, but in patients with clinical disease, gastrointestinal and cutaneous manifestations are the most common.
- The gastrointestinal symptoms include epigastric pain, postprandial fullness, heartburn, and brief episodes of intermittent diarrhea and constipation.
- Less commonly, patients may present with fecal occult blood, or massive colonic and gastric hemorrhage.
- Presentations resembling inflammatory bowel disease, specifically ulcerative colitis, are rare. Also rare, but documented, are endoscopic exams revealing pathology similar to pseudopolyposis.
- Cutaneous symptoms include chronic urticaria and the pathognomonic larva currens - a recurrent serpiginous maculopapular or urticarial rash along the buttocks, perineum, and thighs due to repeated autoinfection. The rash has been described as advancing as rapidly as 10 cm/hr.
- Rarely, patients with chronic strongyloidiasis have complained of arthritis, cardiac arrhythmias, and signs and symptoms consistent with chronic malabsorption, duodenal obstruction, nephrotic syndrome, and recurrent asthma.
- Up to 75% of people with chronic strongyloidiasis have mild peripheral eosinophilia or elevated IgE levels.
Hyperinfection syndrome and disseminated strongyloidiasis
- Hyperinfection syndrome and disseminated strongyloidiasis are most frequently associated with subclinical infection in patients receiving high-dose corticosteroids for the treatment of asthma or chronic obstructive pulmonary disease (COPD) exacerbations.
- Subsequent impaired host immunity leads to accelerated autoinfection and an overwhelming number of migrating larvae.
- While in chronic strongyloidiasis and hyperinfection syndrome, the larvae are limited to the GI tract and the lungs, in disseminated strongyloidiasis, the larvae invade numerous organs.
- Left untreated, the mortality rates of hyperinfection syndrome and disseminated strongyloidiasis can approach 90%.
The following are signs and symptoms that can be seen with hyperinfection syndrome and disseminated strongyloidiasis:
Gastrointestinal manifestations
- Abdominal pain
- Nausea and vomiting
- Diarrhea
- Ileus
- Bowel edema
- Intestinal obstruction
- Mucosal ulceration
- Massive hemorrhage
- Peritonitis
- Bacterial sepsis
Pulmonary manifestations and findings
- Cough
- Wheezing
- Dyspnea
- Hoarseness
- Pneumonitis
- Hemoptysis
- Respiratory failure
- Diffuse interstitial infiltrates
Neurologic findings
- Aseptic or gram-negative meningitis
- Larvae have been reported in the CSF, meningeal vessels, dura, epidural, subdural, and subarachnoid spaces
Systemic symptoms
- Peripheral edema and ascites secondary to hypoalbuminemia from protein losing enteropathy
- Recurrent gram negative bacteremia/sepsis from larvae carrying bacteria that penetrate mucosal walls
- Syndrome of inappropriate secretion of anti-diuretic hormone (SIADH)
- Peripheral eosinophilia is frequently absent
Cutaneous manifestations
- Recurrent maculopapular or urticarial rash most commonly found along the buttocks, perineum, and thighs due to repeated autoinfection, but can be found anywhere on the skin
- Larva currens - pathognomonic serpiginous or urticarial rash that advances as rapidly as 10 cm/hr
References
- ↑ Montes M, Sawhney C, Barros N (2010). "Strongyloides stercoralis: there but not seen". Curr. Opin. Infect. Dis. 23 (5): 500–4. doi:10.1097/QCO.0b013e32833df718. PMC 2948977. PMID 20733481.
- ↑ Marcos LA, Terashima A, Dupont HL, Gotuzzo E (2008). "Strongyloides hyperinfection syndrome: an emerging global infectious disease". Trans. R. Soc. Trop. Med. Hyg. 102 (4): 314–8. doi:10.1016/j.trstmh.2008.01.020. PMID 18321548.