Strongyloidiasis history and symptoms

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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. The majority of people infected with Strongyloides are asymptomatic. The symptomatic spectrum of strongyloidiasis ranges from subclinical in acute and chronic infection to severe and fatal in hyper infection syndrome. On acquiring the infection, there may be respiratory symptoms (Löffler's syndrome). The infection may progress to chronic stage with mainly digestive symptoms. On reinfection there may be respiratory, skin, and digestive symptoms. Finally, hyper infection syndrome sets in and cause symptoms in many organ systems, including the central nervous system.

History

The significant information that needs to be focused on in the history of the patient includes:

• History of travel to the endemic areas
• History of exposure to individuals with similar complaints

Symptoms

The majority of people infected with strongyloides are asymptomatic. The symptomatic spectrum of strongyloidiasis 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 patients 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:

Organ involved	Symptoms
Gastrointestinal	Abdominal pain Nausea and vomiting Diarrhea Ileus Bowel edema Intestinal obstruction Mucosal ulceration Massive hemorrhage Peritonitis Bacterial sepsis
Pulmonary	Cough Wheezing Dyspnea Hoarseness Pneumonitis Hemoptysis Respiratory failure Diffuse interstitial infiltrates
CNS	Aseptic or gram-negative meningitis Larvae have been reported in: CSF, meningeal vessels, dura, epidural, subdural, and subarachnoid spaces
Systemic	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
Skin	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, a pathognomonic serpiginous or urticarial rash that advances as rapidly as 10 cm/hr