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. On acquiring the infection, there may be respiratory symptoms (Löffler's syndrome). The infection may then become chronic with mainly digestive symptoms. On reinfection (when larvae migrate through the body), there may be respiratory, skin and digestive symptoms. Finally, the hyperinfection syndrome causes symptoms in many organ systems, including the central nervous system.[1][2]
History
The significant information that needs to focused 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 without symptoms. 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.
- It 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.
- Whereas in chronic strongyloidiasis and in 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 or consolidation on chest radiographs
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. Unknown parameter
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