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LETTER TO EDITOR Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 4  |  Page : 895-896
Strongyloides stercoralis infection in a patient undergoing allogeneic stem cell transplantation


1 Department of Microbiology, Christian Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Clinical Haematology, Christian Medical College and Hospital, Ludhiana, Punjab, India

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Date of Web Publication27-Oct-2010
 

How to cite this article:
Oberoi A, Varghese SR, John M J. Strongyloides stercoralis infection in a patient undergoing allogeneic stem cell transplantation. Indian J Pathol Microbiol 2010;53:895-6

How to cite this URL:
Oberoi A, Varghese SR, John M J. Strongyloides stercoralis infection in a patient undergoing allogeneic stem cell transplantation. Indian J Pathol Microbiol [serial online] 2010 [cited 2019 Dec 8];53:895-6. Available from: http://www.ijpmonline.org/text.asp?2010/53/4/895/72050


Sir,

Strongyloides stercoralis is an intestinal nematode of humans that infects tens of millions of people worldwide [1] and is endemic in tropical and subtropical regions. It causes minimal clinical manifestations in an immunocompetent host. However, S. stercoralis infection, though rare, can be life-threatening in immunocompromised subjects and is associated with neoplastic diseases such as Hodgkins disease and other lymphomas, leukemias, nonmalignant conditions treated with corticosteroids, e.g., organ transplantation, hematological malignancies, alcoholism, and there have also been reports of widespread dissemination of S. stercoralis in AIDS patients. [2]

Relatively few cases of S. stercoralis hyperinfection following allogenic bone marrow transplant have been reported in the literature. Such infection in the immediate post-transplant period can often be confused with acute graft versus host disease (GVHD) of the gut. We report a case of S. stercoralis hyperinfection in a stem cell transplant patient.

A 33-year-old gentleman with Philadelphia chromosome positive acute lymphoblastic leukemia underwent allogeneic stem cell transplant with his brother as his donor. He complained of intermittent episodes of lower abdominal pain and frequent stools during the conditioning regimen which was attributed to regimen-related toxicity. However, the volume of stools increased to 1000 ml on Day +15, post stem cell infusion. As the patient had engrafted with normal counts, possibility of gut GVHD was considered and he was taken up for upper gastrointestinal and rectal biopsy. Stool samples were also sent for routine microscopic examination and culture sensitivity.

Stool examination - The normal saline preparation showed the larval form of S. stercoralis [Figure 1].
Figure 1: Strongyloides stercoralis larval form (Normal Saline, ×40)

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He was treated with weekly doses of ivermectin (2 weeks) and 5 days of albendazole along with steroids for the treatment of gut GVHD. Patient showed good response to ivermectin and the dose was repeated after 1 week. He responded well to the treatment and repeat stool examination showed absence of infection.

S. stercoralis is unique among intestinal nematodes in its ability to complete its lifecycle within the host through an asexual autoinfective cycle, allowing the infection to persist in the host indefinitely. Under some immunocompromised conditions, this autoinfective cycle can become amplified into a potentially fatal hyperinfection syndrome, characterized by increased numbers of infective filariform larvae in stool and sputum and clinical manifestations of the increased parasite burden and migration, such as gastrointestinal bleeding and respiratory discomfort.

Glucocorticoids are employed in the treatment of many hematological malignancies, but there are case reports of S. stercoralis hyperinfection developing in such patients prior to therapy. [3],[4] The majority of cases of hyperinfection that have occurred following organ transplant have occurred following renal transplant, and relatively few cases of S. stercoralis hyperinfection following bone marrow transplant have been reported in literature. Paul et al. [5] documented the presence of S. stercoralis eggs containing viable larvae in a urethral smear. In our case, the patient was diagnosed to have acute lymphoblastic leukemia and had undergone induction chemotherapy prior to starting the transplant. During the transplant, he underwent myeloablative conditioning followed by GVHD prophylaxis with methotrexate and cyclosporine (which acts in inhibiting the T-cells) inducing further immunosuppression.

A single stool examination is said to be about 50% sensitive for making the diagnosis of S. stercoralis infection in someone with symptomatic chronic disease. In asymptomatic individuals, stool examinations are probably even less sensitive. GVHD can be aggravated by any infection due to upregulation of major histocompatibility antigens by the inflammation and severity can be worsened. In this case, we had to treat the patient with glucocorticoids and antiparasitic medications.

It is important to have a high index of suspicion in patients on immunosuppressive treatment or patients who are immunosuppressed per se.

 
   References Top

1.Grove DI. Historical introduction. In: Grove DI, editor. Strongyloidiasis: A major roundworm infection of man. Philadelphia: Taylor and Francis; 1989.p. 1-9.  Back to cited text no. 1
    
2.Satyanarayana S, Nema S, Kalghatgi AT, Mehta SR, Rai R, Duggal R, et al. Disseminated Strongyloides stercoralis in AIDS: a report from India. Indian J Pathol Microbiol 2005;48:472-4.  Back to cited text no. 2
    
3.Adam M, Morgan O, Persaud C, Gibbs WN. Hyperinfection syndrome with Strongyloides stercoralis in malignant lymphoma. BMJ 1973;1:264-6.  Back to cited text no. 3
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4.Wilkinson R, Leen CL. Chronic lymphocytic leukaemia and overt presentation of underlying Strongyloides stercoralis infection. J Infect 1993;27 : 99-100.   Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Steiner B, Riebold D, Wolff D, Freund M, Reisinger EC. Strongyloides stercoralis eggs in a urethral smear after bone marrow transplantation. Clin Infect Dis 2002;34 : 1280-1.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Shereen Rachel Varghese
Department of Microbiology, Christian Medical College and Hospital, Ludhiana-141 008, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.72050

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    Figures

  [Figure 1]

This article has been cited by
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Transplantation Proceedings. 2017; 49(2): 373
[Pubmed] | [DOI]
2 Strongyloides stercoralisinfection in allogeneic stem cell transplant: a case report and review of the literature
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