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  Table of Contents    
LETTER TO EDITOR  
Year : 2021  |  Volume : 64  |  Issue : 1  |  Page : 221-223
Immune thrombocytopenia, Strongyloides stercoralis hyperinfection syndrome with coinfection of Cryptosporidium: A rare case


1 Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

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Date of Submission14-Oct-2019
Date of Decision15-Jan-2020
Date of Acceptance21-Jan-2020
Date of Web Publication8-Jan-2021
 

How to cite this article:
Kalita JM, Yedale K, Tak V, Nag VL, Kumar D, Bohra GK. Immune thrombocytopenia, Strongyloides stercoralis hyperinfection syndrome with coinfection of Cryptosporidium: A rare case. Indian J Pathol Microbiol 2021;64:221-3

How to cite this URL:
Kalita JM, Yedale K, Tak V, Nag VL, Kumar D, Bohra GK. Immune thrombocytopenia, Strongyloides stercoralis hyperinfection syndrome with coinfection of Cryptosporidium: A rare case. Indian J Pathol Microbiol [serial online] 2021 [cited 2021 Apr 23];64:221-3. Available from: https://www.ijpmonline.org/text.asp?2021/64/1/221/306535




Dear Editor,

Strongyloidiasis is a neglected nematode infestation with an extensive global prevalence and high prevalence is especially seen in the tropics and sub-tropics. The global burden of strongyloidiasis is estimated to be between 30 and 100 million people.[1] It is an important human parasitic infection primarily because of its potential to cause serious and even lethal disease primarily in immunocompromised patients. Intestinal coccidial infections are also increasingly becoming prevalent among immunocompromised individuals. Intestinal infection by Cryptosporidium is self-limited, but can lead to persistent diarrhea in immunocompromised individuals. These parasitic infections have been commonly reported from various parts of India.[2] The onset of strongyloides hyper-infection syndrome is associated with a myriad of apparently unrelated symptoms, including diarrhea, abdominal pain, urticaria, sepsis, anemia, shock, and acute respiratory distress syndrome.[3]

A 65-year-old female patient was admitted with complaints of nausea, vomiting, abdominal cramps, diarrhea, fever, and cough. The patient was a diagnosed case of immune thrombocytopenia (ITP) and was on oral corticosteroid therapy (Prednisolone 60 mg, once daily) and Azathioprine (50 mg, twice daily). However, the patient had developed the above mentioned symptoms after 23 days of immunosuppressive therapy. Injection Meropenem was added empirically as an anti-infection treatment along with continuation of the previous medications. Laboratory investigations revealed: normal white blood cell count with neutrophilia (85%) and eosinophilia (5%). Platelet count and hemoglobin level were on a lower side. Highly sensitive C-reactive protein had increased to 105.61 mg/L (normal, <10 mg/L). Renal function test and liver function tests were within the normal range. Serology was negative for human immunodeficiency virus, hepatitis B surface antigen, and hepatitis C virus. Urine culture was sterile and sputum culture showed mixed growth of upper respiratory tract commensal flora. Blood culture was positive, which showed growth of Escherichia coli (E. coli), and the isolate was susceptible to aminoglycosides and colistin. After antimicrobial susceptibility report, injection amikacin (750 mg, once daily) was added to the therapy. Although fever had subsided after treatment, diarrhea and cough persisted. Stool sample was received on 5th day of admission for routine microscopy. With wet mount preparation of stool specimen, numerous larvae of Strongyloides stercoralis were seen [Figure 1]. Modified Ziehl–Neelsen (ZN) staining was performed and oocysts of Cryptosporidium species were also seen [Figure 2]. Retrospectively wet mount preparation of sputum sample was done, which was received for bacterial culture and showed few larvae of S. stercoralis. Modified ZN staining of the sputum sample was also performed in which filariform larvae of S. stercoralis were seen [Figure 1]. Patient was then treated with ivermectin and albendazole for strongyloides with repeated stool examination to verify eradication. Tab Azathioprine was discontinued and Tab Nitazoxanide (500 mg) was added to the regimen as the patient had loose stool although there was absence of S. stercoralis larvae in stool sample after 3 days of therapy. Subsequently tapering of oral prednisolone was done, and patient also symptomatically improved and got discharged.
Figure 1: Larva of S. stercoralis in (a) wet mount preparation of stool sample and in (b) modified ZN staining of sputum sample (Magnification 400×)

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Figure 2: Magnification is 1000× and because of that part of Strongyloides larva is seen in part a along with Cryptosporidium oocyst (larger one). In part b only Cryptosporidium oocyst seen

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Strongyloidiasis is a significant public health problem with varying degrees of severity and clinical presentation. The hyper-infection syndrome is estimated to occur in 1.5%–2.5% of patients with S. stercoralis infection and mortality can be up to 90%.[4] Corticosteroids enhance the apoptosis of T helper 2 (Th2) cells, and subsequently reduce natural immunity, thereby leading to hyper-infection or disseminated infection.[5] It has been proposed that corticosteroids increase ecdysteroid-like substances, which are naturally occurring sterols with nonhormonal anabolic effects and act as moulting signals causing the rhabtidiform larvae to change into infective filariform larvae that amplify the infection manifesting as hyper-infection syndrome.[6] The diverse clinical manifestations of strongyloidosis make the diagnosis difficult, and thus, result in a delay of the specific treatment. High suspicion is important to protect those patients who are receiving steroid therapy and those having infection with viruses like human T-lymphotropic virus (HTLV-1) and HIV, those receiving immunosuppressive therapy, patients with haematological malignancies, and those with diabetes and malnutrition.[7] The gold standard for the diagnosis of strongyloidiasis is serial examination of the parasites with routine saline or iodine wet mount preparations, concentration techniques (Baermann concentration, quantitative acetate concentration technique, Harada–Mori filter paper culture), culturing the samples (stool, sputum, BAL, duodenal aspirate) on agar plates, and histopathological and cytological studies (duodenal biopsy, duodenal aspirate).[6] Larvae of S. stercoralis were found in the patient's stool and sputum samples and isolation of E. coli from blood samples provided a diagnostic proof of strongyloides hyper-infection syndrome with E. coli sepsis relating to the present case. In India, the prevalence rate of cryptosporidiosis was reported to be 4%–13%.[8] Coinfection with Cryptosporidium species in the present case further complicated the case. Most of the reported cases of strongyloides hyper-infection syndrome are associated with either steroid or other immunocompromised state as seen in the present case. However, hyper-infection syndrome in immunocompetent patient has also been reported.[9] Coinfection of S. stercoralis and Cryptosporidium species has been reported very rarely. A study by Getaneh et al. showed coinfection of these two parasites in 2 cases out of total 192 HIV positive individuals.[10] As corticosteroid is the mainstay of treatment in immune thrombocytopenia, an early diagnosis followed by prompt administration of specific antiparasitic therapy is required to eradicate these infections.

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.
Center for Disease Control and Prevention. Strongyloides-Epidemiology and Risk Factors. Available from: https://www.cdc.gov/parasites/strongyloides/epi.html.  Back to cited text no. 1
    
2.
Prasad KN, Nag VL, Dhole TN, Ayyagari A. Identification of enteric pathogens in HIV positive patients with diarrhoea in Northern India. J Health Popul Nutr 2000;8:23-6.  Back to cited text no. 2
    
3.
Donadello K, Cristallini S, Taccone FS, Lorent S, Vincent JL, de Backer D, et al. Strongyloides disseminated infection successfully treated with parenteral ivermectin: Case report with drug concentration measurements and review of the literature. Int J Antimicrob Agents 2013;42:580-3.  Back to cited text no. 3
    
4.
Vadlamudi RS, Chi DS, Krishnaswamy G. Intestinal strongyloidiasis and hyperinfection syndrome. Clin Mol Allergy 2006;4:8.  Back to cited text no. 4
    
5.
Concha R, Harrington W, Rogers AI. Intestinal strongyloidiasis: Recognition, management, and determinants of outcome. J Clin Gastroenterol 2005;39:203-11.  Back to cited text no. 5
    
6.
Siddiqui AA, Berk SL. Diagnosis of Strongyloidesstercoralis infection. Clin Infect Dis 2001;33:1040-7.  Back to cited text no. 6
    
7.
Fardet L, G_En_Ereau T, Cabane J, Kettaneh A. Severe strongyloidiasis in corticosteroid treated patients. Clin Microbiol Infect 2006;12:945-7.  Back to cited text no. 7
    
8.
Ajjampur SS, Sarkar R, Sankaran P, Kannan A, Menon VK, Muliyil J, et al. Symptomatic and asymptomatic Cryptosporidium infections in children in a semi-urban slum community in Southern India. Am J Trop Med Hyg 2010;83:1110-5.  Back to cited text no. 8
    
9.
Mohammed S, Bhatia P, Chhabra S, Gupta SK, Kumar R. Pulmonary hyperinfection with Strongyloides stercoralis in an immunocompetent patient. Indian J Crit Care Med 2019;23:481-3.  Back to cited text no. 9
    
10.
Getaneh A, Medhin G, Shimelis T. Cryptosporidium and Strongyloides stercoralis infections among people with and without HIV infection and efficiency of diagnostic methods for Strongyloides in Yirgalem Hospital, southern Ethiopia. BMC Res Notes 2010;3:90.  Back to cited text no. 10
    

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Correspondence Address:
Vibhor Tak
Department of Microbiology, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_787_19

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