Strongyloides stercoralis

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Strongyloides stercoralis

• Clinico-Pathologic Correlation
• Dr. Christina Day

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CLINICAL HISTORY

• 54 yo Male with Hx of DM, ESRD and right sided
  renal transplant in Oct. 2003.
• BIB EMS with a 1 day Hx of left lower chest gas
  pain radiating to the back and lower abdomen.
• Associated symptoms included nausea, vomiting,
  chills, bloating lethargy, anorexia and shortness
  of breath.

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MEDICATIONS

• Immunosupressive therapy
• Rapamune, FK-506, Corticosteroids
• Warfarin
• Lasix
• Lipitor
• Minocyclin
• Nexium
• Bactrim

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PHYSICAL EXAM

• Genaral Mod. distress, Pain 5/10, afeb
• CVS Tachycardic, regular, no murmurs
• Respiratory Pox 92, CTAB
• Abdomen
• Moderate-severe tenderness
• Rebound and voluntary guarding
• Guiac

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LABS

• WBC- 11.3, Na-122, K-5.8, BUN-51, Cr-3.1,
  Glucose-269
• Autoimmune w/u- Negative (except lupus
  anticoagulant )
• Sputum cytology initally negative
• Rapamune/FK-506 in theraputic range
• ESR-59, Fibrinogen-671, D-dimer neg
• PSA- 9.7

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IMAGING

• 1/29/04
• CXR negative
• Abdo XR thick loops of small bowel in RUQ, edema
  vs. hemorrhage, no obstuction
• 2/2/04
• CXR ?ARDS with bilateral infiltrates, ?diffuse
  alveolar hemorrhage

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CINICAL COURSE

• 1/29 Pt kept NPO, Abx started with impression of
  Rapamune induced enteritis vs. infective.
• 1/30 Febrile with afib. Cr gt3, Rapamune held, ?
  Induced gastritis.
• 1/31 Resp. distress and hemoptysis, b/l rals.
  Impression- pulmonary edema and hemoptysis
  secondary to NGT. DDAVP given and Warfarin held.

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CINICAL COURSE (cont.)

• 2/1 Rapid Afib, resp. distress requiring
  intubation with frank blood on suctioning.
  Transfused PRBC and FFP.
• 2/2 Intermittent Afib. Impression of ARDS with
  diffuse alveolar hemorrhage.
• 2/3 Episodes of de-sats, hypotension and tachy.
  Large clots on suctioning. Cardiac arrest with
  failed resuscitation. Pt pronounced dead at
  455am.

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GROSS AND MICROSCOPIC FINDINGS
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STONGYLOIDES STERCORALIS

• Free living parasitic nematode of the small
  intestine of humans and animals.
• Adult females as large as 2.7mm
• Live deep in crypts of duodenum and lay eggs?
  rhabditoid larvae?fecal excretion? infective
  larvae in soil? penetrate skin? travels to lungs
  and intestine via blood? adult females.

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S. Stercoralis in Immunocompromised Host

• Rhabditoid larvae?infective filariform larvae
  within the intestine?re-enter the blood through
  the intestinal wall? lungs?small intestine.
• This second phase of development is know as
  autoinfection. When massive?Hyperinfection.
• Explains longevity of infection in humans know to
  be up to 40 years in some patients.

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Clinical Course of Infection

• Majority of infected immunocompetent hosts have
  no symptoms.
• How S.stercoralis produces symptoms is unknown.
• Hyperinfection occurs in patients with organ
  transplant, some lymphoid tumors, prolonged
  steroid treatment, malnutrition.
• NOT associated with HIV infection.

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Symptoms and Signs of Hyperinfection

• Diarrhea
• Abdominal pain
• Can mimic peptic ulcer or duodenitis
• SOB
• Pleuritic pain
• Peripheral eosinophilia

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Morphologic Changes

• Usually minimal in duodenum, edema and hyperemia
  with hyperinfection.
• Colon with ulcerations of various size.
• Lungs are heavy, consolidated and hemorrhagic.

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Microscopic findings

• Intestine shows adult worms, eggs and larvae.
• Lungs and other organs show only larvae.

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Diagnosis

• Clinical lab finding rhabditoid larvae in stool.
• With hyperinfection
• filariform larvae may be recovered in stool if
  fixed rapidly.
• Sputum samples
• Other body fluids and tissue may also yield
  larvae.