Non-oral treatment with ivermectin for disseminated strongyloidiasis

Critically ill patients with disseminated strongyloidiasis may not be candidates for oral treatment. We report four patients with disseminated strongyloidiasis, believed to be unable to absorb oral therapy, who were treated with ivermectin by rectal and/or subcutaneous administration. Obtaining subcutaneous ivermectin and dosing it appropriately is a challenge. These cases underscore the need for improved access to subcutaneous ivermectin and more pharmacological data to guide use of this treatment approach.     

Salvage treatment of disseminated strongyloidiasis in an immunocompromised patient: therapy success with subcutaneous ivermectin

Disseminated strongyloidiasis is a disease with high mortality rate, especially in immunocompromised individuals. Paralytic ileus and intestinal malabsorption are frequent symptoms caused by this severe disease. As there are no licensed parenteral anthelmintic drugs for human use, off-label formulations are often used in the treatment of this disease. In this case report, the use of subcutaneous ivermectin is described as a successful therapy for this life-threatening infection.     

Hyperinfection strongyloidiasis in a liver transplant recipient treated with parenteral ivermectin

Abstract: Severe strongyloidiasis, including hyperinfection and dissemination, is a recognized complication of solid organ transplantation. However, the development of strongyloidiasis in a liver transplant recipient has not been previously described. We present a case of severe strongyloidiasis occurring in a patient 4 months after liver transplantation and 1 month after receiving treatment for acute rejection. We assess the management challenges in this patient who remained symptomatic despite oral treatment with ivermectin and albendazole and eventual successful treatment with parenteral ivermectin. We review the published experience with alternative methods of ivermectin administration. We also investigate the possible source of infection, as the patient was not from an endemic area.     

Disseminated strongyloidiasis successfully treated with extended duration ivermectin combined with albendazole: a case report of intractable strongyloidiasis

We describe a patient with an overlapping syndrome disseminated strongyloidiasis and gram-negative sepsis. She was previously treated with albendazole 400 mg/day 14 days before admission without success. This admission, she was treated with a combination of oral ivermectin (injectable solution form), with a dosage of 200-400 microg/kg/day, and albendazole for 14 days. Strongyloides larvae disappeared from the stool by day 4 and from the sputum by day 10. No side effects were encountered during hospitalization or at the 1-month follow-up visit.     

Parenteral ivermectin in Strongyloides hyperinfection

Strongyloides hyperinfection, unresponsive to oral ivermectin and oral albendazole, was controlled by subcutaneous administration of a veterinary preparation of ivermectin.     

Disseminated strongyloidiasis in a patient with acquired immunodeficiency syndrome

We report a case of Strongyloides stercoralis hyperinfection in a Spanish patient who had never traveled to an endemic area and in whom HIV infection and long-term immunosuppressive treatment most likely contributed to the dissemination of strongyloidiasis.     

An autopsy case of disseminated strongyloidiasis combined with cytomegalovirus infection

We report a rare autopsy case of disseminated strongyloidiasis combined with cytomegalovirus co-infection involving a 68-year-old man, who was originally from Okinawa Prefecture in southern Japan, where strongyloidiasis occurs sporadically among the elderly. This patient was admitted with a diagnosis of drug eruption and hypereosinophilic syndrome. He was administered steroid therapy, but suffered complications of fever, respiratory distress, and pulmonary hemorrhaging. The autopsy findings showed disseminated strongyloidiasis in the alveolar spaces and the intestine and cytomegalovirus inclusion body foci in the lungs.     

Pulmonary strongyloidiasis in a patient receiving prednisolone therapy

Strongyloidiasis is widely distributed in tropical and subtropical areas. Disseminated strongyloidiasis may develop in patients with immunodeficiencies. In the absence of early diagnosis and treatment, the prognosis of disseminated strongyloidiasis is extremely poor. We report a case of pulmonary strongyloidiasis that was successfully treated. The patient was an 83-year-old woman who had been receiving long-term oral prednisolone therapy for uveitis. The patient visited our emergency department complaining of breathing difficulties and diarrhea. A chest X-ray revealed a diffuse enhancement of interstitial shadows. A bronchoalveolar lavage (BAL) was performed, and both Gram staining and Grocott's staining revealed the presence of multiple filariform larvae of Strongyloides stercoralis in the bronchoalveolar lavage fluid (BALF). A stool examination performed at the same time also yielded S. stercoralis. The patient was diagnosed as having pulmonary strongyloidiasis and was treated with thiabendazole and ivermectin, in addition to antimicrobial agents; her respiratory symptoms and diarrhea improved, and S. stercoralis was not detected in subsequent follow-up examinations thereafter. In endemic areas of S. stercoralis, pulmonary strongyloidiasis should be considered as part of a differential diagnosis if chest imaging findings like alveolar and interstitial shadow patterns or lobar pneumonia are seen in patients with immunodeficiencies.     

Marked eosinophilia in an immunosuppressed patient with strongyloidiasis

Abstract. Strongyloidiasis in immunocompromized patients is typically associated with a fulminant clinical course and little eosinophilia. We describe an immunocompromized patient with strongyloidiasis in whom the infection was only minimally symptomatic in association with a dramatic increase in eosinophil count.     

Recurrent paralytic ileus associated with strongyloidiasis in a patient with systemic lupus erythematosus

We present an interesting case of recurrent paralytic ileus due to strongyloidiasis in a woman who was being treated with corticosteroids and immunosuppressants for systemic lupus erythematosus (SLE). She was also a carrier of human T-cell leukemia virus type I. She had a history of strongyloidiasis 8 years earlier. Recurrent episodes of paralytic ileus due to strongyloidiasis occurred during treatment of her SLE with corticosteroids. Ivermectin was given and improved the symptoms. This case shows that symptomatic strongyloidiasis can be induced in immunocompromised hosts by immunosuppressive therapy. It is important to rule out strongyloidiasis prior to starting immunosuppressive therapy in patients from endemic areas.     

Clinical study of eradicated and resistant patients to treatment with ivermectin for strongyloidiasis]

We treated 70 patients with strongyloidiasis (41 males and 29 females) with ivermectin (IVM), and obtained the following results: 1. The eradication rates at 1-2 months, 3-4 months and 5-6 months after treatment were 90.7% (49 of 54 patients), 100.0% (47 of 47 patients) and 95.7% (45 of 47 patients), responsively. Twelve patients were resistant (non-responsive) to treatment. 2. When compared to patients whose parasites were completely eradicated, the resistant patients showed the following results: 1) Incidence of symptoms observed before treatment was significantly lower (50.0% vs. 84.5%). 2) Positive rate of anti-HTLV-I antibody was significantly higher (66.7% vs. 20.7%). 3) Blood eosinophil counts before treatment were significantly lower (266.6 +/- 117.2/mm3 vs. 533.2 +/- 429.7/mm3). 4) Serum IgE levels before treatment were significantly lower (217.2 +/- 442.9 IU/ml vs. 1,076.8 +/- 2,108.0 IU/ml). 5) There were no significant differences in age, sex and dosage of ivermectin. 3. Comparing anti-HTLV-I antibody positive and negative patients, the following results were obtained: 1) Eradicated patients; a) Eosinophils and IgE levels before and after the first administration of medicine in anti-HTLV-I antibody positive patients were significantly lower than those of negative patients. b) Gammaglobulin levels before treatment and after both administrations of the drug, IgG before therapy and OKT4/OKT8 after therapy were significantly higher than in anti-HTLV-I antibody positive patients. 2) Resistant patients; Eosinophils after treatment were significantly lower in anti-HTLV-I antibody negative patients than in positive patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Experimental disseminated strongyloidiasis in Erythrocebus patas. I. Pathology

Fatal disseminated disease was induced in ten patas monkeys infected with two Southeast Asian strains of Strongyloides stercoralis. While some animals died within 6 weeks after infection, others controlled their infections until placed on high doses of corticosteroids. Larvae were first noted in the stools 11-20 days after transcutaneous exposure to filariform larvae. Daily larval counts tended to increase as the infections progressed, but the number of larvae in the stool was not predictive of whether a monkey would control his infection or succumb to fatal disease. Hyperinfection was confirmed in the six monkeys in which counts were made of the adult female parasites in the duodenum at postmortem, as well as by pathologic findings in all animals. Clinical signs of disease were vague until dyspnea induced by terminal pulmonary hemorrhage occurred. Eosinophilia and/or basophilia were noted intermittently in some infections. Severe necrotizing duodenitis, colitis, and pulmonary hemorrhage were the most conspicuous postmortem findings. Hyperinfection has been predictably induced in a cercopithecoid monkey for the first time; a species which may lend itself to further investigations into the pathogenesis of disseminated strongyloidiasis .     

Proptosis in a post-renal transplant patient with disseminated tuberculosis

Abstract: A 55-year-old male patient 13 years post living-related renal transplant on immunosuppressives presented with prolonged fever and a recent protrusion of the right eyeball. Evaluation revealed disseminated tuberculosis with a tuberculoma in the right orbit.     

The use of etanercept in a patient with disseminated tuberculosis

Tumor necrosis factor (TNF) is a central regulator of chronic inflammatory diseases and plays a major role in the host immune system against tuberculosis (TB). TNF antagonists, infliximab and etanercept are effective in treating chronic inflammatory diseases by inhibiting TNF, but increase the risk of TB as a result of immunosuppression. Previous studies have shown that the risk of TB is greater in patients who received infliximab than in those who received etanercept and several hypotheses on the action mechanisms of the two agents have been presented in order to explain this difference in the risk of TB. As the clinical use of TNF antagonists increase, the incidence rate of TB may increase. Therefore, it is necessary that clinicians considering the use of TNF antagonists pay much attention to the prevention and control of TB and understand the mechanisms of action of the TNF antagonists. This case shows that etanercept treatment can be safely administered during the treatment of TB. In the future, additional studies will be needed to determine the safety of etanercept and the optimal time for the administration of etanercept during the TB treatment.