larva currens and strongyloidiasis cutan med surg 2012;16(6):433-435. images courtesy of a. boggild...

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Larva Currens and StrongyloidiasisAndrea K. Boggild, MSc, MD, FRCPC

Tropical Disease UnitToronto General HospitalDepartment of Medicine

University of Toronto

Disclosure of Potential Conflict of Interest

Financial Disclosures Research / Grant support – Public Health

Agency of Canada; Public Health Ontario

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Audience Question: Which of the Following Statements is True of

Strongyloidiasis?

Profound eosinophilia occurs in almost all cases

Remote travel history does not inform risk assessment

Half of all infections are asymptomatic Strongyloidiasis is very rare in Canada Many easily accessible treatment options

exist in Canada

Clinical Case 64M previously healthy, immigrated to

Canada from southern Italy 38 years ago Presented with a 5-year history of episodic

generalized pruritus lasting 7 to 10 days once per month, and not relieved by anti-histamines

Reported a migratory erythematous rash that occurred on the buttock, abdomen, chest, and shoulders x several years

Eosinophilia of ~3.5 x 109/L

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J Cutan Med Surg 2012;16(6):433-435.

Images courtesy of A. Boggild

Suspected Diagnosis = ??

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Strongyloidiasis – Larva Currens Caused by geotropic helminth Strongyloides

stercoralis Epidemiology of S. stercoralis

Affects 30-100 million people worldwide Endemic in Africa, Asia, SE Asia, Central & South

America High risk countries within high risk regions:

Jamaica, Haiti, Cambodia, Laos, Vietnam, beach areas of West and East Africa

Risk Factors for severe disease & dissemination Major: Steroids, Hematologic malignancy, HTLV-1 Minor: Malnutrition, DM, ESRD, EtOH

PLoS NTDs 2013; 7(7):e2288.

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What do we know about the Epidemiology of Strongyloidiasis in

Canada? South Asian refugees to Canada:

Seroprevalence 11.8% in those from Vietnam, 76.6% from Cambodia

6.8 million Canadians are foreign-born, with approximately 85% immigrating from regions endemic for strongyloidiasis

Assuming a source country average prevalence of 40%, ~2.5 million Canadians are infected with simple intestinal strongyloidiasis

Open Medicine 2014;8(1):e20-32.

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What are the clinical manifestations of strongyloidiasis?

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Clinical Manifestations of Strongyloidiasis

Immunocompetent GI – weight loss, diarrhea, abdo pain, vomiting Dermatologic – larva currens

Immunocompromised (Fatal Hyperinfection) GI symptoms as above + perforation Respiratory – dyspnea, wheezing, hemoptysis,

cough, respiratory distress Fever, decreased LOC/Encephalopathy Gram-negative/polymicrobial sepsis

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Spectrum of Strongyloidiasis

GI + Respsymptoms

Gram-negative sepsis

MeningitisEnd-organ

failure

DiarrheaAbdominal pain

Productive cough

Weight loss

DiarrheaAbdominal painLarva currens

Nausea

Eosinophilia

Disseminated Strongyloidiasis

StrongyloidesHyperinfection

Simple Intestinal

Strongyloidiasis

Asymptomatic

Strongyloidiasis as a mimic of UC

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Strongyloidiasis as a mimic of UCKEY FEATURES DISTINGUISHING

STRONGYLOIDIASIS FROM ULCERATIVE COLITIS:

1. SKIP PATTERN OF INFLAMMATION

2. DISTAL ATTENUATION OF DISEASE

3. EOSINOPHIL RICH INFILTRATES

4. RELATIVE PRESERVATION OF CRYPT ARCHITECTURE

5. FREQUENT INVOLVEMENT OF SUBMUCOSA


Occurs in the setting of accelerated autoinfective cycle with migration of larvae outside the bowel to distant sites

Almost always associated with HTLV-1 infection, glucocorticoids, or other immunosuppressants (rituximab, etc)

Almost always preceded by prolonged diarrheal illness, during which stage larvae can be found in stool

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Host-Worm Interaction

Suspected Diagnosis = Larva Currens

due to Strongyloidiasis

How do you confirm the diagnosis?

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Diagnosis of Strongyloidiasis Labs – eosinophilia in >40-70% uncomplicated

cases, but if complicated eosinophils often absent Uncomplicated disease

3+ serial stool examination for larvae Serology – EIA sensitivity 82-95%, specificity 84-

92% Patient unwell with respiratory symptoms, Gram-

negative sepsis, + risk factors for dissemination Blood, sputum, urine, CSF for larvae 3+ serial stools Serology

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IPAC Issues to Consider Simple intestinal strongyloidiasis or larva currens in

a patient NOT shedding larvae >> routine precautions

Strongyloides hyperinfection / disseminated strongyloidiasis >> contact precautions Why? Filariform larvae are motile and will penetrate intact skin Filariform larvae are found in all bodily effluents and can

reside on surfaces and at ambient temperatures Filariform larvae are difficult to disinfect Person-to-person transmission is possible and difficult to

document

Diagnosis = Larva Currens(Simple Intestinal Strongyloidiasis)

How do you treat the infection?

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Management of Strongyloidiasis Immunocompetent

Albendazole 400 mg po BID x 7d OR Ivermectin 200 mcg/kg/d x 2 doses

Immunosuppressed/Dissemination Albendazole + Ivermectin Broad spectrum antibiotics for gram-negative /

polymicrobial sepsis/meningitis Continue treatment until evidence that parasite

has cleared (monitor clinical specimens for larvae; long-term fall in antibody titres)

Mortality with disseminated strongyloidiasis 86%

PLoS NTDs 2011;5(5):e1044.

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What do you need to know about screening for Strongyloidiasis?

New National Guidelines

http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/16vol42/dr-rm42-1/ar-03-eng.php

CCDR 2016;42(1):12-19.

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Very LowVery LowBirth or residence or long-term travel* in rural or beach area of: Australia, North America or Western Europe

LowModerateBirth or residence or long-term travel* in rural or beach area of: Mediterranean, Middle East, North Africa, Indian sub-continent, Asia

ModerateHighBirth or residence or long-term travel* in rural or beach area of: Southeast Asia, Oceania, sub-Saharan Africa, South America, Caribbean

No known defects in cell-mediated immunity

HTLV-1Glucocorticoid therapyImmunomodulatory agent†Hematologic malignancy

Clinical Risk FactorEpidemiologic Risk Category

SerumSAF-preserved stool specimenFresh sputum in sterile containerUrine in sterile containerCSF in sterile containerTissue, paraffin-embedded or unprocessedAny specimen as above for agar plate culture

SerologyStool O&P examinationSputum O&P examinationUrine O&P examinationCSF O&P examinationTissue O&P examinationAgar plate culture

Disseminated strongyloidiasis‡

SerumSAF-preserved stool specimenFresh sputum in sterile container

SerologyStool O&P examinationSputum O&P examination

Mild hyperinfectionsyndrome†

SerumSAF-preserved stool specimen

SerologyStool O&P examination

Simple intestinal strongyloidiasis*



Asymptomatic ± eosinophilia(this would include asymptomatic individuals undergoing planned immune suppression)

Appropriate Diagnostic Specimen

Appropriate Diagnostic TestSuspected Clinical Syndrome

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Send appropriate specimens for diagnostic testing


Screening not recommended. Consider alternate diagnosis


Very Low





Low

Empiric treatment while awaiting diagnostic testing




Moderate





High


Mild Hyperinfection

Syndrome

Simple intestinal strongyloidiasis

Asymptomatic ±eosinophilia

Suspected Clinical SyndromeRisk Category for Disseminated Strongyloidiasis

Ivermectin 200 g/kg/day po or sc¶ once daily PLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement

Ivermectin 200 g/kg/day po or sc¶ once dailyPLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement

Disseminated strongyloidiasis‡,§,a,b,c,d

Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 days OR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days

Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 daysOR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days

Mild hyperinfectionsyndrome†,a,b,c

Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£


Simple intestinal strongyloidiasis*,a,b



Asymptomatic ± eosinophiliaa,b

(including asymptomatic individuals undergoing planned immune suppression)

Pediatric ManagementAdult ManagementClinical Syndrome

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Clinical Example

38F from Ghana with HTLV-1 Presents with ongoing non-bloody loose

stools for several years Mild occasional productive cough Otherwise well







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Very Low





Low





Moderate





High


Mild Hyperinfection

Syndrome




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Clinical Scenario 66M from Italy with renal transplant in

2007 for ADPKD Presents in 2015 with 8-month history of

worsening renal function and graft rejection

Meds include prednisone, tacrolimus, mycophenolic acid among others

Presents to hospital with E. coli bacteremiaand 3-4 loose stools per day

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Very Low





Low





Moderate





High


Mild Hyperinfection

Syndrome


















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Clinical Scenario

62M from Haiti with HTLV-1 associated myelopathy / tropical spastic paraparesis (HAM/TSP)

Ambulatory with minimal gait deterioration

Otherwise well Empiric steroids being considered







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Very Low





Low





Moderate





High


Mild Hyperinfection

Syndrome




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Clinical Scenario 33M from Canada returned from

peacekeeping work in Sierra Leone with amoebic dysentery

Responded to metronidazole and iodoquinol treatment

Mild intermittent loose stools persist New papular rash on buttocks Eosinophilia of 0.6 x 109/L Extensive travel in developing world

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Very Low





Low





Moderate





High


Mild Hyperinfection

Syndrome


















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Clinical Scenario 58 year-old previously well, UK born woman

presents with a 20-year history of pruritic, rapidly migrating, serpiginous, erythematousrash on back, buttocks, and legs once per month lasting 3-5 days

Rheumatologic, allergic, and dermatologic work-up was negative

Referred to the Tropical Disease Unit for query cutaneous larva migrans

Travel hx = 2 weeks in each of Thailand and the Gambia in the year prior to sx onset

J Cutan Med Surg 2015;19(4):412-415.

Images courtesy of A. Boggild

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Very Low





Low





Moderate





High


Mild Hyperinfection

Syndrome


















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Clinical Scenario 7-year-old previously well girl presents with

a 4-week history of GI upset and diarrhea following a 1-week trip to Cuba 6-weeks ago

Remained well during trip but cut her toe on a shell on the beach

2-weeks post-travel developed fever, productive cough, diarrhea >> seen in ED and eosinophil count of 22.0 x 109/L

Stools negative, Strongyloides serology negative

Referred to the Tropical Disease Unit for high-grade eosinophilia







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Very Low





Low





Moderate





High


Mild Hyperinfection

Syndrome




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Clinical Scenario

We ignored the guidelines and repeated stools at 6- and 8-weeks post-travel Positive for rhabditiform larvae

By 8-weeks post-travel her GI illness had nearly resolved despite lack of treatment















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5 Key Points – Strongyloidiasis Strongyloidiasis is one of the most common

helminthic causes of diarrhea in the developing world

It is a lifelong infection unless treated Confirmation of Strongyloidiasis is by serology +

examination of stools for larvae (or histopath) Prompt initiation of therapy essential to minimize

risk of hyperinfection in setting of immune suppression. Advanced screening of patients at high risk should occur prior to iatrogenic immune suppression

Larva currens may also occur in patients with hyperinfection or dissemination therefore contact precautions for hospitalized patients with larva currens until stools and sputum deemed negative

Contact Information

Dr. Andrea K. Boggild Tropical Disease Unit, Toronto General

Hospital Phone – 416-340-3675 Fax – 416-340-3260 Email – [email protected]

larva currens and strongyloidiasis cutan med surg 2012;16(6):433-435. images courtesy of a. boggild...

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