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The results of blood tests on the last day are presented in Table 2. Strongyloidiasis is a significant public health problem with varying degree of severity and clinical presentation. The infection is categorized into three types: acute, chronic uncomplicated, and chronic complicated or hyper-infection syndrome [ 7 ]. The hyper-infection syndrome is estimated to occur in 1.

Hyper-infection syndrome progresses when immunosuppression decreases the effectiveness of the immune system and results in augmentation of the normal life cycle of the parasite leading to a dramatic upsurge in larval density [ 9 ]. The rhabtidiform larvae mature into filariform larvae and penetrate the colonic mucosa of the host, carrying enteric organisms along with them.

As part of their normal life cycle, they enter the lungs where they cause eosinophilic pneumonitis and what often appears at first to be an exacerbation of COPD, and which in turn may progress rapidly to ARDS [ 10—13 ].

The administration of corticosteroids has long been a mainstay of therapy for the treatment of acute exacerbations of COPD [ 14 ]. Short courses of corticosteroids prednisone have been shown to improve both spirometric and clinical outcomes in acute exacerbations of COPD [ 15 ]. It has been proposed that corticosteroids increase ecdysteroid-like substances naturally occurring sterols with non-hormonal anabolic effects which act as moulting signals causing the rhabtidiform larvae to change into infective filariform larvae which amply the infection, eventually leading to hyper-infection syndrome [ 10 ].

The pulmonary symptoms are a consequence of the organism's normal life cycle, in which the filariform larvae progress to the lungs and are swallowed. On entry into the intestine, the filariform larvae mature into adult females and produce rhabtidiform larvae that mature into infectious filariforms, either in the intestine or in the environment [ 18 ].

Therefore, all those those who harbour S. The diverse clinical manifestations of strongyloidosis are rarely associated with diagnosis until it is too late to successfully treat the infection, and the pulmonary symptoms are frequently regarded as an exacerbation of COPD [ 19 ].

This leads to the initiation or an increase in steroid therapy, which leads to more rapid progression of the strongloides hyper-infection [ 20 ]. In turn, this results in severe complications that are often fatal [ 12 ]. A high index of suspicion is important to protect those with who are receiving steroid therapy and those immunocompromised by viruses such human T-lymphotropic virus HTLV-1 and HIV, those receiving immunosuppressive therapy, patients with haematological malignancies, and those with diabetes and malnutrition [ 17, 22 ].

The diagnosis of strongyloidiasis is based on the observation of juvenile larvae in copro-parasitological studies [ 20 ]. The gold standard for the diagnosis of strongyloidiasis is serial examination of the parasites with routine saline or wet mount preparations, concentration techniques Baermann concentration, Horadi—Mori filter paper culture, quantitative acetate concentration technique , culturing the samples on agar plates faecal, sputum, BAL, duodenal aspirate , and histopathological and cytological studies duodenal biopsy, duodenal aspirate [ 10, 23 ].

Numerous larvae of S. However, it is widely reported that eosinophils may be decreased during hyper-infection and this may be an explanation of the poor prognosis. We did not determine whether the patient had pulmonary eosinophilia, which is often seen as larvae of S. Ivermectin and benzimidazoles thiabendazole, mebendazole and albendazole are becoming the drugs of choice for strongyloides infection in many countries [ 27, 28 ].

Ivermectin inhibits neurotransmission, while benzimidazoles disrupt energy production in the parasites with optimal anthelmintic activities [ 7 ]. However, early detection and subsequent dosing schedules, plus monitoring for toxicity of ivermectin and albendazole is mandatory [ 27 ].

Additionally, post-therapy stool examinations are also recommended to verify Strongyloides eradication and to exclude other parasitic infections. Broad-spectrum antibiotic therapy directed toward enteric pathogens , supportive treatment intravenous fluids if volume depletion, blood transfusion if gastrointestinal or alveolar haemorrhage, mechanical ventilation if respiratory failure and symptomatic treatment are crucial in case management [ 1, 7 ].

Meanwhile, empirical steroid therapy is contraindicated because of its immunosuppressive effects, which increase susceptibility to parasitic infections and the apparent role of this therapy as a maturation factor causing the rhabtidiform larvae to mature into infectious filariform larvae, amplifying the infection [ 13, 22 ]. To the best of our knowledge, this is the first case report of strongyloidiasis hyper-infection with concurrent enteric sepsis from Nepal. Despite intensive care, aggressive antibiotics and anti-helminthic therapy, the patient died.

Diagnostic delay, empirical steroid therapy and enterococcal bloodstream infection — caused by the filariform larvae moving from the colon to the bloodstream — were the probable causes of death in this case [ 21, 29 ]. Avoiding corticosteriod therapy in strongyloidiasis is imperative and thus a high index of suspicion is required.

An early diagnosis followed by prompt administration of anti-helminthic therapy is required to eradicate this infection before the infected patient is subjected to immunosuppressive therapy. Ethics approval and consent to participate was granted by the Institutional Review Board Sumeru Hospital.

Written informed consent was obtained from the patient's wife for publication of this case report and accompanying images. The patient's wife provided written informed consent to extract pertinent data from her husband's clinical file. She also consented to an interview in which she provided socio-demographic data.

Two supplementary figures and one supplementary video are available with the online version of this article. National Center for Biotechnology Information , U. JMM Case Rep. Published online Sep Author information Article notes Copyright and License information Disclaimer. Received Jan 4; Accepted Jul This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article has been cited by other articles in PMC. Abstract Introduction Strongyloidiasis is a neglected tropical disease with global prevalence. Case presentation A year-old Nepalese man presenting with chief complaints of nausea, vomiting, joint pain and abdominal cramps was admitted to Sumeru Hospital. Conclusion The findings of our study suggest that corticosteroid administration in strongyloidiasis can lead to the development of fatal strongyloides hyper-infection syndrome.

Keywords: corticosteroid, hyper-infection, strongyloidiasis, immunosuppression. Introduction Strongyloidiasis is a neglected nematode infestation with an extensive global prevalence especially in the tropics and sub-tropics. Case presentation A year-old Nepalese man presenting with chief complaints of frequent wheezing, nausea, vomiting, joint pain and abdominal cramps was admitted to Sumeru Hospital on 15 November Open in a separate window. Table 1. Anti-helmenthic activities on strongyloides hyper-infection syndrome.

Table 2. Blood investigation report on day 1, day 1 and the last day. Discussion Strongyloidiasis is a significant public health problem with varying degree of severity and clinical presentation. Conclusion Avoiding corticosteriod therapy in strongyloidiasis is imperative and thus a high index of suspicion is required. Supplementary Data Supplementary File 1: Click here for additional data file.

Supplementary File 2: Click here for additional data file. Funding information The authors received no specific grant from any funding agency. Conflicts of interest The authors declare that there are no conflicts of interest. Ethics approval Ethics approval and consent to participate was granted by the Institutional Review Board Sumeru Hospital.

Consent to publish Written informed consent was obtained from the patient's wife for publication of this case report and accompanying images. References 1. Fatal septicemic shock associated with Strongyloides stercoralis infection in a patient with angioimmunoblastic T-cell lymphoma: a case report and literature review.

Parasitol Int. A public health response against Strongyloides stercoralis : time to look at soil-transmitted helminthiasis in full. Strongyloides stercoralis. Fatal strongyloides hyperinfection complicating a gram-negative sepsis after allogeneic stem cell transplantation: a case report and review of the literature. Case Rep Hematol. Strongyloides disseminated infection successfully treated with parenteral ivermectin: case report with drug concentration measurements and review of the literature.

Int J Antimicrob Agents. Chandrasekar PH. Medscape; [ Google Scholar ]. Intestinal strongyloidiasis and hyperinfection syndrome. Strongyloides hyperinfection syndrome combined with cytomegalovirus infection. Case Rep Transplant. Diagnosis of Strongyloides stercoralis infection. Clin Infect Dis. Hyperinfection with Strongyloides stercoralis in an asthmatic patient on corticosteroids.

Strongyloides stercoralis hyperinfection after corticosteroid therapy: a report of two cases. Ann Saudi Med. Lippincott Manual Series. Manual of clinical problems in pulmonary medicine; pp. Corticosteroids in the treatment of acute exacerbations of chronic obstructive pulmonary disease. S stercoralis hyperinfection is rare in our area. Medline search from revealed only one report from Kuwait. The presentation in our patients was similar in many aspects to that described by others.

Both patients presented initially with severe pulmonary disease that necessitated mechanical ventilation. These clinical features are nonspecific, therefore a high index of suspicion is needed for early diagnosis. It is of interest that the first patient developed the hyperinfection syndrome after receiving a short course of corticosteroid therapy 13 days only. Both the fatal outcome in our patients and the development of the condition after a short course of corticosteroid therapy suggests the need to be vigilant in such patients to allow for early diagnosis and institution of appropriate treatment in order to avoid such unfortunate outcome.

Physicians in the Gulf area should be aware of this. Although it is hard to draw conclusions from two cases, it may not be unreasonable to screen immunocompromised patients from endemic areas by serology before initiating steroid therapy to prevent the development of Strongyloides hyperinfection. Screening is not recommended for patients before starting short courses of corticosteroids for bronchial asthma or COPD, but may be considered in severe cases of bronchial asthma or COPD requiring recurrent and frequent steroids courses.

In conclusion, S stercoralis hyperinfection syndrome is a disease of immunocompromized patients, especially those who are receiving systemic steroids. Early diagnosis is a real challenge. Clinicians should be aware of the possibility of hyperinfection in immunocompromized patients, and that it may mimic other diseases leading to misdiagnosis.

National Center for Biotechnology Information , U. Journal List Ann Saudi Med v. Ann Saudi Med. Mona A. Al Maslamani , a Hussam A. Al Soub , a Abdel Latif M. Al Khal , a Issam A. Al Bozom , b Mohammed J. Abu Khattab , a and Kadavil C. Chacko a. Al Maslamani. Hussam A. Al Soub. Abdel Latif M. Al Khal. Issam A. Al Bozom. Mohammed J. Abu Khattab. Kadavil C. Author information Copyright and License information Disclaimer. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article has been cited by other articles in PMC. Abstract Two cases of Strongyloides stercoralis hyperinfection are described. CASE 1 A year-old Bangladeshi male was admitted to Hamad General Hospital on 31 December with progressive shortness of breath, fever, and productive cough with yellowish sputum of four days duration.

Open in a separate window. Figure 1. Figure 2. Figure 3. CASE 2 A year-old Nepali male was diagnosed with multiple myeloma complicated by spinal cord compression on 17 June , for which he received radiotherapy and dexamethasone which was given for a total of six weeks.

Genta RM. Global prevalence of strongyloidiasis: critical review with epidemiologic insights in to the prevention of disseminated disease. Rev Infect Dis. Diagnosis of Strongyloides stercoralis infection. Clin Infect Dis. Fatal strongyloidiasis in patients receiving Corticosteroids. N Engl J Med. Keiser PB. Clin Microbiol Rev. Opportunistic infections with Strongyloides stercoralis in renal transplantation. Clinical and epidemiologic features of strongyloidiasis: A prospective study in rural Tennessee.

Arch Intern Med. Pulmonary manifestation of strongyloidiasis. Semin Respir Infect. Overwhelming strongyloidiasis in a diabetic patient following adrenocorticotropin treatment and keto-acidosis. Diabetes Metab. Hyperinfection syndrome with Strongyloides stercoralis. Ann Intern Med. Link K, Orenstein R. Bacterial complications of strongyloidiasis: Streptococcus bovis meningitis. South Med J. Fluctuations of larval excretion in Strongyloides stercoralis infection.

Am J Trop Med Hyg. Gutierra Y. Diagnostic pathology of parasitic infections with clinical correlations. Oxford: Oxford University Press; Strongyloides stercoralis: identification of antigens in natural human infections from endemic areas of the United States. Parasitol Res. A randomized comparative study of albendazole and thiabendazole in chronic strongyloidiasis.

A randomized trial of single- and two-dose ivermectin versus thiabendazole for treatment of strongyloidiasis. J Infect Dis. Clinical study on ivermectin against strongyloidiasis patients. Kansenshogaku Zasshi. Patterns of detection of Strongyloides stercoralis in stool specimens: implications for diagnosis and clinical trials.

J Clin Microbiol. Hyperinfection strongyloidiasis: an anticipated outbreak in kidney transplant recipients in Kuwait. Transplant Proc.

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Skip directly to site content Skip directly to page options Skip directly to A-Z link. Parasites - Strongyloides. Section Navigation. Facebook Twitter LinkedIn Syndicate. Disease Minus Related Pages. If they do feel sick the most common complaints are the following: Abdominal Stomachache, bloating, and heartburn Intermittent episodes of diarrhea and constipation Nausea and loss of appetite Respiratory Dry cough Throat irritation Skin An itchy, red rash that occurs where the worm entered the skin Recurrent raised red rash typically along the thighs and buttocks Rarely, severe life-threatening forms of the disease called hyperinfection syndrome and disseminated strongyloidiasis can occur.

To receive email updates about this page, enter your email address: Email Address. What's this? Links with this icon indicate that you are leaving the CDC website. His past history revealed: COPD, systemic hypertension and formerly treated pulmonary tuberculosis. Twelve days prior to presentation at Sumeru Hospital 3 November , he was admitted to a local hospital with a diagnosis of acute gastritis with acute exacerbated COPD for 2 days.

Nonetheless, his pulmonary condition worsened with haemoptysis, chest tightness and increased cough. On arrival at the emergency Intensive Care Unit, he was found to be hypotensive, hypoxaemic and febrile. Meanwhile, body temperature Physical examination of the abdomen revealed epigastric tenderness but no hepatosplenomegaly.

No oedema, cyanosis or clubbing was noted. Consequently, he was given a preliminary diagnosis of septic shock from an abdominal source and acute respiratory failure. Concurrently, mechanical ventilation, aggressive volume resuscitation and vasopressor support were rapidly begun.

On radiological assessment, chest X-ray showed collapse consolidation with pleural effusion on the right lower lobe, hilar lymph nodes and cardiomegaly Fig. However, haemoglobin concentration, coagulation-related test, platelet count, renal function tests RFTs and liver function tests LFTs were within the normal range. Chest X-ray: collapse consolidation with pleural effusion on the right lower lobe, hilar lymph nodes and cardiomegaly were noted. A flexible bronchoscopy was performed on day 2 of admission; on bronchoscopy severe diffuse alveolar haemorrhage was seen.

Therefore, microbiological examination of broncho-alveolar lavage BAL was recommended. Neither fungal elements nor malignant cells were detected on subsequent fungal staining and cytological examination. With wet preparation of a stool specimen, numerous larvae of S.

S1, available in the online version of this article. Gradually, the physical condition of patient began to deteriorate and a few days after admission vancomycin-sensitive Enterococcus faecium was isolated from his blood sample. AFB staining : Strongyloides stercoralis [usual size: 0. He was then treated with ivermectin and albendazole for strongyloides with repeated daily stool examination to verify eradication and to exclude indwelling other parasitic infections.

On day 1, the wet preparation of stool and sputum revealed actively motile larvae of S. Although the count reduced significantly, the species was found to be motile in sputum samples until day 5. The detailed treatment protocol, duration of treatment and parasite examinations of stool and sputum are shown in Table 1.

Simultaneously, linezolid plus vancomycin was prescribed for two different strains of E. His white blood cell count had decreased to 2. A brief blood investigation report is presented in Table 2. Although the number of larvae was dramatically reduced, the patient developed a high-grade fever, vomiting, lower abdominal pain, abdominal distention and constipation, dyspnoea, wheezing and pleuric pain, and ARDS.

He was therefore mechanically ventilated. However, his condition worsened and he died on day 6 after admission. The results of blood tests on the last day are presented in Table 2. Strongyloidiasis is a significant public health problem with varying degree of severity and clinical presentation. The infection is categorized into three types: acute, chronic uncomplicated, and chronic complicated or hyper-infection syndrome [ 7 ].

The hyper-infection syndrome is estimated to occur in 1. Hyper-infection syndrome progresses when immunosuppression decreases the effectiveness of the immune system and results in augmentation of the normal life cycle of the parasite leading to a dramatic upsurge in larval density [ 9 ]. The rhabtidiform larvae mature into filariform larvae and penetrate the colonic mucosa of the host, carrying enteric organisms along with them. As part of their normal life cycle, they enter the lungs where they cause eosinophilic pneumonitis and what often appears at first to be an exacerbation of COPD, and which in turn may progress rapidly to ARDS [ 10—13 ].

The administration of corticosteroids has long been a mainstay of therapy for the treatment of acute exacerbations of COPD [ 14 ]. Short courses of corticosteroids prednisone have been shown to improve both spirometric and clinical outcomes in acute exacerbations of COPD [ 15 ]. It has been proposed that corticosteroids increase ecdysteroid-like substances naturally occurring sterols with non-hormonal anabolic effects which act as moulting signals causing the rhabtidiform larvae to change into infective filariform larvae which amply the infection, eventually leading to hyper-infection syndrome [ 10 ].

The pulmonary symptoms are a consequence of the organism's normal life cycle, in which the filariform larvae progress to the lungs and are swallowed. On entry into the intestine, the filariform larvae mature into adult females and produce rhabtidiform larvae that mature into infectious filariforms, either in the intestine or in the environment [ 18 ].

Therefore, all those those who harbour S. The diverse clinical manifestations of strongyloidosis are rarely associated with diagnosis until it is too late to successfully treat the infection, and the pulmonary symptoms are frequently regarded as an exacerbation of COPD [ 19 ]. This leads to the initiation or an increase in steroid therapy, which leads to more rapid progression of the strongloides hyper-infection [ 20 ].

In turn, this results in severe complications that are often fatal [ 12 ]. A high index of suspicion is important to protect those with who are receiving steroid therapy and those immunocompromised by viruses such human T-lymphotropic virus HTLV-1 and HIV, those receiving immunosuppressive therapy, patients with haematological malignancies, and those with diabetes and malnutrition [ 17, 22 ].

The diagnosis of strongyloidiasis is based on the observation of juvenile larvae in copro-parasitological studies [ 20 ]. The gold standard for the diagnosis of strongyloidiasis is serial examination of the parasites with routine saline or wet mount preparations, concentration techniques Baermann concentration, Horadi—Mori filter paper culture, quantitative acetate concentration technique , culturing the samples on agar plates faecal, sputum, BAL, duodenal aspirate , and histopathological and cytological studies duodenal biopsy, duodenal aspirate [ 10, 23 ].

Numerous larvae of S. However, it is widely reported that eosinophils may be decreased during hyper-infection and this may be an explanation of the poor prognosis. We did not determine whether the patient had pulmonary eosinophilia, which is often seen as larvae of S.

Ivermectin and benzimidazoles thiabendazole, mebendazole and albendazole are becoming the drugs of choice for strongyloides infection in many countries [ 27, 28 ]. Ivermectin inhibits neurotransmission, while benzimidazoles disrupt energy production in the parasites with optimal anthelmintic activities [ 7 ]. However, early detection and subsequent dosing schedules, plus monitoring for toxicity of ivermectin and albendazole is mandatory [ 27 ].

Additionally, post-therapy stool examinations are also recommended to verify Strongyloides eradication and to exclude other parasitic infections. Broad-spectrum antibiotic therapy directed toward enteric pathogens , supportive treatment intravenous fluids if volume depletion, blood transfusion if gastrointestinal or alveolar haemorrhage, mechanical ventilation if respiratory failure and symptomatic treatment are crucial in case management [ 1, 7 ]. Meanwhile, empirical steroid therapy is contraindicated because of its immunosuppressive effects, which increase susceptibility to parasitic infections and the apparent role of this therapy as a maturation factor causing the rhabtidiform larvae to mature into infectious filariform larvae, amplifying the infection [ 13, 22 ].

To the best of our knowledge, this is the first case report of strongyloidiasis hyper-infection with concurrent enteric sepsis from Nepal. Despite intensive care, aggressive antibiotics and anti-helminthic therapy, the patient died. Diagnostic delay, empirical steroid therapy and enterococcal bloodstream infection — caused by the filariform larvae moving from the colon to the bloodstream — were the probable causes of death in this case [ 21, 29 ].

Avoiding corticosteriod therapy in strongyloidiasis is imperative and thus a high index of suspicion is required. An early diagnosis followed by prompt administration of anti-helminthic therapy is required to eradicate this infection before the infected patient is subjected to immunosuppressive therapy. Ethics approval and consent to participate was granted by the Institutional Review Board Sumeru Hospital.

Written informed consent was obtained from the patient's wife for publication of this case report and accompanying images. The patient's wife provided written informed consent to extract pertinent data from her husband's clinical file. She also consented to an interview in which she provided socio-demographic data. Two supplementary figures and one supplementary video are available with the online version of this article.

National Center for Biotechnology Information , U. JMM Case Rep. Published online Sep Author information Article notes Copyright and License information Disclaimer. Received Jan 4; Accepted Jul This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article has been cited by other articles in PMC. Abstract Introduction Strongyloidiasis is a neglected tropical disease with global prevalence. Case presentation A year-old Nepalese man presenting with chief complaints of nausea, vomiting, joint pain and abdominal cramps was admitted to Sumeru Hospital.

Conclusion The findings of our study suggest that corticosteroid administration in strongyloidiasis can lead to the development of fatal strongyloides hyper-infection syndrome. Keywords: corticosteroid, hyper-infection, strongyloidiasis, immunosuppression. Introduction Strongyloidiasis is a neglected nematode infestation with an extensive global prevalence especially in the tropics and sub-tropics. Case presentation A year-old Nepalese man presenting with chief complaints of frequent wheezing, nausea, vomiting, joint pain and abdominal cramps was admitted to Sumeru Hospital on 15 November Open in a separate window.

Table 1. Anti-helmenthic activities on strongyloides hyper-infection syndrome. Table 2. Blood investigation report on day 1, day 1 and the last day. Discussion Strongyloidiasis is a significant public health problem with varying degree of severity and clinical presentation.

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Patient underwent monitored pulse steroid doses with tapering, and thereafter, achieved resolution of respiratory symptoms. Discussion: Strongyloidiasis is an infection caused by the parasitic nematode Strongyloides. This parasite has the distinctive ability to replicate within a host for decades, producing minimal symptoms.

Because of its subclinical course in immunocompetent individuals, the incidence of Strongyloidiasis is often underestimated. Our case illustrates a misdiagnosis of COPD, diagnosing a coinfection of Stronglyoides and sarcoidosis, successfully treating the Stronglyoides first and then, treating the sarcoidosis.

Conclusions: Strongyloidiasis may mimic other illnesses like COPD, or may even coexist with diseases such as sarcoidosis both of which typically require steroids as treatment. One must be discerning regarding systemic corticosteroids as they may trigger fatal Stronglyloides hyperinfections.

Previous Next. Category: Clinical Vignettes. Sub-Category: Adult. Keywords: Copd , Sarcoid and Strongyloidiasis. By admin T February 25th, August 12th SYDNEY — Think twice before prescribing oral steroids for patients who have urticarial dermatitis, diarrhea, and cough, especially if they have lived in or recently traveled to tropical areas, Ian McCrossin, MD, said at the annual meeting of the Australasian College of Dermatologists.

Strongyloides stercoralis, or threadworm, infection can flare dramatically when patients take oral steroids. McCrossin, a dermatologist from Liverpool Hospital, Sydney, said in an interview. McCrossin cited an Australian study that found a strongyloides infection was present in Risk factors for Strongyloides hyperinfection include compromised immunity, human T-cell lymphotropic virus type 1, alcohol use disorder, malnutrition, and oral steroid use.

McCrossin said. IgG ELISA is a reliable test for established strongyloidiasis, but is less effective for recent infection, hyperinfection, and in patients who are immunosuppressed. Eosinophilia has a poor predictive value.

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Golden dragon blue fire cited an Australian study that found a strongyloides infection was present in Risk factors for Strongyloides hyperinfection include compromised have lived in or recently type 1, alcohol use disorder, McCrossin, MD, said at the annual meeting of the Australasian. IgG ELISA is a reliable may require evaluation of multiple is less effective for recent had hyperinfection. Strongyloides stercoralis, or threadworm, infection can flare dramatically when patients confirm clearance of infection. Consider strongyloidiasis before giving oral. Eosinophilia has a poor predictive. Light microscopy of stool samples Hospital, Sydney, said in an interview. Follow-up stool exams should be performed weeks after treatment to stool samples unless the patient.

The findings of our study suggest that corticosteroid administration in strongyloidiasis can lead to the development of fatal strongyloides hyper-infection syndrome. Hence our experience suggests the need for early diagnosis of strongyloidiasis to avoid such an outcome. Of all the immunosuppressive drugs, corticosteroids are the most widely used and the most specifically associated with transforming chronic strongyloidiasis to. Strategy to Avoid Steroid-Related Strongyloides Hyperinfection or delayed and when treatment with steroids is imminent, waiting for.