Strongyloides stercoralis in transplant patients Alisa Alker

Life cycle

Geographic distribution ❖ Over 50 million people are infected worldwide ❖ It endemic in Africa, parts of Asia, South America, Mexico, and the Southern US ❖ National survey of 216,275 stool samples in 1987 found the prevalence of S. stercoralis to be 0.4% (CDC, 1991)

Clinical manifestations ❖ diarrhea, abdominal pain, nausea, and vomiting ❖ dry cough, dyspnea, transient pulmonary infiltrate, throat irritation, wheezing ❖ Loffler syndrome (eosinophilic pneumonia) ❖ fluctuating eosinophilia ❖ rash (larva currens) ❖ asymptomatic

Severe manifestations ❖ Almost always found in immunocompromized hosts (associated with steroid use, HTLV, lymphoma, not HIV) ❖ Hyperinfection and dissemination, leading to ileus, obstruction, GIB, pneumonitis, meningitis, peritonitis, UTI ❖ the larvae bring with them bowel flora, leading to bacteremia, bacterial pneumonia, bacterial meningitis, etc ❖ mortality is ~50% with treatment

Transplant patients ❖ S. stercoralis has been reported in kidney (n=54), liver (n=3), lung (n=1), heart (n=3) and stem cell (n=7) transplant patients ❖ More common for transplant patients to have hyperinfection, though more mild presentations have been reported ❖ 0.7% of the renal transplant recipients between at Vanderbilt had strongloidiasis (Morgan 1986)

Transplant patients ❖ Strongloidiasis can be transmitted by solid organs and it has been documented in people who have not left the US ❖ presentation more likely after transplantation or after treatment of acute rejection ❖ associated with steroid use ❖ cyclosporine may be protective ❖ mortality rate in kidney transplant patients: 49% (Roxby 2009)

Diagnosis Roxby 2009

Treatment ❖ ivermectin 200 ug/kg once daily for 2-3 days ❖ thiabendazole 25 mg/kg twice daily for 3 days ❖ more effective in killing the adult worms than the migrating larvae

Prevention ❖ wearing shoes ❖ improved sanitation ❖ screening prior to transplantation?

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