4. Strongyloides stercoralis in transplant patients Alisa Alker

5. Life cycle

6. 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)

7. 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

8. 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

9. 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 1971- 1984 at Vanderbilt had strongloidiasis (Morgan 1986)

10. 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)

11. Diagnosis Roxby 2009

12. 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

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

14. References 1.Neva FA. Biology and immunology of human strongyloidiasis. J. Infect. Dis. 1986 Mar ;153(3):397- 406. 2.Siddiqui AA, Berk SL. Diagnosis of Strongyloides stercoralis infection. Clin. Infect. Dis. 2001 Oct 1;33(7):1040-1047. 3.Segarra-Newnham M. Manifestations, diagnosis, and treatment of Strongyloides stercoralis infection. Ann Pharmacother. 2007 Dec ;41(12):1992-2001. 4.DeVault GA, King JW, Rohr MS, Landreneau MD, Brown ST, McDonald JC. Opportunistic infections with Strongyloides stercoralis in renal transplantation. Rev. Infect. Dis. 1990 Aug ;12(4):653-671. 5.Morgan JS, Schaffner W, Stone WJ. Opportunistic strongyloidiasis in renal transplant recipients. Transplantation. 1986 Nov ;42(5):518-524. 6.Marty FM. Strongyloides hyperinfection syndrome and transplantation: a preventable, frequently fatal infection. Transpl Infect Dis. 2009 Apr ;11(2):97-99. 7.Vilela EG, Clemente WT, Mira RRL, Torres HOG, Veloso LF, Fonseca LP, et al. Strongyloides stercoralis hyperinfection syndrome after liver transplantation: case report and literature review. Transpl Infect Dis. 2009 Apr ;11(2):132-136. 8.Roxby AC, Gottlieb GS, Limaye AP. Strongyloidiasis in transplant patients. Clin. Infect. Dis. 2009 Nov 1;49(9):1411-1423. 9.Mandell G, Bennett J, Dolin R. Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, PA: Elsevier; 10.Center for Disease Control and Prevention. CDC surveillance summaries. MMWR. 1991 ;40(SS):