surgery. BRCA carriers have a greater risk of second breast cancer than individuals without the mutation. Thus, bilateral mastectomy is often the surgical procedure of choice. This strategy has been shown to improve breast cancer– specific survival and appears to be independent of age.8 The role of systemic and radiation therapy is similar in BRCA- and non-BRCA-associated cancers. Existing guidelines for management of elderly adults with breast cancer can be applied.9
A HIDDEN CAUSE OF RECURRENT ASTHMATIC ATTACKS
A 78-year-old woman was admitted for dyspnea, dyspepsia, and vomiting for 3 days. She was a nonsmoker and had been diagnosed with asthma approximately 10 years before based on lung function test. She experienced one to two asthmatic attacks per year despite good adherence to and correct technique for using inhalational bronchodilators including Salbutamol on an as-needed basis and regular beclomethasone. She had three episodes of vomiting of undigested food on the day of admission. She was afebrile and did not have pleuritic chest pain, diarrhea, or a significant travel or contact history. On physical examination, her blood pressure was 145/71 mmHg, oxygen saturation was 97% on 2 L/min of supplementary oxygen with diffuse bilateral audible wheezing. Chest and abdominal radiographs were unremarkable. Complete blood count showed no leukocytosis or eosinophilia, and renal function test, liver function test, troponin I, amylase, and electrocardiogram were all normal. Nasopharyngeal aspirate was negative. She was initially managed as having asthmatic exacerbation with salbutamol every 4 hours, increased frequency of inhalational beclomethasone, and intravenous hydrocortisone 100 mg every 8 hours. Despite 5 days of treatment, she continued to experience significant dyspnea on exertion, with diffuse audible wheezing. A detailed review of her history showed that she had been a farmer before the age of 20 and then worked as a healthcare assistant in a hospital that involved procedures such as changing patients’ diapers. She was noted to have on-and-off peripheral eosinophilia
Management of elderly BRCA carriers poses interesting challenges for physicians that the existing literature does not adequately address. The availability and exponential increase in genetic testing will result in clinicians encountering this problem with increasing frequency. Contemporary models and guidelines must include age and competing causes of morbidity and mortality to reflect the nature of the population seen in everyday practice. Caroline Mariano, MD Trevor Jolly, MD Division of Geriatric Medicine, University of North Carolina, Chapel Hill, North Carolina
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Both authors participated in preparation of manuscript. Sponsor’s Role: None.
REFERENCES 1. Chen S, Parmigiani G. Meta-analysis of BRCA1 and BRCA2 penetrance. J Clin Oncol 2007;25:1329–1333. 2. van der Kolk DM, de Bock GH, Leegte BK et al. Penetrance of breast cancer, ovarian cancer and contralateral breast cancer in BRCA1 and BRCA2 families: High cancer incidence at older age. Breast Cancer Res Treat 2010;124:643–651. 3. Saslow D, Boetes C, Burke W et al. American cancer society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007;57:75–89. 4. Rebbeck TR, Lynch HT, Neuhausen SL et al. Prophylactic oophorectomy in carriers of BRCA1 or BRCA2 mutations. N Engl J Med 2002;346:1616–1622. 5. Kauff ND, Satagopan JM, Robson ME et al. Risk-reducing salpingooophorectomy in women with a BRCA1 or BRCA2 mutation. N Engl J Med 2002;346:1609–1615. 6. Obermair A, Youlden DR, Baade PD et al. The impact of risk-reducing hysterectomy and bilateral salpingo-oophorectomy on survival in patients with a history of breast cancer—A population-based data linkage study. Int J Cancer 2014;134:2211–2222. 7. National Comprehensive Cancer Network (NCCN) guidelines [on-line]. Available at www.nccn.org Accessed January 6, 2014. 8. Boughey JC, Hoskin TL, Degnim AC et al. Contralateral prophylactic mastectomy is associated with a survival advantage in high-risk women with a personal history of breast cancer. Ann Surg Oncol 2010;17:2702– 2709. 9. Biganzoli L, Wildiers H, Oakman C et al. Management of elderly patients with breast cancer: Updated recommendations of the International Society of Geriatric Oncology (SIOG) and European Society of Breast Cancer Specialists (EUSOMA). Lancet Oncol 2012;13:e148–e160.
To the Editor: We report a patient with strongyloidiasis presenting with recurrent asthmatic attacks. The attacks were brought under control only after the infection was treated.
Figure 1. Rhabditiform larvae of Strongyloides stercoralis (arrows) were detected in the stool specimen of our patient.
JULY 2014–VOL. 62, NO. 7
with an absolute eosinophil count of 0.57 to 0.9 9 109/L (reference range, 0.2–0.45 9 109/L) over the previous 5 years. Stool examination revealed the rhabditiform larvae of Strongyloides stercoralis (Figure 1). Serum IgE level was high at 1,120 IU/mL. She was treated with two doses of ivermectin (200 lg/kg daily), and the intravenous hydrocortisone was stopped. Over the next few days, her symptoms markedly improved, and the eosinophil count normalized. She was discharged after 11 days of admission, and her asthma became better controlled with a combined salmeterol and fluticasone inhaler. There was no further asthmatic exacerbation in the following 2 years, and her maintenance therapy was gradually tapered.
LETTERS TO THE EDITOR
Yat-Fung Shea, MBBS Winnie Wing-Yee Mok, MBBS Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China Jasper Fuk-Woo Chan, FRC Path Department of Microbiology, Carol Yu Centre for Infection, University of Hong Kong, Hong Kong, China Joseph Shiu-Kwong Kwan, FRCP Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
ACKNOWLEDGMENTS DISCUSSION Strongyloidiasis can present as asthma that may be refractory to the usual asthma treatment regime.1–4 The prevalence of S. stercoralis in individuals with asthma from endemic areas was reported to be as high as 13%.5 A high degree of clinical vigilance is needed to diagnose such cases of strongyloidiasis, because it may remain asymptomatic for years and manifest only as the individual ages and experiences immunosenescence. It is particularly relevant to older adults in endemic areas. The first clue to the diagnosis in the woman described above was the lack of clinical improvement despite the use of intravenous hydrocortisone during an asthma attack. The life cycle of the nematode starts with the filariform larvae inside soil penetrating the intact human skin. The larvae enter the venous circulation, reach the lungs, and penetrate the alveolar spaces. They then ascend through the bronchial tree, are swallowed, and reach the small bowel. The female worms embed in the submucosa of the duodenum and produce embryonated eggs. The eggs hatch and release the rhabditiform larvae in the intestinal wall. The larvae migrate into the bowel lumen and are passed into the feces or mature into filariform larvae. The filariform larvae can infect the intestinal mucosa or perianal skin to restart the parasitic cycle. Through this process of autoinfection, the parasite can persist for many years before its discovery.6 Corticosteroids are a well-known risk factor that can exacerbate the severity of strongyloidiasis, leading to hyperinfection syndrome or disseminated infection.3,7 The other clues in our patient’s case included her previous occupation as a farmer and the presence of on-andoff eosinophilia for years. Farmers and miners are two of the best known at-risk groups,8 others include nursing staff5 and conservancy services.9 It is important to consider repeating stool microbiological examinations in suspicious cases because a single stool sample may miss up to 70% of cases.4 A high level of awareness of possible underlying strongyloidiasis in individuals with asthma is important because initiation of antiparasitic treatment can improve asthmatic control and corticosteroids should also be avoided to prevent a hyperinfection syndrome or disseminated infection, which may be associated with a poor clinical outcome.10 Clinicians should have a strong clinical suspicion of strongyloidiasis in older adults with asthma living in endemic areas who have suboptimal response to asthma therapy.
Conflict of Interest: The authors have no financial or any other personal conflict to report. Author Contributions: Study concept and design: Shea, Mok. Acquisition of subject and data: Shea, Mok, Chan. Analysis and interpretation of data: all authors. Preparation of manuscript: all authors. Critical review and approval: all authors. Sponsor’s Role: None.
REFERENCES 1. Dunlap NE, Shin MS, Polt SS et al. Strongyloidiasis manifested as asthma. South Med J 1984;77:77–78. 2. Kabirdas D, Afonso B, Avella H et al. An elderly woman with asthma, eosinophilia, and septic shock. Cleve Clin J Med 2007;74(877–881):885– 886. 3. Altintop L, Cakar B, Hokelek M et al. Strongyloides stercoralis hyperinfection in a patient with rheumatoid arthritis and bronchial asthma: A case report. Ann Clin Microbiol Antimicrob 2010;9:27. 4. Khan WA, Santhanakrishnan K. Hypereosinophilic syndrome secondary to strongyloides infection: A case of recurrent asthma exacerbations. BMJ Case Rep 2013;2013:1–3. 5. Wehner JH, Kirsch CM, Kagawa FTJ et al. The prevalence and response to therapy of Strongyloides stercoralis in patients with asthma from endemic areas. Chest 1994;106:762–766. 6. Montes M, Sawhney C, Barros N. Strongyloides stercoralis: There but not seen. Curr Opin Infect Dis 2010;23:500–504. 7. Chan JF, Choy BY, Lai KN. Nephrotic syndrome secondary to strongyloidiasis: A common infection with an uncommon presentation. Hong Kong J Nephrol 2008;10:37–41. 8. Olsen A, van Lieshout L, Marti H et al. Strongyloidiasis—the most neglected of the neglected tropical diseases? Trans R Soc Trop Med Hyg 2009;103:967–972. 9. Shea YF, Chau KM, Hung IF et al. Strongyloidiasis in a nonagenarian who previously worked in conservancy services. Hong Kong Med J 2013;19:74–76. 10. Mokhlesi B, Shulzhenko O, Garimella PS et al. Pulmonary strongyloidiasis: The varied clinical presentations. Clin Pulm Med 2004;11:6–13.
UROLITHIASIS AS AN UNUSUAL CAUSE OF FAILURE TO THRIVE To the Editor: A 65-year-old woman presented to the emergency department (ED) from clinic for worsening failure to thrive, with a reported unintended weight loss of 175 pounds over the preceding year. She described experiencing early satiety, fatigue, dyspnea on exertion, and occasional bilious emesis over this time. She had been hospitalized in the intensive care unit 11 months earlier for
A hidden cause of recurrent asthmatic attacks.
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