PHOTO QUIZ
crossm Answer to Photo Quiz: Disseminated Strongyloidiasis Presenting with Larva Migrans or Cutaneous Strongyloidiasis Nattapol Pruetpongpun,a Pansachee Damronglerd,a Worapop Suthiwartnarueput,b Sasinuch Rujanavej,a Thana Khawcharoenporn,a William Michael Dunne,c Anucha Apisarnthanaraka Division of Infectious Diseases, Faculty of Medicine, Thammasat University, Pathumthani, Thailanda; Department of Pathology and Forensic Medicine, Thammasat University Hospital, Pathumthani, Thailandb; bioMérieux, Inc., R&D Microbiology, Durham, North Carolina, USAc
A
repeated stool examination for ova and parasites revealed a few typical rhabditiform larvae (not shown); examination of a fresh sputum smear revealed no larvae. On hospital day 6, the patient developed septic shock and was started on imipenemcilastatin, colistin, and ivermectin. Repeated blood cultures grew Candida albicans. He died on hospital day 7. Disseminated strongyloidiasis typically occurs in immunocompromised hosts, especially systemic corticosteroid users (1, 2). We hypothesize that the patient’s underlying autoimmune hemolytic anemia (AIHA) predisposed him to use chronic steroids, which is a significant risk factor for disseminated strongyloidiasis. Larvae may be found in almost any organ. Larva migrans (3, 4), an atypical presentation, is caused by intradermal migration of Strongyloides larvae leading to interstitial hemorrhage. Differential diagnoses include hookworm and Gnathostoma spinigerum infections. Hookworm larvae are larger than Strongyloides stercoralis larvae and can penetrate only in the superficial dermis, while cutaneous gnathostomiasis is often seen as a creeping eruption or migratory swelling (5). Eosinophilia is not usually found in corticosteroid users with severe strongyloidiasis, because eosinophil proliferation is inhibited and apoptosis is increased by corticosteroid use (2). The sensitivity of a single stool examination is about 30% because of the small number of larvae that are shed. It is therefore necessary to repeat the stool examination (5). Septicemia caused by enteric Gram-negative, enterococcal, or Bacteroides fragilis bacteria frequently occurs after the gut mucosa is compromised by migrating larvae (5). In a previous case series, 2 of 19 patients with disseminated strongyloidiasis (10.5%) had candidemia (6). Although no specific risk factors for candidemia in disseminated strongyloidiasis have been reported, we hypothesize that prior broad-spectrum antibiotic use is a possible risk factor. The mortality associated with untreated disseminated strongyloidiasis is nearly 100% (5). This case highlights the importance of early detection of disseminated strongyloidiasis and adequate empirical antimicrobial therapy in septic shock patients. Additional studies to define risks for candidemia associated with disseminated strongyloidiasis are needed.
Citation Pruetpongpun N, Damronglerd P, Suthiwartnarueput W, Rujanavej S, Khawcharoenporn T, Dunne WM, Apisarnthanarak A. 2017. Answer to Photo Quiz: Disseminated strongyloidiasis presenting with larva migrans or cutaneous strongyloidiasis. J Clin Microbiol 55:988 –989. https://doi.org/10.1128/JCM.00946-15. Editor P. Bourbeau Copyright © 2017 American Society for Microbiology. All Rights Reserved. Address correspondence to Anucha Apisarnthanarak, [email protected]. See page 663 in this issue (https://doi.org/ 10.1128/JCM.00945-15) for photo quiz case presentation.
ACKNOWLEDGMENTS A.A. and T.K. were supported by the National Research University Project of the Thailand Office of Higher Education Commission. We report no conflicts of interest. REFERENCES 1. Buonfrate D, Requena-Mendez A, Angheben A, Muñoz J, Gobbi F, Van Den Ende J, Bisoffi Z. 2013. Severe strongyloidiasis: a systematic review of case reports. BMC Infect Dis 13:78. https://doi.org/10.1186/1471-2334 -13-78. March 2017 Volume 55 Issue 3
2. Fardet L, Généreau T, Poirot JL, Guidet B, Kettaneh A, Cabane J. 2007. Severe strongyloidiasis in corticosteroid-treated patients: case series and literature review. J Infect 54:18 –27. https://doi.org/10.1016/j.jinf.2006 .01.016.
Journal of Clinical Microbiology
jcm.asm.org 988
Photo Quiz
3. Corte LD, da Silva MV, Souza PR. 2013. Simultaneous larva migrans and larva currens caused by Strongyloides stercoralis: a case report. Case Rep Dermatol Med 2013:381583. https://doi.org/10.1155/2013/381583. 4. Ly MN, Bethel SL, Usmani AS, Lambert DR. 2003. Cutaneous Strongyloides stercoralis infection: an unusual presentation. J Am Acad Dermatol 49: S157–S160. 5. Maguire JH. 2015. Intestinal nematodes (roundworms), p 3204 –3206. In
March 2017 Volume 55 Issue 3
Journal of Clinical Microbiology
Bennett JE, Dolin R, Blaser MJ (ed), Mandell, Douglas, and Bennett’s principles and practice of infectious diseases, 8th ed, vol 2. Elsevier, Philadelphia, PA. 6. Ehtesham Sahidi Rayhane. 2011. Bacterial infections transmitted by pathogenic nematode Strongyloides stercoralis, poster 2847. Abstr 1st Int 4th Nat Congr Health Educ Promot. Tabriz University of Medical Sciences, Tabriz, Iran.
jcm.asm.org 989
crossm Answer to Photo Quiz: Disseminated Strongyloidiasis Presenting with Larva Migrans or Cutaneous Strongyloidiasis Nattapol Pruetpongpun,a Pansachee Damronglerd,a Worapop Suthiwartnarueput,b Sasinuch Rujanavej,a Thana Khawcharoenporn,a William Michael Dunne,c Anucha Apisarnthanaraka Division of Infectious Diseases, Faculty of Medicine, Thammasat University, Pathumthani, Thailanda; Department of Pathology and Forensic Medicine, Thammasat University Hospital, Pathumthani, Thailandb; bioMérieux, Inc., R&D Microbiology, Durham, North Carolina, USAc
A
repeated stool examination for ova and parasites revealed a few typical rhabditiform larvae (not shown); examination of a fresh sputum smear revealed no larvae. On hospital day 6, the patient developed septic shock and was started on imipenemcilastatin, colistin, and ivermectin. Repeated blood cultures grew Candida albicans. He died on hospital day 7. Disseminated strongyloidiasis typically occurs in immunocompromised hosts, especially systemic corticosteroid users (1, 2). We hypothesize that the patient’s underlying autoimmune hemolytic anemia (AIHA) predisposed him to use chronic steroids, which is a significant risk factor for disseminated strongyloidiasis. Larvae may be found in almost any organ. Larva migrans (3, 4), an atypical presentation, is caused by intradermal migration of Strongyloides larvae leading to interstitial hemorrhage. Differential diagnoses include hookworm and Gnathostoma spinigerum infections. Hookworm larvae are larger than Strongyloides stercoralis larvae and can penetrate only in the superficial dermis, while cutaneous gnathostomiasis is often seen as a creeping eruption or migratory swelling (5). Eosinophilia is not usually found in corticosteroid users with severe strongyloidiasis, because eosinophil proliferation is inhibited and apoptosis is increased by corticosteroid use (2). The sensitivity of a single stool examination is about 30% because of the small number of larvae that are shed. It is therefore necessary to repeat the stool examination (5). Septicemia caused by enteric Gram-negative, enterococcal, or Bacteroides fragilis bacteria frequently occurs after the gut mucosa is compromised by migrating larvae (5). In a previous case series, 2 of 19 patients with disseminated strongyloidiasis (10.5%) had candidemia (6). Although no specific risk factors for candidemia in disseminated strongyloidiasis have been reported, we hypothesize that prior broad-spectrum antibiotic use is a possible risk factor. The mortality associated with untreated disseminated strongyloidiasis is nearly 100% (5). This case highlights the importance of early detection of disseminated strongyloidiasis and adequate empirical antimicrobial therapy in septic shock patients. Additional studies to define risks for candidemia associated with disseminated strongyloidiasis are needed.
Citation Pruetpongpun N, Damronglerd P, Suthiwartnarueput W, Rujanavej S, Khawcharoenporn T, Dunne WM, Apisarnthanarak A. 2017. Answer to Photo Quiz: Disseminated strongyloidiasis presenting with larva migrans or cutaneous strongyloidiasis. J Clin Microbiol 55:988 –989. https://doi.org/10.1128/JCM.00946-15. Editor P. Bourbeau Copyright © 2017 American Society for Microbiology. All Rights Reserved. Address correspondence to Anucha Apisarnthanarak, [email protected]. See page 663 in this issue (https://doi.org/ 10.1128/JCM.00945-15) for photo quiz case presentation.
ACKNOWLEDGMENTS A.A. and T.K. were supported by the National Research University Project of the Thailand Office of Higher Education Commission. We report no conflicts of interest. REFERENCES 1. Buonfrate D, Requena-Mendez A, Angheben A, Muñoz J, Gobbi F, Van Den Ende J, Bisoffi Z. 2013. Severe strongyloidiasis: a systematic review of case reports. BMC Infect Dis 13:78. https://doi.org/10.1186/1471-2334 -13-78. March 2017 Volume 55 Issue 3
2. Fardet L, Généreau T, Poirot JL, Guidet B, Kettaneh A, Cabane J. 2007. Severe strongyloidiasis in corticosteroid-treated patients: case series and literature review. J Infect 54:18 –27. https://doi.org/10.1016/j.jinf.2006 .01.016.
Journal of Clinical Microbiology
jcm.asm.org 988
Photo Quiz
3. Corte LD, da Silva MV, Souza PR. 2013. Simultaneous larva migrans and larva currens caused by Strongyloides stercoralis: a case report. Case Rep Dermatol Med 2013:381583. https://doi.org/10.1155/2013/381583. 4. Ly MN, Bethel SL, Usmani AS, Lambert DR. 2003. Cutaneous Strongyloides stercoralis infection: an unusual presentation. J Am Acad Dermatol 49: S157–S160. 5. Maguire JH. 2015. Intestinal nematodes (roundworms), p 3204 –3206. In
March 2017 Volume 55 Issue 3
Journal of Clinical Microbiology
Bennett JE, Dolin R, Blaser MJ (ed), Mandell, Douglas, and Bennett’s principles and practice of infectious diseases, 8th ed, vol 2. Elsevier, Philadelphia, PA. 6. Ehtesham Sahidi Rayhane. 2011. Bacterial infections transmitted by pathogenic nematode Strongyloides stercoralis, poster 2847. Abstr 1st Int 4th Nat Congr Health Educ Promot. Tabriz University of Medical Sciences, Tabriz, Iran.
jcm.asm.org 989
