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Key Features

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Essentials of Diagnosis
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  • Abdominal pain, diarrhea

  • Eosinophilia

  • Larvae in stools and duodenal aspirates

  • Serum antibodies

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General Considerations
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  • Strongyloides stercoralis is unique in having both parasitic and free-living forms; the latter can survive in the soil for several generations

  • Parasite is found in most tropical and subtropical regions of the world

  • Older children and adults are infected more often than are young children

  • Even low worm burden can result in significant clinical symptoms

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Clinical Findings

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Symptoms and Signs
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  • Chronic S stercoralis infections can be asymptomatic or cause cutaneous, gastrointestinal, or pulmonary symptoms

  • At the site of skin penetration, a pruritic rash may occur

  • Most prominent features include abdominal pain, distention, diarrhea, vomiting, and occasionally malabsorption

  • Large numbers of migrating larvae can cause wheezing, cough, shortness of breath, and hemoptysis

  • Disseminated infection involving the intestine, the lungs, and the meninges may develop in patients

    • Who have cellular immunodeficiencies

    • Who are receiving corticosteroids or chemotherapy

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Differential Diagnosis
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  • Peptic disease

  • Celiac disease

  • Regional or tuberculous enteritis

  • Hookworm infections

  • Pulmonary phase may mimic asthma or bronchopneumonia

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Diagnosis

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  • Finding larvae in the feces, duodenal aspirates, or sputum is diagnostic

  • IgG antibodies measured by ELISA or immunoblot are relatively sensitive (83–93%)

  • Marked eosinophilia is common

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Treatment

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  • Ivermectin (two doses of 0.2 mg/kg given 1–14 days apart) is the drug of choice

  • Tiabendazole at a dose of 25 mg/kg orally twice orally twice a day for 3 days is an alternative therapy

  • Albendazole has a much lower efficacy

  • In the hyperinfection syndrome,

    • Ivermectin for 1–3 weeks may be necessary

    • Multiple follow-up stool studies for 2 weeks after therapy are indicated to ensure clearance of larvae

  • Patients from endemic areas should be tested for specific antibodies and receive treatment before undergoing immunosuppression

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Outcome

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Complication
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  • Gram-negative sepsis may complicate disseminated strongyloidiasis

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Prognosis
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  • Fatal disseminated strongyloidiasis, known as the hyperinfection syndrome, may develop in immunosuppressed patients

  • Autoinfection can result in persistent infection for decades

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References

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Krolewiecki  AJ  et al: A public health response against Strongyloides stercoralis: time to look at soil-transmitted helminthiasis in full. PLoS Negl Trop Dis. 2013 May 9;7(5):e2165
[PubMed: 23675541] .
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Montes  M  et al: Strongyloides stercoralis: there but not seen. Curr Opin Infect Dis 2010;23:500–504
[PubMed: 20733481]
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Olsen  A  et al: Strongyloidiasis—the most neglected of the tropical diseases? Trns R Soc Trop Med Hyg 2009;103:967–972
[PubMed: 19328508] .

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