Anne Straily, Barbara L. Herwaldt, Susan Montgomery
An intestinal nematode, Strongyloides stercoralis.
Filariform larvae found in contaminated soil penetrate human skin. Person-to-person transmission is rare but documented.
Endemic to the tropics and subtropics; limited foci elsewhere, including Appalachia and the southeastern United States. Estimates of global prevalence range from 30 to 100 million. Most documented infections in the United States occur in immigrants, refugees, and military veterans who have lived in Strongyloides-endemic areas for long periods. Risk for short-term travelers is low, but infections can occur.
Most infections are asymptomatic. With acute infections, a localized, pruritic, erythematous papular rash can develop at the site of skin penetration, followed by pulmonary symptoms (a Löffler-like pneumonitis), diarrhea, abdominal pain, and eosinophilia. Migrating larvae in the skin cause larva currens, a serpiginous urticarial rash.
Immunocompromised people, especially those receiving systemic corticosteroids, those infected with human T cell lymphotropic virus type 1 and those with hematologic malignancies or who have had hematopoietic stem cell or organ transplants, are at risk for hyperinfection or disseminated disease, characterized by abdominal pain, diffuse pulmonary infiltrates, and septicemia or meningitis from enteric bacteria. Untreated hyperinfection and disseminated strongyloidiasis are associated with high mortality rates.
Peripheral blood eosinophilia is common in intestinal strongyloidiasis but often absent in hyperinfection and disseminated strongyloidiasis. Rhabditiform larvae can be visualized on microscopic examination of stool, either directly or by culture on agar plates. Repeated stool examinations or examination of duodenal contents may be necessary. Hyperinfection and disseminated strongyloidiasis are diagnosed by examining stool, sputum, cerebrospinal fluid, and other body fluids and tissues, which typically contain high numbers of filariform larvae. Serologic testing is available through commercial laboratories and through the National Institutes of Health and CDC (www.cdc.gov/dpdx; 404-718-4745; email@example.com).
Treatment of choice for acute, chronic, and disseminated disease or hyperinfection is ivermectin. The alternative is albendazole, although it is associated with lower cure rates. Prolonged or repeated treatment may be necessary in patients with hyperinfection, disseminated disease, or coinfection with human T cell lymphotropic virus 1, as relapse can occur.
No vaccines or drugs to prevent infection are available. Protective measures include wearing shoes when walking in areas where humans may have defecated. It may be reasonable to perform serologic testing on patients at risk for Strongyloides infection who will be placed on corticosteroids or other immunosuppressive drug regimens, or who will undergo procedures such as transplantation that involve immunosuppression. If indicated, these patients should be treated before immunosuppression. Empiric treatment may be considered in people deemed at risk of strongyloidiasis in whom immediate immunosuppression is required.
Henriquez-Camacho C, Gotuzzo E, Echevarria J, White Jr AC, Terashima A, Samalvides F, et al. Ivermectin versus albendazole or thiabendazole for Strongyloides stercoralis infection. Cochrane Database Sys Rev. 2016 Jan;(1):CD007745.
Keiser PB, Nutman TB. Strongyloides stercoralis in the immunocompromised population. Clin Microbiol Rev. 2004 Jan;17(1):208–17.
Nutman TB. Human infection with Strongyloides stercoralis and other related Strongyloides species. Parasitology. 2017 Mar;144(3):263–73.
Puthiyakunnon S, Boddu S, Li Y, Zhou X, Wang C, Li J, et al. Strongyloidiasis—an insight into its global prevalence and management. PLoS Negl Trop Dis. 2014 Aug;8(8):e3018.
Requena-Mendez A, Buonfrate D, Gomez-Junyent J, Zammarchi L, Bisoffi A, Munoz J. Evidence-based guidelines for screening and management of strongyloidiasis in non-endemic countries. Am J Trop Med Hyg. 2017 Sep;97(3):645–52.
Seybolt LM, Christiansen D, Barnett ED. Diagnostic evaluation of newly arrived asymptomatic refugees with eosinophilia. Clin Infect Dis. 2006 Feb 1;42(3):363–7.