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HELP!!!! Strongyloidiasis AND Steroids

Gerald L. McLaughlin, Ph.D gmclaugh at iupui.edu
Tue Jul 14 09:58:01 EST 1998


Dr. Speare's excellent summary may be useful to have on hand for clinicians
regarding severe strongyloidiasis in immunocompromised patients.  I hope
they managed this case correctly!

Jerry

At 06:15 AM 7/14/98 -0700, Rick Speare wrote:
>Dear Cheri
>
>At 07:50 PM 7/12/98 GMT, you wrote:
>>
>>    My mother, 49 yrs old, was diagnosed with strongyloidiasis
stercoralis on
>>July 3rd, 1998 after being misdiagnosed for almost 3 months.  First
diagnosis
>>was a stroke after finding a mass within her brain. She was then treated
with
>>masses amounts of steroids.    2nd diagnosis was "Brain Tumor"... we went
to MD
>>Anderson for a brain biopsy. Biopsy came back non-dianostic.  The first
week of
>>July she began having bad diarrhea, so a stool sample was taken.  Finally a
>>proper diagnosis was made.
>>
>
>>   She is now lying in the ICU unit in East Jefferson Hospital, in Metarie
>>Louisiana. The parasites are now in every part of her body.... Several
attempts
>>have been made to eradicate her body of these vicious parasites/ worms,
yet all
>>have failed.
>
>>As of now she in on a venilator at 100% oxygen with 12 peep. Her heart
rate is
>>very high, and her blood preassure seems to be dropping very, very slow.
There
>>is a severe rash from her knee's to her chin, which we were told , were the
>>parasites migrating to the skin surface. She also has been in a coma for
6 days
>>now.
>
>Sounds like you are talking about a case of the hyperinfective syndrome due
>to Strongyloides stercoralis. Diagnosis is often missed since presentations
>can vary quite markedly. If your mother still has larval migration tracks on
>the skin, antinematode therapy has not yet killed them. Typically with
>hyperinfection the patient has thousands of adult S. stercoralis in the
>mucosa in many parts of the gastrointestinal tract, and thousands of
>autoinfective larvae migrating in the gut wall and other organs of the body. 
>
>> We have many questions, yet the doctors can't seem to answer us.. They keep
>>giving us hope. small, yet hope. If anyone can help us at all, with any
>>information, we'd greatly appreciate it. we are at our last ropes
physically as
>>well as mentally...
>
>What sort of information are you after? Hyperinfection is a life threatening
>situation as you know. Many patients in this state die from bacterial
>infection and multisystem failure. Management consists of focusing on
>controlling the septic aspects if they exist, manageing organ failure,
>killing the adult parasites in the gut, and killing the migrating
>autoinfective larvae. 
>
>To kill the adult Strongyloides the best drugs are ivermectin and
>albendazole. In hyperinfection, ivermectin may be the drug of choice. No
>double blind therapeutic trials appear to have been published on treatment
>of hyperinfection
>but one interesting case series was reported in Clin Infect Dis (1993)
>"Efficacy of ivermectin in the treatment of strongyloidiasis complicating
>AIDS." by Torres JR, Isturiz R, Murillo J, Guzman M, Contreras R. They found
>that the best treatment was 200 micrograms/kg on a multidose schedule on
>days 1, 2, 15, and 16. All seven patients who received multiple doses showed
>sustained clinical and parasitological cure; whereas one of two patients who
>received single dose therapy relapsed promptly and fatally. However,
>treatment failures have been reported even after multiple doses of
>ivermectin in some cases of chronic uncomplicated strongyloidiasis.
>
>Killing autoinfective larvae of S. stercoralis is more difficult, and both
>drugs may not be very efficient.  If a patient does survive a severe
>hyperinfective crisis, monitoring for Strongyloides after recovery has to be
>prolonged and enthusiastic as the parasite is quite difficult to eradicate.
>Repeat courses of albendazole or ivermectin will be required.
>
>Hope this is of some assistance.
>
>Regards
>
>Rick Speare
>School of Public Health and Tropical Medicine
>James Cook University
>Townsville 4811
>AUSTRALIA  
>http://www.jcu.edu.au/dept/PHTM/staff/spebio.htm
>
>
>
Gerald McLaughlin, Ph.D.
Associate Professor
Dept Pathology and Laboratory Medicine
635 Barnhill Drive, MS A128
Indianapolis, IN  46202-5120
317-274-2651; FAX 317-278-2018
E-mail:  gmclaugh at iupui.edu



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