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HELP!!!! Strongyloidiasis AND Steroids

Rick Speare Richard.Speare at jcu.edu.au
Tue Jul 14 08:15:47 EST 1998

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

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.


Rick Speare
School of Public Health and Tropical Medicine
James Cook University
Townsville 4811

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