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Indian Journal of Medical Microbiology, Vol. 28, No. 4, October-December, 2010, pp. 407-408 Case Report Disseminated infection with Strongyloides stercoralis in a diabetic patient A Murali, G Rajendiran, K Ranganathan, S Shanthakumari PSG Institute of Medical Sciences & Research, Coimbatore, Tamil Nadu - 641004, India Date of Submission: 25-Jun-2010 Code Number: mb10121 PMID: 20966585 Abstract A 58-year-old male diabetic who was operated for carcinoma larynx 4 years back was admitted with exertional dyspnoea and bilateral leg swelling for the past 2 years. Over the last 2 months, there was a progressive worsening of symptoms. Echocardiography done 2 years back showed pericardial effusion. Echo done during the current admission also showed pericardial effusion with preserved left ventricular function; cytological examination of the pericardial fluid showed larvae of Strongyloides stercoralis. He was treated with antinematodal drugs. A follow-up echo done at discharge showed no pericardial effusion and the patient was completely asymptomatic. To our knowledge, this is the first reported case of Strongyloides pericardial effusion in a diabetic patient. Keywords: Disseminated infection, hyperinfection, parasitic pericardial effusion, Strongyloides stercoralis Introduction Strongyloides stercoralis is an intestinal nematode that causes gastrointestinal infections which are often asymptomatic. It is endemic in tropical and temperate regions. [1] Hyperinfection refers to a state of accelerated autoinfection and disseminated infection is a condition where the larval migration occurs in organs other than its original life cycle. Both these conditions are common in immunocompromised states. The hyperinfection syndrome is on the rise with increasing number of immunocompromised individuals. However, the outcome is poor with 50% mortality. [2] We describe a case of disseminated Strongyloides infection causing chronic pericardial effusion in a patient with poorly controlled type 2 diabetes mellitus. Case Report A 58-year-old male, an agricultural labourer, known to have type 2 diabetes mellitus for the past 10 years, on irregular treatment, presented with worsening dyspnoea on exertion and bilateral leg swelling for the past 2 years. There was no history of angina. He had undergone total laryngectomy for carcinoma larynx, 4 years back. Echocardiogram done 2 years back showed minimal pericardial effusion and a normal left ventricular ejection fraction (EF 65%), without any regional wall motion abnormality. There were no other details available. Examination revealed that he was tachypnoeic, had bilateral pedal oedema, elevated jugular venous pressure and muffled heart sounds. His laboratory investigations were as follows: total count 10,800/mm 3 ; absolute eosinophil count 100; erythrocyte sedimentation rate (ESR) 46 mm in 1 hour; HbA1C 10.2%; blood urea 52 mg/dl; serum creatinine 2.3 mg/dl; normal liver function tests; and thyroid stimulating hormone (TSH) 2.6 μIU/l. ECG showed low voltage complexes with no evidence of ischaemia, and chest X-ray showed cardiomegaly and minimal pleural effusion. An HIV enzyme-linked immunosorbent assay (ELISA) was negative. Echocardiogram revealed a moderate pericardial effusion with preserved left ventricular (LV) function (EF 67%). Diagnostic aspiration of pericardial fluid was done and it was exudative [lactate dehydrogenase (LDH) 336 U/dl, protein 5.7 mg/dl, sugar 152 mg/dl] with a cell count of 60/mm 3 , predominantly lymphocytic. Gram's stain of the fluid and culture were negative. Cytological examination revealed numerous macrophages, activated mesothelial cells and larval forms of S. stercoralis with the background of lymphocytes and neutrophils [Figure - 1]. Repeated stool and sputum examination for larvae of Strongyloides were negative. He was treated with ivermectin 12 mg/day for 2 days. Glycaemic control was achieved with insulin. His symptoms of dyspnoea and pedal oedema improved and at discharge he was asymptomatic with no pericardial effusion in echocardiogram. We conclude that this was an instance of chronic pericardial effusion related to disseminated Strongyloides infection because of the chronicity of the effusion, presence of Strongyloides larvae in the pericardial fluid and prompt resolution with ivermectin therapy. Discussion Strongyloidiasis is an intestinal nematodal infection ubiquitous in tropical and temperate regions. Low socioeconomic status, alcoholism, White race, male gender have been associated with higher prevalence of Strogyloides stool positivity. [3] Humans get infected when the filariform larvae from faecally contaminated soil penetrate the skin and then migrate through blood stream to lungs and break into alveoli. They then ascend along the tracheobroncheal tree and are subsequently swallowed to reach the intestine. The larvae mature into adult females, deposit their eggs on the gastrointestinal (GI) mucosa. These eggs hatch into rhabditiform larvae to be excreted in the faeces. They become filariform larvae in soil and hence the life cycle is continued. In some patients, the larvae remain in the GI tract, change into infective filariform larvae and penetrate the intestinal mucosa to continue the pulmonary life cycle. S. stercoralis is unique amongst the intestinal nematodes in its ability to persist in humans for many years through autoinfective cycle. As the host immunity wanes, autoinfection accelerates leading to increased numbers of filariform larvae causing hyperinfection syndrome. The term hyperinfection describes the syndrome of accelerated autoinfection, consisting of signs and symptoms attributable to increased larval migration. The syndrome is characterised by the development or exacerbation of GI and pulmonary symptoms, with increased numbers of larvae seen in stool or sputum. This is usually restricted to organs of the autoinfective cycle. Hyperinfection is often complicated by sepsis due to gastroinestinal flora and is common in immunocompromised states. [3] The term "disseminated infection" implies the migration of larvae to organs beyond the pulmonary autoinfective cycle. Involvement of brain, heart, liver, lymph nodes, pancreas, gallbladder and kidneys has been reported. [3] The clinical features of hyperinfection syndrome consist of GI, pulmonary and constitutional symptoms. GI manifestations include abdominal pain, watery diarrhoea, weight loss, vomiting and occasionally bleeding. Pulmonary symptoms include cough, breathlessness, pneumonia, pulmonary haemorrhage and pleural effusion. Skin manifestations like pruritic linear streaks in lower trunk (larva currens) also frequently accompany hyperinfection. Eosinophilia is commonly seen in chronic infection but is less common in hyperinfection. Diagnosis of Strongyloides is usually on the basis of detection of larvae in stool or sputum although the sensitivity of a single examination is only about 50%. [4] The blood agar culture method is preferred because of its higher sensitivity; in this method, serpiginous tracts of bacterial growth are seen along the path of motile larvae. [4] Detection of larvae in the duodenal aspirate is more sensitive and hence should be considered when there is clinical suspicion of hyperinfection. [5] Serological tests are available but not commonly used. [3] Strongyloides infection in humans is treated with the aim to eradicate the infection. In chronic infection, ivermectin (200 μg/kg orally, once daily) for 1-2 days or albendazole (400 mg orally, twice daily) for 7 days is sufficient. Recent evidence suggests ivermectin as the drug of choice. [6],[7] But disseminated or hyperinfection may need prolonged therapy. Our patient was an immunosuppressed individual due to poorly controlled diabetes mellitus with a high HbA1C and was operated for solid tissue cancer. He had chronic pericardial effusion and the pericardial fluid was exudative and showed larvae of S. stercoralis. His stool and sputum were negative for Strongyloides larva which is likely to be due to the low sensitivity of the test. Peripheral eosinophilia was absent due to the immunocompromised state. We are aware of only one published report of pericardial strongyloidiasis. The patient was on steroid therapy and developed pericardial effusion. [8] There is another case report on cardiomyopathy due to Strongyloides. [9] To our knowledge, this is the first report of chronic pericardial effusion related to Strongyloides infection in a diabetic, with symptoms resolving with ivermectin. Microscopic examination of a smear of the pericardial fluid may help in diagnosis and to institute appropriate antiparasitic therapy. References
Copyright 2010 - Indian Journal of Medical Microbiology The following images related to this document are available:Photo images[mb10121f1.jpg] |
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