Volume 196 - Issue 7
Case series of four patients with strongyloides after occupational exposure
Authors: Hannah M Soulsby, Saliya Hewagama and Stephen Brady
Med J Aust 2012; 196 (7): 444. || doi: 10.5694/mja11.11505
Published online: 16 April 2012
Published online: 16 April 2012
To the Editor: Strongyloidosis
in Australia has been reported
in Indigenous Australians, war veterans who have served in
South-East Asia and travellers and immigrants from regions in which strongyloidosis is endemic.1,2
The condition is caused by ...
To the Editor: Strongyloidosis in Australia has been reported in Indigenous Australians, war veterans who have served in South-East Asia and travellers and immigrants from regions in which strongyloidosis is endemic.1,2
The condition is caused by Strongyloides stercoralis, and chronic infection with the nematode is maintained by an autoinfective life cycle. The consequences of infection range from asymptomatic minor infection to chronic symptomatic strongyloidosis. In immuno-compromised people, life-threatening dissemination can occur3 with a mortality of nearly 90%.2
In the past 8 years at Alice Springs Hospital, four people have presented with strongyloidosis, in whom the only identifiable exposure was their occupation. Work-related exposure resulting in S. stercoralis infection has been documented previously in healthy Australian medical professionals volunteering in the Solomon Islands.4
In our series, Patient 1 was a middle-aged white man who had previously worked as a teacher in an Indigenous school. He had documented Still’s disease treated with prednisolone, methotrexate and hydroxychloroquine, and presented with urticaria, diarrhoea and a cough. Patient 2 was a child care worker with rheumatoid arthritis, treated with methotrexate and hydroxychloroquine. She presented with a rash, cough, wheezing and eosinophilia. Patient 3 was a middle-aged ex-nurse treated with methotrexate for rheumatoid arthritis, who presented with recurrent epigastric pain. Patient 4 was a paediatrician with systemic lupus erythematosis, who developed abdominal pain, nausea, diarrhoea and eosinophilia after commencing prednisolone for worsening arthralgia and vasculitis.
All four patients tested positive for S. stercoralis in serological tests. The “gold standard” for diagnosis of strongyloides infection is finding typical larvae in stool samples or biopsies, but the strongyloides serological test has a sensitivity of 97% and a specificity of 100%.5 Symptoms for all four patients resolved with two doses of ivermectin 200 mg/kg, spaced 2 weeks apart. Follow-up serological tests performed 6 months later showed an adequate reduction in titres.
This case series describes four individuals who were exposed to strongyloides at work, and highlights the importance of considering strongyloidosis in patients with possible occupational exposure, especially in those on immunosuppressive therapy.3
Whether professionals with occupational exposure to strongyloides should be routinely screened for infection, or should receive regular empirical ivermectin treatment, is of potential debate.
Competing interests
No relevant disclosures.
References
- Einsiedel L, Fernandes L. Strongyloides stercoralis: a cause of morbidity and mortality for indigenous people in Central Australia. Intern Med J 2008; 38: 697-703. 0_CBBBEFAJ
- Marcos LA, Terashima A, Dupont HL, Gotuzzo E. Strongyloides hyperinfection syndrome: an emerging global infectious disease. Trans R Soc Trop Med Hyg 2008; 102: 314-318. 0_CBBGFEHE
- Keiser PB, Nutman TB. Strongyloides stercoralis in the immunocompromised population. Clin Microbiol Rev 2004; 17: 208-217. 0_i1142873
- Pattison DA, Speare R. Strongyloidiasis in personnel of the Regional Assistance Mission to Solomon Islands (RAMSI). Med J Aust 2008; 189: 203-206. 0_i1142875
- Montes M, Sawhney C, Barros N. Strongyloides stercoralis: there but not seen. Curr Opin Infect Dis 2010; 23: 500-504. 0_i1142877