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Strongyloides stercoralis

Strongyloides stercoralis. Clinico-Pathologic Correlation Dr. Christina Day. CLINICAL HISTORY. 54 yo Male with Hx of DM, ESRD and right sided renal transplant in Oct. 2003. BIB EMS with a 1 day Hx of left lower chest “gas” pain radiating to the back and lower abdomen.

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Strongyloides stercoralis

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  1. Strongyloides stercoralis Clinico-Pathologic Correlation Dr. Christina Day

  2. CLINICAL HISTORY • 54 yo Male with Hx of DM, ESRD and right sided renal transplant in Oct. 2003. • BIB EMS with a 1 day Hx of left lower chest “gas” pain radiating to the back and lower abdomen. • Associated symptoms included; nausea, vomiting, chills, bloating lethargy, anorexia and shortness of breath.

  3. MEDICATIONS • Immunosupressive therapy: • Rapamune, FK-506, Corticosteroids • Warfarin • Lasix • Lipitor • Minocyclin • Nexium • Bactrim

  4. PHYSICAL EXAM • Genaral: Mod. distress, Pain 5/10, afeb • CVS: Tachycardic, regular, no murmurs • Respiratory: Pox 92%, CTAB • Abdomen: • Moderate-severe tenderness • +Rebound and voluntary guarding • Guiac +

  5. LABS • WBC- 11.3, Na+-122, K+-5.8, BUN-51, Cr-3.1, Glucose-269 • Autoimmune w/u- Negative (except lupus anticoagulant +) • Sputum cytology initally negative • Rapamune/FK-506 in theraputic range • ESR-59, Fibrinogen-671, D-dimer –neg • PSA- 9.7

  6. IMAGING • 1/29/04 • CXR: negative • Abdo XR: thick loops of small bowel in RUQ, edema vs. hemorrhage, no obstuction • 2/2/04 • CXR: ?ARDS with bilateral infiltrates, ?diffuse alveolar hemorrhage

  7. CINICAL COURSE • 1/29: Pt kept NPO, Abx started with impression of Rapamune induced enteritis vs. infective. • 1/30: Febrile with afib. Cr >3, Rapamune held, ? Induced gastritis. • 1/31: Resp. distress and hemoptysis, b/l rals. Impression- pulmonary edema and hemoptysis secondary to NGT. DDAVP given and Warfarin held.

  8. CINICAL COURSE (cont.) • 2/1: Rapid Afib, resp. distress requiring intubation with frank blood on suctioning. Transfused PRBC and FFP. • 2/2: Intermittent Afib. Impression of ARDS with diffuse alveolar hemorrhage. • 2/3: Episodes of de-sats, hypotension and tachy. Large clots on suctioning. Cardiac arrest with failed resuscitation. Pt pronounced dead at 4:55am.

  9. GROSS AND MICROSCOPIC FINDINGS

  10. STONGYLOIDES STERCORALIS • Free living parasitic nematode of the small intestine of humans and animals. • Adult females as large as 2.7mm • Live deep in crypts of duodenum and lay eggs rhabditoid larvaefecal excretion infective larvae in soil penetrate skin travels to lungs and intestine via blood adult females.

  11. S. Stercoralis in Immunocompromised Host • Rhabditoid larvaeinfective filariform larvae within the intestinere-enter the blood through the intestinal wall lungssmall intestine. • This second phase of development is know as autoinfection. When massiveHyperinfection. • Explains longevity of infection in humans know to be up to 40 years in some patients.

  12. Clinical Course of Infection • Majority of infected immunocompetent hosts have no symptoms. • How S.stercoralis produces symptoms is unknown. • Hyperinfection occurs in patients with: organ transplant, some lymphoid tumors, prolonged steroid treatment, malnutrition. • NOT associated with HIV infection.

  13. Symptoms and Signs of Hyperinfection • Diarrhea • Abdominal pain • Can mimic peptic ulcer or duodenitis • SOB • Pleuritic pain • Peripheral eosinophilia

  14. Morphologic Changes • Usually minimal in duodenum, edema and hyperemia with hyperinfection. • Colon with ulcerations of various size. • Lungs are heavy, consolidated and hemorrhagic.

  15. Microscopic findings • Intestine shows adult worms, eggs and larvae. • Lungs and other organs show only larvae.

  16. Diagnosis • Clinical lab finding rhabditoid larvae in stool. • With hyperinfection • filariform larvae may be recovered in stool if fixed rapidly. • Sputum samples • Other body fluids and tissue may also yield larvae.

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