strongyloides stercoralis l.
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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

Strongyloides stercoralis

Clinico-Pathologic Correlation

Dr. Christina Day

clinical history
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.
medications
MEDICATIONS
  • Immunosupressive therapy:
    • Rapamune, FK-506, Corticosteroids
  • Warfarin
  • Lasix
  • Lipitor
  • Minocyclin
  • Nexium
  • Bactrim
physical exam
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 +
slide5
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
imaging
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
cinical course
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.
cinical course cont
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.
stongyloides stercoralis
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.
s stercoralis in immunocompromised host
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.
clinical course of infection
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.
symptoms and signs of hyperinfection
Symptoms and Signs of Hyperinfection
  • Diarrhea
  • Abdominal pain
  • Can mimic peptic ulcer or duodenitis
  • SOB
  • Pleuritic pain
  • Peripheral eosinophilia
morphologic changes
Morphologic Changes
  • Usually minimal in duodenum, edema and hyperemia with hyperinfection.
  • Colon with ulcerations of various size.
  • Lungs are heavy, consolidated and hemorrhagic.
microscopic findings
Microscopic findings
  • Intestine shows adult worms, eggs and larvae.
  • Lungs and other organs show only larvae.
diagnosis
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.