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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 2  |  Page : 153-155

Pulmonary strongyloidiasis: A case report from Western Uttar Pradesh


Department of Microbiology, Shri Ram Murti Smarak Institute of Medical Sciences, Bhojipura, Bareilly, Uttar Pradesh, India

Date of Web Publication16-Mar-2015

Correspondence Address:
Rajesh Bareja
Department of Microbiology, Shri Ram Murti Smarak Institute of Medical Sciences, Bhojipura, Bareilly - 243 202, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.153263

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  Abstract 

Infections due to Strongyloides stercoralis are unusual in western Uttar Pradesh. We report a case in which S. stercoralis was isolated from the sputum of an immunocompetent female patient who presented with fever and hemoptysis. No elevation of eosinophils had been shown during peripheral blood smear examination. Microscopic examination of sputum for acid-fast bacilli with light emitted diode (LED) microscope and stool revealed the larval form of S. stercoralis. The patient was treated with ivermectin and recovered gradually.

Keywords: Ivermectin, immunocompetent, sputum, strongyloides stercoralis


How to cite this article:
Goyal RK, Bareja R, Mishra V, Behara RN. Pulmonary strongyloidiasis: A case report from Western Uttar Pradesh. CHRISMED J Health Res 2015;2:153-5

How to cite this URL:
Goyal RK, Bareja R, Mishra V, Behara RN. Pulmonary strongyloidiasis: A case report from Western Uttar Pradesh. CHRISMED J Health Res [serial online] 2015 [cited 2022 May 23];2:153-5. Available from: https://www.cjhr.org/text.asp?2015/2/2/153/153263


  Introduction Top


0Strongyloides stercoralis is an intestinal nematode of humans. Patients with hyperinfection syndrome often develop severe respiratory distress and Gram-negative sepsis, which may be caused by the migration of larvae studded with gram-negative bacilli from the gastrointestinal tract to the pulmonary system. [1] Although most infected individuals are asymptomatic, S. stercoralis is capable of transforming into a fulminant fatal illness under certain conditions associated with a compromise of host immunity. [2]

Here, we report a case of pulmonary S. stercoralis hyperinfection syndrome with the initial presentation of acute dyspnea mimicking exacerbation of chronic obstructive pulmonary disease (COPD), with severe complications.


  Case Report Top


A 50-year-old female presented with a history of high-grade fever without chills and rigor since the last two and half months, productive cough with expectoration for one and half months along with two to three episodes of hemoptysis three days ago. She had been having a feeling of breathlessness since the last two months, which was gradual in onset and progressive. She also had the history of loss of appetite and vomiting that was associated with food. There was no history of hematemesis.

As far as her past medical history is concerned, she was having facial nerve weakness since the last one year and skin allergy from the last two years, for which she took medicine for six months. Two years back, she developed large black spots throughout the body that were associated with itching and purulent discharge. For this, she took medicine from a local practitioner and at the time of presentation in this institute, these black spots were comparatively smaller without any discharge. There was no history of any chronic illness like tuberculosis, diabetes mellitus and hypertension. She was a non-smoker and non-alcoholic, but she had a habit of chewing pan that she left two months ago because of vomiting. Her husband had a history of lung cancer.

Laboratory investigations demonstrated a white blood count of 9,100 cells/mm 3 with predominance of neutrophils (70%); eosinophil count was 1%. Her hemoglobin, PCV (packed cell volume), ESR (erythrocytes sedimentation rate), and platelets count were 10.5 g%, 30%, 29 mm/hour, and 440,000/mm 3 , respectively. Her viral markers that include HIV, HBsAg and HCV were negative. Chest radiograph showed normal findings. Computed tomography showed an area of consolidation antero-medially in the right upper lobe with minimal associated fibrotic changes and bronchiectasis with patchy areas of ground glass opacity in left perihilar region and antero-medially in left upper lobe, which indicate an infective etiology. It also revealed mild emphysematous changes bilaterally [Figure 1]a and b.
Figure 1: (a) and (b) CT scan of chest shows an infective etiology

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Sputum sample was sent to the microbiology department for culture sensitivity and acid-fast bacilli (AFB) staining. However, there were no acid-fast bacilli seen during fluorescent microscopy by light emitted diode (LED) microscope but fluorescent larvae of some parasite were observed. Those larvae were having a worm-like configuration with one rounded and thicker end [Figure 2]. Then, a wet mount of sputum was prepared and motile larvae were seen. A fixed smear of sputum sample was stained with Giemsa stain to see the morphology of the larvae. Culture was done on MacConkey and blood agar. After overnight incubation, we got the formation of various migrating tracts on blood agar plate, which were due to the movement of live larvae. Rest only normal commensal bacterial floras of throat were grown on culture plates [Figure 3]. Patient was asked to send the stool specimen for further confirmation of diagnosis. On examination of stool specimen, a large number of motile larvae were detected [Figure 4]. After considering all the facts, history of patient, symptoms and morphology of larvae, infection of Strongyloides stercoralis, a nematode was diagnosed. Therefore, she was treated with ivermectin, and the clinical condition gradually improved. After two days of treatment, the patient was asked again to send sputum and stool specimens to microbiology laboratory. This time numerous non-motile larvae of S. stercoralis were seen. This change may have occurred under the effect of drug.
Figure 2: Larvae of S. stercoralis in sputum specimen observed under LED microscope (×40)

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Figure 3: Creeping of S. stercoralis larvae at the surface of blood agar plate

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Figure 4: S. stercoralis larvae in stool specimen (×40)

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  Discussion Top


Strongyloidiasis, caused by S. stercoralis, is an endemic disease in tropical and subtropical regions. [3] This infection is usually seen in immunocompromised patients, such as severe malnutrition, HIV-infected patients, or patients receiving corticosteroid or chemotherapy, etc. [4] But in this case, neither such type of chronic illness nor endemicity was seen, as no case report of strongyloidiasis has been reported till today in Western Uttar Pradesh.

The pulmonary manifestation of strongyloides hyperinfection may induce bronchospasms, cough, and respiratory failure. [5] It can mimic acute exacerbation of underlying chronic obstructive pulmonary disease (COPD) or new-onset asthma. [6],[7] In the present case, the patient showed pulmonary manifestation and lacking of eosinophilia. In a study by Newberry et al., three of seven patients with strongyloides hyperinfection died, and all of the fatal cases had eosinophil counts <400/mm 3 . In addition, blood counts in chronic infection often show eosinophilia, but the condition of eosinophilia is often absent in hyperinfection syndrome. [5] Therefore, the absence of eosinophilia in patients cannot exclude the diagnosis.

The diagnosis of strongyloidiasis is always established based on the visualization of larvae in the stool specimens or in the respiratory secretions. [8] In this case, initial findings of larvae in sputum specimen provided the hint for diagnosis. Further findings of larvae in stool and the creeping tract on the surface of agar plate provided the confirmatory diagnosis of strongyloidiasis. Although several immunodiagnostic assays have been developed for screening latent S. stercoralis infection, a highly specific and sensitive diagnostic test is still lacking. [9] There is no facility for serodiagnosis of strongyloidiasis in this region that may be due to no prevalence of this disease.


  Conclusion Top


Clinical manifestations of strongyloides hyperinfection are diverse. The patients usually presented with gastrointestinal and respiratory manifestations. Therefore, the main tool for the diagnosis of strongyloidiasis is based on thorough examination of sputum and stool specimens. The case illustrates the need even in non-endemic areas, to suspect opportunistic pulmonary strongyloidiasis when a patient's asthma-like symptoms worsens despite treatment with increasing doses of corticosteroids even without documented abnormalities in cell-mediated immunity.

 
  References Top

1.
Keiser PB, Nutman TB. Strongyloides stercoralis in the Immunocompromised Population. Clin Microbiol Rev 2004;17:208-17.  Back to cited text no. 1
    
2.
Grove DI. Clinical manifestations. In: Grove DI editors. Strongyloidiasis: A major roundworm infection of man. Philadelphia, Pa: Taylor and Francis; 1989. p. 155-73.  Back to cited text no. 2
    
3.
Genta RM. Global prevalence of strongyloidiasis: Critical review with epidemiologic insights into the prevention of disseminated disease. Rev Infect Dis 1989;11:755-67.  Back to cited text no. 3
    
4.
Bava AJ, Troncoso AR. Strongyloides stercoralis hyperinfection in a patient with AIDS. J Int Assoc Physicians AIDS Care (Chic) 2009;8:235-8.  Back to cited text no. 4
    
5.
Newberry AM, Williams DN, Stauffer WM, Boulware DR, Hendel-Paterson BR, Walker PF. Strongyloides hyperinfection presenting as acute respiratory failure and Gram-negative sepsis. Chest 2005;128:3681-4.  Back to cited text no. 5
    
6.
Smith B, Verghese A, Guiterrez C, Dralle W, Berk SL. Pulmonary strongyloidiasis: Diagnosis by sputum gram stain. Am J Med 1985;79:663-6.  Back to cited text no. 6
    
7.
Nwokolo C, Imohiosen EA. Strongyloidiasis of respiratory tract presenting as "asthma". Br Med J 1973;2:153-4.  Back to cited text no. 7
    
8.
Marchi Blatt J, Cantos GA. Evaluation of techniques for the diagnosis of Strongyloides stercoralis in human immunodeficiency virus [HIV] positive and HIV negative individuals in the city of Itajaý×, Brazil. Braz J Infect Dis 2003;7:402-8.  Back to cited text no. 8
    
9.
Siddiqui AA, Berk SL. Diagnosis of Strongyloides stercoralis infection. Clin Infect Dis 2001;33:1040-7.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


This article has been cited by
1 Disseminated strongyloidiasis in an immunocompromised host: A case report
Nurul Suhaiza Hassanudin,Zubaidah Abdul Wahab,Khalid Ibrahim,Fadzilah Mohd Nor
Asian Pacific Journal of Tropical Biomedicine. 2017;
[Pubmed] | [DOI]



 

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