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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 160-163

Intestinal strongyloidiasis in a patient of myasthenia gravis and diabetes mellitus


Department of Microbiology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India

Date of Submission26-Feb-2020
Date of Decision27-Jun-2020
Date of Acceptance24-Jul-2020
Date of Web Publication19-Aug-2020

Correspondence Address:
Prachala Rathod
Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_225_19

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  Abstract 


Strongyloidiasis is endemic in tropical and subtropical countries. It can become fatal and life-threatening in immunocompromised patients. We report a case of a 36-year-old female who was diagnosed with myasthenia gravis and type II diabetes mellitus. The patient complained of diarrhea with fever, vomiting, and dyspnea. On examination of stool in wet mount, 10–15 motile larvae/high-power field were seen. A methylene blue staining of fecal specimen was done to confirm the larvae as rhabditiform larvae of Strongyloides stercoralis. The patient was successfully treated with ivermectin. The authors recommend that in patients with myasthenia gravis, presenting with gastrointestinal manifestations, strongyloidiasis should be suspected, investigated, and treated accordingly.

Keywords: Immunosuppressed, ivermectin, myasthenia gravis, strongyloidiasis


How to cite this article:
Rathod P, Sharma A, Mishra B, Thakur A, Loomba P, Bajaj A, Das M. Intestinal strongyloidiasis in a patient of myasthenia gravis and diabetes mellitus. Saudi J Health Sci 2020;9:160-3

How to cite this URL:
Rathod P, Sharma A, Mishra B, Thakur A, Loomba P, Bajaj A, Das M. Intestinal strongyloidiasis in a patient of myasthenia gravis and diabetes mellitus. Saudi J Health Sci [serial online] 2020 [cited 2020 Oct 29];9:160-3. Available from: https://www.saudijhealthsci.org/text.asp?2020/9/2/160/292645




  Introduction Top


Strongyloidiasis, a parasitic infection by a soil-transmitted nematode, is prevalent worldwide, with an estimated 30–100 million populations being affected.[1] Prevalence in India is reported to be 20% in southern states and 5%–8.5% in northern and northeastern states.[2],[3] Factors such as poor personal hygiene, insufficient safe water supply, inadequate sanitary conditions, and hot and humid climate favor the endemicity of this parasite in tropical and subtropical regions.[4]

Strongyloides stercoralis shows a peculiar and unique life cycle with a parasitic and free-living stage. It shows distinctive features of random migration of autoinfective larvae, rapid hatching of embryonated eggs, and single generation of free-living male and female adults.[5] Recently, strongyloidiasis is being reported in immunocompromised patients in increasing numbers. Immunocompromised conditions associated with strongyloidiasis are HIV/AIDS, human T-cell lymphotropic virus infections, corticosteroid treatment, organ transplantation, malnutrition, hypogammaglobulinemia, collagen/vascular diseases, metabolic disorders, alcoholism, and old age.[4]

Strongyloidiasis may be asymptomatic or cause intermittent symptoms that mostly affect the intestine and present as abdominal pain and intermittent or persistent diarrhea. However, it may present as a fulminant fatal infection in immunosuppressed individuals. Thus, early diagnosis and management is the key to prevent hyperinfection and disseminated infections in these strata of patients.

Here, we present a case of intestinal strongyloidiasis in a patient with myasthenia gravis and diabetes mellitus. To our knowledge, this would be the first case from India reporting Intestinal Strongyloidiasis in this immunosuppressed group.


  Case Study Top


We present a case of 36-year-old female, a known case of myasthenia gravis and type II diabetes mellitus, on treatment with prednisolone and pyridostigmine for 3 years. She was not taking antihyperglycemic medications for the past 1 year. She presented with fever without chills and rigors, vomiting, diarrhea, and dyspnea for 3 days. She complained of passing green-colored, nonfoul-smelling stools, with an increased frequency of 7–8 times a day. On general examination, the patient was conscious, co-operative, and oriented with time and place. Her temperature was 99°F, pulse rate 150/min, respiratory rate 28/min, and systolic blood pressure 60 mmHg. Pallor and bilateral pedal edema were also present. Hematological investigations were within the normal limit except hemoglobin (8.7 g%) and slightly raised complete blood count (15,500/mm3). Her eosinophil count was also within the normal range.

A stool specimen was received in the Department of Microbiology. Microbiological investigations were done. On gross stool examination, the stool was green colored, watery, and nonfoul smelling. Direct microscopy with saline/Lugol's iodine wet mount did not show any ova, cyst, or parasite. The specimen was inoculated on blood agar and MacConkey agar for routine bacterial culture. On blood agar, many trails of bacteria were seen outside the inoculation area [Figure 1]. This finding guided us toward the suspicious presence of parasites, and thus, another stool sample was requested. On wet mount examination of the second specimen, 10–15 motile larvae/low-power field were seen. No pus cells and red blood cells were seen [Figure 2]. Methylene blue staining for morphological features of larvae showed shorter buccal cavity, double bulb esophagus, prominent and large genital primordium, and pointed posterior end [Figure 3] and [Figure 4]. The larvae were identified as rhabditiform larvae (L1) of S. stercoralis. The patient was successfully treated with ivermectin 200 μg/kg per dose, two doses 2 weeks apart. The choice of drug and duration of treatment was based on previous successful studies.[6]
Figure 1: Trails of bacteria on blood agar culture plate

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Figure 2: Rhabditiform larvae in an unstained wet mount

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Figure 3: Rhabditiform larvae in methylene blue-stained fecal specimen

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Figure 4: Morphological features of rhabditiform larvae in methylene blue staining (a) small buccal cavity, (b) double bulb esophagus, (c) prominent genital primordium

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  Discussion Top


The route of transmission of Strongyloides is the transdermal penetration of filariform larvae. Walking barefoot, contact with sewage-contaminated soil, and engaging in agricultural or recreational activities are some of the mode of transmission of S. stercoralis. In the present case, the patient gave a history of having been engaged in constructional activities of her house, which could have been the probable mode of exposure to this helminth.

The diagnosis of strongyloidiasis is difficult in chronic and mild infections where excretion of the larvae is intermittent, infrequent, and in less numbers. The most commonly used technique of direct stool microscopy shows greater sensitivity with increasing number of samples. In this study, we could detect the Schistosoma larvae in the second specimen. However, the blood agar plate culture technique[7] was more sensitive in comparison to the stool microscopy and gave results within 18 h. [Table 1] shows the advantages and disadvantages of the available diagnostic methods.[7]
Table 1: Diagnostic advances for detection of Strongyloides stercoralis

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Various immunosuppressed conditions are associated with Strongyloides infection. [Table 2] shows a few studies from India and outside, mentioning Strongyloides infection associated with immunosuppressed conditions.
Table 2: Studies on strongyloidiasis in immunocompromised hosts

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Corticosteroid therapy is the most frequently used immunosuppressive drug therapy. The patient in the present study was a diagnosed case of myasthenia gravis receiving prednisolone for 3 years. The risk of severe form of S. stercoralis infection increases 2–3-fold with steroid treatment.[14] Eosinophilia is generally present during the acute and chronic stages in most helminthic/parasitic infections but may not occur in patients on glucocorticoids as they cause acute suppression of eosinophil response and lymphocyte activation.[15] Eosinophil count can be considered as a prognostic marker as increased eosinophilia is associated with better patient outcome.[15]

Glucocorticoids are thought to directly affect the parasite by accelerating the transformation of rhabditiform larvae to invasive filariform larvae, which may trigger the autoinfective stage and lead to fatal hyperinfection.[15] Thus, regular screening for parasitic infections such as strongyloidiasis should be carried in immunosuppressed patients, to prevent or delay the associated complications.

The treatment of strongyloidiasis is based on antihelminthic drugs such as azoles, for example, thiabendazole, mebendazole, and albendazole.[6] However, they have major drawbacks because of associated side effects such as nausea, neuropsychiatric complaints, dizziness with thiabendazole, and poor absorption with mebendazole. Ivermectin is reported to efficiently clear larvae within short duration and is associated with fewer side effects such as transient changes in transaminases.[6] Our case was successfully treated with ivermectin.


  Conclusion Top


Immunosuppression is an important risk factor for severe strongyloidiasis. Health-care providers must be aware of this parasitic infection, especially in immunocompromised groups, where disseminated strongyloidiasis is a possibility. Clinicians should develop a high level of suspicion of strongyloidiasis infection in patients on steroid therapy with gastrointestinal signs and symptoms. Eosinophil count may not be considered as an indicator of possible parasitic infection in immunosuppressed individuals as they may present with normal eosinophil counts. Repeated stool examination and eosinophilic counts are of diagnostic importance to rule out S. stercoralis infection and are advocated in patients with diabetes and those who are immunosuppressed and on steroids. Hence, one must be vigilant when the therapy of such patients is being monitored.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We are thankful to the Head of Department, Gastroenterology, for sending stool sample for examination.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nutman TB. Human infection with Strongyloides stercoralis and other related Strongyloides species. Parasitology 2017;144(3):263-73.  Back to cited text no. 1
    
2.
Ghoshal U, Khanduja S, Chaudhury N, Gangwar D, Ghoshal UC. A series on intestinal strongyloidiasis in immunocompetent and immunocompromised hosts. Trop Gastroenterol 2012;33(2):135-39.   Back to cited text no. 2
    
3.
Nagpal S, Oberoi A. Strongyloides stercoralis- an underdiagnosed parasitic infection?- a study fron a tertiary care hospital in North India. J Evolution Med Dent Sci 2018;7(12):1468-72.  Back to cited text no. 3
    
4.
Puthiyakunnon S, Boddu S, Li Y, Zhou X, Wang C, Li J, Chen X. Strongyloidiasis-an insight into its global prevalence and management. PLoS Negl Trop Dis 2014;8(8):e301810.  Back to cited text no. 4
    
5.
Page W, Judd JA, Bradbury RS. The Unique Life Cycle of Strongyloides stercoralis and Implications for Public Health Action. Trop Med Infect Dis 2018;3(53):1-11.  Back to cited text no. 5
    
6.
Suputtamongkol Y, Premasathian N, Bhumimuang K, Waywa D, Nilganuwong S, Karuphong E, et al. Efficacy and safety of single and double doses of ivermectin versus 7-day high dose albendazole for chronic strongyloidiasis. PLoS Negl Trop Dis 2011;5(5):e1044.  Back to cited text no. 6
    
7.
Requena-Mendez A, Buonfrate D, Bisoffi Z. Advances in the diagnosis of human Strongyloides. Curr Trop Med Rep 2014;1(4):207-14.   Back to cited text no. 7
    
8.
Gupta N, Choudhary A, Mirdha BR, Kale P, Kant K, Ghosh A, et al. Strongyloides stercoralis infection: A case series from a tertiary care Center in India. J Glob Infect Dis 2017;9(2):86-7.  Back to cited text no. 8
    
9.
Chand T, Bansal A, Jasuja S, Sagar G. Pulmonary strongyloidiasis and hyperinfection in a renal transplant patient. Lung India: Official Organ of Indian Chest Society 2016;33(6):692-4.  Back to cited text no. 9
    
10.
Randale A, Dani A, Chawhan S, Meshram S, Tathe S, Kumbhalkar D. A case report of Strongyloides stercoralis duodenitis in an immunocompromised patient. Parasitol United J 2015;8:127-9.  Back to cited text no. 10
  [Full text]  
11.
Khuroo MS. Hyperinfection strongyloidiasis in renal transplant recipients. BMJ Case Rep 2014;2014:bcr2014205068.  Back to cited text no. 11
    
12.
Reddy IS, Swarnalata G. Fatal disseminated strongyloidiasis in patients on immunosuppressive therapy: Report of two cases. Indian J Dermatol Venereol Leprol 2005;71(1):38-40.  Back to cited text no. 12
    
13.
Saraei M, Hosseinbigi B, Shahnazi M, Bijani B. Fatal Strongyloides hyper-infection in a patient with myasthenia gravis. Infection 2014;42(6):1039-42.  Back to cited text no. 13
    
14.
Fardet L, Genereau T, Cabane J, Kettaneh A. Severe strongyloidiasis in corticosteroid-treated patients Clin Microbiol Infect 2006;12:945-7.  Back to cited text no. 14
    
15.
Keiser PB, Nutman TB. Nutman Strongyloides stercoralis in the Immunocompromised Population. Clin Microbiol Rev 2004;17(1):208-17.  Back to cited text no. 15
    


    Figures

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

  [Table 1], [Table 2]



 

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