eMedicine Specialties > Dermatology > Parasitic Infections
Strongyloidiasis: Treatment & Medication
Updated: May 29, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- The pathogen in strongyloidiasis cannot be extracted from the area of eruption because it is not localized in any single area.
- Anthelmintic therapy is the standard treatment.20
- Supportive therapy should be administered as indicated.
- In instances in which co-infection with enteric bacteria is suspected, antibiotic therapy is indicated as well.
- Cyclosporine, an immunosuppressive agent, has anthelmintic activity. To date, no cases of severe strongyloidiasis development have been reported in patients receiving this agent.
- Strongyloides hyperinfection syndrome, usually precipitated by immune suppression, should be considered in patients who have resided in endemic regions. It is often caused by corticosteroidal drugs.21 Attempts at the detection and eradication of this infection are recommended to prevent this potentially fatal complication.
Consultations
- Consider consulting an infectious disease specialist.
- To ensure that the optimal larval-detection tests are performed, notify the local microbiology laboratory staff that strongyloidiasis is suspected.
- Physicians in the United States may obtain assistance with serologic testing from the Centers for Disease Control and Prevention (CDC). Send a serum sample with the patient's history and physical examination findings to the state public health laboratory, which will then send the data to the CDC. Be aware that this process is often lengthy.
- Several commercial laboratories in the United States can perform serologic testing within a few days. Two are listed below.
- Parasitic Disease Consultants
PO Box 616
2177 Flintstone Drive, Suite J
Tucker, GA 30084
770-496-1370
(This facility performs ELISA for Strongyloides detection.) - Specialty Laboratories
2211 Michigan Avenue
Santa Monica, CA 90404
800-421-4449 or 310-828-6543
(These laboratories perform EIA for Strongyloides detection.)
- Parasitic Disease Consultants
Diet
No specific diet is required.
Activity
The patient's activity does not need to be limited when a cutaneous or systemic infection exists, unless severe disseminated infection occurs.
Medication
The goals of pharmacotherapy are to eradicate the infection, reduce morbidity, and prevent complications.
The medications listed below are available from the CDC Drug Service, Centers for Disease Control and Prevention, Atlanta, GA 30333 (404-639-3670 during business hours, 404-639-2888 during evenings and weekends).
Anthelmintics
Parasitic biochemical pathways are sufficiently different from those of the human host to allow selective interference by chemotherapeutic agents in relatively small doses.
Ivermectin (Stromectol, Mectizan)
DOC for treatment of acute and chronic infection in intestinal stages. Selectively binds to glutamate-gated chloride ion channels in invertebrate nerve and muscle cells, causing paralysis and death of the organism. Half-life is 16 h; metabolized in liver.
Adult
170-200 mcg/kg PO for 1 dose; may repeat if larvae reappear in stool; in immunocompromised patients, several treatments every q2wk may be necessary
Intestinal strongyloidiasis, nondisseminated: 200 mcg/kg PO once
Pediatric
<15 kg: Not established
>15 kg: Administer as in adults
May interact with other ligand-gated chloride channels (eg, those gated by GABA)
Documented hypersensitivity; do not use in first trimester of pregnancy and avoid use until after delivery if possible
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Treat mothers who intend to breastfeed only when risk of delayed treatment outweighs possible risks to newborn (excreted in breast milk); following symptoms primarily seen with accidental intoxications from veterinary formulations, headaches, nausea, vomiting, ataxia, seizures, and mild CNS depression; may cause drowsiness; infection with Loa loa, rarely, may develop encephalopathy with ivermectin treatment; Mazzotti reaction, a severe generalized immune reaction resulting from rapidly killed microfilariae in large numbers, may occur (symptoms include intolerable pruritus, papular rashes, lymphadenopathy, fever, ocular damage, and hypotension)
Albendazole (Albenza)
Second-best agent for treatment of acute and chronic infection. High-affinity binding to free beta-tubulin in parasite cells. Causes energy depletion by inhibiting glucose uptake, immobilization, and finally death.
Adult
400 mg/d for 3 d; repeat in 2-3 wk if necessary
Pediatric
³ 2 years: 400 mg/d PO for 3 d with food; repeat in 3 wk if necessary
Coadministration with carbamazepine may decrease effectiveness; dexamethasone, cimetidine, and praziquantel may increase toxicity; monitor theophylline levels if coadministered
Documented hypersensitivity to albendazole, benzimidazole class of compounds, or any components of the product; not for use in first trimester of pregnancy and avoid use until after delivery if possible
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue use if LFT values increase significantly (resume when levels decrease to pretest values); leukopenia, thrombocytopenia (rare), anemia (rare), abdominal pain, nausea, vomiting, diarrhea, dizziness, vertigo, fever, increased intracranial pressure, and alopecia may occur; in neurocysticercosis, anticonvulsants and high-dose glucocorticoids must also be administered; increased risk of retinal damage in patients with cysticercosis (weigh risks versus benefits of therapy)
Thiabendazole (Mintezol)
DOC for treatment of hyperinfection syndrome and disseminated infection. Inhibits helminth-specific mitochondrial fumarate reductase. Useful for treatment of cutaneous larva migrans.
Adult
>100 lb: 1 g/dose PO
>125 lb: 1.25 g/dose PO
>150 lb: 1.5 g/dose PO; not to exceed g/d
Alternatively: 50 mg/kg PO once (expect higher incidence of adverse effects)
Cutaneous larva migrans:
25 mg/kg bid for 2 to 5 d; not to exceed 3 g/d
Topical: Apply 15% extemporaneous lipophilic ointment bid for 5 d
Hyperinfection syndrome: May need to continue treatment for 7-14 d
Pediatric
Administer PO bid for 2 d using weight-based dosing
>30 lb: 0.25 g/dose
>50 lb: 0.5 g/dose
>75 lb: 0.75 g/dose
>100 lb: Administer as in adults
Severe infection: 25 mg/kg PO q12h for 7-14 d; not to exceed 3 g/d
Cutaneous larva migrans: Administer as in adults
May elevate serum levels of theophylline, increasing toxicity (monitor serum levels and reduce dose prn)
Documented hypersensitivity; do not use in first trimester of pregnancy and avoid use until after delivery if possible
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Closely monitor in hepatic or renal dysfunction; pretherapeutic supportive therapy needed patients who are anemic, dehydrated, or malnourished; caution in confirmed worm infestation (not prophylactic); may cause nausea, vomiting, and mild CNS depression
More on Strongyloidiasis |
| Overview: Strongyloidiasis |
| Differential Diagnoses & Workup: Strongyloidiasis |
 Treatment & Medication: Strongyloidiasis |
| Follow-up: Strongyloidiasis |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
Robson D, Welch E, Beeching NJ, Gill GV. Consequences of captivity: health effects of far East imprisonment in World War II. QJM. Feb 2009;102(2):87-96. [Medline].
Chandrasekar PH, Bharadwaj RA, Polenakovik H, Polenakovik S. Strongyloidiasis. eMedicine from WebMD [serial online]. April 3, 2009;Available at http://emedicine.medscape.com/article/229312-overview.
Milder JE, Walzer PD, Kilgore G, Rutherford I, Klein M. Clinical features of Strongyloides stercoralis infection in an endemic area of the United States. Gastroenterology. Jun 1981;80(6):1481-8. [Medline].
Pelletier LL Jr. Chronic strongyloidiasis in World War II Far East ex-prisoners of war. Am J Trop Med Hyg. Jan 1984;33(1):55-61. [Medline].
Pelletier LL Jr, Gabre-Kidan T. Chronic strongyloidiasis in Vietnam veterans. Am J Med. Jan 1985;78(1):139-40. [Medline].
Pattison DA, Speare R. Strongyloidiasis in personnel of the Regional Assistance Mission to Solomon Islands (RAMSI). Med J Aust. Aug 18 2008;189(4):203-6. [Medline].
Yori PP, Kosek M, Gilman RH, et al. Seroepidemiology of strongyloidiasis in the Peruvian Amazon. Am J Trop Med Hyg. Jan 2006;74(1):97-102. [Medline].
Johnston FH, Morris PS, Speare R, et al. Strongyloidiasis: a review of the evidence for Australian practitioners. Aust J Rural Health. Aug 2005;13(4):247-54. [Medline].
Fardet L, Genereau T, Poirot JL, Guidet B, Kettaneh A, Cabane J. Severe strongyloidiasis in corticosteroid-treated patients: case series and literature review. J Infect. Jan 2007;54(1):18-27. [Medline].
Guyomard JL, Chevrier S, Bertholom JL, Guigen C, Charlin JF. [Finding of Strongyloides stercoralis infection, 25 years after leaving the endemic area, upon corticotherapy for ocular trauma]. J Fr Ophtalmol. Feb 2007;30(2):e4. [Medline].
Salluh JI, Bozza FA, Pinto TS, Toscano L, Weller PF, Soares M. Cutaneous periumbilical purpura in disseminated strongyloidiasis in cancer patients: a pathognomonic feature of potentially lethal disease?. Braz J Infect Dis. Oct 2005;9(5):419-24. [Medline].
Goncalves AL, Machado GA, Goncalves-Pires MR, Ferreira-Junior A, Silva DA, Costa-Cruz JM. Evaluation of strongyloidiasis in kennel dogs and keepers by parasitological and serological assays. Vet Parasitol. Jun 20 2007;147(1-2):132-9. [Medline].
Meamar AR, Rezaian M, Mohraz M, Hadighi R, Kia EB. Strongyloides stercoralis hyper-infection syndrome in HIV+/AIDS patients in Iran. Parasitol Res. Aug 2007;101(3):663-5. [Medline].
Qu Z, Kundu UR, Abadeer RA, Wanger A. Strongyloides colitis is a lethal mimic of ulcerative colitis: the key morphologic differential diagnosis. Hum Pathol. Apr 2009;40(4):572-7. [Medline].
Sato Y, Kobayashi J, Toma H, Shiroma Y. Efficacy of stool examination for detection of Strongyloides infection. Am J Trop Med Hyg. Sep 1995;53(3):248-50. [Medline].
Sithithaworn J, Sithithaworn P, Janrungsopa T, Suvatanadecha K, Ando K, Haswell-Elkins MR. Comparative assessment of the gelatin particle agglutination test and an enzyme-linked immunosorbent assay for diagnosis of strongyloidiasis. J Clin Microbiol. Jul 2005;43(7):3278-82. [Medline].
Page WA, Dempsey K, McCarthy JS. Utility of serological follow-up of chronic strongyloidiasis after anthelminthic chemotherapy. Trans R Soc Trop Med Hyg. Nov 2006;100(11):1056-62. [Medline].
Kishimoto K, Hokama A, Hirata T, et al. Endoscopic and histopathological study on the duodenum of Strongyloides stercoralis hyperinfection. World J Gastroenterol. Mar 21 2008;14(11):1768-73. [Medline].
Mittal S, Sagi SV, Hawari R. Strongyloidiasis: endoscopic diagnosis. Clin Gastroenterol Hepatol. Feb 2009;7(2):e8. [Medline].
Pacanowski J, Santos MD, Roux A, et al. Subcutaneous ivermectin as a safe salvage therapy in Strongyloides stercoralis hyperinfection syndrome: a case report. Am J Trop Med Hyg. Jul 2005;73(1):122-4. [Medline].
Robson D, Beeching NJ, Gill GV. Strongyloides hyperinfection syndrome in British veterans. Ann Trop Med Parasitol. Mar 2009;103(2):145-8. [Medline].
Fasih N, Irfan S, Sheikh U, Beg MS. A fatal case of gram negative bacterial sepsis associated with disseminated strongyloidiasis in an immunocompromised patient. J Pak Med Assoc. Feb 2008;58(2):91-2. [Medline].
Nuesch R, Zimmerli L, Stockli R, Gyr N, Christoph Hatz FR. Imported strongyloidosis: a longitudinal analysis of 31 cases. J Travel Med. Mar-Apr 2005;12(2):80-4. [Medline].
Amer M, Attia M, Ramadan AS, Matout K. Larva currens and systemic disease. Int J Dermatol. Jul-Aug 1984;23(6):402-3. [Medline].
Markell EK, John DT, Krotoski WA. Markell and Voge's Medical Parasitology. 8th ed. Philadelphia, Pa: WB Saunders; 1999:287-93.
Ouimet MJ, Munoz M, Narasiah L, Rambure V, Correa JA. [Current pathologies among asylum seekers in Montreal: prevalence and associated risk factors]. Can J Public Health. Nov-Dec 2008;99(6):499-504. [Medline].
Roeckel IE, Lyons ET. Cutaneous larva migrans, an occupational disease. Ann Clin Lab Sci. Sep-Oct 1977;7(5):405-10. [Medline].
Smith JD, Goette DK, Odom RB. Larva currens. Cutaneous strongyloidiasis. Arch Dermatol. Aug 1976;112(8):1161-3. [Medline].
Stone OJ, Newell GB, Mullins JF. Cutaneous strongyloidiasis: larva currens. Arch Dermatol. Nov 1972;106(5):734-6. [Medline].
von Kuster LC, Genta RM. Cutaneous manifestations of strongyloidiasis. Arch Dermatol. Dec 1988;124(12):1826-30. [Medline].
Further Reading
Clinical trials in recruiting phase
Keywords
strongyloidiasis, cutaneous strongyloidiasis, cutaneous larva migrans, larva currens, racing larva, creeping eruption, creeping infection, threadworm infection, disseminated strongyloidiasis, Strongyloides stercoralis, S stercoralis
