eMedicine Specialties > Infectious Diseases > Gastrointestinal Tract and Intra-abdominal Infections

Strongyloidiasis

Author: Pranatharthi Haran Chandrasekar, MD, Director of Infectious Disease Fellowship, Professor, Department of Internal Medicine, Harper Hospital, Wayne State University School of Medicine
Coauthor(s): Ramesh A Bharadwaj, MD, Fellow in Infectious Diseases, Detroit Medical Center, Wayne State University; Hari Polenakovik, MD, Assistant Professor of Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH; Sylvia Polenakovik, MD, Clinical Instructor, Internist, Department of Internal Medicine, Wayne Hospital, Wright State University
Contributor Information and Disclosures

Updated: Apr 3, 2009

Introduction

Background

Strongyloidiasis is an intestinal infection caused by two species of the parasitic nematode Strongyloides. The most common and clinically important pathogenic species in humans is Strongyloides stercoralis. Strongyloides fuelleborni is found sporadically in Africa and Papua New Guinea. Distinctive characteristics of this parasite are its ability to persist and replicate within a host for decades while producing minimal or no symptoms and its potential to cause life-threatening infection (hyperinfection syndrome, disseminated strongyloidiasis) in an immunocompromised host.

For more information on cutaneous manifestations of strongyloidiasis, see the article Strongyloidiasis in eMedicine’s Dermatology volume. For additional information on pediatric strongyloidiasis, see the article Strongyloidiasis in eMedicine’s Pediatrics: General Medicine volume.

Pathophysiology

The life cycle of S stercoralis is complex and unique among the intestinal nematodes. It has two types of life cycles—a free-living life cycle and a parasitic life cycle.

Human infection is acquired via penetration of intact skin by filariform larvae during contact with contaminated soil or other material contaminated with human feces. The larvae then enter the circulation and are carried hematogenously to the lungs, where they enter the alveolar space. They then ascend the tracheobronchial tree and are swallowed. When they reach the small bowel, they molt twice and mature into adult females (2 mm X 0.05 mm in diameter). (All parasitic adult worms are female.)

First stage, life cycle of <EM>Strongyloides ster...

First stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman.

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First stage, life cycle of <EM>Strongyloides ster...

First stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman.


Second stage, life cycle of <EM>Strongyloides ste...

Second stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman.

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Second stage, life cycle of <EM>Strongyloides ste...

Second stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman.


Third stage, life cycle of <EM>Strongyloides ster...

Third stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman.

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Third stage, life cycle of <EM>Strongyloides ster...

Third stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman.


Fourth stage, life cycle of <EM>Strongyloides ste...

Fourth stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman.

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Fourth stage, life cycle of <EM>Strongyloides ste...

Fourth stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman.


Fifth stage, life cycle of <EM>Strongyloides ster...

Fifth stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman.

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Fifth stage, life cycle of <EM>Strongyloides ster...

Fifth stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman.


The parasitic females produce eggs via parthenogenesis. These eggs hatch into noninfective rhabditiform larvae, which may then be passed through the stool into the environment, where they mature into adult males and females. Alternatively, they may cause autoinfection.

Autoinfection involves premature transformation of noninfective larvae (rhabditiform, 0.25 mm X 0.015 mm) into infective larvae (filariform, 0.5 mm X 0.015 mm), which can penetrate the intestinal mucosa (internal autoinfection) or the skin of the perineal area (external autoinfection), thus establishing a developmental (parasitic) cycle within the host. Infection can be maintained by repeated migratory cycles for the remainder of the host’s life.

Autoinfection is kept in check by a normal host immune response. However, in patients with impaired cell-mediated immunity, autoinfection may give rise to the two most severe forms of strongyloidiasis: hyperinfection syndrome and disseminated strongyloidiasis.

Hyperinfection syndrome represents an acceleration of the normal life cycle of S stercoralis, leading to excessive worm burden without the spread of larvae outside the usual migration pattern (eg, gastrointestinal tract, lungs). Disseminated strongyloidiasis involves widespread dissemination of larvae to extraintestinal organs (eg, CNS, heart, urinary tract, endocrine organs), which are outside the realm of the parasite's ordinary life cycle. In these severe forms, translocation of enteric bacteria may occur, leading to polymicrobial bacteremia and occasionally meningitis with enteric pathogens. The enteric pathogens may be carried on the filariform larvae or may enter the circulation through intestinal ulcers.

Frequency

United States

Strongyloidiasis is uncommon, although endemic foci exist in rural areas of the southeastern states and the Appalachia region, with prevalence rates close to 4%. Populations in whom strongyloidiasis is more prevalent include patients in long-term institutionalized care, immigrants or refugees from tropical and subtropical countries, and persons who were stationed in Southeast Asia during World War II1 and the Vietnam War.

International

Strongyloidiasis is endemic in tropical and subtropical countries. Prevalence rates are as high as 40% in certain areas, especially West Africa, the Caribbean, and Southeast Asia. The disease is estimated to affect more than 70 million people worldwide.

Mortality/Morbidity

Severe strongyloidiasis carries a high mortality rate (up to 80%) because the diagnosis is often delayed. This relates to its nonspecific presentation and the host's immunocompromised status. Most immunocompetent individuals who develop strongyloidiasis have asymptomatic chronic infections that result in negligible morbidity.

Race

Strongyloidiasis has no predilection for any racial or ethnic group.

Sex

Strongyloidiasis has no predilection for either sex.

Age

Strongyloidiasis occurs in all age groups, although acquisition is more common during childhood.

Clinical

History

  • Acute strongyloidiasis
    • Lower-extremity itch (eg, mild rash at the site of larval skin penetration, usually on feet)
    • Cough, dyspnea, wheezing, and low-grade fever (due to larval migration through lungs)
    • Epigastric discomfort, diarrhea, occasional nausea, and vomiting
  • Chronic strongyloidiasis
    • Asymptomatic or vague abdominal discomfort (most patients)
    • Abdominal pain, burning, and cramping (sometimes worse after eating)
    • Intermittent diarrhea (eg, alternating with constipation)
    • Occasional nausea and vomiting
    • Weight loss (if heavier infestation)
    • Recurrent maculopapular or serpiginous rashes (larva currens)
  • Severe strongyloidiasis
    • Insidious and occasionally abrupt onset
    • Nausea, vomiting, and severe abdominal pain
    • Diarrhea, occasionally bloody
    • Cough, hemoptysis, dyspnea, and wheezing
    • Stiff neck, headache, and confusion (if CNS involvement)
    • Rash
    • Fever, chills

Physical

  • Acute strongyloidiasis
    • Pruritic erythematous maculopapules at the site of larval skin penetration, usually on the feet
    • Wheezing
    • Low-grade fever
    • Epigastric tenderness
  • Chronic strongyloidiasis
    • Epigastric tenderness
    • Chronic urticaria
    • Larva currens ("racing larva") - Rapidly progressive serpiginous wheals beginning perianally and extending to the buttocks, upper thighs, and abdomen at a rate of 5-10 cm/h; pathognomonic lesion of strongyloidiasis possibly due to an external autoinfection (ie, filariform larvae in feces penetrate perianal skin, producing local allergic reaction)
  • Severe strongyloidiasis
    • Diffuse abdominal tenderness; abdominal distension; hyperactive, hypoactive, or absent bowel sounds; vomiting; hematemesis; and hematochezia
    • Altered mental status and meningismus (if CNS involvement)
    • Rash (petechiae, purpura) over the trunk and proximal extremities caused by small dermal blood vessel disruption due to massive migration of filariform larvae within the skin
    • Cough, respiratory distress, wheezing, hemoptysis, and crackles
    • Fever, chills

Causes

  • Risk factors for severe strongyloidiasis
    • Corticosteroid therapy - Most important risk factor; other immunosuppressive agents (eg, chemotherapeutic agents, tacrolimus, tumor necrosis factor [TNF] modulators)
    • Human T-cell leukemia virus type 1 infection2,3
    • Neoplasms, particularly hematologic malignancies (lymphoma, leukemia)
    • Organ transplantation4,5,6
    • Malabsorption states
    • End-stage renal disease
    • Diabetes mellitus
    • Advanced age
    • HIV infection
    • No obvious precipitating factor

More on Strongyloidiasis

Overview: Strongyloidiasis
Differential Diagnoses & Workup: Strongyloidiasis
Treatment & Medication: Strongyloidiasis
Follow-up: Strongyloidiasis
Multimedia: Strongyloidiasis
References
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References

  1. Gill GV, Welch E, Bailey JW. Chronic Strongyloides stercoralis infection in former British Far East prisoners of war. QJM. Dec 2004;97(12):789-95. [Medline].

  2. Porto AF, Neva FA, Bittencourt H, et al. HTLV-1 decreases Th2 type of immune response in patients with strongyloidiasis. Parasite Immunol. Sep 2001;23(9):503-7. [Medline].

  3. Satoh M, Toma H, Sato Y, et al. Reduced efficacy of treatment of strongyloidiasis in HTLV-I carriers related to enhanced expression of IFN-gamma and TGF-beta1. Clin Exp Immunol. Feb 2002;127(2):354-9. [Medline].

  4. DeVault GA, King JW, Rohr MS, et al. Opportunistic infections with Strongyloides stercoralis in renal transplantation. Rev Infect Dis. Jul-Aug 1990;12(4):653-71. [Medline].

  5. Schaeffer MW, Buell JF, Gupta M. Strongyloides hyperinfection syndrome after heart transplantation: case report and review of the literature. J Heart Lung Transplant. Jul 2004;23(7):905-11. [Medline].

  6. Stone WJ, Schaffner W. Strongyloides infections in transplant recipients. Semin Respir Infect. Mar 1990;5(1):58-64. [Medline].

  7. Kishimoto K, Hokama A, Hirata T, Ihama Y, Nakamoto M, Kinjo N, et al. Endoscopic and histopathological study on the duodenum of Strongyloides stercoralis hyperinfection. World J Gastroenterol. Mar 21 2008;14(11):1768-73. [Medline].

  8. Newberry AM, Williams DN, Stauffer WM. Strongyloides hyperinfection presenting as acute respiratory failure and gram-negative sepsis. Chest. Nov 2005;128(5):3681-4. [Medline].

  9. Morimoto J, Kaneoka H, Sasatomi Y, et al. Disseminated strongyloidiasis in nephrotic syndrome. Clin Nephrol. May 2002;57(5):398-401. [Medline].

  10. Asdamongkol N, Pornsuriyasak P, Sungkanuparph S. Risk factors for strongyloidiasis hyperinfection and clinical outcomes. Southeast Asian J Trop Med Public Health. Sep 2006;37(5):875-84. [Medline].

  11. Boatright MD, Wang BW. Clinical infection with Strongyloides stercoralis following etanercept use for rheumatoid arthritis. Arthritis Rheum. Apr 2005;52(4):1336-7. [Medline].

  12. Concha R, Harrington W Jr, Rogers AI. Intestinal strongyloidiasis: recognition, management, and determinants of outcome. J Clin Gastroenterol. Mar 2005;39(3):203-11. [Medline].

  13. Czachor JS, Jonas AP. Transmission of Strongyloides steracolis person to person. J Travel Med. Jul-Aug 2000;7(4):211-2. [Medline].

  14. Drugs for parasitic infections. Med Lett Drugs Ther. Jan 2 1998;40(1017):1-12. [Medline].

  15. Gann PH, Neva FA, Gam AA. A randomized trial of single- and two-dose ivermectin versus thiabendazole for treatment of strongyloidiasis. J Infect Dis. May 1994;169(5):1076-9. [Medline].

  16. Genta RM. Dysregulation of strongyloidiasis: a new hypothesis. Clin Microbiol Rev. Oct 1992;5(4):345-55. [Medline].

  17. Genta RM. Global prevalence of strongyloidiasis: critical review with epidemiologic insights into the prevention of disseminated disease. Rev Infect Dis. Sep-Oct 1989;11(5):755-67. [Medline].

  18. Gordon SM, Gal AA, Solomon AR, Bryan JA. Disseminated strongyloidiasis with cutaneous manifestations in an immunocompromised host. J Am Acad Dermatol. Aug 1994;31(2 Pt 1):255-9. [Medline].

  19. Grove DI. Human strongyloidiasis. Adv Parasitol. 1996;38:251-309. [Medline].

  20. Grove DI. Strongyloidiasis: a conundrum for gastroenterologists. Gut. Apr 1994;35(4):437-40. [Medline].

  21. Intapan PM, Maleewong W, Wongsaroj T. Comparison of the quantitative formalin ethyl acetate concentration technique and agar plate culture for diagnosis of human strongyloidiasis. J Clin Microbiol. Apr 2005;43(4):1932-3. [Medline].

  22. Johnston FH, Morris PS, Speare R. Strongyloidiasis: a review of the evidence for Australian practitioners. Aust J Rural Health. Aug 2005;13(4):247-54. [Medline].

  23. Kalb RE, Grossman ME. Periumbilical purpura in disseminated strongyloidiasis. JAMA. Sep 5 1986;256(9):1170-1. [Medline].

  24. Keiser PB, Nutman TB. Strongyloides stercoralis in the Immunocompromised Population. Clin Microbiol Rev. Jan 2004;17(1):208-17. [Medline].

  25. Kim AC, Lupatkin HC. Strongyloides stercoralis infection as a manifestation of immune restoration syndrome. Clin Infect Dis. Aug 1 2004;39(3):439-40. [Medline].

  26. Kitchen LW, Tu KK, Kerns FT. Strongyloides-infected patients at Charleston area medical center, West Virginia, 1997-1998. Clin Infect Dis. Sep 2000;31(3):E5-6. [Medline].

  27. Lim S, Katz K, Krajden S. Complicated and fatal Strongyloides infection in Canadians: risk factors, diagnosis and management. CMAJ. Aug 31 2004;171(5):479-84. [Medline].

  28. Link K, Orenstein R. Bacterial complications of strongyloidiasis: Streptococcus bovis meningitis. South Med J. Jul 1999;92(7):728-31. [Medline].

  29. Liu LX, Weller PF. Strongyloidiasis and other intestinal nematode infections. Infect Dis Clin North Am. Sep 1993;7(3):655-82. [Medline].

  30. Loutfy MR, Wilson M, Keystone JS, Kain KC. Serology and eosinophil count in the diagnosis and management of strongyloidiasis in a non-endemic area. Am J Trop Med Hyg. Jun 2002;66(6):749-52. [Medline].

  31. Mahmoud AA. Strongyloidiasis. Clin Infect Dis. Nov 1996;23(5):949-52; quiz 953. [Medline].

  32. Mandell GL, Bennett JR, Dolin R. Intestinal nematodes (roundworms). In: Principles and Practice of Infectious Diseases. Vol 2. 6th ed. Elseiver Inc.; 2005:Ch 285.

  33. Mansfield LS, Niamatali S, Bhopale V, et al. Strongyloides stercoralis: maintenance of exceedingly chronic infections. Am J Trop Med Hyg. Dec 1996;55(6):617-24. [Medline].

  34. Mariappan MR, Vielemeyer O, Fadare O. Displaced bacterial colonies indicating Strongyloides larval migration on agar plates. Arch Pathol Lab Med. Jun 2004;128(6):711-2. [Medline].

  35. Neva FA. Biology and immunology of human strongyloidiasis. J Infect Dis. Mar 1986;153(3):397-406. [Medline].

  36. Neva FA, Gam AA, Maxwell C, Pelletier LL. Skin test antigens for immediate hypersensitivity prepared from infective larvae of Strongyloides stercoralis. Am J Trop Med Hyg. Nov 2001;65(5):567-72. [Medline].

  37. Palau LA, Pankey GA. Strongyloides hyperinfection in a renal transplant recipient receiving cyclosporine: possible Strongyloides stercoralis transmission by kidney transplant. Am J Trop Med Hyg. Oct 1997;57(4):413-5. [Medline].

  38. Polenakovik H, Polenakovik S, Weinstein J, Pelstring RJ. New-onset purpura in a patient with recently diagnosed temporal arteritis. Clin Infect Dis. Jul 15 2003;37(2):238-40, 299-301. [Medline].

  39. Safdar A, Malathum K, Rodriguez SJ. Strongyloidiasis in patients at a comprehensive cancer center in the United States. Cancer. Apr 1 2004;100(7):1531-6. [Medline].

  40. Salazar SA, Gutierrez C, Berk SL. Value of the agar plate method for the diagnosis of intestinal strongyloidiasis. Diagn Microbiol Infect Dis. Dec 1995;23(4):141-5. [Medline].

  41. Sanchez PR, Guzman AP, Guillen SM, et al. Endemic strongyloidiasis on the Spanish Mediterranean coast. QJM. Jul 2001;94(7):357-63. [Medline].

  42. Schaffel R, Nucci M, Carvalho E, et al. The value of an immunoenzymatic test (enzyme-linked immunosorbent assay) for the diagnosis of strongyloidiasis in patients immunosuppressed by hematologic malignancies. Am J Trop Med Hyg. Oct 2001;65(4):346-50. [Medline].

  43. Shoop WL, Michael BF, Eary CH, Haines HW. Transmammary transmission of Strongyloides stercoralis in dogs. J Parasitol. Jun 2002;88(3):536-9. [Medline].

  44. Siddiqui AA, Berk SL. Diagnosis of Strongyloides stercoralis infection. Clin Infect Dis. Oct 1 2001;33(7):1040-7. [Medline].

  45. Siddiqui AA, Stanley CS, Skelly PJ, Berk SL. A cDNA encoding a nuclear hormone receptor of the steroid/thyroid hormone-receptor superfamily from the human parasitic nematode Strongyloides stercoralis. Parasitol Res. Jan 2000;86(1):24-9. [Medline].

  46. Sithithaworn J, Sithithaworn P, Janrungsopa T. 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].

  47. Sithithaworn P, Srisawangwong T, Tesana S. Epidemiology of Strongyloides stercoralis in north-east Thailand: application of the agar plate culture technique compared with the enzyme-linked immunosorbent assay. Trans R Soc Trop Med Hyg. Jul-Aug 2003;97(4):398-402. [Medline].

  48. Smith B, Verghese A, Guiterrez C, et al. Pulmonary strongyloidiasis. Diagnosis by sputum gram stain. Am J Med. Nov 1985;79(5):663-6. [Medline].

  49. Speare R, Durrheim DN. Strongyloides serology - useful for diagnosis and management of strongyloidiasis in rural Indigenous populations, but important gaps in knowledge remain. Rural Remote Health. Oct-Dec 2004;4(4):264. [Medline].

  50. Grove DI, ed. Strongyloidiasis: A Major Roundworm Infection of Man. London, UK: Taylor & Francis Ltd; 1989.

  51. Tarr PE, Miele PS, Peregoy KS, et al. Case report: Rectal administration of ivermectin to a patient with Strongyloides hyperinfection syndrome. Am J Trop Med Hyg. Apr 2003;68(4):453-5. [Medline].

  52. Thompson BF, Fry LC, Wells CD. The spectrum of GI strongyloidiasis: an endoscopic-pathologic study. Gastrointest Endosc. Jun 2004;59(7):906-10. [Medline].

  53. Toma H, Sato Y, Shiroma Y, Kobayashi J, Shimabukuro I, Takara M. Comparative studies on the efficacy of three anthelminthics on treatment of human strongyloidiasis in Okinawa, Japan. Southeast Asian J Trop Med Public Health. Mar 2000;31(1):147-51. [Medline].

  54. Turner SA, Maclean JD, Fleckenstein L. Parenteral administration of ivermectin in a patient with disseminated strongyloidiasis. Am J Trop Med Hyg. Nov 2005;73(5):911-4. [Medline].

  55. Viney ME, Brown M, Omoding NE. Why does HIV infection not lead to disseminated strongyloidiasis?. J Infect Dis. Dec 15 2004;190(12):2175-80. [Medline].

  56. von Kuster LC, Genta RM. Cutaneous manifestations of strongyloidiasis. Arch Dermatol. Dec 1988;124(12):1826-30. [Medline].

  57. Zaha O, Hirata T, Kinjo F, Saito A. Strongyloidiasis--progress in diagnosis and treatment. Intern Med. Sep 2000;39(9):695-700. [Medline].

  58. Zeana C, Kubin CJ, Della-Latta P, Hammer SM. Vancomycin-resistant Enterococcus faecium meningitis successfully managed with linezolid: case report and review of the literature. Clin Infect Dis. Aug 15 2001;33(4):477-82. [Medline].

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Further Reading

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Keywords

strongyloidiasis, hyperinfection syndrome, disseminated strongyloidiasis, Strongyloides, threadworm infection, Cochin China diarrhea, parasitic nematodes, Strongyloides stercoralis, S stercoralis, Strongyloides fuelleborni, S fuelleborni, bacterial meningitis, rhabditiform larvae, parthenogenesis, filariform, bacteremia, Escherichia coli, E coli, Klebsiella species, helminth, strongyloidosis, acute strongyloidiasis, chronic strongyloidiasis, intestinal strongyloidiasis

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Contributor Information and Disclosures

Author

Pranatharthi Haran Chandrasekar, MD, Director of Infectious Disease Fellowship, Professor, Department of Internal Medicine, Harper Hospital, Wayne State University School of Medicine
Pranatharthi Haran Chandrasekar, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Ramesh A Bharadwaj, MD, Fellow in Infectious Diseases, Detroit Medical Center, Wayne State University
Ramesh A Bharadwaj, MD is a member of the following medical societies: American College of Physicians and Michigan State Medical Society
Disclosure: Nothing to disclose.

Hari Polenakovik, MD, Assistant Professor of Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH
Hari Polenakovik, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Sylvia Polenakovik, MD, Clinical Instructor, Internist, Department of Internal Medicine, Wayne Hospital, Wright State University
Sylvia Polenakovik, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Wesley W Emmons, MD, FACP, Assistant Professor, Department of Medicine, Thomas Jefferson University; Consulting Staff, Infectious Diseases Section, Department of Internal Medicine, Christiana Care, Newark, DE
Wesley W Emmons, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and International AIDS Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist  Speaking and teaching

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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