Strongyloidiasis Treatment & Management

  • Author: Pranatharthi Haran Chandrasekar, MBBS, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Jun 29, 2011
 

Approach Considerations

All persons found to harbor Strongyloides organisms should be treated, even if they are asymptomatic, because of the risk of hyperinfection. However, for infected pregnant patients, clinicians may prefer to defer treatment for strongyloidiasis until after the first trimester. All of the anthelmintic medications discussed in this article are US Food and Drug Administration (FDA) category C agents.

Strongyloides species are the hardest worms to eradicate. Treatment of early infection is with symptomatic support, because specific therapy is more effective once intestinal infection is established. Posttherapy stool examinations are recommended to verify Strongyloides eradication and to exclude other parasitic infections.

Empiric corticosteroid administration used to treat wheezing is problematic, because it may cause life-threatening hyperinfection. Thus, Strongyloides hyperinfection syndrome, usually precipitated by immune suppression, should be considered in patients who have resided in endemic regions.[63] Attempts at the detection and eradication of this infection are recommended to prevent this potentially fatal complication.

Surgical intervention may be required in the rare instance of acute abdominal symptoms (peritonitis) due to bowel obstruction or infarction in the context of severe strongyloidiasis.

Intensive care and transfer

Immunocompromised hosts may require hospitalization and intensive care in disseminated infection. Consider contact isolation in these patients, because sputum, stool, vomitus, and other bodily excreta may contain infective (filariform) larvae.

Patients with hyperinfection syndrome often have complications of sepsis, shock, and acute respiratory distress syndrome (ARDS). Any patient suspected of disseminated disease should receive care in a facility properly equipped for intensive management.

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Anthelmintic Therapy

Strongyloides infection should be suspected in a patient with nonspecific gastrointestinal, respiratory, or recurrent dermatologic symptoms of unclear etiology with risk factors for Strongyloides infection. Conduct definitive treatment with anthelmintic drugs, although these medications target adult worms and are not very effective against larvae in the initial infection.

Strongyloides infections should be treated even in the absence of symptoms as hyperinfection syndrome carries a high mortality rate. Disseminated strongyloidiasis requires treatment for at least 7 days or until the parasite can no longer be identified in clinical specimens. Concomitant infections should be treated aggressively, and any immunosuppressants, including exogenous corticosteroids, should be quickly tapered.[64] Corticosteroid therapy must be avoided, because hyperinfection and death may occur.

Anthelmintic treatment may have to be repeated or the duration prolonged in patients with hyperinfection syndrome. Relapses may occur despite proper therapy.

Anthelmintic agents

Benzimidazoles (thiabendazole, mebendazole, and albendazole) are anthelmintic agents that disrupt energy production in the parasites. The final common pathway of the benzimidazoles is inhibition of beta-tubulin polymerase, which causes disruption of cytoplasmic microtubule formation. These anthelmintics not only kill adult gut-dwelling stages of the parasite but sterilize the larvae and eggs.

Thiabendazole is the most commonly administered agent but a number of side effects makes it less desirable. Ivermectin inhibits neurotransmission in nematodes by stimulating the release of gamma-aminobutyric acid-dependent neurotransmission; eradication rates with this agent are as high as 97%.

Ivermectin and thiabendazole have shown to be superior to albendazole, and ivermectin is becoming the drug of choice in many countries due to its more favorable side effects compared with albendazole.[65, 66, 25] A newer drug, tribendimidine, remains under investigation in China and shows some promise in the treatment of strongyloidiasis.[67]

Patients with hyperinfection and disseminated disease should be treated with ivermectin. In this select group of patients, ivermectin should be administered daily until symptoms have resolved and until larvae have not been detected for at least 2 weeks.

Among the immunosuppressive agents, only cyclosporine A is known to possess anthelmintic activity. This was initially confirmed in animal models and subsequently observed in clinical practice. To date, no cases of severe strongyloidiasis developing in transplant recipients treated with cyclosporine have been reported.

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Antibiotic Therapy and Supportive Care

Provide antibiotic therapy directed toward enteric pathogens if bacteremia or meningitis is present or suggested; treat such bacterial complications for 2-4 weeks with antibiotics according to the results of in vitro testing against the bacterial isolate(s).

Provide supportive treatment as indicated (eg, intravenous fluids if volume depletion, blood transfusion if gastrointestinal or alveolar hemorrhage, mechanical ventilation if respiratory failure). Symptomatic treatment should be initiated. Pruritic dermatologic manifestations should be treated with antihistamines. Inhaled beta-agonists may improve wheezing; steroids should be avoided as they will worsen the infection. The use of leukotriene synthesis inhibitors for wheezing may also worsen infection, because leukotrienes are shown to play a potential role in the immunity against Strongyloides infection.

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Contributor Information and Disclosures
Author

Pranatharthi Haran Chandrasekar, MBBS, MD  Professor, Department of Internal Medicine, Director of Infectious Disease Fellowship, Harper Hospital, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, 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)

Leslie L Barton, MD  Professor Emerita of Pediatrics, University of Arizona College of Medicine

Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Rosalie Elenitsas, MD  Herman Beerman Associate Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System

Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology

Disclosure: Lippincott Williams Wilkins Royalty Textbook editor; DLA Piper Consulting fee Consulting

Mark Louden, MD, FACEP  Assistant Medical Director, Emergency Department, Duke Raleigh Hospital

Mark Louden, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Antonio Muñiz, MD  Professor of Emergency Medicine and Pediatrics, University of Texas Medical School at Houston; Medical Director of the Pediatric Emergency Department, Children's Memorial Hermann Hospital

Antonio Muñiz, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, American Medical Association, Society for Academic Emergency Medicine, and Southern Medical Association

Disclosure: Nothing to disclose.

James J Nordlund, MD  Professor Emeritus, Department of Dermatology, University of Cincinnati College of Medicine

James J Nordlund, MD is a member of the following medical societies: American Academy of Dermatology, Sigma Xi, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Hari Polenakovik, MD  Assistant Professor of Medicine, Wright State University, Boonshoft School of Medicine

Hari Polenakovik, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society for Microbiology, European Society of Clinical Microbiology and Infectious Diseases, Infectious Diseases Society of America, and Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Sylvia Polenakovik, MD  Clinical Instructor, Internist, Department of Internal Medicine, Wayne Hospital, Wright State University, Boonshoft School of Medicine

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.

Allison J Richard, MD  Assistant Professor of Emergency Medicine, Keck School of Medicine, University of Southern California; Associate Director, Division of International Medicine; Attending Physician, Los Angeles County-University of Southern California Hospital Emergency Department

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Mordechai M Tarlow, MD  Clinical Associate, Department of Dermatology, University of Pennsylvania School of Medicine

Mordechai M Tarlow, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for MOHS Surgery, American Society of Cosmetic Dermatology and Aesthetic Surgery, and Sigma Xi

Disclosure: Nothing to disclose.

Jeter (Jay) Pritchard Taylor III, MD  Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist

Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi Pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

Eric L Weiss, MD  DTM&H, Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Professor, Department of Surgery (Emergency Medicine), Stanford University Medical Center

Eric L Weiss, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Ronald A Greenfield, MD  Professor, Department of Internal Medicine, 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; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist Honoraria Speaking and teaching; Forest Pharmaceuticals Speaking and teaching

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

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.

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Ramesh A Bharadwaj, MD, Emily Anne Carpenter Rose, MD, and Ashir Kumar, MD, MBBS, FAAP, to the development and writing of the source articles.

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First stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman.
Second stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman.
Third stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman.
Fourth stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman.
Fifth stage, life cycle of Strongyloides stercoralis. Illustration by Tessa Kalman.
Rhabditiform larva of Strongyloides stercoralis in stool specimen (wet mount stained with iodine).
 
 
 
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