1 Larva Currens and Strongyloidiasis Andrea K. Boggild, MSc, MD, FRCPC Tropical Disease Unit Toronto General Hospital Department of Medicine University of Toronto Disclosure of Potential Conflict of Interest Financial Disclosures Research / Grant support – Public Health Agency of Canada; Public Health Ontario
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Larva Currens and Strongyloidiasis Cutan Med Surg 2012;16(6):433-435. Images courtesy of A. Boggild Suspected Diagnosis = ?? 4 Strongyloidiasis – Larva Currens Caused by geotropic
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Larva Currens and StrongyloidiasisAndrea K. Boggild, MSc, MD, FRCPC
Tropical Disease UnitToronto General HospitalDepartment of Medicine
University of Toronto
Disclosure of Potential Conflict of Interest
Financial Disclosures Research / Grant support – Public Health
Agency of Canada; Public Health Ontario
2
Audience Question: Which of the Following Statements is True of
Strongyloidiasis?
Profound eosinophilia occurs in almost all cases
Remote travel history does not inform risk assessment
Half of all infections are asymptomatic Strongyloidiasis is very rare in Canada Many easily accessible treatment options
exist in Canada
Clinical Case 64M previously healthy, immigrated to
Canada from southern Italy 38 years ago Presented with a 5-year history of episodic
generalized pruritus lasting 7 to 10 days once per month, and not relieved by anti-histamines
Reported a migratory erythematous rash that occurred on the buttock, abdomen, chest, and shoulders x several years
Eosinophilia of ~3.5 x 109/L
3
J Cutan Med Surg 2012;16(6):433-435.
Images courtesy of A. Boggild
Suspected Diagnosis = ??
4
Strongyloidiasis – Larva Currens Caused by geotropic helminth Strongyloides
stercoralis Epidemiology of S. stercoralis
Affects 30-100 million people worldwide Endemic in Africa, Asia, SE Asia, Central & South
America High risk countries within high risk regions:
Jamaica, Haiti, Cambodia, Laos, Vietnam, beach areas of West and East Africa
Risk Factors for severe disease & dissemination Major: Steroids, Hematologic malignancy, HTLV-1 Minor: Malnutrition, DM, ESRD, EtOH
PLoS NTDs 2013; 7(7):e2288.
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What do we know about the Epidemiology of Strongyloidiasis in
Canada? South Asian refugees to Canada:
Seroprevalence 11.8% in those from Vietnam, 76.6% from Cambodia
6.8 million Canadians are foreign-born, with approximately 85% immigrating from regions endemic for strongyloidiasis
Assuming a source country average prevalence of 40%, ~2.5 million Canadians are infected with simple intestinal strongyloidiasis
Open Medicine 2014;8(1):e20-32.
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What are the clinical manifestations of strongyloidiasis?
Strongyloidiasis as a mimic of UCKEY FEATURES DISTINGUISHING
STRONGYLOIDIASIS FROM ULCERATIVE COLITIS:
1. SKIP PATTERN OF INFLAMMATION
2. DISTAL ATTENUATION OF DISEASE
3. EOSINOPHIL RICH INFILTRATES
4. RELATIVE PRESERVATION OF CRYPT ARCHITECTURE
5. FREQUENT INVOLVEMENT OF SUBMUCOSA
Disseminated Strongyloidiasis
Occurs in the setting of accelerated autoinfective cycle with migration of larvae outside the bowel to distant sites
Almost always associated with HTLV-1 infection, glucocorticoids, or other immunosuppressants (rituximab, etc)
Almost always preceded by prolonged diarrheal illness, during which stage larvae can be found in stool
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Host-Worm Interaction
Suspected Diagnosis = Larva Currens
due to Strongyloidiasis
How do you confirm the diagnosis?
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Diagnosis of Strongyloidiasis Labs – eosinophilia in >40-70% uncomplicated
cases, but if complicated eosinophils often absent Uncomplicated disease
3+ serial stool examination for larvae Serology – EIA sensitivity 82-95%, specificity 84-
92% Patient unwell with respiratory symptoms, Gram-
negative sepsis, + risk factors for dissemination Blood, sputum, urine, CSF for larvae 3+ serial stools Serology
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IPAC Issues to Consider Simple intestinal strongyloidiasis or larva currens in
a patient NOT shedding larvae >> routine precautions
Strongyloides hyperinfection / disseminated strongyloidiasis >> contact precautions Why? Filariform larvae are motile and will penetrate intact skin Filariform larvae are found in all bodily effluents and can
reside on surfaces and at ambient temperatures Filariform larvae are difficult to disinfect Person-to-person transmission is possible and difficult to
SerumSAF-preserved stool specimenFresh sputum in sterile containerUrine in sterile containerCSF in sterile containerTissue, paraffin-embedded or unprocessedAny specimen as above for agar plate culture
Screening not recommended. Consider alternate diagnosis
Screening not recommended. Consider alternate diagnosis
Very Low
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Low
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Moderate
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Send appropriate specimens for diagnostic testing
High
Disseminated Strongyloidiasis
Mild Hyperinfection
Syndrome
Simple intestinal strongyloidiasis
Asymptomatic ±eosinophilia
Suspected Clinical SyndromeRisk Category for Disseminated Strongyloidiasis
Ivermectin 200 g/kg/day po or sc¶ once daily PLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement
Ivermectin 200 g/kg/day po or sc¶ once dailyPLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement
Disseminated strongyloidiasis‡,§,a,b,c,d
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 days OR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 daysOR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days
Mild hyperinfectionsyndrome†,a,b,c
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Simple intestinal strongyloidiasis*,a,b
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
SerumSAF-preserved stool specimenFresh sputum in sterile containerUrine in sterile containerCSF in sterile containerTissue, paraffin-embedded or unprocessedAny specimen as above for agar plate culture
Screening not recommended. Consider alternate diagnosis
Screening not recommended. Consider alternate diagnosis
Very Low
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Low
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Moderate
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Send appropriate specimens for diagnostic testing
High
Disseminated Strongyloidiasis
Mild Hyperinfection
Syndrome
Simple intestinal strongyloidiasis
Asymptomatic ±eosinophilia
Suspected Clinical SyndromeRisk Category for Disseminated Strongyloidiasis
19
Ivermectin 200 g/kg/day po or sc¶ once daily PLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement
Ivermectin 200 g/kg/day po or sc¶ once dailyPLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement
Disseminated strongyloidiasis‡,§,a,b,c,d
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 days OR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 daysOR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days
Mild hyperinfectionsyndrome†,a,b,c
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Simple intestinal strongyloidiasis*,a,b
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
SerumSAF-preserved stool specimenFresh sputum in sterile containerUrine in sterile containerCSF in sterile containerTissue, paraffin-embedded or unprocessedAny specimen as above for agar plate culture
Screening not recommended. Consider alternate diagnosis
Screening not recommended. Consider alternate diagnosis
Very Low
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Low
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Moderate
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Send appropriate specimens for diagnostic testing
High
Disseminated Strongyloidiasis
Mild Hyperinfection
Syndrome
Simple intestinal strongyloidiasis
Asymptomatic ±eosinophilia
Suspected Clinical SyndromeRisk Category for Disseminated Strongyloidiasis
Ivermectin 200 g/kg/day po or sc¶ once daily PLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement
Ivermectin 200 g/kg/day po or sc¶ once dailyPLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement
Disseminated strongyloidiasis‡,§,a,b,c,d
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 days OR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 daysOR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days
Mild hyperinfectionsyndrome†,a,b,c
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Simple intestinal strongyloidiasis*,a,b
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
SerumSAF-preserved stool specimenFresh sputum in sterile containerUrine in sterile containerCSF in sterile containerTissue, paraffin-embedded or unprocessedAny specimen as above for agar plate culture
Screening not recommended. Consider alternate diagnosis
Screening not recommended. Consider alternate diagnosis
Very Low
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Low
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Moderate
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Send appropriate specimens for diagnostic testing
High
Disseminated Strongyloidiasis
Mild Hyperinfection
Syndrome
Simple intestinal strongyloidiasis
Asymptomatic ±eosinophilia
Suspected Clinical SyndromeRisk Category for Disseminated Strongyloidiasis
24
Ivermectin 200 g/kg/day po or sc¶ once daily PLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement
Ivermectin 200 g/kg/day po or sc¶ once dailyPLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement
Disseminated strongyloidiasis‡,§,a,b,c,d
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 days OR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 daysOR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days
Mild hyperinfectionsyndrome†,a,b,c
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Simple intestinal strongyloidiasis*,a,b
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
SerumSAF-preserved stool specimenFresh sputum in sterile containerUrine in sterile containerCSF in sterile containerTissue, paraffin-embedded or unprocessedAny specimen as above for agar plate culture
Screening not recommended. Consider alternate diagnosis
Screening not recommended. Consider alternate diagnosis
Very Low
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Low
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Moderate
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Send appropriate specimens for diagnostic testing
High
Disseminated Strongyloidiasis
Mild Hyperinfection
Syndrome
Simple intestinal strongyloidiasis
Asymptomatic ±eosinophilia
Suspected Clinical SyndromeRisk Category for Disseminated Strongyloidiasis
Ivermectin 200 g/kg/day po or sc¶ once daily PLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement
Ivermectin 200 g/kg/day po or sc¶ once dailyPLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement
Disseminated strongyloidiasis‡,§,a,b,c,d
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 days OR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 daysOR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days
Mild hyperinfectionsyndrome†,a,b,c
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Simple intestinal strongyloidiasis*,a,b
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Clinical Scenario 58 year-old previously well, UK born woman
presents with a 20-year history of pruritic, rapidly migrating, serpiginous, erythematousrash on back, buttocks, and legs once per month lasting 3-5 days
Rheumatologic, allergic, and dermatologic work-up was negative
Referred to the Tropical Disease Unit for query cutaneous larva migrans
Travel hx = 2 weeks in each of Thailand and the Gambia in the year prior to sx onset
J Cutan Med Surg 2015;19(4):412-415.
Images courtesy of A. Boggild
28
Very LowVery LowBirth or residence or long-term travel* in rural or beach area of: Australia, North America or Western Europe
LowModerateBirth or residence or long-term travel* in rural or beach area of: Mediterranean, Middle East, North Africa, Indian sub-continent, Asia
ModerateHighBirth or residence or long-term travel* in rural or beach area of: Southeast Asia, Oceania, sub-Saharan Africa, South America, Caribbean
SerumSAF-preserved stool specimenFresh sputum in sterile containerUrine in sterile containerCSF in sterile containerTissue, paraffin-embedded or unprocessedAny specimen as above for agar plate culture
Screening not recommended. Consider alternate diagnosis
Screening not recommended. Consider alternate diagnosis
Very Low
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Low
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Moderate
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Send appropriate specimens for diagnostic testing
High
Disseminated Strongyloidiasis
Mild Hyperinfection
Syndrome
Simple intestinal strongyloidiasis
Asymptomatic ±eosinophilia
Suspected Clinical SyndromeRisk Category for Disseminated Strongyloidiasis
Ivermectin 200 g/kg/day po or sc¶ once daily PLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement
Ivermectin 200 g/kg/day po or sc¶ once dailyPLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement
Disseminated strongyloidiasis‡,§,a,b,c,d
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 days OR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 daysOR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days
Mild hyperinfectionsyndrome†,a,b,c
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Simple intestinal strongyloidiasis*,a,b
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
SerumSAF-preserved stool specimenFresh sputum in sterile containerUrine in sterile containerCSF in sterile containerTissue, paraffin-embedded or unprocessedAny specimen as above for agar plate culture
Screening not recommended. Consider alternate diagnosis
Screening not recommended. Consider alternate diagnosis
Very Low
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Low
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Send appropriate specimens for diagnostic testing
Send appropriate specimens for diagnostic testing
Moderate
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Empiric treatment while awaiting diagnostic testing
Send appropriate specimens for diagnostic testing
High
Disseminated Strongyloidiasis
Mild Hyperinfection
Syndrome
Simple intestinal strongyloidiasis
Asymptomatic ±eosinophilia
Suspected Clinical SyndromeRisk Category for Disseminated Strongyloidiasis
32
Clinical Scenario
We ignored the guidelines and repeated stools at 6- and 8-weeks post-travel Positive for rhabditiform larvae
By 8-weeks post-travel her GI illness had nearly resolved despite lack of treatment
Ivermectin 200 g/kg/day po or sc¶ once daily PLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement
Ivermectin 200 g/kg/day po or sc¶ once dailyPLUSAlbendazole 400 mg po BID until cessation of larval shedding and clinical improvement
Disseminated strongyloidiasis‡,§,a,b,c,d
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 days OR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£PLUSAlbendazole 400 mg po BID x 7 daysOR, Monotherapy:Ivermectin 200 g/kg/day po once daily x 7 days
Mild hyperinfectionsyndrome†,a,b,c
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Simple intestinal strongyloidiasis*,a,b
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
Ivermectin 200 g/kg/day po once daily x 2 doses on day 1 and 2, or 14-days apart£
5 Key Points – Strongyloidiasis Strongyloidiasis is one of the most common
helminthic causes of diarrhea in the developing world
It is a lifelong infection unless treated Confirmation of Strongyloidiasis is by serology +
examination of stools for larvae (or histopath) Prompt initiation of therapy essential to minimize
risk of hyperinfection in setting of immune suppression. Advanced screening of patients at high risk should occur prior to iatrogenic immune suppression
Larva currens may also occur in patients with hyperinfection or dissemination therefore contact precautions for hospitalized patients with larva currens until stools and sputum deemed negative
Contact Information
Dr. Andrea K. Boggild Tropical Disease Unit, Toronto General