Department of Hematology and Rheumatology, Kindai University School of Medicine, 377-2 Oonohigashi, Osaka-Sayama, Osaka, 589-0014, Japan.
BMC Infect Dis. 2020 Jul 2;20(1):470. doi: 10.1186/s12879-020-05195-0.
Strongyloidiasis is a gastrointestinal parasitic infection caused by percutaneous infection with Strongyloides stercoralis. Digestive symptoms such as diarrhea and abdominal pain are the main manifestation, but serious infections such as septicemia, purulent meningitis, and bacterial pneumonia may occur in individuals harboring human T-lymphotropic virus type 1 (HTLV-1) or who are immunocompromised. Although coinfection with Strongyloides stercoralis and HTLV-1 can lead to chronic strongyloidiasis and a disseminated form of the disease, there is a high rate of response to the anthelmintic ivermectin.
We report a case of strongyloidiasis infection syndrome that was difficult to differentiate from immune reconstitution inflammatory syndrome (IRIS) for various reasons. The patient had been treated with the corticosteroids tacrolimus (Tac) and mycophenolate mofetil (MMF) for systemic lupus erythematosus (SLE) with lupus nephritis and pancytopenia. When the steroid was reduced, she developed cytomegalovirus (CMV) enteritis, and her respiratory status rapidly deteriorated immediately after the withdrawal of Tac and MMF. It was difficult to distinguish immune reconstitution inflammatory syndrome from strongyloidiasis infection syndrome because stool cultures were negative and eosinophils were not increased. Bronchoscopy revealed viable Strongyloides, leading to a diagnosis of strongyloidiasis infection syndrome, but the patient died despite treatment.
Both corticosteroid therapy and HTLV-1 infection can be associated with a decrease of eosinophils, despite the presence of parasitic infection. In conclusion, even if multiple culture tests are negative, the risk of parasitic infection should be assessed in patients receiving immunosuppressants and steroids even in non-endemic areas.
旋毛虫病是一种由 Strongyloides stercoralis 经皮感染引起的胃肠道寄生虫感染。腹泻和腹痛等消化症状是主要表现,但在携带人类 T 淋巴细胞病毒 1 型(HTLV-1)或免疫功能低下的个体中,可能会发生败血症、化脓性脑膜炎和细菌性肺炎等严重感染。虽然 Strongyloides stercoralis 和 HTLV-1 的合并感染可导致慢性旋毛虫病和播散性疾病,但对驱虫药伊维菌素的反应率很高。
我们报告了一例因多种原因难以与免疫重建炎症综合征(IRIS)区分的旋毛虫病感染综合征病例。该患者因系统性红斑狼疮(SLE)伴狼疮性肾炎和全血细胞减少症而接受了环孢素(Tac)和吗替麦考酚酯(MMF)的皮质类固醇治疗。当激素减少时,她发生了巨细胞病毒(CMV)肠炎,并且在停用 Tac 和 MMF 后,她的呼吸状况迅速恶化。由于粪便培养呈阴性且嗜酸性粒细胞未增加,因此难以将免疫重建炎症综合征与旋毛虫病感染综合征区分开来。支气管镜检查显示有活力的旋毛虫,导致诊断为旋毛虫病感染综合征,但尽管进行了治疗,患者仍死亡。
尽管存在寄生虫感染,皮质类固醇治疗和 HTLV-1 感染均可导致嗜酸性粒细胞减少。总之,即使多次培养测试均为阴性,在非流行地区,接受免疫抑制剂和类固醇治疗的患者也应评估寄生虫感染的风险。