Rash, diarrhea, and eosinophilia

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Rash, diarrhea, and eosinophilia

J Fam Pract. 2015 October;64(10):655-658

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References

1. Centers for Disease Control and Prevention. Parasites - Strongyloides. Epidemiology & risk factors. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/parasites/strongyloides/epi.html. Accessed September 4, 2015.

2. Buonfrate D, Angheben A, Gobbi F, et al. Imported strongyloidiasis: epidemiology, presentations, and treatment. Curr Infect Dis Rep. 2012;14:256-262.

3. Siddiqui AA, Berk SL. Diagnosis of Strongyloides stercoralis infection. Clin Infect Dis. 2001;33:1040-1047.

4. Buonfrate D, Requena-Mendez A, Angheben A, et al. Severe strongyloidiasis: a systematic review of case reports. BMC Infect Dis. 2013;13:78.

5. Centers for Disease Control and Prevention. Parasites - Strongyloides. Resources for health professionals. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/parasites/strongyloides/health_professionals/index.html. Accessed September 4, 2015.

6. UpToDate. Klion AD, Weller PF. Approach to the patient with unexplained eosinophilia. UpToDate Web site. Available at: http://www.uptodate.com/contents/approach-to-the-patientwith-unexplained-eosinophilia. Accessed August 27, 2015.

7. Mokhlesi B, Shulzhenko O, Garimella PS, et al. Pulmonary strongyloidiasis: the varied clinical presentations. Clin Pulm Med. 2004;11:6-13.

8. Requena-Méndez A, Chiodini P, Bisoffi Z, et al. The laboratory diagnosis and follow up of strongyloidiasis: a systematic review. PLoS Negl Trop Dis. 2013;7:e2002.

9. Centers for Disease Control and Prevention. Guidelines for overseas presumptive treatment of strongyloidiasis, schistosomiasis, and soil-transmitted helminth infections. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/immigrantrefugeehealth/guidelines/overseas/intestinal-parasites-overseas.html#me-asia-na-la-caribbean. Accessed April 3, 2014.

10. Centers for Disease Control and Prevention. Treatment options for presumptive parasitic infections. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/immigrantrefugeehealth/guidelines/overseas/interventions/interventions.html. Accessed April 3, 2014.

Treatment begins with ivermectin

First-line treatment for strongyloidiasis is oral ivermectin, 200 mcg/kg/d.⁵ Optimal treatment duration is unknown because it is difficult to determine when S. stercoralis has been eradicated due to the low sensitivity of stool samples.⁴ For a patient with HS or DS, the CDC recommends treatment until stool and/or sputum samples are negative for 2 weeks.⁵

For refugees arriving from the Middle East, the CDC recommends presumptive treatment with ivermectin for Strongyloides and albendazole for infections caused by soil-transmitted helminths.

The CDC recommends that prior to arrival in the United States, all refugees should receive pre-departure treatment for parasites depending on their country of origin. For individuals arriving from the Middle East, the CDC recommends presumptive treatment with ivermectin for Strongyloides and albendazole for infections caused by soil-transmitted helminths.⁹ However, ivermectin was not routinely administered in the Middle East until January 2014.^9,10 As a result of limited pre-departure treatment, US clinicians need to be cognizant of strongyloidiasis and have a high degree of suspicion in patients with nonspecific symptoms, especially when starting treatment with high-dose corticosteroids for other conditions.

We started our patient on a weight-based dose of ivermectin. Piperacillin/tazobactam 3.375 g (IV) every 6 hours was empirically started to cover enteric bacteria in the setting of HS, but was discontinued after blood cultures were negative. An HTLV-1/2 antibody test was negative. A repeat stool O&P test looking specifically for S. stercoralis came back positive on Day 6 of treatment. To determine the course of treatment, repeat O&Ps were done every 72 hours and ivermectin was continued until stool O&Ps were negative for 2 weeks. The total treatment course lasted 22 days.

During the course of treatment, our patient gained weight and her rash, diarrhea, and abdominal pain improved. She was discharged home and followed up with an infectious disease specialist as an outpatient. Three months later, repeat Strongyloides IgG testing was negative.

CORRESPONDENCE
Komal Soin, MD, MPH, Kaiser Permanente Waipio Medical Office, 94-1480 Moaniani Street, Waipahu, HI 96797; komal.soin@gmail.com

Rash, diarrhea, and eosinophilia

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