Disseminated Strongyloides stercoralis infection with a cutaneous presentation in an immunosuppressed patient

ARTICLE

Auteur(s) : Felipe Benvenuti, Jose-Manuel Carrascosa, Aram Boada, Carlos Ferrandiz

Hospital Universitari Germans Trias i Pujol, Department of Dermatology, Universitat Autònoma de Barcelona, Carretera de Canyet, S/N, 08916 Badalona (Barcelona) Spain

We report a case of widespread strongyloidiasis with significant cutaneous involvement, in an immunocompromised patient.

A 43-year-old male immigrant from Colombia (Cali) presented with a 3-month history of back pain, progressive motor impairment and paresthesia affecting the lower limbs that required admission for further study. Medical history was significant for HIV infection, currently under anti-retroviral therapy, and a past history of syphilis -properly treated 8 years previously - and acute hepatitis-B infection. During his admission the patient developed an intensively pruritic skin rash. Physical examination showed two different kinds of cutaneous lesion: a) a non-evanescent skin rash consisting of macules and slightly elevated papules, with a reticular to flagelliform appearance, in a widespread distribution over the trunk and the proximal limbs, and b) a symmetrical and confluent rash consisting of small, red to purpuric, mildly palpable papules which was observed on the dorsal part of his feet and ankles (figure 1). Neurological examination revealed a complete loss of strength, mobility and sensitivity of the lower limbs with loss of the osteo-tendinous reflexes. No other abnormalities were detected. Magnetic resonance imaging (MRI) suggested a nonspecific myelitis. No microorganisms were found in the cerebrospinal fluid. Parvovirus-B19 serology was negative. Histological study from a foot lesion was compatible with leukocytoclastic vasculitis. The development of peripheral eosinophilia (up to 60%) during the patient’s admission, associated with the geographical origin of the patient, as well as the clinical picture, raised the possibility of a parasitic disease, particularly from Strongyloides stercoralis, which was confirmed when rabditiform larvae were found in the stool examination.

With the diagnosis of disseminated strongyloidiasis with neurological impairment and a secondary cutaneous rash, therapy with oral antihistamine and ivermectin 200 μg/kg/day was prescribed for 4 days. Progressive improvement of the pruritus as well as of the cutaneous lesions with partial recovery of neurological impairment was observed. Control blood counts showed normal eosinophil levels and the stool examination was negative.

Strongyloides stercoralis is endemic in Africa, Asia and Latin-America [1]. The prevalence in Colombia varies from 1% to 16% according to the population and area studied [2]. Although it has been considered a tropical or subtropical disease, increased worldwide travel and migration is changing this traditional perspective. Once infected, most people have an asymptomatic, chronic infection of the gastrointestinal tract. S. stercoralis has the ability to complete its life cycle within the human host and increase its number of worms through a cycle of autoinfection [3]. In immunosuppressed hosts, the internal cycle is magnified, leading to millions of filariform larvae that can disseminate to other organs, including the skin [3]. Clinical manifestations of hyperinfection may vary widely, according to the degree of organ affectation.

Skin manifestations of strongyloidiasis mostly consist of pruritic linear streaks (larva currens) secondary to the penetration of the parasite within the skin [4, 5]. Cutaneous signs are uncommon in disseminated disease. Our patient presented with two different cutaneous lesions. Red to purpuric macules in a reticular and widespread distribution, as observed in our case, has rarely been described [6]. On the other hand, a symmetrical purpuric distal rash was also observed. Rashes and/or petechiae developing in systemic strongyloidiasis have been related to the migration of the larvae through the endothelium of capillary papillary dermis causing petechial hemorrhaging, which was not detected in our case [5]. On the contrary, leukocytoclastic vasculitis, suggesting a hypersensitivity type III reaction to strongyloides, was demonstrated.

In conclusion, we report a case of disseminated strongyloidiasis with cutaneous and neurological features in an immunosuppressed host in whom the cutaneous signs, in addition to peripheral eosinophilia and the epidemiological context, contributed highly to the final diagnosis.

Acknowledgements

References

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