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      Strongyloides stercoralis Hyperinfection and Concomitant Cytomegalovirus Gastroenteritis in an Immunocompromised Host

      case-report
      , MD 1 , , MD 1 , , MD 2 , , MD 1 , , MD 1 ,
      ACG Case Reports Journal
      Wolters Kluwer

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          ABSTRACT

          Strongyloides stercoralis infection typically presents with nonspecific gastrointestinal symptoms and no definitive or pathognomonic endoscopic findings. Disease burden can vary depending on a patient's immune status. Immunocompromised patients with strongyloidiasis can develop tremendous disease burden, extraintestinal dissemination, and are at risk for coinfection with other organisms. We present the case of an immunocompromised patient presenting with multiple gastrointestinal complaints found to have S. stercoralis hyperinfection and concomitant cytomegalovirus gastroenteritis.

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          Most cited references18

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          Cytomegalovirus Infections in Solid Organ Transplantation: A Review

          Cytomegalovirus (CMV) continues to have a tremendous impact in solid organ transplantation despite remarkable advances in its diagnosis, prevention and treatment. It can affect allograft function and increase patient morbidity and mortality through a number of direct and indirect effects. Patients may develop asymptomatic viremia, CMV syndrome or tissue-invasive disease. Late-onset CMV disease continues to be a major problem in high-risk patients after completion of antiviral prophylaxis. Emerging data suggests that immunologic monitoring may be useful in predicting the risk of late onset CMV disease. There is now increasing interest in the development of an effective vaccine for prevention. Novel antiviral drugs with unique mechanisms of action and lesser toxicity are being developed. Viral load quantification is now undergoing standardization, and this will permit the generation of clinically relevant viral thresholds for the management of patients. This article provides a brief overview of the contemporary epidemiology, clinical presentation, diagnosis, prevention and treatment of CMV infection in solid organ transplant recipients.
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            Screening, prevention, and treatment for hyperinfection syndrome and disseminated infections caused by Strongyloides stercoralis.

            This review discusses the latest approaches to the diagnosis and treatment of patients with strongyloidiasis, with an emphasis on infection in the immunocompromised host and the risk for disseminated strongyloidiasis. The differences in acute, chronic, accelerated autoinfection, and disseminated disease in Strongyloides stercoralis infection are explored with particular emphasis on early diagnosis, treatment, and prevention. The goals of treatment are investigated for the different infection states. Predisposing risks for dissemination are delineated, and the roles played for newer diagnostics in the identification of at-risk individuals are detailed. The use of newer diagnostic tests and broader screening of immunocompromised patients from Strongyloides-endemic areas is of paramount importance, particularly if prevention of life-threatening dissemination is the goal.
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              Strongyloides hyperinfection syndrome: an emerging global infectious disease.

              The hyperinfection syndrome (HS) caused by Strongyloides stercoralis has a high mortality rate (15% to 87%). A variety of risk factors and predisposing conditions have been described, including new immunosuppressive therapies; HTLV-1 infection; cadaveric transplantation; immune reconstitution syndrome; haematological malignancies (especially lymphoma); tuberculosis; malnutrition secondary to chronic Strongyloides diarrhoea; international travel and immigration. Inhibition of Th2 cell-mediated, humoral or mucosal immunity is associated with HS. HS is more frequently seen in HTLV-1 than HIV patients. In AIDS, there is an increase in Th2 cytokines, while in HTLV-1 infection there is a decrease in the Th2 response, leading to an increased risk of autoinfection. Corticosteroid use remains the most frequent risk factor for HS. A number of ELISAs are useful for diagnosis and post-treatment evaluation. Once diagnosed, the disease may be managed effectively with anthelminthic drugs, including ivermectin. HS causes diverse symptoms and signs, with unusual manifestations leading to misdiagnosis and medical errors related to healthcare providers' lack of familiarity with the condition. HS is an example of an emerging tropical infection migrating to developed countries and requiring greater clinician awareness.
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                Author and article information

                Journal
                ACG Case Rep J
                ACG Case Rep J
                ACGCRJ
                ACGCRJ
                AC9
                ACG Case Reports Journal
                Wolters Kluwer (Maryland, MD )
                2326-3253
                15 July 2019
                July 2019
                : 6
                : 7
                : e00135
                Affiliations
                [1 ]Department of Internal Medicine, New York University School of Medicine, New York, NY
                [2 ]Department of Pathology, New York University School of Medicine, New York, NY
                Author notes
                Correspondence: Renee Williams, MD, Division of Gastroenterology, NYU School of Medicine/Bellevue Hospital Center, 462 First Ave, 10N1, New York, NY 10016 ( Renee.Williams@ 123456nyulangone.org ).
                Article
                ACGCR-19-0425 00013
                10.14309/crj.0000000000000135
                6722353
                c0ba41f9-cd35-4b07-b759-2600fb30d9c7
                © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

                History
                : 31 October 2018
                : 13 May 2019
                Categories
                Case Report
                Small Bowel
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