BRIEF REPORTFulminant Fatal Strongyloides stercoralis Infection in a Postchemotherapy

Immunosuppressed Cancer Patient

Poonam Patil, MD,* R.S. Jayshree, PhD, Rani S. Acharya, MD, Hema Sridhar, MD,Govind Babu, DM, and T.M. Suresh, DM

Key words: Strongyloides stercoralis; immunosuppression; parasitic infection;cancer

Strongyloides stercoralis, a parasitic roundworm, cancause life-threatening disease in an immunocompro-mised host, such as the patient with lung cancer wetreated. He was a 53-year-old man with nonsmall cellbronchogenic carcinoma, which was locally advancedand inoperable. He was given chemotherapy (CT) con-sisting of gemcitabine, to which there was no response.The chemotherapy regimen was then changed to a com-bination of cisplatin, etoposide, and ifosfamide, withgrowth factor support (GM-CSF). On the third day fol-lowing completion of CT, he passed loose stools twiceand vomited once. He was started on norfloxacin andtinidazole, and became asymptomatic on the fourth day.The next day, however, he developed severe loose stools,vomiting, and pain in the epigastric and umbilical re-gions. He was dehydrated, and examination revealed bi-lateral crepitations and epigastric tenderness. Bowelsounds were normal. Hemogram revealed pancytopenia,with total WBC counts of 1,000/mm3. Biochemical pa-rameters were normal except for hypoproteinemia (totalserum proteins 4.5 g/dl, albumin 2.7g/dl, and globulin 1.8g/dl). X-ray films of the chest were normal, but an ab-dominal film showed a dilated splenic flexure of thecolon. Stool microscopy revealed rhabditiform larvae ofStrongyloides stercoralis. Bacterial culture of the stoolrevealed no pathogen. He was started on parenteral an-tibiotics (cefotaxime, gentamicin, and metronidazole)empirically for gram-negative sepsis and albendazole,because thiabendazole and ivermectin were not available.The next day he deteriorated and required dopamine in-fusion to maintain his blood pressure along with rehy-dration measures, to which he did not respond. He finallysuccumbed within 48 hr of the diagnosis of theStrongy-loides infection.

Strongyloides stercoralishas a widespread but patchyworldwide distribution in both tropical and subtropicalclimates. Its importance lies in its unique ability to rep-licate within its host for decades. This biologic behaviourprovides the potential for explosive disease in an immu-

nocompromised host. Highly endemic areas have beenidentified in Southeast Asia and rural Brazil, whereprevalence rates may approach 60% [1]. The exact inci-dence is, however, difficult to determine because offalse-negative stool tests owing to autoinfection, seasonalvariations in infection, and so on. Disseminated strongy-loidiasis may extend beyond the gastrointestinal tract toinvolve the lungs, liver, and central nervous system andis frequently associated with invasive bacterial infec-tions. Among patients with cancer, it has been encoun-tered most frequently with leukemia or lymphoma and inthose who have received systemic corticosteroids [2]. Inthe last few years, increasing reports of parasitic hyper-infection have been documented in patients with AIDS[3,4].

Nucci et al. [5] reported a retrospective study of 253patients with hematologic malignancies seen over a pe-riod of 14 years in whom stool examinations had beendone. Fifty-three patients with strongyloidiasis weredocumented; one of them developed disseminated stron-gyloidiasis that proved lethal (1.9%). A case report byAydin et al. [6] included a literature review. They encoun-tered 21 cases of malignant lymphoma withStrongyloi-des stercoralisinfections. Most had a diffuse hyperin-fection, which was fatal, confirming the results of Igra-Siegman et al. [7], who found a mortality rate of 86% inStrongyloidesinfections in immunocompromised hosts.The exact prevalence ofStrongyloidesinfection in Indiais not known.

The history of most cases reported from hyperendemicareas indicates that patients remain asymptomatic carri-ers ofS. stercoralisfor many years. The infestation be-

Kidwai Memorial Institute Of Oncology, Bangalore, India

*Correspondence to: Dr. Poonam Patil, 103 RIFCO Santosh Apart-ments, NAL Wind Tunnel Road, Murugesh Palya, Bangalore 560017,India. E-mail: poonampatil@yahoo.com

Received 22 January 1999; Accepted 2 June 1999

Medical and Pediatric Oncology 33:504–505 (1999)

© 1999 Wiley-Liss, Inc.

comes symptomatic in patients who become immunosup-pressed, such as those who fall ill with a malignant dis-ease and are given immunosuppressive chemotherapy.An average time interval of 1–5 months has been re-ported between initiation of the chemotherapy and thediagnosis of strongyloidiasis [6].

We at Kidwai Memorial Institute of Oncology found aprevalence of 0.6% among all our cancer patients [8].The patient discussed here did not have a history of fre-quent bowel disturbances. Myelosuppression is not adose-limiting toxicity for gemcitabine, but later, when hewas switched to a combination chemotherapy regimen,despite growth factor support, he developed myelosup-pression and the manifestations ofS. stercoralisinfec-tion. This infection has been reported to be found pre-dominantly in patients with hematologic malignancies,but now, in the era of aggressive chemotherapy regimensfor solid tumors, the incidence of myelosuppression isincreasing in these patients. A high index of suspicion isrequired to rule out this otherwise fatal parasitic infectionin patients in endemic areas who are placed on suchregimens and who have complaints pertaining to the gas-trointestinal tract. Genta et al. [9–11] have recommendedthat the cancer patients in tropical and other endemicareas should be screened forStrongyloidesinfection be-fore starting immunosuppressive therapy. When avail-able, serology is preferable and is highly sensitive; stoolexaminations may be falsely negative. Patients should becarefully observed for gastrointestinal complaints of nau-sea, vomiting, diarrhea and abdominal pain, skin lesions,eosinophilia, or lung infiltrates. The predictive value ofscreening tests that include the possibility of false-negative stool specimens is, however, not known.

Infested patients can be treated with thiabendazole 50mg/kg for 2 days, with a cure rate of 80% even in im-munocompromised patients [12,13]. Ivermectin also hasyielded good results. Mebendazole and albendazole arealso useful. Both are less toxic and better tolerated buthave a lower efficacy.

We conclude that every cancer patient in high-riskareas scheduled to receive intensive, immunosuppressivechemotherapy, whether for hematologic or solid malig-

nancies, should be screened forStrongyloidesinfection.A high index of suspicion will go a long way towardsdiagnosing this otherwise fatal parasitic infection.

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