Strongyloides

A Neglected Tropical Disease

A Review of Diagnosis
Dr Harsha Sheorey
Clinical Microbiologist St Vincents Hospital, Melbourne

Clinical presentations
Asymptomatic

carriers (ma ority!

Reactivation wit" immunosuppression

Acute

infection

Cutaneous # larva currens Ab$ominal # %& symptoms (uncommon!

C"ronic

infection wit" vague ab$o symptoms Hyperinfection 'ife t"reatening %( sepsis)meningitis

When is diagnosis/screening indicated

Acute)recent

infection

'arva currens or une*plaine$ eosinop"ilia, urticarial or serpiginous s+in lesions Diarr"oea)%& symptoms),ulmonary symptoms in people from en$emic areas -ne*pecte$)une*plaine$ invasive %( sepsis)meningitis

C"ronic

infection

Refugees)migrants)resi$ents. of en$emic areas ,o/, past e*posure in en$emic areas, sanitation wor+ers

&mmunosuppresse$)H0'V12)un$ergoing

immunosuppression)transplant)c"emot"erapy 3ollow up of treatment

* Including Indigenous Australians

Acute infection

C"

ro n

ic

in

fe ct io

Whats available for diagnosis

4osinop"ilia Microscopy (faeces, ot"er! Culture (faeces, ot"er! Histology 4n$oscopy Ra$iology Serology Intradermal skin tests (ot Copro-antigen routinely Molecular diagnosisavailable

Requenq-Mendez et al !"#S $%D &an '()*+ , -). e'((

What are the issues in diagnosis

Most

met"o$s are insensitive

Variable e*cretion 4ggs not present in faeces &ne*perience 3res" specimen usually not available

-se

of Serology is not well 5stan$ar$ise$ Many ot"er met"o$s are non1

Eosinophilia (or IgE levels)

(on1specific

# ot"er parasites 0ransient # only in migratory p"ase 'ow ,,V for intestinal parasites in travellers from en$emic areas (6278! an$ 69:8 in pe$iatric refugees &f positive, coul$ be a potential mar+er of Strongyloi$iasis in t"e rig"t groups

Eosinophilia
arasites that cause Eosinophilia

!vervie"

4osinop"ilia is a reaction to tissue invasive stages of "elmint" (worm! infection; 0wo proto<oans, Cystisospora, an$ Sarcocystis, rarely cause a mil$ eosinop"ilia; 0"e following "elmint" infections cause eosinop"ilia, in travelers or ot"erwise;

&oderate During 'arval &igration( Absent or &ild During Chronic Infections)

Ascaris Hoo+worm 0asciola Clonorchus !aragonimus #pisthorchis

Schistosoma Cysticercosis 1chinococcus (especially if cyst rupture occurs! %richuris Angiostrongylus #nchocerca "oa 2nathastoma Capillaria 0asciolopsis %richostrongylus 3aylisascaris @t"er "uman an$ non1"uman filarias (Diro4ilaria5 Mansonella! Anisakis

!ccurs at *arious #tages of infection)

#pecific Infections

$re%uent and !ften Intense (=7,::: eos)>'!?

Strongyloides (absent in compromise$ "osts! 'ymp"atic filariasis (especially tropical pulmonary eosinop"ilia! %o/ocara (visceral

#peci+en for D, of Strongyloidis

3aeces

3res" (not refrigerate$! Several (sensitivity increases wit" numbers!

Respiratory spec? sputum, AA' Duo$enal aspirate? 4ntero1string

test, en$oscopy CS3 1 rare

&icroscop 'oo+

for rab$itiform larvaeB eggs not e*crete$ Hig"ly specific ($)$ from Hoo+worm larvae! 'ow sensitivity

intermittent s"e$$ing tec"nical e*perience

4asier

if motile

fres" specimen, not refrigerate$ wit"out preservative

/et ,rep of $uo$enal contents Rha6diti4orm lar7ae

/et ,rep of plate culture or in "yperinfection syn$rome 0ilari4orm lar7ae

Culture (concentration)
3res" specimen reCuire$ Various tec"niCues

Aaermanns Hara$a1Moris Agar plate /ater emergence met"o$ (ot $one C"arcoal culture routinely

.aer+anns techni%ue
Most

sensitive (cf A,C! 'abour intensive DmessyE C"ances of lab infection

/arada0&ori culture
3alcon tube 3ilter paper

Close$

3aeces specimen 'arvae migrate towar$s water /ater

system Relatively easy to set up 'ess sensitive Superse$e$ by A,C

Agar plate culture (A C)) no" the preferred techni%ue

Endoscop Any segment of %& involve$ (on1specific unless larvae)a$ult

seen -lceration (apt"oi$, eryt"ematous, serpigenous!, blee$ing, pustule li+e lesions (F larvae burying! mucosal oe$ema, $uo$enal spasms, t"ic+ene$ fol$s, brown $iscoloration, yellowis" no$ules

/istolog Hig"ly specific Sections of larvae

or a$ults (occasionally eggs! Mainly in $uo$enum or gastric crypts 4osinop"ilic infiltrates in lamina propia # $irectly relate$ to intensity

Histology (HG4!

1adiolog (on1specific fin$ings Hig"ly variable

(ormal appearance of %&0 Mil$ e$ema wit" t"ic+ene$ fol$s o" mucosa Significant $ilatation Stricture (best seen wit" Aarium Swallow!

Intra0der+al s2in test

-sing Cross

somatic an$ 4S antigens reactions wit" ot"er nemato$es ,ersists after successful treatment 'ower sensitivity in H0'V12 an$ ot"er immunosuppression Difficult to perform an$ rea$

#erolog

Various met"o$s use$? &3A0, &HA,EIA %,A0, 4&A, /A, '&,S

4&A? An optic $ensity (@;D;!HIH:;J is consi$ere$ negative, w"ile @;DHKH:;7 is consi$ere$ positiveB interme$iate values are recor$e$ as in$eterminate

Various antigens use$ # variable sensitivity an$ specificity

Cross reacts wit" ot"er nemato$es 4*act time of sero1conversion not clearly $efine$ Varies wit" stage)severity of infection # wi$e variation %enerally "ig"er in pts from en$emic areas

Hig"ly variable response

Table 34 Characteristics of the +ain serological tests for strong-loidiasis4

ReCuena1MLn$e< A, C"io$ini ,, Aisoffi M, Auonfrate D, et al; (J:2N! 0"e 'aboratory Diagnosis an$ 3ollow -p of Strongyloi$iasis? A Systematic Review; ,'oS (egl 0rop Dis O(2!? eJ::J; $oi?2:;2NO2) ournal;pnt$;:::J::J "ttp?))www;plosnt$;org)article)info?$oi)2:;2NO2) ournal;pnt$;:::J::J

'uciferase I++uno0 recipitation #-ste+) 'I #

'&,S assay was $evelope$ base$ on immunoglobulin &g % antibo$y to a N2+D recombinant Strongyloides antigen ((&4! an$ was compare$ wit" an (&4 en<yme1lin+e$ immunosorbent assay (4'&SA!; A secon$ antigen, S stercoralis immunoreactive antigen (Ss&R!, was teste$ alone an$ in combination wit" (&4; purifie$ easily an$ pro$uce$ in large amounts '&,S involves fusion of a protein antigen to t"e en<yme reporter Renilla luciferase (Ruc!, e*pression of t"e Ruc1 antigen fusion in mammalian C@S cells, immobili<ation of t"e Ruc1antigen fusion on protein bea$s, an$ Cuantitation of antigen1specific antibo$y by t"e a$$ition of a coelentera<ine substrate an$ t"e measurement of lig"t pro$uction generates values wit" substantial separation between negative an$ positive antibo$y responses P'&,S (Cuic+)rapi$! "as been $esigne$

Copro0antigen
4'&SA on faeces 'ittle cross reaction 4asy an$ ine*pensive Aetter wit" formalin1treate$

faeces More "uman stu$ies reCuire$

&olecular diagnosis
Several R01,CRs $esigne$ 0argets # 2Qs rR(A an$ JQs Directly on faeces Specificity an$ sensitivity

rR(A

$epen$s on number of larvae (severity of infection! (cf A,C!

62::8 in en$emic areas Role in low inci$ence countries unclear

Multiple*

(up to O parasites! $esigne$

$ollo" up of treat+ent
3aeces

micro not reliable

negative $oes not R cure e*crete$ intermittently

A,C

better # multiple over one year Serology most suitable currently

Abs fall ta+es between 21J years (mini S m!? $epen$s on initial titre (en$emic = non1en$emic! S"oul$ be $one in same lab wit" same met"o$, preferably in parallel (o uniform international criteria)(o reliable cut1off Ratio T:;S ($ivi$e postR* titre by preR* titre!

Current #creening 5 Issues

Serology

(Ueosinop"ilia!

(o stan$ar$isation (antigen, +its! Aot" (@0 sensitive)specific enoug" 4&A "as no titre an$ very narrow range

3res"

faeces for A,C

3res" specimen $ifficult to get ($istances! Multiple reCuire$

9 R 6Q:8 sensitivity O R 62::8 sensitivity

Combination

# i$eal

&nterme$iate )in$eterminat e may be an issue

F A,C *9

'oa G (C s"oul$ be rule$ out 3res" Multiple samples may be necessary 3res" Multiple samples may be necessary

A4/AR4 V may ta+e 2J A4/AR4 mt"s V Variable A4/AR4 V Variable (4&A? @D! 4*pect $efinite $rop

'oa G (C s"oul$ be rule$ out

Hyper1infection Syn$rome in a Vietnamese man on steroi$s for %iant cell arteritis

e$ t a i o c c al s s a ti i s i r c n o is i t t i c in , e e f y t i it in l s r a a is e t r t r p i a o y p " re m t"is f e e " o c " g n i n w i r " S io fo reas t a a n i " wit scree om a "e init n; t fr io to s s e t r s fo ppre ien e t b a u p ic s o m n e u $ n m e im

( 4ngl W Me$ J:2NB NSQ?e27 Marc" J2, J:2N

0 3 A R D

Aefore immunosuppression
4veryone ,,V X 3rom non1en$emic area or no "istory of e*posure Serology !#ITI* E
6et +ore histor-

3rom)been in en$emic area or $oubtful "istory Serology U A,C*9

Aot" 4it"er NE6ATI* !#ITI* E 1ule out Loa E

loa7 and pregnanc-

4P-&V@CA' A,C*9

NE6ATI* E

%reat 8ith I7ermecti n

!#ITI* E

NE6ATI* E

Continue "ith i++unosuppression testing . "oa "oa en$emic in /esternRepeat an$ Central Africa

after immunosuppression? F on fres" faece A,CR Agar ,late Culture every N mt"s

ossible $uture #creening/tests

'&,S

wit" (&4 (in place of 4&A! (possibly Cuantitative! in faeces (in place of

More sensitive)specific t"an 4&A)&3A0)&HA Multiple*e$ wit" ot"er parasites

,CR

Copro1antigen

A,C!

Can be $one on preserve$ faeces

Combination

1 i$eal

T/AN8 9!:;
Dont forget to chec2 out