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antihelminthic therapy (eg, monthly ivermectin) may be required It is important to be aware of the possibility of strongyloidiasis in those with even a distant history of residence in an endemic area, since the infection can be maintained for decades Screening of such individuals for infection is appropriate before institution of immunosuppressive therapy Screening can consist of serologic tests, with stool examinations in those with positive serologic tests, but consideration of presumptive treatment even if the stool evaluations are negative

FIGURE 10-3

or urticarial rashes of the buttocks, perineum, and thighs, due to migrating larvae, may be seen Large worm burdens can lead to malabsorption or intestinal obstruction Eosinophilia is common but may fluctuate The most dangerous manifestation of S stercoralis infection is the hyperinfection syndrome, with dissemination of large numbers of filariform larvae to the lungs and other tissues in immunocompromised individuals Mortality with this syndrome approaches 100% without treatment and has been about 25% with treatment The hyperinfection syndrome is seen in those receiving corticosteroids and other immunosuppressive medications, those with hematologic malignancies, malnutrition, or alcoholism, or those infected with HIV The risk seems greatest for those receiving corticosteroids, and considering the large number of at risk individuals, the risk in those with AIDS seems relatively low With hyperinfection large numbers of larvae can migrate to many tissues, including the lungs, CNS, kidneys, and liver Gastrointestinal symptoms can include abdominal pain, nausea, vomiting, diarrhea, and more severe findings related to intestinal obstruction, perforation, or hemorrhage Bacterial sepsis, probably secondary to intestinal ulcerations, is a common presenting finding Pulmonary findings include pneumonitis, cough, hemoptysis, and respiratory failure Sputum may contain adult worms, larvae, and eggs CNS disease includes meningitis and brain abscesses; the CSF may contain larvae Various presentations can progress to shock and death

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Enterobius vermicularis, the pinworm, is a common cause of intestinal infections worldwide, with maximal prevalence in school-age children Enterobiasis is transmitted person-toperson via ingestion of eggs after contact with the hands or perianal region of an infected individual, food or fomites that have been contaminated by an infected individual, or infected bedding or clothing Autoinfection also occurs Eggs hatch in the duodenum and larvae migrate to the cecum Females mature in about a month, and remain viable for about another month During this time they migrate through the anus to deposit large numbers of eggs on the perianal skin Due to the relatively short lifespan of these helminths, continuous reinfection, as in institutional settings, is required, for long-standing infection

The diagnosis of strongyloidiasis can be difficult, as eggs are seldom found in feces Diagnosis is usually based on the identification of rhabditiform larvae in the stool or duodenal contents These larvae must be distinguished from hookworm larvae, which may hatch after stool collection Repeated examinations of stool or examination of duodenal fluid may be required for diagnosis because the sensitivity of individual tests is only about 30% Hyperinfection is diagnosed by the identification of large numbers of larvae in stool, sputum, or other body fluids An ELISA from the CDC offers about 90% sensitivity and specificity, but cross-reactions with other helminths may occur Eosinophilia and mild anemia are common, but eosinophilia may be absent with hyperinfection Hyperinfection may include extensive pulmonary infiltrates, hypoproteinemia, and abnormal liver function studies

Most individuals with pinworm infection are asymptomatic The most common symptom is perianal pruritus, particularly at night, due to the presence of the female worms or deposited eggs Insomnia, restlessness, and enuresis are common in children Perianal scratching may result in excoriation and impetigo Many mild gastrointestinal symptoms have also been attributed to enterobiasis, but associations are not proven Serious sequelae are uncommon Rarely, worm migration results in inflammation or granulomatous reactions of the gastrointestinal or genitourinary tracts Colonic ulceration and eosinophilic colitis have been reported

Full eradication of S stercoralis is more important than with other intestinal helminths due to the ability of the parasite to replicate in humans The treatment of choice for routine infection is ivermectin (200 mcg daily for 1 2 days) This treatment has replaced thiabendazole (25 mg/kg twice daily for 3 days), which is relatively poorly tolerated, and albendazole (400 mg twice daily for 3 days), which is less effective For hyperinfection, ivermectin should be administered daily until the clinical syndrome has resolved and larvae have not been identified for at least 2 weeks Follow-up examinations for larvae in stool or sputum are necessary, with repeat dosing if the infection persists With continued immunosuppression, eradication may be difficult, and regular repeated doses of

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