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Comment on: Strongyloidiasis: a mistaken diagnosis and a fatal outcome in a patient with diarrhoea
Transactions of the Royal Society of Tropical Medicine and Hygiene (2006) 100, 83—84
CORRESPONDENCE
Comment on: Strongyloidiasis: a mistaken diagnosis and a fatal outcome in a patient with diarrhoea We read with interest the recent report by Rahim et al. (2005) concerning misdiagnosis of strongyloidiasis. The case raises several additional points. As the authors state, strongyloidiasis is an important possible diagnosis in former Far East prisoners of war (FEPOW), particularly those who worked on the Thai/Burma Railway between 1942 and 1945. The unreferenced prevalence of 20% quoted for this group of veterans, originates from a 1980 report from the Liverpool School of Tropical Medicine, where strongyloidiasis was found in 44/206 (21.4%) FEPOWs who worked on the Burma Railway, compared with 10/113 (8.8%) who were imprisoned elsewhere (P < 0.005) (Gill and Bell, 1980). Subsequent reports from Australia (Grove, 1980), the USA (Pelletier, 1984) and elsewhere (Proctor et al., 1985) have confirmed that strongyloidiasis is relatively common in FEPOWs from various areas of Southeast Asia and the Far East. A review of our own 30 years experience of 2072 FEPOWs has shown the overall prevalence of strongyloidiasis to be 12.0% with a prevalence of 16.1% for those who worked on the Thai/Burma Railway (Gill et al., 2004b). The disease also occurs in former (nonimprisoned) soldiers of the Burma campaign (Gill and Bell, 1987), and we have recently described disseminated strongyloidiasis in an ex-soldier involved with the relief of Changi Jail (in Singapore) in 1945 (Gill et al., 2004a). The diagnosis was made 57 years later, shortly before his death in the UK with recurrent pneumonic episodes and bronchogenic carcinoma. Anyone exposed in an endemic area, even many years previously, may be at risk of chronic strongyloidiasis, and of disseminated disease if they become immunocompromised. One single clue that may alert the clinician to the diagnosis is the presence of peripheral blood eosinophilia, present in about two-thirds of cases (Gill and Bailey, 1989; Gill
et al., 2004b). The report by Rahim et al. (2005) does not mention whether this was ascertained in their patient. They correctly state that strongyloidiasis may not be detected by simple faecal microscopy, but it is important that ancillary diagnostic methods, including stool culture and serology, are used (Gill et al., 2004b). We disagree with Rahim et al. (2005) in their suggested treatment of cases with tiabendazole. This drug is less effective than modern alternatives, and very prone to side effects (Archibald et al., 1993; Gill and Bell, 1980; Grove, 1980, 1982). Albendazole and ivermectin are both more effective and less toxic for treating acute and chronic strongyloidiasis (Archibald et al., 1993), and ivermectin is probably the treatment of choice for disseminated infection (Chiodini et al., 2000). Finally, the case of Rahim et al. (2005) demonstrates the importance of travel history in diagnosing tropical disease. Emphasising this point in The Lancet in 1963, Brian Maegraith entitled his article ‘Unde Venis?’ (Where have you been? literally, Where are you coming from?) (Maegraith, 1963). Over 40 years later this message remains equally true. Conflicts of interest statement The authors have no conflicts of interest concerning the comments in this correspondence.
References Archibald, L.K., Beeching, N.J., Gill, G.V., Bailey, J.W., Bell, D.R., 1993. Albendazole is effective treatment for chronic strongyloidiasis. Quart. J. Med. 86, 191—195. Chiodini, P.L.M., Reid, A.J.C., Wiselka, M.J., Firmin, R., Foweraker, J., 2000. Parenteral ivermectin in Strongyloides hyperinfection. Lancet 355, 43—44. Gill, G.V., Bailey, J.W., 1989. Eosinophilia as a marker for chronic strongyloidiasis — use of a serum ELISA test to detect asymptomatic cases. Ann. Trop. Med. Parasitol. 83, 249— 252. Gill, G.V., Bell, D.R., 1980. Strongyloidiasis in ex-prisoners of war in south-east Asia. Brit. Med. J. 1, 1319—1320.
0035-9203/$ — see front matter © 2005 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.trstmh.2005.06.030
84 Gill, G.V., Bell, D.R., 1987. Strongyloides stercoralis infection in Burma Star veterans. Brit. Med. J. 294, 1003—1004. Gill, G.V., Beeching, N.J., Khoo, S., Bailey, J.W., Partridge, S., Blundell, J.W., Luksza, A.R., 2004a. A British Second Word War veteran with disseminated strongyloidiasis. Trans. R. Soc. Trop. Med. Hyg. 98, 382—386. Gill, G.V., Welch, E., Bailey, J.W., Bell, D.R., Beeching, N.J., 2004b. Strongyloides stercoralis infection in former British Far East prisoners of war. Quart. J. Med. 97, 789—795. Grove, D.I., 1980. Strongyloidiasis in ex-prisoners of war in South-East Asia. Brit. Med. J. 1, 598—601. Grove, D.I., 1982. Treatment of strongyloidiasis with thiabendazole: an analysis of toxicity and effectiveness. Trans. R. Soc. Trop. Med. Hyg. 76, 114—118. Maegraith, B., 1963. Unde venis? Lancet 1, 401—404. Pelletier, L.L., 1984. Chronic strongyloidiasis in World War II Far East ex-prisoners of war. Am. J. Trop. Med. Hyg. 33, 55—61.
Correspondence Proctor, E.M., Isaac-Renton, J.L., Robertson, W.B., Block, W.A., 1985. Strongyloidiasis in Canadian Far East war veterans. Can. Med. Assoc. J. 133, 876—877. Rahim, S., Drabu, Y., Jarvis, K., Melville, D., 2005. Strongyloidiasis: a mistaken diagnosis and a fatal outcome in a patient with diarrhoea. Trans. R. Soc. Trop. Med. Hyg. 99, 215— 217.
Geoff V. Gill ∗ Nick Beeching Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK ∗ Tel.: +44 151 529 4749; fax: +44 151 529 4688. E-mail address: [email protected] 20 May 2005
CORRESPONDENCE
Comment on: Strongyloidiasis: a mistaken diagnosis and a fatal outcome in a patient with diarrhoea We read with interest the recent report by Rahim et al. (2005) concerning misdiagnosis of strongyloidiasis. The case raises several additional points. As the authors state, strongyloidiasis is an important possible diagnosis in former Far East prisoners of war (FEPOW), particularly those who worked on the Thai/Burma Railway between 1942 and 1945. The unreferenced prevalence of 20% quoted for this group of veterans, originates from a 1980 report from the Liverpool School of Tropical Medicine, where strongyloidiasis was found in 44/206 (21.4%) FEPOWs who worked on the Burma Railway, compared with 10/113 (8.8%) who were imprisoned elsewhere (P < 0.005) (Gill and Bell, 1980). Subsequent reports from Australia (Grove, 1980), the USA (Pelletier, 1984) and elsewhere (Proctor et al., 1985) have confirmed that strongyloidiasis is relatively common in FEPOWs from various areas of Southeast Asia and the Far East. A review of our own 30 years experience of 2072 FEPOWs has shown the overall prevalence of strongyloidiasis to be 12.0% with a prevalence of 16.1% for those who worked on the Thai/Burma Railway (Gill et al., 2004b). The disease also occurs in former (nonimprisoned) soldiers of the Burma campaign (Gill and Bell, 1987), and we have recently described disseminated strongyloidiasis in an ex-soldier involved with the relief of Changi Jail (in Singapore) in 1945 (Gill et al., 2004a). The diagnosis was made 57 years later, shortly before his death in the UK with recurrent pneumonic episodes and bronchogenic carcinoma. Anyone exposed in an endemic area, even many years previously, may be at risk of chronic strongyloidiasis, and of disseminated disease if they become immunocompromised. One single clue that may alert the clinician to the diagnosis is the presence of peripheral blood eosinophilia, present in about two-thirds of cases (Gill and Bailey, 1989; Gill
et al., 2004b). The report by Rahim et al. (2005) does not mention whether this was ascertained in their patient. They correctly state that strongyloidiasis may not be detected by simple faecal microscopy, but it is important that ancillary diagnostic methods, including stool culture and serology, are used (Gill et al., 2004b). We disagree with Rahim et al. (2005) in their suggested treatment of cases with tiabendazole. This drug is less effective than modern alternatives, and very prone to side effects (Archibald et al., 1993; Gill and Bell, 1980; Grove, 1980, 1982). Albendazole and ivermectin are both more effective and less toxic for treating acute and chronic strongyloidiasis (Archibald et al., 1993), and ivermectin is probably the treatment of choice for disseminated infection (Chiodini et al., 2000). Finally, the case of Rahim et al. (2005) demonstrates the importance of travel history in diagnosing tropical disease. Emphasising this point in The Lancet in 1963, Brian Maegraith entitled his article ‘Unde Venis?’ (Where have you been? literally, Where are you coming from?) (Maegraith, 1963). Over 40 years later this message remains equally true. Conflicts of interest statement The authors have no conflicts of interest concerning the comments in this correspondence.
References Archibald, L.K., Beeching, N.J., Gill, G.V., Bailey, J.W., Bell, D.R., 1993. Albendazole is effective treatment for chronic strongyloidiasis. Quart. J. Med. 86, 191—195. Chiodini, P.L.M., Reid, A.J.C., Wiselka, M.J., Firmin, R., Foweraker, J., 2000. Parenteral ivermectin in Strongyloides hyperinfection. Lancet 355, 43—44. Gill, G.V., Bailey, J.W., 1989. Eosinophilia as a marker for chronic strongyloidiasis — use of a serum ELISA test to detect asymptomatic cases. Ann. Trop. Med. Parasitol. 83, 249— 252. Gill, G.V., Bell, D.R., 1980. Strongyloidiasis in ex-prisoners of war in south-east Asia. Brit. Med. J. 1, 1319—1320.
0035-9203/$ — see front matter © 2005 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.trstmh.2005.06.030
84 Gill, G.V., Bell, D.R., 1987. Strongyloides stercoralis infection in Burma Star veterans. Brit. Med. J. 294, 1003—1004. Gill, G.V., Beeching, N.J., Khoo, S., Bailey, J.W., Partridge, S., Blundell, J.W., Luksza, A.R., 2004a. A British Second Word War veteran with disseminated strongyloidiasis. Trans. R. Soc. Trop. Med. Hyg. 98, 382—386. Gill, G.V., Welch, E., Bailey, J.W., Bell, D.R., Beeching, N.J., 2004b. Strongyloides stercoralis infection in former British Far East prisoners of war. Quart. J. Med. 97, 789—795. Grove, D.I., 1980. Strongyloidiasis in ex-prisoners of war in South-East Asia. Brit. Med. J. 1, 598—601. Grove, D.I., 1982. Treatment of strongyloidiasis with thiabendazole: an analysis of toxicity and effectiveness. Trans. R. Soc. Trop. Med. Hyg. 76, 114—118. Maegraith, B., 1963. Unde venis? Lancet 1, 401—404. Pelletier, L.L., 1984. Chronic strongyloidiasis in World War II Far East ex-prisoners of war. Am. J. Trop. Med. Hyg. 33, 55—61.
Correspondence Proctor, E.M., Isaac-Renton, J.L., Robertson, W.B., Block, W.A., 1985. Strongyloidiasis in Canadian Far East war veterans. Can. Med. Assoc. J. 133, 876—877. Rahim, S., Drabu, Y., Jarvis, K., Melville, D., 2005. Strongyloidiasis: a mistaken diagnosis and a fatal outcome in a patient with diarrhoea. Trans. R. Soc. Trop. Med. Hyg. 99, 215— 217.
Geoff V. Gill ∗ Nick Beeching Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK ∗ Tel.: +44 151 529 4749; fax: +44 151 529 4688. E-mail address: [email protected] 20 May 2005