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Strongyloides stercoralis hyperinfection in the acquired immunodeficiency syndrome
CORRESPONDENCE
gyloidiasis was reported by Armignacco et al (Am J Med 1989; 86: 258). Clinicians in Africa, where both AIDS and strongyloidiasis are very common, do not believe that 1987-1988(%) 19861986(%) systemic strongyloidiasis is present (n = 11,241) (n = 9,427) Diseases and Disorders in their AIDS patients and suggested that this diseaseshould not be used to define AIDS [3,4]. Some 10.2 9.4 0.2 Nervous system Eye 22:2 ii 0.6 authors found a higher prevalence Ear, nose, and throat 19.0 Respiratory system of antibodies to S. stercoralis in pa20.6 21.5 Circulatory system tients infected by HTLV-I virus, a 2.0 2.7 3.2 4.5 Digestive system and disease also associated with imHepatobiliary system pancreas 1.7 1.9 mune deficiency. Antibody prevaMusculoskeletal system and connective tissues 0.8 Skin, subcutaneous tissue, and breast lence in parasitology is not regard::: 4.5 Endocrine, nutritional, and metabolic ed as a good sign of active infection 19.0 Kidney and urinary tract and its value can be controversial; Z:i 0.2 Male reproductive system 0.5 0.2 this higher antibody prevalence Female reproductive system was not even found by other au0.2 0.0 0.1 0.0 Newborns and Pregnancy, childbirth, other neonates and the puerperium thors [5,6]. 3.7 4.8 Blood and blood-forming organs and immunity We tried to evaluate the real in2.1 1.6 Myeloproliferative disorders 2.5 cidence of strongyloidiasis and Infections and parasitic disorders 2.9 Mental diseases and disorders ii AIDS in Sgo Paulo, Brazil. Some 3:9 3.2 Substance use and abuse reports showedthat 2.4%of the citInjuries, poisonings, and toxic effects of drugs 2.9 izens of Brazil have strongyloides i:: 0.0 Burns 0.2 0.2 in their intestines, as evidenced by Factors influencing health status routine stool examination. Other 100.0% 100.0% authors reported 0.7% of all stool specimens showed strongyloides larvae, again with routine stool jority of cases,a broad spectrum of ACKNOWLEDGMENT tests [7]. Those tests probably disdiseaseswas present for residents’ I am indebted to Mr. Stephen Kowal and Mr. Michael close 40% to 60% of all cases of Anthony for providing the data on hospital admistraining at both institutions. strongyloidiasis as revealed by During the two-year period sions. Baermann’s test [8,9], and it can be 1987-1988, there was no substan- Submitted July 18, 1969, and accepted August 7. assumedthat 1.4% of the popula1969 tial change in the spectrum of distion of Sao Paulo is infected with easesof patients admitted to our strongyloides. There are no data medical center (Table I) other about the prevalence of strongythan an increase in hemodialysis loides in Brazilian patients with admissions, accounting for the AIDS, most of whom are homosexdoubling of MDC 11. Specifically uals. STRONGYLOIDES STERCORALIS in regard to AIDS patients, al- HYPERINFECTION IN THE We followed 100 AIDS patients though the number of admissions ;I ;;FlRE;MMUNODEFlClENCY with three consecutive stool teats for diagnosis-related groups using Baermann’s method, and dis8 (DRGs) 398 and 399 (reticuloendo- To the Editor: covered that 10 had positive findthelial and immunity disorders) in- Strongyloides hyperin- ings for strongyloides larvae. All of stercoralis creased between 1985-1986 (140 fection used to include human im- them were treated with thiabendacases)and 1987-1988 (197 cases), munodeficiency virus (HIV) anti- zole and closely followed; none dethese patients accounted for far body-positive patients in the group veloped systemic strongyloidiasis. lessthan 5% of all medical admis- IV Cl subset, until this condition We also reviewed autopsy protosions. If our hospital is representa- wasdiscontinued in the Centers for cols and histologic material from 99 tive of a large acute-care municipal DiseaseControl criteria for the re- consecutive subjects with AIDS facility, it is a misrepresentation vised definition of acquired immu- and again no systemic strongyloiand misconception to assert that nodeficiency syndrome (AIDS) [I]. diasis was found. This autopsy sesuch hospitals are flooded nearly This was a very rational decision, ries included two of the patients exclusively with AIDS patients. A as until recently no clear-cut cases from our aforementioned series of broad spectrum of diseasesis and of systemic strongyloidiasis had 100 AIDS patients; strongyloides continues to be available for resi- been reported in this patient popu- intestinal infection was diagnosed dent education in internal medi- lation. Pialoux et al [2] described a in these two when they were alive. cine. case of an intestinal infection by We concur with Petithory and FRED ROSNER, M.D., F.A.C.P. strongyloides; Maayan et al (Am J Derouin [3] in that there is no inQueens Hospital Center Affiliation Med 1987; 83: 945-948) reported creasein systemic strongyloidiasis of the Long Island Jewish Medical reported in AIDS patients, so this on one patient with AIDS, filariCenter form larvae in sputum, broncho- parasitosis should not be used to Jamaica, New York pneumonia and sepsis,and no ex- include patients in the AIDS defiand traintestinal S. stercoralis at aunition. We also agree with Maayan Albert Einstein College of Medicine topsy. The only case of et al and Armignacco et al that sysof Yeshiva University Bronx, New York well-documented systemic stron- temic strongyloidiasis should be TABLE I Major Diagnostic Categories (MDC) of Medical Admissions to a Municipal Hospital during a Four-Year Period
602
November
1989
The American
Jour ,nal of Medicine
Volume
87
kept in mind in patients with AIDS when clinical data suggest it, as it is one potentially treatable disease; and strongyloides prophylaxis should be considered as well in these patients, as we routinely do in Brazil in patients undergoing bone marrow transplantation and renal transplantation. The best way to administer rational prophylaxis would be to perform three consecutive Baermann’s tests of the stool to detect positive findings and not to treat everyone routinely; if time is lacking, we would empirically administer prophylaxis in all patients, regardless of the results of routine parasitologic examination.
torio da estrongiloidiase (Strongylodes sfercoralis). 0 Hospital 1952; 41: 11. 9. Hakfm S. Genta R: Fatal disseminated strongyloidiasis in a Vietnam War veteran. Arch Pathol Lab Med 1986: 110: 809. Submitted
May 25, 1989,
and accepted
August 7. 1989
The Reply: In their letter, Neto et al confirm that S. stercoralis hyperinfection rarely occurs in HIV-infected subjects. In fact, only eight casea of this syndrome have been reported in patients with AIDS (Am J Med 1989; 86: 258). Six of them had extraintestinal strongyloidiasis while a disseminated infection developed in two patients, one of whom was a VICENTE A. NETO heterosexual subject from Zaire [l]. JACYR PASTERNAK As we pointed out, the small ANTONIO A. B. MOREIRA number of such cases, also in areas MARIA I. S. DUARTE in which HIV infection and stronRUBENSCAMPOS gyloidiasis are both endemic, quite LUCIA M. A. BRAZ Hospital das Clinicas da Faculdade justifies the exclusion of this helde Medicina da Universidade de minthiasis from the list of opportuE&i0Paul0 nistic infections indicative of AIDS Siio Paula, Brazil [2]. Nevertheless, in view of the very high mortality from the hy1. Revision of the CDC surveillance case definition for perinfection syndrome, HIV-seroacquired immunodeficiency syndrome. MMWR 1987: 36 (1-S): 3s. positive patients should be careful2. Pialoux G, Seriel P. Caudron J. Chousterman M. ly examined for this treatable paraMeyrignac D: Syndrome d’immunodepression acsitosis. In this regard, it is quise associe a une anguillulose severe. Presse Med interesting to remark that, using 1984; 13 1960. 3. Petithory J, Derouin F: AIDS and strongyloidiasis in three Baermann’s tests, Neto et al Africa. Lancet 1987: I: 921. found the prevalence of strongy4. Lucas SB: AIDS in Africa-dinicopathological asloides to be about seven times highpects. Trans R Sot Trop Med Hyg 1988: 82: 801. er in AIDS patients than in the 5. Nakada K, Kohahura M, Komada M. Hinuma Y: High incidence of HTLV-I antibody in carriers of Strop general population in Sao Paulo, g&ides stercoralis. fancet 1984; I: 633. Brazil. Since we have only recently 6. Nova F, Hanchard S, Peter Figueroa J, Blattner W: begun a similar study, sufficient Antibodies to Strongyloides sfercoralis in healthy Jadata on the prevalence of strongymaican carriers of HTLV-I. N Engl J Med 1989; 320: 252. loidiasis among HIV-infected pa7.Coutinho JC, Campos R, Amato Neto V: Nota tients attending our hospital are sobre o diagnostic0 e prevalencia da estrongilodiase not yet available. However, in reem Sao Paulo. Rev Clin Sao Paula 1951; 27: 11. viewing 132 autopsies in AIDS sub8. Coutinho JC, Croce J, Campos R, Amato Neto V: Contribui@o para o estudo do diagndstico de laborajects, we also found no S. stercora-
November
1989
The American
lis hyperinfection apart from the one reported case (Am J Med 1989; 86: 258).
Finally, since strongyloides in Italy is more common in the rural areas [3] and homosexual men account for less than 17% of AIDS cases, we do not see the necessity of treating HIV-seropositive patients without proved strongyloidiasis. OawDo ARMIONACC~, M.D. OspedaleLazzaro Spallanzani 00149Rome, Italy 1. Piot P. Taelman H. Minlanau KB. et at Acouired immunodeficiency syndrome 1’1 a heterosexual population in Zaire. Lancet 1984; II: 6569. 2. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MMWR 1987; 36 (1s): 3S-15s. 3. ScaeJia M. Brustfa R. Gatti S. et ab Autochthonous stron&oidiasis in Italy: an epidemiological and clinical review of 150 cases. Bull Sot Pathol Exp 1984; 77: 328-332.
CORRECTION In the August 16,1989 supplement entitled Proceedings of a Symposium-clinical Settings for Selective Alpha-Adrenergic Receptor Inhibition: Rationale and Management Strategies, praxosin hy-
drochloride capsules (Minipress@) were incorrectly identified as Minipress XL in the first sentence of the article “Efficacy and Safety of Minipress XL, a New Once-a-Day Formulation of Praxosin” by Singleton et al (page 2A-455). Praxosin in the GITS formulation (Minipress XL) is currently approved in France and awaiting Food and Drug Administration approval in the United States.
Journal
of Medlclne
Volume
87
603
gyloidiasis was reported by Armignacco et al (Am J Med 1989; 86: 258). Clinicians in Africa, where both AIDS and strongyloidiasis are very common, do not believe that 1987-1988(%) 19861986(%) systemic strongyloidiasis is present (n = 11,241) (n = 9,427) Diseases and Disorders in their AIDS patients and suggested that this diseaseshould not be used to define AIDS [3,4]. Some 10.2 9.4 0.2 Nervous system Eye 22:2 ii 0.6 authors found a higher prevalence Ear, nose, and throat 19.0 Respiratory system of antibodies to S. stercoralis in pa20.6 21.5 Circulatory system tients infected by HTLV-I virus, a 2.0 2.7 3.2 4.5 Digestive system and disease also associated with imHepatobiliary system pancreas 1.7 1.9 mune deficiency. Antibody prevaMusculoskeletal system and connective tissues 0.8 Skin, subcutaneous tissue, and breast lence in parasitology is not regard::: 4.5 Endocrine, nutritional, and metabolic ed as a good sign of active infection 19.0 Kidney and urinary tract and its value can be controversial; Z:i 0.2 Male reproductive system 0.5 0.2 this higher antibody prevalence Female reproductive system was not even found by other au0.2 0.0 0.1 0.0 Newborns and Pregnancy, childbirth, other neonates and the puerperium thors [5,6]. 3.7 4.8 Blood and blood-forming organs and immunity We tried to evaluate the real in2.1 1.6 Myeloproliferative disorders 2.5 cidence of strongyloidiasis and Infections and parasitic disorders 2.9 Mental diseases and disorders ii AIDS in Sgo Paulo, Brazil. Some 3:9 3.2 Substance use and abuse reports showedthat 2.4%of the citInjuries, poisonings, and toxic effects of drugs 2.9 izens of Brazil have strongyloides i:: 0.0 Burns 0.2 0.2 in their intestines, as evidenced by Factors influencing health status routine stool examination. Other 100.0% 100.0% authors reported 0.7% of all stool specimens showed strongyloides larvae, again with routine stool jority of cases,a broad spectrum of ACKNOWLEDGMENT tests [7]. Those tests probably disdiseaseswas present for residents’ I am indebted to Mr. Stephen Kowal and Mr. Michael close 40% to 60% of all cases of Anthony for providing the data on hospital admistraining at both institutions. strongyloidiasis as revealed by During the two-year period sions. Baermann’s test [8,9], and it can be 1987-1988, there was no substan- Submitted July 18, 1969, and accepted August 7. assumedthat 1.4% of the popula1969 tial change in the spectrum of distion of Sao Paulo is infected with easesof patients admitted to our strongyloides. There are no data medical center (Table I) other about the prevalence of strongythan an increase in hemodialysis loides in Brazilian patients with admissions, accounting for the AIDS, most of whom are homosexdoubling of MDC 11. Specifically uals. STRONGYLOIDES STERCORALIS in regard to AIDS patients, al- HYPERINFECTION IN THE We followed 100 AIDS patients though the number of admissions ;I ;;FlRE;MMUNODEFlClENCY with three consecutive stool teats for diagnosis-related groups using Baermann’s method, and dis8 (DRGs) 398 and 399 (reticuloendo- To the Editor: covered that 10 had positive findthelial and immunity disorders) in- Strongyloides hyperin- ings for strongyloides larvae. All of stercoralis creased between 1985-1986 (140 fection used to include human im- them were treated with thiabendacases)and 1987-1988 (197 cases), munodeficiency virus (HIV) anti- zole and closely followed; none dethese patients accounted for far body-positive patients in the group veloped systemic strongyloidiasis. lessthan 5% of all medical admis- IV Cl subset, until this condition We also reviewed autopsy protosions. If our hospital is representa- wasdiscontinued in the Centers for cols and histologic material from 99 tive of a large acute-care municipal DiseaseControl criteria for the re- consecutive subjects with AIDS facility, it is a misrepresentation vised definition of acquired immu- and again no systemic strongyloiand misconception to assert that nodeficiency syndrome (AIDS) [I]. diasis was found. This autopsy sesuch hospitals are flooded nearly This was a very rational decision, ries included two of the patients exclusively with AIDS patients. A as until recently no clear-cut cases from our aforementioned series of broad spectrum of diseasesis and of systemic strongyloidiasis had 100 AIDS patients; strongyloides continues to be available for resi- been reported in this patient popu- intestinal infection was diagnosed dent education in internal medi- lation. Pialoux et al [2] described a in these two when they were alive. cine. case of an intestinal infection by We concur with Petithory and FRED ROSNER, M.D., F.A.C.P. strongyloides; Maayan et al (Am J Derouin [3] in that there is no inQueens Hospital Center Affiliation Med 1987; 83: 945-948) reported creasein systemic strongyloidiasis of the Long Island Jewish Medical reported in AIDS patients, so this on one patient with AIDS, filariCenter form larvae in sputum, broncho- parasitosis should not be used to Jamaica, New York pneumonia and sepsis,and no ex- include patients in the AIDS defiand traintestinal S. stercoralis at aunition. We also agree with Maayan Albert Einstein College of Medicine topsy. The only case of et al and Armignacco et al that sysof Yeshiva University Bronx, New York well-documented systemic stron- temic strongyloidiasis should be TABLE I Major Diagnostic Categories (MDC) of Medical Admissions to a Municipal Hospital during a Four-Year Period
602
November
1989
The American
Jour ,nal of Medicine
Volume
87
kept in mind in patients with AIDS when clinical data suggest it, as it is one potentially treatable disease; and strongyloides prophylaxis should be considered as well in these patients, as we routinely do in Brazil in patients undergoing bone marrow transplantation and renal transplantation. The best way to administer rational prophylaxis would be to perform three consecutive Baermann’s tests of the stool to detect positive findings and not to treat everyone routinely; if time is lacking, we would empirically administer prophylaxis in all patients, regardless of the results of routine parasitologic examination.
torio da estrongiloidiase (Strongylodes sfercoralis). 0 Hospital 1952; 41: 11. 9. Hakfm S. Genta R: Fatal disseminated strongyloidiasis in a Vietnam War veteran. Arch Pathol Lab Med 1986: 110: 809. Submitted
May 25, 1989,
and accepted
August 7. 1989
The Reply: In their letter, Neto et al confirm that S. stercoralis hyperinfection rarely occurs in HIV-infected subjects. In fact, only eight casea of this syndrome have been reported in patients with AIDS (Am J Med 1989; 86: 258). Six of them had extraintestinal strongyloidiasis while a disseminated infection developed in two patients, one of whom was a VICENTE A. NETO heterosexual subject from Zaire [l]. JACYR PASTERNAK As we pointed out, the small ANTONIO A. B. MOREIRA number of such cases, also in areas MARIA I. S. DUARTE in which HIV infection and stronRUBENSCAMPOS gyloidiasis are both endemic, quite LUCIA M. A. BRAZ Hospital das Clinicas da Faculdade justifies the exclusion of this helde Medicina da Universidade de minthiasis from the list of opportuE&i0Paul0 nistic infections indicative of AIDS Siio Paula, Brazil [2]. Nevertheless, in view of the very high mortality from the hy1. Revision of the CDC surveillance case definition for perinfection syndrome, HIV-seroacquired immunodeficiency syndrome. MMWR 1987: 36 (1-S): 3s. positive patients should be careful2. Pialoux G, Seriel P. Caudron J. Chousterman M. ly examined for this treatable paraMeyrignac D: Syndrome d’immunodepression acsitosis. In this regard, it is quise associe a une anguillulose severe. Presse Med interesting to remark that, using 1984; 13 1960. 3. Petithory J, Derouin F: AIDS and strongyloidiasis in three Baermann’s tests, Neto et al Africa. Lancet 1987: I: 921. found the prevalence of strongy4. Lucas SB: AIDS in Africa-dinicopathological asloides to be about seven times highpects. Trans R Sot Trop Med Hyg 1988: 82: 801. er in AIDS patients than in the 5. Nakada K, Kohahura M, Komada M. Hinuma Y: High incidence of HTLV-I antibody in carriers of Strop general population in Sao Paulo, g&ides stercoralis. fancet 1984; I: 633. Brazil. Since we have only recently 6. Nova F, Hanchard S, Peter Figueroa J, Blattner W: begun a similar study, sufficient Antibodies to Strongyloides sfercoralis in healthy Jadata on the prevalence of strongymaican carriers of HTLV-I. N Engl J Med 1989; 320: 252. loidiasis among HIV-infected pa7.Coutinho JC, Campos R, Amato Neto V: Nota tients attending our hospital are sobre o diagnostic0 e prevalencia da estrongilodiase not yet available. However, in reem Sao Paulo. Rev Clin Sao Paula 1951; 27: 11. viewing 132 autopsies in AIDS sub8. Coutinho JC, Croce J, Campos R, Amato Neto V: Contribui@o para o estudo do diagndstico de laborajects, we also found no S. stercora-
November
1989
The American
lis hyperinfection apart from the one reported case (Am J Med 1989; 86: 258).
Finally, since strongyloides in Italy is more common in the rural areas [3] and homosexual men account for less than 17% of AIDS cases, we do not see the necessity of treating HIV-seropositive patients without proved strongyloidiasis. OawDo ARMIONACC~, M.D. OspedaleLazzaro Spallanzani 00149Rome, Italy 1. Piot P. Taelman H. Minlanau KB. et at Acouired immunodeficiency syndrome 1’1 a heterosexual population in Zaire. Lancet 1984; II: 6569. 2. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MMWR 1987; 36 (1s): 3S-15s. 3. ScaeJia M. Brustfa R. Gatti S. et ab Autochthonous stron&oidiasis in Italy: an epidemiological and clinical review of 150 cases. Bull Sot Pathol Exp 1984; 77: 328-332.
CORRECTION In the August 16,1989 supplement entitled Proceedings of a Symposium-clinical Settings for Selective Alpha-Adrenergic Receptor Inhibition: Rationale and Management Strategies, praxosin hy-
drochloride capsules (Minipress@) were incorrectly identified as Minipress XL in the first sentence of the article “Efficacy and Safety of Minipress XL, a New Once-a-Day Formulation of Praxosin” by Singleton et al (page 2A-455). Praxosin in the GITS formulation (Minipress XL) is currently approved in France and awaiting Food and Drug Administration approval in the United States.
Journal
of Medlclne
Volume
87
603