Brief report
Strongyloidiasis in immigrants in Southern Spain
Strongyloidiosis en inmigrantes en el sur de España
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Teresa" "apellidos" => "Cabezas-Fernández" "email" => array:2 [ 0 => "tcabezasf@yahoo.es" 1 => "mariateresa.cabezas@ephpo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Joaquin" "apellidos" => "Salas-Coronas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Ana Belen" "apellidos" => "Lozano-Serrano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Jose" "apellidos" => "Vazquez-Villegas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "M. Isabel" "apellidos" => "Cabeza-Barrera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Fernando" "apellidos" => "Cobo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Microbiology-Medicine Tropical Unit, Public Health Agency Business Poniente Hospital, Almería, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Medicine Tropical Unit, Public Health Agency Business Poniente Hospital, Almería, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Strongyloidiosis en inmigrantes en el sur de España" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Strongyloidiasis is a helminthic infection caused by <span class="elsevierStyleItalic">Strongyloides stercoralis</span>, a nematode ubiquitous in tropical and subtropical countries including Africa, Southeast Asia, and Latin-America<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and occasionally reported in temperate countries, including Spain.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> The estimated prevalence of strongyloidiasis is around 50–100 million infections worldwide, although the accuracy of these estimates is uncertain due to poor sensitivity of screening methods.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S. stercoralis</span> is unique in its ability to replicate in the human host, permitting on-going cycles of auto-infection that can persist for decades without further exposure to exogenous infection.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Disease spectrum for strongyloidiasis includes acute infection with Loeffler's syndrome, chronic intestinal infection, asymptomatic auto-infection, symptomatic auto-infection, and hyper-infection syndrome with massive dissemination through the bloodstream,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> particularly in patients with HTLV-1 or HIV infection, or on steroid medication and other immunosuppressive drugs, such as organ transplant recipients.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Several diagnostic methods have been compared to detect the presence of <span class="elsevierStyleItalic">S. stercoralis</span> including stool examination, stool culture, polymerase chain reaction (PCR) and specific antibodies detection.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">As immigrant population and international travels continue to increase, imported tropical diseases are becoming more frequent in developed countries. In order to preclude the re-emergence of strongyloidiasis in such areas as the Mediterranean one, where transmission is rare but possible, screening may be recommended. In contrast, to prevent hyper-infection syndromes among immunosuppressed immigrants or previous to the administration of immunosuppressive therapies (i.e. pre-transplantation), early diagnosis and treatment is mandatory.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The objective of our study is to analyse the clinical and epidemiological characteristics of migrants patients diagnosed with strongyloidiasis in our area.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">We undertook an observational study analysing retrospectively the epidemiological and clinical characteristics, microbiological findings, and outcome of those patients with strongyloidiasis who attended the Tropical Medicine Unit of the Poniente Hospital in Almeria (Spain), from April 2004 to May 2012. This Unit serves as the health care reference centre for an area of nearly 300,000 inhabitants, where close to 30% of the population are migrants from low rent countries.</p><p id="par0040" class="elsevierStylePara elsevierViewall">All migrants from endemic areas referred to the clinic were studied in order to rule out <span class="elsevierStyleItalic">S. stercoralis</span> infection by means of parasite search in stool smears from 3 stool samples (direct stool examination and/or faeces larvae culture) and serology, although not every patient was studied with all three techniques. Parasite stool culture was undertaken following each patient's attending physician criteria. Diagnosis of strongyloidiasis was considered when any of these three tests yielded a positive result.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Diagnosis of strongyloidiasis was made by detection of rhabditiform larvae in stool (3 stool samples examined by light microscopy using formalin-ethyl acetate concentration techniques), detection of forked tailed filariform larvae in a culture with charcoal Dancescu, or detection of specific <span class="elsevierStyleItalic">Strongyloides</span> IgG antibodies (ELISA kit PALEX Medical SA, Ref EIA-4208, DRG Diagnostics, Germany).</p><p id="par0050" class="elsevierStylePara elsevierViewall">Demographic data were obtained from patients’ clinical history and statistical analysis was performed using SSPS 15.0 program, using mean and standard deviation as central tendency and dispersion measurements respectively.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">During the study period, 1384 immigrant patients have been evaluated in this Unit, of which 320 (23%) have been diagnosed with <span class="elsevierStyleItalic">S. stercoralis</span> infection. Most patients attended in our Tropical Medicine Unit were referred from Primary Health Care Institutions (67%). Patients’ regions of origin were sub-Saharan Africa (89%), Maghreb (4.7%) and Latin America (6.3%). HIV infected patients were excluded from the study and attended in a specific clinic.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Medical records of all patients were reviewed and epidemiological and clinical and analytical data registered. Data are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. One hundred and thirty-one (42.3%) patients reported symptoms, mainly gastrointestinal complaints such as abdominal pain (38.4%) or diarrhoea (2.3%), and pruritus (2%).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Forty-five percent (144) of patients with strongyloidiasis had eosinophilia (≥500<span class="elsevierStyleHsp" style=""></span>cells/μL) at first visit.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Mean absolute eosinophil count was 713.85<span class="elsevierStyleHsp" style=""></span>cells/μL (SD 842.5), mean serum IgE 1572<span class="elsevierStyleHsp" style=""></span>UI/mL (SD 2981.5) and mean haemoglobin 14.5<span class="elsevierStyleHsp" style=""></span>mg/dL (SD 1.74).</p><p id="par0075" class="elsevierStylePara elsevierViewall">Other parasitises was frequent, with a total of 142 (44%) patients infected with other parasites besides <span class="elsevierStyleItalic">Strongyloides</span>. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows concurrent parasitosis total figures.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The results of the various diagnostic tests performed are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Human T-lymphotropic virus type 1 (HTLV-1) infection was tested in six patients with persistent disease despite a correct treatment, being positive in one of them.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Standard treatment was Ivermectin, 200<span class="elsevierStyleHsp" style=""></span>μg/kg/day divided in 2 doses, for 2 consecutive days.</p><p id="par0095" class="elsevierStylePara elsevierViewall">For patients with persistent infection, including that one patient with HTLV-1 infection, same treatment was re-administered. Patients were considered cured based on the disappearance of symptoms and/or eosinophilia. In those patients in whom larvae were visualised in stool samples or with a positive coproculture, a negative result of these tests was found in later controls. During last year, serological response to treatment was monitored in 20 patients (6.25%), confirming significant falling of even negativization of antibodies in 19 of them.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Strongyloidiasis is a major global health challenge underestimated in many countries. It remains as an important helminthic disease due to increases in travel and migration from endemic countries.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Twenty-two percent of all patients treated in our Unit have been diagnosed with strongyloidiasis, with a mean time of residence in Spain of 48.11 months (range 1–256), many having been living in Spain for years, reflecting the potential of <span class="elsevierStyleItalic">S. stercoralis</span> for causing persistent infection and becoming an emerging disease.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Diagnosis of <span class="elsevierStyleItalic">S. stercoralis</span> may be missed when not specifically sought and it is often delayed due to patients presenting with non-specific gastrointestinal complaints. Only 42.3% of our patients reported symptoms associated with chronic infection, mainly abdominal pain (38.4%). Peripheral eosinophilia may often be the first hint of a parasitic infection,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> however, less than 50% of our patients had eosinophilia. Eosinophilia is an inconstant finding in <span class="elsevierStyleItalic">S. stercoralis</span> infection and may fluctuate in different degrees.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Besides, eosinophilia is an unspecific finding as may be due to other helminthic parasitosis.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Due to a low parasite load and irregular larval output, multiple stool sample tests are required for accurate diagnosis (being a single sample positive in only 30–50% of cases).<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,9</span></a> In our study, <span class="elsevierStyleItalic">S. stercoralis</span> larvae in stool samples were found in only 22.9% of patients. Multiple repeated stool studies and other techniques are needed to improve sensitivity but these are more laborious, time consuming and expensive.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Owing to the technical difficulties for detecting <span class="elsevierStyleItalic">Strongyloides</span> larvae in stool, serologic tests using crude parasite antigens have been increasingly used for diagnosis, with a reported sensitivity of 83–93%. In our study, 93.4% of the patients had positive serologic results, although 33 patients, in whom larvae were detected in faeces, had a negative serology. On the other hand, specificity of serology is dubious when used among samples of polyparasited individuals, like in our study, because false positive results due to cross-reactions with other nemathelminthes infections might occur.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Recently, it has been advocated that serological studies should be done to assure clearance of infection at 6 and 12 months<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> after treatment. Although there is no test of cure currently available, IgG antibody levels decrease markedly within 6 months of successful treatment, and DNA-based diagnosis have lately been shown to hold promise as a proof-of-cure technique.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Throughout the last year, we have also evaluated the response to treatment by serological monitoring, confirming loss of antibodies in all 20 patients studied.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Our study has some limitations. The sample comprised mainly patients from sub-Saharan Africa, raising the question about the possibility of our results not being valid for migrants coming from other geographic areas. Second, the above mention lack of specificity of serologic tests when used among polyparasited individuals; in our series, polyparasited patients comprised 44% of the patients, so false positive cross-reactions should be taken into account. Third, not all three diagnostic techniques – direct stool examination, faeces larvae culture, and specific serology – were performed in every patient. If such were the case, the number of patients diagnosed with <span class="elsevierStyleItalic">Strongyloides</span> infection would surely be greater and we could also had been able to compare diagnostic sensitivity between the three different techniques.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0135" class="elsevierStylePara elsevierViewall">Strongyloidiasis may be a silent infection or present with vague symptoms and no specific laboratory findings. In our study, we have searched for <span class="elsevierStyleItalic">Strongyloides</span> infection in all migrants attended at our Unit during a period of eight years, irrespective of the reason they consulted for, finding a significant 23% of migrants being infected by <span class="elsevierStyleItalic">S. stercoralis</span>. Out of these 320 infected patients, only 42.3% reported symptoms related to strongyloidiasis, such as gastrointestinal complaints, and less than 50% showed eosinophilia in the first visit blood test.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Health professionals in developed countries who care for patients from endemic areas, or for patients who have travelled to these areas, must therefore, try to rule out the presence of <span class="elsevierStyleItalic">Strongyloides</span> infection, especially in patients presenting with eosinophilia or unspecific gastrointestinal or pulmonary symptoms and mandatorily, in all HIV infected patients or patients receiving corticosteroid therapy, organ transplantation, or any other type of immunosuppression.</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres847526" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec842445" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres847525" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec842446" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0125" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-11-22" "fechaAceptado" => "2014-06-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec842445" "palabras" => array:4 [ 0 => "Strongyloidiasis" 1 => "HTLV" 2 => "Immigrants" 3 => "Immunocompromised" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec842446" "palabras" => array:4 [ 0 => "Strongyloidiosis" 1 => "HTLV" 2 => "Inmigrantes" 3 => "Inmunosupresión" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyse clinical and epidemiological characteristics of immigrant patients diagnosed with strongyloidiasis in our area.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">An analyse was performed on patients with strongyloidiasis seen in the Tropical Medicine Unit of the “Hospital de Poniente” in Almeria (Spain), from April 2004 to May 2012.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 320 patients were diagnosed with <span class="elsevierStyleItalic">Strongyloides stercoralis</span> infection, and 284 out of 314 patients (90.4%) had a positive specific serology. Forty-two percent of the patients reported symptoms and 45% had eosinophilia. The serological results were monitored in some of the patients, confirming a loss of antibodies in all 20 patients studied.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Strongyloidiasis is a parasitic disease increasingly diagnosed in developed countries due to increased migratory flows from endemic areas. Often being asymptomatic, its diagnosis and treatment may prevent fatal outcomes, especially in immunocompromised patients.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analizar las características clínicas y epidemiológicas de los pacientes inmigrantes diagnosticados de strongyloidiasis en nuestra área.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se analizaron retrospectivamente los pacientes con strongyloidiasis que acudieron a la Unidad de Medicina Tropical del Hospital de Poniente de Almería (España), entre abril de 2004 mayo de 2012.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">320 pacientes han sido diagnosticados con infección por <span class="elsevierStyleItalic">S. stercoralis</span>, 284/314 pacientes (90,4%) tenían una serología específica positiva. 42,3% de los pacientes presentaron síntomas y el 45% de los pacientes tenían eosinofilia. La monitorización del tratamiento confirmó la pérdida de anticuerpos en los 20 pacientes estudiados.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La estrongiloidiasis es una parasitosis diagnosticada cada vez con más frecuencia en países desarrollados debido al aumento de los movimientos migratorios procedentes de zonas endémicas. Siendo a menudo asintomática, su diagnóstico y tratamiento pueden prevenir resultados fatales.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Gender, N (%)</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">271 (85) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 (15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Age (years)</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean (range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31.3 (13–71) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Area of origin, N (%)</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sub-Saharan Africa \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">285 (89) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Latin America \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (6.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Maghreb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (4.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Administrative status, N (%)</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Regular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">127 (39.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Irregular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">193 (60.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Reason for referral, N (%)</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Abdominal pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">118 (36.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Eosinophilia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88 (27.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Liver disorders \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (11.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diarrhoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (2.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pruritus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (1.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 (19.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Laboratory tests (1st visit), mean (range)</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Eosinophils (cells/μL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">713.85 (5–10.361) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hb (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.54 (6.9–18.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IgE (UI/mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.572 (236–36.333) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Other concurrent parasitosis, N (%)</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Hookworms</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80 (25) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Blastocystis hominis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 (20.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Entamoeba hystolitica/dispar</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 (12.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Mansonella perstans</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (11.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Schistosoma haematobium</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Plasmodium falciparum</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11(3.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Giardia lamblia</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (2.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Trichuris trichuria</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (2.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Schistosoma mansoni</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (1.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Ascaris lumbricoides</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Trypanosoma cruzi</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1430661.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Characteristics of the patients (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>320).</p>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Serologic test (ELISA) was performed in 314 patients (98.1%). Results were positive in 284 patients (90.4%).</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Direct stool examination was performed in 293 patients (91.6%). Results were positive in 67 patients (22.9%).</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Faeces larvae culture was performed in 51 patients (15.9%). Results were positive in 19 patients (37.3%).</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Method of diagnosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. patients (total: 320) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Positive ELISA only \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">238 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Positive ELISA<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>positive direct stool examination \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Positive ELISA<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>positive faeces larvae culture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Positive ELISA<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>positive direct stool examination<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>positive faeces larvae culture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Positive direct stool examination only \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Positive direct stool examination<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>positive faeces larvae culture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Positive faeces larvae culture only \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1430662.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Diagnostic tests used for <span class="elsevierStyleItalic">Strongyloides</span> infection diagnosis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Strongyloidiasis – the most neglected of the neglected tropical diseases?" 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 11 | 1 | 12 |
| 2024 September | 26 | 3 | 29 |
| 2024 August | 26 | 1 | 27 |
| 2024 July | 18 | 2 | 20 |
| 2024 June | 9 | 7 | 16 |
| 2024 May | 16 | 4 | 20 |
| 2024 April | 15 | 3 | 18 |
| 2024 March | 23 | 8 | 31 |
| 2024 February | 18 | 3 | 21 |
| 2024 January | 19 | 4 | 23 |
| 2023 December | 31 | 3 | 34 |
| 2023 November | 18 | 4 | 22 |
| 2023 October | 14 | 4 | 18 |
| 2023 September | 14 | 1 | 15 |
| 2023 August | 16 | 3 | 19 |
| 2023 July | 12 | 4 | 16 |
| 2023 June | 20 | 6 | 26 |
| 2023 May | 16 | 2 | 18 |
| 2023 April | 8 | 6 | 14 |
| 2023 March | 14 | 7 | 21 |
| 2023 February | 19 | 9 | 28 |
| 2023 January | 21 | 7 | 28 |
| 2022 December | 19 | 12 | 31 |
| 2022 November | 40 | 6 | 46 |
| 2022 October | 19 | 17 | 36 |
| 2022 September | 23 | 15 | 38 |
| 2022 August | 19 | 9 | 28 |
| 2022 July | 12 | 11 | 23 |
| 2022 June | 22 | 6 | 28 |
| 2022 May | 21 | 9 | 30 |
| 2022 April | 31 | 15 | 46 |
| 2022 March | 40 | 11 | 51 |
| 2022 February | 35 | 7 | 42 |
| 2022 January | 36 | 10 | 46 |
| 2021 December | 19 | 14 | 33 |
| 2021 November | 28 | 10 | 38 |
| 2021 October | 20 | 20 | 40 |
| 2021 September | 15 | 10 | 25 |
| 2021 August | 19 | 8 | 27 |
| 2021 July | 20 | 16 | 36 |
| 2021 June | 34 | 13 | 47 |
| 2021 May | 46 | 12 | 58 |
| 2021 April | 67 | 23 | 90 |
| 2021 March | 48 | 13 | 61 |
| 2021 February | 47 | 16 | 63 |
| 2021 January | 39 | 19 | 58 |
| 2020 December | 25 | 6 | 31 |
| 2020 November | 29 | 13 | 42 |
| 2020 October | 22 | 4 | 26 |
| 2020 September | 31 | 19 | 50 |
| 2020 August | 31 | 16 | 47 |
| 2020 July | 23 | 18 | 41 |
| 2020 June | 16 | 19 | 35 |
| 2020 May | 40 | 13 | 53 |
| 2020 April | 20 | 16 | 36 |
| 2020 March | 26 | 14 | 40 |
| 2020 February | 20 | 21 | 41 |
| 2020 January | 20 | 14 | 34 |
| 2019 December | 35 | 18 | 53 |
| 2019 November | 28 | 10 | 38 |
| 2019 October | 24 | 10 | 34 |
| 2019 September | 18 | 14 | 32 |
| 2019 August | 28 | 13 | 41 |
| 2019 July | 35 | 22 | 57 |
| 2019 June | 60 | 23 | 83 |
| 2019 May | 148 | 20 | 168 |
| 2019 April | 66 | 21 | 87 |
| 2019 March | 18 | 5 | 23 |
| 2019 February | 32 | 13 | 45 |
| 2019 January | 16 | 11 | 27 |
| 2018 December | 17 | 12 | 29 |
| 2018 November | 28 | 4 | 32 |
| 2018 October | 28 | 4 | 32 |
| 2018 September | 28 | 4 | 32 |
| 2018 August | 24 | 3 | 27 |
| 2018 July | 34 | 2 | 36 |
| 2018 June | 35 | 4 | 39 |
| 2018 May | 22 | 1 | 23 |
| 2018 April | 31 | 4 | 35 |
| 2018 March | 23 | 2 | 25 |
| 2018 February | 24 | 1 | 25 |
| 2018 January | 32 | 5 | 37 |
| 2017 December | 15 | 3 | 18 |
| 2017 November | 18 | 3 | 21 |
| 2017 October | 28 | 4 | 32 |
| 2017 September | 19 | 1 | 20 |
| 2017 August | 31 | 4 | 35 |
| 2017 July | 20 | 5 | 25 |
| 2017 June | 34 | 10 | 44 |
| 2017 May | 29 | 3 | 32 |
| 2017 April | 42 | 6 | 48 |
| 2017 March | 43 | 7 | 50 |
| 2017 February | 31 | 6 | 37 |
| 2017 January | 29 | 0 | 29 |
| 2016 December | 56 | 13 | 69 |
| 2016 November | 55 | 6 | 61 |
| 2016 October | 76 | 16 | 92 |
| 2016 September | 50 | 2 | 52 |
| 2016 August | 41 | 9 | 50 |
| 2016 July | 56 | 7 | 63 |
| 2016 June | 56 | 1 | 57 |
| 2016 May | 47 | 3 | 50 |
| 2016 April | 28 | 2 | 30 |
| 2016 March | 59 | 9 | 68 |
| 2016 February | 47 | 17 | 64 |
| 2016 January | 53 | 19 | 72 |
| 2015 December | 59 | 20 | 79 |
| 2015 November | 38 | 15 | 53 |
| 2015 October | 49 | 21 | 70 |
| 2015 September | 42 | 17 | 59 |
| 2015 August | 60 | 15 | 75 |
| 2015 July | 35 | 13 | 48 |
| 2015 June | 29 | 5 | 34 |
| 2015 May | 38 | 15 | 53 |
| 2015 April | 44 | 21 | 65 |
| 2015 March | 36 | 26 | 62 |
| 2015 February | 65 | 47 | 112 |
| 2015 January | 67 | 76 | 143 |
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