Scientific letter
Recurrent meningitis associated to Strongyloides hyperinfection
Meningitis recurrente asociada a hiperinfección por Strongyloides
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"https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X1830404X?idApp=UINPBA00004N" "url" => "/0213005X/0000003700000010/v1_201911290911/S0213005X1830404X/v1_201911290911/es/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Recurrent meningitis associated to <span class="elsevierStyleItalic">Strongyloides</span> hyperinfection" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "683" "paginaFinal" => "684" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Inês Pintado Maury, Diana Neves, Aida Pereira" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Inês" "apellidos" => "Pintado Maury" "email" => array:1 [ 0 => "ines.pintadomaury@gmail.com" ] "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" => "Diana" "apellidos" => "Neves" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Aida" "apellidos" => "Pereira" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Centro Hospitalar Lisboa Norte, Hospital Santa Maria, Department of Infectious Diseases, Lisbon, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Lisbon University, Medicine Faculty, Lisbon, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Meningitis recurrente asociada a hiperinfección por <span class="elsevierStyleItalic">Strongyloides</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 570 "Ancho" => 1250 "Tamanyo" => 175542 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Jejunum and duodenum segmentary changes: villous atrophy and edema, mucosal stripping, ulcers and stenosis. Visualization of the parasite <span class="elsevierStyleItalic">Strongyloides stercoralis.</span> (B) Various eggs and larvae morphologically compatible with <span class="elsevierStyleItalic">Strongyloides stercoralis</span> (H&E, 400×).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Strongyloides stercoralis</span> is an intestinal nematode endemic in tropical areas with high public health impact.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a> In Europe, sporadic cases of local infection have been reported in countries like Spain.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a> Exposure to contaminated soils with larvae leads to its penetration into the human skin and venous system.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> It is known to cause a persistent autoinfection in the host, regulated by the Th2 immune response, mediated by interleukins and IgE, which confers protection against hyperinfection.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Severe strongyloidiasis cases with autoinfection occur when immunity is impaired with consequent increase of larvae burden.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Consequently the parasites cross the intestinal wall, causing a hyperinfection syndrome (HIS) or disseminated strongyloidiasis with high mortality rate.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Carriage of Gram negative bacteria through the intestine along with the larvae or through bowel ulcers is a frequent complication, with consequent septic shock and meningitis.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Human T-cell leukemia virus type 1 (HTLV-1), a retrovirus with clusters of high endemicity around the world,<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7–9</span></a> and strongyloidiasis have been associated.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> Infection of T cells lymphocytes leads to an altered humoral immunity response with decreased immunoglobulin secretion.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a> Other HTLV-1-associated diseases such as lymphoproliferative, autoimmune disorders T-cell leukemia, tropical spastic paraparesis and uveitis, and opportunistic infections<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> have been described.</p><p id="par0015" class="elsevierStylePara elsevierViewall">It is important to recognize the risk of strongyloidiasis and HTLV-1 co-infection among the immigrant population<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,10</span></a> in order to prevent severe complications.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical case</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 53-year-old Brazilian man, living in Portugal for 15 years, with previous history of bacterial meningitis (six months before) without microbiological identification, treated with ampicillin, ceftriaxone, vancomycin and corticosteroids.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was admitted with the hypothesis of a bacterial meningitis (CSF<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>1000 polymorphonuclears, 413<span class="elsevierStyleHsp" style=""></span>mg/dL proteins and hypoglycorrhachia 4<span class="elsevierStyleHsp" style=""></span>mg/dL). Antibiotherapy with ampicillin plus ceftriaxone and dexamethasone (10<span class="elsevierStyleHsp" style=""></span>mg every 6<span class="elsevierStyleHsp" style=""></span>h) were started with initial clinical improvement. Gram stain and cultures were negative. After 14 days of admission fever, headache and neck stiffness were noticed with high CSF polymorphonuclears count and hypoglycorrhachia. Assuming a nosocomial meningitis, meropenem and vancomycin were initiated. After <span class="elsevierStyleItalic">Enterococcus faecium</span> isolation in the CSF, meropenem was suspended. Considering the anemia and recurrent meningitis, further investigation was done: negative HIV screening, CD4 T cell count 324<span class="elsevierStyleHsp" style=""></span>cells/mm<span class="elsevierStyleSup">3</span> (38%) with lymphocytes 840<span class="elsevierStyleHsp" style=""></span>cells/mm<span class="elsevierStyleSup">3</span>, positive HTLV-1 serology, negative neoplastic screening. Myelogram showed increased eosinophils (14%) with peripheral eosinophils 270<span class="elsevierStyleHsp" style=""></span>cells/mm<span class="elsevierStyleSup">3</span>. Small bowel enteroscopy showed jejunum and duodenum segmentary changes with scalloping areas (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The biopsy revealed an infectious enteritis with several eggs and larvae suggestive of <span class="elsevierStyleItalic">S. stercoralis</span> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Stool culture was negative. Stool examination identified rare larvae of <span class="elsevierStyleItalic">S. stercolaris</span> and treatment with albendazole for 10 days was prescribed, followed by another cycle one week after, while waiting for evermectine pharmacy approval. <span class="elsevierStyleItalic">Strongyloides</span> serology was not available.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">The presented case concerns a man with recurrent bacterial meningitis episodes without any apparent immunosuppression. Investigation revealed strongyloidiasis and HTLV-1 infection.</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S. stercoralis</span> is endemic in Brazil, where the patient was born; nevertheless is frequently neglected in industrialized countries, leading to recurrent and severe Gram negative bacterial infections.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Epidemiological European studies about HTVL-1 are scarce, reporting infection mostly in blood donors and pregnant women, as they are mostly tested. In Portugal HTLV-1 seropositivity is related to African or South American migrants.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> There is no specific therapy or chemoprophylaxis for HTLV-1; prevention and counseling about transmition routes have been the base the past years.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A correlation between HTLV-1 and strongyloidiasis has been shown, with a high percentage of <span class="elsevierStyleItalic">S. stercoralis</span> carriers also infected with HTLV-1. Studies in São Paulo demonstrated an immunological impairment in co-infected individuals with more severe HIS cases.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> This could be explained by the fact that by infecting T cells lymphocytes, HTLV-1 alters the humoral immunity with an increase of Th1-type (INF-γ and TNF-α) and decrease of Th2-type (IL-4 and IL-10) responses. A decreased IgE secretion, required to the parasitic infection control is observed,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7,10</span></a> contributing to severe helminthic infections.</p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S. stercoralis</span>, when associated with immunosuppression, has the ability of acting as an opportunistic agent. Severe strongyloidiasis cases associated to short courses of corticotherapy have been reported.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Our patient, presented a strongyloidiasis and HTLV-1 infection with a probable impaired Th2 response, that together could justify the recurrent meningitis episodes. Therapy with dexametasone during admission was a major trigger to larvae burden increase and to a nosocomial meningitis episode.</p><p id="par0060" class="elsevierStylePara elsevierViewall">This case highlights the aspects of two infectious diseases mostly neglected in developed countries and how they can influence the development of a life-threatening disease.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Although we have been observing an increased knowledge about these pathogens, routine screening guidelines are not established. Imunossupressed patients who present a high risk of exposure to <span class="elsevierStyleItalic">S. stercoralis</span> (who have visited or native from endemic areas) should be screened for strongyloidiasis. Individuals starting immunussupressive drugs or chemotherapy are at risk and eosinophil levels, stool examination and serology should be done. Risk categories should be established and European guidelines created due to recent incidence increase in Europe, mostly due to migration. Migrants at risk with previous hyperinfection syndrome should be investigated for immunosuppressive conditions, including HTLV-1.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest and did not receive any financial support. All authors contributed equally to this article. The authors followed their institutions’ protocols to access patient's data, with the unique purpose of scientific investigation and disclosure. All necessary ethical approval and consents were followed.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical case" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:2 [ "identificador" => "xack435752" "titulo" => "Acknowledgements" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 570 "Ancho" => 1250 "Tamanyo" => 175542 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Jejunum and duodenum segmentary changes: villous atrophy and edema, mucosal stripping, ulcers and stenosis. Visualization of the parasite <span class="elsevierStyleItalic">Strongyloides stercoralis.</span> (B) Various eggs and larvae morphologically compatible with <span class="elsevierStyleItalic">Strongyloides stercoralis</span> (H&E, 400×).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Case report: five cases of recurrent meningitis associated with chronic strongyloidiasis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T. Shimasaki" 1 => "H. Chung" 2 => "S. 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Cassar" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Front Microbiol" "fecha" => "2012" "volumen" => "15" "paginaInicial" => "388" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Meningitis associated with strongyloidiasis in an area endemic for strongyloidiasis and human T-lymphotropic virus-1: a single-center experience in Japan between 1990 and 2010" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. Sasaki" 1 => "T. Taniguchi" 2 => "M. Kinjo" 3 => "R.L. McGill" 4 => "A.T. McGill" 5 => "S. Tsuha" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s15010-013-0483-2" "Revista" => array:6 [ "tituloSerie" => "Infection" "fecha" => "2013" "volumen" => "41" "paginaInicial" => "1189" "paginaFinal" => "1193" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23761268" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack435752" "titulo" => "Acknowledgements" "texto" => "<p id="par0075" class="elsevierStylePara elsevierViewall">The authors would like to thank all medical doctors from the Infectious Disease Department for the fruitful discussion concerning this case investigation, Dr. Narcisa Fatela and Dr. Carolina Simões from the Gastroenterology Department who helped us reviewing all gastric exam images to achieve the final diagnosis.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The authors would like to thank Dr. Catarina Quadros and Dr. Emília Vitorino from the Department of Pathology, whose work was essential to achieve the anatomopathological diagnosis.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/0213005X/0000003700000010/v1_201911290911/S0213005X19300102/v1_201911290911/en/main.assets" "Apartado" => array:4 [ "identificador" => "8590" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas científicas" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/0213005X/0000003700000010/v1_201911290911/S0213005X19300102/v1_201911290911/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X19300102?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 9 | 5 | 14 |
| 2024 September | 27 | 17 | 44 |
| 2024 August | 36 | 5 | 41 |
| 2024 July | 24 | 15 | 39 |
| 2024 June | 25 | 7 | 32 |
| 2024 May | 15 | 9 | 24 |
| 2024 April | 25 | 14 | 39 |
| 2024 March | 37 | 29 | 66 |
| 2024 February | 25 | 13 | 38 |
| 2024 January | 21 | 14 | 35 |
| 2023 December | 18 | 15 | 33 |
| 2023 November | 17 | 19 | 36 |
| 2023 October | 26 | 21 | 47 |
| 2023 September | 16 | 21 | 37 |
| 2023 August | 13 | 9 | 22 |
| 2023 July | 25 | 102 | 127 |
| 2023 June | 31 | 38 | 69 |
| 2023 May | 37 | 1 | 38 |
| 2023 April | 53 | 2 | 55 |
| 2023 March | 40 | 1 | 41 |
| 2023 February | 26 | 6 | 32 |
| 2023 January | 21 | 2 | 23 |
| 2022 December | 21 | 11 | 32 |
| 2022 November | 40 | 25 | 65 |
| 2022 October | 33 | 20 | 53 |
| 2022 September | 43 | 17 | 60 |
| 2022 August | 33 | 27 | 60 |
| 2022 July | 25 | 16 | 41 |
| 2022 June | 26 | 30 | 56 |
| 2022 May | 43 | 29 | 72 |
| 2022 April | 37 | 19 | 56 |
| 2022 March | 45 | 14 | 59 |
| 2022 February | 44 | 6 | 50 |
| 2022 January | 58 | 7 | 65 |
| 2021 December | 36 | 6 | 42 |
| 2021 November | 41 | 13 | 54 |
| 2021 October | 46 | 19 | 65 |
| 2021 September | 38 | 7 | 45 |
| 2021 August | 83 | 11 | 94 |
| 2021 July | 37 | 12 | 49 |
| 2021 June | 17 | 7 | 24 |
| 2021 May | 27 | 8 | 35 |
| 2021 April | 82 | 31 | 113 |
| 2021 March | 53 | 23 | 76 |
| 2021 February | 32 | 13 | 45 |
| 2021 January | 34 | 23 | 57 |
| 2020 December | 27 | 15 | 42 |
| 2020 November | 33 | 6 | 39 |
| 2020 October | 37 | 6 | 43 |
| 2020 September | 72 | 13 | 85 |
| 2020 August | 38 | 22 | 60 |
| 2020 July | 23 | 6 | 29 |
| 2020 June | 15 | 12 | 27 |
| 2020 May | 3 | 3 | 6 |
| 2020 April | 0 | 1 | 1 |
| 2020 March | 9 | 2 | 11 |
| 2020 February | 1 | 2 | 3 |
| 2020 January | 7 | 7 | 14 |
| 2019 December | 61 | 68 | 129 |
| 2019 November | 2 | 2 | 4 |
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