Donor-Derived Strongyloides stercoralis Infections in Renal Transplant Recipients

TitleDonor-Derived Strongyloides stercoralis Infections in Renal Transplant Recipients
Publication TypeJournal Article
Year of Publication2011
AuthorsHamilton KW, Abt PL, Rosenbach MA, Bleicher MB, Levine MS, Mehta J, Montgomery SP, Hasz RD, Bono BR, Tetzlaff MT, MildinerEarly S, Introcaso CE, Blumberg EA
Date PublishedMay 15
Accession Number00007890-201105150-00013
KeywordsClinical Medicine, Donor-derived infection, Hyperinfection syndrome, Life & Biomedical Sciences., Renal transplant, Steroid preconditioning., Strongyloidiasis

Background. Donor-derived Strongyloides stercoralis infection occurs rarely after transplantation, and the risk factors are not well understood. We present cases of two renal allograft recipients who developed Strongyloides hyperinfection syndrome after receipt of organs from a common deceased donor who received high-dose steroids as part of a preconditioning regimen. Methods. The two renal transplant patients who developed Strongyloides hyperinfection syndrome are reported in case study format with review of the literature. Results. Microscopic examination of stool from one renal transplant patient and of tracheal and gastric aspirates from the other transplant patient revealed evidence of S. stercoralis larvae. Retrospective testing of serum from the deceased donor for Strongyloides antibodies by enzyme-linked immunosorbent assay was positive at 11.7 U/mL (Centers for Disease Control reference >1.7 U/mL positive). One patient was treated successfully with oral ivermectin. The other patient also had complete resolution of strongyloidiasis, but required a course of parenteral ivermectin because of malabsorption from severe gastrointestinal strongyloidiasis. Conclusions. These case studies provide some of the best evidence of transmission of S. stercoralis by renal transplantation. Because of the high risk of hyperinfection syndrome and its associated morbidity and mortality, high-risk donors and recipients should be screened for Strongyloides infection, so that appropriate treatment can be initiated before the development of disease. This study indicates that parenteral ivermectin can be used safely and effectively in patients in whom severe malabsorption would preclude the effective use of oral formulation. These cases also suggest that reconsideration should be given for the safety of steroids in donor-preconditioning regimens. (C) 2011 Lippincott Williams & Wilkins, Inc.; References: 1. Kitchen LW, Tu KK, Kerns FT. Strongyloides-infected patients at Charleston area medical center, West Virginia, 1997-1998. Clin Infect Dis 2000; 31: E5. 2. Mandell GL, Bennett JE, Dolin R. Mandell, Douglas, and Bennett's principles and practice of infectious diseases [ed. 7]. Philadelphia: Churchill Livingstone; 2010, pp 3582. 3. Roxby AC, Gottlieb GS, Liaye AP. Strongyloidiasis in transplant patients. Clin Infect Dis 2009; 49: 1411. 4. Keiser PB, Nutman TB. Strongyloides stercoralis in the immunocompromised population. Clin Microbiol Rev 2004; 17: 208. 5. Rodriguez-Hernandez MJ, Ruiz-Perez-Pipaon M, Canas E, et al. Strongyloides stercoralis hyperinfection transmitted by liver allograft in a transplant recipient. Am J Transplant 2009; 9: 2637. 6. Hoy WE, Robers NJ, Bryson MF, et al. Transmission of strongyloidiasis by kidney transplant? Disseminated strongyloidiasis in both recipients of kidney allografts from a single cadaver donor. JAMA 1981; 246: 1937. 7. Valar C, Keitel E, Dal Pra RL. Parasitic infection in renal transplant recipients. Transplant Proc 2007; 39: 460. 8. Vilela EG, Clemente WT, Mira RR, et al. Strongyloides stercoralis hyperinfection syndrome after liver transplantation: Case report and literature review. Transpl Infect Dis 2009; 11: 132. 9. Ben-Youssef B, Baron P. Strongyloides stercoralis infection from pancreas allograft. Transplantation 2005; 80: 997. 10. Rosendale JD, Kauffman HM, McBride MA, et al. Aggressive pharmacologic donor management results in more transplanted organs. Transplantation 2003; 75: 482. 11. Rosendale JD, Kauffman HM, McBride MA, et al. Hormonal resuscitation yields more transplanted hearts, with improved early function. Transplantation 2003; 75: 1336. 12. Bank DE, Grossman ME, Kohn SR, et al. The thumbprint sign: Rapid diagnosis of disseminated strongyloidiasis. J Am Acad Dermatol 1990; 23: 324. 13. Thomas MC, Costello SA. Disseminated strongyloidiasis arising from a single dose of dexamethasone before stereotactic radiosurgery. Int J Clin Pract 1998; 52: 520. 14. Kainz A, Wilflingseder J, Mitterbauer C, et al. Steroid pretreatment of organ donors to prevent postischemic renal allograft failure: A randomized, controlled trial. Ann Intern Med 2010; 153: 222. 15. Marti H, Haji HJ, Savioli L, et al. A comparative trial of a single-dose ivermectin versus three days of albendazole for treatment of Strongyloides stercoralis and other soil-transmitted helminthic infections in children. Am J Trop Med Hyg 1996; 55: 477. 16. Tarr PE, Miele PS, Peregoy KS, et al. Case report: Rectal administration of ivermectin to a patient with Strongyloides hyperinfection syndrome. Am J Trop Med Hyg 2003; 6: 453. 17. Chiodini PL, Reid AJ, Wiselka MJ, et al. Parenteral ivermectin in Strongyloides hyperinfection. Lancet 2000; 355: 43. 18. Lichtenberger P, Rosa-Cunha I, Morris M, et al. Hyperinfection strongyloidiasis in a liver transplant recipient treated with parenteral ivermectin. Transpl Infect Dis 2009; 11: 137. 19. Boram LH, Keller KF, Justus DE, et al. Strongyloides in immunosuppressed patients. Am J Clin Pathol 1981; 76: 778. 20. DeVault GA, Brown ST, Montoya SF, et al. Disseminated strongyloidiasis complicating acute renal allograft rejection. Prolonged thiabendazole administration and successful retransplantation. Transplantation 1982; 34: 220. 21. Fowler CG, Lindsay I, Levin J, et al. Recurrent hyperinfestation with Strongyloides stercoralis in a renal allograft recipient. BMJ 1982; 285: 1394. 22. Patel G, Arvelakis A, Sauter BV, et al. Strongyloides hyperinfection syndrome after intestinal transplant. Transpl Infect Dis 2008; 10: 137. 23. Schaeffer MW, Buell JF, Gupta M, et al. Strongyloides hyperinfection syndrome after heart transplantation: Case report and review of the literature. J Heart Lung Transplant 2004; 23: 905. 24. Huston JM, Eachempati SR, Rodney JR, et al. Treatment of Strongyloides stercoralis hyperinfection-associated septic shock and acute respiratory distress syndrome with drotrecogin alfa (activated) in a renal transplant recipient. Transpl Infect Des 2009; 11: 277. 25. Balagopal A, Mills L, Shah A, et al. Detection and treatment of Strongyloides hyperinfection syndrome following lung transplantation. Transpl Infect Dis 2009; 11: 149. 26. Palau LA, Pankey GA. Strongyloides hyperinfection in a renal transplant recipient receiving cyclosporine: Possible Strongyloides stercoralis transmission by kidney transplant. Am J Trop Med Hyg 1997; 57: 413. 27. Vishwanth S, Baker RA, Mansheim BJ. Strongyloides infection and meningitis in an immunocompromised host. Am J Trop Med Hyg 1982; 31: 857. 28. Weller IV, Copland P, Gabriel R. Strongyloides stercoralis infection in renal transplant recipients. BMJ (Clin Res Ed) 1981; 282: 524. 29. Beltran Catalan S, Crespo Albiach JF, Morales Garcia AI, et al. Strongyloides stercoralis infection in renal transplant recipients. Nefrologia 2009; 29: 482. 30. Venizelos PC, Lopata M, Bardawil WA, et al. Respiratory failure due to Strongyloides stercoralis in a patient with renal transplant. Chest 1980; 78: 104.

Alternate JournalTransplantation
Notify Library Reference ID1797

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