Strongyloides hyperinfection syndrome after intestinal transplantation

Strongyloides stercoralis is a helminth with the ability to autoinfect the human host and persist asymptomatically for several years. Immunosuppression can accelerate autoinfection and result in Strongyloides hyperinfection syndrome (SHS), which is associated with significant morbidity and mortality. Immunosuppressed solid organ transplant recipients, particularly in the setting of rejection, are at increased risk for reactivation of latent infections, such as Strongyloides. We describe a case of SHS in an intestinal transplant recipient; we hypothesize that she acquired the infection from the donor. We also review the current literature and address both prophylaxis and treatment of strongyloidiasis in the solid organ transplant patient. Copyright (C) 2008 Blackwell Publishing Ltd.; References: 1. Mahmoud AAF. Strongyloidiasis. Clin Infect Dis 1996; 23: 949-953. 2. Kaiser PB, Nutman TB. Strongyloides stercoralis in immunocompromised populations. Clin Micro Rev 2004; 17: 208-217. 3. Pacanowski J, Santos MD, Roux A, et al. Subcutaneous ivermectin as a safe salvage therapy in Strongyloides stercoralis hyperinfection syndrome: a case report. Am J Trop Med Hyg 2005; 73: 122-124. 4. Hoy WE, Roberts 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: 1937-1939. 5. Ben-Youssef R, Baron P, Edson F, Raghavan R, Okechukwu O. Strongyloides stercoralis infection from pancreas allograft: case report. Transplantation 2005; 80: 997-998. 6. 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: 413-415. 7. Morgan JS, Schaffner W, Stone WJ. Opportunistic strongyloidiasis in renal transplant recipients. Transplantation 1986; 42: 518-523. 8. Devault GA, King JW, Rohr MS, Landreneau MD, Brown ST, McDonald JC. Opportunistic infections with Strongyloides stercoralis in renal transplantation. Rev Infec Dis 1990; 12: 653-671. 9. Schad GA. Cyclosporine may eliminate the threat of overwhelming strongyloidiasis in immunosuppressed patients. J Infect Dis 1986; 153: 178. 10. Schaeffer MW, Buell JF, Gupta M, Conway GD, Akhter SA, Wagoner LE. Strongyloides hyperinfection syndrome after heart transplantation: case report and review of the literature. J Heart Lung Transplant 2004; 23: 905-911. 11. Tarr PE, Miele PS, Peregoy KS, Smith MA, Neva FA, Lucey DR. Case report: rectal administration of ivermectin to a patient with Strongyloides hyperinfection syndrome. Am J Trop Med Hyg 2003; 68: 454-455. 12. Soman R, Vaideeswar P, Shah H, Almeida AF. A 34 year old renal transplant recipient with high-grade fever and progressive shortness of breath. J Postgrad Med 2002; 48: 191-196. 13. El Masry HZ, O'Donnell J. Fatal Strongyloides hyperinfection in heart transplantation. J Heart Lung Transplant 2005; 24: 1980-1983. 14. Brousse N, Goulet O. Small bowel transplantation. Br Med J 1996; 312: 261-262. 15. Tzakis AG, Todo S, Reyes J, et al. Intestinal transplantation in children under FK506 immunosuppression. J Pediatr Surg 1993; 28: 1040-1043. 16. Grant D, Abu-Elmagd A, Reyes J, et al. 2003 Report of the Intestine Transplant Registry: a new era has dawned. Ann Surg 2005; 241: 607-613. 17. Nolan TJ, Schad GA. Tacrolimus allows autoinfective development of the parasitic nematode Strongyloides stercoralis. Transplantation 1996; 62: 1038. 18. Turner SA, Maclean JD, Fleckenstein L, Greenaway C. Parenteral administration of ivermectin in a patient with disseminated strongyloidiasis. Am J Trop Med Hyg 2005; 73: 911-914. 19. Marty FM, Lowry CM, Rodriguez M, et al. Treatment of human disseminated strongyloidiasis with a parenteral veterinary formulation of ivermectin. Clin Infect Dis 2005; 41: e5-e8. 20. Boken DJ, Leoni PA, Preheim LC. Treatment of Strongyloides stercoralis hyperinfection syndrome with thiabendazole administration per rectum. Clin Infect Dis 1993; 16: 123-126. 21. Screening of donor and recipient prior to solid organ transplantation. Am J Transplant 2004; 4 ((Suppl 10)): 10-20.