4/10/2020 CDC - Strongyloides - General Information - Frequently Asked Questions

Parasites - Strongyloides

About Strongyloidiasis Infection

What is strongyloidiasis?

Strongyloidiasis is a disease caused by a nematode, or a roundworm, in the genus Strongyloides. Though there are
over 40 species within this genus that can infect birds, reptiles, amphibians, livestock and other primates,
Strongyloides stercoralis is the primary species that accounts for human disease. It sometimes infects primates, dogs
and cats, and some dog and primate infecting strains have been shown to be capable of causing human infection.
We do not know if cat-infecting strains can infect humans or not. The larvae are small; the longest reach about 600
µm in length—making them very di cult to see with the naked eye.

How do people get infected with strongyloides?

Strongyloides stercoralis is classi ed as a soil-transmitted helminth. This means that the primary mode of infection is
through contact with soil that is contaminated with free-living larvae. When the larvae come in contact with skin, they
are able to penetrate it and migrate through the body, eventually nding their way to the small intestine where they
burrow and lay their eggs. Unlike other soil-transmitted helminths such as hookworm and whipworm, whose eggs do
not hatch until they are in the environment, the eggs of S. stercoralis hatch into larvae in the intestine. Most of these
larvae will be excreted in the stool, but some of the larvae may mature and immediately re-infect the host either by
burrowing into the intestinal wall, or by penetrating the skin around the anus. This characteristic of S. stercoralis is
termed auto-infection. The signi cance of auto-infection is that unless treated for S. stercoralis, persons may remain
infected throughout their lifetime.

In addition to contact with soil and auto-infection, there have been rare cases of person-to-person transmission in
the following:

Organ transplantation
Institutions for people with cognitive disability requiring assistance with daily living
Long-term care facilities
Daycare centers

Where do most cases of strongyloidiasis occur in the United States?

In the United States, S. stercoralis infection has classically been associated with uniformed-service veterans who
returned from tropical regions such as Southeast Asia and the South Paci c during World War II or the Vietnam wasr.
Small domestic studies have shown focal locations of infection in rural Appalachia. The highest rates in the United
States have been documented in immigrant populations.

Strongyloides is more commonly found in areas that are relatively warm and moist, in rural areas, and areas
associated with agricultural activity, but it can occur anywhere. It is found more frequently in socio-economically
disadvantaged persons and in institutionalized populations.

What are the signs and symptoms of strongyloidiasis?

Th j it f l i f t d ith St l id d th t Th h d d l t ft
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The majority of people infected with Strongyloides do not have symptoms. Those who do develop symptoms often
have non-speci c, or generalized complaints. Some people develop abdominal pain, bloating, heartburn, intermittent
episodes of diarrhea and constipation, a dry cough, and skin rashes. Rarely people will develop arthritis, kidney
problems, and heart conditions.

Strongyloidiasis can be severe and life-threatening in persons who

Are taking corticosteroids (oral or intravenous) for asthma or chronic obstructive pulmonary disease (COPD)
exacerbations, lupus, gout, or other conditions requiring steroids for immunosuppression or symptomatic relief;
Are infected with the virus HTLV-1;
Have hematologic malignancies such as leukemia or lymphoma; or
Are transplant recipients.

How soon after the exposure do symptoms develop?

Most people do not know when their exposure occurred. For those who do, a local rash can occur immediately. The
cough usually occurs several days later. Abdominal symptoms typically occur approximately 2 weeks later, and larvae
can be found in the stool about 3 to 4 weeks later.

What should I do if I think I might have strongyloidiasis?

See your health care provider.

How is infection with Strongyloides diagnosed?

Strongyloides infection is best diagnosed with a blood test. Microscopic examination of stool is another option for
diagnosis, but it might not nd the worms in all infected people.

How is strongyloidiasis treated?

Safe and e ective drugs are available to treat infection with Strongyloides.

How can strongyloidiasis be prevented?

The best way to prevent Strongyloides infection is to wear shoes when you are walking on soil, avoid contact with
fecal matter or sewage, and clean up after dogs. Proper sewage disposal and fecal management are keys to
prevention.

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4/10/2020 CDC - Strongyloides - Epidemiology & Risk Factors

Parasites - Strongyloides

Epidemiology & Risk Factors

Strongyloides is known to exist on all continents except for Antarctica, but it is most common in the tropics, subtropics, and in
warm temperate regions. The global prevalence of Strongyloides infection is unknown, but experts estimate that there are
between 30–100 million infected persons worldwide.

In the United States, a series of small studies in select populations have shown that between 0–6.1% of persons sampled were
infected. Studies in immigrant populations have shown a much higher percentage of infected persons ranging from 0–46.1%.

Strongyloides infection is found more frequently in the socioeconomically disadvantaged, in institutionalized populations, and
in rural areas. It is often associated with agricultural activities.

The most common way of becoming infected with Strongyloides is by contacting soil that is contaminated with Strongyloides
larvae. Therefore, activities that increase contact with the soil increase the risk of becoming infected, such as

Walking with bare feet

Contact with human waste or sewage
Occupations that increase contact with contaminated soil such as farming and coal mining

Furthermore, many studies have shown an association with Strongyloides and infection with Human T-Cell Lymphotropic
Virus-1 (HTLV-1). These studies have shown that people infected with HTLV-1 are more likely to become infected with
Strongyloides, and that once infected, are more likely to develop severe cases of strongyloidiasis.

Of note, HIV/AIDS infection has not been shown to be a risk factor for acquiring strongyloidiasis or having a worse clinical
course.
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Parasites - Strongyloides

Biology
Causal Agents
The rhabditid nematode (roundworm) Strongyloides stercoralis is the major causative agent of strongyloidiasis in humans.
Rarer human-infecting species of Strongyloides are the zoonotic S. fuelleborni (fülleborni) subsp. fuelleborni and S.
fuelleborni subsp. kellyi, for which the only currently known host is humans. Strongyloides spp. are sometimes called
“threadworms” (although in some countries this common name refers to Enterobius vermicularis).

Other animal-associated Strongyloides spp., including S. myopotami (nutria), S. procyonis (raccoons), and possibly others,
may produce mild short-lived cutaneous infections in human hosts (larva currens, “nutria itch”), but do not cause true
strongyloidiasis.

Life Cycle
Strongyloides stercoralis

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The Strongyloides stercoralis life cycle is complex, alternating between free-living and parasitic cycles and involving
autoinfection. In the free-living cycle: Rhabditiform larvae are passed in the stool of an infected de nitive host , develop
into either infective lariform larvae (direct development) or free-living adult males and females that mate and
produce eggs , from which rhabditiform larvae hatch and eventually become infective lariform (L3) slarvae . The
lariform larvae penetrate the human host skin to initiate the parasitic cycle (see below) . This second generation of
lariform larvae cannot mature into free-living adults and must nd a new host to continue the life cycle.
Parasitic cycle: Filariform larvae in contaminated soil penetrate human skin when skin contacts soil , and migrate to the
small intestine . It has been thought that the L3 larvae migrate via the bloodstream and lymphatics to the lungs, where
they are eventually coughed up and swallowed. However, L3 larvae appear capable of migrating to the intestine via alternate
routes (e.g. through abdominal viscera or connective tissue). In the small intestine, the larvae molt twice and become adult
female worms . The females live embedded in the submucosa of the small intestine and produce eggs via
parthenogenesis (parasitic males do not exist) , which yield rhabditiform larvae. The rhabditiform larvae can either be
passed in the stool (see “Free-living cycle” above), or can cause autoinfection .

Rhabditiform larvae in the gut become infective lariform larvae that can penetrate either the intestinal mucosa or the skin of
the perianal area, resulting in autoinfection. Once the lariform larvae reinfect the host, they are carried to the lungs, pharynx
and small intestine as described above, or disseminate throughout the body. The signi cance of autoinfection in
Strongyloides is that untreated cases can result in persistent infection, even after many decades of residence in a non-
endemic area, and may contribute to the development of hyperinfection syndrome.

Life Cycle
Strongyloides fuelleborni

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Strongyloides fuelleborni follows the same life cycle as S. stercoralis, with the important distinction that eggs (rather than
larvae) are passed in the stool . Eggs hatch shortly after passage into the environment, releasing rhabditiform larvae ,
that develop to either infective lariform larvae (direct development) or free-living adult males and females . The free-
living adults mate and produce eggs, from which more rhabditiform larvae hatch and eventually become infective
lariform larvae . The lariform larvae penetrate the human host skin to initiate the parasitic cycle . These larvae
migrate via the bloodstream to the lungs, where they are eventually coughed up and swallowed, or reach the intestine via
migration through connective tissue or abdominal viscera . In the small intestine, larvae molt twice and become adult
female worms. Parasitic females embedded in the submucosa of the small intestine and produce eggs via
parthenogenesis (parasitic males do not exist) .

Since eggs do not hatch within the host as with S. stercoralis, autoinfection is believed to be impossible. Transmission of S.
fuelleborni subsp. kellyi to infants as a result of breastfeeding has been reported.

Hosts
Strongyloides spp. are generally host-speci c, and S. stercoralis is primarily a human parasite. However, patent infections with
parasitic females have been detected in other primates (chimpanzees, monkeys, etc.) and domestic dogs. Two genetic
populations have been found in domestic dogs, one that appears to only infect dogs and one that may infect both dogs and
humans; all human infections have been attributed to this second genetic population. Domestic cats are experimentally
susceptible to S. stercoralis infections although it is unknown if they have a role as a natural reservoir.

Strongyloides fuelleborni subsp. fuelleborni is a parasite of Old World apes and monkeys. The only identi ed host of S.
fuelleborni subsp. kellyi is humans.

Geographic Distribution
Strongyloides stercoralis is broadly distributed in tropical and subtropical areas across the globe. Transmission has been
reported during summer months in temperate areas. Infections are most common in areas with poor sanitation, rural and
remote communities, institutional settings, and among socially marginalized groups.

S. fuelleborni subsp. fuelleborni occurs in non-human primates throughout the Old World. The vast majority of human
infections are reported from sub-Saharan Africa. Sporadic cases have been reported from Southeast Asia. S. fuelleborni
subsp. kellyi is found in Papua New Guinea, and has not been reported elsewhere thus far.

Clinical Presentation
The initial sign of acute strongyloidiasis, if noticed at all, is a localized pruritic, erythematous rash at the site of skin
penetration. Patients may then develop tracheal irritation and a dry cough as the larvae migrate from the lungs up through
the trachea. After the larvae are swallowed into the gastrointestinal tract, patients may experience diarrhea, constipation,
abdominal pain, and anorexia. Chronic strongyloidiasis is generally asymptomatic, but a variety of gastrointestinal and
cutaneous manifestations may occur. Rarely, patients with chronic strongyloidiasis may develop other complications (e.g.
arthritis, cardiac arrhythmias, chronic malabsorption, duodenal obstruction, nephrotic syndrome, recurrent asthma). Up to
75% of people with chronic strongyloidiasis have mild peripheral eosinophilia or elevated IgE levels.

Hyperinfection syndrome and disseminated strongyloidiasis are most frequently associated with subclinical infection in
patients receiving high-dose corticosteroids. Subsequent impaired host immunity leads to accelerated autoinfection and an
overwhelming number of migrating larvae. In chronic strongyloidiasis and in hyperinfection syndrome, the larvae are limited
to the GI tract and the lungs, whereas in disseminated strongyloidiasis the larvae invade numerous organs. A variety of
systemic, gastrointestinal, pulmonary, and neurologic signs/symptoms have been documented; complications can be severe.
Left untreated, the mortality rates of hyperinfection syndrome and disseminated strongyloidiasis can approach 90%.

The subcutaneous migration of lariform larvae in the autoinfective cycle, or “larva currens”, presents as a recurrent
serpiginous maculopapular or urticarial rash along the buttocks, perineum, and thighs due to repeated autoinfection. This
rash usually advances very rapidly (up to 10 cm/hr).

In infants infected with S. fuelleborni subsp. kellyi, a severe, often fatal, systemic illness involving protein-losing enteropathy
has been described, which sometimes presents with peritoneal ascites (“swollen belly syndrome”).
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4/10/2020 CDC - Strongyloides - Disease

Parasites - Strongyloides

Disease
Most people infected with Strongyloides do not know they are infected. If they do feel sick the most common complaints are
the following:

Abdominal

Stomachache, bloating, and heartburn

Intermittent episodes of diarrhea and constipation
Nausea and loss of appetite

Respiratory

Dry cough
Throat irritation

Skin

An itchy, red rash that occurs where the worm entered the skin
Recurrent raised red rash typically along the thighs and buttocks

Rarely, severe life-threatening forms of the disease called hyperinfection syndrome and disseminated strongyloidiasis can
occur. These forms of the disease are more common in people who are on corticosteroids (for example, prednisone) or other
immunosuppressive therapies or who are infected with HTLV-1. In this situation, people become critically ill, and should be
taken to the hospital immediately.
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Parasites - Strongyloides

Diagnosis
Strongyloides infection is best diagnosed with a blood test. Strongyloides infection may be diagnosed by seeing larvae in stool
when examined under the microscope, but it might not nd the worms in all infected people. This may require that you
provide multiple stool samples to your doctor or the laboratory.
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4/10/2020 CDC - Strongyloides - Treatment

Parasites - Strongyloides

Treatment
Treatment for strongyloidiasis is recommended for all persons found to be infected, whether symptomatic or not, due to the
risk of developing hyperinfection syndrome and/or disseminated strongyloidiasis. Furthermore, it is recommended that
patients be considered for testing prior to being initiated on any immunosuppressive therapy, particularly corticosteroids.

More on: Resources for Health Professionals: Treatment

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4/10/2020 CDC - Strongyloides - Prevention & Control

Parasites - Strongyloides

Prevention & Control

The best way to prevent Strongyloides infection is to wear shoes when you are walking on soil, and to avoid contact with fecal
matter or sewage. Proper sewage disposal and fecal management are keys to prevention.

Furthermore, if you believe that you may be infected, the best way to prevent severe disease is to be tested and, if found to
be positive for disease, treated.

You should discuss testing with your doctor if you are

Taking steroids or other immunosuppressive therapies

About to start taking steroids or other immunosuppressive therapies
A veteran who served in the South Paci c or Southeast Asia
Infected with Human T-cell Lymphotropic Virus-1 (HTLV-1)
Diagnosed with cancer
Going to donate or receive organ transplants
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Parasites - Strongyloides

Resources for Health Professionals

On this Page
Disease Disease
The symptomatic spectrum of Strongyloides infection ranges from subclinical in acute and chronic Diagnosis
infection to severe and fatal in hyperinfection syndrome and disseminated strongyloidiasis, which have
Treatment
case-fatality rates that approach 90%. In either case, patients’ symptoms are a result of the parasite’s
larval form migrating through various organs of the body. Screening
Precautions

Acute strongyloidiasis
The initial sign of acute strongyloidiasis, if noticed at all, is a localized pruritic, erythematous rash at the site of skin
penetration. Patients may then develop tracheal irritation and a dry cough as the larvae migrate from the lungs up through
the trachea. After the larvae are swallowed into the gastrointestinal tract, patients may experience diarrhea, constipation,
abdominal pain, and anorexia.

Chronic strongyloidiasis
Chronic strongyloidiasis is generally asymptomatic, but in patients with clinical disease gastrointestinal and cutaneous
manifestations are the most common. Of the gastrointestinal complaints, epigastric pain, postprandial fullness, heartburn,
and brief episodes of intermittent diarrhea and constipation are the most frequent. Less commonly, patients may present
with fecal occult blood, or massive colonic and gastric hemorrhage. Presentations resembling in ammatory bowel disease,
speci cally ulcerative colitis, are rare. Also rare, but documented, are endoscopic exams revealing pathology similar to
pseudopolyposis.

Cutaneous symptoms include chronic urticaria and larva currens- a recurrent serpiginous maculopapular or urticarial rash
along the buttocks, perineum, and thighs due to repeated auto-infection. It has been described as advancing as rapidly as
10cm/hr.

Rarely, patients with chronic strongyloidiasis have complained of arthritis, cardiac arrhythmias, and signs and symptoms
consistent with chronic malabsorption, duodenal obstruction, nephrotic syndrome, and recurrent asthma.

Up to 75% of people with chronic strongyloidiasis have mild peripheral eosinophilia or elevated IgE levels.

Hyperinfection syndrome and disseminated strongyloidiasis

Hyperinfection syndrome and disseminated strongyloidiasis are most frequently associated with subclinical infection in
patients receiving high-dose corticosteroids for the treatment of asthma or chronic obstructive pulmonary disease (COPD)
exacerbations. Subsequent impaired host immunity leads to accelerated autoinfection and an overwhelming number of
migrating larvae. In chronic strongyloidiasis and in hyperinfection syndrome the larvae are limited to the GI tract and the
lungs whereas in disseminated strongyloidiasis the larvae invade numerous organs. Left untreated, the mortality rates of
hyperinfection syndrome and disseminated strongyloidiasis can approach 90%.

The following are signs and symptoms that can be seen with hyperinfection syndrome and disseminated strongyloidiasis:

Gastrointestinal manifestations

Abdominal pain, nausea, vomiting, diarrhea

Ileus, bowel edema, intestinal obstruction
Mucosal ulceration, massive hemorrhage, and subsequent peritonitis or bacterial sepsis

Pulmonary manifestations and ndings

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Cough, wheezing, dyspnea, hoarseness

Pneumonitis
Hemoptysis
Respiratory failure
Di use interstitial in ltrates or consolidation on chest radiographs

Neurologic ndings

Aseptic or gram-negative meningitis

Larvae have been reported in the CSF, meningeal vessels, dura, epidural, subdural, and subarachnoid spaces

Systemic signs and symptoms

Peripheral edema and ascites secondary to hypoalbuminemia from protein losing enteropathy
Recurrent gram negative bacteremia or sepsis from larvae carrying bacteria that penetrate mucosal walls
Syndrome of inappropriate secretion of anti-diuretic hormone (SIADH)
Peripheral eosinophilia is frequently absent

Cutaneous manifestations

Recurrent maculopapular or urticarial rash that can be found anywhere on the skin but is most commonly found along
the buttocks, perineum, and thighs due to repeated auto-infection
Larva currens—serpiginous or urticarial rash that advances as rapidly as 10cm/hr.

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Diagnosis
The gold standard for the diagnosis of Strongyloides infection is serial stool examination. However, traditional stool
examinations are insensitive and require up to seven stool exams to reach a sensitivity of 100%. Specialized stool exams
include Baermann concentration, Horadi-Mori lter paper culture, quantitative acetate concentration technique, and nutrient
agar plate cultures. Duodenal aspirate is more sensitive than stool examination, and duodenal biopsy may reveal parasites in
the gastric crypts, in the duodenal glands, or eosinophilic in ltration in the lamina propria. Frequently, larvae can be seen by a
simple wet-mount in uid from a bronchoalveolar lavage (BAL).

Many of the serologic tests that are available are quite sensitive, but cross-react with other larial parasites, schistosomes,
and Ascaris lumbricoides, decreasing the speci city of the tests. Furthermore, it can be di cult to distinguish between active
cases and historical cases since antibodies can persist for some time. A signi cant proportion of people become antibody
negative within 6 months after successful treatment. More sensitive and speci c serologic tests using recombinant antigens
have been developed.

Of note, CDC performs reference serologic testing only to con rm test results, which are occasionally di cult to interpret or
equivocal.

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Treatment

Acute and chronic strongyloidiasis

First line therapy
Ivermectin, in a single dose, 200 µg/kg orally for 1—2 days

Relative contraindications include the following:

Con rmed or suspected concomitant Loa loa infection

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p

Persons weighing less than 15kg

Pregnant or lactating women

Oral ivermectin is available for human use in the United States.

Alternative

Albendazole, 400 mg orally two times a day for 7 days.

Relative contraindications:

Hypersensitivity to benzimidazole compounds or any component of product

Use should be avoided in the 1st trimester of pregnancy

Oral albendazole is available for human use in the United States.

In patients with positive stool examination for Strongyloides and persistent symptoms, follow-up stool exams should be
performed 2—4 weeks after treatment to con rm clearance of infection. If recrudescence of larvae is observed, retreatment
is indicated.

Hyperinfection syndrome/Disseminated strongyloidiasis

If possible, immunosuppressive therapy should be stopped or reduced, and:

Ivermectin, 200 µg/kg per day orally until stool and/or sputum exams are negative for 2 weeks.

For patients unable to tolerate oral therapy, such as those with ileus, obstruction, or known or suspected malabsorption,
published case reports have demonstrated e cacy with rectal administration.

If oral and/or rectal administrations are not possible, there have been instances where Investigational New Drug (IND)
exemptions for the veterinary subcutaneous formulation of ivermectin have been granted by the FDA.

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Screening
Physicians should be particularly diligent to consider Strongyloides in patients:

Who are on or about to begin corticosteroid therapy or other immunosuppressants

Known to have HTLV-1 infection
With hematologic malignancies including leukemias and lymphomas
Who have had or are being considered for organ transplantation
With persistent peripheral or unexplained eosinophilia
With recent or remote travel histories to endemic areas.

Of note, though persons with HIV/AIDS can have disseminated strongyloidiasis or hyperinfection syndrome, observational
studies have not shown an increased risk in this population.

Precautions
Standard precautions should be observed for patients hospitalized with strongyloidiasis. Wearing gloves and gowns, good
hygiene, and diligent handwashing is important when coming into contact with the patient’s feces.

More on: Handwashing

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Ivermectin
Note on Treatment in Pregnancy

Note on Treatment During Lactation

Note on Treatment in Pediatric Patients

Albendazole
Note on Treatment in Pregnancy

Note on Treatment During Lactation

Note on Treatment in Pediatric Patients

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