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Strongyloides stercoralis infection in the early post- partum period: a case

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 P Peruvian journal
J
P of parasitology
Volumen 21- Número 1 - Año 2013
ISSN 2311-4533 (Electronic version)

Caso Clínico / Clinical Case

Strongyloides stercoralis infection in the early post- partum period: A case study

Infección por Strongyloides stercoralis en el puerperio inmediato: Estudio de un caso

Vasquez-Rios George,1,2 Gonzalez Carmen, 1, 3 Machicado Jorge D., 2, 4

Canales Marco, 2 Marcos Luis A.,2, 5 Terashima Angelica. 1,2

1.Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
2.Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru.
3.Departamento de Ginecología y Obstetricia, Hospital Nacional Cayetano Heredia, Lima, Perú.
4.Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
5.Adjunct Clinical Professor , William Carey University and Medical Director of the Infection Prevention Department and Head of the
Antimicrobial Stewardship Program, Infectious Diseases Department, Forrest General Hospital, Hattiesburg, MS, USA

Resumen Abstract
Strongyloides stercoralis es un nemátodo intestinal Strongyloides stercoralis is an intestinal nematode
con un ciclo de vida complejo que coloniza la with a complex life cycle that colonizes the
mucosa intestinal. Describimos el caso de una intestinal mucosa. We describe the case of a 26
mujer de 26 años en el tercer trimestre de year-old pregnant woman (third trimester) who
embarazo, quien presentó diarrhea, eosinofilia presented with intermittent loose stools,
y trombocitopenia después del parto. En el eosinophilia and thrombocytopenia after
exámen coprológico se encontraron larvas de delivery. S. stercoralis larvae were found in stool
Strongyloides stercoralis. La paciente recibió examination. Patient received ivermectin and
ivermectina y el estudio de heces 1 mes después stool examination at 1-month post-treatment
del tratamiento demostró la eliminación del and was negative for larvae.
parásito.
Key words: Strongyloides stercoralis | Pregnancy |
Palabras clave: Strongyloides stercoralis | Postpartum Period (Source: DeCS:BIREME)
Embarazo | Puerperio (Fuente:
DeCS:BIREME).

Citation: Vasquez-Rios G, Gonzalez C, Machicado JD, Canales M, Marcos LA, Terashima A. Strongyloides stercoralis infection in the early post- partum period: A
case study. Peruv j parasitol. 2013;21(1):e41-e47.

Open access peer-reviewed scientific journal published by the Asociación de Parasitólogos del Perú. Copyright ® 2013. All rights reserved.

41
Peruvian journal of parasitology
Volumen 21- Número 1 - Año 2013
ISSN 2311-4533 (Electronic version)
Introduction
S trongyloides stercoralis is a nematode with a
worldwide distribution, highly endemic in
tropical and subtropical areas. It is
estimated that 30-100 million people are
affected by this parasite around the world1.
However, the real burden of this infection may
be much higher since asymptomatic individuals
are likely to be underreported,2,3. Human
infection begins when the filariform larvae
(infective larvae) penetrate uncovered skin,
which subsequently reaches the intestinal
mucosa and continues towards the lungs. Here,
the larvae ascend the airways and pass to the
gastrointestinal tract via the swallowing of the
host. Finally, the larvae reach the adult stage in
the small bowel. Immature larvae are shed in
stools, reach the soil and maturate under
appropriate environmental conditions3. These
are known as the rhabidiform larvae. In
immunocompetent individuals the maturation
cycle continues at low and sometimes
undetectable rates, leading to chronic
autoinfection. Nonetheless, under immune
suppressing conditions, massive reproduction
can occur and the filariform larvae can invade
several organs, leading to disseminated
strongyloidiasis and multi-organ failure, which
can be fatal4. This has been named as
hyperinfection syndrome.
Pregnancy has already been described as a state
of relative immunosuppression.
Immunological Th1 and Th2 responses are
altered as the hormone levels change
dramatically compared to non-pregnant
woman, in favor of fetus preservation 5,6.
Although only one case of hyperinfection
syndrome has been described in a pregnant
woman previously, this group of patients is
u n d e r p ot e n t i a l r i s k o f p re s e n t i n g
complications such as diarrhea, anemia,
gastrointestinal bleeding, nutritional deficit,
and ultimately fetal loss 5.
We report a woman in the early post-partum
period with intermittent loose stools,
Peruv. j. parasitol 2013; 21 (1)
Acceso gratuito en línea a texto completo.
Clinical Case
Vasquez-Rios et al. Strongyloides stercoralis infection in the early
post- partum period.
thrombocytopenia and eosinophilia that
ultimately had Strongyloides larvae detected in
stools.
Case presentation
A 26 year-old pregnant woman born in the
northern coast of Perú (Piura) and currently
residing in Lima arrived at the obstetrical triage
unit in the Hospital Nacional Cayetano
Heredia, Lima-Peru; at 38 weeks of gestational
age, with painful contractions over the past 4
hours. There was no family history of
autoimmune disease or platelet disorder.
Medications included iron and calcium
supplements. She had avoided consumption of
alcohol or any recreational drugs. Travel history
included a visit to the highlands of Peru
(Huancayo) three years ago where she reported
the consumption of unpasteurized milk. On
physical examination vital signs were stable.
She was alert and in moderate discomfort with
contractions. There were neither rash, petechial
signs nor ecchymosis; cervical, axillary and
genital lymphs were conserved. Lungs and heart
auscultation was unremarkable. The abdomen
was gravid and non-tender. The cervix was 3 cm
dilated; the membranes were intact and there
was no evidence of significant vaginal bleeding.
The patient had an uncomplicated
spontaneous delivery of a 2900 gram baby (50-
75 percentile).
Postpartum blood tests showed hematocrit:
37%, hemoglobin 12.5 g/dL, MCV: 72.3,
WBCs: 14, 900/mm3, eosinophils 9% and
platelets 70,000/mm3. Because of moderate
thrombocytopenia, a full work up was pursued
in order to rule out an autoimmune or
infectious etiology. Liver and thyroid function
tests, as well as peripheral blood smear, were
under normal limits (Table 1). Considering her
travel history (epidemiological risk factors for
being in a Brucella endemic country) and an
extensive work up (Table 1) that revealed no
other apparent cause to explain her
thrombocytopenia; Brucella spp. tests were
requested. Rosa de Bengala and Agglutinations
42
Peruvian journal of parasitology
Volumen 21- Número 1 - Año 2013
ISSN 2311-4533 (Electronic version)
returned positive (Agglutinations: 1/120;
normal limits below 1:80). Bone marrow
aspiration and culture were not performed in
o u r p a t i e n t . T h e p a t i e n t re m a i n e d
asymptomatic until day 2 when she reported
loose stools (3 episodes) with no blood or
mucus. Stool samples were collected for
bacterial culture and also tested for ova and
parasites by means of the Spontaneous
Sedimentation Tube Technique (SSTT) and
Lumbreras' Cup-modif ied Baermann
Technique (MBT) which are routinely
parasitological techniques performed at the
Figure 1. Filariform larvae of Strongyloides stercoralis
The newborn was afebrile and the physical
examination was unremarkable. Additional
tests in the newborn were negative (data not
shown) and he was closely followed up without
complications reported by the Neonatal Care
Unit. The mother and the baby were reassessed
at 1, 3 and 6 months after delivery with no
relevant findings nor self-reported complains.
Stools samples were collected from the mother 1
Peruv. j. parasitol 2013; 21 (1)
Acceso gratuito en línea a texto completo.
Clinical Case
Vasquez-Rios et al. Strongyloides stercoralis infection in the early
post- partum period.
Instituto de Medicinal Tropical Alexander von
Humboldt (IMTAvH). The bacterial culture
was negative, but microscopic examination of
stools revealed larvae of Strongyloides stercoralis
(Figure 1) and cysts of Blastocystis spp.(Figure 2).
Previous infection with Brucella was possible
due to epidemiological risk factors and positive
antibodies titers seen in our patient. Because
she never received treatment against this
infection, a course of doxycycline and amikacin
was started. In addition, a single dose of
ivermectin 200ug/kg was given for S. stercoralis
infection.
Figure 2. Cyst of Blastocystis spp
month after treatment showed no presence of
S. stercoralis but Blastocystis was still present.
Since no abdominal pain, diarrhea or
constipation was reported, Blastocystis was
considered to be likely a commensal rather
than a pathogen. New lab tests showed the
normalization of the blood count as shown in
Table 1.
43
Peruvian journal of parasitology Clinical Case
Vasquez-Rios et al. Strongyloides stercoralis infection in the early
Volumen 21- Número 1 - Año 2013 post- partum period.
ISSN 2311-4533 (Electronic version)

Table 1. Laboratory studies during the admission and follow-up.

Time
Test
6 hrs 8 hrs 1 month 3 months
HCT 37% 37.20% 35% 35%
HB 12.5 12.1 12 12
MCV 72.3 71.3 83 88
MCH 33.5 32.5 33.6 33.4
CHMC 34 33.4 34 33.6
WBC 14 900 15 550 9 000 8 500
ABS 0% 0% 0% 0%
EOS 9% 10% 3% 2%
110
PLATELETS 70 000 80 000 000 220 000
FIBRINOGEN - 3 g/L - -
-
Bleeding Time UNL - -
-
Coagulation Time 5 min - -
-
VWF UNL - -
-
Peripheral smear No abn - -
-
Total Bilirrubin 1.8 - -
-
Direc Bilirrubin 1.2 - -
-
ALT 25 - -
-
AST 22 - -
-
LDH 110 - -
-
ALP 123 - -
-
GGT 68 - -
-
TSH UNL - -
-
T3 UNL - -
-
T4f UNL - -
-
ANA Neg - -
-
ANCA Neg - -
-
Anti DNAds Neg - -
-
Anti-cardiolipinAbs Neg - -
-
HIV 1-2 Neg - -
-
HTLV 1-2 Neg - -
-
Hep B Neg - -
-
Hep C Neg - -
-
Urea breath Test Neg - -
-
Rosa de Bengala Positive - -
-
ABS against Brucella 1/120 - -

*UNL: Under normal limits

Peruv. j. parasitol 2012; 20 (1) 44

Acceso gratuito en línea a texto completo.
Peruvian journal of parasitology
Volumen 21- Número 1 - Año 2013
ISSN 2311-4533 (Electronic version)
Discussion
Parasitic infections affect tens of millions of
pregnant women worldwide and directly or
indirectly lead to a spectrum of adverse
maternal and fetal effects. Almost every parasite
causes some degree of anemia and
malnutrition, which are related to restricted
fetal growth and poor weight gain8. Although
parasitic infections are prevalent in developing
countries, the popularization of world travel
results in a higher number of potentially
infected individuals. Hence, physicians are
responsible for treating not only patients who
have visited endemic regions, but also
individuals who have lived or emigrated from
these areas.
S. stercoralis prevalence among pregnant women
has been assessed in some community–based
studies ranging between 2-17%9,10 in some rural
areas. However, it is speculated that these rates
m ay b e u n d e re st i m a te d b e c a u s e o f
methodological limitations such as the lack of
sensitive diagnostic tools, appropriate number
of stool specimens collected, among others.
Symptoms of S. stercoralis infection include
epigastric abdominal pain, vomiting and
chronic diarrhea all of which are non-specific.
Little is known about the most common clinical
manifestations among pregnant women. Thus,
a high clinical suspicion based on
epidemiological grounds (i.e. travel history to
an endemic area) is needed to consider this
parasite as a possible cause. Some risk factors
among pregnant women have been proposed:
(1) Occupation (farmers, traders and artisans)
and (2) women with children less than 8 years of
age10. Laboratory abnormalities can include
leukocytosis and commonly eosinophilia (>500
eosinophils). Hypereosinophilia (>1,500
eosinophils) can also be present among S.
stercoralis infection, and is distinctive from other
parasitic infections (i.e. Fasciola hepatica and
Toxocara canis). Although our patient did not
have a clear risk factor for S. stercoralis
transmission, sanitary conditions, the use of
latrines and fecal contamination of food
Peruv. j. parasitol 2013; 21 (1)
Acceso gratuito en línea a texto completo.
Clinical Case
Vasquez-Rios et al. Strongyloides stercoralis infection in the early
post- partum period.
associated with low income or rural areas may
have played a role in acquiring this agent.
Diagnosis of S. stercoralis can be difficult since
common diagnostic techniques such as direct
microscopy has low sensitivity in comparison to
more sensitive concentration techniques such
as SSTT and especially MBT, which has been
recognized by the WHO as one of the best
methods for diagnosis of this parasite11.
Although typical features of S. stercoralis larvae
can be recognized under light microscopy,
certain laborator y training might be
additionally needed 12.
Although the presence of acute diarrhea along
with leukocytosis and eosinophilia raised
suspicions of a possible parasitic infection, an
analysis of other causes was done. Non-
inf lammator y causes (malabsor ption
syndromes) were not considered since there was
no previous history of steatorrhea or food
intolerance. Inf lammator y/infectious
conditions involving preforming toxin bacteria
such as Staphylococcus aureus and Bacillus cereus
were excluded since the cornerstone of this
infection includes iterative nausea and
vomiting along with abdominal pain,
commonly as a consequence of food poisoning.
Other bacterial infections including
Campylobacter spp, Salmonella spp, Shiguella spp.
and Clostridium difficile were ruled out since
stool cultures were negative for such agents.
Viral tests were not performed due to the
limited availability of PCR tests in most
laboratory centers. Thus, direct examination of
the stool sample by means of MBT lead to a
confirmatory diagnosis of acute
strongyloidiasis. Diarrhea, leukocytosis and
eosinophilia resolved progressively after our
patient received ivermectin and larvae
clearance was confirmed by subsequent stool
studies at 1 month follow-up.
Immunological changes during pregnancy are
responsible for a variety of clinical responses to
an offending organism. As pregnancy
progresses, increasing levels of maternal
estrogen down regulate Th1/cytotoxic response
45
Peruvian journal of parasitology
Volumen 21- Número 1 - Año 2013
ISSN 2311-4533 (Electronic version)
to avoid fetus rejection. Hence, Th2 (humoral)
response predominates increasing levels of IL-4,
IL-5, and the number of eosinophils.
Classically, Ig.E and eosinophils 5,6 are involved
in the immune response against helminthes,
through the Th2 pathway, whereas cytotoxic T
cells and macrophages are recruited, through
the Th1 pathway, to a greater extent against
intracellular infections (i.e. protozoan). Thus,
although helminthic infection can be
dangerous in pregnancy, the severity of
maternal, placental and fetal infection is not as
severe as with intracellular infections 13.
Although these immunological changes during
pregnancy could have conferred to our patient
some degree of maternal protection against S.
Stercoralis and possibly explain the benign
progress of the infection, several cases of
malnutrition and poor fetus weight gain have
been described as complications by this
infection in other regions14. Hence, appropriate
treatment should be considered once the
diagnosis of S. stercoralis is made.
Additionally, our patient had positive antibody
titers against Brucella spp. It is a major zoonotic
disease with an interesting ability to produce a
variety of hematological abnormalities such as
a result of hyperesplenism/splenomegaly or
bone marrow infiltration by granulomas 15.
Anemia has been described to be as frequent as
in 75% of the patients, while leukopenia and
severe thrombocytopenia have been seen in
50% and 1-2% of them, respectively. Pregnant
women with active Brucellosis experience
higher rates of spontaneous abortion and
intrauterine death, compared to the general
population of pregnant women16. Although
erythritol (hypothesized to favor Brucella spp.
growth) has not been found in human
placental tissue, bacteremia can result in
abortion, especially early in pregnancy16,17.
However, even in light of these facts, the
possibility of maternal infection without fetal
implications cannot be dismissed. In
consequence, positive titers against Brucella spp.
should have a careful interpretation. In this
Peruv. j. parasitol 2013; 21 (1)
Acceso gratuito en línea a texto completo.
Clinical Case
Vasquez-Rios et al. Strongyloides stercoralis infection in the early
post- partum period.
specific case scenario, given the unknown time
of infection, lack of bone marrow aspiration
and culture and the fact that she had never been
treated for this infection, we decided to start a
course of doxycycline and amikacin. In
addition, an important differential for
thrombocytopenia in a pregnant woman is
gestational thrombocytopenia, which is an
exclusion diagnosis. Features to consider in this
diagnosis include: (1) No past history of
thrombocytopenia, (2) thrombocytopenia
resolved spontaneously within 1 month after
delivery and (3) no fetal implication in terms of
hematological abnormalities18,19. Subsequent
blood analysis 1 month after delivery showed
the normalization of the platelet counts.
Awareness of S. stercoralis infecting pregnant
women may be important to avoid pregnancy
complications. Although our patient had a
benign course, there are some issues that should
be considered regarding pregnant women and
parasitic infections: (1) They experience more
severe form of disease than their non-pregnant
counterparts; (2) those who are infected with
one parasite are usually infected with a second
parasite and (3) infections occurring during the
first trimester are associated with more fetal and
placental consequences than those occurring
later in pregnancy8. This case highlights the
importance of considering intestinal parasites
in the differential diagnosis of those pregnant
patients presenting with gastrointestinal
complaints in an endemic country for S.
stercoralis.
Acknowledgement:
The authors would like to thank Bristol
University PhD. Bert Wuyts for the review of
this manuscript.
Author's contributions: GV and CG
reviewed the case. GV wrote the manuscript.
GV, JM , AT, MC and LM critical revisions. MC
and GV obtained the images. All authors
reviewed the manuscript and approved it for
publication.
46
 Peruvian journal of parasitology
Volumen 21- Número 1 - Año 2013
ISSN 2311-4533 (Electronic version)
Conflict of interest: None
Funding: Authors disclose no funding
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post- partum period.
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