Case guesses:

Anthony writes:

This case reminded me of an episode of monsters inside me (season 1 episode 4) wherein a steroid treatment had reactivated a latent strongyloides infection

My final guess:

Reactivation of latent Strongyloides stercoralis infection

Ivermectin + a benzimidazole is supposedly the treatment but prognosis seems poor

Anthony

Laura writes:

Hello TWIP team!

This time I am sending this the right way, that is by email, and not in the comments section on microbe.tv 🙂

My guess for the diagnosis of last TWIP’s case is systemic strongyloidiasis, caused by Strongyloides stercoralis. This is a usually self limited infection that is prevalent in tropical climates, acquired through contact of the skin with soil containing the larvae or through the fecal-oral route. The larvae migrate through the blood vessels to the lungs, where they mature, are then coughed up and swallowed and upon reaching the colon, they penetrate into the circulation again to restart the infectious cycle, thus persisting in the host possibly for life. They rarely cause problems except in immunosuppressed individuals – in this case the gentleman had diabetes and was treated with corticosteroids. Strongyloidiasis usually presents with gastrointestinal symptoms and the parasite is found by examining the stool. Searching online for sputum examination in this infection I have found this 

https://academic.oup.com/qjmed/article/107/3/235/1569135

which has a nice picture of an agar plate with a serpiginous tract – bingo!. Being a dermatologist I was familiar with the serpiginous aspect of larva currens dermatitis caused by the same nematode, although happily (or sadly?) more from books than from my own practice.

As for the initial lack of eosinophilia, that frequently accompanies strongyloidiasis, that is probably due to the use of corticosteroids.

Treatment is with ivermectin – a 14 day course in the case of disseminated strongyloidiasis. In my country that would probably be replaced with albendazole, because we don’t have ivermectin, except for veterinary use.

I hope the patient is doing well.

Thank you for all your podcasts!

Laura (from Romania)

Daniel writes:

Dear TWIP Professors,

While it would be possible to cough up Ascaris lumbricoides I think this week’s case is Strongyloides stercoralis caused in no small measure by the patient’s steroid therapy.  UpToDate says that “Larvae crawl on the agar and spread bacteria in their paths, creating bacterial growth patterns on the agar surface. Larvae may be observed by macroscopic examination of the plates; their presence can be confirmed by washing the plate surface with formalin and examining the washing sediment.”  Thanks for sharing these interesting cases and all the great work you do on TWIV!

Dan

Let’s all look out for each other.

Daniel A. Nafziger MD, MS, FIDSA, FSHEA
Chief Medical Officer
Goshen Hospital
Goshen, IN 

Byron writes:

Hello TWIP hosts,

Is the question getting harder, or it is just me? However, I persist. I feel this is a tricky one, after debating among a number of nematodes, I decided to go with Strongyloides stercoralis. Hope I am right, and welcome to the show Dr. Lier for bringing such an interesting case! I think he is a keeper! Thanks for all you do…. till next case. 

Byron 

Joseph writes:

Greetings from wintery Taos New Mexico.

My guess for 192 is Strongyloides stercoralis, which can be pharmacologically treated with Albendazole and Ivermectin. The literature shows an 83% correlation to Dexamethasone and Strongyloides hyperinfection, and also can be found an up to 40% likelihood that someone from the tropics is carrying this parasite, thus indicating the need for screening all patients before the use of Dexamethasone. Here is where I will have to diverge from the published recommendations of… Give Ivermectin before Dex… if parasitic infection is suspected, and say that certainly a deeper consideration is warranted here. If I was in the position of caring for anyone that may be suffering from this combo, I would likely take a very different route from the modern clinical approach. This would be made up of anti-parasitic compounds orally ingested along with vitamin/nutritional zinc, d3 supplementation, even possibly intravenous vitamin C. But friends, I’m a woodworker, so take my words for a grain of sand. What really strikes me as interesting is that when I heard the case described, and then subsequently found pictures of the Strongyloides parasite, in both cases my mind was taken directly to the descriptions made by Enderlein of how protists develop into stranded organisms with the classic loop at the tail end. With just a modest understanding of pleomorphism, I certainly have to wonder about the entire concept of viruses or parasites laying dormant within us, and at least consider the potential that somehow it is just the memory, perhaps stored in the structured water of our lymphatic systems, of these organisms we call pathogens, that then re-create themselves when the conditions for their survival, and the need for their arrival somehow, arises. This would be more fitting with the “experimental facts” discovered by Béchamp and those that came after him. 

Ultimately, the development of co-occurrent pathologies is a very serious concern with the use of any pharmaceutical, thus, finding nutritional remedies and preventatives and natural therapies is always the safest option.

Thanks for this chance to reply, and thanks for sharing your ideas and thoughts online in a way that’s been accessible, it’s very much appreciated.

Kindly, Joseph

Caroline writes:

Bonjour from snowy Ontario, Canada

My guess is this is a case of strongyloidiasis caused by Strongyloides stercoralis.

Infections are commonly transmitted by contact through soil and patients will often not show any symptoms. S. stercoralis is prevalent in many rural areas in Ecuador. The patient in this case potentially came into contact with this parasite when living in rural Ecuador or working on a farm/in the timber industry.

However severe disease can develop if the patient is given steroids; symptoms can include sepsis and pulmonary complications. This cause and effect was seen in the patient when he was treated for covid19 with steroids and then developed a bloodstream infection and pneumonia.

Finally larvae may be detected in sputum samples, which may be what was seen on the agar plates?

Treatment for this is usually ivermectin, to be re-administered for at least two weeks to completely kill this parasite.

Thanks again for all that you do,

Caroline L.

Alvaro and Gaby write:

Dear TWiP team,

I thoroughly enjoy your podcasts and all the educational material you create and freely distribute. I used to use Vincent’s videos when I taught virology and immunology at Springfield College a couple of years ago, my girlfriend and I regularly listen to Daniel’s COVID updates, and I enjoy #beNiceToDickson’s presence on Twitter.

When I heard the case presentation I had a couple of thoughts for the differential diagnosis, but as soon as I shared the case with my girlfriend, who is an infectious disease physician working in Corona, Queens, New York, she said it’s Strongyloides stercoralis – without hesitation. She said that the use of steroids (for the COVID management) is probably the cause of a Strongyloides hyperinfection syndrome and that would have caused the patient’s worsening condition. This is produced because of impaired cell-mediated immunity. Moreover, she shared that the serpiginous trail on the agar plate can be seen in these conditions (and showed me a photo). Finally she pointed out how this case highlights the importance of looking for this parasite in people from areas where it is endemic, especially with increased steroid usage due to the COVID pandemic, since Strongyloides hyperinfection and disseminated strongyloidiasis can be life threatening.

Both my girlfriend and I are from Ecuador, so we were excited to tackle this case. She is working in a primary care clinic in Corona and sees many patients from Ecuador, and often diagnoses strongyloidiasis. I am pursuing doctoral studies in epidemiology, and my simple contribution is that after conducting a literature review, I found Strongyloides is highly underdiagnosed in Ecuador (and many other countries). In fact, national studies on parasitic worms don’t even look for this parasite. Estimates looking at the global burden of disease often use proxies to estimate the prevalence of strongyloidiasis, such as this one that uses hookworm burden to estimate Strongyloides stercoralis.

This is a topic we have become interested in since living in New York, and some day would like to study the real burden of this parasite in Ecuador.

Thanks again for your work in education and we look forward to listening to the submissions and answer to this clinical case.

Kind regards,

Alvaro (and Gaby).

Martha writes:

Dear Sirs: 

First off let me admit that I cheated. After listening to Dr. Lier’s case of a Covid19 patient not doing well on steroids, I recalled that Dr. Griffin had dropped a hint on his weekly update that Ivermectin would play a role in the upcoming TWiP. I was on my daily walk so could not immediately google, but my personal random access memory recalled a discussion in some earlier episode of the success of Ivermectin in some studies. It was opined that in areas where Strongyloides infection was frequent the use of steroids could permit an indolent infection to become disseminated. When I got home I googled Dr. Lier & Strongyloides. This took me to his paper in The American Journal of Tropical Medicine and Hygiene, August 14, 2020. 

So my answer is disseminated strongyloidiasis from a prior infection with Strongyloides stercoralis. Interesting that the life cycle of this creature has the option for autoinfection and can persist for decades after the initial exposure.

Best wishes to you all

Martha.

Dhruti writes:

Dear Twip team, 

Listening to Dr Daniel Griffin talk about ivermectin and Covid I think the diagnosis is given. Concerned older gentleman who is an immigrant from Ecuador must be suffering from strongyloidiasis caused by Strongyloides Stercoralis. He must be having Hyperinfection caused by Strongyloides brought on by steroids. 

Listening to Twiv  Covid-19 updates I made a habit of checking the wet mounts of sputum or ETS of Covid-19 ICU patients but ended with no luck and then I stopped. I guessed treatment with Ivermectin might have changed the course of illness for the concerned gentleman. 

Thanks for all the education.

Dr Dhruti Sheth
M.B.B.S. , 1st year DNB Microbiology,
Breach Candy Hospital 

Mumbai 

Madiha writes:

Hi everyone, 

I recently discovered your podcast and I love it. My answer for this case is Strongyloides stercoralis hyperinfection in the setting of corticosteroid use. 

Keep doing what you are doing!!

Thank you

Madiha

Johan writes:

Dear Vincent, Dickson and Daniel.

Thank you for an informative and entertaining podcast. Appreciate the light touch.

First-time guesser.

My guess is that the gentleman has a case of disseminated strongyloides infection.

Ivermectin has been touted by some in COVID-19 treatment, and in this case it is likely to make a difference, should the guess be correct. Jipijapa!

As an aside, even though there is no evidence of benefit for Ivermectin in COVID-19 today, until a large RCT definitely proves or disproves its efficacy, I try to stay open-minded. Who would have guessed two months ago that one would be pondering what a study using 

 would have shown….

Kind regards

Johan, Sweden

Sophia writes:

Hello twipsters

my guess for this case is Srongyloides stercoralis, (after reading this article https://academic.oup.com/cid/article/33/7/1040/429704 it kind of fits) but I didn’t really understand what the culture looked like. Also, how old is this older gentleman? He seems to have had a light COVID infection. Could the parasite have contributed to a light COVID? (who knows….there are no studies yet, I know, just wondering).

keeping these short as you seem to be getting many answers now. Many thanks to Kevin for his long and insightful answers. He writes with “meraki”= a Greek word to mean you’re taking longer than usual to do something only because you love it so much that you want to make it right/perfect/beautiful. Doesn’t mean that you are a perfectionist though.  Just that you don’t care about the time or effort involved. Not sure of the English equivalent.

Glad you are all vaccinated!

Sophia

Alexander writes:

Dear TWiP-Trio,

my guess for the gentleman from Ecuador who was hospitalised for COVID-19 is reactivated infection with strongyloides stercoralis. While several helminths include a little detour through the lungs and the trachea on their way to the intestinal tract in their life cycle, strongyloides is known for its potential for pulmonary symptoms and reactivation after years to decades in response to immunosuppression.

This so-called hyperinfection syndrome is a very serious illness that is associated with considerable mortality and warrants close monitoring of organ systems and systemic inflammatory markers.

Differentials include infection with ascaris, ancylostoma, nercator or capillaria species, although microscopy and stool testing should quickly rule them out if any doubts remain.

In this case, the dexamethsaone treatment for COVID-19 is implicated in the reactivation of strongyloides infection, but I wonder if the pronounced aneosinophilia that is typical for COVID-19 might have contributed to the pathology even before drug therapy was initiated.

Since typhoid fever is also associated with eosinopenia or aneosinophilia, I’d be very interested to know if Dr. Griffin has ever encountered strongyloides hyperinfection syndrome as a consequence of typhoid fever.

All the best to you,

Alexander,
from foggy 6°C/42 F Vienna

Christian writes:

Hi

I “strongly” suspect the patient developed Strongyloides hyperinfection syndrome after he received corticosteroids for his CSARS-CoV-2 infection. He probably acquired his Strongyloides infection while walking barefoot over contaminated soil most likely in his home country, but the parasite is a cosmopolitan and can be found throughout many temperate to tropical zones globally. More importantly the infection appears to be life long due to the parasites auto-infection cycle. 

The hyperinfection syndrome is primarily triggered by the use of corticosteroids or HTLV1 infection, but not by HIV. Strongyloides will then at mass penetrate the gut to fulfill its lifecycle, this migration will then lead to translocation of gut bacteria and cause sepsis. It is an important differential in patients who suddenly develop gram negative sepsis after or during steroid treatments. 

Treatment for strongyloides itself is ivermectin according to the local guidelines. 

As a side note, it was ignored as a soil transmitted helminth until recently because microscopy is nearly useless in diagnosis as no eggs can be found in stool samples, therefore culture plates would be needed, which are not necessarily available in rural areas of developing countries. 

BW

Christian

James writes:

Patient with travel to Ecuador, beautiful country, I took some medical students there on a Medical Brigade a couple of spring breaks ago. We had roasted Guinea Pig, they called in Cui. (like quee) and hiked even higher than any peak in Colorado up to 16000 feet up Mt. Chimborazo. I wonder if it snows at the equator anywhere else in the world? Africa possibly?

A variety of nematodes goes through the lungs. My Differential:

Ascaris (very common worldwide)Hookworms
Strongyloides stercoralis.
Tropical pulmonary eosinophilia (filariasis)
Dirofilaria
Visceral larva migrans

But myalgias? Not in my memory bank as a classic symptom of the above. 

But, to my surprise, Trichinella spiralis.

Would our younger ID doc be that much of a brown-noser? https://www.trichinella.org/ I wonder… the muscle aches certainly are a clue for trichinosis, and you could get a cluster (the guy who does the Meat Eater Netflix series served undercooked bear meat to his crew and they all got it, sick as dogs apparently.)

The Trichinella Page

General information on the biology, clinical presentation, and epidemiology of infection with Trichinella spiralis.

www.trichinella.org

I’m not finding it in guinea pigs on a brief search but the Ecuadorian eat regular old pork pigs too. Rats and Bears are also known vectors. Who eats RATS? Ever seen the first few seasons of Survivor?

Not sure why he got septic. Could it be bugs carried by the nematode larvae through the GI wall? Or is a red herring caused by COVID pneumonia? Might be interesting to know what bacteria he had: enteric or gram pos cocci?

We just got past a cold snap in Colorado, below zero F, lots below zero C!

James M. Small, MD, PhD, FCAP
Associate Professor of Pathology and Microbiology
Clinical Career Adviser
Rocky Vista University

Andrew writes:

Kia ora from Pongaroa.

The weather is drought. Well at least I don’t have to mow the lawn so often.

No book won yet but I would rather have a livestream. I suppose that would depend on Daniel’s schedule which will still be very busy. I can wait – I have been waiting quite a while for a book 🙂

My guess is Strongyloidiasis due to Strongyloides stercorali. This parasite is found in the region and there are great pictures in the net of the serpiginous trails left by the nematodes in agar plates. What a lovely word serpiginous is, I have added it to my vocabulary. I am going to avoid the treatment phase as with Covid-19 being a co-infection it would seem to me that using steroids to treat any SARS-CoV-2 complications might have a dangerous interaction with the strongyloidiasis infection. I am looking forward to Audun’s “reveal” to see how his treatment was handled.

n ā 

Andrew

Taudgirdas writes:

Good day TWiP, hope all is going well.

This is my first time guessing a case so I hope it goes okay.  Lately, I’ve been going through Dickson’s lectures on “Parasites without borders”, so his lectures definitely helped me a lot in trying to make this diagnosis.

So, given the patient’s epidemiology, it is highly likely that he had a soil-transmitted helminth. There are a few of them, namely ascaris, hookworm and strongyloides whose life cycle passes through the lungs and trachea, and (I think) theoretically can be found in the sputum sometimes, however, ascaris and hookworm produce thousands of eggs per day which would easily be found in the stool examination but in strongyloidiasis it is the L2 larva that is usually excreted with the stool and their numbers are usually small thus giving the sensitivity of stool examination only about 50%, and this is probably why the stool examination in the patient’s case was clean. In addition, the L3 of  strongyloides stercoralis is known for moving as fast as 10cm/hour, so I’m guessing that is the serpiginous trail that was seen on the agar plate of the sputum sample.

In conclusion, my guess is that the steroid treatment he received for COVID (and maybe his diabetes too) resulted in L2 larva in the intestines developing into L3, thereby facilitating autoinfection and the migration of L3 throughout the body including the lungs, causing disseminated strongyloidiasis.

— 

Regards,

Taudgirdas Persaud, MD, MHM

Mahmoud writes:

Hello everybody.

Thanks for all what you do. Too sad that I missed all these years.

I think the case presented is a case of steroid induced Strongyloides stercoralis hyper-infection ( auto-infection) 

The larva seen in sputum is a stage of SS going through the lungs.

Bacterial sepsis with more than one organism growing from peripheral blood is expected following massive larval penetration through the gut wall.

Sometimes peripheral eosinophilia is observed on a peripheral blood smear with eosinophilic pneumonitis of the lungs.

Great case.

Thank you all.

Elise writes:

Dear TWiP Trifecta, 

I hope this finds you all well and congratulations to all three of you for successfully getting vaccinated. It may be a peculiar thing to cheer on but I feel such a tremendous relief every time I encounter someone who has completed the vaccine regimen.

It is bright, windy and  43 degrees F (6 C) in lower Manhattan and I am trying to type quickly because I’m very late and want to submit a diagnostic guess. 

I think that the Ecuadorian patient may perhaps be suffering from Pulmonary strongyloidiasis, and I suspect the piece of information that shifted the patient’s diagnosis away from being purely COVID-19 was an appearance of the nematode in the agar.

While strongyloidiasis is not uncommon in Ecuador, and it is possible to be infested with Strongyloides stercoralis  for a long time and not have particular symptoms, or at least not have symptoms  profound enough to seek a diagnosis, pulmonary strongyloidiasis is more rare. 

Strongyloides stercoralis is a nematode common in tropical and subtropical countries, including Ecuador, and is easily transmitted through soil. Since the gentleman worked in the timber industry and on a farm in Ecuador, he had ample opportunity to get exposed. Since these infections can be chronic, I  suspect that the combination of his diabetes, the COVID-19 and especially the steroids he took may have nudged the latent strongyloides infection into the pulmonary form, which tends to appear most often in patients who are immunocompromised. (This may also explain why he developed florid eosinophilia so rapidly after not presenting much in the way of eosinophils weeks earlier.)

Was the gentleman able to recover? It seems so horrible to have to face down a nematode on top of a savage virus and a chronic health condition.

I”m sending this off to you all now with no more fanfare because I suspect you are recording very shortly and don’t want to miss my chance. 

As always, so many best wishes and thanks for all you do. 

Elise (in Lower Manhattan)

Peter writes:

Dear Luminaries in the TWIP Firmament

TL;DR: strongyloidiasis

The gentleman mentioned in TWIP 192 is from rural Ecuador, a region where strongyloides infection is common [1]. WHO warns [2] that treatment with corticosteroids can lead to hyperinfection or disseminated strongyloides, leading to the bacteraemia and pneumonia mentioned [3]. Eosinophilia in strongyloidiasis is commonly intermittent, especially in asymptomatic patients [4]. While Agar Plate Culture (APC) is one of the more sensitive methods for detecting strongyloides, it is time consuming to perform [4]. The WHO recommends presumptive treatment with ivermectin for patients from regions where strongyloides infection is common [2] (an *recommended* use of ivermectin in the context of COVID-19). 

This case reminds us of the importance of a good patient history (although perhaps not one so good that “cultures wait on *me* to finish” [5]).

Peter

from sunny Cape Town (22°C/71°F)

References

[1] https://www.ajtmh.org/view/journals/tpmd/102/2/article-p346.xml

[2] https://www.who.int/news/item/17-12-2020-a-parasitic-infection-that-can-turn-fatal-with-administration-of-corticosteroids

[3] Parasitic Diseases 7th edition (p. 234).

[4] https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002002

[5] https://twitter.com/DGlaucomflecken/status/1367560030329790466

Katy-Jane writes:

Hi all,

I’ll keep it short because you are getting tons of emails these days (which is awesome, because it means you have tons of listeners).

Weather:

25F, heading to 40F and the maple trees have been tapped for syrup.

Differential:

The soil-borne helminths: Hookworm (Necatur americanus), common roundworm (Ascaris lumbricoides), and threadworm (Strongyloides stercoralis).

Hookworm results in more GI tract symptoms, and Ascaris is more commonly seen in children than adults. This leaves the threadworm – reading in PD7, threadworm infections flare up in times when the patient is immunocompromised (our patient had COVID-19), and can be exacerbated by use of steroids (with which our patient was treated).

Diagnosis:

Threadworm (Strongyloides stercoralis).

Thanks again for spreading your knowledge!

Katy-Jane Shanak
Adjunct Faculty in Veterinary & Dairy Sciences
Northcentral Technical College
Wausau, WI

Kevin writes:

Rather than the customary claim of providing a ‘deep dive’, I will provide a shallow paddle in my response to Dr. Lier’s clinical case (and his enjoyable October 2020 ASHTM case report).

Serpiginous tracks? This doesn’t sound like bacterial swarming motility on culture media…..which produces some beautiful fractal patterns. Dr. Lear didn’t hide his hoof tracks too well, and his beautiful pictures are quickly unearthed on google images. Hookworm larvae can also be detected on agar plates, though stool is needed for that… (see endnotes on the Koga agar plate method.)

The patient’s tropical origins, high dose steroid treatment, absence followed by appearance of eosinophilia point in a particular direction. And those subtle serpiginous tracks on the agar,( credited by Lier to the astute powers of Sid Tansey.) The search string “serpiginous tracks” is pretty taut. My references to strongyloides hyperinfection syndrome can be reviewed in TWiP 154.

What interests me most in this case is the patient’s sepsis and the relationship of the primary pathogen (NO, not SARS-CoV-2, which seems to be a bystander here — I defer to the worm) to the risk of the development of bacterial sepsis with Streptococcus constellatus and Citrobacter freundii. The question is, can strongyloides be a vector? Does our patient’s strongyloides have a balanced diet of gram positive and gram negative bacteria? In this case is it appropriate to ask, “When you hear hoofbeats, should one think of Trojan horses?”

More to the point, what is the relationship between strongyloides infection/hyperinfection and bacterial infection?

So ends this shallow paddle. Discussion of these midnight whispers can be found in ‘A Terminal Curiosity.’

A TWiP of the hat to you three plus Lier

ENDNOTES

Lier AJ, Tuan JJ, Davis MW, Paulson N, McManus D, Campbell S, Peaper DR, Topal JE. Case Report: Disseminated Strongyloidiasis in a Patient with COVID-19. Am J Trop Med Hyg. 2020 Oct;103(4):1590-1592.

Clinical Infectious Diseases 2005; 40:1464 An Elderly Man with Immunosuppression, Shortness of Breath, and Eosinophilia Jehad Abdalla Picture of ‘serpiginois tracks’. Lier’s photos are much better.

  Newberry AM, et al. Strongyloides hyperinfection presenting as acute respiratory failure and gram-negative sepsis. Chest. 2005;128(5):3681-3684. doi:10.1378/chest.128.5.3681

Definition:  The Koga agar plate culture is a technique for the detection of helminth larvae. The principle behind this technique is that when fresh stool is incubated on the agar plate, the larvae of helminths will grow and move around the plate, leaving characteristic tracks on the surface of the agar. The larvae can subsequently be detected with microscopic examination. This SOP is applicable for the diagnostic evaluation of Strongyloides stercoralis and hookworms in patients enrolled under the digestive syndrome of the NIDIAG study in Côte d’Ivoire, Indonesia, Mali and Nepal /// from the Procedure section:3. Scoop approximately 2 g of a fresh stool sample and place it at the center of the agar plate. Cover the agar plate (please see Figure 1). 3. Incubate the stool-filled agar plate in an incubator (26 – 33ºC) for 48 hours (hr). 4. Examine the agar plate visually for characteristic tracks of the larvae.    YUMMY!  

https://journals.plos.org/plosntds/article/file?type=supplementary&id=info:doi/10.1371/journal.pntd.0004818.s015

A TERMINAL CURIOSITY

Abbreviations: HIS (strongyloides hyperinfection syndrome), DS (disseminated strongyloides)

The patient in TWiP 192 had a nice smorgsrbord of organisms: virus, nematode, and bacteria. I’m curious about the relationship between the worm and the germ.

A frequently postulated mechanism by which strongyloidiasis causes bacteremia and meningitis is that parasitic ulceration/perforations of the intestinal mucosa create a portal of entry for enteric bacteria to reach the bloodstream.

A different view, advanced by Lacharme-Lora (2009) is that helminths may ‘play a role as pathogen vectors…to livestock and humans.’ She discusses both free living and parasitic helminths. There is no doubt that nematodes like to eat bacteria, and that the bacteria remain alive in the gut of the worm (see photo below)

There are also interesting associations between DS/HIS and bacterial meningitis. Though this association is rare, it raises interesting questions about the possibility of helminthic phoresis of pathogenic bacteria. The worm being a kind of public transit system for bad cocci.

Anyway, it’s food for thought….as bacteria may be food for worms.

Sue me, I said it was gonna be a shallow paddle.

REFERENCES TO ‘A TERMINAL CURIOSITY’

Sasaki Y, Taniguchi T, Kinjo M, et al. 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. Infection. 2013;41(6):1189-1193. doi:10.1007/s15010-013-0483-2

Mantovani A, Restani R, Sanguinetti V. Parasitic nematode larvae as agents of transmission of pathogenic bacteria. Wiad Parazytol. 1976;22(4-5):379-83. PMID: 189513.

nematodes are believed to be vectors of bacterial and fungal infections in plants…

Hübner MP, Layland LE, Hoerauf A. Helminths and their implication in sepsis – a new branch of their immunomodulatory behaviour?. Pathog Dis. 2013;69(2):127-141. doi:10.1111/2049-632X.12080

highly speculative article suggesting that the rise of sepsis morbidity and mortality, and increasing Gm+ sepsis could be do to the lack of helminth infection and its associated immune modulation….??? crankish  Overall, there is a growing body of evidence suggesting that helminths or molecules thereof may improve the outcome of bacterial co-infections and bacterial-induced sepsis. This extends upon their already established role in preventing allergy and autoimmunity but as with that line of research, prevention appears to be dependent on the combination of helminth and bacteria.

concept: bacterial translocation (shown in exptl hookworm, schistosome and fasciola infections)

Lacharme-Lora L, et al. Bacteria isolated from parasitic nematodes–a potential novel vector of pathogens? Environ Health. 2009 Dec 21;8 Suppl 1(Suppl 1):S17.  “Here, we determine the potential for bacteria to be associated with parasitic helminths.”….We concluded that bacteria of livestock can be isolated inparasitic helminths and that this suggests a mechanism by which bacteria, pathogenic or otherwise,can be transmitted between individuals. The potential for helminths to play a role as pathogenvectors poses a potential livestock and human health risk. Further work is required to assess theepidemiological impact of this finding….

David on behalf of the Parasitology Club of the University of Central Lancashire writes:

Dear TWIP Professors, 

Thank you for another fascinating case study. 

The University of Central Lancashire is in Preston in the wonderful North West of England and Preston is famous for a number of things with an American connection. 

The parents of legendary American outlaw Butch Cassidy lived in Preston before emigrating to America. It was said that Butch spoke with a strong Lancashire accent. 

For example, ‘Ay-up’, means how are you doing. ‘Artoreet’ – are you alright.  ‘Aye’ – Yes, I am alright thank you.  Lancashire is quite an efficient language.  

Benjamin Franklin, once stayed at a property in Preston whilst visiting family. 

The UK’s first Kentucky Fried Chicken store is on Fishergate High Street, in Preston and was opened by Ray Allen who met Colonel Harland Sanders in 1963, securing the rights for his secret fried chicken recipe for the UK.  

We believe the Ecuadorian gentleman who fell even more sick during his recovery from COVID-19 infection was likely carrying a chronic quiescent infection with either hookworm or Strongyloides stercoralis which was activated to cause a hyperinfection syndrome when the patient was given an immunosuppressive corticosteroid to control some of the immune pathology associated with COVID-19 infection.  Secondary pneumonia following a viral respiratory tract infection is not uncommon and pathogens such as Streptococcus pneumoniae, Haemophilus influenzae and others can be found in high numbers in sputum and brochoalveolar washings.   The serpiginous trail indicates a microscopic worm that may have been coughed up or washed up in the BAL crawling out of the well of inoculum on the agar surface and taking with it some bacterial cells which subsequently grew into a serpiginous trail of colonies.  Hookworm larvae are in the region of 5-13mm depending on the species so would likely be visible on the agar surface but Strongyloides are much smaller in the range of 0.6-1.0 mm and are likely not visible even at the end of the trail, without the aid of microscopy. 

The patient recovered quickly with treatment presumably with ivermectin (CDC, 2021) and developed an eosinophilia in response to the extra-intestinal systemic parasitaemia whereas the chronic infection is largely restricted to the gut lumen and may not normally stimulate a strong eosinophilic response (Shin et al., 2009).    

Guevara et al (2020) report an incidence of between 21-67 % seropositivity for Strongyloides in samples from 8 regions in Ecuador and reported that 69 of 78 seropositive patients demonstrated eosinophilia before testing seropositive for Strongyloides. The highest incidence was found in the rural, coastal community of Jipijapa where coffee and corn are grown, and purified water supplies are limited. 

Thank you again for a great case to study. 

David on behalf of the Parasitology Club of the University of Central Lancashire. 

https://www.cdc.gov/parasites/strongyloides/treatment.html

Guevara, A. G., Anselmi, M., Bisoffi, Z., Prandi, R., Márquez, M., Silva, R., Vicuña, Y., Calvopiña, M., Cevallos, W., Pérez, J., Baldeón, L., & Buonfrate, D. (2020). Mapping the Prevalence of Strongyloides stercoralis Infection in Ecuador: A Serosurvey, The American Journal of Tropical Medicine and Hygiene, 102(2), 346-349. Retrieved Mar 4, 2021, from https://www.ajtmh.org/view/journals/tpmd/102/2/article-p346.xml 

Shin MH, Lee YA, Min DY. Eosinophil-mediated tissue inflammatory responses in helminth infection. Korean J Parasitol. 2009;47 Suppl(Suppl):S125-S131. doi:10.3347/kjp.2009.47.S.S125 

Owain writes:

Dear TWIP,

Cool case this week! This man sounds like his initial symptoms were due to COVID-19, but I think the steroids he was given caused a pre-existing infection with Strongyloides to flare up and become disseminated strongyloidiasis. Steroids are a common precipitant, and this can also cause secondary bloodstream infections as this gentleman unfortunately had. 

The trail on the plate suggests that a larval stage was coughed up during the heart-lung migration stage. Other nematodes develop this way, including hookworm and Ascaris – he might have been exposed to in Ecuador, but these infections would not self-perpetuate for a long time outside an endemic area, and would be less likely to cause such a severe illness. 

Here’s hoping I’m right!

All the best,

Owain

Jody writes:

Greetings, distinguished docs,

It’s 48 and sunny here in Seattle — decidedly mask-and-flip-flop weather around these parts! — and many of us are lurching out of our caves, putting on pants (hopefully remembering to do the latter before the former), and taking our kids to hybrid school. We are all going through the awkward process of relearning basic skills of civilized society (greetings, small talk, etc.), but at least we are doing it together and in small, forgiving groups to start.

I’m afraid I might miss the window to get this in, so I’ll keep it short. I believe the older, male human formerly of Ecuador is suffering from an infection with Strongyloides. The key word “serpiginous” was my fast track to this frisky helminth featured in PD7, and I cannot not share the morbid-grin-inducing factlet dropped in the chapter entitled The Nematodes: that the larvae “have been observed to migrate through the skin as fast as 5-15 cm per hour.” Oh, the exquisite horror of parasitic disease! Larvae can be identified in sputum as seems to have occurred in this case, and either albendazole or ivermectin may have been administered to help this poor gentleman to an eventual recovery. I am relieved to hear that he made it through both this trial and a bout with covid, the combination of which must have been very scary. 

Episode 192’s title reminded me of an article I read before visiting Iceland many years ago: “Wash Thoroughly Without a Swimsuit.” I remember it being a detailed look into the swimming and soaking culture of Iceland (including their obsession with swimmers’ pre-swim hygiene) and I was so glad I read it before I took my own dip in a public Reykjavik pool, as it prepared me for the icy glare of the octogenarian locker room attendant in charge of nook-and-cranny surveillance. She cruelly watched my bashful attempts to quickly scour away any offensive microbial passengers I might be harboring on my naked body, and even barked at me mid-rinse to do a better job before I hurriedly squeezed my swimsuit on. A terrifying experience for someone raised in the prudish USA, but their methods seem to work as they keep their bacteria levels down despite minimal use of chlorine.

I hope you’re all doing well, and I’d like to shout my support here for something Vincent teased us with during his livestream with Amy last night: a livestream with Daniel. Yes please! And I can’t wait to hear more about the recording studio in the works. 

Thanks as always and stay safe,

Jody

Caton writes:

Greetings all,

Greetings Everyone:

I strongly believe it is Strongyloides.

The patient had a silent infection which he probably contracted years before from soil contaminated with human feces while doing agricultural work in Ecuador, or perhaps some time during his childhood there.  

While being treated for Sars-CoV-2 in the hospital, the use of dexamethasone induced a hyper infection of Strongyloidiasis.  Fortunately for the patient, an experienced African physician recognized the larvae in his sputum sample. The patient probably would have died if not promptly treated with Ivermectin.   

Question: Should there be an awareness campaign to get infected people treated to avoid unnecessary Covid-19 deaths? 

After reading about Strongyloides I can’t help but wonder if I, too, was infected 30 years ago during my two-year Peace Corps service in Jamaica.  There were plenty of opportunities to get it there.  I  experienced chronic urticaria, including at a location “where the sun don’t shine”.  Upon inspection, the Peace Corps nurse told me I had a case of diaper rash.  I remember thinking how odd a diagnosis it was since at age 26, I hadn’t worn a diaper for about 25 years.

I am currently trying to find a doctor to write me a script for Ivermectin.  It looks like I will have to wait at least 2-3 weeks to see an Infectious Disease Specialist.  I have thought about ingesting my dog’s Heartgard, as an alternative to waiting.  Lucky for me, today I scored a vaccination appointment on St. Patrick’ Day—it’s Moderna.  That puts my mind to rest about landing in the hospital.  But I can’t help to think about how many other people may have this silent ticking time bomb residing within.

Caton Gauthier-Nelson 
S&C Nelson Farm, Grass-fed Beef
Iron River, MI