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weakness&#44; fever&#44; and progressive dyspnea&#46; He had lost 8<span class="elsevierStyleHsp" style=""></span>kg weight in 2 months&#44; but had no other complaint&#46; His oxygen saturation in room air was 96&#37;&#46; Laboratory findings were normal&#46; Chest CT revealed numerous bilateral small nodules&#44; with some coalescence in the posterior and lower lung regions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#44; B&#41;&#46; On day 8&#44; he developed a maculopapular &#40;purpuric&#41; rash &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; Bronchoalveolar lavage &#40;BAL&#41; performed during flexible fiberoptic bronchoscopy revealed the presence of <span class="elsevierStyleItalic">S&#46; stercoralis</span> larvae &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; BAL findings for bacteria&#44; fungus&#44; and acid-fast bacteria were negative&#46; Blood cultures were also negative&#46; A stool sample demonstrated numerous larvae&#44; as well as a few adult organisms&#46; The patient was negative for human immunodeficiency virus &#40;HIV&#41;&#44; but positive for human T-cell lymphotropic virus &#40;HTLV&#41; I&#47;II quantitative antibodies&#46; A diagnosis of <span class="elsevierStyleItalic">Strongyloides</span> hyperinfection syndrome was made&#44; and treatment with ivermectin and albendazole was started&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Strongyloidiasis&#44; an infection caused by the nematode <span class="elsevierStyleItalic">S&#46; stercoralis</span>&#44; is prevalent in tropical and subtropical countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#8211;4</span></a> In the setting of severe immunosuppression&#44; the worm may disseminate&#44; causing severe life-threatening syndromes such as hyperinfection and dissemination&#44; showing massive infection&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> These syndromes are associated with significant morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> The clinical diagnosis is often delayed because the clinical and radiographic findings are nonspecific&#46; The most important risk factor for the development of <span class="elsevierStyleItalic">Strongyloides</span> infection is residence in or visit to an endemic area&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleItalic">S</span>&#46; <span class="elsevierStyleItalic">stercoralis</span> hyperinfection is generally fatal&#44; as it is normally associated with immunosuppression&#44; either iatrogenic &#40;e&#46;g&#46;&#44; caused by systemic corticosteroid use&#41; or to underlying illness &#40;e&#46;g&#46;&#44; HIV infection&#44; HTLV-1 carriage&#44; or organ transplantation&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#44;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Hyperinfection syndromes manifest clinically in a nonspecific manner&#44; with gastrointestinal and pulmonary symptoms being the most common findings&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> The pathognomonic rash of <span class="elsevierStyleItalic">Strongyloides</span> infection is a serpiginous and urticarial petechial purpuric eruption over the abdomen and proximal thigh&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Pulmonary symptoms and signs consistent with adult respiratory distress syndrome or intra-alveolar hemorrhage may be seen&#46; Radiographic changes may include nodular&#44; reticular&#44; and airspace opacities&#44; with distribution ranging from multifocal to lobar&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Blood eosinophilia is seen in more than 75&#37; of patients with chronic <span class="elsevierStyleItalic">Strongyloides</span> infection&#44; but may be absent in immunocompromised patients with hyperinfection syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#44;3&#44;5</span></a> Detection of a large number of larvae in stool and&#47;or BAL fluid or sputum is a hallmark of hyperinfection&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Therefore&#44; the diagnosis rests mainly on the recognition of the organism&#39;s morphology in pathology specimens&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> In conclusion&#44; in endemic areas&#44; <span class="elsevierStyleItalic">Strongyloides</span> hyperinfection should be included in the differential diagnosis of pulmonary miliary lesions&#46;</p></span>"
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Scientific Letter
Strongyloides stercoralis Infection with a Diffuse Miliary Pattern
Infección por Strongyloides stercoralis con patrón miliar difuso
Bruno Hochheggera, Gláucia Zanettib, Edson Marchiorib,
Corresponding author
edmarchiori@gmail.com

Corresponding author.
a Irmandade Santa Casa de Misericórdia de Porto Alegre, Rio Grande do Sul, Brazil
b Department of Radiology, Federal University of Rio de Janeiro, Río de Janeiro, Brazil
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    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Infecci&#243;n por <span class="elsevierStyleItalic">Strongyloides stercoralis</span> con patr&#243;n miliar difuso"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Axial &#40;A&#41; and coronal &#40;B&#41; reformatted CT images show numerous bilateral small nodules&#44; with some confluence in the posterior and lower lung regions&#46; &#40;C&#41; Physical examination demonstrated a purpuric serpiginous rash on the patient&#39;s abdomen&#46; &#40;D&#41; Bronchoalveolar lavage revealed the presence of <span class="elsevierStyleItalic">Strongyloides stercoralis</span> filariform larvae&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the well-written letter to the editor by Ronda et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> who reported the case of an 84-year-old man presenting with severe involvement by <span class="elsevierStyleItalic">Strongyloides stercoralis</span> infection&#46; Chest computed tomography &#40;CT&#41; demonstrated consolidation in the left upper lobe&#44; with areas of cavitation with irregular walls&#46; Cytological analysis of bronchial aspirate showed <span class="elsevierStyleItalic">S&#46; stercoralis</span> larvae&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We would like to report another case of <span class="elsevierStyleItalic">S&#46; stercoralis</span> hyperinfection&#44; with a very uncommon CT pattern&#58; micronodular dissemination&#46; A 73-year-old man was admitted to our hospital with a 2-week history of productive cough&#44; weakness&#44; fever&#44; and progressive dyspnea&#46; He had lost 8<span class="elsevierStyleHsp" style=""></span>kg weight in 2 months&#44; but had no other complaint&#46; His oxygen saturation in room air was 96&#37;&#46; Laboratory findings were normal&#46; Chest CT revealed numerous bilateral small nodules&#44; with some coalescence in the posterior and lower lung regions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#44; B&#41;&#46; On day 8&#44; he developed a maculopapular &#40;purpuric&#41; rash &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; Bronchoalveolar lavage &#40;BAL&#41; performed during flexible fiberoptic bronchoscopy revealed the presence of <span class="elsevierStyleItalic">S&#46; stercoralis</span> larvae &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; BAL findings for bacteria&#44; fungus&#44; and acid-fast bacteria were negative&#46; Blood cultures were also negative&#46; A stool sample demonstrated numerous larvae&#44; as well as a few adult organisms&#46; The patient was negative for human immunodeficiency virus &#40;HIV&#41;&#44; but positive for human T-cell lymphotropic virus &#40;HTLV&#41; I&#47;II quantitative antibodies&#46; A diagnosis of <span class="elsevierStyleItalic">Strongyloides</span> hyperinfection syndrome was made&#44; and treatment with ivermectin and albendazole was started&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Strongyloidiasis&#44; an infection caused by the nematode <span class="elsevierStyleItalic">S&#46; stercoralis</span>&#44; is prevalent in tropical and subtropical countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#8211;4</span></a> In the setting of severe immunosuppression&#44; the worm may disseminate&#44; causing severe life-threatening syndromes such as hyperinfection and dissemination&#44; showing massive infection&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> These syndromes are associated with significant morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> The clinical diagnosis is often delayed because the clinical and radiographic findings are nonspecific&#46; The most important risk factor for the development of <span class="elsevierStyleItalic">Strongyloides</span> infection is residence in or visit to an endemic area&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleItalic">S</span>&#46; <span class="elsevierStyleItalic">stercoralis</span> hyperinfection is generally fatal&#44; as it is normally associated with immunosuppression&#44; either iatrogenic &#40;e&#46;g&#46;&#44; caused by systemic corticosteroid use&#41; or to underlying illness &#40;e&#46;g&#46;&#44; HIV infection&#44; HTLV-1 carriage&#44; or organ transplantation&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#44;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Hyperinfection syndromes manifest clinically in a nonspecific manner&#44; with gastrointestinal and pulmonary symptoms being the most common findings&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> The pathognomonic rash of <span class="elsevierStyleItalic">Strongyloides</span> infection is a serpiginous and urticarial petechial purpuric eruption over the abdomen and proximal thigh&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Pulmonary symptoms and signs consistent with adult respiratory distress syndrome or intra-alveolar hemorrhage may be seen&#46; Radiographic changes may include nodular&#44; reticular&#44; and airspace opacities&#44; with distribution ranging from multifocal to lobar&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Blood eosinophilia is seen in more than 75&#37; of patients with chronic <span class="elsevierStyleItalic">Strongyloides</span> infection&#44; but may be absent in immunocompromised patients with hyperinfection syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#44;3&#44;5</span></a> Detection of a large number of larvae in stool and&#47;or BAL fluid or sputum is a hallmark of hyperinfection&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Therefore&#44; the diagnosis rests mainly on the recognition of the organism&#39;s morphology in pathology specimens&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> In conclusion&#44; in endemic areas&#44; <span class="elsevierStyleItalic">Strongyloides</span> hyperinfection should be included in the differential diagnosis of pulmonary miliary lesions&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Hochhegger B&#44; Zanetti G&#44; Marchiori E&#46; Infecci&#243;n por <span class="elsevierStyleItalic">Strongyloides stercoralis</span> con patr&#243;n miliar difuso&#46; Arch Bronconeumol&#46; 2017&#59;53&#58;352&#8211;353&#46;</p>"
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Article information
ISSN: 15792129
Original language: English
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