Scientific Letter
Strongyloides stercoralis Infection with a Diffuse Miliary Pattern
Infección por Strongyloides stercoralis con patrón miliar difuso
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Letter</span>" "titulo" => "<span class="elsevierStyleItalic">Strongyloides stercoralis</span> Infection with a Diffuse Miliary Pattern" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">To the Editor</span>," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "352" "paginaFinal" => "353" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Bruno Hochhegger, Gláucia Zanetti, Edson Marchiori" "autores" => array:3 [ 0 => array:3 [ "nombre" => "Bruno" "apellidos" => "Hochhegger" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Gláucia" "apellidos" => "Zanetti" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:4 [ "nombre" => "Edson" "apellidos" => "Marchiori" "email" => array:1 [ 0 => "edmarchiori@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Irmandade Santa Casa de Misericórdia de Porto Alegre, Rio Grande do Sul, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Radiology, Federal University of Rio de Janeiro, Río de Janeiro, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infección por <span class="elsevierStyleItalic">Strongyloides stercoralis</span> con patrón miliar difuso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1250 "Ancho" => 1500 "Tamanyo" => 317534 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Axial (A) and coronal (B) reformatted CT images show numerous bilateral small nodules, with some confluence in the posterior and lower lung regions. (C) Physical examination demonstrated a purpuric serpiginous rash on the patient's abdomen. (D) Bronchoalveolar lavage revealed the presence of <span class="elsevierStyleItalic">Strongyloides stercoralis</span> filariform larvae.</p>" ] ] ] "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.,<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. Chest computed tomography (CT) demonstrated consolidation in the left upper lobe, with areas of cavitation with irregular walls. Cytological analysis of bronchial aspirate showed <span class="elsevierStyleItalic">S. stercoralis</span> larvae.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We would like to report another case of <span class="elsevierStyleItalic">S. stercoralis</span> hyperinfection, with a very uncommon CT pattern: micronodular dissemination. A 73-year-old man was admitted to our hospital with a 2-week history of productive cough, weakness, fever, and progressive dyspnea. He had lost 8<span class="elsevierStyleHsp" style=""></span>kg weight in 2 months, but had no other complaint. His oxygen saturation in room air was 96%. Laboratory findings were normal. Chest CT revealed numerous bilateral small nodules, with some coalescence in the posterior and lower lung regions (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A, B). On day 8, he developed a maculopapular (purpuric) rash (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Bronchoalveolar lavage (BAL) performed during flexible fiberoptic bronchoscopy revealed the presence of <span class="elsevierStyleItalic">S. stercoralis</span> larvae (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D). BAL findings for bacteria, fungus, and acid-fast bacteria were negative. Blood cultures were also negative. A stool sample demonstrated numerous larvae, as well as a few adult organisms. The patient was negative for human immunodeficiency virus (HIV), but positive for human T-cell lymphotropic virus (HTLV) I/II quantitative antibodies. A diagnosis of <span class="elsevierStyleItalic">Strongyloides</span> hyperinfection syndrome was made, and treatment with ivermectin and albendazole was started.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Strongyloidiasis, an infection caused by the nematode <span class="elsevierStyleItalic">S. stercoralis</span>, is prevalent in tropical and subtropical countries.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2–4</span></a> In the setting of severe immunosuppression, the worm may disseminate, causing severe life-threatening syndromes such as hyperinfection and dissemination, showing massive infection.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> These syndromes are associated with significant morbidity and mortality.<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. The most important risk factor for the development of <span class="elsevierStyleItalic">Strongyloides</span> infection is residence in or visit to an endemic area.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleItalic">S</span>. <span class="elsevierStyleItalic">stercoralis</span> hyperinfection is generally fatal, as it is normally associated with immunosuppression, either iatrogenic (e.g., caused by systemic corticosteroid use) or to underlying illness (e.g., HIV infection, HTLV-1 carriage, or organ transplantation).<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Hyperinfection syndromes manifest clinically in a nonspecific manner, with gastrointestinal and pulmonary symptoms being the most common findings.<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.<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. Radiographic changes may include nodular, reticular, and airspace opacities, with distribution ranging from multifocal to lobar.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Blood eosinophilia is seen in more than 75% of patients with chronic <span class="elsevierStyleItalic">Strongyloides</span> infection, but may be absent in immunocompromised patients with hyperinfection syndrome.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3,5</span></a> Detection of a large number of larvae in stool and/or BAL fluid or sputum is a hallmark of hyperinfection.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Therefore, the diagnosis rests mainly on the recognition of the organism's morphology in pathology specimens.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> In conclusion, in endemic areas, <span class="elsevierStyleItalic">Strongyloides</span> hyperinfection should be included in the differential diagnosis of pulmonary miliary lesions.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hochhegger B, Zanetti G, Marchiori E. Infección por <span class="elsevierStyleItalic">Strongyloides stercoralis</span> con patrón miliar difuso. Arch Bronconeumol. 2017;53:352–353.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1250 "Ancho" => 1500 "Tamanyo" => 317534 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Axial (A) and coronal (B) reformatted CT images show numerous bilateral small nodules, with some confluence in the posterior and lower lung regions. (C) Physical examination demonstrated a purpuric serpiginous rash on the patient's abdomen. (D) Bronchoalveolar lavage revealed the presence of <span class="elsevierStyleItalic">Strongyloides stercoralis</span> filariform larvae.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary <span class="elsevierStyleItalic">Strongyloides stercoralis</span> infection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "V. Esteban Ronda" 1 => "J. Franco Serrano" 2 => "M.L. 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Ong" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2014" "volumen" => "59" "paginaInicial" => "601" "paginaFinal" => "602" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Strongyloides</span> hyperinfection syndrome: an emerging global infectious disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L.A. Marcos" 1 => "A. Terashima" 2 => "H.L. Dupont" 3 => "E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 5 | 9 |
| 2024 October | 61 | 22 | 83 |
| 2024 September | 65 | 18 | 83 |
| 2024 August | 63 | 40 | 103 |
| 2024 July | 64 | 23 | 87 |
| 2024 June | 81 | 45 | 126 |
| 2024 May | 88 | 26 | 114 |
| 2024 April | 66 | 31 | 97 |
| 2024 March | 51 | 24 | 75 |
| 2024 February | 43 | 29 | 72 |
| 2023 March | 17 | 11 | 28 |
| 2023 February | 70 | 24 | 94 |
| 2023 January | 102 | 26 | 128 |
| 2022 December | 118 | 33 | 151 |
| 2022 November | 114 | 31 | 145 |
| 2022 October | 96 | 51 | 147 |
| 2022 September | 86 | 19 | 105 |
| 2022 August | 100 | 42 | 142 |
| 2022 July | 103 | 49 | 152 |
| 2022 June | 106 | 38 | 144 |
| 2022 May | 88 | 32 | 120 |
| 2022 April | 112 | 36 | 148 |
| 2022 March | 164 | 39 | 203 |
| 2022 February | 115 | 37 | 152 |
| 2022 January | 160 | 40 | 200 |
| 2021 December | 125 | 47 | 172 |
| 2021 November | 108 | 50 | 158 |
| 2021 October | 131 | 55 | 186 |
| 2021 September | 85 | 42 | 127 |
| 2021 August | 116 | 40 | 156 |
| 2021 July | 72 | 28 | 100 |
| 2021 June | 107 | 45 | 152 |
| 2021 May | 118 | 59 | 177 |
| 2021 April | 316 | 122 | 438 |
| 2021 March | 197 | 27 | 224 |
| 2021 February | 89 | 31 | 120 |
| 2021 January | 94 | 24 | 118 |
| 2020 December | 79 | 31 | 110 |
| 2020 November | 94 | 24 | 118 |
| 2020 October | 76 | 18 | 94 |
| 2020 September | 55 | 19 | 74 |
| 2020 August | 58 | 24 | 82 |
| 2020 July | 48 | 28 | 76 |
| 2020 June | 55 | 18 | 73 |
| 2020 May | 57 | 18 | 75 |
| 2020 April | 68 | 19 | 87 |
| 2020 March | 66 | 12 | 78 |
| 2020 February | 79 | 26 | 105 |
| 2020 January | 65 | 17 | 82 |
| 2019 December | 72 | 17 | 89 |
| 2019 November | 45 | 20 | 65 |
| 2019 October | 63 | 18 | 81 |
| 2019 September | 49 | 20 | 69 |
| 2019 August | 32 | 23 | 55 |
| 2019 July | 45 | 21 | 66 |
| 2019 June | 38 | 8 | 46 |
| 2019 May | 67 | 20 | 87 |
| 2019 April | 54 | 53 | 107 |
| 2019 March | 60 | 34 | 94 |
| 2019 February | 28 | 18 | 46 |
| 2019 January | 35 | 20 | 55 |
| 2018 December | 37 | 28 | 65 |
| 2018 November | 55 | 35 | 90 |
| 2018 October | 86 | 26 | 112 |
| 2018 September | 29 | 12 | 41 |
| 2018 May | 24 | 0 | 24 |
| 2018 April | 41 | 9 | 50 |
| 2018 March | 45 | 8 | 53 |
| 2018 February | 59 | 8 | 67 |
| 2018 January | 82 | 4 | 86 |
| 2017 December | 54 | 8 | 62 |
| 2017 November | 23 | 4 | 27 |
| 2017 October | 27 | 9 | 36 |
| 2017 September | 43 | 12 | 55 |
| 2017 August | 2 | 1 | 3 |
| 2017 April | 0 | 1 | 1 |
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