Infection (2015) 43:691–698

DOI 10.1007/s15010-015-0799-1

ORIGINAL PAPER

Strongyloides stercoralis hyperinfection syndrome: a case series

and a review of the literature
Guillaume Geri1,2 · Antoine Rabbat4 · Julien Mayaux5 · Lara Zafrani6,7 ·
Ludivine Chalumeau‑Lemoine8 · Bertrand Guidet9,10 · Elie Azoulay6,7 ·
Frédéric Pène1,2,3

Received: 18 January 2015 / Accepted: 15 May 2015 / Published online: 26 May 2015
© Springer-Verlag Berlin Heidelberg 2015

Abstract respiratory (88.6 %), and gastrointestinal (71.2 %) symptoms

Background Strongyloides stercoralis may lead to over- were common clinical manifestations. Shock occurred in 75
whelming infestation [Strongyloides hyperinfection syn- (57.3 %) patients and mechanical ventilation was required
drome (SHS)]. We aimed at describing a case series of in 89 (67.9 %) patients. Hypereosinophilia and a concomi-
patients admitted in intensive care unit (ICU) with SHS and tant bacterial infection were observed in 34 (34.3 %) and 51
report a literature review of such cases. (38.4 %) patients, respectively. The in-ICU mortality rate
Patients and methods Retrospective multicenter study of was 60.3 %. Predictive factors of ICU mortality were shock
11 patients admitted to the ICU of tertiary hospitals with occurrence [Odds ratio (OR) 18.1, 95 % confidence interval
SHS between 2000 and 2013. Literature review with Pub- (95 % CI) 3.03–107.6, p < 0.01] and mechanical ventilation
med retrieved 122 cases. Logistic regression analysis was (OR 28.1, 95 % CI 3.6–217, p < 0.01). Hypereosinophilia
performed to identify predictive factors of ICU mortality (OR 0.21, 95 % CI 0.06–0.7, p = 0.01) and a concomitant
and shock occurrence. bacterial infection (OR 4.68, 95 % CI 1.3–16.8, p = 0.02)
Results 133 patients [median age 53 (39, 64), 72.2 % were independent predictors of shock occurrence.
males] were included. Underlying immunosuppression Conclusion SHS remains associated with a poor outcome,
was present in 127 patients, mostly long-term corticos- especially when associated with shock and mechanical ven-
teroid treatment in 111 (83.5 %) patients. Fever (80.8 %), tilation. Deterioration to shock is often related to concomi-
tant bacterial infection. The poor outcome of established
SHS pleads for a large application of antiparasitic primary
On behalf of the Groupe de Recherche sur la Réanimation prophylaxis in at-risk patients.
Respiratoire en Onco-Hématologie (Grrr-OH).

Electronic supplementary material The online version of this

Keywords Strongyloides stercoralis · Hyperinfection ·
article (doi:10.1007/s15010-015-0799-1) contains supplementary Eosinophilia
material, which is available to authorized users.

6
* Guillaume Geri Service de réanimation médicale, Hôpital Saint Louis, APHP,
guillaume.geri@cch.aphp.fr Paris, France
7
1 Université Paris Diderot, Paris, France
Service de réanimation médicale, Hôpital Cochin, APHP,
8
27 rue du faubourg Saint‑Jacques, 75014 Paris, France Service de réanimation polyvalente, Institut Gustave Roussy,
2 Villejuif, France
Université Paris Descartes, Paris, France
9
3 Service de réanimation médicale, Hôpital Saint-Antoine,
Institut Cochin, INSERM U1016, CNRS UMR8104, Paris,
APHP, Paris, France
France
10
4 Université Pierre et Marie Curie, Paris, France
Unité de soins intensifs respiratoires, Hôpital Cochin, APHP,
Paris, France
5
Service de réanimation médicale, Groupe Hospitalier
Pitié-Salpêtrière, APHP, Paris, France

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692 G. Geri et al.

Introduction research network within a 14-year period (2000–2013). To

this aim, we performed searches both through medical files
Strongyloidiasis encompasses various disorders caused by in the ICU and records from the parasitology laboratories.
a soil dwelling nematode helminth, Strongyloides stercor- In addition we performed an exhaustive review of the lit-
alis. It occurs in about 30 million people in 70 countries erature in order to collect the previously published cases of
worldwide [1–3]. It is more frequently observed in endemic SHS.
tropical and subtropical zones including the southern SHS was defined as disseminated strongyloidiasis
United States of America, but it can be observed as well implying the presence or exacerbation of gastrointestinal
in non-endemic areas such as European countries. Besides and/or respiratory symptoms attributable to increased lar-
the common gastrointestinal presentation with diarrhea, val migration [5]. Parasitologic detection was performed on
two characteristic clinical syndromes of acute infection and available samples: stools, gastrointestinal biopsies, respira-
hyperinfection syndrome have been described. Acute infec- tory samples analysis, cerebrospinal fluid, skin biopsy, and
tion, also known as Loeffler’s syndrome, is caused by larval other histologic or necropsic examinations. Hypereosino-
invasion and migration and is characterized by cutaneous philia was defined as an eosinophil count higher than 500/
manifestations such as serpiginous urticarial rash, cough, mm3. Endemic areas were defined as zones with Strongy-
dyspnea, and gastrointestinal symptoms. Strongyloides loides stercoralis infection prevalence and was higher than
hyperinfection syndrome (SHS) [4–7] was first described in 10 % as previously described [3].
1970 and is related to disseminated infection with multiple
organ involvement [8]. SHS is caused by massive intesti- Literature review
nal invasion by a high load of parasites, which reach pul-
monary circulation and perforate alveolar membrane lead- The published cases were retrieved in the National Library
ing to alveolar damage and acute respiratory failure [4]. of Medicine’s MEDLINE using the keywords Strongyloi-
The incidence of SHS may reach 2 % among patients with diasis and immunocompromized, Strongyloides hyperinfec-
strongyloidiasis [9]. It typically occurs in immunocompro- tion, malignant Strongyloidiasis, Strongyloides superin-
mised patients with underlying illnesses such as advanced fection. Papers in English and in French were included in
HIV infection. However, it is noteworthy that it is also the review. Two investigators (GG and FP) independently
frequently related to immunosuppressive treatments such reviewed the case reports. The search period ranged from
as corticosteroids, most especially at the time of initiation January 1970 to June 2010. The references of all articles
or dosing increase [4]. Respiratory, gastrointestinal, cuta- were also checked for additional relevant reports. Only
neous, and neurologic symptoms are observed in variable reports including the main clinical and biological data and
frequencies, but a hallmark of SHS is the severity of organ the survival status were taken into account.
failures requiring ICU admission.
To date, single case reports stand for the most part of Data collection
literature in the field of SHS. In this study, we aimed at
describing the clinical and biological characteristics and the We collected the following data for the unpublished and
outcome of critically ill patients with SHS requiring ICU literature cases: demographic data (age, gender, geographic
admission. We performed a retrospective multicenter study origin), underlying immunosuppressive disease [HIV infec-
in order to maintain a high level of suspicion toward diag- tion, hematologic malignancy, cancer, autoimmune dis-
nosis and prevention. In addition, we performed a review ease, Human T-lymphotropic virus 1 (HTLV1) infection],
of literature to identify the previously published cases and treatment with corticosteroids (presence of corticosteroids
series of SHS. treated as a binary variable, daily dose, and time from
corticosteroids initiation and identification of Strongyloi-
des infection), chemotherapy or other immunosuppres-
Patients and methods sive drugs, clinical features including respiratory failure
requiring mechanical ventilation, and shock defined by a
Study design and definitions circulatory failure with persistent hypotension despite fluid
loading and requiring vasopressors, eosinophil count, para-
We performed a retrospective study in order to address the sitologic investigations (serology, stools’ material, gastro-
features and the outcomes of patients admitted to the inten- intestinal tract biopsies, respiratory samples, cerebrospinal
sive care unit for SHS. To this aim, we gathered a cohort of fluid). Standard stool microscopy and Baermann concentra-
original cases (unpublished cases) of SHS from the ICUs tion technique were routinely used. Serological testing con-
involved in the Grrr-OH (Groupe de Recherche sur la Réan- sisted of an enzyme-linked immunosorbent assay to detect
imation Respiratoire chez le patient d’Onco-Hématologie) IgG to a filariform larval antigen. The type of antiparasitic

13
Strongyloides stercoralis hyperinfection syndrome: a case series and a review of the literature 693

treatment (albendazole, thiabendazole, and/or ivermectin) males, with a median age of 53 (39–64) years. Two-thirds of
was collected as well and the outcome was ICU survival. patients originated from Strongyloides endemic area.
An underlying immunosuppression was reported in 127
Statistical analysis patients (95.5 %), 33 of them (25.8 %) had autoimmune
disorders, 27 (21.1 %) had hematologic malignancies, 20
Descriptive statistics were reported as medians (with inter- (15.6 %) had obstructive airway disorders, 16 (12.5 %) had
quartile range) and as numbers (percentage) for continuous solid organ transplantation, 14 (10.9 %) had HIV infec-
and categorical variables, respectively. The characteristics tion, and 12 (9.4 %) had miscellaneous disorders. In HIV-
of patients from the unpublished series and from the litera- infected patients, the median CD4 lymphocyte count was
ture review were compared using Student or Mann–Whit- 34 (14–48) per mm3 and the median viral load was 50157
ney–Wilcoxon’s rank sum test, and Pearson χ2 test or the [6-430000] copies/mL. 111 (83.5 %) patients were treated
Fisher’s exact test, as appropriate. Variables associated with with corticosteroids at a median dose of 40 mg per day. Of
ICU mortality and shock occurrence in univariate analysis note, the corticosteroid dosing had been recently increased
(p value <0.10) were then entered in a multivariate logistic prior to SHS in 34 patients (46.6 % of available data). The
regression analysis using a backward stepwise procedure. median time from corticosteroid treatment initiation to the
The calibration of the model was evaluated by the Hosmer– occurrence of SHS symptoms was 42 days. Adjunctive
Lemeshow test in which a p value >0.20 indicated adequate immunosuppressant or chemotherapy was reported in 33
calibration. Clinically relevant interactions were tested two (24.8 %) and 24 (18.1 %) patients, respectively.
by two using the Wald test (p for interaction <0.10).
Features of Strongyloides hyperinfection syndrome

Results Clinical and biological characteristics of SHS, treatment

modalities, and outcome are presented in Table 2. Fever
Baseline characteristics of patients was observed in most patients (n = 105, 80.8 %). Gastro-
intestinal and respiratory symptoms were very frequent as
One hundred and thirty-three patients including 11 unpub- well (n = 94, 71.2 % and n = 117, 88.6 %, respectively). A
lished cases and 122 previously published cases that met eli- majority of patients exhibited organ failures such as shock
gibility criteria were included in the study. The flow diagram (n = 75, 57.3 %) and acute respiratory failure requiring
of the literature review and the complete list of references mechanical ventilation (n = 89, 70.0 %). Of note, shock
are available in the supplementary file. The patients’ baseline and mechanical ventilation were more frequent in the
characteristics are presented in Table 1. Patients were mostly unpublished case series.

Table 1  Baseline characteristics of patients with Strongyloidiasis (cases retrieved from the literature between 1970 and 2010 and unpublished
cases from France)
All patients Current cases Literature cases
n = 133 n = 11 n = 122

Epidemiologic characteristics
Male gender n (%) 96 (72.2) 8 (72.7) 88 (72.1)
Age [years median (IQR)] 53 (39–64) 50 (45–69) 53 (38–64)
Native from endemic area n (%) 82 (66.7) 7 (87.5) 75 (65.2)
Immunosuppressive medications
Corticosteroids n (%) 111 (83.5) 9 (81.8) 102 (83.6)
Corticosteroid dose [mg/day median (IQR)] 40 (15–60) 40 (20–60) 40 (15–60)
Immunosuppressants n (%) 33 (24.8) 3 (27.3) 30 (24.6)
Chemotherapy n (%) 24 (18.1) 4 (36.4) 20 (16.4)
Time from initiation of corticosteroids to identification of 42 (14–90) 42 (5–42) 42 (14–90)
Strongyloides infection [days median (IQR)]
Underlying disease
Autoimmune disease n (%) 33 (24.8) 3 (27.3) 30 (24.6)
Hematological malignancy n (%) 27 (20.3) 3 (27.3) 24 (19.7)
HIV infection n (%) 13 (10.7) 2 (18.2) 11 (9.9)

Endemic areas were defined as zones with Strongyloides stercoralis infection prevalence was higher than 10 % [3]

13
694 G. Geri et al.

Biologic explorations evidenced hypereosinophilia addition, two cases of Candida albicans fungemia have
in 34 (34.3 %) patients for whom the median count was been reported. Bacterial meningitis was mostly related to
1638 (747–3000) per mm3. Human T-lymphotropic virus 1 Enterobacteriaceae (n = 10), while Enterococcus fae-
(HTLV1) serology was positive in seven out of 16 patients. cium and Streptococcus viridans were documented in three
Strongyloides larvae were retrieved in stools in 98 (93.3 %) and one cases, respectively. The overall outcome of SHS
cases. Respiratory samples including sputum, tracheal aspi- patients was poor with an in-ICU mortality rate of 60.3 %.
rates, or bronchoalveolar fluid evidenced parasitic infection
in 93 (93.9 %) patients. SHS diagnosis was made post- Prognostic factors
mortem in 10 (7.5 %) cases in which necropsy evidenced
multi-organ parasitic invasion. Serological diagnosis was We performed univariate and multivariate analysis in order
reported in 14 cases and was positive in 12 of them. Anti- to identify the factors predictive of ICU mortality (Table 3).
helminthic treatment was distributed between thiabenda- In univariate analysis, fever, concomitant bacterial infec-
zole in 45 (35.3 %) patients, albendazole in 37 (28.9 %) tion, shock, and mechanical ventilation were associated
patients, and ivermectin in 52 (40.6 %) patients. Ivermectin with ICU mortality whereas the endemic zone origin and
was administered by enteral route in most cases (n = 46, hypereosinophilia were negatively associated with ICU
95.8 %), but parenteral administration was occasionally mortality. All these variables were entered into a multivari-
required in 13 (26.5 %) cases. ate logistic regression model. Not surprisingly, organ fail-
Interestingly, a concomitant bacterial infection was ures such as shock (Odds ratio (OR) 18.1, 95 % confidence
observed in 51 (38.4 %) patients. Thirty-four had bactere- interval (95 % CI) 3.03–107.6, p < 0.01) and mechanical
mia, 23 had pneumonias, and 14 had meningitis. Bactere- ventilation (OR 28.1, 95 % CI 3.6–217, p < 0.01) were
mia were due to Enterobacteriaceae in 29 cases, Entero- independently associated with ICU mortality. Further-
coccus species in four cases, Pseudomonas aeruginosa more, we performed an additional analysis with shock as
in two cases, and were polymicrobial in seven cases. In the dependent variable (Table 4). A concomitant bacterial

Table 2  Strongyloides All patients Current cases Literature cases

hyperinfection syndrome n = 133 n = 11 n = 122
features
Clinical features (n = 133)
Fever 105 (80.8) 10 (90.9) 95 (79.8)
Gastrointestinal symptoms 94 (71.2) 10 (90.9) 84 (69.4)
Respiratory symptoms 117 (88.6) 10 (90.9) 107 (88.4)
Neurologic symptoms 33 (25.6) 8 (72.6) 25 (21.2)
Cutaneous symptoms 22 (16.7) 2 (18.2) 20 (16.5)
Concomitant bacterial infection 51 (38.4) 11 (100) 40 (32.8)
Biological features (n = 99)
Hypereosinophiliaa 34 (34.3) 0 (0) 34 (36.6)
Eosinophil count (per mm3) 319 (83–1400) 100 (0–200) 336 (94–1485)
Parasitologic diagnosis modalities
Positive stool detection 98/105 (93.3) 9 (100) 89 (92.7)
Positive respiratory detection 93/99 (93.9) 8 (100) 85 (93.4)
Positive CSF detection 4/28 (14.3) 0 (0) 4 (20)
Positive cutaneous biopsy 6/133 (4.5) 1 (9.1) 5 (4.1)
Post-mortem diagnosis 10/133 (7.5) 0 (0) 10 (8.2)
Antiparasitic treatmentb
Thiabendazole 45 (35.2) 0 (0) 45 (38.5)
Albendazole 37 (28.9) 1 (9.1) 36 (30.8)
Ivermectin 52 (40.6) 10 (90.9) 42 (35.9)
ICU mortality 79 (60.3) 6 (60) 73 (60.3)

Except indicated otherwise, results are expressed as n (%)

a
Hypereosinophilia was defined as eosinophil count higher than 500/mm3
b
Ivermectin and albendazole were used from 1994 to 1995, respectively. Thiabendazole was not used any-
more since 2007

13
Strongyloides stercoralis hyperinfection syndrome: a case series and a review of the literature 695

Table 3  Prognostic factors of Univariate analysis Multivariate analysis

ICU mortality
Odds ratio 95 % CI p value Odds ratio 95 % CI p value

Male gender 1.31 0.60–2.85 0.49 – – –

Age > 53 years 1.23 0.61–2.47 0.57 – – –
Endemic zone 0.43 0.18–0.98 0.05 0.25 0.04–1.61 0.14
Corticosteroids 1.33 0.53–3.35 0.55 – – –
Chemotherapy 0.73 0.30–1.79 0.5 – – –
Autoimmune disease 0.8 0.36–1.80 0.59 – – –
Hematological malignancy 0.78 0.33–1.84 0.57 – – –
HIV infection 2.47 0.64–9.50 0.19 12.03 0.11–1284.76 0.3
Hypereosinophilia 0.28 0.12–0.66 <0.01 0.64 0.12–3.44 0.61
Fever 2.83 1.16–6.94 0.02 1.91 0.14–26.80 0.63
Gastrointestinal symptoms 1.34 0.62–2.88 0.45 – – –
Respiratory symptoms 2.21 0.72–6.80 0.17 0.87 0.06–13.55 0.92
Neurologic symptoms 0.96 0.42–2.16 0.92 – – –
Concomitant bacterial infection 1.96 0.93–4.14 0.08 0.21 0.03–1.48 0.12
Shock 15.65 6.55–37.43 <0.01 18.06 3.03–107.60 <0.01
Mechanical ventilation 24.71 8.96–68.14 <0.01 28.08 3.64–216.95 <0.01
Ivermectin treatment 0.79 0.39–1.62 0.52 – – –

Table 4  Predictive factors of Univariate analysis Multivariate analysis

shock
Odds ratio 95 % CI p value Odds ratio 95 % CI p value

Male gender 1.28 0.59–2.78 0.52 1.09 0.30–3.84 0.91

Age > 53 years 1.32 0.66–2.64 0.43 0.82 0.23–2.94 0.76
Endemic zone 0.89 0.41–1.93 0.77 – – –
Corticosteroids 1.42 0.57–3.56 0.45 – – –
Chemotherapy 1.31 0.53–3.24 0.57 – – –
Autoimmune disease 0.8 0.36–1.79 0.59 – – –
Hematological malignancy 1.11 0.47–2.62 0.81 – – –
HIV infection 0.9 0.28–2.85 0.86 – – –
Hypereosinophilia 0.32 0.14–0.77 0.01 0.21 0.06–0.70 0.01
Fever 2.19 0.89–5.38 0.09 0.60 0.14–2.50 0.48
Gastrointestinal symptoms 2.05 0.95–4.40 0.07 1.61 0.52–5.03 0.41
Respiratory symptoms 0.88 0.29–2.63 0.82 – – –
Neurologic symptoms 1.73 0.75–3.95 0.2 2.40 0.53–10.80 0.26
Concomitant bacterial infection 4.68 2.10–10.41 <0.01 4.68 1.30–16.78 0.02

infection (OR 4.68, 95 % CI 1.3–16.8, p = 0.02) was an cases from about 20 ICUs over a 14-year period; (2) SHS
independent predictor of shock while hypereosinophilia is usually associated with immunosuppressive conditions
(OR 0.21, 95 % CI 0.06–0.7, p = 0.01) was protective. but may be observed without any comorbidities; (3) a con-
comitant bacterial infection is commonly encountered,
most especially in patients with shock; (4) SHS is associ-
Discussion ated with a poor outcome owing to the frequency of organ
failures; (5) Hypereosinophilia may carry a protective role
This study combining original and previously published toward deterioration to shock.
cases of SHS highlights five striking messages: (1) SHS The immune response against Strongyloides sterc-
is a rare disorder in France since we only identified 11 oralis is complex and relies both on polymorphonuclear

13
696 G. Geri et al.

eosinophils and on a potent Th-2 adaptive immune patients and that were identified as an independent predic-
response. The particular susceptibility of HTLV1-infected tor of shock. Such bacterial infections are mostly related
patients to SHS emphasizes the importance of T cell to Enterobacteriaceae, thereby suggesting a digestive ori-
response in the host defense against Strongyloides. HTLV-1 gin. Several mechanisms linking helminthic migration and
induces both a Th-1 response and the expansion of regu- bacterial infections have been proposed, including gastro-
latory T cells that result in decreased production of IL-5 intestinal mucous damage [28–30], small bowel bacterial
and eosinophil depletion [10, 11]. Accordingly, expansion overgrowth [31], and bacterial carriage onto the parasite’s
of regulatory T cells has been associated with impaired surface. Furthermore, the release of a Macrophage Migra-
immune response against Strongyloides infection in mouse tion Inhibitory Factor-like protein by the parasite itself may
models, whereas their depletion decreased the worm bur- promote an anti-inflammatory cytokine pattern likely to
den [12]. The polymorphonuclear eosinophil is the corner- favor bacterial superinfections [32, 33]. Thus, patients with
stone of anti-helminthic host defense, acting as an antigen- SHS carry a high risk of bacterial infections that should
presenting cell to induce Th2 adaptive immunity in an prompt early empirical antibiotic treatment in case of organ
IL-5-dependent manner [13–18]. Several experimental data failures.
have demonstrated the critical role of eosinophils against The rarity of SHS precluded a comprehensive assess-
helminths by modulating their numbers or their antigen- ment of treatment in critically ill patients, and the indica-
presenting functions in mice [13, 17, 19–21]. Hypere- tions of antiparasitic drugs in SHS remain largely based on
osinophilia is encountered in about 70 % of patients with their efficacy in chronic strongyloidiasis. Thus, ivermectin
Strongyloides infection but only 20 % of SHS patients [22, currently represents the gold standard treatment of SHS
23]. The involvement of eosinophils was suggested in the since it has been shown to be more efficient than high-dose
present study by the association between hypereosinophilia albendazole in chronic strongyloidiasis [34, 35]. However,
and protection from shock. This finding is consistent with the lack of parenteral formulation of ivermectin approved
previous reports suggesting that eosinopenia was associ- for humans represents a major limit for administration to
ated with a worse outcome in SHS [24, 25]. Whether eosin- critically ill SHS patients who often evidence occlusive
ophilia is directly involved in the pathophysiology of organ syndrome and malabsorption. For this reason, a veteri-
failures or is just a bystander of appropriate antiparasitic nary parenteral formulation of ivermectin has successfully
immune response remains unclear. been used subcutaneously in some case reports, although
A number of immunosuppressive medications are likely the compound’s efficacy remains difficult to establish in
to alter the antiparasitic immune response. Our study high- such biased publications [36–39]. Most importantly, the
lights the major role of corticosteroid treatment as a risk high mortality rate of established SHS strongly pleads for
factor of SHS [7, 8, 26]. Indeed, corticosteroids promote a large implementation of antiparasitic primary prophylaxis
apoptosis of eosinophils and have potent effects on their in patients who stayed in Strongyloides endemic zones and
main functions. In the present report, 83.5 % of patients who have risk factors of SHS, such as initiation or intensi-
were receiving corticosteroid treatment at a median dose fication of immunosuppression. As of today, a single-dose
of 40 mg per day. The main indications for corticosteroids treatment with ivermectin represents a simple, efficient,
were autoimmune disorders or hematological malignancies and cheap preventive intervention against hyperinfection
in combination with chemotherapy [8, 27]. Of note, chronic syndrome [40].
airway disorders were also quite frequent indications of The present study has several limitations. First, we may
corticosteroid treatment (15 % of patients). The very high have missed some cases due to the retrospective design of
prevalence of corticosteroid treatment probably accounted the study. Second, our original cases were obtained from
for the absence of impact on ICU mortality or shock. Con- a non-endemic zone. Third, the literature review of SHS
sidering the lack of specificity of gastrointestinal and res- cases was obviously dependent on publication biases, mak-
piratory symptoms or fever in such immunocompromised ing it impossible to address the real prevalence and inci-
patients, physicians should remain aware that any increase dence of SHS. Fourth, HIV infection might have been
in immunosuppression may result in SHS in patients with underestimated since detection was not available before
chronic Strongyloides infection. 1985. Last, some relevant data were not exhaustively
Multiple organ involvement is a hallmark of SHS. recorded in published cases. However most cases were very
Accordingly, organ failures were frequently observed both detailed, making it possible performing a reliable statistical
in our case series and in the literature cases. Thus shock analysis.
developed in 60 % of the whole cohort, and in 90 % of In conclusion, we here report a comprehensive analy-
unpublished cases. Organ failures might be explained by sis of original and previously published cases of SHS. The
not only overwhelming parasitic invasion, but also by con- deterioration to shock may evoke a concomitant bacterial
comitant bacterial infections that were present in 38.4 % of infection. The poor outcome of established SHS strongly

13
Strongyloides stercoralis hyperinfection syndrome: a case series and a review of the literature 697

supports the large application of antiparasitic eradication eosinophil-dependent immune-mediated killing of third stage
prophylaxis in at-risk patients, particularly in case of initia- larvae in BALB/cByJ mice. Exp Parasitol. 1996;82:267–78.
17. Padigel UM, Hess JA, Lee JJ, Lok JB, Nolan TJ, Schad GA,
tion or intensification of immunosuppression. et al. Eosinophils act as antigen-presenting cells to induce
immunity to Strongyloides stercoralis in mice. J Infect Dis.
Conflict of interest None. 2007;196:1844–51.
18. Padigel UM, Lee JJ, Nolan TJ, Schad GA, Abraham D. Eosino-
phils can function as antigen-presenting cells to induce primary
and secondary immune responses to Strongyloides stercoralis.
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