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Strongyloidiasis
Author: Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of
Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-
New Jersey Medical School
Coauthor(s): Mordechai M Tarlow, MD, Clinical Associate, Department of Dermatology,
University of Pennsylvania School of Medicine
Contributor Information and Disclosures
Introduction
Background
Pathophysiology
Strongyloidiasis is typically acquired when the infective filariform larvae penetrate the skin
during contact with contaminated soil, although ingestion of filariform larvae via the fecal-oral
route can also result in infection. The larvae are transferred through the circulation to the lungs.
From the lungs, they ascend to the glottis via the bronchi and are subsequently swallowed. In the
duodenum and jejunum, the larvae burrow into the mucus membrane, where, after molting, the
female worm produces eggs by parthenogenesis, which yields noninfective rhabditiform larvae.
These larvae can be passed in the stool and become infective filariform larvae, or they can
develop into adults in the external environment and produce rhabditiform larvae. In the external
environment, the rhabditiform larvae can complete the free-living cycle, or they can become
infective filariform larvae with the potential to penetrate the skin of another individual.
Autoinfection occurs when noninfective rhabditiform larvae prematurely transform into infective
filariform larvae (ie, before leaving the body) and reenter the circulation by 1 of 3 methods. For
the first, the larvae penetrate the mucosa of the colon and cause indirect endoautoinfection. For
the second, the larvae penetrate the mucosa of the upper small intestine and cause direct
endoautoinfection. For the third, the larvae penetrate the perianal skin and cause
exoautoinfection. The last method has been associated with the development of larva currens.
After entering the circulation, the larvae are carried to the lungs, where the cycle repeats itself.
This mechanism accounts for the chronicity and frequent recurrence of the disease in patients
who no longer live in areas in which the disease is endemic.
In immunocompromised hosts, larvae may migrate beyond the normally controlled internal
pathways, with widespread dissemination to the extraintestinal regions, including the CNS, heart,
urinary tract, endocrine organs, and skin. Millions of filariform larvae reach the skin by means of
the circulation or direct invasion from body cavities; they can migrate through all levels of the
dermis and involve the subcutaneous tissue.
Frequency
United States
Strongyloidiasis is relatively uncommon. Endemic foci exist in rural areas of the southeastern
United States and Appalachia, with prevalence rates close to 4%.3 Infections acquired in the
United States, while not usually associated with larva currens, are not clinically silent; the
infected individuals usually have a chronic relapsing illness of mild to moderate severity. Among
veterans of the US military forces who served in Southeast Asia, the prevalence of larva currens
in those with confirmed strongyloidiasis is high, with studies showing a range of 30-90%.4,5
International
Mortality/Morbidity
Race
No racial predilection is recognized; however, it is highly prevalent in some tropical Aboriginal
communities in Australia.8
Sex
No sex predilection is reported.
Age
Infection can occur in individuals at any age, although infection is more common during
childhood than at other times. Advanced age is a risk factor for severe strongyloidiasis because it
may be associated with an immunosuppressed state.
Clinical
History
Strongyloides infection is associated with cutaneous and systemic signs and symptoms that can
be categorized by the stage of disease. Infection can be asymptomatic, can cause a wide variety
of clinical syndromes, or can result in death.
Acute infection
o Cutaneous features
Most often, the area is also pruritic. This rash has been referred to
as ground itch.
o Systemic features
Pulmonary symptoms caused by the migration of larvae through
the lungs may result in coughing, shortness of breath, and fever.
Chronic infection
o Cutaneous features
o Systemic features
o Cutaneous features
Physical
Strongyloides infection is associated with cutaneous and systemic signs and symptoms that can
be categorized by the stage of disease.
Acute infection
o Cutaneous findings
o Systemic findings
Chronic infection
o Cutaneous findings
Similar lesions may also occur on the groin and trunk, and areas of
involvement on the thighs and upper body have been described as well.
o Systemic findings
o Cutaneous findings
o Systemic findings
Causes
The parasite responsible for strongyloidiasis is S stercoralis. Other species in the genus
Strongyloides include Strongyloides myopotami and Strongyloides procyonis. These species have
animal hosts and are thus responsible for zoonotic infections.12
o Malignancy
o Collagen-vascular disease
o Diabetes mellitus
o Malnutrition
o Advanced age
In patients who were exposed to the parasite, the likelihood of Strongyloides
should be carefully assessed before immunosuppressive therapy is begun.