Introduction a marker to evaluate the immunosuppressed state

Introduction

•      
Severe
eosinophilia is defined as the association of high numbers of eosinophils (>
5000 x 10^3 cells/uL) in the peripheral blood.

•      
When
caused by Strongyloidiasis in an immunocompromised host, the elusive nature of
the parasite is an obstacle for establishing a diagnosis.

•      
Strongyloidiasis
Stercoralis is considered a marker to evaluate the immunosuppressed state of
patients with impaired cell mediated immunity in many countries. The vast
majority if not all of Strongyloidiasis cases that are documented are found in
patients that are extremely immunosuppressed, most commonly accompanied by
specific risk factors, and present as chronic low-intensity infections which
present as asymptomatic while still remaining dangerous due to the potential of
developing fatal disseminated forms.

•      
Although
reactivation of a latent infection is rare and scarce in literature; cases have
been documented where organ recipients who were negative for IgG levels before
transplantation received an organ from an IgG positive donor and severe
disseminated forms of Strongyloidiasis occurredGB1 .

 

Case

•      
We
present for your consideration GB2 the case of a 63-year-old man
with history of liver transplant performed in July 2015 with no record of
rejection and a positive response to Tacrolimus and Corticosteroid
immunosuppressive therapy.

•      
 A right nephrectomy was performed on January
2017 due to a primary renal pelvis carcinoma discovered by CT-Scan; with
evidence of metastasis to the lungs, liver, and bone, for which he received his
first round of chemotherapy.

•      
Shortly
after his first cycle of chemotherapy he was found with incidental leukocytosis
(88.59 x 10^3 cells/mL) and severe eosinophilia
(67.33 x 10^3 cells/mL) in a control work-up;
which was associated with skin eruption and pruritus, lower back and gluteal
pain secondary to metastatic disease.

•      
He
lived in Caguas his whole life, and worked as telephone and cable specialist.

He traveled to the Dominican Republic constantly; last trip was reported to be
during 2014. He also had history of alcoholism and smoking prior to transplant.

•      
He
was treated with Cefepime to resolve his Gram negative bacteremia with reported
E.Coli predominance and vast susceptibility to antibiotics.

•      
Prednisone
and Tacrolimus were placed on hold when the eosinophilia emerged.

•      
Completed
eosinophilia workup during his inpatientGB3  period.

•      
He
was started on Hydroxyurea and after his leukocytes were seen on a decreasing
trend he was discharged home on the medication.

•      
The
eosinophilia workup showed positive Strongyloides IgG; hence GB4 the treatment was initiated
with Ivermectin which had a positive response as evidenced by the gradual decreasing
values of eosinophils.

 

Discussion

 

•      
Strongyloidiasis
rarely presents as reactivation of a latent infection and in this case where
there has been no known exposure to the parasite. GB5 Clinical manifestations at
the initial stage of Strongyloidiasis vary from urticaria, generalized
pruritus, to abdominal pain. This patient presented pruritus and skin eruption
after his first round of chemotherapy. No other noticeable symptoms, manifestations
or signs in contrast to laboratory results other than high eosinophilic values
over 20,000 in the peripheral blood were found; high IgE levels and a positive
Strongyloides Stercoralis IgG.

•      
The
detection of Gram negative bacteremia with E.Coli was a pivotal sign that
pointed towards the diagnosis of Strongyloides; which is usually the result of
larvae penetrating through the intestinal wall contaminating the exterior with
the intestinal flora.

•      
We
propose the possibility of 3 ways of infection: reactivation of a latent
infection, exposure to the parasite recently, or the result of organ
transplantation; hence our motives of presenting the case being that the incidence
and prevalence of the parasite remains unknown in Puerto Rico.

•      
Other
complications such as hyper-infection syndrome and disseminated
Strongyloidiasis could have easily presented in this patient due to the
multiple present risk factors.

•      
The
possibilities of identifying the etiology of this patient’s infection are
minimal due to: no history of exposure to the parasite, and secondly the
absence of Strongyloides screening in the actual organ transplant protocol
approved by the American Society of Transplantation.

Conclusion

•      
This
case raised awareness of the potential of development of severe and
disseminated forms of Strongyloidiasis in patients who have traveled to, lived
in any endemic area; or patients with fluctuant eosinophilia, since unlike
other intestinal parasites, Strongyloides may remain latent for years, and the
presence of eosinophilia could be the only sign of infection.

•      
Ever
since the Organ Transplant Department of Hospital Auxilio Mutuo has started its
operations there has not been any documented cases of Strongyloidiasis in a
post-transplanted patient. This investigation has raised awareness of the risk
of Strongyloidiasis in the institution and it has helped implement screening
measures, even when the protocol for organ transplantation established by the
American Society of Transplantation does not include any screening for
Strongyloides Stercoralis in non-endemic areas.

 

 

 

References.

 

Schär F, Trostdorf U, Giardina F, et al. Strongyloides stercoralis: Global Distribution and
Risk Factors. Brooker S, ed. PLoS Neglected Tropical Diseases.

2013;7(7):e2288. doi:10.1371/journal.pntd.0002288.

 

Chen
Y-YK, Khoury P, Ware JM, et al. Marked and persistent eosinophilia in the
absence of clinical manifestations. The Journal of allergy and clinical
immunology. 2014;133(4):1195-1202.e2. doi:10.1016/j.jaci.2013.06.037.

 

Roufosse
F, Weller PF. Practical approach to the patient with hypereosinophilia. The
Journal of allergy and clinical immunology. 2010;126(1):39-44.

doi:10.1016/j.jaci.2010.04.011.

 

Abanyie
FA, Gray EB, Delli Carpini KW, et al. Donor-Derived Strongyloides stercoralis
Infection in Solid Organ Transplant Recipients in the United States,
2009–2013. American journal of transplantation?: official journal of
the American Society of Transplantation and the American Society of Transplant
Surgeons. 2015;15(5):1369-1375. doi:10.1111/ajt.13137.

 

Martin,
P., DiMartini, A., Feng, S., Brown, R. and Fallon, M. (2014), Evaluation for
liver transplantation in adults: 2013 practice guideline by the American
Association for the Study of Liver Diseases and the American Society of
Transplantation. Hepatology, 59: 1144–1165. doi:10.1002/hep.26972

 GB1Esta parte me parece que deberia ire n la
discussion.

 GB2El caso ya esta aceptado, no se esta
sometiendo a consideracion en este momento.

 GB3Cambie a inpatient

 GB4Se dice hence??? O seria mejor Therefore?

 GB5En este caso que paso??? Me parece que se
pierde la ilación