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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">Parasitic infections in transplant patients are infrequent&#46;<span class="elsevierStyleSup">1</span> Of the 342 parasite species that can infect humans&#44; only 5&#37; have been described in transplant patients&#46;<span class="elsevierStyleSup">2</span> In a series of 675 transplant patients&#44; the prevalence of symptomatic parasite infections was 2&#46;4&#37;&#59; S&#46; stercoralis&#44; followed by Giardia lamblia and Toxoplasma gondii were the most frequently implicated parasites&#46;<span class="elsevierStyleSup">3</span> Up until now&#44; Spanish literature has described multiple cases of S&#46; stercoralis infection in the general population&#44; but never in transplant patients&#46;</p><p class="elsevierStylePara">Strongyloides stercoralis is an intestinal parasite which is endemic in some parts of Spain&#46; Its infection can provoke isolated eosinophilia or even diarrhoea associated with haemoptysis and bronchospasm with a high mortality rate&#46; In transplant patients&#44; the symptoms can worsen with an increase in the number of adult worms&#44; provoking multiple organ failure&#59; in these patients&#44; diagnosing the infection may be complicated&#46; Clinical examination may sometimes mistake the symptoms for side effects from the drugs that are widely used in transplants&#44; and for this reason&#44; there must be a high suspicion index in order for it to be diagnosed correctly&#46; We present two cases of active infection with S&#46; stercoralis in kidney transplant patients in our centre&#44; with their diagnostic procedure and evolution with treatment&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE 1</span></p><p class="elsevierStylePara">Male patient&#44; aged 55 years in a chronic CAPD due to renal failure secondary to chronic glomerulonephritis&#46; He received a kidney transplant from a cadaver donor in July 2005 and the immunosuppressants tacrolimus&#44; mycophenolate mofetil and prednisone&#44; and maintained a stable renal function with creatinine levels around 2&#46;5mg&#47;dl&#46; Two years after the transplant&#44; he presented a profile of persistent diarrhoea with 4-5 bowel movements a day and weight loss of 2kg&#46; Microbiological analysis of the faeces detected numerous S&#46; stercoralis larvae &#40;figure 1&#41;&#46; The eosinophil count was normal &#40;0&#46;3 x 103&#47;&#956;l&#41;&#46; The patient resided in a part of the Valencian Community that is considered to be an endemic area for S&#46; stercoralis&#46; We reviewed the case history prior to the transplant&#44; which revealed outbreaks of urticaria as well as mild asthma&#44; which had been treated sporadically with bronchodilators&#46; Pre-transplant analytical tests showed that the patient had intermittent mild eosinophilia &#40;1&#46;0 x 10<span class="elsevierStyleSup">3</span>&#47;&#956;l&#41;&#46; Treatment was begun with thiabendazole in doses of 1&#46;5g&#47;12 hours &#40;25mg&#47;kg&#47;day&#41; administered orally during five days&#59; the cycle was repeated after seven days due to persistence of the infection&#46; 14 days after beginning treatment&#44; the diarrhoea had not subsided&#44; weight loss had reached 4kg and renal function had decreased&#46; Consequently&#44; the patient was admitted to receive intravenous hydration&#46; Both the stool sample obtained during that stay and the one obtained following the second treatment with thiabendazole tested negative for parasites&#46; The diarrhoea improved and the renal function recovered progressively until reaching normal creatinine levels&#46; An additional stool sample was analysed for parasites one month later and tested negative&#46; At present&#44; the patient remains asymptomatic&#44; the episodes of urticaria and asthma have improved&#44; and renal function is stable&#46; A study of family members residing in the same household detected S&#46; stercoralis in the patient&#191;s son&#44; who was treated with thiabendazole as an outpatient&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE 2</span></p><p class="elsevierStylePara">Male patient 51 years of age with renal failure secondary to Alport syndrome&#44; on haemodialysis since 2003&#46; The patient received a renal transplant from a cadaver donor in August 2006 and tacrolimus&#44; mycophenolate mofetil and prednisone as immunosuppressants&#46; The patient maintains a stable renal function with creatinine levels around 2mg&#47;dl&#46; Immediately following the transplant&#44; the patient presented mild diarrhoea with 4-5 soft bowel movements daily&#44; which were attributed to the treatment with mycophenolate mofetil&#46; The patient also presented a disproportionate level of normocyticnormochromic anaemia for his level of renal failure&#44; and that condition did not respond to treatment with erythropoietic agents&#46; Seven months after the transplant&#44; a routine analytical test showed an absolute eosinophilia of 3&#46;7 x 10<span class="elsevierStyleSup">3</span>&#47;&#956;l that was confirmed with a second haematological sample&#46; The patient continued to present the same clinical profile of 4-5 soft bowel movements as had been the case since the transplant&#44; with no urticaria or asthma&#46; Analysis of the stool showed numerous S&#46; stercoralis larvae&#46; Treatment was begun with albendazole in oral doses of 400mg every 12 hours during three weeks&#46; After finishing the first treatment cycle&#44; the patient presented a more normal daily number of bowel movements&#44; had improved the eosinophil count to 0&#46;8 x 10<span class="elsevierStyleSup">3</span>&#47;&#956;l and had normal haemoglobin levels&#46; After this first cycle of abendazole treatment&#44; the stool sample tested negative for S&#46; stercoralis&#46; We subsequently administered two new cycles of one week of treatment at one month and at two months after the diagnosis&#44; and reached a completely normal peripheral eosinophil count&#46; In the study of parasites in family members living in the same household&#44; we identified signs compatible with Blastocystis hominis and Endolimax nana in the patient&#191;s wife&#44; who was treated with oral metronidazole&#46; Both reside in an area that is endemic for S&#46; stercoralis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">S&#46; stercoralis is an intestinal parasite that is particularly endemic in some parts of Spain&#44; particularly along the Mediterranean coast and in populations close to the city of Valencia&#46;<span class="elsevierStyleSup">4</span> Infection with S&#46; stercoralis occurs when the patient&#191;s skin comes into contact with materials contaminated with human faeces&#59; the larva then develops through its life cycle within the body&#44; and becomes an adult worm that infects the digestive tract&#46; Its larvae are excreted once again in the patient&#191;s stool&#46; One aspect that makes this parasite particularly virulent is that larvae in the intestine may also mature and cross the colonic mucosa&#44; which leads to chronic infection or re-infection&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">In immunocompetent patients&#44; this auto-infection process can perpetuate without causing any symptoms other than sporadic eosinophilia&#44; cases of diarrhoea or mild asthma&#44; but in immunocompromised patients&#44; there may be a massive proliferation of larvae throughout the digestive tract&#44; lungs&#44; liver&#44; heart and central nervous system&#46; This can lead to a multiple organ failure with a high mortality rate&#44; known as hyperinfection syndrome&#46;<span class="elsevierStyleSup">2</span> In transplant patients&#44; infection with the parasite may become evident due to the immunosuppressant treatment&#46; Normally&#44; these are latent infections that were present before the transplant&#44; but patients may also suffer a primary infection following the transplant&#44; particularly those living in endemic areas&#46;</p><p class="elsevierStylePara">Diagnosing S&#46; stercoralis may be difficult&#46; Eosinophilia may be the only anomaly&#44; and it may not be present in transplant patients&#46; For this reason&#44; when a transplant patient presents a profile of diarrhoea that is not self-limited&#44; we should rule out possible complications induced by drugs such as mycophenolate mofetil&#44; especially if it is associated with the pro-kinetic effect of tacrolimus&#46; Furthermore&#44; if a conventional stool analysis gives a negative result&#44; we should contemplate the possibility of diarrhoea secondary to a parasitic infection&#46; When diagnosing parasitosis by S&#46; stercoralis&#44; it may be necessary to collect various fresh stool samples before detecting any larvae<span class="elsevierStyleSup">6</span> &#40;figure 1&#41; because a single sample does not show the infection in up to 70&#37; of all cases&#46; Detection sensitivity increases to 50&#37; for direct vision of fresh stool when three samples are used&#44; and to 100&#37; with seven samples&#46;<span class="elsevierStyleSup">7</span> If the stool samples are cultivated in an agar plate&#44; as we did in these two cases&#44; the infective larvae can be seen &#40;figure 2&#41;&#46; We also had a specific ELISA test with high sensitivity and specificity&#44;6 and an indirect ELISA test for detecting the presence of IgG and IgM antibodies for S&#46; stercoralis&#46;<span class="elsevierStyleSup">8</span> In immunocompromised patients&#44; the specific ELISA test could be indicated when there is a high suspicion of parasite infection and the stool samples give a repeated negative result&#59; it could be helpful in achieving early diagnosis and treatment&#46; Specific IgG antibodies may remain positive years after completing anthelmintic treatment&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara">The treatment indicated for Strongyloidiasis is thiabendazole dosed at 25mg&#47;kg&#47;day&#44; distributed in two doses&#46; Two days of treatment are recommended for non-complicated infections&#44; and five for complicated infections&#46; In immunodepressed patients&#44; repeating the cycle of thiabendazole is also recommended&#44;10 as we did in the first case&#46; The most common side effect is digestive intolerance&#46; Albendazole in doses of 400mg&#47;12 hours during three weeks&#44; as we used in case 2&#44; is a treatment alternative to thiabendazole that has also been proven effective against S&#46; stercoralis&#44; although clinical experience with the drug is more limited&#46;<span class="elsevierStyleSup">11</span> Ivermectine with a dosage of 200mg&#47;kg&#47;day&#44; distributed in two doses&#44; is also an approved treatment and has fewer adverse effects than thiabendazole&#44; but its prescription in Spain requires a foreign medication request&#46; The effectiveness of the treatment must be documented with a negative stool sample upon completion of that treatment&#44; and a new sample must be collected if the disease reappears&#59; relapses are frequent&#46; It has been indicated that cyclosporin could have an anti-parasitic effect against S&#46; stercoralis in both mice<span class="elsevierStyleSup">12</span> and humans&#44;<span class="elsevierStyleSup">13</span> and we must point out that neither of our patients received that particular immunosuppressant&#46;</p><p class="elsevierStylePara">In conclusion&#44; although infection with S&#46; stercoralis is not very frequent&#44; it can cause serious problems for a transplant patient if it is not diagnosed and treated in time&#46; When evaluating candidates for receiving a kidney transplant&#44; special attention must be paid to the presence of unexplained eosinophilia and a history of corticoidresistant pruritus or asthma in order to diagnose a possible parasitic infection and eradicate it before beginning treatment with immunosuppressants&#46; Furthermore&#44; differential diagnosis of diarrhoeal syndromes in kidney transplant patients must include testing fresh stool samples for possible parasites&#44; especially if there is a clinical or analytical suspicion of S&#46; stercoralis infection&#46; If this infection is diagnosed&#44; family members living in the same household should also be examined&#46; The risk of relapse is frequent with this disease&#44; which is why it is recommended that we always obtain a negative stool sample after completing the treatment and repeat the examination if there is a suspicion of a new S&#46; stercolaris infection&#46; </p><p class="elsevierStylePara"><a href="grande&#47;42018078&#95;f1&#95;pag483&#46;jpg" class="elsevierStyleCrossRefs"><img src="42018078_f1_pag483.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p><p class="elsevierStylePara"><a href="grande&#47;42018078&#95;f2&#95;pag484&#46;jpg" class="elsevierStyleCrossRefs"><img src="42018078_f2_pag484.jpg"></img></a></p><p class="elsevierStylePara">Figure 2&#46; </p>"
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