Letter to the Editor
Strongyloides stercoralis after renal transplantation—A global threat
Strongyloides stercoralis después del trasplante renal: una amenaza mundial
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The yellow lightning icons indicate A Rh-positive transfusion. The red lightning icons indicate 0 Rh-positive transfusions. <span class="elsevierStyleItalic">Abbreviations</span>: ATG; anti-thymocyte globulin, IA; immunoadsorption, IVIG; intravenous immunoglobulin, PLS; passenger lymphocyte syndrome, PP; plasmapheresis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ahmet Burak Dirim, Erol Demir, Seda Safak, Nurana Garayeva, Ayse Serra Artan, Ozgur Akin Oto, Yasemin Ozluk, Savas Ozturk, Halil Yazici, Sevgi Kalayoglu Besisik, Aydin Turkmen" "autores" => array:11 [ 0 => array:2 [ "nombre" => "Ahmet Burak" "apellidos" => "Dirim" ] 1 => array:2 [ "nombre" => "Erol" "apellidos" => "Demir" ] 2 => array:2 [ "nombre" => "Seda" "apellidos" => "Safak" ] 3 => array:2 [ "nombre" => "Nurana" "apellidos" => "Garayeva" ] 4 => array:2 [ "nombre" => "Ayse Serra" "apellidos" => "Artan" ] 5 => array:2 [ "nombre" => "Ozgur Akin" "apellidos" => "Oto" ] 6 => array:2 [ "nombre" => "Yasemin" "apellidos" => "Ozluk" ] 7 => array:2 [ "nombre" => "Savas" "apellidos" => "Ozturk" ] 8 => array:2 [ "nombre" => "Halil" "apellidos" => "Yazici" ] 9 => array:2 [ "nombre" => "Sevgi Kalayoglu" "apellidos" => "Besisik" ] 10 => array:2 [ "nombre" => "Aydin" "apellidos" => "Turkmen" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211699522000066?idApp=UINPBA000064" "url" => "/02116995/0000004300000006/v3_202410220448/S0211699522000066/v3_202410220448/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Strongyloides stercoralis after renal transplantation—A global threat" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "789" "paginaFinal" => "790" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Rita Abrantes, Rui Barata, Fernando Caeiro, Aníbal Ferreira, Fernando Nolasco" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Rita" "apellidos" => "Abrantes" "email" => array:1 [ 0 => "anaritamabrantes@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Rui" "apellidos" => "Barata" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Fernando" "apellidos" => "Caeiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Aníbal" "apellidos" => "Ferreira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Fernando" "apellidos" => "Nolasco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Nephrology and Dialysis Department – Centro Hospitalar do Médio Tejo, EPE, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Transplantation Department – Hospital Curry Cabral, Centro Hospitalar Lisboa Central, EPE, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Strongyloides stercoralis después del trasplante renal: una amenaza mundial" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">As we know, despite of the several efforts made in the last decades to minimize the infectious risk in kidney transplantation, including pre-transplant screening, vaccination, and antimicrobial prophylaxis, post-transplant infections remain a major cause of morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Strongyloides stercoralis</span> (Ss) <span class="elsevierStyleItalic">is</span> a parasite frequently forgotten, that affects about 613.9 million people,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> and it is associated with a high mortality rate in kidney transplant recipients. We present a case that illustrates the importance of pre-transplant screening and prompt recognition of this parasite in this population.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 53-year-old portuguese Caucasian female, resident in Lisbon, with end-stage renal disease of unknown cause, underwent deceased donor renal transplantation after four years on hemodialysis. Past medical and travel history unremarkable.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The pre-transplant workup showed normal blood eosinophil count and immunization against hepatitis B virus and Cytomegalovirus. <span class="elsevierStyleItalic">Strongyloides stercoralis</span> IgG by the enzyme-linked immunosorbent assay was negative.</p><p id="par0025" class="elsevierStylePara elsevierViewall">She started induction immunosuppression protocol with basiliximab, and immunosuppression maintenance therapy with tacrolimus, mycophenolate mofetil and prednisolone. Donor-specific antibodies were negative. The post-transplant period was uneventful, and she was discharged with a serum creatinine (SCr) of 1.4<span class="elsevierStyleHsp" style=""></span>mg/dL.</p><p id="par0030" class="elsevierStylePara elsevierViewall">After three months, she started complains of anorexia, fatigue, weight loss and presented periumbilical and dorsal region petechiae. The laboratory results revealed peripherical eosinophilia and worsening of graft function (SCr of 2.4<span class="elsevierStyleHsp" style=""></span>mg/dL). The coprological examination confirmed the presence of <span class="elsevierStyleItalic">S. stercoralis</span> larvae. Pulmonary involvement was excluded by chest computerized tomography.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment with ivermectin (15<span class="elsevierStyleHsp" style=""></span>mg/day) in association with albendazole (400<span class="elsevierStyleHsp" style=""></span>mg 2 id) was started as well as prophylactic cotrimoxazole (480<span class="elsevierStyleHsp" style=""></span>mg/day). Tacrolimus levels were reduced to less than 8<span class="elsevierStyleHsp" style=""></span>mg/dl.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient evolved favorable with rapid graft function recovery and resolution of the symptoms. A negative stool testing was obtained after 6 days. Peripheral eosinophilia resolved after one month. Albendazole was suspended after the first negative stool. Ivermectin was maintained in a daily dose until day 21 and in a monthly administration (200<span class="elsevierStyleHsp" style=""></span>mg) until complete 6 months of therapy. After the discontinuation, stool cultures remained negative.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The other receptors (kidney, heart, and liver) from the same donor were evaluated. No clinical symptoms of strongyloidiasis, blood eosinophilia or Ss IgG were identified. Despite of that, a prophylactic regimen of ivermectin (15<span class="elsevierStyleHsp" style=""></span>mg/month) was performed.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Presently, the patient remains without symptoms, with normal peripheral eosinophil count and renal function preserved with SCr of 1.5<span class="elsevierStyleHsp" style=""></span>mg/dl.</p><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Strongyloides stercoralis</span> is an intestinal nematode able to remain in the same host indefinitely, due to a process known as autoinfection. It can be asymptomatic or cause nonspecific symptoms like abdominal pain, diarrhea and urticaria.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The latency and missed diagnosis of Ss infection, as we know, can be a problem if we prescribe high doses of immunosuppressive agents, as the regimes used nowadays in kidney transplantation.</p><p id="par0065" class="elsevierStylePara elsevierViewall">With the cell-mediated immunity impaired, after immunosuppression initiation, Ss larvae can freely disseminate in the gut and lungs, causing gastrointestinal hemorrhage and dyspnea, a clinical illness named as Strongyloides Hyperinfection Syndrome. If not promptly controlled, the larvae proliferation will cause multiple organ failure, known as Disseminated Strongyloidiasis.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The incidence of hyperinfection and dissemination in kidney recipients remains unidentified but it is well-known the higher risk associated with latent Ss reactivation, primary infection, and less frequent, donor-derived infection.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Donor strongyloidiasis does not contraindicate transplantation or delay kidney implantation. The purpose of pre-transplant screening is to identify donor/receptor pairs at higher risk of Ss reactivation that will benefit of prophylactic treatment and closer surveillance, especially in the early post-transplant period.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Some medical societies have recommended Ss pretransplant screening in recipients and donors from endemic areas<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5,6</span></a> but, what about the non-endemic areas and the impact of globalization and population migration flows in Ss global spread? In fact, recent data have confirmed a prevalence of Ss infection or seropositivity of 3% in Central Europe, among renal transplant recipients.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">One of the concerns with <span class="elsevierStyleItalic">Ss</span> screening and prophylactic eradication are the costs. However, if we consider the improvement in overall patient and graft survival,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> it seems reasonable to justify the implantation of the Ss screening in the pre-transplant protocol, as we did it in our center.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">One important aspect to retain is that only a high level of suspicion by the clinicians will allow an early diagnosis and prompt treatment and Ss should not be forgotten.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Regarding the therapeutic options available, monotherapy may not be enough to control the dissemination in immunocompromised patients.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">We proposed albendazole and ivermectin association, given the different mechanisms of action and absence of known interactions, followed by a maintenance course withivermectin for 6 months, given the higher risk of relapse and great tolerance.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3–5,9</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The purpose of this letter is to remind the high level of suspicion needed to a prompt diagnosis and treatment of Ss infection in kidney recipients and reinforce that pre-transplantation protocols should include Ss screening, even in non-endemic areas.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infectious complications in kidney transplant recipients: review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.A. 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| 2024 Agosto | 57 | 67 | 124 |
| 2024 Julio | 36 | 28 | 64 |
| 2024 Junio | 60 | 44 | 104 |
| 2024 Mayo | 52 | 44 | 96 |
| 2024 Abril | 48 | 42 | 90 |
| 2024 Marzo | 43 | 30 | 73 |
| 2024 Febrero | 43 | 39 | 82 |
| 2024 Enero | 34 | 54 | 88 |
| 2023 Diciembre | 83 | 44 | 127 |
| 2023 Noviembre | 144 | 56 | 200 |
| 2023 Octubre | 116 | 48 | 164 |
| 2023 Septiembre | 114 | 56 | 170 |
| 2023 Agosto | 74 | 42 | 116 |
| 2023 Julio | 39 | 32 | 71 |
| 2023 Junio | 74 | 23 | 97 |
| 2023 Mayo | 91 | 30 | 121 |
| 2023 Abril | 52 | 17 | 69 |
| 2023 Marzo | 77 | 29 | 106 |
| 2023 Febrero | 50 | 17 | 67 |
| 2023 Enero | 38 | 27 | 65 |
| 2022 Diciembre | 82 | 56 | 138 |
| 2022 Noviembre | 66 | 59 | 125 |
| 2022 Octubre | 92 | 38 | 130 |
| 2022 Septiembre | 60 | 39 | 99 |
| 2022 Agosto | 45 | 36 | 81 |
| 2022 Julio | 60 | 58 | 118 |
| 2022 Junio | 52 | 52 | 104 |
| 2022 Mayo | 46 | 35 | 81 |
| 2022 Abril | 61 | 47 | 108 |
| 2022 Marzo | 70 | 54 | 124 |
| 2022 Febrero | 42 | 42 | 84 |
| 2022 Enero | 39 | 33 | 72 |
| 2021 Diciembre | 37 | 44 | 81 |
| 2021 Noviembre | 29 | 46 | 75 |
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