Rinsho Shinkeigaku (Clinical Neurology)

Case Report

Fulminant strongyloidiasis successfully treated by subcutaneous ivermectin: an autopsy case

Nobuyoshi Takashima, M.D.1)4), Shogo Yazawa, M.D.1), Akira Ishihara, M.D.2), Sei-ichiro Sugimoto, M.D.3), Kazutaka Shiomi, M.D.4), Kenji Hiromatsu, M.D.5) and Masamitsu Nakazato, M.D.4)

1)Department of Neurology, Miyazaki Prefectural Hospital of Nobeoka
2)Department of Anatomic Pathology, Miyazaki Prefectural Hospital of Nobeoka
3)Department of Neurology, Miyazakihigashi Hospital, National Hospital Organization
4)Department of Internal Medicine, School of Medicine, University of Miyazaki
5)Department of Microbiology and Immunology, School of Medicine, Fukuoka University

We report a 49-year-old man who was a human T-cell leukemia virus type 1 (HTLV-1) carrier, born in Okinawa prefecture where both strongyloidiasis and HTLV-1 are endemic. He presented with fever, headache and urinary retention. On the basis of CSF examination and MRI findings, his condition was diagnosed as myelitis. He received methylprednisolone pulse therapy. He was transferred to our hospital due to severe paralytic ileus. Strongyloides stercoralis (S. stercoralis) was found in the duodenal stained tissue of a biopsy specimen. Ivermectin applied both orally and through enema were ineffective because of severe ileus and intestinal bleeding. Nine mg (200 μg/kg) of ivermectin solution was administered subcutaneously every other day for five days (total amount 45 mg). The S. stercoralis burden in the stool decreased and paralytic ileus gradually resolved. Three weeks after the resolution of S. stercoralis infection, purulent meningitis developed and acute obstructive hydrocephalus appeared. The hydrocephalus improved by ventricular drainage. Approximately three months after drainage, he died of incidental aspiratory pneumonia. Autopsy showed neither eggs nor larvae of S. stercoralis in the organs. In this case, the fourth reported case in the world, subcutaneous ivermectin injection was dramatically effective. We should consider a diagnosis of strongyloidiasis for any patient from Okinawa prefecture who was an HTLV-1 carrier presenting with unknown origin ileus after treatment of steroid therapy.
Full Text of this Article in Japanese PDF (638K)

(CLINICA NEUROL, 48: 30|35, 2008)
key words: strongyloidiasis, HTLV-1 infection, subcutaneous ivermectin injection, hydrocephalus

(Received: 26-Mar-07)