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Strongyloidiasis

Key sources
The following summarized guidelines for the evaluation and management of strongyloidiasis are prepared by our editorial team based on guidelines from the National Institutes of Health (NIH 2021), the Center for Disease Control (CDC 2020), the Infectious Diseases Society of America (IDSA 2018), and the Barcelona Institute for Global Health (BIGH 2017).
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Guidelines

1.Screening and diagnosis

Screening, indications
Obtain routine screening for strongyloidiasis in immunocompetent patients at high risk of exposure to Strongyloides stercoralis infection.
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Obtain routine screening for strongyloidiasis in immunosuppressed patients and candidates for immunosuppression at high or intermediate risk of exposure to Strongyloides stercoralis.
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  • Screening (choice of test)

2.Diagnostic investigations

Stool examination: obtain serial stool examinations as the gold standard for the diagnosis of Strongyloides infection.
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  • Serology

3.Diagnostic procedures

Endoscopy and biopsy: recognize that duodenal aspirate is more sensitive than stool examination, and duodenal biopsy may reveal parasites in the gastric crypts, in the duodenal glands, or eosinophilic infiltration in the lamina propria. Recognize that larvae can frequently be seen by a simple wet-mount in fluid from a BAL.
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4.Medical management

Antihelminthic therapy: as per CDC 2020 guidelines, administer ivermectin 200 µg/kg PO in a single dose for 1-2 days as first-line therapy for the treatment of patients with acute or chronic strongyloidiasis.
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5.Specific circumstances

Patients with COVID-19 infection: consider administering prophylactic treatment with ivermectin in patients receiving a combination of dexamethasone and tocilizumab, coming from areas where strongyloidiasis is endemic, because the combination of dexamethasone and tocilizumab may increase the risk of opportunistic infections or reactivation.

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  • Patients with neurocysticercosis

6.Follow-up and surveillance

Follow-up: as per CDC 2020 guidelines, obtain follow-up stool examinations 2-4 weeks after treatment to confirm clearance of infection in patients with positive stool examination for Strongyloides and persistent symptoms. Offer retreatment if recrudescence of larvae is observed.
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