Disseminated strongyloidiasis in a patient with rheumatoid arthritis: A case report

lNTRODUCTlON

Strongyloidiasis is a disease caused by the human pathogenic parasitic roundworm

(

). Most larvae are excreted in the stool but re-infection or self-infection can occur when the mature larvae burrow into the intestinal wall or the anal tissue.

infections can become chronic and even fatal in immunosuppressed patients[1]. This report describes the clinical features of disseminated strongyloidiasis in an immunosuppressed patient as well as the diagnosis and treatment.

日本骨科协会评估治疗分数（Japanese Orthopaedic Association Scores，JOA评分）[3]：通过主观症状、临床体征、日常活动能力及膀胱功能评定腰痛疾患效果，术前及术后3个月进行JOA评分。

CASE PRESENTATlON

Chief complaints

A 68-year-old male with repeated multi-joint pain for 3 years, abdominal pain and abdominal distension for 2 mo and progressive difficulty in swallowing, coughing, hoarseness and dysphonia for 1 wk.

History of present illness

The patient with rheumatoid arthritis was treated successively using a variety of immunosuppressants(methylprednisolone, tocilizumab, adalimumab, rituximab) for the past 3 years. Recently, the patient received treatment in several hospitals for a partial small-bowel obstruction of unknown origin which reoccurred repeatedly after treatment. As the patient’s condition worsened, new symptoms appeared including petechia, progressive difficulty in swallowing, coughing, hoarseness and dysphonia. A neurologist considered peripheral neuropathy because electromyography indicated peripheral nerve axonal damage. High-dose intravenous immunoglobulin therapy (2 g/kg over 5 d) was not effective, so plasmapheresis was recommended. At the same time, a parasite was detected in the stool, however, the species was neither identified nor treated. Due to the progress of bulbar palsy, the patient was referred to our hospital.

History of past illness

Zheng JH designed the study, analyzed the data and wrote the manuscript; Xue LY contributed to study conception and design and revision of the manuscript.

综上所述，B7-H4和B7-H6蛋白在卵巢良、恶性肿瘤中的表达存在差异，并与恶性肿瘤患者年龄、组织类型、p53蛋白表达相关，提示这两种蛋白参与卵巢恶性肿瘤的发病。此外，近年来已有研究获得B7家族靶向治疗肿瘤的证据[14-15]，但确切作用机制尚不清楚，须加大样本量进行深入的体内及体外研究。研发针对B7-H4和B7-H6的卵巢恶性肿瘤靶向药物，联合经典的治疗方法，有望为卵巢癌提供新的治疗方案，进而提高患者的生存率。

Personal and family history

After 1 wk of treatment with albendazole 400 mg tid and other supportive treatments, the sputum smear was still positive. The addition of ivermectin 0.2 mg/kg/d × 2 d every 2 wk was then given. On day 4 of ivermectin treatment, the sputum smear and stool tested negative for intestinal parasites. After 2 wk of comprehensive treatment, the patient's mental state gradually improved and muscle strength of the limbs recovered. After 6 wk of hospitalization, his abdominal pain and all previously mentioned symptoms except for the joint pain had dissipated. The patient was discharged and given a small dose of methylprednisolone + methotrexate + celecoxib to control the rheumatoid arthritis and relieve the joint pain. We used albendazole for 4 wk total and ivermectin for a total of 6 wk[2].

Physical examination

Upon admission, he displayed weight loss, stable vital signs, hoarseness, dysarthria, wet rales audible in both lungs, weak bowel sounds, muscle strength grade 3 in all limbs and diminished tendon reflexes.

从图1可见，1) 在350 nm波长处生物总碱的吸光度随小檗碱标准溶液浓度升高而升高，即二者间存在线性关系，其回归方程为y=0.022 4x+0.009 7(R2=0.999 4)，即小檗碱溶液浓度为7.712～38.56 μg/mL时与吸收度有良好的线性关系。2) 随着小檗碱含量(C)升高，峰面积(A)呈上升趋势，二者间存在线性关系，其直线回归方程为A=0.025 2C-0.100 2(R2=0.999 9)。表明，小檗碱含量在48.2～867.6 μg与峰面积有良好的线性关系。

Laboratory examinations

His biochemistry panel was as follows: K of 3.4 mmol/L, Na of 129 mmol/L, Ca of 1.88 mmol/L, and albumin of 25 g/L. Stool-Rt and sputum smears tested positive for

larvae with active movement (Figure 1).

Strongyloidiasis is a zoonotic intestinal parasitosis caused by

. It is estimated that 30-100 million people are infected worldwide with this parasite[3]. Most infected individuals are asymptomatic or present with intermittent symptoms[4]. Immunosuppressed patients can develop hyperinfection syndrome and disseminated nematode disease which have high mortality rates[5-7]. Strongyloidiasis has been reported following concomitant tocilizumab and methylprednisolone treatment[8]. Some case reports suggest that paralytic ileus may be caused by massive intestinal infestation with

[9].

Imaging examinations

A chest CT showed bilateral infiltrates indicating pneumonia. Echocardiography showed impaired movement of the left ventricular myocardium (EF 42%).

FlNAL DlAGNOSlS

At 3 mo after discharge, a follow-up chest CT and electromyography showed lung and cardiac function had recovered.

TREATMENT

The patient had no specific personal and family history.

OUTCOME AND FOLLOW-UP

The diagnosis of disseminated strongyloidiasis was established.

DlSCUSSlON

（教学心得：这样的争论非常有意思，学生的直觉是顶点位置有6个，这可能是受6个面的影响。如果在教学中采用讲解的方法，学生理解会比较抽象，就算是记住了也很容易遗忘。采用实验动手操作的方法，学生一看就明白了，从中心出发，顶点的位置不是6个，而是8个，所以在顶点的方块是8块。这样对空间结构的认知和体会对将来进一步学习立体图形非常有益。）

结果提示：在控制了人口统计学变量后，社会隔离对生存质量(β=-0.226，P<0.01)具有显著的负向影响，经济状况对生存质量(β=0.224，P<0.01)具有显著的正向影响(见表2)。社会隔离与经济状况的交互项对生存质量具有显著的负向影响(β=-0.084，P<0.05)(见表2与图1)，因此经济状况在社会隔离对生存质量的影响中起调节作用。

The Centers for Disease Control and Prevention and World Health Organization recommend ivermectin as the first choice for strongyloidiasis. In endemic areas, a combination of albendazole and ivermectin is recommended[13], and Moxidectin has also been tried as a treatment[14]. Repeated or extended dosing is preferred until worms are no longer detected[15]. Considering that the patient was still taking low-dose methylprednisolone and methotrexate tablets for rheumatoid arthritis, we adopted a multi-dose and long course of treatment. At the 3 mo follow-up, no recurrence of the disease was detected, so the treatment was effective.

CONCLUSlON

This case highlights important considerations for patients receiving immunosuppressive therapy. It is necessary to improve medical workers’ awareness of strongyloidiasis to avoid delays in diagnosis and ensure adequate management of infected patients.

Our case has two important clinical features. First, the patient had a history of immunosuppression and subsequently developed clinical symptoms (

, intestinal obstruction, pneumonia and petechia).The patient’s heart was also affected. Previous hospitals detected the presence of parasites but focused instead on the neurological manifestations. We confirmed the presence of

larvae in the patient’s stool and sputum[10]. Second, the patient presented with choking and hoarseness at the time of diagnosis. Head, neck, mediastinal MRI, cerebrospinal fluid and other examinations found no evidence of neurological invasion. Therefore, we considered two possibilities: (1) Nutritional deficiencies in vitamin B1, vitamin B12 and folic acid due to long periods of fasting, causing malabsorption and intestinal obstruction which can lead to peripheral neuropathy[11]; and (2)Neurotoxic biological agents (

, TNF inhibitors, anti-IL-6 receptor antibody), which can cause peripheral neuropathy in approximately 42% of cases[12].

脱稿讲授，理解通透，娴熟自如；表达准确，分析明晰，论证精要；思路清晰，重点突出，节奏合理；媒体设计得当，板书科学合理；基础知识通俗易懂，适度够用，针对性强；专业知识深入浅出，启发引导，拓展得当；技能指导规范熟练，示范点拨，乐学活训；用语规范，普通话比较标准，快慢适度；表达流畅，活泼机智，感染力强；课堂行为，合理灵动；教态端庄，饱满热情；互动有节，氛围融洽；形态丰富，信息充实，容量适度。

FOOTNOTES

Diabetic history: Diabetic history for several years, maximum 18 mmol/L. Taking insulin medication,blood sugar is unsatisfactory for control.

Informed consent was obtained from the patient. The participant consented to the submission of the case report to the Journal.

The authors have no conflicts of interest to declare that are relevant to the content of this article.

The authors have read the CARE Checklist(2016), and the manuscript was prepared and revised according to the CARE Checklist(2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

合理性，就是目标定位是否合理，是否符合主体的年龄和身心特征，是否符合主体的能力，是否符合主体的学段。只有符合这四个方面的目标，才是合理的目标。这四个“符合”会让主体看到更多的可能性，帮助主体全力以赴达成目标。

China

Jin-Hao Zheng 0000-0003-0864-5156; Lu-Yu Xue 0000-0001-8773-7088.

Ma YJ

Filipodia

大学生机械创新设计大赛是教育部举办的全国性科技创新实践竞赛活动，是依托全国普通高等学校教学科研这一平台。它具有非常强烈的现实意义和实际意义，同时也为促进各高校提高工程实践和机械创新设计教学改革和教学水平，加强学生理论与实践的有机结合，养成良好的学风、教风，为优秀人才脱颖而出创造条件。

Ma YJ

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