Does chest X-ray (CXR) infiltration due to Strongyloides infection worsen with corticosteroid (steroid) therapy?

From the Guidelines

Yes, chest X-ray infiltrates due to Strongyloides infection can worsen significantly with steroid administration. Steroids can trigger hyperinfection syndrome or disseminated strongyloidiasis by suppressing the immune response that normally contains the parasite. When steroids are given to patients with undiagnosed Strongyloides infection, the parasite's reproductive cycle accelerates dramatically, allowing larvae to penetrate the intestinal wall in large numbers, migrate through the lungs, and spread throughout the body. This can transform a previously mild or asymptomatic infection into a life-threatening condition with mortality rates exceeding 50% 1.

Key Considerations

• The radiographic findings typically progress rapidly, showing worsening bilateral interstitial or alveolar infiltrates that may mimic bacterial pneumonia or ARDS.
• Patients from endemic areas or with unexplained eosinophilia should be screened for Strongyloides before starting steroid therapy.
• If Strongyloides is detected or suspected in a patient requiring steroids, treatment with ivermectin (200 μg/kg daily for 1-2 days, or longer in hyperinfection) should be administered before initiating steroid therapy whenever possible 1.
• The use of steroids in patients with Strongyloides infection can lead to hyperinfection syndrome, which is a potentially fatal condition 1.

Treatment and Prevention

• Treatment with ivermectin is recommended for patients with Strongyloides infection, especially those requiring steroid therapy.
• Empiric treatment with ivermectin may be considered in patients from endemic areas or with unexplained eosinophilia, even if Strongyloides infection is not confirmed 1.
• Screening for Strongyloides infection should be performed in patients from endemic areas or with unexplained eosinophilia before starting steroid therapy.

From the Research

Strongyloides Infection and Corticosteroid Use

• Strongyloidiasis, caused by the intestinal helminth Strongyloides stercoralis, can lead to hyperinfection and disseminated infection in immunosuppressed patients, especially those receiving corticosteroid treatment 2, 3.
• The use of corticosteroids is a well-established risk factor for life-threatening hyperinfection syndrome and disseminated disease owing to suppression of the immune system 4, 5.

Effect of Steroids on CXR Infiltrates due to Strongyloides

• There is no direct evidence in the provided studies that specifically addresses whether CXR infiltrates due to Strongyloides get worse with steroids.
• However, it is known that immunosuppression, particularly by corticosteroids, can lead to hyperinfection syndrome and disseminated strongyloidiasis, which can cause severe disease states, including respiratory symptoms 3, 4.

Treatment and Prevention of Strongyloidiasis

• Ivermectin is the first-line drug for the treatment of strongyloidiasis, with an estimated efficacy of about 86% and excellent tolerability 6.
• Empiric ivermectin treatment protocols have been implemented for patients receiving high-dose corticosteroids for severe COVID-19, but more research is needed to determine the effect on hyperinfection and/or disseminated strongyloidiasis risk and mortality rate 4, 5.