What is the treatment for Loeffler's syndrome?

Treatment of Loeffler's Syndrome

The first-line treatment for Loeffler's syndrome is empirical therapy with albendazole 400 mg twice daily for 3 days, plus ivermectin 200 μg/kg once daily for 3 days during the prepatent period, with consideration of steroids in severe cases. 1

Definition and Etiology

• Loeffler's syndrome results from larval migration through the lungs following acute helminth infection, most commonly involving nematodes such as Ascaris lumbricoides, hookworm (Ancylostoma duodenale/Necator americanus), and Strongyloides stercoralis 1
• The syndrome typically occurs during the prepatent period (1-2 weeks after infection), when larvae migrate through the lungs 1

Clinical Presentation

• Fever, urticaria, wheeze, dry cough, and rarely hemoptysis 1
• Migratory pulmonary infiltrates may be seen on chest radiograph 1
• Peripheral blood eosinophilia is a characteristic finding 2
• Symptoms are typically self-limited but can be severe in some cases 3

Diagnostic Approach

• Diagnosis is primarily clinical, as symptoms occur during the prepatent period when stool examinations may still be negative 1
• Key diagnostic features include:
  • Respiratory symptoms (cough, wheeze)
  • Peripheral eosinophilia
  • Pulmonary infiltrates on imaging
  • Recent travel to or residence in endemic areas 1
• Concentrated stool microscopy should be performed in all patients returning from the tropics with eosinophilia 1
• In some cases, larvae may be seen in sputum (rare) or bronchoalveolar lavage 1

Treatment Recommendations

First-line Treatment

• Where no specific organism is identified, empirical treatment with:
  • Mebendazole 100 mg twice daily for 3 days plus ivermectin 200 μg/kg once daily for 3 days 1
  • Alternatively, single dose ivermectin 200 μg/kg and albendazole 400 mg can be used 1

Organism-Specific Treatment

1. For Ascaris lumbricoides:

   • Albendazole 400 mg as a single dose 4, 5
   • Alternative: Mebendazole 500 mg as a single dose 4

2. For Hookworm infection:

   • Albendazole 400 mg as a single dose 1
   • Alternative: Mebendazole 500 mg as a single dose 1

3. For Strongyloides stercoralis:

   • Ivermectin 200 μg/kg once daily for 1-2 days 2
   • For immunocompromised patients: Ivermectin 200 μg/kg on days 1,2,15, and 16 1

Adjunctive Therapy

• For severe symptoms, particularly with significant respiratory distress:
  • Prednisolone 30 mg daily for 5 days may reduce the duration of symptoms (expert opinion) 1
  • Caution is advised when using steroids in cases of suspected strongyloidiasis, as they may precipitate hyperinfection syndrome 1
• Symptomatic treatment with bronchodilators (e.g., levosalbutamol) may be beneficial for wheezing 6

Follow-up and Monitoring

• Consider retreatment 1 month after the resolution of pulmonary symptoms to ensure adult worms are treated (expert opinion) 1
• Complete resolution of pulmonary pathology should be confirmed with follow-up chest imaging 6, 3

Special Considerations

• Caution with steroids: Use with extreme caution if strongyloidiasis is suspected, as steroids may precipitate hyperinfection syndrome 1
• Pregnancy/lactation: Consult specialist advice for treatment during pregnancy or lactation 1
• Immunocompromised patients: These patients require more aggressive treatment and monitoring, particularly for strongyloidiasis 1

Prevention

• Preventive measures include:
  • Proper hand hygiene
  • Avoiding walking barefoot in endemic areas
  • Proper food handling and cooking practices 5