Reemergence of Strongyloidiasis, Northern Italy

To the Editor: Strongyloidiasis is a helminth infection caused by Strongyloides stercoralis, a nematode ubiquitous in tropical and subtropical countries and occasionally reported in temperate countries, including Italy (1). Sources of infection are filariform strongyloid larvae present in soil contaminated by infected feces; the larvae penetrate through the skin of a human host. After the first life cycle, a process of autoinfection begins, which persists indefinitely in the host if the infection is not effectively treated. The infection can remain totally asymptomatic for many years or forever or cause cutaneous (itching and rash), abdominal (epigastric pain, pseudoappendicitis, diarrhea), respiratory (cough, recurrent asthma), and systemic (weight loss, cachexia) symptoms that can be enervating. More importantly, when host immunity is impaired because of a concurrent disease or immunosuppressive therapy (including corticosteroids, sometimes used to treat symptoms of the unrecognized infection or the concurrent eosinophilia), disseminated strongyloidiasis may occur (2–4), causing a massive and almost invariably fatal invasion of virtually all organs and tissues by filariform larvae and even adult worms (Figure), often combined with bacterial superinfection. This complication is believed to be rare but is probably underestimated because of the extreme variability of the clinical presentation.

Evaluation of the main effect model identified a decreasing probability of latrine occurrence with increasing distance from the nearest forested area and the presence of an outdoor pet, although these relationships were only marginally significant (p = 0.07 and 0.08, respectively). No other variables were closely associated with the presence of raccoon latrines (p>0.20). When evaluated alone, distance from the forest preserve was significantly related to latrine occurrence (p = 0.03); probability decreased with increasing distance. Evaluation of the simplified model identified a weakly positive association with the presence of a food source (p = 0.09) and no association with the presence of latrine substrate (p = 0.35). Although the findings were not statistically significant, raccoon latrines did appear to be associated with the availability of a food source such as bird feed (odds ratio [OR] 1.9, 95% CI 0.9-4.1); the presence of an outdoor pet (OR 0.27, 95% CI 0.06-1.2) and increasing distance from the nearest forested area reduced the likelihood of latrines. No other variables were associated with the presence of raccoon latrines; however, low statistical power may have precluded adequate assessment.
Our results suggest that when humans live close to protected forests or natural areas, they are more likely to attract raccoons into their yards. In addition, anthropogenic food sources such as pet food, garbage, and bird feed may increase the likelihood that a raccoon will create a latrine, and the presence of outdoor pets appears to be a deterrent. In areas of high raccoon density, these attractants should be removed. Homeowners with small children should remove latrines as quickly as they are discovered (2). The risk of children acquiring potentially fatal baylisascariasis can be reduced if parents understand how to reduce the likelihood that children will come into contact with raccoon latrines.

Reemergence of Strongyloidiasis, Northern Italy
To the Editor: Strongyloidiasis is a helminth infection caused by Strongyloides stercoralis, a nematode ubiquitous in tropical and subtropical countries and occasionally reported in temperate countries, including Italy (1). Sources of infection are filariform strongyloid larvae present in soil contaminated by infected feces; the larvae penetrate through the skin of a human host. After the first life cycle, a process of autoinfection begins, which persists indefinitely in the host if the infection is not effectively treated. The infection can remain totally asymptomatic for many years or forever or cause cutaneous (itching and rash), abdominal (epigastric pain, pseudoappendicitis, diarrhea), respiratory (cough, recurrent asthma), and systemic (weight loss, cachexia) symptoms that can be enervating. More importantly, when host immunity is impaired because of LETTERS a concurrent disease or immunosuppressive therapy (including corticosteroids, sometimes used to treat symptoms of the unrecognized infection or the concurrent eosinophilia), disseminated strongyloidiasis may occur (2-4), causing a massive and almost invariably fatal invasion of virtually all organs and tissues by filariform larvae and even adult worms (Figure), often combined with bacterial superinfection. This complication is believed to be rare but is probably underestimated because of the extreme variability of the clinical presentation.
Although strongyloidiasis can be suspected in the presence of symptoms or eosinophilia (which is frequent but not mandatory), the low sensitivity of direct diagnostic methods often lets the disease go unrecognized (5-7). By far the most sensitive diagnostic tools are serologic tests: sensitivity and specificity of indirect fluorescent antibody test (IFAT) (in-house produced IFAT) are 97.4% and 97.9%, respectively, at a dilution >1/20, and 70.5% and 99.8% at a dilution >1/80 (6). A suspected case is defined by a positive antibody titer >20 (IFAT); a case is confirmed by a positive direct test result (culture in agar being the most sensitive direct technique) or by a positive antibody titer >80 (6). Despite some anecdotal reports on the presence of strongyloidiasis in Italy (1,6), reliable information about the real prevalence of the infection is lacking. After seeing several patients affected by the disease, 1 of whom died because of dissemination (Z. Bisoffi, unpub. data), we decided to carry out a preliminary rapid assessment of the extent of the problem in elderly patients with eosinophilia.
During a 4-month period, from February through May 2008, every patient born in 1940 or earlier who came to the clinical laboratories of 2 contiguous health districts in northern Italy (Mantova, Lombardy Region, and Legnago, Veneto Region) for a diagnostic blood test (hematocrit and leukocyte count/formula) for whatever reason and having a eosinophil count >500 cells/μL was asked to join the study. This study was the pilot phase of a larger, multicentered study, which obtained formal approval from the Ethical Committee of Sacro Cuore Hospital of Negrar, Verona. Informed consent was required of each patient. Of the 132 patients eligible for inclusion (mean age 76.4 years, range 68-90 years, male:female ratio 1.6), none refused to give informed consent. Serum specimens were subjected to the IFAT for S. stercoralis at the Sacro Cuore Hospital Centre for Tropical Diseases.
Unexpectedly, we found that 37 (28%) of 132 patients were positive, with titers ranging between 20 and >320 (and >80 in most cases). However, caution should be exercised in interpreting the results because the patients may not be representative of the general population. Moreover, our results are based on an indirect (although highly sensitive and specific) test. Because the reported cases involve only a few patients every year (of whom some are anecdotally reported as dying from the infection, usually unpublished), we suspect that most strongyloidiasis cases remain undetected.
If relevant transmission still exists in the area, it is unknown but is unlikely because of the improvement of hygienic conditions in the past 5 decades. Reports of the infection in children or young adults with no travel history outside Italy are lacking. Strongyloidiasis in the elderly is therefore most likely to result from an infection that occurred much earlier in life, either in infancy or at a young age, while walking or working barefoot in agricultural fields. The long persistence is the consequence of the autoinfection cycle typical of this parasite as described above. The result is an important and unrecognized public health problem affecting the geriatric population of northern Italy. These preliminary results confirm the need for the already planned, multicentered study involving a larger sample and a wider geographic area. Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 9, September 2009