*** MJesus changes topic to 'Course Tropical Diseases: STRONGILOIDIASIS. The Slides are at http://bio.hgy.es/conganat/stron/' > se puede seguir esa misma charla en portugues en la direccion > http://www.conganat.org/iicongreso/conf/022/anexo.html [23:35] ATENTION..please... [23:35] :) [23:35] we are very glad to introduce [23:36] Dr Andreia R. Costa [23:36] pathologyst from Rio de Janeiro [23:37] she is going to speak about a tropical disease [23:37] Strongiloydiasis [23:38] ok let's go to business [23:38] Thanks Anddreia and come on.. [23:38] Good morning , good afternoon or good night .... [23:39] I'm from Rio de Janeiro - Brazil , where I am a residente in Anatomy Pathologic . [23:39] I would like to thank the people who have taken part on my education : [23:39] Professor Christina Maeda Takyia, MD ... [23:39] Professor Kalil Madi, MD [23:39] both from Federal University of Rio de Janeiro . [23:39] Professors and residents in my hospital . [23:39] To a very special person , who is always bringing news , new channels and servers ; always incentivating me "My friend" MJESUS !!!! [23:39] Today's theme is : STRONGYLOIDIASIS > tx Celeste!! [23:40] After reviewing an autopsy of my center .. I got curious and decided to study this case . [23:40] I have try to show everything from the etilogical agent to the prognostic and treatment . During the explanation you will be able to see the slides which are on the web (http://bio.hgy.es/conganat/stron) [23:40] I will "speak slowly", so that everyone can understand me. I will be pleased to answer your questions at the end of the presentation. [23:40] Case : [23:40] IGV. , 14 years old , black , female , student , living in the outskirts of Rio de Janeiro . [23:40] History of losing 20 kg in two months , diarrhea ( up to 6 times a day , without mucus , blood or fat ) , anorexia , nausea , vomit , equimosis , 38 C fever , and asthenia .The patient was not able to stand still . [23:41] About 15 days before the patient has noticed cutaneous alterations ( like measles ) which disappeared spontaneously . [23:41] Had hemoptoics a week ago . [23:41] Physical examination : [23:41] The patient was caquetica with loss of the Bichat fat , looking hipodevelopment , mucosae ( +/4+ ) , petequias in the conjuntive . Its weight was 26 kg . In the cardiac asculta revealed ejection systolic pancardiac blow (+/4+) , regular cardiac rhythm 3 T presence the B4 . In the pulmonar ausculta , the sounds were reduced on the bases . [23:41] Presence of the limphodenomegalias cervical , supraclavicular and inguinal , measuring about 0,5 cm , without pain and mobil . [23:41] Gum Hiperplasia was observed . [23:41] Laboratorial findings revealed leucocitosis , non reactive PPD , EAS without alterations , studies radiological of the chest was nomal , and positive stool examination for Strongiloides . [23:41] The patient evaluated to diarrhea and vomiting episodes and fever , as well as taquicardia . Five days later the patient died. [23:42] STRONGYLOIDIASIS [23:42] Strongyloidiasis is a very important infection because of its high frequency ,as well as its growing number of death cases , [23:42] specially in immunocompromised hosts . [23:42] It is a worldwide infection ( 85% of certain Brazilian areas ) , along with ancylostomides . [23:42] Its incidence is smaller because the filarioides larvae do not have protective wall, they last less ( about 5 weeks ) . [23:42] ETIOLOGIC AGENT : [23:43] Strongyloides stercoralis [23:43] A kind of dimorphobiotic , presents two forms : Parasitic and Stercoralis ( "free life") [23:43] The parasitic forms are thin partenogenetics females ( about 1,7 -2,5 micrometer ) - figure : 1Ac . [23:43] with a rounded anterior extremity and a slender posterior extremity , rombe tip, thin cuticle and delicate groove . [23:43] Free adult life ( partenogenetic female ) are small and result from parasitic evolution . [23:43] The male measures 0,5 - 0,7 micrometer and the female about 1,2 micrometer. - figure : 1A.a . [23:43] The free living generation or stercoralis are distinct from parasitic or intestinal form [23:43] because they are smaller and have separate genders , as well as a rabdthoid esophagus. [23:43] The worms's esophagus is filariform [23:44] HABITAT : [23:44] - Duodenum and upper jejunum ( localized infection ) [23:44] - In great infection the worm can be found in the extension of the intestine as well as other areas of the body ( disseminated infection ) [23:44] EVOLUTIVE CYCLE : [23:44] In human beings (definite host), they present a parasitic life cycle : direct [23:44] and indirect host ( found on the soil ) . [23:45] In the direct host , the eggs are laid on the intestinal mucosae by the females , and the larvae are set free , being called rabdthoides , measuring about 250 - 350 micrometer and having two bulbs esophagus . [23:45] The larvae evacuated in the feces are developed into filariforms ( second stage ) within 24-48 hours , measuring about 350-450 micrometer . The esophagus is about half these larvae dimension, which are infective . [23:45] They survive in the soil for some days ( 5 - 6 ) and penetrate the skin , reaching the bloodstream and the right circulation , following the lung circulation , arriving at the capillary wall , the alveolar coort , and the respiratory tract . [23:45] They go to the nasopharinx along with the mucus (LOSS CYCLE ) . [23:45] They are swallowed and fixed at duodenum and jejunum , up to its nature life , following the laying of eggs . It last about 12 days . [23:45] In the indirect cycle , the rabdthoid larvae are transformed in the free lives of males or females in the soil . [23:45] The female posture the eggs and its larvae are liberated in the soil . [23:45] They penetrate the skin and follow the same course above described . [23:46] TRANSMISSION : [23:46] People can be infected by : [23:46] - prime infection : the infective larvae penetrate skin [23:46] - internal auto-infection : filarioides larvae from the intestine penetrate the mucosae making the lung cycle ( LOSS) . [23:46] - external auto-infection : the rabdthoide larvae are eliminated through the feces but may penetrate perineal and perianal areas , making themselves filarioides larvae . Thus , following the cycle . [23:46] This hyperinfestactives mechanisms explains the long duration of the infestation without skin reinfestation . [23:47] There are report of the case lasting 40 years or even more . [23:47] PATHOGENESIS : [23:47] In the immunocompetent host small histologic alterations can be seen, while in the immunocompressed host the disease is disseminated and fatal . [23:47] The larvae parasitic action and its migration in the organism , as well as adult forms localization will determine morbidity disturbances . [23:47] - SKIN - [23:47] The penetration of the larvae in the skin can take to edemathosus -papulo reactions unrelated with the infestation , urticariform reaction with petequias , prurity , edema , and congestion sometimes complicated by secondary bacterial infection . [23:47] - RESPIRATORY TRACT - [23:48] When the larvae penetrate the pulmonary capillary , a vascular lesion which results in puntiforms hemorrhages and the minor lesions is caused .This leads to an inflammatory reaction and a secondary infection determining the symptomathology of bronquitis or pneumonia , symptoms of the Löeffler Syndrome . [23:48] The combined weight of the lung is over 1000 g .Uniform consolidation of all lobes , hemorrhagic cut surfaces and bronchi filled with inspisated mucus can be observed, as well as the worm inside the mucus of the respiratory tract . [23:48] GASTROINTESTINAL TRACT : [23:48] Histological changes vary depending on the number of invasive parasite forms and the evolutive phase that follows the infestation . [23:48] The female penetrates the intestinal mucosae by mechanical and litic action causing congestion , hemorrhagea and necrosis . [23:48] After the posture of the eggs , the larvae are liberated in the glands and migrate to intestinal lumen causing traumatic litic , infection and toxic action in the mucosae , thus its inflammation . [23:49] In the beginning , the lesions are deep , inside Liberkün glands and its consequence is epithelial proliferation . [23:49] When parasitism is high , the lesions flow together forming hiperplastic process , which are limited to the mucosae . [23:49] The lesioned areas of the mucosae will suffer tecidual repairement , resulting on fibrosis and thickening of the intestinal wall . [23:49] The larvae can be found in the submucosae or muscle . In the invasive case , they determine granulomatousus reaction of the strange body type and eosinophilia . [23:49] Generally , the ulcers are small and disseminate giving the mucosae "tigroide aspect". [23:49] The secondary infection may occur , originating thick ulcerations , granulation tissue and later , hypotrophy of the mucosae . [23:49] In massive infections , because of the thickening the intestinal wall , occurs estenosis of the lumen simulating neoplasia . [23:50] CENTRAL NERVOUS SYSTEM : [23:50] Alterations like petequias , hemorrhagea , edema , and focal necrosis can be found . [23:50] Microscopically , the larvae can be identified but without inflammatory infiltrate around it , necrosis focus and thromboses of blood vases . [23:50] The thrombosis may clinically simulate a vasculitic syndrome . [23:50] OTHER ORGANS : [23:50] In serious case many organs may be lesioned by the parasite such as : lungs , nervous system , liver , kidney , heart , pancreas , etc.. taking to sepsis by enteric microbiota and making the parasitosis serious and fatal . [23:50] The larvae are found in many organs and tissues without inflammatory reaction around it. [23:51] In some cases , there are reports of the granulomatous infection in the liver . [23:51] SYMPTOMATOLOGY : [23:51] The symptomatology varies according to the intensity , depending if the infestation is localized or disseminated . [23:51] According to this , we may have an acute and chronic form ( periods of exacerbation and acalmia ) . [23:51] According to its extensions , it is classified in three forms of presentation : [23:52] a) Localized - undertakes only the duodenum and jejunum ; [23:52] b) Hyperinfective - all extension of the intestine ; [23:52] c) Generalized - dissemination through any parts of the organism . [23:52] The symptoms relate with the lesions of the organs the parasites go through . [23:52] In the skin , dermatitis and urticaria , may be present but do not relate to the infestation . [23:52] In the gastrointestinal tract , there is abdominal pain , specially in epigastric region and cystic point , simulating peptic ulcer and colecistitis , enteritis catarrhal , diarrhea , sometimes with mucus and blood or gastrointestinal alterations . [23:53] There are cases of abdominal post prandial pain , pirose , indisposition , drowsiness , nausea , sometimes followed by vomiting , intestinal obstruction and also peritonitis , when intestinal perforation occurs . [23:53] Atipic Pneumonia , and medium intensity , symptoms simulate bronquitis because of the presence of larvae in the respiratory tree , can be found in the respiratory tract . [23:53] They may stop spontaneously , constituting Loefller Syndrome . [23:53] General symptoms are : mild anemia , astenia , alterations of the psiquism since mild variations to neurasthenic pictures . [23:53] Sepsis can be found because its dissemination in any part of the organism . [23:53] In general the patient has a base disease which depresses the cellular immunity , such as , malignant neoplasias , immunosupressers as corticoids . [23:54] Thus , high doses of corticoids and other immunosupressers must be initiated after the investigation and treatment of the Strongyloides . [23:54] HIV patients must be parasitologically investigated before the development of AIDS , because of opportunistic Strongyloidiasis . [23:54] CLINICAL AND LABORATORIAL : [23:54] Strongyloidiasis must be suspected in cases of present diarrhea with mucus ( enterite catarrhal ) or epigastric pain and eosinophilia . [23:54] The eosinophilia is very important , being in the most determinant parasitosis . [23:54] The laboratorial diagnostic of Strongyloidiasis is made verifying the larvae in the feces or duodenum secretion . [23:55] Baerman - Moraes stool examination is the most appropriate to show the larvae . [23:55] The method can be also used in the sputum and gastric washing . [23:55] Every parasitic forms (egg , larvae and female) can be present in the duodenal aspirate . [23:55] In some thin intestinal biopsies can be found the Strongyloides . [23:55] In immunocompressed patients , we can find great amount of parasites in the intestine and also , larvae in the sputum , alveolar brushing , cervical smears , pleural and ascitic fluid . [23:55] Serologic tests for the diagnosis have been described but with little specificity . [23:56] The immune enzimatic technic - ELISA - have high sensibility . [23:56] The Indirect Haemoglutination - IH - is other serologic test . [23:56] However , these tests are not commonly used . [23:56] TREATMENT : [23:56] Thiabendazol and Albendazol are most effective on the parasite . [23:56] Thiabendazol is a first choice drug being orally administered in many ways , with 90-95 % of efficacy . [23:56] 1) 25 mg/kg/day , during 5 - 7 days - the most used ; [23:57] 2) 50mg/kg only dose before sleeping maximum dose 3 g . Repeating the doses on the 10th and 20 th day . - not much used because of collateral effects , such as : anorexia , nauseas, diarrhea , drowsiness , cutaneous rash , all which stop with suspension of the drug. [23:57] 3) 10 mg /kg/day during 30 days . - this scheme used for patients who have their cellular immunity system and in cases of auto-endoinfection . [23:57] Albendazol , helmintic polyvalent drug used 400 mg during three consecutive days .Efficacy is about 60 % . [23:57] A symptomatic carriers must be treated by epidemiology questions because they keep infection in the soil , thus intensifying endemic focuses . [23:57] After the treatment , a cure control must be used , repeating the diagnostic method on the 7th , 14th , and 21th day . [23:57] The prognostic is good in most cases , except on the most severe disseminated form , where they are correlated to the hyperinfection picture , which determine fatal cases . [23:58] In the Brazilian Literature many fatal cases have been reported . [23:58] Answers ??? > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas > thank you very much!! [23:59] 6p7l1a5s13! 5p4l4a6s3! 12p5l5a14s6! 14p14l13a10s10! 10p14l6a7s3! 10p10l2a13s12! 12p2l2a12s13! 10p12l14a7s14! [23:59] 10p5l7a7s6! 1p3l14a14s1! 4p10l3a5s4! 4p5l7a14s12! 10p13l14a14s2! 2p6l12a2s3! 12p7l12a13s2! 2p5l6a13s6! [23:59] 4p12l5a2s14! 6p4l10a13s2! 14p3l3a14s6! 2p5l10a13s7! 2p10l14a7s12! 1p1l13a7s7! 4p10l7a7s5! 3p4l3a1s13! [23:59] 10p1l3a14s5! 5p1l2a10s7! 12p2l7a3s1! 10p4l3a10s14! 1p5l10a12s14! 7p7l1a12s12! 13p7l7a2s4! 2p2l7a7s14! [23:59] any questions ? [23:59] yes.. [0:00] why the female died so quickly? [0:00] was she.. [0:00] an immunocompetent patient? > oh Andreia .. very interesting.. I like to ask you about the reported incidence os Strongilosidosis in Brazil [0:04] 85% of certain Brazilian areas > is more frequent in the Amazonia than in the Coast?? [0:05] the basic disease of the patient not identify .. because she died very quickly [0:05] Does strongyloidiasis promote T lymphocyte-induced nephrotic syndrome? [0:05] ok thanks.. [0:06] we believve that the patient had a depress of the immunity celular .. but why .. not identify [0:07] what type of program does the brazilian government use to prevent spreading the disease? [0:07] in Spain is very frecuent in the east.... [0:07] if any? [0:08] The disease not had seen as regional .. in location special . > Andreia.... how is the disease transmitted from the host to other humans? [0:09] In patients with depress of the immunity celular , base disease as neoplasia , AIDS .. have been seen as dissemanated [0:10] By larvae presents in the feces [0:10] what type of program does the brazilian government use to prevent spreading the disease? if any? [0:11] prevention .. [0:11] I've seen in a paper the mortality is 40% is it true in Brasil or more....? [0:11] does this program reach the poorest regions? [0:12] the mortality is high in patients immunodepressers [0:13] no program [0:13] Those tests you mentioned, why aren't they used if it is so serious a disease? [0:15] diagnostic . stool examination [0:15] Endoscopic evaluation of chronic human immunodeficiency virus-related diarrhea: is colonoscopy superior to flexible sigmoidoscopy? [0:16] BAERMAN MORAES .. the presenca of the larvae [0:16] gracias gracias [0:17] In Spain the firstone treatment is Albendazole..what do you think?? > Abendazole is a antibiotic?? [0:17] is better Tiabendazole? [0:17] no...is a derivated from Tiabendazole [0:18] hable demasiao pronto :/ [0:18] The efficacy of the Thiabendazol is 90-95% [0:18] The efficacy of the Albendazol is 60% > cristina... have you know about Spanish cases? [0:19] yes [0:19] in AIDS patients [0:20] is there a way to prevent the indirect cycle from recurring?, such as water sterilization? [0:20] the prevalence in spain is 3% (patients no immunocompromised) > ohhhhhh ..... there are too much in Spain! [0:21] yes [0:21] overall in Levante [0:21] in the east coast [0:21] Crisitina, are you in the east coast of Spain? [0:22] no [0:22] but this is the prevalence in general.. [0:22] ok, thanks, I was just wondering :) [0:23] probably the warm in Levante in a quite good medium.. [0:23] to larvae [0:23] I'm a biologist, I know nothing of strongiloidiasis, but I live in Valencia, so I was curious. [0:24] you can read the last number of Medicine.. [0:24] there we are!!! > I have reed in Med. Clin. that in Valencia.. have high incidence [0:25] general , In Brazil there is the polinfestation . the patient have other disease parasitic .. we haven't a location in special .. in many cases are identified as found .. > Alex.....you are an amateur paleopathologist, do you know if in the mummy coprolits we can find egg remainders? [0:26] thank Mjesus > Alex.. do you know about this? [0:29] can you see Acanthocefalan eggs in animal coprolites from archaeological sites from Brazil. > I reminder....Alex tell us many class on paleopathology six month ago!! [0:30] Strongyloidosis is a very interesting patology and is increasing a lot.. [0:30] I saw a case . where the patient had larvae in LCR .. [0:31] I saw throw a warm by the mouth in a patient!!!! [0:31] yuck! [0:31] do you know Acanthocefalan eggs in animal coprolites from archaeological sites from Brazil. [0:31] with cough.. > alex... all us, the pathologist are not paleo-pathologist!! [0:32] jajajajajaja [0:33] you never know.... [0:33] ;-))))) > Andreia.. are you afraid to become infected in the departmen of Pathology? [0:34] is true! [0:34] no , I haven't [0:34] no??? > formaline is a sufficient antiseptic? > Andreia.. the slides are beautifull!! [0:36] yesssss [0:36] I agree, i'm very impressed!! [0:36] The larvae haven't a protective wall [0:37] duration . about 5 weeks > yes-... and to find the strongiloides in the cardiac muscle..... is tremendous! [0:37] Congratulations Andreia.....we are afraid it is too late in Spain.. > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas [0:38] and we must finish.... > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas [0:38] IT'S A PITTY!!! > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas [0:38] and know a little mention to our dear sponsor TIMOFONICA, thanks to cut my call XDDDDDDDDDDDDDD [0:38] PLAS,PLAS,PLAS,PLAS > Andreia .... thank you very much!!! [0:38] thanks Andreia [0:38] the humidity and the sunlight causing it dissecation , and death [0:39] OK! [0:39] great speech [0:39] Thanks a lot Andreia!!!!!!! [0:39] interesting slides [0:39] :) > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas > 4plas 5plas 6plas 7plas 8plas 9plas 10plas 11plas 12plas 13plas > 4 FIN DE LA GRABACION