An Unexpected Epidemic: Schistosomiasis and Strongyloides Infections Detected in an Academic Urban Community GI Practice. A Case Series of 104 patients

Abstract

 A gastroenterologist’s practice in a Boston metropolitan academic community hospital was reviewed for all cases of parasitic disease seen in that practice as part of routine GI referral patterns from October 10, 2009 to September 9, 2013. The practice did not specialize in the treatment of parasitic diseases. 104 patients were identified and evaluated for their methods of diagnosis, treatment, laboratory values and types of parasites. Serological results for all testing done by health care providers at the Cambridge Health Alliance (CHA) for Strongyloides stercoralis and Schistosomiasis (all species) were then reviewed for two one year periods. The study patients had parasitic infections that reflected the infestations endemic in their countries of origin. Language was used as a surrogate for the patient’s country of origin. The methods used for the diagnosis of parasitic infections included serologic studies (98/104: 94.2%), pathological examination of biopsy specimens with serology (19/104: 18.3%), pathological examination alone (6/104: 5.8%) and fecal ova and parasite testing (O&P) (2/104: 1.9%). 93/104 (89.4%) of the patients had a positive serology for Schistosomiasis, Strongyloides or both. None of the Schistosomiasis or Strongyloides patients were detected or confirmed with O&P studies (0/103: 0.0%). Several neoplastic lesions of the gut were noted (16/104: 15.4%), of which 3 (3/104: 2.9%) were adenocarcinomas of the colon. Tissue biopsy is a specific test. Schistosomiasis and Strongyloides serology are sensitive tests. Given the short time needed to treat these infections, and the relatively safe side effect profile for these therapies, the use of antibody and pathological testing with treatment of positive results seems to be a reasonable approach. Evaluation for parasites in asymptomatic, newly arrived immigrants and individuals with a distant history of immigration or travel to areas at risk (especially patients with eosinophilia) should be done as part of their routine health care. Transplant donors originally from endemic areas should have serological examination for Strongyloides stercoralis and Schistosoma species prior to organ transplant or fecal microbiota transplantation (FMT). All patients at risk for these infections should be diagnosed and treated prior to immunosuppressive therapy. This is especially true for patients with Strongyloides, given the unacceptable high mortality rate of hyperinfection syndrome. Such a strategy may prevent the consequences of chronic parasitic infestations and limit a potential public health hazard.