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Most infected persons are asymptomatic A pruritic maculopapular rash (ground itch) may occur at the site of larval penetration, usually in previously sensitized persons Pulmonary symptoms may be seen during larval migration through the lungs, with dry cough, wheezing, and lowgrade fever, but these symptoms are less common than with ascariasis Eosinophilia is common, especially during the phase of worm migration About 1 month after infection, as maturing worms attach to the small intestinal mucosa, gastrointestinal symptoms may develop, with epigastric pain, anorexia, and diarrhea, especially in previously unexposed individuals Persons chronically infected with large worm burdens may have abdominal pain, anorexia, diarrhea, and findings of marked iron-deficiency anemia and protein malnutrition In particular, anemia can lead to pallor, weakness, dyspnea, and congestive heart failure, and protein loss can lead to hypoalbuminemia, edema, and ascites These findings can be accompanied by impairment in growth and cognitive development in children Infection with the dog hookworm Ancylostoma caninum can uncommonly lead to abdominal pain, diarrhea, and eosinophilia, with intestinal ulcerations and regional lymphadenitis



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Strongyloidiasis is caused by infection with Strongyloides stercoralis Although much less prevalent than ascariasis, trichuriasis, or hookworm infections, strongyloidiasis is nonetheless a significant problem, infecting tens of millions of individuals in tropical and subtropical regions Infection is also endemic in some temperate regions of North America, Europe, Japan, and Australia Of particular importance is the predilection of the parasite to cause severe infections in immunocompromised individuals due to its ability to replicate in humans A related parasite, Strongyloides fuelleborni, infects humans in parts of Africa and New Guinea Among nematodes, S stercoralis is uniquely capable of maintaining its life cycle both within the human host and in soil Infection occurs when filariform larvae in soil penetrate the skin, enter the bloodstream, and are carried to the lungs, where they escape from capillaries into alveoli, ascend the bronchial tree, and are then swallowed and carried to the duodenum and upper jejunum, where maturation to the adult stage takes place Females live embedded in the mucosa for up to 5 years, releasing eggs that hatch in the intestines, to free rhabditiform larvae that pass to the ground via the feces In moist soil, these larvae metamorphose into infective filariform larvae Autoinfection can occur in humans, when some rhabditiform larvae develop into filariform larvae that penetrate the intestinal mucosa or perianal skin, and enter the circulation The parasite also can complete its full life cycle in soil

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Diagnosis is based on the demonstration of characteristic eggs in feces; concentration techniques are usually not needed Microcytic anemia, occult blood in the stool, hypoalbuminemia, and eosinophilia are common

Treatment is with albendazole (single 400 mg oral dose) or mebendazole (100 mg orally twice daily for 3 days) These drugs are teratogenic, but experience suggests that they are safe in children over 1 year of age and during the second and third trimesters of pregnancy Occasional adverse effects are diarrhea and abdominal pain Pyrantel pamoate and levamisole are also effective Anemia should be managed with iron replacement and, for severe symptomatic anemia, blood transfusion Mass treatment of children with single doses of albendazole or mebendazole at regular intervals limits worm burdens and the extent of disease and is advocated by the WHO

As with other intestinal nematodes, most infected persons are asymptomatic An acute syndrome can be seen at the time of acute infection, with a pruritic, erythematous, maculopapular rash, usually of the feet These symptoms may be followed by pulmonary symptoms (including dry cough, dyspnea, and wheezing) and eosinophilia after a number of days, followed by gastrointestinal symptoms after some weeks, as with hookworm infections Chronic infection may be accompanied by epigastric pain, nausea, diarrhea, and anemia Maculopapular

antihelminthic therapy (eg, monthly ivermectin) may be required It is important to be aware of the possibility of strongyloidiasis in those with even a distant history of residence in an endemic area, since the infection can be maintained for decades Screening of such individuals for infection is appropriate before institution of immunosuppressive therapy Screening can consist of serologic tests, with stool examinations in those with positive serologic tests, but consideration of presumptive treatment even if the stool evaluations are negative

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