Answer to CC #18

Case challenge #18 presented a 68 year old Asian female with HIV admitted for fever and SOB. Three days prior to admission, she developed watery diarrhea, approximately 5-6 BM a day. The work-up revealed 40% Eos and stool O&P with larval forms.

CC18 

  • The correct answer is: Strongyloides Stercoralis!

    • General Information
      • Strongyloidiasis is a chronic parasitic infection of humans caused by Strongyloides stercoralis.
      • Transmission occurs mainly in tropical and subtropical regions but also in countries with temperate climates.
      • An estimated 30–100 million people are infected worldwide
      • Infection is acquired through direct contact with contaminated soil during agricultural, domestic and recreational activities.
      • Like other soil-transmitted helminthiases, the risk of infection is associated with hygiene, making children especially vulnerable.
    • Clinical Manifestations
      • Strongyloidiasis is frequently underdiagnosed because many cases are asymptomatic
      • Strongyloidiasis may cause intermittent symptoms that mostly affect the intestine (abdominal pain and intermittent or persistent diarrhea), the lungs (cough, wheezing, chronic bronchitis) or skin (pruritus, urticaria).
      • Infection may be severe and even life-threatening in cases of immunodeficiency.
      • Without appropriate therapy, the infection does not resolve and may persist for life.
    • Diagnosis
      • Most diagnostic methods lack sensitivity.
      • Locating juvenile larvae, either rhabditiform or filariform, in recent stool samples will confirm the presence of this parasite.
        • Ascaris, Necator, and Schistosoma will have eggs in the fecal smear, not larvae
        • Trichinella will have larvae in the muscle 
      • Other techniques used include direct fecal smears, serodiagnosis through ELISA, and duodenal fumigation.
    • Management
      • Ivermectin is the drug of choice, but is not available in all endemic countries.
      • Albendazole is also an option, but is considered less effective.

What species of Strongyloides-small

For more information, as Nico Barros or Fernando Woll, our resident Strongy scientists!

A Practical Guide to the Novel Anticoagulants

This morning, Dr. Craig Malloy, Richard A. Lange, M.D. Chair in Cardiology, gave an amazing update for internists on New Therapies fo Atrial Fibrillation. One of the most important topics covered was the noval anticoagulants, or NOACS. Here is a quick review for use in the clinic or hospital!

Dabigatran, rivaroxaban and apixaban are three new drugs that have different mechanisms of action, daily doses, and metabolic and elimination profiles.

Dabigatran (Pradaxa) is a direct thrombin inhibitor (it inhibits factor II) that has a half-life of about 12-14 hours and needs to be administered twice daily. It partially binds plasma proteins and can therefore be partially dialysed. Pradaxa is only eliminated renally: it is therefore contraindicated in patients whose creatinine clearance is

Rivaroxaban (Xarelto) is a direct factor X inhibitor with a half-life of 5-13 hours, but completely binds plasma proteins. It is administered once daily with evening meal in NVAF patients, and twice daily in those with DVT or PE. It is eliminated by the kidney and liver, and can be used at a lower dose if creatinine clearance is15 mL/min in NVAF patients; its use should be avoided in DVT/PE patients whose creatinine clearance is

Apixaban (Eliquis) is a direct factor X inhibitor with a half-life of 9-14 hours, but completely binds plasma proteins. It is administered twice daily and eliminated by kidney and liver. It should not be used if creatinine clearance is

NOAC trial comparisons

Turiel M, Galaverna S, Colombo C, Gianturco L, Stella D (2015) Practical Guide to the New Oral Anticoagulants. J Gen Pract 3:194. doi: 10.4172/2329-9126.1000I194