Introduction. The human T cell lymphotropic virus type 1 (HTLV-1) is the causative agent of inflammatory immune-mediated disorders of the central nervous system (CNS), including the progressive myelopathy called HTLV-1-associated myelopathy or tropical spastic paraparesis (HAM/TSP)[1]. The infection has a worldwide distribution and is endemic in the Carribeans and South America. Women with low educational and socioeconomic levels are primarily infected and they are more likely to develop HAM/TSP. HTLV-1 is transmitted by sexual contact, contaminated blood products and breastfeeding [2]. A relationship between HTLV-1 infection and Strongyloides stercolaris has been reported: the frequency of helminthic infection is 23% in HTLV carriers, but it is low in patients with HAM/TSP (only in 3%) [3]. Case report. A 44-year-old Peruvian woman presented with a 3 months history of stiffness of right leg and difficulties in walking. She complained painful cramps in the lower limbs during the night. Neurological examination revealed hyperreflexia with bilateral patellar clonus and Babinski’s sign. Blood tests showed hypereosinophilia. A brain and spinal magnetic resonance imaging (MRI) revealed T2-hyperintense areas at the level of the upper and middle cerebellar peduncles, with contrast-enhancement. Cerebrospinal fluid examination (CSF) was normal; oligoclonal bands in serum and CSF were absent. Diagnostic procedures, including antineuronal antibodies (Anti-Yo, Hu, Ri, anphiphisin and GAD), tests for celiac disease, screening of vasculitis, polymerase chain reaction (PCR) amplification of viral (CMV, EBV, HSV1/2, VZV) and BK DNA from CSF, resulted negative. Since serum hypereosinophilia is common during nematode infections, stool samples were collected and Rhabditiform larvae of Strongyloides stercolaris were detected. Moreover, patient was tested for the presence of HTLV-1 and HTLV-2 antibodies in serum. HTLV-1 Western blot tests were positive for gag, pol and env (open reading frames coding viral proteins). The patient was treated with steroids and physical exercises, with a complete resolution of painful cramps and improvement of walking. Complete eradication of parasites was achieved by using Ivermectin. A complete family screening was performed. Discussion. HTLV-1 infection can be asymptomatic or present with various isolated or assorted evidences. Very little is known about the natural history of HTLV-1 infection and regarding the time between infection and appearance of clinical manifestations. Early neurological manifestations of HAM/TSP may be only a single symptom (e.g. cramps) and/or a physical sign (e.g. hyperreflexia). Concurrent infection with parasites may be a cofactor in development of HTLV-1 disease. Stool examinations to detect helminthic infection are recommended in all patients who have HTLV-1 infection. References. 1. Araujo AQ, Silva MT. The HTLV-1 neurological complex. Lancet Neurol. 2006 Dec;5(12):1068-76. 2. Araujo AQ. Update on Neurological Manifestations of HTLV-1 Infection. Curr Infect Dis Rep. 2015 Feb;17(2):459. doi: 10.1007/s11908-014-0459-0. 3. Carvalho EM, Da Fonseca Porto A. Epidemiological and clinical interaction between HTLV-1 and Strongyloides stercoralis. Parasite Immunol. 2004 Nov-Dec;26(11-12):487-97.

Strongyloides stercolaris and HTLV-1-associated myelopathy : a case report / R. Pagani, F. Gervasoni, A. Previtera. - In: NEUROLOGICAL SCIENCES. - ISSN 1590-1874. - 36:Supplemento(2015 Oct), pp. 101-101. ((Intervento presentato al 46. convegno Congresso della Società Italiana di Neurologia : 10-13 ottobre tenutosi a Genova nel 2015.

Strongyloides stercolaris and HTLV-1-associated myelopathy : a case report

F. Gervasoni
Secondo
;
A. Previtera
Ultimo
2015-10

Abstract

Introduction. The human T cell lymphotropic virus type 1 (HTLV-1) is the causative agent of inflammatory immune-mediated disorders of the central nervous system (CNS), including the progressive myelopathy called HTLV-1-associated myelopathy or tropical spastic paraparesis (HAM/TSP)[1]. The infection has a worldwide distribution and is endemic in the Carribeans and South America. Women with low educational and socioeconomic levels are primarily infected and they are more likely to develop HAM/TSP. HTLV-1 is transmitted by sexual contact, contaminated blood products and breastfeeding [2]. A relationship between HTLV-1 infection and Strongyloides stercolaris has been reported: the frequency of helminthic infection is 23% in HTLV carriers, but it is low in patients with HAM/TSP (only in 3%) [3]. Case report. A 44-year-old Peruvian woman presented with a 3 months history of stiffness of right leg and difficulties in walking. She complained painful cramps in the lower limbs during the night. Neurological examination revealed hyperreflexia with bilateral patellar clonus and Babinski’s sign. Blood tests showed hypereosinophilia. A brain and spinal magnetic resonance imaging (MRI) revealed T2-hyperintense areas at the level of the upper and middle cerebellar peduncles, with contrast-enhancement. Cerebrospinal fluid examination (CSF) was normal; oligoclonal bands in serum and CSF were absent. Diagnostic procedures, including antineuronal antibodies (Anti-Yo, Hu, Ri, anphiphisin and GAD), tests for celiac disease, screening of vasculitis, polymerase chain reaction (PCR) amplification of viral (CMV, EBV, HSV1/2, VZV) and BK DNA from CSF, resulted negative. Since serum hypereosinophilia is common during nematode infections, stool samples were collected and Rhabditiform larvae of Strongyloides stercolaris were detected. Moreover, patient was tested for the presence of HTLV-1 and HTLV-2 antibodies in serum. HTLV-1 Western blot tests were positive for gag, pol and env (open reading frames coding viral proteins). The patient was treated with steroids and physical exercises, with a complete resolution of painful cramps and improvement of walking. Complete eradication of parasites was achieved by using Ivermectin. A complete family screening was performed. Discussion. HTLV-1 infection can be asymptomatic or present with various isolated or assorted evidences. Very little is known about the natural history of HTLV-1 infection and regarding the time between infection and appearance of clinical manifestations. Early neurological manifestations of HAM/TSP may be only a single symptom (e.g. cramps) and/or a physical sign (e.g. hyperreflexia). Concurrent infection with parasites may be a cofactor in development of HTLV-1 disease. Stool examinations to detect helminthic infection are recommended in all patients who have HTLV-1 infection. References. 1. Araujo AQ, Silva MT. The HTLV-1 neurological complex. Lancet Neurol. 2006 Dec;5(12):1068-76. 2. Araujo AQ. Update on Neurological Manifestations of HTLV-1 Infection. Curr Infect Dis Rep. 2015 Feb;17(2):459. doi: 10.1007/s11908-014-0459-0. 3. Carvalho EM, Da Fonseca Porto A. Epidemiological and clinical interaction between HTLV-1 and Strongyloides stercoralis. Parasite Immunol. 2004 Nov-Dec;26(11-12):487-97.
HTLV-1; Strongyloides; myelopathy; rehabilitation
Settore MED/34 - Medicina Fisica e Riabilitativa
Settore MED/26 - Neurologia
Settore MED/17 - Malattie Infettive
Società Italiana di Neurologia
http://congress.wooky.it/web/eventi/neuro2015/poster/pdf/pst532.pdf
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