238.3 🩺 內科專科考前版

238.3.0.1 1️⃣ Pre-Immunosuppression Screening for Strongyloides

• Patients from endemic regions (Latin America, Africa, Caribbean, SE Asia, Appalachia, parts of Eastern Europe):
  • Stool O+P × 3
  • Serology (most sensitive)
  • PCR (emerging)
• Empirical ivermectin if positive or strong clinical suspicion
• Before corticosteroids, organ transplant, anti-TNF, chemotherapy
• Reduces hyperinfection risk dramatically
• 2 doses ivermectin 200 µg/kg, 2 weeks apart

238.3.0.2 2️⃣ Strongyloides Hyperinfection Triggers

• Corticosteroids (even oral dexamethasone for COVID-19) — dose-dependent
• Organ transplant immunosuppression
• HTLV-1 infection
• Hematologic malignancy
• Chemotherapy
• Anti-TNF (rare but reported)
• BMT
• Don’t forget pre-screening even for “low-dose” corticosteroids in high-risk patients

238.3.0.3 3️⃣ Hyperinfection Treatment

• Ivermectin 200 µg/kg PO daily × 2 weeks (extended duration)
• Add albendazole 400 mg PO bid × 2 weeks (combination)
• Reduce immunosuppression if possible
• Subcutaneous / rectal ivermectin if PO not tolerated (off-label, sometimes used)
• Supportive: ICU + ventilator + IV antibiotics for gram-negative sepsis + dialysis

238.3.0.4 4️⃣ Cutaneous Larva Migrans Differential

• Strongyloides larva currens — serpiginous, intermittent, lower trunk/buttocks (from autoinfection)
• Animal hookworm CLM — serpiginous, lower extremities/buttocks, beach exposure
• Gnathostomiasis — migratory swellings (Asia, Latin America)
• Loa loa migration (Africa)
• Treatment: ivermectin or albendazole (both effective for most)

238.3.0.5 5️⃣ Ascaris Intestinal Obstruction

• Heavy burden pediatric
• Surgical emergency
• Often requires laparotomy + manual extraction
• Treat all family members
• Improve sanitation

238.3.0.6 6️⃣ Biliary Ascariasis

• Adult worm migrates into common bile duct
• Cholangitis, pancreatitis
• ERCP + extraction
• Albendazole post-extraction
• Endemic areas common

238.3.0.7 7️⃣ MDA + STH Elimination Targets

• WHO 2030: STH elimination as public health problem (< 2% moderate-heavy infection in target groups)
• Albendazole / mebendazole annual / biannual
• School + community-based
• Combination with other antiparasitics
• Major reductions achieved 2010s+

238.3.0.8 8️⃣ 健保 / Taiwan

• 公費 STH deworming (school-age children historically; now selective)
• 健保 albendazole / mebendazole + ivermectin
• 通報 (some STH)
• Endemic + imported cases

238.3.0.9 9️⃣ Anemia Workup + Hookworm

• Unexplained iron deficiency anemia in patient with endemic exposure / from endemic area
• Stool O+P for hookworm eggs
• Empirical deworming if high suspicion
• Iron supplementation + albendazole

238.3.0.10 10. Future

• mRNA helminth vaccines (research)
• New antiparasitics
• Combination drugs (ivermectin + moxidectin)
• Improved diagnostics (POC tests)

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