Recommendations from the Brazilian Society of Rheumatology on the diagnosis and treatment of intestinal parasitic infections in patients with autoimmune rheumatic disorders

Braz, Alessandra Sousa; Andrade, Carlos Augusto Ferreira de; Mota, Licia Maria Henrique da; Lima, Caliandra Maria Bezerra Luna

doi:10.1016/j.rbr.2014.10.010

Acessibilidade / Reportar erro

Brasil

Revista Brasileira de Reumatologia

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Recommendations of the Brazilian Society of Rheumatology • Rev. Bras. Reumatol. 55 (4) • Jul-Aug 2015 • https://doi.org/10.1016/j.rbr.2014.10.010 copy

Recommendations from the Brazilian Society of Rheumatology on the diagnosis and treatment of intestinal parasitic infections in patients with autoimmune rheumatic disorders

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Intestinal parasites – helminths and protozoa – are cosmopolitan diseases which are most prevalent in tropical regions. Patients with diagnoses of autoimmune rheumatic diseases have, due to the underlying disease or its treatment, an increased risk of occurrence of severe manifestations of intestinal parasites. Although the prevalence of these parasitic infections is very high in our environment, not always is the rheumatologist attentive to the need for investigation and treatment of helminthiasis and protozooses before the use of immunomodulatory, immunosuppressive therapies, and of biological drugs that are modifiers of the course of the disease. In this document, the Brazilian Society of Rheumatology establishes general recommendations on the diagnosis and treatment of intestinal parasitic infections in Brazil in patients with autoimmune rheumatic diseases, highlighting rheumatoid arthritis, systemic lupus erythematosus and spondyloarthritis.

Keywords:
Parasitarian entheropathy; Diagnostic; Therapeutics; Autoimmune diseases; Rheumatic diseases

Authors/year	Therapy used	Event	Etiological agent/isolated material	Manifestations/evolution
Grunnet al. (1981) ⁷⁵75 Grunnet ML, Cannon GH, Kushner JP. Fulminant amebic meningoencephalitis due to Acanthamoeba. Neurology. 1981;31:174–6.	SLE/immunosuppressor	Fulminant meningoencephalitis	Acanthamoeba castellanii (Trophozoites in the lung)	Possible primary focus in the lung/death
Tai and Fong (1997) ⁷⁶76 Tai ES, Fong KY. Fatal amoebic colitis in a patient with SLE: a case report and review of the literature. Lupus. 1997;6:610–2.	SLE/immunosuppressor	Fulminant colitis	Entamoeba histolytica (Trophozoites in intestinal mucosa)	Intestinal amoebiasis complicated by Salmonella/Sepsis and death
Okusawa et al. (1998) ⁷⁷77 Okusawa E, Ito T, Mori S, Abe T. Granulomatous amoebic encephalitis caused by Acanthamoeba in a patient with systemic lupus erythematosus. Clin Rheumatol. 1998;17:329–32.	SLE/immunosuppressor	Granulomatous encephalitis	Acanthamoeba encephalitidis(Trophozoites in the lung)	Possible primary focus in the lung/death
Shrestha et al. (2003) ⁷⁸78 Shrestha NK, Khanal B, Sharma SK, Dhakal SS, Kanungo R. Primary amoebic meningoencephalitis in a patient with systemic lupus erythematosus. Scand J Infect Dis. 2003;35:514–6.	SLE/immunosuppressor	Meningoencephalitis	Entamoeba histolytica(Trophozoites from the species Naegleria fowleri in the cerebrospinal fluid)	Death
Shirwadkar et al. (2006) ⁷⁹79 Shirwadkar CG, Samant R, Sankhe M, Deshpande R, Yagi S, Schuster FL, et al. Acanthamoeba encephalitis in patient with systemic lupus, India. Emerg Infect Dis. 2006;12:984–6.	SLE/immunosuppressor	Encephalitis	Acanthamoeba mitochondrial(Neuropathological exam)	Death
Lange et al. (2008) ⁸⁰80 Lange P, Bauer C, Hügens-Penzel M, Lehmann HW, Zimmer KP, Kuchelmeister K. Acanthamoeba meningoencephalitis: a case in an adolescent female patient with systemic lupus erythematosus. Pathologe. 2008;29:442–8.	Juvenile SLE/immunosuppressor	Meningoencephalitis with central nervous system vasculitis	Acanthamoeba meningoencephalitis(Neuropathological exam)	Multiple hemorrhagic focci in leptomeninges/death
Castillo et al. (2012) ⁸¹81 Castillo RD, Garza JX, Shamszadeh M, Reiff AO, Marzan KA. Acanthamoeba meningoencephalitis presenting as neuropsychiatric lupus in a pediatric patient. Clin Exp Rheumatol. 2012;30:272–6.	Juvenile SLE/immunosuppressor	Meningoencephalitis	Acanthamoeba meningoencephalitis(Trophozoites in cerebral biopsy)	Behavioral change, coma and death
Lee et al. (2012) ³⁶36 Lee J, Jung HS, Nam HC, Kwok SK, Ju JH, Park KS, et al. Fulminant amoebic colitis mimicking intestinal vasculitis in a patient with systemic lupus erythematosus. Lupus. 2012;21:1351–5.	SLE/immunosuppressor	Amoebic colitis	Entamoeba histolytica (Trophozoites in resected colon)	Multiple intestinal perforations, respiratory failure. Improvement with antiparasitic therapy
Alkhunaizi et al. (2013) ⁸²82 Alkhunaizi AM, Dawamneh MF, Banda RW, Daabil RA, Al-Tawfiq JA, Akkad SA, et al. Acanthamoeba encephalitis in a patient with systemic lupus treated with rituximab. Diagn Microbiol Infect Dis. 2013;75:192–4.	SLE/immunobiologicals(Rituximabe)	Meningoencephalitis	Acanthamoeba encephalitidis	Behavioral change, headache. It improves with treatment.

Authors/year	Event	Drugs used	Manifestations/evolution
Koh et al. (2004) ⁸⁴84 Koh MS, Leng PH, Eng P, Hwang J. An unusual cause of pulmonary haemorrhage in a patient with rheumatoid arthritis. Ann Acad Med Singap. 2004;33:365–7.	Pneumonia	Metotrexate and prednisolone	Lung hemorrhage/death
Boatright and Wang (2005) ⁸⁵85 Boatright MD, Wang BWE. Clinical infection with Strongyloides sterocoralis following etanercept use for rheumatoid arthritis. Arthritis and Rheumatism. 2005;52:1336–7.	Abdominal pain and diarrhea	Etanercept and prednisone	Latent abdominal infectionResolution after treatment
Miguel-Fraile et al. (2006) ⁸⁶86 Miguel-Frailea OS, Vasallob FJ, Rodríguez-Condec I, Ortiz-Reya JÁ. Diarrea aguda en paciente con artritis reumatoide. Enfermedades Infecciosas y Microbiología Clínica. 2006;24:347–8.	Diarrhea, vomiting and malaise	Metotrexate, prednisone and paracetamol	Gastritis due to parasite/Resolution after treatment
Das et al. (2007) ⁸⁷87 Das P, Raghu P, Dinda AK, Garg P. Strongyloides hyperinfection in rheumatoid arthritis. Int J Surg Pathol. 2007;15:391–2.	Diarrhea and anorexia	Prednisone	Duodenitis due to parasiteResolution after treatment
Altintop et al. (2010) ⁸⁸88 Altintop L, Cakar B, Hokelek M, Bektas A, Yildiz L, Karaoglanoglu M. Strongyloides stercoralis hyperinfection in a patient with rheumatoid arthritis and bronchialasthma: a case report. Ann Clin Microbiol Antimicrobials. 2010;9:27.	Weakness, dyspepsy, dyspnea and cough	Metotrexate and deflazacort	Gastritis and duodenitis due to parasiteResolution after treatment

Parasitic infection	Etiological agent	Transmission	Characteristics	Clinical picture
Giardiasis	Giardia lamblia	Cysts ingestion, orally	Monoxenic cycle; parasite of the small intestine; absence of a pulmonary cycle; no tissue invasion of trophozoites; waterborne disease and responsible for diarrhea outbreaks; zoonosis; important cause of diarrhea in children.	Asymptomatic or symptomatic forms; acute or chronic diarrhea; steatorrhea; abdominal discomfort; nausea; weight loss; vomiting; flatulence; malaise.
Amoebiasis	Entamoeba histolytica	Cysts ingestion, orally	Monoxenic cycle; parasite of the large intestine; likelihood of tissue invasion; extraintestinal amebiasis; absence of a pulmonary cycle; asymptomatic patients are an important source of infection; food handlers play an important role in the transmission; morphologically similar to Entamoeba dispar.	Asymptomatic or symptomatic forms; dysenteric and non-dysenteric colitis; mucous and bloody stools; amebic appendicitis; extraintestinal amebiasis; hepatic abscesses; fever; hepatomegaly.
Ascarisis	Ascaris lumbricoides	Eggs ingestion, orally	Monoxenic cycle; infects uniquely humans; parasite of the small intestine; pulmonary cycle in the larval stage, erratic parasite.	Asymptomatic or symptomatic forms which are determined by the number of parasites; abdominal symptoms, pulmonary symptoms; elimination of adult worms; intestinal occlusion or obstruction; Loeffler's syndrome.
Ancylostomiasis	Ancylostoma duodenale/Necator americanus	Infective larvae penetration in the skin or mucosas	Monoxenic cycle; parasite of the small intestine; pulmonary cycle; parasite blood spoliation that causes anemia in the host proportional to the parasite load	Abdominal and pulmonary symptoms; transient cutaneous manifestations; iron deficiency anemia; hypoalbuminemia; fecal occult blood; Loeffler's syndrome.
Strongyloidiasis	Strongyloides stercoralis	Infective larvae penetration in the skin or mucosas, possible autoinfection	Monoxenic cycle; parasite of the small intestine in which the female parasite lodges in the intestinal villi; pulmonary cycle; eggs hatch still within the intestine; hyperinfection and disseminated forms described in immunocompromised patients.	Asymptomatic or symptomatic forms, skin, lung and intestinal symptoms; epigastric pain is a frequent report; Loeffler's syndrome; cases of hyperinfection and disseminated forms in immunocompromised patients.

Parasitic infections	Parasitological tests	Complementary diagnostic tests	Treatment options	Prophylaxis	Recommendations for patients with autoimmune rheumatic diseases
Giardiasis	Spontaneous sedimentation; Ritchie's method/cysts and trophozoites search	Intermittent elimination of parasitic forms may require the collection of stools every seven days; evaluation of duodenal content for search of trophozoites; search for antigen in stools	Metronidazole 250mg, (orally) PO, bid, for 3 to 5 days; secnidazole 2g, PO, single dose; a lbendazole 400mg, PO, once a day for 5 days; nitazoxanide 500mg, PO, bid for 3 to 7 days.	Proper cleaning of fruits and vegetables; use of filtered or boiled water; control of mechanical vectors; health education.	Prophylaxis before the onset of immunomodulatory, immunosuppressive or immunobiological drugs with secnidazole, 2g, orally, single dose. Repeat annually if patient's immunosuppression persists and he/she lives in endemic areas
Amoebiasis	Spontaneous sedimentation; Ritchie's method/search for cysts and trophozoites.	Serological methods; search for antigen in stools; ultrasonography in cases of amebic abscess	Metronidazole 500–750mg, PO, bid for 7–10 days; secnidazole 2g, PO, single dose; tinidazole 2g, PO, for 2 days; nitazoxanide500mg, PO, bid for 3 to 7 days.	Proper cleaning of fruits and vegetables; use of filtered or boiled water; control of mechanical vectors; health education	Prophylaxis before the onset of immunomodulatory, immunosuppressive or immunobiological drugs with secnidazole, 2g oral, single dose. Repeat annually if patient's immunosuppression persists and he/she lives in endemic areas
Ascariasis	Spontaneous sedimentation; Kato-katz method/eggs search	Elimination of adult worm; eosinophilia	Albendazol 400mg, PO, single dose; mebendazole 100mg, PO, bid, for 3 days or 500mg, VO, single dose; Nitazoxanide 500mg, PO, bid for 3 to 7 days.	Health education; sanitation; hands and food washing.	Prophylaxis before the onset of immunomodulatory, immunosuppressive or immunobiological drugs, with albendazole, 400mg orally, a single dose. Repeat annually if the patient's immunosuppression persists and he/she lives in endemic areas
Ancylostomiasis	Spontaneous sedimentation; Willis method/eggs search	Investigate the presence of anemia	Albendazole 400mg, PO, single dose; mebendazole 100mg, PO, bid, for 3 days or 500mg, PO, single dose; nitazoxanide 500mg, PO, bid for 3 to 7 days	Health education; sanitation; hands and food washing; use of shoes.	Prophylaxis before the onset of immunomodulatory, immunosuppressive or immunobiological drugs, with albendazole, 400mg orally, a single dose. Repeat annually if the patient's immunosuppression persists and he/she lives in endemic areas
Strongyloidiasis	Baermann-Moraes method; Rugai method, Mattos and Brisola- use fresh stools/Search for larvae	Cases of hyperinfection; larvae are found in body fluids.	Ivermectin 200µg/kg, PO, 1 to 2 days; albendazole 400mg/day PO, during 3 days; tiabendazole 25mg/kg, PO, bid, for 2 days.	Health education; sanitation; hands and food washing; use of shoes.	Prophylaxis before the onset of immunomodulatory, immunosuppressive or immunobiological drugs, with ivermectin 200µg/kg/day, orally, for 2 consecutive days, repeated within 2 weeks. Repeat prophylaxis each 6 months, if immunomodulation or immunosuppression persists, if patient lives permanently in endemic area

Sociedade Brasileira de Reumatologia Av Brigadeiro Luiz Antonio, 2466 - Cj 93., 01402-000 São Paulo - SP, Tel./Fax: 55 11 3289 7165 - São Paulo - SP - Brazil
E-mail: sbre@terra.com.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] *Corresponding author. E-mail: carlosandrade07@gmail.com (C.A.F.d. Andrade).