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Review
. 2023 Apr 25;8(5):248.
doi: 10.3390/tropicalmed8050248.

Coinfection with Strongyloides and SARS-CoV-2: A Systematic Review

Elena C Rosca  1 , Carl Heneghan  2 , Elizabeth A Spencer  2 , Annette Plüddemann  2 , Susanna Maltoni  3 , Sara Gandini  4 , Igho J Onakpoya  5 , David Evans  6 , John M Conly  7 , Tom Jefferson  5
Affiliations
Review

Coinfection with Strongyloides and SARS-CoV-2: A Systematic Review

Elena C Rosca et al. Trop Med Infect Dis. .

Abstract

Background: Treatments for COVID-19, including steroids, might exacerbate Strongyloides disease in patients with coinfection. We aimed to systematically review clinical and laboratory features of SARS-CoV-2 and Strongyloides coinfection, investigate possible interventions, assess outcomes, and identify research gaps requiring further attention.

Methods: We searched two electronic databases, LitCOVID and WHO, up to August 2022, including SARS-CoV-2 and Strongyloides coinfection studies. We adapted the World Health Organization-Uppsala Monitoring Centre (WHO-UMC) system for standardized case causality assessment to evaluate if using corticosteroids or other immunosuppressive drugs in COVID-19 patients determined acute manifestations of strongyloidiasis.

Results: We included 16 studies reporting 25 cases of Strongyloides and SARS-CoV-2 coinfection: 4 with hyperinfection syndrome; 2 with disseminated strongyloidiasis; 3 with cutaneous reactivation of strongyloidiasis; 3 with isolated digestive symptoms; and 2 with solely eosinophilia, without clinical manifestations. Eleven patients were asymptomatic regarding strongyloidiasis. Eosinopenia or normal eosinophil count was reported in 58.3% of patients with Strongyloides reactivation. Steroids were given to 18/21 (85.7%) cases. A total of 4 patients (19.1%) received tocilizumab and/or Anakirna in addition to steroids. Moreover, 2 patients (9.5%) did not receive any COVID-19 treatment. The causal relationship between Strongyloides reactivation and COVID-19 treatments was considered certain (4% of cases), probable (20% of patients), and possible (20% of patients). For 8% of cases, it was considered unlikely that COVID-19 treatment was associated with strongyloidiasis reactivations; the relationship between the Strongyloides infection and administration of COVID-19 treatment was unassessable/unclassifiable in 48% of cases. Of 13 assessable cases, 11 (84.6%) were considered to be causally associated with Strongyloides, ranging from certain to possible.

Conclusions: Further research is needed to assess the frequency and risk of Strongyloides reactivation in SARS-CoV-2 infection. Our limited data using causality assessment supports recommendations that clinicians should screen and treat for Strongyloides infection in patients with coinfection who receive immunosuppressive COVID-19 therapies. In addition, the male gender and older age (over 50 years) may be predisposing factors for Strongyloides reactivation. Standardized guidelines should be developed for reporting future research.

Keywords: COVID-19; SARS-CoV-2; Strongyloides; coinfection; systematic review.

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Conflict of interest statement

T.J. disclosure is available here: https://restoringtrials.org/competing-interests-tom-jefferson/(accessed on 21 April 2023). C.H. holds grant funding from the NIHR, the NIHR School for Primary Care Research, the NIHR BRC Oxford, and the World Health Organization for a series of living rapid reviews on the modes of transmission of SARS-CoV-2, reference WHO registration No2020/1077093, and to carry out a scoping review of systematic reviews of interventions to improve vaccination uptake, reference WHO Registration 2021/1138353-0. He has received financial remuneration from an asbestos case and given legal advice on mesh and hormone pregnancy test cases. He has received expenses and fees for his media work, including occasional payments from BBC Radio 4 Inside Health and The Spectator. He receives expenses for teaching EBM and is also paid for his GP work in NHS out of hours (contract Oxford Health NHS Foundation Trust). He has also received income from the publication of a series of toolkit books and appraising treatment recommendations in non-NHS settings. He is the Director of CEBM, an NIHR Senior Investigator, and an advisor to Collateral Global. D.E. holds grant funding from the Canadian Institutes for Health Research and Li Ka Shing Institute of Virology relating to the development of COVID-19 vaccines and the Canadian Natural Science and Engineering Research Council concerning COVID-19 aerosol transmission. He is a recipient of World Health Organization and Province of Alberta funding, which supports the provision of BSL3-based SARS-CoV-2 culture services to regional investigators. He also holds public and private sector contract funding relating to the development of poxvirus-based COVID-19 vaccines, SARS-CoV-2 inactivation technologies, and serum neutralization testing. J.M.C. holds grants from the Canadian Institutes for Health Research on acute and primary care preparedness for COVID-19 in Alberta, Canada, and as a coinvestigator for a study on N95 respirators vs medical masks in the care of COVID-19 patients. He was the primary local Investigator for a Staphylococcus aureus vaccine study funded by Pfizer, for which all funding was provided only to the University of Calgary. He is a co-investigator on a WHO-funded study using integrated human factors and ethnography approaches to identify and scale innovative IPC guidance implementation supports in primary care with a focus on low-resource settings and using drone aerial systems to deliver medical supplies and PPE to remote First Nations communities during the COVID-19 pandemic. He also holds grants from the Synder Institute and a Catalyst Grant from the VPR Office at the University of Calgary for studies on the transmission of SARS-CoV-2 in K18-mice and received funding from BioMérieux Canada for accommodations and travel expenses to attend a meeting on AMR outside the submitted work. He is a member and Chair of the WHO Infection Prevention and Control Research and Development Expert Group for COVID-19 and the WHO Health Emergencies Programme (WHE) ad hoc COVID-19 IPC Guidance Development Group, both of which provide multidisciplinary advice to the WHO, for which no funding is received and from which no funding recommendations are made for any WHO con-tracts or grants. He is also a member of the Cochrane Acute Respiratory Infections Group. S.M. is a pharmacist working for the Italian National Health System since 2002 and a member of one of the three Institutional Review Boards of the Emilia-Romagna Region (Comitato Etico Area Vasta Emilia Centro) since 2018. A.P. holds grant funding from the NIHR School for Primary Care Research. I.J.O., E.A.S., S.G. and E.C.R. have no interests to disclose.

Figures

Figure 1
Figure 1
Flow diagram showing the process for inclusion of studies investigating coinfection with Strongyloides and SARS-CoV-2.
See this image and copyright information in PMC

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