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Case Study An Extensive History: Always Useful

Answer: Until recently thiabendazole was the drug of choice to treat strongyloidiasis. Parasite eradication in uncomplicated infections is approximately 90% or higher. However, S. stercoralis is a significant health risk in many developing countries and even in parts of eastern Kentucky and rural Tennessee. It presents a serious potential for severe disease in the many military servicemen who were stationed in Southeast Asia during World War II and the Vietnam era. In fact, it was first described in 1876 as "diarrhea of China" in French colonial troops in Indochina by Louis Alexis Norman, physician first class in the French Navy. It is acquired by infective larvae that penetrate the skin and frequently maintain a low level of autoinfection asymptomatically for many decades. Hyperinfection and widespread dissemination may occur following immunosuppression or chronic disease. Prompt treatment can be lifesaving, as hyperinfection syndrome is associated with mortality rates up to 86%. Steroids may suppress the eosinophil response normally seen in this disease, so an appropriate history must be taken and characteristic intestinal and skin findings examined, and a high index of suspicion is needed to make a timely diagnosis of patients who spent time in endemic areas. In immunocompro-mised hosts, persistent infection and relapse may complicate therapy with thiabendazole (even when given over 7 to 10 days). Alternative therapy with ivermectin appears as effective (64-100% cure rates) as thiabendazole with fewer side effects. Other drug choices are albendazole (cure rates of 38-81%) and mebendazole, but these have not been approved by the FDA for this indication.

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