Mysterious Symptoms: Chest Pain, Fever and Fatigue
Patient: Angeline, a 32-year-old administrative assistant
Doctor: Dr. Anne McCarthy, chair of the Committee to Advise on Tropical Medicine and Travel and professor of medicine at the University of Ottawa
In 2013, Angeline visited her doctor. She’d had a fever for several days, her chest felt tight, and she was exhausted. The physician noticed that her lymph nodes were swollen and that she’d lost some weight. He decided to refer her to the Ottawa Hospital for a CT scan and biopsy, which led to a diagnosis of non-Hodgkin’s lymphoma.
The fifth most commonly diagnosed cancer in Canadian adults, non-Hodgkin’s lymphoma has a good prognosis when it’s caught early-especially if the patient is under 60. Angeline was given medication to support her immune system, chemotherapy to target the cancer cells and steroids to bolster the treatment. A week later, she became tired and nauseous, and her blood-cell count dropped dramatically. These can be side effects of chemo, but in this case, they were unusually pronounced.
Within days, Angeline’s fever spiked and she had trouble breathing. Bacteria had entered her bloodstream, and she’d developed an infection in her lungs and abdomen. The patient was admitted to the ICU and given antibiotics, but the drugs didn’t help. Instead, Angeline’s breathing worsened, and she was put on a ventilator.
That’s when Dr. Anne McCarthy was called in. The infection disease specialist found traces of a rash on Angeline’s abdomen. When she learned the patient had grown up in Haiti and immigrated to Canada eight years earlier, McCarthy immediately thought of strongyloides.
Strongyloides are a type of roundworm common in Southeast Asia, South Africa and the Caribbean. The larvae are small-about the size of a mustard seed-and are transmitted to humans through contaminated soil. They can penetrate unbroken skin (often through bare feet) and migrate through the body to the small intestine, where they lay eggs.
In this case, the wavy rash on Angeline’s stomach was a clue: it can appear in patients with strongyloides. When McCarthy checked the patient’s stool sample, she says, “the larvae were everywhere.”
Because there are no obvious symptoms, people can be infected for years without knowing they have the parasite. Angeline had experienced mild gastrointestinal issues at times, but otherwise wealthy, apart from her recent cancer diagnosis-until she was given some steroids as part of her treatment. “Strongyloidiasis is a sleeping disease,” McCarthy says. “It can exist in your body and do relatively little harm until you give it an advantage.” Doctors aren’t entirely sure why, but steroids stimulate the parasite to reproduce faster.
Those drugs had indeed unleashed the bug throughout Angeline’s body, a condition known as disseminated strongyloides, which causes death in 50 to 90 per cent of cases. Unfortunately, it takes time to get treatment because the two anti-parasite drugs that fight the disease (albendazole and ivermectin) aren’t licensed in this country, though they are used in the United States. McCarthy had to request permission from a special program through Health Canada. Although she remained in the ICU for almost a month, the patient received the drugs and made a full recovery, at which point she was able to resume treatment for the non-Hodgkin’s syndrome.
Like most people, Angeline had no idea she could be at risk for strongyloides. Even physicians often know very little about the parasite. McCarthy, who chairs the advisory committee that’s developing strongyloides guidelines, encourages practitioners to adopt a few key queries into their preventive care routine: Where were you born? Where have you lived? Have you travelled anywhere for six months or longer? “There is treatment for strongyloides and people can survive it,” she says. “We just need to ask the right questions from the beginning.”