Eosinophilia is usually observed. We interestingly recorded that mild splenomegaly and increased transaminase levels can be transiently present also during the early phase of infection while this has been previously described only in the hyperinfection syndrome or disseminated strongyloidiasis.10

Strongyloidiasis is rarely described in travelers to endemic countries (2% in a German study on travelers with eosinophilia,11 0.8% in a Belgian case series5). More than one third of patients with imported chronic strongyloidiasis described by Nuesch and colleagues were travelers.12 To our knowledge in the current literature no cases of acute strongyloidiasis are described in clinical settings. These two cases thus underline

the need to take into account acute strongyloidiasis as well as other invasive helminth this website infections (eg, schistosomiasis, trichinosis, fascioliasis, and toxocariasis) within the causes of urticaria and/or fever in returning travelers, particularly when eosinophilia is present.13 Our cases confirm that not only migrants but also travelers may be at risk of acquiring strongyloidiasis and therefore potentially exposed to hyperinfection and disseminated, life-threatening illness in case of immunosuppression and/or corticosteroid treatment. This is a real cause of concern given that physicians are largely unaware of strongyloidiasis and of its potential, life-threatening complications. In a recent survey among US physicians-in-training, only 9% recognized the need for parasitic screening in a hypothetical case of strongyloidiasis and 23% advocated steroids for wheezing and eosinophilia.14 LDE225 clinical trial If we add the low sensitivity of direct diagnostic methods,6,15 with the consequent risk of missing the infection even when this is correctly suspected, the scenario becomes much more worrisome. As a consequence, the use of an antihelminthic drug efficient against strongyloidiasis (ivermectin, thiabendazole) might be discussed to prevent disseminated strongyloidiasis BCKDHA in all patients candidated to immunosuppression if they have been resident or traveled in disease-endemic countries,

regardless of the result of parasitic screening.16 In conclusion, acute strongyloidiasis is a potential cause of fever and/or urticaria associated with eosinophilia in returning travelers. Western doctors should thus be aware of this unusual occurrence, potentially affecting also the travelers. Single exposure of the skin to garden terrain in apparently “safe” touristic resorts is a largely unknown risk factor for developing strongyloidiasis as well as hookworm infections and prevention measures should be discussed during pretravel advice. As the diagnosis is difficult during the invasive, acute phase, direct (stool) and indirect (serologic) examinations should be repeated up to at least 1 month after return. The authors state that they have no conflicts of interest to declare.