fatal. The worms enter the bloodstream from the bowel wall, simultaneously allowing entry of bowel bacteria such as Escherichia coli. This may cause symptoms such as sepsis (bloodstream infection), and the bacteria may spread to other organs where they may cause localized infection such as meningitis. Dissemination without hyperinfection may present to a lesser degree the above and many other symptoms. Dissemination can occur many decades after the initial infection and has been associated with high dose corticosteroids, organ transplant, any other instances and causes of immunosuppression, HIV, lepromatous leprosy, tertiary syphilis, aplastic anemia, malnutrition, advanced tuberculosis and radiation poisoning. It is often recommended that patients being started on immunosuppression be screened for chronic strongyloidiasis; however, this is often impractical (screen tests are often unavailable) and in developed countries, the prevalence of chronic strongyloidiasis is very small, so screening is usually not cost-effective, except in endemic areas. The reality of global travel and need for modern advanced healthcare, even in the so-called "developed world", necessitates that in non-endemic areas there is easily accessible testing and screening for neglected tropical diseases such as strongyloidiasis. It is important to note that there is not necessarily any eosinophilia in the disseminated disease. Absence of eosinophilia in an infection limited to the gastrointestinal tract may indicate poor prognosis. Eosinophilia is often absent in disseminated infection. Steroids will also suppress eosinophilia, while leading to dissemination and potential hyperinfection. Escalated disseminated infections caused by immunosuppression can result in a wide variety and variable degree of disparate symptoms depending on the condition and other biological aspects of the individual, that may emulate other diseases or diagnoses. In addition to the many palpable gastrointestinal and varied other symptoms drastic cachexia amidst lassitude is often present, although severe disseminated infections can occur in individuals without weight loss regardless of body mass index. Diagnosis Diagnosis rests on the microscopic identification of larvae (rhabditiform and occasionally filariform) in the stool or duodenal fluid. Examination of many samples may be necessary, and not always sufficient, because direct stool examination is relatively insensitive, with a single sample only able to detect larvae in about 25% of cases. It can take 4 weeks from initial infection to the passage of larvae in the stool. The stool can be examined in wet mounts: directly after concentration (formalin-ethyl acetate) after recovery of the larvae by the Baermann funnel technique after culture by the Harada-Mori filter paper