Strongyloides : Not Strongly Suspected

Abstract

INTRODUCTION: Most individuals infected with Strongyloides stercoralis are asymptomatic however infestation with Strongyloides is capable of transforming into a fulminant illness called the hyperinfection syndrome (HS) under conditions of host immune compromise [1]. S. stercoralis hyperinfection was once considered an AIDS-defining illness, however there is a relative rarity of such case reports [2]. There are also only occasional case reports of S. stercoralis hyperinfection developing in patients with hematologic malignancies prior to therapy [3]. We report the case of an immigrant male with HS who presented with symptoms resembling bacterial pneumonia. CASE PRESENTATION: A 48-year-old Hispanic male patient with Non-Hodgkin's lymphoma and HIV was transferred to our hospital for management of these diagnoses. He presented with a 2-week history of shortness of breath, cough productive of clear sputum and occasional hemoptysis, fevers and chills; abdominal pain and poor appetite. He was yet to receive therapy for HIV or lymphoma. Physical examination revealed a cachectic man who was febrile and tachypneic. Pulmonary examination revealed bilateral diffuse rhonchi. The results of laboratory tests were remarkable for a WBC count of 2800 cells/mL, without eosinophilia, HIV viral load of 423,000 and a CD4+ T cell count of 13. CT of the chest showed centrilobular nodules throughout both lungs. Culture of sputum was negative. A PPD test was read as negative. Bronchoscopy was performed and samples of bronchoalveolar lavage (BAL) fluid were sent for fungal, bacterial and mycobacterial cultures. Organisms seen on a BAL specimen were clearly identifiable as strongyloides larvae. A diagnosis of hyperinfection syndrome was made and the patient was treated with Ivermectin and Albendazole. His shortness of breath and abdominal symptoms improved dramatically. Cure was documented with negative stool studies. DISCUSSION: An increased number of larvae are found in organs in hyperinfection syndrome This usually occurs in the setting of host immune compromise. Symtoms range from cough to respiratory collapse. Intestinal obstruction and perforation has also been reported. Blood counts more often show a suppressed eosinophil count. Yield of stool examination is low. Treatment with oral ivermectin and albendazole is safe and effective. CONCLUSIONS: Strongyloidosis should be actively considered in immunocomprised patients presenting with unexplained pulmonary or gastrointestinal symptoms.